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Background and purpose: In late December 2019, pneumonia originating from nCOV-2019 spread rapidly around the world, and in March 2020, the World Health Organization officially declared it a pandemic and chose the name "COVID-19" for the resulting disease. A significant proportion of COVID-19 patients experience severe pulmonary complications and life-threatening conditions that necessitate respiratory support and admission to the intensive care unit (ICU). Since the detection of the first case of COVID-19 in Iran, the country has experienced several waves, with different strains of the coronavirus prevailing in each wave. According to the studies conducted in this field, in the first wave, the alpha strain (B.1.1) 7), the second wave of the beta strain (B.1.351), the third wave of the gamma strain (P.1), the fourth wave of the delta strain (B.1.617.2) and in the fifth wave the Amicron strain (B.1.1.529) of the strain were dominant in patients. This study aims to evaluate the clinical and paraclinical findings, as well as the outcomes, of COVID-19 patients admitted to the intensive care units at a referral teaching hospital in northern Iran during the first through fifth waves of the pandemic. Materials and methods: This research is a descriptive-analytical retrospective study that was conducted on all patients with COVID-19 who were hospitalized in the ICU of Razi Qaemshahr Hospital (Infectious Diseases Referral Center of Mazandaran Province) in first to fifth waves. Personal information, underlying diseases, time from the onset of symptoms to a hospital visit, laboratory tests, and length of stay of the patient in the intensive care unit was collected through dossier reading and spss25 software was used for statistical analysis. Results: Out of the 304 patients admitted to the ICU during the first through fifth waves of the COVID-19 outbreak, 50.3% were male. The age range of the patients was from 22 years to 98 years with an average of 65.14±15.08. 244 patients had at least one underlying disease. So 41% of the patients had diabetes and 50% had blood HTN. Among 244 patients with underlying disease, only 28 patients recovered and 216 patients died, which difference was significant (P=0.01). The second wave had the highest number of patients (25.7%), while the third wave had the lowest (16.4%). The average hemoglobin level differed significantly between the second and fourth waves, being 1.37 units lower in the fourth wave. The mortality rates varied significantly across the different waves (P

Tuberculosis (TB) remains a significant global health concern and kills millions of people every year. While TB can affect any organ in the body, breast TB is relatively uncommon. This study presents a comprehensive review of literature spanning 23 years, with a focus on cases of breast TB in Iran. Among the 96 cases found, the majority (89.6%) fell within the age range of 20–60, with a striking prevalence among women (98.9%). Common symptoms included pain and palpable mass, each presenting in approximately 60.4% of cases. Notably, only a quarter of patients had a confirmed history of exposure to a known TB case. Left breast involvement was more prevalent (58.3%), with ipsilateral lymph node enlargement observed in 40.6% of cases. Given the clinical presentation of breast TB, which often leads to misdiagnosis, a significant proportion of cases (68.7%) were diagnosed through excisional biopsy. Following a standard 6-month regimen of anti-TB drugs, relapse occurred in only 4.2% of cases. This study highlights the need for heightened awareness and vigilance in diagnosing breast TB, especially in regions with a high burden. Although breast TB poses diagnostic challenges, with prompt identification and treatment, the prognosis is generally favorable, with a low incidence of relapse.

Background and purpose: Although various vaccines have been produced to provide immunity against COVID-19, these vaccines do not provide lifelong immunity, and over time, their level of immunity diminishes. Considering that at least 50% of the population must be immune to prevent the chain of transmission of COVID-19, we conducted this study to measure the level of immunity against this virus after at least 6 months of the third dose injection among the employees of Razi Hospital, Qaimshahr. Materials and methods: In this analytical observational study, the blood samples of 88 volunteers were used to determine the SARS-Cov-2 RBD antibody. The 18-item self-report questionnaire of the side effects of the COVID-19 vaccine was provided to the participants. Statistical analysis was done with SPSS software (version 0.24). Results: The mean age of the participants was 41 years, and men and women accounted for 36.36% and 63.63% of the samples, respectively. The youngest participant was 23 years old, while the oldest was 72 years old. Comorbidities were found in 21% of the participants. Among the 88 participants, 98.86% had antibody levels higher than the cut-off, which was 5 (RU/ml). Systemic side effects of the third dose included fever (46.5%), myalgia (25%), as well as local reactions of pain (29.5%) and redness (6%). The systemic side effects of the fourth dose were fever (22%), myalgia (12%), and the local reactions were injection site pain (42%) and redness (4%). Conclusion: No significant relationship was found between the investigated variables and the antibody level. However, it was observed that humoral immunity against COVID-19 was present in most of the injectors after 6 months from the third dose injection.

BACKGROUND: Assessing the prevalence of chronic diseases is necessary to reduce complications and mortality rates in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aimed to evaluate the chronic diseases in patients with coronavirus disease 2019 (COVID-19) and describe the clinical course of symptoms and changes in laboratory findings during the hospitalization of these patients. METHODS: This cross-sectional and retrospective study investigated the frequency of various chronic diseases in hospitalized patients with COVID-19, and compared them to deceased and improved patients in Razi Teaching Hospital, Ghaemshahr, Mazandaran Province, the northern part of Iran, during the March to September 2020. Data analysis was performed by SPSS -21 using mean and standard deviation (SD) and chi-square test (P < 0.05). RESULTS: 1000 patients were evaluated for chronic diseases. The most common chronic disease in patients with COVID-19 was diabetes (30.3%), followed by hypertension (HTN) (28.8%), and ischemic heart disease (IHD) (14.7%). Other chronic illnesses were less than the mentioned diseases including hypothyroidism (4.9%), heart failure (HF) (4.3%), renal failure (4.3%), obesity (2.3%), and corticosteroid consumption (2.1%). CONCLUSION: According to the results, chronic diseases such as diabetes, HTN, and cardiovascular disorders can increase the risk of mortality from COVID-19. The mortality rate in the present study was similar to the majority of studies in this field. However, the difference in mortality rates with other studies may be because patients who required advanced medical care in the hospital and had an advanced stage of the disease were examined in our study.

