Normal ESR Research Articles

Scavenger receptor-A is a sensitive disease activity biomarker in ESR and CRP normal rheumatoid arthritis.

Identification of rheumatoid arthritis (RA) patients in active disease with normal ESR and CRP is a challenge in disease activity assessment. The objective of this study was to evaluate the performance and clinical significance of Scavenger receptor-A (SRA) as a disease activity biomarker in RA, especially in ESR and CRP normal patients. One hundred and sixty-two RA (40 discovery cohort; 122 validation cohort), 20 osteoarthritis (OA), and 36 healthy controls (HCs) were recruited. Ten disease activity markers were evaluated by Bio-Plex Pro Human Cytokine Assay in the discovery cohort. SRA levels were measured by enzyme-linked immunosorbent assay (ELISA) in the validation cohort. The association between SRA and clinical phenotypes was also analyzed. ROC analysis was performed for disease activity prediction. SRA was found to be correlated with disease activity in the discovery cohort. The serum SRA level was verified by ELISA in the validation cohort, and was found to be correlated with disease activity index in RA patients, including DAS28-ESR (r = .477, p < .001), swollen joint counts, and tender joint counts; as well as inflammation markers, including ESR and CRP. In ESR and CRP normal RA, there was a strong correlation between SRA and DAS28-ESR ( = 4.564, p = .003). In addition, area under the ROC of SRA was higher than AUCESR and AUCCRP in ESR and CRP normal RA patients, suggesting that serum SRA could be more sensitive than ESR and CRP for disease activity assessment in this group of patients. In the low DAS28-ESR (≤3.2) group, the AUC of SRA for disease activity measurement was higher than that of ESR and CRP, indicating that SRA was also more sensitive than ESR and CRP in low-disease activity RA. SRA was correlated with RA disease activity and may be a sensitive serum biomarker for disease activity evaluation, especially in ESR and CRP normal patients, as well as in the low-disease activity group. SRA could be a promising marker for disease activity assessment.

Impact of Comorbid Pathology and Severity of Clinical Course on Anti-infective Protection in Patients with COVID-19

Objective — to establish and evaluate the impact of comorbid pathology and the severity of the clinical course on the activity of anti-infective protection in patients with coronavirus disease 2019 (COVID-19), based on the analysis of the absolute and relative counts of major immune cell populations in peripheral blood. Materials and methods. A cross-sectional prospective study was conducted involving 204 patients with COVID-19-associated pneumonia of mild, moderate and severe stages. The cohort included 106 (51.97 %) women and 98 (48.03 %) men, with an average age of (55.93 ± 8.75) years. Anti-infective ­protection was studied using comprehensive clinical blood analysis, including the count of major immune-competent cells. Patients were categorised into groups based on comorbi­dity, taking into account the predominant concurrent pathology at the time of examination (endocrine, cardiovascular or other). Results and discussion. More severe COVID-19 cases were characterised by leukopenia, relative and absolute granulocytopenia, neutropenia, a slight hyporegenerative nuclear shift to the right and a reduction in the number of segmented neutrophils by 24.63—34.72 % (p ≤ 0.047—0.009) and eosinophilic granulocytes by 52.94—70.59 % (p ≤ 0.004—0.001). This was accompanied by relative and absolute agranulocytosis due to lymphocytosis (by 20.10—63.33 %; p ≤ 0.05—0.003) and monocytosis (by 40.0—74.12 %; p ≤ 0.046—0.049), indicating an active inflammatory infectious process of viral etiology against a background of decreased resistance and increased activity of the lymphocyte-macrophage link with the beginning of the formation of specific immune protection (cellular and humoral response to coronavirus intervention). Mild cases of COVID-19 showed a higher absolute count of peripheral blood granulocytes (by 48.25 %; p = 0.018), neutrophils, particularly segmented neutrophils and eosinophilic granulocytes, compared to moderate and severe cases (by 32.36—53.18 % (p ≤ 0.049—0.01) and 3.4 times (p ≤ 0.005—0.002)) and the lowest content of monocytes (by 35.41—42.57 %; p ≤ 0.049—0.046). In cases with concurrent endocrine and cardiological pathologies against a background of a more severe clinical course of COVID-19, immunoinflammatory changes intensified due to absolute and relative leukopenia, neutrophilic granulocytopenia, neutropenia, with the presence of relative lymphocytosis and monocytosis, and normal ESR indicators, confirming the inflammatory process of viral etiology, which, in the absence of treatment, may tend to form post-COVID and/or long-term effects of COVID-19 with multisystem involvement. Conclusions. The study found an enhancement of the immunoinflammatory response and an increase in the depletion of cellular factors of non-specific anti-infective protection with the progression of the clinical manifestations of COVID-19, particularly against the backdrop of comorbid endocrine and/or cardiological pathology.

