AB1306 AA AMYLOIDOSIS IN CHRONIC RHEUMATIC DISEASES: ABOUT 20 CASES

Background

Secondary AA amyloidosis is a complication of certain uncontrolled chronic inflammatory rheumatic diseases. The diagnosis of AA amyloidosis is anatomo-pathological based on the detection of amyloid deposits within a biopsy specimen.

Objectives

The aim of this study is to determine the clinical, biological, therapeutic and evolutionary aspects of amyloidosis during these diseases.

Methods

This is a retrospective descriptive study conducted in the rheumatology department in Monastir, Tunisia, including patients followed for chronic inflammatory rheumatism complicated by AA amyloidosis.

Results

Our study included 20 patients (13 women and 7 men). Their mean age at the time of diagnosis of amyloidosis was 55.4 years [18-76]. The rheumatic diseases were: Rheumatoid Arthritis (RA) in 13 cases (65%), Ankylosing Spondylitis in 3 cases (15 %), Behçet’s disease in 2 cases and Juvenile idiopathic arthritis in its systemic form in 2 cases (10% for both). Amyloidosis occurred after a mean duration of rheumatic disease of 11.5 years [3-27]. The mean sedimentation rate at diagnosis of amyloidosis was 100.5 mm per hour [21-131]. The mean C-reactive protein at diagnosis was 38.35 mg/L [1.4-135]. Inaugural manifestations of amyloidosis were: edema of lower limbs in 8 cases, nephrotic syndrome in 7 cases, renal failure in 4 cases and an abdominal clinical presentation (diarrhea and abdominal pain) associated with proteinuria in 2 cases. Proteinuria was constant, with a mean level of 7.5 g/24 h [3.5-20]. It was isolated in 5 cases. Amyloidosis was subclinical in 2 cases and was discovered by an abdominal fat biopsy performed during a research protocol. The diagnosis was confirmed by: renal biopsy (n=9), rectal biopsy (n=5), salivary gland biopsy (n=4) and abdominal fat biopsy (n=2). Amyloidosis extension was assessed for 50% of our patients. Cardiac involvement was the most frequent, revealed in 5 patients. Concentric left ventricular hypertrophy was found in 4 patients. Pulmonary arterial hypertension and pericardial effusion were found in 1 case. Hepatic involvement was detected in 2 cases in the form of hepatomegaly without disturbance of liver function tests. Adrenal gland involvement was detected in 1 case with homogeneous hypertrophy of the adrenal glands associated with adrenal dysfunction. Only 1 patient had peripheral nerve damage in the form of bilateral carpal tunnel syndrome. Concerning the treatment; 12 patients received Colchicine. Chloraminophen was tried for 4 patients with amyloidosis secondary to RA and Azathioprine for one patient with RA. The evolution was unfavorable in 6 cases marked by death within a mean time of 3.4 years.

Conclusion

Although its prevalence is decreasing, owing to therapeutic progress in chronic rheumatic diseases, AA amyloidosis remains a not exceptional complication. It has a poor prognosis, particularly because of renal disease and cardiac involvement.

Disclosure of Interests

None declared

AB1216 TUBERCULOUS, BRUCELLAR AND PYOGENIC SPONDYLODISCITIS: A DESCRIPTIVE AND COMPARATIVE STUDY OF 70 CASES

Background

Infection spondylodiscitis is a serious infectious disease which involves intervertebral disc and its adjacent vertebral bodies but later may also extend into the the adjacent neural structures. Early diagnosis and identifing the causative agent seem critical in term of prognosis.

Objectives

To describe and to compare the clinical, biological and radiological features of tuberculous (TS), brucellar (BS) and pyogenic spondylodiscitis (PS).

Methods

A retrospective monocentric study involving 70 cases of infectious spondylodiscitis admitted between January 2009 and August 2019 at our rheumatology department. Clinical, laboratory and radiological data of the patients were collected.

Results

Of these 70 patients, 18 (25.7%) had TS, 8 (11.4%) BS and 44(62.9%) PS. There were 37 women (52.9%) and 33 men (47.1%). The age of the patients ranged from 12 to 82 years, with a mean of (SD±) 54± 15,23 years. The patients with TS were younger than those with PS (p=0.0016). Of our cases, 67.1% had comorbid chronic diseases such as predominantly renal failure and diabetes. The median diagnostic delay (MDD) in our series was 120,180 and 30 days for TS, BS and PS respectively (p=0.004).All of the patients included in this study suffered from pain, 30 of these had fever and 19 had night sweats. Radiculalgia was found in 50% of cases and 8.6% of them had a neurological deficit. There were no significant differences those clinical features between the groups. In view of laboratory findings, increased erytrocyte sedimentation rate (ESR) was detected in 82.9%, C-reactive protein(CRP) positivity in 84.3% and hyperleukocytosis in 33.3% of patients. ESR and CRP levels were significantly higher in PS patients when compared with TS cases (p=0.005; P=0.006, respectively). Standard X-rays showed abnormalities suggestive of spondylodiscitis in 78.6% of cases. Computed tomography and Spinal magnetic resonance imaging were performed respectively in 52.9% and 63% of cases and were pathological in all cases. A great majority of the patients had involvement at only one vertebrae level (70%). The most frequently affected level, were the thoracic (33.3%), the lombosacral (100%) and the lombar (38.6%) segment in the TS, BS and PS respectively. In BS the lombosacral segment was significantly the most frequently affected level (p<0.0037). The intervertebral disc narrowing was observed in 87.3% of patients. Paravertebral or epidural masses were present respectively in 53.5% and 86.7% of TS, versus 14.3% and 71.4% of BS, and 46.3% and 80.5% of PS, there were no significant differences between the groups.

Conclusion

There are significant clinical, biological and radiological differences between TS, BS and PS. The presence of back pain, fever, moderate elevation of inflammatory markers with thoracic radiological involvement was suggestive of tuberculous spinal infection.

Disclosure of Interests

None declared

AB0871 Factors associated with radiographic hip involvement in ankylosing spondylitis

Background

Hip involvement is a classic feature of ankylosing spondylitis (AS). It causes functional impairement and disability in patients with AS. Although, many studies have looked at factors associated with radiographic hip involvement, these remain debated.

Objectives

To define the factors associated with radiographic hip involvement in patients with AS.

Methods

A cross-sectional comparative study of 105 patients was performed. Hip involvement was defined as hip pain considered related to AS inflammation and confirmed radiographically. The patients were classified into two categories: (1) no hip involvement, (2) hip involvement according to a Bath Ankylosing Spondylitis Radiology Index (BASRI)-hip score ≥2. Multivariate logistic regression analyses were used to identify the factors associated with radiographic hip involvement.

Results

Fifty-three patients had radiological hip involvement and 52 patients were whithout hip involvement. Multivariate logistic regression analyses showed male sex (OR 6.383 IC 1.553-26.29, p=0.010), Bath Ankylosing Spondylitis Functional Index (BASFI) score (OR 1.436, IC 1.079-1.913, p=0.013), and BASRI-spine score (OR 1.456, IC 1.190-1.783, p<0.001) to be significantly associated with radiographic hip involvement, and an inverse relation-ship with age at onset (OR 0.955, IC 0.995-0.998, p=0.038) was seen.

Conclusion

Male sex, younger age at onset, worse BASFI score and worse BASRI-spine score are associated with radiographic hip involvement. AS patients with risk factors for radiographic hip involvement should be diagnosed at an early stage to improve their quality of life.

References

[1]Zhao J, Zheng W, Zhang C, Li J, Liu D, Xu W. Radiographic hip involvement in ankylosing spondylitis: factors associated with severe hip diseases. J Rheumatol. 2015 Jan;42(1):106-10.

