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Previous multicenter/multinational studies were evaluated to determine the frequency of the absence of cerebrospinal fluid pleocytosis in patients with central nervous system infections, as well as the clinical impact of this condition. It was found that 18% of neurosyphilis, 7.9% of herpetic meningoencephalitis, 3% of tuberculous meningitis, 1.7% of Brucella meningitis, and 0.2% of pneumococcal meningitis cases did not display cerebrospinal fluid pleocytosis. Most patients were not immunosuppressed. Patients without pleocytosis had a high rate of unfavorable outcomes and thus this condition should not be underestimated. © 2017 The Author(s)

BACKGROUND: The Thwaites and Lancet scoring systems have been used in the rapid diagnosis of tuberculous meningitis (TBM). However, brucellar meningoencephalitis (BME) has similar characteristics with TBM. The ultimate aim of this study is to infer data to see if BME should be included in the differential diagnosis of TBM when these two systems suggest the presence of TBM. METHOD: BME and TBM patients from 35 tertiary hospitals were included in this study. Overall 294 adult patients with BME and 190 patients with TBM were enrolled. All patients involved in the study had microbiological confirmation for either TBM or BME. Finally, the Thwaites and Lancet scoring systems were assessed in both groups. RESULTS: The Thwaites scoring system more frequently predicted BME cases (n = 292, 99.3%) compared to the TBM group (n = 182, 95.8%) (P = 0.017). According to the Lancet scoring system, the mean scores for BME and TBM were 9.43 ± 1.71 and 11.45 ± 3.01, respectively (P < 0.001). In addition, TBM cases were classified into "probable" category more significantly compared to BME cases, and BME cases were categorized into the "possible" category more frequently. CONCLUSIONS: When the Thwaites or Lancet scoring systems indicate TBM, brucellar etiology should also be taken into consideration particularly in endemic countries.

Aim: The aim of this study is to describe the methods used to control the first monoclonal vancomycin resistant enterococcus (VRE) outbreak which emerged in September 2005 in a university hospital in Turkey. Material and Methods: Following detection of the first VRE positive case, surveillance with stool or rectal swab cultures from all the hospital inpatients was performed. Patients were categorized according to their potential risk of exposure to VRE; VRE positive cases, primary contacts and secondary contacts. Isolation and cohortion of the patients were performed according to this categorization. Hospital wide information and training programs were conducted for healthcare workers (HCW) and strict contact isolation precautions were implemented in the hospital. Results: Apart from the index case, three additional cases were detected. The recommendations of the Center for Disease Control and Prevention (CDC) were adopted and implemented in our hospital and the outbreak was controlled within one month. Conclusion: Categorization of patients according to their possible risk of exposure to VRE may be useful in determining the form and extent of control measures, especially in the hospitals with limited resources.

Visceral leishmaniasis (VL) which is a chronic disease caused by the protozoon, Leishmania, occurs widely worldwide and it is widespread in most of the countries in the Mediterranean basin. The infection which is transmitted by a sandfly (Phlebotomus) vector, has a prolonged incubation period and insidious onset. VL generally affects children and may be fatal if not treated. In this report, a 31 years old male patient, who was the first adult VL case from Zonguldak (a province located at western Black-Sea region of Turkey) was presented. He was admitted to the hospital with two-months history of fever, chills, sweating and weight loss. There was no history of travel outside the city nor insect bites, however, he indicated that there would be unnoticed sandfly bites since sandflies were very common in the coal mines he worked. His physical examination revealed body temperatue of 39.2°C and hepatosplenomegaly, while laboratory findings yielded anemia, leucopenia, hypoalbuminemia and hypergamaglobulinemia. Erythrocyte sedimentation rate was 62 mm/h, C-reactive protein was 113 mg/L and liver transaminases were 2 to 5 folds higher than the reference values. The only pathological finding was hepatosplenomegaly in the abdominal ultrasound and computerized tomography. He was further examined to rule out infections with similar signs and symptoms, connective tissue diseases and malignancies and all were found negative. Hypercellular bone marrow were detected in the aspiration material. Bone marrow smears, bone marrow samples inoculated in NNN medium and serum samples of the patient were sent to the reference parasitology laboratory of Refik Saydam National Public Health Agency for evaluation in terms of VL. The diagnosis was confirmed by the detection of Leishmania IgG titer as 1/512 with in-house indirect immunofluorescence antibody test, by positivite rK39 Dipstick (InBios, USA) test and by the observation of Leishmania amastigote forms in the bone marrow smears. Bone marrow culture in NNN medium also revealed positive result by the determination of Leishmania promastigote forms on the 7 th day. The treatment was initiated by pentavalent antimony [glucantime 1 × 10 mg/kg/day intramuscular (IM)] however, due to severe adverse effects it has switched to liposomal amphotericin B (3 mg/kg/day). The patient completely recovered without complication. In conclusion VL should be considered in the differential diagnosis of patients, even adults, with persistent fever, hepatosplenomegaly and pancytopenia, in endemic countries such as Turkey.

