[Prevalence and role of IgG anti-Chlamydia trachomatis in a population of infertile men in Morocco]. / Prévalence et rôle des IgG anti-Chlamydia trachomatis chez une population d'hommes infertiles au Maroc.

INTRODUCTION: Infertility is a global public health problem that affects 15% of couples of childbearing age. Male infertility is involved in 20 to 50% of cases. These figures are sharply increasing around the world. Several factors may be responsible for this infertility with especially hormonal, genetic, toxic or infectious factors. The latter are dominated mainly by Chlamydia infection. Among the most serious complications of this infection are infertility related to urethritis, epididymitis and irreversible total azoospermia in men and tubal obstructions and ectopic pregnancies in women. STUDY OBJECTIVE: To determine the prevalence of IgG anti-Chlamydia trachomatis in men consulting for infertility and the association between previous contact with this bacterium and the impairment of sperm quality and sperm function. MATERIAL AND METHODS: Prospective study over 26months of 143 patients referred to the service for infertility assessment of the couple. Demographic data, primary or secondary character of infertility, risk factors (tobacco, inguinal hernia, varicocele and history of urogenital infections), semen parameters (volume, mobility, pH, vitality and morphological abnormalities) were studied as well as the determination of the anti-C. trachomatis IgG titer. The prevalence of Chlamydia infection and the association of the infection and alteration of the various parameters of the semen were analyzed. RESULTS: The average age of patients was 38.5±8.55. Infertility was primary in 72% of patients. Among the patients, 54.5% had an abnormal spermogram. Chlamydia IgG antibodies were positive in 37.1% of patients whose 58.5% had abnormal spermogram. Analysis of sperm parameters of patients with and without IgG C. trachomatis showed an altered vitality in Chlamydia positive patients with an OR at 2.41, P=0.02, (95% CI: 1.15-5.06). CONCLUSION: The prevalence of Chlamydia infection is high in infertile male. C. trachomatis IgG antibodies may be associated with an alteration of spermatozoa vitality without significant impairment of other semen parameters. LEVEL OF EVIDENCE: 3.

Successful treatment of refractory adult onset Still's disease with rituximab.

Adult-onset Still's disease (AOSD) is an uncommon inflammatory condition of unknown origin. In chronic disease, joint involvement is often predominant and erosions are noted in one third of patients. Therapeutic strategies derive from observational data. Corticosteroids are usually the first-line treatment. With inadequate response to corticosteroids, methotrexate appears the best choice to control disease activity and allow for tapering of steroid use. For refractory disease, biological therapy seems the most promising. We report here the case of a 38-year-old female patient with AOSD refractory to cytotoxic agents, treated by rituximab infusion therapy with favorable outcome.

Inflammatory optic neuropathy in Behçet's disease.

Inflammatory optic neuropathy (ON) is a rare event in Behçet's disease (BD). We report herein a series of ten BD Tunisian patients with ON and describe its clinical features among them. A retrospective review of BD patients (International Study Group for BD criteria) was performed. The patients were divided into two groups: those presenting an inflammatory ON, and those none. The diagnosis of inflammatory ON was based on the clinical examination, visual field and visual evoked potentials. We analyzed the characteristics of the two groups. Ten patients (2.3%) presented an inflammatory ON among our 440 patients. Inflammatory ON was inaugural in 8 cases. Clinical manifestations were as follows: blurred vision (7 cases) and periorbital pain (3 cases). In two cases, the patients did not complain from ophthalmological symptoms. The fundus revealed a papilledema (2 cases), papillary pallor (4 cases), and was normal in 5 cases. Visual field realized in only three patients showed a scotoma in all cases. Visual evoked potentials revealed increased latency in all cases. All patients received corticosteroids associated to an immunosuppressive agent. The comparative study between the two groups revealed that inflammatory ON was significantly more associated to neurological involvement (p<0.0001) and that the disease was more severe in the ON group (p<0.0001). Inflammatory ON in BD is rare and may occur at an early stage of the clinical course of the disease. Its prevalence is certainly underestimated. A systematic visual evoked potential may be interesting as a screening tool.

