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.

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.

Mental health status of healthcare workers at a third line Tunisian hospital during COVID-19 pandemic.

INTRODUCTION: During the COVID-19(coronavirus-19 disease) pandemic, health care workers (HCWs) faced the risk of infection and distressing work to meet health requirements. The aim of the present stud ywas to evaluate perceptions of HCWs of their security at work in COVID-19 units and their coping strategies, at the military hospital of Tunis, during the second wave of COVID-19. METHODS: A cross-sectional study was conducted via an auto-questionnaire on February 2021.HCWs of the military hospital of Tunis were included. Participants were asked about their perceived security at work in COVID-19 units and their coping behaviors. Mental disorders were assessed, via qualitative questionnaires. RESULTS: A total of 110 HCWs' responses were collected. Fifty-eight participants (52.7%) were females. The mean age was 33.7 years (SD 9.3). They were doctors at 45.5% and nurses at 39.1%. HCWs declared having worked in COVID-19 units in 81.8% of cases. The participants reported their fears about being infected in 58.2% and infecting family members in 85.5% of cases. Protective factors included information about the disease (80%), availability of personal protective equipment (PPE) (80.9%), support from colleagues(72.7%)or superiors at work (50.9%), and ability to communicate with others (63.6%). Depression, anxiety, and insomnia were found in respectively 25.5%, 30%, and 41.8% of HCWs. In multivariate analysis, suffering from a traumatic distress was significantly associated with anxiety and depression (p (p<0.01 and, p<0.05 respectively). In addition, insomnia severity was linked to age (p=0.05) and having colleagues infected with COVID-19 (p<0.05). CONCLUSION: In the present study, HCWs of the military hospital of Tunis stated having high levels of insomnia, anxiety, and depression since the early outbreak of the COVID-19 pandemic. These mental disorders may have a negative impact on the quality of life of HCWs and should be enhanced by psychological support and preventive measures.

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.

Spontaneous hemothorax and neurofibromatosis type 1: How to explain it, how to explore it and how to treat it?

Neurofibromatosis type 1 (NF1), also known as Von Recklinghausen's disease is an autosomal dominant genetic disorder. It is the most common of phacomatoses. Pulmonary complications have been rarely described in the literature. It is generally a benign disease, but has the potential for rare and fatal complications, such as spontaneous hemothorax. We reported two cases of patients with a history of von Recklinghausen's disease. Both of them suffered sudden chest pain. Chest-X ray revealed a hemi-thoracic opacity. Enhanced chest computed tomography showed massive hemothorax, but no evidence of tumors or an obvious bleeding point in the thorax. After we had ensured a stable hemodynamic condition, we performed video-assisted thoracic surgery to remove the hematoma. No evidence of bleeding was noticed in the first patient whereas an active bleeding was observed in the second patient. We could not determine which vessel was responsible of the hemorrhage. Electrocoagulation and clot removal were performed.  Evolution was favorable for both patients. Spontaneous hemothorax is a rare and potentially life threatening NF1's complication. A tumor like neurofibroma or more rarely vascular involvement of large or small caliber arteries may be at hemothorax's origin.

Antinuclear antibodies in interstitial lung disease: Prevalence and clinical significance.

INTRODUCTION: The diagnosis of interstitial lung disease (ILD) requires elimination of underlying connective tissue disease. Consequently, antinuclear antibodies (ANA) are routinely screened in patients with idiopathic interstitial pneumonia. However the clinical usefulness of this practice is not well clear. AIM: In this study, we evaluated the frequency of ANA in ILD's patients and investigated the clinical significance of the ANA's presence in these patients. METHODS: We conducted a retrospective study of hospitalized patients diagnosed ILD at pulmonary department and for which ANA was performed in the immunology laboratory of our institution. Demographic features, clinical symptoms, biological and radiologic findings and CTD-ILD diagnoses were compared between patients with positive ANA versus negative ANA. RESULTS: We enrolled 73 patients. The ANA's prevalence was 32%. There were no significant differences in demographics, pulmonary function test values and radiologic findings between patients with and without ANA. Patients with positive ANA had more cutaneous manifestations (p꞊0.011) and Raynaud's phenomenon (p꞊0.029). The diagnosis of connective tissue disease was made in 42% of patients with positive ANA versus 8% with negative ANA (p꞊ 0.001). ANA's titer higher than 1/320 was predictive of CTD diagnosis (OR꞊14.4) (p<0.001). CONCLUSIONS: The research of ANA in PID's patients is an important tool of CTD diagnosis specially in those with suggestive symptoms of autoimmune disease.

Cold abscess in the immunocompetent subject.

INTRODUCTION: Tuberculous cold abscesses are a rare and unusual form, accounting for 1% of extrapulmonary tuberculosis (TB). AIM: To describe clinical, diagnostic, therapeutic and prognostic aspects of cold tuberculous abscesses. METHODS: Retrospective multicentre study of 26 patients followed for cold abscesses tuberculous in respiratory departments of AbderrahmenMami hospital between 2009 and 2017. RESULTS: We included 24 patients. Mean age was 36.9 years. Six patients had a personal history of pulmonary TB. Circumstances of the discovery were chronic pain (n = 15), parietal swelling (n = 7) and parietal fistulization (n = 2). The mean duration of the symptoms was 2.8 months. Fever was absent in 15 patients. The cold abscess was multifocal in 3 patients, associated with pleuropulmonary TB in 16 patients and extrapulmonary TB in 9 patients. Thoracic wall was the most frequent localization (n=13), followed by subcutaneous and intramuscular localization (n = 6). The surgical flattening of the abscess with biopsy of the edges was performed in 15 patients. The positive diagnosis was pathological in 15 patients and bacteriological in 12 patients. GeneXpert was positive in 2 patients. All patients received anti-tuberculosis treatment. The mean duration of TB was 10.7 months. Evolution was marked by the cure of 20 patients and tuberculous relapse in 1 patient after 6 months. CONCLUSION: Tuberculous cold abscess should be evoked in front of any chronique collection occurring especially in a context of risk factors of TB. Early diagnosis is the best guarantee of a cure without complications.