Post-covid-19 arthritis and sacroiliitis: Natural history with longitudinal magnetic resonance imaging study in two cases and review of the literature

Severe acute respiratory coronavirus-2 syndrome (SARS-CoV-2) is a well-known pandemic infectious disease caused by an RNA virus belonging to the coronaviridae family. The most important involvement during the acute phase of infection concerns the respiratory tract and may be fatal. However, COVID-19 may become a systemic disease with a wide spectrum of manifestations. Herein, we report the natural history of sacroiliac inflammatory involvement in two females who developed COVID-19 infection with mild flu-like symptoms. After the infection they reported inflammatory back pain, with magnetic resonance imaging (MRI) studies showing typical aspects of sacroiliitis. Symptoms improved with NSAIDs therapy over the following months while MRI remained positive. A literature review was performed on this emerging topic. To our knowledge, this is the first MRI longitudinal study of post-COVID-19 sacroiliitis with almost one year of follow-up. Predisposing factors for the development of articular involvement are unclear but a long-lasting persistence of the virus, demonstrated by nasopharyngeal swab, may enhance the probability of altering the immune system in a favourable background

Safety of Biologic-DMARDs in Rheumatic Musculoskeletal Disorders: A Population-Based Study over the First Two Waves of COVID-19 Outbreak

This study aims to explore disease patterns of coronavirus disease (COVID-19) in patients with rheumatic musculoskeletal disorders (RMD) treated with immunosuppressive drugs in comparison with the general population. The observational study considered a cohort of RMD patients treated with biologic drugs or small molecules from September 2019 to November 2020 in the province of Udine, Italy. Data include the assessment of both pandemic waves until the start of the vaccination, between February 2020 and April 2020 (first), and between September 2020 and November 2020 (second). COVID-19 prevalence in 1051 patients was 3.5% without significant differences compared to the general population, and the course of infection was generally benign with 2.6% mortality. A small percentage of COVID-19 positive subjects were treated with low doses of steroids (8%). The most used treatments were represented by anti-TNF agents (65%) and anti-IL17/23 agents (16%). More than two-thirds of patients reported fever, while gastro-intestinal symptoms were recorded in 27% of patients and this clinical involvement was associated with longer swab positivity. The prevalence of COVID-19 in RMD patients has been confirmed as low in both waves. The benign course of COVID-19 in our patients may be linked to the very low number of chronic corticosteroids used and the possible protective effect of anti-TNF agents, which were the main class of biologics herein employed. Gastro-intestinal symptoms might be a predictor of viral persistence in immunosup-pressed patients. This finding could be useful to identify earlier COVID-19 carriers with uncommon symptoms, eventually eligible for antiviral drugs

DECESSO PER OMICIDIO O INTOSSICAZIONE DA ETANOLO ?

Il meccanismo di morte dovuto all\u2019intossicazione da etanolo \ue8 generalmente ascritto alla soppressione del centro cerebrale del respiro con un seguente abbassamento della saturazione dell\u2019ossigeno arterioso. Evidenze scientifiche dalla Medicina Forense e studi di avvelenamenti acuti da etanolo, suggeriscono che le concentrazioni letali di Blood Alcohol Concentration (BAC) relative ad etanolo siano > 400 mg per 100 mL. Il valore di BAC \ue8 solitamente ottenuto analizzando il sangue dell\u2019arteria femorale mediante gas cromatografo a spazio di testa. Un altro parametro utile \ue8 il rapporto della concentrazione nell\u2019umor vitreo (VAC) su BAC. Quando VAC: BAC \ue8 1 la fase di eliminazione era raggiunta prima della morte. Questo parametro potr\ue0 essere utile per stabilire il tempo intercorso tra l\u2019assunzione dell\u2019alcool ed il decesso. La stima del BAC e/o VAC pu\uf2 per\uf2 essere complicata da variabilit\ue0 individuale, dalle matrici biologiche utilizzate e molti altri fattori. L\u2019etnia pu\uf2 contenere differenti livelli di alcool deidrogenasi. Per es. nativi Americani non producono sufficienti ADH e quindi avranno una Cl ridotta con accumulo dell\u2019alcool e maggiori effetti tossici. In circostanze come suicidio e omicidio la intossicazione da alcool pu\uf2 giocare una ruolo indiretto come causa di morte. In una recente revisione, il consumo eccessivo di alcool (es. binge drinking, heavy drinking e uso di alcool da individui sotto i 21 aa) \ue8 associato con un aumentato rischio di morte violenta. Gli effetti farmacologici del consumo di alcool possono contribuire all\u2019associazione tra alcool e aggressione (subita o eseguita). In questo case report, portiamo l\u2019esempio di un individuo di 28 aa, sesso maschile, peso 75 Kg, altezza 175 cm, razza afro-americana, che \ue8 stato trovato deceduto in un sottoscala con n\ub05 ferite da arma da taglio, di cui tre in regione addomino-pelvica, una alla regione del collo e una in sede toracica. All\u2019apparenza, in sede di sopraluogo giudiziario, la causa del decesso poteva essere messa in relazione con le ferite, ma in sede autoptica tali ferite non avevano lesionato organi vitali e neppure avevano prodotto eccessiva emorragia. All\u2019esame della BAC e/o VAC aveva una concentrazione di 473 e 278 mg/dL, rispettivamente. Poich\ue9 queste concentrazioni ematiche sono state frequentemente correlate come causa di decesso e le ferite non avevano leso organi vitali, la causa del decesso \ue8 stata ascritta ad intossicazione da alcool. In conclusione, questo caso solleva l\u2019importanza di eseguire, nella vittima e/o nell\u2019aggressore, correttamente le analisi di alcool ematico, urinario e dell\u2019umor vitreo anche se, in una prima analisi, esistono prove per ferite da armi da taglio, da fuoco, incidenti, ecc. In secondo luogo l\u2019importanza di prevenire il binge drinking che porta a maggiore rischio di morte violenta come vittima o aggressore

