Mehmet Ulug

The evaluation of microbiology and Fournier's gangrene severity index in 27 patients

OBJECTIVES The objectives of this study were to identify the causative microorganisms and factors associated with survival in patients with Fourniers gangrene and to determine the accuracy of the Fourniers gangrene severity index. MATERIALS AND METHODS We retrospectively evaluated 27 patients with Fourniers gangrene who were treated and followed up at our hospital between January 2005 and December 2006. Biochemical, hematologic, and bacteriologic study results at admission and at the final evaluation, etiologic and predisposing factors at admission, physical examination findings, the timing and extent of surgical debridement, and antibiotic therapy used were all recorded. RESULTS The admission laboratory parameters that were significantly correlated with outcome included urea, creatinine, sodium, and potassium; at the final evaluation, in addition to these parameters, hematocrit, albumin, and bicarbonate levels were also significantly associated with outcome. The mean Fourniers gangrene severity index score (FGSIS) at admission for survivors was 5.04+/-2.49 compared with 13.6+/-4.61 for non-survivors. There was a strong correlation between the FGSIS and mortality (p<0.0001). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated microorganisms. CONCLUSIONS Patient metabolic status and predisposing factors are important in the prognosis of Fourniers gangrene. Hence, we believe that the FGSIS should be used clinically to evaluate therapeutic options and assess results.

Results of a Multinational Study Suggest the Need for Rapid Diagnosis and Early Antiviral Treatment at the Onset of Herpetic Meningoencephalitis

ABSTRACT Data in the literature regarding the factors that predict unfavorable outcomes in adult herpetic meningoencephalitis (HME) cases are scarce. We conducted a multicenter study in order to provide insights into the predictors of HME outcomes, with special emphasis on the use and timing of antiviral treatment. Samples from 501 patients with molecular confirmation from cerebrospinal fluid were included from 35 referral centers in 10 countries. Four hundred thirty-eight patients were found to be eligible for the analysis. Overall, 232 (52.9%) patients experienced unfavorable outcomes, 44 died, and 188 survived, with sequelae. Age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.05), Glasgow Coma Scale score (OR, 0.84; 95% CI, 0.77 to 0.93), and symptomatic periods of 2 to 7 days (OR, 1.80; 95% CI, 1.16 to 2.79) and >7 days (OR, 3.75; 95% CI, 1.72 to 8.15) until the commencement of treatment predicted unfavorable outcomes. The outcome in HME patients is related to a combination of therapeutic and host factors. This study suggests that rapid diagnosis and early administration of antiviral treatment in HME patients are keys to a favorable outcome.

Brucellar epididymo-orchitis in southeastern part of Turkey: an 8 year experience

OBJECTIVE the different clinical and laboratory features and response to treatment of patients with acute brucellar epididymo-orchitis (BEO) reporting to the reference hospital in Southeastern Anatolia of Turkey. MATERIAL AND METHODS in this study, 27 male patients with brucellosis, who presented with epididymitis or epididymo-orchitis (EO) at the university hospital in Diyarbakir from 1998 to 2006, were included. They were compared with the other male patients. Positive blood culture or high agglutination titers of > 1/160 and positive clinical manifestations of brucellosis were the main criteria for diagnosing brucellosis. RESULTS fourteen patients had unilateral EO. Leukocytosis was present in 10 patients; all of them had initial agglutination titers of > 1/160 and 10 patients had a positive blood culture. All patients received combined therapy with streptomycin for the first 21 days (or oral rifampicin for 6-8 weeks) with doxycycline or tetracycline for 6-8 weeks. All showed improvement, fever subsided in 3-7 days, and the scrotal enlargement and tenderness regressed. Only one patient had a relapse within one year. CONCLUSION in brucellosis-endemic areas, clinicians encountering EO should consider the likelihood of brucellosis. In this study, young age was the most common risk factor, and leukocytosis and high CRP level were the most common laboratory findings. Most cases were unilateral. All patients responded to medical management very well. Conservative management with combination antibiotic therapy was adequate for managing BEO. Conclusively, brucellosis must be considered as a cause of orchitis, especially in endemic regions like Turkey.

