Search

Background: Synovial chondromatosis is an uncommon benign condition characterized by synovial membrane proliferation and metaplasia. Synovial chondromatosis cases in patients with rheumatoid arthritis have been reported. However, involvement of the glenohumeral joint is rare. Case presentation: We herein report a case of a rare association of synovial chondromatosis involving the shoulder in a rheumatoid arthritis patient. The symptoms have improved with anti-tumor necrosis factor drugs. Consequently, there was no need for invasive therapy for treating synovial chondromatosis. Conclusions: Synovial chondromatosis can be aggressive and destructive. More trials are needed to establish a better clinical diagnostic strategy and pharmacological management.

Background: Knee osteoarthritis, a chronic degenerative disease, is becoming a public health problem around the world due to increasing life expectancy. Objectives: We aimed to assess the impact of knee osteoarthritis on the quality of life (QoL) of the patients and to identify factors associated with impaired QoL. Materials and Methods: We conducted a cross-sectional monocentric study including patients with knee osteoarthritis. The pain was evaluated by the Visual Analog Scale (VAS). The short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-PS) was used to assess functional im-pact. QoL was assessed using the OsteoArthritis of Knee Hip Quality Of Life (OAKHQOL) ques-tionnaire. Results: Fifty patients were included. The mean age of patients was 59 ± 9 years. The sex ratio was 0.25. At least one comorbidity was noted in 77% of patients. The mean disease duration was 8.82 years. Mean VAS pain and KOOS-PS were 6.8 ± 1.1 and 54.7 ± 9.6/100; respectively. Assessment of the QoL by OAKHQOL showed impaired QoL in all domains; the worst scores concerned the areas of social functioning and pain. Factors associated with an altered QoL were age > 65 years, longer disease duration, higher pain intensity, comorbidities, and functional impairment. Conclusion: Our patients showed an impaired QoL in all domains, particularly in terms of physical activity and social functioning. Lower QoL scores were associated with age, comorbidities, pain, function, and disease duration. Factors associated with QoL should be considered in the manage-ment program of these patients. Screening and the treatment of comorbidities are also useful for the management of knee OA.

Backgroung: Fibromyalgia may be associated to Spondyloarthritis with which it shares some common symptoms such as sleep disorders, fatigue and diffuse pain, leading to diagnostic and treatment dilemmas. Objectives: We aimed to determine the prevalence of fibromyalgia in axial spondyloarthritis and to determine how fibromyalgia might influence the assessments of disease activity and how it might impact treatment. Methods: An observational cross-sectional study was conducted. The study included 100 patients with axial spondyloarthritis according to the Assessment of SpondyloArthritis international Society criteria. Fibromyalgia was diagnosed based on the 2010 American College of Rheumatology crite-ria. Demographics, disease characteristics, activity parameters and treatment were compared be-tween patients with and without fibromyalgia. Patients were recruited from the hospitalization unit and the outpatient clinic of rheumatology. Results: The mean age of patients was 44.65 ± 13.13 years, with a sex ratio equal to 2. The preva-lence of fibromyalgia was 20%. Fibromyalgia associated factors were advanced age and a late age at the onset of axial spondyloarthritis. Disease activity parameters such as global pain VAS, BASDAI, ASDAS-ESR, ASDAS-CRP, BASFI and BAS-G as well as MASES and BASMI were significantly higher in the presence of FM. Doses of paracetamol were significantly higher among FM+ patients. Also, treatment duration of the current anti-TNF alpha agent was significantly shorter among FM+ patients. Conclusion: Our study showed that fibromyalgia was associated with axial spondyloarthritis in 20% of patients. Its presence was associated with higher disease activity parameters and negative impact on the treatment.

Since Fc-gamma receptors (FcgRs) are involved in the degradation of IgG complexes, we assessed whether a modification in FcgRs' affinity to Fc portion, caused by single nucleotide polymorphisms such as rs1801274-R131H FcgRIIa, rs396991-F158V FcgRIIIa and NA1/NA2-FcgRIIIb, might impact clearance of therapeutic monoclonal antibodies and thus, serum drug levels and the development of anti-drug antibodies.A cross sectional, multicentral and non-interventional study was conducted in Tunisian RA patients treated with rituximab (RTX), etanercept (ETA), infliximab (IFX) and adalimumab (ADL). Serum drug level (SDL) of the different biologics and ADA against them were measured. All patients were genotyped for the three FCGR SNPs.A total of 81 patients were included: 47 were under TNF-inhibitors (18 ETA, 13 ADL and 16 IFX) and 34 were under RTX. Regardless of the type of biotherapy, SDL was in therapeutic range, in 35 patients (43.2%) of whom only one was treated with RTX. Fourteen patients (22.2%) developed ADA but none of the patients treated with ETA had detectable ADA levels. There was no association between SDL positivity and FCGR polymorphisms. However, the high affinity FCGR2A 131 H/H receptor was statistically more prevalent in patients with detectable ADA treated with ADL, IFX and RTX (p=0.018). The same result was obtained in mAb TNFi subgroup (n=29, p=0.022) as well as in patients treated only with IFX (n=16, p=0.029).Our work supports the hypothesis of an impact of FCGR SNPs on biologics' immunogenicity, particularly FCGR R131H polymorphism, but further studies with larger cohorts needs to be undertaken to confirm these results.

We aimed to investigate the relationship between epicardial adipose tissue (EAT) thickness, flow-mediated dilation (FMD), and carotid intima-media thickness (cIMT) in spondyloarthritis (SpA) patients compared to healthy controls.We performed a cross-sectional study including SpA patients aged ≤ 50 years without traditional cardiovascular risk factors and healthy controls matched for age and gender. Baseline characteristics, laboratory data, and SpA-related parameters were recorded. All participants underwent ultrasound examination with measurement of EAT thickness, FMD, and cIMT by both an experienced cardiologist and radiologist blinded to clinical data. The relationships between the ultrasound measurements were analyzed using Spearman's correlation coefficient and Person correlation.The study included 94 subjects (47 SpA and 47 healthy controls). The sex-ratio was 2.35; the median age of patients was 36 years (IQR: 28-46), and the median disease duration was 11 years (IQR: 5-16). Compared to the control group, SpA patients had significantly higher values of EAT thickness (p = 0.001) and cIMT (p 0.0001). FMD values were significantly lower in SpA patients compared to controls (p = 0.008). The univariate analysis detected a significant negative association between EAT thickness and FMD (p = 0.026; r = - 0.325), and between left cIMT and FMD (p = 0.027; r = - 0.322). No association was found between EAT thickness and cIMT.EAT thickness, FMD, and cIMT were significantly impaired in SpA patients compared with healthy controls supporting evidence of accelerated atherosclerosis in SpA. EAT thickness was correlated to endothelial dysfunction suggesting the role of EAT in predicting the early reversible stages of atherosclerosis. Key Points • Spondyloarthritis is associated with impaired subclinical atherosclerosis markers accurately increased epicardial fat and carotid intima-media thickness and endothelial dysfunction. • Increased epicardial fat thickness is correlated with impaired endothelial function in spondyloarthritis patients.

INTRODUCTION: Tumor necrosis factor alpha (TNF alpha) blockers such as infliximab (IFX) and adalimumab (ADA) had significantly changed the course of inflammatory diseases such as rheumatoid arthritis (RA), spondyloarthritis (SpA) and Crohn’s disease (CD). However, about 30% of patients do not respond to these treatments. This lack of response may be due to the formation of antibodies against these drugs (anti-drug antibodies: ADAbs). The aim of this study was to determine the prevalence ADAbs against IFX and ADA, and the trough serum concentration of IFX and ADA in RA, SpA or CD patients and to assess their impact on the therapeutic response. METHODS: A cross sectional, multi-centric study was conducted including patients with RA, SpA or CD treated with IFX or ADA as a first biotherapy for at least 6 months. ADAbs and trough levels were measured by an Enzyme Linked Immunosorbent assay (ELISA). RESULTS: 137 patients were included (37 RA, 53 SpA and 47 CD). ADAbs were positive in 40% of cases for IFX and 25% for ADA. They were positive in 39% of SpA, 35% of RA, and 21% of CD. The presence of ADAbs was inversely correlated to the trough levels of IFX and ADA during RA (p=0.01 and p

Background: The objective of the study was to assess clinical and imaging features of rheumatoid arthritis (RA) associated with interstitial lung disease (ILD), (RA-ILD) group, in comparison to RA without ILD (RA-C) and to identify the associated factors to ILD.Methods: This was a retrospective comparative study (June 2015 to March 2022) including RA patients aged ≥18 years. The RA-C control group was matched according to age (±2 years), gender, and RA duration (±2 years). General data, RA characteristics, ILD features, and treatment modalities were recorded. Statistical analysis was performed to determine the predictive factors of ILD.Results: A total of 104 patients were included (52 RA-ILD and 52 RA-C); sex ratio was 0.36. Mean age was 66.3±11 years (RA-ILD) versus 65.6±10.8 years (RA-C) (p=0.72). In comparison to RA-C, RA-ILD patients were significantly higher smokers (p=0.01) and physically inactive (p=0.01). Regarding RA features, RA-ILD patients have significantly increased positive anti-citrullinated peptide antibody (ACPA) (p=0.01), ACPA rate (p

The objective of the study was to assess clinical and imaging features of rheumatoid arthritis associated with atlantoaxial dislocation (RA-AAD) in comparison to RA without AAD (RA-C) and to identify the associated factors to AAD.This was a retrospective comparative study including RA patients over 18 years old. The control group of RA-C was matched according to age (±2 years), gender, and RA duration (±2 years). General data, RA characteristics, AAD features, and treatment modalities were recorded. Statistical analysis was performed to determine the predictive factors of AAD.A total of 120 patients were included (78 RA-AAD and 42 RA-C); sex-ratio was 0.15. Mean age was 58.55 ± 9.14 years (RA-AAD) versus 60.43 ± 10.78 years (RA-C), (p = 0.31). Regarding RA features, RA-AAD patients have significantly a higher rheumatoid factor (RF) rate (p = 0.002), extra-articular manifestations (p = 0.009) especially osteoporosis (p 10Our results confirmed that predictive factors of AAD were related to higher disease activity and structural damage. These modifiable factors may be prevented by tight control, early treatment, and educating RA patients to improve treatment adherence.

