Seroprevalence and Risk Factors of Crimean-Congo Hemorrhagic Fever in Selected Seven Provinces in Turkey

Turkey has been one of the most endemic regions since 2002, when Crimean-Congo hemorrhagic fever emerged worldwide. The aim of the present study was to estimate the seroprevelance of CCHF virus in humans who reside in rural and urban areas of known endemic and nonendemic selected provinces of Turkey by using commercial ELISA kit. CCHFV IgG antibodies were detected in 2.3% of the population. The most important risk factors for CCHF seropositivity, were older age, male gender, illiterate, farmer, animal husbandry, living in rural residence in adobe houses, and a previous tick bite history. J. Med. Virol. 86:306-314, 2014. (c) 2013 Wiley Periodicals, Inc

An Imported Dengue Fever Case in Turkey and Review of the Literature

Dengue fever is an acute viral disease that can affect all age groups in tropical and subtropical countries. The predominant vectors are the mosquitoes namely Aedes aegypti and A.albopictus. Although there have been no case reports in Turkey due to DF, there is seroepidemiological evidence indicating the presence of Dengue virus (DENV) in Turkey. In this case report we presented an imported dengue fever case. The patient was 40 years old, previously healthy male, Switzerland citizen. He had immigrated from Dubai to India two weeks ago and after one week from immigration he attended to a hospital in India because of high fever. The NS1 antigen test (Bio-Rad Laboratories, USA) was found positive and the patient was followed-up with diagnosis of dengue fever in India. During his visit to Turkey, he attended to the hospital for a routine control and his analysis revealed thrombocytopenia (PLT: 48.000/mu l), leukopenia (white blood cell: 2800/mu L) and elevated liver enzymes (AST: 76 U/L, ALT: 83 U/L). Fever was not detected in follow-up. The patient had petechial rash on his lower extremities, white blood cell and PLT count increased to 4100/mu l and 93.000/mu l, respectively. Liver function tests revealed a decrease in AST (63 U/L) and ALT (78 U/L) on the third day. The PLT count increased to 150.000/ml. Since the patient had no fever and had normal physical and laboratory findings, he was discharged from the hospital. For the confirmation of dengue fever diagnosis the serum sample was sent to National Public Health Center, Virology Reference and Research Laboratory where IgM and IgG antibodies against DENV types 1-4 were investigated by indirect. immunofluorescence method (Euroimmun, Germany). The serum sample yielded positive result at the dilutions of 1/1000 for IgM and 1/10.000 for IgG. The last dilution of type 3 DENV IgM and IgG were determined high density of fluorescein, thus the serotype was identified as "DENV type 3". Travel-related diseases become important with increasing travel opportunities, globalization and transportation, recently. As a result, this imported case with foreign nationality was the first dengue fever case confirmed by clinical and laboratory tests in Turkey

SANDFLY FEVER OUTBREAK IN A PROVINCE AT CENTRAL ANATOLIA, TURKEY

Sandfly fever virus (SFV), which is classified in Phlebovirus genus, Bunyaviridae family, is widely seen in the Middle East and Mediterranean basin. SFV has four serotypes known as Sicilian (SFSV), Cyprus (SFCV), Naples (SFNV) and Toscana virus (TOSV). Sandfly fever, which is transmitted to human by different species of sandflies, especially Phlebotomus spp., starts with acute onset of high fever and lasts for three days. Headache, anorexia and myalgia are the most common symptoms. The aim of this study was to present the clinical and laboratory findings of the patients who were diagnosed during sandfly fever outbreak in Kirikkale province (located in central Anatolia in Turkey) during July 2009. A total of 20 patients from different districts of Kirikkale province with the history of fly bite and with the clinical findings of fever, myalgia-arthralgia, headache, conjunctival hyperemia and gastrointestinal symptoms such as diarrhea and nausea-vomiting were admitted to the Infectious Disease Unit of State Hospital. All the patients were followed up after hospitalization. A sandfly fever outbreak has been considered in the area since the cases shared a common history of insect bite, similar clinical and laboratory features in a particular time interval. The first patients from each different districts were accepted as the "index case" and 11 patients' serum samples have been sent to Refik Saydam National Public Health Agency, Virology Reference and Research Laboratory, Ankara. Serum samples were analyzed by using a commercial mosaic immunofluorescence test (IFT) (Euroimmun, Germany) to detect IgM and IgG antibodies against SFSV, SFCV, SFNV and TOSV. SFV-IgM positivity was demonstrated in 8 out of 11 patients (Naples virus in 5, Sicilian virus in 3 cases), while all of the cases were IgG negative. Of seropositive patients, two were female and six were male with a mean age of 30.7 (age range: 16-53) years. Sandfly fever was diagnosed in five cases by the positive IgM results and in three cases by the detection of IgM seroconversion in the second samples collected 6 days later. Clinically, fever and myalgia-arthralgia were detected in all of the cases, diarrhea and nausea-vomiting in 7, headache in 5 and conjunctival hyperemia in 1 of 8 seropositive patients. The evaluation of laboratory findings revealed leukopenia (1800-3800 cell/mu l) in all cases, thrombocytopenia (69000-140.000 cell/mu l) in 7, elevated AST (42-271 IU/L) in 7, elevated ALT (46-173 IU/L) in 5, elevated CK (185-1560 U/L) in 6 and elevated CRP (5.18-83.6 mg/L in 5 of 8 patients. All the patients were treated symptomatically without any sequella and discharged with complete cure. Turkey is a country in the Mediterranean basin and it is known that there is a favorable sandfly fauna in Anatolia. Therefore sandfly fever should be considered in patients presenting with fever and arthralgia-myalgia and with a history of insect bite especially during summer months

