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.

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

AB1079 INFECTIOUS SACROILIITIS ACCORDING TO THE GERM: ABOUT 42 CASES

Background

Infectious sacroiliitis is a rare rheumatological emergency. Its semiology is misleading due to the deep location of the joint. The responsible germs play an important role in its semiology.

Objectives

The objective of this work was to identify the germs responsible for infectious sacroiliitis and their effect in the sacroiliac joint.

Methods

We conducted a retrospective study, including 42 patients hospitalized for infectious sacroiliitis over a period from 2000 to 2020. Demographic, clinical, biological and radiographic data were collected.

Results

A total of 42 Patients were enrolled (11 men and 31 women). The mean age was 36,7 years [29-76]. Low back pain with difficulty walking were the most common manifestations (88%). The inflammatory syndrome was present in 70% of cases.

Standard radiographs showed loss of cortical margins with erosion of the sacroiliac joints in 34 cases and were normal for the rest of the patients.

MRI and CT scan were performed to confirm the diagnosis in 28 and 13 cases respectively.

A puncture guided by ultrasound or scanner was performed in 24 patients. In the cases of absence of germ on the conventional examinations, we performed a sacroiliac biopsy and histological examinations.

Pyogenic germs were responsible for 46% of infectious sacroiliitis: Staphylococcus Aureus in 11 cases (28%), Escherichia Coli in 7 cases (16 %) and Streptococcus in one case (2%). Tuberculosis and Brucella were responsible for 38% and 7% of the cases respectively. A subcutaneous abscess was associated with tuberculous sacroiliitis in 4 patients.

The outcome was favorable in 36 cases (86%) under appropriate antibiotic therapy. Eight patients presented a treatment-related complication. Progression to multifocal bone tuberculosis and chronic brucellosis was noted in one case each. In 3 cases, rapid ankylosis was found on radiological control.

Unfortunately, one patient died from septic shock.

Conclusion

Common germs are most responsible for infectious sacroiliitis and seem to have the best prognosis. Tuberculosis is responsible for various complications and its treatment has a high iatrogenic risk. Chronicity is the most feared development, mainly during Brucella sacroiliitis and would be related to a loss of antibiotic efficacy.

Disclosure of Interests

None declared

AB1364 IMAGING DIAGNOSIS OF BRUCELLAR SPONDYLODISCITIS

Background

Spondylodiscitis is the most common location in the musculoskeletal involvement of brucellosis.

Objectives

The aim of this study is to describe magnetic resonance imaging (MRI) and computed tomography scan (CT) results in patients with brucellar spondylodiscitis.

Methods

A retrospective study over a period of 15 years, including 18 patients diagnosed with brucellar spondylodiscitis and having benefited from a CT scan and/or an MRI of the spine.

Results

Eighteen patients were included. In all cases spinal pain was reported, associated with radiculalgia in 8 patients. Low back pain was the most common symptom, present in 17 cases, associated with back pain in 3 cases including one case with neck pain. Isolated neck pain was noted in one patient.

Neurologic examination was normal in all cases.

Standard Radiographs showed disc narrowing in 14 cases, erosions in 9 cases and hazy changes of the vertebral end plate in 2 cases.

A CT scan was performed in 11 cases. It showed disc narrowing in 6 cases, erosions in 3 cases and endplate destructions in 5 cases. Abscesses were found in 4 patients.

Complementary MRI was performed in three of the patients who had already undergone CT. The MRI results were consistent with those of the CT scan, except for one patient in whom it revealed spondylodiscitis while the CT scan revealed degenerative lesions.

Eleven patients underwent MRI in total. It showed unifocal and multifocal spondylodiscitis in 5 and 6 cases respectively, epiduritis in 6 cases, spinal cord compression in 2 cases and abscesses in 4 cases.

Conclusion

Our study showed that CT and spinal MRI allow early diagnosis of spondylodiscitis. They help to identify asymptomatic lesions and neurological complications.

Disclosure of Interests

None declared

AB1224 NON-CONTIGUOUS MULTIFOCAL SPONDYLODISCITIS: A RETROSPECTIVE OBSERVATIONAL STUDY

Background

Non-contiguous multifocal spondylodiscitis (mSpD) is a serious infection. Although literature data highlight the opportunity to miss a non-contiguous spondylodiscitis (SpD), recommendations for which cases an MRI of the entire spine should be performed are missing.

Objectives

The aim of the study was to assess the clinical features of mSpD to reveal risk factors underlining the need for screening a multifocal spine involvement

Methods

We retrospectively evaluated the data of patients with confirmed non-contiguous multifocal spondylodiscitis

Results

Twelve patients suffered from mSpD were included (6 males, 6 females). The mean age was 60 years. Four patients had underlying chronic comorbidity, Diabetes (n=3), hepatitis C virus (n=1). Most patients had spine pain (11 patients,), radiculalgia in one patient, neurologic deficit (3 patients), worsening health status (7 patients). Symptoms onset was acute (n=1) or sub-acute (n=3) or long term (n=8) before admission. The mean duration between the diagnosis and the onset on symptoms was 9,6 months. Tubercular spondylodiscitis was the most detected etiology (n=8), confirmed by histological analysis (n=3) then brucellar, confirmed by serlology lab test, and pyogenic SpD in two patients each. Non-contiguous multi-level involvement in the lumbar, thoracic, and cervical spine was detected in one patient for each region. Seven patients suffered from a lumbar and thoracic spine involvement and SpD occurs in the three regions in two patients. Elevated inflammatory biomarkers (CRP and ESR) were present in all cases. Entire spine MRI was performed for almost all patients, confirmed the diagnosis, showed para-vertebral abscess (n=3), epidural inflammation (n=6), and spinal cord compression (n=3). The majority of cases showed a favorable evolution with appropriate antibiotic therapy. One patient maintain a neurologic deficit, and one suffered from a severe degree of pain. Surgical approach was not indicated.

Conclusion

In our study, mSpD did not appear to be associated with a particular pattern. Tuberculosis was the dominant etiology. That suggests, an MRI of the entire spinal column should be performed for each patient with suspicious SpD, especially when tuberculosis is evocated

Disclosure of Interests

None declared

AB0342 EVALUATION OF SELF-CARE SAFETY SKILLS AND THERAPEUTIC KNOWLEDGE OF RHEUMATOID ARTHRITIS PATIENTS ON BIOLOGIC DRUGS

Background

The management of rheumatoid arthritis (RA) was revolutionized by the use of biologic therapies (bDMARD). Nevertheless, bDMARDs may carry some specific risks such as infection. However, data about self-care safety skills are poor [1]. An assessment of the level of information and education is therefore essential for patients followed for RA.

Objectives

The purpose of our study was to assess knowledge and safety skills of RA patients under bDMARDs.

Methods

We conducted a descriptive, bi-centric, and cross-sectional study, including RA patients receiving intravenous (IV) or subcutaneous (SC) bDMARD for at least 3 months. Sociodemographic, clinical, and paraclinical data were collected. Knowledges and self-care safety skills were assessed by a pre-specified questionnaire.

