Large spontaneous HBV DNA fluctuations and potential usefulness of a single-point measurement of combined HBV DNA and quantitative HBsAg for the exclusion of HBeAg-negative chronic hepatitis B: A prospective Tunisian cohort study.

BACKGROUND AND STUDY AIM: During the natural course of HBeAg-negative chronic hepatitis B (CHB), fluctuations in hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) levels are often observed, making the classification of patients difficult. We aimed to describe spontaneous short-term HBV DNA level fluctuations and to assess the usefulness of qHBsAg in Tunisian patients with HBeAg-negative chronic HBV infection. PATIENTS AND METHODS: We included 174 treatment-naive Tunisian patients with HBeAg-negative chronic HBeAg-negative HBV infection. A prospective 1-year follow-up was conducted with serial determinations of HBV DNA, ALT levels, and qHBsAg. The patients were classified into three groups: inactive carriers (G1), patients with negative HBeAg CHB (G2), and patients with an "indeterminate state" (G3). For the latter group, a liver biopsy was indicated. RESULTS: Only genotype D was detected. During follow-up, 21.6% and 19.5% of patients with a low initial (<2,000 IU/ml) and intermediate viral load (2,000-20,000 IU/ml) experienced a subsequent increase in their HBV DNA levels above 2,000 and 20,000 IU/ml, respectively. Significant variations in viral load were observed in 61.1% of patients at 6-month intervals. Among the 174 patients, 89 (51.1%) belonged to G1, 33 (19%) to G2, and 52 (29.9%) to G3. Fourteen patients have undergone a liver biopsy, of whom seven showed moderate to severe liver disease. Combination of HBV DNA < 2,000 IU/ml and qHBsAg < 832 IU/ml excluded CHB in 98.4% of cases. A cutoff point for qHBsAg < 100 IU/ml associated with an annual decline of > 0.5 log 10 IU/ml is a good predictor marker of functional cure for hepatitis B. CONCLUSIONS: This study highlights the large short-term fluctuations in HBV DNA in patients with HBeAg-negative chronic HBeAg-negative HBV infection with genotype D. Thus, using the cutoff value of 832 for qHBsAg combined with that of 2,000 for HBV DNA makes it possible to exclude CHB for most patients.

Cystic lesions of the brain: Think of the hydatid cyst.

BACKGROUND: Hydatidosis is an endemic parasitosis in Tunisia that affect mostly the liver and the lung. Brain involvment is rare. AIM: To focus on diagnostic, therapeutic and evolutive characteristics of cerebral hydatidosis. METHODS: We report all cases of cerebral hydatidosis seen in the infectious diseases and neurosurgery departments between January 2013 and June 2020. RESULTS: Six cases of intracranial hydatid cyst were reported. The male to female ratio was 3:3. Age ranged from 3 to 60 years with a median age of 20,5 years. All patients lived in rural areas. The clinical symptomatology was progressive in 4 cases. It was dominated by headache (all cases). Brain imaging confirmed the diagnosis in all cases. The hydatid cyst was solitary and supratentorial in 3 cases. All the patients were operated. Albendazole was prescribed immediately after surgery, for 6 months in 5 cases and for 3 years in the case of disseminated hydatidosis. The outcome was favorable without recurrence in all patients with an average follow-up of 3,5 ± 0,5 years. CONCLUSION: Hydatid cyst of the brain is characterized by the severity of the neurological signs, the mandatory use of surgery because of life threatening and the excellent outcomes.

[Acute osteomyelitis caused by community-acquired methicillin-resistant Staphylococcus aureus in children: about 15 cases]. / L´ostéomyélite aiguë à Staphylocoque aureus résistant à la méthicilline d´origine communautaire chez l´enfant: à propos de 15 cas.

The treatment of acute osteomyelitis is becoming more challenging since the emergence of community-acquired methicillin-resistant Staphylococcus aureus. We collected data on all patients with acute osteomyelitis caused by this germ over a period of 21 years (January 1995-December 2016) and we analyzed the peculiarities of this disorder. Our case series includes 15 children, with an average age of 9 years. All patients had affected lower limb. Local trauma was reported in 8 cases and skin carriage in 4 cases. Acute onset was reported in 12 cases associated with pseudo-paralysis of the affected limb. One patient had Staphylococcus aureus pulmonary infection with signs of septicopyemia. Blood culture was positive in 8 cases. In one case PCR assay for detection of Panton-Valentine leukocidin was performed with positive result. All these patients underwent surgical debridement and received secondarily adapted empirical antibiotic therapy. Outcome was good in 8 cases and poor in the other cases, with transition to a chronic state in 6 cases and one case of death. Pathological fracture was reported in 3 cases. Osteomyelitis cause by community-acquired methicillin-resistant Staphylococcus aureus is associated with a pejorative outcome. Recognizing the clinical and paraclinical signs of these infections is essential for a specific and early therapeutic management.

