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PubMed1993

Pemphigus foliaceus in young women. An endemic focus in the Sousse area of Tunisia.

BACKGROUND AND DESIGN: With the exception of some areas in Brazil, pemphigus is an exceptional disease. Several previous observations suggested that pemphigus foliaceus occurred more frequently than expected in Tunisia. To confirm these observations, a 15-month prospective survey was undertaken at the University Hospital of Sousse in Tunisia. RESULTS: During the survey, 23 patients with pemphigus were observed. Twenty of 23 cases were of pemphigus foliaceus that affected only young women. Seven patients had the clinical features of pemphigus herpetiformis. The estimated incidence of pemphigus foliaceus in the Sousse area was four new cases per million inhabitants per year, far above European or North American incidence but lower than the incidence in the most severely affected areas in Brazil. The high prevalence of the herpetiform clinical variant, the young age, the feminine exclusivity, and the absence of familial cases differentiated this Tunisian pemphigus both from pemphigus foliaceus observed in Europe and North America and from the Brazilian fogo selvagem. No etiologic factor was identified. CONCLUSIONS: This study suggests the existence in Tunisia (and possibly in all North Africa) of an endemic form of pemphigus foliaceus restricted to young women.

Adult↗
PubMed2006

Hepatitis B genotypes, precore and core promoter mutants circulating in Tunisia.

Hepatitis B virus (HBV) is characterized by genetic heterogeneity, including genotypes and mutations. Eight genotypes (A-H) have been identified throughout the world with a characteristic geographical distribution. Previous studies also suggest that the viral genotypes may correlate with differences in clinical features of the infection. Two types of mutations were particularly described, precore and basal promoter mutations; they may play an important role in the clinical outcome of HBV infection. The aim of this study was to investigate the prevalence of HBV genotypes and HBV variants in Tunisia, and their eventual association with severity of liver disease. Using a molecular method, HBV genotypes, precore and basal core promoter mutations were determined in 56 asymptomatic carriers and in 82 patients with histologically verified chronic liver disease and hepatocellular carcinoma (HCC). Three genotypes (D, A, and E) were detected; the prevalence was 80%, 8%, and 9%, respectively. No significant difference was observed for genotype D with clinical status. HBV mutants were detected in 93% of cases, precore mutants were the most prevalent. Basal core promoter mutants were observed in 61% of cases, they were frequently characterized by a double mutation in 1762 and 1764. Co-infection by these two types of mutants was detected in 50% of cases. Genotype D was the most prevalent HBV genotype in Tunisia. High circulation of precore and basal core promoter mutants are common in chronic hepatitis B infection in Tunisia.

Adolescent↗
PubMed2006

Identification of viral agents causing diarrhea among children in the Eastern Center of Tunisia.

Viral diarrhea remains a major cause of childhood morbidity and mortality worldwide. In Tunisia, no comprehensive studies of all viral agents related to diarrhea in children have yet been conducted. The present study was performed to investigate the role of enteric viruses in acute diarrhea in the country. Six hundred thirty-eight stool samples were collected from children under 5 years of age seeking medical care for acute diarrhea between October 2003 and September 2005 in hospitals from the Eastern-Center Tunisia. All samples were tested for rotavirus, astrovirus, and adenovirus using commercial antigen enzyme immunoassays (EIAs). Positive samples for rotavirus and astrovirus were confirmed by an "in-house" reverse transcriptase-polymerase chain reaction (RT-PCR). Samples positive for adenovirus antigen were subjected to further EIA screening for species F enteric adenovirus types 40 and 41. At least one viral agent was found in 30% of the specimens. The frequency of rotavirus, astrovirus, and adenovirus was 20%, 7%, and 6%, respectively. Of the stool samples containing adenovirus, 57% (20/35) were found to be positive for species F adenovirus types 40/41. Dual infections were found in 9% (17/191) of the positive samples. Enteric viruses appear to play an important role in pediatric diarrhea in Tunisia. The introduction of affordable viral diagnosis in pediatric hospitals will improve patient care by reducing the unnecessary use of antibiotics.

