AB1131 IDENTIFICATION OF FACTORS ASSOCIATED WITH THE OCCURRENCE OF SEVERE FORMS OF COVID-19 INFECTION IN PATIENTS WITH AUTOIMMUNE/INFLAMMATORY RHEUMATIC DISEASES

Background

Patients with autoimmune/inflammatory rheumatic diseases (AIRD) were suspected to be an at-risk population of severe COVID-19. However, whether this higher risk is linked to the disease or to its treatment is difficult to determine.

Objectives

To identify, among AIRD patients, factors associated with occurrence of moderate-to-severe COVID19 infection and to evaluate if having an AIRD was associated with an increased risk of severe form of COVID19 infection (defined by hospitalization in ICU or death), compared to general population.

Methods

Data source: The “Entrepôt des Données de Santé (EDS)” collect data from electronic health records of all patients hospitalized or followed in the AP-HP (39 hospitals in Paris area, France). The French RMD COVID19 cohort is a national multi-center cohort that included patients with confirmed AIRD and diagnosed with COVID-19. All AIRD patients diagnosed with COVID-19 before September 2020 from both cohorts were included.

-We Identified factors associated with severe COVID-19 was made in a combined analysis of the 2 cohorts.

-Then, we compared COVID-19 infection severity in the EDS-COVID database in AIRD patients and controls, by a propensity score (PS)-matched case-control (1:4) study

Results

Among 1213 patients (334 in EDS and 879 in RMD cohort), 195 (16.1%) experienced a severe COVID19. In multivariate analysis, greater age, history of interstitial lung disease, arterial hypertension, obesity, sarcoidosis, vasculitis, auto-inflammatory disease and treatment with corticosteroids or rituximab were associated with severe COVID-19 (Table 1).

Table 1.

AIRD patient’s characteristics associated with severity of COVID-19

Patients with mild or moderate infectionPatients with severe infectionOR ajustés 95%CIp-value(N = 1018)(N = 195)Patients characteristics Age55.9 (16.7%)70.3 (14.3%)1.05 [1.03;1.07]<0.001 Gender: Female695 (68.3%)105 (54.1%)0.59 [0.38;0.94]0.025 Interstitial pneumonia38 (3.7%)20 (10.3%)2.94 [1.34;6.34]0.008 Obesity143 (17.8%)38 (27.7%)2.09 [1.26;3.43]0.004 Hypertension268 (26.3%)114 (58.5%)1.81 [1.13;2.89]0.013Underlying Disease: Chronic inflammatory arthritis618 (60.8%)72 (36.9%)Ref. Auto-inflammatory disease29 (2.9%)5 (2.6%)3.91 [1.2;11.32]0.025 Other29 (2.9%)4 (2.1%)0.35 [0.06;1.41]0.15 Connectivitis190 (18.7%)34 (17.4%)1.13 [0.62;2.01]0.69 Sarcoidosis40 (3.9%)24 (12.3%)5.19 [2.15;12.3]<0.001 Vasculitis111 (10.9%)56 (28.7%)1.8 [1.02;3.16]0.044Treatments Corticosteroid318 (31.2%)117 (60.0%)2.47 [1.58;3.87]<0.001 Leflunomide44 (4.3%)2 (1.0%)0.13 [0;0.97]0.045 Rituximab37 (3.7%)22 (11.5%)4.05 [1.96;8.27]<0.001Not significant in multivariate analysisCOPD, Asthma, Coronary heart diseases, stroke, diabetes, smoking, cancer, non-steroidal anti-inflammatory drugs, colchicine, hydroxychloroquine, methotrexate, salazopyrine, mycophenolate mofetil, azathioprine, intravenous immunoglobulins, anti-TNFα, anti-IL1, -IL6, -IL17, Abatacept, JAK inhibitor

Among 35741 COVID-19 patients in EDS, 316 with AIRD were compared to 1264 PS-matched controls. Severe form occurred in 118 (37,3%) AIRD cases and 384 (30.4%) controls (Adjusted OR (aOR) for severe form= 1.43 [1.1;1.9], p=0,01). In analysis restricted to rheumatoid arthritis (RA) and spondylarthritis (SpA), no increased risk of severe form (aOR=1.11 [0.68;1.81]) form or death (aOR=1.00 [0.55;1.81]) was observed.