Staphylococcus lugdunensis is an infrequent cause of infective endocarditis (IE) and usually involves native valves of the heart. It causes life-threatening events such as rupture of cardiac valve or cerebral or pulmonary embolism due to necrosis on the endocardial tissue involved by the bacteria. Antibiotic therapy without cardiac surgery or delayed cardiac surgery usually follows a fatal course in S.lugdunensis endocarditis. In this report the first case of S.lugdunensis endocarditis from Turkey was presented. A 37 years-old man was admitted to the emergency department with a 2-weeks history of fever chills and accompanying intermittent pain on the left side of the thorax. Other than recurrent folliculitis continuing for 20 years, his history was unremarkable. Echocardiography revealed vegetation on the mitral valve of the patient and vancomycin plus gentamicin were initiated with the diagnosis of IE. All blood cultures (5 sets) taken on admission and within the initial 48 hours of the antibiotic therapy yielded S.lugdunensis. According to the susceptibility test results, the antibiotic therapy was switched to ampicillin-sulbac-tam plus rifampin. Blood cultures became negative after the third day of therapy, however, cardiac failure was emerged due to rupture of mitral valve and chorda tendiniea on the 12 th day of the therapy. Cardiac surgery revealed that mitral valve and surrounding tissue of the valve were evidently necrotic and fragile, anterior leaflet of the mitral valve was covered with vegetation, posterior leaflet and chorda tendiniea were ruptured. Vegetation was removed and the destructed mitral valve was replaced with a mechanical valve. Vegetation culture remained sterile, however, antibiotics were switched to vancomycin plus rifampin due to persistent fever on the 21 st day of the therapy (9 th day of operation). Fever resolved four days after the antibiotic switch. Antibiotics were stopped on the 9 th weeks of admission and the patient was discharged. He had no problem in follow-up controls for one year. In conclusion, proper antibiotic therapy combined with early cardiac surgery seems to be the optimal therapeutic approach in IE caused by S.lugdunensis.

Community-acquired pneumonia (CAP) is a common infectious disease with high morbidity and mortality. In this study, demographic features, underlying conditions, causative pathogens and factors affecting length of hospital stay and mortality were retrospectively investigated in patients who were diagnosed as CAP and followed-up in our unit between January 2005-December 2007. Among 97 patients 65 (67%) were male, 32 (33%) were female and the mean age was 62.7 (age range: 18-94) years. Patients were grouped according to criteria of Turkish Thoracic Society into four groups; 22 were group 2 (patients with risk factors, without aggrevating factors), 59 were group 3 (patients with aggravating factors), and 16 were group 4 (patients who have necessity for intensive care) CAP. The patients have also been grouped according to criteria of American Thoracic Society (CURB-65 score = Confusion, Urea > 7 mmol/L, Respiratory rate ? 30/min, low Blood pressure and being ? 65 years old), as group I (n= 65), group II (n= 20), and group III (n= 12). During follow-up 11 (11.3%) patients required mechanical ventilation support and 6 (6.2%) patients have died. Causative pathogens were isolated from 14 (23.3%) out of 27 well-qualified sputum samples obtained from 60 patients who could produce sputum (8 Streptococcus pneumoniae, 2 methicillin-sensitive Staphylococcus aureus, 2 Klebsiella pneumoniae, 1 Haemophilus influenzae, 1 Moraxella catarrhalis). Thirty-seven of cases were treated with levofloxacin, 10 with moxifloxacin, 24 with ceftriaxone ± clarithromycin, 16 with sulbactam-ampicillin ± ciprofloxacin, 10 with beta-lactam/beta-lactamase inhibitor combinations, and fever declined within 2.5 days in 83 (85.6%) of them. The mean duration of hospital stay was estimated as 11.1 days. In the evaluation of the factors that affect the length of hospital stay, being ? 65 years old, gender, underlying conditions, central venous catheterisation, presence of nasogastric tube, positive culture result, previous antibiotic treatment, fever continuing for > 3 days despite antibiotic therapy and scoring groups were not determined as risk factors (p> 0.05 for all of these parameters). However, mechanical ventilation was found as a significant risk factor (p< 0.05). In the evaluation of the factors that affect mortality, mechanical ventilation (p< 0.001), staying in intensive care unit (p< 0.001), being group 4 CAP (p< 0.001) and fever continuing for > 3 days despite antibiotic therapy (p= 0.05) were found to be significant risk factors. In conclusion, length of hospital stay, mortality and treatment costs in CAP patients could be reduced by defining the risk factors and starting empirical antibiotic therapy according to the national and international guidelines.

