VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic) syndrome is a novel adult-onset autoinflammatory disorder caused by variants in the UBA1 gene. Here, we report a Japanese case of VEXAS syndrome in which symptoms began 1 day after the second booster dose of a coronavirus disease 2019 (COVID-19) messenger ribonucleic acid vaccine, and a UBA1 variant was subsequently confirmed. Combined with the three cases reported thus far, this suggests that the COVID-19 vaccine may be one of the triggers for development of VEXAS syndrome in Asian populations. Since COVID-19 vaccines have been reported to be associated with various autoinflammatory and autoimmune diseases, it is important to continue to pay close attention to the relationship between COVID-19 vaccines and VEXAS syndrome.

Giant cell arteritis (GCA) is closely associated with polymyalgia rheumatica (PMR). We herein report an 82-year-old woman who developed GCA during PMR treatment. She initially presented with shoulder pain and was diagnosed with PMR based on elevated serum C-reactive protein (CRP) levels and bursitis detected in both shoulders on ultrasonography (US). Treatment was initiated with a daily dose of 15 mg prednisolone (PSL), which led to rapid symptom alleviation, and the dosage was tapered to 1 mg/day. One month later, she developed myalgia extending from the lumbar region to the thigh and tenderness in the left temporal region. However, no abnormalities in the temporal artery were observed on US. Although the PSL dose was increased to 2 mg for relapse of PMR, the symptoms did not improve. One week later, she developed occipital pain with an increased CRP level of 9 mg/dL. She was diagnosed with GCA based on the 1990 ACR Classification Criteria. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) detected anomalous accumulations in the bilateral superficial temporal and vertebral arteries, but not in the larger vessels. We therefore diagnosed her with cranial-type GCA. At this time point, we repeated US and found a halo sign in the temporal artery. Although epithelioid and giant cells were not observed in the temporal artery biopsy, vascular inflammatory findings such as disruption of the internal elastic lamina and chronic inflammatory cell infiltration were noted. Symptoms improved immediately and CRP levels decreased after the PSL dose was increased to 30 mg daily. To mitigate the risk of steroid-induced diabetes, tocilizumab was introduced, and gradual tapering of PSL was implemented. In conclusion, we encountered a case of GCA that developed after PSL reduction during the course of PMR. PET/CT confirmed intracranial artery inflammation and facilitated a definitive diagnosis. Although PET/CT cannot be routinely performed for diagnose in Japan, we consider it useful as an adjunctive diagnostic tool.

OBJECTIVES To efficiently detect somatic UBA1 variants and establish a clinical scoring system predicting patients with pathogenic variants in VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. METHODS Eighty-nine Japanese patients with clinically suspected VEXAS syndrome were recruited [81 males and 8 females; median onset age (IQR) 69.3 years (62.1-77.6)]. Peptide nucleic acid-clamping PCR (PNA-PCR), regular PCR targeting exon 3 clustering UBA1 variants, and subsequent Sanger sequencing were conducted for variant screening. Partitioning digital PCR (pdPCR) or targeted amplicon deep sequencing (TAS) was also performed to evaluate the variant allele frequency (VAF). We developed our clinical scoring system to predict UBA1 variant-positive and ‑negative patients and assessed the diagnostic value of our system using receiver operating characteristic (ROC) curve analysis. RESULTS Forty patients with reported pathogenic UBA1 variants (40/89, 44.9%) were identified, including a case having a variant with VAF of 1.7%, using a highly sensitive method. Our clinical scoring system considering >50 years of age, cutaneous lesions, lung involvement, chondritis, and macrocytic anaemia efficiently predicted patients with UBA1 variants (the area under the curve for the scoring total was 0.908). CONCLUSIONS Genetic screening with the combination of regular PCR and PNA-PCR detected somatic UBA1 variants with high sensitivity and specificity. Our scoring system could efficiently predict patients with UBA1 variants.

