[Toxoplasmic infections in pregnancy: about 94 cases diagnosed at the Pasteur Institute of Tunis]. / Infections toxoplasmiques au cours de la grossesse: à propos de 94 cas diagnostiqués à l'institut Pasteur de Tunis.

OBJECTIVES: The objectives of this study were to estimate the risk of maternal-fetal transmission of toxoplasmosis and its consequences on the fetus and to emphasize the importance of follow-up of newborns in Tunisia. PATIENTS AND METHODS: It was a retrospective study of 94 cases of pergravidic toxoplasmic seroconversion who were diagnosed and followed in the Laboratory of Parasitology of Pasteur Institute of Tunis between 2005 and 2010. RESULTS: In our series, amniocentesis was performed for 60 parturients. Among the amniotic fluid tested, research of toxoplasmosis DNA by PCR was positive in 12 cases (12/60, 20 %). Twenty-six cases of congenital toxoplasmosis were diagnosed with 14 postnatal cases. The rate of maternal-fetal transmission of Toxoplasma gondii was 27.6 % (26/94). This risk increases with gestational age, from 19 % at seroconversion of the 1st quarter to 29.4 % in the 2nd quarter and 44.4 % in the 3rd trimester. Monitoring of newborns with congenital toxoplasmosis showed that only 3 children were symptomatic. There were 2 cases of toxoplasmic chorioretinitis and a case of brain damage. Under serological monitoring of newborns, 21 cases were lost to follow-up and monitoring was stopped for 29 after decrease of anti-toxoplasmic IgG. DISCUSSION AND CONCLUSION: The prenatal diagnosis allowed to decrease the severe forms of congenital toxoplasmosis in Tunisia. Nevertheless, it is always necessary to raise the problem of the significant number of newborn children whose follow-up is incomplete.

[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.

[Evaluation and contribution of OptiMAL-IT® test for the diagnosis of imported malaria in Tunisia]. / Évaluation et apport du test OptiMAL-IT® dans le diagnostic du paludisme d'importation en Tunisie.

The rapid test OptiMAL-IT® was evaluated in the diagnosis and the screening of imported malaria in Tunisia in comparison with microscopic techniques. This prospective study focused on 500 individuals recruited from September 2010 to September 2012 in laboratory of Parasitology of Pasteur Institute of Tunis. They include 192 patients with clinical manifestations suggestive of malaria and 308 students originating from endemic areas. Microscopy of thick-and-thin blood smears and OptiMAL-IT® test were systematically performed on blood samples of all participants. Sixty individuals revealed infected by Plasmodium (12%). Positivity rates were respectively 20.3% in patients (44 cases) and 5.2% among asymptomatic students (16 cases) (p<0.01). The sensitivity and specificity of the OptiMAL-IT® test were respectively 88.6% and 100%. The concordance kappa was 0.92. The sensitivity and specificity during the screening of asymptomatic subjects were respectively 68.8% and 98.3% with a concordance of 0.67.

[Toxoplasmosis mother-to-child screening: study of cases followed in the Pasteur Institute of Tunis (2007-2010)]. / Dépistage de la toxoplasmose materno-foetale : étude des cas suivis à l'Institut Pasteur de Tunis (2007-2010).

Toxoplasmosis when occurring during pregnancy can be transmitted to the fetus and lead to congenital toxoplasmosis (CT). Therefore, pregnant women are a risk group, for which it is necessary to determine the serologic profile. The objective of this study is to determine the serologic profile of toxoplasmosis in pregnant women followed at the Parasitology Laboratory of the Pasteur Institute in Tunis, to establish the prevalence of toxoplasmic infections during pregnancy and the incidence of the CT, noting the difficulties faced in the interpretation of serological results. This is a retrospective study concerning 2833 toxoplasmic serologies practiced on 2070 pregnant women, followed at the Parasitology-Mycology Laboratory of the Pasteur Institute of Tunis, between 2007 and 2010. Serological diagnosis of toxoplasmosis was done by ELISA (Enzyme Linked Immunosorbent Assay) for the detection of Immunoglobulin (Ig) G and M and the study of toxoplasmosis IgG avidity. Prenatal diagnosis was performed for 58 women by amniotic fluid sampling. Toxoplasma gondii was detected by Polymerase Chain Reaction (PCR). At birth, the diagnosis of congenital toxoplasmosis was established based on serology. The toxoplasmic serologies carried out have shown that 45.6% of the pregnant women were formerly immunized while 49.6% had a negative serology. A toxoplasmosis primary infection acquired during pregnancy was detected in 79 cases (3.8%). Among them, 33% had a true seroconversion while 67% had a recent toxoplasmosis infection in view of the positivity of IgG and IgM on the first sample with a low index of avidity (IA). For 21 parturients whose serology showed the presence of IgG, IgM and an intermediate or high IA. Among the 58 parturients in whom prenatal diagnosis was performed, PCR was positive in four cases. After birth, six cases of congenital toxoplasmosis were detected by serology.

