Eiman Soliman

Association of PTPN22 gene polymorphism and systemic lupus erythematosus in a cohort of Egyptian patients: impact on clinical and laboratory results

To assess the possible association between the protein tyrosine phosphatases non-receptor 22 (PTPN22) gene 1858 CT polymorphism and the predisposition to systemic lupus erythematosus (SLE) in Egyptian patients and its influence on clinical and laboratory parameters. PTPN22 gene 1858 CT polymorphisms were analyzed in forty SLE patients and 20 normal controls by real-time polymerase chain reaction (PCR) technology, using the TaqMan 5-allele discrimination assay. Detailed history, clinical examination, and investigations were done to detect various organ involvement. The homozygous genotype TT was absent in both SLE and controls. The CC genotype was observed in 47.5% SLE and 80% controls; the CT genotype was found in 52.5% patients and 20% controls. The frequencies of the C and T alleles were 74 and 26% in SLE and 90 and 10% in controls, respectively. The presence of CT genotype increased the risk for developing SLE by 4.42. Renal involvement was significantly higher in SLE patients with CT (76.2%) compared to those with CC genotype (42.1%).

Local infliximab injection of sacroiliac joints in non-radiographic axial spondyloarthritis: Impact on clinical and magnetic resonance imaging parameters of disease activity

Abstract Objectives. To evaluate the effectiveness of infliximab (IFX) injection into sacroiliac joints (SIJs) of non-radiographic axial spondyloarthritis (nr-axial SpA) and its impact on clinical and MRI parameters of disease activity. Methods. Thirty-seven patients fulfilling the Association of Spondyloarthritis International Society (ASAS) criteria for axial SpA were initially studied, with disease duration not exceeding 1 year and failed to respond to non-steroidal anti-inflammatory drugs (NSAIDs). Only SpA having active sacroiliitis on MRI without spondylitis (number = 7) were selected to receive bilateral SIJ injection of 20 mg IFX. Follow-up MRI was done at 24 weeks post-injection. Patients were clinically evaluated before, and 12 and 24 weeks after SIJ injection. Evaluation included back pain and stiffness scores, and Bath Ankylosing Spondylitis (BAS) Disease indices and C-reactive protein (CRP) levels. ASAS response criteria were also assessed. Results. Twelve and twenty-four weeks after injection, there was significant decrease in back pain, stiffness, and BAS Disease Activity and Global indices. BAS Functional index, CRP, and mean bone marrow edema score of SIJs were decreased without reaching statistical significance. All patients achieved ASAS20 and five (71.4%) achieved ASAS40. Conclusion. SIJ injection of IFX could be a therapeutic option in early nr-axial SpA who failed to respond to NSAIDs.

THU0268 Local infliximab injection of sacroiliac joints in early axial spondyloarthropathies: Impact on parameters of disease activity

