Trace element assessment in Neoechinorhynchus agilis (Rudolphi, 1918) (Acanthocephala: Neoechinorhynchidae) and its fish hosts, Mugil cephalus (Linnaeus, 1758) and Chelon ramada (Risso, 1827) from Ichkeul Lagoon, Tunisia.

Acanthocephalans belonging to the species Neoechinorhynchus agilis were collected from two mullets, Mugil cephalus and Chelon ramada from Ichkeul Lagoon in northern Tunisia. Collected parasites, as well as tissues of their hosts (muscle, liver and intestine), were analysed for trace elements (silver, arsenic, cadmium, cobalt, copper, iron, manganese, nickel (Ni), lead (Pb), selenium, vanadium (V), zinc) using inductively coupled plasma mass spectrometry. Our results showed different accumulation patterns of trace elements in fish tissues and parasites. Among the host tissues, liver accumulated the highest metal amounts. Acanthocephalans showed Ni, Pb and V in significantly higher concentrations compared to their host's tissues. Further, the calculated bioconcentration factors demonstrated a 390-fold higher Pb accumulation in the parasite compared to fish muscle. This study is the first field survey in Tunisia dealing with elements' uptake in parasites and their hosts. Our results corroborate the usefulness of the acanthocephalans for biomonitoring of metal pollution in aquatic ecosystems and promote more research in order to understand host-parasite systems in brackish waters of the Mediterranean area.

Diagnosis and management of autoimmune hemolytic anemia in children.

BACKGROUND AND AIM: The aim of this study is to evaluate the clinical, biological and hematological profiles of autoimmune hemolytic anemia (AIHA) in children and to specify its etiologies, therapeutic modalities, and treatment responses. METHODS: This is a 14-year retrospective study of AIHA cases collected at the department of pediatric emergency and reanimation of Hedi Chaker University Hospital in Sfax. We included patients under 14 years old with clinical and biological features of hemolysis and a positive direct antiglobulin test (DAT). The selected patients' demographic characteristics, physical signs, laboratory findings, and treatment responses were recorded. RESULTS: Thirteen cases of AIHA were collected, including 8 girls and 5 boys. The median age at diagnosis was 4 years and 6 months (range: 8 months to 13 years). Consanguinity was reported in 6 cases and 4 patients had a previous infection history. The onset of AIHA was progressive in 9 cases, marked by an anemic syndrome and hemolysis symptoms in 6 and 8 cases, respectively. The clinical triad (pallor, jaundice and splenomegaly) was found in only 4 cases. At the time of diagnosis, the median hemoglobin (Hb) level was 6g/dL (range: 4.2 to 9.2g/dL), anemia was non-regenerative in 2 patients. Thrombocytopenia and neutropenia were noted in 5 and 1 patient, respectively. Peripheral smear examination showed spherocytosis in 2 cases. All the patients had a positive DAT. Of these, 10 were positive with IgG and 3 with both IgG and C3d. AIHA was secondary to other conditions in 9 patients: infection (3 cases), autoimmune disease (4 cases), and immunodeficiency (2 cases). All the patients received first-line corticosteroid therapy but only 8 of them required blood transfusions due to severe anemia. Complete remission was obtained in 7 cases. Corticosteroid resistance and dependence were noted in 1 and 2 cases, respectively. During evolution, additional therapy was indicated in 4 patients and it included cyclosporine A, azathioprine, and mycophenolate mofetil (MMF). After a median follow-up of 4.5 years, the cure rate was 80% and only 1 patient (a boy) died due to his underlying pathology. CONCLUSION: Our study highlights the rarity, severity, and heterogeneity of etiological contexts of AIHA in children. The therapeutic difficulties justify specific expertise in pediatric hematology.

The Diversity of Teleost Fish Trematodes in the Bay of Bizerte, Tunisia (Western Mediterranean).

