POS1016 ANKYLOSING SPONDYLITIS IN WEST AFRICAN PATIENTS: A SERIES OF 37 CASES REPORTED IN TOGO

Background:

Spondyloarthritis (SpA) is generally uncommon in sub-Saharan Africa, in part because of the rarity of HLA-B27 in this region.

Objectives:

The aim of our study was to determine the epidemiological, semiological, paraclinical and therapeutic aspects of ankylosing spondylitis in rheumatology in Togo.

Methods:

This was a retrospective multicenter descriptive study on the files of patients suffering from ankylosing spondylitis seen in an outpatient setting or hospitalized in one of the four Rheumatology departments of Togo in the period from January 1, 2000 to December 31, 2019. The diagnosis was essentially radio-clinical based on the modified New York criteria.

Results:

In 20 years, and out of a population of 35,304 rheumatic patients, we have collected 37 cases of ankylosing spondylitis, meaning a hospital frequency of 0.10% and an annual frequency of 1.85 cases. There was clearly a male predominance with an M / F ratio of 4.28. The onset of the disease was on average of 29.62 ± 10.27 years and the diagnosis delay on average of 9.45 ± 9.20 years. The clinic was dominated by spinal pain in the form of chronic inflammatory cervical-dorsal-lumbar pain (41.2%) or lumbar pain (29.4%). Common joint injuries were those of the knees (57.69%), ankles (26.9%) and shoulders (23.1%). The most frequent extra-articular manifestations were ocular with conjunctivitis (62.5%) and uveitis (37.5%). Due to the delayed diagnosis, significant spinal deformities including hypercyphosis, straightness and ankylosis were found; the radiography of the spine objectified syndesmophytes (50.0%) with ankyloses and the bamboo column (23.5%) and that of the pelvis objectified sacroiliitis at stage 3 (54.6%) and at stage 4 (27.3%). The HLA B27 antigen was positive in 10.8% of cases. NSAIDs and sulfasalazine were the most commonly used drugs in management, respectively in 94.3% of symptomatic treatment and 92.6% of background therapy.

Conclusion:

Ankylosing spondylitis is relatively rare in Togo, affecting more men and young adults. There are no clinical or paraclinical particularity. The delay in diagnosis reflects the importance of the radiological signs. Treatment is mainly done by NSAIDs and DMRADs in particular sulfasalazine, due to their accessibility.

References:

[1]Dean LE, Jones GT, MacDonald AG, Downham C, Sturrock RD, Macfarlane GJ. Global Prevalence of Ankylosing Spondylitis. Rheumatology (Oxford). 2014;53:650-7.

[2]Zabsonre TWJ, Sawadogo SA, Kabore F, Ilboudo A, Sougue C, Zongo E, et al. Ankylosing Spondylitis in Sub-Saharan Africa: A Series of 48 Cases Reported in Burkina Faso (West Africa). Open J Rheumatol Autoimmune Dis. 2018;8:87-92.

[3]Mijiyawa M. Ankylosing Spondylitis in Togolese Patients. Med Trop. 1993;53:185-9.

Disclosure of Interests:

None declared.

POS1291 PROFILE OF LUMBAR SPINE DEGENERATIVE PATHOLOGY IN RHEUMATOLOGIC CONSULTATION IN NORTHEN TOGO

Background:

Degenerative spine pathology is a common reason for consultation in rheumatology. The lumbar spine is the first seat.

Objectives:

To determine the epidemiological and semiological profile of degenerative lumbar spine damage in Kara.

Methods:

It was a cross-sectional study based on patient records who had consulted for a degenerative lumbar spine pathology in the rheumatology department of the CHU-Kara (Northen Togo) over a three-year period.

