Involvement of the IL23/Th17 Pathway in the Pathogenesis of Tunisian Pemphigus Foliaceus.

Pemphigus foliaceus (PF) is a rare autoimmune skin disease caused by anti-Dsg1 pathogenic autoantibodies. It is considered as a Th2-mediated disease. Likewise, Th17 cells were recently described in the pathogenesis of the disease but their role is still unclear. We aimed to unravel the eventual implication of the IL23/Th17 pathway in the development of PF. A case-control study was conducted on 115 PF patients and 201 healthy controls using PCR-RFLP and AS-PCR methods. SNPs in IL23R, RORγt, IL17A, IL17F, IL17AR, TNFa, and STAT3 genes were genotyped. mRNA expression of IL23R and RORγt was evaluated using Q-PCR. The frequency of circulating Th17 cells was analyzed by flow cytometry. Genetic associations between IL23R>rs11209026, IL17A>rs3748067, IL17F>rs763780, and TNFa>rs1800629 and the susceptibility to PF were reported. Moreover, we revealed a significant increased frequency of circulating CD4+IL17+ cells as well as higher mRNA levels of RORγt and IL23R in PBMCs of patients. However, no significant increase of RORγt and IL23R mRNA expression was observed in lesional skin biopsies. In spite of the little size of specimens, our results provide converging arguments for the contribution of the IL23/Th17 pathway in the pathogenesis of PF.

Biomarkers of oxidative stress in epidermis of Tunisian pemphigus foliaceus patients.

BACKGROUND: Reactive oxygen species play a key role in the development of many dermatological disorders. OBJECTIVE: The purpose of this study is to examine the lipid peroxidation, protein oxidation and antioxidative profile in Tunisian pemphigus foliaceus (PF) patients. METHODS: Malondialdehyde (MDA), conjugated dienes (CD), protein thiol levels, catalase (CAT) and superoxide dismutase (SOD) activities were evaluated in skin biopsies of 13 patients compared to biopsies of 7 healthy controls. RESULTS: Oxidative stress was confirmed in these three types of patient biopsies as compared to controls. Thus, MDA, CD levels and catalase CAT and SOD activities were significantly increased in lesional, perilesional and normal biopsies of PF patients than in those of control subjects. Protein oxidative was confirmed by lower levels of protein thiols in lesional, perilesional and normal biopsies than in control's biopsies. Otherwise, in patients, a significant rise of these biomarkers was observed in lesional and perilesional biopsies compared with normal biopsies. CONCLUSION: This study shows that oxidative stress could be involved in the pathogenesis of PF by the spread of skin lesions and/or by the increase in auto-antibodies' reactivity.

Spectrum of autoantibodies other than anti-desmoglein in pemphigus patients.

BACKGROUND: Pemphigus is a life-threatening autoimmune blistering disease mediated by autoantibodies against adhesion molecule of the skin. Its concurrence with systemic and organ-specific autoimmune disease was described in case reports. OBJECTIVES: To evaluate the presence of a broad spectrum of organ-specific and non-organ-specific autoantibodies other than anti-desmoglein antibodies in pemphigus patients. PATIENTS AND METHODS: Serum samples were obtained from 105 pemphigus foliaceus (PF) patients, 51 pemphigus vulgaris (PV) patients and 50 controls. Both indirect immunofluorescence assay and ELISA were used to assess the presence of autoantibodies related to connective tissue diseases, autoimmune hepatitis, vasculitis, rheumatoid arthritis, coeliac disease, diabetes and thyroiditis. RESULTS: Significant difference was observed between the three groups for anti-thyroglobulin antibodies in the pemphigus foliaceus group (18% vs. 4%, P=0.03). A significantly higher occurrence of IgM anti-cardiolipin (P=0.03), IgG anti-reticulin (P=0.01) and IgG anti-gliadin antibodies (P=0.008) were observed in the PV group. Cases with more than four autoantibodies were frequently positives for both anti-desmoglein 1 and anti-desmoglein 3. CONCLUSION: Autoantibodies other than anti-desmoglein antibodies are not rare in pemphigus patients. Clinical and serological follow-up of pemphigus patients with positive autoantibodies are needed to clarify their impact in disease evolution.

