Mucosal leishmaniasis of the lip: an emerging clinical form in Tunisia.

BACKGROUND: Mucosal leishmaniasis (ML), which mostly occurs in the New World, is mainly associated with Leishmania braziliensis. Primary lip ML is very rare in the Mediterranean basin and particulary in Tunisia despite the endemicity of both cutaneous and visceral leishmaniasis in this area. OBJECTIVES: To highlight a recent emergence of primary lip ML in Tunisia, to describe its epidemiological and clinical features and to identify the causative Leishmania species. METHODS: Epidemiological, clinical and therapeutic data of 10 cases presenting a ML of the lip were collected. Diagnosis confirmation of leishmaniasis was obtained by microscopic examination of Leishmania parasites in Giemsa stained smears of the lesion sampling and in cutaneous biopsies. Polymerase chain reaction (PCR) detecting Leishmania DNA directly from dermal scraping was also performed for diagnosis and species identification. RESULTS: Seven men and three women with lip ML were diagnosed during the last 6 years (2008-2013). The mean age was 29.7 years. Clinical presentation was characterized by an infiltrated and ulcerated plaque leading to macrocheilitis involving the upper lip in eight cases and the lower lip in two cases. Mean diagnosis delay was 6.9 months. PCR identified L. infantum in seven cases and L. major in two cases. Seven patients received intramuscular injections of meglumine antimoniate (MA) and three patients received both MA intralesional injections of MA and cryotherapy. A clinical remission was rapidly observed in all cases (on average in 2.2 months). CONCLUSIONS: Primary lip ML is emerging in Tunisia. Macrocheilitis of the upper lip is the main clinical presentation. PCR revealed more sensitive than direct examination in the diagnosis of such form (P < 0.01). Leishmania infantum was the most identified species (7 cases) while L major was involved in only two lesions. A benign local evolution and a rapid recovery were observed in all cases after MA treatment.

Phlebotomus (Paraphlebotomus) riouxi: a synonym of Phlebotomus chabaudi without any proven vectorial role in Tunisia and Algeria.

Phlebotomus (Paraphlebotomus) riouxi Depaquit, Léger & Killick-Kendrick (Diptera: Psychodidae) was described as a typological species based on a few morphological characters distinguishing it from Phlebotomus (Paraphlebotomus) chabaudi Croset, Abonnenc & Rioux. The naming of P. riouxi coincided with its incrimination as a rural vector of Leishmania tropica Wright (junior synonym: Leishmania killicki Rioux, Lanotte & Pratlong) in Tataouine governorate, an arid region of southern Tunisia. The current report finds insufficient evidence to incriminate either phlebotomine sandfly as a vector of L. tropica in North Africa. Phlebotomus riouxi was found not to have the characteristics of a phylogenetic or biological species, and therefore it is synonymized with P. chabaudi. Both taxa were recorded together for the first time in Tunisia, in Tataouine, where three of 12 males showed intermediate morphology and both sexes of each taxon were not characterized by specific lineages of the nuclear gene elongation factor-1α or the mitochondrial gene cytochrome b, for which a long 3' terminal fragment is recommended for phlebotomine phylogenetics. This case study indicates that the eco-epidemiology of leishmaniasis should focus more on identifying key components of vectorial transmission that are susceptible to interventions for disease control, rather than on defining sibling species of vectors.

[Contribution of Leishmania identification using polymerase chain reaction--restriction fragment length polymerase for epidemiological studies of cutaneous leishmaniasis in Tunisia]. / Place de l'identification des leishmanies par la polymerase chain reaction--restriction fragment length polymerase dans l'étude de l'épidémiologie des leishmanioses cutanées en Tunisie.

