Chronic meningitis in adults: a comparison between neurotuberculosis and neurobrucellosis.

BACKGROUND: In regions endemic for tuberculosis and brucellosis, distinguishing between tuberculous meningitis (TBM) and brucella meningitis (BM) poses a substantial challenge. This study investigates the clinical and paraclinical characteristics of patients with TBM and BM. METHODS: Adult patients diagnosed with either TBM or BM who were admitted to two referral hospitals between March 2015 and October 2022, were included, and the characteristics of the patients were analyzed. RESULTS: Seventy patients formed the study group, 28 with TBM and 42 with BM, were included. TBM patients had a 2.06-fold (95% CI: 1.26 to 3.37, P-value: 0.003) higher risk of altered consciousness and a 4.80-fold (95% CI: 1.98 to 11.61, P-value: < 0.001) higher risk of extra-neural involvement as compared to BM patients. Cerebrospinal fluid (CSF) analysis revealed a significantly higher percentage of polymorphonuclear leukocytes (PMN) in TBM compared to BM (Standardized mean difference: 0.69, 95% CI: 0.18 to 1.20, P-value: 0.008). Neuroimaging findings indicated higher risks of hydrocephalus (P-value: 0.002), infarction (P-value: 0.029), and meningeal enhancement (P-value: 0.012) in TBM compared to BM. Moreover, TBM patients had a 67% (95% CI: 21% to 131%, P-value:0.002) longer median length of hospital stay and a significantly higher risk of unfavorable outcomes (Risk ratio: 6.96, 95% CI: 2.65 to 18.26, p < 0.001). CONCLUSIONS: Our study emphasizes that TBM patients displayed increased frequencies of altered consciousness, PMN dominance in CSF, extra-neural involvement, hydrocephalus, meningeal enhancement, and brain infarction. The findings emphasize the diagnostic difficulties and underscore the importance of cautious differentiation between these two conditions to guide appropriate treatment strategies.

Neurobrucellosis: report of 54 cases.

BACKGROUND: Brucellosis is among the most widespread zoonotic diseases worldwide. Although rare, nervous system involvement due to Brucella infection is a major diagnostic challenge in endemic regions. PATIENTS AND METHODS: This study was a cross-sectional investigation of hospitalized adults with neurobrucellosis from March 2007 to February 2017. We described the clinical characteristics, radiographical and laboratory features, and clinical outcomes of patients with neurobrucellosis. RESULTS: Fifty-four patients with neurobrucellosis were included. The median age was 35 (interquartile range, 25-50) years, and 32 (59%) cases were male. Thirty-four (63%) patients were stockmen or shepherds. The most common clinical manifestations were fever in 49 (91%) cases, headache in 47 (87%), decreased consciousness in 12 (22%), and seizures in 6 (11%). Meningeal signs were detected in 36 (67%) cases. Brucella species were isolated in five cases from blood or cerebrospinal fluid (CSF). The median of CSF leukocytes was 75 per µL, CSF protein 83 mg/dL, and CSF glucose 39 mg/dL. Only two cases had severe hypoglycorrhachia and one CSF protein ≥ 500 mg/dL. No patient died during hospitalization. CONCLUSIONS: The symptoms of neurobrucellosis could be mild and nonspecific and the classic triad of meningitis is uncommon. Mild CSF pleocytosis of fewer than 50 leukocytes per microliter of CSF was common but severe hyperproteinorrhachia and severe hypoglycorrhachia were rare in neurobrucellosis. Differentiation between neurobrucellosis and systemic brucellosis is important, because more prolonged treatment is indicated for neurobrucellosis, and it could be associated with a broad spectrum of complications that require close follow-up.

