History Of Pain Research Articles

EGS SO28 - Management of oesophageal diverticulitis in a 71-year-old female: Case report and review of management approaches

Abstract Background Oesophageal diverticulitis is a rare condition with fewer than ten reports in the literature. We present a case of oesophageal diverticulitis in a 71-year-old female with a history of COPD, TIA, and known oesophageal diverticulum. She was managed conservatively with NBM, total parenteral nutrition and intravenous antibiotics requiring a 16-day inpatient stay. The rarity of this condition poses challenges in its diagnosis and management, necessitating a thorough understanding of both conservative and surgical interventions. This case highlights the complexity involved in treating oesophageal diverticulitis, especially in patients with significant comorbidities. Method Patient presented with a 6-day history of upper abdominal pain and sepsis (elevated inflammatory markers; CRP 320, WCC 11.1, temperature 38.0, pulse 104). Abdomen was soft with upper abdominal tenderness. Imaging was consistent with diverticulitis of a 5.9cm lower oesophageal diverticulum without perforation. Initial management included making the patient nil by mouth, total parenteral nutrition, and intravenous antibiotics (vancomycin and metronidazole). The patient’s condition was closely monitored with serial blood tests and clinical assessments. Opinion was sought from a tertiary upper GI centre. Discharge was planned once the patient safely transitioned to oral diet and was apyrexial for 48 hours. Results Inflammatory markers improved over five days (CRP from 320 to 51, WCC from 11.1 to 9). She remained intermittently pyrexial until day 8 of admission. Clinical improvement allowed transition from intravenous to oral therapy, and she was discharged on day 16 with double dose oral PPI therapy. Patient has been followed up by tertiary upper GI services with plans for consideration of surgical resection of the oesophageal diverticulum. The patient’s successful discharge without surgical intervention during the acute phase underscores the effectiveness of a conservative management approach initially, with a plan for definitive surgical treatment in a stable outpatient setting. Conclusion Oesophageal diverticulitis, though rare, requires a nuanced approach to management, especially in patients with significant comorbidities. This case demonstrates the importance of an awareness of thorough history taking and review of previous examinations to prevent delayed diagnosis of a rare pathology not demonstrated on a CT abdomen and pelvis. This approach highlights the importance of individualised treatment plans and the potential for conservative management to provide stabilisation, followed by elective surgical management. The paucity of cases of oesophageal diverticulitis has prevented development of evidence based guidelines, underscoring the importance of seeking advice from tertiary centers when managing rare presentations.

BN SO03 - "Stuck in the Middle: A Case of SMA Syndrome on a 68/Male"

Abstract Background A case is a 68-year-old male presenting with 1 year history of bilious vomiting, abdominal pain, weight loss and early satiety. Intraoperatively, the stomach, 1st and 2nd part of the duodenum were dilated, while the 3rd part of the duodenum was identified to be compressed by the superior mesenteric artery, distal duodenum and was noted to be collapsed, and a side-side duodenojejunostomy was performed. Post-operatively, the patient’s course in the ward was unremarkable. On 1-month follow up, the patient wasclinically well with no recurrence of symptoms, able to tolerate regular solid full diet and has gained weight since the procedure. Method N/A CASE REPORT Results N/A CASE REPORT Conclusion N/A CASE REPORT

HPB SO14 - Surprise Inside: Gallbladder Herniation in a Parastomal Hernia - A Rare Case Report and Management Insight

Abstract Background Parastomal hernias are a common complication of stoma formation, affecting approximately 40% of patients within two years. Gallbladder herniation within a parastomal hernia is a rare phenomenon, with only 18 cases previously reported. Patients are typically elderly females, with the condition attributed to ageing factors such as loss of visceral fat and elastic tissue, liver shrinkage, and the increased length and loss of elasticity of the gallbladder mesentery. These factors contribute to visceroptosis of the gallbladder, increasing its mobility and the risk of herniation. Method We present the case of a 68-year-old female with a four-day history of severe parastomal hernia pain and swelling. She had an emergency left hemicolectomy and transverse colostomy in the right upper quadrant 10 years prior for ischaemic colitis and perforation. Her stoma was functioning well. Vital signs and biochemistry results were normal. On examination her hernia was severely tender but partially reducible. CT revealed a right upper abdominal parastomal hernia containing loops of colon and surprisingly the gallbladder with a long stretched cystic duct. There was no evidence of cholecystitis, bowel obstruction, or compromise within the hernial sac. Results With analgesia, the patient's pain improved, though her hernia remained irreducible. She was discharged after two days of conservative management and referred back to the hospital where she had the initial operation. On enquiry with that hospital it was reported that an elective parastomal hernia repair with completion right colectomy and end ileostomy was performed. The gallbladder was mobilised and reduced back into the peritoneal cavity, and the hernial defect was closed. The patient made an excellent recovery and was discharged home three days after surgery. Conclusion Cholecystic parastomal herniation is a very rare phenomenon and should be considered as a differential in similar cases. Management should be based on clinical presentation, radiological diagnosis, and a multidisciplinary team approach. No standardised classification or approach exists. We propose classifying gallbladder herniations as either being simple (without inflammatory sequelae) or complicated (with cholecystitis, gallbladder torsion, incarceration or perforation). Simple herniations, such as the case presented, can be managed electively with intra-operative reduction of the gallbladder sufficing. Complicated herniations during acute admissions indicate the need for emergency surgical intervention with combined cholecystectomy and parastomal hernia repair.

EGS SO18 - Entero-enteric intussusception secondary to a capillary haemangioma of the small bowel: A case of a diagnostic conundrum

