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Objectives: Anti-drug antibodies (ADA) are responsible for decreased adalimumab efficacy in axial spondyloarthritis (SpA). We aimed to evaluate the ability of methotrexate (MTX) to decrease adalimumab immunisation., Methods: A total of 110 patients eligible to receive adalimumab 40 mg subcutaneously (s.c.) every other week were randomised (1:1 ratio) to receive, 2 weeks before adalimumab (W-2) and weekly, MTX 10 mg s.c. (MTX+) or not (MTX-). ADA detection and adalimumab serum concentration were assessed at weeks 4 (W4), 8 (W8), 12 (W12) and 26 (W26) after starting adalimumab (W0). The primary outcome was the proportion of patients with ADA at W26. Four years after the study completion, we retrospectively analysed adalimumab maintenance in relation with MTX co-treatment duration., Results: We analysed data for 107 patients (MTX+; n=52; MTX-; n=55). ADA were detected at W26 in 39/107 (36.4%) patients: 13/52 (25%) in the MTX+ group and 26/55 (47.3%) in the MTX- group (p=0.03). Adalimumab concentration was significantly higher in the MTX+ than MTX- group at W4, W8, W12 and W26. The two groups did not differ in adverse events or efficacy. In the follow-up study, MTX co-treatment >W26 versus no MTX or ≤W26 was significantly associated with adalimumab long-term maintenance (p=0.04)., Conclusion: MTX reduces the immunogenicity and ameliorate the pharmacokinetics of adalimumab in axial SpA. A prolonged co-treatment of MTX>W26 seems to increase adalimumab long-term maintenance., Competing Interests: Competing interests: EDu was invited to attend international congresses by Roche and UCB; she has acted as a consultant and given lectures on behalf of her institution for BMS and Abbvie. eDe participated on behalf of her institution in clinical trials sponsored by Abbvie, Roche, BMS, Novartis, Pfizer, UCB and Sanofi; she has given lectures for Abbvie, BMS, Janssen, Pfizer, UCB, Novartis; she has acted as a consultant for BMS and UCB, Novartis; she has been invited to attend international congresses by MSD, Roche, BMS Abbvie and Novartis. FLG has been invited to attend an international congress by Abbvie, Pfizer. LA was invited to attend international congress by Abbvie, Novartis, Pfizer and UCB. EL has received speaker and consultant fees from Amgen, Expanscience, Lilly, and MSD; and research grants from Abbvie, Amgen, Lilly, MSD and UCB. GC was invited to attend international congress by Abbvie. VD-P has received speaker and consultant fees from MSD, BMS, UCB, Roche; and research grants from Roche-Chugai. EG has participated on behalf of his institution in clinical trials sponsored by Roche, Lilly, Novartis, Amgen, and BMS; she has acted as a consultant and given lectures for Abbvie, BMS, MSD, Pfizer, Roche, UCB, Novartis; she has been invited to attend international congresses by MSD, Roche, Novartis and BMS. BLG has participated on behalf of his institution in clinical trials sponsored by Roche, Lilly, Novartis, Pfizer, UCB and MSD; he has acted as a consultant and given lectures for Abbvie, BMS, Janssen, MSD, Pfizer, Sanofi-Genzyme, UCB, Novartis; he has been invited to attend international congresses by MSD, Roche, Abbvie, Sanofi and Pfizer. EP was invited to attend an international congress by Buhlmann. GP reports grants received by his research team from Novartis, Roche Pharma, Sanofi-Genzyme, Chugai, Pfizer and Shire, outside of the submitted work. DT has acted as a consultant and given lectures for Sanofi, Amgen, PG participated on behalf of his institution in clinical trials sponsored by Abbvie, Roche, BMS, Boehringer, Lilly, Novartis, Pfizer, UCB, Janssen and MSD; he has acted as a consultant and given lectures for Abbvie, Biogaran, BMS, Hospira, Janssen, MSD, Pfizer, Sanofi-Genzyme, UCB; he has been invited to attend international congresses by MSD, Roche, BMS and Abbvie. DM has acted as a consultant and given lectures on behalf of his institution for Pfizer and Novartis; he has been invited to attend an international congress by Janssen-Cilag. His institution received grants for research from the non-governmental organisation Lions Club Tours Val de France. TR, MS, AP, CD, AdV, TA, AM and HW declared that they have no disclosure with the manuscript., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Brucellosis is uncommon in humans and only rarely manifests as osteomyelitis. We report the case of a 57-year-old patient with chronic Brucella osteomyelitis of both humeri. The diagnosis was established upon evaluation of a spontaneous fracture of the right humerus. The organism was recovered in fluid draining to the skin from an abscess located in the bone and soft tissues.

