Possible macrophage activation syndrome following initiation of adalimumab in a patient with adult-onset still’s disease

Macrophage activation syndrome (MAS) has been rarely reported in the course of adult-onset Still’s disease (AOSD) and in the majority of cases, it was triggered by an infection. Here, we report, to our knowledge, the first case of MAS occurring after adalimumab treatment initiation and not triggered by an infection. A  26-yearold woman with classical features of AOSD developed persistent fever, severe bicytopenia associated with extreme hyperferritinemia, hyponatremia and abnormal liver function two months after the initiation of adalimumab treatment. The diagnosis of MAS was made without histological proof. The patient was treated with methylprednisolone pulse therapy and her condition improved. During the disease course, extensive studies could not identify any viral infection or other known underlying etiology for the reactive MAS. The  adalimumab was incriminated in this complication. Currently, the patient is in remission on tocilizumab and low-dose prednisoloneKey words: Adult-onset Still´s disease, macrophage activation syndrome, hemophagocytic syndrome, adalimumab

African League Against Rheumatism (AFLAR) preliminary recommendations on the management of rheumatic diseases during the COVID-19 pandemic

Objectives: To develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic. Method: A task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1-3, 4-6 and 7-9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a \u27low\u27 level of agreement. Results: A total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting. Conclusions: The preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges. Key Points • AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic. • COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists. • Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs. • Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk

Reparative radiological changes of hip joint after TNF inhibitors in ankylosing spondylitis

Background: Hip involvement in ankylosing spondylitis (AS) is a common extraspinal arthritic manifestation, which is associated to a worse functional outcome. Little data are available on the effectiveness of conservative treatment strategies. The TNF inhibitors have been proven effective on AS activity parameters. Their structural effect on hip disease however, little is studied. Case presentation: We describe four new cases of reparative changes of a damaged hip joint after treatment with TNF inhibitors. The average of age was 32.5 (27- 36) years. There were 3 men and 1 woman. Hip involvement was bilateral in all cases. Etanercept was prescribed in 3 cases and infliximab in 1 case. At baseline, all patients had a painful and limited hip with high disease activity and an important functional impairment. After an average of 5.5 years of treatment with TNF inhibitors, the BASRI hip evaluated in antero-posterior x-rays of the pelvis remained unchanged at 2.4. The average of mean hip joint space was 2.9mm (2.3-3.6). A widening in hip joint space was observed in all cases with less subchondral cysts. Conclusion: TNF inhibitors seem to be effective on hip joint disease in patients with AS

Zoledronate Associated Seizure in Chronic Recurrent Multifocal Osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an auto-inflammatory disease characterized by sterile bone lesions. We report a case of a patient with CRMO who developed a seizure post bisphosphonate administration. Although, the treatment of CRMO is currently not codified, the most promising results have been observed in patients under treatment with bisphosphonates. Keywords: CRMO; Bisphosphonate; tonico-clonic seizure

Patient satisfaction with medication in rheumatoid arthritis: an unmet need

Objectives Shared decision-making between rheumatologists and patients has become an overarching principle in current treatment recommendations in rheumatoid arthritis (RA). Therefore, in the present study, we aimed to assess the satisfaction of patients with RA with their treatment and to investigate the associated factors. Material and methods A cross-sectional study was carried out in the Rheumatology Department of Mongi Slim Hospital. We included adults with RA receiving their current disease-modifying anti- rheumatic drugs for at least 12 months. Satisfaction among patients was assessed by the Treatment Satisfaction Questionnaire for Medica-tion (TSQM) and it was defined by a score ≥ 80%. The factors indirectly influencing patient satisfac-tion that were assessed were: satisfaction with medical care management, disease activity, function-al impact, professional impact, and the impact of RA. Multivariable regression analysis was applied to determine the predictors of satisfaction. Results We included 70 patients (63 female/7 male) with a mean age of 57.8 ±10.6 years. The mean disease duration was 13.71 ±7.2 years. Mean TSQM scores were 65.42 ±14.77 for convenience, 68.71 ±18 for effectiveness, 70.60 ±24.5 for side effects, and 67.95 ±17.10 for global satisfaction. Satisfaction rates were: 20% for convenience, 39% for effectiveness, 46% for side effects and 30% for global satisfaction. In multivariable analysis, the predictors of global dissatisfaction were Rheumatoid Arthritis Impact of Disease (RAID) overall score (p = 0.003) and the degree of physical difficulties (p = 0.001). Satisfac-tion with the physician was correlated with better global satisfaction (p = 0.029). Difficulties in adapt-ing to RA (p = 0.043) and current treatment with biologics (p = 0.027) were predictors of dissatisfaction with convenience. Predictors of dissatisfaction with efficiency were the RAID over-all score (p = 0.032) and the difficulties of adapting to RA (p = 0.013). The predictors of satisfaction with side effects were a lower degree of interference with domestic work (p = 0.02) and better in-volvement of the patient in the treatment decision (p = 0.014). Conclusions The satisfaction with the attending physician, the participation in the treatment decision, and the impact of RA seem to influence treatment satisfaction the most. These data suggest that a better understanding of patients’ medical needs and preferences would improve satisfaction outcomes