Foot function is usually assessed using self-reported outcome measures which remain subjective in patients with rheumatoid arthritis (RA). Physical performance tests were recommended for functional assessment in lower limb osteoarthritis. However, foot function assessment's guidelines in RA are lacking. We aimed to investigate the correlation between a self-reported outcome measure and two performance-based physical tests for assessing foot function in RA patients.A cross-sectional study was performed over 7 months' period including RA patients. We used Rheumatoid and Arthritis Outcome score (RAOS) as a self-reported functional tool. Physical performance tests were 4-min walk test (4-MWT) and Timed up and go test (TUGT).Fifty RA patients were included with 96% females and a mean age of 54.7 ± 10.4 years. Foot involvement occurred since the diagnosis of RA in 36% of patients. Foot pain was reported by 68% of patients (48% forefoot), and foot stiffness in 46% of patients. Skin lesions of the feet were found in 78% of patients, 90% had foot deformities and 56% had inflammatory disorders of feet. Radiographic lesions were found in 94% of patients. The most impaired RAOS subscales were Sports and Recreation and Quality of life. Poor physical-based performance was found in 34% of RA patients according to 4-MWT, in 42% of RA patients according TUGT, and in 46% of patients based on at least one performance test. RAOS was negatively correlated to the 4-MWT and positively correlated in the subscales pain, other symptoms, activities of daily living, and Sport/Rec of the RAOS. Poor performance-based physical tests were significantly associated with advanced age, sedentary lifestyle, higher disease activity score and impaired functional status. Foot-related parameters significantly associated with poor performance-based physical tests were: foot pain, foot deformity and inflammatory disorders. Multivariate analysis identified foot deformities and higher functional impairment as predictive factors for lower gait speed (4-MWT) and older age and higher functional impairment for higher duration of TUGT.RAOS was significantly associated with performance-based physical function. In the era of connected technologies, these results encourage the regular assessment of rheumatoid foot function by the RAOS score through a connected programme using wearable trackers.

Sarcopenia is a syndrome defined by generalized and progressive loss of skeletal muscle mass, strength, and function. Besides affecting elderly population, it is actually common among inflammatory rheumatic diseases (IRD) patients. We performed a systematic literature review with a meta-analysis to investigate the influence of biologic and target synthetic disease-modifying anti-rheumatic drugs (bDMARDs/tsDMARDs) on sarcopenia in IRD. A systematic search has been performed on Pubmed, Scopus, and Web of science. Studies characteristics were collected. Assessment tools were body composition (total lean mass (TLM) and percentage, appendicular skeletal mass (ASM), fat-free mass and index (FFM and FFMI), skeletal mass index (SMI) and segmental lean mass (SLM)), and muscle strength and physical performance tests. Treatment effect defined the difference in change from baseline to the end of follow-up treatment was divided by the pooled SD of the difference. Twenty-two studies on 778 patients receiving bDMARDs/tsDMARDs and 157 controls were reviewed. They investigated rheumatoid arthritis (RA) (N = 14), spondyloarthritis (SpA) (N = 6), psoriatic arthritis (N = 1), and both RA and SpA (N = 1). tsDMARDs were used in one study with no effect on sarcopenia. Ten studies demonstrated that bDMARDs increased significantly muscle measures in 347 patients (44.6%) with a significant increase in TLM (6/15 studies; 57.4%), FFMI (4/6 studies; 59.9%), ASM (2/5 studies; 17.6%), SMI (2/5 studies; 18.1%), and SLM (2/2 studies; 3.6%). bDMARDs showed also a positive effect on handgrip strength in 1/3 of studies (45.2%) and on physical performance in 1/2 of studies (61%). In 1/5 of comparative studies, IRD patients on bDMARDs showed significantly higher increase of TLM in comparison to controls naïve bDMARDs. Regarding diagnosis, positive effect of bDMARDs was seen in 67.4% in SpA versus 49.3% in RA, with a significant increase of TLM, ASM and FFMI in 59.4%, 100%, and 65.2% in SpA versus 54.9%, 24.1%, and 54.8% in RA, respectively. Meta-analysis assessed the effect of bDMARD on TLM in 10 studies. There was no statistically significant difference [SMD - 0.10 (95% Confidence Interval - 0.26 - 0.06; tau

Gitelman syndrome represents the clinical manifestations of inactivation of the Slc12a3 genes encoding the thiazide-sensitive sodium chloride cotransporter and the Trpm6-Mg genes encoding the magnesium transporters in the distal convoluted tubule. In fact, the biochemical findings resemble those with thiazide diuretics such as hypokalemia, hypomagnesaemia, hypocalciuria, metabolic alkalosis, and low normal blood pressure. He is usually associated with calcium pyrophosphate deposition. Serum uricemia level is rarely affected in Gitelman syndrome. We aimed to report a rare association of chronic gout with Gitelman syndrome, hence the interest of our case. We describe a 29-year-old male patient with a history of Gitelman syndrome associated with articular gout including pelvic localization. We provided pictorial evidence of extensive and diffuse monosodium urate deposition in articular and periarticular structures to confirm the gout origin. A literature review illustrates 4 reported cases of Gitelman syndrome associated with gout. The gender distribution was equal with a mean age of 40 years.

Objectives: The aim of this study was to evaluate the prevalence of neuropathic pain components of knee osteoarthritis (OA) patients and to identify the relation between associated neuropathic pain and comorbidities, pain intensity, function, and radiographic severity of knee OA. Methods: This cross-sectional study enrolled patients with knee OA (ACR criteria 1986). Visual Analog Scale (VAS), DN4 questionnaires were performed for each patient. A score of DN4≥4/10 was classified as diagnostic for neuropathic pain. Functional impairment was estimated using the short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-PS) ad radiographs were rated using the Kellgren Lawrence (KL). Results: We recruited 101 patients with a sex ratio was 0.1. The mean age was 65.5±10.8 years [41-95]. The mean duration of symptoms was 3.5 years. At least one comorbidity was revealed for 88.1% of patients. Mean VAS pain was 6.5±1.69. The mean DN4 score was 4.8± 2.4. The prevalence of NP (DN4≥4) was detected in 68.3%. The most frequently described NP characteristic was the sensation of burning (74%). The mean KOOS-PS score was 46.4±19.2. Based on KL grading, 78.2% of OA were classified grade III-IV. Female gender, number of comorbidities, bilateral knee OA, mean VAS pain, and mean KOOS-PS score were significantly higher in the neuropathic pain group when compared to the group without neuropathic (respectively: p=0.01,p=0.04, p=0.017, p=0.00, p=0.00). In multivariate regression, KOOS-PS and bilateral knee OA were independently associated with NP. Conclusion: Our results highlight the frequent NP in patients with knee OA (68.3%) and its relation with function and comorbidities.

Introduction: There is a growing interest in the role of epicardial adipose tissue (EAT) as a novel marker of subclinical coronary atherosclerosis. We aimed to assess EAT thickness in spondyloarthritis (SpA) patients compared with healthy controls and to identify its predictive factors.Methods: This was a cross-sectional study including SpA patients and age and gender-matched healthy volunteers without traditional cardiovascular risk factors. General and biological data were obtained for all participants. Disease characteristics and therapeutic modalities were recorded at the time of inclusion. Both patients and control groups underwent echocardiography with measurement of EAT thickness. Results: A total of 47 SpA patients and 47 healthy controls were included, with a median age of 36 years and a sex-ratio of 2.35.Ultrasound EAT thickness was significantly increased in SpA patients compared with healthy controls (median value of 3.1 mm versus 2.4 mm; p=0.001). EAT thickness was positively correlated with patient-related parameters (age, systolic blood pressure, triglyceride level). Regarding disease-related characteristics, EAT thickness was positively correlated to age at onset of SpA and negatively correlated to chest expansion. Moreover, EAT thickness was significantly associated with radiographic structural damage (syndesmophytes, bony bridging, facet joint arthritis, and mSASSS score). In multivariate linear regression, age at onset of SpA, triglyceride level, and mSASSS were identified as the independent predictive factors of increased EAT thickness in SpA.Conclusion: SpA patients exhibited significantly more subclinical coronary atherosclerosis than controls. EAT thickness was independently associated with mSASSS score supporting the role of the inflammatory process in cardiovascular risk.

