Tanaffos Respiration Journal
Volume:9 Issue: 3, Summer 2010

Incidence of Tuberculosis (TB) in Golestan province is higher than its national incidence rate in Iran (about 13 in 100,000). Considering the proximity of Mazandaran to Golestan this survey was conducted to determine the high risk areas in Mazandaran province. This was an observational, longitudinal, ecological study conducted during the years 1999 to 2008. Our understudy cases were 2,444 TB patients registered in the TB center of Mazandaran province. Collected data including patients’ age, gender, type of disease and residential location were analyzed using descriptive statistical methods and Nested Poisson regression models. Of 2,444 registered patients, 1,283 (52.5%) were males and 1,161(47.5%) were females; among which, 61% were urban and 39% were rural residents. A total of 96.4% of them were Iranian. No significant difference was observed in TB incidence between the two genders, but incidence of TB in the cities of Tonekabon and Behshahr was 30% higher than the mean incidence rate of this province (P<0.05). Risk of contracting TB infection was 1.46 times greater in urban compared to rural areas (95% confidence interval=1.35-1.59). No significant difference was detected between our study results and those of similar studies conducted in Gilan and Golestan provinces. Higher incidence of TB in Behshahr and Tonekabon compared to the mean incidence of the province is indicative of the spatial correlation of the disease. Lower incidence of TB in neighboring cities might be due to delayed detection of smear-positive pulmonary TB patients. (Tanaffos 2010; 9(3): 15-21)

Latent TB infection can persist for many years with about 10% lifetime risk of reactivation to active disease. However, in children with latent TB infection, disease develops within 2 years of infection. Recently, a new diagnostic test (Quantiferon-TB Gold) which measures the production of interferon (IFN) gamma in whole blood upon stimulation with Mycobacterium tuberculosis has been introduced. The aim of this study is to compare the performance of the IFN-gamma assay with tuberculin skin test (TST) for the identification of latent TB infection in children in contact with active TB in the pediatric pulmonary ward. This cross-sectional study was conducted on 100 children, aged 2months – 15 years admitted to the Pediatric Ward of Masih Daneshvari Hospital during 2007-2008. Whole blood was collected for measuring Interferon-gamma using Quantiferon-TB Gold kit (QFT-Cellestis Comp). In this procedure, Mycobacterium tuberculosis specific antigens (ESAT-6 and CFP-10) are used. In the present research, 100 children were studied and divided into 3 groups of case (TB), contact and control. PPD test was performed by injecting 0.1 ml of the 5 unit solution (Pasteur Institute of Iran) for all cases. Twenty-eight percent of the contacts, 60% of the cases and 10% of the controls were Afghans; the remaining were Iranians. Smear of the gastric washing (3×) was prepared in contact and case (TB) groups; 30% of the cases (TB) were AFB positive, while all of the contacts had negative smears. History of BCG vaccination during neonatal period and BCG scar were present in all cases. Positive PPD test (PPD≥ 10 mm) was observed in 90% of the cases and 24% of the contacts. PPD test was negative in the control group. Out of 50 contacts, 18 (36%) showed positive QFT test; and of 20 TB patients, 18 (90%) had positive tests. Regarding age, children with positive QFT test belonged to the older age group. To our knowledge, this is the first study to investigate the performance of the whole blood IFN-γ assay in diagnosing latent TB infection in children in Iran. This study found a fair correlation between the TST and the whole blood IFN-γ assay in children at high risk of latent TB infection. Our study also highlighted fair and moderate agreement in contact and TB groups respectively between the TST and QFT –TB test in children at high risk for latent TB infection. More studies are required to clarify this relationship. (Tanaffos2010; 9(3): 22-27)

Tuberculosis remains a formidable challenge to health care providers in developing countries and chest wall tuberculosis is a rare entity. Its clinical presentation may resemble a pyogenic abscess or chest wall tumor. There is still controversy regarding the diagnosis and treatment of chest wall tuberculosis. During a 10-year period (1998–2009), 12 cases with chest wall tuberculosis were managed by our team. Patients’ medical records were retrospectively reviewed. After confirming the diagnosis by histopathological examination, patients underwent surgical management. There were 8 male and 4 female patients. Patients’ age ranged from 4 to 60 years. Eight patients had a fluctuating abscess and 4 had a chest wall mass. Surgical procedure was drainage along with debridement in 6 patients, wide debridement along with rib resection in 2 patients and wide debridement along with chest wall resection and reconstruction in 4 patients. Recurrence of cold abscess and fistula formation were detected in 2 patients after a follow-up of 1 to 5 years. Outcome of patients with chest wall tuberculosis was good. chest wall tuberculosis mimics symptoms and signs of chest wall tumors or abscesses. The combination of symptoms and radiographic findings suggests the diagnosis of tuberculosis. Wide debridement and resection are shown to have lower rates of fistula formation, sinus formation and recurrence. Medical treatment must be started immediately after surgery. (Tanaffos2010; 9(3): 28-32)

