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Introduction La pandemie COVID-19 est une realite particuliere et inhabituelle. Elle affecte les personnes aussi bien sur le plan physique mais aussi psychologique. Un etat de stresse, d’anxiete et de depression s’instaure. Nous rapportons dans ce travail, la frequence de l’anxiete et sa correlation avec le motif d’hospitalisation chez les sujets âges admis en service de rhumatologie en periode du coronavirus COVID-19. Patients et methodes C’est une etude transversale, descriptive faite en deux semaines au cours de la periode du confinement general pour cause de COVID-19 en fevrier 2020. L’etude a ete portee sur 50 patients, âges de plus de 60 ans, hospitalises dans le service de rhumatologie de l’hopital militaire de Tunis. Le score utilise dans ce travail est Hospital Anxiety and Depression Scale (HADS, Zigmond et Snaith, 1983). C’est un autoquestionnaire facile et rapide, utilise dans la litterature internationale. Il evalue l’etat anxieux et depressif des patients suivis pour une pathologie somatique. Ce score est fait de 14 items cotes de 0 a 3. Sept questions evaluant l’anxiete et sept autres evaluant la depression. D’ou l’obtention de deux scores avec une note maximale de 21 pour chacun. Si le score est inferieur a 7 : pas de symptomatologie, entre 8 et 10 la symptomatologie est douteuse et superieur a 11 la symptomatologie est certaine. Resultats Cette etude est faite de 50 patients, 36 sont de sexe feminin et 14 de sexe masculin. L’âge moyen etait de 72 ans avec des extremes de 60 et 90 ans. Trente-neuf patients sont maries, 6 sont veufs, 4 sont divorces et 1 patient est celibataire. Le motif d’hospitalisation etait une atteinte articulaire peripherique handicapante dans 58 %, une osteoporose dans 22 % des cas, une lombalgie dans 12 % des cas et une spondylarthrite dans 8 % des cas. La duree d’hospitalisation etait entre 1 et 15 jours chez 60 % des patients, entre 16 et 30 jours chez 36 % des patients et au-dela de 30 jours chez 4 % des malades. Les antecedents etaient comme suit : hypertension arterielle chez 60 % des cas, un diabete chez 46 % des cas et des antecedents psychiatrique chez 10 % des patients. Le score HADS a montre que 36 % des patients ont presente une symptomatologie anxieuse certaine, 18 % ont presente une symptomatologie douteuse et 44 % des patients n’ont presente aucune symptomatologie. Pour la relation entre le motif d’hospitalisation et l’anxiete, on a constate que la moyenne de score d’anxiete des personnes enquete presentant une lombalgie est egale a 13,1 et pour les atteintes rhumatologiques handicapantes peripheriques egale a 14,63. Ces deux motifs ont le score d’anxiete les plus eleve. Discussion L’anxiete est souvent accompagnee de depression chez les sujets âges [1] , [2] . Les resultats des etudes scientifiques ont montres qu’entre 5,6 % et 14,5 % des personnes âgees souffrent de troubles anxieux [3] , [4] , [5] . Notre etude a montre que 36 % des patients ont presente une symptomatologie anxieuse certaine. Ces resultats vont dans le sens de la litterature. Selon l’enquete PAQUID, enquete de reference dans le champ de la gerontopsychiatrie, la prevalence de l’anxiete atteint 15,9 % chez les personnes dont la tranche d’âge est entre 65–74 ans, alors que chez les personnes qui sont plus que 75 ans elle atteint 12,7 % d’ou un taux globale d’anxiete chez les personnes plus que 65 ans egale a 28,6 %. Conclusion Il est classiquement admis que la vieillesse s’accompagne d’un repli sur soi generant un etat anxieux. Seule la connaissance des mecanismes physiopathologiques des maladies mentales du sujet âge permettra de developper des traitements curatifs et surtout preventifs.

Background: Over the years, drug monitoring-such as Anti-Drug Antibodies (ADA) dosage- has witnessed major transformations. In fact, ADA are more and more used in rheumatology and gastro-enterology in monitoring chronic inflammatory disease therapeutic response. The main purpose of those researches is to produce less immunogenic drugs and, in consequences, to improve tolerance and efficiency since immunogenicity of those drugs still is the main constraint to their long-term use. The aim of this review was to highlight anti-drug-antibodies potential effects on the pharmacokinetics and bioavailability of biotherapies as well as their clinical implications. Methods: For this purpose, we collected and summarized published data on PubMed using keywords “Biologics, Rheumatoid Arthritis, Spondyloarthritis, Crohn disease, Anti-drug antibodies, residual rate, immunogenicity, efficacy, tolerance”. The time-period selected for this study was 2000-2019. Results: Anti-Drug-antibodies decrease the pharmaco-availability of drugs and, in consequences, its efficiency and high risk of refractory diseases and side effects. Conclusion: Recent literature is consistent with the fact that drug monitoring using ADA dosage coupled with residual drug concentration offers reliable options to comfort practitioner’ therapeutic management decisions. This is particularly interesting in failure of treatment or in side effects onset situations.

Background:Chronic inflammatory rheumatic diseases are associated with a high cardiovascular risk. However, data in ankylosing spondylitis (AS) are still limited.Objectives:The aim of our study was to assess the atherosclerotic risk in patients with AS, by comparing the Systematic coronary risk evaluation: SCORE, with biomarkers of atherosclerosis: High sensitivity C-reactive protein (Hs-CRP), LDL/HDL ratio and apoliprotein A1 (Apo A) /apolipoprotein B (Apo B) ratio.Methods:We conducted a cross-sectional observational study of 40 patients with AS, over a period of 3 months. Socio-demographic data, clinical characteristics of the disease, as well as biological, radiological and therapeutic data were collected for each patient. Coagulated blood samples were collected following a 12-hour fast. Cardiovascular risk was considered high for Hs-CRP>3.0 mg/L [1], LDL/HDL> 3.5 in men and 3.0 in women [2], and ApoB/ApoA level>0.9 [3,4]. SCORE was calculated for all patients.Results:The mean age of our population was 44±10 years. Male predominance was noted with a sex ratio =11.1. The mean ASDAS-CRP and BASDAI levels were 2.1±0.95 and 2.25±1.33. Thirty-two percent of the patients had a high risk of cardiovascular diseases according to Hs-CRP level, with an average of 10.7 mg/L. The mean LDL/HDL ratio was high in twenty-two percent of the patients. The mean value of ApoA1 and ApoB was respectively 1.3 g/l. and 0.9 g/l. Low values of Apo A1 were determined in 12.5% of the subjects, and high values of ApoB were found in 15% of subjects. The mean value of ApoA/ApoB ratio was 0.7. Ten percent of the studied subjects had an unfavourable ApoB/ApoA1. The predicted 10-year risk of CV mortality according to SCORE was high in 5% of the patients, very high in 2.5% and moderate in 35% of them. Over 17 patients with moderate, high and very high risk according to SCORE: Four patients (23.5%) had high LDL/HDL ratio, 8 (47%) had high waist/hip ratio, 5 (29.4%) had high Hs-CRP level, and 2 (11.7%) had high ApoB/ApoA ratio.We found ApoB/ApoA to be positively correlated with Hs-CRP (r=0.31, p=0.05). The SCORE was correlated to the age at the onset of the disease (r=0.78, p-3).Conclusion:The atherosclerotic risk in our population ranged from 10 to 43%. SCORE presented with the highest percentage, making it more suitable for mass screening. Biomarkers on the other hand are more precise. Hs-CRP is biomarker to be included in daily practice, even when AS is in remission. Accuracy of the apoB/apoA ratio is significantly great and appears to be associated with inflammation.References:[1]Myers GL, Rifai N, Tracy RP, Roberts WL, Alexander RW, Biasucci LM, et al. CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: Report From the Laboratory Science Discussion Group. Circulation [Internet]. 2004 Dec 21 [cited 2020 Oct 20];110(25).[2]Munoz. Lipoprotein ratios: Physiological significance and clinical usefulness in cardiovascular prevention. VHRM. 2009 Sep;757.[3]Walldius G, Jungner I, Holme I, Aastveit AH, Kolar W, Steiner E. High apolipoprotein B, low apolipoprotein A-I, and improvement in the prediction of fatal myocardial infarction (AMORIS study): a prospective study. The Lancet. 2001 Dec;358(9298):2026–33.Disclosure of Interests:None declared.

Background:The tight control strategy is recommended in rheumatoid arthritis to tailor treatment for patients. This strategy requires regular monitoring of both disease activity and structural damage. However, radiographic assessement cannot be performed frequently and the modified Sharp score is rarely evaluated in current practice. Besides, no biomarker was able to mirror structural damage (1).Objectives:Our study aimed to assess the relationship between the modified Sharp score and the inflammatory ratios (platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), fibrinogen to albumin ratio (FAR) and CRP to albumin ratio (CAR)).Methods:We performed a cross-sectional study including 53 patients with rheumatoid arthritis (RA). A cell blood count, fibrinogen and an albumin blood test were measured for each patient. Inflammatory ratios were also measured (PLR, NLR, LMR, FAR, and CAR). Modified Sharp score and its components (erosion score and joint space narrowing score) were evaluated using the radiograph of hand and foot.Patients with infectious or hematological diseases were excluded from the study.Statistical analysis was performed using SPSS (Statistical Package for Social Sciences).Results:Of the 53 patients, 39 were female (Sex Ratio: 2.8). The mean age was 53.9 ± 12.7 years. The mean disease duration was 10.1 ± 8.2 years.The average age of the onset of the disease was 43.8±13.5 years.The mean DAS 28-ESR score was 4.64 ± 1.23. Forty three patients had a score higher than 3.2 (patients with moderate or high disease activity).The mean values of PLR, NLR, LMR, FAR and CAR were 161.62 ± 86.59, 2.84 ± 2.39, 4.99 ± 3.23, 0.12 ± 0.06 and 1.15 ± 1.38.The mean scores of joint erosion and joint space narrowing were respectively 12.76 ± 15.05 and 33.57 ± 25.80. The mean modified Sharp score was 46.33 ± 37.74.There was a positive correlation between modified Sharp score and following ratios: PLR (r: 0.501; p -3), NLR (r: 0.302; p:0.031), FAR (r: 0.300; p:0.030), CAR (r:0.286; p:0.042).Moreover, a positive correlation between joint space narrowing score and these ratios was identified: PLR (r: 0.558; p -3), NLR (r: 0.428; p:0.002), FAR (r: 0.371; p:0.007), CAR (r:0.387; p:0.005).Joint erosion score correlated with PLR (r: 0.299; p:0.033).No correlation was found between LMR and radiographic score.Conclusion:Our study showed that the modified Sharp score correlated with PLR, NLR, FAR and CAR in patients with RA. This finding suggests that these ratios could be used as inexpensive and reliable markers to reflect radiographic joint damage.Longitudinal studies are necessary to confirm our results.References:[1]Syversen SW, Landewe R, Van Der Heijde D, Bathon JM, Boers M, Bykerk VP, et al. Testing of the OMERACT 8 draft validation criteria for a soluble biomarker reflecting structural damage in rheumatoid arthritis: a systematic literature search on 5 candidate biomarkers. J Rheumatol. 2009;36(8):1769-84.Disclosure of Interests:None declared

