It is striking in this question that we are told that our patient has returned to Spain, but not from where (which could help us to make digressions about the possible cause). However, the description of the picture is very exhaustive as well as typical, so the question is easy. It is a disease that produces fever, arthralgias and a generalized exanthema with petechiae on the lower limbs. The CBC shows leukopenia accompanied by plateletopenia and elevated transaminases. Malaria has been ruled out as a possible cause. All the data are highly suggestive of Dengue, especially the plateletopenia and petechiae (suggestive of capillary fragility), answer 3 correct.

It is striking in this question that we are told that our patient has returned to Spain, but not from where (which could help us to make digressions about the possible cause). However, the description of the picture is very exhaustive as well as typical, so the question is easy. It is a disease that produces fever, arthralgias and a generalized exanthema with petechiae on the lower limbs. The CBC shows leukopenia accompanied by plateletopenia and elevated transaminases. Malaria has been ruled out as a possible cause. All the data are highly suggestive of Dengue, especially the plateletopenia and petechiae (suggestive of capillary fragility), [HIDDEN].

A 54-year-old man diagnosed with type 2 diabetes mellitus comes to our office. He reported a fever of 40ºC with chills and shivering, arthromyalgia and headache, for which he started treatment with paracetamol. The symptoms started 24 hours before his return to Spain. Three days later she presented a generalized maculopapular rash that evolved into more intense petechiae on the lower limbs. She presented blood tests with leukopenia with 3,200/mm3 and platelets 91,000/mm3 and severe elevation of aminotransferases. The thick blood drop, peripheral blood smear, PCR and malaria antigen are negative. What is the most likely diagnosis?

[Travel Related Fever and Rash: Two Cases of Dengue Fever].

The frequency of travel-related infections in the world has increased due to the easily and widespread use of travel facilities in the 21st century. Vector-borne diseases are an important part of infectious diseases. Dengue fever is one of the travel-related infections that has been reported increasingly in recent years through the development of diagnostic methods. The aim of this report was to present two Dengue fever cases originating from travel. There was a story of mosquito bite during a trip to Sri Lanka travel in our first case. The patient was 30 years old and maculopapular rash appeared on the fifth day of contact. Three days after the onset of the rash, she has admitted to our clinic, complaining with fever and chills. Increased leukopenia and muscle enzymes were detected in the laboratory analysis. Real-time reverse transcriptase polimerase chain reaction (RT-PCR) was positive in the serum sample. The patient was followed up with supportive care and discharged by improvement. The second case, a 24-year-old male, had a story of mosquito bite during his trip to Malaysia. After the patient complained of fever, chills, fever, nausea, vomiting and muscle pain, the Dengue virus (DENV) NS1 antigen test performed in this country was found to be positive. In the second case, there was no maculopapular rash and laboratory analysis showed an increase in leukopenia, thrombocytopenia and muscle enzymes. RT-PCR positivity was detected in the serum sample. The patient was followed up with supportive treatment and discharged with cure. DENV infections are caused by DENV which is common in the tropical areas of the world. There are four DENV-1, DENV-2, DENV-3 and DENV-4 serotypes. DENV infections can present different clinical manifestations such as asymptomatic disease, viral syndrome, Dengue haemorrhagic fever, and Dengue shock syndrome. Dengue fever is often accompanied by arthritis, maculopapular rash and high fever. Our cases were defined as Dengue fever according to this definition. In the diagnosis of the disease, it is necessary first to be suspicious of the disease and the travel history must be questioned. In the definitive diagnosis, virus isolation, antigen, nucleic acid detection and serological tests are used. The virus can be isolated from blood, serum, urine and tissues. In the first five days after beginning of the symptoms associated with DENV infections, serum RT-PCR and Dengue NS1 antigen test may be positive.

COVID-19 Pneumonia and Dengue Fever Coinfection in an Individual From Southeast Asia.

COVID-19 infection is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was declared a pandemic in 2020. Dengue fever (DF) is caused by the dengue virus (DENV) from the <iFlaviviridae</i family and is transmitted via the bite of the female <iAedes</i <iaegypti</i mosquito. COVID-19 pneumonia and dengue fever coinfection is a relatively difficult diagnosis to be established considering the similarities in the clinical manifestation of both diseases. I hereby report an unusual case of dual diagnosis involving COVID-19 pneumonia and dengue fever (DF) on the same day of presentation to the hospital. A 62-year-old male presented to the emergency department with a fever of six days duration associated with chills, rigors, arthralgia, myalgia, and a generalized pinpoint rash over the chest and abdomen. He had contact with a worker who recently tested positive for COVID-19. However, his vital signs were stable with peripheral capillary oxygen saturation (SPO2) of 99% under room air. Laboratory investigations showed polycythemia, increased hematocrit levels, and thrombocytopenia. Liver function tests showed evidence of acute hepatitis. Otherwise, the basic metabolic panel and coagulation profile were normal. Viral screens for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) were negative. The posterior-anterior chest radiograph of the patient showed ground glass opacity in both middle and lower zones of the lungs, which is mostly peripheral with preservation of lung markings. The diagnosis was confirmed by a positive SARS-CoV-2 polymerase chain reaction (PCR) test with a cycle threshold (CT) value of 19.97 and positive immunoglobulin M (IgM) and immunoglobulin G (IgG) titers on the dengue serology panel on the same day of testing. Predisposing risk factors were chronic medical illnesses (type 2 diabetes mellitus, hypertension, and ischemic heart disease) and exposure to probable COVID-19-infected individuals. The patient fully recovered after treatment with oral paracetamol 1 g four times a day for five days and an intravenous drip of 0.9% sodium chloride for 24 hours.

[Dengue. Apropos of 2 cases].

BACKGROUND. Dengue is an acute febrile illness caused by several arthropod-born viruses and characterized by biphasic fever, myalgia or arthralgia, rash, leukopenia and lymphadenopathy. Its diagnosis is based on knowledge of the geographic distribution of dengue viruses. CASE REPORTS Case no 1: A 11 year-old boy suffered from sudden onset of fever accompanied by retro-orbital headache, arthralgia and diffuse myalgia. There was no rash. Hemogram showed: hemoglobin: 11.6 g%; leukocytes: 3,400/mm3 (PMN: 76%); platelets: 190,000/mm3. A diagnosis of viral infection was considered, but, as the boy had recently been to the French West-Indies, a serologic study was performed. This was negative 2 days after the onset of disease and positive (specific IgM for the 4 dengue types), 13 days later. Case no 2: A 7 year-old boy suffered from sudden onset of fever. Severe calf muscle pain 4 days later led to his admission. Creatine phosphokinase activity was very high: 83,100 units (N: 30-120). Hemogram showed: hemoglobin: 11.4 g%; leukocytes: 2,500/mm3 (PMN: 60%); platelets: 124,000/mm3. A diagnosis of acute myositis was considered, but as the patient had recently visited Venezuela, a serologic study was performed. This was negative 8 days after the onset of disease and positive (specific IgM for the 4 dengue types) 16 days later. CONCLUSION. The first case is characteristic of the classical form of dengue fever. The second patient presented with very localized myalgia. The diagnosis in both cases was facilitated by the knowledge that the patient had recently stayed in an endemic area.