Predictive factors of methotrexate monotherapy success in patients with rheumatoid arthritis in a national referral center: a cohort study

BackgroundMethotrexate (MTX) remains the recommended first-line treatment for rheumatoid arthritis (RA); however, its response varies and is influenced by various factors. This study aimed to identify predictors of MTX monotherapy treatment success in an Indonesian cohort.MethodsThis retrospective cohort study included newly diagnosed RA patients receiving MTX monotherapy. Treatment success was defined as achieving remission or low disease activity according to Disease Activity Score-28 with erythrocyte sedimentation rate (DAS28-ESR) after 12 months of MTX therapy. The association between demographic, clinical, and laboratory factors and achieving therapy targets was evaluated using multivariate logistic regression analysis.ResultsAmong 254 subjects, 59.4% achieved treatment success with MTX monotherapy, with remission attained in 33% and low disease activity in 26.4%. Most subjects were female (95.7%) with a mean age of 48 ± 11 years. Multivariate analysis revealed that lower disease activity (OR 1.97; 95% CI [1.04–3.72]), normal ESR (OR 2.58; 95% CI [1.05–6.34]), normoweight (OR 2.55, 95% CI [1.45–4.49]), and tender joint count ≤ 5 (OR 2.45, 95% CI [1.31–4.58]) were significant predictors of treatment success.ConclusionThe rate of MTX monotherapy success in our study was 59.4%. Lower disease activity, normal ESR, normoweight, and fewer tender joints at baseline were significant predictors of treatment success.

Predictive Factors for Total Knee Arthroplasty: An Observational Study.

Introduction Knee osteoarthritis (KOA) is the most common form of osteoarthritis. It is diagnosed based on clinical symptoms, physical examination, and imaging, most frequently by knee X-ray in at least two views. In front of a patient with early KOA, all the predictive factors and risk factors that can be modified, but also that can lead to a rapid evolution of the symptoms and the need for total knee arthroplasty (TKA), must be taken into account and identified. There were a series of prognostic factors associated with KOA, such as age, sex, BMI, degree of physical activity, decrease in bone mineral density, C-reactive protein, malalignment, clinical severity at baseline, and previous traumas. The treatment of KOA is varied and involves pharmacological and non-pharmacological measures and surgical treatment in the final stages of evolution. Materials and methods In the University Emergency Hospital of Bucharest, Bucharest, Romania, patients with KOA presented to the Department of Orthopedics and Traumatology, and those who required surgical treatment, such as TKA, arthroscopy, or non-surgical treatment, were enrolled. We conducted a descriptive and prospective observational study that included 70 patients clinically and imaging diagnosed with KOA. The inclusion criteria consisted of a patient over 45 years old with knee pain and radiological signs of KOA. The exclusion criteria referred to patients with recent traumatic history, signs of active osteoarticular infection, the lack of radiological changes of KOA that imposed the differential diagnosis, patients known to have rheumatological diseases in the Algic phase, and patients in whom it was not possible to collect complete required data. Results Patients who required TKA were older (65.12 ± 8.19 years) than patients who required other therapeutic interventions (52.55 ± 3.63 years), the difference of 12.57 years being statistically significant (t = -8.882, p ≤ 0.001). Women were more than three times more likely to require TKA than men (80.85% vs. 52.17%, OR = 3.87, CI [1.29, 11.56]). Patients with HBP were more than four times more likely to require TKA than patients without HBP (78.57% vs. 42.86%, OR = 4.88, CI [1.42, 16.82]). Patients with elevated ESR were more than 26 times more likely to require TKA than patients with normal ESR (96.67% vs. 52.50%, OR = 26.23, CI [3.25, 211.67]). There are statistically significant differences between the non-TKA group (mean rank = 60.20) and TKA patients' score (mean rank = 25.62) (U = 6.000, Z = -6.606, p ≤ 0.001). Thus, patients who required TKA had a significantly lower KSS score than patients who required other treatments. Conclusion According to the data obtained in the studied group of patients, the characteristics of the patient at high risk of requiring TKA are the following: a female patient over 65 years of age who associates hypertension, high ESR, and fibrinogen values ​​with KSS score and KSS function with low values, recording an average value of 56.70.

Vasculopathy Leading to Stroke in Adult Onset Still’s Disorder

Abstract Background Rheumatological disorders may predispose patients to hypercoagulability and/or vasculopathy increasing stroke risk. Adult-Onset Still’s Disease (AOSD) is not usually associated with either, with only two reported cases in the literature to have had strokes. We present a case of AOSD with acute stroke manifesting as lateral medullary syndrome. We hypothesize that vasculopathy and thrombocytosis may have contributed to stroke occurrence. We further explore the possible underlying pathomechanism in this patient population. Case Presentation A 35-year-old woman with AOSD on methotrexate, tocilizumab and daily prednisone presented with vertigo and numbness involving her right face and left arm. She was found to have an ischemic stroke in the lateral medulla with vertebral artery thrombotic changes. No recent trauma. Investigation of other underlying stroke etiologies was unyielding with negative lupus anticoagulants, ANCAs and normal ESR and CRP. Discussion &amp; Conclusion Our case marks the third report of stroke occurrence in AOSD in the literature. While our patient had no elevated inflammatory markers, she still developed stroke due to ongoing endothelial inflammation and thrombotic changes in the vertebral artery. The presence of vascular involvement leading to stroke may provide initial insight into the nature of this event. Further research should thus be done to investigate the exact mechanism of stroke and vasculopathy in AOSD patients.

