Periodic fever: a review on clinical, management and guideline for Iranian patients - part I

Periodic fever syndromes are a group of diseases characterized by episodes of fever with healthy intervals between febrile episodes. The first manifestation of these disorders are present in childhood and adolescence, but infrequently it may be presented in young and middle ages. Genetic base has been known for all types of periodic fever syndromes except periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis [PFAPA]. Common periodic fever disorders are Familial Mediterranean fever [FMF] and PFAPA. In each patient with periodic fever, acquired infection with chronic and periodic nature should be ruled out. It depends on epidemiology of infectious diseases. Some of them such as Familial Mediterranean fever and PFAPA are common in Iran. In Iran and other Middle East countries, brucellosis, malaria and infectious mononucleosis should be considered in differential diagnosis of periodic fever disorders especially with fever and arthritis manifestation. In children, urinary tract infection may be presented as periodic disorder, urine analysis and culture is necessary in each child with periodic symptoms. Some malignancies such as leukemia and tumoral lesions should be excluded in patients with periodic syndrome and weight loss in any age. After excluding infection, malignancy and cyclic neutropenia, FMF and PFAPA are the most common periodic fever disorders. Similar to other countries, Hyper IgD, Chronic Infantile Neurologic Cutaneous and Articular, TRAPS and other auto-inflammatory syndromes are rare causes of periodic fever in Iranian system registry. In part 1 of this paper we reviewed the prevalence of FMF and PFAPA in Iran. In part 2, some uncommon auto-inflammatory disorders such as TRAPS, Hyper IgD sydrome and cryopyrin associated periodic syndromes will be reviewed

Periodic fever: a review on clinical, management and guideline for Iranian patients - part II

Periodic fever syndromes are a group of diseases characterized by episodes of fever with healthy intervals between febrile episodes. In the first part of this paper, we presented a guideline for approaching patients with periodic fever and reviewed two common disorders with periodic fever in Iranian patients including familial Mediterranean fever [FMF] and periodic fever syndromes except for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis [PFAPA]. In this part, we review other autoinflammatory disorders including hyper IgD, tumor necrosis factor receptor-associated periodic syndrome [TRAPS], cryopyrin associated periodic syndromes, autoinflammatory bone disorders and some other rare autoinflammatory disorders such as Sweet's and Blau syndromes. In cryopyrin associated periodic syndromes group, we discussed chronic infantile neurologic cutaneous and articular [CINCA] syndrome, Muckle-Wells syndrome and familial cold autoinflammatory syndrome. Autoinflammatory bone disorders are categorized to monogenic disorders such as pyogenic arthritis, pyoderma ;gangraenosum and acne [PAPA] syndrome, the deficiency of interleukine-1 receptor antagonist [DIRA] and Majeed syndrome and polygenic background or sporadic group such as chronic recurrent multifocal osteomyelitis [CRMO] or synovitis, acne, pustulosis, hyperostosis and osteitis [SAPHO] syndrome are classified in sporadic group. Other autoinflammatory syndromes are rare causes of periodic fever in Iranian system registry

[Tuberculosis of spine as the first clinical presentation of multiple myeloma: a case report]

Patients with hematologic malignancies are at risk of advanced tuberculosis. The prevalence of tuberculosis between these patients is 2.1-2.6 percent. The cellular immune deficiency caused by hematologic malignancies and or its treatment increases the risk of tuberculosis in these patients. Multiple Myeloma is malignant proliferations of plasma cells that involves different classes of immune system. Cellular and humeral immune deficiency due to the Multiple Myeloma and drugs for its treatment results in susceptibility to unusual infections. Infections are of the important factors of morbidity and mortality in patients suffering from multiple myeloma, but coincidence of Multiple Myeloma and tuberculosis is rare and very little has been reported. In this paper a 60-year-old woman from Kermanshah, Iran who is suffering from back pain, weight loss, weakness and sweating will be introduced. Spondylitis was seen in her lumbar imaging. Her husband suffered from pulmonary tuberculosis. In diagnostic studies tuberculose spondylitis and multiple myeloma were diagnosed simultaneously. Although the accompanying of Multiple Myeloma and tuberculosis is not common, but immunodeficiency caused by a hematologic malignancy as well as a history of close contact with a patient with tuberculosis resulted in tuberculosis of spine in this patient. Clinical features of abovementioned diseases are very similar. But in endemic area for tuberculosis, this disease should be considered because delay in diagnosis leads to increment in mortality and morbidities. Diagnosis of tuberculos spondylitis is based on radiologic and histologic features of the disease and on the response to treatment because the sensitivity of definitive diagnostic tests such as culture and PCR is low in extra pulmonary tuberculosis.

