Massive dermal ulcerative lesions due to brown recluse spider bite: a rare case report and review of literature

A brown recluse spider (BRS) bite is challenging to confirm, but may be clinically diagnosed by considering the location, the season of the year, and the clinical manifestations. Here, the case of a 26-year-old male who presented after an insect bite with a skin lesion, bruising, severe swelling, and diffuse blisters on the right lower extremity after three days, is described. Following clinical examination, patient history assessment, and consideration of other relevant factors, the patient received a differential diagnosis of necrotizing fasciitis caused by BRS bite. Although spider bite poisoning is rare, proper diagnosis and management are important because, in some cases, the outcomes may be devastating.

Massive dermal ulcerative lesions because of brown recluse spider bite: a rare case report and review of literature

A brown recluse spider (BRS) bite is challenging to confirm, but can be clinically diagnosed by considering the location, the season of the year and the clinical manifestations. We described a 26-year-old male who presented after a BRS bite with a skin lesion, bruising, severe swelling and diffuse blisters on the right lower extremity after 3 days. This case should be considered in the differential diagnosis of necrotizing fasciitis. Although spider bite poisoning is rare, proper diagnosis and management are important because, in some cases, it can have devastating outcomes.

Rabies Virus Infection: A Case Series and Literature Review

Background: Rabies is a fatal and often neglected disease leading to encephalomyelitis following a bite by an infected mammal. According to the necessity of rabies disease in Iran, we present four cases of rabies virus infection. Case Presentation: We presented 4 cases of rabies virus infection hospitalized in different hospitals in Iran in 2021-2022. Three patients were male. The youngest patient was 6 years old and the oldest was 81 years old. In all 4 cases, RT-PCR detected the positive virus infection. Three cases received rabies immunoglobulin. All of them received at least one dose of rabies vaccination; but, unfortunately, all patients died. Conclusions: The present case series showed the necessity of early rabies vaccination and also the early organization of stray dogs in the community. Unfortunately, two cases were lost to follow-up. So, the population education and follow-up of suspected rabies patients must be taken seriously by healthcare facilities.

Mucormycosis, one month after recovery from COVID-19: A case report

Introduction

and importance: There are increasing case reports of mucormycosis in patient with coronavirus disease 2019 (Covid-19). Herein, we describe the case of mucormycosis after recovery from Covid-19.

Case presentation

The patient was a 73 years old woman with a history of chronic kidney disease, diabetes mellitus, hypertension, and dyslipidemia that referred to the emergency department with clinical presentation of Covid-19. On the third day of admission, the Covid-19 PCR test was negative, but the patient presented headache and pain in her upper jaw. Physical examination showed fever, erythema, and tenderness in the right cheek. Emergency biopsy and culture from sinus by subsection to mucormycosis conducted. and the diagnosis of mucormycosis was confirmed by the positive result of biopsy and culture. Despite anti-fungal treatment with Amphotericin B, patient developed severe diarrhea and became hemodynamically unstable. In the stool analysis, Strongyloides stercoralis was reported. Unfortunately, patient was expired on day thirty-two of this admission.

Clinical discussion

Mucormycosis is a dangerous infection, and its rapid diagnosis is so important. On the other hand, Covid-19 may associated with many nonspecific sign and symptoms. These finding may overlap with other infections.

In patients with prolonged mucormycosis infection, the development of strongyloidiasis should not be neglected. A single dose of ivermectin as strongyloidiasis prophylaxis should be given if the duration of the illness is prolonged.

Conclusion

Clinicians should consider mucormycosis and its complications after Covid-19 treatment in diabetic and immunocompromised patients.

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COVID-19 may be associated with bacterial or fungal co-infections.

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Nonspecific sign and symptoms of COVID-19, may overlap with other infections.

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Mucormycosis may occur following COVID-19, especially in patients with risk factors.

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We report a case of mucormycosis, one month after recovery from COVID-19 in a patient with poor diabetic control.

