[Off label uses of tigecycline]. / Les utilisations hors-autorisation de mise sur le marché de la tigécycline.

INTRODUCTION: Tigecycline is a relatively new antibiotic that have very limited valid indications. When no other alternative is available, this drug is widely used off label with promising results. The objective of this study is to summarize the different off label uses of tigecycline so that we can decide when and how to prescribe it in the absence of guidelines. MATERIAL AND METHODS: This study a revue of the literature collecting all the articles concerning the off label uses of tigecycline. RESULTS: Tigecycline was widely prescribed, off label, to treat infections with controversial results. Randomised clinical trials were conducted to evaluate its use to treat pneumonia. The results for this indication have a respectable level of evidence. For the other indications, the data collected was insufficient to support tigecycline prescription. In fact, different protocols were used which makes it hard to evaluate the efficacy and to conclude to the best treatment regimen. A tendency to prescribe high doses of the molecule was noted in different studies. When prescribed off label, tigecycline prescriptions were associated with a higher mortality and incidence of side effects. CONCLUSION: The tigecycline remains a valid option for the treatment of infections dues to multi-resistant bacteria especially when other alternatives are scarce or in cases of renal failure.

Mediterranean spotted fever as a cause of septic shock.

Mediterranean spotted fever is a generally benign disease but with the potential of serious manifestations. We report a case of Mediterranean spotted fever in a 56-year-old woman, with pet dog exposure, who presented with a septic shock pattern. Based on clinical symptoms, history, and laboratory results, the diagnosis of Mediterranean spotted fever was suspected and the outcome was favorable with doxycycline treatment. Although rickettsiae remain an uncommon cause of the sepsis syndrome, it is important to consider it, especially as people are now traveling to endemic areas more frequently.

Epidemiological, clinical and laboratory features of murine typhus in central Tunisia.

OBJECTIVE: Murine typhus is an endemic zoonosis. It is difficult to diagnose because of its non-specific clinical manifestations. Our objective was to describe the epidemiological, clinical, laboratory, and treatment features of murine typhus. METHODS: We conducted a retrospective study of 73 adult patients hospitalized for murine typhus from 2006 to 2011. The diagnosis was confirmed by a single titer of IgM≥128 or by seroconversion to typhus group antigen identified by indirect fluorescent assay. RESULTS: The mean age of patients was 33.1 years (range, 13-68 years). Thirty-eight patients (52%) lived in rural or suburban areas; neither fleabites nor exposure to rats were reported. The most common clinical symptoms were: fever, headache, and myalgia. A maculopapular and non-confluent rash was observed in 47 patients (64.4%). No inoculation eschar was observed in any patient. Eight patients presented with interstitial pneumonia and two with lymphocytic meningitis. The diagnosis was confirmed by indirect fluorescence assay in every case. A single titer of IgM ≥ 128 was found in 62 (84.9%) cases. The other 11 cases were diagnosed by seroconversion. All patients were given antibiotics. Tetracyclines were prescribed in 57 cases (78%). The two patients presenting with meningitis were treated with fluoroquinolone. The outcome was favorable for all patients and no relapse was observed. CONCLUSION: The features of murine typhus are non-specific. The definitive diagnosis is based on serologic testing by indirect fluorescent assay. Cyclins were the most prescribed antibiotics.

[Bartonella quintana meningoencephalitis in an immunocompetent: rare case]. / Méningo-encéphalite à Bartonella quintana chez un sujet immunocompétent : une observation rare.

INTRODUCTION: Bartonella quintana (Bq) is responsible of various clinical pictures. Neuromeningeal complications are rarely reported. CASE: A 20-year-old woman was admitted for fever, headache lasting for 5 days. On admission, she was febrile at 39.3°C and had a stiff neck. Symptoms, contact with animals, biological tests and lumbar puncture (PL) rendered viral meningitis a likely diagnosis. She had received symptomatic treatment and the outcome was favorable. Three days later, the patient had headache, agitation and confusion with fever. The PL noted 130/mm(3) whites, 90% lymphocytes. The albuminorachie was 0.98 g/L, glucorachie was normal. The patient was treated with 400 mg of ofloxacine/day, seven days. Serologic tests for B. quintana were reactive. The outcome was favorable. CONCLUSION: B. quintana infection should be considered in neurological symptoms of unknown etiology.