Acute Disease↗
PubMed2007

The spectrum of Vogt-Koyanagi-Harada disease in Tunisia, North Africa.

OBJECTIVE: To analyze the clinical profile of Vogt-Koyanagi-Harada (VKH) disease in Tunisia, North Africa. METHODS: We retrospectively reviewed the clinical records of 49 patients diagnosed with VKH disease at the Department of Ophthalmology of Fattouma Bourguiba University Hospital, Monastir, Tunisia, between January 1994 and September 2005. RESULTS: Of all the uveitis cases diagnosed during the study period, VKH disease was the fourth most commonly occurring type (7.4%). Thirty-two patients (65.3%) were female, and 17 patients (34.7%) were male. The mean age at disease onset was 35 years (range: 16-54 years). The majority of patients (51%) had probable VKH disease, followed by incomplete type (47%); only 2% had the complete type. At presentation, 47 patients (96%) had bilateral ocular involvement. Clinical presentation was a panuveitis in 25 patients (51%) and a posterior uveitis in 24 patients (49%). Visual acuity (VA) at presentation ranged from less than 20/200 (40.8%) to more than 20/40 (28.5%). All patients were treated with systemic corticosteroids for 2-19 months (mean: 10.5 months). Four patients (8%) were treated with cyclosporin because of serious systemic side effects of corticosteroids. Complications included cataract in 18 eyes (33.9%), glaucoma in nine eyes (16.96%) and choroidal neovascularization in one eye (1%). Fifty-eight eyes (59%) had a final VA of 20/40 or better. Factors associated with a poor VA at the final follow-up were the presence of a poor VA at presentation (P = 0.02), the occurrence of complications (P = 0.001) and/or recurrences (P = 0.02). CONCLUSION: In Tunisia, VKH disease is a common cause of uveitis that predominantly affects young women. The overwhelming majority (98%) have probable or incomplete VKH disease, presenting as panuveitis or posterior uveitis. More than 50% of patients undergoing treatment with corticosteroids will maintain a VA of 20/40 or better.

Adolescent↗
PubMed1989

Distribution of surgical hydatidosis in central Tunisia (1982-1985).

The mean annual surgical incidence rates (MASIR) of hydatidosis were measured for the 1982-1985 period in central Tunisia in order to investigate the natural history of human hydatidosis and provide baseline data for the evaluation of future prevention campaigns. 986 cases were identified from surgical records of regional hospitals to which cases from central Tunisia are mandatorily referred. The overall MASIR was 19.3 per 10(5) inhabitants. The MASIR according to district varied from 0 to 56.6 per 10(5), was higher in women than in men (22.6 versus 15.8 per 10(5] and increased with age (maximum 53.0 per 10(5) in the 50-59 age group for women and 27.1 per 10(5) in the 40-49 group for men). Among the 940 cases with single organ hydatidosis, liver ranged first (55.3%, 545/940), then lung (32.4% 320/940), kidney (2.7%) and spleen (1.8%). Among the 865 subjects with single lung or liver hydatidosis, liver was more often involved in women (349 out of 503) than in men (196 out of 362) (chi 2 = 20.9, p less than 0.001). In both sexes, the lung/liver ratio decreased with age. These data reveal the existence of highly endemic foci of hydatidosis within central Tunisia. The predominance of infection in women might be due to sex related behavioral differences. The causes of liver predominance in women and variation of lung/liver ratio are open to question.

Age Factors↗
PubMed2004

Clinical and molecular aspects of haemoglobinopathies in Tunisia.

