Clinical and laboratory features of murine typhus in central Tunisia: a report of seven cases.

INTRODUCTION: Murine or endemic typhus, caused by Rickettsia typhi, has been reported in all continents. In the 1970s, no cases of murine typhus were diagnosed in Tunisia. METHODS: The clinico-epidemiological characteristics of seven cases of murine typhus diagnosed at our hospitals since 1993 are reported. Diagnosis was confirmed by indirect fluorescence assay detecting specific R. typhi antibodies. RESULTS: Murine typhus occurred in all ages from 18-80 years during the hot season in rural areas. Clinical features were: sudden onset of fever and absence of eschar in all cases, with maculo-papular rash (five cases), prostration (four cases), meningism (three cases) and pneumonia (four cases). Frequent laboratory findings were moderate thrombopenia (four cases) and elevated transaminases (four cases). Before the results of serology, clinical diagnoses were Mediterranean Spotted Fever (four cases), Q fever (one case), pneumonia (one case), and lymphocytic meningitis (one case). Serology confirmed all diagnoses with cross-reactivity with Rickettsia conorii. CONCLUSION: Murine typhus exists in Tunisia and its prevalence is underestimated. Further, more specific studies are needed to evaluate the true prevalence.

Unusual presentation of gastric dilatation. Dramatic complete atrioventricular block.

We report a case of gastric dilatation in a ventilated 18-year-old woman, which was revealed by the acute onset of hypotension, sinus bradycardia, and complete atrioventricular block. Hypotension and cardiac rhythm disturbances resolved with intravenous injection of atropine, but recurred a few minutes later and required a second bolus of atropine, which had a transient beneficial effect. Only gastric decompression, as soon as gastric distention was recognized, was able to restore normal cardiac rhythm and adequate blood pressure. This case highlights the seriousness of gastric dilatation and argues for the vagal mechanism of cardiac rhythm and conduction troubles complicating gastric dilatation.

Evaluation of clinical diagnosis scores for Boutonneuse fever.

Mediterranean spotted fever (MSF) is endemic in Tunisia. Diagnosis is confirmed retrospectively based on serology. Clinical features are suggestive of diagnosis if the triad (fever, rash, and eschar) is present. Otherwise clinical diagnosis could be difficult. A diagnosis score was already proposed by Raoult et al. The aim of this study was to evaluate this score, considering only clinical parameters, in order to help clinicians in diagnosing MSF before confirmation. We retrospectively analyzed 62 consecutive charts of patients with diagnosis of suspected MSF. Diagnosis confirmation was made by serology (IgG anti-R. conorii exceeding 128 or seroconversion). Epidemiological and clinical features and total score for each patient were reviewed. To validate the clinical score, we calculated sensitivity, specificity and the Youden index for each score in order to establish the ROC curve. SPSS was used for these statistical tests. Area under curve was 0.70 (P = 0.02). The cutoff score with the most predictive value of MSF diagnosis was 18, according to our study (sensitivity 60%, specificity 84,6% and Youden index 0.44). The MSF diagnosis score is a helpful tool to aid the clinician with presumptive management before confirmation. In our study we demonstrated that a score based only on epidemiological and clinical features could be sufficient, but we have to indicate that these results and cutoff score of 18 were from a retrospective study and should be confirmed by a well-designed prospective one.

Juvenile idiopathic chronic calcifying pancreatitis: report of 10 cases from central Tunisia.

A series of 10 cases of chronic calcifying pancreatitis from central Tunisia are reported. The mean age at presentation was 23 years and the male to female ratio was 1.5. The main clinical manifestations of the disease were abdominal pain (eight cases), weight loss (four cases), and diarrhea (three cases). Diabetes was recorded in four cases. The etiological investigations yielded negative results in all the patients. It is concluded that central Tunisia should be added to the regions where juvenile chronic calcifying pancreatitis of the "tropical type" may be observed.

