Tehran University Medical Journal

Background: Botulism is mostly caused by Clostridium botulinum neurotoxin which has been described as a bilateral symmetric descending flaccid paralysis. Preventing and responding to botulism outbreaks is a public health emergency. In this study, the disease is reported in a family.
Methods: In a case series study, during an outbreak, four members of a family with symptoms including paralysis, ptosis, blurred vision, diplopia, weakness, dysphagia, dry mouth, respiratory problems, vertigo, and lethargy, referred to Loghman Hospital of Tehran. Among the patients was an elderly woman and a pregnant woman. All clinical signs and symptoms of the patients were recorded daily in a researcher-made questionnaire from 27 August to 3 September 2018. At the time of admission, vital signs (pulse rate, respiration rate, and body temperature) of patients were stable and within normal limits. Following clinical suspicion of food-borne botulism in these patients, samples of the first two patients, including serum, stool, gastric secretions, and homemade whey were sent to the Botulism Laboratory of Microbiology Department of Pasteur Institute of Iran for the mouse bioassay.
Results: Type A neurotoxin was detected in homemade whey after the mouse bioassay. Therefore, foodborne botulism was confirmed in patients with laboratory results. Patients included two men and two women with a mean age of 52.7 years old. The length of hospitalized days was between 2 and 6 days. Two of the patients were admitted to the intensive care unit (ICU). Patients under study were fully recovered with timely diagnosis of the disease, treatment with antitoxin, and supportive care.
Conclusion: When conscious patients referred to the hospital with symptoms of paralysis, foodborne botulism is an important differential diagnosis. On-time diagnosis and antitoxin treatment can prevent serious complications.

Background: Information on the coronavirus infection 2019 (COVID-19) which can clinically range from asymptomatic infection to severe pneumonia, in transplant recipients is still low. Infections are a major cause of death in kidney transplant recipients, and kidney transplant recipients, like other organ recipients, appear to be more vulnerable to a variety of infections due to comorbidities and immunosuppressive drugs that predispose them to infection.
Case presentation: In this study, we reviewed 10 transplant recipients with a mean age of 50.3±11.25 years who were admitted to Ayatollah Rouhani Hospital in Babol due to COVID-19 From April 2019 to September 2019. Four patients were female and six ones were male. Fever (100%) and cough (60%) were the most common symptoms in patients. All patients used standard immunosuppressive drugs (tacrolimus, corticosteroids, mycophenolate, and cyclosporine). The mean level of oxygen saturation at the time of admission in these patients was 87.9±11.3 and in two patients with death outcomes of 57% and 95%, it was at the beginning of hospitalization. The mean leukocytes of patients at the beginning of hospitalization was10470±5784.08 per ml and the mean lymphocytes of these patients were 1081.5±516.05. In the studied patients, the mean of previous years of transplantation was 8/05±7.13 and two patients died 20 years and 5 years after their kidney transplantation. Two patients (20%), aged 57 and 50 years, died from progressive respiratory symptoms and the other eight patients recovered and were discharged from the hospital.
We reported COVID-19 infection in ten kidney transplant recipients with different clinical outcomes and periods, which may be a reference for the management of COVID-19 in such patients.
Conclusion: It seems that more information is needed to better understand the effect of anti-transplant immunosuppressive therapy on the outcome of COVID-19 infection in kidney transplant recipients. Long-term follow-up studies and more cases are needed to clarify the diagnosis, outcome, and treatment options for COVID-19 in these patients.

Background: Sporadic lymphangioleiomyomatosis (S-LAM) is a rare disease that generally affects young women and involves the abnormal proliferation of smooth muscle cells (LAM cells) in the lungs (pulmonary LAM). There are two types of LAM, sporadic and LAM with tuberous sclerosis, which is an autosomal dominant genetic disease caused by mutations in the Tsc1 and Tsc2 genes. The most common manifestation of this disease is pneumothorax due to cyst rupture. Median transplant-free survival for pulmonary LAM is 23 years from diagnosis. Factors associated with a poor prognosis are often those associated with a more rapid decline in lung function.
Case Presentation: The patient was a 24-year-old woman who presented with pneumothorax and multiple bullae in both lungs. The patient had no family history of respiratory disease, and the patient herself had no symptoms other than mild shortness of breath following activity from a year ago. A lung CT scan was performed for the patient and multiple bullae were evident in both lungs, which confirmed the diagnosis. There was no evidence of involvement of other organs but the lung. For the patient in the ICU with the diagnosis of left pneumothorax, a chest tube was inserted and she underwent mechanical ventilation. Finally, after 24 days of hospitalization, oxygen therapy of the patient was performed with a normal mask, and she underwent left lung pleurodesis with talcum powder, and a few days later, right lung pleurodesis was performed on the patient. On the 36th day of hospitalization, her general condition improved and she was discharged from the ICU. The patient was discharged in good general condition and had no problem on her four months follow-up.

Conclusion: Fortunately, with the diagnosis of LAM for the patient according to the CT scan of the patient's lung, she was treated with insertion of a chest tube and by performing pleurodesis, the recurrence of pneumothorax was prevented. In a young woman with spontaneous pneumothorax, sporadic LAM is one of the differential diagnoses.

Background: Noninvasive ventilation (NIV) has been used as one of the most promising methods to treat hypoxic respiratory failure in COVID-19.
Methods: In this study, the clinical outcomes of 80 patients with acute respiratory failure caused by COVID-19 were evaluated. The disease was confirmed in two methods: clinical and radiographic confirmation of disease in patients with an acute respiratory infection (highly suspected) or in some cases with a positive PCR test. The rate of discharge from the ICU without the need for intubation was evaluated as the primary outcome and based on that, the patients were divided into two groups: NIV failure and NIV success. Mortality rate, length of stay in ICU, frequency of intubated patients and laboratory factors of patients as secondary outcomes in two groups were compared.
Results: Regarding the outcome of death and discharge, there was a statistically significant difference between the two groups. Therefore, all patients with corona who were admitted to ICU and received NIV and were intubated due to non-responsiveness to NIV died and the patients were discharged from the hospital without intubation. All the patients investigated in this study, had received antiviral, antibiotic, and glucocorticoid treatment during hospitalization. In this study, the patients who were in the NIV success group and were not intubated had a lower mean age compared to the group without NIV success (54 vs. 67 years, respectively). The number of white blood cells in the NIV success group was 3945.28±10011.21 and in the group without NIV success was 9242.38±17296.16, which was statistically significant (P=0.004). The number of blood neutrophils in the successful and unsuccessful NIV groups was 12.19±83.04 and 4.31±89.49, respectively (P=0.034). The mean APACHEII score in patients in the NIV success group (11.07±5.05) was significantly lower than the group without NIV success (20.16±4.96).

Conclusion: Mortality was higher in the intubated group than in the NIV group. The combination of APACHEII score and respiratory rate one hour after receiving NIV can predict success with NIV.