Background and Aims:Nonspecific clinical presentations, absence of timely available paraclinical indicators of infection, and increasing concerns for antimicrobial resistance complicate decision-making in initiation of antibiotic therapy in patients with diabetic ketoacidosis (DKA). The authors have aimed to explore the role of white blood cell (WBC) counts as an indicator of infectious disease in patients with DKA. Methods:A retrospective observational study was conducted using data from patients hospitalized with DKA in a tertiary care center in Iran. Patient data was retrieved from the hospital information system (HIS). Associations between leukocytosis and leukopenia along with several paraclinical tests (including ESR and CRP levels) and a final diagnosis of infectious disease were examined. Results:Data from 129 patients were analyzed. Patients diagnosed with infection were significantly older (p < 0.001) and spent more time in-hospital (p = 0.008). Mean WBC counts, ESR and CRP were elevated in patients with and without infectious disease. There was a significant association between leukocytosis and infection (p < 0.001). ESR (p = 0.01) and CRP (p = 0.002) were also significantly higher in patients with an infection. Leukocytosis had a sensitivity of 82.3%, and a specificity of 49.2% (AUC = 0.665, 95% CI 0.571-0.759) for infection detection. Excluding cases with leukopenia, leukocytosis had a negative predictive value of 81.8%-91.4% for predicting infectious disease. Conclusions:We discourage the use of leukocytosis, per se, as a marker of infection in the setting of DKA. We found the absence of leukocytosis or leukopenia of high predictive value in exclusion of the possibility of infectious disease in DKA cases.

Since late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) pandemic has dramatically affected public health worldwide. Although systemic antibodies like Immunoglobulin G (IgG) and Immunoglobulin M (IgM)have been widely studied in Coronavirus disease 2019 (COVID-19), the role of Immunoglobulin A (IgA) in mucosal immunity remains less understood. This study evaluated whether salivary IgA levels could serve as prognostic markers for disease severity, progression, and outcomes in hospitalized patients with COVID-19. In this cross-sectional study, 61 hospitalized patients with COVID-19 were enrolled. After obtaining informed consent, saliva samples were collected at admission to measure IgA levels using an ELISA-based assay. Comprehensive clinical and laboratory data, including chest CT results, oxygen saturation, inflammatory markers, and clinical outcomes, were also recorded. Statistical tests were used to examine the association between salivary IgA levels and disease severity, progression, and outcomes. We enrolled 61 hospitalized patients with COVID-19 (30 females, 31 males; mean age: 56.20 ± 17.45 years; mean admission oxygen saturation: 89.98 ± 5.77%). At admission, 39.3% of patients reported dyspnea, and 40% demonstrated severe lung involvement on chest CT scans. The mean salivary IgA level was 1729.69 ± 391.35 mg/dL. No significant associations were found between salivary IgA levels and COVID-19 severity, disease progression, or clinical outcomes, including mortality. Our findings show that salivary IgA levels did not significantly correlate with COVID-19 severity, disease progression, or clinical outcomes in hospitalized patients. Therefore, salivary IgA alone cannot be recommended as a prognostic biomarker for COVID-19. Further research is needed to identify more reliable immunological indicators for predicting COVID-19 severity and outcomes.

Background & Objective:Septic arthritis is an emergent condition caused by an infection of the joint synovial fluid. If left untreated, it can lead to irreversible damage to the affected joint. Our study focused on providing a concise profile of the Iranian population and the diagnostic roles of synovial pan-PCR and culture. Methods:In an observational study, we evaluated the characteristics of all patients diagnosed with septic arthritis and admitted to a teaching center hospital complex. We extracted and analyzed the study of population's demographics and laboratory values. Results:This study included 50 patients diagnosed with septic arthritis. 56% of our study population were male, and the mean age was 50.48. There were significant associations between synovial WBC counts and positive synovial culture results. Further comparison of the two diagnostic methods revealed higher pan-PCR accuracy than synovial culture. Conclusion:Pan-PCR may have higher diagnostic accuracy than synovial culture in hospitalized patients with septic arthritis.

