[Show abstract][Hide abstract] ABSTRACT: A 70-year-old woman with a history of medial femoro-tibial compartment of knee osteoarthritis was admitted for acute arthritis six days after a second intra-articular injection of Hyaluronic acid. The joint fluid was inflammatory, with no crystals, and laboratory tests showed marked inflammation leading to antibiotic treatment for suspected septic arthritis. The persistent symptoms and negative results of joint fluid and blood cultures led to discontinuation of the antibiotic therapy after 10 days. Anti-inflammatory with rehabilitation therapy of the knee relieved the symptoms, and the patient was discharged home 3 weeks after her admission. Aseptic arthritis induced by repeated Hyaluronic acid injection is the most likely diagnosis. Physicians should be conscious of this extremely severe complication.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: In Morocco, the patients affected by ankylosing spondylitis (AS) presents a high frequency of coxitis. Our study reports, for the first time, the polymorphism of Human Leukocyte Antigen (HLA) class I and class II molecules in the Moroccan patients. METHODS: Forty-six patients diagnosed with an AS and coxitis were compared to a group of 183 healthy controls matched by age, sex and ethnic origin. The HLA typing was performed using microlymphocytotoxicity for the class I (-A, -B) and PCR-SSP for the class II (-DR, -DQ). RESULTS: We found a significant increase of the HLA-B27 antigen frequency (P<0.0001, RR=20.9) in AS patients (29.3%) compared to the controls (3.2%) and a significant decrease in the frequency of HLA-B12 and HLA-B18 antigens. Examination of HLA class II distribution shows a significant increase of the HLA-DRB1*11 allele frequency in patients (P<0.0001). Concerning HLA-DQB1* alleles, no significant difference between patients and controls was appreciable. CONCLUSIONS: The HLA-B27 antigen is involved in the predisposition to the AS with coxitis in the Moroccan population. However, the low frequency observed in our population suggests the existence of other genetic and/or environmental factors. Other HLA genes seem to confer a predisposing effect (DRB*11) or a protective effect (B12 and B18) against the disease.
[Show abstract][Hide abstract] ABSTRACT: This study aimed to establish the profile and the evolution of an early Rheumatoid arthritis (RA) cohort in the Moroccan population and also to search possible predictor factors of structural progression.
Patients with early RA (< 12 months) were enrolled in a 2-year follow-up study. Clinical, biological, immunogenetic, and radiographical data were analyzed at study entry and at 24 months. Presence of radiographic progression was retained when the total score was superior to the smallest detectable difference (SDD) calculated to be 5.4 according the Sharp/van der Heijde (SVDH) method.
Fifty one patients (88.8% women, mean age of 46.9 [ 24-72 ] ± 10.8 years, mean disease duration of 24 [ 6-48 ] ± 13.9 weeks) were enrolled in this study. 68.6% were illiterate and 19.6% reported at least one comorbid condition. The mean delay in referral for specialist care was 140 [ 7-420 ] ± 43 days.Thirteen patients (62.5%) were IgM or IgA RF positive. HLA-DRB1*01 and DRB1*04 alleles were present respectively in 11.8% and 45.1% of patients.At baseline, 35.3% patients were taking corticosteroids and 7.8% were under conventional DMARDs.At 24 months, 77.2% received a median dose of 5 mg/day of prednisone. Methotrexate (MTX) was the most frequently prescribed DMARD, being taken by 65.2% of patients. 13.6% of patients had stopped their DMARD because of socioeconomic difficulties.Comparison of clinical and biologic parameters between baseline and 24 months thereafter revealed a significant global improvement of the disease status including morning stiffness, pain score, swollen joint count, DAS 28 and HAQ scores, ESR and CRP.Sixteen patients (34.8%) were in remission at 2 years versus no patients at baseline; P < 0.001.Forteen patients (27.5%) had at least one erosion at baseline. Radiographic progression occurred in 33.3% of patients and was associated in univariate analysis to swollen joint count (p = 0.03), total SVDH score (P = 0.04) and joint space narrowing score (P = 0.03). No independent factors of radiographic progression were shown by logistic regression.
