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Objective: To investigate the frequency of exoU and exoY genes in patients with Pseudomonas aeruginosa infection. Methods: In this study, 100 clinical isolates of Pseudomonas aeruginosa were collected from patients hospitalized in educational-therapeutic hospitals and were identified using standard microbiological tests. Then, the antibiotic resistance pattern of the isolates was determined by the disk agar diffusion method. The bacterial DNAs were extracted by the alkaline lysis method. Finally, the presence of exoU and exoY genes was evaluated by the PCR test. Results: In this study, 47%, 72%, 29%, 39%, 40%, and 44% of the isolates were non-susceptible to piperacillin, aztreonam, ceftazidime, imipenem, tobramycin, and ciprofloxacin, respectively. In addition, 95% and 93% of the clinical isolates carried the exoU and exoY genes. Blood and fecal isolates had both virulence genes, while only one wound isolate had neither genes. Meanwhile, all urinary isolates contained the exoY gene and only one isolate lacked the exoU gene. Also, 88 isolates simultaneously had both exoU and exoY genes. Conclusions: High prevalence of exoU and exoY genes in this region indicates a significant role of type III secretion system in pathogenesis of Pseudomonas aeruginosa. The type III secretion system may be a suitable target to reduce the pathogenicity of this bacterium.

Background and purpose: Influenza virus is scattered around the world and causes epidemics of varying severity annually. Mortality caused by influenza is more common in cardiovascular patients than in other chronic diseases. Paying attention to this is very important in preventing the disease and its complications in children and adults with cardiovascular diseases. Therefore, this study was conducted with the aim of epidemiological investigation of hospitalized cases caused by influenza in cardiovascular patients and its effect on the health of these patients in Mazandaran Heart Center. Materials and methods: The present study is a cross-sectional descriptive study that was conducted on patients who were admitted to the Mazandaran Heart Center between 2016 and 2018. All patients who were hospitalized with the initial and final diagnosis of influenza and were treated with all flu medicine were included in the study. Since the PCR test was not available for all these patients, as the value of clinical diagnosis was based on symptoms and initial laboratory findings during the epidemic, in addition to PCR-positive cases, cases with clinical diagnosis were also included in the study. All data analysis with SPSS version 16 software was used. Results: In this study, 113 patients with an average age and standard deviation of 63.3+15 years were included. Among these patients, the highest frequency of history of heart disease was related to congestive heart failure (35.4%) and angioplasty (292%), and the lowest frequency was related to valve replacement 8.0%. Among other underlying diseases, the highest frequency was related to hypertension (65.5%), diabetes mellitus (41.6%), and hyperlipidemia (31.0%), and the lowest frequency was related to thyroid disorders (2.7%). Also, 31.9% of patients had diabetes and hypertension and 16.8% had diabetes and hyperlipidemia. Examining the signs and symptoms of influenza among the patients also showed that the highest frequency related to fever (76.1%), sputum (66.4%), cough (64.6%), shortness of breath (611%) and myalgia (548%) and the lowest frequency was related to diarrhea (5.3%). Only 7% of patients had a recent history of flu vaccination. In the chest radiography report, 25.7% of the patients had increased bronchial marking and 17.7% had evidence of pneumonia. Finally, 82.3% of patients were discharged after complete recovery. Also, only 12 cases (10.6%) of the patients died. Heart failure was the most common underlying disease among deceased patients. Conclusion: The results of this study revealed that the symptoms of influenza in heart patients are similar to other patients and the type of underlying disease has no effect on the disease presentation and its initial manifestations, but persisting of the symptoms and progression towards severe disease were more common. Most of the deaths were due to heart failure, and this issue highlights the importance of these patients' adherence to the flu vaccine. Unfortunately, the results of the study indicated that this high-risk population had little adherence to influenza and pneumococcal vaccinations.

Key Clinical Message Here we present a case of a 4‐year‐old girl who suffered from vulvovaginitis caused by Enterobius vermicularis. All members of her family were also infected by this helminth. Treatment with mebendazole was administered to all family members and it was found that the entire family had been cured. Abstract Vulvovaginitis, an inflammation of the vulvovaginal mucous membranes, is a common reason for pediatric gynecology consultations. One of the causes of this condition is a parasitic worm known as Enterobius vermicularis (E. vermicularis). In girls, adult worms can infiltrate the vagina and release eggs, leading to the development of vulvovaginitis. Furthermore, these worms have the ability to invade the endometrial cavity too. Here we present a case of a 4‐year‐old girl who suffered from vulvovaginitis caused by E. vermicularis. All members of her family were also infected by this parasitic helminth. In the vaginal sample, apart from the eggs, the female adult worm was observed under the microscope. Treatment with mebendazole was administered to all family members, and their progress was followed for a period of 3 weeks, during which it was found that the entire family had been cured. This patient experienced significant improvement in symptoms related to severe anxiety, nervousness, vaginal inflammation, itching, and vulvovaginitis caused by E. vermicularis. To prevent infection by E. vermicularis, it is crucial to disinfect underwear and bed sheets. In kindergartens, the spread of this parasite should not be underestimated, and asymptomatic individuals who have been exposed to infected persons should receive treatment to prevent an epidemic. Maintaining cleanliness and hygiene, especially after using the toilet, is of the most importance, particularly for girls who are more susceptible to E. vermicularis infection. Additionally, it is essential for all family members to be aware of the transmission routes of this parasite.