Central nervous system infections in patients with systemic lupus erythematosus: a systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis of studies on central nervous system (CNS) infections in patients with SLE, in order to describe their clinical and microbiological characteristics, and outcomes. A systematic search of PubMed/Medline and Embase electronic databases was performed (March 2021) to identify all published studies on CNS infections and their characteristics in patients with SLE. A random-effects model was adopted and findings were reported with 95% CI. Overall, 6 studies involving 17 751 patients with SLE and 209 SLE cases with CNS infection were included in our meta-analysis. The frequency rate of CNS infections in patients with SLE was 0.012 (95% CI: 0.008 to 0.018). Meningitis was the most common clinical syndrome (93.5%, n=109/114, 95% CI: 82.6% to 97.8%) and Cryptococcus neoformans (35.9%, n=55, 95% CI: 27.2% to 45.7%) and Mycobacterium tuberculosis (27.1%, n=43, 95% CI: 14.6% to 44.8%) were the most common causative pathogens. Our patient-pool showed a mean SLE Disease Activity Index (SLEDAI) score of 7.9 (95% CI: 6.1 to 9.6), while 92.4% (n=72/76, 95% CI: 83.0% to 96.8%) of cases were on oral systemic corticosteroids, with a prednisone equivalent mean daily dose of 30.9 mg/day (95% CI: 18.0 to 43.7). Our meta-analysis revealed a mortality rate of 29.0% (95% CI: 15.0% to 48.6%). Clinicians should maintain a high index of suspicion for cryptococcal and tuberculosis (TB) meningitis in patients with SLE with suspected CNS infection, particularly in those with higher SLEDAI and on higher doses of systemic corticosteroids. In conclusion, initiation of empiric antituberculous treatment for patients with SLE who are highly suspected to have CNS TB is warranted while awaiting the results of diagnostic tests. Antifungals might also be potentially useful empirically in patients with SLE who are suspected to have fungal CNS infections. However, with respect to side effects such as toxicity and high cost of antifungals, decision regarding early antifungal therapy should be guided by early and less time-consuming fungal diagnostic tests.

A Systematic and Meta-Analysis Study on the Prevalence of Tuberculosis and Relative Risk Factors for Prisoners in Iran.

INTRODUCTION: Tuberculosis (TB) is a serious infectious disease that affects human health globally. The incidence of TB in prisons is usually much higher than the general population in different countries. The aim of this study was to evaluate the incidence of TB among prisoners in Iran, estimating the relative risk factors by performing a systematic and meta-analysis study on the related articles. METHODOLOGY: Our systematic and meta-analysis study was performed according to the PRISMA guidelines. Two authors systematically searched Scopus, Iran doc, Cochrane, Pubmed, Medline, Embase, Iran medex, Magiran, SID, Google Scholar, and EBSCO. The quality assessment of articles was performed by using the Newcastle-Ottawa Scale. After article quality assessment, a fixed or random model, as appropriate, was used to pool the results in a meta-analysis. Heterogeneity between the studies was assessed using I-square and Q-test. Forest plots demonstrating the point and pooled estimates were drawn. RESULTS: Overall, data from 19562 prisoners indicated 63 cases of TB. The prevalence of TB in prisoners was reported to range from 0.025% to 52% in eight studies. The highest prevalence of tuberculosis was related to the study of Rasht, 517 in 100,000, and the lowest rate was related to the study of Sought Khorasan, 25 in 100,000. The ES of the random effect model is 0.003 (95% CI, 0.001-0.005) and p-value <0.0001. The Higgins' I2 of all studies is 86.55%, and the p-value of the Cochrane Q statistics is <0.001, indicating that there is heterogeneity. Based on the Egger regression plot (t=2.18, p = 0.08, CI 95%: -0.001, 0.005), no publication bias existed. CONCLUSION: According to the analysis findings, the frequency of tuberculosis among the prison in Iran was low. The highest prevalence obtained in our systematic study was 517 in 100,000 in Rasht, which was near the world statistics in the systematic review of world studies. Due to significant limitations in this study, it is not possible to indicate the exact prevalence of TB in prisons in Iran and compare this with the general population. However, more studies are needed to assess the related risk factors for designing health intervention plans to decrease the incidence rate of TB among prisoners.

Errors in Diagnosing Infectious Diseases: A Physician Survey.

