An evaluation of suspected cases of Hantavirus infection admitted to a tertiary care university hospital in Düzce, Turkey, between 2012 and 2018

Background/aim: Hantavirus is a rodent borne zoonosis caused by the members of the virus family Bunyaviridae, genus Hantavirus. In this study, we aimed to determine the role of peripheral blood leukocyte ratio in differential diagnosis of Hantavirus disease. Materials and methods: The medical records of patients at the Düzce University Medical Faculty were examined retrospectively. A total of 20 patients diagnosed with hantavirus infection confirmed by serologic tests were included in the study (Group 1). The other group consisted of 30 patients suspected of hantavirus infection but found negative (Group 2). Demographic, clinical and laboratory characteristics, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte (LMR) ratios of both groups were compared. Results: As a result of the istatistics analysis, no difference was found between the groups' age, sex, and clinical complaints except lethargy-weakness (P = 0.004) and diarrhea (P < 0.001). Hemogram analysis showed a significant difference between the groups in terms of leukocyte, hemoglobin, hematocrit, platelet, mean platelet volume (P < 0.05) and PLR (P = 0.001) and LMR (P = 0.003) values from peripheral blood leukocyte ratios. Conclusion: In conclusion, NLR, PLR, and LMR ratios may be useful for clinicians in differential diagnosis of Hantavirus in patients presenting with similar symptoms of Hantavirus disease.

[Travel Related Fever and Rash: Two Cases of Dengue Fever]. / Seyahat Iliskili Ates ve Döküntü: Iki Dengue Atesi Olgusu.

The frequency of travel-related infections in the world has increased due to the easily and widespread use of travel facilities in the 21st century. Vector-borne diseases are an important part of infectious diseases. Dengue fever is one of the travel-related infections that has been reported increasingly in recent years through the development of diagnostic methods. The aim of this report was to present two Dengue fever cases originating from travel. There was a story of mosquito bite during a trip to Sri Lanka travel in our first case. The patient was 30 years old and maculopapular rash appeared on the fifth day of contact. Three days after the onset of the rash, she has admitted to our clinic, complaining with fever and chills. Increased leukopenia and muscle enzymes were detected in the laboratory analysis. Real-time reverse transcriptase polimerase chain reaction (RT-PCR) was positive in the serum sample. The patient was followed up with supportive care and discharged by improvement. The second case, a 24-year-old male, had a story of mosquito bite during his trip to Malaysia. After the patient complained of fever, chills, fever, nausea, vomiting and muscle pain, the Dengue virus (DENV) NS1 antigen test performed in this country was found to be positive. In the second case, there was no maculopapular rash and laboratory analysis showed an increase in leukopenia, thrombocytopenia and muscle enzymes. RT-PCR positivity was detected in the serum sample. The patient was followed up with supportive treatment and discharged with cure. DENV infections are caused by DENV which is common in the tropical areas of the world. There are four DENV-1, DENV-2, DENV-3 and DENV-4 serotypes. DENV infections can present different clinical manifestations such as asymptomatic disease, viral syndrome, Dengue haemorrhagic fever, and Dengue shock syndrome. Dengue fever is often accompanied by arthritis, maculopapular rash and high fever. Our cases were defined as Dengue fever according to this definition. In the diagnosis of the disease, it is necessary first to be suspicious of the disease and the travel history must be questioned. In the definitive diagnosis, virus isolation, antigen, nucleic acid detection and serological tests are used. The virus can be isolated from blood, serum, urine and tissues. In the first five days after beginning of the symptoms associated with DENV infections, serum RT-PCR and Dengue NS1 antigen test may be positive.

[Cases of Zika virus infection in Turkey: newly married couple returning from Cuba]. / Türkiye'de görülen Zika virüsü olgulari: Küba'dan dönen yeni evli çift.