Elevated serum 25-hydroxyvitamin D: a potential indicator of remission in Takayasu arteritis patients with normal ESR and CRP levels.

The goal of the present study was to investigate the correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and disease remission in Takayasu arteritis (TAK) patients. This retrospective study included 59 patients in the study group and 80 patients in the validation cohort with TAK. After 6months of therapy, patients were re-evaluated, and serum 25(OH)D levels were compared before and after treatment. Correlations between changes in 25(OH)D levels and changes in disease activity scores (NIH, ITAS2010, ITAS.A) were analyzed. Additionally, a predictive cut-off value for disease remission was determined. After 6months of therapy, serum 25(OH)D levels in TAK patients significantly increased compared to baseline [(18.33 ± 7.25)µg/L vs (11.77 ± 4.14) µg/L] (P < 0.001). Positive correlations were observed between the increasing changes in the 25(OH)D level and the decreasing changes in the reduced NIH, ITAS2010, and ITAS.A scores (r = 0.455, P < 0.001; r = 0.495, P < 0.001; and r = 0.352 P = 0.006, respectively). A change of 8.45µg/L in 25(OH)D level was identified as the predictive cut-off value for TAK remission (sensitivity 54.1%, specificity 90.9%, area under the curve = 0.741). Similarly for patients with normal baseline ESR, sensitivity is 68.0%, specificity is 92.3%, and area under the curve is 0.831, and for patients with normal baseline CRP, sensitivity is 58.3%, specificity is 90.0%, and area under the curve is 0.748. Validation in an additional 80 patients demonstrated a higher remission rate in those with a 25(OH)D level change > 8.45µg/L. Serum 25(OH)D levels significantly increased after treatment in TAK patients, and an increase of ≥ 8.45µg/L was predictive of disease remission, especially in individuals with normal baseline ESR and/or CRP levels. Key Points • Following treatment, there was a significant increase in serum 25(OH)D levels among TAK patients. • The elevated changes in 25(OH)D levels before and after treatment demonstrated a positive correlation with the reduction in disease activity scores. • In patients with TAK before and after treatment, an elevation in serum 25(OH)D levels exceeding 8.45µg/L serves as an indicator for disease remission, particularly prominent in individuals with normal baseline ESR and/or CRP levels.

A peculiar case of idiopathic orbital myositis in adolescence

Abstract&#x0D; Introduction : Idiopathic orbital myositis, an inflammation localized at the extraocular muscles, is rarely reported in pediatrics. Until now, the prevalence and incidence of orbital myositis remain unknown. This paper aims to report a case of idiopathic orbital myositis in a young girl with headache.&#x0D; Case Illustration : A-16-year-old presented with a droopy eyelid of the left eye (LE) and double vision since 1 week before admission. She also experienced swollen eyelid and cluster headache for 5 months with no neurological abnormalities. Ophthalmic examinations showed exotropia with limited eye movement of LE. Ptosis of LE was noted with margin reflex distance 1 (MRD-1) +2 mm, while MRD-1 +6 mm for the right eye. Other examinations were unremarkable with normal funduscopy and negative RAPD. Non-contrast orbital sinus CT-Scan revealed an enlargement of the superior rectus and lateral rectus muscle. The laboratory result showed slight leucocytosis and normal ESR. High-dose intravenous corticosteroid was administered and tapered with oral steroid. The orbital clinical findings showed improvements, better ocular movements, and diminished headache complaints.&#x0D; Discussion : As a rare case, the diagnosis of orbital myositis in adolescence can be challenging and requires detailed examination, and proper imaging to exclude other diagnosis such as ophthalmoplegic migraine, infections, malignancies, or congenital lesions (hemangioma). The first-line therapy is a systemic corticosteroid, which well responded in this patient.&#x0D; Conclusion : In this patient, intravenous corticosteroid represent an effective treatment. Close monitoring of the disease progression is required after switching to oral therapy to prevent relapse.

FRI634 Diagnostic Delay Of Diabetic Amyotrophy Is Associated With Complicated Disease Leading To Mental, Physical, And Financial Debilitation- A Case Report

