MEDICAL JOURNAL OF MASHHAD UNIVERSITY OF MEDICAL SCIENCES
Year:2007 | Volume:50 | Issue:97|Papers Count:25

Introduction: Cirrhosis is the most important etiology of portal hypertension worldwide. Even with improvements in noninvasive therapies, portosystemic shunts still remain one of the most important approaches after failure in medical treatment. Tran jugular Intrahepatic Portosystemic shunt and liver transplantation are alternatively used in other countries. Evaluation of complications and patency rates can be a great help in choosing the best technique in patients. The aim of this study was to evaluate patency rate and complications of portosystemic shunts in patients with chronic hepatic diseases.Materiasl and Methods: Inthis cross sectional study, from summer 2000 to spring 2004, carried out at General and Vascular Surgery Departments 19 patients with portal hypertension underwent surgery. Patients with portosystemic shunts were followed up for at least one year after surgery, considering blood flow in anastomosis, using color Doppler ultrasonography and symptoms such as gastro intestinal bleeding, hepatic encephalopathy and etc. Data were analyzed using SPSS version 13 and descriptive statistics.Results: Male to female ratio was 1:1.7. Portosystemic shunt was performed for 16patients (2 distal splenorenal, 10central splenorenal, 2 portocaval, 2 mesocaval) and 3 underwent splenectomy. Of patients 2 complicated with pneumonia after a week, and 2 with encephalopathy. After at least one year, 66.6% of shunts were patent, 8% were closed and in 25.4% doppler ultra sonography could not localize the shunt. One patient died under surgery. There was no death at the end of the first year; but during a 6 years follow up, 6 mortalities occurred.Conclusion: The major etiology of portal hypertension in these patients was cirrhosis secondary to hepatitis B. This finding is due to the cultural and religious differences with other countries.There was no relationship between pneumonia and splenectomy (p= 0.45). Also, no significant difference observed between pre and post surgery encephalopathy (p =0.14). Mortality rate did not depend on pre (p= 0.09) and post (p= 0.11) surgery encephalopathy. Survival rate of patients was 94.7% after one year and 73.7% after 2 years, demonstrating better results in comparison with other similar studies.

Introduction: Metabolic Triad is one of the risk factors of cardiovascular disease s (CVDs) which has an effective, determinant effect on these diseases. Hypertriglyceridemia and abdominal obesity (waist circumference) are among CVDs risk factors and the increase of these factors can predict the occurrence of TM. This project was aimed to investigate the relation of high phenotype triglycerid and waist circumference with CVD risk factors.Material and Methods: In a descriptive cross-sectional study, carried out in the year 2005, in Isfahan, 6123 men were selected based on the results of IHHP's phase I by random-cluster sampling method. Their blood sugar and blood lipids measured by blood sampling. Also, their blood pressure, waist circumference, height and weight measured. They were divided into 4 groups based on their tryglycerid and waist circumference: TgHWH group (TG2³165mg/dl, waist circumference ³102cm), TgHWL group (TG2³165mg/dl, waist circumference <102cm), TgLWL group (TG<165mg/dl, waist circumference<102cm) and TgLWH group (TG<165mg/dl, waist circumference £102cm). Data was analyzed by SPSS software. The variables of these four groups studied by variance test. Regression logestic test, used to determine the prevalence of risk factors. Results: The prevalence of risk factors in TgHWH group was higher than other groups and in TgLWL group lower than others. Also, it differed significantly these groups. The prevalence of TgHWH in the studied population recorded as 20.8%. Cholesterol, triglyceride, LDL cholesterol, Body mass index, and Blood Pressure in this group were higher and the mean HDL, was lower than others.Conclusion: In large population, it is impossible or non-economiccal and time consuming to evaluate all risk factors, in order to predict other CVD risk factors and to determine high risk people. However, according to the high prevalence of risk factors in people with TghWh, this phenotype can be used as a simple tool for evaluation in larger population.

