Involvement of the IL23/Th17 Pathway in the Pathogenesis of Tunisian Pemphigus Foliaceus.

Pemphigus foliaceus (PF) is a rare autoimmune skin disease caused by anti-Dsg1 pathogenic autoantibodies. It is considered as a Th2-mediated disease. Likewise, Th17 cells were recently described in the pathogenesis of the disease but their role is still unclear. We aimed to unravel the eventual implication of the IL23/Th17 pathway in the development of PF. A case-control study was conducted on 115 PF patients and 201 healthy controls using PCR-RFLP and AS-PCR methods. SNPs in IL23R, RORγt, IL17A, IL17F, IL17AR, TNFa, and STAT3 genes were genotyped. mRNA expression of IL23R and RORγt was evaluated using Q-PCR. The frequency of circulating Th17 cells was analyzed by flow cytometry. Genetic associations between IL23R>rs11209026, IL17A>rs3748067, IL17F>rs763780, and TNFa>rs1800629 and the susceptibility to PF were reported. Moreover, we revealed a significant increased frequency of circulating CD4+IL17+ cells as well as higher mRNA levels of RORγt and IL23R in PBMCs of patients. However, no significant increase of RORγt and IL23R mRNA expression was observed in lesional skin biopsies. In spite of the little size of specimens, our results provide converging arguments for the contribution of the IL23/Th17 pathway in the pathogenesis of PF.

Hydroxychloroquine-induced hyperpigmentation in systemic diseases: prevalence, clinical features and risk factors: a cross-sectional study of 41 cases.

Introduction Hydroxychloroquine is an antimalarial agent widely prescribed in internal medicine, rheumatology and dermatology. Its use can be complicated by various side effects including skin pigmentation. Objectives The aim of the study is to review epidemiological, clinical features and risk factors of hydroxychloroquine-induced pigmentation. Materials and methods We performed a cross-sectional study conducted over a period of 5 months. During this period, patients who had been treated with hydroxychloroquine for over 6 months, in the internal medicine department, underwent a complete dermatological examination. All patients completed a structured questionnaire to collect demographic data, dosage and treatment duration of hydroxychloroquine, other drug intake, hydroxychloroquine indication, and presence of pigmentary changes on the skin, nail, hair, and mucosa. Results A total of 41 patients (38 women and 3 men) were included in the study. The mean age was 39.2 ± 15.4 years. The hydroxychloroquine was indicated for systemic lupus erythematosus in 73.2%, dermatomyositis in 12.2%, rheumatoid arthritis in 9.8%, actinic lichen and sarcoidosis each in 2.4%. Cutaneous pigmented lesions were found in 21 cases (51%), mucous pigmentation in 5 cases (12%) and nail pigmentation in 1 case (2.5%). In 12 of 41 (29%) of the hydroxychloroquine users, we conclude a hydroxychloroquine-induced pigmentation. There were 11 women and one man with a mean age of 43 years and all of them were systemic lupus erythematosus patients. Pigmented lesions were located on the lower limbs in seven cases, the face in two cases, lips in two cases and the gum in two cases. Pigmentation appeared after a median duration of hydroxychloroquine treatment of 32 months with a median cumulative dose of 361 g. Overall, two patients reported that the appearance of pigmented lesions was preceded by the occurrence of ecchymotic areas following microtrauma. Significant association was found between hydroxychloroquine-induced pigmentation and treatment with oral anticoagulants and/or antiplatelet agents ( p = 0.03). Conclusion Our systematic examination of patients demonstrated that hydroxychloroquine-induced pigmentation is not rare. The imputability of hydroxychloroquine in the genesis of this discoloration is difficult to establish. Our study supports the hypothesis that ecchymosis, platelet antiaggregants and oral anticoagulants may be the main predisposing factors to hydroxychloroquine-induced pigmentation.

Molecular Identification of Malassezia Species in Patients with Malassezia folliculitis in Sfax, Tunisia.