Comparison of the Efficacy and Safety of Atazanavir/Ritonavir Plus Hydroxychloroquine with Lopinavir/Ritonavir Plus Hydroxychloroquine in Patients with Moderate COVID-19, A Randomized, Double-blind Clinical Trial

This was a randomized, double-blind clinical trial to compare the efficacy and safety of Atazanavir/Ritonavir (ATZ/RTV) with Lopinavir/Ritonavir (LPV/RTV) in moderate Coronavirus disease 2019 (COVID-19). Participants were randomly assigned to receive a single dose of hydroxychloroquine (HCQ) plus ATZ/RTV or LPV/RTV for a minimum of 5 to a maximum of 10 days. The primary outcomes were the reduced length of hospital stay and clinical recovery within 10 days from starting the intervention. The rate of intensive care unit (ICU) admission, intubation, and mortality, the lengths of ICU stay and being intubated, recovery within 14 days, and the frequency of adverse reactions were considered as secondary outcomes. Among 132 enrolled patients, 62 cases in each arm were analyzed at the end of the intervention. Fifty-one (82.3%) cases in the ATZ/RTV arm versus 41 (66.1%) in the LPV/RTV arm were discharged within 10 days (P = 0.06). The median number of the intervention days was 6 (IQR: 5-8) in ATZ/RTV arm versus 7 (IQR: 6-9) in LPV/RTV arm (P = 0.01). The rate and length of ICU admission and intubation (P ≥ 0.99), rate of mortality (P = 0.49), and recovery within 14 days (P = 0.09) were not statistically different between groups. The most reported adverse reactions were nausea and vomiting that all cases were in the LPV/RTV arm (P = 0.006). ATZ/RTV is better tolerated in comparison with LPV/RTV; however, it did not show more efficacy than LPV/RTV in clinical outcomes of COVID-19 in this study.

Evaluation of Tuberculin Skin Test (TST) in Medical Students in Mazandaran University of Medical Sciences, Sari, Iran

<p><strong>BACKGROUND: </strong>Working in health care units has been known as occupational risk factor in mycobacterium tuberculosis (TB) infection. The TB exposure rate in medical students is more than other people. In several studies significant correlation has been reported between hospital presence hours and positive PPD test prevalence. With regard to morbidity of several medical students and nursing staff due to primary tuberculosis in recent years, we decided to investigate positive tuberculin skin test (TST) prevalence in medical students and examine correlation between positive cases prevalence with presence hours in hospitals.</p><p><strong>METHODS: </strong>This was a cross sectional study and 297 medical students of Mazandaran University of medical sciences were investigated. TST was done with Mantoux method. After 48 hours, injection site induration was measured. Subjects that had induration &lt;10 millimeters were injected again (1-3 weeks later) with same method. (As a booster dose)</p><p><strong>RESULTS: </strong>32 cases (10.7%) had positive test at the first phase. Second phase was done on rest 265 persons and 20 cases had positive test. In summation 52 positive cases (17.5%) were observed. 21 cases of 151 persons (13.9%) in group with &lt;100 hours/annual hospital presence, had positive tests. 21 cases of 71 persons (16.9%) in group with 100-1000 h/a hospital presence (Extern) and 19 cases of 75 people (25.3%) those who had  &gt;1000 h/a hospital presence(Intern),  had positive tests. There was a meaningful statically difference in positive tests, between groups &lt; 1000 hours exposure and the other who had &gt; 1000 hours contact (p=0.032).</p><p><strong>CONCLUSIONS: </strong>Because of, Interns’ high responsibilities and their more involvement in patient’s diagnostic and therapeutic process, they have high chance to contact with undiagnosed and diagnosed tuberculosis patients. Due to these reasons, TB infection rate is increasing among Interns. As a result of these findings, performing PPD test should be considered at the beginning of entrance to hospital departments and then annually. Necessary tasks and following up are needed to new positive cases.</p>

Clinical and laboratory manifestation and outcome of icterohemorrhagic leptospirosis patients in Northern Iran

BACKGROUND

Icterohemorrhagic form of leptospirosis has a high mortality rate. In this study, the clinical manifestations, epidemiologic and laboratory findings and outcome of Weil's disease were investigated.

METHODS

A descriptive cross- sectional study was conducted on 66 consecutive patients with icterohemorrhagic leptospirosis who were admitted to Razi Hospital (The Therapeutic Center of Infectious Diseases in the North of Iran) in 2013. The inclusion criteria were as follows: All patients who had clinical and epidemiological data suggestive of leptospirosis and displayed icterohemorrhagic form at the time of admission or during hospitalization. All patients were visited on admission, one, two and six weeks later. Demographic data, clinical, laboratory features and complications were evaluated, and statistical analysis was performed using SPSS version 13.0.

