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.

[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.

Inflammatory breast cancer in Tunisia in the era of multimodality therapy.

BACKGROUND: This study aimed to identify prognostic factors for outcome in Tunisian patients with nonmetastatic inflammatory breast cancer (IBC) receiving multimodality therapy. PATIENTS AND METHODS: From 1994 to 2000, 100 patients with nonmetastatic IBC were reviewed. Patients underwent neo-adjuvant chemotherapy including anthracyclines (99%), then mastectomy (93%) when feasible, radiotherapy (83%) and adjuvant chemotherapy (84%). Sixty patients (60%) had hormone therapy. RESULTS: Median age at diagnosis was 44 years (range 23-71). Seventy patients had premenopausal status (70%). Ten cases occurred during pregnancy (10%). Body mass index indicated overweight or obesity in 76 patients (76%). After neo-adjuvant chemotherapy, pathologic complete response (pCR) rate was 20%. Median time of follow-up for surviving patients was 44 months. Median progression-free survival (PFS) was 19 months and overall survival (OS) 30 months. Factors associated with improved survival were no pregnancy (P = 0.0095), estrogen receptor positivity (P = 0.028), tumor size <5 cm (P = 0.021), clinical complete response (cCR) (P = 0.022), pCR (P = 0.011), negative nodes (P = 0.053) and hormone therapy (P < 0.001). In multivariate analysis, cCR, negative nodes and hormone therapy were independently associated with better OS and PFS. Factors predictive to pCR were age >45 years, negative nodes and cCR. CONCLUSIONS: Tunisian patients with IBC have particular epidemiologic characteristics, with earlier disease and context of overweight and obesity, but prognostic factors are similar to those reported in the literature. Hormone therapy seems to improve patient outcome.

[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.

[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.

Immunolocalization of BRCA1 protein in tumor breast tissue: prescreening of BRCA1 mutation in Tunisian patients with hereditary breast cancer?

BRCA1 is a tumor suppressor gene which is inactivated by mutation in familial breast and ovarian cancers. Over 300 different disease causing germ-line mutations have been described; 60% are unique to an individual family. This diversity and the large size of the gene lead us to search for a prescreening method for BRCA1 mutations. Since BRCA1 is a nuclear protein in normal cells, but reported by some authors to be cytoplasmic in breast tumor cells of patients with BRCA1 mutation, we evaluated immunohistochemistry as a prescreening technique to identify BRCA1 mutations in patients with familial presentation of breast cancer. Using a monoclonal antibody against the carboxy-terminal region of BRCA1, we performed immunohistochemistry on 18 tumor samples from patients with hereditary breast cancer. Cytoplasmic staining of BRCA1 was observed in 10 cases. Of the 18 tumors, 12 (66%) showed either BRCA mutation or BRCA1 accumulation or both, indicating that BRCA1 function might be lost in breast tumor cells not only through mutation, but also via abnormal cytoplasmic location. The immunohistochemical test used in this study would not be efficient as a pre-screening method of deleterious mutations, but it appeared useful to investigate tumor physiology.

[Acute respiratory failure as the sol inaugural sign of Arnold-Chiari malformation. Two cases]. / Insuffisance respiratoire aiguë isolée révélant une malformation d'Arnold-Chiari.

Arnold-Chiari malformation is an occipitocervical malformation where the cerebellar amygdales descend below the occipital foramen. Acute respiratory failure is an exceptional inaugural sign. We report two cases disclosed by alveolar hypoventilation associated with type I Arnold-Chiari malformation. The two patients age 51 and 52 years had an uneventful past history and presented with hypercapnic encephalopathy with acute respiratory failure requiring ventilatory assistance. Respiratory function tests, helicoidal thoracic computed tomographic angiography, electromyogram, cardiac echography, and thyroid and immunological tests were normal. Blood gases and polysomnography were in favor of central hypoventilation without sleep apnea. Magnetic resonance imaging demonstrated type I Arnold-Chiari malformation. The course was complicated by recurrent respiratory failure in both patients. Surgical decompression performed for the first patient provided no improvement. This patient died two months after surgery subsequent to aspiration pneumonia. The second patient was treated with continuous positive pressure noninvasive ventilatory assistance and had a good outcome at 25 months. These two cases illustrate the absence of any neurological sign, acute respiratory failure being the only sign of Arnold-Chiari malformation.

