Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

Background: Brucellosis is among the most widespread zoonotic diseases worldwide. Although rare, nervous system involvement due to Brucella infection is a major diagnostic challenge in endemic regions. Patients and methods: This study was a cross-sectional investigation of hospitalized adults with neurobrucellosis from March 2007 to February 2017. We described the clinical characteristics, radiographical and laboratory features, and clinical outcomes of patients with neurobrucellosis. Results: Fifty-four patients with neurobrucellosis were included. The median age was 35 (interquartile range, 25–50) years, and 32 (59%) cases were male. Thirty-four (63%) patients were stockmen or shepherds. The most common clinical manifestations were fever in 49 (91%) cases, headache in 47 (87%), decreased consciousness in 12 (22%), and seizures in 6 (11%). Meningeal signs were detected in 36 (67%) cases. Brucella species were isolated in five cases from blood or cerebrospinal fluid (CSF). The median of CSF leukocytes was 75 per µL, CSF protein 83 mg/dL, and CSF glucose 39 mg/dL. Only two cases had severe hypoglycorrhachia and one CSF protein ≥ 500 mg/dL. No patient died during hospitalization. Conclusions: The symptoms of neurobrucellosis could be mild and nonspecific and the classic triad of meningitis is uncommon. Mild CSF pleocytosis of fewer than 50 leukocytes per microliter of CSF was common but severe hyperproteinorrhachia and severe hypoglycorrhachia were rare in neurobrucellosis. Differentiation between neurobrucellosis and systemic brucellosis is important, because more prolonged treatment is indicated for neurobrucellosis, and it could be associated with a broad spectrum of complications that require close follow-up.

SUMMARY: We report a nosocomial outbreak of Crimean-Congo haemorrhagic fever (CCHF) that affected six patients in June 2009 in Ghaem Hospital, Mashhad, Iran, apparently related to one index case. The last four cases were healthcare workers. Infection was spread by percutaneous exposure to two cases, and probably by direct contact with blood, clothes and sheets, to three others. The diagnosis in the two fatal cases was not confirmed virologically. The diagnosis in four cases who survived was confirmed by specific reverse transcription polymerase chain reaction. The patients were treated with ribavirin. In endemic areas, every patient presenting with a febrile haemorrhagic syndrome should be considered to have a viral haemorrhagic fever until proven otherwise. Patients who meet the criteria for probable CCHF should be admitted to hospital and treated with ribavirin. Appropriate isolation precautions should be immediately initiated.

Infective endocarditis (IE) is now the third or fourth most common life-threatening infectious disease. The high morbidity and mortality rates in the absence of appropriate care necessitate a thorough understanding of the obstacles towards the early diagnosis and management of IE. The aim of this study was to evaluate the frequency of discrepancy in diagnosis (i.e. discrepancy between the reason for admission and discharge diagnosis) and associated factors in patients with IE. It was a retrospective review of hospital records of all adult patients admitted in a 1000-bed academic general hospital in Mashhad, Iran with the discharge diagnosis of IE. Discrepancy in diagnosis on admission was observed in 64 (54.2%) of 118 episodes of IE. For patients with discrepant diagnosis, the odds of poor outcome were more than two times higher than the odds of those with the non-discrepant diagnosis. Multivariate analysis identified the only history of prosthetic valve replacement as an independent factor in predicting non-discrepant diagnosis. We suggest that in facing a patient with the complex clinical scenario, proposing a comprehensive clinical syndrome that includes predisposing factors instead of a symptom or finding-based diagnosis can help making the differential diagnosis more accurate.

Although there is still much to learn about the types of errors committed in health care and why they occur, enough is known today to recognize that a serious concern exists for patients. Tuberculosis (TB) is an infectious disease that is frequently subject to diagnostic errors. Missed or delayed diagnosis of TB can affect patients and community adversely. Our aim in the present study was at evaluating the type of diagnostic errors in TB patients from symptom onset to diagnosis. This was a multicenter cross-sectional study conducted in three university hospitals in Mashhad, Iran. We showed a long delay in diagnosing TB that is mostly related to the time from first medical visit to diagnosis. Errors in the diagnostic process were identified in 97.5% of patients. The most common type of error in diagnosing TB was failure in hypothesis generation (72%), followed by history taking and physical examination. In conclusion, it seems likely that efforts to improve public awareness of and health literacy for TB, to coordinate the referral and follow-up systems of patients, and to improve physicians’ skills in history taking and physical examination and clinical reasoning will result in reduced delay in diagnosis of TB and, perhaps, improved patient safety and community health.