These study reports, provided for the first time in Morocco, a developing African country, a large amount of information concerning the profile and the course of early RA.Patients who were receiving, for most of them, Methotrexate in monotherapy and low doses of corticosteroids, showed an improvement of all clinic and biologic disease parameters. Moreover, DAS remission was obtained in one third of patients and two thirds of the cohort had no radiographic progression at 2 years. No predictor factors of radiographic progression were found out.These results should be confirmed or not by a large unbiased RA cohort which will give more relevant information about early RA characteristics and its course and will constitute a major keystone of its management.
[Show abstract][Hide abstract] ABSTRACT: This study aimed to evaluate remission in patients with early RA treated by conventional DMARDs and to identify its possible predictor factors.
Patients with early RA (<12 months) were enrolled in a 2-year follow-up study. Standard evaluation completed at baseline and at 24 months included clinical, laboratory, functional and structural assessment. Clinical remission after 2 years of follow-up was defined when DAS28 was less than 2.6. Possible predictor factors for remission were analyzed.
Fifty-one patients (88.2% women, mean age of 46.9 [24-72] years, mean disease duration of 24 [6-48] weeks) were enrolled in this study. The delay in referral for specialist care was 140 [7-420] days. Rheumatoid factor, anti-CCP, HLA-DRB1*01 and DRB1*04 alleles were present respectively in 62.5, 56.6, 11.8, and 45.1% of patients. At 24 months, 77.2% received a median dose of 5 (0-8) mg/day of prednisone and 65.2% was taking methotrexate (MTX). 13.6% of patients had stopped their DMARD because of socioeconomic difficulties. At 24 months, we noted a significant improvement of morning stiffness, pain score, swollen joint count, ESR, CRP, DAS28 and HAQ scores. Remission at 2 years was noted in 34.8% of patients and was significantly associated in univariate but not in multivariate analysis to male sex (P=0.02) and to short delay in referral for specialist (P=0.03).
In this cohort of early RA patients treated with conventional DMARDs, especially with methotrexate in monotherapy, remission at 2-year of follow-up was obtained in one third of patients. No predictor factors of remission were found out. These results should be verified by further studies.
[Show abstract][Hide abstract] ABSTRACT: Stiff limb syndrome is a clinical feature of the stiff person syndrome, which is a rare and disabling neurologic disorder characterized by muscle rigidity and episodic spasms that involve axial and limb musculature. It is an autoimmune disorder resulting in a malfunction of aminobutyric acid mediated inhibitory networks in the central nervous system. We describe a patient diagnosed by neurological symptoms of stiff limb syndrome with a good outcome after treatment, and a review of the related literature.
A 49-year-old male patient presented with a progressive stiffness and painful spasms of his both legs resulting in a difficulty of standing up and walking. The diagnosis of stiff limb syndrome was supported by the dramatically positive response to treatment using diazepam 25 mg/day and baclofen 30 mg/day.
This clinical case highlights the importance of a therapeutic test to confirm the diagnosis of stiff limb syndrome especially when there is a high clinical suspicion with unremarkable electromyography.
[Show abstract][Hide abstract] ABSTRACT: We report two cases of primary Non-Hodgkin's Lymphoma in the spine leading to radicular compression secondary to infiltration of lumbar body vertebras. The two patients were free of either nodular or other extra-nodular disease. Treatment consisted of chemotherapy alone, one patient have had a cauda equina syndrome and surgical decompression was performed in emergency. The patients were in remission for 20 months after diagnosis. A review is given for the incidence of primary vertebral localization of lymphoma, its diagnosis, treatment and prognosis.
