[Symmetrical peripheral gangrene: 4 cases]. / La gangrène périphérique symétrique : à propos de 4 cas.

BACKGROUND: Symmetric peripheral gangrene (SPG) is a symmetrical distal ischemic lesion on at least 2 or more extremities in the absence of proximal arterial obstruction and vasculitis. It is a rare and severe clinical entity. The aim of this study was to describe clinical symptoms, etiological agents and the management of SPG through a series of 4 cases. PATIENTS AND METHODS: We included all cases of SPG hospitalized between 2000 and 2014. The inclusion criterion was the presence of distal ischemic damage at two or more sites in the absence of large vessel obstruction. RESULTS: Four patients (2 men and 2 women) were included. The mean age was 43.2±12 years. Two patients had a history of splenectomy. All patients had blackening of the tips of the fingers and toes. Three patients presented with septic shock. The etiology was bacteremia involving Streptococcus pneumoniae in two cases and a malignant form of Mediterranean spotted fever (MSF). In addition to specific antibiotics, we used a potent vasodilator (iloprost) in two cases and curative heparin therapy in two cases. The outcome was favorable in 3 cases, with regression of necrotic lesions. One case required the amputation of non-perfused necrotic fingers and toes. CONCLUSION: SPG can complicate MSF in some rare cases. Thorough and repeated skin examinations are essential to ensure timely diagnosis and treatment of GPS in order to improve the prognosis.

[Myoplasty by reversal of the pectoris major muscle in the treatment of mediastinitis. A case report and review of the literature]. / Myoplastie par retournement du grand pectoral dans le traitement des médiastinites. À propos d'un cas et revue de la littérature.

Mediastinitis are among the most dreadful infectious complications following cardiac surgery. Their prognosis depends essentially on the precociousness of the diagnosis. In most of the cases, the medical treatment associated with an irrigation drainage is sufficient. But in case of severe sternal dehiscence, plastic surgery becomes necessary in order to fill up the loss with a well-vascularized tissue. We report the case of a 78-year-old patient, chronic bronchitic who presented, after a coronary artery bypass, an aseptic sternal dehiscence necessitating an osteosynthesis, then a Klebsiella pneumoniae mediastinitis with an enlarged sternal necrosis which was treated by bone resection and a myoplasty via reversal of the right pectoris major muscle. The postsurgery course was favourable. Now, after one-year remote, cicatrisation is complete and we have not noticed any infectious recurrence.

[General practitioners' management of childhood asthma in Sfax, Tunisia]. / Prise en charge de l'asthme de l'enfant par le médecin de première ligne au Gouvernorat de Sfax, Tunisie.

AIMS: To study primary care physicians' attitudes toward childhood asthma management and their adherence to international guidelines. METHODS: Cross-sectional, descriptive and analytical survey conducted among 400 primary care physicians practicing in the governorate of Sfax. Data collection was done through a self-administered questionnaire with 36 questions. RESULTS: the participation rate was 53.75%. The average age was 49.72years and the sex ratio=1.52. 56.3% reported that they assisted in childhood asthma medical education between 2019 and 2020. Poor knowledge was found in 53.3% of practitioners. It concerns in 60.5% of cases the long-term asthma treatment. We found that 49.8% of doctors did not use the GINA guidelines in their daily practice. These guidelines were considered too complex by 45.8%. Oral salbutamol was prescribed by 10.2% of physicians in childhood asthma exacerbation and 64.2% antibiotics as therapy for childhood febrile asthma exacerbation. The practice of prescribing antihistamines as long-term therapy is still present in 28.8% of physicians. In front of exercise-induced asthma, sports exemptions were given by 33% of participants. Adherence to asthma guidelines was found in 34,41%. Physicians who are aged between 35 and 45years and who used GINA guidelines had better childhood asthma management score than other physicians. CONCLUSION: Despite guidelines, childhood asthma is still underdiagnosis and undertreated. Our study revealed difficulties faced by primary care physicians in the management of childhood asthma.

[A childhood case of antiphospholipid syndrome]. / Le syndrome des antiphospholipides à propos d'une nouvelle observation pédiatrique.