Background and purpose: Zygomycosis (mucormycosis) is a rare fungal infection with high morbidity and mortality. This study evaluated mucormycosis's clinical and paraclinical features in patients admitted to Buali Hospital in Sari & Razi Hospital in Ghaemshahr, Mazandaran Province, Iran. Materials and methods: This retrospective and cross-sectional study reviewed the patients' files with proven or probable mucormycosis admitted to Buali & Razi hospitals from 20 April 2011 to 20 April 2018. The Student's T-test and Fisher's exact test were performed for data analysis using SPSS version 27 software. P ≤ 0.05 was considered as a significant value. Results: Out of 33 patients studied, 18 (54.55%) were female and 15 (45.45%) were male. The average age of the patients was 48.84 years. Among the signs and symptoms of the disease, most cases were related to headache. Diabetes was the most common underlying disease in these patients 28 (93.3%). The mortality rate in these patients was 48.48%, of which 25% related to mucormycosis. The genus Mucor and Rhizopus were the most common agents isolated in 9 cases of positive cultures. Conclusion: Results indicate that people with diabetes are more susceptible to mucormycosis than others, and that control and reduction of diabetes in the community can significantly reduce the incidence of mucormycosis. surgery combined with timely medical treatment also has the highest survival rate.

Background and purpose: Tuberculosis is one of the leading causes of death from infectious diseases worldwide. Rifampin, a drug used to treat tuberculosis, has recently come under the spotlight. It is particularly important for the treatment of tuberculosis, and a reduction in its bioavailability has a significant impact on patient treatment and drug resistance. Therefore, this study aims to investigate the serum levels of rifampin in patients with tuberculosis. Materials and methods: The current study is descriptive-cross-sectional. In the years 2019-2020, plasma samples were collected from 30 patients treated for tuberculosis in educational-therapeutic centers in Mazandaran province. Only patients between 18 and 65 years of age who had been definitively diagnosed with tuberculosis, who were not pregnant or breastfeedingand who were being treated with a drug regimen were included in the study. Rifampin levels in the collected samples were measured using HPLTC. Results: According to the data, 30% of patients had a rifampin level of less than 8, while 16.7% had a rifampin level of more than 24. The study found that there was a significant association between rifampin serum levels and full or empty stomach status. However, there was no significant association between rifampin serum level and the age, sex, liver toxicity, and mortality rate of the patients. Conclusion: It has been observed that many tuberculosis patients do not reach the required rifampin serum level, which may lead to treatment failure. To minimize this failure, it is recommended to take the drug on an empty stomach.

Background and purpose: Hospital infections remain a significant health concern despite advancements in treatment methods. The emergence and spread of pathogens with multiple resistance remain a global health issue. The purpose of this study was to investigate the prevalence of nosocomial infections and determine the antibiotic resistance pattern in Razi Ghaemshahr Hospital, Mazandaran. Materials and methods: This descriptive cross-sectional study was carried out at Razi Ghaemshahr Hospital in Mazandaran province during 2016-2017. Positive cultures from hospitalized patients were used as samples and subjected to antibiotic resistance pattern analysis using the disk diffusion method. Results: Out of the 672 hospitalized patients in different wards, the infectious ward had the highest frequency distribution of patients (40%). The most commonly isolated pathogens were Escherichia coli (26.2%), Acinetobacter baumannii (14.7%), Enterobacter (14.1%), Pseudomonas aeroginosa (13.5%), and Citrobacter (12.8%). The pathogens were highly resistant to cephalosporins, fluoroquinolones, beta-lactamase inhibitors, and carbapenems. Conclusion: It was found that the most frequently isolated pathogen was Escherichia coli. The emergence of Citrobacter with high antibiotic resistance can possibly be attributed to a shift in the prevalence pattern of microorganisms within this hospital

Background and purpose: Seborrheic dermatitis (SD) is a chronic skin condition that is accompanied by scaling and itching. Stress and mental rumination followed by the disease affect the quality of life. The aim of this study was to investigate the effect of seborrheic dermatitis on the quality of life and to compare it with the quality of life of healthy people. Materials and methods: This study was a cross-sectional study. The study sample included 60 randomly selected patients with seborrheic dermatitis who referred to Bouali and Tooba dermatology clinics in Sari during 2019-2020. Two questionnaires (DLQI and SF-36) were used to assess general quality of life in patients. Results: The relationship between the disease and occupation was statistically significant. There was a significant relationship between smoking and seborrheic dermatitis. We also found a significant relationship between the frequency of recurrences and quality of life. The mean of physical and social function in the healthy group was higher than its value for the patient group, but the difference was not significant. Conclusion: Our study showed that age, education, occupation, and smoking are factors that contribute to seborrheic dermatitis. Moreover, the findings revealed that physical and mental health as well as quality of life were less affected in the married group compared to the single group.

