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Lyme disease is a multisystem disorder transmitted by ticks of the genus Ixodes and caused by Borrelia burgdorferi sensu lato. Its early clinical symptom is erythema chronicum migrans. Herein, two seronegative erythema chronicum migrans cases diagnosed by polymerase chain reaction (PCR) are reported. We emphasize the importance of PCR in early detection of B. burgdorferi sensu lato.

Herpes simplex virus (HSV) is the most common causative agent of acute, sporadic viral encephalitis. HSV encephalitis usually proceeds with focal edema, necrosis and bleeding in the temporal and frontal lobes. Acute fever and especially signs of temporal lobe involvement are typical clinical findings. It is difficult to differentiate HSV encephalitis from other viral encephalitis or other noninfectious states. The mortality rate is high in untreated patients. The most sensitive noninvasive method used in early diagnosis of HSV encephalitis is to demonstrate HSV-DNA in cerebrospinal fluid (CSF) by polimerase chain reaction (PCR). The most sensitive radiological method is magnetic resonance imaging (MRI). In this study, we present two cases diagnosed as HSV encephalitis, in our clinic in the year 2001, with characteristic MRI findings and positive results of HSV-DNA by PCR in CSF and the current literature has been reviewed. In conclusion, in cases suggesting herpes encephalitis according to the clinical, CSF and cranial MRI findings, CSF must be studied for HSV-DNA by PCR and treatment with acyclovir must be started as soon as possible. Combining MRI findings with PCR result would strongly suggest the diagnosis.

We aimed to determine the followings: The patients with Mediterranean spotted fever (MSF) followed during last 10 years, the rate of these patients to the ones admitted with fever and rash, clinical features, and the factors predicting the diagnosis of MSF among the patients admitted with fever and rash. Between 1993 and 2002, all the patients admitted with fever and rash were determined. The clinical features and serological results of the patients diagnosed as MSF were further investigated through their files. The diagnosis of MSF was established by epidemiological and clinical features, and also by clinical response within 2 days after doxycycline treatment. During the last 10 years, 140 patients admitted with fever and rash, 14 (10%, 4 female, 10 male, mean age: 41 years, range: 17-70) were diagnosed as MSF. Clinical features were as follows: Fever (100%), rash (100%), myalgia and/or arthralgia (93%), headache (86%), petechiae (21%), tache noire (14%), leukocytosis (71%), thrombocytopenia (19%), and accelerated erythrocyte sedimentation rate (100%). In nine patients, the diagnosis of MSF established by epidemiological and clinical features was confirmed by serological studies. As a complication, one patient developed facial paralysis. Six patients (60%) had been given several antibiotics. MSF should be considered in the differential diagnosis when a patient is admitted with fever, maculo-papular rash, headache and/or myalgia-arthralgia especially in spring, summer and autumn.

In this study we aimed to investigate the followings in the patients with adult-onset Still’s disease (AOSD), admitted and followed as fever of unknown origin (FUO) during the last 18 years in our unit: 1. The rate of them to all the patients with FUO during the same period, 2. Clinical features, 3. Predicting factors of the diagnosis of AOSD in FUO. The number and the etiology of the patients with FUO between 1984 to 2001 and also clinical features of those with AOSD were investigated from the patients’ files. The diagnosis of AOSD was re-analyzed according to the diagnostic criteria of Cush et al. The presumed diagnoses before establishing AOSD and antibiotics used were also noted. Chi-square and Fisher’s exact tests were used for statistical analysis. We determined 130 patients with the diagnosis of FUO and 36 (28%) had collagen vascular diseases. Twenty out of these 36 patients (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%), anemia (65%), neutrophilic leukocytosis (90%), accelerated erythrocyte sedimentation rate (100%), hypertransaminazemia (65%), negative RF (100%), and negative ANA (80%). Antibiotics had been prescribed in 18 (90%) of the patients. The presumed infectious diagnoses were streptococcal tonsilitis/pharyngitis (50%), infective endocarditis (4 patients), sepsis (2 patients), and acute meningitis syndrome (2 patients). The presumed non-infectious diagnoses were acute rheumatic fever (3 patients), seronegative rheumatoid arthritis (2 patients), and polymyositis (2 patients). Sixteen of our patients were followed for a mean duration of 30 months (range: 2-59). A remission was obtained by indomethacine in three (19%) and prednisolone in the remaining. Relapse was detected in three (19%) of these patients. AOSD is one of the most frequent etiologies 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. Since the disease had a heterogeneous clinical findings, certain bacterial infections (e.g. streptococcal pharyngitis and sepsis) are generally considered and prescribing antibiotic is a frequent event.

Endocarditis is a rare complication of brucellosis but it is the main cause of mortality in this disease. The accepted treatment for Brucella endocarditis is a combination of valve replacement and antibiotics. Conservative antibiotic treatment alone is not recommended by most of the authors as it is considered ineffective and to be increasing the risk of fatality. In our literature review, we have found 14 patients with brucellosis endocarditis treated with antibiotics alone with a favorable outcome. In this report, we described a patient treated with antibiotics alone and reviewed the literature. Depending on the data from the current literature and our patient we suggest that in selected patients with Brucella endocarditis who do not have congestive heart failure, valve destruction, abscess formation, or a prosthetic valve, conservative antibiotic treatment may be a valid alternative to surgery.

