Background Dermatologists are recommended to ask psoriasis patients about musculoskeletal complaints to allow early detection and treatment of psoriatic arthritis (PsA). Screening tools have been developed to help identify patients warranting further rheumatologic assessment, but evidence suggests room for improvement in their diagnostic value and ease of use for outpatient practice. ObjectiveMethodsTo develop and internally validate a brief tool for dermatologists to screen patients to refer to a rheumatologist for PsA diagnosis. After the literature review, 23 items were selected, covering pain at various locations and inflammatory signs of PsA. The validation study was conducted in medically diagnosed psoriasis patients consecutively recruited between 2012 and 2014 (Saint Joseph Hospital, Paris, France). Patients were enrolled by a dermatologist who helped to complete the questionnaire. Diagnosis of PsA was established by a rheumatologist based on CASPAR criteria. Multivariate logistic regression models were performed to build the scale, assessing discrimination through sensitivity, specificity and area under the ROC curve (AUC). Final model was internally validated using bootstrapping techniques. ResultsConclusionOne hundred and sixty-eight patients were recruited, of whom nine were excluded for known PsA and 21 did not attend the rheumatologist consultation. Of 137 included patients (median age 43 years, 59.6% men), 21 (15.3%) had a PsA diagnosis. Final regression model retained four independent items, including evocative signs of dactylitis, inflammatory heel pain, bilateral buttock pain and peripheral joint pain with swelling in patients aged <50. A total score (the PURE-4) was computed (0-4 points) that demonstrated excellent discriminative power (AUC = 87.6%; Sensitivity = 85.7% and Specificity = 83.6% at the threshold of 1/4 points), with no evidence for over-optimism in bootstrapped internal validation. These findings demonstrate the good diagnostic properties of a new screening scale using only four easy-to-collect items. If confirmed in other populations, it may prove useful in outpatient dermatology clinics for triage of psoriasis patients requiring further assessment by the rheumatologist. Linked article: This article is commented on by P.C.M van de Kerkhof, pp. 1836-1837 in this issue. To view this article visit

Un rhumatisme psoriasique (PsA) peut s’associer à 30 % des cas de psoriasis (Pso) et doit être dépisté précocement pour réduire les destructions articulaires associées. Or, 15 % des patients avec un Pso auraient un PsA non diagnostiqué par les dermatologues. Les questionnaires de dépistage du PsA déjà validés (ToPAS, PEST, PASE, EARP) sont limités par leur relative complexité et longueur, une faible reproductibilité. L’objectif de cette étude était de développer et réaliser la validation interne d’un nouvel outil de dépistage rapide du PsA destiné aux dermatologues afin d’orienter vers le rhumatologue les patients pris en charge pour Pso : le questionnaire Psoriatic arthritis Uncluttered screening Evaluation (PURE). Un groupe d’experts dermatologues et rhumatologues a identifié par une revue de la littérature 23 items candidats pour la création de ce questionnaire, soit : caractéristiques du Pso, symptômes douloureux (arthralgies périphériques, axiales, fesses, paroi thoracique, doigts, orteils), signes inflammatoires évocateurs du PsA (raideurs matinales, gonflements et inflammation articulaires). Une étude de validation a été réalisée auprès de tous les patients vus consécutivement par un dermatologue pour un Pso entre 9/12 et 6/2014 à l’hôpital St-Joseph, Paris. Les patients devaient compléter le questionnaire avec l’aide du dermatologue avant d’être adressés systématiquement à un rhumatologue qui établissait ou non le diagnostic de PsA (critères CASPAR). La sensibilité (Se), spécificité (Sp), valeurs prédictives nég et pos et l’aire sous la courbe ROC (AUC) étaient calculées pour chaque item et pour le score synthétique obtenu par régression logistique multivariée, avec validation interne par méthodes de bootstrap. Au total, 137 patients inclus (âge médian 43 ans, 59,6 % d’hommes, durée médiane du Pso de 12 ans), dont 21 cas (15,3 %) avec un diagnostic de PsA retenu par le rhumatologue. Sur les 23 variables candidates, 15 significativement associées au PsA en analyse univariée. En analyse multivariée, 4 items indépendants étaient retenus, incluant signes de dactylite, talagies, fessalgies bilatérales et douleurs articulaires périphériques avec gonflement chez les moins de 50 ans, la dactylite étant l’item le plus spécifique (VPP = Sp = 100 %). Les propriétés du score total sur 4 points (1 point/item positif) étaient excellentes (Se 85,7 % ; Sp 83,6 % ; AUC (valeur corrigée par validation interne) : 87,5 %). Malgré le faible effectif et en attente de validation externe, les performances diagnostiques du PURE-4 sont prometteuses, avec 4 items faciles à questionner pour un dermatologue, ne nécessitant aucune formation spécifique, et administrable dans la salle d’attente. Le questionnaire PURE 4 pourrait être utile en pratique dermatologique courante pour identifier les patients avec un Pso nécessitant une consultation par un rhumatologue pour dépister de façon optimale un PsA.

