An Evaluation of the Hitit Index in Differential Diagnosis of Crimean-Congo Hemorrhagic Fever in the Emergency Department.

Background and Objectives: Crimean-Congo Hemorrhagic Fever (CCHF) is a viral zoonotic infection, which is seen over a wide geographic area. The mortality rate is in inverse proportion to the ability of patients to access healthcare services. Therefore, early identification of patients is extremely important. The aim of this study was to test the sensitivity and specificity of the Hitit Index in the differentiation of CCHF cases at the time of presentation at the Emergency Department and to evaluate the agreement of this index with molecular (CCHFV RNA) and/or serological diagnostic tests (ELISA-CCHF IgM). Materials and Methods: The patients included were those who presented at the Emergency Department (ED) with the complaint of a tick bite or those identified as potential CCHF cases as a result of complaints and/or laboratory findings. For cases that met the study inclusion criteria, the Hitit Index score was calculated automatically from the parameters included in the index formula uploaded to the automation system in the ED at the time of presentation. Through comparisons of the agreement of the Hitit Index with the CCHFV-RNA and/or IgM results the power of the Hitit Index for differentiation of CCHF cases in ED was evaluated. Results: The data of 273 patients were analyzed. There was a history of tick bite in 236 (86%) cases. Of the evaluated cases, 110 (40.2%) were hospitalized; CCHF positivity was determined in 72 (26.4%). The Hitit Index values calculated in ED and at 24 h after hospitalization were determined to be significant in the prediction of the CCHF cases (p < 0.001, AUC = 0.919 (0.887-0.951); p < 0.001, AUC = 0.902 (0.841-0.962). For a cut-off point of 0 of the Hitit Index evaluated in ED, the classification success was found to have a sensitivity of 75% and specificity of 88% (PPV-NPV). For a cut-off point of 0 of the Hitit Index evaluated at 24 h after hospitalization, the classification success was found to have a sensitivity of 79.7% and specificity of 84% (PPV-NPV). Conclusions: The defined form of the Hitit Index can be used in the differentiation of CCHF cases in ED with high sensitivity and specificity levels. Just as evaluation with the Hitit Index prevents unnecessary hospitalization, it can also contribute to reducing mortality rates with the early identification of CCHF cases.

In a Real-Life Setting, Direct-Acting Antivirals to People Who Inject Drugs with Chronic Hepatitis C in Turkey.

BACKGROUND: People who inject drugs (PWID) should be treated in order to eliminate hepatitis C virus in the world. The aim of this study was to compare direct-acting antivirals treatment of hepatitis C virus for PWID and non-PWID in a real-life setting. METHODS: We performed a prospective, non-randomized, observational multicenter cohort study in 37 centers. All patients treated with direct-acting antivirals between April 1, 2017, and February 28, 2019, were included. In total, 2713 patients were included in the study among which 250 were PWID and 2463 were non-PWID. Besides patient characteristics, treatment response, follow-up, and side effects of treatment were also analyzed. RESULTS: Genotype 1a and 3 were more prevalent in PWID-infected patients (20.4% vs 9.9% and 46.8% vs 5.3%). The number of naïve patients was higher in PWID (90.7% vs 60.0%), while the number of patients with cirrhosis was higher in non-PWID (14.1% vs 3.7%). The loss of follow-up was higher in PWID (29.6% vs 13.6%). There was no difference in the sustained virologic response at 12 weeks after treatment (98.3% vs 98.4%), but the end of treatment response was lower in PWID (96.2% vs 99.0%). In addition, the rate of treatment completion was lower in PWID (74% vs 94.4%). CONCLUSION: Direct-acting antivirals were safe and effective in PWID. Primary measures should be taken to prevent the loss of follow-up and poor adherence in PWID patients in order to achieve World Health Organization's objective of eliminating viral hepatitis.

Efficacy and Safety of Direct-Acting Antivirals in Elderly Patients with Chronic Hepatitis C: A Nationwide Real-Life, Observational, Multicenter Study from Turkey.

