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Candida albicans has become an important cause of nosocomial infections in neonatal intensive care units (NICUs). The aim of the present study was to compare C. albicans strains isolated from neonates (NN) suffering from systemic candidosis and from nurses in order to determine the relatedness between NN and health workers’ strains. Thirty-one C. albicans strains were isolated from 18 NN admitted to the NICU of the neonatology service of Farhat Hached Hospital of Sousse, Tunisia and suffering from systemic candidosis, together with five strains recovered from nurses suffering from C. albicans onychomycosis. Two additional strains were tested, one from an adult patient who developed a systemic candidosis and the second from an adult with inguinal intertrigo. All strains were karyotyped by pulsed-field gel electrophoresis (PFGE) with a CHEF-DR II system. Analysis of PFGE patterns yielded by the 38 strains tested led to the identification of three pulsotypes that were designated I, II and III, and consisted of six chromosomal bands with a size ranging from 700 to >2500 kbp. The most widespread was the pulsotype I, which was shared by 17 NN and the five nurses’ strains. The identity between NN and nurses’ strains is very suggestive of a nosocomial acquisition from health-workers. [ABSTRACT FROM AUTHOR]

Objectives. – The aim of this study was to evaluate infantile cryptosporidiosis prevalence in central Tunisia.Population and methods. – Stool samples from 34,020 immunocompetent children were investigated for oocysts through a 12-year study.Results. – Cryptotosporidia were detected in 0.32% (108) of samples. Ninety three per cent of children were less than five years old. Incidence was much higher in summer and autumn. Leading clinical symptoms were diarrhea, fever and vomiting. Symptoms spontaneously resolved in all patients. In three cases, infection was asymptomatic.Conclusion. – Data analysis indicate that cryptosporidiosis is not uncommon in diarrheic central Tunisian children. [Copyright &y& Elsevier]

Dermatomycosis, such as candidiasis and mycosis among others, has emerged recently as the most frequent fungal infection worldwide. This disease is due to the skin's exposure to microorganisms that are able to pass through skin barrier defects. Therefore, textiles in direct contact with skin can serve as a source of contamination and fungus spread. In the current study, a sustainable and eco-friendly method for antifungal cotton finishing using Curcuma longa L extracted from rhizomes was investigated. To enhance the natural bioactive dye uptake and attachment, cellulosic cotton fibers were chemically modified using dopamine, a biocompatible molecule, leading to the deposition of a hydrophilic layer of polydopamine. The efficiency of the polydopamine coating on the cotton surface has been assessed by x-ray photoemission spectroscopy analyses, with the detection of nitrogen, and by water contact angle for the wettability enhancement. Furthermore, characterization of the modified samples confirms that the modification did not affect either the cellulosic fiber morphology or the mechanical properties. The dyeability and bioactive dye immobilization were then assessed by colorimetry. Finally, the effectiveness of the finished fabrics against Trichophyton (rubrum/mentagrophytes) and Candida albicans strains was evaluated and was shown to induce growth inhibition mainly on Candida albicans strains.

Aspergillus flavus is the most common species associated with invasive aspergillosis in Tunisia. The molecular epidemiology of the species is poorly documented. We used five highly discriminative microsatellite markers for the genotyping of clinical and hospital environmental A. flavus strains to assess whether IA could be hospital-acquired in the onco-hematology unit of the Farhat Hached teaching hospital of Sousse, Tunisia. The genotyping of 18 clinical isolates, collected from sputa of 17 acute leukemia patients, and 81 isolates, collected in these patients' hospital environment and food, identified 57 isolates that were grouped in 10 clones, each of them including 2-17 isolates. The remaining 42 isolates showed a unique genotype. Two main transmission scenarios were observed: (1) the same clone was isolated from different patients; (2) the same clone was isolated from a patient, its hospital environment and/or food. These findings strongly suggest the occurrence of hospital-acquired A. flavus infection/colonization in the investigated onco-hematology unit.