Evaluation of aseptic technique used in interventional rheumatology: survey among Moroccan and Tunisian rheumatologists

The objective of our study was to evaluate the aseptic technique used in interventional rheumatology by Moroccan and Tunisian rheumatologists. We performed an online survey among rheumatologists from Morocco and Tunisia. The questionnaire included 15 questions with single and multiple-choice answers and three open sections for freetext comments. An online survey was prepared and sent to 380 rheumatologists. One hundred and four rheumatologists (27.36%) replied to the survey. More than half of the participants (56.7%) were from Tunisia and 43.3% were from Morocco. Interventional procedures on superficial joints were performed by all participants. Ultrasonography was used by 41.3% of respondents to guide interventional procedures. Regarding the aseptic precautions taken to avoid infection, the majority of participants used povidone iodine to clean the skin and only 8.7% wore a mask. Hand washing alone without gloves wearing was done by 19.2% of participants. 2.9% of participants reported a history of iatrogenic septic arthritis and the duration of practice was the only factor associated with its occurrence (P=0.007). Our study showed that aseptic technique used during interventional rheumatologic procedures is heterogeneous. However, the majority of participants were aware of its necessity to avoid iatrogenic septic arthritis

Validity of Remission Criteria in Rheumatoid Arthritis Compared to Ultrasound-Defined Remission

Objectives: Remission is the ultimate purpose of treatment in Rheumatoid Arthritis (RA). However, even when the most stringent composite scores were used, structural damages can occur. For that purpose ultrasonography (US) appears to be the best way to assess real remission. Our principal aim was to investigate the validity of different RA remission scores using the US as the reference. Methods: An analytic diagnostic study of 30 RA patients in remission according to DAS28 and a control group with active RA was conducted between January and October of 2018. Among them, we identified patients in remission according to the SDAI, the CDAI, and the ACR/EULAR remission score. The validity of each activity score for remission was calculated using as a gold standard the absence of PD signal. Results: All patients were in remission according to DAS28 with an average score of 2.03 [1.13-2.6]. US examination showed PD signals in 57% of all patients. Twenty-six patients were in remission according to CDAI, a Doppler signal was detected in 58% of those cases. SDAI remission was accomplished in 19 patients with PD activity in 53% of cases. For the 14 patients in remission according to ACR/EULAR criteria, synovial hyper-vascularization was found in 64%. Considering true remission as the absence of PD signals, the most sensitive and specific score was DAS28 (93% and 68% respectively). Conclusion: Considering remission in RA as the absence of vascularized synovitis, the DAS28 was the most sensitive and the most specific score. Keywords: Rheumatoid Arthritis, remission, ultrasonography, validit

Lower urinary tract symptoms in rheumatoid arthritis and spondyloarthritis male patients versus controls

Background. We aimed to evaluate the severity of lower urinary tract symptoms (LUTS) in rheumatoid arthritis (RA) and spondyloarthritis (SpA) male patient versus control, then to determine the relation of LUTS with rheumatic diseases (RD) characteristics and with erectile dysfunction (ED)