Les mycoses profondes restent encore une pathologie peu connue du fait de leur rareté dans la pratique médicale quotidienne en zone d’endémie subsaharienne. L’histoplasmose africaine Histoplasma capsulatum variété duboisii (H. capsulatum duboisii) est la plus décrite au Mali, à travers des études parcellaires chez des sujets adultes, depuis la description du premier cas par Catanei et Kervran (1945) au Soudan. Notre observation porte sur une histoplasmose africaine disséminée d’un jeune enfant de 6 ans, masculin, rural. Les localisations étaient cutanéo-muqueuses, ganglionnaires, urinaire et osseuse. L’évolution a été émaillée d’un épisode d’aggravation de la symptomatologie malgré une amélioration clinique initiale par le kétoconazole. Après guérison des ulcérations cutanéo-muqueuses, on a noté une limitation de mouvement des deux poignets. Les lésions osseuses séquellaires radiographiques étaient faites d’image lacunaire de l’extrémité inferieure du radius droit et du cubitus droit et une fragmentation de l’épiphyse cubitale du même bras. Sur le 5e doigt droit existaient des lacunes des métatarses et des phalanges. Une lacune et un aspect soufflé de la 2e phalange du 3e doigt gauche étaient notés. La forme disséminée de l’histoplasmose africaine peut survenir sur terrain VIH négatif. Le pronostic dépend de la précocité du diagnostic et l’administration d’un traitement adapté et bien conduit.Endemic deep fungal infections are still under recognised diseases in daily medical practice because of their rarity in sub-Saharan area. The African histoplasmosis Histoplasma capsulatum var. duboisii (H. capsulatum duboisii) is the most frequent variety described in Mali through limited studies in adult patients, since the first case described by Catanei and Kervran (1945). Our case report is a disseminated histoplasmosis in a young 6-year-old african child. He was male and rural. The infectious localisations were mucosae, skin, lymphnodes, urinary tract and bones. Evolution has been marred by an episode of worsening of symptoms despite initial clinical improvement with ketoconazole. After healing of mucocutaneous lesions, we noticed a limitation of ampliation of both wrists. The radiographic bone lesions were lysis of the right lower end of the right radius and cubitus and fragmentation of cubital epiphysis of the same arm. Lacunes were present on the fifth right finger in metatarsus and phalanx; lacune and blowing aspect of the second phalanx of the left third finger was noted. The disseminated form of African histoplasmosis may occur in HIV-negative subject. The prognosis depends on early diagnosis and administration of appropriate and well-conducted therapy.

Introduction. - Intestinal microsporidiosis is recognised as an important cause of opportunistic parasitosis in immunocompromised patients, especially HIV-infected patients. Enterocytozoon bieneusi is the common causal agent. The diagnosis of intestinal microsporidiosis has usually based on microscopic detection of the spores of microsporidia species in stool samples, requires additional staining techniques as Modified Weber's trichrome stain. However, the detection of the spores can be difficult and species determination, which is important for defining the appropriate treatment, is impossible. Polymerase chain reaction (PCR)-based methods have been successfully used for detection of microsporidian infections. They are more sensitive and are able to identify microsporidia species. The purpose of this study is to identify E. bieneusi to adapt treatment and assess the true prevalence of the intestinal microsporidiosis due to this species in compromised patients in Tunisia.Patients and methods. - One hundred and eighteen stools from immunocompromised patients, with a symptomatology in favour of the intestinal microsporidiosis, were analysed using light microscopy after staining with Modified Weber's trichrome stain and PCR.Results. - Only four were positive by Modified Weber's trichrome stain whereas eleven stools were positive by PCR, giving a prevalence of 20% in HIV-infected patients and 5,35% in human immunodeficiency virus-negative patients.Conclusion. - This study confirms the usefulness of PCR in the diagnosis of the intestinal microsporidiosis due to E. bieneusi. Indeed, PCR has greater sensitivity than Modified Weber's trichrome stain and can identify the species of microsporidia in order to adapt the treatment. (C) 2009 Elsevier Masson SAS. All rights reserved.

