Les uvéites sont la manifestation la plus fréquente de la sarcoïdose oculaire. Elles peuvent survenir à tout âge mais touchent préférentiellement les adultes âgés de 30 à 60 ans, avec une prédominance féminine, en particulier dans formes de révélation tardive. Les caractéristiques sémiologiques évocatrices sont : une uvéite antérieure granulomateuse définie par des précipités rétrodesmétiques épais, dits en graisse de mouton ou des nodules iriens, des synéchies antérieures, une hyalite, des périphlébites, des granulomes choroïdiens et un oedème maculaire. Le diagnostic repose sur une combinaison de ces caractéristiques ophtalmologiques et d’examens paracliniques, notamment des biomarqueurs sériques et une imagerie thoracique évocatrice. La prise en charge est guidée par les caractéristiques anatomiques de l’uvéite dont la latéralité et la gravité de l’inflammation, ainsi que les manifestations extra-ophtalmologiques associées et le terrain du patient. Un traitement systémique est proposé en cas d’échec, de contre-indication ou d’effets secondaires de la corticothérapie locale, d’atteinte bilatérale active du segment postérieur. Les agents immunosuppresseurs conventionnels, en particulier le méthotrexate, demeurent le traitement de première intention. L’hydroxychloroquine apparaît une bonne option dans les uvéites antérieures et intermédiaires. Les agents biologiques, tels que les anti-TNFα, en particulier l’adalimumab sont utilisés pour les formes réfractaires. Le tocilizumab apparaît en particulier chez les patients atteints d’œdème maculaire. Les techniques de multi-omiques et l’intelligence artificielle offrent des perspectives pour le diagnostic, pour affiner le pronostic et personnaliser la thérapeutique des uvéites sarcoïdosiques.

PURPOSE:To report a rare case of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) revealing Crohn's disease in an adolescent, and to discuss potential immunopathological links between these two inflammatory conditions. METHODS:Case-Report. RESULTS:A 16-year-old boy presented with a rapidly progressive bilateral central vision blurring. Examination revealed bilateral granulomatous hypertensive anterior uveitis, mild vitritis, and multifocal placoid lesions involving posterior poles. Multimodal imaging demonstrated active choriocapillaritis mimicking atypical APMPPE, with non-occlusive retinal vasculitis. Systemic evaluation, prompted by recent weight loss and digestive symptoms, led to a diagnosis of histologically confirmed Crohn's disease. Systemic corticosteroid therapy followed by anti-TNFα therapy (adalimumab) resulted in full remission, with no recurrence of inflammation or development of choroidal neovascularization after one year. CONCLUSION:Although the exact pathophysiology of APMPPE remains uncertain, increasing evidence suggests an immune-mediated vasculitic mechanism rather than primary ischemia alone. This case is noteworthy as APMPPE revealed previously undiagnosed Crohn's disease. It highlights the need for systemic evaluation in atypical presentations, especially when granulomatous anterior involvement is present. Modern multimodal imaging, including OCT, provided precise characterization of the lesions and contributed to the comprehensive evaluation of this rare association.

Background Prognostic factors for systemic outcomes and mortality of sarcoidosis in patients with uveitis have been poorly studied. Methods Multicenter retrospective cohort study of sarcoidosis patients with uveitis. Sarcoidosis diagnosis was established according to the recommendations of the American Thoracic Society. Sarcoid uveitis diagnosis was based on the Standardization of Uveitis Nomenclature classification criteria. Systemic relapse-free survival (RFS) and sequelae-free survival (SFS) were analysed using Kaplan-Meier curves and Cox proportional hazards models. Results 336 patients were included, of whom 208 (61.9%) were female. Median age at sarcoidosis diagnosis was 52 years (range, 10–89 years). Median follow-up was 7.8 years. Systemic relapses occurred in 129 of 334 (38.6%) patients. Shorter systemic RFS was associated with Sub-Saharan African ethnicity (HR, 3.65, 95% CI, 2.26–5.90, P < .001) and anterior uveitis (HR, 1.95, 95% CI, 1.25–3.03, P = .007). Sequelae occurred in 46 of 334 (13.8%) patients. Shorter systemic SFS was associated with neurologic involvement (HR, 5.05, 95% CI, 2.46–10.34, P < .001) and anterior uveitis (HR, 3.10, 95% CI, 1.45–6.66, P = .002). All-cause mortality was 7.7% (24/312) with no sarcoidosis-related deaths. Conclusions Relapses occurred in approximately 40% of patients and were associated with Sub-Saharan African ethnicity and anterior uveitis. One in seven patients developed sequelae of sarcoidosis, which were associated with neurologic involvement and anterior uveitis. These characteristics may help identify patients who could benefit from closer follow-up and consideration of more intensive immunosuppressive therapy. Mortality was approximately 8%, with no sarcoidosis-related deaths.

