Co-infections of human herpesviruses (CMV, HHV-6, HHV-7 and EBV) in non-transplant acute leukemia patients undergoing chemotherapy.

BACKGROUND: Human herpesviruses (HHVs) remain latent after primary infection and can be reactivated in response to immunosuppression and chemotherapy. Little is known about their incidence, potential relationships, risk factors and clinical impact in non-transplant leukemia patients. This study investigated prospectively incidence, risk factors, clinical impact and possible association of HHVs-(1-7) infections in patients with newly diagnosed acute leukemia. METHODS: Study design involved longitudinal sampling before chemotherapy and in different phases of chemotherapy: post-induction, post-remission, and post-salvage during 2016-2018. A total of 734 plasma samples from 95 patients were analyzed by a qualitative, multiplex PCR for HHVs detection and a quantitative real-time PCR was used for cytomegalovirus (CMV) quantification. HHVs-(1-6) IgG and IgM antibodies were tested using immunoassays. Risk factors were analyzed by binary logistic regression and relationships between viruses were analyzed using the Chi-square or Fisher's exact test as appropriate. RESULTS: The overall seroprevalences of HHV-(1-6) IgG were high (> 80%). At least one herpes viral agent was detected in 60 patients (63.3%). CMV was the most commonly detected virus in the different phases of chemotherapy (19.4%), followed by HHV-6 (9.7%), HHV-7 (5.2%) and EBV (2.7%). HSV-1/2 and VZV DNA were not detected. Twenty-seven patients (28.4%) had more than one virus detected in the follow-up, with 23 who were co-infected. CMV/HHV-6 was the most frequent co-infection (69.5%, 16/23). HHV-6 infection (p = 0.008) was identified as a risk factor for CMV infection while salvage treatment (p = 0.04) and CMV infection (p = 0.007) were found to be independent risk factors for HHV-6 infection. CMV co-infection was associated with severe lymphopenia with an absolute lymphocyte count (ALC) (< 500/µL) (p = 0.009), rash (p = 0.011), pneumonia (p = 0.016) and opportunistic infections [bacteremia, p < 0.001 and invasive fungal infection, (p = 0.024)] more frequently than CMV mono-viral infections. CONCLUSIONS: Our data suggest that co-infection with HHVs, especially CMV and HHV-6, may contribute to the development of serious clinical manifestations with profound lymphopenia, pneumonia rash and increased risk for bacterial and fungal co-infections. These findings may suggest the synergistic effect of HHVs associated infection.

A Novel Mutation c.153 C>A in a Tunisian Girl With Wolman Disease and Unusual Presentation: Hemophagocytic Lymphohistiocytosis.

Wolman disease is an ultrarare lysosomal storage disease caused by a mutation in the LIPA gene. The clinical features of Wolman disease include early onset of vomiting, diarrhea, failure to thrive, hepatosplenomegaly, and bilateral adrenal calcification. We report the case of a 3-month-old infant who presented clinical features of hemophagocytic lymphohistiocytosis. Genetic sequence analysis of the LIPA gene revealed homozygous mutation c.153 C>A (p.Tyr51*). The parents were heterozygous for this mutation. Prenatal diagnosis has been carried out in the next pregnancy. To our knowledge, this mutation has never been reported before, and this is an unusual case of secondary hemophagocytic lymphohistiocytosis complicating Wolman disease.

X-Linked Agammagobulinemia in a Large Series of North African Patients: Frequency, Clinical Features and Novel BTK Mutations.

PURPOSE: X-linked agammagobulinemia (XLA) is a primary immunodeficiency caused by Bruton's tyrosine kinase (BTK) gene defect. XLA patients have absent or reduced number of peripheral B cells and a profound deficiency in all immunoglobulin isotypes. This multicenter study reports the clinical, immunological and molecular features of Bruton's disease in 40 North African male patients. METHODS: Fifty male out of 63 (male and female) patients diagnosed with serum agammaglobulinemia and non detectable to less than 2% peripheral B cells were enrolled. The search for BTK gene mutations was performed for all of them by genomic DNA amplification and Sanger sequencing. RESULTS: We identified 33 different mutations in the BTK gene in 40 patients including 12 missense mutations, 6 nonsense mutations, 6 splice-site mutations, 5 frameshift, 2 large deletions, one complex mutation and one in-frame deletion. Seventeen of these mutations are novel. This large series shows a lower frequency of XLA among male patients from North Africa with agammaglobulinemia and absent to low B cells compared with other international studies (63.5% vs. 85%). No strong evidence for genotype-phenotype correlation was observed. CONCLUSIONS: This study adds to other reports from highly consanguineous North African populations, showing lower frequency of X-linked forms as compared to AR forms of the same primary immunodeficiency. Furthermore, a large number of novel BTK mutations were identified and could further help identify carriers for genetic counseling.

