Mucahit Yemisen

Prevalence of Hepatic Granulomas in Chronic Hepatitis B

An increasing frequency of hepatic granulomas, up to 10%, in chronic hepatitis C patients is reported, and their presence is considered to be a predictor of treatment success. However, there is only one prevalence study on granuloma in chronic hepatitis B, and its significance for treatment outcome is unknown. We aimed to determine the prevalence of hepatic granulomas in a larger group of chronic hepatitis B patients and to compare their presence with the response to interferon therapy. Biopsy specimens of chronic hepatitis B patients were reevaluated for the presence of hepatic granulomas. All patients with hepatic granuloma were screened for other granulomatous diseases by tuberculin skin test, chest X-ray and computed tomography, venereal disease research laboratory, Brucella agglutination tests, and exposure to hepatotoxic agents. We screened 663 cases of chronic hepatitis B. Hepatic granulomas were found in 10 cases (1.5%). The granulomas could not be ascribed to any other reason. Of the 10 patients with hepatic granulomas, 4 responded to interferon therapy, 2 dropped out, and 4 were nonresponders. We conclude that hepatic granuloma is a rare finding in chronic hepatitis B and its presence does not seem to predict the response to interferon therapy.

Blood stream infections due to OXA-48-like carbapenemase-producing Enterobacteriaceae: treatment and survival

BACKGROUND Blood stream infections (BSIs) due to carbapenem-resistant Enterobacteriaceae (CRE) are associated with high hospital mortality rates and present a tremendous challenge to clinicians. The optimal treatment remains undefined. We aimed to investigate the risk factors for mortality and the correlation between different treatment modalities and outcomes. METHODS The clinical characteristics and treatment outcomes of a cohort of 36 patients with BSIs due to CRE were investigated and a retrospective nested case-control study of surviving and non-surviving patients was conducted. RESULTS Fifty percent of the cases were male and the mean patient age was 54.9 ± 15.8 years. Klebsiella pneumoniae was the etiological agent in 26 cases (72.2%), Escherichia coli in eight (22.2%), and Enterobacter aerogenes in two (5.5%). All strains were phenotypically positive for carbapenemase activity and all except two (one E. coli and one K. pneumoniae) yielded both blaOXA-48 carbapenemases and blaCTX-M-type extended-spectrum beta-lactamases (ESBLs) in PCR products. The 14-day, 28-day, and all-cause in-hospital mortality rates were 41.6%, 50%, and 58.3%, respectively. The median time to death was 8 days (range 2-52 days). No significant differences were observed between survivors and non-survivors in terms of baseline characteristics, comorbid conditions, etiologies, or sources of bacteremia, however hematological malignancies (p=0.015) and prolonged neutropenia (p=0.044) were more common in non-survivors. Microbiological eradication and clinical response within 7 days were two major determinants of 28-day attributable mortality (p=0.001 and p=0.001, adjusted r(2)=0.845). Colistin-based dual combinations, and preferably triple combinations, were associated with significantly better outcomes when compared to non-colistin-based regimens (p<0.001). Time to active treatment had a significant effect on the course of infection (p=0.014). CONCLUSION Earlier active treatment with colistin based regimens and microbiological and clinical response within 7 days are major predictors of survival in cases of BSIs due to CRE. Rectal screening offers the advantage of earlier recognition and prompt empirical treatment.

The microbiological diagnosis of tuberculous meningitis: results of Haydarpasa-1 study