Tunisian endemic pemphigus foliaceus is associated with the HLA-DR3 gene: anti-desmoglein 1 antibody-positive healthy subjects bear protective alleles.

BACKGROUND: Pemphigus foliaceus is an autoimmune blistering skin disease that partly results from genetic factors, especially human leucocyte antigen (HLA) class II genes. OBJECTIVES: The aim of the study was to determine the HLA DR/DQ markers of susceptibility and protection in the Tunisian endemic form. METHODS: Genomic DNA from 90 patients with pemphigus foliaceus recruited from all parts of the country and matched by age, sex and geographical origin with 270 healthy individuals, was genotyped. RESULTS: Firstly, when the whole patient population was studied, DRB1*03, DQB1*0302 and DRB1*04 alleles were significantly associated with the disease while a significant decrease of, in particular, DRB1*11 and DQB1*0301 was observed in patients compared with controls. DRB1*0301 was the dominant allele in DR3-positive patients and controls, while DRB1*0402 was found in 42% of DR4-positive patients. Secondly, when the HLA DR/DQ allele distribution was studied after dividing patients according to their geographical origin, the southern group, which consisted exclusively of patients with the endemic form of the disease, showed the same associations as the whole pemphigus foliaceus population, particularly with DRB1*03. In the northern group, only the DRB1*04 and DQB1*0301 alleles were found to be associated. Interestingly, anti-desmoglein 1 antibody-positive healthy controls did not carry susceptibility alleles but, in contrast, most carried negatively associated alleles. CONCLUSIONS: These observations indicate that a particular genetic background characterizes the Tunisian endemic form of pemphigus foliaceus and that HLA class II genes control the pathogenic properties of the autoimmune response rather than the initial breakage of B-cell tolerance.

Anti-desmoglein 1 antibodies in healthy related and unrelated subjects and patients with pemphigus foliaceus in endemic and non-endemic areas from Tunisia.

BACKGROUND: Pemphigus foliaceus is an autoimmune blistering skin disease characterized by the production of pathogenic IgG autoantibodies directed against desmoglein 1. AIM: To determine the prevalence of anti-desmoglein 1 antibodies in healthy subjects and their distribution in the different regions of Tunisia and to better identify endemic areas of pemphigus foliaceus. METHODS: We tested, by enzyme-linked immunoserbent assay, sera of 270 normal subjects recruited from different Tunisian areas and 203 related healthy relatives to 90 Tunisian pemphigus foliaceus patients. Results Seventy-six patients (84.4%), 20 healthy controls (7.4%), and 32 relatives (15.76%) had anti-desmoglein 1 antibodies. In southern regions where pemphigus foliaceus is associated with a significant sex ratio imbalance (9 female : 1 male in the south vs. 2.3 : 1 in the north) and a lower mean age of disease onset (33.5 in the south vs. 45 years in the north), a higher prevalence of anti-desmoglein 1 antibodies in healthy controls was observed (9.23% vs. 5.71% in the north). Interestingly, the highest prevalence of anti-desmoglein 1 antibodies in healthy relatives (up to 22%) was observed in the most rural southern localities. More than half anti-desmoglein 1-positive healthy controls were living in rural conditions with farming as occupation, which suggests that this activity may expose the subjects to particular environmental conditions. CONCLUSION: These results show that the endemic features of Tunisian pemphigus foliaceus are focused in these southern areas more than in other areas and that both environmental and genetic factors contribute to the disease.

[Giant insulinoma]. / Un insulinome géant : à propos d'un cas.

