R. Tekaya

AB0650 LATENT TUBERCULOSIS SCREENING AND MANAGEMENT BEFORE BIOLOGIC AGENTS INSTAURATION AND RISK OF REACTIVATION: THE EXPERIENCE OF AN ENDEMIC TUBERCULOSIS COUNTRY

Background Using biologic agents has significantly improved the management of chronic inflammatory rheumatism. However, there is clear evidence that these treatments increase the risk of infections and tuberculosis reactivating (TB). Objectives To specify latent TB screening procedures in Tunisian patients candidates for biologic agents and to assess the risk of subsequent reactivation. Methods It’s a retrospective monocentric study of medical records of patients with chronic inflammatory rheumatism receiving biologic agents (TNF alpha blockers and Rituximab) between 2007 and 2012 since at least 3 months. Before treatment instauration, latent TB infection was detected on the basis of history taking, physical examination, 5-unit intradermal tuberculin test (ITT), Chest X-ray and BK research in sputum and urine. In Tunisia all patients were vaccinated with Bacille Calmette-Guérin at birth and at the age of 6 years if schooled. The national Tunisian guidelines for TB management, in patients receiving biologic agents, were followed. The particularity of Tunisian recommendations is, before 2010, positive ITT was considered positive beyond 10mm, now the Affsaps recommendations are used. Patients outcome has been reported. Results Eighty-three patients were included in this study with a mean age of 47 years. It was about 53 women and 30 men with rheumatoid arthritis (n=53), spondylarthropathis (n=28), refractory adult onset Still disease (n=1) and severe ocular involvement of Behçet disease (n=1). Ninety one prescriptions of biologic agents were reported. Etanercept was prescribed in 32 cases, infliximab in 26 cases, adalimumab in 10 cases and rituximab in 21 cases. History of TB was found in 2 patients. Physical examination was normal in all cases. The chest-X-ray showed suggestive images of TB in 1 patient proved to be sequellar in the lung scan. The ITT was< 5mm in 66 cases, between 5 and 10mm in 10 cases and >10mm in 7 cases. Prophylactic TB treatment by Izoniazide 5mk/kg/day and Rifampicine 10 mg/kg/day for 3 months was prescribed in 10 cases. It was indicated for positive ITT (8cases), opacity of the chest radiography (1case) and positive culture of mycobacterium TB in urine in 1case (in this case no urogenital TB was confirmed). Nine patients, seen before 2010, had ITT between 5 and 10mm and didn’t receive chimioprophylaxis. The biotherapy was initiated 3 weeks after chemoprophylaxis beginning. During the following-up, 2cases of active pulmonary TB after the initiation of biologics was reported. The first case was in 48-years-old woman treated with rituximab, 26 months after the last infusion. Rituximab reintroduction, 2 months after TB treatment, was safe. The other case was a 28-years-old man treated with etanercept for 5months. In this tow cases, initially latent TB screening was negative. No case of TB reactivation has been reported after a mean follow-up of 16 months, even in the group of patients with ITT between 5 and 10mm who didn’t receive preventive treatment. Conclusions Our study showed that the Tunisian recommendations have prevented the occurrence of TB reactivation under biologic agents. The use of these treatments in an endemic country does not increase the risk of TB reactivation if preventive measures have been complied. Disclosure of Interest None Declared

AB1166 Socio-Economic and Professional Factors' Impact on Sleep Quality in Axial Spondyloarthritis Patients

Background Work and socio economic related factors have a great impact on patients quality of life. Objectives To explore the effect of work-related and socio-economic factors on quality of sleep in patients with Axial Spondyloarthritis (AS). To explore the effect of work-related and socio-economic factors on quality of sleep in patients with Axial Spondyloarthritis (AS). Methods A cross sectional case-control study was conducted between August 2012 and August 2013 in the department of Rheumatology of Charles Nicolle Hospital. Only patients with Axial Spondyloarthritis according to the 2009 Eular criteria were included. The 100 age- and sex-matched healthy controls were included in this case-control study. The patients and controls who had malignancy, fibromyalgia, serious infections or systemic diseases, and other chronic diseases were excluded from the study. Demographic characteristics, disease specific variables, years of education, marital status, disease duration, occupation and absenteeism during the three last months were documented for each patient. They answered a self-assessing: sleep quality the Medical outcome study sleep scale (MOS-SS). Results One hundred patients with AS and 100 control group patients age and sex matched participated in this study. Patients were divided into 71 men and 29 women. Their average age is 41.72 years [16-74].The majority of patients belonged to an average socioeconomic class (70%). 16% had a higher education, 68% secondary education, and 16% were illiterate. One-half of patients were unemployed and 26% displayed a disability related to their disease. Absenteeism was noted in 23% cases. The duration of the disease is on average 11.7 years and the age of disease onset is 28.9 years on average. In the group of women through, there were many more disruption sleep (p=0.016), headache/breathlessness on waking (p=0.008), and a fewer sleep hours amount (p=0.037). There was no difference between the sexes in terms of adequacy, sleepiness, snoring and sleep index I and II. Age was significantly correlated with sleepiness and areas snoring (p=0.002, p=0.001). The age of onset of the disease was significantly correlated with the areas drowsiness (p=0.015) and snoring (p=0.01) Comparison of sleep disorders by socio economic level showed that sleep adequacy, headache and breathlessness are more observed in disadvantaged class (p=0.022). Workplace absenteeism was related to sleep disorders in the area sleep disturbance with p=0.002. Conclusions Socio economic and professional status affects greatly the quality of life of patients and especially their sleep quality. Disclosure of Interest None declared