Zika virus is a Flavivirus in the family Flaviviridae, and transmitted to humans by Aedes species mosquitoes. Zika virus infection is asymptomatic in 80% of cases and has a mild course when symptoms occur. These symptoms include headache, myalgia, mild fever, maculopapular rash and conjunctivitis. Zika virus has been associated with serious neurological complications such as Guillain-Barre syndrome in adults and microcephaly development in neonates. It has recently become a global public health problem as a result of increasing cases. As it is known that the vector of this disease is present in our country; entry of Zika virus infection in our country has a great importance. In this report the clinical and laboratory findings of two cases of Zika virus infection imported to Turkey by a couple returning from Cuba in October 2017 were presented. Newly married couple, both 29 years old, without a known chronic disease history, went on honeymoon to Cuba between 17-29 September and they visited Havana and Varadero. They reported that they were bitten repeatedly by the mosquitoes and did not use insect repellents during this time. Four days after returning to Turkey, they had headaches, back pain and myalgia followed by rash and joint pain. They reported having their symptoms started in the same day in a few hours difference. The symptoms for both patients disappeared in 10 days. Serum samples from the patients were sent to the Public Health General Directorate National Arboviruses and Viral Zoonoses Laboratory to be tested for Dengue, Chikungunya and Zika viruses. Nucleic acid testing yielded negative results. The Arbovirus Indirect Immunofluorescence test were positive both for IgM and IgG for Zika virus. No cross reactivity with Dengue virus was detected. Chikungunya antibodies were found as negative. At two months of the diagnosis, urine and semen samples of the male patient were tested by real-time reverse transcriptase polymerase chain reaction (rRT-PCR). The result was negative for urine but positive for semen sample. This report is important to present the first cases of Zika virus infection published in Turkey. Zika virus infection should be suspected in patients with fever, headache, rash, myalgia and joint pain returning from an endemic areas. All travelers, especially pregnant women, have to take precautions for mosquitos during the trip.

Dengue virus transmission by blood stem cell donor after travel to Sri Lanka; Germany, 2013.

Three days after donation of peripheral blood stem cells to a recipient with acute myeloblastic leukemia, dengue virus was detected in the donor, who had recently traveled to Sri Lanka. Transmission to the recipient, who died 9 days after transplant, was confirmed.

[Acute Toscana virus infection in an anti-HIV positive patient]. / Anti-HIV pozitif bir hastada saptanan akut Toskana virus enfeksiyonu.

Sandfly fever is an infectious disease transmitted to people through sandfly bites. It usually takes three days and causes chills, high fever, headache, nausea-vomiting and myalgia. The causative agent, namely sandfly fever virus (SFV), is a member of the Bunyaviridae family, Phlebovirus genus. Toscana virus (TOSV) is a serotype of SFV, as so Sicilian and Naples viruses. Seroprevalence studies have demonstrated that SFV infections which have mild symptoms or asymptomatic, can be overcome. Studies concerning TOSV infections in Turkey are limited to a small number of regional seroprevalence surveys, blood-donor screening studies and detection of viral RNA in previously collected cerebrospinal fluid samples of suspected meningoencephalitis patients in whom no causative agents were identified. In this report from Turkey, the first acute case of TOSV infection diagnosed in a patient with HIV seropositivity, was presented. A 42-year-old male patient was admitted to Numune Research and Training Hospital Adana, Turkey with high fever, headache and malaise. The patient who lived in an area near to a forest in Istanbul, had no contact history with ticks, mosquitoes and other animals. He stated that he had had the symptoms before arriving to Adana. The patient was hospitalized due to leucopenia, anemia, and thrombocytopenia accompanying high fever. Serum samples were sent to National Arbovirus and Viral Zoonotic Diseases Unit of the Turkish Public Health Institute, for the detection of Crimean-Congo haemorrhagic fever (CCHF) virus and SFV. Western Blot test was run to confirm the presence of anti-HIV antibodies detected twice with ELISA. In the following days, the patient's fever and symptoms decreased, and thrombocyte levels increased. Although CCHF virus PCR and ELISA IgM tests as well as SFV IgM and IgG immunofluorescence antibody (IFA) tests were negative, real time reverse transcriptase PCR test yielded a positive result for TOSV. SFV IgG antibodies against Toscana and Naples viruses were found to be positive in the serum sample collected at the end of a three-week follow-up. Even though TOSV infection is usually known to have an asymptomatic clinical course, it may rarely lead to serious manifestations like meningoencephalitis. In our country where SFV is endemic, TOSV should be considered in the differential diagnosis of patients presenting with high fever and meningoencephalitis symptoms.

[Investigation of West Nile virus in central nervous system infections of unknown etiology in Ankara, Turkey]. / Ankara bölgesinde nedeni bilinmeyen merkezi sinir sistemi enfeksiyonlarinda Bati Nil virusunun arastirilmasi.

