Intra-articular osteolipoma of the elbow: A case report and a review of the literature.

Introduction: Lipomas are the most common benign mesenchymal tumors. The intra-articular localization is exceptional.We report the first case of an intra-articular osteolipoma at the elbow. Case report: A 36-year-old patient with no pathological history, presented to the emergency room with a two weeks history of a painless, progressively left elbow swelling in a context of apyrexia.Physical examination revealed a hot, edematous left elbow. The gentle mobilization of the joint was painless. Biologie was normal. Initial radiograph showed a well-defined lobular image. Ultrasound revealed an anechoic intra-articular collection associated to a synovium hyperaemia and the MRI shows an aspect of synovitis. An arthrotomy was done via an internal approach of the elbow. Joint fluid was red. A free ossified intraarticular mass was discovered. Bacteriological samples were sterile. Histological examination concluded to an osteolipoma with no histological signs of malignancy. At the last 3-year follow-up, the patient didn't report any pain or functional discomfort. Elbow mobility was complete, with the absence of recurrences. Discussion: Osteolipoma is defined as a histological variant of lipoma having undergone bone metaplasia. Allen found 06 cases in a series of 635 lipomas over five years. Pain has not been reported in the literature. In our case the pain was explained by the interposition of the tumoral mass between the articular surfaces. Histological examination confirms the diagnosis and recurrences are rare. Conclusion: Osteolipoma is an extremely rare entity of mesenchymal tumors whose intra-articular location, although exceptional, does not worsen the prognosis.

Blastomyces dermatitidis in a Renal Transplant Recipient: A Case Report.

Fungal infections have an important role in organ transplant recipients, and in some cases can be lethal. Blastomycosis is rare in kidney transplantation. We present a case of cutaneous blastomycosis in a kidney transplant recipient in Tunisia, a country outside the known endemic countries. This case, with the very uncommon and unexpected diagnosis of blastomycosis, demonstrates the diversity of infections in transplant recipients and reflects the importance of histologic and serologic tests in the immunocompromised patient.

[A multicenter study on profile of hypertension in focal segmental glomerulosclerosis in Tunisia]. / Profil de l'hypertension artérielle dans la hyalinose segmentaire et focale (HSF). Étude multicentrique de 116 cas en Tunisie.

UNLABELLED: Hypertension in focal segmental glomerulosclerosis is frequent and responsible for the progression of the disease. It could be a circumstance of the diagnosis of FSG or a complication of the nephrotic syndrome. PURPOSE: To determine the prevalence of hypertension among patients with FSG diagnosed in Tunisia and to describe the profile of patients with FSG having hypertension in contrast with who do not. PATIENTS AND METHODS: It was a retrospective multicentric study based on 116 patient files having FSG located in 5 specialized centers in Tunisia. RESULTS: The prevalence of hypertension among our patients was 41%, with a feminine predominance, their mean age was 36.34 ± 15.71 years. The systolic blood pressure among the patients with hypertension was 153.18 mmHg. The nephrotic syndrome was impure due to hypertension in 14.5% of the cases. The patients affected by hypertension were more obese. Proteinuria was higher among those not having hypertension than those with it, who score an average value of 5.67 ± 4.51 g/24h, with an insignificant difference. Serum creatinine at presentation was significantly higher among patients with hypertension. Vascular lesions were present at the renal biopsy among 39.45% of patients affected by hypertension, associated with renal failure in 58.50% of patients. The etiopathogenic treatment of FSG was essentially based on steroids full dose. CONCLUSION: Hypertension is often present in FSG and its' treatment must be as soon as possible in order to slow the progression of kidney chronic disease.

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.

Diaphragmatic dysfunction in Collagen VI myopathies.