BACKGROUND: The number and proportion of elderly patients living with chronic hepatitis C are expected to increase in the coming years. We aimed to compare the real-world efficacy and safety of direct-acting antiviral treatment in elderly and younger Turkish adults infected with chronic hepatitis C. METHODS: In this multicenter prospective study, 2629 eligible chronic hepatitis C patients treated with direct-acting antivirals between April 2017 and December 2019 from 37 Turkish referral centers were divided into 2 age groups: elderly (≥65 years) and younger adults (<65 years) and their safety was compared between 2 groups in evaluable population. Then, by matching the 2 age groups for demographics and pretreatment risk factors for a non-sustained virological response, a total of 1516 patients (758 in each group) and 1244 patients (622 in each group) from the modified evaluable population and per-protocol population were included in the efficacy analysis and the efficacy was compared between age groups. RESULTS: The sustained virological response in the chronic hepatitis C patients was not affected by the age and the presence of cirrhosis both in the modified evaluable population and per-protocol population (P = .879, P = .508 for modified evaluable population and P = .058, P = .788 for per-protocol population, respectively). The results of the per-protocol analysis revealed that male gender, patients who had a prior history of hepatocellular carcinoma, patients infected with non-genotype 1 hepatitis C virus, and patients treated with sofosbuvir+ribavirin had a significantly lower sustained virological response 12 rates (P < .001, P = .047, P = .013, and P = .025, respectively). CONCLUSION: Direct-acting antivirals can be safely used to treat Turkish elderly chronic hepatitis C patients with similar favorable efficacy and safety as that in younger adults.

Which scoring system is effective in predicting mortality in patients with Crimean Congo hemorrhagic fever? A validation study.

We aimed to decide which scoring system is the best for the evaluation of the course of Crimean-Congo Hemorrhagic Fever (CCHF) by comparing scoring systems such as qSOFA (quick Sequential Organ Failure Assessment), SOFA (Sequential Organ Failure Assessment), APACHE II (Acute Physiology and Chronic Health Evaluation II) and SGS (Severity Grading System) in centers where patients with CCHF were monitored. The study was conducted with patients diagnosed with CCHF in five different centers where the disease was encountered most commonly. Patients having proven PCR and/or IgM positivity for CCHF were included in the study. The scores of the scoring systems on admission, at the 72nd hour and at the 120th hour were calculated and evaluated. The data of 388 patients were obtained from five centers and evaluated. SGS, SOFA and APACHE II were the best scoring systems in predicting mortality on admission. All scoring systems were significant in predicting mortality at the 72nd and 120th hours. On admission, there was a correlation between the qSOFA, SOFA and APACHE II scores and the SGS scores in the group of survivors. All scoring systems had a positive correlation in the same direction. The correlation coefficients were strong for qSOFA and SOFA, but poor for APACHE II. A one-unit rise in SGS increased the probability of death by 12.818 times. qSOFA did not provide significant results in predicting mortality on admission. SGS, SOFA and APACHE II performed best at admission and at the 72nd and 120th hours.

COVID-19 and Crimean-Congo Hemorrhagic Fever: Is there any Similarity in Chest Radiology?

Objective: While the coronavirus disease 2019 (COVID-19) pandemic was continuing at full speed, patients with Crimean-Congo hemorrhagic fever (CCHF), which is endemic in our region, apply to the emergency department simultaneously. The presence of computed tomography (CT) lesions suggesting COVID-19 in some CCHF patients has brought to our mind the question of whether there is CCHF lung involvement even though respiratory symptoms are not at the forefront. Methods: In this study, the findings of chest CT, demographic data and clinical symptoms of cases who had thorax tomography scan with suspicion of COVID-19 in the emergency department in the spring and summer of 2020 and were diagnosed with CCHF as a result of the evaluation and followed up in our clinic were compared with the findings of COVID-19 cases that were hospitalized and treated in the same period. Results: Seventy-seven COVID-19 and 25 CCHF cases were included in the study. Myalgia, headache, diarrhea, nausea and vomiting were significantly higher in CCHF patients ( p<0.05). Cough was significantly more common in COVID-19 patients ( p=0.034). Ground-glass opacity (GGO) was the most common tomography finding in CCHF, and cases without lung involvement were significantly higher (p=0.001). GGO, consolidation, vascularization, atelectasis band, reverse halo, air-bubble, nodule were significantly high in COVID-19 patients. Conclusion: During the epidemic period, no pathological finding was found in thoracic CT in most of the CCHF cases, and the presence of involvement in the lung tomography in cases with similar clinical and laboratory findings should primarily suggest the diagnosis of COVID-19.

