Caspian Journal of Internal Medicine
Volume:4 Issue: 2, Spring 2013

The treatment of human brucelosis is controversial. The purpose of this study was to search published clinical trial papers to provide a simple and effective treatment in brucellosis. Many studies on brucellosis treatment in a twenty- year span from 1993 to 2012 were searched in PubMed, Web of Science (ISI), Scopus, Google Scholar, Magiran, Iranmedex and SID. The studies that were searched and classified in groups according to combination therapy and monotherapy and their results in treatment outcome were compared. Regimens with lower treatment failure or relapse were considered as more suitable for brucellosis treatment. The comparison of combined doxycycline and rifampicin (DR) with a doxycycline plus streptomycin (DS) favors the latter regimen. The combined doxycycline/co-trimoxazole (DCTM) showed similar effect with DR. The treatment with the combined regimen including quinolones was similar to DR but with higher relapse rates. Higher relapse rate was searched in monotherapy (13% vs. 4.8%) and in short-term (less than 4 weeks) treatment regimen (22% vs. 4.8%), respectively. Although in children, clinical trials were limited but showed cotrimoxazole plus rifampin for six weeks was the best treatment regimen. In uncomplicated brucellosis in adult patients, doxycycline-aminoglycoside combination is the first choice with doxycycline- rifampin and doxycycline-cotrimoxazole should be the alternative regimens. The other oral regimens including quinolones may be considered as alternatives. Cotrimoxazole plus rifampin for six weeks may be the regimen of choice for the treatment of patients younger than 8 years old. Gentamicin for 5 days plus cotrimoxazole for six weeks may be a suitable alternative regimen.

Blind percutaneous pleural biopsy has traditionally been performed to investigate the etiology of exudative pleural effusion in which the initial thoracocentesis has been non- diagnostic. In view of the increasing use of image-guided and thoracoscopic pleural biopsies, this study examined the role of blind Abrams pleural biopsy in the investigation of the exudative pleural effusion in the largest tertiary pulmonary center in Tehran, Iran. All patients with pleural effusion admitted from September 2007 to April 2009 entered in this study. The patients with exudative pleural effusion underwent blind Abrams pleural biopsy when the initial thoracocentesis was non-diagnostic. The patients with non-diagnostic blind biopsy underwent surgical biopsy or other investigations based on the physician’s decision. The data were collected and analyzed. Blind percutaneous pleural biopsy was performed in 171 patients. Malignancy was diagnosed in 56 and tuberculosis in 52 cases with blind biopsy. For all the diagnoses, blind biopsy had a sensitivity of 70.1% and negative predictive value of 14.8%. For malignant diagnosis, the sensitivity value was 58.9%, specificity 100% and negative predictive value 63.2%. For TB diagnosis, sensitivity value was 88.1%, specificity 100% and negative predictive value 93.6%. The overall malignancy was diagnosed in 95 (58.6%) and TB in 59 (36.4%) patients. Blind Abrams needle biopsy was diagnostic in approximately three out four patients presented with undiagnosed exudative pleural effusion. The data support the use of the Abrams needle in the investigation of pleural effusion especially in the less developed countries.

Early diagnosis of albuminuria and the prevention of its progression to macroalbuminuria and diabetic nephropathy are crucial. Angiotensin converting enzyme inhibitors (ACEIs) and antagonists of angiotensin II receptors type I (ARBs) are currently used as first-line treatment for albuminuria in these patients. The present study was conducted to assess the efficacy of addition of spironolactone to ACEIs or ARB in the prevention of diabetic nephropathy. Sixty patients were selected from the patients who referred to a Diabetes Clinic in this randomized clinical trial study. The control group received enalapril and the case group took additive therapy with spironolactone for 12 weeks. Blood pressure, concentrations of creatinine and albumin in the serum and urine, urinary albumin/creatinine ratio, serum potassium were determined for each patient in the beginning of and every 4-6 weeks until the end of the study. This clinical trial was registered in the Iranian Registry of Clinical Trials (www.irct.ir) with registration number ID: IRCT201105084849N2. There was statistically significant difference in albumin/creatinine ratio between the two groups (p<0.001). Albuminuria reduced more significantly in case group compared to control group. It was measured 66.6±26.8 mg/mmol and 45.7±19 mg/mmol in control and case groups, respectively. The patients did not develop any significant adverse effect including reduction in GFR, hyperkalemia, and hypotension. Low to moderate doses of spironolactone can augment the effect of ACEIs in the prevention of diabetic nephropathy.

Cefepime was used as empirical treatment in ventilator-associated pneumonia (VAP) induced by gram-negative and gram-positive bacteria. This study aimed to determine the antimicrobial susceptibility pattern of cefepime against microorganism causing VAP in Mazandaran, North of Iran. This study was performed on VAP patients diagnosed with clinical pulmonary infection score (CPIS) scores in ICU of two hospitals. For each patient suspected of having VAP, quantitative culture of endotracheal aspiration (QEA) was performed and MIC was determined by micro dilution test. Data were collected and analyzed. Thirty- five cases of enterobacteriaceae were isolated orderly including E coli 13, P. aeruginosa 11, Enterobacter 7 and K. pneumonia 4 cases. All the isolated E. coli, Enterobacter and Klebsiella, 54.5% of P. aeruginosa isolated were fully resistant to cefepime. The results of this study show that cefepime is not a reasonable choice for empirical treatment of nosocomial pneumonia and VAP.