Community-acquired pleuropneumonia in children: Bacteriological and therapeutic challenges.

Background Community-acquired pleuropneumonia (CPP) is a common complication of pneumonia in children. It is serious given its high morbidity and significant mortality. Aim To study clinical and paraclinical features of CPP in children and to establish a common therapeutic strategy. Methods Our retrospective study included patients who were hospitalized for CPP between 2004 and 2012. All data were collected from patients' medical files. Statistical analysis was made by Epi-Info 6. Results One hundred and sixty four patients were registered. The mean age was 32 months (15 days - 14.5 years). The hospital incidence of CPP doubled between 2004 and 2012. The symptomatology was dominated by fever (93.9%), cough (56.7%) and dyspnea (48.1%). The pleural effusion was frequently moderately abundant and loculated. Pleural sample, performed in 53.6% of cases, was the most beneficial bacteriological examination (p=10-6 ). The bacteriological confirmation was attained in 44.5% of cases with the predominance of Staphylococcus aureus (59%) followed by Streptococcus pneumoniae (26%). The S. aureus occurred basically in most young infants (p=0.04) and was responsible for the most severe cases (p=0.01). The CPP management included heterogeneous intravenous antibiotics associated with a pleural drainage in 40% of cases. The quarter of our patients were transferred to an intensive care unit. Six patients died. Conclusion The bacteriological confirmation is difficult. Pleural aspiration is the key tool. S. aureus is the first microorganism followed by S. pneumoniae. A therapeutic strategy is proposed based on large spectrum intravenous antibiotics. The pleural drainage indication is limited.

[Clinical predictors of high risk bleeding endoscopic lesions in children with hematemesis]. / Les facteurs cliniques prédictifs de lesions endoscopiques à haut risqué de saignement chez un enfant présentant une hématémèse.

BACKGROUND: Haematemesis is an alarming symptom in children, even if the proportion of normal endoscopies ranges from 10 to 21% and the causes are often benign. The purpose of the study was to identify clinical predictors of endoscopic lesions with high risk of bleeding and to establish a score that predict the presence of these lesions. METHODS: Retrospective study carried in Children's Hospital of Tunis between 1997 and 2006 involved children with haematemesis who underwent Upper gastrointestinal endoscopy. Several clinical parameters were analyzed. Univariate analysis and multivariate logistic regression were performed to identify predictive parameters of endoscopic lesions with high risk of bleeding. A score was developed from the parameters derived from the multivariate analysis. The sensitivity and specificity of the score were determined. RESULTS: Among 2814 endoscopies, 814 were conducted for haematemesis and 489 were selected for the study. 140/489 had lesions with high risk of bleeding. Multivariate logistic regression analysis identified six factors independently associated with high risk bleeding lesions: endoscopy performed within 48 hours (OR=2.2; 95% CI 0.7-6.9), re-bleeding (OR=1.4; 95% CI 0.7-2.5), the importance of the bleeding, mild to severe (OR=1.8; 95% CI 1.1-3), bright red haematemesis (OR=1; 95% CI 0.2-5.8), history of gastrointestinal and liver disease (OR=1.6; 95% CI 1.1-3) and intake of gastro toxic drugs (OR=1.3; 95% CI 0.8-2.3). Then, we established a score. The sensitivity, specificity, positive predictive value and negative predictive value of this score were respectively 79.6%, 32.9%, 34.9% and 78% for a cut off value>0.22. CONCLUSION: The clinical predictive parameters of high risk bleeding lesions identified have not yielded a score with significant sensitivity and specificity. A prospective study should be performed to improve the score.

