[Discordance between spine and hip Bone Mineral Density measurement using DXA in osteoporosis diagnosis: prevalence and risk factors]. / Prévalence et facteurs de risque de discordance de la dentisté minérale osseuse au rachis lombaire et à la hanche dans diagnostic d'ostéporose.

BACKGROUND: Diagnostic discordance for osteoporosis is the presence of different categories of T-scores in 2 skeletal sites of an individual patient, falling into 2 different diagnostic categories identified by the World Health Organization classification. AIM: To determinate the prevalence and risk factors for T-score discordance between spine and hip measurement sites. METHODS: Demographic data, anthropometric measurements, and risk factors for osteoporosis were derived from a database of 1780 patients referred to the outpatient osteoporosis testing center of the departement of Rheumatology between September 2006 and February 2010. Bone mineral density (BMD) was performed by Dual-energy x-ray absorptiometry (DXA) on L1-L4 lumbar spine and total hips for all cases. Minor discordance was considered when the difference between 2 sites was no more than 1 World Health Organization diagnostic class. Major discordance was present when 1 site is osteoporotic and the other is normal. RESULTS: In 1780 participants (1606 women and 174 males; mean age, 59.5 ± 14.3 years), concordance of T-scores, minor discordance, and major discordance were seen in 49.4%, 45.7%, and 4.8% of the cases, respectively. In both minor and major discordance BMD was lower in lumbar spine than total hips. In univariate and multivariate logistic regression analysis only menopause was identified as risk factors against T-score discordance with p<0.001 and [OR=5.47; IC: 2.61- 12.79]. The others factors: age, gender, BMI, fracture history, corticotherapy, rheumatoid arthritis, tobacco and diabetes were not associated with the T-score discordance. CONCLUSION: Clinicians should expect that at least half of patients tested by DXA will demonstrate T-score discordance between spine and total hip measurement sites. T-score discordance can occur for a variety of reasons related to physiologic and pathologic patient factors as well as the performance or analysis of DXA itself.

[Survival prognosis factors in multiple myeloma]. / Les facteurs pronostiques de survie au cours du myélome multiple.

BACKGROUND: Outcome in multiple myeloma (MM) is very heterogeneous in survival and therapeutic response, constantly fatale despite her therapy progress. AIM: To determine the prognostic factors and survival in MM. METHODS: We carried out a transversal study of 100 patients in the rheumatology department of hospital Monastir between 1991 and 2010. In each case we determinate the survival delay and also the clinical, laboratory, radiological data at diagnosis and therapeutic response. RESULTS: The mean age was 64.4 years and sex ratio H/F=1.27. MM is IgG type in 57%, IgA in 28% and light chain in 11% of cases. The survival mean is 34 months and the survival median is 26 months. Univariate analysis showed five prognostic factors: age (p = 0.016), anaemia (p=0.033), ß2 microglobulin ( p < 0.0001) , CRP (p = 0.0001), albumin (p = 0.002), LDH (p=0.001), plasmocyte proliferation rate (p=0.003) and rapidly therapeutic response (p <0.001). ß2 microgrobulin-CRP classification and the international staging system (ISS) presented a high prognosis signification (p < 0.0001). Multivariate analysis demonstrated two prognostic factors: ß2 microglobulin and CRP. CONCLUSIONS: Our study showed that MM presented many prognostic factors, which easily realised in daly practice. These prognostic factors are essentially to evaluate prognosis and select patients for appropriate therapeutic indication. ß2 microgrobulin- CRP classification and the international staging system (ISS) are more predictive than Durie Salmon classification in MM survival.

[Ochronosis: report of two familial cases]. / L'ochronose: a propos de deux cas familiaux.

