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2016 Abstracts for Poster Presentation (PDF) 1 Rat Bite Fever Resembling Rheumatoid Arthritis in a 46 Year Old Female Ripa Akter (Memorial University, St. John’s); Paul Boland (Memorial University, St. John’s); Peter Daley (Memorial University, St. John’s); Proton Rahman (Memorial University, St. John’s); Nayef Al Ghanim (Memorial University, St. John’s) A 46 year old female was admitted with a 1 week history of fever and symmetrical inflammatory polyarthritis associated with morning stiffness of 30 minutes duration. Past medical history was significant for seizure disorder, irritable bowel syndrome, chronic back pain and iron deficiency anemia. Family history was unremarkable for any rheumatological disease. On examination, she was febrile (38 degree celsius) with synovitis of her wrists, ankles, bilateral 5th metatarsophalangeal joints and left 3rd metacarpophalangeal joint. ESR and CRP were found to be elevated (76 MM/HR and 149 mg/L). Initial blood culture and serological tests including hepatitis B and C, parvovirus B19, HIV, Lyme disease and Neisseria gonorrhea were negative. Rheumatological work up including rheumatoid factor, anti-nuclear antibody, anti-cyclic citrullinated peptide antibody, anti-neutrophil cytoplasmic antibodies, anti-dsDNA antibody and compliment levels were all within normal limits. The patient was treated with a presumed diagnosis of rheumatoid arthritis with oral prednisone with mild improvement in synovitis. She was discharged home on triple therapy (methotrexate, sulphasalazine and hydroxychloroquine). The patient then returned to the hospital next day with worsening synovitis, fever 39 degree celcius and significant worsening of lower back pain. Sulphasalazine and methotrexate were discontinued due to mild elevation of liver enzymes. She continued to be febrile intermittently with ongoing elevated ESR of 124 MM/HR and CRP of 170 mg/L. Synovial fluid culture of the left ankle was negative. She then received intravenous methylprednisone for 2 days for ongoing severe pain with no improvement. Repeat blood culture grew Streptobacillus moniliformis. MRI revealed L5-S1 diskiitis .On further questioning, patient admitted to having a pet rat and a pet cat, both of which had died of an unknown illness in the week prior to the initial presentation to hospital. She also reported receiving a rat scratch to her chest. A diagnosis of Rat Bite fever (RBF) was made. The patient then was treated with intravenous ceftazidime with discontinuation of steroids and hydroxycholoquine. Synovitis improved significantly. Conclusion: Rat bite fever is very uncommon and very difficult to diagnose. A history of zoonotic exposure is the key to diagnosis. Prognosis is good when treated appropriately but potentially lethal if left untreated. It is important for rheumatologists to be aware of RBF as a cause of symmetrical inflammatory polyarthritis and mimic of rheumatoid arthritis. This case highlights the potential hazard of misdiagnosis and treatment with immunosuppressive agents. 2 RheumExam Atlas: A Web-Based Photographic Atlas to Support Physical Exam Teaching Sonia Seto (University of Toronto, Toronto); Lori Albert (University of Toronto, Toronto) Objectives: The diagnosis of rheumatic diseases often rests heavily on the physical examination. Therapeutic advances in the last decade have made it more challenging to find individuals with early disease manifestations or persistent physical findings to participate in clinical instruction of trainees. Many pictures are available on an internet search, but in the absence of support by an experienced clinician, these pictures may be misinterpreted by learners and lead to chronic misconceptions. In 2008 a bedside teaching atlas was developed to support learner recognition of physical findings in rheumatology during clinical teaching. (Albert LJ, Mills K and Roper N. Creation of a Bedside Teaching Atlas. Poster presented at: CRA-ASM 2009). This included pictures of real patients’ physical findings (eg.PIP joint effusions, sclerodactyly, etc.) and explanatory text for self-study or use by non-rheumatologist teachers. The atlas has been a very successful teaching tool locally. Limitations of the atlas, however, include its lack of availability, its size and bulk (making it difficult to compare and contrast pictures such as PIP effusions vs Bouchard's nodes) and the inability to add new pictures. Development of an electronic atlas was undertaken to overcome these limitations. Methods: A student enrolled in the MSc program in Biomedical Communications at University of Toronto (SS) was engaged through the Office of Integrated Medical Education summer Educational Information Technology program to build a tablet-responsive app to replace the hardcopy atlas. A web-based application was used that