Chronic renal failure patients undergoing hemodialysis are susceptible to periodontal diseases due to systemic complications of the disease and using different drugs. The present study investigated the periodontal status of patient’s who underwent hemodialysis, in Babol, northern Iran. One-hundred-fifteen hemodialysis patients (63 males, 52 females) with the mean age of 47.9±15.3 years were studied at Shahid Beheshti Hospital in Babol, Iran. Periodontal parameters including plaque index (PI), gingival index (GI), clinical attachment level (CAL) and probing pocket depth (PPD) were measured in these patients. The data were collected and analyzed. The PI, GI, CAL and PPD were 2.37±0.55, 2.36±0.63, 3.98±1.61 and 4.41±1.4, respectively. Significant positive correlations were found between the participants’ age and PI (p<0.024) and p<0.001, respectively. Also, CAL was significantly higher in males than females (4.39±1.57 vs. 3.53±1.56, p<0.02). The results show that longer duration of hemodialysis is associated with severe periodontal diseases, especially in males.

Lactic acidosis in cardiac surgical patients is a manifestation of systemic inflammation and excess pro-inflammatory cytokine production. This investigation was designed to integrate basic concepts about lactate acidosis with a clinically used of serum lactate in patients under coronary artery bypass surgery (CABG) by on pump method. From August to September 2012, 15 patients scheduled for routine cardiac surgery entered to our sample and followed up two weeks. Lactate concentration in arterial blood sample was studied. Method of surgery duration of cardiopulmonary bypass, aorta cross clamp timing, hemodynamic parameters, inotrope dosage and patient outcome were documented. The data were collected and analyzed. The mean age of the patients was 62±14 years. The patients with a poor outcome had significantly higher lactate levels in ABG samples (p<0.001). ABG lactate levels did not correlate with the magnitude of intra-operative bleeding or volume of packed cell transfusion (p>0.05). The PH of ABG samples did not generally correlate with the ABG lactate concentration (r=0.116, p=0.68). Increased lactate concentration was reliably associated with patient hemodynamic parameters, inotrope dosage, duration of on pump time and aorta cross clamp time. This study demonstrates a correlation between serum lactate levels and patient prognosis after CABG surgery by on pump method.

Periodontitis is common in adults and cardiovascular diseases (CVD) are the most common cause of adult death in the world. This study aimed to investigate the relationship between CVD and periodontitis. Sixty patients with myocardial infarction (MI) as case and 63 subjects with periodontitis without MI as control were studied. Periodontitis was assessed according to Ramfjord periodontal diseases index and the number of missing teeth besides classic risk factors of MI were recorded. The patients who lost more than 10 teeth were at more risk of myocardial infarction (OR=2.73). There was a significant relationship between mean attachment loss and MI (p=0.0001). There was also a relation between attachment loss more than 3 mm and MI with OR of 4. Significant difference between mean PDI (periodontal disease index) was seen in case and control groups (p=0.0001). Subjects with PDI>4 were at more risk of periodontal diseases (OR=7.87). The results show the presence of significant relation between periodontitis and MI which could serve as an alarm to treat periodontitis carefully.

Bacillus anthracis may usually cause three forms of anthrax: inhalation, gastrointestinal and cutaneous. The gastrointestinal (GI) anthrax develops after eating contaminated meat. Thus, in this paper were report 5 cases of intestinal anthrax. We report a case series of intestinal anthrax, with history of consumption of raw or poorly cooked liver of sheep. One patient was female and 4 were males with the age range between 17 and 26 years. All patients were admitted with abdominal pain, nausea, and vomiting. Examination revealed abdominal distention on the right lower quadrant or diffuse tenderness. Laboratory examination in all patients showed leukocytosis with polymorphonuclear of >80%. Because of the unclear and questionable diagnosis, exploratory laparotomy was performed on several patients, invariably showing an abundant yellowish and thick ascitic fluid, soft hypertrophied mesenteric lymph nodes (3-5 cm) mostly in the ileocecal region, and substantial edema involving one segment of small bowel, cecum or ascending colon. Anthrax was diagnosed on the epidemiologic basis (ingestion history of half cooked liver of sheep) or microbiologic (microscopy with bacterial culture) and pathologic testing (post surgery in four patients or autopsy in one patient). With appropriate treatment, 4 survived and one patient died. Gastrointestinal anthrax is characterized by rapid onset, fever, ascitis and septicemia. The symptoms can mimic those seen in an acute surgical abdomen. Rapid diagnosis and prompt initiation of antibiotic therapy and then exploratory laparotomy (right hemicolectomy) are keys to survival.

Alkaptonuria is a rare genetic disease leading to the accumulation of homogentesic acid in joint and ear cartilage, sclera and some other tissues causing significant morbidity in these patients. In this paper, we report three cases of Alkaptonuria among the family or household members. A 51-year-old man with mechanical low back and knee pain was referred to Rheumatology Clinic of Babol University of Medical Sciences. The physical examination showed thoracic kyphosis and limitation of motion in thoraco-lumbar spine, severe knee osteoarthritis and blue-black discoloration of ear cartilages. There was intervertebral disc calcification in plain radiography, and mitral valve calcification in echocardiography. His urine sample was tested positive in Benedict’s test. The diagnosis was confirmed by qualitative assessment of homogentesic acid (HGA) that was highly positive. In addition, we found two more cases of Alkaptonuria in his family. Although alkaptonuria is a rare disease, but it may be found in cluster among the family members.