[Pain management in radiation oncology]

The goal of this article is to propose some practical means of pain management in radiation departments. Pain management in radiation oncology is difficult because of the high proportion of painful patients, underestimation by medical teams, and limited therapeutic options. Pain can cause mobilization difficulties, set-up errors, treatment interruption. According to procedure steps, a preventive attitude (for pre-radiation consultation) or an active attitude (for treatment) to quickly relieve the patient can be planned. This work is a brain storming about pain management. It is not a review about analgesic radiotherapy. The practical situations apply to patients to whom radiotherapy is indicated. Teamwork and anticipation are keywords to relieve patients. All proposed means are not always available for different reasons (time, finance, staff, training). The idea is to establish simple procedures that are appropriate to each center to fluidify acts, to optimize time for a successful irradiation.

Epidemiological investigation of keratinophilic fungi from soils of Djerba (Tunisia)

INTRODUCTION

Epidemiological investigation of keratinophilic fungi in soil has been carried out in different parts of the world. However, our knowledge of the present occurrence and distribution of keratinophilic fungi in Tunisian soils remains unknown. This study was carried out to evaluate the epidemiological characteristics of keratinophilic fungi in the soils collected in Djerba (South of Tunisia).

MATERIAL AND METHODS

One hundred and forty one soil samples were collected from various sites in Djerba and screened for the presence of keratinophilic fungi and related dermatophytes using hair-baiting technique. Fungi were identified using macro- and micro-morphological features.

RESULTS

Among them, 29 (20.6%) soil samples were positive. Seven species were isolated in the following order of dominance: Chrysosporium keratinophilum (48.3%), Microsporum gypseum (41.4%), C. tropicum (10.4%), C. parvum (3.45%), C. anamorph of Anixiopsis stercoraris (3.45%), C. anamorph of Arthroderma cuniculi (3.45%) and Chaetomium sp. (3.45%). The association of M. gypseum and C. keratinophilum was detected in 13.8% of positive soils. Sixty-nine percent of fungi were found in organic matter rich soil. Our results revealed a higher prevalence of keratinophilic fungi in the regions far from the sea (33.3%) than in those near the sea (11.1%) with a statistically significant difference (P=0.001). All keratinophilic fungi were isolated from soils with pH ranging from 6.2 to 7.6.

CONCLUSION

Our study showed that keratinophilic fungi were present in the various soils of Djerba. They may represent a risk to human health.

[Rosacea-like demodicidosis and chronic blepharitis]

Demodicidosis is a parasitic skin disease caused by the follicle mites Demodex sp. In this article, we present a case of rosacea-like demodicidosis, discuss the clinical features of Demodex infestation in man and review their diagnosis and therapeutic modalities. A 37-year-old woman presented in our department with chronic blepharitis present for one year. On physical examination, the patient presented blepharitis and papulovesicles with fine scaling limited to the face. There was no telangectasia. The patient did not report flushing episodes or any kind of photosensitivity. A diagnosis of rosacea-like demodicidosis and Demodex blepharitis was based on the presence of numerous Demodex folliculorum in the eyelashes and scrapings of skin lesions. The patient was put on topic and oral metronidazole for 2 months and on yellow mercury ointment for 15 days. The course involved disappearance of the facial mites and complete remission without recurrence. Screening for Demodex sp is essential to establish the correct diagnosis and ensure suitable treatment.

[Conjonctival human myiasis by Oestrus ovis in southern Tunisia]

Conjunctival myiasis is the most frequent expression of ocular myiasis. It results from infestation of the conjunctiva by the larval form of flies. We report 11 cases of conjunctival myiasis to encourage ophthalmologists to be aware of the diagnosis of external ophthalmomyiasis, its complications, and its treatment. Most of the cases occurred amongst males during summer and autumn. Symptoms are related to the foreign body with a sudden evolution. We diagnosed this affection by direct observation of the larva on conjunctiva. The number of larvae ranged from 2 to 30. The larvae were identified as first-instars of Oestrus ovis. The treatment was performed by removal of the larvae which resulted in rapid improvement. In conclusion, early diagnosis and management are important in preventing complications of internal ophthalmomyiasis.

[Identification of Enterocytozoon bieneusi by PCR in stools of Tunisian immunocompromised patients]

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.

Pediatric visceral leishmaniasis diagnosis in Tunisia: comparative study between optimised PCR assays and parasitological methods

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.

[Cutaneous leishmaniasis caused by Leishmania infantum MON-24 in Tunisia: extension of the focus to the center of the country]

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.

Portage asymptomatique de Leishmania infantum chez des malades tunisiens infectés par le VIH

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.

Quel est le rôle des parasites et des levures dans la genèse des blépharites chroniques?

INTRODUCTION

The chronic blepharitis is a current ophthalmic disease posing a therapeutic problem. The etiologic diagnosis is essential for adapting the treatment.

PURPOSE

The aim of this study is to describe the role of Demodex sp, Malassezia sp and Candida sp in the pathogenesis of chronic blepharitis.

