[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.

[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.

[Epidemiological and clinical characteristics of intestinal microsporidiosis]. / Caractéristiques épidémiologiques et cliniques de la microsporidiose intestinale chez les immunodéprimés vus à Tunis.

INTRODUCTION: Intestinal microsporidiosis is an opportunistic parasitological infection affecting mainly immunocompromised patients, particularly those infected with HIV. PURPOSE: The purpose of this study was to analyse the epidemiological and clinical characteristics of intestinal microsporidiosis and the treatments available for it. MATERIAL AND METHODS: This retrospective study examined records collected over a 13-year period (from January 1995 through December 2007). It included 572 immunocompromised patients (279 HIV-infected patients and 293 without HIV infection) with symptoms suggesting intestinal microsporidiosis. All were tested systematically for microsporidia spores by modified (Weber's) Trichrome staining. RESULTS: Fourteen patients (10 men, 4 women) were diagnosed with intestinal microsporidiosis, for a prevalence of 2.4% overall, 3.6% in HIV-infected patients and 1.4% in those without HIV infection. Intestinal microsporidiosis affected 10 HIV-infected patients, 70% of whom had a CD4 count <100 cells/mm3. Their mean age was 30+/-15 years (range: 15 months to 48 years). The average age of HIV-infected patients (36 years) was significantly higher than of those without HIV infection (15 years). Thirteen patients had symptoms, most frequently diarrhea (11 cases), sometimes associated with dehydration (5 cases). Eight patients (57%) received only symptomatic treatment, and 4 (28.6%) received albendazole. No treatment was recommended in 2 cases (14.3%). Clinical course was marked by improvement in 6 cases, death in 5, and persistence of asymptomatic carriage in one. Two patients were lost to follow-up. CONCLUSION: Intestinal microsporidiosis is a parasitological disease that mainly affects AIDS patients with CD4 counts <100 cells/mm3. Its diagnosis requires special techniques. Its symptomatology is dominated by chronic diarrhea that can cause dehydration. Effective treatment requires identification of the species.

[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.

[Twenty-two cases of neuromeningeal cryptococcosis in Tunisia]. / Vingt-deux cas de cryptococcose neuromeningée en Tunisie.

Neuromeningeal cryptococcosis is a serious infection witch occurs essentially in immunodepressed patients and especially AIDS patients. We report 22 cases of cryptococcosis meningitis confirmed by the parasitology laboratory, in the Tunis Rabta hospital, over a 16-year period. Sixteen patients were HIV infected and six were not HIV infected. The clinical examination documented fever and headache as well as focal neurological signs especially in HIV infected patients. The mycological examination of CSF proved the diagnosis of neuromeningeal cryptococcosis in all cases. The first line treatment was Amphotericin B in 13 cases, Amphotericin B and 5Fluorocytosine in three cases, and fluconazole in six cases. 14 patients died, seven recovered, and one was lost to follow-up.

[Pnemocystis jiroveci pneumonia: Comparison between conventional PCR and staining techniques]. / Pneumocystose à Pneumocystis jiroveci : étude comparée de la PCR et des techniques de coloration.

Diagnosis of pneumocystis pneumonia is usually based on clinical features and X-rays photography and confirmed in the laboratory by visualisation of Pneumocystis organisms in stained preparations of respiratory specimens using several techniques (Gomori-Grocott, May-Grünwald Giemsa, bleu de toluidine O). Actually, PCR has considerably increased sensitivity of detection of Pneumocystis. The aim of this study is to compare conventional PCR results to those of staining techniques (Gomori-Grocott, May-Grünwald Giemsa) in addition to the X-ray and clinical findings in order to evaluate the contribution of each method. Sixty-four respiratory specimens were collected from 54 immuno-compromised patients with clinical symptoms of pulmonary infection. We diagnosed pneumocystis pneumonia in 16 patients according to staining techniques and/or typical clinical and radiological findings and/or response to treatment. Of the 15 patients, 14 were positive by PCR and only five were positive by direct examination, yielding a sensitivity and specificity of 93.3 and 87.1% for PCR and 33.3 and 100% for staining techniques. Conventional PCR provides a sensitive and objective method for the detection Pneumocystis jiroveci from less invasive sample.

Profile of drug resistance mutations among HIV-1-infected Tunisian subjects failing antiretroviral therapy.

