A challenging case of carbapenem resistant Klebsiella pneumoniae-related pyogenic liver abscess with capsular polysaccharide hyperproduction: a case report

BACKGROUND

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are a major public health problem, necessitating the administration of polymyxin E (colistin) as a last-line antibiotic. Meanwhile, the mortality rate associated with colistin-resistant K. pneumoniae infections is seriously increasing. On the other hand, importance of administration of carbapenems in promoting colistin resistance in K. pneumoniae is unknown.

CASE PRESENTATION

We report a case of K. pneumoniae-related pyogenic liver abscess in which susceptible K. pneumoniae transformed into carbapenem- and colistin-resistant K. pneumoniae during treatment with imipenem. The case of pyogenic liver abscess was a 50-year-old man with diabetes and liver transplant who was admitted to Abu Ali Sina Hospital in Shiraz. The K. pneumoniae isolate responsible for community-acquired pyogenic liver abscess was isolated and identified. The K. pneumoniae isolate was sensitive to all tested antibiotics except ampicillin in the antimicrobial susceptibility test and was identified as a non-K1/K2 classical K. pneumoniae (cKp) strain. Multilocus sequence typing (MLST) identified the isolate as sequence type 54 (ST54). Based on the patient's request, he was discharged to continue treatment at another center. After two months, he was readmitted due to fever and progressive constitutional symptoms. During treatment with imipenem, the strain acquired blaOXA-48 and showed resistance to carbapenems and was identified as a multidrug resistant (MDR) strain. The minimum inhibitory concentration (MIC) test for colistin was performed by broth microdilution method and the strain was sensitive to colistin (MIC < 2 µg/mL). Meanwhile, on blood agar, the colonies had a sticky consistency and adhered to the culture medium (sticky mucoviscous colonies). Quantitative real-time PCR and biofilm formation assay revealed that the CRKP strain increased capsule wzi gene expression and produced slime in response to imipenem. Finally, K. pneumoniae-related pyogenic liver abscess with resistance to a wide range of antibiotics, including the last-line antibiotics colistin and tigecycline, led to sepsis and death.

CONCLUSIONS

Based on this information, can we have a theoretical hypothesis that imipenem is a promoter of resistance to carbapenems and colistin in K. pneumoniae? This needs more attention.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature

BACKGROUND

Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population.

METHOD

We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs.

RESULTS

Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis.

CONCLUSION

Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Functional magnetic resonance imaging in coronavirus disease 2019 induced olfactory dysfunction

OBJECTIVE

To evaluate the functional magnetic resonance imaging changes in the olfactory structures of coronavirus disease 2019 patients experiencing olfactory dysfunction.

METHODS

This study included patients aged 25-65 years who presented with a sudden loss of smell, confirmed coronavirus disease 2019 infection, and persistent olfactory dysfunction for a minimum of 2 months without any treatment.

RESULTS

Irrespective of the side of brain activation, the analysis of the cumulative maximum diameter of the activation zones revealed significantly lower activation in the upper frontal lobe (p = 0.037) and basal ganglia (p = 0.023) in olfactory dysfunction patients. Irrespective of the side of activation, the analysis of the number of activation points demonstrated significantly lower activation in the upper frontal lobe (p = 0.036) and basal ganglia (p = 0.009) in olfactory dysfunction patients.

CONCLUSION

Patients with coronavirus-triggered olfactory dysfunction exhibited lower activity in their basal ganglia and upper frontal lobe.

Successful Sealing of Post-COVID-19 Bronchopleural Fistula with Computed Tomography Scan-Guided Percutaneous Cyanoacrylate Glue Injection: A Case Series

Bronchopleural fistula (BPF), a sinus tract between the bronchial system and the pleural space, is associated with COVID-19 and can lead to pneumothorax, which increases the mortality rate. Due to the analytical status of COVID-19 patients, sealing the BPF necessitates the least minimal invasive treatment. Herein, we demonstrated a technique of sealing post-COVID-19 BPF with direct injection of cyanoacrylate glue under the guidance of a computed tomography scan. Following glue injection, the BPF was completely sealed in all four patients. In conclusion, in COVID-19 patients with small and distal BPF, percutaneous glue injection is recommended for BPF closure.

