Breast Tuberculosis in Iran: A Comprehensive Review.

ABSTRACT: Tuberculosis (TB) remains a significant global health concern and kills millions of people every year. While TB can affect any organ in the body, breast TB is relatively uncommon. This study presents a comprehensive review of literature spanning 23 years, with a focus on cases of breast TB in Iran. Among the 96 cases found, the majority (89.6%) fell within the age range of 20-60, with a striking prevalence among women (98.9%). Common symptoms included pain and palpable mass, each presenting in approximately 60.4% of cases. Notably, only a quarter of patients had a confirmed history of exposure to a known TB case. Left breast involvement was more prevalent (58.3%), with ipsilateral lymph node enlargement observed in 40.6% of cases. Given the clinical presentation of breast TB, which often leads to misdiagnosis, a significant proportion of cases (68.7%) were diagnosed through excisional biopsy. Following a standard 6-month regimen of anti-TB drugs, relapse occurred in only 4.2% of cases. This study highlights the need for heightened awareness and vigilance in diagnosing breast TB, especially in regions with a high burden. Although breast TB poses diagnostic challenges, with prompt identification and treatment, the prognosis is generally favorable, with a low incidence of relapse.

Implementation of an In-House Platform for Rapid Screening of SARS-CoV-2 Genome Variations.

BACKGROUND: Global real-time monitoring of SARS-CoV-2 variants is crucial to controlling the COVID-19 outbreak. The purpose of this study was to set up a Sanger-based platform for massive SARS-CoV-2 variant tracking in laboratories in low-resource settings. METHODS: We used nested RT-PCR assay, Sanger sequencing and lineage assignment for 930-bp of the SARS-CoV-2 spike gene, which harbors specific variants of concern (VOCs) mutations. We set up our platform by comparing its results with whole genome sequencing (WGS) data on 137 SARS-CoV-2 positive samples. Then, we applied it on 1028 samples from March-September 2021. RESULTS: In total, 125 out of 137 samples showed 91.24% concordance in mutation detection. In lineage assignment, 123 out of 137 samples demonstrated 89.78% concordance, 65 of which were assigned as VOCs and showed 100% concordance. Of 1028 samples screened by our in-house method, 78 distinct mutations were detected. The most common mutations were: S:D614G (21.91%), S:P681R (12.19%), S:L452R (12.15%), S:T478K (12.15%), S:N501Y (8.91%), S:A570D (8.89%), S:P681H (8.89%), S:T716I (8.74%), S:L699I (3.50%) and S:S477N (0.28%). Of 1028 samples, 980 were attributed as VOCs, which include the Delta (B.1.617.2) and Alpha (B.1.1.7) variants. CONCLUSION: Our proposed in-house Sanger-based assay for SARS-CoV-2 lineage assignment is an accessible strategy in countries with poor infrastructure facilities. It can be applied in the rapid tracking of SARS-CoV-2 VOCs in the SARS-CoV-2 pandemic.

Antibiotic use during the first 6 months of COVID-19 pandemic in Iran: A large-scale multi-centre study.

WHAT IS KNOWN AND OBJECTIVE: Although antibiotics are ineffective against viral infections, epidemiological studies have revealed that the COVID-19 pandemic resulted in the overuse of antibiotics and disruption of antimicrobial stewardship programmes. We investigated the pattern of antibiotic use during the first 6 months of the COVID-19 pandemic in Iran. METHODS: A multi-centre retrospective study was designed to investigate the use of 16 broad-spectrum antibiotics in 12 medical centres. The rate of antibiotic use was calculated and reported based on the Defined Daily Dose (DDD) per 100 hospital bed-days. The bacterial co-infection rate was also reported. RESULTS AND DISCUSSION: Totally, 43,791 hospitalized COVID-19 patients were recruited in this study. It was found that 121.6 DDD of antibiotics were used per 100 hospital bed-days, which estimated that each patient received approximately 1.21 DDDs of antibiotics every day. However, the bacterial co-infections were detected only in 14.4% of the cases. A direct correlation was observed between the rate of antibiotic use and mortality (r[142] = 0.237, p = 0.004). The rate of antibiotic consumption was not significantly different between the ICU and non-ICU settings (p = 0.15). WHAT IS NEW AND CONCLUSION: In this study, widespread antibiotic use was detected in the absence of the confirmed bacterial coinfection in COVID-19 patients. This over-consumption of broad-spectrum antibiotics may be associated with increased mortality in hospitalized COVID-19 patients, which can be an alarming finding.