Fever of unknown origin (FUO) was described by the criteria of Petersdorf and Beeson, and the aetiology 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. In this study, we reviewed 117 cases fulfilling the criteria of FUO followed in our unit between 1984-2001. In 34% of the patients with FUO, the aetiology was infectious diseases, in 23% collagen vascular diseases, in 19% neoplasms, and in 10% miscellaneous diseases. In 14% of the cases the aetiology could not be found. Three leading diseases were tuberculosis (24%), lymphomas (19%), and Still’s disease (11%). The study reports tuberculosis as a more frequent cause of FUO than the other FUO series reported from the developed countries. Invasive procedures helped to establish the diagnosis in 50 out of 92 patients (43%). As a final diagnostic procedure, laparotomy contributed to the establishment of the diagnosis in 15 out of 20 patients (75%).In our country, infectious diseases and especially tuberculosis is a more frequent cause of FUO. Beside infectious diseases, collagen-vascular and neoplastic diseases should be considered in the differential diagnosis of a patient admitted with FUO.

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.

We aimed to evaluate epidemiological and clinical features of the patients with malaria followed in our clinic, and to review current status of malaria in Turkey. Epidemiological, clinical, diagnostic, therapeutic and prognostic 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 retrospectively evaluated. Malaria data of our country for 1926-2000 were obtained from Ministry of Health. Diagnosis was established by thin blood smears obtained in the febrile period in all cases. Plasmodium vivax was detected in 26 patients (25 local and 1 foreign origin), and P. falciparum in 7 (2 local and 5 foreign origin). Sixty-one percent of the patients had the prodromal symptoms of the disease and various antibiotics have been used. 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 3) or mefloquin (for 3) alone were given to the patients with P. falciparum. One patient with P. falciparum died soon after admission, all the remaining recovered. Data from Ministry of Health revealed that the most common (~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. Every febrile patient with a history of travel to the regions where malaria is endemic (tropical regions for the world, Southeast Anatolia and Çukurova for Turkey) should raise the suspicion of malaria. Every country should fight against malaria and a global cooperation is essentially important.

Herpes simplex esophagitis is generally seen in immunosuppressive patients; however, it has rarely been encountered in healthy subjects. We diagnosed herpes esophagitis in an immunocompetent patient with acute pyelonephritis-sepsis who developed odynophagia. The patients odynophagia recovered rapidly after parenteral acyclovir therapy. We diagnosed herpes esophagitis based on the typical endoscopic findings and the detection of HSV DNA by PCR in the esophageal biopsy specimen. We think that the predisposing factor for the development of esophagitis in our patient was temporary cellular immune dysfunction secondary to sepsis. We conclude that herpes esophagitis may develop in patients with sepsis without any other predisposing factor.

In this study, we aimed to evaluate the frequency and etiology of hepatic granulomas (HG) in liver biopsy specimens and the particular role of sarcoidosis and tuberculosis (TB) in etiology. Liver biopsy specimens examined last 7 years in pathology department were included into this study. All liver biopsy reports were screened and those revealing HG were further studied. Primary diseases, clinical findings, liver function tests and indications for biopsy were determined from the files, and characteristics of the granulomas were analyzed from the biopsy results. In addition, acid-fast bacilli (AFB) (by Ziehl-Neelsen staining) and Mycobacterium tuberculosis DNA (by PCR) were studied in specimens revealing HG due to TB. HG were found in 74 out of 4490 biopsy specimens (1.6%). Files of 56 (30 female, 26 male, mean age: 30 ± 12, range: 2 - 60) out of 74 patients were available. Etiologies in HG were, in order of frequency sarcoidosis (36%), TB (20%; pulmonary 3.5%, miliary 13%, localized hepatic 3.5%), hydatid disease (9%), brucellosis (5%), typhoid fever (3.5%), and one cases for each: Chronic hepatitis C, infectious mononucleosis, Hodgkin’s disease, and drug induced hepatitis (allopurinol). No etiology was found in 20% of cases. Infectious diseases (primarily tuberculosis) were responsible for 51% of cases with a determined etiology. Overall clinical features included fever (40%), fever of unknown origin (32%), hepatomegaly (43%), splenomegaly (35%), hypertransaminasemia (56%), elevated alkaline phosphatase (44%), elevated gamma glutamyl transpeptidase (31%), and hyperbilirubinemia (8%). In patients with sarcoidosis, biopsy was done to screen for the liver involvement; and was done in the other patients either to diagnose the disease or verify the diagnosis. Among TB granulomas, caseating necrosis was found in 50%, M. tuberculosis DNA in 57% of studied cases (4/7) and AFB was not found in any. In conclusion, infectious diseases (primarily TB) were found responsible for nearly half of HG and sarcoidosis was found responsible for the remaining cases with a determined etiology.

Chickenpox, an infection of childhood with vesicular skin rash, is caused by Varicella-zoster virus (VZV). Although the infection is rare in adults, it can cause serious complications. In this report, a VZV pneumonia case in a previously healthy adult is presented and the related literature is reviewed. The patient was treated with oral acyclovir and both clinical and radiographic recovery has been observed.

Group A streptococci (GAS) have long been considered CAMP negative. Moreover, the CAMP reaction has been commonly accepted as an important method to differentiate GAS from group B streptococci (GBS). During identification of beta-hemolytic streptococci in our laboratory, we have observed that GAS also produced a positive CAMP reaction. We here conclude that although CAMP reaction is one of the most important tests in presumptive identification of GBS, it should be questioned at this point with the review of relevant literature.