Collagen VI-related myopathies are hereditary disorders causing progressive restrictive respiratory insufficiency. Specific diaphragm involvement has been suggested by a drop in supine volumes. This pilot study aimed at characterizing the respiratory muscle phenotype in patients with COL6A1-3 genes mutations. Lung function, blood gases, muscle strength and respiratory mechanics were measured in 7 patients between 2002 and 2012. Patients were classified as Early-Severe (n = 3), Moderate-Progressive (n = 2) and Mild (n = 2) according to clinical disease presentation. Seven patients (aged 6-28) were evaluated. Forced vital capacity distinguished the Mild group (>60% predicted) from the two other groups (<50% predicted). This distinction was also possible using the motor function measure scale. Diaphragmatic dysfunction at rest was observed in all the Early-Severe and Moderate-Progressive patients. During a voluntary sniff maneuver diaphragmatic dysfunction was observed in all patients, as assessed by a negative gastric pressure. All patients had diaphragmatic fatigue assessed by a tension-time index over the threshold of 0.15. Diaphragmatic dysfunction during a maximal voluntary maneuver and diaphragmatic fatigue are constant features in Collagen VI myopathies. These observations can assist the diagnosis and should be taken in account for the clinical management, with the early detection of sleep-disordered breathing.

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.

Tacrolimus therapeutic drug monitoring in Tunisian renal transplant recipients: effect of post-transplantation period.

BACKGROUND: Most previous studies having focused on therapeutic drug monitoring of tacrolimus in renal transplant recipients have assessed the clinical response of patients. The aim of this study is to investigate the influence of post-transplant delay on tacrolimus dose, trough levels (C0) and dose/C0 ratio in a Tunisian renal transplant population. PATIENTS AND METHODS: A retrospective study including 110 renal transplant patients has been performed. Tacrolimus trough concentrations were adjusted according to the target range proposed by the European consensus conference on tacrolimus optimization. Samples for determination of tacrolimus blood level were subdivided according to the post-transplantation period into three groups. RESULTS: The initial dose required was 0.17 ± 0.05 mg/kg/day during the first 3 months after transplantation. A reduction of 36 and 65% of tacrolimus initial dose during the second (3-12 months) and third period after transplantation (>12 months), respectively, was required to maintain the concentration level within therapeutic range. These results were different from those found in other studies performed in different populations. We hypothesize that these differences in dosing requirement may be due to an interethnic polymorphism in the expression of enzymes involved in tacrolimus metabolism. CONCLUSION: These results could provide a simple therapeutic strategy to optimize tacrolimus prescription after renal transplantation in Tunisian population.

[Isolated congenital tracheoesophageal fistula]. / Fistules oesotrachéales congénitales isolées.

INTRODUCTION: Isolated tracheoesophageal fistula without esophageal atresia is a rare congenital malformation. Its etiology is obscure. Diagnosis is difficult but must be made early. PURPOSE: To study the clinical, radiological, and evolutionary sights of this malformation. PATIENTS AND METHODS: We report 4 cases of tracheoesophageal fistula, collected in the department of pediatric surgery of Monastir Hospital and in the neonatology unit of Sousse Hospital during the period between January 2001 and December 2010. RESULTS: The clinical picture consisted in a coughing bout and cyanosis after each feeding. Thoracic and abdominal imaging showed aspiration pneumonia, atelectasis, and gas within the colon. Gastrointestinal opacification demonstrated the fistula in 2 cases. Tracheoscopy visualized the tracheoesophageal fistula in the other 2 cases. Treatment was surgical and consisted in the section-ligation of the tracheoesophageal fistula with pleural interposition in all cases. The course was simple in two cases with a 3-year and 3.5-year follow up, respectively, but the infants died in the other 2 cases. CONCLUSION: Although a rare malformation, tracheoesophageal fistula should be suggested as a diagnosis when respiratory symptoms occur during feeding starting during the neonatal period.

Adrenal epithelial cyst: a case report.

Epithelial-lined or true cysts of the adrenal gland are exceedingly rare accounting for only 9% of all adrenal cysts. A 55-year-old woman with a medical history for cholecystectomy and liver hydatidosis presented with an 8-month history of abdominal pain in the upper left quadrant. Physical examination was unremarkable and laboratory tests were within normal range. Computed tomography displayed a homogeneous and finely calcified cystic mass of the left adrenal gland measuring 12 x 10 cm. A hydatid cyst of the adrenal gland was suspected preoperatively and the patient underwent uneventful excision of the cyst. Histological examination of the surgical specimen revealed that the cyst wall was lined by cuboidal to flattened cells with bland cytologic features. Immuohistochemically, the cyst lining expressed intensely cytokeratin but was negative for CD 34 and calretinin. The final pathological diagnosis was epithelial adrenal cyst.