A Rare Presentation of Leptospirosis: Dysarthria and Guillain-Barré Syndrome.

Leptospirosis can present with severe cases such as polymyositis, peripheral neuropathy, and rarely, Guillain-Barré Syndrome (GBS). This paper reports a case who presented with dysarthria and GBS. A female patient presented with complaints of weakness, dizziness, diarrhea, and dysarthric. Her assessments included muscle strength globally 4/5 and deep tendon reflexes as hypoactive. An electromyographic examination was performed with the increase of weakness in the lower extremities, which indicated findings compatible with GBS. Antibodies against Leptospira biflexa serovar Patoc 1 at 1/400 titer were detected in the microscopic agglutination test (MAT). Neurological involvement in leptospirosis cases can range from meningoencephalitis to GBS.

The Role of Pneumococcal Pneumonia among Community-Acquired Pneumonia in Adult Turkish Population: TurkCAP Study.

OBJECTIVE: To evaluate the rate of pneumococcal pneumonia (PP) among patients with community-acquired pneumonia (CAP) in Turkey and to investigate and compare features of PP and non-PP CAP patients. MATERIAL AND METHODS: This multicenter, non-interventional, prospective, observational study included adult CAP patients (age ≥ 18 years). Diagnosis of PP was based on the presence of at least 1 positive laboratory test result for Streptococcus pneumoniae (blood culture or sputum culture or urinary antigen test [UAT]) in patients with radiographic findings of pneumonia. RESULTS: Four hundred sixty-five patients were diagnosed with CAP, of whom 59 (12.7%) had PP. The most common comorbidity was chronic obstructive pulmonary disease (30.1%). The mean age, smoking history, presence of chronic neurological disease, and CURB-65 score were significantly higher in PP patients, when compared to non-PP patients. In PP patients, 84.8% were diagnosed based ony on the UAT. The overall rate of PP patients among CAP was calculated as 22.8% considering the UAT sensitivity ratio of 63% (95% confidence interval: 45-81). The rate of intensive care treatment was higher in PP patients (P = .007). While no PP patients were vaccinated for pneumococcus, 3.8% of the non-PP patients were vaccinated (P = .235). Antibiotic use in the preceding 48 hours was higher in the non-PP group than in the PP group (31.8% vs. 11.1%, P = .002). The CURB-65 score and the rate of patients requiring inpatient treatment according to this score were higher in the PP group. CONCLUSION: The facts that PP patients were older and required intensive care treatment more frequently as compared to non-PP patients underline the burden of PP.

Monitoring Crimean-Congo haemorrhagic fever virus RNA shedding in body secretions and serological status in hospitalised patients, Turkey, 2015.

IntroductionCrimean-Congo haemorrhagic fever (CCHF) is a tick-borne disease in Africa, Asia, the Balkan peninsula, the south-east of Europe and the Middle East, with mortality rates of 3-30%. Transmission can also occur through contact with infected animals or humans.AimThis observational, prospective case series aimed to investigate detectable viral genomic RNA in whole-body fluids and antibody dynamics in consecutive daily samples of patients diagnosed with CCHF until discharge from hospital.MethodsWe tested 18 patients and 824 swabs and sera with RT-PCR and 125 serum samples serologically.ResultsThe longest duration until clearance of viral RNA was 18 days from serum collection and 18, 15, 13, 19 and 17 days, respectively, from nasal, oral, genital (urethral or vaginal) and faecal swab, and urine. In seven patients, viral load decreased in serum at the same time as it increased in urine or persisted at the same logarithmic values. Despite clearance in serum, viral RNA was detected in faeces and genital swabs in two and three patients, respectively. Viral clearance from body fluids occurred earlier than from serum in eight patients on ribavirin treatment. The shortest seroconversion time was 3 days after symptom onset for IgM and IgG. Seroconversion of IgG occurred until Day 14 of symptoms.ConclusionWe report persistence of viral RNA in urine, faeces and genital swabs despite serum clearance. This may indicate a need for extending isolation precautions, re-evaluating discharge criteria and transmission risk after discharge, and considering oral swabs as a less invasive diagnostic alternative.

Hitit Index to distinguish patients with and without Crimean-Congo hemorrhagic fever.