Para-Kala-Azar Dermal Leishmaniasis (para-KDL) is a rare manifestation of leishmaniasis that occurs concurrently with active Visceral Leishmaniasis (VL). It is characterized by a combination of cutaneous and systemic symptoms, posing diagnostic and therapeutic challenges. This condition is even more complex in immunocompromised patients, such as those with HIV. We report a case of a 52-year-old male from south of Iran, who presented with prolonged fever, severe weight loss, pancytopenia, and massive splenomegaly. The patient was diagnosed with HIV and had been receiving antiretroviral therapy (ART). He underwent a splenectomy 1 month later and developed progressive generalized lymphadenopathy and hepatomegaly 5 months after that. Histopathological analysis of lymph node biopsies confirmed leishmaniosis, and the patient was started on Meglumine antimoniate. Shortly after, he developed widespread maculopapular skin lesions. Subsequent diagnostic evaluations, including skin biopsy, confirmed the presence of Leishman bodies. The patient was successfully treated with liposomal amphotericin B, leading to significant clinical improvement. The co-existence of active VL and PKDL can make diagnosis difficult, potentially leading to misdiagnosis and treatment, particularly in immunocompromised patients. The simultaneous occurrence of VL and PKDL-like skin lesions requires heightened clinical suspicion, especially in endemic regions. Delayed or misdiagnosed cases may lead to significant morbidity. Further research is needed to understand the pathophysiology, immune response, and optimal treatment strategies for para-KDL in HIV-infected individuals.

Concerns of increased metabolic dysfunction have been heightened for HIV patients on long-term antiretroviral therapy (ART). Among first-line ART agents, Tenofovir alafenamide (TAF) may entail a marked increase in weight compared to Tenofovir disoproxil fumarate (TDF). We retrospectively evaluated changes in weight and glucose regulation among 153 treament-naïve patients. Weight-gain was more pronounced after one year of treatment with TAF versus TDF (3.5 kg versus − 1 kg, P-value < 0.001). However, weight-gain was attenuated with longer follow-up, and no increase in glucose dysregulation was noted for TAF treatment. Attribution of increased metabolic risk to treatment with TAF remains questionable.

Chronic blood culture-negative endocarditis (BCNE) presents a significant challenge for early diagnosis and treatment, leading to increased morbidity and mortality. This report presents a 30-year-old man with a history of BCNE who presented with an intermittent fever lasting 3 months. His medical history was complex and characterized by tetralogy of Fallot (TOF), multiple cardiac surgeries, and previous positive pathological results for infection and endocarditis. A PET/CT scan revealed hypermetabolic lesions near the prosthetic valves and aortic grafts, prompting further investigation for potential causative organisms. Subsequent serological testing and PCR confirmed the presence of Coxiella burnetii, leading to a diagnosis of Q fever endocarditis. Treatment with doxycycline and hydroxychloroquine initiated significant improvement. Follow-up after 3 months showed that the patient remained stable with significant improvements in serological tests and imaging. This case underscores the necessity of considering atypical pathogens like C. burnetii in patients with BCNE and chronic endocarditis, particularly those with complicated cardiac histories.

Background & Objective:Community-acquired Staphylococcus aureus bacteremia (CA-SAB) is associated with substantial morbidity, mortality, and healthcare costs. This study aimed to identify clinical and laboratory factors associated with in-hospital mortality among patients with CA-SAB. Methods:This retrospective cross-sectional study was conducted at a tertiary referral hospital in Tehran, Iran. Adult patients with positive blood cultures for S. aureus who met CA-SAB criteria were included. Demographic, clinical, and laboratory data were collected from medical records. The primary outcome was in-hospital mortality. Univariate and multivariate logistic regression analyses were performed to assess associations with mortality. Results:A total of 114 patients with CA-SAB were included. No significant association was observed between underlying comorbidities and mortality. Although methicillin-resistant S. aureus (MRSA) infection was associated with a higher mortality rate, this difference was not statistically significant (P = .32). Multivariate analysis revealed that older age (odds ratio [OR], 1.053; 95% CI, 1.012-1.095; P = .01), elevated C-reactive protein (CRP) levels (OR, 1.016; 95% CI, 1.005-1.028; P < .01), and lower serum albumin levels (OR, 0.249; 95% CI, 0.097-0.642; P < .01) were independently associated with in-hospital mortality. Conclusion:Although age was not significant in univariate analysis, it emerged as a significant predictor after adjustment for other variables. Routine laboratory parameters such as CRP and albumin may serve as valuable prognostic indicators. Early identification of high-risk patients using these markers could inform timely interventions and improve outcomes in CA-SAB.

