Introduction First onset of mania in older adults is unusual, and not often mentioned in literature. Studies suggest that new-onset mania in older adults is most commonly secondary due to pharmacological, metabolic or neurologic causes. Objectives Present the case report of a 70-year-old patient with an acute manic episode without previous health issues. Methods Psychiatric interview, laboratory tests, neuroradiological, microbiological and immunological examinations. Results A 70-year-old patient was admitted to a psychiatric hospital for treatment due to altered behavior accompanied by agitation, thought process disorder, presence of paranoid delusions and increased sexual urges. The family provides information that the symptoms have lasted for about a year, but were intense 10 days before admission. In the first days of hospitalization, in addition to psychotic symptoms, strong affective irritability to the level of affective incontinence was noted, which led us to suspect the development of brain damage in the frontotemporal lobe. Information was obtained from family members that the patient had never previously had mental difficulties or been treated by a psychiatrist or other specialists. So far, he has been mostly healthy. Diagnostic tests were performed. Brain CT is completely normal. Laboratory findings show significantly elevated eosinophil values. The patient told us that approximately 8 months ago he ate pork that was not sufficiently heat-treated. An infectious disease specialist was consulted. Microbiological tests for trichinosis, leptospirosis, borreliosis, brucellosis and Q-fever were performed, as well as a series of immunological tests, of which IgE was elevated up to 160. All other tests were negative, except for elevated IgM antibodies to leptospirosis. Further infectious treatment is ongoing. The patient was treated with a mood stabilizer and antipsychotic in lower doses, which resulted in the cessation of psychomotor restlessness, reduction in delusional content and stabilization of affect. A double diagnosis of mania with psychotic symptoms and leptospirosis was made. Conclusions Although rare, first episodes of mania with or without psychotic symptoms also occur in the elderly population and are most often secondary, therefore a detailed diagnostic work-up and careful titration of psychopharmacotherapy is required. Disclosure of Interest None Declared

Introduction: Traditional diagnostics rely on microscopy, dipstick tests, and the gold‑standard urine culture, which is reliable but time‑consuming. Flow cytometry for urinary analysis offers a fast, objective, and highly automated approach that can improve the selection of samples for culture and accelerate clinical decision‑making. Flow cytometry uses fluorescent and scatter detection to quantify cells, bacteria, and other particles in urine, processing thousands of events per sample and generating parameters that correlate with the presence of infection. Methods: This retrospective study included 200 hospitalized adult patients (>18 years) admitted to the Clinic for Infectious Diseases, University Clinical Center Tuzla in Tuzla, Bosnia and Herzegovina. A urinary tract infection (UTI) was diagnosed based on standardized clinical and laboratory criteria. Urine samples were analyzed using the Sysmex UF‑4000 flow cytometer, and diagnostic thresholds for leukocyte and bacterial counts were determined by receiver operating characteristic (ROC) analysis and Youden’s Index. Results: Among 200 hospitalized patients, females predominated (124 vs. 76). Optimal cut-offs were ≥120/µL for leukocytes (area under the curve (AUC) 0.88, sensitivity 91.2%, specificity 75.3%) and ≥1367/µL for bacteria (AUC 0.95, sensitivity 90.3%, specificity 90.7%). Sex-specific analyses showed higher accuracy in males, with cut-offs of ≥1012/µL for bacteria (AUC 0.97) and ≥122/µL for leukocytes (AUC 0.94), while in females, the best thresholds were ≥1797/µL for bacteria (AUC 0.94) and ≥113/µL for leukocytes (AUC 0.84). The empirically developed UTI risk score (0-2) further improved stratification: Score 0 strongly predicted negative cultures (NPV >97%), while Score 2 was highly associated with positive cultures (PPV >94%). Conclusions: Automated urine flow cytometry offers a fast and accurate screening tool for UTIs, with bacterial counts outperforming leukocytes in diagnostic reliability. Sex-specific cut-offs and the UTI risk score enhance clinical applicability by improving stratification and reducing unnecessary cultures. While findings support integration of flow cytometry into routine practice, the single-center design, hospitalized cohort, and exclusion of pregnant women and children limit broader generalization, warranting validation in larger, multicenter studies.

