Greyscale and power Doppler ultrasonographic evaluation of normal synovial joints: correlation with pro- and anti-inflammatory cytokines and angiogenic factors.

OBJECTIVE: US is a promising tool in evaluating RA synovitis, but abnormal US findings have been reported in small subsets of normal joints in healthy subjects. This study aimed to systematically assess greyscale US (GSUS) and power Doppler US (PDUS) findings in 40 peripheral joints-the 28-joint DAS (DAS28) set, ankles and MTP joints-in healthy subjects. A composite score of abnormal US findings in 40 joints was compared with serum levels of pro-inflammatory cytokines. METHODS: US of 60 standard views in 40 joints was performed in 30 healthy subjects (total 3600 images). GSUS and PDUS were scored semi-quantitatively (0-3). Serum samples were obtained at the time of US and analysed for IL-1α, IL-1ß, IL-2, IL-6, IL-8, VEGF, TNF-α and IFN-γ using biochip array technology. RESULTS: GSUS abnormalities were more frequent than PDUS abnormalities [mean total GSUS score = 20.07 (range 6-45; maximum potential score = 180), mean total PDUS score = 4.8 (range 0-13)]. GSUS score increased with increasing age (Spearman's ρ = 0.383, P = 0.037). A PDUS signal >1 was observed only in the wrist (8%) and MTP1 (3%). GSUS scores did not correlate with any pro-inflammatory cytokine level. The total PDUS score correlated significantly with serum VEGF (r = 0.395, P = 0.046). CONCLUSION: PDUS signals >1 are rarely seen in normal synovial joints. GSUS synovitis, but not PDUS, may reflect age-related joint changes. PDUS correlated with VEGF, providing further evidence of a central role for VEGF in synovial neo-angiogenesis.

A case of macrophage activation syndrome in a patient with anti-synthetase syndrome.

Anti-synthetase syndrome (ASS) is an autoimmune disease characterized by autoantibodies against an aminoacyl transfer RNA synthetase with clinical features including interstitial lung disease, non-erosive arthritis, myositis, Raynaud's phenomenon, unexplained fever and/or mechanic's hands. Macrophage activation syndrome (MAS) is a potentially fatal hyper- inflammatory syndrome that can occur as a complication of systemic rheumatic diseases. However, the association of MAS and ASS has rarely been reported in the literature. Here, we report this association in a patient with overlap ASS and anti-CCP positive rheumatoid arthritis. First line management with steroids was complicated by diabetic ketoacidosis, hence requiring use of anti-IL1 therapy (anakinra) for disease control.

Teleclinics in rheumatology introduced during the first lockdown phase of the COVID-19 pandemic of 2020.

The COVID-19 pandemic has led to a crisis in the provision of usual services, including face-to-face (FTF) outpatient clinics. The need for change came abruptly in late March 2020 as routine clinics were cancelled. We accelerated the delivery of our teleclinics (telephone and video) in rheumatology, which we had started doing prior to the pandemic. 396 patients were reviewed during the lockdown by teleclinics. 39 (10%) of patients were discharged, 102 (26%) had treatment adjusted without bringing forward their appointment, 39 (10%) had tests ordered and prescriptions issued, 160 (40%) were reviewed and booked for a future appointment, thus reducing the current waiting list, and 22 (6%) were placed a patient-initiated follow-up plan. Only 10 (3%) required a conversion from the teleclinic to a FTF clinic in the near future. The COVID-19 crisis offered us the opportunity to do things we had been considering for some time. Our aim is now to continue with this new way of working as we move to the recovery phase and beyond. We would suggest that adoption of these changes in other trusts could significantly improve the quality of the care for patients not only in rheumatology but also throughout the NHS.

Fulminant diffuse cerebral toxoplasmosis as the first manifestation of HIV infection.

