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.

Prévalence du COVID-19 chez les patients atteints de rhumatismes inflammatoires chroniques traités par biothérapies, données du registre marocain des biothérapies (RBSMR)

Introduction

L’objectif de ce travail était de déterminer la prévalence du coronavirus 2 du syndrome respiratoire aigu sévère (SARS-CoV-2) 2019 (COVID-19) chez les patients adultes atteints de rhumatismes inflammatoires chroniques traités par biothérapies.

Matériels et méthodes

Les données ont été recueillies à partir du registre RBSMR, un registre historico-prospectif multicentrique de patients adultes (> 18 ans) ayant une polyarthrite rhumatoïde (PR) ou une spondyloarthrite (SpA), traités par des médicaments biologiques dans les 10 services universitaires de rhumatologie du Maroc. Les patients ont été évalués tous les six mois et chaque fois qu’ils subissaient un événement indésirable ou un changement de traitement, avec un suivi programmé de 3 ans. Un questionnaire électronique a été complété à chaque visite par l’investigateur. L’inclusion a débuté en juin 2017 et s’est terminée en janvier 2019, date du premier gel de la base de données.

Résultats

Le nombre de patients inclus était de 441, dont 419 patients validés. 225 patients étaient atteints de PR et 194 étaient atteints de spondylarthrite. L’âge moyen des patients suivis pour PR était de 51,9 ± 11,3 ans, dont 197 femmes (87,1 %). La durée moyenne de la maladie était de 11,8 ± 8,3 ans et la durée médiane du traitement était de 125 semaines dont 42 % en initiation. L’âge moyen des patients ayant une SpA était de 40,4 ± 13,8 ans, 123 patients étaient des hommes (63,4 %), la durée médiane du traitement biologique en cours était de 84 semaines.

Dix patients (2,38 %) ont été touchés par le COVID-19, dont 5 suivis pour PR et 5 pour SpA. La prévalence du COVID-19 chez les patients atteints de PR était de 2,2 % et de 2,6 % chez les patients atteints de SpA.

Chez les patients suivis pour PR ayant été testés positifs au COVID 19, l’âge moyen était de 51,2 ± 7,56 ans, tous de sexe féminin, aucune n’était tabagique, 3 patients (60 %) étais sous rituximab, 1 sous tocilizumab et 1 sous infliximab. 2 patients (40 %) étaient sous CsDMARDs concomitant ; MTX 15 mg/s. Quatre patients (80 %) étaient sous corticothérapie à des doses allant de 5–10 mg équivalent de prédnisone/jour.

Chez les patients suivis pour spondylarthrite touchés par le COVID-19, l’âge moyen était de 50,40 ± 19,16 ans, le sex-ratio H/F était de 0,66, aucun patient n’était tabagique, 2 patients (40 %) étaient sous etanercept, 2 (40 %) sous adalimumab et 1 patient sous secukinumab. Deux (40 %) patients étaient sous CsDMARDs concomitant ; Sulfasalazine 2 g/j. Trois patients (60 %) étaient sous corticothérapie à des doses allant de 5–15 mg équivalent de prédnisone/j.

Discussion

La prévalence du COVID-19 au sein de la population suivie pour un rhumatisme inflammatoire chronique sous biothérapie était faible, cela étant probablement dû à la prudence de ces patients quant aux mesures préventives contre le COVID-19 (gestes barrières, isolement social) compte tenu de leur immunosuppression.

Conclusion

Les données relatives à la prévalence et au risque de COVID-19 chez les patients atteints de rhumatismes inflammatoires chroniques traités par biothérapies sont encore rares mais rassurantes, d’où l’intérêt d’encourager ces patients à poursuivre leur traitement tout en respectant les mesures de prévention et de protection contre le COVID-19.

AB0867 Particularities of uveitis associated with spondyloarthritis: Data from the moroccan RBSMR registry

Background

Acute anterior uveitis is the most frequent extra-articular manifestation in spondyloarthritis (SpA). [1]

Objectives

The purpose of this study is to assess the prevalence of uveitis during SpA and to identify associated factors with its presence.

Methods

A cross-sectional multicentric observational study was conducted; the main data source was the Moroccan registry of biological therapies in rheumatic diseases (RBSMR registry). Patients, included from May 2017 to January 2019, were all adult patients (age > 18 years old), presenting SpA, according to ASAS (Assessment of Spondyloarthritis International Society) classification criteria for SpA 2010.

