Discontinuation of biologic therapy in patients with rheumatoid arthritis and ankylosing spondylitis: analysis from multicenter cohort study.

Despite of the availability of several effective bDMARDs, a significant proportion of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients discontinued bDMARDs. The aims of this study were to analyze causes of bDMARDs discontinuation in RA and AS included in the Moroccan registry RBSMR. A historical prospective multicenter cohort study based on the RBSMR database at 12 months of follow-up, which included 225 RA and 170 AS. Using T student, Mann-Whitney U, chi-squared or Fischer exact tests, baseline demographic and clinical features were compared between patients discontinuing bDMARDs and patients remaining on initiated bDMARDs or switching bDMARDs. Logistic regression models were used to identify factors associated with drugs discontinuation. 61 RA discontinued bDMARDs and 47 AS interrupted anti-TNF. The most common reasons for drugs discontinuation were adverse events (7.5%) in RA patients and social security reimbursement problems (16.8%) in AS. RA patients discontinuing bDMARDs were more frequently first-line biological drugs users, more frequently female and had more comorbidities and lower DAS28 CRP than RA patients remaining on initiated bDMARDs or switching bDMARDs (p < 0.001, p = 0.01, p < 0.001 and p < 0.001 respectively). Female sex and comorbidities were the significant predictors of bDMARDs discontinuation in RA patients. Higher baseline BASDAI had a protective role on anti-TNF interruption in AS patients. Adverse events and social security reimbursement problems were the main reasons for drugs discontinuation in RA and AS patients respectively. Female sex and comorbidities in RA patients, baseline BASDAI in AS patients impacted bDMARDs discontinuation in real-life settings.

Vertebral fracture assessment in Moroccan women: prevalence and risk factors.

INTRODUCTION: Vertebral fracture assessment (VFA) is a fast, low-radiation technique which produces images that are of sufficient quality to be used to diagnose the presence of vertebral deformity consistent with fracture. OBJECTIVE: To study prevalence and risk factors of vertebral fractures using VFA in asymptomatic Moroccan women. METHODS: The study cohort consists of a population of 328 consecutive women aged over 50 (mean age, weight and BMI of 65+/-6.5 (50-84) years, 72.0+/-12.8 (42-125) and 29.4+/-5.0 (17.1-45.8)kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: 68% of vertebrae from T4-L4 and 75% from T8-L4 were adequately visualized on VFA. Vertebral fractures (grades 2 or 3) were detected in 25.6% (84/328) of these women. Thirty-two of women with VFA-identified fracture (38.0%) had only a single vertebral fracture, while the other 61.9% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. Stepwise regression analysis showed that presence of vertebral fracture was mainly related to the spine osteoporotic status, age older than 65, history of peripheral fracture and more than six parities. CONCLUSION: Vertebral fractures are common in asymptomatic Moroccan women and are related to age, low BMD, history of fracture and multiparity.

Performance of calcaneus quantitative ultrasound and dual-energy X-ray absorptiometry in the discrimination of prevalent asymptomatic osteoporotic fractures in postmenopausal women.