Bone involvement in sarcoidosis is rare; its estimated prevalence ranges between 3 and 13%. Osseous lesions usually occur in the phalanges of the hands and feet. Involvement of the axial skeleton is more uncommon. Osseous involvement may be asymptomatic. It is often incidentally discovered on imaging modalities. Radiological techniques can reveal sclerotic and/or destructive lesions. We present a case of a 61-year-old woman in whom osseous sarcoidosis of the sacrum was revealed by back pain and sciatica. To our knowledge, only one isolated case of sacral sarcoidosis has been reported in the literature. Sarcoid bone lesions can be present at disease onset without pulmonary involvement. A biopsy is often required in order to eliminate other conditions, especially malignancy. Treatment is not specific and also not needed in a significant number of cases.

Knee osteoarthritis (OA) is a common osteoarticular disease. Its prevalence increases with age, as well as the coexistence of other chronic diseases. Recent research has revealed an association between OA and cardiovascular diseases. However, the association between knee OA and comorbidities has not been fully studied. Therefore, the purpose of this study was to investigate the association between knee OA and comorbidities. In this cross-sectional study, patients with knee OA were enrolled. Sociodemographic data, as well as comorbidities, were collected. Grading of knee OA was performed using the Kellgren-Lawrence (KL) grading system. The functional impact of knee OA was assessed by KOOS-Physical Function Shortform (KOOS-PS). This study assessed 104 patients with knee OA (10 men and 94 women). The mean age was 65.83±11.08 years. Mean VAS pain was 6.56±1.72. Mean KOOS-PS was 15.58±6.73. Up to 81 patients (77.9%) had severe knee OA, according to the KL grading system. Comorbidity was noted in 92 cases (88%). The most frequent comorbidities were obesity (62.5%), hypertension (61.5%), and dyslipidemia (43.3%). Comorbidities in knee OA were associated with age (P=0.04), axial deviation in the sagittal plane (P=0.01), neuropathic pain component (P=0.02), and VAS pain (P=0.04). Our study also showed a significant correlation between comorbidities and structural grading of knee OA (P=0.04). However, comorbidities were not correlated with the KOOS-PS score (P=0.06). The accumulation of comorbidities is significantly associated with higher intensity scores in knee OA. Physicians should additionally pay close attention to the prevention and treatment of comorbidities in the routine management of OA.

Calcium-pyrophosphate-dihydrate-disease (CPPD) is a crystal-induced arthropathy. The lumbar-spinal involvement is rare and often under-diagnosed. This study aimed to report the case of a lumbar spine CPPD involvement and to perform a systematic review of clinical, imaging features of lumbar involvement in CPPD patients, and treatments that have been implemented.This systematic review was conducted in accordance with the Preferred-Reporting-Items-for-Systematic-Reviews and Meta-Analyses (PRISMA) guidelines.One hundred and sixty-seven articles met the search criteria using electronic databases searches. We retained 28 articles (20 case reports, 2 case series, 1 family survey, 4 retrospective studies, and 1 prospective study) involving a total of 62 patients. The age ranged between 39 and 89 years old. Among patients with lumbar spine CPPD, 32 were women. The duration of symptoms varied between one day and 8 years. The affection has been discovered during back pain in most cases. In 5 studies, the diagnosis was made on histological specimens of patients operated on for another pathology. X-ray showed calcifications in 2 cases. CT-scan detected calcium deposit in 7 cases. MRI showed lesions going from the increased signal of the disk, to calcified or not-cystic lesion of the facet joints, an intramedullary mass mimicking a schwannoma. Histological examination established the diagnosis of CPPD in 21 patients in all studies. Medical treatment included NSAIDs, Colchicine, Interleukin-1-receptor-antagonist, and antibiotics. Surgery was performed on 13 patients and allowed to establish the histological diagnosis.In the case of inflammatory back pain in elderly subjects, without an infectious gateway, diagnosis of CPPD should be considered, especially for patients with a history of spinal surgery or degenerative radiography changes. CT scan is more sensitive than conventional radiographs. The discovertebral biopsy is the Gold-Standard and should be performed whenever the diagnosis was uncertain. Treatment includes the medical and surgical components.

BackgroundThe aim of our study was to assess subclinical atherosclerosis in spondyloarthritis (SpA) by combining three ultrasound methods (flow-mediated dilation (FMD), carotid intima–media thickness (cIMT) and Ankle Brachial Index (ABI)) and to determine the predictive factors of theses parameters.MethodsThis was a case control study conducted over 12 months including 47 patients with SpA-free-cardiovascular (CV) disease in comparison with age and sex matched 47 healthy controls. Sociodemographic, clinical and biological features as well as therapeutic modalities were recorded in our patients. All subjects had Doppler ultrasound with measurement of cIMT, FMD and ABI. Ultrasound measurements were compared between patients and controls. Linear regression was performed and assessed by machine learning to determine the predictive models of markers of subclinical atherosclerosis.ResultsWe found higher cIMT (pConclusionOur study supported the accelerated subclinical atherosclerosis in patients with SpA. This subclinical atherosclerosis was mainly mediated by traditional CV risk factors.

The aim of this study was to evaluate the variation of homocysteine (Hcy) levels in patients with rheumatoid arthritis (RA) and to analyze the relationship to inflammatory parameters, cardiovascular risk, and methotrexate (MTX).This cross-sectional study assessed disease activity and treatment in RA patients. The European League Against Rheumatism (EULAR) 2015 HeartSCORE was performed for cardiovascular (CV) risk estimation and levels of plasma Hcy, serum folate concentrations, vitamin B12, and erythrocyte sedimentation rate (ESR) were measured.A total of 103 participants with mean age 53 ± 10 years and mean disease duration 10.55 ± 7.34 years were included. Patients were treated with MTX in 69.9% of cases and corticosteroid in 80.5% of cases. Of all patients, 13% had a cardiovascular inheritance, 25% were hypertensive, and 18% had diabetes. The EULAR 2015 HeartSCORE was high and very high (≥5%) in 35% of cases. Mean Hcy level was 12.54 ± 4.2 µmol/L [6.89-32.92] and hyperhomocysteinemia was noted in 20.4% of patients. Analytic study demonstrated that hyperhomocysteinemia was associated with male gender (p = 0.01), MTX use (p = 0.01), smoking (p = 0.008), renal failure (p = 0.04), and high disease activity (p = 0.05), but there was no association with the HeartSCORE (p = 0.23). Hcy level was negatively correlated with folate (p = 0.009) and vitamin B12 level (p = 0.02) and positively with age (p = 0.01), C‑reactive protein (CRP; p = 0.05), and Simplified Disease Activity Index (SDAI; p = 0.03). In multivariate logistic regression analysis, current MTX use, levels of vitamin B12 and creatine, and Clinical Disease Activity Index (CDAI) appeared to be independent factors associated with hyperhomocysteinemia.MTX use, CDAI, and the levels of vitamin B12 and creatine are independent factors associated with hyperhomocysteinemia.HINTERGRUND: Ziel der vorliegenden Studie war es, Unterschiede in den Werten für Homocystein (Hcy) bei Patienten mit rheumatoider Arthritis (RA) und den Zusammenhang mit Entzündungsparametern, Herz-Kreislauf-Risiko und Methotrexat (MTX) zu untersuchen.In dieser Querschnittstudie wurden Krankheitsaktivität und Therapie von RA-Patienten analysiert. Zur Abschätzung des kardiovaskulären Risikos wurde The European League Against Rheumatism (EULAR) 2015 HeartSCORE eingesetzt und die Werte für Plasma-Hcy, Folsäurekonzentration im Serum, Vitamin B12 und Blutsenkungsgeschwindigkeit (BSG) bestimmt.Es wurden 103 Teilnehmer mit einem mittleren Alter von 53 ± 10 Jahren und einer mittleren Krankheitsdauer von 10,55 ± 7,34 Jahren in die Studie einbezogen. In 69,9% der Fälle wurden die Patienten mit MTX und in 80,5% mit Kortikosteroiden behandelt. Bei 13% der Patienten bestanden familiär kardiovaskuläre Erkrankungen, bei 25% Hypertonie und bei 18% Diabetes mellitus. In 35% der Fälle war der EULAR 2015 HeartSCORE hoch oder sehr hoch (5%). Im Mittel betrug der Hcy-Wert 12,54 ± 4,2 µmol/l [6,89–32,92], und eine Hyperhomocysteinämie lag bei 20,4% der Patienten vor. Die Auswertung ergab, dass eine Hyperhomocysteinämie mit männlichem Geschlecht (p = 0,01), MTX-Therapie (p = 0,01), Rauchen (p = 0,008), Niereninsuffizienz (p = 0,04) und hoher Krankheitsaktivität (p = 0,05) assoziiert war, aber es gab keinen Zusammenhang mit dem HeartSCORE (p = 0,23). Der Hcy-Wert war negativ mit den Werten für Folsäure (p = 0,009) und Vitamin B12 (p = 0,02) korreliert und positiv mit dem Alter (p = 0,01), C‑reaktivem Protein (CRP; p = 0,05) und dem Simplified Disease Activity Index (SDAI; p = 0,03). In der multivariaten logistischen Regressionsanalyse schienen eine derzeitige MTX-Therapie, Werte für Vitamin B12 und Kreatin sowie der Clinical Disease Activity Index (CDAI) unabhängige Faktoren zu sein, die mit Hyperhomocysteinämie assoziiert waren.MTX-Therapie, CDAI und die Werte für Vitamin B12 und Kreatin sind unabhängige, mit Hyperhomocysteinämie assoziierte Faktoren.

