pBFK, a new thermosensitive shuttle vector for Streptococcus pyogenes gene deletion by homologous recombination

Streptococcus pyogenes, or Group A Streptococcus (GAS), is a major human pathogen for which genetic manipulation remains an ongoing challenge. We created a new temperature-sensitive plasmid pBFK expressing spectinomycin resistance adapted to homologous recombination procedure to perform a complete gene deletion in GAS. Herein the mutagenesis strategy with pBFK was performed in a highly virulent GAS emm3 genotype.

Analysis of the Genomics and Mouse Virulence of an Emergent Clone of Streptococcus dysgalactiae Subspecies equisimilis

Streptococcus dysgalactiae subsp. equisimilis is a bacterial pathogen that is increasingly recognized as a cause of severe human infections. Much less is known about the genomics and infection pathogenesis of S. dysgalactiae subsp. equisimilis strains compared to the closely related bacterium Streptococcus pyogenes. To address these knowledge deficits, we sequenced to closure the genomes of seven S. dysgalactiae subsp. equisimilis human isolates, including six that were emm type stG62647. Recently, for unknown reasons, strains of this emm type have emerged and caused an increasing number of severe human infections in several countries. The genomes of these seven strains vary between 2.15 and 2.21 Mbp. The core chromosomes of these six S. dysgalactiae subsp. equisimilis stG62647 strains are closely related, differing on average by only 495 single-nucleotide polymorphisms, consistent with a recent descent from a common progenitor. The largest source of genetic diversity among these seven isolates is differences in putative mobile genetic elements, both chromosomal and extrachromosomal. Consistent with the epidemiological observations of increased frequency and severity of infections, both stG62647 strains studied were significantly more virulent than a strain of emm type stC74a in a mouse model of necrotizing myositis, as assessed by bacterial CFU burden, lesion size, and survival curves. Taken together, our genomic and pathogenesis data show the strains of emm type stG62647 we studied are closely genetically related and have enhanced virulence in a mouse model of severe invasive disease. Our findings underscore the need for expanded study of the genomics and molecular pathogenesis of S. dysgalactiae subsp. equisimilis strains causing human infections. IMPORTANCE Our studies addressed a critical knowledge gap in understanding the genomics and virulence of the bacterial pathogen Streptococcus dysgalactiae subsp. equisimilis. S. dysgalactiae subsp. equisimilis strains are responsible for a recent increase in severe human infections in some countries. We determined that certain S. dysgalactiae subsp. equisimilis strains are genetically descended from a common ancestor and that these strains can cause severe infections in a mouse model of necrotizing myositis. Our findings highlight the need for expanded studies on the genomics and pathogenic mechanisms of this understudied subspecies of the Streptococcus family.

A recurrent prosthetic joint infection caused by Erysipelothrix rhusiopathiae: case report and literature review

Prosthetic knee joint infection caused by Erysipelothrix rhusiopathiae is uncommon and only one case of recurrent infection has previously been described. Here, we describe the case of a 77-year-old male patient who was admitted to the teaching hospital of Rennes (France) with bilateral and nocturnal gonalgia evolving for 1 month. He had bilateral knee prosthesis 10 years ago, and a history of large B-cell lymphoma in remission. A diagnosis of infective endocarditis, with prosthetic knee infection, was made, with positive cultures of synovial fluids and blood; colonies of E. rhusiopathiae were identified by MALDI-TOF MS. Initial treatment involved debridement, implant retention surgery and intravenous amoxicillin (12 g day^-1) for 6 weeks with gentamicin 3 mg kg^-1 day^-1 added for the first 4 days. One year later, a second episode of E. rhusiopathiae infection occurred, suggesting a recurrence or reinfection due to the same bacterial species. The patient was finally cured after a two-stage exchange with a cemented articulated spacer and a 3 month course of amoxicillin (12 g day^-1, iv). Different characteristics of E. rhusiopathiae infection were discussed, with a review of all cases of prosthetic joint infections caused by Erysipelothrix species. This case highlights the need for a long-term survey of patients, and a good knowledge of their environment to avoid any risk of reinfection.

Cerebral nocardiosis in a patient treated with pembrolizumab: a first case report

Background

Checkpoints inhibitors (CPIs) are increasingly used for the treatment of several malignancies. The most common side effects are Immune Related Adverse Events, while infectious complications are rare, especially cerebral nocardiosis.