Background Systemic administration of tumor necrosis factor-alpha (TNF-α) antagonists, such as infliximab, has been shown to be effective in the treatment of spondyloarthropathies (SpA). However, experience with the local use of anti-TNF-α in patients with sacroiliitis, ankylosing spondylitis, or other forms of SpA is limited. The effects of intravenous infliximab therapy on MRI signs of sacroiliac joint (SIJ) activity and on clinical measures of disease activity has been previously demonstrated, however the effects of its local injection into SIJ is not yet studied. Objectives To study the effects of local SIJ injection of infliximab on clinical and MRI signs of disease activity in early axial SpA. Methods The study included thirty-seven patients fulfilling the ASAS criteria for axial SpA, with disease duration of less than one year, who failed to respond to non-steroidal anti-inflammatory drugs (NSAID). Patients with associated peripheral arthritis, psoriasis or inflammatory bowel disease were excluded. STIR, T2 Fat saturation and T1W MRI of spine and SIJ were performed for all patients. Only those having active sacroiliitis without signs of spondylitis were selected (number = seven patients) to receive fluoroscopic- guided local injection of 20 mg of infliximab in each SIJ. Leeds scoring system was used to score bone marrow edema (BME) representative of active inflammation. MRI of SIJ was repeated six months after the SIJ injection. Patients were clinically evaluated before, three and six months after SIJ injection. This included Bath Ankylosing Spondylitis Disease Activity index (BASDAI), Bath Ankylosing Spondylitis Functional index (BASFI) and Bath Ankylosing Spondylitis Global index (BASGI), back pain and back stiffness scores, in addition to measuring erythrocyte sedimentation rate (ESR). Results There was a significant decrease in the mean levels of BASDAI, BASGI, back pain and stiffness scores (table) following local infliximab injection of SIJs. This improvement was detected after three months and was maintained at six months post injection. Furthermore, there was a decrease in the mean BME score, BASFI and ESR but without reaching statistical significance. BME scores decreased in five patients, increased in one patient and remained unchanged in another one, but none of them developed MRI signs of chronic sacroiliitis. Table 1. Measured disease parameters in SpA before and six months after local infliximab injection of the SIJ Measured parameters Before injection After injection t-test P value Back Pain score 6.3±2.4 3.9±2.8 3.238 0.023* Stiffness score 6.7±3.3 2.7±2.7 2.712 0.042* BASDAI 6.36±1.9 3.04±1.7 3.350 0.029* BASFI 4.99±1.9 3.07±1.7 2.436 0.059 BASGI 7.14±1.1 4.5±2 3.467 0.018* BME 3.7±1.5 2.7±2.2 1.52 0.177 ESR (mm/hr) 29.8±10.4 19.8±8.2 1.929 0.112 *P is significant at values ≤0.05 Conclusions Local infliximab injection of SIJ can be an effective therapeutic option in early axial SpA patients who failed to respond to NSAIDS. This modality can be considered in selected cases to avoid the high cost and side effects of systemically administered anti-TNF-α drugs. Longer period of follow up is needed to detect the maximum duration of disease improvement. Disclosure of Interest None Declared

Proximal Tibial Fracture after Bone-Patellar Tendon-Bone Autograft Harvesting in Anterior Crutiate Ligament Reconstruction: Literature Review and Report of Two Cases

ACL reconstruction surgery shows low incidence of complications (1.38%) like DVT, Infection, patellar tendon rupture and fractures whether in the proximal tibia or the distal femur. We hereby present two cases that have had the rare complication of proximal tibial fracture. The circumstances of each case are discussed together with discussion of similar cases described in the literature. We tried in the end to have an idea about the possible causes and how to prevent such a devastating event. Case presentation: Case 1 shows a 38-year-old female patient who had an ACL reconstruction surgery by BTB graft followed by iatrogenic proximal tibial fracture managed by open reduction internal fixation by T plate and screws. Case 2 shows a 28-year-old male patient who had an ACL reconstruction surgery by BTB graft also followed by Proximal tibial fracture 3 weeks later managed by open reduction internal fixation using a locked plate and screws. Discussion: Fractures are a rare complication that may follow ACL reconstruction surgery. These fractures can be femoral or tibial that may be due to the reduction of the bone strength as a result of the drill holes which behave as a stress riser. We also suggest that usage of osteotomes during grafting plays a role in these fractures. Management of these fractures is either by open reduction and internal fixation or closed reduction. What is known about the subject: Patellar fractures are a known complication of ACL reconstruction using patellar tendon graft. What this study adds to the existing knowledge: Raising the Knowledge that also the tibia can be fractured as a complication of patellar tendon harvesting not only the patella.

