Peripheral lymphadenopathy: approach and diagnostic tools

Peripheral lymph nodes, located deep in the subcutaneous tissue, clean antigens from the extracellular fluid. Generally, a normal sized lymph node is less than one cm in diameter. Peripheral lymphadenopathy [LAP] is frequently due to a local or systemic, benign, self-limited, infectious disease. However, it could be a manifestation of underlying malignancy. Seventy-five percent of all LAPs are localized, with more than 50% being seen in the head and neck area. LAP may be localized or generalized. Cervical lymph nodes are involved more often than the other lymphatic regions. Generally, it is due to infections, but most of the supraclavicular lymphadenopathies are associated with malignancy. Based on different geographical areas, the etiology is various. For example, in tropical areas, tuberculosis [TB] is a main benign cause of LAP in adults and children. Complete history taking and physical examination are mandatory for diagnosis; however, laboratory tests, imaging diagnostic methods, and tissue samplings are the next steps. Tissue diagnosis by fine needle aspiration biopsy or excisional biopsy is the gold standard evaluation for LAP. We concluded that in patients with peripheral LAP, the patient's age and environmental exposures along with a careful history taking and physical examination can help the physician to request step by step further work-up when required, including laboratory tests, imaging modalities, and tissue diagnosis, to reach an appropriate diagnosis

An active serological survey of antibodies to newcastle disease and avian influenza (H9N2) viruses in the unvaccinated backyard poultry in Bushehr province,Iran, 2012-2013

<p><b>OBJECTIVE</b>To test the antibodies against newcastle disease virus (NDV) and avian influenza virus (AIV, H9N2) in the unvaccinated backyard poultry in Bushehr province, Iran from 2012 to 2013.</p><p><b>METHODS</b>A total of 1 530 blood samples from unvaccinated backyard chickens in Bushehr province, south of Iran, were tested for antibodies against NDV and AIV (H9N2) by hemagglutination inhibition test according to International Epizootic Office (OIE) recommendation.</p><p><b>RESULTS</b>Of these, 614 (40.13%) and 595 (39.00%) were positive for NDV and AIV (H9N2) respectively.</p><p><b>CONCLUSIONS</b>The findings of the present study indicated that NDV and AIV (H9N2) were endemic and widely distributed in backyard areas of Bushehr province which should be incorporated in the control strategies. Further studies are needed to identify the circulating virus genotypes, model their transmission risk, provide adapted control measures and design proper and applicable vaccination program.</p>

[Isolation and identification of Nocardia asteroids complex isolated from thigh abscess in a patient with Behcet's syndrome: the first report from Iran]

Nocardia species are Gram-positive, partially acid fast, non-motile, cata-lase positive, aerobic and saprophytic actinomycetes found all around the world. They invade the human body from the environment via trauma and respiratory tract and cause cutaneous, pulmonary and systemic diseases. They are able to grow in various media.The organisms opportunistically infect both immunocompromised and immuno-competent individuals. Behcet's disease is an autoimmune disease and immunocompromised patient which may suitable host for Nocardia bacterium. The present study is the first case report of isolation of Nocardia from the thigh abscess in a patient with behcet's disease from Iran. A 39-year-old man with Behcet's disease in August 2011 was admitted to Shariati hospital Tehran, with swelling and pain in the left flank and left thigh. Microscopic identification from direct microbiological slide of thigh abscess discharge demonstrated number of lymphocytes, neutrophils and macrophages foamy and white blood cells together with filamentous bacteria. Further microbiological characterization using phenotypic and antibiogram tests with disk diffusion method, demonstrated that the isolated bacterium is Nocardia asteroides complex. The bacteria were sensitive to ampicillin, vancomycin, ceftriaxone, amikacin and cotrimoxazole but it was resistant to clindamycin, erythromycin, penicillin G, cephalothin and gentamicin. The patient was treated with cotrimoxazole. Because of the high incidence and high mortality of Nocardia infection in immunocompromised cases, rapid detection and timely treatment for these patients is necessary

