Empirical cefepime+vancomycin versus ceftazidime+vancomycin versus meropenem+vancomycin in the treatment of healthcare-associated meningitis: results of the multicenter ephesus study.

BACKGROUND: Herein, we analyzed the efficacy of main antibiotic therapy regimens in the treatment of healthcare-associated meningitis (HCAM). MATERIALS/METHODS: This retrospective cohort study was conducted in 18 tertiary-care academic hospitals Turkey, India, Egypt and Romania. We extracted data and outcomes of all patients with post-neurosurgical meningitis cases fulfilling the study inclusion criteria and treated with empirical therapy between December 2006-September 2018. RESULTS: Twenty patients in the cefepime + vancomycin-(CV) group, 31 patients in the ceftazidime + vancomycin-(CFV) group, and 119 patients in the meropenem + vancomycin-(MV) group met the inclusion criteria. The MV subgroup had a significantly higher mean Glasgow Coma Score, a higher rate of admission to the intensive care unit within the previous month, and a higher rate of antibiot herapy within the previous month before the meningitis episode (p < 0.05). Microbiological success on Day 3-5, end of treatment (EOT) clinical success (80% vs. 54.8%% vs 57.9%), and overall success (EOT success followed by one-month survival without relapse or reinfection 65% vs. 51.6% vs. 45.3%), EOT all cause mortality (ACM) and day 30 ACM (15% vs. 22.6% vs. 26%) did not differ significantly (p > 0.05) among the three cohorts. No regimen was effective against carbapenem-resistant bacteria, and vancomycin resulted in an EOT clinical success rate of 60.6% in the methicillin-resistant staphylococci or ampicillin-resistant enterococci subgroup (n = 34). CONCLUSIONS: Our study showed no significant difference in terms of clinical success and mortality among the three treatment options. All regimens were ineffective against carbapenem-resistant bacteria. Vancomycin was unsuccessful in approximately 40% of cases involving methicillin-resistant staphylococci or ampicillin-resistant enterococci.

Comparative Evaluation of COVID-19 Associated Mucormycosis (CAM) and Non-COVID-19-associated Mucormycosis (non-CAM).

OBJECTIVE: To compare COVID-19 associated mucormycosis cases (CAM) with non-COVID-19 associated mucormycosis (non-CAM) cases followed as in-patients. STUDY DESIGN: Observational Study. PLACE AND DURATION OF STUDY: Department of Infectious Diseases and Clinical Microbiology, Adana City Training and Research Hospital, Health Sciences University (HSU), Adana, Turkey, between January 2018 and March 2022. METHODOLOGY: Patients with a diagnosis of mucormycosis (proven and probable) were dichotomised as COVID-19 associated mucormycosis and non-COVID-19 associated mucormycosis cases. Both groups were compared for underlying malignancy, chemotherapy, antifungal therapy related side effects and overall survival. RESULTS: Of the 35 cases enrolled in the study, 17 (48.6%) had CAM and 18 (51.4%) had non-CAM. A statistically significant difference was detected between non-CAM and CAM cases in terms of haematological malignancy, receiving chemotherapy, and antifungal therapy-related side effects (p=0.019, p=0.019, and p=0.027 respectively). Steroid use was found as a risk factor for the diabetic CAM cases (p<0.0001). The difference between the CAM and non-CAM cases in terms of overall survival was not statistically significant (p=0.088). CONCLUSION: Because of the ongoing COVID-19 pandemic and the increasing number of critical patients, treatment of COVID-19 should be performed cautiously in patients who have the risk of developing CAM, particularly those with diabetes and immunosuppression (haematologic malignancy, receiving steroid or chemotherapy, etc.) and these patients should be monitored closely. KEY WORDS: Mucormycosis, COVID-19, Mucormycosis associated with COVID-19, Diabetes mellitus, Turkey.

Evaluation of the effect of the COVID-19 pandemic on mucormycosis studies with bibliometric analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) is a relatively new concept in the literature that emerged during the pandemic. Bibliometric analysis is a type of analysis that uses mathematical and statistical methods to study the formal properties of knowledge areas. This study aimed to reveal the main themes, conceptual structures, and trends of bibliometric studies on mucormycosis in 2 different periods, pre-and during the pandemic. METHODS: This study consisted of 2 periods: pre-COVID-19 and COVID-19. Articles were collected from the Web of Science (WOS) Core Collection database. We provided AND and OR connectors for the keyword query and selected studies based on relevant keywords. Collected data were classified based on their publication date and examined using the R programming language (Version 4.0.3) package Bibliometrix and SciMAT Software. RESULTS: A total of 1261 articles were investigated, and performance and information structure analyses were conducted. Based on Bradford's law, the Journal of Fungi was the top-ranked journal in both periods. Cureus and mycoses were placed 2nd and 3rd in the second period. India is the largest contributor. In performance analysis, conceptual structures such as Rhizopus oryzae, epidemiology, diagnosis, management, treatment, and outcomes were at the forefront of mucormycosis publications during the COVID-19 period. CONCLUSIONS: Research trends have shifted to the clinical treatment and management of COVID-19. Therefore, pathogenesis, diagnosis, follow-up, and treatment strategies for CAM should be developed in the future.