BACKGROUND: For the last two decades, studies on the population genetics of Tunisians have focused on variations of protein and genetic markers. Results confirmed the genetic heterogeneity of Tunisians caused by the admixtures with migratory human groups arriving mainly from Africa, Europe, and Asia. These studies also allowed the screening of rare mutants and many haemoglobin variants. METHODS: The present study delineates the incidence of the different haemoglobinopathies in Tunisia. Previously collected data and results obtained from epidemiological and clinical studies of 1238 blood donors and 276 patients were compared. The chromosomal backgrounds of different haemoglobinopathies were explored by molecular techniques (denaturing gradient gel electrophoresis (DGGE), amplification refractory mutation system (ARMS) polymerase chain reaction (PCR), and sequencing). RESULTS: This study indicates that appropriate DNA methodologies required for a nationwide preventive program in Tunisia are available and that prenatal diagnosis is feasible. Additionally, analysis of sequence polymorphisms allowed a better understanding of the gene recombination events and their application for tracing back the origin and the diffusion of the mutations. CONCLUSIONS: Molecular analysis techniques such as DGGE and ARMS PCR are socially and economically the most suitable techniques to be used in Tunisia for the detection and the identification of haemoglobin abnormalities. At present, their use is essential to conduct a clear and efficient screening program.

Anemia, Sickle Cell↗
PubMed2004

The medical abortion experiences of married and unmarried women in Tunis, Tunisia.

CONTEXT: The study explores the social dimensions of abortion in Tunisia and offers evidence supporting the provision of medical abortion to special populations, such as young and unmarried women. METHODS: For this study we recruited 222 women (unmarried: n = 101, married: n = 121) at three clinics in Tunis, Tunisia, from April 1999 to March 2001. All eligible women who consented to participate were administered a simplified regimen of medical abortion consisting of 200 mg oral mifepristone + 400 microg oral misoprostol 2 days later either at home or in the clinic. RESULTS: Our results demonstrate that unmarried women (94.8%) are as likely as married women (94.1%) to have a successful abortion using this regimen. We noted a strong initial preference for home administration of misoprostol among both groups (unmarried: 73.3%, married: 80.2%), which grew even stronger after the procedure. Women indicated that home administration is desirable because transportation to the clinic is expensive (32.7%), home administration is more confidential (26.3%), easier and more convenient (12.8%). Both groups expressed a high degree of satisfaction with the method. CONCLUSIONS: Medical abortion with the option of home administration of misoprostol is safe and feasible for special populations; such as unmarried women in Tunisia.

Abortifacient Agents↗
PubMed2004

Cervical cancer in Tunisia: an epidemiological, clinical and pathological study.

BACKGROUND: This study was undertaken to determine epidemiological and pathological profile of cervical cancer in Tunisia. DESIGN STUDY: Registration and analysis of all cervical cancer newly diagnosed during the year 1994 (year of general census) based on review of all pathology laboratory files in the country with exclusion of previously diagnosed cases according to clinical data. RESULTS: During the year 1994, 216 new cases were registered among which 195 cases (89.81%) were invasive carcinoma. The standardized incidence (invasive cancer) is 5.91 per 100000 women per year. The average age was 53.7 year. Sixty-three percent cases are diagnosed at an advanced stage (IIB, III, IV FIGO stages). Invasive carcinoma has distributed as follows: 177 cases (91.23%) were squamous invasive carcinoma, 17 cases (8.77%) were invasive adenocarcinoma. In the same year, 21 cases of in situ squamous carcinoma were registered with an average age equal to 44.21 year. Only one case of cervical cancer was a sarcoma (0.52%). CONCLUSION: The incidence of cervical cancer in Tunisia is relatively low in spite of the absence of a screening program. This may be related to monogamy and observance of legal age of marriage. Squamous invasive carcinoma is the most frequent pathological type. CONDENSATION: The incidence of cervical cancer in Tunisia is relatively low in spite of the absence of a screening program.

Adult↗
PubMed2006

Celiac disease in Tunisia: serological screening in healthy blood donors.

BACKGROUND: Recent epidemiological studies in Europe and in USA using antigliadin antibodies and antiendomysium antibodies for initial screening have shown that the overall prevalence of celiac disease (CD) is about 1:200 (0.5%). AIM: To screen for CD in healthy blood donors in Tunisia. PATIENTS AND METHODS: Sera from 2500 healthy blood donors (median age: 21 years, 70% men and 30% women) were screened for IgG-antigliadin antibodies and IgA-antigliadin antibodies with an enzyme-linked immunosorbent assay. All sera with positive antigliadin antibodies were tested for antiendomysium antibodies using human umbilical cord cryosections as substrate. RESULTS: Seven healthy blood donors (median age: 21 years; four men, three women) have antiendomysium antibodies. The prevalence of antiendomysium antibodies in healthy blood donors in Tunisia is 1:355 (0.28%). CONCLUSIONS: On the basis of a high specificity of the antiendomysium antibodies, it is likely that the seven blood donors identified in this study have CD. These data suggest that CD is frequent in Tunisia.