Thyroid synovial sarcoma: a case report

Sarcomas are rare tumors account for about 1% of cancers in adult. Soft tissue sarcomas are the most common one. Synovial sarcoma's incident is about 10% of all sarcomas and most commonly rise from para-articular regions in young adults. Based on our knowledge there have been only two reports of thyroid synovial sarcoma in medical literature. We report a 44-year old woman presented with a rapid growing neck mass. The pathology report revealed sarcoma and the immunohistochemistry [IHC] was compatible with synovial sarcoma. It could be understood that synovial sarcoma can be found in various tissues even if there is no synovial cells

Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful

Background: Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy

Methods: In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct [CBD] exploration according to our center's protocol. Endoscopic retrograde cholangiopancreatography [ERCP] was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube inser-tion without routine intraoperative cholangiography [IOC]

Results: We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 [87.2%] patients. A total of 186 [12.8%] underwent surgery. Of these, 82 [45.2%] had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 [44.1%] patients and choledochojejunostomy was performed in 20 [10.8%]. Retained stones were found only in 4 cases which were treated by ERCP

Conclusion: ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions

rare case report of appendix and cecum in the sac of left inguinal hernia [left Amyand's hernia]

This case is a rare aspect of left inguinal hernia. The patient was a 60-years old man with left scrotal mass since childhood. In the operating room, the hernia sac was opened which included cecum and appendix that is called left Amyand's hernia. The patient underwent herniorrhaphy with Lichtenstein repair

Evaluation of supporting role of early enteral feeding via tube jejunostomy following resection of upper gastrointestinal tract

Today, early diagnosis of upper gastrointestinal [GI] tract malignancies and their surgical resection is becoming more feasible. One of the important side effects in upper GI tract malignancies is malnutrition which has direct relationship with postoperative complications. Nonetheless, there is no easy regimen of nutrition for these patients especially for the first week after operation. Accordingly we present a simple method for improving feeding such patients via tube jejunostomy. The aim of this study was to investigate the impact of early enteral feeding [EEF] on postoperative course after complete resection of upper gastrointestinal tract malignancy and reconstruction. Between September 2005 to September 2008, 60 consecutive patients [22 female, 38 male] with upper GI tract malignancies who had undergone complete resection and reconstruction enrolled in this study. The patients randomly divided equally in two groups of control and EEF. Control group was treated with traditional management of nil by mouth and intravenous fluids for the first five postoperative days and then with liquids and enteral regular diet when tolerated. In EEF group the patients were fed by tube jejunostomy from 1[st] postoperative day and assessed for nutritional status before surgery and 5 days after surgery. Both groups were monitored on the basis of weight gain, clinical and paraclinical parameters and postoperative complications. Sixty patients were randomly divided to two equal groups. Surgical procedures were similar in two groups and no significant difference in demographic and basic nutritional status were found. On 5[th] postoperative day serum albumin was 4.2 +/- 0.4 g/dl in EEF and 3.6 +/- 0.3 g/dl in control group [p= 0.041]. Also serum transferrin was 260.8 +/- 2.5 mg/dl and 208 +/- 1.8 mg/dl in EEF and control group respectively [p<0.001]. Moreover, hospital stay was shorter in EEF group [7.7 +/- 3.1 vs. 14 +/- 2.5 days, p=0.009].There were four [13.3%] anasatomotic leakages in control group and one [3.3%] in EEF group [p=0.353]. Also there was six [20%] wound infection in control group and three [10%] in EEF group [p=0.472]. The EEF by tube jejunostomy can be an effective method of feeding patients in postoperative days of resection of GI malignancies. Postoperative hospital stay would be shorter and the level of laboratory parameters especially serum transferrin is higher in EEF in comparison with control group. It also may reduce postoperative complications such as wound infection and enterocutaneous fistula

Case report of a perforated appendix in the sac of inguinal hernia [Amyand's Hernia]

This case is a rare aspect of inguinal hernia. The patient was admitted with a 10-day pain of right groin and a past history of an inguinal hernia which was irreducible at the time of admission. In the operating room, the hernia sac was opened which included a perforated and gangrenous appendix that is called Amy and' s hernia. The patient underwent appendectomy and herniorrhaphy at the same operation

Isolated primary hydatid disease of omentum; report of a case and review of the literature

Hydatid disease, most commonly caused by the larval stage of Echinococcus granulosus, affects mainly human liver and lung, and rarely other parts of the body. It is prevalent in most sheep-raising Mediterranean Countries including Iran. Peritoneal hydatid cyst, either primary or secondary, represents an uncommon but significant manifestation of the disease. The present case report describes a case of primary isolated hydatid disease of omentum, which to our knowledge constitutes the first case of this kind in Iran