Candidemia Among Coronavirus Disease 2019 Patients in Turkey Admitted to Intensive Care Units: A Retrospective Multicenter Study.

Background: We evaluated the epidemiology of candidemia among coronavirus disease 2019 (COVID-19) patients admitted to intensive care units (ICUs). Methods: We conducted a retrospective multicenter study in Turkey between April and December 2020. Results: Twenty-eight of 148 enrolled patients developed candidemia, yielding an incidence of 19% and incidence rate of 14/1000 patient-days. The probability of acquiring candidemia at 10, 20, and 30 days of ICU admission was 6%, 26%, and 50%, respectively. More than 80% of patients received antibiotics, corticosteroid, and mechanical ventilation. Receipt of a carbapenem (odds ratio [OR] = 6.0, 95% confidence interval [CI] = 1.6-22.3, P = .008), central venous catheter (OR = 4.3, 95% CI = 1.3-14.2, P = .02), and bacteremia preceding candidemia (OR = 6.6, 95% CI = 2.1-20.1, P = .001) were independent risk factors for candidemia. The mortality rate did not differ between patients with and without candidemia. Age (OR = 1.05, 95% CI = 1.01-1.09, P = .02) and mechanical ventilation (OR = 61, 95% CI = 15.8-234.9, P < .0001) were independent risk factors for death. Candida albicans was the most prevalent species overall. In Izmir, Candida parapsilosis accounted for 50% (2 of 4) of candidemia. Both C parapsilosis isolates were fluconazole nonsusceptible, harbored Erg11-Y132F mutation, and were clonal based on whole-genome sequencing. The 2 infected patients resided in ICUs with ongoing outbreaks due to fluconazole-resistant C parapsilosis. Conclusions: Physicians should be aware of the elevated risk for candidemia among patients with COVID-19 who require ICU care. Prolonged ICU exposure and ICU practices rendered to COVID-19 patients are important contributing factors to candidemia. Emphasis should be placed on (1) heightened infection control in the ICU and (2) developing antibiotic stewardship strategies to reduce irrational antimicrobial therapy.

Tuberculosis in Solid-Organ Transplant Recipients in Turkey: Meta-Analysis From the Tuberculosis Study Group of Turkish Transplantation Society, Solid Organ Transplantation Infections.

OBJECTIVES: Tuberculosis risk in solid-organ transplant recipients is more than the general population, although tuberculosis incidence has been reported to decrease 5% in the last decade in Turkey. In Turkey, solid-organ transplants started in 1975; however, routine pretransplant tuberculosis risk screening programs are still not established. Therefore, we conducted a meta-analysis of tuberculosis prevalence, clinical forms, and prognosis of tuberculosis in solid-organ transplant recipients. MATERIALS AND METHODS: We searched PubMed, Web of Knowledge, Google Scholar, EBSCOhost, and Scopus databases in English and Turkish Medical Index of Turkish Academic Network and Information Center, Turkish Citation Index, Turkish Medline, Central Thesis of ULAKBIM databases in Turkish (from inception until December 2018) for national and international reference lists of all relevant papers. We used standard methodological procedures (Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009). RESULTS: We found 199 published studies in English and 26 in Turkish. After exclusion of noneligible studies, there were 10 retrospective research articles and 16 case reports. There were 148 (3.2%) tuberculosis cases with 4553 solid-organ transplant recipients (4031 renal, 522 liver). Of the tuberculosis cases, 50 (33.8%) were pulmonary, 21 (14.2%) were pulmonary and extrapulmonary, 13 (8.8%) were miliary, 27 (18.2%) were disseminated, and 37 (25.0%) were extra-pulmonary tuberculosis cases involving a maximum of 2 organs. There were 19 cases (12.8%) of graft lost. Of the patients with tuberculosis, 34 (19.9%) died resulting from either tuberculosis or other reasons. CONCLUSIONS: In this meta-analysis, most of the centers did not perform pretransplant risk evaluations; every center had different clinical procedures and follow-ups. Tuberculosis prevalence in solid-organ transplant recipients differs according to study population. Case reports were mostly about extrapulmonary tuberculosis. All such patients should be followed-up by a standard regimen during pretransplant and posttransplant periods. Prospective studies should be considered.

Necrotizing Fasciitis: Evaluation of 85 Cases and Usage of LRINEC Score.

