Assessment of the functional impact of foot involvement in patients with rheumatoid arthritis.

AIM OF THE WORK: We aimed to evaluate the impact of foot involvement in patients with rheumatoid arthritis (RA) using the functional foot index (FFI) and to identify predictive factors of the functional impact of foot abnormalities in RA patients. PATIENTS AND METHODS: This was a cross-sectional study including patients with RA meeting the criteria of the American College of Rheumatology and the European League Against Rheumatism 2010. The main epidemiological data, results of podoscopic and clinical examination of the foot and ankle, biological tests and radiological findings were collected. The presence of foot pain was assessed by a visual analogic scale (0-10), and the functional impact of foot involvement was assessed based on the validated French version of the FFI. RESULTS: Fifty RA patients with an average age of 59.3 ± 9.9 years [39-79] were included, and 80% of them had foot involvement. Foot pain was present in 32 patients (64%), most frequently situated in the forefoot (56%). The average FFI score was 33.67 ± 30.53 [0-92.67]. The following factors had a significant association with the FFI score: an occupation soliciting the feet (p = 0.001), disease duration (p = 0.033, r = 0,302), the Health Assessment Questionnaire (p = 0.0001, r = 0,480), body mass index (p = 0.0001, r = 0,654), the presence of podiatric abnormalities (p = 0.0001) and Visual Analog Scale foot pain (p = 0.0001, r = 0,854). A significant association was also found between the FFI score and the presence of a hallux valgus (p = 0.004), a spread of the forefoot (p = 0.029), a claw of the toes (p = 0.002), a triangular forefoot (p = 0.0001), a quintus varus (p = 0.002), flat feet (p = 0.0001) and a valgus of the hindfoot (p = 0.001). CONCLUSION: Due to the high frequency of foot involvement and its significant functional impact, meticulous examination of the feet and assessment of their functional impact must be one of the parameters for monitoring the disease. Its impact on one's quality of life can be important. LEVEL OF CLINICAL EVIDENCE: 4 (cohort studies, non experimental, observational studies).

Journey of rheumatoid arthritis patients in Tunisia: From symptoms to treatment.

Objectives: This study aims to assess the different delays of rheumatoid arthritis (RA) patients' journey from disease onset to treatment initiation and to identify possible influencing factors. Patients and methods: This cross-sectional study included a total of 100 patients (14 males, 86 females; mean age: 56.5±12.4 years; range, 26 to 82 years) who met the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for RA between January 2019 and January 2020. Demographic and clinical data and disease characteristics were collected from the patient interviews and medical files. Five different intervals were defined from symptom onset until the initiation of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Results: The mean age at RA onset was 46.6±12.4 years. Median delays from onset of symptoms until general practitioner (GP) and rheumatologist consultations were six (range, 0.25 to 240) months and 12 (range, 0 to 242) months, respectively. Median delays from onset of symptoms to RA diagnosis and treatment with csDMARDs were 15.7 (range, 2 to 252) months and 18 (range, 2 to 270) months, respectively. The mean number of consultations was 7.3±4.2 and the median number of physicians visited before the diagnosis was three (range, 1 to 8). The RA diagnosis delay was associated with rural geographic environment (p=0.02), lack of social insurance (p=0.027), progressive symptoms onset (p=0.006), morning stiffness (p=0.023), being initially examined by a GP (p=0.02), number of consultations (p<0.001; r=0.49), and number of physicians consulted before diagnosis (p=0.001; r=0.33) respectively. Based on the patients' self-perception, the main causes of this long delay were lack of financial means (33%), wait times until exploration results (31%), wait times until the first GP or rheumatologist visit (26%), and geographical difficulty in accessing healthcare services (18%). Conclusion: Our study results suggest that patients with RA experience a significant delay until diagnosis and initiation of treatment. Healthcare providers should urgently consider factors related to diagnosis delay to shorten RA patients' journey.

Common low back pain hiding tuberculous sacroiliitis.

The sacroiliac joint is rarely affected by tuberculosis. Only few cases have been reported. Consequently, the diagnosis is often delayed. This case report highlights the importance of continued awareness for early detection and treatment of a tuberculous sacroiliac joint infection.

Complications of Paget Bone Disease: A Study of 69 Patients.