Seroepidemiological survey of rickettsial infections among blood donors in central Tunisia.

In this report we attempt to evaluate the prevalence of antibodies against Rickettsia conorii, R. typhi, Coxiella burnettii, and Ehrlichia chaffeensis in central Tunisia. Five hundred sera from blood donors, collected between March and June 1993, were tested for these 4 antibodies using an indirect immunofluorescence antibody assay (IFA). Nine percent of the sera had antibodies against R. conorii (IgG > 1:32) by IFA, and 8% by Western blotting; with IFA, 3.6% had antibodies to R. typhi, 26% to C. burnetii (> 1:50), and none to E. chaffeensis. Infection rates with R. conorii and R. typhi did not differ significantly between the sexes, but fewer young people had antibodies to R. typhi. A significantly higher prevalence of antibodies to C. burnetii was noted for males with no difference between age classes. No significant difference was detected between urban and rural areas. This study confirmed the endemicity of rickettsioses, and revealed a high seroprevalence of Q fever, in central Tunisia.

[Infectious endocarditis with negative blood cultures]. / Endocardites infectieuses à hémocultures négatives. A propos de 48 cas.

Blood culture is a key investigation for the diagnosis of infectious endocarditis (IE). When negative, there are diagnostic and therapeutic problems. The aim of this study was to determine the frequency, the clinical features and the aetiological factors of IE with negative blood cultures compared with IE with positive blood cultures compared with IE with positive blood cultures. The authors undertook a retrospective review of 98 cases of patients admitted for IE from 1991 to 2000 to the Department of Infectious Diseases and Cardiology of Sousse (Tunisia). Of the 98 patients, 48 (48.9%), 29 men and 19 women with an average age of 34.3 years, had negative blood cultures. An infectious agent was identified in 7 cases (14.5%) by serology, valve culture or cerebrospinal fluid including Brucella (2), Coxiella (1) and Candida (1). Therefore, in 41 cases (42%), the cause of IE was not determined. Transthoracic echocardiography was of diagnostic value in 96% of cases and transoesophageal echocardiography showed disease not observed on transthoracic echocardiography in 5 cases. The main complication was cardiac failure (27 cases). The mortality was 14.5%. Comparison of the two groups showed that negative blood cultures were associated with a higher incidence of previous antibiotic therapy, extracardiac signs of IE and cardiac failure. Early surgical indications and mortality were the same in both groups. This report confirmed the high frequency of IE with negative blood cultures. Previous antibiotic therapy seems to be an important aetiological factor but cannot explain this high frequency. Methodological problems of blood cultures and the absence of systematic investigation for rare infectious agents are other possible factors.

[Surgical incidence of hydatidosis in the Sahel and Central Tunisia]. / Incidence chirurgicale de l'hydatidose dans le Centre et le Sahel Tunisiens.

A retrospective hospital survey of patients having undergone surgery for hydatidosis was undertaken in order to evaluate hydatic endemicity in central Tunisia and the Sahel. The study made it possible to establish the following: an average prevalence of 22.8 cases per 100,000 inhabitants; a significant underregistration of the illness, only 51.5% of the cases being reported; certain high-risk rural areas are characterized by a prevalence exceeding 40 per 100,000 inhabitants; the disease is more frequent among women; surgical hydatidosis is not rare among the very young and the very old; among adults, the liver is the first organ affected, followed by the lungs; among children, it is the opposite. Hydatidosis thus represents a commonly-occurring disease that is frequently underestimated in official statistics. A preventive program must be conceived to control this scourge.

[Superior caval syndrome in adults in central Tunisia. Apropos of 26 cases]. / Le syndrome cave supérieur de l'adulte en Tunisie centrale. A propos de 26 cas.

