M. Koubaa

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.

Acute pancreatitis as initial manifestation of adult Henoch-Schönlein purpura: report of a case and review of literature

Abdominal pain observed in Henoch-Schönlein purpura (HSP) is usually attributed to edema and hemorrhage in the small bowel wall, secondary to a small-vessel vasculitis. Pancreatitis secondary to HSP is extremely rare. Here we report a 53-year-old man presented with acute pancreatitis that developed into characteristic rashes seen during HSP at the second day of the clinical onset, together with arthritis and glomerulonephritis. HSP is a rare and benign cause of acute pancreatitis. This complication can occur as an initial manifestation of HSP. Elevated serum amylase level can be considered as the early diagnostic tool for HSP pancreatitis. The patients with HSP who have abdominal pain as their chief complaint should be evaluated for pancreatitis, by routine serum amylase and abdominal computed tomography scan, to plan the specific treatment and avoid unnecessary surgery.

Deep vein thrombosis associated with acute brucellosis: a case report and review of the literature

To the Editor, Human brucellosis remains the most common zoonotic disease worldwide, with more than 500,000 new cases annually. It is still a serious and uncontrolled public health problem in many countries, including Tunisia. Human brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations and its complications can affect almost all organs and systems, with varying incidence. Vascular complications of Brucella infection have rarely been reported in the medical literature. By searching MEDLINE, eight cases of deep vein thrombosis (DVT) associated with acute brucellosis have been reported [1-8]. We describe a new case of DVT in the left leg in association with acute brucellosis. A 52-year-old Tunisian man was admitted to our hospital with a 4-day history of fever and left calf pain associated with myalgia and night sweats. He also reported the ingestion of raw sheep milk. The patient was febrile, to 38.3℃. Homan sign was positive on the left. The circumference of his left calf was 3 cm larger than that of the right. Palpation of the right sacroiliac joint was painful. The rest of the physical examination was unremarkable. A Doppler ultrasound study showed a thrombosis in the left femoral vein. Laboratory examinations revealed the following results: white blood cell count 7,300 cells/mm3 (neutrophils, 49%), platelet count 275,000/mm3, erythrocyte sedimentation rate 30 mm, and C-reactive protein 43 mg/dL. Results of other routine biochemical blood tests were all normal. Protein C, protein S, antithrombin III, and activated protein C resistance activity were within normal ranges, and anticardiolipin and lupus anticoagulant were negative. The chest X-ray and abdominal ultrasound were normal. An anteroposterior X-ray of the pelvis showed grade II sacroiliitis of the right sacroiliac joint. Standard tube agglutination testing of initial samples were positive for antibodies to Brucella (titer, 1/640). Based on the history of ingestion raw sheep milk, fever associated with myalgia and night sweats, the presence of sacroiliitis, and a positive Wright test, a diagnosis of acute Brucella infection associated with a DVT in the left leg was made. The patient was treated with rifampicin 900 mg/day and doxycycline 200 mg/day combined with low molecular weight heparin. The treatment durations for both anticoagulant and brucellosis were extended to 3 months. After a follow-up period of 9 months, the patient was asymptomatic and, during this period, no recurrence of brucellosis or DVT was observed. Vascular complications of brucellosis are rare; the arteries are more affected than veins. Arterial complications of brucellosis include aneurysm formation in diverse arteries, such as the aorta, brachial, tibioperoneal, and cerebral arteries, with or without underlying endocarditis. Cutaneous vasculitis has also been noted. Vein thrombosis is a rare vascular complication in acute brucellosis. In 1973, Romem et al. [8] reported the first case of brucellosis complicated with central vein thrombosis. Since this publication, seven further cases of vein thrombosis due to brucellosis have been reported. Table 1 shows demographic data and clinical and laboratory findings of the eight case reports of brucellosis complicated with vein thrombosis. Thrombosis involved the portal vein [7], the central retinal vein [8], the cerebral vein [6], and the lower limb veins [4] in one case each. Acute brucellosis was associated with DVT in the legs in four patients (three men, one woman). The diagnosis of DVT in the leg was made before the onset of other clinical features of brucellosis in one case [2] and concomitant with the diagnosis of brucellosis in two [3,5]. The duration between DVT diagnosis and the occurrence of brucellosis clinical features was 4 weeks. One patient had a history of brucellosis [1]. Table 1 Summary of all reported cases of deep vein thrombosis associated with brucellosis Suggested mechanisms by which brucellosis may cause DVT include induction of inflammation by the infectious process in adjacent tissues, direct endothelial damage, granulomatous endophlebitis, compression from a local soft tissue mass or abscess, induction of a transient hypercoagulable state, and an immune reaction in the vessel wall to a Brucella antigen. In the present case, protein C, protein S, and antithrombin III levels, and activated protein C resistance activity were normal, and no antiphospholipid antibodies were detected. Also, no local infection adjacent to his left leg deep veins was observed in his illness. Thus, it is possible that granulomatous endophlebitis or a possible immune reaction in the vessel wall to a Brucella antigen was responsible for the patients DVT. DVT is a rare complication of brucellosis. We report a new case of leg thrombophlebitis revealing acute brucellosis. The present case and the others reported previously suggest that brucellosis must be considered in patients suffering with DVT, particularly in patients from Brucella-endemic areas.

