The prevalence of healthcare-associated infection in medical intensive care units in Tunisia. Results of the multi-centre nosorea1 study.

OBJECTIVES: To determine the prevalence of Healthcare-Associated Infection (HAI) in medical Intensive Care Unit (ICU), risk factors for these infections and identify the predominant infecting organisms. METHODS: A 1-day point-prevalence study within all medical ICUs in Tunisia, all patients occupying an ICU bed over a 48-hour period were included. Rates of HAI, resistance patterns of microbiological isolates and potential risk factors for HAI were recorded. RESULTS: One hundred and three patients were collected from 15 Tunisian medical ICUs. HAI prevalence was 25.2% CI 95% [15-35].The most frequent HAIs were hospital acquired pneumonia in 19 cases (59%) and catheter related infection in 5 cases (15%). Independent factors associated with HAI occurrence were SAPSII score ≥ 33 with OR 1.047; CI 95% [1.015-1.077], p=0.003 and recent hospitalization with OR 4.14 CI 95% [1.235-13.889], p=0.021. Non-fermenting pathogens were the most frequent microorganisms reported in ICUs ecology, prior colonization and HAIs of the screened patients. CONCLUSION: HAIs are frequent in medical ICUs in Tunisia, which emphasize the importance of specific measures for surveillance and infection control in critically ill patients. Implementing a national monitoring system of HAI should be a major priority of public health in Tunisia.

Coinfection with Mycobacterium tuberculosis and Pneumocystis Jirovecii in immunocompetent young woman.

Pneumocystis pneumonia is a severe opportunistic infection in immunocompromised patients, caused by Pneumocystis jirovecii (P. jirovecii). The co-infection with community-acquired P. jirovecii and Mycobacterium tuberculosis (M. tuberculosis) is exceptionally described in non immunocompromised patients. We herein report the case of a young woman, with no medical history, who developed an acute respiratory failure due to P. jirovecii pneumonia associated with miliary tuberculosis. An extensive immunological investigation ruled out any acquired or primary immunodeficiency, suggesting that she was most likely immunocompetent. This report shows that such infections are not restricted to immunocompromised hosts. Moreover, it is tempting to speculate that the development of M. tuberculosis infection in this patient could be a risk factor for transition from colonization status of respiratory tract by P. jirovecii to pneumocystosis.

Ewing-like adamantinoma.

The Ewing-like variation of adamantinoma is a rare entity, leading to challenge its differential diagnosis, notably with Ewing's sarcoma. We are reporting a case of a 20-year-old male who presented with swelling in the left leg that had progressed over a 2-year period. X-rays revealed a tumour in the tibia that was intracortical, osteolytic, multilocular and invaded the soft tissues. A surgical biopsy was performed. Histopathology examination showed a tumour growth with small round cells expressing CD99. A diagnosis of Ewing's sarcoma was made. Since the patient declined surgical treatment, chemotherapy was administered. Two years later, the patient returned because the tumour had grown in size. A second biopsy was performed. Microscopic evaluation showed a tumour growth with osteofibrous and epithelial components, which expressed pankeratin and vimentin, but was negative for CD99. A diagnosis of Ewing-like adamantinoma was made.

Expression patterns of Notch receptors and their ligands in human osteoarthritic and healthy articular cartilage.

Notch pathway plays a pivotal role in cell fate determination. There is much interest surrounding its therapeutic potential, in osteoarthritis, but the expression profile of Notch-related molecules, as well as their relation with cartilage pathological parameters, remains unclear. The purpose of our study is to analyze the expression pattern of Notch family members, type II and type I collagen, in normal (healthy) and osteoarthritic human knee cartilage. Osteoarthritic cartilages were obtained from 3 patients undergoing a total knee replacement. Macroscopically normal cartilage was dissected from 3 human knees at the time of autopsy or surgery. Immunohistochemical staining was performed using Notch1,2,3 and 4, Delta, Jagged, type II collagen and type I collagen antibodies. In healthy cartilage, type II collagen was abundantly expressed while type I was absent. This latter increased proportionally to the osteoarthritic grade. Type II collagen expression remained intense in osteoarthritic cartilage. In healthy cartilage as well as in cartilage with minor lesions, Notch family member's proteins were not or just weakly expressed at the surface and in the cells. However, Notch molecules were over-expressed in osteoarthritic cartilage compared to healthy one. This expression pattern was different according to the cartilage zone and the severity of OA. Our data suggest that Notch signaling is activated in osteoarthritic cartilage, compared to healthy cartilage, with a much more abundant expression in the most damaged areas.

[Enigmatic evolution of an association of pulmonary tuberculosis and amyloidosis]. / Évolution énigmatique d'une association de tuberculose et d'amylose pulmonaire.