PATIENTS AND METHODS

It's a prospective study realized during a period of 14 months. It interested 69 patients with chronic blepharitis and 96 controls. The prevalence of Demodex sp, Malassezia sp and Candida sp on the eyelash of chronic blepharitis patients and controls was investigated.

RESULTS

Demodex folliculorum was found in 58% of patients with chronic blepharitis and in 15,6% of controls. The difference between the two groups was statistically significant (P<0,00001). The sex and the age intervene neither in the frequency, nor in the abundance of D. folliculorum in the two groups. Malassezia sp was identified in 10,4% of the control group and 31,88% of the group with chronic blepharitis. The difference is significant (P<0,00001). There is no correlation between frequency and abundance of Malassezia, sex and age in the two groups.

CONCLUSION

In our study, D. folliculorum and Malassezia sp seem to be accused in the genesis of the chronic blepharitis. Their systematic search is necessary in order to adapt the treatment.

Diagnostic biologique des candidoses systémiques : difficultés et perspectives

The diagnosis of systemic Candidiasis is difficult to establish and biologic diagnosis raises problems. Blood culture which is the gold standard for the diagnosis of systemic Candidiasis lacks sensitivity and usually takes several days to become positive. Early diagnostic approach is imperative to avoid delays in the initiation for treatment. Therefore, nonculture methods like test for Candida antigen detection, metabolite detection or Candida DNA detection by PCR are being developed for the laboratory diagnosis. Candida derived metabolites and antigens detection lacks sensitivity. A new strategy consisting of the combined detection of mannanemia and an antibody response was developed. The combined detection has a high specificity and sensitivity in the diagnosis of invasive candidiasis. The results of tests for the detection of yeast DNA by PCR obtained recently are promising in terms of sensitivity, specificity and identification of species of Candida.

[Candida dubliniensis: a novel emerging species]

Over the past decade, the incidence of opportunistic fungal infections continues to increase. Candida albicans remains the most important pathogenic yeast. Since 1995, a novel Candida specie has been identified and named Candida dubliniensis. This specie shares many phenotypic characteristics with Candida albicans, including the ability to produce germ tubes and chlamydospores. These similarities have caused significant problems in the identification of Candida dubliniensis. A large variety of methods have been developed for the discrimination of these two species. They included the sensitivity to different stress (temperature, salinity), growth on chromogenic and specific medium and carbohydrate assimilation. However, these methods can fail to assert the identification of Candida dubliniensis, but molecular typing methods are highly reliable and can confirm the identification. However, they are too complex for routine use. The identification of this specie in routine is essential in order to further understand the epidemiology, to better define the role of Candida dubliniensis as a potential pathogen and its susceptibility to develop a resistance to the antifungal agents. So, new methods have to be developed.

[Parasitic etiology of blood hypereosinophilia]

Blood hypereosinophilia is a common finding in medical practice requiring further investigations. Parasitic diseases are a major cause of eosinophilia and eosinophilia is mainly due to helminths. The investigation of eosinophilia is a long and complicated process. The etiologic diagnosis of eosinophilia requires a review of the patient's history which may reveal travel out of country, symptoms and rate and evolution of eosinophilia. For subjects originating from a country as Tunisia, suspected parasitosis -if eosinophilia is massif- are toxocariasis, distomiasis and scabies. Anguilluliasis and ankylostomiasis will be suspected if the subject is originating from some hot and wet focus. For subjects who have traveled to tropical country, bilharziasis, anguilluliasis and ankylostomiasis will be suspected. Since filariasis and onchocerciasis are diseases by accumulation, they will be suspected if the stay has been long.

[Entamoeba histolytica and Entamoeba dispar: differentiation methods and implications]

Entamoeba histolytica and Entamoeba dispar are two species morphologically identical (except hematophagous trophozoites) but one of them is pathogenic. Sensitive and specific molecular techniques which are able to distinguish E. histolytica from E. dispar have been developed recently. Detection of antigen in stool using the ELISA method is the diagnostic test method of choice for clinical use in the developing world. It is rapid and simple. Cultures for zymodeme analysis and PCR detection of the parasite remain research tools. Species identification is imperative both for improved clinical diagnosis and treatment and for planning control strategies.

[Onychomycosis in Tunis area: epidemiological and mycological data]

BACKGROUND

Onychomycosis is by far the most frequent cause of nail disease. We describe epidemiological and mycological features observed in the Tunis area in Tunisia.

MATERIAL AND METHODS

Data were collected from 292 nail samples performed in 255 patients with suspected onychomycosis.

RESULTS

Request for samples were made late, on the average 48 months after development of nail disorders. Most of the patients were women (63.5%). One hundred ninety-six samples were positive (67%), 130 from toe nails and 66 from finger nails. Simultaneous infections of both finger and toe nails were found in 22 cases. Associated onychomycosis and skin mycosis was found preferentially in feet onychomycosis. The sensitivities of direct examination and culture depended on the site of the onychomycosis. Cultures were more sensitive for hands where yeasts, particularly Candida albicans, predominated, but the direct examination was more sensitive for feet where dermatophytes, particularly Trichophyton rubrum, predominated.

CONCLUSION

Mycological examination is compulsory for confirmation of onychomycosis. It is also recommended before initiating a costly long-term treatment.