[Contribution of dynamic radiographs in atlantoaxial subluxation in rheumatoid arthritis]

Cervical spine [CS] involvement is common during rheumatoid arthritis [RA] and it is distinguished by its potential gravity. To determinate the occurrence of atlantoaxial subluxation [AAS] by dynamic incidences X-Ray and to assess its predictive factors. Our study included a cohort of 40 patients carrying RA, who fulfilled the American College of Rheumatology criteria, for more than 2 years. All patients had a complete physical and laboratory evaluation. Radiological evaluation included CS radiographs in anteroposterior, lateral, and lateral in full flexion and extension views. The occurrence of CS involvement was about 47.5% by XRay dominated by AAS which found in 42,5% of the cases. Among AAS, anterior AAS was the most frequent with a prevalence of 22,5% followed by lateral AAS in 12,5% then vertical and rotatory AAS in 10% of cases each one and posterior AAS in 2,5% of the cases. Comparison between patients with and without CS involvement indicated the presence of two predictive factors: the sharp modified score and the C - reactive protein [p=0.002 and p=0.004 respectively]. Our study demonstrated that AAS is frequent in RA particularly in active forms with structural lesions. AAS can be asymptomatic, for this reason systematic diagnosis by X-Ray with dynamic views is important

[Survival prognosis factors in multiple myeloma]

Outcome in multiple myeloma [MM] is very heterogeneous in survival and therapeutic response, constantly fatale despite her therapy progress. To determine the prognostic factors and survival in MM. We carried out a transversal study of 100 patients in the rheumatology department of hospital Monastir between 1991 and 2010. In each case we determinate the survival delay and also the clinical, laboratory, radiological data at diagnosis and therapeutic response. The mean age was 64.4 years and sex ratio H/F=1.27. MM is IgG type in 57%, IgA in 28% and light chain in 11% of cases. The survival mean is 34 months and the survival median is 26 months. Univariate analysis showed five prognostic factors: age [p = 0.016], anaemia [p=0.033], beta 2 microglobulin [p < 0.0001], CRP [p = 0.0001], albumin [p = 0.002], LDH [p=0.001], plasmocyte proliferation rate [p=0.003] and rapidly therapeutic response [p <0.001]. beta 2 microgrobulin-CRP classification and the international staging system [ISS] presented a high prognosis signification [p < 0.0001]. Multivariate analysis demonstrated two prognostic factors: beta 2 microglobulin and CRP. Our study showed that MM presented many prognostic factors, which easily realized in daily practice. These prognostic factors are essentially to evaluate prognosis and select patients for appropriate therapeutic indication. beta 2 microgrobulin- CRP classification and the international staging system [ISS] are more predictive than Durie Salmon classification in MM survival

fracture risk assessment tool [FRAXTM], where one is in Tunisia?

The fracture risk assessment tool [FRAXTM], published in February 2008, is developed based on the use of clinical risk factors with or without bone mineral density tests. To calculate the FRAX tool in a cohort of Tunisian patients in whom bone mineral density [BMD] was assessed by dual X ray absorptiometry [DXA]; to correlate this score to osteoporotic fracture and to BMD assessment and to propose a threshold for therapeutic intervention. In a cross sectional study of 582 patients older than 40 years, in whom a BMD measurement by DXA has been performed between January 2006 and December 2009, clinical risk factor for osteoporotic fracture and the occurrence of a prior fragility fracture were assessed. The French version of the FRAX tool was used. Threshold for pharmacological intervention was evaluated by ROC curve. Patients were aged 62.3 +/- 10.4 years. They were female in 91.2% of cases. BMD measurement was under 2.5 standard deviation in 53.2%. Osteopenia was noted in 29.2% of cases and BMD was normal in 17.4% of cases. Osteoporotic fractures were observed in 38.2% of cases. Major osteoporotic fractures [FOM] [hip, vertebra, radius] occurred in 82% of cases. The FRAX score calculated with T-score was 8.55 +/- 8.54% for the FOM and 3.02 +/- 6.37% for femoral neck [FN], while it was 7.81 +/- 6.45% for the FOM and 2.58 +/- 3.97% for the FN if calculated without T-score with a significant difference [p <10[3]]. For the patients having T-score under 2.5 SD, FRAX score was 11.39 +/- 10.32% for the FOM and 4.74 +/- 8.13% for the FN if calculated with T-score and it was 9.18 +/- 6.95% for the FOM and 3.19 +/- 4.11% if calculated without T-score. The score FRAX was correlated to BMD [r=0, 53, p <10-3] and to fracture prevalence [p < 10[3]]. The threshold of therapeutic intervention was fixed to 30% for the FOM and 7% for the FN. Our study confirms the usefulness of the FRAX score in the prediction of fracture risk in Tunisian population. The determination of therapeutic threshold intervention requires other prospective and larger studies with medico-economic analyses

Ochronosis: report of two familial cases

Ochronosis of alkaptonuria is a rare hereditary autosomal recessive disease in wich there is an absence of homogentisic acid oxidase resulting in accumulation of homogentisic acid in tissues. To report a new case of alkaptonuria. A 49-year-old man had been followed for 4 years for chronic lombalgia and arthropaty of two knees. He is married to his cousin and father of 4 girls. His parents are also cousins. The clinical examination has found a cutanuous pigmentation and a lumbar stiffness. At biological checking, creatininemia was at 190 micro mol/L and there are not inflammatory indicators. The radiography have shown a discal dorsolumbar calcifications, anterior inter somatic bridges and bilateral arthritis of knees without articular chondrocalcinosis. The diagnosis of ochronosis have been suspected and confirmed by the blackness of urine and the dosage of alkaptonuria. The patient has been treated symptomatiquely. Familial investigation have revealed that his daughter suffred from the same disease with the notion of blackness of urine. She is 12 year old and she's asymptomatic on the osteoarticular level. Alkaptonuria causes a degenerative arthropaty wich can endanger functional prognosis. Early diagnosis and scanning of this innate error of metabolism by genetic study play a fundamental interest, especially for molecular and genetic advisement

