Remdesivir treatment for patients with moderate to severe COVID-19.

BACKGROUND: Remdesivir, which was first developed for the treatment of Ebola disease but failed to meet expectations, has become hope in the fight against the COVID-19 pandemic. This study aimed to evaluate risk factors for mortality and prognosis of adult moderate/severe COVID-19 patients treated with remdesivir, and safety and tolerability of 5 days of remdesivir treatment. METHODS: This multicenter prospective observational study was conducted in 14 centers in Turkey. Pregnancy or breastfeeding, multiorgan failure, or usage of vasopressors for septic shock, ALT > 5 × the upper limit of the normal range, or eGRF <30 mL/min or dialysis and receiving favipiravir were the exclusion criteria of the study. RESULTS: Among 500 patients, 494 patients were included in the study. On admission, 392 (79.3%) patients had moderate and 102 (20.6%) patients had severe COVID-19. The 28-day mortality was 10.1%. The median of the scores of the seven-category ordinal scale assessed on days 0, 3, 5, 7 were 4 and 3 on day 14. When the survival status of the patients was evaluated according to the time between the remdesivir start date and the end date of the symptoms, no statistically significant difference was found between the medians of the groups (p = 0.404). In multivariable analysis, age (OR, 1.05; 95%CI, 1.02-1.08; p = 0.003), SpO2 level on admission (OR, 3.03; 95%CI, 1.35-6.81; p = 0.007), heart rate (OR, 2.48; 95%CI, 1.01-6.07; p = 0.047), follow-up site at the hospital (clinic/ICU) (OR, 26.4; 95%CI, 11.6-60.17; p < 0.001) were independently associated with increased mortality. Grade 3 adverse event (AE) was observed in 4 (0.8%) patients. None of the patients experienced grade 4 or 5 AEs. DISCUSSION: Remdesivir is a safe and well-tolerated drug and older age, low SpO2 level on admission, tachycardia, and ICU admission are independently associated with increased mortality among patients with moderate/severe COVID-19 receiving remdesivir treatment.

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.

Evaluation of Blood Stream and Biliary Tract Infections Related to Percutaneous Transhepatic Cholangiography and Prophylaxis Given in Patients with Malignancy.

Objective: Percutaneous transhepatic cholangiography (PTC) is an invasive procedure used in patients with obstructive jaundice in the progress of some malignancies, and its most common complication is infection. We aimed to evaluate the patients who underwent PTC regarding their cultures, prophylaxis, and antibiotics used for treatment. Materials and Methods: In this cross-sectional study, patients who underwent PTC and were followed up in a medical oncology outpatient clinic between 2010-2017 were evaluated retrospectively. Patients' data were obtained from the hospital record system (FONET), epicrisis forms, and patient progress files. Results: A total of 93 patients were included in the study. Prophylaxis was given in 50% of the cases. Complications developed in 68% of the cases after the intervention, and the infectious disease clinic consulted all. Blood cultures were obtained from 89% of the febrile patients; however, bile cultures were obtained only from 29%. The rate of resistant Gram-negative enteric bacteria in growing microorganisms was 52% (n=13). It was determined that 65% of the initiated empirical treatments were appropriate for the growth of microorganisms. Conclusion: The growth rate was significantly higher in blood cultures than in bile cultures. The lower growth rate in bile culture was attributed to the low number of bile cultures. There was no significant difference regarding the growth rate and drug resistance of the microorganisms. Therefore, we think giving antibiotics as treatment rather than prophylaxis is more appropriate. Taking cultures will ensure that patients receive appropriate antibiotic therapy for the causative agent.

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.

Intravoxel incoherent motion parameters in the evaluation of chronic hepatitis B virus-induced hepatic injury: fibrosis and capillarity changes.

OBJECTIVE: To evaluate the diagnostic efficacy of intravoxel incoherent motion (IVIM) parameters in hepatitis B virus (HBV)-induced hepatic fibrosis using different calculation methods and to investigate histopathologic origins. MATERIALS AND METHODS: Liver biopsies from 37 prospectively recruited chronic hepatitis B patients were obtained. Twelve b-value (0-1000 s/mm2) diffusion-weighted imaging (DWI) was performed with a 1.5 T scanner and was followed by blinded percutaneous liver biopsy. All biopsy specimens were evaluated with Ishak staging, and the microvascular density (MVD) was calculated. Patients were classified as having no/mild (F0-1), moderate (F2-3), or marked (F4-5) fibrosis. Pseudodiffusion (D*), the perfusion fraction (f), and the apparent diffusion coefficient (ADC) were calculated using all b-values, while true diffusion (D) was calculated using all b-values [D0-1000] and b-values greater than 200 s/mm2 [D200-1000]. Three concentric regions of interest (ROIs) (5, 10, and 20 mm) centered on the biopsy site were used. RESULTS: D* was correlated with the MVD (p = 0.015, Pearson's r = 0.415), but f was not (p = 0.119). D0-1000 was inversely correlated with Ishak stage (p = 0.000, Spearman's rs = - 0.685) and was significantly decreased in all the fibrosis groups; however, only the no/mild and marked fibrosis groups had significantly different D200-1000 values. A pairwise comparison of receiver operating characteristic (ROC) curves of D0-1000 and D200-1000 showed significant differences (p = 0.039). D* was the best at discriminating early fibrosis (AUC = 0.861), while the ADC best discriminated advanced fibrosis (AUC = 0.964). CONCLUSION: D* was correlated with the MVD and is a powerful parameter to discriminate early hepatic fibrosis. D significantly decreased with advanced fibrosis stage when using b-values less than 200 s/mm2 in calculations.

