Molecular epidemiology of the Bacillus anthracis isolates collected throughout Turkey from 1983 to 2011.

The main perspective of this study was to determine cross-transmissions amongst anthrax cases and provide detailed information regarding the genotypes of Bacillus anthracis isolates circulating in Turkey. A total of 251 B. anthracis isolates were obtained from human (93 isolates), animal (155 isolates), and environmental (three isolates) samples in various provinces of Turkey. All isolates were susceptible to quinolones, vancomycin, tigecycline, and linezolid, but not to ceftriaxone. Excluding human isolates, one of the animal isolates was found to be resistant to penicillin, erythromycin, and doxycycline. Multiple-locus variable-number tandem repeats analysis including 8 loci (MLVA8) revealed 12 genotypes, in which genotype 43 was observed at the highest frequency (41.8 %), followed by genotype 35 (25.5 %) and genotype 27 (10.4 %). Major subtype A3.a was the predominant cluster, including 86.8 % of the isolates. The MLVA25 analysis for the 251 isolates yielded 62 different genotypes, 33 of which had only one isolate, while the remaining 29 genotypes had 2 to 43 isolates, with a total of 218 isolates (86.9 %). These findings indicate very high cross-transmission rates within anthrax cases in Turkey. The genotypes diagnosed in Turkey are populated in the A major cluster. Penicillin prescribed as the first-choice antibiotic for the treatment of anthrax is still effective.

Pulsed-field gel electrophoresis characterization of Bordetella pertussis clinical isolates circulating in Turkey in 2001-2009.

Our purpose was to evaluate the natural epidemiological history of circulating Bordetella pertussis clinical isolates in Turkey, comparing isolates by means of pulsed-field gel electrophoresis (PFGE) profiles according to years, geographic regions, vaccination status, and demographic characteristics. We analyzed genotypically a collection of 92 clinical isolates recovered during the period 2001-2009 at the National Pertussis Reference Laboratory by PFGE. A total of 61 genotypes were identified among the 92 isolates. Fifteen of 61 genotypes were a cluster including 46 isolates, and the remaining 46 genotypes were unique. The clustering rate was 50% (46/92). The size of the cluster varied from 2 to 14 clinical isolates. There was no association between clustering rates and age, gender, or quarterly season. The clustering rate was significantly higher in 2006. When the isolates were grouped according to similarity coefficient higher than 85%, 89 (96.7%) of the 92 isolates were clonally related. There was one major group including 65.2% of the isolates mainly observed. This is the first study on the molecular characterization of B. pertussis isolates in Turkey. We consider that this study lays a good foundation for further monitoring of the circulating B. pertussis clinical isolates in Turkey.

Quercetin both partially attenuates hydrogen peroxide-induced toxicity and decreases viability of rat glial cells.

Quercetin is one of the most ubiquitous flavonoids in foods of plant origin. Although quercetin is generally considered to provide protection against oxidative injury, recent studies have shown to be cytotoxic to many cell types. We intended here to determine whether quercetin protects against H2O2-induced toxicity and/or affects viability of rat mixed glial cells. The cells were obtained from 1-3 day olds rat brains and incubated in a humidified atmosphere of 5% CO2, at 37 °C in flasks. In the quercetin groups, different quercetin concentrations (1, 10, 50, 75 or 100 µM) were applied alone for 24 h. For H2O2 cytotoxicity group, the glial cells were treated for 3 h with 100 µM H2O2 which induced 75% cell death. In another group, the cells were treated with 100 µM H2O2 plus respective quercetin concentrations simultaneously for 3 h, the medium was removed and refed for 24 h. MTT test was then applied and statistical significance was ascertained by one way analysis of variance, followed by Tukey's multiple comparison test. Quercetin starting from 50 µM decreased the glia survival significantly. In H2O2 plus quercetin co-treated groups, both 75 and 100 µM quercetin attenuated toxic effect of H2O2 by 15%. In conclusion, quercetin both partially protects H2O2-induced gliotoxicity and decreases rat glial cell viability in primary culture.

Legionnaire's disease: a nosocomial outbreak in Turkey.

