Extra-Articular Manifestations in Patients with Ankylosing Spondylitis: Baseline Characteristics from the RBSMR Study.

Objectives: To describe and analyse the prevalence of extra-articular manifestations (EAMs) including acute anterior uveitis (AAU), psoriasis and inflammatory bowel disease (IBD) in patients with ankylosing spondylitis (AS) in the Moroccan registry of biological therapies in rheumatic diseases RBSMR (Registre des Biothérapies de la Société Marocaine de Rhumatologie). Methods: A cross-sectional, multicentre and analytical study based on the RBSMR database, which included 170 AS. Incidence rates for the development of AAU, psoriasis and IBD were calculated, and risk factors were analysed. Results: Prevalence of EAMs in AS was 13.5%, 4.7% and 11.2% for AAU, psoriasis and IBD respectively. No significant differences were found while establishing a comparison of the prevalence of these EAMs between AS patients with and without peripheral arthritis. Interestingly, AAU was the most common EAM, and was positively associated in multivariable regression with family history of spondyloarthritis (OR= 7.21, CI 95%: 2.23-23.24). Conclusions: AAU was the leading EAM in patients with AS included in the Moroccan biotherapy registry (RBSMR) and it was associated with family history of spondyloarthritis.

Therapeutic Maintenance Level of Methotrexate in Rheumatoid Arthritis: A RBSMR Study.

Objectives: The aim of this study was to determine the therapeutic maintenance level of methotrexate for rheumatoid arthritis patients enrolled in the Moroccan biotherapy registry and to identify predictive factors for discontinuing MTX treatment. Methods: A cross-sectional study was conducted using the baseline data of the Moroccan biotherapy registry for RBSMR (a multicentric study that aims to evaluate tolerance of biological therapy on patients affected with rheumatic diseases). Demographics and disease features were compared using descriptive statistics. Therapeutic maintenance levels were determined according to a Kaplan-Meier survival curve and a univariate Cox proportional hazards regression model was used to compare the strength of potential factors, followed by a multivariate Cox model to identify significant predictors of MTX discontinuation. Statistically significant results were considered for p values less than 0.05. Results: 224 patients with rheumatoid arthritis were included in this study. The mean age of patients was 51.83±11.26 years with a majority of females (87.50%). The median duration of disease was 12 [1.66-41.02] years. The therapeutic maintenance level of MTX was 91.1% at 1 year, 87.1% at 2 years, and 68.3% at 5 years. The median of treatment duration was 2, 02 [0, 46-27,76] years. Causes of treatment interruption were side effects (66/88=75%), inefficiency (12/88=13.63%), and other reasons (10/88=11.36%). Predictive factors for stopping MTX were presence of rheumatoid factor (HR 2.24; 95% CI 1.14-5.15; p=0.02) and the access to education (HR 0.37; 95% CI 0.16-0.88; p=0.02). Conclusion: The therapeutic maintenance level of MTX in our study was satisfactory and comparable to other series, and influenced by many factors such as the occurrence of a side effect. It is necessary to sensitise medical practitioners on symptomatic prevention and management of side effects.

Hypertrophic Osteoarthropathy Associated with Probable Smear-Negative Pulmonary Tuberculosis.

Association of hypertrophic osteoarthropathy (HOA) with pulmonary tuberculosis is rarely reported, especially with smear-negative pulmonary tuberculosis (SNPT), in which its diagnosis is a challenge. We used a systematic approach to analyze all relevant literature reviews, and we identified only two cases of HOA associated with pulmonary tuberculosis in the last 10 years. We report the case of a 36-year-old man who presented with bilateral symmetric polyarthralgia and digital clubbing. Laboratory exams associated elevated acute phase reactants with negative immunological examinations. Two series of three acid-fast Bacillus (AFB) smear microscopy in sputum, separated by 15 days of broad-spectrum antibiotic therapy, were negative. A sputum culture was negative for Mycobacterium tuberculosis. A chest X-ray and computed tomography (CT) showed an apical pulmonary cavity. Plain X-ray and bone scintigraphy revealed periostosis of the tubular bones. Therefore, the diagnosis of HOA associated with probable SNPT was made. HOA symptoms had remitted after 3 months of antitubercular therapy. After 7 months of treatment, chest CT and bone scintigraphy showed a regression of the pulmonary cavity and disappearance of periostosis. The search for tuberculosis in front of any HOA seems to be justified in our epidemiological context.