Genitourinary brucellosis: results of a multicentric study

This study reviewed the clinical, laboratory, therapeutic and prognostic data on genitourinary involvement of brucellosis in this largest case series reported. This multicentre study pooled adult patients with genitourinary brucellar involvement from 34 centres treated between 2000 and 2013. Diagnosis of the disease was established by conventional methods. Overall 390 patients with genitourinary brucellosis (352 male, 90.2%) were pooled. In male patients, the most frequent involved site was the scrotal area (n=327, 83.8%), as epididymo-orchitis (n=204, 58%), orchitis (n=112, 31.8%) and epididymitis (n=11, 3.1%). In female patients, pyelonephritis (n=33/38, 86.8%) was significantly higher than in male patients (n=11/352, 3.1%; p<0.0001). The mean blood leukocyte count was 7530±3115/mm3. Routine laboratory analysis revealed mild to moderate increases for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The mean treatment duration and length of hospital stay were significantly higher when there were additional brucellar foci (p<0.05). Surgical operations including orchiectomy and abscess drainage were performed in nine (2.3%) patients. Therapeutic failure was detected in six (1.5%), relapse occurred in four (1%), and persistent infertility related to brucellosis occurred in one patient. A localized scrotal infection in men or pyelonephritis in women in the absence of leucocytosis and with mild to moderate increases in inflammatory markers should signal the possibility of brucellar genitourinary disease.

Managing atypical and typical herpetic central nervous system infections: results of a multinational study

There have been many studies pertaining to the management of herpetic meningoencephalitis (HME), but the majority of them have focussed on virologically unconfirmed cases or included only small sample sizes. We have conducted a multicentre study aimed at providing management strategies for HME. Overall, 501 adult patients with PCR-proven HME were included retrospectively from 35 referral centres in 10 countries; 496 patients were found to be eligible for the analysis. Cerebrospinal fluid (CSF) analysis using a PCR assay yielded herpes simplex virus (HSV)-1 DNA in 351 patients (70.8%), HSV-2 DNA in 83 patients (16.7%) and undefined HSV DNA type in 62 patients (12.5%). A total of 379 patients (76.4%) had at least one of the specified characteristics of encephalitis, and we placed these patients into the encephalitis presentation group. The remaining 117 patients (23.6%) had none of these findings, and these patients were placed in the nonencephalitis presentation group. Abnormalities suggestive of encephalitis were detected in magnetic resonance imaging (MRI) in 83.9% of the patients and in electroencephalography (EEG) in 91.0% of patients in the encephalitis presentation group. In the nonencephalitis presentation group, MRI and EEG data were suggestive of encephalitis in 33.3 and 61.9% of patients, respectively. However, the concomitant use of MRI and EEG indicated encephalitis in 96.3 and 87.5% of the cases with and without encephalitic clinical presentation, respectively. Considering the subtle nature of HME, CSF HSV PCR, EEG and MRI data should be collected for all patients with a central nervous system infection.

The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

An unusual presentation of brucellosis: acute hepatitis

We report a case where hepatitis was the only manifestation of acute brucellosis.A 33-year-old female patient was admit-ted to our clinic with complaints of fever, chills, headache, nausea and dark urine. Her temperature was 38.4°C, pulse was 76/min, respiratory rate was 16/min and blood pressure was 110/80 mmHg. Physi-cal examination revealed yellow sclera and a hepatosplenomegaly of 1 cm. The labora-tory test results revealed a leukocyte count of 3.8x109/L, C-reactive protein (CRP) of 26 mg/L, and an erythrocyte sedimenta-tion rate (ESR) of 17 mm/h. Serum alanine transferase (ALT) level was 372 U/L, se-rum aspartate transferase (AST) 303 U/L, serum alkaline phosphatase 454 U/L, se-rum γ-glutamyl transpeptidase 192 U/L and total bilirubin concentration was 3.2 mg/dL. The HBs-Ag, anti-HBc IgM, anti-HAV IgM, anti-HCV, anti-CMV IgM, anti-VCA IgM and Gruber Widal tests were negative. The patient had a positive history of fresh cheese ingestion, so a Wright agglutination test was also performed and the titer was found to be positive at 1/320. Abdominal ultrasonography showed moderate hepat-osplenomegaly, without any structural or morphological changes. With these findings, she was diagnosed as having acute hepatitis due to brucellosis. Blood cultures had been performed before the antibiotic therapy was started. Doxycycline 200 mg/d and strepto-mycin 1 g/d treatment were started. The fe-ver subsided on the fourth day of the treat-ment and blood cultures isolated

Comparison of brucellar and tuberculous spondylodiscitis patients: results of the multicenter "Backbone-1 Study".