Autoimmune thyroid disorders in seropositive versus seronegative rheumatoid arthritis

Background Autoimmune diseases are chronic conditions initiated by the loss of immunological tolerance to self-antigens; they represent a heterogeneous group of disorders that afflict specific target organs or multiple organ systems. Autoimmune thyroid disease (AITD) is a common organ-specific autoimmune disorder affecting mostly middle-aged women. AITD is a term that includes various clinical forms of autoimmune thyroiditis; among these diseases, Hashimoto′s thyroiditis and Graves′ disease are the two most common types and share many features immunologically. Rheumatoid arthritis (RA) is a chronic inflammatory disease that leads to severe disability and premature mortality. Given the same pathogenic mechanisms, autoimmune diseases tend to cluster together, and hence this study was designed to investigate the relationship between AITD and RA, particularly seropositive versus seronegative subtypes. Patients and methods The study included 70 patients with evidence of RA. Their diagnosis was based on the 2010 American College of Rheumatology (ACR)-EULAR classification criteria, and they were subclassified into two groups: group I, comprising 35 patients with seropositive RA (positive to one or both seromarkers), and group II, comprising 35 patients with seronegative RA (negative to both seromarkers). Twenty healthy age-matched and sex-matched controls constituted group III. All of the studied participants underwent detailed history-taking and physical examination, focusing on RA duration of illness, clinical features suggestive of thyroid dysfunction, and disease activity score (DAS28). We determined the complete blood count, erythrocyte sedimentation rate, C-reactive protein, urea, creatinine, alanine aminotransferase, aspartate aminotransferase, thyroid stimulating hormone (TSH), serum total T3 (TT3), serum total T4 (TT4), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), anti-thyroid peroxidase (anti-TPO), thyroglobulin Ab, and TSH receptor antibody (TRAb) levels, and also performed a neck ultrasound. Results It was found that erythrocyte sedimentation rate, C-reactive protein, RF, and anti-CCP were significantly higher in RA patients versus controls, particularly in seropositive versus seronegative patients. No significant difference was found between the studied groups as regards TSH, T3, and T4 levels; however, hypothyroidism was found to be more common than hyperthyroidism in RA patients (29 vs. 3% in group I and 9% in group II). Anti-TPO and antithyroglobulin were significantly higher in RA patients versus controls (P < 0.001) and specifically in seropositive (1301.9 ± 1716.0 and 1750.0 ± 1866.2, respectively) versus seronegative patients (799.4 ± 1597.7 and 898.1± 988.11, respectively). TRAbs were detectable in a small subset of RA patients (6% regardless of the serostatus) with significant difference between patients and controls (P = 0.006). Ultrasonographic features of thyroiditis were significantly evident in RA patients versus controls (P = 0.001). A positive correlation was found between RA autoantibodies (RF and anti-CCP) and thyroid autoantibodies (mainly anti-TPO and TRAbs) (P = 0.007, 0.012, 0.004, and 0.035, respectively). Conclusion Thyroid dysfunction and AITD are common in RA patients, with hypothyroidism being the most common disorder, which is prevalent in 29% of patients regardless of their serostatus. This association was independent of disease activity assessed by DAS28. Increased incidence of thyroid autoimmunity was seen in seropositive RA versus seronegative RA patients, as evidenced by higher levels of thyroid autoimmune markers in the former. TRAbs were detectable in a small subset of patients with RA.

AB0343 Thyroid Autoantibodies in Seropositive Versus Seronegative Rheumatoid Arthritis: Is There a Link?