Rheumatology International 05/2009; 30(1):113-7. DOI:10.1007/s00296-009-0898-3 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We describe a 47-year-old woman with severe spondylarthropathy secondary to ulcerative colitis who developed a Guillain-Barre after the use of anti-TNF-alpha. She first developed ulcerative colitis in November 1997. In 2003, she developed uveitis and, in 2005, axial and enthesitis form of spondylarthropathy. In May 2007, her condition was exacerbated. Therapy with infliximab has been initiated. The patient received 5-mg/kg infusions of infliximab. She had significant improvement in her arthritis and was in remission for her ulcerative colitis. She was admitted to the hospital 2 weeks after her third dose of infliximab for having developed paraesthesia of her hands and lower limbs. Neurophysiology studies demonstrated an acquired segmental demyelinating polyneuropathy consistent with Guillain-Barre syndrome (GBS). Laboratory investigations were unremarkable. She was treated with intravenous corticosteroids with no improvement. After this, she received infusions of intravenous gammaglobulin (IVIg) with complete recovery of the muscle strength within a few weeks. A follow-up electromyographic study 3 months later showed normal finding. The development of GBS in our patient may be secondary to her anti-TNF-alpha treatment. At present, she remains off anti-TNF-alpha therapy.
[Show abstract][Hide abstract] ABSTRACT: Rheumatoid arthritis (RA) is an autoimmune multifactorial disease which has a great socio-economic impact in Morocco. The association of HLA genes with RA was studied in various ethnic groups but not in the Moroccan population. Our study focused on evaluating the distribution of class I and class II HLA genes among Moroccan patients presenting early signs of RA.
Forty nine patients diagnosed with early RA were compared to a group of healthy controls matched by age, sex, and ethnic origin. Among the patient group, 34 were seropositive (presence of the rheumatoid factor). HLA typing of the patients and the controls was performed using microlymphocytotoxicity for class I (A and B) and PCR-SSP for class II (DR and DQ).
We found a significant increase of the frequency of the HLA-A24 antigen (p=0.03), the DRB1*04 (p=0.004) and DQB1*03 (p=0.03) alleles and a significant decrease of the DRB1*07 allele (p=0.03) in seropositive patients. The analysis of the frequency of the DRB1*01, DRB1*10, and DRB1*14 alleles did not show any difference between the RA patients and the controls. The frequency of DR4-DQ2 and DR4-DQ4 haplotypes was increased in the patients compared to the controls while that of DR7-DQ2 and DR13-DQ6 was decreased.
Our study suggests that DRB1*04 predisposes to RA while DRB1*07 seems protective for the Moroccan patients population. In addition we show the influence of some haplotypes DR-DQ in the susceptibility and protection against the disease.
[Show abstract][Hide abstract] ABSTRACT: Objectifs
La polyarthrite rhumatoïde (PR) est une maladie auto-immune d’origine multifactorielle qui pose un problème socioéconomique important au Maroc. L’association de cette maladie avec les gènes HLA a été étudiée dans différents groupes ethniques. Notre étude s’est intéressée, pour la première fois au Maroc, à évaluer la distribution et l’implication des gènes HLA classe I et II chez des patients présentant une PR précoce.
Quarante-neuf patients atteints de PR précoce ont été comparés à des témoins sains appariés par âge, sexe et origine ethnique. Parmi ces patients, 34 étaient séropositifs (présence du facteur rhumatoïde). Le typage HLA des patients et des témoins a été réalisé par microlymphocytotoxicité pour la classe I (A et B) et en biologie moléculaire (PCR-SSP) pour la classe II (DR et DQ).
Nous avons observé, chez les patients séropositifs, une augmentation significative de la fréquence de l’antigène A24 (p = 0,03) et des allèles DRB1*04 (p = 0,004) et DQB*03 (p = 0,03) et une diminution significative de l’allèle DRB1*07 (p = 0,03). La fréquence des allèles DRB1*01, DRB1*10 et DRB1*14 était comparable chez les patients et les témoins. La fréquence des haplotypes DR4-DQ2 et DR4-DQ4 était augmentée, alors que celle des haplotypes DR7-DQ2 et DR13-DQ6 était diminuée chez les patients.
Notre étude montre que l’allèle DRB1*04 prédispose à la PR alors que l’allèle DRB1*07 semble protecteur chez les patients marocains. Nos résultats suggèrent également le rôle de certains haplotypes DR-DQ dans la prédisposition ou la protection vis-à-vis de la maladie.
