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Background: The assessment of nail changes in connective tissue diseases (CTD) has been rarely explored in previous studies. The use of dermoscopy to study vascular changes in nailfolds is an interesting diagnostic technique. The aim of the study was to describe the epidemiological, clinical, and dermoscopic features of nail lesions in CTD., Methods: A prospective study was performed at the Dermatology Department of Habib Thameur Hospital (Tunis, Tunisia) in collaboration with the Internal Medicine Department over a period of 15 months, from July 2020 to September 2021, including patients diagnosed with systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis (DM)., Results: Our study included 48 patients. Nail involvement was found in 44 cases. Dermoscopic nailfold abnormalities were identified in 37 cases. The most common clinical features were ragged cuticle, nailfold erythema, and onycholysis. Additionally, splinter hemorrhage, longitudinal ridging, lunula abnormalities, melanonychia, trachyonychia, leukonychia, increase in transverse curvature, parrot beak nail, half and half nails, and onychorrhexis were described. Nailfold dermoscopy showed a normal pattern in 10 cases, a nonspecific pattern in nine cases (SLE), and a scleroderma pattern in 29 cases (SS and DM). The scleroderma pattern was further categorized into an early pattern (6), an active pattern (14), and a late pattern (9). Normal pattern was observed solely in patients in remission. The late scleroderma pattern was associated with disease duration and systemic involvement. In SLE, disease activity correlated with onycholysis, nailfold erythema, and pathologic pattern in dermoscopy. However, patients with DM displayed a positive correlation between pulmonary involvement and scleroderma pattern., Conclusion: Nail involvement in CTD includes a diverse range of abnormalities. Despite being nonspecific, it can provide crucial clues for establishing a diagnosis. Nailfold dermoscopy serves as a mirror for microangiopathy, enabling the detection of changes at an initial stage, and thus, it becomes a diagnostic and prognostic tool., (© 2024 the International Society of Dermatology.)

Introduction: to describe the epidemiological, clinical, therapeutic and evolving characteristics of Behçet´s disease and identify prognostic factors., Methods: we have realized a retrospective, single-center study, conducted over a period of 26 years and including 130 patients presenting Behçet´s disease and hospitalized in an Internal Medicine Department., Results: the mean age of the Behçet´s disease at onset was 30.3 ±8.8 years and that at diagnosis was 34.6 ±9.4 years. The sex ratio (male/female) was 2.5. The mean delay of diagnosis was 53.5 months. Oral aphthosis was constant. The frequency of the manifestations was: genital aphtosis 71.5%, pseudofolliculitis 84.6%, erythema nodosum 11.5%, positive pathergy test 50%, ocular disease 36.9%, venous thrombosis 30%, arterial disease 4.6%, joint damage 30.8%, neurological disease 19.2% and digestive disease 0.8%. The male gender was significantly associated with ocular involvement (p =0.02), venous disease (p =0.01) and occurrence of relapses (p =0.01). The mean follow up was 68.5 ± 77.3 months. The poor survival prognostic factors were male gender, ocular involvement, venous disease, cardiovascular disease, a duration of follow up ≤12 months and a diagnostic delay ≤ 24 months. Conclusion: improving the prognosis of Behçet´s disease requires a shortening of the time to diagnosis, multidisciplinary collaboration, intensive treatment of functional threats, regular monitoring, and patient adherence., Competing Interests: The authors declare no competing interests., (Copyright: Fatma Daoud et al.)

Inroduction: Smoking and tuberculosis are two major public health issues worldwide, particularly in emerging countries. Currently, the relationship between these two scourges is well established., Aim: Describe the clinical, radiological and progressive features of common pulmonary tuberculosis in smokers., Methods: Comparative study, carried out at the Pneumology department of the Hédi Chaker in Sfax, Tunisia, including 120 patients hospitalized for common pulmonary tuberculosis  from January 2014 to December 2016 and who completed their follow-ups for a minimum period of 2 years . The patients were divided into 2 groups: Group1 (G1) consisting of 60 smoking patients and Group 2 (G2) consisting of 60 non-smoking patients. To assess the severity of radiological lesions, we used the International Labour Organization classification for simple pneumoconiosis and the Brouet classification., Results: The mean age of the patients was comparable in the two groups with a predominance of male for G1 (91%) and female for G2 (70%). The smokers consulted later (113 days versus 60 days (p=0.023). Dyspnea, hemoptysis and chest pain were significantly more frequent in the smokers. The radiological lesions were more serious in smoking group. Bilateral lesions were more observed in smokers (58% vs 25% p = 0.004). A positive association was noted between the extent of radiological lesions, stage 3 and 4 according to the Brouet classification, and smoking status (p <0.001). Similarly for the International Labour Organization classification for simple pneumoconiosis , the radiological lesions were more severe (scores 6 - 15) in the smokers (p <0.001).Smoking was associated with poor adherence (p <0.008), prolonged anti-tuberculosis treatment (p <0.001), delayed RBK negativation in sputum (p <0.001), and more frequent reactivation of tuberculosis (p=0.001). After the diagnosis of CPT, 83% of patients continued to smoke at the same rate and only 7% of patients had quit smoking., Conclusion: Smoking worsens CPT by making the clinical picture noisier, radiological lesions more aggressive, negativation of BK in sputum later, and reactivation of CPT more frequent.

