Rheumatoid Arthritis Flare Research Articles

Ultrasound-detected tenosynovitis as a risk factor for flares in rheumatoid arthritis patients in clinical remission.

Our objective was to investigate the value of ultrasound (US) detected synovitis and tenosynovitis as risk factors for short term flare in rheumatoid arthritis (RA) patients in clinical remission. Consecutive RA patients in clinical remission (DAS28 ERS < 2.6) for at least 3months underwent Power Doppler ultrasound (PDUS) examination of 1st to 6th extensor compartments at the wrist, 2nd to 5th finger flexor, posterior tibial tendon, and peroneal tendons. To assess synovitis, carpal joints, 1st to 5th metacarpophalangeal (MCP) joints, and 2nd to 5th interphalangeal proximal (IPP) joints were bilaterally examined. Synovitis and tenosynovitis were defined according to OMERACT. Patients were followed for 1year. Disease flare was defined as an increase in disease activity generating the need for a change in therapy by the attending rheumatologist. Ninety patients were included. After 1year of follow-up, 26 patients (29%) experienced a flare. At baseline 39%, 23% and 8% had US-detected synovitis, tenosynovitis or both, respectively. In the 1-year period after the baseline US examination, US-detected tenosynovitis (RR: 4.9; 95% CI: 2.2-10.8) was associated with an increased risk of exacerbation. This association was not shown with US-detected synovitis (RR: 1.3; 95% CI: 0.76-2.2). In the multivariate analysis, only subclinical tenosynovitis (OR: 9.8; 95% CI: 2.5-39.1; p = 0.001) and baseline DAS28 (OR: 5.7; 95% CI: 1.1-31.6; p = 0.047) were significantly associated with an increased risk of having a flare. In our study, subclinical tenosynovitis was associated with disease flare in patients with RA in clinical remission. • Synovitis and tenosynovitis are risk factors for short term flare in RA patients in clinical remission. • Subclinical tenosynovitis, but not synovitis, was associated with disease flare in patients with unstable remission. • Ultrasound-detected tenosynovitis could be useful to predict relapses in RA patients in clinical remission.

Using patient-reported data from a smartphone app to capture and characterize real-time patient-reported flares in rheumatoid arthritis.

ObjectiveWe aimed to explore the frequency of self-reported flares and their association with preceding symptoms collected through a smartphone app by people with RA.MethodsWe used data from the Remote Monitoring of RA study, in which patients tracked their daily symptoms and weekly flares on an app. We summarized the number of self-reported flare weeks. For each week preceding a flare question, we calculated three summary features for daily symptoms: mean, variability and slope. Mixed effects logistic regression models quantified associations between flare weeks and symptom summary features. Pain was used as an example symptom for multivariate modelling.ResultsTwenty patients tracked their symptoms for a median of 81 days (interquartile range 80, 82). Fifteen of 20 participants reported at least one flare week, adding up to 54 flare weeks out of 198 participant weeks in total. Univariate mixed effects models showed that higher mean and steeper upward slopes in symptom scores in the week preceding the flare increased the likelihood of flare occurrence, but the association with variability was less strong. Multivariate modelling showed that for pain, mean scores and variability were associated with higher odds of flare, with odds ratios 1.83 (95% CI, 1.15, 2.97) and 3.12 (95% CI, 1.07, 9.13), respectively.ConclusionOur study suggests that patient-reported flares are common and are associated with higher daily RA symptom scores in the preceding week. Enabling patients to collect daily symptom data on their smartphones might, ultimately, facilitate prediction and more timely management of imminent flares.

Predictive Factors for Rheumatoid Arthritis Flare After Switching From Intravenous to Subcutaneous Formulation of Tocilizumab in Real-World Practice.

