Evaluation of Vitamin D Status in Rheumatoid Arthritis and Its Association with Disease Activity across 15 Countries: "The COMORA Study".

The aims of this study are to evaluate vitamin D status in 1413 RA patients of COMORA study from 15 countries and to analyze relationship between patients' RA characteristics and low levels of vitamin D. All demographic, clinical, and biological data and RA comorbidities were completed. The results showed that the average of vitamin D serum dosage was 27.3 ng/mL ± 15.1 [0.1-151]. Status of vitamin D was insufficient in 54.6% and deficient in 8.5% of patients. 43% of RA patients were supplemented with vitamin D and absence of supplementation on vitamin D was related to higher prevalence of vitamin D deficiency (p < 0.001). Finally, our study shows that the status of low levels of vitamin D is common in RA in different countries and under different latitudes. Absence of supplementation on vitamin D was related to higher prevalence of vitamin D deficiency. Low levels of vitamin D were associated with patients characteristics (age, BMI, and educational level), RA (disease activity and corticosteroid dosage), and comorbidities (lung disease and osteoporosis therapy). This suggests the need for a particular therapeutic strategy to improve vitamin D status in RA patients.

The prevalence of medical nomadism of the followed patients in rheumatology.

The nomads are defined as patients related to multiple practicians of the same speciality or different specialities for the same symptomatology during a certain period. The objectives of this investigation were to evaluate the prevalence of medical nomadism of the followed patients in rheumatology and compare their profile with those patients followed in neurology and gastroenterology. A multicentric transverse study (September 2009-March 2010) was conducted in three departments of CHU Ibn Sina Rabat-Salé, Morocco; rheumatology, gastroenterology and neurology. Only patients seen in external consultations were included. Patients' socio-economic and demographic background (familial status, instruction level, monthly revenue, social assistance) were recorded, as well as the clinical parameters related to the pathology (pathology, duration of the illness, diagnosis final time). A questionnaire containing variables on the patients' state concerning diagnosis, satisfaction degree of the patients and other variables evaluated the notion of taking medication and the practice of alternative medicine. Medical nomadism has been defined by the consultation for the same symptomatology of three different practicians, either of the same speciality or of different specialities during the study period of 6 months. There were 250 patients included in this study (150 patients in rheumatology, 50 in gastroenterology and 50 in neurology), the mean age was 46 ± 13 years and females dominated (65.6%). The average duration of the evolution was 7 ± 5 years, 35% of the patients were illiterate, 30% had a primary school education, 22% had a secondary school education and 13% had a university-level education. Sixty-two percent of the patients were jobless, 27% were workers, 9% were the functionary and 2% were the based liberal. Fifty-six percent had no social assistance. Rheumatoid arthritis and degenerative pathology were the most frequent diagnoses in rheumatology, being 20% and 40%, respectively. In gastroenterology, the most frequent pathologies were functional colopathy (25%) and proctology (20%), and migraine (42%) in neurology. The global prevalence of nomadism was 51%; 36% in rheumatology, 58% in neurology and 86% in gastroenterology. The associated factors of nomadism phenomena in rheumatology were: the satisfaction degree of the patient (P = 0.001), the wrong beliefs (P = 0.007), the practice of alternative medicine (P = 0.009), the pathology (P = 0.01) and the psychic profile (P = 0.001). Our study suggests that medical nomadism is frequent. It seems to be more frequent in the gastroenterology area, was linked with the degree of the patients' satisfaction, the alternative medicine practice and the type of the pathologies. Other studies of a high level would be necessary.

Septic polyarthritis caused by group A streptococcus in an immunocompetent adult: rare case.

We report a rare case of multifocal septic arthritis associated to spondylodiscitis and endocarditis caused by group A beta-hemolytic streptococcus (GABHS) in an immunocompetent adult, and we discuss diagnosis and therapeutic difficulties, while insisting into the rational use of corticosteroids that seems to be the only risk factor in our patient.