The questionnaire was divided into three domains:

- Five questions about general theoretical knowledge domain: assessing patient’s knowledge of the name of the current bDMARD, duration and rate of intake, and a question on annual cost estimation.

- Three questions about the current bDMARD management: assessing cold chain compliance and management of the biologic in SC emphasizing adherence to the steps to be taken prior to giving the injection.

- Tow questions about knowledge regarding safety skills in special situations: infection, cough, contraception, surgery, vaccination, and regarding the need to inform others about the use of bDMARD.

Based on the data analysis, patients were divided into 3 groups according to their knowledge level:

- Group A (low knowledge level: percentage of correct answers <40%)

- Group B (moderate knowledge level: percentage of correct answers >40% and <60%)

- Group C (high level of knowledge: percentage of correct answers > 60%).

Results

Seventy-five patients with RA were collected. Their mean age was 56.92 ± 9.06 years [34-80]. The mean duration of bDMARD was 37.17 ± 39.44 months [4-248] with a mean rank of 1.41 ± 0.9 [1-5]. The SC route was used in 41 patients (54.7%) followed by the IV route in 34 patients (45.3%)

The most prescribed molecules were Infliximab, Certolizumab and Tocilizumab (22.7% respectively). The average order of the current biologics was 1.41 ± 0.9 [1-5] in combination with a csDMARD in 48 patients (64%).

Safety skills were low in 24 patients (32%), moderate in 36 patients (48%), and high in 15 patients (20%).

The mean percentage of correct answers for each domain was respectively: 56.53 ± 18.4% [20-100] for general theoretical knowledge domain, 68.44 ± 26.21% [0-100] for the management of current biologic treatment domain, and 40.8 ± 16.87% [6.67-80] for knowledge regarding safety skills in special situations.

Safety skills levels were significantly related to occupational status (p=0.001), DAS28 CRP (p=0.04), joint deformities (p=0.01) and radiographic erosions (p=0.006), number of previous bDMARDs (p=0.009), and the rank of the current bDMARD (p=0.009).

Conclusion

The major finding of our study was the insufficient level of knowledge and safety skills of RA patients under bDMARDs. We highlight the importance of involving patients in the decision-making process and emphasize the role of the therapeutic patient education programs.

References

[1]Orefice D, Beauvais C, Gossec L, Flipon E, Fautrel B, Marguerie L, et al. Cross-sectional study of self-care safety skills in 677 patients on biodrugs for inflammatory joint disease. Joint Bone Spine. 2014;81(6):502‑7

Disclosure of Interests

None declared

AB1217 CHRONIC LOW BACK PAIN AND MUSCULAR HYDATIDOSIS: THE TREE THAT HIDES THE FOREST

Background

Hydatid cyst disease is a zoonosis caused by Echinococcus granulosus. The parasite implants most commonly in the liver and lung. Musculoskeletal involvement is rare.

Objectives

To describe clinical and imaging presentation of spinal and muscular hydatidosis.

Methods

We report two cases of chronic low back pain caused by hydatid cyst.

Results

Case 1: A 36-year-old woman living in a rural area presented with a three-years history of lumbar back pain complicated with right-sided sciatica and intermittent episodes of urinary retention. The pain was gradually worsening and resisting conventional analgesics and physiotherapy. On physical examination, she had tenderness of the lumbar back and left sacroiliac joint with limited mobility. Biological findings were normal and X-ray features showed osteolytic lesions of L5 left side. The magnetic resonance imaging (MRI) results revealed septated multilocular hydatic cysts with high signal intensity in T2-weighted images and low signal intensity in T1-weighted images along L5 and the sacrum left side. Serological test for hydatid disease was positive. The treatment was wide surgical resection combined with Albendazole (400 mg/day) for one year postoperatively.

Case 2: A 62-year-old woman presented with a one-year history of lumbar back pain with gait instability and right flank swelling. Biological findings and X-ray features were normal. The patient first was explored by uro-CT to assess for nephrolithiasis and it revealed retro and sub-peritoneal two multilocular hydatic cysts (60x80mm, 36x35mm) along right iliopsoas and adductor muscles. MRI showed same cystes described on the CT (Figure 1). No other localizations were detected. The diagnosis of hydatidosis was confirmed perioperatively after visualization of the cyst. Wide resection was performed but signs of recurrence were detected by MRI at the 3-month follow-up.

Figure 1.

MRI showing two multilocular cysts along right iliopsoas (white arrow) and adductor muscles (black arrow).

Conclusion

In endemic areas, bone and muscle involvement from echinococcosis should be considered during clinical investigation of chronic lumbar pain.

Disclosure of Interests

None declared

AB0338 BELIEFS ABOUT BIOLOGIC DRUGS AMONG RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease requiring a long-term follow-up and the use of chronic therapies. The management of this disease is based on a multidisciplinary care, requiring total patient involvement. Previous personal experiences, the experiences of others and the daily impact of the disease on patients fuel their perceptions of the treatment especially biologic one. There are few studies evaluating patient’s beliefs about these drugs [1,2].

Objectives

The aim of our study was to investigate beliefs about biologic Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) among patients with RA and to identify factors related to specific beliefs.

Methods

We conducted a bi-centric cross-sectional study, including patients with RA fulfilling the ACR/EULAR 2010 criteria. All patients were on bDMARDs associated or no to conventional synthetic (sc) DMARDs. Sociodemographic, clinical, biologic, and therapeutic data were collected. Patients were interviewed about their medication beliefs using the Beliefs about Medicines Questionnaire (BMQ).

Results

There were 75 RA patients: 60 female (80%) and 15 males (20%). The sex ratio was about 0.25. The mean age was 56.92 ± 9.06 years [34-80]. Thirty-three percent of patients were illiterate. Twenty patients were employed. Sixty-four patients (85.3%) were married. The mean disease duration was 14.85 ± 8.5 years [2-39]. Thirty-three patients had joint deformities. Twenty-seven patients had extra-articular manifestations and thirty-six patients had comorbidities. The mean disease activity scale (DAS28 CRP) was 3.94 ± 1.32 [1.21-7.15]. Fifteen patients (20%) had high disease activity, 11% had low disease activity, and 19% were in remission. The mean functional impairment scale (HAQ) was 0.64 ± 0.48 [0-2.2]. Twelve patients had moderate to severe disability and only one patient had severe to very severe disability. The mean duration of the current bDMARD was 37.17 ± 39.44 months and the mean rank of the current biotherapy was 1.41 ± 0.9 [1-5].

Regarding the BMQ, the mean score for General Overuse was 14 ± 2.37 [6-20]. The mean score for General Harm was 10.82 ± 4.42 [4-20].

The mean score of patients’ specific beliefs regarding the necessity of taking the current bDMARD (Specific Necessity) was 20.62 ± 5.71 [5-25]. The mean Specific Concerns score regarding the current bDMARD was 10.33 ± 3.29 [5-25]. Necessity about taking bDMARD was reported by 77.3% patients in the present and 61.3 % patients consider maintaining the bDMARD in the future.

There were 4% of patients who reported concerns about taking bDMARD. Twenty four percent of patients reported concerns about long term effects, and 16% about becoming too dependent on bDMARD.

