Derya Alabaz

The emergence of Leishmania major and Leishmania donovani in southern Turkey

BACKGROUND In southern Turkey, Leishmania tropica and L. infantum are both the causative agents of cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL), respectively. However, L. major and L. donovani were known to exist after the influx of Syrian refugees. METHODS Between the years of July 2003 and July 2013, a total of 167 smears and 113 bone marrow samples were taken from CL and VL-suspected cases, respectively. Samples were analysed through real-time PCR and ITS1 DNA sequencing. RESULTS One hundred and seven 64% (107/167) smears and 56% (63/113) bone marrow samples were positive for leishmaniasis according to the real-time PCR. Three different Leishmania species were found in the 107 CL cases by real-time PCR: 42% (45/107) L. tropica, 36.5% (39/107) L. infantum and 21.5% (23/107) L. major. In addition, three different Leishmania species were identified in the 63 VL cases: 60.3% (38/63) L. infantum, 30.2% (19/63) L. donovani and 9.5% (6/63) L. tropica using real-time PCR. The results of real-time PCR were confirmed with Leishmania ITS1 DNA sequencing. CONCLUSIONS This study revealed that in southern Turkey, L. major and L. donovani were the aetiological agents of CL and VL, respectively. It was assumed that emergence of L. major and L. donovani was due to influx of Syrian refugees, as well as the effects of global warming.

Systemic phaeohyphomycosis due to Exophiala (Wangiella) in an immunocompetent child

We report a rare case of systemic lymphadenitis and hepatic involvement due to Exophiala (Wangiella) dermatitidis in a pediatric patient. An 8-year-old immunocompetent boy with chronic fever was examined through the use of sonography and CT scan which demonstrated cervical and mesenteric lymph node enlargement and numerous small hepatic lesions. The etiologic agent was isolated by means of lymph node aspiration. The fungus was identified by its morphological characteristics and through DNA sequencing of the internal transcribed spacer region of rDNA. Despite initial amphotericin B and voriconazole therapy, the childs jaundice subsided and he died 7 months later. In addition to pathogenic aspects of Exophiala dermatitidis, the diagnostic approaches and relevant therapeutic strategies are discussed.

Cerebral salt wasting in tuberculous meningitis: treatment with fludrocortisone.

Abstract Three cases of cerebral salt wasting complicating tuberculous meningitis are described. Diagnosis was based on hyponatraemia associated with high urinary sodium excretion and inappropriately high urine output in the presence of dehydration. Treatment with fludrocortisone resulted in sodium and fluid homeostasis.

Aetiological agents, interleukin-6, interleukin-8 and CRP concentrations in children with community- and hospital-acquired pneumonia

Abstract Objective: To determine the pathogens causing pneumonia in community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) and to investigate serum levels of interleukin-6 (IL-6), interleukin-8 (IL-8) and CRP in pneumonia caused by different aetiological agents. Study design: Eighty-seven children (mostly < 5 years of age) were recruited in a prospective study, 55 of them with CAP without prior antibiotic treatment and 32 with HAP. Thirty healthy outpatient children served as controls. Results: The causative micro-organisms were determined by serological and microbiological methods in 40 cases with CAP (72.7%) and 30 with HAP (93.7%). In CAP, M. pneumoniae was the most common causative agent (43.6%), followed by S. pneumoniae (20%) and C. pneumoniae (18.1%). Bacteria alone were the sole causative agents in only 21.8% of cases with HAP. Pseudomonas aeruginosa (34.3%) and K. pneumoniae (32.5%) were the most frequently isolated. Although IL-6 and IL-8 levels were raised, there was no statistical difference between the CAP and HAP groups, or between bacterial and mycoplasma infections; neither was there a difference in CRP levels between these two groups. Conclusion: The causes of pneumonia differ between CAP and HAP. Levels of IL-6, IL-8 and CRP are raised in pneumonia but are unhelpful in differentiating the various aetiologies.

Bacillary Angiomatosis in an Immunocompetent Child with a Grafted Traumatic Wound

Bacillary angiomatosis is an infectious disease which usually develops in immunocompromised patients. Contact with cats is implicated in its pathogenesis. We report a seven‐year‐old immunocompetent boy with bacillary angiomatosis without a history of direct contact with cats. The clinical diagnosis of bacillary angiomatosis was made following histopathological examination of a biopsy sample from the infected facial wound, in the vicinity of which angiomatous lesions had developed. Surprisingly, similar lesions also appeared at the donor site of the skin graft which was grafted on the facial wound. This case demonstrates that bacillary angiomatosis may also be seen in immunocompetent patients and that it may contaminate wounds without the intermediary of cats.

A comparative analysis of different molecular targets using PCR for diagnosis of old world leishmaniasis

The different sensitivity values were obtained in each study conducted for the diagnosis of leishmaniasis with the polymerase chain reaction (PCR). However, a standardized PCR target for the diagnosis of leishmaniasis does not exist. The aim of the current study, the most ideal PCR target was determined for diagnosis of leishmaniasis. A total of 72 smear and 48 bone marrow samples were analyzed with six different molecular targets to determine their potential as a tool for the specific molecular diagnosis of leishmaniasis using PCR. The positivity-negativity value and the sensitivity-specificity of each PCR targets were calculated. The positivity value of PCR targets were sequenced in different levels in the diagnosis of leishmaniasis from highest to lowest in the order of kDNA-PCR > SSU rRNA-PCR > ITS2-PCR > ITS1-PCR > ME-PCR > HSP70-PCR. The sensitivities of PCR targets except ITS1-PCR, ME-PCR and HSP70-PCR were found to be 100% in cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) cases as compared to microscopic examination accepted as a gold standard. The sensitivities of ITS1-PCR, ME-PCR and HSP70-PCR were found 96.6%, 90.0% and 86.6%, respectively, in CL-cases. In addition, the sensitivities of ITS1-PCR, ME-PCR and HSP70-PCR were found 90.0%, 70.0% and 60.0%, respectively, in VL-cases. The kDNA genomic region was the most sensitive for routine diagnosis of leishmaniasis. ITS1-PCR restriction fragment length polymorphism, the alternative method for the identification of Old World Leishmania species, did not require culturing of the parasites.

