Demographics, laboratory parameters and outcomes of 1061 patients with coronavirus disease 2019: a report from Tehran, Iran

We aimed to determine the characteristics of coronavirus disease 2019 (COVID-2019) among the Iranian population. In this study, we collected and analysed the demographics, laboratory findings and outcomes of patients with COVID-19 who were admitted to Masih Daneshvari Hospital in Tehran, Iran between 20 February 2020 and 2 April 2020. Among 1061 patients, 692 (65.2%) were male and the median age was 55 years (interquartile range (IQR), 44–66 years). Totally, 129 (12.2%) patients died during hospitalization in the ward or intensive care unit. From the remaining 932 individuals, 46 (5.0%) were admitted to the intensive care unit and 886 (95.0%) were hospitalized in the ward. Those patients who died were significantly older than those hospitalized in the ward (p < 0.001). The median absolute number of lymphocytes was 1.2 × 10³/μL (IQR 0.9 × 10³ to 1.6 × 10³/μL) and 708 (66.7%) patients had lymphopenia (absolute lymphocyte count <1500/μL). Among the laboratory tests, D-dimer, serum ferritin and albumin had the strongest correlations with mortality (r = 0.455, r = 0.412, r = –0.406, respectively; p < 0.001 for each one). In conclusion, laboratory findings could provide useful information with regard to the management of individuals with COVID-19.

Genomic analysis of globally diverse Mycobacterium tuberculosis strains provides insights into the emergence and spread of multidrug resistance

Multidrug-resistant tuberculosis (MDR-TB), caused by drug resistant strains of Mycobacterium tuberculosis, is an increasingly serious problem worldwide. In this study, we examined a dataset of 5,310 M. tuberculosis whole genome sequences from five continents. Despite great diversity with respect to geographic point of isolation, genetic background and drug resistance, patterns of drug resistance emergence were conserved globally. We have identified harbinger mutations that often precede MDR. In particular, the katG S315T mutation, conferring resistance to isoniazid, overwhelmingly arose before rifampicin resistance across all lineages, geographic regions, and time periods. Molecular diagnostics that include markers for rifampicin resistance alone will be insufficient to identify pre-MDR strains. Incorporating knowledge of pre-MDR polymorphisms, particularly katG S315, into molecular diagnostics will enable targeted treatment of patients with pre-MDR-TB to prevent further development of MDR-TB.

Epidemiology of multidrug-resistant, extensively drug resistant, and totally drug resistant tuberculosis in Middle East countries

The 2015 represent the deadline for the global tuberculosis (TB) targets set through the Millennium Development Goals (MDG). From 2016 and onward, new goals were set to end the global TB epidemic via implementing new campaign entitled "the End TB Strategy". The major hurdle to end TB epidemic in several parts of the world is the emergence and spread of drug resistant Mycobacterium tuberculosis (MTB) strains. The better understanding of the actual global burden of drug resistant tuberculosis would feed into better implementing the End TB Strategy. In this article we summarize the current knowledge on the patterns of drug resistance tuberculosis cases in the Middle East countries. These countries are served by the Eastern Mediterranean Regional Office (EMRO), one out of six regional offices of World Health Organization. Middle East countries are characterized by geographic vicinity and population's interaction. However, they are dissimilar in several aspects such as economy and health infrastructures. Regarding economy, countries in this region are ranging from wealthy to very poor. Prevalence of tuberculosis and patterns drug resistance tuberculosis cases are also following variable trends within countries of this region. In almost all Middle East countries, there is under-reporting of drug-resistance tuberculosis cases. There are shortages in the infrastructures and facilities for detecting the pattern of drug-resistance tuberculosis. For instance, sixout of 14 countries have neither in-country capacity nor a linkage with a partner laboratory for second-line drug susceptibility testing and only 4 countries have registered site performing Xpert MTB/RIF.

Pulmonary computed tomography scan findings in chronic granulomatous disease

BACKGROUND

Chronic granulomatous disease is a phagocyte defect, characterised by recurrent infections in different organs due to a defect in NADPH oxidase complex. This study was performed to investigate pulmonary problems of CGD in a group of patients who underwent computed tomography (CT) scan.

METHODS

Computed tomography scan was performed in 24 patients with CGD. The findings of the CT scan were documented in all of these patients.

RESULTS

Areas of consolidation and scan formation were the most common findings, which were detected in 79% of the patients. Other abnormalities in order of frequencies were as follows: small pulmonary nodules (58%); mediastinal lymphadenopathy (38%); pleural thickening (25%); unilateral hilar lymphadenopathy (25%); axillary lymphadenopathy (21%); bronchiectasis (17%); abscess formation (17%); pulmonary large nodules or masses (8%); and free pleural effusion (8%).