Due to its low cost, portability, and nonionizing radiation, quantitative ultrasound (QUS) of the heel is an alternative to the measurement with dual X-ray absorptiometry (DXA) in the evaluation of bone status. The objective of the study is to compare in asymptomatic postmenopausal women the ability of QUS and DXA to discriminate between those with and without prevalent vertebral fractures (VFs). The study cohort consists of a population of 295 postmenopausal women aged between 60 and 84 (mean age, weight and BMI of 66.3 years, 72.0 kg and 29.4 kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. All women had a calcaneous QUS examination. The mean age of the women in our sample was 66.3 (+/-5.3) years, ranging from 60 to 84 years. Eighty-seven (29.3%) women had VFs Genant grade 2 and 3. Patients with VFs had an age and a number of years of menopause higher to those without VFs, but showed lower height, weight, and BMI. All densitometric and ultrasonometric measurements were significantly reduced in women with VFs. The intercorrelations of BMD at different sites were high, and the correlations of BUA with BMD were lower. BUA correlated weakly with total hip BMD (r = 0.36), lumbar spine BMD (r = 0.32), and much less with femur BMD (r = 0.30); all correlations were significant (P < 0.01). Analysis of the AUC for the ROC curves showed lumbar spine T-score below -2.5 to provide consistently the highest AUC (0.64). Age-adjusted ORs after correction for confounding variables (years of menopause, weight, height, and BMI) for QUS and BMD measurements showed that only lumbar spine T-score below -2.5 could predict significantly the presence of VFs (OR, 1.94; 95%CI, 1.02-3.41). Lumbar spine BMD (and not QUS) was able to discriminate asymptomatic postmenopausal women with prevalent VFs from women without VFs and independently contributed to determining the association with fracture. The combination of QUS and BMD did not improve the diagnostic ability of either individual technique.

Drug-induced lupus-like syndrome in ankylosing spondylitis treated with infliximab.

Specific antagonists of tumour necrosis factor (TNF-alpha) have rapidly gained popularity for the treatment of rheumatoid arthritis and ankylosing spondylitis (AS). Reported side effects from these agents include drug-induced autoimmune disorders. The monoclonal antibody against TNF-alpha, infliximab, has been associated with induction of systemic lupus erythematosus (SLE) in only one patient with AS in the literature. However, there have been no published reports of drug induced lupus-like syndrome (LLS) with positive anti-histone antibodies. We describe a 59-year-old woman with a 12-year history of refractory axial AS who developed signs and symptoms of LLS during treatment with infliximb with positive antinuclear and anti-histone antibodies. On diagnosis of LLS, infliximab was discontinued and the LLS-related symptoms promptly resolved.

Pulmonary Sarcoidosis following Etanercept Treatment for Ankylosing Spondylitis: A Case Report and Review of the Literature.

Antitumor necrosis factor therapies have revolutionized the treatment of some inflammatory diseases. However, the use of these agents is associated with the development of many paradoxical autoimmune diseases. Less well-recognized is the association with sarcoidosis. We report a 55-year-old female with long-standing ankylosing spondylitis who developed persistent dry cough and dyspnea while receiving etanercept therapy. High-resolution computed tomography scanning showed mediastinal lymphadenopathy and multiple nodules in both lung fields developed two months after the administration of etanercept. Lymph node biopsy was not practicable. Histopathological examination of minor salivary gland biopsy revealed noncaseating granulomata, and the serum angiotensin-converting enzyme was very elevated. All infectious studies were negative. Etanercept was discontinued plus a course of corticosteroids with a clinical improvement, and a follow-up high-resolution computed tomography scanning 4 months later showed evident regression of mediastinal lymph nodes and pulmonary nodules. Potential pathogenic mechanisms of this paradoxical effect of tumor necrosis factor-alpha blocking agents are discussed.

Bone turnover and hormonal perturbations in patients with fibromyalgia.

OBJECTIVE: Studies of bone turnover in fibromyalgia (FM) have, to date, shown conflicting results. Although most patients with FM are women, only a few investigations have paid attention to the changes of sex hormones in FM. Moreover, FM is often viewed as a stress related disorder, and abnormalities of the hypothalamic-pituitary-adrenal (HPA) axis have been found in FM. The aim of the study was to assess bone turnover using serum osteocalcin and CTx in patients with FM and study correlation between bone turnover parameters and parathormon and hormones of the HPA axis. METHODS: A total of 81 subjects participated in this study: 41 healthy volunteers and 40 patients with FM. Serum osteocalcin, crosslaps (C-telopeptide: CTx), parathyroid hormone (PTH), testosterone, estrogen, prolactin, FSH, and LH were measured. The mean age of the study population was 49.5 (7.6) years (32-69) and the mean disease duration was 8.1 (12.0) years (4.5-30.7). RESULTS: No difference between patients and controls were observed in serum calcium, phosphorus, creatinine, albumin, osteocalcin, testosterone, and urinary calcium. Patients had lower serum levels of CTx, estrogen, PTH and prolactin than controls and higher serum levels of LH and FSH with a significant statistical difference. No significant statistical correlation was observed between intensity of pain and fatigue and bone turnover parameters and PTH or hormones of the HPA axis. CONCLUSION: Our study showed that patients with FM had low bone resorption and normal bone formation compared to a control group. This was not related to several hormonal perturbations observed in these patients and may reflect functional impairment as suggested in previous studies.