Background Rheumatoid arthritis (RA) and autoimmune thyroid disease (AITD) tend to cluster together. However the relation between RA autoantibodies and thyroid autoantibodies is debatable. Objectives To investigate the relation between RA autoantibodies namely anti-cyclic citrullinated peptide (anti –CCP) and rheumatoid factor (RF) and autoimmune thyroid markers [thyroid peroxidase antibodies (anti-TPO), thyroglobulin antibodies (anti-TG) and TSH receptor antibodies (TRAbs)] in RA patients. Methods The study included 70 RA patients, subclassified according to the presence of RF and anti-CCP into 35 seropositive RA patients (positive to one or both seromarkers), and 35 seronegative RA (negative to both seromarkers). 20 healthy age and sex matched were also included as controls. Detailed history and physical examination focusing on clinical features suggestive of thyroid dysfunction and disease activity score (DAS 28) were assessed. Investigations included measurement of thyroid stimulating hormone (TSH), total triiodothyronine (TT3), total thyroxin (TT4), anti-TPO, anti-TG, and TRAbs in addition to ESR and CRP. Ultrasound neck for assessing thyroid was done in all patients and controls. Results Hypothyroidism was found in 20/70 (28.57%) RA compared to 15% of controls. Whereas hyperthyroidism was found in 4/70 RA patients (5.71%) compared to 0% of controls. There was no significant difference in thyroid dysfunction between seropositive and negative patients. Mean levels of anti-TPO, anti-TG and TRAbs were significantly higher in RA patients versus controls (p<0. 001). Furthermore, mean anti-TPO was significantly higher in seropositive than seronegative RA (1301. 9±1716. 0 and 799. 4±1597. 7 respectively) (P<0.001). Anti-TG was higher in seropositive than seronegative RA (1750. 0±1866.2 and 898. 1±988. 11 respectively) (P<0.001). Similarly, TRAbs were significantly higher in seropositive than negative RA (p=0. 006). Ultrasonographic thyroiditis was significantly evident in RA patients versus control (p=0.001) with no difference between seropositive and negative RA. Significant positive correlation was found between RA autoantibodies (RF and anti-CCP) and thyroid autoantibodies in seropositive patients. Conclusions Thyroid dysfunction and AITD are common in RA patients, with hypothyroidism being the commonest regardless of RA serostatus and disease activity assessed by DAS 28. Seropositivity to RF and/ or anti-CCP infers a state of increased immune reactivity in RA as evidenced by the significantly higher levels of all thyroid autoantibodies in seropositive patients than seronegatives and controls and by the positive correlation between the RA autoantibodies and thyroid autoantibodies. Accordingly, screening for thyroid autoantibodies in RA patients especially seropositives is recommended. Disclosure of Interest None declared

Ewing’s Sarcoma Presenting as Hip Monoarthritis in a Spondyloarthritis Patient

Seronegative spondyloarthritis (SpA) and Ewing’s sarcoma (ES) are common disorders affecting young males. A great challenge is to diagnose both diseases in the same patient. Here we describe a case of a young male patient having SpA, who developed ES that presented as monoarthritis of left hip which was misdiagnosed twice; first as peripheral manifestation of SpA and second as septic arthritis; before the correct diagnosis was reached. A 17 year-old boy presented with inflammatory low back pain of gradual onset lasting for 4 months and knee arthralgias. Examination revealed the presence of localized tenderness over both SIJs and limited lumbar flexion. Plain x-ray showed bilateral grade 2 sacroiliitis and he was Rheumatoid factor negative. The diagnosis of seronegative SpA was made based on fulfillment of the Association of Spondyloarthritis International Society classification criteria for axial SpA. Nonsteroidal anti-inflammatory drugs (NSAIDs) and sulphasalazine were prescribed resulting in rapid improvement of back pain and knee arthralgia. Four months later, the patient had increased severity of his back pain with pain at the left hip region associated with painful limited internal hip rotation. The diagnosis of left hip arthritis associated with SpA was made without requesting imaging study at that time. The dose of NSAIDs was increased and a low dose steroid was added. Few days later, the general condition of the patient deteriorated with the development of night fever, poor night sleep and poor appetite. On presentation, the patient looked very ill with fever. Hip examination revealed marked painful limited hip movement with flexion deformity. New investigations revealed an ESR of 110 mm/hr, and a CRP of 88 mg/L. There was normochromic normocytic anemia (HB: 9g/dl) and leucocytosis (WBC: 13.300/µL). The diagnosis initially considered was acute septic arthritis. Left hip arthrocentesis failed to aspirate any fluid and ultrasound revealed the absence of joint effusion. A multislice computerized tomography (CT) revealed the presence of a destructive osseous lesion targeting the left pubic bone and the left acetabulum with intra-articular extension into the left hip joint causing bony erosion of the medial aspect of the left femoral head. An MRI showed intra-pelvic extension with enlarged iliac lymph nodes. A biopsy was obtained from the mass. Histopathology revealed a malignant round-cell tumor consistent with ES. The patient was referred for chemotherapy and we knew that he was started on a combination of drugs for a short time before he died. To the best of our knowledge this is the first report in literature of ES in SpA patient and the second report of ES presenting as hip monoarthritis.

