Sevgi Ergin

The first clinical case due to AP92 like strain of Crimean-Congo Hemorrhagic Fever virus and a field survey

BackgroundCrimean-Congo Hemorrhagic Fever (CCHF) is a fatal infection, but no clinical case due to AP92 strain was reported. We described the first clinical case due to AP92 like CCHFV.MethodsA case infected by a AP92 like CCHFV was detected in Balkanian part of Turkey. Diagnosis was confirmed by RT-PCR and sequencing. A human serologic and tick survey studies were performed in the region, where the case detected.ResultsThirty eight individuals out of 741 were found to be anti CCHFV IgM positive. The attack rate for overall CCHFV was calculated as 5.2%. In univariate analyses, CCHFV IgM positivity was found to be associated with the age (p < 0.001), male gender (p = 0.001), agricultural activity (p = 0.036), and history of tick bite (p = 0.014). In multivariate analysis, older age (OR: 1.03, CI:1.01–1.05, p < 0.001), male gender were found to be the risk factors (OR: 2.5, CI:1.15–5.63, p = 0.020) for CCHFV infection.ConclusionThis is the first human case with AP92 like CCHFV infection. Furthermore, this is the first report of AP92 like strain in Turkey. In the region, elderly males carry the highest risk for CCHFV infection.

Crimean-Congo hemorrhagic fever in European part of Turkey: genetic analysis of the virus strains from ticks and a seroepidemiological study in humans.

A survey of ticks from domestic ruminants, together with a serosurvey in humans was conducted in Thrace (northwestern Turkey) to evaluate the prevalence of Crimean-Congo hemorrhagic fever virus (CCHFV) in ticks and humans. More prevalent ticks were Hyalomma marginatum, Hyalomma aegyptium, Rhipicephalus bursa, and Rhipicephalus (Boophilus) annulatus, with low numbers of Dermacentor marginatus, Rhipicephalus sanguineus group, and Ixodes ricinus. No differences in the tick faunal composition were found among surveyed provinces. CCHFV was detected using specific primers for strains belonging to both Europe 1 and Europe 2 clades in a total of 15 pools of ticks collected in nine localities. The maximum likelihood estimate of infection rate was calculated as 0.72/100 ticks (95% CI = 0.42-1.16). Viral RNA was observed only in H. marginatum, R.(B.) annulatus, and R. bursa with overall maximum likelihood estimate infection rates being 0.93 (95% CI = 0.35-2.05), 0.74 (95% CI = 0.24-1.78), and 1.67 (95% CI = 0.69-3.46), respectively. The surveyed region is the only place where both viral strains are circulating together in nature in Turkey. Results from serosurvey on 193 samples from three localities in the region showed that immunoglobulin M and immunoglobulin G rates are compatible with an epidemiological situation in which the virus has been present for a long time and is not the result of a recent invasive event from the main epidemic center in Anatolia (north-central Turkey). Seropositivity rates cannot be compared against the tick faunal composition, because of the homogeneity in the results about tick surveys. The high rate of seropositivity, and the prevalence of CCHFV in both Europe 1 and 2 clades among the ticks, but few clinical cases suggest that the circulation of both viral strains may confer protection against the CCHFV infection.

A cluster of acute-onset postoperative endophthalmitis over a 1-month period: investigation of an outbreak caused by uncommon species

Aim To report the clinical course, treatment response and prognosis of eight cases which developed acute-onset postoperative endophthalmitis over a 1-month period. Methods 8 patients who were operated on over a period of 1 month and developed acute postoperative endophthalmitis were evaluated. Five of the patients had cataract surgery, one had cataract surgery combined with silicone extraction, and two patients had pars plana vitrectomy (PPV). Clinical patterns were observed, intraocular cultures were obtained, and the source of the organisms causing the epidemic was investigated. All patients had intravitreal antibiotic injections, three had PPV, and in two patients anterior chamber irrigation was performed. Results Vitreous cultures showed Cellulosimicrobium cellulans in three cases and Stenotrophomonas maltophilia in one case. Four of the cases were culture negative. Stenotrophomonas maltophilia were also isolated from unused bottles of irrigating solutions. The final visual acuity of the patients ranged between HM and 7/10. All three patients with Cellulosimicrobium cellulans had a final visual acuity of ≥5/10. The available irrigating solutions were changed, and the endophthalmitis did not recur. Conclusions The authors are unaware of any previous reports of postoperative endophthalmitis associated with Cellulosimicrobium cellulans. Prompt management with microbiological support, intravitreal antibiotics and PPV when needed were the key to good visual outcomes in this endophthalmitis outbreak.

