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Background:Computed tomography (CT) of sacroiliac joints (SIJ) is usually considered as a third-line modality in the diagnosis of spondyloarthritis (SpA), as it shows only structural lesions. According to 2015 EULAR recommendations, CT may be helpful if conventional radiograph is inconclusive and MRI cannot be performed [1]. However, its contribution for the early assessment of sacroiliitis is still little-studied.Objectives:The purpose of this study was to assess the performance of CT scan for detecting sacroiliitis and the contribution of the different structural lesions to the early diagnosis of SpA.Methods:This cross-sectional prospective monocentric study included consecutive patients, aged over 16, consulting for symptoms suggestive of SpA between February 2014 and 2017. Patients with a pelvic radiograph showing a confirmed sacroiliitis (making CT unnecessary to confirm the diagnostic) were not included. Eligible patients underwent CT of SIJ and the images were reviewed by 2 experimented musculoskeletal radiologists blinded to clinical findings. Then, 2 experienced rheumatologists analyzed clinical, biological and radiological data and classified patients into 2 groups: confirmed non-radiographic spondyloarthritis (nr-SpA) or no SpA. This classification was considered as the gold standard of this study.Results:A total of 60 patients, 45 women and 15 men, were included in this study. Forty-six patients were assessed as confirmed nr-SpA (76.6%) and 14 patients as no SpA (23.4%). Mean age at the diagnosis was 39.5±10.8 years [17-59], and the disease duration from first symptoms was 48.6 ± 40 months [6.6-180]. Chronic back pain met the Calin criteria in 37 patients (61.7%), the Berlin criteria in 46 patients (76.7%) and the ASAS criteria in 32 patients (53.3%).Among the patients diagnosed as confirmed SpA, 71.7% were determined to have sacroiliitis at CT. As shown by the following table, the most sensitive lesion was subchondral bone sclerosis and the most specific one was new bone formation at entheses:TableConfirmed SpANo SpAPSe (%)Sp (%)PPV (%)NPV (%)Interruption of subchondral bone67.4%28.6%0.01 (S)67.471.488.640subchondral bone erosions65.2%35.7%0.05 (S)65.264.385.736Subchondral bone sclerosis78.3%28.6%0.001 (S)78.371.49050new bone formation at entheses10.9%7.14%0.68 (NS)10.992.983.324.1CT conclusion: sacroiliitis71.7%28.6%0.04 (S)71.771.489.243.5CT: computed tomography, SpA: Spondyloarthritis, Se: Sensitivity, Sp: Specificity, PPV: Positive Predictive Value, NPV: Negative Predictive ValueConclusion:The relatively limited place of SIJ CT can be explained by the lack of investigations evaluating its real contribution in detecting sacroiliitis. In this study, we found that the main SI structural lesions were significantly associated to the final diagnosis of SpA with a sensitivity up to 78.3% and a specificity up to 92.9%. The main limitation of this technique remains the large radiation dose delivered to the gonads, especially with the commonly used axial position for CT. However, recent studies found that oblique coronal CT imaging seems to be a very promising technique, since it allows visualization of the subtle radiologic signs of sacroiliitis while delivering less radiation dose [2].References:[1]Mandl P, Navarro-Compán V, Terslev L, et al (2015) EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis 74:1327–1339.https://doi.org/10.1136/annrheumdis-2014-206971[2]Li SG, Liu X, Zhou H, Zhang Q (2018) Interrater reliability and radiation dosage of oblique coronal computed tomography. Br J Radiol 91:6.https://doi.org/10.1259/bjr.20150700Disclosure of Interests:None declared

Background:In view of the limited accuracy of clinical evaluation to recognize sacroiliitis, several imaging techniques such as conventional radiographs, scintigraphy, ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) have been used to examine the sacroiliac joints (SIJ).Objectives:The aim of this study was to assess the performance of MRI for detecting sacroiliitis in early stages of spondyloarthritis (SpA).Methods:This cross-sectional prospective monocentric double-blind study included 57 patients consulting for symptoms suggestive of SpA during more than 3 months between February 2014 and February 2017. Patients with conventional radiograph showing a confirmed sacroiliitis (grade 3 or 4) were not included. After clinical examination and blood sampling, eligible patients underwent MRI of SIJ. MR images were interpreted by 2 experimented musculoskeletal radiologists blinded to clinical and laboratory data. Two professors in rheumatology blinded to radiologists’ conclusions, analyzed clinical data, laboratory tests, HLA typing, X-rays and MRI images and divided the patients into 2 groups: confirmed non radiographic SpA (nr-SpA) or no SpA. This classification was considered as the gold standard when analyzing the results.Results:Fifteen men and 42 women were enrolled. The mean age at inclusion was 39.75 ± 11 years [17-59]. The mean duration from the first symptom was 47 ± 39 months [6.6-180]. Forty-three patients were assessed as nr-SpA (75.4%) and 14 patients as no SpA (24.6%). Thirty-three percent of patients were HLA B27 positive. Totally 22 patients had sacroiliitis at MRI, all of them classified as confirmed nr-SpA. Among the nr-SpA group, MRI showed bone marrow edema (BME) in 34.9% of patients and erosions in 44.2% of patients. Among the patients in whom the diagnosis of SpA was excluded, MRI showed bone marrow edema (BME) in 7% of patients and erosions in 7% of patients. A statistically significant association was observed between the presence of sacroiliitis at MRI and rheumatologists’ diagnosis of SpA (p=0.001). The diagnostic value of MRI lesions is presented in the following table:Sensitivity (%)Specificity (%)Positive Predictive Value (%)Positive Predictive Value (%)BME34.992.993.731.7Erosions44.292.99535.1MRI conclusion: sacroiliitis51.210010040Conclusion:SIJ MRI had an excellent specificity for the diagnosis of SpA but a moderate sensitivity. Consequently, some patients in early stages of SpA might be missed by MRI. In addition, we found that diagnostic based solely on BME lacked sensitivity. Detection of erosions in addition to BME enhanced sensitivity (from 34.9% to 44.9%) without changing specificity. Indeed, many recent studies have pointed out the importance of considering structural lesions of SIJ in addition to inflammatory lesions [1, 2].References:[1]Weber U, Lambert RGW, Pedersen SJ, et al (2010) Assessment of structural lesions in sacroiliac joints enhances diagnostic utility of magnetic resonance imaging in early spondylarthritis. Arthritis Care Res 62:1763–1771.https://doi.org/10.1002/acr.20312[2]Weber U, Jurik AG, Lambert RGW, Maksymowych WP (2016) Imaging in Spondyloarthritis: Controversies in Recognition of Early Disease. Curr Rheumatol Rep 18:58.https://doi.org/10.1007/s11926-016-0607-7Disclosure of Interests:None declared