[Value of the radiographic criteria "fingers and toes" in the early diagnosis of psoriatic arthritis]. / Apport des critères doigts--orteils dans le diagnostic précoce du rhumatisme psoriasique.

PURPOSE: To assess the value of Fournie's radiological criteria "fingers and toes" in the early diagnosis of psoriatic arthritis. MATERIALS AND METHODS: 47 patients with psoriatic arthritis were studied retrospectively. Clinical and radiological features at the hands and fingers were assessed. Radiographic analysis was performed using Fournie's criteria. RESULTS: Of 47 patients studied, 25 patients developed hand and finger involvement. Asymmetrical joint distribution was observed in 76% of cases. Distal interphalangeal arthritis was noted in 60% of cases. Nail lesions were present in 11 cases and dactylitis in 3 cases. Eight patients had erosions of the distal interphalangeal joints. Osteolysis with pencil-in-cup deformity was noted in 3 cases. Ankylosis of interphalangeal joints was found in 7 cases and acro-osteolysis in 3 cases. CONCLUSION: Psoriatic arthritis frequently affects the small joints of the hands and fingers. Asymmetrical and distal interphalangeal joint involvement are a characteristic feature of this arthropathy. Some radiological lesions are suggestive and contribute to the early diagnosis of psoriatic arthritis.

Cervical spine involvement in ankylosing spondylitis.

Our objective was to study cervical spine involvement in a Moroccan population of ankylosing spondylitis (AS) patients and evaluate correlations with disease symptomatic and structural severity. Patients were prospectively enrolled for a 1-year period. Clinical, biological, and radiological data were collected. The risk of cervical spine involvement was estimated using the Kaplan-Maier method. Sixty-one patients were enrolled: 38 males (62.2%) and 23 females of mean (SD) age 35.1 years [11] (range 17-66). The mean disease duration was 10.6 years [7] (0.5-30). Forty-three patients (70.4%) had a history of neck pain. Radiological involvement was present in 33 cases (54%). The concordance between clinical and radiological involvement was statistically significant (kappa=0.49; P<10(-6)). The risk of cervical spine involvement with regard to disease duration showed that 19.6% of patients had radiological involvement after 5 years, 29.9% after 10 years, 45.1% after 15 years and 70.0% after 20 years. Comparison between patients with and without cervical spine radiological involvement showed no difference in age of onset or sex. There was statistical difference in symptomatic severity parameters (Schöber, chest expansion, BASMI, BASFI, BASDI, BASG) and structural severity parameters (lumbar syndesmophytes score, BASRI). Our study confirms the greater severity of AS in North African countries. Cervical spine involvement increases with age and disease duration in AS and is more frequent in symptomatic and structural severe forms of the disease.

A controlled study of sacroiliitis in Behçet's disease.