Case presentation

Here, we report the first clinical case of a cerebral nocardiosis revealed after seizure in a patient treated by pembrolizumab for a metastatic lung cancer, in the absence of any additional immunosuppressive therapy or risk factors for cerebral nocardiosis. The extended evaluation including a brain CT-scan did not reveal any lesion before pembrolizumab. Nevertheless, the 3-month delay between the start of Pembrolizumab and the diagnosis of cerebral nocardiosis suggests that the infection occurred prior to the CPI. Unfortunately, the patient died during treatment for cerebral nocardiosis, while the lung cancer tumor mass had decreased by 80% after the sixth cycle of pembrolizumab.

Conclusions

This case report emphasizes that clinicians should consider diagnoses other than metastasis in a patient with a brain mass and metastatic cancer treated with CPI, such as opportunistic infections or IRAE.

Clinical value of serology for the diagnosis of strongyloidiasis in travelers and migrants: A 4-year retrospective study using the Bordier IVD® Strongyloides ratti ELISA assay

Strongyloides stercoralis serology is a sensitive method for strongyloidiasis diagnosis, but it is prone to cross-reactions with other helminthiases. This four-year retrospective study aimed at estimating the performance of the Bordier IVD^®Strongyloides ratti ELISA assay in a non-endemic country (France). The study included all patients tested for strongyloidiasis in our center between 2015 and 2019, by both serology and stool examination. Cases were defined using an algorithm considering serological results, microscopic examination of stools, and other biological, clinical or epidemiological data. The study included 805 stools from 341 patients (70% migrants, 20% travelers, 10% without travel to a highly endemic area). Thirty patients (8.8%) had positive serology, 9 had microscopically proven strongyloidiasis, and 11 and 10 were classified as probable and possible strongyloidiasis, respectively. Performances of microscopy and serology were compared, considering proven and probable strongyloidiasis as true infections. The sensitivity, specificity, positive predictive value and negative predictive value of serology were 100%, 97%, 67% and 100%, respectively, and those of microscopic examination of stools were 45% (p < 0.01), 100% (p < 0.01), 100% (p = 0.079) and 96% (p < 0.001), respectively. Eosinophilia did not help in discriminating true-positive from false-positive results. Overall, these results underline the high value of the S. stercoralis serologic assay, compared to stool examination. The systematic use of this technique for screening purposes in travelers or migrants, or before onset of immunosuppressive therapy, could help to improve patient management and epidemiological knowledge.

Performance of commercial methods for linezolid susceptibility testing of Enterococcus faecium and Enterococcus faecalis

BACKGROUND

Linezolid-resistant enterococci (LRE) causing infections that are challenging to treat are rising, highlighting the need for reliable screening of LRE clinical isolates.

OBJECTIVES

To evaluate the ability of the broth microdilution (BMD) method for LRE detection and to assess the performance of seven commercially available techniques for linezolid susceptibility testing.

METHODS

A collection of 100 clinical isolates (80 Enterococcus faecium and 20 Enterococcus faecalis), including 20 optrA-positive isolates, 17 poxtA-positive isolates and 1 optrA/poxtA-positive E. faecium isolate, were studied. MICs were determined after 18 h [Day 1 (D1)] and 42 h [Day 2 (D2)] of incubation and interpreted following EUCAST and CLSI guidelines, which currently provide different interpretative breakpoints. Performance of commercial techniques was compared with BMD results.

RESULTS

MIC50/D1 and MIC50/D2 were both 8 mg/L, while MIC90/D1 and MIC90/D2 were 16 and 32 mg/L, respectively. MICD1 values for poxtA-positive isolates were lower than those for optrA-positive isolates. Proportions of susceptible isolates at D1 and D2 were 48% and 41%, respectively, according to EUCAST breakpoints and 35% and 13%, respectively, according to CLSI criteria (the proportions of isolates categorized as intermediate following CLSI recommendations were 13% and 28% at D1 and D2, respectively). Percentage susceptibility assessed by the commercially available techniques was always higher. The four commercial methods allowing MIC determination provided an overall essential agreement of ≥90% at D1. Categorical agreement and error rates were generally improved at D2.

CONCLUSIONS

Non-automated methods (Sensititre and UMIC) and, to a lesser extent, gradient strip Etest appear to show an acceptable correlation with the BMD reference method for the detection of isolates with low MICs of linezolid after prolonged incubation.