Crimean-Congo hemorrhagic fever (CCHF) is fatal. Therefore, it is very important to use an inexpensive, easily accessible, quick and accurate screening index based on clinical signs and laboratory parameters to identify patients suspected of having CCHF. Laboratory test results on the day of hospitalization for 268 inpatients suspected of having CCHF were used to calculate the laboratory section of the Hitit Index, while 65 of these were also monitored daily during their hospital stay to develop the clinical section of the Hitit Index. Two-hundred CCHF-negative outpatients were also evaluated. One-hundred and forty-nine inpatients were CCHF-positive and 119 inpatients were CCHF-negative. The Hitit Index is 5.6 - (5.3*lymphocyte) - (0.02*fibrinogen) - (12*direct bilirubin) + (0.04*AST) + (0.32*hematocrit) - (0.5*neutrophil) - (0.07*CKD-EPI) - (0.001*CK) ± conjunctival hyperemia (+1.5 in conjunctival hyperemia presence and -1.5 in conjunctival hyperemia absence). In 65 inpatients monitored daily, Hitit Index results for CCHF-positive and negative inpatients were 6.10(1.90-12.30) and -5.35(-8.83- -1.95), while CCHF-negative outpatients were -10.99(-15.64- -6.95) (P < 0.001), respectively. On hospitalization day, just one inpatient was false-negative in 27 CCHF-positive inpatients, while four were false-positive among 38 CCHF-negative inpatients using the Hitit Index. After 24 h, just one inpatient was diagnosed falsely among 27 CCHF-positive and 38 CCHF-negative inpatients, and there was no change after 48 h. Management of patients living in endemic regions suspected of having CCHF could be achieved within minutes using the Hitit Index. Patients with Hitit Index less than zero can be monitored as outpatients, while patients with Hitit Index results above zero must be hospitalized in infectious diseases wards. This study was not registered since it was retrospective.

Clinical, radiological and prognostic features of influenza cases in the influenza epidemic during years 2016-2017.

INTRODUCTION: Influenza subtypes vary by clinical, radiological, and prognostic courses and may go along with viral pneumonia. We aimed to identify clinical, radiological, and prognostic aspects of influenza epidemic during years 2016-2017. MATERIALS AND METHODS: Influenza cases reported to the Public Health Directorate in our city was assessed retrospectively. Clinical, radiological, and prognostic parameters were compared based on influenza subtypes. RESULT: We analyzed samples from 197 cases with suspected influenza. Mean age of the subjects was 51.17 ± 26.74. We found influenza A/H1N1, influenza A/H3N2, and influenza B in 59 (30.0%), 29 (14.7%), and 3 (1.5%) cases, respectively. Comorbidity was present in 48 (24.4%) cases. Most common radiological finding was interstitial pattern. Seventy-one and 79 per cent of H1N1 and H3N2 cases were influenza pneumonia, respectively. The prevalence of overall mortality was 5.5% with a predominance in H1N1 over H3N2. Influenza vaccination had been performed in 6.8% and 3.4% of H1N1 and H3N2 cases, respectively. We detected no mortality in any vaccinated patient. We identified 6 pregnant women, 2 of which ended up with preterm birth, and another one with abortion. CONCLUSIONS: Often manifested as lower respiratory tract infection, influenza may cause epidemics with increased mortality rate. Influenza should be suspected when interstitial pattern was seen on radiological images. H1N1 cases course worse. Since the prognosis is better in vaccinated patients, seasonal influenza vaccination among the community needs to be elevated. In addition, protective measures like vaccination should be taken in pregnancy to avoid preterm delivery or abortion.

The role of Treg population in pathogenesis of Crimean Congo hemorrhagic fever.

