Nazif Elaldi

Efficacy of oral ribavirin treatment in Crimean-Congo haemorrhagic fever: a quasi-experimental study from Turkey.

OBJECTIVE The aim of this study was to evaluate the efficacy of oral ribavirin treatment in patients with Crimean-Congo haemorrhagic fever (CCHF). METHODS In 2004, all patients diagnosed with CCHF were treated with oral ribavirin, however in 2003 none of the CCHF patients had been given treatment due to lack of confirmatory diagnostic information at that time in Turkey. In this study, patients treated with ribavirin in 2004 (n=126) were compared with ribavirin-untreated CCHF patients (n=92) in 2003. Patients only with a definitive diagnosis of CCHF (clinical symptoms plus the presence of specific IgM antibodies against CCHF virus and presence of viral antigen) were included in this study. RESULTS There was no difference in the case-fatality rate between treated and untreated patients (7.1% vs. 11.9%; P>0.05). A Cox Proportional Hazards regression analysis revealed that altered sensorium and prolonged international normalized ratio were independent predictors of mortality. CONCLUSION Our results showed that oral ribavirin treatment did not improve the survival rate in CCHF patients. Ribavirin and supportive care are the only available choices for treatment of CCHF patients, but to ascertain the efficacy of ribavirin, more laboratory and observational studies are necessary and ultimately, to elucidate these conflicting results and evaluate the efficacy undoubtedly, a multicenter randomised controlled trial will be needed.

Crimean-Congo Hemorrhagic Fever Virus in High-Risk Population, Turkey

In the Tokat and Sivas provinces of Turkey, the overall Crimean-Congo hemorrhagic fever virus (CCHFV) seroprevalence was 12.8% among 782 members of a high-risk population. CCHFV seroprevalence was associated with history of tick bite or tick removal from animals, employment in animal husbandry or farming, and being >40 years of age.

Case Management and Supportive Treatment for Patients with Crimean-Congo Hemorrhagic Fever

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne infection which has been increasing in Turkey and European countries since the year 2000. The disease is particularly endemic in the Middle East and in some African countries. It is also seen in European countries as a travel infection. Patients with confirmed diagnosis are usually hospitalized for monitoring, while patients with good overall condition may be monitored on an outpatient basis. Hospitals that manage CCHF should have easy access to a blood bank, and tertiary care hospitals must have a well-equipped intensive care unit. Strict blood and body fluid control precautions should be started on admission to limit CCHF exposure. The follow-up period for each patient is determined based on individual clinical status and laboratory values. Since there is no specific antiviral treatment for CCHF, supportive treatment is essential. This review highlights some of the major features of case monitoring and supportive treatment in CCHF.

Effects of giardiasis on school success, weight and height indices of primary school children in Turkey.

Abstract Background : Giardia intestinalis, the most common parasite in the world, causes several adverse effects on school children, with the prevalence rate ranging between 7.3% and 28% (mean 13.8%) in Turkey. The aim of the present study was to investigate possible adverse effects of G. intestinalis on success at school, and the mean weight and height of primary school children in Sivas, Turkey.

Diabetic ketoacidosis and rhino-orbital mucormycosis

Mucormycosis often develops in immunocompromised patients, particularly in patients with diabetic ketoacidosis. Unless early diagnosis and treatment is established mucormycosis leads rapidly to death. A 38-year-old woman was admitted to the hospital with a severe diabetic ketoacidosis. Her clinical status improved in 4 days as a result of aggressive medical treatment. She has complained left cheek pain on the 10th day and had a swelling of her left cheek, facial edema, a black eschar on the palate and nasal cavity in association with visual disturbance and total ophthalmology in a short time. CT scan revealed left orbital cellulitis and pansinusitis. Excessive surgical treatment was performed and liposomal amphotericin-B, 4 mg/(kg day) was applied. Extensive fungal invasion of the orbit and the sinuses was demonstrated in the pathological species and Rhizomucor species were yielded with culture. Repeated superficial debridement was also performed. After 10 weeks, she was discharged with suggestion of insulin treatment and liposomal amphotericin-B with progressively decreasing doses. At the 13th month following the presentation, the patient was free of disease as confirmed by serial imaging and under good glycaemic control with insulin treatment. Although mucormycosis is a fatal infection, early diagnosis and aggressive treatment may decrease mortality.