Non-effectiveness of Ivermectin on Inpatients and Outpatients With COVID-19; Results of Two Randomized, Double-Blinded, Placebo-Controlled Clinical Trials.

Background: Ivermectin which was widely considered as a potential treatment for COVID-19, showed uncertain clinical benefit in many clinical trials. Performing large-scale clinical trials to evaluate the effectiveness of this drug in the midst of the pandemic, while difficult, has been urgently needed. Methods: We performed two large multicenter randomized, double-blind, placebo-controlled clinical trials evaluating the effectiveness of ivermectin in treating inpatients and outpatients with COVID-19 infection. The intervention group received ivermectin, 0.4mg/kg of body weight per day for 3 days. In the control group, placebo tablets were used for 3 days. Results: Data for 609 inpatients and 549 outpatients were analyzed. In hospitalized patients, complete recovery was significantly higher in the ivermectin group (37%) compared to placebo group (28%; RR, 1.32 [95% CI, 1.04-1.66]; p-value = 0.02). On the other hand, the length of hospital stay was significantly longer in the ivermectin group with a mean of 7.98 ± 4.4 days compared to the placebo receiving group with a mean of 7.16 ± 3.2 days (RR, 0.80 [95% CI, 0.15-1.45]; p-value = 0.02). In outpatients, the mean duration of fever was significantly shorter (2.02 ± 0.11 days) in the ivermectin group versus (2.41 ± 0.13 days) placebo group with p value = 0.020. On the day seventh of treatment, fever (p-value = 0.040), cough (p-value = 0.019), and weakness (p-value = 0.002) were significantly higher in the placebo group compared to the ivermectin group. Among all outpatients, 7% in ivermectin group and 5% in placebo group needed to be hospitalized (RR, 1.36 [95% CI, 0.65-2.84]; p-value = 0.41). Also, the result of RT-PCR on day five after treatment was negative for 26% of patients in the ivermectin group versus 32% in the placebo group (RR, 0.81 [95% CI, 0.60-1.09]; p-value = 0.16). Conclusion: Our data showed, ivermectin, compared with placebo, did not have a significant potential effect on clinical improvement, reduced admission in ICU, need for invasive ventilation, and death in hospitalized patients; likewise, no evidence was found to support the prescription of ivermectin on recovery, reduced hospitalization and increased negative RT-PCR assay for SARS-CoV-2 5 days after treatment in outpatients. Our findings do not support the use of ivermectin to treat mild to severe forms of COVID-19. Clinical Trial Registration: www.irct.ir IRCT20111224008507N5 and IRCT20111224008507N4.

Multiple Candida strains causing oral infection in COVID-19 patients under corticosteroids and antibiotic therapy: An observational study.

Introduction: The occurrence of oral candidiasis (OC) is expected in patients with COVID-19, especially those with moderate to severe forms of infection who are hospitalized and may be on long-term use of broad-spectrum antibiotics or prolonged corticosteroid therapy. We aimed to characterize clinical conditions, the prevalence profile of Candida species, and outcomes of COVID-19 patients with OC. Methods: In this observational study, oral samples were obtained from COVID-19 patients suspected of OC admitted to Razi teaching hospital. Patients with OC were monitored daily until discharge from the hospital. Species identification was performed by a two-step multiplex assay named YEAST PLEX, which identifies 17 clinically important uncommon to common yeast strains. Results: Among the 4133 patients admitted with COVID-19, 120 (2.90%) suffered from OC. The onset of signs and symptoms of OC in patients was, on average (2.92 ± 3.596 days) with a range (of 1-29 days). The most common OC presentation was white or yellow macules on the buccal surface or the tongue. In (39.16%) of patients suffering from OC multiple Candida strains (with two or more Candida spp.) were identified. The most common Candida species were C. albicans (60.57%), followed by C. glabrata (17.14%), C. tropicalis (11.42%), C. kefyr (10.83%) and C. krusei (3.42%). Notably, OC caused by multiple Candida strains was more predominant in patients under corticosteroid therapy (P <0.0001), broad-spectrum antibiotics therapy (P = 0.028), and those who used nasal corticosteroid spray (P <0.0001). The majority of patients who recovered from OC at the time of discharge were patients with OC by single Candida species (P = 0.049). Discussion: Use of corticosteroids and antimicrobial therapy in COVID-19 patients increases risk of OC by multiple Candida strains.

