Risk factors for treatment failure in multidrug resistant tuberculosis in Tunisia: An analytic study.

INTRODUCTION-AIM: The emergence of multidrug resistant tuberculosis (MDR-TB) is a threat to global public health. The aim of our study was to determine risk factors for treatment failure in MDR-TB. METHODS: Retrospective study conducted between January 2000 and March 2019 including patients with MDR-TB. Characteristics of patients with therapeutic failure were compared to cured ones. Logistic regression analysis was used to identify risk factors for treatment failure. RESULTS: Our study included 140 patients aged of 42±13 years (18-80). Fifty-seven percent of patients had treatment success and 12% had treatment failure. In multivariate logistic regression analysis, treatment failure was associated with age over 45 years (OR=1.05; 95%CI, 1.024-7.736;p=0.014), primary education level and illiteracy (OR=5.022; 95%CI, 1.316-19.161;p=0,018), history of incarceration (OR=3.291; 95%CI, 1.291-21.083;p=0.016), undernutrition (OR=4.544; 95%CI, 2.304-54.231;p=0,027), extensive TB (OR=6.406; 95%CI, 1.761-23.922; p=0.038), initial high grade positive smears (OR=1.210; 95%CI, 1.187-32.657; p=0.045), positive smear culture at 90 days of treatment (OR=6.871, 95%CI, 3.824-23.541; p=0.003), poor adherence (OR=6.110; 95%CI, 2.740-12.450; p=0.021) and occurrence of psychiatric adverse events (OR=3.644 95%CI, 2.560- 27.268; p=0.041). CONCLUSION: Therapeutic education, nutritional and psychological support and close follow-up are strongly recommended to optimize the prognosis of MDR-TB.

Drug reintroduction testing and beta-lactam hypersensitivity in children: Protocols and results, a 12-year experience.

Introduction: Oral provocation test (OPT) to beta-lactam antibiotics (BL) is a gold standard in allergology investigation. We aimed to demonstrate the contribution of OPT in BL hypersensitivity (HS) indicated as a first step in diagnosis. Methods: We conducted a retrospective study from 2007 to 2019, in a single Tunisian tertiary care academic center. It concerned children with presumed non-severe allergic manifestations to BL, with a reaction that has occurred at least 6 months before the OPT. Results: We identified 35 children for inclusion. After the first OPT, a second OPT with a different BL was performed in case of a positive result of the first one. In 12 cases (34.2%), the OPT elicited a reaction. In eight cases the allergy was to penicillin and in two cases to cephalosporins (cefixim). Cross-reactivity was noted in two cases. Conclusion: An OPT to BL indicated in the first instance in non-severe reaction in children will allow a rapid diagnosis in case of suspicion of HS to BL.

Anaphylaxis following a pleural puncture bringing back a rock water-like liquid.

INTRODUCTION: Anaphylaxis is a life-threatening medical emergency. Its occurrence in the hospital environment should lead to the first evocation of a drug allergy or a latex allergy. However, many other etiologies need to be investigated early. We publish this case report to highlight a rare differential diagnosis of drug allergy, namely hypersensitivity caused by Ecchinoccocus granulosis. CLINICAL CASE: An 18-year-old female patient with no previous pathological history, from a rural environment, consulted for a 4-month history of right basi-thoracic pain without any other associated clinical sign. Her physical examination revealed a right pleuritic syndrome. Chest radiograph showed a right pleural opacity. The patient had a pleural puncture bringing back a rocky water-like fluid. Five minutes later, the patient had an injection of paracetamol to relieve the pain. Thirty minutes later, plaques of urticaria on the extremities and trunk and arterial hypotension occurred. The diagnosis of grade III anaphylaxis was retained. Following vascular filling and administration of antihistamines, the evolution was rapidly favorable. The thoraco-abdominal ultrasound showing the presence of a ruptured liver hydatid cyst in the pleura. A surgical treatment was thus proposed. Despite contact with latex gloves and the administration of paracetamol after surgery, the patient did not present any allergic reaction. Thus the retained cause of the anaphylaxis was ecchinoccocus granulosis. CONCLUSION: Anaphylaxis following a pleural puncture bringing back a rock water-like liquid must suggest the diagnosis of complicated hydatic cyst.