We here report a case of COVID-19 with effusion prior to the development of pneumonia in an adult with Down syndrome. Serositis due to rheumatic disease was initially suspected because of a high titer of serum autoantibodies and leukocytopenia; however, SARS-CoV-2 infection was confirmed by reverse transcription polymerase chain reaction on admission after previous negative tests. Several cases of COVID-19 have been associated with autoimmune responses along with some cases of COVID-19 with autoimmune manifestations. Furthermore, patients with Down syndrome have a higher mortality risk from COVID-19 than the general population, and it is believed that a high sensitivity to the interferon response may contribute to the increased severity of the disease. Thus, careful attention should be paid to autoimmune manifestations due to SARS-CoV-2 infection for ensuring a proper and timely diagnosis, especially in patients with Down syndrome.

To the Editor—We read with great interest the recently published article by Shi et al. [1]. By using the quasi-randomization approach to target patients who visit urgent care centers in the United States, they reported that patients who visit clinicians who prescribe antibiotics for acute respiratory illnesses (ARI) at higher rates are significantly prone to have higher rates of visits and antibiotic receipt for ARI during the subsequent year. Through this study, they clearly demonstrated the presence of an illusionary correlation [2] in the field of infectious disease treatment, in which patients often attribute their improvement in symptoms to the preceding use of antibiotics. Looking back on our own clinical experience, we also feel this phenomenon exists in the real world as a driver for inappropriate antibiotic prescription. This study has several strengths. First, the study data included more than 230 000 individuals from a health...

An 86-year-old woman in a wheelchair was accompanied by her husband and son as she visited our outpatient clinic due to disturbed consciousness and fever. Twenty-seven years earlier, she had been diagnosed with rheumatoid arthritis and had been treated with methotrexate (MTX) and low-dose prednisolone (PSL). She stopped taking MTX four years previously when she was diagnosed with diffuse large B cell lymphoma of the paranasal sinus. Her lymphoma went into remission after six cycles of systemic immunochemotherapy. MRI after hospitalization revealed a lesion in the splenium of the corpus callosum that was hyperintense on diffusion-weighted imaging and which had low apparent diffusion coefficient values. An analysis of the cerebrospinal fluid revealed no atypical cells. The MRI findings were atypical, but her consciousness disturbance improved, leading to the diagnosis of mild encephalitis/encephalopathy with a reversible splenial lesion, which would be associated with a transient consciousness disturbance with a good course. However, her consciousness worsened over the next 3 weeks. One month later, a contrast-enhanced MRI showed an enlarged lesion in the callosum as well as new lesions, and the diagnosis of secondary CNS lymphoma was made. Brain biopsy is often not feasible. Less invasive and highly accurate diagnostic methods are needed, such as the identification of a spinal fluid tumor marker.

We report two cases recovered from coronavirus disease 2019 with rheumatoid arthritis which had been in remission or low disease activity by taking calcineurin inhibitor (CNI). Both cases had moderate to severe pneumonia treated with intravenous dexamethasone or in the severe case remdesivir in addition to it. These cases suggest that the use of CNI may have affected the improvement of severe pneumonia.

BACKGROUND Relapsing polychondritis (RP) is a rare inflammatory disease involving the systemic cartilage, such as the auricle, trachea, and bronchiole, among others. A patient with RP shows variable symptoms based on the involved cartilage. CASE SUMMARY A 72-year-old Japanese woman with a history of redness of the bilateral auricles for 3 d was referred to a clinician. The clinician prescribed antibiotics to the patient; however, the symptoms worsened; thus, she was referred to our hospital. Head and neck magnetic resonance imaging (MRI) showed edematous auricle with remarkable contrast, fluid collection in the bilateral mastoid cells, suggesting otitis media. The eustachian tube (ET) on the right side was also edematous with contrast enhancement. The patient was suspected of RP according to the diagnostic criteria. A biopsy of the auricular cartilage was performed by an otorhinolaryngologist, confirming pathological proof of RP. Treatments with steroids were immediately administered thereafter. CONCLUSION We highlight a rare case of RP with radiologically confirmed involvement of ET in the MRI.

