Comparison of time to negative conversion of SARS-CoV-2 between young and elderly among asymptomatic and mild COVID-19 patients: a cohort study from a national containment center

Objective

We aimed to study the relationship between age and time to negative conversion of SARS-CoV-2 in patients with asymptomatic and mild forms of COVID-19.

Methods

We conducted a cohort study including all patients diagnosed with COVID-19 from the national COVID-19 containment center of Tunisia. Patients were subdivided into two cohorts: (under 60 years) and (over 60 years) and were followed up until PCR negativization. Log rank test and Cox regression were applied to compare time to negative conversion between the old group and the young group.

Results

The study included 289 patients with non-severe forms of COVID-19. Age over 60 was significantly associated with delayed negative conversion in male sex (Hazard ratio (HR): 1.9; 95% CI: 1.2-3.07) and among patients with morbid conditions (HR:1.68; 95% CI: 1.02-2.75) especially diabetics (HR: 2.06; 95% CI: 1.01-4.21). This association increased to (HR:2.3; 95% CI: 1.13-4.66) when male sex and comorbidities were concomitantly present and rose to (HR: 2.63; 95% CI: 1.02-6.80) for men with diabetes. Cox regression analysis revealed a significantly delayed negative conversion in symptomatic patients. Significant interaction was observed between gender and age and between age and chronic conditions.

Conclusion

Age is associated with delayed negative conversion of viral RNA in certain subgroups. Identifying these subgroups is crucial to know how prioritize preventive strategies in elderly.

COVID-19 during pregnancy: case report and literature review

The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the newly discovered coronavirus is a serious public health emergency and a highly infectious disease. Evidence to date suggests that there are groups of people who are at a higher risk of getting severe COVID-19 disease such as pregnant women and their fetuses. We reported 4 cases of pregnant women with COVID-19 admitted in the national containment center, Tunisia (3 imported cases and one local case). The age range of the patients was 27-35 years and the range of gestational weeks at admission was 16 weeks to 32 weeks. None of the patients had underlying diseases. All four cases were totally asymptomatic and presented no complications. Two of them gave birth one by vaginal and the other by cesarean delivery, neonates presented no symptoms and no adverse outcomes. The current report does not present significant differences in the disease prognosis in the pregnant women´s group compared with the general women´s population. Careful observation, data collection and consecutive research are necessary.

Effect of vitamin D supplementation versus placebo on recovery delay among COVID-19 Tunisian patients: a randomized-controlled clinical trial

INTRODUCTION

The present study aimed to determine the impact of vitamin D supplementation (VDs) on recovery delay among COVID-19 patients.

METHODS

We performed a randomized controlled clinical trial at the national COVID-19 containment center in Monastir (Tunisia), from May to August 2020. Simple randomization was done in a 1:1 allocation ratio. We included patients aged more than 18 years who had confirmed reverse transcription-polymerase chain reaction (RT-PCR) and who remained positive on the 14th day. The intervention group received VDs (200,000 IU/1 ml of cholecalciferol); the control group received a placebo treatment (physiological saline (1 ml)). We measured the recovery delay and the cycle threshold (Ct) values in RT-PCR for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The log-rank test and hazard ratios (HR) were calculated.

RESULTS

A total of 117 patients were enrolled. The mean age was 42.7 years (SD 14). Males represented 55.6%. The median duration of viral RNA conversion was 37 days (95% confidence interval (CI): 29-45.50) in the intervention group and 28 days (95% CI: 23-39) in the placebo group (p=0.010). HR was 1.58 (95% CI: 1.09-2.29, p=0.015). Ct values revealed a stable trend over time in both groups.

CONCLUSION

VDs was not associated with a shortened recovery delay when given to patients for whom the RT-PCR remained positive on the 14th day.

TRIAL REGISTRATION

This study was approved by the Human Subjects Protection Tunisia center (TN2020-NAT-INS-40) on April 28, 2020, and by ClinicalTrial.gov on May 12, 2021 with approval number ClinicalTrials.gov ID: NCT04883203 .