Beliefs about the necessity to stop occasionally chronic therapies were reported by 13.3% of patients.

Specific necessity was correlated to the current bDMARD duration (p=0.01), Patient Global Evaluation (p=0.03), VAS pain scale (p<10-3), the number of nocturnal awakenings (p=0.01), tender joint count (p<10-3), swollen joint count ((p<10-3), HAQ (p=0.005), DAS28 (CRP) (p<10-3). Specific concerns were correlated to the actual bDMARD rank (p=0.01).

Conclusion

Our study showed stronger beliefs in the necessity of taking biologic drugs if indicated. Disease activity parameters and functional impairment influence those beliefs. Further studies are required to evaluate the impact of beliefs on biologic drug adherence.

References

[1]Cea-Calvo L, Raya E, Marras C, Salman-Monte TC, Ortiz A, Salvador G, et al. The beliefs of rheumatoid arthritis patients in their subcutaneous biological drug: strengths and areas of concern. Rheumatol Int. 2018;38(9):1735‑40.

[2]Heuckelum M van, Linn AJ, Vandeberg L, Hebing RCF, Dijk L van, Vervloet M, et al. Implicit and explicit attitudes towards disease-modifying antirheumatic drugs as possible target for improving medication adherence. Plos One. 2019;14(8):e0221290.

Disclosure of Interests

None declared

AB0365 BELIEFS AND ADHERENCE IN RHEUMATOID ARTHRITIS PATIENTS ON BIOLOGIC DRUGS

Background

Patients with chronic rheumatic diseases play an important role in their disease management. Adherence to their long-term therapies may depend on their therapeutic beliefs [1].

Objectives

The purpose of our study was to investigate the relationship between beliefs and adherence among patients with rheumatoid arthritis (RA) on biologic therapies (bDMARDs).

Methods

We conducted a multi-centric cross-sectional study, including patients with RA fulfilling the ACR/EULAR 2010 criteria. All patients were on bDMARD. Sociodemographic, clinical, biologic, and therapeutic data were collected. Patients were interviewed about their medication beliefs using the Beliefs about Medicines Questionnaire (BMQ) and about their therapeutic adherence.

Results

There were 75 RA patients: 60 female (80%) and 15 males (20%). The sex ratio was about 0.25. Their mean age was 56.92±9.06 years [34-80]. Thirty-three percent of patients were illiterate. Twenty patients were employed (15%). The mean disease activity scale (DAS28 CRP) was 3.94±1.32 [1.21-7.15]. Fifteen patients (20%) had high disease activity, 11% had low activity, and 19% were in remission. The mean duration of the current bDMARD was 37.17±39.44 months [4-248]. The mean Specific Necessity score was 21.02±5.38 [5-25] for adherent patients and 13.5±7.54 [5-19] for non-adherent patients.

The mean Specific Concerns score was 10.07±3.13 [5-15] for adherent patients and 15±2.82 [5-20] for non-adherent patients.

A statistically significant association was found between Specific Concerns beliefs and adherence behavior (p=0.009) and between Specific Concerns beliefs and adherence behavior (p=0.003). No statistically significant association was noted between general beliefs (General Harm and General Overuse) and adherence behavior (p=0.4 and p=0.6 respectively).

Conclusion

Beliefs about therapeutic were identified as a key factor of adherence among rheumatic disease patients. Practitioners should detect negative patient beliefs and perceptions earlier to prevent nonadherence.

References

[1]Suh YS, Cheon YH, Kim HO, Kim RB, Park KS, Kim SH, Lee SG, Park EK, Hur J, Lee SI. Medication nonadherence in Korean patients with rheumatoid arthritis: the importance of belief about medication and illness perception. Korean J Intern Med. 2018 Jan;33(1):203-210.

Disclosure of Interests

None declared

AB1077 INFECTIOUS SPONDYLODISCITIS IN ELDERLY: IS IT MORE SEVERE DISEASE?

Background

Spondylodiscitis is a chameleon among infectious diseases due to the lack of specific symptoms. In older patients, there are often difficulties in diagnosis and management.

Objectives

This retrospective study aimed to assess the characteristics of infectious spondylodiscitis in patients over 65 years of age.

Methods

This retrospective, monocentric study included patients aged over 65 years olds hospitalized in our department of rheumatology for spondylodiscitis.

Results

A total of 20 consecutive patients (10 males, 10 females) aged over 65 years were analyzed. The mean age of patients was 74 years (65-85). The most common comorbidities included diabetes (20%), chronic renal failure (5%). A history of nodal tuberculosis (10%), a tuberculosis contagion (30%), and raw milk ingestion (15%) were reported. The average delay for diagnosis was 10 months. The most common symptom was axial back pain (100% patients), then worsening health status (34%), and one patient had a significant neurological deficit. C-reactive protein was elevated in 95%. The most common involvement was in the lumbar vertebrae (13 patients, 65%), followed by thoracic and cervical level disease respectively in 3 patients (15%) and 2 patients (10%). Two patients (10%) had a multifocal spondylodiscitis. All patients underwent an MRI exam that confirmed the diagnosis. A percutaneous spine biopsy was performed in 80%. Pyogenic spondylodiscitis was the most common etiology (50%), followed by tuberculosis (35%) and brucellosis (15%). Antibiotic therapy was indicated to all patients with spinal immobilization in 65% of cases. Two patients underwent percutaneous drainage of paravertebral abscesses. The outcome was favorable in almost all cases until 12 months of following-up after completion of treatment. One patient died of septic shock and multi-visceral failure.

Conclusion

Elderly patients with infectious spondylodiscitis have fewer clinical symptoms leading to a delayed presentation. Increasing morbidity and mortality make rigorous monitoring necessary.

Disclosure of Interests

None declared

AB1482 PROGNOSTIC FACTORS FOR TUBERCULOUS SPONDYLODISCITIS

Background

Tuberculous spondylodiscitis (SPDT) or Pott’s disease is an infectious involvement of the disc-vertebrate couple, caused by the tubercular bacillus (Mycobacterium tuberculosis). It accounts for 46% to 64% of infectious spondylodiscitis and is the most common form of vertebral tuberculosis. Pott’s disease still poses a public health problem in Tunisia due to the endemicity of tuberculosis and the increase in extra-pulmonary forms.

Objectives

Our aim was to study factors impacting SPDT outcome.

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. The diagnosis was based either on a range of highly evocative clinical, biological and radiological arguments or on the disco-vertebral biopsy puncture. The study included correlations of the promoting factors of SPDT (tuberculosis infection, history of tuberculosis, diabetes, corticosteroids and trauma), epidemiological, clinical, biological, radiological and therapeutic data with good clinical outcome in the fourth week of the anti-tuberculosis drugs treatment.

