Badreddine Kilani

Cutaneous tuberculosis in Tunisia

INTRODUCTIONnTuberculosis is endemic in Tunisia. Pulmonary tuberculosis is the most common presentation in our country. Cutaneous presentations are rare (1-2% of cases). The diagnosis of cutaneous tuberculosis (CT) is difficult. Histological and clinical presentations are polymorphous, many differential diagnoses are available, and it is difficult to isolate Mycobacterium.nnnOBJECTIVEnWe had for aim to study the epidemiological and clinical features of CT in Tunisia, and to compare presentations before and after 1990.nnnPATIENTS AND METHODSnWe conducted a retrospective study between Januaryxa01991 and Decemberxa02011, in which we included all cases of CT observed at the Infectious Diseases and Dermatology Units of the Tunis la Rabta Hospital.nnnRESULTSnHundred and thirty-seven patients were included, with a mean age of 43.8years; 72.3% were female patients. Hundred and fifty locations were observed, most of which on the head and neck. Scrofuloderma was the most frequent presentation, observed in 65% of cases. The diagnosis was confirmed by histology and/or microbiology in 75.8% of cases. The treatment was prescribed for a mean 11.3months, leading to full recovery in most cases.nnnCONCLUSIONnCT is still reported in Tunisia. The diagnosis relies mainly on histology. Controlling this mutilating tuberculosis requires a global control of this disease, and especially lymph node location, given the high rate of scrofuloderma.

Paradoxical reaction associated with cervical lymph node tuberculosis: predictive factors and therapeutic management

OBJECTIVESnThe aims of this study were to determine predictive factors of paradoxical reaction in patients with cervical lymph node tuberculosis (TB) and to discuss the therapeutic management of this condition.nnnMATERIALS AND METHODSnA retrospective study was performed of 501 patients managed for cervical lymph node TB over a period of 12 years (from January 2000 to December 2011). Statistical data were analyzed using IBM SPSS Statistics version 20.0.nnnRESULTSnParadoxical reaction occurred in 67 patients (13.4%), with a median delay to onset after starting TB treatment of 7 months. Lymph node size ≥3cm and associated extra-lymph node TB were independently associated with paradoxical reaction. Treatment consisted of surgical excision (71.6%), restarting quadruple therapy (10.4%), reintroduction of ethambutol (23.8%), and addition of ciprofloxacin (20.8%); steroids were given in two cases . All patients recovered after an average treatment duration of 14.91±7.03 months.nnnCONCLUSIONnThe occurrence of paradoxical reaction in cervical lymph node TB seems to be predicted by associated extra-lymph node TB and a swelling size ≥3cm. The treatment of paradoxical reaction remains unclear and more randomized trials are necessary to improve its management.

Myélite transverse révélant une maladie de Hodgkin

Resume Introduction Les complications neurologiques au cours de la maladie de Hodgkin sont rares. Leur diagnostic est parfois difficile. Nous rapportons une observation de myelite transverse. Observation Il s’agissait d’un patient de 32 ans hospitalise pour paraplegie flasque febrile evoluant depuis 1 mois avant son admission associee a une alteration progressive de son etat general. L’examen trouvait un patient febrile, conscient, avec abolition des reflexes osteotendineux aux membres inferieurs, un signe de Babinski bilateral et un niveau sensitif en D6-D7. Par ailleurs, il existait une hepatosplenomegalie sans adenopathies peripheriques. Biologiquement, on notait une bicytopenie avec un syndrome inflammatoire important et une cytolyse hepatique. L ’examen tomodensitometrique thoraco-abdominal montrait des adenopathies profondes et l’IRM medullaire trouvait un aspect de myelite transverse. La biopsie medullaire etait normale alors que la biopsie hepatique montrait une infiltration du foie par des cellules de Sternberg. L’evolution a ete rapidement fatale avant le debut du traitement. Discussion Les manifestations neurologiques polymorphes observees au cours de la maladie de Hodgkin peuvent constituer un mode de revelation. Leur association a un syndrome tumoral doit faire evoquer le diagnostic meme si les signes neurologiques ne sont pas specifiques. L’atteinte peut etre medullaire ou encephalique. Le diagnostic de certitude ne peut etre qu’histologique. Le pronostic depend de la precocite du diagnostic et de la prise en charge.

Availability of hepatitis C diagnostics and therapeutics in European and Eurasia countries

Background Treatment with direct acting antiviral agents (DAAs) has provided sustained virological response rates in >95% of patients with chronic hepatitis C virus (HCV) infection. However treatment is costly and market access, reimbursement and governmental restrictions differ among countries. We aimed to analyze these differences among European and Eurasian countries. Methods A survey including 20‐item questionnaire was sent to experts in viral hepatitis. Countries were evaluated according to their income categories by the World Bank stratification. Results Experts from 26 countries responded to the survey. As of May 2016, HCV prevalence was reported as low (≤1%) in Croatia, Czech Republic, Denmark, France, Germany, Hungary, the Netherlands, Portugal, Slovenia, Spain, Sweden, UK; intermediate (1–4%) in Azerbaijan, Bosnia and Herzegovina, Italy, Kosovo, Greece, Kazakhstan, Romania, Russia, Serbia and high in Georgia (6.7%). All countries had national guidelines except Albania, Kosovo, Serbia, Tunisia, and UK. Transient elastography was available in all countries, but reimbursed in 61%. HCV‐RNA was reimbursed in 81%. PegIFN/RBV was reimbursed in 54% of the countries. No DAAs were available in four countries: Kazakhstan, Kosovo, Serbia, and Tunisia. In others, at least one DAA combination with either PegIFN/RBV or another DAA was available. In Germany and the Netherlands all DAAs were reimbursed without restrictions: Sofosbuvir and sofosbuvir/ledipasvir were free of charge in Georgia. Conclusion Prevalence of HCV is relatively higher in lower‐middle and upper‐middle income countries. DAAs are not available or reimbursed in many Eurasia and European countries. Effective screening and access to care are essential for reducing liver‐related morbidity and mortality. HighlightsPrevalence of HCV is relatively higher in lower‐middle than in upper‐middle income countries.DAAs are not available in European and Eurasia countries for treatment of acute HCV.DAAs are not available or reimbursed in many European and Eurasia countries for treatment of chronic hepatitis C.Effective screening and access to care are essential for avoiding liver‐related morbidity and mortality.

