Epidemiological profile and performance of triage decision-making process of COVID-19 suspected cases in southern Tunisia.

INTRODUCTION: During an epidemic, screening processes can play a crucial role in limiting the spread of the infection. The aim of this study was to describe the epidemiological profile of COVID-19 suspected cases and to evaluate the performance of the triage process in predicting COVID-19 in Southern Tunisia. METHODS: It was a prospective study including all patients consulting to the Hedi Chaker University Hospital departments from March to June 2020. A clinical triage score (CTS) was used to assess the risk of the infection and to refer patients to the appropriate part of the facility accordingly. RESULTS: Overall, 862 patients were enrolled, among whom 505 patients (58.6%) were classified as suspected cases (CTS ≥4). Of these, 46.9% (n = 237) were of mild form. Samples were collected from 215 patients (24.9%), among whom five were COVID-19 positive, representing a positive rate of 2.3%. The in-hospital cumulative incidence rate of COVID-19 was 580/100000 patients. The total daily incidence decreased significantly during the study period (p < 0.001, chi-square for linear trend = 25.6). At a cut-off of four, the CTS had a sensitivity of 40%, a specificity of 32.4%, and negative and positive predictive values of 95.8% and 1.4%, respectively. DISCUSSION: Although the triage process based on the CTS was not as performant as the RT-PCR, it was crucial to interrupt virus spread among hospitalized patients in "COVID-19-free departments".

Survival of an immuno-competent patient from splenic and gastric mucormycosis-case report and review of the literature.

Mucormycosis is a life-threatening disease responsible for a high mortality rate. The disease usually affects immuno-compromised patients. While all sites might be involved, gastrointestinal disease is rare, occurring for 5% to 13% of all mucormycosis cases. We report herein the fifth case of splenic and gastric mucormycosis revealed after gastric perforation and the first case occurring among an immuno-competent patient, and we review all reported cases of splenic mucormycosis by searching PubMed publications till October 2020. The literature search yielded 27 cases of splenic mucormycosis including our case. The majority of the cases had underlying immuno-compromised conditions, except for 6 cases, including ours. A male predominance was noted (22 cases). Involvement of the spleen and the stomach was rare, occurring among four immuno-compromised patients. The outcome was death in more than half of the cases. Splenic and gastric mucormycosis is a rare disease. The diagnosis of splenic mucormycosis should be considered in front of splenic lesions suggesting abscess or infarction, especially among immuno-compromised patients.

Comparative analysis between tuberculous meningitis and other forms of extrapulmonary tuberculosis.

INTRODUCTION: Tuberculosis is a multisystem disease that may affect any organ or tissue. Tuberculous meningitis (TBM) is the most severe form of tuberculosis and commonly affects the brain. We aimed to study the epidemiological, clinical, therapeutic and evolutionary features of TBM among adults and to compare them with other forms of extrapulmonary tuberculosis. METHODS: We conducted a retrospective study including all patients hospitalized for extrapulmonary tuberculosis in the infectious disease department in Sfax, Tunisia between 1993 and 2018. We specified the particularities of TBM cases, and we compared them with other extrapulmonary tuberculosis cases. RESULTS: We encountered 78 patients diagnosed with TBM, among 519 patients with extrapulmonary tuberculosis (15%). The median age was 36 years (23-50) years. There were 44 females (56.4%). In comparison with other forms of extrapulmonary tuberculosis, fever [odds ratio (OR)=4.4; p<0.001], asthenia (OR=3.4; p<0.001) and anorexia (OR=2.3; p=0.001) were significantly more frequent in TBM patients. Adverse effects of antitubercular therapy were more frequent among TBM patients (OR=3.1; p<0.001). The mean duration of antitubercular therapy was 15 (12-20) months. Recovery occurred in 66 cases (84.6%), complications in 44 cases (56.4%) and death in 7 cases (9%). Comparison of the disease evolution showed that complications (OR=7.4; p<0.001) and mortality rates (OR=10.7; p<0.001) were significantly more frequent in TBM patients, while recovery was significantly more frequent in other sites of extrapulmonary tuberculosis patients (OR=0.5; p=0.02). CONCLUSIONS: In our country, TBM remains a disabling disease. Despite antitubercular therapy, the prognosis was more severe with the occurrence of not only complications but also a high mortality rate in comparison with other forms of extrapulmonary tuberculosis. When clinical and laboratory features suggest the diagnosis of TBM, clinicians should look for tuberculosis elsewhere in the body.