Objective: The present study aims to define the characteristics of the necrotizing fasciitis (NF) cases followed at our hospital and to compare our results with the literature. Materials and Methods: In this study, NF cases followed and treated at our hospital from January 2005 to April 2019 were evaluated retrospectively. Results: A total of 85 cases of NF were included in the study. Of the cases, 33 (39%) were female and the median age was 59.8±13.1 years (range: 26-92 years). Diabetes mellitus (DM) (56%) was the most prevalent comorbid condition. Extremities were the most frequently involved field found in 41 (48%) of the cases followed by Fournier's gangrene found in 34 (40%) of the cases. All of the cases had undergone surgical intervention (debridement and/or amputation) and received broad-spectrum antibiotic therapy. Laboratory risk indicator for necrotizing fasciitis (LRINEC) score was calculated for 60 cases, and it was 6 or higher in 78% of them. Nineteen (22%) of 85 cases had died. Conclusion: Necrotizing fasciitis affects generally older male patients with DM. In NF cases to avoid the higher risk of mortality, the removal of necrotic tissue via surgical procedure together with antimicrobial therapy is required urgently; therefore, it is very important to differentiate NF from soft tissue infections as soon as possible. As the LRINEC score predicted NF among nearly 80% of our patients, this score could be used as an early diagnostic tool of NF. Level of Evidence: Level IV, case series.

Modified Lung Ultrasound Score in Evaluating the Severity of Covid-19 Pneumonia.

Severe acute respiratory syndrome coronavirus 2 causes coronavirus disease 2019 (Covid-19), which has been declared as a pandemic by the World Health Organization. The aim of the study described here was to determine the severity of pneumonia and the clinical parameters related to a modified lung ultrasound score (mLUS) in patients with COVID-19 pneumonia. The study included 44 patients with proven COVID-19 pneumonia. Patients were divided into three groups on the basis of pneumonia severity: mild/moderate pneumonia (group I), severe pneumonia (group II) and critically ill patients (group III). It was determined that mLUS values in groups I-III were 6.51 ± 4.12, 23.5 ± 5.9 and 24.7 ± 3.9, respectively. mLUS values were significantly higher in group II and III patients than in group I patients. There was a positive relationship between mLUS and age and N-terminal pro-brain natriuretic peptide level and a negative relationship with PaO2/FiO2 (p = 0.032, ß = 0.275 vs. p = 0.012, ß = 0.315 vs. p = 0.001, ß = -0.520, respectively). In patients with COVID-19 pneumonia, mLUS increases significantly with the severity of the disease.

Disease Severity Affects Ventricular Repolarization Parameters in Patients With COVID-19. / A Gravidade da Doença Afeta os Parâmetros de Repolarização Ventricular em Pacientes com COVID-19.

BACKGROUND: There is no study evaluating the Tpeak-Tend (Tpe) interval, Tpe/QT ratio, and Tpe/QTc ratio to assess cardiac arrhythmias in patients with COVID-19. OBJECTIVE: We aimed to examine whether there is a change in QT, QTc, Tpe interval, Tpe/QT ratio, and Tpe/QTc ratio in patients with COVID-19. METHODS: The study included 90 patients with COVID-19 infection and 30 age-and-sex-matched healthy controls. QT, QTc, Tpe interval, Tpe/QT ratio, and Tpe/QTc ratio were measured. The participants included in the study were divided into the following 4 groups: healthy controls (group I), patients with COVID-19 without pneumonia (group II), patients with COVID-19 and mild pneumonia (group III), and patients with COVID-19 and severe pneumonia (group IV). Statistical significance was set at p < 0.05. RESULTS: It was found that baseline heart rate, presence of hypertension and diabetes, white blood cell count, blood urea nitrogen, creatinine, potassium, aspartate aminotransferase, alanine aminotransferase, NT-proBNP, high sensitive C reactive protein, D-dimer, hs-cTnI, Tpe, Tpe/QT, and Tpe/QTc increased from group I to group IV, and they were significantly higher in all patients in group IV (p < 0.05). Systolic-diastolic blood pressure, hemoglobin, and calcium levels were found to be lowest in group IV and significantly lower than in other groups (< 0.05). QT and QTc intervals were similar between groups. It was determined that increased heart rate, calcium, D-dimer, NT-proBNP and hs-CRP levels were significantly related to Tpe, Tpe/QT, and Tpe/QTc. CONCLUSIONS: In patients with COVID-19 and severe pneumonia, Tpe, Tpe/QT ratio, and Tpe/QTc ratio, which are among ventricular repolarization parameters, were found to be increased, without prolonged QT and QTc intervals. In this study, we cannot definitively conclude that the ECG changes observed are directly related to COVID-19 infection or inflammation, but rather associated with severe COVID-19 scenarios, which might involve other causes of inflammation and comorbidities. (Arq Bras Cardiol. 2020; 115(5):907-913).