Revue du Rhumatisme 10/2008; 75(9):824-830. DOI:10.1016/j.rhum.2008.01.015
[Show abstract][Hide abstract] ABSTRACT: This study aimed to investigate the proxy-reported Health related quality of life (HRQOL) and its determinants in patients with juvenile idiopathic arthritis (JIA). It was hypothesized that HRQOL would decrease with worsening disease and disability. Data were available in cross-sectional study on children and adolescents with JIA according to the ILAR criteria. Patient demographics, type of JIA, clinical determinants and laboratory parameters relating to JIA were obtained for each patient. Functional disability was assessed using the parent's or children's version of the child health assessment questionnaire (CHAQ). The HRQOL was evaluated using the juvenile arthritis quality of life questionnaire (JAQQ). These questionnaires were previously translated and validated in Moroccan children. A total of 80 participants were enrolled with mean age of 11 [6-17 years], and female predominance (59%). Many patients (42.5%) had oligoarticular subtype; 31.3% polyarticular subtypes and 26.2% systemic form. The mean global score of JAQQ was 2.6 +/- 1.3 (1-6). Patients with persistant oligoarticular had better gross motor function (P < 0.0001), better fine motor function (P < 0.0001), less psychosocial impact (P = 0.001), and less symptoms (P = 0.001) in comparison with polyarticular and systemic subtypes. The HRQOL assessed by the JAQQ was worse in adolescent patients in comparison with children except for symptoms (P = 0.15). The gender (P = 0.95), age at onset of JIA (P = 0.81), and evolution duration (P = 0.34) were not correlated with global score of JAQQ. The diagnosis delay was significantly associated with decrease of HRQOL (P = 0.001). The decrease of HRQOL was correlated with disease activity [pain (VAS), painful and swollen joints, erythrocyte sedimentation rate (for P < 0.0001)], with disability index (CHAQ) (P = 0.001) and presence of hip involvement (P = 0.01). This study suggests that JIA can have a significant adverse effect on the HRQOL of moroccan patients, particularly adolescents with polyarticular and systemic subtypes. Disease duration, disability score (CHAQ) and pain were the strongest determinants of poorer HRQOL.
Rheumatology International 08/2008; 29(3):275-9. DOI:10.1007/s00296-008-0672-y · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective of the study is to test the reliability and validity of a translated version of health assessment questionnaire (HAQ) on Moroccan patients with rheumatoid arthritis (RA). We led a prospective study from July 2004 to September 2005. A total of 100 Moroccan patients were recruited. After translation to dialect Arabic, back translation, expert committee review and pretesting of the questionnaire, it was administered to the selected patients and tested for construct validity, reliability and internal consistency. The construct validity was evaluated by correlating the yield of the questionnaire with other disease activity and severity parameters. The questionnaire was administered again after a time interval of between 2 and 10 days for evaluation of the reliability of this test. All the items were tested for their loyalty to the principal component. The adapted questionnaire showed a good internal consistency. Cronbach's alpha test was 0.994. The test-retest showed a strong reliability with a kappa test ranging from 0.70 to 0.92 for all domains. Intraclass correlation coefficient for the total score was 0.987. The Moroccan HAQ showed a strong validity. It correlates significantly with disease activity and severity parameters. The unidimentionality has been demonstrated. About 71.5% of all variabilities was accounted for by the first principal component. The Moroccan Arabic dialect version of HAQ is a reliable and valid instrument that can be self-administered by Moroccan RA patients to assess their functional disability.