Individuals with HIV may present to the emergency department with HIV-related or HIV-unrelated conditions, toxicity associated with antiretroviral therapy or primary HIV infection (seroconversion). In individuals with HIV infection, central nervous system toxoplasmosis occurs from reactivation of disease, especially when the CD4+ count is <100 cells/µL, whereas in those taking immunosuppressive therapy, this can be either due to newly acquired or reactivated latent infection. It is a rare occurrence in immune-competent patients. Vertical transmission during pregnancy can manifest as congenital toxoplasmosis in the neonate and is often asymptomatic until the second or third decade of life when ocular lesions develop. Toxoplasmosis is an infection caused by the intracellular protozoan parasite Toxoplasma gondii and causes zoonotic infection. It can cause focal or disseminated brain lesions leading to neurological deficit, coma and death. Typical radiological findings are multiple ring-enhancing lesions. Histopathological examination demonstrating tachyzoites of T. gondii and the presence of nucleic material in the spinal cerebrospinal fluid (CSF) confirms the diagnosis. The authors present the case of a 52-year-old male UK resident, born in sub-Saharan Africa, with a 3-week history of visual hallucinations. He attended the emergency department on three occasions. Laboratory investigations and a CT head were unremarkable. He was referred to psychological medicine for further evaluation. On his third presentation, 2 months later, a CT head showed widespread lesions suggestive of cerebral metastasis. Dexamethasone was initiated and he developed rigours. An MRI head showed multiple ring-enhancing lesions disseminated throughout his brain parenchyma. CSF analysis and serology confirmed the diagnosis of HIV and toxoplasmosis, respectively. His CD4 count was 10 and his viral load (VL) was 1 245 003. He was then initiated on Biktarvy 50 mg/200 mg/25 mg, one tablet daily, which contains 50 mg of bictegravir, 200 mg of emtricitabine and tenofovir alafenamide fumarate equivalent to 25 mg of tenofovir alafenamide. After 3 months of antiretroviral therapy, his HIV VL reduced to 42. However, his abbreviated mental test remained at 2/10. Despite presenting with neurocognitive impairment and being born in a HIV prevalent region, an HIV test was not offered. This case highlights missed opportunities to request HIV serology and raises awareness that cerebral toxoplasmosis can occur as the first manifestation of HIV. Prompt diagnosis and early initiation of antiretroviral therapy reduces morbidity and mortality in this patient cohort.

Corrigendum to: A case of pseudo-pseudo Meigs' syndrome.

[This corrects the article DOI: 10.1093/omcr/omy136.][This corrects the article DOI: 10.1093/omcr/omy136.].

A case of pseudo-pseudo Meigs' syndrome.

Here we report a case of a patient with systemic lupus erythematosus presenting with pseudo-pseudo Meigs' syndrome (PPMS): a triad of pleural effusion, ascites and raised CA-125. There have only been nine other cases reported in the literature. To our knowledge, this is the first to have an oesophago-gastro-duodenoscopy and liver biopsy as part of the diagnostic work up. Its mechanism of action is not yet fully understood but PPMS is a treatable condition that is responsive to immunosuppression. It is therefore important to consider it in patients presenting like this, where alternative diagnoses, including malignancy, have been ruled out.

Implementing and delivering a successful biosimilar switch programme - the Berkshire West experience.

BACKGROUND AND AIMS: Biosimilars used in multiple rheumatic conditions offer the -potential for cost savings. We present the outcomes of a -service evaluation of switching rheumatic patients established on originator etanercept (Enbrel) to biosimilar Benepali, using a managed switching programme funded through a novel fixed price incentivisation model. METHODS: Evaluation outcomes included savings in drug acquisition costs, patient-reported side effects, adverse events, patient outcomes and patient experience. RESULTS: A total of 154 patients on Enbrel were identified for switching. A total of 113 patients (43 had rheumatoid arthritis, 43 had axial spondyloarthritis and 27 had psoriatic arthritis) were switched from originator etanercept to Benepali from August 2016 to March 2017. The Royal Berkshire NHS Foundation Trust had the highest percentage of switches in the Thames Valley in this period. There was no increased incidence of side effects before and after switch. Drug acquisition costs were decreased by £95,000 with an overall reduction in prescribing costs of £186,000 for the local health economy. CONCLUSIONS: A managed switching programme from originator etanercept to biosimilar Benepali, using a novel fixed price model, delivers significant cost savings and investment in clinical services while maintaining similar patient-reported outcomes and good patient experience.