Actinomycotic brain abscess as the first clinical manifestation of hereditary hemorrhagic telangiectasia—case report and review of the literature

Dear Editor, Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu–Osler–Weber syndrome is a highly penetrant autosomal dominant disorder [1]. The diagnosis of HHT is based on the Curaçao criteria [2]. A definite diagnosis of HHT is made in the presence of at least three separate manifestations: spontaneous recurrent nosebleeds, mucocutaneous telangiectasia, visceral arteriovenous malformations (AVM), family history (a first-degree relative affected according to these criteria). For patients with definite clinical HHT, molecular testing is not required to confirm their diagnosis [1]. Brain abscess was observed in 75 % of the patients with HHT, since AVM is often asymptomatic prior to neurological presentation [3]. We report a rare case of multiple brain abscesses due to Actinomyces israelii in a 32-year-old immunocompetent woman as the first clinical manifestation of HHT. By searching in Medline till October 2012, we reviewed all published reports of HHT and actinomycotic brain abscess. A 32-year-old woman with a history of recurrent epistaxis was admitted for persistent headache and vomiting during the last 21 days. Her physical examination revealed multiple small telangiectases on the mucosal surface of the mouth, tongue, lips, and face. The patient was afebrile. Her neck was supple and the neurologic exam was normal. A chest Xray revealed a mass in the apex of her left lung. Computed tomography (CT) of the chest showed multiple AVM in both lungs especially in the apex of her left lung. Cerebral magnetic resonance imaging revealed two right parietal (33×19 mm) and temporal (35×20 mm) abscesses surrounded by cerebral edema, showing ring enhancement following contrast administration. Echocardiography was normal. The patient was transferred to the neurosurgical intensive care unit, where she had craniotomy with excision of the parietal abscess. Culture of the pus grew A. israelii and she was treated with ampicillin (12 g daily) and rifampin (1.2 g daily). Abdominal ultrasound showed vascular malformations in the liver. A stomatology exam and a panoramic X-ray showed a dental abscess. So, tooth extraction was performed. Based on the history of recurrent epistaxis, the presence of cutaneous and mucosal telangiectases, as well as the AVM in both lungs and liver, we made the diagnosis of HHT. Four weeks after surgery, the treatment with ampicillin had to be discontinued because of allergic reaction and the patient was started on oral thiamphenicol (1.5 g daily) associated with rifampin. She continued to take this medication for 3 months. A CT of the brain before interruption of the treatment indicated that all lesions in the brain had improved. Clinically, the patient was doing well without any neurological deficit and she refused the follow-up of the pulmonary AVM. Streptococcus was the most common organism isolated in brain abscesses in patient with HHT [4, 5]. Actinomycotic brain abscesses associated with HHT have been reported in seven cases (Table 1) [6–12]. Actinomyces is a fastidious organism requiring prolonged culturing for growth and M. Koubaa (*) :D. Lahiani : I. Mâaloul : C. Marrakchi : M. B. Jemâa Department of Infectious Diseases, Hedi Chaker Hospital, Sfax 3029, Tunisia e-mail: makram.koubaa@gmail.com

