Survival in rhino-orbito-cerebral mucormycosis: An international, multicenter ID-IRI study.

BACKGROUND: Mucormycosis is an emerging aggressive mold infection. This study aimed to assess the outcome of hospitalized adults with rhino-orbito-cerebral mucormycosis (ROCM). The secondary objective was to identify prognostic factors in this setting. METHODS: This study was an international, retrospective, multicenter study. Patients' data were collected from 29 referral centers in 6 countries. All qualified as "proven cases" according to the EORTC/MSGERC criteria. RESULTS: We included 74 consecutive adult patients hospitalized with ROCM. Rhino-orbito-cerebral type infection was the most common presentation (n = 43; 58.1%) followed by rhino-orbital type (n = 31; 41.9%). Twenty (27%) had acquired nosocomial bacterial infections. A total of 59 (79.7%) patients (16 in combination) received appropriate antifungal treatment with high-doses of liposomal amphotericin B. Fifty-six patients (75.7%) underwent curative surgery. Thirty-five (47.3%) required intensive care unit admission (27; 36.5% under mechanical ventilation). Hospital survival was 56.8%, being reduced to 7.4% in patients with invasive mechanical ventilation. A multivariate binary backward logistic regression model identified confusion at admission (OR 11.48), overlapping hospital-acquired infection (OR 10.27), use of antifungal treatment before diagnosis (OR 10.20), no surgical debridement (OR 5.92), and the absence of prior sinusitis (OR 6.32) were independently associated with increased risk for death. CONCLUSION: Today, ROCM still has high mortality rate. Improving source control, rational therpy, and preventing nosocomial infections may improve survival in this severe infection.

Brucellosis in pregnancy: results of multicenter ID-IRI study.

Brucellosis in pregnant women is reported to be associated with obstetric complications (OCs), and adequate data for human brucellosis during pregnancy are largely lacking. We performed this multicenter retrospective cross-sectional study to evaluate the epidemiology, clinical course, treatment responses, and outcomes of brucellosis among pregnant women. The study period comprised a 14-year period from January 2002 to December 2015. All consecutive pregnant women diagnosed with brucellosis in 23 participating hospitals were included. Epidemiological, clinical, laboratory, therapeutic, and outcome data along with the assessment data of the neonate were collected using a standardized questionnaire. Data of 242 patients were analyzed. The OC rate was 14.0% (34/242) in the cohort. Of the 242 women, 219 (90.5%) delivered at term, 3 (1.2%) had preterm delivery, 15 (6.2%) aborted, and 5 (2.1%) had intrauterine fetal demise. Seventeen (7.0%) of the newborns were considered as low birth weight. Spontaneous abortion (6.1%) was the commonest complication. There were no maternal or neonatal deaths and pertinent sequelae or complications were not detected in the newborns. Splenomegaly (p = 0.019), nausea and/or vomiting (p < 0.001), vaginal bleeding (p < 0.001), anemia (blood hemoglobin < 11 g/dL; p < 0.001), high level of serum aspartate aminotransferase (> 41 IU/L; p = 0.025), oligohydramnios on ultrasonography (p = 0.0002), history of taking medication other than Brucella treatment during pregnancy (p = 0.027), and Brucella bacteremia (p = 0.029) were the significant factors associated with OCs. We recommend that pregnant women with OC or with fever should be investigated for brucellosis if they live in or have traveled to an endemic area.

Chronic Hepatitis B and Leishmania Coinfection.

Visceral leishmaniasis is an endemic disease in many parts of world, and if untreated, it is a potentially life-threatening infectious disease. It is similar to chronic liver disease because of signs and symptoms such as fever, weight loss, hepatosplenomegaly, and pancytopenia. In this study, we present a case of visceral leishmaniasis, which is known to be a chronic hepatitis B infection, that was coincidentally diagnosed with liver biopsy. Visceral leishmaniasis should be considered as an infectious disease in the differential diagnosis of chronic liver diseases.

Prevalence and associated factors of thrombocytopenia among human immunodeficiency virus-infected patients at a tertiary care hospital in Izmir, Turkey.

BACKGROUND/AIM: The aim of this study was to determine the prevalence and associated factors of thrombocytopenia in human immunodeficiency virus (HIV)-infected patients. MATERIALS AND METHODS: A cross-sectional study was conducted in a tertiary care hospital in Izmir, Turkey. All HIV-infected patients admitted to the Department of Infectious Diseases and Clinical Microbiology between 2006 and 2011 were recruited. Patients with thrombocytopenia at any time point were defined as the case group and the remaining patients were defined as the control group. RESULTS: The frequency of thrombocytopenia was 35.8%. Thrombocytopenia was more frequent in patients with acquired immune deficiency syndrome (AIDS) than in patients without AIDS (P < 0.05) and in antiretroviral-naive patients than in patients on combination antiretroviral therapy (cART) or those who had ever used cART in the past (P < 0.05). Additionally, rates of tuberculosis infection, prophylactic use of trimethoprim-sulfamethoxazole (TMP/SMX), and being anti-HCV seropositive at any time point were higher in patients with thrombocytopenia than in the control group (P < 0.05), and the case group had lower CD4+ T lymphocytes at first admission (P < 0.05). CONCLUSION: The main finding was the clear association between thrombocytopenia and advanced and uncontrolled HIV infection. Tuberculosis and HCV coinfections were also identified as associated factors for thrombocytopenia.

