Drug resistance to Human Immunodeficiency Virus (HIV) antiretroviral therapy (ART) is a major factor in treatment failure. Resistance monitoring is recommended before initiating ART. However, in Tunisia, the pre-treatment resistance related data are missing. This study aimed to investigate the HIV-1 pre-treatment drug resistance in Tunisia. Viral RNAs were extracted from the plasma samples of 77 ART-naïve patients and used for the sequencing of Reverse Transcriptase (RT) and Protease (PR) regions. 12.9

Introduction Antiretroviral therapy (ART) has significantly improved prognosis of human immunodeficiency virus (HIV) infection by reducing both morbidity and mortality rates. However, this therapy leads to an increased incidence of metabolic disorders, such as insulin resistance (IR). The aim of this study was to determine the prevalence of IR in non-diabetic HIV-infected patients receiving ART, and to investigate the potentially associated factors. Material and methods We conducted a cross-sectional study among 67 non-diabetic HIV-infected patients receiving ART. IR was determined through homeostasis model assessment (HOMA-IR). Bivariate and multivariate analyses were performed to investigate the association between demographic, clinical, and biological variables, and IR. Results A total of 67 HIV-infected patients were enrolled, among whom 43 (64.2%) were males, and the median age was 38.7 years. The prevalence of metabolic syndrome was 28.3%, and IR was found in 30 patients (44.7%). Seventeen of these patients had not a metabolic syndrome. HOMA-IR values were ranging between 2 and 3.99 in 11 patients (64.7%), between 4 and 6 in 5 patients (29.4%), and was greater than 6 in one patient. In the multivariate analysis, there was no significant association between body mass index, CD4+ count, ART regimen, and IR. Conclusions Asymptomatic IR, responsible in the long-term for the occurrence of other serious metabolic disorders, is common among HIV-infected patients, and cannot be predictable. Screening of insulin resistance by measuring HOMA-IR is the main parameter for early detection of metabolic risk and personalized management.

Abstract Background Studies regarding salivary biochemical parameters and dental caries in adult people living with HIV/AIDS (PLWHA) are scanty. Aim: To investigate salivary biochemical parameters and dental caries in adult PLWHA who are on antiretroviral therapy (ART) and compare the findings with people negative for HIV infection. Methods The study included 50 HIV positive individuals as a test group (TG) and 50 HIV negative individuals as a control group (CG). Dental examination was performed according to WHO guidelines to assess DMFT. Digital panoramic radiographs were taken to detect additional infectious foci. Non-stimulated saliva was collected between 9 and 12 a. m for 5 min to evaluate 18 biochemical parameters and salivary flow rate (SFR). Parametric and non parametric tests were used according to data distribution. The level of significance was set at p < 0.05%. Results Patients’ mean ages and M/F sex ratios for TG and CG were 38.80 ± 9.69 y/o. vs. 37.98 ± 13.47 y/o. and 3.54 vs. 2.33, respectively. Higher means of decayed teeth were recorded in TG, 4.47 ± 3.00 vs. 3.88 ± 2.81 in CG with no significant difference (p = 0.41). Means of filled teeth were significantly lower in TG 2.38 ± 2.16 vs. 4.16 ± 3.35 in CG (p = 0.01), respectively. No statistical significant difference was noted in DMFT indices between the 2 groups (8.04 ± 6.90 vs. 8.52 ± 6.24, p = 0.71). The following salivary parameters were significantly lower in TG compared to CG, respectively: mean SFR 0.44 ± 0.18 ml/min vs. 0.61 ± 0.26 ml/min; median levels of sodium and chlorides, 4 mmol/L and 13.5 mmol/L vs. 9 mmol/L and 19 mmol/L (p < 0.001) and uric acid, 103.50 mmol/L vs. 163 (p = 0.009). However, higher median levels were recorded with calcium, 1.09 mmol/L vs. 0.54 (p < 0.001) and sIgA 23 mg/dl vs. 5 mg/dl (p < 0.001). In TG, a positive correlation was found between DC, potassium, urea, and chlorides (p < 0.05). Salivary renal and hepatic biomarkers were comparable between the two groups. Conclusions PLWHA have shown an alteration in some salivary parameters, more decayed teeth and less filled teeth. Preventive measures should be implemented to lower dental caries and enhance accessibility to oral care services. In addition, saliva can be utilized to monitor oral and general health status among PLWHA on ART.