The aim of the study was to evaluate the prevalence of sacroiliitis in a group of patients with Behçet's disease (BD). Pelvic X-rays of 27 patients with BD responding to the International Study Group of BD and 30 controls (15 AS and 15 sciatica) were read blind and sacroiliac involvement was graded according to the New York criteria. In a second step, patients or controls with equivocal sacroiliitis had a sacroiliac CT scan. Two patients with BD (7.4%) and all patients with AS had evident bilateral sacroiliitis (at least grade 2). One patient with BD and two patients with sciatica had equivocal sacroiliitis (grade 1). CT confirmed sacroiliitis in the two patients with BD and eliminated inflammatory sacroiliitis in the three other patients with equivocal sacroiliitis showing mild degenerative lesions. A review of the literature showed that sacroiliitis and AS are rarely associated with BD. There remains insufficient evidence to suggest that sacroiliitis is an intrinsic feature of BD and that BD belongs to the group of SpA.

Involvement of the foot in patients with psoriatic arthritis. A review of 26 cases.

OBJECTIVE: To describe the clinical and radiological features of foot involvement in patients with psoriatic arthritis. METHODS: We retrospectively reviewed the medical records of patients admitted between 1972 and 1999 for psoriatic arthritis with involvement of the foot. We included all patients who had peripheral and/or axial, asymmetric, chronic inflammatory joint disease meeting or not Avila's radiological criteria for psoriatic arthritis, with or without other imaging findings suggestive of psoriatic arthritis and with or without psoriasis. RESULTS: Twenty-six patients were included. Inflammatory heel pain was reported by 14 patients, whereas forefoot involvement was found in only seven patients. Sausage toe was present in two patients. None of the patients had Bauer's toe (combining arthritis and psoriatic skin and/or nail changes) or psoriatic onychopachydermoperiostitis of the great toe. Radiological abnormalities were found in 20 patients. Half the patients had calcaneal changes. Osteoperiostitis of the great toe was noted in two patients and mushrooming in five. DISCUSSION: The features of psoriatic arthritis in Morocco seem similar to those in other countries. Hindfoot involvement was present in 53% of patients. Involvement of the forefoot was rarely recorded in the charts, suggesting missed cases because of insufficient attention to the forefoot during the physical examination and availability of anteroposterior radiographs only. Oblique views (Hirtz and Chaumet) should be obtained because they give a clearer image of the distal part of the toes, which is often difficult to analyze on anteroposterior films.

Idiopathic retroperitoneal fibrosis and ankylosing spondylitis. A new case report.

The case of a 52-year-old man with retroperitoneal fibrosis and ankylosing spondylitis is described. Inflammatory low back pain and acute renal insufficiency prompted a computed tomography scan of the abdomen with contrast agent injection. A fibrous sheath surrounding the aorta and attracting the ureters toward the midline was seen, strongly suggesting retroperitoneal fibrosis. The diagnosis of ankylosing spondylitis was based on the presence of inflammatory low back pain responsive to nonsteroidal anti-inflammatory drugs, syndesmophytes at the lumbar and cervical spine, bilateral sacroiliitis, and presence of the HLA-B27 antigen. Prednisone therapy in a daily dosage of 1 mg/kg induced a marked improvement. Only nine cases of concomitant retroperitoneal fibrosis and ankylosing spondylitis have been reported. These two conditions share similarities in some of the etiologic factors and anatomic localizations, suggesting that both may stem from a predisposition to fibrotic diseases.

[McDuffie hypocomplementemic urticarial vasculitis. Two cases and review of the literature]. / Vascularite urticarienne hypocomplémentémique de McDuffie. Deux observations et revue de la littérature.

INTRODUCTION: Hypocomplementemic urticarial vasculitis (HUV) described by McDuffie is a rare entity recently individualized among vasculitis. We report two new cases. EXEGESIS: Case 1: a 41-year-old woman presented in 1994 with inflammatory polyarthralgia, diffuse urticaria, fever, and weight loss. Biology showed proteinuria, positive rheumatoid factor with hypocomplementemia and negative immunological tests. Skin and renal biopsies showed leukocytoclastic vasculitis and extramembranous glomerulopathy, respectively. Outcome within steroid therapy was marked by alternating clinical improvement and relapses. Case 2: a 39-year-old woman presented in 1994 with inflammatory polyarthritis, diffuse urticaria, Raynaud phenomenon, cough and dyspnea. Chest x-rays and CT scan showed interstitial fibrosis and echocardiography revealed pericarditis. Biology showed positive rheumatoid factor with hypocomplementemia and negative antinuclear antibodies. Skin biopsy showed leukocytoclastic vasculitis. Corticosteroids and cyclophosphamide improved the patient's condition. McDuffie HUV is a disease with varied systemic manifestations. Its existence is still contested by some authors. Treatment is still empirical and depends on the clinical features. It is based primarily on corticosteroids. CONCLUSION: McDuffie HUV is a defensible entity among urticarial vasculitis because of its particular clinical and biological features.