First case of imported chikungunya infection in Croatia, 2016.

In recent years, several European countries reported cases of imported chikungunya infection. We present the first imported clinically manifested chikungunya fever in Croatia. A 27-year-old woman returned to Croatia on 21 March 2016, after she stayed in Costa Rica for two months where she had noticed a mosquito bite on her left forearm. Five days after the mosquito bite she developed severe arthralgias, fever and erythematous papular rash. In next few days symptoms gradually subsided. After ten days she felt better, but arthralgias re-appeared accompanied with morning stiffness. Two weeks after the onset of the disease she visited the infectious diseases outpatient department. The physical examination revealed rash on the trunk, extremities, palms and soles. Laboratory findings showed slightly elevated liver transaminases. Serological tests performed on day 20 after disease onset showed a high titer of chikungunya virus (CHIKV) IgM and IgG antibodies which indicated CHIKV infection. CHIKV-RNA was not detected. Serology to dengue and Zika virus was negative. The patient was treated with nonsteroid anti-inflammatory drugs and paracetamol. Her symptoms ameliorated, however, three months later she still complaint of arthralgias. The presented case highlights the need for inclusion of CHIKV in the differential diagnosis of arthralgia in all travelers returning from countries with documented CHIKV transmission.

[Experience of integrated traditional Chinese and Western medicine in first case of imported Zika virus disease in China].

Zika virus disease is an acute infectious disease caused by Zika virus transmitted through Aedes mosquitoes. To explore the therapeutic effect of integrated traditional Chinese and Western Medicine for Zika virus disease, the treatment process of the first imported case in China was reviewed. The first imported Zika virus disease in China was admitted to Ganxian People's Hospital in Jiangxi Province on February 6th, 2016, and the patient received isolation treatment for 9 days and cured later. The effect of antiviral treatments including Xiyanping injection was evaluated based on clinical diagnosis and treatment process of the patient. A 34-year old male patient was admitted with chief complaint of fever for 9 days, orbital pain and itching rash for 4 days on February 6th, 2016. (1) Epidemiological characteristics: the patient was bitted by mosquitoes during his business trip in Venezuela since January 1st, where Zika virus disease was spreading. On January 20th he had dizziness without fever, and the symptom disappeared after taking medicines without details. Paroxysmal dizziness, chills and mild fever without myalgia was experienced on January 28th. On February 3rd small red rash appeared in the neck, spreading to anterior part of chest, limbs and trunk, and the fever, fatigue, nausea was continued, and a new symptom of paroxysmal pain in back of ears and orbits appeared, during which he had not go to hospital. The symptoms relieved on February 4th. He returned to Ganxian County on February 5th, he had yellow stool 3 times with normal temperature, without abdominal pain, and red rash still appeared in the neck. He went to Ganxian People's Hospital on February 6th, 2016. (2) Clinical manifestation: the vital signs showed a temperature of 36.8?centigrade, a pulse rate of 80 bpm, a respiratory rate of 20 bpm, and a blood pressure of 110/70 mmHg (1 mmHg = 0.133 kPa). It was showed by physical examination that red rash appeared in the neck, and no superficial enlarged lymph nodes were found. Bilateral conjunctival congestion was obvious, physiological reflex existed and pathological reflex was not found. (3) Auxiliary lab test and examination: no abnormal finding were revealed throughout examination and laboratory tests, including routine blood test, liver function, renal function, serum myocardial enzyme, electrolyte, blood sugar, C-reactive protein (CRP), troponin I (TnI), and procalcitonin (PCT), except slight prolongation in activated partial thromboplastin time (APTT, 38.6 s) on February 6th; and slightly dense shadow in left lung in lung CT scan, considering inflammatory changes and slight emphysema (especially in the left lower lung) as well as bilateral renal calculus on February 8th. No significant abnormalities were found in electrocardiogram and B ultrasound test of liver, spleen, and pancreas. (4) Virus confirmation: Zika virus nucleic acid was positive reported by Jiangxi Province Center for Disease Control and Prevention (CDC) on February 7th and Chinese CDC on February 9th, respectively, though Dengue virus were negative reported by Ganzhou CDC on February 6th. Right after the first diagnosis, anyone who had been in close contact with the patient received medical monitoring. (5)Treatment process: on February 6th, symptomatic treatment was prescribed since admitted into the infectious isolation wards and daily intravenous drip of Xiyanping injection 250 mg was prescribed for antiviral therapy. On February 7th, the patient had no fever, with occasional chills, neck rash was disappeared, orbital pain relieved and bilateral conjunctival hyperemia range was paler and narrowed, and his condition improved. Ibuprofen was administered for defervesce 3 times a day when his temperature reached to 37.5?centigrade at 16:00. On February 8th, the patient had no fever, times of chills was significantly reduced, without myalgia and rash, orbital pain and conjunctival hyperemia further recovered. On February 9th, bilateral eyes slightly tingling, mild conjunctival congestion, no fever chills or other discomfort was found. The chloramphenicol eye drops was prescribed for relieving sting pain with conjunctival congestion twice a day as recombinant human interferon alpha eye drops was out of store. The patient was comfortable from February 11th to February 13th. Blood and urine test for Zika were reported negative by the Chinese CDC and Jiangxi Province CDC. Because all the discharge criteria were satisfied, the patient was discharged on February 14th. At present, there is no specific effective drug to prevent and treat Zika virus disease effectually. After receiving symptomatic treatment and antiviral treatments including Xiyanping injection, the patient's symptoms were relieved. Zika virus nucleic acid in blood and urine was negative. The patient was discharged. Combination of traditional Chinese medicine and Western medicine maybe a good method to prevent and treat Zika virus disease.

[Chikungunya: fever and joint pains after vacation in a tropical area].