Objectives:To investigate the response of glucocorticoid (GC) therapy for patients with polymyalgia rheumatica (PMR) and predictive factors which correspond to the long-term GC. Methods:We reviewed 93 patients with PMR who were treated with GC for more than 6 months. We compared the clinical findings between patients who achieved remission within 24 months (early-remission group,n = 40) and those who required GC therapy for more than 24 months (long-therapy group,n = 24). Results:Among 93 patients, 49 have achieved a remission, 35 were undergoing treatment, and 9 have transferred to other hospitals or died. Rate of remission of patients treated for one year GC therapy was in 12% and 53% after 2 years. Serum CRP of long-therapy group was significantly higher than those of the early-remission group. The ratio of patients who experienced more than one relapse within 6 months was 37.5% of long-therapy group and 7.5% of early-remission group. Multivariate logistic regression analysis showed that the history of relapse until 6 months was a significant predictor of long therapy. Conclusions:Some patients need the long-term therapy for more than 4 years. The history of relapse till 6 months is a significant predictor of the long-term GC therapy.

Background: In Japan, sexual and gender minorities (SGM) remain stigmatized, provoking hospital access barriers and health disparities from judgmental care. Japan's Western-influenced introduction of SGM course content into medical education for future physicians addresses these disparities, although often perfunctorily and inconsistently.Objective: To examine the prevalence and characteristics of medical education curriculum with respect to SGM patients, we surveyed medical schools.Methods: A medical education faculty member from each of 80 Japanese medical schools received double postcards to identify relevant SGM coursework. Upon acknowledgement, 43 schools received seven-item anonymous questionnaires in March 2018. Survey results were analyzed from the perspective of three of the qualities and abilities required of a physician - Patient Care, Knowledge for Practice, and Professionalism from Japan's Medical Core Curriculum - to develop recommendations for outcomes-based SGM curriculum through the lens of Van Melle's medical education framework.Results: The response rate was 46%, with 22 schools providing SGM lectures mostly to first- and third-year students. Obstetrics and Gynecology, Neuropsychiatry, and Introduction to Medicine lectures were the top three subjects offering SGM lectures, primarily consisting of basic knowledge of SGM and Differences in Sex Development. Several lectures addressed the health challenges of SGM. Primary reasons for not offering SGM lectures were lack of suitable instructors or no school policies.Conclusions: Students can best experience the humanity of SGM patients and employ more appropriate diagnostic practices and modes of treatment with targeted curriculum to address SGM health disparities and inclusion of SGM patients in clinical practice training. To disseminate SGM education in Japanese medical schools, development of qualified instructors and policies is essential, employing currently active experts. The Van Melle reforms framework can guide in the development of recommended tailored learning experiences and lectures for improved and expanded SGM education, integrating appropriate coursework within current medical core curriculum structure.

