Evaluation of Seropositivity of Toxoplasmosis Suspected Patients Admitted to the National Parasitology Reference Laboratory Between 2009 and 2019

Objective: Toxoplasmosis caused by Toxoplasma gondii (T. gondii), which is an obligatory intracellular parasite, is a worldwide zoonotic parasitic disease. In this study, results of T. gondii test conducted between January 2009 and May 2019 were analysed. This study aimed to evaluate the results of T. gondii test of patients who were admitted to the General Directorate of Public Health, National Parasitology Reference Laboratory between 2009 and 2019. Methods: The results of anti-T. gondii IgG, IgM, IgG avidity and Sabin-Feldman dye tests (SFDT), which are used to detect the presence of T. gondii, were examined. ELISA was used for anti-T. gondii IgG, IgM and IgG avidity tests. SFDT, which is the reference test in the diagnosis of T. gondii, is still the gold standard. In addition to laboratory analyses, information on gender, age, city of origin, year distribution of all cases and type of sample sent was also collected. Results: Of the 2.778 patients evaluated, 25.4% were males and 74.6% were females. Moreover, 47.1% and 10.2% of the patients were positive for anti-T. gondii IgG and anti-T. gondii IgM antibodies, respectively. In SFDT, 1.228 (52%) patients were found to be positive, including 319 (59.4%) of 537 men and 909 (49.8%) of 1.824 women. In this 10-year study, the most common seropositivity titre of SFDT was at the level of 1/64. In our study, IgG levels were found to be positive in all cases in which IgG avidity was studied when all the cases in which all three of the anti-T. gondii IgG, IgM and IgG avidity tests were studied together in one patient were evaluated. In addition, of the 293 patients with positive anti-T. gondii IgG, 62.8% had high avidity, 24.2% had a limit value and 13% had a low avidity. In cases involving both mother and baby, anti-T. gondii IgG and IgM seropositivity rates were 80% and 5% for both, respectively. These high rates support the transfer of antibodies from the mother to the baby. Regarding the distribution of provinces from which the samples originated, the highest number of cases came from Ankara (80.7%). Blood is the most predominant sample, followed by cerebrospinal fluid. Conclusion: T. gondii maintains its importance in public health, owing to its high positivity rates. This study, in which 10-year data were collected, showed that despite an increase in awareness, high seropositivity still continues. Therefore, systematic collection and evaluation of laboratory analysis results for toxoplasmosis diagnosis will contribute in taking control measures.

Investigation of Anti-Toxoplasma gondii Antibodies in Cats Using Sabin-Feldman Dye Test in Ankara in 2016

Objective: Toxoplasmosis, in which obligate intracellular protozoa Toxoplasma gondii (T.gondii) is the causative organism, is a multisystemic disease that can be seen all over the world and can impair all vertebrates. The only hosts known for T.gondii are members of Felidae family. Our study aimed to determine anti-Toxoplasma gondii antibodies with Sabin-Feldman Dye Test (SFDT) in cats in Ankara. It's aimed to evaluate the current situation in terms of Toxoplasmosis spread by comparing our findings with previous studies in the same region. Methods: Rh strain of Toxoplasma used in our study is maintained in our laboratory. SFDT is still accepted as the gold standard. Material of the study was obtained by taking blood samples from cats who were admitted to the clinics between March 2016 and October 2016 in Ankara. Blood samples were inactivated and measurements were done with SFDT 1/4, 1/16, 1/64, 1/256, 1/1024 titers. Results: SFDT resulted positive in 56 (43.4%) cats at a dilution of 1/16, in 7 (5.4%) cats at a dilution of 1/64, in 23 (17.8%) cats at a dilution of 1/256 and negative in 43 (33.3%) cats. Comparison of demographic data with SFDT results showed that positive test results did not differ according to gender and age (P=0.803 and P=0.991, respectively). Seropositivity was higher in stray cats than house cats (P<0.001). Test results were negative in the cats that fed only by commercial dry food (P<0.001). Positivity in hunter cats was more than in non-hunters (P<0.001). Conclusion: Seropositivity was detected in 66.6% of the cats, which was quite a high rate. As a result, taking precautions in terms of Toxoplasma for stray cats that are hunting and feeding naturally is a necessity for public health.

Performance evaluation of nine different syphilis serological tests in comparison with the FTA-abs test.