Background:Cystic echinococcosis (CE) is a zoonosis caused by the larve of Echinococcus granulosus. Cysts can develop in any part of the body, although the liver and lungs are most frequently involved. Bone echinococcosis is one of the rarest forms of the disease, accounting for 0.5 to 4.0% of all echinococcosis. Spinal cysts are disabling causing destruction similar to malignant bone lesions, with high risk of neurological deficit.Objectives:To increase awareness of this disease, the clinical data of eight patients with spinal CE were analyzed retrospectively.Methods:Clinical data of eight patients with spinal CE were analyzed retrospectively, collected over ten years on the department of orthopedics in the Military hospital of Tunis.Results:The mean age of the patients was 49 years. The median disease duration was five years. All patients presented with back pain and paresthesia without neurological deficit. Radicular pain was reported by two patients. The diagnosis of spinal CE was made after the diagnosis of visceral CE in two patients. Former X rays showed nonspecific abnormalities and patients were treated initially by symptomatic treatments based on paracetamol and nonsteroidal antiinflammatory drugs without any improvement. All of the patients needed Magnetic resonance imaging (MRI) to explore chronic back pain with paresthesia, revealing spinal CE. The typical MRI appearance is a multilocular cyst. Six patients had cervical and thoracic spinal cysts, one patient had a lumbar spinal cyst and one patient had cervical, thoracic and lumbar cysts. Further examinations with Computed tomography scans (CTscans) were needed before surgery for better examination bone destruction. All patients underwent surgery. Cysts were removed with spinal fixation. All the patients showed relapses and needed at least three surgical interventions.Conclusion:Bone echinococcosis is rare and often misdiagnosed. Radiographic and CT images lack disease-specific characteristics whereas MRI images offers a greater chance of direct diagnosis. Treatment of spinal hydatid disease is entirely surgical with high risk of relapses.Disclosure of Interests:None declared

Background:Interleukin 23 (IL-23) is a pivotal pro-inflammatory cytokine in the Th17/IL-23 axis which became the center of attention in researches during these last decades, especially during spondyloarthritis (1).Objectives:We aimed to study the diagnosis value of IL-23 serum in spondyloarthritis.Methods:We conducted a case-control study, including 144 subjects divided into 2 groups:-G1: 72 patients meeting the Assessment of SpondyloArthritis International Society (ASAS) criteria for spondyloarthritis (SA)-G2: 72 healthy controls matched for age and sex.For each SA patient we collected the following parameters: BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), ASDAS (Ankylosing Spondylitis Disease Activity Score), BASFI (Bath Ankylosing Spondylitis Functional Index), and BASRI (Bath Ankylosing Spondylitis Radiology Index).The IL-23 level was measured using Enzyme-linked immunosorbent assay (ELISA).Erythrocyte Sedimentation rate (ESR) and C-reactive protein (CRP) were also measured.We performed a ROC analysis and computed the air under the curve (AUC) at IL-23 to diagnose SA patients.Statistical analysis was performed using “IBM SPSS Statistics” software version 25.Results:The study included 57 men and 15 women. The mean age was 44.84 ± 13.42 years. The mean age at the onset of the disease was 35.97 ± 12.88 years. The disease duration was 8.54 ± 7.7 years.Seventy-nine per cent of our patients had axial radiographic spondyloarthritis (n=57). Peripheral involvement was found in 45.8% (n=33). Eighteen patients had both axial and peripheral involvement concomitantly. Psoriasis was found in 36.1% of the cases (n=26).The mean BASDAI and ASDAS-CRP were 3.21 ± 1.64 and 3.05 ± 1.51, respectively.The mean was BASFI 3.88 ± 2.69. The mean was BASRI 5.26 ± 4.14.The mean ESR and CRP were 36.74 ± 29.38 mm/hr and 20.45 ± 25.19 mg/dL, respectively.IL-23 level was significantly higher in patients compared to healthy controls (23.1 ± 2.72 pg/mL and 5.02 ± 0.59 pg/mL, respectively, pAs shown in Figure 1, the AUC value to distinguish between spondyloarthritis and healthy control was 0.705 (pFigure 1.AUC at IL-23 between SA patients 0.705 (pConclusion:As reported to previous studies, our study showed that IL-23 is significantly higher in SA patients (2).Interestingly, IL-23 was able to distinguish between SA patients and healthy controls with a cut-off of 7.96 pg/mL. This finding suggests that IL-23 may be practical for the diagnosis of SA.References:[1]K V, D E. IL-23 Responsive Innate-Like T Cells in Spondyloarthritis: The Less Frequent They Are, the More Vital They Appear [Internet]. Vol. 17, Current rheumatology reports. Curr Rheumatol Rep; 2015 [cité 13 avr 2020]. Disponible sur: https://pubmed.ncbi.nlm.nih.gov/25874346/[2]Wang X, Lin Z, Wei Q, Jiang Y, Gu J. Expression of IL-23 and IL-17 and effect of IL-23 on IL-17 production in ankylosing spondylitis. Rheumatol Int. sept 2009;29(11):1343-7.Disclosure of Interests:None declared

Background:The cardiovascular burden in inflammatory rheumatic diseases is well recognized. This burden has been reported in spondyloarthritis. Atherogenic indexes are known with their role of predicting cardiovascular risk.Objectives:The aim of our study was to determine the relation between pro-inflammatory cytokines and atherogenic indexes in spondyloarthritis.Methods:We performed a cross sectional study including 38 patients with spondyloarthritis according to ASAS criteria. For each patient we measured interleukin (IL)1, IL6, IL17, IL23 and tumor necrosis factor (TNF) alpha, total Cholesterol (CT), Triglycerides (TG), High density lipoprotein Cholesterol (HDLc) and Low density lipoprotein cholesterol (LDLc). We also calculated the following ratios: CT/HDLc, TG/HDLc, LDLc/HDLc, and LogTG/HDLc.Disease activity was measured using ASDAS (Ankylosing Spondylitis Disease Activity Score) and BASDAI (Bath Ankylosing Spondylitis Disease Activity Index).Statistical analysis was performed using IBM SPSS Statistics 25.Results:The mean age were 45.4±12.5 years. There were 33 Male (sex ratio were 6.6).The mean C-reactive protein(CRP) were 29.6 ±40.34mg/L, mean erythrocyte sedimentation rate(ESR) were 41±33.9mm.The mean ASDASCRP, BASDAI were 2.8±1.24, 3.7±2.12, respectively.Active disease were noted in 68 % of patients using ASDASCRP score.The mean IL1, IL6, IL17, IL23, TNF alpha were 11.6 ±25pg/ml, 15.4±45.9pg/ml, 84.6±77.9pg/ml, 15.3±15.26pg/ml, 25.3± 47.9pg/ml respectively.The mean CT,HDLc,LDLc, TG were 4.47±0.93mmol/l, 1.09±0.3mmol/L, 2.77±0.78mmol/L, 1.29±0.54mmol/L respectively.The mean CT/HDLc, TG/HDLc, LDL/HDLc, LogTG/HDLc were 4.28±1.26, 1.22±0.6, 2.7±1.06, 0.03±0.23, respectively.Correlations were found between TG/HDLC ratio and IL1 (pHowever, no correlations were noted between atherogenic indexes and IL7, IL17, IL23, TNFalpha.Conclusion:Our study showed a correlations between atherogenic indexes and both IL1 and IL6.These findings suggests that serum IL-6 and IL1 levels in spondyloarthritis contribute to the development of cardiovascular disease atherosclerosis.References:[1]Lau et al. Role of Adipokines in Cardiovascular Disease. Circ J. 2017; 81(7): 920-8.Disclosure of Interests:None declared

Background:The development of biologics for the treatment of systemic rheumatic diseases increased the risk of infections. The management of this complication deserves particular attention since it remains a major cause of morbidity and mortality.Objectives:The aim of our study was to determine infection frequency under biological treatment and consequences on the therapeutic management.Methods:Patients included in the Biological National Registry (BINAR) from 2016 to 2020. Data related to the disease, biological agents, and infections occurring under biologic disease-modifying antirheumatic drugs (bDMARDs) were collected.Results:The study included 298 patients with a mean age of 49.2 years [18-79] 175 patients with rheumatoid arthritis and 123 with spondyloarthritis (Axial Spondyloarthritis=48, Enteropathic Arthritis=41, Psoriatic Arthritis=34). Anti Tumor necrosis factor-alpha (Anti-TNF) agents were the most prescribed bDMARDs in 87.9% (n=263) of patients: Infliximab 20.4% (n=61),Etanercept 23.1%(n=69), Adalimumab 24.6%(n=74) and Certolizumab (n=79). No patients were treated with Golimumab. Tocilizumab and Rituximab were prescribed respectively in 10.4% (n=31) and 5% (n=15) of patients. Infections occured in 9 patients (3.1%) with a total of 13 infectious episodes 12 bacterial and a viral one. The site of infections was: respiratory (38%), urinary (15%), cutaneous (23%), ORL (8%), infective endocarditis (8%), and other (8%). The infectious agent was identified in only 3 patients. The outcomes were favorable in most cases except in one patient where there was a definitive interruption of bDMARDs. The patient was hospitalized for sepsis complicating a cutaneous infection with favorable outcomes under antibiotics within a week. The biological agent with higher risk of infections was Tocilizumab (p = 0.056), unlike Rituximab (p = 0.483) and Anti-TNF (p = 0.082). All patients who had an infectious episode were under corticosteroids.Conclusion:Our results confirm that bDMARDs are predisposing to infections, but data from BINAR showed that most infections were trivial with no serious outcomes. Therefore, infections should be assessed in patients under bDMARDs for an early therapeutic intervention.Disclosure of Interests:None declared.