The human immunodeficiency virus (HIV) increases susceptibility to measles, mumps, and rubella (MMR) infections due to decreased cluster of differentiation 4 + T-cell levels and rapid waning of protective antibodies following vaccination, which imposes a significant impact on HIV-positive women of reproductive age, for whom MMR vaccination is a crucial preventive measure. This study aimed to shed light on the immunity status of women of childbearing age with HIV infection post-MMR-vaccination during their childhood and the necessity of further vaccination in these individuals. To evaluate seroconversion rates following vaccination through Iran’s NIP or previous infection by assessing MMR IgG levels, all Iranian women aged 18–45 years referred to our voluntary counseling center, with or without HIV infection and CD4 levels 200 cells/mm3 or higher at the time of enrollment, were invited to participate. Data were collected through the Hospital Information System and questionnaires, and blood samples were taken to evaluate the seroconversion following MMR vaccination via NIP or previous MMR infection. In this study, 150 women participated, with a mean age (± SD) of 36.49 (± 6.80). Mean rubella and measles IgG levels of HIV-positive participants (95.08 ± 79.42 IU/Ml) were higher than HIV-negative peers (8.98 ± 3.83 mg/dL) with no significant associations (p-value > 0.05). However, mumps IgG levels were significantly lower compared to HIV-negative participants (9.87 ± 28.70 mg/dL, p-value < 0.001). Additionally, HIV-positive participants significantly exhibited lower total immunity (n = 73, 97.3) compared to HIV-negative participants (n = 64, 85.3) (p-value = 0.07). HIV-positive individuals who did not have seroimmunity against mumps infection had significantly lower CD4 NADIR counts (cells/mm3) (mean ± SD = 259.00 ± 203.31, p-value: 0.025). Moreover, regression analyses demonstrated significant associations between decreased mumps IgG levels and lower CD4 NADIR counts (AOR = 1.004, 95

Background and Objectives: To explore the prevalence and characteristics of secondary bacterial infections among patients suffering from mucormycosis following COVID-19 infection. Materials and Methods: We conducted a cross-sectional, retrospective analysis from March 2020 to April 2022 at Imam Khomeini Hospital Complex in Tehran. The study included patients with histopathologically confirmed mucormycosis and documented secondary bacterial infections. We extracted and analyzed data from hospital records using SPSS software, version 26. Results: The study comprised 27 patients, with a predominance of females (70.4%) and an average age of 56 years. The majority of these patients (63%) had pre-existing diabetes mellitus. The severity of their COVID-19 infections varied. Treat- ment regimens included immunosuppressive drugs and antibiotics. Rhinocerebral mucormycosis was the most common form observed. The predominant secondary infections involved the urinary tract, respiratory system, bloodstream (bacteremia), and soft tissues, with resistant strains of Acinetobacter baumannii, Escherichia coli, and Klebsiella pneumoniae being the most frequently identified microorganisms. Notably, cases of bacteremia and pneumonia exhibited a higher mortality rate. Ultimately, 55.6% of patients were discharged, while 44.4% succumbed to their infections. Conclusion: Patients recovering from COVID-19 with mucormycosis are significantly susceptible to secondary bacterial infections, particularly those with diabetes mellitus or those undergoing immunosuppressive therapy. Such infections com- pound the morbidity and mortality risks in this vulnerable patient cohort.