Background: Pregnancy-related hip diseases epidemiology has been poorly evaluated. We report our experience of gestational and postpartum hip diseases and evaluate their incidence., Methods: (1) Prospective survey: all pregnant or early postpartum women suspected to have hip involvement during their follow-up in an Obstetric unit were referred to a rheumatologist. If clinically confirmed, magnetic resonance imaging (MRI) and additional investigations as needed were performed. This survey had 2 years duration. (2) Retrospective study: all cases of definite (with MRI confirmation) pregnancy-related hip disease referred to our Rheumatology unit during the past 15 years were analyzed., Results: During the 2-year prospective survey, 3 patients (4 hips) of pregnancy-related hip disease were observed over 4900 pregnancies (1 case of transient osteoporosis of the hip (TOH) and 2 cases of occult fracture of the femoral head). During the 15-year retrospective study, 12 patients (17 hips) with hip diseases during pregnancy or early postpartum were identified. There were 6 patients (9 hips) with TOH, 4 patients (6 hips) with occult fracture of the femoral head, 1 patient with osteonecrosis of the femoral head, and 1 coxitis in a patient with ankylosing spondylitis. Differentiating diagnosis between TOH and occult fractures could only be made by MRI. Five of the 6 women with TOH had osteopenia at the lumbar spine at dual energy X-ray absorptiometry (DEXA). The 4 women with occult fractures had either osteopenia or osteoporosis at the lumbar spine., Conclusion: Hip diseases are infrequent during pregnancy and early postpartum. Transient osteoporosis of the hip and occult stress fractures of the femoral head appear the main causes and those diagnoses justify evaluation for an underlying bone fragility. Osteonecrosis is very rare in this setting.

Introduction: The pathophysiology of intravertebral vacuum (IVV) remains unclear, although vertebral osteonecrosis is often incriminated. Gas may migrate from the disk to the vertebral body. The objective of this study was to investigate the relations between IVV and intradiscal vacuum (IDV)., Methods: We prospectively evaluated the presence of radiological findings suggestive of IVV in patients admitted to a rheumatology department for vertebral fracture, over a 6-year period. Suggestive radiological findings were defined as a radiolucent collection within a vertebral body, an increase in the anteroposterior diameter of the vertebral body, and/or evidence of horizontal dissection of a vertebral body. Patients with any of these findings underwent computed tomography; when this investigation showed IVV, the adjacent disks were examined for IDV, and when this was found a communication between the two cavities was looked for., Results: Of 278 patients admitted for vertebral fracture during the study period, 15 had IVV. IDV adjacent to the fractured endplate was visible in 13 of these 15 patients. All 15 patients had severe fractures (Genant semi-quantitative classification, grade 3 in 10 patients and grade 2 in five patients). A communication between the intradiscal and intravertebral collections was seen in five patients. Only two patients had evidence of IVV on plain radiographs., Conclusion: Our findings support migration of gas from the disk to a fracture in the adjacent vertebral body. The term "vertebral osteonecrosis" used to designate IVV may be inappropriate. IVV is rarely shown by plain radiographs, indicating a need for other morphological criteria.