RESULTS

Among 66 patients, 89.4% (n = 59) were male, 60% (n = 40) were farmers and 9.1% (n= 6) had a history of swimming in rivers. The most common complaints were fever and jaundice, respectively. The most common clinical symptoms were fever (90.9%), myalgia (75.8%), chills (70.8%) and headache (65.1%). Hyponatremia and hypernatremia were seen in 7.6% and 72.8% of the participants, respectively. Also, hypokalemia was observed in two patients (3%). Approximately, half of the cases had leukocytosis and 90% had thrombocytopenia. Rise of AST, ALT, ALP and bilirubin were seen in 95.2%, 93.6%, 76.2% and 100% of the patients, respectively. Of the patients, 42.4% experienced complications of icterohemorrhagic leptospirosis including acute renal failure (30.3%) pneumonia (25.8%), pancreatitis (4.5%), subarachnoid hemorrhage (1.5%) and gastrointestinal bleeding (1.5%). Three cases (4.5%) died, 42 cases (63.7%) were discharged with residual effects and 52 patients (78.8%) had positive serology.

CONCLUSION

The most significant biochemical abnormalities were thrombocytopenia, hyperbilirubinemia, hyponatremia and hypernatremia and azotemia and the latter remained stable in 2% of the patients at least until the end of the 6-week period.

Cryptococcal meningitis due to Cryptococcus neoformans genotype AFLP1/VNI in Iran: a review of the literature

Cryptococcal meningitis is the most important opportunistic fungal infection with a high mortality in HIV-patients in less developed regions. Here, we report a case of cryptococcal meningitis in a 49-year-old HIV-positive female due to Cryptococcus neoformans (serotype A, mating-type alpha, genotype AFLP1/VNI) in Sari, Iran. In vitro antifungal susceptibility tests showed MICs of isavuconazole (0.016 μg ml(-1) ), voriconazole (0.031 μg ml(-1) ), posaconazole (0.031 μg ml(-1) ), itraconazole (0.063 μg ml(-1) ), amphotericin B (0.125 μg ml(-1) ) and fluconazole (8 μg ml(-1) ). Despite immediate antifungal therapy, the patient died 4 days later due to respiratory failure. Cryptococcal infections have been infrequently reported from Iran and therefore we analysed all published cases of cryptococcosis in Iran since the first reported case from 1969.

Resistance Pattern of Antibiotics in Patient Underwent Open Heart Surgery With Nosocomial Infection in North of Iran

Background:

Patients who undergo cardiac surgery appear to be at increased risk for the development of Nosocomial infections (NIs). The development of antibiotic-resistant infections has been associated with significantly greater hospital mortality rates compared to similar infections caused by antibiotic-sensitive pathogens.

Objectives:

The purpose of this study is survey of Nis and antibiotic resistance patterns of causative bacteria among patients who underwent open heart surgery in the north of Iran during a 2-year period between September 2012 and September 2014.

Methods:

In this cross-sectional study we evaluated 187 patients that underwent open heart surgery with NIs. Demographic feature, clinical characteristics and risk factors of each infection were recorded. The antibiotic susceptibility test was performed using the Minimum inhibitory concentration (MIC) method according to the standard protocol of Clinical & Laboratory Standards Institute (CLSI). Detection of Extended-spectrum beta-lactamase (ESBL) producing bacteria was performed by the double-disk synergy (DDS) test; also Methicillin-resistant Staphylococcus (MRSA) strains were identified by MRSA Screen Agar. The collected data were analyzed using the SPSS software (ver. 16) and, descriptive statistics were used.

Results:

Out Of total of 2253 hospitalized patients who underwent open heart surgery, 187(5.05%) patients had NIs. 51.9% of the patients were female. The rates of surgical site infection (SSI), respiratory tract infection, endocarditis, Urinary tract infection (UTI), blood Infection and mediastinitis were 27.80, 25.66%, 17.64, 17.11% 8.55% and 3.20% respectively. E.coli and S.aureus were the most causative agents of NIs. The rate of ESBL-producing bacteria was 14.28- 71.42% among enterobacteriaceae and the rate of MRSA was 54.2% among S.aureus strains. All isolated Acinetobacter.spp were Multi-drug resistance (MDR).

Conclusions:

We showed that the rate of NIs among these high-risk patients was in the average level. But the emergence of MRSA and ESBL bacteria is increasing in our region.

Corticosteroid in the treatment of moderate to severe thrombocytopenia due to leptospirosis

Background:

Thrombocytopenia is associated with a bad prognosis in Leptospirosis.

Objectives:

We investigated the effect of corticosteroids to improve thrombocytopenia due to leptospirosis.

Patients and Methods:

In a clinical trial, all patients admitted with leptospirosis in Razi Hospital of Ghaemshahr, north of Iran were enrolled in a 2-year study. Totally, 56 patients with moderate to severe thrombocytopenia were randomized to control and treatment groups. The treatment group received corticosteroid (prednisolone 1 mg/kg/day for maximum one week) in addition to the standard antibiotic therapy.

