Clinical and laboratory features of brucellosis in a university hospital in Tunisia.

AIM OF THE STUDY: The increase in the number of brucellosis cases between 2014 and 2017 (14 and 90 cases respectively) led us to study the biological and clinical-epidemiologic characteristics patients hospitalized in Rabta hospital of Tunis. MATERIAL AND METHODS: This retrospective study was conducted in Rabta Hospital in Tunis between 2016 and 2017. It includes 131 patients who had a positive bacteriological diagnosis of Brucella between 2016 and 2017. Diagnosis of brucellosis was made in blood culture by using Bactalert (Biomerieux®). Identification of Brucella was realized by Gram staining, catalase, oxydase. Serological diagnosis was made by testing sera for brucellosis agglutinins with Rose Bengale and the standard agglutination test. The collected data were analyzed by SPSS softcare version 24. RESULTS: The prevalence of Brucellosis in Rabta hospital increases from 14 cases in 2014 to 90 cases in 2017. The mean age was 45 years and ages range from 16 to 84 years. Rural origin was found in 75 cases (68%). Ninety-seven patients (89%) were hospitalized in the infectious diseases department. The average length of hospitalization was 17.25 days. Fifty-seven patients (52%) had a history of consuming unpasteurized dairy products and 45 (41%) were farmers. Fever was the predominant symptom in 104 cases (95%). Osteoarticular involvement is the most common complication of brucellosis and it occurred in 28% of patients. Blood cultures were 73 cases and 42 (57%) were positive for Brucella spp. Rose Bengale was positive in 100% of cases. High titles of the standard agglutination test (superior to 1/1280) were noted in 24 cases (22%). CONCLUSION: Brucellosis is still endemic In Tunisia. Contact with domestic animals and consumption of raw milk and milk products seems to be the major mode of transmission. Control of animal infection by vaccination, occupational and personal hygiene, farm sanitation and preventive measures can reduce disease incidence.

COVID-19 circuit management: la Rabta experience.

Covid-19 pandemic was associated to fear among patients, doctors and nurses, it was responsible of a work impairment in health structures organisation. All patients were at home, only Covid patients were at hospital. Our country has a quick reaction, we declared the pandemic as a social disease with free management. All hospital had the order to create their own Covid-19 circuit. We report the experience of our hospital in the crisis management with the creation of the circuit, its organisation, the management of the different financial, technical, human, sanitary, psychological and logistical aspects. The great point of this crisis was the fear, stress of caregivers for themselves and their families. The other point for members of Covid Cell was the race against time, the learning of a new job: a manager or a polyvalent chief. The presence of a Covid-19 circuit is necessary for each hospital at the epidemic time but it must be managed by infectious diseases doctors, lung specialists, intensive care givers and emergency room caregivers in collaboration. An enhancement of the structures is necessary at the level of medical wards and beds of intensive care.

Étude épidémio-clinique des infections à entérobactéries productrices de carbapénémases chez les brûlés.

This study was longitudinal, conducted at the Trauma and Burn Centre between January and June 2017. Its purpose was to determine the prevalence of CPE infection among patients admitted to the Burn Intensive Care Unit, and to study their clinical and biological characteristics. Molecular typing of carbapenemases was performed with PCR type GeneXpert. Thirteen patients were infected with 7 episodes of bacteremia, 2 had ventilator acquired pneumonia and 4 catheter infections, with a prevalence of 7% of admissions. The average length of stay in the intensive care unit prior to infection was 12 days. Antibiotic exposure involved 12 of the 13 patients: 9 patients were transferred from other intensive care units. Thirteen and ten patients were respectively exposed to central catheterization and mechanical ventilation. The predominant carbapenemase among the infecting carbapenemase-producing enterobacteriacae strains was NDM carbapenemase (9/15), with a first description of P. stuartii carrying blaNDM strain in Tunisia. One patient died before adapting antibiotic therapy. For the others, 13 adapted bi-antibiotherapies were prescribed. There were five patient deaths from infection, four of whom had received appropriate antibiotic therapy. Imipenem was used each time the MIC was ≤4mg/l, in combination with another antibiotic: amikacin (3/8), colimycin (4/8), or tigecycline (1/8). Three of these prescriptions resulted in death. The prevalence of carbapenemase-producing enterobacterial infections is high among burn patients with a predominance of NDM-type carbapenemase.

