Caspian Journal of Internal Medicine
Volume:4 Issue: 3, summer 2013

Hepatitis activity index (HAI) and fibrosing stage are two important findings during the evaluation of liver samples in patients with chronic hepatitis B. The aim of this study was to determine the HAI and fibrosing stage in patients with anti-HBe positive chronic hepatitis B. Liver biopsy slides of 72 patients were evaluated at the Department of Pathology in two teaching hospitals of Babol University of Medical Sciences, Iran, from April 2006 to August 2011. Total HAI or grading as well as its components including piecemeal necrosis, confluent necrosis, spoty necrosis, portal inflammation and fibrosis scores or staging in considering with viral loads more or less than 105 copies/ml were enumerated according to Ishak scoring system. The mean age of these patients was 34.4±12 years. Fifty-six patients had viral load> 105 copies/ml. Piecemeal necrosis and grading scores with viral load (103,103-105 and >105 copies/ml) were 0.8±0.7, 0.9±0.4, 1.8±1 and 3.8±1.9, 4.4±2, 5.9±2.6, respectively (p=0.005 and p=0.04, respectively). There was not any significant difference with fibrosis stage regarding different viral loads. In total, 18 cases had fibrosis scores > 1 and 24 cases had confluent necrosis. HAI?4 was seen in 29 (60.4%) of the 48 cases without confluent necrosis and in 23 out of 24 cases with confluent necrosis (p=0.007). The results show that piecemeal necrosis and higher grading scores are associated with higher viral loads. The presence of confluent necrosis is associated with more severe diseases.

Varicella zoster virus (VZV) infection is one of the nosocomial infections and healthcare workers (HCWs) are at high risk group who work in the hospital with likelihood of varicella acquisition or transmission. This study evaluated the VZV seroprevalence in this high risk population in Babol, Iran. Serological testing for VZV using enzyme linked immunosorbent assay (ELISA) was performed on 459 HCWs in Ayatollah Rouhani Hospital, Babol, Northern Iran from 2011 to 2012. The questionnaire consisted of age, gender, place of residence, marital status, history of chickenpox, educational level, working experience and risk of exposure. The data were collected and analyzed. The mean age of these subjects was 32.2±1.1 years. Four hundred-sixteen (90.6%) cases were females and 43 (9.4%) were males. The overall positive seroprevalence of VZV was 94.6%. No statistically significant differences were observed between age, gender, place of residence, risk of exposure, marital status, educational level, working experience and seropositivity. The seropositivity of varicella was seen in 278 (95.5%) of 297 cases with positive history and in 30 (81.1%) of 37 cases who did not (p=0.005). The results show that a positive history of VZV is associated with positive seroprevalence but can not be a reliable indicator of the immunity, therefore, serological screening should be considered for all the HCWs. Also, vaccination of susceptible subjects was recommended.

Iron-mediated cardiomyopathy is the main complication of thalassemia major (TM) patients. Therefore, there is an important clinical need in the early diagnosis and risk stratification of patients. The aim of this study was to evaluate the efficacy of tissue doppler imaging (TDI) to study cardiac iron overload in patients with TM using T2* magnetic resonance (MR) as the gold-standard non-invasive diagnostic test. A total of 100 TM patients with the mean age of 19±7 years and 100 healthy controls 18.8±7 years were evaluated. Conventional echocardiography, TDI, and cardiac MRI T2* were performed in all subjects. TDI measures included myocardial systolic (Sm), early (Em) and late (Am) diastolic velocities at basal and middle segments of septal and lateral LV wall. The TM patients were also subgrouped according to those with iron load (T2*? 20 ms) and those without (T2* > 20 ms), and also severe (T2*? 10 ms) versus the non-severe (T2*? 10 ms). Using T2* cardiovascular MR, abnormal myocardial iron load (T2*? 20 ms) was detected in 84% of the patients and among these, 50% (42/84) had severe (T2*? 10 ms) iron load. The mean T2* was 11.6±8.6 ms (5–36.7). A negative linear correlation existed between transfusion period of patients and T2* levels (r = -0.53, p=0.02). The following TDI measures were lower in patients than in controls: basal septal Am (p<0.05), mid-septal Em and Am (p<0.05), basal lateral Am (p<0.05), mid-lateral LV wall Sm (p<0.05) and Am (p<0.05). Tissue doppler imaging is helpful in predicting the presence of myocardial iron load in Thalassemia patients. Therefore, it can be used for screening of thalassemia major patients.