Background: Vulvovaginal candidiasis is a common infection among women worldwide, being Candida albicans the most commonly isolated species. Therefore, controlling this opportunistic yeast is one of the key factors for reducing nosocomial infection., Aims: We investigated several virulence properties of 28 vaginal strains of Candida isolated from Tunisian women suffering from vulvovaginitis. We also analyzed the virulence properties of a clinical Candida krusei strain and five Candida reference strains., Methods: Candida strains were subjected to microscopic analysis and culture in Candida ID2 chromogenic medium. The adhesive properties of these strains were estimated by the microtiter plate - the safranin-staining - and the Congo red agar (CRA) methods, for determining yeast ability to form biofilms on biomaterials used in urinary catheter manufacturing. Their potency to produce hydrolytic enzymes was also studied., Results: Our results showed that nine out of the total studied strains produced phospholipase. In addition, very high protease activity was detected in 23 Candida strains. All Candida strains were beta-hemolytic and adhered to polystyrene microtiter plates in varying degrees. Two vaginal C. albicans strains were strongly adhesive to polystyrene and glass slides. Also, our results showed that vaginal Candida strains were more adhesive to the three tested materials than the reference strains., Conclusions: This study shows the presence of a range of virulence and adhesion factors in clinical isolates of vaginal Candida. Consequently, control and treatment of vaginal candidiasis as a means to prevent biofilm formation on urinary catheters is of crucial importance., (Copyright © 2013 Revista Iberoamericana de Micología. Published by Elsevier Espana. All rights reserved.)

Hospital environment is considered the main source of invasive aspergillosis (IA) in leukemic patients. This study aimed to describe Aspergillus colonisation in leukemic patients and their hospital environment and to test whether Aspergillus environmental contamination was associated with IA. For a 2-year period including 14-month renovation work, 91 acute leukaemia inpatients at the hematology department of University hospital in Sousse (Tunisia) were prospectively included. The incidence of probable IA (EORTC/MSG criteria) was 9.9%. Fifty-six Aspergillus were isolated from 53 (6.5%) of 811 sputa collected from 35 (38.5%) patients. Aspergillus spp. were isolated in 59.7% of 494 air samples and in 52.8% of 1579 surface samples taken in the patients' room. Aspergillus section Nigri (72.7%) was the most frequent. Aspergillus contamination peaked in autumn and winter on surface and in summer and autumn in air samples and was higher (P = 0.03) during the renovation work period. Multivariate analysis showed that for each Aspergillus section Nigri CFU airborne contamination IA risk increased by 1.05 (P = 0.04). In Tunisia, Aspergillus section Nigri and Flavi, but not Fumigati, are chiefly involved in IA. Our findings support swift implementation of airborne fungal contamination control measures in areas where immunocompromised patient are hospitalised., (© 2015 Blackwell Verlag GmbH.)

The determination of the accurate immune status of pregnant women is crucial in order to prevent congenital toxoplasmosis. Equivocal results with conventional serological techniques are not uncommon when IgG titers are close to the cut-off value of the test, so that a confirmatory technique is needed. For this purpose, we developed a homemade immunoblot (IB) using soluble extract of Toxoplasma gondii tachyzoites and assessed it by testing 154 positive, 100 negative, and 123 equivocal sera obtained from pregnant women. In order to select the more valuable bands in terms of sensitivity and specificity, we used the Youden Index (YI). The highest YIs were those given by the 32, 36, 98, 21, and 33 bands. The simultaneous presence on the same blot of at least 3 bands showed a much higher YI (0.964) and was adapted as the positivity criterion. The analysis of results showed that our homemade IB correlated well with the commercial LDBIO Toxo II IgG® kit recently recommended as a confirmatory test (96.7% of concordance).

Although scarce, available data suggest that the epidemiology of invasive aspergillosis (IA) in North Africa differs from northern countries, where more than 80 % is caused by Aspergillus fumigatus. This study aimed at describing the epidemiology of IA in the region of Sousse, Tunisia, and at assessing the usefulness of the available diagnostic tools. For 2 years, clinical and mycological data were prospectively collected from 175 neutropenia episodes of 91 patients hospitalised in the haematology department at the Farhat Hached hospital in Sousse (Tunisia). Screening for galactomannan antigen was positive in 40 % of neutropenia episodes; Aspergillus PCR was positive in 42 % of the tested sera. Nine patients were classified as probable and two as possible IA according to the EORTC/MSG criteria. Twelve patients who prematurely died, had no CT scan and could not be classified. Fifty-six Aspergillus spp. were isolated in 53 (6.5 %) sputa collected from 35 (20 %) patients. The following species were identified with MALDI-TOF mass spectrometry and DNA sequencing: A. niger, 35 %; A. flavus, 38 %; A. tubingensis, 19 %; A. fumigatus, 4 %; A. westerdijkiae, 2 % and A. ochraceus, 2 %. Our findings highlight the epidemiological features of IA in Tunisia, which is characterised by the predominance of Aspergillus spp. from sections Nigri and Flavi.

