Cellulitis in aged persons: a neglected infection in the literature

Cellulitis is a frequent soft tissue and skin infection. The lower limbs are affected in 70 to 80% of cases. Cellulitis in aged persons is not yet well described in literature. A retrospective descriptive study conducted in the Internal Medicine Department of Sahloul hospital in Sousse in Tunisia. It included patients whose age was up to 65 years old admitted into hospital for cellulitis of the legs, the arms or the face. One hundred fifty eight patients with a mean age of 73 years old (range: 65 to 94 years old) were included. Female to male sex ratio was 0.68. Among them, we noted diabetes mellitus in 81 cases (50.6%). The infection was located in the lower limbs in 155 cases (98%), in the face in two cases (1.3%) and in the upper limb in one case (0.7%). Twenty one patients (13.3%) presented with severe cellulitis and one presented with necrotizing fasciitis. All patients received intra venous antibiotic therapy. Surgical treatment was indicated in 14 cases. Cefazolin was prescribed in 77 cases (48%). Favorable evolution was noted in 144 patients (91.1%). Forty four patients (27.8%) received prophylactic antibiotics. Prevention of skin and soft tissue infection is a crucial step to preserve health in aged persons.Keywords: Cellulitis, aged person, diabetes, necrotizing fasciitis, antibiotic, surger

Atlantoaxial instability: An exceptional complication of ankylosing spondylitis

Background: Atlantoaxial instability (AAI) and more rarely odontoid pannus formation, similar to the one observed in Rheumatoid Arthritis, are seldom reported in ankylosing spondylitis (AS). We report a new case of a patient with AS with a pannus in the atlanto-axial region and cervical C1-C2 instability. Case presentation: The patient, now aged 41, was diagnosed with AS in 2010. She was put on different non steroidal anti inflammatory treatments with persistent spinal pain. She was referred to our department in 2015 with severe cervical pain and stiffness since 3 months. On examination, the patient had severely limited cervical spine movements. Lumbar spine movements were moderately affected. There was no neurological deficit. Her Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was 4.9/10 and Bath Ankylosing Spondylitis Functional Index (BASFI) was 5/10. Plain Radiographs of the pelvis showed bilateral grade 4 sacroilitis and bilateral coxitis. Dorsal and lumbar spine plain radiographs showed squaring of vertebral bodies. Cervical spine radiographs showed an increased atlanto-axial distance. Spinal MRI confirmed the atlantoaxial subluxation with an anterior distance of 8 mm, with marked intraspinal pannus formation and synovitis around the odontoid peg. Synovial thickening exerted an anterior mark on the bulbo-medullary junction with no evidence of oedema signs. Posterior zygapophysial ankylosis involving all cervical levels was also observed. The patient had a cervical collar with anti-tumor necrosis factor-α (cerolizumab-pegol) prescription with favorable outcome. Conclusion: Odontoid pannus formation is rare in AS. Clinical and radiological follow-up are important to assess the impact on the cervical spine. Keywords: Ankylosing spondylitis, Atlantoaxial instability, MRI, Cerolizumab-pego

Complete form pachydermoperiostosis in Tunisia – A case series and literature review

Introduction: Pachydermoperiostosis (PDP) or hypertrophic osteoarthropathy (HOA) is a rare disease that has genetic predisposition and defined clinical features. Aim of the work: To study and analyse the clinical features of Tunisian PDP patients and review the literature. Patients and methods: The PDP cases attending the Rheumatology Department of the University Hospital Farhat Hached of Sousse in Tunisia were retrospectively studied over a period of 17 years (2000–2017). Secondary causes were excluded. Results: The PDP cases had a primary and complete form of the disease and included 6 men at a frequency of 0.03% (6/20,000) of the total number of rheumatic diseases cases attending the rheumatology clinic. The mean age was 27 ± 12.3 years [18–46 years]. Five patients had arthralgia and one polyarthritis. Thickening of the skin of the head and distal extremities (pachyderma) and deep folds and furrows of the skin of the forehead was observed in all cases. Digital clubbing of the fingers and toes and spade-like enlargement of the hands and feet was noted in 5 cases. Hyperhidrosis of the hands and feet was observed in 4 cases and seborrhea in 2. Elevated acute phase reactants were found in 4 cases. Hypergammaglobulinemia was present in one case. Periostosis of the long bones was observed in all cases. Treatment consisted of analgesics in all cases, non-steroidal anti-inflammatory drugs in 2 cases and tamoxifen in 2 cases. Conclusions: Complete form of primary PDP is rarely present among rheumatic diseases patients in Tunisia. A multicenter larger number longitudinal study is recommended. Keywords: Pachydermoperiostosis, Clubbing, Hypertrophic osteoarthropathy, Periostosi

