Epileptic encephalopathy and amelogenesis imperfecta: What about KohlschüttereTönz syndrome? Case report and literature review

BACKGROUND

KohlschüttereTönz syndrome (KTS), also called amelo-cerebro-hypohidrotic syndrome, is a very rare genetic condition, described for the first time by Kohlschutter, which typically manifests as a triad of symptoms:  amelogenesis imperfecta, infantile onset epilepsy, and intellectual disability. 47 cases were reported in English language literature since 1974-2021.

CASE REPORT

A 7-year-old girl was referred for dental evaluation. Oral examination revealed yellowish color of all the teeth due to enamel hypoplasia. The radiographic exam revealed a thin layer of enamel with decreased radiopacity of the enamel compared to that of dentin. The diagnosis of amelogenesis Imperfecta was established. In addition to that, the child's parents reported that she had spasticity, epileptic seizures and psychomotor developmental delay. The association of all these features leads us to conclude to KTS.

CONCLUSION

It seems that numerous cases of KTS are still undiagnosed in the world, so this paper highlights the common clinical features of Kohlschütter-Tönz Syndrome helping to an early diagnosis and more research about this condition.

Ultrasonography Enthesitis and Synovitis Screening in Psoriatic Patients: A Case Control Study

Background

The clinical screening of enthesitis and synovitis in patients with psoriasis lacks specificity and sensitivity during the preclinical phase.

Aims

to assess US subclinical synovitis and enthesitis in psoriatic patients compared with healthy controls.

Methods

A cross-sectional study on 40 psoriatic patients and 40 healthy sex- and age-matched controls. US examination of 18 joints was performed along with 22 entheseal sites on the upper and lower limbs. US subscores were established according to the US abnormalities: inflammatory score (tendon thickening, hypoechogenicity, bursitis, Doppler signal), damage score (calcification, enthesophytes, bone erosion) and total score (the sum of inflammatory and damage scores).

Results

US synovitis were more frequent in psoriatic patients (0.68%) than in controls (0.29%), but the difference was not significant. Patients with psoriasis had more US enthesitis (92,5%) compared to controls (40%)(p<0.001). The total number of enthesitis was higher in the psoriatic group (20.90%) compared to controls (4,78%)(p<0.001). There were more US abnormalities in the psoriatic group compared to controls for calcaneal tendon enthesis(p<0.001), distal patellar tendon enthesis(p<0.001) and deep flexor tendons of the finger enthesis(p<0.001). Compared to controls, psoriatic patients had a significantly higher inflammatory score (Mean±SD) (2.85±3.34 versus 0.58±1.17), damage score (3±2.57 versus 0.60±1.41), and total score (5.85±5.20 versus 1.18±2.07) (p < 0.001 each). Patients with scalp psoriasis had more US enthesitis (p=0.020).

Conclusion

Our results indicate that US enthesitis and synovitis are more frequent in patients with psoriasis. Prospective studies with larger sample size are needed to define the contribution of US in predicting the clinical onset of PsA.

Spinal Tuberculosis: Features and Early Predictive Factors of Poor Outcomes

Introduction

Tuberculosis is still endemic in Tunisia. Among musculoskeletal involvement, spinal tuberculosis (STB) or «Pott's Disease» is the most common and can lead to serious neurological complications. The purpose of our study was to focus on STB features (clinical, biological, and radiological) and to identify factors associated with early unfavorable outcomes.

Methods

This was a monocentric retrospective study, over a period of 20 years (2000-2020). Only patients treated appropriately were included. Patients' informations were noted. We defined the favorable outcome criterion as weight gain, apyrexia, improvement of the general state, relief of pain, improvement in the classic inflammatory markers (CRP), and absence of vertebral deformities, neurological impairment, or sepsis. The outcome was considered unfavorable otherwise.

Results

Our study involved 52 patients. Their average age was 55.21 years±17.79. The average symptom duration was 8.9 months±6.54. Spinal pain was the most common functional sign (90.4%) often inflammatory. Physical signs were dominated by segmental spinal stiffness (71.2%). Spinal magnetic resonance imaging was performed in 38 patients. The disco-vertebral biopsy puncture confirmed the diagnosis in 15 cases. All patients received anti-tuberculosis treatments with an average duration of 10.02±1.97months. The outcome at one month of follow-up was favorable in 32 cases. Poor prognosis factors were normochromic normocytic anaemia (p=0.018), initial lymphocytosis (p=0.048), and fever (p=0.01). However, vertebral fracture at standard X-ray was predictive of favorable outcome (p=0.001).

Conclusion

STB is a frequent condition that needs to be treated rapidly. Poor prognosis factors were identified in this study such as normocytic normochromic anemia, initial lymphocytosis, and fever at baseline.

Focal Segmental Glomerulosclerosis and Hyalinosis in a Patient with Spondyloarthritis: A Rare Renal Involvement Case Report

Background

During its course, spondyloarthritis (SpA) may be associated with extra-articular manifestations affecting several organs. Renal involvement is one of the most common extra-articular manifestations and is dominated by secondary amyloidosis (AA), immunoglobulin A (IgA) nephropathy, and urolithiasis. Other nephropathies such as Focal segmental glomerulosclerosis and hyalinosis (FSGS) are less common and are limited to few case reports.

Case

We report the case of a patient followed for axial SpA, who consulted, after being lost to follow-up for 3 years, for elevated blood pressure and edema of both lower limbs associated with an hydrocele and bilateral pleural effusion. Biological examinations showed hypoproteinemia, hypoalbuminemia, and proteinuria. In this context of nephrotic syndrome, the diagnosis of FSGS was confirmed by renal biopsy. Furthermore, the etiological investigation ruled out the causes of secondary FSGS.

Conclusion

Renal involvement is a sign of severity in SpA. Its detection and management should be part of the overall management of SpA.

