[Visceral leishmaniasis in immunocompetent adults. About six cases]. / La leishmaniose viscérale de l'adulte immunocompétent. À propos de six cas.

OBJECTIVE: Studying the epidemiological variations of visceral leishmaniasis in Tunisia and proving the importance of parasitological investigations to raise the diagnosis. PATIENTS AND METHODS: Six patients hospitalised during the period between January 1998 and January 2009 at Fattouma Bourguiba Teaching Hospital in Monastir, five men and an only one woman, aged from 26 to 70 years old, originating from the central and eastern regions of the country. Epidemiological, clinical, biological and therapeutic data were obtained from the patient's medical files. RESULTS: The major clinical symptoms were fever, weakness and spleen enlargement. Biological data revealed the presence of anaemia in every case and leucopoenia associated or not associated with thrombopenia in four cases. The diagnosis of visceral leishmaniasis was confirmed by the identification of the parasite in the blood or in the bone marrow. All patients were treated with two courses of antimoniate of meglumine separated by a 6-week interval. The outcome was positive and the patients were cured. CONCLUSION: Visceral leishmaniasis is increasing among adults in Tunisia. Moreover, it is spreading outside its epidemiological area in the north to reach the central and southern regions. It should be raised when fever and spleen enlargement occur. Biological data are hardly specific. Diagnosis is based on finding the parasite in human fluids, mainly by molecular techniques. The rapid establishment of a specific treatment is vital.

[Retrospective study of the distribution and the fertility of hydatid cysts in the child in Tunisia]. / Étude rétrospective de la distribution et de la fertilité des kystes hydatiques chez l'enfant en Tunisie.

PURPOSE OF THE STUDY: Our aim was to study the distribution and the fertility of the hydatid cysts in function of the age and the sex of patients and to identify the strain(s) responsible(s) of the children hydatidosis. PATIENTS AND METHODS: We have analyzed a total of 241 cysts coming from 195 children aged 2 to 16 years operated in the CHU F. Bourguiba of Monastir during the period from November 1999 to December 2009. For each cyst, the localization and the fertility of the métacestode as well as age, sex and origin of the patient are listed. Identification of strains was carried out by PCR/RFLP and has targeted the ribosomal gene ITS1. RESULTS: The lung was the primary localization of cyst (61.8%) followed by the liver (34.85%). The greatest number of cases is observed in the age groups 4-9 years (138 cases) where children's infection is more frequent in the male than in the female sex. The fertility of the cyst was independent of its site or its size and no incidence of age of children was detected. The G1 sheep strain is responsible for the contamination of children. CONCLUSION: The cystic echinococcosis described as a young adult disease may actually observed at any age and remains a serious problem of public health in Tunisia.

Usefulness of a PCR-based method in the detection and species identification of Leishmania from clinical samples.

The aim of this study is to assess the usefulness of a simple, low-cost method for the detection and species identification of Leishmania isolated by in vitro culture or detected directly from clinical samples. A total of 110 samples were used in this study. Among these, 21 were human and canine peripheral bloods, 63 skin lesion material samples, eight reference strains and 18 Leishmania culture. Detection of Leishmania DNA with PCR using primers designed to amplify the internal transcribed spacer 1 (ITS1) region of the rRNA gene proved sufficiently sensitive at the level of 0.1 parasites per PCR reaction. Furthermore, followed by single-strand conformational polymorphism (SSCP), the PCR-ITS1 allowed the species identification of Leishmania. The inter-specific polymorphism of Leishmania was first validated on reference strains, and then this method was applied on clinical samples and culture. Typing identified all human and canine visceral leishmaniasis samples (21 samples) as L. infantum, 95.23% of the cutaneous leishmaniasis samples as L. major and 3.17% as L. killicki and 1.58% as L. infantum. A scheme of the PCR diagnosis procedure for the detection and identification of Leishmania parasites is proposed in this study.

Use of PCR, IFAT and in vitro culture in the detection of Leishmania infantum infection in dogs and evaluation of the prevalence of canine leishmaniasis in a low endemic area in Tunisia.

The aim of this study was to assess the use of parasitological, serological and molecular methods for the detection of Leishmania infection in blood of 67 dogs and to investigate the prevalence of canine leishmaniasis (CanL) in Kairouan (central Tunisia), an area known to be of reduced endemicity and has not been studied since 1973. Veterinarians clinically examined all dogs, and the titer of anti-Leishmania antibodies was determined by indirect immune-fluorescence antibody test. The presence of Leishmania was performed by PCR and in vitro culture. IFAT was positive in 12% of dogs and promastigote form of the parasite was isolated by in vitro culture from only 4.5% of them. However, DNA of Leishmania was detected by PCR in 20.9% of dogs. PCR was more sensitive than IFAT (p = 0.004) and in vitro culture (p < 10(-5)). A prevalence of 21% was found in Kairouan, which is significant high (p < 10(-3)) when compared to that of thirty years ago. This state is in correlation with the increase in other Mediterranean countries. Furthermore, 50% of positive dogs were asymptomatic. Preventive measures must be taken against these dogs as for symptomatic ones since their role in the transmission of the infection to vectors has been proven.