Active tuberculosis infection in moroccan patients with rheumatic diseases under biologic therapy: A multicenter national study.

Background: The aim of this study was to evaluate the prevalence of active tuberculosis (TB) infection in Moroccan patients with rheumatic diseases under biologic therapy, and to describe the demographic characteristics of these patients as well as to explore potential risk factors. Methods: This 14-year nationally representative multicenter study enrolled Moroccan patients with rheumatic diseases who had been treated with biologic therapy. Patient medical records were reviewed retrospectively for demographic characteristics, underlying rheumatic diseases, associated comorbidities, and TB-related data. Results: In total, 1407 eligible patients were studied, detailed records were obtained for only 130 patients; 33 cases with active TB were identified at an estimated prevalence rate of 2.3%. The mean age was 42.9 ± 12 years and 75.8% were males. Ankylosing spondylitis accounted for 84.8% of active TB cases, and the majority of the cases (31/33) occurred among antitumor necrosis factor-alpha (TNF-α) users. A total of 8 out of 33 patients were positive at initial latent TB infection (LTBI) screening by tuberculin skin test and/or interferon-gamma release assay. Consumption of unpasteurized dairy products (odds ratio [OR], 34.841; 95% confidence interval [CI], 3.1-389.7; P = 0.04), diabetes (OR, 38.468; 95% CI, 1.6-878.3; P = 0,022), smoking (OR, 3.941; 95% CI, 1-159.9; P = 0.047), and long biologic therapy duration (OR, 1.991; 95% CI, 1.4-16.3; P = 0.001) were identified as risk factors for developing active TB. Conclusion: Moroccan patients with rheumatic diseases under anti-TNF-α agents are at an increased TB risk, especially when risk factors are present. Strict initial screening and regular monitoring of LTBI is recommended for patients living in high TB prevalence areas.

Hodgkin Lymphoma Mimicking Lumbar Spine Tuberculosis.

INTRODUCTION: The clinical manifestations of Hodgkin lymphoma (HL) can closely mimic spine and lymph node tuberculosis (TB). Case Description. A 48-year-old man was initially treated for retroperitoneal lymph nodes TB, and this diagnosis was made without bacteriological and histopathological confirmation. After four months of regular therapy for TB, he did not improve and was admitted to our department for lumbar spine pain. We first made diagnosis of tuberculous spondylodiscitis, and anti-TB treatment was strengthened. But, after three weeks of hospitalization, his condition worsened clinically with onset of swelling of the left supraclavicular lymph node. So, after surgical excision and anatomopathological examination of the lymph node, the diagnosis of nodular sclerosis classic Hodgkin lymphoma was made. He was treated by chemotherapy, and his condition improved significantly after the first 2 cycles of chemotherapy. CONCLUSION: Repeated investigations may be helpful in establishing a correct diagnosis and starting an effective treatment in this highly curable disease.

Prevalence of latent tuberculosis before biotherapy initiation in rheumatoid arthritis and spondyloarthritis: data from the Moroccan biotherapy registry.

