Volume 27, Issue 2, 2019
Review
Nipah virus - the rising epidemic: a review
Ochani Rohan Kumar,
Batra Simran,
Shaikh Asim,
Asad Ameema
The Nipah virus was discovered twenty years ago, and there is considerable information available regarding the specificities surrounding this virus such as transmission, pathogenesis and genome. Belonging to the Henipavirus genus, this virus can cause fever, encephalitis and respiratory disorders. The first cases were reported in Malaysia and Singapore in 1998, when affected individuals presented with severe febrile encephalitis. Since then, much has been identified about this virus. These single-stranded RNA viruses gain entry into target cells via a process known as macropinocytosis. The viral genome is released into the cell cytoplasm via a cascade of processes that involves conformational changes in G and F proteins which allow for attachment of the viral membrane to the cell membrane. In addition to this, the natural reservoirs of this virus have been identified to be fruit bats from the genus Pteropus. Five of the 14 species of bats in Malaysia have been identified as carriers, and this virus affects horses, cats, dogs, pigs and humans. Various mechanisms of transmission have been proposed such as contamination of date palm saps by bat feces and saliva, nosocomial and human-to-human transmissions. Physical contact was identified as the strongest risk factor for developing an infection in the 2004 Faridpur outbreak.
Geographically, the virus seems to favor the Indian sub-continent, Indonesia, Southeast Asia, Pakistan, southern China, northern Australia and the Philippines, as demonstrated by the multiple outbreaks in 2001, 2004, 2007, 2012 in Bangladesh, India and Pakistan as well as the initial outbreaks in Malaysia and Singapore.
Multiple routes of the viremic spread in the human body have been identified such as the central nervous system (CNS) and respiratory system, while virus levels in the body remain low, detection in the cerebrospinal fluid is comparatively high. The virus follows an incubation period of 4 days to 2 weeks which is followed by the development of symptoms. The primary clinical signs include fever, headache, vomiting and dizziness, while the characteristic symptoms consist of segmental myoclonus, tachycardia, areflexia, hypotonia, abnormal pupillary reflexes and hypertension. The serum neutralization test (SNT) is the gold standard of diagnosis followed by ELISA if SNT cannot be carried out. On the other hand, treatment is supportive since there a lack of effective pharmacological therapy and only one equine vaccine is currently licensed for use. Prevention of outbreaks seems to be a more viable approach until specific therapeutic strategies are devised.
Original article
Is there a role for procalcitonin determination in avoiding unnecessary exposure to antibiotics in a non-intensive care setting?
Giacomelli Andrea,
van den Bogaat Lorena,
Corbellino Mario,
Oreni Letizia,
Dolci Alberto,
Panteghini Mauro,
Rizzardini Giuliano,
Galli Massimo,
Antinori Spinello
The use of procalcitonin (PCT) as a tool to assist clinicians in using antibiotics in intensive care patients has been postulated. Here we evaluate the efficacy of procalcitonin determination in helping clinicians in the decision to start or discontinue an antibiotic treatment in patients admitted to infectious disease wards. A retrospective observational single centre study was conducted in two infectious disease wards. Descriptive and inferential statistical analysis was carried out and receiver operating characteristic curves and area under the curve (AUC) were used to assess the accuracy of PCT and C-reactive protein (CRP) in separating patients undergoing antibiotic treatment or otherwise. In all, 164 patients were analysed of whom 99 (60.4%) were not on antibiotic treatment at the time of PCT determination, whereas 65 (39.6%) took antibiotics. Regarding the accuracy of PCT and CRP in determining a subsequent antibiotic prescription in patients without an ongoing antibiotic treatment, no statistically significant difference between the two markers was detected [AUC, 0.75; confidence interval (CI) 95%: 0.66-0.84; vs 0.69; CI 95%: 0.59-0.79 for PCT and CRP, respectively; p=0.32]. Conversely, in patients with an ongoing antibiotic treatment a statistically significant difference between PCT and CRP AUC in their ability to determine an antibiotic interruption was observed [0.77 (CI 95%: 0.65-0.89) vs 0.59 (CI 95%: 0.45-0.73) (p=0.03)]. PCT determination appeared to be more helpful than CRP in determining discontinuation of an antibiotic treatment in non-intensive care patients. However, PCT should supplement and not supplant a careful clinical evaluation.