BACKGROUND: Serological methods have great importance for the detection of Treponema pallidum antibodies in syphilis diagnosis. The goal of the present study is to evaluate various commercially available screening assays in comparison with the FTA-abs test. METHODS: A total of 363 serum samples were enrolled in the study. Following routine testing including RPR and TPHA tests, each sample was tested by treponemal immunoassays (Chorus Syphilis Screen Recombinant, Architect Syphilis TP, Syphilis Virclia Monotest, Siemens Advia Centaur Syphilis, Euroimmun Treponema pallidum Screen ELISA, Vircell Syphilis ELISA IgG + IgM, SD Bioline Syphilis). The result obtained from each test was compared with the confirmatory FTA-abs test. Kappa (κ) coefficients were used to compare the concordance of the tests. RESULTS: When the various tests were evaluated in comparison with the FTA-abs test, the sensitivity, specificity and percent agreement of each test were as follows: Architect Syphilis TP, 92.3%, 94.5%, 92.8%; Chorus Syphilis Screen Recombinant, 87.9%, 91.2%, 88.7%; Syphilis Virclia Monotest, 80.5%, 97.8%, 84.9%; Siemens Advia Centaur Syphilis, 87.5%, 89%, 87.9%; Euroimmun Treponema pallidum Screen ELISA, 87.5%, 85.7%, 87.1%; Vircell Syphilis ELISA IgG + IgM, 73.2%, 62.6%, 70.5%; TPHA, 89%, 63.7%, 82.6%; SD Bioline Syphilis, 58.1%, 94.5%, 67.2%; RPR test, 57.7%, 57.1%, 57.6%. CONCLUSION: The results of the present study show that Treponema pallidum specific immunoassays with a performance similar or better than TPHA test generally performed well with the confirmatory FTA-abs test and may be an alternative for screening total antibodies in syphilis infection.

Investigation of syphilis coinfection and performance of the Architect Syphilis Tp ELISA screening test in HIV positive patients

Background/aim: Limited data on syphilis coinfection in human immunodeficiency virus (HIV) positive cases exist in Turkey. Our aim is to investigate syphilis coinfection and to evaluate the compatibility of the screening Architect Syphilis Tp ELISA with the fluorescent treponemal antibody absorption (FTA-abs) confirmation test in HIV positive cases. Materials and methods: Totally 519 HIV positive patients were included in the study. Enzyme linked fluorescent assay (ELFA) was used as a screening test and positive samples were confirmed by line immunassay (LIA). In order to discriminate acute HIV infection and false ELISA positivity, HIV-1 RNA PCR was performed in ELFA positive and LIA negative samples. Architect Syphilis TP ELISA was used for the detection of total antibodies against Treponema pallidum in HIV positive patients. Positive results were confirmed by the FTA-abs test. Results: Out of 519 HIV-1 positive patients, IgG and IgM positivity, and only IgG positivity was detected as 1.9% and 11.4% in all the samples, respectively. A total of 79 (15.2%) sera were positive with Architect Syphilis Tp ELISA test and 69 (13.3%) were positive with FTA-abs test. Statistically significant, almost perfect agreement was found between Architect Syphilis Tp ELISA and FTA-abs tests (kappa = 0.921 and P < 0.001). Conclusion: Implementation of syphilis and HIV screening tests together among risk groups is considered to be appropriate.

Evaluation of Symptomatic Patients with Resistant Discharge.

The aim of this study was to detect the presence of Chlamydia trachomatis, Neisseria (N.) gonorrhoeae, Mycoplasma (M.) hominis, M. genitalium, Ureaplasma (U.) urealyticum, and Trichomonas (T.) vaginalis in patients with resistant discharge. The study also evaluated the concordance of the diagnostic tests. Samples from 156 patients were tested by direct microscopy and culture for T. vaginalis and Mycoplasma IES for M. hominis and U. urealyticum. Multiplex Polymerase Chain Reaction (PCR) was used to determine the presence of six agents. Statistical analyses were performed using the SPSS program. Out of 156 patients, 38 had positive result for the agents tested. Of these 38 patients, 28 (73.7%) had single agent positivity and 10 (26.3%) had multiple agent positivity. The detection rate of U. urealyticum, M. hominis, N. gonorrhoeae, C. trachomatis, T. vaginalis, M. genitalium specifically was 10.3%, 9.6%, 6.4%, 3.2%, 2.6%, 0.6% respectively. N. gonorrhoeae and U. urealyticum were the most common in male patients, while M. hominis and U. urealyticum were mostly found in female patients. Different methods used for detecting T. vaginalis were compared to find that interrater reliability was perfect for culture-direct microscopy (κ:0.85; P<0.001) and also for culture-PCR (κ:0.89; P<0.001). The interrater reliability was moderate (κ:0.53; P<0.001) for PCR-Mycoplasma IES test for M. hominis and fair (κ:0.21; P<0.007) for U. urealyticum. U. urealyticum and M. hominis were among the most commonly found sexually transmitted infections (STI) agents in patients with resistant discharge. Multiple agent positivity was high and should be kept in mind in every STI case.