Do inhaled corticosteroids increase the risk of Pneumocystis pneumonia in people with lung cancer

Pneumocystis pneumonia (PCP) is a life-threatening infection in immunocompromised patients. It is relatively uncommon in patients with lung cancer. We report a case of PCP in a 59-year-old man with a past medical history of chronic obstructive pulmonary disease treated with formoterol and a moderate daily dose of inhaled budesonide. He had also advanced stage non-small lung cancer treated with concurrent chemo-radiation with a cisplatin-etoposide containing regimen. The diagnosis of PCP was suspected based on the context of rapidly increasing dyspnea, lymphopenia and the imaging findings. Polymerase chain reaction testing on an induced sputum specimen was positive for Pneumocystis jirovecii. The patient was treated with oral trimethoprim-sulfamethoxazole and systemic corticotherapy and had showed clinical and radiological improvement. Six months after the PCP diagnosis, he developed a malignant pleural effusion and expired on hospice care. Through this case, we remind the importance of screening for PCP in lung cancer patients under chemotherapeutic regimens and with increasing dyspnea. In addition, we alert to the fact that long-term inhaled corticosteroids may be a risk factor for PCP in patients with lung cancer. Despite intensive treatment, the mortality of PCP remains high, hence the importance of chemoprophylaxis should be considered.

Safety and Disease Evolution of Fixed-Dose Combination of Antitubercular Treatment Compared to Separate-Drugs Preparation in Extra-Pulmonary Tuberculosis

Purpose of ReviewExtra-pulmonary tuberculosis (EPTB) treatment was previously based on separate-drugs preparation (SDP). In the hope of reducing the rates of treatment default and resistance, the WHO have recommended the use of fixed-dose combination (FDC) for first-line in EPTB. We aimed to compare the tolerance and the disease evolution between FDC and SDP regimens in EPTB patients.Recent FindingsWe conducted a retrospective study including 388 cases of EPTB hospitalized between 1996 and 2016. We compared anti-tuberculosis treatment outcomes and the disease evolution between patients receiving FDC and those receiving SDP. The main EPTB site was lymph node (39.2%). There were no statistical differences between the two groups in terms of musculoskeletal, hematological disorders, cutaneous events, and hepatotoxicity. We noted that neurological disorder (OR = 12; p < 0.001), notably paresthesia (OR = 16; p < 0.001), and retrobulbar neuritis (OR = 10; p = 0.006), as well as gastro-intestinal intolerance (OR = 4; p = 0.015) including nausea (OR = 8.9; p = 0.011) and vomiting (OR = 1.1; p = 0.005) were significantly more frequent in the SDP group. The disease evolution comparison showed that complicated forms were statistically more frequent in the SDP group than those in the FDC group (OR = 2.4; p = 0.003), while there was no significant difference in relapse, sequelae, and death frequencies between the two groups.SummarySDP tolerance was characterized by higher frequency of paresthesia, retrobulbar neuritis, nausea, and vomiting than FDC. Evolutionary profiles were similar, except a higher risk of complicated forms in SDP.

Elevated Neutrophil-to-Lymphocyte Ratio is an Effective Prognosis Indicator In Extra-Pulmonary Tuberculosis