Cervical Benign Teratoma: Case Report and Review of Literature.

Cervical teratomas are extremely rare germ cell tumours and it is much more common in newborn than adults, and in contrast to the paediatric cases adult teratomas have been highly malignant. Cervical teratoma incorporates lesions arising in the anterior and posterior triangles of the neck. This tumor can reach enormous size and cause airway obstruction and patients should be quickly treated. Surgery is the primary modality of treatment as malignant transformation can occur. Hereby, we present a case of benign teratoma of neck in adult which was completely misdiagnosed preoperatively due to its rare occurrence in adults.Even though cervical teratoma of adult is extremely rare, it should be considered as an important differential diagnosis in patient of midline cystic neck swelling. Preoperative radiological investigations requires high index of suspicion. Complete surgical resection is recommended. We believe that upper cervicotomy approach is a safe and effective method for the treatment of mature cervical teratoma with a few protruding into the superior mediastinum. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03748-8.

Sex-specificity in Surgical Stages of Lung Cancer in Young Adults.

Background: Young Patients with lung cancer represent a distinct subset of patients with this neoplasm. Young International studies show increased lung cancer rates in females, while the incidence in males continues to decline. There is evidence to suggest that this trend recurs in younger patients. We studied the effects of gender differences on the incidence of surgical stages of lung cancer in young adults and its mortality rate. Methods: This study is a retrospective review (2010-2020) of young adults (aged under 45 years) with surgical-stage of lung cancer. We calculated female-to-male differences in incidence rate ratios, tumor characteristics, surgical management, and survival. Cumulative survival curves were generated by the Kaplan-Meier method. Results: We examined 46 men and 24 women, under 45 years. Female patients were diagnosed at earlier stages. The proportion of stage IA disease was significantly higher in women than in men (46% versus 13%, respectively) (p=0.03). Women were more likely never smokers (42% versus 83%, p=0.02). A histologic subtype, females were more likely to have typical carcinoid tumors (13.54% versus 10.21% for males) (p>0.05). The largest histological type in men was adenocarcinoma (25.53% versus 4.16%, p>0.05). All the patients were operated. Three men had neoadjuvant chemotherapy and one was operated on for cerebral oligometastatic before his chest surgery. Adjuvant chemotherapy was given to 7 women and 21 men. Despite the small number of postoperative complications in our study (n= 8, 11.2%), the male sex was significant in predicting this complication (p<0.05). The mortality rate was 1.4%. The 5-year overall survival rates were 84% in men and 87% in women. Conclusion: Our study identified sex differences in the incidence and mortality rates for surgical lung cancers in young adults, but the biological and endocrine mechanisms implicated in these disparities have not yet been determined.

Drainage of tuberculous pneumothorax in a Northern African country: Characteristics and difficulties.

INTRODUCTION-AIM: Tuberculous pneumothorax (TP) is a serious complication of cavitary pulmonary tuberculosis. The aim of this study was to identify TP drainage characteristics and difficulties. METHODS: This was a retrospective multicenter study of patients hospitalized for TP between 1999 and 2021 in three hospitals from Tunis (Tunisia): Abderahmen Mami, La Rabta, and Charles Nicolle. Clinical, biological, radiological, therapeutic and evolutionary data were collected. RESULTS: Seventy-three patients were enrolled. The mean±standard-deviation (SD) of age was 37±17 years. The sex ratio was 3.3. TP was isolated in 39 patients (53.4%) and was associated with a purulent effusion in 34 patients (46.6%). It was bilateral in three patients (4.1%). Chest drainage was indicated in 67 patients (91.7%). It was performed with a chest drain in 61 cases, with a pleuro-catheter in one case, and with a pleuro-catheter then a chest drain in five cases. The mean±SD (ranges) duration of drainage was 43±39 (3-175) days. Drainage was prolonged in 36 cases (53.7%). The duration of drainage for pyopneumothorax was significantly longer than for isolated TP (p=0.04). The mean±SD (ranges) number of drains inserted in each patient was 2.02 ±1 (1-7) drains. Spontaneous drain fall was observed in 13 patients. Drainage failure was observed in 16 patients, and was more frequent in cases of pyopneumothorax (p=0.039). Recurrence of pneumothorax was noted in nine patients (13.4%). CONCLUSION: The drainage of TP is often extended and requires the use of multiple drains. It is associated with several complications. Failure of thoracic drainage is not negligible.