Results

Fifty-two cases of SPDT were collected (37F/15M). The mean age was 55.21±17.79 years [19-91]. Thirty-three patients (69.2%) were aged under 65 years versus 16 elderly patients (30.8%), with female predominance in both groups (69.4% and 75% respectively, p = 0.57). The diagnosis of SPDT was based either on a range of highly evocative clinical, biological and radiological arguments (71.2%) or on the disco-vertebral biopsy puncture (28.8%). Among the clinical arguments suggestive of tuberculous SPD 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 contibutive to positive diagnosis using standard X-rays, computed tomography and magnetic resonance imaging. Disc pinch, erosion of vertebral plateaus and vertebral collapse were the major signs. The treatment was based on anti-tuberculosis drugs for at least nine months. Only four factors had an unfavourable predictive value (p ≤ 0.05): Normochromic normocytic anemia observed in 53.8% of our patients (p = 0.018; Odds Ratio = 6.66), initial lymphocytosis (p = 0.048), fever in 36.5% of our patients (p = 0.01; Odds Ratio = 9.6) and standard X-ray vertebral compression in 67.3% of our cases (p = 0.001; Odds Ratio = 13).

Conclusion

Tuberculous spondylodiscitis is a frequent condition that needs to be diagnosed and treated rapidly. Poor prognosis factors have been identified to provide insight into disease progression.

Disclosure of Interests

None declared

AB1459 IMPACT OF SOCIOECONOMIC FACTORS ON THE DISEASE ACTIVITY: DATA FROM THE TUNISIAN BINAR REGISTRY

Background

Despite the considerable therapeutic progress of inflammatory rheumatic diseases, access to treatment still challenging in developing countries because of scarce health resources and low socioeconomic status.

Objectives

To determine the influence of socioeconomic factors on disease activity in a national registry cohort, the Biological National Registry (BINAR) in Tunisia.

Methods

We enrolled patients with inflammatory rheumatic diseases under the first received biological drug and included in the BINAR registry from 2016 to 2020. Data on the inflammatory rheumatic disease (rheumatoid arthritis (RA) and spondyloarthritis (SA)), disease activity of RA and SA (DAS28-CRP and ASDAS-CRP respectively) at baseline, gender, active smoking, marital and work status and educational attainment were collected. Two groups were identified: Groupe 1 (G1) for patients with remission or low disease activity and groupe 2 (G2) for moderate or high disease activity according to DAS28-CRP and ASDAS-CRP.

Results

The study included 298 patients with a mean age of 49.2 years [18-79]. The mean disease duration was 6.7 ± 3.5 years [1-14] in patients with RA and 6.5 ±3.6 years [1-12] in patients with SA. G1 was made of 13 patients and G2 of 285 patients. The were no significant difference between G1 and G2 for (49.5 ± 11.9 versus 49.5±14.2, p=0.93) gender (% of females, 46.2% versus 37.1%, p=0.51) and marital status (% of single patients, 30.8 % versus 33.7%,p=0.82). Patients of G1 had better employability than G2 (61.5% % versus 45.6%) but this difference was not significant (p=0.26). Smoker patients had better disease outcomes comparing to nonsmokers but this difference was not significant (23.1 % versus 13.7%, p=0.34). Illiterate patients had more active diseases, comparing to literate, but this difference was not significant (30.8% versus 40.4%, p=0.49).

Conclusion

Our results did not confirm any difference in disease activity according to the collected socioeconomic factors. Data on the personal income, health insurance type and geographic distribution of our population should be further studied.

Disclosure of Interests

None declared

AB0193 BIOLOGIC DRUGS RETENTION IN ELDERLY RHEUMATOID ARTHRITIS: WHAT FEATURES?

Background

The elderly RA population is expanding. The management of RA in elderly patients can be challenging because of comorbidities, the frequency of adverse events. The efficacy and safety of RA therapies; particularly biologics drugs (bDMARDs); are poorly studied in this age group.

Objectives

To investigate the therapeutic response to bDMARDs in elderly rheumatoid arthritis.

Methods

We conducted a cross-sectional and observational study. Files of patients with RA on biologics drugs (archived from the files of patients on the National Health Insurance Fund of Tunis) were studied. The characteristics of RA, and the current treatments were studied. We have divided our population into two age groups. G1 aging under 65 years and G2 aged 65 or over. The therapeutic maintenance rate as well as the biologics survival was analyzed using Kaplan-Meier survival curves and compared using the Log-Rank test.

Results

Three hundred and seventy-four files were selected. Their average age was 55±12.54 years [20-90]. A female predominance was noted with a sex ratio M/F=0.147. The average duration of RA was 11.7±6.76 years [2-41]. Subjects over the age of 65 represented 22.2% of the workforce, i.e. 83 patients. The first biotherapy prescribed was etanercept in 54% of cases, adalimumab in 14% of cases, certolizumab pegol 13%, infliximab 6%, tocilizumab 6% and rituximab in 7% of cases. The 4-year survival was 54.41% and 60.94% for subjects under 65 and 65 or older, respectively. Treatment maintenance for RA in the elderly (≥ 65 years old) was 42.21 months, [53.51–46.92]. In our study, age did not influence the survival of biologics with a Hazard Ratio (HR) = 0.997 (p=0.667).

Conclusion

RA therapy is generally effective and safe in elderly patients. We did not find any influence of age on survival and therapeutic maintenance of biological treatments. Further studies with a broader spectrum are needed to better understand this notion

Disclosure of Interests

None declared

POS1516-HPR CHRONIC INFLAMMATORY RHEUMATISMS: DOES PERIODIC FASTING REDUCE THE DISEASE ACTIVITY?

Background

Many experimental studies have emphasized the role of periodic fasting in the adaptive responses that reduce inflammation.

Objectives

Our purpose was to assess the impact of periodic fasting on the activity of chronic inflammatory rheumatisms (CIR).

Methods

We conducted a cross-sectional study involving patients with rheumatoid arthritis (RA) (2010 ACR/EULAR criteria) and spondyloarthritis (SpA) (2009 ASAS criteria). CIR activity was assessed during the period of Ramadan (periodic fasting) and three months following Ramadan using clinical parameters including the Patient’s Global Assessment of disease activity (PGA), 10-cm Visual Analog Scale (VAS) pain score, morning stiffness, nocturnal awakenings, and joint count for RA (tender joint count (TJC) and swollen joint count (SJC)); biological parameters including C-reactive protein (CRP); disease activity scores including the SDAI, CDAI and DAS28 CRP for RA, BASDAI and ASDASCRP for SpA. An analysis of variance (ANOVA) was used to assess the statistical relationship between fasting and CIR activity.

Results

We enrolled 75 patients (40 RA and 35 SpA) with a sex ratio of 0.4 and a mean age of 55.35 ± 9.81 years [22-85]. The mean chronic CIR duration was 11.85 ± 3.4 years. RA was erosive in 92% of cases. Rheumatoid factor and anti-citrullinated peptides antibodies were positive respectively in 82% and 84% of cases. Seventy-five percent of RA patients were on corticosteroids with a mean dose of 10.20 mg/day of prednisone equivalent, and 81% of SpA patients were on non-steroidal anti-inflammatory drugs. Eighty-three percent of our patients were treated with conventional synthetic DMARD, and 40% with biological DMARD. The following parameters were lower in the month of Ramadan compared to the period following Ramadan in RA patients: mean PGA 4.3 vs 4.6 (p=0.01); mean morning stiffness 1.1 vs 1.5 (p=0.01); mean SJC 4.7 vs 8.5 (p=0.01); mean DAS28 CRP 3.56 vs 4.25 (p= 0.05); mean CDAI 17.5 vs 20.35 (p= 0.01), and mean SDAI 13.87 vs 18.44 (p=0.01). As for SpA, the following parameters were lower in the month of Ramadan compared to the period following Ramadan: mean morning stiffness 1.3 vs 2.1 (p= 0.01); mean ASDASCRP 2.9 vs 3.3 (p= 0.01), and mean BASDAI 3.6 vs 4.9 (p= 0.05). However, we found no statistically significant correlation between periodic fasting and VAS pain score, nocturnal awakenings, TJC, and CRP.