Assessment Tools for Pulmonary Involvement in Patients with Ankylosing Spondylitis: Is Diaphragmatic Ultrasonography Correlated to Spirometry?

Objective

Spondyloarthritis (SpA) is a chronic inflammatory rheumatic disease that can lead to spinal ankylosis and consequently, restrictive pulmonary dysfunction. Thus, the present study aimed to assess the accuracy of diaphragm ultrasound compared to spirometry in the screening of restrictive pulmonary disorders in radiographic SpA patients.

Methods

We conducted a cross-sectional study of 50 patients with radiographic SpA, over six months. Sociodemographic data, clinical characteristics of the disease, as well as biological, radiological, and therapeutic data, were collected. Spirometry and diaphragm ultrasound were performed.

Results

The mean age of the study participants (N= 50) was 42.7±11 years [range: 25-66] with male predominance (N= 41). Spirometry showed a restrictive disorder in 32% of cases. The mean chest expansion (CE) value was 3.9±1.81cm [range: 1-9] with a median of 4 cm. A pathological value (<5cm) was observed in 72% of cases. A significant positive correlation was found between the right inspiratory diaphragmatic thickness and forced vital capacity (FVC) (r= 0.36; p = 0.02) and the supine FVC (r=0.29; p = 0.04). The left inspiratory diaphragmatic thickness was correlated with the percentage of the FVC decrease (r= 0.35; p = 0.01) defined as the percentage of difference between FVC and supine FVC. The right expiratory diaphragmatic thickness was associated with the FVC (r=0.32; p = 0.02). A significant positive correlation was found between the CE and the presence of B lines (r=0.32; p = 0.02), but not between the CE and the FVC.

Conclusion

The present study showed that diaphragm ultrasonography is correlated with spirometric findings in radiographic SpA patients. Further studies are required to assess its reliability, specificity, and sensitivity in this pathology.

Low Back Pain Among Students of Medical University of Tunis

OBJECTIVE

Low Back Pain (LBP) is the most common musculoskeletal disorder among working adults. It is one of the most prevalent complaints among students. Medical students are among those who are most exposed to this condition; due to stress, numerous hours of studying, and the sedentary lifestyle. Our study aimed to determine the prevalence and associated factors of LBP among the students of Tunis Faculty of Medicine and to assess its impact on student life.

METHODS

This cross-sectional study was carried out on the Tunis Faculty of Medicine students. Data were collected through an online self-administered questionnaire. Sociodemographic, personal, and lifestyle characteristics were collected. LBP was assessed using the Nordic Musculoskeletal Health Questionnaire and Its impact using the Oswestry Disability Index (ODI).

RESULTS

One hundred and forty-eight students were included. The mean age was 22.9 ± 2.3 years (19.64-38.21). The sex ratio was 0.29. According to the Nordic questionnaire, the point, annual and lifetime prevalence of LBP were 37.8%, 80.4%, and 90.5%, respectively. The mean ODI score was 10.32 ± 8.48 % (0-32). The ODI score was minimal in 87.3% and moderated in 12.7% of cases. The associated factors with LBP were: young age (p = 0.015), spending more than 4 hours in a sitting position (p = 0.059), second cycle of medical studies (p = 0.006), low screen projection in the amphitheater (p = 0.029) and poor layout of the amphitheatres (p = 0.000). The feeling of depression was significantly higher among LBP students (p = 0.018). In the multivariate analysis, the factors that remained statistically significant were the second cycle of medical studies (OR= 3.41), feeling of depression (OR = 3.7), and the belief in the responsibility for the poor layout of the amphitheaters in the genesis or maintenance of LBP (OR = 7.66).

CONCLUSION

LBP in medical students is multifactorial across both personal and college-life domains.

Foot Functional Disability in Rheumatoid Arthritis: the Involvement of Body Mass Index

Introduction:

Overweight and obesity are common in patients with Rheumatoid Arthritis (RA), with a probable impact on bearing foot joints.

Aim:

Our study aimed to explore the impact of Body Mass Index (BMI) on foot health parameters in RA patients.

Methods:

It was a cross-sectional study. Domains of foot health explored were: foot pain (Numeric Rating Scale), foot-related activity limitations (Foot Function Index (FFI), and WOMAC scale), foot synovitis, foot deformity (Platto Score (PS)), radiological joint damage and footwear problems.

Results:

Fifty RA were included, 82% were female. The mean age was 45.68±10.3 years. The mean DAS28-CRP was 3.25±0.98. Sixty-six percent were overweight or obese, with a mean BMI of 29 Kg/m2±5.74. The average foot pain intensity while walking was 6±1.75. The mean swollen foot joint was 2.2±1.55. The average foot structural index was 7.8 ± 2.73. The mean FFI Disability score was 32±14.2 and WOMAC score was 33.8 ± 13.98. Half of our patients had footwear problems predominantly because of claw toe (40%). High BMI was significantly correlated with foot pain and foot-related activity limitations. It was also correlated with foot deformities assessed with PS (B=4.78; CI[3.87-5.68]; p=0.02), foot synovitis (OR=4.66, CI[2.61-8.32]; p<0.001) and problems with footwear (OR= 0.32; CI[0.18-0.56]; p=0.05). However, it was significantly associated with less radiological joint damage (CI[-0.7-1.1]; p=0.01) and lower foot sharp score (B= -13.9; CI[-0.34-0.01]; P = 0.06).

Conclusion:

Despite our findings of a possible protective effect of obesity on structural damage, obesity is still an important cause of increased pain, functional disability, and impaired QoL in RA patients.

