Presentation A 63-year-old man developed polyarthritis two months post recovery from COVID-19 infection. Diagnosis We concluded that the diagnosis was rheumatoid arthritis based upon raised inflammatory markers, positive rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Treatment His symptoms improved with naproxen, corticosteroids, and methotrexate. Discussion We describe a patient with late onset rheumatoid arthritis possibly triggered or unmasked by COVID-19.

Background Rheumatoid arthritis (RA) is a chronic, autoimmune disease characterized by hyperplasia and inflammatory changes within the synovium. The recruitment and accumulation of monocytes in the synovium contribute to inflammatory response and bone destruction. Fractalkine (FKN) is a chemotactic cytokine that promotes monocyte transmigration and adhesion. The CX3C chemokine receptor 1 (CX3CR1) is a chemotactic and adhesion receptor for FKN. Both are highly expressed in human RA3. Two missense, conservative single nucleotide polymorphisms (SNPs) located in the sixth and seventh transmembrane domains of CX3CR1 affect FKN binding to peripheral blood mononuclear cells (PBMCs) (rs3732379 (G/A = V249I) and rs3732378 (C/T = T280M), respectively)1,2. FKN binding to PBMCs is significantly reduced in patients with coronary artery disease heterozygous for rs3732379 and in human immunodeficiency virus (HIV) positive patients homozygous for the rs3732379 variant allele1,4. Moatti et. al., suggested that the rs3732379 variant allele may contribute to reduced CX3CR1 expression and monocyte chemotaxis4. Objectives Association analysis between two CX3CR1 SNPs, rs3732378 and rs3732379, and RA susceptibility in a Caucasian case control cohort. Methods Cases (n=384) were selected based upon an established diagnosis of RA. Recruitment took place at Cork University Hospital (CUH) and Kerry General Hospital, Ireland. Age-matched controls (n=483) were selected from the Osteoporosis Genetics Database that was generated in the Bone Densitometry Unit, CUH for osteoporosis genetics studies. Genomic DNA was extracted from whole blood using the MagNA Pure LC instrument. All genotyping was performed blind to case control status by KBioscience. SPSS and PLINK were used for statistical analysis. Results The genotype distributions did not deviate from Hardy Weinberg Equilibrium (HWE) (P >0.05). CX3CR1 SNPs were in strong but incomplete linkage disequilibrium (LD) (D’ =1.0, r2 =0.53). Significant association was observed between rs3732379 and RA risk under a dominant model for the minor allele following 1000 permutations (AA+AG vs GG; OR: 1.18 (95% CI, 1.18 – 1.36); P =0.017). There was a higher frequency of AA or AG carriers in the controls (53.6%) versus the cases (45.4%). There was a higher frequency of rs3732379 A alleles in the controls (31.0%) versus cases (26.6%), however, this was not significant (OR: 0.81, (95% CI, 0.65-1.00); P =0.055). No association was observed between rs3732378 and RA risk (P >0.05). There was no association observed between CX3CR1 haplotypes and RA risk (P >0.05). Conclusions Individuals with one or more copies of the rs3732379 variant allele had a significantly reduced risk of RA compared to individuals that were homozygous for the wild-type allele. Monocyte recruitment and adhesion to the synovium contributes to the RA phenotype and is influenced by FKN binding to CX3CR1. FKN binding to CX3CR1 in rs3732379 allele specific RA patients will need to be investigated following an independent replication of these association results. References Faure, S. et. al. Science 2000;287 (5461):2274-7. Apostolakis et. al. Atherosclerosis 2009;207 (1):8-15. Ruth et. al. Arthritis & Rheumatism 2001;44 (7):1568-81. Moatti et. al. Blood 2001;97:1925–8. Disclosure of Interest None Declared

A case of debilitating cavitating lung disease associated with rheumatoid arthritis and bronchocentric granulomatosis, which failed to respond to conventional medical or surgical treatment, is described. The patient was treated over 10 years with steroids, antimicrobial agents, disease-modifying antirheumatoid drugs and surgery. Lung function continued to decline and the patient presented for admission with recurrent pneumonia. Abatacept was initiated to modify the underlying immunopathology. Following 12 months of treatment with abatacept the patient has demonstrable improvement in lung function and lung anatomy, and has not presented to hospital with pneumonia. She has tolerated the treatment without complication. The use of abatacept has stabilised the lung disease in this case in the medium term and prevented readmission to hospital. These results suggest a larger role for abatacept in those with such disease in the future and may warrant further investigation.

"Successful control of scleroderma myocarditis using a combination of cyclophosphamide and methylprednisolone." Scandinavian Journal of Rheumatology, 39(4), pp. 349–350

Natalizumab reduces clinical relapses and the risk of sustained progression of disability in patients with relapsing remitting multiple sclerosis (RR MS). It has been associated with the development of progressive multifocal leucoencephalopathy, a rare demyelinating disease caused by JC virus. BK virus is a related polyomavirus known to cause morbidity in the immunocompromised host. Studies in the HIV population have linked BK viruria with immunodeficiency as evidenced by depressed CD4+ counts. We evaluated the relationship between the prevalence of JC and BK in MS patients receiving natalizumab and the degree of immunosuppression by sampling serum and urine specimens at baseline and at 3-monthly intervals. This is an ongoing prospective, longitudinal study that started in January 2007. A total of 86 subjects with active RRMS received natalizumab in our Department. We found no significant relationship between duration of natalizumab therapy and activation of JC virus. The risk of developing BK viruria, however, increased over time with the number of doses received. No significant reductions in CD4+ counts or in CD4+/CD8+ ratios were noted. These findings indicate that while there is a link between natalizumab and BK activation no significant immunosuppressive effect was observed. Further studies on the implications of BK virus in MS remain to be done but these results may have consequences for this patient group in terms of development of infection-related adverse effects.

