Clinical features and outcomes in patients with human immunodeficiency virus-negative, Castleman's disease: a single medical center study in Tunisia

INTRODUCTION

Castleman's disease (CD), known as angiofollicular lymph node hyperplasia, is an uncommon condition. The two most common histological subtypes are hyaline vascular and plasma cell. We performed a retrospective analysis to define the clinic-pathological features and survival of CD, which is quite rare focusing on the particularities of our series with a review of the recent literature.

METHODS

This is a retrospective study conducted in the department of internal medicine of Hedi Chaker hospital in Sfax, Tunisia over 25 years. The disease was histologically confirmed in all patients. For each file, we collected a set of data by filling in a pre-designed form.

RESULTS

18 patients were included. There were 8 men and 10 women with a mean age of 42.8 years. CD was monocentric in 5 cases (28%) and multicentric in 13 cases (72%). Clinically, peripheral adenopathy was present in 77.7% of patients and deep adenopathy in 72.2%. Systemic signs were found in 13 patients, including general condition (4.4%), fever (16.6%), serositis (27.7%), and skin involvement (33.3%). A biological inflammatory syndrome accompanied the clinical picture in 66% of patients. Abnormalities in the blood count were found in 12 cases (66%), with anemia in 11 cases, thrombocytosis in 3 cases, and hypereosinophilia in 3 cases. Cutaneous Kaposi's sarcoma was associated with Castleman's disease in 2 cases, Hodgkin's lymphoma, angioimmunoblastic T-cell lymphoma, and lymph node T-cell lymphoma were found in 1 case respectively. 3 of the patients had associated connective tissue diseases such as Sjögren's syndrome in 2 cases and rheumatoid arthritis in 1 case. HHV8 serology was positive in 1 case with a multicentric plasma cell form. Histologically, the plasma cell form represented 50% of cases, hyaline-vascular (39% of cases), and mixed (11% of cases). Therapeutically, high-dose corticosteroid therapy was initiated in 13 cases. As a second-line treatment, MOPP chemotherapy was used in 1 case due to transformation into Hodgkin's lymphoma, and biotherapy (rituximab) was used in 2 cases in the multicentric form. Surgical removal of superficial adenopathy was performed in 2 patients with monocentric CD.

CONCLUSION

: Castleman's disease (CD) is a non-malignant lymphoproliferation of localized or multicentric form with a wide and heterogeneous clinical spectrum. Diagnosis can be difficult due to the lack of clinical and radiological specificity. Management depends on the clinical form involving surgical and/or medical management.

Central retinal vein occlusion : an uncommon complication in sarcoidosis

Sarcoidosis is a multi-system granulomatosis of unknown etiology, defined by the presence of epithelioid and gigantocellular granulomas, without caseous necrosis. Ocular sarcoidosis manifests mainly as bilateral granulomatous anterior uveitis. Occlusion of the central retinal vein in sarcoidosis is a rare manifestation, which is the particularity of our observation. We report the case of a patient presenting with unilateral central retinal vein occlusion associated with granulomatous anterior uveitis on the same side. Systemic manifestations and further investigations led to the diagnosis of sarcoidosis.

Metanephric adenoma diagnosed on biopsy in an infant: a case report

BACKGROUND

Metanephric adenoma is a rare benign renal tumor of the kidney, uncommonly observed in children. It is often misdiagnosed preoperatively as a malignant neoplasm, leading to an unnecessary nephrectomy. The challenge is to make the right diagnosis preoperatively and therefore manage it with conservative surgery. We report a case of a child with metanephric adenoma who underwent nephron-sparing surgery.

CASE PRESENTATION

A renal tumor was discovered fortuitously in an 18-month-old Caucasian girl with several congenital malformations. Investigations showed a 28 × 27 × 27 mm left renal mass centrally located, well defined, nonvascularized, with no calcifications and which compressed the adjacent renal tissue. Furthermore, there were no signs of metastasis. The decision of a multidisciplinary meeting was to perform a computed tomography (CT)-scan-guided biopsy. Histologic examination concluded it was a metanephric adenoma. We performed a left open partial nephrectomy via a flank retroperitoneal incision. The final histopathological examination confirmed the diagnosis. The postoperative course was uneventful.

CONCLUSION

Preoperative diagnosis of metanephric adenoma is challenging. Because of the high probability of unnecessary radical nephrectomy, preoperative biopsy can be safe and determining to guide a more conservative approach so nephron-sparing surgery can be performed.

