Bone mineral density, turnover, and microarchitecture assessed by second-generation high-resolution peripheral quantitative computed tomography in patients with Sheehan's syndrome

Sheehan's syndrome (SS) is a rare but well-characterized cause of hypopituitarism. Data on skeletal health is limited and on microarchitecture is lacking in SS patients.

PURPOSE

We aimed to explore skeletal health in SS with bone mineral density (BMD), turnover, and microarchitecture.

METHODS

Thirty-five patients with SS on stable replacement therapy for respective hormone deficiencies and 35 age- and BMI-matched controls were recruited. Hormonal profile and bone turnover markers (BTMs) were measured using electrochemiluminescence assay. Areal BMD and trabecular bone score were evaluated using DXA. Bone microarchitecture was assessed using a second-generation high-resolution peripheral quantitative computed tomography.

RESULTS

The mean age of the patients was 45.5 ± 9.3 years with a lag of 8.3 ± 7.2 years prior to diagnosis. Patients were on glucocorticoid (94%), levothyroxine (94%), and estrogen-progestin replacement (58%). None had received prior growth hormone (GH) replacement. BTMs (P1NP and CTX) were not significantly different between patients and controls. Osteoporosis (26% vs. 16%, p = 0.01) and osteopenia (52% vs. 39%, p = 0.007) at the lumbar spine and femoral neck (osteoporosis, 23% vs. 10%, p = 0.001; osteopenia, 58% vs. 29%, p = 0.001) were present in greater proportion in SS patients than matched controls. Bone microarchitecture analysis revealed significantly lower cortical volumetric BMD (vBMD) (p = 0.02) at the tibia, with relative preservation of the other parameters.

CONCLUSION

Low areal BMD (aBMD) is highly prevalent in SS as compared to age- and BMI-matched controls. However, there were no significant differences in bone microarchitectural measurements, except for tibial cortical vBMD, which was lower in adequately treated SS patients.

Unusual and lesser-known rare causes of adult growth hormone deficiency

Growth hormone is among the most common hormones to be deficient in pituitary insult. It can occur either in isolation or combined with other hormone deficiencies. Growth hormone deficiency in adults (AGHD) can be due to causes acquired in adulthood or have a childhood-onset etiology, but the former is about three times more common. Usual causes of AGHD include mass effects due to a pituitary tumour, and/or its treatment (surgery, medical therapy, or radiotherapy), or radiotherapy to the head and neck region for non-pituitary lesions. The unusual or lesser-known causes of AGHD, are usually due to non-tumoral etiology and range from vascular and infective to inflammatory and miscellaneous causes. These not only expand the spectrum of AGHD but may also contribute to increased morbidity, adverse metabolic consequences, and mortality due to the primary condition, if unrecognised. The review features these lesser-known and rare causes of AGHD and highlights their clinical and diagnostic implications.

Osteoporosis and Obesity

Introduction

This article concisely overviews the complex relationship between obesity and bone health. Obesity, characterized by excessive fat accumulation, has been traditionally associated with higher bone mineral density. Also, recent data suggest a favorable bone microarchitecture profile in these patients. However, the increase in bone mineral density does not necessarily confer protection against fractures, and the risk of fractures may vary depending on the skeletal sites.

Factors affecting bone health

Various factors, including mechanical factors, hormones, cytokines, inflammation, and bone marrow adiposity, contribute to the adverse effect of obesity on bone. The article explores these factors alongside non-invasive techniques and tools like the Fracture Risk Assessment (FRAX) to evaluate fracture risk.

Bone and Adipose tissue

This article also highlights the essential roles of hormones such as vitamin D, Parathormone (PTH), FGF-23 (Fibroblast Growth Factor 23), which affect bone health, and some of the hormones secreted from the adipose tissues such as adiponectin and leptin.

Obesity Paradox and Sarcopenic Obesity

The article delves into the intriguing obesity paradox, where an increased BMI correlates with higher bone mineral density but not necessarily reduced fracture risk. Sarcopenic obesity, a combination of excessive fat accumulation and reduced muscle mass, further complicates the relationship between obesity and bone health.

Conclusions

Physicians should keep a comprehensive approach to treating obese patients with osteoporosis, including lifestyle modifications, weight management, fall prevention strategies, and pharmacological interventions. Further research is needed to better understand the relationship between obesity and bone health.

Normative Data on Dehydroepiandrosterone Sulphate (DHEAS) and its Attributes in Healthy Indian Children and Adolescents

Dehydroepiandrosterone sulphate (DHEAS), the biochemical indicator of adrenarche and pubarche, is of paramount importance in the evaluation of puberty-related disorders. The reference range of DHEAS should be ethnicity, age, sex, pubarche and Tanner stage specific. Anthropometry, puberty assessment and hormonal parameters were estimated using electrochemiluminescence assay. Bone age was estimated using the BoneXpert software. Of 2191 healthy Indian children aged 5-18 y screened at Chandigarh, 1919 were included in the final analysis (994 boys). The median DHEAS levels at pubarche stage P2 were 82.10 (55.0-129.0) g/dl in girls and 132.50 (95.12-205.50) g/dl in boys. By ROC analysis, the level of DHEAS at pubarche was 63.7 g/dl (sensitivity 72.6%, specificity 64.4%) in girls and 82.2 g/dl (sensitivity 81.8%, specificity 68.8%) in boys. The median age at adrenarche was 9.5 y in both sexes. On multivariate regression analysis; bone age, body mass index (BMI), gonadal steroids, and insulin-like growth factor-1 (IGF-1) significantly correlated with serum DHEAS levels in either sex.

A Rare Case of Headache in a Patient With McCune-Albright Syndrome: A Triple Threat

A 26-year-old male presented with facial asymmetry since 11 years of age and painless progressive diminution of vision in the left eye since 16 years of age. He presented with an exacerbation of headaches for the past two months. On examination, he was tall and had acral enlargement, craniofacial deformity, and bilateral asymmetric testicular enlargement. Investigations revealed high insulin-like growth factor 1, non-suppressible growth hormone on oral glucose tolerance tests, and multiple pituitary hormone deficiencies. MRI showed pituitary macroadenoma with craniofacial and sphenoid fibrous dysplasia as well as multiple tuberculomas. Cerebrospinal fluid testing showed high protein, low glucose, and high adenosine deaminase, all consistent with a diagnosis of central nervous system (CNS) tuberculosis. His headache did not respond significantly to either octreotide or zoledronic acid. The patient was then initiated on antitubercular therapy, which led to near-complete resolution of the headache and CNS lesions within three months of therapy. CNS tuberculosis was a masquerader in the index case of acrogigantism due to McCune-Albright syndrome. Headaches may be multifactorial in a given case of acromegaly, and investigating for alternative or additional causes especially when dealing with treatment-refractory cases can be rewarding.

Efficacy, safety, and dose-response effects of calcifediol supplementation on 25-hydroxyvitamin D, parathyroid hormone, and 1,25-dihydroxyvitamin D levels in healthy adults: An open-label, interventional pilot study

BACKGROUND

Vitamin D deficiency (VDD) is highly prevalent across the globe. Cholecalciferol (Vitamin D3) fails to attain sufficient serum concentrations of 25-hydroxyvitamin D (25(OH)D) in a significant proportion of supplemented individuals. Calcifediol (25-hydroxyvitamin D3) is less studied in healthy adults and its effects on 25(OH)D, parathyroid hormone (PTH), and 1,25-dihydroxyvitamin D (1,25(OH)2D) at higher doses are not well known.

MATERIALS AND METHODS

The study was an open-label, interventional trial recruiting consecutive participants with VDD who were allocated to receive either 2 capsules (50 μg-group) or 1 capsule (25 μg-group) daily doses of calcifediol. Baseline assessment included clinicodemographic parameters, dietary calcium, calcemic (calcium, inorganic phosphate, albumin, alkaline phosphatase, urine spot calcium/creatinine), and hormonal parameters (25(OH)D, PTH, and 1,25(OH)2D). Participants were followed up at 4 and 8 weeks with repeat assessments of calcemic and hormonal parameters.

RESULTS

There were 64 participants, 35 (50 μg-group) and 29 (25 μg-group), without any significant difference in any of the baseline parameters. 97.1% participants in the 50 μg-group (at 4 and 8 weeks) and 93.1% (at 4 weeks) and 96.5% (at 8 weeks) in the 25 μg-group attained 25(OH)D sufficiency (≥30 ng/ml) with calcifediol. The mean serum 25(OH)D was 84.0 ± 27.7 ng/ml in the 50 μg-group and 58.0 ± 23.6 ng/ml in the 25 μg-group group at 4 weeks, which later rose to 94.3 ± 21.8 ng/ml and 76.0 ± 16.4 ng/ml, respectively, at 8 weeks. PTH levels decreased in both groups at both time points. 1,25(OH)2D rose significantly in both groups at 4 and 8 weeks but was not significantly different between both groups. There was no case of incident hypercalcemia or symptomatic nephrolithiasis.