Influencing factors in Tunisian Rheumatoid arthritis patients’ Quality of life: burden and Solutions

Background:

Rheumatoid Arthritis (RA) is a disease with a heavy functional, psychological, and socioeconomic impact. The management of Quality of Life (QoL) as a therapeutic objective is a fairly recent notion, especially in Tunisia. We aimed to evaluate QoL in RA patients and to identify its affecting factors.

Methods:

This was a cross-sectional study in a Tunisian rheumatology center. To assess QoL, we used the Short Form Health Survey (SF-36) and the Arthritis Impact Measurement Scales Short Form (AIMS2-SF). Health Assessment Questionnaire Disability Index (HAQ), the Hospital Anxiety and Depression Scale (HAD) for psychological disorders, Visual Analog Scale for Pain (VAS Pain), and for fatigue (VAS Fatigue) were also used. Disease activity was assessed by the Disease Activity Score (DAS28 CRP).

Results:

We enrolled 120 established RA, the mean age of our patients was 56.9±11.4 years, with a predominance of women (83.3%). The mean disease duration was 10.97±7.7 years. According to the HAD scale, 27% of our patients presented anxiety, and 26.7% had depressive disorders. There was significantly impaired QoL in patients with low educational level, dependent financial situation, long disease duration, high disease activity, high pain and fatigue levels, poor therapeutic education, functional disability, and psychological disorders (p<0.001). A strong negative correlation was detected between inflammatory markers, structural damage, and the scores of QoL. Patients under biologics scored significantly higher in the SF36 mental health domain (p<0.001).

Conclusion:

QoL is significantly poor in Tunisian RA. These patients should be managed using a multidisciplinary approach involving the patients themselves.

14 Juvenile idiopathic arthritis: osteoporosis and fractures

Background

Juvenile idiopathic arthritis (JIA) is the most common inflammatory arthritis in children. Chronic inflammation, as well as the various treatments used during JIA increase the risk of occurrence of osteoporosis (OP) and fractures.

Objectives

The objective of this work was to determine the frequency of OP in JIA and to investigate the factors associated with its occurrence.

Methods

This was a retrospective study including adults with long-standing JIA according to the International League of Associations for Rheumatology (ILAR) criteria over a period of 28 years (1994–2022). We collected sociodemographic and anthropometric parameters, clinical data, results of biological assessments, bone densitometry results and data on prescribed therapies. We compared these variables according to the bone densitometry profile to assess the factors associated with OP in JIA.

Results

There were 29 patients (17 females and 12 males), the mean age was 35.69 ± 11.72 [18–61] years. The mean age of disease onset was 11.10 ± 4.25 [2–16] years. The average diagnostic delay was 52.96 ± 95.97 [0–336] months. The average disease duration was 24.48 ± 12.76 [1–47] years. Three patients were smokers. The mean BMI was 21.20 ± 4.88 [14.17–27.55] kg/m2, and 4 patients had a BMI ≥ 25 kg/m².

The polyarticular form was the most frequent, noted in 55.2% of cases (n = 16). NSAIDs, corticosteroids and methotrexate were prescribed in 62.1%, 69% and 79.3% of cases respectively.

OP was found in 24.1% of cases (n = 7). Mean T-score values at the lumbar and femoral sites were −2.20 ± 1.22 SD and −2.31 ± 0.97 SD, respectively. Six patients suffered at least one fracture.

Patients with OP had lower BMI than patients with normal bone density (17.02 ± 2.46 vs 23.91 ± 5.42; p = 0.046). Furthermore, absence of rheumatoid factor was associated with OP in our study (83.3% vs 16.7%; p = 0.008).

On the other hand, the following parameters were not associated with the occurrence of OP in our study: age, gender, smoking, age at onset and duration of progression of JIA, BMI, extra-articular manifestations, CRP, antinuclear antibodies, ACPA and erosive character. Regarding the treatment received (NSAIDs, corticosteroids and methotrexate), no difference was found between patients.

Conclusion

Osteoporosis in JIA is common and has a prognostic impact. It must be systematically screened throughout the follow-up. In our study, OP was associated with the absence of rheumatoid factor and was more frequent in patients with low BMI.

12 Hip involvement in juvenile idiopathic arthritis: frequency and associated factors

Background

Juvenile idiopathic arthritis (JIA) is a pediatric rheumatic disease with several subgroups. The hip is frequently affected. The frequency of this involvement can reach 50% especially in the severe and destructive forms. Arthroplasty may be indicated in advanced cases.

Objectives

To assess the frequency and associated factors with hip involvement in (JIA).

Methods

We conducted a retrospective study including adults with long-standing JIA according to the International League of Associations for Rheumatology (ILAR) criteria over a period of 28 years (1994–2022). Demographic, clinical, biological, and radiographic data were collected. These parameters were compared according to the presence or absence of hip involvement.

Results

A total of 29 Patients were enrolled (12 men and 17 women), the mean age was 35.69 ± 11.72 [18–61] years. The mean age of disease onset was 11.10 ± 4.25 [2–16] years. The average diagnostic delay was 52.96 ± 95.97 [0–336] months. The average disease duration was 24.48 ± 12.76 [1–47] years.

Sixteen patients had a polyarticular form. Mean CRP values were 42.74 ± 63.37 [2–218] mg/l, a biological inflammatory syndrome was present in 19 cases. Rheumatoid factor, ACPA and anti-nuclear antibodies were observed in 12, 7 and 5 cases respectively. At least one extra-articular manifestation was noted in 16 cases.

Hip involvement was noted in 14 patients (48.3%). It was bilateral in 64.3% of cases (n = 9). Twenty-three hips were affected in total (56.9%). Hip involvement was diagnosed 14.5 ± 9.37 [1–28] years after disease onset. Arthroplasty was performed on 10 hips with a delay of 201.60 ± 104.75 [108–348] months between diagnosis of JIA and surgery.