A randomized, controlled trial of nebulized 5% hypertonic saline and mixed 5% hypertonic saline with epinephrine in bronchiolitis.

BACKGROUND: Bronchiolitis is a public health problem in the word and in Tunisia. Nebulized hypertonic saline seems to have some benefits in bronchiolitis. The aim of this study is to evaluate the efficacy of nebulized 5% hypertonic saline alone or mixed with epinephrine in bronchiolitis as measured by improvement in clinical score, oxygen saturation or reduction in duration of hospitalization. METHODS: This prospective, double blind, placebo controlled, randomized clinical trial was performed at Children's Hospital of Tunis from February 2012 to Mars 2012. A total of 94 patients less than 12 months of age with diagnosis of moderately severe bronchiolitis were enrolled and assigned to receive 5% nebulized hypertonic saline, mixed 5% hypertonic saline with standard epinephrine 0,1% or normal saline (placebo) at admission and every 4 hours during hospitalization. RESULTS: There were no significant difference between nebulized 5% hypertonic saline, mixed 5% hypertonic saline with epinephrine or normal saline at baseline, T30 min, T60 min, and T120 min after start study in Wang severity score, oxygen saturation in room air, rate respiratory and heart rate. There was no difference in duration of hospitalization. CONCLUSION: Nebulized 5% hypertonic saline or mixed 5% hypertonic saline with epinephrine are safety but does not appear effective in treating moderately ill infants with the first acute bronchiolitis.

Endoscopic diagnosis in a Tunisian pediatric population with upper gastrointestinal bleeding.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is currently considered the first line diagnostic procedure chosen for Upper Gastrointestinal Bleeding (UGIB) since 1970. However, studies are still limited in our country. AIM: Finding out the most common causes of UGIB in children and whether the causes differed according to age in developing and developed countries. METHODS: A retrospective review of the medical records of children referred to the Paediatric Gastroenterology Department of The Tunis Hospital of Children between January 1998 and December 2006 for upper gastrointestinal bleeding. The children were divided into three groups; G1: neonates; G2: infants; G 3: children and adolescents. RESULTS: The study involved 614 endoscopies. The aetiology was not ascertained in 20.68%of cases. G1 included 125 newborns: 24 with no identified causes, 97 mucosal lesions (isolated or associated); two ulcers and two tumours. G2 and G3 included respectively 205 infants and 289 children. Toxic drug intake was recorded in 140 out of 489 patients. Endoscopy was normal in 101 cases. Peptic oesophagitis was recorded in 57/205 (27.8%) of G2 infants versus 52/284 (10%) of G3 children (p=0.015). Gastritis was recorded in 164/284 (55.6%) of G2 infants versus 86/205 (41.9%) of G3 children (p≤0.001). Peptic ulcers were reported in ten boys. Mallory Weiss tears and Variceal lesions were found in respectively eleven and ten cases. CONCLUSION: Aetiologies of UGIB in children in Tunisia varied according to age and geographic areas.

Nodular gastritis: an endoscopic indicator of Helicobacter pylori infection in children.

BACKGROUND: Helicobacter pylori (Hp) infection is a common and universally distributed bacterial infection. It is predominantly acquired in childhood. AIM: To assess the relationship between endoscopic nodular gastritis and Hp infection. METHODS: A retrospective study was conducted in children who underwent upper gastrointestinal endoscopy for chronic abdominal pain. All children who had five gastric biopsies for histologic analysis, urease test and Hp culture were included in the study. The Sensitivity and sensibility of nodular gastritis were determined and different parameters were studied according the presence or not of nodular gastritis(age, gender, Hp status, gastritis score and lymphoid follicles). RESULTS: 49 children, mean age 6.9 ± 3 years (range 1-12 years) were eligible for the analysis. Hp Infection was diagnosed in 35 out of the 49 children (71.5 %). Nodular gastritis was recorded in 16 out of 49 children and in 14 infected children and 2 out of 14 non infected children (p=0.07), 40% sensitivity, 85.7% specificity, 87.5% positive predictive value, and 36,4% negative predictive value. The parameters associated significantly to the presence of nodular gastritis were older age: (p=0.04), Hp infection: (p=0.01), chronic gastritis: (p=0.05), active gastritis: (p=0.02), follicular gastritis: (p=0.005), higher gastritis score: (p=0.005). Completely normal gastric mucosal histology was never found in infected children with antral nodularity. Among all infected children, the gastritis score was significantly higher when there was a nodular gastritis and follicular gastritis was significantly associated to nodular gastritis. CONCLUSION: The endoscopic pattern of antral nodularity identifies children with Hp infection, and active chronic follicular gastritis.