Conclusion

Our study concluded that periodic fasting was associated to a lower CIR activity. The incorporation of periodic fasting may promote optimal health and reduce the activity of some chronic inflammatory diseases.

Disclosure of Interests

None declared

AB0321 ADHERENCE TO MEDITERRANEAN DIET AND PREVALENCE OF CARDIOVASCULAR RISK FACTORS IN RHEUMATIC DISEASES

Background

Rheumatic diseases (RD) are autoimmune inflammatory arthritis. However involvement to other organs can occur and leads to atherosclerosis and cardiovascular (CV) risk factors. Mediterranean diet (MD) has attracted considerable interest because it seems to offer significant benefits to that end.

Objectives

To evaluate the role of MD in the development of the cardiovascular risk factors in RD.

Methods

We conducted a cross-sectional study including patients with RA (ACR-EULAR 2010 criteria) or with SA (ASAS 2009 criteria), in remission or in low activity disease and with no history of cardio vascular risk factors before the diagnosis of their RD. Sociodemographic and disease related data were collected: Disease Activity Score (DAS28-CRP), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP) and medication. We asked the patients to complete the 14-items MD adherence questionnary. We evaluated the association of adhrence to MD with cardiovascular risk factors: obesity, type-2 diabetes, hyperlipidemia and hypertension. We estimated odds ratios for each cardiovascular risk factors and their 95% confidence intervals. In all analyses, the high adherence category of MD adherence score [10–14) was considered the reference category.

Results

We included 61 patients (40 women and 21 men) with a mean age of 42.2 ± 1.1 years old [20-66]. Among them, 32.7% belong to urban environment and 26.2% were professionally active. The mean disease duration was 83.2 months [9-180]. The mean DAS28-CRP was 1.2 [0.8-1.9] and the mean ASDAS-CRP was 1.8 [1.1-2.01]. Methotrexate was used by 52.4%, either as monotherapy or combination and biological in 47.6 %. Thirty patients had high adherence to MD (H-MD) and thirty-one had medium or low adherence to MD (L-MD). We found that higher adherence to the MD is inversely associated with the prevalence of each of the four cardiovascular risk factors, results are shown in Table 1.

Table 1.

Prevalence of cardiovascular risk factors and odds ratio in high adhrence to Mediterranean diet in rheumatic diseases.

Prevalence %Odds ratio95% confidence intervalsObesity57.40.017[0.03-0.93]Type-2 diabetes50.80.01[0-0.019]Hyperlipidemia50.80.126[0.04-0.3]Hypertension42.60.13[0.43-0.4]

Conclusion

Our results suggest that the healthy effects of the MD observed in epidemiologic studies are exerted partly through plausible mechanisms: low prevalence of obesity, of type2 diabetes, of hyperlipidemia and of hypertension. Interventional studies may eventually provide stronger evidence. In the meantime, an increasing of knowledge supports the Mediterranean diet as a useful tool in managing individuals with RD, who are at high risk ofcardiovascular diseases.

Disclosure of Interests

None declared

AB1078 SPECTRUM OF INFECTIONS DURING RHEUMATOID ARTHRITIS

Background

Immunosuppression during rheumatoid arthritis (RA) induced by the disease but especially immunomodulatory treatments, is responsible for an increased frequency of infections in these patients.

Objectives

The purpose of this study is to assess the incidence of infections during RA and to determine their nature and management.

Methods

A retrospective study over a period of 10 years, including 150 patients with RA. We identified 33 patients who had at least one infectious episode during their follow-up.

Results

There were 19 women and 14 men. The mean age was 51 years old [39-63]. RA was immunopositive and erosive in all cases. The average disease duration was 8 years. A comorbidity was associated with RA in 14 patients (42%): diabetes in 7 cases, hypertension in 3 cases, ethylism in 2 cases and history of pulmonary tuberculosis in 2 cases.

As an extra-articular manifestation, 15% of patients had Sjogren’s syndrome and 18% had pulmonary interstitial fibrosis (3 cases) or pulmonary nodules (3 cases).

The most prescribed DMARDs was Methotrexate, prescribed in monotherapy at the average dose of 17.5 mg/week [10-25mg] in 18 cases. The other patients received Methotrexate associated to Hydroxychloroquine in 4 cases, Sulfasalazine in 3 cases and biotherapy in 8 cases. Corticosteroid therapy at an average dose of 7.5 to 15 mg/day was received in 16 cases (48.5%).

All infections noted in our population were community acquired. Urinary tract infection was the most common infection noted in 15 cases: pyelonephritis in 3 cases and cystitis in 12 cases. Other infection sites were ENT in 4 cases, bronchopulmonary in 6 cases including 2 cases of tuberculous infection and viral hepatitis (B and C) in 4 cases. Osteo-articular infections were noted in 3 cases: one cervical spondylodiscitis and two septic arthritis. Finally, one case of RA treated with rituximab was complicated by staphylococcal sepsis.

Germs causing these infections were identified in 14 cases (42%).

Conclusion

The risk of infections is increased during RA, this is due to lymphocyte and autoimmune abnormalities but also to treatments and comorbidities that predispose to the emergence of infectious agents.

Disclosure of Interests

None declared

AB1578-PARE A PATIENT-REPORTED OUTCOME SCALE: RASQ FOR MEASURING SYMPTOMS OF RHEUMATOID ARTHRITIS

Background

Patient-reported outcome (PRO) instruments are used to assess the patient experience of rheumatoid arthritis (RA) symptoms and impacts and can capture RA treatments effects. Also, there are often discrepancies between patient and physician perspectives.

Objectives

The objective of our study was to proceed with a psychometric evaluation of patients with RA using the Rheumatoid Arthritis Symptom Questionnaire (RASQ).

Methods

Adults with clinically confirmed RA, as defined by the ACR/EULAR criteria, were recruited for this cross-sectional study, and then completed the RASQ. Medical records were reviewed, clinical features, treatments, and outcomes were analyzed.

