Evaluation of DNA extraction kits for molecular diagnosis of human Blastocystis subtypes from fecal samples.

Blastocystis sp. is now recognized as one of the most common intestinal parasite in human fecal examinations. Recently, PCR-based diagnostic methods of Blastocystis infection using direct DNA extraction from fresh fecal samples with commercially available kits are reported. Several kits have been developed, but little has been done in comparing the detective sensitivity between PCR methods using the commercial kits. In this study, we compared the detective sensitivity among five commercially available kits (MagNA Pure LC DNA Isolation Kit I, Roche; QuickGene SP Kit DNA, FujiFilm; NucleoSpin Plant II, Macherey-Nagel; QIAamp DNA Stool Mini Kit, Qiagen; ZR Fecal DNA Kit, Zymo Research) and fecal culture method. In a preliminary test, the DNA isolated with two kits (FujiFilm and Macherey-Nagel) showed negative PCR, while the other three kits showed positive PCR. Then, DNA from 50 clinical samples that was Blastocystis-positive in the examination of fecal culture method were isolated with the three kits and 1.1 kbp SSU rRNA gene was detected with PCR. The positive rates of the three kits (Roche, Qiagen, and Zymo Research) were 10, 48 and 94%, respectively. The present study indicated that there is different detective sensitivity among the commercial kits, and fecal culture method is superior in detection rate and cost performance than DNA-elution kits for diagnosis of Blastocystis sp. subtypes.

Comparison of the surface and core bacteria in tonsillar and adenoid tissue with Beta-lactamase production.

Adenoidectomy and tonsillectomy, indicated for children with recurrent or persistent symptoms of infection or hypertrophy, are among the most frequent operations performed in children. This study was carried out for investigating the microbial flora of the tonsils and adenoids regarding to core and surface microorganisms and also pathogen microrganisms' beta-lactamase production rate. Cultures were taken from the core and surface of tonsils and adenoids of the 91 patients at the time of the surgery for tonsillectomy and adenoidectomy. Aerobic and anaerobic cultures were inoculated and identified. Beta-lactamase production was detected also. The most frequently isolated aerobic microorganisms were Streptococcus viridans and Neisseria spp. The number of the microorganisms isolated from the tonsil core compared to the surface of the tonsils was found statistically insignificant (P > 0.05). The number of the adenoid surface aerobic microorganisms was found higher from the adenoid core (P < 0.05). The amount of adenoid and tonsil core anaerobic microorganisms were alike. The patients' preoperative antibiotherapy whether using beta-lactam or beta-lactamase resistant were compared for beta-lactamase producing bacteria production and the number of beta-lactamase producing bacteria were found statistically insignificant (P > 0.05). The togetherness of Staphylococcus aureus and other beta-lactamase producing bacteria was found statistically significant (P < 0.05). This study demonstrates that there is polymicrobial aerobic-anaerobic flora in both adenoids and tonsils. There was a close relationship between the bacteriology of the tonsil and adenoid flora. Staphylococcus aureus and and other beta-lactamase producing bacteria may be responsible for treatment failures in patients with tonsillitis.

PCR-based subtyping of Blastocystis isolates from symptomatic and asymptomatic individuals in a major hospital in Ankara, Turkey.

The stool samples obtained from 94 patients with gastrointestinal symptoms and 109 asymptomatic individuals, who checked in due to other reasons, admitted at a major hospital in Ankara, Turkey were examined with native Lugol's iodine, trichrome, and Kinyoun's acid-fast stainings for parasitology examinations and with in vitro culture method for detection of Blastocystis. In a total of 203 stool samples tested, native Lugol's iodine and trichrome stainings could detect 12 (5.9%) and 20 (9.9%) positive samples for Blastocystis, respectively. Conversely, culture method could detect 66 (32.5%) positive samples, and this method was more sensitive compared to the both microscopic examinations (p < 0.001). Among 66 positive samples for Blastocystis, 27 were from symptomatic patients and 39 were from asymptomatic group. Subtypes (STs) were determined by PCR using seven different sequence-tagged site primers. ST3 was the most dominant in both symptomatic and asymptomatic groups and followed by ST1 or ST2. There were mixed infections with STs 1 and 2 or STs 1 and 3 in nine isolates. There was no statistical significance of the distribution of Blastocystis sp. subtypes between symptomatic and asymptomatic individuals (p > 0.05).

