Pseudotumoural pulmonary tuberculosis: a case series.

This report describes three cases of tumour-like pulmonary tuberculosis: two patients had stage C3 human immunodeficiency virus (HIV) infection (with uncontrolled HIV-1 in one case) and one patient was immunocompetent. All patients initially presented with general and respiratory symptoms, with radiological findings simulating lung carcinoma. Tuberculosis was diagnosed from microbiological testing and/or histological examination results. A disseminated form was described in one case. All patients were treated successfully with antimycobacterial therapy, with control of HIV infection in both cases.

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.

Testicular adrenal rest tumours in young adult males with congenital adrenal hyperplasia: prevalence and impact on testicular function.

Testicular adrenal rest tumours (TARTs) have been described in patients with congenital adrenal hyperplasia (CAH). The aim of the study was to determine the prevalence of TARTs in patients with CAH, the associated factors and their impact on gonadal function. It is a prospective study concerning six young adult men with CAH, four cases with 21-hydroxylase deficiency and two cases with 11-hydroxylase deficiency. All patients were under glucocorticoid therapy. The mean age was 25 years (range: 20-31). All patients underwent a physical examination with testicular palpation, scrotal ultrasonography, a blood sample for serum testosterone, FSH, LH, inhibin B, ∆4-androstenedione and 17-OH-progesterone measurements and a semen analysis. Ultrasound revealed TARTs in four patients; three were bilateral. The mean tumour size was 6.3 ml (range: 0.02-14.1). The tumours were palpable in two cases. 17-OH-progesterone was <10 ng/ml in all cases. Decreased testosterone level was found in one case. The semen analysis revealed azoospermia in one case and poor semen quality in four patients. TARTs were common and associated with impaired spermatogenesis.

Arrhythmia and thyroid dysfunction.

CONTEXT: Arrhythmia is a major cause of morbidity and mortality in Europe and in the United States. The aim of this review article was to assess the results of the prospective studies that evaluated the risk of arrhythmia in patients with overt and subclinical thyroid disease and discuss the management of this arrhythmia. EVIDENCE ACQUISITION: A literature search was carried out for reports published with the following terms: thyroid, hypothyroidism, hyperthyroidism, subclinical hyperthyroidism, subclinical hypothyroidism, levothyroxine, triiodothyronine, antithyroid drugs, radioiodine, deiodinase, atrial flutter, supraventricular arrhythmia, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation, torsade de pointes, amiodarone and atrial fibrillation. The investigation was restricted to reports published in English. EVIDENCE ANALYSIS: The outcome of this analysis suggests that patients with untreated overt clinical or subclinical thyroid dysfunction are at increased risk of arrhythmia. Hyperthyroidism increased atrial arrhythmia; however, hypothyroidism increased ventricular arrhythmia. CONCLUSION: The early recognition and effective treatment of thyroid dysfunction in patients with arrhythmia is mandatory because the long-term prognosis of arrhythmia may be improved with the appropriate treatment of thyroid dysfunction.

[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.

[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.

[Evaluation of blood pressure control by ambulatory blood pressure monitoring and study of factors associated with poor blood pressure control in 300 treated hypertensive type 2 diabetic patients]. / Évaluation de l'équilibre tensionnel par la mesure ambulatoire de la pression artérielle et étude des facteurs associés à un mauvais contrôle tensionnel chez 300 diabétiques de type 2 hypertendus traités.

UNLABELLED: Hypertension is frequently associated with type 2 diabetes and is often difficult to control. AIM: Evaluate the frequency of controlled hypertension in our type 2 diabetic patients with known and treated hypertension and determine the factors associated with poor blood pressure control. SUBJECTS AND METHODS: Prospective study concerning 300 type 2 diabetic patients with a known and treated hypertension, sex-ratio: 0.64, mean age: 61.2±9.1 years (37-86). All subjects underwent physical examination, biological investigations and a 24 hours ambulatory blood pressure monitoring (ABPM). RESULTS: Hypertension was well controlled in 70 patients (23.3%). The concordance rate between clinical measure of blood pressure and ABPM was 70.3%. Subjects with uncontrolled hypertension were older (61.8±8.9 vs 59.1±9.3 years, P<0.05), more frequently of male sex (sex-ratio: 0.77 vs 0.34, P<0.01), smokers (36.4 vs 21.7%, P<0.05) and with abdominal adiposity (P<0.05). Duration of diabetes, body mass index and the frequency of peripheral neuropathy, retinopathy and coronary insufficiency were not different between the two groups. Diabetic nephropathy was more frequent (29.8 vs 16.1%, P<0.05) in the group with uncontrolled hypertension. Loss of circadian blood pressure rhythm was noted in 239 patients (79.6%) and it was more frequently observed in patients with uncontrolled hypertension (84 vs 66%, P<0.001). CONCLUSION: Our type 2 diabetic patients had a poorly controlled hypertension. Close monitoring of blood pressure with adjustment of antihypertensive treatment are necessary to improve cardiovascular prognosis of our patients.