[Smoking prevalence in A Mami hospital of Ariana: prospective study about 700 health professionals]. / Prévalence du tabagisme à l'hôpital A Mami de l'Ariana : Etude prospective à propos de 700 professionnels de la santé.

BACKGROUND: smoking is one of the most serious threats to public health worldwide. Health structures are the cornerstone of each program against smoking , or some studies have shown a prevalence of smoking as high in hospitals than in the general population. Aim : To assess the prevalence of smoking, smoking behavior and attitudes of health professionals towards smoking within the A Mami Ariana Hospital METHODS: This is a cross-sectional survey conducted among 700 health professionals (doctors, nurses, workers, technicians and administrative staff) in the first quarter of 2010, based on a detailed questionnaire containing 15 closed-end items. RESULTS: The average age was 37 years and the sex ratio 0,5. Response rate to questionnaire was 81,4% and overall smoking prevalence 24,8%, five times higher in men (52,5% vs 9,8% p< 0,001). Smoking was greater among workers, night health professionals employees and employees of technical services, administration and intensive care services and only 13% among doctors. 50% of the surveyed have already tried at least once to quit, twice as many women than men. Former smokers accounted for 5,5% of all health professionals. CONCLUSION: Although our hospital has been declared non-smoking area since 2009, 75% of professionals continue to smoke at the scene of their work. Strengthening of existing measures against smoking as smoking bans in the hospital, and improving training of health professionals on the dangers of smoking and ways of weaning are needed now.

[Lung manifestations of sickle-cell disease]. / Manifestations respiratoires de la drépanocytose.

Sickle-cell disease is an autosomal recessive genetic disorder of hemoglobin that causes systemic damage. Hypoxia is the main actor of sickle-cell disease. It initiates acutely the pathogenic cascade leading to tissue damages that in turn induce chronic hypoxia. Lung lesions represent the major risk of morbidity and mortality. Management of sickle-cell disease requires a tight collaboration between hematologists, intensivists and chest physicians. Recurrent episodes of thrombosis and hemolysis characterize the disease. New therapeutic protocols, associating hydroxyurea, transfusion program and stem cell transplantation in severe cases allow a prolonged survival until the fifth decade. However, recurrent pain, crisis, frequent hospital admissions due to infection, anemia or acute chest syndrome and chronic complications leading to organ deficiencies degrade the patients' quality of life. In low-income countries where the majority of sickle-cell patients are living, the disease is still associated with a high mortality in childhood. This paper focuses on acute chest syndrome and chronic lung manifestations.

Chest pain in patients with undiagnosed Behçet's disease.

Behçet's disease (BD) is a systemic inflammatory disease having a chronic and prolonged course with 4 major symptoms: oral and genital ulcerations, eye disease and cutaneous manifestations, as well as other multisystem involvements. Arterial involvement is a comparatively rare complication in BD and coronary lesions are extremely rare. We report here two cases of BD presenting as myocardial infarction (MI) with coronary artery aneurysm (CAA), with good improvement after immunosuppressive therapy.

[A case of pulmonary arteriovenous malformation treated surgically]. / Bisegmentectomie pour une malformation artérioveineuse pulmonaire.

Pulmonary arteriovenous malformation is a rare abnormality consisting of a direct connection between the arteries and the pulmonary veins. Most of the malformations are related to hereditary hemorrhagic telangiectasia, although 10 to 20% cases are idiopathic. Clinical manifestations are due to right-to-left shunting. Embolization is the treatment of choice, when it is possible and accessible. Surgery continues to be appropriate in certain cases. We report the case of a woman who presented with an isolated complex arteriovenous malformation fed by two afferent arteries, a lingular one and an antero-basal one. Surgical treatment by lingual and antero-basal bisegmentectomy was undertaken with a good outcome.

[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]. / Prise en charge diagnostique et thérapeutique des tumeurs carcinoïdes broncho-pulmonaires opérables.

INTRODUCTION: Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified. METHODS: Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period. RESULTS: Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years. CONCLUSION: The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

[Woman's asthma throughout life: Towards a personalized management?] / Asthme de la femme au fil du temps : vers une prise en charge personnalisée ?