Complication Rate after Percutaneous Liver Biopsy Using a Real-time Ultrasound Approach and Introducing a Uniform Methodology: A Brief Report

Following the initial liver biopsy attempts, several techniques using a wide range of methodologies and materials were developed. Many studies on the evaluation of post-liver biopsy complications were conducted. However, their fundamental limitation was significant variance in patient demographics and methodology, which might account for the inconsistent outcomes. Therefore, a uniform methodology to perform percutaneous liver biopsies that result in comparable outcomes around the world is required. This study aimed to determine the precise complication rate following percutaneous liver biopsy using a consistent method in all individuals. It also aimed to establish a consistent operating procedure for a percutaneous liver biopsy that yielded comparable outcomes. Between July 2018 and July 2019, 116 patients were enrolled in this retrospective study for percutaneous liver biopsy. All individuals underwent a biopsy using the same procedure. There was an attempt to exclude elements that could have an impact on the complication rate. For this purpose, the same type and size of needle were utilized. Moreover, a single needle pass, a subcostal approach, deep inspiration breath holding, identical pre- and post-biopsy preparation, real-time ultrasonography guidance, the use of a single operator, and the absence of sedation or general anesthesia were the other approaches that were used to minimize the impact of variables that could raise complication rates. The overall complication rate was 19.8%, of which 18.9% of patients experienced pain and mild bleeding, and one patient (0.9%) experienced hematoma necessitating precautionary hospitalization. The overall percentage of patients who experienced pain was 13.8%. No further complications were observed. The findings of this study could provide an accurate estimate of the post-liver biopsy complication rate. Furthermore, due to a lower complication rate than other practiced procedures, this uniform methodology could be an attractive alternative in clinical practice. However, more research is required to confirm these results.

Predictive factors of delayed bleeding after percutaneous nephrolithotomy requiring angioembolization

Objectives

To investigate the predictive factors of delayed post-percutaneous nephrolithotomy (PCNL) haemorrhage because of arteriovenous fistula (AVF) or pseudoaneurysm (PA) and compare the factors between AVF and PA.

Patients and methods

This is a case-control study with a case-to-control ratio of 1:3. Out of 5077 patients who underwent PCNL from April 2015 to April 2018 in three different teaching hospitals, 113 had post-PCNL haemorrhages because of AVF and/or PA. Seventy-two patients met the inclusion criteria and entered the study as cases, while 216 patients without any postoperative complications were selected as controls.

Results

Of all 72 studied patients with complications after PCNL, 35 (48.6%) had AVF, and the rest had PA. The regression model revealed that a history of diabetes (odds ratio [OR]: 2.799, 95% confidence interval [CI]: 1.392-5.630, p-value = 0.004) and renal anomalies (OR: 2.929, 95% CI: 1.108-7.744, p-value = 0.03) were associated with developing delayed post-PCNL haemorrhage. However, no differences were seen between AVF and PA regarding selected variables (p-value > 0.05).

Conclusion

History of diabetes and renal anomalies were predictive factors for delayed post-PCNL haemorrhage, but no predictive factors were found to differentiate PA and AVF from one another.

Nonoperative management of biliopleural fistula following living-donor liver transplantation: A case report

Key Clinical Message

Biliopleural fistula is a rare but serious complication after liver transplantation that should be managed nonoperatively with antibiotics, pleural drainage, decompression of high-pressure biliary tract, or ultimately surgery in unresponsive cases.

Abstract

Bilious pleural effusion is a rare entity often iatrogenic, following hepatobiliary surgeries and biliary interventions, and has been reported only in a limited number of patients after liver transplantation. A 5-year-old girl underwent living donor liver transplantation due to progressive familial intrahepatic cholestasis. At the 7th day of the postoperative course, due to increased liver enzymes and bilirubin levels and intrahepatic bile duct dilatation on sonography, Magnetic Resonance Cholangiopancreaticography followed by a liver biopsy were performed; the findings demonstrated moderate intrahepatic bile duct dilatation and moderate cellular rejection associated with mild cholestasis, respectively. The patient was therefore administered a pulse of methylprednisolone; however, due to fever, peritonitis and also sonographic evidence of infected biloma collection adjacent to the transplanted liver, the patient underwent surgery. Laparotomy and peritoneal washout were performed and a Jackson-Pratt drain was inserted adjacent to the liver cut surface. Succeeding tachypnea on 28th post day, led to detection of right side massive pleural effusion on chest Xray and hence thoracostomy tube was inserted. A diagnosis of biliopleural fistula was established and broad-spectrum intravenous antibiotic therapy was started, followed by cholangiography, fistula closure, and bile duct stricture ballooning and internal-external biliary catheter insertion. The patient was discharged in generally good condition on the 50th posttransplant day. The diagnosis of biliopleural fistula is facilitated with the utilization of chest imaging and pleural fluid analysis, however, a high index of suspicion is required.