[Sacro-iliac involvement in he course of Paget disease. Report of 6 cases]. / L'atteinte sacro-iliaque au cours de la maladie de Paget. 6 observations.

OBJECTIVES: Determine the characteristic features of sacroiliac lesions observed in patients with Paget's disease. PATIENTS AND METHODS: A retrospective analysis of the hospital files of 87 patients cared for over a period of 12 years was performed. Six patients, 4 women and 2 men, mean age 79 years, were retained for study. In 4 patients one or both sacroiliac joints were involved with complete fusion of the sacral and iliac bones, confirmed by CT-scan in 3. In the 2 other patients, only one border was involved. Scintigraphy showed polyostotic Paget's disease in 3 cases with pelvic localization in the 3 others. Ankylosing spondylarthritis (B27+) was associated in 1 case and in 2 joint chondrocalcinosis without a calcium rim was visualized at the sacroiliac joint. Sacroiliac fusion was related either to new bone forming a bridge in front of the articular space or destruction of the joint cartilage with pagetic fusion. CONCLUSION: Sacroiliac involvement in Paget's disease leads to joint fusion by cartilaginous destruction and should suggest possible ankylosing spondylarthritis, ankylosing vertebral hyperostosis, or joint chondrocalcinosis.

[Pubic tuberculous osteo-arthritis. Apropos of 2 cases]. / L'ostéoarthrite pubienne tuberculeuse. A propos de deux cas.

OBJECTIVE: The authors report an exceptional site of tuberculous osteo-articular infection which must be diagnosed before the destructive stage. OBSERVATIONS: Case 1 : a 21 years old woman presented an inflammatory pubic pain after a trauma with weight loss of 4 kgs in 3 weeks. She presented also 2 satellite inguinal nodes. Erythrocyte sedimentation rate (ESR) was elevated, X-rays showed an important osteolysis of the left ischio-pubic rami, tuberculous skin test (TST) was positive, mycobacterium tuberculosis (MT) could not be found neither in sputtum nor in urine but the node biopsy showed the specific features of tuberculosis. Evolution under a 6 months antibiotic treatment was good. Case 2 : a 19 years old woman, with history of tuberculous contagion, presented in April 1996 cervical nodes and a month later inflammatory pubic and knee pain with weight loss and vesperal sudation. ESR was elevated, TST was phlyctenular, MT searching and HIV serology were negative. X rays showed irregular osteolysis of the pubic symphysis. Scintigraphy showed an increased fixation of pubis and left knee. Cervical nodes biopsy diagnosed tuberculosis. Evolution was good under a 6 months antibiotic treatment. DISCUSSION: Many factors can favorize the development of a pubic tuberculosis and are similar for all forms of tuberculous osteo-articular infection (trauma and contagion in our cases). Radiological features, characterized by a slow evolution, are note specific. Diagnostic confirmation must be bacteriologic or pathologic, and if possible far from the pubic foci. Any traumatic medical procedure has to be avoided because of painful outcome and local risk. Evolution under specific treatment, even of short course (6 months), is sufficient for a good outcome. CONCLUSION: One must think to pubic tuberculous osteo-arthritis in any pubic pain even if it is post-traumatic especially, in endemic countries of tuberculosis.

