COVID-19-Induced Rheumatoid Arthritis: Case Series and Systematic Review of the Literature.

COVID-19, caused by a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to severe infection and has been suggested to induce autoimmune phenomena. We report three cases of rheumatoid arthritis (RA) occurring after COVID-19 infection and we present a systematic review of the literature of cases of RA post COVID-19. Our findings suggest that RA may be trigged by COVID-19 infection in genetically predisposed individuals.

Relevance of the video capsule as a tool for learning Schöber Index measurement in medical students.

INTRODUCTION: Medical education has progressed considerably. Information and communication technologies have been adopted as a learning tool. AIM: We aimed to evaluate the contribution of an educational video in the acquisition of knowledge on the measurement of the Schöber index in young medical students. METHODS: This is a prospective study, spread over 4 months (February 2022-May 2022) and conducted in the rheumatology and orthopedics departments of the Charles Nicolle Hospital in Tunis. We included medical students during their externship at the mentioned services. We compared the realization of the steps of the Schöber test (testing the flexibility of the lumbar spine) before and after the visualization of an educational video. RESULTS: A total of 32 students (6 men and 26 women) were enrolled. There were 18 students (56%) in DCEM1 and 14 students (44%) in PCEM2. Our study showed that the number of students who correctly performed the different steps of the Schöber test increased after viewing the instructional video compared to the beginning, but this increase was not significant. There were some differences between the PCEM2 and DCEM1 groups before viewing the video, but this difference decreased after viewing the video. CONCLUSION: Our study has demonstrated the value of an educational video in improving the knowledge of medical students. This work needs to be applied on a larger scale in different medical specialties.

Unexpected diagnosis of vertebral osteolysis.

This is the case of a 50-year-old patient suffering from inflammatory low back pain. Radiological exploration showed posterior vertebral damage compatible with discovertebral pseudo-tumor tuberculosis. Pathological examination found no malignant cells, but caseous necrosis was present. The patient was put on antitubercular drugs. The evolution was favorable under treatement.

Eumycotic mycetoma involving the right foot: A new Tunisian case.

A Tunisian patient with painless swelling and discharging sinuses of the right foot was diagnosed with Eumycetoma after 1 year of evolution. Mycetoma is a neglected disease relatively rare in our country. An early and accurate diagnosis, based on histopathological and microbiological examinations, limits functional and esthetical damage.

Involvement of foot in patients with spondyloarthritis: Prevalence and clinical features.

BACKGROUND: The purpose of this study was to evaluate the foot involvement in a group of patients with spondyloarthritis in regard to symptoms, type and frequency of deformities, location and radiological changes. METHODS: We conducted a cross sectional study including 60 patients with spondyloarthritis over a period of six months. Anamnesis, clinical examination, podoscopic examination, biological tests and X-rays of feet were done for each patient. RESULTS: Foot involvement was found in 31 patients (52%). It was symptomatic in 35% of cases and inaugural in 42% of cases. The most frequent site was the hindfoot (22 patients/31). Radiological findings were: erosion (17%), reconstruction (33%), erosion and reconstruction (50%). Forefoot involvement was found in 18/31 patients. Forefoot deformities were found in 9 patients. Two patients had sausage toe and feet skin abnormalities were observed in 12 patients. At podoscopic examination, 23 patients had abnormal footprints. Foot involvement was more frequent in peripheral spondyloarthritis (p=0.008). Patients with foot involvement had an advanced age of disease onset (p=0.05), a shorter disease duration (p=0.038) and more comorbidities (p=0.039). Foot involvement was correlated with C Reactive protein (p=0.043). CONCLUSION: In our study, foot involvement and foot symptoms were seen frequently in spondyloarthritis and it is associated with late onset of the disease and with higher inflammation in blood tests.

Endovascular repair of inflammatory aortic aneuvrysm.

