Trend towards increased arterial stiffness or intima-media thickness in ankylosing spondylitis patients without clinically evident cardiovascular disease.

OBJECTIVES: Increased incidence of cardiovascular disease (CVD) has been observed in AS. The reasons of this increase are not fully understood (greater prevalence of traditional cardiovascular risks, consequences of treatment (NSAID) or biological inflammation). The objectives of this study are to assess intima-media thickness (IMT) and arterial stiffness (i.e augmentation index AIx), markers of sub-clinical atherosclerosis in AS patients and to examine the effects of TNF-alpha inhibitors on arterial stiffness in active AS patients. METHODS: Sixty AS patients were enrolled with 60 healthy controls. Their BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASFI (Bath Ankylosing Spondylitis Functional Index) scores, ESR and CRP levels were recorded. Subclinical atherosclerosis was assessed by measurement of AIx by pulse wave analysis and IMT by carotid echography. RESULTS: We found significantly increased IMT in the AS group compared with healthy controls. After adjustment for confounding factors, an underlying trend towards increased IMT was still present (P = 0.06). No difference was found in arterial stiffness between the two groups. AS patients, treated or not with anti-TNF-alpha at baseline, had significantly increased IMT and AIx or a trend towards increase. IMT was positively correlated with tobacco use, WHR and blood pressure but not correlated with CRP level. Despite improvement in markers of disease activity, arterial stiffness was unchanged after 14 weeks of treatment with TNF antagonists. CONCLUSION: This study shows a trend towards increased subclinical atherosclerosis in AS patients. TNF-alpha blockade does not seem to improve arterial stiffness in AS patients, but our results lack statistical power.

[Fractures of the ankylosed spine: MRI features]. / Fractures du rachis ankylosé: intérêt de l'IRM.

The diagnosis of transverse spinal fractures in patients with ankylosing spondylitis and Forestier's disease (DISH) may be difficult. The MRI features of 9 such fractures at the disk, vertebral body, spinal canal and posterior elements are presented. Fractures of the posterior elements (posterior arch fractures and/or rupture of interspinous or supraspinous ligaments and contiguous soft tissue structures) were present in all cases, underscoring the importance of MR signal abnormalities of posterior structures for diagnosis of these fractures. MR is advantageous due to its ability to demonstrate signal abnormalities of the posterior elements, which combined with disk and vertebral body abnormalities, play a major role for accurate diagnosis of this type of fracture.

Polyarticular septic arthritis.

Twenty-five cases of polyarticular septic arthritis (PASA) were observed in our department over a 13-year period. They accounted for 16.6% of all septic arthritis (15% on average in the literature). A male predominance was noted in our patients, as well as in the literature. The knee was the most frequent location followed by the elbow, shoulder, and hip, in varying order depending on the series. An average of 4 joints was involved. The causative microorganism was Staphylococcus aureus in 20/25 of our patients and in about 50% of published cases. Other frequently causative organisms were streptococci and gram-negative bacteria. Blood cultures and joint aspirations were positive in 19/22 and 23/25 of our cases, respectively. Other septic lesions were noted in 10/25 of our cases. Fever and severe leukocytosis were absent at admission in 5/25 (literature, 37%) and 10/25 of our 25 patients, respectively. The underlying disease was rheumatoid arthritis in 13/25, while 9 of the other patients had immunodepression caused by drugs or by concurrent illness. Typically, rheumatoid arthritis was long-standing and erosive, patients having ulcerated calluses on the feet. This skin source was also noted in 23/36 published cases of PASA in rheumatoid arthritis. Systemic lupus erythematosus was an uncommon disease in PASA, but its presence promoted gram-negative infection. Despite effective therapy with 2 antibiotics, 8/25 patients died, a prognosis that is equally severe in cases reported in the literature (30%) and one that has remained surprisingly stable over the last 40 years. For comparison, the death rate was only 4% in our patients with MASA. Factors contributing to a poor prognosis were age greater than 50 years, rheumatoid arthritis as an underlying disease, and disease of staphylococcal origin. Septic polyarthritis should be considered even when the clinical picture is not florid--when patients have low fever and normal white blood cell counts. Nor should the simultaneous involvement of distant joints rule out infection. Indeed, the frequency of underlying rheumatic disease and its treatment may further confuse the clinical presentation. Joints suspected of harboring infection should be aspirated, including those previously affected by the concurrent rheumatism.

Kinetics of allopurinol and its metabolite oxypurinol after oral administration of allopurinol alone or associated with benzbromarone in man. Simultaneous assay of hypoxanthine and xanthine by gas chromatography-mass spectrometry.

