IRANIAN JOURNAL OF MEDICAL SCIENCES (IJMS)
Year:2000 | Volume:25 | Issue:1-2|Papers Count:18

Background: There is a growing concern about the rapid rise in resistance of Staphylococcus aureus to antimicrobial agents.Objective: To determine the prevalence and pattern of antibiotic sensitivity among methicillin-resistant and -sensitive S.aureus in Shiraz, south of Iran.Methods: One hundred and six S. aureus isolates from patients with staphylococcal infections were collected. The isolates were screened for methicillin-resistance by minimum inhibitory concentration (MIC) determination and agar screen plate. Detection of acquired resistance was accomplished by addition of a b -lactamase inhibitor to the test media. Tolerance was detected by determination of minimum bactricidal concentration (MBC)/MIC ratio. Results: The frequency of intrinsic-resistant S. aureus was 33.0% (90% in isolates from burn unit patients). Acquired-resistant and tolerant isolates comprised 4.7% and 0.9% of all isolates respectively. None of the isolates showed MOD-type resistance [for "modified" penicillin binding proteins (PBPs)]. The pattern of resistance to 13 antibiotics were determined by disk diffusion method. None of the intrinsic-resistant isolates were resistant to vancomycin or rifampin but the frequency of resistance to other compounds was high. The methicillin-sensitive and acquired-resistant isolates were highly sensitive to all tested antibiotics except penicillin. Conclusion: In this study, methicillin-resistance proved to be a useful marker in selecting appropriate antimicrobial agents for treatment of infections caused by S. aureus. Changing pattern of resistance of S.aureus makes its periodic surveillance (each 3 to 4 years once) mandatory.

Background/Objective: Multiple endocrinopathy is a common manifestation in thalassemia. Although the response of the stress hormones to induced hypoglycemia has been studied in these patients, the impact of surgical stress is not yet determined. Methods: The hypothalamo-pituitary-adrenal axis of 27 thalassemic patients (TP), [4-15 years old (y.)] admitted for splenectomy, was evaluated before and after surgical stress during 1996-8. Blood samples for measurement of ACTH, cortisol, growth hormone (GH), thyroid stimulating hormone (TSH) and prolactin (PRL) were taken a day before and also approximately two hours after surgical insult. For comparison, 22 non-thalassemic patients (NTP) (3.5-14 y.) admitted for elective laparotomy, were selected as the control group. Results: The cortisol response after surgical stress was significantly higher than baseline in both the TP (17.4 ? 6.3 vs 30.81 ? 11.49 ?g/dl; P<0.00l) and the NTP (20.65 ? 9.1 vs 36.87 ? 11.08 ?g/dl; P<0.001). NTP showed a significant elevation of ACTH upon surgical stress (P<0.001), while the difference between pre- and post-stress ACTH was not statistically significant in TP (P=0.123). However, the ACTH concentration before operation in TP. was significantly higher than that of NTP (P<0.042) with no remarkable difference after surgical stress between the two groups (P=0.261). GH increased significantly after operation in TP and NTP (P< 0.016 and <0.05, respectively). A significant change in TSH (P< 0.03) and PRL (P< 0.004) was also observed in TP after operation. Conclusion: The hypothalamo-pituitary as well as the pituitary-adrenal axes are usually intact and responsive in TP. It is concluded that, the remarkable increase in ACTH concentration before operation may be due to a decreased adrenal reserve. Thus, the possibility of primary partial adrenal insufficiency, particularly under stress situations, should be considered in every thalassemic patient.