Axial spondyloarthritis (SpA) is a common inflammatory arthritis characterized by axial skeletal inflammation, enthesitis, and association with HLA-B27. Pro-inflammatory cytokines play important roles in the regulation of inflammatory response and seem to be good candidates involved in the development of this pathology.To assess the influence of the functional polymorphisms of single nucleotide polymorphims (SNPs) of IL-1 and IL-1 Ra in SpA susceptibility Tunisian patients.One hundred and one patients and 100 ethnic-matched healthy controls were genotyped. Susceptibility to SpA was showed with SNP's: C/T of IL-1α (-889) (p=0.0001) and 1/1 of IL-1Ra (p10-3). Analysis of SpA patients according to clinical behavior of the disease reveled the influence of these polymorphisms in SpA course. Indeed, individuals carrying the allele T (+3954) of IL-1β and allele 1 of IL-1Ra had an increased risk of peripheral arthritis (p=0.047, p=0.05, respectively). Also the 1/1 genotype of IL-1Ra was significantly decreased in SpA patients having an active disease (BASDAI4) (p=0.033).Genetic polymorphisms of pro-inflammatory IL-1/IL-1Ra cytokines seem to be involved in susceptibility and clinical course of SpA in Tunisian patients.

Objectives To evaluate the serum dosage of the biomedicine (DBM) and the incidence of antidrug antibody (ADA) against antitumor necrosis factor (TNF) in spondyloarthritis, and to demonstrate the influence of these parameters on the clinical efficiency. Methods We conducted a cross-sectional multicentric study including patients with spondylarthritis (SpA) under antiTNF (infliximab [INF], etanercept [ETA] and adalimumab [ADL]) for at least 6 months. A dosage of the ADA and DBM were practiced by the immuno-enzymatic essay. Result Seventy one patients were recruited. Disease modifying antirheumatic drugs (DMARDs) were associated with anti-TNF in 30%. ADA was positive in 54% for INF, 33% for ADL and 0% for ETA with a significant difference(p Conclusion The ADA formation lowered the DBM and favored the therapeutic failure.

The shoulder may be affected in a large portion of patients with rheumatoid arthritis (RA) worldwide. However, this joint does not receive the attention required during follow-up. Indeed, although numerous clinical tests for diagnosis of a painful shoulder are available, differentiating articular from peri-articular lesions may be difficult in daily practice. Fortunately, the precise diagnosis of shoulder pain in RA has benefited from a reliable imaging modality used to detect its exact origin—ultrasonography (US). This study was aimed at assessing the intra- and inter-observer reliability of ultrasonographic findings for patients with established RA with shoulder pain in a patient-based exercise as a clinical challenge among Maghrebian rheumatologist experts in US. A total of 7 operators examined 10 patients in two rounds independently and blindly of each other. Before beginning the session, all of the rheumatologists reached a consensus on sites and US settings by performing a brief exercise on a normal shoulder. Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions of US-detected pathologies were used. Each patient underwent US scanning of the painful shoulder in predefined sites based on US technical guidelines of the European Society of Musculoskeletal Radiology: long head of biceps (LHB), subscapularis recess, posterior recess and axillary recess. The presence of subdeltoid or subcoracoid bursitis or full rupture of the suprasupinatus was identified if present. Intra- and inter-observer reliability measures were calculated using the κ coefficient. Intra-observer reliability was good for gray-scale (GS) synovitis in subscapularis and posterior recesses (κ = 0.77 and 0.73, respectively). It was moderate in the presence of GS synovitis and effusion in LHB (κ =0.53 and 0.40, respectively), posterior and subscapularis recess effusion (κ = 0.56 and 0.60, respectively) and GS and power Doppler (PD) synovitis in axillary recesses (κ = 0.58 and 0.49, respectively). Inter-observer reliability was good for PD for LHB signals (κ = 0.78). It was moderate for GS for LHB synovitis (κ = 0.54). Inter-observer agreement was poor for effusion and GS synovitis for subscapularis, posterior and axillary recesses, and very poor for PD signals in these recesses. US was a reliable imaging tool for detecting tenosynovitis in the LHB. However, reliability was moderate to poor in detecting synovitis in subscapularis, posterior and axillary recesses. These findings could be optimized by standardization of sites to assess.

Summary Objectives The screening of latent tuberculosis infection (LTBI) is necessary to prevent infection in patients with chronic inflammatory disease (CID) undergoing biological treatment. We aimed to assess the efficacy of LTBI screening prior to biological treatment in Tunisia, considered as a high-incidence area of active TB disease. Methods We conducted a retrospective study over a period of 8 years [2007–2014] including patients with chronic inflammatory rheumatism receiving biologic agents since at least 6 months. The screening of LTBI was performed according to national Tunisian guidelines. Results There were 35 men and 78 women. The mean age was 47.67 ± 13.50 years. Rheumatoid arthritis (70.8%) was the most common cause of CID. The diagnosis of LTBI was established in 23 cases. Among these 23 patients, 12 patients had negative tuberculin skin test (TST) associated with positive QuantiFERON-TB Gold (QFT-G), 10 had TST more than 10 mm, one patient had a TST between 5 and 10 mm associated with positive QFT-G and one patient had a history of tuberculosis inadequately treated. Preventive anti-tuberculous therapy was prescribed before biological therapy initiation in cases of LTBI. During the follow-up period (3.91 years), no case of tuberculosis reactivation has been reported among patients diagnosed with LTBI. However, 2 cases of active pulmonary tuberculosis were reported in patients with initially negative TST and QFT-G. Conclusion Our study showed that the Tunisian recommendations allowed detecting a LTBI in 20% of biologic therapy candidates. Preventive measures including screening of LTBI and eventually a prophylactic treatment improve the safety of biological treatments.

Background: Liver involvement is not considered a typical extra-articular manifestation and has rarely been studied in rheumatoid arthritis (RA). : We aimed to identify the prevalence and aetiologies of liver disease in RA patients. Methods: A cross-sectional study included 150 patients with RA enrolled over 5 years (2010- 2015). The clinical and paraclinical features of RA were analyzed. The clinical and biological characteristics of liver impairment and its aetiologies were collected. Results: One hundred and fifty RA patients (124 women) with a mean age of 57.09 years and a mean RA duration of 7.52 years were included. Liver involvement was diagnosed in 66 patients (44%). The liver disease was asymptomatic in 94% of the cases, revealed by increased gammaglutamyl transferase levels in 74% of the patients. The aetiologies of liver involvement were hepatotoxicity of medications in 38 cases (57%), hepatitis B and C in 14 patients (21%), fatty liver disease in 10 cases (15%), autoimmune liver disease in 2 patients (3%), hydatid cyst in 1 case (2%), and liver angiomas in 1 case (2%). Non-steroidal anti-inflammatory drugs and methotrexate were the drugs most often involved in the genesis of hepatotoxicity (21% and 20% of the cases, respectively). Conclusion: Liver involvement occurred in 44% of RA patients. Aetiologies were mainly hepatotoxicity and viral hepatitis B and C. Patients with RA should be systematically screened for liver disease, which is rarely symptomatic.

Background: Infectious spondylitis is an infectious disease of the spine or paraspinal structures that can be caused by various microorganisms. Without adequate chemotherapy, the outcome can be fatal or result in severe neurologic damage. Therefore, differentiating the etiology of spondylitis is very important. Objectives: To compare the clinical features, laboratory and radiological aspects, treatment and outcome data of patients diagnosed as brucellar spondylitis (BSP) and pyogenic spondylitis (PSP). Methods: Retrospective study including 45 (22 BSP and 23 PSP) spondylodiscitis hospitalized in our department between 1999 and 2019. The diagnosis was based on clinical, biological, radiological and bacteriological data. Results: The patients’ mean age was 54 years. There were 31 men (68.8%) and 14 women (31.2%). There was no difference in mean age and sex between the two groups (p=0.8 and p=0.4; respectively). The pyogenic group had a relatively higher proportion of Predisposing factors especially diabeties (p=0.04). PSD patients suffered an impaired general condition more frequently than BSD patients (p=0.01) while BSD patients complained of night sweats more frequently compared to PSD cases (p=0.026). The peak CRP value was higher in the pyogenic group than in the brucella group (87 mg/L and 37 mg/L, respectively, p=0.027), whereas the ESR was not significantly different between the groups (71 mm/h and 67 mm/h, respectively, p=0.7). We found no statistically significant difference regarding the seat of the spondylitis. Whereas, multifocal involvement was higher in PSD (p=0.049). Radiologically, the frequency of prevertebral, paravertebral, epidural, and psoas abscess formations and spinal cord compression was similar in both groups (p=0.8) Surgical interventions and percutaneous sampling and/or abscess drainage were applied more frequently in PSD but with no significant difference (p Conclusion: The clinical and radiological manifestations of spontaneous spondylitis differ based on the causative organism. Pyogenic spondylitis patients tend to have a more severe clinical course and a higher CRP level. However, there was no significant difference regarding the presence of abscess and epiduritis or the occurrence of complications between brucella and pyogenic spondilitis. Disclosure of Interests: None declared

