Occam's razor, the principle that a single explanation is the most likely in medicine, assumes that when a patient has multiple symptoms the clinician seeks a single diagnosis rather than diagnosing multiple and different ones. However, as proposed by Hickam’s dictum, sometimes rare different diseases occurred in only one patient. We present a patient with a simultaneous diagnosis of two rare tumours, a cardiac hemangioma (primary cardiac tumour, often misdiagnosed as myxoma) and an appendiceal mucocele (a lesion of the appendix that can be neoplastic or not). A 71-year-old male presented with anorexia, asthenia, fever and weight loss for about one month. During the etiological investigation, a cardiac mass and an appendiceal lesion were detected and both lesions required surgical intervention. Cardiac and abdominal surgeries were uneventful and full recovery was achieved. The histological examination showed a cardiac hemangioma and a neoplastic appendiceal mucocele.

Reactive arthritis (ReA) with the classic triad of arthritis, conjunctivitis and urethritis, previously termed Reiter’s syndrome, is a systemic illness, usually induced by genitourinary or gastrointestinal infections. However, it can be a rare complication of intravesical Bacillus Calmette-Guérin instillation (iBCG), a therapy prepared from attenuated strains of Mycobacterium bovis, a common and effective treatment for carcinoma in situ of the bladder (CisB). We report a case of a patient with CisB who developed ReA after iBCG. The symptoms resolved completely with corticosteroids. iBCG was stopped with no recurrence of carcinoma within 2 years.

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Background:Autoimmune disease (AID) has been associated with increased risk of influenza and influenza-like illness (ILI) and its worse clinical outcomes complications.Objectives:We aimed to assess the influence and difference of several immunosuppressive (IS) treatments in the incidence of ILI, including glucocorticoids (GC), classic DMARDs and biologic DMARDs.Methods:We conducted a cross-sectional study in two autoimmune clinics. Patients were invited to answer a survey reporting ILI symptoms between October 2017 and March 2018. ILI definition was considered according to the European Center for Disease Control. Data regarding current IS, diagnostic, disease activity, comorbidities, and vaccination coverage were collected from electronic registry. Patients with history of cancer, HIV, IGIV treatment, or lack of information were excluded. Univariate and multivariate logistic regression analysis were used to access predictors of ILI.Results:We included 109 patients, with mean age 51 years and 81% female gender. The majority of patients had autoimmune arthropathy (n=54) or a connective tissue disease (n=44). Active disease was present in in 39% of patients. IS treatment was: GC 31%, classic DMARD 44%, biologic DMARD 28%. Vaccine coverage was 51%. Overall 41% reported ILI. We did not find any association between studied variables and ILI, including univariate and multivariate analysis. Univariate odds ratio calculation for IS treatment were: GC [OR 1,68 IC 0,7-3,8], classic DMARD [OR 1,03 IC 0,5-2,2], and biologic DMARD [OR 0,86 IC 0,4-2,0]. Comorbidity of pulmonary disease (n=8) may contribute to higher risk to ILI [OR 2,76 IC 0,8-10,0].Conclusion:There was no difference in risk of ILI within different IS treatment regimens, although GC may increase the risk. The study is limited by the subjectivity of the ILI survey and the small size of the sample. The stratification of influenza risk will help in designing better vaccine coverage strategies in this population.References:[1]Nakafero G, Grainge MJ, Myles PR, Mallen CD, Zhang W, Doherty M, Nguyen-Van-Tam JS, Abhishek A. Predictors and temporal trend of flu vaccination in auto-immune rheumatic diseases in the UK: a nationwide prospective cohort study. Rheumatology (Oxford). 2018 Oct 1;57(10):1726-1734.[2]Danza A, Ruiz-Irastorza G. Infection risk in systemic lupus erythematosus patients: susceptibility factors and preventive strategies. Lupus. 2013 Oct;22(12):1286-94.[3]McLean-Tooke A, Aldridge C, Waugh S, Spickett GP, Kay L. Methotrexate, rheumatoid arthritis and infection risk: what is the evidence? Rheumatology (Oxford). 2009 Aug;48(8):867-71.[4]Lacaille D, Guh DP, Abrahamowicz M, Anis AH, Esdaile JM. Use of non biologic disease-modifying antirheumatic drugs and risk of infection in patients with rheumatoid arthritis. Arthritis Rheum. 2008 Aug 15;59(8):1074-81.[5]Bernatsky S, Hudson M, Suissa S. Anti-rheumatic drug use and risk of serious infections in rheumatoid arthritis. Rheumatology (Oxford). 2007 Jul;46(7):1157-60.[6]Doran MF, Crowson CS, Pond GR, O’Fallon WM, Gabriel SE. Predictors of infection in rheumatoid arthritis. Arthritis Rheum. 2002 Sep;46(9):2294-300.[7]Fessler BJ. Infectious diseases in systemic lupus erythematosus: risk factors, management and prophylaxis. Best Pract Res Clin Rheumatol. 2002 Apr;16(2):281-91. Review.[8]Singh JA, Wells GA, Christensen R, Tanjong Ghogomu E, Maxwell L, Macdonald JK, Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008794.Acknowledgments:None.Disclosure of Interests:None declared

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