Molecular characterization of CTNS mutations in Tunisian patients with ocular cystinosis

Background

Ocular cystinosis is a rare autosomal recessive disorder characterized by intralysosomal cystine accumulation in renal, ophthalmic (cornea, conjunctiva), and other organ abnormalities. Patients with ocular cystinosis are mostly asymptomatic and typically experience mild photophobia due to cystine crystals in the cornea observed accidently during a routine ocular examination. The ocular cystinosis is associated with different mutations in CTNS gene. Cysteamine therapy mostly corrects the organ abnormalities.

Methods

This study was performed in collaboration with the department of ophthalmology of Farhat Hached Hospital. The Optical Coherence Tomography (OCT) of the cornea and retinal photography were used to search cystine crystals within the corneas and conjunctiva in eight Tunisian patients. Screening for the common 57-kb deletion was performed by standard multiplex PCR, followed by direct sequencing of the entire CTNS gene.

Results

The studied patients were found to have cystine crystal limited anterior corneal stroma and the conjunctiva associated with retinal crystals accumulation. CTNS gene sequencing disclosed 7 mutations: three missense mutations (G308R, p.Q88K, and p.S139Y); one duplication (C.829dup), one framshift mutation (p.G258f), one splice site mutation (c.681 + 7delC) and a large deletion (20,327-bp deletion). Crystallographic structure analysis suggests that the novel mutation p.S139Y is buried in a first transmembrane helix closed to the lipid bilayer polar region, introducing a difference in hydrophobicity which could affect the hydrophobic interactions with the membrane lipids. The second novel mutation p.Q88K which is located in the lysosomal lumen close to the lipid membrane polar head region, introduced a basic amino acid in a region which tolerate only uncharged residue. The third missense mutation introduces a positive change in nonpolar tail region of the phospholipid bilayer membrane affecting the folding and stability of the protein in the lipid bilayer.

Conclusions

Our data demonstrate that impaired transport of cystine out of lysosomes is the most common, which is obviously associated with the mutations of transmembrane domains of cystinosine resulting from a total loss of its activity.

Custom Next-Generation Sequencing Identifies Novel Mutations Expanding the Molecular and clinical spectrum of isolated Hearing Impairment or along with defects of the retina, the thyroid, and the kidneys

Background

In the Tunisian population, the molecular analysis of hearing impairment remains based on conventional approaches, which makes the task laborious and enormously expensive. Exploration of the etiology of Hearing Impairment and the early diagnosis of causal mutations by next‐generation sequencing help significantly alleviate social and economic problems.

Methods

We elaborated a custom SureSelect^QXT panel for next‐generation sequencing of the coding sequences of 42 genes involved in isolated hearing impairment or along with defects of the retina, the thyroid, and the kidneys.

Results

We report eight pathogenic variants, four of which are novel in patients with isolated hearing impairment, hearing impairment, and renal tubular acidosis, Usher syndrome and Pendred syndrome. Functional studies using molecular modeling showed the severe impact of the novel missense mutations on the concerned proteins. Basically, we identified mutations in nuclear as well as mitochondrial genes in a Tunisian family with isolated hearing impairment, which explains definitely the phenotype detected since 2006.

Conclusion

Our results expanded the mutation spectrum and genotype‒phenotype correlation of isolated and syndromic hearing loss and also emphasized the importance of combining both targeted next‐generation sequencing and detailed clinical evaluation to elaborate a more accurate diagnosis for hearing impairment and related phenotypes especially in North African populations.

P–122 Benefit of use of theophilline in ICSI with testicular sperm

Study question

Would the use of theophylline have an effect on ICSI outcomes?

Summary answer

The cumulative pregnancy rate after the transfer of fresh and frozen embryos (FET) becomes more important justifying the addition of theophylline as an efficacy variable.

What is known already

Absolute immotile spermatozoa is one of the most important causes of reduced fertilization and pregnancy rates after ICSI, immotility of testicular spermatozoa is a physiological event resulting from metabolic sperm immaturity. Over the years, there have been numerous attempts to resolve this problem by identification of pharmacological agents that might improve sperm motility. In particular, theophylline turned out to be an effective tool in stimulating motility in human semen and identifying viable sperm in testicular sperm extraction sperm (TESE) patients. aim of this study is to evaluate ICSI outcomes after the use of theophylline to select viable spermatozoa

Study design, size, duration

This prospective, comparative randomised study was conducted in Fertillia ART center in Tunisia, between november 2017 to november 2020. All patients underwent ICSI cycles with testicular sperm were included. The exclusion criteria consist of cycles with female partner age >42 years and/or cycles with no information about pregnancy outcomes. In our study, the cycles were categorized into two groups according to sperm selection method used in ICSI procdure.

