Management of gout by Moroccan rheumatologists: a Moroccan Society for Rheumatology National Survey.

To assess the modalities and current practices in gout management reported by Moroccan rheumatologists. We performed a cross-sectional online survey using a questionnaire e-mailed to 360 rheumatologists included 30 multiple-choice questions. 105 rheumatologists responded to the survey with 29% of response rate. The number of gout patients seen per month was five (3-9); they were referred in 58.7% by a general practitioner. The clinical presentation of gout patients was dominated by gout crisis in 71%, and the association gout crisis and gouty arthropathy accounted for 19% of severe forms. 40% of rheumatologists apply the 2015ACR/EULAR classification criteria. Obesity accounted for 85.7% of the associated comorbidities. The most commonly prescribed Urate-lowering therapy (ULT) was allopurinol in 81.3% (± 12). 48% of rheumatologists reported starting allopurinol at 200 mg daily and associated it with colchicine during the first 6 months by 33.3%. The determination of uric acid levels was monitoring in 76.2% every 3 months. Administration of ULT to asymptomatic hyperuricemia was found in 69.5% when patients had renal complications, while only 14.3% recommended dietary and lifestyle measures. The median duration for therapeutic education was 15 min (10, 20). In 96.2%, the education of the patient was done orally. 93.3% of rheumatologists inform their patients on how to manage a gout attack, and 96.2% on the measures of hygiene and diet has adopted. Our survey gives an insight into the elements that should be improved in the management of gout by the Moroccan rheumatologists. It highlights the need to standardize the management of gout, hence the importance of developing Moroccan recommendations on gout.

Ultrasound features of shoulder involvement in patients with ankylosing spondylitis: a case-control study.

BACKGROUND: During Ankylosing spondylitis (AS) courses, shoulder involvement is common. However, etiologies of shoulder pain in patients with AS remain to be defined. The aim of this study was to investigate the prevalence of ultrasound (US) abnormalities in shoulders of patients with ankylosing spondylitis (AS), and to determine predictive factors of ultrasound shoulder enthesitis. METHODS: 38 patients with AS were included with 38 age and sex-matched healthy controls. All patients fulfilled the modified New York criteria for ankylosing spondylitis. Clinical and demographical data were recorded. US examination of bilateral shoulders was performed by a musculoskeletal sonographer according to a defined protocol that included imaging of the insertions of supraspinatus, subscapularis and infraspinatus tendons, rotator cuff tendons, subacromial-subdeltoid bursa, acromioclavicular joint, and glenohumeral joint. RESULTS: The mean age of patients and controls was 36 years, each group of patients and controls comprised 22 men (57.9%) and 16 women (42.1%). Disease duration was 9.6 ± 7.2 years. Among 38 patients with AS, 21 had coxitis (55%) and 19 had previous or current shoulder pain (50%). AS shoulders presented significantly more ultrasound enthesitis than controls shoulders (43 shoulders (56.6%) versus 8 shoulders (10.5%) respectively). Involvement of rotator cuff tendons was significantly higher in patients with AS compared with control subjects (16/38 (42.1%) versus 6 (15.2%) respectively). However, involvement of gleno-humeral and acromio-clavicular joints was infrequent in both groups. In patients with AS, we found that the presence of coxitis was the only significant predictive factors of shoulder enthesitis (Odds Ratio (OR) = 9.4; Confidence interval (CI) 95% (1.10; 81.9), p = 0.04). CONCLUSIONS: Ultrasound abnormalities of shoulders are common in patients with AS, and the most frequent abnormalitie was enthesitis, which was associated with the presence of coxitis.

A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis.

BACKGROUND: Tenosynovitis is widely accepted to be common in rheumatoid arthritis (RA) and postulated to be the first manifestation of RA, but its true prevalence in early disease and in particular the hand has not been firmly established. The aims of this study were first to investigate the frequency and distribution of finger flexor tenosynovitis using ultrasound in early arthritis, second to compare clinical examination with ultrasound (US) using the latter as the gold standard. METHODS: 33 consecutive patients who had who were initially diagnosed with polyarthritis and suspected of polyarthritis and clinical suspicion of inflammatory arthritis of the hands and wrists were assessed during consecutive, routine presentations to the rheumatology outpatient clinic. We scanned a total of 165 finger tendons and subsequent comparisons were made using clinical examination. RESULTS: Flexor tenosynovitis was found in 17 patients (51.5%) on ultrasound compared with 16 (48.4%) of all patients on clinical examination. Most commonly damaged joint involved on US was the second finger followed by the third, fifth, and fourth. Both modalities demonstrated more pathology on the second and third metacarpophalangeal (MCP) compared with the fourth and fifth MCP. A joint-by-joint comparison of US and clinical examination demonstrated that although the sensitivity, specificities and positive predictive values of clinical examination were relatively high, negative predictive value of clinical examination was low (0.23). CONCLUSIONS: Our study suggest that clinical examination can be a valuable tool for detecting flexor disease in view of its high specificity and positive predictive values, but a negative clinical examination does not exclude inflammation and an US should be considered. Further work is recommended to standardize definitions and image acquisition for peritendinous inflammation for ultrasound.