AIM: Three forms of cutaneous leishmaniasis (CL) are endemic in Tunisia. The identification of the causative species is useful to complete epidemiological data and to manage the cases. The aim of this study is to assess PCR-RFLP technique in the identification of Leishmania species responsible of CL in Tunisia and to compare the results of this technique to those of isoenzyme analysis. PATIENTS AND METHODS: Sixty-one CL lesions were sampled. Dermal samples were tested by culture on NNN medium and analyzed by PCR-RFLP assay targeting the ITS1 region of ribosomal DNA. Species identification was performed by both iso-enzymatic typing for positive cultures and analysis of restriction profiles after enzymatic digestion by HaeIII of the obtained amplicons. RESULTS: Thirty-eight (62%) samples were positive by culture. The iso-enzymatic typing of 32 isolates identified 3 L. infantum, 23 L. major MON-25 and 6 L. tropica MON-8. Sixty samples were positive by PCR. The PCR-RFLP digestion profiles of the 56 PCR products identified 12 L. infantum, 38 L. major and 6 L. tropica. The results of both techniques were concordant in the 32 strains identified by both techniques. Species identification correlated with the geographical distribution of CL forms endemic in Tunisia. CONCLUSION: Results of PCR-RFLP revealed highly concordant with those of isoenzyme electrophoresis. Thanks to its simplicity, rapidity and ability to be performed directly on biological samples, this technique appears as an interesting alternative for the identification of Leishmania strains responsible of CL in Tunisia.

[Contribution of PCR for detection and identification of intestinal microsporidia in HIV-infected patients]. / Apport de la PCR dans la recherche et l'identification des microsporidies intestinales chez les sujets infectés par le VIH.

AIM: Intestinal microsporidiosis are among the most frequent opportunistic diseases in immunocompromised subjects. This study aimed to evaluate the contribution of PCR for a better detection and species identification of microsporidia in stool specimens of HIV-infected patients. PATIENTS AND METHODS: Stool samples obtained from 119 HIV-infected Tunisian subjects were screened for intestinal microsporidiosis by light microscopy using Weber's modified Trichrome stain and by a PCR method using universal primers V1/PMP2 which amplified a common fragment of the small subunit rRNA gene of microsporidia. The obtained PCR products were then sequenced using an ABI PRISM 377 DNA sequencer. RESULTS: The results showed a better sensitivity of PCR in the detection of microsporidia with an infection rate of 14.3% significantly higher than that of 6.7% obtained by light microscopy (p=0.03). As previously described, intestinal microsporidiosis was associated with low CD4 cell counts; 23.9% infection rate in patients having CD4 cell count under 200/mm(3) against 5.6% in patients with higher CD4 cell count (p=0.008). The sequencing of 15 out of the 17 positive PCR products has confirmed in all cases the species identified based on the PCR fragment size i.e., 250pb for Enterocytozoon bieneusi (seven cases) and about 270pb for Encephalitozoon intestinalis (nine cases); one case revealed a double infection. CONCLUSION: PCR proved to be more effective than classical Trichrome stain for the diagnosis of intestinal microsporidiosis. Moreover, the ability of PCR to identify the species involved could also be useful for cases management.

Genotype identification of Enterocytozoon bieneusi isolates from stool samples of HIV-infected Tunisian patients.

The microsporidian species Enterocytozoon bieneusi is a major cause of chronic diarrhea and malabsorption in patients with AIDS. Genotyping was performed on seven E. bieneusi strains for the first time in Tunisia. All the strains were isolated from stool samples of humans with immunodeficiency virus (HIV) infection. Analysis of the ribosomal RNA gene internal transcribed spacer (rDNA ITS) allowed the identification of three distinct genotypes previously described in other studies. Genotypes D and B were characterized in four and two respectively. The Peruvian genotype (Peru 8) was detected in the last isolate. These results indicate a genetic diversity in E. bieneusi strains from HIV Tunisian patients and suggest the coexistence of both zoonotic and anthroponotic route of transmission.

[Comparative characterization of skin lesions observed in the three endemic varieties of cutaneous leishmaniasis in Tunisia]. / Caractérisation comparative des trois formes de leishmaniose cutanée endémiques en Tunisie.