Many reports are available about the increasing rate of mortality due to overuse of opioids. It has been suggested that sleep apnea can be a cause of mortality because of overuse of opioids. Opium use is common in Iran. This study aimed to assess the effect of opium on polysomnographic findings in opium addicts with sleep apnea syndrome. In this prospective case-control study, 50 opium addicts with sleep apnea were compared and matched for age, sex and body mass index with 50 non-addict patients with sleep apnea to determine the effect of opium on sleep disorders and polysomnographic findings. Sleep stages, apneas, hypopneas and desaturation were evaluated and recorded for participants in both groups. Data were analyzed and compared using SPSS version 15 software. There were significant differences between the two groups in sleep efficiency (P-value=0.00), apnea/hypopnea index (0.02), hypopnea (P-value=0.00), desaturation (P-value=0.01), sleep latency to stage 1(P-value=0.00) and central apnea (P-value=0.00) but no difference was detected for obstructive apnea (P-value=0.48). Opium can increase central apnea, apnea- hypopnea index and desaturation in opium addicts compared with non-addicts. (Tanaffos2010; 9(3): 33-36)

Silicosis is an irreversible progressive lung disease which leads to ultimate death. This study aimed to describe characteristics of individuals affected by silicosis, evaluate the prevalence of silicosis in miners and also introduce preventive policies. Cases with pathologic diagnosis of silicosis were retrieved from archive of pathology department of national research institute of tuberculosis and lung disease (NRITLD) during 2000-2009. All hematoxylin and eosin stained slides were reviewed by two pathologists independent of clinical and imaging findings. Occupational history, clinical information, imaging findings, history of associated disease, method of biopsy and pathologic diagnosis were reviewed. During 2000 and 2009, 29 cases had pathologic diagnosis of silicosis, 4 of them were excluded due to unavailable occupational history. The disease presented among patients in the age range of 22-80 years. The most common occupation was sandblasting while mining was in the second position. The male patients who were miners were old except for one who was a 28-year old car painter whose previous job was mining. Most sandblasters were young except one who was 55. The most prevalent radiologic finding was pulmonary nodules. Restrictive pattern was the most common finding in pulmonary function test (PFT). Of patients, 28% had current tuberculosis. Transbronchial lung biopsy was the method of choice in 14 cases. The most prevalent pathologic finding was early silicotic nodules. Our study demonstrated that mining was not the main occupational history in our understudy cases. We also observed the change in the age range of patients suffering from silicosis which may be due to the prevalence of sandblasting and job demands in young patients. It is recommended that protective measures be applied not only in mining industries, but also in small workshops and studios. It is also necessary that working conditions in these workplaces be evaluated regularly by the occupational safety and health administration. (Tanaffos2010; 9(3): 37-43)

Stenotrophomonas maltophilia and Acinetobacter baumannii are serious offending agents of nosocomial pneumonia and of serious morbidity and mortality in intensive care units (ICU). We report an unexpected sudden surge in cases of pneumonias caused by the above organisms in an intensive care unit of a community hospital in a span of two months. The source was traced back to a contaminated bronchoscope. The records from the patients with diagnosis of pneumonia with the above organisms were retrospectively reviewed. Specimens from the ports and channels of the bronchoscope that was suspected to be the cause were taken and microbiologically analyzed. Two patients with Acinetobacter and four patients with Stenotrophomonas positive bronchoalveolar lavage (BAL) fluid cultures were identified within a 2-month period in one of our two intensive care units. All of the patients were mechanically ventilated, and had clinical features of pneumonia. Their bronchoscopies were performed and their BALs were obtained by a scope with an identical serial number. The microbiologic evaluation of samples taken from the suspected scope revealed that it was improperly decontaminated between procedures. After implementation of strict and revised decontamination protocol, there were no further cases of pneumonia caused by the above organisms in a span of several months in mechanically ventilated patients. Inadequate disinfection of bronchoscopes and cross contamination between patients could be a potential cause of ventilator-associated pneumonia. Strict implementation of infection prevention guidelines in bronchoscopies of mechanically ventilated patients could prevent cases of ventilator-associated pneumonias by nosocomial agents including S. maltophilia and A. baumannii. (Tanaffos2010; 9(3): 44-49)