Participants/materials, setting, methods

The present study include 678 cycles. This cohort was randomly divided into two groups according to method of spermatozoa selection. Treatements arms were performed by theophylline to improve sperm motility (Group A) and the Hyposmotic swelling (HOS) test to indicate sperm vitality (Group B). Clinical and biological parameters, the duration of sperm selection and ICSI outcomes were compared between the two groups. A statistical significant difference was accepted when the p value was <0.05.

Main results and the role of chance

Baseline clinical parameters were found to be comparable in the two groups. No differences regarding number of oocytes retrieved or MII oocytes were reported . he sperm selection was easier in the group A (time interval : 12±7,2 minutes) than group B (time interval : 22±10 minutes) (p < 0,05). No significative difference was observed between goups in the Fertilization rate (group A : 66% vs group B : 68%) ; Cleavage rate (group A : 76.20% vs. Group B : 75.56%) and Blasulation rate (group A : 63.60% vs. Group B 60.61%) p > 0 ,05. The Cumulative Pregnancy rate for group A (31. 5%) was higher than group B (30%, p > 0 ,05). Indeed, The rate of frozen cycles is significantly higher for group A compared to group B (30% vs. 4.5% p < 0,05).

Limitations, reasons for caution

Need large sample size.

Wider implications of the findings: Theophylline reduces significantly the time needed for sperm selection, Which positively affects the ICSI result.

Trial registration number

Not applicable

Multifocal bone tuberculosis simulating metastasis

Multiple skeletal tuberculosis can be the first sign of tuberculosis. In such cases, physicians should consider tuberculosis diagnosis and take biopsies for anatomopathological evidence to make the correct diagnosis.

Burn-out of the Medical Oncology Health Care Professionals and Associated Factors in Tunisia

Introduction: Burn-out is defined as a syndrome of emotional exhaustion, depersonalization and diminished self-achievement that affects individuals exposed to chronic occupational stress. Physicians and caregivers faced with the death of their patients, such as oncology, are particularly vulnerable to this syndrome.

Objectives: To evaluate the burn-out of medical professionals in medical oncology, to research the predisposing factors and to analyze the functional complaints and the behavior of the staff associated with this syndrome.

Methods: A descriptive and analytical cross-sectional study among medical oncology professionals practicing in public hospitals in the Tunisian territory who exercise more than two years in oncology; with the Maslach Burnout Inventory (MBI).

Results: Our study population was predominantly female (81%). 53% are doctors and 47% are paramedical health care professionals. A high degree of emotional exhaustion, depersonalization and personal achievement were found in 63%, 53% and 59% in our population, respectively. With 21% global high burn-out. The female sex was associated with high emotional exhaustion and low personal accomplishment as well as global burn-out. This burn-out was attributed to factors associated with working conditions and professional climate, mainly: overwork, poor organization of service, lack of resources and time, lack of recognition, lack of communication, lack of respect, conflicts with colleagues, report unsatisfactory salary effort and aggressions by patients and their families. Functional complaints and health care professional’s behavior associated with burn-out were: feelings of sadness, blockage, and irritability, sleep disorders, unexplained pain, epigastralgia, addictive behaviors, psychotropic consumption, suicidal thoughts, decreased performance and desire for a job transfer.

Conclusions: By its impact on professionals, burn-out in medical oncology represents a major threat to the quality of health care. Its etiologies, although complex and intricate, are well known. Its prevention and its support are possible, but involve mobilization at all levels.

Early screening of cardiotoxicity of chemotherapy by echocardiography and myocardial biomarkers

INTRODUCTION

cardiotoxicity remains the most serious complication of anticancer chemotherapy, especially if it manifests by heart failure. Early detection of myocardial involvement, before alteration of LVEF, would involve the necessary measures to be taken to prevent progression to heart failure.

AIM

Early detection of the cadiotoxicity of anti-cancer chemotherapy, through clinical, echocardiographic and biological parameters.

METHODS

Prospective comparative study in a cohort of 100 patients treated with anti-cancer cardiotoxic chemotherapy for any type of cancer. Each patient received before his first course of chemotherapy, as well as three weeks after, a clinical evaluation, electrocardiography, echocardiography and an assay of biological markers.

