Medical Journal of Mashhad University of Medical Sciences
Year:2007 | Volume:50 | Issue:96|Papers Count:22

Introduction: Transthoracic needle biopsy (TNB) is a well established method for obtaining pathologic diagnosis in the lung masses that is performed after a previous negative bronchoscopy. The goal of this study was evaluation of the safety and accuracy of ultrasonography guided TNB in diagnosis of peripheral lung masses. Material and Methods: This descriptive study was done from 200S to 2006 in Ghaem Hospital. 30 patients with peripheral lung mass, greater than 3cm in diameter and within 5cm from the chest wall, underwent ultrasonography guided TTNB. Data was gathered in a questionnaire and analyzed by descriptive statistics and frequency distribution tables. Results: Male to female ratio was about 1:2, and means age was 61.2 years. 60% lesions were located in the right side. Adequate biopsy specimens were obtained in all patients; but TNB was diagnostic in 86.6%, 13.3% patients underwent thoracotomy for definitive diagnosis. Pathological diagnoses were malignant in 83.3%, with SCC and ACC being the most common, and benign in 16.6%, the most common of which was tuberculosis. Complications were observed in 13.3%, including pneumothorax in 6.6%, and hemoptysis in 6.6%; mortality was not observed.Conclusion: According to this study, TNB with ultrasonography guide due to appropriate diagnostic accuracy and low complication rate with low cost and good availability is recommended for diagnosis of peripheral lung mass.

Introduction: Antipsychotic drugs have an important role in psychiatric treatment. Their side effects such as drug induced Parkinsonism, which has been a historical challenge for patients and physicians, account a major cause of treatment rejection by the patients. Drug induced Parkinsonism is the second cause of Parkinson syndrome. The aim of this study was to evaluate antipsychotic induced Parkinsonism in patients with schizophrenia. Material and Methods: This cross sectional descriptive study was done in the year 1999 in Noor and Shariaty Hospitals of Isfahan. 200 patients with schizophrenia, affected with Parkinsonism complication, were investigated. Variables were sex, age, dosage and group of drug, duration of treatment, Parkinsonism criteria and simultaneous anti cholinergic prescription. Data was gathered in a questionnaire and analyzed by descriptive statistics and frequency distribution tables.Results: 122men and 78 women were studied. 26.5% of patients had drug induced Parkinsonism, which was mostly seen in women (32% versus 22.9% in men), higher age (10-19 years: 0%, 50 years and higher: 33%), and when anticholinergic was not used simultaneously (35.7% versus 25% in anticholinergic users group). Prevalence of Parkinsonism, in high, medium, and low drug potentials was 28.7%, 29.4% and 19.2%, respectively. Differences in all of the above groups were not significant. Prevalence increased in dosage of less than 100mg (chlorpromazine equivalent dosage) versus 101-300mg (p>0.05), and in 3-6 months after onset of treatment (p<0.05). The most prevalence criterion was rigidity (84.9%). Parkinsonism was diagnosed in 11.76% of patients using atypical drug (clozapin).Conclusion: Anti psychotic induced Parkinsonism increased in higher ages, women and when anticholinergic was not used simultaneously. This side effect was found in all groups even with clozapin. It had a greater prevalence in the beginning of treatment but decreased with treatment continuation and anticholinergic prescription. Future studies particularly on the atypical groups are suggested.

Introduction: Accident is the third common cause of mortality in population. Traumatic head Injury is the most common cause of mortality among these events. In different studies, Coagulation disorder is one of the most important factors for determination of severity of Injury. The present study was designed to evaluate post traumatic fibrinolysis in adults after head Injury. Material and Methods: In this descriptive cross sectional study, ninety six patients (22 patients With mild head injury and 74 patients with severe or moderate head injury), who admitted in Mashhad Shahid Kamyab Hospital for six months, were chosen randomly. All of them had only Head injury and admitted in hospital in less than 6 hours after trauma. The clinical & paraclinical Findings including FDP were evaluated. Data was gathered in a questionnaire and analyzed by Descriptive statistics and frequency distributes tables. Results: Most cases of delayed hematoma happened within 14 hours of trauma. FDP value was correlated with severity of head injury and there was a meaningful correlation between FDP value And GCS. Higher FDP was seen with lower BMR, and vise versa. The most common cases with delayed hematoma were intracerebral hematoma.Conclusion: FDP may be a valuable predictive factor in traumatic head injury and changes in coagulation cascade may improve the outcome of patients with traumatic head injury.

