Revue du Rhumatisme Monographies最新文献

Lyme Borreliosis is a polyvisceral infectious disease due to Borrelia burgdorferi sensu lato transmitted by tick bite. Although the disease can evolve through different stages with mainly dermatological and neurological attacks, the typical clinical picture is that of monoarthritis of the knee. It is not always preceded by earlier stages such as erythema migrans. Its diagnosis is based on a combination of amnestic, clinical and biological criteria. Elisa and Western blot serology are always positive for Ig G. Treatment is based on antibiotic therapy for 28 days with doxycycline 200 mg/d. The evolution is generally favourable with in the majority of cases a restitution ad integrum. Polyalgesic syndromes with positive Lyme serology and a history of confirmed or suspected Lyme borreliosis must be treated with particular care, and diagnostic approach must be rigorous in order not to overlook differentials diagnosis which are many. Repeated antibiotic treatment does not improve these clinical pictures.

Olecranon and prepatellar septic bursitis are a common medical problem. However, evidence regarding the management of septic bursitis is limited and no recommendations have been published. Previous studies showed considerable variability in treatment practices, the data available being mainly from retrospective series. The objective of the review was to synthesize the published data about the diagnosis and management of olecranon and patellar septic bursitis.

No germ can be identified in nearly 20% of clinically suspected septic arthritis (SA). Some studies show that SA with and without germ identified are the same and should be treated in the same way while others suggest that if the clinical features are the same, the prognosis of SA without an identified germ is better and patients can be given alternative diagnoses. Culture-negative SA may be due to prior antibiotic therapy, a fastidious or non-cultivable bacteria on usual media, or to the fact that the arthritis is not septic. Crystal arthritis is the most common cause of acute arthritis, but it can coexist with SA. Rheumatoid arthritis and spondyloarthritis are the most common causes of pseudoseptic arthritis, but many other rare causes are possible. There is no reliable way to differentiate septic and non-septic arthritis when bacteriological finding is negative. The quality of the bacteriological investigation before any antibiotic therapy remains the best way to limit the frequency of SA without germ identified.

The Covid-19 pandemic has clearly impacted the management of inflammatory rheumatisms in terms of discontinuation of follow-up and discontinuation of treatment due to the risk of severe infection linked to the disease and to immunomodulatory treatments. Treatments are now available to prevent severe forms of the disease, including vaccines and specific monoclonal antibodies directed against the S protein of the SARS-CoV2 virus. Among the treatments used to treat inflammatory rheumatisms, corticosteroids and rituximab are clearly associated with a severe form of Covid. The humoral vaccine response after vaccination with messenger RNA (mRNA) vaccines appears to be reduced with methotrexate, abatacept and especially rituximab. Specific vaccine regimens have already been proposed for patients undergoing rituximab and should be refined as more knowledge becomes available, as these vaccines should now be part of our patients’ vaccination schedule. For those who do not develop antibodies after a complete vaccination regimen, the combination of casirivimab and imdevimab antibodies can be given monthly as a preventive measure or just after exposure.

Sexually transmitted infections (STIs) have been on the rise for about twenty years in France and around the world. They are often asymptomatic and yet are responsible for significant genital and systemic morbidity. Although infrequent, the rheumatic manifestations of venereal diseases, in particular arthritis and tenosynovitis, have been known for a long time. They are generally of two types: infectious directly linked to the pathogen (N. gonorrhoeae, syphilis) and more frequently reactive, indirectly linked to the pathogen, which may be necessary for inflammatory rheumatism (C. trachomatis, arthropod-borne viruses, mycoplasmas). Broadly speaking, many other STIs can cause rheumatic manifestations (viral hepatitis, meningococcus). Knowledge of the epidemiology, clinical, diagnostic and therapeutic techniques of STIs is important for rheumatology practice.

Patients with chronic inflammatory rheumatic disorders may present an increased risk of osteoarticular infection related to age, comorbidities, previous intra-articular corticosteroid injection, surgical procedures or the use of immunosuppressive drugs including corticosteroids or targeted therapies. Data regarding the risk of osteoarticular infection remain scarce and mainly restricted to TNF-α inhibitors. Although an increased risk of osteoarticular infection in native or prosthetic joints of patients receiving targeted biological therapies has been reported in various national and international registries, it appears to be moderate, lower than respiratory, skin, and urinary infections. The risk of osteoarticular infection also remains stable over time, similar to what was described before the era of biologic therapies. Moreover, this risk must be balanced against that of corticosteroids, which are often necessary to control flare-ups induced by the suspension of the biological agent. Staphylococcus aureus remains the most frequently observed microorganism, but certain species usually barely involved in osteoarticular infections should be assessed in these patients. Osteoarticular infection in patients receiving targeted therapies should not be ruled out in absence of fever and/or elevation of acute phase reactants. Several questions need to be addressed, including the weight of targeted therapies in the increased risk of osteoarticular infection compared to other risk factors, in particular age, the underlying rheumatic disease or corticosteroid therapy.

Septic arthritis (SA) is a rare but severe condition due to its mortality and the risk of joint destruction responsible of functional disability. In 2020, the Société française de rhumatologie (SFR) in cooperation with the Société française de pathologies infectieuse de langue française (SPILF) and the Société française de chirurgie orthopédique et traumatologique (SOFCOT) developed sixteen clinical practice recommendations for the diagnostic and management of adult native joint SA. They remind the importance of initial microbiological investigations, in particular synovial fluid analysis and blood cultures to be carried out if possible before any antibiotic therapy. They also underline the place of additional exams (X-rays, ultrasound, others) and the major therapeutic principles: duration and modalities of antibiotic therapy with proposals adapted to the most frequent germs, place of joint drainage whether medical or surgical, early rehabilitation and monitoring.

Diagnosis and Treatment of peripheral septic arthritis have been recently updated thanks to new French recommendations published in 2020. “Peripheral arthritis” means shoulder, elbow, wrist and fingers for the upper limb, and groin, knee, ankle, and foot and toes for the lower limb. Nevertheless, some specific joint localization connected with axial skeleton can also be involved by bone and joint infections, and their management can be slightly different. This is because of different mechanical problems, different microbiological environment and different type of patients. In this monography, we focus on four “axial-peripheral” joints: sacroiliac joint, pubic symphysis, sternoclavicular joint and acromioclavicular joint.

Joint aspiration is the key examination for the diagnosis of septic arthritis. There is no contraindication to performing this procedure if there is a strong suspicion of septic arthritis. It must be carried out before any antibiotic treatment, by the doctor treating the patient for a superficial joint, by the radiologist or surgeon in the case of hip arthritis. Direct examination, cytological analysis, and prolonged bacterial culture on enriched media, are essential to confirm the diagnosis and document the infection. Other investigations (mycobacteria, fungi, etc.), synovial molecular biology techniques or biological markers (alpha-defensin, lactate, etc.) or ultra-sound guided biopsy may be requested in the event of a specific diagnostic orientation or if a first aspiration has remained negative.