Tehran University Medical Journal

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Background: Measuring end tidal carbon dioxide (ETCo2) is one of the methods used for estimating arterial carbon dioxide (PaCo2) during general anesthesia. ETCo2 measurements maybe obviate the need for repeating arterial puncture for determination of arterial PaCo2. This study performed to determine the accuracy of ETCo2 levels as a measure of PaCo2 levels in patients undergoing coronary artery bypass graft and also to evaluate variation of the gradient between PaCo2 and ETCo2, peri- cardiopulmonary bypass operation. Methods: In a prospective, cross-sectional study, a total of 40 patients with age 57±11 (35-73) years old undergoing coronary artery bypass graft were enrolled. ETCo2 levels (mmHg) were recorded using side stream capnography at the time of arterial blood gas sampling, before (T0) and after (T1) cardiopulmonary bypass. Results: Mean P(a-ET)Co2 at T0 was 4.3±4.4mmHg, with the mean PaCo2, 33±6mmHg and mean ETCo2, 29±5mmHg and these values at T1 were 4.5±4.1mmHg, 33±5mmHg and 29±2mmHg respectively. There was no variation of the mean gradient (PaCo2-PETCo2) during, before and after cardiopulmonary bypass (p>0.870). Significant correlation was found between ETCo2 and PaCo2 at T0 and T1 (r=0.754 and 0.685respectively and p=0.001). Conclusion: Capnography is a non- invasive and a safe technique for determining arterial PCo2 and for measurements of ETCo2 that correlate well with PaCo2 values in healthy patients undergoing coronary artery bypass graft. ETCo2 measurements maybe sufficient measures of PaCo2 in selected patients and obviate the need for repeatingarterial blood gas determination. Further study is warranted.

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Background: Cutaneous leishmaniasis is a major health problem in Iran and especially Isfahan province is considered as an endemic area for this disease. Regarding the previous report of positive effects of Cassia fistula boiled extract in the treatment of cutaneous leishmaniasis, this study was designed to evaluate the effect of combination therapy with intralesional meglumine antimoniate and Cassia fistula fruit gel compared to placebo in this disease.
Methods: 140 patients with cutaneous leishmaniasis referring to Skin Disease and Leishmaniasis Research Center of Isfahan (SDLRC) were randomly allocated in two groups. One group received intralesional meglumine antimoniate injection and Cassia fistula fruit gel and the second group were treated with intralesional meglumine antimoniate and placebo gel. Improvement was defined as complete cure, partial cure and treatment failure.
Results: At 12 week, 47 patients treated with intralesional meglumine antimoniate and topical Cassia fistula fruit gel achieved complete cure (67.1%) compared to 29(41.4%) patients in placebo treated group. There was significant difference in cure rate between two treatment groups of this study (p<0.001). Nine patients (19%) in each group suffered from adverse effects of the treatment such as itching and erythema. There was no significant difference in this regard between two groups (p=0.82).
Conclusions: The results of this study shows the efficacy of Cassia fistula fruit gel in increasing the cure rate of cutaneous leishmaniasis lesions achieved by intralesional meglumine antimoniate. Combination therapy of intralesional meglumine antimoniate and Cassia fistula fruit gel could be suggested as a choice for the treatment of acute cutaneous leishmaniasis lesions.