Prevalence and risk factors of overweight and obesity in elementary schoolchildren in the metropolitan region of Tunis, Tunisia.

BACKGROUND: Local data about prevalence of obesity in emerging countries are rather scarce. Risk factors for obesity, well known in most industrialized countries, are poorly understood in Tunisia. AIMS: To assess prevalence of overweight and obesity and to investigate associations with possible risk factors in a group of 6-12 year- old schoolchildren in Tunis, Tunisia. METHODS: A descriptive transversal study including a sample of 1335 schoolchildren (6-12 years; mean: 9.7 ± 1.5 years) was conducted in Tunis. Personal and parental data were collected by questionnaires completed by parents. Height and weight were measured and body mass index was calculated. Prevalence of overweight and obesity was defined based on international agreed cut-off points. RESULTS: Prevalence of overweight and obesity was 19.7% and 5.7%, respectively. Risk factors associated with overweight were: high degree- educated mother and father: 17.3% vs 11.7% (p=.01) (OR (95%CI): 1.58; 1.09-2.29) and 26% vs 17.4% (p=.002) (OR: 1.66; 1.21-2.29), respectively; mother, father high in occupational hierarchy: 7.2% vs 3.6% (p=0.009) (OR: 2.1; 1.2-3.7) and 14% vs 9% (p=.014) (OR: 1.6; 1.1-2.48), respectively. Overweight children had a significantly higher consumption of bread (p=.044), of snack intake (p=0.046) and of soft drink consumption (p=.035). CONCLUSIONS: Prevalence of overweight and obesity in this cohort are 19.7% and 5.7%, respectively. Substantial differences in food choices in families with the highest socio-economic status are among risk factors contributing to obesity development.

Abdominal tuberculosis in children.

BACKGROUND: Abdominal tuberculosis (TB) includes infection of the gastrointestinal tract, peritoneum, mesentery, abdominal lymph nodes, liver, spleen, and pancreas. The most common forms of abdominal TB in children are adhesive peritonitis and nodal disease. PATIENTS AND METHODS: We report our experience with abdominal TB treated in our hospital from 1995 to 2008. RESULTS: Thirteen patients (3 boys and 10 girls) of mean age 9.8 years were diagnosed as having abdominal TB. Eight patients presented with abdominal distension and abdominal pain. Fever was seen in 4 patients. One patient had surgical abdominal pain and 2 had abdominal mass. Two patients had coexisting pleural effusion and 1 of them had multifocal TB. Abdominal TB involved peritoneum in 9, abdominal lymph nodes in 7, gastrointestinal tract in 3, spleen in 2 patients, and liver in 1. Ascitic fluid analysis of 9 patients showed exudative fluid with predominately lymphocytes. Laparotomy was performed in 3 patients. The diagnosis of abdominal TB was confirmed histopathologically in 5 patients and microbiologically in 3. The remaining patients had been diagnosed by ascitic fluid diagnostic features, abdominal imaging, tuberculin skin test, history of exposure, and a positive response to antituberculous treatment. Twelve patients completed the antituberculous therapy without any complications. One patient with multifocal TB had neurological sequelae. CONCLUSIONS: In the areas with a high prevalence of tuberculosis and confirmatory investigations are inadequately available, treatment may be initiated, based on strong clinical diagnosis and supportive investigations. In such situations, it is the response to therapy that indirectly proves the diagnosis.

Mediastina Tuberculosis mass in a three-month-old boy.