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.

Disseminated Nocardia farcinica infection presenting as a paravertebral abscess in a patient with systemic lupus erythematosus.

Disseminated Nocardia infections occur particularly in immunosuppressed hosts and are most often due to Nocardia farcinica, Nocardia nova, and Nocardia cyriacigeorgica. Here, we report an unusual case of disseminated N. farcinica infection presenting as a paravertebral abscess in a patient with systemic lupus erythematosus.

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.

HIV-1 Transmitted Drug Resistance Mutations in Newly Diagnosed Antiretroviral-Naive Patients in Turkey.

HIV-1 replication is rapid and highly error-prone. Transmission of a drug-resistant HIV-1 strain is possible and occurs within the HIV-1-infected population. In this study, we aimed to determine the prevalence of transmitted drug resistance mutations (TDRMs) in 1,306 newly diagnosed untreated HIV-1-infected patients from 21 cities across six regions of Turkey between 2010 and 2015. TDRMs were identified according to the criteria provided by the World Health Organization's 2009 list of surveillance drug resistance mutations. The HIV-1 TDRM prevalence was 10.1% (133/1,306) in Turkey. Primary drug resistance mutations (K65R, M184V) and thymidine analogue-associated mutations (TAMs) were evaluated together as nucleos(t)ide reverse transcriptase inhibitor (NRTI) mutations. NRTI TDRMs were found in 8.1% (107/1,306) of patients. However, TAMs were divided into three categories and M41L, L210W, and T215Y mutations were found for TAM1 in 97 (7.4%) patients, D67N, K70R, K219E/Q/N/R, T215F, and T215C/D/S mutations were detected for TAM2 in 52 (3.9%) patients, and M41L + K219N and M41L + T215C/D/S mutations were detected for the TAM1 + TAM2 profile in 22 (1.7%) patients, respectively. Nonnucleoside reverse transcriptase inhibitor-associated TDRMs were detected in 3.3% (44/1,306) of patients (L100I, K101E/P, K103N/S, V179F, Y188H/L/M, Y181I/C, and G190A/E/S) and TDRMs to protease inhibitors were detected in 2.3% (30/1,306) of patients (M46L, I50V, I54V, Q58E, L76V, V82A/C/L/T, N83D, I84V, and L90M). In conclusion, long-term and large-scale monitoring of regional levels of HIV-1 TDRMs informs treatment guidelines and provides feedback on the success of HIV-1 prevention and treatment efforts.

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.

Transmitted antiretroviral drug resistance mutations in newly diagnosed HIV-1 positive patients in Turkey.

INTRODUCTION: The objective of this study was to determine the transmitted drug resistance mutations (TDRMs) in newly diagnosed HIV-1 positive patients in Turkey. MATERIALS AND METHODS: The study was carried out between 2009 and 2014 and antiretroviral naïve 774 HIV-1 infected patients from 19 Infectious Diseases and Clinical Microbiology Departments in Turkey were included; gender: 664 (86%) male, median age: 37 (range; 1-77), median CD4+T-cell: 360 (range; 1-1320) count/mm(3), median HIV-RNA load: 2.10+E6 (range; 4.2+E2-7.41+E8) IU/mL. HIV-1 drug resistance mutations were detected by population based sequencing of the reverse transcriptase (codon 41-238) and protease (codon 1-99) domains of pol gene of HIV-1, and analyzed according to the criteria by the World Health Organization 2009 list of surveillance drug resistance mutations [1]. RESULTS: The patients had TDRMs to NRTIs (K65R, M184V), NNRTIs (K101E, K103N/S, G190A/E/S, Y181I/C, Y188H/L) and PIs (M46L, I54V, L76V, V82L/T, N83D, I84V, L90M). The prevalence of overall TDRMs was 6.7% (52/774). Resistance mutations were found to be 0.7% (6/774), 4.1% (32/774) and 2.1% (17/774) to NRTIs, NNRTIs and PIs drug groups, respectively. Three patients had NRTIs+NNRTs resistance mutations (M184V+K103N) as multi-class drug resistance. However, thymidine analogue resistance mutations (TAMs) determined two distinct genotypic profiles in the HIV-1 reverse transcriptase: TAM1: M41L, L210W and T215Y, and TAM2: D67N, K70R, K219E/Q, and T215F. The prevalence of TAM1 and TAM2 were 7.7% (60/774) and 4.3% (34/774), respectively. CONCLUSIONS: The TDRMs prevalence of antiretroviral naïve HIV-1 infected patients may be suggested current situation of Turkey. These long-term and large-scale results show that the resistance testing must be an integral part of the management of HIV infection in Turkey.