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: Crimean-Congo hemorrhagic fever (CCHF) is one of the viral hemorrhagic fevers caused by Nairovirus group. Epidemiological investigation and clinical symptoms of the disease in each region can help to identify disease-prone foci and early diagnosis of the disease in epidemic cases. Therefore, the purpose of this study was to investigate the clinical, epidemiological, and laboratory symptoms of patients with CCHF in Mazandaran province in 2014-2018. Materials and methods: In this cross-sectional epidemiological survey, 135 patients with proven CCHF in Mazandaran province were enrolled in a census manner. The clinical, epidemiological, and laboratory findings in these patients were determined. Results: In this study, 23% were younger than 30 years of age and 80.7% were men. In hospitalized patients, 33.3% had high risk jobs linked to the disease and 39.3% had livestock exposure. The patients were most affected in spring (45.9%) and summer (42.2%) and less during fall (5.9%), and winter (5.9%). Clinical manifestations, including fever, rash, abdominal pain, bleeding, epistaxis, headache, musculoskeletal pain, cough, and menorrhagia were observed in 88.1%, 11.1%, 23%, 28.9%, 7.4%, 52.6%, 69.7%, 0%, and 0% of the infected subjects, respectively. Thrombocytopenia were seen in 51.9% of the patients and about other laboratory results there were no any specific findings in 29.6%. According to laboratory findings, LFT raise, anemia, leukopenia, leukocytosis, LTF raise plus anemia, and LFT raise plus leukopenia were seen in 13.3%, 5.2%, 27.4%, 9.6%, 3.7%, and 11.1%, respectively. Conclusion: According to the present study, although the clinical, epidemiological, and laboratory findings in CCHF cases in Mazandaran province are similar to other studies worldwide, so, the regular analysis of CCHF patients is highly recommended.

Background and purpose: Cryotherapy, which causes inflammation, is one of the methods used in treatment of warts. Including a topical steroid in a regular wound care regimen slows the course of damage and promotes re-epithelialization. The purpose of this study was to assess the therapeutic efficacy of topical betamethasone valerate on inflammation after cryotherapy in patients with warts compared to placebo. Materials and methods: Twenty people were included in a double blind clinical trial. Cryotherapy was used on both sides of the body to treat the lesions. Following cryotherapy, topical betamethasone was applied to the lesions on one side, while placebo ointment was applied to the lesions on the opposite side. The patient's symptoms were documented during four visits. To assess pain intensity, the visual pain scale (VAS) was used. Finally, treatment evaluation was scored during these four sessions. SPSS V16 was used to analyze the data. Results: None of the samples at the end of the study had hypertrophic or atrophic scars and depigmentation, hyperpigmentation or hypopigmentation lesions. Mean erythema, pain, frequency of blistering and frequency of edema during 14 days of follow-up were not significantly different between the two groups (P>0.05). Conclusion: During the 14-day follow-up period after therapy, topical betamethasone had no effect on the incidence of blisters and edema, as well as the average score of pain and erythema. As a result, this treatment modality cannot be used to relieve inflammation following cryotherapy in patients with warts. (Clinical Trials Registry Number: IRCT20170818035762N3)

Background and purpose: In detection of precancerous lesions of the cervix, HPV testing is more sensitive than cytology alone. This study aimed at investigating PCR HPV in Pap smear specimens in women in Sari, Iran. Materials and methods: This cross-sectional descriptive study was performed to investigate the prevalence of HPV in Pap smear samples of women attending dermatology, infectious diseases, or women centers in Sari Touba Clinic due to cutaneous warts. Two samples were taken from 50 patients by brush or spatula; one sample for Pap smear and cell cytopathic effects and the second sample was used for HPV PCR. Data were analyzed using SPSS V22. Results: There were three (6%) HPV-positive samples. Ten patients (20%) had a history of sexual contact with a person with warts. Findings showed significant relationships between HPV infection and history of contact with a person with warts and a history of recurrent vaginal infections (P