Objective To identify predictive factors of remission in patients with sarcoid uveitis and to evaluate recurrence rates and patterns following remission. Methods Multicentre retrospective study of patients with sarcoid uveitis and a minimum follow-up of 3 years. Remission was defined as the absence of clinical symptoms of sarcoidosis for at least 3 years without treatment. Remission-free Kaplan-Meier survival curves were constructed for selected variables. Cox proportional hazards model was then applied. HRs and 95% CIs were estimated for each variable. Statistical significance was set at the p<0.05 level. Rates and patterns of recurrence after remission were collected and compared with initial presentation. Results A total of 329 patients were included (62% female, median age 53 years). Remission occurred in 98 (30%) patients after a median follow-up of 6.5 years. Macular oedema at baseline was associated with a lower likelihood of remission (HR, 0.594, 95% CI 0.342 to 0.996, p=0.043), whereas pulmonary involvement at baseline was associated with a higher likelihood of remission (HR, 1.588, 95% CI 1.047 to 2.419, p=0.032). Recurrence after remission occurred in 6 of 98 patients (6%), with a median time to recurrence of 46 months after remission. At recurrence, patients predominantly had anterior uveitis (83%) and shared similar anatomical patterns with their initial presentation. Conclusions Approximately one in three patients with sarcoid uveitis achieved remission. Macular oedema at baseline was associated with delayed remission, while lung involvement at baseline was associated with faster remission. Recurrence after remission was uncommon and typically mirrored the initial uveitis phenotype.

Sjögren’s Syndrome (SjS) has historically been associated with classical anti-Ro60/SSA, Ro52/SSA and La/SSB, however they are lacking in one third of the patients, which induces delays in diagnosis, and their disease-contributing role is debated. Here we have applied a SjS-tailored Systems Serology approach to a cohort of 58 SjS and 16 non-SjS sicca syndrome patients, and 40 healthy individuals, involving a multiplex assay measuring antibody isotype, subclass, Fc Receptor and complement engagement to 14 SjS-related autoantigens, an antibody-glycosylation profiling assay and a phagocytosis cell-based assay. Via a machine learning approach, we have identified unique autoantibody signatures, including classical and non-classical autoantigens-related features especially involving autoantigen-specific Fc Receptor binding, with apparent functional consequences. These findings provide interesting insights into the autoantibody responses in SjS, possibly paving the way for improved diagnostics, especially in difficult-to-diagnose patients (e.g., seronegative SjS and non-SjS sicca syndrome patients), and novel therapeutic options targeting autoantibody-specific Fc/Fc Receptor-related effector functions. This study reports that a Systems Serology approach, dedicated to the evaluation multiple Sjögren’s syndrome autoantibodies’ Fab and Fc related features, could possibly improve its diagnosis, and reveal novel pathogenic mechanisms. This study reports that a Systems Serology approach, dedicated to the evaluation multiple Sjögren’s syndrome autoantibodies’ Fab and Fc related features, could possibly improve its diagnosis, and reveal novel pathogenic mechanisms.