Demographic and clinical characteristics, disease activity, radiographic damage and functional ability have been compared between two groups of patients: Patients with SpA suffering from uveitis and patients without uveitis. General and specific data regarding uveitis were collected.

Results

194 patients were included in the study. The mean age was 40.22 ± 13.68 years. The sex ratio was 1, 7 (man/woman). The mean duration of disease was 615.90 ± 349.12 weeks.

96.4 % of the patients had axial involvement, 70 % had peripheral involvement and 61.5 % had enthesic involvement. SpA was radiographic in 88.1 % of the cases and coxitis was found in 40.9 %. The mean erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) was 39.04 ± 27.16 mm/h and 32.87 ± 38.77 mg/l, respectively. HLA B27 was positive in 34 % of patients. The mean ASDAS (Ankylosing Spondylitis Disease Activity Score) ESR, BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASFI (Bath Ankylosing Spondylitis Functional Index) was 3, 19 ± 2,118; 4.8 ± 1.8 and 5.29 ± 2.21, respectively. Uveitis was seen in 14.5% of cases.

The bi-variate analysis did not reveal any statistically significant difference between the two groups regarding demographic and clinical characteristics, disease activity and radiographic damage.

Conclusion

Acute anterior uveitis is the most frequent extra-articular manifestation in spondyloarthritis (SpA). The presence of uveitis in Moroccan patients diagnosed with SpA wasn’t associated with specific characteristics. Even though, its screening is systematic because it conditions the treatment.

References

[1]I. Gómez-García, M.L. Ladehesa-Pineda, M.Á. Puche-Larrubia et al. Uveitis as the first symptom in spondyloarthritis and its association with the evolution of the disease. Results from the REGISPONSER registry. Joint Bone Spine 88 (2021) 105136

Disclosure of Interests

None declared

AB0374 EFFICACY AND SAFETY OF BIOTHERAPY IN ELDERLY PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM THE MOROCCAN RBSMR REGISTRY

Background

Limited data have been published on tolerance and efficacy of biotherapy in elderly patients with rheumatoid arthritis (RA) [1]

Objectives

To assess in real life the efficacy and safety of biological treatments in elderly patients with rheumatoid arthritis (RA) and to identify predictive factors for a good therapeutic response.

Methods

A cross-sectional observational study was conducted, the main data source was the Moroccan registry of biological therapies in rheumatic diseases (RBSMR registry).

The duration of this study was 12 months. Patients included were all elderly patients (age > 65 years old), presenting RA,according to ACR /EULAR classification criteria for RA 2010.Demographic and clinical characteristics, disease activity, radiographic damage and functional ability have been compared between two groups of patients: those with response to biotherapy and those without response to biotherapy. Clinical and biological tolerance of biotherapy was assessed at 12 months of follow-up in all patients

Results

Among 224 patients included in the RBSMR registry, 23 patients were over 65 years. The average age of patients was 69,57 years ±4.33 with a sex ratio women/man: 4.75. The mean duration of the disease was 964,79 weeks +/-588,8. RA was seropositive in 87% of patients, with positive anti-cyclic citrullinated antibodies (ACPAs) in 60.9%. It was erosive in 83.3%, with carpitis in 50% of our cases. Concerning biological features, the mean erythrocyte sedimentation rate (ESR) was 55,05 mm H1± 26 and the mean C - reactive protein (CRP) was 26.79 mg/l ± 18. The average initial disease activity score 28-ESR (DAS 28 ESR) was 4,08+/-1,60. The average 12-month DAS was 2,67+ /-1,49.

The Health Assessment Questionnaire (HAQ) average was 1.22. Concerning the treatment taken, 8.7% of patients were under Etanercept,4,3% were under Golimumab,69,6% were under Rituximab and 17,4% of patients received Tocilizumab.

The analysis did not reveal any statistically significant difference between the two groups regarding demographic, clinical characteristics, disease activity, radiographic damage, biological feature and therapeutic data. 78.3% of our patients had a good tolerance to biotherapies, on the other hand 21.7% had presented undesirable effects.

Conclusion

RA is a common and even more common disease in the elderly, our study as well as The literature data confirms the efficacy of biotherapy and its good tolerance in our Moroccan patients with RA. It represents a therapeutic alternative of choice. Our results further encourage its use in our Moroccan context.

