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Background: Several genes and their single nucleotide polymorphisms (SNPs) are associated with either spontaneous resolution of hepatitis C infection or better treatment-induced viral clearance. We tested a cohort of intravenous drug users (IVDU) diagnosed with chronic hepatitis C virus (HCV) for treatment response and its association with the SNPs in the interleukin-6 (rs1800795-IL6) and the interleukin-28B (rs12979860-IL28B) genes., Methods: The study included 110 Croatian IVDU positive for anti-HCV antibody. Genotyping was performed by polymerase chain reaction (PCR) based approach. Patients were treated by standard pegylated-interferon/ribavirin and followed throughout a period of four years, during which sustained virological response (SVR) was determined. All data were analysed with statistical package SPSS 19.0 (IBM Corp, Armonk, NY, USA) and PLINK v1.07 software., Results: Patients showed a significantly better response to treatment according to the number of copies of the C allele carried at rs1800795-IL6 (P = 0.034). All but one of the patients with CC genotype achieved SVR (93%), whereas the response rate of patients with GG genotype was 64%. The association of rs1800795-IL6 with SVR status remained significant after further adjustment for patients' age, fibrosis staging, and viral genotype (OR 2.15, 95% CI 1.16-4.68, P = 0.019). Distributions of allele frequencies at the locus rs12979860-IL28B among the study cohort and the underlying general population were suggestive of a protective effect of CC genotype in acquiring chronic hepatitis C in the Croatian IVDU population., Discussion: The rs1800795-IL6 polymorphism is associated with positive response to treatment in IVDU patients positive for HCV infection. A protective role of rs12979860-IL28B CC genotype in acquiring chronic hepatitis C is suggested for Croatian IVDU population., Competing Interests: The authors declare that they have no competing interests.

Health concerns associated with Legionnaires' disease have been identified as an area of the increasing public and professional interest. Any natural water or man-made water systems worldwide might be reservoirs of Legionellae. We presented a sporadic, community-acquired case of Legionnaires' disease caused by Legionellapneumophila serogroup 1 in a bus driver who used water for hand and face washing from a bus water storage tank. The history of any other usual place of exposure to Legionellae was negative. The water from the tank was dirty, filled with sediment and leaves, at the temperature of 22 degrees C. The water was heavily contaminated with Legionella pneumophila serogroup 1 isolated from each sample with the concentration of 66,000, 16,000, 42,000, 56,000 and 34,000 CFU/L. The disinfection of the bus water storage tank was made using hyperclorination with 50 mg/L of free residual chlorine. The control sampling one week after the disinfection yielded negative results. So far, there are no recommendations on regular management or disinfection of water in bus storage tanks, but it seems to be reasonable to assume that passengers as well as bus drivers may be exposed to Legionella and therefore at risk of acquiring the infection. These recommendations should include regular empting, rinsing and filling the tank with fresh tap water, at least once a week. Finally, we have to be aware that Legionella bacteria are ubiquitous and any potential mode of producing contaminated aerosol should not be overlooked during an epidemiological field investigation and proposed appropriate measures.

Currently, therapy for hepatitis B has a limited effect and can rarely eradicate infection (ALT normalization, undetectable HBV DNA, HBsAg/anti-HBs seroconversion). Minimal progress in terms of treatment success has been achieved in the past four years. Changes from the previous Croatian Consensus Conferences in 2005 and 2009 are based on standings of the Consensus Conference of the American Association for the Study of Liver Disease (AASLD) 2009, Consensus Conference of the European Association for the Study of Liver (EASL) 2012, and Asia-Pacific Association Guidelines for the Study of Liver (APASL) 2012. In this paper, we will mention only differences in relation to the before mentioned Croatian guidelines from 2005 and 2009. New developments relating to the application of noninvasive methods for assessing fibrosis, quantification of HBsAg to predict treatment outcome, registration of new drugs, and some new recommendations for more efficient and rational treatment will be reviewed. New findings as well as recommendations for the treatment of patients in special circumstances including treatment of pregnant women, patients with drug resistance, patients with co-infection, hepatic decompensation, patients on immune and chemotherapy, patients after liver transplantation, and patients with HCC will also be included.

