Idiopathic granulomatous mastitis: A case report and literature review.

Key Clinical Message: Idiopathic granulomatous mastitis (IGM) is a challenging chronic inflammatory disease in diagnosis with unknown etiology. Although the most appropriate treatment protocol has not yet been identified, prednisolone was used in our patient as an effective and practical choice in the treatment of IGM. Abstract: Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory disease of the breast and mimics disorders such as breast cancer and breast abscess. Due to the uncommon of this disease, there is no definitive etiology, or treatment. A 38-year-old woman presented with a 3-week history of painful right retro-areolar mass. She had no history of breast trauma and a family history of breast cancer. She had a history of breastfeeding her second child for 12 months in the past year. Diagnostic tests and investigations led to the IGM diagnosis. Therefore, the patient was successfully treated with a course of corticosteroids, but after 2 months, during treatment, she developed Brucellosis. Despite the patient's Brucella infection and treatment with anti-Brucella drugs, prednisolone as an anti-inflammatory corticosteroid therapy was influential in the treatment of IGM.

Manifestations, complications, and treatment of neurobrucellosis: a systematic review and meta-analysis.

PURPOSE: Central nervous system involvement by Brucella species is the most morbid form of brucellosis disease. Studies on neurobrucellosis are scarce and limited to case reports and series. Brucella is unable to infect or harm neurons without the assistance of monocytes. This raises the question of whether ceftriaxone-based regimens are effective. METHODS: The primary aim of this study was to identify, evaluate, and summarize the findings of all relevant individual studies in the past 30 years to help better understand the disease. To achieve this, a broad systematic search was undertaken to identify all relevant records. Epidemiological and clinical features of the disease were assessed by the pooled analysis of descriptive studies. Through a meta-analysis, the treatment period duration was compared between the ceftriaxone-based and oral regimens using Standardized mean differences to measure effect size. RESULTS: 448 patients were included in the Meta-analyses from 5 studies. A moderate positive effect was found for ceftriaxone-based regimens over oral treatments, and there was a significant difference between these two groups (SMD 0.428, 95% CI -0.63 to -0.22, I 2 = 37.64). Neurobrucellosis has a different clinical picture in pediatric patients. The disease is less chronic in children. Fever, nausea and vomiting, fatigue, and abdominal pain were significantly more prevalent symptoms in children, and Convulsions, ascites, sensorineural hearing loss, and papilledema were significantly more prevalent signs in children than adults. CONCLUSION: It is recommended to initiate the treatment of neurobrucellosis with IV ceftriaxone therapy in combination with oral therapy.

Comparison of three interventional approaches to prevent ventilator-associated pneumonia in intensive care units (ICUs): A clinical trial study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is an infectious pulmonary disease that develops after 48 hours of ventilation. To date, several methods have been proposed to reduce VAP occurrence, such as the VAP prevention bundle, which involves raising the head of the bed, reducing sedation, avoiding deep vein thrombosis, and preventing peptic ulcer in the gastrointestinal system. The purpose of this study was to evaluate the role of personnel in hand washing, case airway suctioning, and systematic monitoring in the prevention of VAP. METHODS: In the current clinical trial, 129 patients hospitalized and intubated at Vali-e-Asr Hospital ICU in Arak, Iran, were included in the study and randomized to one of the three VAP prevention methods: group A, VAP prevention bundle measures; group B, group A measures plus washing of patients' mouth with 0.12% chlorhexidine and suction of secretion every six hours; and finally group C, group B measures plus 72-hour suction package. Demographic information, VAP diagnosis, and outcome of each patient were recorded in the special checklist. RESULTS: The age of the patients ranged from 18 years to 93 years with a mean of 54.6 ± 21.8 years. There was no significant difference in age, sex, Clinical Pulmonary Infection Score (CPIS), and Glasgow Coma Scale (GCS) between the three groups. However, there is a significant relationship between chest X-ray (CXR) index and pneumonia in the three groups (p < 0.05). The prevalence of pneumonia is generally seen to be higher in patients who were local, diffuse, or patchy than those who had no infiltration (p < 0.05). CONCLUSION: This study showed that the application of VAP prevention bundle measures, mouthwash with chlorhexidine, personnel hand washing, airway suctioning, and systematic monitoring is an efficient approach to the prevention of VAP in ICUs.

