Combination of amphotericin B and caspofungin in the treatment of mucormycosis.

We report a case of invasive mucormycosis in 52 year-old woman. CT-scan and magnetic resonance imaging found a partial right sinus thrombosis associated with homolateral ethmoidal and maxillary sinusitis with submucosal inflammation. Histopathological examination of excised tissue was positive for mucormycosis. Our patient was treated by surgical debridement and a combination of amphotericin B and caspofungin, with a good outcome.

Performance of an Easy and Simple New Scoring Model in Predicting Multidrug-Resistant Enterobacteriaceae in Community-Acquired Urinary Tract Infections.

BACKGROUND: Multidrug resistance (MDR) is a growing global problem in bacterial community-acquired urinary tract infections (CUTIs). We aimed to propose an easy-to-use clinical prediction model to identify patients with MDR in CUTI. METHODS: We conducted a retrospective study including 770 patients with documented CUTI diagnosed during 2010-2017. Logistic regression-based prediction scores were calculated based on variables independently associated with MDR. Sensitivities and specificities at various cutoff points were determined, and the area under the receiver operating characteristic curve (AUROC) was computed. RESULTS: We found MDR Enterobacteriaceae in 372 cases (45.1%). Multivariate analysis showed that age ≥70 years (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.8-3.5), diabetes mellitus (aOR, 1.65; 95% CI, 1.19-2.3), history of urinary tract surgery in the last 12 months (aOR, 4.5; 95% CI, 1.22-17), and previous antimicrobial therapy in the last 3 months (aOR, 4.6; 95% CI, 3-7) were independent risk factors of MDR in CUTI. The results of Hosmer-Lemshow chi-square testing were indicative of good calibration of the model (χ2 = 3.4; P = .49). At a cutoff of ≥2, the score had an AUROC of 0.71, a sensitivity of 70.5%, a specificity of 60%, a positive predictive value of 60%, a negative predictive value of 70%, and an overall diagnostic accuracy of 65%. When the cutoff was raised to 6, the sensitivity dropped (43%), and the specificity increased appreciably (85%). CONCLUSIONS: We developed a novel scoring system that can reliably identify patients likely to be harboring MDR in CUTI.

[Psoas abscess of the adult: study of 38 cases]. / L'abces du psoas de l'adulte: etude de 38 cas.

OBJECTIVE: Our aim is to report the clinical aspects, the etiologies, the treatment and the evolution of the psoas abscess in the adult. METHODS: Our retrospective study concerns 38 cases of psoas abscesses collected in the Department of Infectious Diseases of Sfax (Tunisia), over a period of 16 years (January 1990 - December 2005). RESULTS: The average age is 44 years (extremes: 16-76 years). The sex-ratio is 1.4. Six patients were diabetics and one had a chronic renal injury at the stage of hemodialysis. The clinical manifestations were: a fever (76.4%), an abdomino-pelvic ache (84.2%) and a psoitis (34.2%). All patients had a biologic inflammatory syndrome with a hyperleucocytosis in 28 cases. The abscess was one-sided in 29 cases and bilateral in 9 cases. After microbiological study and/or histological study, pathogens were identified in 31 patients, they were Staphylococcus aureus (10 cases), Staphylococcus lugdunensis (1 case), Streptococci (3 cases), Escherichia coli (2 cases), Bacteroides fragilis (1 case), Actinomyces (2 cases), Brucella (3 cases), Mycobacterium tuberculosis (8 cases) and Candida glabrata (1 case). The psoas abscess was primary in 10 cases and secondary in 28 cases. All the patients received an antibiotherapy or an antifungal therapy adapted to the micro-organism in cause, with a drainage of the abscess in 25 cases (surgical in 9 cases and percutaneous in 16 cases). The evolution was favourable in 36 cases. One patient presented recurrences and one patient died. CONCLUSION: The psoas abscess of the adult is characterized by a polymorphe clinical presentation. Germs in cause are very variable.