Introduction: Castleman's disease (CD) is characterized by non-neoplastic lymph node hyperplasia, and may be localized in a single lymph node (unicentric) or occurs systemically (multicentric). Nowa days, multicentric CD is most commonly observed in individuals infected with human immunodeficiency virus (HIV) type 1, in association with Kaposi's sarcoma. Histopathologic and immunohistochemical evaluation of excised lymph node as well as imaging modalities, such as computed tomography (CT) and magnetic resonance imaging, are required for the diagnosis of CD. Case description: We present a case of 46-year-old HIV-infected woman with fever, weakness, weight loss, and splenomegaly in the past 18 months. On physical examination, pale conjunctiva, jaundice, multiple cervical, inguinal, and axillary lymphadenopathies as well as hepatosplenomegaly were detected. Chest CT scan showed alveolar opacity in the lower lobe of the right lung and multiple lymph nodes in the mediastinum and bilateral perivascular, cervical, and axillary areas. Abdominopelvic CT scan showed huge splenomegaly, hepatomegaly, and multiple bilateral para-aortic, celiac, and inguinal lymphadenopathies, which were further confirmed as CD in pathological examination. Conclusions: Huge splenomegaly is a rare manifestation in CD. Among the more prevalent differential diagnoses, CD in patients with HIV and huge splenomegaly was emphasized as important differential diagnosis.

Introduction: Disseminated nocardiosis is a rare but life-threatening infectious disease that occurs most often in immunocompromised individuals. This report presents a human immunodeficiency virus (HIV)-infected patient with disseminated nocardiosis in the liver, lung, and brain. Case Presentation: A 38-year-old woman who had recently been diagnosed with HIV infection complained of fever, abdominal pain, productive coughs, and occasional headaches from 2 months ago. Imaging findings of her abdomen and lungs displayed evidence of pyogenic liver abscess and lobar pneumonia with abscess formation, respectively. The patient underwent percutaneous liver abscess drainage and bronchoalveolar lavage (BAL). Using reverse transcription-polymerase chain reaction (RT-PCR), the genome of Nocardia farcinica was detected in the specimens obtained from both procedures. Besides, she had seizures during hospitalization. Based on cerebrospinal fluid (CSF) analysis, the specimen was positive for N. farcinica. Brain imaging also revealed evidence of multiple bacterial abscess formation. She was diagnosed with disseminated nocardiosis and treated with intravenous imipenem, trimethoprim/sulfamethoxazole, and amikacin, followed by appropriate oral agents. After a 6-month follow-up, the patient had no symptoms. Additionally, the lesions improved on brain imaging. Conclusions: Patients who are HIV-positive are particularly prone to opportunistic infections. Health care providers should consider all pathogens, even rare ones, like Nocardia spp., to establish a diagnosis if they're present. Furthermore, in cases initially diagnosed with localized nocardiosis, other body organs should also be reviewed so that the disseminated form of the disease can be diagnosed and treated immediately.

Abstract Hyperglycemia or diabetes mellitus during COVID-19 has always been a great concern and heralds severe forms of the disease, we also don’t know whether this condition will continue as diabetes mellitus even after convalescence. For this purpose we conducted a study to investigate this condition and factors related to it in hospitalized patients and even three months post-discharge we followed them up. We gathered data from 202 patients that fulfilled our inclusion criteria, among them 100 patients were hyperglycemic. Patients in hyperglycemic status experienced significantly longer duration of hospitalization than normoglycemic patients and significantly showed more severe forms of the disease. During their follow up three months post-discharge for the investigation of glycemic status, 46 out of 97 patients were diagnosed with diabetes mellitus and have been taking anti-diabetic drugs while 29 patients only had normal glycemic status.

