Azeem Ahmed

69. A case of two autoimmune conditions

neous low-signal intensity. Two patterns are observed on T2-weighted MRI: diffuse lower-signal, or nodular with alternating areas of highand low-signal. A long-term follow-up study suggests overall prognosis in tumoralcalcinosis isgenerallygood.Ourpatientpresentedwithepisodic flitting joint pain and swelling; this does not exactly match the presentation of tumoral calcinosis described in the literature. Her presentation maybepartof thebroadclinicalandgeneticspectrumoftumoralcalcinosis. However, it is also possible that tumoral calcinosis may represent an incidental finding inhercase.Sheremainsunderfollow-up. KeyLearningPoints:Tumoralcalcinosis isa familialdisordercharacterisedbyperiarticularcalcinosis.TheMDThasanimportant role inthediagnosis and management of this rare condition. Imaging is valuable in the evaluation of joint pain and swelling when there is clinical uncertainty. Tumoral calcinosis has a characteristic appearance on plain radiographs. Other underlying causes for calcinosis, such as metabolic disease and CTD, must be excluded before diagnosing tumoral calcinosis. Immunosuppressivetreatment isnotneededintumoralcalcinosis. Disclosure:M.Chetan:None.B.Empson:None.P.Chandratre:None.

41. Localised amyloid: a rare cause of stridor

and outpatient clinic with recurrent DVT. During one of these episodes, the patient presented with altered visual acuity, and was diagnosed to have left eye retinal vein thrombosis which further deteriorated to complete visual loss. The patient has no family history of BD, other thromboembolic or vasculitic disorders. Unexpectedly, he presented again with DVT despite being on VKA and low molecular weight heparin (LMWH) most likely due to poor compliance, then rivaroxiban was discussedasanalternativetreatment.Thepatient informedabouttheuncertain use of this medication, side effecst and the fact that there is no evidence of its effectiveness in treating or preventing VT in his disease. Patient commenced on rivaroxaban with satisfying outcome for four years of regular follow-up with no complications or features of vascular thrombosis. The compliance improved as patient felt more comfortable withouthavingrepeated INRmonitoring.Thepatienthashadanuneventfulclinicalcourseafterstartingrivaroxaban. Discussion: This is the first known case of BD in Saudi Arabia where the frequency of venous thromboembolic events were successfully managed with rivaroxaban over a course of over four years of outpatient follow-up. BD has a high prevalence in the Mediterranean, and considerable prevalence in others. Vascular BD is unique in affecting both arterial and venous systems and is a major cause of morbidity and mortality, despite there being no clear guidelines for the treatment and secondary prevention of VBD. Immunosuppressive agents have demonstrated significant reduction of venous thromboembolic events in BD; however, in clinical practice we often encounter patients with BD who have recurrent VT while on immunosuppressant medications, and oral VKA (warfarin) with thecommonest reasoncausebeingsub-therapeuticdrug levelsdue to poor compliance or intolerance. Rivaroxaban has a fixed dose and doesn’t require blood monitoring. Moreover, it has limited drugs interactions. Ithasbeenproventobeeffective,safeandhassignificant impact in decreasing the recurrence of VT with lower risk of gastrointestinal bleeding and subsequent complications comparing to VKA in situations other than BD. Patients with DVT treated with rivaroxiban have a lower rate of hospitalisation and outpatient visits without increasing the risk of readmission. Rivaroxaban has shown a great result in treatment and secondary prevention in this patient, so this might open a new line of treatment andsecondarypreventionofVBDifproveninfurtherclinical trials. Key Learning Points: BD is rare but has serious complications, especially vascular issues, if not detected and treated carefully. There are no new guidelines in the treatment of BD. Although immunosuppressive agents proved reduction in vascular complications in BD, we still face patients with venous thrombosis despite being on immunosppressant medications. Rivaroxaban might be a new line in treatment and secondarypreventionofvascularBDifproveninfurtherclinical trials. Disclosure:R.Musa:None.L.AlDhahir:None.

AB0984 Herpes Zoster Vaccination, Should Our Patients with Rheumatological Disorders Be Prioritized?

Background Herpes Zoster infection is a common and painful condition with potential for serious complications. The overall life time risk is one in three but the risk is much higher in immunosuppressed patients and in our patients with rheumatological diseases. For example in patients with rheumatoid arthritis alone the risk is 2 fold higher compared to the age and sex matched controls. The risk also increases with age and more than 50% of Herpes infection occurs in those aged over 60. The Herpes Zoster vaccination has been approved by FDA for people aged 50 years and older and CDC recommends it in those aged 60 and above. In United Kingdom this vaccination has recently been started, last year only people who were 70 and 79 years old were being offered the vaccine and this year those aged 71 and 78 are being vaccinated. Current guidelines do not recommend vaccination on biologic treatment, high dose steroid or other significant immunosuppression. Objectives This is a small study to look into Herpes infection in our rheumatology patients and whether we need a more pro-active approach towards vaccinating our patients particularly those who are about to start biologic therapies. Methods We looked at the self-reported incidence of Herpes Zoster infection in our cohort of rheumatology patients. We sent out a questionnaire to all patients on our biologics database asking if they had ever suffered from shingles and whether they had it before or after their respective rheumatological diagnosis and if they were on a biologic or non-biologic DMARD at the time of shingles. Of 512 sent, 160 replied. Mean Age was (65) and main rheumatological diagnoses were: Rheumatoid Arthritis 96/160 (60%), Psoriatic Arthritis 29/160 (18%), and Ankylosing spondylitis 21/160 (13%), the rest were other conditions treated with biologics. Results 38 of 160 (23.75%) had previous shingles and 6 of these 38 patients (15.7%) had suffered more than one episode. 24 of 38 (63.1%) patients had shingles post rheumatologic diagnosis and out of these 24; 6 (25.0%) had shingles whilst on biologic treatment; 6 (25.0%) had it whilst on combination DMARDs plus biologics; 9 (37.5%) on small molecule DMARDS; 3 patients could not tell their drugs at the time of shingles. The mean age for those who had shingles was 61.8 years. Conclusions Nearly one quarter of patients on our biologic database reported one or more episodes of shingles. Out of them 63% had it post their rheumatological diagnosis, and most patients had it whilst on Biologic or Non-Biologic DMARDs. The mean age of those who had shingles was 61.8 years which is much less than the current cut off for vaccination in UK. This is a small study but serves as a reminder for us to consider a more proactive approach towards shingles vaccination in our rheumatology patients, particularly before starting Biologics, in older patients who do not qualify for routine government funded Vaccination. References Allison L. Smitten, Hyon K. Choi, Marc C. Hochenberg, Samy Suissa, Teresa A. Simon, Marcia A. Testa, K. Arnold Chan. The risk of herpes zoster infection in patients with rheumatoid arthritis in United States and United Kingdom. 29 Nov 2007. DOI: 10. 1002/ART.23112. Craig M. Hales, MD, Rafael Harpaz, MD, Ismael Ortega-Sanches PhD, Stephanie R. Bialek, MD. Update on recommendations for use of Herpes Zoster Vaccine August 22, 2014/63(33);729–731 Disclosure of Interest None declared