Case report - Introduction In December 2019, the first cluster of Coronavirus disease 2019 (COVID-19) cases caused by the novel coronavirus SARS-CoV-2 was identified in Wuhan, China. The disease was declared a global pandemic on 11th March 2020. COVID-19 was initially thought to cause respiratory complications only, however several extra pulmonary manifestations of the infection have since emerged. We report a rare case of reactive arthritis (ReA), urticarial rash and angioedema in a young female secondary to COVID-19 infection. Rashes were recently added to the World Health Organisation (WHO) criteria for diagnosis of COVID-19 demonstrating their significance. Case report - Case description A 31-year-old female doctor was admitted with acute swelling of her lips, dysphagia, and a widespread urticarial rash. Preceding this she had a one-week history of fever, cough, and constitutional symptoms of malaise and weight loss. Her symptoms had started at the end of April 2020 during the peak of the COVID-19 pandemic in the United Kingdom. Three days later she developed painful swelling of her wrists, elbows, knees, and hands. She reported no back or sacroiliac joint pain, enthesitis or any previous history of inflammatory joint pains. She had a history of platelet dysfunction and was treated with Desmopressin. Clinical examination revealed a widespread urticarial rash over her face, limbs, and trunk, with no nail abnormalities. She had active synovitis in her right wrist, elbow, and mild bilateral knee effusions. All other joints including spine and sacroiliac joints were normal. She had no dactylitis or enthesitis. Systemic examination was normal. Investigations revealed Hb 113 g/L, MCV 88.2 fL, Platelets 282 x 109/L, WCC 6.6 x 109/L and Lymphocytes of 0.63 x 109/L with normal neutrophil and eosinophil count. CRP was raised at 107mg/L. She had a negative autoimmune screen including ANA, ANCA, IgM-RF, anti-CCP antibodies and HLA B27. Plain radiographs of knees were normal. SARS CoV-2 PCR was positive following a nasal swab. Urine and blood cultures were negative. Treatment was commenced with intravenous hydrocortisone and antihistamines with resolution of her angioedema symptoms; however, her rash and arthritis persisted. The patient was diagnosed with Reactive Arthritis (ReA), urticarial rash and angioedema secondary to COVID-19 infection. Prednisolone 30mg daily was started, and within a week her arthritis and rash markedly improved. Prednisolone was tapered over six weeks. By her two-month clinic follow up, she reported no further joint swelling and was functioning normally. Case report - Discussion The most common complication of COVID-19 is Acute Respiratory Distress Syndrome (ARDS) however several other serious complications have been identified including cardiac injury, thromboembolic events, neurological abnormalities, and an aggravated inflammatory response causing a cytokine storm. ReA is a post infectious arthritis commonly seen following gastrointestinal or genitourinary infections and is yet to be recognised as a complication of this disease. ReA most commonly presents as an asymmetrical peripheral or axial spondyloarthropathy. The affected joints do not contain pathogen. More than half of ReA cases resolve spontaneously within six months without requiring long-term treatments. Up to 20% of patients with COVID-19 infection have been shown to develop cutaneous manifestations including erythematous rash, vesicular rash, acral ischaemia, rash with petechiae, and widespread urticaria. This has led to the recent addition of rashes to the World Health Organisation (WHO) Criteria for diagnosis of COVID-19 infection. Additionally, as COVID-19 has an incubation period of 14 days where patients can be asymptomatic, cutaneous manifestations may serve as an early indicator of infection, aiding in a more rapid diagnosis. Case report - Key learning points We present a rare case of ReA secondary to COVID-19 infection, with complete resolution of symptoms following administration of oral glucocorticoids. A detailed history and examination of the musculoskeletal system should be undertaken in all patients presenting with COVID-19. Urticarial rashes should be considered as an early symptom of COVID-19 infection as per the WHO criteria for diagnosis. Glucocorticoids can be considered in treating patients with this presentation, where traditional anti-inflammatory agents have been refractory or contraindicated.