Disease Waves of SARS-CoV-2 in Iran Closely Mirror Global Pandemic Trends.

BACKGROUND: Complete SARS-CoV-2 genome sequencing in the early phase of the outbreak in Iran showed two independent viral entries. Subsequently, as part of a genome surveillance project, we aimed to characterize the genetic diversity of SARS-CoV-2 in Iran over one year after emerging. METHODS: We provided 319 SARS-CoV-2 whole-genome sequences used to monitor circulating lineages in March 2020-May 2021 time interval. RESULTS: The temporal dynamics of major SARS-CoV-2 clades/lineages circulating in Iran is comparable to the global perspective and represent the 19A clade (B.4) dominating the first disease wave, followed by 20A (B.1.36), 20B (B.1.1.413), 20I (B.1.1.7), leading the second, third and fourth waves, respectively. We observed a mixture of circulating B.1.36, B.1.1.413, B.1.1.7 lineages in winter 2021, paralleled in a fading manner for B.1.36/B.1.1.413 and a growing rise for B.1.1.7, prompting the fourth outbreak. Entry of the Delta variant, leading to the fifth disease wave in summer 2021, was detected in April 2021. This study highlights three lineages as hallmarks of the SARS-CoV-2 outbreak in Iran; B4, dominating early periods of the epidemic, B.1.1.413 (B.1.1 with the combination of [D138Y-S477N-D614G] spike mutations) as a characterizing lineage in Iran, and the co-occurrence of [I100T-L699I] spike mutations in half of B.1.1.7 sequences mediating the fourth peak. It also designates the renowned combination of G and GR clades' mutations as the top recurrent mutations. CONCLUSION: In brief, we provided a real-time and comprehensive picture of the SARS-CoV-2 genetic diversity in Iran and shed light on the SARS-CoV-2 transmission and circulation on the regional scale.

Evaluation of the effect of sofosbuvir and daclatasvir in hospitalized COVID-19 patients: a randomized double-blind clinical trial (DISCOVER).

BACKGROUND: The combination of sofosbuvir and daclatasvir has shown preliminary efficacy for hospitalized patients with COVID-19 in four open-label studies with small sample sizes. This larger trial aimed to assess if the addition of sofosbuvir/daclatasvir to standard care improved clinical outcomes in hospitalized patients with COVID-19. METHODS: This was a placebo-controlled, double-blind, randomized clinical trial in adults hospitalized with COVID-19 at 19 hospitals in Iran. Patients were randomized to oral sofosbuvir/daclatasvir 400/60 mg once-daily or placebo in addition to standard of care. Patients were included if they had positive PCR or diagnostic chest CT, O2 saturation <95% and compatible symptoms. The primary outcome was hospital discharge within 10 days of randomization. Secondary outcomes included mortality and time to clinical events. The trial is registered on the Iran Registry of Clinical Trials under IRCT20200624047908N1. RESULTS: Between July and October 2020, 1083 patients were randomized to either the sofosbuvir/daclatasvir arm (n = 541) or the placebo arm (n = 542). No significant difference was observed in the primary outcome of hospital discharge within 10 days, which was achieved by 415/541 (77%) in the sofosbuvir/daclatasvir arm and 411/542 (76%) in the placebo arm [risk ratio (RR) 1.01, 95% CI 0.95-1.08, P = 0.734]. In-hospital mortality was 60/541 (11%) in the sofosbuvir/daclatasvir arm versus 55/542 (10%) in the placebo arm (RR 1.09, 95% CI 0.77-1.54, P = 0.615). No differences were observed in time to hospital discharge or time to in-hospital mortality. CONCLUSIONS: We observed no significant effect of sofosbuvir/daclatasvir versus placebo on hospital discharge or survival in hospitalized COVID-19 patients.