Arthropod-borne viral infections have recently gained considerable attention and importance as re-emerging infections in a global scale. West Nile Virus (WNV), a member of Flaviviridae, is an enveloped positive strand RNA virus that is usually transmitted to humans by the bite of Culicine mosquitoes. Although the majority of the human infections are asymptomatic, WNV may also cause febrile and neuro-invasive diseases. Seroprevalence data from Turkey indicate that WNV activity is present in Central Anatolia. In this study performed at Hacettepe University Hospital, paired serum and cerebrospinal fluid (CSF) samples from 87 adult patients with the preliminary diagnosis of aseptic meningitis/encephalitis of unknown etiology were evaluated retrospectively to identify WNV-related syndromes. Bacterial, fungal and mycobacterial cultures yielded negative results and Mycobacterium tuberculosis and Herpes simplex virus nucleic acid tests were also negative for the selected patients. Commercial enzyme-linked immunosorbent assay (ELISA)s and indirect immunofluorescence test (IIFT)s were employed for WNV IgM and IgG antibody detection (Anti-WNV Virus IgG/IgM ELISA, Anti-WNV Virus IgG/IgM IIFT; Euroimmun, Germany). Additional ELISA/IIFT assays were further performed for WNV antibody reactive samples to identify cross-reactions and/or infections with other flaviviruses and phleboviruses. All WNV antibody positive samples were also evaluated by a WNV real-time reverse-transcription polymerase chain reaction (RT-PCR) assay. WNV IgM and IgG antibodies were detected in %9.2 (8/87) and 3.4% (3/87) of the serum samples, respectively. All IgG reactive samples were negative for IgM. All sera with WNV antibody reactivity (n = 11) and the corresponding CSF samples were negative for viral RNA via RT-PCR. In 5 of the 8 WNV IgM positive subjects, sandfly fever virus IgM antibodies were detected, which was also accompanied by Dengue virus IgM positivity in one sample. In another case, intrathecal antibody synthesis against measles virus was demonstrated. Two cases (2/87; 2.3%) with WNV IgM positivity as the only serologic marker were identified as probable WNV infections and clinical features were discussed. In conclusion, in order to fully understand the impact of WNV and/or other flavivirus infections in Turkey, epidemiology and ecological features of these agents need to established.

Neuroinvasive West Nile Virus Disease in an Elderly Patient with Diffuse Large B-Cell Lymphoma Treated with R-CHOP Therapy: A Case Report

Background: West Nile virus is an arthropod-borne virus (arbovirus) and emerging cause of significant illness in European and Mediterranean countries. West Nile virus infection can cause severe and potentially fatal neurological illnesses, including encephalitis, meningitis, and acute flaccid paralysis. Additionally, immunosuppression, alcohol abuse, old age, and diabetes mellitus are common factors associated with West Nile neuroinvasive disease. Case Report: In August 2018, a 60-year-old male patient with a history of diffuse large B-cell lymphoma initially presented with symptoms including abdominal pain and distention, nausea, and vomiting. Three days after open abdominal surgery due to adhesive small bowel obstruction, he developed fever, prominent tremors, and rapidly progressing flaccid paralysis. The identification of West Nile virus RNA in the serum sample led to the diagnosis of West Nile neuroinvasive disease. Conclusion: Clinicians should evaluate patients with acute flaccid paralysis for the evidence of West Nile neuroinvasive disease. It is particularly important for healthcare providers to consider West Nile neuroinvasive disease in the differential diagnosis of aseptic meningitis, encephalitis, and acute paralysis cases, especially in endemic areas.

Pleural fluid PCR method for detection of Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae in pediatric parapneumonic effusions.

BACKGROUND: Parapneumonic effusions cause significant morbidity and mortality despite current developments in diagnostic and therapeutic approaches. Causative microorganisms may remain unidentified in a significant number of patients by cultures and Gram smears. Polymerase chain reaction (PCR) is a molecular technique for the detection of causative bacteria; however, its efficiency in pleural fluids is less known. OBJECTIVES: The present study was performed to compare the efficiency of PCR in the detection of the three most common organisms (Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae) with conventional methods. METHODS: Twenty-eight consecutive patients with parapneumonic pleural effusions were studied. On admission, pleural fluid samples were obtained for Gram staining, routine culture and PCR analysis for S. aureus, S. pneumoniae and H. influenzae. RESULTS: PCR analysis allowed detection of 11 microorganisms in 10 patients (35.7%), whereas pleural fluid cultures detected the etiological agent in only 2 (7.1%). S. pneumoniae was the most frequent agent. CONCLUSIONS: Pleural fluid cultures may have low diagnostic yields, partly due to prior antibiotic use. Pleural fluid PCR analysis may improve the etiologic diagnosis in parapneumonic pleural effusions, with technical advances leading to higher yields than obtained in this study.

[Molecular typing of clinical Candida krusei isolates by using restriction endonuclease analysis of genomic DNA and polymerase chain reaction]. / Candida krusei klinik izolatlarinin genomik DNA restriksiyon enzim analizi ve polimeraz zincir reaksiyonu ile tiplendirilmesi.