Introduction: Cutaneous leishmaniasisis an endemic disease in many countries that is caused by different species of Leishmania. Nowadays, standard medication for leishmaniasis is pentavalent antimony compounds that are used intramuscular or intralesional. Though, they are drugs of choice, there are limitations such as hematologic, hepatic, renal and cardiac side effects. This study reviewed hematological, hepatic, and renal side effects of glucantim.Material and Methods: The present work was a pre- and post- treatment study on 35 patients with cutaneous leishmaniasis referred to Dermatology Department, Imam Reza Hospital, Mashhad.Their disease was confirmed by direct smear. The patients were treated with intramuscular glucantime 60mglkg daily for 20 days. Complete blood count (CBC, diff), serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), blood urea nitrogen (BUN), creatinine (Cr) were evaluted at 3 times: before treatment, on the 20th day of treatment course (last day of injection), and a month after the end of treatment. Demographic, laboratory and treatment results, and drug complications were recorded in a questionnaire. Data were analyzed by descriptive statistics.Results: Of 35 patients in this study, 26 completed the course. Red blood cell count, hemoglobin and hematocrit levels significantly reduced (P<0.05), but no significant difference was shown in white blood cell and platelet count. The increase of serum SGOT and SGPT levels were considerable (P<0.05). Elevated serum levels of Cr and BUN observed in 11.5% and 34.6% of patients, respectively; and renal side effects were more common in females than in males (64% in females VS 10%in males).Conclusion: Systemic glucantime is associated with hematologic, hepatic, and renal side effects. Therefore, evaluation of hematologic, hepatic and renal statement in patients receiving glucantim, before and during treatment is suggested.

Introduction: In gastric pull-up esophageal surgery, functional obstruction of the pylorus is seen in almost 20% of patients. The purpose of this study was launching finger bougie of pylorus instead of traditional pyloroplasty or pyloromyotomy.Materials and Methods: This descriptive study carried out from 2002to 2004 on patients, admitted to the Department of General Surgery of Imam Reza Hospital, Mashhad. Of 58 patients with esophageal cancer, who underwent gastric pull-up esophageal surgery, pyloroplasty or pyloromyotomy was randomly performed on 31 cases (group A), and finger bougie of pylorus (group B) on 24 patients. On the 9th day postoperatively static function of pylorus was evaluated with gastric emptying study. Based on emptying time of the stomach, patients were divided into normal, delayed drainage and complete obstruction groups Using a questionnaire, individual characteristics, surgical outcome and results of gastric emptying scan were recorded and analyzed by descriptive statistics, frequency distribution tables, Chi-2 and Chi- Square tests.Results: Of patients, 58 with average age of 58 years old were evaluated from these. 40 cases (69%) were male and 18 cases (31%) were female. Pyloric operations were finger bougie in 31 cases (53/4%), pyloromyotomy in 24 cases (42/4%), and pyloroplasty in 2 cases (3/4%). In 1 case (1/7%) pylorus was intact. Complications were, wound infections in 8 patients (13/8%), cervical fistula in 2 (3.4%) thoracic fistula in I (1.7%), chylothorax in 3 patients and tracheal injury in I patient. Gastric emptying time was measured in 53 patients with TC99scanning. The result was normal in 44 cases (75/9%), delayed in 8 cases (13/8%), and gastric outlet obstruction in 1 (1/7%).Conclusion: Although transhiatal esophagectomy is considered as a palliative procedure, some surgeons prescribe it for all stages of the disease. Most of tracheal injuries are in membranous portion. In small tearing, conservative management with bypassing the site of injury by endotracheal or tracheostomy tube was recommended. Surgery is suggested in large tear or failure of conservative therapy. The first recommendation for fistula in cervical anastomosis is conservative. Early surgery is suggested in complete disruption, non responsive patient after 3 -weeks, and intra thoracic fistula. In the present study the results of gastric emptying test in group A (finger bougie of pylorus) and group B (pyloromyotomy or pyloroplasty) were compared. Finger Bougie of pylorusin gastricpull-upsurgery is preferred and suggested.

