Hepatotoxicity From Marijuana Gummies

Introduction: We report a case of drug-induced liver injury (DILI) induced by cannabis gummies containing Corydalis Rhizome. Case Description/Methods: A 37-year-old female presented to her primary care clinic with recurrent fevers, night sweats, and myalgias for 7 weeks accompanied by eye redness, brain fog, headache, nausea, and abdominal pain. She denied rashes, tick-bites, cough, dyspnea, chest pain, joint swelling, or genitourinary symptoms. Past medical history was notable for IBS, migraines, and anxiety. She reported edible marijuana use four times a week, rare alcohol use, and denied tobacco use. She denied a family history of liver disease. Physical exam was notable for tachycardia to 110 and scleral injection with the remainder of vitals and exam unremarkable. Initial labs were notable for AST 61, ALT 44 and CRP of 12. CBC, BMP, urinalysis, ESR, blood cultures, blood smear for parasite screen, tests for Lyme disease, Babesia, Tularemia, Anaplasma, Ehrlichia, Rickettsia, EBV, HIV, RPR, ANA, CMV, parvovirus B19, and chest x-ray were all negative. The patient was referred to infectious disease with further testing for West Nile, Leptospira, lymphocytic choriomeningitis virus, and COVID-19 returning negative. Repeat LFTs showed worsening transaminitis with ALT 979 and AST 712, alkaline phosphatase 88, total bilirubin 0.7, and albumin 4.9. Hepatitis workup including hepatitis A, B, and C, HSV, EBV, VZV serologies, AMA, ASMA, antiLKM Ab, acetaminophen level, INR, iron panel, CPK, TSH, and abdominal ultrasound were all normal. It was later discovered that her marijuana gummies contained Corydalis rhizome extract known to be hepatotoxic. Cessation of this drug was strongly advised. She was discharged with hepatology follow-up and underwent a liver biopsy showing patchy periportal and lobular inflammation with extension across the limiting plate, hepatocyte injury and apoptosis, and increased lipofuscin for age compatible with mild to moderate hepatitis. She had complete recovery after cessation of Corydalis-containing gummies. (Figure) Discussion: Our patient consumed '1906 Midnight', an American cannabis brand containing Corydalis rhizopus 100 mg, advertised to improve sleep, pain, and have a liver protective effect. A Korean systematic review on herbal-induced liver injury reported that Corydalis was the 3rd most frequent causative herb, with 36 cases. Although there are several personal accounts on social networking sites and other websites, there are no American-based publications reported on DILI from Corydalis. (Table Presented).

Spontaneous knee hemarthrosis associated with enoxaparin treatment in a post covid 19 patient

Purpose: To report a case of a 66-year- old Filipino male who developed spontaneous knee hemarthrosis following enoxaparin prophylaxis. Method(s): Case report Result: Case: We report a case of a 66-year- old Filipino male who developed spontaneous hemarthrosis of the left knee following enoxaparin use as venous thromboembolism prophylaxis. Pertinent in the medical history was the diagnosis of chronic kidney disease and chronic respiratory failure as sequelae of COVID 19 infection. During the course of admission, the patient developed acute pain and swelling of the left knee. He was bedridden and no prior traumatic events were noted. Coagulation parameters were within normal range. Arthrocentesis revealed viscous hemorrhagic synovial fluid (25 ml) with fluid analysis showing predominance of red blood cells (Red blood cells: 680,000/muL, White blood cells: 7200/muL) with no crystals seen on polarizing microscopy. Microbial culture was negative. Intravenous methylprednisolone was given and enoxaparin was continued. One day post arthrocentesis, there was improvement of pain and joint function. Joint swelling resolved. Patient had no recurrence of joint pain and swelling. Ethical consideration: Informed consent for both written and photographic content was secured and patient confidentiality was observed. Conclusion(s): Our patient is an elderly with chronic kidney disease who recently recovered from COVID 19 infection. He received prophylactic dose of enoxaparin at 40 mg every 24 hours subcutaneously. No other drugs that can affect hemostasis were given. The patient's bleeding parameters were within normal during admission and at the onset of hemarthrosis. We hypothesize that elderly patients with chronic kidney disease receiving low dose enoxaparin may present with spontaneous hemarthrosis even in the absence of trauma. Whether the association between history of recent COVID-19 infection and hemarthrosis is co incidental or causal remains to be elucidated. Prompt aspiration can provide early diagnosis and facilitate proper treatment. (Figure Presented).