Effect of incisional site infiltration of Bupivacaine on postoperative pain and meperidine consumption after midline laparotomy

The purpose of the current study was to determine whether infiltration of bupivacaine in the incision site of midline laparotomy reduces postoperative pain and opioid consumption. Fifty-six, 30-60 year-old patients who were undergoing midline laparotomy were enrolled in the present study. The patients were randomly assigned into two groups of control [group C, n = 28] or bupivacaine [group B, n= 28]. Just before suturing, the incision sites were infiltrated by 20 ml epineprinated bupivacaine 0.25% [group B] or 20 ml normal saline as placebo [group C]. The patients were asked to score their pain at 6, 24, and 48 hours after surgery. Demographic characteristics of the patients were similar in the two groups. There was no significant difference in the mean of visual analogue scale pain scores measured over time between the two groups. There was a significant difference in post operative meperidine consumption between the two groups, and in the bupivacaine group, meperidine request was less [90.53 +/- 13.36 mg in bupivacaine group v127.5 +/- 23.14 mg in the control group, P < 0.05]. After midline laparotomy, incisional site infiltration with 20 ml epineprinated bupivacaine 0.25% causes a significant decrease in postoperative meperidine consumption

Post-thoracotomy pain and pulmonary function - comparison of intermittent intercostal- bupivacaine vs intravenous pethidine

In a prospective, observer-blind study, 50 patients scheduled for posterolateral thoracotomy were investigated to compare the effects of intermittent intercostal extrapleural bupivacaine [n= 25] and intravenous pethidine [n = 25] on post-thoracotomy pain and pulmonary function. The severity of chest pain [objectified by the use 5- point scale of Prince Henry] and changes in spirometric values [forced vital capacity [FVC], forced expired volume in 1 s [FEV1] and FEV1/FVC] were monitored during the first three postoperative days. Because intravenous pethidine was used to supplement pain relief in the patients who received intercostal analgesia, total pethidine used was compared to that administered to patients in the intravenous pethidine group. There were no statistical significant differences regarding patient demographics in both groups. No complications occurred. There was no significant difference between mean pain scores in the first postoperative day, but in the second and third postoperative days and also in the whole first 72 post-operative hours, pain scores were significantly higher in the intravenous group than the intercostal group. The postoperative decrease in FVC and FEVI was significantly less with intercostal bupivacaine compared with the intravenous pethidine. There was no significant intergroup difference in the post-to pre-operative FEVI/FVC ratio. The total amount of the pethidine received by the patients was significantly higher in the intravenous group than the intercostal group. Intermittent intercostal nerve block with bupivacaine appears to be a promising, safe and reliable technique in the management of post-thoracotomy pain. Use of intercostal bupivacaine could significantly reduce or even eliminate the postoperative need for systemic narcotics

Post-thoracotomy analgesia comparison epidural fentanyl to intravenous pethidine

To evaluate the efficacy of post-thoracotomy analgesia with intermittent epidural fentanyl. 50 patients were allocated randomly into 2 groups. The first group received intermittent epidural fentanyl and the second group received intermittent intravenous analgesia using pethidine. The variables studied were: pain score; total amount of additional intravenous opioid analgesia, and ventilatory function parameters [forced vital capacity [FVC], forced expiratory volume in the first second [FEV[1]] and FEV[1]/FVC ratio]. In the first postoperative day, pain scores were higher in the epidural group [P = 0.034], but there was no significant difference between mean pain scores in the second and third days [P = 0.61, P = 0.15, respectively]. On all three days, significantly more additional analgesics were required in the epidural group. A difference was found between both groups in the post- to pre-operative FEV[1], FVC and FEV[1]/FVC ratios, with the better preservation of the ventilatory function in the epidural group [P= 0.001, 0.013, O.0001, respectively]. The analgesic effect of intermittent epidural fentanyl is not adequate, and postoperative pain relief has not any significant advantage over the more easily-applied intravenous analgesia. However, better preservation of ventilatory function makes epidural fentanyl a useful adjunct analgesia in reduction of post-thoracotomy pulmonary complications