Hospital Practices and Research

Abstract Introduction: Iatrogenic aortocoronary dissection (ACD) is a nightmare in interventional cardiology. Although ACD is rarely reported, the real-world prevalence is suspected of being higher due to unreported cases. The right coronary artery (RCA) ostium is involved in the majority of cases, and dissections are usually limited to the aortic sinus in half of the clinical presentations. There are different treatment strategies, including interventional approaches, surgery, and medical follow-up. Immediate stent deployment to the coronary osteum might be a life-saving procedure, and the surgical approach should be preferred in occasions of dissection extension beyond the sino-tubular junctions. Catheter trauma and subintimal progression of guidewires are major causes of ACD occurrence.
Case Presentation: Herein presented is a case report of spontaneous ACD observed after contrast injection to the RCA ostium. Approximately 8 cc of radiocontrast agent was injected into the right coronary ostium. Antegrade and retrograde dissections which extended to the distal RCA and aortic root were observed. The right sinus of Valsalva was stained with contrast agent, and the border of the stained area was extended to the sinotubular junction. Medical follow-up was proposed by the heart team. Close follow-up with echocardiographic examination indicated the complete regression of the dissection.
Conclusion: The authors consider conservative follow-up with echocardiogaphy rather than computed tomography and/or magnetic resonance to be the most appropriate imaging technique for use with stable patients.

Abstract Introduction: Attention deficit and hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children and adolescents. Atomoxetine is a non-stimulant drug used in the treatment of ADHD.
Case Presentation: In this article, a case of obsessive-compulsive disorder (OCD) which occurred in an 11-year-old boy with an increased dose of atomoxetine during ADHD treatment and disappeared with dose reduction is reported. This case is only the second OCD case resulting from the use of atomoxetine.
Conclusion: The case reported herein is the second case caused by the use of atomoxetine and the first in which OCD symptoms regressed when the atomoxetine dose was reduced. OCD development due to atomoxetine consumption may occur at different doses. When OCD develops, the solution may be dose reduction, or it may be necessary to discontinue treatment with atomoxetine.

Abstract  
Introduction: Hypothyroidism is a common disorder of the endocrine system in which the production of thyroid hormones is inadequate. In addition to various physical manifestations, patients who suffer from hypothyroidism may also present with psychological problems, as described in previous studies.
Case Presentation: Herein, the reports of 2 patients who suffered from hypothyroidism and experienced improvement in their psychological symptoms after levothyroxine therapy are presented. The patients referred with depressive mood with psychotic features and psychomotor retardation. Treatment simultaneously with psychopharmacotherapy and hormone therapy was considered.
Conclusion: Although hypothyroidism and depressive disorders are separate issues, hypothyroidism can induce depression and psychosis, and psychopharmacotherapy plus hormone therapy can be effective and boost treatment.

Abstract Introduction: Because of bilateral involvement in many cases with diabetic macular edema, Intravitreal bevacizumab injection perform in both eyes. There are some reports of therapeutic effects in the fellow eye after monocular injection of anti-vascular endothelial growth factors. In this study we describe a case of bilateral improvement of diabetic macular edema following unilateral intravitreal bevacizumab injection.
Case Presentation: We report a patient with bilateral non-proliferative diabetic retinopathy and diabetic macular edema. Central macular thickness was 398µ in the right eye and 337µ in the left eye. Two months after intravitreal injection of 1.25mg bevacizumab in the right eye, significant improvement of diabetic macular edema was happened in both eyes including the left eye without intravitral injection. Central macular thickness was 245µ in the right eye and 250µ in the left eye.
Conclusion: Unilateral injection of intravitreal bevacizumab may have therapeutic effects in the fellow untreated eye. Therefore; unilateral injection in bilateral cases may reduce the costs and complications of bilateral injection.