Background Early microbiological diagnosis and multidisciplinary management are the main predictive factor for successful treatment in septic spondylitis. However, the therapeutic management of spondylodiscitis without bacteriological diagnosis is not well codified. Objectives To evaluate whether there is clinical, biological or significant imaging between patients with infectious sondylodiscitis as they had or not a microbiological diagnosis. Methods Retrospective study including 107 patients hospitalized in our department between 1999 and 2018. The diagnosis was based on clinical, biological, radiological and bacteriological data. Results This study involved 107 patients, including 58 men (54.2%) and 49 women (45.8%) with a mean age of 55 years [16–86]. Spinal pain was observed in all cases and the lumbar spine was most affected (54.2%). A neurological deficit was noted in 16.82% of cases. The inflammatory syndrome was present in 90.6% of cases. Radiographs of the spine were abnormal in 83.1% of cases. CT and Spinal MRI were performed respectively in 60% and 78.8% of cases. Disco vertebral biopsy was performed in 73 patients and was contributory in 46.5% of cases. We divided patients into two groups: patients with a confirmed biological diagnosis (group 1: 45.3%) versus patients in whom the diagnosis had been held on presumptive criteria (group2: 54.2%). There was no statically significant difference in the age (p=0.5), sex (p=0.3), risk factors such as diabetes (p=0.8), the start mode (p= 0.4), the presence of an impaired general condition (p=0.3), night sweats (p=0.1) and a neurological deficit (p=0.8), biological parameters (p=0.3) and the occurrence of complications (p=0.09) between the two groups. Vertebral condensation in radiographs of the spine was higher in group 2 and this was statically significant (p=0.03). In addition, the consumption of unpasteurized milk and positivity of wright serology was higher in the first group (p= 0.001 and p Conclusion Diagnosing infectious spondylodiscitis is facilitated by improved access to MRI testing. However, microbiological diagnosis is the main key to a successful management of this life threatening infection. Disclosure of Interests: None declared

Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by polyarticular synovial inflammation and progressive joint destruction. Orthopedic surgery is an integral part of the treatment of RA and it is mainly reserved for severe and advanced forms where there is a failure of medical treatment. Objectives: To assess the rate of joint surgery in rheumatoid arthritis (RA) Tunisian patients and to determine the risk factors of surgical treatment Methods: A retrospective cross sectional study over a period of 15 years including 500 Tunisian patients with RA was conducted. The prevalence of joint surgery indication has been evaluated. Clinical, paraclinical and therapeutic characteristics of RA were compared according to the need of surgical treatment Results: Mean age was 53.4 years. Female to male ratio was 5. The indication of joint surgery was noted in 59 patients (12%). Factors associated with joint surgery were delayed diagnosis (p = 0.037), long RA duration (p = 0.017), young onset of RA (p Conclusion: Twelve percent of RA patients needed joint surgery treatment. Predictive factors of surgical treatment were young age at disease onset, high ESR level and association of methotreaxte with other csDMARDs References [1] Waljee J, Zhong L, Baser O, Yuce H, Fox DA, Chung KC. The incidence of upper and lower extremity surgery for rheumatoid arthritis among medicare beneficiaries. J Bone Joint Surg Am. 2015;97(5):403-10. [2] Kapetanovic MC, Lindqvist E, Saxne T, Eberhardt K. Orthopaedic surgery in patients with rheumatoid arthritis over 20 years: prevalence and predictive factors of large joint replacement. Ann Rheum Dis. 2008;67(10):1412-6. Disclosure of Interests: None declared

Background Spondylodiscitis is a potentially life-threatening infection burdened by high morbidity rates. MRI remains the key examination in the diagnosis of infectious spondylodiscitis. The microbiological diagnosis is the main predictive factor for successful treatment. Objectives To evaluate the MRI characteristics associated with the detection of microbial pathogens by computed tomography (CT) guided biopsy in case of suspicion of infectious spondylodiscitis. Methods Retrospective study including all patients hospitalized in our department between 1999 and 2019 and who underwent MRI and CT-guided biopsy for suspicion of septic spondylodiscitis.The diagnosis was based on clinical, biological, radiological and bacteriological data. We divided the patients into two groups: patients with a non-contributory CT guided biopsy (group 1) and patients with a contributory biopsy (Group 2). Results We included 82 patients including 37 women and 45 men with a mean age of 56 years old [16 - 86]. The median delay of consultation was 3 months. Inflammatory back pain was reported in 78% of cases. Neurologic deficiency was noticed in 19.5% of cases. The lumbar spine was involved more than 50% of cases. Spinal MRI was performed to all patients and showed paravertebral abscess in 64.6%, epiduritis in 62.1%,intra-discal abscess in 3.6%, spinal cord compression 10.9%, and vertebral ostelysis in 6.09% of cases.The causative microorganism was mycobacterium tuberculosis in 53.6%, brucella in 24.3%, and pyogenic germs in 15.8% of cases. Disco vertebral biopsy was performed in 55 patients and was contributory in 45.4% of cases. The presence of spinal cord compression, intra-discal abscess and vertebral osteolysis was more frequent in group 2, but with no statistically significant difference (p = 0.65, 1 and 0.58; respectively). In addition, there was no significant difference in the presence of paravertebral abscess and epiduritis (p = 0.41 and 0.53; respectively). Conclusion Spondylodiscitis is an emergency which must be diagnosed on time to avoid life threatening complications, neurological sequelae and spinal deformities. Disclosure of Interests None declared

Background: Tunisia is considered as a country with high tuberculosis endemicity. The anti-tuberculous treatment is quite long and binding and requires close hepatic monitoring. Objectives: The purpose of this study was to highlight the hepatitic safety of anti-tuberculous treatment in tuberculous spondylodiscitis. Methods: This is a retrospective descriptive study, over 20 years (1999-2019) collating cases of tuberculous spondylodiscitis in a rheumatology department. We studied the epidemiological, clinical, radiological and therapeutic aspects. Results: Our study included 62 patients, 35 women and 27 men. Mean age was 56 years [16-86]. The diagnosis delay averaged 5.59 months [0.23-24]. Tuberculous contact was noted in 11.3% of the cases. Neurological abnormalities were noted in 16,1% of cases with spine compression in 3,22%. The tuberculin skin test was positive in 29 cases and the Koch bacillus investigations in the sputum and the urine were positive in only 3 patients. Magnetic resonance imaging was performed in 71% of the patients, and mainly showed images of disc destruction with images of abscess, epiduritis and epidural extension. Infectious spondylodiscitis affected the lumbar spine in 66.1% of the cases, the dorsal spine in 14.51% of the cases and the cervical spine in 6.55% of the cases. It was bi-staged in 19.35% of the cases and bifocal in 17.74% of the cases. Disco-vertebral biopsy was performed for 72.5% of patients and helped to make the diagnosis in 33.87% of the cases. All patients have received anti-tuberculosis treatment based on rifampicin, pyrazinamide, ethambutol and Isoniazid for an average duration of 2.8 months. Following the initial 4-drug regimen, most patients continued to receive a two-drug regimen with RMP and INH for a mean duration of nine months. Hepatotoxicity was seen in 13% : 11.4% of the patients had a history of cholestasis due to TB treatment, Only 2% of the patients had cytolysis. We nedded then to modify the treatment in 3,22%, and switch to triple anti-TB therapy based on Isoniazid, Rifampicin and ethambutol with a favorable evolution. No cases of hepatic insufficiency were noted. Conclusion: In our study, we note 8 cases of hepatotoxicity. The diagnosis of tuberculous spondylodiscitis requires urgent treatment with anti-tuberculosis antibiotics. However, it should be kept in mind that this treatment can lead to severe and life-threatening hepatotoxicity. Thus a rigorous monitoring of the treatment will be required. Disclosure of Interests: None declared

Background Fc gamma receptors (FcgR) type IIA IIIA and IIIB play an important role in the recognition of immune complexes (ICs) by binding their Ig-Fc portion. However, it has been demonstrated that FcgR single nucleotide polymorphisms (SNP) leads to low binding affinity alleles (FcgRIIA-131R, IIIA-158V and IIIB NA2). Therefore, we can make an assumption that the presence of these risk alleles could influence the outcome of immune mediated disease such as rheumatoid arthritis (RA). Objectives The aim of this study was to assess the relationship between functional SNP of FcgR IIA H13R, IIIA V158F and IIIB NA1/NA2 and disease severity scores in RA. Methods We assessed disease severity in RA patients based on the Health Assessment Questionnaire (HAQ) and Sharp/van der Heijde (mSharp) method. To reduce selection biais, all recruited patients were treated with conventional DMARDs.We considered patients with HAQ score ranged from 2 to 3 as having severe disability. For radiographic evaluation, since there is not validated threshold for joint damage severity, we took mSharp score median value of our population as a reference. Patients underwent FcgRIIA, FcgRIIIA and FcgRIIIB SNP study using PCR-SSP and direct sequencing process. Then, biallelic polymorphisms were examined for association with HAQ and mSharp score. Results Fifty-eight RA patients were enrolled. The mean duration of the disease was 11.77 years [0.5-24]. Among these patients, 34 (58.62%) had severe disability according to HAQ score. The mSharp median value was 43,5 [0-232] and 28 (48.28%) patients had a score above this value. Genotypic study showed that FcgR IIIB-NA2 was significantly associated with severe disability (p=0.021) (Table 1). Furthermore, FcgRIIIA-158F and IIA-131R carriers were more frequent in patients with severe disability but the association was not statistically significant. Finally, no correlation was found between radiographic evaluation and FcgR SNP study (table 2). Conclusion FcgR low affinity alleles seem to confer susceptibility to severe functional impairment in RA but not to structural damage. However further studies on larger population must be done to corroborate these findings. References [1] Brun JG, Madland TM, Vedeler CA. Immunoglobulin G Fc-receptor (FcgammaR) IIA, IIIA, and IIIB polymorphisms related to disease severity in rheumatoid arthritis. J Rheumatol. 2002;29:1135–40. [2] Kastbom A, Ahmadi A, Soderkvist P, Skogh T. The 158V polymorphism of Fc gamma receptor type IIIA in early rheumatoid arthritis: increased susceptibility and severity in male patients (the Swedish TIRA project) Rheumatology (Oxford)2005;44:1294–8. [3] Lee YH, Bae SC, Song GG. FCGR2A, FCGR3A, FCGR3B polymorphisms and susceptibility to rheumatoid arthritis: a meta-analysis.Clin Exp Rheumatol. 2015 Sep-Oct; 33 (5):647-54. Disclosure of Interests None declared