Dorsal intradural spinal arteriovenous fistula associated with giant intradural spinal aneurysm, a case report

Arteriovenous fistula and spinal aneurysms like other vascular malformations can mimic radiculopathy and low back pain. Precise imaging work combined with a hybrid endovascular-microsurgical approach is the key element for the best clinical outcome.

A less aggressive approach to the treatment of aggressive vertebral hemangioma of the thoracic spine: A case report and literature review

BACKGROUND

Different treatments are available for aggressive vertebral hemangioma [AVH], but a consensus is yet to be reached about the best therapeutic approach.

PURPOSE

To explore the possibility that selecting a less aggressive therapeutic approach for AVH decreases the intraoperative and postoperative complications while providing similar clinical, radiographic, and disease-free survival results to more aggressive therapeutic methods.

STUDY

We report the case of an AVH of the thoracic spine at the T5 level, treated via perioperative selective arterial embolization plus surgical decompression via laminectomy and reconstruction with polymethylmethacrylate (PMMA) vertebroplasty.

PATIENT

The patient was a 17-year-old male referred to our center with the chief complaint of low back pain from two months earlier, without any response to analgesics, and with neurologic manifestations as paraparesis (one month) and progressive sphincter problems (one week). Upon imaging, the impression was an aggressive spinal tumor with cord compression.

OUTCOME MEASURES

After the operation, the patient's pain immediately improved, and his neurologic manifestations progressively improved.

RESULTS

The patient started walking with help about three weeks after the operation. Roughly six months later, he achieved a complete neurological recovery. At present, about two years following the operation, he has a normal life without any neurological problems.

CONCLUSION

Based on our experience with AVH, the selection of less aggressive therapeutic approaches such as perioperative diagnostic angiography and selective embolization decrease the intraoperative and postoperative complications like intraoperative bleeding and neurological injury, while achieving similar clinical, radiographic, and disease-free survival outcomes to more aggressive therapeutic methods.

Emergence of K1 ST23 and K2 ST65 hypervirulent klebsiella pneumoniae as true pathogens with specific virulence genes in cryptogenic pyogenic liver abscesses Shiraz Iran

Hypervirulent Klebsiella pneumoniae (hvKp) pathotype is emerging worldwide in pyogenic liver abscesses (PLAs). However, the role of virulence factors in pathogenicity remains unclear. On the other hand, the epidemiology of PLAs in Iran is unknown. From July 2020 to April 2022, bacterial species were isolated and identified from the drainage samples of 54 patients with PLAs. K. pneumoniae as the most common pathogen of pyogenic liver abscesses was identified in 20 (37%) of the 54 patients. We analyzed the clinical and microbiological characteristics of K. pneumoniae-related pyogenic liver abscesses. Antibiotic susceptibility testes and string test were performed. 16S rRNA, antibiotic resistance, and virulence genes were determined by polymerase chain reaction amplification. Clonal relatedness of isolates was identified by multilocus sequence typing. Virulence levels were assessed in the Galleria mellonella larval infection model. Four hvKp isolates (K1/K2) were found to be responsible for cryptogenic PLAs, and 16 classical K. pneumoniae isolates (non-K1/K2) were associated with non-cryptogenic PLAs. Three capsular serotype K1 strains belonged to sequence type 23 (ST23) and one K2 strain to ST65. Meanwhile, the non-K1/K2 strains belonged to other STs. ST231 was the most common strain among the classical K. pneumoniae strains. Compared with the non-K1/K2 strains, capsular serotypes K1/K2 strains were less resistant to antibiotics, had positive string test results, and had more virulence genes. In Galleria mellonella, a concentration of 10⁶ colony-forming units of the K1 hvKp strain resulted in 100% death at 24 hours, confirming the higher virulence of the hvKp strain compared with cKp. K. pneumoniae isolates represented that the acquisition of any plasmid or chromosomal virulence genes contributes to pathogenicity and high prevalence in PLAs. Meanwhile, hvKp isolates with a specific genetic background were detected in cryptogenic PLAs.

Anatomic Variations of the Cystic Duct in Magnetic Resonance Cholangiopancreatography in Shiraz: A Cross-Sectional Study

BACKGROUND

Anatomic variations of the cystic duct (CD) are commonly encountered. Being aware of these variants will reduce complications subsequent to surgical, endoscopic, or percutaneous procedures. Magnetic resonance cholangiopancreatography (MRCP) is the least invasive and the most reliable modality for biliary anatomy surveys. This study aimed to determine the prevalence of cystic duct variations in the Iranian population.