Therapy is strongly recommended in patients with acute infection, patients with elevated ALT levels, patients with normal ALT level and F > or = 2 METAVIR score, in genotype 1 nonresponders and relapsers to antiviral therapy with triple therapy (pegylated interferon, ribavirin, bocaprevir or telaprevir), in patients with compensated cirrhosis and patients on hemodialysis. It is possible to treat patients with HBV and HIV co-infection, patients with severe HCV extrahepatic manifestations and patients with transplanted liver. Drug users and alcoholics can be treated after 6-month abstinence, but also with supportive therapy. This therapy is not recommended in patients with fulminant hepatitis, patients with persistent normal ALT levels and without fibrosis, in kidney transplant recipients and in pregnant women.

Croatian Consensus Conferences on Viral Hepatitis took place in 2005 and 2009. Considering the numerous novel concepts on the epidemiology, diagnosis and management of viral hepatitis (chronic hepatitis C genotype 1 in particular) that have emerged in the past four years, a new Croatian Consensus Conference on Viral Hepatitis was held in Zagreb on February 28, 2013. The abridged text of the Croatian Consensus Conference on Viral Hepatitis 2013 presents the new concepts on the epidemiology of viral hepatitis, serologic and molecular diagnosis of viral hepatitis, determination of the IL-28 gene promoter polymorphism, fibrosis grading, algorithm for patient diagnostic follow up, treatment of chronic hepatitis C (genotypes 1-6) and hepatitis B, treatment of special populations (children, dialysis patients, transplanted patients, individuals with HIV/HCV co-infection), and therapy side effects.

Background: Phleboviruses are large and widespread group of viruses that are transmitted by arthropods and they have been reported to circulate in endemic regions of Mediterranean Basin, including Croatia., Objectives: To investigate the role of Toscana virus, as a cause of the aseptic meningitis, in summer months in Croatia., Study Design: Samples from 30 patients with aseptic meningitis were retrospectively tested by serology and RT-PCR for TOSV., Results: TOSV RNA was detected in 2/30 and TOSV IgM antibodies were found in 4/30 of patients. Phylogenetic analysis of partial L and S segments suggests that TOSV from Croatia represents an autochthonous strain., Conclusions: The study has confirmed the role of TOSV as an agent that causes aseptic meningitis in Croatia, therefore it should be considered by physicians when encountering meningitis or febrile illness among indigenous population or travellers during the summer months., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Echinococcosis is rarely encountered as a cystic brain disease. In this article we are presenting a case of a young woman repeatedly operated due to echinococcosis of lung, heart and brain. Recurrent brain ecchinococcosis developed despite preoperative and postoperative albendazol therapy after first and combined therapy with albendazol and praziquantel after the second brain surgery. The mechanism of recurrence remains unclear (primary infestation, dissemination after spontaneous or intraoperative cyst rupture or new infestation).

All patients with hepatitis C virus (HCV) infection should be considered as candidates for antiviral therapy. In order to make decision whom to treat, it is necessary to evaluate the following parameters: stage of disease, comorbidity, patient age, contraindications and therapy risks. Therapy is strongly recommended in patients with acute infection, with elevated ALT levels, with normal ALT level and F > or = 2 METAVIR score, in non-responders to standard interferon monotherapy, in relapsers to antiviral therapy, in patients with compensated cirrhosis, and in hemodialysis patients. It is possible to treat patients with persistent normal ALT levels and without fibrosis, patients with HBV and HIV co-infection, patients with severe extrahepatic manifestations of HCV infection, and patients with liver transplant. Drug addicts and alcoholics can be treated after 6 months of abstinence, but also with supportive therapy. Therapy is not recommended in patients with fulminant hepatitis, kidney transplant recipients and pregnant women.