Side effects and Immunogenicity following administration of the Sputnik V COVID-19 vaccine in health care workers in Iran.

The Sputnik V is a COVID- 19 vaccine developed by the Gamalia institute of epidemiology and microbiology and released on August 11, 2020. We provided independent evidence on side effects and immunogenicity following the administration of the Sputnik V COVID-19 in Iran. In this observational study, the healthcare workers who were vaccinated with the Sputnik V COVID-19 vaccine within February and April 2021 were evaluated. Among a total of 13,435 vaccinated healthcare workers, we received 3236 self-declaration reports of Sputnik V associated adverse events with the mean age 39.32 ± 10.19 years old which 38.8% were men and 61.2% were women. Totally 68.8% of females versus 66.2% of males reported side effects after receiving the first dose and 31.2% of females versus 33.8% of males reported side effects after the second dose of vaccine. The most common side effect was a pain in the injection site (56.9%), fatigue (50.9%), body pain (43.9%), headache (35.7%), fever (32.9%), joint pain (30.3%), chilling (29.8%) and drowsiness (20.3%). Side effects of the vaccine were significantly more frequent in females and younger individuals. Among a total of 238 participants, more than 90% after the first and second dose of vaccine had a detectable level of SARS-CoV-2 RBD antibody and SARS-CoV-2 neutralizing antibody. Although the overall rate of adverse effects was higher than the interim results from randomized controlled trials, our findings support the manufacturer's reports about the high humoral immunogenicity of vaccine against COVID-19.

The efficacy of corticosteroids therapy in patients with moderate to severe SARS-CoV-2 infection: a multicenter, randomized, open-label trial.

BACKGROUND: We performed a multicenter, randomized open-label trial in patients with moderate to severe Covid-19 treated with a range of possible treatment regimens. METHODS: Patients were randomly assigned to one of three regimen groups at a ratio of 1:1:1. The primary outcome of this study was admission to the intensive care unit. Secondary outcomes were intubation, in-hospital mortality, time to clinical recovery, and length of hospital stay (LOS). Between April 13 and August 9, 2020, a total of 336 patients were randomly assigned to receive one of the 3 treatment regimens including group I (hydroxychloroquine stat, prednisolone, azithromycin and naproxen; 120 patients), group II (hydroxychloroquine stat, azithromycin and naproxen; 116 patients), and group III (hydroxychloroquine and lopinavir/ritonavir (116 patients). The mean LOS in patients receiving prednisolone was 5.5 in the modified intention-to-treat (mITT) population and 4.4 days in the per-protocol (PP) population compared with 6.4 days (mITT population) and 5.8 days (PP population) in patients treated with Lopinavir/Ritonavir. RESULTS: The mean LOS was significantly lower in the mITT and PP populations who received prednisolone compared with populations treated with Lopinavir/Ritonavir (p = 0.028; p = 0.0007). We observed no significant differences in the number of deaths, ICU admission, and need for mechanical ventilation between the Modified ITT and per-protocol populations treated with prednisolone and Lopinavir/Ritonavir, although these outcomes were better in the arm treated with prednisolone. The time to clinical recovery was similar in the modified ITT and per-protocol populations treated with prednisolone, lopinavir/ritonavir, and azithromycin (P = 0.335; P = 0.055; p = 0.291; p = 0.098). CONCLUSION: The results of the present study show that therapeutic regimen (regimen I) with low dose prednisolone was superior to other regimens in shortening the length of hospital stay in patients with moderate to severe COVID-19. The steroid sparing effect may be utilized to increase the effectiveness of corticosteroids in the management of diabetic patients by decreasing the dosage.

Evaluation of the efficacy of sofosbuvir plus daclatasvir in combination with ribavirin for hospitalized COVID-19 patients with moderate disease compared with standard care: a single-centre, randomized controlled trial.