Background:Low back pain is an extremely common patient complaint. Most cases resolve quickly after the acute episode. However, a significant number of patients develop chronic low back pain; a persistent disabling condition. Patients suffer from unremitting pain and often become functionally impaired.Objectives:The aim of this study is to describe the characteristics of chronic LBP, physical examination abnormalities, treatment strategies and the impact of LBP on the professional life of the patients.Methods:It was a an analytical cross-sectional study including 50 patients with at least three months of LBP, in the department of rheumatology and orthopedics at the Military Hospital of Tunis between January 1st and March 31, 2020. All patients had a standardized investigation and clinical assessment.Results:The study included 80% of active military serving members and 20% of administrative officers. The mean age of the patients was 41.9 ± 8.4 years and the sex ratio was 4.5. Four patients were suffering from diabetes; two patients were suffering from high blood pressure. All the patients were suffering from chronic LBP lasting for an average of 66.4 months. LBP was associated with radicular pain in 78% of the cases. It was a unilateral radicular pain in 72% of the cases and bilateral in 28% of the cases. The main triggering factors were: carrying heavy loads in 98% of the cases, standing or sitting for long periods in 90% and 76% of the cases, tremors in 74% of the cases. Neuropathic pain was found in 26% of patients. Physical examination showed paravertebral muscle tenderness in 66% of the cases and slack abdominal muscles in 56% of the cases. Assessement of range of flexion of the lumbar spine showed: fingertip to floor test was 18 ±12.2 cm [054cm], schober test was +3.8±1.2cm [16cm]. The extension of lumbar spine was painful in 80% of the cases. A trigger point was found in 28% of the cases. Lasegue sign was positive in 18% of the cases. Leri’s test was positive in 8% of the cases. Required treatments during the last episode of LBP were: Paracetamol (62%), nonsteroidal antiinflammatory drugs (26%), tramadol (4%), myorelaxant (4%) and pregabalin (2%). Half of the patients needed functional rehabilitation. Forty percent of the patients reported improvement; 46% of them reported improvement then recurrence of the pain, 8% of them reported no improvement and 4% reported worsening of the symptoms. Thirty six percent of the patients needed an average of 21 days of leave and 35% of them needed exemption from work for LBP problems. One patient needed an outplacement from his original work and one patient needed an early retirement.Conclusion:Chronic low back pain can cause significant functional disability, and commonly becomes frustrating for both patients and physicians to cope with and treat. There is still no consensus on the best way to manage chronic low back pain, and clinical guidelines are scarce. A combination of pharmacological agents and non-pharmacological methods is the most appropriate therapeutic regimen.Disclosure of Interests:None declared

Background:Hip involvement can reveal a spondyloarthritis (SA) or appear later. It hampers patient’s life quality and can be responsible of significant handicap (1). Military patients are a special population. They are more exposed to physical stress which makes their SA characteristics quite different to other patients.Objectives:We aimed to determine the frequency of hip involvement in SA and to study its characteristics and associated factors in military patients.Methods:We conducted a cross-sectional study carried out in Rheumatology department of Military Hospital of Instruction of Tunis over a 10-year period (2010-2020) including SA patients meeting The Assessment of SpondyloArthritis international Society (ASAS). For each patient we collected the following informations: age, characteristics of hip involvement, ASDAS (Ankylosing Spondylitis Disease Activity Score), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), BASMI (Bath Ankylosing Spondylitis Metrology Index) and BASRI (Bath Ankylosing Spondylitis Radiology Index). We also measured Erythrocyte Sedimentation rate (ESR) and C-reactive protein (CRP).Results:One hundred forty-one patients were included. They were 103 men and 38 women. The mean age was 43.01± 12.9 years. The mean age at the onset was 34.28±12.05 years. The mean delay of the disease was 9.16±8.98 years.The mean BASDAI and l’ASDAS-CRP were 3.89±2.29 and 3.07±1.83, respectively.Hip involvement was noted in 35.5% of the cases (n=50). It was bilateral in 41 of the cases. The number of affected hips was thus 91. The mean delay between the onset of SA and the discovery of hip involvement was 32.24±53.58 months [0-264 months].A significant difference was noted in the axial mobility between patients who have hip involvement and those who don’t (BASMI was 3,8±2.45 versus 1,45±1.8, pMoreover, functional impact was higher in patients with hip involvement (BASFI was 5.7±2.24 versus 3.45±2.86, pPatients with hip involvement had significantly higher BASRI compared to patients with no hip involvement (5.79±3.17 versus 3.14±2.42, pHowever, no difference was found between patients who have hip involvement and those who don’t with these following parameters: ESR, CRP, BASDAI and ASDAS-CRP.Conclusion:Our study showed that hip involvement is quite common in military SA patients. It is responsible of an important functional impact and it seems to be associated to a major limitation of axial mobility. Nevertheless, hip involvement was not associated neither to inflammation parameters levels nor to the disease activity, this suggest that hip involvement may progress independently of the disease activity in military patients due to physical stress and micro traumas.References:[1]López-Medina C, Castro-Villegas MC, Collantes-Estévez E. Hip and ShoulderInvolvement and Their Management in Axial Spondyloarthritis: a Current Review. CurrRheumatol Rep. sept 2020;22(9):53.Disclosure of Interests:None declared.

Background:Common low back pain (LBP) is a common health problem affecting 50 to 80% of working age adults. It is one of the common and costly health problems in Tunisia. Actually, the role of the immune response and inflammatory cytokines in the pathogenesis of chronic pain has been of growing interest.Objectives:The aim of this study was to assess whether pro and anti-inflammatory cytokines could be detected in serum in patients with LBP compared with healthy subjects and whether they could be related to pain severity and to clinical findings.Methods:It was a an analytical cross-sectional study including 50 patients with at least three months of LBP, in the department of rheumatology, orthopedics and immunology at the Military Hospital of Tunis between January 1st and March 31, 2020. All patients had a standardized clinical assessment.Levels of serum cytokines IL-6, IL-8, IL-1β and TNF- α, were measured using the chimiluminescence technique. Serum concentration of IL-10 was assayed by the enzyme-linked immunosorbent assay technique (ELISA). The normal levels of cytokines were determined in 50 healthy controls.Results:The mean age of the patients was 41.9 ± 8.4 years and the sex ratio was 4.5. LBP duration was 66.4 months. The mean lumbar visual analog scale (VAS) was 4.5 ± 1.9, and the root VAS was 2.6 ± 2.5. Neuropathic pain was found in 26% of patients. The average BMI was 27 ± 3.7 kg/m2. Only serum level of IL-8 was significantly higher in subjects with LBP compared to healthy controls (p Conclusion:Interleukin-8 is a biomarker of common low back pain and correlate with anxiety and functional disability. These results suggest that IL-8 may be a therapeutic target to reduce chronic back pain and reduce the social and profession impact.Disclosure of Interests:None declared

Background:The screening and treatment of latent tuberculosis infection (LTBI) is required before starting biologic therapy. Tuberculin skin test (TST) and interferon γ gamma release assay (IGRA) are the two commonly used tests.Objectives:The aim of our study was to analyze data from the Biological National Registry BINAR between 2016 and 2020 in order to compare the diagnostic value of TST and IGRA tests.Methods:We collected data of patients diagnosed with LTBI (having had a TST and/or IGRA before receiving any biotherapy) from the BINAR registry (a National Tunisian registry of patients with inflammatory rheumatic diseases under biologic therapy since less than two years from the inclusion date).Results:From a total of 298 patients included in our study, 199 patients (66.8%) were screened by TST and 159 patients were screened (53.4%) by IGRA.Thirty-four patients (11.4%) had a positive TST and 27 patients (9.1%) had a positive IGRA test.Three patients having negative TST and two having negative IGRA developed tuberculosis.There was no significant difference in our study between these two tests for LTBI diagnosis. The reactivation of tuberculosis can occur even when LTBI screening is negative using TST and IGRA tests.Conclusion:Our results show that the predictive diagnostic value for these two tests is the same. It would be more interesting to practice one of those tests prior to biotherapy.Disclosure of Interests:None declared.

Background:Common low back pain (LBP) is a common health problem affecting 50 to 80% of working age adults resulting in significant personal, social and occupational impairment. Chronic pain has a negative impact on quality of life and psychological well-being.Objectives:The aim of this study was to examine the relationship between anxiety, depression and pain intensity in patients with low back pain in a population made of military agents.Methods:It was an analytical cross-sectional study including 50 patients with at least three months of LBP, in the department of rheumatology and orthopedics at the Military Hospital of Tunis between January 1st and March 31, 2020. All patients had a standardized clinical assessment. Patients completed the «hospital anxiety and depression scale» (HADS) and the «Fibromyalgia Rapid Screening Tool» (FIRST) to evaluate psychological impact of chronic LBP. Pain intensity was assessed using a visual analog scale (VAS).Results:The mean age of the patients was 41.9 ± 8.4 years and the sex ratio was 4.5. LBP duration was 66.4 months. The mean lumbar visual analog scale (VAS) was 4.5 ± 1.9, and the root VAS was 2.6 ± 2.5. Neuropathic pain was found in 26% of patients. Abnormal level of anxiety and depression were found in 58% and 62% of the patients respectively. Out of them 20% and 26% were borderline abnormal for anxiety and depression respectively, while 38% (16.4%) and 36% were certainly abnormal for anxiety and depression respectively. Twelve percent of the patients had fibromyalgia syndrome associated with LBP as they had a FIRST score ≥5. Positive correlations were found between lumbar VAS and HAD anxiety/depression scores (r = 0.35; pConclusion:The results of this study showed that anxiety, depression and fibromyalgia syndrome are not only frequent with patient suffering from chronic LBP but they are also correlated to the pain intensity. As a consequence, assessment of and intervention in anxiety, depression symptoms and fibromyalgia syndrome is crucial in the provision of pain-relief nursing treatment in patients with low back pain.Disclosure of Interests:None declared

Background:Radiographic axial spondyloarthritis is a chronic inflammatory disease that involves the spine and the sacroiliac joints. No specific biomarker that reflects disease activity is yet available.Objectives:This study aimed to assess the relationship between fibrinogen (Fib) to albumin (ALB) ratio (FAR) and disease activity in radiographic axial spondyloarthritis.Methods:We performed a cross-sectional study including 51 patients with radiographic axial spondyloarthritis. Disease activity was assessed using Ankylosing Spondylitis Disease Activity Score (ASDAS). C-reactive protein (CRP), fibrinogen (Normal value: 2 -4g/L), erythrocyte sedimentation rate (ESR) and albumin levels (Normal value: 35 -50 g/L) were measured. The fibrinogen to albumin ratio (FAR) was calculated. We excluded patients with infectious disease, hematological disease, and those with malabsorption syndromeStatistical analysis was performed using SPSS 26.Results:The study included 43 males and 8 females with a mean age of 41.25 ± 10.97 years. The mean disease duration was 117.92 (85.4 months). The mean fibrinogen and albumin levels were 3.94 ± 1.24 g/L and 36.94 ± 5.89 g/L, respectively. Fibrinogen level was elevated in 45% patients and albumin levels was decreased in 51% cases. Mean FAR was 0.11 ± 0.44.ESR levels were elevated in 67% with a mean of 40.22 ± 34.64 mm. CRP levels were high in 61% with a mean of 28.57 ± 33.25 mg/L. Mean ASDAS was 3.32 ± 1. 27 patients had very high disease activity (ASDAS>3.5).Significant correlation was found between FAR and following parameters: ESR (r = 0.836, p< 0.001), CRP (r = 0.785, p < 0.001), and ASDAS (r = 0.463, P < 0.001).The ability of FAR to distinguish patients with very high disease activity from those without very high disease activity was excellent, with Aire under the curve of 0.819. The optimal FAR cutoff value with the highest accuracy was 0,1065 with a sensitivity of 0,792 and specificity of 0,852.Conclusion:Our study showed that fibrinogen to albumin ratio correlate with ESR, CRP and ASDAS. This finding suggests that this ratio may be a used to assess disease activity in radiographic axial spondyloarthritis (1).References:[1]Liu M, Huang Y, Huang Z, Zhong Z, Deng W, Huang Z, et al. The role of fibrinogen to albumin ratio in ankylosing spondylitis: Correlation with disease activity. Clin Chim Acta. juin 2020;505:136-40.Disclosure of Interests:None declared.