Conclusion

In this multicenter study we confirmed that AIRD patients treated with rituximab or corticosteroids were at increased risk of severe COVID-19, as were those with vasculitis, auto-inflammatory disease, and sarcoidosis. Also, when compared to controls from the same cohort of hospitalized patients, AIRD patients had, overall, an increased risk of severe COVID-19, increased risk not observed in an analysis restricted to patients with RA or SpA.

Acknowledgements

FAI2R /SFR/SNFMI/SOFREMIP/CRI/IMIDIATE consortium and contributors

Patricia Martel

All clinicians/physicians implicated in COVID-19 patient care in APHP hospital and generated EDS patient data

Disclosure of Interests

None declared

OP0254 FACTORS ASSOCIATED WITH THE SEVERITY OF COVID-19 INFECTION IN PATIENTS WITH SPONDYLOARTHRITIS: RESULTS OF THE FRENCH RMD COVID-19 COHORT

Background

To our knowledge, no published work has described precisely the severity and evolution of SARS-CoV-2 infection in patients with spondyloarthritis (SpA). Data on COVID-19 from cohorts of patients with immune-mediated inflammatory diseases concern small samples of SpA.

Objectives

Our objective was to describe the severity and course of COVID-19 in a large cohort of patients with SpA, including axial SpA (axSpA) and psoriatic arthritis (PsA), and to identify factors associated with severe forms.

Methods

Patients: individuals with Spondyloarthritis (SpA) from the French RMD COVID-19 cohort (observational, national, multicenter cohort) with a diagnosis of COVID-19 (clinical, PCR, CT or serology) were included.

Data collected: demographics, type of SpA, comorbidities, treatments, severity of COVID-19. Severity of COVID-19 was graded according to care needed: mild = outpatient care; moderate = non-intensive hospital treatment; severe = intensive care unit admission or death; severe = moderate or severe.

Statistical analyses: Logistic regression models were used to identify factors associated with these severe forms. All variables with p <0.20 in the univariate analysis were proposed in the multivariate model. Treatment variables (non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate (MTX), sulfasalazine (SLZ), TNF inhibitors (TNFi), IL-17 inhibitors (IL-17i) and IL-23p19/p40 inhibitors (IL-23p19/p40i)) were included in the models, even if p≥0.20.

Results

Between March 2020 and April 2021, 626 SpAs reported COVID-19 with a mild course in 508 cases (81.1%), moderate in 93 cases (14.8%), and severe in 25 cases (3.9%), including 6 deaths.

The cohort analyzed included 349 women (55.8%), mean age 49.3 ± 14.1 years, mean BMI 27.1 ± 5.4 with 403 axSpA (64.4%), 187 PsA (29.9%) and 36 other SpA, duration of disease 11.3 ± 9.8 years; 352 (56.2%) had at least one comorbidity, of which obesity (23.6%), hypertension (15.5%), and smoking (10.4%) were the most frequent. Among them, 104 were treated with NSAIDs (16.6%), 186 with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) including 156 MTX, and 460 (73.5%) with biological DMARDs (379 TNFi, 57 IL-17i, 15 IL-23p19/p40i, 9 others).

The following variables were associated with severe COVID-19 outcomes: age, body mass index, chronic obstructive lung disease, cardiovascular disease, diabetes, hypertension, interstitial lung disease, renal failure, and corticosteroids intake.

The factors independently associated with severe COVID-19 outcomes were corticosteroid intake (3.15 [CI95%: 1.46-6.76], p 0.004), and age (OR=1.06 [CI95%: 1.04-1.08], p <0.001] while anti-TNF (OR=0.26 [CI95%: 0.09-0.78], p=0.01]) was protective. NSAIDs intake (OR=0.97 [CI95%: 0.48-1.98]), SLZ (OR=7.9 [CI95%: 0.60-103]), or anti-IL17 (OR=0.37 [CI95%: 0.10-1.31]) was not associated with infection severity.