Abstract Background This is a case of a 50 year-old female who presented with acute on chronic abdominal pain, and she was intra-operatively diagnosed with entero-enteric intussusception secondary to a large small bowel tumour . The video demonstrates the findings during the diagnostic laparoscopy. The lead point appeared to be a tumour and histopathology confirmed it is a benign capillary haemangioma. The patient had a long standing history of abdominal pain that was previously investigated on multiple occasions, but without a definitive diagnosis. Method This is an interesting case of a challenging diagnosis of a rare disease. The patient has been suffering for four years with unexplained upper abdominal pain not associated with weight loss, rectal bleed, or change in bowel habit, but had occasional anaemia. The patient had a normal abdominal US, multiple CTs where she was found to have a right renal stone and an OGD that showed gastritis and positive CLO test initially. A repeat OGD and colonoscopy were negative. While the patient was awaiting further investigations for profound iron deficiency anaemia she presented with acute abdomen and required emergency surgery. Results The patient presented to ED with excruciating colicky pain for one day, one episode of melena and nausea. She was haemodynamically stable, peritonitic with increased inflammatory markers, hb 86 g/dL and lactate of 2 mmol/L. The CT abdomen and pelvis showed small bowel intussusception with possible ischemia, therefore the patient underwent an emergency operation.The laparoscopy showed small bowel intussusception and the patient underwent mini laparotomy. The intussusception was reduced, the small bowel was viable and the lead point was a large size tumour.The patient underwent small bowel resection and primary anastomosis, and made good post operative recovery. Conclusion Rare conditions are hard to diagnose. Small bowel intussusception is rare and in adults is usually linked to serious underlying pathology. Capillary haemangioma of the small bowel is very rare too. The patient's symptoms and occassional anaemia can now be explained. Although the patient went through an appropriate work up at the time, her symptoms remained unexplained to some extent or they were linked to other potential causes. Only when the anaemia became profound the patient warranted further investigations. In retrospect, capsule endoscopy would have been inevitable, however the patient became acutely unwell and required an emergency surgery.

A Case Report of Dorsal Pancreatic Agenesis and Uterus Didelphys in a Young Woman: A Seldom- reported Association

Agenesis of the dorsal pancreas is a rare congenital anomaly that often remains asymptomatic and is frequently discovered incidentally during imaging for other conditions. Its association with Müllerian anomalies, such as uterus didelphys, suggests that both conditions may stem from similar embryological disruptions during early fetal development. This report aims to raise awareness of Agenesis of the Dorsal Pancreas (ADP) and its potential associations with Müllerian anomalies. By presenting a detailed case study, we seek to address the diagnostic challenges faced by healthcare professionals and the implications for patient management, emphasizing the importance of early detection and appropriate intervention. We present a case involving a 24-year-old Iranian female who presented with a 10-day history of abdominal pain and vomiting. Initial ultrasound imaging revealed moderate hydroureteronephrosis in the right kidney, prompting further investigation. A contrast-enhanced CT scan was performed, which not only confirmed ureteropelvic junction obstruction but also unexpectedly revealed dorsal pancreatic agenesis. In addition to these findings, the patient was diagnosed with uterus didelphys, highlighting a significant developmental anomaly. This case underscores the necessity for increased awareness of ADP and its associations with Müllerian anomalies among healthcare providers. Early and accurate diagnosis through advanced imaging modalities significantly improves patient outcomes and facilitates better management strategies for associated complications.

THE RELATIONSHIP OF POSTERIOR TIBIAL SLOPE WITH CRUCIATE LIGAMENTS AND MENISCAL INJURIES BASED ON MRI– A PROSPECTIVE OBSERVATIONAL STUDY

Purpose: Various studies show that the disparities in the posterior tibial slope can make native cruciate ligaments and the menisci susceptible to tears. This study is to determine the relationship between posterior tibial slope with the anterior cruciate ligament, posterior cruciate ligament and meniscal injuries. Methods: A total of 72 subjects between 18 and 60 years having a history of traumatic knee pain were included in the study. All subjects were clinically examined, radiologically investigated, and the posterior tibial slope of the patients was calculated. Incidences of cruciate ligaments and menisci injury were identified. Results: In our study, the mean medial compartment posterior tibial slope and lateral compartment posterior tibial slope in all the Anterior Cruciate Ligament injured patients are 7.82 ± 2.56 and 10.53 ± 3.46. But in controls, it is 5.91 ± 4.49 and 6.24 ± 5.15, respectively. The differences are statistically significant ([Formula: see text]10). In cases with increased lateral Posterior Tibial Slope, more degeneration was seen in the lateral meniscus. Less Posterior Tibial Slope is associated with Posterior Cruciate Ligament tears. Conclusion: Anterior cruciate ligament is more prone to tears with a steeper posterior tibial slope. Lateral Meniscus tear is frequently associated with acute Anterior Cruciate Ligament injury and Medial Meniscus tear is predominantly associated with a chronic Anterior Cruciate Ligament injury. A decreased posterior tibial slope is more often associated with patients with a posterior cruciate ligament injury and is considered a risk factor for native Posterior Cruciate Ligament.

Rapidly Developing and Elusive Rhino-Orbital-Cerebral Mucormycosis

Purpose: To report a case of rapidly progressing rhino-orbital cerebral mucormycosis that was particularly difficult to diagnose, initially presenting as orbital apex syndrome. Major findings: In this case, a 59-year-old male patient with uncontrolled diabetes presented with a history of facial pain with no ocular involvement. Within 1 day of hospitalization, the patient developed complete ophthalmoplegia and total visual impairment of the right eye. Over the course of 2 hospital stays, several biopsies resulted in no significant histopathological findings, and several cultures resulted in growth of only a single colony of rhizopus mucor from the sinonasal mucosa. Given the high clinical suspicion of an invasive fungal infection, a universal PCR test was performed from a rapidly developing abscess in the frontal lobe and confirmed a diagnosis of mucormycosis. Conclusions: Orbital apex syndrome is a significant diagnosis that can be caused by a variety of factors, including those of fungal, bacterial, neoplastic, or inflammatory origin. Fungal infections, are a particularly concerning cause of orbital apex syndrome, given their ability to penetrate in and through the orbit to the brain, often resulting in an alarmingly high mortality rate. Mucormycosis, specifically rhino-orbital cerebral mucormycosis, is a very severe opportunistic invasive fungal infection, most often afflicting the immunocompromised. A clinician must be very thorough in their workup so as to not miss such a devastating diagnosis. Histopathology and cell cultures are currently the gold standard for diagnosis, with the potential to augment their technical success through the use of molecular techniques, such as universal PCR.

072. Subhepatic Appendicitis in A 23 Year Old Woman: A Rare Case Report

Background: Subhepatic appendicitis is a rare condition that occurs in only 0.01% of all acute appendicitis cases. The subhepatic position of the appendix is due to a developmental anomaly resulting from the failure of the caecum to descend during embryonic development. Its symptoms often resemble those of other diseases such as cholecystitis, pyelonephritis, and urolithiasis, which can lead to a delay in diagnosis and treatment. Case: A 23-year-old woman presented with four-day history of pain in the right upper quadrant of her abdomen, fever, anorexia, nausea, and vomiting. Abdominal examination revealed tenderness of all abdominal quadrants, which was more pronounced over the right upper and middle quadrant with positive rebound tenderness. Laboratory tests showed high levels of neutrophilic leukocytosis. Ultrasound imaging revealed an inflamed vermiform appendix in the subhepatic region. A diagnosis of an abnormally located appendix was made, and the patient underwent laparotomy. During exploration, an inflamed appendix was found covered by omentum in the right upper quadrant, and appendectomy was carried out smoothly. The patient was in good clinical condition without any complications. Conclusion: Subhepatic appendicitis presents a significant challenge to clinicians due to its unusual location. Failure to diagnose and manage it promptly can lead to complications such as abscesses, peritonitis, sepsis, and increased morbidity. Midline laparotomy is recommended due to the subhepatic location of the appendix and the possibility of retrocecal, dense adhesion or fibrosis, and perforation, which would make a laparoscopic approach unsafe.