METHODS

In this retrospective cross-sectional study, MRCP images of 350 patients referred to Shiraz Faraparto Medical Imaging and Interventional Radiology Center from October 2017 to October 2018 were reviewed. The CD course and insertion site to the extrahepatic bile duct (EHBD) was determined and documented in 290 cases. Descriptive statistics and Chi square test were applied for data analysis via SPSS software.

RESULTS

About 77% of cases revealed the classic right lateral insertion to the middle third of EHBD. The insertion of CD to the upper third and the right hepatic duct was 10%, and the insertion to the medial aspect of the middle third of EHBD from anterior or posterior was noted to be about 7.6%. From 2.8% of insertions to the lower third, 1% demonstrated parallel course, and finally, 0.3% of cases presented short CD.

CONCLUSION

CD variations are relatively common, and MRCP mapping prior to the hepatobiliary interventions could prevent unexpected consequences.

Impact of iterative reconstruction algorithms on image quality and radiation dose in computed tomography scan of patients with malignant pancreatic lesions

Background:

The objective of this study was to investigate the influence of iterative reconstruction (IR) algorithm on radiation dose and image quality of computed tomography (CT) scans of patients with malignant pancreatic lesions by designing a new protocol.

Methods:

The pancreas CT was performed on 40 patients (23 males and 17 females) with a 160-slice CT scan machine. The pancreatic parenchymal phase was performed in two stages: one with a usual dose of radiation and the other one after using a reduced dose of radiation. The images obtained with usual dose were reconstructed with Filtered Back Projection (FBP) method (Protocol A); and the images obtained with the reduced dose were reconstructed with both FBP (Protocol B) and IR method (Protocol C). The quality of images and radiation dose were compared among the three protocols.

Results:

Image noise was significantly lower with Protocol C (10.80) than with Protocol A (14.98) and Protocol B (20.60) (P < 0.001). Signal-to-noise ratio and contrast-to-noise ratio were significantly higher with Protocol C than with Protocol A and Protocol B (P < 0.001). Protocol A and Protocol C were not significantly different in terms of image quality scores. Effective dose was reduced by approximately 48% in Protocol C compared with Protocol A (1.20 ± 0.53 mSv vs. 2.33 ± 0.86 mSv, P < 0.001).

Conclusion:

Results of this study showed that applying the IR method compared to the FBP method can improve objective image quality, maintain subjective image quality, and reduce the radiation dose of the patients undergo pancreas CT.

Percutaneous Transhepatic Radiologic Intervention of Biliary Complications following Liver Transplantation: A Single-center Experience

Background

Biliary complications are the leading cause of morbidity and mortality in patients undergo¬ing Liver Transplantation (LT). Post-biliary transplantation strictures (BSs) are a severe problem with a high risk of graft failure. However, management of these BSs has remained controversial, and consid¬erable variability has been reported in Percutaneous Transhepatic Radiological Interventions (PTRIs) related to broad differences in technical procedures.

Objective

This study aimed to evaluate the efficacy of percutaneous treatments in managing post-LT BSs in a center in Shiraz.

Methods

PTRIs including balloon dilatation, metallic stent, and internal or internal-external hand-made plastic stent insertion were done for 34 transplanted patients with BSs referring to the Interventional Radiology Unit of Shiraz Namazi Hospital. Technical success rate, patency rates, and complications were evaluated.

Results

The. In this study, 31 strictures were successfully treated without any significant difference between the anastomotic and non-anastomotic types of stricture (success rate: 91.2%). Based on the results, 12- , 24-, and 36-month primary patency rates were 90.1%, 84.5%, and 76.8%, respectively. The secondary patency rate was 100% at 12 and 24 months and 93.3% at 36 and 60 months. The rate of minor complica¬tions (mild cholangitis and hemobilia) was 6.4%, and no major complications were detected.

Conclusion

According to the findings, PTRI is an effective method for treating anastomotic and non-anas- tomotic strictures with a high success rate and low complications.

Hepatic Computed Tomography Volumetry for Noninvasive Detection of Hepatic Steatosis and Steatohepatitis in Living Liver Donors

OBJECTIVES

Detection of hepatic steatosis in donors is an important step for selection of a suitable liver allograft in living-donor transplant. This study aimed to investigate the role of hepatic computed tomography volumetry as a noninvasive method for detection of hepatic steatosis in living liver donors.