BackgroundTo evaluate the incidence and related factors of rheumatoid arthritis (RA) flares after switching from intravenous tocilizumab (TCZ-IV) to subcutaneous tocilizumab (TCZ-SC) injection in stable RA patients.MethodsWe retrospectively evaluated the medical records of stable RA patients who used TCZ-IV for more than 6 months and switched to TCZ-SC between January 2013 and April 2020. RA flare was defined as an increase of more than 1.2 in the RA disease activity as assessed by the disease activity score in 28 joints. The factors associated with RA flare were evaluated by logistic regression analysis.ResultsAmong 106 patients treated with TCZ-IV for > 6 months, 37 patients were switched to TCZ-SC after the acquisition of remission or low disease activity. RA flares occurred in 11 (29.7%) of patients who switched TCZ-SC. Results from the multivariable logistic analysis revealed that the dose of TCZ-IV per weight at switching (odds ratio [OR], 20.70; 95% confidence interval [CI], 2.22–192.84; P = 0.008) and methotrexate (MTX) non-use (OR, 8.53; 95% CI, 1.21–60.40; P = 0.032) were associated with the risk of RA flares after switching to TCZ-SC. Interestingly, most patients who switched back to TCZ-IV had their RA activity controlled again.ConclusionMTX non-use and high dose of TCZ-IV per weight were associated with a risk of RA flare after switching to TCZ-SC. RA patients with these factors need to be carefully observed for flare after switching from TCZ-IV to TCZ-SC.

Intravenous pegylated liposomal prednisolone outperforms intramuscular methylprednisolone in treating rheumatoid arthritis flares: A randomized controlled clinical trial

Glucocorticoids (GCs) are potent anti-inflammatory drugs but their use is limited by systemic exposure leading to toxicity. Targeted GC delivery to sites of inflammation via encapsulation in long-circulating liposomes may improve the therapeutic index. We performed a randomized, double-blind, active-controlled, multi-center study in which intravenously (i.v.) administered pegylated liposomal prednisolone sodium phosphate (Nanocort) was compared to equipotent intramuscular (i.m.) methylprednisolone acetate (Depo-Medrol®; i.e. a current standards-of-care for treating flares in rheumatoid arthritis patients). We enrolled 172 patients with active arthritis who met all eligibility criteria, eventually resulting in 150 patients randomized in three groups: (1) Nanocort 75 mg i.v. infusion plus i.m. saline injection; (2) Nanocort 150 mg i.v. infusion plus i.m. saline injection; and (3) Depo-Medrol® 120 mg i.m. injection plus i.v. saline infusion. Dosing in each group occurred at baseline and on day 15 (week 2). Study visits occurred at week 1, 2, 3, 4, 6, 8 and 12, to assess both efficacy and safety. The primary endpoint was the “European League Against Rheumatism” (EULAR) responder rate at week 1. Safety was determined by the occurrence of adverse events during treatment and 12 weeks of follow-up. Treatment with Nanocort was found to be superior to Depo-Medrol® in terms of EULAR response at week 1, with p-values of 0.007 (good response) and 0.018 (moderate response). Treatments were well tolerated with a comparable pattern of adverse events in the three treatment groups. However, the Nanocort groups had a higher incidence of hypersensitivity reactions during liposome infusion. Our results show that liposomal Nanocort is more effective than Depo-Medrol® in treating patients with rheumatoid arthritis flares and has similar safety. This is the first clinical study in a large patient population showing that i.v. administered targeted drug delivery with a nanomedicine formulation improves the therapeutic index of glucocorticoids.

Potential Short-Term Air Pollution Effects on Rheumatoid Arthritis Activity in Metropolitan Areas in the North of Italy: A Cross-Sectional Study.

Rheumatoid arthritis (RA) flare is related to increased joint damage, disability, and healthcare use. The impact of short-term air pollution exposure on RA disease activity is still a matter of debate. In this cross-sectional study, we investigated whether short-term exposure to particulate matter (PM)10, PM2.5, nitrogen dioxide (NO2), and ozone (O3) affected RA disease activity (DAS28 and SDAI) in 422 consecutive RA residents in Lombardy, North of Italy. Air pollutant concentrations, estimated by Regional Environmental Protection Agency (Lombardy—Italy) at the municipality level, were used to assign short-term exposure from the day of enrolment, back to seven days. Some significant negative associations emerged between RA disease activity, PM10, and NO2, whereas some positive associations were observed for O3. Patients were also stratified according to their ongoing Disease-Modifying anti-Rheumatic Drugs (DMARDs) treatment: no DMARDs (n = 25), conventional synthetic DMARDs (n = 108), and biological or targeted synthetic DMARDs (n = 289). Therapy interaction seemed partially able to influence the relationship between short-term air pollution exposure and RA disease activity (PM2.5 levels and DAS28 at the day of the visit-O3 levels and disease activity scores for the seven days before the evaluation). According to our results, the impact of short-term air pollution exposure (seven days) minimally impacts disease activity. Moreover, our study suggests therapy could alter the response to environmental factors. Further evidence is needed to elucidate determinants of RA flare and its management.