[Macrophage activation syndrome: rare complication of murine typhus]. / Syndrome d'activation macrophagique: complication rare de typhus murin.

INTRODUCTION: Typhi is one of the rickettsial species endemic in the Mediterranean countries and is associated with the zoonotic infection of murine typhus, which may have a complicated course especially in adult patients. The association with macrophage activation syndrome (MAS) has rarely been reported in the medical literature. CASE REPORT: We describe a case of murine typhus in a diabetic woman complicated with MAS, who was effectively treated with cyclin and parenteral immunoglobulin. CONCLUSION: The murine typhus can be exceptionally complicated with SAM. This infection should be suspected in front of the discovery of SAM.

Rhino-orbito-cerebral mucormycosis: five cases.

INTRODUCTION AND OBJECTIVE: Mucormycosis is an invasive fungal infection usually observed in immunocompromised patients. Mucormycosis is rapidly fatal without an early diagnosis and treatment. We report five patients of rhino-orbital-cerebral mucormycosis and a literature review. DESIGN: The medical records of five patients presenting with rhino-orbital-cerebral mucormycosis, admitted between January 1995 and December 2007, were analyzed. All patients underwent tissue biopsy. The histologic sections revealed the presence of non-septate hyphae of the order Mucorales. RESULTS: The five patients, three men and two women, between 27 and 61 years of age, were all diabetic. The main symptoms were exophthalmia (five patients), facial swelling (four patients), periorbital cellulitis (four patients), and cranial nerve palsy (four patients). Anterior rhinoscopy revealed palatine or nasal necrotic lesions in four patients. All presented with diabetic ketoacidosis and CT scan revealed rhino-orbital-cerebral involvement in every patient. All patients were given intravenous amphotericin B. Four patients underwent surgical debridement of necrotic tissue. Two patients survived. CONCLUSIONS: Mucormycosis is usually a fatal infection in diabetic patients. Early diagnosis should be based on imaging data and histology. Amphotericin B must be rapidly initiated and associated with aggressive surgical debridement to reduce mortality.

[Tuberculosis of finger bones: three cases]. / Tuberculose digitale : à propos de trois cas.

Tuberculosis dactylis is exceptional. We report tuberculous dactylitis in three women who were 51, 44, and 62-year-old, respectively. The diagnosis was suspected on chronic and insidious clinical presentation, and confirmed by histology. Disease course was favourable with antibuberculosis regimen but two patients had permanent hand disability. Clinical and therapeutic issues are discussed in the context of an endemic country.

Quatre premiers cas de meningites a Toscana Virus dans la Region de Monastir

Les meningites a Toscana Virus ont ete largement decrites en Italie ou le virus a ete isole pour la premiere fois. Actuellement; elles sont de plus en plus decrites dans le pourtour du bassin mediterraneen devenant ainsi une pathologie emergente dans cette region. Nous rapportons; dans ce travail; 4 cas de meningites a Toscana Virus hospitalises dans le service des Maladies Infectieuses de l'hopital Fattouma Bourguiba de Monastir - Tunisie; en rappelant les caracteristiques epidemiologiques; cliniques; biologiques et evolutives. Tous les malades etaient de sexe masculin; demeurant dans une region cotiere et hospitalises pendant la saison estivale. Ils etaient ages en moyenne de 26 ans (14 - 41). Le diagnostic clinique reposait sur la presence d'un syndrome meninge febrile. La ponction lombaire avait montre dans les 4 cas une meningite lymphocytaire a liquide clair avec une glycorrachie normale. La detection des IgM et des IgG dans le sang et le LCR avait permis de confirmer le diagnostic. L'evolution etait favorable sous traitement symptomatique; dans tous les cas; avec un recul de 9 mois

