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Background: Immunomodulatory drugs have been used in patients with severe COVID-19. The objective of this study was to evaluate the effects of two different strategies, based either on an interleukin-1 inhibitor, anakinra, or on a JAK inhibitor, such as baricitinib, on the survival of patients hospitalized with COVID-19 pneumonia. Methods: Individuals admitted to two hospitals because of COVID-19 were included if they fulfilled the clinical, radiological, and laboratory criteria for moderate-to-severe disease. Patients were classified according to the first immunomodulatory drug prescribed: anakinra or baricitinib. All subjects were concomitantly treated with corticosteroids, in addition to standard care. The main outcomes were the need for invasive mechanical ventilation (IMV) and in-hospital death. Statistical analysis included propensity score matching and Cox regression model. Results: The study subjects included 125 and 217 individuals in the anakinra and baricitinib groups, respectively. IMV was required in 13 (10.4%) and 10 (4.6%) patients, respectively (p = 0.039). During this period, 22 (17.6%) and 36 (16.6%) individuals died in both groups (p = 0.811). Older age, low functional status, high comorbidity, need for IMV, elevated lactate dehydrogenase, and use of a high flow of oxygen at initially were found to be associated with worse clinical outcomes. No differences according to the immunomodulatory therapy used were observed. For most of the deceased individuals, early interruption of anakinra or baricitinib had occurred at the time of their admission to the intensive care unit. Conclusions: Similar mortality is observed in patients treated with anakinra or baricitinib plus corticosteroids.

Background: Gastric angiodysplasia and the typical “watermelon stomach” aspect is one of the most characteristic vascular manifestations in systemic sclerosis (SS). These angiodysplasias can affect the intestine ocasionally as well as the stomach. Objectives: Description of a series of 5 patients with systemic sclerosis and presence of intestinal angiodysplasia (IA). Methods: Retrospective unicentric observational study in a tertiary hospital. Demographic data, comorbidities, manifestations of the disease, serological profile, concomitant treatments and bleeding manifestations, as well as endoscopic findings and received treatment were collected. Descriptive statistics was used to present the data. Results: We reviewed the medical records of the 88 patients with a diagnosis of SS followed up in the Rheumatology Service. Five cases (5.6%) of IA were identified (4 women and one male), with a mean age of 73 years (SD 13.71). In one case, the diagnosis of SS and IA was simultaneous. In the remaining 4 cases, the mean time from the diagnosis of ES to the diagnosis of the IA was 7.75 years (SD 2.6). Regarding the clinical presentation, 4 of the cases presented as anemia with iron deficiency. In these cases IA were found in the endoscopic studies. In one case, IA were a finding in the context of the study of diarrhea. In 4 of the cases, the IA were in the small intestine, so the diagnosis was made using an endoscopic capsule. In one case they were found in the colon, so the diagnosis was by colonoscopy. Only one of the cases of angiodysplasias in the small intestine required specific treatment with argon laser by enteroscopy. One case required a transfusion of packed red blood cells. In the remaining cases, treatment with oral or intravenous iron therapy was enough. In all 5 cases, it was a limited form of the SS with the presence of anticentromere antibodies. All cases presented Raynaud’s phenomenon, 3 of them with digital ulcers. Three of the cases associated primary biliary cholangitis, 3 cases pulmonary hypertension, 3 cases peristaltic involvement, 1 case interstitial lung disease and 1 case restrictive cardiomyopathy. As comorbidities, we identified 1 case of essential mixed cryoglobulinemia associated with hepatitis C virus, 2 cases of valvular heart disease, 2 cases of atrial fibrillation. Conclusion: The extragastric localization of the angiodysplasias should be taken into account in the patient with SS and iron deficiency, especially in those with a limited form of the illness and positive anticentromere antibodies Disclosure of interests: Carolina Merino argumanez: None declared, Olga Rusinovich: None declared, Maria Espinosa: None declared, Consuelo Ramos Giraldez Speakers bureau: Sanofi, Carmen Barbadillo Mateos: None declared, Jose Luis andreu Sanchez: None declared, Hilda Godoy: None declared