Background and purpose: Recently, many studies have been conducted on the role of selenium in autoimmune diseases. Trace element deficiency is not an uncommon finding in autoimmune diseases. This deficiency may be a consequence of autoimmune diseases or may contribute to their aetiology. The aim of this study was to investigate the level of selenium in patients with sarcoidosis compared to healthy controls in teaching hospitals affiliated with Mazandaran University of Medical Sciences. Materials and methods: In this case-control study, serum selenium levels were measured in 42 patients with sarcoidosis and compared with 42 healthy, age- and sex-matched controls. Two cc non-fasting blood samples were collected. The serum selenium level was measured using Atomic Absorption Spectrometry (AAS). The normal range for serum selenium is between 46 to 143 micrograms per liter. Results: The mean ages in the case group and controls were 47.45±7.6 and 47.24±7.23 years, respectively (P=0.898). Serum selenium levels were significantly lower than the controls (82.42±24.11 vs. 94.79±27.01 µg/ml, P=0.03). In case group, there was no significant difference between serum selenium levels and sex (P=0.165). The study showed no relationship between serum selenium levels and age (P=0.258), duration of disease (P=0.121), duration of treatment (P=0.837), delay in initiation of treatment (P=0.316), and type of treatment (P=0.859). Conclusion: Serum selenium levels were significantly lower in patients with sarcoidosis than the healthy controls, so, these patients may benefit from selenium supplements.

Background and purpose: Reduced function of immune system and underlying diseases make older people more susceptible to Shingles (herpes zoster). The present study aimed to compare the clinical findings and underlying conditions between patients with herpes zoster under 50 years and over 50 years of age. Materials and methods: This cross-sectional descriptive study included all patients who were admitted or hospitalized in Sari hospitals due to herpes zoster in 2016-2018 with complete medical records. Information was collected by census. Results: There were 180 cases who were investigated according to their age. In patients under 50 years of age, 97 had no underlying diseases, while diabetes, hypertension, malignancy, and cardiovascular diseases were seen in 6, 4, 3, and 12 patients, respectively. In patients over 50 years of age, 21 were found with no underlying diseases, but 15, 2, 11, and 9 cases had diabetes, hypertension, different types of malignancies, and cardiovascular diseases, respectively. The frequency of underlying diseases in patients with cancer and diabetes in patients with herpes zoster were significantly higher in people over 50 years of age (P= 0.042 and P= 0.05). Conclusion: Given the risk factors presented in this study, patients with underlying diseases or those on immunosuppressive drugs are required to be closely monitored and receive early treatments as soon as developing herpes zoster to avoid severe complications.

Background and purpose: Acute hepatitis is an acute inflammation of liver cells that can occur due to viral, bacterial, fungal, and medicinal causes. This study investigated the final diagnosis of inpatients with the initial diagnosis of acute hepatitis in Qaemshahr Razi Hospital. Materials and methods: In this descriptive cross-sectional study, the medical records of all patients (n=120) admitted with the initial diagnosis of acute hepatitis in 2014-2019 were studied. Data, including demographic information, clinical signs, and laboratory test results were obtained and analyzed in SPSS V21. Results: The patients were 120 and there were significant differences between place of residence, family history, previous history of hepatitis, blood transfusion, smoking and drugs, alcohol, high-risk sexual relationships, and having HIV (P

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: Computed tomography (CT) scan is of great help in confirming the diagnosis of tuberculosis (TB) before the sputum test result. The purpose of this study was to investigate the relationship between pulmonary involvement patterns in CT scans of TB patients with positive sputum smears. Materials and methods: This retrospective descriptive-analytical study was conducted using the records of TB patients admitted to Ghaemshahr Razi Hospital between 2012 and 2018. Demographic information and CT scan reports were collected and compared with the sputum smear results. Results: The records of 271 patients (185 men and 86 women) with an average age of 49.31±15.08 years were examined. Sputum smears were positive in 191 (70.5 %) patients and negative in 80 (29.5 %). The most prevalent lesions were cavitation (72.7%) and consolidation (42.8%), and the most common locations were the upper lobe of the right lung (61.3%) and the upper lobe of the left lung (53.5%). Cavitary and consolidation lesions were significantly more common in patients with smear positive TB (P

Background and purpose: Ventilator-associated pneumonia (VAP) is one of the major factors of mortality and morbidity in Intensive care units (ICUS), especially in open-heart surgery patients. The purpose of this study was to investigate VAP in open-heart surgery patients admitted to the ICU in Sari Fatemeh Zahra Hospital, 2017-2019. Materials and methods: In this retrospective descriptive cross-sectional study, demographic, clinical, laboratory, and therapeutic information of patients with VAP were examined. Data were analyzed using SPSS V25. Results: A total of 52 patients with VAP were elevated after open heart surgery. The mean age of patients was 64.41±10.85 years and 55.8% were men. Half of the patients (51.9%) underwent intubation for less than five days and the mean duration of occurrence of VAP after initiation of ventilation was about six hours. The most common microorganisms causing pneumonia were Acinetobacter baumannii (23.63%) and Citrobacter freundii (16.36%). In general, the highest resistance of isolated microorganisms was toward third-generation cephalosporins and their highest sensitivity was to aminoglycosides. Conclusion: Control and prevention of ventilator-associated pneumonia is of particular importance, especially in patients after open-heart surgery admitted to intensive care units.