BACKGROUND: Mediastinal mass of tuberculous origin is exceedingly rare in infant. AIM: to report an exceedingly rare case of mediastinal mass of tuberculous origin. CASE REPORT: We report a three-month-old boy who presented a one month history of wheezing and persistent pneumopathy. Radiological investigations showed a large posterior mediastinal mass which infiltrates lungs. Thoracoscopic biopsy showed caseous necrosis with granuloma suggestive of tuberculosis. The outcome was favourable with antituberculous chemotherapy. CONCLUSION: Mediatinal mass of tuberculous origin should considered in differential diagnosis of mediastinal masses in children; be suggested in mediastinal mass in children.

Temporal and climate characteristics of respiratory syncytial virus bronchiolitis in neonates and children in Sousse, Tunisia, during a 13-year surveillance.

This study established the correlation between respiratory syncytial virus (RSV) bronchiolitis and climate factors in the area of Sousse, Tunisia, during 13 years (2003-2015), from neonates and children <= 5 years old and hospitalized in Farhat Hached University-Hospital of Sousse. The meteorological data of Sousse including temperature, rainfall, and humidity were obtained. RSV detection was carried out with the direct immunofluorescence assay. The impact of climate factors on viral circulation was statistically analyzed. From 2003 to 2015, the total rate of RSV bronchiolitis accounted for 34.5% and peaked in 2007 and 2013. RSV infection was higher in male cases and pediatric environment (p<0.001) and was detected in 47.3% of hospitalizations in intensive care units. The epidemic of this pathogen started in October and peaked in January (41.6%). When the infectivity of RSV was at its maximum, the monthly average rainfall was high (31 mm) and the monthly average temperature and the monthly average humidity were at their minimum (11 °C and 66%, respectively). RSV activity was negatively correlated with temperature (r = - 0.78, p = 0.003) and humidity (r = - 0.62, p = 0.03). Regression analysis showed that the monthly average temperature fits into a linear model (R2 = 61%, p < 0.01). No correlation between RSV activity and rainfall was observed (p = 0.48). The meteorological predictions of RSV outbreaks with specific Tunisian climate parameters will help in determining the optimal timing of appropriate preventive strategies. In the area of Sousse, preventive measures should be enhanced since October especially, when the temperature is around 11 °C and humidity is above 60%.

[Infectious diarrhoea in children under five years]. / Les gastroentérites aigues chez les enfants de moins de 5 ans.

AIM: to determine the prevalence of rotavirus in acute diarrhea among children under 5 years and to describe the epidemiology, clinical trials of rotavirus diarrhea and compare them with those of other gastroenteritis. METHODS: A Prospective study during 1 year (1 January 2007-31 December 2007) was conducted in the department of Pediatrics B of the Children's Hospital of Tunis. 117 children aged under than 5 years and admitted for acute community gastroenteritis were included in the study. A search of rotavirus in the stool, collected within 48 hours of admission, was performed by a rapid detection of viral antigens: proteins specific RV group A (VP6 protein of the capsid) using enzyme immunoassay technique: sandwich ELISA (IDEIA Rotavirus Dako). RESULTS: Rotavirus diarrhea accounted for 25% of acute gastroenteritis. The average age of rotavirus gastroenteritis was 11 months +/- 1.78. We have noted a male predominance with a sex ratio of 1.2. The seasonal distribution of rotavirus gastroenteritis showed three peaks of incidence (January, May and July). The respiratory signs were more frequently found in rotavirus gastroenteritis group. Rotavirus gastroenteritis had a higher severity score compared with other gastroenteritis (8.44 vs 6.75 P = 0.01). The duration of hospitalization was longer in rotavirus group with a difference close to significance p = 0.07. CONCLUSION: The seasonal distribution of rotavirus gastroenteritis has three peaks of incidence. The gastroenteritis Rotavirus affects very young infants and has more severe symptoms than other gastroenteritis and is significantly associated with respiratory signs.

[Community acquired pneumonia in children]. / Pneumopathies communautaires chez l'enfant.

