Imed Maaloul

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.

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.

Murine typhus in Tunisia: a neglected cause of fever as a single symptom.

OBJECTIVES We had for aim to describe the epidemiologic and clinic characteristics of murine typhus in a series of 43 serologically confirmed cases, in our region. PATIENTS AND METHODS Serologic screening for IgG and IgM against Rickettsia typhi was performed in 1024 patients during three years (2006-2008). The characteristics of patients with a positive serology were examined retrospectively. One hundred and seventy sera obtained from blood donors were tested to detect IgG against R. typhi to determine the seroprevalence of the infection. RESULTS There was evidence of recent R. typhi infection in 43 patients (4.2%) during the study period, and 3.7% of blood donors had IgG against R. typhi. The mean age of patients was 43.1 years and the sex-ratio was 1.04. Among the patients, 58.1% were from rural areas. No patient reported any exposure to rats or rat-fleas. There were more cases during the summer and fall. The most frequent complaint was fever as a single symptom (67.5%). A cutaneous rash was reported in 44.1% and headache in 60.5% of patients. Among the patients, 44.1% presented with thrombopenia and 47.2% with elevated liver enzymes. CONCLUSION Murine typhus seems to be frequent in Tunisia. This infection could be a threat for travellers. Serology should be performed systematically in patients with fever as a single symptom since its clinical presentation is non-specific.

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.)

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.

Angine de poitrine et fièvre boutonneuse méditerranéenne

Summary The authors report a case of an angina pectoris occurinG in the course of a mediterranean spotted fever. Recovery arose with antibiotics. Such a complication is very unusual.

Early onset of paucisymptomatic cryptococcal meningitis in a kidney transplant patient: a case report and review of the literature.

Fungal infections of the central nervous system are rare and are more frequently encountered in immunocompromised patients. Cryptococcocal infection is the most common opportunistic fungal infection after Candida and Aspergillus in organ transplant recipients. Atypical manifestations and nonspecific neuroradiological findings due to the lack of inflammatory response in these immunocompromised patients are responsible for a delay in diagnosis. This diagnosis should be considered even in atypical neurological signs, and additional tests (cerebrospinal fluid examination, magnetic resonance, etc) that may help to suggest the correct diagnosis should be used. We report a case of cryptococcal meningitis in a renal transplant recipient, which was misdiagnosed for several months because of an atypical presentation of headaches without fever or neurological signs.

Méningite à Streptococcus oralis après myélographie

Summary Bacterial meningitis is a rare complication of myelography.Viridans streptococci are responsible in must cases. The authors described a new case of meningitis due to Streptococcus oralis occurring more than 3 days after myelography in a 55 year old woman. The probable origin and the mechanism of infection are discussed.

Les modifications électrocardiographiques au cours de la fièvre boutonneuse méditerranéenne

Summary Mediterranean spotted fever is an eruptive disease caused by Rickettsia conorii . Endothelitis comes as a consequence of this infection. In this work we studied the electrocardiographic change of 9 patients with mediterranean spotted fever. Six had alteration of cardiac conduction. The pathogenic mechanism of vascular injury induced myocardial oedema. All patients with mediterranean spotted fever should be screened with an ECG.