INTRODUCTION: Paget bone disease (PBD) is characterized by a disorder in the bone remodeling activity at sites of involvement. This can produce dramatic alterations of local bone architecture and causes most of the complications. We aimed to focus on the characteristics of complications of PDB among hospitalized patients. MATERIAL AND METHODS: A retrospective study was conducted, on PBD patients hospitalized in two rheumatology centers from 1994 to 2019. Characteristics of the PBD complications were studied. RESULTS: Sixty-nine patients were collected with a sex ratio of 0.76 and a mean age of 75.4±6.4 years [43-101]. The diagnosis of PBD was established in the average age of 64.2±11.5 years. The primary reason for consultation was pain (78.3%). The PBD was localized in the pelvis (58%), lower limb (42%), spine (36.2%), skull (23.2%) and upper limb (5.8%). It was polyostotic in 44.9% of cases. Dosage of ALP was 324 [68-8390]. The PDB complication rate was 52.2% and it decreased over time. The main complication was osteoarthritis (23.2%), followed by deafness (17.4%), fracture (15.9%), hydrocephalus (7.2%), neurological disease (7.2%) and osteosarcoma (1.4%). The presence of complications was significantly associated with the polyostotic form (p=0.01), the skull localization (p=0.04), an increased ALP (p=0.02). CONCLUSION: According to our study, the incidence rate of PBD among hospitalized cases is higher among elderly women and decreases over time. Complications related to PDB are frequent (52%). It concerns patients with a polyostotic form, skull localization and high ALP.

Reactive Arthritis following Bacillus Calmette-Guerin Therapy for Bladder Cancer: a Systematic Literature Review.

PURPOSE OF REVIEW: Intravesical BCG therapy (ivBCG) is a treatment for bladder cancer that complements surgery and prevents tumor progression. Reactive arthritis (ReA) is a rare osteoarticular manifestation that can complicate this treatment. An updated systematic literature review has been investigated to identify clinical, biological, and therapeutic data of this pathology. RECENT FINDINGS: A systematic literature was performed on October 2020 to identify papers published from 2000 to 2020. Study eligibility criteria included case reports, case series, cohort studies, systematic reviews, meta-analysis, and letters to the editor, in English and French. Independent extraction of articles was performed by two investigators. Thirteen studies met the search criteria for the systematic review with a good quality assessment. The total number of patients was 107, with an average age of 61.5 [24-80]. The symptoms of ReA appeared after a mean number of 5.71 instillations and 13.9 days. Arthritis was the most common symptom (98.13%) followed by fever (80.76%) and conjunctivitis (64.42%). Human leukocyte antigen (HLAB27) was positive in 28.97% of patients. Therapeutic modalities included non-steroidal anti-inflammatory drugs (NSAIDs) (51.4%), corticosteroids (27.1%), conventional synthetic disease-modifying antirheumatic drugs (3.84%), antitubercular drugs (14.42%), and tocilizumab (0.93%). BCG therapy was discontinued in 29.9% of patients. Remission was achieved in 92.3% of patients and one patient progressed to spondyloarthritis. ReA is a rare complication of BCG therapy. Clinical signs are similar to those of typical ReA and treatment is primarily based on NSAIDs and corticosteroids.

Diffuse large B cell lymphoma presenting with renal failure and bone lesions in a 46-year-old woman: a case report and review of literature.

Renal involvement in large B-cell lymphoma represents an exceptional manifestation of non-Hodgkin lymphomas. Renal failure and bone metastasis by lymphomatous infiltration is extremely rare. We describe a 46-year-old woman presenting with a renal failure and a 5-month history of intermittent left knee pain that was previously misdiagnosed with osteoarthritis. It was due to a bilateral primary renal lymphoma (PRL) associated with bone metastasis. Knee MRI showed a permeative lesion and an abnormal signal in the metaphysis and diaphysis of the left proximal tibia with periosteal reaction and surrounding soft tissue swelling. The CT body scan showed a bilateral nephromegaly and multiple lytic bone lesion of aggressive appearance at the right iliac wing and right sacral ala evoking lymphomatous involvement. Node biopsy with immunohistochemistry study confirmed a diagnosis of large B-cell lymphoblastic lymphoma. In this article, we focus on clinical, radiological, immunohistochemical presentation, differential diagnosis and review the literature. Ten cases including our case were reported in our literature review of both renal and bone lymphoma. There was a male predominance, with a mean age of 55.1 years old. We noted a high frequency of renal failure in diagnosis. In X-rays, the metaphysis is the most common site of occurrence in long bones and the main sign was osteolytic bone destruction. The subtype of lymphoma was DLBCL stage IV in most cases except in one case where it was a hystiocytic lymphoma. Finally, prognosis was poor, more than half of patients died. PRL with bone metastasis is a rare malignancy that is difficult to diagnose. Clinicians should increase the awareness of the disease and consider a differential diagnosis of bone lesions. Early diagnosis and active treatment can improve patient prognosis.

Do immunosuppressive agents hamper the vaccination response in patients with rheumatic diseases? A review of the literature.

