Anti-tumour necrosis factor treatment in patients with refractory systemic vasculitis associated with rheumatoid arthritis.

OBJECTIVE: To assess anti-tumour necrosis factor (anti-TNF) agents in patients with refractory systemic rheumatoid vasculitis (SRV). METHODS: 1200 rheumatologists and internists were asked to provide medical files for patients with anti-TNF agents given as a second-line treatment for active SRV refractory to cyclophosphamide and glucocorticoids. RESULTS: We identified nine cases in which anti-TNF drugs were given for active SRV, despite previous treatment with a mean cumulative dose of 8.4 g of cyclophosphamide in association with high-dose glucocorticoids. The mean prednisone dose before anti-TNF therapy was 29.6 mg/day. After 6 months, six patients were in remission (complete in five, partial in one). The treatment failed in one patient and two patients stopped taking the anti-TNF treatment due to side-effects. Mean prednisone dose was reduced to 11.2 mg/day. Severe infection occurred in three patients. Relapses were observed in two patients. Remission was re-established by reintroducing anti-TNF therapy in one case and increasing the dose in the other. CONCLUSIONS: This study provides evidence of efficacy of anti-TNF therapy in adjunct to glucocorticoids for treating active refractory SRV. Remission was achieved in two-thirds of patients, with a significant decrease in prednisone dose, although there was a high rate of infection in these severely ill patients.

Interleukin-1 receptor antagonist (anakinra) treatment in patients with systemic-onset juvenile idiopathic arthritis or adult onset Still disease: preliminary experience in France.

BACKGROUND: Anakinra treatment has been reported to be effective in some patients with systemic-onset juvenile idiopathic arthritis (SoJIA) or adult-onset Still disease (AoSD). OBJECTIVES: To assess the efficacy and the safety of anakinra treatment in SoJIA and AoSD. METHODS: SoJIA and AoSD patients were treated with anakinra (1-2 mg/kg/day in children, 100 mg/day in adults); we analysed its effect on fever, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, numbers of swollen and tender joints, the assessment of disease activity (by physician and parent/patient) and pain (by parent/patient), and American College of Rheumatology (ACR) pediatric core set criteria for JIA activity. RESULTS: A total of 35 patients were included, 20 with SoJIA and 15 with AoSD. Their mean age (range) at the onset of treatment was 12.4 (3-23) and 38.1 (22-62) years, respectively; disease duration was 7.0 (1-16) and 7.8 (2-27) years, respectively. Active arthritis was present in all cases but one. Of the 20 SoJIA patients, 5 achieved ACR 50% improvement in symptoms (ACR50) response criteria at 6 months. Steroid dose had been decreased by 15% to 78% in 10 cases. A total of 11 of the 15 AoSD patients achieved at least a 50% improvement for all disease markers (mean follow-up: 17.5 (11-27) months). Steroids had been stopped in two cases and the dose was decreased by 45% to 95% in 12 patients. Two patients stopped anakinra due to severe skin reaction, and two patients due to infection: one visceral leishmaniasis and one varicella. CONCLUSION: Anakinra was effective in most AoSD patients, but less than half SoJIA patients achieved a marked and sustained improvement.

[Cutaneous vasculitis with necrotic ulcers in rheumatoid arthritis: treatment with anti-TNFalpha]. / Vasculite avec ulcérations cutanées au cours de la polyarthrite rhumatoïde: traitement par anti TNFalpha.

INTRODUCTION: Anti-TNFalpha has occasionally been used in the treatment of recalcitrant forms of systemic vasculitis such as Behçet's disease, Wegener's granulomatosis and Churg-Strauss syndrome. We report on the outcome of treatment in rheumatoid arthritis patients with cutaneous vasculitis lesions on anti-TNFalpha. OBSERVATIONS: Two patients with rheumatoid arthritis present for several years had necrotic ulcers of the lower limbs due to cutaneous vasculitis. After the failure of various immunosuppressive drugs (cyclophosphamide, azathioprine, methotrexate), the two patients were treated with anti-TNFalpha: infliximab in the first case and adalimumab in the second. Cutaneous ulcers healed within two to four months of the start of anti-TNFalpha treatment. Despite ongoing anti-TNFalpha treatment, these cutaneous ulcers relapsed four to six months after complete healing. CONCLUSION: Initially spectacular healing of cutaneous vasculitis ulcers under anti-TNF alpha treatment followed by relapse after several months of treatment is suggestive of an escape mechanism.

Spinal abscess and spondylitis due to actinomycosis.