Lack of Chlamydophila pneumoniae and predominance of Alloiococcus otitidis in middle ear fluids of children with otitis media with effusion

OBJECTIVE To investigate the presence of Chlamydophila pneumoniae and other bacterial pathogens in middle ear effusion samples obtained from children with otitis media with effusion (OME). MATERIALS AND METHODS Twenty-eight children (mean age 7.03; standard deviation 2.18) with OME unresponsive to medical therapy were included in the study. All of the children underwent ventilation tube insertion under general anesthesia. Eighteen patients were bilaterally affected whereas 10 children had unilateral disease. The middle ear fluids (46 samples in total) were collected during ventilation tube insertion, and were evaluated subsequently for the presence of C. pneumoniae and other bacterial pathogens using polymerase chain reaction (PCR). RESULTS Although all samples were negative for C. pneumoniae, bacterial DNA was detected in 21 of 46 samples. Overall 40% of the patients (4/10) with unilateral involvement, and 61% of the patients (11/18) with bilateral involvement were positive for bacterial DNA. In 6 patients with bilateral OME bilateral samples were positive, whereas 5 patients with bilateral OME showed only unilateral positivity. According to the results of DNA sequencing analysis, all of the positive samples harbored only one bacterial species. In 12 of 46 samples Alloiococcus otitidis DNA (26%), in 7 Haemophilus influenzae DNA (15%), in one Streptococcus pneumoniae DNA (2%) and in one Moraxella catarrhalis DNA (2%) were present. CONCLUSIONS Our findings support that C. pneumoniae does not seem to have a role in OME in children whereas A. otitidis was found to be more frequent than the other common pathogens. Further studies are required to elucidate the exact pathogenetic role of these microorganisms in OME.

The detection of occult HBV infection in patients with HBsAg negative pattern by real-time PCR method

AIM Diagnostic problems may be encountered in Hepatitis B virus (HBV) infections by serological tests and HBV DNA can be detectable in plasma and liver tissue while the HBsAg test is negative. This situation can be defined as occult or isolated Anti-HBc infections. Occult HBV infections may be divided into two categories by using hepatitis markers. One of them being that all hepatitis markers are negative and the other situation is having Anti-HBc +/- and Anti-HBs+patterns. These situations can be seen in isolated Anti-HBc cases. METHOD In this study, we aimed to detect the ratio of occult HBV infections by investigating HBV DNA in four different groups. These groups are: (1) 20 isolated Anti-HBc positive individuals, (2) 23 individuals naturally immune to HBV infection, (3) 20 individuals with seronegative hepatitis markers and high ALT levels, and (4) 23 vaccinated individuals against HBV. In order to detect HBV DNA the real-time PCR kit (QIAGEN, Artus HBV RG PCR Kit, Germany) with high analytical sensitivity (≤3.8IU/ml) was used. RESULTS The reliability of the molecular methods was assessed by increasing the quantitation standards of internal, external and also positive controls. No HBV DNA was detected in any of the 86 individuals consisting of four study groups. CONCLUSION In conclusion, we did not detect occult HBV infection in our four study groups by using a high sensitivity real-time (RT) PCR method, while occult HBV infections with various frequencies were detected in other large, serial international studies in which highly sensitive analytical molecular methods were used. Although we also used a high standard molecular kit to detect occult HBV infections, we suggest that the reason for the absence of detection of occult HBV infections may be due to the small number of cases included in this study. However, it was assumed that the use of a nucleic acid amplification technology (NAT) with high analytical sensitivity in blood banks to prevent HBV transmission by blood transfusion is controversial due to both costs and diagnostic efficacy and for this reason we suggest that it will be useful to perform large serial studies regarding occult HBV infections in the future.

