Caspian Journal of Internal Medicine
Volume:7 Issue: 4, Autumn 2015

Human toxoplasmosis is an important zoonotic infection worldwide which is caused by the intracellular parasite Toxoplasma gondii (T.gondii). The aim of this study was to review briefly the general aspects of toxoplasma infection in in Iranian health system network.
We searched published toxoplasmosis related articles in English databases including Science Direct, Pub Med, Scopus, Google Scholar, Magiran, Iran Medex, Iran Doc and Scientific Information Database (SID) for toxoplasmosis.
Out of 1267 articles from the English and Persian databases search, 40 articles were suitable with our research objectives and so were selected for the study. It is estimated that at least a third of the world human population is infected with T.gondii, suggesting it as one of the most common parasitic infections through the world. Maternal infection during pregnancy may affect dangerous outcome for the fetus, or even cause intrauterine death. Reactivation of a previous infection in immunocompromised patient such as drug induced, AIDS and organ transplantation can cause life-threating central nervous system infection. Ocular toxoplasmosis is one of the most important causes of blindness, especially in individuals with a deficient immune system.
According to the increasing burden of toxoplasmosis on human health, the findings of this study highlight the appropriate preventive measures, diagnosis, and management of this disease.

Transient elastography (TE) is a new modality for the diagnosis of liver fibrosis caused by various etiologies. This study was conducted to determine the accuracy of TE in detecting the different stages of liver fibrosis in non-alcoholic fatty liver disease (NAFLD) patients.
MEDLINE/PubMed, Embase, Ovid, Cochrane Library, American College of Physicians (ACP) Journal Club, Google Scholar, Database of Abstracts of Reviews of Effects, and Web of Science that evaluated the liver stiffness by means of TE and liver biopsy were enrolled in this systematic review and meta-analysis. Published articles were extracted from 2002 to March 2015.
A total of 7 articles from 114 papers were included which consisted of 698 patients. The results indicated that when F ≥3, the outcomes were 93.7% (95% confidence interval (CI): 92-95.5), 91.1% (95% CI: 89-93.2), 82.4% (95% CI: 79.9-84.9), and 95.9% (95% CI: 94.4-97.4) for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), respectively. With fibrosis stage ≥4, it has reached the sensitivity of 96.2 % (95% CI: 94.5-97.8), a specificity of 92.2% (95% CI: 89.9-94.6), a PPV of 5.5% (95% CI: 51.2-59.8) and NPV of 98.5% (95% CI: 97.4-99.5).
We concluded that as the pathological fibrosis increases, the sensitivity, specificity and NPV of TE in the diagnosis of fibrosis improves in NAFLD patients. TE can be considered as a unique alternative instead of liver biopsy in NAFLD patients and it has an important role in the exclusion of liver cirrhosis. More studies are required to confirm the results.

Vitamin D (Vit D) is linked to various conditions including musculoskeletal, metabolic and cardiopulmonary diseases. However, it is not clear whether correction of vit D deficiency exerts any beneficial effect in patients with pulmonary hypertension.
This study was a prospective uncontrolled longitudinal study. Patients with pulmonary hypertension and vit D deficiency were enrolled into this study. All patients in addition to standard treatment for pulmonary hypertension received cholecalciferol at a dose of 50,000 IU weekly plus calcicare (at a dose of 200 mg magnesium 8 mg zinc 400 IU vit D) daily for 3 months. Serum level of 25-hydroxy vit D, serum level of pro-brain natriuretic peptide, six minute walk test (6MWT), peak and mean pulmonary artery pressure, right ventricular size and function, ejection fraction (EF) and New York Heart Association (NYHA) functional class were measured at baseline and after 3 months of treatment.
Twenty-two patients with pulmonary hypertension and vit D deficiency were enrolled into the study. At endpoint, the serum vit D level increased significantly to 54.8 ng/ml, the mean of baseline distance of 6MWT increased significantly to 81.6 m and the RV size significantly improved. The mean pulmonary artery pressure also improved after the intervention, but their changes did not reach to statistically significant levels.
Vit D replacement therapy in patients with pulmonary arterial hypertension and vit D deficiency results in significant improvement of right ventricular size and 6 MWT. Moreover, mean pulmonary artery pressure improves nonsignificantly. This issue requires further studies with long-term follow-up period.