FUNDAMENTO: Não há estudos avaliando o intervalo Tpico-Tfim (Tpe), a relação Tpe/QT e a relação Tpe/QTc para avaliar arritmias cardíacas em pacientes com COVID-19. OBJETIVO: Visamos investigar se há alterações nos intervalos QT, QTc e Tpe e nas relações Tpe/QT e Tpe/QTc em pacientes com COVID-19. MÉTODOS: O estudo incluiu 90 pacientes com infecção por COVID-19 e 30 controles saudáveis pareados por sexo e idade. Foram aferidos os intervalos QT, QTc e Tpe e as relações Tpe/QT e Tpe/QTc. Os participantes incluídos no estudo foram divididos nos seguintes 4 grupos: controles saudáveis (grupo I), pacientes com COVID-19 sem pneumonia (grupo II), pacientes com COVID-19 e pneumonia leve (grupo III) e pacientes com COVID-19 e pneumonia grave (grupo IV). Significância estatística foi definida por valor p < 0,05. RESULTADOS: Verificou-se que a frequência cardíaca basal, a presença de hipertensão e diabetes, a contagem de leucócitos, o nitrogênio ureico no sangue, a creatinina, o potássio, o aspartato aminotransferase, a alanina aminotransferase, o NT-proBNP, a proteína C reativa de alta sensibilidade, o dímero-D, a TncI-as, o intervalo Tpe, a relação Tpe/QT e a relação Tpe/QTc aumentaram do grupo I para o grupo IV e foram significativamente mais altos em todos os pacientes do grupo IV (p < 0,05). A pressão arterial sistólica, a hemoglobina e os níveis de cálcio eram menores no grupo IV e significativamente menores em comparação com os demais grupos (< 0,05). Os intervalos QT e QTc eram semelhantes entre grupos. Determinou-se que os níveis elevados de frequência cardíaca, cálcio, dímero-D, NT-proBNP e PCR-as eram significativamente relacionados a Tpe, Tpe/QT e Tpe/QTc. CONCLUSÕES: Em pacientes com COVID-19 e pneumonia grave, o intervalo Tpe, a relação Tpe/QT e a relação Tpe/QTc, que estão entre os parâmetros de repolarização ventricular, foram aumentados, sem prolongação dos intervalos QT e QTc. A partir deste estudo, não podemos definitivamente concluir que as alterações eletrocardiográficas observadas estão diretamente relacionadas à infecção por COVID-19 ou à inflamação, mas sim associadas a cenários graves de COVID-19, que podem envolver outras causas de inflamação e comorbidades.

A Gravidade da Doença Afeta os Parâmetros de Repolarização Ventricular em Pacientes com COVID-19 / Disease Severity Affects Ventricular Repolarization Parameters in Patients With COVID-19

Resumo Fundamento: Não há estudos avaliando o intervalo Tpico-Tfim (Tpe), a relação Tpe/QT e a relação Tpe/QTc para avaliar arritmias cardíacas em pacientes com COVID-19. Objetivo: Visamos investigar se há alterações nos intervalos QT, QTc e Tpe e nas relações Tpe/QT e Tpe/QTc em pacientes com COVID-19. Métodos: O estudo incluiu 90 pacientes com infecção por COVID-19 e 30 controles saudáveis pareados por sexo e idade. Foram aferidos os intervalos QT, QTc e Tpe e as relações Tpe/QT e Tpe/QTc. Os participantes incluídos no estudo foram divididos nos seguintes 4 grupos: controles saudáveis (grupo I), pacientes com COVID-19 sem pneumonia (grupo II), pacientes com COVID-19 e pneumonia leve (grupo III) e pacientes com COVID-19 e pneumonia grave (grupo IV). Significância estatística foi definida por valor p < 0,05. Resultados: Verificou-se que a frequência cardíaca basal, a presença de hipertensão e diabetes, a contagem de leucócitos, o nitrogênio ureico no sangue, a creatinina, o potássio, o aspartato aminotransferase, a alanina aminotransferase, o NT-proBNP, a proteína C reativa de alta sensibilidade, o dímero-D, a TncI-as, o intervalo Tpe, a relação Tpe/QT e a relação Tpe/QTc aumentaram do grupo I para o grupo IV e foram significativamente mais altos em todos os pacientes do grupo IV (p < 0,05). A pressão arterial sistólica, a hemoglobina e os níveis de cálcio eram menores no grupo IV e significativamente menores em comparação com os demais grupos (< 0,05). Os intervalos QT e QTc eram semelhantes entre grupos. Determinou-se que os níveis elevados de frequência cardíaca, cálcio, dímero-D, NT-proBNP e PCR-as eram significativamente relacionados a Tpe, Tpe/QT e Tpe/QTc. Conclusões: Em pacientes com COVID-19 e pneumonia grave, o intervalo Tpe, a relação Tpe/QT e a relação Tpe/QTc, que estão entre os parâmetros de repolarização ventricular, foram aumentados, sem prolongação dos intervalos QT e QTc. A partir deste estudo, não podemos definitivamente concluir que as alterações eletrocardiográficas observadas estão diretamente relacionadas à infecção por COVID-19 ou à inflamação, mas sim associadas a cenários graves de COVID-19, que podem envolver outras causas de inflamação e comorbidades.