A total of 39 digeneans species allocated to 28 genera in 12 families were recovered from 534 fishes belonging to 14 species in three families (Carangidae, Mullidae and Sparidae) collected in the Bay of Bizerte off the coast of Tunisia. We provide a host-parasite list of records from this locality, including 63 host-parasite combinations. The Opecoelidae Ozaki, 1925 is the most diverse group with 12 species. The species richness of individual digenean genera in the Bay of Bizerte ranges from 1 - 6 species. The mean number of 2.58 species per host indicates a relatively high digenean diversity in the Bay of Bizerte, which is related to its geographical location, its connection with the neighbouring Bizerte Lagoon and the nature of the bottoms of the littoral marine areas off the northern Tunisian coasts. This diversity is significantly higher than that reported off the southern coast of Tunisia and distinctly lower than that observed for teleost hosts in the Scandola Nature Reserve off Corsica. Generally, the levels of infection in teleosts fishes from the Bay of Bizerte are lower than those from the other two localities.

[Primary Sjögren syndrome in a child]. / Syndrome de Goujerot-Sjögren primitif de l'enfant : à propos d'un cas.

Sjögren syndrome is uncommon in children and occurs most often in association with autoimmune diseases (secondary Sjögren syndrome). We describe the clinical and biological features of a 7-year-old girl with primary Sjögren syndrome revealed by recurrent parotiditis. CASE REPORT: A 7-year-old girl was referred for investigation of multiple episodes of parotid swelling since age 4 years, without systemic symptoms. The examination was unremarkable except for enlarged and painless parotid glands. Laboratory investigations and labial salivary gland biopsy revealed Sjögren syndrome without associated disease. Hydroxychloroquine was prescribed with clinical improvement. CONCLUSION: Recurrent parotiditis in children is an uncommon condition. The onset of parotid swelling at 5 years or over deserves screening for disimmune disorders, sarcoidosis, or Sjögren syndrome. Diagnosis of Sjögren syndrome is based on diagnostic criteria.

The occurrence of acanthocephalans in teleost fish from the Bizerte lagoon, Tunisia.

Seven species of acanthocephalans were identified for the first time in teleost fish from the Bizerte lagoon, Tunisia, including Neoechinorhynchus (Hebesoma) agilis (Rudolphi, 1819) Van Cleave, 1916; N. (Neoechinorhynchus) rutili Müller, 1780 (Neoechinorhynchidae); Acanthocephaloide propinquus (Dujardin, 1845) Meyer, 1932; A. incrassatus (Molin, 1858) Meyer, 1932 (Arhythmacanthidae); Longicollum pagrosomi Yamaguti, 1935 (Pomphorhynchidae); Rhadinorhynchus cadenati (Golvan et Houin, 1964) Golvan, 1969 (Rhadinorhynchidae); and Telosentis exiguus (von Linstow, 1901) Van Cleave, 1923 (Illiosentidae). Acanthocephaloide propinquus, N. (N.) rutili, L. pagrosomi and R. cadenati were restricted to the rectum and the posterior intestine, whereas the other species (A. incrassatus, T. exiguus and N. (H.) agilis) colonized two or three parts of the intestine. The most diverse acanthocephalan fauna was recorded in Lithognathus mormyrus, with three species; two species were reported from Trachurus trachurus; and a single species was recorded in Liza aurata and in Atherina boyeri. Neoechinorhynchus (N.) rutili, L. pagrosomi and R. cadenati attained the lowest prevalences of less than 6% and were considered as to be rare species. Acanthocephaloide incrassatus, A. propinquus, T. exiguus and N. (H.) agilis were satellite species. The diversity of the acanthocephalan fauna in the fish from the Bizerte lagoon is compared with previous studies from other localities. The report of A. incrassatus, A. propinquus and N. (N.) rutili in L. mormyrus presents new host records in Mediterranean waters.

Morphology and molecular analysis of life-cycle stages of Proctoeces maculatus (Looss, 1901) (Digenea: Fellodistomidae) in the Bizerte Lagoon, Tunisia.

The life cycle of Proctoeces maculatus (Looss, 1901) (Digenea, Fellodistomidae) was studied in Bizerte Lagoon (Tunisia). Three sequential hosts appear to be involved: the Mediterranean mussel Mytilus galloprovincialis Lamarck, 1819 (Mytilidae) as the first intermediate host; the polychaete Sabella pavonina Savigny, 1822 (Sabellidae), as the second intermediate host; and fishes (Lithognathus mormyrus (Linnaeus, 1758) (Sparidae), Trachinotus ovatus (Linnaeus, 1758) (Carangidae) and Sparus aurata Linnaeus, 1758 (Sparidae) as the definitive hosts. It should be noted that S. pavonina was recorded as second intermediate host for P. maculatus for the first time. Molecular confirmation of the morphological identification of the life-cycle stages of this digenean was obtained using partial 28S rDNA sequences. Comparative sequences revealed that the sporocysts and the metacercariae are conspecific but they diverged by 0.3% from the adults. The present results raised the possibility of the existence of cryptic species within the different developmental stages. However, all the present isolates differed from material from Archosargus probatocephalus in the Gulf of Mexico identified as P. maculatus.