[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.

Metabolic syndrome in Tunisian psoriatic patients: prevalence and determinants.

BACKGROUND: A significant association between psoriasis and the metabolic syndrome (MetS) has been frequently reported. OBJECTIVE: The aim of this study was to specify the main factors that determine the MetS in psoriatic Tunisian patients. METHODS: A case-control study has included 164 psoriatic patients and 216 controls. RESULTS: The prevalence of MetS was higher in cases than in controls but without statistical differences [35.5% vs. 30.8%, odds ratio (OR): 1.39 CI: 0.88-2.18; P=0.095]. According to gender, the prevalence of MetS was significantly increased only in psoriatic women (47.4% vs. 30%, OR: 1.89, CI: 1.11-3.21; P=0.01). A multiple logistic regression, considering the effect of age, and gender, showed that the prevalence of MetS was significantly higher in cases than in controls (OR: 1.73, CI: 1.06-2.82; P=0.03). MetS components analysed seperately showed a significantly higher prevalence of decreased high-density lipoprotein cholesterol (HDLc) (60.9% vs. 35.9%, OR: 2.77, CI: 1.8-4.27, P<0.001) and for increased hypertension (50% vs. 40%, OR: 1.48, CI: 0.97-2.257, P=0.04) in psoriatic patients. According to gender, HDLc was significantly decreased in both genders (male: OR: 2.075, CI: 1.24-3.47, P=0.004; female: OR: 3.58, CI: 2.07-6.19, P<0.0001), while hypertension was increased only in psoriatic men (OR: 2.09, CI: 1.24-3.51, P=0.004) and abdominal obesity only in psoriatic women (OR: 2.31, CI: 1.30-4.11, P=0.002). CONCLUSION: Decreased HDLc is the main biological abnormality that characterized MetS in Tunisian psoriatic patients. Moreover, contrary to men, psoriatic women have shown a significantly higher prevalence of MetS, which is, in addition to decreased HDLc, mainly attributed to abdominal obesity.

[Demographic, clinical and therapeutic features of adult visceral leishmaniasis at the Rabta hospital in Tunis (tunisia) from 1983 to 2002]. / Aspects épidémiologiques, cliniques et thérapeutiques de la leishmaniose viscérale de l'adulte à l'hôpital de la Rabta à Tunis (tunisie) entre 1983 et 2002.

The purpose of this study was to evaluate in a retrospective analysis, cases of Mediterranean visceral leishmaniasis (VL) diagnosed in adults during a 20-year period in a department of infectious diseases. Demographic data, clinical and laboratory features and therapeutic findings were considered. During the study period, 22 cases of VL were diagnosed, and 6 (27%) were associated with HIV infection. Fever and splenomegaly were observed in all cases. Anaemia was constant. The anti-leishmanial IF titer was positive among 21 patients (95%). Smears from bone marrow aspiration were positive at microscopy in 95% of cases. Zymodeme analysis was carried out in nine isolates. L. infantum zymodeme MON-1 was characterized in all cases. Seventeen patients (77%) received meglumine antimoniate (MA) (20 mg SbV/kg per day) and 5 (23%) patients amphotericin B (AB) (0.5-1 mg/kg per day) for an average period of 25 days (10-49 days). Adverse events occurred in 7 patients (32%), among them 4 received AB. Clinical cure was achieved with success in 21 patients (95%). After a successful MA treatment of the initial episode, VL relapse was observed in one HIV-positive patient. Only one HIV-positive patient died from neurological disorders. VL is rare in adults. However, its incidence is increasing everywhere in the world, because of HIV-related cases. Its prognosis depends on the precocity of diagnosis and treatment.

[Celiac disease revealed by hypocalcemia complicating total thyroidectomy: a case report]. / Maladie coeliaque révélée par une hypocalcémie secondaire à une thyroïdectomie totale: à propos d'un cas.