Abstract Background: There is no study evaluating the Tpeak-Tend (Tpe) interval, Tpe/QT ratio, and Tpe/QTc ratio to assess cardiac arrhythmias in patients with COVID-19. Objective: We aimed to examine whether there is a change in QT, QTc, Tpe interval, Tpe/QT ratio, and Tpe/QTc ratio in patients with COVID-19. Methods: The study included 90 patients with COVID-19 infection and 30 age-and-sex-matched healthy controls. QT, QTc, Tpe interval, Tpe/QT ratio, and Tpe/QTc ratio were measured. The participants included in the study were divided into the following 4 groups: healthy controls (group I), patients with COVID-19 without pneumonia (group II), patients with COVID-19 and mild pneumonia (group III), and patients with COVID-19 and severe pneumonia (group IV). Statistical significance was set at p < 0.05. Results: It was found that baseline heart rate, presence of hypertension and diabetes, white blood cell count, blood urea nitrogen, creatinine, potassium, aspartate aminotransferase, alanine aminotransferase, NT-proBNP, high sensitive C reactive protein, D-dimer, hs-cTnI, Tpe, Tpe/QT, and Tpe/QTc increased from group I to group IV, and they were significantly higher in all patients in group IV (p < 0.05). Systolic-diastolic blood pressure, hemoglobin, and calcium levels were found to be lowest in group IV and significantly lower than in other groups (< 0.05). QT and QTc intervals were similar between groups. It was determined that increased heart rate, calcium, D-dimer, NT-proBNP and hs-CRP levels were significantly related to Tpe, Tpe/QT, and Tpe/QTc. Conclusions: In patients with COVID-19 and severe pneumonia, Tpe, Tpe/QT ratio, and Tpe/QTc ratio, which are among ventricular repolarization parameters, were found to be increased, without prolonged QT and QTc intervals. In this study, we cannot definitively conclude that the ECG changes observed are directly related to COVID-19 infection or inflammation, but rather associated with severe COVID-19 scenarios, which might involve other causes of inflammation and comorbidities. (Arq Bras Cardiol. 2020; 115(5):907-913)

Lumbosacral discitis as a rare complication of laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is considered to be the gold-standard procedure for apical compartment prolapse. However, complications such as sacral hemorrhage, small bowel obstruction, port site herniation, mesh erosion, mesh exposure, and occasionally discitis may occur. The aim of this study is to show laparoscopic treatment of L5-S1 discitis 3 months following laparoscopic sacrocolpopexy. METHODS: Two surgical interventions of a case with narrated video footage is presented. RESULTS: Laparoscopic sacrocolpopexy following hysterectomy in the first part and re-laparoscopy because of a diagnosis of discitis refractory to medical treatment, and removal of mesh along with anterior L5-S1 discectomy for curative debridement in the second part is demonstrated. CONCLUSION: Frequency of postoperative discitis has been increased by the widespread use of a laparoscopic approach. In order to reduce the complication rate, surgical technique allowing the needle to penetrate only the depth of the anterior longitudinal ligament and usage of monofilament suture for mesh attachment is recommended. In treatment, removal of the sacral mesh, and even extensive tissue debridement, may be necessary.

Variables determining mortality in patients with Acinetobacter baumannii meningitis/ventriculitis treated with intrathecal colistin.

AIM: To examine the variables associated with mortality in patients with Acinetobacter baumannii-related central nervous system infections treated with intrathecal colistin. MATERIALS AND METHODS: This multi-centre retrospective case control study included patients from 11 centres in Turkey, as well as cases found during a literature review. Only patients with CNS infections caused by multidrug-resistant or extensively drug-resistant Acinetobacter baumannii treated with intrathecal colistin were included in this study. The variables associated with mortality were determined by dividing the patients into groups who died or survived during hospitalisation, and who died or survived from Acinetobacter meningitis. RESULTS: Among the 77 cases enrolled in the study, 35 were found through a literature review and 42 were cases from our centres. Forty-four cases (57.1%) were male and the median age was 48 years (range: 20-78 years). Thirty-seven patients (48%) died during hospitalisation. The variables associated with increased all-cause mortality during hospitalisation included old age (odds ratio, 1.035; 95% confidence interval (CI), 1.004-1.067; p=0.026) and failure to provide cerebrospinal fluid sterilisation (odds ratio, 0.264; 95% confidence interval, 0.097-0.724; p=0.01). There is a trend (P=0.062) towards higher mortality with using of meropenem during meningitis treatment. Fifteen cases (19%) died from meningitis. There were no significant predictors of meningitis-related mortality. CONCLUSIONS: The mortality rate for central nervous system infections caused by multidrug-resistant or extensively drug-resistant Acinetobacter baumannii is high. Old age and failure to provide CSF sterilisation are associated with increased mortality during hospitalisation.

Evaluation of 28 cases of mucormycosis.