Crimean-Congo hemorrhagic fever: aid of abdominal ultrasonography in prediction of severity.

Crimean-Congo hemorrhagic fever (CCHF) is a fatal viral infection that involves multiple organs, and endothelium. We described abdominal sonographic findings of the patients infected with the Crimean-Congo hemorrhagic fever virus (CCHFV) in relation to the severity of the disease. This is a prospective study performed among hospitalized patients infected with CCHF between 2005 and 2011. A total of 210 hospitalized patients with confirmed CCHF infection were included in the study. The mean age was 47 and 49.5% of the patients were female. Patients were classified as mild, moderate, or severe disease according to their clinical and laboratory findings. The relationship between the clinical severity of CCHF and the abdominal sonographic findings was analyzed. Sonographic findings of abdomen included gallbladder wall thickening (GBWT) in 44 (21%), splenomegaly in 39 (19%), hepatomegaly in 52 (25%), decrease in echo of liver parenchyma in nine (4%), increase in echo liver parenchyma in 13 (6%), intra-abdominal fluid collection/ascites in 23 (11%), and enlarged periportal lymph nodes in seven (3%) cases. GBWT was detected in 3% of mild patients, 23% of moderate patients, and 61% of severe patients (p<0.001). In multivariate analysis to predict the severity, GBWT (odds ratio [OR] 5.4, confidence interval [CI] 1.76-16.49, p=0.003) and intra-abdominal fluid collection/ascites (OR 3.5, CI 1.07-12.61, p=0.049) were found to be significantly associated with disease severity. In conclusion, ultrasonography is a reliable, useful, and noninvasive diagnostic tool for evaluation of the abdominal findings of the patients with CCHFV infection. GBWT and intra-abdominal fluid collection/ascites were found to be predictors of severity.

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.

Crimean-Congo hemorrhagic fever among health care workers, Turkey.

We investigated 9 cases of Crimean-Congo hemorrhagic fever (1 fatal, 2 asymptomatic) among health care workers in Turkey. Needlestick injuries were reported for 4 workers. Eight received ribavirin. In addition to standard precautions, airborne infection isolation precautions are essential during aerosol-generating procedures. For postexposure prophylaxis and therapy, ribavirin should be given.

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.

Characteristics of cutaneous anthrax in Turkey.

BACKGROUND: Incidence of anthrax is diminishing in developed countries; however, it remains a public health problem in developing countries, especially those whose main source of income is farming. METHODOLOGY: Charts of patients hospitalized between 1992 and 2008 in the Infectious Diseases and Clinical Microbiology Department of Ankara Numune Education and Research Hospital were reviewed. RESULTS: Fifty-eight cases with cutaneous anthrax were reviewed. The mean age was 49.8, and 36.2% were female. The most common professions were farmers (62%), butchers (19%), and housewives (15%). The mean incubation period was eight days. Most cases (62%) were exposed to bacteria when butchering sick animals. Eighteen patients used an antibiotic before admission to hospital (31%). The predominantly affected sites were hands (39%) and fingers (29%), followed by forearms (12%), eyelids (7%) and necks (3%). All cases initially had painless ulcers with vesicles; dissemination of the lesion was seen in 27.5% of patients. Gram stain was positive in 11 cases; culture was positive in 7 cases for Bacillus anthracis. All patients except one were discharged and treated with penicillin and/or ciprofloxacin or imipenem. One patient with a disseminated lesion on the neck died even though a steroid was used with the antibiotic. CONCLUSIONS: Cutaneous anthrax should be considered as a possible diagnosis in cases with a painless ulcer with vesicles, edema, and a history of exposure to animals or animal products. Despite previous antibiotic use, taking smears and cultures should be encouraged. Treatment with penicillin G or penicillin procain alone is effective for cases with cutaneous anthrax without severe edema and superinfection.

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.