Background: Infectious diseases are commonly missed or misdiagnosed. Errors in diagnosing infectious diseases not only affect the patient but also the community health. Objectives: To describe our investigation on the most common errors in diagnosing infectious diseases and their causes according to the physicians' reports. Methods: Between August 2018 and February 2019, specialist physicians and residents across Mashhad, Iran were invited to participate in a survey to report errors they had made or witnessed regarding the diagnosis of infectious diseases. Results: Overall, 465 cases were reported by 315 participants. The most common infectious diseases affected by diagnostic errors were upper respiratory tract infections (URTIs) (n = 69, 14.8%), tuberculosis (TB) (n = 66, 14.1%), pleuro-pulmonary infections (n = 54, 11.6%), central nervous system (CNS) infections (n = 51, 10.9%), and urinary tract infections (n = 45, 9.6%). Errors occurred most frequently in generating a diagnostic hypothesis (n = 259, 55/7%), followed by history taking (n = 200, 43%), and physical examination (n = 191, 41/1%). Errors related to the diagnosis of TB (odds ratio [OR]: 2.4, 95% confidence interval [CI]:0.9-5.7; P value: 0.047) and intra-abdominal infections (OR: 7.2, 95% CI: 0.9-53.8; P value: 0.02) were associated with more-serious outcomes. Conclusion: A substantial proportion of errors in diagnosing infectious diseases moderately or seriously affect patients' outcomes. URTIs, TB, and pleuropulmonary infections were the most frequently reported infectious diseases involved in diagnostic error while errors related to the diagnosis of TB and intraabdominal infections were more frequently associated with poor outcomes. Therefore, contagious and potentially life-threatening infectious diseases should always be considered in the differential diagnosis of patients who present with compatible clinical syndromes.

Antimicrobial Resistance among Community-Acquired Uropathogens in Mashhad, Iran.

Background: Antimicrobial resistance among community-acquired uropathogens is an emerging concern over the past decades that warrants a continuing reevaluation of the appropriateness of recommended empiric antimicrobial regimens for treatment of urinary tract infections (UTIs). Aims: To describe the microbial spectrum and resistance profile of community-acquired uropathogens and predictors of isolation of resistant strains. Methods: Between October 2017 and June 2019, individuals who visited the outpatient clinics for diagnosis of UTIs or screening of asymptomatic bacteriuria were included in the study if they were tested for urine culture in one of the three main medical diagnostic laboratories of Mashhad, Iran. The standard disk diffusion antimicrobial susceptibility testing was used, with the Clinical and Laboratory Standards Institute (CLSI) threshold cutoffs for susceptibility of isolated uropathogens. Results: Three hundred thirty cases were included with a median age of 47 years. Two hundred seventy-six (83.6%) were female. The most common isolated uropathogens were Escherichia coli in 201 (60.9%) cases and Klebsiella species in 46 (13.9%) cases. E. coli isolates showed the highest rates of susceptibility to nitrofurantoin (89.3%), cefixime (75%), and gentamicin (72.4%). Exposure to antibiotics in the past 3 months was a predictor of resistance to ciprofloxacin (OR: 2.8, 95% CI: 1.33-6.28), and older age was a predictor of resistance to TMP-SMX (OR: 2.1, 95% CI: 1.07-3.97) among E. coli isolates. Conclusion. E. coli and Klebsiella species accounted for about two-thirds of community-acquired uropathogens. In regard to the high susceptibility rates, nitrofurantoin was identified as the first-choice agent for empiric treatment of community-acquired cystitis, while cefixime and gentamicin might be the second-choice alternatives. Ciprofloxacin and TMP-SMX, on the other hand, cannot be considered appropriate agents for empiric therapy of community-acquired UTIs, particularly in those who had exposure to antibiotics in the past 3 months and the elderly.

Ocular Manifestations of Hospitalized Patients with COVID-19 in Northeast of Iran.