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.

Background: Acne vulgaris is a skin condition in children and has various presentations and differential diagnoses. Objectives: The purpose of this review was to evaluate the therapeutic approaches of infantile acne. Methods: In this narrative review, we searched articles published in English on infantile acne in Google Scholar, PubMed, and Scopus from 1981 to 2019. Results: A total of 35 articles were selected for review. The treatment of acne often involves various medications that acne lesions. Different factors contribute to the pathogenesis of acne and its severity. The same principle and treatment strategy applies to all age groups diagnosed with acne. Conclusions: The treatment strategy for infantile acne is similar to acne treatment at any age. Treatment is based on the severity of the acne and the risk of a future scar.

Background: In late December 2019, a kind of pneumonia caused by a novel coronavirus (SARS-CoV-2) emerged in Wuhan, Hubei Province, China. This virus rapidly spread worldwide and infected 195 countries and territories, including Iran. By March 22, 2020, the virus had affected more than 40000 people worldwide and caused more than 19000 deaths. Pregnant women are a vulnerable group to viral infections because partial immune suppression occurs during pregnancy. Therefore, the COVID-19 epidemic may cause a rising global concern about its consequences for pregnant women and fetuses. Objectives: In this case study, we report the delivery of a pregnant woman after her COVID-19 confirmation. Methods: We report a 44-year-old pregnant woman (32 weeks gestation) with COVID-19 who gave birth to a healthy baby with no evidence of COVID-19. We did not observe any worse clinical outcomes, such as maternal mortality, stillbirth, spontaneous abortion, and preterm delivery. Results: A preterm baby girl with 2500 g weight and Apgar scores at 5 minutes and 10 minutes were 9 and 10 was delivered. The preterm baby was normocephalic, had no icteric sclera, and the heart sounded normal without murmurs, Lung ventilation was normal. Conclusion: Viral pneumonia may severely be presented in pregnancy because of physiological and immunological changes and shift from cell-mediated to humoral-mediated immunity during the pregnancy period. Vertical transmission of COVID-19 from mother to child, short-term and long-term adverse effects on mother and newborn are still unclear and controversial.

Background and Purpose: Coronavirus disease 2019 (COVID-19) and Candida prostatic valve endocarditis present various clinical manifestations which may overlap;hence, discrimination between them is extremely difficult.Case report: The case was a 66-year-old man with a past medical history of mitral and aortic valves replacement one year before COVID-19 co-infection. He was admitted with fever (for 7 days), shortness of breath, cough, seizure, lethargy,headache, and 85% oxygen saturation. Transesophageal echocardiography revealed multiple large-sized, highly mobile masses on both sides of the mechanical mitral valve highly suggestive of vegetation. Chest computed tomography scanning showed simulating scattered COVID-19 peripheral ground-glass opacities confirmed by reverse-transcription polymerase chain reaction. The set of blood cultures yieldedyeast colonies that were identified as Candida tropicalis. The patient died of septic shock shortly after receiving antifungal therapy.Conclusion: This case emphasized the importance of early diagnosis andimplementation of antifungal treatment, particularly in patients with prosthetic cardiacvalves, to reduce their unfavorable outcomes in COVID-19 patients

Abstract In the years since the start of the COVID‐19 pandemic, numerous neurological manifestations have been reported following this novel virus. Myasthenia gravis is one of them. Here, we present the patient that was referred to us with myasthenia gravis symptoms after a COVID‐19 infection.

Background and purpose: Hydatidosis is one of the most prevalent zoonotic diseases around the world that is endemic in Iran too. In rural areas, there is a higher risk of infection. To the best of our knowledge, no study was done on seroprevalence of hydatidosis in Qaemshahr, north of Iran, so, we aimed to investigate this condition and its risk factors in patients attending Qaemshahr rural health centers using ELISA method. Materials and methods: A total of 403 serum samples were collected. The participants completed a researcher-made questionnaire. Then, anti-echinococcus­­ granulosus antibody was analyzed using ELISA method. Data analysis was done applying logistic regression in SPSS V24. Results: Eleven cases (2.73%) were found positive for anti-echinococcus granulosus antibody. There were no significant differences between seropositivity and gender, consumption of raw vegetable, non-chlorinated water and contact with dog and soil (P>0.05), but significant relationships were seen between anti-echinococcus granulosus antibody and abdominal pain and consumption of wild vegetables (P< 0.05). Conclusion: In this study, the prevalence of hydatidosis was similar to other parts of Iran. Further studies considering lifestyle and other variables are suggested in all areas of Mazandaran province with similar climate to Qaemshahr.

