Evolving trends in infective endocarditis over three decades in a developing country

Introduction

Infective endocarditis (IE) is a rare serious disease for which diagnosis and treatment and prophylaxis continue to develop.

Purpose

The aim of our work were to analyze evolution in its epidemiologic, clinical, and microbiologic characteristics, as well as the outcomes.

Methods

This study compare data from a retrospective study conducted by Bennis and Al based on 157 cases of infectious endocarditis admitted in tertiary care Hospital between January 1983 and December 1994, theses cases are referred as Group A; and 103 cases of infective endocarditis according to Duke criteria admitted to the same center three decades afterwards from december 2013 to January 2020, which are referred as Group B.

Results

The mean age of the patients has became older over decades, with a mean of 27.5 years (11–65 years) in the group A versus 39.2 years [13–84] in the group B, with preservation of the male predominance (62.8% in group A vs 62.1% in group B).

Infectious endocarditis secondary to rheumatic valvular heart disease has significantly decreased from 63.% of patients in group A to 27.5% in group B.

Mitral or mitro-aortic valve involvement stayed predominant in both groups with a increase of mechanical prosthetic valve involvement with 9.7% in group B.

A portal of entry of the infection was identified in 63% of patients in group A versus 41% in group B, we noted a significant decrease of dental-related cases from 64% in group A to 29% in group B, and a predominance of invasive procedure/devices cases in group B with 36% of identified cases.

In group A Blood cultures were positive in 42% of cases with a predominance of Staphylocci (30%) and coagulase-negative Staphylococci (25.7% of cases) whilst in group B blood cultures were positive in 30% of cases with a predominance of Staphylococci (36.6%) and Streptococci (20% of cases).

Echocardiography as a useful diagnostic tool demonstrated specific lesions of infectious endocarditis (abcess or vegetations) in 73.2% of cases in group A and 82% in group B. The clinical course in group A was complicated by congetive heart failure CHF (47.8%) or neurological lesions (11.5%) while in group B CHF was noted in 35% of cases and 8% of neurological lesions and The global mortality went from 28.7% in group A to 15% in group B related mostly to cardiogenic shock.

Conclusion

Our work demonstrated changes in the epidemiologic characteristics of IE that parallel changes in demographic and risk factors. The progress of diagnosis and treatement options in developing countries explains the better prognosis for this condition today.

Funding Acknowledgement

Type of funding sources: None.

Disorders of sodium balance in COVID-19 patients: two Tunisian patients report

Coronavirus disease 2019 (COVID-19) was first reported in December 2019. The disease is caused by severe acute respiratory syndrome virus corona virus 2 (SARS-CoV-2). Mild respiratory symptoms are the most common manifestations of SARS-CoV-2, but new signs are constantly being discovered as it spreads. Disorders of sodium balance are increasingly described in patients with SARS-CoV-2. We report, here, the cases of two patients presented with COVID-19 and in whom we discovered sodium disorders. The first patient is a 74-year-old man who presented with fatal hypernatremia. The second patient is a 66-years-old man presented with COVID-19 and euvolemic hyponatremia attributed to syndrome of inappropriate anti-diuretic hormone secretion (SIADH). This hyponatremia persisted long after the respiratory signs disappeared. Sodium balance disorders are increasingly described in the literature; special attention should be paid to the electrolyte status of COVID-19 patients. Pathophysiological mechanisms associating SARS-CoV-2 with these disorders are being studied.

Impact de la période du confinement sur la prise en charge des patients diabétiques

Introduction

Pour éviter la propagation du virus lors de la pandémie du COVID-19, un confinement était imposé. Pendant cette période, les patients atteints de maladies chroniques, tel que le diabète, ont eu des difficultés à l’accès aux soins. L’objectif de cette étude est d’évaluer le retentissement de la période de confinement sur la prise en charge des patients diabétiques et sur leur qualité de vie.

Patients et méthodes

Il s’agit d’une étude descriptive transversale, réalisée au service d’endocrinologie CHU Farhat Hached de Sousse et au Centre de santé de base Bouhssina, sur 3 mois (février mars avril 2020) (après le premier confinement en Tunisie).