AB0418 Effectiveness of Rituximab as First and Second Line Therapy in Patients with Rheumatoid Arthritis

Background The order of use of biologic agents after failing a TNF inhibitor is still a question for debate. Recent clinical practice guidelines recommend the use of Rituximab after previous failure of one anti-TNF. Objectives This study aims to compare the efficacy of first and second line of Rituximab and factors associated with, in patients with rheumatoid arthritis (RA). Methods Retrospective analysis of 40 Tunisian RA database was included. RA patients initiating a first line either anti-TNF (adalimumab (ADA), etanercept (ETA) or infliximab (INF)) or Rituximab (RTX) were identified and followed forward in time. Anti TNF was then switched with Rituximab, which has become the second line. Baseline demographics included age, disease duration, fatigue and pain visual analogical scale evaluations (VAS) and DAS 28 ESR. The therapeutic efficacy was assessed on the EULAR response criteria. Results The analyzed cohort comprised patients with average age of 53,85 years (80% female). 21 patients initiating a first line anti TNF (ADA (n=2), ETA (n=7), INF (n=10), ETA then ADA in one case and INF then ETA in another one case). The evolution marked by a primary therapy failure in 6 cases and a secondary therapy failure in 8 cases. Anti TNF was then switched to RTX. The reason for the switch was therapy failure (n=12) and adverse effects (n=8). In this group, the EULAR response criteria were positive in 57% (Good in 6 cases and moderate in 6 cases). For patients (n=19) who have started in a first line RTX, the EULAR response criteria were positive in 94% (Good in 8 cases and moderate in 10 cases). Seven patients had positive antinuclear antibodies whose 57% had positive EULAR response criteria (Good in 1 case and moderate in 3 cases) and whose 3 patients were under second line RTX therapy who have not developed therapy response. Total, 75% of patients developed positive EULAR response criteria under RTX, whose 50% were under Methotrexate, 43% received more than one course of RTX whose 53% maintained therapeutic efficacy at week 16. Conclusions As a first line agent, RTX demonstrates a better retention rate than in second line. Disclosure of Interest None declared

AB0851 Laboratory Abnormalities in Tuberculous Spondylodiscitis

Background Tuberculous spondylodiscitis still frequent in our country. Biologic aspects can help diagnosis in some cases. Objectives Our objective is to describe laboratory features of tuberculous spondylodiscitis among monocentric experience. Methods This is a retrospective study which included medical records of patients treated for tuberculosis spondylodiscitis during the ten past years [2002-2012]. Biologic data were recorded and analysed. Results Fifty seven cases of 29 women and 28 men of tuberculous spondylitis were treated during the ten past years. The mean age was 56.6 years (range 20 to 86 years). A contact history of tuberculosis was reported by 2 patients. The predisposing conditions were present in the third of cases: diabetes mellitus (13 cases), hepatic cirrhosis (5 cases) and high-dose corticosteroid intake (2 cases). It was a progressive starting of disease in two thirds of cases with median duration from the onset of symptoms to the diagnosis about 5.4 months (0.7 range to 24 months). Fever was observed in 29% of cases. Night sweats were present in 40% of cases Anorexia and weight loss were present in 71.9% of cases. Stiffnes was noted in 70% of cases. Pulmonary tuberculosis was associated in 3 cases and cutaneous tuberculosis was noted in 1 case. Biological inflammatory tests were rised in 91% of cases with a mean erythrocyte sedimentation rate of 93mm (range 2 to 150) and an average value of c Reactive protein of 55mg/l (range 0,2 to 331). The blood count showed leukocytosis (15 cases), lymphocytosis (9 cases), leukopenia and anemia in one case each. Disturbance of liver function tests was noted in 5 cases: hepatic cholestasis (n=3), hepatic cytolisis (n=2). Hyerglycemia was noted in the 13 cases of diabetes mellitus. Identification of mycobacterium tuberculosis in sputum was positive in 1 case. Conclusions Inflammatory blood tests were rised in major of cases and leukocytosis was frequent among patients with tuberculous spondylodiscitis in this study. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2758