MATERIALS AND METHODS

In a cross-sectional study, individuals who had undergone liver biopsy as a pretransplant checkup before living-donor liver transplant were included. The segmental liver volumes were measured by computed tomography scan with intravenous contrast enhancement.

RESULTS

Our study included 179 individuals. Mean total volume of the liver was 1705.2 ± 256.5 cm³ in those with steatohepatitis and 1419.4 ± 241.2 cm³ in those without steatohepatitis (P < .001). Higher total volume of the liver (odds ratio of 1.005; 95% confidence interval, 1.001-1.010; P = .012) and total liver volume-to-standard liver volume ratio (odds ratio of 1.090; 95% confidence interval, 1.021-1.163; P = .009) were independent predictors of steatohepatitis. A cutoff value of 1531 cm³ for total liver volume was a predictor of presence of steatohepatitis in liver biopsies of donors (sensitivity = 83%; specificity = 71%; area under the curve = 0.809; P < .001).

CONCLUSIONS

Computed tomography volumetry may be considered as an auxiliary noninvasive method for estimation of hepatic steatosis/steatohepatitis and may be used as a guide to select donor candidates for liver biopsy.

Differentiation between metastatic and tumour-free cervical lymph nodes in patients with papillary thyroid carcinoma by grey-scale sonographic texture analysis

PURPOSE

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer, and cervical lymph nodes (LNs) are the most common extrathyroid metastatic involvement. Early detection and reliable diagnosis of LNs can lead to improved cure rates and management costs. This study explored the potential of texture analysis for texture-based classification of tumour-free and metastatic cervical LNs of PTC in ultrasound imaging.

MATERIAL AND METHODS

A total of 274 LNs (137 tumour-free and 137 metastatic) were explored using the texture analysis (TA) method. Up to 300 features were extracted for texture analysis in three normalisations (default, 3sigma, and 1-99%). Linear discriminant analysis was employed to transform raw data to lower-dimensional spaces and increase discriminative power. The features were classified by the first nearest neighbour classifier.

RESULTS

Normalisation reflected improvement on the performance of the classifier; hence, the features under 3sigma normalisation schemes through FFPA (fusion Fisher plus the probability of classification error [POE] + average correlation coefficients [ACC]) features indicated high performance in classifying tumour-free and metastatic LNs with a sensitivity of 99.27%, specificity of 98.54%, accuracy of 98.90%, positive predictive value of 98.55%, and negative predictive value of 99.26%. The area under the receiver operating characteristic curve was 0.996.

CONCLUSIONS

TA was determined to be a reliable method with the potential for characterisation. This method can be applied by physicians to differentiate between tumour-free and metastatic LNs in patients with PTC in conventional ultrasound imaging.

Diagnostic accuracy of magnetic resonance imaging, transvaginal, and transrectal ultrasonography in deep infiltrating endometriosis

To determine the diagnostic accuracy of pelvic magnetic resonance imaging (MRI), transvaginal sonography (TVS), and transrectal sonography (TRS) in diagnosis of deep infiltrating endometriosis (DIE).This diagnostic accuracy study was conducted during a 2-year period including a total number of 317 patients with signs and symptoms of endometriosis. All the patients were evaluated by pelvic MRI, TVS, and TRS in the same center. The criterion standard was considered to be the laparoscopy and histopathologic examination.Of 317 patients being included in the present study, 252 tested positive for DIE. The sensitivity, specificity, positive predictive value, and negative predictive value of TVS was found to be 83.3%, 46.1%, 85.7%, and 41.6%, respectively. These variables were 80.5%, 18.6%, 79.3%, and 19.7% for TRS and 90.4%, 66.1%, 91.2%, and 64.1% for MRI, respectively. MRI had the highest accuracy (85.4%) when compared to TVS (75.7%) and TRS (67.8%). The sensitivity of TRS, TVS, and MRI in uterosacral ligament DIE was 82.8%, 70.9%, and 63.6%, respectively. On the contrary, specificity had a reverse trend, favoring MRI (93.9%, 92.8%, and 89.8% for TVS and TRS, respectively).The results of the present study demonstrated that TVS and TRS have appropriate diagnostic accuracy in diagnosis of DIE comparable to MRI.

