Onychomycosis: Which fungal species are involved? Experience of the Laboratory of Parasitology-Mycology of the Rabta Hospital of Tunis.

Onychomycosis is a fungal infection of nails caused by dermatophytes, yeasts or non-dermatophyte molds. The aim of our study was to describe the epidemiological features of onychomycoses encountered in the Tunis region. A retrospective study concerned 3458 cases of onychomycosis, confirmed by direct examination and/or a positive culture, was conducted in Parasitology - Mycology Laboratory, Rabta hospital, over a five-year period (2012-2016). Our patients were aged 1 to 85; more than half of the patients were aged over 60 years with a female predominance (67%). Toenail infections were most common, observed in 2702 cases (78%). Direct examination was positive in 3284 cases (95%), culture in 2409 cases (69.6%); these two examinations were positive simultaneously in 2235 cases (64.6%). The causative agents of these onychomycoses were dominated by the genus Candida in fingernails: Candida albicans (55.6%), Candida tropicalis (8.5%) and Candida parapsilosis (8.2%) were the most frequently incriminated species; while in toenail lesions, Trichophyton rubrum was by far the most frequently isolated species (96.8%). Our results join the literature; onychomycosis is a pathology of the adult, mainly candidosic etiology in hands and dermatophytic in feet.

Disseminated histoplasmosis diagnosed in the bone marrow of an HIV-infected patient: First case imported in Tunisia.

Histoplasmosis is a fungal infection caused by a dimorphic fungus, Histoplasma capsulatum. We report a first case of disseminated histoplasmosis in a 34-year-old woman, infected with human immunodeficiency virus (HIV), originating from Ivory Coast and living in Tunisia for 4 years. She was complaining from fever, chronic diarrhoea and pancytopenia. The Histoplasma capsulatum var. capsulatum was identified by direct microscopic examination of the bone marrow. She was treated by Amphotericin B, relayed by itraconazole. Even though a regression of symptoms and normalization of blood cell count (BCC), the patient died in a respiratory distress related to CMV hypoxemic pneumonia.

[Tinea capitis: Main mycosis child. Epidemiological study on 10years]. / Teignes du cuir chevelu : principale mycose de l'enfant. Étude épidémiologique sur 10 ans à Tunis.

Despite the changes in their epidemiology, and the improving level of hygiene of the population, tinea capitis is still considered a public health problem in our country, and is the most common type of dermatophytosis in our country. The aim of our study was to evaluate the epidemiological, clinical and mycological features of tinea capitis in children encountered in the Tunis region. A retrospective study concerned 1600 children aged 6 months to 15 years suspected to have tinea capitis was conducted in Parasitology-Mycology laboratory, Rabta hospital, over a 10-years period (2005-2014). Dermatophyte infections were confirmed using scalp scrapings examinated with direct microscopy using potash at 30% and/or culture on Sabouraud medium agar. Tinea capitis diagnosis was confirmed in 947 cases (59.18%). The sex ratio was 2.61 and the average age of 6.28 years with predominance in the age group of 4 to 8 years (52.27%). The most common clinical presentation was ringworm (87.65%). Ringworm large plaque was predominant (65.9%). Direct examination was positive in 884 cases (93.35%). Microsporic tinea was the most frequent (63.25%) followed by trichophytic tinea (29.78%). Positive cultures of dermatophytes were obtained in 912 cases (96.30%). The following dermatophyte species were isolated: Microsporum canis (67%), Trichophyton violaceum (31.68%), Trichophyton mentagrophytes (0.66%), Microsporum audouinii (0.22%), Trichophyton schoenleinii (0.22%) and Microsporum gypseum (0.22%). M. canis is currently the most frequently incriminated species in tinea capitis in Tunisia. This change is related to a change in behavior of our population, in fact the cat; main reservoir of M. canis cohabiting increasingly with Tunisian families.

Vulvovaginal candidiasis: Etiology, symptomatology and risk factors.