Background and purpose: There are limited studies on co-infection of COVID-19 and tuberculosis (TB). This study aimed to describe the clinical, radiological, laboratory characteristics, treatment and outcome of patients admitted with tuberculosis and COVID 19 co-infection. Materials and methods: In this retrospective study, we investigated all patients with either active TB or old TB and COVID-19 admitted to Qaemshahr Razi Teaching Hospital between 2020 and 2022. Results: A total of 9251 patients with COVID-19 were admitted to our hospital between February 2020 and May 2022. There were eight patients with pulmonary tuberculosis and COVID-19 co-infection, including five (62.5%) male patients. The mean age of these patients was 61.13±22.63 years old. The mean time of symptom onset to hospital admission was 15.13±30.56 days and 50% were diagnosed with active TB and other half had old TB. Four patients were admitted to the ICU, three of whom required ventilation. Finally, four (50%) patients deceased. In this study, among factors that influence patients’ outcomes, only underlying diseases were significantly associated with death. Conclusion: Tuberculosis is assumed to cause a higher mortality risk in COVID-19 patients, especially in those with chronic underlying diseases.

Background and purpose: The COVID-19 pandemic resulted in an uncontrolled disease burden on healthcare workers (HCWs) worldwide. We aimed to investigate the prevalence and severity of COVID-19 in HCWs of selected hospitals in Mazandaran province and examine the association between COVID-19 and missed opportunities of HCWs. Materials and methods: In this retrospective descriptive-analytical study, 1105 HCWs in Qaemshahr Razi Hospital and Sari Fatemeh-Zahra Hospital were studied between February 2020 and June 2020. In order to evaluate the frequency and severity of the disease, clinical and paraclinical manifestations were recorded by a trained HCW. Data were analyzed in SPSS V18. Results: The frequency of COVID-19 was 16.19% among HCWs. The patients included 113 (63.13%) nurses, 47(26.26%) service providers and administrative personnel, and 19(10.61%) physicians. Duration of sick leave was found to be significantly associated with severity of COVID-19 (P=0.006). This length was also significantly associated with the job and was longer in nurses (P=0.013). Our findings revealed a significant relationship between the level of adherence to personal protective equipment (PPE) and the severity of COVID-19 (P=0.001). Conclusion: COVID-19 could exert remarkable impact on the quality of work in HCWs, especially among nurses. Effective training of HCWs regarding PPE instructions results in suitable protection against severe forms of the disease.

Background and purpose: Violet is a plant that has received interest in complementary medicine due to its anti-inflammatory, antipyretic, and antimicrobial effects. Fever is one of the major symptoms of COVID-19. This study was conducted to determine the effect of violet extract in the form of syrup on fever in patients with COVID-19. Materials and methods: In this randomized clinical trial, 52 patients with COVID-19 were studied in Intensive Care Unit in Amol Imam Khomeini Hospital (2021). In intervention group in addition to an injection of acetaminophen, 5 cc of violet extract syrup prepared from the aqueous extract of the plant was taken. The temperature was recorded after 30 and 60 minutes and four hours. The follow-up of the patients continued for three days and the temperature was recorded every six hours. Results: There was a significant difference between the intervention group (36.84±0.37) and control group (37.13±0.62) in mean temperature at second time in second day of follow-up (P=0.04). Also, the mean temperature was found to be significantly different between the two groups at 30 (P=0.001) and 60 minutes (P=0.05) after the intervention. At other groups, there was no significant difference between the intervention and control groups. Conclusion: The aqueous extract of violet plant in the form of syrup reduces fever in patients with COVID-19 causing no complication. Due to the ease of access to this herbal product, it can be used to prevent problems caused by fever. (Clinical Trials Registry Number: IRCT20150916024047N6)

Background: Lymphopenia is an important but nonspecific laboratory indicator of COVID-19. Objectives: To describe epidemiologic and clinical characteristics of the first cases of the COVID-19 referred to a center dedicated to COVID-19 patients in Iran. Methods: This research is a retrospective cross-sectional study on 100 confirmed cases with COVID-19, hospitalized from February 25 to March 10, 2020, in Qaemshahr Razi Hospital in Mazandaran Province, Iran. The main demographic data, clinical features, including outcomes, laboratory findings, and therapeutic protocols, were collected in a structured form and analyzed. Results: The Mean±SD age of the patients was 56.7±15.6 years. Fifty-nine percent (n=59) of the patients were male. Nineteen percent (n=19) were admitted to the ICU. The median (IQR) time from disease onset to hospital admission was 5 (3-7) days. The most common symptoms were fever (73%), dyspnea (67%), dry cough (61%), and myalgia (61%). The severity of the disease was moderate in most patients (n=54). The average hospital stay for patients was 7 days. The non-survivor cases in comparison to survived ones were from a higher age group (65 vs 52 years; P=0.001), had a higher frequency of underlying diseases (68.4% vs 39.5%; P=0.039), had a lower peripheral capillary O2 saturation at the time of admission (79% vs 94%; P

Background and purpose: Recently, due to the reduction of hepatitis A in Iran there are people with low or no Hepatitis A Virus- Antibody (HAV-Ab), therefore, people at Arbaeen Pilgrimage are at risk for hepatitis A. This study aimed at examining HAV-Ab in pilgrims traveling from Mazandaran province, Iran to Karbala in 2018. Materials and methods: This cross-sectional study was performed in 200 people selected from 40,000 pilgrims in Mazandaran province. Serum samples were evaluated for presence of HAV-Ab and data for demographic characteristics and history of hepatitis A immunity were recorded. Data analysis was performed in SPSS V16. Results: The participants were 137 (68.5%) males and 63 (31.5%) females. Positive and negative HAV-Ab were seen in 156 (78%) and 44 (22%), respectively. Mean ages of people with positive and negative HAV-Ab were almost similar (50 years and 47 years, respectively). HAV-Ab status was found to be significantly associated with job (P0.05). Conclusion: Twenty-two percent of people who were travelling to Karbala had no HAV-Ab, which is significant because the risk of developing fulminant hepatitis increases in adults, therefore, vaccination of Karbala pilgrims for hepatitis A virus is suggested.

Abstract The Sputnik V is a COVID- 19 vaccine developed by the Gamalia institute of epidemiology and microbiology and released on August 11, 2020. We provided independent evidence on side effects and immunogenicity following the administration of the Sputnik V COVID-19 in Iran. In this observational study, the healthcare workers who were vaccinated with the Sputnik V COVID-19 vaccine within February and April 2021 were evaluated. Among a total of 13,435 vaccinated healthcare workers, we received 3236 self-declaration reports of Sputnik V associated adverse events with the mean age 39.32 ± 10.19 years old which 38.8% were men and 61.2% were women. Totally 68.8% of females versus 66.2% of males reported side effects after receiving the first dose and 31.2% of females versus 33.8% of males reported side effects after the second dose of vaccine. The most common side effect was a pain in the injection site (56.9%), fatigue (50.9%), body pain (43.9%), headache (35.7%), fever (32.9%), joint pain (30.3%), chilling (29.8%) and drowsiness (20.3%). Side effects of the vaccine were significantly more frequent in females and younger individuals. Among a total of 238 participants, more than 90% after the first and second dose of vaccine had a detectable level of SARS-CoV-2 RBD antibody and SARS-CoV-2 neutralizing antibody. Although the overall rate of adverse effects was higher than the interim results from randomized controlled trials, our findings support the manufacturer’s reports about the high humoral immunogenicity of vaccine against COVID-19.