Mucocutaneous Manifestations in HIV-Infected Patients and Their Relationship to CD4 Lymphocyte Counts.

BACKGROUND: More than 90% of human immunodeficiency virus- (HIV-) infected patients show at least one mucocutaneous manifestation during the course of their disease. The frequency, pattern, and associated factors of these complications vary among different populations. OBJECTIVE: This study was planned to evaluate the frequency of cutaneous presentations in HIV-infected patients and their association with the count of CD4 cells. METHODS: A cross-sectional study was conducted on eighty-four HIV-positive patients, who attended the Behavior Consultation Center of Arak University of Medical Sciences. All subjects had a complete physical examination by an expert dermatologist. Further diagnostic procedures were performed, if necessary. Counts of CD4 were determined using flow cytometry. RESULTS: From 84 patients who enrolled in this study, 95.2% manifested at least one type of mucocutaneous lesions. The most common presentation was xerosis, followed by seborrheic dermatitis, herpes simplex, and oral candidiasis. Oral candidiasis and furuncle were significantly associated with decrease in CD4 cell counts. CONCLUSIONS: Cutaneous manifestations are common in HIV-positive patients, some of which (oral candidiasis and furuncle) could be applicable as useful clinical indicators to predict the immune status of the patients. Therefore, regular skin examinations are recommended as routine HIV-infected patients' healthcare programs.

Hydatid Disease in the Central Region of Iran: A 5-year Epidemiological and Clinical Overview.

INTRODUCTION: Hydatid cyst is caused by an infection by the larval stage of Echinococcus granulosus. Patients with cystic echinococcosis often remain asymptomatic until the hydatid cysts grow large enough to cause symptoms and signs. The cysts grow in the course of several years before reaching maturity and the rate of growth depends on the location of the cyst. METHODS: This study was conducted in the Central region of Iran and involved all patients diagnosed with hydatid disease from 2012 to 2016 with the records identifed from 10 centers for disease control. Descriptive statistics including range and percentage were used in analyzing the patient characteristics. RESULTS: Hydatid disease was confirmed in 84 cases. The mean age of patients was (23.1±5.1) years (range: 15-53 years) and 55.9% of cases were female. Single organ involvement was found in 86.9% of cases. 98.8% cases were successfully treated. The most common sites of infection were lung (42.9%), followed by liver (38.1%), and joint liver/lung (10.7%). The diagnosis was established by abdominal ultrasound, abdominal CT, and serology in all patients. The diagnosis was confirmed by histology in 80 (95.2%) of cases. All of cases were treated with albendazole, and 80 (95.2%) of cases had surgical intervention. The prevalence of human hydatidosis in our study was 1.16 per 100,000 population. CONCLUSIONS: Hydatid disease is common in Iran and should be a focus of public health interventions. The organ sites affected in this study include lung and liver.

Effect of Combination Therapy of Ceftazidime/Amikacin and Monotherapy with Imipenem on the Treatment of Fever and Neutropenia in Patients with Cancers.

AIM: This study aimed to compare the effect of Imipenem monotherapy and combination therapy with Ceftazidime/Amikacin in febrile episodes in neutropenic cancer patients. MATERIALS AND METHODS: In this double-blind randomised trial, 122 adult patients with cancer, neutropenia and fever who were treated by chemotherapy were gathered by simple sampling method and were divided randomly to two equal Imipenem (IP) and Ceftazidime/Amikacin (CA) groups. 500 mg of Imipenem was administered every 6 hours IP group and 2 g of Ceftazidimeplus 15 mg/kg/day in 2 equally divided doses of Amikacin was administered in the CA group. The treatment was continued for 72 hours in both groups. Data were analysed with SPSS19. RESULTS: There was a significant difference between the mean temperatures of three days in each group (P < 0.001). There was no significant difference between the two groups regarding microbial response to antibiotics. There was no significant difference between 19 patients of IP and 13 patients of CA groups regarding bacteriologically documented infection (P = 0.3). CONCLUSION: Unmodified therapy by Imipenem is as effective as combinational therapy by Ceftazidime/Amikacin in clinically and bacteriologically documented infection.