Before the initiation of biotherapy in the treatment of rheumatic diseases, it is highly recommended for the patients to be screened for latent tuberculosis infection (LTBI). The objective of this study is to identify the prevalence of LTBI among patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) before the initiation of biologic therapy in the Moroccan biotherapy registry (RBSMR). A cross sectional study was conducted using the baseline data of the Moroccan biotherapy registry. Tuberculin skin test or IGRA test or both tests were done before starting anti-TNF treatment for screening LTBI. The comparisons between positive and negative LTBI patients according to rheumatic disease were examined using categorical comparisons. 259 patients were included in this study.94 patients had RA and 165 had SpA. The mean age of the RA patients was 50.49 ± 11.82 years with a majority of females (84%). The mean age for the SpA patients was 36 ± 13.7 years with a majority of males (67.3%). The prevalence of LTBI in the RBSMR was 21.6%. This prevalence was at 24.8% in SpA patients, while it was at 15.9% for RA patients. After the comparison between positive and negative LTBI patients according to rheumatic disease, no demographic, clinical, or therapeutic characteristics were statistically associated with LTBI. This study found that in an endemic TB country like Morocco, a high prevalence of patients with SpA and RA had LTBI, and that RA patients had a lower prevalence than SpA patients.

Achilles Tendon Xanthoma and Cholestanol Revealing Cerebrotendinous Xanthomatosis: A New Case Report.

Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid storage disease rarely reported in Africa. Therefore, we report a Moroccan first case report of CTX. A 20-year-old woman was presented in our department for bilateral swelling of the posterior aspect of ankles and the anterior aspect knees with gait disturbances evolving since the age of 7. The patient was the first child of consanguineous marriage. She had bilateral cataracts and developmental delay. Laboratory findings revealed that the plasma cholestanol level was remarkably elevated, and plasma and urine bile alcohol levels were elevated. MRI of ankles showed a bilateral diffuse thickening of the Achilles tendon with hypointense in T1 and heterogeneous hypersignal in T2 with spots in hypersignal in T1 and T2. Brain MRI revealed bilateral and symmetrical T2 hypersignal of dentate nuclei, without white matter signal alterations or cerebral or cerebellar atrophy. A biopsy obtained of the Achilles swelling with a histological study showed an aspect of tendon xanthoma. Hence, the diagnosis of CTX was made. MRI, especially brain MRI, plays an important role in the diagnosis of CTX.

The first biological choice in patients with rheumatoid arthritis: data from the Moroccan register of biotherapies.

INTRODUCTION: the aim of our study is to determine, from data of the Moroccan register of biotherapies, the factors influencing the choice of the first prescribed biological treatment. METHODS: cross-sectional multicenter study including rheumatoid arthritis patients who were initiated the first biological treatment either: Rituximab, an anti-TNF, or Tocilizumab. The determinants related to the patient and disease have been gathered. A univariate and then multivariate analysis to determine the factors associated with the choice of the first bDMARDs was realized. RESULTS: a total of 225 rheumatoid arthritis patients were included in the Moroccan registry. The mean age was 52 ± 11 years, with female predominance 88% (n = 197). The first prescribed biological treatment was Rituximab 74% (n = 166), the second one was Tocilizumab, 13.6% (n = 31) then comes the anti-TNF in 3rd position with 12.4% (n = 28). The factors associated with the choice of Rituximab as the first line bDMARDs prescribed in univariate analysis were: the insurance type, the positivity of the rheumatoid factor. In multivariate analysis, only the insurance type that remains associated with the choice of Rituximab as the first biological drugs. The Tocilizumab was associated with shorter disease duration and was more prescribed as mono-therapy compared to non Tocilizumab group. TNFi was associated with the insurance type. CONCLUSION: our study suggests that Rituximab and TNFi are associated with the type of insurance and Tocilizumab is the most prescribed biologic mono-therapy in RA patients. Further studies are needed to confirm these results.

One-year direct costs of biological therapy in rheumatoid arthritis and its predictive factors: data from the Moroccan RBSMR registry.