Three years after the introduction of antiretroviral therapy (ART) in Tunisia (North Africa), we aimed to determine the prevalence of drug resistance mutations in Tunisian HIV-1-infected patients failing ART. Plasma samples of 80 patients were tested for genotypic resistance using two distinct line probe assays, LiPA HIV-1 reverse transcriptase RT and LiPA HIV-1 protease assay. Of the 80 patients, 82.5% showed resistance to at least one antiretroviral molecule. In the RT gene, resistance to nucleoside RT inhibitors (NRTIs) and non-nucleoside RT inhibitors (NNRTIs) were recognized in 66.25 and 37.5%, respectively, with M184V, T215Y and K103N being the codons most frequently involved. Resistance to protease inhibitors (PIs) was found in 46.25% of cases. Despite the presence of different mutations, the viral variants were still susceptible to other RTIs and PIs that are currently not available in Tunisia. Thus, alternative therapeutic options exist but are not yet accessible.

[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.

Vibrational study of Li6P6O18.3H2O and ab initio calculations in P6O18 and P6O18.3H2O.

The infrared and polarized Raman spectra of the trigonal Li(6)P(6)O(18).3H(2)O crystal are reported. The results are analysed using several group theory approaches, in terms of internal and external modes of the highly symmetric P(6)O(18) cyclophosphoric ring and water molecules. Equilibrium geometries and vibrational spectra of P(6)O(18) units, free and in interaction with water molecules (P(6)O(18).3H(2)O) have been determined by ab initio calculations using the basis set 6-31+G(d) of Hartree Fock method. Experimental frequencies and polarisation conditions are remarkably consistent with ab initio calculations. A detailed description of the normal modes of vibration of these systems is presented.

[Peripheral blood culture as a diagnostic modality for visceral leishmaniasis: apropos of 61 cases]. / La culture du sang peripherique comme moyen diagnostique de la Leishmaniose viscerale: a propos de 61 cas.

The purpose of this prospective study was to assess the efficacy of culture of peripheral blood samples on NNN medium for detecting Leishmania. A total of 61 peripheral venous blood samples were tested. Most samples were collected from immunocompetent children presenting visceral leishmaniasis. The sensitivity of peripheral blood culture was 61%. Concordance with conventional bone marrow culture was good but the marrow technique was quicker. Since it is minimally invasive and easy to perform, peripheral blood culture is an attractive diagnostic alternative in immunocompetent patients. In addition peripheral blood culture presents a major epidemiological advantage in allowing identification of the causative strain of Leishmania if bone marrow culture was not performed for isoenzymatic characterization.

[Multicentric giant cell tumor of the upper arm]. / Tumeur à cellules géantes bifocale du membre supérieur.

Multicentric giant cell tumors of bone are rare; they represent less than 1% of all giant cell tumors. We report the case of a 35-year-old right-handed man, who presented in 1985 with a giant cell tumor of the upper end of the right humerus. After failure of conservative treatment (curettage and bone grafting), resection-arthrodesis of the shoulder with a free vascularized fibular autograft was performed. Three years later, the patient developed an osteolytic lesion of the lower end of the ipsilateral radius, involving the soft tissues and the wrist joint. He was treated with resection-arthrodesis of the wrist with a free vascularized fibular graft. The histologic study confirmed the diagnosis of giant cell tumor of similar grade. After 13 years follow-up, the patient had a satisfactory function of the limb and no recurrence of the tumor was noted.

First molecular characterization of HIV-1 Tunisian strains.

In order to identify HIV-1 subtypes circulating in Tunisia, blood specimens from 25 HIV-1 infected Tunisian patients were collected. Proviral HIV-1 DNA was genotyped by sequence analysis of the C2-V3 env region. HIV-1 subtypes were determined in 21 DNA sequences: 20 were of subtype B and one was a circulating recombinant form (CRF02 AG). Subtype B largely dominates the epidemiology of HIV-1 infection in Tunisia, suggesting the probable imported origin of HIV-1 infection, but further studies are needed to investigate the potential diversification of HIV-1 isolates in Tunisia.

[Bacterial spondylodiskitis: pyogenic or tuberculous?]. / Les spondylodiscites bactériennes: à pyogènes ou tuberculeuses?