La leishmaniose cutanée (LC) est une maladie parasitaire qui constitue un problème de santé publique aussi bien dans le monde qu’en Tunisie. Son diagnostic repose sur des techniques de routine, examen direct (ED) et culture, qui, en raison de plusieurs facteurs, manquent de sensibilité. La biologie moléculaire, plus rapide et plus sensible, a montré son apport dans le diagnostic de la LC. Le but de notre travail était de démontrer, d’une part, l’apport de la Polymerase Chain Reaction (PCR) dans le diagnostic de la LC (en comparant les résultats obtenus par cette technique de biologie moléculaire à ceux trouvés à l’ED) et, d’autre part, de comparer deux paires d’amorces ciblant le gène leishmanien codant pour la sous-unité 18s ribosomale : la paire R221/R332 (PCR1) et la paire Lei70L/Lei70R (PCR2). Notre travail a été réalisé sur 299 échantillons. Cent quatre-vingt-huit prélèvements étaient positifs par l’ED et/ou la PCR et 111 étaient négatifs. Deux prélèvements seulement étaient positifs uniquement par l’ED contre 74 qui étaient positifs uniquement en PCR (PCR1 et/ou PCR2). Parmi ces 74 prélèvements, 64 étaient positifs par la PCR2 seule contre deux prélèvements qui étaient positifs par la PCR1 seule. Les huit prélèvements restants étaient positifs à la fois par la PCR1 et la PCR2. La PCR (notamment la PCR2) montre un pourcentage de positivité plus important que l’ED : 98,93 % pour la PCR contre 60,6 % pour l’ED.

INTRODUCTION:Intestinal microsporidiosis is an opportunistic parasitological infection affecting mainly immunocompromised patients, particularly those infected with HIV.PURPOSE:The purpose of this study was to analyse the epidemiological and clinical characteristics of intestinal microsporidiosis and the treatments available for it.MATERIAL AND METHODS:This retrospective study examined records collected over a 13-year period (from January 1995 through December 2007). It included 572 immunocompromised patients (279 HIV-infected patients and 293 without HIV infection) with symptoms suggesting intestinal microsporidiosis. All were tested systematically for microsporidia spores by modified (Weber's) Trichrome staining.RESULTS:Fourteen patients (10 men, 4 women) were diagnosed with intestinal microsporidiosis, for a prevalence of 2.4% overall, 3.6% in HIV-infected patients and 1.4% in those without HIV infection. Intestinal microsporidiosis affected 10 HIV-infected patients, 70% of whom had a CD4 count <100 cells/mm3. Their mean age was 30+/-15 years (range: 15 months to 48 years). The average age of HIV-infected patients (36 years) was significantly higher than of those without HIV infection (15 years). Thirteen patients had symptoms, most frequently diarrhea (11 cases), sometimes associated with dehydration (5 cases). Eight patients (57%) received only symptomatic treatment, and 4 (28.6%) received albendazole. No treatment was recommended in 2 cases (14.3%). Clinical course was marked by improvement in 6 cases, death in 5, and persistence of asymptomatic carriage in one. Two patients were lost to follow-up.CONCLUSION:Intestinal microsporidiosis is a parasitological disease that mainly affects AIDS patients with CD4 counts <100 cells/mm3. Its diagnosis requires special techniques. Its symptomatology is dominated by chronic diarrhea that can cause dehydration. Effective treatment requires identification of the species.

Objective. - Vulvovaginal candidiasis is a common cause of feminine genital tract infection encountered in medical practice. The purpose of this study was to determine the epidemiological, clinical and mycological characteristics of vulvovaginal candidiasis in a Tunisian population and to evaluate predisposing factors.Material and method. - In this prospective study, 1415 vaginal swabs were collected over a period of 1 year (between February 2006 and January 2007). Candida albicans was isolated most frequently (81.16%) followed by C. glabrata (12.2%). Vaginal discharge was the most common symptom (89.70%) followed by vulvar prurits (77.28%) and dyspareunia (49.12%). Reproductive age, pregnancy, frequent genital hygiene, abortion, parity up to two, duration of diabetes correlated positively with vulvovaginal candidiasis. Vulvovaginal candidiasis was not associated with diabetes, type of diabetes, oral contraceptives, intrauterine device, condoms, antibiotic use or tight underclothing. The overall recurrence rate was 1.6%. Women with recurrent vulvovaginal candidiasis were infected more frequently by C. glabrata (28.6%) than women with sporadic vulvovaginal candidiasis (11,39%).Conclusion. - Our study showed that specific factors are involved in the genesis of vulvovaginal candidiasis. Their correction would be necessary to prevent the occurrence of vulvovaginal candidiasis, especially in its recurrent form. (C) 2010 Published by Elsevier Masson SAS.

