[Uncommon cervicobrachial neuralgia: about 17 cases]. / Les névralgies cervico-brachiales symptomatiques : Apropos de 17 cas.

BACKGROUND: 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. AIM: To investigate the epidemiology, clinical features, aetiologies and paraclinical characteristics of uncommon CBN. METHODS: 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]. RESULTS: 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 patient presenting chronic renal failure managed by hemodialysis. CONCLUSION: 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.

HLA-B, DR and DQ antigens polymorphism in Tunisian patients with ankylosing spondylitis (a case-control study).

The objective of the study is to assess the distribution of HLA-B genes, HLA-B27 subtypes, HLA-DRB1 and HLA-DQB1 alleles in patients with ankylosing spondylitis (AS) and in control subjects in the Tunisian population and to compare their distribution with that found in other countries. This is a case-control study that included 100 consecutive patients (85 males/15 females) with AS according to the modified New York criteria and 100 control individuals. HLA-B, B27 subtypes and class II (DR and DQ) typing of all subjects was performed by polymerase chain reaction amplification with sequence-specific primers (PCR-SSP). HLA-B27 was found in 62% of patients against 3% in controls (P = 0.0000, OR = 52.6, 15.6 < CI < 166.7). On the other hand, B*07 and B*51 were significantly decreased in comparison with controls (P = 0.01, OR = 0.3, 0.1 < CI < 0.8 and P = 0.0000, OR = 0.2, 0.1 < CI < 0.4, respectively). Eight B*27 subtypes were identified in the AS group, but the most frequent ones were B*2702 (32%) and B*2705 (24%). Among HLA-DRB1 alleles, a significant increase in DRB1*11 was found in comparison with controls (P = 0.01, OR = 2.2, 1.2 < CI < 4.5). However, DRB1*13 had a negative association with AS (P = 0.01, OR = 0.4, 0.2 < CI < 0.8). For HLA-DQB1 alleles, a significant positive association with DQB1*03 was observed in AS group (P = 0.03, OR = 1.8, 1.0 < CI < 3.4). Multivariate analysis by logistic regression revealed that DRB1*11 and DQB1*03 had no direct links with the disease, but were dependent on the presence of HLA-B27. Moreover, B*07 and B*51 seemed to have independently a negative correlation with AS, but DRB1*13 seemed to depend on B*51. Haplotypes carrying B27 were significantly associated with AS and those carrying B*07 or B*51 were negatively correlated with the disease. In conclusion, our study confirms that B27 predisposes to AS while B*07 and B*51 are negatively correlated with the disease.

Magnetic resonance imaging evaluation of the cervical spine in patients with rheumatoid arthritis. Report of 30 cases.

AIM: To investigate by magnetic resonance (MR) imaging the occurence of cervical spine (CS) involvement in rheumatoid arthritis (RA) patients. METHODS: Thirty consecutive unselected patients, who fulfilled the revised American College of rheumatology criteria for RA, were investigated. All patients had a complete physical and laboratory evaluation. Radiological evaluation included hand and wrist x-rays, as well as CS radiographs in anteroposterior, lateral and lateral in full flexion views. In addition, MR (Spin Echo T2-weighted saggital scans, palin and contrast enhanced T1-weighted sagittal and axial scans) was performed in all patients. Hand x-rays were evaluated according to the Sharp score. Disease activity was assessed by disease activity score for 28 joint indices (DAS-28). RESULTS: There were 25 females and 5 males with a mean age of 46.6 years (23-67) and mean disease duration 9 years (1-22). Twenty three patients (76.6%) had positive IgM rheumatoid factor (RF). Five patients presented clinical findings, mainly cervical pain and stiffness of CS (four with positive and one with negative MR), while radiological findings of CS involvement were found in seven patients (23%). Five patients (16.6%) presented MR findings of CS involvement (anterior atlantoaxial subluxation 100%; vertical subluxation 20%; peridental pannus 80%; dens erosion 40%; brainstem compression 20%). Atlantoaxial subluxation correlated with high DAS-28, high level of swellen joint, high level of C-reactive protein and advanced erosive changes of the wrist and hand (high level of Sharp score) in the univariate analysis. CONCLUSION: We conclude that the frequency of CS involvement in RA patients is high. In pateints with active erosive peripheral disease it is very probable to also have some changes in CS. These may be clinically important and in such cases, MR offer valuable information.

