Tehran University Medical Journal

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Background: Bickerstaff's brainstem encephalitis (BBE) is a very uncommon central nervous system disease with unknown etiology. As it is usually responsive to treatment, the diagnosis this disease is important. It seems There is no reported Bickerstaff's brainstem encephalitis case in Iran.
Case presentation: An 83 year old woman presented with vertigo, ataxia and dysarthria from a week prior to admission. Her T2 weighted MRI revealed high intensity lesions in the pons area. She received treatment with impression of ischemic stroke. After few days, lower extremities became weak symmetrically and deep tendon reflexes depressed. Deep sensory loss was noted too. The EMG-NCV studies showed acute polyneuropathy and in CSF examination increased protein content was noted. The patient improved after IVIG and corticosteroid therapy with impression of Bickerstaff's brainstem encephalitis.
Conclusion: In spite of severe initial presentation, Bickerstaff's brainstem encephalitis has a good prognosis if it diagnosed and treated properly. Although clinical features is too important, but paraclinical work up are necessary to diagnose this syndrome.

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Background: Hydatid disease or echinococcosis is a common parasitic disease of human and bovine, caused by infection with larva of the cestode echinococcus. Liver is the most common organ that is involved in this disease. Pelvic involvement and neurological symptoms, due to mass effect of pelvic involvement, in lower extremities are very uncommon manifestations of the disease.
Case presentation: A forty six year old man was referred to clinic of surgery at Ghaem Hospital, Medical University of Mashhad, Iran. The patient complained about weakness and motor impairment in right lower extremity accompanied by numbness and radicular pain over past two months. Physical examination demonstrated muscular atrophy and reduced muscular strength in right lower extremity. Computed tomography and ultrasonographic studies showed a cystic mass in right side of the pelvic cavity with extention to the sciatic notch and another cystic mass in right gluteal region. Surgical operation revealed a cystic mass deep in pelvic cavity with the extention to the right sciatic notch with compression of nerve roots. The cystic mass was contained of daughter cysts which confirmed the diagnosis of hydatid cyst disease. This diagnosis was confirmed by pathologic assessment.
Conclusion: Although uncommon, but hydatid disease can involve the pelvic cavity and make a pelvic, usually cystic, mass that can make compression on nerve roots and so making neurologic symptoms in lower extremities. So in endemic areas for hydatid disease, such as Iran, pelvic hydatid cysts should be considered as a possible differential diagnosis in patients presenting with the sciatic pain and neurological manifestations in whom a pelvic mass has been found too.

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Background: The Trigemino-cardiac reflex (TCR) has been studied as a phenomenon including bradycardia, arterial hypotension, apnea and gastric hypermotility during manipulation of the peripheral or central parts of the trigeminal nerve.
Case presentation: We report a case of a 26-year-old man undergoing surgery for a skull base extra axial tumor in right petrous bone suspected to metastasis of a previous renal cell carcinoma which had been treated four years ago. The patient presented with continuous and unilateral headache and difficulty in swallowing, sensory neural hearing loss, nasal speech and tongue deviation to left side. He underwent general anesthesia with standard monitoring and total intravenous anesthetic technique. The first episode of sudden onset bradycardia and hypotension related to surgical manipulation was detected intraoperatively in which the heart rate spontaneously returned to normal level once the surgical manipulation stopped. However, it repeated several times by beginning of tumor resection and manipulation in the region of trigeminal nerve. The intensity of bradycardia in subsequent episodes of TCR was relatively crescendo and had no fatigability. Finally, it was treated by administration of a single dose of atropine (0.5mg/IV) and did not happen again.
Conclusion: The risk of TCR should be considered in any neurosurgical intervention involving trigeminal nerve and its branches, especially at the skull base surgeries. The vigilance of the medical team and continuous intraoperative hemodynamic monitoring alerts the surgeons to interrupt surgical maneuvers upon the TCR occurrence, immediately.

