Hela Sahli

Synovial fluid and serum levels of IL-17, IL-23, and CCL-20 in rheumatoid arthritis and psoriatic arthritis: a Tunisian cross-sectional study

Sir, Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by abnormal synovial hyperplasia associated with local infiltration of various inflammatory cells leading to cartilage and bone destruction. Interleukine-17-producing T helper (Th17) cells are a recently discovered effectors T-lymphocyte subset that plays a critical role in several chronic inflammatory diseases, like RA and psoriatic arthritis (PsA) [1–4]. The objective of our study was to appreciate the role of interleukine (IL)-17, IL-23, the major Th17 driving cytokine, and CCL-20, a major Th17-attracting chemokine in the regulation of RA and PsA, by comparing concentrations in sera and in knee synovial fluid (SF) among three groups of patients, one with an active form of RA, one with active peripheral psoriatic arthritis PsA and a control group of osteoarthritis (OA) (Table 1). A case–control study was carried out, during the period of January to May 2010, in the department of Rheumatology with the Immunology laboratory of La Rabta hospital at Tunis (Tunisia). The first group of 26 patients with active form of RA (DAS 28 [ 5.1), according to the 2010 ACR/ EULAR criteria [5], was composed of 21 women and 5 men, with a mean age of 46 ± 12 years and a mean disease duration of 13.5 ± 6 months. The second group was composed of 18 patients with active peripheral PsA, fulfilling the CASPAR criteria [6], with a mean age of 35 ± 9 years and mean disease duration of 20 ± 7 months. The control group was composed of nine patients with flare-up of OA, with a mean age of 56.5 ± 12 years and a mean disease duration of 36 months ± 9. All patients were enrolled after informed consent. Paired concentrations of IL-17, IL-23, and CCL-20 in sera and in SF were determined using an enzyme-linked immuno-sorbent assay (ELISA) technique (R&B, United States). A correlation analysis was performed between parameters of RA’s activity (number of tenderness joints, number of swollen joints, number of night awakening, duration of morning stiffness, disease activity score DAS 28, modified Sharp score [7], serum and SF levels of all the mediators (IL-17, IL-23, and CCL-20). Analyses were performed using SPSS software. Non-parametric tests were used to compare the concentrations, Kruskal–Wallis and Mann–Whitney tests for the comparison of independent samples and paired Wilcoxon test for the comparison of paired samples. Correlations were calculated using the Spearman’s coefficient. A P value below 0.05 was considered as significant. The IL-17 and IL-23 levels were similar in the serum of patients with RA, PsA, and OA. This finding was also demonstrated in the joints of patients with RA, PsA, and OA. In addition, only the synovial concentrations of CCL20 were significantly higher in RA patients than the control groups (P = 0.001). However, when comparing the SF CCL-20 levels in RA versus PsA, no significant difference was found. D. Mrabet (&) S. Sellami Department of Rheumatology, La Rabta Hospital, 1007 Tunis, Tunisia e-mail: mrabetdalila@yahoo.fr

Association of serum levels of aggrecan ARGS, NITEGE fragments and radiologic knee osteoarthritis in Tunisian patients

OBJECTIVES Proteolytic degradation of aggrecan is a hallmark of the pathology of osteoarthritis. The aim of this study was to develop enzyme-linked immunosorbent assay (ELISA) to quantify the serum levels of specific aggrecan fragments generated by aggrecanases-mediated cleavage. We investigated the relationships between these two aggrecan degradations fragments and urinary CTX-II levels. METHODS The competitive ELISAs employ a polyclonal antibody raised against the aggrecan fragments containing two neoepitopes NITEGE(373)and (374)ARGSVI. We measured serum levels of ARGSV and NITEGE in 125 women with knee osteoarthritis (mean±SD age of 53.6±7.6 years, mean±SD disease duration of 3.6±3.8 years), and 57 women age-matched controls. RESULTS Aggrecan neoepitopes assays showed an intra- and inter-assay imprecision (CV) lower than 20% for both tests and good linearity. Median serum ARGSVI (by 18%; P=0.002), and NITEGE (36.4%; P<0.001) levels were significantly decreased in patients with knee osteoarthritis compared with controls. Minimal joint space width was negatively correlated with ARGSVI (r=-0.368, P=0.04) and NITEGE (r=-0.274, P=0.038) in knee osteoarthritis patients. Median urinary CTX-II levels were significantly increased by 39.5% (P=0.001) in knee OA patients compared with controls. CONCLUSION Markers of degradation aggrecan were analyzed for the first time in an African osteoarthritis population. These markers can be used to monitor aggrecanase activity in human joint disease. Their combination with CTX-II can improve clinical investigation of patients with osteoarthritis patients.

