Ten-year experience of Q fever endocarditis in a tertiary cardiac center in Saudi Arabia.

BACKGROUND: Q fever endocarditis (QFE) is considered rare in the Middle East, with only a few cases reported in Saudi Arabia. The aim of this study is to report on the experience of our centre on QFE. METHODS: We searched the medical records for cases of QFE at our cardiac center from 2009-2018. Demographic data, clinical features, serology and echocardiography results, treatments, and outcomes were assessed. RESULTS: Five hundred and two cases of infective endocarditis were detected over the 10 years period. Among the 234 patients with blood culture-negative endocarditis (BCNE), 19 (8.10%) had QFE. All patients had a previously diagnosed congenital heart disease except for one patient with rheumatic heart disease. Eleven patients had received a bovine jugular vein-related implant, e.g., a Melody valve (seven patients) or Contegra conduit (four patients). Coinfection was detected in three patients, and immunologic and embolic phenomena were observed in five patients. All patients received a combination of hydroxychloroquine and doxycycline, with good outcomes. Only two patients required surgery while on treatment. Two patients died several months after treatment; the cause of death was not identified. CONCLUSION: This study indicates that Q fever exists in our population. The majority of the patients had congenital heart disease (CHD) and underwent bovine jugular vein implants. Patients with CHD are at increased risk of infective endocarditis. Bovine jugular vein implants increase the risk of infective and possibly QFE. Proper exclusion of Q fever is warranted in all BCNE and possibly in culture-positive endocarditis cases in areas endemic to Q fever. KEY POINTS: We presented the largest series of Q fever endocarditis cases in Saudi Arabia. We showed that Q fever is not rare in the Middle East and suggest that it should be considered in all blood culture-negative endocarditis cases.

Fatal allopurinol-induced hypersensitivity syndrome associated with pancreatic abnormalities.

Allopurinol hypersensitivity syndrome is a severe adverse reaction characterized by rash, fever, and internal organ involvement. We report a case of fatal allopurinol-induced hypersensitivity syndrome associated with acute pancreatitis.A 46-year-old man was treated by allopurinol for asymptomatic hyperuricemia. The patient developed a diffuse erythrodermic maculopapular eruption and fever. Laboratory analysis revealed cytolysis and cholestasis, amylases and lipases were highly elevated. Computed tomography scans revealed pancreatitis Grade C. The treatment of asymptomatic hyperuricemia should only be initiated when there is a clear indication to reduce the incidence and the severe consequences of allopurinol hypersensitivity syndrome.

[Hepatitis B and pregnancy]. / Hépatite virale B et grossesse.

BACKGROUND: Chronic Hepatitis B infection can lead to liver cirrhosis and hepatocellular carcinoma. In women, these viral infections can be responsible for transmission to the husband and to the child during delivery. AIM: The purpose of this review is to analyze from the literature the mechanism of mother-to-child transmission and the consequences. METHODS: We conducted a review of the literature through the interrogation of the MEDLINE database using a query documentary by combining the Boolean (AND) keywords (MeSH) as follows: <>; <>; <>; <>. RESULTS: Hepatitis B virus transmission by sexual contact in low prevalence areas and infection occurs during either the perinatal period or early in childhood in moderate or high prevalence areas. In Tunisia, the prevalence of Antigen HBS (HBs Ag) with pregnant women is 3 to 4%. The risk of maternal-infant contamination is high, from 20 to 90 per cent according to the viral load in the mother. Mother-to-child transmission can be avoided by serovaccination of the newborn.The women with very high viral loads may receive lamivudine treatment at the end of pregnancy to diminish viral load and thus the risk of chronic carriage in the child; however the role of this drug in this situation is not yet clearly defined.

A case of primary biliary cirrhosis associated with pernicious anemia: a case report.

Primary biliary cirrhosis is often associated with autoimmune diseases. However, its association with pernicious anemia has rarely been reported.We report a case of a 68-year-old woman who presented jaundice and pruritus. Mildly elevated serum levels of alkaline phosphatase and gamma-glutamyl transpeptidase were detected. The titer of anti-mitochondrial M(2 )anti-body was elevated. Histology of liver biopsy showed features of primary biliary cirrhosis. In addition, aregenerative macrocytic anemia was found in the full blood count. The diagnosis of pernicious anemia was established by megaloblastosis in bone marrow, atrophic gastritis without Helicobacter pylori, low level of vitamin B(12 )and good response to treatment regimen of vitamin B(12). The association of primary biliary cirrhosis and pernicious anemia is unlikely to be casual and may be explained by autoimmune mechanism commonly shared by the diseases.

Characterization of rickettsial diseases in a hospital-based population in central Tunisia.