We retrospectively studied the epidemiological, clinical, radiological and evolutive aspects of bacterial spondylodiskitis observed in 39 patients diagnosed from January 1989 to December 1998, in order to find criteria to distinguish between pyogenic spondylodiskitis (PS) and tuberculous spondylodiskitis (TS). During the study period, we collected 13 patients (33.3%) with PS and 26 patients (66.7%) with TS. The mean age was 44 years. The delay in diagnosis was much longer in TS (8.4 months) than in PS (2 months). Diagnosis was certain in 6 cases (46%) of PS and in 12 cases (46%) of TS. Clinically, paravertebral abscesses and neurologic complications were significantly more frequent in TS. The main causative agents in PS were staphylococci. Diagnosis of spondylodiskitis is based on the imaging techniques, especially magnetic resonance imaging which is more sensitive and specific than computed tomography. Except in patients with positive blood cultures or positive urine culture in PS, and isolation of Mycobacterium tuberculosis in another visceral foci in TS, bacteriologic diagnosis was based on discovertebral needle biopsy. The yield of this technique was poor in our study (12.5%), even if bacteriologic confirmation of spondylodiskitis was made in 15 patients (38.5%). In the other cases, diagnosis rested on a set of clinical, biological and radiological criteria.

[Kaposi's sarcoma in Tunisia. Review of 91 cases]. / La maladie de Kaposi en Tunisie. A travers une serie de 91 observations.

The sickness of Kaposi's sarcoma (KS) knows, currently, a renewal of interest since the emergence of 2 new forms: the iatrogenic KS and the epidemic KS. Through a retrospective study on 21 years (1978 to 1998) we have tried to specify the epidemiologic and clinical characters of KS in Tunisia. Our study interests 91 patients: 85 cases of classic KS (94%), 4 cases of iatrogenic KS and 2 cases of epidemic KS. The incidence of iatrogenic KS in renal transplant recipients in our study is 1.9%. A male predominance is found in the 3 forms. The mean age of beginning was 60 years in classic KS and more lower in the 2 other forms (31 years in iatrogenic KS and 46 years in epidemic KS). A predominance of lesions in the lower limbs was found in the 3 forms. The visceral locations was more frequent in iatrogenic KS (3 cases) while it has been found in only 1 case of classic KS. In Tunisia, the classic KS is the most frequent form. In iatrogenic and epidemic KS, visceral lésions are frequent and must be researched systematically.

[Tuberculosis, primary biliary cirrhosis and autoimmunity (apropos of a case in Tunisia)]. / Tuberculose, cirrhose biliaire primitive et autoimmunité (a propos d'un cas tunisien).

We report the case of a 70 year-old Tunisian patient who developed antimitochondrial antibodies and anti-ADN during urogenital tuberculosis with clinical and biological signs of primary biliary cirrhosis and systemic lupus erythematosus. We discuss the association of the three diseases and the etiopathogeny of the autoimmune mechanisms induced by Mycobacterium tuberculosis.

Correlation between 31P chemical shift tensor and local structure in lithium cyclohexaphosphates Li6P6O18 x 3H2O and Li6P6O18.

To understand the surprising behavior between the variations of the P'-P-P" angles and the correlated variations of the O'-P-O" ones, two lithium cyclohexaphosphate compounds Li6P6O18 x 3H2O and Li6P6O18 are studied by solid state nuclear magnetic resonance (NMR) spectroscopy. The two compounds exhibit the same [P6O18]6- ring anions but with 3m or 1 internal symmetry, respectively. Such symmetries induce local distortions that are exhibited by NMR spectroscopy. One-dimensional (1D) NMR gives information on structural sites of 7Li and 31P ions and the crystallographic non-equivalencies are observed. Nevertheless, in the anhydrous compound, X-ray diffraction and NMR results do not completely agree and some discrepancy exists between the number of sites observed with the first technique and the number of lines exhibited in the NMR spectra either for 7Li or 31P nuclei. This problem is elucidated by using 2D double quantum NMR spectroscopy coupled with theoretical considerations. We find that the 31P chemical shift tensor is dependent on the deviations of the O-P-O angles from those in the regular tetrahedron. Within the same empirical model, we suggest that the surprising behavior between the variations of the P'-P-P" and the ones of the O'-P-O" is related to the overall charge on the PO4 group. We also find the positions of the isotropic lines for 7Li essentially depend on the site co-ordination of this nuclei.