CONCLUSION

The pulmonary CT scans of the patients with CGD demonstrated a variety of respiratory abnormalities in the majority of the patients. While recurrent respiratory infections and abscesses are considered as prominent features of CGD, early diagnosis and precise check-up of the respiratory systems are needed to prevent further pulmonary complications.

Modification of Acute Physiology and Chronic Health Evaluation II score through recalibration of risk prediction model in critical care patients of a respiratory disease referral center

Background:

Several models have been developed to measure the severity of illness in intensive care unit (ICU) patients, It is suggested that the models should be customized depending on the characteristics of different population of patients. This study is aimed to assess and modify the performance of Acute Physiology and Chronic Health Evaluation II (APACHE-II) model in a respiratory diseases referral center.

Materials and Methods:

A total of 730 patients, admitted to an intensive care unit during one year, were divided into two sets (71% training and 29% test). Our modified APACHE-II model was developed and calibrated on training set. Then, the integrity of the customized model was checked and compared to the original APACHE-II, on the test set. Logistic regression was used to develop ROC analysis, F-measure and kappa coefficient and were employed to calibrate the model.

Results:

Both Original and Our modified APACHE-II scores performed acceptable discriminative power (AUC = 0.908: 95%CI 0.861-0.854; and AUC = 0.856: 95%CI 0.789-0.923, respectively); the difference was not significant (P = 0.132). Our modified APACHE-II showed improved accuracy (87.9% vs. 84.1%) and sensitivity (56.4% vs. 16.3%) compared to the original model. F-measure and Kappa also gave the impression of improvement for our modified APACHE-II system.

Conclusion:

The results demonstrated that a modified APACHE-II system in a local ICU of respiratory disease could have similar discrimination and comparable calibration to the original model.

IL-2-inducible T-cell kinase deficiency with pulmonary manifestations due to disseminated Epstein-Barr virus infection

IL-2-inducible T-cell kinase (ITK) deficiency is a rare inherited immunodeficiency disease characterized by homozygous mutations in the ITK gene and the inability to control Epstein-Barr virus (EBV) infection leading to EBV-associated lymphoproliferative disorders of B cell origin. Many aspects of its clinical presentation and immunologic phenotype are still unclear to clinicians. We report on a 14-year-old female patient with complaints of an 8-month history of cough and fever. Imaging studies revealed diffuse pulmonary nodules and mediastinal lymphadenopathy. Transbronchial lung biopsy showed nonmalignant polyclonal B cell proliferation. High titers of EBV DNA were detected by PCR analysis in bronchoalveolar lavage fluid, bone marrow, and blood. Genomic analysis revealed a homozygous single base pair deletion in exon 5 of the ITK gene (c.468delT) in this patient. Treatment with rituximab (anti-CD20 mab) resulted in complete clinical remission with resolution of pulmonary lesions and a negative EBV titer in serum. All patients with EBV-associated lymphoproliferative disorders should be analyzed for mutations in ITK.

Interferon-gamma receptor-1 gene promoter polymorphisms and susceptibility to leprosy in children of a single family

The autosomal recessive disorder, because of a single mutation in interferon-γ receptor-1(IFNGR1) at position -56, was found to be associated with susceptibility to leprosy in children of the same family. The existence of such heterozygous carriers might explain the crucial role of IFNGR1 in the host defense against intracellular pathogens such as Mycobacterium leprae. The single nucleotide polymorphisms (SNPs) in major candidate genes, i.e., natural resistance-associated macrophage protein 1 (NRAMP1), vitamin D receptor (VDR), tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), interleukin-12-receptor 1 (IL-12R1), were not found to be associated with this disease.

Inflammatory myofibroblastic tumor of the trachea

This report described a 2-year-old boy who presented with severe respiratory distress and stridor. Bronchoscopy and CT revealed a mass in the left anterolateral tracheal wall and histopathology showed a tracheal inflammatory myofibroblastic tumor. Initial removal by rigid bronchoscopy resulted in prompt recurrence of the tumor. Therefore he underwent tracheal surgical resection. A bronchoscopy at 12 months after surgery did not show any recurrence sign.

Eight years of lung transplantation: experience of the National Research Institute of Tuberculosis and Lung Diseases

BACKGROUND

Lung transplantation has evolved from an experimental procedure to a viable therapeutic option in many countries. In Iran, the first single-lung transplantation was performed in the year 2000, more than 3 decades after the first successful procedure in the world, and the first double-lung transplantation was performed in the year 2006.