CONCLUSION

Calcifediol is a safe and efficacious alternative for oral Vitamin D supplementation in young adults. Increment in 25(OH)D levels is rapid and dose-dependent.

Utility of myxedema score as a predictor of mortality in myxedema coma

OBJECTIVE

Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking.

DESIGN AND METHODS

All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients.

RESULTS

A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine.

CONCLUSION

Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.

Impulse Control Disorders with Short-term Use of Cabergoline in Macroprolactinomas: A Prospective Study with a Brief Review of Literature

Impulse control disorders (ICDs) are less-emphasized adverse effects of dopamine agonists. Evidence on prevalence and predictors of ICDs in patients with prolactinomas is limited and confined chiefly to cross-sectional studies. This was a prospective study performed to investigate ICDs in treatment-naïve patients with macroprolactinomas (n = 15) using cabergoline (Group I), compared to consecutive patients of nonfunctioning pituitary macroadenomas (n = 15) (Group II). Clinical, biochemical, radiological parameters and psychiatric comorbidities were evaluated at baseline. ICD was assessed by Minnesota impulsive disorder interview, modified hypersexuality and punding questionnaires, South Oaks gambling scale, kleptomania symptom assessment scale, Barratt impulsive scale (BIS), and internet addiction scores (IAS) at baseline and 12 weeks. Group I had a significantly lower mean age (28.5 vs. 42.2 years) with a female predominance (60%) compared to group II. Median tumor volume was lower in group I (4.92 vs. 14 cm³) despite significantly longer symptom duration (2.13 vs. 0.80 years) than in group II. Serum prolactin decreased by 86% (P = 0.006) and tumor volume decreased by 56% (P = 0.004) at 12 weeks in group I, with a mean weekly cabergoline dose of 0.40 ± 0.13 mg. There was no difference between both groups in hypersexuality, gambling, punding, and kleptomania symptom assessment scale scores at baseline and 12 weeks. Mean BIS showed a more remarkable change in group I (16.2% vs. 8.4%, P = 0.051), and 38.5% of patients transitioned from average to above-average IAS in group I. The current study found no increased risk of ICD with short-term use of cabergoline in patients with macroprolactinomas. The use of age-appropriate scores (such as IAS in younger individuals) may help diagnose subtle alterations in impulsivity.

Approach to a case with an unusual cause of hypopituitarism

Hypopituitarism refers to insufficiency of one or more hormones of the pituitary and can be due to myriad causes. The clinical and radiological spectrum of the condition is heterogeneous, based on the age, gender, clinical setting and/or other past medical history. Hypopituitarism includes central hypocortisolism, hypothyroidism, hypogonadism and growth hormone deficiency. Both hypo- and hyperprolactinemia can be associated with hypopituitarism, with low prolactin signifying more extensive pituitary damage. Posterior pituitary insufficiency (arginine vasopressin deficiency), occurs either in isolation or with anterior pituitary hormone deficiency. Clinical symptomatology of hypopituitarism is usually non-specific and insidious in onset and progression. Overall, the most common cause of hypopituitarism is a pituitary adenoma and/or its management (surgery, radiotherapy, pharmacotherapy or a combination of these). However, it is this subset of patients which is more likely to be identified and managed timely, possibly alleviating the premature mortality associated with hypopituitarism. What is more challenging is the recognition of hypopituitarism in less common settings, which may be either due to direct involvement of the pituitary (infection, traumatic brain injury, or infiltrative causes) or indirectly as a consequence of the primary process (thalassemia, vasculotoxic snakebite, subarachnoid hemorrhage). These entities are often under-recognised, and increased awareness can help in greater recognition of the problem burden. Further, pituitary insufficiency in most of these settings is dynamic, which may progress, or rarely, show recovery of function. This renders complexity to the problem, but makes it even more imperative to suspect, screen and appropriately manage patients with less common causes of hypopituitarism.

Long-term hepatic and cardiac health in patients diagnosed with Sheehan's syndrome

PURPOSE

Sheehan's syndrome (SS) is characterised by chronic pituitary insufficiency following a vascular insult to the pituitary in the peripartum period. There is a lack of substantial evidence on the long-term hepatic and cardiac consequences in these patients, following hormone replacement.

METHODS

Patients with a diagnosis of SS were recruited for the study. Detailed clinico-biochemical and radiological evaluation were performed in all patients (n = 60). Hepatic and cardiac complications were assessed using fibroscan and echocardiography (2D speckle-tracking) respectively, in a subset of patients (n = 29) as well as age-and BMI-matched controls (n = 26). Controlled attenuation parameter (for steatosis) and liver stiffness measurement (for fibrosis) were used to define non-alcoholic fatty liver disease (NAFLD). Diastolic cardiac function was evaluated using standard criteria and systolic function by ejection fraction and global longitudinal strain (GLS).

RESULTS

The mean age of the cohort was 42.7 ± 11.6 years. Multiple (≥ 2) hormone deficiencies were present in 68.8% of patients, with hypothyroidism (91.4%), hypocortisolism (88.3%), and growth hormone (GH) deficiency (85.7%) being the most common. At a mean follow-up of 9.8 ± 6.8 years, NAFLD was present in 63% of patients, with 51% having severe steatosis, which was predicted by the presence of GH deficiency and higher body mass index. Though the ejection fraction was similar, increased left ventricular GLS (18.8 vs. 7.7%) was present in a significantly higher number of patients versus controls.

CONCLUSION

NAFLD, especially severe hepatic steatosis, is highly prevalent in SS. Subclinical cardiac systolic dysfunction (impaired GLS) is also more common, but of mild intensity.

LBMON65 Generation Of Serum Insulin Like Growth Factor -1 (IGF-1) Normative Data According To Age, Tanner Staging & Bone Age In Healthy Indian Children And Adolescents With Two Different Assays: The Germinative Study

Context

To diagnose and monitor GH-related disorders, serum IGF-I is a cornerstone, but Indian ethnicity based data, following consensus criteria for establishment of normative data are not available.

Objectives

To generate normative IGF-I data for chronological age (CA), Tanner stage and bone age (BA) [Greulich & Pyle (GP)] for both genders. Setting and Participants: We conducted a cross-sectional epidemiological study for Indian children (age 5-18 years) that included 2226 apparently normal subjects (1145 males; 1081 females). We used robust clinical exclusion criteria initially and later statistically we removed outliers separately for Age,Tanner Stage & Bone age using software SPSS 26. 0. Outcome Measures:: Serum IGF-I (ng/ml) using the Roche ECLIA & Immunodiagnostic Systems & Immunoassay System (IDS iSYS) were measured and normative data for 2.5th, 5th,10th, 25th, 50th (median), 75th, 90th, 95th and 97.5th centiles were generated.

Results

Age- and gender-specific serum IGF-I normative data generated from a uniquely large cohort reflected various patterns. With Roche assay, females (n=910) had IGF-I median peak at 13 years (356.85) [BA (n=804) at 14 years (401.5 ng/mL)] and & Tanner (n = 936) stage IV (368) while males (n=959) had median peak at 14 years (329.5) [BA (n=906) at 15 years (351 ng/mL)] & Tanner (n = 986) stage III (311. 0). With IDS iSYS assay, females had IGF-I median peak at Age (n=913) 13 years (397.5), Tanner (n=941) stage IV (418.5) and GP BA (n=843) 14 years (448.5) and males had median peak at Age (n=974) 14 years (376), Tanner (n=1003) stage III (367) and GP BA (n=909) 15-16 years (383). Females had earlier rise & peak and higher IGF-I values with both assays. In Tanner-specific data maximum difference noticed between stage II and III in both genders with both assays. On comparison of both assays, IGF-1 median peak was achieved at similar ages and Tanner stage but all the values are higher with IDS iSYS assay. When reviewed published literature on Caucasians, females had IGF-I median peak at 15 years (300.1) and Tanner stage III (382.8) and males had median peak at 15 years (318.3) and Tanner stage IV (439). The Indian & Caucasian IGF-1 normative data clearly demonstrates that every ethnicity has a unique pattern of growth.

Conclusions

The normative data on serum IGF-I are ethnicity-specific and it will improve the diagnostic utility of IGF-I in evaluation and management of growth disorders in Indian Children. Using both age- and Tanner stage-specific normative data simultaneously can improve diagnostic work-up.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

POS1297 SACROILIITIS AT DIAGNOSIS ASSOCIATED WITH LESS DISEASE FLARE AFTER STOPPING MEDICATION - OUTCOMES AND PREDICTORS OF A SOUTHEAST ASIAN ENTHESITIS RELATED ARTHRITIS (ERA) LONGITUDINAL COHORT

Background

ERA is a subtype of Juvenile Idiopathic Arthritis (JIA) characterized by involvement of entheses and axial skeleton. Outcomes have been shown to be poorer compared with oligoarticular and polyarticular JIA1.

Objectives

To assess short-and long-term outcomes and predictors of ERA in a large monocentric cohort in Singapore.

