Post-COVID-19 fibromyalgia syndrome: A report of two case

COVID-19 is a viral infection caused by SARS-CoV-2 that primarily targets the respiratory system. COVID-19 may be followed in some patients by post-COV-ID-19 syndrome, fatigue, anxiety, and musculoskeletal pain. These symptoms may be associated with other symptoms, resulting in a constellation of symptoms consistent with fibromyalgia syndrome (FMS). Two patients were evaluated at the rheumatology outpatient clinic for diffuse persistent musculoskeletal pain after COVID-19 infection. Patients presented with generalized musculoskeletal pain, fatigue, anxiety, depression, headache, hand paresthesia, and non-restorative sleep. General examination and various laboratory investigations, including autoimmune profile and radiological investigation, were normal. After examining eighteen tender points, both patients fulfilled the 1990 ACR classification criteria for FMS. Post-COVID-19 FMS should be considered during the management of post-COVID-19 syndrome to alleviate pain and prevent worsening of symptoms during the COVID-19 pandemic.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Nail ridging in rheumatoid arthritis patients and relation to disease activity: An integrated rheumatology-dermatology multi-centre study

Aim of the work: To evaluate the frequency of nail ridging (NR) in patients with rheumatoid arthritis (RA) and to study its relation to disease activity. Patients and methods: 230 RA patients and 97 matched controls from Helwan, Ain Shams and Mansoura university hospitals were studied. Disease activity score (DAS28) was assessed. NR has been searched for in all patients. The number of affected fingers was recorded. NR was determined by a magnifying lens, seen by naked eye or seen and felt. Dermoscopic photography of the NR using Dermalite DL4 3Gen dermatoscope has been recorded. Results: The median age of patients was 49 years (42–58 years);they were 221 females and 19 males (F:M 11.1:1) with a disease duration 9 years (5–11 years). Their DAS28 was 3.6 (2.9–4.6). NR was significantly increased in RA cases vs. control;73% vs 20%;p < 0.001. In patients, NR was detected by a magnifying lens in 32.6%, seen in 27% and seen and felt in 13.5%. Joint deformities were significantly higher in those with NR. DAS28 was a significant independent predictor of NR;for every one-point increase in DAS28, there was a 153 times higher odds to exhibit NR at a sensitivity of 93.5%, specificity 80.3% and at a diagnostic accuracy of 90%. Conclusion: NR is a frequent finding in RA. An integrated rheumatological- dermatological clinical evaluation may be helpful and further studies are required to prove the importance of this sign for follow up of RA patients.

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.

INTERSTITIAL LUNG DISEASE IN SERONEGATIVE RHEUMATOID ARTHRITIS

SESSION TITLE: Autoimmune Diffuse Lung Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Interstitial lung disease (ILD) associated with connective tissue diseases (CTD) present with varying degrees of severity and functional impairment. Patients with CTD-ILD may often initially present for pulmonary evaluation. Pulmonologists must be familiar with the spectrum of CTD syndromes, the associated serologic testing, and referral criteria to rheumatology. CASE PRESENTATION: A 62-year-old never-smoking female with prior mild COVID-19 infection, previously vaccinated, presented to clinic with a diagnosis of pulmonary fibrosis. She endorsed three years of progressive shortness of breath and dyspnea on exertion walking only eight blocks and with light household chores. The patient had worked as a professional chef in poorly ventilated kitchens. Review of systems was notable for morning stiffness and pain in bilateral hand joints with associated difficulty opening medication bottles secondary to symptoms. Previous computed tomography (CT) of the chest demonstrated peripheral, subpleural, and basal predominant reticulations accompanied by bronchiectasis and bronchioloectasis consistent with probable usual interstitial pneumonia (UIP). Envisia® genomic testing was performed and results were negative for idiopathic pulmonary fibrosis. Extensive serologic testing for CTD was performed, including rheumatoid factor and anti-cyclic citrullinated peptides which were normal. The patient was referred to rheumatology, and hand x-rays demonstrated diffuse MCP joint narrowing. The patient was diagnosed with seronegative rheumatoid arthritis (RA) with RA-ILD and started on treatment. DISCUSSION: Multiple society guidelines recommend serologic testing to rule out CTD-ILD in patients with new ILD. ILD has been reported to occur in 20-60% of patients with RA with multiple patterns. Patients with seronegative RA are more likely to develop extraarticular manifestations of RA including fibrotic lung disease. Patients who are asymptomatic from RA-ILD may be monitored clinically for worsening RA-ILD. The selection of patients for treatment with an immunosuppressive agent or glucocorticoids should be done with a multidisciplinary team. Patients with RA-ILD and a UIP pattern may not respond to immunosuppressive medications but are typically trialed on treatment for worsening lung disease. Randomized controlled trials that included patients with RA-ILD with fibrosis have suggested a role for nintedanib, an anti-fibrotic agent, in slowing the progression of forced vital capacity decline. CONCLUSIONS: CTD-ILD is a common diagnosis in pulmonary clinics, and ILD symptoms may be the chief complaint at presentation. Providers must be familiar with diagnostic criteria for CTD and obtain a detailed review of systems that might suggest the diagnosis of CTD. Early diagnosis of CTD-ILD and monitoring of disease activity is important to prevent progression of CTD-ILD. Reference #1: Yoo H, Hino T, Han J, et al. Connective tissue disease-related interstitial lung disease (CTD-ILD) and interstitial lung abnormality (ILA): Evolving concept of CT findings, pathology and management. Eur J Radiol Open. 2020;8:100311. Published 2020 Dec 16. doi:10.1016/j.ejro.2020.100311 Reference #2: Sahatciu-Meka V, Rexhepi S, Manxhuka-Kerliu S, Rexhepi M. Extra-articular manifestations of seronegative and seropositive rheumatoid arthritis. Bosn J Basic Med Sci. 2010;10(1):26-31. doi:10.17305/bjbms.2010.2729 Reference #3: Cottin V. Pragmatic prognostic approach of rheumatoid arthritis-associated interstitial lung disease. Eur Respir J. 2010 Jun;35(6):1206-8. doi: 10.1183/09031936.00008610. PMID: 20513909. DISCLOSURES: No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih No relevant relationships by Priyanka Makkar No relevant relationships by Jonathan Moore