Mucormycosis is a rare but invasive fungal disease with high mortality. The present study aimed to retrospectively investigate the demographic characteristics, as well as the clinical, radiological and laboratory features and the results of treatment, in the patients followed in our hospital because of mucormycosis. The present study retrospectively evaluated 28 cases, which were followed in our hospital because of mucormycosis between January 2002 and July 2013. The clinical form was rhinocerebral in 27 cases (rhinoorbital in 12, nasal in 8 and rhinoorbitocerebral in 7) and disseminated in one case. With regard to predisposing factors, diabetes mellitus (n = 20), haematological malignancy (n = 6) and chronic renal insufficiency (n = 5) were the leading concomitant diseases. Seventeen (61%) of 28 cases showed atypical clinical picture. With regard to the therapeutic outcomes; it was found that 14 (50%) cases died and six cases recovered with sequel. Today, when particularly the prevalence of immunosuppressive diseases and conditions are gradually increasing, the incidence of mucormycosis is also increased. Considering that the majority of our cases had atypical clinical involvement and complications, being familiar with the characteristics of this disease could be life-saving together with early diagnosis and treatment.

[An unusual cause of febrile neutropenia: brucellosis]. / Nötropenik atesin ender bir nedeni: Bruselloz.

Febrile neutropenia which is a common complication of cancer treatment, is one of the major causes of morbidity and mortality. Several gram-negative and gram-positive bacteria are responsible for infections in neutropenic patients, however the most common microorganisms are Escherichia coli and coagulase-negative staphylococci, in decreasing order. Although Brucella spp. infections are endemic in Turkey, brucellosis-related febrile neutropenia has only rarely been reported. In this report, a case of brucellosis-related febrile neutropenia in a patient with acute myeloblastic leukemia (AML) was presented. A 56-year-old male patient presenting with fever, petechiae/purpura, leukocytosis, thrombocytopenia, and anemia was admitted to our hospital. Laboratory studies revealed a hemoglobin level of 8.27 g/dl, leukocyte count of 77.100 k/ml, absolute neutrophil count of 200 k/ml, and platelets at 94.200 k/ml. The patient was diagnosed as AML-M1 and piperacillin/tazobactam was started as the first-line antibiotic therapy due to the febrile neutropenia. On admission, blood and urine cultures were negative. Once the fever was controlled, remission/induction chemotherapy was initiated. However, fever developed again on the eight day, and vancomycin was added to the therapy. Since the fever persisted, the antibiotic therapy was gradually replaced with meropenem and linezolid. However, fever continued and the patient's general condition deteriorated. Subsequently performed Brucella tube agglutination test revealed positivity at 1/320 titer and the microorganism grown in blood culture (Bactec 9050; BD, USA) was identified as B.melitensis by conventional methods. Rifampicin and doxycycline therapy was started immediately, however, the patient died due to septic shock. If the tests for brucellosis were performed earlier when response to second step antibiotic therapy lacked in this patient, it was assumed that mortality could be prevented by the prompt initiation of the appropriate treatment. Thus, since brucellosis is endemic in Turkey, it should be considered as a possible agent of febrile neutropenia especially in patients unresponsive to empiric antibiotherapy and appropriate diagnostic tests should be performed.

Endovascular treatment of an iliac artery rupture caused by invasive Salmonella spondylodiscitis.

The rate of non-typhoid Salmonella infections has increased remarkably in recent years. Endovascular system infection is one of the most serious forms of extraintestinal Salmonella infection. The abdominal aorta is frequently involved, while bone and joint involvement are rarely seen. We present a rare case of successful endovascular treatment of a left iliac artery rupture and pseudoaneurysm both occurring due to the direct invasion of lumbar spondylodiscitis caused by Salmonella typhimurium.

[Evaluation of fourteen adult cases with visceral leishmaniasis]. / On dört eriskin viseral leyismanyoz olgusunun degerlendirilmesi.

Visceral leishmaniasis is a life threatening systemic infectious disease caused by Leishmania protozoon, which is transmitted by phlebotomine sandflies, and is widespread in Mediterranean countries including Turkey. The aim of this study was to retrospectively evaluate the visceral leishmaniasis cases followed in our clinic between January 2005 to April 2012, under the light of the current literature. A total of 14 cases (7 female, 7 male; age range: 19-64 years, mean age: 41.6 ± 12.9 years) diagnosed as visceral leishmaniasis and followed for one year after their treatment were included in the study. Data of the cases were obtained from the patient files. Ten of the cases were immunocompetent and four were immunosuppressive. While six of the cases were residents in Adana, eight were from different cities of south and southeastern Anatolia, Turkey. The median period between the development of symptoms and diagnosis was 75 (range: 2-272) days and 79% (11/14) of them were admitted to a health center and used antimicrobial agents. The leading presenting complaint was fever (100%) followed by chills and shiver (93%), weakness (71%) and weight loss (57%). Physical examination revealed fever in 8 (57%), splenomegaly in 11 (79%) and hepatosplenomegaly in 7 (50%) cases. Based on laboratory findings, pancytopenia was detected in 10 (71.4%) and hypoalbuminemia was detected in all (100%) of the cases. The diagnosis of visceral leishmaniasis was made by the detection of amastigote form of the parasite in the smears of bone marrow aspiration for 12 (86%) cases and of tissue (liver/spleen) biopsies for two cases. Bone marrow samples obtained from all of the patients were inoculated into NNN (Novy-MacNeal-Nicole) media and only 4 (29%) of them yielded the growth of Leishmania promastigots. Parenteral lipozomal amphotericin B was initiated to 10 immunocompetent patients at a dose of 3 mg/kg/day and to three immunosuppressive patients at a dose of 4 mg/kg/day. One immunosuppressive patient lost his life before initiation of treatment. With regard to disease progression, it was detected that two cases (of whom one was renal and one was bone marrow transplant patient) lost their lives (mortality rate: 14%), however all the other cases were cured completely. The present study comprised the highest number of visceral leishmaniasis adult cases reported in Turkey and enabled the review of disease characteristics. In conclusion, cases presenting with fever, hepatosplenomegaly, pancytopenia and hypoalbuminemia and living in endemic regions should be precisely evaluated in terms of visceral leishmaniasis.