Background:Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are disabling and common chronic inflammatory rheumatic diseases.Objectives:The aim of our study was to evaluate the socio-professional impact of RA and AS.Methods:Using the Biological National Registry (BINAR) data, which includes ten tunisian rheumatology centers,we identified patients≥18 years with AS and RA according to the ACR and EULAR 2010 criteria(RA) and ASAS 2009 (AS), receiving biotherapy for less than two years.Results:298 patients were included in the study. The percentage of patients with RA was 58.7 % and those with AS 41.3%. The sex ratio was 0.6. The average age of the onset of the disease was 49.1 years ± 14.1 years [18–79]. For marital status, 72% were married, single (25%), widowed (2.6%) and divorced (0.4%). 22.4% of patients were illiterate, 32.7 % (primary), 28.3% (secondary) and 16.6% had an university level. For the RA population, a high disease activity (DAS28-ESR >5.1) was detected in 36% of patients, an erosive arthritis in 73.1% and 7.2% had a coxitis. In the AS group, an elevate BASDAI (BASDAI≥4) was detected in 56.9% of patients and 39% had coxitis. All patients have received Biological therapy concomitant with corticosteroids (59.1%), methotrexate (42.6%), salazopirine (20.8%) and leflunomide (4.7%). 54% of patients had a comorbidity, of which 1.7% was depression. More than half of our patients (54.3%) were unemployed, 40 % were professionally active, and 5.7% were retired due to the rheumatic condition. Absence from work was observed in 15.1% of cases with a total duration exceeding three months in 55.5% of cases. 37.9 % of patients were physically active: regularly (9.8%), irregularly (28.1%) and (62.1%) were sedentary. For the functional impact, HAQ score was 1.31± 0.7 for RA and BASFI was 5.2 ± 4.8 for AS. The working abandonment is significantly associated to: marital status (p=0.039), low level of education (p=0.04),depression (p4 (p=0,001).Conclusion:RA or AS requiring biotherapy have a high socio-economic impact and are responsible for absenteeism at work and even for early working abandonment. Early therapeutic management and a global assessment are essential in order to improve quality of life and working conditions. Longitudinal studies are needed to assess the effect of biological therapy on the socio-professional impact of these chronic inflammatory rheumatic disease.Disclosure of Interests:None declared