We aimed to provide data on the diagnosis of tuberculous meningitis (TBM) in this largest case series ever reported. The Haydarpasa-1 study involved patients with microbiologically confirmed TBM in Albania, Croatia, Denmark, Egypt, France, Hungary, Iraq, Italy, Macedonia, Romania, Serbia, Slovenia, Syria and Turkey between 2000 and 2012. A positive culture, PCR or Ehrlich-Ziehl-Neelsen staining (EZNs) from the cerebrospinal fluid (CSF) was mandatory for inclusion of meningitis patients. A total of 506 TBM patients were included. The sensitivities of the tests were as follows: interferon-γ release assay (Quantiferon TB gold in tube) 90.2%, automated culture systems (ACS) 81.8%, Löwenstein Jensen medium (L-J) 72.7%, adenosine deaminase (ADA) 29.9% and EZNs 27.3%. CSF-ACS was superior to CSF L-J culture and CSF-PCR (p <0.05 for both). Accordingly, CSF L-J culture was superior to CSF-PCR (p <0.05). Combination of L-J and ACS was superior to using these tests alone (p <0.05). There were poor and inverse agreements between EZNs and L-J culture (κ = -0.189); ACS and L-J culture (κ = -0.172) (p <0.05 for both). Fair and inverse agreement was detected for CSF-ADA and CSF-PCR (κ = -0.299, p <0.05). Diagnostic accuracy of TBM was increased when both ACS and L-J cultures were used together. Non-culture tests contributed to TBM diagnosis to a degree. However, due to the delays in the diagnosis with any of the cultures, combined use of non-culture tests appears to contribute early diagnosis. Hence, the diagnostic approach to TBM should be individualized according to the technical capacities of medical institutions particularly in those with poor resources.

The Syrian conflict and infectious diseases

ABSTRACT The conflict in Syria is a big humanitarian emergency. More than 200,000 Syrians have been killed, with more than half of the population either having been displaced or having immigrated. Healthcare has been interrupted due to the destruction of facilities, a lack of medical staff, and a critical shortage of life-saving medications. It produced suitable conditions leading to the re-emergence of tuberculosis, cutaneous leishmaniasis, polio, and measles. Lebanon and Jordan reported increased rates of tuberculosis among Syrian refugees. Cutaneous leishmaniasis outbreaks were noted not only in Syria but also in Turkey, Jordan, and Lebanon. After a polio-free 15 years, Syria reported a polio outbreak. Ongoing measles outbreaks in the region was accelerated by the conflict. Iraq declared a cholera outbreak among the Syrian refugees. The healthcare facilities of the countries hosting immigrants, mainly Turkey, Lebanon, Jordan, Iraq, and Egypt, are overburdened. The majority of the immigrants live in crowded and unsanitary conditions. Infectious diseases are big challenges for Syria and for the countries hosting immigrants. More structured support from international organizations is needed for the prevention, control, diagnosis, and treatment of infectious diseases.

Management of Brucella endocarditis: results of the Gulhane study

Brucella endocarditis (BE) is a rare but life-threatening complication of human brucellosis. The aim of this study was to investigate the course of BE along with the therapeutic interrelations. A total of 53 patients with BE hospitalised in 19 health institutions between 2006 and 2011 were included in the Gulhane study. Diagnosis of brucellosis was established by either isolation of Brucella sp. or the presence of antibodies, and the definition of endocarditis was made according to Dukes criteria. There were four treatment groups: ceftriaxone combined with oral antibiotics (Group 1); aminoglycosides combined with oral antibiotics (Group 2); oral antibiotic combinations (Group 3); and aminoglycoside plus ceftriaxone combined with an oral antibiotic (Group 4). Involvement rates of the aortic, mitral and tricuspid valves were 49.1%, 43.4% and 5.7%, respectively. Thirty-two patients (60.4%) had an underlying cardiac valvular problem, including previous prosthetic valve replacement (n=18). Medical treatment was provided to 32 patients (60.4%), whilst concordant medical and surgical approaches were provided to 21 patients (39.6%). Mortality in Group 1 was 15% (3/20), whilst in Group 2 it was 5.3% (1/19). In Group 3, 25.0% (3/12) of the cases died, whereas none of the cases in Group 4 died. In conclusion, mortality increased 47-fold with pericardial effusion and 25-fold due to congestive heart failure that developed after BE. Although mortality was lower in the aminoglycoside-containing arm (Groups 2 and 4), statistical analysis could not be performed owing to the small number of patients.