Ventriculitis: A Severe Complication of Central Nervous System Infections

BACKGROUND

Ventriculitis, a dreaded complication of brain abscess, meningitis, and various neurosurgical procedures, has attracted limited attention in the medical literature.

METHODS

This is a retrospective, single-center study. We screened the medical files of all patients who had a brain imaging report that included the word "ventriculitis" during years 2005-2019. Only patients with clinical, microbiological, and imaging features of ventriculitis were included. Data were collected through a standardized questionnaire.

RESULTS

Ninety-eight patients fulfilled inclusion criteria: 42 women and 56 men, and the median age was 60 years (interquartile range, 48-68). The primary mechanism for ventriculitis was classified as follows: brain abscess (n = 29, 29.6%), meningitis (n = 27, 27.6%), intraventricular catheter-related (n = 17, 17.3%), post-neurosurgery (n = 13, 13.3%), and hematogenous (n = 12, 12.2%). The main neuroimaging features were intraventricular pus (n = 81, 82.7%), ependymal enhancement (n = 70, 71.4%), and intraventricular loculations (n = 15, 15.3%). The main pathogens were streptococci (n = 44, 44.9%), Gram-negative bacilli (n = 27, 27.6%), and staphylococci (n = 15, 15.3%). In-hospital and 1-year mortality rates were 30.6% (n = 30) and 38.8% (n = 38), respectively. Neurological sequelae were reported in 34 of 55 (61.8%) survivors, including cognitive impairment (n = 11), gait disturbances (n = 9), paresis (n = 7), behavior disorder (n = 6), and epilepsy (n = 5). On multivariate analysis, age >65 years, Glasgow Coma Scale score <13 at initial presentation, status epilepticus, hydrocephalus, and positive cerebrospinal fluid culture were associated with 1-year mortality. We built a scoring system to stratify patients with ventriculitis into low risk (12.5%), intermediate risk (36.5%), and high risk (71.4%) of death.

CONCLUSIONS

Ventriculitis is a severe complication of brain abscess, meningitis, or neurosurgery, with an in-hospital mortality rate of 30% and neurological sequelae in 60% of survivors.

A prospective survey of Streptococcus pyogenes infections in French Brittany from 2009 to 2017: Comprehensive dynamic of new emergent emm genotypes

Streptococcus pyogenes or group A Streptococcus (GAS) causes diseases ranging from uncomplicated pharyngitis to life-threatening infections. It has complex epidemiology driven by the diversity, the temporal and geographical fluctuations of the circulating strains. Despite the global burden of GAS diseases, there is currently no available vaccination strategy against GAS infections. This study, based on a longitudinal population survey, aimed to understand the dynamic of GAS emm types and to give leads to better recognition of underlying mechanisms for the emergence of successful clones. From 2009 to 2017, we conducted a systematic culture-based diagnosis of GAS infections in a French Brittany population with a prospective recovery of clinical data. The epidemiological analysis was performed using emm typing combined with the structural and functional cluster-typing system for all the recovered strains. Risk factors for the invasiveness, identified by univariate analysis, were computed in a multiple logistic regression analysis, and the only independent risk factor remaining in the model was the age (OR for the entire range [CI_95%] = 6.35 [3.63, 11.10]; p<0.0001). Among the 61 different emm types identified, the most prevalent were emm28 (16%), emm89 (15%), emm1 (14%), and emm4 (8%), which accounted for more than 50% of circulating strains. During the study period, five genotypes identified as emm44, 66, 75, 83, 87 emerged successively and belonged to clusters D4, E2, E3, and E6 that were different from those gathering “Prevalent” emm types (clusters A-C3 to 5, E1 and E4). We previously reported significant genetic modifications for emm44, 66, 83 and 75 types resulting possibly from a short adaptive evolution. Herein we additionally observed that the emergence of a new genotype could occur in a susceptible population having specific risk factors or probably lacking a naturally-acquired cluster-specific immune cross-protection. Among emergent emm types, emm75 and emm87 tend to become prevalent with a stable annual incidence and the risk of a clonal expansion have to be considered.