A case of polyarteritis nodosa limited to the right calf muscles, fascia, and skin: a case report.

INTRODUCTION: Limited polyarteritis nodosa is a rare benign disease that usually responds well to systemic corticosteroid treatment. We report a case limited to calf muscles, fascia, and skin treated with local corticosteroid therapy directed to the affected areas by ultrasound guidance. CASE PRESENTATION: A 36-year-old Caucasian woman presented with a 10-month history of progressive right calf pain and swelling, which were unresponsive to treatment with non-steroidal anti-inflammatory drugs and physiotherapy. An examination revealed a swollen tender right calf with indurated overlying skin. Laboratory investigations showed an erythrocyte sedimentation rate of 24 mm/hour and a C-reactive protein of 15 mg/dl. Full blood count, renal profile, and creatinine kinase level were normal. A full autoantibody screen and hepatitis B and C serology results were negative. A chest X-ray was unremarkable. Magnetic resonance imaging of the right leg revealed increased signal intensity in T2-weighted images and this was suggestive of extensive inflammatory changes of the gastrocnemius muscle and, to a lesser extent, the soleus muscle. There were marked inflammatory changes throughout the gastrocnemius muscle and the subcutaneous tissue circumferentially around the right lower leg. A biopsy of affected skin, muscle, and fascia showed histopathological features consistent with polyarteritis nodosa, including small-vessel vasculitis with fibrinoid changes in the vessel wall and intense perivascular and focal mural chronic inflammatory changes. Our patient declined treatment with oral steroids. She received a course of ultrasound-guided injections of steroid (Depo-Medrone, methylprednisolone) in the involved muscle area and commenced maintenance azathioprine with a good response. CONCLUSIONS: Limited polyarteritis nodosa is rare and affects middle-aged individuals. In most cases, treatment with moderate- to high-dose corticosteroids gives symptomatic relief within one week. Resistant cases require treatment with cytotoxics or intravenous immunoglobulins. This case demonstrates response to local targeted steroid therapy as an alternative to systemic steroids.

Piperacillin/tazobactam-induced paresthesiae.

OBJECTIVE: To describe a case of a delayed-type hypersensitivity (DTH) reaction to piperacillin/tazobactam in which painful paresthesiae were a predominant feature. CASE SUMMARY: A 27-year-old man with a history of intravenous drug abuse was admitted for treatment of a pulmonary parenchymal abscess in the setting of lower-limb deep-venous thrombosis and methicillin-sensitive Staphylococcus aureus bacteremia. He was treated with intravenous piperacillin/tazobactam 4.5 g 3 times daily; however, after 2 weeks of therapy, he developed symptoms (eg, fever, chills) and laboratory abnormalities (eg, white blood cell count 2.1 x 10(3)/mm3, erythrocyte sedimentation rate 63 mm/h) suggestive of a DTH reaction. This was accompanied by infusion-related painful paresthesiae. The symptoms and laboratory abnormalities resolved within 48 hours of treatment being switched to flucloxacillin. DISCUSSION: Due to the close temporal association and the absence of any other obvious explanation, we believe these paresthesiae represent an additional feature of the DTH reaction to piperacillin/tazobactam in this patient. Use of the Naranjo probability scale indicated a probable relationship between the paresthesiae and administration of piperacillin/tazobactam. CONCLUSIONS: To our knowledge, as of March 24, 2006, this is the first case in which a DTH reaction to piperacillin/tazobactam manifesting as fever, neutropenia, and thrombocytopenia has been associated with paresthesiae.