Adult↗
PubMed2005

Occurrence of Leishmania infantum cutaneous leishmaniasis in central Tunisia.

Cutaneous leishmaniasis (CL) due to Leishmania infantum occurs sporadically in Tunisia where its distribution is confined to the northern parts of the country. However, during the past decade there have been occasional repeated reports of cases from areas in central Tunisia, known to be free of CL. Epidemiological, clinical and parasitological data regarding these patients were collected and analysed. Data were very suggestive of the sporadic form of CL due to L. infantum. The parasites contained within the lesions of some of the patients were characterised by two different previously described PCR assays, each having different resolutive powers. The first assay, which amplified complete kDNA minicircles, showed a fragment size characteristic of the L. donovani complex; whilst the second consisted of a PCR-RFLP analysis targeting the gp63 coding sequences that confirmed assignment of the parasites to L. infantum species while illustrating its differences from the reference isolate. These findings confirm the aetiology of CL in the concerned areas in central Tunisia and suggest that L. infantum CL might be more prevalent and widespread than previously thought, or possibly emerging in these areas.

Adolescent↗
PubMed2005

Molecular evidence of ovine (G1) and camel (G6) strains of Echinococcus granulosus in Tunisia and putative role of cattle in human contamination.

Three hundred and seventy-two cysts coming from 50 humans, 166 cattle, 153 sheep and 3 camels were collected in order to establish some epidemiological molecular information in Tunisia for the first time. The analysis by PCR-RFLP of ITS1 sequence showed that all the human, ovine and bovine cysts were due to the common sheep strain of Echinococcus granulosus. The sequencing of the CO1 gene of 37 isolates confirm the G1 genotype of this strain. For seven of these isolates, we found the mutation C56T which is present in the three principal intermediate hosts: human (three cysts), cattle (three cysts) and sheep (one cyst). With regard to the G1 genotype, we identified three other point mutations. The camel strain G6 is uniquely found in the three camels isolates and not in the other intermediate hosts analysed. The fertility of the bovine cyst represents 48% that means that this host is involved in a bovine-dog cycle and consequently represents a reservoir of sheep strain in Tunisia. Our results confirm the importance of the prophylaxis measures in order to disrupt the cycle of transmission sheep-dog in Tunisia. Nevertheless, the supervision of bovine infection should be reinforced because this intermediate host may constitute an important link with the human contamination.

Animals↗
PubMed2005

Epidemiology and prevention of tobacco use in Tunisia: a review.

INTRODUCTION: This paper describes trends in tobacco sales and smoking prevalence in the Tunisian population, it estimates the consequences of smoking on mortality of this population and discusses anti-tobacco actions: educational actions, legislative measures, and price increases. DATA SOURCES: Sales data were collected from the Tunisia tobacco monopoly, smoking prevalence data from surveys conducted by several institutes, and numbers of deaths by causes have been estimated from WHO for 1998 year. RESULTS: Tobacco sales increased from 4.96 g per adult per day in 1981 to 6.3 g in 1993, then decreased widely. The proportion of smokers was 30% in 1996, 55% among men versus 5.6% among women. Among 17 to 24 years old young adults, the proportion of smokers was 29.2% in 1994 (50% among men versus 3.9% among women). Mortality attributable to tobacco in Tunisia has been estimated to 6430 deaths in 1997 (5580 among men versus 850 among women). These deaths represent 22% of total male deaths and 4% of female ones. Anti tobacco measures have been reinforced by the enactment of anti tobacco law. CONCLUSION: Proportion of young smokers remaining high, it is expected that the consequences of tobacco addiction in Tunisia in term of mortality will be even heavier in the next two decades if efficient anti tobacco actions are not implemented.