Bone mineral density in healthy Tunisian women

Interpretation of densitometric results requires a comparison with reference bone mineral density (BMD) values of normal age and sex-matched persons. Thus the aim of this study was to determine these values for healthy Tunisian women, to estimate the prevalence of osteoporosis and to compare our findings with other populations. A cross-sectional study of 1378 Tunisian women aged between 20 and 96 years was carried out using DXA (GE-Lunar Prodigy). Subjects with suspected conditions affecting bone metabolism were excluded. Measurements were taken at the lumbar spine and femoral neck. These values were expressed at T-scores, with reference to the mean BMD values of the group aged 20-40 years. The peak bone mass, estimated in this age group was 1.174+0.127 g/cm(2) at the lumbar spine and 1.016+/-0.118 g/cm(2) at the femoral site. It was attained respectively within the age of 25 years and 36 years. For both sites, the expected decline in BMD was shown when the successive age groups [40-49 years] and [50-59 years] were compared. Bone loss was rapid during the first 5 years after menopause. Thereafter BMD declined slowly but continually. The prevalence of osteoporosis in the women over 50 years of age, taking account of peak bone mass observed in our cohort, was 23.3% at the spine and 17.3% at the femoral neck with a combined prevalence of 23.4%. These rates attained respectively 30.4%, 11.8% and 32.9% when we considered the Italian values, which demonstrate the variability of osteodensitometric depending to the reference population adopted.

Tuberculosis tenosynovitis of the extensor tendons of the wrist

Mycobacterial tuberculous tenosynovitis of the extensor tendon sheath is an extremely rare manifestation of extrapulmonary tuberculosis. The diagnosis may be easily delayed because of its non-specific clinical signs. We report a new case of tuberculous tenosynovitis of the extensor without concomitant pulmonary tuberculosis or documented immunodeficiency.

Positive Association of Obesity and Insulin Resistance With Bone Mineral Density in Tunisian Postmenopausal Women

The association of bone mineral density (BMD) with obesity and insulin resistance remains unclear. This study aimed to explore these associations in Tunisian menopausal women. Eighty-one postmenopausal women were recruited. Data were analyzed for obese (N = 57) and non-obese women (N = 24) and for insulin-resistant (N = 43) and non insulin-resistant women (N = 36). Anthropometric and biochemical parameters were recorded. BMD in different sites and body composition were measured using dual-energy X-ray absorptiometry. Higher BMD was observed in obese women than those non-obese in the left femur (p = 0.0067), right femur (p = 0.0108), total hip (p = 0.0077), and the whole body (p = 0.0276). Also BMD was significantly greater in insulin-resistant women than in non-insulin-resistant women when measured in the left femur and total hip. Positive correlations were recorded between BMD and anthropometric parameters, body composition parameters, and glycemia (r = 0.249, p < 0.05). Multiple linear regression analysis shows that only trunk fat (p < 0.05) and lean mass (p < 0.05) were independently and positively related to BMD, and the waist circumference was the only anthropometric parameter independently and negatively associated to BMD. BMD is improved in obese and insulin-resistant women. Also, trunk fat and lean mass are likely to be key positive independent factors for BMD.

An extensive hemimelic polyostotic fibrous dysplasia: a case report.

We report a new case of polyostotic fibrous dysplasia (FD). A 26-year-old woman was referred to our department complaining of pain in her left arm. She had suffered for tow fractures in left leg and arm previously. Plain radiographs showed osteolytics lesions at the left humerus and radius. Histological examination of the surgical specimens showed FD. She has beneficed with zoledronic acid perfusion.

Back pain caused by a pseudo-tumorous vertebral collapse: atypical presentation of primary vertebral hydatidosis

Hydatidosis, also known as echinococcosis, is a rare but serious parasitic disease in endemic areas. Primary spinal location is extremely rare. This case report describes a rare instance of hydatid cyst that caused severe and progressive low-back pain and neurologic dysfunction. Spine MRI showed a unique vertebral collapse of Th12 body with multicystic lesions filling the spinal canal. In addition, hydatidosis serodiagnostic test was positive at 1/725. Treatment depended on the actual surgical removal of the cysts. Surgery consisted in excision and extirpation of the cysts, associated with decompressive laminectomy. The diagnosis was confirmed on the basis of histological results. No coincidental hydatid visceral involvement was found. Antihelminthic drugs (Albendazole) were promptly given before surgery for a long period. The outcome was satisfactorily marked by total regression of the motor deficit and sphincter disorders.