Hip involvement was associated with male gender in our study (75% vs 29.4%; p = 0.016). On the other hand, our study showed that age, age at onset, diagnostic delay, symptoms duration, smoking, BMI, extra-articular manifestations, CRP, rheumatoid factor, antinuclear antibodies, ACPA and erosive character were not associated with hip involvement.

Conclusion

Our study showed that hip involvement is common in JIA, mainly in male patients. It usually occurs late in the disease course. Since hip involvement is a cause of disability and functional impairment, it should be assessed regularly.

13 Juvenile idiopathic arthritis and cardiovascular risk factors

Background

Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disease. Although, some patients achieve remission, some cases of JIA may persist into adulthood. Patients with JIA and other inflammatory joint diseases have increased cardiovascular disease risk compared with the general population.

Objectives

To study the cardiovascular risk factors in JIA and their association with disease parameters.

Methods

This was a retrospective study including adults with long-standing JIA according to the International League of Associations for Rheumatology (ILAR) criteria over a period of 28 years (1994–2022). We collected sociodemographic and anthropometric parameters, clinical data, results of biological assessments, and data on prescribed therapies.

We studied the following cardiovascular risk factors: family history of cardiovascular event, physical inactivity, smoking, arterial hypertension, diabetes, dyslipidaemia and obesity.

Results

We included 29 patients. The M/F sex ratio was 0.71, the mean age was 35.69 ± 11.72 [18–61] years. The mean age of disease onset was 11.10 ± 4.25 [2–16] years. The average diagnostic delay was 52.96 ± 95.97 [0–336] months. The average disease duration was 24.48 ± 12.76 [1–47] years. The mean BMI was 21.20 ± 4.88 kg/m2 [14.17–27.55].

The polyarticular form was the most frequent, noted in 55.2% of cases (n = 16). Extra-articular manifestations were observed in 55.2% of cases. Mean CRP was 42.74 ± 63.37 [2–218] mg/l and biological inflammatory syndrome was present in 19 cases. Rheumatoid factor, ACPA and anti-nuclear antibodies were observed in 12, 7 and 5 cases respectively.

Corticosteroid therapy and NSAIDs were prescribed to 18 of the subjects.

Cardiovascular risk factors were present in 41.4% (n = 12) of cases: family history of cardiovascular event (n = 2 cases), physical inactivity (n = 5 cases), smoking (n = 3 cases), arterial hypertension (n = 4 cases), diabetes (n = 4 cases), dyslipidaemia (n = 4), and BMI ≥ 25 kg/m² (n = 4).

Following parameters were significantly higher in patients with cardiovascular risk factors: the presence of a biological inflammatory syndrome (81.8% vs 35.3%; p = 0.016), the frequency of prescription of corticosteroids (91.7% vs 52.9%; p = 0.026) and NSAIDs (83.3% vs 47.1%; p = 0.047).

However, no significant difference was noted when comparing these parameters: gender, age, age of disease onset, disease duration and presence of extra-articular manifestations. Moreover, cardiovascular risk factors were not associated with the presence of rheumatoid factor, ACPA, and antinuclear antibodies.

Conclusion

Inflammation, corticosteroid therapy and NSAIDs are associated with the presence of cardiovascular risk factors in JIA. The evaluation and control of this risk must be regular during patient follow-up. Control of inflammation and rationalization of treatment are necessary.

11 Evaluation of doctors’ knowledge (excluding rheumatologists and pediatricians) of juvenile idiopathic arthritis

Background

Juvenile idiopathic arthritis (JIA) is the most common pediatric inflammatory arthritis. However, this disease is not fully understood by all practitioners.

Objectives

The objective of this survey is to assess the level of knowledge and attitudes of doctors excluding rheumatologists and pediatricians on the management of JIA.

Methods

In this cross-sectional descriptive study, an anonymous questionnaire composed of 20 questions, designed with the Google-Forms software, was sent via social networks to doctors from different specialties (excluding rheumatologists and pediatricians) and to interns and residents of the University Hospitals of Tunis.

Results

A total of 100 physicians responded to the questionnaire (61 women and 39 men). The mean age was 31.01 ± 5.64 [24–51] years. Fifty-seven percent of the participants were in training, 27% worked in public hospitals and 16% in private clinics. Most participants were general practitioners (32%), followed by ophthalmologists (9%), gynecologists (7%), and internists (5%). the mean length of service was 4.99 ± 4.5 [0–22] years. Thirty-six participants affirmed they have been confronted with patients with JIA. Twenty percent of participants believed they have knowledge about JIA. Among them, 25% believed they have sufficient knowledge, the others had superficial knowledge. Thirty-four percent of participants knew the definition of the disease according to the age, 17% knew its frequency and 18% had an idea about its various sub forms. The most frequent sub form was known only by 32 participants.

Regarding the complications of JIA, only 25% of the participants thought of the macrophage activation syndrome in case of deterioration of the general state, fever, and pancytopenia. In addition, 44% of participants knew that JIA can be complicated by ocular involvement.

Concerning the presence of rheumatoid factors and anti-nuclear antibodies during JIA, 64% and 60% respectively answered that their presence was not necessary.

Concerning the care of JIA, 64% of participants referred these patients to rheumatologists, 31% to a pediatrician, and 5% took care of them themselves.

The interest of methotrexate and biological treatments were known by 48% of the participants. However, 37% of participants had no idea of the therapeutic management of JIA.

Concerning the prognosis, only 25% of the participants know the sub forms of bad prognosis. However, 48% had no idea about the prognosis of the disease.

Conclusion

The level of knowledge of doctors on JIA is low to average. Training for physicians on this potentially serious disease is needed.