Methods

Children diagnosed with ERA according to ILAR criteria from 2002 to 2021 at KK Women’s and Children’s Hospital, Singapore, were recruited. Outcome statuses were defined according to the criteria for clinical inactive disease (CID) and complete remission (CR) proposed by Wallace et al.2, with additional criteria of no enthesitis and no active sacroiliitis on MRI. Nonparametric descriptive statistics were used. Univariate and multivariate analysis were performed using logistic regression analyses. The significant level was set at < 0.05.

Results

A cohort of 151 ERA patients (male 86%; Chinese 81%) were included. Median age at onset was 11.9 years (IQR 9.4-13.9) and disease duration was 5.3 years (IQR 2.9-8.4). HLA-B27 was positive in 83% of the patients. At diagnosis, 39% of the patients had sacroiliitis, 46% had hip arthritis, 36% had knee arthritis and 25% had enthesitis. Methotrexate was used in 77% of the patients, while biologics was started in 72% of the patients.

CID was achieved in 92% of the patients, of which 27% achieved CID in 6 months or less. Sacroiliitis at diagnosis is an unfavourable predictor of CID at 6 months but not a significant predictor of ever achieving CID. Older age at diagnosis is also an unfavourable predictor of CID ever.

Medication was totally discontinued in one third of the patients. Half of them went on to have complete remission (CR) off medication. Favourable predictor includes male gender, while positive HLA-B27 and ANA were unfavourable predictors.

Two thirds of the patients with CID had at least one disease flare (23% flared after off medication, 13% flared after CR). Both intra-articular joint injection and anti-TNF use were associated with flare after CID, while anti-TNF use was associated with flare after off medication. Sacroiliitis at diagnosis is a protective predictor of flare after stopping medication.

Conclusion

Despite a high proportion of ERA patients achieving CID, only one third could stop medication completely with high rates of disease flare even after attaining CR. Unfavourable predictors include older age at onset as well as HLA-B27 and ANA positivity. While sacroiliitis at diagnosis is a negative predictor of CID at 6 months, it is protective predictor of flare after discontinuing medication.

References

[1]Teh, Kai Liang, et al. “Outcomes and predictors of juvenile idiopathic arthritis in Southeast Asia: A Singapore longitudinal study over a decade.” Clinical Rheumatology 40.6 (2021): 2339-2349.

[2]Wallace, Carol A., et al. “American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis.” Arthritis care & research 63.7 (2011): 929-936.

Table 1.

Predictors of outcomes

Clinical parametersUnivariate analysisMultivariate analysisOR95% CIpOR95% CIpCID at 6 months Sacroiliitis at diagnosis0.1870.048-0.7240.0150.0230.003-0.177<0.001CID ever Age at onset0.7900.626-0.9980.0480.7770.605-0.9970.047Off medication ever Male5.0291.121-22.5660.0357.7031.622-36.5750.010 HLA-B270.3740.158-0.8860.0250.2900.110-0.7640.012 ANA0.1040.013-0.8030.0300.0770.010-0.6130.015Flare after CID Intra-articular injection2.5851.116-5.9880.0273.2051.299-7.9090.011 Anti-TNF3.6831.697-7.9930.0014.3281.905-9.832<0.001Flare after discontinue medication Sacroiliitis at diagnosis0.2220.060-0.8210.0240.0790.009-0.7220.025 Anti-TNF17.3333.696-81.300<0.00137.9424.151-346.8410.001

CID – Clinical Inactive Disease, TNF – Tumor Necrosis Factor, HLA-B27 – Human Leukocyte Antigen-B27, ANA – Antinuclear Antibodies

Figure 1.

Probability of attaining outcomes over time

Disclosure of Interests

None declared

POS0342 ANTI-TUMOUR NECROSIS FACTOR (aTNF) WEANING STRATEGY IN JUVENILE IDIOPATHIC ARTHRITIS (JIA): DOES LONGER DURATION MATTER?

Background

The efficacy of aTNF in the treatment of children with JIA has been demonstrated. However, once the disease is under control, strategy towards discontinuing aTNF should be considered. Thus far, there is no convincing information regarding how biologics should be weaned.

Objectives

To compare the outcomes of a short- and long-weaning strategies of aTNF in our prospective observational JIA cohort

Methods

Children with JIA taking aTNF with at least 6 months follow-up duration were recruited from our JIA registry (May 2010-Jan 2022) at KK Women’s and Children’s Hospital, Singapore. Once remission on medication, ROM1 (including no enthesitis and sacroiliitis by MRI for ERA) was achieved, aTNF was weaned according to 2 different protocols– short (Etanercept every 2 weeks, and Adalimumab every 4 weeks, for 6 months) and long (extending frequency by every 2 weeks for 3 cycles until reaching 12 weekly interval for another 3 cycles then stop biologic thereafter) protocols. Flare (recurrent of arthritis, enthesitis or uveitis) rates were compared, and potential predictors were assessed. Nonparametric statistics were used to described data and logistic regression and Kaplan-Meier analyses were used to assess clinical parameters and outcome association and cumulative probability of disease flare, respectively.

Results

Out of 143 JIA patients, 105 (78% male, 82% Chinese; enthesitis related arthritis 78%, oligoarticular JIA 9%, polyarticular JIA 11%, psoriatic arthritis 1%, undifferentiated JIA 1%) underwent aTNF weaning with 53% on short- and 47% on long-weaning protocol. Median disease duration at aTNF start was 13.5 (10.6-15.8) and duration of follow-up was 6.6 (3.9-9.5) years. There was no significant difference in demographic and clinical parameters between groups. There was none of the short- but 49% of the long-weaning group flared during the weaning period, Table 1. However, no significant difference in the total flare rate (during and after stopping aTNF) was observed between the 2 groups despite less patient flare after stopping aTNF in the later, p=0.004. Median time to flare after stopping aTNF was not different, p=0.270. Furthermore, probability of flare after stopping aTNF was not different as well, Log Rank p=0.095, Figure 1. Positive ANA predicts flare during weaning (OR 5.2, 95%CI: 1.224-22.416, p=0.026), but none of clinical parameters were associated with risk of flare after discontinuing aTNF therapy in our cohort.

Table 1.

Rate of flare and duration related to aTNF between short- and long-weaning groups

FLARETotal (n=105)Short (n=56)Long (n=49)pNumber of JIA patients flared during wean (%)24 (22.9)0 (0.0)24 (49.0)<0.001Time to flare during aTNF weaning after starting (month)*6.5 (4.5-14.5)Number of JIA patients flared after DC aTNF (%)50 (47.6)34 (60.7)16† (32.7)0.004Time to flare after stopping aTNF (month)*6.2 (2.7-11.8)6.9 (5.5-11.6)0.270Total number of patients who flared68 (64.8)34 (60.7)34 (69.4)0.353

*Median (interquartile range), †included 6 patients who flare during weaning and after stopping aTNF, aTNF = anti-tumour necrosis factor

Figure 1.

Cumulative probability of flare between the short- and long-weaning group after discontinuing aTNF therapy

Conclusion

Duration of spacing out the aTNF therapy after achieving ROM may not minimize the flare rate or delay time to flare after stopping the therapy in JIA patients. Further validation in larger multinational longitudinal cohorts is required to confirm our initial findings.

References

[1]Wallace CA, Giannini EH, Huang B, et al. American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis. Arthritis care & research 2011;63(7):929-36.

Disclosure of Interests

None declared

AB1235 MULTISYSTEM INFLAMMATORY DISEASE IN CHILDREN (MIS-C) IN SINGAPORE CHILDREN: ARE WE DIFFERENT?

Background

Multisystem Inflammatory Syndrome in Children (MISC) is a hyper-inflammatory state with similarities to Kawasaki Disease, 4 to 6 weeks after Covid-19 infection1. Literature describes a 11:1 Relative Risk for Asian children versus Caucasians2. Since the start of the pandemic, 17,699 children under 12 years were infected with Covid-193.

Objectives

To describe presentation and short term outcomes, for a cohort of children with MIS-C at the sole Children’s Hospital in Singapore.

Methods

Demographic and clinical/lab data were collected from children diagnosed with MIS-C accrording to the WHO criteria4 at KK Woman’s and Children’s Hospital, Singapore. Nonparametric descriptive statistics were used to describe and analyse data.

Results

Eleven patients were diagnosed with MIS-C between October 2021 and Jan 2022. Seven (64%) were male and 4 (36%) were Chinese, with median age at presentation was 8.08 years (IQR 4.54 - 9.79). All patients had positive COVID-19 serology at the time of diagnosis. Median duration of fever prior to diagnosis was 5 days (IQR 4 - 5); Nine (82%) had gastrointestinal symptoms and median number of Kawasaki Disease (KD) features were 2 (IQR 2 - 3.5); common manifestations were conjunctivitis (90%), red lips (55%) and rash (36%). Of note, 8 (70%) patients had KD type peeling on follow-up. No BCGitis was found during acute phase. Seven (64%) were admitted to higher dependency care.