OBJECTIVE

To describe our 8-year experience in lung transplantation.

PATIENTS AND METHODS

During 8 years, we performed 24 lung transplantation procedures. Underlying lung diseases were pulmonary fibrosis in 16 patients (66.6%); chronic obstructive pulmonary disease in 2 (8.3%); bronchiectasis in 5, including 2 patients with cystic fibrosis (20.8%), and alveolar microlithiasis in 1 (4.16%). Data for all patients were collected and analyzed. Procedures were carried out using standardized methods. The induction suppression regimen consisted of cyclosporine and methylprednisolone. Maintenance immunosuppression drugs were cyclosporine and mycophenolate mofetil, and tapering dosage of prednisolone. Patients were followed up with physical examinations, 3 times a week, as well as and cycle ergometry 3 times a week and spirometry and laboratory tests once a week and chest radiography per needed for up to 3 months posttransplantation.

RESULTS

The longest survival time was 7.2 years, in a 60-year-old patient with idiopathic pulmonary fibrosis. Fourteen patients died, 8 as a result of hemodynamic instability and/or hemorrhage, 1 as a result of bone and fat emboli, 3 after cessation of drug and 2 of them after infection.

CONCLUSION

Although lung transplantation is a complex procedure it can be performed in developing countries such as Iran.

Organ retrieval from brain-dead patients by a single organ procurement center in Iran

INTRODUCTION

The majority of transplantations depend solely on cadaveric organs. In recent years, special focus has been directed toward brain-dead patients in Iran, but it seems that there is limited information regarding the characteristics of cadaveric organ donation in our country.

MATERIALS AND METHODS

This is a retrospective analysis of data of our Organ Procurement Unit (OPU), which is one of the most active organ procurement units in Iran. We incorporated the data on all organ donations from brain-dead patients between 2004 and 2008 into the present study. Demographic characteristics of the patients along with data regarding brain death and organ donation were extracted from already registered data on patients.

RESULTS

Among 93 brain-dead patients registered in the database of the OPU, organs were retrieved from 85% (n = 79). Out of the 14 patients from whom no organ was retrieved, the cause for this failure was death before donation in 85% (n = 12). The numbers of donated organs varied between zero and six (mean +/- standard deviation = 3.1 +/- 1.7). The most donated organs in terms of frequency and count were: right kidney (n = 68; 73.1%), left kidney (n = 67; 72%), liver (n = 63; 67.7%), heart (n = 40; 43%), pancreas (n = 5; 5.4%), and lung (n = 4; 4.3%).

DISCUSSION

The overall organ retrieval rate from brain-dead patients by this OPU was comparable to that of developed countries; however, we still believe we can improve this rate/scale.

Extensively drug-resistant tuberculosis treatment outcome in Iran: a case series of seven patients

BACKGROUND

Extensively drug-resistant tuberculosis (XDR-TB) has recently been identified as a major threat to global health. XDR-TB poses a risk of higher failure rates and death during TB treatment. We report herein the outcomes of XDR-TB in patients treated with the standardized regimen in Iran.

PATIENTS AND METHODS

Between 2002 and 2006, seven patients were diagnosed with XDR-TB. All patients were treated with the standardized second-line regimen containing cycloserine, prothionamide, amikacin, and ofloxacin. First-line drugs, such as ethambutol and pyrazinamide, were added to the regimen if drug susceptibility testing showed sensitivity to these drugs.

RESULTS

Four (57.1%) patients were male. All seven patients were HIV-negative. The patient age range was 22-79 years. Of the seven cases, the final outcome was 'cure' in two (28.6%), 'relapse' in one, 'treatment failure' in one, and 'death' in two; the outcome for one patient was unknown.

CONCLUSION

Our study shows a poor prognosis in patients with XDR-TB. This indicates the necessity of detecting XDR-TB cases earlier, as well as the need to gain access to more second-line agents. This is particularly important in resource-limited settings in order to administer individualized regimens.

Frequency of isolated hepatitis B core antibody in HIV-hepatitis C virus co-infected individuals