BACKGROUND:Early warning scores (EWS) are used to identify physiological deterioration in patients. Studies to date have primarily focused on the correlation between trends in serially recorded EWS of inpatients and clinical outcomes. This study examined the predictive value of an EWS calculated immediately on presentation to hospital for acute medical patients.METHOD:A prospective study of 225 consecutive medical admissions. Pulse, systolic blood pressure, respiratory rate, oxygen saturation and neurological status were used to calculate an EWS. Patients were divided into four score categories based on their EWS. The primary endpoints examined were intensive care unit (ICU)/coronary care unit (CCU) admission, death, cardiac arrest and length of hospital stay.RESULTS:For each rise in score category there was an increased risk of admission to ICU (odds ratio (OR) 3.35, CI 1.52 to 7.40, p = 0.003), admission to CCU (OR 1.82, CI 1.07 to 3.09, p = 0.027), death (OR 2.19, CI 1.41 to 3.39, p = 0.000) and reaching the combined endpoint of CCU/ICU admission or death (OR 2.19, CI 1.41 to 3.39, p = 0.000). The higher the score the longer the length of hospital admission (p = 0.04). A decrease in EWS between first presentation to hospital and transfer to the ward was associated with a decreased risk of reaching the combined endpoint of CCU or ICU admission or death (OR 2.56, CI 1.11 to 5.89, p = 0.028).DISCUSSION:Higher admission EWS correlate with increased risk of CCU/ICU admission, death and longer hospital stays independent of patient age. An improvement in serial EWS within 4 h of presentation to hospital predicts improved clinical outcomes. The EWS is a potential triage tool in the emergency department for acute medical patients.

Mammographic screening has been shown in international randomised controlled trials and case-control studies to be effective in reducing mortality from breast cancer. Ireland has a high mortality rate from breast cancer when compared with rates from other countries. Organised population-based mammographic screening for breast cancer is about to begin in Ireland. The purpose of this study was to examine current mortality from breast cancer, as well as trends in breast cancer mortality in Ireland since 1975, as a baseline against which future evaluations of the impact of screening can be carried out. Over the 23-yr period of review, mortality from breast cancer appears to have remained quite stable. Within the period, however, there is some variation in adjusted rates, most notably an increase to a peak in 1989, followed by a decrease between 1989 and 1997. Continued monitoring of recent trends is required, with in-depth analysis of possible explanations, such as changing breast cancer incidence rates, biological characteristics, therapeutic regimes and coding practices.

This paper reports two patients who had clinical disorders of eye movements which suggested discrete brainstem lesions. When magnetic resonance imaging (MRI) was performed, areas of demyelination Ear larger than expected were demonstrated and which had mass effect mimicking brainstem glioma. In both cases, there was clinical improvement with resolution of the MRI lesions without steroids or other treatment. The literature on MRI scanning in demyelinating disease is reviewed. MRI is an invaluable diagnostic tool in eye movement disorders related to demyelination, although the clinician must be aware of its limitations in tissue differentiation. We suspect that many ophthalmologists are unaware that the MRI appearances of demyelination may mimic tumour, particularly if it has mass effect.

OBJECTIVE:This study was undertaken to demonstrate a shift in tendon alignment at the first metatarsophalangeal joint in patients with hallux valgus by means of magnetic resonance imaging.DESIGN:Ten normal feet and 20 feet with the hallux valgus deformity conforming to conventional clinical and radiographic criteria were prospectively studied using magnetic resonance imaging. Correlation was made between tendon position at the first metatarsophalangeal joint and the severity of the hallux valgus deformity.RESULTS:There is a significant shift in tendon position at the first metatarsophalangeal joint of patients with hallux valgus. The insertion of the abductor hallucis tendon is markedly plantarward and the flexor and extensor tendons bowstring at the first metatarsophalangeal joint compared with patients without the deformity. The severity of the tendon shift correlates with the hallux valgus angle and clinical severity of the hallux valgus deformity in each case.CONCLUSION:Patients with hallux valgus have a significant tendon shift at the first metatarsophalangeal joint which appears to contribute to development of the deformity.

Lateral ligament injuries of the ankle are common and, while mild sprains usually heal without significant disability, more severe sprains can lead to chronic symptoms. Accurate diagnosis of the extent of the sprain facilitates correct management and rehabilitation. One hundred patients with acutely sprained ankles were evaluated. Fifty-four patients demonstrated ankle instability on stress radiographs and were referred for technetium radionuclide scanning. Twenty-one scans demonstrated increased uptake. Magnetic resonance imaging (MRI) scanning of these joints demonstrated synovitis in 80%, deltoid ligament injury in 60% and unsuspected osteochrondral fractures in 10%. Bone scanning was the most sensitive investigation as it detected all five osteochondral fractures, while plain radiographs and MRI each detected three osteochrondral fractures. We conclude that ankle lateral ligament injuries should be investigated first by plain radiographs with stress views, followed by isotope scanning where an osteochondral fracture is clinically or radiographically suspected. MRI is of limited value but can provide useful information about the anatomical site and size of an osteochondral lesion.