[Transverse myelitis associated with toxocariasis and the importance of locally produced antibodies for diagnosis]. / Toksokariyaza bagli bir transvers miyelit olgusu ve tanida yerel antikor üretiminin önemi.

Toxocariasis caused by Toxocara canis or less frequently by T.catis is a common parasitic infection worldwide. Clinical spectrum in humans can vary from asymptomatic infection to serious organ disfunction depending on the load of parasite, migration target of the larva and the inflammatory response of the host. Transverse myelitis (TM) due to toxocariasis is an uncommon illness identified mainly as case reports in literature. In this report, a case of TM who was diagnosed as neurotoxocariasis by serological findings has been presented. A 44-year-old male patient complained with backache was diagnosed as TM in a medical center in which he has admitted two years ago, and treated with pregabalin and nonsteroidal drugs for six months. Because of the progression of the lesions he readmitted to another center and treated with high dose steroid therapy for three months. After six months of follow up, improvement has been achieved, however, since his symptoms reccurred in the following year he was admitted to our hospital. Magnetic resonance imaging (MRI) examination revealed a TM in a lower segment of spinal cord. He was suffering with weakness and numbness in the left lower extremity. There was no history of rural life or contact with cats or dogs in his anamnesis. Physical examination revealed normal cranial nerve functions, sensory and motor functions. There has been no pathological reflexes, and deep tendon reflexes were also normal. Laboratory findings yielded normal hemogram and biochemical tests, negative PPD and parasitological examination of stool were negative for cysts and ova. Viral hepatitis markers, anti-HIV, toxoplasma-IgM, CMV-IgM, rubella-IgM, EBV-VCA-IgM, VDRL, Brucella tube agglutination, echinococcus antibody, autoantibody tests and neuromyelitis optica test were negative. Examination of CSF showed 20 cells/mm3 (mononuclear cells), 45 mg/dl protein and normal levels of glucose and chlorine. In both serum and CSF samples of the patient Toxocara-IgG antibodies were detected by Western blot (WB) assay. Low molecular weight bands (30-40 kDa) were detected in both of the samples by repeated WB testing. CSF revealed more intense bands suggesting local antibody production. Therefore the patient was diagnosed as neurotoxocariasis, and treated with steroid and mebendazole for six weeks. Clinical improvement was detected in the case and thoracic MRI revealed significant improvement in myelitis signs two months after treatment. In conclusion, toxocariasis should be considered in the differential diagnosis of TM although the involvement of central nervous system is rare and serological testing should be performed properly in the serum and CSF samples for the diagnosis.

Clinical and microbiological findings of infective endocarditis.

INTRODUCTION: Infective endocarditis (IE) is an infection that develops on the endothelial surface of the heart. Endocarditis is a major problem for the clinicians despite of the developments in diagnostic, surgical, and medical treatment methods. In this study, we aimed to evaluate symptoms, laboratory findings, treatment options, and clinical endpoint of the patients who were diagnosed with IE in a tertiary healthcare organization according to the literature data. METHODOLOGY: Between January 2006 and March 2013, 80 IE patients who were diagnosed and treated in accordance with modified Duke criteria were enrolled in the study. Demographic features, symptoms, and laboratory and echocardiographic findings were recorded after reviewing the patient files. RESULTS: The mean age of the patients was 51.3 ± 16.0, and IE was more common in men (n = 56; 70%). Of 41 patients who had positive blood cultures, 20 patients had Staphylococcus spp. (48.7%) and 8 patients had Streptococcus spp. (19.5%). Brucella spp. was isolated from 5 patients (12.2%). While 48.7% (n = 39) of the patients had cardiac complications, 22 patients (27.5%) had embolic complication. Hospital mortality was observed in 20 patients (15%). CONCLUSIONS: In our patients, endocarditis was seen at a young age, and staphylococci were the most frequently isolated microorganism from blood culture. There were more patients with Brucella endocarditis compared to the general population. Complications are frequently seen in the course of endocarditis, and they cause problems for the clinicians during follow ups due to the high mortality rate of IE.

[Evaluation of clinical and laboratory findings of adult visceral leishmaniasis cases]. / Eriskin viseral leysmanyaz olgularinin klinik ve laboratuvar bulgularinin degerlendirilmesi.