We report 26 cases of superior vena cava obstruction (SVC) observed in Sousse University Hospital (TUNISIA). The diagnosis was confirmed by CT scan and/or superior vena cava angiography. The underlying disease was revealed by SVC on 76.9% of cases. Malignant underlying disease was noted on 61.53% of cases. Non malignant causes of SVC was Behçet disease (4 cases) and mediastinal fibrosis (5 cases). SVC revealed Behçet disease in the 4 cases.

[Pyomyositis in adults in central Tunisia. Apropos of 10 cases]. / La pyomyosite chez l'adulte en Tunisie centrale. A propos de dix cas.

Ten adult patients treated for pyomyositis between 1988 and 1994 in Sousse's university hospital (Tunisia) were retrospectively reviewed. Due to the non specific symptoms, the diagnosis was often delayed (mean = 17 days) and other primary diagnoses were considered, mainly including synovitis. The muscles around hip and thigh were most commonly involved (ten patients), and Staphylococcus aureus was the most common pathogen (nine patients). Ultrasonography was very helpful in the accurate diagnosis of the infection. Incision, drainage, and antibiotic therapy eradicated the infection in all patients. No residual functional limitations and no residual symptoms were noted. Our study showed that pyomyositis is present in central Tunisia and not associated with HIV infection. Clinical features and prognosis are similar to those previously described in the literature.

[Emphysematous pyelonephritis. Apropos of a case diagnosed by ultrasonography]. / Pyélonéphrite emphysémateuse. A propos d'un cas diagnostiqué par échographie.

Emphysematous pyelonephritis is a severe infection of the Kidney observed mainly in diabetic patients. The disease is characterized by the production of intra-renal and occasionally perirenal gas. Because of the high mortality associated with this fulminant septic infection, it is imperative to establish a prompt diagnosis and start an appropriate therapy early in the course of the disease. We report a case of emphysematous pyelonephritis diagnosed by sonography: sonographic features consist of multiple high amplitude echoes within the renal parenchyma, renal sinus and perirenal space associated with distal shadows containing low level echoes. We discuss the value of the radiologic imaging methods.

[Pyogenic abscess of the psoas]. / Les abcès à pyogènes du psoas.

11 cases (7 primary and 4 secondary) of pyogenic psoas abscesses are reported. In all cases Staphylococcus aureus was isolated on blood culture or pus drained under ultra-sonographic control. US is very useful for diagnosis and the follow up of psoas pyogenic abscesses. Percutaneous aspiration and drainage of psoas abscesses under ultrasonographic control combined to antibiotherapy is an effective therapeutic procedure. Our experience suggests that antibiotherapy alone is an effective therapy of presuppurative pyogenic psoas abscesses and even in collected and non complicated primary psoas abscesses.

[Sheehan's syndrome followed by spontaneous pregnancy. Apropos of 2 cases]. / Syndrome de Sheehan suivi d'une grossesse spontanée. A propos de deux observations.

There are few reports of spontaneous pregnancies in patients with Sheehan's syndrome. We describe two cases which exhibited adrenal and thyroid insufficiency but not amenorrhea, return of the menstrual periods being at the expected time after delivery. Endocrinologic studies confirmed thyrotropin and corticotropin insufficiency. Clinical evidence of preserved gonadotropin secretion was supported by the response of LH and FSH to acute administration of synthetic LHRH and by the fact that thyroid and corticoid hormonal replacement resulted in a spontaneous pregnancy with successful outcome.

[Neurological complications in adults following rabies vaccine prepared from animal brains]. / Les complications neurologiques observées chez l'adulte, secondaires au vaccin antirabique préparé sur cerveaux d'animaux.

