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SARS-CoV-2 multisystem inflammatory syndrome in an adult presenting with polyarthritis treated with anakinra DEAR EDITOR, Coronavirus disease 2019 (COVID-19) multisystem inflammatory syndrome in adults (MIS-A) is a new inflammatory disorder characterized by fever and cardiovascular, gastrointestinal, mucocutaneous and neurologic symptoms, with a striking absence of severe pulmonary illness, presenting either simultaneously or subsequently to a recent positive COVID-19 test [1]. This is likely the same as the better-described condition of multisystem inflammatory syndrome in children (MIS-C) [2]. Both of these are thought to be post-infectious complications. Pathophysiology remains unknown, but it is characterized by abnormal inflammatory markers, including CRP, ferritin and IL-6 [3].We describe a case of COVID-19 MIS-A in a patient who responded to treatment with anakinra. This case is unique because the patient presented with inflammatory arthritis, which is rarely reported in COVID-19 MIS-A, and its presence enabled comparisons between adultonset Still's disease (AOSD), and its complication, macrophage activation syndrome (MAS).We encountered a 58-year-old male with medical history of hypertension, gout and mild severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on 1 April 2021, who presented on 1 May 2021 with malaise, fever and inflammatory arthritis of the left wrist, right ankle and left first MTP joint. Two weeks before hospitalization, he was prescribed ibuprofen and prednisone for presumed gout, without symptom resolution. He was febrile to 103 F, tachycardic and hypotensive, with leucocytosis, and elevated ESR, CRP, procalcitonin and ferritin. On examination, his left wrist was inflamed and tender to palpation and movement. He was started on antibiotics and admitted for presumed septic arthritis. However, culture of the left wrist SF did not reveal any organisms.Within 72 h, he developed diarrhoea, nonexudative conjunctivitis, shock and respiratory distress, ultimately requiring intubation and vasopressor support. CT angiogram of the chest showed minimal ill-defined airspace opacities in the left lower lobe, and antibiotics were

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Table. Systemic Lupus Erythematous-Associated Conditions by Chief Complaint a Chief Complaint SLE-Associated Conditions (Emergent conditions bolded) Suggested Workup Clinical Pearls Fever Active SLE Pericarditis Infection (consider opportunistic infections if immunocompromised) Arterial or venous thromboembolism Acute lupus pneumonitis Diffuse alveolar hemorrhage Chest X-ray Urinalysis Consider blood cultures Other infectious workup based on symptoms Imaging if concern for thromboembolic disease Double-stranded DNA and C3 and C4 complements can suggest general SLE flare, but results may not be available during ED visit. Joint pain Active SLE Avascular necrosis (especially when hips or knees are involved) Septic arthritis Plain radiography Non-urgent MRI if avascular necrosis is suspected Arthrocentesis if septic arthritis is suspected A single inflamed, painful joint is less likely to be caused by active SLE and should prompt consideration of septic arthritis. Cover for Salmonella and typical gram-positive organisms with ceftriaxone and vancomycin. Rash Malar rash Photosensitive rash Discoid lupus Cutaneous vasculitis Evaluate for systemic vasculitis if cutaneous vasculitis is present Headache Primary headache disorder CNS infection Dural sinus thrombosis CNS vasculitis Consider imaging or LP if headache is new or different from previous headaches, or if there are other concerning signs or symptoms CT is not sensitive for dural sinus thrombosis. Choose MRI when this is suspected.