A Useful Gadget to Reduce the Radiation Dose of Interventionist's Hands

Increased demand for interventional radiology techniques has interventionists performing a large number of these procedures. Measurements and calculations have shown that the radiation doses received by these specialists can exceed the threshold of radiation-induced deterministic effects unless radiation protection procedures and devices are used. Proper usage of radiation protection devices can protect them from radiation-induced effects, even with a high workload. Occupational radiation protection entails proper training of interventionists to increase their awareness about available appropriate protection tools and equipment, and devices that can be used to minimize exposure, such as needle holders, tubing extensions, and injectors. This study introduces a device that can be used to fix the catheter to prevent the physician from holding the catheter by hand. The authors, also, discuss the importance of radiation protection training along with the training on new medical equipment, which can be applied to reduce the radiation dose.

A comprehensive approach in high-grade glioma management: position statement from the Neuro-Oncology Scientific Club (NOSC), Shiraz, Iran

Establishing a robust teamwork model in the practice of neuro-oncology requires continued interdisciplinary efforts. The Neuro-Oncology Scientific Club (NOSC) initiative is an interdisciplinary clinical forum promoting the comprehensive approach across involved disciplines in the management of central nervous system (CNS) malignancies. With its provincial founding panels and national steering board, NOSC has been operational in Iran since 2011. This initiative has pursued its mission through interval strategic meetings, tumor boards, case discussions as well as publishing neuro-oncology updates, case study periodicals, and newsletters. A provincial meeting of NOSC in Shiraz put together insights from international practice guidelines, emerging evidence, and expert opinions to draw a position statement on high-grade glioma management in adults. The present report summarizes key highlights from the above clinical forum.

Prevalence of hypothyroidism and thyroid nodule in chronic hemodialysis Iranian patients

INTRODUCTION

End stage renal disease (ESRD) reasons several changes in the function of thyroid gland as; lower levels of thyroid hormones, altered hormone metabolism, and increased iodine storage. The aim of this study was to evaluate the prevalence of nodular goiter and hypothyroidism in hemodialysis (HD) patients compared with normal population.

METHODS

This cross-sectional study was conducted among HD patients and healthy people as the control group for thyroid function evaluation. Thyroid gland was evaluated by physical examination and ultrasonography. Blood level of FT3, FT4, TSH, TPO Ab, and urinary iodine excretion were checked in both groups. Data were analyzed using SPSS-17 and P-value less than 0.05 was considered as the significance level.

FINDINGS

Eighty six HD patients (57.2 ± 17.2 mean age, 48 men) and 86 healthy people (56.6 ± 16.8 mean age, 48 men) were enrolled in this study. Goiter was confirmed by physical examination in 29.0% of the HD patients and 12.8% of the control group (P = 0.04). Nodular goiter that was shown by ultrasonography was found in 27.9% and 3.5% of the HD and control groups, respectively (P = 0.01). HD patients had a higher frequency of reduced FT3 (40.9% vs. 4.6%, P < 0.01) and increased TSH (18.6% vs. 8.1%, P < 0.03(. TPO Ab was positive in 15.1% of the HD and 11.6% of the control groups (P = 0.14).

DISCUSSION

The high incidence of nodular goiter and hypothyroidism in ESRD patients shows that screening for thyroid dysfunction and goiter, using appropriate laboratory tests, should be considered in evaluations of ESRD patients.

The use of micro pulse oximetery as a new detector of tissue perfusion in solid organ transplantation

Vascular complications are a frequent cause of transplant failure; angiography, duplex sonography, computerized tomography (CT) scan, CT-angiography and microdialysis are the methods that were suggested for the detection of arterial obstruction after transplantation. In this study, we suggest a new method. Eight healthy adult dogs were included in the trial. All cases were operated by the same surgeon and the liver, pancreas, spleen, kidney and bowel tissue were exposed. The probes of the device, which were designed for this study, were inserted on the organ parenchyma. The device, a neonatal pulse oximeter, has two probes that were fixed by a holder in front of each other; the distance between the probes was changeable via a spring. The pulse and the oxygen saturation of the tissue were measured initially. Following this, by inducing ischemia with vessel clamping, the pulse and the oxygen saturation were measured again. The collected data were analyzed under the supervision of a statistician. In the liver and spleen, we could not detect a clear pulse wave and oxygenation. On the other hand, in the pancreas, kidney and bowel, we detected a clear curve of oxygenation and pulse in all cases. Obstruction caused significant changes: the pulse was not detected and the oxygenation decreased significantly. Our study suggests that with early diagnosis, the surgeons can detect arterial occlusion immediately and early intervention may decrease parenchymal damage. This study is the first experience in this field, and these findings need to be validated with further studies.