Current therapy for hepatitis B has a limited effect and can rarely eradicate viral infection (normalization of ALT, nullification of HBV DNA, or seroconversion of HBsAg to anti-HBs). Progress in hepatitis B therapy over the last 5 years did not have much influence in this segment. Modifications in therapeutic indications for both acute and chronic hepatitis B presented below are based on standings of the Consensus Conference of the American National Institutes of Health (NIH) from 2008, Canadian Consensus Conference from 2007, and Consensus Conference of the European Association for the Study of the Liver (EASL) from 2009. It seemed appropriate to retain the division of treatable patients in 3 groups: 1) patients in whom therapy is indicated; 2) patients in whom therapy may be indicated; and 3) patients in whom immediate therapy is not routinely indicated, as stated in the guidelines of the 2002 EASL Consensus Conference, 2004 Croatian Consensus Conference and 2008 NIH Consensus Conference.

The aim of this study was to provide an overview of the snakebites in patients hospitalized at the Mostar Clinical Hospital, admitted between 1983 and 2006. A total of 341 patients were recorded, with moderate men predominance (52.8%). Majority of patients were bitten for the first time (99.1%). In 98.8% of patients snakebite occurred to the bare skin, most commonly during June to September period (64.2%). Snakebites were the commonest in agricultural workers (48.1%). Until 2003 all admitted patients were treated according to Russel's scheme (3-anti). As of 2003 new treatment scheme was applied, resulting in the reduction of antidote and supportive treatment use, causing a reduction in the number of clinically apparent allergic reactions. Serum sickness was recorded in only 2 patients, while lethal outcome was recorded in one (0.3%). Overall results indicate that lethality of snakebite is low, and that patients were often administered treatment without medical indication. High number of tourists as well as the presence of the peace keeping troops and other visiting personnel in this region make the snakebites and awareness on snakes not only a local issue, but also more general concern.

Aim: To evaluate the association between human leukocyte antigens (HLA) class I and therapeutic response to interferon-alpha in Croatian patients with chronic hepatitis C., Methods: HLA-A, -B, and -C genotyping was performed in 55 patients with sustained virological response and in 57 patients without sustained virological response to interferon-alpha therapy. Patients were treated in the period from 1998-2001 with interferon-alpha at a dose of 3 million units three times a week. Patients who became negative for hepatitis C virus RNA after 12 weeks of therapy completed 48 weeks of therapy., Results: There was no association between therapeutic outcome and frequency of HLA-A, as well as of HLA-B alleles. HLA-Cw7 was significantly more frequent in patients with than those without sustained virological response (27.0% vs 6.7%; P=0.011)., Conclusion: In Croatian patients with chronic hepatitis C, HLA-Cw7 is the predictor of sustained virological response to interferon-alpha therapy.

Objective: The goal was to investigate the number and origin of typhoid fever cases in Split-Dalmatia County, Croatia, during the period of 1970-2005., Methods: Data from the medical records of typhoid fever cases treated at the University Hospital during the 35-year period were analyzed. Cases were defined as those in which Salmonella typhi was isolated from blood and/or stool. All isolates were tested for susceptibility to antimicrobial agents., Results: A total of 45 cases were identified. Forty-four patients originated from Bosnia and Herzegovina, and all of their isolates were susceptible to all antimicrobial agents tested. One patient from Pakistan was infected with multidrug-resistant S. typhi. No autochthonous case of typhoid fever was identified., Conclusion: All cases of typhoid fever were acquired in countries where typhoid fever is endemic, and their importation to Croatia was the result of war-associated population movements. Increased awareness of health care workers regarding persons who originated from or have traveled to a typhoid-endemic area is needed. To avoid treatment failure, particular attention should be given to persons coming from regions with a known presence of multidrug-resistant S. typhi.