Six cas d'actinomycoses

L'actinomycose est une affection granulomateuse rare due a des bacteries anaerobies du genre Actinomyces. Ses localisations sont multiples pouvant simuler un processus inflammatoire; neoplasique ou infectieux a pyogenes. Nous rapportons 6 cas d'actinomycose dont le diagnostic etait retenu sur des criteres anatomopathologiques. L'evolution etait favorable sous antibiotherapie adaptee et prolongee. Ce travail illustre les difficultes diagnostiques et l'importance de l'examen anatomopathologique qui doit etre systematique

Ocular manifestations associated with murine typhus.

AIMS: To characterise and analyse ocular manifestations associated with acute murine typhus (MT), an infectious disease caused by Rickettsia typhi. METHODS: Nine consecutive patients (18 eyes) with serologically confirmed MT at the acute stage were enrolled in this prospective, non-comparative study. All patients underwent complete ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography (FA) and indocyanine green (ICG) angiography. RESULTS: Of nine patients, eight (88.9%) had bilateral ocular involvement related to MT, with (n = 3) or without (n = 5) associated ocular symptoms. Findings included mild vitreous inflammation (10 eyes; 55.6%), white retinal lesions (nine eyes; 50%), retinal haemorrhages (four eyes; 22.2%), retinal vascular leakage (seven eyes; 38.9%), hypofluorescent choroidal dots on FA and/or ICG angiography (11 eyes; 61.1%), optic-disc swelling (two eyes; 11.1%), optic neuritis (one eye; 5.6%) and optic-disc staining (11 eyes; 61.1%). All ocular findings had a self-limited course. CONCLUSION: Ocular involvement is frequently observed in acute MT. A systematic fundus examination, complemented by angiography in selected cases, may be helpful in establishing an early clinical diagnosis of the disease while serological testing is pending.

[Hydatid disease of bone: a report of 2 cases]. / Kyste hydatique primitif intraosseux: à propos de deux cas.

INTRODUCTION: The hydatid cyst of Echinococcus granulosus tends to develop in liver. The primary bone hydatidosis is rare. EXEGISIS: The authors report 2 cases of primary hydatidosis of bone in a 57 year old men and 60 year old diabetic women. The symptoms and signs were not specific. The ultrasound investigation: standard radiography and computed tomographic scan, was suggestive of the lesion. The chest radiograph and the abdominal ultrasound were normal. Serological tests for hydatid disease were positive. The two patients have surgical excision and medical treatment: Albendazole administrated for 6 months. Histologic evidence confirmed the diagnosis. The outcome was good for both patients without recurrence after 2 years. CONCLUSION: Through these 2 cases and a review of the literature, the authors analyse the epidemiological and clinical aspects of bone hydatidosis and discuss the therapeutic procedures.

[Adverse effects of antitubercular drugs: epidemiology, mechanisms, and patient management]. / Les effets indésirables des antituberculeux: épidémiologie, mécanismes et conduite à tenir.

Tuberculosis, what ever its localization, is an infectious disease which can be totally cured by combining antitubercular drugs. Current therapeutic regimens with isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin have proved successful in treating tuberculosis. However, they are associated to a high rate of adverse effects that can lead to therapeutic failure. Understanding the nature and the severity of these adverse effects allows for their appropriate management. Toxic neuropathy and hepatitis are the most common adverse reactions to isoniazid. Rifampicin is generally well tolerated but some severe immuno-allergic reactions may occur in case of intermittent regimen. Pyrazinamide-induced liver injury is rare but sometimes lethal. Joint affections, usually due to hyperuricemia, are more frequent but easily manageable. The major adverse effect related to ethambutol is ocular optic neuropathy. It occurs dose-dependently and can be irreversible. Finally, administration of streptomycin is potentially associated with renal and cochleo-vestibular toxicity that might be milder than when induced by other aminoglycosides. The management of antituberculosis-induced adverse effects depends on parameters related to the adverse effect itself and to the administrated drug.