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Background : Open fractures are associated with an increased risk of infection and healing complications. Management of open fractures is based on the following principles: assessment of the patient, classification of the injury, antibiotic therapy, debridement and wound management, Fracture stabilization, early bonegrafting, and supplemental procedures to achieve healing.
Methods : In a case- control retrospective study we evaluated 33 patients with open tibial fracture (type two gustillo) who were admitted in sina General hospital in Tehran, Iran during years 1999-2009 and were treated uniformly with external fixation as primary treatment in our center as case group and the other 33 patients with the same method and another 33 patients who had not been infected as control group. W e compared the folders of case and control groups retrospectively. 
Results : There was no statisticant difference between two groups in mean age, gender, the mechanism of trauma and body mass index (p >0.05 ), while statistically significant difference between them in smoking habitus, blood transfusion, first debridment time, diabet mellitus, femoral shaft fracture (p <0.05 ).
Conclusions: Accompanying femoral fracture is the sign of high energy trauma and it is logical that it is an important risk factor for infection. In our study the time of the first debridment stablished as a significant factor influencing the infection rate in tibial open fracture. In some studies smoking had been recognized as a significant factor influencing in tibial bone open fracture our study reveals the same.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Salmonellosis is a bacterial gasteroenteritis caused by different serovars of Salmonella. In the recent years, Salmonella enterica subspecies. Enterica serovar enteritidis is a major cause of gastroenteritis and food poisoning in the worldwide.  Different genus of salmonella is increasingly being resistant to common antibiotics. The aim of this study was to determine the frequency and the antibiotic resistance patterns of Salmonella enterica isolated from medical health centers in Tehran.

Methods: In this descriptive cross- sectional study from April to December 2008, 1950 fecal specimens from children with diarrhea were cultivated to identify Salmonella enteritidis. We used Clinical and Laboratory Standard Institute (CLSI) protocol to determine resistance patern of the isolates to 16 different antibiotics.

Results: In this study, out of 26 isolates 14(54%) were S. enteritidis, 2(8%) S. para B, 6(23%) S. para C, 3(11%) S. arizonea and 1(4%) S. para A. all of them were sensitive to ceftazidime, cephalexin, cefotaxime, ceftiraxone, ciprofloxacin, imipenem, meropenem, gentamicin and colistin sulfate. All of the isolates were resistant to nitrofurantoin whereas 71.4% of them were resistant to nalidixic acid.