Candida krusei is inherently resistant to fluconazole and is an important pathogen responsible for nosocomial candidiasis especially in patients with hematological malignancy. Despite the growing clinical importance of C. krusei infections, little is known of its genetic diversity and molecular epidemiology. Therefore, differentiating between C. krusei isolates is of importance for a better understanding of the epidemiology, mode of transmission and pathogenesis of the organism. We investigated the use of two different methods (restriction endonuclease analysis of genomic DNA (REAG) with Hinfl and polymerase chain reaction by using Arno1 and Arno2 primers) for molecular typing of 56 C. krusei isolates from 56 patients. Ten different types (A-J) were determined by REAG. Depending on the patterns of isolates, the number of the bands varied from 12 to 15 and the size of the fragments varied from 2.0 kb to 6.2 kb. Of the isolates 71.4% were gathered under three major patterns (D, F, H). In the second method, PCR amplified different sizes of fragments varied approximately from 1 kb to 2 kb, which yielded 13 types (a-m) from 56 patients. Four major patterns (d, f, h, k) were observed for 58.9% of the isolates. The genotypes detected by REAG and PCR methods were found to be same in 43 isolates out of 56. As the banding patterns of the isolates were found to be similar in this study, it was thought that an exogenous origin could be the source of infections caused by C. krusei isolates. Both REA of genomic DNA and PCR analysis seem to be useful for the typing of C. krusei, however PCR assay can be preferred as it is a simple and rapid method. As a result, further studies are required for the validation of reproducibility and discriminatory power of these methods.

West Nile virus seroprevalence in blood donors from Central Anatolia, Turkey.

INTRODUCTION: West Nile virus (WNV) is a reemerging flavivirus that has displayed a drastic change in epidemiology in the last decade. Data on WNV activity in Turkey are currently limited. This study investigated WNV exposure in blood donors from Central Anatolia, Turkey. MATERIALS AND METHODS: A total of 2516 sera, collected from blood donors at four major branches of the Turkish Red Crescent Middle Anatolia Regional Blood Center, were evaluated by a commercial WNV immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA). Positive and borderline samples were investigated further by a WNV IgG indirect immunofluorescence test (IIFT), IgG ELISAs for tick-borne encephalitis virus and dengue virus, an IgG IIFT for yellow fever virus, and a multi-Flavivirus biochip IgG IIFT. WNV antibody specificity and titer values were determined by plaque reduction neutralization assay. IgG avidity and IgM were determined for confirmed samples. IgM-positive samples were also evaluated by a real-time reverse transcription polymerase chain reaction assay. RESULTS: Twenty-five samples (25/2516; 0.99%) were found reactive in the WNV ELISA/IIFT assays, and 14 could be confirmed by the plaque reduction neutralization assay (14/2516; 0.56%). All IgGs were of high avidity, and four samples (4/14; 28.6%), which were negative for viral RNA, were IgM positive. Although samples with neutralizing WNV IgGs had strong fluorescence intensity in IIFTs, no correlation between antibody titer values and IIFT intensity or quantitative ELISA results could be found. Three WNV nonreactive samples were positive in the dengue IgG ELISA test; one of these also displayed positive results for dengue virus in the mosaic biochip IIFT and reactivity in yellow fever virus IIFT. DISCUSSION: WNV exposure is confirmed in 0.56% of the tested healthy blood donors in Central Anatolia, with evidence for dengue/yellow fever and/or other flaviviral infections. This study is the first to document WNV exposure in individuals from Konya, Yozgat, and Sivas provinces in Central Anatolia, and it also establishes viral activity in Ankara, the capital of Turkey.

Methicillin-resistant Staphylococcus aureus heterogeneously resistant to vancomycin in a Turkish university hospital.

OBJECTIVES: We investigated vancomycin-intermediate Staphylococcus aureus (VISA) and heterogeneously vancomycin-intermediate S. aureus (hetero-VISA) isolates from clinical specimens of hospitalized patients at Hacettepe University over a 4 year period. METHODS: Strains were screened for VISA and hetero-VISA by using brain heart infusion agar containing 4 mg/L vancomycin (BHI-V4) and macro Etest. Confirmation of the isolates that were found to have intermediate susceptibility to vancomycin with either of the methods was done by population analysis of subpopulations with reduced susceptibility to vancomycin. The MIC of vancomycin for the isolates grown on BHI-V4 was determined by the microdilution method. RESULTS: Among 256 methicillin-resistant S. aureus (MRSA) isolates, 145 grew on BHI-V4. Forty-six of these were also found to be heterogeneously vancomycin-intermediate strains when screened with the macro Etest. There were no VISA among 256 MRSA tested but 46 (17.97%) S. aureus strains with reduced susceptibility to vancomycin were identified by population analysis. Vancomycin MIC values for all isolates with reduced susceptibility were between