INTRODUCTION: While open repair was the gold standard treatment of atherosclerotic abdominal aortic aneurysms, its place in the treatment of inflammatory aortic aneurysms remains controversial. AIM: To specify the place of endovascular repair in the treatment of inflammatory aneurysms. OBSERVATION: We report 2 cases of inflammatory aortic aneurysms. The first patient was followed for Behçet's disease and the other patient for Giant Cell arteritis 's disease. We noted a biological inflammatory syndrome. CT scan suggested the diagnosis of inflammatory aortic aneurysm. We have implemented a bifurcated stent graft for the patient with a Behcet's disease. For the second patient, we converted to conventional surgery. Corticosteroid therapy was prescribed in two cases with favorable evolution. CONCLUSION: Endovascular repair is a good alternative to surgery for inflammatory aneurysms. Medical therapy occupies a prominent place in its therapeutic management.

[Thoracic outlet syndrome]. / Le syndrome du défilé cervico-thoraco-brachial.

BACKGROUND: The thoracic outlet syndrome (TOS) is recognized as a cause of upper limb pain. It is often under-diagnosed and its frequency under-estimated by rheumatologists. AIM: To report the diagnostic problems related to TOC though a literature review. METHODS: A narrative review of literature RESULTS: The diagnosis of TOS is difficult because of intricacy of vascular and neurological symptoms. It requires provocative tests, electrophysiological investigations and Doppler ultrasonography. A good anatomical knowledge is mandatory in order to clarify the mechanisms and the location of the lesions which depend on sophisticated imaging exams. It is also recommended to exclude all other causes of upper limb pain, as well as peripheral nerve compression syndromes, which can coexist with TOS. CONCLUSION: Diagnosis and treatment of the TOS involves rheumatologists, neurologists, physiatrists, orthopedic surgeons,vascular surgeons, thoracic surgeons, neurosurgeons and sometimes psychiatrists who have to cooperate in order to prevent severe functional after-effects.

[Uncommon cervicobrachial neuralgia: about 17 cases]. / Les névralgies cervico-brachiales symptomatiques : Apropos de 17 cas.

BACKGROUND: Cervicobrachial neuralgia (CBN) is frequent in out patient clinic as well in general medicine as in rheumatology. Even though cervical disc degeneration and osteophytosis constitute the most frequent etiology of such a trouble, the practitioner must be aware of much more serious underlying cause. AIM: To investigate the epidemiology, clinical features, aetiologies and paraclinical characteristics of uncommon CBN. METHODS: Retrospective chart review about 17 cases of uncommon CBN among the 84 cases of CBN hospitalized at the rheumatology department of the Charles Nicolle Hospital during a 16-years-period [1990-2005]. RESULTS: There were 11 men and 6 women with a mean age of 63 years [33y-81y]. All patients presented a CBN since in average five months [2 months- 24 months]. Neck stiffness was noted in 60% of cases and a neurological impairment in 47% of cases. X-ray radiographs of cervical spine were normal in five cases. In the remaining cases, they showed lytic images (six cases), disk space narrowing with vertebral erosions (two cases) and vertebral fracture (three cases). Further investigations concluded that the CBN was due to a Pancoast'syndrome in five cases, an infectious spondylitis in three cases, cervical bone metastasis in two cases, a syringomyelia in two cases, a neuroma in one case, a thoracic outlet syndrome in one case and an erosive spondylarthropathy in a patient presenting chronic renal failure managed by hemodialysis. CONCLUSION: In comparison with common CBN, our patients presenting symptomatic CBN were characterised by an inflammatory and refractory pain. The more frequent recourse to modern imaging is justified.

[Bisphosphonates: indications in bone diseases other than osteoporosis]. / Indications des bisphosphonates dans les affections osseuses autres que l'ostéoporose

AIM: Report of bisphosphonates indications for osseous diseases other than osteoporosis. METHODS: Narrative review of the literature. RESULTS: Bisphosphonates represent a new medication which is increasingly used. Besides osteoporosis, it is indicated as first choice in different bone diseases such as Paget's disease and the prevention of bone complications in tumoral osteolysis. Bisphosphonates' efficiency has been proven in other pathologies: the fibrous dysplasia and the osteogenesis imperfecta. More over, many studies are driven having for goal to show the efficiency of bisphosphonates in the algoneurodystrophy, non corticosteroid-treated osteoporosis in chronic inflammatory rheumatism and aseptic osteonecrosis. CONCLUSION: Bisphosphonates are a powerful inhibition of osseous resoption frestable indicated for osteoporosis. Their indications were retended to paget's disease, malignant hypercalcemia, and osseous complications of malignant osterlysis.

