[Complete auriculoventricular block during chloroquine treatment]. / Bloc auriculoventriculaire complet au cours d'un traitement par chloroquine.

INTRODUCTION: The cardiac toxicity of antimalarial agents is rare, it includes conduction disorders which can be complicated by third atrioventricular block and hypertrophic cardiomyopathy. We report two observations of patients who presented a complete heart block after several years of treatment by chloroquine. CASE REPORT: Two patients followed for rheumatoid polyarthritis, treated by antimalarial agents for average 12 years and corticotherapy, presented a syncopal complete heart block which required an implantation of a pace maker. After having eliminated all the other underlying causes for complete heart block, the antimalarial agents were accused and were stopped. The clinical evolution after interruption of the treatment was favorable. CONCLUSION: Our observations illustrate rare cardiac side effects observed in our two patients after long-term treatment by antimalarial agents. The diagnosis of antimalarial agents responsibility was retained on clinical and biological arguments after having eliminated the other causes. The insidious character of these complications imposes vigilance during the use of long-term treatment by antimalarial agents.

Cervical spine involvement in ankylosing spondylitis.

Our objective was to study cervical spine involvement in a Moroccan population of ankylosing spondylitis (AS) patients and evaluate correlations with disease symptomatic and structural severity. Patients were prospectively enrolled for a 1-year period. Clinical, biological, and radiological data were collected. The risk of cervical spine involvement was estimated using the Kaplan-Maier method. Sixty-one patients were enrolled: 38 males (62.2%) and 23 females of mean (SD) age 35.1 years [11] (range 17-66). The mean disease duration was 10.6 years [7] (0.5-30). Forty-three patients (70.4%) had a history of neck pain. Radiological involvement was present in 33 cases (54%). The concordance between clinical and radiological involvement was statistically significant (kappa=0.49; P<10(-6)). The risk of cervical spine involvement with regard to disease duration showed that 19.6% of patients had radiological involvement after 5 years, 29.9% after 10 years, 45.1% after 15 years and 70.0% after 20 years. Comparison between patients with and without cervical spine radiological involvement showed no difference in age of onset or sex. There was statistical difference in symptomatic severity parameters (Schöber, chest expansion, BASMI, BASFI, BASDI, BASG) and structural severity parameters (lumbar syndesmophytes score, BASRI). Our study confirms the greater severity of AS in North African countries. Cervical spine involvement increases with age and disease duration in AS and is more frequent in symptomatic and structural severe forms of the disease.

[Polyostotic fibrous dyplasia: a case report of a diffuse form with hemimelic predominance]. / Dysplasie fibreuse polyostotique: à propos d'une forme diffuse à prédominance hémimélique.

Fibrous dysplasia is an uncommon condition characterized by the presence of mesenchymatous tissue in bone. There are various risks. We describe the clinical and radiological features observed in a patient with fibrous polyostotic fibrous dysplasia and discuss risks. A 37-year-old man suffered from bone pain and multiple fractures without endocrine disorder since the age of 10 years. At admission in 1998, he presented limb deformities and hyperchromic spots on the thorax. Calciuria was low and alkaline phosphatase was 1274 IU/ml. Endocrine tests were normal. Radiographs showed polyostotic defects in the right hemibody and in the skull. They also showed a right subtrochanteric fissure. CT scan of the face and skull did not demonstrate nerve compression. Histology analysis identified fibrous dysplasia. Vitamin and calcium supplementation and preventive measures were instituted. No deformity led to surgical correction despite the early beginning. Polyostotic fibrous dysplasia is a congenital disease. Radiological aspects are variable. There is a risk of deformities, fractures, osteomalacia (as in our case), neurological compression, and finally a risk of sarcomatous transformation. Recently introduced biphosphonate therapy appears to provide effective pain relief and probably satisfactory prevention of fractures.

Third-degree atrioventricular block in a patient under chloroquine therapy.

The first case of chronic cardiac toxicity due to an antimalarial agent was reported in 1971 and since then several cases of heart failure, restrictive cardiomyopathy or atrioventricular block have been ascribed to this family of drugs. We report the case of a 43-year-old woman who developed juvenile chronic arthritis at the age of ten, followed in adulthood by sero-positive rheumatoid arthritis. In 1980 she was put under chloroquine sulfate (hydroxychloroquine was not available) in a dose of 200 mg/d (152.66 mg of chloroquine), with 10 mg/day of prednisone. She developed myalgia and increased skin pigmentation, but disregarded recommendations that these symptoms required discontinuation of chloroquine therapy. She was lost to follow-up, but continued the chloroquine therapy of her own accord. In December 1993, she developed a third-degree atrioventricular block with syncopes requiring implantation of a pacemaker. The rare but well-documented myopathy induced by antimalarial agents can produce early severe lesions of the cardiac muscle, which may have a predilection for the interventricular septum, explaining the risk of atrioventricular block. Although histologic studies were not performed in our patient, the clinical evidence of toxicity, absence of underlying heart disease and fairly young age of the patient pointed to chloroquine toxicity. Periodic cardiac investigations including electrocardiography may be warranted in patients under antimalarial therapy.

Osteomalacia as a presenting manifestation of Sjögren's syndrome.

Osteomalacia is still common in Morocco, where the leading causes are nutritional deficiencies followed by intestinal diseases. Osteomalacia rarely occurs as the first manifestation of a renal tubule disorder due to a connective tissue disease such as Sjögren's syndrome. The case of a 40-year-old woman who presented with a five-year history of generalized bone pain, severe weight loss and a waddling gait is reported. She had low levels of serum phosphate (0.74 mmol/L), serum calcium (1.97 mmol/L), and urinary calcium (1.22 mmol/24 h). Serum alkaline phosphatase was 210 IU/L. Roentgenograms showed Looser's zones (right femoral neck, sixth and seventh right ribs). There was bilateral parotid gland enlargement, dryness of the mouth, nose and eyes, and bilateral punctate keratitis. A lip biopsy showed changes corresponding to stage II of the Chisholm and Mason classification. Tests for rheumatoid factor (latex and Waaler-Rose) and antinuclear factor were negative. The alkaline reserve was 18 mmol/L, serum potassium was 3.5 mmol/L, serum chloride was 112 mmol/L and urinary pH was 6.5. A renal biopsy showed tubulointerstitial lesions, lymphoplasmocytic infiltrates and interstitial sclerosis with patchy tubular atrophy. The patient was given bicarbonates, high-dose vitamin D followed by 1-alpha-hydroxycholecalciferol (0.3 microgram/d), and calcium (1 g/d). Follow-up was 42 months at the time of this writing. The role of tubular disorders in the genesis of osteomalacia is discussed, and the renal manifestations of Sjögren's syndrome are reviewed.