STUDY DESIGN: Report of a rare case of spinal actinomycosis in a young immunocompetent woman. OBJECTIVE: To show the difficulties in diagnosing spinal actinomycosis. SUMMARY OF BACKGROUND DATA: Spinal actinomycosis is rare and usually occurs as a result of a contiguous (abdominal, pelvic, or thoracic) spread of the infection. This localization represents less than 5% of the infectious sites and was mainly, before the penicillin era, a postmortem discovery. METHODS: A case is reported of a 34-year-old Algerian woman who had fever, persistent cough, right-side thoracic pain, and progressive severe back pain. Radiographs, computed tomographic scan, and magnetic resonance imaging demonstrated lytic areas on the vertebral bodies of T11 and T12 and a paravertebral mass, without disk involvement. A surgical biopsy of T12 and the paravertebral abscess was performed. RESULTS: Presence of characteristic sulfur granules and gram-positive filamentous bacteria in surgical biopsy tissues and isolation of Actinobacillus actinomycetemcomitans in cultures led to the diagnosis of vertebral actinomycosis. The patient was virtually free of pain and fever after a 3-month regimen of ofloxacin and rifampicin (Rifadine, Marion-Merell, France) and was without recurrence after 18 months of follow-up. CONCLUSIONS: Actinomycosis of the spine, caused by the spread of a paraspinal abscess, is extremely rare. The previously poor prognosis has been transformed by antibiotics.

A shock associated with adult-onset Still's disease.

Only two cases of adult-onset Still's disease associated with shock have been previously described. We report a case of shock in a man with adult-onset Still's disease and discuss the relationship between the two processes by assessing tumor necrosis factor-alpha, procalcitonin and interleukin-6 concentrations.

Septic Arthritis of the Knee with Toxoplasma gondii in a Patient with Rheumatoid Arthritis.

Toxoplasmosis is a parasitic infection that may affect several viscera. The locomotor system is rarely involved, and no case has been published of a septic arthritis in which Toxoplasma gondii was identified in the cultures of the joint fluid and of the synovial specimen.We describe a patient with septic arthritis of the knee in which Toxoplasma gondii was found by culture in a patient with seropositive rheumatoid arthritis treated with corticosteroids and gold salts who developed multi-visceral toxoplasmosis.

[Treatment of arthroses in the elderly patient]. / Les traitements de l'arthrose du sujet âgé.

BACKGROUND: Elderly subjects with osteoarthritis are treated with analgesic drugs, non-steroidal antiinflammatory drugs (NSAID) and intra-articular corticosteroid injections as well as symptomatic slow acting drugs in osteoarthritis (Sy-SADOA). BASIC REGIMENS: Initial treatment for osteoarthritis pain should be paracetamol, followed by NSAID if necessary, especially in the elderly, because of their adverse effects. EFFICACY: Sy-SADOA are effective on pain and function with a persistent effect, allowing the reduction of analgesic and NSAID dosage.

[Osteoarticular manifestations of palmoplantaris pustulosis. A prospective study of 15 cases]. / Manifestations ostéo-articulaires de la pustulose palmo-plantaire. Etude prospective de 15 cas.

Between 1986 and 1989, we conducted a clinical, biochemical, radiological and scintigraphic prospective study of 15 patients (8 men, 7 women) with histologically proven palmoplantar pustulosis. In 70 percent of the cases the time interval between the first cutaneous and the first osteoarticular signs was 2 years. Anterior thoracic clinical manifestations were frequent. The joints and the numbers of patients involved were: sternoclavicular (12), manubriosternal (6), sternocostal (5), intervertebral (11), sacroiliac (6) and peripheral (10). Two patients had osteitis. The clinical, radiological and scintigraphic findings, as well as the distribution of these arthropathies over the anterior thorax (i.e. over a sternocostoclavicular complex with numerous ligaments), suggest a preference for entheses. Despite the absence of link with the HLA B27 antigen, the frequent association with pelvic and spinal lesions indicate that the articular disease of palmoplantar pustulosis is a spondyloarthropathy.

[Intra and interindividual variations of pelvic mobility in normal adult walk]. / Variations intra et interindividuelles de la mobilite pelvienne au cours de la marche du sujet sain.

PURPOSE OF THE STUDY: Pelvis motion appears as a main human gait component, it is linked to the lower limb joints and to the spine. Current devices, especially the opto-electronical systems, allow quantitative and tri-dimensional gait studies. The purpose of this study was to quantify the pelvic motion individual variability in a sample of healthy subjects. MATERIALS AND METHODS: The study based on a 18 volunters sample. There were 14 men and 4 women, ranged in age from 25 to 37 years. A clinical examination and a AP radiograph of pelvis allowed to include healthy subjects. We used the three-dimensional analysis VICON system with five cameras. Nine records were performed for each subject during a free-speed walking. These nine records were distributed on three different days. RESULTS: The step length medianes varied from 1100 to 1600 mm with a significantly (p < 0.05) regression between the step length, the walking speed and the subjects height. Vertical pelvic oscillations varied in this sample from 25 to 60 mm and linked with step length and walking speed. Pelvic rotation around the vertical axis varied from 1.5 to 15 degrees. We did not found regression between this pelvic rotation and the length step. It seems there are three types of pelvic rotation around the vertical axis. At the beginning of the stance phase, in type I, the pelvis is in the transversal plane whereas in the type II, it appears with the maximal rotation. In type III, the value of pelvic rotation is very low. The successive lateral inclinations of pelvic described a complex motion which varied from 1.5 to 9 degrees. The rotation of shoulders around the vertical axis varied from 4 degrees to 13 degrees and the successive inclinations varied from 3.25 degrees to 12 degrees. We did not found any regression between the pelvic and shoulders motion values. DISCUSSION: This study showed that the pelvis motion varied considerably from one subject to another. These variations induce different ways of walking with various consequences on the hip joint and the spine. We suppose that these variations could take a part in etiology of some diseases as hip arthritis or in total hip arthroplasty failure, especially in cup wearing.