Impact of early appropriate antimicrobial therapy on survival in Acinetobacter baumannii bloodstream infections.

The impact of appropriate empirical antimicrobial therapy for Acinetobacter baumannii bacteraemia on patient outcomes has not been clearly established. We assessed predictors of 30-day mortality and the effect of inappropriate empirical antimicrobial treatment on mortality among patients with A. baumannii bacteraemia between July 2005 and June 2008. Initial empirical antimicrobial therapy was considered to be appropriate if the initial antibiotics that were administered within 48 h after the acquisition of a blood culture sample included at least one antibiotic that was active in vitro and when the dosage and route of administration were in accordance with current medical standards. Overall, 103 patients with nosocomial A. baumannii bacteraemia were included in the study. Appropriate empirical therapy was administered to 41.7% of patients within 48 h. The overall mortality rate was 54.4%, with rates of 39.5% and 65% for patients who received appropriate and inappropriate antimicrobial therapy within 48 h, respectively. Thus, a 25.5% reduction in the overall crude mortality rate was associated with adequate early empirical antimicrobial therapy. Multivariate analysis using a Cox regression model showed that significant independent risk factors for mortality were delayed appropriate treatment [hazard ratio (HR)=2.4, 95% confidence interval (CI) 1.3-4.2; P=0.004], development of septic shock (HR=2.6, 95% CI 1.4-4.8; P=0.004), age>65 years (HR=2.1, 95% CI 1.2-3.7; P=0.007) and mechanical ventilation (HR=3.3, 95% CI 1.5-7.4; P=0.003). It is concluded that a delay in receiving appropriate antimicrobial therapy had an adverse influence on clinical outcome in patients with A. baumannii bacteraemia.

A cluster of Klebsiella pneumoniae bacteremia in a radiation oncology ward.

BACKGROUND: We report an outbreak of genetically related strains of Klebsiella pneumoniae bloodstream infection. METHODS: The practices that were possibly related to the outbreak were investigated through direct observation and interviews with staff by infection control team. Cultures of potential environmental sources of bacteria were obtained. RESULTS: Six patients receiving intravenous medications in saline solution developed fever and shaking chills 1.5 to 4 hours after the infusion was initiated. Cultures of the blood from 4 patients yielded K. pneumoniae. Molecular characterization of K. pneumoniae done by pulsed-field gel electrophoresis revealed the same strain. CONCLUSION: Although a definite source for the outbreak could not be identified, probably environmental contamination, lack of adherence to hand hygiene practices, contamination, and cross contamination led to this outbreak.

Risk factors for nosocomial imipenem-resistant Acinetobacter baumannii infections.

OBJECTIVES: To identify the risk factors for nosocomial imipenem-resistant Acinetobacter baumannii (IRAB) infections. METHODS: A prospective case-control study, set in an 1100-bed referral and tertiary-care hospital, of all patients who had nosocomial A. baumannii infections between January 1 and December 31, 2004. Only the first isolation of A. baumannii was considered. RESULTS: IRAB was isolated from 66 (53.7%) patients and imipenem-sensitive Acinetobacter baumannii (ISAB) was isolated from 57 (46.3%) patients during the study period. The mean duration of hospital stay until A. baumannii isolation was 20.8+/-13.6 days in IRAB infections, whereas it was 15.4+/-9.4 days in ISAB infections. Of the patients, 65.2% with IRAB infections and 40.4% with ISAB infections were followed at the intensive care unit (ICU). Previous carbapenem use was present in 43.9% of the patients with IRAB and 12.3% of the patients with ISAB infection. In univariate analysis female sex, longer duration of hospital stay until infection, ICU stay, emergent surgical operation, total parenteral nutrition, having a central venous catheter, endotracheal tube, urinary catheter or nasogastric tube, previous antibiotic use, and previous administration of carbapenems were significant risk factors for IRAB infections (p<0.05). In multivariate analysis, longer duration of hospital stay until A. baumannii isolation (odds ratio (OR) 1.043; 95% confidence interval (CI) 1.003-1.084; p=0.032), previous antibiotic use (OR 5.051; 95% CI 1.004-25.396; p=0.049), and ICU stay (OR 3.100; 95% CI 1.398-6.873; p=0.005) were independently associated with imipenem resistance. CONCLUSIONS: Our results suggest that the nosocomial occurrence of IRAB is strongly related to an ICU stay and duration of hospital stay, and that IRAB occurrence may be favored by the selection pressure of previously used antibiotics.