Clinical manifestations and genetic variation of Leishmania infantum and Leishmania tropica in Southern Turkey

L. infantum was isolated from cutaneous leishmaniasis (CL) skin lesions in patients having no signs and symptoms of visceral leishmaniasis (VL). Similarly, L. tropica had previously been isolated from patients with VL in the absence of cutaneous lesions. It was not certain how visceralization occurred. Smears (207) and bone marrow samples (135) were taken from CL and VL-suspected patients, respectively. Microscopic examination, ITS1-PCR, RFLP and DNA sequencing for all samples were analyzed. The microscopic examination of smears was found to be 61.3% (127/207) in CL-suspected cases and bone marrow samples were found to be positive 8.8% (12/135) in VL-suspected cases. L. tropica 48.6% (72/148), L. infantum 35.8% (53/148), L. major 15.6% (23/148) in CL, and L. infantum 56.3% (18/32), L. donovani 31.2% (10/32), L. tropica 12.5% (4/32) in VL were found with PCR-RFLP. In addition, the DNA sequencing revealed a genetic variation in L. infantum (variants 1-3) and L. tropica (variants 1-5). We assume that the increased disease occurrence may have resulted from geographical expansion of disease, changing patterns of international travel, population migrations, non-immune people into endemic regions of infected people into non-endemic regions. In this study, L. infantum (variant 3) only in CL-patients and L. tropica (variant 2) only in VL-patients were identified. We hypothesize that genetic variation might play a role in the causation of CL and VL in southern Turkey and the genetic variants may differ according to the geographical location among Leishmania strains.

Unusual Idiopathic Calcinosis Cutis Universalis in a Child

Calcinosis cutis is an uncommon disorder characterized by the progressive deposition of crystals of calcium phosphate (hydroxyapatite) in the skin in various areas of the body. It is classified into four types according to etiology, namely as dystrophic if calcium and phosphorus levels are normal and tissue damage is present, as idiopathic if calcium and phosphorus levels are normal and no tissue damage is present, or as metastatic if there is hypercalcemia or hyperphosphatemia. Medical and surgical treatments are options to cure calcinosis cutis. Medical therapy is not very effective. Surgical excision has shown to be beneficial, as it can provide a symptomatic relief. However, since calcinosis cutis limits are not always well defined, a recurrence of the lesions may occur. We dealt with a very rare form of calcinosis cutis in a healthy 6-year-old girl. There was no evidence of connective tissue disorder or abnormal mineral metabolism. Hence, she was diagnosed as idiopathic calcinosis cutis and, although calcifications in idiopathic cutis are most commonly localized to one area, our patient unusually exhibited widespread calcific deposits. Although the existing lesions showed slow improvement, systemic pamidronate therapy was effective in preventing the occurrence of new lesions. Surgical excision proved to be an effective and successful treatment. This report aims to raise doctors’ awareness on the presentation, etiopathogenesis, and course of the relatively rare idiopathic calcinosis cutis.

Assessment of central venous catheterization and complications in a tertiary pediatric intensive care unit

Tolunay İ, Yıldızdaş RD, Elçi H, Alabaz D. Assessment of central venous catheterization and complications in a tertiary pediatric intensive care unit. Turk J Pediatr 2018; 60: 63-69. In catheter-using units as pediatric intensive care, it is important to know the complications that may occur during the insertion and use of central venous catheterization (CVC), and to take appropriate measures in order to reduce the mortality and morbidity of critical patients. The aim of this study was to evaluate CVC and catheter related complications in our tertiary pediatric intensive care unit. For this prospective study, 155 central venous catheters and/or hemodialysis catheters used with 106 patients, between August 2014 and August 2015 were evaluated. Demographic information about patients, catheter insertion procedure and catheter related complications were recorded. Sixty-two (58.5%) male and forty-four (41.5%) female patients were evaluated in this study. The median age was 67.5 months (1-212). The mean dwell time of catheters was 10.54±8 days. Twenty-two (14.2%) catheters were removed from patients because of catheter related complications. The mean dwell time of complicated catheters was 10.6±8.5 days and there was no statistically significant difference between complicated and non-complicated catheters. Catheter related blood stream infections was diagnosed in 5.1% (8/155) patients and these catheters were removed from patients. Including these patients, positive blood culture was found to be at 14.2% (22/155). The mean dwell time of catheters with positive blood culture was 14.25±7.3 days. The mean dwell time of catheters with positive blood culture was statistically significantly longer than catheters with negative blood culture. In the 3 patients who developed catheter thrombosis, 2 patients were followed up because of infection/sepsis and 1 patient had a neurological disease. Catheter thrombosis developed in 1 femoral vein and 2 internal jugular veins. The development of central venous catheter complications depends on many different factors and it is possible to reduce the complications with precautions taken during replacement and daily use.

Antifungal consumption, indications and selection of antifungal drugs in pediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey

OBJECTIVES The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey. METHODS A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed. RESULTS A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies. CONCLUSION The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.