BACKGROUND: Community acquired pneumonia is responsible for a high morbidity in children. The etiological diagnosis is not always easy and treatment remains probabilistic. AIM: To analysis clinical patterns and the outcome of community acquired pneumonia and to find arguments in favour of its origin. METHODS: A prospective analysis of the files of 39 children (20 boys, 19 girls) hospitalized between (1 december 2004 - 30 june 2005) for community acquired pneumonia was performed. Included dchildren whad between 6 months and 15 years-old. RESULTS: The mean age was of 3 years and three months. Germ was identified in 41% of cases: Mycoplasma pneumoniae was the most important germ found in 9 cases, pneumococcus was found in 4 cases and hemophilus in four cases. Coinfection pneumococcus and mycoplasma were found in two cases. None virus was identified. We have separated two groups: bacterial pneumonia and pneumoniae without definite etiology. Fat cough was associated to bacterial pneumonia. mycoplama pneumoniae was significantly associated with high fever and dry cough. We haven't found any others associations between clinical, biological or radiological patterns and the two groups of pneumonia. C-reactive protein more than 66 mg/l has sensitivity of 77%, specificity of 73.3%, positive predictive value of 46.7% of and negative predictive value of 91.7%. The outcome was favourable in all cases. CONCLUSION: Theses results showed the necessity to improve our microbiological methods to identify infectious agents of pneumonia. Mycoplasma pneumonia seems to be a frequent germ in preschool children.

Infantile onset of Cockayne syndrome without photosensitivity in a Tunisian girl.

BACKGROUND: Cockayne syndrome is a rare autosomal recessive disorder with dwarfism, mental retardation, and otherwise clinically heterogeneous features. Classically, the onset of Cockayne syndrome starts in the second year of life. The failure of RNA synthesis to recover to normal rates after UV-C irradiation provides a useful diagnostic test and the clinical feature that correlates most strongly with defective RNA synthesis is photosensitivity. AIM: To report an unusual case of Cockayne Syndrome. CASE REPORT: A case of a five-year-old girl with Cockayne with an onset in early infancy the girl and without photosensitivity is presented. The diagnosis was confirmed by the failure of RNA synthesis to recover to normal rate after UV-C irradiation. The patient died at the age of 6 of pneumonia. CONCLUSION: Although rare, Cockayne syndrome may be presented without photosensitivity and had an early onset.

A randomized, controlled trial of nebulized terbutaline for the first acute bronchiolitis in infants less than 12-months-old.

BACKGROUND: Despite the common clinical practice, the available evidence on the efficacy of bronchodilators therapy for bronchiolitis is conflicting. The aim of this study is to evaluate the efficacy of nebulized terbutaline in bronchiolitis as measured by improvement in clinical score, oxygen saturation or reduction in duration of hospitalization. METHODS: This prospective, double blind, placebo controlled, randomized clinical trial was performed at Children's Hospital of Tunis from December 2004 to April 2006. A total of 35 patients less than 12 months of age with diagnosis of moderately severe bronchiolitis were enrolled and assigned to receive nebulized terbutaline or normal saline placebo at admission (T0), at 30 minutes after admission (T30) and every four hours during a study period. Outcome measurements included: Respiratory Distress Assessment Instrument (RDAI) score, respiratory rate, oxygen saturation, heart rate and the duration of hospitalization. RESULTS: There were no significant difference between terbutaline and placebo at baseline, T30 min, T60 min, and T120 min after start study in RDAI score, oxygen saturation in room air, rate respiratory and heart rate. There was no difference in duration of hospitalization. CONCLUSION: Nebulized terbutaline therapy does not appear effective in treating moderately ill infants with the first acute bronchiolitis.

Neonatal meningitis by Neisseria meningitidis B.

BACKGROUND: Neisseria meningitidis is one of the major causes of meningitis in children and adolescents, but it is uncommonly found in neonatal meningitis. AIM: to report a rare case of meningitis by Neisseria meningitides B. CASE REPORT: We report the case of neonatal meningitis in a 20-day-old girl without shock or purpura. The symptoms were fever and seizures. The culture of cerebrospinal fluid showed to be positive for Neisseria meningitidis B. culture blood was negative. Antibiotic therapy was started at admission and maintained for 3 weeks. The outcome was favourable without neurological sequelae. CONCLUSION: Early diagnosis and treatment are mandatory for life saving.

Decompressive hemicraniectomy in a space-occupying presentation of hemiconvulsion-hemiplegia-epilepsy syndrome.