Abstract Background Uveitis is a major cause of blindness in developed countries, and adverse effects associated with long-term use of topical or systemic steroids and immunosuppressive agents are notable. This study aimed to evaluate the efficacy and safety of hydroxychloroquine (HCQ) in sarcoidosis-associated uveitis (SAU) and idiopathic uveitis (IdU). Methods This monocentric retrospective study included 42 patients with SAU and 15 patients with IdU treated with HCQ for at least six months between March 2003 and December 2022. All types of uveitis were included. Most patients had chronic bilateral granulomatous SAU or IdU. Efficacy was determined by the success rate of HCQ at 6 and 12 months, and at the last visit and was defined as having control of inflammation, no more than 5 mg prednisone daily and less than or equal to 2 drops of dexamethasone phosphate 0.1%, and no treatment failure due to safety. Biomicroscopic data, best-corrected visual acuity, inflammation grading (SUN criteria) and optionally data from optical coherence tomography and fluorescein or indocyanine green angiography were assessed. The Fisher’s exact test and the Wilcoxon rank test were used for the comparison of qualitative data and quantitative data respectively. Prednisone dose was compared using a mixed model. Results The median [IQR] duration to the last visit was 19.5 [11-44.8] months in SAU patients and 18 [13–38] months in IdU patients. At the last visit, 55% of patients with SAU (including 70% of anterior SAU and 77% of intermediate SAU) and 40% patients with IdU (including 27% of anterior IdU) were successfully treated with HCQ ; the median [IQR] prednisone dose decreased from 10 [8.0-27.5] to 4 [2.5–5.75] mg/day and from 15.5 [12.5–19.5] to 3.0 [3.0–5.0] mg/day in SAU and IdU patients, respectively. The reduction in median prednisone dose was significant in patients with SAU ( p = 0.002). The incidence rate ratio of flare was 0.73 ( p = 0.143) in SAU patients and 0.26 ( p < 0.001) in IdU patients. Conclusion HCQ could be an interesting therapeutic option for specific types of SAU and IdU. Additionally, HCQ decreased the incidence of flare-ups and the need for oral prednisone in these patients.

Objective Despite considerable advances in diagnostic work-up, approximately one-third of uveitis remains of undifferentiated etiology. Few studies have evaluated the proportion of etiological diagnoses made during follow-up in patients initially classified as undifferentiated uveitis. The study aimed to assess the achievement of a diagnosis during the follow-up and to describe how the diagnosis was reached for these patients. Methods We conducted a retrospective study of patients with uveitis referred to our tertiary center between 2002 and 2023. Uveitis was classified as undifferentiated after an exhaustive diagnostic work-up and at least one year of follow-up. An etiological diagnosis can be established through new clinical signs, ophthalmologic examinations, or additional tests. Results 338 patients with uveitis were initially classified as undifferentiated. During a median follow-up of 58.4 months, an etiological diagnosis was established in 52 patients (15.4%), mainly by the appearance of new clinical symptoms in twenty-two patients. Specifically, ten patients presented with neurological symptoms, five with mucocutaneous involvement, and five with rheumatological symptoms. In nineteen patients, an etiology was diagnosed by the contribution of complementary investigations, mainly by next-generation sequencing in 7 patients and a PET (Positron Emission Tomography) scan in 3 patients. In eleven patients, new specific ocular signs were identified during ophthalmological examinations, leading to the establishment of a new diagnosis. Conclusion In patients with initially undifferentiated uveitis, an etiology was identified during follow-up in about one-sixth of the patients, primarily through repeated physical examinations and the performance of new complementary tests.

Introduction: La sarcoïdose est la granulomatose la plus fréquente observée dans les pays occidentaux. Des réactions granulomateuses liées aux prothèses orthopédiques, induites par des particules métalliques, peuvent mimer une sarcoïdose et doivent être envisagées dans le diagnostic différentiel.Observation: Nous rapportons le cas d’une femme de 50 ans, porteuse d’une prothèse totale de hanche droite, ayant présenté une panuvéite granulomateuse bilatérale aiguë. Les recherches infectieuses étaient négatives mais le bilan biologique montrait un syndrome inflammatoire systémique et une élévation de l’enzyme de conversion de l’angiotensine (ECA). La tomographie par émission de positons (TEP) objectivait un hypermétabolisme périprothétique intense associé à des adénopathies iliaques. La biopsie ganglionnaire révélait des granulomes épithélioïdes non caséeux et des cellules géantes multinucléées. L’analyse par microscopie électronique à balayage couplée à la spectrométrie dispersive en énergie des rayons X (MEB-EDX) du tissu granulomateux mettait en évidence de nombreuses particules métalliques, principalement du titane et un alliage titane–vanadium. La concentration sanguine en titane était nettement augmentée (138 µg/L ; normale < 12). L’analyse de l’implant explanté montrait une zone d’usure importante du col de la tige fémorale, expliquant la libération particulaire. Après ablation de la prothèse, nous avons observé une amélioration clinique, avec une récidive légère de l’uvéite facilement contrôlée par une corticothérapie locale. Après deux ans de suivi, la patiente demeure asymptomatique et la TEP montre une rémission partielle.Conclusion: La granulomatose associée aux prothèses orthopédiques peut mimer une sarcoïdose. Chez les patients présentant une granulomatose systémique inexpliquée et des antécédents d’arthroplastie, l’analyse particulaire associée à une expertise des implants peut apporter une aide diagnostique déterminante.