[2]Burki V, Gossec L, Payet J, Durnez A, Elhai M, Fabreguet I, Koumakis E, Meyer M, Paternotte S, Roure F, Dougados M. Prevalence and characteristics of hip involvement in spondyloarthritis: a single-centre observational study of 275 patients. Clin Exp Rheumatol. 2012 Jul-Aug;30(4):481-6. Epub 2012 Aug 29.

[3]Chen HA, Chen CH, Liao HT, Lin YJ, Chen PC, Chen WS, et al. Factors associated with radiographic spinal involvement and hip involvement in ankylosing spondylitis. Semin Arthritis Rheum 2011;40:552-8.

Disclosure of Interests

None declared

AB0303 RELATION BETWEEN CLINICAL ANTHROPOMETRIC MEASUREMENTS AND MALNUTRITION IN ELDERLY PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is associated with an increased risk of malnutrition, especially among the elderly. However, nutritional assessments in this population are scarce in the clinical situation. Various anthropometric measurements can help to assess malnutrition.

Objectives

To evaluate the nutritional status using anthropometric measurements in elderly patients with RA.

Methods

A prospective study was conducted, including RA patients aged 65 years or older and followed in rheumatology department. Clinical findings, disease activity and nutritional profile were studied. The mini-nutritional assessment (MNA) was used to identify altered nutritional status. The anthropometric measurements studied were: Weight loss, Body mass index (BMI), Triceps skin fold thickness (TSF) which reflects fat mass, Mid-arm circumference (MAC), Arm muscle circumference (AMC) which indicates lean mass and the calf circumference (CC).

Results

Sixty-three patients were included, 82% were female. Their mean age was 68.17±4.35 years. The mean duration of RA was 11 years. The average DAS28 was 3.72±1.48. The mean MNA total score was 20.19 ± 4.71 with a range of 8 to 27.5. The prevalence of malnutrition in our population was 20.6%. 55.6% of the patients were at risk of malnutrition. Only 23.8% had a normal nutritional status. The average BMI was 27.97 ± 5.44 kg/m2 [14.85 - 43.2]. The diagnosis of malnutrition according to the BMI (< 21 kg/m2) was made for 7.9% of patients, of which 4.8% were severely malnourished. The average weight loss was 2.26 ± 2.51 kg during the last month [0 – 10]. The average percentage of weight loss in the last month was 3.39 ± 4% [0-11%]. Among our patients, 26 patients (41.3%) did not report a weight loss, 19 patients (30.2%) had a weight loss of less than 5%. Eighteen patients (28.6%) had malnutrition defined as weight loss greater than or equal to 5% in one month, of whom 7 patients (11.1%) had severe malnutrition with a loss of at least 10% of their habitual weight. The mean TSF was 18.38 ±6.77 mm [5 - 30] (19.15±6.72 mm in women and 14.72±6 mm in men). 28.6% of patients had decreased values of TSF. The mean MAC was 29.48 ± 4.52 cm [18 - 40]. The mean AMC was 23.7 ± 3.64 cm [15.86-34.43] (24±3.57 cm in women and 22.19±3.75 cm in men). The AMC was decreased in 20.6% of cases. The mean CC was 33.25 ± 4.62 cm [20-43]. 31.7% of patients had a decreased CC. There were significant association between the nutritional status using the MNA and BMI, loss of weight and TSF (p=0.013, p<0.001 and p=0.05, respectively). MNA was not associated with MAC, ACM or CC (p=0.6, p=0.8 and p=0.4, respectively).

Conclusion

This study showed that the prevalence of malnutrition varies depending on the used anthropometric tool. BMI, weight loss and TSF are, according to our study, reliable tools to detect the malnutrition in elderly patients with RA.

Disclosure of Interests

None declared

AB1215 A COMPARATIVE ANALYSIS OF RADIOLOGICAL FINDING BETWEEN TUBERCULOUS, BRUCELLAR AND PYOGENIC SPONDYLODISCITIS

Background

Infection spondylodiscitis (IS) is a serious infectious disease which involves intervertebral disc and its adjacent vertebral bodies but later may also extend into the the adjacent neural structures. The clinical picture of IS is rather non specific but there are significant radiological differences that permit a presumptive aetiological diagnosis and orient the initial empirical treatment.

Objectives

This study aimed to compare the radiological features of of tuberculous (TS), brucellar (BS) and pyogenic spondylodiscitis (PS).

Methods

A retrospective monocentric study involving 70 cases of infectious spondylodiscitis admitted between January 2009 and August 2019 at our rheumatology department. Clinical, laboratory and radiological data of the patients were collected.

Results

Of these 70 patients, 18 (25.7%) had TS, 8 (11.4%) BS and 44(62.9%) PS. There were 37 women (52.9%) and 33 men (47.1%). The age of the patients ranged from 12 to 82 years, with a mean of (SD±) 54± 15,23 years. Standard X-rays showed abnormalities suggestive of spondylodiscitis in 78.6% of cases. A great majority of the patients had involvement at only one vertebrae level (70%). The most frequently affected level, were the thoracic (33.3%), the lombosacral (100%) and the lombar (38.6%) segment in the TS, BS and PS respectively. In BS the lombosacral segment was significantly the most frequently affected level (p<0.0037). Computed tomography was performed in 52.9% of cases and showed that the epidural and paravertebral abscess were characteristic of tuberculous involvement (p=0.013 and 0.05). Magnetic resonnance imaging was performed in 63% of cases. The intervertebral disc narrowing was observed in 87.3% of patients. Paravertebral or epidural masses were present respectively in 53.5% and 86.7% of TS, versus 14.3% and 71.4% of BS, and 46.3% and 80.5% of PS, there were no significant differences between the groups.The enhancement was rather heterogeneous in the SDT and homogeneous in the two other groups, but these differences were not statistically significant.

Conclusion

There are significant radiological differences between TS, BS and PS. A better understanding of typical and atypical manifestations on imaging can be an excellent diagnostic tool for every attending physician.

Disclosure of Interests

None declared

AB0319 PREALBUMIN SERUM LEVEL AS A USEFUL TOOL IN THE ASSESSMENT OF MALNUTRITION IN ELDERLY PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Protein-energy malnutrition is a common condition among elderly patients with RA associated with a poor prognosis. Although many screening tools are developed, there’s no consensus on which test is more reliable in clinical practice. Serum prealbumin (PAB) may be a useful malnutrition biomarker.

Objectives

Our objective is to evaluate the usefulness of serum PAB in the assessment of malnutrition in elderly patients with RA.

Methods

We conducted a prospective study including RA patients who were followed in rheumatology department and aged 65 years or older. We studied malnutrition prevalence, risk of complications related to malnutrition and PAB serum concentrations. The mini-nutritional assessment (MNA) score was used as the reference method to determine malnutrition. We also dosed inflammatory proteins: Orosomucoide (Oroso), C-reactive protein (CRP) and Haptoglobine (Hapto). For the prognosis assessment, we calculated the Geriatric nutritional risk index (GNRI) and the Prognostic Inflammatory and Nutritional Index (PINI).