Abstract Cystic echinococcosis is one of the most important zoonotic parasitic diseases caused by the tapeworm Echinococcus granulosus. To date, the genotype of multivesicular CE has not been identified. In this regard, the genotyping of multivesicular types of CE could help clinicians understand and manage the disease effectively.

Abstract Rhino‐orbito‐cerebral mucormycosis (ROCM) is a progressive and life‐threatening disease that is caused by a fungal infection. Every uncontrolled diabetic patient with a skin lesion on their head and neck, sinusitis symptoms, headache, and orbital edema should be evaluated for mucormycosis.

Background and purpose: This study aimed at evaluating utilization of imipenem and assessing the role of pharmacist in rational use of antibiotics. Materials and methods: A retrospective/prospective observational study was conducted in Ramsar Imam Sajjad Hospital in 59 patients receiving imipenem, 2018-2019. In retrospective phase, patients’ records were reviewed, while in prospective phase, a pharmacist provided recommendations on use of imipenem. Duration of taking imipenem, dosage, and dosage adjustment in renal insufficiency were compared with standard protocols. Results: Mean age of the patients was 69.89±16.12 years and there were 29 males. The most common reason for prescribing imipenem was lower respiratory tract infection (54%) which was more used in internal medicine ward (67.28%) ordered by infectious diseases specialist (65%). In retrospective and prospective phases, mean dosage of imipenem, duration of receiving the antibiotic, and dosage adjustment in renal insufficiency were according to standard protocols in 65% and 85%, 45% and 65%, and 60% and 90% of the cases, respectively (P

Abstract Background Findings on the association between Toxoplasma gondii (T. gondii) infection and suicide are contradictory. This paper aimed to resolve this uncertainty by conducting a meta-analysis. Methods We found the relevant studies using keywords include “Toxoplasmosis” and “Suicide” and the related synonyms in international databases such as ISI, Medline, and Scopus. The eligible studies were included in the meta-analysis phase. The random effect approach was applied to combine the results. Results Out Of 150 initial studies, 15 were included in the meta-analysis. Odds of suicide in people with T. gondii infection was 43% (OR: 1.43, 95%CI; 1.15 to 1.78) higher than those without this infection. The test for publication bias was not statistically significant, which indicates the absence of likely publication bias. Conclusion This study confirms that T. gondii infection is a potential risk factor for suicide. To reduce cases of suicide attributable to T. gondii infection, it is recommended to implement some measures to prevent and control the transmission of the disease.

Background: Human papillomavirus (HPV) is a large group of DNA viruses that cause skin and mucosal warts. Zinc is used in the treatment of skin diseases. Zinc has been used in the treatment of various skin and systemic diseases. Warts are benign proliferation of the skin and mucosa. The prevalence of skin warts is higher in children and its peak is in adolescence and then decreases with age. Some species of HPV can cause malignancies. The effective role of zinc in the treatment of warts has recently been discussed. This study aimed to evaluate the serum zinc levels in patients with cutaneous warts compared to healthy controls. Methods: This case-control study was performed on patients, aged 18 to 60 years old, referred to the Dermatology Clinic of Bo’Ali Sina and Razi Hospitals, Mazandaran Province in, Iran, from April to March 2016. Serum zinc level and severity of disease were assessed in case and control groups. Data were analyzed by SPSS software, version 22 (SPSS Inc., Chicago, IL, USA). Results: A total of 94 subjects (47 in the case and control group) entered the study. The mean age of the case group was 26.40±9.33 years and in the control group 28.32±7.35 years. The gender status was 42 (44.7%) male and 52 (56.3%) female. Single and married were 63.8% and 36.2%, respectively. The mean zinc level in patients with cutaneous wart was 82 and the control group was 85.65. The mean number of warts was 5.09±6.33. The most frequent site of lesions were on the hands and foot with 48.93% and 40.42%, respectively, and the face (3.2%) had the lowest rate. Almost half of the patients were affected by the disease for 12 to 18 months. There was no significant relationship between age, sex, and severity of disease with serum zinc level (P>0.05). Serum zinc level was significantly associated with the duration of warts involvement (P=0.043). Conclusion: Serum zinc levels were lower in patients with cutaneous warts than in healthy controls, but this difference was not statistically significant. Serum zinc level and duration of warts involvement were related. The duration of warts and serum levels were inversely correlated.