UNLABELLED: Many conditions can lead to cerebral strokes in children. The antiphospholipid syndrome widely described in adults in association with systemic lupus erythematosus, is rare in childhood. CASE REPORT: Two months after recovering from varicella and a few days after an episode of bronchitis, a 17-month-old girl developed left facial paralysis associated with right hemiplegia. Brain MRI and angio-scan showed thrombosis in the internal left carotid associated with ischemia in the superficial posterior territory of the left Sylvian artery. Echocardiography and hemoglobin electrophoresis were normal. Tests were negative for protein S, C and antithrombin III deficiencies and no resistance to activated protein C. IgM anticardiolipin antibodies were detected at high level (greater than 25IU/l) initially and six weeks later. In the absence of an evident etiology, mainly systemic lupus erythematosus (negative antinuclear antibodies), the diagnosis of primary antiphospholipid syndrome was retained. The girl was treated by heparin then by salicylate at antiaggregate doses associated with re-habilitation. Twelve months later, the patient had not developed any other thrombosis, in spite of a high level of anticardiolipin antibodies. CONCLUSION: In children with cerebral strokes, antiphospholipid syndrome must be discussed when the usual etiologies have been ruled out.

Prosthetic valve endocarditis: management strategies and prognosis: A ten-year analysis in a tertiary care centre in Tunisia.

BACKGROUND: Prosthetic valve endocarditis (PVE) is a rare and serious complication after heart valve replacement; its optimal management strategy, though, still needs to be defined. OBJECTIVE: To study the clinical, microbiological and echocardiographic characteristics of PVE and to analyse the influence of the adopted therapeutic strategy (medical or surgical) on short- and midterm outcome in a tertiary care centre in a developing country (Tunisia). METHODS: All cases of PVE treated in our institution between 1997 and 2006 were retrospectively analysed according to the modified DUKE criteria. RESULTS: A total of 48 PVE episodes were diagnosed (30 men and 18 women), mean age was 37.93 years. Twenty-eight patients (58.33%) were exclusively medically treated, whereas 20 (41.66%) were treated by a combined surgical and medical strategy. Indications for surgery were haemodynamic deterioration in eight patients (40%), annular abscess in six (30%) and persisting sepsis in six (30%). In comparison with those from the medical group, operated patients had a longer delay to diagnosis (p=0.025), were more frequently in heart failure (p=0.04) and experienced more early complications (p=0.011); they also more frequently had prosthetic dehiscence (p=0.015), annular abscesses (p=0.039) and vegetations >10 mm (p=0.008). Conversely, no differences were found between the groups in terms of age, sex, or nature of involved organisms. In-hospital mortality for the medical group was 14.28% and for the surgical group 35% (p=0.09). CONCLUSION: PVE is a very serious condition carrying high mortality rates regardless of the adopted strategy. Our study demonstrates that, in selected patients, medical treatment could be a successful and acceptable approach. (Neth Heart J 2009;17: 56-60.).

A new combined predicting model using a non-invasive score for the assessment of liver fibrosis in patients presenting with chronic hepatitis B virus infection.

OBJECTIVES: Several non-invasive markers have recently been proposed to predict liver fibrosis without percutaneous liver biopsy (PLB). We aimed to evaluate the performance of non-invasive scores and to highlight the value of a new combined score in the prediction of liver fibrosis in chronic hepatitis B (CHB) patients. PATIENTS AND METHODS: We performed a retrospective study of patients presenting with CHB who underwent PLB between 2008 and 2016. We calculated ASAT/Platelet Ratio Index (APRI), Fibrosis-4 Score (FIB4), GGT-to-platelet ratio (GPR), and ASAT/ALAT Ratio (AAR). Then, we combined APRI and FIB-4 scores into a new combined score. We assessed their performance in predicting liver fibrosis according to the Metavir score. RESULTS: A total of 179 patients presenting with CHB were included. Multivariate analysis showed that the APRI score was the only independent factor of significant fibrosis (OR=3.78; P=0.02), whereas the FIB-4 score was the only independent factor for severe fibrosis (OR=2.85; P<0.001) and cirrhosis (OR=2.5; P=0.001). At a threshold of severe fibrosis, APRI had the best specificity (75%) and FIB-4 had the greatest sensitivity (74%). Using the combined score, we improved the diagnostic performance of APRI and FIB-4 scores at the three thresholds of liver fibrosis. With this combined score, maximum 25.1% of patients presenting with CHB would undergo PLB. CONCLUSION: APRI, FIB-4, and GPR scores were well performing to predict liver fibrosis during CHB. The new combined score using APRI and FIB-4 was more accurate at the three-fibrosis thresholds.