16 Spectrum of infections during juvenile idiopathic arthritis

Background

Objectives

Methods

Results

Conclusion

15 Fertility in juvenile idiopathic arthritis

Background

Objectives

Methods

Results

Conclusion

17 Anemia in juvenile idiopathic arthritis: analysis of associated factors

Background

Anaemia is the most frequent hematological disorder in chronic inflammatory rheumatic disease. Few studies have focused on this impairment in juvenile idiopathic arthritis (JIA).

Objectives

To identify the factors associated with anaemia in JIA.

Methods

We conducted a retrospective study including adults with long-standing JIA according to the International League of Associations for Rheumatology (ILAR) criteria over a period of 28 years (1994–2022). Demographic, clinical, biological, and radiographic data were collected. These parameters were compared according to the presence or absence of anaemia.

Results

Seventeen women and 12 men were enrolled. The mean age was 35.69 ± 11.72 [18–61] years. The mean age of disease onset was 11.10 ± 4.25 [2–16] years. The average diagnostic delay was 52.96 ± 95.97 [0–336] months. The average disease duration was 24.48 ± 12.76 [1–47] years.

The polyarticular form was the most frequent (n = 16). Rheumatoid factor, ACPA and antinuclear antibodies were present in 41.4%, 24.1% and 17.2% of cases respectively. Mean CRP values were 42.74 ± 63.37 [2–218] mg/l, a biological inflammatory syndrome was present in 19 cases.

NSAIDs, corticosteroids and methotrexate were used in 62.1% (n = 18), 69% (n = 20) and 79.3% (n = 23) respectively.

Anaemia was noted in 69% (n = 20) of cases, it was hypochromic in 8 cases and microcytic in 11 cases. The mean haemoglobin value was 11.31 2.10 [6.5–15] g/dl.

Anaemia was associated with the following parameters in our study: female sex (88.2% vs 41.7%; p = 0.008), absence of anti-nuclear antibodies (76.9% vs 20%; p = 0.026) and corticosteroid therapy (85% vs 33.3%; p = 0.005). However, the comparison of patients according to the presence of anaemia did not show any significant difference for these parameters: age, age at onset, diagnostic delay, duration of symptoms, extra-articular manifestations, CRP value, presence of biological inflammatory syndrome, rheumatoid factor, ACPA, erosive nature and treatment (NSAIDs and methotrexate).

Conclusion

Anaemia is common in JIA. Its treatment is part of the overall management of the disease.

Case Report: Extensive digital gangrene as a primary manifestation of late-onset systemic lupus erythematosus

Background: Digital gangrene is a rare but serious complication of systemic lupus erythematosus (SLE). It occurs usually in middle-aged patients with longer disease duration. Case: Herein we report the case of a 56-year-old man (with no history suggestive of Raynaud's phenomenon, diabetes mellitus, smoking, trauma, infection, or chemical exposure), who presented with SLE and digital gangrene was among the first signs. He presented with a one-month history of joint pain, hair loss, photosensitivity, mouth ulcers, malar rash, dyspnea, and digital pain. Physical examination revealed painful and diffuse erythematous skin lesions in the extremities and back, as well as cyanosis in the fingers. We noted lymphocytopenia (600 cells/mm 3), and an elevated C-reactive protein (15.1 mg/l) on laboratory tests. Immunological tests were positive for antinuclear antibodies (ANA) with Title 1:400. Pulmonary computed tomography revealed pulmonary fibrosis, and pulmonary function tests revealed the restrictive pulmonary disease. Diagnosis of SLE with lung involvement was retained. The immunological assessment in search of elements in favor of a vascular origin of the patient's skin lesions was negative. Treatment was initiated with 200 mg/day hydroxychloroquine. For dermal and pulmonary involvement, intravenous (IV) pulse therapy was used with methylprednisolone (1,000 mg/d for three consecutive days monthly) and cyclophosphamide (1 g/month). Calcium blocking agents were also prescribed. However, the lesions did not improve. The patient was given two infusions of rituximab (1 g) at a 14-day interval with a marked improvement ofthe majority of vasculitis lesions, and a partial improvement of dyspnea. Conclusions: Digital gangrene is a rare complication of late-onset SLE, especially as a primary manifestation.

AB1115 COVID-19 VACCINE HESITANCY AMONG RHEUMATOID ARTHRITIS PATIENTS ON BIOLOGICS

Background

Vaccine hesitancy is defined by the OMS as ”a delay in acceptance or refusal of vaccines despite availability of vaccination services” [1], and it is considered as one of threats to global health. This hesitancy emerges around Covid-19 vaccination. Patients on biologic Disease-Modifying Anti-Rheumatic Drug (bDMARD) are vulnerable to Covid-19 infection and their perception to vaccination is unknown.

Objectives

The aim of our study was to identify Covid-19 vaccine hesitancy among rheumatoid arthritis (RA) patient on bDMARD.

Methods

We conducted a monocentric, cross-sectional study, including patients with RA who met the ACR/EULAR 2010 criteria. All patients were on bDMARD with or without conventional synthetic (Cs) DMARD for at least 3 months. Disease activity was assessed using the Disease Activity Score (DAS) 28 (CRP) and the functional impairment using the Health Assessment Questionnaire (HAQ). A structured interview was done using a prepared questionnaire evaluating their vaccine hesitancy behavior.