OBJECTIVE: To determine epidemiological, clinical and mycological characteristics of vulvovaginal candidiasis (VVC) in Tunisian population and to evaluate predisposing factors. PATIENTS AND METHODS: In this retrospective study, 2160 vaginal swabs were performed over 2 years (January 2014-December 2015). It was carried out at the laboratory of Parasitology and Mycology, Rabta Hospital in Tunisia. After swab collecting, direct examination and culture on Sabouraud Chloramphenicol and Sabouraud Chloramphenicol Actidione media were implemented to research yeasts. Then identifying of yeast species was through chlamydosporulation test and auxanogram. For each patient, a questionnaire was filled noting age, medical and surgical history, symptoms and risk factors. Statistical analysis of data was performed on SPSS 16 using Khi2 test, P<0.05 was considered significant. RESULTS: Direct examination was positive showed spore and/or pseudohypha in 24.72%. Candida albicans was isolated most frequently (76.61%) followed by Candida glabrata (17.18%). The maximum frequency of Candida-positive cultures was in 25-34 years old age group. Leucorrhea was the most common symptom (72.25%) followed by vulvar prurits (63.23%), dyspareunia (32.25%) and urinary burning (24.92%). Only pregnancy was correlated positively with VVC. CONCLUSION: It appears from our study that VVC is relatively common in Tunisia. His diagnosis results from confrontation of anamnestic, clinical and mycological data. The knowledge of risk factors and their correction would be necessary to prevent the occurrence of VVC, especially in its recurrent form.

[Indigenous malaria in Tunisia: 4 cases registered in 2013 in Tunisia]. / [Paludisme autochtone en TUnisie: à propos des 4 cas enregistres a TUnis en 2013.

BACKGROUND: Malaria has been eliminated in Tunisia since 1979, but the country remains, like all other countries harboring the vector, exposed to the potential risk of resurgence. OBJECTIVES: Describe the clinical and epidemiological investigation of 4 cases of autochthonous malaria in July 2013 and report the main actions of regional and national response. METHODS: Retrospective descriptive survey of the 4 clinical observations as well as the study of the regional report data of basic health care for the region of Tunis in 2013. RESULTS: Febrile table concomitant for 4 Tunisian male patients, aged from 21 to 27 years old ; fortuitous discovery of Plasmodium falciparum when checking thrombocytopenia of patient 1 ; diagnosis in cascade of other cases following the epidemiological investigation and field consultation with clinicians ; 3 simple forms and a neuromalaria of favorable evolution ; negative entomological survey for anopheles ; elimination of imported malaria and blood-borne ; airport malaria highly probable. The response included the establishment of a regional and national monitoring unit, an information program aimed at health professionals concerned and public opinion, the involvement of health and entomology teams for the detection and census of potential larval habitats and the implementation of local mosquito eradication measures. CONCLUSION: The clinical vigilance and competent biologist's eye is necessary to prevent the resurgence of this disease. The epidemiological surveillance system should be maintained and kept as well as the food safety standards monitoring at the borders.

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.

[The occupational radiation-induced cataract in five industrial radiographers]. / La cataracte radio-induite professionnelle chez cinq radiographes industriels.

UNLABELLED: The industrial uses of ionizing radiation in Tunisia are expanding, especially in industry and most particularly in the nondestructive testing of welds. Thus workers operating in the non-destructive testing of welds may develop a radiation-induced cataract varying in time to onset depending on the dose. OBJECTIVES: To describe the characteristics of the radiation-induced cataract in patients exposed to ionizing radiation, determine the risk factors of radiation-induced cataracts. METHODS: This was an anamnestic, clinical, and environmental study of five cases of radiation-induced cataract in workers employed in non-destructive testing of welds. RESULTS: This series of five cases had a mean age of 30.2 years and 5.53 years of work experience, ranging from 14 months to 15 years. All the patients were male and industrial radiographers specialized in nondestructive testing of welds. The average duration of exposure to ionizing radiation was 5.53 years. None of the patients had worn protective gear such as eye goggles. The ophthalmic check-up for the five special industrial radiographers showed punctuate opacities in three cases, punctiform opacities in one eye in one case, and phacosclerosis with bilateral lens multiple crystalline stromal opacities in a case of micro-lens opacities in both eyes with opalescence of both eyes in one case. These cataracts had been declared as occupational diseases. CONCLUSION: The value of a specialized ophthalmologic surveillance among these workers and the early diagnosis of lens opacities must be emphasized.

[Choice of primers: a determining element in molecular diagnosis of cutaneous leishmaniasis]. / Choix des amorces: élément déterminant dans le diagnostic moléculaire de la leishmaniose cutanée.