Uncommon case of ankylosing spondylitis associated with spontaneous occurring hypoparathyroidism.

Hypoparathyroidism and ankylosing spondylitis are two conditions with distinctive features which allow their differentiation. Hypoparathyroidism can be responsible for clinical and radiological changes resembling those seen in patients with ankylosing spondylitis. We report an exceptional case of a patient with an association between ankylosing spondylitis and a severe idiopathic hypoparathyroidism with difficulties in diagnosis. To our knowledge, this is the first case of such an occurrence.

Mc Cance syndrome.

The case is that of a 17-year old Moroccan boy presenting a growing delay and a vitamin D-resistant ricket (VRR). Osseous plain radiographs show demineralization with metaphyseal enlargement, thorax, legs and wrists deformities. Biology data confirms phosphocalcic anomalies with deep hypophosphatemia, normal phosphaturia, low phosphate renal reabsorption rate, normal plasma hydroxyvitamin D in addition to low calciuria. Clinical and biological data evokes an X-linked hypophosphatemia with ricket. This phenomenon is due to Phosphate regulating gene with Homolgy to Endopeptidase on the X chromosome (PHEX) gene mutation. No similar case was reported previously within the family, however, it would have been desirable to complement existing data with parents and siblings genetic study results. Pseudo-deficiency vitamin D resistant ricket (VRR), also referred to as Mc Cance syndrome, has a belated onset within children, and can be linked to a phosphate reabsorption anomaly. The aim of the treatment is to normalize phosphatemia with calcic and vitamin D (vit D) supplementation, so as to make up for calcium lack and avoid hypophosphatemia osseous complications (plasma vitamin D rate reduction and secondary hyperparathyroidism).

Idiopathic hypoparathyroidism and adhesive capsulitis of the shoulder in two first-degree relatives.

INTRODUCTION: Primary hypoparathyroidism and adhesive capsulitis of the shoulder in the same patient does not seem to have been reported previously. We report two cases in first-degree relatives. PATIENTS: Case 1: In 1999, a 41-year-old woman experienced seizures simulating epilepsy. She had been treated 5 years earlier for idiopathic adhesive capsulitis of both shoulders. Computed tomography of the brain showed calcifications in the basal ganglia meeting criteria for Fahr's disease, and incipient bilateral cataract was found. A diagnosis of idiopathic primary hypoparathyroidism was given. After 1 month of calcium and vitamin D supplementation, improvements were noted in the clinical symptoms, laboratory test, and electroencephalogram. Case 2: The 70-year-old father of case 1, who had an unremarkable medical history, had been receiving treatment for about 2 years for adhesive capsulitis of the left shoulder. Routine laboratory tests disclosed idiopathic primary hypoparathyroidism. The outcome was favorable with calcium and vitamin D supplementation. CONCLUSION: Our cases suggest that there may be a common immunological or genetic basis for primary hypoparathyroidism and adhesive capsulitis. Alternatively, adhesive capsulitis may be a manifestation of hypoparathyroidism. Although genetic factors involved in primary hypoparathyroidism have been elucidated, the pathophysiology of the disease remains unclear. Finally, a chance association remains possible.

Lead-related gout. A case report.

Gout secondary to lead-induced nephropathy is a long-term complication of occupational lead exposure. We report a case of this now-rare condition. The patient was a 63-year-old man who had been a miner from 1950 to 1970. Thirty years after cessation of his exposure to lead, he experienced onset of inflammatory symmetric polyarthritis with joint deformities. Hyperuricemia, moderately severe renal failure, and tubular acidosis were found, indicating gouty polyarthritis. Blood lead levels were high, establishing that the cause was lead poisoning. EDTA chelation therapy was effective. Lead poisoning is frequently under-recognized because the clinical manifestations are often minimal and the diagnosis difficult to establish. We suggest that lead bound to bone may result in continued exposure to lead after cessation of industrial or environmental exposure. Chelating agents are valuable for the diagnosis and can ensure a full recovery.