Introduction: Type 1 diabetes is an autoimmune disease characterized by T-cell mediated destruction of pancreatic b-cells. A variety of environmental and genetic factors are involved in the development of the disease. IL-12 is a cytokine secreted by different cells and plays and important role in cell-mediated immune responses and maintenance of cytokine network balance. Genetic polymorphisms in the IL-12 gene were shown to interfere with the transcriptional activity of the IL-12 gene, and this influences the production, secretion or activity of IL-12 growth factor. In this study the polymorphism in the 3'-untranslated region of the IL12B gene encoding IL- 12p40 was investigated.Materials and Methods: in this case control study 75 type 1 diabetic patients who had definitely been diagnosed at least 2 years before sampling and were under Insulin therapy, recruited. A total of 88 healthy controls selected from voluntarily blood donors who had referred to IRAN Blood Transfusion Organization. DNA extracted from whole blood and polymorphism at +1188 nucleotide was assessed by SSP-PCR. Data were analyzed by SPSS, using chi- square test with 95% confidence interval.Results: A statistical significance of AA presence (57%) at the +1188 3'-UTR position of IL-12 B gene in patients was found, after genotyping, compared to the control group (p<0.05).Conclusion: Interleukin-12 (IL-12) is a key cytokine for the induction of Thl immune responses. Polymorphism in the 3' -UTR of the IL-12 p40 gene and association with susceptibility to Diabetes type I evaluated. AA genotype was more frequent than AC and the AC more common than CC in diabetic patients. In another word, the A allele of the (A/C) polymorphism at position +1188in the 3'-UTR found to be preferentially transmitted to people with type I diabetes. These polymorphisms may affect gene transcription of IL-12 p40, causing individual variations in cytokine production. A better understanding of the molecular mechanisms, will give us the opportunities to develop new and effective therapeutic approaches.

Introduction: Hirsutism is a common problem with the presence of terminal (coarse) hair in female, in a male-like pattern that has different etiologic factors. This project was carried out to determine the etiologic factors of hirsutism with clinical and para clinical studies. Material and Methods: This descriptive cross sectional study was performed at Khatam –Alanbia Hospital in Zahedan, Iran, from August 2001 to September 2003. Clinical and para clinical findings of 180 hirsute women, referred to Dermatology Clinic were evaluated. Paraclinical tests included serum testostrone, dihydroep and rostendionsulfate, thyroid stimulating hormone, follicle stimulating hormone, luteinzing hormone, prolactin, 17-0H progesterone, and ultrasonography.Results: levels of one or more androgens elevated in 70 patients (39%). Poly cystic ovary syndrome was diagnosed in 96 patients (53/3%). A group of 80 patients (44/4%) with regular menstrual cycles and normal laboratory and sonographic findings had idiopathic hirsutism. Of patients 28, (29/2%) with poly cystic ovaries had regular menstruation. Late onset of adrenal hyper plasia, due to partial 21- Hydroxylase deficiency, was diagnosed in 4 patients (2/2%).Conclusion: There are various causes of excessive hair in women. The present study's results like other studies indicated that poly cystic ovary syndrome is the most common cause and a screening work-up should be recommended on all patients with hirsutism, even women with regular menstrual cycles.

Introduction: Hyperuricosuria (HU), defined as an increased uric acid excretion, has different symptoms in children and is responsible for the formation of kidney stone. This study was aimed to outline the clinical presentation and natural history of HU in children with hematuria, dysuria, discoloration of urine, and recurrent abdominal/flank pain. Material and Methods: In this cross sectional study, from October 2002 to May 2006, 88 children with Hyperuricosuria at Dr Sheikh Hospital, Mashhad were evaluated. Urinalysis, urine culture, 24-hour urine collection for measurement of uric acid, Calcium and Creatinine, serum evaluation for BUN, Creatinine, uric acid, Calcium, Phosphorous and HC03- and renal ultrasonugeraphy were carried out done for patients. All data were recorded and analyzed with descriptive statistical methods.Results: From 88 evaluated patients, 51% were boys and 48.8 % were girls. The mean age of children was 5.3±1.2 years. The mean Urine Uric Acid was nA mg/kg/24h and mean Urine PH was 5.3. Hematuria was not among the presenting symptoms in 41 patients. Thirty three patients had normal urinalysis at the first examination, 28 of them had microcalculi (<3 mm in diameter) at renal ultrasonography and 12 had stones (4-13 mm). Dysuria and abdominal/flank pain were present in 22 and 17 patients, respectively. There was no microscopic hematuria in 24.3% of patients with microcalculi or stone. Family history of urolithiasis was positive in 63 of the children.Conclusion: Hyperuricosuria has to be suspected in children with dysuria, recurrent abdominal / flank pain, discoloration of urine, and familial history of urolithiasis. The lack of hematuria is not predictive of the absence of urolithiasis.