Variability in the community consumption of antibiotics: a problem in Europe, Spain and Asturias
Sanchez Maria Luisa,
Vallina-Victorero Manuel Javier,
Bachiller Maria Rosario,
Arbizu Ricardo,
Llaneza Eugenia,
Rozada Shura,
Eiros Jose Maria
Increasing bacterial resistance is strictly correlated to the increasing use of antibiotics, currently constituting a public health problem. The aim of this study was to describe the consumption of antibiotics in Asturias, an autonomous community in northwestern Spain, and compare the results obtained with data from elsewhere in Spain and other European countries. A descriptive study was carried out on the use of antibacterial drugs for systemic use, ATC code J01 [5, 6] in Asturias in 2011-2015. Data were obtained from the prescription-billing information system charged to the Health Service of Asturias. The consumption data are expressed in daily doses per 1,000 inhabitants and day (DHD), and number of packages per thousand inhabitants per day. The average weighted consumption of antibiotics for systemic use in the Asturian community was 26.23 daily doses per 1000 inhabitants per day (DHD) in 2015. This figure was higher than that of the EU/EEA population, which was 22.4 DHD, and that of the whole of Spain at 22.2 DHD. There is a wide variability in consumption among the different areas of the Asturian region. This variability is common to the rest of the country and Europe. It can be explained by the influence of the data used in the indicators and by the variability in medical practice. Priority should be given to homologating consumer-monitoring information systems and implementing national strategies aimed at providing more information to medical practitioners, encouraging the appropriate use of antibiotics so as to reduce variability, consumption and resistance.
Diagnostic accuracy of a commercial multiplex PCR for the diagnosis of meningitis and encephalitis in an Italian general hospital
Leli Christian,
Di Matteo Luigi,
Gotta Franca,
Vay Daria,
Calcagno Lara,
Callegari Tiziana,
Cassinari Maurizio,
Cattana Elena,
Ciriello Maria Matilde,
Copponi Valeria,
Cristina Maria,
Zambon Daniele,
Guaschino Roberto,
Rocchetti Andrea
Infectious meningitis and encephalitis are potentially life-threatening conditions caused mostly by bacterial and viral agents. Rapid diagnosis and prompt treatment are associated with a more favorable outcome. In recent years nucleic acid amplification tests have been developed to speed detection and identification of pathogens directly from cerebrospinal fluid (CSF). The aim of this study was to compare the diagnostic accuracy of a commercially available multiplex PCR assay for etiological diagnosis of infectious meningitis directly from CSF samples with culture. A secondary endpoint was to look for a possible screening threshold based on main CSF indices and urgent blood test results, to define CSF samples with low pre-test probability of PCR and/or culture-positive result. We performed a secondary analysis of results of CSF samples already processed as part of routine clinical care from February 2016 to December 2018. In all, 109 CSF samples were included in the study and a total of 14 bacteria were identified by either PCR, culture or both methods, along with nine samples positive for viruses. The comparison of PCR results with culture showed no significant difference: 7/109 (6.4%) vs 13/109 (11.9%) respectively, p=0.07. After exclusion of the isolates not detectable by the multiplex PCR panel, the diagnostic accuracy was: 100% (95% confidence interval (CI): 54.1% to 100%) sensitivity; 98.9% (95% CI: 93.5% to 99.9%) specificity; 85.7% (95% CI: 42% to 99.2%) positive predictive value; 100% (95% CI: 95.1% to 100%) negative predictive value; 96 (95% CI: 13.6 to 674.6) LR+; Zero LR-; Cohen’s kappa: 0.918, p<0.0001. CSF protein value ≤ 28 mg/dl and CSF glucose/blood glucose ratio ≥0.78 were associated with both PCR-negative result for bacteria or viruses and culture-negative result. The multiplex PCR evaluated in this study showed a very good diagnostic performance compared to culture, and the thresholds found can be a useful tool to best choose which samples to test.