Asymptomatic intestinal carriage of microsporidia in HIV-positive patients in Tunisia: prevalence, species, and pathogenesis.

Asymptomatic carriage of microsporidia (ACM) has not been described in patients living with HIV (PLHIV) in Tunisia. To determine the prevalence of ACM in PLHIV followed at Tunis la Rabta hospital, describe its clinical features and course, and identify the species involved. This prospective study (2005-2009) included 71 asymptomatic PLHIV compared with 37 PLHIV with diarrhea. One stool sample per patient was examined by microscopy after Weber staining and by PCR. Species identification was confirmed by specific PCR and sequencing. In cases of ACM, a second stool sample was examined in 2010 and a clinical check-up took place in 2013. The prevalence of ACM in asymptomatic PLHIV was 11.3 % (8/71). PCR was more sensitive than microscopy (P = 0.0047). ACM was associated with stage C of HIV infection (P = 0.008) and CD4 T cells <100/µl (P = 0.033). The species involved were E. intestinalis (6 cases) and E. bieneusi (2 cases). Six PLHIV remained asymptomatic with negative stool examinations, but two developed digestive signs. ACM is common among Tunisian PLHIV and it appears to be associated with E. intestinalis.

Epidemiological and clinical characteristics of neurobrucellosis case patients in Tunisia.

OBJECTIVE: We aimed to identify epidemiological, clinical, therapeutic, diagnostic, and outcome characteristics of neurobrucellosis case patients in Tunisia. PATIENTS AND METHODS: We conducted a retrospective and descriptive study over a 17-year period (January 1997-December 2013). We included all neurobrucellosis patients hospitalized in the infectious disease department of La Rabta Hospital of Tunis during the study period. RESULTS: A total of 13 patients were included in the study: 9 men and 4 women. Mean age was 31.6 years. Six patients presented with meningitis, three with encephalitis, two with meningoencephalitis, and two with meningo-myeloradiculitis. All patients had a lumbar puncture performed. Eleven patients had an abnormal cerebrospinal fluid (CSF) (84.6%): lymphocytic pleocytosis in seven patients, high level of CSF proteins in 11, and low level of CSF glucose in seven. All patients had a positive Brucella serological test in blood. A Brucella serological test was also performed in CSF and was positive for 10 patients (77%). A total of nine patients had a cerebral CT scan and/or MRI performed and abnormalities were observed in six patients. Antibiotic therapy was prescribed to all patients: a combination of rifampicin and co-trimoxazole (n=9) or doxycycline (n=4) for an average duration of eight months. Two patients also received steroids. A positive outcome was observed in 10 patients. Three patients were lost to follow up. CONCLUSION: Brucellosis may be severe when neurological involvement occurs. Brucellosis should be considered in the event of any neurological involvement associated with suggestive epidemiological features.

[Syndrome coronarien aigu sous traitement antirétroviral]. / Acute coronary syndrome during antiretroviral treatment.

AIM: The aim of this study is to determine epidemiological, clinical, therapeutic and outcome characteristics of acute coronary syndrome in AIDS patients under HAART. Results- The charts of 5 patients were reviewed. The mean age, at the time of the discovery of HIV infection, was 35 years. Three patients were smokers and one had a family history of diabetes and acute coronary syndrome (ACS). Three patients received 2 nucleoside reverse transcriptase inhibitors (NRTIs) with indinavir. The 2 others received 2 NRTIs with efavirenz with good immunovirologic response. Four patients developed mixed dyslipidemia after an average period of 26 months. Tow patients developed diabetes and one a hypertension. A specific treatment was initiated in all cases. These five patients developed an ACS after respectively 51, 95, 96,103 and 145 months of ART (median=98 months). ACS occurred in 3 patients receiving 2 NRTIs and PI and two others 2 NRTIs with efavirenz. The mean age at the onset of ACS was 46 years. One patient underwent a triple bypass surgery, tow a stenting of the stenotic coronary and the last 2 patients received medical treatment with a good clinical outcome. The PI was replaced by efavirenz in two patients. Four patients had a recurrence of ACS respectively after 2months, 3 months, 12 months, and 62 months after the first episode. The five patients are still followed with good clinical and biological outcome.

