Immunosuppression is a Double-Edged Sword in COVID-19 Treatment: a Case Report of Rhino-Orbito-Cerebral Mucormycosis.

BACKGROUND: Mucormycosis is a life-threatening fungal infection mostly occurring in immunosuppressed patients such as organ transplant or diabetic patients. In this paper, we described a case of COVID-19 with rhino-orbito-cerebral mucormycosis. METHODS: The nucleic acid amplification test (NAAT) from a nasopharyngeal sample for SARS-CoV-2 was done. Demographic data, biochemical tests, paranasal sinuses (PNS) CT scan, brain CT scan, chest CT scan, and palate biopsy were performed. RESULTS: The NAAT was positive for SARS-CoV-2. PNS CT scan revealed mucosal thickening of all paranasal sinuses, brain CT scan showed hypodense area in antero-inferior cortex, and chest CT scan revealed diffuse ground glass opacity in favor of COVID-19 infection. Palate biopsy revealed fibroconnective tissue with broad pauciseptated ribbon-like hyphae. CONCLUSIONS: In this paper, a case of COVID-19 with rhino-orbito-cerebral mucormycosis was described. The treatment with immunosuppressive drugs predisposed this patient to secondary fungal infection. Immunosuppression is a double-edged sword in COVID-19 treatment and immunosuppressive drugs should be prescribed only in severely ill patients and for a short period.

Effect of Pentoxifylline on Inflammatory Cytokines, Adequacy of Dialysis, Anemia and Biochemical Markers of Hemodialysis Patients: a Randomized Controlled Trial.

BACKGROUND: The main cause of death in hemodialysis patients is cardiovascular disease (CVD). Chronic inflammation is strongly related with CVD, atherosclerosis, and malnutrition in end-stage renal disease (ESRD) patients. We aimed to investigate the effect of pentoxifylline on adequacy of dialysis, anemia, inflammatory cytokines, and biochemical markers in patients with ESRD on hemodialysis. METHODS: This was a randomized controlled trial with a negative result conducted on 42 hemodialysis patients. The patients were randomly divided to two groups; intervention group (400 mg pentoxifylline every night for three months) and control group (followed up without taking pentoxifylline). The blood samples were taken to measure the levels of inflammatory cytokines, anemia-related parameters, and biochemical markers at baseline and the end of treatment. RESULTS: Thirty-six patients finished the study (18 patients in each group). There was significant reduction in C-reactive protein (CRP) [9.25 (4.60, 17.62) vs. 5.60 (1.90, 11.52), p = 0.048] and TNF-α [28.06 (19.76, 61.22) vs. 18.06 (14.39, 28.97), p = 0.029], and significant increase of albumin levels (4.05 ± 0.25 vs. 4.35 ± 0.24, p = 0.000) in the intervention group, but these changes were not significant in comparison with the control group. No statistically significant difference was observed between intervention and control groups in other parameters. CONCLUSIONS: Although pentoxifylline administration had caused significant reduction in CRP and TNF-α, as well as significant increase of albumin levels in the intervention group, but these changes were not significant in comparison with control group. The current study does not support the use of pentoxifylline in hemodialysis patients.

Treatment of critical aluminum phosphide (rice tablet) poisoning with high-dose insulin: a case report.

BACKGROUND: Aluminum phosphide (rice tablet) is a highly efficient agent for preserving grains against rodents and insects. It accounts for a large number of poisoning cases. Aluminum phosphide poisoning has a high mortality rate of about 90%, and to date, no antidote is available. It releases phosphine gas after exposure to moisture, and this reaction is catalyzed by the acidity of the stomach. Phosphine is then absorbed throughout the respiratory or gastrointestinal tracts and causes toxicity through inhibition of cytochrome c oxidase and formation of highly reactive free radicals. Treatment of patients with aluminum phosphide poisoning is supportive, including mechanical ventilation and vasopressors. The usage of infusion of glucose-insulin-potassium in rice tablet poisoning has been suggested, after its positive beneficial cardiac inotropic effects in patients with beta-blocker and calcium channel blocker poisoning. CASE PRESENTATION: We report the case of a 30-year-old Iranian woman with critical aluminum phosphide poisoning, presented with hypotension and other signs of shock and severe metabolic acidosis, successfully treated with high-dose regular insulin and hypertonic dextrose and discharged from hospital in good condition. In contrast to our previous experiences, in which nearly all patients with critical aluminum phosphide poisoning died, this patient was saved with glucose-insulin-potassium. CONCLUSION: Aluminum phosphide poisoning has a high mortality rate, and to date, no antidote is available. Administration of high-dose intravenous regular insulin and dextrose is suggested as a potential life-saving treatment for patients with critical aluminum phosphide poisoning.