EVALUATION of PATIENTS with RHEUMATOID ARTHRITIS in TELECONSULTATION during the FIRST WAVE of the COVID-19 PANDEMIC

Background: The sudden emergence of SARS-CoV-2 onto the world stage has accelerated a major change in the management of patients with chronic rheumatic diseases and has catalyzed the rapid emergence of telemedicine. Objectives: Our aim was to describe which parameters were used by rheumatol-ogists to monitor patients with rheumatoid arthritis (RA) in teleconsultation during the frst wave of the pandemic and identify the most relevant for decision making. Methods: Retrospective monocentric routine care cross-sectional study including RA patients seen in teleconsultation between March and September 2020. Available parameters assessing disease status were collected in teleconsultation files. Clinician intervention was defned by treatment escalation and/or the need for a rapid face-to-face consultation or day hospitalization. Results: 143 RA patients were included (117 females, mean age of 58±16 years, mean disease duration of 14±11 years). The presence or absence of patient self-reported RA fares was mentioned in all medical files, followed by the presence and/or the number of tender joints (76%), the duration of morning stiffness (66%), the number of pain-related nocturnal awakenings (66%) and the CRP value (54%). Patient self-reported RA fares concerned 43/143 patients (30%). The presence of self-reported RA fares was associated with a more detailed evaluation of patient in teleconsultation: The presence (or number) of tender joints and swollen joints were more signifcantly reported in patients who presented a fare (39/43, 91% vs. 70/100, 70%, p=0.008 and 25/43, 58% vs. 23/100, 23%, p<0.001, respectively). Teleconsultation led to a clinician intervention in 22/143 patients (14%), representing 51% of patients with self-reported fares (22/43 patients). Therapeutic escalation was necessary in 13 patients: introduction or dose increase of cor-ticosteroids in 8 patients, introduction or dose increase of methotrexate in 4 patients and introduction of hydroxychloroquine in 1 patient. Face-to-face consultation or day hospitalization were organized for 10 patients. Active disease was confrmed during this next face-to-face visit in 9 patients, with DAS28 ranging from 3.35 to 5.62, leading to therapeutic modifcation. The 133 other patients were seen in face-to-face consultation 6±2 months after the teleconsultation. No DMARD modifcation was recorded during this next face-to-face consultation. The following variables were associated with clinician intervention during the tel-econsultation in univariate analysis: patient self-reported RA fares since the last visit (p<0.001), CRP >10 mg/mL (p=0.012) and a morning stiffness > 30 minutes (p<0.001). Multivariate analysis confrmed RA fares (Odds Ratio, OR: 15.6 95% CI 3.37-68.28) and CRP values >10 mg/L (OR: 3.32, 95% CI % 1.12-13.27) as the variables independently associated with clinician intervention. Conclusion: Our study identifed patient reported RA fares and increased CRP values as 2 red fags in teleconsultation, independently associated with therapeutic modifcation and/or the need for a rapid face-to-face consultation. These indicators may help clinician's decision making in teleconsultation.

INTERNATIONAL IMPACT OF A CO-PRODUCED TRAINING VIDEO: SELF-EXAMINATION OF TENDER AND SWOLLEN JOINTS FOR PEOPLE WITH RHEUMATOID ARTHRITIS