Imipenem-resistant Pseudomonas aeruginosa: risk factors for nosocomial infections.

The aim of this study was to determine the risk factors for nosocomial infections of imipenem-resistant Pseudomonas aeruginosa (IRPA). A prospective case-control study was performed at a tertiary care hospital in Ankara from January to December 2004. The patients with nosocomial P. aeruginosa infection were included in the study. The features of the patients with IRPA infections were compared to those with imipenem-sensitive P. aeruginosa (ISPA) infections. Only the first isolation of P. aeruginosa was considered. Nosocomial infections were defined according to Center for Disease Control (CDC) criteria. IRPA was isolated from 75 (44.1%) patients, and ISPA was isolated from 95 (55.9%) patients during the study period. IRPA were most frequently isolated from endotracheal aspirate (19%) cultures (p=0.048), whereas ISPA were most frequently isolated from urine (28%) cultures (p=0.023). In multivariate analysis, a longer duration of hospital stay until P. aeruginosa isolation (odds ratio [OR], 1.027; 95% confidence interval [CI], 1.002-1.054, p=0.034), arterial catheter administration (OR, 2.508; 95% CI, 1.062-5.920, p=0.036), vancomycin (OR, 2.882; 95% CI, 1.130-7.349, p=0.027), piperacillin-tazobactam (OR, 6.425; 95% CI, 2.187-18.875, p=0.001), and imipenem (OR, 3.580; 95% CI, 1.252-10.245, p=0.017) treatment within the 14 days before isolation of IRPA were independently associated with imipenem resistance. It was concluded that treatment with imipenem, vancomycin and piperacillin-tazobactam were major risk factors for IRPA infections in hospitalized patients. The nosocomial occurrence of IRPA was also strongly related to the duration of hospital stay, arterial catheter administration.

[The relationship between Candida albicans 25S intron genotypes and antifungal susceptibilities]. / Candida albicans 25S intron genotipleri ile antifungal duyarliliklari arasindaki iliskinin arastirilmasi.

Due to the increase in the number of immunosuppressive patients, an increase in the frequency of Candida albicans infections is recorded during the recent years. C. albicans strains can be grouped into three genotypes (genotypes A, B and C) by 25S intron analysis according to the presence of a transposable group-1 intron. Genotype A isolates were found to be associated with increased resistance to flucytosine. The aim of this study was to determine the genotypic distribution of C. albicans isolates and investigate the relationship between the genotypes and antifungal susceptibility patterns. Seventy clinical C. albicans isolates were included in the study. The strains were identified by API ID 32C (bioMerieux, France), and antifungal susceptibilities were determined by ATB Fungus 2 (bioMerieux, France) system. Following DNA extraction from the isolates, polymerase chain reaction (PCR) was performed as indicated in the literature. The genotypes were determined according to the size of the amplified PCR product. For the statistical analysis of the relationship between the genotypes and antifungal susceptibility patterns, Pearson's khi square and Fisher's exact tests were performed. Among the 70 strains investigated, 35 (50%) were found as genotype A, nine (12.9%) were genotype B and 26 (37.1%) were genotype C. Nystatin, miconazole and ketoconazole susceptibilities were significantly different among the genotypes, genotype B being more resistant to these agents (p values were 0.032, 0.035 and 0.035, respectively). When the susceptibility of the strains were compared according to the presence of the transposable intron, no significant difference was observed. There was also no statistically significant difference between the genotype distribution of the isolates and flucytosine, amphotericin B and econazole susceptibilities (p values were 0.357, 0.602 and 0.051, respectively). As a result, in order to clarify the resistance mechanisms of different genotypes of C. albicans isolates, more sophisticated and large-scale studies should be performed.

PCR evaluation of false-positive signals from two automated blood-culture systems.