References

[1]STE´PHANE GENEVAY et al. Tolerance and Effectiveness of Anti–Tumor Necrosis Factor Therapies in Elderly Patients With Rheumatoid Arthritis: A Population-Based Cohort Study Arthritis & Rheumatism. American College of Rheumatology 2007

Disclosure of Interests

None declared

AB0847 Profile of Spondyloarthritis in the Moroccan population: Results of a multicenter study

Background

Spondyloarthritis (SpA) is a frequent group of chronic inflammatory rheumatic diseases, their epidemiology varies considerably in different regions of the world.

Objectives

The aim of our study was to describe the epidemiological, clinical, paraclinical and therapeutic profile of SpA in the Moroccan population.

Methods

This is a multicenter descriptive study, including patients followed for SpA. 8 hospital centers participated in this study. All data were measured by standard instruments.

Results

Seven hundred patients were included, 54% were men, the mean age was 40.42±14.19 years at the time of diagnosis [14 years-90 years]. The patients lived in urban and rural areas in 83.5% and 13.8% of cases, respectively. 38.4% were without occupation. A history of tuberculosis was noted in 5.9% of cases. Associated pathologies were autoimmune in 2.3% and neoplasia in 1.5% of cases. 15.6% of patients were smokers. A family history of SpA was noted in 11.7%, psoriasis in 1% and Inflammatory bowel disease (IBD) in 0.6% of cases. The average diagnostic delay was 59.76 months [0-444 months]. The revealing symptomatology was axial in 19%, peripheral in 10.1%, enthesitis in 0.4%, and a combination of the 3 forms in 22.1% of cases. Dactylitis was noted in 2.3% of cases. SpA was non-radiographic in 14% of cases. The forms of SpA were: ankylosing spondylitis (80.1%), IBD associated with SpA (9.4%), psoriatic arthritis (6%), and undifferentiated SpA (4%). Juvenile SpA accounted for 15.5% of cases. The prevalence of HLA-B27 was 65.51%. The mean BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) was 4.42 ± 1.67 and the mean ASDAS (Ankylosing Spondylitis Disease Activity Score) was 3.19 ± 1.24. Systemic involvement was dominated by uveitis (11.3%), followed by IBD (9.4%), restrictive syndrome (2.7%), renal involvement (0.6%) including amyloidosis (0.1%), IgA nephropathy (0.4%), interstitial nephropathy (0.1%), and aortic insufficiency in 0.2% of cases. The most commonly used treatments were non-steroidal anti-inflammatory drugs (81.7%), sulfasalazine (24.2%), methotrexate (22.9%) and 31.8% of patients were on biotherapy. Surgery for arthroplasty was necessary in 5.6% of patients.

Conclusion

This is a study of the clinical and demographic characteristics of Spondyloarthritis in a population in Morocco, on which a large scale data base could be initiated, in order to better determine the role of genetic and environmental factors in the pathogenesis of the disease.

References

[1]Sharip A, Kunz J. Understanding the Pathogenesis of Spondyloarthritis. Biomolecules. 2020 Oct 20;10(10):1461.

[2]Slimani S, Hamdi W, Nassar K, Kalla AA. Spondyloarthritis in North Africa: an update. Clin Rheumatol. 2021 Sep;40(9):3401-10.

[3]Wang R, Ward MM. Epidemiology of axial spondyloarthritis: an update. Current Opinion in Rheumatology. 2018 Mar;30(2):137-43.

Disclosure of Interests

None declared

POS1417 DO SOCIAL FACTORS IMPACT ON BIOLOGICS COSTS IN RHEUMATOID ARTHRITIS? RESULTS FROM THE MOROCCAN RBSMR REGISTRY

Background:

Objectives:

The aim of this study was to estimate the annual direct cost of biologics in rheumatoid arthritis and to evaluate the impact of social factors on biological use and costs.

Methods:

Patients in the Moroccan register of biologicals (RBSMR) with available 1-year data were included. Variables related to socio-economic status, disease and biological were collected. Direct costs included prices of biologics, costs of infusions, and subcutaneous injections. Biological use and costs were compared based on social factors.