Results

In total 28subjects (82% females) with RA were included. The meanagewas58.5years (31-79 years). Comorbiditieswerepresentin86 %, diabetes (50%), high blood pressure (32,1%), dyslipidemia (25%), thyroid disease (3,7%), Depression (7.1%).The mean duration since RA diagnosiswas9,8 years. Almost all the patients had at least one of the disease severity criteria, high level of CRP (76%), radiographic erosion (96%), C1-C2 involvement (18%), or hip involvement (14,2%). All of the patients received CsDMARDs and biological therapy. Disease activity evaluated by the DAS28 score was in remission or very low disease activity in 38%, moderate (46%), and high (16%). Functional impact evaluated by the Health Assessment Questionnaire (HAQ)was an average of 1.1 (0.2–3). The RASQ total symptomwas6.6 (2-10). The mean of each item was joint pain (5.4), joint swelling (5.5), joint stiffness (6.1), joint tenderness (4.1), joint warmth (4.3), muscle pain (6), tiredness (5.7). The RASQ total symptom was statistically significantly different (p=0.01) across the DAS28severityrankings but only the first two single items of the RASQ were not statistically significantly different (p=0.9 and p=1,6). A medium positive correlation was found between subjects’ HAQ score and the total symptom score of the RASQ (r=0,38).

Conclusion

The primary goal of treating patients with RA is to maximize the long-term health-related quality of life. In this order, measurement of all of the signs and symptoms of RA that are significant and relevant to patients living with the disease is important to achieve this main objective.

Disclosure of Interests

None declared

POS1515-HPR CONJUGAL RELATIONSHIPS IN MARRIED PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATISMS

Background

The consequences of chronic inflammatory rheumatisms (CIR) on the sexuality and the relationships between the subject and his/her partner are still underestimated and insufficiently studied.

Objectives

The aim of this study was to investigate the impact of CIR on conjugal relationships.

Methods

We conducted a cross-sectional study involving patients with rheumatoid arthritis (RA) (2010 ACR/EULAR criteria) and spondyloarthritis (SpA) (2009 ASAS criteria). All the patients included in the study were married. We collected demographic data, and participants were asked to complete a questionnaire on their conjugal relationships.

Results

We enrolled 75 patients (40 RA and 35 SpA) with a sex ratio of 0.4 and a mean age of 55.35 ± 9.81 years [22-85]. The mean chronic CIR duration was 11.85 ± 3.4 years. The mean duration of marriage was 9.5 ± 2.6 years. The mean age at marriage was 27 ± 6.41 years [19-33]. The mean number of off-springs was 4. Forty-nine percent of patients and 22.3% of the partners had a profession, respectively. Forty one percent of the partners had a chronic disease: diabetes (n=12), hypertension (n=10), dyslipidemia (n=7), CIR (n=7), coronary disease (n=3), and other conditions (n=5). A psychiatric illness was noted in 22.6% of cases: depression (n=9), anxiety (n=6), and bipolar disorder (n=2). Sixty-four percent of patients consider their spouses sympathetic to their illness. Eighty-nine percent of participants have noticed a change in their life as a couple before and after the CIR onset. According to 64% of participants, the CIR had a negative impact on their married lives. The spouses’ emotional reactions to the disease were as follows: indifference (30.6%), denial (29.3%), anger (26.6%), and fear (13.6%). Patients reported being accompanied by their spouses to their medical appointments in 36% of cases, and 40% of them were asked questions by their spouses about their disease and treatment. The CIR has resulted in the termination of the marriage in 2.6% of cases.

Conclusion

Patients suffering from chronic diseases such as CIR are more frequently exposed to difficulties in their conjugal relationships. The disease has thus important consequences on the subject’s quality of life, emotional and interpersonal state. A better compliance with the chronic disease and its treatment may improve the couples’ relationships.

Disclosure of Interests

None declared

AB0950 Detection of asymptomatic entheseal involvement in patients with psoriasis: A case-control ultrasound study

Background

Enthesopathy is one of the major features of psoriatic arthritis (PsA). The clinical screening for enthesopathies and synovitis in patients with psoriasis is nonspecific during the subclinical phase. Ultrasonography (US) has already demonstrated its ability to study entheses and joints in early stages of PsA.

Objectives

To evaluate the prevalence of ultrasonographic subclinical synovitis and enthesopathies in psoriasis patients with no clinical evidence of PsA compared with controls.

Methods

A cross-sectional study conducted on 40 patients with psoriasis and 40 healthy sex- and age- matched controls. The Leeds Enthesitis Index (LEI) and Spondyloarthritis Research Consortium of Canada (SPARCC) were used to evaluate entheseal involvement. US examination of 18 joints (wrists, metacarpophalangeal, and proximal interphalangeal joints) was performed along with 22 entheseal sites (deep flexor of the fingers, lateral epincondyle, triceps, quadriceps, patellar and calcaneal tendons and plantar fascia). Inflammatory-score (thickening, hypoechogenocity, bursitis and Doppler signal) and damage-score (calcifications, enthesophytes and erosions) were calculated (0= absent, 1=present for each abnormality). A total-score was obtained by adding these two scores.

Results

The mean age of psoriatic patients 51,90±15,90 [19 -76] and the sex ratio of males to females was 3:2. US synovitis were more frequent in psoriatic patients 7/1040 (0,68%) than in controls 3/1040 (0,29%) but this was not significant (p= 0,420). Patients with psoriasis had more US enthesopathies 37 (92,5%) comparing to controls 16 (40%) (p < 0,001). The total number of enthesopathies was higher in the psoriatic group 184/880 (20,90%) comparing to controls 42/880 (4,78%) (p < 0,001). Entheses with more US abnormalities in the psoriasis group comparing to controls were deep flexor tendons of the fingers entheses (p<0,001), distal patellar tendon entheses (p<0,001) and calcaneal tendon entheses (p<0,001). LEI and SPARCC scores were positively correlated to higher number of US enthesopathies (p=0,046, p=0,006). SPARCC was positively correlated to inflammatory-score and damage-score (p=0,009, p=0,024). The mean C-reactive protein level was higher in psoriatic arthritis 5,77±10,10 mg/L than in controls 2,15±3,26mg/L (p=0,037).

Conclusion

Our results confirm that US enthesopathies and synovitis are more frequent in patients with psoriasis comparing to healthy population. The US screening for subclinical enthesopathies should be the object of longitudinal investigations to define its value in predicting the clinical onset of PsA.

Disclosure of Interests

None declared

AB1225 TUBERCULOUS SPONDYLODISCITIS: DIAGNOSTIC DELAY AND OUTCOMES

Background

Tuberculous spondylodiscitis (SPDT) is a serious clinical condition that must be treated promptly. Despite the actual availability of more effective diagnostic tools, early diagnosis of SPDT remains difficult and a high index of suspicion is needed due to the chronic nature of the disease and its insidious and variable clinical presentation.

Objectives

Our aim was to study the correlation between the diagnostic delay of SPDT and its outcomes.

Methods

We conduct a monocentric retrospective and descriptive study in a rheumatology department. Data were collected from observations of patients hospitalized in the past 20 years (2001-2021) who have been diagnosed with SPDT. An early diagnosis is defined by a diagnosis within the first six months versus a late diagnosis that is retained after 6 months of symptoms.

Results

Fifty-two cases of SPDT were collected (37F/15M). The mean age of the population was 55.21±17.79 years [19-91]. Late diagnosis was more common: 41 patients (78.8%) versus 11 patients (21.2%) diagnosed early. Complications were more frequent (61%) in patients diagnosed late, but with no statistically significant difference (p=0.1). Disease-related complications, such as spinal compression, spinal deformation and recurrence of the disease, was statistically higher (45.5%) in early diagnosed patients (p < 0.001). Drug complications, such as disruption of liver balance, hyperuricemia and major intolerance to anti-tuberculosis, were more frequent (36.6%) in patients diagnosed late (p = 0).