The aim of the study was to estimate the annual direct costs of biological therapies in rheumatoid arthritis (RA), and to establish possible factors associated with those costs. The main data source was the Moroccan registry of biological therapies in rheumatic diseases (RBSMR Registry). We included patients with available 1-year data. Variables related to socio-economic status, disease and biological therapy were collected. Direct costs included prices of biologics, costs of infusions, and subcutaneous injections. Differences in costs across groups were tested by Mann-Whitney and Kruskal-Wallis tests. Correlations analysis was performed in search of factors associated with high costs. We included 197 rheumatoid arthritis patients. The mean age was 52.3 ± 11 years, with female predominance 86.8%. Receiving one of the following therapies: rituximab (n = 132), tocilizumab (n = 37), or TNF-blockers (n = 28). Median one-year direct costs per patient were €1665 [€1472-€9879]. The total annual direct costs were € 978,494. Rituximab, constituted 25.7% of the total annual budget. TNF-blockers and tocilizumab represented 27.3% and 47% of this overall budget, respectively. Although the costs were not significantly different in terms of gender or level of study, the insurance type significantly affected the cost estimation. A positive correlation was found between the annual direct cost and body mass index (r = 0.15, p = 0.04). In Morocco, a developing country, the annual direct costs of biological therapy are high. Our results may contribute to the development of strategies for better governance of these costs.

Bilateral swelling of the forearms revealing muscular sarcoidosis: a case-based review.

Muscular sarcoidosis is rarely symptomatic and mainly affects proximal muscles of the lower extremities. However, the distal localization in the upper extremities is rare. We used systematic approach to analyze all relevant literature review and we identified only three cases of muscular sarcoidosis of the upper extremities. We report the case of a 56-year-old woman who presented distal and bilateral swelling of the extensor surface of the forearms revealing muscular sarcoidosis. The laboratory exams associated elevated acute phase reactants with elevated serum angiotensin-converting enzyme levels and normal serum muscle enzymes. Ultrasound and MRI showed a bilateral and symmetrical muscle hypertrophy of the extensors of the fingers. Histological examination of muscle specimen and minor salivary gland biopsy revealed noncaseating epithelioid-cell granulomas. Therefore, the diagnosis of muscular sarcoidosis of the finger extensor muscles was made. Swelling of the forearms disappeared gradually under prednisolone 1 mg/kg/day. We used methotrexate as a steroid-sparing agent. Muscular MRI in sarcoidosis is not specific, but is to make a diagnosis of the lesion to optimize the biopsy which the cornerstone of the diagnosis ofsarcoidosis.

Leflunomide-Induced Hidradenitis Suppurativa.

Hidradenitis suppurativa is an inflammatory disease of the pilosebaceous unit with a chronic intermittent course and a devastating effect on quality of life. Rare reports of drug-induced hidradenitis suppurativa exist. We report on 2 women on follow-up for rheumatoid arthritis, who presented hidradenitis suppurativa after different periods of treatment with leflunomide and who improved few weeks after discontinuation of the medication.

Does Rheumatoid Cachexia Predispose Patients with Rheumatoid Arthritis to Osteoporosis and Vertebral Fractures?

OBJECTIVE: To assess the prevalence and risk factors of rheumatoid cachexia (RC) and evaluate its relationship with osteoporosis and vertebral fractures (VF) in patients with rheumatoid arthritis (RA). METHODS: We enrolled into a cross-sectional study 178 consecutive patients with RA (82.6% women) with a mean age of 54.1 ± 11.5 years (25-82) and who fulfilled the American College of Rheumatology criteria for the classification of RA. Body composition, lateral VF assessment images, and scans of the lumbar spine and proximal femur were obtained using dual-energy x-ray absorptiometry. RC was defined by a fat-free mass index below the 10th percentile and a fat mass index above the 25th percentile compared with a reference population. VF were defined using Genant semiquantitative approach. RESULTS: RC was observed in 96 patients (53.9%) and osteoporosis in 52 patients (29.2%). Comparison between women with and without RC showed that women with RC had a longer disease duration, higher disease activity variables, higher steroid cumulative dose, and higher proportion of patients with erosive arthritis. Women with RC had lower total hip bone mineral density (BMD) and T score than women without RC, while comparison in men found only body mass index to be significantly lower in men with RC. Regression logistic analysis showed an independent and significant association between RC and age and disease activity in women. CONCLUSION: Our study showed that half of the patients with RA may have RC, a condition that was significantly associated with disease activity and low hip BMD, but not with VF.