Abstract Disclosure: A.J. Zaidi: None. W. Staehle: None. Introduction: Delay in diagnosis is a major problem impacting medicine, especially if pathology is not very common, like Diabetic amyotrophy. It typically presents with unilateral proximal muscle weakness and pain affecting thighs, hips and buttocks. It is relatively a rare neurological complication of Diabetes Mellitus and prediabetes, affecting approximately 1 percent of the patients. It is commonly underrecognized leading to long course to diagnosis. Case presentation: A 58 year old female presented to clinic with 5 year history of Lower back and left hip pain, slowly progressive leg weakness, with weight loss 25 pounds. Her past medical history included Type 2 diabetes mellitus with A1C 6.9, controlled by Metformin alone. She had multiple previous presentations to local primary care physicians, with unclear clinical diagnosis. She underwent several tests and imaging, was seen by neurologist, orthopedist and spine physician. Her treatments included pain regimens with N-acetylcysteine, Ibuprofen, gabapentin, tizanidine, lidocaine patch, low dose steroids, physical therapy and chiropractor visits. These provided only partial symptomatic relief. She had no other significant history, She lost her job due to being limited by her pain. Exam revealed discomfort to palpation on lower lumbar, generalized atrophy of left thigh muscles, asymmetric proximal weakness, normal sensation and reflexes. Blood work showed normal ESR, CRP, CPK, ANA, myomarker panel, Vit D levels. CSF evaluation was deferred by the patient. Imaging from previous records included Hip X-ray with mild degenerative disease, Lumbar CT with mild arthropathy on the Left L5- S1. Unremarkable lumbar and Sacral MRI. EMG revealed L4 radiculopathy with denervation of L vastus medialis and tibialis anterior, Irritation in S1 nerve root, without denervation. Based on overall investigations, and lack of evidence of alternative diagnosis, it was determined that the patient had Diabetic Amyotrophy. She refused IVIG, treated with prednisone 5mg PO oral for a month, Duloxetine and gabapentin, with significant improvement in pain and weakness. Patient was also connected with appropriate social services, physical and occupational therapy. Conclusion: Diagnostic delay of diabetic amyotrophy can lead to mental, physical, and financial debilitation. Due to low prevalence and broad differential of proximal muscle wasting, it is a challenging to diagnose and remains the diagnosis of exclusion. EMG studies with polyradiculopathy in proximal leg musculature is suggestive. Physicians should have a high clinical suspicion for diabetic amyotrophy to prevent long clinical course leading to harm to the patient. The emphasis is on creating awareness of the disease, and improving communication among clinicians and with patients, which are relatively minor investments to prevent delayed diagnosis of underrecognized complication. Presentation: Friday, June 16, 2023

Clinical characteristics and laboratory parameters in differentiating dengue from other acute febrile illnesses

BackgroundDengue infection is one of the most common viral infections globally, with a broad spectrum of clinical manifestations, including hemorrhage and shock. Early diagnostic confirmation of dengue infection is essential, but some areas may not have the appropriate diagnostic tools while its clinical symptoms are similar to other diseases. We aim to determine some significant clinical characteristics and laboratory parameters in differentiating dengue from other causes of febrile.ResultsThis study included 527 dengue patients and 268 control patients. Multivariate analysis showed older age (OR = 12.11; 95% 5.42–26.63, p < 0.001), the absence of diarrhea (OR = 0.12; 95% CI 0.06–0.25, p < 0.001), leukopenia (OR = 13.35; 95% CI 4.99–38.71, p < 0.001), thrombocytopenia (OR = 7.12; 95% CI 2.37–21.38, p < 0.001), and normal ESR (OR = 3.03; 95% CI 1.54–5.96, p = 0.001) are significant parameters in differentiating dengue with excellence (AUC value of 0.96) and good fit of the model (p value = 0.8). The cut-off is two significant variables with a sensitivity of 91.4% and specificity of 87.5%.ConclusionsTwo or more clinical signs can help clinicians differentiate dengue from other acute febrile illnesses.

Abstract 14459: Case Report: Unusual Presentation of Cardiobacterium Hominis Bioprosthetic Valve Endocarditis

Introduction: Cardiobacterium hominis , part of the oropharyngeal flora, is a gram-negative bacteria reported to cause infection in less than 5% of patients with infective endocarditis (IE). In children, congenital heart disease (CHD) is a predominant risk factor for developing IE. Herein we describe an unusual presentation of C. hominis bioprosthetic valve endocarditis. Case Presentation: A 23-year-old woman with bicuspid aortic valve and aortic valve stenosis underwent aortic bioprosthetic valve placement in 2017. In March 2022, she presented to an emergency room with left lower abdominal pain. A CT scan demonstrated occlusion of the left iliac artery. Medications at that time included oral contraceptive pills and baby aspirin. No echocardiogram was obtained at that visit. She presented for a routine cardiology follow-up in May 2022 at which time she was asymptomatic. Transthoracic echocardiogram demonstrated moderate to severe aortic insufficiency, though the mechanism could not be delineated. There was concomitant development of mild mitral valve and tricuspid valve insufficiency. She denied dyspnea, chest pain, or fevers. Laboratory investigation showed mild elevation of CRP and a normal ESR. A transesophageal echocardiogram demonstrated that the severe aortic regurgitation was through a paravalvar leak (figure 1). There was no evidence of vegetations. Three separate blood cultures grew C. hominis . The patient was admitted for IV antibiotic therapy prior to bioprosthetic replacement. Conclusions: C. hominis is an infrequent cause of endocarditis and most cases present with fever and elevated ESR. This patient had an unusual presentation with left iliac thrombus, which in retrospect was likely due to embolism of a vegetation. She also developed aortic bioprosthetic paravalvar leak. This case highlights the need for a high degree of suspicion for endocarditis in patients with CHD and bioprosthetic valves.