Objective: To determine the risk of thoracic vessels involvement in patients with Beh?’s disease (BD) presenting with lower extremity deep vein thrombosis (DVT). Methods: The study was performed from August 1997 to April 1998, on 10 patients with BD, who had at least one episode of DVT in the lower extremities in their past or present illness. The diagnosis of DVT was based on physical examination and sonography and/or Doppler sonography. Medical history taking regarding pulmonary symptoms such as: cough, with or without sputum production, dyspnea, chest pain, and hemoptysis as well as physical examination, including vascular examination, was performed in all the cases. A new chest x-ray was taken from all 10 cases and following an informed consent, 7 patients had a high resolution CT scan (HRCT) of the chest. All of the 10 studied cases underwent thoracic vessels angiography using the intra-venous digital subtraction angiography (IVDSA) method. The analysis of data was done using Fisher"s exact test and student T-Test. Results: Out of the 10 studied cases, seven were male and three were female. Three patients had only one episode, while the other 7 had more than one episode of DVT in the lower extremities. The time interval from diagnosis of BD to the emergence of vascular lesions was 7.8 years. Regarding respiratory manifestations, 5 out of 10 cases were symptomatic and the rest were asymptomatic. Chest x-rays of 9 out of 10 cases were normal, while in one case changes in favor of pulmonary artery aneurysm (PAA), were observed. HRCT scans from the thoracic cage were done in 7 out of 10 cases, with 3 positive findings, [2 with pulmonary artery thrombosis (PAT) and 1 with superior vena cava obstruction (SVCO)]. On thoracic vessel IVDSA 6 cases with positive findings were detected (3 with PAA, 3 with SVCO, and 2 with pulmonary artery thrombosis), in both symptomatic and asymptomatic cases. (Fisher exact =0.4850)(p value=0.05%, t (9) = 1.97, risk = 30%). Gender and pulmonary symptomatology had no significant effect with respect to the results. Conclusion: Patients with (BD) with at least one episode of DVT in the lower extremities have a 30% risk of thoracic vessels involvement by non-invasive angiography using the IVDSA method. Hemoptysis is a late heralding sign for thoracic vessels involvement in BD patients with thrombophelebitis of the lower extremities. Therefore, we recommend radiological screening of thoracic vessels by IVDSA method in this group of BD patients, especially in areas with an increased prevalence of BD. Chest x-ray is not a good screening method for detection of thoracic vessels involvement although HRCT scan can be a helpful procedure for detection of thrombosis in thoracic vessels.

Background: The thalassemias are among the most prevalent genetic diseases worldwide. There is a high incidence of thalassemia in Iran; one of the countries located on the so-called "thalassemia belt". Repeated blood transfusion in thalassemia may cause iron deposition in many tissues including endocrine organs. Objective: To study the pituitary changes in ?thalassemia detected by MRI in correlation with hormonal changes. Methods: Thirty-six patients with thalassemia major with mean age of 17.8 3 years (17 male and 19 female) were enrolled in this study. The control group comprised of 20 (10 male and 10 female) age- and sex-matched individuals. All of the patients and controls underwent clinical examination, hormonal study and MRI of the pituitary gland. Results: Forty-seven percent of the girls and 53% of the boys with thalassemia major had small size pituitary gland. Fifty-three percent of the boys and 58% of the girls patients had low pituitary signal in T2 weighted image. Seventy-eight per cent of the patients had hypogonadotropic hypogonadism (H.H). There was a statistically significant correlation between low hormonal level (H.H) and both low pituitary signal (P<0.012) and small pituitary size (P<0.04). Conclusion: A significant percent of thalassemic patients show small size and hyposignal pituitary gland in sagittal and coronal T2 weighted MRI images which have a statically significant correlation with hormonal deficiency and pituitary dysfunction.

Background: Many studies from the West have documented the comorbidity of psychiatric disorders among patients with substance use disorder but, little has been published on this subject from Iran. Objective: To investigate the comorbidity of psychiatric disorders among substance use disorders in two central and southern provinces of Iran. Method: Psychiatric and substance use disorder comorbidity was assessed by means of the Research Version of Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) during the admission process of 89 treatment-seeking opioid addicts. Results: All psychiatric disorders comorbidity (excluding substance use disorder) during lifetime and current time frames were 78.7% and 74.8%, respectively. Mood disorder was found to be the most frequent, although most of this rate is accounted for by substance-induced mood disorder (57.3% of the subjects). Conclusion: Psychiatric disorders comorbidity, especially substance-induced mood disorder, was common among the subjects, and Axis I psychiatric disorder does not seem to precede opioid dependency in the majority of opioid addicts seeking treatment.