Background and purpose: Spondylitis is infection of the vertebrae and the intervertebral discs. Mycobacterium Tuberculosis, Brucella, and Pyogenic bacteria are among the major causes of this disease. There are reports on the epidemiology of this disease in Mazandaran, northern Iran. Evidence suggests differences between different types of spondylitis, but there is paucity of information on the differences between all types of spondylitis, especially Pyogenic spondylitis. The aim of this study was to investigate the clinical epidemiology of spondylitis in the region to make early diagnosis and appropriate treatments. Materials and methods: A descriptive study was done using the records of patients with spondylitis in Qaemshahr Razi Hospital, 2013-2017. Information including epidemiologic and demographic characteristics, main complaints and clinical symptoms, disease complications, radiological findings, and laboratory findings were extracted. Data were analyzed in SPSS V24. Results: The records of 39 patients (19 males and 20 females) were reviewed. Among the patients Brucellar spondylitis, tuberculous spondylitis, and pyogenic spondylitis were identified in 35.9%, 38.5%, and 25.6%. Conclusion: In current study, the rate of spondylitis was higher than that in other studies, which may be due to higher rates of tuberculosis in Mazandaran. Thoracic involvement was found to be more common in tuberculosis while Brucella and pyogenic spondylitis involved lumbar vertebrae. These findings could be of great help in distinguishing between the three conditions.

Introduction: Efficacious therapies are urgently required to tackle the coronavirus disease 2019 (COVID-19). This trial aims to evaluate the effects of atorvastatin in comparison with standard care for adults hospitalized with COVID-19. Methods: We conducted a randomized controlled clinical trial on adults hospitalized with COVID-19. Patients were randomized into a treatment group receiving atorvastatin + lopinavir/ritonavir or a control group receiving lopinavir/ritonavir alone. The primary outcome of the trial was the duration of hospitalization. The secondary outcomes were the need for interferon or immunoglobulin, receipt of invasive mechanical ventilation, and O2 saturation (O2sat), and level of C-reactive protein (CRP) which were assessed at the onset of admission and on the 6th day of treatment. Results: Forty patients were allocated and enrolled in the study with a 1 to 1 ratio in atorvastatin + lopinavir/ritonavir and lopinavir/ritonavir groups. Clinical and demographic characteristics were similar between the two groups. CRP level was significantly decreased in the lopinavir/ritonavir + atorvastatin group (P

Background: Recent studies from multiple countries have shown a high prevalence of coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) among severely ill patients. Despite providing valuable insight into the clinical management of CAPA, large-scale prospective studies are limited. Here, we report on one of the largest multicenter epidemiological studies to explore the clinical features and prevalence of COVID-19-associated pulmonary mold infections (CAPMIs) among mechanically ventilated patients.Methods: Bronchoalveolar lavage (BAL) and serum samples were collected for culture, galactomannan (GM), and β-D-glucan (BDG) testing. Patients were classified as probable CAPMI based on the presence of host factors, radiological findings, and mycological criteria.Results: During the study period, 302 COVID-19 patients were admitted to intensive care units (ICUs), among whom 105 were mechanically ventilated for ≥4 days. Probable CAPMI was observed among 38% of patients (40/105), among whom BAL culture of 29 patients turned positive for molds, while galactomannan testing on BAL (GM index ≥1) and serum (GM index >0.5) samples were positive for 60% (24/40) and 37.5% (15/39) of patients, respectively. Aspergillus (22/29; 75.8%) and Fusarium (6/29; 20.6%) constituted 96.5% of the molds isolated. Diaporthe foeniculina was isolated from a COVID-19 patient. None of the patients who presented with CAPMI were treated with antifungal drugs.Conclusion: Despite being prevalent, the absence of appropriate antifungal treatment highlights that CAPMI is a neglected complication among mechanically ventilated COVID-19 patients admitted to ICUs. CAPMI can be caused by species other than Aspergillus.

Abstract Wound infections due to snake bites such as cellulitis and necrotizing fasciitis, although not common, are seen in snake bites and if left untreated can cause serious complications.

Background and purpose: Q fever is a worldwide zoonosis which is an endemic in many regions. Its diagnosis is usually missed especially in human. This research aimed at investigating acute Q fever among suspected patients in northern Iran. Materials and methods: This cross-sectional study was conducted in 56 suspected cases of Q fever selected from 476 febrile patients admitted in Qaemshahr Razi Hospital, Iran 2016, with systemic or respiratory symptoms. Blood samples and sera were tested for detection of IgG phase II antibodies against C. burnetii by quantitative ELISA. Seroconversion and/or four-fold rise in IgG phase II titers were the diagnostic criteria of acute Q fever infection. Results: The prevalence of acute Q fever was 5.37% (95% CI: 1.84, 14.61%). Risk factors for Q fever infection included living close to livestock farms and consumption of unpasteurized milk or dairy products. However, these risk factors were not significantly different between patients with Q fever and seronegative cases of Q fever (P