Six nosocomial cases of Legionella pneumophila occurred over a two-week period, with one further case being diagnosed retrospectively after 30 days. Strains isolated from the hospital water system were clonally related to a single sputum isolate. A sero-epidemiological investigation into legionella exposure amongst staff and inpatients was undertaken at the eight-year-old Inonu University Medical Centre in Turkey, which has 600 beds and central air conditioning. There is no disinfection programme for the hospital water system. A total of 500 serum samples (400 hospital staff and 100 inpatients) were screened for antibody to L. pneumophila by enzyme-linked immunosorbent assay (ELISA). Seroreactive cases were confirmed by a four-fold antibody rise in ELISA, a high indirect immunofluorescent assay (IFA) antibody titre or a positive urinary antigen test. ELISA showed that 24 (6%) of the 400 hospital staff and seven (7%) of the 100 inpatients had antibody titres higher than the cut-off value. ELISA-seroreactive cases were followed for two to four weeks. Of these subjects, seven (three patients and four staff) showed a four-fold rise in antibody titre by ELISA, six (three patients and three staff) had a high IFA titre, three patients with pneumonia had a positive urinary antigen test, and one of these patients also had a positive sputum culture. In addition, 22 water distribution systems were screened for the presence of L. pneumophila by culture. L. pneumophila was isolated from 15 sites. Pulsed-field gel electrophoresis typing indicated that all strains isolated from water systems were identical and clonally related to the strain isolated from sputum. Superheating and flushing of water systems were undertaken with legionella being re-isolated from four sites. Repeated superheating and flushing eliminated legionella completely. This study demonstrated that rapid detection of L. pneumophila and adequate superheating and flushing of water systems are effective for elimination and reduction of spread of this organism.

[Antimicrobial susceptibility and serotype distribution of pneumococci strains isolated from meningitis patients]. / Menenjitli hastalardan izole edilen pnömokoklarin serotip dagilimi ve antibiyotiklere duyarliliklari.

Treatment of life threatening pneumococcal infections such as meningitis has recently become problematic due to the emergence of antibiotic resistant strains. Antimicrobial susceptibility data usually derived from the studies that included all clinical pneumococcal isolates. However, resistance patterns of this microorganism isolated from meningitis cases in our country are not exactly known. The aim of this study was to determine the antimicrobial susceptibility and serotypes of Streptococcus pneumoniae strains isolated from meningitis cases. This retrospective study was designed in three university hospitals in Turkey and 72 pneumococci isolated from patients with meningitis were evaluated. In this study disk diffusion test and E-test methods were used to determine the susceptibility of pneumococci to some antibiotics. All S. pneumoniae isolates were serotyped using Quellung reaction. Although resistance for oxacillin was found by disc diffusion method in 11 isolates, only six of them were found to be resistant by E-test. By the latter procedure, no resistance was recorded against ceftriaxone and meropenem, while chloramphenicol resistance was found as 1.4%. In our study, erythromycin, ciprofloxacin and levofloxacin resistance were 2.8%, TMP-SMX resistance was 26.4%, while no vancomycin resistance was detected by disk diffusion. In evaluation of 72 pneumococci, we found 16 different serotypes and four isolates could not be serotyped. The serogroup 23 (n: 19) was the most common one followed by serotype 19 (n: 9) and serotype 14 (n: 7). Of six resistant isolates, three pneumococci were serogroup 23 and the remaining were from three different serotype/serogroups 11, 14 and 19. As a result penicillin resistance in pneumococci isolated from meningitis was low and there was no resistance to ceftriaxone. It seems that ceftriaxone is an appropriate choice for empirical treatment of meningitis in our patients. These findings also revealed that pneumococcal polysaccharide capsule vaccines in use cover most of the invasive pneumococcal serotypes.

Postoperative changes in serum cytokines profile and nitric oxide levels in patients with cystic echinococcosis.