Comparison of community‐onset healthcare‐associated and hospital‐acquired urinary infections caused by extended‐spectrum beta‐lactamase‐producing Escherichia coli and antimicrobial activities

We aimed to compare community‐onset healthcare‐associated (CO‐HCA) and hospital‐acquired (HA) urinary tract infections (UTIs) caused by extended‐spectrum beta‐lactamase (ESBL)‐producing Escherichia coli in terms of epidemiology, clinical outcomes and antimicrobial activities.

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.

A meningitis case due to Stenotrophomonas maltophilia and review of the literature

Stenotrophomonas maltophilia (formerly Xanthomonas maltophilia) is a Gram-negative bacillus increasingly associated with serious nosocomial infections. Here, we describe a 30-year-old male patient who developed meningitis associated with this organism after several neurosurgical procedures. A review of the literature revealed only 15 previous reports. Most cases were associated with neurosurgical procedures. Antimicrobial therapy is complicated by multiple drug resistance of the organism, and trimethoprim-sulfamethoxazole is the recommended agent for treatment.

Abiotrophia defectiva: A rare cause of infective endocarditis

A case of Abiotrophia defectiva-caused infective endocarditis is described. The patient was successfully treated with penicillin combined with gentamicin. Due to the fastidious nature of the agent, there is a need for special media for isolation and moreover, there is a need for a future development of susceptibility assays applicable to the organism.

Spontaneous intracranial hypotension syndrome may mimic aseptic meningitis

Background: Spontaneous intracranial hypotension (SIH) is recognized with increasing frequency. A throbbing headache occurring or worsening in the upright position and improving after lying down, a so-called ‘orthostatic headache’, low cerebrospinal fluid (CSF) pressure, and diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI) are the major features of the classic syndrome. These patients, who are admitted with fever, headache, and CSF findings revealing lymphocytic pleocytosis, elevated protein concentration, normal glucose levels, and negative culture results, are prone to be misdiagnosed with aseptic meningitis. The aims of this single-centre retrospective study were to determine the epidemiological, clinical, laboratory, and radiological features of patients initially evaluated as having aseptic meningitis but subsequently diagnosed with SIH, and to touch upon the key points of the differential diagnosis in daily infectious diseases practice. Methods: Patients referred to Cerrahpasa Medical School with a presumed diagnosis of aseptic meningitis or viral meningitis between 1 January 2006 and 1 January 2011 were reviewed. Epidemiological, clinical, laboratory, radiological, and follow-up data obtained from the hospital database were processed. Patients confirmed to have SIH syndrome were included for evaluation. Results: Eleven cases of SIH syndrome were diagnosed during the study period (8 male and 3 female, median age 30 y, range 21–44 y). All had headache, hearing changes, and nausea. Vomiting (10/11) and posterior neck pain (9/11) were also frequent. Seven had fever and 5 had a stiff neck. Four cases had lymphocytic pleocytosis, 4 cases had elevated CSF protein concentrations (> 1.5 times the upper limit of normal), and 2 cases had slightly lower CSF glucose levels. Polymerase chain reaction (PCR) analyses of the CSF for Mycobacterium tuberculosis complex, herpes simplex viruses 1 and 2, and enteroviruses were negative in all cases. MRI of the 11 cases revealed signs of spontaneous CSF leaks with diffuse pachymeningeal gadolinium enhancement (11/11), sagging of the brain (9/11), enlargement of the pituitary (6/11), engorgement of the venous structures (5/11), and subdural fluid collections (2/11). CSF leaks were demonstrated by intrathecal magnetic resonance or computed tomography myelography at different levels along the thoracic spine (7/11), cervico-thoracic junction (2/11), and thoraco-lumbar junction (2/11). Autologous blood injection into the spinal epidural space (‘blood patch’) was performed for treatment. Strict bed rest followed, and all patients recovered fully within a week; no recurrence or complication was observed during the follow-up periods, which ranged from 6 months to 5 y.Conclusions: Findings of fever, headache, and meningeal irritation are generally accepted as the clinical features of meningitis. When CSF findings are not characteristically compatible with bacterial meningitis and particularly when the headache is orthostatic in nature, SIH should also be included in the differential diagnosis. MRI findings are characteristic and clearly contribute to the differential diagnosis between viral meningitis and SIH.