Background and purpose: Influenza is a seasonal respiratory illness that affects all age groups and causes excess mortality. Identifying the clinical manifestations and complications could be of great value in preventing the flue pandemic. Recent H1N1 pandemic is associated with some unusual findings such as thrombocytopenia, leukopenia, and lymphopenia which are not reported in other types of Influenza. Herein we investigate the hematological manifestations of influenza patients. Materials and methods: This study included all patients with flu symptoms attending Sari Imam Khomeyni Hospital and Qaemshahr Razi Hospital, winter 2015. H1N1 influenza infection was confirmed by polymerase chain reaction from nasopharyngeal specimen received through nasopharyngeal swabs according to the National Committee of Influenza guidelines. CBC and WBC differentiation were performed to detect leukopenia, anemia, or thrombocytopenia. Results: In this research 96 patients including 53 (55.2%) females and 43 (44.8%) males (mean age: 43.6±16.9) were studied. Mean WBC of patients were 6.9±2.62×103/cc and leukopenia was detected in 22 (22.9%) patients. The mean platelet count was 100×103/cc and 36 (37.5%) patients were thrombocytopenic. Mean hemoglobin levels were 6.1±1.12 g/dL and anemia was seen in 68 (70.8%) patients. There was no significant association between age, thrombocytopenia and leukopenia. Conclusion: In this study, thrombocytopenia, leukopenia, and anemia were detected in patients infected with H1N1 influenza.

On December 31, 2019, the World Health Organization was informed of a cluster of cases of pneumonia of unknown cause detected in Wuhan City, Hubei Province, China. The pneumonia was caused by a virus called SARS-Cov-2 (severe acute respiratory syndrome coronavirus 2), which was later named coronavirus infectious disease 2019 (COVID-19). The symptoms most commonly reported by patients affected by COVID-19 include fever, dry cough, and shortness of breath. In this report, we present a case of a 57-year-old woman who presented to the clinic’s infectious department with swelling, pain, warmth, and redness in the left leg who was treated with therapeutic heparin. There were no typical and distinguished symptoms of COVID-19, and she had no risk factor for deep vein thrombosis. Then chest X-ray revealed bilateral patchy ground-glass opacity, and computed tomography angiography was performed to rule out pulmonary thromboembolism, which showed no evidence of thrombosis. Left lower limb venous color Doppler ultrasound revealed dilatation and thrombosis in the external iliac and left iliac veins up to the level of the bifurcation of the common iliac veins, as well as thrombosis to the superficial and small saphenous veins. Because of ground-glass opacity and lymphopenia, nasal swabs were used for sampling, and SARS-CoV-2 nucleic acid was detected by reverse transcription polymerase chain reaction (RT-PCR). This case aims to arouse the medical staff’s awareness of deep vein thrombosis as a clinical symptom of COVID-19 even if the patient has no typical symptoms of COVID-19.

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: Candida endocarditis is an infrequent disease with a high mortality rate, which commonly occurs in immunosuppressed patients with cardiac valve replacement. We reported a 70-year-old woman diagnosed with Candida prosthetic valve endocarditis (PVE). This study also involved a review of all published cases of Candida PVE from 1970. Case report: Herein, we reported a 70-year-old woman with the history of severe mitral stenosis and myelodysplasia syndrome. She underwent mitral valve replacement for two times. The blood cultures were positive, and phenotypic identification of the isolates at the species level was performed based on microscopic and macroscopic characteristics. In the second prosthetic valve replacement, huge fungal white and creamy vegetation was observed which was identified as Candida albicans based on the conventional and molecular methods. Despite the administration of antifungal treatments, the patient passed away probably due to the multidrug-resistant Candida PVE. Conclusion: As PVE is a late consequence of prosthetic valve replacement, extended follow-up visits, early diagnosis, repeating valve replacement surgeries, and timely selective antifungal treatments are warranted. Keywords: Amphotericin B, Antifungal resistant, Azoles, Candida endocarditis, Multi-drug resistant, Myelodysplasia syndrome, Prosthetic valve replacement

Echinococcus granulosus has been described as the common etiology of hydatid cysts in many parts of the world. A 54-yr-old female with lower abdominal pain referred to Gynecology Ward of Sari Imam Khomeini Hospital, Iran in 2016. Sonography was carried out and cysts in ovaries and liver were observed. The cysts of liver seemed to be hydatidosis but physicians were suspected about ovarian cystic mass. Anti-Echinococcus antibodies (ELISA) screen was positive. The operation was done on her and treatment by albendazole started one week before surgery and continued after discharge from the hospital. Pathology confirmed hydatidosis in ovary, also patient follow-up was performed for three months by abdominal CT scan that showed peritoan full of many small hydatid cysts. Uncommon locations for constitution of hydatid cysts such as ovary and peritoan often make the diagnosis very difficult. Hydatidosis is considered in differential diagnosis of any cysts of the entire body, especially in endemic countries such as Iran.

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.

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.