Association between isolated hepatitis B core antibody (anti-HBc) and hepatitis C virus (HCV) infection has been noted in HIV-infected individuals. This study describes the frequency of isolated anti-HBc and its possible value for the detection of HBV-DNA in HIV-infected patients with or without HCV co-infection. Ninety-two HIV-infected patients were enrolled in the study. Hepatitis B surface antigen (HBs Ag), anti-HBs, anti-HBc, anti-HCV, HIV viral load and CD4 count were tested in all subjects. Then we compared 63 subjects with HIV-HCV co-infection with 29 subjects with HIV infection alone regarding isolated anti-HBc (HBs Ag negative, anti-HBs negative and anti-HBc positive). The presence of HBV-DNA was determined by real-time polymerase chain reaction in serum samples of patients with isolated anti-HBc. Of 63 anti-HCV-positive patients, 18 subjects (28.6%, 95% [confidence interval] CI: 22.6-34.6%), and of 29 anti-HCV-negative patients, five subjects (17.2%, 95% CI: 11.5-22.9%) had isolated anti-HBc. HBV-DNA was detectable in three of 18 anti-HCV-positive patients (16.7%, 95% CI: 9.7-23.7%) and none of the anti-HCV-negative patients with isolated anti-HBc. Our study showed that individuals co-infected with HIV and HCV were more likely to have isolated anti-HBc than subjects with HIV alone. This investigation also demonstrates that the presence of isolated anti-HBc in HIV-HCV-infected individuals may reflect occult HBV infection in these patients.

Outcome of treatment of MDR-TB patients with standardised regimens, Iran, 2002-2006

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) imposes a formidable burden on national health systems. There is still no consensus on the subject, with controversies regarding treatment protocols, treatment outcomes and the various treatment regimens.

METHODS

The present study describes Iran's second national cohort for treatment of MDR-TB. The study comprised all documented MDR-TB cases in Iran referred to our centre during the period 2002-2006. All patients received a standardised second-line regimen consisting of ofloxacin, cycloserine, prothionamide and amikacin. Based on drug susceptibility testing results, ethambutol and pyrazinamide were added to the regimen.

RESULTS

Forty-three patients diagnosed with MDR-TB, with a mean age of 44.38 +/- 19.05 years, received treatment; of these, 27 (62.8%) were male. Twenty-three were (53.5%) Iranians and the remainder were Afghans. All patients were acquired MDR-TB cases. Of the 43 cases, 25 (58.1%) experienced severe clinically significant adverse effects; 29 (67.5%) had a successful outcome and 14 (32.5%) had a poor outcome (treatment failure in six [14%] and death in eight [18.6%]). Mortality was higher in Iranians (P = 0.039) and in patients whose initial regimen was changed due to adverse drug reactions (P = 0.01).

CONCLUSION

Compared with previous studies, our study was able to obtain more favourable outcomes of MDR-TB treatment using a standardised regimen.

Impact of anti-tuberculosis therapy on plasma zinc status in childhood tuberculosis

This study compared plasma zinc levels in 15 children with active pulmonary tuberculosis, 15 malnourished children and 15 healthy children. Mean plasma zinc concentrations in children with tuberculosis (71.7 microg/dL) were not significantly different than the other 2 groups (72.5 and 76.9 microg/dL). The zinc status of the children with tuberculosis was evaluated after 2 months and 4 months of DOTS therapy. The serum zinc level during anti-tuberculosis therapy decreased after 1 month and then recovered to the initial level after 4 months of treatment.

Clinical and laboratory profile of patients with tuberculosis/HIV coinfection at a national referral centre: a case series

This case series describes the clinical and laboratory profile of 15 patients with tuberculosis (TB) HIV coinfection admitted to a referral centre in the Islamic Republic of Iran. Most of the patients (13) were male; the mean age was 36.9 years. Intravenous drug use was the route of transmission for all males and heterosexual intercourse for the 2 females; 12 patients had a history of imprisonment. All patients had pulmonary TB; 13 were smear-positive and all except 1 had atypical radiological presentation. Drug-induced hepatitis occurred in 3 patients and 12 had hepatitis C coinfection. Five patients died. The mean CD4 count was 229.2 (SD 199.5) cells/mm3 and 78.6% had CD4 count < 350. TB may be an AIDS-defining illness in this country.

Pulmonary mycobacterium Simiae infection and HTLV1 infection: an incidental co-infection or a predisposing factor?

There is little information on atypical mycobacterium and human T lymphotropic virus Type I (HTLV-I) co-infection. We present the first case of pulmonary M. simiae infection in co-infection with HTLV-1, confirmed by ELISA antibody test and Western Blot. We discuss the clinical characteristics and laboratory tests of the patient and presumptive immunological relation. We propose that in patients with the HTLV infection and pulmonary symptoms and signs compatible with tuberculosis, evaluation for atypical mycobacteriosis may be recommendable.