Localized ileal giant pseudopolyposis in Crohn's disease: a case report.

Localized giant pseudopolyposis is a rare complication in inflammatory bowel disease defined as a pseudopolyp (isolated or clustered) larger than 1.5 cm in size. Giant pseudopolyps are more commonly found in ulcerative colitis compared to Crohn's disease and mainly involve the left colon. A 26-year-old male patient with a two-year history of Crohn's disease was admitted with increasing abdominal pain, vomiting, anorexia, weight loss and fever. On physical examination, the abdomen was diffusely tender. Computed tomography showed diffuse irregular thickening of the ileal wall and stenosis of the terminal ileum. The patient underwent ileo-cecal resection with re-anastomosis. The ileal portion of the resected specimen harboured multiple finger-like pedunculated polyps, with the smallest measuring 0.5 cm and the largest measuring 1.8 cm. Histologically, the polyps were consistent with granulation tissue. No evidence of dysplasia or malignancy was found. The post-operative course was uneventful considering one month follow-up. This report illustrates an unusual case of giant pseudopolyposis involving the ileum in a patient with Crohn's disease. The natural history of these lesions, as well as their optimal management, remain uncertain.

Pancreatic heterotopia in the gallbladder neck associated with chronic cholecystitis.

The gallbladder is an unusual location of pancreatic heterotopia defined as the presence of pancreatic tissue lacking anatomical and vascular continuity with the main body of the gland. A 55-year-old previously healthy male patient presented with repeated attacks of right hypochondriac pain and vomiting. On physical examination, the right upper abdomen was tender to palpation with a positive Murphy's sign. Abdominal ultrasonographic examination showed multiple gallstones within a thin-walled gallbladder. Laparoscopic cholecystectomy was performed with uneventful recovery. Macroscopic examination of the surgical specimen revealed a yellowish intramural nodule measuring 7 mm close to the neck of the gallbladder. Histological examination revealed chronic cholecystitis and subserosal foci of heterotopic pancreas made up of exocrine acinar and ductal elements without islet cells corresponding to incomplete heterotopia. Heterotopic pancreas is usually detected as an incidental microscopic finding in a gallbladder specimen removed by cholecystectomy. Pre-operative diagnosis is difficult primarily due to its non-specific clinical features.

Adenomatous transformation in a giant solitary Peutz-Jeghers-type hamartomatous polyp.

Solitary Peutz-Jeghers-type polyp is a rare hamartomatous polyp without associated mucocutaneous pigmentation or a family history of Peutz-Jeghers Syndrome. It is usually encountered in the small intestine, but rarely involves the rectum. A 27-year-old previously healthy female patient presented with a two-month history of rectal bleeding. The patient had neither mucocutaneous pigmentation nor a family history of gastro-intestinal polyposis. Endoscopic examination revealed a solitary lobular polypoid lesion in the lower rectum. The polyp was sessile and measured 15 cm in diameter. As histological examination of the biopsy specimen was suggestive of adenoma, endoscopic polypectomy was performed. Histologically, this polyp had an arborizing muscular network originating from the muscularis mucosa, and was covered by well organized mucosa with several foci of dysplastic glands. The final pathological diagnosis was solitary Peutz-Jeghers type hamartomatous polyp with adenomatous transformation.

[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.

[Pyomyositis in adults in central Tunisia. Apropos of 10 cases]. / La pyomyosite chez l'adulte en Tunisie centrale. A propos de dix cas.

Ten adult patients treated for pyomyositis between 1988 and 1994 in Sousse's university hospital (Tunisia) were retrospectively reviewed. Due to the non specific symptoms, the diagnosis was often delayed (mean = 17 days) and other primary diagnoses were considered, mainly including synovitis. The muscles around hip and thigh were most commonly involved (ten patients), and Staphylococcus aureus was the most common pathogen (nine patients). Ultrasonography was very helpful in the accurate diagnosis of the infection. Incision, drainage, and antibiotic therapy eradicated the infection in all patients. No residual functional limitations and no residual symptoms were noted. Our study showed that pyomyositis is present in central Tunisia and not associated with HIV infection. Clinical features and prognosis are similar to those previously described in the literature.