[Tuberculosis Laboratory Surveillance Network (TuLSA) study group. The first step for national tuberculosis laboratory surveillance: Ankara, 2011]. / Ulusal Tüberküloz Laboratuvar Sürveyansina ilk adim: Ankara, 2011.

The most effective method for monitoring country-level drug resistance frequency and to implement the necessary control measures is the establishment of a laboratory-based surveillance system. The aim of this study was to summarize the follow up trend of the drug-resistant tuberculosis (TB) cases, determine the load of resistance and evaluate the capacities of laboratories depending on laboratory quality assurance system for the installation work of National Tuberculosis Laboratory Surveillance Network (TuLSA) which has started in Ankara in 2011. TuLSA studies was carried out under the coordination of National Tuberculosis Reference Laboratory (NRL) with the participation of TB laboratories and dispensaries. Specimens of TB patients, reported from health institutions, were followed in TB laboratories, and the epidemiological information was collected from the dispensaries. One isolate per patient with the drug susceptibility test (DST) results were sent to NRL from TB laboratories and in NRL the isolates were rechecked with the genotypical (MTBDRplus, Hain Lifescience, Germany) and phenotypical (MGIT 960, BD, USA) DST methods. Molecular epidemiological analysis were also performed by spoligotyping and MIRU/VNTR. Second-line DST was applied to the isolates resistant to rifampin. A total of 1276 patients were reported between January 1st to December 31th 2011, and 335 cases were defined as "pulmonary TB from Ankara province". The mean age of those patients was 43.4 ± 20 years, and 67.5% were male. Three hundred seventeen (94.6%) patients were identified as new cases. The average sample number obtained from pulmonary TB cases was 3.26 ± 2.88, and 229 (68.3%) of them was culture positive. DST was applied to all culture positive isolates; 90.4% (207/229) of cases were susceptible to the five drugs tested (ethambutol, isoniazid, pyrazinamide, rifampicin, streptomycin). Eight (3.5%) of the isolates were multidrug-resistant (MDR-TB), while no extensively drug-resistant strains were detected. MDR-TB is likely to occur in 63.3 times more among previously treated cases, and 73.3 times more in legal aliens. The achievement of therapy among pulmonary TB cases was 91.9%. Spoligotyping performed for 221 M.tuberculosis complex isolates, showed that all strains were clustered in nine groups. SIT 41 (105/221; 47.5%) was the most frequent spoligotype detected, and clustering rate based on MIRU-VNTR results were found as 16.3%. All of the clustered strains were sensitive while all of MDR-TB isolates showed specific MIRU-VNTR profiles. In conclusion, TuLSA studies started in Ankara in 2011 and the system is still expanding in the country. Our data obtained with TuLSA have been published as a regional surveillance data in the WHO Global Tuberculosis Report 2011, and as a national surveillance data in Global Tuberculosis Report 2012.

[Investigation of the presence of Mycobacterium tuberculosis in the lymph node aspirates of the suspected tularemia lymphadenitis cases]. / Tularemi lenfadeniti süphesi ile alinan lenf aspirati örneklerinde Mycobacterium tuberculosis s varliginin arastirilmasi

Recently reports of cervical tuberculous lymphadenitis and oropharyngeal tularemia which are the most common infectious causes of granulomatous lymphadenitis, have been significantly increased in Turkey. The differentiation of cervical tuberculous lymphadenitis and oropharyngeal tularemia is usually confusing on the basis of clinical and histopathological findings. Thus, in tularemia endemic areas, the patients are more commonly evaluated in terms of tularemia lymphadenitis leaving tuberculosis out. The aim of this study was to investigate the presence of Mycobacterium tuberculosis in cervical lymph node aspirates, obtained from tularemia suspected cases. A total of 105 oropharyngeal tularemia-suspected cases which were found negative for Francisella tularensis by bacteriological (culture), molecular (PCR) and serological (microagglutination) methods, were included in the study. The samples had been previously studied at National Tularemia Reference Laboratory, Turkish Public Health Institution, between 2009-2011. The study samples were evaluated in terms of M.tuberculosis by culture and real-time PCR (rtPCR) methods in the National Tuberculosis Reference Laboratory. Both Lowenstein-Jensen (LJ) medium and liquid-based MGIT (BD, USA) automated culture system were used for mycobacterial culture. Samples that yielded mycobacterial growth were identified as M.tuberculosis by immunochromotographic test (BD, USA). The lymph node aspirates of 65 patients who were F.tularensis PCR negative but antibody positive, were used as the control group. As a result, M.tuberculosis was found to be positive in 9 (8.6%) of 105 tularemia-negative lymph node aspirates, sent to our laboratory from different geographic regions for the investigation of tularemia. Six of the M.tuberculosis positive cases were male and the age range of the patients was 26-85 years. The presence of M.tuberculosis was detected only by culture in two samples, only by rtPCR in five samples and both by culture and rtPCR in two samples. M.tuberculosis was not identified in the control group specimens. Three of the samples which revealed tuberculosis, were from the tularemia endemic areas. In conclusion, the data of this preliminary study indicated that tuberculous lymphadenitis should be kept in mind in suspected tularemia cases and those patients should also be investigated simultaneously for the presence of tuberculous lymphadenitis.

