Prevalence and risk factors of hepatitis B and C among hemodialysis patients in Tunisia.

OBJECTIVE: Hemodialysis patients are at increased risk of infection by hepatitis C and B viruses, which are significant causes of mortality and morbidity. Prevention of their transmission in hemodialysis units remains a challenge worldwide. We aimed to investigate the prevalence of these two infections and to explore major risk factors among patients on chronic hemodialysis. MATERIALS AND METHODS: We performed a cross-sectional study of 109 hemodialysis patients (mean duration of hemodialysis of seven years) between 2012 and 2014 in a Teaching Hospital of Monastir, Tunisia. Hepatitis B and C serological markers were searched for using a chemiluminescent assay. Genome detection was performed using a commercially available quantitative real-time PCR test. RESULTS: A total of 109 hemodialysis patients were enrolled (75 males and 34 females). Ages ranged from 21 to 81 years. Six (5.5%) of these 109 patients had HBV infection defined by a positive HBsAg in four (3.7%) patients and by a detectable DNA associated with an "isolated anti-HBc" profile in the remaining two patients. Hepatitis C was observed in eight patients (7.3%) and five of them had detectable RNA. Hemodialysis duration ˃5years was the main risk factor for hepatitis C infection (P=0.01; OR: 3.11; 95% CI [1.57-13.71]). CONCLUSION: Our findings confirm the downward trend of the prevalence of both hepatitis B and C infections among Tunisian hemodialysis patients. Hemodialysis duration remains the main risk factor for hepatitis C infection. Occult hepatitis B infection should be suspected and investigated, especially among patients with an "isolated anti-HBc" profile.

Emphysematous pyelonephritis in a diabetic patient on maintenance hemodialysis: a case report.

INTRODUCTION: Emphysematous pyelonephritis (EP) is an uncommon acute infection characterized by the presence of gas in the renal parenchyma. It is extremely rare in hemodialysis (HD) patients and diabetics account for most cases. It is a rapidly progressive and life threatening infection with a high mortality rate. We report a case of emphysematous pyelonephritis in a HD patient who was treated successfully with radical nephrectomy and antibiotic therapy. CASE REPORT: A 46-year-old diabetic male with end stage renal disease (ESRD) secondary to diabetic nephropathy and on maintenance HD for the last five years presented with a two weeks history of fever and loin pain. He was treated with oral ciprofloxacin for one week with no improvement. His blood culture isolated Escherichia coli. Computed tomography scan of the abdominal disclosed an enlarged left kidney with massive gaseous collections. Accordingly, the diagnosis of emphysematous pyelonephritis was put forward, the patient underwent left nephrectomy together with intravenous imipenum and amikacin with good clinical response. The removed kidney showed features of acute pyelonephritis with micro-abscesses on histopathology. . CONCLUSION: Emphysematous pyelonephritis should always be considered in diabetics presenting with fever, loin pain, and features of sepsis not responding to antibiotic therapy; even though being on dialysis. Computed tomography scan of the abdomen remains an early diagnostic tool. Early treatment with potent antibiotics with or without surgical intervention can save patients' life.

Acute post-infectious glomerulonephritis in adults: a single center report.

Acute post-infectious glomerulonephritis (APIGN) is uncommonly seen in adults; its incidence is progressively declining, particularly in developed countries. The aim of this study was to evaluate the epidemiological, clinical and biologic features of APIGN in a Tunisian center. A retrospective descriptive analytic study was carried out on 50 patients aged more than 15 years who were admitted to the Monastir Hospital between 1991 and 2007, with a diagnosis of APIGN. There were more males than females (66% vs. 34%), and the mean age of the patients was 36.8 ± 10 years. Only 10% had an immunocompromised background, including diabetes. The most common site of infection was upper respiratory tract, followed by skin and pneumonia. The most common causative agent was Streptococcus (66%), followed by Staphylococcus (12%). 73.8% of the patients had low C3 complement levels. The mean peak serum creatinine was 190 µmol, and 4% of patients required acute dialysis. The patients were followed-up for a mean period of 18 months (range, 0.16-97 months). During follow-up, of the 46 patients reviewed in the consultation, the majority showed complete remission, 12 patients had persisting abnormalities such as hypertension in 17%, chronic renal failure in 8% and proteinuria in 6.5%, and one patient had concomitant hypertension and chronic renal failure. Our study suggests that APIGN is still endemic in some parts of the world such as Tunisia, and our data showed a favorable prognosis in adults.