Twice-Daily Oral Zinc in the Treatment of Patients With Coronavirus Disease 2019: A Randomized Double-Blind Controlled Trial

BACKGROUND

Zinc supplementation has been considered a potential therapy for coronavirus disease 2019 (COVID-19). We aimed to examine zinc efficacy in adult patients with COVID-19 infection.

METHODS

We conducted a prospective, randomized, double-blind, placebo-controlled multicenter trial. Patients who were tested positive for COVID-19 without end-organ failure were randomized to oral zinc (n = 231) or matching placebo (n = 239) for 15 days. The primary combined outcome was death due to COVID-19 or intensive care unit (ICU) admission ≤30 days after randomization. Secondary outcomes included length of hospital stay for inpatients and duration of COVID-19 symptoms with COVID-19-related hospitalization for outpatients.

RESULTS

190 patients (40.4%) were ambulatory and 280 patients (59.6%) were hospitalized. Mortality at 30 days was 6.5% in the zinc group and 9.2% in the placebo group (OR: .68; 95% CI .34-1.35); ICU admission rates were, respectively, 5.2% and 11.3% (OR: .43; 95% CI .21-.87). Combined outcome was lower in the zinc group versus the placebo group (OR: .58; 95% CI .33-.99). Consistent results were observed in prespecified subgroups of patients aged <65 years, those with comorbidity, and those who needed oxygen therapy at baseline. Length of hospital stay was shorter in the zinc group versus the placebo group (difference: 3.5 days; 95% CI 2.76-4.23) in the inpatient group; duration of COVID-19 symptoms decreased with zinc treatment versus placebo in outpatients (difference: 1.9 days; 95% CI .62-2.6). No severe adverse events were observed during the study.

CONCLUSIONS

Our results showed that, in COVID-19 patients, oral zinc can decrease 30-day death, ICU admission rate and can shorten symptom duration. Clinical Trials Registration. ClinicalTrials.gov, NCT05212480.

Particularités de l’infection à coronavirus chez les patients diabétiques

Objectif

Décrire les caractéristiques épidémio-cliniques, radiologiques et thérapeutiques de l’infection au SARS-COV2 chez les diabétiques.

Matériels et méthodes

Étude rétrospective portant sur les malades diabétiques hospitalisés au service des maladies infectieuses pour une infection à coronavirus durant la période (2020–2021).

Résultats

On a colligé 95 malades diabétiques parmi les 224 malades hospitalisés pour une infection SARS-cov2 (42,4 %). Ils étaient âgés en moyenne de 64 ans (32 ans–86 ans) avec une prédominance masculine (sex-ratio = 1,26). Quatre-vingt-douze malades (96,8 %) avaient un diabète de type 2 dont 18 étaient insulinonécessitants.

Les manifestations cliniques étaient dominées par les arthromyalgies (n = 82, 86,3 %), la toux sèche (n = 55, 57,9 %) et la fièvre (n = 41, 43,1 %). Deux patients (2,1 %) présentaient une douleur thoracique secondaire à une embolie pulmonaire et un syndrome coronarien aigu. La dyspnée était le maître symptôme observé dans 94,7 % des cas, apparue dans un délai moyen de 8,6 jours. Une tomodensitométrie thoracique réalisée chez 52 malades (54,7 %), montrait une atteinte minime (< 10 %) dans 3,85 % des cas, modérée (10–25 %) et étendue (25–50 %) dans 25 % chacune, sévère (50–75 %) dans 36,5 % et critique (> 75 %) dans 9,6 % des cas. Tous les malades bénéficiaient d’une anticoagulation et 92 malades (96,8 %) d’une oxygénothérapie associée à la corticothérapie dans 91,6 % des cas. L’évolution était favorable dans 87,4 % des cas. Douze malades (12,6 %) étaient transférés à l’unité des soins intensifs.