[Soft tissue metastasis revealing an asymptomatic bronchial adenocarcinoma]. / Métastase musculaire squelettique révélatrice d'un adénocarcinome bronchique.

Skeletal muscle metastases from non-small-cell lung cancer are uncommon. We report a case of lung adenocarcinoma disclosed by metastatic dissemination to a forearm muscle. A 46-year-old man consulted for a painful mass of the right forearm. Ultrasonography and computed tomography revealed a heterogeneous collection in the forearm invading the cortex of the humerus. An excisional biopsy of the right forearm showed an infiltration of the muscle with metastatic adenocarcinoma. Immunohistochemical patterns suggested the pulmonary origin. Chest x-ray was normal. Bronchoscopy revealed an endobronchial mass that was confirmed by biopsy to be an adenocarcinoma. The lung tumor was staged T2N0M1. The patient has received local radiation therapy and chemotherapy. After eighteen months, the disease progressed but without local muscular recurrence. Skeletal muscle metastases from lung cancer are rare and although their prognosis is poor, local treatment may be worthwhile.

[Hodgkin disease of the nasopharynx: report of three cases]. / Maladie de Hodgkin du cavum: à propos de trois cas.

We report three cases of Hodgkin's disease (HD) involving the nasopharynx. Their clinical presentations, morphological and immunohistochimical features and their therapy modalities are discussed. The patients were aged 36, 41 and 77, presenting with increasing bilateral nasal obstruction in one case and a cervical mass in the two others. Histological study showed mixed cellularity type of HD in all cases. The Reed Sternberg cells expressed both of CD15 and CD30 in one case, and only one of them in the other cases. In one case, LMP1 was detected, CD20 and CD3 were not. HD of nasopharynx should be differentiated from EBV-associated lymphoproliferations. The treatment is based on radiotherapy that can be associated to neoadjuvant chemotherapy if nodes are involved.

[Deep benign fibrous histiocytoma: a case report]. / L'histiocytofibrome bénin profond: à propos d'un cas.

Bening fibrous histiocytoma is one of the most frequent benign tumors. Most tumors are found in the skin, particularly on the limbs. Tumor size is usually small. According to the WHO, a deep location is found for less than 1% of all benign fibrous histiocytomas. Most deep tumors occur in the subcutaneous tissue. Deep locations in other organs have also been reported. We report a case and discuss the pathological and clinical aspects of this rare tumor.

[Disseminated form of Rosai-Dorfman disease. A case report]. / Forme multifocale d'une maladie de Rosai-Dorfman. A propos d'une observation.

INTRODUCTION: Extranodal involvement in sinus histiocytosis with massive lymphadenpathy (SHML) or Rosai-Dorfman disease is common, seen in 43% of cases. We present a case of disseminated form of SHML with thyroid, renal, bone and lung involvement. EXEGESIS: A 53-year-old woman presented with cervical lymphadenopathy and a large palpable mass in the submandibular area. A thyroid nodule was palpable. Laboratory data showed an increase of the erythrosedimentation rate and a polyclonal hypergammaglobulinemia. Histopathological examination of a cervical lymph node biopsy showed typical features of SHML. CT scan showed enlargement mediastinal lymph node, mass of the right lung and infiltrative mass in the right renal hilium. Radiographs revealed lytic lesions in the right proximal tibia and left patella. Histopathology of a biopsy from the kidney mass and thyroidectomy displayed typical characteristics of SMHL. The patient was treated by steroids with a markedly regression of the kidney and renal masses. CONCLUSION: Multiple extranodal involvement in SMHL is rare, the prognosis may be poor when lesions are massive and involve vital organs.

[Epithelioid hemangioendothelioma of bone complicated by femoral fracture]. / Hémangio-endothéliome épithélioïde osseux compliqué d'une fracture du fémur.

A 54-year-old man was seen with a fracture of the left femur. Plain radiographs revealed a 40-mm lytic centromedullary lesion. Magnetic resonance T1- and T2-weighted sequences showed high and low signals. After stabilization of the fracture, the tumor was removed followed by reconstruction with a vascularized fibula. The pathological examination demonstrated proliferation of non atypical CD34 and CD31 positive epithelioid cells with few lumens, accompanied by abundant fibrous stroma, sometimes masking tumor cells. Satisfactory motion was achieved with no recurrence at 20 months follow-up. Bone hemangioendothelioma can simulate metastasis and must be distinguished by immunohistochemistry. Prognosis is a subject of debate as the tumor is considered to exhibit intermediate malignancy by some authors while other consider it to be a malignant tumor.