Results

We enrolled 60 patients: 10 male (16.7%) and 50 females (83.3%). Their average age was 58.16±9.04 years [34-80]. For the education level; 38.5% of patients were illiterate, 34.6% had primary education, 23.1% had secondary education, and 3.8% have a university degree. Forty-four patients (73.3%) had no occupation, 13 patients (21.7%) were employed, and 5% were retired. The majority of patients lived in urban areas (85%) and 98.2% with their families. The average duration of RA was 15.23±8.92 years [2-39]. The average DAS28 (CRP) and the average HAQ were 4.05±1.22 [1.5-7.2] and 0.7±0.4 [0-2.4], respectively. Fifteen patients (25%) had a high disease activity and seven (11.7%) were in remission. When asking patients about their Covid19 infection and vaccination status; 15% had caught the virus and 61.7% have already received the vaccine. One third (35.6%) believed that they had enough information about vaccination. Their main sources were their family, friends, and the media. More than half of the asked patients (68.3%) reported vaccine hesitancy. Reasons of vaccine hesitancy were divided into three categories: lack of confidence (66.7%, p<0.005) (63.3% fear related to side effects, 10% conspiracy theory, 6.7% lack of confidence in the provider), complacency problem (16.7%, p=0.01) and lack of convenience (8.6%). There was no association between vaccine hesitancy and sociodemographic data. The existence of comorbidities had no influence on vaccine hesitancy (p=0.4). This hesitancy was not associated with DAS28 (CRP) (p=0.6) and with HAQ (p=0.7). Patients with moderate to high disease activity were more likely to deny the usefulness of Covid-19 vaccination (p=0.09). Regarding to the therapeutic data, there was no association between corticotherapy and vaccine hesitancy (p=0.1). There was no influence on the type of the current bDMARD (p=0.3) or of the rate of administration (p=0.4). The route of administration was associated with hesitation (53.65% intravenous vs 46.34% subcutaneous, p=0.04).

Conclusion

Our study showed that Covid-19 vaccination coverage among RA patients on bDMARDs was not optimal with a high percentage of hesitancy. The reasons are complex and they may be related to a lack of awareness. Rheumatologists should play a key role in the vaccine company.

References

[1]MacDonald NE, SAGE Working Group on Vaccine Hesitancy Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161–4.

Disclosure of Interests

None declared

AB1222 POSITIVE DIAGNOSIS OF TUBERCULOUS SPONDYLODISCITIS: CT-GUIDED PERCUTANEOUS BIOPSY OF SPINAL LESIONS VERSUS CLINICAL, BIOLOGICAL AND IMAGING ARGUMENTS

Background

Tuberculosis is still endemic in Tunisia. Although pulmonary localization is the most common, other localizations, including osteo-articular involvement, are increasingly diagnosed. Spinal or «Pott’s Disease» is the most common expression. A bundle of clinical, paraclinical and evolutionary arguments or a disco-vertebral biopsy puncture (DVBP) contribute to the positive diagnosis.

Objectives

Our aim was to assess the real contribution of DVBP compared to clinical-biological and imaging arguments for the diagnosis of tuberculous spondylodiscitis (SPDT).

Methods

We conduct a retrospective and descriptive study in a single rheumatology department. Data were collected from files of patients hospitalized in the past 20 years (2000-2020) who have been diagnosed with SPDT.

Results

Fifty-two cases of SPDT were collected (37F/15M). The mean age of the population was 55.21 years ± 17.79 [19-91]. Diagnosis SPDT was retained based on the results of the DVBP in 15 patients (28.8%); and it was strongly suspected in front of the presence of clinico-biological and imaging arguments in 37 patients (71.2%). Among the clinical arguments suggestive of SPDT were: progressive onset of symptoms in 47 patients (90.4%), segmental spinal stiffness in 37 patients (71.2%), spinal pain with general signs of tuberculosis such as impaired general condition, fever, night sweats and weight loss in 32 patients (61.5%). Lumbar spine involvement was the most common in tuberculous SPD (57.7%). A biological inflammatory syndrome has been objectified in 38 patients (73.1%). Imaging was contributive to positive diagnosis using standard X-rays, computed tomography and magnetic resonance imaging (MRI). Disc pinch, erosion of vertebral plateaus and vertebral collapse were the major signs. Once the diagnosis was retained for these patients, the first week noted a most significant clinical improvement (56.8%) in patients diagnosed with a range of suggestive arguments (p = 0.002). During the second week, clinical improvement was most marked in patients diagnosed with suggestive clinical and paraclinical arguments (70.3%) but with no statistically significant difference (p = 0.1). The improvement was statistically greater during the fourth week (66.7%) and the third month (60%) in patients diagnosed with histological examination (p < 0.001).

Figure 1.

SPDT Diagnostic Strategy

SPDT= Tuberculous spondylodiscitis, CBC= Cell blood count, NNA= Normochromic normocytic anemia, CRP= C reactive protein, SR= Sedimentation rate, BK= koch’s bacillus, SPDI= infectious spondylodiscitis, SPDNT= Non-tuberculous spondylodiscitis

Conclusion

Tuberculous spondylodiscitis is a frequent condition that needs to be treated rapidly. A range of highly suggestive clinical, paraclinical and evolutionary arguments contribute in the majority of cases to the positive diagnosis with a comparative clinical evolution to that of the DVBP which remains an invasive exam with variable sensitivity depending on studies.

Disclosure of Interests

None declared

AB1369 DISCO-VERTEBRAL BIOPSY VERSUS INDIRECT DIAGNOSTIC TOOLS IN BRUCELLAR SPONDYLODISCITIS

Background

The diagnosis of brucellar spondylodiscitis can be made by serological examinations or by isolating the germ on disco-vertebral biopsy (DVB).

Objectives

We aimed to study the interest of DVB and other less invasive diagnostic tools in brucellar spondylodiscitis.

Methods

A retrospective study over a period of 15 years, including 18 patients diagnosed with brucellar spondylodiscitis.

Results

Eighteen cases were collected (13 men and 5 woman).

Nine patients had a DVB. In all cases, microbiological study did not reveal the causative agent (Brucella). A case of superinfection with Staphylococus Xylosus was noted. Histopathological examination was performed in eight patients. It showed osteitis and chronic spondylodiscitis lesions in 4 cases, a non-specific inflammatory infiltrate in 3 cases, and a progressive infectious spondylitis in one case. Wright’s serodiagnosis and the rose bengal test were positive in 7 out of 8 cases performed. As for the diagnosis by indirect immunofluorescence made in 6 cases, it was positive in 5 cases.