Breast tuberculosis: a diagnosis not to be forgotten

Objective: To study the clinical characteristics and imaging features of breast tuberculosis (TB) and to describe treatment. Material and Methods: A retrospective study including all patients hospitalized in the infectious diseases department for breast TB between 1997 and 2018. Results: Twenty-two women, with a mean age of 39±12 years, were identified. In total, 18 patients were multiparous (81.8%). Both lump and mastalgia were the presenting symptoms in 19 cases (86.3%). Ipsilateral axillary lymphadenopathy was noted in 14 cases (63.6%). The most common finding on ultrasound was a well or poorly defined mass lesion, noted in 17 cases (77.2%), followed by fistulous tracts in seven cases (31.8%). Mammography showed focal, asymmetric breast density in 17 cases (89.5%) and diffuse in two cases (10.5%). The diagnosis was confirmed based on the presence of epithelioid cell granulomas and caseous necrosis in 13 cases (59.1%). Patients received antitubercular therapy for a mean duration of 11±5 months. The disease evolution was favorable in 20 cases (91%). There were two relapsing cases (9%). Conclusion: Breast TB should be considered in the differential diagnosis of young patients presenting with palpable lump with axillary lymphadenopathy, especially in endemic regions. The diagnosis confirmation usually requires an excision biopsy providing histological or bacteriological evidence.

Tuberculous and Brucellar Spondylodiscitis: Comparative Analysis of Clinical, Laboratory, and Radiological Features.

STUDY DESIGN: This was a retrospective study. PURPOSE: The aim was to compare the clinical, laboratory, radiological, and evolutionary features of tuberculous spondylodiscitis (TS) and brucellar spondylodiscitis (BS). OVERVIEW OF LITERATURE: Clinical presentation of spondylodiscitis varies according to the underlying etiology, among which brucellosis and tuberculosis represent the primary cause, in endemic countries. Only a few studies have compared the characteristics between TS and BS. METHODS: A retrospective study was conducted using the data of all patients hospitalized for TS and BS in the infectious diseases department between 1991 and 2018. RESULTS: Among a total of 117 patients, 73 had TS (62.4%) and 44 had BS (37.6%). Females were significantly more affected with TS than males (56.2% vs. 22.7%, p<0.001). Fever (72.7% vs. 45.2%, p=0.004) and sweating (72.7% vs. 47.9%, p=0.009) were significantly more frequent among patients with BS. The median erythrocyte sedimentation rate was significantly higher in the TS group (median, 70 mm/hr; interquartile range [IQR], 45-103 mm/hr) than in the BS group (median, 50 mm/hr; IQR, 16-75 mm/hr) (p=0.003). Thoracic involvement was significantly more frequent in the TS group (53.4% vs. 34.1%, p=0.04), whereas lumbar involvement was significantly more frequent in the BS group (72.7% vs. 49.3%, p=0.01). Initial imaging findings revealed significantly higher frequencies of posterior vertebral arch involvement, vertebral compaction, and spinal cord compression in the TS group. Percutaneous abscess drainage (20.5% vs. 2.3%, p=0.005) and surgical treatment (17.8% vs. 2.3%, p=0.01) were more frequently indicated in the TS group, with a significant difference. CONCLUSIONS: A combination of clinical, laboratory, and radiological features can be used to distinguish between TS and BS while these patients await diagnosis confirmation.

Update on urogenital tuberculosis in Southern Tunisia: a review of a 26-year period.

INTRODUCTION: Tuberculosis affects commonly the lungs, but any other organs can be affected as well. Urogenital tuberculosis is usually misdiagnosed. In this perspective, we aimed to give an update on the epidemiological, clinical and evolutionary features of urogenital tuberculosis in Southern Tunisia. METHODS: We conducted a retrospective study including all patients with extrapulmonary tuberculosis notified during the period from 1992 to 2017 in Southern Tunisia. We specified the particularities of urogenital tuberculosis cases, and we compared them with other extrapulmonary tuberculosis cases. RESULTS: Overall, we analyzed 240 cases with urogenital tuberculosis, among 1702 patients with extrapulmonary tuberculosis (14.1%). There were 121 women (50.4%). The mean age was 49±17 years. Multifocal tuberculosis was noted in 29 cases (12.1%). There were 169 cases with urinary tract tuberculosis (70.4%). Chronological trends analysis showed that the median age at diagnosis increased significantly (Rho=0.41; p=0.039) and the number of urogenital tuberculosis declined during the study period, without a statistical significance (Rho = -0.07; p=0.721). Compared to other extrapulmonary tuberculosis sites, patients aged 60 years and above (OR=2.7; p<0.001) and coming from rural areas (OR=1.4; p=0.021) were more frequently diagnosed with urogenital tuberculosis. Treatment duration was significantly longer in patients with urogenital tuberculosis (10.13±3.79 vs 9.20±3.77 months; p<0.001). As for the disease evolution, relapse was significantly more frequent in patients with urogenital tuberculosis (OR=4.1; p=0.045). CONCLUSIONS: Although decreasing trends over time were noted, the prognosis of urogenital tuberculosis was more severe compared to other extrapulmonary tuberculosis sites.