A 27-year-old man was admitted to our hospital, two days after returning from a vacation in Mauritius, with fever, chills, headache and myalgia, as well as arthritis of the legs. He had a temperature of 38.6 C and painful swellings of both talocalcanean joints. Laboratory studies revealed leukopenia, lymphopenia and thrombopenia, as well as a slight elevation of transaminases and serum bilirubin. Diagnostic tests for malaria were negative, as were tests for antibodies against Epstein-Barr virus, cytomegalovirus, leptospirosis, dengue, chikungunya and hepatitis viruses, legionella, streptococcus and HIV. But PCR with chikungunya virus RNA was positive, establishing the diagnosis of acute chikungunya. All symptoms disappeared on administration of analgesics and antipyretics. But after two days a maculopapular rash on the trunk and limbs was noted: it responded well to the application of clemastine. The patient was discharged from hospital three days after admission. Chikungunya virus belongs to the family of alphaviruses and is common in Southeast Asia and Africa. It can be transmitted to humans by bites of the Aedes mosquitoes. Symptoms are similar to those of dengue and consist of fever, headache, arthralgia, myalgia and conjunctivitis. After two or three days these symptoms subside and a maculopapular rash appears. The fever may return. Arthralgia can persist over weeks and even months. While the diagnosis is normally established by antibody tests, these may be negative in early stages of the disease. when the diagnosis can be made by PCR. Treatment is symptomatic with analgesics and antipyretics.

Pharmacology_Katzung

Philip J. Rosenthal, MD A 5-year-old American girl presents with a 1-week history of intermittent chills, fever, and sweats. She had returned home 2 weeks earlier after leaving the USA for the first time to spend 3 weeks with her grandparents in Nigeria. She received all standard childhood immunizations, but no additional treat-ment before travel, since her parents have returned to their native Nigeria frequently without medical consequences. Three days ago, the child was seen in an outpatient clinic and diagnosed with a viral syndrome. Examination reveals a lethargic child, with a temperature of 39.8°C (103.6°F) and splenomegaly. She has no skin rash or lymphadenopathy. Ini-tial laboratory studies are remarkable for hematocrit 29.8%, platelets 45,000/mm3, creatinine 2.5 mg/dL (220 μmol/L), and mildly elevated bilirubin and transaminases. A blood smear shows ring forms of Plasmodium falciparum at 1.5% parasit-emia. What treatment should be started?

[A Case of Simultaneous Acute Lymphoblastic Leukemia Diagnosis with Crimean-Congo Hemorrhagic Fever].

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease that can be presented with fever, fatigue, generalized joint/body pain, diarrhea and bleeding in various parts of the body. The risk of developing a severe fatal disease in humans, the possibility of being infected with aerosols and the risk of being used as a biological weapon make the disease still an important health problem all over the world as there is no a specific treatment and vaccine that has proven effective againt the virus today. The pathogenesis of the disease is not known, but vascular endothelial damage is prominent. Therefore, it progresses with thrombocytopenia, anemia, leukopenia and this hematological findings can be confused with hematological malignancies. Acute lymphoblastic leukemia (ALL) is a malignancy included in differential diagnoses and occurs as a result of mutations occuring at a stage of differentiation in the lymphoid precursor cells in the bone marrow. In this study, we present a case of ALL who was diagnosed with CCHF simultaneously. A 43-year old female patient who works in the library and does not have a chronic disease other than asthma and thyroid disorder, has admitted to our hospital with the complaints of intermittent fever, weakness, generalized joint and body pain for about 3 weeks. She had fever and the physical examination revealed bilateral cervical and right postauricular lymphadenopathies. Her aspartate aminotransferase: 77 U/L, alanine aminotransferase: 117 U/L, lactate dehydrogenase: 616 U/L, hemoglobin: 8.27 g/dl, leukocyte count: 15.690/mm3 , neutrophil count: 550/mm3 (%3.5), lymphocyte count: 6690/mm3 (%42.6), platelet count: 102.100/mm3 , C-reactive protein: 163.6 mg/L was detected and the patient was hospitalized on 5 August 2019 for further examination and treatment. Considering that the patient may have viral infection in the foreground the requested test results were detected as; anti-CMV IgM negative, anti-CMV IgG positive, anti-toxoplasma IgM negative, anti-toxoplasma IgG positive, anti-rubella IgM negative, anti-rubella IgG positive, HBsAg negative, anti-HBc IgM negative, antiHBs positive, anti-HAV IgM negative, anti-HAV IgG positive, anti-HCV negative, anti-HIV negative, EpsteinBarr virus (EBV) VCA IgM negative, EBV VCA IgG positive, EBV EBNA IgG positive. Brucella Rose Bengal and Coombs tube agglutination was found be negative. As the cytopenia of the patient deepened, the patient was accepted to have neutropenic fever and it was planned to start piperacillin-tazobactam 4 x 4.5 g/day and two units of erythrocyte replacement therapy. When the patient's history was questioned again, it was learned that she had a tick on her neck about three weeks ago and she had removed the tick herself; 4-5 days later she had the complaints of fever and flu like symptoms and also diarrhea complaints lasting for 3-4 days. Considering the current anamnesis and laboratory findings, the patient was thought to have CCHF and the patient was isolated. The serum sample taken from patient with an initial diagnosis of CCHF and sent to Department of Microbiology Reference Laboratory Public Health Agency of Turkey. The patient was referred to the Antalya Training and Research Hospital. The patient's CCHF serum result was positive. Ribavirin treatment was not initiated in the patient who was accepted to be in the convalescence period, piperacillin-tazobactam 4 x 4.5 g/day treatment was continued and supportive treatment was given. In the follow-up, as the patient's neutropenia, thrombocytopenia and lymphocytopenia still continuing, she was transferred to hematology clinic for malignancy examination and bone marrow biopsy performed by hematology and B cell ALL was diagnosed. She was accepted to be convalescent in terms of CCHF and chemotherapy was started for ALL treatment by hematology. The patient is still being followed up by the hematology clinic and allogenic hematopoietic stem cell tranplantation is planned for the patient. As a result, CCHF is a disease that can be confused with many differential diagnosis. With this case, it is aimed to draw attention to the diagnostic difficulties of CCHF and ALL and to be the first case in the literature.

Chikungunya

Diagnosis Chikungunya is diagnosed on the basis of clinical, epidemiological, and laboratory criteria. Clinically, acute onset of high fever and severe joint pain would lead to suspicion of chikungunya. Epidemiological criteria consist of whether the individual has traveled to or spent time in an area in which chikungunya is present within the last twelve days (i.e.) the potential incubation period). Laboratory criteria include a decreased lymphocyte count consistent with viremia. However a definitive laboratory diagnosis can be accomplished through viral isolation, RT-PCR, or serological diagnosis. The differential diagnosis may include other mosquito-borne diseases, such as dengue or malaria, or other infections such as influenza. Chronic recurrent polyarthralgia occurs in at least 20% of chikungunya patients one year after infection, whereas such symptoms are uncommon in dengue.