Visceral leishmaniasis (VL, kala-azar) is a zoonotic infection caused by Leishmania species which are transmitted to humans by the bites of infected female phlebotomine sandflies. Leishmania infantum is the responsible species of VL in Aegean, Mediterranean, and Central Anatolia regions of Turkey mainly observed sporadically in pediatric age groups. The aim of this study was to evaluate the clinical and laboratory findings of adult patients with VL who were admitted to our hospital. A total of 10 patients (3 female, 7 male; age range: 18-67 years, mean age: 39.3 ± 16.51) followed in the infectious diseases clinic of the hospital between 2000 and 2013 were evaluated retrospectively. The diagnosis of VL was based on the presence of appropriate clinical and physical examination, as well as biochemical findings, positive serological test results (indirect fluorescent antibody test, and rK39 rapid antigen test) and/or detection of amastigote forms of parasite in the bone marrow aspiration samples. Of the cases three were diagnosed with both bone marrow and serology positivity, five with bone marrow positivity and one of each only with liver biopsy and positive serology result. Time interval from onset of the symptoms until the establishment of the specific clinical diagnosis was ranged from 2 to 12 weeks. The most frequent initial symptoms were fever, fatigue and abdominal distension. None of the patients had immunosupressive conditions such as HIV infection, corticosteroid use, immunosupressive treatment, or transplantation. All the patients were from Aegean region and six were living in rural areas. In all cases, hepatosplenomegaly, increased erythrocyte sedimentation rate, albumin/globulin ratio inversion, anemia, leukopenia and among nine cases trombocytopenia were detected. In one case acute renal failure has been developed before treatment and the patient was admitted to dialysis program. Bacterial superinfection occurred in two cases. Patients were treated with either meglumine antimonate (Glucantime(®), 20 mg/kg/day, intramuscularly for 28 days) or liposomal amphotericin B (3 mg/kg/day, intravenously for the first 5 days, then on 14(th) and 21(st) days) according to the availability of drugs. During one year follow-up period all of the patients improved and no recurrence was seen in any patient. In conclusion, among adult patients with fever uncontrolled within 2-week course of ampiric antibiotic treatment without any infectious focus or malignancy, VL should also be considered.

A Case of Healthcare Associated Pneumonia Caused by Chryseobacterium indologenes in an Immunocompetent Patient.

Chryseobacterium indologenes is nonmotile, oxidase, and indole positive Gram-negative aerobic bacilli which is widely found in plants, soil, foodstuffs, and water. It can colonize hospital environment due to ability to survive in chlorine-treated water supplies. Chryseobacteria can also colonize patients via contaminated medical devices such as respirators, intubation tubes, humidifiers, intravascular catheters, and prosthetic valves. Immune suppression, comorbidities, use of broad-spectrum antibiotics, and extreme age are other important risk factors for Chryseobacterium infections. We report a case of an 82-year-old male admitted to our hospital with the complaint of altered mental status with history of trauma, and recent orthopedic and neurosurgery operations. He was transferred to neurosurgery intensive care unit due to respiratory failure. Urine culture yielded extended spectrum beta lactamase (ESBL) (+). E. coli and C. indologenes were isolated from transtracheal aspirate. He was treated with ertapenem, and levofloxacin and discharged with full recovery.

Gemella morbillorum Endocarditis.

Infective endocarditis caused by Gemella morbillorum is a rare disease. In this report 67-year-old male patient with G. morbillorum endocarditis was presented. The patient was hospitalized as he had a fever of unknown origin and in the two of the three sets of blood cultures taken at the first day of hospitalization G. morbillorum was identified. The transthoracic echogram revealed 14 × 10 mm vegetation on the aortic noncoronary cuspis. After 4 weeks of antibiotic therapy, the case was referred to the clinic of cardiovascular surgery for valve surgery.

Brucellar spondylodiscitis: comparison of patients with and without abscesses.

Brucellosis is an important cause of spondylodiscitis in endemic areas. Brucellar spondylodiscitis is a serious complication because of its association with abscess formation. Prospective studies comparing patients with and without abscesses are lacking. The objective of this study was to determine the frequency and demographic, clinical, laboratory, and radiological features of brucellar spondylodiscitis and to compare patients with and without abscesses regarding treatment and outcome. Out of 135 consecutive patients with brucellosis, 31 patients with spondylodiscitis were recruited for the study. Patients were grouped according to magnetic resonance imaging findings. The frequency of spondylodiscitis was 23.0 %. Sites of involvement were lumbar (58.1 %), lumbosacral (22.6 %), cervical (9.7 %), thoracolumbar (6.5 %), and thoracic (3.2 %). Abscesses occurred in 19 (61.3 %) patients and were associated with low hemoglobin levels. Medical treatment included a combination of streptomycin (for the first 3 weeks), doxycycline, and rifampin. The total duration of treatment was 12-39 (mean 17.0 ± 8.5 SD) weeks. By 12 weeks of treatment, evidence of clinical improvement (67 vs. 28 %) and radiological regression (92 vs. 50 %) was significantly greater in patients without abscesses. The duration of treatment was longer if an abscess was present. Two female patients with abscesses required surgical intervention. Both patients presented with high fever, neurologic deficit, and high Brucella standard tube agglutination test titers. Each patient should be evaluated individually, based on clinical findings, laboratory data, and radiological results, when undergoing treatment for brucellar spondylodiscitis. If abscesses are found, a longer course of treatment and even surgical intervention may be needed.