Undifferentiated embryonal sarcoma of the liver masquerading as a cystadenoma in a young adult: a case report

BackgroundUndifferentiated embryonal sarcoma of the liver is an infrequent hepatic malignancy, primarily observed in the pediatric population. This neoplasm is exceedingly rare among adults. Despite its scarcity in adult cases, it remains imperative to accurately discern undifferentiated embryonal sarcoma of the liver utilizing diverse imaging modalities to prevent misdiagnosis with more prevalent benign and malignant hepatic masses. In this case, a comprehensive imaging examination was conducted, encompassing ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography–computed tomography scans. Notably, the positron emission tomography–computed tomography scan revealed 18F-fluorodeoxyglucose uptake characteristics indicative of malignancy, providing a pivotal clue for prompt diagnosis of undifferentiated embryonal sarcoma of the liver.Case presentationThis report presents the diagnostic procedure employed for a 37-year-old female patient of Han ethnicity in China diagnosed with undifferentiated embryonal sarcoma of the liver. The patient was admitted with a 2-day history of mid-upper quadrant abdominal pain. The patient’s temperature and inflammatory markers, such as white blood cell count and hypersensitive reactive protein, were slightly elevated. Ultrasound showed a cystic–solid nodule in the liver. The computed tomography revealed a cystic mass in the right lobe of the liver, characterized by a low-density shadow and a lack of significant enhancement during contrast-enhanced scanning, initially suggesting cystadenoma. Enhanced magnetic resonance imaging revealed a block-like abnormal signal shadow in the right hepatic lobe, suggestive of various etiologies, including benign lesions, cystadenoma with hemorrhage, or hemangioma with hemorrhage. However, the positron emission tomography–computed tomography showed increased 18F-fluorodeoxyglucose consumption within both the cystic wall and lesion, raising suspicion of malignancy. Surgical resection of the posterior hepatic lobe was performed under general anesthesia after comprehensive preoperative preparations. During the procedure, a space-occupying lesion was identified in the right posterior hepatic lobe, adhering to the diaphragm. Surface liver parenchyma overlying the tumor exhibited rupture, with several blood clots visible. The tumor was successfully and completely excised. Pathological examination revealed a fusiform cell tumor, necrosis, hemorrhage, cystic changes, cellular atypia, mitotic images, and eosinophilic globules suggestive of undifferentiated embryonal sarcoma of the liver. Immunohistochemical staining indicated CK (+), vimentin (Vim; +), Desmin (+), actin (−), α1-AT (+), GPC-3 (+), PDGFRa (+), MDM2 (+), P16 (+), Ki-67 (+) 30–35%, and PAS (+). The patient underwent five cycles of combination chemotherapy with ifosfamide and epirubicin, administered at 21-day intervals at our hospital. Following 3 years of postoperative surveillance, the patient remained stable, with no evidence of hepatic tumor recurrence.ConclusionOn the basis of this case and a comprehensive literature review, we recommend that clinicians consider the possibility of undifferentiated embryonal sarcoma of the liver in patients presenting with non-specific clinical and serological markers, particularly when there is inconsistency between ultrasound and computed tomography imaging findings, along with elevated 18F-fluorodeoxyglucose uptake observed in both the cystic wall and lesion on positron emission tomography–computed tomography examination. Given the rarity and high-grade malignancy of undifferentiated embryonal sarcoma of the liver, heightened clinical awareness and recognition are crucial for early diagnosis and successful therapy.

P01 Adult-onset chronic recurrent multifocal osteomyelitis – case series of four adult patients in Liverpool University Teaching Hospitals Foundation Trust

Abstract Introduction Chronic recurrent multifocal osteomyelitis (CRMO) is a rare inflammatory bone disorder. Classically known as a childhood disorder and diagnosis of exclusion, it characteristically presents with relapsing sterile bone inflammation affecting the metaphysis of lung tubular bones, shoulder girdle, clavicle, vertebral column or bony pelvis. Links with autoimmune conditions have been suggested. Evidence of adult-onset cases (age >18 at diagnosis) remains sparse and sporadic, with mostly individual case reports on searches. We present a case series of four patients with adult-onset CRMO in Liverpool, with varying responses to bisphosphonate treatment and no clinical features of SAPHO. Case description We list four cases of adult patients with CRMO. Case 1: 53-year-old female presented in 2023 with a 10 year history of on-off chest pain isolated to her sternum, and back pain since 2021. MRI confirmation of bone marrow oedema. Bone biopsy normal. Treated with zoledronate. MRI following treatment suggested some improvement but patient remained in pain. Case 2: 24-year-old female presented in 2019 to services with a 10 year history of worsening back pain. Medical background of asthma, type 1 diabetes mellitus, primary biliary cirrhosis and psoriasis. MRI suggestive of persistent pre-sacral soft tissue and sacral oedema since 2015. ANA, Anti-CCP, ENA and dsDNA were negative. Bone biopsy done was positive for inflammation. Pain improved with pamidronate. Case 3: 31-year-old male presented in 2022 with 14 years of relapsing pains and swelling in left clavicle and improvement with NSAIDs. Initially presented via orthopaedic services who arranged an MRI scan that demonstrated oedema of his left clavicle. Received zoledronate infusion with improvement in pain. Case 4: 45-year old-female presented in 2024 with eight year history of chronic right hip and right sacroiliac joint pain. Persistent lower back pain, central right sided with radiation down right knee to her knee. Examination showed tenderness over her lumbar spine and sacroiliac joints. PET-CT done showed avid uptake in L3/4, with subtle lucencies in left frontal bone, right femur and right sacrum. Treated as CRMO with pamidronate with a positive response. All patients received bisphosphonate therapy and varied response to treatment was seen. Two of the four patients had an excellent response with complete resolution of symptoms. One patient has had initial positive response to treatment with resolution of pain but is still planned for more bisphosphonate cycles. One patient had no response to treatment. Discussion Current literature searches describe CRMO mostly in the paediatric populace, with peak incidence aged 10. Most cases of CRMO are diagnoses of exclusion, hence leading to diagnostic delays as differentials such as malignancy, infection, and histiocytosis are first excluded. The Bristol review study suggested a mean time of 15 months to diagnosis in the paediatric populace. We highlight here our findings that CRMO can also present within the adult populace. Typically in adults when similar symptoms arise, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) is considered as a differential. Our patients, whilst having features on imaging suggestive of bone inflammation, did not have any features of SAPHO syndrome. Our findings are corroborated by the Eurofever International Registry study that enrolled 485 patients and showed adult-onset disease in 6.3% of their cohort, accounting for 31 cases. Our patients were all treated with bisphosphonate therapies. Currently, bisphosphonate therapies are often agreed as a first line treatment approach. Some reports exist of beneficial effects in the use of corticosteroids, DMARDS - particularly sulfasalazine and methotrexate - and biologic treatments (anti-TNF agents), though no common consensus guideline for treatment of CRMO within the UK exist at the moment to our knowledge. We feel the varied clinical response of our patients highlights a need for more research to be targeted towards this area. Key learning points Learning points are as follows: • Few cases of adult-onset CRMO are reported in the UK. Most are single site case reports or case series of paediatric patients. • This cases series is the largest adult-onset cohort in Europe from a single hospital site. • Bisphosphonates are used first line - typically pamidronate. • Corticosteroids, DMARDs (SLZ/MTX) and biologic treatments (anti-TNF agents) have been reported to be effective in some single case reports. • Additional research is required for a national consensus guideline for the treatment of CRMO, including additional management options for those patients that fail first line treatment (bisphosphonate).