Conclusions: The most prevalent isolated salmonella was S.enteritidis. According to high sensivity of these isolates to cephalosporin and flourqouinolon family, they can used as infective treatment for salmonellosis infections.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Since the recognition of true number of human chromosomes in 1956, many techniques have been developed to detect chromosomal aberrations. A number of those, such as karyotyping and fluorescence in situ hybridization (FISH), are valuable tools in both research and diagnostics. But these techniques have defects that limit their application. One of the important limitations is resolution resolution limitations make it impossible to detect small aberrations. The other major defect is the disability to analyze whole genome. In 1997 Solinas-Toldo introduced a new technique that could cover other techniques' defects. This new technique called microarray-based comparative genomic hybridization (array CGH). Array CGH, with the powerful resolution of FISH and also the ability of whole genome analysis in single experiment accelerated the genetic research. Array CGH has resulted in to a great progress in oncology and genetic disorders research. In addition, this technique has the ability to be used in diagnostics too. This review article, witch include the data of recent published papers and our experiences, gives an overview of the array CGH and compare it with the other molecular cytogenetic techniques. Its application in oncology and genetic disorder is also discussed.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Cystic fibrosis is a monogenic recessive disorder founds predominantly in caucasian population causes exocrine glands function defect. This disease arises from mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Because of heterogeneity of the mutations in CFTR gene, phenotypic symptoms in this disease are very variable. In this study we consider poly T polymorphism (T₅, T₇, T₉) in the intron 8 of CFTR gene in normal individuals and cystic fibrosis patients in mazandaran province.
Methods: Forty cases of cystic fibrosis patients and 40 normal individuals were screened for poly T polymorphism in intron 8 of CFTR gene using Reverse Dot Blot method.
Results: T₇ allele is the most prevalent in normal individuals and CF patients and it's abundance is approximately 75%. T₉ and T₅ represent approximately 20% and 5% of normal or mutant alleles respectively. T₇/T₇ genotypes in normal individuals and CF patients are the most prevalent with 72.5% and 60% prevalence rate, respectively. T₅/T₉ and T₅/T₅ genotypes were not found. 22.5% of normal individuals and 30% of CF patients had heterozygote genotypes.
Conclusion: The abundance of T₅, T₇, T₉ alleles and the presence of 22.5-30% heterozygote genotypes in normal individuals and CF patients indicates that poly T polymorphism in intron 8 of CFTR gene can be used as a marker for detection of normal and mutant alleles in prenatal diagnosis or can be used in carrier assessment in families with previous history of the disease.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Allergic rhinitis is a common disorder with great morbidity. Its prevalence has increased during recent years, therefore attracting attentions to its mechanisms. Type 2 cytokines play a major role in allergies. It has been proposed that Natural killer (NK) cells may be able to produce type 2 cytokines. This study was done to evaluate NK cells number and subtypes in patients with allergic rhinitis, comparing healthy subjects.
Methods: In a case control study, patients with allergic rhinitis were compared to healthy non-atopic subjects. Allergic rhinitis was diagnosed according to ARIA guidelines. NK cells quantity was studied by staining of peripheral blood mono nuclear cells with anti-CD16-FITC and anti-CD56-PE and evaluated by two color flowcytometry. Intracellular cytokines were evaluated by tri-color flowcytometry. NK cells were separated by magnetic beads, and cultured for 72 hours. Secretion of IL-4, IL-5, IL-10, IL-13, and IFN-γ was measured by ELISA, in stimulated and unstimulated conditions.
Results: Patients had more CD16+ CD56+ NK cells than control group. IL-4+ NK cells were significantly higher in patients (p<0.001), but the number of IFN-γ+ NK cells was not different. Cytokine secretion of NK cells was similar in case and control groups. Although IL-13 level after stimulation seemed higher in patients, the difference was not significant.
Conclusion: NK cells number is increased in patients with allergic rhinitis and a considerable number of them produce IL-4.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Recent studies present a high prevalence of multiple sclerosis (MS) in Iran. Treatment with interferon is now the first choice in management of MS. CinnoVex^TM (an interferon beta 1-a) is available in Iran, with achievement of the technology of producing beta interferon. The aim of the present study is to evaluate the efficacy and safety of CinnoVex^TM in a national study named CINA study.

Methods: This study was conducted from 2007 to 2008 in cities of Tehran, Isfahan, Mashhad, Tabriz, and Shiraz. Patients with relapsing/remitting MS with 16-50 years of age and EDSS of <4 received CinnoVex^TM (30µg/week, IM) after diagnosis by a neurologist. EDSS, drug side effects, and frequency of relapse were evaluated for one year in four 3-month visits.

Results: A total of 1050 patients entered the study. Complete data were collected from 627 (60%) patients. Mean age was 30.7±8.6 year and 514 (82%) were female. The most common onset presentations were sensory symptoms (44%). Changes of EDSS through the study showed a significant decrease in the last 3-month of evaluation (p<0.05). Drug side effects were observed in 47%, 50%, 61%, and 61.4% (p>0.05) and relapse was occurred in 13.4%, 15.7%, 16.9%, and 2.4% of the patients in the first, second, third, and forth evaluation visits (p=0.001), respectively.

Conclusion: CinnoVex^TM prevents progression and improves clinical course of MS. The conventional side effects of beta interferon therapy, however, are observed with CinnoVex^TM.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: American pediatric Association proposes to screen all neonates with Oto-Acoustic Emission (OAE). In developing countries, because of several limitations, health policy makers recommend to screen only in high risk patients. This study is performed with the aim to screen hearing loss in 950 high risk newborns hospitalized in hospitals affiliated to Tehran University using the OAE test.
Methods: A total of 950 neonates hospitalized in the Neonatal and NICU wards of Vali-e-Asr, Shariati, Medical Center and Bahrami Hospitals during the years 2004-2006 who showed at least one risk factor using TEOAE hearing test were enrolled into this cross-sectional descriptive analytical study and were diagnosed with mild deafness and total deafness. Blood exchange due to hyperbillirubinemia, septicemia, congenital heart disease, the fifth minute apgar scores below six, PROM more than six hours, epilepsia, need to NICU more than five hours, pneumonia and Oto-Toxic drugs were considered as risk factors. Data was past medical history, current disease, admission cause, sign & symptoms and complications of disease.
Results: Multivariate logistic regression and paired t-test showed that blood exchange, low birth weight and low first minute Apgar scores had the highest independent risk for hearing loss among newborn.
Conclusion: Despite of the low prevalence of neonatal hearing loss, screening of hearing loss at early stages is important.