Background The infection of a native or prosthetic heart valve usually occurs in patients with structural valvular anomalies that predispose to turbulent flows. Manifestations such as arthralgia, arthritis or back pain appear in up to 40% of patients, which acts as a confounding factor when this infection occurs in patients with rheumatic diseases. On the other hand, in the latter patients, noninfectious endocarditis has been described, which adds even more complexity to the diagnosis. Objectives To describe the characteristics of endocardial lesions in patients with rheumatic diseases. Methods Patients attending clinics at the Department of Rheumatology were analyzed to determine how many of them required hospitalization for causes directly related to endocardial lesion, from January 2015 until December 2018. The following information was recorded: age, sex, type of rheumatic disease, duration of the disease, immunosuppressive treatment, characteristics of endocardial lesions, complications of endocardial lesions, and cardiovascular risk factors. Results All patients were identified from an electronic database. Results regarding to demographic and clinical data are as follows: Conclusion The spectrum of endocardial involvement in patients with rheumatic diseases is variable. In this case review, we found lesions of different origin: infectious, thrombotic and tumoral. The appearance of fever of unknown origin in patients with rheumatic diseases, requires ruling out an endocarditis, needing transesophageal echocardiography in case the transthoracic study, which is less sensitive, is negative. It is striking the case of patient 3, a systemic sclerosis with calcinosis in limbs, whose endocardial wart, was studied histologically, revealing in its composition mainly calcium and fibrin. We have not found a bibliographic reference of calcium endocarditis in systemic sclerosis. In conclusion, patients with rheumatic diseases can develop infectious endocarditis, but also thrombotic valvular vegetations, as well as myxomas whose consequences, from their clinical debut, may pose life-threatening situations for the patient. The presence of fever, stroke or embolic events in these patients should put us on the track of an underlying endocardial involvement. References [1] Am J Med (2007) 120, e1-e2 [2] World J Cardiol 2014 September 26; 6(9): 993-1005 [3] Rev Esp Enferm Metab oseas 2002;11(2): 50-58 Disclosure of Interests Sergio Rodriguez Montero: None declared, Consuelo Ramos Giraldez Speakers bureau: Sanofi, NAHIA PLAZA: None declared, Jose Luis Marenco Speakers bureau: abbie, pfizer, novartis, janmsen

Background: The time of rheumatoid arthritis (RA) evolution until treatment begins is key to controlling the disease. Many studies have shown that a prolonged duration of symptoms at the onset of treatment is associated with a more severe course of RA. The time from symptoms onset to first DMARD prescription is >12 weeks in Spain, because of diagnostic delay due to either patient-related factors (delay in consultation), Primary Care Physician (PCP) (delay in citation/referral) or rheumatologist (delay in citation). Objectives: To evaluate the usefulness of teleconsulting as a preferred referral tool from PCP to Rheumatology for early detection, diagnosis and treatment of inflammatory joint disease in adults, in the health area of a tertiary hospital. Methods: A preferential referral circuit was established between the PCP and the Rheumatology Service of a tertiary hospital, defining the referral criteria as “patient suspected of recent onset arthritis (ROA)”: arthritis or inflammatory arthralgia in >1 peripheral joint for >2 weeks with neither traumatic cause nor previous diagnosis of rheumatic disease. PCP performed first assessment, the request for initial tests (blood test including acute phase reactants, rheumatoid factor ± ANA, elemental urine and hands radiography) as well as the referral to Rheumatology with “ROA suspicion” motive. These consultation requests were cited from the Rheumatology Service within Before the protocol was established, its functioning was communicated as a face-to-face clinical session: by 2 rheumatologists in a Health Centre (HC) and by 1 PCP in the rest of the HC in the area. A poster was edited and published, exposing criteria and referral method for PCP‘s offices. Results: During the first 6 months 33 patients were correctly referred. 78.8% were women and the average age was 49 years old. 48.8% (16 patients) were diagnosed with some inflammatory arthropathy: 31.5% were RA (5 cases); other diagnoses were arthropathy due to microcrystals deposit (2), overlap SLE/RA (1), MCTD(1), psoriatic arthritis (1), spondyloarthritis associated with IBD (1) or inflammatory arthralgia associated with retroperitoneal fibrosis (1). 12% (4 patients) were diagnosed with hands incipient osteoarthritis and 33.8% (12 patients) with arthralgias without data on inflammatory pathology. One patient missed her follow-up. The median time from symptom onset to Rheumatology assessment was 90 days in all patients; in the inflammatory pathologies subgroup, 68.8% was assessed in Conclusion: In our experience, the establishment of a specific protocol in collaboration with Primary Care for the preferential referral of patients with suspected recent onset arthritis, obtained diagnoses not only for patients with rheumatoid arthritis, but also for other systemic autoimmune diseases in early stages, as well as early treatment initiation ( Disclosure of Interests: Consuelo Ramos Giraldez Speakers bureau: Sanofi, Maria Espinosa: None declared, Carolina Merino Argumanez: None declared, Patricia Fernandez Crespo: None declared, Olga Rusinovich: None declared, Fernando Leon Vazquez: None declared, Jose Luis Andreu Sanchez: None declared, Carmen Barbadillo Mateos: None declared