Allopurinol, oxypurinol, hypoxanthine and xanthine were assayed simultaneously using a highly specific method combining gas chromatography and mass spectrometry. Two hypo-uricaemic prescriptions were compared: i) 300 mg of allopurinol (AL); and ii) 100 mg of allopurinol plus 20 mg of benzbromarone (AL + BZB). When administered acutely, their effects on blood uric acid levels were similar. Analysis of the pharmacokinetic parameters of allopurinol and its metabolite after each treatment showed dose-linearity for the metabolite but not for the drug itself. The area under the concentration time curve for allopurinol was 40.3 +/- 9.3 mumol l-1 h after AL, against 8.4 +/- 3.9 mumol-1 h after AL + BZB, while for oxypurinol it was 948.0 +/- 125.4 mumol l-1 h after AL and 285.2 +/- 77.9 mumol l-1 h after AL + BZB. The difference in dosage form may partly account for this difference, but the benzbromarone also seems to be involved. Its role on the blood uric acid lowering action of the drug association is complex. Although benzbromarone appreciably favors the elimination of oxypurinol, which should result in a weakening of its hypo-uricaemic action, this is offset by enhanced elimination of hypoxanthine and xanthine. Renal clearance of xanthine was significantly increased under AL + BZB (173.1 +/- 65.6 ml/min against 112.2 +/- 32.9 ml/min after AL). Similarly, blood xanthine levels were proportionately higher in the presence of benzbromarone. The action of the two agents may thus be synergistic and not antagonistic, a pharmacological justification for the therapeutic use of this drug association.

Pamidronate in the treatment of diffuse sclerosing osteomyelitis of the mandible.

Diffuse sclerosing osteomyelitis of the mandible is characterized by bouts of intense pain, sometimes associated with trismus and paresthesia, and leads to progressive deformity. It is of unknown etiopathology, but it is suggested to be one manifestation of the synovitis, acne, pustulosis, hyperostosis, osteomyelitis syndrome, the other features of which may have been overlooked. Treatment results are disappointing, and decortication may be necessary to achieve an acceptable outcome. We report a case restricted to the mandible that responded favorably to treatment with pamidronate. Further trials of pamidronate in patients with diffuse sclerosing osteomyelitis of the mandible, even in those with the aforementioned syndrome, are needed to assess its effectiveness.

[Assay of plasma xanthine and hypoxanthine by coupled gas chromatography-mass spectrometry and sampling problems]. / Dosage de la xanthine et de l'hypoxanthine plasmatiques par couplage chromatographie en phase gazeuse-spectrométrie de masse et problèmes d'échantillonnage.

The differential assay of xanthine and hypoxanthine in plasma, serum and erythrocytes was performed using a combination of GC and MS with chemical ionisation. The influence of sampling conditions was studied, in particular the latency period between the collection of the blood and the separation of the plasma and the cells, the nature of the anticoagulant used and the method of storage of the samples. Firstly, this study confirms that EDTA is the most appropriate anticoagulant. It also showed that an immediate deproteinisation is necessary after separation of the plasma and the cells, in order to prevent any "in vitro" modification of the oxypurines, in particular erythrocyte hypoxanthine.

[Prognosis of multiple myeloma treated with conventional chemotherapy has not improved in 20 years]. / Le pronostic du myélome traité chimiothérapie conventionnelle ne s'est pas amélioré en 20 ans.

The treatment of multiple myeloma has changed over the last 20 years. We investigated the effects of theses changes on patient survival in the current practice of a rheumatology ward. Two hundred and seventy-nine patients were hospitalised between 1972 and 1993: 30 from 1972 to 1976, 70 from 1977 to 1981, 86 from 1982 to 1986, 75 from 1987 to 1991 and 18 from 1992 to 1993. Staging according to Durie and Salmon was I in 8%, II in 29% and III in 65%. In principle, the initial therapy was monochemotherapy in 65% of the cases and polychemotherapy in 35%. At the time of the present study, 197 patients have died. The actuarial curves of survival were similar in all historical classes defined by the date of first admission. Curves of median of follow-up and of floating means were level between 1972 and 1990. No correlation was found between the date of first admission and survival in the 174 patients who died between 1972 and 1987. The following parameters were associated with longer survival: achievement of an objective response on chemotherapy, lower patient's age, high haemoglobin, low creatinine, low stage according to Durie and Salmon, low number of plasma cells in bone marrow, low calcemia and low levels of IgA, monoclonal component. The comparison of prognosis factors in historical classes showed a difference only for haemoglobin which was lower in the earlier class. The type of the first chemotherapy regimen varied widely between historical classes. The number of responders was significantly greater after polychemotherapy than after monochemotherapy but no correlation was observed between the type of chemotherapy and survival. The frequencies of early death, and the causes of death in general, were not different in the historical classes. The lack of improvement of survival over the last 20 years shows that the efficacy of current chemotherapies is limited, a conclusion which warrants the exploration of other therapeutic avenues.