Instability of IS6110 patterns in multidrug-resistant strains of Mycobacterium tuberculosis

The stability of IS6110 restriction fragment length polymorphism (RFLP) pattern was determined in 31 isolates from patients with multidrug-resistant tuberculosis (MDR-TB). These patients were in actual chains of transmission and they referred to the National Institute of Tuberculosis and Lung Diseases, Tehran, Iran. Susceptibility testing against first- and second-line drugs were performed by the proportional method on Lowenstein-Jensen culture media. Thereafter, DNA fingerprinting by IS6110 with direct repeat (DR) region as a probe was performed by standard protocols. The rate of IS6110 changes was 16%, although, no variation was found in the DR region, in a time-span of 1-63 months. The strains with unstable IS6110 patterns were resistant to all drugs tested, and the majority of them (60%) were collected from HIV-positive patients. The results demonstrated that for a reliable interpretation of strain typing, it is better to use an additional marker along with IS6110 RFLP.

Primary immune deficiencies presenting in adults: seven years of experience from Iran

Primary immunodeficiencies (PIDs) are not solely diseases of childhood. We describe the clinical presentation and outcome for 55 adult patients with previously unrecognized PIDs. This series provides unique data regarding PIDs presenting in adulthood, and serves as a timely reminder that physicians must consider the diagnosis of PIDs in their adult patients. Using the experience gained from these patients, we outline key "warning signs" suggestive of an underlying PID. Only through increased physician awareness will patients with PIDs receive timely diagnosis and optimal management.

Tuberculosis of the breast: report of 4 clinical cases and literature review

Nearly 18% of tuberculosis (TB) cases have only extrapulmonary manifestations. Breast tuberculosis is a rare type of extrapulmonary TB. This paper reports 4 cases of breast TB confirmed either pathologically or mycobacteriologically or both. These reports showed that TB should always be considered first in the differential diagnosis of granulomatous mastitis in TB-endemic areas. Therapy included at least 6 months of anti-TB medication and surgery when indicated.

Trends of drug resistant Mycobacterium tuberculosis in a tertiary tuberculosis center in Iran

OBJECTIVE

To determine the drug resistance pattern to first line antituberculous drugs in National Research Institute of Tuberculosis and Lung Disease and to compare resistant rates with previous studies.

METHODS

An anterograde cross-sectional study was performed. The study includes all adults with documented pulmonary tuberculosis (TB) that were hospitalized in National Research Institute of Tuberculosis and Lung Disease in Tehran, from June 2003 to September 2004. Demographic characteristic, TB categories, and drug susceptibility test results were recorded. Two previous studies regarding drug susceptibility in Iran were selected as historical controls.

RESULTS

One hundred and ninety-six new cases and 68 previously treated patients were enrolled in the study. The strains of 61% of new patients and 21% of previously treated patients were fully sensitive to all drugs. The most common resistance was streptomycin (27%) followed by isoniazid (23%) in new cases. Multiple drug resistant strains were noted in 2.6% (95% CI 0.8% to 5.8%) of new cases versus 56% (95% CI 43% to 68%) in previously treated group. The frequency of primary drug resistance to isoniazid was 9.8%-15% or streptomycin 9.8%-13% in the previous studies (p<0.00001).

CONCLUSION

While these rates may not reflect the true prevalence of drug resistance on a national scale, it does partially demonstrate some defects in the existing tuberculosis control program. The significant increase of isoniazid and streptomycin resistance in the last few years would present a serious challenge to effective management of TB.

Primary and acquired drug resistance in childhood tuberculosis

This study determined the resistance pattern of Mycobacterium tuberculosis to 4 first-line anti-tuberculosis drugs in children with pulmonary tuberculosis at the Iranian National Research Institute of Tuberculosis and Lung Diseases from 1999 to 2004. There were 350 children with positive cultures over the study period: 7 (2%) were resistant to at least one of the 4 anti-tuberculosis drugs. Primary resistance was detected in 4 cases and secondary resistance in 3 cases. Most cases (6) were among Afghan refugees. Resistance to rifampicin both in primary and secondary resistances was high, showing that children in the Islamic Republic of Iran face the threat of drug-resistant tuberculosis transmission.

Inherited disorders of the IL-12-IFN-gamma axis in patients with disseminated BCG infection

Disseminated BCG infection is a rare complication of vaccination that occurs in patients with impaired immunity. In recent years, a series of inherited disorders of the IL-12-IFN-gamma axis have been described that predispose affected individuals to disseminated disease caused by BCG, environmental Mycobacteria, and non-typhoidal Salmonella. The routine immunological work-up of these patients is normal and the diagnosis requires specific investigation of the IL-12-IFN-gamma circuit. We report here the first two such patients originating from and living in Iran. The first child is two years old and suffers from complete IFN-gamma receptor 2 deficiency and disseminated BCG infection. He is currently in clinical remission thanks to prolonged multiple antibiotic therapy. The other, a 28-year-old adult, suffers from IL-12p40 deficiency and presented with disseminated BCG infection followed by recurrent episodes of systemic salmonellosis. He is now doing well. A third patient of Iranian descent, living in North America, was reported elsewhere to suffer from IL-12Rbeta1 deficiency. These three patients thus indicate that various inherited defects of the IL-12-IFN-gamma circuit can be found in Iranian people. In conclusion we recommend to consider the disorders of the IL-12-IFN-gamma circuit in all patients with severe BCG infection, disseminated environmental mycobacterial disease, or systemic non-typhoidal salmonellosis, regardless of their ethnic origin and country of residence.