[Attitudes and side effects related to pandemic influenza A (H1N1) vaccination in healthcare personnel]. / Hastane Personeline Pandemik Influenza A (H1N1) Asi Uygulamasinin Ardindan Asilama Hakkindaki Görüsler ve Gözlenen Yan Etkiler.

The aims of this study were to evaluate the attitudes towards H1N1 vaccination and to determine the safety and side effects following 2009 pandemic influenza A (H1N1) vaccination. Pandemic influenza vaccine had been administered to the healthcare personnel in our research and training hospital in December 2009. The rate being vaccinated was established as 40% (800/2000). Four months following vaccination, the opinions about vaccination were asked to the healthcare workers, and also side effects were questioned to the vaccinated group. Two different questionnaires (for vaccinated and unvaccinated subjects) were delivered to the volunteers who agreed to participate in the study. Demographic features, reasons related to being vaccinated or not, were questioned. The vaccinated group was also questioned for the presence of chronic diseases, previous vaccinations (pandemic/seasonal influenza), local or systemic reactions that develop after vaccination. A total of 332 volunteers participated in the questionnaire. Of them 247 (74.4%) were vaccinated and 85 (25.6%) were unvaccinated. Male/female ratio of the participants was 1.2, and 55.7% of them were older than 30-year-old. Most of the participants (82.8%) were highly educated (high school and faculty-graduated). Vaccination rates were found statistically significant in advanced age group compared to young adults (p= 0.042); in male gender compared to females (p= 0.001) and in parents compared to subjects who didn't have children (p= 0.021). Vaccination rates were observed to be higher (57.5%) in non-medical staff (cleaning employers, administrative personnel, etc.) than the physicians (29.1%) and nurses (13.4%), and the rate was also high (54.7%) in personnel who worked in intensive care units, emergency department and administrative units than the personnel who worked in the clinics of internal medicine (22.3%) and surgery (23.1%) (p= 0.001). The most important causes of rejecting vaccination were being afraid of the side effects (69.4%) and not believing the effectiveness of the vaccine (56.4%). The leading causes of accepting vaccination were worries about infecting their family (60.3%) and being in a risk group (54.3%). After vaccination, local reactions (pain, swelling and redness at the vaccination site) were described in 43.3% and systemic reactions (weakness, fatigue, muscle aches, influenza-like symptoms, etc.) were described in 43.7% of the subjects. Severe side effects such as vasculitis, neuritis, encephalomyelitis, Guillian-Barre syndrome and anaphylactic reaction were not observed in any of the vaccinated cases. It was detected that worries about the safety of vaccine had negative impact for vaccination. Since no serious side effects were detected related to vaccination, it was concluded that the vaccine was safe. In spite of the scientific proofs, negative concerns about the safety of the vaccines can unfavorably affect the vaccination campaigns and can jeopardize efforts of influenza control. As a result, data collection systems about the safety and side effects of the vaccine all over the country and regular reports about these data may more efficiently guide vaccination programs in the future.

Evaluation of real-time PCR method for rapid diagnosis of brucellosis with different clinical manifestations.

In this study, we tested the advantages of TaqMan real time PCR technique and compare it to conventional methods using serum samples from patients with different clinical forms of brucellosis. A total of 50 patients were included in the study. Blood culture using BACTEC 9240 system, Standard Wright's tube agglutination, and real time PCR methods were used. Control blood samples from 30 people with no history of brucellosis or exposure to Brucella spp. were examined too. Serological assay was positive for 49 patients (98%). Forty-four (88%) of the 50 patients had a positive PCR result, whereas Brucella spp were isolated from blood cultures of 18 patients (36%). STA test was all positive for focal brucellosis. Real time PCR test was positive in 9 patients with focal disease (90%), whereas blood culture was positive only in 4 patients (40%). The sensitivity, specificity, positive and negative predictive values of the real time PCR method were calculated as 88%, 100%, 100%, and 83%, respectively. Our results suggest that the high sensitivity and specificity of real time PCR method make it a useful tool for diagnosis of brucellosis with different clinical manifestations.