Caractéristiques épidémio-cliniques de la tuberculose génitale chez la femme tunisienne: une série de 47 cas

Lobjet est de relever les caractéristiques épidémio-cliniques, diagnostiques, thérapeutiques et évolutives de la tuberculose génitale (TG) chez la femme en Tunisie. Nous avons mené une étude rétrospective, descriptive au service des maladies infectieuses de lhôpital la Rabta de Tunis, sur une période de 15 ans et demi (janvier 2000-juin 2014). Nous avons inclus toutes les patientes hospitalisées pour une tuberculose génitale. 47 cas ont été colligés. Lâge moyen était de 42,2 ans. Dix-huit femmes étaient dorigine rurale. Un comptage tuberculeux a été retrouvé dans cinq cas. Pour tous les cas, le début était insidieux. Un ou plusieurs signes dimprégnation tuberculeuse ont été rapportés dans 23 cas. Lintradermoréaction (IDR) à la tuberculine réalisée chez 35 femmes (74,8%), était positive dans 26 cas (74%). Trente-neuf patientes (83%) avaient eu une exploration radiologique par une échographie et / ou une tomodensitométrie (TDM) abdomino-pelvienne. Une cœlioscopie diagnostique a été réalisée dans 37 cas (75,5%). Lexamen Anatomopathologique a permis de confirmer le diagnostic de TG dans 42 cas (89,3%) en retrouvant un granulome épithéloïde et giganto-cellulaire. Nous avons relevé 21 cas de TG isolée, alors que les 26 autres avaient une atteinte péritonéale associée. Toutes les patientes ont reçu une antibiothérapie spécifique associant lIsoniazide, la Rifampicine, le Pyrazinamide et lEthamubutol pour une durée moyenne de 12 mois. Aucune patiente na reçu de corticothérapie et aucune chirurgie secondaire na été indiquée. Lévolution était favorable dans 39 cas, 8 patientes ont été perdues de vue. La TG est une pathologie rare qui ne représente que 0,5% de la tuberculose extra-pulmonaire, mais dun grand polymorphisme clinique. La confirmation diagnostique est difficile et repose sur létude bactériologique et/ou histologique. Le diagnostic doit être évoqué devant toute symptomatologie abdomino-pelvienne trainante, devant une stérilité chez la femme, associé à un contexte épidémio-clinique évocateur.This study aimed to identify the epidemio-clinic, diagnostic, therapeutic and evolutionary features of genital tuberculosis (GT) among Tunisian women. We conducted a retrospective, descriptive study in the Department of Infectious Diseases at the La Rabta Hospital, Tunisia, over a period of 15 and a half years (January 2000 - June 2014). All patients hospitalized for genital TB were included in the study. The study focused on 47 cases. The average age of patients was 42.2 years. Eighteen women were from rural areas. Tuberculous contact was found in five cases. In all cases, the onset was insidious. Twenty-three patients showed one or several signs of TB infection. Tuberculin intradermal reaction (IDR) test was performed in 35 women (74.8%), it was positive in 26 cases (74%). Thirty-nine patients (83%) had undergone radiological examination using abdomino-pelvis ultrasound and/or CT scan. Diagnostic coelioscopy was performed in 37 cases (75.5%). Anatomopathological examination helped to confirm the diagnosis of GT in 42 cases (89.3%), showing epithelioid and giant-cell granuloma. We identified 21 cases of isolated GT, the remaining 26 cases had peritoneal involvement. All patients received specific antibiotic therapy combining isoniazid, rifampicin, pyrazinamide and ethamubutol with an average treatment duration of 12 months. No patient received corticosteroids or secondary surgery. Patients outcome was favorable in 39 cases, 8 patients were lost to follow-up. Genital tuberculosis is rare, representing only 0.5% of extra-pulmonary tuberculosis, but it accounts for a high prevalence of clinical polymorphism. Diagnostic confirmation is difficult and it is based on bacteriological and/or histological examinations. Diagnosis should be suspected in patients with chronic abdominopelvic symptoms, in women with infertility associated with suggestive epidemioclinical manifestations.

Délai diagnostique du paludisme d’importation en Tunisie

Introduction : l’incidence du paludisme d’importation est en augmentation en Tunisie, mais son diagnostic semble parfois long. L’objectif ici etait d’evaluer le delai diagnostic du paludisme d’importation en Tunisie et etudier I ’origine des retards diagnostics. Methodes : tous les cas de paludisme d’importation hospitalises dans le service des maladies infectieuses entre 2012 et 2015 ont ete evalues prospectivement. Le delai diagnostic “patient” etait defini comme le delai entre le debut de la fievre et la 1ere consultation medicale. Le delai diagnostic “medecin” etait le delai entre la 1ere consultation medicale et le diagnostic parasitologique. Le delai diagnostic total etait la somme de ces deux delais. Le retard diagnostic medical etait defini par un delai diagnostic “medecin” superieur a une journee.