Epidemiological profile of eumycetomas in Rabat, Morocco, over 40 years.

Eumycetomas are chronic subcutaneous pseudo-tumoral infections, endemic in arid tropical areas, which are caused by exogenous fungi that produce grains in vivo. The objective of our work is to establish their epidemiological, clinical and mycological profile in our Moroccan context. Therefore, we conducted a retrospective study, extending from 1975 to 2019, compiling all cases of eumycetomas that were diagnosed in the parasitology-mycology laboratory of the Ibn Sina University Hospital of Rabat. The diagnosis, based on the swabbing of exudates and eventual grains or the study of biopsies, included the direct examination of 30% KOH mounts, the realization of appositions colored by May-Grünwald-Giemsa and the incubation on 3 Sabouraud media at 27° and 37°C. In 44 years, 12 cases of eumycetoma have been diagnosed, with a male to female ratio of 5:1 and a mean age of 44.8 years. The lesions, evolving from 1 to 30 years, were podal in 10 cases, popliteal and gluteal in one case each, with osteolysis in 3 patients. The collected grains were black in 9 cases, white in 2 others. Direct examination was unanimously positive, revealing entangled hyphae, whilst culture isolated Madurella sp. in 9 cases, Trichophyton rubrum, Acremonium sp. in one case each and remained sterile in the last case. The treatment was medical in 8 cases, medico-surgical in 3 others, with loss of sight of most patients.

Imported malaria: 54 cases diagnosed at the Ibn Sina Hospital Center in Rabat, Morocco.

Morocco does not record any indigenous malaria case since 2004 and is certified by the World Health Organization as malaria-free since 2010. However, the country continues to record a significant number of imported malaria cases from endemic areas, especially from West Africa. The purpose of our work is to determine the epidemiological and diagnostic characteristics of malaria cases diagnosed at Ibn Sina Hospital Center in Rabat, Morocco. This work is a retrospective study of a series of malaria cases diagnosed between January 2012 and December 2016 at the Central Laboratory of Parasitology and Mycology of Ibn Sina Hospital Center. The methods used for the parasitological diagnosis are the search for the parasite at direct examination on thin blood film and thick drop and the search for parasite antigens by a rapid diagnostic immunochromatographic test (OptiMAL-IT® kit). Of 192 patients in whom malaria was sought, we recorded 54 positive cases (average of 10.8 cases per year). The prevalence was 28.12%. The age ranged from 4 to 76 years (average of 29.5 years). The sex ratio was 2.6. All cases had in their antecedents a notion of recent travel in an endemic area. The most common travel area was West Africa: Ivory Coast, with 31.43% of cases, followed by Guinea, with 14.29% of cases. The symptomatology was dominated by fever in 52 patients (96.3% of cases), followed by headache in 22 cases (40.74%). Anemia was present in 7 and thrombocytopenia in 12 patients. The most isolated species was Plasmodium falciparum (84.21% of cases), followed by P. vivax (10.53% of cases) and P. ovale (5.26% of cases). One case involved two species: P. falciparum and P. vivax. Parasitaemia was between less than 0.1 and 20%. Despite the local eradication of malaria, the persistence of imported cases, mainly due to the lack of chemoprophylaxis, should call for the strengthening of health education of travelers, especially in endemic areas.

[Multiple facial nodules revealing disseminated cryptococcosis in an immunocompetent patient]. / Nodules multiples du visage révélant une cryptococcose disséminée chez un patient immunocompétent.