Introduction: Apnea testing is mandatory to confirm brain death. Serious side effects such as severe cardio-pulmonary complications, ICP elevation and pneumothoraces may occur during apnea testing. So, it should be performed as the last test after the other ones.However, its safety is a major issue. The aim of this study was to evaluate the results and complications of apnea test in brain dead patients in the course of three years.Material and Methods: This cross sectional study was corried out from 2002 to 2005 at Mashhad University of Medical Sciences with a simple sampling method on 57 brain dead patients in whom apnea test was performed by the authors. After preoxygenation the test was done in 10 minutes during which the patients had been disconnected from the ventilator. ABG analysis proceeded in minutes 2, 5, 8 and 10. The test result assumed positive if PaCO2 was increased up to 60mmHg or more than 20mmHg from baseline value. All patients should have been preoxygenated.The test stopped whenever predefined complications occurred. All the data collected in a separated questionnaire. Statistical analysis was done using SPSS software and with ANNOVA test.Results: From 57 brain dead patients in this study, 11 were female and 46 were male. The mean age of the patients was 25.28 years, ranging from 6 to 38 (SD= 14.3). Serious complications occurred in 11 patients including severe hypoxia in 10 and cardiac arrest in one. These complications were more common in patients, before testing, with an unstable cardiopulmonary condition than the ones with a stable condition (53.84% versus 9.6%). The mean period from death time to apnea testing was between minimally 36 hours and maximally 11 days. It was 11 days in a patient aged 15. In all cases, the results of the tests were positive and supported by clinical diagnosis of brain death.Conclusion: Apnea test is an invasive test. It may reduces the organ reservoirs and potentially induces tissue ischemia, due to severe cardio-pulmonary complications. Also, it is not able to reject brain death diagnosis, if it has already been confirmed by the other tests. It seems that an alternative test with a high index of safety should be considered or some modifications are needed. At least, it is suggested to be avoided in patients with an unstable cardiopulmonary condition.

Introduction: Spasticity is a common and disabling complication that occurs as a result of upper motor neuron lesion. Recently, Botulinum Toxin - A (BTX-A) has received a pronounced position in spasticity treatment because of its efficacy, high capability of selective effects and low side effects. In this study, through electrophysiologic tests, mechanisms involved in spasticity reduction following BTX-A injection were studied.Materials and Methods: This descriptive study was carried out in the year 2006, on IS hemiplegic patients (age ranged 44- 70 yrs) with spasticity of ankle plantar flexors at Tehran University of medical Sciences. According to the Original Ashworth Scale (OAS), before and after intervention, spasticity of muscles was assessed. Electrophysiologic measurements consisted of amplitude of maximum H- reflex, M response and H/M ratio of soleus muscle, were recorded before and after injection. Toxin was injected in Gastronomies (200 units), soleus (75 units) and posterior tibialis muscles (50 unit). Data were recorded in a questionnaire and analyzed by descriptive statistics and frequency distribution tables.Results: Four weeks after injection, significant reduction in H- reflex, M response amplitudes and H/M ratio were seen. According to the OAS, severity of spasticity also, showed a meaningful reduction. H- Reflex amplitude had more expressive reduction than Mresponse.Conclusion: Reduction of H -reflex amplitude and H/M ratio is the result of toxin effect on intrafusal fibers and reduction of M response amplitude is the result of toxin effect on extrafusal fibers. More significant reduction of H – reflex amplitude in comparison to M response, showed that BTX-A can reduce the spasticity through modification of gamma motor neuron system. Results of this study could help the therapists, in selecting the most efficient therapeutic exercises, for application after the BTX-A injection.

