History Of Gout Research Articles

A Case of Histoplasmosis Detected Through Bone Marrow Analysis.

Histoplasmosis is an endemic infection caused by Histoplasma capsulatum, leading to a broad spectrum of disease from asymptomatic to severe disseminated disease. To diagnose Histoplasmosis, culture remains the gold standard for the laboratory diagnosis; however, this fungus grows slowly, taking a long time 2 to 3 weeks or may take up to 8 weeks. Therefore, some other methods such as bone marrow examination play an essential role in rapid identification and early diagnosis, especially in cases of severe disseminated disease. In this case, we report a 55-year-old man with a 1-year history of gout, self-medicating (including Medrol) who was admitted to the hospital because of persistent fever and swelling of his left arm. About laboratory investigation, there was a bicytopenia (RBC and PLT), blood and pus cultures many times were negative. On the slide of the bone marrow specimen, images of yeast suspected of Histoplasma capsulatum were observed. Therefore, the patient was treated with antifungal medication, and the culture was repeated with prolonged follow-up time and positive results with H. capsulatum after 16 days. In conclusion, bone marrow test plays a significant role in the diagnosis of some fungal infections, which can contribute to an early diagnosis, especially in cases of culture and serological tests are not available or cannot be performed. Patients who present with fever and bicytopenia or pancytopenia should be performed early bone marrow test, which can support the earlier diagnosis to have appropriate treatment.

Anesthetic management and the role of TEE in the entrapment of a paradoxical embolus by a patent foramen ovale

BackgroundA paradoxical embolism arises when a venous thrombus passes through a cardiac right to left shunt and enters the arterial circulation. This can manifest as cardiovascular ischemia, cerebrovascular insults, increased right ventricular pressure, and/or volume overload leading to signs and symptoms of heart failure. While rare, paradoxical emboli carry high mortality and morbidity if diagnosis is missed and/or treatment is delayed. Transesophageal echocardiography can be diagnostic. Initial treatment revolves around anticoagulation and/or thrombolysis to prevent clot propagation. However, for clots in transit, emergent surgical removal is often necessary. Anesthetic induction can be tricky given the potential for rapid deterioration and the need to avoid increased right sided pressures and further clot migration.Case presentationIn this report, we present a 72-year-old obese female with a history of hypertension, hyperlipidemia, gout, and diabetes found to have a paradoxical embolism caught in transit, trapped in a patent foramen ovale, and managed surgically. We describe the role of intraoperative transesophageal echocardiography in successfully treating this patient.ConclusionsTEE plays an important role in the diagnosis and management of paradoxical PE. It can detect right and left heart thrombi and intracardiac shunts, can help in the successful closure of intracardiac shunts, and can impact intraoperative surgical decision making.

The Risk of BPPV, Meniere's Disease, and Vestibular Neuronitis in Patients with Gout: A Longitudinal Follow-Up Study Using a National Health Screening Cohort.

This study evaluated the impact of pre-existing gout on the occurrence of benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and vestibular neuronitis, with the goal of identifying novel associations of gout with other comorbid diseases. The 2002−2019 Korean National Health Insurance Service Health Screening Cohort data were retrospectively analyzed. 23,827 patients with gout were matched to 95,268 controls without gout for age, sex, income, region of residence, and index date. The occurrence of BPPV, Meniere’s disease, and vestibular neuronitis was evaluated in both groups. The hazard ratios (HRs) of gout for BPPV, Meniere’s disease, and vestibular neuronitis were calculated using a stratified Cox proportional hazard model. Participants with gout demonstrated a 1.13-fold higher risk of BPPV (95% CI, 1.06−1.21, p < 0.001) and a 1.15-fold higher risk of Meniere’s disease (95% CI, 1.15−1.37, p < 0.001) than the matched control group. However, the HR for vestibular neuronitis was not significantly higher in the gout group (adjusted HR = 1.06, 95% CI, 0.93−1.21, p = 0.391). A previous history of gout was related to a higher risk of BPPV and Meniere’s disease. Additional studies are necessary to elucidate the mechanism underlying the relationship between gout and comorbid diseases such as BPPV and Meniere’s disease.

High Prevalence of Prediabetes and Associated Risk Factors in Urban Areas of Pontianak, Indonesia: A Cross-Sectional Study.