Rapid detection of micro-organisms from blood is one of the most critical functions of a diagnostic microbiology laboratory. Automated blood-culture systems reduce the time needed to detect positive cultures, and reduce specimen handling. The false-positive rate of such systems is 1-10%. In this study, the presence of pathogens in 'false-positive' bottles obtained from BACTEC 9050 (Becton Dickinson) and BacT/Alert (Biomérieux) systems was investigated by eubacterial and fungal PCR. A total of 169 subculture-negative aerobic blood-culture bottles (104 BacT/Alert and 65 BACTEC) were evaluated. Both fungal and eubacterial PCRs were negative for all BACTEC bottles. Fungal PCR was also negative for the BacT/Alert system, but 10 bottles (9.6%) gave positive results by eubacterial PCR. Sequence analysis of the positive PCR amplicons indicated the presence of the following bacteria (number of isolates in parentheses): Pasteurella multocida (1), Staphylococcus epidermidis (2), Staphylococcus hominis (1), Micrococcus sp. (1), Streptococcus pneumoniae (1), Corynebacterium spp. (2), Brachibacterium sp. (1) and Arthrobacter/Rothia sp. (1). Antibiotic usage by the patients may be responsible for the inability of the laboratory to grow these bacteria on subcultures. For patients with more than one false-positive bottle, molecular methods can be used to evaluate the microbial DNA in these bottles. False positives from the BACTEC system may be due to elevated patient leukocyte counts or the high sensitivity of the system to background increases in CO(2) concentration.

Risk factors for ICU-acquired methicillin-resistant Staphylococcus aureus infections.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen that causes severe morbidity and mortality in many hospitals worldwide, and MRSA infections are frequent in intensive care units (ICUs). OBJECTIVE: A prospective study was implemented to investigate the risk factors for ICU-acquired MRSA infections. METHODS: This study was conducted in surgical and neurologic ICUs from May to November 2003. The patients staying in ICUs more than 48 hours were included in the study. All of the patients were visited daily, and data were recorded on individual forms for each patient until discharge or death. Nasal swab cultures were done within 48 hours of ICU admission and repeated every week until the patients colonized with MRSA or were discharged from ICUs. ICU-acquired MRSA infection was diagnosed when MRSA was isolated from the infected site. RESULTS: Overall, 249 patients were followed during the study. MRSA infection was detected in 21 (8.4%) of these patients. The most frequent infection was primary bloodstream infection (10/21, 47%). It was followed by pneumonia (8/21, 38%) and surgical site infection (3/21, 14%). Nasal MRSA colonization was detected in 59 (23.7%) patients, and 12 of them (20.3%) developed MRSA infection. In univariate analysis, hospitalization period in an ICU, intraabdominal and orthopedic pathologies, mechanical ventilation, central venous catheter insertion, total parenteral nutrition, previous antibiotic use, surgical ICU stay, nasal MRSA colonization, and presence of more than 2 patients having nasal colonization in the same ICU at the same time were found significant for MRSA infections. In multivariate analysis; hospitalization period in an ICU (OR, 1.090; 95% CI: 1.038-1.144, P = .001), central venous catheter insertion (OR, 1.822; 95% CI: 1.095-3.033, P = .021), previous antibiotic use (OR, 2.337; 95% CI: 1.326-4.119, P = .003) and presence of more than 2 patients having nasal colonization in the same ICU at the same time (OR, 1.398; 95% CI: 1.020-1.917, P = .037) were independently associated with MRSA infections. CONCLUSION: According to the our results, hospitalization period in an ICU, presence of patients colonized with MRSA in the same ICU at the same time, previous antibiotic use, and central venous catheter insertion are independent risk factors for ICU-acquired MRSA infections. Detection of these factors helps to decrease the rate of MRSA infections in the ICUs.

The use of enzyme linked immunosorbent assay (ELISA) and direct fluorescent antibody (DFA) methods for diagnosis of Giardia intestinalis.

The aim of this study was to evaluate the value of the direct fluorescent antibody (DFA) techniques reported to have high sensitivity and specificity and the enzyme linked immunosorbent assay (ELISA) test used to determine antigens in stool samples in the routine diagnosis of Giardia intestinalis. When 44 stool samples in which G. intestinalis cysts and/or trophozoites had been seen during native Lugol examination were investigated, positivity detected with the trichrome staining method, monoclonal ELISA method and monoclonal DFA method was found to be 37 (84.0%), 39 (88.6%) and 35 (79.5%) respectively. DFA detected Crytosporidium parvum cysts in addition to G. intestinalis in one sample. Twenty-seven (61.4%) of the samples were positive with all three methods. When compared with the DFA method, the ELISA method had a sensitivity of 88.6%, a specificity of 88.8%, a positive predictive value of 79.5% and a negative predictive value of 20.0% while the trichrome staining method had a sensitivity of 85.7%, a specificity of 77.8%, a positive predictive value of 81.1% and a negative predictive value of 22.2%. There was no statistically significant difference between the DFA and ELISA tests and between the DFA test and the trichrome staining method for diagnosing G. intestinalis (p > 0.05).