Age Distribution↗
PubMed2006

[Epidemiologic study of autoimmune thyroid disease in south Tunisia].

In order to study incidence and prevalence of autoimmune thyroid diseases (AITDs), we studied a retrospective cohort of 1,079 patients explored in the department of Endocrinology of Sfax (south of Tunisia). The overall incidence of AITDs was 9.9%. Mean age was 39.6+15 years; sex ratio 5 F/1M. Graves' disease was the most frequent (45%). Atrophic thyroiditis was present in 32.2% of patients and Hashimoto's thyroiditis in 22.8%. The incidence of AITDs increased from 1990 to 2000 and by 2003 it had fallen to 67 cases per year. TPO antibody was present in two-thirds of patients with Hashimoto thyroiditis, and half of those with atrophic thyroiditis. TG antibodies were less frequent (one-third of patients). Association with other autoimmune diseases was noted in 6.3% of patients: type I diabetes mellitus, adrenal insufficiency and vitiligo. Statistic analysis did not disclose any association between autoantibody levels and thyroid dysfunction. There was an association between TG antibody and TSH levels among patients with Graves' disease and between TG antibody level and age in atrophic thyroiditis patients (p<0.05); a correlation was also noted between these antibodies and other autoimmune diseases (p=0.05). It is difficult to assess the frequency of ATD in the clinical setting. Characteristic features of AITDs in patients seen in south Tunisia were found to be similar to those described in the literature. Other more large-scale representative studies would be useful to establish the epidemiology of AITDs in Tunisia.

Autoantibodies↗
PubMedDate not supplied

Seroepidemiology of hepatitis B, C and delta viruses in Tunisia.

Serum samples from 33,363 healthy people in Tunisia have been tested for serological markers of hepatitis B, C and delta viruses (HBV, HCV and HDV). Hepatitis B surface antigen (HBsAg) was detected in 6.5% of sera. The overall seroprevalence of HBV was 37.5%. Vertical and perinatal transmission of HBV in the first 3 months of life occurred in only 0.4% of 177 mother and child pairs. HBV seroprevalence was 10.7% in infants under 5 years old and increased with age rapidly till 25 years of age and then more slowly in adulthood, reaching 54% for people aged over 40 years. HBsAg seropositivity varied throughout the country, ranging from 3% to 13% with higher prevalences in the south and central-west regions. Overall seroprevalences for HDV and HCV were 17.7% and 0.4%, respectively. HDV superinfection occurred later than HBV and increased with age in parallel with HBV. Overall, HCV and HBV infections had different geographical distributions throughout the country. The study confirmed the high prevalence of HBV infection in Tunisia; it occurs mainly in children and teenagers, and vertical and perinatal transmission of HBV does not appear to be significant. HDV superinfection is quite common in Tunisia and occurs in almost 44% of individuals infected with HBV. In contrast, seroprevalence of HCV in the Tunisian general population was low (0.4%). These results indicate differences in the distribution of the viruses and/or different routes of transmission.

Adolescent↗
PubMed1998

[Hemoglobin beta S haplotype in the Kebili region (southern Tunisia)].

Sickle cell anemia is a monogenic hereditary disease characterized by a mutation in the beta globin gene. Five major haplotypes associated with the beta S mutation have been defined: Benin, Bantu, Senegalian, Camerounian, and Arabo-Indian. Previous studies in northern Tunisia showed that sickle cell anemia was of Benin origin in this region. Patients from the south of Tunisia, mainly from the Kebili region, were not previously concerned. In this study, we have determined the beta S haplotype and evaluated phenotypical expression of the disease in 14 patients from this latter region. The use of four restriction endonucleases having polymorphic sites in the beta globin gene showed that all patients had the Benin haplotype, confirming the Benin origin of sickle cell anemia in Tunisia. This haplotype is associated with an heterogeneous expression of fetal hemoglobin (HbF) with extremes varying from 2.4 to 16.3% and a mean expression rate of 8.16%, which is in accordance with literature data. In spite of the haplotype homogeneity in our patients, clinical heterogeneity was noted. A unique case of alpha-thalassemia could not explain this heterogeneity. In contrast, we found a certain correlation between fetal hemoglobin expression and clinical severity.