Background:Interleukin 17 (IL-17) is pro-inflammatory cytokine that plays a crucial role in spondyloarthritis via the Th17/IL-17 axis. (1)Objectives:We aimed to study the diagnosis value of IL-17 serum in spondyloarthritis.Methods:We conducted a case-control study, including 104 subjects divided into 2 groups:-G1: 52 patients meeting the Assessment of SpondyloArthritis International Society (ASAS) criteria for spondyloarthritis (SA)-G2: 52 healthy controls matched for age and sex.The IL-17 level was measured using Enzyme-linked immunosorbent assay (ELISA).We performed a ROC analysis and computed the air under the curve (AUC) at IL-17 to assess the ability of IL-17 to diagnose SA.Statistical analysis was performed using “IBM SPSS Statistics” software version 25.Results:Eighty per cent of the patients were men (n=41). The mean age was 44.96 ± 13.09 years. The mean age at the onset of the disease was 35.07 ± 12.66 years. The disease duration was 9.25 ± 8.09 years. Axial radiographic spondyloarthritis and peripheral involvement were found in 53.8% (n=28) and 44.2% (n=23) of cases, respectively. Psoriasis was noted in 46% of cases (n=24). The mean ASDAS-CRP was 3.21 ± 1.64.IL-17 level was significantly higher in patients compared to healthy controls (92.76 ± 71.85 pg/mL and 2.67 ± 9.01 pg/mL, respectively, pAs shown in Figure 1, the AUC value to distinguish between spondyloarthritis and healthy control was 0.987 (pFigure 1.AUC at IL-17 between SA patients and healthy controls 0.987 (pConclusion:According to previous studies, our study showed that serum IL-17 level is significantly higher in SA patients compared to healthy controls (2).Interestingly, IL-17 was able to distinguish between SA patients and healthy controls with a cut-off of 13.79 pg/mL. This finding suggests that IL-17 may be useful for the diagnosis of SA.References:[1]Ruiz de Morales JMG, Puig L, Daudén E, Cañete JD, Pablos JL, Martín AO, et al. Critical role of interleukin (IL)-17 in inflammatory and immune disorders: An updated review of the evidence focusing in controversies. Autoimmun Rev. janv 2020;19(1):102429.[2]Chen W-S, Chang Y-S, Lin K-C, Lai C-C, Wang S-H, Hsiao K-H, et al. Association of serum interleukin-17 and interleukin-23 levels with disease activity in Chinese patients with ankylosing spondylitis. J Chin Med Assoc. juill 2012;75(7):303-8.Disclosure of Interests:None declared

Background:Ankylosing Spondylitis (AS) is associated with an increased cardiovascular risk. Obesity and limited activity in patients with AS may contribute to this cardiovascular risk.Objectives:We aimed to evaluate physical Activity and obesity in patients with AS.Methods:We conducted a cross-sectional observational study of 40 patients with AS, over a period of 3 months. We evaluated the level of physical activity using the IPAQ (International Physical Activity Questionnaire). We also measured body mass index (BMI), body fat percentage, waist circumference, hip circumference and their ratio in all patients.Results:The mean age of our population was 44±10 years. A male predominance was noted with a sex ratio =11.1. The mean ASDAS-CRP and BASDAI levels were 2.1±0.95 and 2.25±1.33. The mean of IPAQ was 3900 MET minutes per week, with a median of 3069 and extremes of 339 and 11000. 45.5% of patients had moderate physical activity and 20% had low activity.The mean BMI was 26.5 + 4.7 kg/m2. Twenty percent of patients were obese. The mean body fat percentage was 25% with a median of 23.7% and extremes of 8-46%. Forty-five percent of the patients had a high fat mass. The mean waist circumference was 95±13 cm, hip circumference 104±9.5 cm. The mean waist to hip ratio was 0.9±0.07. Thirty-seven percent of patients had a high waist to hip ratio. BMI and body fat percentage were negatively correlated with HDL level; (r=-0.365,p=0.024)and(r=-0.393,p=0.015) respectively.Conclusion:The majority of our patients have moderate or low levels of physical activity. The increase in BMI and fat mass appear to be associated with disturbance of the lipid balance, with low HDL values.Disclosure of Interests:None declared.

Background:Patients with rheumatoid arthritis are at increased risk for cardiovascular disease (CVD).The early myocardial dysfunction in RA patients may be detectable sooner using speckle-tracking echocariodgraphy to evaluate ventricular strain especially the global longitudinal strain (GLS), this has provided more comprehensive information on ventricular dysfunction in these patients.Objectives:In the present study, we evaluated comorbidities that interfered the most with the GLS in rheumatoid arthritis patients.Methods:The study population was comprised of a case group (36 patients with rheumatoid arthritis with no history of CVD and normal LVEF in the outpatient population of the Rheumatology department in the military hospital of Tunis) and a matched control group (individuals without a history of rheumatoid arthritis or cardiac abnormalities referred for clinical check-ups). In both groups, 2D and 3D echocardiographic examinations were performed by a single cardiologist to assess cardiac functional parameters.Results:Anemia (36%) was found to be the most common comorbidity followed by diabetes mellitus (25%), arterial hypertension (17%) and dyslipidemia (17%).Myocardial deformation study revealed that rheumatoid arthritis patients had a significantly worse global longitudinal strain than healthy controls (18.99±2.81% vs 20.42±1.33%; P=.015). Moreover, a third of the rheumatoid arthritis patients (and no healthy controls) exhibited subclinical left ventricular systolic dysfunction (GLSAnemia (r=−0.368, P=.027), Age (r=−0.365, P=.029), Diabetes mellitus (r=−0.540, P=.001) and E/A (r=0.351, P=.036) were significantly correlated with GLS in our univariate study. Receiver operating characteristic curve analysis revealed hemoglobin as the best predictor for subclinical LVSD (AUC=0.752, 95% CI: 0.577-0.927, P=.02) when compared to Age and E/A.Conclusion:This prospective comparative study highlighted the diabetes mellitus and anemia burden on myocardial dysfunction in RA patients.Disclosure of Interests:None declared

Background:Spondyloarthritis is a group of chronic inflammatory diseases involving axial and peripheral joints. It mainly affects young patients typically of working age. Therefore, its impact on work outcomes may be considerable particularly in military patients.Objectives:The aim of this study was to evaluate the impact of spondyloarthritis on work ability and productivity in military patients, and to assess relationship between work productivity loss and disease activity.Methods:Thirty Three patients diagnosed with spondyloarthritis in the militay hospital of Tunis were included in the study. Age, gender and C-reactive protein were recorded. Data related to duration of the disease, Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were also recorded. Employed patients completed Work Productivity and Activity Impairment (WPAI) questionnaire witch assesses four subscales: presenteism, absenteism, overall work impairemend and daily activity impairement in the 7 past days.Results:Among the thirty three patients, 63 % were men and 37% were women. The average age was 43,7 ± 13,5. The average duration of disease was 8,5 ± 7,75 years. Mean C-Reactive protein was 27,5 ± 39,3. Mean ASDAS and BASDAI were 3,12 ± 1,39 and 4,26 ± 1,78 respectively. 22 patients (66%) had an active disease and 11 (33%)were in remission. 48,4% of patients were using NSAIDs, 48,4% were under DMARDs and 42% were under biologics (12 patients using TNF-alpha blockers and 2 patients were given IL-17 inhibitors). Among this patients, 27 were employed. Three patients (11%) had a total work disability and were retired from work and two have been outplaced.Employed patients worked an average of 35,6 ± 10,3 hours per week and missed an average of 3,48 ± 6,49 hours per week. The mean rates of absenteeism, presenteeism and work productivity loss were 8,8 ± 16,9 %, 48,4 ± 19,9 % and 48,6 ± 19,7 %.There was a statistically significant correlation between BASDAI and work missed hours (pConclusion:This study demonstrates that spondyloarthritis has a major impact on military patients’ work productivity with a significant correlation between WAPI indexes and disease activity scores (ASDAS CRP and BASDAI). No relation was found with C-reactive protein.Disclosure of Interests:None declared.

Background:The role of rheumatoid arthritis as an ischemic heart disease and heart failure risk factor is well acknowledged even if the physiopathological pathways are still debated. The effect of anemia on myocardial deformation has already been established and a hemoglobin level below 9g/dL was associated with a significantly lower global longitudinal strain (GLS) patients with no history of CVD or chronic inflammatory diseases.[1]Objectives:In the present study, we looked into the effect of anemia and hemoglobin on the myocardial impairement in RA patients.Methods:We conducted a monocentric cross-sectional study between march 2019 and september 2019 on 36 RA patients without any history of cardiovascular disease and non-altered left ventricular ejection fraction in the outpatient population of the rheumatology department of the military hospital of Tunis matched with 36 healthy control subjects. Both groups underwent conventional echocardiography and STE to measure GLS; subclinical left ventricular systolic dysfunction was defined as a GLS > −18%, and a complete blood cell count; anemia was defined as Hemoglobin levels < 12 g/dL for women and < 13 g/dL for men.Results:Myocardial deformation study revealed that rheumatoid arthritis patients had a significantly worse GLS than healthy controls (18.99±2.81% vs 20.42±1.33%; P=.015). We also observed that third of the RA patients had subclinical left ventricular systolic dysfunction.In our report 36% of RA patients were anemic. In our univariate analysis anemia was found to be significantly correlated with GLS (r=−0.368, P=.027) and hemoglobin was found to be the best predictor of subclinical LVSD in our ROC curve analysis (AUC=0.752, 95% CI: 0.577-0.927, P=.02). In our multivariate analysis anemia was the only factor that was independently related to subclinical LVSD (OR: 11.39, 95% CI: 1.57-82.89, P=.016).Figure 1.ROC curve analysis for Hemoglobin as a predictor of subclinical left ventricular systolic dysfunctionConclusion:To our knowledge, this is the first study to look into the relationship between GLS and anemia among RA patients, and now it is safe to say that anemia is yet another added burden on the myocardial function in RA patients that needs to be taken into account when discussing therapeutic action.References:[1]Zhou Q, Shen J, Liu Y, Luo R, Tan B, Li G. Assessment of left ventricular systolic function in patients with iron deficiency anemia by three-dimensional speckle-tracking echocardiography. Anatol J Cardiol. 2017;18(3):194–9.Disclosure of Interests:None declared

