Revue du Rhumatisme Monographies最新文献

Bone and joint infection (BJI) are heterogeneous: acute infections, chronic infections, prothetic infections, osteomyelitis, diabetic foot infections... Acute infections are not diagnostic problems. Staphylococcus aureus is mostly involved and cause noisy clinical manifestation (fever, pain ± functional impairment, redness, heat and edema). Chronic infections mainly concerned prosthetic joint infection and usually are not therapeutic emergencies but a diagnostic challenge. Indeed, the management of this type of infection combine prolonged antibiotic therapy (12 weeks) with heavy operative procedure. Overall, BJIs very rarely show signs of systemic severity, however there are some elements of poor prognosis to be aware of. The SOFA quick score (qSOFA) can be used at bedside. This score includes the following clinical items: respiratory rate ≥ 22 / min, upper function disorders, systolic blood pressure ≤ 100 mmHg. A qSOFA score ≥ 2 implicated a transfer in intensive care unit. The sepsis criteria were simplified in 2016 during the “Surviving sepsis campaign”. The new recommendations define sepsis as life-threatening organ dysfunction due to a dysregulated host response to infection. BJIs imply the functional prognosis but the risk of sepsis is low. Bacteriemia during BJIs occurs in 20% of cases. In case of sepsis during BJI, the probabilistic antibiotic therapy must include an anti-gram positive cocci. The involvement of methicillin-resistant Staphylococcus aureus and Ponto-Valentine Staphylococcus aureus in BJIs should be identified early in order to limit the consequences through appropriate aggressive medico-surgical management.

The use of a vertebral biopsy remains very frequently relevant in the management of patients with infectious spondylodiscitis without identified germs or vertebral metastases without identified primary cancer in order to obtain bacteriological and/or histological proof of the disease. There are few Rheumatology departments which remain completely independent in carrying out these vertebral biopsies. We describe here a technique of spinal biopsies under robotic assistance. This aims to be more precise than current techniques, more comfortable for the patient, and to reduce the average length of stay of patients hospitalized in rheumatology. The biopsy is performed in the operating room by a rheumatologist/neurosurgeon duo guided by a robot. The precision of the biopsy is based on the acquisition of three-dimensional spinal anatomy by a plane sensor scanner coupled to the robot. This technique of vertebral biopsies is easily acquired and allows the rheumatologist to be independent from the first consultation to the aetiological diagnosis, then to the treatment of infectious spondylodiscitis. This technique is however dependent on the availability of an equipped operating theater.

Bone and joint infections gather heterogeneous clinical situation according to the infected site, the presence of orthopedic device and the infection chronicity. Their pathophysiology implicates complex interactions between the infectious agent, host immune system and osteoarticular tissue. It involves virulence factors at the initial phase of tissue invasion and destruction, and persistence mechanisms leading to chronicity and relapse. Infection can arise from three different pathways: direct inoculation during and invasive procedure or an open trauma, extension of a contiguous infection, or hematogenous spread during a bacteremia. Then, bacteria adhesion and the initial development of infection induces an inflammatory response that unbalances bone homeostasis resulting in bone lysis. Conversely, persistence mechanisms allow bacterial escape from the host immune system and the action of most antimicrobials. They include: (i) biofilm formation, a bacterial community adherent to the osteoarticular tissue and/or orthopedic device and organized in a self-produced matrix, that regulates bacterial survival in hostile growth conditions; (ii) bacterial internalization and persistence within bone cells constituting intracellular reservoirs; and (iii) phenotype switching to small colony variants characterized by a reduced metabolism and a tolerance to antimicrobials.

Synovial fluid analysis is essential for the diagnosis and management of septic arthritis (SA). It allows to identify the pathogen (mainly bacterial) and to study the antibiotics sensitivity (essential for the therapeutic management). Nevertheless, the direct examination is often negative (positive in 15–40% of the cases) and the bacterial culture can be taken in default (positive in 75–85% of the cases) because of an antibiotic therapy set up before the joint puncture, a too small bacterial inoculum or in case of fragile/fastidious bacterial species. Molecular biology techniques (DNAr16S PCR or multiplex PCR) are only of value if positive, and do not seem to increase the sensitivity of bacterial detection during SA. Synovial biomarkers are therefore necessary to allow a diagnosis of SA without bacteriological documentation or to formally eliminate this diagnosis. A synovial white blood cells threshold ≥ 50,000/mm³ seems insufficient to discriminate SA from another diagnosis (metabolic, crystal-induced or reactive arthritis). Synovial biochemical parameters seem to be of particular interest (lactate, glucose, calprotectin, procalcitonin) while others should be abandoned (protides, LDH). This article reviews the performance of cytological, bacteriological and biochemical parameters of synovial fluid for the diagnosis of SA.