Results:

Our study included 197 patients (female sex of 86.8%, mean age of 52.3 ± 11 years). Patients were on one of the following therapies: Rituximab (n=132), Tocilizumab (n=37) or TNF-blockers (n=28). 44.2% of included patients have the RAMED medical assistance (health insurance scheme for the economically underprivileged). Illiteracy was noted in 45.7% of cases. Median one-year direct costs per patient were €1,665 [€1,472 - €9,879].

There was no statistically significant difference in costs between men and women (p>0.05), between illiterate and literate (p>0.05). There was a statistically significant difference in costs between patients with the RAMED medical assistance scheme and other health insurances (p<0.01).

Conclusion:

This study showed that Moroccan RA patients had equal access to biologics regardless of their gender or level of education. Indeed, the insurance system influence the costs of biologics. Accessibility of those expensive treatments in a developing country seems be explained by efforts of the Moroccan ministry of health who has allocated a substantial budget for biologic DMARDs for patients with RAMED in the tertiary structures in our country.

Disclosure of Interests:

None declared

AB0486 ONE-YEAR DIRECT COSTS OF BIOLOGICAL THERAPY IN ANKYLOSING SPONDYLITIS AND ITS PREDICTIVE FACTORS: DATA FROM THE MOROCCAN RBSMR REGISTRY

Background:

NA

Objectives:

To estimate the annual direct costs of biological therapies in Spondyloarthropathies (SpA) and to establish possible factors associated with those costs.

Methods:

The main data source was the Moroccan registry of biological therapies in rheumatic diseases (RBSMR). We included SpA patients with available 1-year data. Variables related to socioeconomic status, disease and biological therapy were collected. Differences in costs across groups were tested by Mann–Whitney and Kruskal–Wallis tests. Correlations analysis was performed in search of factors associated with high costs.

Results:

We included 89 SpA patients. The mean age was 40.6± 13.6 years, with male predominance 68.9 %. Patients received one of the following therapies: TNF-blockers (n =79), Biosimilar of TNF-blockers (n =8) and Il17-blockers (n =2). Median one-year biologic costs per patient were 9 569, 39 €. The total annual of biotherapies in AS patients was 851 675, 98 €.

Figure 1

Annual mean drug costs per treated patient (€: Euro)

The costs are presented in Euro using an exchange rate of (1 Moroccan Dirham = 0.091Euro).

TNF-blockers constituted 95 % of the total annual budget. Biosimilar of TNF-blockers and Il17-blockers represented 3 % and 2 % of this overall budget, respectively.

Although the costs were not significantly different in terms of gender or level of study, the insurance type significantly affected the cost estimation.

No correlation was found between the annual direct costs of biotherapies and body mass index nor with BASFI or BASDAI.

Conclusion:

In Morocco, a developing country, the annual direct costs of biological therapies are high in AS patients. Our results may contribute to the development of strategies for better governance of these costs.

Disclosure of Interests:

None declared.

AB0811 DIRECT COST OF BIOLOGICS IN RHEUMATOID ARTHRITIS PATIENTS IN A DEVELOPING COUNTRY: RESULTS FOR THE MOROCCAN RBSMR REGISTRY

Objectives:

The aim of this study was to calculate direct costs amount in rheumatoid arthritis (R.A) patients in the Moroccan register of biologicals RBSMR registry.

Methods:

Patients in the Moroccan register of biologicals RBSMR registry with available 1-year data were included. Variables related to socio-economic status, disease and biological therapy were collected. Direct costs included prices of biologics, costs of infusions, and subcutaneous injections. Biologic use and costs were compared.

Results:

197 patients data (female sex (86,8%), mean age (52,3± 11 years), illiteraty (45,7%)) were analyzed. The median annual direct costs per patient were €1,665 [€1,472 - €9,879]. For all patients, the mean annual direct costs per treated patient for each biological agent is presented in Figure 1.

The total annual direct costs of biological agents in the RBSMR registry were 978 494 €. Rituximab was given to 67% of patients and constituted 25.7% of the total annual budget. TNF-blockers and Tocilizumab were prescribed in 14.2% and 18.8% of cases and represented respectively 27.3% and 47% of this overall budget.

Conclusion:

This study presents a global overview of the direct costs of biological therapy associated with RA patients, taking as a source the Moroccan registry of biological therapies in rheumatic diseases. Those results show that overall cost of biological agents according to the Moroccan register is very high. There is a real need for development of strategies for better governance of those costs.