Background:Hip involvement is a common feature in spondyloarthritis (SpA). Whether the hip is part of the axial or appendicular skeletal is still a matter of discussion.Objectives:We aimed to assess the relationship between sacroiliitis, spinal and hip involvement in SpA.Methods:Patients with SpA diagnosed according to the assessment of Spondyloarthritis International Society criteria were included in this retrospective cross-sectional study.The modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and the Bath Ankylosing Spondylitis Radiology Index-spine (BASRI-s) were used to assess the radiographic involvement of the spine.The sacroiliac joints were scored according to the modified New York criteria.Radiological hip involvement was scored using the Bath Ankylosing Spondylitis Radiology Index hip (BASRI-h).Patients were divided into two groups: G0 including patients without hip involvement and G1 patients with hip involvement.Results:We included 112 patients with a sex ratio of 2.4. The average SpA symptom duration was 9.33 ± 8.93 years. The diagnostic delay was 42.92 ± 52 months.Radiographic hip involvement was noted in 39.28% of cases. It was bilateral in 31 patients (70.4%). The total number of coxitis was 75. Severe and moderate hip involvement (BASRI-h ≥ 3) affected 21 hips. The most common radiographic pattern was early coxitis (n=31, 41.3%) followed by the destructive form (n=22, 29.3%, mimicking-osteoarthritis form (n=15, 20%), condensing form (n=5, 6.6%) and ankylosing form (n=2, 2%).Radiographic sacroiliitis was noted in 75.8% of patients. It was bilateral in 91.7% of cases. Among the 161 sacroiliac joints fulfilling the m-New-york criteria, 32.9% had grade 4 and 37.2% had grade 3.The mean mSASSS was 10.26 ± 15. The mean BASRI-t, BASRI-C, and BASRI-L were 3.99 ± 2.9, 0.89 ± 1.3, and 1.1 ± 1.3 respectively.Radiographic sacroiliitis was more common in patients with hip involvement (G1) (90.9% vs 68.2%, p=0.00). Patients in G1 had higher mSASSS (15.78 ± 18.24 vs 6.29 ± 11.85, p=0.01), BASRI-L (1.73±1.46 vs 0.75 ± 1.131, p=0.009), and BASRI-s (5.46 ± 3.02 vs 3.19 ± 2.46, p< 10-3) than patients in G2. There was no significant difference between the two groups regarding the BASRI-C.Multivariable analysis revealed that radiographic sacroiliitis was associated with hip involvement (OR=14.81, 95%, [1.1-198], p=0.042).When comparing patients with severe and moderate hip involvement (BASRI-h ≥ 3) and those with mild involvement, we didn’t find significant differences regarding BASRIs, BASR-L, BASRI-c, mSASSS, and sacroiliac involvement.Conclusion:As reported in previous studies [1], we concluded that structural axial lesions were higher in patients with coxitis. Structural damage to the sacroiliac joint in SpA was predictive of hip involvement.We suggest that sacroiliitis, spinal and hip involvement are part of the same spectrum.References:[1]Chen H-A, Chen C-H, Liao H-T, Lin Y-J, Chen P-C, Chen W-S, et al. Factors associated with radiographic spinal involvement and hip involvement in ankylosing spondylitis. Semin Arthritis Rheum. 2011;40 (6):552-8Disclosure of Interests:None declared

Background:The arrival of Biotherapy has changed the management and prognosis of rheumatoid arthritis (RA). However, drug survival of the first biotherapy is changing according to the studies.Objectives:We aimed to report the data on the drug survival of biotherapies in RA, collected from the Tunisian BIologics National Registry (BINAR)Methods:BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) and refractory to conventional background treatments (csDMARDs), who required the use of biological treatment of anti TNF, anti IL6 or Rituximab type. Data were collected and analyzed through an electronic platform managed by DACIMA. Sociodemographic data (age, gender, body mass index (BMI), smoking) and characteristics of RA (duration of evolution, erosive character) were collected. RA activity was studied by the DAS28-VS score and drug survival was evaluated by the duration of the biologics.Results:We included 175 patients with a sex ratio of 5.7 and a mean age of 54.1 ± 12.6 years [19-79]. Patients were smoking in 6.7% of cases and mean BMI was 27.9 ± 5.2 kg/m2[15.1-45.2]. RA was erosive in 73.1% of cases and the mean disease duration was 6.7±3.5 years. Disease activity was moderate (mean DAS28vs: 4.9±1.5). Concerning the treatments, 139 (79.4%) of the patients received TNFα inhibitor, 31 (17.7%) of the patients were on IL6 inhibitor and 15 (8.6%) were on Rituximab.The mean duration of drug survival for TNFα inhibitor agents was 15.2 months, 18 months for anti IL6 and 16.3 months for Rituximab. The drug was discontinued by 19 patients (10.8%). The causes of discontinuation were primary failure in 31.8% (7 subjects), secondary escape in 9.1% (4 subjects), the occurrence of adverse effects in 31.8% (7 subjects), intolerance to drug in 9.1% (2 subjects), non-compliance for one patient and for other reasons in one case.The drug survival of TNF inhibitor was not associated with socio-demographic data (gender (p=0.9), age (p=0.4), smoking (p=0.9), BMI (p=0.9)), nor with the characteristics of the disease duration (p = 0.5), DAS28 vs (p = 0.9), association with a csDMARDs (p = 0.2)) except the presence of erosion (p = 0.013).Also, drug survival of IL6 inhibitor drugs was not associated with socio-demographic parameters (gender (p = 0.1), age (p= 0.6), smoking (p= 0.6), BMI (p = 0.4)) and the characteristics of the disease (duration (p = 0.9), erosive character (p = 0.6), DASvs (p = 0.1), association with a csDMARDs (p = 0.2)).Similarly, drug survival of Rituximab was not associated with socio-demographic data (gender (p = 0.6), age (p = 0.7), BMI (p = 0.7)) or with the characteristics of RA (duration of evolution (p= 0.5), erosive character (p = 0.6), DASvs (p = 0.08), association with a csDMARDs (p = 0.5))Conclusion:Our study demonstrated that IL6 inhibitor had the longest duration of drug survival (18 months). The major causes of cessation were dominated by primary failure and the occurrence of an adverse event. Finally, the drug survival of TNF inhibitor agents was associated with the erosive character.Acknowledgments:noneDisclosure of Interests:None declared

Background:In the recent decades, biological disease-modifying antirheumatic drugs (bDMARDs) have significantly improved management and quality of life in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA).However, bDMARDs have also a strong influence on the immune system, leading to a risk of serious infection. Reactivation of hepatitis B (HBV) and C (HCV) virus is one of the most redoubtable complications of these immunosuppressive agents.Objectives:The aims of this study were to determine the screening rate for hepatitis B and C before starting a biological treatment and to examine the prevalence of their markers in patients with RA or SpA.Methods:Our study evaluated all patients included in the Tunisian registry BINAR (Biologic National Registry) since 2018 who had RA (ACR/EULAR 2010) or SpA (ASAS criteria) aged with more than eighteen years old and receiving their first bDMARDs during the two past years.The following information were retrieved from the registry: demographic data on the patients, disease parameters, medication, HBV surface antigen (HBs Ag), antibody to HBs Ag (Anti HBs), antibody to HBV core antigen (Anti HBc), HBV-DNA, antibody to HCV (anti HCV) status and liver function tests (AST: aspartate aminotransferase; ALT:alanine aminotransferase).Results:A total of 298 patients was included, 111 men and 178 women, with a mean age of 49.2 ± 14.1 years old [18-79]. Among them, 58.7% were diagnosed with RA and 41.3% were diagnosed with SpA. The mean disease duration was 6.7±3.5 years [1-12] in patients with RA and 6.5±3 [1-12] in patients with SpA. The mean Disease Activity Score (DAS28) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were respectively of 4.9±1.5 [1-8] and 4.1±1.8 [0-9].Therapeutically, 167 patients (56%) were on Prednisone at a mean daily posology of 8.2±5.4 mg [4-60] and 70.3% on conventional synthetic disease modifying antirheumatic drug (csDMARD) in association with bDMARDs. It was about Tumor Necrosis Factor alpha antibodies (anti TNF a) in 87.9% of cases, Tocilizumab in 10.4% of cases and Rituximab in 5% of cases.A screening of HBV was performed in 286 patients (96%). Ag HBs was positive in two cases (0.7%), and anti-HBc was positive in 16 cases (6.4%) which indicate a prior HBV infection. Fifteen patients (6%) were immunized with positive anti HBs. HBV-DNA was measured in 177 cases (66.8%) and was positive in 15 patients (6%).HCV infection was searched in 282 patients (94.6%) and anti-HCV was negative in all cases.AST and ALT mean rates were respectively of 18.3 [2-108] and 17.9 UI/l [2-74]. A perturbation of these liver function tests was observed in 13 patients (4.4%).Conclusion:Screening for hepatitis B and C were performed respectively in 96% and 94% of our Tunisian patients before receiving any bDMARDs. This should be systematic to avoid HBV reactivation which can lead to fulminant hepatic failure with a severe prognosis.Disclosure of Interests:None declared

Background:Comorbidities can be associated with rheumatoid arthritis (RA) and spondyloarthritis (SpA). This association can be fortuitous but can also be secondary to rheumatism itself or to the effects of the treatments used. These comorbidities can worsen the disease and even increase patient mortality.Objectives:To assess the prevalence of comorbidities in RA or SpA patients from the Tunisian BIologics National Registry (BINAR) and to focus on their influence on the disease activity.Methods:BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) or SpA (ASAS 2009 criteria). Data were collected and analyzed through an electronic platform managed by DACIMA. They included demographic data, smoking status and types of comorbidities (cardiovascular disease, diabetes, dyslipidemia, osteoporosis, high blood pressure (HBP), neoplasia, gastrointestinal ulcer, depression and fibromyalgia). RA activity was evaluated by the DAS28-VS score and SpA activity by the BASDAI and ASDAS-CRP scores.Results:We included 298 patients (175 PR and 123 SpA) making the mean sex ratio 0.6 and mean age 49.18 years ± 14.1 [18-79]. Mean BMI was 27.0 ± 5.5 kg / m2[15 -45] and 17.7% of the patients were current smokers. Concerning disease activity, mean DAS28-VS in RA was at 4.9 ± 1.5 [1.1 - 8.1 and mean BASDAI and ASDAS-CRP, in SpA, were respectively 4.1 ± 1.8 and 2.8 ± 1.1. Comorbidities were noted in 54% of patients (62.1% in SpA and 37.9% in RA), with an average of 1.7 comorbidities per patient.The most common comorbidities were osteoporosis (38.8%), cardiovascular disease (20.1%), diabetes (16.8%), HBP (18.1%), dyslipidemia (6.7%) and GIU (6.0%). Depression, fibromyalgia and neoplasia were mentioned in 1.7%, 1% and 1%, respectively.No correlation was found between the number of comorbidities and the activity level of RA: DAS28-VS (p=0.12), nor the activity level of SpA: BASDAI(p=0.07), ASDAS-CRP(p=0.15). Correlations were studied between each comorbidity and activity disease parameters of RA and SpA, they are specified in Table 1. We found that only the presence of osteoporosis was associated with SpA activity, (ASDAS-CRP; p = 0.02).Tableau n°1:Relation between comorbidities and the disease activity parameters of rheumatoid arthritis and SpondyloarthritisDAS 28 ESRBASDAIASDAS CRPDiabetesp = 0.737p = 0.633p = 0.652High Blood pressurep = 0.252p = 0.998p = 0.323Obesityp = 0.565p = 0.585p = 0.904Dyslipidemiap = 0.332p = 0.349p = 0.997Osteoporosisp = 0.372p = 0.989p = 0.020Gastrointestinal ulcerp = 0.829p = 0.286p = 0.910DAS: disease activity score; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; ASDAS: Ankylosing Spondylitis Disease Activity ScoreConclusion:According to this study, in patients with RA and SpA associated comorbidities may occur more frequently than expected (54%). However, they had no relation to the activity of the disease according to their frequencies or their types, except osteoporosis which was significantly associated with the SpA activity. Identifying these comorbidities may affect the management and treatment decisions for these patients to ensure an optimal clinical outcome.Acknowledgments:noneDisclosure of Interests:None declared