Background and purpose: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that was first reported in December 2019 in China and spread rapidly around the world. The aim of this study was to compare clinical and laboratory findings and disease outcome between survived and deceased COVID-19 patients admitted to Qaemshahr Razi Hospital, Iran. Materials and methods: In this retrospective study, demographic, clinical, paraclinical, and treatment information of hospitalized COVID-19 patients were analyzed. Logistic regression analysis was performed using SPSS V25. Results: Among 1013 COVID-19 patients, 145 (14.3%) died. Mortality rate was significantly higher in patients older than 65 years of age (54.5%) (P= 0.0001). Comorbidities was seen in 631 patients (62.4%). Mortality rate was significantly higher in patients with hypertension (P= 0.005), diabetes (P 250 (U/L) (P

IntroductionThe occurrence of oral candidiasis (OC) is expected in patients with COVID-19, especially those with moderate to severe forms of infection who are hospitalized and may be on long-term use of broad-spectrum antibiotics or prolonged corticosteroid therapy. We aimed to characterize clinical conditions, the prevalence profile of Candida species, and outcomes of COVID-19 patients with OC.MethodsIn this observational study, oral samples were obtained from COVID-19 patients suspected of OC admitted to Razi teaching hospital. Patients with OC were monitored daily until discharge from the hospital. Species identification was performed by a two-step multiplex assay named YEAST PLEX, which identifies 17 clinically important uncommon to common yeast strains.ResultsAmong the 4133 patients admitted with COVID-19, 120 (2.90%) suffered from OC. The onset of signs and symptoms of OC in patients was, on average (2.92 ± 3.596 days) with a range (of 1-29 days). The most common OC presentation was white or yellow macules on the buccal surface or the tongue. In (39.16%) of patients suffering from OC multiple Candida strains (with two or more Candida spp.) were identified. The most common Candida species were C. albicans (60.57%), followed by C. glabrata (17.14%), C. tropicalis (11.42%), C. kefyr (10.83%) and C. krusei (3.42%). Notably, OC caused by multiple Candida strains was more predominant in patients under corticosteroid therapy (P

Abstract Background We performed a multicenter, randomized open-label trial in patients with moderate to severe Covid-19 treated with a range of possible treatment regimens. Methods: Patients were randomly assigned to one of three regimen groups at a ratio of 1:1:1. The primary outcome of this study was admission to the intensive care unit. Secondary outcomes were intubation, in-hospital mortality, time to clinical recovery, and length of hospital stay (LOS). Between April 13 and August 9, 2020, a total of 336 patients were randomly assigned to receive one of the 3 treatment regimens including group I (hydroxychloroquine stat, prednisolone, azithromycin and naproxen; 120 patients), group II (hydroxychloroquine stat, azithromycin and naproxen; 116 patients), and group III (hydroxychloroquine and lopinavir/ritonavir (116 patients). The mean LOS in patients receiving prednisolone was 5.5 in the modified intention-to-treat (mITT) population and 4.4 days in the per-protocol (PP) population compared with 6.4 days (mITT population) and 5.8 days (PP population) in patients treated with Lopinavir/Ritonavir. Results The mean LOS was significantly lower in the mITT and PP populations who received prednisolone compared with populations treated with Lopinavir/Ritonavir (p = 0.028; p = 0.0007). We observed no significant differences in the number of deaths, ICU admission, and need for mechanical ventilation between the Modified ITT and per-protocol populations treated with prednisolone and Lopinavir/Ritonavir, although these outcomes were better in the arm treated with prednisolone. The time to clinical recovery was similar in the modified ITT and per-protocol populations treated with prednisolone, lopinavir/ritonavir, and azithromycin (P = 0.335; P = 0.055; p = 0.291; p = 0.098). Conclusion The results of the present study show that therapeutic regimen (regimen I) with low dose prednisolone was superior to other regimens in shortening the length of hospital stay in patients with moderate to severe COVID-19. The steroid sparing effect may be utilized to increase the effectiveness of corticosteroids in the management of diabetic patients by decreasing the dosage.

Identifying and determining the origin of the first human case of COVID-19, which has caused pandemic will be of great benefit in preventing and controlling next epidemics and pandemics. The first confirmed case of COVID-19 was reported in December 2019 in China. This article reports three cases of pneumonia compliant with COVID-19 admitted to Qaemshahr Razi Hospital in Mazandaran province, Iran before the first official report of confirmed case of the disease (November-December 2019). The pattern of radiological involvement was completely consistent with COVID-19 in all three patients. Two patients died of acute progressive respiratory failure despite supportive respiratory therapy and systemic corticosteroids, and the other patient recovered. Study of these cases highlights the fact that emerging and re-emerging diseases should be considered in management of patients with infection and unusual symptoms.

Background and purpose: This research aimed at investigating the effect of herbal medicine on reduction of pulmonary complications in patients with Coronavirus disease 2019 (COVID-19). Materials and methods: Forty patients with COVID-19 infection older than 18 years of age (60% men) with the average age of over 55 years old enrolled in this study. Written consent was obtained and participants with the following symptoms were divided into experimental group and control group: body temperature higher than 38℃, lymphocyte counts of less than 1200, positive CRP, respiratory symptoms, and pulmonary involvement in lung CT scan. The control group was treated with 400 mg Kaletra® and 200 mg hydroxychloroquine oral every 12 hours, and the experimental group, in addition to this regimen, received 5 ml of a herbal medicine (consisting of Satureja hortensis L., Hypericum perforatum L. and Foeniculum vulgare L.) three times a day. Statistical analysis was done in SPSS applying Chi-square test and t-test. Results: The herbal medicine was found to be significantly effective in decreasing the time of hospitalization and recovery from the disease (8.5 days in control group vs. 5 days in experimental group, (P