Visceral Leishmaniasis (VL) is the most severe and fatal disease if left untreated. In people living with HIV/AIDS (PLHA), VL is considered an emerging opportunistic infection. The aim of this manuscript was to report a first case in Tunisia of a concomitant presentation of visceral and oral leishmaniasis in a patient LHA. A systematic review of the literature was performed according to PRISMA guidelines, as well. The patient, a 43-year-old heterosexual man, treated for HIV/AIDS was referred for macrocheilitis of the upper and lower lips. A noticeable nodular and painless swelling extending to the cheeks’ mucosa was noted. The patient's poor oral hygiene was evident due to the presence of multiple dental caries. Histological analysis of the biopsied lower lip sample revealed the presence of numerous Leishmania amastigotes. The diagnosis of VL was clinically confirmed by the presence of a mild splenomegaly and pancytopenia and biologically by the identification of the parasite using PCR Lei and the species L. infantum involved using RFLP-PCR and culture. The treatment consisted of an intravenous administration of liposomal Amphotericin B (Ambisome®, 40 mg/kg/weight) for a period of 6 weeks. A favorable outcome was noted after one year with the resolution of clinical symptoms and a negative Leishmania blood PCR test. After 2 years, the patient remained asymptomatic but showed a positive Leishmania blood PCR test. Dolutegravir® was introduced in the patient’s ART regimen. To the best of our knowledge, this is the first case report in Tunisia of atypical VL diagnosed through an uncommon oral location in an HIV/AIDS co-infected patient . Since VL is a severe and potentially fatal disease, it is essential for dentists to perform a thorough clinical examination and adopt a multidisciplinary approach in order to ensure an early diagnosis and an effective treatment outcome.

Kaposi’s sarcoma is a well-known multifocal vascular tumor initially described by pathologist Moritz Kaposi. This report presents the case of a 38-year-old bisexual male who consulted the infectious diseases department with non-itchy maculopapular and purpuric lesions on the skin with the involvement of the oral mucosa, suggesting a diagnosis of Kaposi’s sarcoma. Biological and radiological investigations were performed. The patient was found to be human immunodeficiency virus positive with a viral load of 251.000/mL and a CD4 count of 182/mm 3 . In addition, secondary syphilis was diagnosed. Histopathological examinations confirmed HHV-8 KS. The patient was treated with Extencilline ® and antiretroviral therapy. After 10 months of chemotherapy, a favorable outcome was noted with complete resolution of skin and oral mucosa lesions.

Introduction: Antiretroviral therapy has significantly improved the prognosis of human immuno-deficiency viruses (HIV) infection. Therefore, life expectancy of people living with HIV (PLHIV) has increased. However, this therapy may have some side effects. This study aimed to detect the prevalence of sub-clinical carotid and coronary atherosclerosis among asymptomatic patients living with HIV, free from known cardiovascular diseases, and to identify the factors associated with sub-clinical athe-rosclerosis. Material and methods: We conducted a cross-sectional prospective study over one year (between July 2018 and June 2019). We included 75 PLHIV, followed-up in the outpatient clinic of the Infectious Diseases Department of the University Hospital Fattouma Bourguiba in Monastir, Tunisia. Cardio-vascular assessment, including carotid doppler ultrasonography, electrocardiogram, exercise stress testing, and transthoracic echocardiography was proposed to all study participants. Results: The cardiovascular assessment revealed sub-clinical atherosclerosis in 9 PLHIV (12%): carotid atherosclerosis in 9 cases and coronary artery atherosclerosis in one case. One patient had presented both carotid and coronary atherosclerosis. After multivariate regression analysis, smoking (OR = 2.6; 95% CI: 1.08-6.62%; p = 0.03) and age >= 40 years (OR = 2.3; 95% CI: 1.02-5.22%; p = 0.04) were found to be independent risk factors of sub-clinical atherosclerosis in PLHIV. Conclusions: Our study revealed that sub-clinical atherosclerosis was present in 1 of 8 PLHIV. Therefore, screening for atherosclerosis using carotid ultrasound imaging, transthoracic echocardiography, and ex-ercise stress test should be suggested for all PLHIV under 40 years and/or smokers.