Introduction: TCD is an expensive diagnostic investigation for patients and health insurance Companies. Based on the therapeutic view, cost-effectiveness of transcranial doppler (TCD) is important inpatients with cerebrovascular disease. Material and Methods: This descriptive study was conducted in Neurosonology Center, Ghaem Hospital, Mashhad, within 2006-2007. Indication of TCD was made by neurologists previously. 200 TCD on 166 patients was performed by neurosonologists based on the standard protocol with AKAI device, France and 2MHz probe. The effect of TCD results on changing the dose and type of medicine and neurosurgical consultation of the patients was recorded. Data was analyzed with descriptive statistics and frequency distribution tables.Results: 166 patients (64 males and 80 females) with mean age of 53.4 years were investigated. Abnormal results were found in 27.5% of TCD. Performance of 3D TCD (15%) had influence on therapeutic decisions of the patients. Among this later group, 83% were patients with subarachnoid hemorrhage and 17% had high risk cardiac source of embolism or sever carotid stenosis with recurrent cererbral ischemic events. The cost of 200 TCD in non-private center was evaluated to be about 10million thomans.Conclusion: Due to high expenses and low percentage of therapeutic influences, performance of TCD is recommended in a restricted group of patients. However TCD is a safe and non-invasive test for assessment of main cerebral arteries, which provide useful information.

Introduction: 0.5 to 1% of children are epileptic, and 25% of these patients are resistant to therapy. Uncontrolled seizures produce multiple impairments in personal and social life of the patient. Any reduction in seizure number or obviation of them will raise quality of life and can refine educational, occupational and familial situation of the patient. Multiple studies in adults and children have shown efficacy of topiramate as mono or add-on therapy in reduction of seizures. The aim of this study was to evaluate the effects of this drug on intractable epilepsy. Material and Methods: This study was done as a clinical trial in Pediatric Neurology Clinic of Ghaem Hospital in the year 2005. 24 drug resistant epileptic patients entered the study. In all of them topiramate administered as add-on therapy in a daily dose of 3 mg/kg and increased up to 9 mg/kg, in a therapy period of at least two months. Any change in seizure number, probable side effects of drug consumption, and patient’s individual data was evaluated and recorded in a questionnaire and analyzed by descriptive statistics and frequency distribution tables.Result: Mean of seizure number of patients was 119.95per month, which reduced to 53.41 after receiving topiramate. In 25% of patients seizures resolved completely and in 20.9% of them no improvement was noted. The results of this study implied the efficacy of topiramate in reduction of seizure number.Conclusion: Topiramate and other new antiepileptic drugs due to their effectiveness and lesser adverse effects can be used progressively, and in many cases they can be substituted for older antiepileptic agents.

Introduction: Exophthalmia is defined as an abnormal protrusion of the eyeball; also labeled as proptosis. Proptosis, due to any cause, can compromise visual function and the integrity of the eye structure. The aim of this study was to evaluate etiological factors, clinical findings, imaging studies, histopathological, and prognostication in patients with exophthalmia. Material and Methods: This descriptive study was done from 1995 to 2005 in Neurosurgery Department of Gham Hospital of Mashhad. 50 cases with documented medical history, clinical examination, and pathology reports were studied. Data was gathered in a questionnaire and analyzed with descriptive statistics and chiary-square test.Results: There were 28 male (56%) and 22 female (44%) patients. Mean age was 32.9 years (with range of 10months to 70 years); Mean age of female patients was 36.8 years and in male ones it was 27.8 years. Right eye was involved in 48% of patients and left eye in 52%. The most common cause of proptosis was meningioma with orbital involvement (12%), in 10% of cases it was located in the .lesser wing of sphenoid and in 2% in the optic nerve sheath. Other common causes of proptosis were frontal bone osteoma with extension to orbit (8%), fibrous dysplasia (8%), orbital pseudo tumor (6%), sinus mucocele (6%), orbital cavernous hemangioma (6%), dermoid and epidermoid cysts of the orbit (6%), hydatid cyst (6%), carotid- cavernous Fistula (6%), and optic never glioma (4%). In 25%, proptosis was associated with decreased vision.Conclusion: The most common cause of proptosis in neurosurgery ward was meningioma; mostly lesser wing sphenoid meningioma, which in most cases was associated with decreased vision.