In a woman's life, asthma can affect her in a variety of ways, with the onset of premenstrual asthma currently under-diagnosed. It is estimated that about 20% of women with asthma have premenstrual asthma, which is more common in patients with severe asthma. Women with asthma are at high risk of exacerbations and of severe asthma. Asthma is the most common chronic disease during pregnancy with potential maternal and foetal complications. Asthma medications are safe for the foetus and it is essential to continue pre-existing treatment and adapt it to the progress of asthma during the pregnancy. Sex steroids modulate the structure and function of bronchial and immune cells. Understanding their role in asthma pathogenesis is complicated by the ambivalent effects of bronchodilating and pro-inflammatory oestrogens as well as the diversity of response to their association with progesterone. Menopausal asthma is a clinical entity and is part of one of the phenotypes of severe non-allergic and low steroid-sensitive asthma. Targeted assessment of the domestic and professional environment allows optimization of asthma management.

Elevated levels of MMP-9 and TIMP-1 in the cerebrospinal fluid of neuro-Behçet's disease.

Matrix metalloproteinases (MMP-) are involved in leukocyte invasion into the central nervous system (CNS) during inflammation. In a retrospective cohort study of 18 neuro-BD patients, CSF samples were studied for MMP-9, TIMP-1 and cell characteristics in neuro-BD patients compared to 12 Headache attributed to BD (HaBD) patients, 15 multiple sclerosis (MS) and 20 Non-inflammatory Neurological Disease (NIND) patients. Concentrations of MMP-9 and TIMP-1 were measured in CSF by using an enzyme-linked immunosorbent assay (ELISA). The MMP-9/TIMP-1 ratio was significantly increased in neuro-BD group (mean +/- SD: 0.145+/-0.045) compared to (HaBD) (0.065+/-0.029; p=0.0001) and NIND patients (0.070+/-0.031; p=0.0001). No significant differences were observed between neuro-BD and MS patients. A significant correlation was observed between CSF-PMN cells and MMP-9 in neuro-BD patients (r=0.714; p=0.0009), indicating probably that PMN cells were in part the source of MMP-9. A significantly positive correlation was also observed between MMP-9 and CSF-mononuclear cells in neuro-BD patients (r=0.623; p=0.0012). This is the first study to evaluate the expression of matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase-1 in cerebrospinal fluid of neuro-BD patients. It demonstrates increased matrix metalloproteinase-9/tissue inhibitors of metalloproteinase-1 ratio. The results suggested that MMPs released in the CSF may be involved in the pathogenesis of neuro-BD by promoting local damage, similarly as suspected in other inflammatory diseases.

A polymorphism in the CCL2 chemokine gene is associated with asthma risk: a case-control and a family study in Tunisia.

Asthma is a complex genetic disorder characterized by chronic airway inflammation. We hypothesized that genetic polymorphisms in chemokines and their receptors alter leukocyte mobilization and may thus influence the risk and severity of childhood asthma. Distributions of the chemokine CCL2-2578G, CCL2-927C, CCR2-V64I, CX3CR1-V249I and CX3CR1-T280M receptor polymorphisms were examined in a case-control study of 121 children with asthma and 226 age-matched healthy controls and then replicated in a family study of 99 simplex families (297 individuals). The case-control study revealed that the CCL2-2578G allele was less frequent in children with than in those without asthma (P=0.0012). No association with asthma was found for the CCL2-927, CCR2 or CX3CR1 polymorphisms. The finding in the family study that the CCL2-2578G allele was transmitted less often by heterozygous parents to their children with asthma (P=0.0016) confirms the association of CCL2-2578G with asthma risk. Biochemical studies indicated that plasma CCL2 concentrations were higher in both patients (P=0.0214) and controls (P=0.001) carrying the G allele than in subjects with other polymorphisms. Both case-control and family-based studies suggest a protective effect of allele CCL2-2578G in Tunisian asthmatic children.

Vascular endothelial growth factor gene polymorphisms and serum levels in Behçet's disease.