Background:Giant cell arteritis (GCA) is an emergency. The initial treatment with high dose glucocorticoids (GC) is often started on clinical suspicion without waiting for Temporal artery biopsy (TAB) results, which can take days to be available. TAUS is a simple, non-invasive test which is readily available. However, like any other ultrasound, it is also operator dependent. A positive halo sign is the most specific abnormality seen on TAUS in GCA patients. The percentage of false positive TAUS in GCA diagnosis is low (1), but it can result in over diagnosis and unnecessary exposure to high dose GC in elderly population.Objectives:We looked at the reliability of TAUS in ruling out GCA after it was introduced within our rheumatology department one year ago.Methods:We adopted the quality improvement methodology for assessment. Retrospective data of suspected GCA patients was collected over the last two years. TAUS was introduced regularly to the investigative plan after eleven months. Two Rheumatology consultants were trained in TAUS. Results were compared before and after the introduction of ultrasound as a diagnostic tool. In collecting the data, our main focus for documentation was based on clinical symptoms, TAUS and TAB results. We aimed to increase the awareness of appropriate GCA referrals among the primary and secondary care with the support of teaching sessions.Results:From January 2018 to November 2019, 101 patients were referred to rheumatology with suspected GCA. Median age of our cohort was 72 years with male to female ratio of 1:3. 35 patients were referred in the first 11 months out of which, 10 (28.6%) were diagnosed with GCA. TAUS and TAB was done in 20% and 49% of patients respectively. 66 patients were referred in the next 12 months after TAUS was introduced. Out of 66, 14 patients (21.2%) were diagnosed as GCA. TAUS and TAB were done in 82% and 38% of the patients respectively. As listed in table 1, only 1 patient was found to have positive TAB after a negative TAUS (false negative). All of patients with positive TAUS were treated as GCA on the basis of clinical grounds, irrespective of TAB results. Despite the regular use of TAUS as a diagnostic tool in the second phase, there is a higher percentage of patients (78.8%) in which GCA was ruled out.TAUS introductionBefore regular TAUS(Jan 2018 – Nov 2018)After regular TAUS(Dec 2018 – Nov 2019)Patients referred3566GCA10 (28.6%)14 (21.2%)Not GCA25 (71.4%)52 (78.8%)TAUS done in20%82%TAB done in49%38%TAUS -ve and TAB +ve01TAUS +ve and TAB -ve/not done28Conclusion:After the routine introduction of TAUS, the percentage of patients diagnosed with GCA has declined and clinicians have been able to exclude suspected GCA diagnosis in a larger proportion of patients referred. This is noteworthy as our Rheumatologists are still in the learning phases of determining the significance of utility of TAUS. There is only a small decline in TAB frequency, which is expected to go down further in the coming years. We also noticed that the number of patients referred has almost doubled. This might be due to better education and awareness at the primary and secondary care level which was done as part of the project.References:[1]Fernández E, Monjo I, Bonilla G, et alOP0210 FALSE POSITIVES OF ULTRASOUND IN GIANT CELL ARTERITIS. SOME DISEASES CAN ALSO HAVE HALO SIGNAnnals of the Rheumatic Diseases2019;78:181Disclosure of Interests:None declared

Background Timely diagnosis of tuberculosis (TB) infection is important in patients receiving biologics. Current BSR guidelines on biologic safety in inflammatory arthritis (2018) advise to screen all patients for TB before starting treatment. Due to limitations of tuberculin skin test (TST), IFN-γ release assay (IGRA) is frequently used in addition to clinical examination, risk assessment and chest x-ray (CXR). There are no clear guidelines whether IGRA should be part of follow up assessments. The Royal College of Nursing suggest patients on biologics should have repeat CXR in 3 months after starting biologics and then annually. The American College of Rheumatology suggest an annual TST or IGRA for high-risk individuals receiving biologics. Centers for disease control and prevention guidelines allows to use TST and IGRA for surveillance in selected population. Methods We present two cases in which patients developed TB after starting biologics. Both patients had negative IGRA, normal CXR and low risk of developing TB on prebiologic screening. Results First patient was a 64-year-old female with rheumatoid arthritis diagnosed in 2001. She failed multiple conventional DMARDs and was started on Certolizumab in 2014. Prebiologic screen showed a negative IGRA (T Spot) and CXR was clear. She was a smoker and her mother had pulmonary TB when she was a child. After 4 years she presented with weight loss and cough. CXR showed 1.4 cm round opacity in right upper lobe. She underwent surgical resection and histology showed acid fast bacilli on ZN stain with superimposed aspergilloma. She was started on quadruple therapy and we switched Certolizumab to Etanercept due to its shorter half-life. Second patient was a 27-year-old man with ankylosing spondylitis diagnosed in 2015. He was a smoker and had no past medical history. He was started on Adalimumab in 2016. T Spot was negative and CXR was clear. There were no risk factors for TB. Two years later he presented with multiple tender subcutaneous nodules over thighs and lower abdomen. Skin biopsy after dermatology assessment showed superficial and deep perivascular inflammation with lymphocytes and small number of eosinophils. Differential were granulomatous infection or panniculitis due to injection site reaction. TB cultures came back negative but repeat T Spot was positive. He was treated as latent TB infection for 3 months and Adalimumab was restarted without any problems. Conclusion Current BSR guidelines advise to monitor patient clinically for any signs of TB while receiving biologics. We suggest that there is a need to review whether TST or IGRA should be done annually on high risk patients along with CXR. Disclosures A.A. Sidhu None. A. Nandagudi None.