[Multiple complications of monoclonal IgM]. / Multiples complications d'une IgM monoclonale.

A 64 year old woman with monoclonal IgM Kappa cryoglobulinemia had developed neurologic, vascular and bone involvements. If each features were previously reported, their association appears to be rare. The polyneuropathy was consistent with an IgM anti MAG neuropathy rather than a cryoglobulinemic neuropathy. The vascular occlusion is well known in dysglobulinemia. The diffuse osteosclerosis without medullary fibrosis or myeloproliferative disorder was as like as a Schnitzler's syndrome (chronic urticaria, osteosclerosis, monoclonal IgM Kappa gammopathy.

[Rheumatoid arthritis preceding microscopic polyangitis. Report of two cases]. / Polyarthrite, manifestation inaugurale d'une polyangéite microscopique. A propos de deux observations.

INTRODUCTION: Although joint manifestations are common in microscopic polyangiitis (MPA), including arthralgia reported in 15-65% of cases and arthritis in 6-17%, there have been only two published cases of polyarthritis as the first manifestation of the disease. We report on two new cases. EXEGESIS: A 71-year-old woman had symmetric polyarthritis of the hands which initially suggested the existence of seronegative rheumatoid arthritis. A 52-year-old woman had seropositive asymmetric oligoarthritis. The diagnosis was not established until renal insufficiency appeared, prompting a renal biopsy which showed in both cases an extra-capillary glomerulonephritis and an anti-myeloperoxydase (p-ANCA) assay which was postive in both patients. The incidence and specificity of antineutrophil cytoplasmic antibodies (ANCA), including MPA, in rheumatoid arthritis are reviewed. CONCLUSION: Our two observations show that in cases of polyarthritis or oligoarthritis with renal involvement, testing for and typing of ANCA should be performed so as not to misdiagnose vasculitis.

[Fluoroscopy guided L5-S1 transforaminal injection as a treatement for s1 radiculopathy]. / Infiltration foraminale L5-S1 radioguidée dans le traitement de la lombosciatique S1.

OBJECTIVE: To assess the efficacy of fluoroscopy guided L5-S1 transforaminal steroid injections for the treatment of S1 radiculopathy secondary to intervertebral disk disorder. METHOD: 41 patients were included: prospective study (20 patients) and retrospective study (21 patients). All patients suffered from S1 radiculopathy secondary to nerve root compression by intervertebral disk material, as demonstrated by lumbar spine CT. The patients underwent 2 fluoroscopy guided L5-S1 transforaminal injections of steroid (Hydrocotancyl 125 mg), at 8 days interval. RESULTS: 60% of patients showed significant improvement of their painful radiculopathy at day 8 (n:41), 60-67% at day 30 (n:41) and 67% at day 90 (n:18). CONCLUSION: Fluoroscopy guided L5-S1 transforaminal injection showed good efficacy in the treatment of S1 radiculopathy.

[Does reactive arthritis caused by Brucella exist? Apropos of 4 cases]. / Les arthrites réactionnelles à Brucella existent-elles? A propos de 4 observations.

OBJECTIVES: Arthritis observed in patients with Brucella infection is usually considered to result from live micro-organisms invading the synovia. We observed four cases of brucellosis in which the clinical and laboratory findings suggested a different mechanism: reactive arthritis. CLINICAL OBSERVATIONS: The diagnosis of brucellosis was made on the basis of serology tests in 3 patients and blood cultures in 1. All 4 patients presented oligoarthritis. The synovial fluid was sterile in 3. Antibiotics were ineffective in reducing joint pain and inflammation whereas local and systemic anti-inflammatory drugs were effective. Three patients also had other manifestations (sausage-shaped toes, talalgia, sacroiliitis) and fulfilled the diagnostic criteria for spondylarthropathy. All patients were positive for antigen HLA-B27. DISCUSSION: These observations suggest that Brucella should be added to the list of intracellular infectious agents capable of inducing reactive arthritis, despite the lack of all the diagnostic criteria. For some, such as the uretritis or diarrhea observed before joint involvement, it would be difficult to implicate the germ. Brucella serology should be part of the etiology work-up for reactive arthritis in endemic areas.