Table 1, all patient received IVIG and IV steroids; 6 (55%) as pulse (30mg/kg/day) therapy. Patient 8, additionally received Anakinra. Median duration of admission was 6 days (IQR 5-13). One patient developed complications post therapy and was re-admitted to hospital for hematochezia. Treatment involved stopping Enoxaparin and Prednisone. Aspirin was resumed as soon as bleeding ceased. Laboratory characteristics and outcomes are denoted in Table 1. All patients had a monophasic course during the median of 10 weeks (IQR 8 - 11.5) of follow-up.

Table 1.NoAge (yr)GI symptomsKD featuresHemoglobin (g/DL)Absolute Lymphocyte (10x9/L)Platelet (10x9/L)CRP (mg/L)D-Dimer (mg/L FEU)Ferritin (ug/L)Enoxaparin startedPeelingAbnormal echo110YES212.20.2367173.2323179.1YESYESYES211NO214.8116694.92.51350NOYESYES34.25YES210.41.02241134.66.05277.2YESNOYES47.67YES5110.41102250.69.323607.6YESYESNO58.58YES411.40.5693105.61.31846.6NOYESNO64.58YES210.33.09198137.41.87291NONONO79.58YES312.21.311191842.51244.3NOYESNO84.5YES411.90.45102181.811.121798.4YESNOYES911YES110.11.235974.24.531445.8YESYESNO103.42NO29.11.09138153.98.66609.4YESYESNO118.08YES211.41.2510166.81.31521.8NOYESYES

Conclusion

1.Asian prevalence of MIS-C is not as high as that reported from the West. Similarities in presentation as to age and gender were noted.

2.Most of our MIS-c patients developed periungual peeling at follow up, similarly to Kawasaki Disease.

3.Different from our typical KD population, no BCG site inflammation was found.

References

[1]Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA. 2021;325(11):1074-1087.

[2]Middelburg JG, Crijnen TEM, D’Antiga L, et al. Association of Ethnicity with Multisystem Inflammatory Syndrome in Children Related to SARS-CoV-2 Infection Frontiers in Pediatrics Oct 2021 Vol 9.

[3]Ang Qing, Number of children admitted for covid-19 at KKH doubles since December 2021. New Straits Times, 27 Jan 2022.

[4]World Health Organization. Multisystem inflammatory syndrome in children and adolescents with COVID-19: Scientific Brief. 2020

Disclosure of Interests

None declared

POS1294 SAFETY AND EFFICACY OF ADALIMUMAB BIOSIMILAR (AMGEVITA) IN PAEDIATRIC RHEUMATOLOGY PATIENTS

Background

The approval of biosimilars requires pharmacokinetic studies to prove that there are no clinically significant differences to the originator molecule. These studies are also used to extrapolate additional indications and for different populations including paediatrics. Literature is lacking for the efficacy and safety of biosimilars for paediatric rheumatology conditions. Amgevita, a biosimilar of adalimumab, was approved for use in Singapore on 31 July 2019. It was used in KK Women’s and Children’s hospital (KKH), Singapore from 1 September 2020.

Objectives

To report the safety and efficacy of adalimumab biosimilar in children at our centre.

Methods

This is an ongoing prospective, IRB-approved, observation study in a paediatric rheumatology clinic sited within KKH, a tertiary children’s hospital. Patients were reviewed in clinic to determine the need to initiate adalimumab (Amgevita), and completed pre-biologic screening to assess suitability to start. Patients were included if they received minimum 1 dose of adalimumab biosimilar. Safety parameters tracked: allergy, including urticaria, anaphylaxis, severe injection site reactions, rate of new onset infections requiring hospitalization and reactivation of latent infections (e.g., tuberculosis or herpes zoster). Adverse reactions were graded according to CTCAE v5.0. Efficacy parameters were tracked for patients with juvenile idiopathic arthritis (JIA) included JADAS27, JADAS71 and JSpADA.

Results

From 1 September 2020 to 31 October 2021, a total of 187 of 20mg syringes and 1403 pre-filled 40mg pens were dispensed to 117 paediatric rheumatology patients. Mean age was 14.9 years, 53.9% were male, 70.9% were Chinese and ethesitis-related arthritis (46.1%) was the most common indication. There were 68 (58.1%) biologic naïve patients. Two patients experienced injection-site urticaria which prompted discontinuation (grade 2). One patient reported initial injection site soreness which resolved spontaneously (grade 1). One patient developed latent tuberculosis requiring inpatient management and temporary interruption in adalimumab therapy (grade 3). No other adverse events were reported. Efficacy data was available for 96 patients. Median scores at baseline and at 3-months and 6-months are presented in Table 1.

Table 1.

Summary of paediatric patients initiated on adalimumab biosimilar (Amgevita)

Diagnosis, n (%)Enthesitis related arthritisOf which HLA-B27 positive54 (46.1)44 (81.5)Polyarthritis21 (17.9)Extended or persistent oligoarthritis15 (12.8)Undifferentiated JIA6 (5.1)Psoriatic arthritis1 (0.8)Other indications21 (17.9)Concomitant DMARDs, n (%)Methotrexate50 (42.7)Sulfasalazine37 (31.6)*Efficacy, Median (range)Biologic naïveNot biologic naïveMonth number036036JADAS272(0-21.6)0(0-8.5)0(0-6.05)2(0-10.6)0(0-8.4)0(0-12.2)JADAS712(0-27.8)0(0-12.0)0(0-6.08)2(0-10.6)0(0-8.4)0(0-12.2)JSpADA0.25(0-3.5)0(0-1.0)0(0-1.0)0.5(0-1.5)0(0-0.5)0(0-2.0)

DMARDs: Disease modifying anti-rheumatic drugs; JADAS: Juvenile Arthritis Disease Activity Score; JSpADA: Juvenile spondyloarthritis disease activity. *Efficacy data only for patients with juvenile idiopathic arthritis

Conclusion

We report our 14-month experience of using adalimumab biosimilar in a pediatric rheumatology population. Majority of the patients did not report major adverse reactions. Majority of JIA patients responded well when initiated on adalimumab (Amgevita). Rheumatologists should continually monitor patients for latent infections after prescribing biologics including biosimilars.

References

[1]Scientific considerations in demonstrating biosimilarity to a reference product: guidance for industry. FDA website. Apr 2015. https://www.fda.gov/media/82647/download. Accessed 28 Dec 2021.

[2]De Cock D, Kearsley-Fleet L, Baildam E, Beresford MW, et al. Biosimilar Use in Children and Young People with Juvenile Idiopathic Arthritis in aReal-World Setting in the United Kingdom [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10).

Disclosure of Interests

None declared

The role of steroid receptors, peptides and growth factors in the aetiopathogenesis of idiopathic gynecomastia

Idiopathic gynecomastia is a diagnosis of exclusion. We aimed to evaluate the role of steroids, peptides and growth factors in these patients. Those with bilateral idiopathic gynecomastia (n = 29) (Simon's grade IIb or III) who underwent gland excision were evaluated by immunohistochemical techniques using semi-quantitative grading for oestrogen receptor (ER), progesterone receptor (PR), aromatase, androgen receptor (AR), peptides (IGF-1, IGF-2, HER-2, parathyroid-hormone related peptide [PTHrP]) and growth factors (EGFR, TGFβ). The cohort comprised 29 patients, with a mean age of 25.3 ± 5.1 years and a mean body mass index of 27.2 ± 2.3 kg/m² . Grade IIb gynecomastia was present in 79.1% and moderate-to-severe insulin resistance (HOMA-IR >3) in 53.7% of patients. ER expression was positive in 100% samples, followed by AR (96.5%), aromatase (96.5%) and PR (93.1%). IGF-1 was expressed in 86.2% of the cohort, IGF2 in 27.5% and HER-2 in only two samples, with both showing weak immunoexpression. None of the patients had positive expression of EGFR, TGF-β or PTHrP. There was no association between immunoexpression and gynecomastia grade. This study demonstrates the predominant role of oestrogen, aromatase and insulin resistance in the aetiopathogenesis of idiopathic gynecomastia and implicates the paracrine hyperestrogenic milieu in its causation as circulating hormones were normal.