Conclusion

The course of COVID-19 was mild for the majority of SpA patients (81.1%). Corticosteroid intake was associated with more severe COVID-19 outcomes, whereas TNFi were found to be protective.

Disclosure of Interests

None declared

Facteurs associés à la sévérité de l’infection COVID-19 chez les patients atteints de spondyloarthrite : résultats de la French RMD COVID-19 cohorte

Introduction

Il n’y a pas, à notre connaissance, de publication décrivant précisément la sévérité et l’évolution de l’infection à SARS-CoV-2 dans la spondyloarthrite (SpA). Les données sur la COVID-19 issues des cohortes de patients avec maladies inflammatoires à médiation immunitaire concernent de faibles effectifs de SpA.

Notre objectif était de décrire la sévérité et l’évolution de la COVID-19 dans une large cohorte de patients atteints de SpA (SpA axiale et rhumatisme psoriasique) et d’identifier les facteurs associés aux formes sévères.

Patients et méthodes

Patients : spondyloarthrites (SpA) de la French RMD COVID-19 cohort (cohorte observationnelle, nationale, multicentrique) avec un diagnostic de COVID-19 (clinique, PCR, scanner ou sérologie). Données collectées : démographiques, type de SpA, comorbidités, traitements, gravité de la COVID-19. La gravité de la COVID-19 a été classée en fonction des soins nécessaires : bénin = soins ambulatoires ; modéré = traitement hospitalier non intensif ; sévère = admission en unité de soins intensifs ou décès ; grave = modéré ou sévère.

Analyses statistiques : des modèles de régression logistique ont été utilisés pour identifier les facteurs associés à ces formes graves. Toutes les variables avec p < 0,20 en analyse univariée ont été proposées dans le modèle multivarié. Les variables de traitement (AINS, méthotrexate [MTX], sulfasalazine [SLZ], anti-TNF et anti-IL17) étaient incluses dans les modèles, même si p ≥ 0,20.

Résultats

Entre mars 2020 et avril 2021, 626 SpA ont déclaré une COVID-19 dont l’évolution avait été bénigne dans 508 cas (81,1 %), modérée dans 93 cas (14,8 %) et sévère dans 25 cas (3,9 %), dont 6 décès.

La cohorte analysée comprenait 349 femmes (55,8 %), âge moyen 49,3 ± 14,1 ans, IMC moyen 27,1 ± 5,4 avec 403 SpA axiale (64,4 %), 187 RPso (29,9 %) et 36 autres SpA, durée de la maladie 11,3 ± 9,8 ans ; 352 (56,2 %) avaient au moins une comorbidité dont l’obésité (23,6 %), l’hypertension artérielle (15,5 %) et le tabagisme (10,4 %) étaient les plus fréquentes. Parmi eux, 104 étaient traités par AINS (16,6 %), 186 par csDMARD dont 156 méthotrexate, et 460 (73,5) % par biomédicaments (379 anti-TNF, 57 anti-IL17 : 57, 15 anti-IL12/23, 9 autres).

Les facteurs indépendamment associés à une COVID-19 grave étaient la corticothérapie (OR = 2,83 [IC95 % : 1,41–5,66]) et l’âge (OR = 1,07 [1,05–1,09]) alors le genre féminin (OR = 0,64 [0,41–0,99]) et les anti-IL17 (OR = 0,51 [0,32–0,81]) avaient un caractère protecteur. Un traitement par AINS (OR = 0,91 [IC95 % : 0,47–1,77]), par sulfasalazine (OR = 6,81 [0,59–77,41]) ou par anti-TNF (OR = 0,67 [0,33–1,35]) n’était pas associé à la gravité de l’infection.

Conclusion

L’évolution de la COVID-19 a été bénigne pour la majorité des patients atteints de SpA (81,1 %). La corticothérapie était associée à des infections plus graves alors que les anti-IL17 avaient un caractère protecteur.

OP0284 OUTCOME OF COVID-19 IN PATIENTS WITH RHEUMATIC AND INFLAMMATORY DISEASES TREATED WITH RITUXIMAB: DATA FROM DE FRENCH RMD COVID-19 COHORT

Background:

Various observations have suggested that the course of the COVID-19 infection may be less favorable in patients with inflammatory rheumatic and musculoskeletal diseases (iRMD) receiving rituximab (RTX).