Prognosis of urinary tract infections: predictive factors and role of Ramadan fasting.

BACKGROUND: The role of Ramadan fasting (RF) as a predictive factor of urinary tract infection (UTI) recurrence was controversially discussed in the literature. AIM: The present study aimed to identify the prognosis factors of recurrent UTIs. METHODS: Data were retrospectively collected from patients with UTI diagnosed at the infectious diseases department and its affiliated outpatient department in Hedi Chaker University Hospital, Sfax, Tunisia, between 2010 and 2017. Kaplan-Meier method was used to generate recurrence-free survival (RFS) curves for first episode of UTI diagnosed in two groups: during and outside Ramadan, which were compared using Log-rank test for statistical inference. Univariate and multivariate Cox proportional hazards regression models were used to identify UTI recurrence factors (sex, age, age group, season, comorbidities, first UTI episode diagnosed during Ramadan, UTI requiring hospitalization, length of hospital stay, nosocomial UTI, clinical presentation). RESULTS: During the follow up, among the 867 patients with UTI, 105 (12.1%) developed a recurrent UTI one. The RFS median [95% confidence interval] was 60 [40 to 82] days. Survival curves showed that patients with UTI diagnosed during Ramadan had shorter RFS compared with those diagnosed outside of Ramadan (32 vs. 60 days, respectively, p=0.002). RF (hazard ratio = 2.96; p = 0.033) and diabetes mellitus (hazard ratio =1.6; p = 0.033) were independently associated with UTI recurrence in multivariate Cox regression analysis. CONCLUSION: Recurrent UTI was a prevalent and challenging condition among patients with UTI. Diabetes mellitus and RF had a prognosis value for recurrence in UTI.

Combination of amphotericin B and caspofungin in the treatment of mucormycosis.

We report a case of invasive mucormycosis in 52 year-old woman. CT-scan and magnetic resonance imaging found a partial right sinus thrombosis associated with homolateral ethmoidal and maxillary sinusitis with submucosal inflammation. Histopathological examination of excised tissue was positive for mucormycosis. Our patient was treated by surgical debridement and a combination of amphotericin B and caspofungin, with a good outcome.

Epidemiology and disease burden of tuberculosis in south of Tunisia over a 22-year period: Current trends and future projections.

BACKGROUND: Tuberculosis (TB) is a public health problem worldwide. Characterizing its trends over time is a useful tool for decision-makers to assess the efficiency of TB control programs. We aimed to give an update on the current chronological trends of TB in Southern Tunisia from 1995 to 2016 and to estimate future trajectories of TB epidemic by 2030. METHODS: We retrospectively collected data of all notified TB new cases by the Center of Tuberculosis Control between 1995 and 2016 in South of Tunisia. Joinpoint Regression Analysis was performed to analyze chronological trends and annual percentage changes (APC) were estimated. RESULTS: In the past 22 years, a total of 2771 cases of TB were notified in Southern Tunisia. The annual incidence rate of TB was 13.91/100,000 population/year. There was a rise in all forms of TB incidence (APC = 1.63) and in extrapulmonary tuberculosis (EPTB) (APC = 2.04). The incidence of TB increased in children and adult females between 1995 and 2016 (APC = 4.48 and 2.37, respectively). The annual number of TB declined in urban districts between 2004 and 2016 (APC = -2.85). Lymph node TB cases increased (APC = 4.58), while annual number of urogenital TB decreased between 1995 and 2016 (APC = -3.38). Projected incidence rates would increase to 18.13 and 11.8/100,000 population in 2030 for global TB and EPTB, respectively. CONCLUSIONS: Our study highlighted a rise in all forms of TB and among high-risk groups, notably children, females and lymph node TB patients in the last two decades and up to the next one.