Uncontrolled prediabetes can develop into Type 2 Diabetes mellitus (T2DM). The incidence of T2DM among adults in Pontianak, Indonesia was reported remarkably high. Therefore, this study aimed to investigate the risk factors for prediabetes in adults living in urban areas of Pontianak, Indonesia. A cross-sectional study was conducted in 5 subdistricts of Pontianak. A total of 506 adults underwent screening to obtain subjects with fasting blood glucose (FBS) of ≤124 mg/dL and aged >30 years. Blood pressure and body mass index (BMI) were measured. Interview using a structured questionnaire were performed to obtain data on predictor variables (age, sex, education, income, health insurance, tobacco use, history of hypertension, gout, high cholesterol level, frequency of exercise per week, and diabetic education). The prevalence of prediabetes among subjects was significantly high (76.4%). Subjects were predominantly above 40 years, female, had low income, low education level, and had health insurance. About a third of the subjects had a history of hypertension, gout, and high cholesterol level, respectively. The exercise frequency was mostly less than 3 times/week, and the BMI was mainly classified as overweight and obese. The result of spearman's rho correlation showed that age (r = 0.146; p=0.022) and BMI (r = 0.130; p=0.041) significantly correlated with prediabetes incidence. Moreover, the chi-square analysis demonstrated that health insurance ownership (OR = 4.473; 95% CI 1.824-10.972; p ≤ 0.001), history of hypertension (OR = 3.096; 95% CI 1.542-6.218; p=0.001), and history of gout (OR = 2.419; 95% CI 1.148-5.099; p=0.018), were associated with prediabetes incidence. For all these significant risk predictors except BMI, the significant associations were found only among female subjects after specific sex analysis. Moreover, multivariate logistic regression showed that health insurance ownerships (OR = 5.956; 95% CI 2.256-15.661; p ≤ 0.001) and history of hypertension (OR = 3.257; 95% CI 1.451-7.311; p=0.004), and systolic blood pressure (OR = 2.141; 95% CI 1.092-4.196; p=0.027) were the risk factors for prediabetes. It is concluded that the prevalence of prediabetes is probably high especially among urban people in Pontianak, Indonesia. Health insurance ownership and hypertension may have an important role in prediabetes management. The risk factors might be different between male and female.

Gout Prevalence, Practice Patterns, and Associations with Outcomes in North American Dialysis Patients.

Gout occurs frequently in patients with kidney disease and can lead to a significant burden on quality of life. Gout prevalence, and its association with outcomes in hemodialysis (HD) and peritoneal dialysis (PD) populations located in North America, is unknown. We used data from North America cohorts of 70,297 HD patients (DOPPS, 2012-2020) and 5117 PD patients (PDOPPS, 2014-2020). We used three definitions of gout for this analysis: (1) having an active prescription for colchicine or febuxostat; (2) having an active prescription for colchicine, febuxostat, or allopurinol; or (3) having an active prescription for colchicine, febuxostat, or allopurinol, or prior diagnosis of gout. Propensity score matching was used to compare outcomes among patients with versus without gout. Outcomes included erythropoietin resistance index (ERI=erythropoiesis stimulating agent dose per week/(hemoglobin×weight)), all-cause mortality, hospitalization, and patient-reported outcomes (PROs). The gout prevalence was 13% in HD and 21% in PD; it was highest among incident dialysis patients. Description of previous history of gout was rare, and identification of gout defined by colchicine (2%-3%) or febuxostat (1%) prescription was less frequent than by allopurinol (9%-12%). Both HD and PD patients with gout (versus no gout) were older, were more likely male, had higher body mass index, and had higher prevalence of cardiovascular comorbidities. About half of patients with a gout history were prescribed urate-lowering therapy. After propensity score matching, mean ERI was 3%-6% higher for gout versus non-gout patients while there was minimal evidence of association with clinical outcomes or PROs. In a large cohort of PD and HD patients in North America, we found that gout occurs frequently and is likely under-reported. Gout was not associated with adverse clinical or PROs.

Tophaceous Gout in Adults: Case Report and Review of the Literature

Gout is a microcrystalline arthropathy resulting from the deposition of sodium urate microcrystals in the articular and periarticular tissues, and even in the extra-articular tissues. It affects mainly men and its mechanism is at the origin of a delay in diagnosis, and consequently its severe forms can occur. We report a case of tophaceous gout in a 59 year old adult, with no family history of gout. Gout, whose first attack was at the age of 40, was polyarticular and affected the left wrist, elbows, knees, ankles and the left big toe. The diagnosis was based on clinical signs (tophi at the elbows, ankles, hands, and auricles) and paraclinical signs ( hyperuricemia at 620 ʯmol/l With normal at150-360 ʯmol/l in women and 310-420 ʯmol/l in men, presence of sodium urate cristals in the puncture fluid of the right knee, double- contour image on ultrasonography) by the ACR/Eular classification criteria. The background treatment was based on 120mg of Febuxostat per day with a favorable follow-up marked by the regression of signs.