INTRODUCTION: Amyloidosis is characterized by tissue deposits of amyloid material. Secondary amyloidosis can occur as a sequel to pulmonary tuberculosis over a relatively long period. However, this was not the case with our patient. Subsequently we conducted a literature review to try to explain the unusual course of AL amyloidosis in our patient. CASE REPORT: A 36- year-old patient was admitted to our department for investigation of haemoptysis. A diagnosis of primary pulmonary tuberculosis was made and antituberculous treatment was started. On the second day of treatment, a haematoma appeared on the sole of the right foot, which spread down to the toes during the following days. Renal investigations showed a 24h proteinuria of 9 g/L and serum protein electrophoresis revealed an albumin level of 11.8 g/L. A diagnosis of nephrotic syndrome was made. A renal biopsy was indicated but this was not possible on account of a marked worsening of the patient's condition after 14 days of treatment. The patient's level of consciousness deteriorated and he was transferred to the intensive care unit for ventilation. He died 48 hours later. Post-mortem histological examination of pulmonary and cutaneous tissue revealed AL amyloid deposits. CONCLUSION: In view of the association of active pulmonary tuberculosis and a pulmonary localisation of amyloidosis, a causal relationship is not definite. Coexistence of active pulmonary tuberculosis and primary amyloidosis must also be considered, particularly as the immunohistochemical characterisation revealed AL amyloidosis.

[Dermatofibrosarcoma protuberans in children]. / Dermatofibrosarcome protubérant de l'enfant.

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare skin neoplasm. Usually affecting adults, the incidence in children is even less frequent. Through a report of three pediatric cases of DFSP, we describe the particularities of this tumor in children. Three boys aged 8, 9, and 15 years presented with a firm nodular skin lesion of the trunk, varying in size from 1 to 5 cm. No previous trauma event had occurred. Diagnosis was confirmed in all cases by immunohistological study. Surgical excision was performed in all cases. No recurrence was evident during the follow-up period of, respectively, 15, 36, and 49 months. The DFSP is an infiltrative tumor of intermediate malignancy, with a limited potential for metastasis (<5%) but a high rate of local recurrence (≥ 50%). The incidence in children is even less frequent. In children, its seemingly benign clinical appearance may explain delays in diagnosis; the majority of lesions affect the extremities, suggesting a potential role-played by injury. In our observations, however, as in adults, the trunk was the site of occurrence. Despite the uncertain pathogenesis of this tumor, the finding of certain characteristic histopathological features helps establish an accurate diagnosis. As in adults, surgical treatment with large surgical margins remains the best practice for children with DFSP, directly affecting the prognosis.

Endometrial stromal sarcoma presenting as a cystic abdominal mass.

Endometrial stromal sarcoma (ESS) is rarely localized in extrauterine sites if metastasis or local extension of the primary uterine tumour are excluded, and diagnosis can be delayed because of the unusual site. We report a case of abdominal ESS in a 45-year-old woman who presented with an abdominal complaint. Ultrasound of the abdomen showed a large multiloculated cystic mass. The complete excision of the tumour revealed ESS arising in endometriosis. The tumour expressed hormonal receptors and the patient was administered hormonal therapy. ESS has a better prognosis than the sarcoma that is part of differential diagnosis, and is associated with endometriosis in about one-half of cases.

Primary CD30/ALK-1 positive anaplastic large cell lymphoma of the skeletal muscle in a child.

Anaplastic large cell lymphoma (ALCL) represents approximately 10 to 30% of all childhood non-Hodgkin lymphomas. It frequently involves both lymph nodes and extranodal sites whereas primary or secondary muscular involvements are quite uncommon. We describe a case of an 8-year-old boy presented with one month progressively swelling right buttock mass without association of lymphadenopathy or skin extension. Biopsy of the lesion showed large anaplastic cells with voluminous and abundant cytoplasm as well as folded nuclei. The tumour cells were positive for CD30, CD3, EMA and ALK-1. Chemotherapy resulted in durable remission status. This case emphasizes the occurrence of anaplastic large cell lymphoma in the soft tissue and the favourable outcome of ALK-positive anaplastic large cell lymphoma.

Primary cutaneous marginal zone B-cell lymphoma: clinical and histological aspects.