Introduction:Despite the benefits of an efficient antiretroviral therapy (ART), HIV/AIDS epidemic still represents the most seriousaffection worldwide that negatively impacts people's quality of life (QoL). As no studies exist on QoL in Tunisia, the aim of the present work was i: to assess, based on WHOQOL-HIV BREF tool, the perception of QoL of people living with HIV (PLHIV) receiving ART and ii: to investigate the relationship between socio-demographic features, disease-related variables and QoL domains' mean scores.Methods:This cross-sectional study was conducted at the department of infectious diseases of F. Bourguiba Teaching Hospital in Monastir, Tunisia. One hundred and five participants receiving ART were involved. QoL assessment was based on the WHOQOL-HIV Bref including six domains with 29 items with scores ranged from the lowest (4) to the highest (20). Results were reported as frequencies and means (±SD). The Student's t-test for independent samples and the one-way ANOVA were performed to assess differences in QoL mean scores. Linear regression analysis was used to investigate predictors of QoL. The confidence interval was set at 95%.Results:Clients' mean age was 39.20±10.18 years old with a male to female sex ratio of 3.12. Low mean scores were seen with the environment (12.34±2.90), social relations (12.58±3.94) and psychological domains (12.76±3.31), and moderate mean scores were noted for the physical (14.11±3.52), the spiritual (14.05±3.78) and the level of independence (13.98±3.57) domains. Regression analysis showed that health status and feeling healthy were related to all QoL domains and that profession, marital status and the presence of a confident person were related to environment and spiritual domains.Conclusion:QoL of PLHIV on ART is affected. Concrete measures and strategies should be undertaken by healthcare stakeholders to improve QoL determinants.

Tuberculosis (TB) is a life-threatening bacterial disease that is prevalent in several regions of the world. TB usually manifests with pulmonary infection. However, other areas of the body can be affected. The main risk factors for acquiring TB include immunosuppression, diabetes mellitus, lung disease, end-stage renal disease, gastrectomy, malnutrition, tobacco smoking and drug use. Worldwide, the most important risk factor for TB is human immunodeficiency virus infection. Tuberculous lymphadenitis, pleuritis, and spondylodiscitis are the most common forms of extrapulmonary TB. Although central nervous system infections are increasingly rare, they are one of the most devastating clinical forms of TB.

L'atteinte neuroméningée est une localisation extra-pulmonaire fréquente et grave au cours de la tuberculose. L'objectif de notre étude est de décrire les aspects épidémio-cliniques, paracliniques et les modalités thérapeutiques de la tuberculose neuroméningée. Une étude rétrospective et descriptive incluant tous les patients hospitalisés dans notre service (2005–2020) pour une tuberculose neuroméningée (TNM) confirmée ou suspectée sur un faisceau d'arguments. Douze cas de TNM (cinq hommes et sept femmes) étaient colligés dans notre étude, âgés en moyenne de 41,8 ans. Les signes cliniques inauguraux étaient variables. La recherche de bacille de Koch dans le liquide céphalo-rachidien n'était positive que dans un seul cas. L'intradermoréaction à la tuberculine était positive dans 8 cas. L'imagerie médicale avait permis de retenir le diagnostic dans 5 cas. Tous les patients avaient bénéficié d'un traitement antituberculeux avec une bonne évolution. Le polymorphisme clinique rend le diagnostic de la TNM parfois difficile à établir en l'absence d'autres localisations. L'imagerie médicale est d'un grand apport diagnostique. L'évolution favorable dans notre série est liée à la précocité du diagnostic et à l'instauration rapide d'un traitement antituberculeux d'épreuve. La TNM est grave, pouvant engager le pronostic fonctionnel et vital. Un diagnostic précoce et une prise en charge thérapeutique rapide permettraient d'améliorer le pronostic de cette infection.

Nocardia infection is an uncommon and rare condition in immunocompetent patient. A case of cutaneous nocardiosis complicated with osteomyelitis of the vault scalp in a 64-year-old man, with no remarkable past medical history, is reported. Treatment with trimethoprime-sulfamethoxazole than doxycycline for 12 months led to complete resolution and no evidence of recurrence was noted. Nocardia infection should be considered even in immunocomptent patients and doxycycline is a good alternative for treatment.