Tularemia is caused by a small, Gram-negative, pleomorphic coccobacillus, Francisella tularensis. Oculoglandular tularemia is a rare clinical form. There are few reports about oculoglandular tularemia, and less than 20 cases with oculaglandular tularemia have been reported in PubMed up to date. We reviewed the literature about oculoglandular tularemia, and reported a 31-year-old woman with oculoglandular and oropharyngeal tularemia. She admitted to our hospital with a three-week history of sudden onset of fever, fatigue, headache, sore throat, swollen left upper lid, injected and erythematous left eye, epiphora, preauricular nontender lump on the left and generalized aches, but there was no history of eye injury. She was living in a village where tularemia is endemic, but no history of encountering with an animal. The clinical diagnosis of oculoglandular and orophayngeal tularemia was confirmed by microagglutination test and PCR. She was fully improved on the eighth day of the ciprofloxacine treatment. Tularemia should come to mind in patients with fever, severe throat, conjunctivitis and cervical masses especially unresponsive to penicillin or cephalosporine therapy, coming from a tularemia endemic area. © Medical Journal of Trakya University. Published by Ekin Medical Publishing. All rights reserved.

Infective endocarditis has variable clinical presentations and may present with rheumatologic manifestations. Infective endocarditis due to high level aminoglycoside resistant enterococci represents a severe therapeutic challenge as none of the currently recommended treatment regimens are bactericidal against these isolates. In this report, a case of infective endocarditis with double aetiology, high level aminoglycoside resistant Enterococcus faecalis together with methicillin-resistant coagulase-negative staphylococci (MR-CNS), presenting with leukocytoclastic vasculitis and rapidly progressive glomerulonephritis, has been presented. A 48-years-old woman was admitted to our hospital with malaise and non-pruritic purpural rush on her lower extremities. On admission she had no fever or leukocytosis. Skin biopsy showed leukocytoclastic vasculitis and steroid therapy was started. On 12th day of admission rapidly progressive glomerulonephritis was diagnosed and she received plasmapheresis and haemodialysis support. Transthoracic echocardiography (TTE) demonstrated 1 × 1.5 cm vegetation on the mitral valve. An initial diagnosis of infective endocarditis was made and empirical treatment with vancomycin and gentamicin was started. All blood cultures yielded high level aminoglycoside resistant E. faecalis and additionally two of them yielded MR-CNS. Vancomycin was administered in combination with high dose ampicillin and repeated blood cultures taken after administration of ampicillin, revealed no growth. The patient remained afebrile, renal functions improved and a repeat TTE done on 20th day of ampicillin therapy showed waning of the vegetation. On 42nd day of treatment repeat TTE showed new vegetation on the mitral valve and severe valve insufficiency, so the patient was scheduled for mitral valve replacement. She was treated for 12 weeks with vancomycin and ampicillin and recovered successfully. In conclusion; infective endocarditis should be considered in the differential diagnosis of leukocytoclastic vasculitis and rapidly progressive glomerulonephritis. Physicians should document their treatment outcomes and experience with high level aminoglycoside resistant enterococcal infective endocarditis, which is a therapeutic challenge, so that the best therapeutic options can be identified.