INTRODUCTION:[18F]FDG PET/CT scan is sometimes performed as part of the diagnostic evaluation of non-compressive myelopathies, but the spinal cord lesion metabolism is not systematically evaluated. We aimed to investigate the diagnostic value of spinal cord lesion metabolism on [18F]FDG PET/CT for differentiating inflammatory myelitis from neurosarcoidosis and tumoral lesions. METHODS:We conducted a retrospective cohort study of patients presenting with spinal cord lesions who underwent [18F]FDG PET/CT. Patients were classified as primary inflammatory myelitis, neurosarcoidosis, tumoral lesions, or other etiologies. PET/CT examinations were reviewed by a nuclear medicine physician, masked to final diagnosis, who assessed the presence of hypermetabolism (qualitative analysis) and measured lesion SUVmax, lesion-to-liver ratio, and level-standardized Z-score to account for physiological uptake variability (quantitative analysis). RESULTS:A total of 106 patients were included: 60 (56.6%) with inflammatory myelitis, 20 (18.9%) with neurosarcoidosis, 10 (9.4%) with tumoral lesions, and 16 (15.1%) with other etiologies. Hypermetabolism was found in 80.0% of tumoral lesions, 50.0% of neurosarcoidosis, and 23.3% of inflammatory myelitis. PET/CT showed good performance in differentiating inflammatory myelitis or neurosarcoidosis from tumoral lesions using qualitative analysis (hypermetabolism: sensitivity 0.77, specificity 0.80, and 0.50, respectively) and quantitative analysis (SUVmax: AUC 0.89 and 0.84, respectively). The performance of SUVmax for distinguishing inflammatory myelitis from neurosarcoidosis was low (AUC 0.55), but improved with the lesion-to-liver ratio (AUC 0.64) and level-standardized Z-score (AUC 0.65). CONCLUSION:Spinal cord hypermetabolism on [18F]FDG PET/CT demonstrated good performance for distinguishing tumoral lesions from inflammatory or neurosarcoidosis, but lower performance for differentiating inflammatory myelitis from neurosarcoidosis.

IgG4-related disease (IgG4-RD) is a recently described entity comprising pseudo-tumoral and inflammatory conditions that were previously considered separately. It is characterised by specific histological abnormalities, including polyclonal lymphoplasmacytic infiltration, fibrosis and contingent of IgG4+ plasma cells, often associated with elevated serum IgG4 levels and a good response to glucocorticoids. The clinical presentation is highly heterogeneous and requires a multidisciplinary assessment. The diagnosis is based on the identification of suggestive clinical or radiological signs, such as pancreatic, salivary or lacrimal gland involvement, retroperitoneal fibrosis, cholangitis, aortitis, lymphadenopathy or interstitial nephritis. It is also based on the search for laboratory evidence of abnormalities such as polyclonal gammopathy, elevated serum IgG4 levels and complement consumption, and is most often confirmed by organ biopsy. The disease progresses slowly, with gradual symptoms and a risk of sequelae related to fibrosis, particularly pancreatic or renal failure. Management is based on providing the patient with comprehensive information about symptoms, warning signs, adverse events of treatments, vaccination, diet and physical activity. Initial treatment consists of oral glucocorticoids at a dose of 0.4 to 0.6mg/kg/day for two to four weeks, followed by a gradual tapering until discontinuation at three months if possible. This treatment induces remission in more than 90% of cases, but relapses are common, sometimes requiring treatment with immunosuppressants. Follow-up includes regular consultations, imaging tests and laboratory workups, in particular serum IgG4 measurement, in order to monitor disease activity, predict relapses and prevent complications.

