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.

Hydatid disease of bone. Review of 11 cases

Osseous hydatid disease is defined as development within bone of multiple cysts that are the larval form of the tapeworm Echinococcus granulosus. Bone cysts account for only 0.5-2.5% of all hydatid cysts in humans. We report on our experience.

METHODS

This retrospective study included patients managed between 1988 and 1998 for histologically documented hydatid disease of bone.

RESULTS

Eleven patients were included, six men and five women, with a mean age of 40.7 +/- 11.04 years (range, 27-60 years). Mean time to diagnosis was 22.7 +/- 18.2 months (range, 5-36). The pelvis was involved in six patients and a long bone in five (the femur in three, the tibia in one, and the fibula in one). Peripheral eosinophil counts were high in four patients and serological tests for hydatid disease were positive in five patients. Surgical treatment was used alone in 10 patients and with albendazole in one patient. The main complications were fistulization (n = 6) and suppuration (n = 4). Five patients experienced recurrences.

CONCLUSION

Hydatid disease still occurs in Morocco. The liver and lungs are the most common targets. Bone cysts are uncommon but severe. The behavior of osseous hydatid cysts resembles that of locally malignant lesions. Although immunofluorescent assays are useful, the final diagnosis depends on histology. The treatment rests on surgical excision. Recurrence is common, particularly at sites that are difficult to access.

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.

Idiopathic phalangeal acroosteolysis: a case report

Acroosteolysis is characterized by bone resorption in the fingers and toes and can occur in several diseases. Phalangeal acroosteolysis is a rare idiopathic form. We report a case in a 13-year-old girl with a 2-year history of swelling and skin ulcers of the second and third left fingers and second right finger. The fingers were abnormally short and the nails were hypertrophic. Roentgenograms disclosed terminal phalangeal resorption in the fingers and toes. Findings were normal from tests for inflammation and dysimmunity. Biopsies of the skin lesions showed fibrosis without inflammation. Neurological evaluation and electromyographic study were normal. Serological tests for syphilis were negative. Calcium and phosphate levels in blood and urine were normal. A diagnosis of idiopathic phalangeal acroosteolysis (Joseph and Shinz disease) was given. This inherited form of acroosteolysis is transmitted on an autosomal dominant or recessive basis. It affects the tips of the distal phalanges of the fingers and toes but occasionally spreads to other bones.

Evaluation of the smallest detectable difference in outcome or process variables in ankylosing spondylitis

OBJECTIVE

To evaluate the smallest detectable difference (SDD) of symptomatic outcome or process variables in ankylosing spondylitis (AS) patients from various countries.

METHODS

Thirty consecutive AS patients with axial involvement were recruited from 1 center in each of 4 countries (Spain, Morocco, France, The Netherlands), for a total of 120 patients. Fourteen variables were studied in 6 domains: pain (3 variables), stiffness (1 variable), function (2 variables), spinal mobility (3 variables), patient global assessment (4 variables), and the domain of enthesiopathy (1 variable). All patients were evaluated twice within a 1-week period during which no clinical or therapeutic change occurred. Intracenter reliability was evaluated using the intraclass correlation coefficient (ICC). The SDD was determined using the Bland-Altman method.

RESULTS

Of the 14 variables evaluated in the 120 patients (82% males, 42 +/- 12 years old, with a mean disease duration of 17 +/- 13 years), only the SDD for the variable occiput-to-wall distance showed statistically significant difference among centers. For the entire group, the SDD, expressed as percentage of the range of the variable, varied from 10% (Mander enthesis index) to 39% (spinal pain at night last week). The intraobserver reliability was good (ICC > 0.80) except for the variables morning stiffness and modified Schober test (ICCs of 0.76 and 0.60, respectively).

CONCLUSION

This study suggests that the evaluation of AS patients is homogenous and reliable in different centers of different European and North African countries. Evaluation of the SDD of the symptomatic outcome or process variables is a starting point to determine the minimum clinically important difference, permitting the presentation of results of clinical studies on an individual basis.

Hip dislocation revealing hip tuberculosis. A case report

Hip dislocation is an uncommon presentation of hip tuberculosis. We report a case in an 18-year-old woman with active hip tuberculosis. An attempt to reduce the dislocation 7 weeks into antituberculous therapy was followed by necrosis of the femoral head. Although severe forms of hip tuberculosis are common in endemic areas, dislocation is exceedingly rare. Capsule laxity and/or synovial hypertrophy probably contribute more to the occurrence of dislocation than does the accumulation of pus.