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Background: Anemia at the time of birth may cause some problem like asphyxia, heart failure shock or even death in a neonate. Different etiologies can be considered for this problem. Parvovirus B19, as a viral organism, can cause hydrops fetalis and neonatal anemia and consequent complications. We present here a case of newborn infant with severe anemia who had human parvovirus B19 infection.
Case Presentation: A male newborn with gestational age of 36 week was born from a mother with poor prenatal care and history of contact with domestic animal. The neonate was very pale with Apgar score 2 at 1 min and received resuscitation, mechanical ventilation and repeated blood transfusion The hemoglobin level was significantly low. Analysis was made based on the clinical presentations. According to the case history, physical and laboratory findings, neonatal severe anemia induced by parvovirus B19 infection was suggested and Laboratory work up documented his infection with parovirus B19.
Conclusion: Parvovirus B19 (B19 virus) is the smallest single strand linear DNA virus in animal viruses, which is the only strain of parvovirus that is pathogenic in humans. Human parvovirus B19 may cross the placenta and result in fetal infection, morbidity and death. Parvovirus is an uncommon cause of neonatal anemia and hydrops fetalis so this etiology must be considered in differential diagnosis of anemia at birth.

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Background: The anatomy of the palmar vascular arches and their variations, being one of the most challenging anatomical regions for reconstructive surgeon.
Case Presentation: During a routine dissection of a male adult cadaver in dissection hall of zahedan university of medical sciences, a complex, unilateral and rare variation in the pattern of blood supply to the palm of the right hand was observed. The history of the individual and cause of the death is not known. In this cadaver there was an incomplete superficial palmar arterial arch had no contribution from the radial artery. The superficial palmar arch giving only one common palmar digital artery, that supply second interdigital space and then it terminated by giving rise to a common trunk for princeps pollicis and radialis indicis arteries. Absence of the second and third common palmar digital artery with the contiguous sides of the third and forth interdigital spaces supply by the second and third palmar metacarpal arteries from the deep palmar arch respectively. The third palmar metacarpal artery giving rise to a branch which supplies the medial side of the little finger.
Conclusion: Having knowledge of the variations of vascular patterns resulting from a number of developmental errors could provide an important source of information for Anatomists, Radiologist, reconstructive and vascular surgeons.

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Background: Traumatic amputation of upper limb above the level of the elbow, are rare injuries that a surgeon may be faced with a handful of cases during his career. Even with advanced techniques in microvascular surgery, the survival of the transplanted limb that cut off completely from the arm is relatively weak. Case Presentation: Four injured people (patient) in Imam Khomeini Hospital during 1999-2013 in Tehran University of Medical Sciences were treated. Two patients had complete amputation of limb and other patients suffered from complete cutting in artery and vein along with neurological and soft tissue damages. There was not any ischemia or gangrene. However, efficiency of limbs with damages in peripheral nerves was not significant. The main reason was lack of immediate repair of the damaged nerves. In the recent examination, after discharge, the performance of the limb is firstly related to the conditions of the nerve system and secondly it depends on the severity of the injury in each of the muscles. However, none of the patients were dissatisfied of any situation and they were prepared to make any cooperation for improving the condition of their transplanted limb. Conclusion: Transplantation of the amputated limb can be done in spite of limited resources. Any delay in repairing damaged nerves will result great reduction of final organs’ performance. A limb, made from the own body, always take precedence to prosthesis, even when the efficiency is low.

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Background: Twin pregnancy with a fetus and a diploid complete mole is not rare, but, the cases of twin pregnancy with a partial mole are rare. Nowadays, the prevalence of these cases has been increased due to the high rate of assisted reproductive techniques in reproductive medicine. The importance of twin pregnancy with a fetus and a diploid complete mole is mainly due to systemic complications such as hypertension and maternal hemorrhage and the possibility of trophoblastic tumor following delivery. Different studies have reported some results about similar cases, but limited case reports are presented in our country. The aim of this study is to report a case with incomplete molar pregnancy concomitant with a live fetus. Case presentation: A 21 yr old woman (G2 ab1) referred to emergency department of Ghaem University Hospital in Mashhad. She complained of scant vaginal bleeding and spotting and a sonography report of a combined molar and normal pregnancy with 15 weeks gestational aged. During hospitalization, the pregnancy complicated with hypertension and proteinuria. Termination of pregnancy was planned at 17th weeks of gestation due to severe preeclampsia. After evacuation of uterus, during follow up visits, -hCG titer raised. Metastasis evaluation was negative. Pathology reports showed patial mole. Then, three doses of methotrexate (50 mg/m2 intra muscular) was administered and finally, according to the monthly follow up, -hCG level was undetectable. Conclusion: The rate of pregnancy complications such as hypertension, hyperthyroidism, and obstetrics hemorrhage and also the risk of Gestational Trophoblastic Neoplasm (GTN) are increasing in incomplete molar pregnancy. Therefore, early diagnosis and timely treatment of molar pregnancy is very important to reduce maternal morbidity and mortality.