Patients with auto-immune disease are more susceptible to infection than similar populations without auto-immune disease. Vaccination seems to be one of the most effective methods to prevent patients from possible infections, but may be impaired by concomitant immunomodulators. The aim of this review was to evaluate the effect of immunosuppressive drugs on vaccination efficiency. We found that the majority of studies confirms that neither the use of corticosteroids and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) nor the use of biological agents, except rituximab, reduce the efficacy of inactivated vaccines such as pneumococcal and influenza vaccines. Even if rituximab has been shown to reduce humoral responses following influenza and pneumococcal vaccination, this response can be modestly restored 6-10 months after rituximab administration. To sum up, treatment guidelines recommending routine use of pneumococcal and influenza vaccines for immune compromised patients should be followed in order to avoid severe infections.

Physical activity assessment in children and adolescents with juvenile idiopathic arthritis compared with controls.

OBJECTIVE: We aimed to assess physical activity (PA) in children with juvenile idiopathic arthritis (JIA) compared with healthy peers and to determine factors influencing PA level. METHODS: This was a cross-sectional study of the measured level of PA in children with JIA, compared with age- and gender-matched healthy schoolchildren. PA was estimated using a physical activity questionnaire for children and for adolescents (cPAQ/aPAQ). Disease activity was evaluated with the Juvenile Arthritis Disease Activity Score (JADAS). Functional ability was assessed with the Childhood Health Assessment Questionnaire (CHAQ). RESULTS: A total of 55 children with JIA and 55 healthy control schoolchildren were included. Children with JIA had significantly lower levels of PA compared with their healthy peers as assessed with the cPAQ/aPAQ (P=0.0121). In total, 76% of the JIA group spent the day sleeping and sitting, which was significantly higher compared with the reference group (P=0.001 and P=0.055, respectively). Low PA level was associated with systemic JIA (P=0.002, OR=2.123), polyarticular JIA with positive rheumatoid factor (P=0.001, OR=2.014), JADAS-27≥6 (P=0.001, OR=2.524), patients undergoing treatment (P=0.001, OR=1.271), and higher CHAQ (P=0.002, OR=2.461). CONCLUSION: Children with JIA were less physically active than their healthy peers and less active than recommended for general health.

Non-radiographic axial spondyloarthritis in Tunisia: main characteristics and detailed comparison with ankylosing spondylitis.

OBJECTIVES: The aim of the present study is to compare the clinical features, disease activity, and physical impairment between non-radiographic axial spondyloarthritis and ankylosing spondylitis in Tunisian patients. METHODS: This is a retrospective study conducted in a single rheumatology center in Tunisia. Patients with axial spondyloarthritis fulfilling the 2009 ASAS criteria were included. The various spondyloarthritis-related variables were compared between non-radiographic axial spondyloarthritis and ankylosing spondylitis. p Values below 0.05 were considered statistically significant. RESULTS: Among 200 patients with axial spondyloarthritis, 40 had non-radiographic axial spondyloarthritis and 160 had ankylosing spondylitis. The non-radiographic axial spondyloarthritis patients were more frequently female, were younger, and had shorter disease duration. Patients with non-radiographic axial spondyloarthritis experienced enthesitis more frequently compared with ankylosing spondylitis patients. Psoriasis was more frequent in non-radiographic axial spondyloarthritis group, while inflammatory bowel disease was more frequent in ankylosing spondylitis group. The C-reactive protein level and functional score were significantly higher in patients with ankylosing spondylitis compared with non-radiographic axial spondyloarthritis. Tumor necrosis factor inhibitors were offered significantly more often to the ankylosing spondylitis group. There was no statistically significant difference between the 2 groups in other spondyloarthritis parameters. CONCLUSION: The non-radiographic axial spondyloarthritis is characterized mainly by a marked female prevalence, a higher enthesitis prevalence, and a better physical function. KEY POINTS: • Patients with nr-axSpA in Tunisia are more frequently female and have shorter disease duration compared with those with AS. • Peripheral manifestations were similar between nr-axSpA and AS patients except for enthesitis which were more frequent within nr-axSpA patients. • The disease activity is similar between the 2 groups of axSpA but the physical function is better within nr-axSpA patients.

Predictors of renal outcomes in anti-neutrophil cytoplasmic antibody glomerulonephritis.