The cutaneous leishmaniasis (CL) is a parasitic disease which represents a serious problem for the public health not only in Tunisia but also all over the world. Its diagnosis is based on the techniques which are usually used, direct examination and in vitro culture. Because of several factors, these techniques lack sensitivity. The molecular biology, which is indeed more rapid and more sensitive, has proved its effectiveness in diagnosis of the CL. There are two main aims for our research work. First, to show the contribution of the Polymerase Chain Reaction (PCR) during the diagnosis of CL (of course by comparing the results obtained when using this technique with those found through the direct examination); second, to compare the two pairs of primers which amplify the leishmanien gene coding for the 18s ribosomal sub-unit: the pair R221/R332 (PCR1) and the pair Lei70L/Lei70R (PCR2). Our work was carried out upon 299 samples. One hundred and eighty-eight of them were positive using the direct examination and/or the PCR and 111 were negative. Only two samples were positive using of course the direct examination in comparison with 74 which were positive when using only the PCR (PCR1 and/or PCR2). Among these 74 samples, 64 where positive using only PCR2 in comparison with two samples which were positive using only PCR1. The eight remaining samples were at once positive for the PCR1 and the PCR2. The PCR (notably the PCR2) has proved a more significant percentage of positivity in comparison with direct examination: 98.98% for the PCR and 60.6% for direct examination.

[Identification of Enterocytozoon bieneusi by PCR in stools of Tunisian immunocompromised patients]. / Identification d'Enterocytozoon bieneusi par PCR dans les selles des patients immunodéprimés tunisiens.

INTRODUCTION: Intestinal microsporidiosis is recognised as an important cause of opportunistic parasitosis in immunocompromised patients, especially HIV-infected patients. Enterocytozoon bieneusi is the common causal agent. The diagnosis of intestinal microsporidiosis has usually based on microscopic detection of the spores of microsporidia species in stool samples, requires additional staining techniques as Modified Weber's trichrome stain. However, the detection of the spores can be difficult and species determination, which is important for defining the appropriate treatment, is impossible. Polymerase chain reaction (PCR)-based methods have been successfully used for detection of microsporidian infections. They are more sensitive and are able to identify microsporidia species. The purpose of this study is to identify E. bieneusi to adapt treatment and assess the true prevalence of the intestinal microsporidiosis due to this species in compromised patients in Tunisia. PATIENTS AND METHODS: One hundred and eighteen stools from immunocompromised patients, with a symptomatology in favour of the intestinal microsporidiosis, were analysed using light microscopy after staining with Modified Weber's trichrome stain and PCR. RESULTS: Only four were positive by Modified Weber's trichrome stain whereas eleven stools were positive by PCR, giving a prevalence of 20% in HIV-infected patients and 5,35% in human immunodeficiency virus-negative patients. CONCLUSION: This study confirms the usefulness of PCR in the diagnosis of the intestinal microsporidiosis due to E. bieneusi. Indeed, PCR has greater sensitivity than Modified Weber's trichrome stain and can identify the species of microsporidia in order to adapt the treatment.

[Dermatobia hominis furuncular myiasis in a man returning from Latin America: first imported case in Tunisia]. / Myiase furonculeuse à Dermatobia hominis au retour d'Amérique du Sud: premier cas importé en Tunisie.

Human cutaneous myiasis is a common dermatosis in tropical zones. The purpose of this report is to describe the first imported case of furuncular myiasis caused by Dermatobia hominis (human botfly) in Tunisia. The patient was a man returning from Bolivia. Furuncular myiasis was suspected based on epidemiological data and clinical examination showing pruriginous elevated lesions. Diagnosis was confirmed by identification of Dermatobia hominis larvae. Treatment was based mainly on manual removal of larvae. Since furuncular myiasis is unknown in Tunisia, it is important to remember this parasitic disease in differential diagnosis in patients presenting boil-like inflammatory papules following travel to Latin America.

[Epidemiological and clinical characteristics of intestinal microsporidiosis]. / Caractéristiques épidémiologiques et cliniques de la microsporidiose intestinale chez les immunodéprimés vus à Tunis.