In order to illustrate a particular circumstance of diagnosis of celiac disease, we report the case of 54-year-old women with a history of thyroid enlargement with normal thyroid function and positive anti-peroxidase antibodies. Immediately after total thyroidectomy with preservation of the parathyroid glands, she developed tetany with total serum calcium level at 50mg/l. Intravenous calcium infusion increased the calcium level and led to resolution of hypocalcemia-induced signs but there was no result when calcium and vitamin D were taken orally. The diagnosis of malabsorption was very probable in light of the family history of celiac disease, the anemia and the hypoalbuminemia. The diagnosis was confirmed by antibodies assay and endoscopy. The PTH level was less than 1 pg/l and radiography showed signs of hyperparathyroidism. Gluten-free diet, calcium and vitamin D led to an improvement of serum calcium.

[Quality of ambulatory care of non-insulin dependent diabetic patients]. / La qualité de la prise en charge ambulatoire des patients diabétiques non insulinotraités.

We assessed the quality of care provided to non-insulin treated diabetic patients by examining the medical records of 248 such patients attending our outpatient department in 2002. The mean age was 59.5 (SD 10.1) years, 62.1% were women and known duration of diabetes was 8.6 (SD 5.9) years. The majority of patients were treated with a combination of sulfonylurea and metformin. Glycaemic control was assessed using fasting blood glucose in 96.8% of patients, post-prandial blood glucose in 31.9% and glycated haemoglobin in 52.4%. Weight was measured at least once for 88.7% of patients, blood pressure for 91.1% of patients and lipid levels for 64.9%. Body mass index was less than 25 kg/m2 in 12.3% of patients and blood pressure less than 140/90 mmHg in 40.3%. Foot examination was noted in only 2% of records, electrocardiography was performed for 25% of patients and fundoscopy for 21%. Proteinuria was documented in 19.8% of patients and plasma urea and/or creatinine in 57.3%.

[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.

Clinical and metabolic characteristics of newly diagnosed diabetes patients: experience of a university hospital in Tunis.

PURPOSE: The aim of our retrospective study was to explore the clinical and metabolic characteristics of newly diagnosed diabetes patients over the age of 30 years. METHODS: Study participants were consecutive, newly diagnosed patients with diabetes, over the age of 30 years, presenting to our university hospital department between January 1999 and June 2003. Clinical and metabolic data were collected retrospectively by medical record review. RESULTS: Three hundred seventy patients were included; mean age was 54.1+/-14.0 years; 49% were women and a family history of diabetes was reported in 52% of patients. Patients presented with acute complications in 40% of cases. Symptoms of polyuria-polydipsia and weight loss were present at diagnosis in 87% and 76% of cases respectively. 58% of our patients were obese or overweight (BMI> or =25 kg/m(2)), hypertension was present in 22%, hypertriglyceridemia in 27% and high LDL cholesterol in 27%. Neuropathy was diagnosed in 24%, nephropathy in 13%, coronary heart disease in 9%, retinopathy in 8% of cases, stroke in 3% and peripheral arterial disease in 2%. Insulin was prescribed initially in 47% of cases. CONCLUSIONS: Our results demonstrate that clinical symptoms and acute ketosis are the most common presenting features of diabetes mellitus in adults at the hospital level. Associated chronic complications are frequent.

[The quality of ambulatory care provided to non-insulin treated diabetic patients]

We assessed the quality of care provided to non-insulin treated diabetic patients by examining the medical records of 248 such patients attending our outpatient department in 2002. The mean age was 59.5 [SD 10.1] years, 62.1% were women and known duration of diabetes was 8.6 [SD 5.9] years. The majority of patients were treated with a combination of sulfonylurea and metformin. Glycaemic control was assessed using fasting blood glucose in 96.8% of patients, post-prandial blood glucose in 31.9% and glycated haemoglobin in 52.4%. Weight was measured at least once for 88.7% of patients, blood pressure for 91.1% of patients and lipid levels for 64.9%. Body mass index was less than 25 kg/m2 in 12.3% of patients and blood pressure less than 140/90 mmHg in 40.3%. Foot examination was noted in only 2% of records, electrocardiography was performed for 25% of patients and fundoscopy for 21%. Proteinuria was documented in 19.8% of patients and plasma urea and/or creatinine in 57.3%