Background: Community-acquired bacterial meningitis (CABM) remains a life-threatening infection with high morbidity and mortality, despite advances in antibiotic therapy and vaccination. Understanding local epidemiology is crucial for improving outcomes. Objective: To evaluate clinical and epidemiological characteristics and outcome of patients with bacterial meningitis in all age groups. Methods: This retrospective study analyzed 78 cases of CABM treated at the University Clinical Center Tuzla from 2014 to 2024. Patients were divided by age and outcome. Clinical features, laboratory results, microbiological findings, and prognostic factors were examined. Results: Adults comprised 59% of cases, and children 41%, with a median age of 29 years. The most common symptoms were fever (91%), positive meningeal signs (76.9%), vomiting (69.2%), and headache (66.7%). Streptococcus pneumoniae (24.4%) and Neisseria meningitidis (14.1%) were the leading pathogens. Mortality was 14.1%, significantly higher in adults (19.6%) than in children (6.3%). Poor outcomes were associated with older age, coma, ICU admission, and complications such as cerebral abscess or shock. Laboratory indicators of worse prognosis included thrombocytopenia, elevated urea and creatinine, hypokalemia, and low CSF cell count. Conclusion: CABM remains a serious clinical problem in Tuzla Canton. Early recognition, appropriate empiric antibiotic treatment, ICU management, and preventive measures such as vaccination are essential for improving survival, particularly in high-risk populations.

Varicella-zoster virus (VZV) belongs to the group of alpha herpesviruses, and causes two epidemiologically and clinically distinct diseases, chickenpox or varicella as the primary VZV infection, while shingles respresents the endogenous reactivation of latent VZV infection, typically occuring in older individuls and rarely in younger ones. This is a case report of a 12-year-old boy who was hospitalized at the Clinic for Infectious Diseases at the University Clinical Center Tuzla, diagnosed with meningitis from February 20, 2023, to March 7, 2023. Cerebrospinal fluid analysis upon admission showed moderate pleocytosis with mild proteinorrhoea and hypoglycorrhoea. Cerebrospinal fluid was also subjected to microbiological analysis, which returned a positive PCR result for varicella-zoster virus. Laboratory findings showed stable parameters of inflammation throughout the hospitalization. Parenteral antiviral therapy (acyclovir ampoules) was initiated upon admission and continued for 14 days. Follow-up cerebrospinal fluid analysis showed significant improvement. The boy was discharged home in a recovered state with recommendations for follow-up tests and examinations. Varicella-zoster meningitis is a rare but serious and potentially life-threatening complication following primary infection with the varicella-zoster virus, particularly in immunocompromised patients with symptoms of CNS involvement.

Aim To determine risk factors associated with the development and severity of secondary hyperparathyroidism in dialysis patients. Methods A cross-sectional study at the Clinical Centre of the University of Tuzla (March 2022) included 104 adult patients (males 51.9%, females 48.1%) with chronic kidney diseases under dialysis treatment. Based on parathyroid hormone (PTH) values, patients were divided into two groups: study group (45/104, PTH >792pg/mL) and control group (59/104, PTH 176-792 pg/ mL). The analysis aimed to resolve whether there was a connection between the duration of dialysis, the type of therapy treatment administered, the underlying kidney disease, and the presence of comorbidities with the values of PTH, and a wide spectrum of monitored laboratory parameters. Results The most common causes of chronic renal failure were undefined kidney diseases (32.7%), followed by diabetic nephropathy (18.3%) and chronic glomerulonephritis (16.3%). In the examined biochemical parameters, a significant difference was found in mean values of alkaline phosphatase (p<0.001). The correlation was proved between the duration of dialysis (p=0.028), the values of phosphorus (p=0.031), and alkaline phosphatase (p<0.001) with absolute values of PTH. The most common present comorbidity was hypertension (78.8%), followed by cardiovascular diseases (40.4%) and diabetes (22.1%). Conclusion A number of factors contribute to the development and severity of SHPT. Modulation of therapy and better control of risk parameters can prolong and reduce the frequency of SHPT in dialysis patients, as well as the occurrence of comorbidities.