A complication of brucellosis: epididymoorchitis.

BACKGROUND: Epididymoorchitis is the most frequent genitourinary complication of brucellosis. METHODS: This prospective study was conducted between February 2001 and January 2004, prospectively. Male patients diagnosed with brucellosis were included in this study and evaluated for testicular involvement. RESULTS: Epididymoorchitis was detected in 17 out of 134 (12.7%) male patients with brucellosis. Mean age of the patients was 36.9+/-7.1 years. Twelve patients (70.6%) had acute, four patients (23.5%) had subacute, and one patient (5.9%) had chronic brucellosis. The most common symptoms were scrotal pain (94%) and swelling (82%). Eleven patients had unilateral epididymoorchitis, four had unilateral orchitis and two had unilateral epididymitis. A testicular abscess was detected in one patient. Sperm analysis was performed on 14 patients. Five patients had aspermia and eight had oligospermia. Combined antibiotic therapy was started and continued for 6-8 weeks. Orchiectomy was required for two patients and granulomatous orchitis was detected in the resected specimens. Relapse occurred in only one patient. Three patients had permanent oligospermia and one patient had permanent aspermia after the antibiotic therapy. Younger age, high C-reactive protein level and blood culture positivity were statistically significant differences between the patients with and without epididymoorchitis. CONCLUSIONS: Brucellosis should be considered in the diagnosis of scrotal diseases in endemic areas. A conservative approach is usually adequate for managing brucellar epididymoorchitis. However, infertility problems may develop in these patients. Well-designed further investigations are needed to explain the relationship between brucellar epididymoorchitis and infertility in man.

Evaluation of risk factors for mortality in intensive care units: a prospective study from a referral hospital in Turkey.

BACKGROUND: The aim of the clinical practice is to decrease the mortality rate in intensive care units. Determination of the risk factors for mortality may provide useful guidance for intensive care patients. This study sought to find mortality-related risk factors in intensive care units. OBJECTIVE: To investigate risk factors for mortality in intensive care units (ICUs). METHODS: The prospective study was performed from May 2002 to November 2002 in the surgical and medical ICUs of the Ankara Numune Education and Research Hospital. Three hundred thirty-four patients who were followed in the ICUs for at least 48 hours were enrolled in this study. Those patients who died within 48 hours of ICU discharge were included in the mortality analysis. RESULTS: The overall mortality rate in the ICUs was 46.7%. Among the 334 patients, 104 (31.1%) had ICU-acquired infections. The mortality rate was significantly higher in the patients with nosocomial infections (66.3%) than in the patients without nosocomial infections (37.8%) ( P < .001). The mean age, sex, acute physiology and chronic health evaluation (APACHE) II score, trauma and intraabdominal pathology, nosocomial infection, stay in the medical/surgical ICU, coma, TISS score, use of steroid or chemotherapy, use of antibiotic, and serum urea >50 mg/dL and creatinine >1.2 mg/dL levels were associated with mortality in the univariate analysis. Eight variables were determined as independent risk factors: presence of nosocomial infection (hazard ratio (HR) 0.40; 95% confidence interval (CI), 0.27-0.61), mean age (HR, 1.01; 95% CI, 1.00-1.02), mean APACHE II score (HR, 1.99; 95% CI, 1.50-2.64), mechanical ventilation (HR, 1.98; 95% CI, 1.33-2.95), stay in the medical/surgical ICU (HR, 0.41; 95% CI, 0.27-0.61), enteral nutrition (HR, 0.43; 95% CI, 0.29-0.65), tracheostomy (HR, 0.26; 95% CI, 0.094-0.75), and use of steroid or chemotherapy (HR, 1.61; 95% CI, 1.13-2.29). Nosocomial pneumonia (HR, 0.59; 95% CI, 0.38-0.92) and sepsis (HR, 0.29; 95% CI, 0.16-0.51) were related with mortality. CONCLUSION: The most important risk factors of mortality were observed as nosocomial infection, older age, high APACHE II score, mechanical ventilation, enteral nutrition, tracheostomy, and use of steroids or chemotherapy.

Cerebellar abscess caused by Shewanella putrefaciens.

We report a case of cerebellar abscess secondary to chronic otitis by caused by Shewanella putrefaciens and localized in the cerebellar hemisphere, in a paediatric patient.