Discussion

Dans notre étude, la moitié des malades diabétiques ont présenté une atteinte pulmonaire de plus de 50 %. Une prise en charge précoce et adaptée serait essentielle pour améliorer le pronostic.

Factors associated with a prolonged negative conversion of viral RNA in patients with COVID-19

Objectives

The aim of this study was to identify the factors influencing the delay in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA negative conversion.

Methods

A cohort study was conducted that included patients with coronavirus disease 2019 (COVID-19) admitted to the Tunisian national containment center. Follow-up consisted of a weekly RT-PCR test. Multivariate Cox regression analysis was performed to determine independent predictors associated with negative RNA conversion.

Results

Among the 264 patients included, the median duration of viral clearance was 20 days (interquartile range (IQR) 17–32 days). The shortest duration was 9 days and the longest was 58 days. Factors associated with negative conversion of viral RNA were symptoms such as fatigue, fever, and shortness of breath (hazard ratio (HR) 0.600, 95% confidence interval (CI) 0.401–0.897) and face mask use when exposed to COVID-19 cases (HR 2.006, 95% CI 1.247–3.228). The median time to RNA viral conversion was 18 days (IQR 16–21 days) when using masks versus 23 days (IQR 17–36 days) without wearing masks, and 24 days (IQR 18–36 days) for symptomatic patients versus 20 days (IQR 16–30 days) for asymptomatic patients.

Conclusions

The results of this study revealed that during SARS-CoV-2 infection, having symptoms delayed viral clearance, while wearing masks accelerated this conversion. These factors should be taken into consideration for the strategy of isolating infected patients.

[Off label uses of tigecycline]

INTRODUCTION

Tigecycline is a relatively new antibiotic that have very limited valid indications. When no other alternative is available, this drug is widely used off label with promising results. The objective of this study is to summarize the different off label uses of tigecycline so that we can decide when and how to prescribe it in the absence of guidelines.

MATERIAL AND METHODS

This study a revue of the literature collecting all the articles concerning the off label uses of tigecycline.

RESULTS

Tigecycline was widely prescribed, off label, to treat infections with controversial results. Randomised clinical trials were conducted to evaluate its use to treat pneumonia. The results for this indication have a respectable level of evidence. For the other indications, the data collected was insufficient to support tigecycline prescription. In fact, different protocols were used which makes it hard to evaluate the efficacy and to conclude to the best treatment regimen. A tendency to prescribe high doses of the molecule was noted in different studies. When prescribed off label, tigecycline prescriptions were associated with a higher mortality and incidence of side effects.

CONCLUSION

The tigecycline remains a valid option for the treatment of infections dues to multi-resistant bacteria especially when other alternatives are scarce or in cases of renal failure.

Mediterranean spotted fever as a cause of septic shock

•

Mediterranean spotted fever presents with various non‐specific symptoms.

•

There is no reliable test to diagnose the infection in its early stages.

•

Doxycycline should be used upon suspicion of MSF, without awaiting laboratory confirmation.

Mediterranean spotted fever is a generally benign disease but with the potential of serious manifestations.

We report a case of Mediterranean spotted fever in a 56-year–old woman, with pet dog exposure, who presented with a septic shock pattern. Based on clinical symptoms, history, and laboratory results, the diagnosis of Mediterranean spotted fever was suspected and the outcome was favorable with doxycycline treatment.

Although rickettsiae remain an uncommon cause of the sepsis syndrome, it is important to consider it, especially as people are now traveling to endemic areas more frequently.

Hospitalizations for communicable diseases in a developing country: prevalence and trends-Monastir, Tunisia, 2002-2013

BACKGROUND

In spite of the epidemiological transition, communicable diseases remain a public health problem and represent a significant cause of morbidity and mortality worldwide, especially in developing countries. This study aimed to determine the crude and standardized prevalence rates of hospitalizations for communicable disease (HCD) and to assess trends in HCD by age and sex at a university hospital in Tunisia over a period of 12 years (2002-2013).