Abstract Introduction: Essure^® device malposition is a rare, but clinically significant complication, for which management is idiosyncratic. This case report describes an unusual example of Essure^® migration in order to clarify reasonable management options.
Case Presentation: A 50-year old G₄P₂₀₂₂ underwent hysteroscopic sterilization using the Essure^® device. Insertion was complicated by fragmentation of both coils. Two years later, one of the coils was incidentally discovered protruding through the cervical os. The visible portion was clipped when attempts to remove the entire coil were unsuccessful.
Conclusion: Difficult placement increases the risk of Essure^® malposition. In asymptomatic patients, conservative management with removal of only a portion of the device is a rational approach.

Abstract Introduction: Misdiagnosis and the resulting mismanagement are challenging issues in complicated cases which present with obscure complaints. Interpreting radiologic studies, especially conventional plain radiologic images, remains the most frequently prescribed and useful modality for the first step of assessment.
Case Presentation: In this report, we present a case of mismanagement of a strange foreign body in the maxillary sinus of a child not found in a facial x-ray.
Conclusion: Inexperienced non-radiologist physicians may make misdiagnoses when reading conventional x-rays.

Abstract Introduction: It is well known that the tendency toward thrombosis is increased in cancer patients. The increase in cancer procoagulant and tissue factor levels, endothelial damage, and stasis due to compression are among the most accused causes of thrombosis in cancer patients. Hypereosinophilia is a rare condition that causes endothelial damage leading to thrombosis.
Case Presentation: We present a 64-year-old male patient with cardiac involvement of hypereosinophilia which developed in the T-cell lymphoma ground resulting in a fatal cardioembolic stroke. Despite normal left ventricular (LV) contractions, almost half of the ventricular volume was full of thrombus in this case.
Conclusion: Hypereosinophilia is a rare cause of thrombus formation in the left ventricle in patients with preserved ejection fraction. However, hypereosinophilic cardiac involvement can lead to rapid, progressive, life-threatening complications.

Abstract Introduction: Suicide is a major challenge to public health worldwide, and self-inflicted burn is one of the most violent suicide methods.
Case Presentation: In this case, a self-inflicted hot oil burn in a male with schizotypal personality and major depressive disorder is reported.
Conclusion: Psychiatric disorders, marital problems, and economic poverty are mentioned as risk factors for self-inflicted burn. Thus, these risk factors should be considered in the management of self-inflicted burn patients.

Abstract Introduction: Steroid cell tumors (SCTs) constitute less than 0.1% of all ovarian tumors. They are divided into 3 categories according to cell of origin: Stromal Luteoma arising from stromal cells of the ovary, Leydig cell tumor arising from Leydig cells, and SCT not otherwise specified (NOS) when the origin of the tumor is not defined.
Case Presentation: Herein is presented a case of SCT diagnosed one month after a caesarian section delivery of a female fetus with ambiguous genitalia. The patient was admitted to the emergency department with the findings of acute abdomen, and surgery was performed under emergency conditions. The patient had virilization and hoarsening of the voice before surgery. Intraoperatively, a 21-cm ovarian mass was detected and resected with unilateral salpingo-oophorectomy.
Conclusion: A histopathological examination of the tumor showed a tumor with cystic degeneration, necrosis, hemorrhage, and tumoral embolism. The pathological examination revealed ovarian SCT. Virilization was resolved immediately after the surgery. In women with virilization who give birth to a fetus with ambiguous genitalia, SCTs should be kept in mind.

Abstract Introduction: Burkitt lymphoma is an aggressive subtype of Hodgkin lymphoma with a doubling time of 25 hours. It is characterized by a MYC gene coding alteration which results from a translocation of chromosome 8 on the MYC gene locus and immunoglobulin heavy-chain locus (IGH) on chromosome 14. Even though HIV infection is associated to an increased risk of Burkitt lymphoma, these type of malignancies are EBV-negative cases. Sporadic type Burkitt lymphoma is a rare clinical entity.
Case Presentation: A 48-year-old female without any past medical history presented with a chief complaint of mild abdominal pain of 6 months duration located at the epigastrium which was not related to food ingestion. Nausea or vomiting were neither reported. She noted an acute increased abdominal pain over the last 4 hours before presentation, with irradiation to the right lower quadrant. She denied any Fever, night sweats and weight loss. She also reported hypermenorrhea in the last 6 months. During the physical examination, a palpable mass with 10 cm in diameter was found on right lower quadrant.
Conclusion: Sporadic Burkitt lymphoma is one of the rarest hematologic malignancies. The increased tumor size may be more than enough to show clinical or biochemical abnormalities such as serum lactate dehydrogenase (LDH) increased and tumor lysis.