Background:Spondyloarthritis (SpA) is characterized by significant radiographic changes in the spine. The structural spine damage can be assessed using several scorings such as the Bath AS Radiology Index (BASRI) and the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS).Objectives:We aimed to identify factors associated with structural damage in the spine using these scores.Methods:We conducted a cross-sectional study including patients with SpA diagnosed according to the assessment of Spondyloarthritis International Society criteria.To assess the radiographic involvement of the spine, we used the mSASSS, the BASRI-spine (BASRI-S), the BASRI-lumber (BASRI-L) and the BASRI-cervical (BASRI-C).Disease activity was assessed using the BASDAI and ASDAS-CRP.Results:Among the 112 patients, 72.32% were men. The mean age was 43.78 ± 12,91 years. The mean age at diagnosis was 37.8 ± 13.45 years. The diagnostic delay of 37,8 ± 46 months.Forty-nine patients were smockers (43.8%).The mean BASDAI score and ASDAS–CRP score were 4.04 ± 1.99 and 3.30 ± 0.87.The mean ESR and CRP were 36.21 ± 27 (mm/H) and 31.28 ± 47.25 mg/LThe mean BASRI-S was 3,99 ± 21,96 and the mean mSASSS was 10,26 ± 15,41.Twenty-five patients (22.3%) had non-radiographic axial SpA.Men had higher BARSI-L (1.36 vs 0.7, p= 0.045) and BASRI-S (4.3 vs 3.09; p=0.047) than women.Moreover, smokers’ patients had higher mSASSS (14.07 vs 7.02; p=0.031), BASRI-C (1.23 vs 0.62; p=0.031), and BASRI-S (4.82 vs 3.35; p= 0.009) than nonsmokers’ patients.A positive correlation was noted between age and BASRI-C (r= 0.260, p=0.012). There was no correlation between age at the onset of SpA and structural spine damage.We found a positive correlation between disease duration and the following scores: BASRI-C (r=0.245, p=0.018) and BASRI-S (r=0.274, p=0.003).Patients with non-radiographic axial SpA had lower mSASSS (4.05 vs 12.14; p=0.034), BASRI-s (1.2 vs 4.9; p< 10-3), and BASRI-L (0.42 vs 1.4; p=0.003) than patients with radiographic axial SpA.There was no correlation between the radiographic index and BASDAI and ASDAS-CRP.Conclusion:We confirmed previous observations that male gender, smoking and disease duration are associated with structural damage in the spine [1].However, CRP and other inflammatory biomarkers were not associated with radiographic evidence of spine involvement.As observed in previous studies, the radiographic spine damage did not correlate with disease activity (BASDAI) [1].References:[1]Sari I, Haroon N. Radiographic Progression in Ankylosing Spondylitis: From Prognostication to Disease Modification. Curr Rheumatol Rep. 2018 Nov 8;20(12):82.Disclosure of Interests:None declared

Background C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are the main inflammatory biomarkers used in assessment of disease activity in numerous inflammatory diseases such as ankylosing spondylitis (SA). In recent years, it has been shown that Platelet count (PC) provided additional information on inflammatory status. Objectives The present study aimed to investigate the correlation between PC and clinical activity indices assessed by Bath ankylosing spondylitis disease activity index (BASDAI) Methods The study included 68 patients who fulfilled Assessment of Spondyloarthritis International Society Criteria. A cell blood count, including platelet count, ESR (mm/h), CRP (mg/L) and albumin (g/L), was obtained for each patient. Disease activity measures at the time of blood sampling were obtained using the BASDAI. Statistical Package for Social Sciences (SPSS) was used for analysis. Results Of the 68 patients, 73.5% were male (Sex Ratio: 2.7). The mean age was 36±12.9 years. The mean disease duration was 40 months [0–192]. The average age of the onset of the disease was 36.6±11.9 years. No patient had ongoing infection at time of study. The mean BASDAI score was 5.1 [1.55–9.2]. Forty-one% of our patients (n=28) had active AS (BASDAI >4) The mean ESR, CRP, albumin and PC were 39.4 (mm/h), 34.1(mg/dL), 39,32 g/L and 311 (103/mL), respectively. There was a positive correlation between platelet count and following biomarkers: ESR (r: −0.481; p: 0.000), CRP (r: 0.417; p: 0.000) and albumin levels (r: −0.556; p:0.000). A negative correlation between and Haemoglobin (Hg) was noted (r: −0.643; p: 0.000). There was no significant difference in laboratory parameters (ESR, CRP, albumin, PC, Hg) between patients with active AS (BASDAI >4) and those with inactive AS (BASDI Conclusions Although acute phase reactant such as ESR, CRP and PC mirror disease activity in AS,1 their values were not associated with disease activity assessed by BASDAI in our study. However, new prospective studies including larger study groups are required to verify the findings of the present study. Reference [1] Ruof J, Stucki G. Validity aspects of erythrocyte sedimentation rate and C-reactive protein in ankylosing spondylitis: a literature review. J Rheumatol1999;26:966e70. Disclosure of Interest None declared

Background The notions of apprehension-avoidance and beliefs are among the psychosocial factors associated with the occurrence, maintenance and strengthening of the chronic painful process. Therapeutic education is increasingly described in the literature as a means to manage these factors in order to limit the transition to a chronic stage. Objectives The aim of this study is to examine the effect of therapeutic education on fears and beliefs in chronic low back pain. Methods A prospective, comparative study was conducted with two groups of 50 patients each one having chronic low back pain. Both groups had benefited from the same physical rehabilitation program. The second group concurrently attended therapeutic education sessions. Fears and beliefs of patients and their kinesiophobia were evaluated with the FABQ: Fear-Avoidance beliefs questionnaire and the TSK: Tampa scale of kinesiophobia for the evaluation of kinesiophobia index. Results The initial evaluation of apprehension-avoidance showed a high FABQ score in two groups. Management that was limited to physical rehabilitation demonstrated no effect on the apprehension-avoidance indices evaluated by the FABQ scale. However, there was a clear improvement in apprehension and avoidance in the G2 and with a statically significant difference (P=0.03). An initial and high kinesiophobic score (≥48) was noted in two groups. G1 patients showed no significant improvement in their TSK scores after the end of the program. G2 patients who benefited from a therapeutic education workshop improved their TSK scores significantly after the program completion compared to G2. Conclusions The integration of the patient into the therapeutic education workshops improved the behavior of apprehension and kinesiophobia. This further supports the usefulness of applying cognitive therapy to our patients when restructuring of preconceived ideas about movement and physical activities. References Nguyen C, Poiraudeau S, Revel M. Lombalgie chronique: facteurs de passage a la chronicite. Rev rhum.2009;76:537–42. Butron AK, Waddel G, Tilloston KM, Sumerton N. Information and advice to patients with back pain can have positive effects. A randomized controlled trial of a novel educational book in primary care. Spine. 1999;24:2481–91. Fritz JM, George SZ, Delitto A.The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status.Pain. 2000;94:7–15 Disclosure of Interest None declared

Background The occupational impact of low back pain is generally assessed in terms of absenteeism and duration of sick leave. A non-return to work greater than eight days has been considered a poor prognosis factor. Several psychosocial factors have been identified as the original cause. Objectives Studying the impact of erroneous beliefs, avoidance behaviors, apprehension and fear of movement on sick leave in patients with chronic low back pain. Methods A prospective study was conducted in patients with chronic low back pain patients. The notion of apprehension-avoidance was evaluated by the Fear Avoidance Beliefs questionnaire (FABQ), fear of movement by the Tampa scale of kinesiophobia (TSK) and functional disability by the Functional Disability Scale Of low back pain: EIFFEL (French version of Roland Disability Questionnaire). A study of the correlations between these different parameters and the duration of sick leave was carried out subsequently. Results Our study included 100 patients. The findings revealed a 95% absenteeism rate including 67% with a sick leave of more than one month. The FABQ, TSK and EIFFEIL scores were high. The statistical study concluded that there was a positive and significant correlation between sick leave time, fears and erroneous beliefs (r =0.147, P=0.033). We also found a positive and significant correlation between the duration of sick leave and kinesiophobia. There were no statistically significant correlations between sick leave and functional disability. Conclusions The high scores of FABQ and TSK confirm the important role of false beliefs and fear of movement in the genesis of chronicity in chronic low back pain as reported in the literature. The positive correlations found in our study reinforce the theory of the deconditioning of these patients following their beliefs. Management of these factors would be an important contribution to limit sick leave times in chronic low back pain. References Williams RA, Pruitt SD, Doctor JN, Epping-Jordan JE, Wahlgren DR, Grant I et al.The contribution of job satisfaction to the transition from acute to chronic low back pain. Arch Phys Med Rehab.1998;79:366–74. Ratinaud MC,Chamoux A,Glace B,Coudeyre E. Job satisfaction evaluation in low back pain: a literature review and tools appraisal. Ann Phys Rehabil Med. 2013;56(6):465–81. Fayad F, Lefevre-Colau MM, Poiraudeau S,Fermanian J, Rannou F, Wlodyka Demaille S et al. Chronicite, recidive et reprise du travail dans la lombalgie: facteurs communs de pronostic. Ann Readap Med Phy.2004; 47:179–88. Gronblad M, Jarvinen E, Airaksinen O, Ruuskanen M, Hamalainen H, Kouri JP. Relationship of subjective disability with pain intensity, pain duration, pain location and work –related factors in non operated patients with chronic low back pain. Clin J Pain. 1996;12:194–200. Disclosure of Interest None declared

Resume Le syndrome SAPHO (synovite, acne, pustulose, hyperostose, osteite) est une entite rare qui designe l’association d’un ensemble heterogene de manifestations cutanees et osteo-articulaires ayant pour denominateur commun un processus inflammatoire aseptique. L’etiopathogenie de ce syndrome reste discutee. Bien que certains l’integrent dans le cadre des spondylarthropathies, d’autres le considerent comme d’origine infectieuse. Le diagnostic repose sur la presence d’au moins un des trois criteres diagnostiques proposes par Kahn. Le traitement du syndrome SAPHO repose sur les anti-inflammatoires non steroidiens, les antibiotiques, les corticoides, le methotrexate et plus recemment les bisphosphonates et les anti-TNFα.

Background: Primary biliary cirrhosis (PBC) is an autoimmune disease. Implication of TNF alpha in its pathogenesis has been suggested. Findings: We describe the case of a 56-year-old female patient with rheumatoid arthritis (RA) treated with anti- TNF alpha agents (Infliximab). During this treatment, perturbation of liver tests was noted. Investigations concluded to PBC. Ursodesoxicholic acid was prescribed in association with infliximab. This therapy maintained liver enzymes within the normal range with good response of the RA. Conclusions: This case suggests that TNF alpha blockers may be a good therapeutic alternative when PBC is associated to Rheumatoid Arthritis.

Systemic sclerosis is a connective disease usually known to spare the central nervous system. This has been much debated by recent imaging studies. We report a 56-year-old woman followed-up for systemic sclerosis since 2005. Four years later, she presented with cerebellar and pyramidal syndrome. Magnetic resonance imaging showed signs of cerebral vasculitis. The patient was treated by corticosteroids and cyclophosphamide pulses followed by azathioprine for maintenance therapy. Clinical and radiological outcomes were favourable. In patients with systemic sclerosis and neurological symptoms, abnormalities in the cerebral magnetic resonance imaging may, in the absence of another obvious etiology, indicate a central nervous system involvement associated with this systemic disorder.