Background Rheumatoid arthritis (RA) is a common inflammatory disease developing within joints but extra-articular organs such as the lung could be involved. Objectives To determine the relationship between disease activity and lung involvement in rheumatoid arthritis (RA) Tunisian patients. Methods We performed a retrospective study of patients with RA diagnosed according to American College of Rheumatology-European League Against Rheumatism classification criteria for RA 2010 between 2014 and 2017 in a department of rheumatology in the north of Tunisia. The prevalence of pulmonary involvement was determined based on combined results from chest-X-ray, computed tomography of the chest and pulmonary functional tests. Disease activity was evaluated based on number of night waking, morning stiffness duration, painful joints number and swelling joints number, erythrocytes sedimentation rate (ESR) and C-reactive protein levels (CRP). Specific disease activity scores were also noted including the 28-joint Disease Activity Score Index (DAS28), Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI). Results Sixty five patients were collected. Mean age was 56 years ± 12.8 years and mean age of disease onset was 46.4 ± 13.8 years ranging from 17 to 75 years. Mean disease duration was 9.6 ±10.1 year ranging from 1 to 38 years. Number of painful joints was 13.71 at mean and swelling joints number was 5.98. Morning stiffness duration was 1.03 hour at mean and number of night waking was 2.31. Concerning laboratory investigations, mean ESR was 49.7 mm ant mean CRP level was 13.6 mg/l. The average of DAS28 was 5.8. The overall frequency of lung involvement based on different lung investigations was 27.6% (18 patients). Interstitial lung disease was found in 7 cases, bronchiectasis was found in 5 cases, rheumatoid nodule in 4 cases and pleural disease in 2 cases. Patients with lung involvement had significantly higher painful joints number (p=0,034) and no difference was seen concerning swelling joints number. Number of night waking and morning stiffness duration had no impact in lung involvement (p=0,651, p=0,907 respectively). RA patients with lung involvement displayed higher ESR level (p=0,032) and no difference was seen concerning CRP level. No association was found between lung involvement and specific disease activity scores (DAS28, CDAI, SDAI). Conclusion Our study showed that only high level of ESR could be associated with lung involvement in RA Tunisian patients. References [1] Perez-Doramea R, Mejiaa M, Mateos-Toledoa H,Rojas-Serranob J.Rheumatoid arthritis-associated interstitial lung disease: Lung inflammation evaluated with high resolution computed tomography scan is correlated to rheumatoid arthritis disease activity. Clin Rheumatol. 2015;11(1):12-6. [2] Jearn LH, Kim TY. Level of anticitrullinated peptide/protein antibody is not associated with lung diseases in rheumatoid arthritis. J Rheumatol 2012;39:1493-4.2] Jearn LH, Kim TY. Level of anticitrullinated peptide/protein antibody is not associated with lung diseases in rheumatoid arthritis. J Rheumatol 2012;39:1493-4. Disclosure of Interests None declared

Background Hepatic disease in rheumatoid arthritis (RA) are rare, but can be impactful for patients. Though some hepatic manifestations are directly related to RA, whereas others may be sequelae of treatment or caused by concomitant autoimmune diseases. Objectives We have tried through this study to focus on the liver disorders during the monitoring of rheumatoid arthritis and to identify the different etiologies. Methods This is a retrospective descriptive study of patients with rheumatoid arthritis (ACR-EULAR 2010 criteria) followed a rheumatology department between 2012 and 2018 with liver function disorder. We have specified the epidemiological, clinical, biological and therapeutic characteristics and the different explorations carried out for these patients. Results We included 61 patients in our study (3 men and 58 women). Mean age was 52.13 years [26-82]. Average duration of RA was 9.2 years [0.5-30]. Mean DAS28 was 5.95 [3-8.33]. RA was immunopositive in 88,5% of the cases and erosive in 93,44% of the cases. Most of patients received symptomatic treatment (98% paracetamol, 87% non-steroidal anti-inflammatory drugs, 84% corticosteroids).As for conventional csDMARD, 72% of patients were treated with methotrexate, 8.2% with anti-malarial, 22.95% with salazopyrine and 11.47% with leflunomide. Three patients received biologic DMARDs (1 rituximab and 2 TNF-Blockers). Hepatic disorders were:cholestasis (95%), cytolysis (33%) and concomitant cytolysis and cholestasis (28%). The etiological investigation undertaken linked these disorders of the liver function disorders to the RA treatment in 50% of the cases.Methotrexate was incriminated in the genesis of this liver enzyme abnormalities in 14 cases, the salazopyrine in 2 cases, the leflunomide in 1 case, paracetamol and nonsteroidal anti-inflammatory drugs in 11 cases and rituximab in 1 case. Hepatic immunological investigation was negative in all cases. We have not noted any hepatitis B seroconversion. Two patients had hepatitis C. One patient presented active hepatitis C serology with signs of fibrosis (A2F2) at the liver biopsy puncture. Abdominal ultrasound showed signs of non-alcoholic fatty liver disease in 34.42% of cases. The biopsy puncture of the liver was performed in 9 patients showing chronic hepatitis lesions (n=1), hepatic atrophy (n=1), steatosis with portal and peri-sinus fibrosis (n=1). The etiological investigation was negative in 10% of cases. Conclusion In our study, the liver function disorders during RA are in half of the cases of iatrogenic origin. This requires rigorous monitoring of patients followed for RA in order to improve their management. Disclosure of Interests None declared

Background: Spinal tuberculosis or Pott’s disease is one of the many manifestations of active tuberculosis and is still common in Mediterranean countries such as Tunisia with high endemicity. Definitive diagnosis of tuberculous spondylodiscitis requires the identification of Mycobacterium tuberculosis. Objectives: We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis. Methods: Retrospective study including 64 patients followed up in our department between 1999 and 2019. Clinical, biological and radiological data were collected. Therapeutic outcome was studied. Results: We studied 64 patients included 35 women and 17 men with a mean age of 56 years old [16 - 86]. Seven patients had a contact with Mycobacterium Tuberculosis Bacilli and 3 patients had a history of pulmonary tuberculosis. The median delay of consultation was 6 months. Inflammatory back pain was found in 79%. Other clinical symptoms: 27.4% fever, 40.3% night sweats, 74.1% impaired general condition. Neurologic deficiency was noticed in 16.1% of cases. 7 patients had another localization of tuberculosis. The inflammatory biological syndrome was found in 92% of cases. The lumbar spine was involved in 58% of patients, followed by the dorsal spine (41.9%) and cervical spine (9.67%). The spondylitis was multifocal and multi-stage in 24.19% of cases. Plain radiographs revealed narrowing of disc spaces in 67.7% of cases and vertebral erosion, vertebral fracture and a paravertebral spindle in 14.51%. Computed tomography and Spinal magnetic resonance imaging was performed respectively in 62.9% and 70.9% of cases. They showed paravertebral abscess in 66.1%, epiduritis in 56.4%, intra-discal abscess in 3.22%, spinal cord compression in 8.06%, and vertebral ostelysis in 9.67% of cases. Tuberculin Skin Test was performed in 57 (92%) patients and it revealed a positive result in 29 (47%) patients. Disco vertebral biopsy was performed in 45 patients and was contributive in 32.2% of cases revealing caseating granulomas. A four-drug therapy including isoniazid (INH), rifampin (RMP), pyrazinamide (PZA) and ethambutol (EMB) were administered to 59 (95.16%) patients for the initial two months. Three patients received initial three-drug combination therapy. Following the initial 4-drug regimen, most patients continued to receive a two-drug regimen with RMP and INH for a mean duration of nine months. Over 80% of patients had an immobilisation. Adverse effects of anti-TB therapy were noted in 17.7% of the patients; [nausea-vomiting: 1.6%, hepatotoxicity: 9.6%, rash: 3.2%, hyperuricemia: 3.2%]. A surgery was needed for 6.4% of patients. Neurological complication occurred in 4 cases, sepsis occurred in 2 other cases and 2 patients were dead. Conclusion: Spinal tuberculosis results in a significant rate of morbidity due to its insidious course and delayed diagnosis. Early establishment of definitive etiologic diagnosis and appropriate treatment is of paramount importance to prevent development of sequelae. Disclosure of Interests: None declared

