الفهرس 
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Abstract
Fever of unknown origin (FUO) refers to a condition in which the patient has an elevated temperature (fever) but despite investigations by a physician no explanation has been found. If the cause is found it is usually a diagnosis of exclusion that is, by eliminating all possibilities until only one explanation remains, and taking this as the correct one.
The present study was conducted to determine the role of some zoonotic agents in causation of FUO in patients attending Fever hospitals in Behera and Alexandria Provinces.
RBPT is a very useful test for the diagnosis of human brucellosis. It needs no complicated infrastructure or sophisticated training; it is exceedingly cheap, highly sensitive and easily adaptable to test serum dilutions (Díaz et al., 2011).
The data recorded in Table (2) and Fig. (1) clarified that the overall frequency of detection of Brucella antibodies in serum samples of feverish patients was 9% where 18 out of 200 samples showed positive agglutination by RBPT.
The recorded result was nearly similar to that recorded by Abdelbaset et al., (2018) (9.43%). In addition, it was higher than recorded by Handa et al. (1998) (3.3 %), Crump et al. (2003) (3.6%) and Abou Eisha (2001) (5.1%). On the other hand, it was extremely higher than that recorded by Assenga et al., (2015) (0.6 %) and El-Monir et al., (2016) (1.25%). On contrary, it was lower than that recorded by Habib et al. (2003) (37.6%), Afifi et al., (2005) (11%), Haggag and Samaha (2007) (14 %), Ciftdogan et al. (2011) (15.2%), Chegeni et al., (2014) (29.5%) and Zolzaya et al., (2014) (27.3%), Tumwine et al., (2015) (17.0 %), Diab et al., (2018) (24.3%) and Ayoub et al., (2019) (18%).
This variation in prevalence of brucellosis in humans in the current work and others may be attributed to different geographic locations, variation in occupational contact and the type of used tests.
As shown in Table (2) and Fig. (1), males patients (14.6%) showed higher detection frequency compared to that of females (4.5%) with statistical significant association between the two frequencies confirming the effect of sex as risk factor in occurring of Brucella infection in human.
The higher prevalence in males agreed with the finding of Kadri et al., (2003) who found that males outnumbered females by a ratio of 3:1, Chegeni et al. (2014) (males, 54.3% and females, 45.7%), Ghoneim et al., (2014) (males, 23.3% and females 17.5%) and Tumwine et al., (2015) who recorded that the prevalence was highest among males (20.5 %). Also, El-Monir et al., (2016) estimated that the incidence rate of human brucellosis at the governorate level was 0.75/100000 population for males and 0.38/100000 population for females.
On contrary, this result disagreed with Crump et al., (2003) who examined 449 patients with prolonged fever and found that 38.7% of patients were females. Also, Habib et al., (2003), Nossair, (2005), Troy et al., (2005) and Zolzaya et al. (2014) found that more women than men were seropositive for brucellosis.
The effect of age on the frequency of detection of Brucella Abs was tabulated in Table (3) and Fig. (2). It clarified that the highest detection rate was observed in age group 45 – 65 years (15.9%) followed by the age group 15 - < 30 years (9.2%) then the age group 30 - < 45 years (5%) with statistical significant association between these frequencies.
This finding disagreed with Abou Eisha, (2001) who reported that the prevalence of Brucella infection increased among the age group 30-39 years and El Mabrouk, (2013) who found that the highest prevalence was found in the age group (30 - <45 years) (7.5 %). On contrast, it disagreed with the results of Nasinyama et al. (2014) who found that there was no association between sero-positivity with age.
The role of occupation in occurrence of Brucella infection was presented in Table (5) and Fig. (4). The highest detection rate was observed in those who informed that they worked in agriculture fields in close association with different farm animals (farmers) with percentage of 23.9% followed by females who informed that they have no work outside the house and reported as house wives (7.3%) followed by those informing that they have works away from animals (Employees) (2.9%).
This finding agreed with that of Meky et al., (2007) who proved that working with animals was significantly associated with the affections and contact with infected animals and their products was the most important method of transmission and Ayoub et al., (2019) who noticed that the highest detection rate of Brucella Abs occurred in individuals with occupational contact (25%).
