Malaria in Turkey: a review of 33 cases.

AIM: To evaluate epidemiologic and clinical features of the patients with malaria followed in our clinic, and to review current status of malaria in our country. PATIENTS AND METHODS: Epidemiologic, clinical, diagnostic, and therapeutic features of 33 patients with malaria (4 female, 29 male, mean age: 28 +/- 11 years, range: 15-60) followed in our clinic between 1981 and 2000 were evaluated retrospectively. Malaria data of our country for 1926-2000 were obtained from Health Ministry. RESULTS: Diagnosis was established by thin smears of blood preparations obtained in the febrile period in all cases. Plasmodium vivax was detected in 26 patients (25 domestic and one imported), and P. falciparum in seven (two domestic and five imported). Sixty-one percent of the patients had the prodromal symptoms of the disease and used various antibiotics. All cases demonstrated the typical pattern of fever with chills. Fever (100%), splenomegaly (91%), hepatomegaly (55%), anemia (70%), leukopenia (48%), thrombocytopenia (48%), a rise in sedimentation rate (100%), and abnormalities in hepatic enzymes (30%) were determined in the patients. Chloroquine + primaquine were given to all patients with P. vivax, chloroquin (for three) or mefloquin (for four) alone were given to the patients with P. falciparum. One patient with P. falciparum died soon after admission, all the remaining recovered. Data from Health Ministry revealed that the most common (approximately 100%) species in our country is P. vivax. Although an eradication program against malaria initiated in 1926 achieved success, it still remains as an important health problem. CONCLUSION: Every febrile patient with a history of travel to the regions where malaria is endemic (tropical regions for the world, southeast regions for our country) should raise the suspicion of malaria. Every country should fight against malaria and global cooperation is essential.

Fever of unknown origin: a review of 20 patients with adult-onset Still's disease.

In this study we aimed to investigate the findings in patients with adult-onset Still's disease (AOSD) admitted with fever of unknown origin (FUO) during the last 18 years in our unit, in order to discover the ratio of such patients to all patients with FUO during the same period, and to determine the clinical features of AOSD in FUO. The number and the aetiologies of the patients with FUO diagnosed between 1984 and 2001, and the clinical features of those with AOSD, were taken from the patient files. The diagnosis of AOSD was reanalysed according to the diagnostic criteria of Cush et al. [11]. The presumed diagnoses before a diagnosis of AOSD was established were also noted. The chi(2) and Fisher's exact tests were used for statistical analysis. We studied 130 patients with a diagnosis of FUO, 36 (28%) of whom had collagen vascular diseases. Of these 36 patients, 20 (56%, 12 female, 8 male, mean age 34 years, range 16-65) had AOSD. Clinical and laboratory findings were as follows: fever (100%), arthralgia (90%), rash (85%), sore throat (75%), arthritis (65%), myalgia (60%), splenomegaly (40%), hepatomegaly (25%), lymphadenopathy (15%), anaemia (65%), neutrophilic leukocytosis (90%), increased erythrocyte sedimentation rate (100%), elevated transaminase levels (65%), a negative RF (100%), and a negative FANA (80%). Antibiotics had been prescribed in 18 (90%) of cases. The presumed infectious diagnoses were streptococcal tonsillitis/pharyngitis (50%), infective endocarditis (four patients), sepsis (two patients) and acute bacterial meningitis (two patients). The presumed non-infectious diagnoses were acute rheumatic fever (three patients), seronegative rheumatoid arthritis (two patients) and polymyositis (two patients). Sixteen patients were followed for a mean duration of 30 months (range 2-59). A remission was obtained with indomethacin in three cases (19%), and with prednisolone in the remainder. Relapse was detected in three cases (19%). AOSD is one of the most frequent aetiologies of FUO. During the diagnostic course of a patient with FUO, a maculopapular rash and/or arthralgia and/or sore throat should raise the suspicion of AOSD. Because the disease has heterogeneous clinical findings, certain bacterial infections (e.g. streptococcal pharyngitis and sepsis) are generally considered and the prescribing of antibiotics is common.