Crimean-Congo hemorrhagic fever (CCHF) is a severe human infection caused by CCHF virus (CCHFV). Today, although the literature on CCHF pathogenesis is still limited, it is thought to be associated with immunosuppression in the early phase of infection followed by pro-inflammatory immune response that may lead to fatal outcomes. The aim of this study is to investigate the role of regulatory T-cells (Treg cells) in the pathogenesis of CCHFV. Peripheral blood mononuclear cell samples collected from 14 acute CCHF patients with mild disease course and 13 healthy subjects were included in this study. Treg expression and functional levels were analyzed by flow cytometry. Treg cells were identified as CD4+CD25 + CD127dim cells, and their functional levels were compared by measuring their ability to suppress CD69 and CD154 expression by activated T-cells. The flow cytometry analysis revealed that total T-cell and helper T-cell levels did not vary between the two groups. In contrast, CCHF patients displayed higher Treg cell levels but lower Treg suppressive activities when compared with control subjects. This is the first study on the involvement of Treg cells in CCHF pathogenesis. Our results indicate that even though Treg cell levels are elevated during acute phase of CCHF infection, not all generated Treg cells has immunosuppressive capacity, and therefore may not represent 'true' Treg cell population. Future studies on the intrinsic mechanisms responsible for the reduced Treg inhibitory activities are required for further enlightening the CCHF pathogenesis, especially in the acute phase of the disease.

Cytokine response in crimean-congo hemorrhagic fever virus infection.

We described the predictive role of cytokines in fatality of Crimean Congo Hemorrhagic Fever Virus (CCHFV) infection by using daily clinical sera samples. Consequent serum samples of the selected patients in different severity groups and healthy controls were examined by using human cytokine 17-plex assay. We included 12 (23%) mild, 30 (58%) moderate, 10 (19%) severe patients, and 10 healthy volunteers. The mean age of the patients was 52 (sd 15), 52% were female. Forty-six patients (88%) received ribavirin. During disease course, the median levels of IL-6, IL-8, IL-10, IL-10/12, IFN-γ, MCP-1, and MIP-1b were found to be significantly higher among CCHF patients than the healthy controls. Within the first 5 days after onset of disease, among the fatal cases, the median levels of IL-6 and IL-8 were found to be significantly higher than the survived ones (Fig. 3), and MCP-1 was elevated among fatal cases, but statistical significance was not detected. In receiver operating characteristic (ROC) analysis, IL-8 (92%), IL-6 (92%), MCP-1 (79%) were found to be the most significant cytokines in predicting the fatality rates in the early period of the disease (5 days). IL-6 and IL-8 can predict the poor outcome, within the first 5 days of disease course. Elevated IL-6 and IL-8 levels within first 5 days could be used as prognostic markers.

Turkey 2017 Clinical Practice Guidelines on recommendations for screening diagnosing and managing hepatitis C virus.

The present guideline updates the Turkish recommendations for the screening, diagnosis and management of Hepatitis C virus (HCV) infection prepared by the Turkish Association for the Study of the Liver (TASL) and Viral Hepatitis Society (VHS). The aim of this guidance was to provide updates recommendations to physicians, who are interested in HCV care on the optimal screening, diagnosis and pre-treatment management for patients with HCV infection in Turkey. These recommendations, produced by panel experts, were aimed to addresses the management issues ranging from diagnosis and linkage to care, to the optimal treatment regimen in patients with HCV infection. Recommendations are based on evidence and opinions of more than 70% of the panelists. This guidance is supported by the memberships of two societies and not by pharmaceutical companies. This guidance will be updated frequently as new data become available.

Recommendations for intra-abdominal infections consensus report.

Guidelines include the recommendations of experts from various specialties within a topic in consideration of data specific to each country. However, to date there has not been a guideline standardizing the nomenclature and offering recommendations for intra-abdominal infections (IAIs) in Turkey. This is mainly due to the paucity of laboratory studies regarding the clinical diagnosis and treatment of IAIs or the sensitivity of microorganisms isolated from patients with IAIs. However, due to the diversification of host characteristics and advancements in technological treatment methods, it has become imperative to 'speak a common language'. For this purpose May 2015, a group of 15 experts in intra-abdominal infections, under the leadership of the Infectious Diseases and Clinical Microbiology Specialty Society of Turkey (EKMUD) and with representatives from the Turkish Surgical Association, Turkish Society of Colon and Rectal Surgery, Hernia Society, Turkish Society of Hepato-pancreato-biliary Surgery, and the Turkish Society of Hospital Infections and Control, was formed to analyze relevant studies in the literature. Ultimately, the suggestions for adults found in this consensus report were developed using available data from Turkey, referring predominantly to the 2010 guidelines for diagnosing and managing complicated IAIs in adults and children by the Infectious Diseases Society of America (IDSA) and the Surgical Infection Society. The recommendations are presented in two sections, from the initial diagnostic evaluation of patients to the treatment approach for IAI. This Consensus Report was presented at the EKMUD 2016 Congress in Antalya and was subsequently opened for suggestions on the official websites of the Infectious Diseases and Clinical Microbiology Specialty Society of Turkey and Turkish Surgical Association for one month. The manuscript was revised according to the feedback received.

