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

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

POS1192 BEHAVIOR AND FEELINGS OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS DURING LOCKDOWN MEASURES FOR THE COVID-19 OUTBREAK

Background:COVID-19 is a systemic viral disease currently spreading as a pandemic. A more severe course and prognosis of COVID-19 in systemic lupus erythematosus (SLE) and vasculitis has been reported (1).Several papers have focused on the concerns, healthcare-related behaviors and psychological impact of COVID-19 pandemic among patients with rheumatic diseases, and specifically on SLE patients, showing a trend towards remarkable psychological distress (2-4). To date, no investigation on the psychological effects of quarantine strategy on SLE patients has been carried out.Objectives:To investigate the psychological impact of the lockdown measures adopted in Italy to contrasting the COVID-19 outbreak, on patients with SLE as compared to the general population.Methods:Patients affected by SLE were given an online questionnaire focused on psychological impact and self-perception during the lockdown measures contrasting the COVID-19 outbreak. The survey was focused on COVID-19 concerns, emotional impact, self-perception and changes in daily living activities and relationships. Results were compared with those of PRESTO (imPact of quaRantine mEasures againST cOvid19) project, an Italian survey, which used the same questionnaire, directed to the general population, with or without chronic diseases. A propensity matching procedure has been applied to LEPRE (Lupus Erythematosus PRESTO project) cases and the PRESTO responders with a ratio of 2 versus 1.Results:64 patients and 1114 unselected people completed the survey. After the matching procedure, patients were compared to 128 matched adults. Missing data were below 6%. The median age among patients was 43 years (I-III interquartile range 35-54.5), 88% were female and 100% Caucasian. The SLE subjects live mainly in detached houses (38/64 vs 348/1114, p&lt;0.0001), having access to a private garden (52/64 vs 625/1112, p&lt;0.0001) and also owning a pet (43/64 vs 508/1114, p&lt;0.001), in comparison with the PRESTO sample living mainly in flats. The psychological impact measured by IES-R, GHQ.12, and CEDS scores were not statistically different between patients and the general population, such as globally COVID-19 concerns and feelings. However, patients perceived more difficulty to find some free time and enjoy it (13/60 vs 48/121, p=0.01) and to be able to solve own problems (47/61 vs 71/120, p=0.02). On the contrary, patients felt more able to cope with the problem and less sad or depressed in comparison with the PRESTO group (17/61 vs 13/120, p=0.003). Moreover, patients missed playing sports/exercise less than general population (12/63 vs 46/128, p=0.02), while they felt more the distance from family and relatives (45/63 vs 42/86, p&lt;0.0001).Conclusion:the COVID-19 pandemic didn’t unveil a greater psychological fragility of people living with SLE than the others. By contrast, a coping strategy, including the role of the family and the lifestyle, contributes to resilience of SLE in difficult scenarios such as those presented by the pandemic.References:[1]Gianfrancesco M, et al. Ann Rheum Dis 2020;79:859-866.[2]George M, et al. J Rheumatol 2020 Nov 15; doi: 10.3899/jrheum.201017.[3]Rathi M, et al. Lupus 2020 Oct 6:961203320962855. doi: 10.1177/0961203320962855.[4]Koppert TY, et al. Rheumatology 2020;keaa842. doi: 10.1093/rheumatology/keaa842.Acknowledgements:We thank the PRESTO Investigators dr Corrado Lanera and dr Giulia Lorenzoni (Biostatistics, Epidemiology and Public Health, Department of Cardiology, Thoracic and Vascular Sciences, University of Padova, Italy) for their contribution.Disclosure of Interests:None declared</jats:sec

Psychological effects of lockdown measures for the covid-19 outbreak in patients with systemic lupus erythematosus

Objective: To compare the psychological impact of the lockdown measures contrasting the COVID-19 outbreak between systemic lupus erythematosus (SLE) and general population. Patients and Methods: From July 15th to August 15th 2020, a retrospective survey referring to the period March 9th to May 18th 2020 was administered to SLE patients and the results of the survey, called LEPRE (Lupus Erythematosus PREsto) study, were compared with those from the PRESTO (imPact of quaRantine mEasures againST cOvid19) project, the same survey provided to the general population. Consecutive patients &gt;18 years old affected by SLE and regularly followed in a single rheumatologic centre were involved. Primary outcome was to compare the scores of the Impact of Events Scale-Revised (IES-R), the General Health Questionnaire 12 (GHQ-12) and the Center for Epidemiological Depression Scale (CES-D) between patients and general population. Results: A total of 64 patients completed the survey. After a propensity score matching, they were compared to 128 people from PRESTO project. The median age among patients was 43 years (I–III interquartile range 35–54.5), 88% were female and 100% Caucasian. IES-R [(score&gt;23: 57% (34) vs 49% (58)], GHQ-12 [(score&gt;13: 85% (52) vs 88% (106)], and CES-D [(score&gt;15: 45% (28) vs 40% (46)] scores were not statistically different between patients and controls (p&gt;0.05). Conclusion: Restrictive measures for COVID-19 pandemic had no greater impact on patients with SLE than in the general population. Strategy for coping to the SLE might be useful during lockdown measures and may be helpful for other chronic conditions