Fever in returning travelers: a case-based approach.

Overall, 3% to 19% of travelers to the developing world will return to the United States with fever or will develop fever within weeks of their return. When evaluating the returning traveler with fever, it is important to know which pretravel immunizations the patient received; which medications he or she took during travel; the likely pathogen exposures during travel; and the incubation interval between travel and onset of fever. A physical examination that includes a search for focal findings may narrow the list of possible infections. Fever compatible with a common illness that occurs in the United States (e.g., mononucleosis) should always be considered. If the patient has fever without a focus and a tropical infection is suspected, malaria, dengue fever, and typhoid fever are common causes. These infections may appear clinically similar, with symptoms of fever, headache, muscle pain, joint pain, and malaise, and decreased white blood cell and platelet counts. Malaria can usually be diagnosed with a thin blood smear. Dengue fever is a clinical diagnosis. Serologic testing for dengue virus immunoglobulin M and G and virus detection tests can be performed to confirm the diagnosis, but are not immediately available. Typhoid fever can usually be diagnosed with a blood, urine, or stool culture.

Pearls and oy-sters: tuberculous meningitis: not a diagnosis of exclusion.

A 21-year-old man presented to his local emergency department with 5 days of headache, which was dull, occipital, bilateral, nonthrobbing, and progressively worsening. It was associated with mild fever, photophobia, and neck pain and stiffness. He had no history of headache, chronic illness, recent vaccinations, cutaneous rash, cough, diarrhea, arthralgia, or myalgia. He was from Ecuador and had been living in the United States for less than 1 year. He had been incarcerated while in Ecuador. Sublingual temperature on admission was 102.6°F. Other vital signs were within normal limits. On physical examination, he appeared thin but not cachectic. He had meningismus and photophobia, but no papilledema and his mental status was alert and attentive. There were no focal neurologic deficits. CSF contained red blood cells: 24 × 10(3)/μL; white blood cells: 85/μL (lymphocytic predominant); protein: 128 mg/dL; and glucose: 48 mg/dL (CSF/serum glucose ratio = 0.53). CSF Gram stain and cultures, PPD test, and blood and urine cultures were all negative. CT scan of the head on day of admission was entirely normal. MRI without gadolinium contrast showed a single punctate T2 hyperintensity in the left frontal periventricular white matter. Chest radiograph was clear. He received empiric vancomycin, ceftriaxone, and acyclovir. Corticosteroids were not given. The patient did not improve with antibiotics and continued to be intermittently febrile. On day 5, he became abruptly more somnolent, then comatose, opening eyes only to pain, his pupils were 5 mm and reactive, he had intact brainstem reflexes, withdrawing both arms and legs. Emergent head CT showed development of hydrocephalus and a ventriculoperitoneal shunt was emergently placed. The neurologic examination did not improve after shunt placement, and repeat head CT showed increased hydrocephalus with bilateral cerebral infarcts. On day 11, he was transferred to Columbia University Medical Center for intensive care. He was febrile and comatose. He did not open his eyes to pain, pupils were 7 mm minimally reactive, brainstem reflexes were intact, and he exhibited extensor posturing to pain. Mannitol was given, corticosteroid therapy was started, and an extraventricular drain was placed. The next day, his right pupil was 8 mm and nonreactive. MRI showed diffuse contrast enhancement of the arachnoid, extensive infarction of basal ganglia, midbrain, and pons, and small ring-enhancing lesions in the cerebellum (figure 1, A-D). Repeat lumbar puncture showed red blood cells: 550 × 10(3)/μL; white blood cells: 250/μL (14% neutrophils, 80% lymphocytes, 6% monocytes); protein: 65 mg/dL; and glucose: <10 mg/dL (CSF/serum glucose ratio = 0.08). CSF testing for Cryptococcus and toxoplasmosis was negative. CSF acid fast bacilli (AFB) smear was negative ×2, and CSF nucleic acid amplification test was also negative for tuberculosis. Serum HIV test was negative. Not until 14 days after initial presentation and 3 days after transfer to the intensive care unit was antituberculosis therapy finally started, because the pattern of infarcts on the MRI suggested basilar meningitis and he had not improved on broad-spectrum antibiotics. That same day, the first sputum AFB smear was positive, as were all succeeding daily sputum AFB smears. Tuberculosis nucleic acid amplification was positive from the sputum, but persistently negative from the CSF. Daily portable chest radiographs had been normal (read as likely atelectasis), but chest CT showed dense consolidations in the left lung and diffuse micronodular opacities throughout both lungs. Two days later, only 21 days after the onset of his headache, the patient died of cardiopulmonary arrest secondary to transtentorial cerebral herniation. Thirteen days later, the CSF culture became positive for Mycobacterium tuberculosis sensitive to streptomycin, isoniazid, ethambutol, rifampin, and pyrazinamide.

[A Case of Plasmodium vivax Complicated with Reactive Hemophagocytic Syndrome].

Plasmodium vivax is the most common malaria agent in the world, transmitted by vectoring of anopheles mosquitoes. In the clinical course of the disease, non-specific signs of infection (fever, myalgia, joint pain, nausea, vomiting, etc.) can be seen. Hemophagocytic lymphohistiocytosis; also known as hemophagocytic syndrome, is a rapid-onset and life-threatening clinical condition that develops as a result of uncontrolled immune activation and hypercytokinemia. In this case report, a case who developed hemophagocytic syndrome while under treatment for P.vivax infection was presented. A 37-year-old male patient applied to us with the complaints of high fever, chills-shivering and weakness, started on his return from Sudan. Upon admission, the fever was 40°C, the pulse was rhythmic and 115/minute, the respiratory rate was 24/minute, and the blood pressure was 80/49 mmHg, and he was followed up in the intensive care unit due to the signs of systemic inflammatory response syndrome. During the investigation of the etiology of fever, it was learned that he did not receive prophylaxis for malaria during his stay in Sudan. Thin and thick blood smears were examined. P.vivax infection was detected in the patient and the treatment was initiated, a bone marrow aspiration biopsy was performed with the prediagnosis of hemophagocytic syndrome with persistent fever, deepening of thrombocytopenia, findings of hyperferritinemia, hypertriglyceridemia, hepatosplenomegaly, and myeloid serial hemophagocytosis in the 48th hour of the treatment. In addition to antimalarial therapy, clinical and laboratory response was obtained with polyclonal intravenous immunoglobulin (IVIG) therapy.