Combination of amphotericin B and caspofungin in the treatment of mucormycosis.

We report a case of invasive mucormycosis in 52 year-old woman. CT-scan and magnetic resonance imaging found a partial right sinus thrombosis associated with homolateral ethmoidal and maxillary sinusitis with submucosal inflammation. Histopathological examination of excised tissue was positive for mucormycosis. Our patient was treated by surgical debridement and a combination of amphotericin B and caspofungin, with a good outcome.

[Tuberculous bursitis of the shoulder in a patient with chronic renal insufficiency: about a case]. / Bursite tuberculeuse de l'épaule chez une insuffisante rénale chronique: à propos d'un cas.

Tuberculosis of the shoulder is rare. It encompasses all articular and periarticular tuberculouses of the shoulder. Its insidious evolution, mimicking inflammatory and degenerative diseases, reflects the frequency of its diagnostic delay. We report a rare case of tuberculous bursitis of the shoulder in a woman living in rural areas, with renal insufficiency and treated for peritoneal TB and psoas. The anamnesis revealed signs of tuberculous impregnation. Clinical examination showed painful swelling of the shoulder associated with stiffness. MRI of the shoulder objectified infectious bursal disease. Its tuberculous origin was confirmed by the histological examination of ultrasound-guided synovial biopsy. The patient underwent TB treatment with good outcome. At 9-year follow-up, the patient had satisfactory articular function with no recurrence of infectious disease.

Tuberculosis and non-pulmonary malignancies : study of ten cases.

INTRODUCTION: Tuberculosis (TBC) is a major public health problem with high mortality especially in developing countries. It is associated with a higher risk of developing pulmonary and non-pulmonary malignancies including solid and hematologic cancers. Association between TBC and nonpulmonary malignancies is rarely described in the literature. AIM: To describe the epidemiological, clinical, therapeutic modalities and the evolutive aspects of patients treated for cancer and TBC. METHODS: This is a retrospective study conducted over a period of 19 years (between 1993 and 2012), including 10 patients followed up for cancer and tuberculosis at the department of oncology and the department of infectious disease, CHU Habib Bourguiba Hospital and CHU HediChaker, Sfax, Tunisia. RESULTS: The average age of patients was 55 years old. The sex ratio was 1. The different locations of cancer were represented by the breast (4 cases), the nasopharynx (1 case), the colon (1 case), the kidney (1 case) the gum (1 case), the endometrium (1 case) and the blood (1 case).TBC and cancer were synchronous in 5 cases. Concerning the metachronous presentation that interested 5 patients, the average time betweenthe onset of TBC after cancer diagnosis was 3.5 years. Three of these patients were treated by chemotherapy with radiation therapy. TBClocalization was nodal in 6 cases, spinal one case, nasopharyngeal in one case, peritoneal in one case and urogenital in one case. The diagnosisof TBC was made incidentally in two cases during axillary lymph node dissection. The therapeutic management of cancer was based on surgery,chemotherapy and / or radiotherapy. All patients received anti TBC treatment for at least six months. Surgery was indicated in one case(laminectomy). A complete remission of cancer was observed in 9 patients. Concerning TBC, recovery was observed in 8 patients, 1 patient hada spinal recurrence and 1 patient is being treated. CONCLUSION: Chronic inflammation during TBC can lead to cancer development. The etiopathogenesis of this association is still imperfectly known. Association between TBC and non-pulmonary cancer, although rare, should be always kept in mind in order to handle in time these two diseases in order provide the best chances of recovery for patients.

Applicability, Safety, and Cost-Effectiveness of Improvised External Ventricular Drainage: An Observational Study of Tunisian Neurosurgery Inpatients.