Isolated cervical lymphadenopathy: Do not forget atypical leishmaniasis

La Presse Medicale - In Press.Proof corrected by the author Available online since mardi 21 fevrier 2017

AB0980 Epidemiological profile of the pulmonary diseases in mixed connective tissue disease: about 55 cases

Background Mixed connective tissue disease (MCTD) are a systematic autoimmune disease that the aetiopathogeny remains misunderstood. This disease is often associated with systemic involvement which sometimes is very serious, such as pulmonary diseases. Objectives To describe the characteristics of the pulmonary diseases among a sample of MCTD. Methods We conducted a retrospective study including patients cases diagnosed with a MCTD between the period of 10 years in the departement of internal medicine. The demographic, clinical, treated in the immunological, biological and radiological data were collected then analysed. Results In total we had 55 patients. 87% of them were female. The mean age of the sample was 50, 64±15 years. Major types of MCTD were: Rheumatoid polyarthritis (45.5%), sarcoidosis (18.2%), scleroderma (12.7%), and the lupus erythematosus (10. 9%). These causes were diagnosed after a mean delay of 686, 18 days. A lung disease was found in 50.9% of the cases. It was either present without symptoms in 52.8% of the cases or revealed by dyspnoea (22.6%), a cough (18.9%)or hemoptysie isolated or associated to thoracic pains (1.9% each).The most frequent type of respiratory diseases were adenopathies (26.9%). Pleurisy, fibrosis, and interstitial lung diseases were described among 11.5% of the cases. Bronchiectasis, Lung arterial high blood pressure, pleural nodules, bronchi dilatation were reported in 7.7%. In only 3.8% we had patients with cancer and emphysema. Chest radiographs were normal in 65.5% of the cases but we discovered interstitial lung diseases (12.7%), pleurisy (7.3%), pleural nodule and mediastinal enlargement (3.6%) and pneumopathy (1.8%). The same appearences were described in the CT scann normal in 18.5% but in different proportions: adenopathies (25.9%), interstitial lung abnormalities (14.8%), fibrosis (11.1%), bronchiectasis (7,4%) and bronchi dilatation, pleurisy, nodule and mediastinal enlargement (3.7%). Respiratory functional exploration were normal in 69.2% obstructive lung disease and restrictive pulmonary disease were found within 11.5% of the patients. Conclusions Improvement of the knowledge of these diseases will improve the care before the appearance of complications. Disclosure of Interest None declared

AB0902 Risk Factors of Osteoporosis in Hemodialysis Patients

Background Low bone mass is common in patients undergoing hemodialysis. Osteoporosis can be associated with serious bone health problems, especially fragility fractures. Objectives The aim of the study was to determine the frequency of osteoporosis in hemodialysis Tunisian patients and to identify the risk factors of low bone mass in this population. Methods We conducted a cross-sectional study over a period of 4 years [2009-2012] including 90 hemodialysis. Blood samples were drawn before hemodialysis session from patients. We measured calcium, phosphate, alkaline phosphatase (ALP) and intact parathyroid hormone (PTH). Bone mass density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at the lumbar spine and total hip. Using WHO criteria as a cutoff point, osteopenia was defined as a T-score lower than -1 and osteoporosis was defined as a T-score lower than -2.5. All statistical analysis were performed using the Windows SPSS 19 package. Results Ninety patients were included: 58 male (64%) and 32 female (36%). The mean age was 53.01±14.60 years. The mean age of onset of hemodialysis was 50.06±14.82 years. Serum calcium and phosphorus levels were respectively at 2.084±0.32 mmol/L and 1.84±0.57 mmol/L. The average rates of PTH and ALP were respectively at 425.70±380.78 pg/mL and 88.35±72.56 UI/L. Fifty six percent of patients have PTH values between 2 and 9 times the upper normal limit of the assay as recommended by KDIGO (Kidney Disease: Improving Global Outcomes). However, 19% of patients have PTH values less than 2 times the upper normal limit of the assay. The mean of BMD was 0.854±0.152 g/cm2 in the hip and 1.155±0.218 g/cm2 in the lumbar spine. Twenty three percent of patients have osteoporosis and 45% have osteopenia. Osteoporosis affected the hip (20%) more than the spine (5.5%). Regarding risk factors, femoral BMD had significant negative correlations with the with the following parameters: age (r:-0.289; p:0.006), age of onset of hemodialysis (r:-0.359; p:0.001) and PTH level (r:-0.275; p:0.009). However, no correlations was found between lumbar spine BMD and the following parameters: age, age of onset of hemodialysis, calcium, phosphorus and PTH level. Conclusions Our study showed that osteoporosis is common in dialysis patient [1]. The most common region of bone loss was the hip. The decrease in cortical BMD was associated with advanced age, age of onset of hemodialysis and elevated levels of PTH [2]. References Nybo M, Jespersen B, Aarup M, Ejersted C, Hermann AP, Brixen K. Determinants of bone mineral density in patients on haemodialysis or peritoneal dialysis–across-sectional, longitudinal study. Biochem Med. 2013;23(3):342-50. Huang GS, Chu TS, Lou MF, Hwang SL, Yang RS. Factors associated with low bone mass in the hemodialysis patients–a cross-sectionalcorrelation study. BMC Musculoskelet Disord. 2009; 4;10:60. Disclosure of Interest None declared