پنج شنبه ٢٩ ارديبهشت ١٤٠١

A 43 year-old woman with fever eleven years after kidney transplantation

Our patient was a 43 year-old woman referred due to fever eleven years after allograft renal transplantation. She was healthy until 4 months ago on a combination of mycophenolate mofetil (1 gr twice daily) and cyclosporine (50 mg twice daily). Preliminary evaluations for sustained fever without any concomitant symptoms in another center had revealed only diffuse ground glass opacities in both lungs on chest computed tomography (CT) scan (Figure 1). Before admission, based on positive cytomegalovirus (CMV) immunoglobulin G (IgG), mycophenolate mofetil had been discontinued due to an assumption of reactivation of CMV infection. A combination of ganciclovir plus prednisolone 10 mg daily and then valganciclovir for approximately three months resulted in fever cessation.

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Hyperphosphatemia in a patient with respiratory problems

History of Present Illness: The patient was symptomatic for 2 weeks prior to admission and unresponsive to outpatient treatments. The only positive finding on physical examination was a high oral temperature (38°C). Positive laboratory findings at the time of admission include macrocytic anemia (Hb: 11 g/dL, MCV:110 fl) associated with leucopenia and thrombocytopenia, raised ESR, positive CRP, and most notably, hyperphosphatemia (14.7 mg/dL; reference range: 2.5–5.0 mg/dL) accompanied with normal serum calcium, PTH, and mildly disturbed renal function tests (Table 1). Chest X-ray and spiral CT scan showed consolidation of the anterior segment of the right upper lobe of the lung (Figure 1).............

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Value of third sputum smear for detection of pulmonary tuberculosis in HIV infected patients

Abstract:We evaluated dia gnostic yield of third sputum smear in patients co infected with HIV fordetection of pulmonary tuberculosis (TB). Among 139 pulmonary tuberculosis cases confirmed with positive sputum culture, diagnostic yield of first smear of sputum with acid fast staining was 81.9%. Incremental yield of 2 nd and 3 rd samples was 11.7% and 6.3% respectively. So two sputum smears may be enough for primary evaluation of HIV infected patients suspected to TB. © M. Marjani et al., 2012.

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Division-cycle in Mycobacterium tuberculosis

Summary:Mycobacterium tuberculosis is a prototrophic and metabolically flexible bacterium. The microorganism kills approximately 2 million people each year and is thought to latently infect one third of the worlds population. The success of M. tuberculosis as a pathogen is attributed to its extraordinary capacity to adapt to environmental changes throughout the course of infection. Today, based on various in vitro and in vivo models, the researches agreed to consider M. tuberculosis as a two-phase microorganism which can appear either in its metabolically active acid fast or in its inactive forms. It is the purpose of this review to discuss and outline the in-depth understanding of the basic biology of cell division in M. tuberculosis.

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A 35-year-old man with dyspnea and hemoptysis

A man in his thirties was admitted due to new onset dyspnea, right-sided pleuritic chest pain and non-massive hemoptysis since 4 days before admission.

On arrival, he was febrile and tachypneic with normal blood pressure. Bibasilar decreased breath sounds and vocal vibration, prominently in the right lung, and 2cm difference in diameter of the left leg were the remarkable findings.

Blunting of the right costophrenic angle was prominent on chest x-ray. Laboratory analysis revealed normal blood cell count, elevated erythrocyte sedimentation rate (125 mm/hr.) and positive quantitative D-Dimer. Blood biochemistry and coagulation profile and urinalysis were normal.

Anticoagulant was initiated with presumptive diagnosis of pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT). Doppler ultrasonography (DUS) and pulmonary computed tomographic angiography (CTA) were performed. DUS was normal, but right sided pulmonary artery embolus was confirmed with CTA (Figures 1 and ?and2).2). Interestingly, DUS revealed DVT in the right popliteal artery. Echocardiography was normal.......

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Treatment outcome and mortality: Their predictors among HIV/TB co-infected patients from Iran

Abstract:Background: The risk of death is significantly higher in TB/HIV-infected patients than in those patients with just one disease or the other. This study aims to evaluate the impact of demographic, clinical and laboratory characteristics on the treatment outcome and mortality of TB/HIV co-infected patients in a TB tertiary center in Iran. Materials and methods: The study was conducted at Irans National Referral Center for Tuberculosis. In total, 111 patients were recruited between 2004 and 2007. Mycobacteriology studies were performed for all patients. Demographic, clinical, and lab data of all patients were analyzed, and predictors of unsuccessful outcomes, as well as mortality, were determined. Results: The mean age for all 111 TB/HIV patients was 38±9years (range 22-70) and 107 patients (96.3%) were male; 104 patients (93.7%) had a history of drug abuse, and 96 patients (86.4%) had a history of imprisonment. The route of transmission of HIV was intravenous drug use in 88 of the patients (79.3%); 23 patients (20.7%) had a history of Category 1 (CAT-1) (5.4%) and CAT-2 treatment. Highly Active Antiretroviral Therapy (HAART) was given to 48 patients (43.2%). There was no significant association found between treatment outcome or mortality with sex, smoking, drug and alcohol abuse, imprisonment, route of transmission, history of CAT-1 and CAT-2, cluster of differentiation 4 (CD4), and adverse effects (p>0.05). Administration of HAART led to a significantly higher rate of good outcome (p<0.001). Lower Albumin levels and body weight were significantly associated with mortality. Conclusion: Albumin levels and weight can be predictors of mortality and an unsuccessful outcome. Administration of HAART led to a better outcome. © 2012 Asian-African Society for Mycobacteriology.