Background: The coronavirus disease (Covid 19) is caused by the SARS-CoV-2 virus. The virus has spread globally, causing millions of deaths.Aim: This study was made with the aim of revealing the clinical features of corona virus infection, as well as assessing the prevalence of comorbidities in patients infected with coronavirus 2 (SARS-CoV-2).Methods: In this analysis the data was obtained from the hospital information system, involving patients who were treated for Covid-19, in the period January 1 until April 8, 2021.Results: 400 infected patients were included in the study, 86.2% of whom had comorbidities, and 8.8% without comorbidities. The results showed that the most common clinical symptom is fever in 62%, followed by difficulty breathing in 53%, and cough in 42%. The most prevalent comorbidities were cardiac 68.3%, then endocrinological 33.8%, surgical 16.5%, neurological 15%, oncological 12%, nephrological 11%, and pulmonary 10%. The existence of a significant association between the presence of comorbidities and the patients suffering from COVID-19 on mechanical ventilation due to treatment complications was determined, p=0.000 (p<0.05) at the 95% significance level.Conclusion: We assessed the prevalence of comorbidities in patients with COVID-19 and found that underlying disease, including cardiac and endocrinological diseases, may be a risk factor for severe forms of the disease.Key words: Covid-19, clinical features, comorbidities

Aim To evaluate clinical and epidemiological characteristics and outcome of patients with COVID-19, and impact of vaccine against COVID-19 on them. Methods This retrospective study included 225 patients treated from COVID-19 in the period from 1 to 30 September 2021 at the Clinic for Infectious Diseases, University Clinical Centre Tuzla (UCC Tuzla). For the diagnosis confirmation of Covid-19, RTPCR was used. Patients were divided in two groups: fully vaccinated with two doses of vaccine, and non-vaccinated or partially vaccinated. Results Of 225 patients, 120 (53.3%) were females, and 105 (46.7%) males. Mean age was 65.6 years. There were 26 (11.6%) fully vaccinated patients. Most common symptoms in unvaccinated patients were fatigue (70.9%), cough (70.4%) and fever (69.8%), and in vaccinated fever (76.9%), fatigue (69.2%) and cough (46.2%). Cough was more common in unvaccinated patients (p=0.013). Fatal outcome happened in 84 (37.3%) patients. Transfer to the Intensive Care Unit (ICU) and older age had a higher risk of death (p<0.001). Older age patients were more likely to have comorbidities like atrial fibrillation (p=0.017), hypertension (p<001) and diabetes mellitus (p=0.002). Atrial fibrillation (p<0.001), hypertension (p<0.001), diabetes mellitus (p=0.009) and history of stroke (p=0.026), were related to fatal outcome in unvaccinated patients, also did a shorter duration of illness prior to hospitalization (p<0.001) and shorter length of hospitalization (p=0.002). Conclusion Older patients with comorbidities, as well as those who were not vaccinated against COVID-19, were at higher risk for severe form of the disease and poor outcome.