Stevens-Johnson syndrome complicating adalimumab therapy in rheumatoid arthritis disease.

The efficacy of adalimumab, a fully human anti-tumor necrosis factor-α recombinant antibody, has dramatically improved the quality of life of patients with rheumatoid and psoriatic arthritis and Crohn's disease. Because it is fully human, one should not expect immune reactions to this molecule. Adverse reactions to adalimumab are limited mainly to injection site reactions and are very common. We, however, report a case of Stevens-Johnson syndrome that required hospitalization and cessation of adalimumab in a patient with rheumatoid arthritis (RA). In this case report, a 53-year-old woman with RA developed severe mucositis, peripheral rash and desquamation and fever concomitant with the fifth dose of 40 mg adalimumab. Infective etiologies were excluded. The patient responded rapidly to IV hydrocortisone and was able to be commenced on infliximab without recurrence of the Stevens-Johnson syndrome. Severe skin reactions induced by TNF-α antagonists can be very serious, and prescribers need to be aware of the potential for the mucocutaneous adverse effects from the use of these agents, particularly due to the significant morbidity and mortality that are associated with SJS.

Prevalence and Risk Factors of Discordance between Left- and Right-Hip Bone Mineral Density Using DXA.

To determine the prevalence of significant left-right differences in hip bone mineral density (BMD), and the impact of this difference on osteoporosis diagnosis, we measured bilateral proximal femora using dual energy X-ray absorptiometry (DXA) in 3481 subjects (608 males, 2873 females). The difference between left and right hip was considered significant if it exceeded the smallest detectable difference (SDD) for any of the three hip subregions. Contralateral femoral BMD was highly correlated at all measuring sites (r = 0.92-0.95). However, significant left-right differences in BMD were common: the difference exceeded the SDD for 54% of patients at total hip, 52.1% at femoral neck, and 57.7% at trochanter. The prevalence of left-right differences was greater in participants >65 years. For 1169 participants with normal spines, 22 (1.9%) had discordant left-right hips in which one hip was osteoporotic; for 1349 patients with osteopenic spines, 94 (7%) had osteoporosis in one hip. Participants with BMI < 20 kg/m(2) were more likely to show major T-score discordance (osteoporosis in one hip and normal BMD in the other). Multiple regression analysis showed that the only significant statically parameter that persists after adjusting for all potential confounding parameters were age over 65 years.

Relationship between vertebral fracture prevalence and abdominal aortic calcification in men.

OBJECTIVE: To study the relationship between the prevalence of vertebral fractures (VFs) using VF assessment (VFA) in asymptomatic men and the prevalence and severity of abdominal aortic calcification (AAC). METHODS: We enrolled 709 men with mean (s.d.) age 62.4 (8.6) (range 45-89) years. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of the Genant semi-quantitative (SQ) approach and morphometry. VFA images were scored for AAC using a validated 24-point scale. RESULTS: VFA images showed that 68 (14.2%) of the participants had at least one grade 2/3 VF, 82% did not have any detectable AAC, whereas the prevalence of significant atherosclerotic burden, defined as an AAC score of ≥5, was 2.8%. The group of men with grade 2/3 VFs had a statistically significant higher AAC score and higher proportion of subjects with extended AAC, and lower weight, height and lumbar spine and hip BMD and T-scores than those without a VFA-identified VF. Multiple regression analysis showed that the presence of grade 2/3 VFs was significantly associated with BMI [odds ratio (OR 0.915; 95% CI 0.589, 0.975; P = 0.006], AAC score ≥5 (OR 4.509; 95% CI 1.505, 13.504; P = 0.007) and osteoporosis in any site (OR 5.159; 95% CI 3.116, 8.540; P ≤ 0.0001). CONCLUSION: In elderly men, extended AAC is an indicator of the increased risk for prevalent VFs regardless of age, BMI, history of fractures, smoking and BMD.