Résultats

On a interrogé 100 patients diabétiques avec une prédominance féminine (66 %). L’âge moyen était de 56,2 ± 5,6 ans. Pendant le confinement, 69 % des patients n’ont pas pu accéder aux soins, 62 % ont déjà raté un RDV, 20 % des patients n’ont pas pu accéder aux médicaments, 57 % avaient des mesures de glycémie plus élevées et 60 % des patients sentaient plus à risque à cause du diabète. Le score de la qualité de vie était au-dessus de la moyenne sur le plan mental chez 20 % et sur le plan physique chez 14 % des patients interrogés.

Conclusion

Le diabète est connu être associé à des formes graves de COVID-19, ce qui rend ces patients plus vulnérables. Vu la situation sanitaire un accompagnement plus rapproché parait nécessaire basé sur le développement de la télémédecine.

Pituitary apoplexy of a giant prolactinoma during pregnancy

AIMS AND METHODS

Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy.

RESULTS

A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life.

CONCLUSION

This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.

Safety assessment and potential risks of the glucagon stimulation test in the diagnosis of secondary adrenal insufficiency

BACKGROUND

Although it takes more time, the glucagon stimulation test (GST) is a reliable measure for assessing growth hormone (GH) and adrenocorticotropic hormone (ACTH) secretion. The GST is considered to be a safe test, however, it still has mild side effects and potential risks.

OBJECTIVE

The objective of this study was to analyze the side effects of the GST while testing adrenal insufficient patients.

METHODS

This was a prospective study in which GST was performed in eighty-one patients (44 men, 37 women, mean age: 35.83±19.62 years) with pituitary disorder. The GST consisted in an intramuscular injection of 1 mg of glucagon. Blood samples were collected at baseline, and 30, 60, 90, 120, 150, 180 and 210 min after glucagon injection for cortisol measurements. All patients were asked to report side-effects associated with this test.

RESULTS

The mean peak blood glucose level under GST was 9.01±2.03 mmol/L and the mean glycemic nadir was 4.34±1.75 mmol/L was found most frequently during the 30th minute (p <10-3). During the test, 35 subjects (43.2%) had side effects with a mean age of 42.89 ± 19.75 years. Frequent side effects included: nausea (29.62%), vomiting (27.16%), abdominal cramps (18.51%) and hunger (13.58%). All patients tolerated the test until the end. Adverse effects were significantly more prevalent in patients older than 50 years (p=0.012).

CONCLUSIONS

The GST is a reliable alternative to assess hypothalamic pituitary adrenal axis but should be cautiously used especially in the elderly although its minor side effects.

Predictors Factors of Onset de Novo Heart failure after STEMI

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

STEMI gets complicated very often by a heart failure (HF), which it is important to know associated factors. The aim of this study  was to determinate the predictor factors of onset of de novo HF after STEMI in patients with no prior history of heart failure recorded at baseline.

METHODS

A retrospective, descriptive study from 1 center in Morocco, including 210 patients hospitalized in a cardiology intensive care unit for STEMI from September 2019 to November 2020. The main outcomes were HF Killip class at hospital presentation and intra-hospital mortality.

RESULTS

The main age was 59.3 ± 7.02 and Sex ratio: 2, 86. The incidence of de novo HF at admission was higher in women (40, 4% vs. 29.5%, [OR 1, 61; 95%, [CI] 0, 83-3, 11). Forty-nine point eight percent were in Killip≥ 2. The method of early revascularization was Thrombolysis in 82, 3% compared to primary coronary angioplasty without significant difference in onset of the novo HF. There was no association of age, comorbidities, delay to hospital presentation and coronary involvement with incidence of onset of de novo HF.  Women had higher mortality than men with the novo HF (28, 6% vs. 20.5%; OR: 1, 55; 95%).

CONCLUSION

 Gender has appeared associated to onset of de novo HF after STEMI with a superiority of the female sex after controlling for others factors described in the literature. Anterior studies have related this to the increased prevalence of microvascular disease in women predisposing them to heart failure after STEMI.

Subclinical impact of diabetes and hypertention on left ventricular function

Funding Acknowledgements

Type of funding sources: None.