INTRODUCTION This survey aims to assess knowledge, attitude and stigma towards HIV patients, among medical students in Tuzla, Bosnia and Herzegovina. We also aimed to assess potential risk factors for HIV infection among fourth year medical students. METHODOLOGY Data were collected from specific questionnaire that was completed by 171 students of the Faculty of Medicine, University of Tuzla. A multivariable logistic regression was performed. RESULTS Majority of students (79%) had a good knowledge of HIV, (median value of correct answers was 9 (95%) with at least 6 correct responses). Also, majority of students (73.6%) had a positive attitude towards HIV patients and the median positive value was 6 (95% CI: 6-7). More than a third of students considered that all hospitalized patients should be tested for HIV. Total of 81% of students considered that they should inform the sexual partner of HIV positive patient, although she/he disagrees. 61.4% of students had a discriminatory attitude towards HIV, with the median values of 3 (95% CI: 3-3). Multivariate regression analysis identified positive attitude towards HIV patients as an independent predictor for a non-discriminatory attitude. Moreover, an overall attitude towards HIV patients defines student`s determination to work with AIDS population. Male gender, and older age, were identified as predictors of risky behavior. CONCLUSIONS Preventive measures, including better HIV education, are crucial. Knowledge can increase awareness of HIV infection, decrease the incidence and reduce stigma towards HIV patients.

Introduction: Cytomegalovirus (CMV) infection is ubiquitous. It affects all age groups, and its clinical picture ranges from mild to severe, especially as a congenital infection in neonates. Aim: To determine frequency of CMV infection in pregnant women in Tuzla Canton (TC) and the risk factors that lead to the infection. Methods: This prospective study included 300 pregnant women from TC aged 18 to 42 years. CMV serology was performed on all participants, and in case of acute infection additionally IgG avidity test. Participants also completed the questionnaire on the risk factors for CMV infection. Results: The median age of the 300 women was 28 ±4.97 years. There were 161participants (53.6%) who classified their environment as urban and 295 (98.33%) were married. More than half of the women had completed secondary school 168 (56%). Positive IgG antibodies to CMV had 280 (93.0%) women. Positive IgM and IgG antibodies had 9 (3.0%) participants, but all of them had high IgG avidity, which indicates reinfection or recurrent CMV infection. There was a statistically significant higher number of seropositive participants living in rural areas than those living in urban areas (p= 0.048). Also, there was significantly higher percentage of positive anti-CMV IgG in pregnant women with lower education (p=0.04). Conclusion: In our region there is high seropositivity rates of IgG antibodies to CMV in pregnant women. No case of primary CMV infection was proven. The risk factors for CMV infection have been proven to be rural environment and lower level of education.

Aim To investigate predictive value of procalcitonin in diagnosis of sepsis in predicting positive blood culture, and possibility to predict final outcome in septic patients. Method This prospective study involved 106 hospitalized patients who met two or more criteria for systemic inflammatory response syndrome (SIRS). In comparison to Sepsis Related Organ Failure Assessment score (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II score procalcitonin (PCT), C-reactive protein and lactate levels were used to predict final outcome in septic patients (recorded as 28-day survival or non-survival). Using Receiver operating characteristic (ROC) curve the area under the curve (AUC) was calculated for diagnostic value and accuracy of different parameters with the best sensitivity and specificity for given cut-off values. Result Fifty-two out of 82 patients with documented sepsis had positive blood culture. Procalcitonin showed the best predictive value for both diagnosis of sepsis and bacteraemia with the cut-off value of 0.57 ng/mL (AUC 0.99) and 4.68 ng/mL (AUC 0.94), respectively. Serum lactate level showed the best 28-day mortality predictive value with the cut-off value of 3.25 mmol/L (AUC 0.95), and procalcitonin with the cut-off value of 15.05 ng/mL (AUC 0.92), followed by SOFA (AUC 0.92), CRP (AUC 0.84) and APACHE II score (AUC 0.83). Conclusion Monitoring of PCT in SIRS-positive patients raises possibility to distinguish between patients with sepsis and those with non-infectious SIRS. A significant correlation between PCT and SOFA, and APACHE II score in non-surviving septic patients indicates that PTC combined with clinical score could be useful for assessing severity of infection.

