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Background: MTX is the most commonly used DMARD for management of inflammatory arthritis. As part of its monitoring, liver function tests are regularly checked to ensure there is no liver damage. Very often in clinical practice, the liver function tests can become abnormal, which results in attributing the abnormality to MTX, and various investigations are performed including checking for active HBV and HCV infection. Although rare in developed counties, the possibility of HEV infection must be kept in mind in patients on immunosuppression when there is an unexplained sudden increase in liver enzymes which this case report illustrates. Methods: We report two cases of abnormal liver function tests which were detected as part of routine blood monitoring performed every 3 months due to being on MTX monotherapy. The first case is of a 68 year old woman with seropositive erosive RA for 8 years and had been on stable dose of 12.5 mg once weekly for last 6 years. It was noted that she had greater than tenfold elevation of aspartate and alanine aminotransferase levels and moderate elevation of alkaline phosphatase. She felt a bit tired but otherwise well. The other case is of a 32 year old Caucasian man who was on stable dose of 20 mg once weekly for 2 years for PsA. He also felt more tired with reduced appetite and was found to have a >10-fold elevation in alanine transaminase and aspartate transaminase levels. Results: In both cases, MTX was stopped and it took around 2 months for the liver enzymes to go back to previous normal levels. In both cases, there was no history of prior travel abroad when the liver tests became abnormal. Initial non-invasive liver screen was unremarkable along with normal liver US and HBV and HCV test serology; both patients were subsequently diagnosed with having HEV infection which was confirmed by positive PCR detection and positive IgM result. In both cases, following discussion with hepatologist MTX was reintroduced once the liver enzymes had become normal with no evidence of abnormality in liver enzymes later on. HEV infection happens rarely in UK but the incidence is going up due to consumption of undercooked pork and travel to developing countries. There are no reports of chronic HEV infection following immunosuppression and outcome of HEV infection is usually favourable. Conclusion: These cases highlight the importance of arranging investigations looking for HEV infections even if there is no history of travel abroad and not attributing all liver enzyme abnormalities to MTX. The diagnosis of acute hepatitis E should be considered in patients with inflammatory arthritides with acutely raised liver enzymes who are on immunosuppressants. Disclosure statement: The author has declared no conflicts of interest.

Background/Aims  Rheumatological conditions can present with a number of non-specific features like arthralgia, fever, fatigue, weight loss along with raised inflammatory markers and positive antibodies. Due to this, when similar symptoms are referred for input it is very important to consider other ‘mimics’. We report a case of Pigeon fancier’s lung presenting with these symptoms which was referred as likely connective tissue disease. Methods  A 52-year-old lady of South Asian origin was referred by her GP with six month history of 3kg weight loss, arthralgia, fatigue, low grade fever and persistently raised inflammatory markers (ESR ranging from 50-64 mm/hr, CRP 10-14 mg/L, normal BMI). On further questioning there was history of mouth ulcers, non-specific rash, occasional cough but no Raynaud’s or joint swelling. Blood investigations showed weakly positive ANA and RF but negative ENA, DNA, antiCCP , CK, C3,C4. C-ANCA was positive but PR3 negative. CXR was clear and tests for chronic infections including TB were negative. Due to lack of objective CTD signs, plan was to take a careful monitoring approach to see if clinical features evolved. A month later due to worsening cough, a CT chest/abdomen arranged by GP showed ground-glass changes consistent with pneumonitis and hence her rheumatology appointment was expedited to see if there was an autoimmune unifying diagnosis. She was also referred by her GP to the chest clinic in view of CT report and mild shortness of breath. Results  On further review, again there were no objective CTD signs. On direct questioning there was history of travelling before worsening chest symptoms to South Asia. Also around a year before her symptoms started she was given an African grey parrot. Based on this, serology for Avian precipitin was checked which showed strongly positive IgG antibodies to avian antigens (Budgerigar droppings and feathers, Pigeon feathers IgG Abs) confirming the diagnosis of pigeon fanciers lung. She fulfilled the diagnostic criteria and was asked to avoid the trigger. Urgent respiratory input was arranged where diagnosis was agreed with and disease was deemed sub-acute in presentation. Due to PFTs showing low transfer factor of 38%, Prednisolone was started with significant improvement within few days. Review of CT chest only showed inflammatory changes and no established fibrosis predicting excellent prognosis as delay in treatment can cause irreversible pulmonary fibrosis. Conclusion  A number of conditions can mimic rheumatological conditions which usually turn out to be either infectious or malignant in origin. This case highlights the importance of considering other differentials and along with taking a travel history also asking for other possible triggers like pets. In similar scenarios the diagnosis may be ‘cagey’ but as rheumatologists we are expected to answers questions which others can’t. Disclosure  M.F. Kazmi: None.

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