Cutaneous tuberculosis in Tunisia.

INTRODUCTION: Tuberculosis is endemic in Tunisia. Pulmonary tuberculosis is the most common presentation in our country. Cutaneous presentations are rare (1-2% of cases). The diagnosis of cutaneous tuberculosis (CT) is difficult. Histological and clinical presentations are polymorphous, many differential diagnoses are available, and it is difficult to isolate Mycobacterium. OBJECTIVE: We had for aim to study the epidemiological and clinical features of CT in Tunisia, and to compare presentations before and after 1990. PATIENTS AND METHODS: We conducted a retrospective study between January 1991 and December 2011, in which we included all cases of CT observed at the Infectious Diseases and Dermatology Units of the Tunis la Rabta Hospital. RESULTS: Hundred and thirty-seven patients were included, with a mean age of 43.8years; 72.3% were female patients. Hundred and fifty locations were observed, most of which on the head and neck. Scrofuloderma was the most frequent presentation, observed in 65% of cases. The diagnosis was confirmed by histology and/or microbiology in 75.8% of cases. The treatment was prescribed for a mean 11.3months, leading to full recovery in most cases. CONCLUSION: CT is still reported in Tunisia. The diagnosis relies mainly on histology. Controlling this mutilating tuberculosis requires a global control of this disease, and especially lymph node location, given the high rate of scrofuloderma.

[Tuberculosis of the breast: a rare often unrecognized diagnosis]. / La tuberculose mammaire: un diagnostic rare, souvent méconnu.

UNLABELLED: Tuberculosis of the breast (BT) is a rare extrapulmonary localization for tuberculosis that mainly affects young women during their child-bearing years. OBJECTIVE: We report eight cases of BT and describe its clinical characteristics, outcomes, and differential diagnoses. PATIENTS AND METHODS: This retrospective study collected all cases of BT diagnosed at our hospital's infectious disease department in Tunisia from 2000 through 2009. We assessed the epidemiologic and clinical findings and reviewed the laboratory, histology, and radiology results, treatment data, and outcomes. RESULTS: Eight women (mean age: 52.5 years, range: 31-75) had BT. Clinical features included retracted erythematous lesions in four cases, a fluctuating abscess in two, and a well-defined nodule in two. The biopsy culture was positive in two cases. Histology results showed a tuberculoid granuloma with caseous necrosis in all cases. Antituberculosis drugs were administered for 8 to 12 months. Two patients underwent surgery. Outcome included total regression of BT for all women. CONCLUSION: Clinical features of BT are often misleading and can easily be mistaken for those of breast cancer. Identification of the Koch bacillus or the presence of a tuberculoid granuloma with caseous necrosis on histology facilitates diagnosis. The treatment consists essentially of antituberculosis drugs. Despite its rarity, BT must not be misjudged, especially in countries where tuberculosis is endemic.

Genotype identification of Enterocytozoon bieneusi isolates from stool samples of HIV-infected Tunisian patients.

The microsporidian species Enterocytozoon bieneusi is a major cause of chronic diarrhea and malabsorption in patients with AIDS. Genotyping was performed on seven E. bieneusi strains for the first time in Tunisia. All the strains were isolated from stool samples of humans with immunodeficiency virus (HIV) infection. Analysis of the ribosomal RNA gene internal transcribed spacer (rDNA ITS) allowed the identification of three distinct genotypes previously described in other studies. Genotypes D and B were characterized in four and two respectively. The Peruvian genotype (Peru 8) was detected in the last isolate. These results indicate a genetic diversity in E. bieneusi strains from HIV Tunisian patients and suggest the coexistence of both zoonotic and anthroponotic route of transmission.

[Contribution of PCR for detection and identification of intestinal microsporidia in HIV-infected patients]. / Apport de la PCR dans la recherche et l'identification des microsporidies intestinales chez les sujets infectés par le VIH.