THE PATTERN of POST COVID-19 REACTIVE ARTHRITIS

Background: According to the recent medical literature, COVID-19 disease can lead to a constellation of clinical syndromes lasting well beyond the frst 30 days of infection. The most common post COVID sequalae includes pulmonary, nervous system and neurocognitive, mental, metabolic, cardiovascular, gastrointestinal and several other clinical manifestations. Regarding joint involvement and particularly reactive arthritis (ReA), literature data is limited and describes case reports or series of cases of patients diagnosed with this condition following COVID-19 disease. Objectives: To describe the pattern and the management of post-COVID reactive arthritis. Methods: We have conducted a descriptive study of consecutive adult patients who presented to rheumatology outpatient clinic for joint or peri-articular pain/swelling/stiffness and received a diagnosis of post-COVID 19 reactive arthritis, by excluding other types of rheumatological conditions. The assessed clinical variables were: visual analogue scale (VAS) pain, swollen joint count (SJC), tender joint count (TJC), duration of morning stiffness, presence of enthesitis/tendinitis and axial involvement. Biochemistry and serology was performed: rheumatoid factor, ACPA, ANA, HLA B27, antiChlamydia Trachomatis, Ureaplasma Urealyticum and Mycoplasma Hominis Ab, anti HBs and HBc Ab, and anti HCV. COVID-19 disease prior to diagnosis of ReA was confrmed by PCR test. Results: In the study were included 16 patients with confrmed post COVID-19 ReA. The mean age of the study group was 43.5±10.8 (range 21-60), the female: male ratio was 4:1 and the duration of joint symptoms was 10.4±11.8 (range 1-42) weeks. The severity of COVID-19 disease was mild in 68.7% cases, moderate in 18.7% and severe in only 6.2% of the cases. The duration between COVID-19 diagnosis and ReA varied between cases, with a mean value of 4.3±4.2 (range 1-12) weeks. In 43.7% of the cases patients had peripheral joint involvement (synovitis), in 37.5%-periarticular involvement (enthesitis), 6.25%-isolate axial involvement (sacroiliac joints), 6.25% enthesitis and axial involvement (cervical spine) and 6.25% synovitis and enthesitis. In patients with peripheral joint pattern, the distribution of pain was symmetric (71.4%). The pattern of synovitis was determined by a TJC of 6.25±5.2 (range 1-16) joints and SJC 1.6±2.4 (range 0-7) joints. Both TJC and SJC correlated positively with the duration of morning stiffness (r=0.9 and r=0.6), but did not correlate with the VAS pain scale. In most of the cases synovitis affected the hand (wrist, MCP and PIP) 62.5% and the knee, feet and ankles-50%. Two patients presented with monoarthritis, 1 with oligoarthritis and 5 with polyarthritis, in the majority of cases, involvement being symmetric (75%). Periarticular pattern was determined by enthesi-tis, affecting the elbow and shoulder (50%), costo-sternal enthesitis (25%) and trochanteritis (25%). From the entire study group, 31.2% had elevated serum infammatory markers (ESR and/or CRP). Patients responded well to NSAIDs alone in 68.7% cases, local (intra-articular or peri-articular infltrations) or and systemic corticoids (5 mg Prednisolone equivalent) were administered in 5.3% and 12.5% cases respectively, in 12.5% cases (two patients) Methotrexate was administered. Conclusion: Reactive arthritis represents a post COVID-19 sequelae. The time of onset of ReA varied between 1 and 12 weeks after COVID-19 diagnosis. The clinical pattern of the disease was expressed by joint or periarticular involvement, mainly affecting the hand, feet and knee symmetrically. Cases of axial manifestations were less common. Most of the patients responded well to NSAIDs, only in a few particular cases, low doses of corticoids and/or Methotrexate were recommended.