The aim of the present study was to examine serum cytokines and nitric oxide (NO) levels in patients with cystic echinococcosis (CE). 28 patients with CE were studied and all underwent surgery. Serum levels of tumour necrosis factor-alpha (TNF-alpha), interleukin IL-1beta, receptor of soluble IL-2R (sIL-2R), IL-6, IL-8, nitrate/nitrite, and C-reactive protein (CRP) were determined before and after induction of treatment. Data were compared with those obtained from 28 healthy volunteers. IL-6 was elevated in all CE patients (100%). IL-8 was increased in 11/28 (39.3%). Increased levels of IL-2R and TNF-alpha were found in a limited number of them particularly those showing cysts in the central area of the liver (5/28, 6/28). IL-1beta level was not elevated in any patient except in secondary severe CE. CRP and nitrate/nitrite levels were also increased. A positive correlation between CRP and IL-6 (r = 0.74; p < 0.001) was found confirming the link between inflammation due to CE and activation of monocytes. All patients completely recovered and the levels of the studied parameters reverted to normal levels except one patient in whom severe recurrent disease occurred two years after the first operation. These results suggest that there are different immunoregulatory events and cytokines response during CE and may be in part related to slight monocytosis and in part to Th2 activation. IL-6, NO and CRP were unambiguously involved in the host parasite interaction and therefore may be useful markers in monitoring CE management and evaluating surgical stress.

Nosocomial infections in a new medical center, Turkey.

Nosocomial infection was found in 255 (2.5%) of 10,164 inpatients in a new medical center with a 310-bed capacity. The infection rate was 12.5% in the intensive care unit, 9.5% in neurology, 5.5% in general surgery, and 4.0% in orthopedics. Rates in the other services were lower. Hospital-acquired infections in our medical center frequently involved multiply resistant Enterobacteriaceae and staphylococci.

Detection and typing of extended-spectrum beta-lactamases in clinical isolates of the family Enterobacteriaceae in a medical center in Turkey.

To determine and type the extended-spectrum beta-lactamases (ESBLs) among the family Enterobacteriaceae in a medical center, a total of 668 clinical isolates were screened. Of the 668 isolates, the 80 strains were presumptively defined as ESBL producers according to the result of disk method using ESBL marker antibiotics (aztreonam, ceftazidime, and cefoxitin). These 80 strains were retested with the double-disk synergy test (DDST), the E-test ESBL strip, a 5-microg ceftazidime disk, and agar dilution MICs of ceftazidime with and without clavulonic acid. Isoelectric focusing was performed to confirm ESBL production and type the beta-lactamases. By evaluation of the results of all tests used for ESBL detection together with isoelectric focusing, 33 (4.9%) of the 668 isolates were described as ESBL producer. The positive results of the agar dilution test, DDST, the E-test strip, and 5-microg ceftazidime disk were 32, 26, 27, and 26 of the 33 strains, respectively. ESBL positivity was 48.8% in Klebsiella species, 15.4% in Citrobacter species, 4.9% in Enterobacter species and 1.1% in Escherichia coli strains. The ESBL enzymes frequently determined were SHV-2/6-like (pI 7.6), SHV-5-like (pI 8.2), SHV-4-like (pI 7.8), and SHV-3-like (pI 7). SHV-derived enzymes were commonly observed in Klebsiella spp whereas TEM-related enzymes were seen in E. coli strains. The results of this study indicated that SHV-2/6-derived (pI 7.6) ESBL expression among the isolates of the family Enterobacteriaceae is an important problem in our medical center.

Molecular epidemiology of tuberculosis in Turkey.

Our objective was to determine the extent of fingerprint pattern diversity of Mycobacterium tuberculosis isolates from Turkey. Of the 320 patient isolates, 81 (25.3%) carried

Methicillin-resistance among Turkish isolates of Staphylococcus aureus strains from nosocomial and community infections and their resistance patterns using various antimicrobial agents.

The purposes of this study were to determine the prevalence of Turkish isolates of methicillin-resistant Staphylococcus aureus (MRSA) in nosocomial and community infections and their antibiotic resistant patterns. The oxacillin disk diffusion method for the detection of methicillin resistance and the Kirby-Bauer disk diffusion for antibiotic susceptibility tests were used. A total 383 S. aureus strains were identified from different patients. The prevalence of methicillin resistance among S. aureus strains was 31.3% (120/383). The proportions of MRSA isolated from nosocomial and community infections were 26.4% (46/174) and 35.4% (74/209), respectively. The resistance rates of MRSA to other antibiotics were as follows: 71% resistant to erythromycin, 54% to clindamycin, 52% to gentamicin, 44.5% to trimethoprim-sulfamethoxazole and 36% to ciprofloxacin. No strain resistant to vancomycin was recorded in this study.

Bacteriological, clinical and epidemiological characteristics of hospital-acquired Acinetobacter baumannii infection in a teaching hospital.