Frequency of detection of antibodies against Brucella in human serum samples according to type of animal contact was presented in Table (6) and Fig. (5). Higher frequency was observed in patients informed that they have direct animal contact especially with farm animals (12.2%) compared to those with no animal contact (3.9%) with non-significant association between the two frequencies.
This finding agreed with Meky et al., (2007) who proved that contact with infected animals and their products was the most important method of transmission of brucellosis and Tumwine et al., (2015) who found that prevalence of human brucellosis was parallel with animal prevalence. On contrary, it disagreed with El-Monir et al., (2016) who noticed that about the half of the reported human cases with brucellosis in Kafr El Sheikh Governorate had no contact with animals.
Frequency of detection of antibodies against Brucella in human serum samples according to manner of milk consumption was presented in Table (7) and Fig. (8). It clarified non-significant association between the frequencies in patients informed regular milk consumption and those informing irregular consumption where the two frequencies are nearly equal (9.1% vs 8.96%).
The recorded prevalence in those who drank milk even in irregular may confirmed the role that might be played by inefficient heat treated milk or milk products in transmission of brucellosis to man. This was supported by the results of Nasinyama et al., (2014) who found that the seroprevalence of brucellosis among consumers of unpasteurized milk in Kampala Districts was 9%, Ahmetagić et al., (2015) who decided that consumption of unpasteurized dairy products from farms where brucellosis had been already established was an significant risk factor of children brucellosis in Bosnia and Herzegovina, Tumwine et al., (2015) who recorded higher prevalence in those consuming locally processed milk products and Ikeda and Nagamine, (2016) who reported a case study of a man who presented with symptoms of intermittent fever that persisted after returning from a trip to France and he had eaten natural cheese.
Toxoplasma gondii is obligate intracellular protozoan that infect man and wide range of mammals and birds (Urquhart et al., 2003). Toxoplasmosis occurs mostly via ingestion of contaminated undercooked meat or consumption of water and fresh vegetables contaminated with oocysts excreted by infected cats (Fux et al., 2000).
Toxoplasmosis is a widespread disease of both man and different animal species transmitted by many routes to man animals in which T. gondii causes no or unapparent illness causing many hazards to man. So, serological diagnosis is the corner stone in the control of toxoplasmosis among animals and human.
The data presented in Table (9) and Fig. (8) showed that the overall frequency of detection of T. gondii Abs in serum samples of feverish patients was 6% where 12 out of 200 samples showed positive result by ELISA. This result was extremely lower than that recorded by Punda-Polic et al., (2000) (38.1 %), Nissapatron et al., (2003) (39 %), Ghorbal, (2004) (34 %), Luptáková and Petrovová, (2011) (39.9 %) and Sarkar et al., (2012) (49.5 %) and El-Geddawi et al., (2016) (65.3%).
Sex related seropositivity of T. gondii was presented in Table (9) and Fig. (8). It declared that females (6.3%) showed higher detection frequency compared to that of males (5.6%) with statistical significant association between the two frequencies confirming the effect of sex as risk factor in occurring of toxoplasmosis in human.
The effect of age on the frequency of detection of T. gondii Abs was presented in Table (10) and Fig. (9). It clarified that the highest detection rate was observed in age group 15 - < 30 years (7.9%) followed by the age group 45 – 65 years (6.8%) then the age group 30 - < 45 years (3.8%) with statistical significant association between these frequencies.
This result agreed with Samaha et al., (2013) who found that the highest detection rate was observed in the age group (20 - < 40 years) (35.7 %) followed by the age group (< 20 years) (30.3 %) and lastly, the age group (40 - < 60 years) (29.4 %) while it disagreed with Luptáková and Petrovová, (2011) who observed increased rate of infection with increasing age.
According to occupation, the highest frequency was recorded in farmers and houses wives at percentage of 10.9 and 9.1%, respectively then employees (2.9%) with non – significant association between these frequencies (Table, 10 and Fig., 9).
As shown in Table (11) and Fig. (10), statistical analysis of frequencies of detection of IgG against T. gondii according to type of animal contact cleared non-significant association between them although the frequency of detection was higher in patients with non-animal contact (9.1%) compared to those with animal contact (4.1%) that may be attributed to various modes of transmission of toxoplasmosis.