Objectives:

To investigate whether treatment with RTX is associated with severe infection and death.

Methods:

We performed an observational, multicenter, French national cohort study querying the French RMD COVID-19 cohort, including highly suspected/confirmed iRMD-COVID-19 patients. The primary endpoint was to assess the severity rate of COVID-19. Severe disease was defined by hospitalization in intensive care unit or death. The secondary objectives were to analyze death rate and length of hospital stay. Two control groups were considered for comparison with RTX treated patients: a first group including all non-RTX treated iRMD patients and a second consisting on RTX untreated iRMD patients with diseases for which RTX is a recognized therapeutic option. Adjusting on potential confounding factors was performed by using inverse probability of treatment weighting (IPTW) propensity score method.

Results:

We collected a total of 1090 records. Patients were mainly females (67.3%, 734/1090) with a mean age of 55.2±16.4 years, and 51.1% (557/1090) were over the age of 55. Almost 70% of the population had at least one comorbidity (756/1090). A total of 63 patients were treated with RTX, mainly for rheumatoid arthritis (RA) (31/63, 49.2%). RTX treated patients were more likely to be males, with older age, higher prevalence of comorbidities and corticosteroid use. The control population consisted on 1027 non-RTX treated iRMD patients, and 495 RTX untreated iRMD patients with diseases for which RTX is a recognized therapeutic option.

Of the 1,090 patients, 137 developed severe disease (12.6%). After adjusting on potential confounding factors (age, sex, arterial hypertension, diabetes, smoking status, body mass index, interstitial lung disease, cardiovascular diseases, cancer, corticosteroid use, chronic renal failure and the underlying disease), severe disease was confirmed to be observed more frequently in patients receiving RTX compared to all RTX untreated iRMD patients (effect size, ES 3.26, 95% confidence interval, CI 1.66 to 6.40, p<0.001) and the subgroup of untreated RTX patients with diseases eligible for RTX therapy (ES 2.62, 95% CI 1.34 to 5.09, p=0.005). Patients who developed a severe disease had a more recent rituximab infusion compared to patients with mild or moderate disease. Indeed, the time between the last infusion of rituximab and the first symptoms of COVID-19 was significantly shorter in patients who developed a severe form of COVID-19 (Figure 1).

Figure 1.

Distribution (Tukey’s box plot) of Lag time between last infusion of Rituximab according to disease severity. P-Values for comparison between disease severity with Kruskal Wallis test are reported; P-Value<0.001 for either post-hoc comparison of severe disease group with moderate or mild disease group (calculated using Dunn’s test).

Eighty-nine patients in our cohort died, resulting in an overall death rate of 8.2%. Death rate was numerically higher in RTX treated patients (13/63, 20.6%) compared to all RTX untreated iRMDs patients (76/1027, 7.4%) and the subgroup of untreated RTX patients with diseases eligible for RTX therapy (49/495, 9.9%). After considering the previously described confounding factors, the risk of death was not significantly increased in patients treated with RTX compared to all RTX untreated iRMDs patients (ES 1.32, 95% CI 0.55 to 3.19, p=0.53) (Table 2) and the subgroup of untreated RTX patients with diseases eligible for RTX therapy (ES 1.48, 95% CI 0.68 to 3.20, p=0.32). In line with a more severe COVID-19 disease, the length of hospital stay was markedly longer in patients treated with RTX compared to both untreated RTX patient groups.

Conclusion:

RTX therapy is associated with a more severe COVID-19 infection. RTX will have to be applied with particular caution in patients with iRMDs.

Acknowledgements:

Muriel Herasse played a major role in collecting the missing data of the cohort.

We thank Julien Labreuche (biostatistician, CHU-Lille) for the help in the statistical analysis.