Background: Q fever is a common and acute but rare chronic zoonosis caused by Coxiella burnetii. Its acute form manifests as atypical pneumonia, flu-like syndrome, or hepatitis. Some authors observed symptoms of chronic fatigue in a small number of patients after the acute phase of Q fever; in many cases serological assay confirmed the activity of Coxiella burnetii infection. The effect of antibiotic therapy on post-Q-fever fatigue syndrome has not been studied in south-east Europe thus far., Case Reports: Three patients are presented with post-Q-fever fatigue syndrome. All fulfilled the CDC criteria for chronic fatigue syndrome. IgA antibodies to phase I of the growth cycle of Coxiella burnetii were positive in two patients and negative in one. Two patients were treated with doxycycline for two weeks in the acute phase of illness and one with a combination of erythromycin and gentamycin. After 4-12 months they developed post-Q-fever fatigue syndrome and were treated with intracellular active antibiotics (fluoroquinolones and tetracycline) for 3-12 months. Efficacy of the treatment was observed in two patients, but in one patient the results were not encouraging., Conclusions: These results suggest the possibility of the involvement of Coxiella burnetii infection in the evolution of chronic fatigue syndrome. This is the first report on post-Q-fever fatigue syndrome in Mediterranean countries. Evidence of IgA antibodies to phase I of the growth cycle of Coxiella burnetii is not a prerequisite for establishing a diagnosis of CFS. The recommendation of antibiotic treatment in post-Q-fever fatigue syndrome requires further investigation.

The aim of this 10-year retrospective study was to investigate the distribution of HCV genotypes in patients with chronic hepatitis C monitored in the largest center for molecular diagnostics of HCV infection in Croatia. The study enrolled 1163 anti-HCV positive adults with detectable HCV RNA in the plasma. The patients were classified in four regions: Zagreb and surrounding continental area, Split, Slavonija and Rijeka. HCV genotyping was performed by using VERSANT HCV Genotyping Assay (LIPA) (Bayer Diagnostics, Puteaux Cedex, France). Statistical analysis was performed by using Statistica for Windows V.5.1. The majority of HCV infections in the study population were caused by genotypes 1 (58.8% of infected patients) and 3 (35.6%). Percentages of patients infected with subtypes 1b and 1a were 37.4% and 13.1%, respectively. Genotypes 2 and 4 were present in a very low percentage of patients (2.2% and 3.4%, respectively) while genotypes 5 and 6 were not detected. Analysis of regional differences in the distribution of HCV genotypes revealed similar percentages of subtype 3a and 1b infections in the Split region while the majority of infections in other regions were caused by subtype 1b. Infections with genotypes 2 and 4 were present in less than 5% of patients in all geographic regions. Analysis of an association between risk factors for infection and distribution of genotypes and subtypes in a subset of patients from the Split region confirmed the association between IVDU and subtype 3a. We conclude that the prevalence of HCV genotypes and subtypes follows the pattern of other Southern and Eastern European Countries with the predominance of subtypes 1b, 3a and 1a.

The bacillus Listeria monocytogenes is widely distributed in the environment. Listeria monocytogenes most often causes infection in the neonates, pregnant women, elderly and immunosuppressed persons. We report on a case of fatal sepsis and meningitis in a 59-year-old woman receiving cyclophosphamide and glucocorticoid therapy for Wegener's granulomatosis over a 10-year period. Listeriosis should be suspected in case of sepsis and/or meningitis in patients who receive immunosuppressive agents. Since meningitis due to Listeria monocytogenes is not distinguishable clinically from other types of bacterial meningitis, antibiotics against Listeria monocytogenes should be included in the initial empirical therapy of bacterial meningitis in immunosuppressed patients, antibiotics against Listeria monocytogenes should be included.