In vitro activity of eravacycline and mechanisms of resistance in enterococci

Eravacycline (ERC), the first fluorocycline, is a new tetracycline with superior activity to tigecycline (TGC) against many bacterial species. This work aimed to determine the in vitro activity of ERC compared with other tetracyclines against enterococcal clinical isolates and to analyse corresponding resistance mechanisms. A collection of 60 enterococcal strains was studied: 54 epidemiologically unrelated clinical isolates (46 Enterococcus faecium and 8 Enterococcus faecalis) including 42 vancomycin-resistant enterococci (VRE) (33 vanA and 9 vanB), 3 in vitro TGC-resistant mutants (E. faecium AusTig, HMtig1 and HMtig2) and 3 reference wild-type strains (E. faecium Aus0004 and HM1070, E. faecalis ATCC 29212). In vitro susceptibility was determined using Etest strips (for ERC) or by broth microdilution (for TGC, doxycycline, minocycline and tetracycline). Resistance genes [tet(M), tet(L), tet(O) and tet(S)] were screened by PCR for TGC- and/or ERC-resistant strains as well as sequencing of the rpsJ gene (encoding ribosomal protein S10). MIC_50/90 values were 0.016/0.08, ≤0.03/0.5, 4/32, 8/16 and 32/>32 mg/L for ERC, TGC, doxycycline, minocycline and tetracycline, respectively. According to EUCAST guidelines, nine strains were categorised as resistant to TGC (MIC, 0.5-8 mg/L), including four E. faecium vanA(+) strains also resistant to ERC (MIC, 0.19-1.5 mg/L). These four strains all possessed at least one mutation in rpsJ and two tet determinants: tet(M) + tet(L) (n = 2); and tet(M) + tet(S) (n = 2). Although ERC has excellent in vitro activity against enterococci (including VRE), emergence of resistance is possible due to combined mechanisms (rpsJ mutations + tet genes).

Emergence of optrA-mediated linezolid resistance in enterococci from France, 2006-16

OBJECTIVES

To describe the epidemiological trend of linezolid-resistant enterococci (LRE) collected in France from 2006 to 2016 and to extensively characterize LRE isolates.

METHODS

The National Reference Center for Enterococci (NRC-Enc) received enterococcal isolates suspected to be VRE and/or LRE from all French hospitals between 2006 and 2016. LRE isolates were phenotypically characterized and their genomes were entirely sequenced by Miseq (Illumina). Transfer of linezolid resistance was attempted by filter mating experiments.

RESULTS

Out of 3974 clinical isolates of enterococci received at the NRC-Enc over the period, 9 (0.2%) were LRE (MICs 8 to >32 mg/L), including 6 Enterococcus faecium and 3 Enterococcus faecalis. This overall prevalence significantly increased over the study period, reaching 0.8% in 2016. The five LRE isolated before 2016 were vanA-positive E. faecium whereas strains isolated in 2016 (one E. faecium and three E. faecalis) were susceptible to vancomycin. None of these isolates was part of an outbreak, while E. faecium strains were assigned to four different STs [17 (1), 80 (3), 412 (1) and 650 (1)] and all three E. faecalis belonged to ST480. Except for the strain isolated in 2010, all LRE were positive for optrA, which was located on plasmids (5/8) or in the chromosome (3/8). Plasmid transfer of optrA was successful in three cases.

CONCLUSIONS

There has been a significant increase in the prevalence of LRE in France over time; this is due to the spread of optrA among E. faecium and E. faecalis human clinical isolates (VRE or not).

[Pediatric Crohn's disease in Tunisia]

Crohn's disease occur mainly in adults. However, pediatric onset forms are not rare and have many characteristics.

AIM

to study clinical, diagnostic, therapeutic and evolutive characteristics of crohn's disease in tunisian children.

METHODS

Retrospective multicenter study conducted in 10 pediatric departments on a period of 10 years (2000-2008) RESULTS : 43 children were included. The sex-ratio was 1.68. The mean age at the onset of the symptoms was 11+/-2.3 years (5-16 years). The age of onset was inferior to 10 years in 25 % of the children. The delay before management was superior to 1 year in 25% of cases. The initial symptoms were dominated by diarrhea (95%). Perineal manifestations were present at diagnosis in 30% of children and extra-digestive manifestations in 53%. Ileocolonic localization was the most frequent (46%). The initial disease flare was moderate in 83% of cases. The treatment was medical in 77 % of cases, nutritional and medical in 18.5%. Maintenance therapy was instituted in 86% of cases and consisted essentially in azathioprin (62%). The mean follow-up was 3 years and 4 months. 60% of the children had at least one acute flare. During evolution, 7% of children had anoperineal surgery and 11% an intestinal resection.