AIM: Malassezia folliculitis is caused by the invasion of hair follicles by large numbers of Malassezia cells. Several Malassezia researches still use cultures, morphology and biochemical techniques. The aim of this study was to identify Malassezia species isolated from patients diagnosed with folliculitis, at the Parasitology and Mycology Laboratory of Sfax University Hospital, and to explore the genetic diversity of Malassezia by using PCR-RFLP and PCR-sequencing targeting the rDNA region of the Malassezia genome. PATIENTS AND METHODS: Specimens were taken from 27 patients with Malassezia folliculitis. For the molecular identification, PCR amplification of the 26S rDNAD1/D2 region was carried out using the Malup and Maldown primers and three restriction enzymes (BanI, MspI and HeaII) for RFLP analysis. The nucleotide sequences of each isolate were compared to those in the NCBI GenBank by using BLASTIN algorithm. RESULTS: Three species of Malassezia yeasts were identified among the 31 Malassezia strains isolated: M. globosa (83.9%), M. sympodialis (12. 9%) and M. furfur (3.2%). The sequence analysis of M. globosa showed six genotypes. CONCLUSION: There is a high genotypic variability of M. globosa colonizing patients with folliculitis.

Chromosomal instability associated with a novel BLM frameshift mutation (c.1980-1982delAA) in two unrelated Tunisian families with Bloom syndrome.

The Bloom syndrome (BS) is an autosomal recessive disorder associated with dwarfism, immunodeficiency, reduced fertility and cancer risk. BS cells show genomic instability, particularly an hyper exchange between the sister chromatids due to a defective processing of the DNA replication intermediates. It is caused by mutations in the BLM gene which encodes a member of the RecQ family of DExH box DNA helicases. In this study, we reported cytogenetic, BLM linkage and mutational analyses for two affected Tunisian families. The Cytogenetic parameters were performed by chromosomal aberration (CA) and sister chromatid exchange (SCE) assays and results showed a significant increase in mean frequency of CA and SCE in BS cells. BLM linkage performed by microsatellite genotyping revealed homozygous haplotypes for the BS patients, evidence of linkage to BLM gene. Mutational analysis by direct DNA sequencing revealed a novel frameshift mutation (c.1980-1982delAA) in exon 8 of BLM gene, resulting in a truncated protein (p.Lys662fsX5). The truncated protein could explain genomic instability and its related symptoms in the BS patients. The screening of this mutation is useful for BS diagnosis confirmation in Tunisian families.

Biomarkers of oxidative stress in epidermis of Tunisian pemphigus foliaceus patients.

BACKGROUND: Reactive oxygen species play a key role in the development of many dermatological disorders. OBJECTIVE: The purpose of this study is to examine the lipid peroxidation, protein oxidation and antioxidative profile in Tunisian pemphigus foliaceus (PF) patients. METHODS: Malondialdehyde (MDA), conjugated dienes (CD), protein thiol levels, catalase (CAT) and superoxide dismutase (SOD) activities were evaluated in skin biopsies of 13 patients compared to biopsies of 7 healthy controls. RESULTS: Oxidative stress was confirmed in these three types of patient biopsies as compared to controls. Thus, MDA, CD levels and catalase CAT and SOD activities were significantly increased in lesional, perilesional and normal biopsies of PF patients than in those of control subjects. Protein oxidative was confirmed by lower levels of protein thiols in lesional, perilesional and normal biopsies than in control's biopsies. Otherwise, in patients, a significant rise of these biomarkers was observed in lesional and perilesional biopsies compared with normal biopsies. CONCLUSION: This study shows that oxidative stress could be involved in the pathogenesis of PF by the spread of skin lesions and/or by the increase in auto-antibodies' reactivity.

[Disseminated juvenile xanthogranuloma expressing protein S100]. / Xanthogranulomes juvéniles disséminés exprimant la protéine S100.