Glomerulonephritis associated with anti-neutrophil cytoplasmic antibody (ANCA) vasculitis still has a high prevalence of end-stage renal disease (ESRD), particularly in patients with advanced renal failure at presentation. This study aims to evaluate the clinical and histo- pathological features of renal involvement and investigate factors associated with ESRD. Patients with renal biopsy-proven ANCA-associated glomerulonephritis were included retrospectively over a period of nine years (June 2007 to March 2016). The renal survival, defined as time to reach ESRD, was evaluated based on clinical parameters, histopathological classification, and renal risk score. A total of 37 patients with crescentic glomerulonephritis were included in the study. The average age was 54 ± 16 years (range: 17-80) and 51.3% were female. Twenty-two patients were diagnosed with microscopic polyangiitis and 15 had granulomatosis with polyangiitis. The median glomerular filtration rate at presentation was 16.73 mL/min/1.73 m2. Thirty-five patients (94.5%) had renal failure at presentation and 23 patients (62.1%) required initial hemodialysis (HD) therapy. The pattern of glomerular injury was categorized as sclerotic in 48.6% of cases, crescentic in 24.3%, mixed in 24.3%, and focal class in 2.7%. Regarding renal risk score, we had five patients with low risk, 17 with intermediate risk and 15 with high risk. ESRD occurred in 47% of intermediate-risk group and 66% of the high risk group. During follow-up, 17 patients (45.9%) developed ESRD. Tobacco addiction (P = 0.02), alveolar hemorrhage (P = 0.04), hypertension (P = 0.04), initial HD (P = 0.04), and sclerotic class (P = 0.004) were associated with ESRD. In our patients, a sclerotic class was associated with a higher risk of ESRD, suggesting that histo- pathological classification is potentially an important parameter to predict outcomes in renal disease secondary to ANCA-associated vasculitis.

Etiological Features of Liver Involvement in Rheumatoid Arthritis.

BACKGROUND: Liver involvement is not considered a typical extra-articular manifestation and has rarely been studied in rheumatoid arthritis (RA). We aimed to identify the prevalence and aetiologies of liver disease in RA patients. METHODS: A cross-sectional study included 150 patients with RA enrolled over 5 years (2010- 2015). The clinical and paraclinical features of RA were analyzed. The clinical and biological characteristics of liver impairment and its aetiologies were collected. RESULTS: One hundred and fifty RA patients (124 women) with a mean age of 57.09 years and a mean RA duration of 7.52 years were included. Liver involvement was diagnosed in 66 patients (44%). The liver disease was asymptomatic in 94% of the cases, revealed by increased gammaglutamyl transferase levels in 74% of the patients. The aetiologies of liver involvement were hepatotoxicity of medications in 38 cases (57%), hepatitis B and C in 14 patients (21%), fatty liver disease in 10 cases (15%), autoimmune liver disease in 2 patients (3%), hydatid cyst in 1 case (2%), and liver angiomas in 1 case (2%). Non-steroidal anti-inflammatory drugs and methotrexate were the drugs most often involved in the genesis of hepatotoxicity (21% and 20% of the cases, respectively). CONCLUSION: Liver involvement occurred in 44% of RA patients. Aetiologies were mainly hepatotoxicity and viral hepatitis B and C. Patients with RA should be systematically screened for liver disease, which is rarely symptomatic.

Skeletal fluorosis: don't miss the diagnosis!

Skeletal fluorosis is a rare toxic osteopathy characterized by massive bone fixation of fluoride. The disease occurs as an endemic problem in some parts of the world and is the result of prolonged ingestion or rarely by inhalation of high amounts of fluoride. Radiographic presentation is mainly characterized by bone changes with osteocondensation and later ossification of many ligaments and interosseous membranes. Skeletal fluorosis is not clinically obvious and can be confused with other rheumatologic disorders. Its severity lies in the development of skeletal deformities and neurological complications. Management of fluorosis generally focuses on symptom treatment.

Contribution of bone mineral density in stress fractures of elite athletes.

INTRODUCTION: The stress fracture occurs in a healthy bone with a lack of adaptation to sustained, intensive and repetitive physical activity. However, bone mineral density is strongly correlated with bone strength and fractures may occur more easily on osteoporotic bone. AIM: To evaluate the bone densitometric profile of elite athletes with a history of stress fracture and to determine the interest in preventing this type of fracture. METHODS: cross-sectional study comparing a group of elite athletes to a control group matched by sex, age and sports discipline. Bone mineral density is measured by dual energy x-ray absorptiometry. RESULTS: Our study involved 10 elite athletes with a mean age of 20.3 years and a history of stress fracture, compared to a population of 8 controls practicing the same sport with the same training volume per week. The diagnosis of clinically suspected stress fracture is confirmed in all cases by bone scintigraphy. Osteopenia is diagnosed in one patient while osteoporosis is found in one of the controls. No significant difference was found between the 2 mean bone densities (at the lumbar spine and proximal femur) among the 2 groups. CONCLUSION: bone densitometry does not seem to be, according to our study, a relevant tool in preventing stress fractures in elite athletes.