Vocal Cord Gout Nodules: A Case Report and Review of the Literature.

Gout nodules (tophi) are formed by a chronic inflammatory reaction in tissues resulting in deposition of urate crystals. They are commonly seen in joints and surrounding tissues, subcutaneous tissues, as well as the pinna and kidney, and are characteristic manifestations of gout. Vocal cord tophi are rarely reported in the literature, and patients often present with hoarseness, progressive dysphagia, and other symptoms. We report a case of a vocal cord mass found by gastroscopy in a patient with a history of gout for more than 20years. Postoperative pathological findings were vocal cord tophi. Tophi can have serious consequences and should be included in the differential diagnosis of laryngeal masses in patients with a history of gout. Therapy should involve a combination of systemic uric acid-lowering treatment and surgery to improve symptoms and reduce recurrence.

Gout as a risk factor for osteoporosis: A Korean population-based study.

Uric acid acts as both an antioxidant and a pre-oxidant that induces oxidative stress; thus, it plays a paradoxical role in inflammation. However, the effect of gout, a hallmark of hyperuricemia, on osteoporosis remains unclear. Therefore, this study aimed to investigate the association between gout and osteoporosis. This retrospective cohort study used data from the Korean National Health Insurance Service Database. In total, 628,565 participants who were diagnosed with gout and prescribed medications for gout for at least 90 days were selected. The control cohort included patients with no history of gout or use of gout medication. Age and sex 1:1 propensity score matching and Cox proportional hazards models were used to investigate risk factors for osteoporosis. In total, 305,810 patients with gout met the inclusion criteria. Compared with the control group, both men and women with gout showed an increased incidence rate ratio of osteoporosis. In the stratified analysis by age, patients with gout showed an increased incidence rate ratio for osteoporosis in all age groups, except for those over 80 years of age (P < .001). Gout showed an increased hazard ratio of 1.48 (95% CI: 1.45-1.51, P < .001). The female sex has also been identified as a risk factor for osteoporosis. Patients in their 70s had the highest HR. Gout is significantly associated with the risk of osteoporosis. In particular, the results of this study showed that the incidence of osteoporosis increased up to four times in male patients in their 20s with gout compared to without gout.

Abstract 11758: Sex Differences in the Associations Between Uric Acid and Incidence of Hypertension, Diabetes, and Chronic Kidney Disease in a Healthy Japanese Population

Introduction: Uric acid (UA) has been linked to the development of cardiometabolic diseases. However, the effects of UA levels by sex have not been reported. Hypothesis: We hypothesized that UA plays a critical role in the development of hypertension, diabetes, and chronic kidney disease (CKD) in Japanese men and women who are apparently healthy at baseline. Methods: This retrospective cohort study included individuals who participated in a health checkup at the Kagoshima Kouseiren Hospital from October 2008 to April 2019 who had a 5-year follow-up. We excluded participants with hypertension, diabetes, dyslipidemia, obesity, estimated glomerular filtration rate (eGFR) &lt;60 ml/min/1.73m2, history of gout, hyperuricemia medication, and missing data at baseline. Uric acid levels were divided into quartiles as follows: men: 1st quartile UA &lt; 4.8 mg/dL, 2nd quartile 4.9-5.6 mg/dL, 3rd quartile 5.7-6.4 mg/dL, and 4th quartile UA &gt; 6.5 mg/dL; women: 1st quartile UA &lt; 3.4 mg/dL, 2nd quartile 3.5-4.0 mg/dL, 3rd quartile 4.1-4.7 mg/dL, and 4th quartile UA &gt; 4.8 mg/dL. To assess the association between baseline UA levels and the development of hypertension, diabetes, and CKD, we performed a multivariable logistic regression analysis adjusted for age, body mass index, systolic blood pressure, diastolic blood pressure, current smoking, alcohol consumption, exercise habit, serum triglyceride, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, fasting plasma glucose, and eGFR by sex. Results: In total, 21,514 participants (age, 52.9±10.9 years; men, 39.8%), were enrolled. In men, the OR and 95% CI for the fourth to first quartile was associated with increased risk for hypertension (OR, 1.35; 95% CI, 1.13-1.62, P=0.0011), and CKD (OR, 1.42; 95% CI, 1.04-1.95, P=0.0287), and inversely related with diabetes (OR, 0.60; 95% CI, 0.39-0.93, P=0.0221). In women, the OR and 95% CI for the fourth to first quartile showed no association with neither hypertension (OR, 1.14; 95% CI, 0.95-1.36, P=0.1541), diabetes (OR, 0.97; 95% CI, 0.53-1.77, P=0.9271), nor CKD (OR, 1.26; 95% CI, 0.97-1.65, P=0.0828). Conclusion: Elevated serum UA indicates the risk of future hypertension and CKD, and an inverse relation with diabetes in apparently healthy Japanese men.