BackgroundA recent meta-analysis shows patients with rheumatoid arthritis (RA) are at increased risk of lung and lymphoid malignancies compared with general populations1). Rheumatologists perform cancer screening before treatment of biological disease-modifying anti-rheumatic drugs (DMARDs), and do routine blood, urine and imaging tests to find adverse effects of DMARDs. However, they can’t always find malignant solid tumors (cancers) at the early stage in patients with RA.ObjectivesWe examine characteristics of cancers in patients with RA and use the data to help diagnose the cancers in early stages during medical checkups.MethodsIn this retrospective study, we studied 397 patients with RA who visited our rheumatology clinic from April 2011 to December 2018. Thirty-one cancers in 29 patients with RA were reviewed. The onset of RA and cancer, the medication situation and prognosis were analyzed.ResultsTwenty-five were female, and 4 males. The mean age of diagnosis of RA and cancer were 55 years old (SD 15.0) and 66 (SD 11.4). The median duration of RA prior to cancer diagnosis was 8 years (IQR 4-18). The median follow-up was 4.3 years (range 0.2-7.8). One case of breast cancer was diagnosed with RA at the same time. Breast, Lung and Gastrointestinal cancers were the most common, followed by uterine cervix and skin. Two female patients had metachronous double cancers (uterine cervix and lung, skin and lung). Sex cancers; uterine cervix 3, breast 2, and anal melanoma 1, were found by cancer screening tests that the patients received voluntarily. Twelve cases were detected by blood tests or imaging tests performed in outpatient settings. Three lung cancers were found by the chest CT at the diagnosis of RA and before treatment of biological DMARDs, which were all at the early stage and cured by the resection. A gastric and a colon cancer, which were detected by worsening of microcytic anemia, were in advanced stage with hepatic metastases. Nineteen patients were treated with methotrexate (MTX) before detection of cancers. But only 4 patients continued MTX after detection of cancers. Six patients were treated with biological DMARDs (TNF inhibitor 3, tocilizumab 2, abatacept 1) before detection of cancers. Two patients were treated with TNF inhibitor until just before the admission for cancer treatment, because the rheumatologists did not notice their patients’ cancers. After treatment of cancer, 3 patients were treated with tocilizumab and abatacept. The prognosis of 29 patients were as follows; death by cancers 4, death by pneumonia 2, undergoing chemotherapy 6, in remission 17.ConclusionThe consultation rates for breast and cervix cancer screening are lower in Japan than in European nations. Rheumatologists should encourage their patients to have usual age and sex appropriate cancer screening. A large cohort study showed biological DMARDs did not increase risk of second malignant neoplasm among RA patients with a history of cancer2). However, in this study, no patients were treated with TNF inhibitor after treatment of cancer.References[1] Simon TA, et al. Incidence of malignancy in adult patients with rheumatoid arthritis: meta-analysis. Arthritis Research and Therapy 2015; 17:212 [2] Dreyer L, et al. Risk of second malignant neoplasm and mortality in patients with rheumatoid arthritis treated with biological DMARDs: a Danish population-based cohort study. Ann Rheum Dis 2017; 0:1-5Disclosure of InterestsNone declared

BackgroundAs disease modified anti-rheumatic-drugs (DMARDs) were the mainstay in the treatment of rheumatoid arthritis (RA), the opportunity for general physicians to also prescribe DMARDs has recently increased in Japan. After DMARDs were initiated by specialists, subsequent drug prescription by general physicians during remission should be expected1. However, general physicians are more likely than rheumatologists to feel it difficult to accept patients taking even conventional synthetics (cs) DMARDs but not biologics and such discomforts may be potential barriers to cooperative management between specialists and general physicians2. One of the reasons is because some csDMARDs such as methotrexate and leflunomide may induce pneumonitis or worsen RA-related pre-existing interstitial lung disease (ILD) as a rare but severe adverse event3). To minimise the risk, rheumatologists may choose low-risk csDMARDs smartly when the patients are concomitant with risk factors on ILD.ObjectivesTo measure the physicians’ perspective toward the risk of each csDMARDs on drug-induced ILD and their attitude in prescribing the csDMARDs to a pre-existing ILD case.MethodsA questionnaire was given in an internet survey to registered physicians who take care of more than ten patients with RA in Japan. Topics covered were i) how is the risk of each csDMARD for drug-induced lung injury compared to methotrexate, ii) which csDMARDs should be applied to a case with mild pneumonitis on the chest CT. Cross tabulation analysis and χ2 test as a statistical analysis was performed.ResultsA total 184 physicians consisting of 66 rheumatologists (36%) and 118 non-rheumatologists (64%) responded. The physicians’ mean age was 45 years old. The rheumatologists tended to belong to rheumatology and take care of more than 200 RA patients per month in university hospitals. On the other hand, the non-rheumatologists tended to belong to general medicine and manage less than 50 patients per month in their clinics. The csDMARDs except for methotrexate were more significantly prescribed by the rheumatologists. All rheumatologists but 24% of non-rheumatologists had managed RA patients with exacerbated ILD. On physicians’ perspective toward the risk of each csDMARD, the rheumatologists considered that LEF was equal to or higher than MTX and that cyclosporine A (CyA), tacrolimus (TAC), salazosulfapyridine (SASP) was relatively safer (Figure A.). In cases with pre-existing ILD, more rheumatologists agreed to use the csDMARDs except for methotrexate and leflunomide. (Figure B.) R: rheumatologists, non-R: non-rheumatologists, MTX: methotrexate, LEF: leflunomide, CyA: cyclosporine A, TAC: tacrolimus, SASP: salazosulfapyridine, BUC: bucillamine, IGU: iguratimodConclusionsWe can find the gap of risk perception about each csDMARDs between rheumatologists and non-rheumatologist and the difference of attitude in prescribing to patients concomitant with risk factors. Considerable consensus and additional enlightenment to general physicians should be necessary.References[1] Puchner R. Interface Management between General Practitioners and Rheumatologists-Results of a Survey Defining a Concept for Future Joint Recommendations. PLoS One2016Jan 7;11(1). [2] Garneau KL. Primary care physicians’ perspectives towards managing rheumatoid arthritis: room for improvement. Arthritis Res Ther. 2011;13(6). [3] Roubille C. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum2014Apr;43(5).Disclosure of InterestNone declared