Fever of unknown origin in Turkey.

BACKGROUND: The etiology of fever of unknown origin (FUO) includes primarily infectious, collagen-vascular and neoplastic diseases. The distribution of the disorders causing FUO may differ according to the geographic area and the socioeconomical status of the country. Moreover, the developments in radiographic and microbiologic methods have changed the spectrum of diseases causing FUO. MATERIALS AND METHODS: We reviewed 117 cases that fulfilled the criteria of FUO followed in our department during the period 1984 to 2001. RESULTS: The etiology of FUO was infectious diseases in 34% of the patients, collagen-vascular diseases in 23%, neoplasms in 19% and miscellaneous diseases in 10%. In 14% of the cases the etiology could not be found. The three leading diseases were tuberculosis (24%), lymphomas (19%) and adult-onset Still's disease (11%). Tuberculosis was found to be a more common cause of FUO than reported in studies in developed countries. Invasive procedures helped to establish the diagnosis in 50 out of 92 patients (43%). As a final diagnostic procedure, laparotomy aided the establishment of a diagnosis in 15 out of 20 patients (75%). CONCLUSION: Although the relative rate of infectious disease as etiologic category is less commonly encountered, infectious disease, especially tuberculosis, remains a common cause of FUO. Although several diseases may lead to FUO, lymphomas, adult-onset Still's disease and particularly tuberculosis should be considered in the differential diagnosis of a patient admitted with FUO.

Tuberculous lymphadenopathy in adults: a review of 35 cases.

We retrospectively reviewed clinical, diagnostic, therapeutic and prognostic features of 35 patients (25 female, 10 male, mean age: 33 years, range: 16-70) with tuberculous lymphadenopathy (TB LAP) which had been followed since 1980. The diagnosis was established by tissue sampling in 32 cases (caseating granulomatous adenitis in 89%) or presence of acid-fast bacilli (AFB) in the aspirate in 2 cases and in the drainage in 1 case. Paraffin-embedded granulomatous tissues were stained by Ehrlich-Ziehl-Neelsen (EZN) and also Mycobacterium tuberculosis DNA was studied by polymerase chain reaction (PCR) (n = 21). The patients were admitted with enlarging LAP (34%), draining LAP (9%), and both systemic complaints and enlarging LAP (57%). Cervical lymph nodes were the most frequently involved site (77%). Pathologic findings on chest X-ray were seen in 23%. Erythrocyte sedimentation rate (ESR) was higher than 100 mm/hour in 25% and associated with systemic complaints. Tuberculin skin test was positive in 91%. AFB could not be seen in any granulomatous tissue (n: 21), but PCR study was positive in 33% (7/21). All patients were given anti-TB treatment (INH,RMP,EMB and/or PZA). Surgical excision of draining LAP with surrounding inflammatory tissues in addition to the medical treatment was needed in 2 cases. Clinical improvement was obtained within 3 months of the treatment and ESR returned to normal within 5 months. After completion of the treatment, 22 patients were followed-up; mean duration was 3 years, and none relapsed. In conclusion, a patient with TB LAP generally presents with a few small, painless, cervical lymph nodes, which are slowly enlarging. For exact diagnosis, excisional biopsy for histologic and microbiologic studies is essential. Use of anti-TB drugs is the main therapeutic option.

Miliary tuberculosis: clinical manifestations, diagnosis and outcome in 38 adults.