Disclosure of Interests:

None declared

AB0485 DOES THE REASON OF DISCONTINUATION OF THE FIRST TNF INHIBITOR INFLUENCE THE RESPONSE TO THE SECOND TNF INHIBITOR IN SPONDYLOARTHRITIS? PILOT STUDY FROM THE MOROCCAN RBSMR REGISTRY

Background:

In rheumatoid arthritis, studies have shown that the response to a second TNF inhibitor is better if the first TNF inhibitor was stopped for a secondary failure or adverse event compared to a primary failure [1,2]. However, few studies have provided evidence regarding the response to a second TNF inhibitor based on the reason for discontinuation of the first TNF inhibitor in patients with a diagnostic of spondyloarthritis (SpA).

Objectives:

To evaluate the efficacy of the 2nd TNF inhibitor in real life from a cohort of patients with SpA from the Moroccan registry of biological therapies in rheumatic diseases (RBSMR Registry), according to the reason for discontinuation of the 1st TNF inhibitor.

Methods:

We have included from the RBSMR Registry any patient with a diagnosis of SpA starting a 2nd TNF inhibitor on inclusion in the registry or during the 1st year of follow-up. A descriptive study was conducted by measuring the therapeutic maintenance of the 2nd TNF inhibitor as well as the disease activity in different groups of patients according to the reason for stopping the first TNF inhibitor: stopping for ineffectiveness, side effect or non-availability of the drug.

Results:

Of the total 194 patients with SpA included in the RBSMR registry, 40 patients were on their 2nd TNF inhibitor at one year follow-up. The mean age of the patients was 43.6 ± 15.1 with a male predominance (57.5%) and a mean of disease duration of 13.75±6.95 years. At 1 year, treatment was maintained in 72.5% of all patients: 100% after ineffectiveness, 82% after discontinuation for side effects and 52.9% for unavailability of the first TNF inhibitor. Moderate disease activity as defined by an Ankylosing Spondylitis Disease Activity Score using ASDAS-CRP <2.1 was achieved at 1 year in 75%, 64.7% and 52.9% respectively in patients who stopped their first TNF inhibitor for side effects, ineffectiveness or unavailability of treatment.

Conclusion:

This pilot study gives us a small insight into the fate and efficacy of the 2nd TNF inhibitor based on the reason for discontinuation of the first. The follow-up data at 2 and 3 years will allow us to include more patients and thus be able to do a real statistical study with a comparison between the different groups.

References:

[1]Remy A, Avouac J, Gossec L, Combe B. Clinical relevance of switching to a second tumour necrosis factor-α inhibitor after discontinuation of a first tumour necrosis factor-α inhibitor in rheumatoid arthritis: a systematic literature review and meta-analysis. Clin Exp Rheumatol. 2011;29:96–103.

[2]Chatzidionysiou K, Askling J, Eriksson J, Kristensen LE, van Vollenhoven R, ARTIS group. Effectiveness of TNF inhibitor switch in RA: results from the national Swedish register. Ann Rheum Dis. 2015;74:890–6.

Disclosure of Interests:

None declared.

AB0246 COMORBIDITIES APPEARING UNDER BIOLOGIC THERAPY: PREVALENCE AND ASSOCIATED FACTORS

Objectives:

The aims of our study are to determine the new comorbidities appearing under biologic therapy, their prevalence, and the factors implicated in their appearance.

Methods:

It’s a multicentric historical-prospective cohort including 10 rheumatology departments of Moroccan University Hospitals. The data were collected from the national register of patients under biologic therapy supervised by the Moroccan Society of Rheumatology. An electronic follow-up questionnaire is completed every 6 months by the investigator.

Results:

The study included 418 patients: 224 with Rheumatoid Arthritis (RA) who represented 53.6% and 194 with spondyloarthropathy (SP) who represented 46.4%.

The prevalence rate of comorbidities appearing after one year of treatment with biologic therapy was 15.7% in RA and 8.4% in SP. The rate of cardiovascular diseases was 12.9% (arterial hypertension, myocardial infarction and/or ischemic stroke), 6.4% was the same value of hypercholesterolemia and depression, diabetes 3.3%, ulcer 3.2%, and osteoporosis 9.7%. The sedentary rate was 54.8% and smoking was about 3.3%.

No patient had developed hypertriglyceridemia or chronic obstructive pulmonary disease.