Introduction: Reflex epilepsy is a disorder, in which seizure attacks are induced by an external stimulus or, rarely, by a mental activity. The attacks in this disorder are usually provoked just in response to a specific stimulus and patients with this disorder have no unprovoked ictal event in most instances. This research was designed to study different reflex epilepsies and their appropriate managements. Material and Methods: This descriptive study was done by evaluating the medical files of 9676 patients with the diagnosis of epilepsy, visited in a to-year period (1996-2006) in Dr. Nikkhah Clinic. 33 of them with the final diagnosis of reflex epilepsy were selected. The data (such as, types of seizure, type of stimulus, e1ectroencephalographicfindings, and therapeutic strategy) was recorded for each patient in questionnaire and analyzed by appropriate descriptive statistics and frequency distribution tables.Results: In the study population, 15 females and 18 males with reflex epilepsy, seizure attacks had been provoked by the following stimuli: visual stimuli in 21 (63.6%) patients, chewing in 4 (12%) patients, mathematical calculating processes in 3 (9%) patients, micturation in 3 (9%) patients, playing chess in one (3%) patient, and warm bathing in another one (3%) patient. Brain CT scan was normal in all of our patients. Seizure attacks were eliminated in 6 patients with visual-evoked reflex epilepsy after cessation of visual stimuli. Being unable to eliminate the stimulant factor, we started antiepileptic drugs for other patients. 90% of these patients have been seizure- free just with sodium valproate.Conclusion: In a suspected patient whose attacks are related to a specific stimulus, the practitioner should consider the nature and properties of stimulant precisely. The treatment consists of prevention from and elimination of stimulant, and pharmacological managements.

introduction: Both overt hypothyroidism (OH) and subclinical hypothyroidism (SH) have been reported to have side effects on body organs. Hypothyroidism can cause hypercholesterolemia, hyperlipidemia and diastolic hypertension, which are regard ed as risk factors in development of coronary heart disease (CHD); on the other hand, the hypercholesterolemia due to hypothyroidism can be easily treated with levothyroxine. This study was performed to determine the prevalence of hypothyroidism in hypercholesterolemic subjects in Mashhad. Material and Methods: This descriptive study was performed in Mashhad City from May to Nowember 2002. A number of 4300 men and women aged 40 year or over in 97 different regions in Mashhad were interviewed and 2222 subjecs volenteerly encountered the study. A sample of 12-14hr fasting blood was taken from volunteers and the total cholesterol(TC) was determined by enzymatic method (zist chime-Iran)for 2215 (758 men and 1457 women) subjects. Serum FT4 and TSH were determinedby radio-immunoassay methods for 89 subjects with TC2:310 mg/dl and for 82 subjects with TC: 261-309 mg/dl. Individual and laboratory data were gathered in a questionnaire and analyzed using Descriptive statistics and frequency distribution tables and X2 Hest. Results: The results showed that 4.9% of men had TC³310 mg/dl,11.9%,42.2%, and 41% had TC concentrations of 261-309, 200-260 ,and <200 mg/dl, respectively. In women with the same TC concentrations were seen in 4.1%, 15.2%,42.9%, and 37.7%, respectively. In total, 59.4% of men and 63% of women aged over 40 have TC> 200 g/dl. Twelve out of 89 (13.5%) subjects with TC>310 mg/dl were hypothyroid; 6 with OH (4women& 2men) and 6 with SH (5women & 1man). Hypothyroidism in women was more frequent than men and the female /male ratio was 3/1. The correlation between hypercholesterolemia and hypothyroidism at TC>322 mg/dl was significant (X2=4.01, df=l, P=0.045). FT4 level in TC³310 mg/dl was 13.05±3.4, and in TC between 261-309 mg/dl 14.2±2.63;which was significant in the first group (t-test, p=0.024). Conclusion: These data demonstrated that hypercholesterolemia is prevalent in mean-aged and elder people in Mashhad and hypothyroidism, especially.SH form, is also frequent in hypercholesterolemic subjects. Female to male ratio is about 3:1, but seemingly younger women in Mashhad are more affected than what is seen in othtr studies. Therefore, the screening of thyroid function in hypercholesterolemic subjects especially in women is recommended. Keywords: Hypercholesterolemia, Hypothyroidism, Overt hypothyroidism, Subclinical.