BACKGROUND CONTEXT No direct comparison between brucellar spondylodiscitis (BSD) and tuberculous spondylodiscitis (TSD) exists in the literature. PURPOSE This study aimed to compare directly the clinical features, laboratory and radiological aspects, treatment, and outcome data of patients diagnosed as BSD and TSD. STUDY DESIGN A retrospective, multinational, and multicenter study was used. PATIENT SAMPLE A total of 641 (TSD, 314 and BSD, 327) spondylodiscitis patients from 35 different centers in four countries (Turkey, Egypt, Albania, and Greece) were included. OUTCOME MEASURES The pre- and peri- or post-treatment spinal deformity and neurologic deficit parameters, and mortality were carried out. METHODS Brucellar spondylodiscitis and TSD groups were compared for demographics, clinical, laboratory, radiological, surgical interventions, treatment, and outcome data. The Student t test and Mann-Whitney U test were used for group comparisons. Significance was analyzed as two sided and inferred at 0.05 levels. RESULTS The median baseline laboratory parameters including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate were higher in TSD than BSD (p<.0001). Prevertebral, paravertebral, epidural, and psoas abscess formations along with loss of vertebral corpus height and calcification were significantly more frequent in TSD compared with BSD (p<.01). Surgical interventions and percutaneous sampling or abscess drainage were applied more frequently in TSD (p<.0001). Spinal complications including gibbus deformity, kyphosis, and scoliosis, and the number of spinal neurologic deficits, including loss of sensation, motor weakness, and paralysis were significantly higher in the TSD group (p<.05). Mortality rate was 2.22% (7 patients) in TSD, and it was 0.61% (2 patients) in the BSD group (p=.1). CONCLUSIONS The results of this study show that TSD is a more suppurative disease with abscess formation requiring surgical intervention and characterized with spinal complications. We propose that using a constellation of constitutional symptoms (fever, back pain, and weight loss), pulmonary involvement, high inflammatory markers, and radiological findings will help to differentiate between TSD and BSD at an early stage before microbiological results are available.

Pyogenic liver abscess caused by community-acquired multidrug resistance Pseudomonas aeruginosa.

Correspondence to: Mehmet Ulug, MD BSK Anadolu Hospital, Department of Infectious Diseases and Clinic Microbiology, 43100 Kutahya, Turkey Phone (mobile): +90-532-4475756 Fax: +90-274-2244433 E-mail: mehmetulug21@ yahoo.com Pyogenic liver abscess (PLA) is a very uncommon liver disease affecting predominantly young males in the setting of intra-abdominal infection. PLA can be caused by several organisms. An uncommon case of PLA caused by multidrug resistant (MDR) Pseudomonas aeruginosa is described. A previously healthy 28-year-old man was admitted to our clinic with a two weeks history of pain in the right upper abdomen, followed by fever, chills, and vomiting. On admission day, physical examination revealed that he was in pain and feverish (38.6° C), and had hepatomegaly. Laboratory fi ndings included total white blood cell (WBC) count of 14,800/mm, erythrocyte sedimentation rate was 87 mm/h with a C-reactive protein (CRP) measuring 63 mg/dL (range, 0-8 mg/dL), and total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma glutamyl transpeptidase, alkaline phosphatase were within normal limits. Abdominal ultrasonography (US) showed solid mass at right hepatic lobe, which suggested a liver abscess, according to clinical fi ndings. It was also confi rmed by abdominal computed tomography (CT). The abscess was localized with transverse CT images and percutaneous drainage with 20 Fr gauge was performed. Fluid samples were sent for microbiological cultures. He was initially treated with ceftriaxone 2 g/day plus metronidazole 1 g/day with no improvement. After three days, the aspiration culture grew MDR P. aeruginosa. The bacteriological resistance results led us to change the initial treatment to imipenem 2 g/day plus amikacin 1.5 g/day for four weeks. The patient was discharged 21 days after admission without evidence of any complication. Despite continuous improvement in image modalities, availability of potent antibiotics and advancement in the knowledge and treatment of PLA, morbidity and mortality remains high. Its incidence ranges from 0.008 to 0.0022% in hospitalized patients. The diagnosis of PLA was based on clinical fi ndings and evidence from imaging studies, either abdominal US or CT. Treatment with intravenous antibiotics and application of catheter drainage or aspiration are the primary therapeutic strategies. The most common pathogenic agents, which enter the liver by vascular routes, are Escherichia coli, Klebsiella pneumoniae, Salmonella typhi, Proteus vulgaris, streptococci, and staphylococci, but anaerobes may also be present. Nevertheless, P. aeruginosa has long been regarded as a relatively rare pathogen of PLA, especially in patients without underlying conditions, such as lung and renal disease, malignancies, organ transplantation, immunosuppression. P. aeruginosa was defi ned as being MDR when the organism was resistant to all agents studied (ampicillin, amoxicillin-clavulanate, ceftriaxone, ceftazidime, cefepime, aztreonam, chloramphenicol, ciprofl oxacin, gentamicin, piperacillin, and trimetoprim-sulfamethoxazole), except imipenem, amikacin, and colistina. When searching Pub Med, we fi nd only one case report of PLA caused by P. aeruginosa, but it was not MDR. On the other hand, PLA caused by P. aeruginosa was seen 2-6% in literature, and this is the fi rst case of PLA caused by community-acquired MDR P. aeruginosa in literature. The incidence of MDR P. aeruginosa increased in recent years. For this reason, we attach great importance to the rational use of antibiotics in inpatients and outpatients.