Sclérodermie systémique associée à l’exposition à la silice survenant après une exposition professionnelle à la soudure à l’arc

La sclérodermie systémique liée à l’exposition à la silice cristalline peut apparaître chez les personnes utilisant la soudure à l’arc. Une forme diffuse de sclérodermie a été diagnostiquée chez un plombier-soudeur de 57 ans, qui présentait des polyarthralgies inflammatoires, un phénomène de Raynaud, une sclérodactylie, une sclérose cutanée diffuse, des télangiectasies, une atteinte œsophagienne, une hypertension artérielle pulmonaire et une fibrose pulmonaire associées à la présence d’anticorps anti-nucléosomes. Au cours de son activité professionnelle, le patient était fréquemment exposé à des concentrations atmosphériques élevées de silice cristalline lors de la soudure à l’arc. Le diagnostic d’un syndrome d’Erasmus avec une association d’une sclérodermie systémique à une silicose pulmonaire était retenu. Une déclaration en maladie professionnelle au titre du tableau n°17 en Tunisie a été réalisée.The Pan African Medical Journal 2016;2

Acute severe cutaneous methotrexate toxicity in a patient with rheumatoid arthritis: Report of a rare side effect

Background: Skin lesions due to acute methotrexate (MTX) toxicity are rare. The majority of cases of cutaneous MTX toxicity have been reported in patients with psoriasis, exceptionally in patients with rheumatoid arthritis (RA). We report a case of RA who had an acute severe cutaneous MTX toxicity and its management. Case presentation: A 59 year old woman who has been followed up in Rheumatology department in Farhat Hached Hospital in Sousse in Tunisia since 2005 for RA. Since 2005 initially, she was treated with MTX at a dose of 10 mg/week orally that changed in 2014 to the injection route because of gastric intolerance. She also received oral corticosteroids (prednisone: 10 mg/day). In January 2017, she had mucosal and cutaneous erosions, post-bullous affecting the face mostly cheeks and subciliary arches and the forearms. A cutaneous biopsy was performed and showed a histological appearance compatible with photo-aggravated toxiderma with an eroded epidermis, keratinocytic necrosis and the presence of numerous eosinophils in the dermis which is elastosic. The Direct Immunofluorescence study was negative. Based on clinical and histological data, the diagnosis of acute severe cutaneous MTX toxicity was suspected. The patient recovered following MTX withdrawal and using a cicatrizing cream after a duration of 5 months. Treatment with Tocilizumab was started in March 2017. Conclusion: Although MTX is an option of great therapeutic value for RA. Rheumatologists and Dermatologists need to be alert to the possibility of cutaneous adverse events associated with MTX therapy. Keywords: Methotrexate, Rheumatoid arthritis, Cutaneous toxicity, Cutaneous biops

A case of Caplan syndrome in a recently diagnosed patient with silicosis: A case report

Rheumatoid pneumoconiosis, also known as Caplan's syndrome is defined as the association between silicosis and rheumatoid arthritis (RA). It is a rare and usually diagnosed in an advanced stage of RA course. It affects generally patients with long exposure to silica. In this article, we report a case of Caplan's syndrome. Keywords: Caplan syndrome, Rheumatoid arthritis, Silicosis, Chest CT scan, Rituxima