Ali Moghtaderi

Incidence and prevalence of multiple sclerosis in southeastern Iran

BACKGROUND Based on data available, Iran is located in a low risk area for multiple sclerosis (MS). The objective of the current study is to determine the age and sex adjusted prevalence and incidence of MS in southeastern Iran. METHODS This cross-sectional case register study was conducted from January to August 2010. Considering that MS affects people aged between 16 and 50 years, we intended to find the incidence and prevalence of MS during this age range. Since all cases in this area are referred to our university hospital for confirmation of diagnosis, misdiagnosis is rare. Population data, based on the censuses carried out in 1996 and 2006, were obtained from the Iranian Bureau of Statistics to determine the number of people at risk. RESULTS Totally 206 patients were identified according to the McDonald criteria. In 2009 the age-adjusted prevalence and incidence rates of MS for 16-50 year-old adults were 13.96 and 2.67 per 100,000 persons, respectively. Based on those values; the female to male ratio was 2.18. Between 2006 and 2009, the incidence rates increased 2.4 and 2.7 times in women and men, respectively. In 2009, the prevalence rates among the age ranges of <15, 16-35, 36-50 and ≥51 years were 1.44, 14.34, 12.24 and 1.45 per 100,000 persons, respectively, and the relapsing-remitting type of MS was the most prevalent form (65.8%). CONCLUSION According to the Kurtzke geographical distribution, the authors conclude that the prevalence of MS in southeastern Iran is in the intermediate range, and the incidence rate is showing a faster growth rate, compared to previous years.

Diagnostic risk factors to differentiate tuberculous and acute bacterial meningitis.

The objective of this study was to identify independent predictor factors for diagnosis of tuberculous meningitis and develop a clinical prediction tool based upon a set of simple clinical and laboratory parameters in our local population. Clinical and laboratory features were compared in 68 patients with tuberculous meningitis and 123 cases of acute bacterial meningitis in 3 referral centres for tuberculosis in south-eastern Iran. Twenty-two clinical and laboratory features were analysed. Based on the best-fitted model a receiver operating characteristic curve with the highest surface under the curve was constructed. Disease duration before diagnosis (>or=5 d) had the highest odds ratio of 21.9. Age over 30 y, CSF leukocyte count <or=1000 x 10(3) cells/ml and CSF lymphocytosis >or=70% were placed after disease duration with odds ratios of 5.1, 3.7 and 2.6, respectively. Sensitivity, specificity and likelihood ratio for a positive test in this model were 84%, 88% and 7.4, respectively. The area under the ROC curve was 0.92. It appears that a single model can not predict TBM diagnosis in different populations. Using clinical and laboratory parameters may facilitate empirical diagnosis of TBM in endemically low income countries with limited microbiological diagnostic facilities.

Comparative analysis of cerebrospinal fluid adenosine deaminase in tuberculous and non-tuberculous meningitis

OBJECTIVE To calculate cut-off point for the adenosine deaminase (ADA) activity in the CSF of patients with tuberculous meningitis (TBM). PATIENTS AND METHODS The ADA assay was based on the automatic indirect method in which ADA catalyzes adenosine to inosine. ADA activity in the CSF was calculated based on ammonia liberated from adenosine and quantified spectrophotometrically. Arithmetic mean values and standard deviation of each variable were measured. Mann-Whitney U and Fisher exact tests were applied to compare continuous and dichotomous variables between tuberculous and non-tuberculous groups. A receiver operating characteristic curve was plotted to identify various cut-off points to determine the best level for ADA activity. RESULTS Totally 42 patients were enrolled into the study. The median of ADA activity in the TBM group was 22 and in the non-TBM group was 8.0. The mean CSF-ADA activity was found to be significantly higher in TBM group (23.05+/-13.1IU/L) than in the CSF from non-TBM patients (9.39+/-5.18IU/L). The highest accuracy is at the cut-off value of 10.5IU/L. The sensitivity and specificity of the test at this cut-off to differentiate TBM from non-tuberculous meningitis is 81% and 86% respectively. CONCLUSION Considering that a high positive value of ADA activity cannot confirm TBM, however, in suspected patients it may lead the physician to treat patient earlier before the confirmatory diagnostic reports will be received. The suggested cut-off value in this pilot study is 10.5IU/L with high sensitivity and specificity.