CONCLUSION

Crohn's disease seems rare in Tunisia. The time of diagnosis is often delayed. The management is based on immunosuppressive therapy and nutritional support.

Gastric atrophy and Helicobacter pylori infection in children

AIM

To assess the prevalence of gastric atrophy (GA) in Tunisia (a high prevalence region for Helicobacter pylori), and describe its histological, clinical and endoscopic features in children.

METHODS

345 children, 151 male and 194 female, mean age 8.6 +/- 3.7 years, underwent upper gastrointestinal (UGI) endoscopy with gastric biopsies for recurrent abdominal pain (n=232, 67.2%), vomiting (n=72, 20%) associated with or without upper gastrointestinal bleeding (n=59, 17.1%) and miscellaneous causes (n=53, 15.4 %). Biopsies performed both in the gastric antrum (n=2) and corpus (n=2) were analysed for histological assessment according to the updated Sydney classification system and bacterial culture. A positive result was recorded where histology and/or culture were positive, confirming the presence of H. pylori infection (H. pylori +ve). A negative result was recorded when both tests were concomitantly negative (H. pylori -ve).

RESULTS

9.3% (32/345) of the total population, and 14.5% (32/221) of chronic gastritis patients exhibited GA, M/F: 16/16, mean age (SD) 9.4 (3.4) years. Amongst the 32 children with GA, 30 (93.7%) were H. pylori +ve and 2 (6.3%) were H. pylori -ve. GA was localised in the antrum (n=26, 81.2%), the fundus (n=2, 6.3%) and was also seen in both (n=4, 12.5%). GA was categorised as mild, grade 1 (n=18, 56.3%); moderate, grade 2 (n=13, 46.6%); and severe, grade 3 (n=1, 3.1%). GA was associated with mild active gastritis in 18 cases (56.3%). The prevalence of moderate or severe antral GA was detected in 9/26 (34.6%) of H. pylori +ve vs. any of H. pylori -ve (p=0.4), whereas GA in the corpus was detected in 1/2 (50%) vs. none, respectively. None exhibited intestinal metaplasia. There were no clinical features specific to this pathology. UGI endoscopy in GA patients showed nodular gastritis (n=17, 53.1%), congestive gastritis (n=9, 28.1%), and normal tissue (n=6, 18.8%). GA was significantly associated with H. pylori infection (p<0.0001) and nodular gastritis (p<0.005).

CONCLUSION

GA was found in 9.3% of Tunisian children undergoing UGI endoscopy and was significantly associated with H. pylori infection and nodular gastritis.

Foetus-in-fetu: an unusual cause of abdominal mass in the newborn

Foetus-in-fetu (FIF) is a rare congenital condition in which a vertebrate foetus is incorporated within its twin. The authors report the case of a newborn girl with prenatal ultrasonographic diagnosis of an intra-abdominal mass. Abdominal ultrasonography and computed tomography of the abdomen showed a heterogeneous cystic mass containing multiple calcifications. The patient had a laparotomy at 18 days of age with excision of a well-encapsulated 6 x 5 cm retroperitoneal mass, containing many organs. Anatomicopathologic examination showed a relatively well-differentiated FIF attached to an amniotic sac by a rudimentary umbilical cord. Encephalon, coroidal plexus, vertebral bodies, rudimentary limbs, thyroid gland and teeth were identified. The postoperative period was uneventful.

Study of hypothalamic leptin receptor expression in low-birth-weight piglets and effects of leptin supplementation on neonatal growth and development

Low birth weight resulting from intrauterine growth retardation (IUGR) is a risk factor for further development of metabolic diseases. The pig appears to reproduce nearly all of the phenotypic pathological consequences of human IUGR and is likely to be more relevant than rodents in studies of neonatal development. In the present work, we characterized the model of low-birth-weight piglets with particular attention to the hypothalamic leptin-sensitive system, and we tested whether postnatal leptin supplementation can reverse the precocious signs of adverse metabolic programming. Our results demonstrated that 1) IUGR piglets present altered postnatal growth and increased adiposity; 2) IUGR piglets exhibit abnormal hypothalamic distribution of leptin receptors that may be linked to further disturbance in food-intake behavior; and 3) postnatal leptin administration can partially reverse the IUGR phenotype by correcting growth rate, body composition, and development of several organs involved in metabolic regulation. We conclude that IUGR may be characterized by altered leptin receptor distribution within the hypothalamic structures involved in metabolic regulation and that leptin supplementation can partially reverse the IUGR phenotype. These results open interesting therapeutic perspectives in physiopathology for the correction of defects observed in IUGR.