Effect of repeated intra-articular administration of collagen as a treatment for knee osteoarthritis: a case report.

Intra-articular injections aimed at correcting underlying pathophysiological processes and providing pain relief are essential for managing knee osteoarthritis (KOA). Collagen, the primary component of articular cartilage, has a long half-life, making it a promising candidate for intra-articular injections with a low risk of serious side effects. The first of the two cases in this report involved a woman in her early 70s with a 6-year history of persistent left knee pain. The second case involved a woman in her mid-50 s with a >7-year history of right knee pain. Both patients received hyaluronic acid injections every 6 months, totaling 10 injections over 5 years. They were diagnosed with Kellgren-Lawrence grade 2 KOA. The patients received two 3-mL intra-articular injections of 6% collagen, administered at baseline and 6 months later. Improvements in clinical outcomes, including visual analog scale scores and Western Ontario and McMaster Universities Osteoarthritis Index scores, were observed and maintained in both patients, with no side effects reported. In summary, when collagen injections were administered to these two patients with KOA, clinical improvements lasted approximately 6 months, and repeated treatments demonstrated efficacy and safety similar to the initial course.

Natural History of Menstrual Pain and Associated Risk Factors in Early Adolescence

Study ObjectiveTo determine the natural history of menstrual pain without pelvic pathology, the role of progesterone in its pathophysiology, and associated risk factors in a longitudinal study of early post-menarchal girls in North Carolina. MethodsParticipants contributed daily urine samples for up to 3.5 years to measure pregnanediol-3-glucuronide [PdG] (mean 589 urines/participant), completed menstrual diaries, and reported menstrual pain using the Menstrual Symptom Questionnaire (MSQ) biannually. MSQ scores were log-transformed and generalized estimating equations assessed associations with gynecologic age, cycle peak PdG, presumed ovulation, physical activity, anxiety, and depression. Models were adjusted for age at menarche, baseline body mass index, race/ethnicity, parental education and employment, and gynecologic age. ResultsForty-three girls, aged 12.6 ± 1.1 years (mean ± SD) at enrollment with a gynecologic age 0.3 ± 0.2 years, participated. Total MSQ scores were higher for every 1-year increase in gynecologic age (MSQ score ratio: 1.12; 95% CI: 1.08, 1.17; p<0.0001). Overall MSQ (ratio: 1.04; 95% CI: 1.02, 1.06; p=0.0002) and abdominal pain-specific (ratio: 1.04; 95% CI: 1.01, 10.7; p=0.004) scores were higher for every 1000 ng/mg creatinine increase in peak PdG in the preceding cycle. Overall MSQ scores were higher (ratio 1.26; 95% CI: 1.11, 1.44; p=0.0005) if the preceding cycle was presumed ovulatory. Menstrual pain was not associated with physical activity, anxiety, or depression. ConclusionsIn early post-menarchal girls, gynecologic age and PdG were associated with menstrual pain, suggesting a pathophysiologic role for progesterone and other unknown factors in the development of menstrual pain.

The General Public as well as Physiotherapists Evaluate Spinal Flexion as Dangerous Regardless of Their Own Low Back Pain History

BackgroundMaladaptive fear of movement in individuals with low back pain may be associated with worse clinical outcomes. ObjectiveTo explore beliefs about the perceived dangers regarding different spinal postures within the Czech Republic. DesignExploratory cross-sectional study including physiotherapists and members of the general public. MethodsSelf-reported perceived safety/danger of “straight” and “flexed” spinal postures regarding 1) sitting, 2) lifting of light and 3) heavy object from the floor based on three pairs of photographs was measured using numeric rating scales (0-10, safe to dangerous) without any given context and in the context of low back pain. The sum of differences between the ratings of flexed and straight postures were used to calculate Bending Safety Beliefs Thermometer (BSBThermometer) total score potentially ranging -60‒60 (higher values indicates evaluation of flexed spinal postures as more dangerous in comparison to straight postures). Results760 participants were included in the analysis. The mean BSBThermometer total score was 31.1 (SD 16.1) and higher scores were positively associated with being women (b=14.8, 95% CI [9.9-19.8]); non-medical profession (b=24.7, 95% CI [15.2-34.2]); age (b=0.38, 95% CI [0.16-0.6]; and their interactions. There was no significant association with current low back pain status or history of low back pain. ConclusionsOn average, participants evaluated “flexed” spinal postures as significantly more dangerous when compared with “straight” spinal postures, with only subgroups of physiotherapists scoring lower than the general public. Clinically, these beliefs could be targeted by individualized education, exposure-based interventions and public campaigns; however, further research is required.

Intraoperative Methadone in Spine Surgery ERAS Protocols: A Systematic Review of the Literature.