The symptoms of Lyme meningoradiculitis and the value of biological examinations in an endemic area were determined in a prospective study in which data were collected on all patients consecutively hospitalised for Lyme meningoradiculitis at our institution during an 18-month period. Specific antibody titres in the serum and cerebrospinal fluid (CSF) were determined by Vidas enzyme-linked-immunosorbent-assay (IgG + IgM), Dade-Behring enzyme immunoassay (EIA) (IgM; IgG) and Western blot analysis (IgG). We also searched for Borrelia burgdorferi in the CSF by PCR analysis and following culture on a specific medium. A control group was recruited, consisting of 16 consecutive patients who had been referred during the same period with suspected but not confirmed Lyme meningoradiculitis. Eleven patients were included. Borrelia EIA of the serum revealed that 40% of the patients had both elevated specific IgM titres and intrathecal synthesis of specific IgG; 40% of the patients was negative for IgM but had isolated intrathecal synthesis of IgG; 20% of the patients had elevated specific IgM titres without intrathecal synthesis of IgG. PCR analysis and the CSF culture were positive in one case only (B. garinii). The results of this study highlight the importance of systematic serological testing for B. burgdorferi in the CSF in the case of early neuroborreliosis suspicion, even in the absence of IgM serum antibodies, which was the case in 40% of the patients in the present study. Nevertheless, intrathecal anti-B. burgdorferi IgG synthesis, which remains the "gold standard" for the diagnosis of neuroborreliosis, was not detectable in 20% of the patients for whom diagnosis was subsequently confirmed by demonstration of specific serum IgM.

Background Neuroborreliosis has been called "the new great imitator". Objectives The aim of this study was to define the symptoms of meningoradiculitis. Methods We collected prospective data from all patients admitted to hospital with Lyme meningoradiculitis between June 1st, 1998 and December 31st, 1999 in an endemic zone located in western France. Diagnosis was based on lymphocytic meningitis associated with either intrathecal specific antibody synthesis or high serum titers of specific IgM in ELISA and western Blot analysis. Results Eleven patients (9 women, 2 men), with a mean age of 62 years (range: 37 to 87) were included during the study period. Two thirds of these patients were admitted to rheumatology wards during the summer. The onset of symptoms was preceded, 5 to 60 days earlier, by a tick bite in 64% of cases or erythema migrans in 55% of cases. In 18% of patients, neither a tick bite nor erythema was observed. Non specific symptoms were recorded in 82% of cases, with transient fever or flu syndrome in 45% of all cases. Cervical radiculoneuritis was observed in 4 cases, symptoms affecting several nerve roots of the lower limbs in 3 cases, femoral neuropathy in 2 cases, a bilateral sensory radiculoneuritis T11–12 in one case and poorly localised paresthesias in the lower limbs in one case. The meningeal signs and symptoms were minimal or, more frequently, absent. A peripheral motor paresis was observed in one quarter of the cases, but without Bell's palsy or encephalic or medullary signs. In half the patients, there was associated spinal pain not relieved by rest. All patients reported nocturnal exacerbation in pain. The electrocardiographic abnormalities included first-degree atrioventricular block in 2 patients. The course of the disease was consistently favourable on ceftriaxone IV treatment, with rapid effective relief of pain. Conclusion A diagnosis of Lyme meningoradiculitis should be considered in endemic zones in all cases of spine pain and/or radiculitis with nocturnal exacerbation, especially in the summer period.