[Adult-onset of Still's disease with atypical articular and skin manifestations]

Adult-onset Still's disease [ASD] is an uncommon clinical entity. It is a diagnosis of exclusion, characterized by a clinical triad of intermittent fever spikes, evanescent rash, and either arthralgia or arthritis. Destructive arthritis more commonly affects the hips, wrists, tarsal joints and cervical spine. To report an unusual case of ASD with severe distal interphalangeal destructive arthritis and finger skin vesiculopustules. A 19 years old girl was followed for 2 year-history of ASD with polycyclic articular involvement. She noted, since 2 months, rapid appearance of painful tumefaction in the distal interphalangeal joints [DIP] with maculopustular eruption distributed exclusively on the hands, in front, only of DIP and few proximal interphalangeal joints [PIP]. Further more, she complained of polyarticular active disease. Hands and wrists X-ray showed narrowed distal-interphalangeal joint space of only DIP joints. RMN imaging revealed in addition carpal, metacarpal and PIP articular inflammatory damage. The infectious investigation remained negative. A surgical skin and DIP biopsy specimens showed disseminated micro-abscesses with polynuclear leukocyte dermal infiltration. There was no signs of osteitis. Bacterial and fungal cultures from the pus failed to reveal any causative organisms. Skin lesions gradually disappeared in response to conventional ASD therapy after intensification. Hence, the diagnosis of distal destructive arthritis of ASD associated with atypical neutrophilic dermatosis [Sweet's syndrome] was made. ASD is rare, heterogeneous, with unpredictable evolution. The distal destructive arthritis represents a possible complication. The presence of pustules as atypical cutaneous features of Sweet's syndrome may be seen in severe forms of ASD and clinicians must be alert to the possibility of a misdiagnosis in these cases

[Usefulness of ultrasonography for the diagnosis of carpal canal syndrome]

Ultrasound is an emerging tool in the diagnosis of carpal tunnel syndrome [CTS]. The aim of this study is to evaluate the diagnostic role of ultrasound in the CTS. Twenty five patients with signs and positive electromyographic of CTS were evaluated with ultrasound. The cross-sectional areas and the flattening ratio of the median nerve as well as the retinaculum bulging were calculated. There were 24 females and 1 male with the mean age of 48 years. Bilateral involvement was noted in 18 cases witch done 43 wrists. The mean cross-sectional areas of the median nerve in the carpal tunnel is 10.54 +/- 3.46 mm2 and it is over 9 mm2 in 93% of the cases. Mean flattening ratio in the carpal tunnel is 1.96 +/- 0.32. Palmer retinaculum bulging is 3.70 +/- 1.03. All theses parameters are over normally. The sensibility of ultrasound in CTS is 93%. Ultrasound measurement of median nerve more its morphologic data is highly predictive for diagnosis of CTS

[Validation of the Tunisian version of the health assessment questionnaire [HAQ] in rheumatoid arthritis patients]

One hundred twenty two rheumatoid arthritis patients were consecutively included in the study. Test-retest reliability was assessed in 61 patients based on the intra-class correlation coefficient. For the 122 patients [104 female and 18 male] the median age was 47 years [18-70]. The mean age of the patients who filled in the questionnaire at test and retest times was 45 years [18-70]. Test- retest reliability of the HAQ was 0.84. Internal consistency was 0.94. There was a good correlation between the HAQ and the Lee index [r = 0.75, p <10 -4], the HAQ and the RAQoL [rs = 0.96, p <10 -4]. In a logistic regression model Lee index, RAQoL and age account for the variance of the HAQ. The Tunisian version of the HAQ preserves the metrological properties of the original version and can be used for measuring and following functional abilities of Tunisian rheumatoid arthritis patients

Facteurs predictifs d'evolution de l'algodystrophie en rheumatologie. A propos de 60 cas

We analysed 60 cases of algodystrophy admitted in the rheumatology department of the university hospital of Monastir. We used a univariate analysis to search the factors associated with the disease evolution. Our patients were 40 males and 20 females. The mean age was 51.6 years [16-81]. The traumatisation was the dominant cause [46.7% of the cases]. Calcitonines were used in 70% of the cases. Functional results at one year were satisfying and not satisfying in 62.5% and 37.5% of the cases, respectively. The primitive algodystrophy was associated with a satisfying result. Sequella were observed in 10.5% of the cases. The primitive algodystrophy was associated with a satisfying result. Algodystrophy remain a benign disease and the best treatment remains the preventive one mainly in traumatic and orthopaedic circumstances

[Pelvic morphology and lumbar spondylolisthesis]

Pelvic morphology is involved in the genesis of spondylolisthesis. The mean age of patients with spondylolisthesis was 57.9 +/- 9.5 years [40-81]. 14 were complaining of low back pain and 12 had sciatica. Spondylolisthesis was in stage 1 in 75% of the cases and in stage 2 in 25% of the cases. Low lordosis was observed in patients and controls in 73% and 100% of the cases respectively. Sacral slops was slightly higher in patients than in controls and was higher than 40 degrees in patients and controls at a rate of 35% and 25% respectively. The incidence was higher in patients than in controls. There was a high pelvic retroversion in patients than in controls. High incidence and pelvic retroversion were found in patients with spondylolisthesis and pelvic morphology was probably involved in the genesis of spondylolisthesis