Human cutaneous myiasis is a common dermatosis in tropical zones. The purpose of this report is to describe the first imported case of furuncular myiasis caused by Dermatobia hominis (human botfly) in Tunisia. The patient was a man returning from Bolivia. Furuncular myiasis was suspected based on epidemiological data and clinical examination showing pruriginous elevated lesions. Diagnosis was confirmed by identification of Dermatobia hominis larvae. Treatment was based mainly on manual removal of larvae. Since furuncular myiasis is unknown in Tunisia, it is important to remember this parasitic disease in differential diagnosis in patients presenting boil-like inflammatory papules following travel to Latin America.

The cutaneous leishmaniasis (CL) is a parasitic disease which represents a serious problem for the public health not only in Tunisia but also all over the world. Its diagnosis is based on the techniques which are usually used, direct examination and in vitro culture. Because of several factors, these techniques lack sensitivity. The molecular biology, which is indeed more rapid and more sensitive, has proved its effectiveness in diagnosis of the CL. There are two main aims for our research work. First, to show the contribution of the Polymerase Chain Reaction (PCR) during the diagnosis of CL (of course by comparing the results obtained when using this technique with those found through the direct examination); second, to compare the two pairs of primers which amplify the leishmanien gene coding for the 18s ribosomal sub-unit: the pair R221/R332 (PCR1) and the pair Lei70L/Lei70R (PCR2). Our work was carried out upon 299 samples. One hundred and eighty-eight of them were positive using the direct examination and/or the PCR and 111 were negative. Only two samples were positive using of course the direct examination in comparison with 74 which were positive when using only the PCR (PCR1 and/or PCR2). Among these 74 samples, 64 where positive using only PCR2 in comparison with two samples which were positive using only PCR1. The eight remaining samples were at once positive for the PCR1 and the PCR2. The PCR (notably the PCR2) has proved a more significant percentage of positivity in comparison with direct examination: 98.98% for the PCR and 60.6% for direct examination.

Fusarium spp. is a soil saprophyte fungi which may cause local mycoses but also deep infections especially at immunocompromised patients. Local infections are mostly onychomycosis and keratitis. Intertrigo with Fusarium spp. is rare. We report a case of intertrigo due to F solani of the fourth interdigital. spaces of the left foot in a 77-year-old female with inaugural diabetes. A diagnosis of F solani infection was made on the basis of positive direct examination and three successive samples produced pure growing of this mould. Systematic therapy with terbinafine led to disappearance of F solani, but no clinical recovery. In front of any intertrigo with Fusarium spp., the search for an aggravating factor is necessary which enabled us to reveal diabetes. (C) 2009 Published by Elsevier Masson SAS.

This is a retrospective study including 17 patients with rhino-orbito-cerebral mucormycosis diagnosed in a period of 16 years, between 1992 and 2007, in 8 men and 9 women. All patients were diabetic with ketoacidosis diabetes in 8 cases. Necrosis facial and ophthalmic symptoms were the most frequent presenting manifestations. The diagnosis was confirmed by mycological examination, with or without histopathology, identifying Rhizopus oryzae in 12 cases. Treatment consisted in systemic amphotericin B combined with surgical treatment in only 7 cases. The mortality rate was high (65%) due principally to the delay in diagnosis and absence of surgical treatment.