AIM: Intestinal microsporidiosis are among the most frequent opportunistic diseases in immunocompromised subjects. This study aimed to evaluate the contribution of PCR for a better detection and species identification of microsporidia in stool specimens of HIV-infected patients. PATIENTS AND METHODS: Stool samples obtained from 119 HIV-infected Tunisian subjects were screened for intestinal microsporidiosis by light microscopy using Weber's modified Trichrome stain and by a PCR method using universal primers V1/PMP2 which amplified a common fragment of the small subunit rRNA gene of microsporidia. The obtained PCR products were then sequenced using an ABI PRISM 377 DNA sequencer. RESULTS: The results showed a better sensitivity of PCR in the detection of microsporidia with an infection rate of 14.3% significantly higher than that of 6.7% obtained by light microscopy (p=0.03). As previously described, intestinal microsporidiosis was associated with low CD4 cell counts; 23.9% infection rate in patients having CD4 cell count under 200/mm(3) against 5.6% in patients with higher CD4 cell count (p=0.008). The sequencing of 15 out of the 17 positive PCR products has confirmed in all cases the species identified based on the PCR fragment size i.e., 250pb for Enterocytozoon bieneusi (seven cases) and about 270pb for Encephalitozoon intestinalis (nine cases); one case revealed a double infection. CONCLUSION: PCR proved to be more effective than classical Trichrome stain for the diagnosis of intestinal microsporidiosis. Moreover, the ability of PCR to identify the species involved could also be useful for cases management.

[Microsporidia and cryptosporidia coinfection in an HIV-infected newborn]. / Co-infection par des microsporidies et des cryptosporidies chez un nouveau-né infecté par le VIH.

Microsporidiosis and cryptosporidiosis are emerging opportunistic infections responsible for intestinal manifestations that are often severe in immunocompromised patients. A case of microsporidiosis-cryptosporidiosis coinfection is reported in an HIV-infected newborn. The patient was a 17-day-old female, exclusively breastfed and with no contact with animals. Microsporidiosis and cryptosporidiosis were diagnosed after systematic screening in stool samples using both specific staining and PCR. Two species of microsporidia, Encephalitozoon intestinalis and Enterocytozoon bieneusi, and Cryptosporidium hominis were identified. The contamination of the newborn probably resulted from direct human-to-human transmission during close contact with the mother (who had diarrhea and refused stool sampling). This report highlights the usefulness of the screening of intestinal microsporidiosis and cryptosporidiosis in HIV-infected subjects for better management.

[Hereditary complement deficiency in Tunisian adults with purulent meningitis]. / Le déficit héréditaire en complément au cours des méningites purulentes de l'adulte en Tunisie.

Inherited complement deficiency is a rare disease. It predisposes to autoimmune diseases, glomerulonephritis, angioedema, and meningococcal meningitis. A prospective study was conducted over five years. The goal was to evaluate the prevalence of deficiency in Tunisian patients presenting with community acquired purulent meningitis and identify the type of deficiency. We enrolled 122 patients, 15 of whom presented with a complement deficiency (12.3%). This prevalence was higher than the one observed in the global Tunisian population and in reported international data. The mean age of deficient patients (13 men and two women) was 24.7 years.

[Identification of Enterocytozoon bieneusi by PCR in stools of Tunisian immunocompromised patients]. / Identification d'Enterocytozoon bieneusi par PCR dans les selles des patients immunodéprimés tunisiens.

INTRODUCTION: Intestinal microsporidiosis is recognised as an important cause of opportunistic parasitosis in immunocompromised patients, especially HIV-infected patients. Enterocytozoon bieneusi is the common causal agent. The diagnosis of intestinal microsporidiosis has usually based on microscopic detection of the spores of microsporidia species in stool samples, requires additional staining techniques as Modified Weber's trichrome stain. However, the detection of the spores can be difficult and species determination, which is important for defining the appropriate treatment, is impossible. Polymerase chain reaction (PCR)-based methods have been successfully used for detection of microsporidian infections. They are more sensitive and are able to identify microsporidia species. The purpose of this study is to identify E. bieneusi to adapt treatment and assess the true prevalence of the intestinal microsporidiosis due to this species in compromised patients in Tunisia. PATIENTS AND METHODS: One hundred and eighteen stools from immunocompromised patients, with a symptomatology in favour of the intestinal microsporidiosis, were analysed using light microscopy after staining with Modified Weber's trichrome stain and PCR. RESULTS: Only four were positive by Modified Weber's trichrome stain whereas eleven stools were positive by PCR, giving a prevalence of 20% in HIV-infected patients and 5,35% in human immunodeficiency virus-negative patients. CONCLUSION: This study confirms the usefulness of PCR in the diagnosis of the intestinal microsporidiosis due to E. bieneusi. Indeed, PCR has greater sensitivity than Modified Weber's trichrome stain and can identify the species of microsporidia in order to adapt the treatment.