Results:

There was no significant difference regarding age and gender between the two groups (P = 0.254, P = 0.789, respectively). The mean duration to improve thrombocytopenia was 4.41 ± 0.197 days in the treatment group and 5.72 ± 0.318 days in the control group, which was significantly different (P = 0.003). Duration of hospitalization in the treatment group was 5.24 ± 0.244 days and 6.23 ± 0.329 days in the control group, which was significantly different (P = 0.028). The two groups had no significant difference regarding mortality, intubation, level of platelet, duration of ICU admission and pulmonary, renal or hepatic involvement.

Conclusions:

Corticosteroid therapy decreased the length of hospitalization only in severe subgroup thrombocytopenia, but not in the moderate subgroup.

Depression in hepatitis B and C, and its correlation with hepatitis drugs consumption (interfron/lamivodin/ribaverin)

OBJECTIVE

Chronic infection of hepatitis B and hepatitis C are considered as the most important infectious diseases, which lead to drastic consequences such as liver dysfunction. Depression is a psychiatric disorder which is concomitantly present in these patients, and decreases the patients' quality of life. It may lead to suicide, homicide or intentional transmission of infectious to others. Medical treatment with interferon can also lead to depression which is comparable to the depression caused by disease.

METHODS

We performed a cross sectional study on 205 patients with hepatitis B and hepatitis C infection. We aimed to determine the prevalence of depression via Beck Depression Inventory (BDI), and its correlates with hepatitis drugs.

RESULTS

Of 205 patients, 154 cases had hepatitis B and 51 cases had hepatitis C infection. The frequency of depression was 68% in hepatitis B and 86% in hepatitis C infected patients (p<0.05). The frequency of mild depression was 14%, moderate depression was 57.3% and severe depression was 28.7% (p<0.05). Depression frequency in Interferon recipients was 100%, in interferon-ribavirin recipients was 94.4%, in lamivudine recipients was 64%, and in patients that receive no drug was 66.7%. Depression prevalence was significantly higher among those on interferon therapy (p<0.05).

CONCLUSION

There is a high prevalence of depression among patients with hepatitis B and hepatitis C infection, especially patients on interferon therapy. Hence these patients should be repeatedly evaluated for depression.

DECLARATION OF INTEREST

None.

Bilateral breast swelling in a 23-year-old woman with Burkitt lymphoma

Primary breast lymphoma (PBL) of the breast is a rare type of localized non-Hodgkin lymphoma, which is usually of the B-cell. The majority of breast lymphoma present as a unilateral painless breast masses in an older woman, average age at diagnosis 55-60. A less common but distinctive presentation is a young woman of childbearing age who presents during or immediately after pregnancy. We present a 23-year-old postpartum woman with bilateral breast swelling. After surgical drainage and debridement and pathologic examination, the diagnosis of breast Burkitt lymphoma (BL) was confirmed. Chemotherapy was immediately started for her and the patient showed a good response with complete remission.

Validation techniques for quantitative brain tumors measurements

Quantitative measurements of tumor volume becomes more realistic with the use of imaging- particularly specially when the tumor have non-ellipsoidal morphology, which remains subtle, irregular and difficult to assess by visual metric and clinical examination. The quantitative measurements depend strongly on the accuracy of the segmentation technique. The validity of brain tumor segmentation methods is an important issue in medical imaging because it has a direct impact on many applications such as surgical planning and quantitative measurements of tumor volume. Our goal was to examine two popular segmentation techniques seeded region growing and active contour "snakes" to be compared against experts' manual segmentations as the gold standard. We illustrated these methods on brain tumor volume cases using MR imaging modality.

Age-specific seroprevalence of hepatitis A in Sari, northern Islamic Republic of Iran

The declining incidence of hepatitis A virus (HAV) infection in the Islamic Republic of Iran may be reducing the population's natural immunity. This was the first systemized, population-based survey of the seroprevalence of HAV antibodies in urban and rural inhabitants of Sari, Mazandaran province. Serum from 1034 individuals aged 1-25 years in 2007 were tested for anti-HAV lgG antibody using a commercial enzyme immunoassay kit. The overall seroprevalence was 38.9%. The lowest prevalence (5.2%) was among the younger age group (1-5 years) from urban areas and the highest prevalence (82.0%) in the older age group (15-25 years) from rural areas. Seropositivity was significantly higher at higher age, among females and in rural areas. Sari is no longer classified as an area of high endemicity, and immunization against HAV may be needed in our population in the future.