OBJECTIVES: Despite well-known neurological complications, post-exposure semple-type rabies vaccine is still used in Tunisia. We retrospectively studied neurological manifestations following post-exposure rabies vaccine. METHODS: Over a 3-year period, semple-type phenol inactivated lamb nerve tissue vaccine (Pasteur Institute, Tunis) was given to 1392 adults after exposure to rabies. RESULTS: The frequency of neurological complications was 1/200. Seven patients presented complications 4 to 14 days after the first vaccine injection (median 11 days). Central nervous system manifestations occurred in all 7 patients with peripheral neuropathy in 5. Manifestations were meningoradiculitis (n = 3), meningomyeloradiculitis (n = 2), meningomyelitis (n = 1) and myelitis (n = 1). No vaccine-associated death occurred, but one patient suffered persistant paraplegia. CONCLUSION: Semple-type adult animal nerve tissue vaccine produces an unacceptable rate of severe post-vaccinal neurological complications in adults. Human diploid cell rabies vaccine should be used for post-exposure rabies vaccination.

[Prostatic abscess. Apropos of 2 cases]. / L'abcès prostatique. A propos de deux cas.

Prostatic abscess in an acute inflammatory condition in which clinical diagnosis is not always easy. Ultrasound is of considerable help in diagnosis of this prostatic pathology. We report two cases. The first patient was treated by trans-rectal drainage. The second was treated with success by percutaneous drainage. The clinical, diagnostic and therapeutic aspects of this rare pathology are discussed.

[Complications of typhoid fever]. / Les complications de la fièvre typhoïde.

The authors report the complications noted in the course of 120 cases of typhoid fever. Intestinal hemorrhages and ileal perforations were the most frequent complications observed, respectively, among 12.5% and 3.3% of patients. Neuropsychiatric manifestations were also frequent: 6.7% of cases. Only one death was noted (0.8%). According to this high rate of complications, typhoid fever must be managed under hospital conditions.

[AIDS and tuberculosis in central Tunisia]. / SIDA et tuberculose en Tunisie centrale.

PIP: 7 men and 2 women seropositive for HIV were carefully screened for tuberculosis in the internal medicine service of a hospital in Sousse, central Tunisia, and all tuberculosis patients aged 20-50 years registered at the tuberculosis treatment center in Sousse between May 1987-December 1988 were screened for HIV infections using the ELISA test. The HIV seropositive patients ranged in age from 21-42 years and averaged 28 at the time of diagnosis. Marriage to an HIV-positive man was the only risk factor for the 2 seropositive women. 1 of the men had hemophilia and the rest had travelled abroad and used drugs or had homosexual or heterosexual relations while outside Tunisia. 4 of the 9 HIV positive patients were diagnoses with tuberculosis, 2 with isolated pulmonary tuberculosis, 1 with pulmonary and hepatoslenic tuberculosis, and 1 with a cervical ganglionary tuberculosis. 3 of the 4 with tuberculosis had apparently normal thoracic X-rays. The 4 were treated with the normal course of antitubercular drugs for a year or more. Screening for HIV in the 104 tuberculosis patients aged 20-50 years revealed no cases of HIV infection. Tuberculosis appears to be 1 of the most frequent opportunistic infections among patients seropositive for HIV, but it is not an indicator or predictor of HIV infection in central Tunisia as it reportedly is in some African countries.^ieng

[Fast identification of Streptococcus pyogenes serotype M.12 in throat swabs by an improvised coagglutination technique]. / Identification rapide de Streptococcus pyogenes sérotype M. 12 dans les prélèvements de gorge par coagglutination extemporanée.

A rapid procedure for identification of Streptococcus pyogenes serotype M. 12 directly in throat swabs, is reported and compared with standard culture method on blood agar plates and typing of group A Streptococci isolated, with double gel immuno-diffusion. This procedure consist of chlorhydric acid extraction of swabs and testing of the extract towards specific M. 12 protein serum using extemporaneous coagglutination technique. We have tested 1100 throat swabs, with this procedure and with standard culture procedure. Identification of group A Streptococci serotype M. 12 with reported method is obtainable within 30 to 45 minutes of receipt of the clinical specimen. This method is easy to perform, with a sensitivity and a specificity respectively: 89.7% and 98.8%.