BACKGROUND: Ochronosis of alkaptonuria is a rare hereditary autosomal recessive disease in which there is an absence of homogentisic acid oxidase resulting in accumulation of homogentisic acid in tissues. AIM: To report a new case of alkaptonuria CASE REPORT: A 49-year-old man had been followed for 4 years for chronic lombalgia and arthropaty of two knees. He is married to his cousin and father of 4 girls. His parents are also cousins. The clinical examination has found a cutaneuous pigmentation and a lumbar stiffness. At biological checking, creatininemia was at 190 µmol/L and there are not inflammatory indicators. The radiography have shown a discal dorsolumbar calcifications, anterior inter somatic bridges and bilateral arthritis of knees without articular chondrocalcinosis. The diagnosis of ochronosis have been suspected and confirmed by the blackness of urine and the dosage of alkaptonuria. The patient has been treated symptomatiquely. Familial investigation have revealed that his daughter suffered from the same disease with the notion of blackness of urine. She is 12 year old and she's asymptomatic on the osteoarticular level. CONCLUSION: Alkaptonuria causes a degenerative arthropaty which can endanger functional prognosis. Early diagnosis and scanning of this innate error of metabolism by genetic study play a fundamental interest, especially for molecular and genetic advisement.

[Adult-onset of Still's disease with atypical articular and skin manifestations]. / Atteintes articulaire et cutanée atypiques au cours d'une maladie de Still de l'adulte.

BACKGROUND: Adult-onset Still's disease (ASD) is an uncommon clinical entity. It is a diagnosis of exclusion, characterized by a clinical triad of intermittent fever spikes, evanescent rash, and either arthralgia or arthritis. Destructive arthritis more commonly affects the hips, wrists, tarsal joints and cervical spine. AIM: To report an unusual case of ASD with severe distal interphalangeal destructive arthritis and finger skin vesiculopustules. OBSERVATION: A 19 years old girl was followed for 2 year-history of ASD with polycyclic articular involvement. She noted, since 2 months, rapid appearance of painful tumefaction in the distal interphalangeal joints (DIP) with maculopustular eruption distributed exclusively on the hands, in front, only of DIP and few proximal interphalangeal joints (PIP). Further more, she complained of polyarticular active disease. Hands and wrists X-ray showed narrowed distal-interphalangeal joint space of only DIP joints. RMN imaging revealed in addition carpal, metacarpal and PIP articular inflammatory damage. The infectious investigation remained negative. A surgical skin and DIP biopsy specimens showed disseminated micro-abscesses with polynuclear leukocyte dermal infiltration. There was no signs of osteitis. Bacterial and fungal cultures from the pus failed to reveal any causative organisms. Skin lesions gradually disappeared in response to conventional ASD therapy after intensification. Hence, the diagnosis of distal destructive arthritis of ASD associated with atypical neutrophilic dermatosis (Sweet's syndrome) was made. CONCLUSION: ASD is rare, heterogeneous, with unpredictable evolution. The distal destructive arthritis represents a possible complication. The presence of pustules as atypical cutaneous features of Sweet's syndrome may be seen in severe forms of ASD and clinicians must be alert to the possibility of a misdiagnosis in these cases.

An autosomal dominant hypophosphatemic rickets phenotype in a Tunisian family caused by a new FGF23 missense mutation.

Autosomal dominant hypophosphatemic rickets (ADHR) is a rare disease, characterized by isolated renal phosphate wasting, hypophosphatemia, and inappropriately normal 1,25-dihydroxyvitamin D(3) (calcitriol) levels. This syndrome involves rickets with bone deformities in childhood and osteomalacia, osteoporosis, articular and para-articular pain, and fatigue in adulthood. It is caused by mutations in a consensus sequence for proteolytic cleavage of the FGF23 protein. Normally, this protein actively regulates phosphate homeostasis. Here we report a Tunisian family in which one parent and three children show clinical and biological features of ADHR. Mutation analysis of the FGF23 gene finds a heterozygous substitution of the C at position 526 by a T (526 C --> T), leading to an amino acid replacement of the FGF23 protein (R176W) at position 176. This causative new mutation is located in the consensus sequence for the proteolytic cleavage domain. These results confirm the importance of this site in FGF23 function and its essential role in ADHR physiopathology.