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.

Do bio-psycho-social self-reported factors distinguish rotator cuff tendinopathy from other shoulder problems and explain shoulder severity? A case–control study

Keywords: Tendinopathy;Rotator cuff;Digital transformation Purpose: Similar associations between self-reported bio-psycho-social factors and the presentation of people with various shoulder disorders and rotator cuff (RC) tendinopathy have been reported;however, only limited numbers of variables have been assessed, often in small cohorts. We aimed to test whether RC tendinopathy could be distinguished from other shoulder problems using a range of bio-psycho-social self-reported factors and the degree to which they explain severity. Methods: Self-reported bio-psycho-social factors were collected via an online survey battery from an international sample. The dependent variables were diagnosis (having RC tendinopathy or other shoulder problems) and severity. After group comparison and univariate regression analyses, multivariable logistic and linear regression analyses were used to construct explanatory models for group differences and severity. Results: 82 people with RC tendinopathy (42.8 ± 13.9 years, 50 female) and 54 people with other shoulder problems (40.2 ± 14.1 years, 33 female) were recruited and found not to differ in severity on four patient-reported PROMs (Shoulder Pain and Disability Index (SPADI) = 37.3 ± 24.5 vs 33.7 ± 22.5, Western Ontario Rotator Cuff Index (WORCI) = 56.2 ± 22.0 vs 60.3 ± 22.2, Single Assessment Numeric Evaluation = 56.6 ± 25.3 vs 56.5 ± 28.7 and Patient Acceptable Symptomatic State (yes:no) 51:31 vs 23:22, respectively). Eight self-reported factors individually distinguished RC tendinopathy from other shoulder problems, with the model distinguishing tendinopathy from other shoulder problems including 4 variables;having a previous injury in the shoulder (OR (95% CI) = 0.30 (0.13–0.69)), activity effect on pain (OR (95% CI) = 2.24 (1.02–4.90)), General Self-Efficacy Score (OR (95% CI) = 1.12 (1.02–1.22)) and activity level according to Global Physical Activity Questionnaire (moderately active OR (95% CI) = 3.97 (1.29–12.18) and highly active OR (95% CI) = 3.66 (1.41–9.48)), with acceptable overall model accuracy. Univariate linear regression analysis showed that 32 variables were associated with RC tendinopathy severity with a multivariable model consisting of quality of life (β coefficient = −0.38), having night pain (β = 0.19), having unilateral morning stiffness (β = 0.25), BMI (β = 0.29), FABQ (work) score (β = 0.25);and pain catastrophising (β = 0.21) explaining 68% of the variance in severity. Conclusion(s): Well validated patient-reported outcomes to explain severity do not distinguish RC tendinopathy from other shoulder problems however self-reported bio-psycho-social factors do, so may be useful for clinical evaluation. Further, these factors were strongly associated with severity, reinforcing the potential to improve patient assessment, for example, using pre-consultation online data collection in usual care. The models warrant prospective validation and consideration alongside data from physical and imaging assessment. Impact: Online survey including self-reported bio-psycho-social factors may help augment diagnosis and, more importantly, provide some of the detail needed for holistic assessment by complementing physical examination and imaging. Therefore, the online survey may be useful to minimise the clinical time commitment and optimising safety during the Covid-19 pandemic. Funding acknowledgements: The review is a part of Mehmet Delen's Ph.D., which is sponsored by the Turkish Ministry of National Education. The sponsors had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The shift to pediatric rheumatology telemedicine practice impacts the ability to assess and document critical JIA outcome data: A survey within the PR-COIN network