BACKGROUND: New therapeutic options are urgently needed to tackle the novel coronavirus disease 2019 (COVID-19). Repurposing existing pharmaceuticals provides an immediate treatment opportunity. We assessed the efficacy of sofosbuvir and daclatasvir with ribavirin for treating patients with COVID-19. METHODS: This was a single-centre, randomized controlled trial in adults with moderate COVID-19 admitted to the Ghaem Shahr Razi Hospital in Mazandaran Province, Iran. Patients were randomly assigned to 400 mg sofosbuvir, 60 mg daclatasvir and 1200 mg ribavirin (intervention group) or to standard care (control group). The primary endpoint of this study was length of hospital stay. This study is registered by IRCT.ir under the ID: IRCT20200328046886N1. RESULTS: Between 20 March 2020 and 8 April 2020, 48 patients were recruited; 24 patients were randomly assigned to the intervention group and 24 to the control group. The median duration of hospital stay was 6 days in both groups (P = 0.398). The number of ICU admissions in the sofosbuvir/daclatasvir/ribavirin group was not significantly lower than the control group (0 versus 4, P = 0.109). There was no difference in the number of deaths between the groups (0 versus 3, P = 0.234). The cumulative incidence of recovery was higher in the sofosbuvir/daclatasvir/ribavirin arm (Gray's P = 0.033). CONCLUSIONS: This randomized trial was too small to make definitive conclusions. There were trends in favour of the sofosbuvir/daclatasvir/ribavirin arm for recovery and lower death rates. However, there was an imbalance in the baseline characteristics between the arms. Larger randomized trials should be conducted to investigate this treatment further.

Clinical features and para-clinical findings of cryptococcal meningitis in the North of Iran during 2011-19.

BACKGROUND AND PURPOSE: Cryptococcal meningitis (CM) is a serious fungal infection that especially affects patients with human immunodeficiency virus (HIV). In this regard, the present retrospective study aimed to analyze the clinical and laboratory features and therapeutic outcomes of patients with CM admitted to two teaching referral centers in the north of Iran during 2011-19. MATERIALS AND METHODS: This study was performed on all the hospitalized patients diagnosed with CM in two therapeutic centers of infectious diseases in the north of Iran. The required data, such as demographic characteristics and clinical and paraclinical features of patients, were extracted and entered in the information forms. Finally, the collected data were analyzed in SPSS software (version 16). RESULTS: For the purpose of the study, records of 12 confirmed CM patients were evaluated in this research. Based on the results, 75% of the patients were male. Moreover, the average age of the subjects was 40.33± 8.93 years old and 66.6% of them (n=8) were HIV-positive. Other underlying diseases among HIV-positive patients included infection with hepatitis C virus (25%) and a history of tuberculosis (25%). In total, three HIV-negative patients suffered from Hodgkin lymphoma (25%), sarcoidosis (25%), and asthma (25%) and one patient (25%) had no underlying disease. Headache (75%), weakness, and fatigue (75%) were the most common symptoms among the participants. The cluster of differentiation 4 (CD4) count in all HIV-positive patients was less than 100 cells/µl. There was no significant difference between symptoms in HIV-positive and HIV-negative patients. Besides, no significant difference was observed between the groups of HIV-positive and HIV-negative patients regarding the period between the onset of symptoms and diagnosis of CM, the length of hospital stay, and the duration of antifungal medication consumption. In total, three patients (25%) expired, and six patients recovered. The CM recurred in two HIV-negative and one HIV-positive subjects; the two HIV-negative patients were treated, while the HIV-positive patient expired due to this recurrence. CONCLUSION: Clinical features and cerebrospinal fluid parameters were not different in HIV-positive and HIV-negative participants. Despite the fact that CM is not common in Iran, due to the increasing number of immunosuppressive patients, the differential diagnosis of CM should be considered for patients with signs and symptoms of infection in the central nervous system.

Cytochrome P450 Genes (CYP2E1 and CYP1A1) Variants and Susceptibility to Chronic Hepatitis B Virus Infection.