Results

Sixty-three patients (52 female and 11 male) were included. Their mean age was 68.17±4.35 years. The average DAS28 was 3.72±1.48. The mean MNA total score was 20.19 ± 4.71. According to MNA, the prevalence of malnutrition was 20.6%. 55.6% of the patients were at risk of malnutrition and only 23.8% of patients had a normal nutritional status. The median PAB was 0.16 g/L with an IIQ of [0.04-0.24] and extremes ranging from 0.01 to 0.37 g/L. According to PAB, 35.8% of patients had a normal level above 0.20 g/L, 17% had PAB levels between 0.15 and 0.19 g/L, indicating moderate malnutrition and 47.2% of patients had PAB levels below 0.15 g/L, indicating severe malnutrition. Concerning inflammation proteins: the mean CRP was 18.96 ± 27.8 mg/L. 28.6% of patients had a CRP > 15 mg/L, of which 9.5% had a CRP > 50 mg/L. The mean Oroso was 1.29 ± 0.46 g/L [0.6-2.2]. 52.5% of our patients had an elevated oroso value. The mean Hapto was 2.07 ± 0.97 g/L [0.31-5.29]. 42.9% of patients had an increased value above 2.5 g/L. Concerning prognosis indexes, the median GNRI was 116.47 with an IIQ of [106.6-125.12] and extremes ranging from 70.06 to 145.02. The median PINI was 1.77 with an IIQ of [0.47-10.21] and extremes ranging from 0.05 to 222.16. Statistical analysis showed a significant association between PAB and MNA with p=0.05. Negative correlation was found between PAB and inflammatory proteins; with Oroso (p=0.001), CRP (p=0.006) and Hapto (p=0.03). By analysing prognosis indexes, significant negative correlation of the serum PAB was found with the GNRI (p=0.003) and the PINI (p=0.001).

Conclusion

We conclude that PAB could represent a feasible and reliable tool in the diagnosis of malnutrition. It is a good biomarker for the prognosis and the assessment of the risk of complications related to malnutrition among the elderly patients with RA.

Disclosure of Interests

None declared

AB1183 COVID-19 VACCINE: HESITANCY, ACCEPTANCE AND TOLERANCE AMONG PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Patients with rheumatoid arthritis (RA) are considered a high-risk population to develop severe COVID-19 [1] and therefore vaccination is strongly recommended. Previous reports have shown a high hesitancy rate to receive a COVID-19 vaccine among RA.

Objectives

This study aimed to evaluate the attitude of patients with RA to vaccination against SARS-CoV-2, explore the factors which may influence it, and assess adverse events of SARS-CoV-2 vaccines.

Methods

This is a cross-sectional study including 106 patients with RA diagnosed according to the ACR/EULAR 2010 classification criteria and followed in the Rheumatology Department, over a period of 10 months from March to December 2021.Demographic and disease parameters were collected: age, gender, educational status, disease duration, erythrocyte sedimentation rate (ESR), disease activity score (DAS28), and treatments being used. All patients responded to a questionnaire on their perceptions and concerns about the covid-19 vaccine, and the adverse effects for those who got vaccinated.

Results

Among the 106 patients, 90 (84,9%) were females and 16 (15,1%) were males. The

mean age was 54 ±13 years old [23-77]. Sixty-four percent were from urban areas and 36 %

were from rural areas. Thirty-three percent of patients were illiterate. The mean disease

duration was 9.54 ±5.76 years [2-22]. The mean DAS28 ESR was 3,88 ±1.34 [1.2-7.58]. All of

our patients were taking conventional synthetic DMARDs. Seventeen percent of patients

were on biological DMARDs. The majority of the patients (90%) reported that they respected

the preventive measures. Twenty-two percent of patients had stopped their treatment

because they were afraid of the covid-19. Twenty-eight patients had contracted the SARS-

CoV-2. Seventeen percent of the patients reported that they didn’t get vaccinated against

covid-19. The reasons given by these patients were: presumed adverse events (53,3%),

presumed inefficiency (25%), no recommendation from their doctor (46,7%), fear that the

vaccine would make RA worse (64,7%). For the vaccinated patients, the vaccines

administered were: 63,6 % Pfizer BioNTech, 6,8% Oxford/AstraZeneca, 5,7% Moderna, 4,5%

Janssen/Johnson &amp; Johnson, 2,3% Sinovac-CoronaVac and 17% unspecified. The majority of

the patients (72,7 %) received two doses,14,8 % one dose and 12,5% 3 doses. After

vaccination, 73,9% of patients reported adverse events, such as pain at the site of injection

(88,1%), fatigue (35,8%), headache (14,9%), fever (13,4%) and muscle/joint pains (4,5%).

Only 1 patient had experienced rheumatic disease flare. Hesitancy about the COVID-19

vaccination was associated with low intellectual level (p=0.004) and rural origin (p=0.001).RA

disease duration, DAS28-ESR, and treatments have no influence on the attitude of patients

towards COVID-19 Vaccination (p > 0,05).

Conclusion

The acceptance of COVID-19 vaccination by RA patients in our study is quite promising. The

majority of patients tolerated their vaccination well, with rare RA flares up. These results

should reassure rheumatologists and patients. Education and outreach efforts need to be

continued, especially for illiterate people and those who live in rural areas.

References

[1]HABERMAN, Rebecca H., CASTILLO, Rochelle, CHEN, Alan, et al. COVID-19 in patients with inflammatory arthritis: a prospective study on the effects of comorbidities and disease-modifying antirheumatic drugs on clinical outcomes. Arthritis & Rheumatology, 2020, vol. 72, no 12, p. 1981-1989.

Disclosure of Interests

None declared

POS0469 FALL RISK ASSESSMENT IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid arthritis patients may have an increased risk of falls due to changes caused by the disease such as muscle weakness, joint impairment, reduced mobility and postural instability.

Objectives:

The aim of this study was to analyze the occurrence of falls in RA patients and its risk factors.

Methods:

Between January2020 and July 2020, 51 patients with RA were included in the study. fall history, and the number of falls within the past 12 month were questioned. All participants were assessed with Timed Up and Go Test (TUGT), One-Leg Stand Test (OLST), Walking and Talking Test (WTT), Sternal Push Test (SPT), Tinetti Test (TT), Four Test Balance Scale (FTBS), The Short Falls Efficacy Scale-International (FES-I), Pain Severity and Patient Global Assessment (PGA) by Visual Analog Scale (VAS), disability by the Health Assessment Questionnaire (HAQ), and disease activity by Disease Activity Score in 28 joints (DAS28) were evaluated in for for each patient. The Kolmogorov-Smirnov, Mann-Whitney and chi-square tests were performed with a significance level of P ≤ 0.05.

Results:

22 patients had at least one or more falls. The average age was 54.9±11.5 years with a female predominance (sex ratio = 0.13). Comparing the two groups of patients: those with a history of falls and those without, patients with previous falls were mainly married women (p=0.57), with a low intellectual level (p=0.63). The body mass index in this group was higher (p=0.01) with respectively a higher number of painful and swollen joints (p=0.16, p=0.07); the mean HAQ was higher (p=0.03), and the mean VAS was more important (p=0.05). 12/22 patients had co-morbidities and were poly-medicated.20/22 had joint feet deformities (hallux valgus was the most common deformity). 21/22 were on low dosage corticosteroid therapy. The mean TUGT was 18.5 seconds (>14 seconds). The OLST was less than 5 seconds in 12/22, the sternal push test was positive in 9/22, WTT was positive in 6/22 and the mean tinetti test was 22.4±5.4 suggesting a high risk of falls. The average Short FES-I was 14.6 ±4.4 reflecting a high fear of falls in this group of patients.

Conclusion:

Knowledge about risk factors can help to identify high-risk patients in order to decrease their risk of falling, thus preventing fall-related injuries.

Disclosure of Interests:

None declared

AB0037 UNDIFFERENTIATED ARTHRITIS

Background:

Early recognition and treatment of inflammatory arthritis is imperative for the further course of the disease.