BACKGROUND: Juvenile xanthogranuloma (JXG) is a form of self-healing non-Langerhans histiocytosis. We report a new case of disseminated JXG without visceral involvement but with positive immunostaining of the majority of histiocytes for protein S100. PATIENTS AND METHODS: A 6-month-old male infant was admitted to our department in January 2010 for congenital nodular lesions of varying size, shape and appearance. The remainder of the dermatological and physical examination was unremarkable. The diagnosis of disseminated JXG, strongly suggested clinically, was confirmed by a skin biopsy. However, immunohistochemistry was confusing, with positivity for protein S100. The lesions regressed spontaneously. DISCUSSION: The aim of this case report is to highlight the lack of any forced association between alarming skin lesions of eruptive JXG and systemic involvement. The distinguishing feature of our case is the positive immunostaining for protein S100 in the histological section, which although rare in XJG, does not cast doubt on the diagnosis of non-Langerhans histiocytosis providing the clinical presentation is typical. Therapeutic abstention is the rule.

[Prevalence of hepatitis G, B and C virus infections among positive HIV population in a Tunisian Hospital, La Rabta, Tunis]. / Prévalence de l'hépatite G et des hépatites virales B et C dans la population VIH (+) de l'hôpital La Rabta, Tunis, Tunisie.

OBJECTIVE: The viral hepatitis G and HIV coinfection has been largely treated in the litterature. The aim of this study was to evaluate the coinfection rate in our hospital and to compare the HGV frequency to other hepatitis viruses (B and C) in positive HIV subjects at the Rabta hospital in Tunis, Tunisia. PATIENTS AND METHODS: The studied population included 125 HIV positives patients from the infectious diseases unit. The detection of the hepatitis B and C was carried out using serologic test (Elisa-Biorad). The molecular detection of the HGV was realized by reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: The prevalence of serological markers of hepatitis B (antibodies and/or antigens) and C (antibodies) was respectively 32.25% and 26.4%. HGV RNA was detected in 36.8% of the studied population. The unprotected intercourse was the predominant risk factor of the HGV contamination. Among the HGV (+) patients, 28.2% were carriers of the hepatitis C antibodies (anti-HCV). CONCLUSION: This work was the first study enabling to assess the coinfection rate of viral hepatitis B, C and G with HIV patients (+) in Rabta Hospital. The regular screening of HGV is recommended regarding its high frequency and the possibility of its pathogenic role.

[Detection of the first strain of glycopeptide intermediary Staphylococcus aureus in Tunis Rabta hospital]. / Détection de la première souche de Staphylococcus aureus de sensibilité diminuée aux glycopeptides à l'hôpital la Rabta de Tunis.

Since the advent of the first glycopeptide intermediately susceptible Staphylococcus aureus (GISA) and its heterogeneous variant hGISA in 1997, debate still ensues as their clinical significance. We report here the first case of GISA in Rabta hospital of Tunisia. Antimicrobial resistance was determined by the disk diffusion method in accordance with CA-SFM (Comity of Antibiogramm of French society of Microbiology). The MIC of vancomycin and teicoplanin was determined by E-test. The detection of mec A gene, virulence factors genes and agr groups (1-4) was performed by multiplex PCR. spa types were determined with the assistance of Ridom of Staph Type software (Ridom GmbH, Wurburg, Germany). The allelic profiles of MRSA were assigned on the basis of their MLST type using the eBURST program. A MRSA bacteraemia patient was treated with teicoplanin for 14 days. S. aureus isolated from patient's blood culture was identified as MRSA and GISA with teicoplanin MIC of 16 mg/l. The molecular study of this strain showed that it belongs to the clonal complex CC8 and is attached to the iberian clone (agr1, enterotoxin A, ST 247, spa type t052). Clinicians and laboratories alike are increasingly aware that patients on long-term vancomycin therapy may signal the presence and potential spread of hGISA/GISA strains. hGISA/GISA strains emerged from lineages with agr types I and II. The multiresitance of the Iberian clone ST247 could be explained by the presence of several resistance genes.

Multiresistance and endemic status of acinetobacter baumannii associated with nosocomial infections in a tunisian hospital: a critical situation in the intensive care units.