Background: Bullous fixed drug eruption (BFDE) is a rare and particular adverse drug reaction characterized by localized or generalized blisters and erosions, which can be confused with Stevens-Johnson syndrome, toxic epidermal necrolysis, major erythema multiforme and autoimmune bullous dermatosis., Objective: The aim of our study was to assess the epidemiological, clinical and therapeutic features and outcome of BFDE., Methods: A retrospective and descriptive study collecting all observations of BFDE was conducted in the dermatology department of Habib Thameur Hospital in Tunisia, over an 18-year period (2000-2017). The diagnosis of BFDE was confirmed by histopathological examination and all the patients underwent pharmacovigilance investigation., Results: Totally, 18 cases were enrolled in our study with BFDE. The mean age was 57.9 years with a sex ratio M/F of 1. BFDE was localized in 8 cases and generalized in 10 cases. It was the first episode of BFDE in 11 patients and a recurrence in 7 patients. Drugs involved in the genesis of BFDE in our study were mainly non-steroidal anti-inflammatory drugs in 10 patients and antibiotics in 5 cases. Drug patch tests were performed in four patients on the residual plaques of FDE (fixed drug eruption) and were positive to the suspected drug. A favorable outcome was observed in all our patients under treatment and after suspected drug withdrawal., Conclusion: BFDE is a rare adverse drug reaction and could be severe especially when it presents as a generalized eruption. Drugs involved are mainly non-steroidal anti-inflammatory drugs followed by antibiotics., (Copyright © 2019 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.)

78-year-old man presented with complaints of progressive nasal blockage and epistaxis over the previous 2 months. Clinical examination revealed a nodular, polypoid, ulcerated nonpigmented tumor filling the right nasal cavity (Figure 1). A punch biopsy was taken from the mass for histopathologic examination, which revealed many melanocytes in the submucosa. The stroma contained large numbers of spindle-shaped cells with hyperchromatic spindleoid nuclei (Figure 2), confirming the diagnosis of malignant melanoma. The tumor cells stained positive for melan-A (Figure 3) and HMB-45.

Background: Rectovaginal fistulas are abnormal epithelial-lined connections between the rectum and vagina. The aquired etiology caused by child birth are still frequent in many countries., Aim: to describe epidemiology of obstetrical recto vaginal fistula in our country and discuss therapeutic modalities Materiel and methods: A retrospective multicentric study among 19 hospital departments from February 1982 to January 2007 of obstetrical recto-vaginal fistulas including 41 patients., Results: The median diameter of the fistula was 12 mm. the treatment consist on excision of the fistula and perineal suturing in 34 cases, Advancement flaps was used in four cases, the Musset technique repair in two cases, Gracilis transposition for repair was used in one case. Forty five patients had satisfactory anatomic and functional satisfactory results. One patient had reported dyspareunia. Definitive failure was reported in four cases., Conclusion: Our study suggests a regression in obstetrical RVF. However many efforts on institutional, socioeconomic and obstetrical levels have to be done in order to eradicate this pathology. Surgical treatments have good results. However prevention of this complication is the best treatment because a major handicap for women regarding socioeconomic, functional and psychological effects.