BACKGROUND: Cryptococcosis is a potentially severe infection that usually occurs in a setting of immunosuppression. Its occurrence outside of this context is rare. We report a case of disseminated cryptococcosis revealed by a spectacular skin disease in an immunocompetent patient. PATIENTS AND METHODS: A 40-year-old male patient had been presenting multiple nodules and tumors on his face for one month in a context of asthenia and intermittent fever. Histological examination of a skin biopsy revealed encapsulated yeasts strongly suggestive of Cryptococcus neoformans. Mycological examination of the skin biopsy and cerebrospinal fluid isolated Cryptococcus gattii. The blood cultures were positive. Brain MRI demonstrated cryptococcal parenchymal involvement. Screening for primary or secondary immunodeficiency was negative. The patient received amphotericin B 1mg/kg/day and fluconazole 600mg/day but died 2months after diagnosis. DISCUSSION: Cryptococcosis is a potentially severe infection caused by C. neoformans. This rare condition occurs most commonly in patients with profound deficiency in terms of cellular immunity. Although rare, the occurrence of cryptococcosis in immunocompetent patients is possible, and in this event the signs are highly polymorphic, which usually makes it very difficult to diagnose. The diagnosis of cryptococcosis is based on the identification by direct examination and after staining with India ink of encapsulated yeasts of the Cryptococcus genus. Culture on Sabouraud medium is essential for identification of the species. Treatment for disseminated cryptococcosis involves amphotericin B, often associated with flucytosine IV. In the event of meningitis infection in non-HIV patients, mortality continues to be around 15%, despite adequate medical treatment. CONCLUSION: Although rare, cryptococcosis can occur in immunocompetent subjects. The prognosis is severe even after treatment.

[Urinary infection by Saccharomyces cerevisiae: Emerging yeast?]. / Infection urinaire à Saccharomyces cerevisiae : levure émergente ?

Saccharomyces cerevisiae is a commensal yeast of the digestive, respiratory and genito-urinary tract. It is widely used as a probiotic for the treatment of post-antibiotic diarrhea. It most often occurs in immunocompromised patients frequently causing fungemia. We report the case of an adult diabetic patient who had a urinary tract infection due to S. cerevisiae. The disease started with urination associated with urinary frequency burns without fever. The diagnosis was established by the presence of yeasts on direct examination and positivity of culture on Sabouraud-chloramphenicol three times. The auxanogramme gallery (Auxacolor BioRad(®)) allowed the identification of S. cerevisiae. The patient was put on fluconazole with good outcome. This observation points out that this is an opportunistic yeast in immunocompromised patients.

[Disseminated cryptococcosis in an immunocompetent patient]. / Cryptococcose disséminée chez un patient immunocompétent.

Disseminated cryptococcosis is a serious opportunistic fungal infection caused by a yeast-encapsulated fungus of the genus Cryptococcus neoformans. It occurs most often in patients with a significant deficit of cellular immunity and preferentially affects the central nervous system. The skin and the lungs are the most commonly affected sites outside the neuro-subarachnoid location. We report the case of a patient apparently immunocompetent who had a disseminated cryptococcosis. The disease started with the multiple purplish skin lesions, large umbilicated on the face, groin, forearm and leg with progressively increasing volume. This symptomatology had evolved in the context of weight loss and poor general condition. The diagnosis was established by the presence of cryptococcal at the skin biopsy and cerebrospinal fluid. Research of immunosuppression common pathologies were negative. Treatment was initiated based on amphotericin B for 40 days. The patient's condition deteriorates onset of paraplegia and swallowing disorders causing death in an array of cachexia. This observation points out that disseminated cryptococcosis can occur in an immunocompetent patient. The skin lesions may be the first sign of the disease.

[Intestinal cryptococcosis: an unusual presentation of disseminated cryptococcosis]. / Cryptococcose digestive: une présentation inhabituelle de cryptococcose disséminée.

Cryptococcosis is a serious infection caused by an encapsulated yeast-like fungus, Cryptococcus neoformans. It is pathogenic most often in the lungs and central nervous system of immunocompromised patients. In this work we report an unusual localization of cryptococcosis in an HIV-infected patient. This rare localization was diagnosed from a stool sample sent to our laboratory for parasitological study. Direct examination of fresh stool showed the presence of many large, rounded thick-walled fungi. India ink staining of the stool showed encapsulated cryptococci, and C. neoformans was isolated by culture. Despite flucanazole treatment, the patient died.