is compatible with Android or iOS, and can be used on a standard desktop computer if tablet or Wifi are unavailable. Functionality relevant to a clinical teaching session was built into the design: user-friendly index; capacity to move easily through the picture bank and toggle easily between pictures; concealable text for self-study; functionality for videos (e.g. Bulge sign for knee effusions); capacity to add new pictures; an imbedded evaluation/rating template. Results: RheumExam Atlas (rheumexamatlas.com) is now widely available at no cost. It will be of value for clinical teachers and trainees. It can be used by all health professions and all specialities, in urban or remote communities, with or without a rheumatologist teacher. Conclusion: A web-based atlas is readily accessible and provides a resource to support learning and recognition of a broad range of key physical findings in the rheumatic diseases. It is hoped that rheumatologists across Canada will submit photographs and other relevant content for uploading to RheumExam Atlas to enhance and further build this teaching resource. 3 Use of Antibiotics and Subsequent Risk of Systemic Lupus Erythematous: A Matched Case-Control Study Neda Amiri (University of British Columbia, Vancouver); Mehyar Etminan (University of British Columbia, Vancouver); Rachel Lipson (EMMES Canada, Burnaby); Darby Thompson (EMMES Canada, Burnaby); Sharan Rai (Arthritis Research Canada, Richmond); Antonio Avina-Zubieta (Arthritis Research Centre of Canada, Richmond) Objectives: Objective: To examine the association of exposure to cyclines, macrolides, and penicillins antibiotics with the development of subsequent Systemic Lupus Erythematosus (SLE). Methods: Methods: We conducted a nested case-control study using an administrative health database in British Columbia, Canada, from 1997-2010. Cases were defined using a validated algorithm that includes a combination of ICD-9 and ICD-10 codes and SLE drug therapy. Incident cases were age-, sex-, and entry time-matched to 10 controls using density-based sampling. We evaluated cumulative exposure to any cyclines, macrolides, and penicillins prior to SLE diagnosis allowing for removal of cases with any exposure in the year prior to the index date. Adjusted odds ratios were computed using conditional logistic regression. Results: Results: We identified 3,639 new SLE cases corresponding to 361,032 matched controls. All three classes of antibiotics had a statistically significant association with the development of SLE in the unadjusted models (Table 1). However, after adjusting for the Charlson comorbidity index, hormone use, healthcare resource use and socioeconomic status only females exposed to cyclines showed a statistically significant association [OR = 1.6 (95% CI, 1.3–1.9)]. Conclusion: Conclusion: Females exposed to cyclin antibiotics had a 60% increased risk of developing SLE. 4 What is the Location of Dactylitis in Ankylosing Spondylitis and Psoriatic Arthritis Patients and how do they Respond to Anti-TNF Treatment? Regan Arendse (University of Saskatchewan, Saskatoon); Proton Rahman (Memorial University, St. John’s); Denis Choquette (Institut de Rhumatologie de Montréal, Montréal); Antonio Avina- Zubieta (Arthritis Research Centre of Canada, Richmond); Michel Zummer (Université de Montréal, Département de médecine, Montreal); Milton Baker (University of Victoria, Victoria); Jaqueline Stewart (Penticton); Isabelle Fortin (CH Rimouski, Rimouski); Michelle Teo (Penticton); Emmanouil Rampakakis (JSS Medical Research, Montreal); Eliofotisti Psaradellis (JSS Medical Research, St-Laurent); Brendan Osborne (Janssen Inc., Toronto); Cathy Tkaczyk (Janssen Inc., Toronto); Karina Maslova (Janssen Inc., Toronto); Francois Nantel (Janssen Inc., Toronto); Allen Lehman (Janssen Inc., Toronto) Objectives: Dactylitis is one of the most commonly reported features in spondyloarthritis. It has been hypothesized that dactylitis is a functional enthesitis at the proximal interphalangeal joints, resulting in synovitis, tenosynovitis, bone and soft tissue oedema to the digit, and may simultaneously involve multiple digits. Our objective was to identify the location of dactylitis in ankylosing spondylitis (AS) and psoriatic arthritis (PsA) patients and to determine their response to anti-TNF treatment. Methods: BioTRAC is an ongoing, prospective registry of patients initiating treatment for rheumatoid arthritis (RA), AS, or PsA with infliximab (IFX) or golimumab (GLM). Eligible people for this analysis included AS and PsA patients treated with IFX who were enrolled since 2005 or with GLM since 2010 who had available information on dactylitis. The McNemar (paired Chi-square) test was used to compare the presence of dactylitis over time. Results: A total of 260 AS and 261
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