METHODS

All cases of HCD from 2002 to 2013 in the university hospital departments were included. Data collected from the regional register of hospital morbidity were used. The discharge diagnoses were coded according to the International Classification of Diseases, 10th revision (ICD-10).

RESULTS

HCD represented 17.45% of all hospitalizations during the study period (34 289/196 488; 95% confidence interval 17.28-17.62%). The median age at the time of admission was 31 years (interquartile range (IQR) 15-52 years). The median hospital length of stay (LOS) was 5days (IQR 3-9 days). The crude prevalence rate (CPR) was 5.41 per 1000 inhabitants. The CPR was highest among patients aged ≥65 years. The four communicable disease categories that represented 70% of all HCD were abdominal infection, skin infection, genitourinary infection, and lower respiratory tract infection. The majority of HCD decreased over time; however, there was a significant increase in HIV diseases, tuberculosis, and viral hepatitis.

CONCLUSION

This study provides evidence of the epidemiological transition, showing a decline in communicable diseases, which needs to be sustained and improved.

Successful treatment of postoperative multidrug-resistant Acinetobacter baumannii meningitis by tigecycline

Tigecycline is a broad-spectrum antibiotic with activity against multidrug-resistant (MDR) bacteria. It has limited indications. Studies are necessary to elaborate new guidelines. Here we report a case of postoperative MDR Acinetobacter baumannii meningitis treated by tigecycline combined with colimycin for 21 days. The treatment was well tolerated with a favourable outcome. In conclusion, tigecycline was shown to be effective in a case of MDR A. baumannii meningitis.

[Diagnostic and therapeutic management of lymph node tuberculosis in Tunisia]

La tuberculose ganglionnaire est la localisation extra-pulmonaire la plus fréquente de la tuberculose. Nous nous proposons dans ce travail d’étudier les modalités diagnostiques, thérapeutiques et évolutives de cette localisation. Il s'agit d'une étude rétrospective portant sur 100 cas de tuberculose ganglionnaire. L’âge moyen était de 35 ± 15 ans (15-85 ans). Aucun malade n’était VIH positif. L'aire cervicale était la plus touchée (93 cas). L'intradermo-réaction à la tuberculine était positive dans 76/91 cas (83,5%). L'examen bactériologique des prélèvements au niveau des ganglions atteints avait mis en évidence des bacilles acido-alcoolo-résistants à l'examen direct dans 2/31 cas (6,4%) et la culture avait isolé Mycobacteruim tuberculosis dans 1/31 cas (3,2%). La cytoponction ganglionnaire (FNAC) était évocatrice de tuberculose dans 35/42 cas (83,3%). La biopsie ganglionnaire était réalisée dans 69 cas et avait permis de retenir le diagnostic de tuberculose dans tous les cas. La FNAC, comparativement à la biopsie, avait permis de raccourcir significativement le délai de la prise en charge (15,1 vs 22,8 jours; p=0,001) et la durée d'hospitalisation (17,3 vs 24,6; p=0,004). La durée moyenne du traitement antituberculeux était de 9,8 ± 4,6 mois (7 à 44 mois). Le traitement chirurgical initial avait raccourci significativement la durée du traitement médical. Il n'avait pas d'impact sur le taux de guérison. Nous avons noté 10 cas de réponse paradoxale aux antituberculeux, quatre cas de résistance clinique et une rechute dans deux cas. La tuberculose ganglionnaire pose un problème diagnostique et thérapeutique. La microbiologie est d'un faible apport. La FNAC est un moyen diagnostique très utiles dans les pays endémiques et à faibles ressources. Un traitement médical seul permet d’éviter les inconvénients de la chirurgie.