Thyroid eye disease with concurrent orbital lymphoma: a radiological surprise

Summary

Thyroid eye disease (TED) is the most common extra-thyroidal manifestation in Graves' disease (GD). Additional/concurrent/synchronous pathologies may be present, especially in elderly patients who present with atypical features such as non-axial (or eccentric) proptosis, absence of lid lag and restricted superior extra-ocular movements. A 70-year-old female presented with progressive proptosis of her left eye and diplopia. She was diagnosed with GD a year prior and initiated on carbimazole. On examination, she had eccentric proptosis, restricted superior extra-ocular movements and a palpable mass in the supero-temporal quadrant of the left eye. Her T3 (1.33 ng/mL) and T4 (8.85 µg/dL) were normal with carbimazole. Thyroid-stimulating hormone (TSH)-receptor antibody was positive (3.15 IU/L, reference range <1.75). MRI revealed an enhancing lesion infiltrating the left superior rectus, with concurrent characteristic muscle belly involvement bilaterally. Orbital biopsy showed atypical lymphoid cells (CD20+), suggesting marginal zone lymphoma. CT thorax and abdomen, fluorodeoxyglucose-positron emission tomography and bone marrow examination were normal. The patient was administered orbital radiotherapy for her localised lymphoma and carbimazole was continued. TED is the most common cause of orbital involvement overall and in GD. However, additional or alternative pathology may be present which requires evaluation. MRI can be a useful adjunct in these patients. Orbital lymphoma needs to be staged with workup for disseminated disease. Radiotherapy is the treatment of choice for localized disease. The index case provides evidence for synchronous presentation of dual pathology and highlights the importance of astute clinical examination as well as keeps a low threshold for MRI in selected cases.

Learning points

Thyroid eye disease can co-exist with other ocular pathology, especially in elderly individuals. Eccentric proptosis, absent lid lag and restriction of eye movements (suggesting tendon involvement) should alert towards the presence of alternative pathology. Orbital imaging using MRI not only has greater sensitivity in diagnosing radiologically bilateral disease in patients who have unilateral involvement clinically but is also useful to identify concurrent neoplasms.

Paediatric Pituitary Adenomas: Clinical Presentation, Biochemical Profile and Long-Term Prognosis

CONTEXT

Paediatric pituitary adenomas (PPAs) are uncommon, with evidence confined to small cohorts.

AIM

We aimed to elucidate the baseline profile and outcomes of PPAs in a large, contemporary, monocentric cohort.

SETTINGS, DESIGN

Pituitary clinic at PGIMER over 8 years (2010-2018).

SUBJECTS AND METHODS

PPAs in patients (≤20 years at diagnosis) were included. A retrospective review of their baseline clinico-biochemical and radiological profiles and outcomes post pituitary surgery/medical management was performed.

RESULTS

There were a total of 74 patients, of which 42 were female. The median age was 15 (IQR 13-18) years. Corticotropinomas (32.4%) and somatotropinomas (25.7%) were common, with 1 case of TSHoma and pituitary blastoma. The most common presentation was headache (57%) overall and menstrual irregularities (64.2%) in girls. Most (78%) had macroadenomas. Prolactinomas showed an excellent response to primary medical therapy (83.3%). Transsphenoidal surgery was performed in 81% of patients. Diabetes insipidus (30%) and hyponatremia (26.7%) emerged as common postoperative complications. Adjuvant medical management was required in 25%, and radiotherapy in 18%. Remission rates in Cushing's and acromegaly were 62.5% and 57.8%, respectively, with long-term hormone deficits noted in one-third of patients.

CONCLUSION

PPAs have unique features and management challenges, including effects on growth and puberty. Functional tumours and macroadenomas are common. Remission can be achieved in more than half of the patients, with endocrine deficits persisting in about a third of cases, needing long-term surveillance.

Baseline renal dysfunction determines mortality following parathyroidectomy in primary hyperparathyroidism: analysis of Indian PHPT registry

INTRODUCTION

Primary hyperparathyroidism (PHPT) in India is mostly symptomatic with renal and skeletal complications. Evidence on mortality outcomes following parathyroidectomy from India, where the disease is predominantly symptomatic is limited.

MATERIAL AND METHODS

This was a prospective study to evaluate mortality outcomes in the Indian PHPT registry over the past 25 years (n = 464). Pre- and postoperative parameters and mortality data were obtained from medical records and/or by verbal autopsy, a method validated by WHO for data collection in settings where several deaths are noninstitutional. Patients were divided into survivor (SG) and nonsurvivor groups (NSG) to ascertain differences in presentation and the effect of parathyroidectomy.

RESULTS

The overall mortality was 8.8% at a median follow-up of 8 years (IQR 1-13) after parathyroidectomy. Chronic kidney disease was the most common background cause of death (43.5%), followed by pancreatitis (28.2%). NSG had significantly more frequent renal dysfunction (91.9% vs 73.9%), anaemia (50 vs 16.6%) and pancreatitis (24.3 vs 6.4%). PTH (61.9 vs 38.3 pmol/l) and baseline creatinine (97.2 vs 70.7 µmol/l) were significantly higher and eGFR lower (66.7 vs 90.7 ml/min/1.73m²) in the NSG than SG. By Cox proportional modelling, renal dysfunction [HR 2.88 (1.42-5.84)], anaemia [HR 2.45 (1.11-5.42)] and pancreatitis [HR 2.65 (1.24-5.66)] on univariate and renal dysfunction [HR 3.33 (1.13-9.77)] on multivariate analysis were significant for mortality. Survival curves demonstrated a significantly higher mortality with lower eGFR values.

CONCLUSIONS

Nonsurvivors in PHPT had greater prevalence and more severe baseline renal dysfunction than survivors. Survival after parathyroidectomy was significantly associated with estimated glomerular filtration rate at baseline.

Temozolomide Nonresponsiveness in Aggressive Prolactinomas and Carcinomas: Management and Outcomes

Context

Temozolomide (TMZ) is endorsed as the treatment of choice in aggressive or malignant pituitary adenomas.

Objective

Herein we describe a case of an aggressive prolactinoma that was resistant to TMZ. We performed a literature review of similar nonresponsive, aggressive prolactinomas.

Methods

A 40-year-old woman presented with a giant prolactinoma that required cabergoline, transsphenoidal surgery, and radiotherapy to achieve near-normal prolactin and apparently no residual tumor. A year later, she presented with multiple cranial nerve involvement due to a recurrent tumor extending to the infratemporal fossa. She underwent transfrontal surgery, second radiotherapy, and was started on TMZ. Despite 8 cycles of temozolomide (200 mg/m², 5/28-day cycle), she had progressive disease and ultimately succumbed to the disease. PubMed/MEDLINE, Google Scholar, and prior review articles were searched for manuscripts about patients with aggressive prolactinomas who had been treated with TMZ. Data on demography, duration of therapy, and management outcomes were analyzed in those with progressive disease.

Results

We identified 94 cases of patients with aggressive/malignant prolactinomas in the literature who had received TMZ. Progressive disease despite TMZ was present in 36 cases (38%). There was a male preponderance (65%) among these and 40% had aggressive prolactinomas, whereas the rest had carcinomas. Patients received a median of 8 cycles (interquartile range, 3.5-11.5) of TMZ. O6‐methylguanine‐DNA‐methyltransferase (MGMT) immunostaining was negative in 35%. Overall mortality at the time of publication was 40%, at a duration varying from 2 to 20 years from diagnosis.

Conclusion

TMZ resistance in aggressive/malignant prolactinomas is challenging. Progressive disease on optimal TMZ treatment entails the use of newer agents.

Course and outcomes of pregnancy in women treated for acromegaly: Discerning a contemporary cohort

OBJECTIVE

To analyze pregnancy course and outcomes in women treated for acromegaly and compare outcomes based on disease activity at the time of conception.

DESIGN

Retrospective study.

PATIENTS

Women with acromegaly diagnosed prior to or during pregnancy from 2010 to 2019, representing cases (14 pregnancies in 12 cases), were later stratified based on active (n = 5) or controlled disease (n = 9) at time of conception. Female acromegalic patients over the same period constituted the 'acromegaly cohort' (AC) (n = 75).

RESULTS

All cases had macroadenomas with nadir GH of 15.06 ng/ml (IQR 9-30), IGF-I index of 3.04 (1.96-3.82), for which they had undergone pituitary surgery; except two patients diagnosed during pregnancy, who received pharmacotherapy followed by surgery 4 months postpartum. Adjuvant pharmacotherapy was required in 71.4% patients and radiotherapy in 35.7%. Pregnancy occurred at a median of 2 (0.8-5.1) years after surgery and 21.4% required assisted reproduction. All had term delivery with normal APGAR except one case with gestational hypertension, who delivered a preterm baby. None had congenital malformations. Despite higher baseline IGF-I, GH and tumor volume in those with pre-conceptional active acromegaly, materno-fetal outcomes were not different from those with controlled disease (p > 0.05). Similar or greater proportion of cases had normal GH and no residual tumor postpartum, even in those with pre-conceptional active acromegaly.

CONCLUSION

The current study showed conducive outcomes of gestation in women treated for acromegaly and no higher rates of pregnancy parameters or complications than non-acromegaly pregnancies in the same population. Active acromegaly does not seem to have an adverse bearing on outcomes.

Results of ala carte Posteromedial Soft Tissue Release in Idiopathic Clubfoot

Introduction

The aim of this study is to assess the outcomes of ala carte posteromedial release in children over two years of age who were not responding to the Ponseti method of treatment of idiopathic clubfoot.