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Background: A variety of endocrine disorders can complicate pregnancy. Diabetes insipidus although uncommon, may have devastating effect on pregnancy outcome, if unrecognized and untreated. The etiology of diabetes insipidus is often unknown, many cases are likely autoimmune, with lymphocytic infiltration of the posterior pituitary gland. Massive polyuria, caused by failure of the renal tubular concentrating mechanism, and dilute urine, with a specific gravity 1.005, are characteristic of diabetes insipidus. The diagnosis of diabetes insipidus relies on the finding of continued polyuria and relative urinary hyposmolarity when water is restricted. Most women require increased doses Desmopressin Acetate during pregnancy because of an increased metabolic clearance rate stimulated by placental Vasopressinase. By this same mechanism, subclinical diabetes insipidus may become symptomatic during pregnancy. Transient diabetes insipidus is associated with acute fatty liver and HELLP syndrome as well as twin gestation. Increased placental Vasopressinase activity, along with insufficient liver degradation in HELLP syndrome and acute fatty liver, may unmask this condition. Diabetes insipidus in pregnancy is rare. The disease results from inadequate or absent antidiuretic hormone (vasopressin) production by the posterior pituitary gland. The increased glomerular filtration rate seen in pregnancy may increase the requirement for antidiuretic hormone. Case presentation: We present a 39 years old woman, gravida3 para3, was admitted to Akbarabadi Teaching Hospital in september 2013. She was admitted due to polyuria, malaise, thirst with slight fever, six days after normal vaginal delivery. The urine volume was 8 lit/day and the specific gravity (S.G.) of the urine was 1.010. The urine osmolarity was lower than the plasma osmolarity. Electrolyte serum examination showed hypernatremia. The patient received 5 µg/day of synthetic vasopressin, in the form of l- deamino-8-Darginine vasopressin (DDAVP). This drug was given as intranasal spray in doses 0.25 mg twice daily. Plasma electrolytes and fluid status monitored carefully with initiation of therapy. DDAVP was used because it was not degraded by vasopressinase. Treatment was continuing, when the symptoms of central diabetes insipidus resolve and urinary concentrating ability was preferred. Maximum urinary osmolality over the next 11 hours was assessed, 730 mosm/kg was considered normal. Conclusion: Close attention to electrolyte and fluid balance is important in the postpartum period. The symptoms of transient vasopressin-resistant diabetes insipidus resolve in few days to a few weeks after vaginal delivery or when hepatic function returns to normal.

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cBackground: Choriocarcinoma is a highly malignant form of gestational trophoblastic disease. It is characterized by metastatic potential, rapid growth and deeply invasion into blood vessel and then widespread dissemination metastasis. However, the most common sites of metastatic choriocarcinoma are lung, vagina, liver, and brain. But, metastatic choriocarcinomas rarely is extended to gastrointestinal system. It is im-portant to keep in mind that despite extensive metastasis, choriocarcinoma is very curable disease. Due to high responsibility of this disease, early diagnosis of choriocarcinoma and treatment with chemotherapy can prevent mortality and morbidity of these patients. In this case report, we present a rare case of metastatic choriocarcinoma in the small bowel after normal term pregnancy. Case Presentation: A 34-years-old woman G4, P4, L4 presented with abnormal postpar-tum vaginal bleeding (45 days) and unresponsive to usual medical and surgical therapy (oxytocine, metergene, antibiotic, and double curettage). The patient was admitted in the Ghaem Hospital, Mashhad University of Medical Sciences in April 2013. She suf-fered from rectal hemorrhage and severe weakness. Because of unsuitable condition (shock), laparotomy was performed and small bowel involvement was observed. Seg-mental resection of small bowel detected metastatic choriocarcinoma of the lesion. We couldn’t rescue our patient due to unresponsive to combination chemotherapy (actino-mycine, methotrexate, cyclophosfamide, vincrystine, etopuside). Conclusion: In abnormal postpartum hemorrhage, we should consider the possibility of choriocarcinoma. Although, it is important to note rare manifestations of metastatic choriocarcinoma of small bowel in massive gastrointestinal hemorrhage.