Background Methotrexate (MTX) is the most widely used anti-rheumatic drug in the treatment of Rheumatoid Arthritis (RA) due to low costs, efficacy and an acceptable safety profile. However MTX has certain side effects. The most common side effects include the gastrointestinal tract not only after taking MTX, but also before MTX intake (anticipatory) and when thinking of MTX (associative). Objectives The aim of this study was to assess the prevalence of MTX intolerance and particularly the anticipatory and associative symptoms using the validated methotrexate intolerance Severity Score (MISS) (1). Methods We performed a cross-sectional descriptive study that involved patients with RA and treated by MTX for more than 3 months, compiled from Charles Nicolle hospital’s rheumatologic department. The tolerance of MTX was assessed by the MISS questionnaire. The MISS Questionnaire includes five elements: abdominal pain, nausea, vomiting, fatigue, and behavioral symptoms of restlessness, crying, irritability and drug refusal. Each symptom is evaluated after intake of MTX, before taking MTX (anticipatory) and on thinking about MTX (associative). MTX intolerance was defined as ≥6 points on the MISS, with at least 1 point on anticipatory, associative or behavioral adverse effects. Results A total of 100 RA patients (87 women and 13 men) with a mean age of 53,5 years. The MTX was administrated by oral route in 91% of patients; the other 9% received it by intramuscular way. The average MTX weekly dose was 15,4mg. The average MTX duration was 76,7 months. All patients received folic acid with an average of 7,6 mg a week. MTX intolerance was found in 36% of patients. Abdominal pain was the most common symptom occurring in 55% of patients and up to 91.66% in MTX-intolerant patients, followed by nausea in 51% of patients and in 86.11% of MTX-intolerant patients and vomiting in 16% of patients and in 44.44% of MTX intolerant-patients. Anticipatory and associative abdominal pain affected 72,2% and 69,4 of intolerant-patients respectively. Anticipatory and associative nausea were found in 58,3% and 59% of intolerant-patients respectively. Anticipatory vomiting occurred in 16.6% of intolerant-patients. Overall, behavioral symptoms occurred in 75% of intolerant-patients, of whom 19.4% refused MTX. Older age was significantly correlated with better tolerance to MTX (p=0,02). There was no correlation between the dose of MTX, the duration of MTX intake and the route of MTX and the MISS score (respectively p=0,7, p=0,07and p=0,2). Also, the use of other disease modifying drugs didn’t worsen the tolerance of MTX. Conclusion To conclude intolerance to MTX is frequently seen in RA. In addition to gastrointestinal symptoms after taking MTX, RA patients can suffer from anticipatory and associative gastrointestinal symptoms. We should screen these symptoms earlier using MISS questionnaire in order to improve MTX compliance. Reference [1] Bulatovic M, Heijstek MW, Verkaaik M, van Dijkhuizen EH, Armbrust W, Hoppenreijs EP, et al. High prevalence of methotrexate intolerance in juvenile idiopathic arthritis: development and validation of a methotrexate intolerance severity score. Arthritis and rheumatism. 2011;63(7):2007-13. Acknowledgement None Disclosure of Interests None declared

Background: Rheumatoid arthritis (RA) is a common inflammatory disease developing within joints but extra-articular organs such as the lung could be involved. Objectives: To determine the frequency and the characteristics of lung involvement in RA Tunisian patients. Methods: A retrospective study including patients with RA fulfilling ACR/EULAR 2010 criteria was conducted in a department of rheumatology in the north of Tunisia between 2014 and 2017. Pulmonary involvement was evaluated based on chest clinical symptoms, combined results from chest-X-ray, computed tomography of the chest and pulmonary functional tests. Patients with pulmonary involvement not directly related to RA were excluded from this study (emphysema, neoplasm, infection…) Results: Sixty five patients with RA were collected. The mean age was 56 years ± 12.8 years. The mean age of disease onset was 46.4 ± 13.8 years ranging from 17 to 75 years. The mean disease duration was a 9.6 ±10.1 year.A total of 13 patients (20%) were noted to have clinical chest symptoms. It was dyspnea (9 cases (13.8%)), chest pain (2 cases (3%)), dry cough (5 cases (7.7%)) and expectoration (3 cases (4.4%)). Eight patients (12.3%) had crackles in pulmonary auscultation. Mean time to pulmonary involvement onset was 2.5 years [1-4 years]. Chest-X-ray was available in all patients and showed abnormalities in 24 cases (37%). Chest computed tomography was practiced in 24 patients (36.9%). It revealed pulmonary abnormalities in 18 patients (75% of those scanned). Chest computed tomography revealed abnormalities in 3 patients (4.6%) who hadn’t respiratory complaints. Pulmonary functional tests was performed in 26 patients (40%) and revealed abnormalities in 3 cases(obstructive signs in 2 cases and association of obstructive and restrictive signs in 1 case). The overall frequency of lung involvement based on different lung investigations was 27.6% (18 patients). Parenchyma was the most frequent site of pulmonary involvement: interstitial lung disease was found in 7 cases (38.8%); it was a usual interstitial pneumonia in 5 patients (27.7%) and nonspecific interstitial pneumonia in 2 cases (11.1%). Bronchiectasis was found in 5 cases (27.7%), rheumatoid nodule in 4 cases (22.2%) and pleural disease in 2 cases (11.1%). Conclusion: Lung involvement is frequent in RA Tunisian patients and the interstitial lung disease represented the most encountered pulmonary manifestation. References: [1] Megan S, Bridget FC, Lawrence AH, Ganesh R. Rheumatoid arthritis-associated lung disease. Eur Respir Rev. 2015;24:1-16. [2] Kawassaki AM, Pereira DAS, Kay FU, Laurindo IMM, Carvalho CRR, Kairalla RA. Pulmonary involvement in rheumatoid arthritis: evaluation by radiography and spirometry. J Bras Pneumol. 2015;41(4):331-42. Disclosure of Interests: None declared

Background Rheumatoid arthritis (RA)’s prognosis drastically improved with the introduction of TNF-blockers. However, reasons behind therapeutic failure in some patients remain unclear. Several factors might influence pharmacokinetics of these drugs by reducing their half-life and, consequently, their effectiveness. Considering Fc-containing biologics like infliximab (IFX) and adalimumab (ADL), Fc gamma receptors (FcgRs) polymorphism would be an interesting genetic candidate to focus on. Objectives The aim of our study was to determine the influence of low affinity allele FcgRIIA-131R on ADL and IFX bioavailability. Methods We enrolled RA patients treated with IFX and ADL for over six months. Blood samples were collected for each patient immediately prior to drug administration. Quantitative measurements of the residual drug concentration (DC) was carried out by a commercial enzyme-linked immunosorbent assay (ELISA) kit (Promonitor®). Then, we identified patients with DC above therapeutic cut-off (DC+) for each biologic. EULAR criteria were considered to determine treatment outcome. FcgRIIA H131R polymorphism was genotyped using PCR-SSP. Results Twenty-nine patients were included (13 treated with ADL and 16 with IFX). We identified 31.3% and 23.1% non-responders among patients treated with IFX and ADL respectively. Patients with DC+ were more frequent in ADL group (76.9%) than IFX group (43.75%). For IFX, DC+ was significantly correlated with the presence of FcgRIIA 131-R (p=0.033). In fact, none of the HH-genotyped patients had DC+. Furthermore, an association between FcgRIIA 131-R allele and poor response to IFX was noted (p=0.059) while all HH-genotyped patients responded to IFX. For ADL, no correlation was found with both of residual DC and response to treatment. Conclusion The presence of FcgIIA-131 R allele might be a predictive factor of non-responsiveness to TNF-blockers. It also appears to be associated to a higher residual DC. That might be explained by a reduced biologic clearance due to a lower binding affinity to Fc portion compared to wild allele FcgRIIA-131H. Therefore, FcgR polymorphism assessment in RA patients would be a decision-making parameter to consider, as part of the personalized medicine approach. References [1] Montes A, Perez-Pampin E, Narvaez J, et al. Association of FCGR2A with the response to infliximab treatment of patients with rheumatoid arthritis. Pharmacogenet Genomics. 2014;24(5):238-245 [2] DavilaaFajardo CL, van der Straaten T, Baak-Pablo R, et al. FcGR genetic polymorphisms and the response to adalimumab in patients with rheumatoid arthritis. Pharmacogenomics. 2015;16(4):373-381 [3] Canete JD, Suarez B, Hernandez MV, et al. Influence of variants of Fc gamma receptors IIA and IIIA on the American College of Rheumatology and European League Against Rheumatism responses to anti-tumour necrosis factor alpha therapy in rheumatoid arthritis. Ann Rheum Dis. 2009;68(10):1547-1552. Disclosure of Interests None declared