The resistance of Aspergillus species to antifungal is increasingly reported and the knowledge of the local epidemiology and antifungal susceptibility pattern is pivotal to define adequate treatment policies. Our study aimed to: 1) describe the in vitro antifungal susceptibility profile of the Aspergillus species isolated from patients with haematological malignancies in Tunisia; 2) compare the E-test and Sensititre Yeast-One assays for the detection of paradoxical growth and trailing effect, both phenotypes commonly exhibited by Aspergillus spp. upon exposure to caspofungin and 3) to evaluate the mortality rate in patients according to the causative Aspergillus species and the antifungal treatment. We tested amphotericin B, itraconazole, voriconazole, posaconazole and caspofungin against 48 Aspergillus isolates (17, A. niger; 18, A. flavus; 9, A. tubingensis; 1, A. westerdijkiae; and 1, A. ochraceus) with the E-test. Minimal inhibition concentrations were above the epidemiological cut-off values for amphotericin B in 67% of A. flavus strains; for caspofungin in 22% of A. flavus strains; and for itraconazole in 22% of A. tubingensis strains, voriconazole and posaconazole MICs were below the epidemiological cut-off values for all strains. When exposed to caspofungin, 42% of the strains exhibited trailing effect and 38% paradoxical growth. Trailing effect occurred in 61% of A. flavus strains and paradoxical growth in 62% of Aspergillus section Nigri strains. E-test and Sensititre Yeast-One assays were only fairly concordant for the detection of these phenotypes. Repeatability of both assays was high for trailing effect but poor for paradoxical growth. The relatively high frequency of amphotericin B resistant strains makes voriconazole best adapted as a first-line treatment of invasive aspergillosis from amphotericin B to voriconazole in this hospital.

Purpureocillium lilacinum is a saprophytic fungus found in soil and decaying organic matter, but has been reported as an emerging pathogen in immunocompromised patients and following surgical procedures. Infections caused by this mold are often difficult to treat because of its intrinsic resistance to conventional antifungal agents and variable susceptibility to novel triazoles. In immunocompetent subjects, infections caused by P. lilacinum are unusual and mainly involve the skin. We describe herein a case of cutaneous hyalohyphomycosis due to this fungus in an immunocompetent girl without any predisposing risk factors and review the previously reported cases in immunocompetent hosts.

The performance values of available techniques used in serodiagnosis of toxoplasmosis are satisfactory but they raise problems of equivocal and discordant results for very low IgG titers. Recently marketed, LDBio-Toxo II IgG Western blot (IB) showed an excellent correlation with the dye test. We estimated the proportion of equivocal and discordant results between the enzyme immunoassay Platelia Toxo IgG (EIA-IgG) and fluorescent antibody test (FAT) and assessed the usefulness of the IB as a confirmatory test. Out of 2,136 sera collected from pregnant women, 1,644 (77.0%) tested unequivocally positive and 407 (19.0%) were negative in both EIA-IgG and FAT. The remaining 85 (4%) sera showed equivocal or discordant results. Among them, 73 (85.9%) were positive and 12 (14.1%) were negative in IB. Forty-one (89.1%) equivocal sera in EIA-IgG and 46 (86.8%) equivocal sera in FAT were positive in IB. Reducing the cut-off values of both screening techniques improved significantly their sensitivity in detecting very low IgG titers at the expense of their specificity. In conclusion, equivocal results in routine-used techniques and their discordance in determination of the immune status in pregnancy women were not uncommon. IB test appeard to be highly useful in these situations as a confirmatory technique.

Geotrichum capitatum infection is uncommon, and has been exclusively reported in immunocompromised patients. The prognosis is poor with a mortality rate ranging from 50 to 90%. We report 3 cases of Geotrichum capitatum fungemia in neutropenic patients receiving chemotherapy for acute myeloblastic leukemia. The infection was successfully cured with voriconazole in 1 case and was fatal in the 2 remaining cases despite treatment with amphotericin B.