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Background: Spontaneous hepatic rupture is a rare condition during pregnancy. Pregnant women with Hemolysis, Elevated Liver enzymes and Low Platelete count (HELLP) syndrome are more susceptible to hepatic rupture. It can occur per 40000 to 250000 pregnancies with high mortality and morbidity. There is no agreement on the best approach to this severe pregnancy complication. This is the case report of a spontaneous hepatic rupture associated with HELLP syndrome during pregnancy which occurred for the first time in the West Azerbaijan Province, Iran. Case Presentation: A 33 years old lady gravida 6, 3 intrauterine fetal deaths, 2 neonatal deaths at 30th weeks of gestation was admitted for preeclampsia. On admission, she had thrombocytopenia and elevated liver enzyme. Cesarean section was performed due to fetal distress and a preterm fetus was born. Inspection of the abdomen revealed a large hematoma in the right liver lobe associated with rupture of the capsule. Liver packing was performed by general surgeon and the abdomen was closed without repairing of fascia. In the 2nd day after operation, the patient was oriented but the abdomen reopened because of very low blood pressure. There was no severe liver hemorrhage so the liver was packed again with many surgicels. She developed acute kidney and liver failure, pleural effusion and a major coagulopathy post-operatively. Three weeks after surgery the abdomen was reopened for dehiscence and fascia was closed. The patient discharged after 40 days. Conclusion: Spontaneous liver rupture associated with HELLP syndrome is a rare and life-threatening complication of pregnancy. Unruptured liver hematoma is also a rare condition during pregnancy with a very difficult diagnosis. Using clinical diagnostic tests such as CT scan or MRI would be helpful to improve clinical outcomes.

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Background: Cervix is a rare and dangerous site for ectopic pregnancy. When the placenta is implanted lower than internal cervical os, it is called “cervical pregnancy”. Known risk factors for cervical pregnancy are previous cesarean section, cigarette smoking, premature transfer of fertilized ovum before having suitable endometrium and pelvic inflammatory disease. In the past, hysterectomy was the usual treatment. Nowadays, with the newer diagnostic and therapeutic managements, cases of cervical pregnancy treated by fertility sparing methods have been reported. Conservative treatments include using methotrexate and KCl, hyperosmolar glucose, and prostaglandins. Also, surgical methods with fertility sparing have been reported. The purpose of this study is introducing two cases of cervical pregnancies treated by fertility sparing. Case presentation: The first patient had six weeks pregnancy with live fetus and detectable fetal heart beat. There was six weeks menstrual retard and βhCG titer was 10.000 UI/ml. Two doses of methotrexate were prescribed and pregnancy terminated successfully. The other patient had eight weeks pregnancy with fetal heart beat. There was eight weeks retardation and βhCG titer was 70379 UI/ml with no gestational sac in sonography in both patients. After prescribing two doses of methotrexate and doing curettage three days after the last dose of methotrexate, pregnancy terminated. The known risk factors for our patients were history of endometrial curettage in one and history of cesarean section in both of them. Conclusion: Conservative method may be considered for the treatment of cervical pregnancy in patients who desire to preserve their fertility. The treatment is associated with high success rates. Methotrexate (MTX) is the most common medicine for resolving ectopic cervical pregnancy, other medications such as KCl, hyperosmolar glucose, RU486 and prostaglandins have also been used with different success rate. Methotrexate may be administered systemic (intramuscular or intravenous) or local (intra-amniotic transfusion or intrauterine).

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Background: Tumoral calcinosis is a hereditary disorder of metabolic dysfunction of phosphate regulation. It is an idiopathic calcinosis that characterized by the deposition of calcium phosphate in periarticular tissues that causes typically lobulated, well demarcated calcification around large joints particularly the extensor surfaces. It is usually painless. It is common in puberty age and adolescents. The involvement of the hand phalanges is very rare that can make a mistake in diagnosis if it is infected. Tumoral calcinosis is seen the same in both sexes. The electrolyte levels of calcium and phosphorus is normal and sometimes is hyperphosphatemia. It is the first report of tumoral calcinosis in Iran. Case report: A 7-year-old girl presented with redness, yellowish discharge and painful swelling of the left hip and the third web space of left hand admitted to Vali-e-Asr Hospital, Tehran, Iran, in 2013. The onset of the disease was 3.5 years ago. She did not mention the family history of the disease. The pain was at the left hip first. Six months later the third and fourth phalanges of the left hand was swollen. Physical examination revealed an erythematous mass in the extensor surfaces of the third and fourth metacarpals of the left hand. It was tender in palpation. The smear and culture of discharge was staphylococcus aureus. X-rays revealed calcification of the third and fourth metacarpals of the left hand. The entire lesion was managed by surgical excision. Successful postoperative medical management in the form of low calcium and low phosphorus diet and oral cloxacillin was performed. Conclusion: Tumoral calcinosis involves rarely the interphalangeal joints of hand. Because of its compression over adjacent nerves, it is painful. Sometimes it has a sterile discharge and rarely superimposed infections may occur. Radiologists can play a major role in early diagnosis and probable complications.