Complicated brucellar spondylodiscitis: experience from an endemic area.

The demographical, clinical, and therapeutical features of patients with brucellar spondylodiscitis (BS) were evaluated in this study. Of the 96 patients with brucellosis, 20 (20.8%) were diagnosed with spondylodiscitis. Patients who had BS were more likely to be older (p = 0.001), have higher erythrocyte sedimentation rates (p = 0.01), and more likely to be anemic (p = 0.017). Lumbar segment (18/20) was frequently involved region. BS was complicated with paravertebral or epidural abscess in seven, radiculitis in six, and psoas abscess in five of cases. Antibiotic regimens including two or three antibiotics with combination of doxycycline, rifampin, and streptomycin were used. In this series, the mean duration of antimicrobial therapy was 18 weeks (range 12-56 weeks). Attention is drawn to this disease given the need for prolonged duration of treatment especially in complicated cases in order to avoid possible sequelae.

[Evaluation of the distribution of non-tuberculous mycobacteria strains isolated in National Tuberculosis Reference Laboratory in 2009-2010, Turkey]. / Ulusal Tüberküloz Referans Laboratuvarinda 2009-2010 Yillarinda Tespit Edilen Tüberküloz Disi Mikobakterilerin Dagilimlarinin Irdelenmesi.

Non-tuberculous mycobacteria (NTM) are commonly encountered environmental bacteria, and most of them are associated with lung diseases. Diagnosis of infections caused by NTM is based on clinical, radiological and microbiological findings. The aim of this study was to investigate the distribution of non-tuberculous mycobacterial species isolated from clinical specimens as etiologic agents. The NTM strains isolated from clinical specimens in National Tuberculosis Reference Laboratory (NTRL), together with the strains that were sent to NTRL for the advanced identification of non-tuberculous mycobacterial species that have clinical or microbiological significance, were analysed retrospectively. The strains belonged to January 2009 - December 2010 period. If the same NTM type was isolated more than once in the clinical specimens of a patient, then it was defined microbiologically as a causative agent. Identification of mycobacteria species was performed by using a commercial line-probe assay (GenoType Mycobacterium CM/AS; Hain Lifescience, Germany). In our study, pulmonary and non-pulmonary samples obtained from 206 patients yielded mycobacterial growth in their cultures, and of them 24 (11.7%) were identified as NTM. On the other hand, 51 of the 101 samples sent to NTRL for identification were confirmed as NTM. Of the patients who were found to be infected with NTM (n= 75), 59 (78.7%) were male and the mean age was 50.9 ± 18.8 years. The most frequently identified NTM species was M.fortuitum (33.3%, n= 25), followed by M.abscessus (18.7%, n= 14), M.gordonae (10.7%, n= 8) and M.avium (%8; n= 6). The other types of NTM species identified in our laboratory were M.chelonae (n= 3), M.intracellulare (n= 3), M.kansasii (n= 3), M.peregrinum (n= 2), M.scrofulaceum (n= 2), M.szulgai (n= 2), M.celatum (n= 1), M.haemophilum (n= 1), M.smegmatis (n= 1) and M.xenopi (n= 1). Rapidly growing NTM species (M.fortuitum and M.abscessus) were the most frequent (52%) species isolated in our laboratory as the cause of non-tuberculous mycobacterial infection. Interestingly, the majority of M.fortuitum isolates (n= 21) which was the most common species identified in our laboratory, were those received from the peripheral laboratories. The most common species identified in our laboratory were rapidly growing NTM, however the countrywide distribution of the NTM species was found different than previously reported. In conclusion, further investigation of the non-tuberculous mycobacteria profile in adjunct with epidemiological data seems to be essential in our country.