Azithromycin (AZM) is used in periodontal infections. The present study compared gingival crevicular fluid concentration of azithromycin of two pharmaceutical companies through the HPLC method.
Two groups (n=15) of healthy volunteers participated in this study. The first group received an imported azithromycin (ImAZM) tablet (250 mg, PO) and the second group received an azithromycin tablet (250 mg PO) manufactured by an Iranian pharmaceutical company (IrAZM). Intrasulcular paper points (#30) were used in inter-proximal areas of molars and canines to collect gingival crevicular fluid samples at 6, 12, 36, 84 and 156 hours after drug administration.
The maximum concentration of AZM in gingival crevicular fluid was detected in each group 36 hour after administration. The concentration levels for the participants receiving ImAZM and IrAZM were 14.38±5.75 and 12.64±3.53 ng/mL, respectively. The pharmacokinetic (PK) modeling data showed half-life of AZM was 107.47 hr & 91.42 hr while the clearance was 113.02 hr &119.0 hr for the group receiving ImAZM and IrAZM, respectively. No significant differences were observed in other PK parameters, areas under the concentration time curves for the groups were almost identical.
According to the results, there were no significant differences between the PK parameters of ImAZM and IrAZM products. It may be concluded that different doses of AZM have relatively similar PK parameters among the healthy participants.

Helicobacter pylori (H.pylori) infection causes multiple upper gastrointestinal diseases but optimal therapeutic regimen which can eradicate infection in all the cases has not yet been defined. This study was designed to evaluate the efficacy of triple levofloxacin-based versus clarithromycin-based therapy.
In this open-label randomized clinical trial study 120 patients who had esophagogastroduodenoscopy (EGD) with positive rapid urease test (RUT) were enrolled and divided into 2 groups. Case group was treated with levofloxacin (500 mg daily) plus amoxicillin (1 gr twice a day) plus omeprazole (20 mg daily) for 2 weeks. Control group was treated with clarithromycin (500 mg twice a day) plus omeprazole (20 mg daily) for 2 weeks. After the main course of treatment, they received maintenance treatment with omeprazole for 4 weeks. Stool antigen test was performed on them after two weeks of not having any medicine.
H.pylori eradication (intention to treat analysis) was successful in 75% of case group and 51.7% of control group showing a significant difference (P=0.008). H.p infection eradication (per-protocol analysis) was successful in 80.4% in case group and 57.4%% in control group showing significant difference (P=0.009). Drugs adverse effects causing discontinuation treatment were seen in 5% of case group and 3.3% of control group which have not shown a significant difference between the two groups (P=0.648).
Triple therapy with levofloxacin-based regimen has better efficacy than clarithromycin-based regimen and as safe as it is.

In lupus nephritis (LN), deposition of pathogenic autoantibodies in the glomeruli is mediated via cross-reactivity with alpha-actinin. Association of serum alpha-actinin antibody (AαA) with LN has been shown in a few studies but the results are controversial.
Eighty patients into entered the study. The diagnosis of SLE was confirmed according to the American College of Rheumatology criteria and LN was diagnosed by proteinuria ≥ 500 mg/24 hour and kidney biopsy. Serum AαA was measured with ELISA method. Receiver operating characteristics curve (ROC) analysis was applied to determine an optimal cutoff value for AαA to discriminate patients with and without LN at the highest sensitivity and specificity. The association of AαA with LN was determined by logistic regression analysis with calculation of odds ratio (OR).
Serum AαA was significantly lower in LN as compared with SLE patients without LN (P=0.001). Serum AαA at cutoff levels ≤ 59.5 pg/ml discriminated the two groups with sensitivity, specificity, positive predictive values of 60%. 90% and 85.7%, respectively. Serum AαA level ≤ 59.5 pg/ml was significantly associated with LN (OR=13.5, P=0.001) and the OR increased to 25.2 (P=0.003) after adjustment for age, sex, C3, C4, anti-ds-DNA, SLEDAI.
This study indicates that serum AαA decreases in LN and serum level ≤ 59.5 pg/ml is SLE and is predictive of nephritis.

Aspirin is the most widely used drug in medicine for cardiovascular and as recently for its role in cancer prevention. Although the risk of bleeding events increased following regular use of aspirin, little is known about the association of aspirin and hematuria. The present study aimed to evaluate the association of regular aspirin use and microscopic hematuria in elderly.
In this study, we have extracted the data of elderly people who participated in Amirkola Health and Aging Project (AHAP) and taking regular doses of aspirin. The prevalence of microscopic hematuria was compared between the elderly who took aspirin regularly and those who did not take it.
A total of 1243 individuals (54.22% males, 45.78% females) were entered in to the study. Two hundred and eighty-four (23%) elderly took regular doses of aspirin. Microscopic hematuria was seen in 305 (24.54%) elderly. The prevalence of microscopic hematuria was 27.27% in regular users of aspirin and 23.72% in non-users of aspirin (P=0.126). The prevalence of microscopic hematuria was significantly higher among the regular users of aspirin compared to non-users in multiple logistic regression analysis (P=0.035, OR=1.40, 95%CI: 1.02-1.92).
Taking regular doses of aspirin was accompanied with higher rate of microscopic hematuria in the elderly.