[Spinal cord compression due to benign osteoporotic vertebral fracture]. / Compression médullaire par un tassement vertébral ostéoporotique bénin.

BACKGROUND: A neurologic compromise associated with vertebral fractures is generally due to a malignancy causes. Therefore, an osteoporotic vertebral fracture can sometimes cause neurologic complications. AIM: Report a case of neurologic compromise associated with osteoporotic vertebral fractures. OBSERVATION: A-62-year-old man suffered from rheumatoid arthritis since 1985, presented a cervical pain associated with quadriparesia secondary to a C5 osteoporotic vertebral fractures. CONCLUSION: Osteonecrosis may be the cause of neurologic compromise associated with osteoporotic vertebral fractures.

Impact of the ankylosing spondylitis on the professional activity.

PURPOSE OF THE STUDY: Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting axial skeleton, occurring in young and active patients and often condition their professional prospects. OBJECTIVES: To describe the social and occupational characteristics of patients affected by AS, to estimate the impact of the disease on their professional activity and to determine factors exposing to elevated risk of premature withdrawal from the labor force. METHODS: We had performed a cross-sectional study of 103 patients with AS recruited during 2 years (2005-2007) at the Department of Rheumatology, fulfilling the modified criteria of New York. Demographic, social and professional characteristics were determinated and some disease-specific instruments: BASDAI, BASFI, BASMI, BASG-s, BASRI, as well as an indicator of quality of life: the Short Form Survey-36 (SF-36). RESULTS: It is about 88 man and 15 women, the average age is 37.6 years+/-11.7 (18-59 years). Seventy percent of patients live in urban zone and 17% have an educational level superior to 13 years. The disease duration is on average of 11.2+/-9.6 years. The mean score of BASFI is 45.5+/-27.5 (7-100), the mean score of BASDAI is 45.9+/-22.4 (9-100), the mean score of BASG-s is 53.8+/-21.2, the mean score of BASMI is of 4.4+/-2.2 (3-10), the mean score of BASRI is 8.4+/-3.5 (2-16). Among these patients 95 (92%) are eligible to a professional activity (aged between 18 and 65 years and having ended their studies or vocational training). The global unemployment rate is 25.3%, that's attributed to the disease is 20.6%. Some factors are associated with high risk of work withdrawal: female gender (p=0.0005), low educational level (p=0.02), living in rural zone (p=0.028), manual labor (p=0.038), cold exposing in work place (p=0.006), high work time a week (p=0.02) and the absence of colleague help (p=0.001). For the specific disease indexes, high risk of withdrawal is correlated with high scores of BASFI (p=0.00002), BASDAI (p=0.044), BAS-Gs (p=0.0005) and BASMI (0.0000). Concerning the SF-36, only the item of physical activity is more significantly altered in patient's having stopped their work. CONCLUSION: Several factors are identified to be associated to a high risk of premature working withdrawal in patients affected by AS. Prevention of this risk needs an early diagnosis and treatment of the disease, a vocational guidance, work preliminary training and eventually professional redeployment.

Validation of the Tunisian versions of Bath Ankylosing Spondylitis Functional Index (BASFI) and Disease Activity Index (BASDAI).