Sarcoidosis-related uveitis is the most common manifestation of ocular sarcoidosis. It can occur at any age but preferentially affects adults aged 30 to 60 years, with a female predominance, especially in forms with late onset. Suggestive semiological features are: granulomatous anterior uveitis defined by thick retro-descemetal precipitates (so-called "mutton-fat" keratic precipitates) or iris nodules, anterior synechiae, vitreous inflammation (hyalitis), periphlebitis, choroidal granulomas, and macular edema. Diagnosis relies on a combination of these ophthalmological features and paraclinical tests, notably serum biomarkers and suggestive chest imaging. Management is guided by the anatomical characteristics of the uveitis including laterality and the severity of inflammation as well as associated extra-ophthalmic manifestations and the patient's background. Systemic treatment is offered in case of failure, contraindication or side effects of local corticosteroid therapy, or active bilateral posterior-segment involvement. Conventional immunosuppressive agents, particularly methotrexate, remain first-line therapy. Hydroxychloroquine appears to be a good option for anterior and intermediate uveitis. Biologic agents such as anti-TNF alpha drugs especially adalimumab are used for refractory cases because of their steroid-sparing effect demonstrated for chronic non-anterior non-infectious uveitis. Tocilizumab appears to be an alternative to anti-TNF agents, particularly in patients with macular edema. Multi-omics techniques and artificial intelligence offer prospects for diagnosis, refining prognosis and personalizing therapy for sarcoid uveitis.

INTRODUCTION:Rituximab is used for treating autoimmune cytopenia and associated diseases including autoimmune haemolytic anaemia; immune thrombopenia, systemic lupus erythematosus and antiphospholipid syndrome. However, rituximab may induce acquired immune deficiency in some patients, particularly hypogammaglobulinemia (HG), whose risk factors remain poorly defined. PATIENTS AND METHODS:We conducted a retrospective multicentre study including patients with autoimmune cytopenia and related diseases who received at least one rituximab infusion to validate serum protein electrophoresis (SE) as a screening tool for HG and to assess its incidence, risk factors, and clinical outcomes. Univariate and multivariate Cox analysis were performed to characterize predictor of HG. RESULTS:Among 47 patients (391.89 person-years follow-up), Gammaglobulin evaluation on SE strongly correlated with IgG (ρ = 0.97, P=2.2×10-16). HG, defined as gammaglobulin levels <7g/L on SE after rituximab exposure, occurred in 14.9% of patients and was associated with a higher cumulative number of rituximab injections (median 11 vs. 1.5; P=0.033). All immunoglobulin isotypes declined after treatment, and severe infections were more frequent in HG patients. Although cumulative rituximab dose and corticosteroid exposure were associated with HG in univariate analysis, these findings were not confirmed in multivariate models. CONCLUSION:SE appears to be a reliable screening tool for HG, but larger studies are needed to clarify risk factors.

Ocular sarcoidosis is a frequent manifestation of sarcoidosis and may occur most commonly affecting adults between 30 and 60 years old. Uveitis may be anterior, intermediate, posterior, or present as panuveitis, with marked heterogeneity in severity and clinical course. Diagnosis relies on a combination of compatible ocular findings and systemic investigations, including serum biomarkers, thoracic imaging, and histological evidence of noncaseating granulomas while carefully excluding infectious and neoplastic mimickers, particularly in atypical or corticosteroid-resistant cases. Bilateral, intermediate, posterior, and panuveitis often require systemic corticosteroids. Because of the unfavorable long-term safety profile of systemic corticosteroids, early introduction of steroid-sparing therapy is recommended in chronic, severe, or recurrent disease. Emerging therapies such as interleukin-6 receptor antagonists, Janus kinase inhibitors, and mTOR inhibitors represent promising options on top of methotrexate and TNF inhibitors for refractory sarcoid uveitis, although their use requires careful risk-benefit assessment and further validation in controlled trials.