[Macrophage activation syndrome: rare complication of murine typhus]

INTRODUCTION

Typhi is one of the rickettsial species endemic in the Mediterranean countries and is associated with the zoonotic infection of murine typhus, which may have a complicated course especially in adult patients. The association with macrophage activation syndrome (MAS) has rarely been reported in the medical literature.

CASE REPORT

We describe a case of murine typhus in a diabetic woman complicated with MAS, who was effectively treated with cyclin and parenteral immunoglobulin.

CONCLUSION

The murine typhus can be exceptionally complicated with SAM. This infection should be suspected in front of the discovery of SAM.

Tamponnade péricardique révélant un lupus érythémateux systémique au cours d’une leishmaniose viscérale atypique

L'association de leishmaniose viscérale (LV) et lupus érythémateux systémique (LES) est rare et grave. La similitude des signes cliniques peut être responsables de difficultés diagnostiques surtout quand les deux pathologies se déclarent de façon concomitante. Nous rapportons l'observation d'une malade qui avait présenté une association grave et atypique de LV et LES qui se sont déclarés en même temps. La LV était atypique par l'absence du syndrome tumoral, de la fièvre et la négativité de la sérologie leishmaniose. Le LES jusque là méconnu était révélé par une poussée sévère avec différentes atteintes viscérales. L’évolution était favorable sous amphotéricine-B et corticothérapie. En cas d'association des deux pathologies une surveillance particulière est nécessaire à fin de diagnostiquer à temps une atteinte viscérale grave du LES et démarrer précocement une prise en charge étiologique et symptomatique qui est le seul garant de l’évolution favorable.

Méningite révélant une infection à Rickettsia typhi

INTRODUCTION

Neurological manifestations are rarely observed in murine typhus. We present a case of meningitis caused by Rickettsia typhi.

EXEGESIS

We report a case of Tunisian 57-year-old woman admitted for suspicion of meningitis. Clinical examination revealed fever at 39,5 degrees C and nuchal rigidity. There were no focal neurologic signs, cutaneous rash or eschar. Lumbar puncture showed clear cerebrospinal fluid containing normal glucose, 0,48 g/l protein and 30 WBC (78% lymphocyte). Gram-stained smear and culture were negative. Serology confirmed the diagnosis. The patient was initially treated by ampicillin 12 g daily but remained febrile. Retinal lesions were detected on ophthalmic examination, suggesting rickettsial infection. Clinical outcome was good after 7-day treatment with oral ciprofloxacin 1,5 g daily. The mean follow-up was six months.

CONCLUSION

Murine typhus is an endemic zoonosis. Neurological manifestations were uncommon. An ophthalmic examination is recommended if rickettsiosis was suspected.

[Hydatid disease of bone: a report of 2 cases]

INTRODUCTION

The hydatid cyst of Echinococcus granulosus tends to develop in liver. The primary bone hydatidosis is rare. EXEGISIS: The authors report 2 cases of primary hydatidosis of bone in a 57 year old men and 60 year old diabetic women. The symptoms and signs were not specific. The ultrasound investigation: standard radiography and computed tomographic scan, was suggestive of the lesion. The chest radiograph and the abdominal ultrasound were normal. Serological tests for hydatid disease were positive. The two patients have surgical excision and medical treatment: Albendazole administrated for 6 months. Histologic evidence confirmed the diagnosis. The outcome was good for both patients without recurrence after 2 years.

CONCLUSION

Through these 2 cases and a review of the literature, the authors analyse the epidemiological and clinical aspects of bone hydatidosis and discuss the therapeutic procedures.

Une fièvre boutonneuse méditerranéenne compliquée d'une embolie pulmonaire

INTRODUCTION

Thromboembolic complications were uncommon in mediterranean spotted fever.

OBSERVATION

We report a case of 55-years- old man who was admitted for mediterranean spotted fever. Two days later, the patient developed chest pain due to a pulmonary thrombosis confirmed by angio-CT. The outcome was good with heparin therapy. The investigation for another cause of thrombosis was negative.

