A 53-Year-Old Man with Intermittent Colicky Abdominal Pain due to Fasciola Incarceration in Common Bile Duct: A Case Report.

Fascioliasis is a zoonotic disease caused by liver flukes of the genus Fasciola, as F. hepatica, and F. gigantica, mainly affecting the liver and biliary system during the chronic phase. These trematodes migrate through biliary ducts results in mild inflammation, when it is difficult to distinguish from obstructive lesions. Here we describe a 53-yr-old man from Golpayegan, a city in Isfahan Province, Iran, in year 2015, with occasional fever and chills, and also frequent colicky abdominal pain mainly on the right upper quadrant, with tenderness at that part. There was no jaundice and elevated bilirubin, but increased alkaline phosphatase was detected. Dilated common bile duct on abdominal sonography, without any visible lesion at its end and also dilated intra- and extrahepatic biliary ducts on abdominal CT-scan were seen. Endoscopic Retrograde Cholangiopancreatography (ERCP) detected incarceration of parasites behind Oddi's sphincter and also in common bile duct and serologic test (ELISA) confirmed fascioliasis. However, Iran is one of the most affected countries by Fasciola, being aware of rare symptoms and presentations of this disease can aid the physicians to make timely and accurate diagnosis and therefore reduce the consequent morbidities.

Aspergillus terreus-related ureteral obstruction in a diabetic patient.

An Aspergillus fungal ball is a rare cause of ureteral obstruction attributed to indwelling catheters, stents, antibiotics, anastomotic leaks, obstruction, and immunosuppressive therapy and other immunocompromised states. We describe a case of unilateral ureteral obstruction caused by Aspergillus terreus following ureteroscopic lithotripsy and ureteral stenting in a 45-year-old diabetic man. The patient was successfully treated with endoscopic removal of the fungal mass and oral voriconazole. We also review briefly the clinical features, treatment, and outcome in 9 previously reported diabetic patients with ureteral obstruction due to aspergillosis. Obstructive uropathy related to Aspergillus mass may be suspected in diabetic patients with a history of manipulation, impaired kidney function, and persistent passage of a soft mass in urine. Direct microscopy and culture of multiple urine and ureteral washing are necessary for early diagnosis. Antifungal therapy and endoscopic removal of the mass are needed to reduce morbidity.

Genetic characterization of ESBL producing strains of Klebsiella pneumoniae from Tehran hospitals.

INTRODUCTION: This study was conducted to determine the genetic characterization of extended-spectrum beta-lactamase (ESBL) producing strains of Klebsiella  pneumoniae isolated from Iranian patients in hospitals in Tehran. METHODOLOGY: Antibiotic susceptibility of 104 isolates was determined using the disk diffusion test. The Minimum Inhibitory Concentrations (MICs) of imipenem and meropenem were determined for isolates showing reduced susceptibility to carbapenems. The phenotypic confirmatory test (PCT) was used to screen the isolates for ESBL production. PCR was used to detect blaSHV, blaTEM and blaCTX-M and the amplicons from selected clones were sequenced. Isolates producing ESBLs were analyzed by pulsed-field gel electrophoresis (PFGE). RESULTS:   One isolate showed resistance to imipenem (MIC = 16 µg/ml). Resistance to amikacin and ciprofloxacin was 44.2% and 25.0%, respectively. ESBL production was detected in 72.1% (n = 75) of isolates. The prevalence of blaSHV, blaTEM and blaCTX-M genes among the isolates was 55.7% (n = 58), 30.7% (n = 32) and 45.2% (n = 47), respectively. The sequencing revealed the amplicons corresponding to bla (TEM-1, TEM-79, SHV-1, SHV-12, SHV-31, CTX-M-15) genes. While the blaCTX-M-15 is the dominant gene among the Iranian isolates, we detected the blaSHV-31 and blaTEM-79 genes for the first time in the country.  PFGE differentiated the 71 ESBL-producing isolates into 62 different genotypes. Clonal dissemination of ESBLs was found in the neonatal intensive care unit and intensive care unit of one hospital. CONCLUSION: The findings are evidence of the spread of multi-resistant clones of ESBL producers in Tehran hospitals.

Antibiotic-resistance patterns and frequency of extended-spectrum beta-lactamase-producing isolates of Klebsiella pneumoniae in Tehran.

BACKGROUND: Extended-spectrum beta-lactamase (ESBL)-producing strains of Klebsiella pneumoniae have caused major therapeutic problems worldwide since the majority are resistant to various antibiotics. In this study, an investigation was conducted regarding antibiotic-resistant patterns of 128 isolates of K pneumonile cultured from Iranian patients at two teaching hospitals during 2004-2005. MATERIAL/METHODS: The susceptibility of isolates to 21 antimicrobial agents was determined using the disk diffusion method. Disks containing ceftazidime, cefotaxime, ceftazidime/clavulanic acid, and cefotaxime/clavulanic acid were used in the phenotypic confirmatory (PCT) method to detect ESBL isolates. A comparison between the confirmatory method and double-disk synergy test (aztreonam, ceftazidime, ceftriaxone, cefotaxime, and amoxicillin/clavulanic acid) was also made to assign the appropriate method of detection for ESBLs. The E-test was used to determine the susceptibility of isolates to cefepime. RESULTS: All strains were susceptible to imipenem and meropenem. Resistance to ciprofloxacin and gentamicin were found in 37% (n=47) and 33% (n=42) of isolates, respectively. Production of ESBL was detected in 44.5% of isolates. Resistance to cefepime was found in 40% of isolates. CONCLUSIONS: The prevalence of ESBL strains in the study hospitals is high. The double-disk synergy method is not preferable in successfully detecting ESBL strains. More importantly, 33% of ESBL strains were also resistant to ciprofloxacin and aminoglycosides. Based on the laboratory results, it is recommended that prescription of cephalosporins be restricted to susceptible isolates and that the usage of other effective antibiotics be considered.

Randomized trial of a single, double and triple dose of 10 mg/kg of a human formulation of triclabendazole in patients with fascioliasis.

1. A study performed > 10 years ago and case reports published recently suggest that triclabendazole is effective for the treatment of patients with fascioliasis. 2. To confirm the efficacy of a human formulation of triclabendazole, we enrolled 165 patients into the present study and divided the subjects into two groups: (i) those who had fascioliasis, as evidenced by the presence of ova in their stools; and (ii) patients with clinical and laboratory data suggesting fascioliasis. 3. Patients were randomly allocated to receive 10 mg/kg, p.o., triclabendazole for 1, 2 or 3 days (single-, double- and triple-dose groups, respectively). Medical history and physical and laboratory examinations were performed at baseline and at 7, 14, 30 and 60 days after treatment. Results were based on 152 patients who completed the study. 4. A sharp decrease in the proportion of clinical signs and symptoms was observed in all groups immediately after treatment. Ova disappeared from the stools of all patients in the single- and double-dose groups. Thirty days after treatment, ova were identified in the stools of two patients in the triple-dose group who received a second course of triclabendazole. 5. All cases were cured on day 60. However, the cure rate was lower when the patients with suggestive fascioliasis were included in the analysis. The cure rate was not significantly different (P > 0.05) among the three dose groups. No cases of toxic hepatitis were observed. 6. In conclusion, oral administration of 10 mg/kg of the human pharmaceutical preparation of triclabendazole for 1-3 days is safe and effective in the treatment of human fascioliasis.