Introduction: The COVID-19 pandemic disrupted the traditional inperson healthcare delivery model, prompting a shift to telemedicine to ensure continuity of care for pediatric rheumatology patients. The change to virtual practice affected healthcare provider's assessments of disease activity in patients with juvenile idiopathic arthritis (JIA) as they were unable to perform hands-on physical assessments. Understanding the impact of this shift is critical to help address any care gaps that are faced during virtual visits for patients with JIA. Objectives: The objectives of the survey were four-fold: a) understand the impact of the switch from in-person to telemedicine visits from the healthcare provider perspective;b) identify the barriers and facilitators to collecting critical data elements that are important in monitoring JIA disease activity and outcomes;c) identify tools that providers are using during their telemedicine visits to perform disease activity assessments;and d) examine the impact of the telemedicine healthcare delivery on clinical research. Methods: A cross-sectional survey sent to members from all Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) centers (n=21) with total number of targeted respondents of 121. The survey was sent out for completion between 08/17/2020 - 09/ 02/2020. Quantitative responses were analyzed using descriptive statistics. Qualitative responses were analyzed by content and theme. Results: Survey ersponse rate was 98% (n=119) 90% fully completed. Most respondents (99%) indicated that they documented six critical data elements [CDE] (physician global assessment, patient global assessment, active joint count, morning stiffness, arthritis-related pain, and completion of uveitis screen) in 75% of telemedicine visits. Most respondents (74%) indicated that they documented active joint count over 70% of the time, while 30% of respondents reported barriers to documenting active joint count such as inability to palpate joints and the inability to visualize all joints on virtual examination. Identified barriers to assessment and visit documentation included challenges with assessing joint disease activity and platform technical issues. Ten percent of the respondents reported they often forgot to document CDE during telemedicine visits, indicating that setting up automated reminders in their electronic medical records may help with increasing their likelihood of documentation. A few centers reported having processes to assist with the collection of patient data in advance of the visit, such as pre-visitquestionnaires and planning. The ability to perform research activities was significantly impacted with only 37% of centers reported participating in research activities via telemedicine, and 29% reported their ability to consent patients via telemedicine visits. Conclusion: There are multiple barriers and facilitators to conducting successful clinical visits as well as performing clinical research over telemedicine. Our data suggests variation in telemedicine practice and process across centers, as well as within each center, reflecting the need to standardize the process of telemedicine visits. Given that a portion of patients with JIA will likely continue to be serviced over telemedicine post-pandemic, teams need to adapt their existing practices to continue providing quality care and integrating clinical research over this platform where appropriate.