Islet-cell tumors are the most common neuroendocrine tumors that arise from the endocrine pancreas. They are typically benign and sporadic. Diagnosis is generally established late because clinical signs lack specificity. The insulinoma is difficult to localize since it is very small in size, often not exceeding 2cm. We report an exceptional case of giant insulinoma initially revealed by a pseudo-polycythemia in an 80-year-old man. He had been treated for hypertension for a few months. Routine biological investigations showed elevated hematocrit and haemoglobin, suggesting Vaquez disease. History taking revealed recent episodes of nocturnal agitation. On admission, he had reddish skin with a suspected enlarged spleen, but total blood volume was normal. Imaging studies showed a voluminous tumor located between the pancreas and the spleen. The presence of an insulinoma was confirmed on the basis of an elevated level of proinsulin at the time of an asymptomatic episode of hypoglycemia. Spleno-pancreatectomy was performed. Histopathological examination revealed a malignant, well-differentiated neuroendocrine malignant tumor.

Choanal atresia: Diagnosis and management

Objective: Choanal atresia (CA) is a rare congenital malformation caused by the obliteration of the posterior choanae by an atretic plate. The aim of our study is to describe the diagnosis and management modalities of CA and to determine the factors associated with recurrence. Materials and methods: This is a retrospective study based on the medical records of patients with CA managed in our department in the period between 2002 and 2021. We studied the clinical features and management modalities of each patient. For patients who developed a recurrence, we determined the factors associated with recurrence based on a bivariate analysis. Results: We studied the medical records of 26 patients with either a bilateral (n=8) or a unilateral (n=16) form of CA. The median age at surgery was two days for bilateral forms and 5 years and 4 months for unilateral forms. At computed tomography scan, CA was mixed (n=20), bony (n=4) or membranous (n=2). All patients underwent intranasal endoscopic surgical treatment using cold instruments alone in membranous forms and combined to the drilling of the atretic plate in bony and mixed forms. The surgical management included the resection of the posterior part of the vomer bone and the placement of nasal stents in 10 and 16 patients respectively. We recorded 6 cases of recurrence requiring a surgical re-intervention. The presence of associated cranio-facial malformations was the only factor associated with recurrence (p=0,001). Conclusion: Choanal atresia diagnosis was based on nasal endoscopy and CT scan. Surgical treatment using transnasal endoscopic approach was an effective and safe technique. Associated local malformations was a factor associated with re-stenosis

[Susceptibility markers in Tunisian first-degree relatives of patients with type 1 diabetes]. / Marqueurs de risque du diabète de type 1 chez les apparentés au premier degré des diabétiques tunisiens.

To identify the profile of anti-pancreas autoantibodies and elucidate the HLA DRB1, DQB1 polymorphism in Tunisian first-degree relatives of patients with type 1 diabetes, we recruited 96 relatives from 21 families with at least one diabetic child. Islet cell antibodies (ICA) were detected by immunofluorescence on monkey pancreas; glutamate decarboxylase (GADA), IA2 (IA2-A) and insulin (IAA) antibodies were measured by RIA. HLA class II DRB1 and DQB1 alleles were typed by PCR-SSP. ICA, GADA, IA2-A and IAA were found in respectively 11.5, 4.2, 5.2 and 8.3% of relatives. Twenty-two out of 96 had at least one antibody and 20 out of these 22 had a susceptibility allele (DRB1*03, DRB1*04, DQB1*02 or DQB1*0302) with or without protective allele (DRB1*11, DRB1*13, DRB1*15 or DQB1*06). All of the 5 relatives having 2 autoantibodies or more carried the DRB1*04-DQB1*0302 susceptible haplotype. In conclusion, this observational study confirms in a Tunisian population known epidemiological data and demonstrates the usefulness of follow-up to determine the predictive value of studied markers.

[Late-occurring cutaneous vasculitis after successful treatment of diffuse lepromatous leprosy: Lucio's phenomenon]. / Vasculite cutanée a révélation tardive après guérison d'une lèpre lépromateuse diffuse: le phénomène de Lucio.