PURPOSE: To evaluate ocular findings in patients with Coronavirus Disease 2019 (COVID-19) in the Northeast of Iran. METHODS: In a cross-sectional, observational study all consecutive patients with confirmed COVID-19 diagnosis at the central referral center of these patients in northeast of Iran were included. Ocular examinations (external and slit) were randomly performed for the patients who were admitted to the Intensive Care Unit (ICU) and six COVID wards of the hospital. Moreover, Chart records and serum chemistry results were collected. RESULTS: A total of 142 patients with the mean age of 62.6 ± 15 years (range: 23-96 years) and almost equal gender distribution (male: N = 77, 54.2%) were included in the study. During the initial external examination by the ophthalmologist, 44 (31%) patients were found to have conjunctival hyperemia and 22 (15.5%) patients had chemosis. Consecutive slit examination showed 41 (28.9%) conjunctival hyperemia, 22 (15.5%) chemosis, 11 (7.7%) cataract, and 9 (6.3%) diabetic retinopathy. The patients with at least one ocular manifestation had significantly higher blood urea levels at the time of admission compared to those with no obvious ocular involvement (median: 41.5, IQR: 28-66.3 vs. median: 33, IQR: 23.8-51.8, P = .023). Moreover, a significant difference was observed in the total white blood cell count, lymphocyte percent, neutrophil count, Erythrocyte Sedimentation Rate (ESR), and blood urea level between patients with positive and negative Polymerase Chain Reaction (PCR) for SARS-CoV-2 virus. None of the patients reported ocular symptoms prior to systemic involvement. The proportion of patients with at least one ocular manifestation was significantly higher in those admitted in the ICU compared to the non-ICU wards. wards. While conjunctival hyperemia was the most prevalent ocular finding in all patients, chemosis was the most common ocular manifestation in ICU admitted patients. CONCLUSION: Ocular manifestation was observed in more than half of our COVID-19 patients. Hence, it seems important to involve ophthalmologist in the diagnosis and management of these patients.

Diagnostic Errors in Tuberculous Patients: A Multicenter Study from a Developing Country.

Although there is still much to learn about the types of errors committed in health care and why they occur, enough is known today to recognize that a serious concern exists for patients. Tuberculosis (TB) is an infectious disease that is frequently subject to diagnostic errors. Missed or delayed diagnosis of TB can affect patients and community adversely. Our aim in the present study was at evaluating the type of diagnostic errors in TB patients from symptom onset to diagnosis. This was a multicenter cross-sectional study conducted in three university hospitals in Mashhad, Iran. We showed a long delay in diagnosing TB that is mostly related to the time from first medical visit to diagnosis. Errors in the diagnostic process were identified in 97.5% of patients. The most common type of error in diagnosing TB was failure in hypothesis generation (72%), followed by history taking and physical examination. In conclusion, it seems likely that efforts to improve public awareness of and health literacy for TB, to coordinate the referral and follow-up systems of patients, and to improve physicians' skills in history taking and physical examination and clinical reasoning will result in reduced delay in diagnosis of TB and, perhaps, improved patient safety and community health.

Frequency of Different Types of Diagnostic Errors in Patients with Central Nervous System Infections: A Cross-Sectional Observational Study.

OBJECTIVES: To assess the frequency of different types of diagnostic errors in patients with central nervous system (CNS) infection from the onset of symptoms to admission to the hospital, where the correct diagnosis was made. METHODS: A cross-sectional observational design was used, and the information was collected by interviewing patients and/or their knowledgeable relatives as well as reviewing the accompanying medical record documents and hospital records. RESULTS: Of 169 adult patients with CNS infection, 129 (76.33%) were subject to diagnostic errors. Failure in ordering tests and hypothesis generation were the most common types of diagnostic errors that accounted for more than 70% of errors. Several contributing factors that were associated with incorrect diagnostic hypotheses included failure in taking a patient's comprehensive history such as detecting relevant epidemiological clues, conducting a full clinical examination, and interpreting diagnostic evidence. The relationship between poor clinical outcome and longer delay from the onset of illness to diagnosis, inappropriate empirical antibiotic therapy, and lower level of consciousness on admission were found to be statistically significant. CONCLUSIONS: Although diagnosis and management of CNS infection in some patients are straightforward, clinical decision making in facing patients with complex scenarios often requires clinical reasoning instead of relying only on intuitive diagnosis. Justification in requesting diagnostic measures and interpretation of their results based on clinical findings and patient information could be a critical factor in preventing a substantial number of diagnostic errors in patients with CNS infection.