Primary multi-drug resistant tuberculosis presented as lymphadenitis in a patient without HIV infection

Primary multi-drug resistant extrapulmonary tuberculosis is an uncommon form of the disease, but it seems that by increasing the number drug resistant tuberculosis around the world, the number of cases of primary multidrug resistant tuberculosis with extrapulmonary presentation also is going to rise. In this report, we describe a 19- year old, HIV negative man with primary multi-drug resistant TB lymphadenitis, presented with cervical lymphadenopathy and sinus discharge at the site of involved lymph nodes. The Acid Fast Bacilli (AFB) smear of sputum was negative but the AFB smear of discharged fluid as well as the excisional biopsy of the lymph nodes confirmed the M. tuberculosis infection. The patient underwent the treatment with a combination of isoniazide, clofazimine, pyrazinamide, ofloxacin and amikacin with promising results. By increasing the number of drug resistant tuberculosis patients around the world, appropriate diagnosis and treatment of different presentations of the disease need a special attention.

Arylamine N-acetyltransferase 2 slow acetylator polymorphisms in unrelated Iranian individuals

OBJECTIVE

To determine the frequency of mutations at the polymorphic gene coding for arylamine N-acetyltransferase 2 (NAT2, EC 2.3.1.5) and NAT2 genotypes associated with slow acetylation in healthy Iranian individuals.

METHODS

The polymorphisms in the NAT2 gene from 88 unrelated healthy subjects (48 men/40 women) from the general Tehran population were discriminated using polymerase chain reaction (PCR) with allele-specific primers (341 C > T) and PCR-restriction fragment length polymorphism analysis (481 C > T, 590 G > A, and 857 G > A).

RESULTS

Frequencies of the studied polymorphisms showed the most common alleles to be NAT2*4 (0.43) and NAT2*5, 481 C > T (0.32), followed by NAT2*6 (0.19) and NAT2*7 (0.06), previously referred to as WT, M1, M2, and M3, respectively. The most prevalent genotypes were NAT2*4/*5 [(31.8%; 95% confidence interval (CI): 29-34%] and *4/*4 (18.2%; 95% CI: 16-21%). When grouped according to the expected phenotypical effects, the resulting genotypes revealed the significant prevalence of the subjects with slow (32.9%) and intermediate (48.9%) acetylation status compared with wild-type rapid (18.2%) acetylators (P < 0.01).

CONCLUSIONS

The overall allele pattern and acetylator status distribution in Iranians displayed the considerable prevalence of "slow acetylators" over "rapid acetylators," similar to those of Caucasians except for a minor difference observed in the frequency of the NAT2*7 allele. Nucleic acid testing for common NAT2 mutations might be a potentially useful tool for an accurate phenotype interpretation and identification of Iranian individuals at risk.

Use of PCR and culture for detection of Mycobacterium tuberculosis in specimens from patients with normal and slow responses to chemotherapy

In order to examine the utility of PCR as a tool for monitoring the response to short-course chemotherapy, clinical data from 162 tuberculosis patients with drug-susceptible cultures and variables associated with a slow response to antibiotic treatment were retrospectively evaluated. Initial samples were positive by smear in 106 patients and by PCR in 156 patients. A rapid response to therapy was found in 132 patients who had both smear and culture-negative results after 2 months of treatment. After 6 months of therapy, 5 other patients in this group were considered clinically cured but 20 patients had positive cultures. For these 20 patients with a slow response to therapy, treatment was continued for an additional 2-4 months and 15 patients were subsequently cured. However, of all the cured patients 7 had PCR-positive samples at the end of treatment. When these cases were correlated with therapeutic outcome, it was found that 3 of the PCR-positive but none of the PCR-negative patients had a clinical relapse during subsequent follow-up. We conclude that culture and PCR tests are highly informative when used to control the rate of response to therapy. A post-treatment positive result on PCR may be associated with a poor clinical outcome or may predict the likelihood of clinical relapse. Culture and PCR tests, as opposed to smear results, may be the key parameters for individually guiding the duration of treatment in TB patients with a poor response to standard therapy.

