Background/Aims Immune checkpoint inhibitors (ICIs) are increasingly being used in oncology and there is growing evidence of rheumatological problems arising in these group of patients. ICIs have been approved for the treatment of several cancers including non-small cell lung cancer, renal cell carcinoma, Hodgkin lymphoma and other malignancies. Pembrolizumab, an anti-PD1, is known to cause inflammatory arthritis in some patients, and we report a case of relapsing-remitting synovitis with pedal oedema (RS3PE) in a patient with lung cancer. Methods A 67-year-old lady was diagnosed with adenocarcinoma in her left lung with pleural and pulmonary metastasis. She was commenced on carboplatin, pemetrexed and pembrolizumab initially for 4 cycles followed by pembrolizumab maintenance therapy for another 2 years. However, while on pembrolizumab therapy, she started to develop intermittent pain and swelling in her small joints of the hands and feet. There was marked pitting pedal oedema extending up to the knee along with swelling of the dorsum of the hand. She had intermittent swelling in the knee joints as well. Results The blood tests were negative for rheumatoid factor, anti-CCP and ANA. The CRP was markedly raised (120) from her previous values since she started developing joint symptoms. The kidney and liver function tests were within normal limits. A CT chest, abdomen pelvis was done which did not reveal any metastasis or progression of lung cancer. At the time of the review she was started on prednisolone 20mg once daily. Following this, the joint pain and swelling started to resolve, and the patient was advised to taper the steroids gradually. The pembrolizumab therapy was stopped few months later. The pedal oedema resolved within a few weeks of starting steroids and the joint inflammation settled after stopping the treatment. Conclusion ICI therapy has been known to trigger inflammatory arthropathy like RA. Psoriatic arthritis, undifferentiated monoarthritis and oligoarthritis, RS3PE and tenosynovitis have also been reported. Most published cases are mild to moderate in severity often responding to corticosteroids. Several patients have been treated with traditional DMARDs and biologics. RS3PE syndrome could be part of the paraneoplastic process but the onset of symptoms after starting pembrolizumab and rapid resolution after stopping the treatment indicates that this is likely a drug-induced adverse effect. Disclosure D. Ramachandran: None. W. Mushtaq: None. D. Makkuni: None.

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BackgroundPneumocystis jirovicii pneumonia (PJP) is a life-threatening opportunistic fungal infection with a high mortality rate (30-50%) among non-HIV immunosuppressed patients. According to previous studies cotrimoxazole prophylaxis is given for patients when their risk of PJP is greater than 3.5%[1]however these guidelines were established for patients with malignancies, stem cell and solid organ transplantations[2].The data from British registries showed a slightly higher risk in patients treated with Rituximab than Anti TNF therapies. The ACR recommends PJP prophylaxis in their recently published guidelines on ANCA associated vasculitis (AAV) and studies have shown higher PJP infection in patients with GPA than other vasculitis. The benefit for prophylaxis treatment is not clearly established in inflammatory conditions like RA and other autoimmune Rheumatological conditions(ARDs)ObjectivesTo investigate the incidence of PJP infection in patients with ARDs and explore the potential common risk factors.MethodsUsing our, electronic health record (EHR) cohort, we investigated the prevalence of PJP infections in Rheumatic patients on immunosuppressants over a period of one year.ResultsWe identified 6 non HIV patients with a confirmed diagnoses of PJP infection over a period of one year. All patients were diagnosed following bronchial lavage looking for PJP DNA in the aspirate. Only 2 out of six patients were identified to have ARDs on immunosuppressant drugs.Case1: 68 yr old gentleman, was on longstanding methotrexate for RA, presented with breathlessness and dry cough. The blood showed CRP of 200 and CT thorax revealed features consistent with RA-ILD with superimposed ground-glass changes keeping with an acute infection.He did not respond to IV antibiotics and went on to have a bronchial lavage which tested positive for PJP and was started on high dose of steroids and intravenous cotrimoxazole followed subsequently by Vancomycin and Clindamycin after not improving on cotrimoxazole. Despite ongoing medical treatment, patient deteriorated and passed away.Case 2: 77 yr old lady on rituximab for AAV(with positive MPO >129) with an established ILD secondary to the vasculitis for 7years. She presented with breathlessness and cough. Rituximab was started 7 years ago for the AAV and due to its relapsing nature, rituximab was continued with a maintenance dose of prednisolone 5- 10mg. Blood tests showed low IgM levels with normal IgG and A levels. There was no evidence of active vasculitis and she was commenced on antibiotics which made no difference to her symptoms. A HRCT thorax was done which revealed Interval progression of ILD (UIP) bilateral ground-glass changes. Bronchoscopy and lavage showed evidence of PJP DNA on PCR and the patient was commenced on IV cotrimoxazole. Patient made a slow recovery.ConclusionOur survey did not identify a high incidence of PJP in the ARD cohort however, the common denominator for PJP in the two patients we have identified seem to be an underlying ILD. The commonest CT findings noted was ground glass shadowing in addition to ILD in both cases. A strong index of suspicion, early HRCT and bronchial lavage is crucial for the diagnosis.Failure to respond to conventional treatment should alert the clinician to cotrimoxazole resistant PJP.There are case reports of emerging resistance to cotrimoxazole trin in the non-HIV immunosuppressed group, increasing the mortality.We could not make any firm recommendation based on this observational study as the numbers were very small but the clinician should consider PJP prophylaxis in RA ILD patients and patient with AAVs on long term Rituximab therapy. There is a need to incorporate prophylaxis treatment in to the guidelines.Reference[1]Green H etal. Prophylaxis of Pneumocystis pneumonia in immunocompromised non-HIV infected patients: systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2007;82(9): 1052-9.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

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