Acinetobacter baumannii is often implicated in hospital outbreaks in Tunisia. It's a significant opportunistic pathogen associated with serious underlying diseases such as pneumoniae, meningitis and urinary tract infections. The aim of our study was to evaluate its degree of endemicity and its antibiotic resistance evolution essentially in the unit care where its isolation was predominant (57%). This study used 3 methods: antibiotyping, RAPD using 2 primers VIL 1, VIL5 and PFGE with ApaI restriction enzyme. The presence of integron1 and 2 was also studied. Antibiotyping showed that 92% of patients were resistant of all ß- lactams (except Imipenem) and that the resistance to Imipenem occurred in 47% of cases. RAPD profiles obtained with the 2 arbitrarily primers VIL1 and VIL5 gave respectively 5 and 4groups and PFGE fingerprinting patterns revealed 22 different pulsotypes. Integron 1 was present in 25% of unrelated strains and type 2 integron was not detected in any of the studied strains. Among 204 strains, multiple and heterogeneous groups were detected with the genomic studies. In addition, any correlation was obtained with the antibiotyping results. These findings demonstrate the endemic status of A. baumannii in our hospital and the persistence of a large number of multiresistant strains in the unit's care. When outbreaks of A. baumannii occur, it's essential to develop restricted hygiene procedures and a serious surveillance of critical units such as ICU for very ill patients.

Seroprevalence of Helicobacter pylori among Tunisian blood donors (outpatients), symptomatic patients and control subjects.

OBJECTIVES: Helicobacter pylori is a worldwide infection, although little data are available in the Tunisian population. The aims of our study were to detect the prevalence of H. pylori in a blood-donor population (n=250) and in another population of hospital-consulting patients comprising 87 symptomatic patients and 59 controls, and to determine the factors that influence the prevalence. MATERIALS AND METHODS: Study subjects answered a standardized questionnaire, and IgG anti-H. pylori and anti-cag were detected by ELISA. In the second population, culture and cagA polymerase chain reaction were performed. RESULTS: The seroprevalence of H. pylori in blood donors was 64%, and 11% had anti-cag. All patients positive for anti-cag were also positive for anti-H. pylori antibodies. The seroprevalence of H. pylori was 99.3% in the hospital-consulting patients, of whom 55.5% were positive for anti-cag. The difference between the anti-cag and symptomatic patients (66.7%) and controls (39%) was significant. Symptomatic patients had a higher rate of anti-cag (66.7%) compared with the controls (39%) and blood donors (11%). CONCLUSION: H. pylori seroprevalence in blood donors is low (64%) compared with symptomatic patients (99.3%), and anti-cag was statistically associated with symptomatic patients and pathology. Also, some environmental factors were correlated with H. pylori seroprevalence.

[Human demodicidosis in Sfax area (Tunisia)]. / La démodécidose humaine dans la région de Sfax (Tunisie).

Demodicidosis is an ectoparasitosis, common to humans and many mammals. It is caused by the proliferation of a mite Demodex sp in the pilosebaceous follicles. Its pathogenic role remains controversial. The aim of our study was to report epidemiological and clinical particularities of cases of demodicidosis diagnosed in our region. Over a period of nine years (January 2000 to December 2008), 427 cases of demodicidosis were diagnosed. 73.2% of cases were blepharitis and 26.8% of cases were facial dermatosis. The mean age was 44 years. Women were slightly more affected (56%) than men. Among 787 chronic blepharitis, 243 cases were due to Demodex sp (30.9%). They were treated with yellow oxide of mercury (Ophtergine® 1%). In the face, this mite has been isolated from erythematous and pruritic papulopustular lesions, and their distribution was as follows: cheeks (22.1%), forehead (13.4%), and nose (11.5%). The diagnosis was confirmed by parasitological examination of scales showing more than 5 Demodex sp/cm(2) and response to treatment with metronidazole (Flagyl®) for three months. Currently, there were a large number of arguments for the incrimination of Demodex sp in pathogenesis of dermatosis and blepharitis. Dermatologists and ophthalmologists must therefore think to this mite. The density of Demodex sp found by parasitological exam is a determining factor in establishing an anti-Demodex treatment whose effectiveness is a further argument for the diagnosis.