Introduction: Visceral leishmaniasis is a well-recognized opportunistic infection in people living with HIV (PLHIV). Unlike adults, in children this infection is frequently associated with hemophagocytic lymphohistiocytosis (HLH). We report a case of HLH in HIV-positive person with visceral leishmaniasis. Case description: A 25-year-old man known living with HIV since 2013 was admitted to infectious diseases department in March 2017. His clinical examination was clear. His initial viral load was 630,000 copies/mm 3 and CD4+ cells count was 12/mm 3 . No opportunistic infections were noted. The patient was started on antiretroviral therapy. During hospitalization, he developed fever, asthe-nia, rhinorrhea, and odynophagia. The diagnosis of HLH was retained because of pancytopenia, cytolysis, hyponatremia, high level of ferrinemia, and hemophagocytosis. Etiological investigations revealed positive Leishmania PCR. Also, Leishmania was detected in sternal puncture. Patient received meglumine antimoniate (glucantime) 20 mg/kg/day for 21 days with favorable outcomes. To prevent relapse, he received meglumine antimoniate 20 mg/kg/month as long as his CD4+ count was less than 100 cells/mm 3 . After 1-year follow up, no relapse was detected. Conclusions: Clinical and laboratory presentation of visceral leishmaniasis in PLHIV may differ from classic kala-azar. In our case, HLH was the reason for VL discovery.

tBackground/Aims: During the natural course of Chronic Hepatitis B (CHB) infection, differentiationbetween inactive carrier (IC) and HBeAg negative CHB is a subject of ongoing debate. We studied therole of hepatitis B surface antigen (HBsAg) level as a means of differentiating between CHB and IC in agroup of untreated chronic HBeAg-negative HBV-infected patients. Study: A total of 115 HBeAg negative carriers were enrolled and followed up for > 12 months; 78 asinactive carriers (IC), and 37 as active carriers (AC). Among ACs, patients were categorized according tothe highest rate of viral load: AC1 (n = 23), active carriers with persistent HBV-DNA < 20,000 IU/mL; AC2( n = 14), active carriers with HBV-DNA > 20,000 IU/mL. Results: HBsAg levels were higher in AC compared to IC patients (1607 IU/ml vs. 225 IU/ml respectively, P = 0.001). Among the AC group, the 23 AC1 cases had HBsAg levels significantly lower than the 14 AC2patients (1756 IU/mL vs. 3327 IU/mL respectively; P < 10-3). HBsAg showed weak correlation with HBVDNA in the whole cohort (r = 0.44, P < 0.01). The suggested cutoff value of HBsAg titer to differentiatebetween the two groups was 938 IU/mL. Combined single-point quantification of HBsAg (938 IU/mL) andHBV DNA (2000 IU/mL) identified IC with 87.2% specificity and 91.7% positive predictive value. Conclusion: This study confirms the predictability of a one-time combined HBsAg and HBV DNA measurement for true inactive carriers requiring neither strict follow-up nor antiviral treatment.

Self-medication for alleviating pain is very prevalent in most countries. While safe self-medication is supposed to be dependent on both patient's behaviour and pharmacist's counselling, little is known about the context of the delivery of analgesics available without prescription. The primary objective of the study was to define sociodemographic profiles and behaviours of patients seeking non-prescribed analgesics in French community pharmacies. Secondary objectives included the assessment of pharmacist management and identification of risk-associated patients.This is a cross-sectional, national and multicentre study, including adults who asked for a prescription-free medication for acute or chronic physical pain. Information was collected through separate patient and healthcare professional (HCP) questionnaires.The analysis was based on 1215 and 1271 patient and HCP questionnaires, respectively, collected from 164 pharmacies. The patient population consisted in women and men (ratio 6:4), mainly (71%) under 60 years old. Headaches, rheumatologic and musculoskeletal pains were the most frequent reasons for getting analgesics, with a median pain intensity of 6 on a scale graded from 0 (no pain) to 10 (intolerable pain). The main reasons guiding self-medication were time saving, a well-known pain and a well-known product. The mean time allocated to delivery was 4.7 minutes. Indications, dose and posology were almost systematically addressed by the pharmacy staff, while contra-indications, drug-drug interaction or safety were mentioned in around two-third of cases. The proportion of patients identified at risks due to an inappropriate context of self-medication was 15.5%.This study shows a great heterogeneity of the population asking for non-prescribed analgesics in French community pharmacies. While pharmacists were able to identify patients at risks, a significant part may have ‘slipped through the net’. The results support further studies to better define patient care pathway and optimize pharmacist-led medication.L’automédication de la douleur est très fréquente dans la plupart des pays. Si l’automédication est censée être dépendante du comportement du patient et des conseils du pharmacien, il existe peu de données sur le contexte de délivrance des antalgiques disponibles sans prescription. L’objectif primaire de cette étude était de préciser les profils sociodémographiques et les comportements des patients demandeurs d’antalgiques sans ordonnance dans des officines françaises. Les objectifs secondaires incluaient l’évaluation de la gestion de la demande par le pharmacien et de l’identification des patients à risque.Il s’agit d’une étude nationale transversale multicentrique, incluant des adultes demandeurs de traitement sans ordonnance pour une douleur aiguë ou chronique. Les informations ont été recueillies au moyen de questionnaires remplis par les patients et les équipes officinales.L’analyse était basée sur 1215 et 1271 questionnaires patients et pharmaciens, respectivement, recueillis auprès de 164 pharmacies. La population de patients comprenait des femmes et des hommes (rapport 6/4), pour la plupart (71 %) âgés de moins de 60 ans. Les céphalées, les douleurs musculaires ou rhumatologiques étaient les causes les plus fréquentes de demandes d’antalgiques, avec une médiane d’intensité de la douleur de 6 sur une échelle graduée de 0 (pas de douleur) à 10 (douleur insoutenable). Les principales raisons motivant l’automédication étaient le gain de temps et la bonne connaissance de la douleur et/ou du médicament. La durée moyenne dédiée à la délivrance était de 4,7 minutes. Les indications et la posologie étaient presque systématiquement abordées par les équipes officinales, tandis que les contre-indications, les interactions médicamenteuses ou la tolérance n’étaient mentionnées que dans deux-tiers des cas. La proportion de patients jugés à risque du fait d’un contexte d’automédication inappropriée était de 15,5 %.Cette étude montre une grande hétérogénéité de la population demandeuse d’antalgiques disponibles sans ordonnance dans les pharmacies françaises. Si les pharmaciens ont été capables d’identifier des patients à risque, une proportion significative de patients pourrait être passée « entre les mailles du filet ». Ces résultats plaident pour la mise en place d’études complémentaires visant à mieux définir le parcours de soin dans la douleur et à optimiser le rôle des pharmaciens.