Background:The utility of structural lesions of sacroiliac joints (SIJ) for the early diagnosis of spondyloarthritis (SpA) has been well established by previous reports [1]. Computed tomography (CT) is usually the preferred modality to assess structural changes.Objectives:The aim of this study was to evaluate the performance of magnetic resonance imaging (MRI) for detecting subchondral bone erosions of SIJ in patients with suspected SpA. SIJ CT findings were considered as the gold standard when interpreting results.Methods:A cross-sectional prospective monocentric study included consecutive patients aged over 16 and consulting for symptoms suggestive of SpA from February 2014 to February 2017. Patients with a confirmed sacroiliitis on pelvic radiograph were not included. Eligible patients underwent CT and MRI of SIJ. Imaging findings were assessed consensually by 2 experimented musculoskeletal radiologists, blinded to the clinical and laboratory data. Erosion was defined as resorption or destruction of the subchondral bone. The sensitivity, specificity, positive and negative predictive values of MRI for detecting SIJ erosions were determined with CT results as gold standard.Results:Fifty-four patients were enrolled: 13 men and 41 women. The average age at inclusion was 39.4 ± 11 years [17-59], and the average age at onset of symptoms was 35.6 ± 10.6 years [16-55]. Cervical, thoracic, lumbar and buttock pain were noted respectively in 46.3%,37%, 92.6%, and 57.4% of the studied patients. Sacroiliac compression test, distraction provocative test, sacral thrust test, Gaenslen’s test, Faber’s test (Patrick) and Mennel’s test were respectively positive in 23, 18, 24, 12, 28, and 17 patients. HLA B27 typing was positive in 23.4% of patients. Erosions were detected by CT scan in 30 patients. MRI showed erosions in 18 of them. A significant association was found between CT and MRI results (p=0.000), and between the presence of erosions and the diagnosis of SpA (p= 0.05 for CT and p= 0.012 for MRI). Sensitivity, specificity, positive and negative predictive values of MRI for detecting subchondral erosions were respectively estimated at 60%, 100%, 100% and 66.7%.Conclusion:Erosions of SIJ appear in early stages of SpA and have been reported in 60-90% of patients with axial SpA after mean symptom duration of 2.5 years[2, 3], hence the importance of the detection of these structural lesions. In our study, despite its moderate sensitivity, MRI showed an excellent specificity for detecting subchondral bone erosions.References:[1]Weber U, Lambert RGW, Pedersen SJ, et al (2010) Assessment of structural lesions in sacroiliac joints enhances diagnostic utility of magnetic resonance imaging in early spondylarthritis. Arthritis Care Res 62:1763–1771.https://doi.org/10.1002/acr.20312[2]Althoff CE, Sieper J, Song I-H, et al (2013) Active inflammation and structural change in early active axial spondyloarthritis as detected by whole-body MRI. Ann Rheum Dis 72:967–973.https://doi.org/10.1136/annrheumdis-2012-201545[3]Weber U, Lambert RGW, Østergaard M, et al (2010) The diagnostic utility of magnetic resonance imaging in spondylarthritis: an international multicenter evaluation of one hundred eighty-seven subjects. ArthritisRheum 62:3048–3058.https://doi.org/10.1002/art.27571Disclosure 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:Magnetic resonance imaging (MRI) of sacroiliac joints (SIJ) can assess early inflammatory changes, thus allowing an early diagnosis of spondyloarthritis (SpA). However, its use in clinical practice may be limited by its cost, its duration and its limited availability. In this sense, ultrasound (US) has been suggested as a feasible and easy-to-apply alternative.Objectives:The objective of this study was to evaluate the validity of Color Doppler Ultrasound (CDUS) in early assessment of sacroiliitis, compared to MRI findings as the gold standard.Methods:A cross-sectional prospective monocentric study included patients attending the rheumatology department with suggestive signs of SpA between February 2014 and February 2017. Patients with pelvic radiography showing a confirmed sacroiliitis (grade 3 or 4) were not included. Eligible patients underwent US and MRI of SIJ. US examinations were performed by an experimented musculoskeletal radiologist blinded to MRI results. Vascularization within the SIJs was explored by the presence of a CDUS. When an artery was found, the resistive index (RI) was measured. The values of the RI ranged between 0 and 1. Doppler of each SIJ was considered as positive when RI was Results:Forty-three patients were included: 10 men and 33 women, with an average age at inclusion of 40.2 ± 11.1 years [17-59]. The mean duration of symptoms was 46±37.5 months [6.6-180]. A personal history of uveitis was noted in 3 patients and of chronic diarrhea in 3 patients. Morning stiffness was noted in 72% (n=31) of patients. Good response to nonsteroidal anti-inflammatory drugs (NSAIDs) and to physical activity were respectively reported by 41.8% (n=18) and 58% (n=25) of patients. Sacroiliac compression test, distraction provocative test, sacral thrust test, Gaenslen’s test, Faber’s test (Patrick) and Mennel’s test were respectively positive in 39.5%, 32.5%, 48.8%, 23.2%, 32.5%, and 51.2% of the patients. Twenty-seven per cent of the patients were HLA-B27+. The MRI showed a confirmed sacroiliitis in 14 patients. Doppler signal was detected in 44 SIJ of 25 patients, of whom 14 SIJ of 8 patients showed bone marrow edema at MRI (p=0.054). At the joint level, considering MRI-proven sacroiliitis as the diagnostic standard, CDUS had a sensitivity of 70%, a specificity of 54.5%, a positive predictive value of 31.8%, and a negative predictive value of 85.7%. The spectral Doppler RI, averagely estimated at 0.74±0.12 [0.48-0.87], was not associated with the presence of sacroiliitis on MRI (p=0.747).Conclusion:US, an imaging technique increasingly used in the assessment of musculoskeletal diseases, has been suggested to detect active sacroiliitis [1, 2]. Our study revealed that in early SpA, CDUS may be useful to assess active inflammatory changes of SIJ since it had a sensitivity of 70%, despite a relatively reduced specificity. However, RI values, which are expected to be low in patients with active inflammation [3], were unrelated to the presence of sacroiliitis. Future studies on larger numbers of patients might be conducted to complete previous data.References:[1]Mohammadi A, Ghasemi-rad M, Aghdashi M, et al (2013) Evaluation of disease activity in ankylosing spondylitis; diagnostic value of color Doppler ultrasonography. Skeletal Radiol 42:219–224.https://doi.org/10.1007/s00256-012-1412-7[2]Hu Z, Xu M, Wang Q, et al (2015) Colour Doppler ultrasonography can be used to detect the changes of sacroiliitis and peripheral enthesitis in patients with ankylosing spondylitis during adalimumab treatment. Clin Exp Rheumatol 33:844–850[3]Arslan H, Sakarya ME, Adak B, et al (1999) Duplex and color Doppler sonographic findings in active sacroiliitis. AJR Am J Roentgenol 173:677–680.https://doi.org/10.2214/ajr.173.3.10470902Disclosure of Interests:None declared

To assess the performance of ultrasound in detecting erosion, swelling, and new bone comparing to radiographs in five lower limb entheses in patients with ankylosing spondylitis (AS). Prospective study of 60 patients meeting modified New York criteria for AS. Lateral radiographs of both knees and ankles followed by a high-resolution Doppler ultrasound examination with a high-frequency (15 MHz) linear probe were performed. Ultrasound had an excellent sensitivity, but specificity was very weak compared to radiographs for erosion, swelling, and new bone formation. Negative and positive predictive values were good only for erosion. Ultrasound seems to be a performant instrument in detecting signs of chronic enthesitis particularly when radiograph is normal.