[Meningitis revealing Rickettsia typhi infection]. / Méningite révélant une infection à Rickettsia typhi.

INTRODUCTION: Neurological manifestations are rarely observed in murine typhus. We present a case of meningitis caused by Rickettsia typhi. EXEGESIS: We report a case of Tunisian 57-year-old woman admitted for suspicion of meningitis. Clinical examination revealed fever at 39,5 degrees C and nuchal rigidity. There were no focal neurologic signs, cutaneous rash or eschar. Lumbar puncture showed clear cerebrospinal fluid containing normal glucose, 0,48 g/l protein and 30 WBC (78% lymphocyte). Gram-stained smear and culture were negative. Serology confirmed the diagnosis. The patient was initially treated by ampicillin 12 g daily but remained febrile. Retinal lesions were detected on ophthalmic examination, suggesting rickettsial infection. Clinical outcome was good after 7-day treatment with oral ciprofloxacin 1,5 g daily. The mean follow-up was six months. CONCLUSION: Murine typhus is an endemic zoonosis. Neurological manifestations were uncommon. An ophthalmic examination is recommended if rickettsiosis was suspected.

[Pulmonary thrombosis as a complication of Mediterranean spotted fever]. / Une fièvre boutonneuse méditerranéenne compliquée d'une embolie pulmonaire.

INTRODUCTION: Thromboembolic complications were uncommon in mediterranean spotted fever. OBSERVATION: We report a case of 55-years- old man who was admitted for mediterranean spotted fever. Two days later, the patient developed chest pain due to a pulmonary thrombosis confirmed by angio-CT. The outcome was good with heparin therapy. The investigation for another cause of thrombosis was negative. CONCLUSION: Mediterranean spotted fever is usually a moderately severe self-limited illness. Pulmonary thrombosis was uncommon associated with severe disease.

[Phalengeal actinomycosis: a rare disease]. / Actinomycose des os du pied: un diagnostic à ne pas méconnaître.

INTRODUCTION: Bone involvement in actinomycosis is rare. EXEGESIS: We report a case of a 38 year-old woman with foot bone actinomycosis. The clinical symptoms were non-specific and the diagnosis was difficult. An X-ray revealed an osteolysis and a sclerosis of the proximal phalanx of the big toe. A phalengiectomy was carried out after the failure of antistaphylococcic antibiotherapy. The diagnosis of actinomycosis was substantiated by a histological examination. The clinical outcome was good after six-month treatment by penicillin G substitutes for cotrimoxazol. The patient completely recovered and was feeling well. The mean follow up was fifteen months. CONCLUSION: Clinical and therapeutic aspects of this rare localization are reviewed.

[Pyogenic splenic abscesses. A review of 8 cases]. / Les abcès de la rate à pyogènes. A propos de 8 cas.

PURPOSE: Pyogenic splenic abscess is un uncommon and potentially life-threatening disease. Due to inconspicuous and nonspecific clinical picture, it remains a diagnostic challenge. Medical imaging progresses are helpful for diagnosis and treatment. METHODS: We tried to establish epidemiologic and clinical features and therapeutic possibilities of 8 cases of splenic abscesses occurred between 1993 and 2002. RESULTS: There were 5 male patients and 3 female patients. Aged ranged from 17 to 53 years, with a median of 34 years. One patient was immunocompromised (colonic carcinoma). Common clinical presentations included fever (n=8) and left upper quadrant abdominal pain (n=7). Positive blood cultures were found in only four patients (50%) : Staphylococcus aureus (3) and coagulase negative Staphylococcus (1). Staphylococcus aureus and Bacteroïdes fragilis were isolated in one abscess pus respectively. The diagnosis was obtained by ultrasonography in all 8 cases. Antibiotics were prescribed in all cases for a mean length of 60 days (30 - 110 days). Splenectomy and percutaneous CT-guided drainage were performed in one case respectively. Evolution was good in all cases. CONCLUSION: Splenic abscesses are increasingly recognized. The combination of clinical features and imaging findings, early diagnosis and treatment can be made.