[Obesity has a protective effect on radiographic joint damage in rheumatoid arthritis]. / L'obésité est un facteur protecteur contre l'atteinte structurale au cours de la polyarthrite rhumatoïde.

BACKGROUND: Obesity is a state of chronic low-grade inflammation that predisposes people to several diseases and that is increasingly prevalent. Rheumatoid arthritis (RA) is marked by the presence of proinflammatory cytokines and, in general, the presence of high levels of inflammatory markers is associated with a severe disease course and joint damage. AIM: To assess the impact of obesity on disease activity, quality of life and articular damage in patients with established RA. METHODS: Between July 2009 to December 2009, 119 RA patients were included and divided in two groups according to the body mass index (obeses and controls). RA activity was assessed by the Disease Activity Score (DAS) 28, quality of life by the Health Assessment Questionnaire (HAQ) and radiographic joint damage by the modified Sharp score. RESULTS: Obesity was not correlated with worsen RA activity (p=0.71) nor quality of life impairment (p=0.51). The obese group had a lower modified Sharp score than the control group (64.97versus113.64; p < 0.032) and this association remained significant after adjustment for age, sex, disease activity, extraarticular manifestations, comorbidities, presence of rheumatoid factor, and disease duration. CONCLUSION: Obesity does not have an impact on disease activity nor changes in quality of life, but it has a protective effect on the amount of joint destruction in established rheumatoid arthritis.

[Morbidity of the elderly in inpatient rheumatology clinic]. / Morbidité hospitalière du sujet âgé en milieu rhumatologique.

BACKGROUND: The improvement of life expectation in our country explains at least in part the increase of the proportion of the elderly in hospitalized patients. AIM: The aim of this study was to identify the main diseases leading to hospitalization of the aged in a rheumatology department, to establish their clinical profiles and to evaluate the quality of their management. METHODS: Retrospective chart review about the elderly (age > or =65 years) admitted in the rheumatology department of the Charles Nicolle Hospital during a 2-year-period [January 2003-December 2004]. RESULTS: Among the 831 patients admitted to our inpatient clinic during that period, 86 were 65-year-old or more representing 10% of the total. Mean age was 71.2 years [65-88]. The sex ratio was 1/3. A history of a mean of two associated diseases [0-5] was noted. They were dominated by hypertension (50%) and diabetes (26.7%). Almost 1/3 of the elders had a surgical history. Gastro-intestinal troubles have been noted in only 19% of cases. The main cause of hospitalization was a diagnosis exploration (77.6%). The remainings were admitted for therapeutic adjustment. The disease was evolving since in mean 16 months (15 days-15 years). The mean duration of hospitalization was 21.2 days (4-60). The pathologies involved were varied dominated by degenerative rheumatisms (26.7%) with a predilection to lumbar spine, systemic diseases: 18 cases (20.9%) with 13 cases of rheumatoid arthritis, and malignant bone diseases (18.7%). At least two rheumatic diseases were found together in 49 patients (57%). The clinical findings were atypical in almost half cases (42.4%) in such aged patients. Besides drugs prescribed for non rheumatic diseases, our patients took a mean of 3.4 drugs (1-8) as symptomatic, adjuvant or etiologic treatment. The treatment observance was good in 74.4% of cases. Iatrogenic incidents occurred in 14 cases (16.2%). The outcome was favorable in 68.9% of cases. Twelve of our patients necessitated a third help. Half of our patients (54%) were controlled in our outpatient clinic 1-2 months after their issue, 12 have been hospitalized for the same disease, 8 deceased, and 19 have been lost. CONCLUSIONS: The management of the elderly patients in hospitalization must be multidisciplinary. It should take into account the clinical and therapeutic particularities of such a population. Prevention remains the best guarantee for a good quality of life and to decrease social and economic costs.