Conclusion

Despite highly sensitive imaging techniques, the diagnosis of tuberculous spondylodiscitis is often late, which may lead to severe deformity and early or late neurological complications.

Disclosure of Interests

None declared

AB1572-PARE VIEWPOINTS OF YOUNG TUNISIAN WOMEN WITH RHEUMATOID ARTHRITIS REGARDING THE IMPACT OF THE DISEASE ON FERTILITY: ARE THEY AWARE ENOUGH?

Background

Rheumatoid Arthritis (RA) is one of the most common chronic inflammatory disease in women in reproductive age. It seems difficult to acheive parenthood in RA, therefore, reproductive health in these patients is an important issue. Many factors may interfere with procreation such as high disease activity and medication. Female perception and behavior towards fertility are not often assessed.

Objectives

We aimed to evaluate the fertility perceptions and related behavior among young women with RA.

Methods

We conducted a cross sectional study involving young female patients with RA (2010 ACR-EULAR criteria). Sociodemographic data and the following disease-related parameters were collected: diseases activity score (DAS28CRP) and NSAID (Non steroidal Anti-inflammatory Drugs), prednisone and DMARDs being used. We asked the patients about their knowledge about the risk of infertility due to the disease itself, the activity of RA and medication.

Results

Sixty-two females patients were included. The average age was 26.1 ±2.1 years [20-35]. The majority of patients, 54 women, live in rural enviroment and 8 women live in urban enviroment. Forty-two women (67%) were illiterate, ten women (16%) had primary or secondary school level and ten women (16%) had university school level. Only twenty percent (20%) were employed. There were no smokers included. Sixty-six percent (66%) were married. Forty-one women (66%) aimed to have children: 35 women got pregnant and 6 still didn’t get pregnant. The average of gestity was 1.6 [0-4]. The average of parity was of 1.2 [0-3]. The average of time to pregnancy (TTP) was 12 months ± 2 [6-24]. Pregnancy resulted in a live-born baby in 30 women (73%), 4 women (9%) miscarried and there was one intra-uterine fetal death (2%). Ten pregnant women had had fertility treatment to get pregnant. The mean duration of the RA was 3.1 years ± 1.2 [2-10]. The mean DAS28CRP were 3.1 ± 1.25[2-3.9]. Both rheumatoid factor and anti-citrullinated peptides antibodies were positive in 58 women (93%). RA was erosive in 48 cases (76.1%) and deformed in 2 cases (3%). Half of patient were using NSAID daily and 60% were using prednisone with an average daily dose of 5.1 mg/day [2.5-7.5]. Sixty-one percent (61%) of patients were using Methotrexate with an average weekly dose of 15.1 mg/week [10-22.5], 10% Leflunomide, 10% Sulfasalazine, and 45% biotherapy. About half of patient think that RA may cause fertility problems, infertility in 60% and abortion in 40% and they had this information in 60% from media, 30% from siblings and only 10.1% from their rheumatologist. None of patients think that disease activity may interfere with pregnancy and that they should strive low disease activity before trying to conceive. None of patients think that NSAID or COX2 inhibitor or prednisone may interfere with fertility and about 10 women used NSAID in pregnancy. About 24% think that DMARDs may interfere with procreation especially infertility (100%) with respectively: MTX (70%), Leflunomide (3%), Sulfasalazine (5%), biotherapy (20%). Women who didn’t get pregnant accused their impaired fertility to their DMARDs and eight women stopped their DMARDs in pregnancy for fear that it affected their baby. Only 5 women (8%) saw a rheumatologist in the preconception period.

Conclusion

The relationship between RA and fertility seems to be misunderstood in young women with RA. Clinicians must routinely discuss this issue with these young patients to preserve their fertility by learning them the mechanisms by which RA may affects their fertility: the disease itself and medication. Appropriate information about fertility can help women in productive age reach and carry a healthy pregnancy.

Disclosure of Interests

None declared

AB1080 BRUCELLAR SPONDYLODISCITIS: EPIDEMIOLOGICAL, CLINICAL AND BIOLOGICAL ASPECTS

Background

Brucellosis is a systemic infection characterized by significant clinical polymorphism and non-specific manifestations. The spine is a common location for brucellosis.

Objectives

The aim of this study was to describe the epidemiological, clinical and biological characteristics of brucellar spondylodiscitis.

Methods

A retrospective study over a period of 15 years, including 18 patients diagnosed with brucellar spondylodiscitis on clinical, biological and/or imaging data.

Results

Eighteen cases were collected (13 men and 5 woman). The mean age was 52 years [19-76].

The main symptom was unifocal or diffuse spinal pain associated or not with radiculalgia. Inflammatory pain was reported in 12 cases.

Thirteen patients consumed raw milk, eleven had contact with farm animals or professional exposure.

The average duration of symptoms was 5.7 months [0.5-12], the disease had a progressive onset in 13 patients.

The general signs were frequent: deterioration of general condition (13 cases), fever (12 cases) and night sweats (6 cases). All patients had a biological inflammatory syndrome.

Wright’s serology, performed in 17 patients, was positive in 15 cases. The Rose Bengal test was positive in 13 of the 15 patients tested. Diagnosis by indirect immunofluorescence, performed in 11 patients, was positive in nine cases. However, the blood cultures, carried out in 13 patients and the disco-vertebral biopsy, carried out in 9 patients, did not find the causal agent.

Conclusion

The diagnosis of brucellar spondylodiscitis must be based on epidemiological, clinical arguments and biological examinations. Immunological examinations, however, seem to be more contributory and should be performed in case of diagnostic doubt and negative bacteriological investigation.

Disclosure of Interests

None declared

POS0612 COMORBIDITIES IN RHEUMATOID ARTHRITIS DO NOT INFLUENCE BIOLOGICS DRUG RETENTION: DATA FROM THE NATIONAL HEALTH INSURANCE FUND OF TUNIS

Background

The advent of biologics in the late 1990s radically changed the profile of inflammatory diseases, in particular rheumatoid arthritis (RA). The survival of these innovative therapies is an indicator, in clinical practice, of their long-term efficiency in patients with RA.

Objectives

To study the influence of comorbidities on biologics drugs retention rates.

Methods

We conducted a cross-sectional, observational study. Data were identified from the files of the National Health Insurance Fund of Tunis. It included patients with RA on biologics. Epidemiological characteristics such as age, sex, and comorbidities, were collected. Comorbidities were assessed by the Charlson Comorbidity Index (CCI). The therapeutic maintenance rate at 12, 24, 36, and 48 months as well as the biologics survival were analyzed using Kaplan-Meier survival curves and compared using the Log-Rank test.