[The mould onychomycosis in Morocco: about 150 isolated cases in 20 years]. / Les onychomycoses à moisissure au Maroc: à propos de 150 cas isolés en 20 ans.

INTRODUCTION: the involvement of moulds in the fungal ungueal pathology is very variable. In fact a big confusion reigns because of numerous errors in the clinico-biological diagnosis, which could be responsible for therapeutic failure of onychomycosis. AIMS OF STUDY: The aim of this study was to evaluate the relative frequency of moulds involved in onychomycosis over a period of 20 years. PATIENTS AND METHODS: This is a retrospective study, conducted at the laboratory of parasitology-mycology of the Ibn Sina hospital over a period of 20 years. The patients were referred by dermatologists or general practitioners for suspected onychomycosis. The samples were studied according to good rules for performing mycological analysis. RESULTS: One hundred and fifty cases of onychomycosis were diagnosed with mould, with global prevalency of 2.78%. They mainly concern the toes (95%) with a slight female predominance (60%). The total dystrophy of the nail was the predominant clinical representation (88.3%). Moulds isolated were Aspergillus spp. in 53 cases (35.3%) and Fusarium spp. in 45 cases (30%), 19 cases (12.7%) of Scopulariopsis brevicaulis, 17 cases (11.3%) of Penicillium spp., 14 cases (9.3%) of Acremonium spp., one case of Onychocola canadensis (0.7%) and one case of Scytalidium dimitiatum (0.7%). CONCLUSION: A significant number of onychomycosis remains attributed to moulds, which highlights the contribution of the laboratory, which remains essential for the clinician to confirm the involvement of mould in onychomycosis, which allows taking into support early treatment avoiding the emergence of aesthetic complications.

[Tinea capitis etiology in Ibn Sina Hospital in Rabat (Morocco)]. / Profil étiologique des teignes du cuir chevelu à l'hôpital Ibn Sina de Rabat (Maroc).

Tinea capitis (TC) is a contagious infection that affects mainly children and teenagers. A retrospective study was realized at the mycology-parasitology department of the Ibn Sina hospital in Rabat, Morocco. The study includes 125 cases of TC. The mean age is 12.73 ± 11.61 year. The isolation of TC is dominated by two species Trichophyton violaceum 76 (60.8%) and Microsporum canis 27 (21.6%). Trichophyton verrucosum was isolated only in male and all of rural origin. In adults over 18 years, the most isolated species is T. violaceum (six cases) in females. For the last thirty years, the epidemiological profile of TC remains almost the same in Morocco.

Entomological investigations in the region of the last malaria focus in Morocco.

To evaluate the risk of malaria transmission resumption in Morocco, we have studied the current level of receptivity of the region of the last malaria focus in the country. Anopheles (Anopheles) maculipennis labranchiae and Anopheles (Cellia) sergentii, the major vectors of malaria in Morocco, are still presents but their anthropopathic index was low and no parasite positive samples were detected. An. labranchiae was very rare; only 34 females were caught over all the study period. The human biting rate was nil and none of its blood meal was human. An. sergenti was more abundant but its low human aggressiveness and its zoophilic behaviour would not attribute to this species an important vectorial capacity. Thus, the receptivity of Chefchaouen province, the region of the last malaria focus in Morocco, under the current vector control measures undertaken by Public Health services, is low and despite the likely presence of Plasmodium vivax gametocyte carriers, the malariogenic potential appears to be low and the risk of malaria resumption is, at this time, unimportant.

[Resistance of Anopheles labranchiae to DDT in Morocco: identification of the mechanisms and choice of replacement insecticide]. / Résistance d'Anopheles labranchiae au DDT au Maroc: identification des mécanismes et choix d'un insecticide de remplacement.