Background and Study Aims: Hepatic hydatid cyst is a major health problem in endemic areas. Surgery is still the best choice for treatment of the hydatid cyst of the liver. However, it is still associated with high mortality and morbidity. The aim of the study was to evaluate the predictive factors for specific morbidity after conservative surgical treatment of the hydatid cyst of the liver., Patients and Methods: A total of 120 patients who underwent conservative surgical treatment between 2001 and 2011 were evaluated retrospectively., Results: Of the 120 patients, 64 were female subjects and 56 male subjects; the median age was 33 years (14-83 years). The mortality rate was 0%. The overall morbidity rate was 26.6%. The specific morbidity rate was 16.6%. The major specific complications were infection of the residual cavity in 10 cases and an external biliary fistula in eight cases. The predictive factors of morbidity in univariate analysis were bilious cyst content, location of the cyst in the hepatic dome, and size >10 cm. After multivariate analysis, only the size of the cyst was an independent predictive factor of morbidity., Conclusion: The size of the cyst was the significant predictor of morbidity of conservative surgery for liver hydatid cyst., (Copyright © 2014 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

Inflammatory bowel diseases (IBDs), consisting of ulcerative colitis (UC) and Crohn's disease (CD), are complex disorders with multiple genes contributing to disease pathogenesis. We aimed to identify the associations of genetic variations in the ZAP70, PTPN6, BANK1, and CLEC2D genes encoding for intracellular signaling molecules with IBDs. One hundred seven patients (39 CD and 68 UC) with IBD and 162 healthy control subjects from the Southern Tunisia were recruited. We genotyped 4 single-nucleotide polymorphisms (SNPs) in ZAP70 (rs1020396, rs11686881, rs13420683, and rs17695937), 2 SNPs in PTPN6 (rs7310161 and rs759052), 3 SNPs in BANK1 (rs10516487, rs17266594, and rs3733197), and 1 SNP in CLEC2D (rs3764021). ZAP70 displayed a strong genetic association with CD for rs13420683 [allele C, p=0.003, P(corr)=0.006, odds ratio (OR)=2.25 (1.32; 3.85); genotype CC, p=0.016, P(corr)=0.048, OR=2.57 (1.22; 5.41)]. However, in UC, a weak association with PTPN6 was observed [TT (p=0.01; P(corr)=0.03; OR=2.11 (1.18; 3.76)]. No significant association in the BANK1 and CLEC2D genes was observed. These results suggest the involvement of the ZAP70 and PTPN6 genes in the genetic component conferring a general susceptibility to CD and UC, respectively. This work provides motivation for studies aiming to replicate these findings in larger populations.

Autoimmune Polyglandular Syndrome Type II (APSII) is characterized by the co-occurrence of clinical insufficiency of at least two endocrine glands. Although, HLA determinants of APSII predisposition have been identified, little attention has been paid to non-HLA genes. Here, we used SNP genotyping in a Sequenom platform and genetic association tests to study a cohort of 60 APSII Tunisian patients presenting highly frequent co-occurrence of Autoimmune Thyroid Disease (AITD) and Type 1 Diabetes (T1D) and lower frequency of Addison's disease (AD). We tested the high a priori possibility that well-established non-HLA autoimmunity loci were involved in APSII and confirmed five association signals to APSII, namely: (1) two T1D-associated SNPs, in CTLA4 and IL2RA, suggest their involvement in T1D pathogenesis in this cohort; (2) two SNPs in STAT4 and IL15 not previously associated to endocrinopathies, are possibly involved in co-occurrence of organ autoimmunity in APSII, and; (3) one SNP in TNF alpha showed association to APSII irrespective of AD. While this work was performed in a relatively small cohort, these results support the notion that the non-HLA genetic component of APSII include genetic factors specific of particular autoimmune manifestations as well as genetic factors that promote the co-occurrence of multiple autoimmune endocrinopathies., (Copyright © 2012 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved.)

This study aimed to investigate the association between HLA DR/DQ and inflammatory bowel diseases (IBD) in Tunisian patients and to determine the relationship between HLA DR/DQ alleles with the clinical disease patterns. DNA typing of human leukocyte antigen (HLA) genes was performed in 70 ulcerative colitis (UC) patients, 40 Crohn's disease (CD) patients, and 123 healthy controls (HC) using a polymerase chain reaction sequence specific primer technique. Data were analyzed using Cochran-Mantel-Haenszel test and binary logistic regression. Compared with HC, IBD patients showed an increased frequency of the homozygous DRB1*07 genotype. This positive association was maintained when UC and CD were separately compared to HC. In UC patients, DQB1*03:02 was predictive of colonic extension whereas DRB1*13 and DQB1*03:01 were associated limited disease localization (left-sided colitis and proctitis). The DRB1*15 allele increased in patients with extraintestinal manifestations. In CD, female patients showed an increased frequency of DRB1*13, DRB1*15, and DQB1*06 alleles and DRB1*13-DQB1*06 haplotype, whereas a significant increase of DRB1*07, DQB1*02 alleles, and DRB1*07-DQB1*02 haplotype was noted in male patients. These results show a significant association of the homozygous HLA-DRB1*07 genotype with UC and CD and of several HLA DR/DQ alleles and haplotypes with the clinical phenotypes of these diseases in Tunisian patients. Because of limited statistical power, our study findings are subject to further investigation.