ODP515 Severe thyrotoxicosis caused by subacute thyroiditis

Abstract Background Subacute thyroiditis, also named giant cell thyroiditis, painful thyroiditis, and de Quervain's thyroiditis, usually presents with neck pain or discomfort, a tender diffuse goiter and mild or moderate elevation of serum free T4 and T3 levels. Here we report a case of subacute thyroiditis patient presenting with severe thyrotoxicosis. Clinical case: A 27-year-old woman with no significant past medical history presents to the emergency room with palpitations and abnormal EKG with heart rate at 160 beats per minute. She developed a sore throat 3 days prior to the presentation, but she did not have neck pain or fever. She reports a 3-month history of hair loss, headaches and weight gain. Labs showed significantly elevated free T4 greater than 7.7 ng/dl (0.8-1.7) and free T3 level at 20.7 pg/ml (2. 0-4.8), and suppressed TSH less than 0. 01 uIU/ml (0.45-4.5) and normal ESR at 15 mm/hour. Her TPO antibody was greater than 1300 u/ml. Thyroid stimulating immunoglobulin (TSI) and TSH receptor antibody (TRab) were obtained but results were pending when she was discharged from the hospital. She has no typical clinical features of subacute thyroiditis with normal ESR and her free T3 and free T4 levels were significantly elevated. She was discharged on Methimazole and Propranolol and to do neck ultrasound as outpatient and follow-up TSI and TRab results and repeat free T4 and T3 in 1 week. Her neck ultrasound revealed mild hypervascularity but no Graves’ features. Her TSI and TRab were negative and free T4 level had no improvement even on significant dose of Methimazole. All the findings argue against Graves’ disease, but support subacute thyroiditis. Then Methimazole was discontinued and Prednisone was started at 20 mg daily and quickly taper to 5 mg daily in 2 weeks then stopped. After on Prednisone for 3 weeks, her free T4 was close to normal at 2. 0 ng/dl, T3 normal at 120 ng/dl, although TSH is suppressed. After stopped Prednisone for 2 weeks, her free T4, T3 and TSH were all back to normal. She is currently euthyroid without any medication at 5 months after her initial presentation. Conclusion Treatment of patients with subacute thyroiditis is pain relief with NSAID or Prednisone when NSAID is not effective. Anti-thyroid medications are rarely effective even in subacute thyroiditis patient with thyroid storm. Our case illustrated the role of corticosteroids in the treatment of subacute thyroiditis patient with severe thyrotoxicosis. Neck ultrasound and thyroid antibodies including TSI and TRab are critical to make a correct diagnosis in subacute thyroiditis patient with severe thyrotoxicosis. Presentation: No date and time listed

PSAT360 Thyrotoxicosis as a Delayed Response to Amiodarone

Abstract Introduction Amiodarone is often used in the treatment of cardiac dysrhythmia, but has been associated with toxicity of multiple organ systems including the thyroid. Patients treated with amiodarone can develop hypothyroidism or hyperthyroidism, also known as amiodarone induced thyrotoxicosis (AIT). AIT is further categorized into type I or type II depending on pathogenesis of the disease: type I resulting from increased hormone synthesis and type II resulting from glandular destruction. We report a case of a 68-year-old male patient who developed type II AIT approximately four years after cessation of Amiodarone therapy. Case Presentation A 64-year-old man initially presented to an outpatient endocrinology clinic for evaluation of incidental thyroid nodules. He had a normal thyroid function. His significant past medical history included atrial fibrillation/atrial flutter status post ablation. Thyroid ultrasound revealed bilateral subcentimeter nodules which remained stable over the subsequent two years. Approximately four years after establishing care, he presented to the endocrinologist again with weakness, decreased appetite, fatigue, and weight loss. Thyroid function testing revealed new onset hyperthyroidism with suppressed TSH, &amp;lt;0.01 mU/L (normal 0.5-5.0 mU/L), elevated FT4 4.5 ng/dL (normal 0.7-1.9 ng/dL) and elevated FT3, 7.4 pg/mL (normal 2.3-4.1 pg/mL). He had normal TSI, normal ESR, and no history of recent viral infection. Thyroid ultrasound showed stable subcentimetric nodules. Evaluation with radioactive iodine uptake (RAIU) scan was not possible due to recent contrast exposure during CT spine imaging. The patient was started on methimazole therapy with an assumptive diagnosis of toxic multinodular goiter. The dose was rapidly increased, within weeks, to 60mg daily, due to persistent severe hyperthyroidism. He was hospitalized twice for exacerbation of atrial fibrillation with rapid ventricular rate requiring cardioversion and augmentation of medical therapy. Further investigation revealed the patient had received amiodarone therapy for approximately three months, almost four years prior to his current presentation. A trial of 40mg prednisone daily was started in conjunction with methimazole for possible delayed type II AIT, resulting in a rapid improvement of symptoms and Free T4 levels. Once the patient's urinary iodine levels returned to normal, he underwent RAIU scan which revealed low uptake supporting the diagnosis of type II AIT. Methimazole therapy was stopped, and prednisone therapy was tapered down slowly and then discontinued over the course of three months, with complete resolution of hyperthyroidism. Conclusion This report reiterates the difficulties clinicians are often faced with when diagnosing and treating AIT, which, in our case, occurred four years after the discontinuation of amiodarone therapy. It highlights the importance of obtaining a history of remote amiodarone therapy, and considering steroids treatment for type II AIT, especially in patients with no clear other etiology and no response to high dose methimazole. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