BACKGROUND: The recent spread in the geographical distribution of the three forms of cutaneous leishmaniasis (CL) endemic in Tunisia has resulted in the coexistence of more than one species of Leishmania (L.) in some foci, rendering characterization on the basis of geographical criteria alone more difficult. The aim of the study was to establish clinical criteria associated with these noso-geographic forms, namely sporadic CL (SCL) due to L. infantum, zoonotic CL (ZCL) due to L. major and chronic CL (CCL) due to L. tropica. PATIENTS AND METHODS: One hundred and twelve patients with biologically confirmed CL were involved in the study. Leishmania species was systematically identified by iso-enzyme analysis and/or PCR-RFLP. Details of the number, the location, the morphological aspect and the month of outbreak of the lesions were noted for each patient. RESULTS: SCL lesions appeared later than ZCL lesions (53.8% of cases appeared from December onwards vs. 23.6%, P<0.001). ZCL lesions were often multiple (75%) and situated on the limbs (84.7%, P<0.001), whereas SCL lesions were single (92.3%, P<0.001) and located on the face (84.6%, P<0.001). CCL lesions were also single (78.6%) and located on the face (71.4%). The classical ulcerous presentation with scabs was mainly observed in ZCL patients (69.4%) and the erythematous presentation was described more frequently in SCL patients (75%; P<0.001). CONCLUSION: The number, site, morphological aspect and month of outbreak of lesions could be considered as useful criteria that help differentiate between the three noso-geographical forms of CL prevailing in Tunisia. Such characterization is useful for the individual management of patients and for optimizing the combat against the disease.

[Ileocecal ameboma: a case diagnosed by pathology and molecular biology]. / Amoebome iléocaecal: un cas diagnostique par l'anatomie pathologique et la biologie moléculaire.

Colonic ameboma is a rare benign inflammatory tumor due to the infection by Entamoeba histolytica and poses frequently the problem of colon cancer. We report a case of a 52 year-old patient who presented a cecal amoeboma revealed by a painful mass in the right iliac fossa. Radiologic and endoscopic examinations depicted a parietal thickening of the right colon and the cecum. A presumptive diagnosis of colon cancer was firstly discussed. Confirmation of ameboma was made on pathological examination, PCR and serology.

[The intestinal parasites in the food handlers of Tunis area: study of 8502 stool samples (1998-2008)]. / Les parasites intestinaux chez les manipulateurs de denrees alimentaires de la Region de Tunis: etude de 8502 prelevements de selles (1998-2008).

The food handlers control is one of the major measures of the National program against intestinal parasitoses in Tunisia. The collected data allow regular updates of the prevalence and profile of the involved parasitic species and note possible evolutions in time. From 1998 to 2008, 8502 stool samples of food handlers working in Tunis area were examined in the laboratory of Parasitology, Pasteur Institute of Tunis. The mean prevalence of intestinal parasites was 13.5% (1152 positive samples). The protozoa were the most detected parasites (93% of the species observed). Among the pathogenic or potentially pathogenic parasites, Dientamoeba fragilis (15.5%) and Giardia intestinalis (7.6%) were the most frequently encountered. Entamoeba (E.) histolytica/dispar was diagnosed in 41 subjects (a prevalence of 05%). Hymenolepis nana was the most frequent helminth (45% of the whole parasites). Therapeutic failures were noticed in 43.8% of infection by this cestode because of the lack of the appropriate antihelminthic. The identification using PCR of cysts and/or vegetative forms of E. histolytica/dispar revealed the exclusive presence of E. dispar.

[Imported malaria in Tunisia: consequences on the risk of resurgence of the disease]. / Paludisme d'importation en Tunisie: conséquences sur le risque de réintroduction de la maladie.

Although malaria has been eradicated in Tunisia since 1979, the disease is still a health issue due to the persistence of mosquitoes and coexistence with a potential parasite reservoir in the form of imported cases. From 1999 to 2006, 98 cases of imported malaria were diagnosed at the Pasteur Institute in Tunis where nearly 30% of national cases are recorded. Tunisians accounted for 24.5% of these cases versus 75.5% involving foreigners. The occurrence rate has steadily increased in volunteer workers, businessmen, diplomats and athletes who together accounted for 41.7% of cases in 1995 as compared to only 17.4% in 1980 (p<0.01). Most cases (96.5%) were imported from sub-Saharan Africa. The most frequent countries involved in importation were Cote d'Ivoire (23 cases) and Mali (8 cases) that are now linked to Tunisia by regular flights. About one third of patients were asymptomatic at the time of diagnosis. This finding underlines the importance of recommending systematic screening in high-risk groups. Fever (70.6%) and gastro-intestinal manifestations (27.9%) were the most frequent clinical findings in the 69 symptomatic cases. Plasmodium falciparum (71.4%) was the most common species followed by Plasmodium ovale (19.4%). Gametocytes were detected in 9.2% of subjects, thus creating a theoretical source of infection for mosquitoes especially since 60.2% of all cases were recorded between June and October when mosquitoes are active in Tunisia. Due to increasing exchange with endemic malaria areas in Africa that has resulted in a higher incidence of imported cases and a futher risk of introduction of tropical mosquito species as well as to global warming that promotes plasmodium transmission, greater vigilance is necessary to ensure eradication of malaria in Tunisia.