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Background: Epidural catheters are seldom difficult to remove from patients. The breakage of the catheters is uncommon, troublesome and occasionally dangerous. Case presentation: A lumbar epidural catheter inserted in a 17 year-old man for applying anesthesia for internal fixation of femur fracture and subsequent postoperativeepidural analgesia. In the third postoperative day, during unsuccessful attempt for removing the catheter, it was broken and was retained in his back. A CT- scan was performed and shows a fragment of catheter in the sub- laminar ligament between L3 and L4 without any connection with epidural space. As the patient had no complaint the fractured fragment was left in site and he was just followed up in the clinic. Conclusion: The knowledge of practical method in locating the retained epidural catheter, and the indication for surgical removal are very important. CT- scan is useful in showing the mechanism and locating the epidural catheter entrapment and facilitating surgical follow-up.

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Background: Coarctation of aorta is narrowing of proximal descending aorta. Interventional procedures such as balloon angioplasty & stent implantation has been progressively in use as alternatives for surgery in increasing number of children with diagnosis of coarctation of aorta. The aim of this study was to evaluate the use of endovascular stent in children with coarctation of aorta.

Methods: We evaluated effectiveness and safety of stenting in all patients younger than 18 years old with coarctation and re-coarctation of aorta which treated by stenting between years 2004-9 at rajaei - heart centre in Tehran, Iran.

Results: we studied 53 patients younger than 18 years old with a follow up of six months. Totally 54 stents were implanted. Mean (±SD) age of the patients was 11.6±4.2yrs. Seventeen cases (32%) were younger than 10 years old, and 36 cases (68%) were 10 years and older. Mean (±SD) weight was 39.24±18kg. 16 cases weighting less than 25kg. Peak systolic pressure gradient (SPG) decreased from 46.26±17.07 to 1.03±0.19mmHg after procedure (p<0.001). There was no significant difference (p<0.001) in the gradient before and after stenting in the patients with native coarctation (Vs re-coarctation cases), less than 25 kg and under 10 years old groups. Complications developed in 44% of cases while dominantly were minor except in two cases re-dilatation of stent was not needed during six month of follow-up of the patients.

Conclusions: Stenting of coarctation of aorta can decrease complications and can be used safely in children weighing bellow 25kg and in children below 10yrs old.

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Background: CD14 is known as a receptor for bacterial LPS (Lipopolysaccharides) and is followed by inflammatory reactions. This receptor on macrophage surface has a major role for recognition and clearance was happen without inflammatory reaction. Prolonged exposure to microbial products decreases the risk of allergic reactions. This is related to high level of CD14 in blood cells. Although the causes of nasal polyposis is not obviously determined but allergy is a potential risk factor for nasal polyposis. CD14 is in 5q31 chromosomal position and CD14 variants have association with asthma. We try to assay association between CD14 polymorphism and nasal polyposis and severity of this disease.

Methods: We had 106 patients with nasal polyps with mean age 41 y old in case group and 87 with mean age 36.7 in control group. We obtained 3 ml whole blood from each patient and then extract DNA by PCR-RFLP method and determined variant genotypes of CD14. Although there is no previous study in this field, the results of this pilot study shown in more detailed below.