Results:

Of the 1,767 patients examined during the study period, 745 (42.16%) suffered from a degenerative pathology of lumbar spine. They were 285 men (38.3%), and 460 women (61.7%) H/F ratio of 0.62. Traders (30%), civil servants (12.5%), teachers (9.5%), and housewives (8.7%) were the most affected occupational categories. The average age of patients at the consultation was 50.6 ± 12.3 years, and the average duration of disease progression was 4.3 years ± 1.8 years. The clinical forms of degenerative lumbar spine damage were: common low back pain (194 cases; 26.04%), common lomboradiculalgia by probable disco-radicular conflict (457 cases; 61.34%) and the narrowed lumbar canal (94 cases; 12.62%). Common low back pain was acute in 56.7% of cases. The path of radiculalgia during the probable herniated disc was truncated in 19.2% of cases, L5 in 46.4% of cases, S1 in 32.9% of cases, and L4 in 2.7% of cases. The walking perimeter was less than 500 meters in 48% of patients with narrowed lumbar canal. Signs of degenerative disc disease (536 cases), spondylolisthesis (102 cases) and isthmic lysis (37 cases) were the main radiological lesions observed.

Conclusion:

Degenerative damage to lumbar spine is dominated in North Togo by common lomboradiculalgia by probable herniated disc.

References:

[1]Mijiyawa M, Oniankitan O, Kolani B, Koriko T. La lombalgie en consultation hospitalière à Lomé (Togo). Rev Rhum 2000;67:914-20.

[2]Louw QA, Morris LD, Grimmer-Somers K. The prevalence of low back pain in Africa: a systematic review. BMC Musculoskelet Disord 2007;8:105.

[3]Morris LD, Daniels KJ, Ganguli B, Louw QA. An update on the prevalence of low back pain in Africa: a systematic review and meta-analyses. BMC Musculoskelet Disord 2018;19:196.

[4]Ouédraogo D-D, Ntsiba H, Tiendrébéogo Zabsonré J, Tiéno H, Bokossa LIF, Kaboré F, et al. Clinical spectrum of rheumatologic diseases in a department of rheumatology in Ouagadougou (Burkina Faso). Clin Rheumatol 2014;33:385-9.

Disclosure of Interests:

None declared

[Contribution of the x-ray to the diagnosis of the non traumatic knee's pain in the teaching hospitals Tokoin and campus of Lomé]

GOAL

This survey has been realized in order to show the diagnostic interest of the standard radiography in the non traumatic knee's pain.

OBJECTIVES

The main objectives of this work were to describe the elementary lesions, the etiological aspects of the non traumatic knee's pain and to list the met pathologies.

PATIENT AND METHOD

It was about a prospective survey of six months (december 2007-may 2008) track in the departments of radiology of the Teaching Hospitals of Lomé and on a population of 187 patients enduring a non traumatic knee's pain.

RESULTS

The frequency was of 2.5%. The average of age was of 48.55 years (extreme: 18 and 92 years). The feminine sex (63.10%) was the most represented. The housewives were the most represented (36.36%). of The bodily mass indication was consisted between 09 and 42 Kg/m2s with an average of 25.65 Kg/m2s. The osteophyte (26.67%) was the most observed elementary radiographic lesion. The arthrosic knee (47.71%) was the dominant pathology and the chondrocalcinose (02.74%) least represented. A predominance of the tricompartimentale arthrosic knee (38.46%) was cleared itself. The malformatives abnormalities were in 58.62% of the osteoarthritis cases seat.

CONCLUSION

This survey reveals the importance diagnostic of the x-ray and the wealth of the pathology of the knee in Africa particularly in Togo.

[Infectious arthritis in hospital patients in Lomé, Togo]

OBJECTIVE AND METHODS

The purpose of this study was to determine the frequency and semiological profile of infectious arthritis in the outpatient clinic of the Tokoin University Hospital Center in Lomé, Togo.

PATIENTS AND METHODS

This study was based on a review of the charts of patients hospitalized in the rheumatology department over a period of 16 years.