Ecthyma gangrenosum: A manifestation of community-acquired Pseudomonas aeruginosa septicemia in three infants.

OBJECTIVES: Pseudomonas aeruginosa sepsis usually carries a high mortality rate in immunocompromised children. Ecthyma gangrenosum is a known cutaneous manifestation due mainly to Pseudomonas infection with or without septicemia. We describe clinical, biological, and therapeutic data. PATIENTS AND METHODS: Of those children admitted to the pediatric intensive care unit, three pediatric cases of community-acquired P. aeruginosa septicemia associated with ecthyma gangrenosum were retrospectively reviewed. RESULTS: The three patients were aged 5 months, 9 months, and 1 year. Underlying hypogammaglobulinemia was detected in the oldest patient. Pseudomonas aeruginosa was isolated in all patients in blood and once in cultures of skin lesions and endotracheal aspirate. Two deaths occurred due to septic shock and multisystem organ failure despite numerous aggressive resuscitation attempts. CONCLUSIONS: P. aeruginosa sepsis should be treated as early as possible. Recognition of ecthyma gangrenosum allows early diagnosis and prescription of adequate antibiotic therapy without awaiting blood culture reports.

[Auto-immune hepatitis in chronic granulomatous disease in a 2-year-old girl]. / Hépatite auto-immune associée à une granulomatose septique chronique chez une fille de 2 ans.

BACKGROUND: Chronic granulomatous disease is a rare inherited primary immune deficiency disease characterized by recurrent infection and an increased susceptibility to autoimmunity disorders. We report on the case of a girl with autoimmune hepatitis in chronic granulomatous disease to describe the clinical and biological features and treatment implications for patients with chronic granulomatous disease associated with autoimmune disorders. CASE REPORT: An 18-month-old girl was referred to our department for investigation of hepatomegaly. She was the third child of non-consanguineous parents. Her two elder sisters had died from infectious diseases at an early age. She had elevated liver transaminase levels with a normal gamma globulin concentration. Negative results were found for all autoimmune markers (antinuclear antibody, anti-smooth muscle, anti-liver-kidney microsomal, anti-liver cytosol and anti-soluble liver antigen). Her liver biopsy showed features of interface hepatitis with portal fibrosis. The diagnosis of seronegative autoimmune hepatitis was established. Treatment with corticosteroids and azathioprine led to clinical improvement with normalization of transaminases. Six months after initial presentation, at the age of 2 years, she was readmitted for fever. Staphylococcus aureus bacteremia was identified with multiple foci of infection (skin infection, arthritis of the right elbow, pneumonia, buttock abscess). The immunological workup revealed chronic granulomatous disease. The course was marked by a fatal outcome despite appropriate antibiotics and intensive care. CONCLUSION: Early diagnosis of the association between chronic granulomatous disease and autoimmune disorders allows for appropriate treatments, improves the quality of life for affected patients, and reduces the risk of mortality.

Geotrichum capitatum septicemia: case report and review of the literature.

Geotrichum capitatum is an uncommon cause of invasive infections in immunocompromised patients, particularly those with hematological malignancies and severe neutropenia. The aim of this study was to report the cases of invasive geotrichosis in our hospital. It is a retrospective study of invasive geotrichosis diagnosed in the Laboratory of Parasitology-Mycology of the UH Habib Bourguiba, Sfax, from January 2005 to August 2013. Six cases of invasive Geotrichum infections were diagnosed. There were three men and three women. The mean age was 35 years. Five patients have acute myeloid leukemia with a profound neutropenia, and one patient was hospitalized in the intensive care unit for polytraumatism. Clinically, the prolonged fever associated with pulmonary symptoms was the predominant symptom (n = 5). Geotrichum capitatum was isolated in one or more blood culture. Two patients had urinary tract infections documented by multiple urine cultures positive for G. capitatum. Five patients received conventional amphotericin B alone or associated with voriconazole. The outcome was fatal in four cases. Invasive geotrichosis is rare, but particularly fatal in immunocompromised patients. Approximately, 186 cases have been reported in the literature. The prognostic is poor with mortality over 50 %. So, early diagnosis and appropriate management are necessary to improve prognosis.

