[Procedural pain assessment after spinal injections of corticosteroid]

Spinal injections of corticosteroid are commonly performed by rheumatologists in their daily practice but little is known about the frequency, the intensity and the management of procedural pain observed in these osteoarticular injections in daily practice. To evaluate the prevalence and intensity of pain caused by spinal injections. In this observational prospective study, data were collected over 6 months, for up to 44 procedures [corticosteroid spinal injection]. Evaluation of the pain was evaluated immediately before and after the injection using Huskisson's visual analogue scale [VAS]. Statistical analysis was carried out in order to compare patients who had suffered from pain whilst undergoing the procedure to those who had not. Data were analyzed for 17 patients [12 female, mean age 53.6 +/- 10.5 years]. Over 50% of patients experienced procedural pain. Significant predictive factors of genesis of the procedural pain were the young age [p=0.022] and the intensity of the initial pain [p < 0.001], while the existence of a co morbidity is rather a protective factor [p = 0.006]. Others factors such us sex, origin, level of studies, socioeconomic conditions, didn't seem to have of effect on the procedural pain. Most patients undergoing spinal injections suffer from procedural pain. Specific research and guidelines for the management of procedural pain related to rheumatologic care should be established to improve the quality of care provided by physicians

[Bisphosphonates': indications in bone diseases other than osteoporosis]

Report of bisphosphonates indications for osseous diseases other than osteoporosis. Narrative review of the literature. Bisphosphonates represent a new medication which is increasingly used. Besides osteoporosis, it is indicated as first choice in different bone diseases such as Paget's disease and the prevention of bone complications in tumoral osteolysis. Bisphosphonates' efficiency has been proven in other pathologies: the fibrous dysplasia and the osteogenesis imperfecta. More over, many studies are driven having for goal to show the efficiency of bisphosphonates in the algoneurodystrophy, non corticosteroid-treated osteoporosis in chronic inflammatory rheumatism and aseptic osteonecrosis. Bisphosphonates are a powerful inhibition of osseous resoption frestable indicatied for osteoporosis. Their indications were retended to paget's disease, malignant hypercalcemia, and osseous complications of malignant osterlysis

[Uncommon cervicobrachial neuralgia: about 17 cases]

Cervicobrachial neuralgia [CBN] is frequent in out patient clinic as well in general medicine as in rheumatology. Even though cervical disc degeneration and osteophytosis constitute the most frequent etiology of such a trouble, the practitioner must be aware of much more serious underlying cause. To investigate the epidemiology, clinical features, aetiologies and paraclinical characteristics of uncommon CBN. Retrospective chart review about 17 cases of uncommon CBN among the 84 cases of CBN hospitalized at the rheumatology department of the Charles Nicolle Hospital during a 16-years-period [1990-2005]. There were 11 men and 6 women with a mean age of 63 years [33y-81y]. All patients presented a CBN since in average five months [2 months- 24 months]. Neck stiffness was noted in 60% of cases and a neurological impairment in 47% of cases. X-ray radiographs of cervical spine were normal in five cases. In the remaining cases, they showed lytic images [six cases], disk space narrowing with vertebral erosions [two cases] and vertebral fracture [three cases]. Further investigations concluded that the CBN was due to a Pancoast'syndrome in five cases, an infectious spondylitis in three cases, cervical bone metastasis in two cases, a syringomyelia in two cases, a neuroma in one case, a thoracic outlet syndrome in one case and an erosive spondylarthropathy in a paatent presentig chronic renal failure managed by hemodialysis. In comparison with common CBN, our patients presenting symptomatic CBN were characterised by an inflammatory and refractory pain. The more frequent recourse to modern imaging is justified

[Thoracic outlet syndrome]

The thoracic outlet syndrome [TOS] is recognized as a cause of upper limb pain. It is often under-diagnosed and its frequency under-estimated by rheumatologists. To report the diagnostic problems related to TOC though a literature review A narrative review of literature. The diagnosis of TOS is difficult because of intricacy of vascular and neurological symptoms. It requires provocative tests, electrophysiological investigations and Doppler ultrasonography. A good anatomical knowledge is mandatory in order to clarify the mechanisms and the location of the lesions which depend on sophisticated imaging exams. It is also recommended to exclude all other causes of upper limb pain, as well as peripheral nerve compression syndromes, which can coexist with TOS. Diagnosis and treatment of the TOS involves rheumatologists, neurologists, physiatrists, orthopedic surgeons, vascular surgeons, thoracic surgeons, neurosurgeons and sometimes psychiatrists who have to cooperate in order to prevent severe functional after-effects

[Monoarthritis of the elbow revealing an intraarticular osteoid osteoma]