[Infectious complications in systemic lupus erythematosus: a series of 146 patients]. / Complications infectieuses au cours du lupus érythémateux systémique: étude de 146 patients.

PURPOSE: The objective of this study was to analyse the incidence and characteristics of infection in systemic lupus erythematosus (SLE) and to determine the related risk factors. METHODS: A retrospective review of a well documented population of 146 Tunisian patients with SLE was undertaken. All patients fulfilled four or more criteria defined by the American College of Rheumatology. RESULTS: Sixty-five patients (44.5%) suffered at least one infection. Skin, urinary tract and lung were the most affected localizations. Bacterial infections (67.5%) were the most common. In the univariate analysis, nephritis, neuropsychiatric, leucopenia, lymphopenia, decreased complement (CH50, C3 and C4), SLE activity, ever use of steroids and cyclophosphamide were significantly associated with infection. In the multivariate analysis, nephritis, neuropsychiatric and lymphopenia were found to be significant. CONCLUSION: SLE has an increased overall risk for infection and they are especially prone to develop urinary, cutaneous and pulmonary infections. Infectious complications seem to be more associated with major organ damage than with steroid or immunosuppressive therapy.

[Multifocal Langerhans cell histiocytosis of bone: late revelation in a 76-year-old woman]. / Histiocytose langerhansienne osseuse multifocale: révélation tardive chez une femme de 76 ans.

Langerhans cell histiocytosis or histiocytosis X has a variable course from a self-limited eosinophilic granuloma to an aggressive disseminated disease. It mainly affects children. We report a 76-year-old woman with multifocal bone histiocytosis X, involving the rachis, an iliac bone and the skull. The diagnosis has been established by histological exam. Outcome was favourable after chemotherapy.

Fulminant mulch pneumonitis in a previously healthy child.

Chronic granulomatous disease (CGD) is associated with multiple and recurrent infections. In patients with CGD, invasive pulmonary infection with aspergillus species remains the greatest cause of mortality. Acute fulminant presentations of fungal pneumonia are catastrophic. It is a medical emergency, and currently the treatment is based on association of corticosteroids and antifungal therapy. We describe the case of an 11-year-old boy, with late initial presentation of CGD, which was revealed by fulminant aspergillus pneumonia. He was successfully treated with an association of high doses of steroids and voriconazole.

[Management of patients with major beta thalassemia in a paediatric department in the south of Tunisia: About 26 cases]. / Prise en charge thérapeutique des patients atteints de bêta-thalassémie majeure dans un service de pédiatrie du sud tunisien : à propos de 26 cas.

AIM: Our objectives were to assess the management of patients with major thalassemia and identify the various complications and monitoring means. PATIENTS AND METHODS: A retrospective study was conducted on 26 ß-thalassemic patients in the department of paediatrics, Hédi Chaker hospital, Sfax, Tunisia during a period of 25 years (from 1 January 1990 to 31 December 2014). RESULTS: The mean age of the beginning of transfusion was 11.5 months. That was with phenotyped red blood cells but not leukodepleted blood. Twenty-three patients received chelation. Before 2001, all patients received deferoxamine, poor adherence to this treatment was observed in 66% of cases. It was replaced by deferiprone since 2006 and deferasirox since 2009. A combination of 2 or 3 chelators was indicated for four patients. A total splenectomy was performed in 10 cases patients; it was due to hypersplenism. The bone marrow transplant was performed for one patient at the age of 9 year but it was rejected. Many complications were detected: endocrine complications (19 cases), immune complications (9 cases), gallbladder stones (5 cases), cardiac complications (4 cases), osteoporosis (3 cases), infectious complications (3 cases) and thromboembolic complications (2 cases). We noted some side effects related to chelation therapy in twelve cases. Four patients were dead. CONCLUSION: Improving the medical care of homozygous ß-thalassemic children requires adherence to transfusion regimen and chelation therapy. Bone marrow transplantation remains the only possible curative therapy, which must be promoted in our country.