[Profuse subcutaneous nodules in a Tunisian patient: Kaposi sarcoma revealing AIDS]. / Nodules sous cutanés profus chez un Tunisien: maladie de Kaposi révélatrice de SIDA.

The purpose of this report is to describe a case involving Kaposi sarcoma as the inaugural manifestation of HIV infection at the full-blown AIDS stage. The patient was a 59-year-old Tunisian man who presented with profuse subcutaneous nodules and multiple lymph nodes. Treatment was based on antiretroviral therapy in association with radiotherapy.

[Rhino-orbito-cerebral mucormycosis in the diabetic: a better known pathology in Tunisia]. / La mucormycose rhino-orbito-cérébrale chez le diabétique: une pathologie mieux connue en Tunisie.

This is a retrospective study including 17 patients with rhino-orbito-cerebral mucormycosis diagnosed in a period of 16 years, between 1992 and 2007, in 8 men and 9 women. All patients were diabetic with ketoacidosis diabetes in 8 cases. Necrosis facial and ophthalmic symptoms were the most frequent presenting manifestations. The diagnosis was confirmed by mycological examination, with or without histopathology, identifying Rhizopus oryzae in 12 cases. Treatment consisted in systemic amphotericin B combined with surgical treatment in only 7 cases. The mortality rate was high (65%) due principally to the delay in diagnosis and absence of surgical treatment.

[Melitococcal psoas abscesses: study of three cases and review of the literature]. / Les abcès mélitococciques du psoas: etude de 3 cas et revue de la litterature.

Vertebral involvement is a common complication of brucellosis in adults. However psoas abscess related to brucellar spondylitis have rarely reported. The purpose of this report is to describe three cases of bilateral psoas abscess identified during workup for brucellar spondylitis. Medical imaging was helpful in confirming diagnosis of these fluid collections. Epidemiological, clinical, radiological and serological findings were consistent with melitococcal etiology. Treatment was based on a combination of antibiotics (rifampicine-doxycycline) and abscess evacuation by percutaneous drainage, needle aspiration or open surgery. Outcome was favourable. Brucellar psoas abscess is uncommon. Most caseare discovered coincidentally during investigation of melitococcal spondylitis. Management usually consists of fluid drainage and appropriate antibrucellar therapy. Prognosis is favourable.

[Complement protein hereditary deficits during purulent meningitis: study of 61 adult Tunisian patients]. / Déficits héréditaires en protéines du complément au cours des méningites purulentes: étude de 61 patients adultes tunisiens et revue de la littérature.

Sixty one Tunisian adult patients with bacterial meningitis were screened for complement deficiency. Functional activity of the classical and the alternative pathways of complement (CH50 and AP50 respectively) were measured according to standard haemolytic procedures. Serum concentrations of C3 and C4 were determined by nephelometry. Late complement component (C5-C9) and properdin concentrations were assessed by double-ligand EISA. Complement deficiency was found in eight patients (13%): Seven had late complement component deficiency (three C7 deficiency, two C5 deficiency, one C6 deficiency and one C8 deficiency) and one had partial properdin deficiency. Patients with late complement component deficiency had a mean age of 24 years (range 17-32 years). All deficient patients had meningococcal meningitis. Recurrent meningitis was reported in half of the patients. Our findings demonstrated a high prevalence of complement deficiency in Tunisia suggesting that screening for hereditary complement deficiency should be performed in case of bacterial meningitides and meningococcal disease patients.