Predictors of early post-operative hypocalcemia after parathyroidectomy for secondary hyperparathyroidism.

We sought to identify predictors of development of early post-operative hypocalcemia after parathyroidectomy for secondary hyperparathyroidism. The patients were divided into two groups according to their serum calcium (Ca) levels within 24 hours of undergoing para-thyroidectomy: the hypocalcemia group (22 patients) with post-operative serum Ca levels of 2 mmol/L or less, and the normocalcemia group (48 patients), with post-operative serum Ca levels higher than 2 mmol/L. By using multivariate stepwise logistic regression analysis, high pre-operative serum Ca level had the strongest predictive value of development of early hypocalcemia with an adjusted odds ratio (aOR) of 3.01, followed by hypo-albuminemia (aOR = 2.72), younger age (aOR = 2.56), and high pre-operative alkaline phosphatase (ALP) levels (aOR = 2.28). We conclude that among patients with secondary hyperparathyroidism, age, levels of pre-operative serum Ca, ALP and albumin correlate positively with the development of early post-operative hypocalcemia. Patients with one of these factors should be monitored more closely in the early post-parathyroidectomy period.

[Acute renal insufficiency in Boutonneuse Mediterranean fever: description of three cases]. / Insuffisance rénale aiguë au cours de la fièvre boutonneuse méditerranéenne: description de trois observations.

Boutonneuse fever is a bacterial infection caused by Rickettsia conorii. It occurs mainly in countries around the Mediterranean basin. Most cases are benign. However severe forms with major morbidity and a high mortality risk have been described. Severe forms often involve altered mental status, hepatic cytolysis, hemostatic disturbances, pneumopathy, and kidney failure. The causes of renal complications are unclear. The purpose of this report is to describe three cases of boutonneuse fever associated with acute kidney failure due to different underlying mechanisms, i.e., acute renal function failure, acute tubular necrosis, and extracapillary glomerulonephritis. While the first two mechanisms of kidney failure have been reported frequently in association with Boutonneuse fever, extracapillary glomerulonephritis has, to our knowledge, been mentioned only once. This case supports speculation that Rickettsia conorii has a toxic effect on glomeruli.

[Desmoid cervical tumour following the placing of an internal jugular catheter]. / Tumeur desmoïde cervicale après pose d'un cathéter jugulaire interne.

INTRODUCTION: A desmoid tumour is a rare fibroblastic tumour and generally located in the abdomen. However, it can also develop on surgical scars. OBSERVATION: A 36 year-old woman on chronic dialysis consulted for a cervical mass on the left side that was progressively increasing in volume, on the site of a scar of an internal jugular catheter placed 7 months earlier. Histological analysis of a sample of this mass concluded in a benign fibroblastic proliferation and led to the diagnosis of a desmoid tumour. Study of the patient's history revealed that a left jugular catheter had been placed on two occasions to be used for the hemodialysis approach, the lesion provoked by the latter would explain the development of the desmoid tumour. COMMENTS: The potential severity of this tumour is related to its proximity with the carotid, trachea and base of the skull. In general, desmoid tumours, rare benign tumours of the connective tissue, exhibit a complex multifactor etiopathogenesis. A surgical trauma can often trigger-off such tumours.

[Feminine pseudo-hermaphroditism and ovarian polycystic syndrome: the role of hydrocortisone]. / Pseudo-hermaphrodisme féminin et syndrome des ovaires polykystiques: rôle de l'hydrocortisone.