The Etiological Spectrum of Febrile Encephalopathy in Adult Patients: A Cross-Sectional Study from a Developing Country.

The profile of febrile encephalopathy varies based on different demographic and geographical characteristics of the study population. This retrospective, cross-sectional study was conducted to evaluate the etiological spectrum of febrile encephalopathy in hospitalized adult patients. A total of 293 patients with the mean age of 49.7 ± 23 were evaluated of whom 77.1% presented with encephalopathy syndrome. The most common diagnosis in patients with clinical syndromes suggestive of central nervous system (CNS) infection was sepsis associated encephalopathy (SAE) (22.9%), followed by bacterial meningitis (14%) and neurotuberculosis (9.9%). The comparison between the elderly and young adults showed that, in the young adults, bacterial meningitis and neurotuberculosis, and in the elderly SAE, are among the most common causes of clinical syndromes suggestive of CNS infection including febrile encephalopathy in our region. Moreover, we illustrated an upward trend for the proportion of diagnosing CNS infections among those who underwent diagnostic LP, from 40.4% in 2011 to 70% in 2015, that could be indicative of an increasing threshold for performing LP at least in our center in recent years. Whether these changes have been associated with increasing the rate of diagnostic errors or not needs to be evaluated in future studies.

The mask of acute bacterial pneumonia may disguise the face of tuberculosis.

INTRODUCTION: Pulmonary tuberculosis (TB) can present as acute pneumonia. Differentiation of tuberculous from non-tuberculous community-acquired pneumonia (CAP) is an important challenge in endemic areas. The purpose of this study was the comparison between characteristics of tuberculous and non-tuberculous CAP patients. METHODS: In this prospective and observational study, all adult patients (aged ≥16 years) who were admitted to Imam Reza Hospital in Mashhad (Iran) with the diagnosis of CAP, between February 2013 and January 2014, were enrolled. Clinical, radiological, and microbiological data of the patients were collected and reviewed. Statistical analyses were performed using SPSS 14 software and R programming language. RESULTS: We studied 120 patients with diagnosis of acute CAP including 21 (17.5%) tuberculous and 99 (82.5%) non-tuberculous CAP. The etiologies of CAP in the latter group were as follow: S. pneumoniae 29 (29.3%), followed by S. aureus, polymicrobial including anaerobes, and other agents. The diagnosis of pneumonia remained unknown in 49 (40%) patients. We found approximately equal gender distribution among two study groups (14/21 vs. 61/99, 63.6% vs. 62.9%, p=0.948). Fifty percent of patients with tuberculous CAP had opioid addiction that was more frequent compared with non-tuberculous group (p=0.240). 52.4%, 63.2%, 30%, and 90% of patients with tuberculous CAP had severe presentation based on PSI, IDSA/ATS, CURB-65, and SMART-COP, respectively. CONCLUSIONS: The diagnosis of TB should be considered in all patients who presented with CAP in endemic regions. It could not be differentiated from other causes of pneumonia on clinical and radiological grounds.

Effect of modifying the information and training structure on the occupational safety of health care workers in exposure to blood and body fluids: A quasi-experimental study.

This study was a quasi-experimental design to assess the effect of a Web-based information system on the occupational exposure to blood and body fluids (BBFs) among health care workers (HCWs). The outcome was the number of exposure incidents with BBFs among HCWs in both hospital A (intervention) and hospital B (control). The findings showed that the implementation of the Web-based information system about infection prevention and control in hospital A decreased exposure incidents with BBFs among the HCWs (P < .001).

A Complicated Course of Acute Viral Induced Pharyngitis, Icteric Hepatitis, Acalculous Cholecystitis, and Skin Rash.