Hypovitaminosis D and prevalent asymptomatic vertebral fractures in Moroccan postmenopausal women.

BACKGROUND: Hypovitaminosis D is associated to accentuated bone loss. However, association between osteoporotic vertebral fractures (VFs) and vitamin D status has not been clearly established. OBJECTIVE: To determine serum vitamin D status and to assess the association of vitamin D status with bone mineral density (BMD) and asymptomatic VFs prevalence using vertebral fracture assessment (VFA) in a cohort of Moroccan menopausal women. METHODS: from June to September 2010, 178 menopausal women 50 years old and over were enrolled in this cross-sectional study. The mean ± SD (range) age, weight, height and BMI were 58.8 ± 8.2 (50 to 79) years, 73.2 ± 13.8 (35 to 119) Kgs, 1.56 ± 0.06 (1.43 - 1.79) m and 29.8 ± 5.9 (17.5 - 49.8) kg/m2, respectively. VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative approach and morphometry. Serum levels of 25-hydroxyvitamin D (25(OH)D) were measured. RESULTS: Among the 178 women, 45 (25.2%) had densitometric osteoporosis, and on VFA, VFs (grade 2 or 3) were detected in 20.2% while grade 1 were identified in 33.1%. The mean values of serum levels of 25(OH)D were 15.8 ± 11.6 ng/ml (range: 3.0 - 49.1) with 152 patients (85.3%) having levels <30 ng/ml (insufficiency) and 92 (51.6%) <10 ng/ml (deficiency). Stepwise regression analysis showed that presence of VFs was independently related to age, 25(OH)D and densitometric osteoporosis. CONCLUSION: our study shows that advanced age, hypovitaminosis D and osteoporosis are independent risk factors for asymptomatic VFs in Moroccan postmenopausal women.

Homocysteine, folate, and vitamin B12 levels and vertebral fracture risk in postmenopausal women.

The objective of this study was to examine the influence of homocysteine, vitamin B(12), and folate on the prevalence of asymptomatic osteoporotic vertebral fractures (VFs) using vertebral fracture assessment (VFA) in postmenopausal women. The study cohort consisted of 188 consecutive postmenopausal women (mean age, weight, and body mass index of 57.9 ± 8.5 [41-91]yr, 74.4 ± 13.5 [38-150]kg, and 30.4 ± 5.2 [17.1-50.7]kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a Lunar Prodigy Vision densitometer (GE Healthcare Inc., Waukesha, WI). VFs were defined using a combination of Genant's semiquantitative approach and morphometry. Fifty-eight (30.9%) patients had densitometric osteoporosis. VFs were identified using VFA in 76 (40.4%) patients: 61 women had grade 1 VFs and 15 had grade 2 or 3 VFs. No statistical difference was shown between the 3 groups (absence of VFs, VFs grade 1, and VFs grade 2/3) concerning the biological parameters. Comparison of patients according to quartiles of homocysteine levels showed that women in the highest quartile were older and had a lower bone mineral density (BMD); however, the prevalence of VFs was not statistically different from that of women in the other quartile groups. Stepwise regression analysis showed that homocysteine was not independently associated with the presence of VFs, which was mainly related to the osteoporotic status. Although a weak association was observed between hyperhomocysteinemia and low BMD and a trend to higher prevalence of grade 2/3 VFs was observed, our study did not confirm that homocysteine, vitamin B(12), and folate status are important determinants of prevalent asymptomatic VFs in postmenopausal women.

The relationship between sex steroids, bone turnover and vertebral fracture prevalence in asymptomatic men.