Safety and efficacy of N-acetyl-cysteine for prophylaxis of ventilator-associated pneumonia: a randomized, double blind, placebo-controlled clinical trial.

Ventilator-associated-pneumonia (VAP) is characterized by morbidity, mortality, and prolonged length of stay in intensive care unit (ICU). The present study aimed to examine the effect of N-acetyl-cysteine (NAC) in preventing VAP in patients hospitalized in ICU. We performed a prospective, randomized, double-blind, placebo-controlled trial of 60 mechanically ventilated patients at high risk of developing VAP. NAC (600 mg/twice daily) and placebo (twice daily) were administered to NAC group (n = 30) and control group (n = 30), respectively, through the nasogastric tube in addition to routine care. The clinical response was considered as primary (incidence of VAP) and secondary outcomes. Twenty-two (36.6%) patients developed VAP. Patients treated with NAC were significantly less likely to develop clinically confirmed VAP compared with patients treated with placebo (26.6% vs. 46.6%; P = 0.032). Patients treated with NAC had significantly less ICU length of stay (14.36 ± 4.69 days vs. 17.81 ± 6.37 days, P = 0.028) and less hospital stay (19.23 ± 5.54 days vs. 24.61 ± 6.81 days; P = 0.03) than patients treated with placebo. Time to VAP was significantly longer in the NAC group (9.42 ± 1.9 days vs. 6.46 ± 2.53 days; P = 0.002). The incidence of complete recovery was significantly higher in the NAC group (56.6% vs. 30%; P = 0.006). No adverse events related to NAC were identified. NAC is safe and effective to prevent and delay VAP, and improve its complete recovery rate in a selected, high-risk ICU population.

Reduced IFN-γ Production in Chronic Brucellosis Patients.

BACKGROUND: Brucella is a well-known intracellular bacterium entailing acute and chronic illnesses in humans and domestic animals. The infection chronicity may be affected by the cell-mediated immunity and cytokine patterns. OBJECTIVE: To evaluate the patterns of T-helper cytokines in patients suffering from chronic and acute brucellosis. METHODS: In this cross-sectional study, 22 individuals with acute brucellosis, 21 individuals with chronic brucellosis, and 21 healthy individuals with the same genetic background were recruited from October 2015 to April 2016. Peripheral lymphocytes were isolated and stimulated by phytohemagglutinin (PHA) and brucella antigen in cell culture. The lymphocyte proliferation was detected by MTT assay. After collecting the supernatants, and through the use of ELISA method, we quantified the interferon gamma (IFN-γ), interleukin (IL)-5, IL-17 and transforming growth factor-beta (TGF-ß). RESULTS: Patients with chronic brucellosis had a lower level antigen-specific stimulation index compared to those suffering from acute brucellosis (p=0.0001). Cases with chronic brucellosis had a lower level of IFN-γ compared to cases with acute brucellosis (p=0.001). Finally, patients with chronic brucellosis had higher levels of IL-5 and TGF-ß in comparison with the acute group (p=0.01 and p=0.04, respectively). CONCLUSION: Chronic brucellosis reduces lymphocyte proliferation and TH1 cytokine secretion, but it enhances IL- 5 and TGF-ß production. Polarizing the immune responses plays a crucial part in the progression and development of chronic diseases.

Evaluation of Regulatory T Cells in Patients with Acute and Chronic Brucellosis.