RESULTS

for the LV study (LVEF (Tei): before CT: 67.75 ± 5.53, after CT 64.7 ± 5.6%, p = 0.002; LVEF (SBP): before CT: 64.5 ± 3.83, after CT 61.85 ± 1.9%, p <0.001; SLGVG: before CT: -21.85 ± 1.9, after CT: -20.08 ± 1.63%, p <0.001) and for the study of the DV (TAPSE: before CT: 22.9 ± 3.02, after CT: 21 ± 2.86, p = 0.014; SLGVD: before CT: -23.42 ± 2.69, after CT: -21.67 ± 2.6%, p = 0.004). Variations in troponin levels and BNP was not significant.

CONCLUSION

anticancer chemotherapy has harmful cardiovascular effects which can be detected and controlled p by echocardiographic monitoring and  biological markers and prevented by the use of protective agents.

Hemophagocytic Lymphohistiocytosis: A Rare Complication of an Ultrarare Lysosomal Storage Disease

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening hyperinflammatory condition that may be triggered by infections, autoimmune and immunologic disorders, malignancies, and metabolic diseases. Early and accurate diagnosis of HLH and its underlying cause is of paramount importance for proper management and prognosis. We report the case of a Tunisian 21-month-old girl who initially presented clinical features of HLH related to a lysosomal acid lipase deficiency. The genetic sequence analysis of the LIPA gene revealed a never described homozygous mutation c.966G>C (p.Gln322His). The parents were heterozygous for this mutation. Enzyme replacement therapy was not provided for the patient. She received etoposide, corticosteroids, and cyclosporine for the HLH. She is waiting for hematopoietic stem cell transplantation. To the best of our knowledge, this is the second Tunisian case of secondary HLH complicating lysosomal acid lipase deficiency related to a new homozygous mutation: c.966G>C (p.Gln322His).

Disseminated lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy

Dysfunction of the third cranial nerve can be provoked by a number of different conditions. An isolated cranial neuropathy as a first clinical sign of a non-Hodgkin lymphoma is very infrequent. We represent here an atypical case of lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy. The patient was managed by alternating cycles of cyclophosphamide, vincristine, and prednisone. She made a full recovery with a complete resolution of the symptomatology.

Pulmonary embolism in intensive care units: More frequent or more Known? Prospective study of 75 cases

PURPOSE

to evaluate the current rate of pulmonary embolism (PE) in our medico-surgical intensive care unit (ICU), to identify risk factors, and to determine the outcome of PE in ICU.

METHODS

We performed a prospective cohort study of consecutive patients requiring intensive care admission during a one-year period. We included, in this prospective study, all the patients with confirmed PE admitted in ICU with more than 18 years of age, and expected to stay in ICU for more than 48 hours. Only the patients who had a clinical suspicion (unexplained hypoxemia and/or shock) for PE underwent diagnostic studies.

RESULTS

During the study period, 842 patients were admitted in our ICU. One hundred and two patients were excluded. The diagnosis of PE was confirmed in 75 patients (10.1%). In our study, all patients (100%) had received some forms of pharmaceutical prophylaxis (PP) during ICU stay. The median time from ICU admission to diagnosis of PE was 6 days. The diagnosis of PE was made by spiral CT in 74 patients (98.7%), and by echocardiography in 1 case (1.3%). The mean ICU stay was 26.3 ± 26.5 days (median: 20 days). During their ICU stay, 73 patients (97.3%) developed one, or more, organ failure. Respiratory failure was the most observed (97.3%). Moreover, 38 patients (50.6%) developed nosocomial infections and 29 (38.6%) died. The multivariate analysis showed that the risk factors associated with mortality were the presence of shock the day of PE diagnosis and the presence of right ventricular dilatation on echocardiography.

CONCLUSION

Our findings confirm that subjects in the ICU are at high risk of PE, due to a high number of risk-factors. PE was associated with higher ICU mortality and a significantly higher ICU LOS. Our results invite to revise the preventive strategies of deep venous thrombosis and PE in patients requiring ICU admission.

[Rendu-Osler disease and recurrent thromboembolic venous disease]

Rendu-Osler-Weber syndrome is a rare systemic fibrovascular dysplasia, recognized by mucocutaneous telangiectasias, arteriovenous malformations, epistaxis and family history. Venous thromboembolic disease is a poor prognostic factor in this disease given the risk of increased bleeding caused by anticoagulant therapy. We report a new case of a 56-year-old patient with Osler disease who developed recurrent thromboembolic venous disease when anticoagulants were discontinued. According to a review of the literature, this association does not appear to be fortuitous and is a factor of disease severity.