[Contribution of Real-Time PCR in the Diagnosis of Cutaneous Leishmaniasis: Experience of the Pasteur Institute of Tunis]. / Contribution de la PCR en temps réel dans le diagnostic biologique de la leishmaniose cutanée : expérience de l'institut Pasteur de Tunis.

The aim of this study was to assess the performance of real-time PCR (qPCR) in the diagnosis of cutaneous leishmaniasis (CL). Culture, direct microscopic examination (DE) and qPCR were performed on dermal exudate samples collected from 235 confirmed CL cases. The qPCR was found to be more sensitive than other diagnostic techniques and was able to correct the diagnosis in 49 patients (20.9%) with negative dermal smears. Median parasitic load (PL) of the 49 dermal exudates with negative DE was lower than that of positive ones in microscopy. This suggests that PL likely impact the sensitivity of microscopy. On the other hand, qPCR was performed on DNA extracts of scraped products collected from the 23 out of 49 archived negative Giemsa-stained slides and showed 11 positive. Parasitic loads in the latter smears were lower than those in corresponding exudates. The results highlight qPCR relevance for the diagnosis of CL and recommend its use directly on dermal exudates collected from CL lesions.

L'objectif de ce travail était d'évaluer la place de la PCR en temps réel (qPCR) dans le diagnostic de la leishmaniose cutanée (LC). Des sucs dermiques prélevés chez 235 cas confirmés de LC ont été traités par examen microscopique direct (ED), culture et qPCR, et les résultats analysés. La qPCR s'est révélée plus sensible que les autres techniques diagnostiques permettant de redresser le diagnostic chez 49 patients (20,9 %). Les charges parasitaires (CP) des 49 sucs dermiques correspondants étaient inférieures à celles de prélèvements microscopiquement positifs suggérant que la CP serait un facteur limitant la sensibilité de l'ED. La qPCR a été également pratiquée sur les produits de grattage de 23 des 49 frottis négatifs. Elle a permis d'en détecter 11 positifs avec des CP inférieures à celles dans les sucs dermiques correspondants. Ces résultats recommandent l'utilisation de la qPCR pour le diagnostic de la LC et privilégient sa réalisation directement sur le suc dermique.

[Epidemiology of Cutaneous Leishmaniasis in West Africa: a Systematic Review]. / Épidémiologie de la leishmaniose cutanée en Afrique de l'Ouest : revue systématique.

Cutaneous leishmaniasis (CL) has been described in West Africa (WA) since the beginning of the 20th century. The incidence of cases has markedly increased during the last decades in several countries of the region. Despite that, data remain scarce and fragmentary. The current incidence and geographic distribution of the disease as well as the involved vectors and reservoirs remain poorly documented. The objective of this review was to collect and analyze available data about CL in WA in order to improve the management of cases and the control of the disease transmission. A systematic literature review was performed using the Pubmed, Google Scholar and Hinari databases. Publications focusing on epidemiological aspects of CL, involved parasite species, sand flies and potential reservoir hosts were searched without any restrictions. Unpublished studies were extracted from Google. Manuscripts without full text or summary available were excluded as well as those whose summaries did not contain any usable data. One hundred and fifteen studies were recorded. Among them, 93 filled selection criteria. CL has been reported in 10 West African countries with outbreaks described in five countries. Burkina Faso, where the average incidence of the disease is around 928 cases per year, and Ghana seem to be the most affected. Cases have been confirmed in the majority of studies by microscopy sometimes associated with culture or histology. The exposure rate to Leishmania infection based on leishmanin skin test was relatively high with an overall average of 30.2%. Leishmania major was the only species identified with a predominance of MON-74 (62%) and MON-26 (30.6%) zymodemes. Phlebotomus duboscqi is retained as the vector whereas Sergentomyia darlingi and Sergentomyia ingrami were found naturally infected. Rodents including Arvicanthis niloticus, Gerbilliscus gambiana and Mastomys spp. are reported as the main reservoir hosts. Additional studies are needed to better characterize CL in WA in order to optimize the management of cases and to organize the control of the disease transmission.