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Background: Rupture of uterus is a catastrophic complication associated with significant maternal and fetal morbidity and mortality. The prevalence of an unscarred uterine rupture is very rare. Although the most important complication of dilatation and curettage is perforation of uterus, dilatation and curettage is not introduced as an important cause of uterine rupture. Case presentation: Here we present a case of uterine rupture in a pregnant woman that was admitted in Tehran General Women Hospital, in December 2014, with reducing fetal movement in her 41th weeks of pregnancy. She did not have any risk factors for rupture of uterus including cephalo-pelvic disproportion and polyhydramnios, also there was no history of uterine surgery such as myomectomy and uterine abnormality repair. A term dead male neonate was delivered by cesarean section due to arrest of descending in stage 2 of labor. The baby weighed 3400 gr and had anomaly in ears, larynx, uvula and soft palate. Its chromosomal study depicted both trisomy and monosomy for chromosome 13 and 21. Mother had a history of illegal curettage and trauma to the uterus in her first pregnancy two years ago. She did not say to us this history and abortion during admission. After cesarean section we saw that in the left side of the posterior wall of uterus was ruptured and baby was died. At surgical exploration, moderate hemoperitoneum was evident. Fetus was already dead at the time of extraction. Total estimated blood loss was 100 ml, the patient was transfused with two units of packed cell. The woman was discharged on the fifth postoperative day in good condition. Conclusion: Effective contraception and safe curettage can reduce maternal mortality and morbidity. Also special attention to a history of curettage to predict uterine rupture is critical.

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Background: One of the main reasons of hemorrhagic fevers is Ebola. The high rate of mortality and lack of definite treatment have been caused this infection to be a serious problem in the world. Ebola, especially in the early stages, when causes symptoms such as fever, anorexia and nausea, can be confused with malaria infection and conversely, severe malaria with Ebola. Plasmodium falciparum is an important cause of severe malaria that more than other types of plasmodium confused with Ebola. Case presentation: The patient is a 54-year-old man who had gone to Sudan about 8 months ago. The patient reported that fever, chills and headache had been started one week before traveling from Sudan to Iran and hematuria was added to his symptoms in third week of illness in Iran. He was referred to the emergency department with probable diagnosis of Ebola. Plasmodium falciparum gametocytes were revealed in his peripheral blood smear. Finally, he was treated with Coartem (artemether/lumefantrine) for malaria and after clinical improvement discharged to home with good condition. Conclusion: Ebola should be suspected in every patient with fever and a history of traveling to endemic areas. Considering the fact that in most areas where Ebola is endemic also malaria is common, lack of clinical suspicion to malaria causes that clinicians mistake malaria with Ebola. Necessary laboratory tests to rule out important differential diagnoses in patients with suspected Ebola virus contains: Peripheral blood smear for malarial parasite and blood culture and blood cell counts to investigate typhoid fever and other bacterial infections. Therefore, malaria should be considered as an important differential diagnosis in every patient suspected with Ebola.

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Background: Breast cancer is not only considered as the most common cancer in women but also is known as the second cause of death among them. One of the main causes of death in breast cancer patients is metastasis to different organs such as lymph nodes, bones, lung, liver, brain or other parts of the body. Metastasis to genital organs especially uterus is rare and a few cases are reported. Case Presentation: In this report we present a case of invasive ductal breast carcinoma metastasizing to a uterine leiomyoma in a 52 year old woman who was admitted to Imam Khomeini Hospital, Tehran, in September 2013, diagnosed and treated by modified radical mastectomy of the right breast six years ago. Currently, she presented with complaint of persistent abnormal uterine bleeding for which hysterectomy was performed. The histopathologic examination of the uterine specimen revealed a focus in the myometrial wall composed of spindle cell proliferation without signs of atypia which was accompanied by epithelial glandular structures with cells containing hypochromatic nuclei embedded in a desmoplastic stroma. Considering the history of invasive ductal breast carcinoma in this patient, the diagnosis of stromal nodule or metastasis from a breast origin was suggested as the main differential diagnosis. The Immunohistochemical study performed with different markers showed positivity for GCDFP15 staining confirming metastasis from the breast carcinoma. Conclusion: Although metastasis of breast cancer to the genital organs is an uncommon event, breast carcinoma is still considered the second source of extragenital malignant metastasis to the uterus. Overall, the most popular sites for metastasis of breast carcinoma to the female reproductive system include the ovaries and the uterine cervix. The uterine corpus is the least common site involved. In this regard metastasis to a uterine leiomyoma is a rare event.