Hopeful News for Physicians Who Involved in the Treatment of Critical Aluminum Phosphide (Rice Pill) Poisoning Patients.

Introduction: Aluminum phosphide (rice tablet) was first introduced as a pesticide in India. Rice tablets are commonly used in Iran due to their high efficacy against rodents and insects, low cost, and availability. Aluminum phosphide is a lethal poison without antidote and causes cardiocirculatory collapse and has negative inotropic cardiac effect. Human and animal studies showed that high dose insulin had positive cardiac inotropic effects. GIK (glucose, insulin, and potassium) assists heart uptake of carbohydrates that are the major fuel substrate of the myocard muscle under stressed conditions and leading to correction of acidosis, increased myocardial contractility, and peripheral vascular resistance. Case Presentation. In this manuscript, a young woman with aluminum phosphide poisoning was described to have presented with hypotension, hypoxemia, and severe metabolic acidosis. In contrast to our previous experiences that approximately all rice tablet poisoning patients with shock were dead despite full conservative treatment, this patient miraculously was saved with high dose intravenous regular insulin infusion and was discharged from the hospital with good condition and without any complications. Conclusion: Rice tablet poisoning has high fatality rate, and to date, no antidote is available. GIK is suggested as a potential life saving treatment for critical rice tablet poisoning patients with symptoms and signs of shock.

Acute Secondary Adrenal Insufficiency Misdiagnosed as Acute Cholecystitis.

Hypopituitarism refers to insufficient secretion of the pituitary hormones. Patients with acute adrenocorticotropic hormone (ACTH) deficiency may be presented with fatigue, dizziness, orthostatic hypotension, hypoglycemia, nausea, vomiting, or nonspecific abdominal pain. This study described an unusual case of hypopituitarism in a patient who presented with general abdominal pain, abdominal tenderness, nausea, vomiting, hypotension, and hypoglycemia. At first, the patient was admitted with the diagnosis of acute cholecystitis, but after treatment of hypopituitarism and adrenal insufficiency, his symptoms resolved completely, without the need for surgery. Hypopituitarism and secondary adrenal insufficiency should be considered in the differential diagnosis of the patients who present with acute abdomen, hypotension, or hypoglycemia.

Effects of Nasturtium officinale Extract on Antioxidant and Biochemical Parameters in Hemodialysis Patients: A Randomized Double-Blind Clinical Trial.

BACKGROUND: Increased oxidative stress play an important role in the risk of cardiovascular disease, mortality, and mortality patients undergoing dialysis. Nasturtium officinale (watercress) contains numerous phytochemical compounds that act as an antioxidant by preventing oxidative damage to biomolecules. Therefore, this research aimed to explore the effect of the ethanolic extract of Nasturtium officinale (EENO) on antioxidant and biochemical markers of hemodialysis patients. METHODS: In this double-blind, placebo-controlled trial, 46 hemodialysis patients were randomly recruited to consume either 500 mg/day EENO (n = 23) or placebo capsule (n = 23) for 4 weeks, at Shahid Beheshti Hospital, Yasuj, Iran, in 2019. Biomarkers of oxidative stress including glutathione peroxidase (GPX), superoxide dismutase (SOD), malondialdehyde (MDA), total oxidant status (TOS), total antioxidant capacity (TAC), and total sulfhydryl protein (T-SH) and biochemical parameters such as BUN, Hb, WBC, PLT, Ca, Ph, K, ALB, TChol, TG, LDL, and HDL were evaluated on days 0 and 28. RESULTS: The serum levels of MDA and BUN significantly decreased after taking EENO supplementation (P < 0.001); however, SOD activity increased during the same period (P < 0.001). The serum levels of TAC remained constant in the intervention group, while it significantly declined in the placebo group (P < 0.09). The extract also prevented elevation in the serum levels of LDL and TG compared to the placebo group, although it was not statistically significant. CONCLUSIONS: The data indicated that the consumption of EENO improved some of the antioxidant parameters and minimizes the change in TG and LDL in hemodialysis patients. Therefore, due to the role of these factors in mortality and morbidity of dialysis patients, EENO can improve the condition of dialysis patients. However, more studies with longer intervention times and different doses of EENO are recommended.