Clinical Reasoning: A Young Adult Man With Cognitive Changes, Gait Difficulty, and Renal Insufficiency.

A 22-year-old right-handed man with recently diagnosed gout and renal insufficiency presented with 3 months of progressive gait instability and cognitive changes. He initially presented to an outside institution and underwent a broad workup, but an etiology for his symptoms was not found. On subsequent presentation to our institution, his examination revealed multidomain cognitive dysfunction, spasticity, hyperreflexia, and clonus. A broad workup was again pursued and was notable for an MRI of the brain, revealing cortical atrophy advanced for his age, bland CSF, and a weakly positive serum acetylcholine receptor ganglionic neuronal antibody of unclear significance. The history of gout and inadequately explained renal insufficiency led to a workup for inborn errors of metabolism, including urine amino acid analysis, which revealed a homocysteine peak. This finding prompted further evaluation, revealing markedly elevated serum homocysteine and methylmalonic acid and low methionine. He ultimately developed superficial venous thromboses, a segmental pulmonary embolism, and clinical and electrographic seizures. He was initiated on appropriate treatment, and his symptoms markedly improved. The case serves as a reminder to include late-onset inborn errors of metabolism in the differential for young adult patients with onset of neurologic, psychiatric, renal, and thromboembolic symptoms.

LBSAT127 An Underrecognized Entity: Hypercalcemia Induced PRES

Abstract Introduction Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity that can present with headaches, focal neurological deficits, altered mental status, and seizures. Common etiologies are uncontrolled hypertension, preeclampsia/eclampsia, and chemotherapeutic agents. Hereby, we present a patient with status epilepticus secondary to PRES induced by hypercalcemia due to primary hyperparathyroidism. Clinical Case A 59-year-old Caucasian female with history of T2DM, GERD, gout, and bowel resection for an incarcerated abdominal hernia three weeks ago presented to the emergency department due to seizure-like movements. She had no history of seizures. Initial vitals showed HR of 96 bpm, BP of 148/67 mmHg, RR of 20 rpm, Temperature of 97.7F, and a BMI of 31.5 kg/m2. Physical exam revealed the presence of abdominal wound-vac and tonic-clonic movements that failed to improve with lorazepam, midazolam, and levetiracetam; hence she was intubated for airway protection and started on propofol. Lumbar puncture performed in the ED was unremarkable. Laboratory studies were pertinent for acute kidney injury (AKI) with a serum creatinine of 1.78 mg/dL, lactic acid of 6.1 mmol/L, and serum calcium of 14.5 mg/dL (8.7-10.4) with albumin of 4.2 g/dL. AKI and lactic acidosis rapidly improved with IV fluids. CT-head without contrast was negative for any acute pathologies. MRI-brain showed abnormal subcortical FLAIR signals within the bilateral parietal and occipital lobes with corresponding diffusion restriction in bilateral occipital lobes consistent with PRES. Continuous EEG (cEEG) showed ongoing epileptiform activity with an intermittent suppression pattern. Hypercalcemia workup revealed inappropriately normal intact-PTH of 45.9 pg/mL (10. 0-66. 0), PTHrP &amp;lt;2pmol/L, and 25-(OH)-Vitamin-D3 level of 34 ng/mL (30. 0-100. 0). Paraproteinemia work-up was negative. Thyroid ultrasound demonstrated an incidental nodule in the external aspect of the inferior right lobe measuring 6×3×3mm suggestive of parathyroid gland enlargement. Hypercalcemia was successfully treated with aggressive IV fluids and zoledronic acid. Repeat cEEG showed resolution of epileptiform discharges. She was successfully extubated without recurrence of seizures. She was determined to have hypercalcemia induced PRES secondary to primary hyperparathyroidism. Given the significant elevation of calcium and associated neurological symptoms, she met the surgical criteria and was discharged with outpatient parathyroidectomy plan. Conclusion PRES secondary to severe hypercalcemia has been described in the literature, albeit rarely. The exact pathophysiology is unclear but thought to be due to vasospasm based on cerebral angiogram studies. Early recognition of hypercalcemia as a culprit for PRES along with prompt treatment is crucial to treat life-threatening complications of PRES. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Allopurinol versus usual care in UK patients with ischaemic heart disease (ALL-HEART): a multicentre, prospective, randomised, open-label, blinded-endpoint trial