DECESSO PER OMICIDIO O INTOSSICAZIONE DA ETANOLO ?

Il meccanismo di morte dovuto all\u2019intossicazione da etanolo \ue8 generalmente ascritto alla soppressione del centro cerebrale del respiro con un seguente abbassamento della saturazione dell\u2019ossigeno arterioso. Evidenze scientifiche dalla Medicina Forense e studi di avvelenamenti acuti da etanolo, suggeriscono che le concentrazioni letali di Blood Alcohol Concentration (BAC) relative ad etanolo siano > 400 mg per 100 mL. Il valore di BAC \ue8 solitamente ottenuto analizzando il sangue dell\u2019arteria femorale mediante gas cromatografo a spazio di testa. Un altro parametro utile \ue8 il rapporto della concentrazione nell\u2019umor vitreo (VAC) su BAC. Quando VAC: BAC \ue8 1 la fase di eliminazione era raggiunta prima della morte. Questo parametro potr\ue0 essere utile per stabilire il tempo intercorso tra l\u2019assunzione dell\u2019alcool ed il decesso. La stima del BAC e/o VAC pu\uf2 per\uf2 essere complicata da variabilit\ue0 individuale, dalle matrici biologiche utilizzate e molti altri fattori. L\u2019etnia pu\uf2 contenere differenti livelli di alcool deidrogenasi. Per es. nativi Americani non producono sufficienti ADH e quindi avranno una Cl ridotta con accumulo dell\u2019alcool e maggiori effetti tossici. In circostanze come suicidio e omicidio la intossicazione da alcool pu\uf2 giocare una ruolo indiretto come causa di morte. In una recente revisione, il consumo eccessivo di alcool (es. binge drinking, heavy drinking e uso di alcool da individui sotto i 21 aa) \ue8 associato con un aumentato rischio di morte violenta. Gli effetti farmacologici del consumo di alcool possono contribuire all\u2019associazione tra alcool e aggressione (subita o eseguita). In questo case report, portiamo l\u2019esempio di un individuo di 28 aa, sesso maschile, peso 75 Kg, altezza 175 cm, razza afro-americana, che \ue8 stato trovato deceduto in un sottoscala con n\ub05 ferite da arma da taglio, di cui tre in regione addomino-pelvica, una alla regione del collo e una in sede toracica. All\u2019apparenza, in sede di sopraluogo giudiziario, la causa del decesso poteva essere messa in relazione con le ferite, ma in sede autoptica tali ferite non avevano lesionato organi vitali e neppure avevano prodotto eccessiva emorragia. All\u2019esame della BAC e/o VAC aveva una concentrazione di 473 e 278 mg/dL, rispettivamente. Poich\ue9 queste concentrazioni ematiche sono state frequentemente correlate come causa di decesso e le ferite non avevano leso organi vitali, la causa del decesso \ue8 stata ascritta ad intossicazione da alcool. In conclusione, questo caso solleva l\u2019importanza di eseguire, nella vittima e/o nell\u2019aggressore, correttamente le analisi di alcool ematico, urinario e dell\u2019umor vitreo anche se, in una prima analisi, esistono prove per ferite da armi da taglio, da fuoco, incidenti, ecc. In secondo luogo l\u2019importanza di prevenire il binge drinking che porta a maggiore rischio di morte violenta come vittima o aggressore

Medico legal investigations into sudden sniffing deaths linked with trichloroethylene