In this study, we determined the serum levels of IL-17A and IL-10 in context with 1, 2 dihydroxy vitamin D3, parathormone and Ca2ﳸ ions to investigate their pathological or protective roles respectively in bone metabolism.
The bone mineral density (BMD) was determined for 1203 participants using energy X-ray absorptiometry. Subjects with a history of diseases and using bone metabolism medications were excluded and finally serum IL-10 was measured in 82 osteoporotic and 74 healthy individuals (mean age ±SD of 71.04±6.9 and 68.58±6.9 respectively). Also, the serum level of IL-17A was assessed in 42 osteoporotic and 39 non-osteoporotic subjects (mean age±SD of 69.40±6.7 and 70.77±7.1, respectively). Serum levels of 1, 25-dihydroxyvitamin D3, Ca2ﳸ ions and parathormone were extracted from AHAP cohort data bank.
IL-17A was detectable in 7.42(16.67%) osteoporotic subjects and 3.39(7.69%) normal subjects. Surprisingly, patient subjects exhibited a higher level of serum IL-10 than normal subjects (P=0.023). We found that the serum parathormone levels tend to increase in patient group (P=0.003) in comparison to normal control with no correlation with Il-10 levels. There was no significant difference between the two groups in the serum levels of 1, 25-dihydroxyvitamin D3, Ca2橷 Pi ions.
In reaction to chronic inflammation old osteoporotic patients independent of 1, 25 dihydroxy vitamin D3 may produce a higher level of IL-10 to dampen production of inflammatory cytokines including IL-17A which in turn leads to speeding up parathormone production ultimately reaching a new homeostasis status in bone metabolism with normal serum Ca2 /Pi ions.

Acanthosis nigricans (AN) is a brown to black, velvety hyperpigmentation of the skin that usually involves cutaneous folds. Treatment of AN is important regarding cosmetic reasons and various therapeutic modalities have been used for these purposes. The goal of this study was to compare the effectiveness of long-pulsed alexandrite laser and topical tretinoin-ammonium lactate for treatment of axillary-AN.
Fifteen patients with bilateral axillary-AN were studied in Razi Hospital, Tehran, Iran. Diagnosis was confirmed by two independent dermatologists. Each side skin lesion was randomly allocated to either topical mixed cream of tretinoin 0.05%- ammonium lactate 12% or long-pulsed alexandrite laser. Duration of treatment was 14 weeks. At endpoint, the mean percent reduction from baseline in pigmentation area was compared between the two groups.
The study population consisted of 15 patients, three males and 12, females. The mean age of patients was 28.5±4.9 years. The mean percent reduction was 18.3±10.6%, in tretinoin/ammonium lactate group and 25.7±11.8% in laser group (P=0.004).
These findings indicate that the application of alexandrite laser is a relative effective method for treatment of axillary-AN. However, this issue requires further studies with prolonged follow-up period.

Dextrocardia is a congenital anomaly, which may have coexistent coronary artery disease (CAD), arrhythmias and conventional indications for device therapy. However, the implantation of transvenous leads can be technically challenging and the approach needs to be tailored to the patient''s individual anatomy.
A 54-year-old male with dextrocardia situs inversus and ischemic left ventricular dysfunction developed ventricular tachycardia and fibrillation. Therefore, left- sided approach, dual chamber implantable cardioverter-defibrillator (ICD) was applied using a conventional method and standard equipment after complete evaluation of cardiac anatomy and vascular assessment.
Electrical device implantation in patients with dextrocardia is possible after obtaining complete information about anatomy and/or coexisting congenital abnormalities, which helps in obtaining appropriate implantation approach.

There have been reports on stent-related vascular erosions about patients with benign or malignant stenosis of the esophagus who received endoscopic stent insertion for palliative intention for oral intake.
A 61-year-old woman with esophageal cancer located in the middle part of esophagus was treated with esophagectomy. Two years following the surgery, malignant stenosis recurred in the esophagogastric anastomosis. A non-covered self-expanding metal stent (10 cm length with a diameter of 18 mm at expanded state) was inserted. Three months later, a massive hematemesis with subsequent hemorrhagic shock developed from the proximal end of the stent which resulted in the final diagnosis of arterioesophageal fistula on the left subclavian artery. An endovascular repair using a stent graft for the left subclavian artery via the right common iliac artery was performed and the patient remained well until discharge.
Increase in the treatment of esophageal strictures by stent insertion increases the risk of stent-related vascular fistula. These complications should be considered in any patients with massive upper gastrointestinal bleeding.