[Polyostotic fibrous dyplasia: a case report of a diffuse form with hemimelic predominance]

Fibrous dysplasia is an uncommon condition characterized by the presence of mesenchymatous tissue in bone. There are various risks. We describe the clinical and radiological features observed in a patient with fibrous polyostotic fibrous dysplasia and discuss risks. A 37-year-old man suffered from bone pain and multiple fractures without endocrine disorder since the age of 10 years. At admission in 1998, he presented limb deformities and hyperchromic spots on the thorax. Calciuria was low and alkaline phosphatase was 1274 IU/ml. Endocrine tests were normal. Radiographs showed polyostotic defects in the right hemibody and in the skull. They also showed a right subtrochanteric fissure. CT scan of the face and skull did not demonstrate nerve compression. Histology analysis identified fibrous dysplasia. Vitamin and calcium supplementation and preventive measures were instituted. No deformity led to surgical correction despite the early beginning. Polyostotic fibrous dysplasia is a congenital disease. Radiological aspects are variable. There is a risk of deformities, fractures, osteomalacia (as in our case), neurological compression, and finally a risk of sarcomatous transformation. Recently introduced biphosphonate therapy appears to provide effective pain relief and probably satisfactory prevention of fractures.

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.

Atlantoaxial tuberculosis: three cases

Tuberculosis of the craniocervical junction (CCJ) is exceedingly rare but carries a risk of compression of the medulla oblongata and upper spinal cord. Three cases among 63 patients with spinal tuberculosis are reported. Mean age was 51 years (range, 20-69) and mean time to diagnosis was 4.6 months (range, 1-8). Although atlantoaxial dislocation was a consistent feature, none of the patients had neurological deficits. Computed tomography of the CCJ disclosed a suggestive pattern combining osteolysis and an abscess anterior to the spine. The diagnosis was confirmed by microbiological studies in two cases and histology in one. The outcome was favorable after antituberculous therapy, immobilization of the neck, and surgical fusion. Although tuberculosis remains common in developing countries, involvement of the CCJ is rare. Tuberculosis of the CCJ carries a risk of instability and severe neuraxis compression. Consequently, early diagnosis and treatment are of the utmost importance.

Erosive polyarthritis in Crohn's disease. Report of a case

Erosive polyarthritis in Crohn's disease is rare and raises diagnostic and pathophysiological problems. A case with destructive lesions of the shoulders and hips is reported in a 43-year-old woman with a 26-year history of Crohn's disease. Ankylosis of the spine and hips, motion range limitation of the shoulders and wrists, and boutonnière deformity of the third finger of the right hand were present. Tests were negative for rheumatoid factor and the HLA-B27 antigen. Plain radiographs showed a triple rail pattern at the spine; synostosis of the hips; and destructive lesions of the shoulders, wrists, tarsal bones, and third proximal interphalangeal joint of the right hand. Glucocorticoid therapy was effective in suppressing the bowel symptom flares but only partially improved the joint symptoms, whose treatment relied mainly on nonsteroidal antiinflammatory agents and rehabilitation therapy. Erosive arthritis in Crohn's disease is frequently monoarticular, with the hip being the most common target. It can complicate a spondylarthropathy or reveal granulomatous synovitis. Polyarticular forms pose difficult diagnostic and therapeutic challenges and add to the disability caused by the bowel disease. The potential role of genetic factors remains to be studied.

Rigid spine syndrome. Two case-reports

Rigid spine syndrome is characterized by massive spinal rigidity, usually most marked in the cervical region. Stiffness of the peripheral joints is sometimes present. We report two cases. Patient 1 was a 12-year-old boy diagnosed at three years of age with Duchenne's muscular dystrophy because of delayed onset of walking. Contracture of the Achilles tendons, flexion contracture of the elbows, and loss of motion of the cervical spine were the main findings during the current evaluation. Radiographs of the affected joints were normal. An electrocardiogram showed an incomplete left bundle branch block. Muscle enzyme activities were moderately elevated. A myopathic pattern was seen on the electromyogram. A muscle biopsy showed muscle fiber atrophy with peri- and endomysial fibrosis. Patient 2 was a 39-year-old man with a five-year history of isolated rigidity of the cervical spine thought to be due to a spondylarthropathy. Extension was the only movement possible at the cervical spine. The peripheral joints showed no motion range limitation. Findings were normal from radiographs of the spine and sacroiliac joints, an erythrocyte sedimentation rate determination, an electromyogram, and muscle enzyme activity assays. A muscle biopsy showed muscle fiber atrophy with peri- and endomysial fibrosis.