INTRODUCTION: Intestinal microsporidiosis is an opportunistic parasitological infection affecting mainly immunocompromised patients, particularly those infected with HIV. PURPOSE: The purpose of this study was to analyse the epidemiological and clinical characteristics of intestinal microsporidiosis and the treatments available for it. MATERIAL AND METHODS: This retrospective study examined records collected over a 13-year period (from January 1995 through December 2007). It included 572 immunocompromised patients (279 HIV-infected patients and 293 without HIV infection) with symptoms suggesting intestinal microsporidiosis. All were tested systematically for microsporidia spores by modified (Weber's) Trichrome staining. RESULTS: Fourteen patients (10 men, 4 women) were diagnosed with intestinal microsporidiosis, for a prevalence of 2.4% overall, 3.6% in HIV-infected patients and 1.4% in those without HIV infection. Intestinal microsporidiosis affected 10 HIV-infected patients, 70% of whom had a CD4 count <100 cells/mm3. Their mean age was 30+/-15 years (range: 15 months to 48 years). The average age of HIV-infected patients (36 years) was significantly higher than of those without HIV infection (15 years). Thirteen patients had symptoms, most frequently diarrhea (11 cases), sometimes associated with dehydration (5 cases). Eight patients (57%) received only symptomatic treatment, and 4 (28.6%) received albendazole. No treatment was recommended in 2 cases (14.3%). Clinical course was marked by improvement in 6 cases, death in 5, and persistence of asymptomatic carriage in one. Two patients were lost to follow-up. CONCLUSION: Intestinal microsporidiosis is a parasitological disease that mainly affects AIDS patients with CD4 counts <100 cells/mm3. Its diagnosis requires special techniques. Its symptomatology is dominated by chronic diarrhea that can cause dehydration. Effective treatment requires identification of the species.

[Rhino-orbito-cerebral mucormycosis in the diabetic: a better known pathology in Tunisia]. / La mucormycose rhino-orbito-cérébrale chez le diabétique: une pathologie mieux connue en Tunisie.

This is a retrospective study including 17 patients with rhino-orbito-cerebral mucormycosis diagnosed in a period of 16 years, between 1992 and 2007, in 8 men and 9 women. All patients were diabetic with ketoacidosis diabetes in 8 cases. Necrosis facial and ophthalmic symptoms were the most frequent presenting manifestations. The diagnosis was confirmed by mycological examination, with or without histopathology, identifying Rhizopus oryzae in 12 cases. Treatment consisted in systemic amphotericin B combined with surgical treatment in only 7 cases. The mortality rate was high (65%) due principally to the delay in diagnosis and absence of surgical treatment.

[Twenty-two cases of neuromeningeal cryptococcosis in Tunisia]. / Vingt-deux cas de cryptococcose neuromeningée en Tunisie.

Neuromeningeal cryptococcosis is a serious infection witch occurs essentially in immunodepressed patients and especially AIDS patients. We report 22 cases of cryptococcosis meningitis confirmed by the parasitology laboratory, in the Tunis Rabta hospital, over a 16-year period. Sixteen patients were HIV infected and six were not HIV infected. The clinical examination documented fever and headache as well as focal neurological signs especially in HIV infected patients. The mycological examination of CSF proved the diagnosis of neuromeningeal cryptococcosis in all cases. The first line treatment was Amphotericin B in 13 cases, Amphotericin B and 5Fluorocytosine in three cases, and fluconazole in six cases. 14 patients died, seven recovered, and one was lost to follow-up.

[Pnemocystis jiroveci pneumonia: Comparison between conventional PCR and staining techniques]. / Pneumocystose à Pneumocystis jiroveci : étude comparée de la PCR et des techniques de coloration.

Diagnosis of pneumocystis pneumonia is usually based on clinical features and X-rays photography and confirmed in the laboratory by visualisation of Pneumocystis organisms in stained preparations of respiratory specimens using several techniques (Gomori-Grocott, May-Grünwald Giemsa, bleu de toluidine O). Actually, PCR has considerably increased sensitivity of detection of Pneumocystis. The aim of this study is to compare conventional PCR results to those of staining techniques (Gomori-Grocott, May-Grünwald Giemsa) in addition to the X-ray and clinical findings in order to evaluate the contribution of each method. Sixty-four respiratory specimens were collected from 54 immuno-compromised patients with clinical symptoms of pulmonary infection. We diagnosed pneumocystis pneumonia in 16 patients according to staining techniques and/or typical clinical and radiological findings and/or response to treatment. Of the 15 patients, 14 were positive by PCR and only five were positive by direct examination, yielding a sensitivity and specificity of 93.3 and 87.1% for PCR and 33.3 and 100% for staining techniques. Conventional PCR provides a sensitive and objective method for the detection Pneumocystis jiroveci from less invasive sample.

Pediatric visceral leishmaniasis diagnosis in Tunisia: comparative study between optimised PCR assays and parasitological methods.