Introduction

Assessment of longitudinal left ventricular (LV) function has a major clinical significance for the early detection of contractile LV dysfonction. The measurement of the MAPSE (Mitral annular plane systolic excursion) and the systolic peak velocity of the edge of the mitral ring (Sm) allow an accurate assessment of longitudinal systolic performance

Objective

The aim of this study was to compare the impact of isolated type 2 diabetes and the coexistence of hypertension and diabetes on LV longitudinal systolic performance.

Patients and Methods

The study included 170 diabetic patients, of whom 85 had both hypertension and diabetes, and 50 controls. The systolic mitral annulus (Sm) velocity by tissue Doppler and the Mitral annular plane systolic excursion (MAPSE) by M mode were measured in all subjects.

Results

The mean age was 52.8 ± 15 years with a sex ratio M / F 0.23 in diabetic patients, and a mean age 60.8 ± 8 years with a sex ratio M / F 0.45 in control subjects. The mean MAPSE value was reduced in diabetics (11.5 ± 2.6 mm) and even more in hypertensive diabetics (10.5 ± 3.0 mm) compared to controls (16.1 ± 2.4 mm ) (p = 0.02). Similar results were found for Sm (controls, 12.4 ± 2.5 cm / s; diabetics, 9.0 ± "3.3 cm / s; diabetic hypertensive, 7.3 ± 2.0 cm) (p = 0.04).

Conclusions

diabetics present a depression of the LV longitudinal systolic indices compared to healthy controls; the coexistence of diabetes and hypertension results in further impairment of LV longitudinal systolic function in an additive manner.

Incidence, characteristics and outcomes of Infective Endocarditis with low inflammatory markers

Funding Acknowledgements

Type of funding sources: None.

Background

Bacterial infective endocarditis (IE) is rarely suspected in patients with a low C-reactive protein (CRP) concentration.

Aims

To address the incidence, characteristics and outcome of left-sided valvular IE with low CRP concentration.

Methods

This was a retrospective analysis of cases of IE discharged from a tertiary hospital between December 2013 and september 2019. 

The 10% lowest CRP concentration (&lt;25mg/L) was used to define low CRP concentration. Right-sided cardiac device-related IE, non-bacterial IE, sequelar IE and IE previously treated by antibiotics were excluded.

Results

Of the 105 patients, 16 (16%; median age 41 [15–76] years) had definite (n = 12) or possible (n = 4) left-sided valvular IE with CRP &lt; 25mg/L (median 14.25 [1.5–24.8] mg/L). The median white blood cell count was 7.7 (4.2–12.5) G/L. 

The main presentations were heart failure (n = 10; 62%) and stroke (n = 1; 6%). Transthoracic echocardiography (TTE) showed vegetations (n = 12) or isolated valvular regurgitation (n = 4). 

Overall, nine patients (56%) had severe valvular regurgitation on transoesophageal echocardiography (TOE), and seven patients (43%) underwent cardiac surgery. 

68% of patients survived at 1-year follow-up. Bacterial pathogens were documented  only in four patients (streptococci, coagulase-negative Staphylococcus, gamella morbillorum) using blood cultures solely ,  due to lack of disponibility of specific serology / valve culture and/or polymerase chain reaction analysis 

Conclusions

Left-sided valvular IE with limited or no biological syndrome is rare, but is often associated with severe valvular and paravalvular lesions. TOE should be performed in presence of unexplained heart failure, new valvular regurgitation or cardioembolic stroke when TTE is insufficient to rule out endocarditis, even in patients with a low CRP concentration.

Potentially inappropriate home medications among older patients with cardiovascular disease in a Moroccan population

Funding Acknowledgements

Type of funding sources: None.

Background :

Patients with cardiovascular diseases use often multi-drugs regimen , which can often be associated with use of potentially inappropriate medications PIMs especially in elderly , which may pose more risks than benefits to patients and is a major factor contributing to the likelihood of serious adverse drug reactions and negative health outcomes among this population .

Methods

A Prospective study was conducted in a tertiary care hospital in Morocco where home medications of out patients were reviewed during follow-up consults and analyzed over three months, from October till December 2020.  Inclusion criteria were age of 65 years and above, history of cardiovascular disease.  The aim of our study was to determine the frequency and factors associated with PIMs, by applying the updated Beers 2015 criteria.