La leishmaniose cutanée (LC) est décrite en Afrique de l'Ouest (AO) depuis le début du xxe siècle. Les dernières décennies ont été marquées par une augmentation franche de l'incidence des cas dans plusieurs pays de la région. Les données restent cependant rares et fragmentaires. Ainsi, l'incidence et la distribution géographique réelles ne sont pas connues, et les vecteurs et réservoirs impliqués sont largement hypothétiques et peu documentés. L'objectif de cette revue était de collecter et d'analyser les données et les connaissances disponibles dans la région en vue de mieux aborder la prise en charge et le contrôle de la maladie. Une revue systématique de la littérature a été effectuée à l'aide des bases de données Pubmed, Google Scholar et Hinari. Les publications portant sur les aspects épidémiologiques de la LC, les parasites en cause, les phlébotomes et les potentiels réservoirs de parasite ont été recherchées sans aucune restriction. Les études non publiées ont été extraites sur Google.com. Les articles sans texte intégral ou résumé disponibles ont été exclus ainsi que ceux dont les résumés ne contenaient aucune donnée exploitable. Cent quinze études ont été recensées dont 93 ont été retenues. La LC a été rapportée dans dix pays de l'AO. Des foyers épidémiques ont été décrits dans cinq pays. Le Burkina Faso où l'incidence moyenne est d'environ 928 cas par an et le Ghana semblent les plus touchés. Les cas de LC ont été souvent confirmés par la microscopie, associée parfois à la culture ou à l'histologie. Les taux d'exposition à l'infection par Leishmania établis par intradermoréaction à la leishmanine étaient élevés avec une moyenne de 30,2 %. Leishmania major a été la seule espèce identifiée avec une prédominance des zymodèmes MON-74 (62 %) et MON-26 (30,6 %). Phlebotomus duboscqi en est retenu le vecteur, sachant que Sergentomyia darlingi et Sergentomyia ingrami ont été trouvées naturellement infectées. Les muridés Arvicanthis niloticus, Gerbilliscus gambiana et Mastomys spp. en seraient par ailleurs les principaux réservoirs. Des études complémentaires écologiques et en population générale sont nécessaires pour mieux caractériser la LC et son cycle de transmission en AO afin de mieux en organiser la prise en charge, voire la lutte.

[Cultures on NNN medium for the diagnosis of leishmaniasis]. / Les cultures sur milieu NNN dans le diagnostic biologique des leishmanioses.

Cutaneous and visceral leishmaniasis (VL, CL) represent the most frequent vector-borne diseases in Tunisia. Their biological confirmation is necessary before the administration of restricting, expensive and toxic specific treatments. Retrospective evaluation of the contribution of Leishmania cultures on NNN medium in leishmaniasis diagnosis have been done using the data of 375 cultures concerning 214 CL cases and 125 VL cases consecutively recruited in Pasteur Institute of Tunisia between 1995 and 2007. The global sensitivity of the culture in the course of CL was of 68.2%. It was significantly higher during zoonotic CL (78.8%) compared to that during sporadic CL (54.9%); p<0.001. This difference is explained by the easier thrust in NNN medium of Leishmania (L.) major, the agent of zoonotic CL than that of L. infantum, particularly its zymodeme MON-24, agent of sporadic CL. In the course of VL, and in spite of the better sensitivity of bone marrow aspirates (BMA) culture (70.8%), the blood buffy-coat, which permit to avoid the trauma induced by BM aspiration gave promising results (58.2%), the difference being not significant. Besides, in the course of both CL and VL, the direct examination of smears is revealed more sensitive, respectively 89.7% and 93.4% (p<0.01 and p<0.01). Although, systematic cultures practise, in parallel with direct examination, is recommended. In fact, in addition of straightening out some diagnosis, 22 cases in our series, the culture provide the isolation and the isoenzymatic identification of the causative species and strains allowing a better comprehend of parasite life cycles and a disposing of important epidemiological data for suitable control measures. As known with all cultures, those of Leishmania are also exposed to the contamination problem, which reached 5.9% in our study. In conformity with previsions, the contamination concerned much more cutaneous samples (8.4%) than blood or BM ones (2.5%; p=0.015).