THU0286 Imaging Findings in Osteoarticular Brucellosis:Study of Twelve Cases

Background The clinical and radiological diagnosis of osteoarticular brucellosis is not always easy owever essential for early and effective treatment. Objectives The aim of this study is to study radiological findings of osteoarticular brucellosis which were reported and confirmed in a rheumatological department. Methods This is a retrospective study which included medical records of patients treated for osteoarticular brucellosis during the ten past years [2002-2012]. Radiological data were recorded and analysed. Results Twelve cases of osteoarticular brucellosis were treated during the ten past years. All patients had spondylodiscitis. One patient had elbow bursitis associated. We had no case of peripheral arthritis or sacroiliitis. The mean age was 55 years (range 33 to 79 years) with a male to female ratio about 1. The predisposing conditions were present in 2 cases: diabetes mellitus and cirrhosis. Consumption of raw milk products was noted in 8 cases. The median duration from the onset of symptoms to the diagnosis was 3.6 months (range 1.5 to 6 months). The following symptoms were observed: inflammatory back pain (12 cases), sciatalgia with neurological signs (4 cases), weight loss (11 cases), fever (9 cases) and night sweating (n=7). One patient had symptom of spinal cord compression. C Reactive protein level was increased in 8 cases. Lymphopenia was noted in 4 cases. Wright serology was positive in all cases. Spondylodiscitis was uni-staged in all cases: the lumbar spine was the most commonly involved (8 cases). Standard X-ray showed narrowing of the intervertebral space (10 cases), endplate destruction (8 cases), bone condensation (1 case) and were normal in one case. MRI performed in all cases, had showed low signal intensity on T1-weighted images and high signal intensity on T2 weighted images of the vertebral bodies, endplates and intervertebral disc in all cases. Indeed the following findings were observed: paravertebral abcess formation (3 cases), epidural extension (8 cases), posterior longitudinal ligament elevation (1 case) and psoas abcess (2 cases). Conclusions MRIduring osteoarticular brucellosis and especially spondylodiscitis provides early diagnosis and well demonstration of paravertebral soft tissue spreading more than standard X-ray. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2759

THU0288 Osteoarticular Infections in Elderly Patients: A Study of 44 Cases

Background Joint and bone infections are a therapeutic emergency that may occurs at any age but is particular among elderly patients. Objectives The aim of this study is to identify different features of joint and bone infections in elderly patients. Methods We performed a retrospective study of medical records of patients hospitalized for management of osteoarticular infections and who were aged more than 65 years old between 2000 and 2012. Clinical, paraclinical and therapeutic characteristics were recorded and analysed. Results Forty four cases were collected (20 males/24 females). Mean age was 73.8 years (range 65 to 90). The predisposing factors were present in 54,4% of cases (n=24): diabetes mellitus (n=9), renal failure (n=5), cirrhosis (n=3), rheumatoid arthritis (n=2), psoriatic arthritis (n=1), high dose corticoid intake (n=4). Tuberculous and brucellar contage were reported by 4 and 2 patients respectively. Infectious gateway were found in 5 cases: pulmonary (n=2), cutaneous (n=2) and urinary (n=1). Pain was present in all cases. The following symptoms were observed: fever (n=25), impaired general condition (n=20), night sweat (n=13), radiculalgia with neurological signs (n=6). Inflammatory blood tests were rised in all cases with mean CRP of 113.2mg/l (range 4 to 331) and mean ESR of 101.3mm (range 2 to 195). Blood culture was positive in 2 cases and wright serology was positive in 2 cases. Radiological abnormalities were found in 38 of cases. It was an infectious spondylodiscitis in 25 cases, an association of spondylodiscitis and septic arthritis of sternocostal joint in 1 case and a septic arthritis in 18 cases. In the last cases, it was: polyarthritis (n=1), oligoarthritis (n=2) and monoarthritis (n=15). The arthritis involved the: Knee (n=12), elbow (n=2), shoulder (n=2), ankle (n=3) and hip (n=1). The germ was identified in 10 cases: Specific germ in 1 case (Mycobacterium Tuberculosis), and pyogenic germ in 9 cases: Staphylococus (n=3), Pseudomonas (n=1), Escherichia coli (n=1), Streptococcus (n=1), Serratia (n=1), Lactococcus (n=1) Enterobacter (n=1). All patients received antibiotics according to the bacterial agents. Complications were observed in 6 cases: endocarditis (n=1), cauda equina syndrome (n=1), medullar cord compression (n=1) and side therapy effects (n=3). Five patients died. Conclusions Osteoarticular infections in elderly patients were dominated by spondylodiscitis, characterised by blood inflammation and may cause several complications. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2755