BackgroundIvermectin which was widely considered as a potential treatment for COVID-19, showed uncertain clinical benefit in many clinical trials. Performing large-scale clinical trials to evaluate the effectiveness of this drug in the midst of the pandemic, while difficult, has been urgently needed.MethodsWe performed two large multicenter randomized, double-blind, placebo-controlled clinical trials evaluating the effectiveness of ivermectin in treating inpatients and outpatients with COVID-19 infection. The intervention group received ivermectin, 0.4mg/kg of body weight per day for 3 days. In the control group, placebo tablets were used for 3 days.ResultsData for 609 inpatients and 549 outpatients were analyzed. In hospitalized patients, complete recovery was significantly higher in the ivermectin group (37%) compared to placebo group (28%; RR, 1.32 [95% CI, 1.04–1.66]; p-value = 0.02). On the other hand, the length of hospital stay was significantly longer in the ivermectin group with a mean of 7.98 ± 4.4 days compared to the placebo receiving group with a mean of 7.16 ± 3.2 days (RR, 0.80 [95% CI, 0.15–1.45]; p-value = 0.02). In outpatients, the mean duration of fever was significantly shorter (2.02 ± 0.11 days) in the ivermectin group versus (2.41 ± 0.13 days) placebo group with p value = 0.020. On the day seventh of treatment, fever (p-value = 0.040), cough (p-value = 0.019), and weakness (p-value = 0.002) were significantly higher in the placebo group compared to the ivermectin group. Among all outpatients, 7% in ivermectin group and 5% in placebo group needed to be hospitalized (RR, 1.36 [95% CI, 0.65–2.84]; p-value = 0.41). Also, the result of RT-PCR on day five after treatment was negative for 26% of patients in the ivermectin group versus 32% in the placebo group (RR, 0.81 [95% CI, 0.60–1.09]; p-value = 0.16).ConclusionOur data showed, ivermectin, compared with placebo, did not have a significant potential effect on clinical improvement, reduced admission in ICU, need for invasive ventilation, and death in hospitalized patients; likewise, no evidence was found to support the prescription of ivermectin on recovery, reduced hospitalization and increased negative RT-PCR assay for SARS-CoV-2 5 days after treatment in outpatients. Our findings do not support the use of ivermectin to treat mild to severe forms of COVID-19.Clinical Trial Registrationwww.irct.ir IRCT20111224008507N5 and IRCT20111224008507N4.

Background and Purpose:Cryptococcalmeningitis (CM) is a serious fungal infection that especially affectspatients with human immunodeficiency virus (HIV). In this regard,the presentretrospective study aimed to analyze the clinical and laboratory features and therapeutic outcomes of patients with CM admitted totwo teaching referral centersin the north of Iran during 2011-19. Materials and Methods:This studywas performed onall the hospitalized patients diagnosedwith CM in two therapeutic centers of infectious diseases in the north of Iran. The required data,such as demographic characteristicsandclinical and paraclinical featuresof patients,were extracted and entered in the information forms. Finally, the collected data were analyzed inSPSSsoftware(version16). Results:For the purpose of the study, records of 12confirmed CM patients were evaluatedin this research. Based onthe results,75% ofthepatients were male.Moreover,the average age of the subjectswas 40.33± 8.93 years oldand 66.6%ofthem(n=8) were HIV-positive. Other underlying diseases among HIV-positive patients includedinfection with hepatitis C virus (25%) and a history of tuberculosis (25%). In total, threeHIV-negative patients suffered from Hodgkin lymphoma (25%), sarcoidosis (25%),and asthma (25%) and one patient (25%) had no underlying disease. Headache (75%), weakness,and fatigue (75%) were the most common symptomsamong the participants. The cluster of differentiation 4count in all HIV-positive patients was less than 100 cells/μl. There was no significant difference between symptoms in HIV-positive and HIV-negative patients. Besides, no significant differencewas observedbetween the groups of HIV-positive and HIV-negative patientsregardingthe period betweentheonset of symptoms and diagnosisof CM,the length of hospital stay,and the duration of antifungal medicationconsumption. In total,threepatients (25%) expired,and six patients recovered. The CM recurred in two HIV-negative and oneHIV-positivesubjects;the two HIV-negativepatientswere treated,whilethe HIV-positivepatientexpired due to thisrecurrence. Conclusion:Clinical features and cerebrospinal fluid parameters were not different in HIV-positive and HIV-negative participants. Despite the fact thatCM is not commoninIran, due to the increasing number of immunosuppressive patients, the differential diagnosis of CM should be considered forpatients with signs and symptoms of infection in the central nervous system.

Background and purpose: Acute viral hepatitis is one of the world's health problems today. An outbreak of hepatitis A virus occurred in a rural area in ​​Mazandaran province, north of Iran, 2019. This research aimed at examining this outbreak in detail in order to study the epidemiological and economic burden, and the possible source of pollution. Materials and methods: This descriptive case report study presents the cases of seven members of a family of nine with acute symptoms of hepatitis. Results: In this family, seven members were found with clinical and laboratory symptoms of acute hepatitis, all of whom were positive for HAV Igm serology tests. According to the short incubation period and contamination of common origin, the most probable route of transmission, considering the health condition and residence of the people studied, was contaminated water. Conclusion: According to the investigation on water plumbing system and location of the residential building (at the end of the village), contamination entered the water plumbing system through sewage and drinking water is regarded as the main cause of the disease.

Background and purpose: AIDS, can cause psychological and social problems in patients and affects their quality of life. Therefore, infected people need more care. This study was conducted to investigate the effect of different care methods in quality of life of HIV+ patients. Materials and methods: HIV-positive patients in Mazandaran were divided into two groups of intervention (n=34) and control (n=17). Patients in intervention group received medical and social care for one year. Quality of life was assessed in both groups before and after the intervention using WHOQOL-Brief and a researcher-made questionnaire. Results: The study population included 49 patients including 56.67% males and 43.33% females. Before the intervention there was no significant difference in quality of life between the two groups. But after the intervention, satisfaction from personal relationships decreased significantly while social-occupational worries and concerns about the disease showed significant increase in intervention group. Compared to the control group, after one year, satisfaction from current treatment (P=0.02), concerns about the disease (P=0.0009), and quality of social life (P=0.02), showed significant increases in the intervention group. Conclusion: The participants in this study had low levels of quality of life and physical and mental health care could be of great benefit in improving quality of life of HIV+ patients. In designing care protocols for these patients, all aspects of life should be considered.