[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.

[Congenital toxoplasmosis following infection occurring late in pregnancy]. / Toxoplasmose congénitale faisant suite à une primo-infection maternelle en fin de grossesse.

Monthly serological screening of non immune pregnant women is recommended for prevention of congenital toxoplasmosis. However, this screening is often interrupted before delivery. We report a case of congenital toxoplasmosis following infection occurring late in pregnancy. This documented case highlights the need for a final routine serological test, 2-3 weeks post-partum for all seronegative pregnant women. In fact, the screening of congenital toxoplasmosis cases allows the early administration of specific treatment that avoids later severe complications such as chorioretinitis.

[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.

Case of fatal congenital toxoplasmosis associated with I/III recombinant genotype.

We report a case of fatal congenital toxoplasmosis case in Tunis (North of Tunisia) associated with I/III recombinant genotype. The Toxoplasma gondii strain was isolated from placenta and characterized molecularly by a multilocus typing (3'SAG2, 5'SAG2, SAG3, AK69, APICO, and UPRT1) and a sulfadiazine resistance mutation analysis. The isolate was shown to be a wild drug sensitive I/III recombinant strain.

[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.

[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.

[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).

[Contribution of the real time PCR in antenatal diagnosis of congenital toxoplasmosis]. / Apport de la pcr en temps réel dans le diagnostic anténatal de la toxoplasmose congénitale.

BACKGROUND: The antenatal diagnosis of congenital toxoplasmosis rests in Tunisia on ultrasonography coupled with biological explorations. Among these explorations the search of Toxoplasma gondii by means of real time PCR in amniotic fluid is the examination of choice. AIM: We report the results of 33 parturients for which the biological examinations allowed to retain the notion of perigravidic or pergravidic toxoplasmic infection. METHODS: They were 13 patients having a seroconversion during the pregnancy, 19 having anti-toxoplasmic IgM with a low or intermediate index of avidity and a patient having presented a symptomatic anteconceptional primary infection. The ADN was extracted by means of the Kit (Qiagen). Genic amplification by PCR TaqMan targeted a portion of 71 pairs of bases of the B 1 gene. RESULTS: The PCR was positive among 9 patients (27.3%). They were a patient having presented a symptomatic toxoplasmosis during the pregnancy, 4 patients having consulted only in the 2nd quarter and for which the index of avidity was intermediate and 4 patients having presented seoconversions of 1st (n=1) of 2nd (n=2) or 3rd trimester. Among these patients, 2 had a medical interruption of pregnancy. The 7 others were put under pyrimethamine sulfadiazine. The neonatal assessment practised at 5 new-born babies was negative in all the cases. The PCR was negative for 24 patients. 18 pregnancies were followed. The neonatal serology was negative. The follow-up of 13 newborn child showed the disappearance of the antitoxoplasmic IgG between the 6th and 12th month.

[Recurrent chromomycosis of the face and extremities: first case report from Iibya]. / Chromomycose récidivante du visage et des membres: a propos du 1er cas libyen.

Chromomycosis is a chronic cutaneous fungal infection most prevalent in tropical and subtropical countries. It mainly affects adults working in rural areas. This purpose of this report is to describe the first cases in Libya in a 16-year-old girl. This case is also remarkable with regard to location on the face and members, lack of association with trauma and long delay for recurrence, i.e., 6 years after first occurrence.