The nosocomial transmission of Candida albicans in neonatal intensive care units (NICUs) is an increasing concern and understanding the route of this transmission is critical for adequate infection control measures. The aim of our study was to assess the likeliness of nosocomial acquisition of C. albicans in the NICU of Farhat Hached hospital in Sousse (Tunisia). We genotyped 82 isolates from 40 neonates and 7 isolates from 5 health care workers (HCWs) with onychomycosis, by using CDC3 microsatellite length polymorphism (MLP) and the high-resolution melting (HRM) analysis. Combined MLP and HRM CD3 analysis led to the delineation of 12 genotypes. Five temporal clustering caused by five genotypes occurred during the study period. Three of these genotypes were isolated in both neonates and HCWs. The first clustering included 28 isolates obtained between January 2003 and May 2004 from 16 neonates and 2 HCWs. The second clustering included three isolates collected in 2004 from three neonates and two HCWs. The third clustering included 11 isolates obtained from 6 neonates and 1 HCW in 2006. The two remaining clustering could not be associated with any HCW's contamination. These results argue for the nosocomial transmission of C. albicans in our NICU. The combined MLP and HRM analysis is a rapid first approach for tracking cross-contamination.

Unlabelled: The serological tests commonly used for the diagnosis of toxoplasmosis raise the problem of the interpretation of the borderline immunoglobulin G (IgG) levels and discordant results between various tests., Objective: The purpose of our study was to evaluate the contribution of the immunoblotting in the detection of specific IgG in acquired toxoplasmosis of immunocompetent patients especially when levels are equivocal or discordant in enzyme-linked immunosorbent assay (Elisa) and indirect fluorescent antigen test (IFAT)., Material and Methods: [corrected] We tested three groups of sera. The first included 87 positive sera, the second 33 negative sera, and the last one 29 equivocal sera., Results: Results obtained with the first and the second group of sera led us to identify the bands 30kDa and 32kDa as markers of the toxoplasmic infection. The simultaneous presence of both bands showed a sensitivity of 91.5%, a specificity of 96.9%, a VPP of 98.7%, a VPN of 74.4% and a Youden's index of 0.88. Our findings suggest that the presence of these two bands is a reliable criterion for the confirmation of the presence of anti-toxoplasmic IgG in the corresponding serum. The immunoblot allowed us to ascertain serological status of 27 (93.1%) patients from the third group in which results were discrepant or equivocal in Elisa and/or in IFAT., Conclusion: Immunoblot is a useful serological test for detection of very low or equivocal titers., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Fungemia is classically caused by a single species and the detection of more than one species in blood samples is uncommon. We report four cases of mixed fungemia (MF) diagnosed in the parasitology-mycology laboratory of Farhat-Hached hospital in Sousse, Tunisia. The MF episodes occurred in two neonates and two adults suffering from acute myeloid leukemia. Two fungal species were detected concomitantly within the same blood culture in all cases. Species combination was detected by the subculture of the blood culture on Candida ID(®) chromogenic medium in three cases and on Sabouraud agar in one case. Predisposing factors were: indwelling catheters (4/4), broad-spectrum antibiotics (3/4), neutropenia (2/4), exclusive parenteral nutrition (2/4) and Candida colonization (1/4). Patients presented febrile sepsis with no response to broad-spectrum antibiotic therapy in all cases. Outcome under antifungal treatment was favorable in two cases and the two other patients died., Conclusion: MF appears similar to the more common monomicrobial fungemia. The use of chromogenic media in routine can improve the detection of MF episodes allowing appropriate antifungal therapy., (Copyright © 2012. Published by Elsevier SAS.)

Nosocomial invasive candidiasis (IC) has emerged as a major problem in neonatal intensive care units (NICUs). We investigated herein the temporal clustering of six cases of neonatal IC due to Candida albicans in an NICU. Eighteen isolates obtained from the six neonates and two isolates from two health care workers (HCWs) working at the same unit and suffering from fingers' onychomycosis were genotyped by electrophoretic karyotyping (EK) and restriction endonuclease analysis of genomic DNA by using Sfi I (PFGE-Sfi I). PFGE-Sfi I was more effective in discriminating between temporally related isolates. It showed that (i) both HCWs had specific strains excluding them as a source of infections in neonates. (ii) Isolates collected from three neonates were identical providing evidence of their clonal origin and the occurrence of a horizontal transmission of C. albicans in the unit. (iii) The three remaining neonates had specific strains confirming that the IC cases were coincidental. (iv) Microevolution occurred in one catheter-related candidemia case. Our results illustrate the relevance of the molecular approach to investigate suspected outbreaks in hospital surveys and the effectiveness of PFGE-Sfi I for typing of epidemiologically related C. albicans isolates.