The identification of susceptibility genes for inflammatory bowel disease (IBD) is key to understanding pathogenic mechanisms. Recently, the results of genetic association studies have highlighted many loci that are shared among several autoimmune diseases. We aimed to study the genetic epidemiology of polymorphisms in specific genes previously associated with other autoimmune diseases, namely the CREM, STAT4, STAT5a, Stat5b, and IRF5 genes. Twelve polymorphisms in the CREM, STAT4, STAT5a, Stat5b, and IRF5 genes were genotyped in a cohort of 107 IBD patients (39 Crohn's disease [CD] and 68 ulcerative colitis [UC]) and 162 controls from southern Tunisia. One CREM single nucleotide polymorphism (SNP) displayed evidence for genetic association with IBD (p=8.7×10(-4), odds ratio [OR]=2.84 [1.58; 5.09]). One STAT4 SNP (p=0.026; OR=1.65 [1.06; 2.58]) exhibited a marginal association with UC but not with CD. No significant association was observed with the SNPs in STAT5a, IRF5, and STAT5b. These results suggest that common variants of the CREM gene are involved in the genetic component conferring general susceptibility to IBD, whereas STAT4 appears to be more specifically associated with UC. This work provides motivation for studies aiming to replicate these findings in larger populations., (Copyright © 2011 American Society for Histocompatibility and Immunogenetics. All rights reserved.)

Background: Hypertension is a cardiovascular disorder rapidly emerging as a major public health problem in developing countries. However, the acknowledgement of the prevalence and the significant impact of hypertension in elderly are very important for health policy. The objective of the present investigation was to evaluate the prevalence, awareness and treatment of hypertension among the elderly living in their home in Tunisia at Monastir City. We also examined the impact of socio-demographic characteristics and known risk factors for high blood pressure., Methods: A community based sample of 598 non-institutionalized elderly (age ≥ 65 years), was selected using probabilistic multistage cluster sampling., Results: There was a predominance of female (66%) and mean age was 72.3 ± 7.4 years. The prevalence of hypertension was 52% (n = 311), awareness (81%, n = 252), treatment (78.4%, n = 244) and only 30.7% (n = 75) are correctly treated. The prevalence of hypertension was higher for the female population (55.5%) when compared to males (45%). No urban/rural differences were observed and no difference was observed by educational level. Multiple logistic regression analyses identified a higher body mass index, diabetes mellitus and disability as important correlates of the prevalence of hypertension., Conclusion: These findings provide important information on the prevalence, awareness and control of hypertension in Monastir City and confirm their association with other cardio-vascular risk factors. Effective public health measures and strategies are needed to improve prevention, diagnosis and access to treatment of this elderly population.

Introduction: Kindler's syndrome is a rare type of genetic skin condition belonging to the class of bullous poikilodermia. We report three new sibling cases of this rare syndrome., Cases Reports: The condition was seen in three sisters aged 12, 16 and 20 years, born of a first-degree consanguineous marriage with no family history of Kindler's syndrome. The three patients presented spontaneously regressive bullous eruptions, poikilodermia of gradual onset, major cutaneous atrophy on the back of the hands and the feet, photosensitivity and gingival hypertrophy. Electron microscopy examination of poikilodermic skin showed normal anchoring filaments and intraepidermal cleavage., Discussion: Diagnosis of Kindler's syndrome is based upon clinical evidence. Kidler's syndrome is a well defined clinical entity. Ultra-structural studies show intraepidermal, junctional, and dermal cleavage. This syndrome must be differentiated from congenital epidermolysis bullosa, Weary's syndrome, and other bullous hereditary poikilodermas., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Acanthosis nigricans is a well-defined skin disorder with a distinctive appearance and an elective topography to the flexural areas that facilitate its diagnosis. In Tunisia, apart from isolated reports of malignant AN, few epidemiologic data are available., Aim: In order to describe the characteristics of this affection, we conducted a retrospective study in the area of Tunis over a 12-year period., Methods: Retrospective study of all the cases of AN seen in the dermatology department of Habib Thameur teaching hospital between 1991 and 2003, including the cases coming from the north and of the centre of Tunisia., Results: Sixty-nine cases were recorded with a sex-ratio H/F of 0.17. The average age was 24.1 years (extremes of 3 and 66 years) and 57.9% of the patients were aged between 9 and 22 years. The neck (98.6%) and the axillae (75.4%) represented the most common localizations. All the patients presented a benign AN, comprising 51 cases of pseudo-AN, 11 cases of AN associated with endocrine diseases, 5 cases of familial AN and 2 cases of AN associated with an auto-immune disease. Local treatments associated an hypocaloric diet (AN with obesity) were recommended with a light improvement after 3 months an average follow-up., Conclusion: The frequency of the AN is probably underestimated because of the usually asymptomatic character of this affection. AN constitutes a double cutaneous marker, being able to reveal either an hyperinsulinemia constituting a cardiovascular risk factor or an ignored subjacent neoplasm engaging the vital prognosis.