Treatment for tobacco dependency involves a combination of behavioral therapy, antidepressants, and nicotine replacement therapy. This study was conducted in order to compare the outcome of smoking cessation by using each of the four forms of nicotine replacement therapy (NRT) among participants using Trazodone tablet 50 mg. In this non-randomized quasi-experimental study the efficacy of four mentioned forms of nicotine replacement therapy (NRT) including patches, gums and microtabs and two forms of NRT together was evaluated. Smoking cessation while using Trazodone was also studied. All the smokers who referred to the smoking cessation clinic of Iranian National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Tehran, Iran from Oct. 2005 to Oct. 2007 entered the study. They attended 4 weekly sessions followed by 2 sessions in the next 12 months. A total of 286 subjects participated in this study. Trazodone was prescribed for them and 253 used at least one form of NRT. There were 181 (74.6%) males. The mean age was 42.43±13.4 yrs.Thirty three cases selected nicotine patches, 99(39.4%) used nicotine gums, 64(25%) chose microtabs and 57(23%) preferred using two types of NRT simultaneously. A total of 152 participants (60%) quit smoking at the fourth session. At the fourth session, it was proved that nicotine patches had the highest success rate and were most efficient for quitting smoking (94%). Also, after 6 and 12 months follow-up it was found that nicotine patches were most effective for abstinence. Nicotine patches used in combination with Trazodone tablets could result in higher success rates for smoking cessation. (Tanaffos2010; 9(3): 50-57

The aim of this study is to compare the performance of five applied general severity scoring systems and their ability to predict mortality rate for the intensive care unit patients: Simplified Acute Physiology Score II (SAPS II), Mortality Probability Model II at admission (MPM II0), at 24 hours (MPM II24), at 48 hours (MPM II48) and over time (MPM IIovertime). These scoring systems have been developed in response to an increased emphasis on the evaluation and monitoring of health care services; and also making cost-effective decisions. In this historical cohort study, all of the scoring systems were applied to 114 patients and the predicted mortality rate and the Standardized Mortality Ratio (SMR) were calculated for them. Calibration of each model and discriminative powers were evaluated by using Hosmer-Lemeshow goodness of fit test and ROC curve analysis, respectively. The predicted mortalities were not significantly deviated from the main systems (SMR for SAPS II: 0.79, MPM II0: 1.10, MPM II24: 1.32, MPM II48: 1.08 and MPMOvertime: 1.02). The Hosmer-Lemeshow statistics had the least value for MPM II48 (C=2.922, p-value=0.939); and the discrimination was best for MPM II24 (AUC=0.927) followed by SAPS II (AUC=0.903), MPM II0 (AUC=0.899), MPM II48 (AUC=0.848) and MPM IIovertime(AUC=0.861). All five general ICU morality predictors showed accurate standardized mortality ratio. MPM II24 had the best discrimination, MPM II0 had the best SMR before 24 hours and MPMovertime had the best SMR after 24 hours. Performance of MPM II and its ease of use make it an efficient model for mortality prediction in our study. (Tanaffos2010; 9(3): 58-64)

Sinus of Valsalva Aneurysm (SVA) is caused by dilation, usually of a single sinus of Valsalva, from a separation between the aortic media and the annulus fibrosus. Indeed, a deficiency of normal elastic tissues and abnormal development of the bulbus cordis have been associated with the development of SVA. We report a 31-year-old man with unusual presentation of ruptured sinus of valsalva aneurysm. (Tanaffos2010; 9(3): 65-68)

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)

Sarcoidosis is a systemic disorder characterized by noncaseating granulomas, involving multiple organs including thyroid and great vessels. We present a 48 year-old women with sarcoidosis, left subclavian artery occlusion and sarcoidal thyroid gland involvement. The patient presented with a 1 week history of progressive left upper limb pain with coldness of left hand and fingers. On examination, radial, ulnar, and brachial artery pulses were not palpable. She had also enlarged thyroid gland with firm consistency. CT angiography of aortic arc demonstrated occlusion of left subclavian artery. Because of progressive ischemic necrosis of left hand and fingers, amputation above elbow was performed. Fine needle aspiration (FNA) was suspicious for thyroid neoplasm and total thyroidectomy was performed. Thoracic CT scan showed mediastinal and bilateral hilar lymphadenopathy. Fiberoptic bronchoscopy with transbronchial needle aspiration (TBNA) from right hilar lymph nodes and endobronchial biopsy showed multiple granulomas with negative acid-fast stain. Pathologic examination of thyroid also revealed fibrosis and granulomatous inflammation. On follow up, the ACE level was 104 u/l. (Tanaffos2010; 9(3): 75-79)