DISCUSSION

Rigid spine syndrome is rare in rheumatological practice and can simulate a number of other muscle and joint diseases. Peri- and endomysial fibrosis may be strongly suggestive, although nonpathognomonic. Involvement of the heart governs the prognosis.

Polyradiculoneuropathy revealing a solitary plasmacytoma of the ilium. A new case-report

Neurological manifestations are uncommon in myeloma patients, and subacute polyradiculoneuropathy as the inaugural manifestations of solitary plasmacytoma of bone is exceedingly rare. We report the case of a 52-year-old man who was evaluated for a three-month history of flaccid tetraplegia with a gradually ascending onset and for a deterioration in general health. Electromyography findings were consistent with polyradiculoneuropathy. Laboratory tests showed a moderate amount of a monoclonal IgG-lambda antibody. Findings were normal from a radiographic bone survey and a radionuclide bone scan. Computed tomography of the pelvis disclosed a solitary osteolytic lesion in the right iliac crest, which was found upon biopsy to be a malignant plasmacytoma. Radiation therapy and chemotherapy were given. Subacute or chronic polyradiculoneuropathy as the inaugural manifestation of solitary plasmacytoma is exceedingly rare and should be distinguished from the sensorimotor polyneuropathy produced by plasma cell infiltration in some multiple myeloma patients. The polyradiculoneuropathy of solitary plasmacytoma can be likened to the neuropathies seen in some forms of multiple myeloma (sclerotic myeloma and POEMS syndrome). The pathophysiology of these neuropathies remains obscure. The case reported here suggests that patients with unexplained lasting polyradiculoneuropathy should be investigated for a plasma cell proliferation even if they have no serum monoclonal component. Because plasmacytomas are painless, imaging studies are needed for their diagnosis. The management of the neuropathy consists in treatment of the tumor.

Tuberculosis of the sternoclavicular joint. Report of two cases

The sternoclavicular joint accounts for only 1 to 2% of all cases of peripheral tuberculous arthritis and is more often infected by pyogenic organisms than by the tubercle bacillus. We report two cases of sternoclavicular joint tuberculosis, in a 38-year-old man and a 46-year-old woman without risk factors for immune deficiency. Swelling of the joint was the presenting manifestation. Laboratory tests indicated inflammation in only one of the patients. The intradermal tuberculin test was strongly positive in both patients, whereas smears and cultures of sputum and urine samples were negative for the tubercle bacillus. Serologic tests for the human immunodeficiency virus were negative. Erosions of the affected joint were seen by computed tomography. Histological studies of a surgical biopsy specimen confirmed the diagnosis. Cultures of the biopsy specimens were negative. The outcome was favorable after treatment with rifampin, isoniazid and pyrazinamide for six months in the man and nine in the woman. Follow-ups were eight and six months, respectively, at the time of this writing. Tuberculosis of the sternoclavicular joint is extraordinarily rare and can raise diagnostic problems. The diagnosis should be considered in every patient with arthritis in a sternoclavicular joint or unexplained pain in a shoulder. Possible complications include compression or erosion of the large blood vessels at the base of the neck and migration of tuberculous abscesses to the mediastinum.

Primary psoas abscess. A review of 16 cases

OBJECTIVE

Most psoas abscesses are secondary. The objective of this study was to report on the clinical features, diagnosis and treatment of primary psoas abscess.

METHODS

We retrospectively studied 16 cases seen over a ten-year period (1987-1997) and compared our findings to published data.

RESULTS

There were 14 men and two women, with a mean age of 6 years (range, 17-57 years). The right side was affected in nine cases, the left side in six, and both sides in one. Fever, pain and psoas spasm were the presenting symptoms. Laboratory tests for inflammation were positive; four patients had a high neutrophil count. Ultrasonography demonstrated a fluid collection in the psoas in 13 patients. A computed tomography scan was done in 14 patients and showed either a fluid collection (n = 11) or a presuppurative abscess (n = 3). Magnetic resonance imaging was not used. The organism was recovered in nine patients and was a Staphylococcus aureus in seven, an Escherichia coli in one and a Pseudomonas aeruginosa in one. The Brucella agglutination test was strongly positive in two patients. Findings were negative from investigations done to look for a cause (discitis, urinary tract infection, Crohn's disease, ulcerative colitis, malignancy or infection in the vicinity of the psoas muscle). All patients received antimicrobial therapy. Drainage was percutaneous in six patients and surgical in ten. The outcome was favorable in every case.