[Severe corrosive oesophagitis : are high doses of methyl prednisolone efficient to prevent oesophageal caustic stricture in children?]

BACKGROUND

Corrosive oesophagitis stricture is the long term complication of severe corrosive oesophagitis. The aim of our study was to evaluate the effect of a high doses of steroids on incidence and quality of oesophageal stricture.

PATIENTS AND METHODS

We reviewed the case histories of 28 children seen at children hospital from 31 December 1991 to 31 december 2001. These children has second and third degree oesophageal burns and they were treated by systemic Methylprednisolone (1000mg/1,73/m2 SC).

RESULTS

the frequency of stricture was 12/26 (46%). Ten children required A mean of 6,7 (5,74) dilatation range (1 - 17). One patient required an oesocoloplasty. The frequency of stricture in the group treated early before the 24th hour and after the 24th hours was (9/21) (47,4%) versus (3/7) (42,9%). This difference was not significant (P = 1). The frequency of stricture in the group treated less than 21 days and more than 21 days was 6/17 (40%) versus 6/9 (66,7%). This difference was not significant (P = 0,400). High doses of methyl prednisolone seems to decrease the risk of oesophageal stricture. We found no difference between the children treated before the 24th hours and those treated after the 24 hours and those treated less than 21 days and those more than 21 days.

Genetic and mutational heterogeneity of autosomal recessive chronic granulomatous disease in Tunisia

NADPH oxidase, a multi-subunit protein consisting of cytosolic components and the membrane-bound heterodimer, plays an instrumental role in host defence mechanisms of phagocytes. Genetic deficiency of the enzymatic complex results in an inherited disorder, chronic granulomatous disease (CGD), which is characterized by an impaired phagocyte microbicidal activity. X-Linked (XL) CGD results from a mutation in the CYBB gene encoding the gp91phox subunit, while autosomal recessive (AR) CGD is associated with mutations in one of the NCF1, NCF2 and CYBA genes that encode the p47phox, p67phox and p22phox subunits, respectively. In the study reported here, we investigated genetic defects underlying CGD in 15 Tunisian patients from 14 unrelated families. Haplotype analyses and homozygosity mapping with microsatellite markers around known CGD genes assigned the genetic defect to NCF1 in four patients, to NCF2 in four patients and to CYBA in two patients. However, one family with two CGD patients seemed not to link the genetic defect to any known AR-CGD genes. Mutation screening identified two novel mutations in NCF2 and CYBA in addition to the recurrent mutation, DeltaGT, in NCF1 and a splice site mutation previously reported in a North African patient. Our results revealed the genetic and mutational heterogeneity of the AR recessive form of CGD in Tunisia.

Abdominal tuberculosis in children. Report of 10 cases

BACKGROUND

Abdominal tuberculosis is a rare location of this infection with a lot of diagnostic difficulties. The aim of this study was to review our experience of pediatric abdominal tuberculosis with that of the literature data.

PATIENTS AND METHODS

A retrospective study was conducted over a 7-year period; 10 cases of abdominal tuberculosis in children were reviewed (6 girls and 4 boys, mean age: 11 years, extremes 4-14). Eight patients enrolled in this study satisfied the following criteria: a positive culture for mycobacterium tuberculosis on samples of ascites fluid, sputum, urine, abscess puncture and/or caseating granulomas on histologic examination of biopsies obtained by endoscopy, percutaneous aspiration or needle biopsy or exploratory laparotomy. Two other patients (patients No 1 & 5) had a favorable response within 10 weeks of antituberculous therapy.

