British Society for Rheumatology Annual Conference 2023 Abstracts

The proceedings contain 343 papers. The topics discussed include: implementation of a disease modifying anti-rheumatic drug blood monitoring software: 8 years of experience in a single center;effectiveness of colchicine among patients with COVID-19 infection: a randomized, open labelled, clinical trial;rheumatic autoimmune diseases following COVID-19 infection: an observational study in Iraqi Kurdistan region;COVID-19 in male elite Irish-based athletes at a national sports institute;the effects of a pain management program for patients with an inflammatory arthritis;a retrospective analysis of the effectiveness safety of platelet rich plasma injections in primary osteoarthritis in knee joint, in patients attending a tertiary care hospital, Sri Lanka;a cohort study;do proformas used in fracture liaison service appointments reflect national osteoporosis clinical standards? a content analysis;calcium pyrophosphate dihydrate crystal in operated rheumatoid arthritis of the knee;cardiac amyloidosis: a case series of 31 patients with a comprehensive literature review;scoping review for the application of center of pressure for patient or intervention assessment in rheumatoid conditions;and four SNPs associated with monocyte/macrophage cell lineage uniquely associated with CRPS-1 in discovery and replication cohorts and suggest predisposition to regional osteopenia and digit misperception.

All in the Marrow - a Case of Primary Bone Marrow Oedema

Introduction/Background: Primary bone marrow oedema syndrome is an elusive and less well-defined entity. Whether Rheumatologists should consider it as a stand alone diagnosis, is debatable. It possibly would be best described as an MRI feature which could be a finding in a number of diseases which would include the initial phases of Osteonecrosis of the bone, Rheumatoid Arthritis, Spondyloarthritis, Enthesitis related, Post traumatic, OA, Infections and Cancers. The treatment options become constricted due to the paucity of evidence. Rheumatologists need to consider this as an area of unmet need with development of consensus classification criteria and treatment approaches. Description/Method: 27-year-old male, Height 174 cms Weight 90 Kgs BMI 29 Kg/m2, became symptomatic in Jan 2022 with complains of pain in the both hip joints & groin regions, pain became excruciating and he became bed-bound, with early morning stiffness lasting approximately 45 mins. Had received steroids for COVID infection in August 2020. Investigations Hb 13.5gm/dl TLC 7000/mm3 Platelet 400 x 103/mm3 Sr Bil 0.8mg/dl AST 16 IU/L. ALT 24 IU/L Sr Creatininine 1.1mg/dl Blood Sugar Levels, Fasting 89 mg/dl Post Prandial 102 mg/dl ESR 10mm in 1st hour by Wintrobes method CRP Quantitative 29.38mg/L HLA B27 by PCR Negative, RF Negative, ACCP Negative Serum, IgG, Beta2 Glycoprotein 1.44 SGU Serum, IgM, Beta2 Glycoprotein 3.44 SGU Serum, IgG, Cardiolipin antibody 8.4 GPL Serum, IgG, Cardiolipin antibody 17.45 GPL Lupus anticoagulant by DRVVT Negative Sr Cholesterol 211mg/dl HDL 29 mg/dl LDL 156mg/dl TGs 130 mg/dl MRI Hips & SI joints Transient bone marrow oedema/osteopenia of bilateral hip. PET CT Increased metabolic activity in both hip joints Bone Scan (99mTcMDP) Increased vascularity in perfusion phase, increased accumulation in soft tissue in blood pool phase and increased uptake in bilateral Hip joints in skeletal phase scan, suggestive of CRPS Type-I. Management Was initially managed with Tab Etoricoxib 90mg BD, also started on Tab Sulphaslazine and Tab Methotrexate. However, when he had no symptomatic relief he was administered Inj Infliximab on 12 May 2022 and a second dose on 9 June 2022. He had excellent pain relief after the 1st dose, however after 10 days of the administration, he again began experiencing pain especially after walking. He also had pain in the knees on this occasion. He was also administered Inj Zoledronic 4mg on 23 May 2022. He is at present not requiring any NSAIDs over the last 1 month. Discussion/Results: The patient having presented with excruciating and debilitating pain was worked up and evaluation revealed features of bone marrow oedema on MRI which was corroborated with bone scan and PET CT imaging. The acute phase reactant CRP was also significantly elevated. The patient also gave history of early morning stiffness lasting approximately 45 mins. Hence an underlying Inflammatory process such as Spondyloarthritis(Peripheral) with enthesitis was considered. The confounding factors were the pain which worsened on mobilization, HLA B27 negative status, Rheumatoid Factor and ACCP negative status and past history of having received IV Corticosteroids for COVID infection in August 2020. In view of the debilitating pain and aworking diagnosis of Spondyloarthritis, hewas started onNSAIDs alongwith rest, initially, followed by conventional synthetic disease modifying agents in Rheumatic disease followed by biologic synthetic diseasemodifying agent - Inj Infliximab. The thought process was to avoid prolonged NSAID use to prevent the associated side effects. However, since Avascular Necrosis of the Femoral head is a very likely possibility, the patient is planned to be kept under close follow up. Key learning points/Conclusion: Collaborative efforts between the Departments of Nuclear Medicine, Radiology, Orthopaedics and Rheumatology are crucial in the early detection and approach to cases of Bone Marrow oedema. Avascular necrosis of head of Femur is a far more common entity and must be kept in ind even when a diagnosis of Bone Marrow oedema syndrome is being entertained. Diagnosis of Bone Marrow oedema syndrome must be entertained only as a diagnosis of exclusion. Continued follow up and regular imaging must be pursued rigorously in patients diagnosed with Bone Marrow oedema syndromes. There is a requirement to document acute phase reactants such as CRP and ESR in patients diagnosed with Avascular necrosis of bone as this data could help us differentiate AVN from Primary Bone marrow oedema in the early stages.