New approaches to in vitro diagnosis of hepatitis C infection a reason for post transfusion hepatitis: Diagnostic value of determination of hepatitis C virus core antigen

In between the dates of February 2008-March 2009, by applying to Istanbul University CTF Microbiology and Clinical Microbiology Basic Sciences Branch and Duzen laboratories, 123 cases, where HCV RNA and anti-HCV positivity are identified with molecular (real-time PCR) and serologic (ELISA) methods as a positive control group, and 48 cases where HCV RNA and anti-HCV negativity are identified as a negative control group are established. The values of sensitivity, specificity, positive and negative approximation of recently developed HCV Core Ag (Abbott Diagnostics, Germany) kit are determined successively as 94.3%, 97.9%, 99.1%, 87%, 95.3% and 88%. Although the new HCV Ag assay is clearly not sensitive enough to replace HCV NAT it may serve as a valuable tool in the HCV diagnostic algorithm as it is able to pick up a great majority of anti-HCV and HCV RNA positive samples, thus allowing a timely and less expensive serological diagnosis of an active HCV infection. This may be an advantage for labs that do not have access to PCR easily.

Determination of clinical significance of coagulase-negative staphylococci in blood cultures

The aim of this study was to investigate the criteria used to distinguish coagulase-negative staphylococci (CoNS) bacteremia from contamination. We evaluated 162 adult patients with CoNS-positive blood cultures (BCs). Of the 162 patients, 35 (21.6%) had at least 2 positive BCs and 127 (78.4%) had a single positive BC. According to the Laboratory-Confirmed Bloodstream Infection (LCBI) criteria, 24 (14.8%) patients with the same species of CoNS had true bacteremia, and 138 (85.2%) patients had contaminants. Despite the detection of the same CoNS species, 9 of the 24 patients had different CoNS genotypes. Using clinical assessments, only 20 patients were diagnosed with true bacteremia, 8 of them had a single positive BC. We concluded that only using the LCBI criteria or clinical evaluations of a patient were not sufficient to distinguish CoNS bacteremia from contamination. Molecular identification should also be performed as a diagnostic laboratory parameter for CoNS bacteremia.

Failure to Detect Hepatitis B Virus in Vitreous by Polymerase Chain Reaction

Purpose: To assay the vitreous of asymptomatic hepatitis B virus (HBV) carriers for the presence of HBV DNA using polymerase chain reaction (PCR). Methods: Vitreous and serum specimens were collected from 13 carriers of HBV. The presence of HBV DNA was investigated by using PCR and Digene’s Hybrid Capture System. The presence of hepatitis B surface antigen (HBsAg) in vitreous was also investigated by using the enzyme immunoassay (EIA). Results: The serum was positive for HBV DNA in3 of the 13 asymptomatic carriers using PCR. Vitreous samples of all the patients, including 3 patients who were positive for HBV DNA in serum, were negative for HBV DNA with PCR and were negative for HBsAg with EIA. Conclusion: There is no evidence of HBV in the vitreous of asymptomatic HBV carriers.

Role of TTV in acute non-A-E hepatitis in Turkey.