[Congenital toxoplasmosis: clinical and biological analysis of 11 cases in Tunisia]. / La toxoplasmose congénitale en Tunisie: analyse clinique et biologique de 11 cas.

Early diagnosis of congenital toxoplasmosis (CT) is necessary to prevent serious complications. The CT is diagnosed by the identification of the parasite in amniotic fluid during pregnancy or at birth by detection of antibodies synthesized by the fetus. The aim of this study was to determine the clinical and biological particularities of CT in a cohort of 11 cases observed in Tunisia and to evaluate the performance of the prenatal and neonatal diagnostic techniques that were used. In all patients, the presumed date of maternal contamination was determined based on the mother's serological data. Neonatal serological screening included assays for immunoglobulins (Ig) G and IgM by enzyme-linked-immuno-sorbent assay (ELISA), IgM by immuno-sorbent-agglutination-assay (ISAGA), and comparison of the mother-baby immunological profile by western blot IgG and IgM. Seven out of the 11 cases had been diagnosed prenatally; only 3 (43%) had a positive polymerase chain reaction (PCR) test. Ten newborns out of 11 had serological criteria of fetal infection; western blot results were positive in all of them, ISAGA was positive in 2 and ELISA in none. The newborn who had a negative serology had been treated in utero. The date of positivity of the western blot test varied: 6 cases at birth, 2 at 12 days of life and 2 at 1 month of life. The 2 patients who had positive ISAGA results had been contaminated during the 3rd trimester of gestation.

[The current risk factors for hydatidosis in Tunisia]. / Les facteurs actuels d'endémicité de l'hydatidose en Tunisie.

Hydatidosis is a major public health problem in Tunisia. The presence of numerous stray dogs, widespread practice of sheep rearing and frequent slaughter of animals outside slaughterhouses are the main risk factors for spread of this zoonotic disease. Human behaviour associated with poor understanding of the parasite life cycle also has a negative impact. Health education is crucial for effective control. It should emphasize the damaging effects of uncontrolled slaughter, the exact role of dogs in parasite transmission and above all the need for adequate measures to sterilize infested viscera.

Molecular differentiation of Entamoeba histolytica and Entamoeba dispar from Tunisian food handlers with amoeba infection initially diagnosed by microscopy.

The purpose of the study was to obtain more reliable epidemiological data concerning Entamoeba (E.) histolytica infection in Tunisian food handlers using established molecular tools able to differentiate E. histolytica from E. dispar. From 2002 to 2005, 4,266 fresh stools specimens received in the setting of the National program of food handlers' control were analysed by optical microscopy. Twelve (2.8 per thousand) were positive for the presence of four nuclei cysts identified as E. histolytica/E. dispar. Extraction of DNA from the 12 samples, followed by specific amplifications of E. histolytica and E. dispar SSU rDNA, showed that 11 samples (92%) were positive for E. dispar and negative for E. histolytica. Sequencing analysis of 8 PCR products permitted to verify the results obtained with conventional PCR. The remaining sample was negative by PCR amplifying E. histolytica DNA or E. dispar DNA specifically, although it did not show any inhibition. It probably contains protozoan cysts genetically distinct from these two species but morphological similar. Estimation of relative proportions between E. histolytica and E. dispar in cyst carriers showed that all explored individuals harboured the non pathogenic E. dispar strains. This result highlights the need of use in this population of complementary tests that allow specific diagnosis and obviate unnecessary chemotherapy.