[Crohn's disease or intestinal tuberculosis: a diagnostic challenge]. / Tuberculose intestinale ou maladie de Crohn : un défi diagnostique.

Distinguishing intestinal tuberculosis from Crohn disease is difficult and can result in misdiagnosis, especially when active pulmonary infection is absent. A 13-year-old girl was admitted to our hospital with a 2-month history of watery diarrhea, abdominal pain, and 12-kg weight loss. Based on clinical, radiological, endoscopic, and histological findings, she was initially misdiagnosed as having Crohn disease and treated with glucocorticosteroids, with a poor response after 4 weeks. Intestinal tuberculosis was then suspected. Improvement was observed during the 1st week of antituberculous treatment. The differentiation of intestinal tuberculosis from Crohn disease may be very difficult in some patients. A positive response to antituberculous treatment associated with clinical, endoscopic, and histological features argue in favor of the diagnosis of intestinal tuberculosis.

[Serratia marcescens osteomyelitis as the first manifestation of chronic granulomatous disease]. / Granulomatose septique chronique révélée par une ostéomyélite à Serratia marcescens.

Chronic granulomatous disease is a rare, primary immunodeficiency disorder characterized by a defect in oxidative metabolism in phagocytes and recurrent bacterial and fungal infections. We report a case in a 2-month-old infant admitted with metacarpic osteomyelitis due to Serratia marcescens. Chronic granulomatous disease is rare but must be considered in cases of uncommon or atypical infection.

Early-onset of multiple sclerosis in a 5-year-old girl.

Childhood multiple sclerosis is a rare demyelinating autoimmune disease with particular features. Onset of multiple sclerosis is extremely uncommon in early childhood, particularly before 6 years of age. We report the case of a 5-year-old girl admitted to the hospital for altered consciousness and rapid onset of right hemiparaplegia. Magnetic resonance imaging (MRI) of the brain showed multifocal white matter disease with T2 hyperintense oval lesions in subcortical, periventricular, and cerebellar hemispheres. Treatment with high dose intravenous methylprednisolone (30 mg/kg/day for 3 days) improved symptoms. Intravenous corticosteroid therapy was followed by 1mg/kg/day of oral prednisone. A second MRI, 40 days later, revealed new disseminated T2 hyperintense lesions in the frontal periventricular white matter, corpus callosum, left middle cerebellar peduncle, and dorsal spinal cord, leading to the diagnosis of multiple sclerosis. Azathioprine (2.5 mg/kg/day) was started and the steroid dose was tapered before being stopped after 3 months. After 2 years of follow-up, the patient has remained asymptomatic with a normal neurological exam and with no relapse or side effects of azathioprine. This work shows the particularities in clinical and radiological features of multiple sclerosis in a child aged less than 6 years.

[Septic cavernous sinus thrombosis following ethmoiditis: a case report]. / Thrombose du sinus caverneux compliquant une ethmoïdite aiguë

Acute ethmoiditis is a rare infection of ethmoidal cells. The pathognomonic sign is an edema of the internal corner of the eye. Imaging may be necessary to verify the absence of orbital or endocranial complications. Thrombophlebitis of the cavernous sinus is a serious complication of this infectious process. We report the case of an 11-year-old boy who presented with ethmoiditis complicated with thrombophlebitis of the cavernous sinus, with right hemiplegia and left Bell palsy sequelae. Early diagnosis of this disorder and urgent therapy are essential. Treatment is based on the antibiotic therapy.

Type 2 autoimmune hepatitis overlapping with primary sclerosing cholangitis in a 10-year-old boy.