[Soft tissue epithelioid hemangioendothelioma: a case report]. / Hémangio-endothéliome épithélioïde des tissus mous. A propos d'un cas.

We report a case of epithelioid hemangioendothelioma observed in soft tissue in a 35-year-old man who presented a painful mass of the right arm which progressed in size for two years. Imaging revealed a 7-cm poorly limited expansive tumor process located in the medial muscle compartment of the right arm. Surgical resection was performed. Histological and immunohistochemical examination led to the diagnosis of soft tissue epithelioid hemangioendothelioma. The tumor recurred in the right arm and the right axillary fossa with development of multiple nodules in the contralateral thoracic wall and pleural effusion. Adjuvant chemotherapy and radiotherapy were performed, but the patient died at two years.

[Dermatofibrosarcoma protuberans. About 18 cases]. / Le dermatofibrosarcome de Darier et Ferrand A propos de 18 observations.

Dermatofibrosarcoma protuberans (DFSP) is a rare mesenchyma skin tumor. It is characterized by a slow growth with a high rate of recurrence but limited potential for metastasis. We report the result of a retrospective study of 18 cases of DFSP collected over 16 years in the dermatology department of La Rabta Hospital. The mean age was 32 years with a sex ratio of 1.57. The site of predilection was the trunk (77.5%). Histological features were typical in all cases with positivity for CD34 in 14 cases. Treatment was surgical in 13 cases. DFSP is a tumor of intermediate malignancy, which can have aggressive course. This tumor is best treated with surgery in which large excision are necessary to reduce the risk of recurrence.

[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.

[Breast cancer in Tunisia: clinical and epidemiological study]. / Le cancer du sein en Tunisie: étude clinique et épidémiologie.

This study has been realized to determine epidemiological profile and clinicopathologic aspect of breast cancer in Tunisia. We have counted and analyzed all cancers of the breast diagnosed in Tunisia with proof pathologic or to defect cytologic of malignancy, between first January 1994 and 31 December 1994. In the course of this year, 689 new cases of mammary cancers have been diagnosed at the women. The average patient age was 50.0 years, the incidence standardized on the age of the cancer of the breast in Tunisia was 16.7/100,000 women. The average size of the tumor was 49.5 mm (35.8 mm at patients processed in private clinics and 50.7 mm at patients processed in the public hospitals). According to TNM classification of 1988, 7.2% of tumors were classified T1, 48.9% T2, 18.5% T3, and 23.4% T4 (6.2% T4d and 16.1% T4b). 22.1% of tumors were M1. 3.3% were in situ carcinoma. For the infiltrants cancers, the grade II SBR has been the most frequent (53.6%). On the therapeutic plan, the conservative processing has been practiced only at 17.6% of patients. The cancer of the breast in Tunisia rest again relatively little frequent, and its clinic profile resides alarming. The inflammatory cancer notion of the breast (equal T4d) intimately linked to Tunisia overestimates probably the reality. Cancers that were classified "PEV" in many publications would be in reality only for most of locally evolved and neglected cancers.

[Clinical and evolutive aspects of nasopharyngeal T4 N0 neoplasms]. / Aspects cliniques et évolutifs des T4 N0 du nasopharhnx.

Nasopharyngeal carcinoma (NPC) is the primary cancer of the head and neck localisations in the Salah Azaiz Institute (Tunisia). From 1970 to 1987, 80 patients with histologically proven T4 N0 NPC, were treated with exclusive radiation (70-75 Gy to the primary lesion and 50-55 Gy to cervical lymph nodes). The T4 N0 represents 7% of all NPC and 16% of the T4 treated in our Institute. Ninety percent of the patients are over 20 years old with a mean age of 52 years. The sex-ratio was 4:1. Extension to the brain was observed in 55% of the cases. Local control was 70% at 2 months after the end of irradiation. The actuarial survival at 5 years was 47%. Distant metastasis represent 13% (30% of all NPC). The main failure of treatment was local recurrence. The T4 N0 is probably a particular entity concerning the age, the response to radiotherapy and the low rate of distant metastasis.