A study of Anopheles labranchiae resistance in Morocco was conducted in the provinces of Kénitra, Khouribga, Larache, Khémisset and Salé during 2005. An. labranchiae was susceptible to propoxur, fenitrothion and permethrin and resistant to varying degrees to DDT. Genetically there was no change to the target site common to DDT and pyrethroids, the voltage gated sodium channel. The resistance seemed to be due to detoxification mechanisms specific to DDT. In principle, there should be no obstacle to the substitution of DDT by pyrethroids in Morocco. Resistance can then be detected and supervised by more reliable molecular tools in the Laboratory of Medical Entomology of the National Institute of Hygiene.

[Resistance of Anopheles labranchiae to DDT in Morocco: identification of the mechanisms and choice of replacement insecticide]

A study of Anopheles labranchiae resistance in Morocco was conducted in the provinces of K‚nitra, Khouribga, Larache, Kh‚misset and Sal‚ during 2005. An. labranchiae was susceptible to propoxur, fenitrothion and permethrin and resistant to varying degrees to DDT. Genetically there was no change to the target site common to DDT and pyrethroids, the voltage gated sodium channel. The resistance seemed to be due to detoxification mechanisms specific to DDT. In principle, there should be no obstacle to the substitution of DDT by pyrethroids in Morocco. Resistance can then be detected and supervised by more reliable molecular tools in the Laboratory of Medical Entomology of the National Institute of Hygiene

[Seroprevalence of toxoplasmosis in pregnant women in Rabat, Morocco]. / Séroprévalence de la toxoplasmose chez la femme enceinte dans la ville de Rabat au Maroc.

In Morocco, the seroprevalence of toxoplasmosis in pregnant women living in Rabat, was estimated by analyzing antibodies (IgG, IgM) levels using an ELISA test. The analysis of 2456 serums at the Institut National d'Hygiène showed that the seroprevalence of toxoplasmosis is about 50.6%. According to the questionnaire, the lack of knowledge about this disease and soil contact could be the main causes of toxoplasmosis infection. The use of IgG avidity test has excluded a recent infection in 93.5% of pregnant women with IgM positive sera.

[The gonotrophic cycle of Culex pipiens (Diptera: Culicidae), West Nile virus potential vector, in Morocco: evaluation of its duration in laboratory]. / Cycle gonotrophique de Culex pipiens (Diptera: culicidae), vecteur potentiel du virus West Nile, au Maroc: estimation de la durée en laboratoire.

Culex pipiens gonotrophic cycle has been studied, for the first time in Morocco, under experimental conditions. Its average duration was estimated at 5.54 +/- 1.73 days.

Cystic echinococcosis in the Berber of the Mid Atlas mountains, Morocco: new insights into the natural history of the disease in humans.

Precise knowledge of the natural history of cystic echinococcosis (CE) in humans remains somewhat arcane. The aim of the present study was to determine whether aspects of the natural history of established human infection with Echinococcus granulosus could be investigated by using a cross-sectional approach, in a community where CE was endemic. A mass ultrasound-screening survey, coupled with a questionnaire to record all previous surgical histories related to CE, was carried out amongst the primarily transhumant Berber people of the Mid Atlas mountains in Morocco. During two periods of intensive screening, of 10 days in May 2000 and 11 days in May 2001, 11,612 people, representing > 98% of the local population, were checked. One hundred and twenty six (1.1%) of the subjects--75 (59.5%) of the 6864 females investigated and 51 (40.5%) of the 4748 males--were found ultrasound-positive for CE. Overall, 14.1% of the CE cases detected were children aged 1-15 years (who made up 44% of the study population). Most (77.4%) of the ultrasound-positive subjects investigated were also found seropositive for CE. The frequency of a past history of surgery for CE increased with subject age (P = 0.024), 125 (1.1%) of the subjects being recorded as having had such surgery. The frequency of surgery for pulmonary CE was relatively constant in all age-groups, indicating that infection can occur at any time. The frequency of abdominal CE increased with age (R2 = 0.8102). Assuming that the incidence of infection remains fairly constant over time and that the longer a person spends in this endemic area the more likely it is that he or she will develop CE, then a progression from active through transitional to inactive CE should occur. The cysts observed by ultrasound in the present study were categorized, as type 1, 2, 3, 4 or 5, according to the new, standardized, ultrasound classification of CE developed by the World Health Organization (WHO). There was a clear exponential decline in the frequency of the various cyst types, from type 1 (the most frequent) to type 5 (the rarest). This decline validates the assumptions made, about the natural history of established CE, by those who developed the WHO's classification. The classification should therefore be invaluable to surgeons and clinicians, when they have to consider treatment options for patients with the various types of CE, and to policy makers trying to establish the economic costs of treating CE in endemic settings.

