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Presentation of pandemic H1N1 influenza (H1N1) is widely evolving as it continues to involve different geographic locations and populations. This study was conducted to improve the precision of clinical diagnosis of H1N1 (2009) influenza infection in an outpatient setting. A prospective cross-sectional study was conducted among adult patients (age >15 years) with influenza-like illnesses (ILI) from November 2009 to February 2010. Clinical, laboratory and epidemiological findings in the first week of illness were collected using a standardized datasheet. Influenza testing was performed by real-time reverse- transcriptase polymerase chain reaction (rRT-PCR). Thirty nine (24%) patients were positive for H1N1 and 123 (76%) were negative for any subtype of influenza A virus. Whilst otalgia (14% vs. 0 p= 0.01) was more prevalent in non-influenza A cases, cough (90% vs. 72% p = 0.03) and shortness of breath (67% vs. 47% p = 0.02) were more often associated with H1N1-infection. Comparative analysis of co-existing conditions and demographic factors of patients revealed no other significant differences between the two groups. The clinical presentation of H1N1 (2009) infection is largely indistinguishable from other acute respiratory diseases. Although previous studies suggested significant differences in demographic and co-existing conditions of H1N1 infected patients, our study shows that as the pandemic spreads worldwide and affects the majority of the population, H1N1 diagnosis based on clinical presentation and demographic characteristics has become less practical and much more difficult in tertiary care centers.

Aspergillosis is a rapidly progressive, often fatal infection that occurs in severely immunosuppressed patients, including those who are profoundly neutropenic, recipients of bone marrow or solid organ transplants and patients with leukemia, lymphoma, advanced AIDS or phagocytic disorders such as chronic granulomatous disease. Patients with severe liver disease are at a higher risk for infections. Immunocompetent individuals rarely develop this infection and do so only in the presence of pulmonary and systemic abnormalities such as fibrotic lung disease, suppurative infection or when they are on corticosteroids. We present 2 cases of pulmonary aspergillosis in diabetic patients. They presented with cough and dyspnea. Aspergillus was found in obtained respiratory samples. Pulmonary aspergillosis was confirmed in our first case by transbronchial lung biopsy (TBLB) and Galactomannan assay. In the second case, diagnosis of pulmonary aspergillosis was established by thoracic CT guided biopsy plus Galactomannan assay. These patients had none of the suggested risk factors for Aspergillus infection but they had uncontrolled diabetes mellitus. This report highlights that pulmonary aspergillosis can occur in individuals with diabetes mellitus even in the absence of other risk factors such as corticosteroid use, severe granulocytopenia or other associated immunosuppressive factors.It is; therefore, valuable to recognize that in patients with diabetes mellitus pulmonary aspergillosis should be considered as an important differential diagnosis for respiratory problems. (Tanaffos2010; 9(3): 69-74)

A 40 year-old taxi driver residing in Tehran presented with two episodes of massive hemoptysis following a 3-week period of productive cough, dyspnea on exertion, fever, night sweat, anorexia and weakness. He was a heavy smoker (40 packs per year), and an IV drug user since 5 years ago with a history of imprisonment 3 years ago. He had no history of alcohol consumption or unprotected sexual contact. His physical examination revealed poor oral hygiene, diffuse coarse crackles in lungs, edema of the lower extremities which was dominant in the left leg and no petechia, purpura or any other skin lesion. He had normal blood biochemistry, liver function tests and electrolytes. Complete blood count revealed a microcytic, hypochromic anemia with a PMN dominant leukocytosis and normal platelet count. Erythrocyte sedimentation rate was 87. PPD was non-reactive and 3 times sputum smear for acid fast bacilli was negative. Urinalysis was normal. Chest x-ray (Figure 1) and lung CT-scan (Figure 2) were performed. Transthoracic and transesophageal echocardiographies (TTE & TEE) were reported to be normal without vegetation or other abnormalities.

The pandemic influenza A (H1N1/2009) virus as a new challenge for health care providers has caused significant morbidity and mortality worldwide. Although many aspects of this virus are similar to other human influenza viruses, there are some disparities. This article reviews different aspects of influenza H1N1/2009 virus with focus on clinical features and management of patients

A 49 year-old non smoker man from an Iranian rural region residing in Tehran, presented with chronic non-productive cough since 7 months ago. He worked in a dairy farm located in Tehran and had a 7-year history of contact with chemical agents. He had fever and night sweats since 3 months ago with episodes of myalgia and arthralgia and a 10 kg weight loss. He did not give any history of hemoptysis or dyspnea. During this period he was treated with multiple courses of antibiotics including ceftriaxone and azithromycin without any improvement. He was also under a regimen of clonazepam and amitriptyline for a major depressive disorder. On physical examination, his vital signs were stable with no respiratory distress. All physical findings were normal, except for an oral temperature of 38.2˚C and end inspiratory crackles in lower lobes of both lungs. Complete blood count revealed a PMN dominant leukocytosis. Blood biochemistry, liver function tests and urinalysis were normal. Erythrocyte sedimentation rate (ESR) for the first hour was 125mm. PPD test was nonreactive. Three consecutive sputum smears and cultures plus sputum polymerase chain reaction (PCR) were all negative for mycobacterium tuberculosis. Severe restrictive pattern was observed in pulmonary function test. Transthoracic echocardiography was reported to be normal. Chest x-ray (Figure 1) and thoracic spiral CT scan (Figure 2) were performed. Ground glass opacity and infiltration in lingula, right middle lobe and both lower lobes with mild cardiomegaly and small sized mediastinal adenopathy were revealed on CT scan.

The pubic symphysis is a rare site for osteomyelitis. We reported a case of osteomylitis pubic about 9 months after inguinal hernia repair. The causative organism is staphylococcus aureus resistant to all antibiotics except vancomycin. The patient was treated with antibiotics for six months without any surgical debridement. This is a report of a pubic osteomylitis following inguinal hernia repair.

Sarcoidosis is a granulomatous multisystem disease of unknown etiology. It has recently been tired to detect Mycobacteria genome in biopsy specimens of patients with sarcoidosis by Polymorphism chain reaction method. To detect and identify Mycobacteria species in cutaneous lesions of the patients with sarcoidosis by PCR-RFLP. Patients and 20 patients with clinical diagnosis of sarcoidosis were enrolled in this study. Clinical manifestations, appearance of naked granuloma under light microscope and exclusion of other diagnoses confirmed the diagnosis of sarcoidosis in the patients. By PCR-RFLP, genome of Mycobacteria species was searched in paraffin embedded specimen of skin biopsies of the patients. Four PCR positive skin biopsy specimens of patients with cutaneous tuberculosis were used as positive control. 10 skin biopsy specimens with other than tuberculosis were used as negative control. Mycobacteria genome was not detected in any specimens of the patients. Our findings do not support the role of Mycobacteria species in the pathogenesis of sarcoidosis.