[Pubic tuberculous osteo-arthritis. Apropos of 2 cases]

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.

[Familial sarcoidosis: three case reports]

INTRODUCTION

Familial sarcoidosis is rare. We reviewed 147 cases of sarcoidosis, whatever their localization, diagnosed at Rabat-Salé University Hospital, during a period of 10 years (1983-1993). Among these cases, we report those of three patients with sarcoidosis, in a same family. The observations concern three generations.

OBSERVATIONS

Observation 1: the grandmother presented with pulmonary sarcoidosis. Observation 2: the mother presented with sarcoidosis of the skin, joint and lung. Observation 3: the daughter had cutaneous and pulmonary localizations.

DISCUSSION

The real frequency of familial sarcoidosis is probably underestimated because of the big number of latent forms. A review of the literature allowed us to find 43 families with sarcoidosis. There is no clinical difference between familial sarcoidosis and usual forms of the disease, as confirmed by our findings. The preponderance of patients of the same sex in the same family, like our mother-daughter filiation is, described by the majority of the authors. This leads to suppose the existence of genetic factors. Neither this theory nor the one suggesting the possibility for etiologic agent that could perhaps affect the same persons in the same family can be currently demonstrated. Any association with an HLA group in the familial cases of sarcoidosis is unlikely.

CONCLUSION

The rarity of familial sarcoidosis forms makes very difficult to establish theories regarding the familial predisposition.

Third-degree atrioventricular block in a patient under chloroquine therapy

The first case of chronic cardiac toxicity due to an antimalarial agent was reported in 1971 and since then several cases of heart failure, restrictive cardiomyopathy or atrioventricular block have been ascribed to this family of drugs. We report the case of a 43-year-old woman who developed juvenile chronic arthritis at the age of ten, followed in adulthood by sero-positive rheumatoid arthritis. In 1980 she was put under chloroquine sulfate (hydroxychloroquine was not available) in a dose of 200 mg/d (152.66 mg of chloroquine), with 10 mg/day of prednisone. She developed myalgia and increased skin pigmentation, but disregarded recommendations that these symptoms required discontinuation of chloroquine therapy. She was lost to follow-up, but continued the chloroquine therapy of her own accord. In December 1993, she developed a third-degree atrioventricular block with syncopes requiring implantation of a pacemaker. The rare but well-documented myopathy induced by antimalarial agents can produce early severe lesions of the cardiac muscle, which may have a predilection for the interventricular septum, explaining the risk of atrioventricular block. Although histologic studies were not performed in our patient, the clinical evidence of toxicity, absence of underlying heart disease and fairly young age of the patient pointed to chloroquine toxicity. Periodic cardiac investigations including electrocardiography may be warranted in patients under antimalarial therapy.

Features associated with juvenile onset of spondylarthropathies in north Africa

To determine whether juvenile onset of spondylarthropathy is associated with specific features, a prospective, cross-sectional study comparing juvenile-onset and adult-onset spondylarthropathies was conducted in the Maghreb in 523 patients meeting Amor's criteria or the ESSG's criteria for spondylarthropathy. Demographic data and clinical findings at the time of inclusion and during the first two years of the disease were compared in the 437 patients with onset at 16 years of age or older and in the 86 patients with onset before 16 years of age using a Student's t test or a chi-square test. The risk of hip involvement during the course of the disease was estimated using Kaplan-Meier curves and compared in the two groups using a Cox model. Early in the disease, patients in the juvenile onset group were more likely to have peripheral arthritis (52% vs 39%, p = 0.021) and enthesopathies (55% vs 40%, p = 0.002) and less likely to have axial manifestations (41% vs 62%, p = 0.0001), as compared with the adult-onset group. These differences persisted after a follow-up of 9.2 years. Juvenile-onset disease was associated with a greater likelihood of hip involvement (54 +/- 6% vs 34 +/- 3% after ten years, p = 0.012). The male bias was more marked in the juvenile onset group (85%) than in the adult-onset group (72%) (p = 0.016). These data confirm that demographic characteristics, clinical manifestations, and disease severity differ between juvenile-onset and adult-onset spondylarthropathies.