Abstract Introduction: A case of pulmonary sarcoidosis is reported because of difficulties in diagnosis and treatment, including the co-existence of ankylosing spondylitis (AS) and severe corticosteroid dependence.
Case Presentation: A 48-year-old nonsmoking woman referred to the hospital because of chronic nonproductive cough and dyspnea with a 10-year history of AS. Bilateral rhonchi was detected in lung auscultation. There was a significant limitation in lumbar activity and range of motion in flexion (positive Schober’s test), extension, and lateral bending. In lumbosacral magnetic resonance imaging (MRI), irregularities in the sacroiliac joint and bilateral sacroiliitis were evident. The angiotensin-converting enzyme level was elevated. Biopsy in hilar lymphadenopathy by transbronchial lung biopsy was done, and the histopathological findings showed chronic non-necrotizing granulomatosis inflammation compatible with sarcoidosis. Anti-tumor necrosis factor drugs was effective on steroid-dependent coexisting of sarcoidosis and AS. The symptoms were absent in regular follow up.
Conclusion: Pulmonary fibrosis due to sarcoidosis can be prevented by suitable treatment. Clinical trials are needed to confirm the impact of treatments with monoclonal antibodies against tumor necrosis factor (TNF), for curing sarcoidosis.

Abstract Introduction: The main symptoms of new coronavirus in patients are fever or chills, tiredness, and dry cough. In this case, we reported a woman who got involved in COVID-19 pneumonia with gastrointestinal instead of lower respiratory symptoms.
Case Presentation: A 67 years old woman was referred to an outpatient clinic in Tehran with fever, chills, sneezing, tiredness, severe nausea, anorexia, and diarrhea. She did not have a cough, dyspnea, or chest pain and her lung sound was normal. According to the blood O2 saturation decreasing, C-reactive protein increasing, and the lung imaging findings, she was admitted with COVID-19 pneumonia diagnosis in the infectious care department of a hospital. The 2019-nCoV real-time polymerase chain reaction (PCR) intranasal assay was negative. She was treated with intranasal oxygen therapy, anti-inflammatory drugs, and prednisone. After one week she was discharged in generally good condition and quarantined for two weeks later. After 25 days the COVID-19 IgM and IgG antibodies were in positive ranges.
Conclusion: Severe fatigue, mainly in elders caused the inability to cough, and light inspiration force especially in the lower lung lobes could explain the normal lung sounds in the physical examination. Also, we hypothesized that reverse circulation of the virus may occur from the gastro intestine to the respiratory system. The gut-lung microbial imbalance may affect the severity in patients with extrapulmonary symptoms, especially in old ages. Furthermore, damage to the vagus nerve along the path in the proximity to lungs infected with COVID-19 can cause nausea without gastrointestinal involvement.

Abstract Inrtoduction: Granulomatosis with polyangiitis (GPA) is a systematic and necrotizing vasculitis with positive autoimmune antibodies. Some studies have reported the prevalence of eye involvement between 40%-50% of cases. Retro orbital granuloma is a rare complication of GPA which should be treated by surgical involvements, while pachymeningitis can be diagnosed by MRI and treated by medical management. In this study, we tried to present a case of GPA with optic neuritis and typical central nervous system (CNS) involvement, while there were no definite features of sinusitis or kidney injuries.
Case Presentation: A 15-year-old girl was admitted because of blurred vision in her left eye. She was a known case of GPA three years ago with initial features, including left facial nerve paresis due to pan-sinusitis and pulmonary cavity. Neurologic evaluations, including sensory and motor features, were normal, too. Ophthalmologic examinations showed that visual acuity of the right eye was good, while the visual acuity in the left eye decreased to the point of finger counting at a distance of 20 cm. The left eye Marcus gunn test was positive (3+); anterior and posterior eye segments were normal. The patient was evaluated by brain MRI with gadolinium and a pathologic enhancement in the left cavernous was seen which had a pressure effect on the optic nerve. She was treated by intravenous methylprednisolone followed by rituximab.
Conclusion: Reporting orbital mass in a patient who had GPA can be supposed as granuloma which needs a biopsy to confirm a diagnosis. In our case, the imaging manifestation was heterodox for granuloma, while neurosurgical consultation recommended drug treatment for pachymeningitis.