Introduction: Chronic anal fissure is a common problem, and there are different ways for treatment. The goal of this study was to compare the effectiveness and complications of topical nitroglycerin with internal sphicterotomy in the treatment of chronic anal fissure.Materials and methods: This randomized clinical trial study was performed from 2002 to 2005 at Imam Reza Hospital, Mashhad, Iran on 200 patients with symptomatic anal fissure, who randomly categorized into two groups of case (n=100) and control (n=100). The case group (A) treated with nitroglycerin ointment %0.2 twice a day for 6 weeks and the control group (B) received sphincterotomy. Individual, surgical and medical results data were recorded in the questionnaire. Data analyzed using descriptive statistics, frequency distribution tables, and Fisher test.Results: after 6 weeks of treatment, results showed that healing was not significantly different between the two groups, but after 6 months, difference was significant (p=0/11). Surgical group healed 100%. Headache in medical group was more noticeable than the other group (p<0/001). But hypotension attack, palpitation, dizziness, and vomiting were not considerably different between the two groups.Conclusion: Internal sphincterotomy is superior to topical nitroglycerin in treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence.

Introduction: Obsessive compulsive disorder (OCD) in children and adolescents is apparently a much more common disorder than what believed before.Most studies concerning treatment of OCD has been based on experience from adult patients. Only a few controlled trials using medication in children with OCD have been conducted. The present study compared the efficacy of clomipramin and fluoxetin in children and adolescents with OCD.Materials and Methods: This double blind clinical trial, performed from 2002 for one year, at Mashhad Pediatric Psychiatry, compared the efficacy of clomipramin and fluoxetin in 26 OCD children and adolescents, randomized into two groups. Efficacy assessments included the child version of Yale -Brown obsessive compulsive scale (CYBOCS) and NIMH Global rating scale and Maudsely questionnaire. The study took 8 weeks long and assessments were accomplished before the treatment, 4weeks and 8weeks after it. Clomipramin was used 10mg/dayin patients over 20 kg weight and increased to 50 mg /day in one week. Dosage then rose up to 3 mg/kg based on the clinician's decision. Fluoxetin was started with 10 mg/day and reached 20 mg/day in one week.Then titrated up to 1mg/kg/day based on clinical judgment of clinician. Three patients were dropped out because of different reasons and one patient discontinued using Clomipramin because of its adverse effects. Data were collected and analyzed using the descriptive statistics and Mann withney test.Results: There was a significant difference in the efficacy of the two drugs based on total CYBOCS score and the score of obsessions, compulsions and fluoxetine was more effective than clomipramin. However, there was no conciderable variation between them based on maudsely questionnaire, its subscales scores and NIMH Global rating scale score. The CYBOCS total score decreased to 44% and 49% after 8 weeks of clomipramin and fluoxetin consumption; respectively.Conclusion: The results suggested that fluoxetin is at least as effective as clomipramin in short term treatment of children and adolescents with OCD. More studies with larger sample size and longer time for follow-up are recommended.

Introduction: SIRS is known as a condition with the presence of four criteria of: Fever or hypothennia. Tachypnea. Tachycardia. Leukocytosis or leukopenia or bandemia. Sepsis is defined as the SIRS with an infectious etiology. Incidence rate is increasing during the recent 15 years. The key point in treatment of sepsis is early diagnosis and beginning of treatment according to the signs before the occurrence of complications like hypotension. This study was done to evaluate the relationship between the severity of SIRS and its etiology and outcome.Materails and Methods: This descriptive study was carried out in the year 2004 on 306 cases of SIRS, referring to Infectious Ward of Imam Reza Hospital, Mashhad, Iran. The study was accomplished through completing questionnaires, after getting medical history, physical and laboratory examinations (including CBC, urine analysis, platelet count, and ESR) of patients. Then the sensitivity, specififity and positive predictive values for SIRS regarding differentiation of infectious from non- infectious diseases were studied. In addition, the severity of SIRS and its effects on mortality, also, the effects of severe SIRS on any infection in platelet count and ESR were evaluated. The Results were arranged as charts, graphs and described by MANN-WHITENY, T-student.Results: According to the number of patients final diagnosis included pneumonia (n=56), meningitis (n=35), unknown origin infections (n=34), urosepsis (n=25), and miscellaneous etiologies such as brucellosis, hepatitis, etc. There were 23 non-infectious patients and 17 mortal cases. The highest mortality rate was in pneumonia (n=7) that often had serious leukocytosis. Severe SIRS has 20.1 %sensitivity and 95 %positive predictive value for diagnosis of infection. Conclusion: There was no statistically significant difference between the two groups, regarding the primary vital signs, laboratory findings, age, sex, and mortality rate. The mortality rate didn't have any relationship with thrombocytopenia, increased ESR or sex; but was related to hypotension, serious leukocytosis and severity of SIRS. Based on the primary vital signs and laboratory findings, the severity of SIRS has a clear correlation with the mortality rate. Heuce it is recommended that much attention should be paid to the documents of vital signs and routine laboratory findings for the early diagnosis and treatment.