The influence of ethnicity on the characteristics of multiple sclerosis: A local population study between Persians and Arabs

BACKGROUND Based on previous studies, Iran is located in a low risk area in terms of multiple sclerosis (MS). The objective of this study was to determine and compare the incidence, prevalence and demographic characteristics of MS in two ethnic groups of Persian and Arab over the period spanning 2009 in the Khuzestan province, in the Southwest of Iran. METHODS A cross-sectional case register study was conducted between January and August 2009. All cases in the region whom were referred to the MS society in the city of Ahwaz were participants in the study. The population data from the Iranian Bureau of Statistics were used to calculate the population at risk based on the 1996 and 2006 census data. RESULTS A total of 696 patients were identified according to the McDonald criteria during the last 12 years of which 569 patients were Persian. In 2009 the total prevalence and incidence rates of MS were 16.28 and 2.20 per 100,000 individuals. Based on these values, the female to male ratios were 3.11. The Persians manifested more sensory signs and symptoms (40.2%) but motor deficits (19.1%) and cerebellar findings (18.2%) were seen as being more manifest in Arab individuals. The main difference was observed in the progressive types of MS in which 24.7% of the Arab patients showed progressive type symptoms as compared to 15.9% of the cases in the Persian population. CONCLUSION According to this study the authors conclude that the prevalence and incidence of MS were higher in Persians; however progressive forms of MS with motor and cerebellar signs are more frequent in the Arab ethnic group.

An Unusual Intracerebral Hemorrhage

1Department of Infectious Diseases; and 2Neurology Department, Zahedan University of Medical Sciences, Zahedan, Iran Correspondence and reprints: Dr Roya Alavi-Naini, Department of Infectious Diseases, Booali Hospital, Zahedan, 98531773, Iran. Telephone 0098-541-3234551, fax 0098-541-3218848, e-mail ranaini@zdmu.ac.ir or ranaini@iranmedical.com A20-year-old man was admitted to hospital for fever and diarrhea. He was well until three days before admission when fever, nausea, vomiting and watery diarrhea suddenly occurred. The day before admission, he experienced epigastric pain and upper gastrointestinal bleeding. The patient was a student of veterinary medicine. There was no history of recent travel but he had exposure to cattle. On physical examination, he appeared ill and toxic with a temperature of 39.2°C. The patient was tachycardic and tachypneic, and the conjunctivae were injected. On abdominal examination, he had epigastric tenderness without organomegaly. A diffuse maculopapular rash and petechiae were seen over the entire body, especially the chest and abdomen. Large echymoses were seen at the venipuncture sites on the ventral portion of the forearms. The results of laboratory tests are shown in Table 1. Treatment was begun with oral ribavirin (30 mg/kg loading dose, then 15 mg/kg every 6 h for four days followed by 7.5 mg/kg three times daily for six additional days) and intravenous ceftriaxone, along with platelet transfusions and supportive therapy. Fever and petechiae were improved on the fifth day of admission but the following day the patient developed a headache, gait disorder, incontinence and a confusional state. On physical examination, speech was normal except for occasional hesitation but the patient was confused and demonstrated prominent attention and concentration defects. Neck stiffness was not noted. Cranial nerves and deep tendon reflexes were normal. Muscle tone was decreased only in the lower limbs where motor function was graded 3/5 proximally and 4/5 distally. Plantar toe reflexes were extensor (ie, upward) bilaterally. The upper limbs were normal. Sensory examination could not be reliably performed due to the patient’s confused state. The result of finger-to-nose testing was normal but standing and walking were abnormal. Notably, he could walk assisted with a wide-based stance but advanced with small, shuffling, hesitant steps. Turning was accomplished by a series of tiny, uncertain steps that were made by one foot, with the other foot being used as a pivot. A computed tomography (CT) scan of the brain was performed without contrast and a laboratory result was received that day which established the diagnosis. What did the CT of the brain show and what is the patient’s diagnosis?

Lumbar Puncture: Techniques, Complications and CSF Analyses

Lumbar puncture (LP) is one of the well-known ancillary procedures in clinical neurology performed for a variety of functions such as spinal anesthesia, intrathecal administration of drugs, myelography, obtaining cerebrospinal fluid (CSF) samples and measuring pressure since more than 100 years ago. The question that who was really the discoverer of LP is still under debate. Most authors assume that it was Heinrich Irenaeus Quincke (1842-1922) a German internist who was introduced the procedure to medicine in 1891, however, some authors mentioned the American neurologist James Leonard Corning (1855-1923) as the first one who performed LP using birds quills in 1885 (Frederiks et al., 1997; Dakka et al., 2011).