The effectiveness of antibacterial curtains in comparison with standard privacy curtains against transmission of microorganisms in a hospital setting
Al-Tawfiq Jaffar A.,
Bazzi Ali,
Rabaan Ali,
Okeahialam Christopher
Studies have shown a correlation between a cleaner patient environment and lower infection rates and reduced risk of transmission. Privacy curtains are a potentially important sites of bacterial contamination in hospitals. Privacy curtains integrated with antimicrobial properties have been shown to increase the time to first contamination compared with standard privacy curtains. In this study, we examined the difference in bacterial colonization of different curtains. We experimentally contaminated antibacterial Fantex protective curtains and compared the bacterial counts to natural contamination of privacy curtains. There was a significant reduction in the CFU/cm2 on antibacterial Fantex protective privacy curtains after 24 hours of experimental contamination with Pseudomonas aeruginosa, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum-producing organisms (Escherichia coli or Klebsiella pneumoniae), compared to standard privacy curtains. Levels of environmental contamination with S. epidermis, Streptococcus viridians, E. coli, S. haemolyticus, S. aureus, S. capitis, non-fermenting Gram-negative bacteria, and Bacillus species were also significantly less on the Fantex curtains after two months hanging in the emergency department. Healthcare facilities may find that addressing environmental surfaces, including use of antibacterial privacy curtains, an effective horizontal strategy for addressing healthcare-associated infections across the board.
Comparison of the effectiveness of caspofungin and liposomal amphotericin-B for the treatment of C. tropicalis-induced peritonitis in mice
Demirci Melis,
Tünger Özlem,
Banu Çiğdem,
Senol Şebnem
In order to compare the effectiveness of liposomal amphotericin B (LAB) and caspofungin monotherapy in Candida tropicalis-induced peritonitis in an experimental mice model 56 healthy male BALB/c mice (10-12 weeks; 20-25 g) were divided into groups and C. tropicalis strains were intraperitoneally (IP) inoculated into mice groups except the control group. After the injection, three doses of LAB (0.5, 1.0, 2.0 mg/kg/day) and caspofungin (1.0, 2.0, 5.0 mg/kg/day) were administered to groups for five consecutive days, starting 48-h post-infection. The mice were then followed up for 14 days and killed by cervical dislocation. When their peritoneal fluid was examined, the difference in fungal growth between the treatment group and control group was significant (p <0.05). Evaluation of the treatment groups revealed that fungal growth decreased with increasing dose of the antifungal agent (p >0.05). There was no dose-related difference from mice which received LAB or those which received caspofungin in our experimental model. During our study, no death was detected despite the similar injection doses compared with other studies using Candida species. The results of this study suggest that C. tropicalis could have lower virulence, perhaps limited by natural immunity, and causes mortality at much higher doses.
Evaluation of Candida colonization and use of the Candida Colonization Index in a paediatric Intensive Care Unit: a prospective observational study
Altintop Yasemin Ay,
Ergul Ayse Betul,
Koc Ayse Nedret,
Atalay Mustafa Altay
Invasive candidiasis is an important cause of morbidity and mortality, which primarily occurs in intensive care units. The Candida colonization index is an accepted score as an early warning tool for invasive candidiasis. This study was performed in a medical PICU with patients prone to contracting invasive candidiasis, to determine the usefulness of the Candida colonization index in forecasting invasive candidiasis in children. This prospective study including 87 patients (children 1 month to 16 years old with several illnesses and requiring ICU care) was conducted in a 22-bed medical PICU, Health Science University of Kayseri Training and Research Hospital, between January 2015 and September 2016. Those patients not on antifungal therapy, who were expected to stay more than seven days in PICU and had no history of a PICU stay within the previous two months were included in the study. In all patients, rectal, cervical, throat, axillary, perineal and nasal swab cultures, urine culture and blood culture tests were performed at admission and every week throughout their stay. Overall, 2639 swab and urine cultures (mean: 30.3) and 325 blood cultures (mean: 3.73) were obtained from 87 patients and a total of 576 grew Candida spp. In patients' swab and urine cultures C. albicans was detected in 64.5%, C. parapsilosis in 12.1%, C. glabrata in 7.5%, Saccharomyces spp in 3.0 %, C. tropicalis in 2.4%, C. krusei in 2.1% and C. kefyr in 1.2%. Three patients had C. albicans and one had C. parapsilosis growth in blood culture. Sensitivity, specificity, positive predictive value and negative predictive value for CI were found to be 33.73%, 100%, 6.7%, and 100%, respectively.
Patients are at risk of fungal infection in paediatric intensive care units. Specificity and the negative predictive value of 100 % indicate that CI is a useful score to rule out the presence of invasive fungal disease. On the other hand, the low rate of sensitivity (33.3 %) and positive predictive value (6,7%) make this score less reliable in forecasting invasive candidiasis in children.