Leishmaniasis due to Leishmania tropica MON-102 in a new Moroccan focus.

In Morocco, between March and April 2002, large numbers of human leihsmaniasis cases were detected during a survey at Zouagha My Yacoub province in Fès State. Among 95 cases, 76 were positive by direct observation of Giemsa-stained smears. Sixteen stocks were isolated in NNN medium and identified as Leishmania tropica MON-102, using isoenzyme techniques on starch gel electrophoresis.

[Note on Anopheles maculipennis complex in Morocco]. / Note sur le complexe Anopheles maculipennis au Maroc.

Anopheles belonging to Anopheles maculipennis complex, collected from February to June 2002 in eight provinces of Morocco (Khouribga, Taounate, Alhouceima, Chefchaouen, Fes, Khemisset, Kalaa Sraghna and Benslimane), were identified with characterization of the ribosomal DNA by PCR and ITS2 sequence analysis. The results of this study showed that all the identified specimens belong to the Anopheles labranchiae species.

Public health education/importance and experience from the field. Educational impact of community-based ultrasound screening surveys.

The public health educational impact of community-based ultrasound (US) surveys for cystic echinococcosis (CE) can form an important part of the development about the awareness of the importance of the disease in an endemic area. In addition to identifying asymptomatic carriers and thereby facilitating early diagnosis and treatment, such surveys can be used to impart important educational messages at the individual, household, community, regional and national levels. US surveys are usually appealing to rural communities where such services are not available but where the technique is generally appreciated by its application in a wide field of medical applications. The qualities of the test (painless, non-invasive and gives instant recordable results) are also attractive to participants during such surveys and the majority of the population in a selected study area choose to be screened. Two such surveys were carried out amongst the Berber people of the mid-Atlas mountains in central Morocco in May 2000 and 2001. Over 11,000 people were screened in the two 10-day surveys. Informed consent had been obtained through community meetings and with the chiefs of villages prior to the surveys being conducted. Individuals who volunteered to be screened entered the study and as far as is known there were no refusals. The concept of voluntary participation, the explanation of the life cycle and clinical manifestations of the disease and its prevention are all-important educational messages. The occurrence of CE is almost always known in an endemic community but is usually very poorly understood leading in many cases to a fear of the disease, especially amongst families with an infected individual who has previously undergone surgery. During the US survey considerable attention was paid to provide educational input before, during and after the survey. Information was provided at the start of the survey to local leaders, doctors, veterinarians and school teachers on the aims of the study and to obtain informed consent. At the start of the study everyone was individually schooled about the route of transmission of the parasite and how this may be best prevented. The knowledge level of those screened was assessed by showing hydatid cysts, either freshly obtained from the abattoir of from photographs. Animal cysts were recognised by almost everyone but its transmission and link to human disease was invariably unknown. Patients found to be infected with CE were always confidentially counselled and followed up for treatment, if required. Treatment options were explained to the individual or to parents in the case of a child. Local physicians participated in discussions on the WHO guidelines for the treatment of CE and all cases were fully discussed providing an educational element for the local doctors. The 1% US prevalence found sent an important message to the local politicians and the perceived importance of the disease had an impact at the leadership level. Local leaders made calls for a control programme. The long term educational impact remains to be evaluated as does the role such surveys play in the future collaboration of communities with the implementation of a control programme.