Systematic review. To systematically review the use of intraoperative methadone in spine surgery and examine its effects on postoperative opioid use, pain, length of stay, and operative time. Spine surgery patients commonly have a history of chronic pain and opioid use, and as a result, they are at an increased risk of severe postoperative pain. While pure mu opioids remain the standard for acute surgical pain management, they are associated with significant short-term and long-term adverse events. Methadone presents an alternative to pure mu opioids which may improve postoperative management of pain following intraoperative use. A systematic review of MEDLINE, Embase, and Web of Science databases was conducted to review existing literature detailing operating time, postoperative pain, opioid usage, and hospital length of stay (LOS) following intraoperative methadone administration in spine surgery. Following screening of 994 articles and application of inclusion criteria, 8 articles were included, 4 of which were retrospective. Conventional spine surgery intraoperative analgesic strategies used as comparators for intraoperative methadone included hydromorphone, ketamine, and sufentanil. Considering patient outcomes, included studies observed that patients treated with intraoperative methadone had statistically similar or significantly reduced pain scores, opioid usage, and LOS compared with comparator analgesics. However, one study observed that intraoperative methadone used in a multimodal analgesia regimen strategy with ketamine resulted in a shortened LOS compared with the use of intraoperative methadone alone. Differences in operating time between cases that used intraoperative methadone and cases that used comparator analgesics were not statistically significant among included studies. Methadone may present an alternative option for both intraoperative and postoperative analgesia in spine surgery recovery protocols and may reduce postoperative pain, opioid use, and LOS while maintaining consistent operating time and reduced side effects of pure mu opioids. Level II.

OA26 Atypical Multisystem Inflammation related to infection or just plain old polyarteritis nodosa?

Abstract Introduction We present the case of a 5-year-old boy with episodes of pyrexia of unknown origin associated with polyarthritis, central neuroinflammation and mucocutaneous manifestations. His skin biopsy demonstrated a nodular vasculitis which could be consistent with polyarteritis nodosa. Interestingly though, he had additional atypical rashes, ocular inflammation and evidence of acute and past streptococcal infection and his fever and CRP normalised prior to corticosteroid initiation. Case description A five-year-old British African male presented with five-week history of persistent fever, headaches, joint pain and bilateral eye pain. He was transferred to a tertiary paediatric infectious disease’s unit due to unrelenting fever with no fixed pattern, despite nine days of broad-spectrum intravenous antibiotics. He was diagnosed with neuroinflammation of uncertain aetiology, evidenced by leptomeningeal enhancement and bilateral papillitis on brain MRI. CSF microbiology and autoimmune profiles were negative. There was no evidence of primary malignancy. The fever resolved with pulsed IV methylprednisolone and the child was discharged home on a weaning regime of oral prednisolone. After stopping steroid treatment, he represented with high-grade fever, limping, anterior uveitis and new-onset non tender cutaneous lesions, plaques over eyelids and cheek and annular lesions over arms, legs and buttocks. Repeat MRI of the brain and spine showed resolution of previous neuroinflammation. Blood tests revealed raised ANA, IgG and ASOT titre, and his throat swab was positive for Group A Streptococcus. He completed 10 days of intravenous antibiotics and oral high dose ibuprofen (10 mg/kg TDS). On review by tertiary paediatric rheumatology, he was identified to have pleomorphic skin rash and subcutaneous nodules. Skin and deep tissue biopsy confirmed lobular and septal panniculitis with necrotising vasculitis, consistent with a nodular vasculitis. Treatment with high-dose steroid and mycophenolate mofetil (MMF) was initiated, but his CRP and fever had resolved prior to his first dose. He experienced improvement in systemic symptoms and arthritis; however, skin lesions persisted, with appearance of new lesions and hyperpigmentation, on reduction of steroid dose. His course was complicated by acute varicella infection, requiring oral aciclovir. Further treatment trials included topical tacrolimus and topical corticosteroids for his skin lesions. At one biopsy site, he experienced significant delay in wound healing. The genetic panel for primary immunodeficiency panel (R15) demonstrated no pathological variants. Discussion This case report highlights that, whilst the biopsy may be consistent with nodular vasculitis, such as PAN, the clinical manifestations are not perfectly aligned. Discussion within the rheumatology community would support optimal patient care. Childhood-onset Polyarteritis Nodosa (c-PAN) is a rare systemic vasculitis. Although the aetiology is unknown, associations with infections like group A streptococcus and hepatitis B suggest a postinfectious autoimmune response. There are no clear genetic links to PAN, but PAN-like vasculitis is part of reported monogenic autoinflammatory conditions. Key atypical features in this case include uveitis at presentation, nonspecific central neuroinflammation, unusual cutaneous lesion morphology, improvement of acute phase reactants before immunomodulatory treatment, and delayed biopsy wound healing. While ocular findings in PAN may include episcleritis, scleritis, keratitis, retinal vascular occlusions, and ocular ischemic syndrome, uveitis has not been reported in c-PAN. The patient also showed nonspecific inflammatory changes on initial MRI. Neurological involvement in c-PAN typically includes cerebrovascular accidents, cranial nerve palsies, and mononeuritis multiplex, with meningeal involvement being less common (reported 4% in a study of 69 children). Additionally, the patient experienced delayed wound healing following the biopsy, which is undocumented in c-PAN, but may be related to immune modulating treatment. A positive streptococcal throat swab could suggest an immune reaction as part of bacterial tonsilitis, or Acute Rheumatic Fever. However, he did not meet Jones Criteria, there was no response to prolonged antibiotics and the chronic remitting nature made these less likely. An autoinflammatory disorder, Deficiency of Adenosine Deaminase 2 (DADA2), was also considered but he had no evidence of livedo racemosa, strokes and no CECR1 mutation was identified. Our case has been discussed within a multidisciplinary team and we speculate that it could represent a previously undefined immune sensitivity within the autoimmune, autoinflammatory and immune deficiency spectrum giving an exaggerated response to infection. Key learning points • This case presents a significant diagnostic challenge due to its atypical clinical features and inconclusive extensive investigations, including immunologic testing, tissue biopsy, and genetic analysis. • While the patient’s symptoms improved with high-dose steroids and MMF, the recurrence of symptoms upon tapering steroids underscores the persistent inflammatory nature of the disease. • The detection of group A Streptococcus in the patient’s throat swab suggests a potential postinfectious autoimmune trigger, highlighting the role infections can play in the pathogenesis of vasculitis. The negative results from the R15 Primary Immunodeficiency panel suggest that more advanced genetic and immunologic testing may be beneficial. • We invite discussion on whether additional genetic or immunologic testing could optimise this patient’s care and contribute to the broader understanding of atypical vasculitis syndromes.