Background Oral candidiasis is a common opportunistic infection in patients with human immunodeficiency virus (HIV). In addition, most of these patients suffer from vitamin D deficiency. This study aimed to investigate the association between vitamin D levels and oral candidiasis in patients with HIV infection. Methods This case‒control study was conducted on HIV-infected patients. Cases were patients with oral candidiasis diagnosed based on physical examinations. Controls were age- and sex-matched individuals without oral candidiasis. The levels of 25-OH vitamin D and other laboratory markers (CD4 count and viral load) were compared between the case and control groups. Results A total of 104 cases and 102 controls were included in the study. The cases had significantly lower 25-OH vitamin D 3 levels (MD = 33.86 ng/mL, 95% CI= (31.85, 35.87), P < 0.001) and CD4 counts (MD = 267.48 cells/mm 3 , 95% CI= (189.55, 345.41), P < 0.001) than the controls. In addition, viral load was significantly higher in cases than in controls (MD = 7.03 × 10 5 copies/mL, 95% CI= (4.46 × 10 5 , 9.61 × 10 5 ), P < 0.001). The multivariate logistic regression analysis revealed that educational status (OR = 0.032, 95% CI= (0.002, 0.100), P < 0.001), current HAART (OR = 0.005, 95% CI= (0.001, 0.014), P < 0.001), history of oral candidiasis (OR = 20.114, 95% CI= (18.135, 21.957), P < 0.001), CD4 count (OR = 0.004, 95% CI= (0.001, 0.006), P < 0.001), viral load (OR = 12.181, 95% CI= (1.108, 133.392), P < 0.001), and vitamin D level (OR = 0.011, 95% CI= (0.008, 0.015), P < 0.001) were significantly associated with the risk of developing oral candidiasis. Conclusions Based on the findings, most patients with HIV infection suffer from vitamin D deficiency, especially those with oral candidiasis. Hypovitaminosis D was significantly associated with an increased risk of oral candidiasis. Thus, vitamin D supplementation may assist HIV-positive patients in improving their oral health and preventing oral candidiasis.

BACKGROUND:Immunodeficient patients, particularly HIV patients, are at risk of opportunistic infections. Nontuberculous mycobacteria can cause severe complications in immunodeficient patients.CASE PRESENTATION:We describe a 57-year-old HIV patient, primarily presented with coughs and constitutional symptoms, with a unique Mycobacterium genavense abdominal, pulmonary, and central nervous system infection, accompanied by intracranial masses.CONCLUSION:The diagnosis of NTM, including M. genavense, must always be considered by clinicians in immunodeficient patients, especially those with HIV, who have a compromised immune system.

Background: More than 87% of patients with COVID-19 have at least one resistant symptom after recovery, and bullous disease may be as a one of these resistant conditions. Methods: This bicentric cross-sectional study examined hospitalised patients with confirmed COVID-19 and pulmonary bullous disease from July 2021 to February 2022 in two hospitals. A radiologist reviewed all patients' chest CT scans for the presence of bullae or cysts. Results: In this study, 34 COVID-19 patients with lung bullae were identified. The majority of bullae were small or medium-sized and located in the left or right lung, with 20.6% being bilateral. Most patients had a single bulla. The mortality rate was 29.4%, with an average survival time of 13 days for deceased patients. Increased age, smoking, respiratory comorbidities, intubation, and bilateral bullae were associated with lower survival time. However, no significant association was found between survival time and sex, size, or number of bullae. Findings provide important insights into the clinical implications of COVID-19 and lung bullae. Conclusions: Recognizing the coexistence of COVID-19 and pulmonary bullous disease is crucial as bilateral bullae were associated with lower survival time. Further research is needed to determine the relationship between COVID-19 and lung bullae.