La pneumocystose est une mycose opportuniste responsable de pneumopathie interstitielle grave chez les sujets immunodéprimés infectés ou non par le VIH. Son diagnostic suspecté devant l’aspect clinique et radiologique est affirmé par la mise en évidence des trophozoïtes et/ou des kystes de Pneumocystis jiroveci par de nombreuses techniques de coloration (Gomori-Grocott [G-G], May-Grünwald Giemsa [MGG], bleu de toluidine O). Les techniques de biologie moléculaire viennent compléter le diagnostic mycologique classique, augmentant sa sensibilité. Notre travail a comparé les résultats d’une technique PCR en point final à ceux de deux techniques de coloration conventionnelles (G-G et MGG) couplés aux données clinicoradiologiques afin de relever l’apport de chacune d’elles dans le diagnostic de la pneumocystose. Nous avons colligé 64 prélèvements bronchopulmonaires provenant de 54 patients immunodéprimés (sida et autres pathologies) atteints de pneumopathies interstitielles aiguës hypoxémiantes. Le diagnostic de la pneumocystose a été retenu chez 15 patients, sur des arguments biologiques et/ou clinicoradiologique. La PCR a permis le diagnostic de la pneumocystose chez 14 patients avec une sensibilité de 93,3 % et une spécificité de 87,1 %, alors que les techniques de coloration étaient positives seulement dans cinq cas avec une sensibilité de 33,3% et une spécificité de 100%. La PCR dotée d’une grande sensibilité, trouve son intérêt dans la confirmation du diagnostic surtout dans le cas des prélèvements pauciparasités ou superficiels.

This is a retrospective study including 17 patients with rhino-orbito-cerebral mucormycosis diagnosed in a period of 16 years, between 1992 and 2007, in 8 men and 9 women. All patients were diabetic with ketoacidosis diabetes in 8 cases. Necrosis facial and ophthalmic symptoms were the most frequent presenting manifestations. The diagnosis was confirmed by mycological examination, with or without histopathology, identifying Rhizopus oryzae in 12 cases. Treatment consisted in systemic amphotericin B combined with surgical treatment in only 7 cases. The mortality rate was high (65%) due principally to the delay in diagnosis and absence of surgical treatment.

Background. - The newly described species Candida dubliniensis phenotypically resembles Candida albicans so closely that is easily misidentified as such.Objectives. - The present study was designed to determine the frequency of this species among various susceptible populations in Tunis and to assess fluconazole resistance.Patients/Methods. - Over a 1-year period, 350 isolates that were identified initially as C. albicans were revaluated for C. dubliniensis by inability to grow at 45 degrees C, chlamydospores production on Sunflower-agar medium and agglutination on Bichro-Dubli Fumouze (R) test.Results. - A total of 18 isolates were identified as C. dubliniensis giving a prevalence of 5.14% of C. dubliniensis among the C. albicans/C. dubliniensis strains. They were recovered from 11 human immunodeficiency virus-negative patients. Theses patients were immuno-compromised in ten cases. Isolates were recovered from sputum (27.8%), followed by tongue (22.2%), urine (16.7%), throat (11.1%), stool (11.1%) and rectum (11.1%). Antifungal susceptibility testing of the C. dubliniensis isolates showed 100% sensitivity to each fluconazole, 5-fluorocytosine and miconazole and 94.4% sensitivity to both itraconazole and amphotericin B.Conclusion. - Our study highlights the recovery of C. dubliniensis in Tunis (Tunisia). It was isolated in human immunodeficiency virus-negative patients from different clinical specimens. (c) 2009 Elsevier Masson SAS. All rights reserved.

Neuromeningeal cryptococcosis is a serious infection witch occurs essentially in immunodepressed patients and especially AIDS patients. We report 22 cases of cryptococcosis meningitis confirmed by the parasitology laboratory, in the Tunis Rabta hospital, over a 16-year period. Sixteen patients were HIV infected and six were not HIV infected. The clinical examination documented fever and headache as well as focal neurological signs especially in HIV infected patients. The mycological examination of CSF proved the diagnosis of neuromeningeal cryptococcosis in all cases. The first line treatment was Amphotericin B in 13 cases, Amphotericin B and 5Fluorocytosine in three cases, and fluconazole in six cases. 14 patients died, seven recovered, and one was lost to follow-up.

There has been a steady increase of visceral leishmaniasis during the past 20 years in Tunisia. In this study, we assess the value of two optimised PCR versus those of classical methods for the diagnosis of human visceral leishmaniasis. 106 samples were collected from 53 cases of pediatric visceral leishmaniasis. Peripheral blood and bone marrow samples were analysed both by parasitological methods (direct examination, leukocytoconcentration (LCC) and culture) and by PCR methods with two primer pair (R221/R332 and Lei 70L/Lei 70R). We diagnosed visceral leishmaniasis in all patients: 44 cases were diagnosed by culture (83%), 42 by direct examination of bone marrow (79%), 17 by LCC (32%), and 53 positive cases with both PCR assays (R221/R332 and/or Lei 70L/Lei 70R) (100 %). Regarding each PCR assay, for blood samples, the difference between the sensitivities of PCR Lei 70L/Lei 70R (86,8%) and PCR R221/R332 (17 %) is statistically significant with p-value 0.025. For bone marrow, the sensitivities of the two PCR methods were respectively 96,2% (Lei 70L/Lei 70R) and 75,5% (R221/R332). On the whole, PCR Lei 70L/Lei 70R was more effective than PCR R221/R332 and conventional methods for the two biological samples. Moreover, the requirement of less invasive sample using blood has the advantage of being repeatable for screening and for post therapeutic monitoring.