Background: An antimicrobial stewardship program can be defined as the set of actions performed in hospitals for the rational use of antibiotics. Early conversion from intravenous to oral antibiotics plays an important role in reducing the cost of treatment, shortening the length of hospital stay, and decreasing the workload of nurses. The purpose of this study was to evaluate the impact of the implementation of antimicrobial stewardship program on duration of hospitalization and medication costs.Methods: We performed an interventional study in Razi teaching hospital. All hospitalized patients aged 18 and older who met the inclusion criteria were included. This study comprised two groups. The interventional prospective group to assess the impact of intravenous to oral antibiotic conversion, and a retrospective group in which the intervention had not been applied, used as the comparator.Results: A total of 260 cases were enrolled; 47 in the interventional group and 213 in the retrospective one. The length of hospitalization was significantly shorter in the intervention group compared to the retrospective one (5.2 vs7.9 days, p

Tuberculosis (TB) has always been represented as a constant and serious public health challenge throughout human history due to its intensive epidemiological, clinical, and social implications. Risk factors for TB are very important and lack of attention to these parameters can lead to poor therapeutic results. The risk factors for TB in various studies in modern medicine are described. Avicenna, the great Persian scientist described TB in his book “Canon of Medicine” in a chapter related to pulmonary diseases along with its symptoms and treatment. In addition, according to this scientist, there are risk factors that, if present in a person, make him prone to TB. It seems that many of the factors mentioned by the scholars of Persian Traditional Medicine (PTM) are not currently among the risk factors for TB in modern medicine and have not been studied yet. If this hypothesis is supported and confirmed by future research in modern medicine, the recommendations of PTM can be a significant help in controlling the consequences of this disease.

Background and purpose: Tuberculosis is a contagious disease caused by mycobacterium tuberculosis. Approximately 30% of the world's population is infected, 5-10% of whom develop active tuberculosis. The aim of this study was to determine the tuberculin skin test conversion. Materials and methods: A cross-sectional study was conducted in 114 staff working in Qaemshahr Razi Hospital, 2015-2017. Demographic characteristics and the results of tuberculin skin test (TST) were recorded in a checklist. Data analysis was done in SPSS V20. Results: The participants included 15.8% males and 84.2% females (mean age: 29.42±5.03). Among the subjects, 33% had latent tuberculosis. TST was positive in 11.4% in first evaluation and 36.84% had positive TST in the second assessment. TST seroconversion was observed in 25.44%, in 61.4% the working experience was more than 10 years, and 61.5% worked in infectious department. There were significant associations between the positive result of TST and age, gender, and working experience (P=0.002, P=0.021, and P=0.01, respectively). We observed significant differences in the results of TST between the first and second evaluation (P

Background and purpose: Studying the different diagnostic aspects of hydatid cysts (HC) plays a major role in early diagnosis and treatment. This study was conducted to evaluate the clinical and laboratory characteristics of HC cases operated in educational hospitals affiliated with Mazandaran University of Medical Sciences. Materials and methods: In this descriptive study, the records of all cases with HC (n=95) who underwent surgical treatment in two educational hospitals within 11 years (2004-2015) were studied and analyzed. Results: The patients were found to be 53.7% females, 67.4% living in rural areas, and 28.4% were aged 51-60 years old (P

Background and purpose: Tuberculosis (TB) is an infectious disease that is lethal in many cases. The aim of this study was to evaluate the clinical and laboratory findings in patients hospitalized with tuberculosis. Materials and methods: A cross-sectional study was carried out in 61 patients with tuberculosis in Razi Qaemshahr Hospital , Iran 2014-2015. We compared paraclinical and clinical findings in patients, those who died, individuals with recurrent TB, and patients with underlying diseases. Data was analyzed in SPSS V19. All P values less than 0.5 were considered significant. Results: Significant differences were seen in ALP, RBC count, and hemoglobin in patients who had relapsed serum and new cases. Also, there were significant differences between alive and dead patients in levels of ALT, ALP, PPD, FBS, and creatinine levels. The HCT level, FBS, RBC, MCHC, platelet count, and serum ferritin differed significantly in patients who were HIV-positive and negative. Moreover, we found significant differences in MCV, WBC, MCH, MCHC, and AST between TB patients with and without liver disease. In TB patients with and without diabetes the levels of ALT and BS were significantly different. Conclusion: Comparison of paraclinical outcomes in TB patients with and without underlying diseases, proves the importance of early diagnosis of clinical disorders in these patients. Therefore, elimination of these causes can lead to faster recovery and better treatment response in these patients.

Background and purpose: The main purpose of this study was determination of different genotypes and phenotypes of N-acetyltransferase 2 gene and its relationship with drug-induced liver injury among patients in Mazandaran province, Iran, which was done for the first time. Materials and methods: A total of 65 newly diagnosed unrelated pulmonary tuberculosis patients (47 men, 18 women) was enrolled in the study. A combination of polymerase chain reaction -restriction fragment length polymorphism method was used to investigate different allels of N-acetyltransferase-2. The patients were followed for occurrence of antituberculosis induced hepatotoxicity during the course of treatment. Relationship between N-acetyltransferase-2 phenotypes and antituberculosis induced hepatotoxicity was evaluated. Results: Frequency of slow, intermediate and fast acetylator genotypes in patients were 34%, 60% and 6%, respectively. Hepatotoxicity was diagnosed in 13.64% of slow acetylators, in 2.56% of intermediate acetylators and interestingly in none of the fast acetylators. The Chi-Square Test showed no significant difference between different acetylation phenotypes and risk of hepatotoxicity (P = 0.1086). Conclusion: These results could improve treatment profile, prevent from drug-related adverse effects such as hepatotoxicty and lead to better outcomes in tuberculosis patients.

Background and purpose: H1N1 influenza circulate worldwide and affects the world population in case of pandemic. The aim of this study was to evaluate the awareness of urban family physicians in Mazandaran province, Iran about H1N1 influenza. Materials and methods: In a descriptive study, 373 urban family physicians were questioned. A standard questionnaire including different items were completed by participants. The items included epidemiology (7 questions), treatment (5 questions), virology and diagnosis (5 questions), clinical manifestations (6 questions), and prevention (4 questions) of H1N1 influenza. Data was then coded and analyzed in SPSS V18 applying Chi-square, t-test, and Fisher's exact test. Results: The participants were 47.5% females and 52.5% males. The levels of knowledge about H1N1 influenza were poor in 0.8%, fair in 11.3% and good in 60.3%. Also, 27.6% of the participants had excellent levels of knowledge on this type of influenza. The average scores of participants for epidemiology, virology and diagnostics, clinical manifestations, prevention, and treatment were 4.30, 3.38, 4.59, 2.79, and 3.67, respectively. The mean scores for knowledge in epidemiology and treatment were found to be higher in female physicians compared to those of their male counterparts. Our results indicated a direct correlation between experience and knowledge on virology, diagnosis, clinical symptoms, and prevention and treatment, while it was inversely related with knowledge on epidemiology of H1N1 influenza. Conclusion: This study showed a relatively high level of knowledge among urban family physicians in Mazandaran province about H1N1 influenza. But they are strongly recommended to participate in continues education programs that increase their awareness and enhance their knowledge.