Introduction: Major depressive disorder is a common and disabling disorder that causes high rates of morbidity and mortality. Nortriptyline is a tricyclic antidepressant that has been used for geriatric depression since a long time ago. Prescription of SSRIs in geriatric depression has been increased recently, because of more favorable profile of their side effects. This study designed to compare the efficacy of nortriptyline and citalopram in geriatric depression, Because of the importance of choosing the most appropriate medication in geriatric population.Materials and Methods: The present study was a single blind clinical trial, performed from February 2005 for a one year period. Patients age above 60 years referred to Ibne-Sina Hospital with the confirmed diagnosis of major depressive disorder, based on DSM-IV-TR criteria, were included in the study. These patients were randomly divided into two groups: one group (n= 37) taking citalopram 10-20 mg/day and the other group taking nortriptyline 25-150 mg/day (with the mean dose of 100 mg/day). The efficacies of medications were assessed after 8 weeks based on the change in HDRS. Finally, 72 patients completed the study and 13 patients (5 from citalopram group, 8 from nortriptyline group), for different reasons discontinued the medication. Data analyzed using descriptive statistical tests and chi square.Results: Demographic data and HDRS scores did not show statistical considerable variance in the two groups. Also, Changes in HRDS scores before the treatment and after 8 weeks were not significantly different between them. Insomnia was seen in 5 patients taking citalopram (13.4%).Three patients (8.1%) in the citalopram group and one patient (2.8%) in the nortriptyline group complained from nausea in the early treatment phase. Headache was seen in 8.1% and 2.8% in the groups taking citalopram and nortriptyline, respectively. In the patients taking nortriptyline, the most prevalent complaints were dry mouth (28.5%) and drowsiness (22.8%).Conclusion: Results showed that both drugs are efficient in the reduction of geriatric, depressive symptoms and HRDS scores decrease was more than 50% in both groups. No significant difference was seen between the efficacy of two drugs and this result is consistent with the previous studies.These findings need to be confirmed with further researches.

Introduction: Migraine is secondary common cause of headache. Headache is the most common clinical syndrome of pain. There are several methods in treatment of migraine including herbal medicine. Tancetum parthenium, a kind of chrysanthemum from kacny race is traditionally used for treatment of headache. The aim of this research was to assess the effect powder of Tanacetumparthenium in treatment of migraine.Material and Methods: This is a double blinded clinical trial that lengthened for 8 months from 2004 to 2005. Patients were selected from Imam Reza hospital neurology clinic, Mashhad University of medical science. We had two groups: drug and placebo group. 45 people were introduced in each group. In our research, 4 patients in drug group and 11patients in placebo group were missed. Patients with migraine that their headache frequency was more than 3 times in a month were included in our research. Severity and .frequency of headache and kind of prescribed drug were variables that investigated in this study.Results: After 15 days, 29 people (70.7%) in drug group and 21 people (61.8%) in placebo group were good or better than before treatment (p=0.49). There was a significant improvement in severity and frequency of headache in drug group compared to placebo group only 105 days after treatment (P=0.01)Conclusion: This research shows that Tanacetum parthenium is significantly more effective than placebo (p<0.05). So use of this drug is suggested in treatment of migraine.