Crimean-Congo Hemorrhagic Fever: CXCL10 Correlates With the Viral Load

Crimean-Congo hemorrhagic fever (CCHF) is a human disease with high fatality rate. Although its pathogenesis is not elucidated yet, it is considered that cytokines play a significant role in the progression and outcome of the disease. Serum CXCL10 levels were estimated in 35 patients with acute CCHF and were correlated with the viral load, and various demographic and clinical parameters. The mean CXCL10 concentration in the patients' group was higher compared to the respective value in the control group (4421.74pg/ml vs. 28.47pg/ml, P<0.05). A strong positive correlation between CXCL10 and viral load was seen (r(s)=0.57, P<0.001), while the outcome of the disease was related with the viral load (r(s)=0.47, P=0.004) and the presence of hemorrhagic manifestations (P<0.001). The study provides an insight into the strong correlation between CXCL10 and viral load in acute CCHF cases suggesting that it plays an important role in CCHF pathogenesis. J. Med. Virol. 87:899-903, 2015. (c) 2015 Wiley Periodicals, Inc

HANTAVIRUS INFECTION: TWO CASE REPORTS FROM A PROVINCE IN THE EASTERN BLACKSEA REGION, TURKEY

Hantaviruses which are the members of Bunyaviridae, differ from other members of this family since they are transmitted to humans by rodents. More than 200.000 cases of hantavirus infections are reported annually worldwide. Hantaviruses can lead to two different types of infection in humans, namely, hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS). HFRS is the most common type of hantavirus infection in Europe and Asia and the most common virus types are Dobrava, Puumala, Hantaan and Seoul. A total of 25 hantavirus suspected cases have been reported from the Western Black Sea region of Turkey and 12 of these were confirmed serologically as "Puumala" subtype. Serological tests such as indirect immunofluorescence assay (IFA), are used for diagnosis and typing of the hantaviruses, however, since cross-reactions are common between the subtypes, the results of these tests should be confirmed by other methods. In this report two cases with hantavirus infection defined serologically were presented. Two male patients, 55 and 50 years old, respectively, living in Giresun province of Eastern Black Sea region, Turkey, were admitted to the State Hospital with the complaints of fever, sweating and diarrhoea without blood or mucus. Since thrombocytopenia and renal failure were detected in these two cases, they were transferred to the University Hospital. Presence of fever, thrombocytopenia and renal failure, with no laboratory findings of a bacterial infection and no growth of microoorganisms in the clinical specimens, admittance of the patients during summer and history of being present in the fields, necessitated to rule out leptospirosis, Crimean Kongo hemorrhagic fever and hantavirus infection which were all endemic in our area. Further investigation of the serum samples at the National Reference Virology Laboratory by IFA (Hantavirus Mosaic-1, Euroimmun, Germany) revealed hantavirus IgM and IgG antibodies >= 1:100 titer and the results were confirmed by immunoblot test (Hantavirus Profile 1 EUROLINE IgG and IgM, Euroimmun, Germany). Hantavirus Dobrava subtype was determined in both of the cases. Reverse transcriptase real-time PCR (Hantavirus Renal Syndrome General-type I&II Real Time RT-PCR; Shanghai ZJ Bio-Tech, China) revealed negative result. The first case was discharged with complete cure, however, the second case died. These cases which were the first cases from the Eastern Black Sea Region emphasized that hantavirus infections should be taken into consideration in patients presenting with fever, thrombocytopenia and renal function disturbance