Allopurinol is a urate-lowering therapy used to treat patients with gout. Previous studies have shown that allopurinol has positive effects on several cardiovascular parameters. The ALL-HEART study aimed to determine whether allopurinol therapy improves major cardiovascular outcomes in patients with ischaemic heart disease. ALL-HEART was a multicentre, prospective, randomised, open-label, blinded-endpoint trial done in 18 regional centres in England and Scotland, with patients recruited from 424 primary care practices. Eligible patients were aged 60 years or older, with ischaemic heart disease but no history of gout. Participants were randomly assigned (1:1), using a central web-based randomisation system accessed via a web-based application or an interactive voice response system, to receive oral allopurinol up-titrated to a dose of 600 mg daily (300 mg daily in participants with moderate renal impairment at baseline) or to continue usual care. The primary outcome was the composite cardiovascular endpoint of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death. The hazard ratio (allopurinol vs usual care) in a Cox proportional hazards model was assessed for superiority in a modified intention-to-treat analysis (excluding randomly assigned patients later found to have met one of the exclusion criteria). The safety analysis population included all patients in the modified intention-to-treat usual care group and those who took at least one dose of randomised medication in the allopurinol group. This study is registered with the EU Clinical Trials Register, EudraCT 2013-003559-39, and ISRCTN, ISRCTN32017426. Between Feb 7, 2014, and Oct 2, 2017, 5937 participants were enrolled and then randomly assigned to receive allopurinol or usual care. After exclusion of 216 patients after randomisation, 5721 participants (mean age 72·0 years [SD 6·8], 4321 [75·5%] males, and 5676 [99·2%] white) were included in the modified intention-to-treat population, with 2853 in the allopurinol group and 2868 in the usual care group. Mean follow-up time in the study was 4·8 years (1·5). There was no evidence of a difference between the randomised treatment groups in the rates of the primary endpoint. 314 (11·0%) participants in the allopurinol group (2·47 events per 100 patient-years) and 325 (11·3%) in the usual care group (2·37 events per 100 patient-years) had a primary endpoint (hazard ratio [HR] 1·04 [95% CI 0·89-1·21], p=0·65). 288 (10·1%) participants in the allopurinol group and 303 (10·6%) participants in the usual care group died from any cause (HR 1·02 [95% CI 0·87-1·20], p=0·77). In this large, randomised clinical trial in patients aged 60 years or older with ischaemic heart disease but no history of gout, there was no difference in the primary outcome of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death between participants randomised to allopurinol therapy and those randomised to usual care. UK National Institute for Health and Care Research.

S2789 A Rare Triad of Ulcerative Colitis, Large Vessel Vasculitis and Celiac Disease

Introduction: Inflammatory bowel disease (IBD) has been associated with large-vessel vasculitis (LVV), with the diagnosis of IBD preceding that of LVV by years. We present for the first time in known literature a triad of concurrent ulcerative colitis (UC), aortitis and celiac disease. Case Description/Methods: A 58 year old Hispanic man with a history of hypertension and gout presented with two weeks of intractable temporomandibular headaches, and two months of non-bloody diarrhea and weight loss. Physical exam was unremarkable. Labs showed hemoglobin 6.9 g/dL, erythrocyte sedimentation rate 120 mm/hr, C-reactive protein 281 mg/dL and IgA tissue transglutaminase antibody 23 U/mL. ANA, C3, C4, proteinase-3 and myeloperoxidase antibodies were within normal limits. Colonoscopy showed pancolitis from rectum to ascending colon. The terminal ileum was normal. Abdominal MRI found aortic wall hyperintensity from the renal arteries to common iliac bifurcation. CT angiogram showed wall thickening of the left carotid artery, aortic arch, descending thoracic and abdominal aorta, consistent with vasculitis. Patient was given stress dose steroids with improvement in headache and normalization of ESR and CRP. Temporal artery biopsy was unremarkable. Four months after hospitalization, repeat colonoscopy with duodenal biopsies for celiac disease revealed mild increase in intraepithelial lymphocytes with preserved villous architecture. He was started on a gluten free diet and adalimumab in combination with methotrexate for UC and LVV. Discussion: About 10 case reports of patients with both UC and either Takayasu (TAK) or giant cell arteritis (GCA) have been described, with UC typically diagnosed 15-45 years before the vasculitis. Vasculitis in the GI tract can mimic IBD, making colonoscopy and biopsy crucial for diagnosis. HLA haplotypes A24, B52, and DR2 are associated with both UC and aortitis and Interleukin-9, observed in temporal arteritis lesions, may be implicated in the pathogenesis of UC. Shared chromosomal variants between patients with UC and celiac disease may explain why IBD risk is up to 9-fold higher in patients with celiac disease. Our patient may have presented with isolated aortitis or an early form of GCA. Methotrexate is used to treat LVV and is combined with an anti-TNF agent to treat UC, as in our case. This is the first known report of co-occurring UC, celiac disease and aortitis; however, whether the three inflammatory conditions are mechanistically related warrants further research.