[Spondylodiscitis caused by Fusobacterium nucleatum. Apropos of a case]. / Spondylodiscite à Fusobacterium nucleatum. A propos d'un cas.

Spondylodiscitis is rarely caused by anaerobic germs and occurs mainly in patients weakened by another infection. We report a case of Fusobacterium nucleatum spondylodiscitis in a 63-year-old man. This is the third such report and the second in a non-immunodepressed patient. The clinical presentation and laboratory findings in this type of spondylodiscitis vary little from those produced by other germs. Magnetic resonance imaging is the most useful diagnostic tool for spondylodiscitis. The germ is isolated from a discal puncture aspirate in 66% of the cases but can also be obtained from blood cultures. Anaerobic germs are usually sensitive to penicillin or cephalosporins.

[Vitamin-resistant hypophosphatemic rickets and spinal cord compression. Apropos of 2 cases]. / Rachitisme vitamino-résistant hypo-phosphatémique et compression médullaire. A propos de deux cas.

Adults with X-linked vitamin-resistant hypophosphatemic rickets can develop spinal cord compression as a result of spinal canal stenosis due to involvement of the spine with the increased periosteal and ligamentary calcification which is typical of the disease. Two cases are reported. In both patients, spinal cord compression manifested as rapidly progressive spastic paraplegia due to compression at T9 and T5, respectively. Decompressive laminectomy ensured full recovery in one case but was ineffective in the other. In both cases, paraplegia developed approximately one year after initiation of therapy combining a metabolite of vitamin D and phosphorus in high doses. Current imaging techniques (CT scan, magnetic resonance imaging) provide highly accurate information on the anatomic mechanism of the stenosis, its often multiple locations, and its course. Three factors are involved in the stenosis, in variable degrees: thickening of the laminae, hypertrophy of the facet joints, thickening and calcification of the yellow ligament. Magnetic resonance imaging is the investigation of choice in these patients. A deleterious effect vitamin D-phosphorus treatment cannot be outruled. The appropriateness of initiating this treatment should be prudently discussed and treated patients should be closely monitored.

[Involvement of the foot in reactive arthritis. A retrospective study of 105 cases]. / L'atteinte du pied dans les arthrites réactionnelles. Etude rétrospective de 105 cas.

The foot is among the sites most often affected in spondyloarthropathies, whose diagnostic criteria include heel pain and sausage-like swelling of the toes. Few studies have systematically analyzed foot manifestations in reactive arthritides. We retrospectively reviewed 143 patients fulfilling Amor's criteria. One hundred five patients (73%) exhibited inflammatory involvement of one (n = 47) or both feet. In 8 cases no other articular sites were affected. Heel pain was reported by 36% of patients (52/143), within the first six months in half the cases. Both heels were painful in 26 patients. Heel pain was plantar in 36 cases, posterior in 7 cases, and bipolar in 4 cases. Roentgenographic calcaneal changes were found in 54 cases overall but in only 31 of the patients with heel pain. Sixteen patients had asymptomatic calcaneitis. Seventeen patients had involvement of the transverse tarsal joint, usually with no other affected joints. Involvement of the subtalar joint was rare (6 cases). Metatarsophalangeal manifestations were found in 44% of patients (64/143) and were symmetrical in 17 cases; 17 patients had changes of the great toe suggestive of gout. Interphalangeal arthritis was seen in 22% (32/143) of cases; in half these cases the first two rays were affected and sausage-like digital swelling was seen in 28 patients (20%). Permanent roentgenological damage was uncommon.

[Septic arthritis in rheumatoid polyarthritis. 24 cases and review of the literature]. / Les arthrites septiques au cours de la polyarthrite rhumatoïde. Vingt quatre observations et revue de la littérature.

Twenty-four cases of septic arthritis in rheumatoid arthritis patients were compared with 99 cases of septic arthritis in patients without rheumatoid arthritis. In addition, 238 previously published cases of septic arthritis with rheumatoid arthritis were analyzed. Fifteen percent of our patients with septic arthritis had rheumatoid arthritis, which was typically of long duration (mean 15 years), erosive, and seropositive. Fifty-four per cent (28% in the literature) and 9% of patients with and without rheumatoid arthritis, respectively, had pyarthrosis of multiple joints. The knee represented one-third of infected joints and the elbows and wrists were more often infected in patients with than without rheumatoid arthritis. S. aureus was recovered in 80% versus only 60% of patients with and without rheumatoid arthritis, respectively. The source of sepsis was often a skin lesion, in particular at the foot, emphasizing the need for early orthopedic treatment of deformities responsible for skin lesions. Monoarticular infection was more likely to be due to an intraarticular injection. Mortality rate was 17% in patients with rheumatoid arthritis (23% in the literature) versus 7% in patients without rheumatoid arthritis. Staphylococcal infection and infection of multiple joints were associated with higher mortality rates (35% and 49%, respectively). The mortality rate in polyarticular infections has failed to decline over the last 35 years. Initial failure to distinguish septic arthritis from an exacerbation of rheumatoid arthritis contributes to the high mortality rate. The diagnosis of septic arthritis rests on a high index of suspicion. Septic arthritis cannot be ruled out based on absence of local inflammation, fever, or hyperleukocytosis or on presence of inflammation of multiple joints. Joint fluid specimens should routinely be sent to the microbiological laboratory and should be inoculated in blood culture bottles at the least suspicion.