O Lucio's phenomenon is an uncommon type 2 reactional state occurring exclusively in patients with diffuse lepromatous leprosy (Lucio-Latapi leprosy). Previous case reports have been most frequent in Central America and rare in Asia and Africa. Lucio's phenomenon is characterized by necrotic ulcerations of the skin preferentially on the lower extremities usually in association with ongoing Lucio lepromatosis. The purpose of this report is to describe an unusual case of Lucio's phenomenon occurring four years after successful treatment of diffuse lepromatous leprosy. The patient was a 51-year-old man who had presented diffuse lepromatous leprosy ongoing since 1998. Diagnosis was documented based on histological and bacteriologic evidence. After successful treatment using dapsone (100 mg/d), rifadine (600 mg/month) and ethionamide (250 mg/d), the patient was lost from follow-up for 4 years. In January 2005, he consulted again for alteration of general status. Clinical examination showed inflammatory livedo on the lower extremities in association with several infiltrating maculo-papular lesions and painful erythemato-pupuric lesions on the legs and buttocks. The patient's skin was dry, shiny and galabrous with alopecia of the eyelashes and eyebrows. Examination of smear samples (skin and nasal) to identify mycobacterium leprae was negative. Histological study demonstrated epidermic necrosis with aspects of leucocytoclastic vasculitis. No Virchow cells were detected and Ziehl staining was negative. Search for circulating immune complexes and antiphospholipid antibodies was negative. Diagnosis of Lucio's phenomenon was made and the patient was treated using prednisone at a dose of 1 mg/kg/d in association with rifampicine (600 mg/month) and dapsone (100 mg/d). Outcome was favorable after one month of treatment. Lucio's phenomenon has rarely been observed in Tunisia. To our knowledge this is the third case reported from Tunisia and only 13 cases have been reported in the world since 1983. In all cases including the two from Tunisia, Lucio's phenomenon occurred during the course of treatment of ongoing Lucio-Latapi lepromatous leprosy (2). The remarkable features of our case are that Lucio's phenomenon occurred a long time after successful treatment of lepromatous leprosy and that the patient responded promptly to treatment. The pathogenesis of Lucio's phenomenon is often compared with that of erythema nodosum leprosum. Discussion focuses on pathophysiologic features and natural course of Lucio's phenomenon.

[Rhinocerebral mucormycosis in four diabetics]. / la mucormycose rhinocérébrale chez le diabétique. A propos de quatre observations.

UNLABELLED: Mucormycosis is caused by a zygomycetes fungus in a vascular location. This fungus is a saprophytic organism which can become pathogenic in specific conditions, particularly in patients with diabetes mellitus. A rhinocerebral localization is common, leading to often fatal devastating sinusitis. Positive diagnosis requires histological proof with characteristic hyphal tissue invasion. Frozen section is essential for diagnosis and management of rhinocerebral mucormycosis. MATERIAL AND METHODS: We report four cases of rhinocerebral mucormycosis in diabetic patients, two men and two women, mean age 51 years. RESULTS: Histological examination showed characteristic hyphae in a vascular localization. Treatment was systemic antifungal therapy with amphotericin B and debridement of necrotic tissue. Three patients recovered completely. One died. CONCLUSION: Rhinocerebral mucormycosis is a rare fungal infection with very poor prognosis. The aim of this study was to report the clinical and pathological features of rhinocerebral mucormycosis and to evaluate the contribution of frozen section for diagnosis and management.

Clinical significance of antinucleosome antibodies in Tunisian systemic lupus erythematosus patients.