Background Diabetic Ketoacidosis, a fatal complication of diabetes, presents in patients with type 1 and type 2 diabetes mellitus. Psychological stress or any acute medical condition, such as infections and surgeries, can trigger and alleviate diabetic ketoacidosis. Like infections, diabetic ketoacidosis can result in leukocytosis, making it harder to distinguish between the two conditions, resulting in the overuse of antimicrobial agents to blindly treat infections, and increasing the rate of antimicrobial resistance, a global threat to humanity. Methods A retrospective cross-sectional study was conducted on the correlation between infection and leukocytosis in patients referring to Imam Khomeini Hospital Complex, Tehran, Iran, from September 2018 to September 2022. Comorbidities, clinical findings at admission, acidosis severity, hospitalization duration, laboratory data, and radiologic findings were retrieved using the Hospital Information System and then compared and analyzed. Results Of the 129 evaluated patients, 84 showed leukocytosis, while 45 did not. The mean age of participants was 38.17 ± 21.30 years. The total population included 52 males and 77 females; 92 were diagnosed with type 1 diabetes, and 37 had type 2 diabetes, with a mean duration of diabetes of 8.07 ± 6.99. We evaluated the correlation between leukocytosis due to infection in patients with diabetic ketoacidosis and their age, sex, diabetes type, and duration, PH levels, hospitalization duration, erythrocyte sedimentation rate and C-reactive protein levels, chest X-ray findings, blood and urine culture results, patients' prognosis, and presence of an infectious process in general. We found no correlation between leukocytosis and sex, diabetes type, PH levels, and blood cultures. However, there were significant correlations between leukocytosis and infection presence, urine cultures, radiologic findings, patients' age, diabetes and hospitalization duration, and ESR and CRP levels. We also found a white blood cell count threshold of 14.96 as a sign of infection in patients with DKA. Conclusion Our findings suggested that a total WBC count of, 14000/mm 3 or higher can indicate the presence of infection in patients with DKA, which could indicate the start of antibiotic therapy in such patients. Trial registration Not applicable. This study is not a clinical trial.

Gastrointestinal Basidiobolomycosis is a rare manifestation of Basidiobolus ranarum infection. In this report, we present two cases of gastrointestinal Basidiobolomycosis. The first patient presented with obstructive symptoms, fever, and weight loss. The diagnosis of Basidiobolomycosis was not made until after surgery, when Liposomal amphotericin-B combined with itraconazole were administered, leading to the resolution of laboratory markers of inflammation and patient's symptoms. The second case involves a young woman who presented with hem-atochezia, perianal induration, and abdominal pain. The patient had previously been diagnosed with Crohn's disease and treated accordingly, but her symptoms did not improve. Due to the endemicity of tuberculosis in Iran, the patient was treated for TB but still showed no improvement. However, a perianal biopsy sample revealed the Splendore Hoeppli phenomenon and fungal elements in GMS staining, leading to the diagnosis of gastrointestinal Basidiobolomycosis. Treatment with itraconazole and co-trimoxazole led to a significant improvement in symptoms and laboratory indices after one week, including the resolution of perianal induration. The key takeaway from this report is the importance of considering rare infections in the differential diagnosis of gastrointestinal conditions such as IBD and GI obstruction.

In this case report, we are presenting a man with intermittent fever for three months with a history of aortic and pulmonary valve replacement and also recurrent blood culture-negative endocarditis. After several evaluations based on endemic epidemiology, the Real-time PCR and IFA (indirect immunofluorescence assay) were positive for Q fever.

Drug-induced Stevens-Johnson syndrome (SJS) is a rare but life-threatening hypersensitivity reaction. Drug desensitization might be considered in drug-allergic patients with no therapeutic alternative. A 29-year-old man with a recent diagnosis of HIV and HBV (CD4 count: 4 cells/mm3) who has been receiving Trimethoprim/sulfamethoxazole (TMP/SMX) for Pneumocystis pneumonia (PCP) prophylaxis was admitted at Imam Khomeini hospital complex affiliated to Tehran University of Medical Sciences, with the diagnosis of SJS due to TMP/SMX. After 45 days of supportive care, the patient was a candidate for TMP/SMX desensitization due to our region's unavailability of alternative agents. A 9-day desensitization protocol was used, but the patient complained about diarrhea with severe pain in the rectal mucosa, and macules developed over his lips again on the third day. As a result, the desensitization process immediately stopped, and after the signs and symptoms were resolved, the patient was discharged with Clindamycin tablet 600 mg TDS. Unfortunately, two weeks after discharge, the patient experienced acute kidney injury (AKI) and expired after two dialysis sessions.