Uveitis encompasses a heterogeneous spectrum of etiologies, including systemic inflammatory diseases, infections, specific ophthalmologic entities, and pseudo-uveitis. The diagnostic approach relies on an algorithmic strategy aimed at the early identification of a curable etiology and/or an underlying condition suitable for targeted therapy, while taking into account the severity and relative frequency of the various causes. The prospective ULISSE study showed that a standardized diagnostic approach based on the anatomo-clinical classification of uveitis achieved a diagnostic yield comparable to unrestricted testing, while substantially reducing both the number and cost of investigations. Etiological diagnosis is primarily based on anatomo-clinical analysis of uveitis, integrating the site of inflammation, disease course, laterality, and specific ophthalmologic features. Subsequently, consideration of epidemiological and demographic factors, medical history, and extra-ophthalmologic clinical examination allows further refinement of the diagnostic workup. Complementary investigations should be prioritized and targeted, except for a minimal systematic baseline evaluation, as the diagnostic yield of non-directed testing is very low. Clinical decision-support tools based on artificial intelligence (AI) represent a major advancement. Machine learning models integrating clinical, ophthalmologic, laboratory, and imaging data available from the initial consultation achieve etiological prediction performances comparable to those of experts with access to a complete diagnostic workup. These multimodal AI models could transform diagnostic strategies by enabling a personalized etiological assessment based on the prioritization and dynamic adaptation of complementary investigations. However, their implementation in routine clinical practice will require prior medico-economic validation through controlled comparative studies.

Objective To compare patients with SLE associated with either Evans syndrome (ES) or an isolated autoimmune cytopenia (immune thrombocytopenia (ITP) or autoimmune haemolytic anaemia (AIHA)).Methods Multicentre retrospective study including patients with SLE presenting with ITP, AIHA or ES of clinical significance (ie, requiring therapeutic intervention according to European Alliance of Associations for Rheumatology guidelines or clinician discretion). Clinical, laboratory and outcome data were compared between patients with ES and those with ITP or AIHA. Severe SLE flares were defined as flares with SLE Disease Activity Index ≥10.Results Among 95 patients with SLE included, 30 had ES, 43 ITP and 22 AIHA. The number of severe SLE flares per patient was higher in ES than in ITP (1.3 vs 0.4, p=0.0004) and patients with AIHA (0.4, p=0.006). Patients with ES had a higher incidence rate ratio (IRR) of severe SLE flares (IRR =3.03; 95% CI 1.50 to 6.41), which remained significant in inverse probability of treatment weighting analyses. At last follow-up, patients with ES presented higher rates of renal (36.7% vs 9.3%, p=0.007) and neurological (36.7% vs 11.6%, p=0.019) involvement than patients with ITP. Severe infections were more frequent in patients with ES than ITP (47% vs 23%, p=0.045), with a higher mean number of severe infections per patient (1.2 vs 0.5, p=0.04).Conclusion In patients with SLE, ES is associated with an increased risk of severe flares than isolated autoimmune cytopenia. These findings were consistent after adjustment for baseline imbalances, supporting ES as a high-risk SLE phenotype.

Les uvéites regroupent des étiologies hétérogènes, incluant des maladies inflammatoires systémiques, des infections, des entités ophtalmologiques et des pseudo-uvéites. La démarche diagnostique repose sur une approche algorithmique visant à identifier précocement une étiologie curable et/ou une pathologie sous-jacente susceptible de bénéficier d’un traitement spécifique, tout en tenant compte de la sévérité et de la fréquence des différentes étiologies. L’étude prospective ULISSE a démontré qu’une stratégie diagnostique standardisée, guidée par le type anatomoclinique de l’uvéite, permettait un rendement diagnostique comparable à une prescription non protocolisée, avec une réduction significative du nombre et du coût des examens réalisés. Le diagnostic étiologique s’appuie en première intention sur l’analyse anatomoclinique de l’uvéite, intégrant la localisation de l’inflammation, son évolution, sa latéralité et les signes spécifiques. L’analyse secondaire des données épidémiologiques et démographiques, de l’anamnèse et de l’examen clinique extra-ophtalmologique permet d’affiner l’orientation du bilan. Les examens complémentaires doivent être hiérarchisés et ciblés, à l’exception d’un bilan minimal systématique, puisque la rentabilité d’examens complémentaires non orientés est très faible. Les outils d’intelligence artificielle (IA) d’aide à la décision clinique constituent une avancée majeure. Les modèles d’apprentissage automatique intégrant les données cliniques, ophtalmologiques, paracliniques et d’imagerie disponibles dès la première consultation atteignent des performances de prédiction étiologique comparables à celles d’experts disposant du bilan diagnostique complet. Ces modèles d’IA multimodaux pourraient transformer la stratégie diagnostique en permettant un bilan étiologique personnalisé, fondé sur une hiérarchisation et une adaptation dynamique des examens complémentaires. Leur implémentation en pratique clinique nécessitera toutefois une validation médico-économique par des études contrôlées comparatives.