A 25 - years- old man was admitted to the hospital because of fever, chills and jaundice after return from Pakistan. On physical examination he had fever (40' c) and BP of 120170,respiratory rate and pulse rate were 24 and 100 respectively. Heart sounds were normal and there wasn't any pathologic sound in lungs. The sclera was icteric yet there wasn't any signs of anemia 'and no adenopathy was found. In abdomen, hepatosplenomegalywas present and right upper quadrant had tenderness on examination, however, there wasn't ascitis and collateral circulation. Laboratory tests performed and revealed leukopenia (3500) and thrombocytopenia (70000) but no anemia, increased liver function tests and bilirubin, though normal PT and PTT. Wright, 2 ME, widal was negative. Sonography of abdomen revealed hepatosplenomegaly, still other findings were normal. Because of high fever blood culture performed and parenteral antibiotic started. For bicytopenia and increased liver function tests, bone marrow aspiration and additional tests, also, carriedout. Markers of viral hepatitis (HAV. HBV. HCV. CMV HBV.HSV) and autoimmune hepatitis were negative and BMA was normal. After five days of admission when the patient was on parenteral ceftriaxone and did not have any fever and felt much better, the result of blood culture reported as salmonella typhi.As a result in patients with fever, jaundice and hepatosplenomegaly it is essential to consider typhoid fever, although the widal test is negative.

Introduction: Ketoconazole is an antifungal agent of Imidazole group which is used in different parts of the body, such as skin, nails, vagina, and etc. Hepatotoxicity is one of its potentially fatal complications which can be manifested as cholestasis, hepatitis, and fulminant hepatic failure. Hepatic complications of this drug are usually started during 6 weeks, but also they have been reported up to 6 months after the treatment. If the LFT changes are mild, the treatment can be continued cautiously, however, it is necessary to stop it evident hepatitis and jaundice are to be occurred. In this group, Fluconazole as a new agent doesn't have severe hepatic complications, so it is preferred in many cases.Case Reports: In this study two cases of 36 year old women, died because of fulminant hepatic failure due to Ketoconazole induced hepatitis are reported. In both cases, viral and autoimmune hepatitis have been ruled out.Conclusion: Despite the rarity and irreversibility of Ketoconazole induced fulminant hepatic failure, it is essential in most cases to pay attention to the hepatotoxicity symptoms carefully.

Introduction: The endodermal sinus tumor (EST) or yolk sac tumor (YST) is a malignant germ cell neoplasm that usually arises in gonads, but on rare occasion occurs in extragonadal sites such as mediastinum, retoperitoneum and intra cranium. Orbit is an extremely rare location for this tumor.Case Report: In this report a primary yolk sac tumor in the orbit of a 17 months old child is presented. Patient had a rapidly progressive proptosis and high level of serum alpha fetoprotein (12500 IU/ml). After surgical biopsy and histopathological diagnosis, the patient treated with 4 courses of a 3 drugs chemotherapeutic regimen. A period of 6 months follow up did not reveal any sign of recurrence.Conclusion: Although yolk sac tumor is very rare in orbit, a rapid and correct histopathological diagnosis in conjunction with immunohistochemical and other paraclinical evaluation and at last, effective chemotherapeutic regimens can provide a good prognosis and even cure for the patient.

Introduction: Echinococcus multilocularis is the cause of alveolar hydatic cysts in intermediate host, found in the liver and lungs. Alveolar hydatid diseas is the most lethal of helminthic diseases, with radical surgery still being the only curative therapy. The aim of this study was to report a splenic alveolar hydatic cyst.Case Report: The patient was a 62 years old man, from a rural region of Ghochan, Khorasan Province, Iran, who was referred to surgeon, complaining left upper quadran abdominal pain. In CT scan 2 cysts were seen in the right lobe of liver and a septal cyst in spleen. After operation, evacuating and unroofing of the liver cysts, splenectomy was performed.Diagnosis was based on pathologic and histologic examinations. In macroscopic examination spleen was massive and cystic, composed of multiple irregular cysts with infiltrative appearance.The inner part of cysts contained brown necrotic and gelatinous material, at microscopic examination there was a thin acellular laminated layer but the germinal layer and protoscolex were not seen. After a week the patient recovered and left the hospital with good general condition. Conclusion: In conclusion, the presence of this case showed that life cycle of echinococcus multilocularis can be completed in this province. Medical managers and practitioners must notice this disease as a differential diagnosis for malignant of liver and spleen, as well as for prevention and control of the disease itself.