Opportunistic intestinal parasites in immunocompromised patients from a tertiary hospital in Monterrey, Mexico
Rodriguez-Perez Elba Guadalupe,
Arce-Mendoza Alma Yolanda,
Montes-Zapata Édgar Iván,
Limón Alberto,
Rodríguez Luis Édgar,
Escandón-Vargas Kevin
Opportunistic parasites are still important agents causing morbidity and mortality in immunocompromised patients, particularly those living with HIV/AIDS. Few studies in Mexico have attempted to determine the prevalence of opportunistic intestinal parasites causing diarrhea in immunocompromised patients. A study was conducted to determine the intestinal parasites in HIV-positive and HIV-negative immunocompromised patients with diarrhea admitted to a tertiary care hospital in Monterrey, Mexico, from 2014 to 2015. Stool samples were examined for trophozoites, cysts, and eggs using the EGRoPe sedimentation-concentration technique and special techniques (modified Ziehl-Neelsen stain, modified trichrome stain). A total of 56 patients were included. The overall prevalence of intestinal parasitism was 64% (36/56); 22/36 patients were HIV-positive. Prevalence of opportunistic parasites was 69% in HIV-infected patients compared to 44% in HIV-negative patients (P = 0.06). Microsporidia were the most frequently identified parasites (24/36, 67%), followed by Cryptosporidium sp. (6/36, 17%), Sarcocystis sp. (4/36, 11%), Cystoisospora belli (3/36, 8%), and Cyclospora cayetanensis (1/36, 3%). Overall prevalence rates of microsporidiosis and cryptosporidiosis were 43% and 11%, respectively. Among HIV-infected patients, prevalence rates of microsporidiosis and cryptosporidiosis were 48% and 14%, respectively. We also report the first cases of intestinal sarcocystosis in Mexico, all in HIV-infected patients. In conclusion, microsporidia and coccidia are major parasitic agents causing diarrhea in immunocompromised patients, particularly HIV-infected patients.
Case report
Are probiotics safe? Bifidobacterium bacteremia in a child with severe heart failure
Pruccoli Giulia,
Silvestro Erika,
Pace Napoleone Carlo,
Aidala Enrico,
Garazzino Silvia,
Scolfaro Carlo
Although few cases of bacteremia or sepsis caused by probiotics have been reported, it is important to consider their pathogenic potential, especially in some categories of patients. We report a case of Bifidobacterium spp bacteremia in a child with heart disease, undergoing probiotic supplementation to prevent antibiotic-associated diarrhea.
The first Italian case report of leg ulcer and sepsis caused by Shewanella algae in a immunocompetent patient
Brugnaro Pierluigi,
Morelli Erika,
Ebo Francesca,
Rosini Giorgio,
Cattelan Francesca,
Petrucci Andrea,
Raise Enzo,
Panese Sandro,
Grandesso Stefano,
We describe the first Italian case of Shewanella algae septicemia in an immunocompetent patient with chronic leg ulcers. The patient had been exposed to seawater before the onset of symptoms. Despite the absence of severe underlying diseases, the primary soft tissue infection of the leg was complicated by hematogenous dissemination.
Scalp eschar and neck lymphadenopathy after tick bite in Argentina
Faccini-Martínez Álvaro A.,
Echazarreta Sofía,
Fernández Marisa,
Cortés Tatiana,
Díaz de Mayorga-Muñoz Estrella,
Orduna Tomás
Scalp eschar and neck lymphadenopathy after a tick bite (SENLAT) is an emerging non-pathogen-specific syndrome characterized by scalp eschar and occipital and/or cervical lymph node enlargement following a tick bite. We report a case of SENLAT syndrome in an Argentinian patient after exposure to ticks during outdoor work in the Paraná River Delta region.
Placental and pulmonary cryptococcosis associated with fungemia in patient with acquired immunodeficiency syndrome
Guilarde Adriana O.,
A. Andrade Ana Carolina,
De Sousa Marta A.,
De Oliveira Ana Maria,
Sugita Denis M.