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Background: Although Tuberculosis (TB) is prevalent in developing countries, visceral TB is rare. Most cases of pancreatic tuberculosis are seen in association with disseminated TB (miliary) but isolated pancreatic infection is very rare. Especially when present in immunocompetent hosts. In clinical and radiological evaluation, pancreatic TB may present as a pancreatic abscess, acute or chronic pancreatitis, and cystic or solid pancreatic masses, so can confused with neoplasm in most cases. Case presentation: In winter of 2013, a 52-year-old woman was admitted to this hospital with epigastric pain. She also mentioned a history of weight loss during previous three months. Liver transaminases and total bilirubin were within normal range. Chest X-ray performed was negative for any cardiopulmonary process, and lung fields were noted to be clear. A purified protein derivative (PPD) skin test for tuberculosis yielded an induration of less than 1 centimeter. An abdominal CT- scan with IV and oral contrast was done. A 2×2 cm mass was seen in the pancreatic head. A diagnostic laparotomy was done. Conclusion: During surgery, a completely necrotic mass was in the pancreatic head. samples were sent for frozen section. The tuberculosis granuloma was diagnosed. Four drug anti-tuberculosis medication was started and continued for six months. Repeat imaging of the abdomen performed 6-months after the initiation of anti-TB therapy revealed complete resolution of the pancreatic mass, and antitubercular therapy was discontinued after a 6-month duration. Pancreatic tuberculosis can present with a variable spectrum of imaging findings. Furthermore, TB should be considered as a cause of any suspicious pancreatic lesion, especially in patients from areas where the infection is endemic.

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Background: Standard treatment of Gestational Trophoblastic Disease (GTD) is chemotherapy. Single-agent chemotherapy regime including Methotrexate (MTX) or Actinomycin. Single-agent is widely used in treatment of persistent trophoblastic disease. We reported an uncommon toxicity of low-dose single-agent methotrexate in a patient. Case Presentation: A 20-year-old woman, primary gravid after two months missed period and spotting with diagnosis of incomplete abortion with uterine size equivalent of ten weeks pregnancy (8-10 cm) underwent evacuation curettage. In serial follow-up, based on rise of beta-hCG titer and absence of metastatic disease, it was categorized as low-risk persistent trophoblastic disease. She was referred to gynecology oncology center of Ghaem Hospital, Mashhad University of Medical Sciences in May 2014. Because of rise of beta-hCG titer, after complete metastatic work-up and lack of disease in other sites, persistent disease was diagnosed and candidate for chemotherapy (single agent low-dose). The patient received first course of therapy with MTX (50 mg/m², intra muscular). Unfortunately, after two days of treatment she developed uncommon severe toxicity, fever, severe nausea and vomiting, tachycardia, and generalized weakness. Also, we found hematologic abnormality (WBC: -14000-15000 µI, platelet- 540 µI and sever neutropenia), and abnormal rising in liver function test (SGOT, SGPT) (three to four times) and renal function test (BUN and Creatinine) (two times). In addition, she had disseminated erosive lesion in all of body especially in face. Due to the fatal side effects of chemotherapy, she was admitted to intensive care unit (ICU). Fortunately, after two to three weeks, she was improved by conservative management. After few weeks beta-hCG titer was in normal limit. However she had normal serial beta-hCG in one year of follow-up. Conclusion: It is important to emphasis unpredictable side effects of chemotherapy with low-dose methotrexate.