THU0548 Hand Function in Systemic Sclerosis: A Clinical and Ultrasonographic Study

Background Hand involvement is one of the earliest clinical manifestations of systemic sclerosis (SSc) that results in major functional compromise. Several factors may be responsible including skin and periarticular thickening, arthralgias or arthritis, tenosynovitis, Raynaud’s phenomenon, digital ulcers and calcinosis. Although hand dysfunction was investigated using different indices and instruments, to date there is no multi-elemental ultrasonographic assessment of hand structures in SSc. Objectives To evaluate hand impairment and functional disability in SSc patients using clinical and ultrasonographic measures to guide rehabilitation programs aiming at better quality of life. Methods Fifteen consecutive SSc patients and 10 matched healthy controls were included. Patients underwent clinical examination of hands for detection of joint involvement (tenderness, swellings or contractures), digital ulcers, and calcinosis. Skin thickness was clinically assessed using modified Rodnan skin score (mRSS) total and regional of upper limbs. Hand function assessment included pinch and grip strength, finger range of motion using finger to palm tests, Hand Mobility in Scleroderma test and Hand Functional Index. Hand disability was assessed by Health Assessment Questionnaire, Scleroderma HAQVisual Analogue Scale and Cochin scale. Hands and wrists ultrasound (US) was performed aiming at detection of any structural abnormalities as synovitis, tenosynovitis or calcinosis. US measurement of flexor retinaculum (FR) thickness, skin thickness at four sites on each upper limb corresponding to those of the upper limb mRSS were performed in all patients and controls. Results Ten patients (66.6%) had limited and 5 (33.3%) had diffuse SSc. The mean disease duration was 7.13 ±6.96 years. All SSc patients had Raynaud’s phenomenon, nine patients (60%) had healed digital ulcers while only one had active ulcers. Seven patients (46%) had arthralgia in most of the hand joints, eight (53%) had contracures, and one had calcinosis. All patients had a significant decrease in grip strength and finger to palm tests compared to controls. Comparison of the US findings of the hands in patients to controls revealed bilateral significant increase of the middle finger dorsal skin thickness, significant increase of the mean 2nd inter-metacarpal web space skin thickness, significant increase of the mean FR thickness in SSc. There were no US detectable synovitis, or tendon pathologies, but calcinosis was detected in one SSc patient only. There were no significant correlations between US measures of skin thickness and either total or regional mRSS. Hand disability measures showed significant correlations with pinch and grip strength and with hand mobility measures which were significantly negatively correlated with US skin thickness. Conclusions Hand disability in scleroderma is mainly related to impaired hand mobility (attributed to increased skin thickness and arthralgia) and also diminished strength (attributed to pain and disuse). Arthritis, tenosynovitis, digital ulcerations and calcinosis were not major causes of hand disability in this study. The use of US in adjunct to clinical examination refines the evaluation of hand impairment in SSc for a better design of rehabilitation oriented approach to disease management. Disclosure of Interest None Declared

Poster 7 Hand Function in Systemic Sclerosis using Clinical and Ultrasonographic Evaluation: A Feasibility Study

due to low prevalence, severe cognitive and functional deficits, and poor prognosis at time of diagnosis. Conclusions: Those suffering PML are often left with severe disabilities and may benefit from an intense multidisciplinary rehabilitation program to improve function and enhance quality of life. Inpatient rehabilitation also allows for daily monitoring of response to HAART and potential dangerous complications such as immune reconstitution inflammatory syndrome.