Sudden deaths attributed to sniffing trichloroethylene are caused by the abuse of this solvent which produces pleasant inebriating effects with rapid dissipation. In the event of repeated cycles of inhalation, a dangerous and uncontrolled systemic accumulation of trichloroethylene may occur, followed by central nervous system depression, coma and lethal cardiorespiratory arrest. Sometimes death occurs outside the hospital environment, without medical intervention or witnesses and without specific necroscopic signs. Medico legal investigations into sudden sniffing deaths associated with trichloroethylene demand careful analysis of the death scene and related circumstances, a detailed understanding of the deceased's medical history and background of substance abuse and an accurate evaluation of all autopsy and laboratory data, with close cooperation between the judiciary, coroners and toxicologists

AB1125 SAFETY OF BIOLOGIC-DMARDs DURING COVID-19 OUTBREAK: FOLLOW-UP STUDY IN 1051 RHEUMATIC PATIENTS OVER THE FIRST TWO WAVES.

BackgroundA novel viral infection known as COVID-19 (Coronavirus-19 disease) spread up in Wuhan (China) in December 2019, but rapidly diffused worldwide and nowadays it remains an international health problem. Because of its impact on immunologic system, immunomodulating therapies have been studied as possible treatments for severe cases of COVID-19. In that context, patients affected by from rheumatic musculoskeletal disorders (RMD) under disease modifying anti-rheumatic drugs (DMARDs) have been observed in several studies to evaluate the impact of COVID-19 on these subjects, well known to be at higher risk of infection.ObjectivesThe primary objective of this study is to assess prevalence and severity of COVID-19 in patients with RMD under treatment with biologic (b-DMARDs) or targeted synthetic (ts-DMARDs) DMARDs, before the vaccination campaign. The second aim is to compare those data with that in general population of the same Area (Province of Udine, Friuli Venezia Giulia Region, Italy,).MethodsA cohort of RMD patients treated with b-DMARDs or ts-DMARDs was observed from September 2019 to November 2020. Both pandemic waves have been considered, until the start of vaccination (since current variants can overcome vaccine protection), between February 2020 and April 2020 (first wave) and between September 2020 and November 2020 (second one).ResultsAmong 1051 RMD patients treated with b- or ts-DMARDs COVID-19 prevalence was 3.5% (37 cases) without significant differences compared to general population of the same Region (Table 1). Infected patients were 18 men and 19 women, with a median age of 60 years (IQR 49-68). Notably, the infection rate of RMD patients was significantly lower compared to the general population of the same province, particularly during the second wave (p&lt;0.001, Table 1). Almost all patients reported fever (70%). Gastro-intestinal symptoms (nausea, vomit and diarrhoea) have been recorded in 10 subjects (27%) and resulted significantly associated with longer swab positivity (p&lt;0.05) (Figure 1). Only a small percentage of patients with COVID-19 infection was receiving corticosteroids (8%), and the doses were low (3.5 or 5 mg per day of prednisone equivalents). The most used b-DMARDs were anti-TNFs (24/37, 65%), while just 4/37 (11%) employed JAK inhibitors. A small percentage of patients (6/37, 16%) continued ongoing treatment, with no worsened outcomes, while none preventively suspended the immunosuppressant. The course of infection was generally benign with a mortality rate of 2.6% (1 patient, with several risk factors) and only 9 patients needed to be hospitalized (24%). After COVID-19 infection, 12 subjects (32%) had RMD flare and 5 of them subsequently needed to change the immunosuppressive drug.Figure 1.Table 1.Cases and proportion of COVID-19 among different populations. *p&lt;0.001, patients vs province population; °p&lt;0.05 patients vs province population.Cases (proportions)PeriodsRMD patientsProvince populationRegion populationOverall wave37 (0.0352)*14437 (0.1441)32970 (0.0273)First wave5 (0.0048)°1190 (0.0119)3769 (0.0031)Second wave32 (0.0304)*13247 (0.1322)29201 (0.0242)ConclusionThe prevalence of COVID-19 in RMD patients has been confirmed low in both waves and it could be partially explained by the great awareness about preventive strategies by the patients. The benign course of COVID-19 in our patients may be linked to the very low amount of chronic corticosteroids used and the possible protective effect of anti-TNF agents, which were the main class of biologics herein employed. Gastro-intestinal symptoms might be a predictor of viral persistence in immunosuppressed patients. This finding could be useful to identify earlier COVID-19 carriers with uncommon symptoms (without respiratory manifestations), eventually eligible for antiviral drugs.References[1]Gianfrancesco M et al. DOI 10.1136/annrheumdis-2020-217871Disclosure of InterestsNone declared</jats:sec