Disclosure of Interests:

None declared

Four cases of tendinopathy in patients on statin therapy

During the last decade, statins have been widely prescribed as lipid-lowering drugs. Their overall safety profile is good. The main musculoskeletal side effects have consisted of muscle pain and weakness, peripheral neuropathy, and a few cases of drug-induced lupus. We report the first four cases of tendinopathy in patients receiving statin therapy. There were three men and one woman. The diagnoses were extensortenosynovitis at the hands (case 1), tenosynovitis of the tibialis anterior tendon (case 2), and Achilles tendinopathy (cases 3 and 4). Two patients were on simvastatin and two on atorvastatin. The tendinopathy developed 1 to 2 months after treatment initiation. The outcome was consistently favorable within 1 to 2 months after discontinuation of the drug. Similar cases have been reported to French pharmacovigilance centers. This report of four cases of tendinopathy draws attention to a possible and heretofore unrecognized side effect of a drug class that is becoming increasingly popular. Statins are effective in lowering high cholesterol levels in patients with type IIa or IIb hypercholesterolemia. They have been widely used for the last decade, particularly in the secondary and primary prevention of major coronary events. Statins act by inhibiting the enzyme hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase. Although most patients tolerate statins extremely well, a few experience side effects requiring treatment discontinuation. Reported musculoskeletal side effects include myalgia and a few cases of rhabdomyolysis and polymyositis. Induced lupus and peripheral neuropathy are exceedingly rare.

[Postoperative combined medullary sclerosis revealing Biermer's disease: toxic effect of nitrous oxide]

Combined medullary sclerosis developed suddenly postoperatively in a patient with unknown Biermer's disease. The neurological lesions were undoubtedly induced by nitrogen protoxide via an inactivation of vitamin B12.

[Diagnosis and treatment of polymyalgia rheumatica]

Polymyalgia rheumatica is a clinically defined disorder characterised by inflammatory pain in the neck, back, or shoulder or pelvic girdle muscles in a patient over 50 years of age. Results of laboratory work-up reflect only the inflammatory syndrome. Early diagnosis allows rapid initiation of low-dose corticosteroids, which dramatically improves the symptoms and avoids long, costly and difficult investigations. The cause of the disorder is poorly understood and its relationship to temporal arteritis is sometimes unclear, although the two can usually be distinguished, based on recent findings.

[Spinal neurenteric cyst revealed by a cauda equina syndrome]

BACKGROUND

Intraspinal neurenteric cysts are exceptional formations which develop from incomplete separation of the neural tube and the endodermis during the third week of gestation. Symptoms generally appear before the age of 40 years and are associated with spinal malformations. Most neurenteric cysts lie in an extra-spinal position in the lower cervical and upper dorsal spine. We report a case involving the cauda equina with no associated spinal lesion.

CASE REPORT

A 63-year-old woman was admitted for low back pain and right L3 radiculalgia triggered by exertion. Urinary disorders had developed over the preceding year. Physical examination found a spinal syndrome with hypoesthesia of the right para-anal area, an atonic anal sphincter and a globular bladder. Plain films showed a widened interpedicular space between L1 and L2 interpreted as the consequence of an expansive intraspinal lesion. Saccoradiculography led to the diagnosis of an intradural lesion involving L1 and L2. At magnetic resonance imaging, the lesion's signal intensity was similar to cerebrospinal fluid on T1 and T2 sequences, deforming the cauda equina and displacing the nerve roots. Surgical resection of the cyst was incomplete due to adherences to several roots and was followed by persistent radiculalgia and sphincter disorders.

DISCUSSION

This case demonstrates an exceptional cause of cauda equina syndrome. Fissuration or rupture of the cyst might explain symptom exacerbation following trauma. Magnetic resonance imagining can confirm the cystic nature of the intradural lesion and help guide surgery. Resection is often incomplete with the risk of long-term recurrence.

Anti-Sa antibody is an accurate diagnostic and prognostic marker in adult rheumatoid arthritis

OBJECTIVES

To evaluate in various groups of patients with chronic joint disease the sensitivity and specificity of anti-Sa antibody, recently described in sera from adults with rheumatoid arthritis (RA); and to determine the prognostic significance of anti-Sa in initial sera from patients with long standing RA with or without severe joint destruction.