This case reveals the complexities and challenges in the diagnosis of acute Epstein-Barr virus (EBV) infection, indicating the potential relationship between EBV infection and severe icteric hepatitis, acalculous cholecystitis, and lymphocytic vasculitis. We suggest including EBV infectious mononucleosis in the list of differential diagnoses when any of these clinical syndromes (or a combination thereof) occurs without apparent cause, especially in the presence of lymphocytosis. To our knowledge, this is the first report to suggest the possible role of EBV in the pathogenesis of cutaneous lymphocytic vasculitis. Also it is possible that EBV infection triggered the flare-up of the underlying rheumatologic disease. Therefore, it could be assumed that a part of the clinical syndrome (e.g., dermatologic manifestations) might be related to the flare-up of the underlying rheumatologic disease.

Can Procalcitonin Add to the Prognostic Power of the Severity Scoring System in Adults with Pneumonia?

BACKGROUND: The first decision confronting clinicians in the management of patients with community acquired pneumonia (CAP) is whether the patient is to be hospitalized or not. We sought to validate the pneumonia scoring system and assess the power of procalcitonin (PCT) level to predict in-hospital mortality (IHM) and intensive vasopressor and respiratory support (IVRS) requirements in patients with CAP. MATERIALS AND METHODS: A total of 120 patients with CAP were evaluated for severity of illness based on the defined scoring systems including pneumonia severity index (PSI), confusion, urea, respiratory rate, blood pressure, age>65 (CURB-65), confusion, respiratory rate, blood pressure, age>65 (CRB-65), infectious diseases society of America/American thoracic society 2007 criteria (IDSA/ATS 2007) and systolic blood pressure, multilobar infiltrate, albumin, respiratory rate, tachycardia, confusion, low oxygen, low pH (SMART-COP). Demographic, clinical, laboratory and radiographic data were collected prospectively. The accuracy of each scoring system in predicting IVRS requirement and IHM was assessed from the area under the receiver operating characteristic (ROC) curve (AUC). Level of PCT was determined by semi-quantitative PCT-Q method (BRAHMS). The accuracy of the defined scoring systems, PCT levels and each scoring system plus PCT levels in prediction of IHM and IVRS requirement was analyzed. RESULTS: The accuracy of PCT levels in predicting IHM and IVRS requirement based on AUC was 0.542 and 0.658, respectively and the best threshold was ≥ 2ng/mL for both of them. Adding the level of procalcitonin to different scoring systems (based on the defined scoring systems) improved the accuracy of all systems. CONCLUSION: We do not suggest using the PCT level alone as a predictor for mortality and IVRS requirement. Instead, we suggest PSI plus PCT and IDSA/ATS 2007 plus PCT as accurate predictors for IHM and SMART-COP plus PCT for IVRS requirement in patients who presented with CAP.

Etiological Diagnosis of Community-Acquired Pneumonia in Adult Patients: A Prospective Hospital-Based Study in Mashhad, Iran.

BACKGROUND: Pneumonia is the third most common cause of death in the world, and mortality is highest for patients who require hospitalization. OBJECTIVES: This prospective observational study is an etiological survey of community-acquired pneumonia (CAP) over a 12-month period in the Iranian city of Mashhad. To our knowledge, this is one of the first prospective hospital-based studies to comprehensively evaluate the epidemiological, demographical, clinical, and prognostic factors of patients with CAP in Iran. PATIENTS AND METHODS: We studied all adult patients (aged ≥ 16 years) with CAP admitted to Imam Reza Hospital, Mashhad, Iran, between February 2013 and January 2014. The etiological diagnosis of CAP was made through conventional culturing and staining of respiratory secretions (i.e. sputum and pleural fluid), standard BACTEC™ Plus Aerobic/F bottles for blood cultures, and the immunochromatographic assays BinaxNOW(®) Streptococcus pneumoniae antigen and BinaxNOW(®) Legionella pneumophila antigen for the detection of S. pneumoniae antigen and L. pneumophila serogroup 1 antigen, respectively. RESULTS: Among 120 patients with CAP, the most common etiology was S. pneumoniae (24.4%), followed by Mycobacterium tuberculosis (17.5%), S. aureus (6.7%), polymicrobial agents including anaerobes (4.2%), complicated hydatid cyst (2.5%), Influenza A virus (4.2%; including 2 cases of mixed Influenza A-bacterial infection), and Klebsiella pneumoniae, Brucella melitensis, Mucor, and varicella, each in 0.8% of the patients. The diagnosis of pneumonia remained unknown in 49 (40%) patients. CONCLUSIONS: Tuberculosis was an important cause of CAP in our region. Hence, it should be considered in all patients admitted with a CAP diagnosis.