The Effect of the Hydroalcoholic Extract of Watercress on the Levels of Protein Carbonyl, Inflammatory Markers, and Vitamin E in Chronic Hemodialysis Patients.

INTRODUCTION: Chronic kidney disorder is a main public health concern. Inflammatory processes and oxidative stress are common in end-stage renal disease patients. We aimed to evaluate the effect of the hydroalcoholic extract of watercress (WC) on the inflammatory cytokines and protein carbonyl (PCO) contents in chronic hemodialysis patients. METHODS: This was a double-blind randomized clinical trial performed on 46 hemodialysis patients. The participants were randomly divided into two groups: intervention group (500 mg hydroalcoholic extract of WC every day for 4 weeks) and control group (500 mg of white flour every night for 4 weeks). The blood samples were taken to determine the levels of vitamin E, PCO, and inflammatory cytokines at baseline and the end of treatment. RESULTS: Forty-five patients completed the study (22 patients in the intervention group and 23 patients in the control group). There was a significant reduction in the PCO level (20.33 ± 4.40 vs. 15.06 ± 6.41, P=0.001) in the intervention group; also, this change was statistically significant relative to the control group. Furthermore, there were significant reductions in hs-CRP (8953.30 ± 5588.06 vs. 7249.86 ± 5091.62, P=0.007) and IL-6 (60.10 (55.99, 73.10) vs. 55.21 (53.39, 60.48), P=0.050) in the intervention group, but these changes were not significant in comparison with the control group. CONCLUSION: We conclude that the hydroalcoholic extract of WC reduced the PCO content in hemodialysis patients via inhibition of protein oxidation. Although WC administration had caused a significant reduction in IL-6 and CRP levels, these differences were not statistically significant relative to the control group. Further research is needed to identify the antioxidant and anti-inflammatory effects of WC in hemodialysis patients.

Brain Parenchyma (pons) Involvement by Visceral Leishmaniasis: A Case Report.

Leishmaniasis, as a vector-borne disease, is transmitted by sandfly and caused by Leishmania protozoa. Brain involvement rarely occurs in visceral leishmaniasis. In this paper, a rare case of pons involvement by visceral leishmaniasis (VL) is reported. A 54 yr old man from Southwest of Iran (Yasuj) presented to the Emergency Ward with a 3-wk history of headache (continuous, throbbing, and general), fever, chills, weakness, anorexia, and weight loss.

Relationship between bone density and abdominal visceral fat in premenopausal overweight and obese Iranian women aged 30-50 years.

AIM: The presence of a direct relationship between body mass index (BMI) and bone mineral density (BMD) is frequently reported. However, data on the relationship between visceral fat and bone density varies, with positive, negative or no relationship having been reported. This study aims to examine the relationship between abdominal visceral fat and BMD. METHODS: A cross sectional study was carried out on 95 premenopausal, overweight and obese women aged 30-50 years referred to Sina Hospital, Tehran, Iran in 2011-2012. Anthropometric indices and visceral fat levels were measured. RESULTS: Multiple linear regression analysis showed that proximal femur BMD (P = 0.856) and lumbar spine BMD (P = 0.558) were not significantly related to visceral fat level. However, BMI had a direct and significant positive relationship with proximal femur BMD (P = 0.001) and lumbar spine BMD (P = 0.031). Menarche age was negatively related to lumbar spine BMD (P = 0.003). CONCLUSIONS: In this study, after adjusting for fat-free mass, no significant relationship was found between MBD of the proximal femur and lumbar spine, and visceral fat level or visceral fat to total fat percentage ratio. Therefore, abdominal visceral fat may not affect BMD, independent of weight. It seems that the positive relationship between BMI and proximal femur and lumbar spine BMD is due to the mechanical effects of weight on bones.