[Microbiology of the external auditory canal in patients with asteatosis and itching]. / Asteatosis ve kasintili hastalarda dis kulak yolu mikrobiyolojisi.

OBJECTIVES: We examined the microbiology of the external auditory canal in patients with asteatosis and itching and evaluated the efficacy of topical 2% alcohol and boric acid solution in patients with normal flora. PATIENTS AND METHODS: Bacteriological and mycological cultures were obtained from 76 ears of 45 patients (36 females, 9 males; mean age 41.8 years; range 17 to 66 years) presenting with normal otoscopic findings and no history of ear diseases. Treatment protocols were planned according to the culture results. Patients with normal flora were administered topical 2% alcohol and boric acid solution to relieve itching. RESULTS: Cultures yielded normal flora in 65 ears (85.5%), bacterial pathogenic flora in 10 ears (13.1%), and mycosis in one ear (1.3%). Complaints of itching decreased significantly following treatment with alcohol and boric acid solution in patients with normal flora (p<0.05). No correlation was detected between age and the severity of itching (p>0.05). CONCLUSION: Despite normal otoscopic findings, external auditory canal cultures may show pathogenic colonization in patients with asteatosis. Topical administration of alcohol and boric acid solution seems to relieve itching in patients with normal flora.

Biotypes and antimicrobial susceptibilities of Brucella isolates.

41 Brucella strains isolated from blood and cerebrospinal fluid cultures were identified to species level and biotypes detected. All of the isolates were Brucella melitensis: 2 strains of B. melitensis biotype-1 and 39 strains of B. melitensis biotype-3. In vitro activities of these strains were detected by the E test method. According to the 90% minimal inhibitory concentration (MIC90) values, the most active agent was doxycycline (MIC90 0.064 microg/ml), followed by ciprofloxacin (MIC90 0.25 microg/ml), trimethoprim-sulfamethoxazole and ceftriaxone (MIC90 0.38 microg/ml). Rifampin exhibited the highest MIC90 value (0.75 microg/ml).

Neurobrucellosis in an endemic area of brucellosis.

Central nervous system involvement occurs less than 5% of patients with brucellosis. A prospective analysis of 73 patients with brucellosis identified 13 (17.8%) neurobrucellosis cases from February 2001 to May 2002. 10 patients had chronic meningitis and 3 acute meningitis. Two patients had only psychiatric disorders. Cranial nerve involvement was observed in 3 patients (6th, 7th and 8th nerves). Three patients had positive blood cultures and 3 others had positive cerebrospinal fluid (CSF) cultures. 12 patients had positive agglutination titres in CSF. All patients received antibiotic therapy with ceftriaxone, rifampicin and doxycycline initially, and after 1 month they were continued with rifampicin and doxycycline up to 4 months. All patients were completely cured. Hearing loss developed in 1 patient as a sequela.

Arthritis and osteomyelitis due to Aspergillus fumigatus: a 17 years old boy with chronic granulomatous disease.

BACKGROUND: Invasive Aspergillus infections are frequently seen in immunocompromised patients but arthritis is a rare complication of Aspergillus infections in the absence of immune suppressive therapy, trauma or surgical intervention. CASE PRESENTATION: A 17 years old male patient with arthritis and patellar osteomyelitis of the left knee whose further investigations revealed chronic granulomatous disease as the underlying disease is followed. Aspergillus fumigatus was isolated from the synovial fluid and the tissue samples cultures. He was treated with Amphotericin B deoxicolate 0.7 mg/kg/day. Also surgical debridement was performed our patient. Amphotericin B nephrotoxicity developed and the therapy switched to itraconazole 400 mg/day. Itraconazole therapy were discontinued at the 6th month. He can perform all the activities of daily living including. CONCLUSION: We think that, chronic granulomatous disease should be investigated in patients who have aspergillar arthritis and osteomyelitis.

Venous sinus thrombosis after Proteus vulgaris meningitis and concomitant Clostridium abscess formation.

A 19-y-old woman presented with Proteus vulgaris meningitis as a complication of chronic otitis media. Despite treatment with ceftazidime and amikacin no clinical improvement was observed. Cranial MRI revealed right-sided mastoiditis/otitis media and venous sinus thrombosis. After mastoidectomy, repeat cranial MRI demonstrated abscess formation in the venous sinuses. The abscess was drained. Clostridium spp. was isolated from the abscess culture.