[Update in treatment of psoriatic arthritis]. / Actualités thérapeutiques du rhumatisme psoriasique.

Psoriatic arthritis is a chronic rheumatic disease making part of spondylarthropathies. It is the most frequent chronic inflammatory rheumatism after rheumatoid arthritis. Eventhough, it is usually a benign affection, it may be destructive leading to handicap. Several new medications have been introduced, including anti-tumor necrosis factor (TNF alpha blockers) and leflunomide for treatment of psoriatic arthritis. Many studies show the efficacy of these medications in this disease.

[Common lumbosciatic syndrome of the elderly. Report of 67 cases]. / Les lombosciatiques communes du sujet age. A propos de 67 cas.

BACKGROUND: The common lombosciatic is a disease observed at all ages. To the elderly, clinical data, treatment, clinical outcome and prognosis present sometimes some peculiarities. AIM: Report of lombosciatic in the elderly. METHODS: It is a retrospective study including 67 cases of sciatica concerning old patients over 65 years presenting with common lombosciatica, hospitalized between January the 1-st, 2000 and December 31 st, 2004. RESULTS: The mean age of our patients is of 71.2 years, sex ratio female/male of 1.88. A chronic lumbago is found at 16.34% of our patients and a starting factor pains in 14.3% of cases. Pain is of progressive installation in 93.4 % of cases. Mechanical in 77.5 % of cases and impulsive in 55 % of cases. Sciatica was unilateral in 67.3% of cases and interesting the root L 5 in 40.8 % of cases. Physical exam find a painless attitude in 26.5% of cases and a spasm of spinal muscles in 65.3%. The average of schöber index is of 2.4 cms + 1.18. Lasègue is present in 36.7 % of cases. Neurological exam find overdrawn signs in 8 % of cases, sensory signs in 61.2% of cases. No cauda equine syndrome was individualized in our series. Lumbar spine X-rays, made in 98 % of cases, show a L5-S1 disc impairment in 83.6% of cases, a scoliotic attitude in 22.4 % of cases, a spondylolithesis of L4L5 in 26,5 % of cases and lumbar cannal stenosis in 12.2% of cases. Lumbar densitometry, realized in 22.4% of cases, shows a herniated disc in 27.2% of cases, and a lumbar canal stenosis in 27.2% of cases. The MRI, made once, was normal. During their hospitalization, 87.7% of patients received NSAID's, 18.4% of them analgesics drugs (landing I, II , III) and 79.6 % epidurals infiltrations. All our patients observed bed rest. A physiotherapy was prescribed for 44.9 % of them. A good outcome was quickly noticed in 85.7% of the patients. A therapeutic failure was observed at 14.3 %. 6% underwent surgery. Only 102 % of the non operated patient had pain recurrence. CONCLUSION: Nowadays sciatica is a frequent pathology either in oung or in geriatric population. Nevertheless it is necessary to eliminate a tumoral or infectious sciatica that can be misleading by the condition of the old age and by the frequent associated pathologies at such age.

[Adult onset Still's disease: about 11 cases]. / La maladie de still de l'adulte: à propos de 11 cas.

BACKGROUND: Adult onset Still's disease (AOS) is an inflammatory disorder which associates variable articular and systemic manifestations. Despite a better knowledge of its biological and clinical particularities; the pathogeny of this disease remains unknown. The aim of this study is to analyze the epidemiological, clinical, biological and, outcome characteristics of AOS. METHODS: It is a retrospective study about 11 cases of AOS hospitalized over a 24-year-period (1982-2005) at The Rheumatology Department of Charles Nicolle's Hospital of Tunis. All patients responded to the Yamaguchi criteria. RESULTS: Mean age was 35.4 years [20y-70y] with a sex-ratio of 0.57. Fever and articular involvement were the most frequent signs. Cutaneous symptoms were present in 6 patients. Three of our patients developed destructive arthritis. Renal amyloidosis, a rare complication of AOS, has been noted in one case. CONCLUSION: AOS is an unfrequent disorder characterized by its diagnosis and treatment difficulties. Recent advances in immunotherapy may better the management of AOS.