[Inflammatory aortitis in giant cell arteritis]. / Aortite inflammatoire au cours de la maladie de Horton.

A sub-clinical inflammatory aortitis is very frequent in patients with giant cell arteritis, and can be the only localization of the disease. In most patients, this aortitis is asymptomatic and is of no consequence on the patient's survival. The relative risk of developing an aortic dissection or aneurysm is 17.3. Evolution towards an aneurysm or an aortic dissection is unpredictable and rare; and seems independent of the disease activity and the associated vascular risk factors. Isolated aortitis treatment is not consensual, but often similar to the treatment of giant cell arteritis and adapted to clinical and biological markers of disease activity. Screening for sub-clinical aortitis with FDG-PET should not be prescribed in patients with typical presentation of giant cell arteritis. A systematic screening of aortic complications in giant cell arteritis patients could be done with a chest X-ray and an abdominal ultrasound possibly completed with an aortic CT-scan at time of diagnosis, in order to look for aneurysms with possible surgical indication.

Aldolase predicts subsequent myopathy occurrence in systemic sclerosis.

INTRODUCTION: Myopathy related to systemic sclerosis (Myo-SSc) is a disabling and unpredictable complication of SSc. We assessed the predictive value of serum aldolase, creatine kinase (CK), alanine transaminase (ALT), aspartate transaminase (AST) and C-reactive protein (CRP) to estimate the risk of developing Myo-SSc. METHODS: We enrolled 137 SSc patients without proximal muscle weakness in a prospective monocentric study to follow them longitudinally over a four-year period. The risk of occurrence of Myo-SSc was ascertained according to the European NeuroMuscular Centre criteria and was analyzed according to levels of plasma aldolase, CK, transaminase enzymes and CRP at inclusion. Performance of each parameter to predict Myo-SSc occurrence was assessed and compared with the others. RESULTS: The area under the receiver operating characteristic curves (ROC) of plasma aldolase for Myo-SSc occurrence prediction was 0.80 (95% CI: 0.67 to 0.94, P < 0.001), which was higher than that of plasma CK (0.75, P = 0.01), and that of ALT (0.63, P = 0.04). AST and CRP had no predictive value for Myo-SSc occurrence. The best cut-off of aldolase for prediction of Myo-SSc occurrence within three years after inclusion was 9 U/L and higher than the upper normality limit (7 U/L), unlike that of CK and ALT. Myo-SSc occurred more frequently in patients whose plasma aldolase was higher than 9 U/L. Adjusted Hazard Ratio for patients with aldolase > 9 U/L was 10.3 (95% CI: 2.3 to 45.5), P < 0.001. CONCLUSIONS: Increased plasma aldolase level accurately identified SSc patients with high risk to develop subsequent Myo-SSc. This could help initiate appropriate treatment when the disabling muscle damage is still in a reversible stage.

Digital photography as an operational tool for assessing corticosteroid-induced lipodystrophy.

BACKGROUND: Corticosteroid-induced lipodystrophy (CIL) is exclusively diagnosed in a subjective manner. OBJECTIVE: To evaluate the reliability of digital photographs in the diagnosis of CIL. METHODS: All consecutive patients starting long-term, high dosage corticosteroid therapy were photographed at baseline and after 3 months of therapy. At the end of the study, 3 physicians with expertise in corticosteroids classified patients as lipodystrophic yes/no/unclassifiable. Photographs analyses performed by 9 medical readers and evaluation of CIL using visual analog scale (VAS) performed during the M3 visit were compared to this classification. RESULTS: Eighty-eight patients were monitored. Fifty of them were classified by the 3 experts as lipodystrophic and 30 as not lipodystrophic (8 were unclassifiable). Their intra- and inter-observer agreements were moderate or fair (kappa coefficientor=0.75) when M3 photographs were analysed beside baseline ones. By comparison with expert consensus, only 3 out of 4 patients were correctly classified using VAS. The AUROC curve and inter-observer agreement significantly improved with experience for the 9 non-experts. CONCLUSION: The use of digital photographs do better than VAS to evaluate CIL. The accuracy of diagnosis improves with experience. Morphological changes are more important than morphological phenotype.

Occupational exposure to solvents and gender-related risk of systemic sclerosis: a metaanalysis of case-control studies.