For the other nine cases who did not undergo DVB, Wright’s serodiagnosis and rose bengal test were positive in 9 and 6 patients respectively, indirect immunofluorescence made in 5 patients was positive in 4 cases.

Conclusion

Serological examinations in brucellar spondylodiscitis seem more profitable and less invasive than DVB. Other studies with a larger population seem to be necessary to compare the different methods and complete this preliminary study.

Disclosure of Interests

None declared

AB0951 Entheseal involvement in healthy subjects: What can lower limb ultrasonography tell us?

Background

Over the past few years, ultrasonography (US) has been a very useful tool in the detection of subclinical enthesopathy especially in spondyloarthritis patients. However, could US entheseal involvement detection by US in healthy subjects be predictive of evolution to an inflammatory rheumatic disease?

Objectives

To identify by US the prevalence of entheseal abnormalities at the lower limb of healthy subjects and associated risk factors.

Methods

US assessment was performed on 400 entheses of 40 healthy volunteer subjects along with clinical examination. Exclusion criteria: Enthesitis on the physical examination, personal of family history of inflammatory rheumatic disease and previous surgery or procedural interventions in the knees and/or ankles. Quadriceps, patellar and calcaneal tendons, and plantar fascia entheses were scanned. Depending on lesion type, inflammation (thickening, hypoechogenecity, bursitis and Doppler signal) and chronic damage (calcifications, enthesophytes and erosions) scores (0= absent, 1=present) were calculated per entheseal site and per participant. Total score was obtained by adding these two scores. Data about age, gender, body mass index (BMI) and physical activity according to the short form of the International Physical Activity Questionnaire score (IPAQ-SF) were collected.

Results

The mean age of participants was 52.3±14.83 [20-78] and the ratio of males to females was 3:2. Fourteen participants had US subclinical enthesopathy (35%). Among 400 scanned entheses, thickening was the most frequent inflammatory lesion observed in 4 % (n=16) of the entheses, followed by hypoechogenecity (0.5 %, n=2). Enthesophytes were the most frequent chronic damage lesions detected in 1.25% (n=5) of the entheses followed by erosions (0.5%, n=2). The highest total US scores per entheseal site were observed at the calcaneal enthesis [mean (SD) 0.27(0.59)], followed by plantar fascia [0.18(0.50)] and distal patellar tendon origins [0.10 (0.37)]. Age was not associated to higher scores (total, inflammation, chronic damage; p=0.339, p=0.412, p=0.531). Female participants had higher inflammation scores than males (mean inflammation scores (SD) 0.69 (1.44) versus 0.39 (0.71), p=0.044). The BMI was correlated to higher inflammation score (p=0.020, r=0.368) but not to chronic damage nor to total scores (p=0.478, p=0.104). Intense physical activity was associated to higher chronic damage score comparing to moderate physical activity (mean chronic damage scores (SD) 0.30(0.67) versus 0.003(0.00), p=0.058) and to low physical activity (mean chronic damage scores (SD) 0.30(0.67) versus 0.0018(0.00), p=0.043). No association between physical activity and inflammation score had been observed.

Conclusion

Our study demonstrates that US changes within the enthesis are associated with higher BMI and physical activity. These results support the effect of biomechanical forces on the entheses that should be considered when differentiating by US pathological from healthy entheses.

Disclosure of Interests

None declared

POS1568-PARE THE BRIEF-ILLNESS PERCEPTION QUESTIONNAIRE: A METHOD FOR ASSESSING THE COGNITIVE REPRESENTATION OF RHEUMATIC DISEASE

Background

The common-sense model proposes that illness perception (IP), is how patients make sense of their illness and respond emotionally to it, influencing the way they cope with the illness and subsequently illness outcomes. This proposition has gained considerable empirical support, and the relevance of IP in understanding illness-related behaviors or outcomes has also been supported in patients with rheumatic diseases (RD). The Brief Illness Perception Questionnaire (B-IPQ) was designed to provide a simple and rapid assessment of IP. This questionnaire has been widely used in diverse ages, illness types, countries, and languages.

Objectives

This study aimed to examine the construct of IP as measured by the B-IPQ in patients with RD.

Methods

A cross-sectional study was conducted at a Tunisian rheumatology department on 80 patients with RD. Sociodemographic, disease-related variables were reported. Participants completed a questionnaire on illness beliefs (B-IPQ).

Results

Subjects were aged 22-74 years (mean 51 years), 61.6 % were female. Diagnoses included Rheumatoid arthritis (RA) (63%), axial spondylarthritis (AS) (37%). The mean disease duration was 11 years and 7 years for RA and AS respectively. The proportion of physical comorbidities was higher in RA patients (36%) versus AS patients (11%). Disease activity was low in 28.8% of patients. All patients were on medications for their rheumatic disease, and 34,6 % were on biological therapy.

In both diseases, the participants perceived their rheumatic illness as a chronic condition (9.4) that could be controlled by treatment (6.6) but not strongly influenced by personal actions (4.3). Overall, Rheumatic disease was seen as having an important impact on their life (7.9) without significant difference between patients with low or high activity disease (p=0.23). The majority believe that they have a moderate understanding of their illness (6.6). The frequency of symptoms was highly evaluated in RA patients than AS patients (7.3 vs 5.6) (p=0.01). In RA patients, 76% were extremely affected emotionally by their disease, however, the majority of AS patients were moderately affected emotionally with a significant difference (p=0.02). In addition, RA patients considered their disease mainly a result of psychological factors (66.8%). On the other hand, AS patients (73%) attributed their illness to various risk factors (especially physical overexertion).