Haemaphysalis sulcata ticks collected from sheep and goats in southern Croatia were found infected with rickettsiae. Molecular analysis of the complete gltA gene and portion of 17 kDa and ompB genes revealed the presence of Rickettsia felis-like bacteria in up to 26% of tested ticks.

Background: Q fever shows a wide diversity of clinical manifestation. Q fever is endemic in northern Croatia, but the epidemiological and clinical characteristics of this disease in various ecological areas of southern Croatia are unclear., Material/methods: From January 1985 to December 2002, acute Q fever cases hospitalized at Split University Hospital were analyzed. Acute Q fever was defined as fever (>38 degrees C) with clinical findings in lung and/or liver verified by serologic testing with Coxiella burnetii phase II antigen., Results: During the period of observation, 155 acute Q fever cases were hospitalized. The mean incidence of acute Q fever in the study region was 0.20/100,000/year (95%CI:0-0.78) in the coastal area and 4.64/100,000/year (95%CI:0.44-8.85) in the non-coastal areas, with a male predominance (chi2=60.0; p=0.0000) and a mean male to female ratio of 4.2:1. People of essentially all ages (4-76 years) were affected, the highest rate of infection being recorded in 20- to 49-year-old age groups. In contrast to adults, girls were more frequently affected than boys (2:1). No case of acute Q fever was recorded on any of the nearby islands. Clinically, acute Q fever most commonly presented with both pneumonia and hepatitis (60.0%), followed by pneumonia (25.8%), hepatitis (9.0%), and nonspecific febrile illnesses (5.2%)., Conclusions: C. burnetii is endemic in rural, coastal, and non-coastal areas of southern Croatia and is associated with stock breeding. In these areas, Q fever occurs sporadically and epidemically. Males 20-49 years of age were the prevalent cases.

This retrospective study is based on the analysis of 542 snakebite envenomation cases in southern Croatia, which were treated in the University Hospital Split over the period of 21 years. The aim of this study was to determine the incidence of venomous snakebite in southern Croatia, epidemiological and clinical features of snakebite and treatment in the region. The mean annual snakebite incidence in southern Croatia was 5.2 per 100,000 inhabitants. The nose- horned viper (Vipera ammodytes) was responsible for most bites, only a small proportion being inflicted by the adder (Vipera berus). People of all ages were affected (1 - 82 year old), but the bites were more frequent in individuals older than 50 (46% of the cases) and in children and adolescents 19 year old and younger (27% of the cases). Most snakebite accidents happened in warm spring and summer months, the highest number occurring in May (22%). A majority of the victims were rural people engaged in agricultural activities. Bites on the upper limbs were more frequent (57%) than bites on the lower limbs (42%). With regard to envenomation severity, there were 15.1% minor, 40.5% mild, 26% moderate and 18% severe cases. Two victims died (0.4%). The antivenom produced by the Institute of Immunology in Zagreb was given to virtually all patients, and complications following its administration were rare. The antivenom was used more often than it was suggested by the symptoms present.

There has been a dramatic improvement in diagnostic procedures and therapy of viral hepatitis in the last 20 years. Improvements in therapy caused an increase in actual cost, however, with significant long-term savings through a decreased cost of treatment of advanced liver disease including liver transplantation. The Croatian National Board for Viral Hepatitis has decided to initiate the organization of consensus conference on viral hepatitis enabling the leading experts in the country to give the best possible recommendations for the diagnosis, prophylaxis and therapy in our circumstances. The Consensus Conference took place in Zagreb in June 2004, with update in March 2005, organized by the Croatian National Board for Viral Hepatitis, Reference Centers of the Ministry of Health for Chronic Liver Diseases, Infectious Diseases and AIDS, Croatian Society of Gastroenterology--Hepatology Section, Croatian Society for Nephrology, Dialysis and Transplantation, and Croatian Institute for Health Insurance. Invited experts provided written reports on the respective subjects that appear in this issue and their recommendations resulting in this consensus statement.