[Particularities of visceral leishmaniasis in adults not infected by HIV in Tunisia]. / Particularités de la leishmaniose viscérale de l'adulte non infecté par le VIH en Tunisie.

The incidence of adult visceral leishmaniasis in Tunisia has increased in recent years. As a result the epidemiological profile of the disease in our country is now closer to those observed in other Mediterranean countries. Most of the increase involves adults not infected by human immunodeficiency virus (HIV) although 56% of patients presented concurrent disease. In comparison with pediatric visceral leishmaniasis, adult disease is characterized by inconsistence occurrence of some major symptoms such as fever and spleen enlargement. For this reason the clinical disease syndrome may be incomplete and diagnosis may be difficult. Laboratory tests are essential for definitive diagnosis. Although no test is specific, some findings are highly useful, e.g, elevated g-globulins which was observed in 94% of patients in our series. Standard serology is less sensitive in adults with 18% of false negatives in our series probably as a result of immunodeficiency in some patients.

[Value of screening for intestinal and urinary parasites in non-resident permanent students in Tunisia]. / Intérêt du dépistage des parasitoses digestives et urinaires chez les étudiants non résidents permanents en Tunisie.

In order to fight digestive and urinary parasitoses, a national program of surveillance has been founded. The screening of these parasitoses among the non permanent resident students in Tunisia (ENRPTS) is one of the main actions of this program. Among 2560 ENRPTS tested in the laboratory of Parasitologie of Institut Pasteur of Tunis, between 1998 and 2002, 674 were infected by parasites, which represents a global prévalence of 26.3%. The intestinal protozoa constitute the majority of parasites identified (87.4%). Entamoeba histolytica has been isolated in 89 cases, essentially from students from tropical African countries. Urinary bilharziosis has been diagnosed in 25 cases. These results confirm the utility of the control of the ENRPTS. The precocious tracking permits to avoid the introduction and the dissemination of parasites already absent or rare in our country.

[Sero-epidemiologic profile of toxoplasmosis in northern Tunisia]. / Profil séro-épidémiologique de la toxoplasmose au nord de la Tunisie.

Toxoplasma antibodies prevalence was studied in the north of Tunisia where a mild climate prevails. Two groups of individuals were investigated: 857 living in rural area and 564 living in urb town. Sera were analysed by ELISA and indirect immunofluorescence. The overall prevalence was 58.4%. It roses from 24.5% at ten years to 52.1% at 20 years of age. A maximum level, around 70%, was reached by about 30 years. The risk of acute infection after this age seemed low as judging by the proportion of high antibodies titers observed in this group (14.2% before 30 years vs 3.7% after). A significantly higher prevalence was detected in urban residents (67% vs 52.8%). In this group, the rate of seroconversion seems the highest between ten and 20 years of age and the majority of women are infected before reaching childbearing age. In the rural area, the seropositivity is lower between ten-20 years and many women at childbearing age still susceptible to toxoplasmosis. The risk of acute infection seems higher in the youngest ones as showed by the proportion of high antibodies titers observed in the 18-30 age group (9.2%) compared to the one observed after 30 years (1.9%).

[For a better estimation of the prevalence of intestinal parasitism in the Tunis region]. / Pour une meilleure estimation de la prévalence du parasitisme intestinal dans la région de Tunis.

The prevalence of intestinal parasitism is generally based on the results of a single stool specimen which probably underestimates the real situation. In order to propose a coefficient for correction, we examined three stool specimens taken from 112 asymptomatic children. Intestinal parasites other than Enterobius vermicularis were detected in 29 subjects (26%). For those specimens that tested positive, 41% of children had infection detected in all three stool specimens; 21%--in two specimens and 38%--in only one. If we assume that the sensitivity of three stool specimen examinations is 100%, then the calculated sensitivity of one examination is equivalent to 68%. This gives an underestimation of the prevalence of 32%. This underestimation is not homogenous for all species. As regards Giardia intestinalis it is 35%, but for other species it would have to be calculated from a larger sample.