Objectives:

This study aims to determine the evolution of undifferentiated arthritis observed in rheumatology.

Methods:

Retrospective descriptive study which collects patients files identified as undifferentiated Arthritis and followed in the Rheumatology Department at Fattouma Bourguiba Hospital Monastir TUNISIA over a period of 15 years (2005, 2019). Epidemiological, clinical, paraclinical, and evolutionary data were collected and analyzed.

Results:

99 files were analyzed. The average age was 42.06±15.56; they were 42 males and 57 females with an average body mass index of 27±6.1 Kg/m2. The reason leading to consultation was, polyarthritis (37), oligoarthritis (27), mono-arthritis (21), and polyarthralgia (15). The median time to visit was 60 days [15 days, 3 months]. The median number of painful joints and swollen joints was 4 [2, 8], and 2 [1, 4] respectively. The mean duration of morning derusting was 34.8 ±24.4 minutes. Extra-articular manifestations were: a dry syndrome (22), a rheumatoid nodule (2), and serosal damage (1). Anemia (52 patients), leukopenia (6 patients), and lymphopenia (13 patients) were found in the blood cell count with a biological inflammatory syndrome in most patients (72/99). The immunology results showed: positive anti-nuclear antibodies (15/99), positive Anti-Citrullinated Protein Antibodies (9/99) and positive rheumatoid factor (8/99). 31 patients had standard radiological signs represented mainly by joint pinching and erosions. A joint puncture was done in 36/99 revealing inflammatory fluid in most cases. After an average follow-up of 1047 days [365, 1460]. undifferentiated arthritis was classified as rheumatoid arthritis (RA) (23), spondyloarthritis (SpA) (10), connective tissue disease (11), Crystalline Arthritis (5), and paraneoplastic arthritis (2). One patient had self resolution of symptoms and 38 remain undifferentiated.we found that the more the patients were seropositive, the more likely to develop Rheumatoid Arthritis (p=0.001), the more there was disorder in the blood cell count, the more the evolution was towards connective tissue disease (0.01), The more male patients were, the more likely to develop SpA (p=0.04). The patients management was mainly based on: analgesics (94), systemic corticosteroids (57) with a mean dose of 10.89± 5.8 mg/day. The use of Methotrexate and antimalarial drugs was noted in 18 and 15 patients respectively.

Conclusion:

Follow-up of patients with undifferentiated arthritis leads to a definite inflammatory rheumatism diagnosis in 61.6% of cases. Our data indicate that seropositive patients with chronic symptoms carry an increased risk of developing Rheumatoid Arthritis (P=0,001). Clinical, biological and genetic data can help the health care provider to predict future outcomes.

References:

[1]DOI: 10.1007/s00132-018-3539-2.

Disclosure of Interests:

None declared

AB0728 OSTEOGENESIS IMPERFECTA: ABOUT 12 CASES

Background:

Osteogenesis imperfecta (OI), is a rare hereditary disease characterized by bone fragility and low bone mass. The clinical presenatation is various with varying severity skeletal signs and inconstant extra-skeletal signs. Type 1 is the most common form (60% of cases).

Objectives:

Our objective is to describe the various clinical features observed over a period of 15 years.

Methods:

This is a retrospective descriptive study including 12 patients followed for OI, hospitalized in the Rheumatology Department at Fattouma Bourguiba Hospital Monastir TUNISIA between 2006 and 2019. Files were collected and analyzed.

Results:

They are 9 boys and 3 girls with an average age of 14.9 ± 8.6 years. Consanguinity was reported in 25% of cases. The reason leading to consultation was, recurrent fractures (75%), blue sclera (16.7), and bone deformity (8.3%). The number of previous fractures was on average of 5, all of which were caused by a low energy trauma. Similar family cases were noted in 41.6%. The mean age of the first fracture was 4.41 ± 3.2 years. The most frequent fracture sites were respectively: femur (7/12), leg (6/12), tibia (3/12), humerus (4/12), ankle (2/12), and forearm (2/12). A deformity was noted in 58.3% of the cases: lumbar kyphosis (2), exaggerated dorsal kyphosis (2), femurs in parenthesis (2), and an anarchic deformity of 2 lower limbs (1). Imperfect dentinogenesis was found in 8.3% of cases, while ENT examination revealed conductive and sensorineural hearing loss in 2 patients each. The main radiological abnormalities were diffuse bone demineralization (9 patients), cortical thinning (5 patients), vertebral compression (3 patients), and fracture (2 patients). The bone densitometry showed a mean Z score of 3.49±1.4 in the lumbar spine. The average serum calcium level was 2.38±1.15, alkaline phosphatases were elevated in all cases with an average of 756±624.9. The vitamin D level was deficient in all cases with an average of 22.75±5.3. All patients received in addition to the vitamin-calcium supplementation, pamidronate intravenously at a dose of 9mg/kg/year with a mean number of 6 cures. The main side effects observed during the infusion were abdominal pain, polyarthralgia and asthenia (1 patient), chest pain (1 patient) and fever and chills (1 patient). The control bone densitometry showed a mean Z score of 1.81±1.2 in the lumbar spine.

Conclusion:

Despite advances in the OI diagnosis and treatment, more research is needed. Bisphosphonate treatment decreases long-bone fracture rates, but such fractures are still frequent. New antiresorptive and anabolic agents are being investigated but efficacy and safety of these drugs, especially in children, need to be better established before they can be used in clinical practice.

References:

[1]https://doi.org/10.1097/med.0000000000000367

Disclosure of Interests:

None declared

AB0718 ASSESSMENT OF SEXUAL DYSFUNCTION IN WOMEN AND MEN WITH FIBROMYALGIA SYNDROME

Background:

Fibromyalgia syndrome is a chronic musculoskeletal disease, which compromises physical, mental, and sexual health. Although concerns related to sexuality are commonly reported, the literature on sexual functioning in patient with fibromyalgia is limited to female patients.

Objectives:

The aim of our study is to identify sexual dysfunction in women and men with fibromyalgia syndrome compared with patients with rheumatoid arthritis.

Methods:

This is a cross-sectional comparative study: ‘34 patients with fibromyalgia syndrome compared to 100 patients with rheumatoid arthritis’ conducted in the rheumatology department of CHU Fattouma Bourguiba de Monastir over a period from February to November 2017. We used the Female Sexual Function Index (FSFI) and the Sexual Health Inventory for Men (SHIM).

Results:

Our sample comprised 34 patients with fibromyalgia (31 females and 3 males) and 100 patients with rheumatoid arthritis (58 females and 15 males).Sexual dysfunction was present in 100% of female patients with fibromyalgia syndrome compared to 60% of female patients with rheumatoid arthritis. Female patients with fibromyalgia syndrome had a decreased FSFI score: 10,3±8,74 versus 16,86±8,87 in the rheumatoid arthitis group with p=0.001. While among the male patients, we found no significant difference between the two groups.

Conclusion:

Fibromyalgia syndrome had negative side effect on the sexual life of female patients. Recognition of this dysfunction and its inclusion in the multidisciplinary management of fibromyalgia must be part of the treatment.

References:

[1]P. Romero-Alcalá et al., « Sexuality in male partners of womenwithfibromyalgiasyndrome: A qualitative study », PLoS One, vol. 14, no 11, nov. 2019, doi: 10.1371/journal.pone.0224990.

[2]M. D. H. Besiroglu et M. D. M. Dursun, « The association betweenfibromyalgia and femalesexualdysfunction:asystematicreview and meta-analysis of observationalstudies », Int J ImpotRes, vol. 31, no 4, p. 288-297, juill. 2019, doi: 10.1038/s41443-018-0098-3.