A rheumatoid arthritis patient with delivery who started certolizumab pegol and tacrolimus during pregnancy.

We experienced a patient in her 30s with rheumatoid arthritis (RA) who achieved delivery with the use of certolizumab pegol (CZP) and tacrolimus (TAC) during pregnancy. She developed RA in X-3 year and was treated with salazosulfapyridine (SASP). In X-2 year, she became pregnant and discontinued SASP and had a normal delivery despite joint pain during pregnancy. She restarted SASP in X-1 year and became pregnant again in Xyear. She experienced a flare-up of RA and was referred to our rheumatic centre. We introduced CZP and TAC, and she discontinued these agents and started prednisolone just before delivery. There is reportedly minimal placental transfer of CZP because of its Fc-free structure, since the Fc part of CZP is replaced by polyethylene glycol. TAC was contraindicated during pregnancy until 2018, but its usage in such patients is now approved. Despite the flare-up of RA during pregnancy, we were able to reduce the disease activity by introducing CZP and TAC during pregnancy. We believe that the present findings support the efficacy of this approach for treating RA flare during pregnancy.

BIOlogical Factors that Limit sustAined Remission in rhEumatoid arthritis (the BIO-FLARE study): protocol for a non-randomised longitudinal cohort study

BackgroundOur knowledge of immune-mediated inflammatory disease (IMID) aetiology and pathogenesis has improved greatly over recent years, however, very little is known of the factors that trigger disease relapses (flares), converting diseases from inactive to active states. Focussing on rheumatoid arthritis (RA), the challenge that we will address is why IMIDs remit and relapse. Extrapolating from pathogenetic factors involved in disease initiation, new episodes of inflammation could be triggered by recurrent systemic immune dysregulation or locally by factors within the joint, either of which could be endorsed by overarching epigenetic factors or changes in systemic or localised metabolism.MethodsThe BIO-FLARE study is a non-randomised longitudinal cohort study that aims to enrol 150 patients with RA in remission on a stable dose of non-biologic disease-modifying anti-rheumatic drugs (DMARDs), who consent to discontinue treatment. Participants stop their DMARDs at time 0 and are offered an optional ultrasound-guided synovial biopsy. They are studied intensively, with blood sampling and clinical evaluation at weeks 0, 2, 5, 8, 12 and 24. It is anticipated that 50% of participants will have a disease flare, whilst 50% remain in drug-free remission for the study duration (24 weeks). Flaring participants undergo an ultrasound-guided synovial biopsy before reinstatement of previous treatment. Blood samples will be used to investigate immune cell subsets, their activation status and their cytokine profile, autoantibody profiles and epigenetic profiles. Synovial biopsies will be examined to profile cell lineages and subtypes present at flare. Blood, urine and synovium will be examined to determine metabolic profiles. Taking into account all generated data, multivariate statistical techniques will be employed to develop a model to predict impending flare in RA, highlighting therapeutic pathways and informative biomarkers. Despite initial recruitment to time and target, the SARS-CoV-2 pandemic has impacted significantly, and a decision was taken to close recruitment at 118 participants with complete data.DiscussionThis study aims to investigate the pathogenesis of flare in rheumatoid arthritis, which is a significant knowledge gap in our understanding, addressing a major unmet patient need.Trial registrationThe study was retrospectively registered on 27/06/2019 in the ISRCTN registry 16371380.

Renal oncocytoma in a female patient with rheumatoid arthritis and secondary Sjögren’s syndrome: Non-coincidental link to autoimmunity?*

The objective of the article was to describe a female patient with rheumatoid arthritis (RA) and secondary Sjogren’s syndrome (SS) who developed a renal oncocytoma and was cured by percutaneous cryoablation therapy. A 72-year-old female patient with a long-term history of polyarthritis involving her hands, shoulders, knees, and ankles associated with morning stiffness and rheumatoid factor of 107 U/mL (nr: <29 U/mL) and anti-CCP of 121 U/mL (nr:<5 U/mL). A diagnosis of RA was determined 10 years ago, and prednisone with methotrexate were initiated, later changed for leflunomide 20mg/day. In 2014 a diagnosis of secondary SS was determined. In April 2014, during a routine abdominal ultrasound, a tumor was found in her left kidney. A magnetic resonance imaging confirmed a solid nodule with hypervascularization on the left kidney. She was submitted to a percutaneous cryoablation procedure without any intercurrence, and it had success. The histopathological analysis demonstrated a renal oncocytoma limited to the left kidney. No chemotherapy or radiotherapy was needed. After surgery, a flare of RA was noted and was resistant to methotrexate and sulfasalazine. Rituximab was then started, and she had an excellent progressive response. Minor thyroid changes were registered by ultrasound monitoring and signs of hyperparathyroidism manifested. This observation illustrates the first ever described case of a patient with RA and secondary SS who developed several years after the RA onset, a renal oncocytoma, and was successfully treated with cryoablation therapy. The possible links between oncocytic cell metaplasia/neoplasia and autoimmunity are discussed.