Abstract Introduction: Broad ligament hernia was first reported post-autopsy by Quain in 1861. In a 1995 review article, only 61 cases had ever been reported. This paper presents a case report of broad ligament hernia and explores the literature surrounding this topic.
Case Presentation: The patient presented with no significant past medical history, acute lower abdominal pain (several hours), nausea, and vomiting. Clinical examination showed a heart rate of 85 beats per minute; normal temperature, blood pressure, and respiratory rate; and a mildly distended abdomen with tenderness across the right lower quadrant. A plain abdominal X-ray showed dilated small bowel loops, and a blood test showed leukocytosis. Urgent diagnostic laparoscopy showed a broad ligament strangulated hernia with small bowel infarction. Reduction of the small bowel, resection, and side-side anastomosis were performed. The patient had an uneventful recovery, and follow up reported no postoperative complications.
Conclusion: Laparoscopic management of small bowel obstruction due to broad ligament internal hernia is a safe and effective option.

Abstract Introduction: Total hip arthroplasty (THA) after proximal femoral fixation is a challenging procedure due to possible hardware-related complications.
Case presentation: A 78-year-old female with hip osteoarthritis had a proximal femoral osteotomy fixed using a blade plate in the same femur 41 years ago. A two-step approach was planned. After a challenging hardware removal, an iatrogenic subtrochanteric fracture below the degenerated hip occurred after three months. THA with a tapered long stem was successfully performed with no need for additional osteosynthesis, and good results were seen two years later.
Discussion: THAs in subtrochanteric fractures are technically demanding but feasible in selected cases. Hardware removal before THA implantation may carry important risks, and the surgical team should be prepared to perform arthroplasty in case of complications.
Conclusion: THA in a subtrochanteric fracture below hip osteoarthritis is a feasible option in selected cases.

Abstract Introduction: Parquet poisoning has been elaborated to be very common among developing countries, particularly in regions with agriculture economy. One of the most common presentations of paraquat poisoning is oropharyngeal burns. Herein, we report a patient from a dry and warm district in the geographic center of Iran where agriculture and, as a result, paraquat poisoning are not commonly reported.
Case Presentation: A 25-year-old man presented to hospital subsequent to a suicide attempt by ingesting oral paraquat poison. He gradually developed odynophagia and trismus-like appearance that, after a psychiatric consultation, was misdiagnosed as a drug side effect in the form of dystonia. Upon further physical examination, oral ulcers on his tongue were revealed to be responsible for the symptom.
Conclusion: Paraquat poisoning is very rare in regions with lower rates of agriculture activities. In any patient with poisoning, however, it is necessary to consider intraoral examination to rule out any other suspected diagnosis.

Abstract Introduction: Cranial nerve palsy in Wegener’s granulomatosis is a curious incident, particularly if it occurs without kidney or lung involvement. In a review of medical articles, only 1 case of Wegener’s granulomatosis with bilateral facial nerve palsy was found.
Case Presentation: The patient was a 16-year-old female who presented with pain and hearing loss in both ears and reduced muscle tone in the right side of her face. After myringotomy and ventilation tube embedding in both ears, she gradually developed infectious otorrhea in both ears. Despite antibiotic and antifungal therapy for 2 weeks after surgery, the patient developed paresis in the left facial nerve and gag reflex disorder. Both magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) tests were normal, but the C-anti-neutrophil cytoplasmic antibody (CANCA) test result was about forty times higher than normal, and a sinus biopsy also verified Wegener’s granulomatosis. The patient was then treated with pulse corticosteroid and cyclophosphamide therapy. Her gag reflex healed and the ear secretions stopped, but the facial nerve palsy continued.
Conclusion: Although cranial nerve involvement in Wegener’s granulomatosis is an unusual incidence, it may occur in some cases. In the current case, otitis media and cranial nerve paresis without kidney or lung disorders were the only signs of disease onset; of course, computerized tomography (CT) scan revealed a right mandibular sinus disorder without any clinical signs. Another important point in this case is that other identified Wegener’s patients were in their fourth or fifth decade of life; thus, Wegener’s was the last choice for a diagnosis in the current case.

