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.

[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.

[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.

[Cryptosporidium infection in patients with major histocompatibility complex class II deficiency syndrome in Tunisia: description of five cases]. / La cryptosporidiose chez les enfants atteints de déficits immunitaires primitifs par défaut d'expression de protéines du complexe majeur d'histocompatibilité classe II en Tunisie : à propos de 5 observations.

BACKGROUND: In Tunisia, Cryptosporidium is frequently identified in diarrheic stools of children and immunocompromised patients. The infection is usually self-limited in immunocompetent populations, but can be severe and life-threatening in immunocompromised individuals. Cryptosporidiosis is well-documented in patients with the human immunodeficiency virus; however, few data are available concerning children with primary immunodeficiencies (PIDs). PATIENTS AND METHODS: A retrospective study was conducted on 5 cryptosporidiosis cases diagnosed in 11 children with PIDs. Cryptosporidium was systematically investigated when patients presented chronic diarrhea. Stool samples were examined for the parasite oocysts by modified Ziehl-Neelsen staining, and DNA was systematically extracted for a nested polymerase chain reaction (PCR). The species were identified by the analysis of restriction patterns. Epidemiological and clinicobiological data were presented for each patient. RESULTS: All cryptosporidiosis cases presented a CMH class II deficiency syndrome. Chronic diarrhea was associated with failure to thrive in all cases. PCR provided the diagnosis in all patients, while Ziehl-Neelsen staining revealed Cryptosporidium oocysts in only 3 cases. Species identification yielded Cryptosporidium hominis in 2 cases, Cryptosporidium meleagridis in 1 case, and Cryptosporidium parvum in 1 case; a C. hominis/C. meleagridis co-infection was observed in the last case. C. hominis was isolated in children from rural areas, suggesting that the infection could have been contracted in the hospital and thus a probability of nosocomial transmission. One of the C. hominis carriers developed sclerosing cholangitis with a high parasite load. CONCLUSION: Cryptosporidiosis with serious clinical symptoms is observed in PID patients, particularly those with CMH class II deficiency syndrome. Early, regular, and repeated screening, improved by PCR, is recommended in this group of patients. The predominance of C. hominis, the anthropophilic species, in children from rural areas should emphasize hygiene measures in care centers where PID cases are treated.