Over an 18 month period, the bacteriological, clinical and epidemiological characteristics of nosocomial Acinetobacter baumannii infections in a teaching hospital were studied. Typing studies were performed on 38 strains isolated from 36 patients. Twenty-two of the strains were isolated during the three outbreaks. Surgery, catheterization, mechanical ventilation, and antibiotic therapy for adult patients and respiratory distress syndrome, mechanical ventilation, and prematurity for paediatric patients were the main risk factors identified. All isolates were resistant to penicillins (except ampicillin-sulbactam), cephalosporins, gentamicin, and aztreonam but susceptible to carbapenems and colistin. Resistance to tobramycin, ciprofloxacin, ampicillin-sulbactam, trimethoprim-sulfamethoxazole, and amikacin was variable. Antibiotyping, arbitrarily-primed polymerase chain reaction (AP-PCR) and the pulse-field gel electrophoresis (PFGE) indicated the epidemiological relationship. The outbreak strains, demonstrated genetic distinction between our three outbreaks and isolates from specific areas in the hospital.

Antiproliferative properties of the lazaroids U-83836E and U-74389G on glioma cells in vitro.

The 21-aminosteroids (lazaroids) are a new family of steroid compounds that inhibit lipid peroxidation reactions. They are novel antioxidant agents, which have been shown to have antiproliferative properties on cancer cells and also are thought to prevent free radical-mediated blood-brain barrier damage. In order to understand the effect of lazaroids on glioma, we tested U-83836E and U-74389G at doses ranging between 0.1 100 m mM on primary cultures of glioblastoma multiforme from three patients, rat C6 glioma cell line, and 5 th subculture established from one of the patients. The effects of both compounds on cell proliferation were determined using 3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) colorimetric assay. U-83836E in the primary cultures was found to have 50% inhibitory concentrations (IC50 ) of 6.30, 6.75 and 6.50 m mM, respectively. The IC50 value of U-74389G was calculated as 91 m mM in only one of the patients. On C6 glioma cells, while the IC50 of U-83836E was 45 m mM, U-74389G showed no cytotoxic effect. On the 5 th subculture, U-83836E had an IC50 of 37.5 m mM, but the cytotoxic effects of U-74389G was less than in that of the primary culture. In conclusion, these compounds were found to be more cytotoxic in primary culture than the cell lines and there were also differences between their members in the inhibition of cell survival.

Non-hindbrain-related syringomyelia. Obstruction of the subarachnoid space and the central canal in rats. An experimental study.

BACKGROUND: The aim is to determine the mechanism of non-hindbrain-related syringomyelia in experimental models. The effects of obstruction of central canal and subarachnoid space on occurrence of cavities were discussed. METHODS: 31 Sprague-Dawley rats were used with eight (Group D) as a control. In 10 rats (Group A) 1.5 microl kaolin was microinjected into the dorsal columns and central gray matter of the spinal cord at the level of Th6-10. In 10 rats (Group B) 0.1 cc kaolin was injected into the subarachnoid space at the same level. In 3 rats (Group C), 1.5 microl kaolin was administered into both dorsal midline of the spinal cord and the subarachnoid space. RESULTS: In Group A, histological examination revealed cystic cavity and dilatation of the central canal in five rats; denuded ependymal line and multicystic formations in ependymal and periependymal areas in seven rats. In Group B, denuded ependymal line in three rats and microcystic formations in ependymal and periependymal areas in four rats were revealed. In Group C, there were microcystic formations in two rats and syrinx cavity in one rat. CONCLUSIONS: Developments leading to occurrence of cavities are focused on the central canal in all groups. These models indicate that the CSF-flow is from the subarachnoid space to the central canal leading to changes of cavities. In cases of obstruction of the subarachnoid space or the central canal, the occurrence of syrinx cavity initially is due to increased CSF (cerebrospinal fluid) pressure in the central canal. Flow changes in spinal cord is indicated by this study.

Instrumentation for posterior stabilisation of cervical traumatic and degenerative disorders: bullet-shaped implant and titanium cable.