Objectives We investigated the decision-making preferences of rheumatoid arthritis (RA) patients using two different scales: the Decision Making Preference Scale (DMPS) and the modified Control Preference Scale (CPS). In addition, we evaluated the factors associated with patients’ preferences for decision-making. Methods A cross-sectional study was performed using a self-administered anonymous questionnaire between October and December 2010 on 406 RA outpatients who consecutively visited 3 hospitals in Japan. The following variables were investigated: (1) DMPS, which is a subscale of the Autonomy Preference Index, composed of six items; patients responded on a 5-point Likert scale. (2) The modified CPS, in which patients were asked to choose one actual and one desired role in decision-making from among three options (passive role, collaborative role, and active role). (3) Sociodemographic data and RA-specific characteristics. Multivariate analyses were used to assess the relationship between patients’ preferences and selected variables. Results The response rate was 58.6 %. There were few patients who wished to make their own decisions when they were hospitalized or illness became worse. However, the majority of patients desired to collaborate with the doctor in making treatment decisions according to the results of modified CPS. The results of modified CPS were significantly associated with the total scores of DMPS. Multivariate analysis demonstrated they younger age and not-housewife were associated with high scores of DMPS. Conclusions Patient preferences in decision-making vary at RA outpatient clinic. Physicians need to assess decision-making preferences on an individual basis.

The concept of sexual minority contains lesbian, gay, bisexual, transgender (LGBT) and disorders of sex development. Despite many recent advances in rights for sexual minorities in the world, bias against them still exit. We held a workshop ‘toward better care for sexual minorities’ on the 6th Annual Conference of Japan Primary Care Association 2015. Four lecturers talked about health disparities among sexual minority patients. We want this paper help reducing the readers’ prejudice towards the sexual minorities and thus impact their future clinical practice.