BACKGROUND: Brucellosis is one of the most common chronic diseases, with widespread distribution. In spite of cell-mediated immunity (CMI) modulated mainly via activated T-helper type 1 (Th1) cells, brucellosis can advance to chronic disease in about 10-30% of cases. Regulatory T cells (Treg cells) are involved the immune response to brucellosis; however, their role, particularly in the change from the acute to the chronic phase, have not yet been elucidated. The main hypothesis of this study was that Treg cells play critical roles in the progression of brucellosis from the acute to the chronic phase. METHODS: Forty-eight unrelated subjects participated in this case-control study. The percentages of CD4+, CD25+, FoxP3+, and CD25/FoxP3+ T cells in the peripheral blood mononuclear cells (PBMCs) of acute (AB) and chronic brucellosis (CB) patients and healthy controls were determined by flow cytometry. The mean florescence intensities (MFIs) of CD4+, CD25+, and FoxP3+ T cells were also measured. RESULTS: We found a significantly lower percentage of CD25/FoxP3+ Treg cells in CB than in the AB and control groups (p < 0.05). Also, CD4 and CD25 MFIs were significantly less in CB than in AB and controls (p < 0.05). CONCLUSIONS: We propose that the reduced number of CD25/FoxP3+ Treg cells in the CB group leads to T cell anergy and this contributes to the development of chronic infection.

The relationship between personality traits and AIDS in patients with human immunodeficiency virus.

This study carried out to survey the relationship between personality traits and Acquired Immunodeficiency Syndrome (AIDS) in patients with human immunodeficiency virus. This case-control study was conducted on 79 AIDS patients of Triangle Clinic in Arak (case group) and 80 healthy people of Valiasr Hospital in Arak (control group). Demographic information checklist and Cloninger' Temperament and Character inventory (TCI) were two instruments applied in the study. SPSS software V.19 and tests independent t-tests, Chi squared and Spearman correlation coefficient were used for data analysis with significant level of <0.05. The average of innovativeness variables (M:74.12), harm avoidance (M: 65.17), reward dependence (M:50.030), and self-directedness (M:35.02) in case group in comparison with control group was significantly higher, and there was a significant difference between two groups variables (P-0.000). The novelty seeking had the highest average in the AIDS patients with a history of addiction (M:74.00), and there was statistically significant difference between perseverance variable (P-0.021) and cooperativeness variable (P-0.041) in the two groups of AIDS patients. There was a significant relationship between novelty seeking and age at the onset of AIDS (P-0.038), harm avoidance and age at the onset of addiction (P-0.046), persistence and age at the onset of AIDS (P-0.035) and the time infected with HIV (P-0.033). It is found that two groups are different due to the personalities, so it is essential to consider the personality traits in order to prevent AIDS and also successfully treat patients suffering from AIDS.

Efficacy of Synbiotics for Treatment of Bacillary Dysentery in Children: A Double-Blind, Randomized, Placebo-Controlled Study.

Bacillary dysentery is a major cause of children's admission to hospitals. To assess the probiotic and prebiotic (synbiotics) effects in children with dysentery in a randomized clinical trial, 200 children with dysentery were studied in 2 groups: the synbiotic group received 1 tablet/day of synbiotic for 3-5 days and the placebo group received placebo tablets (identical tablet form like probiotics). The standard treatment was administered for all patients. Duration of hospitalization, dysentery, fever, and the weight loss were assessed in each group. It was concluded that there was no significant difference in both groups in the baseline characteristics. The mean duration of dysentery reduced (P < 0.05). The mean duration of fever has been significantly reduced in the synbiotic group (1.64 ± 0.87 days) in comparison to the placebo group (2.13 ± 0.94 days) (P < 0.001). Average amount of weight loss was significantly lower in the synbiotic group in comparison to that in the placebo group (129.5 ± 23.388 grams and 278 ± 28.385 grams, resp.; P < 0.001). There was no significant difference in the mean duration of hospitalization in both groups (P > 0.05). The use of synbiotics as an adjuvant therapy to the standard treatment of dysentery significantly reduces the duration of dysentery, fever, and rate of weight losses. The trial is registered with IRCT201109267647N1.

HCV, HBV, and HIV seroprevalence, coinfections, and related behaviors among male injection drug users in Arak, Iran.