Material and Methods

A retrospective observational study from September 2013 to August 2015 was conducted at a tertiary level medical teaching institution. The clubfeet were classified according to the Harold and Walker classification. Radiographic parameters assessed were the talocalcaneal angle (AP, lateral), talus-first metatarsal angle (AP, lateral) and calcaneal-fifth metatarsal angle. The scar and the functional score, according to Laaveg and Ponseti, were evaluated as outcome measures at the final follow-up.

Results

Twenty-four children with a mean age of 43.7 ± 24.7 months were enrolled in the study. There was a total of 36 clubfeet: 21 (65.6%) with a poor functional outcome; 12 (37.4%) with excellent to good scar in both horizontal and vertical components. There was a statistical significance between the pre-operative and post-operative radiological parameters (p<0.05). None of the patients presented with any limitation of activities of daily living despite the poor functional outcome in many of the children. There was no significant association between the qualities of scar (horizontal, vertical) and the functional outcome with age at presentation, pre-operative Harold and Walker classification and pre-operative radiographic angles.

Conclusion

Surgical intervention in terms of ala carte posteromedial soft tissue release could not produce a good outcome over four years in CTEV. The threshold for surgery in CTEV should be high, given the poor results.

Endocrine Dysfunction in Covid-19

Introduction: Evidence pertaining to new-onset endocrine dysfunction in patients with COVID-19 is currently limited and extrapolated from prior SARS epidemics. Further, identifying whether the quantum of this dysfunction is associated with the severity of disease in patients with COVID-19 is unknown. We aimed to to comprehensively explore the prevalence, nature and degree of endocrine dysfunction stratified based on disease severity at a dedicated COVID care centre.

Patients and Methods: Consecutive patients enrolled at PGIMER Chandigarh, were stratified on the basis of disease severity as: group I (moderate to severe disease including oxygen saturation <94% on room air or those with comorbidities) and group II (mild disease, with oxygen saturation >94% and without comorbidities). Hypothalamo-pituitary-adrenal, thyroid, gonadal axes and lactotroph function were evaluated. Inflammatory and cell-injury markers were also analysed.

Results: Patients in group I had higher prevalence of hypocortisolism (38.5 vs 6.8%, p=0.012), lower ACTH (16.3 vs 32.1pg/ml, p=0.234) and DHEAS (86.29 vs 117.8µg/dl, p= 0.086) as compared to group II. Low T3 syndrome was a universal finding, irrespective of disease severity. Sick euthyroid syndrome (apart from low T3 syndrome) (80.9 vs 73.1%, p= 0.046) and atypical thyroiditis (low T3, high T4, low or normal TSH) (14.3 vs 2.4%, p= 0.046) were more frequent in group I than group II. Male hypogonadism was also more prevalent in group I (75.6% vs 20.6%, p=0.006) than group II, with higher prevalence of both secondary (56.8 vs 15.3%, p=0.006) and primary (18.8 vs 5.3%, p=0.006) hypogonadism. Hyperprolactinemia was observed in 42.4% patients, without significant difference between both groups.

Conclusion: COVID-19 can involve multiple endocrine organs and axes, with a greater prevalence and degree of endocrine dysfunction in those with more severe disease. Involvement of multiple axes, particularly at hypothalamo-pituitary level suggests the possibility of hypophysitis as an underlying etiology. We also observed less characterised findings like atypical thyroiditis and normal DHEAS despite secondary hypocortisolism. Follow-up surveillance of these patients at periodic intervals and estimation of anti-pituitary antibodies could be considered to elucidate viral cytopathic effect or inflammation as the major underlying mechanism of endocrine dysfunction.

Posterior pituitary tumours: patient outcomes and determinants of disease recurrence or persistence

OBJECTIVE

Posterior pituitary tumours (PPTs) are rare neoplasms with the four recognised subtypes unified by thyroid transcription factor -1 (TTF-1) expression, according to the 2017 WHO classification. Though traditionally defined as low-grade neoplasms, a substantial proportion of them show recurrence/persistence following surgery.

METHODS

We selected patients with PPTs in our cohort of 1760 patients operated for pituitary tumours over the past 10 years (2010-2019). The clinical, radiological, hormonal, histopathological profiles and long-term outcomes of the three cases identified (two pituicytomas and one spindle cell oncocytoma, SCO) were analysed. Following a literature review, data of all published cases with documented TTF-1 positive pituicytomas and SCOs were analysed to determine the predictors of recurrence/persistence in these tumours.

RESULTS

Patients presented with compressive features or hypogonadism. Two had sellar-suprasellar masses. One had a purely suprasellar mass with a pre-operative radiological suspicion of pituicytoma. Two were operated by transsphenoidal surgery and one transcranially guided by neuronavigation. Histopathology confirmed spindle cells in a storiform arrangement and low Ki67 index. Immunohistochemistry showed positive TTF-1, S-100 expression and variable positivity for EMA, vimentin and GFAP. Re-evaluation showed recurrence/persistence in two patients. A literature review of recurrent/persistent pituicytoma (n = 17) and SCO (n = 9) cases revealed clinical clues (headache for pituicytomas, male gender for SCO), baseline tumour size (≥20.5 mm with sensitivity exceeding 80%) and longer follow-up duration as determinants of recurrence/persistence.

CONCLUSION

PPTs are rare sellar masses with quintessential TTF-1 positivity. Recurrent/persistent disease following surgery is determined by greater tumour size at baseline and duration of follow-up. This warrants intensive and long-term surveillance in these patients.

Eumycetoma of the Foot due to Fusarium solani in a Person with Diabetes Mellitus: Report of a Case and Review of Literature

Eumycetomas are chronic suppurative granulomas caused by fungi characterised by invasive tumefactive lesions, sinuses and discharging grains. Herein, we describe a case of pedal eumycetoma due to Fusarium solani sensu stricto in a person with diabetes mellitus. A 45-year-old gentleman presented with an insidious onset swelling over his right foot with nodules and discharging grains. He had received itraconazole and anti-tuberculous therapy elsewhere, without response. Re-evaluation included a biopsy which confirmed eumycetoma and newly diagnosed diabetes. Surgical excision followed by histopathological, microbiological and multigene sequencing analyses [translation elongation factor, calmodulin and internal transcribed spacer region of rDNA] of the mould on culture were performed. Histopathology revealed septate fungal hyphae amidst a dense inflammatory infiltrate (Splendore-Hoeppli) reaction. Oral voriconazole was started and good glycemic control attained. Tissue growth sequences showed > 99% similarity with Fusarium solani sensu stricto. Antifungal susceptibility testing showed lowest MIC to voriconazole (0.5 mg/L). The patient showed excellent response to combined therapeutic modality with a near-complete resolution in size of lesion and obliteration of sinuses following 4 months of therapy and is planned for prolonged voriconazole therapy till complete radiological resolution. Diabetes predisposes to fungal infections of foot but eumycetomas are uncommon. Combined surgery and antifungals can improve morbidity and avoid amputations.

Triple A (Allgrove) syndrome due to AAAS gene mutation with a rare association of amyotrophy

INTRODUCTION

Triple A (Allgrove) syndrome is a rare autosomal recessive disorder characterized by cardinal features of primary adrenal insufficiency (AI) due to adrenocorticotropic hormone (ACTH) resistance, achalasia, and alacrima. It is frequently associated with neurological manifestations such as autonomic dysfunction, cognitive dysfunction, cranial nerve, or motor involvement. Amyotrophy/motor neuron disease is a rare association.

CASE PRESENTATION

We herein report a 19-year-old boy diagnosed with triple A syndrome (TAS), with the classic triad of ACTH-resistant adrenal insufficiency, achalasia, and alacrima. Additionally, he had distal spinal muscle amyotrophy. Alacrima was the earliest feature evident in early childhood, followed by achalasia at 12 years of age. He was diagnosed with AI at the age of 19 years, with involvement of the mineralocorticoid axis. Further evaluation showed a neurogenic pattern on electromyography, consistent with a diagnosis of motor neuron disease. A nerve conduction study revealed no significant neuropathy. Genetic analysis confirmed a pathogenic homozygous mutation in the AAAS gene c.43C>A, p.Gln15Lys. He improved with glucocorticoid and mineralocorticoid supplements for AI, and nifedipine for achalasia and artificial tears. He is planned for esophagomyotomy.

CONCLUSION

In any young patient with AI not due to congenital adrenal hyperplasia, Allgrove syndrome should be ruled out. Though mineralocorticoid sparing pattern is classical, it can rarely be involved, as seen in the index case. Various components of the syndrome, as well as amyotrophy and other neurologic features, may present in a metachronous fashion. Hence, a high index of clinical suspicion can aid in early diagnosis and management.