RESULTS

We observed 8 cases of peritoneal tuberculosis and 2 cases of intestinal tuberculosis. Extra-abdominal tuberculosis was found in 4 of those patients. Two patients had a contact with a tuberculosis positive individual. Nine children had BCG immunization. The main clinical features were abdominal distension (6 cases) and abdominal pain (6 cases). Abdominal ultrasonography visualized mesenteric lymphadenopathies (6 cases), an abdominal mass (5 cases), free (1 case) and localized ascites (1 case). Barium enema and small bowell series showed small bowel stenosis (1 case) and ileal ulcerations (1 case). Exploratory laparotomy, performed in 3 patients, showed whitish granulations and peritoneal abscesses with caseous necrosis on histology. Quadruple therapy with tuberculostatic agents was prescribed in all patients, associating isoniazid, rifampicin, pyrazinamide combined at the start of the treatment with streptomycin (7 cases) and ethambutol (3 cases). Short term outcome was favorable with no deaths. The long term outcome was complicated by persistent ascites (1 case) and the development of portal hypertension (1 case).

CONCLUSION

Abdominal tuberculosis remains a rare localization with a lot of diagnostic difficulties.

Corticothérapie à forte dose dans le traitement des œsophagites caustiques sévères chez l’enfant

Esophageal burns are frequent in some countries. Esophageal stricture is a severe complication after caustic ingestion. Its frequency is estimated to 5% and reaches 47% in severe esophagitis.

AIM OF THE STUDY

To study the influence of management of severe esophageal burns with high doses of steroids in the occurrence of esophageal stricture through the experience of an endoscopic unit.

PATIENTS AND METHODS

Twenty-six children with a mean age of 3.5 years (15 months-8 years) with a second b- (N =22) or a third-degree (N =4) esophageal burns due to accidental ingestion of a caustic substance were included between 1993 and 1999. Corrosive substances ingested were sodium hydroxide (N =17), bleach (N =4), alkali (N =3), others (N =2). Upper GI endoscopy was performed in 17 children within the 24 hours of caustic ingestion and within the first 48 hours in all cases. All patients received methylprednisolone (1 g/1.73 m2/day) plus cimetidine and ampicillin plus early oral feeding resumption.

RESULTS

Three children (2 grade II et one grade I) were not controlled on day 30 of the protocol and have then been excluded. The remaining 23 children were divided in two groups depending on the upper GI endoscopic results: group I of 12 patients completely or partially healed and group II of 11 patients who developed an esophageal stricture. No difference was observed between the two groups with regard to the delay between caustic ingestion and the start of treatment and the number of shots of methylprednisolone. Second b- degree esophagitis complicated with an esophageal stricture underwent a median of five esophageal dilations (1-12). After a median follow-up of three years, four of them have a normal esophagus. All children with a third-degree esophagitis developed an esophageal stricture. One had a surgical replacement of the esophagus with a segment of colon with good outcome. The three others underwent a median of seven esophageal dilations (5-10). One of them has a normal esophagus after a follow-up of five years while the two others were lost to follow-up.

CONCLUSION

High dose of corticosteroids seems to improve second b-degree esophagitis prognosis and may prevent from esophageal stricture.

Visceral leshmaniasis diagnosed on duodenal biopsy in a child

Visceral leishmaniasis is usually easy to recognize when clinical presentation is complete: splenomegaly, fever and palor associated to pancytopenia, hypoalbuminaemia and hypergamma globulinemia. Bone marrow smears, culture and serology confirm the diagnosis. We report the case of an infant in whom clinical and biological findings are suggestive of leishmaniasis and the diagnosis confirmed only by duodenal biopsy.

[Heterotopic gray matter. Report of four pediatric cases]

Severe infant epilepsy is included within difficult etiologic diagnosis. Gray matter heterotopias are an uncommon cause. The authors report four observations of gray matter heteropias concerning three-, six-, seven- and nine-year-old girls, presenting no particular antecedents. No consanguinity was noted. The first occurrence of epilepsy ranged from the age of nine months to the age of four years. A mild mental retardation was found in three cases, and mental regression in one case. A status epilepticus was noted in three children. Magnetic resonance imaging scans showed subependymal heterotopias in one case and diffuse cortical heterotopias in three cases associated to a partial agenesis of corpus calloseum in one case and pachygyria in two cases.

[Chronic septic granulomatosis in a young girl manifesting as invasive pulmonary aspergillosis and flaccid paraplegia]

The invasive Pulmonary Aspergillosis (IPA) is the principal cause of death in patients with chronic granulomatosis disease (CGD). It can happen before age of one and can reveal the (CGD). Usually, the transmission of GSD is linked to x in 65% of cases. We report, the case of a girl aged 3 years issued from consanguine marriage referred to hospital for hemoptysia. We note that at 40 days she presents an suppurate adenitis. She is hypotrophic at--3DS without respiratory problem, she have a splenomegaly. The radiography chest note an alveolar and interstitial opacity bilateral, apical right and basal left. There is a biological inflammatory syndrome. During the evolution, the child presents a paraplegia secondary to compression myelitis. A D5 laminectomy in urgency was done. The vertebral Biopsia, the serology and the culture isolate fumigatus aspergillus the GCD is evoqued confirmed by the NBT test who was negative.