[Erosive arthropathies in Crohn disease. Apropos of 3 cases]. / Arthropathies érosives au cours de la maladie de Crohn. A propos de 3 observations.

Three unusual cases of destructive joint lesions in patients with Crohn's disease are reported. One patient with chronic enteropathic polyarthritis developed erosions of the wrists. The other two patients had spondyloarthropathic disease; erosions developed in the right hip in one and in the hips, knees and tibiotarsal joints in the other. The few similar cases reported in the literature are reviewed.

[Still disease in the adult and in pregnancy]. / Maladie de Still de l'adulte et grossesse.

The interactions between pregnancy and adult-onset Still's disease are unclear. Nine pregnancies which occurred from 1983 through 1991 in seven women (mean age 27.7 years; range 23-40) were studied retrospectively. Five patients had one pregnancy and two had two pregnancies. Onset of the joint disease occurred before or during pregnancy. The joint disease occurred at the 5th or 6th month of the first pregnancy in two patients; one of these patients had a second pregnancy which was not associated with a flare. In five patients, onset of the joint disease occurred 4, 15, 42, 44 and 58 months before the first pregnancy, respectively; any effects of the joint disease on the pregnancy were extremely variable. 6 infants were full-term and two were premature (35 weeks); the remaining pregnancy was electively terminated; Apgar scores were normal in all eight infants, who were all male. Adult-onset Still's disease did not influence the outcome of the pregnancy in our patients; no clear-cut effects of pregnancy on adult-onset Still's disease were seen.

[Aspergillus spondylodiscitis. Apropos of 3 cases]. / Spondylodiscite aspergillaire. A propos de trois observations.

Three cases of Aspergillus discitis are reported in immunodepressed patients. Vertebrae osteomyelitis was preceded in 2 cases by pulmonary infection. The diagnosis was established in every case by disc aspiration or closed-needle-biopsy and mycological examination of the material. Aspergillus fumigatus was identified in two cases; in one case itroconazole led to recovery within three months.

Epidemiological data, efficacy and safety of a paracetamol-tramadol fixed combination in the treatment of moderate-to-severe pain. SALZA: a post-marketing study in general practice.

OBJECTIVE: To evaluate the efficacy and safety of the paracetamol-tramadol combination (PTC) in treating moderate-to-severe pain, in patients aged 65 years and over within general practitioner (GP) practice centers. RESEARCH DESIGN AND METHODS: This was an observational, non-interventional, longitudinal, multicenter, open, non-comparative, prospective study. This intermediary analysis was of patients recruited before the French Health Authority confirmation (25th June, 2009) of the EMEA decision to withdraw all analgesics containing dextropropoxyphen. Trial registration information: This study has been submitted for approval to the CNIL and French Medical Council (CNOM) only. RESULTS: A total of 2663 patients aged 65 years or over were assessed 1 month after inclusion in the study. PTC was prescribed as first-line treatment in 30% of patients and, in the other cases, after failed or inadequate efficacy (69.8%), and/or as a result of safety problems (7.8%) with at least one other analgesic. During the month of the study period 14.7% of patients received an additional rescue analgesic. The study confirmed the efficacy of PTC with regard to pain intensity (-3.1 points reduction of pain scored 6.1 points on inclusion), pain relief (64.8% of patients experienced significant pain relief), patient satisfaction (90.5% of patients satisfied or completely satisfied) and clinical global impression evaluated by the patient (78.7% much or very much improved), regardless of the pain etiologies or duration of the underlying pathology. PTC was well-tolerated in this patient group, who had a mean age of 73.6 ± 6.6 years. A total of 119 patients (4.5%) reported at least one adverse event (AE). All were known and predictable AEs. This percentage is comparable to that found under similar conditions in patients of all ages (4.2%). CONCLUSIONS: PTC, due to the complementary action of its two analgesics, is effective in treating the different types of pain in a GP's practice setting and is well-tolerated, even in an elderly population. Study limitations include all those inherent to non-interventional and open-label observations.