Unconventional Transverse Transport above and below the Magnetic Transition Temperature in Weyl Semimetal EuCd_{2}As_{2}

As exemplified by the growing interest in the quantum anomalous Hall effect, the research on topology as an organizing principle of quantum matter is greatly enriched from the interplay with magnetism. In this vein, we present a combined electrical and thermoelectrical transport study on the magnetic Weyl semimetal EuCd_{2}As_{2}. Unconventional contribution to the anomalous Hall and anomalous Nernst effects were observed both above and below the magnetic transition temperature of EuCd_{2}As_{2}, indicating the existence of significant Berry curvature. EuCd_{2}As_{2} represents a rare case in which this unconventional transverse transport emerges both above and below the magnetic transition temperature in the same material. The transport properties evolve with temperature and field in the antiferromagnetic phase in a different manner than in the paramagnetic phase, suggesting different mechanisms to their origin. Our results indicate EuCd_{2}As_{2} is a fertile playground for investigating the interplay between magnetism and topology, and potentially a plethora of topologically nontrivial phases rooted in this interplay.

Phosphorylated EGFR (pEGFR T693) as a Novel Predictor of Recurrence in Non-Functioning Pituitary Adenomas

PURPOSE

Non-functioning pituitary adenomas (NFPAs) exhibit high recurrence rates after surgery. However, the determinants of recurrence are inconsistent in the available literature. The present study sought to investigate the association between nuclear phosphorylated EGFR (pEGFR) levels and recurrence of NFPAs.

METHODS

Tissue microarrays from patients undergoing adenomectomy for NFPAs at our tertiary care center from 2003 to 2015 and having a minimum of 60 months of follow-up (n=102) were accessed. Immunohistochemical analysis (IHC) was performed to determine the expression of nuclear pEGFR T693. h-score was calculated as the product of staining intensity and the number of positively staining cells. Radiological surveillance (MRI) was performed to categorize NFPAs as recurrent or non-recurrent on follow-up.

RESULTS

The mean age of the cohort was 50 ± 11 years with a male preponderance (61.1%). Recurrence was observed in 46.1% of the patients at a median of 123 months (IQR 72-159) of follow-up. pEGFR T693 positivity was higher in a significantly greater number of recurrent NFPAs as compared to non-recurrent NFPAs (95.7% vs 81%, p=0.02). h-scores were also significantly higher in recurrent NFPAs (122.1 ± 6 vs 81.54 ± 3.3, p<0.0001). pEGFR T693 positivity significantly predicted recurrence in NFPAs (HR=4.9, CI 2.8-8.8, p<0.0001). ROC analysis revealed an h-score cutoff of 89.8 as being associated significantly with recurrence (sensitivity 80%, specificity 78%, AUC 0.84, p<0.0001).

CONCLUSION

pEGFR T693 was expressed in significantly higher number of recurrent NFPAs. The h-scores were also higher in recurrent NFPAs. Nuclear pEGFR T693 may serve as a predictor of recurrence in NFPAs.

Early Initiation of Temozolomide Therapy May Improve Response in Aggressive Pituitary Adenomas

INTRODUCTION

Aggressive pituitary adenomas (APAs) are, by definition, resistant to optimal multimodality therapy. The challenge lies in their early recognition and timely management. Temozolomide is increasingly being used in patients with APAs, but evidence supporting a favorable response with early initiation is lacking.

METHODS

This was a single-center study of all patients with APAs who received at least 3 cycles of temozolomide (150-200 mg/m²). Their baseline clinico-biochemical and radiological profiles were recorded. Immunohistochemical evaluation for cell-cycle markers O⁶-methylguanine-DNA methyltransferase (MGMT), MutS homolog 2 (MSH2), MutS homolog 6 (MSH6), MutL homolog 1 (MLH1), and postmeiotic segregation increased 2 (PMS2) was performed, and h-scores (product of the number of positive cells and staining intensity) were calculated. Response was assessed in terms of radiological response using the RECIST criteria. Patients with controlled disease (≥30% reduction in tumor volume) were classified as responders.

RESULTS

The study comprised 35 patients (48.6% acromegaly, 37.1% prolactinomas, and 14.3% non-functioning pituitary adenomas). The median number of temozolomide (TMZ) cycles was 9 (IQR 6-14). Responders constituted 68.6% of the cohort and were more likely to have functional tumors, a lower percentage of MGMT-positive staining cells, and lower MGMT h-scores. There was a significantly longer lag period in the initiation of TMZ therapy in non-responders as compared with responders (median 36 vs. 15 months, p = 0.01). ROC-derived cutoffs of 31 months for the duration between diagnosis and TMZ initiation, low-to-intermediate MGMT positivity (40% tumor cells), and MGMT h-score of 80 all had a sensitivity exceeding 80% and a specificity exceeding 70% to predict response.

CONCLUSION

Early initiation of TMZ therapy, functional tumors, and low MGMT h-score predict a favorable response to TMZ in APAs.

Spectrum of Endocrine Dysfunction and Association With Disease Severity in Patients With COVID-19: Insights From a Cross-Sectional, Observational Study

INTRODUCTION

Evidence on new-onset endocrine dysfunction and identifying whether the degree of this dysfunction is associated with the severity of disease in patients with COVID-19 is scarce.

PATIENTS AND METHODS

Consecutive patients enrolled at PGIMER Chandigarh were stratified on the basis of disease severity as group I (moderate-to-severe disease including oxygen saturation <94% on room air or those with comorbidities) (n= 35) and group II (mild disease, with oxygen saturation >94% and without comorbidities) (n=49). Hypothalamo-pituitary-adrenal, thyroid, gonadal axes, and lactotroph function were evaluated. Inflammatory and cell-injury markers were also analysed.

RESULTS

Patients in group I had higher prevalence of hypocortisolism (38.5 vs 6.8%, p=0.012), lower ACTH (16.3 vs 32.1pg/ml, p=0.234) and DHEAS (86.29 vs 117.8µg/dl, p= 0.086) as compared to group II. Low T3 syndrome was a universal finding, irrespective of disease severity. Sick euthyroid syndrome (apart from low T3 syndrome) (80.9 vs 73.1%, p= 0.046) and atypical thyroiditis (low T3, high T4, low or normal TSH) (14.3 vs 2.4%, p= 0.046) were more frequent in group I than group II. Male hypogonadism was also more prevalent in group I (75.6% vs 20.6%, p=0.006) than group II, with higher prevalence of both secondary (56.8 vs 15.3%, p=0.006) and primary (18.8 vs 5.3%, p=0.006) hypogonadism. Hyperprolactinemia was observed in 42.4% of patients without significant difference between both groups.

CONCLUSION

COVID-19 can involve multiple endocrine organs and axes, with a greater prevalence and degree of endocrine dysfunction in those with more severe disease.

ACTH increment post total bilateral adrenalectomy for Cushing's disease: a consistent biosignature for predicting Nelson's syndrome

PURPOSE

Nelson's syndrome (NS) is regarded as an aggressive complication of total bilateral adrenalectomy (TBA) for Cushing's disease (CD). This challenge may be addressed by using clinical criteria to guide frequency of neuroimaging to enable timely management of NS and also avoid unnecessary frequent imaging.

METHODS

All patients (n = 43) with CD subjected to TBA over 35 years at a tertiary care centre were included. NS was defined as a newly appearing or expanding (> 2 mm) pituitary adenoma with or without ACTH levels exceeding 500 pg/ml. Pre-and post-TBA parameters like clinical symptomatology, cortisol, ACTH and radiology were analysed for the prediction of NS.

RESULTS

NS developed in 39.5% (n = 17) patients with a median follow-up of 7 years. Half of them had new appearance, while rest had an expansion of pre-existing pituitary tumour. Majority (90%) had ACTH above 500 pg/ml. On Cox proportional hazards analysis, frequent discriminatory features of protein catabolism (≥ 4) (HR 1.15, CI 0.18, 7.06), proximal myopathy (HR 8.82, CI 1.12, 69.58) and annual ACTH increment of 113 pg/ml (HR 12.56, CI 1.88, 88.76) predicted NS. First post-operative year ACTH indices predicting NS included ACTH rise of 116 pg/ml and absolute ACTH of 142 pg/ml (sensitivity, specificity exceeding 90%). Annual ACTH increment exceeding 113 pg/ml, ≥ 4 discriminatory features and uncontrolled hypertension had the best overall prediction.

CONCLUSION

Patients who developed NS had higher rebound rise of ACTH following TBA and a more severe disease phenotype at baseline. Consistent ACTH increment can be used as a marker for predicting the development of NS.

ACQUIRED ECTOPIC POSTERIOR PITUITARY BRIGHT SPOT DUE TO VASCULOTOXIC SNAKEBITE

Objective

Vasculotoxic envenomation is an uncommon cause of hypopituitarism. Most described cases have varying extent of anterior pituitary dysfunction, but posterior pituitary involvement is extremely rare.

Methods

Clinical, biochemical, and radiologic evaluation of a young female who presented with secondary amenorrhea was performed. A brief literature review of envenomation-induced hypopituitarism is included.