According to the WHO-EORTC classification of cutaneous lymphomas, primary cutaneous marginal zone B-cell lymphoma are now well characterized. We report here a case of primary cutaneous marginal zone B-cell lymphoma in a 51 year-old man in which the diagnosis was made using both histology and immunopathology. The patient had no remarkable medical history, no history of either acute inflammation or insect bite, and presented with a 5 cm solitary asymptomatic erythematous firm, multinodular and infiltrated plaque on the back for 12 months. Histological examination and immunohistochemical study of a cutaneous biopsy provided a differential diagnosis between B cell lymphoma and lymphocytoma cutis. Full body work up revealed no signs of extracutaneous dissemination. The patient underwent surgical excision of the nodule. Histological examination showed a histological and immunophenotyping profile typical of primary cutaneous marginal zone B-cell lymphoma. The lesion was completely excised with clear margins and no recurrence occurred after a 12 month-follow-up period. Primary cutaneous marginal zone B-cell lymphoma are low-grade lymphomas that have an indolent course and a high tendency to recur. They should be differentiated from lymphocytoma cutis and from the other types of cutaneous B cell lymphomas that have a different course and prognosis.

Femoral parosteal osteosarcoma 18 years after its discovery: a case report.

Osteosarcomas are a heterogeneous group of tumors with diverse anatomical, clinical, and progressional characteristics. Parosteal osteosarcoma, or juxtacortical osteosarcoma, is a rare form of osteosarcoma that develops at the bone surface, but has a better prognosis than other conventional osteosarcomas. We report the observation of a 22-year-old female patient whose initial presentation was an enormous tumefaction of the knee that had been progressing for 10 years. The biopsy concluded in PO of the lower third of the femur. Staging was negative. The tumor had reached an enormous size and required amputation of the left lower extremity. A custom external prosthesis was manufactured to get her back to walking. Eight years after surgery, no local recurrence or metastasis has been detected. Parosteal osteosarcoma is a rare form of osteosarcoma with very slow progression (in spite of the particularly dramatic presentation in our observation), with an excellent prognosis and very rare metastasis.

[Malignant degeneration of benign cystic teratoma of the ovary with synchronous mediastinal teratoma. A case report]. / Association synchrone d'un tératome de l'ovaire cancérisé associé à un tératome du médiastin. A propos d'un cas.

Squamous cell carcinoma arising in mature cystic teratoma of the ovary is an uncommon complication occurring usually in elderly woman. We present an unusual case of a post-menopausal woman with a synchronous mediastinum teratoma. While ovary tumor was symptomatic, mediastinal teratoma was an incidental finding. To the best of our knowledge, this association is the first to be reported in literature.

[Breast cancer in Tunisia: epidemiologic characteristics and trends in incidence]. / Cancer du sein en Tunisie: caracteristiques epidemiologiques et tendance evolutive de l'incidence.

The goal of this study is to analyze certain epidemiologic characteristics of breast cancer in Tunisia and to foresee the consequences that will arise from the trends in incidence of this cancer. Data obtained from the North-Tunisia Cancer Registry (NTCR) and from the Salah AZAIZ Institute (SAI) Registry is used to estimate the different incidence rates and to compare these rates with those of other countries. In 15 years the crude incidence rate for breast cancer in the North Tunisia almost doubled to reach 21.5 cases/100,000 women per year during 1994-1998. The high rate of this cancer among women younger than 35 years (11%) could be related to a relatively low incidence among post-menopausal women. The clinical profile of breast cancer remains quite alarming: 40.2% of cases have a tumor with a clinical diameter equal or greater than 5 cm. Birth cohort effect, also know as the generation effect, is expected to lead to an increase of cancer incidence in the future. The rather high number of young cases is a source of additional cost on social and financial level. The priority is now to solve the problem of late diagnosis it has aggravated the prognosis of this cancer in Tunisia.

[Retrospective results of ultrasonographically-guided biopsy the breast cancer screening program of the Ariana area of Tunisia]. / Etude rétrospective des résultats des cytoponctions et des microbiopsies mammaires écho-guidées du programme du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the results of breast ultrasonographically-guided fine needle aspirations and needle biopsies within the breast cancer screening program of L'Ariana state in Tunisia. MATERIAL AND METHODS: Our retrospective study include 143 patients, with mammographically detected lesions, which underwent a diagnostic percutanous ultrasonographically guided procedures. 57 patients underwent a fine needle aspiration, 25 underwent a needle biopsy and 61 patients underwent both procedures. RESULTS: Sensitivity and specificity of fine needle aspiration are of 84.2% and 98.5%. We report 13.5% of non contributive results. The needle biopsy have a sensitivity of 97.3% and a specificity of 100% with one false negative corresponding to an atypical ductal hyperplasia at the excisional biopsy. CONCLUSION: Fine needle aspiration is a reliable method of accurately establishing a diagnosis. Needle biopsy is recommended for a preoperative lesion characterisation before adequate treatment.

Desmoplastic spitz nevus: report of a case and review of the literature.