P34 A case of haemophagocytic lymphohistiocytosis triggered by primary Epstein–Barr virus infection

Abstract Introduction Haemophagocytic lymphohistiocytosis (HLH) is an uncommon systemic hyperinflammatory state characterised by uncontrolled activation of the immune system. HLH may occur in a primary (familial) form, but more commonly occurs secondary to another disease process. Such triggers include infections, autoimmune disease and malignancy. We present the case of a 24-year-old female who was previously fit and well, who was diagnosed with HLH secondary to primary Epstein-Barr virus (EBV) infection. Case description The patient was admitted with a 10-day history of fever, sore throat and abdominal pain. On examination she had bibasal crackles and epigastric and right upper quadrant tenderness. There was pharyngeal erythema but no exudate. No rash or joint inflammation. Admission blood tests showed WBC 11.7 x109/L, neutrophils 6.5 x109/L, lymphocytes 4.3 x109/L, platelets 142 x109/L, CRP 179 mg/L, ALT 330 U/L, ALP 1022 U/L, bilirubin 37 mmol/L and lactate 1.81 mmol/L. A CT chest/abdomen/pelvis showed bibasal consolidation with small bilateral pleural effusions and mild splenomegaly. The patient was hypotensive and tachycardic, and was spiking temperatures greater than 39 °C. She subsequently developed type 1 respiratory failure and was transferred to the intensive care unit. She was treated with broad-spectrum antibiotics for suspected sepsis secondary to pneumonia. She remained unwell with high spiking fevers. HLH was suspected and ferritin was &amp;gt;100,000 mg/L with triglycerides 6.19 mmol/L, fibrinogen 1.1 g/L and LDH &amp;gt;1800 U/L. Her HScore was 200, indicating a high probability of HLH. Autoimmune screen including rheumatoid factor, ANCA and ANA were negative. A comprehensive infection screen identified a strongly positive EBV viral capsid antigen (VCA) IgM, positive EBV VCA IgG and negative EBV nuclear antigen (EBNA) with a viral load of 49,600 copies/ml. These results were consistent with acute primary EBV infection. Bone marrow biopsy confirmed haemophagocytosis. A diagnosis of HLH triggered by primary EBV infection was made. The patient was discussed with the specialist HLH service at University College Hospital and was commenced on intravenous methylprednisolone and anakinra 200 mg twice daily. She was additionally given antivirals, antibiotics and antifungals as prophylaxis against secondary infection. The patient improved clinically and biochemically. The dose of anakinra was reduced and eventually discontinued, and the patient was discharged on a tapering course of prednisolone. Discussion HLH carries a high mortality rate and early recognition and treatment is vital. However, diagnosis is often delayed as HLH may resemble other conditions such as sepsis. Signs and symptoms of HLH include fever, hepatosplenomegaly, cytopenias, hyperferritinaemia, hypertriglyceridaemia, liver dysfunction and coagulopathy. There may be multi-organ dysfunction. The characteristic histopathological finding is haemophagocytosis on biopsy of bone marrow, lymph node, liver or spleen, however this may initially be absent. EBV is the most common infective trigger for HLH, but it may occur with other viral and bacterial infections including tuberculosis. The most common autoimmune conditions associated with HLH include adult-onset Still’s disease (AOSD), systemic juvenile idiopathic arthritis and lupus. Haematological malignancy, in particular lymphoma, is another important cause and can sometimes be challenging to identify. The initial presentation of AOSD can share many of the same clinical features as EBV infection, including fever, rash, sore throat, hepatosplenomegaly, lymphadenopathy and liver dysfunction. The rash of AOSD is classically salmon-pink coloured and comes and goes with the fever, and the fever typically occurs at the same time each day. In our patient, the absence of arthralgia, rash and leucocytosis meant AOSD was felt to be unlikely, but this was kept under review. Key learning points • Early recognition and treatment of HLH is crucial to reducing mortality • The HScore tool can be used to assess the probability of HLH • Management of HLH involves supportive care, immunosuppression and treatment of the underlying cause • Agents that may be used include steroids, cyclosporine, etoposide, anakinra and intravenous immunoglobulin