Osteoid osteoma is one of the unusual causes of musculoskeletal pain. Its diagnosis is usually not difficult in classic diaphyseal localization. However, the diagnosis of juxta or intraarticular osteoid osteoma is challenging because of atypical clinical presentation responsible for long diagnosis delay. Report a new case. We report herein the case of a 22-year-old woman presenting an intraarticular osteoid osteoma of the elbow. Diagnosis has been established on imaging findings [MRI and CT-scan] after 10 months because of atypical clinical presentation as a chronic monoarthritis of the elbow. The picture of an osteoid osteoma of the lower extremity of the humerus associated to a synovitis and a joint effusion was suspected on MRI. It had been confirmed on CT-scan which showed the nidus. Surgical removal of the tumor allowed pain relief and functional restoration in postoperatively. Regarding an unexplained chronic monoarthritis, the diagnosis of intraarticular osteoid osteoma should be evoked. CT-scan remains the investigation of choice for identifying the nidus. Surgical exicision permits the relief of symptoms

[Morbidity of the elderly in impatient rheumatology clinic]

The improvement of life expectation in our country explains at least in part the increase of the proportion of the elderly in hospitalized patients. The aim of this study was to identify the main diseases leading to hospitalization of the aged in a rheumatology department, to establish their clinical profiles and to evaluate the quality of their management. Retrospective chart review about the elderly [age >/= 65 years] admitted in the rheumatology department of the Charles Nicolle Hospital during a 2-year-period [January 2003-December 2004]. Among the 831 patients admitted to our inpatient clinic during that period, 86 were 65-year-old or more representing 10% of the total. Mean age was 71.2 years [65-88]. The sex ratio was 1/3. A history of a mean of two associated diseases [0-5] was noted. They were dominated by hypertension [50%] and diabetes [26,7%]. Almost 1/3 of the elders had a surgical history. Gastro-intestinal troubles have been noted in only 19% of cases. The main cause of hospitalization was a diagnosis exploration [77,6%]. The remainings were admitted for therapeutic adjustment. The disease was evolving since in mean 16 months [15 days- 15 years]. The mean duration of hospitalization was 21,2 days [4-60]. The pathologies involved were varied dominated by degenerative rheumatisms [26,7%] with a predilection to lumbar spine, systemic diseases: 18 cases [20,9%] with 13 cases of rheumatoid arthritis, and malignant bone diseases [18,7%]. At least two rheumatic diseases were found together in 49 patients [57%]. The clinical findings were atypical in almost half cases [42,4%] in such aged patients. Besides drugs prescribed for non rheumatic diseases, our patients took a mean of 3.4 drugs [1-8] as symptomatic, adjuvant or etiologic treatment. The treatment observance was good in 74,4% of cases. Latrogenic incidents occurred in 14 cases [16,2%]. The outcome was favorable in 68,9% of cases. Twelve of our patients necessitated a third help. Half of our patients [54%] were controlled in our outpatient clinic 1-2 months after their issue. 12 have been hospitalized for the same disease, 8 deceased, and 19 have been lost. The management of the elderly patients in hospitalization must be multidisciplinary. It should take into account the clinical and therapeutic particularities of such a population. Prevention remains the best guarantee for a good quality of life and to decrease social and economic costs

[Update in treatment of psoriatic arthritis]

Psoriatic arthritis is a chronic rheumatic disease making part of spondylarthropathies. It is the most frequent chronic inflammatory rheumatism after rheumatoid arthritis. Eventhough, it is usually a benign affection, it may be destructive leading to handicap. Several new medications have been introduced, including anti-tumor necrosis factor [TNF alpha blockers] and leflunomide for treatment of psoriatic arthritis. Many studies show the efficacy of these medications in this disease

Usefulness of videocapillaroscopy in clinical practice: systomatic review of indications and results in rheumatology and in non rheumatic disorders

Nailfold videocapillaroscopy [VCP] is nowadays worldwide considered as one of the best diagnostic noninvasive imaging technique able to study microcirculation in vivo. To review the applications of VCP in the clinical practice and its results in rheumatic and non-rheumatic diseases. Review of literature. The possibility of managing the imaging, by means of dedicated software able to characterize quantitative and qualitative data, represents another relevant property of VCP. This technique is very useful at the identification of microvascular involvement in many rheumatic diseases, particularly in systemic sclerosis and related disorders. At the same time, VCP has been showed valuable in many other extra-rheumatic diseases. The authors review the applications of VCP in the clinical practice and its results in rheumatic and non-rheumatic diseases

[Septic arthritis in the elderly: about 21 cases]

Septic arthritis [SA] is a serious disease especially if occurring in elderly debilitated by frequent comorbidities and diminished immunity. The authors discuss diagnosis difficulties, prognosis and, therapeutic consequences of the occurrence of septic arthritis in elders It is a retrospective study about 21 cases of septic arthritis [SA] occurring in the elderly aged 65-year-old or more, hospitalized over a ten year period [1994-2005] at the department of Rheumatology of Charles Nicolle's Hospital of Tunis. Mean age was 70.8 years [65y-83y] with a sex-ratio of 1.1 .A history of rheumatologic and/or systemic diseases was present in 62%of cases. Clinic presentation was atypical explaining the long mean diagnosis delay; 23 days for pyogenic SA, 9.3 months for tuberculous arthritis. The germ involved, isolated in 11 cases, was a Staphylococcus Aureus in most ones. Tuberculous arthritis represented 28.6%of cases. The outcome was favourable in 19 cases [90%] after antibiotherapy. Because of its seriousness, SA should be evocated in front of any articular inflammation occurring in elderly. Adequate management must be started as soon as possible