Abstract Introduction: Carbon monoxide (CO) poisoning is a prevalent lethal condition. The clinical feature of this type of poisoning varies from headache and nausea to more severe conditions. After recovery from the acute intoxication, neurological or behavioral problems may emerge. In 3%-40% of cases, delayed neuropsychiatric syndrome (DNS) in post CO poisoning, generally develops within few weeks after a preliminary remission from acute poisoning.
Case Presentation: We report a patient with relatively suitable premorbid. He was admitted to the hospital with fire burning, co poisoning and discharged home with good general conditions and mental status by receiving normal baric oxygen 100%. later in post-operative management of skin graft he developed a fulminant neurological deficit by impaired memory and concentration, loosening of association, disorientation to place, time and person, agitation, aggression, mood labiality, urinary incontinency and encopresis, slow psychomotor retardation, false and approximate answers to questions, auditory and visual hallucination, staring and inappropriate laughing. As the patient was not responsive to neurological treatment, he was referred to psychiatric service. DNS in this patient resolved gradually during a short period of psychopharmacotherapy and supportive psychotherapy.
Conclusion: CO poisoning may lead to neuropsychiatric sequel and neuroimaging changes which could be reversible.

Abstract Background: Toxoplasmosis, caused by Toxoplasma gondii, is a globally prevalent parasitic infection that often presents with nonspecific symptoms, making diagnosis challenging, especially in immunocompetent individuals.
Case Presentation: We report a case of a 22-year-old immunocompetent male presenting with cervical lymphadenopathy, fever, and flu-like symptoms, initially misdiagnosed as influenza or COVID-19. Despite symptomatic treatment, his condition worsened. Serological testing confirmed acute toxoplasmosis (IgM: 6.64 IU/ml; IgG: 44 IU/ml). Ultrasonography showed hypoechoic cervical lymph nodes, consistent with lymphadenopathy. Treatment with azithromycin, pyrimethamine, and folinic acid for 10 days led to complete symptom resolution.
Conclusion: This case highlights the importance of considering toxoplasmosis in the differential diagnosis of cervical lymphadenopathy, especially in patients with persistent flu-like symptoms. Early serological testing and imaging are crucial for accurate diagnosis and timely intervention. The rapid clinical improvement observed underscores the effectiveness of antiparasitic therapy in immunocompetent individuals. Greater clinician awareness of the diverse presentations of toxoplasmosis is essential to prevent misdiagnosis and optimize patient outcomes.

Abstract Introduction: Diarrhea is one of the most common symptoms treated in general practice and gastroenterology. An estimated 1.7 billion cases of diarrhea are reported annually. Anxious and emotional persons are more sensitive to digestive problems. Anxious persons may feel their heartbeat and perceive their intestinal motility and spasm, and this may cause them more concern. Case Presentation: In this case report, a 31-year-old woman with chronic diarrhea and a stressed psyche is presented so as to emphasize the combination of organ disorders and psychiatric moods. Conclusion: Patients suffering from chronic and persistence gastrointestinal disease should be evaluated by a psychiatrist. Psychotherapy and psych pharmacotherapy can greatly help the treatment of somatic complaints of these patients.