Background: Belimumab is a human IgG1l monoclonal antibody directed against BAFF, a B lymphocyte survival factor. It is indicated as adjuvant treatment in adult patients with active systemic lupus erythematosus (SLE), with positive autoantibodies and with a high degree of activity of the disease despite standard treatment. Objectives: This study aims to describe a sample of patients diagnosed with SLE who received treatment with belimumab in a tertiary hospital. Methods: Retrospective longitudinal unicentric observational study. Clinical records of all patients diagnosed with SLE who had received treatment with belimumab were reviewed. Demographic characteristics, clinical manifestations and reason for belimumab indicaton were collected. Results: The twelve patients included in the sample were women. Median age was 48.5 years (31-70). The most frequent reason for indication of belimumab was uncontrolled arthritis. The average time of treatment with belimumab in the total sample was 27.5 (+/- 26.24) months, with a median of 12 months (4-78). Mean treatment time (cases in which belimumab was discontinued excluded) was 31.25 (+/- 26.98) months with a median of 25 (5-78). The average dose reduction of prednisone after initiation of treatment with belimumab (in patients in which it was considered effective) was 5 mg per day (+/- 5). It should be noted that of the 14 cases, treatment was only discontinued in 4 patients, 2 of which were withdrawn due to ineffectiveness. There were 2 adverse events that required drug withdrawal: neutropenia and urothelial carcinoma. (Table). Conclusion: BLM is a well tolerated drug and effective in clinical practice. Adverse effects leading to drug withdrawal are infrequent. Disclosure of Interests: Carolina Merino Argumanez: None declared, Olga Rusinovich: None declared, Consuelo Ramos Giraldez Speakers bureau: Sanofi, Maria Espinosa: None declared, Hilda Godoy: None declared, Carmen Barbadillo Mateos: None declared, Jose Campos Esteban: None declared, Mercedes Jimenez Palop: None declared, Jesus Sanz: None declared, Luis Fernando Villa Alcazar: None declared, Carlos Isasi Zaragoza : None declared, Monica Fernandez Castro: None declared, Jose Luis Andreu Sanchez: None declared

Background Antiphospholipid syndrome (APS) is characterized by spontaneous and recurrent vascular thromboses, abortion and thrombocytopenia. Cardiac manifestations are rare, but may occur as cardiac masses, such as thrombus (Libman-Sacks endocarditis). On the other hand, it is known that the most common type of primary cardiac tumors, myxoma, can produce clinical pictures similar to APS and SLE, and that tumor exeresis resolves symptoms. Methods We examined 2 patients diagnosed with SLE and APS that presented cardiac mass. They were assessed with careful history taking, physical examination, laboratory tests, echocardiography and histological examination. Results Case 1. A 13-years-old girl, with history of autoimmune hemolytic anemia treated with corticosteroids, folic acid and splenectomy a year before, presented a right ischemic stroke with hemiparesis sequel. Laboratory tests revealed ANA, antiDNAds, aCL and lupus anticoagulant positive and echocardiography showed a cardiac mass. She was underwent surgery to exeresis the mass, which was compatible with myxoma. She was diagnosed with immune syndrome secondary to myxoma and did not take treatment. Seven months after the complete exeresis of the myxoma, she was admitted to our hospital because of two months fever, polyarthralgia, oral ulcers and malar rash. Echocardiography showed pericardial effusion and blood tests showed lymphopenia, anemia, ANA and antiDNA positive and elevation of acute phase reactants; urinalysis was normal. She was diagnosed with SLE flare and was successfully treated with corticoids and started hydroxychloroquine, azathioprine and acetylsalicylic acid. The second case is a 48-years-old woman diagnosed with SLE and associated APS (oral ulcers, thrombosis, arthritis, malar rash, ANA, Coombs and aCL positive), with a history of bilateral iliac arterial ischemia caused by myxoma emboli (confimated by histological examination) and a cardiac mass on echocardiogram. Fourteen months after the vascular surgery, the patient still needs treatment with rituximab, azathioprine and corticoids to control SLE activity and is on anticoagulant treatment to prevent thrombotic episodes. Conclusions In patients with myxoma and symptoms of APS and/or SLE, there is doubt whether these are secondary to myxoma or if these diseases coexist, so it is recommended to closely monitor clinical activity after exeresis of myxoma and consider not suspending immunosuppressants and/or anticoagulants or the progressive withdrawal of drugs according to symptoms, in order to avoid possible serious complications of autoimmune disease. Funding Source(s): None