Cryptococcosis is a systemic mycosis with a chronic or subacute progression caused by the inhalation of dehydrated yeasts or basidiospores. The causative agents are C. gattii and C. neoformans. The latter is more commonly associated with cellular immunodeficiency and is not rare in patients with Acquired Immunodeficiency Syndrome (AIDS). Cryptococcosis is common in pregnant women with AIDS; however, it is uncommon for the placenta to be affected, with few reported cases in the literature. We present the case of a pregnant woman with AIDS who had placental and pulmonary cryptococcosis associated with fungemia, with a satisfactory clinical outcome obtained after therapy.
Kaposi-like manifestations in a newly diagnosed AIDS transgendered patient with silicone embolism syndrome and disseminated tuberculosis
Picarelli Chiara,
Borghetti Alberto,
Di Giambenedetto Simona
The use of liquid silicone for cosmetic procedures can yield serious sequelae including embolization and pneumonia. We describe a recent case of silicone embolism syndrome occurring together with systemic tuberculosis in a transgendered patient newly diagnosed with AIDS. She presented with fever, hematochezia, lymphadenopathies, purple nodular lesions and lower limb edema. HIV test was positive. A chest X-Ray showed interstitial infiltrates and a tomography showed necrotic lymph nodes and pulmonary nodules with blurred borders, suggesting Kaposi sarcoma. Psychomotor impairment then occurred in the absence of tomographic signs of acute neurological events. The Mycobacterium tuberculosis genome was isolated from stool and bronchial washing samples. Histological examination of a necrotic lymph node showed lymphoadenopathy due to silicone accumulation. Moreover, the patient presented fever and swelling of lower limbs; a tomography showed multiple foreign body granulomas. After starting antitubercular, antiretroviral and antibiotic treatment she reported symptomatic improvement including a mild recovery of motor-slowing.
There are few reports about silicone-induced pulmonary disease in HIV-1 infected patients and, as far as we know, none of them describes an overlapping pulmonary involvement due to Mycobacterium tuberculosis infection. Even if extensive clinical and radiologic evidence is suggestive of Kaposi sarcoma (fever, severe immunodeficiency, multiple cutaneous nodules, hematochezia, diffuse lymphoadenopathies), it is possible to see Kaposi-like manifestations in patients with systemic silicone embolization. With this article we wish to stress the attention on the possible overlap of more than one concurrent disease in an immunocompromised host.
Aseptic meningitis induced by intravenous immunoglobulins in a child with acute Epstein-Barr virus infection and thrombocytopenia
Vassalini Paolo,
Ajassa Camilla,
Di Ruscio Valentina,
Morace Alessandra,
Vergari Jacopo,
Tosato Cecilia,
Savelloni Giulia,
Mastroianni Claudio M.
Drug-induced aseptic meningitis (DIAM) represents a diagnostic challenge since clinical and cerebrospinal fluid (CSF) findings may be indistinguishable from a bacterial meningitis. Intravenous immunoglobulin (IVIg) are commonly used in a variety of diseases, including inflammatory and autoimmune disorders. Although usually well-tolerated, various adverse effects have been reported. DIAM is a serious neurological side effect of IVIg therapy: albeit rare (0.067% of all IVIg infusions), the condition represents an important diagnostic challenge and should be considered by physicians. Here we report a case of an aseptic meningitis induced by IVIg therapy in a child with acute Epstein-Barr virus (EBV) infection and thrombocytopenia.