RESULTS

During the 16-year study period, 198 of the 13517 patients (1.5%) examined were hospitalized for infectious arthritis. There were 100 women and 98 men with a mean age of 36.3 +/- 17.5 years. Mean disease duration was 9.3 +/- 9.8 months. Diagnosis was banal germ arthritis in 157 cases (79.3%) and likely tuberculosis arthritis in 41 (20.7%). The knee was the most common location (34.3%). Arthritis affected a single joint in 159 cases (80.3%). Isolation of offending microorganism was achieved in 39 patients (19.7%). The most frequently identified agent was Staphylococcus aureus (42.5%). In addition to underdevelopment and poor hygiene observed in most patients in this series, risk factors included human immunodeficiency virus infection in 28 cases, alcoholism in 10, sickle cell anemia in 8, cancer in 3, and diabetes mellitus in 2. Outcome was favorable in 181 patients (88.7%). Four patients died.

CONCLUSION

The frequency of infectious arthritis is correlated with underdevelopment and poor hygiene in black Africa.

[Spondylodiscitis at a hospital outpatient clinic in Lome, Togo]

PURPOSE

This investigation was carried out to determine the frequency and features of spondylodiscitis in patients attending the Tokoin University Hospital Center in Togo.

PATIENTS AND METHODS

A retrospective study of patients examined in the Rheumatology Outpatient Clinic over a 17-year period was conducted.

RESULTS

Out of 14,708 patients examined during the study period, 222 (1.5%) presented spondylodiscitis. There wire 108 women and 114 men with a mean age of 38 years. The mean duration of symptoms was 6 months. Spondylodiscitis was related to presumptive tuberculosis in 169 patients (76.1%). The most common locations were the lumbar (56.8%) or thoracic (21.6%) spine. It was associated with a pulmonary location in 39 patients (17.6%). In addition to underdevelopment and poor hygiene in most patients, risk factors for spondylodiscitis included HIV infection (n=23), alcoholism (n=27), diabetes mellitus (n=7), and sickle cell anemia (n=7). Response to medical treatment was favorable in 197 patients (88.7%).

CONCLUSION

Spondylodiscitis is still a frequent reason for seeking medical care in Black Africa.

[Risk factors of hip osteoarthritis in Lomé, Togo]

The medical records of the Lomé Teaching Hospital Rheumatology Unit (Togo) were retrospectively reviewed to study risk factors for osteoarthritis of hip. Among the 14,090 patients examined over a period of 17 years, 89 (0.63%) including 37 women and 52 men had osteoarthritis of the hip as defined according to the criteria of Kellgren and Lawrence. The mean duration of osteoarthritis of the hip was six years. Involvement was unilateral in 77 patients (86.5%) and bilateral in 12 (13.5%). Osteoarthritis of the hip was primary in 41 patients (46.1%) and secondary in 48 (53.9). Risk factors for secondary osteoarthritis of the hip were necrosis of the femoral head (n = 14), epiphysitis (n = 13), dysplasia (n = 11), traumatism (n = 6) including two femoral neck fractures, and tuberculosis of the hip joint (n = 2). In the 14 subjects with necrosis of the femoral head, hemoglobin was type SC in three cases and SS in two. Necrosis of the femoral head appears to be the main risk factor for osteoarthritis of the hip in black Africa. The impact of this risk factor may increase with longer life expectancies of subjects with hemoglobin SS and SC.

[Osteoarthritis of the knee in hospital outpatients in Lomé (Togo)]

OBJECTIVE AND METHODS

Medical records of patients seen at the Lomé Teaching Hospital rheumatology unit (Togo) were studied retrospectively to determine the frequency and semiological characteristics of osteoarthritis of knee.

RESULTS

Among the 12251 patients seen, 993 (8%, 844 women and 149 men) had osteoarthritis of the knee responding to ACR criteria. Mean age at onset was 51 years and mean duration of osteoarthritis of the knee was four years. The osteoarthritis affected one joint in 470 patients (47%) and two joints in 523 other patients (53%). Mechanic pain (923 patients, 93%) and claudication 251 patients, 25%) were the frequent symptoms. At the knee, the lesions involved the medial femorotibial compartment in 493 patients, the lateral femorotibial compartment in 223 patients, the patellofemoral compartment in 42 patients, and the femorotibial and patellofemoral compartment in 235 patients. 764 of 993 patients (77%) with knee osteoarthritis were obese (femmes: 699, 82.8%) and 729 had varus and/or valgus (73.4%).