Spinal brucellosis in South of Tunisia: review of 32 cases.

BACKGROUND CONTEXT: Brucellosis remains an important economic and public health problem in some parts of the world. The spine is the most common site of musculoskeletal involvement of brucellosis. PURPOSE: Assess the clinical, laboratory, radiological findings, and outcomes of vertebral involvement in brucellosis. STUDY DESIGN: A retrospective study. PATIENT SAMPLE: Thirty-two patients with spinal brucellosis during a period of 21 years (1990-2010) were included. OUTCOME MEASURES: Clinical and radiological improvement. METHODS: Diagnosis made on clinical presentation, laboratory findings, radiographic evidence, and the Brucellar etiology was considered when seroagglutination tests were positive at a titer of 1/160 or higher, and/or Brucella spp were isolated in the blood or sample cultures. RESULTS: The mean age of patients was 51±15.85 years (23 males, 9 females; age range, 19-74 years). The median diagnostic delay was 3 months. Back or neck pain (100% of patients), fever (78%), and sweats (68.6%) were the most common symptoms. Cultures of blood specimens from five patients (15.6%) were positive for Brucella melitensis. Four patients (12.5%) had motor weakness or paralysis. Magnetic resonance imaging was performed in 24 (75%) cases. Paravertebral masses, epidural masses, and psoas abscesses were detected in 65.6%, 59.4%, and 28.1% of patients, respectively. The lumbar vertebra was the most frequently involved region with the rate of 68.7%, followed by thoracal (18.7%), cervical (6.3%), lumbosacral (6.3%), and thoracolumbar (3.1%) segments. The duration of antimicrobial therapy of brucellosis (median, 6 months; range, 3-13 months) varied according to clinical response and the presence of epidural and paravertebral masses. There were no deaths or severe sequelae in this study. CONCLUSIONS: Brucellar spondylitis should be considered in patients with back pain and fever in endemic areas. A high index of suspicion and clinical, laboratory, and radiological examinations help to confirm the diagnosis of vertebral involvement.

A rare cause of Dysphagia in a pregnant woman:herpes simplex esophagitis.

Herpes simplex esophagitis (HSE) has rarely been reported in immunocompetent individuals. In a search of Medline until October 2012, we found only one case of HSE in a pregnant female. We present the first case of HSE in a healthy 36-year-old female at 27 weeks gestation who recovered without antiviral therapy.

[Bilateral emphysematous pyelonephritis caused by Candida glabrata: An exceptional entity]. / La pyélonéphrite emphysémateuse bilatérale à Candida glabrata : une entité exceptionnelle.

Acute emphysematous pyelonephritis (AEP) is a severe form of urinary tract infection. It occurs usually in diabetics. The most concerned agents are the Gram-negative bacilli. We report a first case of bilateral AEP due to Candida glabrata, occurred in a 64-year-old diabetic woman. The clinical presentation started with fever and abdominal pains, without signs of urinary tract infection. Within six hours, the patient had developed a septic shock with renal failure and ketoacidosis. The diagnosis was confirmed by CT scan and the pathogen was isolated in urine. Despite antibiotic and antifungal treatment, she died from a septic shock. Acute emphysematous pyelonephritis due to Candida species is rare. However, the addition of antifungal therapy seems justified if a severe emphysematous pyelonephritis is associated with risk factors of Candida infection.

Short- and long-term outcomes of surgery for active infective endocarditis: a Tunisian experience.