Le lymphome de Burkitt est un lymphome lymphoblastique B caractérisé par une prolifération monoclonale de cellules lymphoïdes B . L'atteinte osseuse au cours de ce type de lymphome est un événement rare. La localisation maxillo-faciale semble être la plus fréquente. Cependant l'atteinte des os long reste exceptionnelle. Nous rapportons une nouvelle observation d'un lymphome de Burkitt révélé par des gonalgies inflammatoires. IL s'agit d'un patient âgé de 17 ans, qui se plaint de gonalgie droite, d'allure inflammatoire évoluant depuis quelques mois. L'examen du genou ne montre pas de signes inflammatoires locaux, ni de limitation de la mobilité. La biologie trouve un SIB et une anémie à 9 g /dl. La radiographie standard du genou (A) montre la présence de lésions ostéolytiques métaphyso-épiphysaire de l'extrémité supérieure du tibia et l'imagerie par résonnance magnétique (B) une ostéolyse géographique ovalaire métaphyso-épiphysaire soufflante mesurant 59/53 cm siégeant au niveau de l'extrémité supérieure du tibia avec une zone de transition étroite qui se rehausse en péri-lésionnel sans rehaussement intra lésionnel après injection du gadolinium. La biopsie de cette lésion était non concluante et devant la survenue d'une hématémèse, une fibroscopie oeso-gastro-duodénale faite a conclu à la présence d'une antrite nodulaire et d'une lésion duodénale dont la biopsie a montré un lymphome de Burkitt. Le bilan d'extension a conclu à une atteinte ganglionnaire diffuse, pancréatique, rénale bilatérale et digestive. Le patient a été traité par chimiothérapie. L'évolution était favorable par la disparition des douleurs. Le scanner de contrôle a montré une régression des lésions osseuses (disparition des lésions tissulaires) avec début de reossification.

Background Pulmonary arterial hypertension (PAH) is a rare disease characterized by the progressive increase in pulmonary artery pressures, leading to right heart failure. Systemic lupus erythematosus (SLE) is the second connectivity after Scleroderma can be complicated by PAH. This study aims to estimate the prevalence of PAH in SLE, detected by echocardiography. Methods This is a retrospective study of ten years about 80 patients with SLE fulfilling the criteria of the ACR (American College of Rheumatology), followed in our department of internal medicine. Echocardiography with measurement of pulmonary artery pressure was performed in 72 patients. Above 30 mmHg mean arterial pressure was used to define PAH. Results Ten patients (7% of cases) had pulmonary arterial pressure greater than 30mmHg. Two of them had lung disease (the first with emphysematous lung and the other a lupus interstitial lung disease). Three patients had mitral insufficiency. A syndrome of anti-phospholipid antibodies (APS) was noted in four patients (40% of cases). Five other lupus patients had isolated PAH (50% of cases). We noted a positive anti-Sm antibody in three patients (40% of cases). Conclusions PAH is a rare and severe complication of SLE and is a bad prognostic factor. Its detection is based on echocardiography. PAH lupus may be the expression of APS or secondary to pulmonary fibrosis or left valvulopathy. The treatment is based on corticosteroids and immunosuppressive association. Anticoagulants are indicated in cases of APS. Due to the severity of PAH in SLE, a screening echocardiography should be systematically offered to patients with SLE to treat early this serious complication and to enhance prognosis. Disclosure of Interest None declared

Background Residual pain after Infectious spondylodiscitis can result in a major handicap in social and professional life. The aim of the present work was to describe predictive factors of Residual pain after Infectious Spondylodiscitis according to the experience of an internal medicine department in Tunisia. Methods Patients with SDI either confirmed or presumed and hospitalized in the internal medicine department of The Principle Military Hospital Of Tunis, Tunisia have been included in the Study. Factors correlated with later pain are gathered in this study. Results See Table 1. Fourty-four patients met the inclusion criteria. They have been gathered over 20 years-period. They were 24 men and 20 women with an average age at 52.5 years. The diagnosis was a Tuberculous Spondylodiscitis in 22 cases (50%): among them 10 patients had a concomitant extra spinal TB. The diagnostic delay was 231 days for TB SDI and 40.5 days for SDP. Treatment duration was 13 months for SDT and 18 weeks for SDP. The outcome was favorabl Regular monitoring was observed in 38 patients (17 SDP, SDT 21) with an average duration of 20 months (5–48 months). Conclusions Neurological signs at first examination and MRI are main factors of residual pain in SDI. Disclosure of Interest None declared

Background The aim of the present work was to describe predictive factors of good or bad outcome Infectious Spondylodiscitis according to the experience of an internal medicine department in Tunisia. Methods Patients with SDI either confirmed or presumed and hospitalized in the internal medicine department of The Principle Military Hospital Of Tunis, Tunisia have been included in the Study. Results Fourty-four patients met the inclusion criteria. They have been gathered over 20 years-period. They were 24 men and 20 women with an average age at 52.5 years. The diagnosis was a Tuberculous Spondylodiscitis in 22 cases (50%): among them 10 patients had a concomitant extra spinal TB. The diagnostic delay was 231 days for TB SDI and 40.5 days for SDP. Length of hospital stay was 48.6 days (6–225 days): with a mean of 48.9 days in SDT and 45.3 days in SDP. Regular monitoring was observed in 38 patients (17 SDP, SDT 21) with an average duration of 20 months (5–48 months). Three were lost views and three died. Evolution was considered positive if there was a clinical and biological improvement and no recurrence or death. The analytical study objectified that existence of a immunosuppression, a longer diagnosis period, or hospitalization period and the follow-up duration were associated with a longer duration of treatment (p=0.038, p The absence of orthopedic complications initially or during the evolution and treatment duration were the only factors associated with good favorable change (p Conclusions Earlier treatment with effective duration and follow up are predictive factors of favorable outcome in SDI either due to TB or regular germs. Disclosure of Interest None declared

Background Spinal infections can be described aetiologically as pyogenic, granulomatous (tuberculous, brucellar, fungal) and parasitic. Its early diagnosis is crucial to the establishment of adequate treatment in order to get favorable outcomes. The aim of the present work was to describe clinical, diagnostic and therapeutic aspects of Infectious Spondylodiscitis according to the experience of an internal medicine department in Tunisia. Methods Patients with SDI either confirmed or presumed and hospitalized in the internal medicine department of The Principle Military Hospital Of Tunis, Tunisia have been included in the Study. Results Fourty-four patients met the inclusion criteria. They have been gathered over 20 years-period. They were 24 men and 20 women with an average age at 52.5 years. The diagnosis was a Tuberculous Spondylodiscitis in 22 cases (50%): among them 10 patients had a concomitant extra spinal TB. The diagnostic delay was 231 days for TB SDI and 40.5 days for SDP. Revealing symptoms were dominated by pain:, often mixed (61%). Radicular pain was noted in 15 cases. Fever was found in 17 cases. On examination: spinal syndrom was present in 65.9% of cases, spinal cord compression signs were found in 8 patients. MRI was contributive in all cases showing a disc enhancement in 50% (SDP in 67%, TSDI in 33%), epiduritis in 63.5% (SDP 60%, TSDI 67%). The disc biopsy was contributive in 71% of cases. The diagnosis was certain in 15 cases, highly probable in 18 cases and presumptive in 11 cases. Treatment duration was 13 months for SDT and 18 weeks for SDP. The outcome was favorable in 30 cases (SDP 13, TSDI 17). Conclusions Infectious sondylodiscitis remains a diagnostic and therapeutic problem in our country. Only an early care can enhance its prognosis. Disclosure of Interest None declared

Background Immunodepressed patients are a high-risk group for tuberculosis. Objectives The aim is to study the differences in presentation, diagnosis and therapeutic management of tuberculosis according to the immune status of patients. Methods A retrospective study of the files of patients hospitalized in the internal department of military hospital of Tunisia for a Mycobacterium tuberculosis infection. Comparison of two populations: immunodepressed versus non immunodepressed. Results 129 patients aged 20 to 90 were included, 49 patients were considered immunodepressed and 80 non immunodepressed. The causes of immunodepression were: age ≥65years (n=27), diabetes (n=20), immunosuppressive drugs (n=16), chronic inflammatory diseases (n=9), chronic renal failure (n=7), neoplasia (n=8), chronic hepatopathy (n=4), and HIV infection (n=2). Comparison between the 2 populations revealed a more frequent history of absence of vaccination in the immunodepressed (p=0.0001), shorter duration of hospitalisation (p=0.01), greater frequency of disseminated forms (p=0.02), more frequent use of corticoids (p=0,007) and enhanced mortality (p=0.04). There was no difference in the 2 groups with regard to the clinical signs having evoked tuberculosis, the diagnostic method and the bacteriological results. Conclusions The severity and the frequency of tuberculosis in immunodepressed patients should incite clinicians to evoke tuberculosis and to initiate rapidly an efficient treatment. In case of alteration in immune defenses, prophylactic treatment Disclosure of Interest None declared

Objectives This study aimed to investigate EULAR 2003 recommandation application on a sample of 60 (KOA) patients. Methods Retrospective longitudinal study done on the department of Physical and Rehabilitation Medicine of the Principal Military Hospital of Tunis between January 2011 and December 2012, about 60 patients with knee OA. These patients were divided into two groups of 30 cases: patients aged 65 years and over (SA) and young adults 30 to 55 years (SJ). Results All patients received therapeutic management combiningpharmacologic and nonpharmacologic. This treatment was individualized, taking into account: clean Knee risk factors (obesity, mechanical, physical activity), general risk factors (age, comorbidity, polypharmacy), the intensity of pain and disability that it entails, to the presence of inflammatory signs (particularly effusions)? of the location and the degree of structural reached. The above-mentioned elements have been identified in interrogation and the initial review of our patients, further management was judged on these factors. However, the treatment received and appreciation of weight reduction have not mentioned in their records. All patients received an educational program focusing on the economy joint, the need for weight loss and self-rehabilitation. this program was initiated concomitantly with functional rehabilitation sessions. The use of assistive devices were limited to 13.3% of our patients, all of elderly. Weight loss could not be assessed (default data). Paracetamol is the most prescribed treatment in our series: 53.3% of our patients received paracetamol alone or in combination. The Topical NSAIDs are prescribed in 63.3% of patients in which 60.5% are of older group In 5 cases of patients with peptic ulcer documented, there has been use of Anti of H2 as gastric coverage during short periods of NSAID prescription. Analgesics II were used in 5 cases. The AASALs were used in 10 cases, especially in young patients. Infiltration of chondroprotectors using hyaluronic acid were found in 4 cases. Intra articular corticosteroid injections were performed in 8 patients. These findings were not influenced by age. Conclusions Application of recommadations depends greatly on socio-economic conditions of countries and their social security systems. In our study, several recommendations were insufficiently met. A study on a larger population should investigate the factors influencing the implementation of these recommendations and the opinion of various stakeholders (physicians, patients and physiotherapists) Disclosure of Interest None declared