METHODS

Serum samples from 489 patients were included. Of these, 154 were collected from patients with RA attending 2 rheumatology units. Controls were 335 patients with a variety of inflammatory joint diseases other than RA. IgG anti-Sa was detected using an immunoblotting method with purified Sa antigen from human placenta extracts. All patients were tested for the following antibodies: rheumatoid factor (RF), anti-keratin antibody (AKA), antiperinuclear factor (APF), and anti-RA 33. HLA class II DRB alleles were also determined.

RESULTS

Anti-Sa was detected in 39.8% of RA sera overall, 46.7% of sera from the long standing RA group, and 23.5% of sera from the recent onset RA group (p<0.01). In patients with long standing RA, statistically significant associations were found between the presence of anti-Sa and the following variables: RF (p<0.0001), AKA (p<0.0001), APF (p<0.00001), and HLA DRB1*04 or 01 (p<0.01). In contrast, no association was found with anti-RA33. Anti-Sa was positive in 11 adult controls (7.8%) and in 26 pediatric patients with juvenile chronic arthritis (22%). The specificity of anti-Sa for RA was 92.1% in adults with well characterized rheumatic diseases and 85.9% in adults and children together. Among patients with long standing RA, those with destructive disease were more likely to test positive for anti-Sa (66.6%) than those with nondestructive disease (22.2%) (p<0.0001). Comparisons with other serologic markers for RA demonstrated that anti-Sa was sensitive (68.4%) and was also the test with the highest specificity (79%), positive predictive value (75%), and negative predictive value (71%) for discriminating between patients who do and those that do not develop late severe radiographic damage.

CONCLUSION

Immunoblot-detected IgG anti-Sa is a sensitive serologic marker for RA patients with severe radiographic damage.

Clinical usefulness of antibodies to U1snRNP proteins in mixed connective tissue disease and systemic lupus erythematosus

OBJECTIVES

To determine whether the anti-68 kDaU1snRNP antibody is associated with mixed connective tissue disease and not with SLE; to evaluate correlations between anti-U1snRNP titers and disease activity; and to look for associations between anti-U1snRNP specificities and specific clinical features.

PATIENTS AND METHODS

40 patients with a positive double diffusion test for anti-68 kDa U1snRNP were studied, including 21 with mixed connective tissue disease, 14 with systemic lupus erythematosus and five with other connective tissue diseases. IgGs to 68 kDa U1snRNP were assayed using an ELISA. Clinical features, disease activity and antibody test findings were evaluated longitudinally in nine patients.

RESULTS

Both proportions of patients with anti-68 kDa U1snRNP and titers of IgG to 68 kDa U1snRNP were similar in the mixed connective tissue disease and systemic lupus erythematosus groups. Patients with mixed connective tissue disease were significantly more likely to have anti-A U1snRNP or anti-C U1snRNP than those with systemic lupus erythematosus (P < 0.03 and P < 0.04, respectively). No significant correlations were found between any of the features of mixed connective tissue disease (e.g., Raynaud's phenomenon, myositis, or sausage digits) and a specific anti-U1snRNP antibody. During follow-up (mean, seven years; range, 1-25 years), changes occurred in the anti-U1snRNP profile and in the anti-68 kDa U1snRNP titer. These changes were not correlated with disease activity.

CONCLUSIONS

IgGs to 68 kDa U1snRNP are not associated with a specific pattern of anti-RNP-positive connective tissue disease. No useful information can be gained by monitoring anti-68 kDa U1snRNP IgG titers over time. A Western blot profile including anti-A U1snRNP or anti-C U1snRNP indicates a high likelihood of U1snRNP-associated mixed connective tissue syndrome (MCTD).

Polyarthritis with cutaneous mucinosis and intrasynovial mucin deposits

We report the first case of cutaneous and articular mucinosis with presence of mucin deposits within the synovium in an HIV-positive patients. Presentation was asymmetric polyarthritis, and subcutaneous nodules developed two months later. Treatment was with hydroxychloroquine. The outcome of both the skin and joint lesions was favourable.