An 85-year-old man was admitted to our hospital for swollen and painful bilateral lower legs and a high fever. He was initially diagnosed with acute cellulitis and treated with antibiotics. Several days after the improvement of his swollen legs, he complained of both shoulder and arm pain. The laboratory data at this time were as follow: C-reactive protein 10.7 mg/dL, uric acid 8.7 mg/dL, and creatinine 1.07 mg/dL. Both rheumatoid factor and anti-CCP antibody were negative. Whole-body gallium scintigraphy showed a high pathological accumulation in both the shoulders and left wrist. As polymyalgia rheumatica was suspected, oral prednisolone (PSL) of 10 mg/day was started. The patient's shoulder pain improved and he was discharged. However, he was hospitalized twice in the next month because of left shoulder, left knee, right arm, and right wrist pain. During the third hospitalization, we found a subcutaneous nodule on right toe. Aspiration material from the nodule was a white paste, showing acicular crystals under the microscope. According to these findings, the nodule was diagnosed as a tophaceous nodule, and recurrent episodes of polyarthritis were diagnosed as chronic tophaceous gout. Low-dose PSL was continued and febuxostat was added. This patient had multiple risk factors for chronic tophaceous gout: obesity, a habit of drinking, diabetes mellitus, hyperlipidemia, congestive heart failure, and interruption of allopurinol treatment. We herein discuss the clinical course of the patient, the interruption of allopurinol treatment and polypharmacy in elderly patients.

Chylothorax results from various causes, such as malignancy, trauma, or infection. POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) is a multisystemic syndrome that is associated with plasma cell disorder. Pleural effusion is a common manifestation of POEMS syndrome, but the association of POEMS syndrome with chylothorax has not been reported. We report on a 61-year-old female patient who initially presented with dyspnea and bilateral leg edema. Importantly, the patient had normal renal function. Her chest X-ray and computed tomographic imaging showed bilateral pleural effusion, and her chest drainage revealed chylothorax. Detailed examination failed to reveal the definitive cause of the chylothorax. She received several treatments for chylothorax, namely, a low-fat diet or fasting, total parenteral nutrition, a somatostatin analog (octreotide), thoracic duct ligation by video-assisted thoracic surgery, and pleurodesis. However, further examination revealed endocrinopathy, monoclonal plasma cell disorder, peripheral neuropathy, and elevation of the serum level of vascular endothelial growth factor. The patient’s condition was consequently diagnosed as POEMS syndrome. Eventually, her chylothorax was controlled by pleurodesis, and she was transferred to another hospital for stem cell transplantation. Herein, we report on the apparent first case of POEMS syndrome with chylothorax. In some cases of idiopathic chylothorax, the underlying primary disease may be latent, such as in the present patient. POEMS syndrome is rare, but this syndrome should be included in the differential diagnosis of chylothorax with unexplained etiology.

目的 : 関節リウマチ (RA) 患者の健康行動に対する自己効力感と患者の疾患評価との関連を明らかにする.対象 : 都市部3病院のRA専門外来に3カ月以上通院している成人RA患者.方法 : 無記名自記入式質問紙法による連続性サンプリング横断的調査研究を2010年10～12月に実施した. 自己効力感の測定には「慢性疾患患者の健康行動に対する自己効力感尺度 Chronic disease-self efficacy scale (CD-SES) 」を用いた. CD-SESは対処行動の積極性14項目 (積極性) と健康に対する統制感10項目 (統制感) の2つの下位尺度で構成される. 患者による疾患の評価として, 疼痛関節数, 腫脹関節数, 最近の血清CRP, 全般的な体の調子, 日常生活動作 (ADL) の障害度を質問した.結果 : CD-SES24項目に回答した191人の回答を解析した. CD-SES全体は高齢者ほど, 全般的な体の調子が良く, ADLの障害が少ないほど高値であった. 積極性は高齢者ほど, 統制感は全般的な体の調子が良いほど高値であった.結語 : RA患者の健康行動に対する自己効力感は, 年齢, 全般的な体の調子やADLの障害度と相関することが示された, 心理的なサポートが統制感を含む自己効力感を改善し, 全般的な体の調子を改善することができるか, 今後縦断的な研究が必要と考えられた.