Results: There is significant relationship between C allele (CC + CT) in comparison with TT (p= 0.03, odds ratio= 1.87, CI 95% (0.99- 3.55)) and nasal polyposis. Further-more another significant relationship had been shown between asthmatic patients and C allele (CC) in comparison with (CT + TT). (p= 0.01, odds ratio= 3.8, CI (0.99- 13.9). In asthmatic patients with C allele of CD14 incidence of nasal polyposis increased.

Conclusion: Based on the results of this study, C allele of CD14 could play a role in nasal polyposis.

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Background: Efforts have been made worldwide to identify and to study parasites of laboratory animals, aiming at the achievement of proper procedures for eradication of parasitic infestations, considering the important role of these animals in scientific research. There is no sufficient data about parasitic infestations of Laboratory animals which are kept in conventional systems in Iran. In this scope, peresent study was designed to investigate the presence of ectoparasites and endoparasites in conventionally maintained laboratory rats (Rattus norvegicus) and in mices (Mus musculus).
Methods: A descriptive cross-sectional study was performed on 240 randomly selected rats and mice from two different animal houses in Kerman city, Iran. Skin scraping blood samples and alimentary tract contents of all animals were fully examined for the presence of parasitic infections.
Results: In the first animal house, Nosopsylla fasciatus (flea), Hymenolepis dimminuta, Entamoeba muris and Cryptosporidium spp. infestation were diagnosed respectively in 35.41%, 36.1%, 3.57%, and 1.25% of rat colonies but only Entamoeba muris infestation was detected in 4.58% of mice colonies. In the second animal house, 2.5% and 2% of rat and mice colonies were infected by Entamoeba muris.
Conclusion: Based to presence of asymptomatic parasitic infection in conventionally maintained laboratory animals, regular periodical samplings, precise sanitary monitoring of barrier maintained system, environment and food seem necessary in animal houses. Eradication of parasites could eliminate the confounding effects of these infections on researches and additionally decrease the risk of zoonotic disease transmission to investigators and animal house personnel's.

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Background: Based on the reports, high frequency of special alleles of HLA class II genes might be associated with susceptibility to or protective from a particular cancer. These alleles might vary depending on the geographical region. Here we investigate the association between alleles of HLA class II genes and breast cancer in Iranian women.
Methods: 100 patients with pathologically proved breast cancer who referred to Cancer Institute, Tehran University of Medical Sciences in Tehran, Iran, were divided to two groups based on ages (40 years old and less/ or more than 40 years old) and were randomly selected and compared with a group of 80 healthy blood donor subjects. HLA class II alleles were determined by amplification of DNA with polymerase chain reaction (PCR) method followed by HLA-typing using sequence-specific primer (SSP) for each allele.
Results: The most frequent alleles in the DR and DQ regions in group 1 (40 years old and less) in comparison with control group were HLA-DQA1*0301 (p=0.002) and HLA-DQB1*0302 (p>0.05). In contrast HLA-DQA1*0505 (p=0.004) had significantly lower frequency in this group compared with control group. Patients of group two (more than 40 years old) had a higher frequencies of HLA-DQA1*0301 (p=0.001) and HLA-DRB1*1303 (p=0.02) and a lower frequency of HLA-DQA1*0101 (p=0.002) compared to healthy control.
Conclusion: These findings provide information of a positive and negative association between certain alleles of HLA class II and breast cancer in our population and also might support that the pattern of inheritance in the early and late onset of breast cancer differ substantially.