Aim: Tinea capitis continues to be considered a public health problem in Tunisia. The purpose of our study was to investigate trends in the incidence and the mycological and epidemiological aspects of tinea capitis in the Sousse region (Central Tunisia)., Method: Our work is a retrospective study concerning all scalp samples taken by the parasitology laboratory of the Farhat Hached Hospital in Sousse, Tunisia, over a 26-year period (1983-2008)., Results: A total of 10,505 specimens were examined. Of these, 5593 were positive with positive direct examination and/or positive culture. The average incidence was 215 cases per year. Patients were aged under 12 years in 89.3% of cases. A total of 175 cases of tinea capitis in adults were diagnosed. Ten dermatophyte species were isolated: Trichophyton (T.) violaceum (66.7%), Microsporum (M.) canis (29.3%), T. schoenleinii (1.6%), T. mentagrophytes (1.1%), T. verrucosum (0.6%), T. tonsurans (0.2%), T. rubrum (0.2%), M. gypseum (0.1%), M. audouinii (0.03%) and M. nanum (0.01%)., Conclusion: Our study showed a decrease in the annual incidence of tinea capitis over the study period with an evident decrease in trichophytic tinea and disappearance of favus giving way to microsporic and inflammatory tinea., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

The association of hemophagocytic syndrome (HS) and visceral leishmaniasis is a frequent disorder during infancy in endemic areas such as Tunisia. The range of severity of HS secondary to visceral leishmaniasis includes both pure biological forms that resolve with antimicrobial therapy and life-threatening emergencies that require specific treatment. We describe 2 cases of severe HS secondary to visceral leishmaniasis. The diagnosis of HS was based on the HLH-2004 diagnostic criteria. Therapy involved pentavalent antimonial (Glucantime) in both cases. The combination of corticosteroids with immunoglobulins, used in the 1st case, but introduced late, led to an unfavorable course and death. In the 2nd case, the specific treatment of HS was based on immunochemotherapy including etoposide and corticosteroids. Progression was favorable with a follow-up of 24 months. Etoposide containing therapeutic regimens can be proposed in severe forms of HS associated with visceral leishmaniasis., (Copyright © 2010. Published by Elsevier SAS.)

Background: Amoeba of the genus Acanthamoeba are ubiquitous free-living protozoa encountered in water and soil. They frequently cause sight-threatening keratitis., Aim: Report of the three first cases diagnosed at the laboratory of Parasitology of Sousse Hospital, (Tunisia)., Case Report: Our study concerned three lens-wearing female patients, aged 17, 20 and 29 years respectively. The patients originate from central Tunisia and presented with unilateral (2 cases) or bilateral (one case) keratitis. Diagnosis was made by demonstrating Acanthamoeba trophozoites and/or cysts on direct examination and/or culture (in agar - Escherichia coli medium) of contact lenses and/or lenses' solution. Direct examination of corneal swabs was negative in three cases but culture was positive in one. The three patients were treated with hexamidine and neomycine eye-drops for three months. Treatment led to scarring of lesions with however sequellar opacities that was minor to moderate in two cases and consisted of a central leucoma with a poor visual outcome in the last case., Conclusion: The need for systematic research of amoeba in lenses wearing patients with keratitis is emphasized.

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.

To report the prevalence and type of intestinal parasites together with their kinetics in Sousse region. Our retrospective study concern data from the examination of 56,268 stool samples and 7552 tape tests, performed in the laboratory of parasitology of F. Hached Sousse hospital from 1st January 1987 up to 31 December 2002. We observed an overall parasite prevalence of 31.5%. Most common parasites were protozoa, Giardia lamblia, Dientamoeba fragilis and Blastocystis hominis being the most frequently encountered. Helminths consisted mainly of Enterobias vermicularis (35.86% positive tape tests) and Hymenolepis nanus. The kinetics data analysis showed an important decrease in the prevalence of Giardia lamblia, the other feco-oral transmitted flagellates and Hymenolepis nanus. In contrast, Dientamoeba fragilis and Blastocystis hominis prevalences increased. The prevalence of the amoeba showed a slight decrease. Intestinal parasites remain quite common in Sousse region, even though their epidemiological patterns are changing. Factors inducing these changes need to be investigated in order to plan efficient control measures.