P30 A mysterious case of lymphadenopathy, joint pain and balance disturbance

Abstract Introduction A patient presented with a long-standing history of double vision, balance disturbance, widespread lymphadenopathy and joint pain. Sarcoid was suspected due to its multisystem inflammatory effects, non-specific presenting features and insidious onset. Tissue confirmation was sought. However, multiple non-diagnostic lymph node biopsies led the clinical team to reconsider their presumed diagnosis. Finally, after further investigations and multidisciplinary input, a surprising unifying diagnosis emerged when syphilis serology was requested. Case description A 51-year-old man attended the Emergency Department with a two-month history of double vision. Prior to this, he described a year-long history of dry cough, arthralgia, myalgia, pins and needles in his hands bilaterally, weight loss, persistent headaches and balance disturbance. There was no travel or sexual history documented. On examination there was evidence of palpable lymphadenopathy, small papules on his forearms and trunk, bilateral wrist tenderness with limited swelling. His chest was clear and muscle power was preserved. On further assessment, he was found to have raised protein on cerebrospinal fluid, low vitamin D, raised alkaline phosphatase and alanine transaminase with normal liver imaging and an elevated serum angiotensin converting enzyme (ACE). Other investigations included serum electrophoresis, liver auto-antibodies, paraneoplastic antineuronal antibody screen, nerve conduction studies and hand x-rays which were all unremarkable. In the context of widespread lymphadenopathy, a working diagnosis of sarcoid was considered however lymphoma needed to be excluded. Two lymph node biopsies and, subsequently, a surgical excision was conducted. The histology indicated follicular hyperplasia without features of malignancy, lymphoma or sarcoid. On follow-up, his outpatient blood tests normalised including the serum ACE and acute phase markers. He also reported improvement of lymphadenopathy and arthralgia although his balance disturbance remained. A Romberg’s test was noted to be positive. Initial management had included vitamin D replacement and bilateral wrist splints for presumed carpel tunnel syndrome. Given the inconclusive tissue diagnosis coupled with a degree of spontaneous clinical improvement, steroids were not initiated despite the suspicion of sarcoid. Instead, syphilis serology was requested and found to be positive thus revealing a unifying diagnosis for this mysterious case. Discussion Syphilis is the clinical manifestation of infection with spirochaete Treponema Palladium (T. Palladium) often transmitted through sexual contact or via vertical transmission. Multisystem involvement is owed to its ability to rapidly invade and infect endothelial tissue, resulting in vasculitis and generalised signs and symptoms as it progresses through its primary, secondary and tertiary phases. It has therefore been given the moniker the “great masquerader”, where it can mimic other multisystem diseases such as sarcoid. Musculoskeletal manifestations of syphilis can present with articular and periarticular pathologies as seen in other inflammatory arthropathies. Where polyarthalgia is a common form of presentation, inflammatory arthritis, periostitis, tensosynovitis, myositis and osteomyelitis have been reported in syphilis. Syphilis can remain latent until the tertiary stage at which point syphilitic arthritis may also manifest for example as a neuropathic joint. This may occur years after initial exposure. Although not seen here, granuloma formation is commonly seen in tertiary syphilis and can also occur in secondary stages, thus further imitating sarcoidosis where granuloma formation is a defining feature. The mainstay of syphilis eradication is treatment with penicillin antibiotics, often with curative results. In contrast, sarcoid is a chronic non-curable condition where steroids and immunomodulatory agents are used to limit disease progression. Our patient presented with nonspecific symptoms over a year-long period with follicular hyperplasia on lymph node biopsy, a non-specific histological finding with a wide range of differentials such as malignancy, infection and autoimmune disease. The definitive diagnosis of syphilis was made on positive serology. With the prevalence of syphilis in England rising (9% increase in new cases from 2022 to 2023), it is increasingly important for clinicians to consider it in their workup. Importantly, this case reinforced the need for a comprehensive travel and sexual history when presented with a complex multisystem disease. Key learning points • Due to its multi-organ involvement and non-specific symptoms, syphilis commonly mimics other diseases. This case highlights the need for a broad differential workup when faced with multisystem disease, particularly when clinical findings are discordant with seen pathology, as seen here where two sequential lymph node biopsies did not support the presumed diagnosis of sarcoid. In the instance of nonspecific symptoms, comprehensive clinical assessment with sexual and travel histories are also advisable, but it should be noted that the sexual history may not always be reliable. • As the incidence of syphilis rises across the UK, it is also important for clinicians to consider this disease within their workup, especially as detection via serological testing and treatment is relatively straightforward and can often yield positive outcomes.

Liver metastasized pancreatic neuroendocrine tumor in a 17-year-old female: A case report.

Pancreatic neuroendocrine tumors (PNETs) are rare and often misdiagnosed due to their vague symptoms and tumor heterogeneity. Early detection using computed tomography (CT) is essential, particularly in regions without access to advanced diagnostic tools like immunohistochemistry and genetic testing. Neuroendocrine tumors (NETs) are rare tumors in adults and extremely rare in the pediatric population, as pancreatic NETs (pNETs) have an incidence rate of <0.1 per million. We present a case of a 17-year-old female with a liver metastasized pNET. A 17-year-old female with a history of intermittent abdomen-back pain presented to the clinic with severe upper abdominal pain radiating to the shoulder. The routine tests were normal. An ultrasound showed multiple lesions in the liver, which were confirmed by a computed tomography (CT) that uncovered a pancreatic lesion too. A liver biopsy proved it was a metastasized pNET with positive NET markers on IMC staining. The metaiodobenzylguanidine (MIBG) scan flared the liver lesion. The patient was started on Octreotide long-acting release (LAR) 30 mg once monthly. The rarity of these tumors makes their diagnosis difficult, but they should not be omitted and must be considered when there are long-lasting symptoms that are not compatible with common illnesses. These tumors are curable in their early stages.

P05 The role of JAK inhibitors in difficult-to-treat adult-onset Still’s disease: a case series

Abstract Introduction Adult-onset Still’s Disease (AOSD) is a rare systemic auto-inflammatory disorder characterised by fever, arthritis and rash. Some patients with AOSD exhibit resistance or intolerance to conventional treatments, necessitating alternative therapeutic strategies. This case series aims to explore the efficacy and safety of JAK inhibitors in managing difficult-to-treat AOSD. The driving force behind Still’s disease lies in the excessive and inappropriate production of pro-inflammatory cytokines, notably IL-6 and interferon. Given the pivotal role of JAK inhibitors in mitigating these cytokine pathways, this study highlights their potential therapeutic impact in the management of difficult to treat AOSD. Case description In this retrospective case series, three adult patients with difficult-to-treat AOSD were evaluated for their response to JAK inhibitors, specifically tofacitinib and baricitinib. Case 1: A 32-year-old male presented with a three-week history of fevers, night sweats, weight loss, and lymphadenopathy. Diagnosed with AOSD 18 months later, his treatment began with prednisolone and methotrexate, which was subsequently switched to azathioprine. Tocilizumab was then introduced, alleviating joint pain but causing dermatitis. He was switched to anakinra, allowing a reduction in prednisolone but failing to induce remission and resulting in abnormal liver functions and increased hepatitis B virus titers. Finally, he commenced tofacitinib, achieving symptom resolution, reduced serum ferritin levels, and cessation of steroids. Case 2: A 32-year-old woman presented with a six-month history of joint pain, swelling, stiffness, night sweats, weight loss, and a recurrent rash. Laboratory tests showed anemia, lymphopenia, elevated inflammatory markers, and high ferritin levels. Initial treatment with 60 mg oral prednisolone showed some response, but polyarthritis necessitated further intervention. Anakinra initially managed systemic symptoms, though joint swelling persisted. Tocilizumab was tried but proved ineffective. Subsequently, transitioning to baricitinib at 4 mg daily resulted in good symptomatic control. Case 3: An 18-year-old female presented with recurrent fevers, an intermittent macular rash, joint pains, diarrhoea and splenomegaly. Despite initial antibiotic treatment, persistent symptoms led to an AOSD diagnosis, prompting steroid therapy. Methotrexate failed to control symptoms and caused significant nausea, leading to a switch to tocilizumab. While anakinra initially resolved skin and joint symptoms, recurrent flares necessitated further changes. Azathioprine was trialed but discontinued due to side effects. Colchicine was tried next. Finally, tofacitinib was introduced, and one year later, she achieved significant progress, reducing prednisolone dosage to 5 mg. Discussion The findings from this case series underscore the potential of JAK inhibitors, particularly tofacitinib and baricitinib, as effective treatments for refractory AOSD. In all three cases, patients showed substantial clinical improvement and were able to reduce or discontinue steroids. This suggests a promising role for JAK inhibitors in managing AOSD, especially given the disease’s association with excessive pro-inflammatory cytokine production, including IL-6 and IFN pathways. The transition to JAK inhibitors was often necessitated by inadequate responses or adverse effects from conventional therapies like methotrexate, azathioprine, and biologics such as tocilizumab and anakinra. The successful outcomes with JAK inhibitors highlight their ability to achieve disease control where other treatments failed, demonstrating their efficacy in reducing systemic inflammation and disease activity. Further research is warranted to establish optimal dosing, duration of therapy, and long-term safety profiles of JAK inhibitors in this patient population. These preliminary results are encouraging and suggest a new avenue for treating AOSD. Key learning points • Efficacy of JAK inhibitors: JAK inhibitors, particularly tofacitinib and baricitinib, demonstrated substantial clinical improvement in patients with refractory AOSD. • Steroid reduction: All three patients were able to reduce or discontinue steroid use, highlighting the potential of JAK inhibitors to minimise long-term steroid dependency. • Management of refractory AOSD: JAK inhibitors provided effective disease control where conventional therapies such as methotrexate, azathioprine, and biologics like tocilizumab and anakinra were inadequate or resulted in adverse effects. • Mechanism of action: The efficacy of JAK inhibitors may be attributed to their ability to block pro-inflammatory cytokine pathways, particularly IL-6 and IFN, which are crucial in AOSD pathogenesis. • Safety profile: The treatment was well-tolerated, with significant symptomatic relief and no severe adverse events reported during the study period. • Need for further research: There is a need for further prospective studies to determine the optimal dosing, duration of therapy, and long-term safety profiles of JAK inhibitors in AOSD patients. • Personalised treatment approach: The study supports a personalised treatment approach, considering JAK inhibitors for patients with difficult-to-treat AOSD who do not respond adequately to conventional therapies.