In Tunisia, 2 rickettsial groups, spotted fever group and typhus group, have been described since the beginning of the 20th century. Mediterranean spotted fever (MSF), also known as Boutonneuse fever, caused by Rickettsia conorii and transmitted by the dog tick Rhipicephalus sanguineus, is the most frequent rickettsial infection observed. Its seroprevalence in our region is 9% among blood donors and 23% in hospitalized febrile patients. Typhus group rickettsioses, caused by R. typhi and R. prowazekii, are less frequently reported than in the 1970s. Only sporadic cases of typhus were reported in the last decade. However, R. typhi antibodies were present in 3.6% among healthy people and 40% in patients with acute fever of undetermined origin. In the unit of Infectious Diseases at Farhat Hached University Hospital in Sousse, during 2007, 5% of hospitalized patients had eruptive fever, and half of the cases met clinical criteria of MSF and/or were confirmed by rickettsial serology. The majority of cases (90%) were noted in hot seasons, and contact with domestic animals was found in 76%. The most common symptoms were fever (present in all cases), skin rash (in 85% to 98% of cases), and headache (in 69.5% of cases). The clinical triad (fever + rash +"tache noire") was noted in 32 to 61%. Normal blood cells or leukopenia, cytolysis, and thrombopenia were the most frequent biological abnormalities. Complications and malignant forms of rickettsial infections were reported in 3.5 to 6% among hospitalized adult patients. When specific serology was performed, MSF was confirmed in 15%, and we noted an emergence of murine typhus (MT) mistaken for R. conorii or viral infection. Rickettsia felis was identified in 1 patient, whereas 17% of cases remained undetermined. Rickettsia conorii Malish was identified by PCR in skin biopsies. Doxycycline was the antibiotic of choice for rickettsial infections; it was prescribed in the majority of patients, associated with fever defervescence, in a mean of 72 hours. The mean length of stay among hospitalized patients with rickettsial infections was 5.9 days. In conclusion, in our region, MSF and murine typhus are endemic. Doxycycline should be prescribed in patients with acute fever and skin rash, especially in hot seasons. These rickettsioses were characterized by benign prognosis. More skin biopsies are needed to identify other SFG rickettsies.

Epidemiological and clinical features of giant cell arteritis in Tunisia.

BACKGROUND: Giant cell arteritis (GCA) is a systemic vasculitis of the elderly that could result in vision loss or even be life threatening. Unlike western countries, this disease is considered exceptional in Tunisia. OBJECTIVE: The aims of this study were to determine epidemiological and clinical features of GCA in Tunisian population and to identify management difficulties. PATIENTS AND METHODS: A multicentric study of 96 patients in whom GCA was diagnosed between 1986 and 2003. All patients fulfilled the ACR criteria for classification of GCA. RESULTS: The majority of cases (77%) were diagnosed since 1994. The male/female ratio was 0.88 and the mean age at the time of diagnosis was 70.8+/-7.7 years. Clinical features were characterized by gradual onset in 64.4% of cases. The most frequent clinical manifestations were headache (91.7%), abnormalities in temporal arteries (85.4%), severe ischemic manifestations (80.2%), constitutional symptoms (75%), and polymyalgia rheumatica (56.3%). Biological inflammatory syndrome was noted in all patients. Temporal artery biopsy established histological diagnosis in 73% of cases. All patients were treated by corticosteroids. Remission was obtained in 45.6%. Relapses occurred in 40.4% of cases and 30 patients were still receiving corticosteroids at the time of study. Four patients died and irreversible ischemic complications were noted in 15.6% of cases. Steroid adverse effects occurred in 56 patients. CONCLUSION: GCA is not exceptional to Tunisia. It occurs amongst elderly patients with no female predominance noticed. Clinical features are similar to those reported in other series.

Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study.

BACKGROUND: Since the first description of infective endocarditis, the profile of the disease has evolved continuously with stable incidence. However, epidemiological features are different in developing countries compared with western countries. OBJECTIVE: To describe epidemiological, microbiological and outcome characteristics of infective endocarditis in Tunisia. PATIENTS AND METHODS: This was a descriptive multicenter retrospective study of inpatients treated for infective endocarditis from 1991 to 2000. Charts of patients with possible or definite infective endocarditis according to the Duke criteria were included in the study. RESULTS: Four hundred and forty episodes of infective endocarditis among 435 patients (242 males, 193 females; mean (SD) age=32.4 (16.8) years, range 1-78 years) were reviewed. The most common predisposing heart disease was rheumatic valvular disease (45.2%). Infective endocarditis occurred on prosthetic valves in 17.3% of cases. Causative microorganisms were identified in 50.2% of cases: streptococci (17.3%), enterococci (3.9%), staphylococci (17.9%), and other pathogens (11.1%). Blood cultures were negative in 53.6% and no microorganism was identified in 49.8%. Early valve surgery was performed in 51.2% of patients. The in-hospital mortality was 20.6%. CONCLUSION: Infective endocarditis is still frequently associated with rheumatic disease among young adults in Tunisia, with a high frequency of negative blood cultures and high in-hospital mortality, given that the population affected is relatively young.