Effect of door-to-antibiotic time on mortality of patients with sepsis in emergency department: a prospective cohort study

Sepsis constitutes an important cause of hospital admission with a high mortality rate. Appropriate antibiotic therapy is the cornerstone of therapy in patients with sepsis. Although numerous studies have recommended early antibiotic initiation in severe sepsis or septic shock stages of sepsis syndrome, its role in treatment of patients with sepsis who have not entered these stages remains to be investigated. The purpose of this study is to investigate the effect of door-to-antibiotic time in sepsis patients with various degrees of severity. This is a longitudinal prospective cohort study on adult patients admitted with sepsis to the emergency department. Sepsis was defined as presence of at least two criteria of systemic inflammatory response syndrome and procalcitonin levels >/= 2 micro g/l. Severity of sepsis was determined using the APACHE II [Acute Physiology and Chronic Health Evaluation II] scoring system. Time to antibiotic administration was recorded and its relationship with mortality was assessed. A total of 145 patients were eligible for enrollment. The mean age was 60.4 years and the mean APACHE score was 13.7. The overall in-hospital mortality was 21.4%, and the mean length of stay in hospital was 211.9 hours. The mean door-to-antibiotic time for our patients was 104.4 minutes. Antibiotic administration time and mortality in patients with APACHE scores of 21 or higher [P=0.05] were significantly related; whereas such a relationship was not observed for patients with APACHE scores of 11- 20 [P=0.46]. We observed early antibiotic initiation for patients in sepsis phase with higher severity scores was associated with significant improvement in survival rate

Prevalence of fungal skin infections in Iranian wrestlers

Fungal infections are one of the most common skin infections. Athletes, especially in contact sports such as wrestlers are the group at risk of fungal skin infections [FSI]. The aim of this study was to determine prevalence of FSI and some effective factors in wrestlers in Tehran, Iran. This study was a cross-sectional descriptive study which was conducted in 2009 and subjects were wrestlers of wrestling clubs of Tehran, Iran. In this study the prevalence of FSI and its related factors was collected based on clinical history, physical examination and laboratory tests. We also determined the rate of dermatophytic contamination of wrestling mats. The relationship between independent variables and incidence of fungal infection analyzed by Chi square test and regression analysis. In this study, out of 454 wrestlers, 111 [24.5%] subjects had suspicious fungal skin lesions on physical examination. The Prevalence of FSI was 8.2% in all of the wrestlers [34.2% of the wrestlers with suspicious lesion]. Malassezia furfur [50%] and trichophyton tonsurans [30%] were the most common causative agents. Epidermophyton floccosum [7.5%], Trichophyton rubrum [5%], Candida albicans [5%] and Trichophyton mentagrophytes [2.5%] were other isolated fungi. Eleven wrestling mats [44%] were contaminated with different fungal organisms. The prevalence of fungal skin infection in Iranian wrestlers is relatively high. Appropriate preventive measures need to be prepared and implemented to reduce incidence of FSI in wrestlers

Diagnosis of latent tuberculosis infection in candidates for kidney transplantation [comparison of two tests]

It is assumed that about 10% of individuals infected with Mycobacterium tuberculosis develop tuberculosis. The rate of tuberculosis in solid organ transplant recipients has been estimated to be 50-fold higher than in the general population. Candidates for solid organ transplantation are routinely screened for latent tuberculosis infection [LTBI]. In this study we aimed to compare Tuberculin Skin Test [TST] with QuantiFERON-TB Gold In-Tube [QFT] for the detection of LTBI in candidate for kidney transplantation. Between October 2009 and November 2010, 64 candidates for kidney transplant who referred to the transplant clinic in Imam Khomeini Hospital, were enrolled in the study. Patients were screened for LTBI with both QFT and TST. Concordance between two test results and variables associated with test discordance were assessed. The mean age of patients was 38.5 years [range 16-65]; female/male ratio was 26/38. Positive results were found in 21.9% and 21.9%, by TST and QFT, respectively. Four patients [6.3%] had indeterminate QFT. Overall agreement between QFT and TST was 75% [k=0.28 and P=0.028]. BCG vaccination and past positive TST were not associated with positive QFT result [P=0.13 and P=0.09 respectively]. Overall agreement between test results was fair. Comparison among test results showed that TST and QFT can be used interchangeably for latent TB screening in kidney transplant candidates. The decision to select QFT or TST will depend on the purpose of testing and resource availability