[3]T. M. Matarín Jiménez, C. Fernández-Sola, J. M. Hernández-Padilla, M. Correa Casado, L. H. Antequera Raynal, et J. Granero-Molina, « Perceptions about the sexuality of womenwithfibromyalgiasyndrome:aphenomenologicalstudy », J Adv Nurs, vol. 73, no 7, p. 1646-1656, juill. 2017, doi: 10.1111/jan.13262.

[4]L. Bazzichiet al., « Fibromyalgia and sexualproblems », Reumatismo, vol. 64, no 4, p. 261-267, sept. 2012, doi: 10.4081/reumatismo.2012.261.

Disclosure of Interests:

None declared

AB0775 MANY RARE AND SERIOUS LOCALIZATIONS IN ONE CASE WITH HEREDITARY EXOSTOSES

Background:

Multiple hereditary exostoses (MHE) is an inherited disorder of bone growth. People who have MHE grow exostoses or boney bumps on their bones that vary in size, location and number. Some localizations are rare but potentially serious such as ribs, spine or pelvis due to proximity to important structures.

Objectives:

The aim of this case report was to illustrate the clinical and radiographic features of some rare localizations of MHE.

Methods:

We are reporting a rare case of a thirty one-year-old male with severe localizations of MHE.

Results:

A thirty one-year-old male affected by hereditary multiple exostoses., not followed up, came to our consultation complaining about chest pain. On examination, he walks with a limp because of the unequalness of his limbs.The osteoarticular examination revealed numerous palpable osseous masses at the distal and proximal end of the 2 arms, 2 forearms, 2 thighs and 2 legs and at the right iliac wing. Neurological examination revealed vivid deep tendon reflexes, bilateral positive Hoffmann’sign and Babinski reflex associated with right hemiparesis. The pulmonary exam was normal. Medullary MRI showed medullary compression with spinal cord atrophy and sign of myelopathy of c1 c2 segment. The ct –scan revealed multiple exostosis, the two largest lesions were located in the second rib measuring 45mm * 35mm axially and 52mm in height compromising blood vessels, and in the right iliac bone with a retroperitoneal growing mass measuring 126 * 94 mm axially and 100 mm in height leading to a serious entrapment of the axial skeleton and the abdominal organs. It also confirmed thickening of the cartilage cap of the right iliac bone suggestive of malignant chondrosarcomatous transformation.

Conclusion:

Exostoses are the most common benign bone tumors. Its complications are rare but can cause a functional disability or even a vital risk.

References:

[1]Eke GK, Omunakwe HE, Echem RC. Hereditary multiple exostoses in a 15-year-old boy: A case report and review of literature. Niger J Paediatr. 2016;43(4):295.

Disclosure of Interests:

None declared

AB0865 EPIDURITIS IN INFECTIOUS SPONDYLODISCITIS

Background:

The main problem with infectious spondylodiscitis (ISD) is the diagnosis difficulty. Tuberculosis, with deceptive clinical semiology, remains to date the most common cause in underdeveloped and developing countries.

Objectives:

To report the frequency and characteristics of epiduritis in ISD and to specify its short and medium-term impact through a series of 70 cases.

Methods:

A descriptive retrospective study was conducted including patients with ISD, hospitalized in the rheumatology department at Fattouma bourguiba Hospital,Monastir TUNISIA between January 2009 and August 2019. Socio-demographic, clinico_biological and radiological data were collected.

Results:

34 male and 36 female were included. The average age was 53.91 ±15.3 years. The mean time to visit was 80.3±89 days [4,520]. Co-morbidity was noted in 66.7% of patients: diabetes (22), hypertension (18), hemodialysis (8), heart disease (4), and long term corticosteroid therapy (4). Tuberculosis contagion was present in 7.2% of patients. The most frequent reason for consultation was low back pain (63.8%) with a root syndrome in most patients (>50%). Neurological abnormalities were noted in 8.7% of patients. Skin swelling was noted in 4.3% of patients. Biological inflammatory syndrome and hyperleukocytosis were the moost biological abnormalities reported respectively in 81.2% and 30.4% of patients,. Among 70 ISD: 29 were with common germ, 18 with tuberculosis, 8 with brucellosis, and 14 with an undetermined germ. 91.3% of patients underwent a spinal magnetic resonance imaging (MRI): epiduritis was documented in 72% of cases, frequently anterior (53%). The epidural abscesses association was noted in 33 patients. It was pronounced mostly at the lumbar (19) and dorsal (14) levels. Epiduritis was frequently associated with para-vertebral soft tissues infiltration: pre-vertebral thickening (32), pre-vertebral collection (17), psoas muscle abscesses, (13). Spinal cord compression was noted in 2 patients. On 3-month visit, the ISD associated with epiduritis evolution was characterized by persistence of pain, hence radiological control was justified in 6 patients. A persistent biological inflammatory syndrome was noted in 27% of cases. Furthermore, 2 deaths were observed in this group of patients.

Conclusion:

Epiduritis rate in ISD requires a well-codified diagnostic and therapeutic strategy that will consider carfelly the neurological prognosis involved.

References:

doi: 10.1155/2019/7413089.

doi: 10.1515/folmed-2016-0035.

Acknowledgments:

Rheumatology Department

Disclosure of Interests:

None declared

AB0943 INFECTIOUS SPONDYLODISCITIS OF THE ELDERLY: CHARACTERISTICS AND OUTCOMES

Background:

Spondylodiscitis still frequent. It affects both old and young patients. It makes diagnostic and therapeutic difficulties.

Objectives:

to identify the characteristics and outcomes of infectious spondylodiscitis (ISD) in patients over 65 years old.

Methods:

A monocentric retrospective study including patients hospitalized for ISD in the rheumatology department of university hospital of Monastir,TUNISIA between January 2009 and August 2019.

Results:

Among 70 patients with ISD, 21 (11 male, 10 female) or 30% are over 65 years old. The average age was 70.6 years (65-82 years). History of diabetes (n = 9), hypertension (n = 9), hemodialysis (n = 5), heart disease (n = 5) were the most risk factors reported, while in younger patients, spinal surgery, epidural infiltrations and long-term general corticosteroid therapy were the main risk factors. The mean time for consultation was 142.3± 73 days longer than for younger patients. Fever was present in 0,14% of cases. Assessment time found that already 5 patients had paraplegia or spinal cord compression. 19/21 patients had epiduritis on spinal cord MRI. Soft tissue abscesses were present in close rate in both younger and old patients. Biological assessment showed an inflammatory syndrome and hyperleukocytosis in 92% and 38% of patients respectively (compared to 73% and 27% in younger patients). Germs ware identified in 14 patients (47.3%). Common germs were the most involved (12 patients), while in younger patients, specific- germs were the most reported. Follow up has shown that neurological sequelae are more prevalent in elderly.

Conclusion:

ISD in patients over 65 years old require a careful attension in therapeutic management given that age according to this study seems to influence the prognosis. In fact, these patients are more susceptible to disability due to neurological complications.

References:

doi: 10.1016/j.medcli.2017.07.027.

doi: 10.1016/j.jinf.2008.02.005.