Increase of canine leishmaniasis in a previously low-endemicity area in Tunisia.

An epidemiological study of canine leishmaniasis (CanL) was carried out in nine districts of Sfax, in the southern central part of Tunisia. Sera from 250 dogs were tested by two serological methods: the indirect immunofluorescence antibody test and the counter-immunoelectrophoresis. Seven to eight months later, before the next season of transmission, seropositive dogs from the first test were re-examined and a second sampling was performed. Infection status was assessed by serology and by other methods. PCR, in vitro culture and direct examination were applied on blood and other samples (bone marrow, liver, lymph node, spleen and cutaneous biopsies). The seroprevalence of the infection in dogs was 6%. Infection was then confirmed by at least one other method. The PCR is the method which agreed most with serology, all seropositive dogs were found PCR-positive. The sensitivity of the direct examination and the culture was only 33% and 55% respectively as compared with serology. A similar value of seroprevalence has been observed previously in Sousse, in the northern central part of Tunisia. The present report suggests a significant increase of CanL in the Sfax area and confirms that the disease is continuing to move southwards in Tunisia.

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).

[Cystic echinococcosis in children in Tunisia: fertility and case distribution of hydatid cysts]. / L'échinococcose hydatique de l'enfant en Tunisie: fertilité et localisation des kystes.

Cystic echinococcosis, which commonly starts during childhood or adolescence, is a serious problem of public health in Tunisia. For 121 children (161 cysts), the localization and fertility of cysts as well as viability of their protoscoleces were determined. Results indicated that the lung was the primary localization of cyst (59%) followed by the liver (35%). Children's infection is more frequent in male than in female (sex ratio 1.96) and the greatest number of cases is observed in the 4-9 year age groups (94 cases). The fertility of the cyst was independent of its site or its size and no incidence of age of children was detected. Nevertheless, the fertility rate is higher in females than in males for the liver localization.

Geographical distribution updating of Tunisian leishmaniasis foci: about the isoenzymatic analysis of 694 strains.

Over a period of ten years, a series of 694 Leishmania strains from Tunisian leishmaniasis foci were isolated and identified by isoenzymatic analysis. Strains were obtained from human cutaneous and visceral leishmaniasis in immunocompetent subjects, visceral leishmaniasis in imunocompromised individuals and from dogs with visceral leishmaniasis. Two classically dermotropic species, Leishmania (L.) major and Leishmania killicki were found. L. major with the single zymodeme MON-25 was the most isolated in cutaneous leishmaniasis foci of the Centre and South of Tunisia with a recent northern extension. L. killicki zymodeme MON-8 was sporadically found both in its classical microfocus of Tataouine in southeastern Tunisia as well as in some new foci in Southwestern, Central and Northern Tunisia. Leishmania infantum with its three zymodemes MON-1, MON-24 and MON-80 was isolated from both visceral and cutaneous human cases. The majority of L. infantum strains were found in the Northern part of the country; however, some strains were reported for the first time in the Southern part. L. infantum MON-1 was the only zymodeme isolated from canine leishmaniasis.

Post-surgical follow-up (by ELISA and immunoblotting) of cured versus non-cured cystic echinococcosis in young patients.

The study was designed to determine comparatively the prognostic value of immunoblotting and ELISA in the serological follow-up of young cystic echinococcosis (CE) patients exhibiting either a cured or a progredient (non-cured) course of disease after treatment. A total of 54 patients (mean age 9 years, range from 3 to 15 years) with surgically, radiologically and/or histologically proven CE were studied for a period up to 60 months after surgery. Additionally, some of the patients underwent chemotherapy. Based on the clinical course and outcome, as well as on imaging findings, patients were clustered into 2 groups of either cured (CCE), or non-cured (NCCE) CE patients. ELISA showed a high rate of seropositivity 4 to 5 years post-surgery for both CCE (57.1%) and NCCE (100%) patients, the difference found between the two groups was statistically not significant. Immunoblotting based upon recognition of AgB subcomponents (8 and 16 kDa bands) showed a decrease of respective antibody reactivities after 4 years post-surgery. Only sera from 14.3% of CCE patients recognized the subcomponents of AgB after 4 years, while none (0%) of these sera was still reactive at 5 years post-surgery. At variance, immunoblotting remained positive for AgB subcomponents in 100% of the NCCE cases as tested between 4 and 5 years after surgical treatment. Immunoblotting therefore proved to be a useful approach for monitoring post-surgical follow-ups of human CCE and NCCE in young patients when based upon the recognition of AgB subcomponents.