Background: Epidermal growth factor receptors (EGFRs) are a group of molecules with structural and functional similarities, which are expressed in some breast cancers. In the present investigation, the presence of two members of the EGFR family namely c-erbB-1 and c-erbB-2 was assessed as a prognostic indicator in a series of breast tumors. Objective: To study the over-expression of c-erbB-1 and c-erbB-2 in a series of primary breast cancer as a prognostic factor. Methods: A series of 100 patients with primary operable breast cancers were investigated for expression of EGFRs in their tumors by immunocytochemical staining with the monoclonal antibodies against erbB-1 and erbB-2 molecules. An indirect immunoperoxidase method was used for determination of these receptors in formalin-fixed paraffin-embedded breast carcinoma tissues. This technique was also used to investigate the expression of c-erbB-1 and 2 in 23 out of the 100 fresh frozen tissues of breast carcinoma. Results: Our results indicate that 20 (20%) and 41 (41%) tumors showed positive immunoreactivity with erbB-1 and erbB-2 monoclonal antibodies, respectively. Results also indicated that in 100% of cases the pattern of immunoreactivity in fresh tissues were comparable with those of the formalin-fixed paraffin embedded tissues. Strong correlation between distinct c-erbB-2 expression and short disease-free interval was observed but no significant association was found with c-erbB-1. Conclusion: The results show that the c-erbB-2 receptor status may be a useful prognostic marker in breast cancer.

Background: Antibodies (Abs) to double-stranded (ds) DNA have been considered most useful in diagnosis and monitoring disease activity in patients with systemic lupus erythematosus (SLE). Objective: To investigate the value of anti-ds-DNA Ab level changes, detected by three different methods, as predictor of disease activity in SLE patients. Methods: Serial sampling from 87 patients with SLE was performed. Samples were assessed for anti-ds-DNA Abs by Crithidia luciliae test (CLT), ELISA and Farr assay. Results: In 17 out of 40 cases with completed sampling, disease activity was occurred during the study. Significant increases in anti-ds-DNA Ab level was detected by ELISA (whole and IgG) and Farr assay prior to disease activity in all clinically active patients. CLT was tested positive in only one case before disease activity. None of the 23 cases with clinically inactive disease were tested positive with CLT, whereas in 3 and 15 of 23 cases positive results were observed by ELISA and Farr assay, respectively. Statistical analysis showed the predictive value of ELISA for disease activity. There was a high correlation between the results of Farr assay and ELISA for all SLE patients in detecting anti-ds-DNA Abs (r=0.63, p<0.0001). ELISA and Farr assay were also correlated well with disease activity (p<0.05). Conclusion: Our findings confirm the predictive value of increases in anti-ds-DNA Abs measured by ELISA method with respect to activity of SLE.

Background: Viral hepatitis, particularly hepatitis B virus (HBV) infection remains a major public health problem worldwide and different profiles of IgG subclasses of anti-HBs antibody have been reported to be produced in individuals infected with HBV and those vaccinated with HBsAg. Objective: To evaluate the difference among various profiles of IgG subclasses produced in response to HBV infection and HBsAg observed in HBV positive patients and those vaccinated with HBsAg. Methods: Antibody to hepatitis B surface antigen (HBsAg) was purified by affinity chromatography from sera of 24 normal individuals vaccinated with recombinant HBsAg (rHBsAg) and 18 persons infected with hepatitis B virus (HBV). The isotype and IgG subclass profiles of the purified anti-HBs antibodies were determined by enzyme-linked immunosorbent assay (ELISA) using plates pre-coated with rHBsAg and isotype specific monoclonal antibodies. Results: IgG2 was the predominant subclass of anti-HBs antibody in both groups of individuals followed by IgG4 and IgG1. IgG3 was hardly detectable in the majority of samples tested. Conclusion: No significant differences were observed between the two subject groups with regards to the levels of IgG subclasses and isotypes, suggesting similar antibody responses to rHBsAg and the wild type HBV.