Ross River virus

The symptoms of Ross River virus are important to recognise for early diagnosis and therefore early treatment. Symptoms have been illustrated in a case report of an infected Thuringian traveller returning from South-East Australia. This case showed flu-like symptoms that include fever, chills, headache and pains in the body. Additionally, joint pain arose in which some joints become swollen and joint stiffness was particularly noticeable. A clinical examination of the infected individual shows a significant decrease of specific antibodies despite the normal blood count levels. A rash is a good indication that is likely to occur but usually disappears after ten days. The symptoms of Ross River virus are important to be aware of so that early treatment can be administered before the virus worsens. The time between catching the disease and experiencing symptoms is anywhere between three days to three weeks, usually it takes about 1–2 weeks. A person can be tested for Ross River virus by

Acute renal failure after a holiday in the tropics.

A 20-year-old, previously healthy woman, presented with high fever, headache and myalgia 3 days after her return from a holiday in Southeast Asia. Laboratory data on admission demonstrated a pronounced increase in plasma creatinine, marked thrombocytopenia and moderately elevated liver aminotransferases. After having ruled out malaria, dengue fever was primarily suspected and supportive intravenous fluid therapy was initiated. Still, 1 day after admission, platelet counts dropped even further and she became anuric although she did not appear hypovolemic. On day 2 after admission, urine production commenced spontaneously and the patient slowly recovered. All laboratory test results had returned to normal approximately 2 months later. Serological analysis for dengue fever was negative. It turned out that the patient had been trekking in the jungle while in Thailand and we, therefore, analyzed serology for Leptospira spirochetes which was clearly positive. The patient was diagnosed with leptospirosis which is a serious condition associated with a high mortality when complicated by acute renal failure. Differential diagnoses in patients with acute renal failure and tropical infections are reviewed. The importance of early recognition of leptospirosis, and prompt treatment with antibiotics in suspected cases, is emphasized.

Prolonged fever and exaggerated hypercoagulopathy in malaria vivax relapse and COVID-19 co-infection: a case report.

Coronavirus disease 2019 (COVID-19) often causes atypical clinical manifestations similar to other infectious diseases. In malaria-endemic areas, the pandemic situation will very likely result in co-infection of COVID-19 and malaria, although reports to date are still few. Meanwhile, this disease will be challenging to diagnose in areas with low malaria prevalence because the symptoms closely resemble COVID-19. A 23-year-old male patient presented to the hospital with fever, anosmia, headache, and nausea 1 week before. He was diagnosed with COVID-19 and treated for approximately 10 days, then discharged to continue self-quarantine at home. 2 weeks later, he returned to the hospital with a fever raised intermittently every 2 days and marked by a chilling-fever-sweating cycle. A laboratory test for malaria and a nasopharyngeal swab for SARS CoV-2 PCR were conducted, confirming both diagnoses. The laboratory examination showed markedly elevated D-dimer. He was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days and primaquine 2 tablets per day for 14 days according to Indonesian National Anti-malarial Treatment Guidelines. After 6 days of treatment, the patient had no complaints, and the results of laboratory tests had improved. This report describes the key points in considering the differential diagnosis and prompt treatment of malaria infection during the pandemic of COVID-19 in an endemic country to prevent the worse clinical outcomes. COVID-19 and malaria may also cause a hypercoagulable state, so a co-infection of those diseases may impact the prognosis of the disease. This case report shows that considering the possibility of a co-infection in a COVID-19 patient who presents with fever can prevent delayed treatment that can worsen the disease outcome. Paying more attention to a history of travel to malaria-endemic areas, a history of previous malaria infection, and exploring anamnesis regarding the fever patterns in patients are important points in making a differential diagnosis of malaria infection during the COVID-19 pandemic.

Guillain-Barre syndrome following dengue fever and literature review.

Dengue is an arboviral infection that classically presents with fever, joint pain, headaches, skin flush and morbilliform rashes. The incidence of neurological symptoms and complications in dengue varies from 1 to 25% that include encephalopathy, Guillain-Barre syndrome (GBS), acute motor weakness, seizures, neuritis, hypokalaemic paralysis, pyramidal tract signs, and a few more. Dengue fever as an antecedent infection in GBS is uncommon. A 34-years-old Sri Lankan Sinhalese male presented with fever, headache and myalgia of 3 days and developed leucopenia and thrombocytopenia without evidence of haemoconcentration. The diagnosis of dengue fever was confirmed as he had positive dengue NS1 antigen test on the third day of fever. He made full recovery and was discharged after 4 days of hospital stay. Six days later, he presented with history of acute flaccid weakness of both lower limbs and upper limbs which was of progressive ascending nature. The electromyography had evidence of demyelinating neuropathy and cerebrospinal fluid showed albuminocytological dissociation. Subsequently, IgM for dengue virus was positive. Dengue is endemic in Sri Lanka. Post dengue Guillain-Barre syndrome is a potential neurological complications of this infection.

[Meningococcemia: Different Serotypes in the Same Region].

Meningococcal infections are important health problems causing high morbidity and mortality. Neisseria meningitidis have 13 serogroups. A, B, C, Y and W135 are the most common causes of invasive disease among those serogroups. The distribution of the serogroups differs according to the geographical regions and the age groups. In this case report, two cases of meningococcemia infected with serogroup C and Y of N.meningitidis rarely seen in our country were presented. First case was a two and a half year-old female patient who has admitted to our pediatric emergency unit with fever and rash spreading from lower extremities to her body. The patient had diffuse purpuric rash with generalized weakness and tendency to sleep at admission. The patient has been suspected as meningococcemia because of the skin rash, tendency to sleep and hypotension. Antibiotics treatment was started immediately and lumber puncture was performed. In blood tests, leukocyte count: 3600/mm3 (61% neutrophils), hemoglobin: 11.1 g/ dl, platelet count: 127.000/mm3 , C-reactive protein: 10 mg/dl, erythrocyte sedimentation rate: 6 mm/ hour, prothrombin time: 28.8 seconds (normal value= 11-16), prothrombin activity: 36%, international normalized ratio (INR): 2.13 (normal value= 1-1.5), activated partial thromboplastin time: 57.7 seconds (normal value= 25-35 sec), fibrinogen: 246 mg/dl (normal value= 200-400 mg/dl) and in cerebrospinal fluid protein: 21 mg/dl and glucose: 62 mg/dl were found. There were eight cells in the microscopic examination. Skin rashes were increased and the patient became hypotensive. No microorganisms were isolated in blood and cerebrospinal cultures. N.meningitidis serogroup C was isolated from the cerebrospinal fluid of the patient using polymerase chain reaction (PCR). The patient suffered from immune-mediated arthritis in the sixth day of treatment and nonsteroidal anti-inflammatory drugs were given. The patient has recovered with antibiotics, fresh frozen plasma and inotropic treatment. Second case was a 13 year-old male patient who has admitted three days after the first case with a pre-diagnosis of malignancy because of pancytopenia and fever. The patient had generalized weakness and a few petechial purpuric rashes at the facial region at admission. After the admission general status of the patient has worsened rapidly and he has died as a result of cardiovascular arrest. Blood tests in admission showed leukocyte count: 6000/mm3 (79% neutrophils), hemoglobin: 17.3 mg/dl, platelet count: 16.000/mm3 , C-reactive protein: 8.63 mg/dl, prothrombin time: 92.6 seconds, prothrombin activity: 10%, INR: 6.78, activated partial thromboplastin time: 231.5 seconds. Cerebrospinal fluid obtained from postmortem lumbar puncture showed no growth (protein: 95 mg/dl, glucose: 35 mg/dl) and N.meningitidis serogroup Y was detected by PCR. Two meningococcemia cases caused by two different serogroups which are rarely seen in our region in recent years were presented at the same time period in the same hospital. This case report pointed out that surveillance has a great importance in such diseases.