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Diagnostic yield of post-bronchoscopy sputum smear in pulmonary tuberculosiss

Abstract:Background: The early definitive diagnosis of pulmonary tuberculosis (TB) is important for control of the disease in the community. We performed this study to evaluate the additional gain of post-bronchoscopy sputum in the diagnosis of pulmonary TB. Methods: Bronchoscopy and bronchoalveolar lavage were performed for 126 patients suspected of pulmonary TB who either had 3 negative sputum smears for acid-fast bacilli or could not expectorate. After bronchoscopy the patients were asked to give sputum samples for 3 consecutive days. All of the obtained specimens were investigated for Mycobacterium tuberculosis by smear and culture. Results: Pulmonary TB was confirmed in 56 patients. Among all confirmed cases, the sensitivity of bronchoalveolar lavage smear was 57.1% (32 of 56), sensitivity of post-bronchoscopy smear was 76.7% (43 of 56), and the yield of a combination of the 2 methods was 83.9% (47 of 56). Results of post-bronchoscopy sputum smears were not significantly related to sex, age, human immunodeficiency virus (HIV) infection, presence of cavitary lesions on chest X-ray, or the ability to expectorate before bronchoscopy (p > 0.05). Conclusion: Evaluation of post-bronchoscopy sputum smears is helpful for earlier diagnosis of pulmonary TB and is an inexpensive and accessible assay. © 2012 Informa Healthcare.

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Correlation of anxiety-depression and sleep quality in mothers of children with cystic fibrosis and asthma

Abstract:Background: Cystic fibrosis and asthma are considered among the chronic respiratory diseases. Taking care of the sick child by the mother-which is usually the main care taker-can be associated with high loads of stress and result in behavioral problems like anxiety, depression and change in sleep quality. This study aimed at evaluating the correlation between depression-anxiety and sleep quality in mothers of children suffering from cystic fibrosis and asthma hospitalized in Masih Daneshvari Hospital. Materials and Methods: This was an analytical descriptive cross-sectional study conducted on 148 subjects (mothers of children with cystic fibrosis and asthma hospitalized in Masih Daneshvari Hospital) during 2008-2010. Data were collected using a questionnaire for demographic characteristics, sleep quality and Hospital Anxiety and Depression Scale (HADS). Pittsburgh sleep quality index questionnaire (PQSI) was developed by Dr. Buysse and colleagues at the University of Pittsburghs Western Psychiatric Institute and Clinic in the late 1980s. The PSQI was created after observing that most patients with psychiatric disorders had sleep disorders as well. Also, required data regarding the pulmonary function of patients was extracted from their medical records. Results: In this study, high levels of anxiety and depression and poor sleep quality requiring clinical intervention were seen in 37.2%, 29.1% and 39% of mothers, respectively. A significant association was detected between sleep quality and depression-anxiety (P-value<0.005). Also, depression-anxiety was significantly correlated with number of children and smoking (P-value<0.005). A total of 20% of mothers suffering from depression and 14.3% of mothers with anxiety disorder had a history of cigarette smoking (P-value<0.005). No significant association was found between substance abuse and occupation with depression-anxiety. Susceptibility was only correlated with anxiety (P-value<0.005). Conclusion: Our study showed a significant association between sleep quality and depression-anxiety in mothers of children suffering from cystic fibrosis and asthma. Greater attention should be paid to prevent development and aggravation of these conditions in susceptible mothers who are the main care taker of their sick child with chronic diseases. © 2012 NRITLD, National Research Institute of Tuberculosis and Lung Disease, Iran.

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Pattern of smoking and nicotine dependence in patients with psychiatric disorders

Abstract:Background: Smoking prevalence is high among psychiatric patients. This study aimed to evaluate the prevalence of smoking, related factors and nicotine dependence in patients suffering from psychiatric disorders. Materials and Methods: This analytical descriptive study was performed on patients who had been hospitalized for at least 2 days in Razi Hospital during 2010. Data were collected via an interview and the obtained information was recorded in a questionnaire. Fagerstrom test was also used. After determining the prevalence of smoking in these patients, the related factors and nicotine dependence were also evaluated using multiple logistic regression test and SPSS software. Results: A total of 78.4% of men and 36.2% of women in this study were smokers and 64.4% had high nicotine dependence. Final logistic regression models showed that smoking was related with advanced age, male sexuality, hookah consumption, and depression. High nicotine dependence was correlated with hookah consumption and history of suicide attempt. Conclusion: Prevalence of smoking is higher among psychiatric patients compared to the public. Adequate intervention and strategies are necessary in these patients to promote smoking cessation. © 2012 NRITLD, National Research Institute of Tuberculosis and Lung Disease, Iran.

