In this multicentre study, which is the largest case series ever reported, we aimed to describe the features of tularaemia to provide detailed information. We retrospectively included 1034 patients from 41 medical centres. Before the definite diagnosis of tularaemia, tonsillitis (n = 653, 63%) and/or pharyngitis (n = 146, 14%) were the most frequent preliminary diagnoses. The most frequent clinical presentations were oropharyngeal (n = 832, 85.3%), glandular (n = 136, 13.1%) and oculoglandular (n = 105, 10.1%) forms. In 987 patients (95.5%), the lymph nodes were reported to be enlarged, most frequently at the cervical chain jugular (n = 599, 58%), submandibular (n = 401, 39%), and periauricular (n = 55, 5%). Ultrasound imaging showed hyperechoic and hypoechoic patterns (59% and 25%, respectively). Granulomatous inflammation was the most frequent histological finding (56%). The patients were previously given antibiotics for 1176 episodes, mostly with β-lactam/β-lactamase inhibitors (n = 793, 76%). Antituberculosis medications were provided in seven (2%) cases. The patients were given rational antibiotics for tularaemia after the start of symptoms, with a mean of 26.8 ± 37.5 days. Treatment failure was considered to have occurred in 495 patients (48%). The most frequent reasons for failure were the production of suppuration in the lymph nodes after the start of treatment (n = 426, 86.1%), the formation of new lymphadenomegalies under treatment (n = 146, 29.5%), and persisting complaints despite 2 weeks of treatment (n = 77, 15.6%). Fine-needle aspiration was performed in 521 patients (50%) as the most frequent drainage method. In conclusion, tularaemia is a long-lasting but curable disease in this part of the world. However, the treatment strategy still needs optimization.

Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system. But, the extent of liver damage in due course of the disease is unclear. This study included 325 brucellosis patients with significant hepatobiliary involvement identified with microbiological analyses from 30 centers between 2000 and 2013. The patients with ≥5 times of the upper limit of normal for aminotransferases, total bilirubin level ≥2 mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3 %) and cholestasis was detected in 215 (66.1 %) patients. Fatigue (91 %), fever (86 %), sweating (83 %), arthralgia (79 %), and lack of appetite (79 %) were the major symptoms. Laboratory tests showed anemia in 169 (52 %), thrombocytopenia in 117 (36 %), leukopenia in 81 (25 %), pancytopenia in 42 (13 %), and leukocytosis in 20 (6 %) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (n = 73), doxycycline plus rifampicin (n = 71), doxycycline plus rifampicin and an aminoglycoside (n = 27). The duration of ALT normalization differed significantly in three treatment groups (p < 0.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (p < 0.05). However, the length of hospital stay did not differ significantly between these three combinations (p > 0.05). During the follow-up, treatment failure occurred in four patients (1 %) and relapse was seen in three patients (0.9 %). Mortality was not observed. Hepatobiliary involvement in brucellosis has a benign course with suitable antibiotics and the use of doxycycline and an aminoglycoside regimen seems a better strategy in select patients.

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BackgroundTraining of infectious disease (ID) specialists is structured on classical clinical microbiology training in Turkey and ID specialists work as clinical microbiologists at the same time. Hence, this study aimed to determine the clinical skills and knowledge required by clinical microbiologists.MethodsA cross-sectional study was carried out between June 1, 2010 and September 15, 2010 in 32 ID departments in Turkey. Only patients hospitalized and followed up in the ID departments between January-June 2010 who required consultation with other disciplines were included.ResultsA total of 605 patients undergoing 1343 consultations were included, with pulmonology, neurology, cardiology, gastroenterology, nephrology, dermatology, haematology, and endocrinology being the most frequent consultation specialties. The consultation patterns were quite similar and were not affected by either the nature of infections or the critical clinical status of ID patients.ConclusionsThe results of our study show that certain internal medicine subdisciplines such as pulmonology, neurology and dermatology appear to be the principal clinical requisites in the training of ID specialists, rather than internal medicine as a whole.

85-year-old female had been hospitalized for a diagnosis of herpes zoster in the Dermatology Department 10 days ago due to redness and vesicular lesions on the left eyelids and the left side of the forehead, and had been started IV acyclovir 500 mg tid. She was consulted with us because of development of diplopia, agitation, and disorientation one day later. She was unconscious, and had partly encrusted vesicular lesions on a hyperemic ground extending to frontotemporal area and involving the left eyelids on her left side of the forehead. She was transferred to our clinic with the prediagnosis of herpes zoster ophthalmicus and varicella zoster virus (VZV) encephalitis, and the acyclovir dose was escalated to 750 mg tid. There were 150/mm 3 leukocytes (90% lymphocytes) and abundant erythrocytes on cerebrospinal fluid (CSF) microscopy. Biochemical analysis of CSF revealed concentrations of protein of 2149 mg/dL, glucose of 37 mg/dL and simultaneous blood glucose of 72 mg/dL. Gram and Ehrlich-Ziehl-Neelsen stained smears showed no microorganism. Both CSF and blood cultures yielded no growth. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis and Brucella standard tube agglutination were negative. In cranial magnetic resonance imaging (MRI), there were bilateral periventricular diffuse, on FLAIR sequences, hyperintense nodular white matter signal abnormalities, deepening of cortical sulci and fissures, a subdural collection (14 mm in thickness) in bilateral frontal areas, and hyperintense abnormalities (5 mm in thickness) suggesting acute-subacute haemorrhage on the right in T1-weighted images. In diffusion MRI, there was no restricted diffusion compatible with cytotoxic edema in brainstem, cerebellum and both cerebral hemispheres. The collection was attributed to cortical atrophy, and an antiedema treatment was recommended in neurosurgical consultation. Dexamethasone 4 mg qid was started, and administered for 6 days by cutting half the dosage every other day. The patient got better beginning from 7 th day of the antiviral therapy. Her consciousness, cooperation and orientation improved, and her skin lesions decreased. VZV DNA was found positive by PCR in CSF. Her therapy was completed on 21 st day, and she was discharged from the hospital with full recovery.