Background Even though biologics have been used for several years in treatment of rheumatoid arthritis (RA), little is known about factors that modify their pharmacokinetics and therefore their efficacy. Polymorphisms (SNPs) in receptors for constant region Fc of IgG (FcgR) might influence the therapeutic outcome of molecules that incorporate an Fc fragment in their structure such as etanercept (ETA), adalimumab (ADL) infliximab (IFX) and rituximab (RTX). Objectives The aim of our study was to determine whether the presence of low affinity allele of FcgR (FcgRIIA-131R, FcgRIIIA-158F and FcgRIIIB-NA2) influences efficiency and immunogenicity of ETA, ADL, IFX and RTX in RA Tunisian patients. Methods We included RA patients treated with biologics for at least six months. Response to treatment was assessed according to EULAR criteria. Quantitative measurement of antidrug antibodies (ADAb) for each biologic agent was carried out by a commercial enzyme-linked immunosorbent assay (ELISA) kit (Promonitor®). To do so, blood samples were collected for each patient right before drug administration. FcgRIIA, FcgRIIIA and FcgRIIIB SNPs was genotyped for all patients using PCR-SSP and direct sequencing process. Results Seventy-nine RA patients treated with biologics were enrolled (18 with ETA,13 with ADL,16 with IFX and 32 with RTX). Regardless of biologic type, 61 patients (77.2%) responded to treatment and 14 patients (17.7%) developed ADAb. Genotypic study revealed a correlation between poor response to treatment and the presence of at least one FcgRIIA 131-R allele (94.7% for RH/RR genotypes versus 5.3% for H/H genotype). But, the difference was not statistically significant (p=0.25). Besides, this mutant allele was significantly associated to the presence of ADAb (71.4% of ADAb positivity for RH/RR genotypes versus 28.6% for H/H genotype: p=0.041). The haplotypic study shows that the risk allele combination of FcgR IIA-131R/IIIA-158F/IIIB-NA2 was more frequent in ADAb+ (27%) compared to ADAb- subjects (23%) and in non-responders (27%) versus good responders (23%). But, neither of these associations was statically significant. Conclusion Our study suggests that RA patients FcgRIIA-131R allele carriers are more susceptible to develop ADAb than those with HH wild genotype. That could be explained by a higher biologic clearance in H-carrier patients, resulting in a decreased half-life and ultimately a lower risk of ADAb formation. Thus, FcgR polymorphism genotyping may be a useful marker for predicting response to Fc-containing biologics in Tunisian RA patients. Further studies need to be done on larger population. References [1] Romero-Cara P, Torres-Moreno D, Pedregosa J, Vilchez JA, Garcia-Simon MS, Ruiz-Merino G, Moran-Sanchez S, Conesa-Zamora P. A FCGR3A Polymorphism Predicts Anti-drug Antibodies in Chronic Inflammatory Bowel Disease Patients Treated With Anti-TNF. Int J Med Sci2018; 15(1):10-15 [2] Lee YH, Bae SC. Associations between PTPRC rs10919563 A/G and FCGR2A R131H polymorphisms and responsiveness to TNF blockers in rheumatoid arthritis: a meta-analysis. Rheumatol Int. 2016Jun;36(6):837-44. [3] Lee YH, Bae SC, Song GG,Functional FCGR3A 158 V/F and IL-6 -174 C/G polymorphisms predict response to biologic therapy in patients with rheumatoid arthritis: a meta-analysis. Rheumatol Int. 2014Oct;34(10):1409-15. Disclosure of Interests None declared

Background The rheumatoid arthritis is responsible of an increased risk of cardiovascular (CV) morbidity and mortality. Objectives The aim of the study is to determine, in established RA patients, the presence of silent myocardial ischemia using a stress test and its association with the disease activity and the CV risk factors and scores. Methods It is a transversal and prospective study in a rheumatologic center in Charles Nicolle hospital in Tunisia. 103 RA patients, asymptomatic for CV disease were submitted to a stress test. Demographic data, cardiovascular risk factors and the disease characteristics were assessed for all patients and risk factors of silent myocardial ischemia in RA patients were identified. The comparison of qualitative variables was performed with the Chi square test and the comparison of qualitative variable and quantitative ones was performed with the Student’s test. The significance level was set at 0.05. Results There were 103 patients (sex-ratio=0.3) with a mean age of 53±10 years. The evaluation of the disease activity showed that the mean DAS28 CRP, CDAI and SDAI were 3.9±1.38, 17.17±11.4 and 33.39±26, respectively. A screening for CV risk factors revealed: 13% of patients had a cardiovascular inheritance, 25% of patients were either smokers or hypertensives, 18% had diabetes, 70% were obese or overweighted and 14 patients had dyslipidemia. The ischemic ratio (CT/HDL) revealed that 42% of patients had a moderate to high myocardial ischemic risk. HeartSCORE was high in 35% of cases. A silent myocardial ischemia in the stress test was found in 11 patients (10.6%) and was associated with male sex (p=0.03), advanced age (p=0.04), erosive character (p=0.05), the advanced age of the rheumatoid arthritis diagnosis (p=0.01) and the ischemic ratio (p=0.06). No relationship was found with the majority of traditional CV factors nor with disease activity variables. Conclusion Our results corroborated the hypothesis that the stress test could reveal subclinical CV dysfunction, supported the utility of the Heartscore as a screening tool, and put in perspective the potential usefulness of complementary approaches in CV risk assessment in RA patients. Disclosure of Interests None declared

Background: Brucellosis is an endemic disease around the Mediterranean and especially in Tunisia and Brucellar spondylodiscitis is the most common osteoarticular localization. Objectives: The aim of our study is to study the,clinical, radiological and therapeutic characteristics of Brucellar spondylodiscitis. Methods: This is a retrospective descriptive study, conducted over 20 years (1999-2019) at a Rheumatology Department. We collected cases of Brucellar spondylodiscitis. We studied the clinical, radiological features and therapeutics outcomes. Results: We included 23 patients, 15 men and 8 women, with a mean age of 53.21 years [31,79]. Contact with livestock or consumption of raw milk was noted in 16 cases. The diagnosis time was, on average, 3.8 months [1,9]. Spine pain was present in all cases, with lumbar seat in 16 cases and was inflammatory in 20 cases. At the examination, 19 patients had a limitation of spinal mobility and 4 had neurological abnormalities. A motor deficit with a horsetail syndrome was objectified in one case. We noted a biological inflammatory syndrome in 19 cases. Wright’s serology was positive in 21 cases. Standard radiographs showed disc narrowing in 10 cases. 21 patients had spinal magnetic resonance imaging showing the abnormalities of the disc and adjacent vertebrae. We found abscess in four patients and epiduritis associated with the abscess in six patients. MRI showed spinal compression in 2 patients. Disco-vertebral biopsy was performed in 11 cases and helped to make the diagnosis in 3 cases. The patients had received antibiotic therapy with a combination of doxycylin and rifampicin with a mean total duration of 4.9 months [2.12]. Evolution was favorable in 19 cases. Complications were mainly neurological (n=3)or related to the toxicity of the treatment(n=3). Conclusion: Brucellar spondylodiscitis can be serious because of the neurological complications that it can cause. At the slightest diagnostic doubt, we should perform an MRI. And antibiotic treatment must be urgent and well-adapted with careful monitoring of patients. Disclosure of Interests: None declared

Background: Infectious spondylodiscitis is defined as an infectious disease involving intervertebral disks and adja- cent vertebral bodies. It is rare and difficult to diagnose due to its non-specific clinical features. Objectives: To study the clinical, microbiological, radiological, therapeutic and evolving of infectious spondylodiscitis. Methods: Retrospective monocentric study including patients diagnosed as spondylodiscitis and hospitalized in our department between January 1999 and December 2018. The diagnosis was based on clinical, biological, radiological and bacteriological data. Results: We included 107 patients. There were 58 men (54.2%) and 49 women (45.8%) with a mean age of 55 years [16–86]. Predisposing factors were found in 59 patients (55.1%): This was diabetes in 21.49% of cases, history of cancer in 2.8% of cases, hepatic disease in 5.6% of cases, a long-term corticosteroid in 1.8% of cases, recent spinal surgery in 0.93% of cases, visceral surgery in 3.73% of cases, extra-articular history of tuberculosis in 2.8% of cases and consumption of unpasteurized milk in 25.23% of cases. The approximate time from onset of symptoms to diagnosis was from 0.23 to 24 months (median 3 months). Back pain was the most common symptom. Impaired general condition was observed in 71% of cases, fever in 35.5% of cases and night sweats in 42.9% of cases. Radiculalgia was found in 42.9% of cases. A neurological deficit was noted in 16.82% of cases: motor deficit in 1.8% of cases, spinal cord compression in 1.8% of cases and Cauda equina syndrome in 2.8% of cases. The inflammatory syndrome was found in 90.6% of cases. The lumbar spine was most affected (54.2%), followed by the dorsal spine (29.9%) and the cervical spine (8.4%). The spondylitis was multifocal in 19.6% and multi-stage in 15.8% of cases. Radiographs of the spine were abnormal in 83.1% of cases. CT and Spinal MRI was performed respectively in 60% and 78.8% of cases and showed paravertebral abscess in 63.5%, epiduratis in 54.2%, spinal cord compression 9.3% and vertebral ostelysis in 8.4% of cases. The causative microorganism was identified in 51 cases (47.66%): brucella in 21 patients, mycobacterium tuberculosis in 16 patient, and pyogenic germs in 12 patients. All of them received initially adapted antibiotics. Surgical treatment was performed in 8 patients. Most of the patients showed good response (71.9%). Disturbance of liver function due to treatment occurred in 8 cases with good subsequent evolution. Neurological complication occurred in 11 cases and sepsis occurred in 4 cases. And 4 patients were dead. Conclusion: The microbiological diagnosis of infectious spondylodiscitis is often difficult to establish and the disease requires prolonged antibiotic treatment. Early diagnosis is needed to avoid neurological complications associated with poorer long-term outcomes. Disclosure of Interests: None declared