This study explored the prevalence and related risk behaviors for hepatitis C (HCV), hepatitis B (HBV), and human immunodeficiency virus (HIV) among a sample of male injection drug users (IDUs) in Arak, Iran. One hundred male IDUs attending methadone maintenance clinics between April and September 2012 were enrolled and evaluated for HCV, HBV, and HIV infection. The majority of study participants (56%) had evidence of HCV exposure, 6% had evidence of HBV, and 19% were HIV-infected. Coinfections were frequent; 15% had evidence of HIV and HCV, 6% had evidence of HBV and HCV, and 5% had serologic markers for all three infections. Most (84%) were susceptible to HBV infection. A history of any syringe sharing (54%) and syringe sharing in prison (25%) were common. In bivariate analyses, a history of any syringe sharing and syringe sharing in prison were both associated with all three viral infections. The high prevalence of HCV, HBV, HIV, and coinfections among IDU in Arak is concerning and indicates rapid disease spread outside of Iran's main urban centers. Prevention efforts should expand vaccination for IDUs who are nonimmune to HBV and continue to target syringe sharing with efforts such as needle exchange programs, including inside prisons.

The effect of Helicobacter pylori eradication on migraine: a randomized, double blind, controlled trial.

BACKGROUND: Recent studies have shown a positive correlation between Helicobacter pylori (H. pylori)infection and migraine headache. OBJECTIVE: To study the impact of H. pylori eradication on migraine headache. STUDY DESIGN: Double blind, randomized, controlled clinical trial. SETTING: Sixty-four patients diagnosed with migraine-type headache were included in the study. The patients were randomly allocated into 2 groups: a treatment group that received migraine treatment and H.pylori eradication treatment, and a control group that received migraine treatment and a placebo in place of H. pylori eradication treatment. METHODS: There were 25 women and 7 men in the treatment group and 22 women and 10 men in the control group. The MIDAS (Migraine Disability Assessment) questionnaire was used to assess the severity of symptoms, before and after treatment. RESULT: There was no significant difference between treatment group patients and control group patients with respect to age (44.6 ± 8.8 vs. 43.8 ± 13.8), clinical symptoms and signs. In the beginning of the study, patients in the treatment group had a higher MIDAS compared to patients in the control group (28.87 ± 6.18 vs. 25.43 ± 7.13, P < 0.05). There was no significant difference between the treatment and control groups, with respect to the MIDAS, after treatment (20.09 ± 1.14 vs. 20.00 ± 1.150, P = 0.5). General linear model, repeated measures demonstrated that the reduction in the MIDAS score was more prominent in the treatment group (Mean Square 164.25, F: 2.02, P = 0.05). LIMITATIONS: Short-term follow up. CONCLUSION: H. pylori eradication may have a beneficial role on migraine headache. This shows the significance of H. pylori treatment in the management of migraine headache among Iranian patients.

Serum level of soluble interleukin-2 receptor alpha as a predictor of treatment response in brucellosis.

INTRODUCTION: Iran is one of the endemic regions with high prevalence of brucellosis. Several serological markers for diagnosis and response to treatment are available. Serum level of Soluble Interleukin-2 Receptor alpha (SIL-2Ralpha) is a new marker to assess response to therapy and clinical relapse of brucellosis. This study intends to investigate the serum levels of SIL-2Ralpha before and after treatment, to evaluate this marker for patients responding to treatment of brucellosis. METHODS: This study is an analytical cross-sectional study. Forty patients who had clinical signs of brucellosis and serological tests confirmed the disease have been treated with standard antibiotics for 6 weeks. 2ME and SIL-2Ralpha levels were measured before and after treatment and these values were compared. RESULTS: Among the 40 patients, 27 patients (67.5%) had improvement in symptoms and 13 patients (32.5%) had no symptoms after treatment. In Comparing serum levels of SIL-2Ralpha and 2ME before and after treatment, decreasing of both markers after treatment was significant (p < 0.001). In patients with false positive for 2ME, SIL-2Ralpha in 57% of patients had a reduction, but in patients with false negative for 2ME, SIL-2Ralpha in only 28% of patients increased. CONCLUSION: Not only is Serum level of SIL-2Ralpha useful for predicting response to treatment of brucellosis, but also in cases of false positive of 2ME can be helpful.