Introduction: Long term of high doses of vitamin C treatment might be a potential risk for the development of secondary oxalosis in end stage renal disease patients. Hyperoxalatemia may increase the risk of cardiac, vascular and bone diseases. Hemodialysis patients (HD) are at high risk for Scurvy disease due to dietary limitation and ascorbic acid losses through dialysis. Vitamin C also decreases HTN and accelerated arthrosclerosis. Thus, vitamin C supplementation is necessary for these patients. The aim of this study was to evaluate efficacy of oral versus intravenous vitamin C on serum oxalate level in hemodialysis patients. Material and Methods: This clinical-trial study was done on hemodialysis patients referred to the three treatment centers of Mazandaran Province. 41 HD patients, who had not consumed vitamin C for two months, were randomly divided into two groups, oral and intravenous. In intravenous (IV AA) group, vitamin C 500 mg/day was administered three times a week; and oral group received vitamin C 125 mg/day for two months. Oxalate serum level was measured before and after treatment. Individual, laboratory, and treatment complication data were gathered in a questionnaire. Intra group comparison was done with t-student test and inter group comparison was done with independent- sample t-test. Data were expressed as SE±Mean and p-value<0.05 was considered significant. Results: Serum oxalate level in each group increased, there was no significant differences intra group and between two groups (p=0.3) (in oral, from 1.8± 0.4mgl/L to 1.85±0.8 mgl/L, P=0.4 and in IVAA from 1.8±0.7 mg/L to 2.1±0.9 mg/L, P=0.3).Conclusion: Oral and IV AA in the used dosage did not increase serum oxalate level and weresafe to use as supplementation in HD patients.

Introduction: Rubella is an exanthematous childhood viral disease that its main importance is because of development of Congenital Rubella Syndrome (CRS) in infants born from non immune mothers infected with rubella, especially in early gestational period. CRS is characterized by hearing defect, cataract, glaucoma, microcephaly, mental rethardation, cardiac anomalies and etc. Measles-Rubella mass campaign was done in late 2003 and 5-25 year-old people were vaccinated. In this study the effect of vaccination on the immunity against rubella was studied. Material and Methods: This retrospective cross- sectional study was done on women reffered to Central Laboratory of Imam Reza Hospital in 2002-2005. The study included 1698 women (1148 women aged 15-23 years) referred for counseling before vaccination and 354 women (162 women aged 15-23 years) after vaccination. Anti-Rubella IgG concentration was measured by ELlSA method. SPSS 12was used to analyze the data. Results: Immunity rates were 67.19% (70.38% in 15-23 year-old women) and 77.40% (89.50% in 15-23 year-old women) in women participated in this study before and after vaccination, respectively. Immunity of non-vaccinated women decreases by age increase.Conclusion: Statistical analysis showed the positive effect of vaccination on immunity status of vaccinated women (Z=5.11, p<0.001). Authors suggest that women older than 25 years should also be included in rubella vaccination program, as well.

Introduction: This study was designed to determine the role of intraocular lens implantation in visual acuity and contrast sensitivity in pseudophakic patients. Material and Methods: This case control study was done in the year 2004 in Mashhad Ophthalmology Center of Khatam- al- Anbia. with convenience sampling method based on object visual acuity and contrast sensitivity in 85 pseudophakic patients (110 eyes) with a mean age of 63.83, and 20 age - matched phakic subjects (40 eyes) were compared. The visual acuity and contrast sensitivity at distance after correction of refractive disorders were 'measured by Snellen chart and Cambridge Low Contrast grating chart at 6 meter. Individual data, surgery date, visual acuity, and contrast sensitivity were gathered in a questionnaire and analyzed by descriptive statistics and frequency distribution tables. Results: Statistical test showed that the best corrected visual acuity in IOL group had no significant difference from that in the phakic group (p=0.36). But the contrast sensitivity reduces in the pseudophakic group comparing with the phakic group (p=0.004).These patients often complain of blur vision, despite of good visual acuity. Contrast sensitivity reduced significantly with increase of age in both groups of normal and pseudophakic patients. No improvement in contrast sensitivity and visual acuity was found over the time (Pva=0.174, Pcs=0.257).Conclusion: This study showed that intraocular lenses could provide good visual acuity for distance but there was slight reduction in contrast sensitivity. Contrast sensitivity test is an important tool for evaluation of visual function; especially age related changes or intraocular differences, which may not have been detected by visual acuity tests.