Vascular endothelial growth factor (VEGF) is important for angiogenesis and inflammation, both of which are codependent and contribute to the pathophysiology of Behçet's disease (BD). In this report, we sought to investigate whether the selected VEGF polymorphisms [-634 C/G, +936 C/T and an 18 bp insertion/deletion (I/D) at -2549 of the VEGF promoter region] are associated with susceptibility and severity of BD in the Tunisian population. One hundred and thirty-five Tunisian BD patients and 157 healthy controls were recruited. The VEGF gene was genotyped by polymerase chain reaction followed by digestion with restriction endonucleases. VEGF serum levels of BD patients and healthy controls were measured by enzyme-linked immunosorbent assay. We found no association between the VEGF polymorphisms and the susceptibility to BD. However, when data were analysed according to the presence of each symptom, we found a positive association between VEGF 18 bp I/D polymorphism and ocular involvement as well as BD severity. Indeed, among the BD patients, the frequency of the 18 bp I/I genotype was less in patients with ocular inflammation (6.1% vs 24.6%, P = 0.007) and in patients with severe BD (9.2% vs 21.4%, P = 0.0014). Moreover, the mean serum VEGF level was considerably higher in BD patients (P < 0.01) than in healthy controls. We suggest that VEGF gene polymorphisms may be involved in the development of the ocular BD as well as the severity of the disease.

Serum BAFF levels and skin mRNA expression in patients with Behçet's disease.

OBJECTIVE: Serum levels of the B-cell activating factor in the tumor necrosis factor family (BAFF), a potent contributor to B-cell survival, are elevated in patients with systemic autoimmune diseases. The objective of this study was to determine serum BAFF levels and to link the results to the clinical features in patients with skin manifestations. METHODS: Serum BAFF levels were examined by an enzyme-linked immunosorbent assay (ELISA) in 42 patients with BD (16 with active disease), 20 healthy controls, and in 20 patients with systemic lupus erythematosus (SLE) and 15 patients with multiple sclerosis (MS), who served as the disease control groups. Expression of BAFF messenger RNA (mRNA) in the skin was quantified by a real-time reverse transcription-polymerase chain reaction; the expression of BAFF receptor (BAFF-R) on CD19+ B cells was assessed by flow cytometry; and ELISA was used to evaluate the production of IgG, interleukin-6 (IL-6) and IL-10 by isolated B cells. RESULTS: Serum BAFF levels were elevated in patients with active BD compared to the healthy controls, and correlated positively with the extent of skin lesions. Disease remission was accompanied by decreased BAFF levels. SLE patients had the highest serum BAFF levels. Skin biopsies showed BAFF mRNA expression to be up-regulated in active BD patients. BAFF-R expression on B cells was increased in BD patients with vasculitis. Furthermore, in BD patients the ability to produce IgG and IL-6 (but not IL-10) was enhanced in BAFF-stimulated B lymphocytes. CONCLUSION: These results suggest that BAFF and its signalling in B cells contribute to B cell abnormalities and the development of skin disease in patients with BD.

Promoter polymorphism of the IL-18 gene is associated with atopic asthma in Tunisian children.

Several lines of evidence point to a relevant role of IL-18 in the process of asthma. Some studies suggest that the polymorphism in the gene of IL-18 can be involved in many inflammatory and atopic diseases such as asthma. The aim of our study is to estimate the frequency of the IL-18-607 C/A (rs 1946518) promoter polymorphism in Tunisian children with asthma. We investigated whether the presence of this polymorphism -607 C/A was associated with asthma or atopy and whether this polymorphism influenced the severity of asthma in affected children. We examined also the relationship between the IL-18 gene polymorphism and the serum total IgE level. The IL-18/-607 C/A polymorphism was analysed by polymerase chain reaction and restriction fragment-length polymorphism (PCR-RFLP) analysis. A total of 105 asthma patients and 112 controls as part of the whole children population were studied in a case-control study. Among the 105 children with asthma, 40 were also studied for linkage analyses with their respective parents. We noted that the A allele was associated with statistically significant increases in the risk of asthma in the case-control study (odd ratio (OR) = 1.55, 95% confidence interval (CI) 1.03-2.33. Moreover, the A allele was also associated with atopic asthma (P = 0.008), but not with asthma severity. The transmission disequilibrium test (TDT) analysis in this family study did not suggest a preferential transmission of the IL-18/ -607 C/A polymorphism to affected children. There is no correlation between the IgE level and the IL-18 -607 C/A promoter polymorphism. Our data indicate that IL-18 -607 C/A promoter polymorphism is associated with susceptibility to developing asthma in Tunisian population.