Background: Cutaneous adverse drug reactions correspond to adverse effects with cutaneous expression resulting from the systemic penetration of a drug in the body. The aim of this study is to evaluate the various clinical pictures of RCM, their epidemiologic characteristics as well as the different causative drugs, through a retrospective hospital series., Methods: It is about a retrospective study about all the patients consulting and/or hospitalized for suspicion of an adverse cutaneous drug reaction led to the service of dermatology of the teaching hospital Habib Thameur of Tunis over a 3-year period (from January 2002 to December 2004). The diagnosis was based on a beam of clinical and anamnestic arguments. Only the patients having a positive pharmacovigilance investigation were retained., Results: 28 patients were retained for this study. The macular and papular exanthema represented the most frequent clinical aspects followed by acute urticaria and fixed drug eruption. The antibiotics represented the most causative drugs followed by analgesics and non steroidal anti-inflammatory., Conclusion: We record a lower frequency of cutaneous adverse drug reactions in comparison with the literature. We also find a high frequency of severe forms and stress on the difficulties encountered in the identification of the causativele drugs. Though, a close cooperation between the various hospital structures and pharmacovigilance centers is mandatory.

Background: Dermatomyositis (DM) is a rare but serious disease. The aim was to evaluate the epidemiology, presenting clinical manifestations, therapeutic features and outcome of patients with DM., Methods: From January 1986 to December 2003, we collected retrospectively cases of DM identified at the dermatology department of Habib Thameur hospital. We included only patients with definitive diagnosis of DM., Results: We included 13 patients, mean aged 32.85 years: 9 adults and 4 children. We identified 9 cases of adult DM among them 2 cases of wiihich were of paraneoplastic DM and 4 cases of juvenile DM among them 1 case of amyopathic DM and 1 case of DM associated with connective tissue disease. The evolution of DM followed the course of the neoplasm for the 2 patients with paraneoplastic DM. All patients received corticotherapy initially. Patients were followed-up for an average of 3 years (2 months to 10 years). We found no serious repercussions on the growth of children with juvenile DM., Conclusion: DM is rare in Tunisia. In our study, its frequency is about 0.72 patients per year. Age of onset of DM is markedly smaller than the one reported in the relevant litterature. Our 2 cases of DM associated with cancer are considered like really paraneoplastic. Juvenile DM seems to have a relatively good prognosis.

Despite prevention programs, tuberculosis is still endemic in developing countries. We assessed the epidemiologic and clinical profiles of childhood cutaneous tuberculosis in our dermatology department from 1981 to 2000 and compared it to previous Tunisian reports and to the relevant literature. This is a retrospective study over a 20-year period (1981-2000) in a large teaching hospital of the capital. Patients included were below age 15 years. Diagnosis was based upon clinical examination, tuberculin reaction, histopathology and response to antitubercular therapy. There were 26 patients with cutaneous tuberculosis, 0.1 percent of the total number of dermatology outpatients for that time period. Of these 26, seven (27 %) were immunocompetent. There were four boys and three girls and the mean age was 9.5 years. Three patients had lupus vulgaris, three had scrofuloderma, and one child had orificial tuberculosis. Six out of seven children were BCG vaccinated. There was no family history of tuberculosis. The Mantoux reaction was positive in six children. There was no systemic organ involvement in all cases. All patients were treated successfully with triple or quadruple anti-tubercular drugs for 4-11 months. Compared to a previous Tunisian report conducted over an 8-year period in the seventies, the incidence of childhood cutaneous tuberculosis has decreased. In that report, scrofuloderma was the most frequent form. Currently the incidence of lupus vulgaris has reached that of scrofuloderma, demonstrating the increase of the clinical pattern associated with strong immunity. All children had localized disease and responded to antimycobcterial chemotherapy.