[Epidemiology of Leishmania (L.) infantum, L. major and L. killicki in Tunisia: results and analysis of the identification of 226 human and canine isolates]. / Epidémiologie de Leishmania (L.) infantum, L. major et L. killicki en Tunisie: résultats et analyse de l'identification de 226 isolats humains et canins et revue de la littérature.

The epidemiological situation of leishmaniasis in Tunisia is characterised by the co-existence in a very limited territory (165,000 km2, Sahara included), of 4 clinical forms: the infantile visceral leishmaniasis (VL) and 3 cutaneous leishmaniasis (CL) forms (sporadic, zoonotic and chronic). In addition to the useful epidemiological data, identification of the causative parasitic species is essential to determine the geographic distribution of each form and to select appropriate therapeutic procedure and suitable control measures. 226 Leishmania isolates, 135 human's coming from 59 VL cases and 76 CL cases and 91 canine's were identified by the isoenzyme electrophoresis reference technique. Results confirm the endemicity of the 4 forms mentioned above. The sporadic CL, confined to the North of the country is principally caused by L. infantum MON-24 (72.2%). VL which has reached the southern ridge in the central area of Tunisia, in the governorate of Kairouan (36 typed isolates), presents an unusual high proportion of L. infantum MON-24. In fact, this zymodeme, rather dermotropic is responsible for 47.2% of the cases vs 13% in the other regions of the country where L. infantum MON-1 remains predominant with 78.3% of typed isolates, the difference being statistically significant (P < 0.01). A third zymodeme, L. infantum MON-80 is sporadically pointed out during VL or in sporadic CL. Despite the high number of canine isolates (n=91) coming from 6 governorates, only the zymodeme L. infantum MON-1 was identified, letting hypothetic the reservoir of the 2 other zymodemes of the species identified in humans. Those absences may be related to cross infections, with a low sensitivity to L. infantum MON-24 leading to a selection of MON-1 at the time of culture passages. Hence it is important to develop molecular tools of direct identification on initial biological samples without going through cultures. Zoonotic CL remains the predominant cutaneous form in the central and southern area of Tunisia. However L. killicki, agent of the chronic CL, is confirming its presence out of its original focus of Tataouine in the southern-east of the country in both zoonotic CL and VL areas.

[Primary Leishmania infantum MON-80 endonasal leishmaniasis in Tunisia]. / Leishmaniose endonasale primitive à Leishmania infantum MON-80 en Tunisie.

BACKGROUND: Mucocutaneous leishmaniasis is endemic in Central and South America. It causes massive mutilating and disfiguring lesions and can lead to destruction of facial structures. In Tunisia, leishmaniasis of the mucous membranes is rare, usually developing as a complication of cutaneous leishmaniasis via direct extension. We report the first case in Tunisia of isolated and primary nasal leishmaniasis. CASE REPORT: A 70-year-old man with a history of nephrectomy for renal lithiasis was seen with a painless nodule that had been present for one month. The latter was erythematous, polypoid and firm, with a diameter of 2 cm, and was situated in the right endonasal mucosa. The diagnosis of leishmaniasis was confirmed by histological and direct examinations revealing high numbers of amastigotes of Leishmania. Culture of the offending organism in NNN medium and isoenzymatic characterization resulted in identification of MON-80 Leishmania infantum leishmaniasis. The outcome was good with treatment, and the nodule was deflated after six months. DISCUSSION: There have been few reports of similar cases of primary and isolated mucosal leishmaniasis caused by Leishmania infantum. Our case is also unusual in that zymodeme MON-80 is only rarely a cause of Mediterranean leishmaniasis.

[Efficacy of Deltamethrine-impregnated collars Scalibor in the prevention of canine leishmaniasis in the area of Tunis]. / Efficacité des colliers Scalibor imprégnés de deltaméthrine dans la prévention de la leishmaniose canine dans la région de Tunis.