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

Background Tuberculous infection of the musculoskeletal system count 10% of all extrapulmonary cases of tuberculosis (TB). In musculoskeletal tuberculous infections, the involvement of TB in peripheral joints and tendons is rare. In this report we will describe 8 cases of flexor tuberculous tenosynovitis (FTT). Objectives The aim of our work is to analyze the diagnostical, therapeutical and evolutionary aspects of this disease through a series of 8 cases of FTT patients treated. Methods A retrospective study was conducted selecting patients followed-up for FTT. Patients hospitalized during the period from 2008 till December 2014 were recruited. Previous history of TB or exposure to TB was searched. All patients underwent hands plain radiographies and ultrasounds, chests radiographies, tuberculin skin test (TST), sputum smears and cultures; then to surgical synovectomy with histological and bacterial examination. Results Eight patients were included (5 females, 3 males), with a mean age of 45 years-old [33 – 59]. All patients were immunocompetent and without a past medical history of TB. A local steroid injection preceding the infectious episode was noted in one case and a cow bite was revealed in another case. The mean period before consulting was 15 months [3-23]. Fever, night sweats and weight loss was noted in 3 patients. First symptom of illness was swelling of the palmar side in 4 cases, of the left 4th finger in 2 cases, of the right 5th finger in one case and a carpal tunnel syndrome in an another case. Hands plain radiographies weren9t contributive for the diagnosis, however ultrasound showed flexor tenosynovitis in all cases. Chest radiography revealed squeal of tuberculosis in one patient. TST was always positive but sputum smears and cultures were negatives in all cases. Histological examinations and bacterial culture confirm the diagnosis of FTT in all patients. Combination of anti-tuberculosis antibiotics was well conducted and evolution was good for all patients. Conclusions Although rarely seen, FTT should be kept in mind if we found chronic flexor tenosynovitis; a detailed medical history and careful clinical examination should be taken to prevent misdiagnosis. Histological examinations and bacterial culture are very important to confirm the diagnosis. Disclosure of Interest None declared

Background Brucellar spondylitis is rare. It is also the most prevalent clinical form of osteoarticular involvement in adults infected by Brucella. Objectives The aim of this study was to report the clinical, biological, radiological and therapeutic features of brucellar spondylodiscitis. Methods Retrospective study including 6 patients followed up in our department between 2006 and 2014. Results We studied 6 cases (5 of them are male) with a mean age of 55.3 years old [20 - 83]. 3 patients were consumers of unpasteurized milk. The median delay of consultation was 6 months. All patients had fever, night sweats and generalized weakness. Lumbar spine was affected in 4 cases and cervical spine in 2 cases. Neurologic examination was normal in 5 cases, 1 patient had neurologic deficiency. Plain radiographs revealed narrowing of disc spaces in 5 cases and erosion of the antero-upper corner of the body of vertebra in 1 case. MRI was performed in all cases and revealed features suggesting spondylodiscitis in all patients. Epidural inflammation was found in 4 cases. Disco vertebral biopsy was performed in 1 patient revealing a nonspecific histological appearance and an inconclusive bacteriological study. Laboratory tests including CRP, sedimentation rate and leucocytes were increased in all cases. Rose-Bengale test and Wright test were positive in all of them. They were treated with double antibiotics (Rifadine and Cycline), during an average of 4 months in all cases. All of them had in immobilisation and also had a favourable development. Conclusions Brucellar spondylodiscitis may be difficult to diagnose and have an acute or chronic course. Only rapid and correct management may prevent irreversible neurologic deficits and spinal deformities. Disclosure of Interest None declared

Background Spondylodiscitis is a quite rare disease characterized by insidious onset and non-specific symptoms such as back pain and fever. Consequently, early diagnosis is difficult and is often missed despite repeated warnings in the medical journals and better access to imaging techniques such as magnetic resonance imaging (MRI). Spondylodiscitis may take acute, subacute or chronic course. Objectives We aimed to describe the clinical and laboratory features as well as diagnostic difficulties in the case series of spondylodiscitis. Methods Retrospective study including patients diagnosed as spondylodiscitis and hospitalized in our department between 2006 and 2014. Results Sixteen patients were included. Ten patients (62,5%) were male. The mean age of our patients was 57 years [20 – 83]. Predisposing factors were found in 7 patients (43%): diabetes in 5 cases, chronic renal failure in 1 case and a patient with sickle cell disease. The lumbar spine was most affected (75%), the dorsal spine was affected in (12,5%) as the cervical spine (12,5%). A-multi stage spondylodiscitis was found in 3 cases. A neurological deficit was noted in 2 patients. Inflammation tests were disturbed in 87,5% of them. Radiographs of the spine were abnormal in all cases. Fourteen patients had MRI exam, showed epiduritis in 6 patients and paravertebral abscess in 7 patients. The causative microorganism was identified in 14 cases (87,5%): brucella in 6 patients, mycobacterium tuberculosis in 5 patients, staphylococcus in 1 case, Gram-negative germs in 1 case and streptococcus in 1 case. Multi-bacterial spondylodiscitis was found in 1 patient. All of them received initially adapted antibiotics. Two patients have not been followed, and most of the rest showed good response (78%). Neurological complication occurred in 1 case and sepsis occurred in 1 other case. Disturbance of liver function due to treatment occurred in two cases with good subsequent evolution. Conclusions Spondylodiscitis is an emergency which must be diagnosed on time to avoid life threatening complications, neurological sequelae and spinal deformities. Disclosure of Interest None declared