Efficacy and Tolerability of Antibiotic Combinations in Neurobrucellosis: Results of the Istanbul Study

ABSTRACT No data on whether brucellar meningitis or meningoencephalitis can be treated with oral antibiotics or whether an intravenous extended-spectrum cephalosporin, namely, ceftriaxone, which does not accumulate in phagocytes, should be added to the regimen exist in the literature. The aim of a study conducted in Istanbul, Turkey, was to compare the efficacy and tolerability of ceftriaxone-based antibiotic treatment regimens with those of an oral treatment protocol in patients with these conditions. This retrospective study enrolled 215 adult patients in 28 health care institutions from four different countries. The first protocol (P1) comprised ceftriaxone, rifampin, and doxycycline. The second protocol (P2) consisted of trimethoprim-sulfamethoxazole, rifampin, and doxycycline. In the third protocol (P3), the patients started with P1 and transferred to P2 when ceftriaxone was stopped. The treatment period was shorter with the regimens which included ceftriaxone (4.40 ± 2.47 months in P1, 6.52 ± 4.15 months in P2, and 5.18 ± 2.27 months in P3) (P = 0.002). In seven patients, therapy was modified due to antibiotic side effects. When these cases were excluded, therapeutic failure did not differ significantly between ceftriaxone-based regimens (n = 5/166, 3.0%) and the oral therapy (n = 4/42, 9.5%) (P = 0.084). The efficacy of the ceftriaxone-based regimens was found to be better (n = 6/166 [3.6%] versus n = 6/42 [14.3%]; P = 0.017) when a composite negative outcome (CNO; relapse plus therapeutic failure) was considered. Accordingly, CNO was greatest in P2 (14.3%, n = 6/42) compared to P1 (2.6%, n = 3/117) and P3 (6.1%, n = 3/49) (P = 0.020). Seemingly, ceftriaxone-based regimens are more successful and require shorter therapy than the oral treatment protocol.

Pancreatic Pseudotumor due to Peripancreatic Tuberculous Lymphadenitis

Peripancreatic tuberculous lymphadenitis is a very rare and difficult diagnosis. We report herein a patient with a clinically solitary abdominal tuberculoma. A 68-year-old woman was admitted to our hospital with moderate-level obstructive jaundice due to a mass located between pylorus and head of the pancreas. There were no clinical signs or symptoms of tuberculosis in lungs or abdomen. After the diagnosis of a neoplasm of the pancreas was made, exploratory laparotomy was performed which revealed a conglomerated mass penetrating into the pancreas. Since an exact diagnosis could not be reached on the basis of frozen sections prepared during the operation, a standard Whipple procedure was performed. After the histopathological examination of the resected specimen revealed tuberculous lympadenitis, the patient was given antituberculous medication. The patient recovered well. An abdominal tuberculoma is often mistaken for a malignant neoplasm, and nonsurgical diagnosis and treatment of this entity continues to be a challenge.

Isolation and identification of free-living amoebae from tap water in Sivas, Turkey.

The present work focuses on a local survey of free-living amoebae (FLA) that cause opportunistic and nonopportunistic infections in humans. Determining the prevalence of FLA in water sources can shine a light on the need to prevent FLA related illnesses. A total of 150 samples of tap water were collected from six districts of Sivas province. The samples were filtered and seeded on nonnutrient agar containing Escherichia coli spread. Thirty-three (22%) out of 150 samples were found to be positive for FLA. The FLA were identified by morphology and by PCR using 18S rDNA gene. The morphological analysis and partial sequencing of the 18S rDNA gene revealed the presence of three different species, Acanthamoeba castellanii, Acanthamoeba polyphaga, and Hartmannella vermiformis. Naegleria fowleri, Balamuthia mandrillaris, or Sappinia sp. was not isolated during the study. All A. castellanii and A. polyphaga sequence types were found to be genotype T4 that contains most of the pathogenic Acanthamoeba strains. The results indicated the occurrence and distribution of FLA species in tap water in these localities of Sivas, Turkey. Furthermore, the presence of temperature tolerant Acanthamoeba genotype T4 in tap water in the region must be taken into account for health risks.