Rheumatoid Vasculitis as an Initial Presentation of Rheumatoid Arthritis.

Extra-articular manifestations like rheumatoid vasculitis and pericarditis rarely present as initial manifestations of rheumatoid arthritis.A high index of suspicion is required to make the diagnosis, especially in an adult who presents with multiorgan manifestations, rash, and a high titre of rheumatoid factor and anti-CCP antibody levels.

Association between environmental air pollution and rheumatoid arthritis flares

Association between environmental air pollution and rheumatoid arthritis flares

Prediction of disease flare by biomarkers after discontinuing biologics in patients with rheumatoid arthritis achieving stringent remission

To elucidate the disease-flare process in rheumatoid arthritis (RA) after discontinuing biological disease-modifying antirheumatic drugs (bDMARDs), we first focused on RA-flare prediction after achieving stringent remission criteria. Patients with RA who maintained a simplified disease activity index ≤ 3.3 for ≥ 3 months during November 2014–January 2018 in our medical centre in Tokyo, Japan, were eligible. The primary endpoint was flare (disease activity score 28—erythrocyte sedimentation rate ≥ 3.2 with increase from baseline > 0.6) within 2 years after bDMARD discontinuation. Comprehensive clinical assessments, ultrasonographic evaluation of 40 joints, and blood sampling for 12 biomarkers were performed every 2–3 months for 2 years unless patients experienced flare. Flare-positive and flare-negative patients were compared using univariate and Kaplan–Meier analyses. Thirty-six patients (80.6% female, median disease duration, 5.2 years; median treatment period with discontinued bDMARD, 2 years; median remission duration, 18 months) were enrolled. Twenty patients (55.6%) experienced RA flare 43–651 (median, 115) days after the first skipped date of bDMARDs. Two patients who withdrew without disease flare were excluded from the comparison. Clinical and ultrasonographic evaluations did not show significant between-group differences; Kaplan–Meier analysis showed that higher baseline soluble tumour necrosis factor receptor 1 (sTNFR1) concentration impacted subsequent disease flare (p = 0.0041); higher baseline interleukin (IL)-2 concentration was exclusively beneficial to patients with lower sTNFR1 (p = 0.0058), resulting in remission maintenance in 83.3% of patients with lower sTNFR1 and higher IL-2. We demonstrated the usefulness of combined biomarker evaluation for predicting sustained remission after bDMARD discontinuation in RA.

Response to Dr. Essouma regarding the article by Adami et al.

Response to Dr. Essouma regarding the article by Adami et al.

Arthritis after SARS-CoV-2 infection.

In COVID-19, the pivotal cytokines that provoke severe disease in the lung are similar to those usually targeted by drugs used for treating rheumatoid arthritis. Although COVID-19 is not yet considered as a trigger for rheumatoid arthritis, this similarity has led to the suspicion that COVID-19 might be a risk factor for inducing a rheumatoid arthritis flare.1 Recently, arthralgia and arthritis have been reported after SARS-CoV-2 infection in three patients that were negative for rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA).

Comment on: Association between environmental air pollution and rheumatoid arthritis flares.

Comment on: Association between environmental air pollution and rheumatoid arthritis flares.

Association between environmental air pollution and rheumatoid arthritis flares.