A case of an acute life-threatening presentation of hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome requiring an urgent decompressive hemicraniectomy is described. A 9 month-old baby had a status epilepticus following a sustained fever, leading to a comatose state and a right pupillary dilatation associated with a left hemiplegia. The MRI showed a swelling right hemisphere with marked temporal herniation. The baby underwent a decompressive right hemicraniectomy with temporal cortical biopsies. The post-operative course was favourable. The histological findings were unspecific, showing a gliotic spongiosis with disseminated granular cells. The post-operative MRI depicted a right hemisphere atrophy. To our knowledge, a space-occupying presentation of HHE syndrome requiring surgical decompression has never been described before while only a few reports dealt with the neuropathological aspects of this syndrome.

Delayed diagnosis of esophageal foreign body: A case report.

INTRODUCTION: Foreign body (FB) ingestion, a common and serious problem in children, can present with a wide variety of symptoms. This paper describes and discusses the case of an esophageal foreign body (EFB), in which the patient presented with primarily respiratory clinical signs causing delayed diagnosis. PRESENTATION OF CASE: A six month old boy presented with three months history of harsh cough, stridor and pulmonary congestion. He was repeatedly treated with steroids and antibiotics. His symptoms worsened progressively. On examination, he was tachypneic with suprasternal recession, scattered crepitations, diffuse wheeze and a continuous stridor. Chest X-ray was normal. The flexible bronchoscopy showed a posterior external compression on the middle wall of the trachea. The CT scan was normal. The contrast X-ray study of the esophagus revealed an endoluminal filling defect. The esophagoscopy revealed narrowing at 12cm of dental arch, and a bourgeoning yellow mass easily bleeding on contact. Esophageal biopsies were obtained, and histology was inconclusive. A surgical exploration was planned, but the infant forced out a pistachio shell after a chest physiotherapy session. DISCUSSION: Ingestion of FB by small children is a common problem. The majority of EFBs pass harmlessly through the gastrointestinal tract; however, some EFBs can cause significant morbidities. The diagnosis may be delayed leading to several complications especially if the ingestion of the FB is unwitnessed and when the clinician does not think of FB ingestion as part of the differential diagnosis of chronic respiratory signs. CONCLUSION: This case highlights, the importance of recognizing, the rare and often forgotten respiratory symptoms of EFB body to avoid diagnostic delay especially in unwitnessed FB ingestion.

Epidemiology and clinical profile of pathogens responsible for the hospitalization of children in Sousse area, Tunisia.

This study aimed to identify a broad spectrum of respiratory pathogens from hospitalized and not-preselected children with acute respiratory tract infections in the Farhat Hached University-hospital of Sousse, Tunisia. Between September 2013 and December 2014, samples from 372 children aged between 1 month and 5 years were collected, and tested using multiplex real-time RT-PCR by a commercial assay for 21 respiratory pathogens. In addition, samples were screened for the presence of Streptococcus pneumoniae 16S rDNA using real-time PCR. The viral distribution and its association with clinical symptoms were statistically analyzed. Viral pathogens were detected in 342 (91.93%) of the samples of which 28.76% were single positive and 63.17% had multiple infections. The most frequent detected viruses were rhinovirus (55.64%), respiratory syncytial virus A/B (33.06%), adenovirus (25.00%), coronavirus NL63, HKU1, OC43, and 229E (21.50%), and metapneumovirus A/B (16.12%). Children in the youngest age group (1-3 months) exhibited the highest frequencies of infection. Related to their frequency of detection, RSV A/B was the most associated pathogen with patient's demographic situation and clinical manifestations (p<0.05). Parainfluenza virus 1-4 and parechovirus were found to increase the risk of death (p<0.05). Adenovirus was statistically associated to the manifestation of gastroenteritis (p = 0.004). Rhinovirus infection increases the duration of oxygen support (p = 0.042). Coronavirus group was statistically associated with the manifestation of bronchiolitis (p = 0.009) and laryngitis (p = 0.017). Streptococcus pneumoniae DNA was detected in 143 (38.44%) of tested samples. However, only 53 samples had a concentration of C-reactive protein from equal to higher than 20 milligrams per liter, and 6 of them were single positive for Streptocuccus pneumoniae. This study confirms the high incidence of respiratory viruses in children hospitalized for acute respiratory tract infections in the Sousse area, Tunisia.