Dhia Kaffel

Correlations among clinical, radiographic, and sonographic scores for enthesitis in ankylosing spondylitis.

OBJECTIVES To look for correlations among clinical, radiographic, and sonographic scores for enthesitis in patients with ankylosing spondylitis (AS). METHODS Prospective study of 60 patients meeting modified New York criteria for AS. The clinical evaluation relied on the BASDAI, BASFI, and ASQoL and on a visual analog scale (VAS) for entheseal pain, as well as on two specific enthesitis indices, the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and the Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Radiographs and ultrasound scans were taken of five entheses on both sides (patellar insertion of the quadriceps tendon, proximal and distal insertions of the patellar tendon, and calcaneal insertions of the Achilles tendon and superficial plantar fascia). Ultrasound scans were obtained using a Philips HD 11™ machine with a high-frequency linear probe. RESULTS We studied 48 men and 12 women with a mean age of 36±11 years. The radiographic score correlated with the VAS pain score, BASDAI, and BASFI. The sonographic score for acute enthesitis correlated only with the MASES, and the sonographic score for chronic enthesitis correlated with none of the clinical scores. The Doppler score correlated with the VAS pain score, BASDAI, BASFI, and ASQoL. The overall sonographic score correlated with the MASES and SPARCC. CONCLUSION Good correlations were found between the clinical and sonographic scores for enthesitis. The radiographic score seemed correlated with the general AS parameters rather than with the clinical scores. Larger studies are needed to better define the role for radiographs and sonography of the entheses in the diagnosis of AS and follow-up of treated AS patients.

Piriformis muscle syndrome: an unusual adverse effect of atorvastatin.

Piriformis syndrome (PS) is an uncommon cause of sciatica-like pain with buttock pain referred to the leg and caused by extraspinal compression of the sciatic nerve by the piriformis muscle.1 Diagnosis is often difficult. Piriformis syndrome is frequently posttraumatic or in relation with anatomic a

Sarcoidosis and spondyloarthritis: A coincidence or common etiopathogenesis?

Background: Sarcoidosis is a multisystem granulomatous disease. Co-existence with spondyloarthritis (SA) has been more described as an adverse effect of anti-TNF α therapy than an association. We report herein a case of a typical sarcoidosis confirmed by histological proofs and an advanced SA with a bamboo column. Case Presentation: A 48-years-old woman presented with inflammatory back pain for 5 years and ankle swelling for 1 year. On physical examination, she had an exaggerated dorsal kyphosis and disappearance of lumbar lordosis with limitation in motion of the cervical and lumbar spine. Laboratory tests did not show an inflammatory syndrome or hypercalcemia. Plain radiographies of the spine and pelvic revealed a triple ray appearance with sacroiliitis grade 4. Chest radiography and CT confirmed the presence of bilateral hilar lymph nodes and parenchymal nodes. Bronchoscopy and biopsies were performed showing non-calcified granulomatous reaction without cell necrosis. The diagnosis of SA was performed based on 9 points of Amor criteria associated with pulmonary sarcoidosis. She was treated with 15 mg per week of methotrexate and 1mg/kg/day of prednisone for pulmonary disease with good outcomes. Conclusions: Sarcoidosis may be associated to SA besides paradoxical drug effect. The same physio pathological pathways mediate by TNF α are arguments for association than hazardous coincidence.

About a subcutaneous calcification

We report a case of 62-year-old Tunisian woman with a 10-year history of a CREST syndrome (systemic sclerosis meeting the criteria of the CREST syndrome of the 1980 American College of Rheumatology classification for raynaud phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia). Her daughter is treated in neurology for myasthenia gravis. Our patient presents a 5-month history of increasing inflammatory right thumb pain concomitant with the discovery of a subcutaneous hard mass (A). Radiographs of her thumb showed a sub-cutaneous calcification (as another part of the CREST syndrome criteria) (B). X-rays of hands found an acro-osteolysis (C). In the CREST syndrome, the calcific deposits can be subclinical. But, when symptomatic, it becomes painful, tender and an inflammatory reaction can occur facing the calcinosis.

About an aggressive bone lesion

We report here a case of hyperparathyroidism with disseminated brown tumors mimicking malignancy. The important clinical teaching of our case is that hyperparathyroidism can take various aspects. Plasma parathyroid hormone concentration should be measured in all patients with multiple bone lesions.

Syringomyelia associated to rheumatoid-atlantoaxial subluxation: about a new case

We report a case of 64-year-old Tunisian woman with a 12-year history of rheumatoid arthritis, who presented with a 3-month history of increasing inflammatory neck pain. Neurological examination noted a quadripyramidal syndrome without any neurological deficit. Radiographs of her neck showed ananterior atlantoaxial subluxation (A). MRI revealed a pannus around the atlanto axial joint. It also showed a co-existing syringomyelia (B). The cervical spine is frequently involved in patients with rheumatoid arthritis. However, rheumatoid atlantoaxial subluxation with syringomyelia is very rare. Many hypothesised mechanisms were suggested for thesyrinx formation. The most commonly admitted, suggested that atlanto axial sub luxation may reduce the rate of ascending cerebrospinal fluid, so it would travel through the spinal cord producing syringomyelia.

Primary idiopathic osteoarthropathy

A 49-year-old man presented with arthralgias and effusion of the knees. His past medical syndrome revealed digital clubbing for 17 years (A) and an idiopathic Raynaud syndrome. Radiographs of the tibias and fibulas showed bilateral, symmetric, extended and multilayered periosteal thickening (B). Thoracic CT and cardiac ultrasound were normal, as well as inflammatory, hepatic and renal tests. Infectious investigations were negative. The diagnosis of primary idiopathic osteoarthropathy (HOA) was made with 3-year follow-up. HOA is a syndrome characterized by three clinical features: digital clubbing (also termed Hippocratic fingers), periostosis of tubular bones, and synovial effusions. HOA can be a primary entity, or can be secondary to extra skeletal conditions. Primary HOA is a rare disease, with male predilection. Hippocratic fingers show a distinctive bulbous deformity of the fingertips. It can be associated with large joint’s effusions but there is neither synovial membrane hypertrophy nor inflammatory cell exudation. Radiographs may show an acro-osteolysis, periostosis of tubular bones. The tibia, fibula, radius, and ulna are the most commonly affected bones.