Environmental air pollution has been linked to the pathogenesis of RA. Nevertheless, evidence linking higher concentrations of air pollutants with the risk of RA reactivations is missing. The objective of the present study was to determine the association between RA flares and air pollution. We collected longitudinal data of patients affected by RA and of the daily concentration of air pollutants in the Verona area. We designed a case-crossover study. We compared the exposure to pollutants in the 30-day and 60-day periods preceding an arthritic flare referent to the 30-day and 60-day preceding a low-disease activity visit. The study included 888 patients with RA with 3396 follow-up visits; 13636 daily air pollution records were retrieved. We found an exposure-response relationship between the concentration of air pollutants and the risk of having abnormal CRP levels. Patients exposed to greater concentrations of air pollutants were at higher risk of having CRP levels ≥5 mg/l. Concentrations of CO, NO, NO2, NOx, PM10, PM2.5 and O3 were higher in the 60-day period preceding a flare. We found a striking association between air pollution and RA disease severity and reactivations in a cohort of patients followed over a 5-year period. The exposure to high levels of air pollutants was associated with increased CRP levels and a higher risk of experiencing a flare of arthritis. This excessive risk was evident at very low levels of exposure.

Is gene expression among women with rheumatoid arthritis dysregulated during a postpartum flare?

BackgroundTo evaluate our hypotheses that, when rheumatoid arthritis (RA) flares postpartum, gene expression patterns are altered compared to (a) healthy women, (b) RA women whose disease activity is low or in remission postpartum, and (c) pre-pregnancy expression profiles.MethodsTwelve women with RA and five healthy women were included in this pilot study. RA disease activity and postpartum flare were assessed using the Clinical Disease Activity Index (CDAI). Total RNA from frozen whole blood was used for RNA sequencing. Differential gene expression within the same women (within-group) over time, i.e., postpartum vs. third trimester (T3) or pre-pregnancy (T0), were examined, using a significance threshold of q < 0.05 and fold-change ≥ 2.ResultsNine of the women with RA experienced a flare postpartum (RAFlare), while three had low disease activity or were in remission (RANoFlare) during that time frame. Numerous immune-related genes were differentially expressed postpartum (vs. T3) during a flare. Fold-changes in expression from T3 to postpartum were mostly comparable between the RAFlare and healthy groups. At 3 months postpartum, compared to healthy women, several genes were significantly differentially expressed only among the RAFlare women, and not among the RANoFlare women. Some of these genes were among those whose “normal” expression was significantly modulated postpartum, and the postpartum expression patterns were significantly altered during the RA flare. There were also some genes that were significantly differentially expressed in RAFlare compared to both healthy and RANoFlare women, even though their expression was not significantly modulated postpartum. Furthermore, while postpartum expression profiles were similar to those at pre-pregnancy among healthy women, significant differences were found between those time points among the RAFlare women.ConclusionsThe large majority of gene expression changes between T3 and 3 months postpartum among RA women who flared postpartum reflected normal postpartum changes also seen among healthy women. Nonetheless, during a postpartum flare, a set of immune-related genes showed dysregulated expression compared to healthy women and women with RA whose disease activity was low or in remission during the same time frame, while other genes demonstrated significant differences in expression compared to RA pre-pregnancy levels.

Efficacy of Oral Vitamin Supplementation in Inflammatory Rheumatic Disorders: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: We aimed to provide a systematic review and meta-analysis of randomized controlled trials assessing the effect of oral vitamin supplementation on symptoms and disease activity in patients with rheumatoid arthritis (RA), spondyloarthritis (SpA) and psoriatic arthritis (PsA). Methods: A systematic literature review and meta-analysis of randomized controlled trials including patients with inflammatory rheumatic diseases were performed using MEDLINE, EMBASE and abstracts from recent international rheumatology congresses. Studies were reviewed in accordance with PRISMA guidelines. We analysed clinical outcomes according to each type of vitamin supplementation. Results. The initial search yielded 606 articles. Of these, 13 studies were included in the qualitative synthesis: eight studied vitamin D supplementation, two assessed vitamin E supplementation, two folic acid, and one vitamin K, all of them on RA patients. No studies on SpA or PsA were selected. Oral vitamin supplementations were not associated with a reduction in RA activity (DAS-28 or pain) or RA flares. Conclusions: Despite their beneficial effects, the effects of vitamin supplementation on RA activity, if any, seem to be limited. Evidence on their efficacy on SpA or PsA activity is lacking. However, folic acid supplementation should be suggested to prevent methotrexate-related side effects, and vitamin D should be given to patients with vitamin D deficiency to prevent musculo-skeletal complications.