Results

A total of 214 patients were included in the study and were taking a total of 1498 medications at home, an average of  7 ± 3 medications per patient. The proportion of PIMS was 32 % of all medications reported, with an average of 2.2 PIM per patient, and 84% of patients were receiving at least one PIM.

 Significant association was found between use of PIMs and number of home medications, female gender, self medication , and number and types of comorbidities.

Comorbidities associated with more PIMs were heart failure, atrial fibrillation/flutter, rheumatological diseases, cerebrovascular accident, and insomnia/depression . The most commonly prescribed PIMs were: drugs that may exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia (27.3%), NSAIDs use in patients under anticoagulants (21.2%) , use of proton pump inhibitors (PPIs) &gt; 8 weeks in non-high-risk patients (10.5%), and benzodiazepines  (5.7%).

Conclusions

A high prevalence of PIMs in older patients with cardiovascular disease was observed. Health care giver’s education and detailed assessment of medication lists upon follow-up consults or hospital admission by multidisciplinary teams can help in preventing the use of PIMs.

Association of an empty sella and grave´s disease in a patient with acromegaly: a case report

Acromegaly is, in most cases, caused by growth hormone secreting pituitary adenomas. Those patients often develop different pathologies of the thyroid gland, however, the occurrence of Grave´s disease is quite a rare situation. We report a case of a 64-year-old female patient who presented with signs of hyperthyroidism and imbalance of her diabetes mellitus. On physical examination, she had facial features of acromegaly. Biochemical testing confirmed the suspicion of acromegaly and Grave´s disease, with an elevated insulin-like growth factor-1 and a suppressed thyroid stimulation hormone (TSH) with positive TSH-receptor antibodies. A pituitary Magnetic Resonance Imaging (MRI) was performed, revealing a macro-adenoma and an empty sella. The patient successfully underwent a transsphenoidal surgery and obtained a remission of her hyperthyroidism under anti-thyroid drugs.

Prostatic tissue in 46XX congenital adrenal hyperplasia: Case report and literature review

The presence of prostatic tissue, in addition to uterus and adrenal tumors, is possible in 46XX patients with CAH. Lesions of these organs are usually benign. However, complications including prostate and adrenal cancer were also reported.

Role of myocardial deformation analysis in the early detection of subclinical Left Ventricular dysfunction in breast cancer under anthracyclines and trastuzumab

Funding Acknowledgements

Type of funding sources: None.

Introduction : Cardio-oncology field has notably raised interest this past decade, it considerably improved cancer patients’ quality of care by monitoring and preventing complications of cardiotoxic treatment like anthracyclines and trastuzumab. Transthoracic echocardiography (TEE) plays a major role in the baseline assessment and follow-up of cardio-oncology patients. While left ventricular ejection fraction (LVEF) still has its place in cardiac monitoring, new modalities like myocardial deformation imaging with speckle tracking strain analysis, show great potential for early detection of subclinical LV dysfunction.

Purpose : The aim of this study was to evaluate the role of Global Longitudinal Strain (GLS) in the early detection of cardiotoxicity and its correlation to LVEF.

Methods : We conducted a longitudinal prospective study including all the breast cancer patients treated with anthracyclines and/or trastuzumab  followed in the Casablanca cardio-oncology unit from January 2017 to December 2019. All patients underwent baseline TEE, and were followed-up every 3 months after that, with GLS assessment whenever it was possible. We evaluated the frequency of GLS drop and its correlation to LVEF reduction.

Results : Out of a total of 793 patients, 677 had available LV GLS assessment. Among them, 83 (12,3%) decreased their GLS during follow-up, 67% of which had no concomitant drop in LVEF. In these patients, impaired LV GLS values were noted at 1 month after chemotherapy and at 3, 6, and 12 months compared with baseline (-22,3 ± 1.8% at baseline, -18.1 ± 2.3% at 1 month, -17.7 ± 2.1% at 3 months, -17.1 ± 2.2% at 6 months, and -16.9 ± 2.1% at 12 months (p &lt; 0,0001). LV GLS at 3 months was strongly correlated to cardiotoxicity (LVEF &lt; 50%) at 12 months (p &lt; 0,0001). A cut-off LV GLS value of -17,7% was then retained to identify LVEF alteration at the end of follow-up. Moreover, lower GLS values were observed in patients under Doxorubicin with a mean cumulative dose &gt;180 mg/m2 (p = 0,0019), while LVEF remained normal. Finally, our study found that GLS at 1 month and 3 months had a prognostic value, since the lower GLS was, the poorest the patient’s clinical outcome was, with further development of symptomatic heart failure (p = 0,0038).