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Background: Streptococcus pneumoniae is a common cause of respiratory infection. Pneumococcal upper respiratory tract infection (URTI) in children is seldom bacteremic. Determination the prevalence of S.pneumoniae infections in children with URTI using rapid urinary antigen test (BINAX now) and titration of serum pneumolysin antibody (added to conventional culture) was the object of this study.
Methods: A cross sectional, case-control study done in ENT & pediatric departments of Rasoul Hospital in Tehran, Iran, (2008 -2010) upon 133 cases with upper respiratory tract infection (otitis media, sinusitis and tracheitis). The nosocomial infection omitted in first step. 60 remaining cases followed for S.pneumoniae infection by culture and rapid urinary antigen test (Binax Now). Serum pneumolysin antibody titers compared between 45 cases and 66 controls.
Results: Positive culture (S.pneumoniae, H.influenza) obtained in 4/60 URTI cases. Positive urinary S.pneumoniae antigen detected in 50% (30/60) of cases and 6% (4/66) of controls (p=0.01). The pneumolysin antibody level with cut-off level 525pg/ml was higher in URTI cases than controls (982±441 Vs. 525±42, p<0.0001). Area under the ROC curve for pneumolysin antibody was 0.923 (95%CI 0.86-0.97, p<0.0001) and had 87% sensitivity and 82% specificity for differentiation between cases and controls.
Conclusions: The high pneumolysin antibody level in cases with URTI strongly indicates the pneumococcal infection. Pneumolysin antibody level even in little amounts (525pg/ml) with 87% sensitivity and 82% specificity is a suitable test for diagnosis of pneumococcal infection in children with URTI, but this test should be added to conventional culture (gold standard) and rapid urinary antigen test.

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Background: Acute Necrotizing Mediastinitis (ANM) is a lethal disease that without antibiotic therapy and surgical Intervention has a mortality rate about 40% in best medical centers. With development of imaging technology (spiral CT- Scan) and shortening in time of diagnosis and surgery, the outcome and prognosis of the patients are improved. The surgical modalities are trans- cervical and trans- thoracic approaches.
Case series: We present a series of four patients with acute necrotizing mediastinitis that admitted to thoracic surgery ward in vali-e-asr Hospital in Tehran, Iran, during years 2009 and 2010. A 31years old woman and three male patients with ages 21, 25 and 63 years. Odontogenic infection was the cause in two cases while pharyngeal perforation and cervical esophageal perforation were the causes of acute necrotizing mediastinitis the others.
Results: Mean±SD of hospitalization time was 24±6 days. Infection of cervical space (periviceral spaces) and the superior mediastinum were found in all patients while extension of infection below the carina was found in two of them. All patients were operated by trans- cervical approach. One patient was operated by trans- thoracic approach. All patients were discharged with good general condition.
Conclusion: Early usage of spiral CT- scan for diagnosis of acute necrotizing mediastinitis and early drainage with trans- cervical approach could be life saving in acute necrotizing mediastinitis patients with good results.

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Background: Common Variable Immunodeficiency (CVID) is a primary immunodeficiency disease, characterized by hypogammaglobulinemia and heterogeneous clinical manifestations. This study was performed to evaluate the clinical and immunological features of pediatric patients with CVID.
Methods: We reviewed the records of 69 children diagnosed under age of 16 years with CVID (35 males and 34 females).
Results: By the year 2008, 15 patients (21%) had died. The total follow-up period was 333 patient-years. The mean diagnostic time between onset and diagnosis in our patient group was 4.40 years. The overall rate of consanguineous marriages was 58%. 10 patients had a positive family history of immunodeficiency. At the time of diagnosis, the mean levels of serum immunoglobulin G (IgG), IgM, and IgA levels were 286.86, 39.92, and 18.39 mg/dl, respectively which were below the normal levels for age. All of the patients presented with infectious diseases at the time of onset, the most common of which were pneumonia, diarrhea and sinusitis. Acute and recurrent infections were also found in almost all of the patients, particularly involving respiratory and gastrointestinal systems. The most common infections during follow-up period were pneumonia (31.9%), acute diarrhea (18.8%), acute sinusitis (18.8%), and otitis media (14.5%). Post-diagnosis survival was estimated to be 79% during the first five years. The survival rate was not shown to be influenced by delayed diagnosis, serum levels of IgG and B-lymphocyte count at the time of diagnosis.
Conclusions: Any child with a history of recurrent infections, decreased levels of serum immunoglobulin isotypes and consanguineous parents should be considered as a CVID patient.