POST COVID RECURRENT FEVER IN A CHILD WITH GENETIC SUSCEPTIBILITY TO FAMILIAL MEDITERRANEAN FEVER

<h3>Introduction</h3> Children and adults with post-acute sequelae of COVID (PASC) sometimes report recurrent fevers. We present the case of 13-year-old male with PASC recurrent fever who was found to have a heterozygous mutation in the gene associated with Familial Mediterranean fever (FMF). <h3>Case Description</h3> Our patient presented with recurrent fever 6 months after acute SARs-CoV-2 infection in January 2022. He endorsed prior episodes of unexplained fever and flushing prior but his recurrent fevers (39 C) post COVID had become more frequent occurring every few days. Laboratory analysis when he was afebrile demonstrated normal serum ESR, CRP, and CMP and normal cytokine levels. Genetic (In-Vitae) panel testing for autoinflammatory syndromes revealed a pathogenic heterozygous missense mutation in MEFV (p.A744S), the gene that controls pyrin production. A trial of colchicine was recommended, and he was referred to pediatric rheumatology. <h3>Discussion</h3> FMF is a genetic disorder that causes recurrent episodes of fever and almost always presents before age 20. Clinically significant FMF gene mutations lead to poorly functional pyrin; a protein that controls inflammation. Most children look and feel well between episodes but some children have such frequent episodes that they do not fully recover. In such cases, daily use of Colchicine should be considered as a safe and effective medication to control fever episodes. This report highlights the utility of genetic testing to identify potential causes of recurrent fever after COVID. Children with PASC related recurrent fevers should have genetic testing for susceptibility to FEF as this is a potentially treatable condition.

An Unusual Case Of A Calcaneal Stress Fracture

HISTORY: A 56-year-old healthy female presented to clinic with several weeks of left heel pain. No inciting injury, patient is generally active but had not done any recent strenuous activity, however after the onset of the pain any slight bump of the heel produced severe pain. She also had mild swelling around the distal ankle, without any warmth or erythema. The pain gradually worsened to the point the patient started using crutches due to the pain she experienced with weight-bearing. She denied any radiation of the pain as well as any numbness, tingling, or weakness of the foot. PHYSICAL EXAMINATION: Examination revealed mild swelling over the lateral calcaneus, without erythema or induration. Patient had severe tenderness to palpation of the lateral aspect of the calcaneal tuberosity. No tenderness was noted over either malleolus or the Achilles tendon. Range of motion revealed normal inversion, eversion, and plantar flexion but dorsiflexion limited to 10 degrees due to pain. Sensation was intact and strength testing was normal. Talar tilt testing and squeeze test of the calcaneus were negative. DIFFERENTIAL DIAGNOSIS:1. Septic arthritis2. Calcaneal fracture3. GoutTEST AND RESULTS:Labs:-Normal WBC, ESR, CRP, RF, ANA, uric acid, and Lyme and anaplasma titersImaging:-Left ankle radiographs: no acute osseous abnormality-Left ankle MRI without contrast:1.Nondisplaced fracture along the posterior dorsal surface of the calcaneus2.Trace ankle joint effusion3. Mild tibialis posterior tenosynovitis FINAL DIAGNOSIS:Nondisplaced stress fracture of posterior calcaneus TREATMENT AND OUTCOMES:1. Patient was referred to Infectious Disease (ruled out infectious origin including tick-borne infection) and Orthopedics.2. Initial treatment consisted of limited weight-bearing with walking boot, however pain worsened in the boot and she developed numbness of her foot with symptoms suggestive of tarsal tunnel syndrome.3. Patient transitioned to non-weight bearing status without boot, and after approximately two months of slow improvement progressed to limited weight-bearing and physical therapy.5. Due to prolonged recovery, patient still undergoing work-up for less common risk factors for stress fractures and bone infections, including Celiac disease, Bartonella, and Rickettsia testing.