Dengue fever

Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. Symptoms typically begin three to fourteen days after infection. These may include a high fever, headache, vomiting, muscle and joint pains, and a characteristic skin rash. Recovery generally takes two to seven days. In a small proportion of cases, the disease develops into a more severe dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs. Dengue is spread by several species of female mosquitoes of the Aedes genus, principally Aedes aegypti. The virus has five serotypes; infection with one type usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of severe complications. A number of tests are available to confirm the diagnosis including detecting antibodies to the virus or its RNA.

Acute human immunodeficiency virus syndrome in an adolescent.

Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient's only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors.

Domestic dengue infection with hemophagocytic lymphohistiocytosis successfully treated by early steroid therapy.

A 34-year-old man, working at a park in Tokyo, Japan, was repeatedly bitten by mosquitoes while cutting grass. He was hospitalized with sudden fever, fatigue, and weakness. He was eventually diagnosed with dengue virus infection, detected using reverse transcription polymerase chain reaction for the genome and by the presence of nonstructural protein 1 in his peripheral blood. Symptomatic treatments such as acetaminophen for the fever were not effective. Moreover, peripheral blood examination showed drastically decreased white blood cells and platelets, as well as marked elevations of ferritin and soluble interleukin 2 receptor. Furthermore, bone marrow examination revealed increased macrophages with hemophagocytosis. Dengue infection with hemophagocytic lymphohistiocytosis (HLH) was ultimately diagnosed. Half-dose steroid pulse therapy for three days dramatically reduced his temperature, thereby ameliorating physical symptoms and restoring normal peripheral blood data. He was discharged 12 days after admission. Dengue infection with HLH is rare and this is the first report, to our knowledge, of domestic dengue infection with HLH in Japan. Early steroid therapy may be effective in such cases.

Rocky Mountain spotted fever

Diagnosis This disease can be diagnosed by a doctor with and without the use of lab testing. Lab tests are not always relied upon because treatment may be necessary before the results are returned. Abnormal laboratory findings seen in patients with Rocky Mountain spotted fever may include a low platelet count, low blood sodium concentration, or elevated liver enzyme levels. Serology testing and skin biopsy are considered to be the best methods of diagnosis. Although immunofluorescent antibody assays are considered some of the best serology tests available, most antibodies that fight against R. rickettsii are undetectable on serology tests during the first seven days after infection. Differential diagnosis includes dengue, leptospirosis, chikungunya, and Zika fever.

Perinatal dengue infection.

We report a case of vertical transmission of dengue infection in an infant. The mother's was a term pregnancy with a history of chronic hypertension. She presented with high fever of 3 days duration 5 days prior to delivery. Her initial complete blood count showed platelet count of 64,000/mm3. Dengue hemorrhagic fever was diagnosed 2 days later and symptomatic treatment was given. During labor her platelets dropped to 11,000/mm3 and platelet concentrate was given. Cesarean section was performed due to prolonged second stage of labor. Her infant was normal at birth except for petechiae on the left thigh. The child's platelet count was 34,000/mm3 and low grade fever was detected on the first day. Clinical sepsis was suspected and antibiotic treatment was started and continued for 4 days until all the cultures came back as negative. Both mother and her baby made an uneventful recovery and were discharged 6 days after delivery with normal platelet counts. Maternal blood was positive for IgM antibody to dengue virus. Both cord blood and the baby's blood were positive for dengue virus serotype 2 by PCR.

Severe, persisting, steroid-responsive Dengue myositis.

Short-term, general muscle affection is frequent in Dengue infection, but severe, persisting, myositis has not been reported. Case report. The patient is a 38 years old, HIV-negative male who developed sudden-onset fever up to 40.0 degrees C, headache, and sore eyes upon looking into light when on holidays in Thailand. One day after onset severe myalgias occurred in the shoulder girdle and hip girdle muscles. Clinical examination was normal, but blood work revealed elevated creatine-phosphokinase, glutamate-oxalate transaminase, and glutamate pyruvate transaminase, leucopenia and thrombocytopenia. Antibodies against Dengue viruses type 2 and 4 were positive and classical Dengue fever was diagnosed. The infection resolved upon symptomatic therapy, but myalgias, responsive only to opiates, resolved persistently not before the administration of corticosteroids, 2 months after onset. The case shows that Dengue fever may also cause persisting, severe, myositis for weeks, which do not respond to non-steroidal analgesics, but promptly to corticosteroids.