Abstract Introduction: Homeopathy can be applied to treat various diseases and conditions such as cancer, allergy, mood disorders, headache and pain. This case showed that homeopathic medicine can be a treatment modality for idiopathic thrombocytopenic purpura (ITP), an autoimmune-mediated hematologic disorder.
Case Presentation: The patient was a 5.5–year-old child with ITP who referred to the homeopathic clinic with extensive petechiae and purpura on her body. Her platelet count was 15000/mcL and her anti-dsDNA and ANA were negative on her first visit. Her disease had first been diagnosed at the age of 2.5 years. She had undergone routine therapy for ITP; however, despite 15 months of corticosteroid therapy and IVIG injections, her platelet count was still low. After treatment with homeopathic remedies, her platelet count increased and signs of ITP disappeared.
Conclusion: Homeopathic remedies can be considered as complementary and alternative medicines for ITP treatment protocols.

Abstract Introduction: Neurofibromas, benign peripheral nerve sheath tumors, are the most common among neural lesion. Neurofibromas are rare in head and neck location, although it may involve any part of oral cavity. However, tongue is the most common region.
Case Presentation: A 27 year-old man was admitted to Otorhinolaryngology Department due to a swelling in the base of his tongue, since two weeks before. This mass was painless, and without any associated symptoms. He was suffered from a mild eating disorder, too. He had no any positive past medical history, and only a large soft 6 × 5 cm mass was found at the base of his tongue without bleeding in the oral cavity. Excisional biopsy was performed for him under general anesthesia and the tumor was easily enucleated. The final diagnosis was neurofibroma. After the diagnosis of neurofibroma, the physical reexamination revealed a series of café au lait spots on his skin.
Conclusion: the neurofibroma should be considered by otorhinolaryngologist, as a differential diagnosis of tongue mass, and more accurate physical examination are recommended for better management. 

Abstract Background: Cutaneous larva migrans (CLM) is a parasitic infection caused by the accidental penetration of canine hookworm larvae into the superficial layers of human skin. Although typically self-limiting, delayed diagnosis may result in complications such as secondary infections or allergic reactions.
Case Presentation: The case involved a 54-year-old man with a history of hypertension who presented with a creeping, erythematous lesion on his left leg, accompanied by severe pruritus and a history of contact with a pet dog. After confirming the dog’s hookworm infection and conducting further clinical evaluation, a diagnosis of CLM was established. Treatment with albendazole and an antihistamine resulted in complete resolution of the patient’s symptoms.
Conclusion: Although CLM is typically a self-limiting condition, timely initiation of treatment can significantly reduce the duration and severity of symptoms. The growing trend of pet ownership has increased the risk of CLM transmission, underscoring the importance of implementing effective preventive measures.

Abstract Introduction: Delusion of pregnancy is a bizarre delusion in which one feels s/he is carrying a fetus. The etiology is unknown, but aloneness, masturbation, and stress may precipitate this disorder.
Case Presentation: We introduce a young, single man who has delusions of pregnancy. This type of delusion is not a well-known disorder; based on investigated articles, this type of somatic delusion is rare.
Conclusion: This was a chronic case, the exact cause and development of which was unknown. We suggest this phenomenon as a novel symptom. No similar case was found in the literature.

Abstract Introduction: Coronary artery anomalies are rare clinical entities reported in 0.6% to 5.6% of diagnostic coronary angiographies. Anomalous origins of coronary arteries from distal segments are rarely reported. Presented herein is a coronary anomaly in which the circumflex artery (CX) originated as a continuation of the posterolateral branch of the right coronary artery (RCA) with separate left anterior descending (LAD) artery origination from the left sinus of Valsalva. The clinical presentation of such a rare anomaly is discussed, and the current literature regarding the congenital absence of CX is reviewed.
Case Presentation: A 66-year-old male presented with angina pectoris. Coronary angiography revealed critical stenosis in the mid segment of the LAD artery and an anomalous origin of CX artery from the distal RCA. The CX was coursing as a continuation of the posterolateral branch of the RCA. Coronary angioplasty and stent deployment was performed for the LAD lesion, and the patient was discharged with medical therapy. The patient did not report recurrent anginal symptoms under medical therapy.
Conclusion: The congenital absence of the circumflex coronary artery is a rare coronary anomaly. The clinical presentation may vary, though most cases are asymptomatic during diagnosis. Such cases require close clinical follow-up since they entertain a future risk for being symptomatic, especially in the setting of atherosclerotic disease.