The anti-sandflies and, insecticides impregnated collars are actually mentioned as the main mean for prevention and control of Canine leishmaniasis. An evaluation of the Scalibor collar was undertaken in leishmaniasis active sites in Tunis area, (northern Tunisia). Eighty leishmaniasis free dogs (42 collared and 38 as control dogs) were submitted to a serological detection using ELISA technique for anti-Leishmania antibodies before and after transmission season in 2005 and 2006. Seroconversions were detected by ELISA and controlled by indirect immunofluorescence antibodies test. Confirmation of infection in seroconverted dogs was based on the detection of the parasite by culture in NNN medium or detection of parasite's DNA by real time PCR. Among 38 control dogs, 6 (15.8%) were infected by Leishmania infantum during the study period against zero in the collar group; the difference is statistically significant (p=0.02). This result is an additional confirmation of the prophylactic properties of Scalibor protector band against canine leishmaniosis.

[Management of Toxoplasmic Seroconversion in the Third Trimester of Pregnancy in Tunisia]. / Particularités de la prise en charge en Tunisie des séroconversions toxoplasmiques du troisième trimestre de grossesse.

The purpose of our study was to report the particularities of the management of toxoplasmosis seroconversion cases occurred during the third trimester of pregnancy and diagnosed in the Institute Pasteur of Tunis. The study was conducted in the Laboratory of Parasitology-Mycology of the Institute Pasteur of Tunis between January 2005 and December 2017. A total of 27 cases of toxoplasmosis seroconversion during the third trimester were included. Prenatal diagnosis was performed in five cases. PCR was positive in one case. Pyrimethamine-sulfadoxine was prescribed in one case with positive PCR and in another case as soon as maternal infection was confirmed. Spiramycine was prescribed in 24 cases for the duration of the pregnancy. One woman did not take any treatment because seroconversion was diagnosed just before delivery. Twenty newborns had congenital toxoplasmosis: 19 cases were diagnosed by serology and one case was diagnosed after amniocentesis. Two newborns (10%) were symptomatic at birth. All the newborns had neither clinical nor radiological signs during the follow-up.

L'objectif de notre travail était de rapporter les particularités de la prise en charge d'une série de cas de séroconversion toxoplasmique du troisième trimestre de grossesse diagnostiquée à l'institut Pasteur de Tunis. Il s'agit d'une étude rétrospective colligée au laboratoire de parasitologie-mycologie de l'institut Pasteur de Tunis entre janvier 2005 et décembre 2017, incluant 27 femmes enceintes ayant présenté une séroconversion toxoplasmique au cours du troisième trimestre de la grossesse diagnostiquée au cours de leurs suivis sérologiques. Cinq femmes ont bénéficié d'un diagnostic anténatal. La PCR (polymerase chain reaction) s'est révélée positive dans un seul cas. Deux femmes ont été mises sous pyriméthamine-sulfadoxine dont une avait une PCR positive. La spiramycine a été instituée chez 24 femmes jusqu'à l'accouchement. Une femme n'a reçu aucun traitement, la séroconversion ayant été diagnostiquée la veille de l'accouchement. Le diagnostic de la toxoplasmose congénitale a été retenu chez 20 nouveau-nés (74 %) dont un en anténatal et 19 à la naissance. Deux étaient symptomatiques (10 %) à la naissance. Aucune manifestation clinique ou radiologique n'a été observée au cours de leurs suivis.

Leishmaniasis in central and southern Tunisia: current geographical distribution of zymodemes.

The authors report the identification of Leishmania strains isolated from the Centre and the South of Tunisia. 266 strains were isolated between 1998 and 2006 from human (n=221 strains) and dogs (n=45 strains) hosts. The isoenzymatic identification exhibits the presence of in total five zymodemes belonging to three Leishmanio complexes: Leishmania infantum, L. major and L. killicki. All strains isolated from human and canine visceral leishmaniasis belonged to L. infantum. zymodeme MON-1 was the only one isolated from canine visceral leishmaniasis. However, it is predominant in human visceral leishmaniasis beside zymodeme MON-24 which was detected in two provinces of the Centre (Monastir and Kairouan) and zymodeme MON-80 isolated for the first time in Kairouan province. Three complexes are responsible for human cutaneous leishmaniasis: L. major MON-25 is the parasite the most frequently found in its classic foci in the Centre and the South of the country. L. infantum MON-24 was isolated for the first time in a small locality of Sfax (southern Tunisia) showing the appearance of a new focus of L. infantum. L. killicki was isolated in its original focus of Tataouine and in two new foci of the central part of the country (Sidi Bouzid and Kairouan).