Evaluation of four hundred and forty seven brucellosis cases.

OBJECTIVE: Brucellosis remains as a widespread zoonosis, both worldwide and in our country that causes serious public health problems with the potential to create disease in humans and animals. The aim of the present study was to examine the characteristics of brucellosis patients followed in our clinic and to compare these cases with those reported in the literature. METHODS: Four hundred and forty-seven patients who were treated in our clinic between March 2004 and March 2011 for a diagnosis of brucellosis and who were followed for one year after the completion of treatment were retrospectively examined. Data for the patients were obtained using brucellosis follow-up forms. RESULTS: Of the 447 patients, 261 (58.4%) were women, and the mean age was 48±17 years. Focal organ involvement was detected in 178 (40%) cases, with the musculoskeletal system being the leading site (30.6%), followed by the central nervous system (5.4%). Spondylodiscitis exhibited a significant correlation with an advanced age, a high erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level on admission (p=0.001, p=0.0001 and p=0.001, respectively). A significant correlation was found between sacroiliitis and a younger age (p=0.003). Relapse was observed in 35 (7.8%) cases. CONCLUSION: The present study allowed us to scrutinize the characteristics and complications of patients with brucellosis. Focal organ involvement of the musculoskeletal system was observed in the present cases, particularly spondylodiscitis and sacroiliitis. Spondylodiscitis was detected in elderly patients with high CRP and ESR values, whereas sacroiliitis was seen in younger patients. We believe that age, symptom duration and laboratory parameters should be evaluated in patients with brucellosis and that older patients in particular should be precisely examined for bone and joint complications.

Purtscher-like retinopathy related to drug-induced hypersensitivity syndrome.

PURPOSE: To report a case with Purtscher-like retinopathy related to drug-induced hypersensitivity syndrome (DIHS). DESIGN: Case report. METHODS: A 31-year-old male with fever, macula-papular rash, lymphadenopathy, and hepatitis was hospitalized. RESULTS: Eosinophilic leukocytosis, as well as cotton wool spots around the optic disc, was observed. Viral, bacteriologic, and parasitologic tests and rheumatologic markers were all negative. Given his history of antibiotic use, he was diagnosed as DIHS. On the seventh day he lost consciousness and and on the tenth day he died. CONCLUSION: Purtscher-like retinopathy might be a sign of DIHS, and should be considered in the differential diagnosis where early intervention is needed.

[A severe falciparum malaria case successfully treated by exchange transfusion as an adjunct therapy]. / Eritrosit Degisimi Destek Tedavisi ile Basarili Sekilde Tedavi Edilen Ciddi Falciparum Sitmasi

Plasmodium falciparum malaria is a type of malaria with high fatality rate despite optimal antimalarial treatment. Exchange transfusion (ET) is successfully used as a means of supportive therapy in severe P. falciparum malaria cases with hyperparasitemia. Herein, we present a case with hyperparasitemia, who received erythrocyte ET therapy due to lack of clinical response to antimalarial treatment. A 24-year-old male patient was admitted to our emergency clinic with the complaints of fever that persisted for 10 days, headache, nausea-vomiting, and impaired consciousness. Medical history revealed that he had been working in Sudan, Africa and returned back 12 days ago. On physical examination; he had fever, hypotension, tachycardia, subicterus and impaired cooperation. Laboratory examination revealed pancytopenia, elevated C-reactive protein, hyperbilirubinemia, hyponatremia, elevated creatinine level and hematuria. On thick blood smear and thin blood smear examinations, multiple (> 5%) trophozoites and gametocytes indicating P.falciparum species were observed. The case was diagnosed as P.falciparum malaria and parenteral fluid support, dopamine infusion, meropenem (IV), doxycycline (PO) and quinine sulphate (PO) were initiated in the intensive care unit. On reevaluation of the patient on the third day of hospitalization, it was observed that arterial hypotension and fever were persistent, anemia and trombocytopenia deteriorated and on thick blood smear parasitemiea was not decreased. It was decided to apply automated erythrocyte ET. After ET, patient's medical status was quickly improved and patient was discharged on the 7th day of hospitalization. In conclusion, it was noted that in addition to antimalarial treatment, erythrocyte ET may provide dramatic improvement in severe cases of P.falciparum malaria with hyperparasitemia.