Immunotherapy with Mycobacterium vaccae and peripheral blood flow in long-treated leprosy patients, a randomised, placebo-controlled trial

OBJECTIVE

to evaluate immunotherapy as a means of improving peripheral blood flow in chronic leprosy patients.

DESIGN

this was a double-blind, randomised, placebo-controlled, clinical trial.

MATERIALS

heat-killed Mycobacterium vaccae 1mg plus 0.02 microg Tuberculin protein per 0.1 ml dose in borate buffer, with saline as placebo. Those studied were 92 long-treated residents of a leprosy centre in Iran, 10 of their healthy children and 10 staff members. Evaluation employed the Perimed PF2, Laser-Doppler Flowmeter, a platinum skin thermistor, and a thermal sensibility tester.

METHODS

single intradermal injections of test or placebo were given to 103 patients 18 months before the blinded evaluation. Fingerpulp blood flux was measured in controlled conditions and vasomotor reflexes and skin sensation to touch, pain and heat were evaluated in 45 and 47 patients in the placebo and M. vaccae groups, respectively, and in 20 healthy control persons.

RESULTS

Laser-Doppler flux, skin temperature, vasomotor reflexes and sensation were impaired in leprosy patients. Immunotherapy improved (p < 0.05) Laser-Doppler flux, skin temperature and temperature sensation.

CONCLUSIONS

immunotherapy, given 18 months earlier, significantly improved blood flow and temperature sensation, in fully-treated, chronic, leprosy patients. The same principles might be employed in other conditions of reduced peripheral blood flow.

Reasons for delay in the management of patients with pulmonary tuberculosis

The study assessed reasons for delay between patient's first symptoms of tuberculosis and initiation of therapy. Fifty newly diagnosed cases of pulmonary tuberculosis admitted to the NRITLD in Teheran were studied. Mean patient delay before consulting a physician was 12.5 +/- 10 days, significantly higher among men than women. Mean delay until the physicians' diagnosis was 93 +/- 80 days, significantly higher for women than for men. Almost no treatment delay was observed (mean 4 +/- 4 days after diagnosis had been confirmed). The major delay was the time taken by physicians to diagnose tuberculosis in symptomatic patients. An active and effective national tuberculosis programme is needed in the Islamic Republic of Iran, with integration of the programme in medical school curricula and in continuing professional training.

Improving sensitivity of direct microscopy for detection of acid-fast bacilli in sputum: use of chitin in mucus digestion

In order to try to improve the results of direct smear microscopy, we used the mucus-digesting quality of chitin in tuberculosis (TB) laboratories. For this purpose, a total of 430 sputum specimens were processed by the N-acetyl-L-cysteine concentration, sodium hypochlorite (NaOCl) liquefaction, chitin sedimentation, and direct microscopy methods. Then, the smear sensitivity for acid-fast bacillus detection by chitin-treated sputum was compared with the sensitivity of smears prepared by other methods. Our results showed that the chitin solution took less time to completely homogenize the mucoid sputum than did the N-acetyl-L-cysteine and NaOCl methods. The N-acetyl-L-cysteine concentration method demonstrated sensitivity and specificity levels of 83 and 97%, respectively. In comparison, the sensitivity of chitin sedimentation was 80%, with a specificity of 96.7%. The NaOCl liquefaction method showed a sensitivity of 78%, with a specificity of 96%. Finally, the sensitivity of direct microscopy was lower than those of the other tested methods and was only 46%, with a specificity of 90%. The chitin and NaOCl liquefaction methods are both easy to perform, and they do not require additional equipment (centrifuges). Also, our results demonstrated that the chitin method is less time-consuming than the NaOCl method, since only 30 min of incubation is required to bring complete sedimentation of bacilli in chitin-treated sputum whereas the NaOCl method needs 10 to 12 h to give the same results in the same sputum specimens. Therefore, the chitin liquefaction and sedimentation method may provide better results in TB laboratories of developing countries than the N-acetyl-L-cysteine concentration, NaOCl overnight sedimentation, and direct smear microscopy methods.