Data recorded in Table (12) and Fig. (11) showed that the frequency of detection of IgG against T. gondii in patients with irregular manner in milk consumption was higher than those with regular milk consumption (6.9 and 3.6 %, respectively) with non-significant association between them.
Toxoplasmosis is a public health concern due to its association with consumption of uncooked meat or unpasteurized milk (Riemann et al., 1975). Milk and meat from intermediate hosts may serve as a potential source for human toxoplasmosis, because of their greater susceptibility to infection (Skinner et al., 1990).
In Egypt, cooking is generally adequate to destroy infectious cysts in tissues, but a possible source of infection is raw milk. Secondly, since cows may become infected by ingestion of contaminated oocysts, the high prevalence of T. gondii in dairy herds suggests that oocysts are widely dispersed in the environment and thus also pose a risk to human health.
The epidemiology of leishmaniasis is extremely diverse, with 12 million people infected worldwide. In the Mediterranean basin, visceral leishmaniasis is caused by Leishmania infantum, known as ‘Mediterranean kala-azar’. The diagnosis of Mediterranean kala-azar is complex and requires detection of parasites in bone marrow smears. Visceral leishmaniasis is a chronic systemic disease that is characterized by persistent pyrexia, weight loss, asthenia, adynamia and anemia, among other clinical manifestations. The disease is fatal when untreated, with death generally occurring 1 to 2 years after the onset of clinical manifestations.
Serological investigation of L. infantum by ELISA in serum samples of patients with FUO was presented in Table (12) and Fig. (11) and clarified that only three samples showed serological reaction with percentage of 1.5 %.
This finding was lower than that recorded by Kejariwal et al., (2001) (5%), Saltoglu et al., (2004) (4.6 %) and Pasic et al., (2006) (37.8%).
As shown in Table (13) and Fig. (12), males’ frequency was higher than that of females (2.24 % vs 0.9%) with non-significant association between them which agreed with Bosilkokvski et al., (2016).
As shown in Table (14) and Fig. (13), the age group impact on the detection rate also showed non-significant association where each age group showed one positive case with percentages of 1.31, 1.25 and 2.27% in different age groups, respectively. Finally, statistical analysis showed that there was no significant association between various occupations and the frequency of detection of L. infantum Abs which agreed with Bosilkokvski et al., (2016).
Boutonneuse fever, also known as Mediterranean spotted fever, is caused by R. conorii and is transmitted by the dog tick. The disease is found in Mediterranean countries between the months of June and September and classically presents with fever, maculopapular rash, and a black eschar at the bite site (Parola et al., 2005).
The recorded data in Table (14) and Fig. (13) showed the serological investigation of R. conorii in serum samples of patients with FUO. It clarified that only three samples showed serological reaction with percentage of 1.5%.
This finding agreed with the finding of Shantaram and Narendra, (2013) who found that there were 2 cases infected by rickettsia (2%) in FUO. On contrary, it was lower than that determined by Raghu et al., (2015) who detected rickettsial antibodies in 14 (23.33%) samples, of which 7 (50%) were positive for scrub typhus, 1 (7.14%) each for spotted fever group and typhus fever group, and 5 (35.71%) for more than one rickettsial illnesses and Ghaoui et al., (2018) who found that 7 out of 55 sera (12.72%) were positive for Rickettsia spp. by IFA; among them 4 cases were diagnosed of MSF caused by R. conorii (7.3%) and Goyal et al. (2018) who studied the incidence of rickettsial infection in 22 patients with FUO and found that 14 patients had positive testing (63.6%).
As shown in Table (15) and Fig. (14), males’ frequency was higher than that of females (2.25 % vs 0.9%) with non-significant association between them. This result agreed with Raghu et al., (2015) who they noticed that seropositivity was higher among male subjects (57.14%) when compared with female subjects (42.86%).
The recorded data in Table (16) and Fig. (15) showed the age group impact on the detection rate also showed non-significant association where age group 15 - < 30 years showed one positive case with percentage of 1.31%, age group 30 -<45 years showed one positive case with percentage of 1.20% and age group 45 – 65 years showed one positive case with percentage of 2.27%. Finally, statistical analysis showed that there was no significant association between various occupations and the frequency of detection of R. conorii Abs. This result agreed with Raghu et al., (2015) who recorded that the maximum positivity (38.46%) was in the 46–60 years age group.