Ultrasonography of the salivary glands is a simple, minimally invasive and reproducible examination that has been developed over the past 30 years. Mainly used in the primary Sjögren syndrome (pSS), it allows a study of the parotid and sub-mandibular glands's parenchyma. This parenchyma is homogeneous and iso-echogenic under normal conditions. The pathological character is marked by heterogeneity linked to the presence of hypoechoic areas (honeycomb pattern) or fibrous aspect due to fat-fibrosus tissue leading to hyperechoic bands by ultrasonography . Despite increasingly robust data on its reliability and usefulness, salivary gland ultrasound is not currently associated with the ACR-EULAR 2016 classification criteria of the pSS, probably due to a lack of consensus on its use. In 2019, the OMERACT published a semi-quantitative sore graded from 0 to 3 whose reliability has been confirmed in several studies. The standardization of practices should allow for the dissemination and validation of the use of salivary gland ultrasound in primary Sjogren syndrome on an international scale.

Past controversies about the contribution of cervical spine to vertigo mainly resulted from confusion between vertigo and dizziness, and dogmatic belief that spine could not contribute to such conditions. In fact, whereas cervical disorders cannot induce vertigo with nystagmus (which are only explained by ENT or neurological disorders) they can conversely contribute to induce dizziness, through two main mechanisms: (1) impingement of vertebral artery during extremes or brisk cervical rotations (bow-hunter syndrome), especially in patients with loops of vertebral artery or arcuate foramen (ossification of atlo-occiptal ligament on the posterior aspect of axis, making an osseous arch around the vertebral artery). Marked sagittal C1-C2 instability can also reduce flow in vertebral arteries; (2) various abnormal proprioceptive inputs from cervical discs, uncus, zygapophyseal joints, muscles and ligaments or fascias, like the occipito-cervical membrane, can also foster dizziness. Patients with dizziness of putative cervical origin must first be examined by an ENT physician, and neurologist could also be asked to check for alternative explanations before classifying the dizziness as arising partly from the cervical spine and related structures. This possibility should not be denied, moreover as some spine surgery can induce a marked improvement of those dizziness in properly selected patients.

Prescription of bone resorption inhibitors implies a thorough evaluation of associated risks weighed against expected benefits. Although quite infrequent but highly debilitating, medication-related osteonecrosis of the jaw (MRONJ) is the most highly feared complication of such treatments, both by patients and some healthcare professionals. A concerted multiprofessional approach, primary prevention via systematic oral health examination as whenever possible, but also regular follow-up with an oral health professional, could all help limit the risk of MRONJ, increase patient adherence to treatment and improve the overall quality of care.

Tension type headache (TTH) has a higher prevalence than migraine; thus it is a frequent reason for consultation and it must not be denied. The diagnostic criteria of TTH defined by the International Classification of Headache Disorders (ICHD) are non-specific, especially allowing to contrast with migraine, because tension type headache is a heterogeneous entity of multifactorial origin. So, explorations are sometimes necessary to exclude a secondary headache. A distinction is made between infrequent and frequent episodic TTH and chronic TTH. Depending on the type of TTH studies suggest different pathophysiological mechanisms. We retain an activation of peripheral myofascial structures and a central sensitization phenomenon. The management is based on the treatment of the pain with NSAIDs, sometimes associated with a prophylactic treatment for frequent and chronic TTH. Patients suffering from chronic TTH justify multidisciplinary management to prevent the risk of chronicization and analgesics abuse.

Temporomandibular joint (TMJ) is a bicondylar synovial joint containing an articular disc between the carnial basis and the mandible. The osseous conditions of this joint constituted by two condyles makes it very unstable. Stability of these two convex articular surfaces (temporal and mandibular), is constituted by the articular disc, which is a biconcave lens, with a thin center and a thick peripheric labrum, made of fibrocartilage. The capsule-ligamental system participates to the TMJ stability. Among TMJ motor muscles, some of them are elevators and diductors of the mandible, innervated by the mandibular nerve (masseter, temporal medial and lateral pterygoid muscles) and others are depressors of the mandible (platysma, digastrics, mylohyoïd and geniohyoïd muscles). TMJ can be studied by conventional Xrays as the orthopantomogram, which allows XRays focused on the TMJ with mouth opening and mouth closed positions. A CT-scanner of the TMJ is useful in bony trauma or illness (fracture of the condylar process, tumor, tempormandibular ankylosis, arthrosis…). The gold standard exam for the TMJ is MRI which allows a multiplanar and dynamic study using acquisitions at different degrees of mouth opening.

Primary Sjögren's syndrome (pSS) is characterized by the association of a symptomatic triad (dryness, pain and fatigue) with various systemic manifestations. While systemic involvement affects about 30 % of patients, sicca, mainly ocular and oral, is present in almost all patients. This symptom causes high burden of the disease and a marked deterioration in quality of life. It should not be neglected in the management of pSS patients. The purpose of this update is to provide a review of the mechanisms that cause dry syndrome in pSS, to outline the potential consequences of this symptom, and to give practical tools to guide the management of our pSS patients. Finally, this article reviews the impact of targeted therapies in development in pSS on dryness.