LONG-TERM DISABILITY SECONDARY to CRPS-1. RETROSPECTIVE MONOCENTRIC STUDY on 106 CASES

Background: Complex regional pain syndrome type-1 (CRPS-1) is a severely disabling pain syndrome characterized by sensory and vasomotor disturbance, swelling, and functional impairment. Persistence of signs and symptoms has been observed in up to 64% of cases until 5.8 yrs after the onset of manifestations. Long-term disability, such as irreversible functional limitation, has been reported in up to 28% of cases with severe consequences on workability. No scores are validated to evaluate residual disability. Bisphosphonates have the best efficacy profile, compared with other therapeutic approaches, but data on long-term effectiveness are lacking. Objectives: To retrospectively evaluate long-term residual disability in patients with CRPS-1 of hand or foot after treatment with IV Neridronate (IVNer). To identify predictors of residual disability. To quantify disease outcomes, such as patient's subjective perception and residual pain. To assess long-term safety profile. Methods: We retrospectively collected data of patients affected by CRPS-1, treated with IVNer, referred to a tertiary Rheumatology Centre between Feb 2013 and Dec 2020. Visual analogue scale (VAS) and McGill Questionnaire (McGQ) were used for pain assessment. Disabilities of the Arm, Shoulder and Hand (DASH) and American Orthopaedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale for hand and foot involvement, respectively, were administered to explore disability through a phone survey. This kind of investigation was preferred for Covid pandemic. Results: 106 patients with definite diagnosis of CRPS-1 were included, mean age±standard deviation 55.6±13 yrs, 67% females, mean follow up duration 56.3 months (range 14-94), 46.2% with hand involvement. The mean VAS score before treatment onset was 55.8±23.4mm, while the McGQ was 12.9±6.7 in the sensory domain, 4.9±3.3 in the affective domain and 17.8±9.2 on the total score. Based on the patient's subjective perception and the proposed semi-quantitative scale, 77.4% described themselves as fully recovered (FR), 15% partially recovered (PR), and 7.6% with persistent disease (PD). Comparison between baseline and follow-up VAS shows a significant reduction (55.8±23.4 vs 15.1±26.4, p<0.00001). Pain assessment by McGQ showed a significant improvement in global score (baseline vs follow-up 17.8±9.2 vs 3.9±7.8, p<0.00001), sensory (12.9±6.7 vs 2.7±5.7, p<0.00001) and affective (4.9±3.3 vs 1.2±2.3, p<0.00001) domains. According to DASH score, 79.2% of the patients were FR, 3.8% had some difficulties, but with overall preserved use of the upper limb, and 17.0% had permanent functional disability. According to AOFAS ankle-hindfoot scale 76.4% of patients were FR, 16.0% had partial recovery, and 7.6% had severe functional impairment. Percentages of DASH and AOFAS scores showed a complete accordance with patients' subjective perception (Figure 1a and b). The only predictor of long-term functional impairment for CRPS-1 in the hand was a delayed treatment compared to symptoms onset (p=0.02). No predictors were found for foot localization. No patients reported the occurrence of osteonecrosis of the jaw or atraumatic fractures/atypical fracture features. Conclusion: IVNer maintained a good long-term effectiveness and safety profile in the treatment of CRPS-1. The effectiveness of IVNer is maintained on both pain symptoms and function, in terms of reductions in the VAS, McGQ and in hand and foot disability scores.