Background/Aims Patients with rheumatoid arthritis (RA) need support to understand and manage their condition. The COVID-19 pandemic rapidly transformed outpatient clinical consultations from face-to-face towards remote models. This increased the emphasis placed upon self-assessment of joints and disease activity, strengthening the need for patient education materials. We planned to develop a video to support patient research participants to monitor disease activity remotely using the REMORA app. We altered the video's scope and made it open access to meet the need created by changes in service delivery models. Methods A video demonstrating self-examination of tender and swollen joints in RA was co-produced with patients and the multi-disciplinary team. A nurse consultant introduces key concepts, (how to identify and examine tender and swollen joints, which joints to include, etc), coaches a patient through self-examination, and answers key questions. Materials co-produced to support implementation into practice include a joint count manikin and table, an advertising poster, and blogs. Collaboration with international research colleagues has led to the production of a version dubbed in German. Subtitles are available in German and Hindi. Online feedback was sought via a survey. Ethical approval was not required as all contributors acted as equal members of the research team. Results The 15-minute video, supporting materials and survey were uploaded to YouTube in February 2021 [tinyurl.com/REMORAvideo]. 1,000 hits were received in week one, reaching >12,500 after eight months. 20% of viewers are UK-based, 15% from the USA, 10% from India. 26% of views used English subtitles, 0.2% German, 0.1% Hindi. 124/125 people engaging with the 'like/dislike' function on YouTube, 'liked' the video. 48 people fed-back online (26 patients, 22 clinicians). Patient ages were: 18-35(5%), 36-55(62%), 56-75(29%), 76+(5%), the majority of whom were female (19/21[91%]). Before watching, 14/ 17(82%) patients rated themselves as 'poor'-'fair' at self-examination: after watching, the same number rated themselves as 'good'- 'excellent'. 19/21(90%) and 17/21(81%) patients respectively either somewhat or strongly agreed with the statements 'I now feel confident to self-examine for' 'tender' or 'swollen' joints. 19/21(90%) of patients and 13/17(77%) clinicians either somewhat or strongly agreed with the statement that 'the video fulfilled my expectations'. 18/21(86%) patients and 12/17(71%) clinicians would recommend the video. To date, several national organisations have engaged with the video. It supports the BSR ePROMS platform and national audit. The National Rheumatoid Arthritis Society plans to incorporate it into the 'Know your DAS app', and it will contribute to an NHSX playbook of digital best practice. Conclusion This co-produced training video for people with RA, originally intended to support a remote monitoring app, has been well-received, with much wider-reaching international impact than anticipated. This demonstrates the need for materials collaboratively designed with patients to support patient self-management of long-term conditions, in the digital era.

TRACKING DOWN AUTOANTIBODIES

Background/Aims Vaccine-associated autoimmunity is not infrequent, pertaining to either the cross-reaction between antigens or the action of adjuvant. This issue is more inexplicable to the COVID-19 vaccine, because of nucleic acid formulation and the hastened development process inflicted by the urgent pandemic condition. Here we are presenting a young patient who developed a significant abnormal autoimmune profile immediately post covid vaccination. Methods A 31-year-old IT engineer was referred to Rheumatology with postvaccine arthralgia. He had a history of recent aortic root aneurysm repair after having chest pain on exertion. Echocardiography showed dilated aortic root with significant aortic regurgitation, CT aortogram confirmed spiral type A dissection. He underwent an emergency cardiothoracic surgery in October 2020, followed by an uneventful recovery. He received the first dose of Pfizer COVID-19 vaccine on 2nd February, the very next day he developed painful ankles, knees, left hip, and right shoulder. Blood tests showed elevated CRP of 45, ESR 34, rheumatoid factor positive at 92, anti-CCP >340, ANA 13, ds-DNA 202, U1RNP positive, anti-SM antibody positive, Ro and La antibodies positive, antiJo1 antibody positive, with normal complements. He denied any swelling of the joints. No history of hair loss, photosensitive skin rashes, Raynaud's, sicca symptoms, oro-genital ulceration, or cracking of the skin. There were no constitutional symptoms, chest pain, or bowel issues. He was previously labeled as asthmatic, which is stable after surgery. He doesn't smoke or drinks alcohol. There was no family history of autoimmune conditions. On examination, he has tenderness across both hands and wrists with palmar erythema but no synovitis. He has painful right shoulder abduction with left hip pain on flexion and extension. Cardiovascular and GI examination was unremarkable apart from sternotomy scar and metallic valvular heart sounds. His dipstick urinalysis was negative for blood and protein. In recent x-rays hands and feet were normal. We agreed on a trial a tapering course of prednisolone started with 20mg daily. Three weeks later in follow-up, he reported partial response to steroids. His inflammatory markers were coming down. We have started azathioprine as a steroid-sparing agent. Results This gentleman with negative autoimmune screening prior to cardiothoracic surgery expressed florid newly detected autoantibodies straightaway after the COVID-19 vaccine. This is suggestive of undifferentiated connective tissue disease with the likelihood of overlap syndrome between rheumatoid arthritis and SLE. Conclusion COVID-19 vaccination showed a beacon of light to end the pandemic by achieving herd immunity. There is an excusable socioeconomic rush towards mass vaccination without long-term safety analysis, however, it is also crucial that any vaccine licensing process should entail meticulous scrutiny of the human proteome against vaccine peptide sequences. This will minimize the risks of acute autoimmune reactions to inoculation and future chronic autoimmune pathology.