About 25% of all liver transplantations in USA are performed for liver disease due to viral hepatitis, 25% of them related to hepatitis B. It is also known that 90%-100% of transplanted persons with proven replicative stage of hepatitis B [HBeAg (+), HBV DNA (+)] develop reinfection of the transplanted liver in the absence of prophylaxis. This percentage is lower (30%-50%) in patients with nonreplicative stage of infection [HBeAg (-), HBV DNA (-)]. The consequence of most transplant infections is death due to the transplanted organ failure. The prophylaxis of infection is possible, however a combination of intravenous hepatitis B hyperimmune gammaglobulin and lamivudin may be too expensive for some transplantation centers in less developed countries. The aim of this article is to recommend prophylaxis and treatment of recurrent hepatitis B in persons with transplanted liver using data of the Consensus Conference on Hepatitis B in Geneva 2002, Canadian Consensus Group for Hepatitis (CASL) and EASL International Consensus Conference on Hepatitis B that should be available for patients in Croatia.

Aim: To detect and isolate rickettsial strains from blood samples of patients with presumptive diagnosis of Mediterranean spotted fever (MSF) in the coastal region of south Croatia, and to compare the results with routine serology., Methods: A "suicide" polymerase chain reaction (PCR), and a shell vial culture were done on samples of ethylenediamine tetra-acetic acid (EDTA) and citrate-anticoagulated blood samples. Indirect immunofluorescence was performed on sera collected from 17 patients clinically diagnosed with MSF during summer in three consecutive years, from 1998 to 2000., Results: The primers used in PCR amplified the expected part of the rickettsia genomic DNA and Rickettsia conorii grew from the shell vial-cultured blood of a single patient. In 13 patients, the diagnosis was confirmed serologically by paired sera, whereas in 4 patients the diagnosis remained presumptive, since no paired sera were available. Analyzing sequences of the ompA and citrate synthase gene, respectively, derived from the shell vial isolate, a 100% similarity with Rickettsia conorii, strain Seven (Malish), was found., Conclusion: To the best of our knowledge, this is the first isolation of Rickettsia conorii from a human sample in Croatia, and the first proof of a causative agent of MSF in the country. Beside PCR-based methods and isolation, correct diagnosis of MSF could be still routinely reached by serology.

