Ümit Çelik

A prospective study of etiology of childhood acute bacterial meningitis, Turkey.

Vaccines to prevent bacterial meningitis in this region must provide reliable protection against serogroup W-135.

Multicenter Prospective Study on the Burden of Rotavirus Gastroenteritis in Turkey, 2005–2006: A Hospital-Based Study

Rotavirus is the main cause of gastroenteritis and dehydration requiring hospitalization among infants and children. Despite the high diarrhea-related mortality rate, there are limited studies describing the prevalence of rotavirus in Turkey. The disease burden of rotavirus gastroenteritis in Turkey was assessed by active, prospective surveillance conducted in accordance with a modified World Health Organization generic protocol from 1 June 2005 through 1 June 2006. A total of 411 children aged <5 years who were hospitalized for gastroenteritis in 4 centers were enrolled. Rotavirus was identified in 53% of samples from the 338 children tested; the range for individual centers was 32.4%-67.4%. Overall, 83.8% of rotavirus-positive children were aged <2 years. Rotavirus gastroenteritis occurred year-round but peaked in the winter. G1P[8] was the most widely prevalent strain (76% of strains), followed by G2P[4] (12.8%). G9P[8] was reported in samples from 3.9% of children. These data support the need for a rotavirus vaccine in Turkey.

Serotype distribution and antibiotic susceptibility of invasive Streptococcus pneumoniae disease isolates from children in Turkey, 2001–2004

Streptococcus pneumoniae is a major cause of childhood invasive infections, including sepsis, pneumonia and meningitis, and of non-invasive disease such as otitis media. Most S. pneumoniae strains from invasive infections capable of creating treatment problems in children because of antibiotic resistance belong to serogroups 14, 6, 9, 19 and 23. Despite progress in antimicrobial therapy, effective treatment is becoming increasingly complicated because of the rising worldwide emergence of pneumococci resistant to penicillin G and other commonly used antimicrobial agents [1, 3, 5].The aim of the present study was to investigate the antibiotic susceptibility pattern and serotype distribution of S. pneumoniae isolates from children younger than 10 years of age hospitalized with invasive pneumococcal disease (IPD) in Turkey during the years 2001–2004. All patients admitted and treated for invasive infections attributable to S. pneumoniae, between November 2001 and April 2004, in the six large university hospitals in Turkey, located in Istanbul, Adana, Ankara and Izmir, were included in this study. The study cohort represents roughly 30% (20 million) of the population of Turkey. Cases were eligible for evaluation if S. pneumonia, isolated from a normally sterile body site, was identified on the basis of typical colony morphology on blood agar as well as Gram strain, optochin sensitivity and bile solubility tests. Isolate identity was confirmed at the central study laboratory (Department of Microbiology and Infection Disease, Istanbul Faculty of Medicine). Susceptibility tests to antimicrobial agents (penicillin G, amoxicillin-clavulanic acid, cefotaxime, erythromycin and trimethoprim-sulfamethoxazole) were performed by standard disc diffusion method on Müller Hinton agar supplemented with 5% sheep blood. The susceptibility for penicillin was detected with a 1-μl oxacillin disc. The minimal inhibitory concentration (MIC) of the antibiotics was determined by the E test. Disc diffusion tests were employed according to the Clinical and Laboratory Standards Institute guidelines (formerly known as the NCCLS guidelines). An inoculum density equivalent to 0.5 MacFarland standard was prepared in Muller Hinton broth. Capsular typing was carried out by the Quellung reaction, using group and factor sera provided by the Statens Serum Institute (Denmark). Vaccine-type strains included serotypes 4, 6B, 9V, 14, 18C, 19F and 23F. We defined vaccine-related strains as pneumococci with serotypes within the same serogroup as the vaccine types (i.e. serotypes 6A, 9A, 9L, 9N, 18A, 18B, 18F, 19A, 19B, 19C, 23A and 23B) [6]. I. Yalçın Department of Paediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey

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.