Acknowledgments:

Rheumatology department

Disclosure of Interests:

None declared

[Systemic lupus erythematosus induced by isoniazid: a rare complication to fear]

Le lupus induit est défini comme un syndrome lupique généralement cutanéo-articulaire secondaire à une exposition continue à un traitement et qui disparaît après arrêt de celle-ci. Nous rapportons deux cas de lupus induit par l'isoniazide. Il s'agissait de deux femmes âgées respectivement de 30 et 35 ans. Elles présentaient un lupus induit par l'isoniazide après un et deux mois de traitement d'une tuberculose ganglionnaire. La maladie s'est manifestée par des signes articulaires, une éruption cutanée, une leucopénie et une anémie. Les anticorps antinucléaires et les anticorps antihistone étaient présents dans le sérum des deux malades. L’évolution était favorable après arrêt de l'isoniazide et une corticothérapie per os. Les médicaments antituberculeux notamment l'isoniazide sont responsables d'effets indésirables fréquents. Le lupus induit doit être évoqué lorsqu'un patient présente un tableau clinico-biologique évocateur.

[Contribution of dynamic radiographs in atlantoaxial subluxation in rheumatoid arthritis]

BACKGROUND

Cervical spine (CS) involvement is common during rheumatoid arthritis (RA) and it is distinguished by its potential gravity.

AIM

To determinate the occurrence of atlantoaxial subluxation (AAS) by dynamic incidences X-Ray and to assess its predictive factors.

METHODS

Our study included a cohort of 40 patients carrying RA, who fulfilled the American College of Rheumatology criteria, for more than 2 years. All patients had a complete physical and laboratory evaluation. Radiological evaluation included CS radiographs in anteroposterior, lateral, and lateral in full flexion and extension views.

RESULTS

The occurrence of CS involvement was about 47.5% by XRay dominated by AAS which found in 42,5% of the cases. Among AAS, anterior AAS was the most frequent with a prevalence of 22,5% followed by lateral AAS in 12,5% then vertical and rotatory AAS in 10% of cases each one and posterior AAS in 2,5% of the cases. Comparison between patients with and without CS involvement indicated the presence of two predictive factors: the sharp modified score and the C - reactive protein (p=0.002 and p=0.004 respectively).

CONCLUSION

Our study demonstrated that AAS is frequent in RA particularly in active forms with structural lesions. AAS can be asymptomatic, for this reason systematic diagnosis by X-Ray with dynamic views is important.

[The role of biochemical markers of bone turnover in the diagnosis of osteoporosis and predicting fracture risk]

BACKGROUND

Currently, for the diagnosis of osteoporosis, we search risk factors and measure bone mineral density (BMD) by DXA method. However, bone turnover markers, unused still in practice, have shown an interest especially in the prediction of fracture risk. aim: To determine the relationship between bone markers, BMD and osteoporotic fracture. methods: Prospective study of 65 women referred for measure of BMD during the period between May and August 2010. Each patient had a dosage of serum bone formation markers: osteocalcin (OC) and N-terminal propeptide of type I collagen (P1NP) and bone resorption markers: serum and urinary C-terminal telopeptide of type I collagen (β-CTX or CrossLaps) as well as parathyroid hormone and calcium. Risk factors of osteoporosis were identified in each case. results: Our 65 women had a mean age of 58.6 ± 12.1 years. The majority (83%) were menopausal women. Osteoporosis was found in 52%, osteopenia 26% and normal BMD 22% of cases. An increase in bone turnover markers was correlated with menopause (p = 0. 001 for the OC, p = 0.016 for urinary CTX), a low body mass index (p = 0.015 for OC, p = 0.042 for serum CTX) and osteoporosis (p <0.001 for P1NP, p <0.001 for serum and urinary CTX). Corticosteroid therapy was correlated with a decrease in bone formation markers (p = 0.002 for P1NP). The presence of fracture was only associated with increased urinary CTX (p = 0.05).

CONCLUSION

Bone turnover markers increase in menopausal women and in case of low BMD. However, their contribution in the diagnosis of osteoporosis is low. They are rather an interest in the prediction of fracture risk.

[Prevalence of bone loss in adult celiac disease and associated factors: a control case study]

BACKGROUND

Bone loss in celiac disease (CD) is important and is associated to increased risk of fractures. The determining factors of this Bone loss and the osteoporosis fracture during this disease remain still unknown. The bone remodeling parameters seem to play it an important role.

AIM

Through a transverse study including 30 patients with adult CD and 30 witnesses, we estimated bone mineral density (BMD) profile of these patients and determined associated factors to the bone loss.

METHODS

Patients and witnesses benefited from an BMD measure, serum calcium and phosphore, alkaline phosphatasis, parathormone and hydroxyvitamin D dosage, bone remodeling parameters containing the osteocalcin, Propeptide N-terminal of the type I procollagen, BTélopeptide C-terminal ( B-CTX) of the type I procollagen I (bloody and urine CrossLaps). The patients benefited from a malabsorption bilan, a radiological examination of spine and an evaluation of the adhesion to the regime without gluten with a histological control.

RESULTS

Our population consists of 3 men (10 %) and 27 women (90 %) with an average age of 30.4 years (19-50 years). The average delay of the diagnosis of the MC is of 46.7 months. The alkaline phosphatases, the P1NP and the bloody crossLaps were more raised at the patient's with regard to the witnesses with respectively p=0.038, p=0.041 and p=0.021. The parathormone was also more raised at the patients but without significant difference 67.8 vs 53.8 ng / l. The DMO is low at 21 patients (70 %) versus 2 witnesses only (6.6 %), with an osteoporosis in 3 patients (10 %) and an osteopenia in 18 patients (60 %). Factors associated to the BMD decline are low body mass index, nulliparity, diagnostic delay > to 2 years, the malabsorption syndrome, exaggerated intraepithelial lymphocytosis at the time of the histological control, an increase of bone remodeling parameters notably the alkaline phosphatasis, osteocalcin and bloody CrossLaps. While the BMD is more raised at the patient's having followed gluten regimens during more than 5 years. The age, the sex, the symptomatic character or not of the disease, the parathormone, hydroyviamin D and fractures are not correlated to the BMD profile patients.

CONCLUSION

The bone loss is more frequent during the adult CD than in the general population. His research has to become integrated into the coverage of this disease notably in the presence of risk factors. The absence of correlation between BMD loss and fractures underlines the importance of others factors in determining of bone fragility during this affection.

[Quality of life in ankylosing spondylitis]

BACKGROUND

Ankylosing Spondylarthritis (AS) involves by its frequency and its repercussion on the functional capacity an important handicap and deterioration of the patients quality of life.

AIMS

To evaluate the handicap and the quality of life during the AS and to seek the predictive factors of the deterioration of this quality of life.

METHODS

A prospective study relating to 50 patients recruited in the Department of Rheumatology of F. B. Hospital of Monastir during 6 months period (Mars to September 2008). The studied parameters were the quality of life evaluated by a specific sore (ASQOL) and a generic score (SF-12). Also the physical, social and economic felt handicap was evaluated using a qualitative scale. Predictive factors (clinical, biological and radiological) of the quality of life were carried out.

RESULTS

Our patients are divided in 42 men and 8 women with an average age of 38.9 ± 10.7 years. The average duration of AS is of 11.9 ± 7.6 years. The average of ASQOL is of 11.9 ± 4 (extremes: 0- 17). The average of physical SF12 is of 29.8 ± 6 (21.7-53.2) and of mental SF-12 of 35.3 ± 6.6 (22.5-55.8). The physical, social and economic felt handicap was considered to be average or important in respectively 88%, 72% and 86% of the cases. The predictive factors of a high ASQOL (faded quality of life) are absence of occupation, high BASMI, a high number of painful articulations and high BASFI, BASDAI, BASG, BASRI and EVA total pain. The factors associated to the alteration of the quality of life according to SF-12'S are male sex, professional statute, high number of painful articulations and high BASDAI, BASFI and BASRI.

CONCLUSION

Our study shows the important deterioration of the quality of life in AS patients. The existence of the predictive factors of quality of life primarily related to the functional capacity of the patients and to the disease activity implicates an early and adequate disease management in order to decrease this repercussion.