Background and purpose: Viral hepatitis is a systemic infection that mainly affects the liver. We studied the prevalence of skin lesions and infectious diseases including hepatitis A and B virus infection in patients attending Qaemshahr Razi Teaching Hospital, Iran 2013-2015. Materials and methods: In this retrospective descriptive study, records of patients diagnosed with hepatitis were investigated for skin lesions and other simultaneous infectious diseases. Results: There were 188 patients with viral hepatitis in whom skin lesions were observed in 16 and 35 were diagnosed with other simultaneous infections. Conclusion: In current study, the incidence of skin lesions in patients with hepatitis B was higher than that of other hepatitis. High rate of infections such as pneumonia and bronchitis among patients with viral hepatitis indicates a decreased ability of their immune system in protecting against other infectious agents.

Toxoplasmic encephalitis is a common presentation of Toxoplasma gondii infection of the central nervous system in the late stage in AIDS patients. A 40 yr old female patient was admitted to Razi Hospital of Qaemshahr City in north of Iran, in Nov 2015, with complaint of headache, blurring of vision, dysarthria and acute left-side hemiplegia and right-side ptosis. Magnetic Resonance Imaging (MRI) was performed with intravenous contrast that showed a ring enhancement lesion in the right basal ganglia showing toxoplasmic encephalitis. Anti-Toxoplasma IgG was positive. HIV antibody test was positive, as well. She was treated successfully with antiparasitic and Anti-HIV drugs and eventually was discharged from hospital. T. gondii infection is commonly detected by serologic tests. Even if in this patient, brain imaging is essential for suitable diagnosis and supervision, its results are not pathognomonic.

Background: Influenza A virus is the most virulent human pathogen and causes the most serious problem. Having epidemiological knowledge about this disease is important. The aim of this study was to determine the prevalence of influenza A/H3N2 virus infection in northern Iran from 2011 to 2013 using the real-time polymerase chain reaction (RT-PCR). Methods: In this cross-sectional study 57 samples were collected from patients with influenza-like illness (T≥ 38 °C and cough or sore throat. Influenza-RNA was extracted from the samples using PureLinkTM Viral RNA/DNA Kit. RT-PCR was one using SuperScript III Platinum, Quantitive Real Time PCR system from invitrogen with a specific type of primers and probs. All samples were examined in the Influenza laboratory of Mazandaran University of Medical Sciences. Results: The mean age of patients was 38.2±14.5 year, 278 (48.69%) were males and 293 (51.31%) females. A total number of 201 patients (35.2%) were diagnosed as influenza A1 H3 N2 infection. Conclusion: The results show that the prevalence of A/H3N2 in the North of Iran is considerable and needs more attention for preventive measures

Abstract Background: A surgical site infection (SSI) is the most common nosocomial infection after surgery and is the third most common infection in hospitalized patients. The aim of this study was to asses minimum inhibitory concentration (MIC) of the causing agents of SSI and antimicrobial susceptibility patterns. Methods: This cross-sectional study was done in three referral hospitals in North of Iran during 2011-2012. The samples were taken one month after orthopedic, abdominal, cesarean section surgery and coronary artery bypass graft (CABG) in patients with scores compatible to SSIs criteria. The sample was sent for bacteriologic culture and MIC determination for positive cases by broth microdilution method. The data were collected and analyzed. Results: From 103 positive cases S. aureus, E.coli and coagulase negative staphylococci were the most common isolated agents as 29.12%, 23.3% and 21.3%, respectively. S. aureus was sensitive to vancomycin (70%), amikacin (70%) and teicoplanin (76.6%) and cogulase negative staphylococci was sensitive to vancomycin (68.1%) and teicoplanin (72.6%) and E.coli to amikacin (95.83%) and imipenem and meropenem (66.66%). P.aeroginosa showed no sensitivity to cefepime and was sensitive to imipenem (93.75%) and meropenem (81.25%). Conclusion: The most important point is worrisome problem of the increased MIC of S. aureus to vancomycin that causes difficult use in the treatment of staphylococcal SSIs. In spite of resistance of micro-organisms to cephalosporins, gram negative organisms had low MIC to carbapenemes especially P.aeroginosa although the rate of its MIC is increasing.

Mindfulness-based Stress Reduction (MBSR) is a treatment program for relieving stress and coping with chronic illnesses. In recent three decades, studies have shown that MBSR has a positive effect on physical and psychological dimensions of chronic illnesses. Chemically pulmonary injured veterans have chronic pulmonary and psychological problems due to mustard gas exposure and complications of Iran-Iraq war. These stresses have negative effects on their general health and immune system. To the best of our knowledge, this is the first study conducted on psychoneuroimmunology and MBSR in these patients. Forty male pulmonary injured veterans were randomly divided in two groups with 20 participants (MBSR and wait-list control). Then MBSR group received 8 weekly sessions of intervention. We tested mental health based on general health questionnaire (GHQ)-28 questionnaire, health-related quality of life (based on St. George respiratory questionnaire (SGRQ) ) and immunity in MBSR groups; before and after intervention "mixed factorial analyses of variance" test was used for analyzing data fpr each dependent variable and appropriate t-tests were done in The necessary condition. Results showed that mental health and health- related quality of life, in MBSR group compared to wait-list control improved [F (1,38)=26.46, p

Background: Studies have shown that Mindfulness Based Stress Reduction (MBSR) has positive effect on physical and psychological dimensions of chronic illnesses. In this study for the first time we examine the effect of this new technique on quality of life and pulmonary function in chemically pulmonary injured veterans who have chronic pulmonary problem, psychological problems and low quality of life.Methods: Forty male pulmonary injured veterans were randomly replaced in two groups with 20 participants (MBSR and control Wait List (WL)). Then MBSR group received 8-weekly sessions intervention. We evaluate quality of life (used SF-36 questionnaire) and Spirometry parameters two times; before and after intervention in two group. We used "mixed factorial analyses of variance" test for analyzing data in each dependent variables. Then if we have significant interactional effect, we used “paired- sample t-test" for comparing before and after intervention data of each group, and "Independent-Sample t-test" for comparing after intervention data of two groups.Results: The MBSR compare to WL group improved SF-36 total score, (F (1, 38) =12.09, P=0.001), "Role limitations due to physical problems"(F(1,38)= 6.92, P=0.01), "Role limitations due to emotional problems"(F(1,38)= 7.75, P=0.008), "Social functioning"(F(1,38)= 9.89, P=0.003), "Mental health"(F(1,38)= 15.93, P=0), "Vitality"(F(1,38)= 40.03, P≤0.001), and "Pain"(F(1,38)= 27.60, P≤0.001). MBSR had no significant effect on "FEV1" (F (1, 38) = 0.03, P=0.85),"FVC" (F (1, 38) = 0.16, P=0.69) and "FEV1/FVC" (F (1, 38) = 2.21, P=0.14).Conclusion: MBSR can improve individual’s quality of life but not lung function in chemically pulmonary injured veterans.