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Background: Alopecia areata, a non-cicatricial form of hair loss, is believed to be an immunologic response that targets hair follicles. Genetic background is important in the pathogenesis of this disorder, although some evidence point to the role of melanocytic antigens. There are some reports on the relationship between alopecia areata and celiac disease. The aim of the present study was to identify antigliadin antibodies in patients with alopecia areata.
Methods: Fifty patients, aged 2.5-50 years, with alopecia areata presenting to the dermatology clinic of Razi Educational Hospital in Tehran, Iran, and fifty healthy individuals, aged 5-48 were matched and enrolled in the study. After signing an informed consent form, blood samples (10 ml clotted blood) were obtained from the participants and sent to referral laboratory for the presence of antigliadin IgA and IgG antibodies. Concentrations of antibodies were measured by ELISA through a full automatic ELISA reader.The data were analyzed statistically.
Results: The study included 29(58%) male and 21(42%) female patients with a mean age of 24.6 years. The control group included 29(58%) male and 21(42%) female individuals with a mean age of 24 years. In the case group, 9(18%) patients were positive for antigliadin antibody, while only one (2%) individual was positive for the antibody in the control group (p<0.001). No other differences were of statistical significance.
Conclusions: Regarding the higher prevalence of antigliadin antibodies in patients with alopecia areata, it would be wise to screen the patients for celiac disease.

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Background: Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is a specific dermatosis of the third trimester of pregnancy, commonly seen in primigravid women.
Case presentation: A 24-year-old primigravida woman who had developed a rash immediately after delivery was admitted to Razi Hospital in Tehran, Iran. She had an erythematous eruption, particularly concentrated on the abdominal striae with umbilical sparing and involvement of limbs and extremities. Skin biopsy of the lesions on the lower abdomen, showed superficial perivascular infiltrates with occasional neutrophils and eosinophils. Both direct and indirect immunofloresence assays were negative. The patient was ultimately treated with topical clobetasol butyrate and oral chlorpheniramine for pruritus. Within a week, the lesions and the itchings had disappeared completely.
Conclusion: Pruritic urticarial papules and plaques of pregnancy are often, but not always, seen during the third trimester of pregnancy, but sometimes they present in postpartum period without any prior manifestations during pregnancy.

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Background: An increased risk for invasive infections with encapsulated bacteria such as Streptococcus pneumoniae has been described in patients with chronic kidney disease (CKD) or in those on dialysis. The aim of this study was to evaluate the antibody response to pneumococcal capsular polysaccharide vaccine in CKD patients. Methods: Sixty-six patients with CKD and 40 healthy individuals were vaccinated with pneumococcal polysaccharide vaccine. The serum antibody response (IgG and IgG2) to the Pneumovax antigens was determined by enzyme-linked immunosorbent assay (ELISA) prior to and four weeks after vaccination. Results: Out of 66 vaccinated patients with CKD, 14 were found to be hyporesponsive to the vaccine (Group 1). Patients with normal specific antibody response were regarded as respondents and were assigned to Group 2 (n=52). The mean post-vaccination IgG titer to the pneumococcal antigens in Group 1 was significantly lower than those in Group 2 (P=0.012 for IgG and P=0.02 for IgG2). The increased anti-pneumococcal IgG titer was significantly lower in patients in Group 1 versus Group 2 (P=0.001) or the healthy control group (P=0.005). During the follow-up period of patients, patients in Group 1 developed higher episodes of pneumococcal infections than those in Group 2 (P=0.007). Conclusion: A substantial proportion of patients with chronic kidney disease fail to mount an adequate antibody response to pneumococcal antigens and remain at significant risk for such infections. These patients should be offered other prophylactic measures to protect them against invasive pneumococcal diseases.