Background/Objective: Anti-phospholipid syndrome (APS) is a well-known cause of thrombosis and can mimic multiple sclerosis (MS). We analyzed the neurologic manifestation, laboratory and MRI findings of our patients with primary APS (PAPS) in an attempt to identify parameters that might differentiate the two entities. Methods: Of 180 cases with the diagnosis of probable or definite MS, we studied 29 patients who had symptoms suggesting an underlying systemic disease, unusual laboratory findings or atypical evolution for MS. Of these, 22 patients (15 female and 7 male, mean age 30 year) proved to have PAPS with antiphospholipid antibody (aPL) positivity (titer 10 GPL units) and were followed-up for at least 8 months. Brain MRI was performed in all of the patients. Results: The most frequent initial manifestations were paresis (10 cases) and cerebellar signs (4 cases). During the established stage, 15 cases had paresis; and cerebellar signs, depression and sensory disturbance were seen in 10, 9 and 8 patients respectively. High ESR, thrombocytopenia and prolonged partial thromboplastin time (PTT) were detected in 8, 4 and 3 patients respectively. MRI of the brain showed multiple lesions in 15 and a single lesion in 7 cases. Also 4 of the female patients had a history of unexplained fetal loss. Conclusion: We believe that all cases with the initial impression of MS who present with systemic or laboratory features of APS or a history of unexplained fetal loss should be screened for the presence of aPL, and APS should be considered as an alternative diagnosis to MS.

Background: Thalassemia is a major health problem in Iran. The prevalence of thalassemia minor is high and screening program for detecting b -thalassemia trait has been established in southern parts of Iran since 1992. Objectives: To determine the efficacy of naked-eye single-tube red cell osmotic fragility test (OFT) as a screening test for b -thalassemia trait. Methods: Three different concentrations (0.36%, 0.37% and 0.38%) of buffered saline solutions were used. OFT were applied to three groups of subjects: 50 normal individuals, 50 subjects with genetically proven b -thalassemia trait, and 15 patients with proved iron-deficiency anemia. Results: The results demonstrated that 0.37% saline was the best solution for OFT. It could detect 98% of heterozygous b -thalassemia patients compared to 96% and 84% detection rate obtained with respective 0.36% and 0.38% saline. Specificity of OFT with 0.37% saline was 96% whereas that of 0.36% and 0.38% saline were 84% and 94%, respectively. The OFT with 0.37% saline was also positive in 5 (33.3%) patients with iron-deficiency anemia. Conclusion: OFT done with 0.37% buffered saline solution provides more accurate results. Since the test is inexpensive and practical it might be considered as the single screening test to be used in areas with limited laboratory facilities and economic resources.

Background: Mouse inoculation and tissue culture employed in the earlier studies of toxoplasmosis, although specific and sensitive, are rather time-consuming and may require up to six weeks to reach a diagnosis.Objective: To use polymerase chain reaction (PCR) as a reliable alternative method in the detection of Toxoplasma gondii organisms in tissue samples.Methods: This method relies on the detection of B1 gene which is unique for T. gondii. After preparing the samples, DNA was separated using centrifugation, then, by application of primers and DNA polymerase, amplification was performed.Results: PCR detected the presence of T. gondii in about 20% of formalin-fixed tissue samples from dead fetuses aborted within four months of gestation.Conclusion: PCR can be considered the method of choice, particularly when the parasites are already destroyed by preservatives or their viability is adversely affected by suboptimal storage and transportation conditions.

Background: MRI and somatosensory evoked potentials (SEP) have been used in evaluation of different aspects of radiculopathies. Investigators have been interested in comparative values of these tests. Objective: To determine the clinical value of truncular and dermatomal SEP in diagnosis, localization and prognosis of lumbosacral radiculopathy and its sensitivity relative to MRI. Methods: The lower extremity SEP studies were done in 34 patients with definite clinical and MRI findings of lumbosacral radiculopathy. The findings were compared with those obtained from the control group which consisted of 35 healthy individuals. Results: Among 33 patients with abnormal MRI, 29 had abnormal SEPs (87.8%). The concordance of SEP with MRI regarding the level and side of affected roots was 65.5%. Conclusion: MRI overestimates disc bulge in some patients. As a low-cost and sensitive tool, SEP is recommended to be used in addition to MRI in evaluation of lumbosacral radiculopathy.