C3 A RARE AND ATYPICAL CASE OF ICD POCKET HEMATOMA CONTAINING PSEUDOCHYLOUS

Abstract Subcutaneous hematoma is a complication in 2–9% of cardiac device implants.In most cases, it is drained or spontaneously reabsorbed; if untreated, there is a risk of infection.While cases of chylothorax and pseudochylothorax are rare, no previous cases of accumulation of chyliform material in the subcutaneous pockets of cardiac devices have ever been documented.We present the case of a 60–year–old man with antibody syndrome antiphospholipids, rheumatoid arthritis, previous acute anterior myocardial infarction and aorto–coronary by–pass surgery, paroxysmal atrial fibrillation, in oral anticoagulant therapy. In 2020, the patient underwent primary prophylactic dual–chamber ICD implantation (EF 33%) at another center, complicated by the formation of a large pocket hematoma, which required drainage and evacuation. In the following weeks, the patient noticed the reappearance of a large swelling in the ICD pocket; however, as it was painless and not troublesome, he did not seek medical attention. After 7 months he came to our observation with signs of heart failure. Clinical examination revealed a large swelling in the left pectoral area (Fig. 1), extending to the nipple, soft, not painful, not hot or red.The patient had no signs of infection (normal ESR, CRP, procalcitonin and WBC). We decided to drain the hematoma, given the size. At the level of the defibrillator pocket, we made a small incision, from wich 100ml of gold–colored, odorless liquid leaked out (Fig. 2), with no evidence of blood material in the pocket. The ICD–case was then wrapped in a rifampicin–releasing antibacterial bag and reinserted into the subcutaneous pocket, without further complications. The chemical–physical examination revealed a cloudy, gold–colored liquid, density of 1020, pH 8.5, high protein content (&amp;gt;400g/l), absence of glucose.Microscopic examination shows isolated leukocytes, rare erythrocytes immersed in mucoid material; this was not pus, as culture testing was negative for bacterial growth. The cholesterol concentration was 704mg/dl, triglycerides 80mg/dl (plasma cholesterol values were 91mg/dl, triglycerides 48mg/dl). The cytological analysis showed a carpet of foamy macrophages filled with cholesterol crystals (Fig. 3). Such evidence supports the diagnosis of pseudochilous, formed from the evolution of an untouched hematoma in a fibrous subcutaneous pocket for more than 6 months.This is the first case in which the presence of chyliform material is documented in an ICD pocket.

Normal ESR, CRP and Platelet Count in Giant Cell Arteritis and Polymyalgia Rheumatica: A Diagnostic Conundrum.

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are both rheumatological diseases of the elderly with a strong association with each other and which rarely present with normal inflammatory markers. Here we present the case of a 61-year-old Caucasian woman who had typical symptoms of both diseases. At the time of presentation, her blood work showed normal inflammatory markers, but because of the high clinical suspicion for GCA, a temporal artery biopsy was done which was positive for giant cells and disruption of the internal elastic lamina. Our patient responded very well to treatment with oral steroids and steroid-sparing medication and was able to return to her normal life without experiencing any complications of the disease. By sharing our case, we aim to increase the awareness of medical personnel regarding the importance of focusing on the clinical presentation as well as the laboratory and pathological aspects of diagnosing GCA and PMR.LEARNING POINTSNormal levels of inflammatory markers like C-reactive protein and the erythrocyte sedimentation rate do not rule out the diagnosis of giant cell arteritis (GCA).We aim to increase clinician recognition and awareness of other parameters, particularly the clinical presentation, that should be considered when diagnosing GCA or polymyalgia rheumatica.If the index of suspicion for the disease is high, it is crucial to start treatment as early as possible for better management and to avoid harmful complications.

OP05 Outcome of induction therapy with vedolizumab in children: Results from the prospective, multi-centre VEDOKIDS study

Abstract Background Limited data are available on the use of Vedolizumab (VDZ) in paediatric Crohn’s Disease (CD) and Ulcerative Colitis (UC). We evaluated the effectiveness and safety of VDZ to induce remission at week 14 in the prospective, multicenter VEDOKIDS study. Methods We enrolled children (age 0–18 years) with CD or UC commenced on VDZ with a standardized dosing of 177mg/BSA up to 300mg at 0, 2, 6 and q8 weeks thereafter. Non-responders had their dose escalated to q4wks at the discretion of the local physician. Explicit demographic, clinical and safety data were prospectively recorded via REDcap. Clinical remission was defined as steroid- and EEN-free remission (i.e. wPCDAI&amp;lt;12.5 or PUCAI&amp;lt;10) without the need for new medications. Complete remission was defined as clinical remission with normal CRP and ESR. Predictors of response were explored by Logistic regression. Results 128 children were enrolled, 60 (47%) with CD, and 68 (53%) with UC (58 (45%) males, mean age 13.8±3.6, 93 (73%) failed previous anti-TNF, median disease duration 2.3 years (IQR 0.9–4.7)). Using the ITT principle, clinical and complete remission rates for CD at week 14 were 30% and 20%, respectively, and for UC 50% and 38%, respectively (Fig 1). Clinical remission rates of those receiving VDZ as first line biologics versus second line were 57% and 34%, respectively (p=0.019; Fig 2); the corresponding complete remission rates were 49% and 23% (p=0.004). In the UC group, disease activity at baseline measured by the PUCAI predicted clinical remission at week 14 (OR=0.95, 95%CI 0.93–0.98; median baseline PUCAI 15 (IQR 0–30) in those achieving remission and 45 (20–55) in those who did not; p=0.002). ESR (OR=0.94, 95%CI 0.89–0.98; p=0.009) and a trend towards extensive disease (L3 vs. L1 and L2; OR 0.14, 95%CI 0.18–1.036, p=0.054) predicted clinical remission in CD. During the 14 weeks, 113 adverse events (AE) were recorded in 58 children: 28 AEs were possibly related to VDZ, all of which were mild-moderate and only 3 (11%) led to discontinuation of VDZ (leukocytoclastic vasculitis, myalgia and dyspnea). There were 18 serious AEs, only one was graded as possibly related to VDZ (headache). There were 18 non-serious cases (19%) of upper respiratory infections (pharyngitis, tonsilitis, parotitis, and otitis media) and one Campylobacter jejuni which was graded as serious. Conclusion In this prospective multicenter study, VDZ was safe and effective for inducing remission in a refractory cohort of paediatric IBD, more so in UC. Disease severity and extent at baseline may predict clinical response.