Introduction: The main route of acquiring infectious blood and body fluids in hospital conditions is accidental exposure to stinging incidents. Aim: The aim of this study was to determine the epidemiological characteristics of accidental exposures to blood-borne pathogens among different professional groups of health care workers (HCWs). Materials and Methods: A cross-sectional study was conducted using the “Questionnaire on the HCWs exposure to blood and blood transmitted infections” at the University Clinical Centre Tuzla, Bosnia and Herzegovina, from the 1st of March to the 31st of December 2014. Study sample consisted of 1031 participants (65% of total employees) stratified into three occupational groups: doctors, nurses and support staff. Results and Discussion: Exposure incident was recorded in 1231 participants (54.8%) at least once in the last 12 months. An average number of exposure incidents per HCWs in total years of service was 7.07± 8.041. Out of total sample, 70% reported at least one type of exposure incident. Nurses had a higher frequency of multiple contacts compared to doctors and support staff (χ2=37.73; df=4; p<0.001). The frequency of reported incidents among nurses at the surgical departments was almost two times higher (1.7). 75.5% (778/1031) of the participants, reported not having been exposed to these incident. Doctors were significantly less likely to report exposure incidents than nurses and support staff. There were significant differences in reporting rate (χ2=32,66; df=4; p<0.001). Conclusion: HCWs in hospitals have a high prevalence of occupational exposure to blood-borne infections. Seventy percent of the HCWs is periodically or constantly exposed to or contact related to blood. Nurses are most frequently exposed occupational group among HCWs, while the lowest reporting rate on an exposure incident is among doctors.

Objective – The aim of this paper is to present the epidemiological and clinical characteristics of a measles outbreak in children age 0-18 years, who were hospitalized at the Clinic for Infectious Diseases of the University Clinical Center, Tuzla in the 2014/2015 period. Patients and methods – The target population of this retrospective study were patients in the 0-18 year age group, who were hospitalized at the Clinic for Infectious Diseases during the measles outbreak in 2014/2015. Results – At the Clinic for Infectious Diseases in Tuzla, 341 patients with the clinical characteristics of measles were hospitalized during the period of the measles outbreak in 2014/2015. Of all hospitalized patients 74.7% (255/341) belonged to the age group from 0 to 18 years. Most of hospitalized children, 146 (57.2%) of them, were in the age group from 0 to 6 years, next was the group of children aged 11 to 18 years, 69 (27.1%) of them, followed by the group of children aged from 6 to 10 years, 40 (15.7%) of them. Complications were present in 176 (69.02%) of the hospitalized children. Among the hospitalized children suffering from measles, 92.5% were unvaccinated or incompletely vaccinated, or their vaccination status was unknown. Conclusion – The youngest population is susceptible to a much higher risk of measles. To reduce the incidence of measles in children a high level of immunization is required.

AIM To analyse clinical, laboratory and epidemiological characteristics of brucellosis in children in Bosnia and Herzegovina. METHODS The study included 246 children aged 0-18 years, who were hospitalized in Clinics and Departments for Infectious Diseases in Tuzla, Sarajevo, Banja Luka, Zenica and Bihać in the period 2000-2013, in whom the diagnosis of brucellosis was established based on anamnestic data, clinical features and positive results from blood culture and/or positive results from one of the serological tests. RESULTS In this period, a total of 2630 patients, 246 (9.35%) of whom were children, were treated from brucellosis at the Clinics and Departments in Bosnia and Herzegovina. In the majority of cases, the children were from rural parts of the country, 226 (91.87%);214 (87.04%) cases had direct contact with sick animals, sick family member or consumption of unpasteurized dairy products from farms where brucellosis had been already established. Male children predominated, 157 (63.82%). The most frequent clinical features in affected children were fever, 194 (78.86%) and joint pain, 158 (64.22%). The average duration of antimicrobial treatment was 42.85 ± 10.67 days. A total of 228 (92.68%) children were completely cured, while relapses occurred in 18 (7.32%) children. CONCLUSION Since brucellosis is an endemic disease in Bosnia and Herzegovina, it is important that physicians in their daily practice consider brucellosis and establish proper diagnosis and therapy in children with prolonged fever, arthralgia, leukopenia and positive epidemiological data, especially in rural parts of the country.