Predictive factors of severity of spondyloarthropathy in North Africa

Both genetic and environmental factors probably influence the severity of Spondyloarthropathies. Hip involvement, which may be used as a marker of disease severity, is more frequent in spondyloarthropathies developed in North Africa. The objective of this study was determine the predisposing factors of hip involvement in spondyloarthropathy in North Africa. Patients fulfilled the Amor or European Spondyloarthropathy Study Group (ESSG) criteria of spondyloarthropathy. The study was retrospective, cross-sectional, multicentre and carried out in North Africa. The data collected were demographic data, socio-cultural factors and clinical presentation at onset. The risk of hip involvement with regard to disease duration was estimated using Kaplan-Meier's method. The predictive value of each variable with regard to time to hip involvement was evaluated using a uni- and then a multivariate Cox proportional hazard model. Five hundred and eighteen patients were included. The risk of hip involvement was estimated at 39+/-3% after 10 yr disease duration. The factors picked up by the multivariate analysis were: diagnostic delay less than 7 yr, age at onset below 24 yr and a combination of 'lower social class' and 'no refrigerator at home'. This study confirms the high prevalence of hip involvement during the course of spondyloarthropathy in North Africa and suggests a role of environmental factors in its appearance.

Osteomalacia as a presenting manifestation of Sjögren's syndrome

Osteomalacia is still common in Morocco, where the leading causes are nutritional deficiencies followed by intestinal diseases. Osteomalacia rarely occurs as the first manifestation of a renal tubule disorder due to a connective tissue disease such as Sjögren's syndrome. The case of a 40-year-old woman who presented with a five-year history of generalized bone pain, severe weight loss and a waddling gait is reported. She had low levels of serum phosphate (0.74 mmol/L), serum calcium (1.97 mmol/L), and urinary calcium (1.22 mmol/24 h). Serum alkaline phosphatase was 210 IU/L. Roentgenograms showed Looser's zones (right femoral neck, sixth and seventh right ribs). There was bilateral parotid gland enlargement, dryness of the mouth, nose and eyes, and bilateral punctate keratitis. A lip biopsy showed changes corresponding to stage II of the Chisholm and Mason classification. Tests for rheumatoid factor (latex and Waaler-Rose) and antinuclear factor were negative. The alkaline reserve was 18 mmol/L, serum potassium was 3.5 mmol/L, serum chloride was 112 mmol/L and urinary pH was 6.5. A renal biopsy showed tubulointerstitial lesions, lymphoplasmocytic infiltrates and interstitial sclerosis with patchy tubular atrophy. The patient was given bicarbonates, high-dose vitamin D followed by 1-alpha-hydroxycholecalciferol (0.3 microgram/d), and calcium (1 g/d). Follow-up was 42 months at the time of this writing. The role of tubular disorders in the genesis of osteomalacia is discussed, and the renal manifestations of Sjögren's syndrome are reviewed.

[Comparison of patients evaluated for spondylarthropathy in France and Morocco]

The authors compared demographic and clinical data in patients with spondylarthropathy residing in Morocco or in France and searched for factors associated with increased disease severity, with special attention to course of the disease, life style, clinical findings and roentgenographic changes. They carried out univariate analyses (chi-square test, Student's t test) to look for factors associated with hip involvement. Evaluation of the relative risk associated with each factor by determination of the odds ratio and corresponding 95% confidence interval. Statistically significant differences were found between the two groups concerning socioeconomic status and disease characteristics. Patients seen in Morocco had more severe disease, with roentgenographic hip involvement in 48% of cases versus only 16% of patients seen in France (p < 0.0001). Several factors were associated with the presence of hip disease, including residence in Morocco, Maghrebine ethnic origin, patient characteristics (male sex, low body mass index), disease characteristics (high erythrocyte sedimentation rate, young age at onset), and environmental factors (no running water in the home). Patients with spondylarthropathy residing in Morocco had more severe disease than their counterparts living in France; both genetic and environmental factors may explain this difference.

[Ankylosing spondylitis and amyloidosis. Apropos of 2 cases]

The authors report 2 cases of ankylosing spondylitis complicated by amyloidosis. In the first case, the development of a nephrotic syndrome in a long-standing case of spondylitis (16 years) led to discovery of the amyloid. In the second case, a nephrotic syndrome appeared in a 38 year old man with a three year history of ankylosing spondylitis. In both cases, the amyloidosis was confirmed on histological examination.