Mediterranean spotted fever (MSF) is one of the tick-borne rickettsial infections caused by Rickettsia conorii. It is transmitted to humans by brown dog ticks (Rhipicepholus songuineus). In this case report, a 16-years-old male patient who was diagnosed as MSF after an exposure to dog-tick in Bartin province (located at middle Black Sea region of Turkey) has been presented. His history revealed that, five days before admission to the hospital (on June, 2007) he had cleaned dog-ticks from his dog, and after 12 hours he found a stucked tick on his leg and he took it out right away with a tweezer. High fever, headache and generalized maculopapular rash including soles and palms and a black-colored lesion at the tick bite site developed three days later. In clinical examination, there was a black escar circled with a red-purple colored halo in front of the right tibia at the site of the tick bite showing high similarity to "tache noire" which was specific to MSF. Indirect immunofluorescence assay (IFA) for Rickettsia yielded negative result in the serum sample collected on admission day, however, it was found positive at 1/512 titer in the serum sample collected 10 days after admission. The patient has recovered completely without any complication after 10 days of doxycycline therapy. The aim of this presentation is to point out that MSF should be considered for the differential diagnosis of a patient with a history of tick bite, fever, maculopapular rash, headache, myalgia, arthralgia and especially with black escar during summer months in our country where the incidence of tick-borne infections has been increasing since recent years.

Nosocomial central nervous system infections constitute 0.4% of all nosocomial infections. The responsible pothogens of nosocomial meningitis are quite different from community-acquired meningitis with high rates of morbidity and mortality. The most important prognostic factor is the appropriate choice of pathogen-specific antibacterial therapy. In this report, a 64 years old woman with nosocomial meningitis caused by Klebsiella pneumoniae and Acinetobacter spp. after lumbar disc hernia operation, has been presented. The risk factors were detected as recent history of neurosurgical operation for three times and long term (29 days) use of external ventricular drainaige (EVD) catheter. Empirical meropenem (3 × 2 g, IV) and vancomycin (2 × 1 g, IV) therapy was initiated upon the diagnosis of nosocomial meningitis based on the clinical and laboratory findings on the postoperative fifth day. Extended-spectrum beta-lactamase (ESBl) producing K. pneumoniae (susceptible to amikacin, imipenem, meropenem, cefoxitine, ciprofloxacin, piperasillin-tazobactam and trimethoprim/ suifamethoxazole) was recovered from cerebrospinal fluid (CSF) and blood samples obtained on the same day. There was no change in the status of the patient on the eighth day of meropenem therapy, with high leukocyte number (1300/mm3) and presence of gram-negative bacilli in CSF, and ESBL positive K. pneumoniae (antibiotic susceptibility pattern same with the previous isolate) growth in CSF culture. Thereupon intravenous ciprofloxacin (3 × 400 mg) was added to the therapy and her EVD has been changed. However, ESBL positive K. pneumoniae (antibiotic susceptibility pattern same with the previous isolate) together with Acinetobacter spp. (susceptible to gentamycin, tobramycin, netilmicin, ciprofloxacin, levofloxacin and cefepime) were isolated from CSF and blood cultures obtained on the 13th day of meropenem and fifth day of ciprofloxacin therapy. Therefore intraventricular and intravenous gentamicin (15 mg/days and 3 × 120 mg, respectively) were added to the therapy. The patient recovered at the end of three weeks treatment without any additional sequela other than her primary illness. This case was the first case of nosocomial meningitis due to ESBL positive K. pneumoniae together with Acinetobacter spp. in the available literature.