Background In rheumatoid arthritis (RA), tendon pathology is a well-recognized, but underestimated aspect of the disease, which may lead to irreversible functional impairment and consequent disability. Clinical joint examination is less time-consuming than ultrasound (US) but it may misdiagnosis tenosynovitis (TS). Objectives The aim of this study was to compare clinical assessment of tenosynovitis detection with US examination. Methods A cross sectional study was performed including patients followed-up for active recent RA (RA 2,6). Clinical examination was performed by a rheumatologist seeking signs suggestive of flexor of extensor TS. US was performed by an experienced radiologist blinded to clinical data. All tendons of the hands were scanned in the transverse view from the more proximal to the more distal portion at the tracts surrounded by synovial sheath. Totally 140 hands were assessed. Results of clinical examination were compared to US findings. The difference is considered significant if the P>0,05. Results Seventy patients were recruited, (56 females, 14 males). The mean age was 53 years-old [24-74 years-old]. The mean duration of the disease was 10 months [3-24 months]. The RA was active with a median DAS28 5,46 ranging from 2,91 to 7,81. Physical examination highlighted TS in 53 (38%) hands, it was bilateral in 50%. Flexor tendons were the most affected (52 hands). Both flexor and extensor tendons were detected affected in 4 hands. US showed TS in 89 (65%) patients. Flexor tendons showed US activity in 80 hands and extensor tendons in 78 hands. US revealed a significant high frequency of TS over clinical examination (p=0,02). The sensitivity of US to detect TS was 80.3% and the specificity was 50,4%. Conclusions The rationale of using US relies on the fact that physical examination provides only limited information on the presence of tenosynovitis. Since TS can be source of functional disagreement, US should be focused, in addition to analyze synovitis, on tendons in RA. References Emilio Filippucci, Alessandra Gabba and al. Hand Tendon Involvement in Rheumatoid Arthritis: An Ultrasound Study. Seminars in Arthritis and Rheumatism 2012;41:752-60. Backhaus M, Kamradt T and al. Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rhem. 1999;42:1232-45. Szkularek M, Court-Payen M and al. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum.2003;48:955-62. Disclosure of Interest None declared

Background New generation of scores to evaluate rheumatoid arthritis (RA) activity has been developed with current insights the importance of close monitoring patients and controlling disease activity. The Simplified Disease Activity Index (SDAI) is simple and easy score, it is well correlated to the RA activity and is less time-consuming in calculation than DAS. In the other hand, ultrasonography (US) showed more sensitivity in detecting synovitis than clinical examination. Objectives The purpose of this study is to compare the clinical and US activity of RA by the SDAI and the US-SDAI. Methods Fifty patients followed-up for active RA were included. The SDAI was calculated by the numerical summation of the number of tender joints, swollen joints (/28 joints), the patient9s and doctor9s evaluation of the disease and the C protein reactive value. Then patients underwent US examination by a radiologist experimented and blinded to clinical data. Twenty two joints of the hands were scanned (wrists, 10 metacarpophalangeal and 10 proximal inter-phalangeal). The US-SDAI was calculated by replacing the swollen joints of the hands by joints expressing B-mode or Power Doppler activity in the US exam. Results Fifty patients were recruited with a mean age of 53,8 years-old [26-78]. Females outnumbered males (42/8). The mean duration of illness was 3,6 years [0,5-15]. Rheumatoid factor was positive in 55% of patients. The mean number of swollen joints of hands found in physical exam was 4 and was 4,2 for US (p=0.82). The mean value of US-SDAI (29.2) was a little bit higher than the clinical one (29) and the difference was not significant (p=0.82). There was a highly significant positive correlation between SDAI and US-SDAI (p Conclusions In our study clinical SDAI seems to be well correlated to US-SDAI. Since the SDAI is simple to calculate and should be more used in our daily practice. Disclosure of Interest None declared

Background Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by the presence of rheumatoid factor (RF) and anti-cyclic citrullined peptide (ACPA). ACPA have higher specificity than RF for RA, and are associated with joint radiographic damage and extra-articular manifestations. Objectives The aim of this study was to evaluate the US RA activity whether the ACPA were present or not. Methods A cross-sectional study of patients followed-up for RA was conducted. Demographic, clinical and biological data were collected. RF and ACPA mesures were collected from medical records. We calculated the US-DAS28 in order to evaluate accurate activity of RA. All patients had an ultrasound (US) examination of 22 joints of hands (wrists, metacarpophalangeal, proximal interphalangeal). US was performed by an operator blinded to clinical and laboratory data. RA activity was evaluated by US-DAS28 by replacing swollen joints of the hands by joints expressing synovial hypertrophy or hyper vascularization in US. Results One hundred and eighteen patients were enrolled, 83% were females. The mean age was 53 years-old. The mean duration of the disease was 11.6 months. The RF was positive in 64 (55%) patients and the ACPA was positive in 31 (26%) patients. The median DAS28 was 5,52 [2,91-7,81]. The medianUS-DAS28 was 5.29 [1.98- 7.83]. The comparison between US-DAS28 according to immunological status is showed in table 1. Conclusions We conclude that there was no significant difference of RA activity between seropositive or seronegative RA and also whether ACPA was positive or not. The analysis of bone damages should be compared in another study order to determinate the prognostic value of ACPA. References Jung C, Jisuk B. Relation of rheumatoid factor and anti cyclic citrullined peptide antobody with disease activity in rheumatoid arthritis: cross sectional study. Rheumatol Int 2013. Disclosure of Interest None declared