HLA-B27 and HLA-B51 determination in Tunisian healthy subjects and patients with suspected ankylosing spondylitis and Behçet's disease.

The aim of this retrospective study is to assess the frequency of HLA-B27 and HLA-B51 in healthy subjects from the center of Tunisia and to investigate their usefulness in the diagnosis of ankylosing spondylitis (AS) and Behçet's disease (BD), respectively. Microlymphocytotoxicity test was used to perform serologic HLA typing in a group of 124 healthy volunteers and a group of 365 patients suffering from clinical manifestations of AS and/or BD. HLA-B27 was found in 3.2% of healthy subjects and in 42.9% of patients with AS (P < 0.00006). HLA-B51 is, however, found in 16.1% of healthy subjects and in 30.0% of patients with BD (P > 0.05). Unlike HLA-B51, which seems to be as frequent in Tunisian patients with BD as in healthy subjects, HLA-B27 is more frequent in patients with AS than in controls. This highlights the usefulness of HLA-B27, rather than that of HLA-B51, in the diagnosis of the respective diseases.

Prevalence of subclinical amyloidosis in Tunisian patients with rheumatoid arthritis.

INTRODUCTION: Secondary amyloidosis is a serious complication of rheumatoid arthritis (RA). Symptoms are late to occur, so that screening is in order, most notably in patients with long-standing RA. The objectives of our study were to determine the prevalence of subclinical amyloidosis in RA patients by abdominal fat aspiration biopsy (AFAB) and minor salivary gland biopsy (MSGB) and to identify factors associated with subclinical amyloidosis. METHODS: We prospectively studied 107 consecutive patients with RA (94 women and 13 men) recruited between March 2005 and January 2006. Clinical and laboratory findings, imaging study results, and treatment were recorded for each patient. AFAB and MSGB were performed routinely. Amyloid deposits were identified by polarized light microscopy after Congo red staining. RESULTS: The prevalence of subclinical amyloidosis was 21.5% by AFAB and 3.7% by MSGB. Factors associated with subclinical amyloidosis were a longer time to diagnosis (P=0.03), extraarticular manifestations (P=0.019), proteinuria >0.3 g/24 h (P=0.024), and absence of methotrexate therapy (P=0.046). Subclinical amyloidosis was not associated with age, sex, RA duration, joint deformities, DAS28 score, Health Assessment Questionnaire score, Steinbrocker radiological stage, rheumatoid factor, erythrocyte sedimentation rate, C-reactive protein, creatinine, or hemoglobin. CONCLUSION: The prevalence of subclinical amyloidosis by AFAB is high (21.5%). AFAB is more sensitive than MSGB for detecting subclinical amyloidosis. A simple screening tool such as AFAB should be used, particularly in patients with risk factors. Subclinical amyloidosis requires close monitoring to ensure the early detection and treatment of symptomatic amyloidosis.

Complete reversal of tumoral calcinosis after subtotal parathyroidectomy in a hemodialysis patient.

INTRODUCTION: Tumoral calcinosis is a rare complication of chronic hemodialysis whose mechanism is incompletely understood. The treatment is challenging and should target the main precipitating factors, most notably secondary hyperparathyroidism and calcium-phosphate (Ca x P) product elevation. CASE REPORT: In this 41-year-old patient, tumoral calcinosis developed in the right hip and subacromial bursa of the right shoulder after 3 years of chronic hemodialysis. Laboratory tests showed hyperparathyroidism with Ca x P elevation. Subtotal parathyroidectomy was performed. Eight months later, there was no evidence of tumoral calcinosis at either of the previously affected sites. CONCLUSION: The effectiveness of parathyroidectomy in our patient underlies the key role played by secondary hyperparathyroidism in the pathogenesis of tumoral calcinosis complicating hemodialysis.

Prevalence and risk factors of disk-related sciatica in an urban population in Tunisia.