S1978 A Rare Case of Leflunomide-Induced Colitis: Clinical, Endoscopic and Microscopic Findings

Introduction: Leflunomide-induced colitis is a rare entity, which can be difficult to diagnose. We present a case of an elderly woman with rheumatoid arthritis (RA) who complained of subacute diarrhea. Colonoscopy with biopsy was performed and investigation of inflammatory and infectious causes were negative. Cessation of leflunomide resolved diarrhea. A wide range of endoscopic findings and late-onset of symptoms makes this a challenging diagnosis. Our hope is to aid in the recognition of this drug-induced colitis to reduce hospitalization stays and improve treatment. Case Description/Methods: A 79-year-old female with a past medical history of RA, COPD and gout, presented to the hospital with 7 days of watery diarrhea. She reported more than 6 bowel movements daily. She denied recent sick contacts, travel, or changes in diet. Patient did not have a family history of inflammatory bowel disease or colorectal cancer. Vitals were stable. CT abdomen/pelvis demonstrated continuous wall thickening of the splenic flexure to rectum. Labs included CRP at 40.7, ESR at 58, and a positive fecal lactoferrin. Patient was empirically treated for infectious colitis with ceftriaxone and metronidazole. Stool cultures and C. difficile toxin were negative. Colonoscopy showed areas of congested and erythematous mucosa from the rectum to the transverse colon. Biopsies demonstrated increased lymphocytic infiltration of the lamina propria, thickened epithelial layer and crypts with increased intraepithelial lymphocytes. Upon further questioning, the patient reported starting leflunomide 2 months prior. She was asked to trial cessation of leflunomide upon discharge. Upon 2 week follow up, diarrhea had resolved. Discussion: Leflunomide is a disease modifying drug used to treat RA among other types of inflammatory arthritis. In approximately 20% of patients, adverse gastrointestinal side effects of abdominal pain, diarrhea and nausea are well recognized. However, drug-induced colitis has only been described in a few case reports, and even fewer endoscopic descriptions exist. Paucity of this diagnosis may be attributed to its nebulous presentation. Unlike most typical drug reactions, symptom onset can range from 18-24 months. As our case exemplifies, this can lead to unnecessary testing and prolonged hospital stays. Due to this patient's symptom improvement with supportive care, we opted for drug cessation. However, for severe colitis, steroids, cholestyramine wash, and biologics may be considered.

S2135 Submucosal Myxoma: The Unusual and Unwanted Tumor Inside the Colon

Introduction: Myxomas are benign mesenchymal neoplasms of unknown etiology and those involving the gastrointestinal (GI) tract are extremely rare. We are presenting an interesting case of myxomas in the GI tract, specifically of a polypoid colonic mucosal myxoma. Mucosal colonic myxoma represents a newly identified mesenchymal polyp of the colon and pathologists and gastroenterologists should be aware of this diagnostic entity. Case Description/Methods: A 60-year-old female with a past medical history of hypothyroidism, hyperlipidemia, gout, anxiety, CKD, and tubular adenomas, presents to the endoscopy unit after being referred for an EMR resection. During the procedure, a large 1.8 cm subpedunculated polyp in the proximal transverse colon is identified via previously placed tattoo. The polyp undergoes Submucosal injection ‘Orise’ to lift the lesion. After successful lifting, a 27mm stiff snare was used to perform the hot snare resection. A hemoclip was placed to close the defect. The specimen/resected lesion was then removed via roth net. Microscopic examination performed shows a polypoid colonic mucosa with a tubulovillous proliferation lined by adenomatous epithelium. In the submucosa there is a collection of myxoid stroma with interspersed blood vessels, collagen fragments, and rare spindle cells. The spindle cells are positive for CD34 immunostain and negative for smooth muscle actin, S100, and CD117 immunostains. Alcian blue stain highlights the myxoid stroma. Patient was stable and discharged after having a successful procedure (Figure). Discussion: Myxoma is originated from mesenchymal tissue and is characterized by the loose textured slimy tissue ofstellate cells, reticulin fibers, and mucoid substance. It is mainly found in the skin, soft tissue, and heart. Tumors that originate from the submucosa tend to protrude into the intestinal lumen as pedunculated masses. Our patient was found to have a polypoid colonic mucosa with a tubulovillous proliferation lined by adenomatous epithelium. Submucosal colonic myxoma represents a newly identified mesenchymal polyp of the colon and pathologists and gastroenterologists should be aware of this diagnostic entity.Figure 1.: Large 1.8 cm subpedunculated polyp in the proximal transverse colon identified via previously placed tattoo. Submucosal injection of 'Orise'; was performed to lift the lesion .