Musculoskeletal Pain and the Prevalence of Rheumatoid Arthritis in Breast Cancer Patients During Cancer Treatment: A Retrospective Study.

Breast cancer patients often develop musculoskeletal pain, resembling that experienced by patients with rheumatoid arthritis (RA), during cancer treatment. This study aimed to investigate the causes of musculoskeletal pain, including RA, among breast cancer patients. This retrospective study included breast cancer patients experiencing new-onset arthralgia during cancer treatment along with age- and sex-matched controls without breast cancer, who were evaluated at the Rheumatologic clinic between 2004 and 2017. The causes of musculoskeletal pain were compared between breast cancer patients and controls. The effects of cancer treatment on arthralgia and factors associated with RA were examined. A total of 146 breast cancer patients and 102 controls were included in the final analysis. The most common cause of arthralgia during breast cancer treatment was osteoarthritis (OA, 61.0%), followed by enthesopathy/tendinopathy (28.1%), which included tendinitis, adhesive capsulitis, and carpal tunnel syndrome. Overall, 50.0% of 72 breast cancer patients receiving aromatase inhibitors (AIs) satisfied the criteria of AI-induced musculoskeletal symptoms (AIMSS). The mean symptom duration (i.e., the time between pain onset and evaluation by a rheumatologist) was shorter in breast cancer patients than in controls (7.0 ± 12.1 vs. 14.8 ± 24.9 months, respectively; p = 0.004). RA was diagnosed in 3 (2.1%) breast cancer patients and 3 (2.9%) controls. All breast cancer patients with RA had an elevated erythrocyte sedimentation rate (ESR, 66.7 ± 25.0 mm/h), whereas those without RA had a normal ESR (20.4 ± 21.5 mm/h). Patients with breast cancer required more analgesics than the controls. OA and enthesopathy/tendinopathy are the most common causes of arthralgia in breast cancer patients, which may concurrently manifest as AIMSS. Patients with breast cancer did not have a higher prevalence of RA than those without breast cancer.

Physical and Blood Examining Characteristics of Shift Workers Nurses in Pandemic COVID-19

Shift work is a rotating work time outside normal working hours, either rotating with the shift work division method; this shift work can cause changes in metabolism, immunological status, and oxidative status, which will cause inflammation due to changes in circadian rhythms. During this Covid-19 pandemic, nurses who are mostly women in providing 24-hour service also continue to do shift work. There are several risk factors that might be in the Covid- 19 pandemics, such as age, hypertension, obesity, and diabetes. The purpose of this study was to look at the physical characteristics of female workers who worked shifts during the Covid-19 pandemic. The results of the study on 40 nurses who worked at Al Ihsan and Muhamadiyah Hospitals West Java showed that 50% were over 31 years old, 97.5% of people had worked &gt;5 years, 80% of people worked in the room, the results were as follows: 97.5% systolic blood pressure normal, diatolic 97.5% normal, BMI less 1.5%, normal 40%, excess 32.5%, 25% fat; Fasting blood sugar 92.5% normal, normal ESR 31 people 97.5%, normal cholesterol as much as 100%, normal triglycerides 95%, aerobic capacity (Vo2max) average 35.15±3.18, while cGMP levels 14.28( 1.4-67.7). These results indicate that there are risk factors for COVID-19, such as high BMI and abnormal fasting blood sugar.

An underrated differential diagnosis for subcutaneous lumps: 26 cases of subcutaneous Dirofilariasis

IntroductionEven though subcutaneous dirofilariasis [worm granuloma] is an emerging zoonosis, it is not commonplace to consider it as a differential diagnosis for a subcutaneous lump even in the endemic zones. Moreover, the available literature lacks attempts to provide a unified clinical profile for it to be considered as a clinical entity.Methods We have retrospectively analyzed patients who were diagnosed with subcutaneous dirofilariasis at a Base Hospital in the Uva Province of Sri Lanka from February 2018 to March 2020. We evaluated patient demographics, symptomatology, clinical signs, ultrasonographic and histopathological features.Results Twenty-six patients with a mean age of 15.6 years [range 1 – 67 years] were analyzed. The locations of the lumps were highly variable, the commonest being the abdominal wall [34.6%]. Most [84.6%] were asymptomatic. The average diameter was 14.2mm [range 8 – 25mm]. The majority were neither tender nor warm, firm, and had ill-defined margins and a smooth surface without fluctuation, transillumination, or slipping sign. All were in the subcutaneous plane often attached to the deep fascia but without attachment to the skin. Blood investigations were unremarkable with a normal ESR and eosinophil count. The ultrasonographic finding was an echogenic tubular structure within a hypoechoic lesion. Histopathology demonstrated a worm surrounded by granulomatous inflammatory infiltrates with eosinophils and lymphocytes. Conclusion We emphasize the importance of regarding subcutaneous dirofilariasis as a differential diagnosis for subcutaneous lumps, especially in the highly prevalent geographical zones to minimize 'incidental diagnosis'.