P32 A case of disseminated pneumococcal infection with musculoskeletal manifestations

Abstract Introduction Septic arthritis should be the first consideration in any patient presenting with a hot, swollen joint. Infection may affect one or more joints, and bacteria typically enter the joint through direct inoculation, haematogenous seeding, or spread from adjacent soft tissue or bone infection. Staphylococcus aureus is the most common causative organism. Streptococcus pneumoniae is an uncommon cause of septic arthritis, accounting for approximately 5% of cases. We present the case of a 78-year-old male with no significant medical history who presented with a polyarticular pattern of joint inflammation related to disseminated pneumococcal infection. Case description The patient presented with a one week history of gradual onset pain and swelling in the right knee and right wrist. He was previously well and remained physically active. He was a non-smoker, drank moderate alcohol and had no history of intravenous drug use. He had no current or preceding infective symptoms, including respiratory tract symptoms, nor history of trauma or recent foreign travel. Examination revealed a warm right knee effusion with restricted range of movement. There was swelling of both wrists (right more than left), both second metacarpophalangeal joints and the left ankle. There were no heart murmurs or peripheral stigmata of endocarditis. He was afebrile and haemodynamically stable. Admission blood tests showed WBC 21 x109/L, neutrophils 18 x109/L, CRP 369 mg/L, urate 452 µmol/L and procalcitonin 3.84 µg/L. Rheumatoid factor was 25.3 IU/mL with negative anti-CCP. Knee X-ray showed significant medial compartment osteoarthritis. Hand and wrist X-rays were unremarkable. Synovial fluid aspirate from the right knee grew Streptococcus pneumoniae and calcium pyrophosphate crystals were also seen on polarised light microscopy. Blood cultures were positive for the same organism. The patient underwent arthroscopic washout of the knee and was treated with colchicine and intravenous amoxicillin. He was taken to theatre for a right wrist washout, however the wrist was found to be clean and dry intraoperatively. He had two further washouts of the right knee and repeat intraoperative samples and blood cultures were negative. Additional screening for HIV, syphilis and myeloma was negative. Transthoracic echocardiogram showed no vegetations. CT chest showed basal atelectasis but no focal consolidation. Left hand and wrist MRI showed extensor compartment tenosynovitis and second metacarpophalangeal joint synovitis. His antibiotics were switched to intravenous ceftriaxone and oral doxycycline. He clinically improved and was discharged with a plan to complete a 6-week course with outpatient review. Discussion Streptococcus pneumoniae is an uncommon cause of septic arthritis, responsible for approximately 5% of all cases, but more often causes polyarticular infection than other organisms. This may be related to higher rates of bacteraemia in patients with pneumococcal septic arthritis. In one review of 190 cases of pneumococcal septic arthritis, polyarticular infection was present in 36% of patients and 72% had concomitant bacteraemia (compared with rates of approximately 20% polyarticular infection and 30-50% bacteraemia for septic arthritis overall). The joints most commonly affected are the knee, followed by the hip, shoulder, ankle and elbow. The original focus of infection is most commonly pneumonia or meningitis, but up to 50% of patients have no identifiable extra-articular source of infection. Pneumococcal septic arthritis more commonly affects patients with predisposing risk factors, such as rheumatoid arthritis, osteoarthritis, joint prosthesis, alcoholism, myeloma and other malignancies, diabetes and immunosuppression. Our patient had no specific predisposing medical conditions other than knee osteoarthritis, and his age was likely to be his main risk factor. It is also important to note that septic arthritis in the elderly can present atypically, with insidious onset and absence of fever or other signs of systemic infection. This was the case in our patient, who despite bacteraemia and markedly elevated inflammatory markers, did not otherwise appear floridly septic or unwell. Our patient presented with a polyarticular pattern of joint inflammation, although joint infection was only ultimately confirmed in the right knee. Also notable was the presence of calcium pyrophosphate crystals in the aspirate. One might theorise whether the infection might have triggered a reactive polyarthropathy or concurrent crystal arthritis. It is well recognised that septic arthritis and crystal arthritis can coexist in the same patient. The case also highlights the value in sampling multiple joints and taking blood cultures in such patients. Key learning points • Polyarthritis does not exclude the possibility of septic arthritis • Joint aspiration should be performed in all patients presenting with a hot, swollen joint • In cases of polyarthritis, consideration should be given to aspiration of all affected joints and taking blood cultures, particularly in the elderly and patients with predisposing risk factors for septic arthritis • Septic arthritis can present atypically in the elderly, with the absence of fever and other typical signs of systemic infection