Adolescent↗
PubMed2006

Pattern of uveitis in a referral centre in Tunisia, North Africa.

AIM: To analyse the pattern of uveitis in a referral centre in Tunisia, North Africa. METHODS: The study included 472 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1992 to August 2003. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with three-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis. RESULTS: The mean age at onset of uveitis was 34 years. The male-to-female ratio was 1:1.1. Uveitis was unilateral in 282 patients (59.7%) and bilateral in 190 patients (40.3%). Anterior uveitis was most common (166 patients; 35.2%), followed by posterior uveitis (133 patients; 28.2%), panuveitis (100 patients; 21.2%), and intermediate uveitis (73 patients; 15.5%). A specific diagnosis was found in 306 patients (64.8%). The most common cause of anterior uveitis was herpetic uveitis (56 patients; 33.7%). Toxoplasmosis was the most frequent cause of posterior uveitis (51 patients; 38.3%). Intermediate uveitis was most commonly idiopathic (63 patients; 86.3%). Behçet's disease was the most common cause of panuveitis (36 patients; 36%), followed by Vogt-Koyanagi-Harada (VKH) disease (15 patients; 15%). A total of 16 patients (3.4%) suffered from blindness, and 59 (12.5%) from uniocular blindness. CONCLUSIONS: In a hospital population in Tunisia, the most common causes of uveitis were Behçet's disease, herpes simplex infection, toxoplasmosis, and VKH disease.

Acute Disease↗
PubMed2005

Spread of Leishmania killicki to Central and South-West Tunisia.

Twenty cutaneous leishmaniasis (CL) cases were notified from December 2001 to February 2002, in a small village in the district of Oueslatia (governorate of Kairouan, central Tunisia) which is an endemic focus of infantile visceral leishmaniasis due to leishmania (L.) infantum and that had never been concerned previously by CL. The parasite typing of two isolates obtained from two children that have never left the region has identified L. killicki. This species had only been reported previously in a limited focus of Tunisian Southeast. In October 2002, an epidemiological survey with isoenzym characterization of the parasite led in a well-known focus of zoonotic cutaneous leishmaniasis of South-West Tunisia also revealed the presence of L. killicki. These results suggest the spread of this species and stress the need of further investigations for a better control of CL in Tunisia.

Adult↗
PubMed2006

Pattern of childhood-onset uveitis in a referral center in Tunisia, North Africa.

PURPOSE: To analyze the pattern of childhood uveitis in a referral center in Tunisia, North Africa. METHODS: The study included 64 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1994 to July 2005. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with 3-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis. RESULTS: The mean age at onset of uveitis was 12.4 years. The male-to-female ratio was 0.68. The process was unilateral in 51.6% of patients. Mean follow-up was 43.2 months. Anterior and intermediate uveitis each represented 31.25% of cases, posterior uveitis 20.3%, and panuveitis 17.2%. Noninfectious uveitis (75%) was the most frequent type of inflammation. Idiopathic uveitis was found in 50% of patients. Infectious uveitis was responsible for 25% of the cases, with toxoplasmosis (14.1%) being the most frequent cause. Twenty percent of the patients had systemic associations; juvenile idiopathic arthritis was found in 6.25%. Ocular complications occurred in 74.7% of affected eyes, of which the most common were posterior synechiae (28.4%), cataract (17.9%), cystoid macular edema (19%), and optic disc edema (32.6%). Fifty-seven affected eyes (60%) had a final visual acuity more than 20/40 and nine (9.5%) had a final visual acuity less than 20/200. CONCLUSIONS: In a hospital population in Tunisia, a specific cause of uveitis in children was found in half the patients. Idiopathic intermediate uveitis was the leading cause of uveitis in our study, followed by idiopathic anterior uveitis and toxoplasmosis. Uveitis associated with juvenile idiopathic arthritis was rare. Visual prognosis appeared to be good.

Adolescent↗