CONCLUSION

This study confirms the high prevalence of osteoarthritis of the knee in black Africa. Female sex, obesity, and varus or valgus deformities are the main risk factors for femorotibial osteoarthritis in black Africa.

[Lumbar spinal stenosis in an outpatient clinic in Lome, Togo]

The purpose of this study was to determine the frequency and semiological characteristics of lumbar spinal stenosis in patients attending the rheumatology outpatient clinic at the Lomé Teaching Hospital. Medical records of 13081 patients seen over a 15-year period were retrospectively reviewed. A total of 760 (5.8%) had lumbar spinal stenosis. There were 556 women (73.2%) and 204 men (26.8%) with a mean age at onset of 52 years (range, 25 to 65 years). The mean duration of lumbar spinal stenosis was 4.5 years. The main symptom was nerve root pain in 712 (93.7%) involving one root in 248 cases and more than one root in 464. Most patients in this group were between the ages of 35 and 65 years. Pain was relieved by bending the spine forward in 456 patients (60%) and claudication was present in 643 patients (84.6%). Walking distance was less than 500 meters in 491 patients and more than 500 meters in 152. Pain was exacerbated by extension of the spine in 475 patients (62.5%) and associated with paresthesia in 532 patients (70%) and sphincter dysfunction in 155 patients (20.4%). Roentgenography of the lumbar spine was performed in 504 patients and showed abnormalities in 475. The most common radiographic abnormality was degenerative disk disease (n = 251). Myelography was performed in 56 patients, showing a rosary-like image in 31 cases and disk herniation in 23. Lumbar spinal stenosis in Black Africa appears to be more common than in industrialized countries and to affect mainly women in the fifth decade of life. The semiological profile of lumbar spinal stenosis appeared to be similar in Black Africa and industrialized countries.

Estimation of the Bath Ankylosing Spondylitis Disease Activity Index cutoff for perceived symptom relief in patients with spondyloarthropathies

OBJECTIVE

To estimate the best Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) cutoff based on patients' perceptions of symptom relief collected in a large population of patients with spondyloarthropathies (SpA), in comparison to the BASDAI cutoff determined by experts.

METHODS

A survey of patient perceptions about current disease control was conducted among the members of Spondylis, one of the main not-for-profit SpA patient organizations in France. BASDAI was among data collected by the questionnaire. To estimate the best BASDAI cutoff for discriminating between poor and well perceived controlled groups, we plotted the receiver operating characteristic (ROC) curve. We also determined the cutoff separately in male and female patients.

RESULTS

Of the 1000 mailed questionnaires, 485 were returned without any missing data regarding perceived disease control and the BASDAI. Of these patients, 55.3% perceived inadequate control of their disease. The mean BASDAI in the overall population was 43.5 +/- 22.9, 30.4 +/- 19.9 in the well controlled group and 54 +/- 19.4 in the poorly controlled group (p < 0.001). The best BASDAI cutoff for discriminating between patients in the 2 groups was 39 (sensitivity 74.6% and specificity 72.4%). According to gender, the best cutoff was 44 for women and 36 for men.

CONCLUSION

The best BASDAI cutoff of 39 based on patients' perceptions was very similar to that selected by international experts, i.e., 40. Gender affected the cutoff for perceived symptom relief in our study. These results need to be confirmed by further studies collecting the opinions of both patients and physicians.

Low back pain in hospital outpatients in Lomé (Togo)

OBJECTIVE

To determine the patterns of low back pain and the conditions associated with this symptom in outpatients attending the rheumatology unit of the Lomé Teaching Hospital.