Background Polymyalgia rheumatica (PMR) is a common inflammatory condition of elderly persons. Clinical symptoms respond to low-dose glucocorticoids, but treatment is often required for several years. The recent UK guidelines and a systematic review reported that an adequate starting dose of prednisolone (PSL) for PMR patients is 15 mg daily1,2. However, the majority of PMR patients in Japan have shorter heights and lower weights than patients in Western countries. Therefore, this starting dose of PSL, when calculated as mg/kg body weight (PSL/BW), might be too high for Japanese patients who generally have a slighter build. Objectives We evaluated the starting doses of PSL and the clinical courses of Japanese PMR patients. Methods This was a retrospective study in a single hospital. We studied 14 patients with a diagnosis of PMR according to the modified Bird9s criteria3 (positive for C reactive protein (CRP) instead of erythrocyte sedimentation rate (ESR) >40mm/1 hour, who were followed-up for more than 6 months. Patients who had one or more of the following symptoms were excluded: recent temporal or occipital pain, a tender and/or swollen temporal artery, jaw claudication, and impairment of vision. The mean starting dose of PSL/BW of the 14 patients was 0.3 mg/kg. Thus, the patients were divided into 2 subgroups based on their starting doses of PSL/BW: less than 0.3 mg/kg (group L) and more than 0.3 mg/kg (group H). Remission was defined as the absence of symptoms for more than one month after the withdrawal of PSL. Relapse was defined by the recurrence of clinical symptoms accompanied by both serum CRP elevation and a requirement for an increase in PSL dose. Demographic and clinical data were obtained from the medical records. The statistical significance of the differences between the two groups of patients was determined by the Mann-Whitney U test and the chi-squared test. Results The median follow-up was 17.5 months (range 8.5-24.5 months). Among the 14 patients, 9 were women. The median body weight was 44.5 kg (interquartile range 40-53 kg); eight of the 9 women and 1 of the 5 men weighed less than 50 kg. Starting doses of PSL were 10 mg in 5 patients, 15 mg in 7 patients, and 20 mg in 2 patients. Seven patients each belonged to group L and H. There was no significant difference in follow-up months, sex, age, BW, or serum CRP at diagnosis between the 2 groups. Two patients from both group L and H achieved remission. In addition, the clinical course, including the relapse and PSL withdrawal rate, were similar between the 2 groups. Conclusions A starting dose of PSL of <0.3 mg/kg was equally as effective as that of >0.3 mg/kg. Calculating the starting PSL dose by BW might be more appropriate, especially for elderly low-BW patients in Japan, to prevent deterioration of their prognosis. References Hemanddez-Rodriguez J, et al. Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med 2009; 169:1839-1850. Dasgupta, B, et al. BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology 2010; 49:186-190 Bird H.A, Esselinckx W, J, et al. An evaluation of criteria for polymyalgia rheumatica. Ann Rheum Dis. 1979; 38: 434-439. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1157

We report on an outbreak of Group A Streptococcus (GAS) pharyngitis among university students in a judo club. Eventually, 14 of total 23 club members developed acute pharyngitis clinically. In a span of 15 days in April 2013, 12 students visited our hospital complaining of sore throat and high fever. All were men with a median age of 19.5 years (interquartile range, 18-21). The rapid streptococcal antigen test was positive in 3 of 4 patients (75%) without previous antibiotic treatment, and in 2 of 8 patients (25%) with previous antibiotic treatment. The definitive diagnosis of GAS pharyngitis was made by either a positive RADT or positive throat culture of GAS when patients had more than 2 findings from the Centor scoring system in this study. 5 students received the definitive diagnosis. The throat culture results showed that 1 out of 9 asymptomatic students was GAS-positive. The outbreak might have occurred by person-to-person contact while living in a dormitory and during judo training, which is a highly close-contact sport. However, there was also the possibility of oral transmission by the shared use of water bottles, although the culture from 1 bottle was negative. Some students continued to participate in the judo club activities after the onset of sore throat or fever. Healthcare professionals, teachers, and coaches should be aware of the potential outbreaks of infectious diseases among university students engaged in athletic activities. Furthermore, it is important to educate athletes about infectious diseases.