Neutropenic patients are vulnerable to a wide spectrum of infectious agents. The aim of this study was to determine the current frequency of bacterial infections in patients with nosocomial fever and neutropenia. In a retrospective study, the neutropenic patients’ specimens with nosocomial fever were cultured on blood and MacConkey agar plates and evaluated at microbiology laboratory. Ninety-five significant isolates as species level were recognized by bacteriological techniques. The most observed microorganism was Escherichia coli, followed by Pseudomonas aeruginosa, Acinetobacter baumanii, Klebsiella pneumoniae, Coagulase positive staphylococci and Coagulase negative staphylococci. One fungal infection was also observed. Overall, 67% of the organisms were gram negative, 29.8% gram positive, and 3.2% polymicrobial. The changing pattern of infectious agents in neutropenic patients overtime postulates the necessity of other studies to give the most up-to-date insight of the organisms to physicians.

Anti-CCP is a test commonly used for the diagnosis of rheumatoid arthritis. The aim of this study was to determine the diagnostic values of ACCP compared to anti-MCV in rheumatoid arthritis patients in north of Iran. The serum samples of 150 RA patients and 75 controls, with the mean age of 49.6+11.8 and 48.8+12 years respectively, were tested using the commercially available ELISA kits for ACCP and anti-MCV. Sensitivity, Specificity were determined and Roc curve were used for comparison between these two groups. The sensitivity of ACCP versus anti-MCV was 85% and 81%, respectively. Specificity was 96% and 95%, respectively. In the RA patients, ACCP was positive in 127 (84.7%) and anti MCV in 121 (80.7%) cases. In the control group, these parameters were positive in 3 (4%) and 4 (5.3%) (p<0.0001 and p<0.0001, respectively). The correlation coefficient for ACCP and anti-MCV was calculated at 0.63 (p<0.001). The area under the curve for ACCP was 0.941±0.015 (p<0.001), anti-MCV was 0.902±0.02 (p<0.001). The measure of agreement (Kappa) for these variables was 0.81. In these patients, there was no correlation between DAS28 and the positivity of these tests. It was concluded, compared to ACCP, anti-MCV has approximately the same accuracy for the diagnosis of rheumatoid arthritis and it does not have additional value.

Cobalamin deficiency and peripheral neuropathy (PN) are commonly seen in HIV-infected adults. The level of urine methylmalonic acid (UMMA), a reliable indicator of tissue cobalamin status, was determined in HIV infected subjects with and without PN to establish this association. One hundred and ninety-eight (198) consenting HIV infected subjects with and without PN were recruited for the study. UMMA level was determined by Cation Exchange High Performance Liquid Chromatography (HPLC) with Ultraviolet detector in 165 subjects. Simple proportions of patients with raised UMMA (defined as value> 3.4 mg in 24hr) were determined for each arm. Among the 198 subjects studied, 146 had PN and 52 had no PN. From the 165 subjects whose UMMA was studied, raised UMMA was found in 76.6% (36 of 47) of subjects with no PN as compared with 53.4% (63 of 118) of those with PN (p=0.018). Cobalamin deficiency (measured by UMMA level) even though common in HIV infected subjects, may not be the cause of peripheral neuropathy in these subjects.

Omeprazole is metabolized predominantly by CYP2C19, a polymorphically expressed enzymes that show marked interindividual and interethnic variation. These variations cause a substantial differences that have been reported in the pharmacokinetics of omeprazole. The aim of the present study was to evaluate the pharmacokinetic parameters of omeprazole in a random Iranian population. From the 20 subjects, only 17 healthy unrelated individuals of either sex (9 females age range 22-24 years) participated in the study. After an overnight fasting, a sample of blood was collected. The subjects received a single oral dose of 40 mg capsule of omeprazole (losec) and blood samples were taken up to 8 hours. Omeprazole was analyzed by the HPLC method and population pharmacokinetic analysis was performed using population pharmacokinetic modelling software P-Pharm. The mean value for apparent plasma clearance (CL/F) was 20.8±6.9 (L.h-1). The corresponding value for apparent volume of distribution (V/F), and t1/2 beta were 21.6±7.5 (L) and 0.8±0.3 (h), respectively. A comparison of the weight normalized V/F and CL/F of omeprazole between males and females revealed that both parameters were significantly higher in females than males (p?0.03). These results show a substantial interindividual variability in omeprazole pharmacokinetics and this might affect the therapeutic effects of omeprazole as reported previously.