Results

Three hundred and seventy-four files were selected. The average age of our cohort was 55±12.54 years [20-90]. A female predominance was noted with a sex ratio M/F=0.147. The average duration of RA was 11.7±6.76 years [2-41].First biogics prescription was: etanercept 54%, adalimumab 14%, certolizumab pegol 13%, infliximab 6%, tocilizumab 6% and rituximab 7%. First-line survival rates at 12, 24, 36, and 48 months were 85.8; 69.9; 60.6, and 55.9% respectively. Biologics drug survival was, on average, 41.7 months [39.47-43.91]. Comorbidities were assessed by the CCI in 373 patients (99.7%). Ninety patients had an ICC of 0 and 103 patients had an ICC of 1. Only one patient had an ICC of 8. The median value of this score was equal to 1, the mean was 1.64 ± 1.48. Osteoporosis was the most observed comorbidity with 78 patients (20.9%). The study of drug survival according to the ICC did not show any significant difference between the different curves (p=0.809). The Hazard Ratio was 0.999. Similarly, we did not find a discriminating threshold for the Charlson score, allowing it to be decisive for the survival of biologic drugs.

Conclusion

This study did not identify the influence of comorbidities on the biologics survival during RA. Comorbidities can have an impact not only on our therapeutic choice but also on the efficacy and maintenance of biomedicines as well as the quality of life of patients and consequently the prognosis of RA (1). The few studies that have looked at this subject have produced variable results.

References

[1]Estíbaliz Loza, Cristina Lajas, Jose Luis Andreu, Alejandro Balsa, et al. Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis. Rheumatol Int 2015 Mar;35(3):445-58.

Disclosure of Interests

None declared

AB0191 OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS: IMPACT ON BIOLOGIC DRUGS TOLERANCE AND SURVIVAL

Background

Osteoporosis is one of the main comorbidity of RA and leads to an increased risk for fragility fractures, which further impair functional ability, quality of life, and life expectancy. The influence of this condition on the maintenance and survival of biotherapies has rarely been studied.

Objectives

To assess the influence of osteoporosis on efficacy, tolerance, and biologic drugs survival.

Methods

We conducted a cross-sectional and observational study. Files of patients with RA on biologics drugs (archived from the files of patients on the National Health Insurance Fund of Tunis) were studied. Epidemiological characteristics such as age, sex, and comorbidities, were collected. All patients had a bone mineral density measurement. The patients were divided into two groups (a group with G1 osteoporosis and a group without osteoporosis G2). The therapeutic maintenance rate at 12, 24, 36, and 48 months as well as the biologic survival were analyzed using Kaplan-Meier survival curves and compared using the Log-Rank test.

Results

Three hundred and seventy-four files were selected. The average age of our cohort was 55±12.54 years [20-90]. A female predominance was noted with a sex ratio M/F=0.147. The average duration of RA was 11.7±6.76 years [2-41]. Osteoporosis was observed in 78 patients (20.9%). First biogics prescription was: tocilizumab 6% and rituximab 7%, etanercept 54%, adalimumab 14%, certolizumab pegol 13%, infliximab 6%.The maintenance of the first biotherapy was 40.53 [35.64-45.43] in G1 and 41.44 [39.01-43.86] in G2. The biologic survival curve study did not find any significant difference between the two group p= 0.598.

The presence of osteoporosis would increase the risk of stopping biotherapy without being a statistically significant factor (HR = 1.109, p = 0.602)

The therapeutic maintenance of the 1st biotherapy, in the presence of osteoporosis, was on average 40.53 months [35.64-45.43].

Conclusion

Osteoporosis has not hitherto been retained as a determining factor in therapeutic maintenance (1), as was indeed the case in our study. Nevertheless, screening and early management of osteoporosis are necessary since it alone constitutes a risk factor for mortality.

References

[1]Leon L, Rodriguez-Rodriguez L, Rosales Z, Gomez A, Lamas JR, Pato E, et al. Long-term drug survival of biological agents in patients with rheumatoid arthritis in clinical practice. Scand J Rheumatol. 2016;45(6):456-60.

Disclosure of Interests

None declared

Unknown Extra-Articular Manifestation of Spondyloarthritis: What About Retroperitoneal Fibrosis? A Case Based Literature Review

INTRODUCTION

Retroperitoneal fibrosis (RPF) is a rare disease characterized by fibro-inflammatory tissue proliferation in the retroperitoneum. It results in a chronic inflammatory and fibrosis condition, possibly leading to compression of the retroperitoneal structures, especially to encasement of the ureters and the inferior vena cava. It may have an idiopathic or a secondary origin. Spondyloarthritis (SpA) is one of the rare conditions described among the secondary forms.

CASE

Herein, we report a new case of RPF in a patient with AS. Who presented with acute abdominal pain radiating to the lumbar region and the left testicle. On clinical examination, we found a mild stiffness of the lumbar spine and a decrease in chest expansion. Sacroiliac joint pain was also found. The rest of the physical examination was normal. Laboratory tests showed inflammation with increased C-reactive protein (130 mg/l) and creatinine (112 micromol/l) levels. The computed tomography scan revealed a soft tissue density mass located around the sub-renal aorta. Diagnosis of idiopathic RPF associated with AS was retained. The patient was treated by a daily dosage of 1 mg/kg of oral glucocorticoid with good outcome.

CONCLUSION

RPF is a rare condition that can be either idiopathic or secondary. Its association with spondyloarthritis, mainly in its ankylosing spondylitis form, seems to be more than anectodal. Treatment may involve medical therapy and/or surgical management.

KEY MESSAGE

In the presence of back pain, fatigue, weight loss, and low grade fever in spondyloarthritis patients, physicians should screen for retroperitoneal fibrosis as it could be a possible cause.

The effects of autoimmune rheumatic-related diseases on male reproductive health: A systematic review

Autoimmune rheumatic-related diseases (ARRDs) have physical and psychological impact on patients, including their sexual life. While many studies have investigated fertility problems in females, data on males-related fertility are scarce, which explains the lack of guidance. The main objective of this systematic review was to evaluate the reproductive health in males with ARRDs. This systematic review followed the preferred reporting items for systematic reviews guidelines. Original articles from Pubmed and Scopus, published until September 16, 2021, and tackling the effects of ARRDs and/or ARRDs treatments on male fertility and/or pregnancy outcomes, were included. A total of twenty-five studies met the inclusion criteria. They were published between 1981 and 2018. The studied ARRDs were spondyloarthritis (n = 9), systematic lupus erythematosus (SLE, n = 6), Behcet disease (BD, n = 5), rheumatoid arthritis (RA, n = 5), antiphospholipid syndrome (n = 1), and dermatomyositis (n = 1). The most reported effects of ARRDs on fertility are i) high levels of reproductive hormones, mainly in RA and SLE; ii) impaired semen quality in SLE, spondyloarthritis, and BD; and iii) higher rate of varicocele in BD and spondyloarthritis. Regarding the treatments effects, i) conventional synthetic disease-modifying anti-rheumatic drugs (e.g.; methotrexate and salazopyrine) increase testosterone level, ii) cyclophosphamide impairs fertility, iii) anti-tumor necrosis factor agents are associated with improvement in semen quality, and iv) no increased number of miscarriages or congenital abnormalities in children fathered by BD was reported. To conclude, both ARRDs and their treatments alter fertility in males with ARRDs. In practice, in addition to the conventional semen analysis, screening for infertility seems legitimate in males with ARRDs.