Aim: To investigate the possibility of permanent renal function impairment and other organ lesions following hemorrhagic fever with renal syndrome (HFRS)., Methods: Data on 30/37 patients infected with HFRS, treated at the Department of Infectious Diseases, Split University Hospital, in 1995 were retrospectively analyzed. The data were collected three to six years following the appearance of HFRS. In 1998, 30/37 patients presented for control checkup, when their history data were collected, along with physical examination, hematology and biochemistry tests, and urinalysis. Creatinine clearance and sodium, potassium, chlorine, phosphorus, beta 2-microglobulin and N-acetyl-beta-D glucosaminase in 24-h urine were determined. In native urine, erythrocyturia was observed, with 10 erythrocytes per field were considered pathologic result. During the 1998-2001 period, renal scintigraphy by means of technetium labeled diethylene triaminopentacetic acid (99mTC DTPA) was performed in 13/30 patients., Results: Of subjective discomforts, 29/30 (96.7%) patients reported lumbar pain. Elevated blood pressure was found in 9/30 (30.0%), erythrocyturia in 4/30 (13.3%) and hepatic lesion in 4/30 (13.3%) patients. Decreased creatinine clearance values (< 1.2 ml/s) were found in 4 and increased values (> 2.35 ml/s) in 10 patients. Increased sodium in 24-h urine was recorded in 10/23 and increased beta 2-microglobulin in 6/23 (26%) patients. Proteinuria exceeding 150 mg/day was detected in 11/23 (47.8%) patients. Scintigraphy of the kidneys demonstrated reduced glomerular filtration (< 100 ml/min/1.72 m2) in 3/13 patients. Prolonged mean times (> 5 minutes) of radiopharmaceutical passage through the renal parenchymae were found in 7/13 (53.8%) patients., Discussion: Studies performed in 30 patients three years after they had recovered from HFRS revealed changes suggesting a mild to moderate impairment of the renal function. Hypertension found in 9/30 patients was a significant finding, considering the fact that all subjects were soldiers, thus having undergone through examinations to prove them completely healthy prior to joining army. Hypertension results were consistent with those reported from the USA. Although erythrocyturia points to urinary tract damage, its glomerular or postglomerular origin was not examined. Decreased creatinine clearance found in 4/23 patients suggested functional renal impairment. Increased natriuresis found in 10/23 patients implied tubular damage, i.e. reduced ability of tubular cells for sodium reabsorption from primary urine. Non-selective albuminuria detected in 11/23 patients indicated permanent lesion of the glomerular basal membrane. Increased beta 2-microglobulin found in 6/23 patients indicated that the lysosomal enzyme level was elevated only in the acute stage of the disease, but may have been an indicator of permanent lesion. No description of post-HFRS scintigraphic lesion of the kidneys was found in the literature. A decreased value of glomerular filtration, found in three patients, and especially the prolonged mean time of glomerular micropharmaceutical passage in 7/13 (53.8%) patients may have suggested glomerular damage. However, the possible reason may have also been a reduced passage of glomerular filtrate through the damaged lower parts of the nephrons. Transaminase increase during the acute stage of HFRS suggested the possible liver infection, maybe even hantavirus replication in hepatocytes. Even though biopsy confirmed the histologic picture of chronic hepatitis in one patient, the question remains whether it could have been caused by hantavirus., Conclusion: Studies performed in 30 patients with a history of HFRS revealed renal function impairment, along with hypertension and damage to the liver parenchyma in some patients. The results obtained showed that the HFRS infection in Croatia may have entailed chronic sequels. To confirm this hypothesis, additional studies including a control group of hantavirus negative persons are needed.

A 46-year-old woman having sustained a rhinoceros viper bite to the left lower leg is presented. She was treated at Department of Infectious Diseases, Split University Hospital. After 20 days she left the hospital in good condition, with a small crust at the bite site. About ten days later suppurative secretion developed at the bite site and a few days later she felt pain in her right hip and leg, and turned febrile. She was treated at home with antibiotics and analgetics for nearly one month. Her condition was worsening, and she was referred to Department of Neurosurgery, for suspected lumboischialgia. Then, she was transferred to the Department of Orthopedics as suspected septic coxitis, where she was operated on. The disease was not recognized on time, appropriate treatment was introduced too late, and irreparable consequences developed in the right hip. To the best of our knowledge, this is the first reported case of coxitis, especially on the contralateral side to the snake bite. Infection from the site of snake bite on the left lower leg could have been transferred to the right hip exclusively by hematogenous way. Our objective is to warn of this rare snake bite complication, and to contribute to better diagnostic and therapeutic management in similar situations.