A self-limiting symmetrical polyarthritis following COVID-19 infection

Case report-IntroductionWe describe an acute onset self-limiting seronegative non-destructive symmetrical polyarthritis five weeks after laboratory confirmed COVID-19 infection.Case report-Case descriptionA 37-year-old male hospital doctor of presented to the Early Inflammatory Arthritis clinic with a four-week history of acute onset joint pain, swelling and early morning stiffness in excess of two hours. The symptoms began at the left ankle with Achilles' tendonitis but progressed over the following 72 hours to a symmetrical polyarthritis affecting the wrists, proximal interphalangeal joints, shoulders, elbows, and knees.Approximately five weeks prior to the onset of his joint symptoms he had laboratory confirmed SARS-CoV-2 infection with six days of fever, non-productive cough, and fatigue. He did not require hospitalisation.His past medical history was significant for biopsy proven non-alcoholic fatty liver disease. There was no prior history of inflammatory arthritis and no personal or family history of skin psoriasis, inflammatory bowel disease or uveitis. There was no preceding genitourinary or gastrointestinal upset. His family history was significant for a sister with seronegative rheumatoid arthritis for which she was taking sulfasalazine.Examination revealed a normal BMI, synovitis at the wrists and proximal interphalangeal joints without evidence of joint effusion in the large joints. Blood tests revealed elevations in the ESR (83 mm/hour, reference range 0-10 mm/hour) and CRP (25mg/dL, reference range <5mg/dL). Serology was negative for the rheumatoid factor, anti-CCP antibodies, antinuclear antibodies, and an extractable nuclear antigen panel. Radiographs of the affected joints were unremarkable. Serological testing was positive for anti-SARS-CoV-2 IgG antibodies.He was started on oral Prednisolone 20mg daily and an NSAID with good symptomatic response and normalisation of his ESR (5mm/hour) and CRP (<1mg/dL). The course of prednisolone was tapered over a 6-week period and he is still in steroid free remission with normal inflammatory markers at follow up. The patient was given a diagnosis of a post-viral reactive arthritis which was attributed to the preceding COVID-19 illness.Case report-DiscussionPost infectious inflammatory arthritis has been described with many viral infections including: hepatitis virus, parvovirus B19, enterovirus, rubella, alphavirus (including Chikungunya), flavivirus (including Zika), herpes viruses (including Epstein-Barr virus), varicella, cytomegalovirus and human immunodeficiency virus (HIV). Interestingly, viral arthritis has not been reported in influenza and human coronaviruses (including SARS and MERS). Arthralgia was reported in 14.9% of laboratory confirmed COVID-19 cases in China during the early phases of the pandemic but inflammatory arthritis was not well described.The clinical course of the inflammatory arthritis in this case was self-limiting with enthesitis and synovitis resolving within six weeks of onset with the mainstay of treatment being symptomatic relief in the form of non-steroidal anti-inflammatory drugs and corticosteroids.Patient perspective: When I woke up that Tuesday morning with severe joint pains and stiffness, I knew something was not right. It was not like anything I have felt before in terms of my joints, having had sports injuries in the past. It was to the point where I was even struggling to go from sitting to standing. Without Prednisolone, I feel as if I would not have been able to work and may even have been house bound. I was relieved that this inflammatory arthritis did respond to Prednisolone. After six weeks of taking Prednisolone, the condition seemed to settle.Case report-Key learning pointsA self-limiting episode of inflammatory arthritis may occur following COVID-19 infection.

Inflammatory arthritis triggered by COVID-19

Case report-IntroductionCOVID-19 is an infectious disease caused by a newly discovered β-coronavirus, named Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), resulted in a recent pandemic of COVID-19.As a novel pathogen, the nature and degree of risk of COVID-19 to individuals with rheumatic diseases were unknown, as was its ability to induce musculoskeletal and autoimmune disease. Concerns were related to the chronic autoimmune or inflammatory disease and immune suppressive medications to treat it. The consequences of this infection are currently not fully understood, including the autoimmune sequelae. Here we present two cases of inflammatory arthritis with a temporal link to COVID-19. Case report-Case description: Case 1A 37-year-old Caucasian male was referred to Rheumatology with severe joint pains. He developed flu-like symptoms in early April 2020, with myalgia, fever, sore throat, anosmia, and fatigue. SARS-CoV-2 PCR swab was positive. He recovered from these initial symptoms, however 4 weeks later, he developed pain and swelling in his hands, feet, ankles, and knee joints with early morning stiffness.On examination, there was marked synovitis of hands, wrists, knees, and ankle joints. Systemic examination was otherwise normal.Case 2A 70-year-old lady developed sore throat and cough started in late March 2020. 3 weeks later, she became generally unwell with lethargy and fatigue. Her cough gradually improved, but she continued to experience breathlessness on minimal exertion. In early May 2020, she developed excruciating pain in her hands, wrists, and right knee joints with morning stiffness. On examination she had synovitis in the wrists, small joints of the hands and right knee. Systemic examination otherwise was unremarkable.Given the severe inflammatory arthritis, both patients were commenced on oral prednisolone with remarkable improvement 4 weeks later.Case report-DiscussionWe present 2 cases of acute inflammatory arthritis, which were suspected to have been triggered by COVID-19 viral infection without any musculoskeletal complications with good prognosis. COVID-19 is a new disease and our understanding of it is continuing to grow.The initial concern was that COVID-19-19 infection may lead to severe illness in immunocompromised patients, including those and with rheumatic conditions. However, this was not seen in large numbers. To our knowledge, COVID-19-related inflammatory arthritis has not previously been reported in the literature.Our current understanding of the COVID-19 pathogenic mechanisms is limited. However, it is likely that the disease may evolve in overlapping phases.Case report-Key learning pointsIn both cases, it was suggested that COVID-19 19 may be a triggering factor for inflammatory arthritis with good prognosis and settled with steroid therapy. It was suggested that arthritis may occur in patients with COVID-19, in previously fit and well patients without any underlying co-morbidities and autoimmune rheumatic disease and warrants urgent Rheumatology review. However, all COVID-19 suspected cases should be investigated on an individual basis to exclude other diagnosis to avoid missing other common reversible illnesses.