Pediatric cases of Crimean-Congo hemorrhagic fever in Turkey

Background: The aim of the present study was to identify the epidemiological, clinical and laboratory features of Crimean-Congo hemorrhagic fever (CCHF) virus infection in children. Methods: Fifty children infected with CCHF virus in 20052010, and hospitalized in the Dr Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital in Ankara, were included. All the patients had positive IgM and/or polymerase chain reaction for CCHF virus. Results: Of the 50 patients, 19 were female and 31 were male. Patients were between 8 months and 15 years of age. The majority (82%) of patients had a history of tick bite. Fever (100%), hemorrhagic symptoms (76%), nauseavomiting (60%), tonsillopharyngitis (50%), malaise (50%), myalgia (46%) and maculopapular rash (24%) were the most common presenting clinical features. Mean platelet count on admission was 110 880/mm3, and the lowest was 7000/mm3. The mean of the lowest white blood cell count was 2860/mm3. Other pathological laboratory findings (asparate aminotransferase, alanine aminotransferase, lactate dehydrogenase and creatine kinase) were elevated, and prothrombin time and activated partial thromboplastin time were prolonged. Twenty-three patients (46%) were given ribavirin. No side-effect of ribavirin was seen. No patient died because of CCHF disease. Conclusion: CCHF virus infections are seen mostly in boys and school children and the adolescent age group. Tick bite is the major risk factor. Fever and hemorrhage are the most frequent presenting symptoms. Tonsillopharyngitis and rash on face or body are probably the most remarkable clinical findings in this disease. The CCHF disease course in Turkey may be mild in children

Cytokines as biomarkers of Crimean-Congo hemorrhagic fever

Crimean-Congo hemorrhagic fever (CCHF) is a potentially severe disease caused by CCHF virus. As in other viral hemorrhagic fevers, it is considered that the course and outcome of the disease depend on the viral load and the balance among the immune response mediators, and that a fatal outcome is the result of a cytokine storm. The level of 27 cytokines was measured in serum samples taken from 29 patients during the acute phase of the disease. Two cases were fatal. Among survivors, significant differences between severe and non-severe cases were observed in the levels of IP-10, and MCP-1, while the levels of IL-1b, IL-5, IL-6, IL-8, IL-9, IL-10, IL-15, IP-10, MCP-1, TNF-, and RANTES differed significantly between fatal and non-fatal cases (P<0.05). RANTES was negatively correlated with the outcome of the disease. A striking similarity with the cytokine patterns seen in Ebola virus disease was observed. A weak Th1 immune response was seen. The viral load was positively correlated with IL-10, IP-10, and MCP-1 levels, and negatively correlated with the ratio IL-12/IL-10. Especially IP-10 and MCP-1 were significantly associated with the viral load, the severity and outcome of the disease, and they could act as biomarkers and, probably, as potential targets for treatment strategies design. J. Med. Virol. 88:21-27, 2016. (c) 2015 Wiley Periodicals, Inc

A SANDFLY FEVER VIRUS (SFV) OUTBREAK IN THE MEDITERRANEAN REGION OF TURKEY AND REVIEW OF THE LITERATURE

Sandfly fever (SF) is a viral infection commonly emerging with outbreaks in the Mediterranean countries. The sandfly fever viruses (SFVs) are transmitted by the bite of infected sandflies. SF is characterized by fever, headache, retro-orbital pain, malaise and myalgia. In Turkey, SF outbreaks were seen between 2008 and 2010. Although Kadirli district is located in the Mediterranean region of Turkey any SF epidemic has not yet been reported. We aimed to present clinical and laboratory findings of the patients diagnosed with SF in the Kadirli outbreak area and compare with previous outbreaks of close locations. 237 patients admitted to the Kadirli State Hospitals with epidemiologic history, clinical and laboratory findings were evaluated. Serum samples of 9 patients were analyzed to detect IgM and IgG antibodies. SF was diagnosed in seven patients by serology. The most common symptom was fever (97%). Thrombocytopenia, leukopenia, elevated serum aspartate aminotransferase and alanine aminotransferase levels, elevated C-reactive protein and elevated lactate dehydrogenase levels were remarkable findings. All patients made a complete recovery with symptomatic treatment. Sandfly fever infection should be considered in the differential diagnosis of patients who have predictive findings in site close to Mediterranean Sea, especially during summer seasons in which sandflies are active

A sandfly fever virus outbreak in the East Mediterranean region of Turkey

Objectives: To report a sandfly fever virus (SFV) outbreak that occurred in Kahramanmaras Province, Turkey