Three clinico-epidemiological forms of cutaneous leishmaniasis (CL) were described in Tunisia: the zoonotic CL (ZCL) epidemic which occurred in the centre of the country caused by Leishmania major MON-25, the chronic CL (CCL) In the south-east of the country caused by Leishmania killicki MON-8 and the sporadic CL In the North (SCL) caused by Leishmania infantum MON-24. The latter form, described in 1991, prevails in northern Tunisia with approximately thirty cases per year. Its vector, unknown for a long time could be according to the last publications, Phlebotomus perfiliewi or Phlebotomus langeroni; however, its reservoir remains unknown until now. The systematic isoenzymatic characterization permits to identify a great number of strains improving then knowledge on the eco-epidemiology of the disease. Indeed, changes were noted in the geographical distribution of these clinical forms: extension of the ZCL to the North and South, extension of the CCL to North and the SCL to the centre. We report in this note the first mention of L. infantum MON-24 in the two provinces of the centre of Tunisia: Kairouan and Sidi Bouzid, confirming the extension of the SCL to the Centre.

Diagnosis of pneumocystis pneumonia is usually based on clinical features and X-rays photography and confirmed in the laboratory by visualisation of Pneumocystis organisms in stained preparations of respiratory specimens using several techniques (Gomori-Grocott, May-Grünwald Giemsa, bleu de toluidine O). Actually, PCR has considerably increased sensitivity of detection of Pneumocystis. The aim of this study is to compare conventional PCR results to those of staining techniques (Gomori-Grocott, May-Grünwald Giemsa) in addition to the X-ray and clinical findings in order to evaluate the contribution of each method. Sixty-four respiratory specimens were collected from 54 immuno-compromised patients with clinical symptoms of pulmonary infection. We diagnosed pneumocystis pneumonia in 16 patients according to staining techniques and/or typical clinical and radiological findings and/or response to treatment. Of the 15 patients, 14 were positive by PCR and only five were positive by direct examination, yielding a sensitivity and specificity of 93.3 and 87.1% for PCR and 33.3 and 100% for staining techniques. Conventional PCR provides a sensitive and objective method for the detection Pneumocystis jiroveci from less invasive sample.

The different clinical forms of leishmaniasis are the result of both the immunological status of individuals and the species of the parasite causing the infection.

The number of visceral leishmaniasis (VL) cases is in continuous growth in Mediterranean countries. In Tunisia, in addition to the traditional infantile form, more and more cases in immunocompetent or immunocompromised adults have been reported. However, co-infection VL-HIV remains rare in Tunisia and diagnosis of all the cases up till now has been done using traditional techniques (serology, direct examination and culture of bone marrow). However, the last years, several studies proved the greatest sensitivity of PCR in VL diagnosis. We carried out a systematic detection of Leishmania in peripheral blood for 25 HIV infected patients (10 were asymptomatic, 6 presented a fever and/or a paleness and/or an asthenia, and 9 had an opportunist infection other than VL). In all cases, the culture on Novy-Nicolle-McNeal (NNN) medium was negative by the end of the month. Serology carried out for 22 patients was negative in IFI in 17 cases, positive at the 1/20 for four others and positive at the 1/40 for one patient (confirmed by Western Blot technique). A PCR using the primers Lei70L-Lei70R, specific of the gene of Leishmania infantum, allowed the display of the specific band of 345 bp for 17 samples. The higher sensitivity of PCR compared to conventional methods is subject to the difficulty of result interpretation in PCR positive testing among patients not having any other marker of the disease which raises the question of significance for this asymptomatic bearing. (C) 2007 Elsevier Masson SAS. Tons droits reserves.