From January 1997 to December 2006, all patients with a Duke criteria-based definite diagnosis of infective endocarditis (IE) operated on during the active phase in a Tunisian high volume tertiary-care centre were included. Among the 186 patients with IE identified during the study period, 88 (48.35%) required surgery in the active phase. Mean age was 34.9 years, 54 (61.4%) were men. The infected valve was native in 70 cases (79.5%) and prosthetic in 18 (20.5%). Streptococcus sp. were the most common causative microorganisms. The most frequent indication for operation was congestive heart failure. There were 24 in-hospital deaths (27.27% early mortality). By multivariate analysis, severe congestive heart failure (HR=13.82, 95% CI [3.38-38.15], P<0.001) and large >15 mm vegetations (HR=6.02, 95% CI [1.48-18.52], P=0.03) were predictive of in-hospital mortality. Survivors were followed-up from 3 to 120 months, mean of 28.6. Actuarial 5- and 10-year survivals free from the combined endpoint of recurrent IE, cardiovascular death and late surgery in survivors were 69+/-5% and 63+/-7%, respectively. In conclusion, despite medical progress, surgery for endocarditis in Tunisia remains challenging and yields high mortality rates. Severe heart failure is the most powerful predictor of mortality. Long-term outcome is, however, satisfactory.

Native valve infective endocarditis in a tertiary care center in a developing country (Tunisia).

The aim of the study was to describe the epidemiological and clinical aspects of native valve infective endocarditis (IE) in a Tunisian high-volume tertiary care center and to identify the predictors of outcome. Demographic, clinical, laboratory, and echocardiographic characteristics were examined in 134 patients who fulfilled the modified Duke criteria for native valve IE between January 1997 and December 2006. Logistic regression analysis was used to identify prognostic factors for death. Mean age was 34.22 years. Diagnosis was definite in 93% of cases. Median time to diagnosis was 21 days. Rheumatic heart disease (RHD) was the predominant (45%) underlying heart condition. One or more vegetations were detected in more than 93% of cases. The median size of vegetation was >15 mm in 28% of cases. In 66 cases (49%), cultures remained negative. Serology was positive in 15 cases, and in 4 cases leaflet culture identified the agent. The infective agent was identified in 87 cases (65%), causative microorganisms were mainly Staphylococci (n = 30, including 6 coagulase-negative Staphylococcus), and Streptococci (n = 32). Overall mortality was 19%. On multivariate analysis, congestive heart failure (hazard ratio = 5.34, 95% confidence interval 1.67 to 17.15, p = 0.005) and large vegetations (>15 mm; hazard ratio = 5.78, 95% confidence interval 1.84 to 18.32, p = 0.002) were predictive of in-hospital mortality but not neurological complications or staphylococcus IE. In conclusion, IE remains a serious disease affecting a young population in Tunisia, with RHD as still the most common underlying heart disease, and it is associated with a high mortality.

Epidemic West Nile virus encephalitis in Tunisia.

West Nile fever (WNF) is a mosquito-borne flavivirus infection. It is epidemic in Africa and Asia. In autumn 1997, a WNF epidemic occurred in the Sfax area (southeastern Tunisia). Fifty-seven patients were hospitalized with aseptic meningitis and/or encephalitis. Search for specific anti-West Nile virus (WNV) antibodies in serum and cerebrospinal fluid (CSF) was performed using an ELISA test. Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to detect the WNV genome in CSF and brain specimens. Recent central nervous system (CNS) infection by WNV was confirmed in 30 patients, probable infection in 17 and it was excluded in 10. In the confirmed subgroup, patients with encephalitis were older than those with meningitis. CSF showed pleocytosis, high protein (47%) and normal glucose levels. Brain computed tomography-scan (CT-scan) and magnetic resonance imaging (MRI) were normal. RT-PCR disclosed WNV genome in the CSF in two cases and in a brain specimen in one. Three patients died rapidly, the remaining cases had favorable prognosis. Autopsy was performed in two cases and showed nonspecific lesions of encephalitis. No viral inclusions were seen with light microscopy. Seropositivity rate in patients' proxies for WNV was 23.4%. Prognosis of CNS involvement during WNF seemed to be poor in older patients. This is the first WNV encephalitis epidemic report in the Sfax area of Tunisia.