[Evaluation of the ChromID ESBL agar for the detection of ESBL-positive Enterobacteriaceae and vancomycin-resistant enterococcus isolates from urine cultures]. / GSBL Pozitif Enterobacteriaceae ve Vankomisine Dirençli Enterokoklarin Idrar Kültürlerinden Erken Tespitinde ChromID ESBL Agarin Degerlendirilmesi.

Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae strains are frequent causative agents both in community-acquired infections and in nosocomial infections. The newly developed ChromID ESBL agar (bioMerieux, Marcy I'Etoile, France) is a chromogenic medium that helps rapid identification of ESBL-positive Enterobacteriaceae species from the clinical samples. The aim of this study was to evaluate the performance of ChromID ESBL agar in the rapid identification of ESBL-positive pathogens from the urine samples of the patients with urinary tract infections. A total of 672 urine samples (437 outpatients, 235 inpatients) were included in the study. All of the samples were inoculated simultaneously to 5% sheep blood agar, McConkey agar and ChromID ESBL agar media, and evaluated after incubation at 37°C for 18-24 hours. Gram-negative pathogens were tested for ESBL both by the standard combined double-disk diffusion (CDD) method using ceftazidime and cefotaxime disks and by doubledisk synergy (DDS) test. Among 672 urine cultures, 199 yielded microbial growth in routine media (sheep blood agar and/or McConkey agar), whereas 57 yielded bacterial growth in ChromID ESBL agar. When CDD method was accepted as the reference method according to Clinical and Laboratory Standards Institute (CLSI) recommendations, the sensitivity, specificity, positive and negative predictive values for ChromID ESBL agar for the detection of ESBL-positive bacteria in urinary tract infections were estimated as 97%, 92.9%, 89.1%, and 98.1%, respectively. Additionally, we also discovered that Chrom ID ESBL agar could detect vancomycin-resistant enterococci (VRE) as well as ESBL-positive bacteria, in our study. In order to investigate this observation we inoculated a total of 203 stock strains of Enterococcus spp. (118 vancomycin-sensitive, 85 vancomycin-resistant) to this medium. None of the vancomycinsensitive Enterococcus spp. did grow in ChromID ESBL medium, while 83 of the 85 resistant isolates (97.6%) did grow in the medium. As a result, it was concluded that ChromID ESBL agar medium was advantageous since it led to the growth of VRE and ESBL-positive Enterobacteriaceae isolates in different colors and helped in early identification of these two problematic bacteria. We thought that especially early detection of VRE will accelerate the establishment of necessary measures to prevent the nosocomial spread of this microorganism.

[Neurological involvement in brucellosis; clinical classification, treatment and results]. / Brusellozda sinir sistemi tutulumu; klinik siniflama, tedavi ve sonuçlar.

The aim of this retrospective study was to describe and to categorize different clinical pictures of patients with neurobrucellosis in our clinic, and present demographical and laboratory data about the patients. Hospital records of 430 patients with brucellosis between 2003 and 2009, were retrospectively reviewed. Out of 430 patients, 19 (4.4%) had neurobrucellosis. These patients were classified into four groups: Meningitis group (n= 14, 13 cases of subacute/chronic meningitis, one case of acute meningitis), encephalomyelitis group (n= 3, one case of meningoencephalomyelitis, one case of cerebellar abscess and one case of transverse myelitis), polyradicular group (n= 1, Miller-Fisher Syndrome), and others (n= 1, one case of intradural abscess). Ten patients (52.6%) were female, and the mean age of the patients was 48.8 years. About 47.4% of the patients had fever, 26% of the patients had neck stiffness and 5% of the patients were in an unconscious state. Out of 19 patients, 18 underwent lumbar puncture and they had positive brucella antibody test in cerebrospinal fluid (CSF) by standard tube agglutination method. Brucella spp. Were grown in four patient's blood culture and one patient's CSF culture. There were cranial nerve involvement in five cases, the most frequent being the sixth cranial nerve. Out of 19 patients, three recovered with sequela (paraparesis, hearing loss, dementia and sphincter disfunction) and 16 patients recovered completely. Although neurobrucellosis is most frequently presented as subacute/chronic meningitis, it may be associated with different clinical pictures. The classical triad of meningitis (fever, neck stiffness, unconsciousness) is rarely seen in brucellosis-related meningitis. Brucellosis should be kept in mind in patients with unexplained neurological findings particularly in areas where brucellosis is endemic. In addition, a current classification of neurobrucellosis, related to involved location of nervous system, clinical picture and pathogenesis, is needed.