Pulmonary involvement in brucellosis.

BACKGROUND Brucellosis is a zoonotic disease caused by a Gram-negative bacillus of the Brucella genus with multisystem involvement, primarily affecting the reticuloendothelial system, joints, heart and kidneys. Although the disease can be spread by inhalation, pulmonary involvement is rare. OBJECTIVE To report a case of brucellosis with pulmonary involvement. CASE PRESENTAION: A previously healthy 36-year-old woman was admitted with complaints of fever, weakness, night sweats, dry cough and bilateral chest pain. She hed been diagnosed with pneumonia 20 days previously and was started on a course of ampicillin for 14 days, with no response. Her chest auscultation revealed diminished breath sounds and scattered crackles and rhonchi over the inferior zone of the right hemithorax. Wright and Coombs testing resulted in titres of 1:1280 and 1:640, respectively. Chest radiography revealed an area of confluent lobar consolidation in the right lower lobe. Treatment was started with a six-week course of oral doxycycline 200 mg/day and rifampicin 600 mg/day. This treatment regimen rapidly improved the patients condition. Follow-up after one year showed no residual effects from the infection. CONCLUSION Pulmonary involvement is a rare event in the course of brucellosis, but the rate could be higher than currently estimated. In endemic regions, brucellosis should be considered as a causative agent in patients with pulmonary symptoms. BACKGROUND Brucellosis is a zoonotic disease caused by a Gram-negative bacillus of the Brucella genus with multisystem involvement, primarily affecting the reticuloendothelial system, joints, heart and kidneys. Although the disease can be spread by inhalation, pulmonary involvement is rare. OBJECTIVE To report a case of brucellosis with pulmonary involvement. CASE PRESENTAION A previously healthy 36-year-old woman was admitted with complaints of fever, weakness, night sweats, dry cough and bilateral chest pain. She hed been diagnosed with pneumonia 20 days previously and was started on a course of ampicillin for 14 days, with no response. Her chest auscultation revealed diminished breath sounds and scattered crackles and rhonchi over the inferior zone of the right hemithorax. Wright and Coombs testing resulted in titres of 1:1280 and 1:640, respectively. Chest radiography revealed an area of confluent lobar consolidation in the right lower lobe. Treatment was started with a six-week course of oral doxycycline 200 mg/day and rifampicin 600 mg/day. This treatment regimen rapidly improved the patient’s condition. Follow-up after one year showed no residual effects from the infection. CONCLUSION Pulmonary involvement is a rare event in the course of brucellosis, but the rate could be higher than currently estimated. In endemic regions, brucellosis should be considered as a causative agent in patients with pulmonary symptoms.