[Ocular tuberculosis : A case series]. / La tuberculose oculaire : une série de 14 cas.

OBJECTIVES: Ocular tuberculosis is a rare form of extra pulmonary tuberculosis. It represents 1-2% of all clinical forms. The aim of this work was to focus on diagnostic and therapeutic characteristics of ocular tuberculosis. METHODS: We report a case series of 14 patients with ocular tuberculosis seen in an infectious diseases department between 2006 and 2015. The diagnosis was retained on clinical data and a positive tuberculin skin test or interferon-gamma release assay. RESULTS: The patient's mean age was 40.7±9years. The most common clinical presentation was uveitis (11 patients and 16 eyes). An extra ocular involvement was associated in three patients. The mean duration of antitubercular therapy was 10±2.5 months. Corticosteroid therapy was associated in 11 cases. The outcome was favorable in all cases. Two patients had maintained visual sequelae. CONCLUSION: Ocular tuberculosis is a rare disease but still remains a diagnostic problem. It should be considered in case of any chronic ocular symptoms, especially in endemic countries. Early management can improve the visual prognosis.

[Prognostic factors of pneumococcal meningitis. Retrospective study of 31 cases]. / Facteurs de pronostic des méningites à pneumocoque. Etude rétrospective de 31 cas.

AIM: Our aim was to study the susceptibility of Streptococcus pneumoniae to antibiotics in patients with pneumococcal meningitis and to search for the prognosis factors in those patients. METHODS: We have studied retrospectively 31 cases of pneumococcal meningitis. Comparaisons were performed with univariate analysis. RESULTS: The mean age was 36.7 +/- 20.5 years (ranged: 9 and 78 years). The sex ratio was 3,4. The susceptibility of Streptococcus pneumoniae to penicillin G was affected in 10 cases (33% of isolated pneumococcus. The MIC to penicillin G was > or =2 in only one case. The hospital mortality was 26% (8/31). With univariate analysis, factors associated with death were: age > or =55 years (Ss p= 0,006, OR: 17.2 IC95%: 2.3-134), albuminorachie > or = 7 g/l (p = 0.002, OR: 22; IC95%: 1.9-2.51), shock (p = 0.031, OR: 6.7; IC95%: 1.05-42) and Glasgow Coma Score (GCS) < or =8 (p = 0.001, OR: 20; IC95%: 2.68-149). CONCLUSION: No susceptibility to penicillin G is not associated with a worse outcome in patients with pneumococcal meningitis. An age > or =55 years, albuminorachie > or =7 g/l shock and Glasgow Coma Score < or =8 at admission were determinant of the prognosis in our study.

Occipital dermoid cyst associated with dermal sinus complicated with meningitis: A case report.

BACKGROUND: Occipital dermal sinus, usually associated with dermoid cyst, is a rare entity; it results from the persistence of an abnormal embryonal communication between the skin and the intradural space. Its main complication is intracranial infection. CASE DESCRIPTION: This 2-year-old girl was hospitalized for meningitis. Neuroradiological studies revealed a cystic mass of the posterior fossa communicating with the skin and hydrocephalus. The diagnosis of dermoid cyst associated with dermal sinus was established at surgery. The patient was treated with radical excision of both the occipital cyst and the dermal sinus associated with systemic antibiotic therapy. She had a good outcome. CONCLUSION: Posterior fossa dermoid cyst should be considered in all children with chronic occipital skin lesion, especially a dermal sinus. We emphasize the importance of early neurosurgical treatment of dermoid cysts to prevent the development of severe complications.

Chediak-Higashi syndrome presenting in accelerated phase: A case report and literature review.