Autologous transplantation of bone marrow-derived mononuclear and CD133(+) cells in patients with decompensated cirrhosis

BACKGROUND

Cirrhosis, the end stage of progressive hepatic fibrosis, is characterized by distortion of the hepatic architecture and the formation of regenerative nodules. Liver transplantation is one of the few available therapies for such patients. However, due to a severe shortage of organ donors, surgical complications, transplant rejection and the high cost of this procedure much interest has focused on research to find new treatment modalities for this disease. There is accumulating evidence for the contribution of bone marrow stem cells to participate in liver regeneration.

METHODS

Here we report on six patients with end stage liver disease who were subjected to intraportal administration of autologous bone marrow-derived CD133(+) in comparison to mononuclear cells in short-term (6 months) and long-term (24 months) follow up.

RESULTS

There were no adverse effects in any of the patients during the short- and long-term follow up period. Moreover, there were no significant alterations of liver function parameters, liver enzymes, serum albumin, creatinine, serum bilirubin and/or liver volume after transplantation of both types of autologous cells in these patients.

CONCLUSION

Our study has shown both the safety and feasibility of this type of liver cell therapy and may be a bridge to liver transplantation. The trial was registered with NIH clinical trials (www.clinicaltrials.gov) as identifier: NCT00713934.

The importance of localizing pulmonary veins in atrial septal defect closure!

An 8-year-old girl was admitted for a simple closure of echocardiographically diagnosed Atrial Septal Defect (ASD). During the operation the right pulmonary veins orifices were not detected in the left atrium and attempt to localize them led to the discovery of three additional anomalies, namely Interrupted Inferior Vena Cava (IIVC), Scimitar syndrome, and systemic arterial supply of the lung. Postoperatively these finding were confirmed by CT angiography. This case report emphasizes the need for adequate preoperative diagnosis and presents a very rare constellation of four congenital anomalies that to the best of our knowledge is not reported before.

Plasma cell tumors with neurologic symptoms: cytological findings

Plasma cell neoplasms (plasma cell dyscrasias) are a group of entities characterized by the neoplastic proliferation of a single clone of plasma cells, typically producing a monoclonal immunoglobulin. These tumors can manifest as multiple myeloma, monoclonal gammopathy of undetermined significance, plasma cell myeloma, or plasmacytoma. We report two plasma cell tumors, one of them presented with headache and diplopia, and the second one complained from low back pain. The aspirate exhibited numerous plasma cells in various stage of maturation and was initially diagnosed as extra-skeletal solitary plasmacytoma on fine-needle aspiration cytology (FNAC). Immunohistochemistry demonstrated monoclonal expression of light immunoglobulin chains together with demonstration of CD 38 positivity. Systematic approach such as bone marrow examination, serum protein electrophoresis, skeletal imaging, and urine examination for Bence-Jones proteins were performed for patients. With these investigations, one case was labeled as multiple myeloma with secondary solitary plasmacytoma in pituitary gland and soft tissue and another one as primary extra-skeletal solitary plasmacytoma. Although fine-needle aspiration is a reliable and rapid technique for initial diagnosis, further work-up and clinical follow-up of these patients is necessary to rule out multiple myeloma. Because of cytomorphological similarity between plasma cells and endocrine cells, EMP of sellar region may be confused with pituitary adenoma especially at the time of intraoperative consultation.

The role of renal autotransplantation in treatment of nutcracker syndrome

To report our experience with renal autotransplantation in treatment of gross hematuria caused by nutcracker Syndrome (NCS). Between September 2005 and January 2008, four patients of mean age 25.5 years (range: 23-28) with gross hematuria were diagnosed to have NCS. Investigations revealed isolated hematuria on urinalysis, a bloody efflux from left ureteral orifice by urethrocystoscopy, dilatation of left renal vein (LRV) with significant difference in peak systolic velocity in colour doppler ultrasonography (CDUS) and dilatation and compression of LRV between aorta and superior mesenteric artery in MRA. After operation, hematuria dis-appeared in all patients. No vascular or urological complication was seen. Follow up ranged from 4 to 24 months. In conclusion, autotransplatation of left kidney is very effective for the treatment of symptomatic NCS.

Renal cell carcinoma in a child

Renal cell carcinoma is a rare disease in children and adolescent. Less than 2% of cases occur in childhood and no treatment protocols exist among urologists and oncologists for management. We present a case of renal cell carcinoma in a child with uncommon presentation.