Background Physical therapists provide a variety of interventions, such as manual therapy techniques, balance, coordination, and functional retraining techniques, knee taping techniques, electrical stimulation, and foot orthotics to assist in overcoming some of the barriers that make participation in exercise and physical activity difficult. Objectives This study aimed to assess the role of physical therapy in management of knee osteoarthritis on both levels pain and function. Methods Retrospective longitudinal study done on the department of Physical and Rehabilitation Medicine of the Principal Military Hospital of Tunis between January 2011 and December 2012, about 60 patients with knee OA. These patients were divided into two groups of 30 cases: patients aged 65 years and over (SA) and young adults 30 to 55 years (SJ). The evaluation protocol included clinical algofunctional before and after medical and rehabilitative treatment performed on an outpatient program with three sessions per week for two months. Results There were 35 women and 25 men with a mean age of 58±6.27 years. The average duration of knee OA was 63.74±38.62 months. The main characteristics of elderly subjects compared to young subjects, before rehabilitation, were the bilateral involvement of the knees (p=0.02), severity of pain (p=0.02), disability (p=0.006), stiffness (p=0.02), muscle weakness of the quadriceps (p=0.006), hamstrings (p=0.03), the retraction of the latter (p=0.04) and reducing the walking distance (p=0.04). 38 patients (19 and 19 SA SJ) adhered to the rehabilitation program. After rehabilitation, the main features were the reduction of pain by 60%, improving activities of daily life of 50%. The rehabilitative treatment was more effective in the elderly in terms of pain (p=0.03) and activities of daily living improvement (p=0.01). Patients in both groups improved their scores with no significant differences related to age. Considering respectively the VAS pain (p=0.48), WOMAC index (p=0.39) and LEQUESNE Index (p=0.75). At the end of the rehabilitation program, a reduction in pain intensity was observed in all AS (19 cases), 13 of them have lowered their VAS pain threshold of less than 50 mm. In young subjects, the pain remained stationary in 2 cases and was exacerbated in one case. Conclusions Physical therapy appears to be an important tool for KOA management. Future studies are needed to improve our understanding of factors that can influence the responsiveness of patients with knee osteoarthritis to exercise and physical activity programs. Disclosure of Interest None declared

Background Brucellosis is the most common zoonotic infection worldwide. It is caused by intracellular gram-negative bacteria, Brucella spp. InTunisia, human brucellosis was reported in the first time in 1909. It represents a notifiable disease that occurs as an endemic evolution. The physical findings depend on the duration of illness, and the disease may be attended by various complications. Methods This is a retrospective study in the internal medicine department (from 2000 to 2013). The aim of this study was to evaluate the clinical, laboratory findings and therapeutic features of patients with brucellosis. Results We have studied 42 cases of brucellosis (29 men and 13 women9s), they were 46-year-old on an average (16-78 years). Most came from country areas, and only 7 came from the city. The source of infection was attributable to the consumption of contaminated milk or cheese, except in 3 cases of workplace exposure (veterinarian=1 case, laboratories=2 cases). Brucellosis is acute in 30 patients (71%) and focused in 12 patient cases (29%): (spondylodiscitis=8 cases, coxite=2 cases, sacroiliitis=3 cases, splenic abscess=1 case). The clinical profile was made of: fever (100%), articular and muscular pains (70%), sweats (50%) and spinal symptoms (19%). The clinical diagnosis of brucellosis was made by serology in 100% of patients (rose Bengal and/or Wright). The only organism identified was brucellosis melitensis in 18 cases (42%). All of patients had medical treatment (rifampicin and tetracycline) associated to corticosteroids in one case (spondylodiscitis with epiduritis). Conclusions Brucellosis presents with a wide clinical spectrum. Brucellosis melitensis is the species most incriminated. Eradication of the disease in humans can only be achieved by the control of the disease in animals. This necessitates a multidisciplinary approach involving both humans and animals. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5770

Background Interstitial lung disease (ILD) is a heterogeneous group of disorders that are classified together because of similar clinical and radiographic manifestations. However, prognosis and therapeutic response are influenced by the presence of an underlying cause. Objectives The aim is to study the etiologic profile of ILD in internal medicine. Methods A retrospective analysis of patients with ILD hospitalized in internal medicine department of military hospital from 2000 to 2013. Results We evaluated 44 patients (30 women, 14 men) with a mean age of 57 years. Among them, 32% were smokers. The most common symptom was progressive dyspnea occurring in 83% of cases. All the patients had abnormal chest radiographs, mainly confluent reticular infiltrates or diffuse reticulonodular shadowing. Pulmonary function tests were restrictive in pattern in 54% of the subjects. The most frequent disease was connective tissue disorders (CTD) - associated ILD (64% of all cases): Sjogren9s syndrome (20%), systemic sclerosis (16%), systemic lupus erythematosus (11%), rheumatoid arthritis (9%), antisynthetase syndrome (5%) and dermatomyositis in one case. The diagnostic of both CTD and ILD was made at the same time in 57% of cases. ILD induced by drugs was observed in 16% followed by sarcoidosis in 11% of cases. Idiopathic pulmonary fibrosis was observed in 3 cases and Churg–Strauss syndrome in one case. Corticosteroid therapy was prescribed in 68% of variable dosage depending on the cause and severity of lung disease. Immunosuppressive treatment with cyclophosphamide was indicated in only 4 cases. The response to therapy was favorable in 48% of cases and not satisfactory in 25% of the cases. Conclusions Collagen and vascular diseases are more common than previously appreciated. A multi-disciplinary evaluation of patients with DPLD can enhance diagnosis, improve prognosis and quality of care. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2378

Background Cardiac involvement in ankylosing spondylitis is uncommon. We have tried through this study to analyze the cardiovascular events among 50 patients with ankylosing spondylitis. Methods A retrospective study including 50 patients with ankylosing spondylitis. all patients underwent a complete physical examination with a heart and lung auscultation and an electro-cardiogram (ECG). Transthoracic ultrasound was performed whenever there was an abnormal physical examination and/or ECG. Results The study included 47 men and 3 women, the sex ratio is 15.6. The average age of onset was 26±7 years. The mode of onset is axial in 95% of cases (low back pain and/or buttock). The extra-articular manifestations are present in 54% of cases. Cardiac involvement is present in 9 cases (18% of cases). The reason for consultation is dyspnea in 2 patients. In other cases, cardiac involvement was discovered incidentally. Aortic regurgitation was noted in 4 patients. Mitral insufficiency was found in 3 cases. Two patients have predominantly septal hypertrophic cardiomyopathy and one patient presented an array of pulmonary insufficiency. The average time of onset of cardiac involvement was 8±5 years. All patients were put under special medical treatment of their heart, with good clinical outcome. Conclusions Cardiac involvement in ankylosing spondylitis is seen more frequently in men, especially in the old cases. A close relationship between time to onset of aortic insufficiency and duration of disease progression was found. It would be responsible for one third of deaths of patients. It was significantly more frequent in HLA B27 positive patients (especially complete atrioventricular block and aortic insufficiency). Cardiac involvement should be sought routinely in patients with APS because it presents a poor prognosis that can be life-threatening. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5835

Introduction Systemic lupus erythematosus (SLE) is an autoimmune disease with a large clinical polymorphism. Many factors: genetic, endocrine, immunological and environment contribute to disease onset. SLE is characterized by the involvement of multiple viscera, particularly the kidney, the heart and the skin. Cardiac manifestations are relatively common and can involve life-threatening. Materials and methods This is a retrospective descriptive study out of ten years, on the records of patients admitted in our department of internal medicine for LES (final diagnosis according to the criteria of the American Rheumatology Association: ACR). We studied the case with cardiac events. Results In a series of 80 cases of SLE patients, cardiac involvement was retained in 70% of patients. It was dominated by pericarditis in 52% of cases and it was symptomatic in 30% of them. Ultrasound noted endocarditis in 44% of cases with lesions of the mitral valve in 74% of cases. Myocarditis with left ventricular failure was observed in six patients. These events had occurred at the beginning of the disease in 60% of patients. Indeed, patients had dyspnea in 30% of cases, chest pain in 25% of cases. At ECG, a micro-voltage was noted in 40% of cases (pericarditis). Echocardiography has contributed to the diagnosis of pericarditis, myocarditis and endocarditis. The treatment was the strengthening of corticosteroids. Conclusion Cardiac manifestations of SLE are severe and asymptomatic in most cases. Their research must be systematic in order to treat earlier. Ultrasound appears to be the first-line examination in the detection of cardiac involvement in SLE. The prognosis remains severe coronary insufficiency and rhythm disorders.

Background Cardiac involvement in ankylosing spondylitis is common. We have tried through this study to analyze the cardiovascular events among 50 patients with ankylosing spondylitis. Methods A retrospective study including 50 patients with ankylosing spondylitis. All patients underwent a complete physical examination with a heart and lung auscultation and an electro-cardiogram (ECG). Transthoracic ultrasound was performed whenever there was an abnormal physical examination and/or ECG. Results The study included 47 men and 3 women, the sex ratio is 15,6. The average age of onset was 26±7 years. The mode of onset is axial in 95% of cases (low back pain and/or buttock). The extra-articular manifestations are present in 54% of cases. Cardiac involvement is present in 9 cases (18% of cases). The reason for consultation is dyspnea in 2 patients. In other cases, cardiac involvement was discovered incidentally. Aortic regurgitation was noted in 4 patients. Mitral insufficiency was found in 3 cases. Two patients have predominantly septal hypertrophic cardiomyopathy and one patient presented an array of pulmonary insufficiency. The average time of onset of cardiac involvement was 8±5 years. All patients were put under special medical treatment of their heart, with good clinical outcome. Conclusion Cardiac involvement in ankylosing spondyllitis is seen more frequently in men, especially in the old cases. A close relationship between time to onset of aortic insufficiency and duration of disease progression was found. It would be responsible for one third of deaths of patients. It was significantly more frequent in HLA B27 positive patients (especially complete atrioventricular block and aortic insufficiency).

Introduction The pericarditis is an inflammation of the pericardium accompanied or not by a pericardial effusion. Its etiopathogeny is variable. Through this work we describe the clinical and paraclinical characteristics of the pericarditis. Materials and Methods it is a retrospective study including 15 patients hospitalized in our service over a period of seven years from 2006 to 2013, presenting a pericarditis. Results It was of 15 patients including 5 men and 10 women, with a sex ratio of 0.5. The average age of our patients was 49 years (26 to 83 years). The pericarditis was revealed by: dysphonia (86% of cases), a chest pain (20% of cases), a flu-like syndrome with a moderate fever (13% of cases) and edema of the lower limbs (26% of cases). All patients had ultrasound a pericardial effusion well tolerated (moderate to abundant) except four patients who were in tamponade. She was of viral origin in 4 cases. It was in relation to a systemic disease in 6 cases: a systemic lupus erythematosus isolated in 3 cases, a rheumatoid arthritis in one case and a Sjogren syndrome in one case. In three cases the pericarditis was of renal origin. In addition, the pericarditis was secondary to radiotherapy for thymom in one case. In a single patient no etiology has been found. The evolution under specific medical treatments was good except of three patients who needed a surgical treatment with transition to chronicity in two cases. Conclusion The pericarditis is often easy to diagnose. A complete etiological investigation allows an earlier and adapted therapeutic. A good collaboration between an internist and cardiologist would allow an effective prevention of the acute risk of tamponade and chronic evolution toward the constriction.