Predicting tularemia with clinical, laboratory and demographical findings in the ED.

INTRODUCTION: We aimed to determine clinical, laboratory and demographical characteristics of tularemia on admission to Emergency Department (ED). MATERIAL AND METHODS: Medical data of 317 patients admitted to ED and subsequently hospitalized with suspected tularemia between January 1, 2011, and May 31, 2015, were collected. Patients were divided into 2 groups according to microagglutination test results, as tularemia (+) and tularemia (-). RESULTS: Of the 317 patients involved, 49 were found to be tularemia (+) and 268 were tularemia (-). Mean age of the tularemia (+) patients was found to be higher than that of tularemia (-) patients. When compared to tularemia (-) patients, a significant portion of patients in tularemia (+) patients were elderly, living in rural areas and had contact with rodents. When clinical and laboratory findings of the 2 groups were compared, any statistical significance could not be determined. CONCLUSION: Tularemia is a disease of elderly people living in rural areas. Contact with rodents also increases risk of tularemia in suspected patients.

Screening Household Members of Acute Brucellosis Cases in Endemic Areas and Risk Factors for Brucellosis.

Early diagnosis and treatment of acute brucellosis cases were targeted by screening the household members of the index cases. We also aimed to describe the causal relations of brucellosis in an endemic region. A cross-sectional study was performed among household members (29 index cases, 113 household members). Brucellosis was diagnosed on the basis of clinical findings, serum agglutinin titer of ≥1/160 in standard tube agglutination test (STA), or a positive blood culture. Index cases were defined as patients who had been admitted to the clinic on suspicion of brucellosis and then confirmed as brucellosis cases. The people who lived in the same house as the index cases were defined as household members. The risk factors for seropositivity were studied by multivariate analysis. Independent variables of gender, consuming fresh cheese, blood groups, dealing with husbandry, and contact with the placenta of infected animals were included to the model. Backward and forward selections were performed. Nineteen out of 113 (17%) screened individuals had agglutination titers ≥1/160. The mean ages of index cases and household members were 43 years (standard deviation [SD] 18) and 29 years (SD 19), respectively. In multivariate analysis, consuming fresh cheese (odds ratio [OR]=3.1, confidence interval [CI] 1.07-9.68, p=0.049), blood group A (OR=2.6, CI 1.18-5.96, p=0.018), contact with the placenta of the infected animals (OR=3.7, CI 1.42-9.68, p=0.007), and age >30 years (OR=2.8, CI 1.25-6.51, p=0.13) were found to be associated with brucellosis. In univariate analysis, the individuals with blood group B were protected from brucella infection (p=0.013). In conclusion, screening of the people in brucellosis-endemic areas should be considered for early diagnosis and treatment. To our knowledge, blood groups were studied for the first time by this study. Higher prevalence of brucellosis among the individuals with blood group A and less prevalence among the individuals with blood group B should be considered for further studies on pathogenesis.

Evaluation of tularemia cases focusing on the oculoglandular form.

INTRODUCTION: Tularemia is a zoonotic disease caused by Francisella tularensis. The oculoglandular form is one of the rarest forms. In this study, evaluated tularemia patients, focusing on the ocular form and the efficacy of early antibiotic therapy. METHODOLOGY: During a tularemia outbreak, the epidemiological and clinical findings, laboratory assays, and drugs used for the treatment of 48 patients were recorded prospectively. The diagnosis of tularemia was confirmed with microagglutination test (MAT) as well as clinical findings. RESULTS: The mean age of the subject was 48.6 years; 23 (47.9%) of them were female. Thirty-six (81.25%) patients had clinical presentation compatible with oropharyngeal tularemia, seven (14.58%) with oculoglandular tularemia, and two (4.1%) with ulceroglandular tularemia. The most common symptoms were fever (91.6%) and sore throat (81.2%), and the most common findings were lymphadenopathy (91.6%) and tonsillopharyngitis (81.2%). In the oculoglandular form, fever, lymphadenopathy, periorbital edema, conjunctival injection, and chemosis were found. The most distinctive ophthalmic feature was follicular conjunctivitis and conjunctival epithelial defects. Forty-five cases had positive serological results with MAT. All the patients were treated with antibiotics considered effective against F. tularensis, and topical antimicrobial treatment was given to the patients with oculoglandular tularemia. Twenty-six (54.16%) patients, who were admitted within three weeks of the onset of symptoms, recovered without sequel. CONCLUSIONS: During tularemia outbreaks, ocular involvement should be considered carefully. The early administration of appropriate treatment will be more effective in resolving the infection and preventing complications. Along with systemic antibiotic therapy, topical treatment will help recovery.