BackgroundMethotrexate (MTX) remains the first line treatment in majority of cases of inflammatory arthritis. The current British Society of Rheumatology (BSR) Guidelines suggest checking Full blood Count (FBC), ALT/AST, Albumin, Creatinine at 0,2,4,6,10,14, 18 weeks and then 12 weekly. Despite this close monitoring recommendation, MTX is generally considered a safe drug by Rheumatologists and its use has grown significantly over last two decades.ObjectivesTo evaluate the incidence of liver, renal and haematological toxicities during Methotrexate treatment and calculate the cost implications.Methods101 patients (30 males 71 females) (Age 40-89 year Mean 66.5 year) prescribed MTX were randomly selected and retrospective analysis was performed. 91 Rheumatoid arthritis, 8 Psoriatic arthritis and 2 patients had Undifferentiated Inflammatory Arthritis. 20 patients had Early Inflammatory Arthritis (<1 year) and 81 had established disease. 24 patients were on MTX for <1 year. Average dose of MTX in our cohort was 15mg once weekly (Min 7.5mg Max 25mg). All patients were on folate supplementation. Blood investigations over last 1 year were reviewed individually for all patients. Severe Liver toxicity (LS) was defined as ALT/AST >100 U/l; unexplained reduction in albumin <30 g/l and mild liver toxicity (LM) was between normal and LS values. Severe haematological toxicity (HS) was defined as WCC <3.5 × 109/l, MCV >105 fL, Neut <1.6 × 109/l, PLT <140 × 109/l unexplained eosinophilia >0.5 × 109/l and mild haematological toxicity (HM) was between normal and HS. Severe renal toxicity (RS) was defined as Creatinine increase >30% over 12 months and/or calculated GFR <60 ml/min. Mild renal toxicity (RM) was between normal and RS.ResultsOver 1 year, 101 patients had total of 609 blood tests for MTX monitoring (Min 1 Max 17). FBC, Liver Function Test, Urea & Electrolytes, CRP and ESR each cost £8.54. LS was found in 4 patients, LM in 15, HM in 3 and RM in 2 patients. MTX was stopped in all 4 patients with LS. Mild toxicities (LM, HM and RM) recovered after close monitoring or reduction in dose. 5 patients with mild toxicities were on MTX for <1 year. Rest of the patients were on stable dose of MTX for >1 year. All patients with severe and mild toxicities did not have any significant comorbidities compared to rest of the patients. It was calculated that detecting one LS cost (609x8.54)/4 = £1300.2. Similarly one LM cost £346.7, one HM £1733.6 and one RM £2600.43. These costs does not include travel expenses, parking charges and time off work for appointments in phlebotomy.ConclusionOur cohort shows that mild liver toxicity is the most commonly found abnormality during MTX monitoring and patients on stable doses still need monitoring for liver toxicity. Haematological and renal toxicities are much less common and a more relaxed monitoring schedule may be acceptable for these parameters. Regular monitoring for inflammatory markers (CRP, ESR) causes an extra cost burden. The direct cost for identifying each abnormality is considerable.Re...