Lapidus with 1st Metatarsal-Intermediate Cuneiform Fixation Improves Rotational Correction of Hallux Valgus

Category: Bunion Introduction/Purpose: The modified Lapidus procedure offers effective correction of the triplanar deformity of hallux valgus; however, complications such as nonunion and recurrence range up to 15% when using a crossing lag screw fixation technique. An alternative form of fixation using a dorsomedial plate and first metatarsal-intermediate cuneiform (1MT-IC) screw has been proposed. This construct may reduce complication rates, facilitate earlier weightbearing and maintain 3-dimensional correction, especially rotation of the first ray. We investigated single-surgeon Lapidus patient cohorts utilizing cross screws (CS) versus plate and 1MT-IC screw (PS) fixation to compare patient reported outcomes, radiologic parameters on pre- and postoperative weightbearing CT (WBCT) and complications. We hypothesized that patients undergoing PS fixation would experience improved correction of first ray pronation. Methods: This single-center, IRB-approved retrospective study identified all patients who underwent first tarsometatarsal joint arthrodesis for hallux valgus by a single surgeon and divided them by CS or PS fixation. Patients were minimum 18 years old with at least 12 months of follow-up. Revision forefoot surgeries, concomitant flatfoot reconstruction or ankle replacement, and patients with history of rheumatoid arthritis or gout were excluded. PROMIS scores in six key domains were compared between groups both preoperatively and at one year postoperatively. Radiographic assessment of hallux valgus angle (HVA) and intermetatarsal angle (IMA) were performed on pre- and postoperative XR. Pronation of the first ray was measured on WBCT using the validated triplanar angle of pronation. Clinical notes were reviewed for complications and reoperations. The PS group began weightbearing at an average 3.6 weeks versus 6 weeks the PS group. Results: We compared 44 patients who underwent Lapidus with PS and 43 with CS fixation. The age, BMI and gender distribution in the two groups were similar. Both groups had significant improvement in HVA and IMA following Lapidus, (p&lt;0.001), with no difference between groups. Average first ray pronation among PS patients was corrected to 26.0 degrees (from 36.6 degrees preoperatively), which was lower than the final pronation of 30.5 degrees in the CS group, (p&lt;0.001). Both cohorts experienced improvement in PROMIS physical function, pain interference, pain intensity and global physical function. There were no differences in PROMIS score improvements between the cohorts. Weightbearing commenced earlier in the PS group without increased complications. Conclusion: The plate and 1MT-IC screw technique for Lapidus fixation has been described to provide better biomechanical stability and potentially maintain the desired hallux valgus correction by spanning the intermetatarsal joint. Prior studies have reported durable radiographic IMA correction with low nonunion rates. We found similar patient-reported outcomes and rates of complications compared with a group of cross-screw fixation patients. However, there was a significant difference in final pronation of the first ray, 26 vs 31 degrees, observed by weightbearing CT. Earlier weightbearing and improved rotational correction are advantages associated with PS fixation of Lapidus bunionectomy.

Rare Case of Persistently Depressed T Lymphocyte Subsets After SARS-CoV-2 Infection

BACKGROUND On rare occasions, viral infections are known to also depress immune cell lines, further worsening clinical outcomes. We describe a patient who presented 3 weeks after recovery from mild COVID-19 disease with clinical features of an atypical pneumonia and was found to have a low CD4+ T-cell count. CASE REPORT An 82-year-old man with a past medical history of coronary artery disease, rheumatoid arthritis, gout, hypertension, and atrial fibrillation presented with a 1-week history of progressively worsening shortness of breath and cough. He was noted to have recovered from mild SARS-CoV-2 infection 3 weeks prior to his current presentation and had been at his baseline level of health following infection. A T cell subset panel was obtained, which revealed an absolute CD3 count of 92 (reference range 840-3060), absolute CD4 count of 52 (reference range 500-1400), absolute CD8 count of 37 (reference range 180-1170), and a normal CD4: CD8 ratio. He was subsequently started on atovaquone for pneumocystis jiroveci pneumonia prophylaxis. CONCLUSIONS This case highlights the need for a high index of suspicion for lymphocyte depletion in older patients with multiple comorbidities who present during or after SARS-CoV-2 infection with atypical symptoms that are suggestive of immunosuppression. In such instances, there should be a low threshold to start prophylactic therapy for possible opportunistic infections.