BACKGROUND: Numerous implants for posterior stabilisation of cervical spine have been described so far. The aims of all these implants and techniques are rigid spinal stabilisation without neurologic damage, restoration of neuroanatomy and excellent radiological studies in postoperative period. The objective of this study was to determine the effectively and clinical safety of this system. METHODS: We conducted a retrospective analysis of patients treated with posterior stabilisation system for the stabilisation of traumatic and osteodegerative disorders of lower cervical spine in our department. This posterior cervical stabilisation system consist of titanium bullet-shaped implant (Ti-Frame) and titanium cables (sof' wire). RESULTS: All patients underwent only posterior fixation except 2 (anterior decompression and posterior stabilisation in 2 stages) and postoperative early immobilisation was allowed with Philadelphia collar in all patients. At the follow-up period 15.2 months (9-25 months), none of the patients had superficial or deep infection, implant resection or failure. CONCLUSIONS: In conclusion, this system (Ti-frame and titanium cables) is a simple, safe and effective system for posterior cervical stabilisation in patients with traumatic and osteodegenerative disorders due to provide rigid fixation and allow CT and MR imaging without the significant artifact.

Multiple nocardial abscesses of cerebrum, cerebellum and spinal cord, causing quadriplegia.

In this paper we present a case of a diabetic patient with nocardial abscesses of cerebrum, cerebellum and the spinal cord. The present case is the first case in the literature of solitary intramedullary abscess in cervical spinal cord, causing tetraplegia. Nocardia asteroides grew in a culture of the abscess pus. After either surgical excision or drainage of lesions, a triple combination regimen of chemotherapy (amikacin, ceftriaxone and trimethoprim-sulfamethoxazole) was given, but the patient was lost in the postoperative period. This case gives suggestive evidence of an association between cervical spinal cord involvement and poor prognosis in CNS nocardiosis.

Management of glioblastoma multiforme: with special reference to recurrence.

Between 1985 and 1995, 46 patients underwent craniotomy for glioblastoma multiforme. The mean age was 47, varying from 9 to 71 years. The influence of such prognostic factors as age, preoperative Karnofsky score, extent of resection, tumour site, tumour size, radiotherapy, reoperation as well as initial symptoms upon survival were studied. Of these, gross complete removal, radiotherapy, preoperative Karnofsky score, and reoperation were shown to be statistically significant to the survival time according to logrank and univariate tests. However, age, preoperative Karnofsky score, tumour size and temporal localisation remained as significant factors in multivariate analysis. The overall median survival was 53 weeks, with no patients surviving more than 3 years. Of the patients, 41% survived over a year and 8.6% lived over two years. Twenty-six patients developed a recurrent mass after an interval of 32 weeks. The median interval time from operation to recurrence was longer in those patients who underwent gross removal than in those who had a subtotal resection, 28.2 against 20 weeks (P < 0.05). Of patients who had a recurrent mass, 16 were reoperated on, with a subsequent median survival time of 26.5 weeks. Our experience suggests that the survival of patients with glioblastoma depends on many factors, including radical surgery as an initial step. In addition, the gross total removal of the tumour also delays the development of recurrence.

The effects of anticancer drugs in combination with nimodipine and verapamil on cultured cells of glioblastoma multiforme.

The presence of the cellular multidrug resistance (MDR1) gene and its product, P-glycoprotein (Pgp), is thought to be a mechanism for the failure of chemotherapy in cancer patients. Calcium channel blockers have been shown to sensitise cancer cells to anticancer drugs by reversing Pgp expression in cell lines. The interactions between anticancer drugs such as carmustine (BCNU), vincristine (VCR) and procarbazine (PCB) and calcium channel blockers such as nimodipine and verapamil on cultured cells of glioblastoma from eight patients were therefore tested. Pgp expression was examined immunohistochemically using C219 monoclonal antibody in cytospin preparation. The cytotoxicity of the drugs was screened using microculture tetrazolium assay. The cells from five patients showed positive immunoreaction for Pgp. Nimodipine showed growth-inhibitory activity against glioblastoma cells at a rate of 16.55-26.88% (P < 0.05), but a similar effect was not observed with verapamil. While antiproliferative effects of BCNU were around 20.91-45.09% (P < 0.05) on the cells from seven patients, VCR was the most effective agent in inhibition of cell growth at a rate of 26.43-48.47% (P < 0.05). The response of the cells from five patients to PCB was from 11.98 to 16.32% (P < 0.05). When used together, nimodipine further enriched cytotoxicity of the anticancer drugs up to 11.14-40.85% (P < 0.05) without relation to Pgp expression. In conclusion, the enhancement of cytotoxicity of anticancer drugs by nimodipine suggests that there might be a synergy between anticancer drugs and nimodipine in the inhibition of glioma cell growth.