OBJECTIVE: The aim of the study was to determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and prognostic variables in patients with miliary tuberculosis (TB). METHODOLOGY: The records of 38 patients (15 male, 23 female; mean age 41 years, range 16-76 years) with miliary TB from 1978 to 1998 were analyzed. Patients were evaluated also as to whether they presented with a fever of unknown origin (FUO). Criteria for the diagnosis of miliary TB were (i) miliary pattern on chest X-ray or (ii) biopsy or autopsy evidence of miliary organ involvement. Paraffin-embedded tissues with granulomata (n = 15) were re-evaluated for the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR). RESULTS: Predisposing conditions were present in 24% of the patients. The findings were fever, weakness, night sweats, anorexia/weight loss (100% for each), hepatomegaly (37%), splenomegaly (32%), choroidal tubercles (13%), neck stiffness (11%), altered mental status (8%), anaemia (76%), leukopenia (26%), thrombocytopenia (16%), lymphopenia (76%), pancytopenia (8%) and hypertransaminasemia (55%). Eighteen patients (47%) met the criteria for a FUO. Miliary infiltrates were found on chest X-rays of 32 of 38 cases (84%). In six cases without miliary infiltrates, the diagnosis was made by laparotomy in four cases, and autopsy in two cases. Tuberculin skin test was positive in 32% of cases. Acid-fast bacilli were demonstrated in 37% (16/43), and cultures for M. tuberculosis were positive in 90% (9/10) of tested specimens (predominantly sputum and bronchial lavage). Granulomas were found in 85% (11/13) of lung, 100% (15/15) of liver, and 56% (9/16) of bone marrow tissue specimens. Acid-fast bacilli staining was negative in all (0/21), while PCR was positive in 47% (7/15) of specimens with granulomata. Mortality was 18%. Stepwise logistic regression identified male sex (P = 0.005), non-typical miliary pattern (P = 0.015), altered mental status (P = 0.002) and failure to treat for TB (P = 0.00001) as independent predictors of mortality. CONCLUSIONS: Miliary infiltrates on chest X-ray or FUO should raise the possibility of miliary TB. Therapy should be administered urgently to prevent an otherwise fatal outcome.

Spontaneous pneumothorax: a rare complication of miliary tuberculosis.

Pneumothorax is a rare complication of miliary tuberculosis. In this report, a 25-year old patient developing pneumothorax while on the treatment for miliary tuberculosis treatment is presented and the related literature has been reviewed. Pneumothorax, although rare, should be considered when a patient with miliary tuberculosis develops a sudden, severe pain on either side of the chest with breathlessness. The treatment should be tailored according to the size of pneumothorax either pleural drainage through chest tube or needle aspiration. Meanwhile, antituberculous treatment should be continued without interruption.

Giant cell arteritis and secondary amyloidosis: the natural history.

Giant cell (temporal) arteritis (GCA) may be a cause of fever of unknown origin (FUO) in elderly patients. The development of secondary (reactive) amyloidosis is an unusual complication of the disease. We describe a 65-year-old male patient who was hospitalized in our hospital with FUO and was diagnosed as having GCA 5 years later. At that time, he also had a nephrotic syndrome and secondary amyloidosis (AA-type). He died due to end-stage renal failure. The probable explanation for the development of this rare complication might be the late diagnosis of this chronic inflammatory disease, which was left untreated for a long period of time.

Tuberculous subcutaneous abscesses developing during miliary tuberculosis therapy.

Although rare, paradoxical subcutaneous abscesses may develop during appropriate treatment of miliary tuberculosis. While the pathogenesis of this phenomenon is not clear, some theories have been postulated. A case of a 37-y-old woman diagnosed as having miliary tuberculosis who developed subcutaneous abscesses within the 5 months of antituberculous treatment is described and all 6 similar cases published in English from 1954 to 1999 are discussed.

A case of cervical Brucella spondylitis with paravertebral abscess and neurological deficits.

Spondylitis is one of the more frequent osteoarticular complications of Brucella infection, but cervical spine involvement is rare. We report here a case of cervical Brucella spondylitis with paravertebral anterior epidural abscess which resulted in neurological deficits. The diagnosis is based on clinical history supported by Brucella serology, radiological findings and histological evidence.