Adult onset still's disease: about 11 cases

Adult onset Still's disease [AOS] is an inflammatory disorder which associates variable articular and systemic manifestations. Despite a better knowledge of its biological and clinical particularities, the pathogeny of this disease remains unknown. The aim of this study is to analyze the epidemiological, clinical, biological and, outcome characteristics of AOS. It is a retrospective study about 11 cases of AOS hospitalized over a 24-year-period [1982-2005] at The Rheumatology Department of Charles Nicolle's Hospital of Tunis. All patients responded to the Yamaguchi criteria. Mean age was 35.4 years [20y-70y] with a sex-ratio of 0.57.Fever and articular involvement were the most frequent signs. Cutaneous symptoms were present in 6 patients. Three of our patients developed destructive arthritis. Renal amyloidosis, a rare complication of AOS, has been noted in one case. AOS is an unfrequent disorder characterized by its diagnosis and treatment difficulties. Recent advances in immunotherapy may better the management of AOS

[Arthritis of the hip in spondylarthorpathy retrospective study about 126 cases]

To determine epidemiological and clinical features of arthritis of the hip in a Tunisian population of spondlarthrpathy [SA].This is a retrospective study about patients suffering from SA treated in a rheumatology unit. A radiological investigation of the pelvis was systematically performed on each patient.The study involved 126 cases of SA [83 men and 43 women], with a middle age of 32.6 years. Arthritis of the hip showed within 3.8 years. Total hip arthroplasty was indicated in 18% of cases. Arthritis of the hip in spondylarthropathy is an important cause of functional disability. We insist in our study on the frequency of arthritis of the hip in North Africa and particularly in patients aged under 16 years

arthrites reactionnelles

Reactive arthritis are definied as steriles arthropathies using classic bacteriological techniques. They are due to extra articular infection and are often associated with HLA B27. the outcome of these arthritis is caracterised by the recurrence of flares with sometimes appearition of ankylosing spondylitis. The pathogenesis of reactive arthritis is modified when bacterial antigens or alive micro-organisms are discovered in involved joints. Several current works have underlined the interest of antibiotic therapy in the chlamydial reactive arthritis. Chronic forms can justify the use of anti-rheumatic drugs such as salazopyrine

Manifestations musculo-squelletiques de l'hypothyroidie

Rheumatologic manifestations are varied during the hypothy-roidism. They can be articular, abarticular, muscular or osseous, consequences oF an inappropriale hormonal secretion. Their diagnosis is easy when hypolhyroidism is known, but they can be inaugural. Their evolution is favorable under substitute treatment

Manifestations rhumatologiques de l'infection a parvovirus B19

Rheumatologic manifestations of parvovirus B19 infection is a recent individualization. They are rather frequent and varied and meet at the young adult's. generally, it is responsible for acute, bilateral and symmetrical arthritis, usually involving distal joints and somrtimes associated to signs caused by viral infections. Prolonged articular forms were described but are rare being able to sometimes feign a nocive rheumatoid arthritis because of their clinical aspect and of a seropositivity. Axial manifestations were also repoted. The diagnosis of the recent infection by the parvovirus B19 can be confirmed by ELISA identification of specific IgM antibodies. The mechanism of the articular manifestations is still unknown and the link between parvovirus B19 and systemic vasculitis is questioned

Association lupus erythemateux systemique - hypothyroidie. A propos d'un cas

The association of systemic lupus erythematosus [SLE] and hypothyroidism is uncommon, and concerns essentially the autoimmun thyroiditis. However, the coexistence SLE-primary hypothyroidism is exceptional. We report an observation of 25-old woman, who presents a clinical form of hypothyroidism, confirmed by hormonal tests, and which is associated lo polyarthritis and proximal myopathy non ameliorated by opo-therapy. The explorations conclude in SLE. A favourable evolution of muscular and articular signs is obtained with cortico-therapy

Aspect pseudo-polymyositoque d'une sclerose laterale amyotrophique

We present three cases of short-coupled variant of torsade de pointes with review of the literature. These women presented with syncope or presyncope due to torsade de pointes initiated by a short-coupled premature ventricular beat and without evidence of prolonged QT. There were no electrolyte disturbances in all cases, no apparent structural heart disease in two cases and a mild interventricular septum hypertrophy in the other case. One patient took spiramycin and metro nidazole and another was taking pheniramin and lincomycin without any evidence of cause to effect relationship. One patient responded to verapamil but died suddendly after 44 months of follow-up. The two others. Received implantable cardioverter-defibrillators and verapamil per os. They still alive 46 and 54 months later. Short-coupled variant of torsade de pointes have a high incidence of sudden death, so it is very important for physicians to identify and treat it promptly, long-term verapamil treatement is effective but still insufficient and patients should be considered for implantable cardioverter-defibrillator therapy