An Update on Imaging in Rheumatoid Arthritis

Modern imaging modalities allow accurate detection of both inflammation and damage in rheumatoid arthritis (RA) joints. This narrative review aims to summarize the recent literature relating to magnetic resonance imaging (MRI), musculoskeletal ultrasound (MSUS) and high-resolution peripheral quantitative computerized tomography (HR-pQCT). Imaging has aided understanding of the pathogenesis of RA: HR-pQCT studies suggest that cortical micro-channels may facilitate erosive changes in the setting of synovitis. Both MRI and MSUS studies have aimed to quantify the degree of changes seen in asymptomatic people where age-related changes are common, highlighting the importance of understanding the thresholds of ‘normality’. Whilst synovitis has been considered the characteristic feature of RA, there is growing evidence that imaging-detected tenosynovitis may be of importance in predicting the development of RA, diagnosing RA and predicting flare in stable RA. Much focus has been placed on recent MRI and MSUS studies demonstrating that systematic repeated imaging of RA treated with tight control strategies does not improve outcomes at the group level; however these studies did not explore pre-test probability issues at the individual patient level. The literature is somewhat mixed on whether MRI and MSUS may provide useful guidance on which patients in remission can safely have therapy de-escalated. Recent work has also continued to validate and refine pathology definitions and semi-quantitative scoring for these tools as outcome measures in clinical trials. A review of recently published literature allowed the identification of several themes: understanding pathogenesis, attempts to define ‘normal’ joints on imaging, the utility of imaging in the diagnosis of RA, predicting the development of RA in at risk populations and the relevance to Ra clinical practice and trials.

SYMPTOMATIC PULMONARY AND INTRACRANIAL NODULES IN A PATIENT WITH LONGSTANDING, UNCONTROLLED RHEUMATOID ARTHRITIS

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary manifestations of rheumatoid arthritis (RA) are found in 60-80% of all RA patients and are responsible for 10-20% of RA-related mortality. RA nodules are observed in approximately 20% of RA patients with 20- 32% prevalence pulmonary RA nodules. Rarer intracranial RA nodules have been described in two case studies.1 Here we present a patient who demonstrates significant symptomatic pulmonary nodulosis along with intracranial nodules leading to intractable seizures and ventilator support. CASE PRESENTATION: Our patient was a 67-year-old woman with a 9-year history of RA, recurrent bilateral knee septic arthritis, and three months of focal seizures who presented to the emergency department for breakthrough focal seizures. Prior magnetic resonance imaging (MRI) showed contrast enhancing right temporal and right thalamic nodules up to 4mm consistent with electroencephalogram (EEG) localization of the seizures. Rheumatologically, the patient had RA flares multiple times per month despite maximal doses of hydroxychloroquine, leflunomide, and methrotrexate (MTX). 6 months prior, an outpatient Chest CT ordered for evaluation of dyspnea showed multiple solid and cavitary pulmonary lesions. Endobronchial ultrasound with biopsy of nodules showed necrotizing granulomatous inflammation consistent with RA nodules. During hospitalization, the patient presented with mildly elevated CRP, RF, and anti-CCP, and mildly decreased complement C3 but otherwise normal exam and negative serologic and cerebrospinal fluid tuberculosis, fungal, bacterial, viral, cancer and autoimmune workup. Repeat imaging showed multiple new bilateral pulmonary nodules up to 2.3 cm with stable intracranial nodules despite empiric acyclovir. The patient continued to have seizures in the unit despite maximal doses of intravenous seizure medication, six days later developing, ultimately fatal severe metabolic acidosis, bradycardia, and hypotension. DISCUSSION: This unique case of symptomatic intracranial and pulmonary nodules in the setting of RA does not have much literature accompaniment, but we hope to add our experience to a potential disease etiology. Several case reports, however, do show reduction in pulmonary nodule size with oral steroid courses. There is currently no strong consensus on treatment of RA nodules. While RA nodules are often considered relatively benign, in this patient the EEG and imaging finding suggest that the nodules may have significantly contributed to this patient’s breakthrough seizures. Unfortunately due to this patient’s comorbidities and tenuous medical status, pathologic review of the brain lesions was not obtained. CONCLUSIONS: This report highlights the need to consider RA as a potentially reversible cause when considering unexplained systemic findings, as well as the need for more research into treatment of extraarticular manifestations of RA. Reference #1: Esposito AJ, Chu SG, Madan R, Doyle TJ, Dellaripa PF. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med 2019;40(3):545–560. DISCLOSURES: No relevant relationships by Oleh Hnatiuk, source=Web Response No relevant relationships by adarsh vangala, source=Web Response No relevant relationships by Nicholas Villalobos, source=Web Response

Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI

Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.