The deletion of 22q13 region in both intracranial and spinal meningiomas in a patient (case report).

We present a 69 year old man with two simultaneous meningiomas in different compartment of neural axis, in both of which 22q13 locus is lost. Histologically the two tumours appeared to be different; meningotheliomatous and transitional with psammoma bodies, respectively. No numerical or structural chromosome abnormalities were seen in karyotype analysis of the cultured spinal and cranial meningioma samples. Since long arm structural aberrations and/or whole loss of chromosome 22 are frequently reported abnormalities of meningiomas, the tumours were also analysed by fluorescence in situ hybridisation (FISH) with different colour-labelled probes in respect to relevant chromosome. The metaphases and interphase nuclei of the samples were evaluated by the combined biotinylated 22q11 and digoxigenin-labelled 22q13 locus specific FISH probes, and 22q13 deletion was revealed in both of spinal and cranial tumour cells. In conclusion, since both tumours from the presented case show the same genetic alterations, multiplicity may be derived from the same clone of cells, and support the theory of development of multiple meningiomas from the spreading of tumour cells via cerebrospinal fluid as a possible mechanism.

New derivatives of benzimidazole and their antimicrobial activity.

Azolium salts and neutral 2-aryl derivatives of benzimidazole, benzothiazole and benzoxazole were synthesized and compounds were identified by 1H and 13C NMR spectroscopy and microanalytical methods. In this work the salts 1 and the neutral compounds 2 were evaluated for their in vitro antimicrobial activity against standard strains: Enterococcus faecalis (ATCC 29212), Staphylococcus aureus (ATCC 29213), Escherichia coli (ATCC 25922), Pseudomonas aeruginosa (ATCC 27853), Candida albicans and Candida tropicals. The compounds 1f, 1g, 1l, 1m, 1n, 2a, 2b, 2c, 2e, 2f showed antimicrobial activity against Enterococcus faecalis (ATCC 29212), Staphylococcus aureus (ATCC 29213), Escherichia coli (ATCC 25922), Pseudomonas aeruginosa (ATCC 27853), Candida albicans and Candida tropicals, with minimum inhibitory concentrations (MICs) ranging between 50 to 200 mg/mL. Compounds 1f, 1g, 1l, lm, 2b, 2c showed the highest activity. Benzothiazolium and benzoxazolium salts were more active than 1,3-disubstituted benzimidazolium salts and neutral 2-substituted benzimidazole, benzothiazole and benzoxazole derivatives.

Cytokine profile and nitric oxide levels in sera from patients with brucellosis.

The aims of this study were to investigate the serum levels of some cytokines [tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta), IL-2R, IL-6, and IL-8] and nitric oxide (NO) levels in patients with untreated brucellosis and to test the correlation of these parameters with each other. The study was conducted on 67 subjects, 37 patients with brucellosis and 30 healthy individuals with no history of Brucella infection. Brucellosis was identified by a positive blood culture and/or increased Brucella antibodies in serological tests in addition to compatible clinical symptoms. Cytokine profile analysis was performed by the immulite chemiluminescent enzyme immunometric assay whose inter- and intra-assay coefficients of variance were 2.6-3.6 and 4.4-8.5%, respectively. The levels of nitrites/nitrates, which are representative of NO levels, were measured by the Griess method. Patients with brucellosis had significantly elevated serum levels of nitrites/nitrates, IL-2R, IL-6 and IL-8 (mean +/- SD, 102.8 +/- 23.8 micromol/l, 806.1 +/- 58.5 U/ml, 21.1 +/- 2.3 pg/ml, and 8.8 +/- 1.6 pg/ml, respectively) compared to healthy controls, whereas TNF-alpha and IL-1beta levels were unchanged. No statistically significant correlation was detected between any of the studied cytokine levels and nitrate/nitrite concentrations according to Pearson's linear correlation test. We conclude that only IL-6, IL-8 and IL-2R are elevated in brucellosis and the extent of elevation depends on the severity and clinical pattern of the disease. Moderate elevation in serum NO was comparable to that observed in previous studies. This explains the absence or very rare occurrence of septic shock in brucellosis.