In the group of patients with RA, the average age of the patients who had developed a new comorbidity was 51,8 ± 11,3 years, women represented 87.5%, the average of Body Mass Index (BMI) was 27,6 ± 5,9 and the average duration of the disease was 14,1 ± 9,2 years. The disease activity score (DAS28) had an average of 3,15 ± 1,47.

59.6% of patients used Rituximab, 23.8% Tociluzimab, 8.1% Etanercept, 5.8% Adalimumab, 0.18% Infliximab, and 0.9% Golimumab.

In the group of patients with SP, the average age of the patients who had developed a new comobidity was 40,2 ± 13,7 years, men represented 63.4%, and the average of BMI was 24,3 ± 4,94.

The activity of the desease, had an average Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 2,62 ± 1,79 and ankylosing Spondylitis Disease Activity Score (ASDAS) of 1,93 ± 1,09.

Regarding the type of biologic therapy, 33.2% of patients used Etanercept, 30.1% Adalimumab, 24.9% Infliximab, 9.8% Golimumab, 1.6% Secukinumab, and 0.5% Tociluzimab.

Conclusion:

Our study showed a high prevalence of cardiovascular disease in patients under biologic therapy. This can be explained by the sedentary lifestyle secondary to rheumatic disease.

Disclosure of Interests:

None declared

[Erosive wrist arthritis: a rare manifestation of Behçet's disease]

It is believed that arthritis in Behçet's disease is usually non erosive and not associated with crippling. We report a 38-year-old female who presented with Behçet's disease and an erosive arthritis of the left wrist.

[Skeletal manifestations in Behçet's disease. A report of 79 cases]

PURPOSE

Our aim is to describe the skeletal manifestations of Behcet's disease (BD) among young adults in a military population.

METHODS

We conducted a retrospective study of 176 patients with BD who were followed between 1980 and 2005. All the patients fulfilled the international study group on Behcet's disease diagnostic criteria.

RESULTS

Rheumatic manifestations were noticed in 79 out of 176 patients (45%), ranking second after the skin and mucosal manifestations of the disease. Articular manifestations were the first disease manifestation in 16.5% of the patients. Inflammatory arthralgias were the most common manifestation and observed in 81%, interesting mainly the large lower limb joints. Disease course was acute in most of the patients. Arthritis was less common: oligoarthritis (7.5%), monoarthritis (6.5%) and polyarthritis (5%). Axial involvement was also noted: spine pain in 29%, isolated sacroiliitis in 7.5%, and definite ankylosing spondylitis in 5%.

CONCLUSION

Joint involvement is common in BD and could be the first manifestation of the disease. Most of the patients present with inflammatory arthralgias of the large lower limb joints. Disease course is usually favourable, spontaneously or with treatment. However, in our study population, skeletal manifestations were responsible for significant disability.

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.

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.

Fractal analysis of trabecular bone texture on calcaneus radiographs: effects of age, time since menopause and hormone replacement therapy

An analysis of trabecular bone texture based on fractal mathematics, when applied to trabecular bone images on plain radiographs, can be considered as a reflection of trabecular bone microarchitecture. It has been shown to be able to distinguish postmenopausal osteoporosis cases from controls. This cross-sectional study was carried out to investigate the influence of age, time since menopause and hormone replacement therapy (HRT) on the fractal dimension of trabecular bone texture at the calcaneus in a sample of 537 healthy women. Fractal analysis of texture was performed on calcaneus radiographs and the result expressed as the Hmean parameter (H = 2-fractal dimension). Total hip, femoral neck and lumbar spine bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. There was a statistically significant Hmean parameter decrease with age (p<0.0001) but the degree of correlation was low (r = -0.2) compared with the correlation between age and BMD (r = -0.36 to -0.61 according to the BMD site). We found a weak but statistically significant correlation between time since menopause and Hmean (r = -0.14, p = 0.03) in the 241 postmenopausal women included in the study. Hmean was significantly lower in a group of postmenopausal women without HRT (n = 110) compared with a group of age-matched postmenopausal women with HRT (n = 110): respectively 0.683 +/- 0.043 and 0.695 +/- 0.038 (p = 0.03). In conclusion, this study suggests that there is a menopause- and age-related decrease in the Hmean parameter and that HRT interferes with the results of the fractal analysis of trabecular bone texture on calcaneus radiographs.

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.