Thromboangiitis obliterans with inaugural rheumatic manifestations. A report of three cases

Thromboangiitis obliterans, or Buerger's disease, is a segmental occlusive inflammatory disorder of the small- and medium-sized arteries and veins seen in young adults and associated with cigarette smoking. The lesions are most marked in the distal limbs. We report three cases in which the first manifestations were rheumatic, consisting in polyarthritis in two cases and carpal tunnel syndrome in one. Rheumatic manifestations are infrequent and rarely inaugural in thromboangiitis obliterans, although they are probably underdiagnosed. Their pathogenesis is unclear but may involve autoimmunity. Heightened awareness of the possibility that rheumatic manifestations can inaugurate thromboangiitis obliterans may allow an earlier diagnosis of this disease, which may improve the functional prognosis. However, recovery can be achieved only if the patient stops smoking.

Female premenopausal tophaceous gout induced by long-term diuretic abuse

We describe 3 cases of tophaceous gout affecting premenopausal women. The only precipitating factor to be found was the chronic and unnecessary overuse of furosemide, apparently resulting from a psychological profile of anorexia nervosa. Our cases emphasize the need for physicians to look for hidden abuse of diuretics in the presence of gouty arthritis in menstruating women, especially if tophi are noted.

Antibodies to cardiolipin and beta 2 glycoprotein I in patients with polymyalgia rheumatica and giant cell arteritis

IgG antibodies to cardiolipin and beta 2-glycoprotein I were looked for using an enzyme-linked immunosorbent assay (ELISA) in 19 patients with giant cell arteritis (meeting 1990 American College of Rheumatology criteria), including 16 with concomitant polymyalgia rheumatica (meeting Bird's criteria) and in three patients with isolated polymyalgia rheumatica. IgG anti-cardiolipin antibodies were demonstrated in eight patients (36%) and IgG anti-beta 2-glycoprotein I antibodies in two patients (9%) including one without anti-cardiolipin antibodies. Titers of anti-cardiolipin antibodies ranged from 27 to 190 units of IgG antiphospholipid antibodies (UGPL) (mean 71 UGPL). Of the eight patients with anti-cardiolipin antibodies, two had giant cell arteritis without polymyalgia rheumatica and six had polymyalgia rheumatica with clinical (n = 2) or histologic (n = 4) evidence of giant cell arteritis. None of the three patients with polymyalgia rheumatica but no giant cell arteritis had anti-cardiolipin or anti-beta 2 glycoprotein I antibodies. The VDRL was negative in the 14 patients who had this test. Tests for lupus anticoagulant were performed routinely, always with negative results. Among giant cell arteritis patients, those who tested positive for anticardiolipin antibody had significantly higher values for the erythrocyte sedimentation rate (p < 0.006) and for serum C-reactive protein (p < 0.03) and fibrinogen values (p = 0.05), and a trend toward higher platelet counts, as compared to those who tested negative for anticardiolipin antibody. The mean daily prednisone dose at the time of sampling was significantly lower in giant cell arteritis patients with anti-cardiolipin antibodies (p < 0.05); this difference may account for the apparent correlation between anti-cardiolipin antibodies and laboratory markers for inflammation. These data, as well as findings from serial measurements, suggest that anti-cardiolipin antibodies are present early in the course of giant cell arteritis and disappear within a few weeks of initiation of corticosteroid therapy in a dose of more than 25 mg prednisone per day. In this study, only one patient without anticardiolipin antibodies developed a cerebrovascular accident. Positive tests for anti-cardiolipin antibody or anti-beta 2 glycoprotein I antibody in a patient with polymyalgia rheumatica suggest a diagnosis of concomitant giant cell arteritis, which is usually symptomatic.

[Lymphomas of the ocular adnexa in Gougerot-Sjögren syndrome. Apropos of 4 cases]

The risk of malignant B cell lymphoma is increased in Sjögren's syndrome (SS). Orbital localization seems infrequent. We report 4 cases of malignant lymphoma (ML) occurring in 4 women aged 47 to 77 years, with primary SS in 3 cases, located to the conjunctiva in 2 cases, the lacrymal gland in 1 case and the eyelid in 1 case. The interval between the diagnosis of SS and orbital ML varied from 6 months to 15 years. All 4 lymphomas were of the B cell type, low histopathologic grade, with monoclonal gammopathy in 1 case. Extraocular lymphoma was initially present in 1 case. ML remained localized in 2 cases with a follow-up of 4 and 6 years. Two patients treated by excisional biopsy alone are in complete remission 3 and 6 years later. The 2 other patients treated with orbital radiotherapy and chemotherapy died rapidly (transformation into a high grade malignancy in 1 case). We conclude that clinical, immunopathologic features, as well as prognosis and treatment of ocular adnexa ML in SS are similar to those of primary ML without SS.