Performance of an Easy and Simple New Scoring Model in Predicting Multidrug-Resistant Enterobacteriaceae in Community-Acquired Urinary Tract Infections.

BACKGROUND: Multidrug resistance (MDR) is a growing global problem in bacterial community-acquired urinary tract infections (CUTIs). We aimed to propose an easy-to-use clinical prediction model to identify patients with MDR in CUTI. METHODS: We conducted a retrospective study including 770 patients with documented CUTI diagnosed during 2010-2017. Logistic regression-based prediction scores were calculated based on variables independently associated with MDR. Sensitivities and specificities at various cutoff points were determined, and the area under the receiver operating characteristic curve (AUROC) was computed. RESULTS: We found MDR Enterobacteriaceae in 372 cases (45.1%). Multivariate analysis showed that age ≥70 years (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.8-3.5), diabetes mellitus (aOR, 1.65; 95% CI, 1.19-2.3), history of urinary tract surgery in the last 12 months (aOR, 4.5; 95% CI, 1.22-17), and previous antimicrobial therapy in the last 3 months (aOR, 4.6; 95% CI, 3-7) were independent risk factors of MDR in CUTI. The results of Hosmer-Lemshow chi-square testing were indicative of good calibration of the model (χ2 = 3.4; P = .49). At a cutoff of ≥2, the score had an AUROC of 0.71, a sensitivity of 70.5%, a specificity of 60%, a positive predictive value of 60%, a negative predictive value of 70%, and an overall diagnostic accuracy of 65%. When the cutoff was raised to 6, the sensitivity dropped (43%), and the specificity increased appreciably (85%). CONCLUSIONS: We developed a novel scoring system that can reliably identify patients likely to be harboring MDR in CUTI.

Optimization of therapeutic drug monitoring of vancomycin in patients with chronic hemodialysis
.

PURPOSE: To validate a simplified vancomycin monitoring algorithm in patients on chronic hemodialysis who required intravenous vancomycin for at least 3 weeks. MATERIALS AND METHODS: In this prospective study, all hemodialysis patients who were admitted between April 1, 2013, and March 31, 2015, in our unit for suspected or confirmed methicillin-resistant Staphylococcus aureus infection that required vancomycin were enrolled. All patients were categorized into two groups. In group 1 (standard vancomycin dosing algorithm), the maintenance doses of vancomycin were adjusted according to the pre-hemodialysis vancomycin concentrations determined before each hemodialysis session. In group 2 (simplified vancomycin dosing algorithm), pre-dialysis vancomycin trough levels were taken before the 2nd and the 6th session of hemodialysis. Maintenance doses were adjusted according to the residual concentrations of vancomycin. RESULTS: A total of 101 blood samples were collected, the average plasma concentration of vancomycin was 13.1 ± 3.8 µg/mL. 64 (63.4%) levels fell out of the therapeutic range. Seven (6.9%) of these exceeded the therapeutic range and 30 (29.7%) were lower. After the loading dose, the average plasma concentration was 11.2 ± 3.4 µg/mL. There were no statistically significant differences between the two groups with respect to the average plasma concentration of vancomycin and the proportion of vancomycin trough levels in the target range. CONCLUSION: The vancomycin dosing algorithm using limited concentration monitoring for hemodialysis patients achieved drug concentrations comparable to those found with more frequent monitoring and resulted in significant cost savings.
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Spinal brucellosis in South of Tunisia: review of 32 cases.