We report the case of a patient who was initially assigned as a male, and in whom the diagnosis of CAH was delayed (17 years of age). He was shown to have female pseudohermaphrodites. Before treatment, plasma testosterone level was: 15 ng/mL (N: 0.1-0.7), 17 OH progesterone (17 OHP): 45 ng/mL (N: 0.1-1.1) and FSH, LH values were below the normal range. While taking hydrocortisone, a rapid onset of new clinical, biological and radiological findings were observed after three months: rapid menarche and thelarche occurred, plasma testosterone and 17 OHP levels decreased, respectively 1 and 3.7 ng/mL, plasma FSH and LH were respectively 4.1 mUI/mL (N: 1.5-7) and 14.3 m UI/mL (N: 1.1-11.7). Polycystic ovaries were shown at sonography. Authors try to discuss the mechanism of the new events observed and specially those related to the polycystic ovarian disease. In a female with untreated CAH at adult age, menarche can rapidly occur once appropriate treatment was started.

Large bilateral adrenal incidentalomas complicating untreated 11B hydroxylase deficiency in the third decade of life. A case report.

The occurrence of bilateral giant adrenal incidentalomas is reported in a 22-year-old man who was evaluated for urinary tract infection. The right gland measured 16 cm, the left one 6 cm at computed tomography. Height was 145 cm, blood pressure 190/100 mm Hg. Testes were not palpable. Laboratory investigations revealed elevated levels of 17 hydroxyprogesterone:>50 ng/ml (n<1,1); 11 desoxycortisol: 919 nmol/l (n<30); testosterone: 19 ng/ml (n<0.7) and ACTH: 1 402 ng/l (n<48). Karyotype was 46 XX. The patient was a female pseudohermaphrodite with congenital adrenal 11 B hydroxylase deficiency. Adrenal masses responded to glucocorticoid therapy with marked reduction of their size after six months. We confirm previous recommendations that patients with adrenal incidentaloma should be checked for congenital adrenal hyperplasia.

[Diagnosis of extruded herniated disks]. / Diagnostic des hernies discales exclues.

In a patient with disk herniation it is often difficult to establish that the disk is free in the spinal canal. A retrospective medical record study comparing 65 cases of free herniated disk (FHD) confirmed upon surgery and 65 cases of disk protrusion (DP) demonstrated that FHD was more common in young male blue collar workers, especially those who worked in the sitting position. No clinical findings were diagnostic of FHD although the straight-leg raising test was positive at smaller angles than in disk protrusion. In this study, sensitivity and specificity of CT scan for the diagnosis of FHD were 75% and 80%, respectively. CT scan findings suggestive of FHD included a free disk fragment, found in 22.5% of cases, and an acute connecting angle. Saccoradiculography was more sensitive but less specific than CT scan in this study. In FDH, migration was common and ragged hernia contours were seen on the saccoradiculography images.

[Primary hypothyroidism and glomerular involvement]. / Hypothyroïdie primitive et atteinte glomérulaire.

Association between auto-immune dysthyroidism and glomerulonephritis is quite rare. The authors report 3 cases with proteinuria varying from 2.72 to 6.06 g/day and hypothyroidism. Nephrotic syndrome was found in 2 cases and thyroid auto-antibodies (microsomal and thyroglobulin) and circulating immun complexes (C.I.C.) in 1 case, complement fractions C3 and C4 were normal in all cases. Renal biopsy showed membranous glomerulonephritis in 2 cases and minimal lesions in the third case. Proteinuria disappeared with glucocorticoids and thyroxine in 1 case, with thyroxine alone in an other case and persisted in the third case with normal thyroid function.

[The nephrotic syndrome in kala-azar]. / Syndrome néphrotique au cours du kala-azar.

Glomerular nephropathy is unusually known in kala-azar. We present 3 cases and we report a review on the clinical, biological and immunohistological aspects of this glomerulonephritis. The immunologic mechanisms of this parasitic nephropathy and its reversibility after specific treatment are characteristic.