[Coxitis after surgical excision of intracapsular osteoid osteoma of the femur neck]

A case of destructive arthropathy of the hip with onset two years after surgical removal of an intracapsular osteoid osteoma of the femoral neck is reported. Coincidental occurrence in the same joint of an osteoid osteoma and a destructive arthropathy of unknown etiology cannot be ruled out. However, another hypothesis which deserves discussion is that self-perpetuating synovitis was triggered by the release of mediators of inflammation due to presence of the osteoid osteoma.

Magnetic resonance imaging assessment of sacroiliac joint involvement in Gaucher's disease

A young woman with Gaucher's disease experienced acute pain in her right sacroiliac (SI) joint. Although pelvic radiographs and computed tomographic scan showed no significant change in the right SI joint, magnetic resonance imaging demonstrated an area of high signal intensity in the iliac part of the right SI joint, and a periosseous collection of blood. This skeletal location is rarely reported in Gaucher's disease; the mechanism of bone crisis is still controversial and our case suggests the occurrence of a bone infarct.

[BCG osteoarthritis on knee prosthesis after intra-vesical BCG therapy]

A case of Calmette-Guérin bacillus (BCG) infection of a knee implant during intravesical BCG-therapy is reported. The course was favorable after replacement of the implant and administration of antituberculous agents. This case of septic osteoarthritis due to the BCG is different from cases of reactive polyarthritis reported after intravesical instillations of BCG. It probably resulted from diffusion of the BCG via the bloodstream.

[Persistent pain following discal sciatica: reflex sympathetic dystrophy, an unusual complication to be examined. Apropos of 4 cases]

Four patients who developed unilateral reflex sympathetic dystrophy of a lower limb associated with a bout of sciatica due to lumbar disc herniation are reported herein. In two cases, reflex sympathetic dystrophy developed after resolution of the sciatica, whereas the two conditions were concomitant in the two other patients. In all four patients, the diagnosis of reflex sympathetic dystrophy was missed. Surgery to release the root was considered in two cases. The reflex sympathetic dystrophy resolved within 1 to 3 months in every case. In view of the incidences of these two conditions, their concomitant occurrence seems rare. To avoid unwarranted therapeutic procedures, reflex sympathetic dystrophy should be considered in patients with chronic painful manifestations accompanying root involvement.

[3 cases of polyarthritis treated with recombinant alfa interferon]

Bilateral symmetrical polyarthritis occurred in three patients (2 males and 1 female), with no previous history of inflammatory rheumatologic disease, given alpha-interferon for 1 1/2, 7, and 10 months as treatment of chronic non A-non B hepatitis, myelofibrosis, and thrombocytopenia with myeloproliferative disorder, respectively. Joint manifestations developed 1 1/2, 3, and 10 months after initiation of alpha-interferon in a dosage of 3.10(6) U three times a week, 4.5.10(6) U per day, and 8.10(6) U three times a week. Polyarthritis persisted following withdrawal of alpha-interferon in the two last patients of whom one had rheumatoid nodules and positive rheumatoid serology and the other had scleritis, exanthema, and negative rheumatoid serology. Erosive rheumatoid arthritis was diagnosed after 28 months and 12 months, respectively, in two patients who required systemic corticosteroids with antimalarials (1 case) or azathioprine after failure of methotrexate (one case). Follow-up in the third case (12 months) is too short to allow differentiation of systemic lupus erythematosus (ANA: 1/1500 H with anti-DNA antibodies 58 U/ml) and chronic autoimmune hepatitis. Reports of chronic inflammatory rheumatologic disease during alpha interferon therapy are exceedingly few in number. In the cases reported herein, alpha-interferon may have either triggered or revealed the joint disease. To prevent occurrence of this complication, exclusion from alpha-interferon therapy of patients with autoantibodies or a positive history for clinical evidence of immune dysfunction may be considered.