Empyema necessitans (EN) is a kind of empyema that diffuses to extrapleural space and can involve chest pain. Tuberculosis (TB) is the most common cause of EN. This disease can be found in both immunocompromised and immunocompetent individuals but is usually seen in the immunocompromised individuals. Because of long duration and ambiguous symptoms of the disease, diagnosis can be hard. The disease can be treated both medically and surgically. Missing the disease can lead to undesirable effects on patient’s condition and health care setting. This problem can be seen in endemic area in which controlling of TB is hard. Report of the disease in local health care center for desirable treatment and health maintenance is necessary. We explained a rare case of pulmonary TB in a patient that was healthy in other fields and just showed the minimum systemic symptoms. The patient came with a mass in lower part of back of chest cage, with a mild pain. The imaging survey showed EN. Smear and Ziehl-Neelsen stains from subcutaneous aspiration were positive for TB. This case showed importance of clinical view and awareness of this silent but serious disease in endemic area especially for TB.

(Received 14 July, 2009 ; Accepted 23 December, 2009)AbstractBackground and purpose: Leptospirosis (also known as Weil's disease, 7-day fever and many more) is a bacterial zoonotic disease caused by spirochetes of the genus Leptospira that affects humans and a wide range of animals, including mammals, birds, amphibians, and reptiles. It was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice and nephritis". Leptospira was first observed in 1907 from a post mortem renal tissue slice. It is recognized as the world's most common zoonoses. This disease continues to have a major impact on people living in urban and rural areas of developing countries with inestimable morbidity and mortality. The disease is an occupational hazard.People in Mazandaran province in the North of Iran, are mostly involved in agricultural fields or animal husbandry and leptospirosis is common in this area. In this study we tried to find seroepidemiology of leptospirosis in workers that were involved in 5 group of high risk jobs (farmers, mine workers, abattoir workers, animal farm workers, anglers).Materials and methods: This is a descriptive case- series study. Our target population was 500 people that were involved in one of fore-mentioned high risk occupations for leptospirosis, 100 of each one, selected them by cluster sampling. They were screened for the presence of serum Leptospira immunoglobulin G. IgG was tested with a commercially available immuno florescent assay (IFA) method.Results: Serologic study showed that 29.5% of farmers, 18% of fishers, 12.5% of mine workers, 6% of animal farm workers and 4% of abattoir workers were positive (IFA ≥ 1/10).Conclusion: Our data emphasize the importance of occupational exposure to leptospirosis among people who have exposure with infected water or soil in Northern Province Mazandaran-Iran. Thus, it is clear that contact with water and soil are risk factors of getting infected with Leptospira.J Mazand Univ Med Sci 2009; 19(73): 11-15 (Persian).

(Received 5 February, 2009 ; Accepted 13 Jan, 2010)AbstractAcute rheumatic fever is an acute systemic disease due to autoimmune reaction against some of BHSA. Similarity between bacterial antigens and cardiaciovascular tissue, synovial membrane, joints and subcutaneous tissues and cerebral basal ganglions are the causes of autoimmune reactions and manifestation of the disease. Most of the ARF occur in children (5-14 years old) followed by streptococcal pharyngitis and the disease is very rare in adults.Sydenham's chorea is a late manifestation of ARF and one of the John's diagnostic criteria that is usually revealed when the other criteria are absent. There is often a long latent period between clinical manifestations of the ARF and the onset of chorea as an uncommon initial presentation of acute rheumatic fever. We report the clinical findings, investigations and the course of clinical development of a seventeen-year-old girl, who presented with acute onset of abnormal involuntary movements in her right hand for two days before her admission. She had sore throat and fever three weeks before development of these new problems. Her complaints disappeared with proper treatment. The considerable findings in this case report was co-incidence of Sydenham's chorea with erythema marginatum, fever, severe mitral valve insufficiency, arthralgia in an adult patient that is a very rare case. She was discharged after a 10-day treatment regime.Key words: Acute rheumatic fever, sydenham's chorea, erythema marginatumJ Mazand Univ Med Sci 2009; 20(74): 91-97 (Persian).

Background: DUE (Drug Utilization Evaluation) studies can help identify and correct problems associated with irrational use of drugs. Considering lack of data regarding how rational vancomycin is being used, we evaluated this DUE study in a referral infectious center to evaluate compliance with guidelines in terms of rational use of this valuable antibiotic. Methods: This retrospective study was done for 6 months from March to September 2012 at Razi hospital, an educational hospital affiliated to Mazandaran University of Medical Sciences. Data including patients’ demographics, vancomycin dose, kidney function assessment, dose adjustments, sampling and culture were collected. Based on the HICPAC (Hospital Infection Control Practices Advisory Committee) and Up-to-date 2012 advices, the concordance of practice with standard guidelines was assessed. Results: One hundred and forty six medical records were reviewed in this study. Fever and shortness of breath were the most common symptoms at the time of initiation of vancomycin. Skin infections, lower respiratory tract infection and septicemia were the most common initial diagnosis of patients. Sampling was done in almost one-third of patients. Most of patient with a specific order were received vancomycin in half an hour. Considering the indication, Vancomycin was administered appropriately in 58 percent of patients. Conclusion: Vancomycin was used irrationally in a great proportion of patients. The main observed drawbacks were empiric use of vancomycin without subsequent adjustment of antimicrobial agent according to culture and sensitivity data and lack of paying enough attention to calculation of creatinine clearance and dosage adjustment.