OBJECTIVE: External ventricular drainage (EVD) is an emergent neurosurgical procedure. Many commercial sets are available for EVD that are not always obtainable in all hospitals. The aim of our study was to describe new techniques to perform EVD using simple improvised materials to check the real-world applicability of the same device in the management of acute hydrocephalus and its effectiveness and safety. METHODS: We illustrated 2 techniques for a "do it yourself" improvised EVD device using materials available even in non-neurosurgery-dedicated operating rooms. We performed an observational study in our institution (April 2015 to December 2016). We included all patients presenting with acute hydrocephalus and requiring EVD. RESULTS: During a 20-month period, the new EVD device was used as a lifesaving solution for 33 patients. Good outcomes were noted in 11 of the 33 patients (33%). The EVD was complicated by fatal meningitis in 4 of the patients (12%). Malfunction occurred in 6 patients. The new EVD device costs less than US$20 for the first technique and less than US$10 for the second technique. In contrast, the cost of a standard EVD set ranges from US$170 to US$380 in Tunisia. CONCLUSIONS: The new EVD device has the potential to improve the quality of efficiency of care in difficult economic times that have changed the medical landscape, because it is both easy to make and cost-effective. Because it is an inexpensive technique, it could also be suitable for low-income countries, where neurosurgery is not yet the first and foremost health priority.

Bilateral septic arthritis of the sternoclavicular joint complicating infective endocarditis: a case report.

BACKGROUND: Septic arthritis is an infectious disease that commonly affects weight-bearing or proximal joints such as the knee and the hip. The sternoclavicular joint is an unusual site of this entity. It usually occurs in patients with diabetes mellitus, intravenous drug abusers, or those with rheumatoid arthritis. Analysis of the previous literature showed few articles and these described essentially cases of unilateral presentation. CASE PRESENTATION: We report a rare case of a bilateral septic arthritis of the sternoclavicular joint sustained by a 71-year-old Tunisian woman whose medical history was significant for methicillin-resistant Staphylococcus aureus infective endocarditis 6 months ago. Imaging investigations revealed destruction of the medial extremities of her two clavicles and bilateral collections in the soft tissues around her sternoclavicular joints. She was treated successfully by needle aspiration drainage combined with a 12-week antibiotherapy. CONCLUSIONS: Bilateral septic arthritis of the sternoclavicular joint is an extremely rare entity, with a paucity of literature. Only early diagnosis, which is obtained from the culture of the joint fluid using needle aspiration, allows satisfactory functional outcome and a good prognosis. Osteoarticular infections should be considered in patients with recent infective endocarditis in cases of fever recurrence.

Molecular diagnosis of Rickettsia infection in patients from Tunisia.

Diagnosis of rickettsioses had largely benefited from the development of molecular techniques. Unfortunately, in Tunisia, despite the large number of rickettsial cases registered every year, the Rickettsia species remain unidentified. In this study, we aimed to detect the Rickettsia species in clinical samples using molecular tests. A study was established to analyze skin biopsies, cutaneous swabs, and cerebrospinal fluid samples taken from clinically suspected patients to have rickettsial infection. Two molecular techniques were used to detect Rickettsia DNA: quantitative real time PCR (qPCR) and reverse line blot test (RLB). An analysis of the RLB hybridization assay results revealed the presence of Rickettsia DNA in skin biopsies (40.6%) and swabs (46.7%). Rickettsia conorii was the most prevalent identified species among tested samples. Other species of interest include Rickettsia typhi and Rickettsia massiliae. Using qPCR positivity rates in skin biopsies was 63.7% against 80% in swabs. R. conorii was the most frequently detected species, followed by R. typhi. The agreement between the two techniques was 68.6% (kappa=0.33). Molecular tests, especially using specific probes qPCR, allow for a rapid, better and confident diagnosis in clinical practice. They improve the survey of Mediterranean spotted fever which is considered to be the most important rickettsial infection in humans in Tunisia.

[Solitary bone plasmacytoma: about 3 cases and review of the literature]. / Le plasmocytome solitaire osseux: à propos de 3 cas et revue de la littérature.

Solitary plasmocytomas are rare, accounting for less than 5% of all plasmocytes proliferations. Its diagnosis is based on the presence of localized tumor of monoclonal plasma cells cytologically identical to those of multiple myeloma, in the absence of other signs of a disseminated form. This study aims to carry out a retrospective study of three cases of solitary bone plasmocytomas associated with a detailed review of the literature describing the diagnostic, therapeutic and evolving characteristics of this rare entity.

Comparison of two quantitative real time PCR assays for Rickettsia detection in patients from Tunisia.