A rare case of reactive arthritis secondary to COVID-19

Case report-IntroductionIn December 2019, the first cluster of Coronavirus disease 2019 (COVID-19) cases caused by the novel coronavirus SARS-CoV-2 was identified in Wuhan, China. The disease was declared a global pandemic on 11th March 2020. COVID-19 was initially thought to cause respiratory complications only, however several extra pulmonary manifestations of the infection have since emerged.We report a rare case of reactive arthritis (ReA), urticarial rash and angioedema in a young female secondary to COVID-19 infection. Rashes were recently added to the World Health Organisation (WHO) criteria for diagnosis of COVID-19 demonstrating their significance.Case report-Case descriptionA 31-year-old female doctor was admitted with acute swelling of her lips, dysphagia, and a widespread urticarial rash. Preceding this she had a one-week history of fever, cough, and constitutional symptoms of malaise and weight loss. Her symptoms had started at the end of April 2020 during the peak of the COVID-19 pandemic in the United Kingdom. Three days later she developed painful swelling of her wrists, elbows, knees, and hands. She reported no back or sacroiliac joint pain, enthesitis or any previous history of inflammatory joint pains. She had a history of platelet dysfunction and was treated with Desmopressin.Clinical examination revealed a widespread urticarial rash over her face, limbs, and trunk, with no nail abnormalities. She had active synovitis in her right wrist, elbow, and mild bilateral knee effusions. All other joints including spine and sacroiliac joints were normal. She had no dactylitis or enthesitis. Systemic examination was normal. Investigations revealed Hb 113 g/L, MCV 88.2 fL, Platelets 282 x 109/L, WCC 6.6 x 109/L and Lymphocytes of 0.63 x 109/L with normal neutrophil and eosinophil count. CRP was raised at 107mg/L. She had a negative autoimmune screen including ANA, ANCA, IgM-RF, anti-CCP antibodies and HLA B27. Plain radiographs of knees were normal. SARS CoV-2 PCR was positive following a nasal swab. Urine and blood cultures were negative. Treatment was commenced with intravenous hydrocortisone and antihistamines with resolution of her angioedema symptoms;however, her rash and arthritis persisted.The patient was diagnosed with Reactive Arthritis (ReA), urticarial rash and angioedema secondary to COVID-19 infection. Prednisolone 30mg daily was started, and within a week her arthritis and rash markedly improved. Prednisolone was tapered over six weeks. By her two-month clinic follow up, she reported no further joint swelling and was functioning normally.Case report-DiscussionThe most common complication of COVID-19 is Acute Respiratory Distress Syndrome (ARDS) however several other serious complications have been identified including cardiac injury, thromboembolic events, neurological abnormalities, and an aggravated inflammatory response causing a cytokine storm.ReA is a post infectious arthritis commonly seen following gastrointestinal or genitourinary infections and is yet to be recognised as a complication of this disease. ReA most commonly presents as an asymmetrical peripheral or axial spondyloarthropathy. The affected joints do not contain pathogen. More than half of ReA cases resolve spontaneously within six months without requiring long-term treatments.Up to 20% of patients with COVID-19 infection have been shown to develop cutaneous manifestations including erythematous rash, vesicular rash, acral ischaemia, rash with petechiae, and widespread urticaria. This has led to the recent addition of rashes to the World Health Organisation (WHO) Criteria for diagnosis of COVID-19 infection. Additionally, as COVID-19 has an incubation period of 14 days where patients can be asymptomatic, cutaneous manifestations may serve as an early indicator of infection, aiding in a more rapid diagnosis.Case report-Key learning pointsWe present a rare case of ReA secondary to COVID-19 infection, with complete resolution of symptoms following administration of oral glucocorticoids. A detailed history and examination of t e musculoskeletal system should be undertaken in all patients presenting with COVID-19. Urticarial rashes should be considered as an early symptom of COVID-19 infection as per the WHO criteria for diagnosis. Glucocorticoids can be considered in treating patients with this presentation, where traditional anti-inflammatory agents have been refractory or contraindicated.