Background Sleep disturbance in patients with Rheumatoid arthritis (RA) seems to be multifactorial. In fact inflammatory pain, depression and anxiety could have a negative impact in sleep quality in patients with RA. Objectives The aim of this study was to evaluate sleep quality and its relationship with psychological features and fatigue in patients with RA. Methods We conduct a cross sectional prospective study including patients with RA fulfilling the ACR1987 criteria. The MOS sleep Questionnaire was used for the assessment of sleep disturbance. It is a 12-item questionnaire exploring 6 domains of sleep: sleep adequacy, sleep disturbance, sleep quantity, daytime sleepiness, snoring and shortness of breath or headache. It leads to two sleep problem indexes (SP1 and SP2). Beck depression and anxiety scores (BDI, BAI) were used to evaluate psychological features and Chalder scale was used to evaluate the fatigue. Results Seventy cases of RA patients were included. The mean age was 51,9 years (range 18 to 78) with a female to ratio male about 4. The mean VAS for joint pain was 49 [range 0 to 100]. The mean BDI score was 16,5 [range 2 to 48] and the mean BAI score was 16,2[range 0 to 42]. The mean somatic fatigue score was 6,5 [range 1 to 8] and the mean mental fatigue score was 2.3 [range 0 to 6]. The results of the MOS sleep questionnaire and the correlations of its items with BDI, BAI and Chalder scale was presented in table 1. Conclusions Our study showed that the poor sleep quality in RA is especially associated with depression anxiety and fatigue Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4666

Background Sleep disturbance in patients with Ankylosing Spondylarthritis (AS) seems to be multifactorial. In fact inflammatory pain, depression and anxiety could have a negative impact on sleep quality in patients with AS. Objectives The aim of this study was to evaluate sleep quality and its relationship with psychological features and fatigue in patients with AS. Methods We conduct a cross sectional prospective study including patients with AS fulfilling the New York modified criteria. The MOS sleep Questionnaire was used for the assessment of sleep disturbance. It is a 12-item questionnaire exploring 6 domains of sleep: sleep adequacy, sleep disturbance, sleep quantity, daytime sleepiness, and shortness of breath or headache. It leads to two sleep problem indexes (SP1 and SP2). Beck depression and anxiety inventories (BDI, BAI) were used to evaluate psychological features and Chalder scale was used to evaluate the fatigue. Results Fifty patients with AS patients were included. The mean age was 42±12.1 years (range 18 to 65) with a male to ratio female about 3.5. The mean VAS for joint pain was 49.85±25.17 [range 0.5 to 90]. The mean BDI score was 16.2±11.8 [0-43] and the mean BAI score was 14.7±10.5 [0-36]. The mean somatic fatigue score was 5.9±2.3 [0-8] and the mean mental fatigue score was 1.8±2 [0-6].The results of the MOS sleep questionnaire and the correlations of its items with BDI, BAI and Chalder scale was presented in Table 1. Conclusions Our study showed that the poor sleep quality in AS is highly associated with depression anxiety and fatigue except for snoring which is related to BMI. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6033

Background Imaging in early rheumatoid arthritis (RA) has undergone extraordinary change in recent years and new techniques are now available to help the clinician diagnose and manage patients much more effectively than previously. Ultrasound (US) examination could be of valuable help in the early diagnosis of RA. Objectives The present study is designed to assess the contribution of the US in diagnosis of the very early RA (within the first 6 months of the disease onset). Methods we conduct a cross sectional study of 36 consecutive patients with recent rheumatoid arthritis (less than 6 months of disease onset) diagnosed according to ACR-EULAR 2010 RA criteria. Patients have been clinically evaluated for pain and swelling of their hand joints, and underwent radiographs and sonography of the hand. The ultrasonography was made by the same radiologist who was unaware of clinical pattern using the same US machine (Philips HD 11) and high frequency linear probe 15 MHz. Results 28 women and 8 men were included. Their mean age was 48.3±1.15years (range: 16-74) and mean disease duration was 4.3±2.4 months (range 2-6 months). The disease have been active in all cases: mean DAS28 4.39±2.46. the mean tender joint count was 12. The mean swollen joint count was 5. The Rheumatoid factor was positive in 44.4% of cases and the ACPA was positive in 30% of cases. In 30% of cases, US had a valuable contribution in establishing RA diagnosis. In fact, among patients having no synovitis on examination, US showed at least one synovitis in 12 cases. In other 12 cases, bone erosions was found only on US (not shown on radiography). Radiography showed joint narrowing in 26 cases and bone erosion in 9 cases. The Sharp score was 7.58±8.36 in average. Ultrasounds showed erosion in 16 cases, joint synovitis in 29 cases, joint effusion in 18 cases and synovial hypertrophy in 24 cases with power doppler in 20 cases. Conclusions US is an accurate tool for the assessment of joint inflammation and bone erosion in patients with very early rheumatoid arthritis (RA). Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5677