Five hepatotropic viruses are the aetiological agents in the majority of acute viral hepatitis cases: HAV, HBV, HCV, HDV and HEV. Their prevalence in the setting of acute hepatitis changes with geographical region. However, in a group of patients with acute hepatitis, serology for these viruses remains negative. The percentage of acute viral hepatitis due to hepatitis-non-A–E viruses has been reported as 13.9% (1). A new, single-stranded and unenveloped DNA virus, known as TTV (transfusion-transmitted virus) was isolated by Japanese investigators in 1997 (2). The prevalence of TTV has been reported as 10% in the general population, 1–1.9% in blood donors, 25% in patients with chronic liver disease, 19–27% in patients with idiopathic fulminant hepatic failure and 15% in patients with cryptogenic cirrhosis (3–5). In spite of a high prevalence of TTV in different liver diseases, current data suggests that it has a pathogenic role in chronic hepatitis (3). The transmission routes of TTV are parenteral or non-parenteral. The latter has been reported as 4% and 38% in 2 different series (3, 5). There is no satisfactory information about vertical, horizontal and sexual transmission. There is a little information about the aetiological role of TTV in acute viral hepatitis cases in MEDLINE research (from 1997 to November 1999) (6). The aim of this study was therefore to determine causes of acute viral hepatitis in Turkey and to assess the relative importance of TTV in the patients with acute viral hepatitis who are seronegative for hepatitis A–E. A total of 109 consecutive patients with acute hepatitis during January 1996 to October 1998 were included in the study. The patients who had an aminotransferase level elevated at least 10fold were included as having acute hepatitis. They were followed in our infectious disease clinic as inpatients or outpatients. The serum samples of inpatients were drawn on the first day of hospitalization. Their mean age was 24 years (range 11–74 years) and 71 were male. Of the 109 cases of acute viral hepatitis, 88% were due to 1 of the 4 recognized hepatitis virus (A–D). ELISA was used for the detection of HbBsAg, anti-HBc-IgM, anti-HAV-IgM (Sanofi Diagnostics Pasteur, Marnes-la-Coqutte, France), anti-HCV, antiCMV-IgM (Dia Sorin Group, Saluggia, Italy), anti-HEV-IgM (Guiliana Cremascoli Chemical, Segrate, Spain), EBV-IgM (Gull, Bad Hamburg, Germany) and parvovirus B19-IgM (Biotrin, Dublin, Ireland). The percentages of HAV, HBV, HCV and HDV were 34.8%, 49.5%, 2.7% and 0.9%, respectively (Fig. 1). It was planned to investigate the 13 seronegative patients further for detection of rare aetiological agents. Serum samples were available for 8 patients, but not for the remaining 5 outpatients. The sera of 8 patients were tested by ELISA for IgM to EBV, CMV, parvovirus B19, HEV; by PCR for HBV-DNA, HCV-RNA and HEV-RNA. All patients were negative for all of the viruses mentioned. The serum samples of these 8 patients, 1 of whom had fulminant hepatitis, were tested for TTV-DNA. TTV-DNA was detected by PCR with semi-nested primers described by Okamoto et al. (7). DNA was extracted from serum with proteinase K-SDS and phenol-chloroform protocol and then TTV-DNA was amplified by semi-nested PCR with TTV-specific primers derived from open reading frame 1 (ORF) of TTV. Amplification products were run by electrophoresis in 2% agarose gel, stained with ethidium bromide and photographed under ultraviolet light. All sera were also negative for TTV. Approximately 12% of cases of acute viral hepatitis in Turkey are of unknown aetiology. This study suggests that TTV is not an aetiological agent of non-A–E acute viral hepatitis in Turkey. One or more additional agents may be responsible for acute viral hepatitis. Therefore, efforts must be made to search for new hepatitis viruses.

Patterns of EPIYA motifs among cagA-positive Helicobacter pylori strains: a case–control study in a Turkish population with Eurasian geographical features

Geographical variation in the frequency of various gastroduodenal pathologies was shown to be related to the geographical diversity of H. pylori CagA Glu-Pro-Ile-Tyr-Ala (EPIYA) patterns. We examined the EPIYA patterns of H. pylori and the association of EPIYA patterns with gastric cancer (GC) for the first time, to the best of our knowledge, in Turkey. The patient group (PG) contained 60 patients [38 GC and 22 duodenal ulcer (DU) patients]. The control group (CG) was 110 individuals [94 gastritis patients and 16 persons with a normal gastrointestinal system (NGIS)]. Specific primers were used for the detection of cagA including empty-site-positive and EPIYA-A, -B, -C, -D PCR. Bands of EPIYA-A, -B, -C were confirmed by DNA sequencing. One hundred and forty-two (83.5 %) strains [60 in the PG (38 GC, 22 DU), 82 in the CG (72 gastritis, 10 NGIS)] were positive for the cagA gene. EPIYA-C with multiple repeats was detected in 34 (23.9 %) strains, and 22 (64.7 %) were from GC patients. EPIYA-C with one repeat was detected in 89 (62.7 %) strains, and 54 (60.7 %) were from gastritis patients. EPIYT was detected in 10 strains, and EPIYA-D was not detected. The number of EPIYA-C with multiple repeats was significantly higher for the PG than for the CG (P < 0.0001). In GC patients, the number of EPIYA-C with multiple repeats was significantly higher than one repeat (P < 0.0001). In conclusion, our study showed that multiple EPIYA-C repeats increases the GC risk by 30.6-fold and the DU risk by 8.9-fold versus the CG. This indicates that Western-type H. pylori strains in Turkey have similar EPIYA motifs to those of neighbouring countries and Western populations.