Desmoplastic spitz nevus (DSN) is an uncommon melanocytic lesion. The histologic features of this benign tumour may mimic those of certain benign (dermatofibroma and desmoplastic cellular blue nevus) or malignant (metastatic carcinoma and malignant melanoma) neoplasms. We report the case of a male with a DSN, and also review the clinical characteristics, histologic features and differential diagnosis of this extremely rare lesion. The lesion is identified as an asymptomatic reddish-brown dome-shaped papule on the forearm. Microscopic examination showed a symmetric lesion in the dermis. The neoplastic cells were large and epithelioid-shaped, and were either isolated as individual cells or arranged in small nests in a paucicellular hyalinized stroma. Nuclei were large and vesicular with small nucleoli and no mitoses. Diffuse expression of S100 and the absence of staining with antibodies to melan-A and HMB45 was observed. A diagnosis of DSN with free margins was made. The histologic presentation of this benign lesion mimics both benign and malignant neoplasms. The immunohistochemical profile (S100 positive, HMB-45 negative and cytokeratin negative) may be helpful to differentiate it from other lesions.

Invasive mucinous carcinoma arising within breast fibroadenoma.

Malignant neoplasms arising in the epithelial component of breast fibroadenomas are rare. The most frequent types are lobular and ductal intra-epithelial carcinomas, with a minority of infiltrating carcinoma. We report a case of 36-year-old patient with invasive mucinous carcinoma (30 x 30 mm) arising in a complex breast fibroadenoma (130 x 60 x 30 mm). The patient underwent mastectomy with dissection of the axillary lymph nodes, which were free of tumour. The patient is alive without disease five years later. To the best of our knowledge, this is the first report of an invasive mucinous carcinoma arising within breast fibroadenoma. Our case provides information about the clinicopathologic characteristic of this unusual tumour.

Smooth muscle differentiation in ovarian granulosa-cell tumours: a new case report.

Smooth muscle differentiation in stromal ovarian tissue has rarely been described in normal and tumoural ovaries, especially in granulosa-cell tumours. A moderately differentiated adult granulosa-cell tumour in an 83-year-old-woman is reported. Tumoural stroma included clusters of regular smooth muscle cells stained positively for smooth muscle actin. The presence of smooth muscle differentiation in an ovarian granulosa-cell tumour should be taken into consideration during diagnosis.

[An unusual renal neoplasm: mucinous tubular and spindle cell carcinoma]. / Une tumeur rénale à connaître: le carcinome tubulomucineux et fusiforme.

Mucinous tubular and spindle cell carcinoma is a rare and newly described type of renal cell carcinoma (RCC) with a relatively indolent behaviour. We report a case of 53-year-old woman who had macroscopic hematuria and flank pain. A right radical nephrectomy was performed showing a well circumscribed tumour confined to the kidney and measuring 17cm. The histologic findings consisted of tightly packed, small, elongated tubules separated by pale mucinous stroma. The tumour cells were cuboidal to spindled with eosinophilic cytoplasm and lower nuclear grade. Tumour was immunoreactive for cytokeratin CK 7, CK19 and epithelial membrane antigen (EMA). The morphological and immunohistochemical features were consistent with mucinous tubular and spindle cell carcinoma of kidney.

[Desmoplastic fibroblastoma of the foot]. / Le fibroblastome desmoplastique du pied A propos d'un cas.

Desmoplastic fibroblastoma is a benign, rare, slow-growing soft tissue tumor which is found in a wide anatomic distribution, predominantly in adult males. The characteristic gross aspect is that of a typical cartilage-like tumor which histologically presents regular fibroblastic proliferation, often in a stellar shape within a dense collagen or myxo-collagen stroma. We report a new case observed in the foot and study the anatomic and clinical aspects of this rare entity.

[Sclerosing epithelioid fibrosarcoma. A case report]. / A propos d'un cas de fibrosarcome épithélioïde sclérosant.

Sclerosing epithelioid fibrosarcoma is a rare variant of fibrosarcomas, which was recently identified as a separate entity due to specific histologic and immunohistochemistry features and its poor prognosis. We report a case of sclerosing epithelioid fibrosarcoma of soft tissues, which developed in a 37-year-old woman who presented a tumor involving the posteromedial aspect of the left knee and which progressed in size for one year. Imaging revealed a well-delimited tumor process measuring 8 cm in its largest diameter and situated in the medial compartment of the left knee. Histology of the tumorectomy specimen and the immunohistochemistry study led to the diagnosis of sclerosing epithelioid fibrosarcoma of soft tissues. This new case illustrates the characteristic features of this tumor and recalls the difficult pathological diagnosis.