Background Sleep disturbance is a frequent feature of chronic inflammatory rheumatisms particularly in Ankylosing Spondylitis (AS). Objectives The aim of this study was to evaluate sleep quality and its relationship with specific disease parameters in patients with AS. Methods We conduct a cross sectional prospective study including patients with AS fulfilling the New York modified criteria. The MOS sleep Questionnaire was used for the assessment of sleep disturbance. It is a 12-item questionnaire exploring 6 domains of sleep: sleep adequacy, sleep disturbance, sleep quantity, daytime sleepiness, snoring and shortness of breath or headache. It leads to two sleep problem indexes (SP1 and SP2). Pain was evaluated by VAS. Disease activity was evaluated by BASDAI, ASDAS ESR and ASDAS CRP, functional impairment and quality of life by ASQOL and BASFI and structural damage by BASRI and mSASS. Results Fifty patients with AS patients were included. The mean age was 42±12,1 years (range 18 to 65) with a male to female ratio about 3,5. The mean body mass index (BMI) was 24,8±4,1 kg/m 2 . The mean disease duration was 9,8±8,1years [range 0,5 to 39]. The mean duration of morning stiffness was 36±35 minutes [range 0to 120] and the mean awakening number was 1,52±1,44 times per night. The mean VAS pain was 49,85±25,17 [range 0,5 to 90]. The mean BASDAI was 47±24,56 [range 0 to 100]. The mean ASDASESR was 3±1,14 [range 1 to 5,1] and the mean ASDASCRP was 2,9±1,03 [range 1to 5]. The mean BASFI was 48,3±29,8 [range 0 to 98]. The mean ASQOL was 4,7±5,38 [range to]. The mean BASRI was 7,5±3,27. The mean m SASSS was 10,52±13,38. The mean ESR was 34,9±21,9 [4-84] and the mean CRP was 18,9±17 [3-73]. The results of the MOS sleep questionnaire and the correlations of its different items with disease specific parameters are presented in Table 1. Conclusions Our study showed that the poor sleep quality in AS is especially associated with disease activity, pain biologic inflammation, poor quality of life but not with structural damage Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6006

Background The hip involvement in patients with ankylosing spondylitis (AS) has been recognized as a common and disabling problem. Many radiological pattern of hip arthritis were recognized and seems to have different clinical profile. Objectives to compare the destructive hip arthritis to other radiological pattern in patients with AS. Methods One hundred patients with AS, diagnosed according to the modified New York criteria for AS, and with hip involvement were recruited. Clinical, biological and radiological examinations for AS and for the hip involvement were performed and disease-specific instruments (BASFI, BASDAI, BASG-s, BASMI, BASRI, mSASSS) were assessed. Chi2 test was used to compare qualitative variables and ANOVA for quantitative variables. Results Eighty-one males and 19 females with AS were included in this study. Their mean age was 36.3 years ± 12.3. The mean disease duration was 12.3 years ± 0.9. Sixty-two patients were HLA-B27 positive. The hip involvement was bilateral in 76 cases (176 hips), inaugural in 46 cases and for the others, the mean disease duration at hip arthritis onset was 5.6 years. The destructive hip arthritis was found in 65% of cases and was associated among hip arthritis parameters to Lequesne index, reduced maximum distance walked, lameness, limitations in hip rotation and total hip replacement requirement. Among AS parameters destructive arthritis was associated to high score of BASRI, high level of ESR and presence of B27 antigen. Conclusions The destructive hip arthritis seems to be the most frequent radiological pattern and associated to the presence of HLA B27 antigen and to a worse prognosis. Disclosure of Interest None Declared

Background Joint hydatidosis is defined as the development within the joint of multiple cysts that are the larval form of the tapeworm echinococcus granulosus. Bone and joint cysts account for less than 0.5% of all hydatid cysts in human. We report three cases of joint hydatidosis. Results Case 1: A 63-year-old woman, who was operated 4 times for lung and liver cyst hydatidosis, was complaining of right inflammatory lumbosciatica S1. Examination revealed pain when pressing the sacral region. X-rays revealed a heterogeneous lesion of the right sacrum. Computed tomography showed an eleven-mm diameter cyst in the right buttock joint with an anterior development into the pelvic cavity. Muscles were not involved. Surgical enucleation of the cysts was performed. Histopathologic examination showed germinative membranes of the hydatid cyst confirming the diagnosis. Case 2: A 35 year old man with history of right hip pain for the past 5 years and a progressive loss of motion range. Examination found a painful and restricted right hip movement in all directions. X-rays and computed tomography scan showed bone destruction of the hip, multiple cysts and ectopic calcifications around the joint. Serological test for hydatid disease was positive (1/280), confirming the diagnosis of hip hydatidosis. Case 3: A 39 year old women with history of liver hydatid cyst treated with surgery 14 years ago, was complaining of right shoulder pain for the past year. Examination revealed diffuse swelling of right shoulder with painful and restricted movement in all directions. X-rays showed multiple cysts of the shoulder with pathological fracture of the humerus diaphysis. MRI and hydatid serological test confirmed the diagnosis. Conclusions Hydatid cysts still occur in Tunisia despite prevention programs. The liver and the lung are the most frequent targets. The joint involvement is uncommon but severe. Joint contamination is usually local from bone lesion and rarely by blood or lymph vessels. Surgical excision of cysts is the main treatment but recurrence is possible particularly at proximal joint that are difficult to access. Disclosure of Interest None Declared