Conclusion : Our study demonstrates that myocardial deformation analysis enables detection of early and progressive subclinical cardiac dysfunction, and GLS at 3 month was positively correlated to LVEF drop at 12 months. Thus, routine GLS should be used in patients undergoing cardiotoxic chemotherapy in order to early detect cardiotoxicity and prevent irreversible cardiac dysfunction by early initiating cardio-protective treatment.

Relationship between level of education and podiatry risk in diabetic patients

CONTEXT

Diabetic foot trophic disorders and their complications leading to the risk of amputation remain a major public health problem.

OBJECTIVE

To determine the level of podiatric risk in our diabetic patients according to the classification of the International Working Group of the Diabetic Foot (IWGDF) and study the relationship between the level of education and the level of podiatry risk..

METHODS

This is a descriptive and analytical cross-sectional study including all diabetics hospitalized at the National Institute of Nutrition in Tunis for chronic diabetes imbalance, carried out over a period of two months (July - August 2019).

RESULTS

The mean age of the patients was 55.08 ± 14.22 years. The sex ratio was 0.67. The majority of our patients were type 2 diabetics (90.24%). During the clinical examination of the foot, plantar hyperkeratosis was the most noted manifestation (65.85%). Based on the IWGDF classification, 42.68% of patients had a grade 0 podiatric risk. Regarding the overall educational level, we noted 76.83% patients with a poor educational level and 23.17% patients with a satisfactory level of education. The overall educational level is significantly associated with the podiatric grade (p <0.05).

CONCLUSIONS

Therapeutic education or even podiatric education of the patient is important in the prevention of complications of the foot. Patient-centered training in foot care practice in public health facilities would reduce the rate of morbidity and mortality from complicated diabetic foot.

Health promotion for migrants in Morocco: Progress, challenges et prospects

Morocco has become a land of permanent settlement for migrants. In promoting their health, we have made a significant progress with persistence of challenges

Progress: Development and implementation of a National Strategy to promote the health of migrantsFree access to primary care and emergency care and screening services;Free access to health coverage program for regular migrants.

Challenges: Development of a health surveillance system for the migrant populationStrengthening the skills of healthcare professionals to take care of the specific health needs of the migrant population (tropical diseases);Strengthening of medical, psycho-social assistance for migrants, protection of particularly vulnerable categories (women and children) and intersectoral coordination;Stimulate action by civil society and the community in promoting the health of migrants.

Prospects for action: Integrate migrant health data into the health information system of health facilities and health programs;Develop and implement a health education plan adapted to the specificities of migrant populations;Establish a network of hospital units specializing in tropical pathology, acting as national reference teams;Define and implement a capacity building program for health professionals (doctors, nurses and social workers);Support civil society organizations to improve their intervention capacity in the area of migrant health.

Congenital adrenal hyperplasia due to 11-Beta-hydroxylase deficiency in a Tunisian family

Congenital adrenal hyperplasia refers to a group of rare genetic disorders affecting the adrenal glands. 21-hydroxylase deficiency is the most prevalent and the most studied cause while the remaining enzymatic defects are less common, accounting for less than 10% of cases. We herein described the clinical, biological and molecular characteristics and outcome of patients of the same family diagnosed with 11-Beta-hydroxylase deficiency. The disorder was revealed by peripheral precocious puberty between the age of 2-3 years in males and by the virilization of the external genitalia in females. Genetics finding a homozygous p.Gly379Val mutation in the CYP11B1 gene. All patients received hydrocortisone supplementation therapy and mineralocorticoid-receptor antagonist. The females underwent a surgical correction of the ambiguous genitalia at the neonatal age. Long term follow-up revealed metabolic syndrome, obesity and hypertension in the first two patients, an impaired final height in the two females and hypokalemia in three patients.