P1521 Enteric fever due to Brucella melitensis: a case report

S426 animals or contaminated animal products. The diagnosis of cutaneous anthrax (CA) may be very difficult especially in rarely seen regions or in atypical presentations. The aim of this study is to evaluate the clinical features of 23 CA cases between May 2004 to September 2006. Methods: Twenty-three patients with CA were included in this study. The diagnosis of the CA was based upon clinical findings and/or microbiological procedures. Results: Of the 22 cases followed up with CA and one patient with CA resulted to anthrax sepsis, 13 (56.5%) were male and 10 (43.5%) were female. The mean age of the patients was 36.04±14.67 years. All of the patients have been living in the rural area of Malatya province in Turkey. Twenty-two patients had a history of slaughtering, skin peeling, meat and bone processing or helping in one of these activities. One patient did not have any history of contact with animals or animal products. He was a construction worker in the village where an attack of CA was seen a year ago. He had only contacted with soil. Clinical presentation of CA was typical in 20 patients. Two patients were misdiagnosed as insect bite and one patient as angioedema. The vesicular fluid cultures were positive for Bacillus anthracis in seven (30.43%) cases and Gram stain revealed Gram-positive rods in eight (34.78%) cases. The diagnosis of CA in remained 15 (65.21%) cases was made by clinical presentation and history of contact with the sick animal. Nine of these cases have history of contact with same sick cow. And also, B. anthracis was detected in the spleen of this cow. Conclusion: CA is a very contagious and important infectious disease in worldwide. Early and accurate diagnosis can dramatically affect the prognosis of the disease. So, CA should be kept in mind especially in endemic regions.

P1521 Enteric fever due to Brucella melitensis: a case report A. Erbay, H. Bodur, E. Akinci, A. Bastug, M.A. Cevik (Ankara, TR) Objectives: Although pathogenetically qualifying as an enteric fever, the gastrointestinal manifestations of brucellosis in humans are relatively uncommon. Alimentary tract complaints such as anorexia, nausea, vomiting, abdominal pain, diarrhoea or constipation are elicited in patients with brucellosis but systemic symptoms generally are more common than symptoms localised to the gastrointestinal tract. A patient with enteric fever caused by Brucella melitensis is reported. Case: A previously healthy 16 year old male was admitted with fever, vomiting, diarrhoea and skin rash. His initial complaint was started with fever six days before admission. He was living at a village and had a history of consumption of unpasteurised dairy products. Physical examination revealed an acutely ill boy with a temperature of 39.9ºC. Blood pressure was 110/60 mmHg and pulse was 96/min. He had abdominal tenderness and hepatosplenomegaly. Maculopapuler rashes with a diameter of 1−2 mm were present on the trunk and arms. After admission, vomiting, abdominal pain and melena were observed. Pertinent laboratory findings were as follows: white blood cell (WBC) count 3,000/mm3 haemoglobin 12.6 g/dl, platelet count 44,000/mm3 , erythrocyte sedimentation rate 9 mm/h, ALT 230 U/L, AST 169 U/L, CRP 77.4 mg/dl. The direct microscopic examination of faecal smear showed prevalent leukocytes. A faecal occult blood test was positive. Initial and follow up Widal tests were negative. Serological tests for acute viral hepatitis were negative. A brucella serum agglutination test was positive, with a titre of 1:1,280. Stool culture revealed no evidence of bacterial pathogens. Brucella melitensis was isolated from the cultures of blood. An upper gastrointestinal endoscopic examination revealed bulbitis. Combined therapy with rifampicin (600 mg/d p.o.) and doxycycline (100 mg p.o., b.i.d.) was started. On the 3rd day of therapy the patient became afebrile. In the following days the patient improved clinically. The faecal occult blood test became negative on the 7th day. A repeated CRP was 18.9 mg/dl. On the 12th day of the therapy laboratory test were as follows; WBC count 5,100/mm3 , haemoglobin 12.8 g/dl, platelet count 275,000/mm3 , alanine aminotransferase 19 U/L and aspartate aminotransferase 41 U/L. Antibiotic therapy was stopped on day 42.

17th ECCMID / 25th ICC, Posters Conclusion: Brucellosis is an infection with multiple presentations, and in an endemic region a thorough history of exposure and clinical suspicion are required. P1522 Preferential sites of eschar for scrub typhus D.M. Kim, S.H. Lee (Gwang-Joo, Nam-won, KR) Background: Eschar has been shown to be an important finding for the diagnosis of scrub typhus patients, and other mite-born rickettsiosis patients. However, any reports on systemic studies, including the difference of the gender regarding the preferential site of eschar as well as a schematic diagram showing the preferential site of eschar, have been rarely reported. Materials and Methods: IFA test using serum for scrub typhus was performed on the adult patients who visited Chosun University hospital and its branches for diagnosing their acute febrile diseases that developed within the previous 4 weeks. The presence or absence of eschar was thoroughly examined. Results: Eschars were preferentially formed on the front of body. The sites in the male where eschars were primarily detected was the area within 30 cm below the umbilicus (19 patients, 34.5%). The lower extremities and the front chest above the umbilicus were 23.6% (13 patients) and 20.0% (11 patients) respectively. However, on the females and different from the males, the most prevalent area was the front chest above the umbilicus for 40.4% (46 patients) of all the detected eschars. Conclusions: For both the males and the females, the front and the rear 30 cm below the umbilicus should be examined thoroughly, and it is thought to be important to carefully examine the lower extremities of the males, and the front chest as well as the back area of the females. Our study is the first report that shows the difference between the males and the females in regard to the area of developing eschars on scrub typhus patients. P1523 Diagnosis of scrub typhus by immunohistochemical staining of Orientia tsutsugamushi in cutaneous lesions D.M. Kim, S.H. Lee, S.C. Lim (Gwang-Joo, KR) Introduction: The aim of this study is to assess the clinical usefulness of an immunohistochemical staining on paraffin-embedded skin biopsy specimens for the diagnosis of scrub typhus with a comparison of indirect immunofluorescent antibody (IFA) assay. Method: A prospective study of patients with possible scrub typhus was conducted from September, 2005 to August, 2006. The patients participating in the study were thoroughly examined for the presence or absence of eschar like lesions and maculopapular lesions. Skin biopsy specimens for immunohistochemical staining (IHC) were obtained using a 3 mm punch upon the consent of the patient. Result: 125 potential scrub typhus patients were studied prospectively. Skin biopsy specimens were obtained from 63 patients. To minimise the effects caused by antibiotics on the IHC, 46 patients were assessed prior to the administration of antibiotics (except for the 4 patients who had received prior antibiotic therapy before admission and 13 patients who were underwent skin biopsy after administration of antibiotics at our hospital). Compared with the result of IFA which is the definite diagnostic method for scrub typhus, the result of IHC of maculopapular skin lesions demonstrated a sensitivity of 65% (95% confidence interval 0.38–0.85) and a specificity of 100% (95% confidence interval 0.6−1). The result of IHC of eschars demonstrated a sensitivity of 100% (95% confidence interval 0.82−1) and a specificity of 100% (95% confidence interval 0.40−1). IHC of eschar from one of the 13 patients who was administered antibiotics at our hospital showed negative results on the 13th day of the initial antibiotic administration. IHC done within 3 to 4 days following the initial antibiotic treatment in the remaining 12 patients showed almost the same results as that of the patients who did not receive prior antibiotics. Oriential antigens, discrete coccobacilli were primarily located within the cytoplasm of the infected endothelial cells, and they were also