Hepatitis B virus (HBV) infection is a worldwide health concern which is associated with significant morbidity and mortality. Both viral and host factors have a significant effect on infection, replication and pathogenesis of HBV. The aim of this study was to investigate the effect of CYP2E1 and CYP1A1 genetic variants on susceptibility to HBV. 143 individuals including 54 chronic HBV patients and 89 healthy controls were enrolled in the genotyping procedure. rs2031920 and rs3813867 at CYP2E1 as well as rs4646421 and rs2198843 at CYP1A1 loci were studied in all subjects using PCR-RFLP (restriction fragment length polymorphism) analysis. Both variants at CYP2E1 locus were monomorphic in all studied subjects. Genotype frequency of rs4646421 was significantly different between chronic HBV patients and healthy blood donors (P = 0.04, OR 4.31; 95% CI 1.04-17.7). Furthermore, individuals carrying at least one C allele (CC or CT genotypes) for rs4646421 seemed to have a decrease risk of hepatitis in comparison with TT genotype (P = 0.039). Our results showed a relationship between rs4646421 TT genotype (rare genotype) and the risk for developing chronic HBV infection (four times higher). Further studies are needed to examine the role of CYP1A1 polymorphism in susceptibility to chronic HBV infection.

Toxoplasmic Encephalitis in an AIDS Patient with Normal CD4 Count: A Case Report.

Toxoplasmic encephalitis is a common presentation of Toxoplasma gondii infection of the central nervous system in the late stage in AIDS patients. A 40 yr old female patient was admitted to Razi Hospital of Qaemshahr City in north of Iran, in Nov 2015, with complaint of headache, blurring of vision, dysarthria and acute left-side hemiplegia and right-side ptosis. Magnetic Resonance Imaging (MRI) was performed with intravenous contrast that showed a ring enhancement lesion in the right basal ganglia showing toxoplasmic encephalitis. Anti-Toxoplasma IgG was positive. HIV antibody test was positive, as well. She was treated successfully with antiparasitic and Anti-HIV drugs and eventually was discharged from hospital. T. gondii infection is commonly detected by serologic tests. Even if in this patient, brain imaging is essential for suitable diagnosis and supervision, its results are not pathognomonic.

Common malignant cutaneous conditions among albinos in Kenya.

Background: Albinos in Africa are at constant risk of developing skin cancer due to the damage caused by ultra-violet exposure. This study identifies the common skin conditions among albinos in Kenya as a country located along the equator. Methods: In this descriptive study on albino patients who were admitted to Mbagathi District Hospital in Nairobi, Kenya the census method was used for sampling and a total of 151 albinos were registered. All necessary data including age, gender, type, site and the number of skin lesions were recorded. Suspected patients with malignant and premalignant lesions were studied individually through skin biopsy and histopathological investigation. Finally, the collected data were analyzed using SPSS software. Results: Albinos with serious skin lesions were 121(80%) patients. Females were 64 (52.9%). The frequency of the following premalignant and malignant skin lesions including actinic-cheilitis, solar elastosis, actinic keratosis (AK), basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) were 17.88%, 11.92%, 37.08%, 7.94% and 5.29%, respectively. Hands (20.52%), face (19.20%), head (18.18%), shoulder (14.56%) and neck (7.94%) were the most affected areas by malignant and premalignant lesions. Conclusions: BCC was the most common type of cutaneous malignancy on the face and shoulders while AK was the most common cutaneous pre-malignancy on the hands and face in albinos in Kenya. Therefore, appropriate physical protection, avoiding any trauma when carrying sharp, heavy or rough instruments by the shoulder and hands, and finally urgent and quality treatment for any lesion even a small erosion and ulcer, especially on exposed areas in albinos, are recommended.

Hepatitis A Is a Health Hazard for Iranian Pilgrims Who Go to Holly Karbala: A Preliminary Report.

