Slaheddine Sellami

Detection and frequency of Chlamydia trachomatis DNA in synovial samples from Tunisian patients with reactive arthritis and undifferentiated oligoarthritis

We aimed to determine the frequency of Chlamydia trachomatis DNA in the synovial compartment of 34 arthritic patients. Chlamydia trachomatis DNA was detected using a nested PCR targeting the cryptic plasmid, the 16S rRNA gene and the outer membrane protein 1 gene. The presence of serum immunoglobulin (Ig)G and IgA antibodies against C. trachomatis was studied by a microimmunofluorescence assay and by an enzyme-linked immunosorbent assay, respectively. Synovial samples from 20 of 34 (59%) patients [nine with reactive arthritis (ReA), seven with undifferentiated oligoarthritis (UOA), two with rheumatoid arthritis and two with osteoarthritis] were positive for at least one C. trachomatis DNA sequence by nested PCR. The high sensitivity results most likely from the combination of a standardized automated MagNA Pure extraction method, PCR targeting three different C. trachomatis genes and the screening for C. trachomatis in synovial tissue and fluid samples. There was no correlation between the presence of C. trachomatis DNA in the joint and a Chlamydia-specific serologic response. Our data support that PCR is the method of choice to establish the diagnosis of Chlamydia-induced arthritis in patients with ReA. We suggest that this diagnosis might also be considered in C. trachomatis-positive patients previously classified as UOA.

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

Systemic lupus erythematosus induced by interferon β1 therapy in a patient with multiple sclerosis

Drug‐induced lupus erythematosus is defined as a lupus‐like syndrome temporally related to a drug exposure. We report a 34‐year‐old woman with multiple sclerosis who developed, while being treated with interferon β‐1a, myalgia and associated with wrist synovitis. Clinical and immunologic investigations were in favor of systemic lupus erythematosus. Interferon therapy was maintained. Under corticosteroids and antipaludeen treatment, the patient did not develop any other lupic manifestations.

Simvastatin-induced dermatomyositis in a 50-year-old man.

Dermatomyositis (DM) is a rare inflammatory autoimmune disease for which an iatrogenic origin has been described in a few cases. The authors report a case of DM occurring after simvastatin intake. A 50-year-old male sought medical attention for a photodistributed rash and considerable muscular weakness present for 3 months. One year earlier, simvastatin had been introduced. Serum creatine kinase levels were elevated. Histological examination of a muscle biopsy was consistent with a diagnosis of DM. Investigation for neoplasia and associated autoimmune disease proved negative. All clinical and laboratory abnormalities diminished corticosteroid therapy (1 mg/kg/day). Case reports have suggested that lipid-lowering drugs, especially statins, could induce or reveal chronic muscle diseases. In statins myopathy, reduction of coenzyme Q has been discussed as a key mechanism. Our case of DM in a patient receiving simvastatin adds to the previous reported cases in the literature and highlights the potential role of statins as triggers of immune systemic diseases.

Brucellar spondylodiscitis affecting non-contiguous spine levels

Brucellosis is a zoonosis that affects several organs. The spine is the most common site of musculoskeletal involvement. However, multiple-level spinal involvement is rare in brucella spondylodiscitis. The authors report a case of a 56-year-old male shepherd who had developed a spondylodiscitis affecting simultaneously the cervical, thoracic and lumbar regions. The diagnosis was established by using MRI after the brucella-agglutination test was found to be positive. A high degree of suspicion in the diagnosis of brucellar spondylodiscitis is essential to reduce the delay for the treatment. Thus, it should be essentially included in the differential diagnosis of longstanding cervical, thoracic or back pain, particularly in regions where brucellosis is endemic. Screening serological tests for brucella should be used more widely in cases with low index of suspicion, especially in endemic areas.

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.

Adamantinoma of the tibia and fibula with pulmonary metastasis: an unusual presentation

Adamantinoma is a rare tumour of long bones, representing less than 1% of them. Adamantinoma commonly occurs in the tibia. It is locally aggressive and recurrences are uncommon after resection. Metastases have been reported in less than 10% of cases. The most common radiographic appearance is multiple sharply demarcated radiolucent lesions surrounded by areas of dense sclerotic bone. The authors report a patient who developed pulmonary metastasis 1 year after complete resection of primary neoplasm.

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.

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.

Detection of Shigella spp. nucleic acids in the synovial tissue of Tunisian rheumatoid arthritis patients and other forms of arthritis by quantitative real-time polymerase chain reaction

Enterobacterial components in the joints of patients are believed to contribute to a perpetuating inflammation leading to a reactive arthritis (ReA), a condition in which microbial agents cannot be recovered from the joint. At present, it is unclear whether nucleic acids from Shigella spp. are playing a pathogenic role in causing not only ReA but also other forms of arthritis. Quantitative real-time polymerase chain reaction assay (qPCR) is the method of choice for the identification of bacteria within the synovium. The aim of our study was to detect the presence of Shigella spp. nucleic acids in the synovial tissue (ST) of Tunisian arthritis patients. We investigated 57 ST samples from rheumatoid arthritis (RA) n = 38, undifferentiated oligoarthritis (UOA) n = 12, and spondyloarthritis (SpA) n = 7 patients; 5 ST samples from healthy individuals were used as controls. Shigella spp. DNA and mRNA transcripts encoding the virulence gene A (VirA) were examined using an optimized qPCR with newly designed primers and probes. Using qPCR, Shigella spp. DNA was found in 37/57 (65%) ST samples (24/38, i.e., 63.2% of RA, 8/12, i.e., 67% of UOA, and 5/7, i.e., 71.4% of SpA patients). Paired DNA and mRNA were extracted from 39 ST samples, whose VirA cDNA was found in 29/39 (74.4%) patients. qPCR did not yield any nucleic acids in the five healthy control ST samples. The qPCR assay was sensitive and showed a good intra- and inter-run reproducibility. These preliminary findings generated by an optimized, highly sensitive PCR assay underline a potential role of past gastrointestinal infections. In Tunisian patients, a bacterial etiology involving Shigella spp. in the manifestation of arthritic disorders including RA might be more common than expected.