Evaluating the association between food insecurity and risk of nephrolithiasis: an analysis of the National Health and Nutrition Examination Survey.

This study aimed to investigate the relationship between self-reported food security and kidney stone formation. Data were collected from the National Health and Nutrition Examination Survey (NHANES), a database representative of the United States population. Food security status was assessed using the US Household Food Security Survey Module: Six-Item Short Form. Characteristics of patients were compared using the Chi-square test and the student t-test. Multivariate logistic regression was performed using a multi-model approach. We analyzed 6,800 NHANES survey respondents. 37.2% of respondents were categorized as having "low food security" (scores 2-4) and 24.0% having "very low food security" (scores 5-6). 8.4% of respondents had a history of kidney stones. We found that people with very low food security had a 42% increased likelihood of developing kidney stones compared to those with high or marginal food security, after controlling for race, age, and comorbidities (OR 1.42; 95% CI 1.01-1.99). Between the different food security groups, no significant differences were observed in age, race/ethnicity, body mass index, gout history, osteoporosis history, or coronary artery disease history. Lower food security was associated with slightly younger age (< 1year difference, p = 0.001), higher poverty-income ratio (p = 0.001), and many comorbidities, including kidney stones (p = 0.007). Our study provides evidence for an association between food access and the risk of kidney stone disease. Given these findings, food insecurity should be investigated as a modifiable risk factor for the development of kidney stone disease.

Computed tomography and magnetic resonance imaging findings in gouty arthritis involving large joints of the upper extremities

BackgroundWe aimed to analyze the computed tomography (CT) and magnetic resonance imaging (MRI) findings of gouty arthritis primarily involving the large joints of the upper limbs, signal or density characteristics of the tophi, growth patterns, involvement of the adjacent joints, and differentiation from other lesions occurring in this area and to discuss the causes of misdiagnosis.MethodsCT and MRI data were collected from 14 patients with gouty arthritis, primarily involving the shoulder and elbow joints, and their imaging features were analyzed.ResultsAll the patiens were ranged from 28-85 years old, and the tophi deposition can be observed on either CT or MRI.The tophi deposition apperas as slightly higher density nodules or masses on CT images,or nodules or masses on MRI with isosignal/hypointensity on T1WI and hyperintensity on T2WI. Five patients showed narrowing of the affected joint space, four had different degrees of bone erosion under the articular surface, eight developed joint effusion, and all showed surrounding soft tissue swelling. The tophi grew around the joint, with anterolateral and posterolateral tophi predominantly in the shoulder joint and dorsal tophi predominantly in the elbow joint on the MRI, with compression and edema of the surrounding soft tissues.ConclusionsGouty arthritis occurs in the large joints of the upper limbs and is characterized by fluid accumulation in the joint capsule and the formation of tophi. These tophi are usually large, with subcutaneous bone resorption and erosion, with or without cartilage destruction. However, extensive edema appeared in the soft tissue around the tophi, but the edema only produced pressure without any obvious signs of soft tissue infiltration, which may be distinguished from the joint tumor. In addition, the gout incidence rate is increased in young patients. Therefore, when the patient has a large joint mass, it is important to confirm whether there is a history of gout.

Cardiovascular risk management in gout patients: do patients benefit from screening in secondary care?

To estimate the 10-year cardiovascular disease (CVD) risk in gout patients in secondary care and to evaluate the effect of CVD risk screening on the 10-year CVD risk after 1 year. A prospective cohort study was performed in patients with gout from Reade Amsterdam. Data on gout and CVD history, traditional risk factors, medication, and lifestyle were collected at baseline and 1 year. The 10-year CVD risk was calculated with the use of the NL-SCORE. A paired sample t-test and McNemar test was performed to test for differences between baseline and the 1-year visit. A very high prevalence of traditional CV risk factors was seen in our secondary care gout patients. Nineteen percent without previous CVD were categorised in the high-risk group according the NL-SCORE. The prevalence of CVD increased from 16% to 21% after 1-year follow-up. A decrease was seen in total- and LDL-cholesterol after 1 year. No decrease in mean BMI, waist-hip ratio, blood pressure or NL-SCORE was observed. The current need for CVD risk screening of gout patients in secondary care was illustrated by the high prevalence of traditional risk factors in this cohort. Recommendations to patients and the general practitioner (GP) alone did not result in overall improvement of traditional CVD risk factors nor the 10-year CVD risk. Our results indicate that a more prominent role of the rheumatologist is necessary to optimise the process of initiation and management of CVD risk in gout patients.