BACKGROUND: Iraq is a highly endemic area for the prevalence of hepatitis A and annually hosts a large number of Iranian pilgrims, most of whom are susceptible to infection with the hepatitis A virus (HAV). OBJECTIVES: This study reports the health hazard of hepatitis A for Iranian pilgrims who go to holly Karbala from the Mazandaran province. PATIENTS AND METHODS: In this cross-sectional study, the data of all patients with acute hepatitis A admitted in the Razi teaching hospital from November 23, 2014 to January 24, 2015, with a history of recently returning from holly Karbala or being exposed to Karbala pilgrims, were registered. RESULTS: A total number of nine patients were registered. Seven patients were male and two were female. The mean age was 30.11 ± 10.09.Two patients were from the same family. All patients had typical symptoms of acute hepatitis A. None of the patients died nor did fulminant occur in any patients. In addition, all patients were treated with supportive treatment and subsequently recovered. CONCLUSIONS: This number of pilgrim patients with acute hepatitis A from a single province compels us to conduct more evaluations and follow up monitoring on all persons travelling to Karbala and be sensitive to early diagnoses of the pilgrims. In the future, it is important to be mindful of administering the HAV vaccine and Ig.

Tuberculous Empyema Necessitatis in a 40-Year-Old Immunocompetent Male.

Empyema necessitans (EN) is a kind of empyema that diffuses to extrapleural space and can involve chest pain. Tuberculosis (TB) is the most common cause of EN. This disease can be found in both immunocompromised and immunocompetent individuals but is usually seen in the immunocompromised individuals. Because of long duration and ambiguous symptoms of the disease, diagnosis can be hard. The disease can be treated both medically and surgically. Missing the disease can lead to undesirable effects on patient's condition and health care setting. This problem can be seen in endemic area in which controlling of TB is hard. Report of the disease in local health care center for desirable treatment and health maintenance is necessary. We explained a rare case of pulmonary TB in a patient that was healthy in other fields and just showed the minimum systemic symptoms. The patient came with a mass in lower part of back of chest cage, with a mild pain. The imaging survey showed EN. Smear and Ziehl-Neelsen stains from subcutaneous aspiration were positive for TB. This case showed importance of clinical view and awareness of this silent but serious disease in endemic area especially for TB.

Mindfulness-based Stress Reduction (MBSR) and Its Effects on Psychoimmunological Factors of Chemically Pulmonary Injured Veterans.

Mindfulness-based Stress Reduction (MBSR) is a treatment program for relieving stress and coping with chronic illnesses. In recent three decades, studies have shown that MBSR has a positive effect on physical and psychological dimensions of chronic illnesses. Chemically pulmonary injured veterans have chronic pulmonary and psychological problems due to mustard gas exposure and complications of Iran-Iraq war. These stresses have negative effects on their general health and immune system. To the best of our knowledge, this is the first study conducted on psychoneuroimmunology and MBSR in these patients. Forty male pulmonary injured veterans were randomly divided in two groups with 20 participants (MBSR and wait-list control). Then MBSR group received 8 weekly sessions of intervention. We tested mental health based on general health questionnaire (GHQ)-28 questionnaire, health-related quality of life (based on St. George respiratory questionnaire (SGRQ) ) and immunity in MBSR groups; before and after intervention "mixed factorial analyses of variance" test was used for analyzing data fpr each dependent variable and appropriate t-tests were done in The necessary condition. Results showed that mental health and health- related quality of life, in MBSR group compared to wait-list control improved [F (1,38)=26.46, p<0.001; F (1,38)=49.52, p<0.001 respectively] significantly.  Moreover, a significant increase was reported in the lymphocyte proliferation with phytohemagglutinin (PHA) [F (1,38)=16.24, p<0.001], and peripheral blood IL-17 [F (1,38)=56.71, p<0.001] However, lymphocyte (CD4+, CD8+, and NK-cell) percentages were not affected significantly [F (1,38)=2.21, p=0.14] ,[F (1,38)=0.90, p=0.78] and [F (1,38)=1.79, p=0.18], respectively. This study suggests that MBSR may be a new treatment approach for improving immunity and overall health in chemically pulmonary injured veterans.

First Autochthonous Coinfected Anthrax in an Immunocompetent Patient.