METHODS

Medical records of patients seen over a ten-year period were studied retrospectively.

RESULTS

Among the 9,065 patients seen during the study period, 3,204 (35.34%; 1,850 women and 1,354 men) had low back pain. Mean age at onset was 41 years, and mean duration of low back pain was three years. Diseases associated with low back pain were as follows: degenerative spinal disease, N = 3,054 (95.32%); spinal infections, N = 79 (2.47%); spondyloarthropathies, N = 44 (1.37%); and tumors, N = 27 (0.84%). The patterns of degenerative spinal disease included low back pain (N = 1,535, 47.91%), low back pain with nerve root pain suggestive of disk herniation (N = 1,108, 34.58%), and low back pain with nerve root pain and claudication suggestive of lumbar spinal stenosis (N = 411, 12.83%). Schöber's index was abnormal in 831 of the 1,408 patients (59%) with acute pain or disk herniation. Most patients with lumbar spinal stenosis were women (72.26%) and were aged 35 to 64 years. Findings suggestive of tuberculosis were present in 62 of the 79 patients with lumbar spinal infection. Among the 44 patients with spondyloarthropathies, 15 had ankylosing spondylitis and 11 had infection with the human immunodeficiency virus (HIV). Multiple myeloma was present in ten patients and metastatic tumors in eight.

CONCLUSION

Low back pain seems to be as common in sub-Saharan Africa as in occidental countries, with a prevalence of one-third among rheumatology outpatients. Lumbar spinal stenosis seems more common than in the occident and is mainly observed in woman. Schöber's index is not useful for measuring forward bending of the lumbar spine in Africans. The epidemiology of spondyloarthropathies in sub-Saharan Africa has been changed by the expanding HIV epidemic, despite the low prevalence of the HLA B27 phenotype.

Risk factors for gout in Togolese patients

OBJECTIVE

To determine the risk factors for gout in Togolese patients.

METHODS

The medical records of patients admitted to the Lomé Teaching Hospital (Togo) rheumatology department over a ten-year period were reviewed retrospectively.

RESULTS

Of the 8351 study patients, 160 (1.9%) fulfilled American Rheumatism Association criteria for gout; 159 were male. Mean age at disease onset was 44 years, and mean disease duration was six years. Tophi were recorded in 35 cases and a history of renal colic in one. Only five patients (3.1%) had no identifiable risk factors. The main risk factors in the remaining patients were alcohol abuse (133/160, 83.12%), overweight/obesity (64/160, 40%), and hypertension (42/160, 26.25%); 153 patients (95.6%) had at least one of these risk factors, 58 patients (36.32%) had two, and 14 (8.8%) had all three. Of the 42 hypertensive patients, 20 were on diuretic therapy. Seventeen patients (10.62%) had a family history of gout. There was no evidence that AS or AC hemoglobinopathy (32 and 13 cases, respectively) influenced the course or natural history of gout.

CONCLUSION

Although population-based studies are needed for confirmation, our study suggests that risk factors for gout in Togolese patients are similar to those in other parts of Africa and in Western countries.

Spondyloarthropathies in sub-Saharan Africa

HLA-B27 is virtually absent in most of the sub-Saharan Africa populations, and ankylosing spondylitis is rare; only a few patients have been reported from central and southern Africa. HLA-B27 was present in only one of 17 patients (6%). The disease shows clinical features that are similar to those observed in white HLA-B27-negative patients with ankylosing spondylitis; ie, the disease onset is later compared with HLAB27-positive patients, the patients rarely get acute anterior uveitis as one of the extra-articular manifestations, and familial occurrence of ankylosing spondylitis is rarely observed. There is a virtual absence of ankylosing spondylitis even in the west African countries of Gambia and Senegal, where 3% to 6% of the general population has HLA-B27. The epidemic of HIV infection in sub-Saharan Africa in recent years, however, has been associated with a dramatic upsurge in the prevalence of spondyloarthropathies other than ankylosing spondylitis, primarily reactive arthritis and undifferentiated forms of the disease, and less often psoriatic arthritis. HLA-B27, because of its rarity and virtual lack of association with the observed cases of spondyloarthropathy in this population, cannot be used as an aid to diagnosis of spondyloarthropathy in black Africans. Conversely, HIV infection is increasingly showing such a strong association with reactive arthritis, psoriatic arthritis, and undifferentiated spondyloarthropathies in sub-Saharan African populations that any patient with acute or chronic inflammatory arthritis may need to be tested for possible HIV infection. More research is needed on the evaluation of risk and protective factors in sub-Saharan African populations to better delineate the relative importance of genetic and environmental factors in the pathogenesis of spondyloarthropathies.