Chediak-Higashi syndrome (CHS) is a rare autosomal recessive lysosomal disorder characterized by frequent infections, oculocutaneous albinism, bleeding diathesis, and progressive neurologic deterioration. In 85% of cases, CHS patients develop the accelerated phase characterized by pancytopenia, high fever, and lymphohistiocytic infiltration of liver, spleen, and lymph nodes. Treatment of accelerated-phase CHS is difficult and the prognosis is poor. Here, we report a case of CHS in a 2-year-old boy who presented in the accelerated phase of the disease. CHS diagnosis was made on the basis of clinical characteristics, hair analysis, and identification of pathognomonic giant azurophilic granules in peripheral blood and bone marrow.

Macrophagic activation syndrome related to an infection by Rickettsia conorii in a child.

Since the Arab Spring, a resurgence of zoonotic diseases such as rickettsiosis, endemic in the Mediterranean basin, has been observed. It preferentially infects microvascular endothelial cells of mammalian hosts inducing vasculitis with endothelial injury. Rickettsioses are considered benign infectious diseases. Severe systemic manifestations have been reported and are often explained by a delay in diagnosis. We present a case of hemophagocytic syndrome occurring in a 4-year-old Libyan girl as a complication of Mediterranean spotted fever. Rickettsial infection was confirmed by serology and the patient was treated with clarithromycin, with a favorable outcome.

[Erysipela after treatment of nasopharyngeal carcinoma]. / Erysipèle de la face et du cou après traitement du cancer du nasopharynx.

PURPOSE: The aim of this work is to study the epidemiological, clinical and evolutive characteristics of the erysipela in patients treated for nasopharyngeal carcinoma (NPC). PATIENTS AND METHODS: Between January 1993 and June 2003, 212 patients were treated for NPC in the radiotherapy department of Sfax hospital. Twenty-two patients among them have presented an erysipela. A neoadjuvant chemotherapy was used for 16 patients with N2-N3 disease. Locoregional radiotherapy was delivered for all of patients. RESULTS: The mean age was 35 years (range: 10 and 69), sex-ratio was 1.2. The median delay between the appearance of erysipela and the end of the treatment was 16 months. The main localisation was the face. The main clinical manifestations were fever in 86% of cases and erythema in 77% of cases. Immediate evolution was favorable in all cases after antibiotherapy. Recurrences were observed in 45% in cases. CONCLUSION: Erysipela is a common skin infection readly found in patients with venous insufficiency. In our study we found a significant correlation between the frequency of erysipela and dystrophic complications. The incidence of erysipela in the face and cervical region after radiotherapy is unknown.

Erysipelas after breast cancer treatment (26 cases).

Erysipelas is a bacterial hypodermal cellulitis usually associated with Streptococcal infection. Erysipelas of the upper limbs in women treated for breast cancer is relatively rare. We undertook a 10-year retrospective study identifying 26 cases of erysipelas of the upper limb following treatment for breast cancer; we describe the clinical, therapeutic, and evolutionary aspects. The age of our patients ranged from 37 to 80 years with a mean age of 53. All patients had a breast surgery and lymphadenectomy. Fifteen patients had chemotherapy and 23 had radiotherapy. The erysipelas appeared with an average of 5.23 years after cancer treatment (3 months to 15 years) and was recurrent in nine cases. Lymphedema occurred in eighteen patients. The first signs were fever and shivering in 25 patients. The clinical aspect was an inflammatory plaque. The physical findings of erysipelas included a raised edge (6 cases), blisters (1 case), purpura (1 case), and cellulitis (1 case). The portal of entry was not found in eleven patients. The upper limb was affected in all cases. Involvement of the axillary folds or the chest was observed in eight cases. Treatment with penicillin was undertaken for all patients; the length of treatment varied from 11 to 26 days. Lympadenectomy and radiotherapy in breast cancer may lead to lymphedema, which can be evident or sometimes discrete. Those patients who developed erysipelas in our series usually fared well with treatment, but many had recurrences attributed to persistent lymphedema. It was also of note that for many patients in this series, the portal of entry was not identified.