Chromosomal aberrations and micronuclei in lymphocytes of patients before and after exposure to anti-tuberculosis drugs

To evaluate the genetic damage induced by tuberculosis infection and also by a combination of therapeutic exposure to anti-tuberculosis (anti-TB) drugs (isoniazid + rifampicin + pyrazinamide + ethambutol or streptomycin) we have considered chromosome aberrations (CA) and micronuclei (MN) in binucleate peripheral blood lymphocytes from 36 patients diagnosed with pulmonary tuberculosis prior to receiving anti-TB drugs in the first phase and in the second phase after 6 months of therapy with anti-TB drugs. The same cytogenetic study has also been performed on 36 healthy individual controls. It was shown that the frequencies of both CA and micronucleated binucleate cells increased significantly after therapy with anti-TB drugs as compared with TB patients and controls. In addition, we observed that both cytogenetic markers (CA and MN) in patients before treatment with anti-TB drugs were significantly (P: < 0.05) higher than controls. No relationship was found between the frequency of MN and donor age. Thus, apart from drug effects, infection with tuberculosis is associated with increased CA and MN.

Detection of Mycobacterium tuberculosis in bronchial washing of smear-positive patients after sputum conversion

The main purpose of chemotherapy of tuberculosis is to ensure the noninfectiousness of patients with active pulmonary tuberculosis. For this reason, the sputum of smear-positive pulmonary tuberculosis patients is examined at the end of the first and second month of therapy to determine the conversion rate, which is expected to be 85% at the end of the second month. The patients whose sputum has converted to smear-negative are considered noninfectious. The aim of this study was to challenge the theory that negative sputum smear test results always indicate the absence of Mycobacterium tuberculosis bacilli in respiratory secretions from patients with active pulmonary tuberculosis after treatment. In order to achieve this goal, 46 patients with pulmonary tuberculosis whose sputum was positive for M. tuberculosis at the first visit were followed until they gave two consecutive negative smears. The bronchoalveolar lavage fluid of these patients was then examined for M. tuberculosis bacilli. It was observed that eight (17.5%) and five (10%) of these patients, who had already undergone sputum conversion, gave positive smear and culture results respectively. It could be concluded that a negative sputum result is not an appropriate index for evaluating the infectiousness of patients with pulmonary tuberculosis, and, since a few Mycobacterium tuberculosis bacilli can cause tuberculosis, especially in an immunocompromised host, it is mandatory that complementary studies to assess the transmission and virulence of Mycobacterium tuberculosis bacilli after sputum conversion be conducted.

Treatment monitoring and prevalence of drug resistance in tuberculosis patients in Tehran

SETTING

Health care clinics and private practitioners in Tehran.

OBJECTIVE

To analyse rates of drug resistance and response to treatment in tuberculosis patients.

DESIGN

A prospective study of 257 patients undergoing treatment for whom data were collected on drug susceptibility testing and outcome as well as age, sex and history of treatment.

RESULTS

Of 774 initially diagnosed patients, 380 were female and 394 were male; 520 (67%) of the cases had pulmonary disease. The overall rate of primary drug resistance among Mycobacterium tuberculosis isolates resistant to at least one drug was 87/563 (15.5%). Twenty-three patients were multidrug-resistant. Among 215 patients with drug-susceptible cultures recruited for follow-up, rapid response to short-course chemotherapy was observed in 190 (88%) who were successively both smear and culture negative after 2 and 4 months of treatment. After 6 months of treatment, 12 of the 25 patients with slow response to treatment had positive cultures; one was smear-positive. Of the 42 patients with drug-resistant isolates, satisfactory bacteriological response was observed after 6 months of treatment in 30 (71%).

CONCLUSIONS

These observations support regional recommendations for short-course treatment regimens. Culture rather than smear result could be a key parameter for individually guiding the duration of treatment in patients with poor response to treatment.

Antimicrobial resistance pattern and plasmid profile of Salmonella typhi isolated from an outbreak in Tehran province

The antimicrobial resistance patterns and plasmid profiles of Salmonella typhi isolates from sporadic cases (n = 33) and an outbreak (n = 48) were compared. Of 28 sporadic drug-resistant isolates, 24 (85.7%) were multiply resistant. The predominant antibiotic resistance pattern was TeCmSmSxTAp, which was also the most common pattern of the outbreak isolates. 13 drug-resistant strains isolated before the outbreak (46.4%) were able to transfer the whole resistance pattern or part of it to Escherichia coli K 12 by conjugation. Although 20 of the sporadic strains contained plasmid DNA, transferable R plasmids were only detected in 13 (65%) of them. Among the outbreak strains, the rate of R plasmid transfer was 92.3%, with only the TeCmSmSxTAp pattern transferred. Plasmid profiling and Hind III endonuclease digestion of plasmid DNA identified a 91.2 megadaltons (Mda) plasmid that was recovered from most of the outbreak isolates and from 4 strains collected before the outbreak. This plasmid coded for TeCmSmSxtAp and transferred the pattern of resistance in toto. The results indicate multidrug-resistant S. typhi as a potential cause of infection in the region.