Aim: To investigate the characteristics and determine risk factors for hantanvirus infection in natural focus of hemorrhagic fever with renal syndrome (HFRS) on the Dinara Mountain, where outbreak of disease emerged among Croatian soldiers in 1995, and to describe the features of HFRS acquired on the Dinara mountain and determine the scale of the largest HFRS epidemic so far in Croatia., Methods: During 1996, small mammals were captured in the region of Dinara Mountain where infected Croatian soldiers had sojourned. By taxonomic classification of 42 captured small mammals, three species were determined: 23 yellow-necked mouse, 9 wood mouse, and 5 bank vole. Hantavirus antigen was determined in the lungs of the captured animals by means of direct immunofluorescence assay. The most important features of HFRS were retrospectively determined in 37 soldiers with HFRS treated in the Department for Infectious Diseases of the Split University Hospital. The degree of inapparent exposure to infection was determined by indirect immunofluorescence in 103 soldiers sojourning in this region of natural focus with no apparent signs of HFRS. Epidemiological questionnaire included 50 soldiers with negative serum antibodies, as well as 33 available out of total 37 soldiers with HFRS. Chi-square test was used to determine risk factors., Results: Hantavirus was found in the lungs of 5/42 (12%) captured animals. Mild form of the disease, with few hemorrhagic symptoms and pronounced renal insufficiency, was present in 19/37 patients. The epidemiological questionnaire determined the following risk factors for hantanvirus infection in this focus: service in artillery corps (p=0.040), sleep in wooden barracks (p=0.004), station in forest biotope (p=0.037), usage of natural camouflage (p=0.024), smoking (p=0.010), and the presence of rodents in the place of housing (p<0.001)., Conclusion: A new natural focus of HFRS in Croatia, and the first one in Dalmatia, was defined by seroepidemiologic, mamologic, and virologic analysis. The risk factors for infection in the new focus have been identified. Our patients suffered from a mild form of HFRS, which predominates in south-eastern Europe, without lethal outcome.

Objective: To show epidemiologic and ecologic characteristics of some diseases transmitted by arthropods on the littoral of the Republic of Croatia., Methods: The pattern of infectious diseases that are transmitted exclusively by vectors was monitored during the period 1985 to 1999. Data on the incidence of the diseases in the Republic of Croatia as a whole and available data on the presence of the vectors for the diseases on the littoral are presented for comparison., Results: Mediterranean spotted fever, murine typhus, Lyme disease, cutaneous and visceral leishmaniasis, and pappataci fever occur sporadically on the Croatian littoral. Tick-borne meningoencephalitis is endemic in the northwestern part of Croatia but is not present on the littoral. Twelve cases of malaria are imported into Croatia per year on average., Conclusion: Diseases transmitted by arthropods are not a major public health problem in Croatia. The medically relevant entomofauna of Croatia has not yet been adequately investigated.

Muscular echinococcosis accounts for 0.5% to 5.4% of all hydatid disease cases, with very little data on the incidence of muscular echinococcosis of the head and neck. We report a unique case of primary echinococcosis of the right sternocleidomastoid muscle in a 56-year-old man. Preoperative assessment by ultrasound and fine needle aspiration did not point to echinococcosis. We suspected the right diagnosis intraoperatively and confirmed it postoperatively by pathohistology and serologic tests. Echinococcosis of the liver and the lungs was also excluded postoperatively. Combination of operative treatment and postoperative albendazole herapy in two 28-day cycles one month apart resulted in complete regression of the disease. Echinococcosis should be considered as differential diagnosis of a multicystic mass in neck, particularly if it is of longstanding duration. Serologic tests for echinococcosis should be included in differential diagnostic procedures for each multicystic formation on the neck, especially in endemic areas.

A 73-year-old female patient presented with Pasteurella multocida erysipelas-like cellulitis, bacteremia, and shock. The onset of the disease occurred 24 h after a cat bit her to the right lower leg. Initially, the picture of bacteremia and shock developed, with minimal local cellulitis. Pasteurella multocida grew in blood culture. A combination of amoxicillin and clavulanic acid was therapeutically successful in respect that the signs of bacteremia and shock disappeared. However, extensive erysipelas-like cellulitis developed on the bitten leg within the next 2 days. The disease was efficiently treated with penicillin G combined with netilmicin and administered for 10 days. This report documents the first case of Pasteurella multocida erysipelas-like cellulitis with bacteremia and shock.

A seroepidemiologic survey of pregnant women in Split region was performed in order to determine a strategy for prenatal screening for HBsAg. Thirty (7.5%) of 400 women had the markers of past or current HBV infection, while 3/400 (0.75%) were carriers. According to demographic data and risk factors they represent low risk population. General prenatal screening for HBsAg is advisable.