Introduction: Traumatic hyphema is among the most common challenges in ophthalmologic emergency. Its most common complication, rebleeding, is accompanied with poor prognosis. Rebleeding could cause corneal blood staining, glaucoma, and optic atrophy. Thus, the most important goal in hyphema treatment is prevention of rebleeding. This study was aimed to evaluate epidemiology, medical treatment, and short term complications of traumatic hyphema. Material and Methods: This was a descriptive cross-sectional study, done in the year in Khatam al- Anbia Ophthalmologic Hospital in Mashhad. 100 patients with traumatic hyphema were evaluated by an epidemiologic questionnaire and complete eye examination in emergency room. They all were treated by topical corticosteroid and cycloplegic with or without systemic medication (prednisone or tranexamic acid) according to degree of hyphema .All patients were followed for at least 10days. Data was analyzed, using descriptive statistics and frequency distribution tables. Results: 81% of patients were male with male to female ratio of 4:1. The patients' mean age was 26.5+/-15.4 years old. 62% of patients were under 30 years of age. The patients' right and left eyes were affected in 48% and 50%, respectively; 2% had both eyes affected. No statistically significant difference was found between right and left eye involvement. The mean visual acuity at presenting time was 4/10. There was a direct correlation between presenting visual acuity and severity of hyphema (p=0.043). No correlation was found between age, sex, and the type of trauma with severity of hyphema. The mean intraocular pressure (IOP) was 18mmHg at presenting time. There wasn't any correlation between IOP and severity of hyphema. The mean visual acuity at the last follow up visit was 8/10. Rebleeding occurred in 10 patients out of 100 cases. The risk of rebleeding with medical treatment was 10%.Rebleeding was found to occur 4.3 days after trauma, averagely. In this study, it was seen in the cases with hyphema of the degree of 4 or more (the only risk factor for rebleeding, in this study). Conclusion: Traumatic hyphema is a common cause of refer to ophthalmology emergency room.Results of this study showed that complications of traumatic hyphema, especially rebleeding, could be prevented, significantly, with medical treatment.

Introduction: Previous studies showed that Ankle Brachial Index (ABI) score less than 0.9 increases probability of ischemic heart disease up to 2 times, risk of TIAI stroke to quadruple, and asymptomatic carotid and popliteal artery stenosis to one and half fold. ABI <0.9 is related with diffuse atherosclerosis. The aim of this study was to review ABI findings in patients with cerebral artery disease. Material and Methods: This cross-sectional descriptive study was done on 98 patients with thrombotic cerebrovascular accident in Yazd Shahid Sadughi Hospital, between February 2001 and February 2002. A questionnaire including demographic, clinical, and paraclinical data was completed and results were analyzed using descriptive statistics and frequency distribution tables. Results: Forty four percent of the patients were men. Mean age was 73/1±1/5. ABI<0.9 was seen in 15% of the cases. In patients older than 65 years old ABI<0.9 frequency rate-was-12.5% AND in patients younger that 65 year old it was 3.1%. There was no significant difference between ABI<0.9 and history of diabetes mellitus, hypertension, smoking, and ischemic heart disease. ABI<0.9 was prominently seen in patients with hyperlipidemia(P<0.05). Conclusion: ABI<0.9 was seen in older ages, hypertensive, smoker, and CAD patients more than the others (P>0.07). Because of lack of samples in the present study, authors suggest a study with a larger sample group.

Introduction: Femoral neck fractures in children, despite adults, are the result of high-energy trauma and, usually, accompanied with injuries of other parts of the body. The aim of this study was to evaluate the outcome and complications of femoral neck fracture surgeries. Material and Methods: This descriptive study was done on 68 children with displaced femoral neck fracture in Mashhad Kamiab Hospital between 1993 and 2003. Demographic characteristics, clinical, laboratory, radiography, and surgery results were collected by a questionnaire and analyzed by descriptive statistics and frequency distribution tables. Results: Of 68 patients, 72% had good radiographic results. Complications included AVN in 10 (14/7%), limb shortening in 9 (13/2%), premature epiphysial fusion in 5 (7/4%), coxa valga in 4 (5/9%), Coxa vara in 2(2/96%) slip in 1 (1/47%).Nonunion was not seen.Conclusion: Anatomical and surgery reduction of the fractured femoral neck lowers the risk of complications. Because of the rarity of this fracture that constitutes 1 % of the all pediatric fractures, orthopedic surgeons treat only a few of such patients. The outcome of this fracture is strongly related to initial management.