IN CONCLUSION

--We have to look for GCD in front of pulmonary aspergillus.--The vertebra lesion is secondary to pulmonary lesion.--Our observation is noticeable by the recessive autosomal transmission who was seen in 35% of cases, and by the neurologic complication rarely reported.

[Dermatitis herpetiformis and chronic diarrhea: a case]

We report on a case of dermatitis herpetiformis in an eight-year-old boy presenting diarrhoea, short stature and characteristic skin rash. Jejunal biopsy showed a partial villous atrophy. The diagnosis was confirmed by immunofluorescence which showed granular IgA deposits in the papillary dermis. On a gluten-free diet associated with dapsone, the child gained weight and height, with partial resolution of the rash.

[Tumoral calcinosis. Apropos of a further case in a child]

Tumor-like calcinosis is an infrequent condition whose etiology is poorly understood. Calcifications develop in the subcutaneous tissue neighboring the large joints. All age groups can be affected, although the disease is more common before the age of twenty years. A new case of tumor-like calcinosis in an eight-year-old girl is reported here. A huge mass in the right hip region and a smaller mass around the right elbow were found. Biologic studies revealed increased serum phosphorus levels with normal serum calcium levels. Roentgenograms confirmed the diagnosis of tumor-like calcinosis by showing calcified masses independent from the bones of the neighboring joint. Management consisted in complete removal of both masses. Outcome was favorable. In this patient's family, the disease appears to be inherited according to a dominant pattern, although recessive autosomal transmission is believed to be more common.

[Skull fracture with progressive separation. Apropos of a case]

A case of fracture of the skull with progressive separation of the fracture line in a seven-month-old is reported. The patient presented with a swelling in the right parieto-occipital area and paresis of the upper left limb; there was no clear history of trauma. The roentgenogram of the skull disclosed a large bone defect and the cerebral CT scan showed herniation of intracranial contents through this defect, confirming the diagnosis of fracture of the skull with progressive separation. In this form of skull fracture, the fracture line separates gradually and herniation of intracranial contents through the opening occurs. Clinical and roentgenographic monitoring should be routinely performed in children under three years with a skull fracture and separation of the fracture line, to detect a delayed complication. The mechanisms of this fracture are discussed in the light of data from the literature.

[Congenital sensory neuropathy with anhidrosis: type IV. Apropos of 2 new cases]

Two new cases of congenital sensory neuropathy (CSN) type IV in brothers aged 10 and 5 years are reported. Features included diffuse lack of response to pain without loss of response to touch, temperature and proprioceptive stimuli. No other neurologic anomalies were found. Both patients had complete anhidrosis. Joint destruction, which was the result of the failure to react to painful stimuli, was the most prominent feature. Nerve biopsy specimens exhibited marked reductions in numbers of amyelinic fibers with normal numbers of myelinic fibers. These two cases of CSN type IV are discussed in the light of previously reported cases and the new classification of congenital sensory neuropathies is reviewed.

[Hemiballism. Description of a clinical case in childhood]

Biballism is an infrequent hyperkinetic disorder characterized by involuntary, intermittent, violent, uncontrollable contractions of the proximal muscles of the limbs. Biballism is classically ascribed to a lesion in the controlateral subthalamic nucleus or its connections but other causes have been reported. These include infections (bacterial, viral parasitic), cerebrovascular lesions, tumors, toxics, and systemic disease (systemic lupus erythematosus). Although poorly understood, the pathophysiology of hemiballism is widely believed to involve hyperactivity of the dopaminergic system. The prognosis of these abnormal movements, formerly poor, has been improved by the use of neuroleptics and drugs acting on the different neurotransmitter systems. A unique case of biballism at resolution of a febrile coma in a 4 1/2 year old is reported. The EEG showed diffuse slow waves. A hyperdense lesion was visible in the right thalamic region on the cerebral CT scan. The magnitude of the abnormal movements decreased under haloperidol. The etiology of this case of biballism is discussed.