BACKGROUND CONTEXT: Brucellosis remains an important economic and public health problem in some parts of the world. The spine is the most common site of musculoskeletal involvement of brucellosis. PURPOSE: Assess the clinical, laboratory, radiological findings, and outcomes of vertebral involvement in brucellosis. STUDY DESIGN: A retrospective study. PATIENT SAMPLE: Thirty-two patients with spinal brucellosis during a period of 21 years (1990-2010) were included. OUTCOME MEASURES: Clinical and radiological improvement. METHODS: Diagnosis made on clinical presentation, laboratory findings, radiographic evidence, and the Brucellar etiology was considered when seroagglutination tests were positive at a titer of 1/160 or higher, and/or Brucella spp were isolated in the blood or sample cultures. RESULTS: The mean age of patients was 51±15.85 years (23 males, 9 females; age range, 19-74 years). The median diagnostic delay was 3 months. Back or neck pain (100% of patients), fever (78%), and sweats (68.6%) were the most common symptoms. Cultures of blood specimens from five patients (15.6%) were positive for Brucella melitensis. Four patients (12.5%) had motor weakness or paralysis. Magnetic resonance imaging was performed in 24 (75%) cases. Paravertebral masses, epidural masses, and psoas abscesses were detected in 65.6%, 59.4%, and 28.1% of patients, respectively. The lumbar vertebra was the most frequently involved region with the rate of 68.7%, followed by thoracal (18.7%), cervical (6.3%), lumbosacral (6.3%), and thoracolumbar (3.1%) segments. The duration of antimicrobial therapy of brucellosis (median, 6 months; range, 3-13 months) varied according to clinical response and the presence of epidural and paravertebral masses. There were no deaths or severe sequelae in this study. CONCLUSIONS: Brucellar spondylitis should be considered in patients with back pain and fever in endemic areas. A high index of suspicion and clinical, laboratory, and radiological examinations help to confirm the diagnosis of vertebral involvement.

A rare cause of Dysphagia in a pregnant woman:herpes simplex esophagitis.

Herpes simplex esophagitis (HSE) has rarely been reported in immunocompetent individuals. In a search of Medline until October 2012, we found only one case of HSE in a pregnant female. We present the first case of HSE in a healthy 36-year-old female at 27 weeks gestation who recovered without antiviral therapy.

[Bilateral emphysematous pyelonephritis caused by Candida glabrata: An exceptional entity]. / La pyélonéphrite emphysémateuse bilatérale à Candida glabrata : une entité exceptionnelle.

Acute emphysematous pyelonephritis (AEP) is a severe form of urinary tract infection. It occurs usually in diabetics. The most concerned agents are the Gram-negative bacilli. We report a first case of bilateral AEP due to Candida glabrata, occurred in a 64-year-old diabetic woman. The clinical presentation started with fever and abdominal pains, without signs of urinary tract infection. Within six hours, the patient had developed a septic shock with renal failure and ketoacidosis. The diagnosis was confirmed by CT scan and the pathogen was isolated in urine. Despite antibiotic and antifungal treatment, she died from a septic shock. Acute emphysematous pyelonephritis due to Candida species is rare. However, the addition of antifungal therapy seems justified if a severe emphysematous pyelonephritis is associated with risk factors of Candida infection.

Epidemic West Nile virus encephalitis in Tunisia.

West Nile fever (WNF) is a mosquito-borne flavivirus infection. It is epidemic in Africa and Asia. In autumn 1997, a WNF epidemic occurred in the Sfax area (southeastern Tunisia). Fifty-seven patients were hospitalized with aseptic meningitis and/or encephalitis. Search for specific anti-West Nile virus (WNV) antibodies in serum and cerebrospinal fluid (CSF) was performed using an ELISA test. Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to detect the WNV genome in CSF and brain specimens. Recent central nervous system (CNS) infection by WNV was confirmed in 30 patients, probable infection in 17 and it was excluded in 10. In the confirmed subgroup, patients with encephalitis were older than those with meningitis. CSF showed pleocytosis, high protein (47%) and normal glucose levels. Brain computed tomography-scan (CT-scan) and magnetic resonance imaging (MRI) were normal. RT-PCR disclosed WNV genome in the CSF in two cases and in a brain specimen in one. Three patients died rapidly, the remaining cases had favorable prognosis. Autopsy was performed in two cases and showed nonspecific lesions of encephalitis. No viral inclusions were seen with light microscopy. Seropositivity rate in patients' proxies for WNV was 23.4%. Prognosis of CNS involvement during WNF seemed to be poor in older patients. This is the first WNV encephalitis epidemic report in the Sfax area of Tunisia.

[Endocarditis caused by Tropheryma whippelii]. / Endocardite a Tropheryma whippelii.

Cardiac involvement in Whipple's discase is frequent. However, its clinical occurrence without gastrointestinal symptoms is rarely described. Whipple's endocarditis occurs ollen in patients wilh native valves, without underlying, disease. It affects frequently more than one valve h, the same patient. Its clhlical presentation is generally subacute or chronic. Fever and congestive heart failure are fickle. Histological findings on the valves suggest the diagnosis, that con be confirmed by PCR technique. Treatment must be prolonged. We report a case of Whipple's endocarditis revealed by arterial embolisms and fever appeured 3 weeks after the onset.