OBJECTIVE: To examine the association between oestradiol (E2), testosterone (T), SHBG levels and vertebral fractures' (VFs) prevalence in asymptomatic men. METHODS: The study cohort consists of a population of 112 consecutive men (mean±SD (range) age, weight and BMI were 62.9±9.2 (41-84) years, 75.0±13.8 (45-120) kgs and 26.4±4.7 (18.0-39.6) kg/m(2), respectively). Lateral vertebral fracture assessment (VFA) images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative approach and morphometry. Serum levels of T, E2, CTx and osteocalcine were measured. Free androgen index (FAI) and free estradiol index (FEI) were calculated respectively from the ratio of serum T and E2 to SHBG. RESULTS: Among the 112 men, 38 (33.9%) had densitometric osteoporosis, and on VFA, VFs were identified in 60 (53.5%): 24 men had grade 1 and 36 had grade 2 or 3 VFs (32.1%). Men with VFs weighted less and had a statistically significant lower lumbar spine and total hip BMD and T-scores than those without a VFA-identified vertebral fracture. Levels of osteocalcine, CTx, and SHBG were statistically higher in men with grades 2 and 3 VFs than men with grade 1 VFs and those without VFs whereas FAI and FEI levels were significantly lower. Comparison of patients according to quartiles of SHBG levels showed that men in the highest quartile were older, had a lower lumbar spine and total hip BMD and a higher prevalence of osteoporosis and VFs. They had also higher levels of CTx. Stepwise regression analysis showed that the osteoporotic status and SHBG was independently associated to the presence of VFs. CONCLUSION: Men with asymptomatic densitometric VFs have lower BMD than subjects without VFs. They have evidence of higher SHBG levels and hence lower free sex steroids as well as increased bone resorption. This study confirms that BMD and CTx are the most important determinant of asymptomatic VFs, and that SHBG is an independent risk factor that must be taken into account.

Prevalence and risk factors of vertebral fractures in women with rheumatoid arthritis using vertebral fracture assessment.

OBJECTIVE: To study the prevalence and risk factors of vertebral fractures (VFs) in a large cohort of patients with RA using VF assessment (VFA). METHODS: We enrolled 172 women with RA, none of whom were taking osteoporosis medications. Patients underwent dual X-ray absorptiometry at the hip and spine and VFA, and completed a questionnaire. Radiological status was assessed by the modified Sharp erosion and narrowing score. VFA was classified using a combination of Genant semi-quantitative approach and morphometry. RESULTS: Patients had a mean (s.d.) disease duration of 8.4 (5.2) years. VFs were detected in 36% (62/172). This group of women had a statistically significant lower weight, height and lumbar spine and total hip BMD and T-scores than those without a VFA-identified VF. They also had more long-standing and severe disease and a greater consumption of corticosteroids. Stepwise regression analysis showed that the presence of VFs was independently associated with low weight and total hip T-score and long disease duration, CRP and Sharp erosion score. CONCLUSION: RA is a risk factor on its own for the development of osteoporosis and VFs and this risk increases more with low weight, disease duration and severe course of disease. These findings may suggest that to prevent the development of VFs, precautions should be taken immediately to suppress the disease activity and correct the weight loss in patients with RA.

Erdheim-Chester disease: a case report with pulmonary, kidney involvement and bone lesions.

We report the case of a 42-year-old woman who was admitted in 2002 for exploration of diffuse bone pain. She had medical history of pulmonary tuberculosis. Her current symptoms had started 9 months earlier and consisted of bone pain, affecting the legs. She had asthenia and weight loss. At admission, physical examination showed bilateral and symmetrical long bone pain, especially the knees and the ankles. Physical exam was normal elsewhere. Laboratory tests showed inflammation, with an erythrocyte sedimentation rate of 90 mm/h and C-reactive protein 8 mg/l. Protein electrophoresis, red and white blood cell count, renal, and liver function tests were normal. Serum calcium, phosphorus, and urinary calcium were normal. Radiographs showed multiple mixed bone lesions with sclerotic and lytic areas of the femora, tibiae, humerus. Chest radiographs and thoracic computed tomography (CT) scan showed pulmonary fibrosis. Biopsy of the tibial area displayed foamy lipid-laden histiocytes, confirming the diagnosis of Erdheim-Chester disease. Patient was treated with prednisolone plus cyclophosphamide. Her clinical condition improved remarkably during 4 years, but she developed acute renal failure leading to death.