Allergy to anti-tuberculosis treatment: Place of reintroduction drug test.

BACKGROUND: Allergy to antitubercular drugs is a real hindrance to the management of TB. AIM: To access the contribution of the reintroduction drug test in the exploration of allergy to anti-tuberculosis treatments. METHODS: Retrospective study of 34 patients treated for tuberculosis who presented a hypersensitivity reaction during a period from January 2011 to December 2017. RESULTS: Our study included 31 women (91%) and three men (9%). The average age was 37 years old. The average time to onset of allergic manifestations compared to the start of TB treatment was 23± 19 days (1-85). They were dominated by cutaneous involvement (76.4%). The reintroduction test achieved in 27 patients, allowed to make the diagnosis of allergy to pyrazinamide in 12 patients (44.4%), to Rifampicin in five cases (18.5%), to Ethambutol in one case (3.7%) and isoniazid in one patient (3.7%). A polyallergy was noted in six patients (22.2%). The average time to onset of these reactions was five hours [15mn-90h]. The drug incriminated in the allergy was stopped definitively in 18 patients or 52.9%. It was substituted by a drug of first line in two patients (5.8%) and a second-line drug in three patients (8.8%). Drug dependence was achieved in five patients. It concerned Isoniazid in one patient, Rifampicin in three patients, pyrazinamide in two patients. It allowed the reintroduction of the allergenic treatment noted in two patients. The evolution of tuberculosis was favorable in 26 cases (77%). CONCLUSION: The identification of the allergenic drug is the key to establishing a new protocol for effective anti-tuberculosis treatment that is less risky for hypersensitivity.

Impact of smoking on the severity of Obstructive Sleep Apnea Hypopnea Syndrome.

BACKGROUND: Smoking is an established risk factor of several respiratory and extra respiratory diseases. However, the effect of smoking on obstructive sleep apnea syndrome (OSAS) is not well characterized. The purpose of this work is to study the influence of smoking on the severity of OSAS. METHODS: We performed a retrospective study, which included patients with an obstructive sleep apnea syndrome diagnosed in the pulmonology department of Charles Nicolle Hospital in Tunis, during the period from January 2008 to December 2014. RESULTS: We collected 104 patients with obstructive sleep apnea syndrome. The average age of patients was 49,4 years (14-81 years). The majority of patients were women (53,8%). Thirty two patients were smokers with an average consumption of 27 PA. The reasons for consultation were nocturnal snoring (90%), daytime sleepiness (77%), respiratory pauses (53%), nocturia (35%), daytime fatigue (34%) and headache (29% ). The average weight was 92 kg. The average BMI was 33 kg / m2. The average waist circumference was 98 cm. On average, the Epworth score was 12. The apnea hypopnea index was on average 32 / h. A slight OSAS was noted in 28,8% of cases, moderate OSAS in 14,4% of cases and severe OSAS in 53,8% of cases. The number of desaturations averaged 155. The CPAP treatment was fixed in 61 patients (58%) and self-controlled in 5 patients (4,8%). Adherence was checked in 48 patients (46%) and it was good in 85% of cases. The comparison between the smoking and non-smoking subjects was about; the Epworth scale, FEV, AHI, mean SpO2 and observance of treatment but no significant difference was found. CONCLUSION: Although our study did not find any difference between smokers and non smokers, smoking cessation takes an important place for management of a patient with OSAS.

Acute Respiratory Failure as the First Manifestation of Antisynthetase Syndrome.

We report the case of a 40-year-old man with acute respiratory failure syndrome that later proved to be an initial manifestation of antisynthetase syndrome. The diagnosis of this rare combination of a connective tissue disease and an acute respiratory failure is difficult in a previously asymptomatic patient. Early diagnosis and immunosuppressive therapy started precociously prevented the disease progression and resulted in a good outcome.