Cutaneous anthrax has a mortality rate of 20% if no antibacterial treatment is applied. The clinical manifestations of cutaneous anthrax are obviously striking, but coinfection may produce atypical lesions and mask the clinical manifestations and proper laboratory diagnosis. Anthrax is known to be more common in the Middle East and Iran is one of the countries in which the zoonotic form of anthrax may still be encountered. We report a case of a 19-years-old male who used to apply Venetian ceruse on his skin. Venetian ceruse (also known as Spirits of Saturn) is an old cosmetic product used for skin whitening traditionally made from sheep's spinal cord. The patient referred to the Referral Laboratory, Mazandaran University of Medical Sciences, Sari, Iran, with atypical dermatosis, pronounced pain, and oedema of the affected tissue. It was confirmed by both conventional and molecular analysis that culture was a mixture of Bacillus anthracis and Trichophyton interdigitale. The patient was initially treated with ceftriaxone (1000 mg/day for two weeks), gentamicin (1.5-2 mg/kg/day), terbinafine (200 mg/week for one month), and 1% clotrimazole cream (5 weeks) two times per day which resulted in gradual improvement. No relapse could be detected after one-year follow-up. Anthrax infection might present a broader spectrum of symptoms than expected by clinicians. These unfamiliar characteristics may lead to delayed diagnosis, inadequate treatment, and higher mortality rate. Clinicians need to be aware of this issue in order to have successful management over this infection.

Types, Risk Factors, Clinical symptoms and Diagnostic Tests of Acute Adult Meningitis in Northern Iran During 2006-2012.

BACKGROUND: Acute bacterial meningitis is a medical emergency condition that requires prompt diagnosis and treatment and otherwise associated with serious morbidity and mortality. AIM: The aim of this study was to assess types, risk factors, clinical symptoms and diagnostic tests of meningitis in hospitalized patients of Mazandaran University of medical sciences hospitals during 2006-2012. MATHERIALS AND METHODS: This is a retrospective descriptive study. Following approval of the ethics committee of Mazandaran University of Medical Sciences, records of adult patients diagnosed with acute meningitis from 2006 to 2012 were extracted from Mazandaran Provincial Health Center and patients attending hospitals affiliated to Mazandaran University of Medical Sciences. STATISTICAL ANALYSIS: Data were analyzed with SPSS-16 using descriptive statistics (frequency, mean, standard deviation, and median). RESULTS: In this study, of the 137 patients with meningitis, 73 (53.9%) were viral, 61 (46%) bacterial, 1 (0.7%) fungal, and 2 (1.4%) unknown. The majority of risk factors in patients were head trauma, upper respiratory infection, and drug addiction. The most common clinical signs were headache, fever, nausea and vomiting, and stiff neck. CONCLUSION: In this study, the incidence of meningitis was much lower than any other country. It could be due to geographic variation or incomplete recording of patient's data. It is recommended to perform a longitudinal study during the coming years on patients with meningitis.

Minimal inhibitory concentration of microorganisms causing surgical site infection in referral hospitals in North of Iran, 2011-2012.

BACKGROUND: A surgical site infection (SSI) is the most common nosocomial infection after surgery and is the third most common infection in hospitalized patients. The aim of this study was to asses minimum inhibitory concentration (MIC) of the causing agents of SSI and antimicrobial susceptibility patterns. METHODS: This cross-sectional study was done in three referral hospitals in North of Iran during 2011-2012. The samples were taken one month after orthopedic, abdominal, cesarean section surgery and coronary artery bypass graft (CABG) in patients with scores compatible to SSIs criteria. The sample was sent for bacteriologic culture and MIC determination for positive cases by broth microdilution method. The data were collected and analyzed. RESULTS: From 103 positive cases S. aureus, E.coli and coagulase negative staphylococci were the most common isolated agents as 29.12%, 23.3% and 21.3%, respectively. S. aureus was sensitive to vancomycin (70%), amikacin (70%) and teicoplanin (76.6%) and cogulase negative staphylococci was sensitive to vancomycin (68.1%) and teicoplanin (72.6%) and E.coli to amikacin (95.83%) and imipenem and meropenem (66.66%). P.aeroginosa showed no sensitivity to cefepime and was sensitive to imipenem (93.75%) and meropenem (81.25%). CONCLUSION: The most important point is worrisome problem of the increased MIC of S. aureus to vancomycin that causes difficult use in the treatment of staphylococcal SSIs. In spite of resistance of micro-organisms to cephalosporins, gram negative organisms had low MIC to carbapenemes especially P.aeroginosa although the rate of its MIC is increasing.