Musculoskeletal conditions in children attending two Togolese hospitals

OBJECTIVE

A retrospective study was conducted in order to point out the different kinds of musculoskeletal conditions observed in children attending two Togolese hospitals.

RESULTS

A total of 434 (242 females, 192 males) of the 29 620 children examined (1.5%) were suffering from these conditions. Probable joint and bone infections (187 patients, 43%), limb deformities (106 patients, 24%), osteochondrosis (60 patients, 14%) and vaso-occlusive crisis due to haemoglobinopathies (29 patients, 7%) were the main conditions observed. Osteomyelitis observed in 128 patients affected the humerus (25 patients), radius (10 patients), femur (68 patients), tibia (15 patients), fibula (five patients), and both tibia and fibula (five patients). Probably, infectious arthritis seen in 30 patients affected mainly the hip (11 patients) and the knee (13 patients). In the spine, infection affected the midthoracic and upper lumbar areas. Underdevelopment, sickle cell anaemia and sickle cell haemoglobin C disease were the main risk factors in determining susceptibility to infections. Vaso-occlusive crises were due to sickle cell anaemia (11 patients) and sickle cell haemoglobin C disease (18 patients). Osteochondrosis seen in 60 patients free from haemoglobinopathy involved the spine (Scheuermann's disease, 38 patients) and the hip (Legg-Calvé-Perthes disease, 22 patients). Limb deformities were observed in the knee (varus and valgus deformities in 64 patients) and the foot (talipes varus equin in 40 patients).

CONCLUSION

This study's findings, which require further confirmation, suggest some conclusions. Scheuermann's disease can explain in part the degenerative disc conditions observed in African adults. Valgus and varus deformities play an important role in the development of knee osteoarthritis in Black Africa. An African child with joint or bone pain should be investigated for sickle cell anaemia. In the future, improved lifestyle and better health care will be essential to reduce bone and joint infections, and allow refined diagnosis of connective tissue diseases now probably underestimated in African children.

[Scleroderma in a hospital setting in Togo]

The purpose of this retrospective study was to determine the epidemiological and semiological profile of scleroderma in Black Africa. Medical records of patients who consulted in the Dermatology Clinic and the Rheumatology Clinic of the Teaching Hospital in Lomé, Togo between 1980 and 1996 and between 1989 and 1996 respectively were reviewed. Scleroderma was diagnosed in 18 of the 34,169 patients seen during the study periods (0,05%). The disease was systemic in 13 cases (8 females, 5 males; mean age: 31 years) and localized in 5 cases (mean age: 20 years). There were no predisposing occupational or therapeutic factors. The clinical manifestations were Raynaud's phenomenon in six of the 13 patients with systemic scleroderma. Extensive cutaneous sclerosis in 10 cases, poikiloderma in seven cases, dysphagia in three cases, pulmonary fibrosis in four cases, and polyarthralgia in two cases. Myalgia and renal involvement were not observed. The findings of this study documents the low incidence of scleroderma in Togo. The high frequency of extensive cutaneous sclerosis, poikiloderma and low frequency of Raynaud's phenomenon which were often mild are the most remarkable features of the disease in Lomé. These features have been pointed out previously but epidemiologic data is still insufficient to confirm the existence of an African form of scleroderma.