Background Joint ultrasound is a sensitive means to detect joint inflammation particularly in recent RA. Ultrasound findings in elderly onset RA patients have not been previously compared with sonographic signs in young onset RA patients. Objectives To compare sonographic scores of inflammation and erosion between patient with elderly onset and young onset patients with recent RA. Methods Cross sectional study of 88 consecutives patients with recent rheumatoid arthritis ( Results Seventy two women and 16 men were included. Their mean age were 52.1±14 years [16-76]. Twenty four patients were diagnosed with elderly onset RA. Comparison of ultrasound scores were showed in table 1. Only erosion score was significantly higher in elderly onset RA than young onset RA patients. Conclusions This study shows that ultrasound detect more erosion in elderly onset recent RA compared with young onset RA but similar inflammation scores. Disclosure of Interest None Declared

Background Ankylosing spondylitis disease activity score (ASDAS) is a new disease activity index that didn’t include enthesitis pain assessment. Correlation of ASDAS with enthesitis pain scores in patients hasn’t be investigated previously. Objectives To investigate correlation between the ASDAS and enthesitis pain assessed by the Maastricht ankylosing spondylitis enthesitis score (MASES) and visual analogical score (VAS). Methods A cross sectional study was conducted in our department of Rheumatology that includes 56 patients (45 male/10 female) with ankylosing spondylitis according to the modified New York criteria. Clinical data used for calculation of ASDAS, MASES and enthesitis pain VAS were collected. ASDAS formula B was used (calculated with erythrocyte sedimentation rate) [1]. Results Patients mean age were 38,35±11 years [16-73]. The mean ASDAS was 4,5±2,3 [0,5-10,2]. The mean MASES was 3,4±3,5 [0-13]. The mean VAS enthesitis pain was 5,6±2,9 [0 -10]. ASDAS was positively correlated to MASES (r: 0.315, p: 0,033) and to VAS enthesitis pain (r:0.273, p: 0,042) [fig1]. Figure 1: Distribution of ASDAS, enthesitis VAS and MASES in patients with ankylosing spondylitis. Conclusions ASDAS is positively correlated to MASES and enthesitis pain VAS despite the fact that he didn’t include enthesitis assessment in his score References C Lukas, R Landewe’, J Sieper, et al. Development of an ASAS-endorsed disease activity (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18–24. Disclosure of Interest None Declared

Background Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting traditionally young male. AS frequently involves the axial skeleton, and can result in abnormal bone formation with eventual ankylosis of the spine, resulting in substantial disability and functional limitation. Female AS is known to be less severe than in male patients. Objectives To compare of clinical, biological and radiological features in male and female patients with ankylosing spondylitis. Methods A cross sectional study was conducted in our department of Rheumatology that includes 165 patients (136 male/29 female) with ankylosing spondylitis according to the modified New York Criteria for AS. Clinical, biological and radiological data are collected. Results Patients mean age were 38,35±11 years [16-73]. Female were older than male patients (the mean age respectively 40/35 years). Comparison between male and female patients was displayed in table 1. Conclusions Clinical feature of AS were comparable in male and female patients. Only age of onset was earlier and HLA B27 was more frequent in male patients than in female. Disclosure of Interest None Declared

Background AnkylosingSpondylitis (AS) is a chronic inflammatory disease belonging to the spondylarthropathy group without immunity marker. Presence of auto-antibodies was unusual and frequently induced by biologic treatment. Objectives to evaluate the frequency and clinical significance of anti nuclear antibodies, (ANA), anti-DNA, anti-ENA, rheumatoid factor (RF) and anti-keratin antibody (AKA) in patients with AS before any biologic therapy. Methods We have performed a cross sectional study of 100 patients who fulfilled the modified New York Criteria for AS. Screening for auto-antibodies was performed by indirect immunofluorescence (Hep2 cells for ANA, Chritidia luciliae for anti-DNA and rat oesophagus for AKA), by ELISA for anti-ENA and by Latex for RF. Statistical analysis was performed by X2 test and Student t test. Significance was accepted for p

Background Ankylosing spondylitis disease activity score (ASDAS) is a new disease activity index with good metrological parameters. It includes the most relevant items of disease activity according to patient and doctors. Weighting of these parameters is the principal characteristic of the ASDAS when compared with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Correlation of ASDAS with mobility limitation parameters in patients hasn’t be investigated previously. Objectives To investigate correlation between the ASDAS and the Bath Ankylosing Spondylitis Metrology Index (BASMI). Methods A cross sectional study was conducted in our department of Rheumatology that includes 56 patients (45 male/10 female) with ankylosing spondylitis according to the modified New York criteria. Clinical data used for calculation of ASDAS and BASMI were collected. ASDAS formula B was used (calculated with erythrocyte sedimentation rate) [1]. Results Patients mean age were 38,35±11 years [16-73]. The mean ASDAS was 4,5±2,3 [0,5-10,2]. The mean BASMI was 4,2±2,3 [0.5-10]. ASDAS was positively correlated to BASMI (r: 0.300, p: 0,029) [fig 1]. Figure 1: Distribution of ASDAS and BASMI in patient with ankylosing spondylitis. Conclusions ASDAS is a new activity index. It confirms that not only structural damage but also disease activity were responsible of mobility limitation in patients with ankylosing spondylitis. References C Lukas, R Landewe’, J Sieper, et al. Development of an ASAS-endorsed disease activity (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18–2 Disclosure of Interest None Declared

Background The early diagnosis of RA is often difficult in the absence of immunologic markers, bone erosions on radiographs or clinical characteristic features such as typical joint involvement or rheumatoid nodules. Objectives The aim of this study was to assess the contribution of High resolution Doppler Ultrasound in the early diagnosis of RA with negative immunologic markers. Methods Cross sectional study of 44 patients admitted in our institution between 2009 and 2011. Inclusion criteria were the following: recent onset inflammatory rheumatism (