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Incidence of thromboembolism in hospitalized patients with tuberculosis and associated risk factors

Abstract:Background:Venous thromboembolism is a serious complication among hospitalized patients. Infectious diseases are known as a risk factor for thrombo-embolic events.

Objectives: The aim of the study is to evaluate incidence, characteristic pattern, and risk factors for thrombo-embolic events among patients hospitalized with pulmonary and extra-pulmonary tuberculosis.

Patients and Methods:This cohort study was performed among 1,153 new cases of tuberculosis. Suspected patients for DVT (deep venous thrombosis) or PTE (pulmonary thromboembolism) were investigated by Doppler sonography and pulmonary CT angiography. Another 100 tuberculosis patients without thromboembolism were also observed as control group.

Results: The incidence of diagnosed thrombo-embolic complication was 32 of 1,153 admitted patients (2.8%; 95% confidence interval: 1.9 to 3.9) with a median interval of 14 days after anti-TB treatment initiation. The incidence of DVT and PTE was 2% and 1%, respectively. Thrombo-embolic events and DVT were more common in men than in women: 4.2% versus 1.3% (P = 0.003) and 3.5% versus 0.4%, respectively (P < 0.001). Hypertension and opium addiction were significantly correlated with thromboembolism.

Conclusions:Incidence of DVT and PTE is noticeable among patients with tuberculosis

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A prospective study of antibiotic susceptibility in patients with ventilator associated pneumonia

Abstract:Background: An outbreak of antibiotic resistant gram-negative bacteria, particularly Acinetobacter, in intensive care unit is of great importance for intensivists due to high mortality and low effective therapy. Objective: We aimed to evaluate antibiotic susceptibility of isolated gram-negatives from patients with ventilator- associated pneumonia (VAP) in ICU. Material and Methods: In a prospective, descriptive study, ICU patients who were under mechanical ventilation and had resistant ventilator-associated pneumonia (VAP) were evaluated for prevalence and antibiotic susceptibility of identified pathogens. The data, including clinical outcome and microbiological results were analyzed. Results: Fifteen ICU patients were included with mean age of 50.5 years (the range between 20-96 years). Median of hospitalization was 53 days (the range of 15 to 135 days), median of hospitalization before admission to ICU was 2.5 day (the range was from zero to 27 days), and median days of bacterial isolation was 18 days (the range of 5 to 30 days). Six patients (42.9%) patients were admitted in ICU after surgery, and 8 patients (57.1%) due to another medical problem. Acinetobacter was dominant isolated pathogen in VAP patients. Imipenem did better than other antibacterials against E.coli, Klebsiela, and Enterobacter, but Tazobactem did worse than imipenem against imipenem-resistant Acinetobacter (p = 0.032). Treatment outcome in 9 cases (50%) was death. No deaths after 28 days of follow-up were observed. Conclusion: It seems that, gram-negative pathogens are the main cause of morbidity and mortality in ICU admitted ventilator induced infection. Imipenem resistant Acinetobacter is among the most prevalent and dif! cult to treat pathogens in ICU, and needs special consideration for initial therapy.

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Pulmonary disease caused by Mycobacterium simiae in Irans national referral center for tuberculosis

Abstract:Introduction: Several species of non-tuberculosis mycobacteria (NTM) can affect humans and can cause either symptomatic or asymptomatic infection. This study aimed to determine the clinical and radiological manifestation, as well as the treatment, of M. simiae in patients in Masih Daneshvari Hospital, a TB referral hospital in Iran. Methodology: This retrospective study involved all patients presenting to our referral center from 2002 to 2009, with confirmation of M. simiae pulmonary infection. For all patients, sputum smear and culture for identification was performed, as was drug susceptibility testing. Additionally, PCR identification methods for NTM, and high-resolution CT scan were conducted. All patients were treated according to American Thoracic Society recommendations. Results: In total, 26 cases of M. simiae were identified in our center. The mean age of the patients was 58.23 ± 16.9years. Only one patient was HIV positive, and all but one were Iranian. The most frequent symptom was coughing (92.3%), and 100% of the patients had nodular lesions. In addition, bronchiectasis and cavitation were present in 84.6% and 88.5% respectively. All the patients were resistant to every first-line drug. Two patients failed the treatment, and twenty-four were cured, after which no recurrence of the disease was observed. Conclusion: M. simiae may present with clinical and radiological manifestations consistent with tuberculosis, and be resistant to anti-TB agents. A more efficient treatment for NTMs such as M. simiae is needed, to shorten the period of treatment and proved fewer adverse effects than current therapies. © 2012 Baghaei et al.

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Clinical and radiological deterioration due to Mycobacterium szulgai in an asthmatic patient

Abstract:We report the case of a 23-year-old asthmatic woman who had clinical and radiological deterioration due to Mycobacterium szulgai infection and good response to anti-mycobacterial treatment without any structural abnormalities in previous lung imaging studies. M. szulgai may be considered a pathogen able to cause deterioration of respiratory health even in patients with previously normal lungs. © 2012 Marjani et al.

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