OBJECTIVE: In 2001 a metaanalysis reported an excess risk of systemic sclerosis (SSc) related to solvents exposure. The magnitude of risk varied among studies and sources of heterogeneity have not been investigated due to a lack of statistical power. We conducted a new metaanalysis to identify features associated with the magnitude of SSc risk in patients exposed to solvents. METHODS: We searched 4 databases (Medline, Pascal, Pascal Biomed, Francis). Inclusion criteria were: case-control study, occupational exposure to solvents (OES) assessed by questionnaire and summarized to "any solvent" or "any organic solvent," SSc defined by the American College of Rheumatology or the consultant's criteria. The quality of studies within this metaanalysis was scored according to the Newcastle-Ottawa scale. Odds ratios (OR) were adjusted for the "publication bias" and validated by a sensitivity analysis. Subgroup analyses investigated the effect of gender, quality of studies, and the type of controls. RESULTS: Among 11 studies (1291 patients and 3435 controls), 9 involved a majority of women (76.2 to 100%), while 2 involved men only. The risk of SSc associated with OES was variable among studies (p for heterogeneity = 0.01) and overrepresentation of higher OR values in smaller studies (p = 0.003) suggested "publication bias." SSc was associated with OES (OR 2.4; 95% CI 1.7-3.4; p < 0.0001), including after adjusting for bias (OR 1.8; 95% CI 1.2-2.5; p = 0.002). The relative risk was higher (p = 0.03) in men (OR 3.0; 95% CI 1.9-4.6; p < 0.0001) than in women (OR 1.8; 95% CI 1.5-2.1; p < 0.0001). CONCLUSION: Whereas SSc affects women predominantly, among subjects with occupational exposure to solvents, men are at higher risk than women for the disease.

Kaposi's sarcoma-associated herpesvirus viremia is associated with the progression of classic and endemic Kaposi's sarcoma.

In order to gain further insight on the role of Kaposi's sarcoma-associated herpesvirus (KSHV) in classic and endemic Kaposi's sarcoma (KS) pathogenesis, we aimed to determine (i) whether KSHV is detectable in peripheral blood mononuclear cells (PBMCs), (ii) which PBMCs subpopulation harbor the virus, (iii) which clinical, histologic, and immunologic parameters are associated with KSHV viremia in a population of classic and endemic KS. KSHV viremia and various immunologic parameters were screened on 81 patients. KSHV viremia was positive in 58% of the patients. KSHV was detected in B cells, T cells, and monocytes. CD34+ cells depleted in circulating endothelial cells (CECs) were never infected and 50% of the patients tested had CECs infected by KSHV. We observed a significant increase of IL-2 and IFN-gamma production by CD4 T cells and an increase of IFN-gamma production by CD8 T cells compared to control patients. KS progression (P = 0.001) and KS staging (P = 0.03) were significantly and independently associated with positive KSHV viremia. Our results show that there is no specific immunosuppression in classic or endemic KS. We showed that KSHV can be detected within CECs and that KSHV viremia could be an indicator of circulating mature or precursor spindle cells.

Tuberculosis in patients with and without primary health coverage.

BACKGROUND: The aim of this study was to determine whether tuberculosis (TB) treatment and follow-up is a feasible option for patients without primary health coverage when free access to health care and drug delivery is provided on an outpatient basis. METHODS: We conducted a retrospective analysis of patient characteristics, treatment modalities, and evolution up to 9 months of follow-up at Saint-Louis Hospital, Paris, France. RESULTS: TB patients without (n=44) compared to those with (n=49) primary health coverage at diagnosis tended to be younger and more frequently homeless (P<0.05) or had illegal status (P<0.001). They had similar TB presentation when starting treatment, but required free drug delivery more often (74 vs. 21%, P<0.001). After the same duration of follow-up, patients considered as cured or as having completed treatment (52.3 vs. 51%), dead (2.3 vs. 8.2%), still under treatment (13.2 vs. 6.1%), or lost to follow-up (31.8 vs. 34.7%) were similar in both groups. At the end of the follow-up period, 43% of the patients without primary health coverage had managed to obtain 70% or 100% free medical aid or social security. CONCLUSIONS: Free access to health care and drug delivery is worthwhile in TB patients without primary health coverage since it permits the same clinical results as in TB patients with primary health coverage. However, efforts should be made to improve the management and follow-up of TB patients and to lower the number of patients lost to follow-up, whatever their social status.