BACKGROUND AND OBJECTIVES: Quantitative real time PCR (qPCR) offers rapid diagnosis of rickettsial infections. Thus, successful treatment could be initiated to avoid unfavorable outcome. Our aim was to compare two qPCR assays for Rickettsia detection and to evaluate their contribution in early diagnosis of rickettsial infection in Tunisian patients. PATIENTS AND METHODS: Included patients were hospitalized in different hospitals in Tunisia from 2007 to 2012. Serology was performed by microimmunofluorescence assay using R. conorii and R. typhi antigens. Two duplex qPCRs, previously reported, were performed on collected skin biopsies and whole blood samples. The first duplex amplified all Rickettsia species (PanRick) and Rickettsia typhi DNA (Rtt). The second duplex detected spotted fever group Rickettsiae (RC00338) and typhus group Rickettsiae DNA (Rp278). RESULTS: Diagnosis of rickettsiosis was confirmed in 82 cases (57.7%). Among 44 skin biopsies obtained from patients with confirmed diagnosis, the first duplex was positive in 24 samples (54.5%), with three patients positive by Rtt qPCR. Using the second duplex, positivity was noted in 21 samples (47.7%), with two patients positive by Rp278 qPCR. Among79 whole blood samples obtained from patients with confirmed diagnosis, panRick qPCR was positive in 5 cases (6.3%) among which two were positive by Rtt qPCR. Using the second set of qPCRs, positivity was noted in four cases (5%) with one sample positive by Rp278 qPCR. Positivity rates of the two duplex qPCRs were significantly higher among patients presenting with negative first serum than those with already detectable antibodies. CONCLUSIONS: Using qPCR offers a rapid diagnosis. The PanRick qPCR showed a higher sensitivity. Our study showed that this qPCR could offer a prompt diagnosis at the early stage of the disease. However, its implementation in routine needs cost/effectiveness evaluation.

[Evaluation of depression in elderly people living in nursing homes: a study involving 35 people]. / De la dépression chez la personne âgée en maison de retraite: Etude auprès de 35 résidents.

BACKGROUND: Depression in the elderly is often inadequately diagnosed and insufficiently treated. Regardless of the nature of the depression, the influence and the impact of the biological, situational, social and psychological factors would be more important in old subjects than in young ones when the disorder occurs. The nursing home, as an institution, is another factor facilitating the appearance of depression. AIM: The aim of our survey is to determine the prevalence of depression in old people living in a nursing home and to evaluate the degree of their autonomy. METHODS: Our study is a transverse, descriptive and analytical survey carried out on 35 old people at a nursing home in Sfax. Forty residents were excluded from this survey for reasons of dementia (25 cases), debility (5 cases), disabling psychiatric pathologies (4 cases), deafness (5 cases) and one resident who refused the interview. The evaluation has been achieved using two scales specific to the geriatric practice: • The scale of depression: GDS (geriatric depression Scale) applied to 30 items. • The scale of autonomy: IADL (Instrumental Activities of Daily Living) applied to 6 items. RESULTS: • The examined population was composed of 35 people aged from 65 to 93 with a sex ratio of 1.05. • 51.4% of the residents were in a state of depression. • Depression was more frequent in: • Female subjects (58.8% of women compared to 44.4% of men) • Subjects aged less than 70 (66% of subjects aged less than 70 versus 40% of older subjects) • 17.1% of the residents were independent, 42.9% were dependent and 40% were heavily dependent. CONCLUSION: Depression in the elderly is related to several depressice factors particularly for patients living in institution. This situation needs very important adaptive capacities.

[Bilateral emphysematous pyelonephritis caused by Candida glabrata: An exceptional entity]. / La pyélonéphrite emphysémateuse bilatérale à Candida glabrata : une entité exceptionnelle.

Acute emphysematous pyelonephritis (AEP) is a severe form of urinary tract infection. It occurs usually in diabetics. The most concerned agents are the Gram-negative bacilli. We report a first case of bilateral AEP due to Candida glabrata, occurred in a 64-year-old diabetic woman. The clinical presentation started with fever and abdominal pains, without signs of urinary tract infection. Within six hours, the patient had developed a septic shock with renal failure and ketoacidosis. The diagnosis was confirmed by CT scan and the pathogen was isolated in urine. Despite antibiotic and antifungal treatment, she died from a septic shock. Acute emphysematous pyelonephritis due to Candida species is rare. However, the addition of antifungal therapy seems justified if a severe emphysematous pyelonephritis is associated with risk factors of Candida infection.