AB0651 Preventive antituberculosis treatment before biologic agents initiating: frequency of prescription and tolerance in a sample of tunisian rheumatologic population

Background Treatment of latent tuberculosis (TB) is mandatory before biologic agents’ instauration to prevent the risk of reactivation. Objectives To assess frequency and reasons of TB chemoprophylaxis prescription in rheumatologic population and its tolerance. Methods It is a retrospective monocentric study of medical records of patients receiving biologic agents (TNFalpha blockers and rituximab) who were hospitalized in Rheumatology department between 2005 and 2012. We included patients who received TB chemoprophylaxis. We noted epidemiologic characteristics, reasons of prescription, levels of alanine aminotransferase (ALAT) aspartate aminotransfere (ASAT,) prethrombin time (PT) and gamma-glutamyl transferase (GGT) before and during treatment and when any side effect was observed. Results Ninety tow prescriptions of biologic agents were reported in 84 patients. Among them, 11 (13%) received prophylaxis. Izoniazide 5mg/kg/day and Rifampicine 10mg/kg/day for 3 months (INH/RIF) were prescribed in all cases. Six patients presented with Rheumatoid arthritis (RA) and 5 with Spondylarthritis (SA). Age ranged from 34 to 76 with an average of 50 years. The mean disease duration was 10.3 years. The mean number of DMARDs previously received before introduction of biotherapy was 1.5 for patients with RA and 1 in patients with SA. The treatment by INH/RIF was prescribed in 11 cases because of intradermal tuberculin test positivity (n=8), an opacity on the chest radiography (n=1), QuantiFERON positivity (n=1) and because of positive culture of mycobacterium tuberculosis in urine (n=1) (in this case no urogenital TB was confirmed). Before INH/RIF instauration hepatic enzymes levels and TP were normal in all cases except one with hepatic steatosis (ALAT 2.7 times and GGT 4.2 times). Acetylating test was performed in all patients and INH dose was adapted based on. Biologic hepatotoxicity was noted in 3 cases. Cytolisis was noted in 1 case, increase of ALAT was 1.5 times and of ASAT 1,2 times. Cholestasis was seen in 2 cases, average increase of GGT of 1.5 times. No variation in TP level was noted. No of this 3 patients was receiving methotrexate or sulfasalazine. No changes in liver biologic tests was observed in the patient who had hepatic steatosis. Gastrointestinal side effects (nausea and abdominal pain) was seen in one case. No haematological, cataneous, neurological or ophthalmologic side effect was described. We did not need a therapeutic modification because the intensity of the side effects was mild. Conclusions Despite being a TB endemic country, prevalence of chemoprophylaxis prescription in Tunisian rheumatologic population is relatively low. Occurred side effects were always benign. Disclosure of Interest None Declared

AB0539 Psychological status evaluation in spondylarthritis tunisian patients and relationship with diseases features

Background The prevalence of psychological disorders is greater in patients with rheumatologic conditions than among the general population. Objectives We aim in this study to determine the frequency of depression and anxiety disorders in spondylarthritis (SA) patients and to determine predictor disease parameters. Methods We performed a cross-sectional monocentric study in 70 SA Tunisian patients. Presence of anxiety or depression disorders was evaluated by the Hospital Anxiety and Depression Scale score (HADS). A certain anxious or depression state was defined by a HADS>10. Epidemiological factors of SA and different disease assessing measures were noted. For statistical analysis, we used Khi2-test for qualitative variables and Student-test for quantitative variables. A p value≤0,05 was considered significant. Results There were 65% men and 35% women. Age ranged from 16 to 74 years with an average of 40,6 years. Disease mean duration was 10,75±9 years. Mean HADS score was 15,9 and 49 patients had HADS score >10 (certain depression or anxious state) corresponding to a frequency of 70%. 63% of patients had peripheral joints involvement and 65% had hips involvement. Mean Pain-VAS was 65mm and mean Tirederness-VAS was 56mm. Mean BASDAI score was 45%, mean BASFI score 44,7% and mean BASG-s score 55%. The mean BASMI score was 4,76 and the mean BASRI score 4,43. Statistical analysis showed that presence of depression or anxious state was correlated best with BASG-s (p=0,00006), followed by BASFI (p=0,001). Depression and anxiety were significally higher in female (p=0,02) and in patients with active disease (BASDAI>40%) (p=0,009). Depression or anxious status was correlated with Tiredness-VAS (p=0,004) and not with Pain-VAS (p=0,171). Psychological status was independent of disease duration (p=0,959), spine mobility (BASMI) (p=0,567) and of the severity of radiologic involvement (BASRI) (p=0,237). No correlation was seen with peripheral joints involvement nor with hips involvement (respectively p=0,914 and 0,660). Conclusions Frequency of depression and anxiety disorders in SA is high. Female gender, general well- being, disease activity and functional impairment are predicting factors. Disclosure of Interest None Declared