Systematic vertebral fracture assessment in asymptomatic postmenopausal women.

INTRODUCTION: Recognition of vertebral fractures (VFs) changes the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing. OBJECTIVE: To study prevalence and risk factors of VFs using VFA in asymptomatic women and measure its effect on treatment recommendations. METHODS: We enrolled 908 postmenopausal women (mean age, weight and BMI of 60.9 ± 7.7 (50-91) years, 73.2 ± 13.2 (35-150) kg and 29.8 ± 5.3 (14.5-50.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: VFs were identified in 382 patients (42.0%): 203 (22.3%) had grade 1 and 179 (19.7%) had grade 2 or 3. The prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 63 (28.3%) women with normal BMD (8.5% had grade 2/3 VFs) and in 145 (38.5%) with osteopenia (15.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to age, BMI, number of parity, history of peripheral fracture and lumbar spine BMD. CONCLUSION: A high proportion of women with asymptomatic VFs would not receive treatment if screening were based only on BMD evaluation. Our results support the recommendation to enlarge the indications of VFA in the presence of risk factors such as age over 60, multiparity, history of peripheral traumatic fractures and low BMI.

Vertebral fractures and abdominal aortic calcification in postmenopausal women. A cohort study.

INTRODUCTION: Vertebral fracture assessment (VFA) imaging with a bone densitometer can simultaneously detect prevalent vertebral fractures (VFs) and abdominal aortic calcification (AAC). OBJECTIVE: To study the relation between the prevalence of VFs using VFA in asymptomatic women and the prevalence and severity of AAC. DESIGN: This is a cross-sectional study. SETTINGS: Subjects were recruited in a third care center from asymptomatic women selected from the general population. PARTICIPANTS: We enrolled 908 post-menopausal women with a mean age of 60.9 years ± 7.7 (50 to 91) with no prior known diagnosis of osteoporosis or taking medication interfering with bone metabolism. PRIMARY AND SECONDARY OUTCOME MEASURES: Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. VFA images were scored for AAC using a validated 24 point scale. RESULTS: VFA images showed that 179 of the participants (19.7%) had at least one grade 2/3 VF, 81% did not have any detectable AAC whereas the prevalence of significant atherosclerotic burden, defined as AAC score of 5 or higher, was 12%. The group of women with 2/3 VFs had a statistically significant higher AAC score and higher proportion of subjects with extended AAC, and lower weight, height, and lumbar spine and hip BMD and T-scores than those without VFA-identified VFs. Multiple regression analysis showed that the presence of grade 2/3 VFs was significantly associated with age, BMI, history of peripheral fracture, AAC score ≥ 5 and densitometric osteoporosis. CONCLUSION: In post-menopausal women, extended AAC is independently associated with prevalent VFs regardless of age, BMI, history of fractures, and BMD.

Vertebral fracture assessment in asymptomatic men and its impact on management.

INTRODUCTION: Recognition of vertebral fractures (VFs) change the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing. OBJECTIVE: To study prevalence and risk factors of VFs using VFA in asymptomatic men and measure its impact on patients' management. METHODS: We enrolled 791 men aged between 45 and 89 (mean age, weight and BMI of 62.4±8.6) (45 to 89) years, 74.9±12.7 (40 to 163) and 26.3±4.0 (16.6 to 43.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry. RESULTS: VFs were identified in 318 (40.3%): 206 (26.0%) had grade 1 and 112 (14.2%) had grade 2 or 3. As would be expected, the prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 85 (32.4%) of men with normal BMD (6.9% had grade 2/3 VFs) and in 144 (35.8%) with osteopenia (11.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to the osteoporotic status (OR=4.761, 95%CI [2.956-7.668]; p<0.0001) and current smoking (OR=1.717, 95%CI [1.268-2.323]; p=0.002). CONCLUSION: Our results support the recommendation to enlarge the indications of VFA to all the men referred for DXA measurement.