The aim of this study was to investigate the clinical significance of antinucleosome antibodies in Tunisian systemic lupus erythematosus (SLE) patients. IgG antinucleosome antibodies were detected by a qualitative enzyme immunoassay (immunodot) in the sera of SLE patients at onset of disease. The patients were divided into two groups according to the result of the antinucleosome antibodies test: positive (group A) and negative (group B). The two groups were also evaluated for clinical and biological parameters. Of 84 patients with SLE, 66 (78.6%) had antinucleosome antibodies. Among 21 patients negative for anti-double-stranded DNA (anti-dsDNA), 5 (23.8%) were antinucleosome positive. The most common initial features were haematological disorders (80.1%) and arthritis or arthralgias (79.8%). Renal disorders, observed in 59.5% of SLE patients, were more common in group A compared to group B (65 vs 38%) (p=0.04). The European Consensus Lupus Activity Measurement (ECLAM) mean score was higher in group A (6.42) than in group B (4.44) (p=0.002). Antinucleosome antibodies were positive in nearly one-fourth of SLE patients negative for anti-dsDNA. We found a correlation between antinucleosome antibodies, nephritis and SLE disease activity. Therefore, the determination of circulating antinucleosome antibodies could be a useful parameter for early diagnosis and follow-up of SLE patients.

Is there any relationship between polymorphism of Heat Shock Protein 70 genes and Pemphigus foliaceus?

The human Heat Shock Proteins (HSP70) family plays a key role in up-regulating stress responses. Some studies reported possible associations of single nucleotide polymorphisms in the HSP70 genes with some autoimmune diseases. However, whether HSP70 polymorphisms represent a risk factor for pemphigus foliaceus (PF) is still unkown. We analyzed by PCR-RFLP polymorphisms of HSP70 genes HSA1A, HSPA1B and HSPA1L in 80 Tunisian patients with PF, 160 matched healthy controls and 147 related healthy subjects. There were significant differences between PF patients and controls in the allelic (pc=5.91×10(-12), pc=1.14×10(-5) and pc=0.0089, respectively) and homozygous genotypic frequencies of HSPA1L>T, HSPA1A>C and HSPA1B>G (p=2.617×10(-12), p=1.017×10(-5) and p=0.0058, respectively). Haplotype analysis showed significant differences between PF patients and controls: the CCA, CGA, CCG and CGG haplotypes were significantly over-represented in controls whereas the TCG haplotype was significantly over-represented in patients. However, the significant LD found between the HSP70 and the HLA class II susceptibility alleles together with the multivariant regression analysis data between the two loci could argue against a direct role of the HSP70 polymorphism in the occurrence of PF.

[Pure gonadal dysgenesis with 46 XY karyotyping (Swyer's syndrome) with gonadoblastoma, dysgerminoma and embryonal carcinoma]. / Dysgénésie gonadique pure à caryotype 46 XY (syndrome de Swyer) avec gonadoblastome, dysgerminome et carcinome embryonnaire.

We report the clinical and pathologic findings in a 22-year-old woman with XY gonadal dysgenesis (Swyer's syndrome), who had bilateral gonadoblastoma associated on the right side with a dysgerminoma and an embryonal carcinoma. Swyer's syndrome is a distinct type of pure gonadal dysgenesis characterized by a 46 XY karyotype. It shows an abnormality in testicular differentiation. The patients are phenotypic females without stigmas of Turner syndrome. They have also elevated gonadotropins and hypoplastic gonads without germ-cells. The tumor that usually develops in Swyer's syndrome is gonadoblastoma. This tumor arises on dysgenesic gonads with a Y chromosome. Although gonadoblastoma is considered benign, the risk of malignant germ cell development is high. This means that these dysgenesic gonads should be removed surgically as soon as Swyer's syndrome is established.

Continuous epidural analgesia with bupivacaine 0.125% or bupivacaine 0.0625% plus sufentanil 0.25 microg.mL(-1): a study in singleton breech presentation.