Conclusion

High scores of B-IPQ shown in our studies, encourage the design of psychotherapeutic trials targeting disease-related cognitions in AS and RA in an attempt to improve patients’ reported outcomes and disease outcomes.

Disclosure of Interests

None declared

AB1454 CLINICAL AND BIOLOGICAL FACTORS CORRELATED WITH MAGNETIC RESONANCE IMAGING RESULTS IN TUBERCULOUS SPONDYLODISCITIS

Background

Tuberculosis is still endemic in Tunisia. Although pulmonary localization is the most common, other localizations, including osteo-articular involvement, are increasingly diagnosed. Tuberculous spondylodiscitis (SPDT) or Pott’s disease is an infectious involvement of the disc-vertebrate couple, caused by the tubercular bacillus (Mycobacterium tuberculosis). Magnetic resonance imaging (MRI) is the most sensitive (95-100%) and the most early abnormal exam.

Objectives

Our aim was to study the correlation of contributing factors, epidemiological, clinical, biological, radiological and therapeutic data with positive signs of spinal MRI.

Methods

We conduct a retrospective and descriptive study in a single rheumatology department. Data were collected from observations of patients hospitalized in the past 20 years (2000-2020) who have been diagnosed with SPDT. Epidemiological, clinical, biological, radiological, and therapeutic data were analyzed. Each patient had spinal MRI. Positive signs have been individualized, represented by intervertebral disc involvement, vertebral body involvement and visualization of a paravertebral abscess.

Results

Fifty-two cases of SPDT were collected (37F/15M). The mean age of the population was 55.21±17.79 years [19-91]. Thirty-three patients (69.2%) were classified as young versus 16 elderly patients (30.8%), with female predominance in both groups (69.4% and 75% respectively, p = 0.57). The positive diagnosis of tuberculous spondylodiscitis was facilitated by the spinal MRI. Positive signs were sought in our patients which are represented by: the achievement of the intervertebral disc with diffuse T2 hypersignal (56.5%) and diffuse or circumferential increase of the signal in sp T1 Gadolinium (50.9%), Involvement of the vertebral body with moderate and extensive condensation (60.4%), macrogeodes (60.4%) and heterogeneous increase in spT1 Gado signal (52.8%) and visualization of a paravertebral abscess (51.9%). Correlations made between the favouring factors, epidemiological, clinical, biological, radiological and therapeutic data and the positive signs of spinal MRI, objecting that six parameters had a statistically significant correlation with MRI signs strongly suggestive of the diagnosis of SPDT: Hospitalization duration was correlated with the diffuse T2 disk hypersignal (p= 0.02; r= - 0.38), Hemoglobin rate was correlated with the diffuse or circumferential increase in T1 disk sp signal (p= 0.03; r= - 0.34), the initial rate of lymphocytes was correlated with the paravertebral abscess (p= 0.04; r= - 0.47). The extra-vertebral tuberculosis location was correlated with the diffuse T2 disc hypersignal (p= 0.03; r= -0.96), the moderate condensation and the extent of vertebral body (p < 0.001) and vertebral body macrogeodes (p < 0.001). The neurological clinical signs were correlated with the heterogeneous increase in vertebral body T1 sp signal (p= 0.04; r= -0.33) and the surgical treatment (p < 0.001).

Conclusion

Tuberculous spondylodiscitis is a frequent condition that needs to be diagnosed and treated rapidly. Spinal MRI is the first-line exam in case of suspicion. Clinical, biological and therapeutic parameters were correlated with the MRI images highly suggestive of positive diagnosis.

Disclosure of Interests

None declared

AB1576-PARE RHEUMATOID ARTHRITIS ASSESSMENT KNOWLEDGE QUESTIONNAIRE (RAKE) IN TUNISIAN POPULATION

Background

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease that has a very high burden on patients their families, and society. So that it is important that RA patients receive education about their disease. The knowledge of RA patients in Tunisia regarding their disease has not yet been assessed.

Objectives

The purpose of the study was to evaluate disease-specific knowledge of patients with rheumatoid arthritis by using the RAKE questionnaire (Rheumatoid Arthritis assessment Knowledge Questionnaire).

Methods

This was a cross-sectional study. Adults with RA fulfilling the ACR/EULAR criteria were asked to participate by responding to RAKE Questionnaire in the short version.

Results

A total of 28 RA patients were included: 23 females (82%) 5 mens (18%). The mean age was 58.5 years with a range of 31 to 79 years. The mean disease duration was 9.8 years. The disease duration was 0-5 years in 5 (17.8%) patients, and more than 5 years in 23 (82.2%) cases. Twenty patients were housewives. Thirteen (46.4%) patients were from rural areas. Almost all of the patients didn’t follow education programs for their RA. Twenty-two (78.5%) patients obtained information’s RA from their rheumatologist. Six patients (21.5%) from other sources (neighbors, nurses, other RA patients, social media). The mean time for answering the questionnaire was11.6 min (9-15 min).The RAKE total score was11.8/32 [3-22]. For the initial part of the questionnaire, related to the general aspects of RA, the mean score was 4.3/8 [0-6]. The mean score of the second component of the questionnaire concerning medications and non-pharmacological management, was respectively 4.3/11 [0-7] and 2.3/5 [0-4]. For comorbidities, the mean score was 0.6/1. The fourth component includes auto-management, pain, and tiredness the mean score was1.4/3 [0-3]. The last component covers psychosocial, occupational, and health system coping skills. Its mean score was 2.1/4. The mean score of unknown answers was 6.7/32 [4-16].

Conclusion

In our study, the knowledge patients of RA was low in all domains of RAKE questionnaire at various degrees. These findings can be used for improving current patient education programs and better disease control.

Disclosure of Interests

None declared