[A fatal case of dermatomycoses with retropharyngeal abscess]. / Un cas de maladie dermatophytique fatale par abcès rétropharyngé

BACKGROUND: Dermatophytic disease is a rare chronic infection caused by dermatophytes and characterised by cutaneous and visceral invasion. It is observed in North Africa. It is associated with cellular immunodeficiency and refractoriness to drug treatment. CASE REPORT: We report a new case of dermatophytic disease in a 26-year-old Tunisian woman. The patient's parents were first cousins; no other family members had a similar disease state. At the age of 3 years, the patient developed extensive tinea corporis associated with onychomycosis resistant to the usual antifungal drugs. The patient was hospitalised for multiple subcutaneous vegetative and ulcerative lesions of the scalp, face and chest associated with multiple adenopathies, occasionally fistular, of the axillary, cervical, mammary and inguinal areas. Mycology and histology confirmed the presence of fungal hyphae. Trichophyton violaceum was isolated in cultures of various skin lesion and lymph node biopsy samples. Investigations showed no evidence of immunodeficiency. Although the patient initially responded well to itraconazole (Sporanox, 400 mg/day), her condition worsened with obstruction and dyspnoea due to retropharyngeal pus collection requiring repeated surgical evacuation, and ultimately leading to a fatal outcome. DISCUSSION: Dermatophytic disease remains a severe disease due to the possibility of potentially life-threatening visceral involvement and antifungal drug resistance.

[Atypical cutaneous Fusarium infection in an immunocompetent patient]. / Fusariose cutanée atypique chez un sujet immunocompétent.

INTRODUCTION: Fusarium are filamentous saprophytic brown fungi found in soil, on plants and outdoors. Invasive, necrotic fusarial skin infections are rare and are found in immunodepressed subjects. We report a case in a woman with no discernible immune deficiency. PATIENTS AND METHODS: A 24-year-old woman in good general health, pregnant at 34 weeks amenorrhoea, consulted for ulcerating, budding lesions with a necrotic centre over her entire body, but mainly localised on the cheeks and four limbs. The diagnosis of fusariosis due to Fusarium oxysporum was made on the basis of direct examination and repeated skin biopsy culture. All investigations were normal, and in particular, the patient had no detectable immune deficiency. Treatment was extremely difficult. The patient received amphotericin B, then voriconazole and terbinafine, ketoconazole and finally liposomal amphotericin. DISCUSSION: In immunocompetent subjects, fusarial species generally colonise the corneal layers of the skin. Our case was special in terms of the clinical aspect of the pseudotumoural lesions with a necrotic centre in an immunocompetent woman and in terms of the difficulty in treating her.

[Appendicular cystadenocarcinoma with cutaneous fistula]. / Cystadénocarcinome appendiculaire fistulisé à la peau.

BACKGROUND: Cutaneous metastasis of colorectal cancer is rare. We report a case of fistular lesions of the buttocks revealing a mixed tumour of the appendix involving mucinous cystadenocarcinoma and carcinoid tumour. CASE REPORT: A 67-year-old woman was admitted for four skin fistulae of the right buttock present for 6 years. Histological examination of skin biopsy specimens identified infiltration of the dermis by metastatic mucinous adenocarcinoma while colonoscopy showed a caecal tumour measuring 4 cm. Surgical excision was performed involving right hemicolectomy, evacuation of retroperitoneal mucin collection and excision of fistulae. Histopathological examination of surgical specimen confirmed mixed tumour consisting of perforated mucinous cystadenocarcinoma and carcinoid tumour of the appendix. Recurrence of the fistular lesions was seen. The patient was hospitalized several times for surgical drainage of mucin. She died one year later. DISCUSSION: Cutaneous metastasis of colorectal cancer is an uncommon event that usually occurs after identification of the primary tumour and generally indicates advanced-stage disease and an ominous prognosis. This case is particular and underlines the need to rule out a metastatic origin of cutaneous fistulae, even in patients otherwise apparently in good health.