[Ochronosis: report of two familial cases]

BACKGROUND

Ochronosis of alkaptonuria is a rare hereditary autosomal recessive disease in which there is an absence of homogentisic acid oxidase resulting in accumulation of homogentisic acid in tissues.

AIM

To report a new case of alkaptonuria

CASE REPORT

A 49-year-old man had been followed for 4 years for chronic lombalgia and arthropaty of two knees. He is married to his cousin and father of 4 girls. His parents are also cousins. The clinical examination has found a cutaneuous pigmentation and a lumbar stiffness. At biological checking, creatininemia was at 190 μmol/L and there are not inflammatory indicators. The radiography have shown a discal dorsolumbar calcifications, anterior inter somatic bridges and bilateral arthritis of knees without articular chondrocalcinosis. The diagnosis of ochronosis have been suspected and confirmed by the blackness of urine and the dosage of alkaptonuria. The patient has been treated symptomatiquely. Familial investigation have revealed that his daughter suffered from the same disease with the notion of blackness of urine. She is 12 year old and she's asymptomatic on the osteoarticular level.

CONCLUSION

Alkaptonuria causes a degenerative arthropaty which can endanger functional prognosis. Early diagnosis and scanning of this innate error of metabolism by genetic study play a fundamental interest, especially for molecular and genetic advisement.

[The fracture risk assessment tool (FRAXTM), where are we in Tunisia?]

BACKGROUND

The fracture risk assessment tool (FRAXTM), published in February 2008, is developed based on the use of clinical risk factors with or without bone mineral density tests.

AIM

To calculate the FRAX tool in a cohort of Tunisian patients in whom bone mineral density (BMD) was assessed by dual X ray absorptiometry (DXA); to correlate this score to osteoporotic fracture and to BMD assessment and to propose a threshold for therapeutic intervention.

METHODS

In a cross sectional study of 582 patients older than 40 years, in whom a BMD measurement by DXA has been performed between January 2006 and December 2009, clinical risk factor for osteoporotic fracture and the occurrence of a prior fragility fracture were assessed. The French version of the FRAX tool was used. Threshold for pharmacological intervention was evaluated by ROC curve.

RESULTS

Patients were aged 62.3 ± 10.4 years. They were female in 91.2% of cases. BMD measurement was under 2.5 standard deviation in 53.2%. Osteopenia was noted in 29.2% of cases and BMD was normal in 17.4 % of cases. Osteoporotic fractures were observed in 38.2% of cases. Major osteoporotic fractures (FOM) (hip, vertebra, radius occurred in 82% of cases. The FRAX® score calculated with T-score was 8.55 ± 8.54% for the FOM and 3.02 ± 6.37% for femoral neck (FN), while it was 7.81 ± 6.45% for the FOM and 2.58 ± 3.97% for the FN if calculated without T-score with a significant difference (p <10-3). For the patients having T-score under 2.5 SD, FRAX score was 11.39 ± 10.32% for the FOM and 4.74 ± 8.13% for the FN if calculated with T-score and it was 9.18 ± 6.95 % for the FOM and 3.19 ± 4.11 % if calculated without T-score. The score FRAX was correlated to BMD (r=0,53, p <10-3) and to fracture prevalence (p < 10-3). The threshold of therapeutic intervention was fixed to 30% for the FOM and 7% for the FN.

CONCLUSION

Our study confirms the usefulness of the FRAX score in the prediction of fracture risk in Tunisian population. The determination of therapeutic threshold intervention requires other prospective and larger studies with medico-economic analyses.

[Adult-onset of Still's disease with atypical articular and skin manifestations]

BACKGROUND

Adult-onset Still's disease (ASD) is an uncommon clinical entity. It is a diagnosis of exclusion, characterized by a clinical triad of intermittent fever spikes, evanescent rash, and either arthralgia or arthritis. Destructive arthritis more commonly affects the hips, wrists, tarsal joints and cervical spine.

AIM

To report an unusual case of ASD with severe distal interphalangeal destructive arthritis and finger skin vesiculopustules.

OBSERVATION

A 19 years old girl was followed for 2 year-history of ASD with polycyclic articular involvement. She noted, since 2 months, rapid appearance of painful tumefaction in the distal interphalangeal joints (DIP) with maculopustular eruption distributed exclusively on the hands, in front, only of DIP and few proximal interphalangeal joints (PIP). Further more, she complained of polyarticular active disease. Hands and wrists X-ray showed narrowed distal-interphalangeal joint space of only DIP joints. RMN imaging revealed in addition carpal, metacarpal and PIP articular inflammatory damage. The infectious investigation remained negative. A surgical skin and DIP biopsy specimens showed disseminated micro-abscesses with polynuclear leukocyte dermal infiltration. There was no signs of osteitis. Bacterial and fungal cultures from the pus failed to reveal any causative organisms. Skin lesions gradually disappeared in response to conventional ASD therapy after intensification. Hence, the diagnosis of distal destructive arthritis of ASD associated with atypical neutrophilic dermatosis (Sweet's syndrome) was made.

CONCLUSION

ASD is rare, heterogeneous, with unpredictable evolution. The distal destructive arthritis represents a possible complication. The presence of pustules as atypical cutaneous features of Sweet's syndrome may be seen in severe forms of ASD and clinicians must be alert to the possibility of a misdiagnosis in these cases.

[Sciatica due to unusual causes: Tarlov cysts and nerve roots anomalies]

Tarlov cysts and nerve roots anomalies usually involve lumbosacral roots and are often asymptomatic. MRI has enabled recognition of many conditions that used to be missed by CT or myelography investigations performed for back and leg pain. However, even without additional compressive impingement (disc hernia, spondylolisthesis or lumbar canal stenosis) these anomalies can be responsible for sciatica, motor deficit and bladder sphincter dysfunction. Tarlov cysts are perinervous dilatations of the dorsal root ganglion. CT and especially MRI can reveal these cysts and their precise relations with the neighboring structures. Delayed filling of the cysts can be visualized on the myelogram. MRI is more sensitive than CT myelography for a positive diagnosis of nerve root anomalies, a differential diagnosis with disc hernia and classification of these anomalies. Surgical treatment is indicated for symptomatic Tarlov cysts and nerve root anomalies resistant to conservative treatment. Better outcome is observed in patients with an additional compressive impingement component. We report two cases of sciatica: one caused by Tarlov cysts diagnosed by MRI and the other by nerve root anomalies diagnosed by CT myelography. In both cases, conservative treatment was undertaken. The clinical, radiological and therapeutic aspects of these disorders are discussed.

WITHDRAWN: Validation of the Tunisian version of the rheumatoid arthritis quality of life (RAQoL) questionnaire

Ahead of Print article withdrawn by publisher

[Inpatients satisfaction in a rheumatology department]

MATERIAL AND METHODS

This prospectivve study aiming to evaluate patients satisfaction included 102 patients (42 men and 60 women with a mean age of 49.7 years) admitted in the department of rhumatology of Monastir University hospital, and was based on a validated questionaire.

RESULTS

Global satisfaction was 80%. Satisfation as regards administrative proceedings (e.g. admission procedure) reached 84%. As for the degrees of satisfaction concerning care, the environment (accomodation meals, noise) and reception, they were as follows : 79%, 81% and 91% respectively. The prioritis whide were considred as important but partly achieved by health care priveders included in formation of the patient's family (47%), of the family physician (23%), and of the patient (22%).

CONCLUSION

Inpatients global satisfaction in a rheumatology department was 80 %. Priorities to improve patient quality of care were family, general practionner and patient information.