Introduction: Fasciculation and myalgia are common complications of succinylcholine and decrease of incidence and intensity of them will reduce succinylcholine-induced side effects. This study was done to evaluate the severity and prevalence of fasciculation and myalgia after succinylcholine and perform a comparison between three groups. Material and Methods: In this case-control study in 2006, 75 patients with ASA I and orthopedic surgery were evaluated in Imam Reza hospital. The patients divided randomly in to three same groups. In first group thiopental and succinylcholine 1.5 mg/kg was injected, in second group propofol 2 mg/kg and succinlycholine 1.5 mg/kg and in third group thiopental and succinylcholine 3 mg/kg was administered. Fasciculation, intubation quality after 1 min, and myalgia after 24 h were analyzed. Demografic parameters, pain scales and fasciculation data were gathered in a questiONNaIr And analyzed by SPSS, descriptive statistics and frequency distribution tables. Results: Fasciculation rate was %76 in first group, 80% in second group, and %84 in third groups. Myalgia was %24 in first group, %28 in second group, and %20 in third group. There were no significant differences between group 1&2 and also 1&3 with respect to fasciculation, Intubation, and post-operative myalgia.Conclusion: We concluded that propofol aggregates muscular relaxation versus thiopental, and low-dose versus high-dose of succinylcholine and chang to phase II block had no differences regarding to these complications.

Introduction: Chronic hepatitis B is a major medical problem, distributing all over the world. Affecting more than 400 million people. In highly prevalence places, childhood transmission is the most common form but in low prevalence areas, injection, drug use and familial transmission are the main routes of acquisation of infection. Hepatocellular carcinoma and cirrhosis are significant problems of chronic hepatitis B. Exposure to HBV early in life may progress to hepatocellar carcinoma. The annual number of deaths from HBV infection and related diseases throughout the world is about 1.2 million. The goal of treatment of chronic hepatitis B with Lamivudin or INF-Alpha is sustained suppression of virus replication and liver disease remission. INF, Alpha and Lamivudin have similiar efficacy. The adventage of Lamivudin is that it is less expensive and is well tolerated and adventages of INF. Alpha are the short duration of treatment and absence of resistance but it is expensive and has many side effects. The response rate of INF. Alpha is better than Lamivudin but it is associated with a large number of side effects, sometimes we have to stop or decrease the dose of INF. Viral genotypes and other factors such as pretreatment viral load, fatty liver and liver histiology may alter the response rate. The long-term use of Lamivudin may be with the emergence of YMDD mutations. Treatment of YMDD form of chromic hepatitis B, with combination of Lamivudin and Adefovir dipivoxil, may improve liver function; and YMDD mutations may be over come. The emergence of YMDD mutations reduces the benefit of Lamivudin but does not negate it.

Introduction: Warfarin is an anticoagulant drug, reducing the synthesis of vitamin K dependent coagulant factors. It has fewer complications than heparin during pregnancy, but it passes easily through the placenta. Therefore it may induce unfavorable condition so called as fetal warfarin syndrome. The common presentations of this syndrome are nasal hypoplasia, epiphysial calcification, and skeletal disorders. Fetuses exposed to warfarin in the first trimester of pregnancy have an increased risk of embryopathy (nasal hypoplasia and stippled epiphyses).Case Report: A male neonate with new symptoms of fetal embryopathy (femoral agenesis bilateral dislocation of hip, agenesis of corpus callozom) is presented. He was born postdate from a mother using warfarin 2.5 mg/kg during the whole pregnancy. He also had short lower limb, finger deformity, nasal hypoplasia, radioulnar dislocation, hydrocephaly, and brachiocephaly.

Introduction: Relapsing fever is a spirochetal disease that is caused by different Borrelia species. Relapsing fever is well recognized as an infection of the blood, characterized with episodes of fever, rigor and spirochetemia; but little is known about its predilection for nervous system. This report is supposed to present a patient with neuroborreliosis during relapsing fever. Case report: The presented patient in this paper is a 22 year old woman from Afghanistan with clinical features of meningitis and recurrent episodes of fever with rigor. In diagnostic evaluation, the patient had a CSF profile with aseptic meningitis pattern, and in third time peripheral blood smear spirochet was reported. With diagnosis of meningitis during relapsing fever, she was treated by intravenous ceftriaxone. With administration of first dose of ceftriaxone, Jarisch- Herxheimer reaction occurred. Patient was treated for 14 days by intravenous ceftriaxone. At the end of treatment, the patient was symptom free and had a normal CSF profile. Therefore patient was discharged. Conlusion: In the patients with aseptic meningitis in endemic regions, besides common agents, relapsing fever should also be considered.

Introduction: Hyperthyroid patients are at increased risk of systemic embolism due to cardiac dysrhythmia, especially atrial fibrillation. Most of these embolic events occur in central nervous system. Systemic emboli in the absence of cardiac dysrhythmia and in arteries of extremities are very uncommon. In review of literature only one case is reported.Case report: It report a hyperthyroid patient with an embolism in left upper extremity in the absence of cardiac dysrhythmia.