Magnetic resonance imaging (MRI) findings of joints in young beta-thalassemia major patients: fluid surrounding the scaphoid bone: a novel finding, as the possible effect of secondary hemochromatosis

BACKGROUND

Beta-thalassemia major is a hereditary disease with developing hemochromatosis as a consequence of repeated blood transfusions. Degenerative arthropathy may be the first manifestation of primary hemochromatosis.

OBJECTIVE

The aim of this study is to determine the possible effects of secondary hemochromatosis in joints of beta-thalassemia major patients, and to evaluate the sensitivity of magnetic resonance imaging (MRI) compared with plain x-ray, in the early diagnosis of hemochromatosis of the joints.

METHODS

Thirty beta-thalassemia major patients were randomly enrolled. A questionnaire regarding their history, careful physical examination, the result of their liver biopsies, and other necessary information were completed for these patients. X-ray and MRI of the left hand and wrist were taken in these patients and also in other 30 healthy people with the same age and sex as the case control group.

RESULTS

The prevalence of minimal fluid surrounding the scaphoid bone in MRI was 23.3%, which is a novel and significant finding. Other interesting changes included hypo signal intensity (T1 and T2) in carpal, metacarpal, radius, and ulna bones.

CONCLUSIONS

Regarding the availability of special health services for thalassemia patients, this imaging study can be used for the accurate detection of hemochromatosis in joints of thalassemia patients.

Clinical manifestations and MRI findings of patients with hydrated and dehydrated lumbar disc herniation

RATIONALE AND OBJECTIVES

In addition to the expected appearance of degenerated discs that become dehydrated, hydrated intervertebral disc herniations are sometimes encountered in radiologic practice. This study was undertaken to evaluate the clinical manifestations and MRI findings of hydrated and dehydrated herniated intervertebral discs.

MATERIALS AND METHODS

This cross-sectional single-institution study included 73 patients with dehydrated (group I) and hydrated (group II) lumbar disk herniation. The criteria for hydrated and dehydrated disc herniation were subjective criteria compared to the normal signal of intervertebral discs. A herniated disc has been regarded to be hydrated if more than two thirds of it was hypersignal in T2-weighted images, while more than two thirds of a dehydrated disc was hyposignal on T2-weighted images.

RESULTS

The mean weight of patients in group I was greater than that of patients in group II (69.3 versus 64.2 kg, P < 0.05). Also, patients in group I tended to be older than those in group II (35.2 versus 28.9 years). Regarding physical activity, a greater number of patients in group II had intense physical activity compared to group I patients (25% versus 13.2%, respectively; P < 0.05). The duration of radicular pain and back pain was significantly greater in group I than in group II (485 versus 202 and 1346 versus 242 days, respectively; P < 0.05).

CONCLUSION

Hydrated intervertebral disc herniation tends to be associated with younger age, lighter body weight, shorter duration of radicular pain, and more intense physical activity compared to dehydrated intervertebral disc herniation. These findings may suggest other mechanisms rather than degenerative changes for hydrated disc herniation.

Left renal vein transposition for treatment of the Nutcracker syndrome

The nutcracker syndrome refers to compression of the left renal vein between the aorta and the superior mesenteric artery, which results in renal vein and left gonadal vein varices. Herein, we report our experience with left renal vein transposition for treatment of the nutcracker syndrome. To the best of our knowledge, this is the first reported case of the left renal vein transposition for treatment of the nutcracker syndrome in Iran.

Giant ileal duplication with extensive gastric heterotopia

A rare case of ileal duplication in a 6-year-old boy is presented. The duplicated area is just like an additional ectopic stomach both in radiologic and pathologic examination. The patient was operated on because of intestinal obstruction.

Fine needle aspiration cytology of foreign bodies presenting as cystic abdominal masses. A report of three cases

BACKGROUND

Foreign body material (gauze sponges) presented as cystic abdominal masses and were confused with malignant tumors.

CASES

Two females and one male presented with abdominal masses. They had undergone laparotomy 5-12 years earlier. Clinically the masses were diagnosed as benign or malignant cystic lesions. Fine needle aspiration revealed necrotic material, hemosiderin-laden macrophages, foreign body giant cells, cholesterol crystals and many fragments of birefringent material. The possibility of malignancy was ruled out. Cut sections of the excised cystic lesions revealed gauze sponges surrounded by a thick, fibrotic wall.

CONCLUSION

This report underscores the usefulness of fine needle aspiration in ruling out malignancy.