Rheumatoid shoulder assessed by ultrasonography: prevalence of abnormalities and associated factors.

INTRODUCTION: The shoulder involvement in rheumatoid arthritis (RA) is common. It can be subclinical and compromise the function of the upper limb. Musculoskeletal ultrasonography can detect subclinical abnormalities in rheumatoid shoulder. Our aim was to assess the prevalence of ultrasound abnormalities in rheumatoid shoulder, and investigate their association with different parameters. METHODS: Cross-sectional study including 37 patients with RA, meeting the ACR/EULAR 2010 classification criteria, who were enrolled during a month. A questionnaire with sociodemographic, clinical and laboratory data was filled in for all patients. Ultrasound evaluation was performed by a single experienced operator. For each patient, both of shoulders were evaluated. RESULTS: Mean age was 50 years with female predominance. Median disease duration of RA was 7.5 years. All patients had a seropositive form of RA. Mean clinical DAS28 was 5.1. Mean HAQ was 1.2. Thirty-one (83.8%) patients had involvement of the shoulder: unilateral in 9(24.3%) cases and bilateral in 22(59.5%) cases. Synovitis was found in 16(43.2%) patients with Doppler in 4 (10.8%) cases. Sub-acromial bursitis was noted in 14 (37.8%) cases and the effusion in 20 (54.1%). Synovitis was noted especially in elderly individuals (p: 0.01). The Doppler was visualized in elderly patients (p: 0.01), with a shorter disease duration (p: 0.02) and with a high SDAI (p: 0.006). US inflammatory findings in anterior recess of glenohumeral joint were linked to a higher synovial index (p: 0.03) and a higher level of rheumatoid factor (p: 0.01). CONCLUSION: 59.5% of our RA patients had bilateral involvement of the shoulder which was related to the disease activity. Ultrasound should be a systematic tool to look for the involvement of this joint in RA patients.

Hydatid disease of bone. Review of 11 cases.

UNLABELLED: Osseous hydatid disease is defined as development within bone of multiple cysts that are the larval form of the tapeworm Echinococcus granulosus. Bone cysts account for only 0.5-2.5% of all hydatid cysts in humans. We report on our experience. METHODS: This retrospective study included patients managed between 1988 and 1998 for histologically documented hydatid disease of bone. RESULTS: Eleven patients were included, six men and five women, with a mean age of 40.7 +/- 11.04 years (range, 27-60 years). Mean time to diagnosis was 22.7 +/- 18.2 months (range, 5-36). The pelvis was involved in six patients and a long bone in five (the femur in three, the tibia in one, and the fibula in one). Peripheral eosinophil counts were high in four patients and serological tests for hydatid disease were positive in five patients. Surgical treatment was used alone in 10 patients and with albendazole in one patient. The main complications were fistulization (n = 6) and suppuration (n = 4). Five patients experienced recurrences. CONCLUSION: Hydatid disease still occurs in Morocco. The liver and lungs are the most common targets. Bone cysts are uncommon but severe. The behavior of osseous hydatid cysts resembles that of locally malignant lesions. Although immunofluorescent assays are useful, the final diagnosis depends on histology. The treatment rests on surgical excision. Recurrence is common, particularly at sites that are difficult to access.

[True intra-articular lipoma in a rheumatoid knee]. / Lipome intra-articulaire vrai sur un genou rhumatoïde.

INTRODUCTION: Lipoma is a frequent benign tumor of the soft tissue, but intra-articular locations are rare. We report a case that occurred in a rheumatoid knee. CASE: A 50-year-old woman had been treated for 17 years for seronegative deforming rheumatoid arthritis. Disease course under corticotherapy (7.5 mg/day) proceeded by flares and remissions. She had reported arthritis of the left knee for the past two years; concern about infection led to aspiration of the knee joint, which found inflammatory aseptic fluid, and radiography of the knee was normal. The patient was unable to afford magnetic resonance imaging or computed tomography. Synovial biopsy showed nonspecific chronic synovitis. Repeated corticosteroid injections produced no improvement. A second synovial biopsy was performed without specific results. Surgical biopsy followed and identified an intra-articular fatty mass, which was then excised surgically. Histologic examination showed a true synovial lipoma. DISCUSSION: True intra-articular lipoma, found mostly in the knee, is extremely rare and usually occurs de novo. For our patient its appearance in an arthritic knee required that lipoma arborescens be ruled out. MRI can provide a positive and differential diagnosis, but nonetheless requires histologic confirmation. It shows an encapsulated adipose mass, surrounded by synovial membrane, while lipoma arborescens is a villous proliferation in which fat cells infiltrate the synovium. Treatment is surgical or arthroscopic.