Epidural analgesia is the most efficient technique for labor pain relief. However, its resultant motor block might impair the mode of delivery, particularly in breech presentation where the risk of dystocia is high. In this trial, we compared bupivacaine 0.125% with a combination of a low concentration of bupivacaine (0.0625%) and sufentanil (0.25 microg.mL(-1)) both administered by continuous infusion. Analgesia, maternal and fetal/neonatal side effects and obstetric outcome were compared between group bupivacaine (n = 23) and group bupivacaine-sufentanil (n = 35). A greater number of patients in the bupivacaine 0.125% group required more than two top-ups (32 vs. 8% of patients, P = 0.03) while pain scores were similar. Motor block at delivery was more pronounced in the bupivacaine 0.125% group. Nausea and pruritus were more often encountered in the bupivacaine-sufentanil group. There was a trend toward a decreased rate of assisted or operative delivery in the bupivacaine-sufentanil group (92% vs. 74%, P = 0.09). Fetal/neonatal data did not differ between groups. Epidural analgesia with bupivacaine-sufentanil required fewer additional top-ups and produced less motor block than did bupivacaine 0.125%. However, there was no significant difference in mode of delivery between the two analgesic regimens.

[Determination of anti-transglutaminase antibodies in the diagnosis of coeliac disease in children: results of a five year prospective study]. / Dosage des anticorps anti-transglutaminase dans le diagnostic de la maladie coeliaque de l'enfant: résultats d'une étude prospective sur cinq ans.

AIM: To evaluate the interest of IgA antibodies to tissue transglutaminase in the diagnosis of children coeliac disease compared with anti-endomysium and anti-gliadin antibodies. SUBJECTS AND METHODS: Seventy children with coeliac disease (mean age: 5 years and 8 months) and 99 disease controls (mean age: 4 years and 5 months). IgA anti-transglutaminase were tested by ELISA using a human recombinant tissue transglutaminase. IgA anti-endomysium were detected by indirect immunofluorescence on monkey oesophagus. RESULTS: The middle rate of IgA anti-transglutaminase was 101.06 units in patients and only 0.47 unit in controls. IgA anti-transglutaminase and IgA anti-endomysium were in agreement in 98.8% of cases; only two cases were discordant (+/- and -/+). Globally, the two markers had the same sensitivity (90%), specificity (98%), negative (93.2%) and positive (96.9%) predictive values. For anti-gliadin antibodies, the IgG were more sensitive (88.6%) and the IgA more specific (93.9%). CONCLUSION: IgA anti-tissue transglutaminase can be used instead of IgA anti-endomysium as a serological marker of screening and diagnosis of coeliac disease in children after 3 years.

[The isolated presence of anti-HBc antibodies: prevalence and interpretation based on the results of viral DNA research and anti-HBs antibodies measurement after vaccination]. / Présence isolée de l'anticorps anti-HBc: prévalence et interprétation à l'aide des résultats de recherche d l'ADN viral et du dosage des anticorps anti-HBs après vaccination.

In order to study the significance of the isolated presence of anti-HBc antibodies, we have looked for the 3 classic serological markers of the hepatitis B (HBs antigen, anti-HBs and anti-HBc antibodies) in 1,586 hospital agents who are to vaccinate in the framework of a campaign of systematic vaccination of the hospital personnel of university hospitals of Sfax for a period of 18 months. We identified subjects who presented isolated anti-HBc antibodies (33 individuals = 2.08%). In these subjects'serum, we performed a research of the DNA of hepatitis B virus (HBV) with a PCR hybridization technique using a couple of primers. One week after administration of a vaccine dose, we also measured anti-HBs antibodies in their sera. Among the tested 18 personnel with anti-HBc isolated antibodies, 11.1% had low rates of anti-HBs antibodies indicating that there is presumably primary antibody response and therefore a false positivity of anti-HBc antibodies in pre-vaccinal serology; while 11.1% others had higher rates of anti-HBs antibodies corresponding to a secondary antibody response, which witness a previous HBV immunisation. The research of the HBV-DNA was positive in 11.1% of tested personnel, testifying a presumably chronic portage of the virus with low rates of the HBs antigen undetectable with the serological techniques. For the remainder subjects with isolated anti-HBc antibodies (66.7%), the interpretation remains ambiguous.