A 28-Year-Old Woman with Fever, Weight Loss, Pancytopenia, and Multiple Hepatosplenic and Bone Lesions.

Brucellosis is a systemic zoonotic infection that can involve any organ or system in the body. It may present with a broad spectrum of clinical manifestations. Considering such myriad presentations, brucellosis should always be considered in the differential diagnosis of any febrile illness in a compatible epidemiological context. Here, we report a rare presentation of acute brucellosis with multifocal osteomyelitis and hepatosplenic lesions.

How should we manage a patient with invasive mucoromycosis who develops life-threatening reaction to amphotericin B? Report of two cases and literature review.

This report presents two cases of invasive rhino-orbital mucormycosis who had life-threatening reactions to amphotericin B. Both cases were treated with a combination of posaconazole-caspofungin favorably with no evidence of recurrence upon long-term follow-up. To our knowledge, this is the first report of successful treatment of invasive mucormycosis with azole-echinocandin combination. It may suggest that caspofungin exerts additional or even synergistic antimucoral effects to posaconazole.

Treatment for and clinical characteristics of granulomatous mastitis.

OBJECTIVE: To describe the clinical and paraclinical characteristics of idiopathic granulomatous mastitis, the management of our patients, and review the literature on this topic. METHODS: Patients referred to our clinic with a presumptive diagnosis of infectious mastitis were only included in the study if they had histopathologic confirmation of granulomatous mastitis. A systemic or infectious etiology was excluded by the testing of tissues and fluids by staining, culture, and polymerase chain reaction methods. Those patients with no reported etiology were categorized as idiopathic granulomatous mastitis and treated with antiinflammatory drugs. All were monitored for signs of recurrence. RESULTS: All 22 patients with a final diagnosis of idiopathic granulomatous mastitis were women with a mean age (± standard deviation) of 32.8 ± 6.2 years. Initial treatment with a prednisone regimen was given in 15 (68.2%) patients, prednisone plus methotrexate (MTX) in six (27.3%), and MTX alone in one (4.5%). Among the total of 22 patients with idiopathic granulomatous mastitis, 12 (54.5%) received MTX either as an initial treatment or as an alternative regimen. Of the 22 patients, three (13.6%) had disease recurrence and four (18.2%) experienced adverse drug reactions. Sixteen (72.7%) patients discontinued the initial treatment regimen with acceptable control of disease activity and without recurrence or adverse drug reactions during the follow-up period. CONCLUSION: Idiopathic granulomatous mastitis is a distinct benign breast condition of unknown etiology but several triggers are suspected, including inflammatory, infectious, and hormonal factors. Corticosteroids and MTX, with or without surgery, are the treatment of choice in these patients.

Fatal nosocomial spread of Crimean-Congo hemorrhagic fever with very short incubation period.

Crimean-Congo hemorrhagic fever is a tick-borne viral zoonosis with the potential of human-to-human transmission with case fatality rates from 3% to 50%. The incubation period depends on host, route of infection, and viral dose. Herein, we report a nosocomial spread of the disease in a hospital at Mashhad, northeastern Iran, with a very short incubation period for one of the secondary cases. The patient was a medical student who had a negligible contact with a Crimean-Congo hemorrhagic fever patient during his admission to the hospital. The time interval between the contact and the onset of symptoms was merely 20 hours. Unfortunately, he died within 1 week of exposure.