Reproducibility of a low back pain questionnaire in Tunisian adolescents

The objective of this study was to evaluate the reproducibility of a 28-item survey questionnaire for back problems in Tunisian adolescents. A test-retest design was used to investigate the reproducibility of the results obtained using the said 28-item survey questionnaire. Participants were recruited from two schools in Monastir. Seventy-two adolescents from the seventh, eighth, and the ninth grade participated in the inquiry. They have a mean age of 14.01 years (SD 1.67, range 11-19). High levels of reproducibility were found for items that evaluated perceived characteristics of back problems and functional limitation (kappa coefficient=0.71-1.00). The results suggest that the questionnaire used in the present study provided reproducible information and can be used as a survey tool for the investigation of low back problems in adolescents.

[Validation of the Tunisian version of the Health Assessment Questionnaire (HAQ) in rheumatoid arthritis patients]

METHODS

One hundred twenty two rheumatoid arthritis patients were consecutively included in the study. Test-retest reliability was assessed in 61 patients based on the intra-class correlation coefficient.

RESULTS

for the 122 patients (104 female and 18 male) the median age was 47 years (18-70). The mean age of the patients who filled in the questionnaire at test and retest times was 45 years (18-70). Test- retest reliability of the HAQ was 0.84. Internal consistency was 0.94. There was a good correlation between the HAQ and the Lee index (r = 0.75, p <10(-4)), the HAQ and the RAQoL (rs = 0.96, p <10(-4)). In a logistic regression model Lee index, RAQoL and age account for the variance of the HAQ.

CONCLUSION

The Tunisian version of the HAQ preserves the metrological properties of the original version and can be used for measuring and following functional abilities of Tunisian rheumatoid arthritis patients.

[Search for crystals in synovial fluid]

Synovial fluid analysis is a very important diagnostic procedure in rheumatology. Cell count allows the differentiation ting between inflammatory arthritis, in which cell count exceeds 2000 cells/mm3, and non inflammatory arthropathy, in which cell count is less than 1000 cells/mm3. Demonstration of crystals in synovial fluid is a rapid and inexpensive way to diagnose microcrystalline arthritis. Synovial fluid must be examined under normal and polarized light. Monosodium urate crystals are negatively birefringent, whereas calcium pyrophosphate dihydrate crystals are positively birefringent. Other crystals (cholesterol, oxalate, corticosteroids....) can also be identified in synovial fluid. Various artefacts must be avoided including anticoagulant crystals and synovial fluid must be anticoagulated with sodium heparin or citrate.

Lipoma arborescens affecting multiple joints

Lipoma arborescens is a rare benign intra-articular lesion of unknown etiology that usually involves the suprapatellar pouch of the knee joint. Clinically, the most common finding is a slow-growing painless swelling, accompanied by intermittent effusion of the joint. We report a case of a multifocal lipoma arborescens localized in the knees and the hips in a 24-year-old man, initially mimicking an inflammatory arthropathy. The diagnosis of lipoma arborescens was made by magnetic resonance imaging of the hips and the knees. Under arthroscopic guidance, the synovial biopsy of the right knee disclosed the specific histological signs of lipoma arborescens. As far as we know, this is the third case of multifocal lipoma arborescens reported in the English literature.

[Pelvic morphology and lumbar spondylolisthesis]

Pelvic morphology is involved in the genesis of spondylolisthesis. The mean age of patients with spondylolisthesis was 57.9 +/- 9.5 years (40-81). 14 were complaining of low back pain and 12 had sciatica. Spondylolisthesis was in stage 1 in 75% of the cases and in stage 2 in 25% of the cases. Low lordosis was observed in patients and controls in 73% and 100% of the cases respectively. Sacral slops was slightly higher in patients than in controls and was higher than 40 degrees in patients and controls at a rate of 35% and 25% respectively. The incidence was higher in patients than in controls. There was a high pelvic retroversion in patients than in controls. High incidence and pelvic retroversion were found in patients with spondylolisthesis and pelvic morphology was probably involved in the genesis of spondylolisthesis.

Reliability of the rheumatoid arthritis articular damage score in Tunisian patients

The clinical rheumatoid arthritis articular damage (RAAD) score is easy to perform and showed good intraobserver reliability. It correlates well with the Larsen score and disease duration and can be recommended for rheumatoid arthritis patients' follow-up in developing countries.

Measuring utilities by the time trade-off method in Tunisian rheumatoid arthritis patients

The objective of this study was to determine the feasibility, reliability and validity of the time trade-off (TTO) in Tunisian rheumatoid arthritis (RA) patients. The TTO was used to measure the utility in 122 RA patients with increasing difficulty in performing activities of daily living. The 1-week test-retest reproducibility was studied in 57 patients using the intraclass correlation coefficient (ICC). Validity was evaluated by comparison with other outcome measures: utility rating scale (RS), quality of life (QOL) [arthritis impact measurement scale 2 (AIMS2), rheumatoid arthritis quality of life (RAQOL)], functional status [health assessment questionnaire (HAQ), Lee index] and disease activity score (DAS). Eight patients (6.6%) did not complete the TTO. The median value of the TTO score was 0.655 (0.019-1.000). The ICC for reliability of the TTO was 0.89 (p<0.001). The TTO showed poor to moderate correlation (Spearman's correlation coefficients between 0.2 and 0.409, p<0.01) with AIMS2, RAQOL, HAQ and Lee index. We did not find any correlation between TTO and DAS. Multiple regression analysis showed that only 32% of TTO scores could be explained. The TTO method appeared to be reliable in a group of Tunisian RA patients, but TTO values were poorly to moderately related to measures of QOL, functional ability, and disease activity. We think that TTO and RS are not feasible for use in RA patients.

Correlations between high-resolution computed tomography of the chest and clinical function in patients with rheumatoid arthritis. Prospective study in 75 patients

INTRODUCTION

The contribution of computed tomography (CT) to the assessment of rheumatoid lung disease is universally recognized. Our objective was to define the usefulness of high-resolution CT (HRCT) in evaluating lung abnormalities in unselected patients with rheumatoid arthritis (RA) and to determine whether HRCT findings were correlated with clinical and lung function test (LFT) abnormalities.

PATIENTS AND METHODS

We prospectively investigated HRCT findings in 75 consecutive RA patients and looked for correlations with clinical, radiological, blood gas, and LFT variables. The 63 women and 12 men had a mean age of 48+/-14 years and a mean disease duration of 8+/-88 months (2 months-27 years). Most of the patients (77.3%) had no known history of respiratory disease.

RESULTS

Respiratory symptoms were noted in one third of patients. HRCT findings were abnormal in 49.3% of patients, showing interstitial disease in 28% and bronchiectasis in 18.7%. Advanced fibrosis was not noted. One patient had bronchiolitis obliterans with organizing pneumonia and another had constrictive bronchiolitis. Smaller proportions of patients had emphysema (13.3%), alveolar involvement (12%), pleural involvement (9.3%), or rheumatoid nodules (4%). HRCT findings were abnormal in 48.6% of the patients with no respiratory symptoms. Factors significantly associated with HRCT abnormalities were age older than 40 years, positive tests for IgM rheumatoid factors, hypoxia at rest, and LFT evidence of distal airway disease. Neither Sjogren's syndrome nor RA duration was significantly associated with the risk of HRCT abnormalities.

CONCLUSION

In our population of unselected RA patients, HRCT proved sensitive in detecting abnormalities that were clinically silent and missed by plain radiography. Correlations between HRCT abnormalities and results of other investigations were inconsistent. Thus, these various investigations may complement one another.