BACKGROUND: Disk-related sciatica (DRS) creates a public health burden because of its high incidence and considerable socioeconomic costs. We are not aware of previous epidemiological studies of the prevalence and risk factors of DRS in Tunisia or other Arab countries, and few studies have addressed these issues elsewhere. OBJECTIVES: To determine the prevalence and incidence of DRS in Monastir, Tunisia; to look for risk factors; and to evaluate socioeconomic costs. METHODS: Data on a cross-section of 5000 individuals aged 15 years or older living in Monastir were collected by interviewers using a previously developed 51-item questionnaire. RESULTS: The study participation rate was 87.6%. The annual prevalence of DRS was 2.21% and the incidence was 1.44%. Among the patients with DRS, 94.8% received healthcare interventions, 64% had plain radiographs taken, and 45.4% underwent computed tomography of the lumbar spine. Sick leaves were given to 77.7% of patients, and mean sick leave duration was 9 weeks. A change in job was required in 5.5% of cases. Factors associated with DRS included male gender (P<0.001), obesity (P<0.0001), smoking (P<0.0001), a history of low back problems (P<0.0001), anxiety and depression (P<0.0001), a job requiring prolonged standing and bending forward (P<0.03), heavy manual labor (P<0.005), heavy lifting (P<0.0001), and exposure to vibrations (P<0.0001). CONCLUSION: The prevalence of DRS in Monastir is 2.2%. We identified a number of patient- and occupation-related risk factors. The high socioeconomic cost should encourage preventive measures.

Prevalence and factors associated to low back pain among hospital staff.

OBJECTIVES: Because of its frequency and consequences on professional life, low back pain (LBP) represents a real health care problem. Our study is aimed at determining the prevalence of LBP among hospital staff, analyzing the medical and professional consequences as well as investigating into the factors associated to this health problem. METHODS: We have conducted an inquiry among 350 employees at Fattouma Bourguiba teaching hospital. The employees have answered a pre-established questionnaire including 51 items. RESULTS: The cumulative life-prevalence was 57.7% of the cases. The annual prevalence was 51.1% of the cases. Chronic LBP prevalence was 12.8% of the cases. Medical care was required in 61.9% of the cases. Radiological explorations were performed in 45% of the cases. Sick leave was observed in 26.1% of the cases and an occupational change was necessary in two cases. Factors associated to LBP were age (P <0.01), female gender (P = 0.024), high BMI (P = 0.01), the fact of being married or divorced (P < 0.01), smoking (P = 0.016), past medical LBP history (P < 0.0001), extra professional activity (P < 0.01), migraine (P < 0.001), years' service (P = 0.007) as well as heavy weight lifting (P = 0.008). Exercise is rather a protecting factor against LBP (P = 0.019). CONCLUSION: The prevalence of LBP among hospital staff as well as the socio-professional drawbacks is important. Many factors are associated to LBP urging medical teams to take some preventive measures to reduce this affliction.

Lipoma arborescens affecting multiple joints.

Lipoma arborescens is a rare benign intra-articular lesion of unknown etiology that usually involves the suprapatellar pouch of the knee joint. Clinically, the most common finding is a slow-growing painless swelling, accompanied by intermittent effusion of the joint. We report a case of a multifocal lipoma arborescens localized in the knees and the hips in a 24-year-old man, initially mimicking an inflammatory arthropathy. The diagnosis of lipoma arborescens was made by magnetic resonance imaging of the hips and the knees. Under arthroscopic guidance, the synovial biopsy of the right knee disclosed the specific histological signs of lipoma arborescens. As far as we know, this is the third case of multifocal lipoma arborescens reported in the English literature.

[Value of imaging in the diagnosis of peripheral neurofibrosarcomas: a case report]. / Apport de l'imagerie dans le diagnostic des neurofibrosarcomes périphériques: à propos d'un cas.

Neurofibrosarcoma is a rare malignant peripheral nerve sheath tumour. It's the consequence of degeneration of neurofibroma in patients with neurofibromatosis. In the absence of clinical symptoms of malignancy, imaging is of prime importance. The observed new case of cubital neurofibrosarcoma stimulated the researchers to give more importance to MR imaging in distinguishing from the benign tumors.