The Infections in the History of Medicine
Plagues and artistic votive expressions (ex voto) of popular piety
Sabbatani Sergio,
Fiorino Sirio,
Manfredi Roberto
In past centuries, epidemics, the scourge of humankind, caused pain, anger, uncertainty of the future, social as well as economic disorder and a significant impact on their victims, involving also their spiritual sphere. The latter effect led to undoubted effects on participation in the religious and social life of communities. The custom of preparing artistic votive expressions has been lost in the mists of time and evidence of ex voto gifts, offered by believers to pagan gods, has been found in prehistoric archaeological sites. Furthermore, several finds from the Ancient Greek and Roman worlds may be observed in our museums. These remains are generally ceramic and metal artifacts, reproducing limbs and other body parts which had been healed. These elements, according to the belief of those making the offerings, had benefited from the miraculous intervention of a thaumaturgical deity. With the advent of Christianity, some pre-existing religious practices were endorsed by the new religion. Believers continued to demonstrate their gratitude in different ways either to miracle-working Saints or to the Virgin Mary, because they thought that, thanks to an act of faith, their own health or that of a family member would benefit from the direct intervention of the divine entities to whom they had prayed. In the Ancient Greek world, it was believed that the god Asclepius could directly influence human events, as testified by the popularity of shrines and temples to the god, especially at Epidaurus. In the Christian world as well, particular places have been detected, often solitary and secluded in the countryside or in the mountains, where, according to tradition, direct contact was established between the faithful and Saints or the Virgin Mary Herself. Manifestations occurred by means of miracles and apparitions, thereby creating a direct link between the supernatural world and believers. Religious communities, in these extraordinary places, responded to the call through the building of shrines and promotion of the cult. Over time, the faithful reached these places of mystery, performing pilgrimages with the aim of strengthening their religious faith, but also with the purpose of seeking intercession and grace. In this case, the request for clemency assumed spiritual characteristics and also became a profession of faith. Accordingly, the shrines in the Christian world are places where supernatural events may occur. In these environments the believer resorted to faith, when medicine showed its limits in a tangible way. For the above reasons, while epidemics were occurring, the requests for clemency were numerous and such petitions were both individual and collective. In particular, by means of votive offerings (ex voto) the believers, both individually and collectively, gave the evidence of the received grace to the thaumaturgical Saint. Through the votive act, a perpetual link between the believer and the saints or Holy Virgin was forged and a strong request for communion was transmitted. The aim of the present study is to describe the role played by votive tablets (ex voto) in the last 500-600 years, as visible evidence of human suffering. From this perspective, these votive expressions may assume the role of markers because, in accordance with the expressions of popular faith, they allow us to follow the most important outbreaks that have caused distress to Christian communities
Gonorrhea, a current disease with ancient roots: from the remedies of the past to future perspectives
Vicentini Chiara Beatrice,
Manfredini Stefano,
Meritati Martina,
Di Nuzzo Mariachiara,
Contini Carlo
Gonorrhea can be traced back to the earliest records of the human race even if Albert Neisser first described gonococcus in 1879. The Romans, Jews and Arabs all have documents referring to gonorrhea and each society had their own description of symptoms and treatment. The Roman physician Galen in 130 AD described the disease as an “involuntary escape of semen”. The word itself derives from the Greek, meaning “the flow of seed”. Gonorrhea is currently the second most commonly notifiable sexually transmitted infection (STI) reported to Centers for Disease Control and Prevention (CDC), second only to chlamydial infection. Gonorrhea notifications have been on the rise all over the world and in several European countries since the early 2000s, particularly in populations with higher frequency of spread of STIs, such as men who have sex with men and young heterosexual individuals of both sexes.
Having been recognized at least 3500 years ago, the fight against the disease began infinitely before the antibiotic era, using healing compounds. In the absence of an ideal vaccine, the most important challenge today is the emergence of the multidrug-resistant gonorrhea, which is currently the main reason for public concern responsible for the evolution of N. gonorrheae into a superbug. N. gonorrheae strains resistant to extended spectrum cephalosporin (ESC) form a threat to effective control of gonorrhea for which there are currently ongoing clinical trials to evaluate the efficacy and safety profile of old and new antimicrobial molecules for monotherapy and as dual therapy of gonorrhea.
In this paper we investigated the remedies and treatments employed against gonorrhea during the 19th century in Ferrara, referring to Campana’s Pharmacopoeia and unpublished manuscripts concerning the treatment of this disease in medical practice. The remedies for gonorrhea adopted in the city were in line with those utilized in other countries. Among these, copaiba oleoresins have been demonstrated to have been efficacious in the past against gonococcal disease in popular medical use and, recently, against a large number of bacteria, fungi and protozoa, which will call for more in vitro and clinical studies to evaluate their real effectiveness on the N. gonorrheae bacterium.
Erratum
Erratum - Paleoparasitology in Iran: A Review
Khodkar Iman,
Feizhadad Mohammad Hossein,
Tavalla Mehdi
Erratum
Following publication of the Original article
“Paleoparasitology in Iran: a review”
(Infez. Med., volume 26, issue 4, pages 364-402, year 2018).
We became aware that the correct affiliation 3) is: Health Research Institute, Infectious and Tropical Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran and acknowledgements were included by mistake in the original paper and have to be considered as deleted