AB0540 Professional characteristics of patients with spondylarthritis

Background Spondylarthritis (Spa) is a chronic inflammatory disease affecting axial skeleton, occurring in young and active patients and often condition their professional prospects. Objectives To describe the social and occupational characteristics of patients affected by Spa, to estimate the impact of the disease on their professional activity and to determine factors exposing to elevated risk of premature withdrawal from the labor force. Methods We had performed a cross-sectional study of 70 patients with Spa recruited during 4 months at the Department of Rheumatology, felling the criteria of AMOR. Demographic, social and professional characteristics were determinate and some disease-specific instruments: BASDAI, BASFI, BASMI, BASG-s, BASRI, lesquene index were performed Results It is about 51 men and 19 women, the average age is 40.61 years. The mean disease duration is 10,75 years. Sixty percent of patients live in urban zone and 17% have an educational level superior to 13 years. The mean score of BASFI is 44.79, the mean score of BASDAI is 45.56, the mean score of BASG-s is 55.64, the mean score of BASMI is of 4.76, the mean score of BASRI is 4,43. Among these patients 82% are eligible to a professional activity (aged between 22 and 65 years and having ended their studies or vocational training). The global unemployment rate is 43%, that’s attributed to the disease is 69%. For the specific disease indexes, high risk of withdrawal is positively correlated with pain-VAS(p=0,005), fatigue-VAS(0,021), the BASFI(0,004), the BASG-s(p=0,016), the BASMI(P=0,001), the BASRI(p=0,001) and Lesquene index(p=0,001). the off work during the last three months is positively correlated to the fatigue(p=0,009)and the BASFI(p=0,009). Conclusions Several factors are identified to be associated to a high risk of premature working withdrawal in patients affected by Spa. Prevention of this risk needs an early diagnosis and treatment of the disease, a vocational guidance, and work preliminary training. Disclosure of Interest None Declared

AB0648 Septic arthritis of the pubic symphysis: a report of 4 cases

Background Septic arthritis of the pubic symphysis is rare and causes many difficulties to get the diagnosis. The risk factors are in most cases pelvic surgery, sports or drug addiction. Its management is not well codified. We report four cases. Results : There were 2 men and 2 women. The mean age of the patients was 56 years (range 35 to 76 years). A predisposing condition was noted in 2 cases: pelvic surgery. Patients presented with hypogastric pain (3 cases) and pain in the gluteal region irradiating to the genitor-urinary organs miming sciatalgia. The fever was present in all cases. The symptoms evolved at mean since 2 months. The physical exam revealed a pain limitation of the hip and a pubic pain (4 cases). Inflammatory tests were rised in all cases. Pelvic radiography showed an irregular cortical with erosion of pubic symphysis and ischio-pubic branchs and enlarging of borders in all cases. Pelvic tomodensitometry was performed in all cases and confirmed these results in three cases and showed the presence of three collections around the pubic symphysis in one case. The bacteriological exams of these collections showed the presence of staphylococcus aureus. The anatomopathological exam, done in the other 3 cases, showed histopathologic signs of pyogenic infection in 2 cases and it was inconclusive in one case. Cytobacteriologic exam of urine revealed a Klebsiella pneumonia in one case. All the patients were treated by association of two antibiotics for 2 weeks, followed by one antibiotic for a total of 6 weeks. Evolution was excellent with resolution of pain, normalization of biologic inflammation and slow radiologic reconstructions, even for the patient with collections. Indeed, magnetic resonance imaging was perfomed a month after antibiotics beginning and has showed their clear regression. Conclusions Infectious symphysitis should be evocated even in the absence of predisposing factors in front of prolonged fever and pain in the pelvic region. Imaging allows positive diagnosis and guide biopsy. Prognosis seems good under appropriate treatment. Disclosure of Interest None Declared