Abstract Background Extra-pulmonary tuberculosis (EPT) may lead to serious outcomes in the absence of an adequate treatment. Factors related to poor prognosis (PP) are still insufficiently understood. The peripheral blood neutrophil to lymphocyte ratio (NLR) has been reported to correlate with the prognosis of many acute or chronic infectious diseases. In this perspective, we aimed to investigate the prognostic relevance of NLR in EPT patients. Methods Data were collected from EPT patients, diagnosed between 1990 and 2014. We defined a PP by the occurrence of clinical complications during the hospital-stay or the follow-up. We evaluated the performance of NLR in identifying PP. The Kaplan-Meier method was used to generate complication-free survival curves which were compared by Log rank test according to NLR categories. Cox proportional hazard regression analysis was used to reveal the independent prognostic factors. Results We included 265 patients with EPT among them 68 cases (25.7%) had a PP. The mean age was 42 ± 19.2 years. Sex ratio was 0.8. EPT incriminated lymph node in 95 cases (35.8%), neuromeningeal sites in 50 cases (19%) and bones in 42 cases (15.8%). Mean value of NLR was significantly higher in the PP group (4.5 ± 3 vs. 3.2 ± 2.5; P = 0.01). NLR had an Area Under the Receiving Operating Curve (AUROC) of 0.63 in predicting PP (P = 0.004). At an optimal cutoff of 2.7, sensitivity and specificity were of 60%. There were 128 cases (48.3%) with a high NLR (≥ 2.7). Positive predictive value of NLR was 67.2% while negative predictive value achieved 80%. Overall, the median complication-free survival was 33 days (CI95% 19.2–46.7). When stratified by NLR cutoff, survival curve analysis showed that the one-month complication-free survival rate was lower in patients with high NLR (45% vs. 55%; P = 0.042). In multivariate Cox regression analysis, high NLR was an independent risk factor of predicting PP in EPT patients (HR=1.7; CI95% 1.1–2.9; P = 0.048). Conclusion In this study, NLR was a useful prognostic factor to predict complications in patients with EPT and may be applied in clinical management of EPT in association with other prognostic indicators in order to identify high-risk patients. Disclosures All authors: No reported disclosures.

APRI Score as a Predictor of Significant Liver Fibrosis in Chronic Hepatitis B

Abstract Background Chronic hepatitis B (CHB) is a global public health problem. Histologic staging of liver fibrosis is crucial to identify patients who need antiviral treatment. As an alternative to percutaneous liver biopsy (PLB), Aminotransferase Platelet Ratio index (APRI) score was recently validated by the WHO. We aimed to evaluate the performance of APRI score in predicting significant fibrosis (SF) in patients with CHB. Methods We conducted a retrospective study including 179 patients aged ≥ 15 years with documented CHB and who underwent a PLB during the period 2008-2016. A SF was defined according to Metavir score (≥ F2). ROC curves assessed the performance of APRI score in predicting SF. We estimated PLB cost of 60 Dollars in our institution. Results Mean age of patients was 37.6 ± 10 years and sex ratio was 1.48. There were 93 patients with SF (52%) who had a high level of aspartate aminotransferase (ASAT) (71.4 ± 38 vs. 34 ± 16 IU/L; P < 0.001) but a low level of platelet count (195 ± 53 vs. 208 ± 52 G/L; P = 0.04). APRI score was significantly higher in patients with SF (1.1 ± 0.7 vs. 0.48 ± 0.26; P < 0.001). Multivariate analysis using logistic regression showed that only APRI score was independently predictive of a SF (HR = 3.78, CI95% 1.23-11.6; P = 0.02). APRI predicted accurately SF with an Area Under the Receiving Operating Curve (AUROC) of 0.7 (CI 95% 0.62–0.77; P < 0.001). At a threshold of 0.5, APRI had a sensitivity of 62%, a specificity of 68%, a positive predictive value of 64.4% and a negative predictive value of 60.7%. The number of avoided PLB with APRI score was 112 PLB with a diagnostic accuracy of 62.5%. Subsequently, the saved cost was estimated to be around 6720 Dollars. Conclusion APRI score was well performing in predicting SF in patients with CHB. This could be of paramount importance particularly in developing countries given that this non-invasive score may help to assess liver fibrosis in CHB. Larger scale and analytic prospective studies are required in order to strengthen the accuracy of this score. Disclosures All authors: No reported disclosures.

Une cause inhabituelle de céphalées

A 64 year old woman presented to the emergency department with a history of sudden onset severe generalised headache after waking, associated with nausea. She had no medical history. On examination, the pain had not eased but she appeared alert with no other discernible features. She underwent a computed tomography scan of the head (fig 1). What is the diagnosis, and are further investigations warranted?

How Easy is the Differential Diagnosis Between Brucellar and Tuberculous Spondylodiscitis

• Spondylodiscitis is a common disease that may lead to serious vertebral sequelae. This entity has aroused a major interest in the endemic countries where M. Tuberculosis and Brucella spp are frequently involved. • The aim of our study was to compare the clinical, biological, radiological and therapeutic characteristics of brucellar (BS) and tuberculous spondylodiscitis (TS). How Easy is the Differential Diagnosis Between Brucellar and Tuberculous Spondylodiscitis ?