[Atypical presentation of Wegener disease in childhood]. / Présentation atypique de la maladie de Wegener de l'enfant.

The pediatric forms of Wegener granulomatosis (WG) are rare. The clinical picture and the profile have specificities compared to those of adults. We report a case of a girl aged of four years and a half who presented initially with a clinical picture of Henoch Schönlein purpura. Physical examination revealed additionally to purpura, scabby lesions on the buttocks. The histopathological examination of a skin biopsy disclosed histiocyte infiltration. There were no Ig A deposits on direct immunofluorescence study. One year later, the diagnosis of WG was suspected, when the patient developed a respiratory problem related to left pulmonary infarction. Screening for thromboembolic factors was positive for antiphosphilipid antibodies. Diagnosis of WG was confirmed by the histopathological study lung tissue and a significant titre of serum ANCA. Blood tests failed to provide evidence of renal involvement. Cyclophosphamide and prednisolone therapy was administrated. A relapse occurred one year later on the controlateral lung; but no biological marker of disease activity could be detected.

[Tuberculous pneumothorax: Diagnosis and treatment]. / Pneumothorax tuberculeux : prise en charge diagnostique et thérapeutique.

BACKGROUND: Pneumothorax is a serious complication of cavitary pulmonary tuberculosis. The aim of this study was to describe clinical futures, to highlight challenges of its management. METHODS: A retrospective multicentric and descriptive study including 65 patients treated for PT (1999-2015) was conducted to figure out clinical futures and its work-up. RESULTS: The mean age was 37.8 years. The sex ratio was 3.6. Smoking history and incarceration were noted respectively in 67.6 and 15.3% of cases. Acute respiratory failure and cachexia were reported in 26.1 and 10.7% of cases. The PT was inaugural in 41.5% of cases. Pyo-pneumothorax was noted in 69.2% of cases. The duration of antituberculous treatment ranged from 6 to 15 months for susceptible TB and was at least 12 months for resistant TB (4 cases). Thoracic drainage was performed in 90.7% patients. Its average length was 47 days. The drain drop was noted in 20% of cases. Bronchopleural fistula was diagnosed in 6 cases and pleural infection in 5 of cases. Surgery treatment was necessary in 6 cases. Mean time to surgery was 171 days. Six patients had pleural decortication associated with pulmonary resection in 4 cases. Persistent chronic PT was noted in 12.6% and chronic respiratory failure in 3% of cases and death in 15.3% of cases. CONCLUSION: The diagnosis of the PT is often easy. Its treatment encounters multiples difficulties. Duration of thoracic drainage and anti-TB treatment are usually long. Surgery is proposed lately.

[Broncholithiasis: six cases]. / La broncholithiase: six observations.

Broncholithiasis is an exceptional condition characterized by the presence of stony formations in the bronchial lumen. We report six cases. Mean age was 41 years. Revealing signs were hemoptysis (n=5), cough (n=5), fever (n=1) and recurrent lower respiratory tract infections (n=1). Physical examination found sonorous rales in two patients and was normal in four. The chest x-ray showed a parenchymal opacity suggestive of calcification in one patient, atelectasia in two, and alveolar images in three. Bronchial endoscopy demonstrated broncholithiasis in one patient, an endobronchial blood clot in one patient with abundant hemoptysis, an endoluminal bud simulating a tumor in two, an inflammatory aspect in one, and was normal in one. Thoracic computed tomography demonstrated broncholithiasis in three patients. Treatment consisted in lobectomy in five patients. The pathology specimen confirmed broncholithiasis in all five and in one revealed caseofollicular lesions of the hillar nodes. Anti-tuberculosis treatment was prescribed for this patient. Therapeutic abstention with regular surveillance was chosen for one patient with an uncomplicated broncholithiasis. Broncholithiasis is an exceptional condition with potentially serious consequences. Certain diagnosis is based on high-resolution computed tomography and endoscopic findings but can nevertheless be a surgical discovery.