BACKGROUND: Overlap syndrome of autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC) is considered when the patient presents with the diagnostic criteria of both diseases at some stage of the medical history, either simultaneously or consecutively. AIM: To report on a new case of overlap syndrome and describe the clinical presentation, progression, radiological studies, histological characteristics, and therapeutic options of this rare association. CASE REPORT: A 10-year-old boy presented with jaundice and hepatosplenomegaly. Levels of plasma aminotransferases, gamma-glutamyl transferase, serum alkaline phosphatase and gammaglobulins were elevated. Anti-liver cytosol and perinuclear antineutrophilic cytoplasmic antibodies were positive. Liver biopsy showed features of interface hepatitis with ductopenia. Magnetic resonance cholangiography revealed bile duct stenosis and dilations. Serological findings associated with radiological and histological features confirmed the diagnosis of overlap syndrome of AIH with PSC. Treatment with prednisone, azathioprine, and ursodeoxycholic acid led to a good response. CONCLUSION: The possibility of AIH-PSC overlap syndrome should be considered in all children with AIH and, with clinical, biochemical, or histological signs of PSC, complementary investigations should be done to confirm the diagnosis so as to urgently initiate appropriate treatment with immunosuppressive medication and ursodeoxycholic acid.

[Nutcracker syndrome: a rare cause of hematuria]. / Le syndrome casse-noisette (Nutcracker) : une cause rare d'hématurie.

Nutcracker syndrome is a rare cause of hematuria in children. Clinical signs relate to compression of the left renal vein between the aorta and the superior mesenteric artery. The diagnosis is suggested on cystoscopy, which reveals unilateral hematuria, and confirmed by imaging. We report the case of a 4-year-old child who presented nutcracker syndrome confirmed by CT angiography of the abdomen after excluding the other causes of hematuria. Through this observation, we emphasize the reality of this syndrome in children and the value of imaging in the evaluation of this rare affection.

[Thymoma in children: a report of one case]. / Le thymome de l'enfant : à propos d'un cas.

BACKGROUND: Thymoma is an uncommon tumor of childhood. It is an anterior mediastinal tumor with few symptoms. The pleura is the most frequent metastatic site. Surgery is the treatment of choice and the most important prognostic factors are the stage at initial presentation and whether complete resection can be performed. CASE REPORT: A 6-year-old girl with no pathological antecedent presented with a history of prolonged fever. Frontal chest radiography showed a large mediastinal soft tissue mass with sharp lateral and inferior margins. Computed tomography showed a large anterosuperior and medium mediastinal mass measuring 83 mm × 70 mm, associated with variable size mediastinal adenopathy, suggesting the diagnosis of lymphoma. Histological examination of bone marrow biopsy found no haematological malignant diseases such as lymphoma. The histological examination of computed tomography (CT)-guided transthoracic biopsy demonstrated proliferation of polyclonal lymphocyte T cells, confirming the diagnosis of thymoma. The patient benefited from induction chemotherapy (cisplatin and VP16) followed by surgery with complete resection. The patient is doing well 24 months after resection and has no signs of recurrence; CT follow-up showed a stable size of residual thymus. CONCLUSION: Thymoma is a benign tumor but the significant risk of recurrence warrants long follow-up.

[Hemorrhagic ascites revealing duodenal duplication]. / Une ascite hémorragique révélant une duplication duodénale.

Duodenal duplication is a rare congenital disorder of the gastrointestinal tract. The presentation is highly variable. We report a case of duodenal duplication presenting with hemorrhagic ascites in a 3-month-old girl. The diagnosis of duodenal duplication can be made preoperatively by resonance magnetic imaging. Surgical resection of the duplication was performed. Microscopic examination of the specimen confirmed the duodenal duplication. To our knowledge, this is the 1st reported case of hemorrhagic ascites caused by duodenal duplication and demonstrated by resonance magnetic imaging.

[Osteosynthesis using micro-plates in fractures of the orbital floor]. / Ostéosynthèse par micro-plaques dans les fractures du plancher de l'orbite.

The exploration of orbital floor in case of blow-out fractures shows frequently only one or two important fragments. This fact leads us to realize osteosyntheses with titanium micro-plates in this kind of fractures. This was done for ten patients by transconjunctival approach. This technic has provided good results, clinically and radiologically. The tolerance of titanium implant was excellent. Therefore, it is unnecessary to preleve bone for grafting or to use biomaterials. Micro-plates ablation is not necessary.