InternalMed_Harrison

2 or 3 of the disease. The rash is most intense on the trunk and limbs and may desquamate. Young children develop less prominent signs and are therefore less frequently hospitalized. Children also often develop a bullous rather than a maculopapular/ petechial rash. Maternal–fetal transmission has been reported and in some cases has led to fetal death. Recovery may require weeks, and some elderly patients may continue to experience joint pain, recurrent effusions, or stiffness for several years. This persistence of signs and symptoms may be especially common in HLA-B27-positive patients. In addition to arthritis, petechiae are occasionally seen and epistaxis is not uncommon, but chikungunya virus should not be considered a VHF agent. A few patients develop leukopenia. Elevated concentrations of aspartate aminotransferase (AST) and C-reactive protein have been described, as have mildly decreased platelet counts. Treatment of chikungunya virus disease relies on nonsteroidal

Zika fever

Zika fever, also known as Zika virus disease or simply Zika, is an infectious disease caused by the Zika virus. Most cases have no symptoms, but when present they are usually mild and can resemble dengue fever. Symptoms may include fever, red eyes, joint pain, headache, and a maculopapular rash. Symptoms generally last less than seven days. It has not caused any reported deaths during the initial infection. Mother-to-child transmission during pregnancy can cause microcephaly and other brain malformations in some babies. Infections in adults have been linked to Guillain–Barré syndrome (GBS). Zika fever is mainly spread via the bite of mosquitoes of the Aedes type. It can also be sexually transmitted and potentially spread by blood transfusions. Infections in pregnant women can spread to the baby. Diagnosis is by testing the blood, urine, or saliva for the presence of the virus's RNA when the person is sick, or the blood for antibodies after symptoms are present more than a week.

[First case of chikungunya fever in Hermosillo, Sonora, Mexico].

The Chikungunya is an arbovirus first described during a 1952 outbreak of febrile exantematic disease in southern Tanganyika (now Tanzania). It is a virus within the alphavirus genus of the Togaviridae family, it is usually transmitted to humans by Aedes mosquitoes. Typically, the disease manifests as acute onset of fever and joint pains. This study describes the clinical characteristics the first imported case infected with chikungunya fever (CHIK) in Hermosillo, Sonora, Mexico. We report the case of a 30 years old man seen in our emergency department due to fever, polyarthralgia, rash and headache. This patient has been in Tapachula, Chiapas, a jungle area in southern México, and he returned from a 45 days trip before the onset his symptoms. The chikungunya viral infection (CHIK) was diagnosed by RT-PCR procedure. Paracetamol therapy was administered and his clinical course was self-limited. We concluded that with the increase of mosquito´s habitat by global warming and frequent traveling, CHIK reemerged and showed global distribution recently. This disease must be suspected in patients with compatible clinical symptoms returning from epidemic/endemic areas. CHIK must be diagnosed on the basis of clinical, epidemiological and laboratory criteria.

[Hemorrhagic dengue and vertical transmission to the newborn: a case report and literature review].

To describe the case of a patient with term pregnancy and infection with hemorrhagic dengue and vertical transmission to the newborn. Thirty-two year old patient with pregnancy at 38 weeks was admitted with fever 2 days earlier (38 degrees C). During her stay she continued with fever of 39 degrees C and platelets of 85,000/mm3. Serology for dengue NS1 antigen was reported positive. Labor was induced getting a new-born, male, 3,220 g, who breathed and cried at birth. During the postpartum period continued with fever, malaise, retro-ocular pain, generalized rash in upper and lower limbs, bleeding gums and petechial on the soft palate and thrombocytopenia of 5,000/mm3, later. At 8 days of stay, platelet concentration increased to 42,000/mm3 without requiring platelet concentrates and she was discharged after ten days in hospital with platelets of 94,000/mm3. The 4th day of extra-uterine live (EUL), neonate shows generalized rash over the trunk; The 5th day starts with 38 degrees C fever and thrombocytopenia (78,000/mm3). Dengue serological tests reported positive for Ag NS1 and negative for Abs IgM and IgG. Neonate was admitted to NICU, he continued with a decrease in platelet of 14,000/mm3- and ecchymotic areas by pressure and veno-punction sites. Four platelet concentrates were transfused. At 10th day of EUL platelet count was reported with 387,000/mm3. In an endemic area, such as Sinaloa state, in a pregnant woman with fever and thrombocytopenia, we should be alert to possibility of a DV infection and its complications. Although rare, such as this case, infection can be transmitted to fetus (vertical transmission) and produce a primary congenital dengue, even in its severe hemorrhagic types.

A case of acalculous cholecystitis in the course of dengue fever in a traveller returned from Brazil.

Dengue is the second cause of fever after malaria in travellers returning from the tropics. The infection may be asymptomatic or it may manifest itself with fever only, some patients, however, may develop haemorrhagic symptoms and shock. A 58-year-old woman came to the University Centre of Tropical Medicine in Gdynia after returning from a tourist journey to Brazil because of fever up to 39°C and malaise. She had lived in South America many years and then moved to Europe 3 years before hospitalisation. On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed. On the second day of the hospitalisation, the patient reported epigastric pain, clinical examination revealed tenderness of the abdomen and macular rash on the skin of the trunk and thighs. The ultrasonography revealed an enlarged gallbladder with thickened walls, with hypoechogenic area surrounding it, a dilated common biliary duct of heterogenic echo, and some free fluid in the peritoneal cavity. An exploratory laparotomy was performed after 24 h because of the persisting strong abdominal pain and high fever. Intraoperatively, enlarged mesenteric lymph nodes were found, with no symptoms of gallbladder pathology. The postoperative course was uncomplicated and the positive result of immunochromatographic assay for dengue was obtained. The acalculous cholecystitis has been described in the course of various diseases and conditions. The typical symptoms include pain in the right hypochondriac region, fever, positive Murphy's sign, and abnormal liver function tests, which were observed in the presented case. Cholecystectomy is not usually indicated in the course of dengue (typically a self-limiting disease) due to a high risk of bleeding. The case provides a rationale for the inclusion of acalculous cholecystitis in the differential diagnosis in patients with abdominal pain returning from dengue endemic areas.

Zika virus

Zika fever Zika fever (also known as Zika virus disease) is an illness caused by Zika virus. Most cases have no symptoms, but when present they are usually mild and can resemble dengue fever. Symptoms may include fever, red eyes, joint pain, headache, and a maculopapular rash. Symptoms generally last less than seven days. It has not caused any reported deaths during the initial infection. Infection during pregnancy causes microcephaly and other brain malformations in some babies. Infection in adults has been linked to Guillain–Barré syndrome (GBS) and Zika virus has been shown to infect human Schwann cells. Diagnosis is by testing the blood, urine, or saliva for the presence of Zika virus RNA when the person is sick. In 2019, an improved diagnostic test, based on research from Washington University in St. Louis, that detects Zika infection in serum was granted market authorization by the FDA.

[The Importance of Differential Diagnosis During Pandemic: A Case Report with Coexistence of COVID-19, Brucellosis and Crimean-Congo Hemorrhagic Fever].