Background The primary antiphospholipid syndrome (APS) is characterized by arterial and/or venous thrombosis and pregnancy morbidity in the presence of anticardiolipin antibodies (aCL) and/or lupus anticoagulant (LA). In addition to prothrombotic effects of aPL on the brain, there are immunologic effects with proof of direct binding of aPL to various types of brain cells, presented as cognitive dysfunction (CD),migraine,seizure, multiple sclerosis-like syndrome (MS-like), transverse myelitis (TM), movement disorders, or psychiatric symptoms. Methods We examined 3 patients who were diagnosed primary APS.The patients were assessed with careful history taking, physical examination, blood laboratory evaluation, andMRI or head-CT.Our main objective was to describe neurologic manifestations of APS in our patients at Valme University Hospital and the response to treatment with hydroxychloroquine Results Among the 3 patients, there was male preponderance with 3 men and no-women.The mean age of presentation was 33.66±5.2 years (range, 23 50 years) and with a current mean age of 37±14,93 years.There was no mortality in our series. One of them debuted with sudden loss of consciousness along with jaw stiffness and posterior amnesia.The other one presented prickling sensation and involuntary movement of his right upper limb extending to right lower limbs without posterior generalization, and the third patient consulted with frontal, pulsating headache and binocular diplopia.100% were LA positive with prolongated Activated Partial Thromboplastin Time and dilute Russell viper venom time and negative for ANA with no collagenosis sign or symptoms. Neither presented complement alteration or cerebrospinal fluid variation.We observed positivity for aCL in one patient (33%). In 2 of 3 patients (66.66%), cortico-subcortical space occupant lesions (SOL) were observed, some of them with contrast enhancement, mimicking demyelinating lesion, while the other patient didn’t present any abnormality in the MRI images.All patients presented an appropriate response to treatment with prednisone,in downward treatment regimen, aspirin and hydroxychloroquine 200 mg twice a day. At the four-year follow-up, all of them remain asymptomatic.We observed a lessening of SOL in MRI images due to the treatment in two patients but the third one presented new lesions due to suspension od prednisone, which was reintroduced, lessening of SOL. Conclusions The neurological affection presented in APS can mimic multiple sclerosis symptoms and it is difficult to differentiate both entities That is why aPL determination should be part of screening tests and should not be delayed if the diagnosis of APS is suspected.Hydroxychloroquine could be a valid treatment in CNS manifestations in patients with APS Funding Source(s): None

Objective The aim of this study was to compare the functional results of 2 different procedure types, medical or surgical used in treating native joint septic arthritis. Methods In this cohort study, we reviewed the clinical registries of patients admitted to a single third-level hospital with the diagnosis of septic arthritis during the period of January 1, 2008, to January 31, 2016. Results A total of 63 cases of septic arthritis were identified in which the initial approach for 49 patients was medical (arthrocentesis), whereas the initial approach for 14 patients was surgical (arthroscopy or arthrotomy). Of the 49 patients who received initial medical treatment (IMT), 15 patients (30%) later required surgical treatment because of poor progress. The median age of the patients was 60 (SD, 18) years. The group who received IMT were older than those who received initial surgical treatment (median, 64 years [interquartile range {IQR}, 54–76 years], vs. 48 years [IQR, 30–60 years]). There was a larger percentage of male patients in the surgical group (78% vs. 42% [p = 0.018]). Thirty percent of the medical group had been receiving corticosteroid treatment (p = 0.018). Results of complete recovery of joint functionality showed no significant differences after 1 year (68% with MT vs. 67% with ST, p = 0.91). Both groups had similar symptom duration until diagnosis, duration of antibiotic therapy (median, 30 days [IQR, 28–49 days], vs. 29.5 days [IQR, 27–49] days), and mortality rate (3 in the medical group). Conclusions The results of the study show that initial surgical treatment in patients with native joint septic arthritis is not superior to IMT. However, half of the patients with shoulder and hip infections treated with IMT eventually required surgical intervention, suggesting that perhaps this should be the preferred initial approach in these cases.

Background: Sialodochitis fibrinosa is a rare disease which is characterized by recurring episodes of pain and swelling of the salivary glands due to the formation of mucofibrinous plugs. Analytic studies ascertain elevated levels of eosinophils and immunoglobulin E (IgE). Imaging studies such as magnetic resonance imaging (MRI) and sialography reveal dilation of the main salivary duct (duct ectasia). Treatment is initially supportive, consisting of compressive massages, and use of antihistamines and/or corticosteroids. Material and methods: In the following, 3 cases of sialodochitis fibrinosa are presented which were diagnosed in a third level hospital during the period of 2008 and 2016, as well as a literature review of all cases reported to our knowledge. Results: Of the 41 cases found, including the 3 of this article, 66% were women with an average age of 45 years old. However, 75% of reported cases were of Japanese heritage. Involvement of the parotid glands was more frequent than the submandibular glands. In more than half of all cases treatment with compressive massages, antihistamines and/or corticosteroids was effective. Conclusion: Clinicians should consider sialodochitis fibrinosa as a diagnostic possibility when presented with cases of recurring parotid and submandibular gland tumescence.