CONCLUSION

Mediterranean spotted fever is usually a moderately severe self-limited illness. Pulmonary thrombosis was uncommon associated with severe disease.

[Phalengeal actinomycosis: a rare disease]

INTRODUCTION

Bone involvement in actinomycosis is rare.

EXEGESIS

We report a case of a 38 year-old woman with foot bone actinomycosis. The clinical symptoms were non-specific and the diagnosis was difficult. An X-ray revealed an osteolysis and a sclerosis of the proximal phalanx of the big toe. A phalengiectomy was carried out after the failure of antistaphylococcic antibiotherapy. The diagnosis of actinomycosis was substantiated by a histological examination. The clinical outcome was good after six-month treatment by penicillin G substitutes for cotrimoxazol. The patient completely recovered and was feeling well. The mean follow up was fifteen months.

CONCLUSION

Clinical and therapeutic aspects of this rare localization are reviewed.

[Pyogenic splenic abscesses. A review of 8 cases]

PURPOSE

Pyogenic splenic abscess is un uncommon and potentially life-threatening disease. Due to inconspicuous and nonspecific clinical picture, it remains a diagnostic challenge. Medical imaging progresses are helpful for diagnosis and treatment.

METHODS

We tried to establish epidemiologic and clinical features and therapeutic possibilities of 8 cases of splenic abscesses occurred between 1993 and 2002.

RESULTS

There were 5 male patients and 3 female patients. Aged ranged from 17 to 53 years, with a median of 34 years. One patient was immunocompromised (colonic carcinoma). Common clinical presentations included fever (n=8) and left upper quadrant abdominal pain (n=7). Positive blood cultures were found in only four patients (50%) : Staphylococcus aureus (3) and coagulase negative Staphylococcus (1). Staphylococcus aureus and Bacteroïdes fragilis were isolated in one abscess pus respectively. The diagnosis was obtained by ultrasonography in all 8 cases. Antibiotics were prescribed in all cases for a mean length of 60 days (30 - 110 days). Splenectomy and percutaneous CT-guided drainage were performed in one case respectively. Evolution was good in all cases.

CONCLUSION

Splenic abscesses are increasingly recognized. The combination of clinical features and imaging findings, early diagnosis and treatment can be made.

[Infectious urgencies in an emergency medical service]

The aim of this study is to evaluate the frequency of infectious urgencies and the quality of their management in an emergency medical service. During the period of study, 21737 consultants are recorded, from which 2011 for an infectious urgency (9,25%), pharyngitis with rhinitis excluded. 692 patients are hospitalized and 1074 receive ambulatory antibiotics. Therapeutic urgencies are the most frequent infectious urgencies (48,4%), followed by protection urgencies (46,3%), urgencies due to antibiotics (5,2%) and prevention urgencies (0,1%). The conduct is considered correct for 1379 cases (68,5%) and incorrect for 500 cases (25%). Main incorrect conducts are the absence of follow-up (81,6%) and the maladjusted antibiotherapy (11,8%). These results incite, mainly, to the improvement of the professional training of emergency physicians and their communication with their colleagues of the other sanitary structures.

[Sweet's syndrome]

Sweet's syndrome or acute febrile neutrophilic dermatosis is relatively frequent. It can be isolated or associated to other diseases, particularly, inflammatory or autoimmune diseases, lymphoproliferative or malignant disorders. In this retrospective study, we report 10 cases of Sweet's syndrome recorded over a 42 months period. The female predominance was net (9 womens for 1 man). The mean age was 45 years. The diagnosis was established, in all cases, on clinical, biological and histological criteria. The lesions occurred most commonly on legs (9 cases). The failure of antibiotics has been noted in all patients, and colchicine has been demonstrated efficient in 6 patients. Our study confirms the interest of cutaneous biopsy in case of papulo-nodular lesions which has not respond to antibiotics.