The pattern of glomerular diseases in northwest Iran is unknown. This study was conducted to evaluate the histological pattern of renal diseases in this region. We retrospectively studied the reports of 266 native adult renal biopsies at the Imam Reza and Taleghani Hospitals from June 2007 to June 2012. Pathological findings include minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), mesangioproliferative glomerulonephritis (MPGN), mesangiocapillary glomerulonephritis (MCGN), post streptococcal proliferative glomerulonephritis (PSPGN), membranous glomerulonephritis (MGN), hypertensive nephropathy (HN), crescentic glomerulonephritis or rapid progressive glomerulonephritis (CGN or RPGN), chronic tubular interstitial necrosis (CTIN), chronic sclerosing glomerulonephritis (CGN), Alport syndrome, acute tubular necrosis (ATN), lupus nephritis, renal amyloidosis. The data were collected and analyzed. The mean age of the patients was 37.41±15.78 years. Nephrotic syndrome was observed in 155 (58.3%) cases which was higher in frequency in females (61.9%) (p<0.005), followed by renal insufficiency in 87 (32.7%) cases. Totally, 187 (70.3%) had primary glomerulonephritis (GN) whereas, 79 (29.7%) had secondary GN. MCD was found to be the most common histological pattern (44%) and CGN (1.12%) was the least common. The frequencies of secondary glomerulonephritis (GN) include lupus nephritis to be the most frequent (41.8%) followed by chronic tubulo interstitial nephritis (38%) and type II diabetic nephropathy (19%). The results showed that MCD ranked first followed by FSGN. We hope that this will form the basis for developing a renal biopsy registry across the continent in Iran.

Although infectious diseases are the most common sources for the fever of unknown origin (FUO), but the spectrum of infectious diseases is changing overtime. The purpose of the study was to define the clinical spectrum and changing the pattern of FUO. This existing data based study was undertaken from 2007 to 2011. One hundred-six patients fulfilling the modified criteria for FUO referred in a teaching hospital in Ahvaz were enrolled for analysis. The data extracted from the patient''s medical files and etiologic agents caused FUO to be assessed. Infections were the most common cause of FUO in 48.4% of the patients. Among the infections, the most important causes of FUO were represented by extra-pulmonary tuberculosis 15 (31.9%), osteomyelitis 10 (21.3%) and abdominal abscesses 6 (12.8%). The pattern of FUO in the region is thought to be changed to extra pulmonary TB and osteomyelitis. Tuberculosis is still the leading cause of FUO in our region.

Inhibitory antibody to exogenous Factor VIII (FVIII) is a major complication of hemophilia treatment. This study was conducted to determine the prevalence of inhibitor antibody directed against FVIII. From May 2010 to May 2011, 52 patients with severe hemophilia A admitted in Amirkola Children’s Hospital were evaluated. Those who had abnormal mixing study, antibody against FVIII were measured. Data were collected and analyzed. The age range of the patients was 4-60 years. The inhibitor antibody was seen in 9 (17.3%) patients. The mean age of patients with inhibitor at the time of diagnosis was 10.22 years (ranged 4-31 years). Old patients had more hemarthrosis than young patients. The mean level of inhibitor antibody was 8.47 Bethesda (ranged 2.3-29). Six patients had inhibitor antibody level? 5 Bethesda unit and three patients had inhibitor antibody level<5 Bethesda unit. This study showed that the prevalence of inhibitor antibody in young patients is more than the old patients.

Sj?gren’s syndrome is an autoimmune syndrome involving the exocrine glands specially the salivary and lacrimal glands leading to xerostomia and xerophtalmia. This paper presents a case with primary Sj?gren’s syndrome that severe dental caries were the first clinical manifestation. A 42-year-old man was referred to the School of Dentistry, Tehran University of Medical Sciences due to unexplained severe dental decays. After systematic evaluation and consultation with the rheumatologist and the ophthalmologist, the diagnosis of primary sj?gren’s syndrome was suggested and confirmed by serologic and histopathologic study. Primary sj?gren’s syndrome should be considered in the differential diagnosis of patients with early severe dental caries

Hyper IgE syndrome (HIES) is a rare primary immune deficiency, described as Job`s syndrome characterized by increased serum levels of IgE, eczema, recurrent cutaneous and pulmonary infections. In this paper, we presented a case of Hyper IgE syndrome. A 16-year-old Iranian boy presented with a one year history of skin lesions in knees and elbows was diagnosed of psoriasis disease. He had a history of recurrent infections including otitis media, pneumonia, diarrea and skin infection. Laboratory results showed increased level of total IgE and normal in other immunoglobulin. Histologic finding showed hyperkeratosis, parakeratosis of acanthotic epidermis with regular elongation of rete ridges diagnose psoriasis disorder. In conclusion, this is the first case of hyper IgE patient with psoriasis disorder. We addressed the important laboratory findings and actual theories explaining possible association between hyper IgE immunoglobulinemia and psoriasis disorder.

Solid tumors may occur in 3% of the patients with chronic myeloid leukemia (CML). In this paper, we presented a case of CML following treatment of colon cancer. A 25 year old man was diagnosed of adenocarcinoma of rectosigmoid treated with fluorouracil-based chemotherapy. Following relapse, he received florouracil, oxaliplatin and irinotecan during the next year. Then he developed BCR-ABL positive CML. With Imatinib 400 mg/day, he achieved hematologic response but died because of progressive colon cancer. This article emphasizes that there is a possibility for etiologic correlation between CML and chemotherapeutic agents in solid cancers.