Cryptococcosis caused by Cryptococcus neoformans has a wide range of clinical presentations, varying from asymptomatic colonization of the respiratory airways to the dissemination of infection into different parts of body. It is more common among immunosupressed patients such as human immunodeficiency virus (HIV) positive ones. in this report we present a case with C. neoformans meningitis and miliary pulmonary infiltrates suggesting pulmonary tuberculosis without HIV infection. A-70-years-old male was admitted to the hospital with mental confusion, 3-weeks history of headache, weight loss, dry cough and fatigue. Physical examination was normal except neck stiffness. Cerebrospinal fluid (CSF) white cell count was 120/mm3 (80% polimorphonuclear cells). Gram staining of CSF revealed poorly stained gram-positive yeast cells. Empirical therapy with lipozomal amphotericin B, ceftriaxone and ampicillin combination was started. When C. neoformans growth was detected on CSF culture, ceftriaxone and ampicillin were discontinued. Patient became conscious at 24th hour of the treatment. Peripheric blood flow-cytometric analysis revealed a significant decrease in absolute CD4+ T lymphocytes, and in CD8+28+ T lymphocytes in addition a significant increase in natural killer cell ratio. Blood immunoglobulin and complement levels were found normal. Cranial magnetic resonance imaging and computerized tomography (CT) of the abdomen were normal, however, chest CT revealed multiple parenchymal millimetric nodular infiltrations on both sides and minimal fibrotic alterations. Acid-fast staining of CSF, tuberculosis culture, tuberculosis PCR results and repeated HIV serology were found negative, Despite the lack of microbiological confirmation, empirical antituberculosis treatment was also started with the suspicion of miliary tuberculosis as the patient had a symptom of long-term dry cough, miliary infiltrations on chest CT anergic tuberculin skin test and a history of pulmonary tuberculosis in childhood. After two weeks, amphotericin B was changed to oral fluconazole which was continued for an additional eight weeks. Antituberculosis therapy was given for nine months. Control chest CT taken after four months of antituberculosis therapy revealed improvement of the lesions. This presentation emphasizes the fact that cryptococcal infections may develop in HIV negative patients, even together with tuberculosis in certain case and radiological findings of the two infections may be confusing when both of them invade the lungs.

Pseudomonas putida is a Gram-negative, nonfermentative, saprophytic soil bacterium with versatile metabolical features. We presented an 18-year-old male patient who developed tibial osteomyelitis due to P. putida after a traffic accident. He had open comminuted fractures in the right fibula and tibia and the site of open fracture was contaminated with dust and soil. He underwent surgical debridement and irrigation of the fracture site followed by fracture reduction and application of an external fixator. Despite empirical antibiotic treatment, there was a discharge from the pin tract on the postoperative fifth day. Cultures obtained from soft tissue and bone during repeat debridement and irrigation yielded P. putida. The patient recovered after four weeks of parenteral antibiotic treatment without any sequela. A case of posttraumatic tibial osteomyelitis caused by P. putida has hitherto not been reported in the literature.

Leptospirosis which is caused by Leptospira species, may present with clinical features that vary from a mild flu-like illness to an acute life-threatening condition. Weil's disease, the most severe form of leptospirosis is characterized by multiorgan involvement including liver, kidney and lungs. In this report a severe Weil's disease was presented. A 43 years old male patient who had a history of swallowing water while swimming in the creek, was admitted to the hospital with the complaints of weakness, cough, bloody sputum, generalized jaundice and dark urine. Acute renal failure, bilateral lung infiltration, hyperbilirubinemia, leukocytosis and thrombocytopenia were detected, and the patient has undergone to hemodialysis. Ceftriaxone and ciprofloxacin treatment was applied to the patient after collection of blood, urine and sputum cultures and serum samples for serological tests. None of the cultures yielded pathogenic microorganisms. Microscopic agglutination test (MAT) was applied to two serum samples which were collected with 10 days interval. The first serum sample revealed antibody positivity at 1/200 titer against L.semeranga Patoc I, while the second serum revealed antibody positivity at 1/400 titer against both L.semeranga Patoc I and L.icterohaemorrhagiae Wijnberg. By the administration of antibiotic therapy and early supportive care the patient was cured completely. In conclusion Weil's disease should be taken into consideration in the patients with multiple organ involvements.

Atypical measles is characterized by high fever, headache, myalgia and atypical rash, in patients who were vaccinated against measles. In this report a 22 years old male patient presenting with severe cervical and shoulder muscles spasms, purpuric and petechial lesions on palm, sole and whole body, has been presented. The patient had not an underlying disease or immunosuppression, and he had experienced single dose of measles vaccine when he was nine months old. Diagnosis of atypical measles was based on the clinical and serological findings (by measles lgM and lgG positivity). The aim of the presentation of this case was to emphasize that atypical measles should be considered for differential diagnosis in the cases complaining of muscle spasms and atypical skin rashes even if vaccinated against measles.