Background: Side effects of steroid therapy of autoimmune hepatitis are seen more frequently with prednisolone only regimen. However, the question of efficacy restrains the broad use of prednisolone in combination with azathioprine. Objective: To compare biochemical responses to the two standard immunosuppressive drug regimens (prednisolone alone and prednisolone in combination with azathioprine) in children with autoimmune hepatitis. Methods: The study was performed on 42 children with autoimmune hepatitis. Patients were attributed to two groups, with group A receiving prednisolone alone and group B receiving prednisolone in combination with azathioprine, using simple random attribution unless there was a contraindication to azathioprine. The patients were evaluated for treatment response on three occasions: short term (one month after starting therapy), intermediate term (four to six month after starting therapy), and long term (one year after starting therapy). Chemical response was defined as decrease in aminotransferases to a level below two times the normal values and gamma globulin to lower than 2.8 g/dL. Clinical response was defined as improvement in the initial clinical signs and symptoms (jaundice, hepatomegaly, splenomegaly, fever, and edema/ascites). Results: There were no differences in chemical and clinical response rates between the two groups. Both clinical and chemical response rates in intermediate term were significantly higher than short term. However, clinical and chemical response rates in long term did not significantly differ from intermediate term. Conclusion: The study shows that some patients need time to respond to therapy. Nonetheless, it seems that whenever there is no improvement after six months of therapy, it is prudent to change the treatment regimen rather than waiting for response. With the same efficacy and less side effects, the combination regimen must be preferred as the standard regimen, unless there is a contraindication to azathioprine.

Hydatid cyst of the breast is rare and is not usually included in the differential diagnosis of the breast lumps. The radiologic findings of hydatid cyst of the breast is non-specific and the differential diagnosis includes cyst, fibroadenoma, phyllodes tumor and circumscribed carcinoma. We report three patients with surgically proven hydatid cysts of the breast.

Abdominal pregnancy is a potentially life-threatening form of ectopic gestation with a worldwide incidence of 1:3300 to 1:10200 births. Its incidence appears to be increasing in both the developed and developing worlds. This paper reports on a 28 year old asymptomatic primigravida with a 38 weeks abdominal pregnancy managed successfully with good maternal and perinatal outcome. The literature is reviewed and challenging diagnostic and management problems are discussed.

Extrarenal Wilms" tumor is extremely rare. Approximately 54 cases have been reported in the world literature through 1993. Only eight extrarenal Wilms" tumors were enrolled in the National Wilms" Tumor Study (NWTS) between 1980 and 1986. These cases constituted a fraction of 1% of all Wilms" tumors reported to the N.W.T.S during this period. The authors report a case of retroperitoneal Wilms" tumor (Stage III) presenting as a lower abdominal mass in a previously healthy 6-year-old girl who was operated and staged according to the current N.W.T.S III criteria.

case of limb gangrene secondary to accidental intra-arterial (I.A.) diazepam injection in an infant is described. Hazards of I.A. diazepam injection, the possible mechanisms leading to this injury, the preventive measures and the therapeutic modalities are discussed.

We present a 30-year-old man with cervical spine osteochondroma who manifested as spasmodic torticollis. The patient was treated medically for three years without any improvement. Eventually patient’s medical records was reviewed and a structural disparity was detected in plain radiography. Further study confirmed a bone tumor in the left pedicle of third cervical vertebra. Upon surgical excision of the mass, the C3 spinal root was released and main bulk of the tumor was resected. Pathologic findings was in favor of osteochondroma and clinical symptoms was fully abated after surgery. Cervical spine tumors such as osteochondroma is an uncommon cause of spasmodic torticollis, however, always should be kept in mind as one of the etiologies.