There has been a steady increase of visceral leishmaniasis during the past 20 years in Tunisia. In this study, we assess the value of two optimised PCR versus those of classical methods for the diagnosis of human visceral leishmaniasis. 106 samples were collected from 53 cases of pediatric visceral leishmaniasis. Peripheral blood and bone marrow samples were analysed both by parasitological methods (direct examination, leukocytoconcentration (LCC) and culture) and by PCR methods with two primer pair (R221/R332 and Lei 70L/Lei 70R). We diagnosed visceral leishmaniasis in all patients: 44 cases were diagnosed by culture (83%), 42 by direct examination of bone marrow (79%), 17 by LCC (32%), and 53 positive cases with both PCR assays (R221/R332 and/or Lei 70L/Lei 70R) (100 %). Regarding each PCR assay, for blood samples, the difference between the sensitivities of PCR Lei 70L/Lei 70R (86,8%) and PCR R221/R332 (17 %) is statistically significant with p-value 0.025. For bone marrow, the sensitivities of the two PCR methods were respectively 96,2% (Lei 70L/Lei 70R) and 75,5% (R221/R332). On the whole, PCR Lei 70L/Lei 70R was more effective than PCR R221/R332 and conventional methods for the two biological samples. Moreover, the requirement of less invasive sample using blood has the advantage of being repeatable for screening and for post therapeutic monitoring.

[Cutaneous leishmaniasis caused by Leishmania infantum MON-24 in Tunisia: extension of the focus to the center of the country]. / La leishmaniose cutanée due a Leishmania infan- tum MON-24 en Tunisie: extension du foyer vers le centre du pays.

Three clinico-epidemiological forms of cutaneous leishmaniasis (CL) were described in Tunisia: the zoonotic CL (ZCL) epidemic which occurred in the centre of the country caused by Leishmania major MON-25, the chronic CL (CCL) In the south-east of the country caused by Leishmania killicki MON-8 and the sporadic CL In the North (SCL) caused by Leishmania infantum MON-24. The latter form, described in 1991, prevails in northern Tunisia with approximately thirty cases per year. Its vector, unknown for a long time could be according to the last publications, Phlebotomus perfiliewi or Phlebotomus langeroni; however, its reservoir remains unknown until now. The systematic isoenzymatic characterization permits to identify a great number of strains improving then knowledge on the eco-epidemiology of the disease. Indeed, changes were noted in the geographical distribution of these clinical forms: extension of the ZCL to the North and South, extension of the CCL to North and the SCL to the centre. We report in this note the first mention of L. infantum MON-24 in the two provinces of the centre of Tunisia: Kairouan and Sidi Bouzid, confirming the extension of the SCL to the Centre.

Isoenzymatic variability of Leishmania infantum in Tunisia concerning 254 human strains.

The different clinical forms of leishmaniasis are the result of both the immunological status of individuals and the species of the parasite causing the infection. In Mediterranean countries, the Leishmania infantum complex groups zymodemes which are responsible for visceral, cutaneous and exceptionally cutaneomucosal or mucosal leishmaniasis. We report in this study a synthesis concerning 254 cases of L. infantum that have been characterized at the "Laboratoire de Parasitologie" of the Rabta Hospital. The strains were isolated from human cases of visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL) by culture on NNN medium: 156 VL cases and 98 CL cases. The isoenzymatic characterization revealed three zymodemes of L. infantum. * L. infantum MON 1, a common zymodeme of VL,occurred in 154 cases (61%): 147 VL (95%) and 7 CL (5%). All CL cases were from the northern provinces, six of them occurring during an epidemic disease in 2001. * L. infantum MON 24, a common zymodeme of CL in the north, occurred in 98 cases (38.5%): 91 CL (93%) and 7 VL (7%). The seven VL cases were immunocompetent children aged from 8 months to 9 years and native of northern Tunisia. Two of the CL cases were from central regions of the country. This is the first time that cases from these regions are reported. * L. infantum MON 80, an uncommon zymodeme in Tunisia, occurred in two VL cases (0.5%): two children aged 7 and 5. The small number of strains of this zymodeme does not allow understanding of its epidemiological role. The results of this study indicate a low enzymatic variability of L. infantum in the country. However, our study includes only human strains and should be extended to animal ones (dogs, rodents and sand flies). This would lead to a better understanding of the epidemiology of leishmaniasis in Tunisia.