Differences between women and men with recent-onset axial spondyloarthritis: results from a prospective multicenter French cohort.

OBJECTIVE: To clarify sex differences in early axial spondyloarthritis (SpA). METHODS: In total, 475 patients included in the Devenir des Spondylarthropathies Indifférenciées Récentes (Outcome of Recent Undifferentiated Spondylarthropathies) cohort, a prospective multicenter French cohort of patients with early inflammatory back pain suggestive of SpA, and fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial SpA were studied. The clinical and imaging features were compared between sexes and according to the clinical or imaging arm of the ASAS criteria using univariate and multivariate analysis. RESULTS: Comparisons between the 239 men and 236 women showed that women had higher disease activity when measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Patient Global Score and higher fatigue and functional scores despite having less radiographic sacroiliitis and magnetic resonance imaging (MRI) inflammation of sacroiliac joints and the spine than men. Disease activity measured by the C-reactive protein (CRP)-based Ankylosing Spondylitis Disease Activity Score was not different between men and women. In contrast to patients classified with the clinical arm, disease activity and functional scores did not differ between women and men with sacroiliitis on imaging scans, except for fatigue and the Ankylosing Spondylitis Quality of Life questionnaire. Women with sacroiliitis had more peripheral involvement and more family history, whereas HLA-B27 positivity, elevated CRP, and MRI inflammation of the spine were associated with male sex. CONCLUSION: Women with early axial SpA according to the ASAS criteria had greater disease activity when measured by the BASDAI and worse functioning despite fewer radiologic abnormalities than men. The differences in disease expression may be confounding factors to establish the diagnosis of SpA and to assess disease activity in women, suggesting that the imaging arm is a pivotal measure in the ASAS criteria.

[Transversal fractures in spinal ankylosis: a case series of 17 patients]. / Fractures transversales du rachis ankylosé : une série de 17 cas.

PURPOSE: Transverse fractures of the spine are rare. They occur in ankylosed spine and may lead to neurological complications. We report a series of 18 cases observed in 17 patients with ankylosing spondylitis (AS). The objective of this study were to describe the clinical, diagnostic and therapeutic features of our series and to compare our results with those of the literature. METHODS: We conducted a retrospective study from 1975 to 2008 in the neurosurgery and rheumatology departments of the university hospital (CHU) of Clermont-Ferrand. RESULTS: Eighteen transverse spine fractures were documented in 17 patients (one female patient had two fractures of the lumbar vertebrae). The 13 male and four female patients included in this series had a mean age of 57.4 ± 17.2 years and AS for a mean time of 21.3 ± 12 years (5-40). All patients had spinal ankylosis with a "bamboo" spine appearance. The reasons for hospital admission were suspicion of AS flare (n=10) and suspected traumatic fracture (n=8). Trauma, in most cases minor, was noted in 15 patients. Fourteen patients presented with mechanical spinal pain and three had both mechanical and inflammatory pain. Three patients experienced severe pain on mobilization. Two patients had pyramidal syndrome. The mean time to diagnosis of the fracture was 6.8 ± 8.4 weeks (0-22). The fracture was located in cervical spine (n=2), dorsal spine (n=8) and lumbar spine (n=8). It was transdiscal and transcorporeal in nine cases each. Standard radiographs (n=18) identified the fracture in nine cases. The fracture was demonstrated in all CT-scan (n=13). Magnetic resonance imaging (MRI) (n=6) showed the fracture in five cases and epidural hematoma in one. Eleven patients had orthopedic treatment and six underwent surgery. Outcome was favorable in 16 patients. One paraplegic patient died of pulmonary embolism. CONCLUSION: Transverse fractures of the spine are rare and diagnosis should be considered in a patient with AS and ankylosed spine who presented mechanical spine pain following even minor trauma. If standard radiographs are normal, further investigations should be performed using MRI, CT-scan, or both.