ACE Gene Polymorphism in Turkish Children with Nephrotic Syndrome

Since 1990, the role of angiotensin converting enzyme (ACE) gene polymorphism in various renal and cardiac diseases is still debated. This study comprised 71 pediatric patients with nephrotic syndrome, 47 males (66%) and 24 females (34%) with a mean age of 57.4 ± 37.6 months, and a control group of 83 healthy males (59%) and 57 healthy females (41%) with a mean age of 505 ± 160.5 months. The distribution of the ACE genotype in the control group was II, 11%; ID, 53%; and DD, 36%, and the nephrotic syndrome was II, 4%; ID, 78%; and DD, 18%. Angiotensin-converting enzyme genotypes were significantly different between patients and control groups (p<0.05). The study groups consisted of 52 (73%) with steroid-sensitive nephrotic syndrome (SNSS) and 19 (27%) with steroid-resistant nephrotic syndrome (SRNS). The distribution of the ACE genotype was II, 6%; ID, 75%; and DD, 19% in the SSNS population and ID, 84% and DD, 16% in the SRNS population. No statistically significant difference was found between steroid sensitivity and ACE genotypes (p=0.5). The results show that ACE I/D polymorphism does not contribute to the steroid resistance, even though this study indicates that the presence of the I/D genotype has a much higher risk—approximately 2.8 times—of having nephrotic syndrome. Further studies with a larger number of patients are needed.

Bacterial agents causing meningitis during 2013–2014 in Turkey: A multi-center hospital-based prospective surveillance study

ABSTRACT This is an observational epidemiological study to describe causes of bacterial meningitis among persons between 1 month and 18 y of age who are hospitalized with suspected bacterial meningitis in 7 Turkish regions. covering 32% of the entire population of Turkey. We present here the results from 2013 and 2014. A clinical case with meningitis was defined according to followings: any sign of meningitis including fever, vomiting, headache, and meningeal irritation in children above one year of age and fever without any documented source, impaired consciousness, prostration and seizures in those < 1 y of age. Single tube multiplex PCR assay was performed for the simultaneous identification of bacterial agents. The specific gene targets were ctrA, bex, and ply for N. meningitidis, Hib, and S. pneumoniae, respectively. PCR positive samples were recorded as laboratory-confirmed acute bacterial meningitis. A total of 665 children were hospitalized for suspected acute meningitis. The annual incidences of acute laboratory-confirmed bacterial meningitis were 0.3 cases / 100,000 population in 2013 and 0.9 cases/100,000 in 2014. Of the 94 diagnosed cases of bacterial meningitis by PCR, 85 (90.4%) were meningococcal and 9 (9.6%) were pneumococcal. Hib was not detected in any of the patients. Among meningococcal meningitis, cases of serogroup Y, A, B and W-135 were 2.4% (n = 2), 3.5% (n = 3), 32.9% (n = 28), and 42.4% (n = 36). No serogroup C was detected among meningococcal cases. Successful vaccination policies for protection from bacterial meningitis are dependent on accurate determination of the etiology of bacterial meningitis. Additionally, the epidemiology of meningococcal disease is dynamic and close monitoring of serogroup distribution is comprehensively needed to assess the benefit of adding meningococcal vaccines to the routine immunization program.

An unusual cause of pleural effusion, urinothorax in a child with urinary stone disease.

The association of obstructive uropathy with ascites has been known since 1863 and with pleural effusion since 1954. Urinothorax is a rare complication of blunt renal trauma, ureteral instrumentation or ureteral surgery. Leakage from the urinary tract may cause urinoma, retroperitoneal collection of fluid, which can lead to urinothorax. This case report describes a child with a massive right-sided pleural effusion that was caused by same-sided renal calculi. The effusion disappeared within a few days after adequate urinary drainage had been established.

Cerebral Salt Wasting in Status Epilepticus: Two Cases and Review of the Literature

BACKGROUND Cerebral salt wasting is a hypovolemic hyponatremia state, caused by natriuresis and diuresis. The most important element of treatment is to replace the volume and sodium loss and improve the current clinic. PATIENTS We present two children who were treated in the intensive care unit who subsequently developed cerebral salt wasting. Diagnosis was based on hyponatremia associated with high urinary sodium excretion and inappropriately high urine output in the presence of dehydration. As part of the treatment, one patient was given fluid and sodium replacement, measures that were insufficient in the other patient, who also required fludrocortisone treatment. CONCLUSION The status epilepticus may be involved in the etiology of cerebral salt wasting. In both patients, cerebral salt wasting was detected in the posttreatment follow-up evaluations. Cerebral salt wasting is particularly likely to occur in individuals with status epilepticus, and the electrolyte and hydration status of these patients should be monitored closely, even after the convulsions are taken under control.

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.