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Background: Chickenpox is a very contagious viral disease that caused by varicella-zoster virus, which appears in the first week of life secondary to transplacental transmission of infection from the affected mother. When mother catches the disease five days before and up to two days after the delivery, the chance of varicella in neonate in first week of life is 17%. A generalized papulovesicular lesion is the most common clinical feature. Respiratory involvement may lead to giant cell pneumonia and respiratory failure. The mortality rate is up to 30% in the case of no treatment, often due to pneumonia. Treatment includes hospitalization, isolation and administration of intravenous acyclovir. The aim of this case report is to introduce the exogenous surfactant replacement therapy after intubation and mechanical ventilation for respiratory failure in neonatal chickenpox pneumonia and respiratory distress.

Case Presentation: A seven-day-old neonate boy was admitted to the Neonatal Intensive Care Unit at Amirkola Children’s Hospital, Babol, north of Iran, with generalized papulovesicular lesions and respiratory distress. His mother has had a history of Varicella 4 days before delivery. He was isolated and given supportive care, intravenous acyclovir and antibiotics. On the second day, he was intubated and connected to mechanical ventilator due to severe pneumonia and respiratory failure. Because of sever pulmonary involvement evidenced by Chest X-Ray and high ventilators set-up requirement, intratracheal surfactant was administered in two doses separated by 12 hours. He was discharged after 14 days without any complication with good general condition.

Conclusion: Exogenous surfactant replacement therapy can be useful as an adjunctive therapy for the treatment of respiratory failure due to neonatal chickenpox.

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Background: Herpes encephalitis is the most common cause of fatal encephalitis in the world which often presents with sudden fever, headache, seizure, focal neurologic symptoms, and consciousness loss. The aim of this study was to report a case of maternal death caused by herpes encephalitis which appropriate antibiotic therapy delayed because of early diagnosis of eclampsia.

Case Presentation: A 16-year-old pregnant woman at 36th weeks of gestation was referred to gynecology emergency department of Ghaem Hospital, Mashhad University of Medical Sciences in 2016. She was admitted due to 4 times of generalized tonic-clonic seizures and blood pressure of 140/90 mmHg with diagnosis of eclampsia. Cesarean section was performed for fetal distress and eclampsia remote from delivery. 6 hours after cesarean section because of higher than 39 °C and reduction in consciousness status, she was transferred to intensive care unit (ICU). The first brain magnetic resonance imaging (MRI) was normal. Lumbar puncture (LP) was performed and brain MRI was repeated that increased signal was observed in two sides of basal ganglia. Intravenous acyclovir was administered by possible diagnosis of viral meningoencephalitis. Cerebrospinal fluid (CSF) was positive in terms of herpes simplex virus type 1 (HSV-1). Unfortunately, the patient died 35 days after hospitalization by diagnosis of HSV-1 encephalitis and bilateral infarction with frequent seizures and clinical manifestation of septic shock refractory to treatment.

Conclusion: Although the first diagnosis for generalized convulsion during pregnancy is eclampsia, but in case of recurrent and specially atypical seizures and low consciousness level, other diagnosis like meningoencephalitis, brain lesions and cavernous sinus thrombosis (CVT) must be considered and ruled out.

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Background: ″Wernicke’s Korsakoff″ syndrome is the most important complication of severe thiamine deficiency. The term refers to two different syndromes, each representing a different stage of the disease. Wernicke’s encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity. Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE. It is a rare complication of hyperemesis gravidarum that confusion, ocular signs, and gait ataxia are the most prevalent symptoms, respectively. Typical brain lesions of wernicke’s encephalopathy (WE) are observed at autopsy in 0.4 to 2.8 percent of the general population in the western world and the majority of affected patients are alcoholic. The prevalence of wernicke’s encephalopathy lesions seen on autopsy was 12.5% of alcohol abusers in one report. Among those who with alcohol-related death, it has been reported to be even higher, 29 to 59%. The aim of this study was to report a case of wernicke’s encephalopathy following hyperemesis gravidarum. Case Presentation: A 28-year-old-pregnant woman in 19th weeks of gestation referred to the hospital with hyperemesis, gait ataxia, and dysarthria before that she had hyperemesis gravidarum with weight loss and unresponsive to outpatient and inpatient medical therapy. MRI showed hyperdense lesion around thalamus which was characteristic of wernicke’s encephalopathy. Rapid improvement in patient’s condition occurred after high dose thiamine infusion.

Conclusion: In hyperemesis gravidarum, presence of either symptoms of ocular or mental disorder or ataxia must be considered to rule out and appropriate treatment of Wernicke’s syndrome which can cause maternal and fetal death.