Severity scoring index for Crimean-Congo hemorrhagic fever and the impact of ribavirin and corticosteroids on fatality.

BACKGROUND: Patients infected with Crimean-Congo hemorrhagic fever (CCHF) virus present with a wide clinical spectrum. In observational studies, the effects of therapeutic agents are confounded by severity. We describe use of a clinical severity scoring index (SSI) for CCHF patients and assess the effect of ribavirin and corticosteroid therapy on the case-fatality rate, stratified by SSI. METHODS: The study group included hospitalized patients who received a diagnosis of CCHF at the Infectious Diseases and Clinical Microbiology Clinic of Ankara Numune Education and Research Hospital between 2004 and 2011. The SSI included platelet count, bleeding, fibrinogen level, activated partial thromboplastin time, and somnolence. The effects of ribavirin and corticosteroid on the case-fatality rate were studied by univariate and multivariate analysis, stratified by SSI. RESULTS: Two hundred eighty-one confirmed cases of CCHF were included in the study. Of 281 patients, 23 (8%) died. The mean age (±SD) of the patients was 47 ± 16 years. Forty-nine percent were female. The mean duration of stay at our clinic after onset of symptoms was 4.4 days, with a range of 1-14 days. In multivariate analysis of factors for the prediction of death, the SSI (odds ratio [OR], 3.27; 95% confidence interval [CI], 2.09-5.13) and ribavirin use (OR, 0.04; 95% CI, .004-.48) were found to be statistically significant factors. CONCLUSION: The SSI is an accurate predictor of death and will therefore be a useful tool for case management and for drug-assessment studies. After stratification of cases by SSI, ribavirin was found to be effective in reducing the case-fatality rate, especially among moderately ill patients, whereas steroids were found to be beneficial particularly among patients with severe disease.

Neurobrucellosis: clinical and diagnostic features.

BACKGROUND: We describe the neurological involvement in brucellosis and revisited diagnostic criteria for neurobrucellosis. METHODS: Patients with laboratory-confirmed brucellosis who were consequently hospitalized were observed prospectively in a brucellosis-endemic region. The neurobrucellosis was diagnosed by any one of the following criteria: (1) symptoms and signs consistent with neurobrucellosis; (2) isolation of Brucella species from cerebrospinal fluid (CSF) and/or presence of anti-Brucella antibodies in CSF; (3) the presence of lymphocytosis, increased protein, and decreased glucose levels in CSF; or (4) diagnostic findings in cranial magnetic resonance imaging or CT. RESULTS: Lumbar puncture was performed in 128 laboratory-confirmed brucellosis cases who had neurological symptoms and signs, and 48 (37.5%) were diagnosed as neurobrucellosis. The sensitivity of tube agglutination (TA) in CSF was 0.94, specificity 0.96, positive predictive value 0.94, and negative predictive value 0.96. Brucella bacteria were isolated from CSF in 7 of 48 patients (15%). The mean age of 48 neurobrucellosis patients was 42 years (SD, 19 years), and 16 (33%) were female. The most common neurological findings were agitation (25%), behavioral disorders (25%), muscle weakness (23%), disorientation (21%), and neck rigidity (17%). Cranial nerves were involved in 9 of 48 patients (19%). One patient was left with a sequela of peripheral facial paralysis and 2 patients with sensorineural hearing loss. CONCLUSIONS: Patients with severe and persistent headache and other neurologic symptoms and signs should be considered for neurobrucellosis in endemic regions and to possibly receive longer therapy than 6 weeks. Brucella TA with Coombs test in CSF is sensitive and specific by using a cutoff of ≥1:8.