Rheumatology International 07/2008; 28(12):1197-203. DOI:10.1007/s00296-008-0595-7 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The case is that of a 17-year old Moroccan boy presenting a growing delay and a vitamin D-resistant ricket (VRR). Osseous plain radiographs show demineralization with metaphyseal enlargement, thorax, legs and wrists deformities. Biology data confirms phosphocalcic anomalies with deep hypophosphatemia, normal phosphaturia, low phosphate renal reabsorption rate, normal plasma hydroxyvitamin D in addition to low calciuria. Clinical and biological data evokes an X-linked hypophosphatemia with ricket. This phenomenon is due to Phosphate regulating gene with Homolgy to Endopeptidase on the X chromosome (PHEX) gene mutation. No similar case was reported previously within the family, however, it would have been desirable to complement existing data with parents and siblings genetic study results. Pseudo-deficiency vitamin D resistant ricket (VRR), also referred to as Mc Cance syndrome, has a belated onset within children, and can be linked to a phosphate reabsorption anomaly. The aim of the treatment is to normalize phosphatemia with calcic and vitamin D (vit D) supplementation, so as to make up for calcium lack and avoid hypophosphatemia osseous complications (plasma vitamin D rate reduction and secondary hyperparathyroidism).
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to assess the reliability and validity of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) in Moroccan patients with knee osteoarthritis. The WOMAC was translated and back translated to and from dialectal Arabic, pre-tested and reviewed by a committee following the Guillemin criteria. The Moroccan version of the WOMAC was administered twice during a 24-48 h interval to 71 Moroccan patients with symptomatic knee osteoarthritis, fulfilling the revised criteria of the American College of Rheumatology. The test-retest reliability was assessed using intra-class correlation coefficient, and the Bland and Altman method. Internal consistency was assessed by Cronbach's alpha coefficient. Construct validity was tested by correlating the WOMAC subscales with visual analogic scale (VAS) of pain, VAS of handicap, maximum distance walked and clinical characteristics. The Moroccan version of the WOMAC showed good reliability, with ICC values of the three dimensions: pain, stiffness and physical function being 0.80, 0.77 and 0.89, respectively. Bland and Altman analysis showed that means of differences did not differ significantly from 0 and that no systematic trend was observed. Internal consistency with Cronbach's alpha for pain was found to be 0.76, and its equivalents for stiffness and physical function subscales were evaluated at 0.76, 0.90, respectively. Construct validity showed statistically significant correlation with all WOMAC subscales and VAS of pain (rho=0.38, 0.42, 0.63 respectively, P<0.01). Correlation between VAS handicap (rho=0.38 P<0.001) and maximum distance walked (rho=-0.40, P<0.01) was observed with physical function subscale. There was no correlation between age, duration of disease, BMI and severity of pain and physical function in knee OA. The Moroccan version of the WOMAC is a comprehensible, reliable, and valid instrument to measure outcome in patients with knee OA.
Rheumatology International 05/2008; 28(7):677-83. DOI:10.1007/s00296-007-0498-z · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intra-articular injections of hyaluronan are generally well tolerated; the most common adverse event associated with their use is an inflammatory reaction or a flare at the injection site. Naturally derived sodium hyaluronates have not been associated with pseudosepsis; we describe a case of severe arthritis mimicking acute septic arthritis after naturally hyaluronan. A 70-year-old woman had a medial femorotibial and patellofemoral compartment knee osteoarthritis. Hyaluronic acid injection was indicated because of the persistence of a pain while walking and restricted ability to walk 100 m, as well as the installation of a flessum. She was admitted for an evaluation of a joint effusion occurring within 48 h after the first hyaluronic acid intra-articular injection (first course), with no fever or chills. Joint fluid was found to be cloudy and contained 24,000 cells per mm(3). A knee aspiration was performed to evaluate the possibility of a joint infection. The examination of synovial fluid under phase contrast and polarizing microscopes showed no crystals, and culture on standard media was negative. Acute septic arthritis was considered to be the most likely diagnosis, and probabilistic antibiotic therapy was started. The result of the bacteriological examinations also returned negative. The absence of general signs, particularly fever and chills, with fast effusion regression in less than 4 days did not plead in favor of a septic origin. In front of this beam of arguments, antibiotic therapy was stopped after 4 days. The nonsteroidal anti-inflammatory drug (Nimésulide) was given. The clinical and laboratory test abnormalities were normalized within 2 weeks. Our case has the particularity to occur after using Curavisc, which is known as producing no allergenic reactions. Moreover, the described reaction occurred with the very first infiltration within the very first course.