A preliminary study to evaluate the effect of intravenous ribavirin treatment on survival rates in Crimean-Congo hemorrhagic fever.

CrimeaneCongo Hemorrhagic Fever (CCHF) is a serious infection with mortality rates of 15e70%. It has been an endemic disease in Turkey and large outbreaks have been seen during spring and summer seasons since 2002. Effective therapy of CCHF is not exactly described yet. Oral ribavirin has been the most applied therapy of choice in clinical practices, but the effect of this therapy on the outcome of the disease is controversial. We present here the efficacy of i.v. ribavirin therapy on survival rate among the patients with severe CCHF. This case-control study was conducted in Ankara Numune Education and Research Hospital and Sivas Cumhuriyet University Hospital between May and August 2006. Patients with suspected cases of CCHF and having severe disease were applied i.v. ribavirin therapy immediately at admission after informed consent was taken. Because the results of diagnostic tests were obtained a few days later, i.v. ribavirin therapy was initiated before laboratory confirmation. According to the laboratory test results, confirmed cases were included in the study. Patients suspected of having CCHF were selected as those who had clinical signs and symptoms, epidemiological risk factors and laboratory findings of CCHF. Confirmed cases were defined as suspected cases with positive serum RT-PCR test and/or positive serum serological test results for CCHF specific IgM by ELISA. Severe cases were defined as having at least one of the findings from splenomegaly, INR 1.4 or impaired consciousness which had been found as independent risk factors for mortality of the patients with CCHF in the study of Bakir et al. Nine patients with severe CCHF were given i.v. ribavirin immediately at admission to the hospital. Intravenous ribavirin (Virazole , Valeant Pharmaceuticals International) was supplied by Ministry of Health of Turkey. The dosage and duration of the therapy were applied according to the recommendations of the World Health Organization (WHO). It was used at the dosage of 17 mg/kg i.v. loading dose, then 17 mg/kg every 6 h for 4 days, and then 8 mg/kg every 8 h for 6 days. Sixteen severe cases of the confirmed CCHF who didn’t receive i.v. ribavirin were included in control group. Totally 25 confirmed CCHF cases with severe disease were included in the study. Nine patients receiving i.v. ribavirin in addition to supportive treatment were included in the i.v. ribavirin group while 16 patients receiving only supportive treatment were included in the control group. There were no statistically significant differences between the two groups for demographic characteristics and laboratory test results. The efficacy of i.v. ribavirin therapy was evaluated with respect to some parameters between the ribavirin group and the control group (Table 1). No statistically significant differences between the two groups were determined for fatality rate, mean duration of hospitalization and the need for transfusion of blood or blood products. Adverse effects associated with i.v. ribavirin were detected in three patients, but it didn’t need discontinuation of the therapy. Allergic maculopapular rash developed in one patient who recovered after antihistaminic therapy. Two patients had nausea and vomiting due to i.v. ribavirin and those symptoms resolved with symptomatic treatment. Ribavirin has in vitro activity against CCHF virus. It is well-absorbed from the gastrointestinal tract. Oral formulation of ribavirin is more easily available and cheaper than intravenous formulation. However, gastrointestinal tract bleeding, impaired consciousness or vomiting affects oral intake and absorption of the drug. Some of the successful results were reported with oral ribavirin. Mardani et al. from Iran reported the largest series of patients with CCHF. In this historical cohort study, the efficacy of oral ribavirin in confirmed cases of CCHF had been

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.