Possible reflex sympathetic dystrophy secondary to 'COVID toes'

A 51-year-old woman presented acutely to dermatology with an 8-week history of painful, purple discolouration of her toes, which started on her left foot but progressed to involve all of her toes. She was noted to have a positive COVID-19 polymerase chain reaction test after her symptoms began. There was some superficial ulceration of two of her toes. The episode lasted for 5 weeks;however, after 6 weeks her toes had flared again. No triggers were indentified;in particular, her symptoms were not related to the cold. There were no other rashes. She has a past medical history of endometriosis and gout. She takes desogestrel and allopurinol, which she had been on for 2 years. Vasculitis screen was negative. She was treated initially with clobetasol propionate and nifedipine. On follow-up 6 weeks later, the patient reported hypersensitivity of her toes, with severe pain reported from socks rubbing against her toes. The toes had normal appearances and cool peripheries. We suspect that the increased sensitivity and pain is a reflex sympathetic response secondary to 'COVID toes' and have treated with it gabapentin. It is thought that reflex sympathetic dystrophy occurs because inflammation causes damage to the nerves;however, the exact mechanism behind reflex sympathetic dystrophy is yet to be elucidated.

COVID-19 Mediated Exacerbation of Complex Regional Pain Syndrome Treated With Spinal Cord Stimulator

Introduction: Complex regional pain syndrome (CRPS) is a debilitating condition characterized by disproportionate pain to the inciting event, changes in sensation, autonomic abnormalities, and motor dysfunction, as defined by the Budapest criteria. It is difficult to treat, often requiring trials of multiple medications or more invasive measures such as a spinal cord stimulator (SCS) to manage symptoms. The onset of symptoms typically follows tissue damage and may be exacerbated by further injury or systemic stressors. One such stressor appears to be COVID-19 infection, which has already been implicated in cases of neuropathic pain. We present a case of a 60-year-old woman with CRPS type I status post SCS placement with a flare-up attributable to COVID-19 infection. Methods: We describe the following patient's case in pertinent detail. The patient's written consent was obtained prior to the undertaking of this report. Results: A 60-year-old woman presented with a right-sided rotator cuff tear with subsequent repair in 2018 which incited pain and related symptoms. CRPS was diagnosed when her symptoms progressed to right thumb numbness as well as right hand color changes, numbness, and weakness. An SCS was placed in August 2019 which provided pain relief, but the patient presented with exacerbation of symptoms in December 2020, coinciding with COVID-19 infection. She experienced migration of symptoms into the right shoulder which has been significantly interfering with work and sleep. She continued to report pain, swelling, stiffness, dry skin, and temperature changes in her right hand. Conclusion: COVID-19 has been found to present with a widely variable clinical presentation with equally varied sequelae, termed Post-Acute Sequelae of SARS-CoV-2 infection (PASC). Human coronaviruses are known to possess neuroinvasive capabilities, typically manifesting as anosmia in the case of COVID-19 but may also present as neuropathic pain. If not attributable to direct viral invasion, the pathophysiologic underpinnings may be related to proinflammatory cytokines and pain-generating neuropeptides. Our case suggests that COVID-19 infection may play a role in exacerbating symptoms of CRPS. Disclosure: Gabrielle Fernandez, BA: None, Ganiru Anunike, BA: None, Nitin Goyal, MD: None