The coronavirus disease-2019 (COVID-19) pandemic, which affects millions of people around the world, has been affecting our country since March 2020. The fact that the symptoms such as fever, myalgia, headache, joint pain which are common in COVID-19 patients are quite similar to the symptoms of diseases such as Crimean-Congo hemorrhagic fever (CCHF) and Brucellosis. This may cause a diagnostic confusion in regions where these diseases are seen as endemic. In this report, a patient hospitalized with a pre-diagnosis of COVID-19 and diagnosed with acute Brucellosis, CCHF and COVID-19 during followup was presented. A 31-year-old female patient living in a rural area admitted to the emergency service with complaints of fever, weakness, headache, and body/joint pain. Physical examination revealed a temperature of 38.3°C, a pulse rate of 102/minute, and a peripheral capillary oxygen saturation of 97% in room air. The system examination was normal. In the laboratory findings, an increase in liver enzymes and acute phase reactants was observed and the platelet count was at the lower limit of the normal range. In terms of COVID-19, no involvement compatible with COVID-19 was detected in the thorax computed tomography (CT) of the patient whose nasopharyngeal and oropharyngeal mixed swab samples were taken.The patient was transferred to our infectious diseases service with a pre-diagnosis of COVID-19 and CCHF. Serum samples were sent to the Public Health Agency Microbiology Reference Laboratory Department (PHA-MRLD) for CCHF diagnostic tests and supportive treatment was started. Brucella Rose Bengal and Coombs' immuncapture (1/1280 titer) tests were found as positive in the patient, who was examined for brucellosis because of living in a rural area and having a history of consuming fresh dairy products. In the tests performed at PHA-MRLD, CCHF-specific IgM positivity and the presence of viral RNA were detected. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) reverse-transcriptase polymerase chain reaction (RT-PCR) test was negative. For Brucellosis, doxycycline and rifampicin were added to the treatment of the patient whom was given supportive therapy for CCHF. In the followup, the patient's fever was persisting and loss of taste and smell complaint developed. In this context, COVID-19 test was repeated and resulted as positive. Upon this, hydroxychloroquine sulfate treatment was started due to the recommendation of the current Ministry of Health Scientific Committee Guide. No new infiltration was detected in the chest radiography of the patient. The patient's fever subsided during follow-up and laboratory findings improved. The treatment of brucellosis was completed to eight weeks at the outpatient clinic. No problems were detected in the follow-up. This report was prepared because of a case with simultaneous brucellosis, CCHF and COVID-19 infections which could not be encountered in the literature review. As a result; in regions such as our country where both brucellosis and CCHF are seen as endemic, it is very important to keep these diseases in mind in the differential diagnosis of COVID-19 infection.

[Plasmodium falciparum malaria: evaluation of three imported cases].

Among Plasmodium species the causative agent of malaria in Turkey is P.vivax, however the incidence of imported falciparum malaria cases is steadily increasing. P.falciparum may cause severe malaria with the involvement of central nervous system, acute renal failure, severe anemia or acute respiratory distress syndrome. Furhermore most of the casualties due to malaria are related with P.falciparum. There is recently, a considerable increase in malaria infections especially in tropical areas. In this report, three cases, who have admitted to our hospital with three different clinical presentations of falciparum malaria, and all shared common history of travelling to Africa were presented. First case was a 27 years old, male patient who returned from Malawi seven days ago where he stayed for two weeks. He admitted to our hospital with the complaints of sensation of cold, shivering and fever. In physical examination his body temperature was 37.9°C, C-reactive protein level was high, and the other systemic results were normal. The second case was a 25 years old, male patient who returned from Gambia two weeks ago. He was suffering from fever, headache, shivering and unable to maintain his balance. The patient's body temperature was 38°C. Laboratory tests revealed hyperbilirubinemia and thrombocytopenia. Parasitological examination of the Giemsa-stained peripheral blood smear of these two patients demonstrated ring forms compatible with P.falciparum. Treatment was commenced with arthemeter plus lumefantrine, resulting with complete cure. Third case was a 46 years old, male patient who had been working in Uganda, and returned to Turkey two weeks ago. He had sudden onset of fever, headache, nausea and vomiting and impaired consciousness. His peripheral blood smear revealed ring-formed trophozoites and banana-shaped gametocytes of P.falciparum. Arthemeter plus lumefantrine therapy was started, however, he developed severe thrombocytopenia and jaundice under treatment. His general condition was detoriated and the patient lost his consciousness. As the patient's clinical signs were compatible with sepsis ceftriaxone plus clindamycin were added to the antiparasitic treatment emprically. Due to the development of acute tubular necrosis, the patient have undergone hemodialysis. On the 9th day of therapy the complaints and laboratory findings of the patient have improved, so he was discharged. However, visual defects due to retinopathy and severe neurocognitive impairment that were thought to be the complications of malaria continued in his follow-ups. As a result, it should be keep in mind that both the African students who have come to our country for education from endemic regions and as well as the returned citizens of our country who have gone to work in endemic areas, are under risk of malaria and it is very important to consider malaria in the distinctive diagnosis of patients with the complaints of fever, headache, nausea, vomiting and muscle pain.

Clinical and Laboratory Characteristics of an Acute Chikungunya Outbreak in Bangladesh in 2017.

From April to September 2017, Bangladesh experienced a huge outbreak of acute Chikungunya virus infection in Dhaka. This series describes the clinical and laboratory features of a large number of cases (690; 399 confirmed and 291 probable) suffered during that period. This observational study was carried out at Dhaka Medical College Hospital, Bangladesh. The median age of the patients at presentation was 38 years (IQR 30-50) with a male (57.3%) predominance. Hypertension and diabetes were the most common comorbidities. The mean (±SD) duration of fever was 3.7 (±1.4) days. Other common manifestations were arthralgia (99.2%), maculopapular rash (50.2%), morning stiffness (49.7%), joint swelling (48.5%), and headache (37.6%). Cases were confirmed by anti-chikungunya IgG (173; 43.3%), IgM (165; 42.3%), and reverse transcription polymerase chain reaction (44; 11.0%). Important laboratory findings include high erythrocyte sedimentation rate (156; 22.6%), raised serum glutamic pyruvic transaminase (73; 10.5%), random blood sugar (54; 7.8%), leukopenia (72; 10.4%), thrombocytopenia (41; 5.9%), and others. The oligo-articular (453; 66.1%) variety of joint involvement was significantly more common compared with the poly-articular (237; 34.5%) variety. Commonly involved joints were the wrist (371; 54.1%), small joints of the hand (321; 46.8%), ankle (251; 36.6%), knee (240; 35.0%), and elbow (228; 33.2%). Eleven cases were found to be complicated with neurological involvement and two of them died. Another patient died due to myocarditis. Public health experts, clinicians, and policymakers could use the results of this study to construct the future strategy tackling chikungunya in Bangladesh and other epidemic countries.