BACKGROUND: The Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Disease Activity (BASDAI) are the most commonly used instruments to evaluate respectively functioning and disease activity in ankylosing spondylitis (AS). OBJECTIVE: The aim of this study was to translate, adapt and validate these instruments into the Tunisian language. METHODS: The studied population consisted of 68 AS patients (59 males and 9 females). Their mean age was 37.9 years (range: 18-76). The mean disease duration was 13.6 years (range: 1-40). After translation and retranslation the BASFI and BASDAI questionnaires were administrated to the patients and tested for reliability, internal consistency and construct validity. RESULTS: The reproducibility of the indices BASFI and BASFAI was good, the intraclass correlation coefficient for reliability was 0.96 (CCI:0.93-0.97) for the BASFI and 0.93 (CCI:0.90-0.97) for the BASDAI, and the coefficient of internal consistency (Cronbach's alpha) was 0.91 for BASFI and 0.90 for BASDAI. Concerning construct validity, both questionnaires were significantly correlated to each other, to the disease-specific instruments (BASG-s, BASMI, BASRI, ASQoL) and to all domains of the SF-36. CONCLUSION: The Tunisian versions of the BASFI and the BASDAI preserve the metrological properties of the original versions and were easy to use for the assessment of disease status in ankylosing spondylitis.

[Osteomalacia and giant cell tumor: a rare case]. / Ostéomalacie et tumeur a cellule géante: une entité rare.

BACKGROUND: Oncogenic octeomalacia is an unusual and rare clinicopathologic syndrome characterized by mesenchymal tumors that apparently produce osteomalacia and biochemical abnormalities consisting of hypophosphatemia and normocalcemia. AIM: We have investigated the mechanism by which a giant cell tumor of bone caused biopsy-proved osteomalacia in a 50-year-old woman. CASE REPORT: A 50-year-old woman presented with generalized bone and pelvicrural pain, associated with fatiguability and muscle weakness. The diagnosis of osteomalacia was retained, associated with a giant cell tumor. The coexistence of giant cell tumor of bone and osteomalacia suggested the diagnosis of oncogenic osteomalacia. Resolution of the biochemical abnormalities of the syndrome after tumor resection, established this diagnosis. CONCLUSION: oncogenic osteomalacia can be a form of vitamin-D-refractory osteomalacia due to altered vitamin D3 metabolism.

[Leflunomide in the treatment of rheumatoid arthritis]. / Le leflunomide (ARAVA) dans le traitement de la polyarthrite rhumatoide.

The aim of this study was to assess the effect and safety of leflunomide (LEF) in refractory RA and to review the literature on this subject. A one year prospective study was conducted on a group of patients (n:15). Mean duration disease was 6.46 years. Rhumatoid factor was present in 12 cases. Leflunomide was administered at a dos of 20mg/day following a loading dose of 100mg/day for three days. The efficacy of LEF was evaluated on clinical and biological parameters of RA evolutivity at one, 3, 6, 9 and 12 months. Our mean follow up period was about 8 months (2 to 12 months). Good prognostic indicators of disease progression were observed with LEF at one month and later in eleven cases with a good safety. Non serious adverse events were observed with LEF. Our result confirm that LEF may present another therapeutic choice that is efficacious for the long term treatment of refractory RA. Nonetheless, these results must be evaluated on a larger series.

[TNF alfa modulators in the treatment of rheumatoid arthritis]. / Les modulateurs du TNFalpha dans le traitement de la polyarthrite rhumatoide.

Current slow-acting anti-rheumatic drugs available at now for rheumatoid arthritis fail in majority of cases and have an inconstant chondro-protective effect. Improvements in our knowledge of its pathogenesis and advances in molecular biology have made possible to develop selective immunotherapy approaches. Tumor necrosis factor alfa (TNF alfa) is an important inflammatory mediator that play a crucial role in rheumatoid arthritis. This studies summarizes clinical essays that evaluate beneficial effects and tolerance of anti TNF alfa antibodies. This study showed the clinical, biological and radiological efficacy of these therapeutic agents. But some doubts persist concerning their long term side effects particularly infections, neoplasm or auto immune ones. High price of this treatment should evaluate report cost benefice to appreciate the better utilisation of these drugs.