Introduction: Brucellosis is a highly contagious zoonosis with high morbidity in human. The objective of this study is to describe epidemiological and clinical aspects and therapeutic outcomes of brucellosis in an endemic region.

Introduction : La tuberculose est un probleme majeur de sante publique en Tunisie. Le but de notre travail est de decrire les manifestations cliniques de la tuberculose chez le sujet âge et d’evaluer les facteurs de risque d’echec therapeutique. Methodes : etude retrospective menee dans le service des Maladies Infectieuses durant la periode (1996-2015) et portant sur les malades dont l’âge est superieur a 60 ans et qui etaient hospitalises pour tuberculose active. Les donnees epidemio-cliniques, radiologiques, therapeutiques et evolutives etaient recueillies. Resultats : deux cent cinq cas etaient colliges avec une incidence de 10,5 cas par an. Quarante-six malades (22,6%) avaient un âge superieur a 60 ans. il s’agissait de 14 hommes (30,2%) et 32 femmes (69,8%) et repartis en 12 cas (26%) de tuberculose pulmonaire et 34 cas (74%) de tuberculose extra pulmonaire. La fievre etait notee dans 21 cas (45,6%). Le diagnostic etait etabli selon des donnees anatomopathologique dans 27 cas (58,7%), radiologique dans 18 cas (39%) et bacteriologique dans 12 cas (26%). Aucun malade n’avait de serologie VIH positive. Quatre malades (2%) sont decedes. Deux cas d’echec therapeutique etaient identifies. Le diagnostic d’echec etait etabli selon des criteres cliniques et radiologiques dans tous les cas histologiques. La cause d’echec etait un diagnostic differentiel. Conclusion : la tuberculose extra-pulmonaire est la forme la plus frequente de tuberculose chez le sujet âge selon notre etude. Dans la majorite des cas, le traitement antituberculeux etait debute sans preuve bacteriologique et ceci pourrait engendrer l’emergence de resistance aux traitements antituberculeux de premiere intention. Ainsi, avant le debut de traitement, les explorations sont indiquees pour obtenir une confirmation bacteriologique et prevenir l’echec therapeutique.

Introduction: la tuberculose est une maladie chronique dont le traitement ncessite une bonne observance. La confirmation du diagnostic au cours de la tuberculose extra-pulmonaire est plus difficile que la tuberculose pulmonaire, cause de la diversit des symptmes. Le but de notre tude tait de dterminer les aspects pidmio-cliniques de la tuberculose extra-pulmonaire chez les patients gs.