Background: Acute bacterial meningitis is a medical emergency condition that requires prompt diagnosis and treatment and otherwise associated with serious morbidity and mortality. Aim: The aim of this study was to assess types, risk factors, clinical symptoms and diagnostic tests of meningitis in hospitalized patients of Mazandaran University of medical sciences hospitals during 2006-2012. Matherials and Methods: This is a retrospective descriptive study. Following approval of the ethics committee of Mazandaran University of Medical Sciences, records of adult patients diagnosed with acute meningitis from 2006 to 2012 were extracted from Mazandaran Provincial Health Center and patients attending hospitals affiliated to Mazandaran University of Medical Sciences. Statistical analysis: Data were analyzed with SPSS-16 using descriptive statistics (frequency, mean, standard deviation, and median). Results: In this study, of the 137 patients with meningitis, 73 (53.9%) were viral, 61 (46%) bacterial, 1 (0.7%) fungal, and 2 (1.4%) unknown. The majority of risk factors in patients were head trauma, upper respiratory infection, and drug addiction. The most common clinical signs were headache, fever, nausea and vomiting, and stiff neck. Conclusion: In this study, the incidence of meningitis was much lower than any other country. It could be due to geographic variation or incomplete recording of patient's data. It is recommended to perform a longitudinal study during the coming years on patients with meningitis.

Background: Infection with Trichostrongylus spp. is common among human and herbivorous in most parts of Iran, especially in southern and northern ar-eas. The aim of present study was to identify Trichostrongylus spp. among hu-man population using excreted egg specimens, by the molecular method, in Mazandaran Province, northern Iran. Methods:Overall, 33 positive fecal specimens were randomly sampled and examined. PCR amplification of ITS2-rDNA region was performed on the isolated egg and then a restriction fragment length polymorphism (RFLP) profile was considered to discriminate of Trichostrongylus spp. Results:A total of 33 positive fecal specimens, 29(78.9%), 4(12.1%) were found T. colubriformis and T. axei respectively. Our data appear the molecular evidence of both human T. colubriformis and T. axei infections in North of Iran. Conclusion:T. colubriformis was the probable most common zoonotic species caus-ing human trichostrongylosis infection in the area

Diabetes is the most common metabolic disease in humans. One of the major complications of the disease is foot ulcer that is prone to infection. The most common causes of infection which have been reported in these patients are bacteria and fungi such as Candida, Aspergillus, and Rhizopus species. We report one such rare case with calcaneal osteomyelitis caused by Aspergillus ochraceus in a patient with diabetic foot osteomyelitis. The case was a 68-year-old male with a history of type II diabetes for 2 years. The patient had two ulcers on the right heel bones for the past 6 months with no significant improvement. One of the most important predisposing factors to infectious diseases, especially opportunistic fungal infection, is diabetes mellitus. Aspergillus species can involve bony tissue through vascular system, direct infection, and trauma. Proper and early diagnosis and treatment of diabetic foot infection can reduce or prevent complications, such as osteomyelitis and amputation. The annual examination of feet for skin and nail lesion, sensation, anatomical changes, and vascular circulation can be useful for prevention and control of infection.

Background. Herpes zoster infection is a painful worldwide disease. Inappropriate and delayed treatment causes prolongation of the disease with debilitating symptoms and postherpetic neuralgia. Method. A cross-sectional study evaluated shingles cases admitted in a teaching hospital with one-year followup in north of Iran from 2007 to 2013. Results. From 132 patients, 60.4% were male. Head and neck involvement occurred in 78 people (59.1%), thoracoabdominal region in 37 cases (28%), and extremities in 16 cases (12.1%), and one case (0.8%) got multisites involvement. 54 cases (40.9%) had predisposing factors including diabetes mellitus in 26 cases (19.7%), malignancy in 15 (11.4%), immunosuppressive medication in 7 (5.03%), HIV infection in 3 (2.3%), radiotherapy in 2 (1.5%), and tuberculosis in one patient (0.8%). The most common symptoms were pain (95.5%), weakness (56%), fever (31.1%), headache (30.3%), ocular complaints (27.3%), itching (24.2%), and dizziness (5.3%). 21 cases (15.9%) had bacterial superinfection on blistering areas and overall 18 cases (13.6%) had opium addiction. 4 cases (3.03%) died during admission because of comorbidities. Postherpetic neuralgia was reported in 56 patients (42.5%) after three months and seven cases (5%) in one-year followup. Conclusion. Shortening interval between skin lesion manifestation and starting medication can accelerate lesion improvement and decrease disease course, extension, and complication.

Cutaneous anthrax has a mortality rate of 20% if no antibacterial treatment is applied. The clinical manifestations of cutaneous anthrax are obviously striking, but coinfection may produce atypical lesions and mask the clinical manifestations and proper laboratory diagnosis. Anthrax is known to be more common in the Middle East and Iran is one of the countries in which the zoonotic form of anthrax may still be encountered. We report a case of a 19-years-old male who used to apply Venetian ceruse on his skin. Venetian ceruse (also known as Spirits of Saturn) is an old cosmetic product used for skin whitening traditionally made from sheep’s spinal cord. The patient referred to the Referral Laboratory, Mazandaran University of Medical Sciences, Sari, Iran, with atypical dermatosis, pronounced pain, and oedema of the affected tissue. It was confirmed by both conventional and molecular analysis that culture was a mixture of Bacillus anthracis and Trichophyton interdigitale. The patient was initially treated with ceftriaxone (1000 mg/day for two weeks), gentamicin (1.5–2 mg/kg/day), terbinafine (200 mg/week for one month), and 1% clotrimazole cream (5 weeks) two times per day which resulted in gradual improvement. No relapse could be detected after one-year follow-up. Anthrax infection might present a broader spectrum of symptoms than expected by clinicians. These unfamiliar characteristics may lead to delayed diagnosis, inadequate treatment, and higher mortality rate. Clinicians need to be aware of this issue in order to have successful management over this infection.

Brucellosis is an infectious disease caused by gram-negative bacteria of the genus Brucella. Involvement of the gastrointestinal, hepatobilliary, and skeletal systems has been reported frequently in the literature. Involvement of the nervous system is relatively uncommon and has been reported in only 3%-25% of cases of generalized brucellosis. Guillain-Barré syndrome is a prototypical postinfectious autoimmune disease. We report a case of Guillain-Barré syndrome in a 26-year-old woman as an uncommon presentation of neurobrucellosis.

Intracranial hemorrhage is a rare and fatal presentation of leptospirosis. In this paper we present the case of a 51-year-old male farmer who lives in northern Iran. He came to our hospital with a severe headache. A paraclinical evaluation showed clear signs of thrombocytopenia, and a brain MRI revealed left temporoparietal hemorrhage. Our preliminary diagnosis was Leptospirosis, and after 26 days of hospital care the patient was discharged in good condition. This paper will educationally help physicians in better diagnosis and treatment of leptospirosis.