Results

A 26-year-old female presented with secondary amenorrhea since the age of 20 years. She had normal stature. Her past medical history was significant for a vasculotoxic snakebite 12 years back requiring hemodialysis, but no hormonal testing was done at that time. Current evaluation showed anterior hypopituitarism. An insulin-induced hypoglycemia test confirmed deficiencies of cortisol and growth hormone axes (peak values 348 nmol/L and 0.03 ng/mL). There was no diabetes insipidus. Magnetic resonance imaging revealed a hypoplastic anterior pituitary with an ectopic posterior pituitary. In view of normal stature and secondary amenorrhea, a diagnosis of envenomation-induced hypopituitarism with ectopic posterior pituitary (EPP) was made. A brief literature review of envenomation-induced hypopituitarism showed both acute and delayed presentation, male predominance, and variable lag period (weeks to years). Nearly half of all patients were asymptomatic. The most common axis involved in acute presentation was the cortisol axis, whereas the thyroid and gonadotroph axes were commonly involved in delayed hypopituitarism.

Conclusion

Vasculotoxic envenomation is a rare cause of acquired hypopituitarism. EPP in the index case was probably due to the "axonal dieback" phenomenon and subsequent regeneration of the axons at a more caudal site. This case, being the first instance of acquired EPP following envenomation, expands the spectrum of envenomation-induced hypopituitarism.

Wolfram syndrome: clinical and genetic profiling of a cohort from a tertiary care centre with characterization of the primary gonadal failure

BACKGROUND

Wolfram syndrome (WFS) is a rare, monogenic neurodegenerative syndrome characterised by insulin requiring non-autoimmune diabetes mellitus (DM) and optic atrophy which are usually the earliest and commonest manifestations. However, there are other features which are under-recognized, adding to morbidity and premature mortality in these patients.

METHODS

Five patients (three males, two females) with genetically confirmed WFS at a single tertiary care centre were prospectively followed up. Their symptomatology, clinical profile, genetic analysis and radiology were analyzed. Multidisciplinary approach was used for comprehensive clinical care of this cohort. Patients with primary gonadal failure were subjected to biopsy and immunohistochemistry (IHC) for wolframin was performed.

RESULTS

DM was the earliest presenting manifestation at 6.2 ± 1.3 years followed by optic atrophy at 10.4 ± 2.3 years, diabetes insipidus at 12 ± 2.1 years and deafness at 12.8 ± 2.1 years. All patients were autoantibody negative with low C-peptide(<0.6 ng/ml). Hypoglycemic episodes were frequent (upto 60%) but there was no instance of diabetic ketoacidosis. Optic atrophy was present alongwith proliferative diabetic retinopathy and cataract in 40%. Uncommon manifestations included neuropsychiatric features, parasuicide, cystopathy, brainstem atrophy and hypergonadotropic hypogonadism only in adult males (n = 2). Testicular biopsy revealed partly hyalinised seminiferous tubules and prominence of Leydig cells. IHC confirmed the presence of mutated wolframin, which was not significantly different from normal testis specimen on protein quantification.

CONCLUSIONS

WFS requires a multidisciplinary approach with special emphasis on early diagnosis and management of other endocrine and non-endocrine features so as to improve long-term outcomes. Gonadal functions need periodic assessment, especially in adult males.

SAT0498 ENTHESITIS-RELATED ARTHRITIS (ERA) IN SOUTHEAST ASIA: A DECADE OF SINGAPORE EXPERIENCE

Background:

ERA is the most common Juvenile Idiopathic Arthritis (JIA) subtype in Singapore (1), but less common in the West. Clinical characteristics and treatment of ERA in the region is not well-described thus impede the diagnosis and management plan which could lead to poorer outcomes.

Objectives:

To describe the clinical characteristics, joint manifestation and treatment of ERA in a large monocentric cohort in Singapore over 10-year period

Methods:

Children diagnosed with ERA according to ILAR criteria with a minimum follow-up of 3-month duration were recruited from our registry, from 2009 to 2019, at KK Women’s and Children’s Hospital, Singapore. Nonparametric descriptive statistics including median (IQR) were used to described data. Kaplan-Meier survival analyses were used to estimate the probability of ever sacroiliitis development. Multivariate logistic and Cox regression analyses were used to determine predictors as appropriate. The significant level was set at < 0.05.

Results:

A cohort of 147 ERA out of 439 JIA patients (male 88%; Chinese 80%) were included. Median age at onset was 11.9 yrs (IQR9.4-14.0) and disease duration was 6.0 yrs (3.1-8.9). Median lag period was 2.9 mo (1.2-7.4). Family history of HLA-B27 related diseases was positive at 8%. Acute uveitis occurred only 3%. Joint distribution at diagnosis and cumulative involvement were shown in Fig 1. Hip, sacroiliac and knee were the three most common joints involved. 24% presented with enthesitis and Achilles tendon enthesis were the most common. Majority presented with pauciarthritis (84%) while 12% of patients had no peripheral joint involvement. 40% of patients presented with sacroiliitis (SIs) with 59% had bilateral involvement. Median duration to develop SIs was 7.6 mo (IQR 2.0-26.9). Probability of SIs development was 36%, 55% and 70% at 1, 5 and 10 yrs after onset, respectively. Interestingly, neg HLA-B27, female and older age at onset predicted SIs (p=0.001-0.044). Hip arthritis increased (p=0.043) but tarsitis decreased (p=0.031) the risk of SIs. Again, female, hip arthritis at diagnosis and neg HLA-B27 had a shorter time to SIs (p=0.004-0.007). Fig 2 showed medication used in our ERA cohort. Methotrexate (MTX) remained the most common DMARD used. However, 76% required anti-TNF therapy (aTNF) due to MTX failure. For SIs patients, 86% were on MTX but 85% of these, as compared to patients without axial disease, 60%, failed MTX. Only 10% of patients had aTNF without MTX.

Fig 1.

Proportion of joint involvement at onset and cumulative involvement during the course of disease (%)

Fig 2.

Proportion of medications used in ERA cohort during the course of disease (%)

Conclusion:

Our ERA cohort had less uveitis and family history of HLA-B27 associated diseases, but comparable gender and age at onset as compared to reports elsewhere(2). Up to 40% of our patients presented with SIs and/or enthesitis. Majority of SIs developed within the first 5 yrs (88%) for which over one-half developed within the first year. When considering only ERA patients, interestingly that female, neg HLA-B27 and older age increased risk of SIs development. 77% of patients were treated with MTX, but 76% of the patients required aTNF later. As for SIs, concurred with adult AS data, 85% failed MTX. About one-half of non-axial disease patients failed MTX which is less response rate as compared to other JIA subtypes.

References:

[1]Arkachaisri T, Tang SP, Daengsuwan T, Phongsamart G, Vilaiyuk S, Charuvanij S, et al. Paediatric rheumatology clinic population in Southeast Asia: are we different? Rheumatology. 2017;56(3):390-8.

[2]Mistry RR, Patro P, Agarwal V, Misra DP. Enthesitis-related arthritis: current perspectives. Open access rheumatology: research and reviews. 2019;11:19-31.

Disclosure of Interests:

None declared

THU0508 LARGE VESSEL VASCULITIS IN A COHORT OF CHILDREN WITH RESISTANT KAWASAKI DISEASE IN SINGAPORE

Background:

Kawasaki Disease (KD) is one of the most common systemic vasculitidies in children today. IVIG is the mainstay of treatment, however, about 1/5 of patients do not respond resulting in an increased risk of Coronary Artery Abnormalities (CAA)1.

Objectives:

To describe a cohort of infants and young children with resistant Kawasaki Disease (rKD) who were noted to have prolonged difficult courses with resultant CAA and ultimately diagnosed with Aortitis.

Methods:

Demographic, clinical manifestations and imaging data were collected from children seen in Rheumatology clinic with a diagnosis of rKD and aortitis. Nonparametric descriptive statistics were used to describe the data.

Results:

Between 2010-2018, 63 out of 417 KD referrals were diagnosed with rKD. 7 children had prolonged time to CRP normalisation, prolonged admission or recurrence of symptoms (Table 2). All patients underwent Magnetic Resonance Angiography (MRA) and were found to have evidence of large vessel arteritis consisting of wall irregularity, thickness and contrast enhancement.

Table 1IDAge at diagnosis(mo)Number of clinical KD signs**BCG site inflammationLowest Hemoglobin g/DLHighestWBC10 (9)L#Highest Platelet10 (9)LHighest CRPmg/LLowest Albuming/LMaximum ALTU/LMaximum ASTU/LA3130NANANANANANANAB7409.537.3875.0206.021.036.032.0C4419.843.2918.0130.022.044.052.0D3.5419.242.41715.0181.418.061.099.0E5416.717.61413.0148.227.020.024.0F2306.435.6959.0212.115.08.019.0G24NANA8.621.91002.0181.427.017.030.0

5 patients were male; All were Singaporean Chinese except for G who was from the Philippines; A & G were treated in an outside facility/separate service initially and some data was not available; # Blood test results were generally taken at the same time apart from the platelet count; **Only D presented with lymphadenitis.

Table 2IDTIme to CRP normalization(weeks)Number of IVIG givenSteroidsTime to abnormal echo(weeks)Time to aneurysm development(weeks)Other outcomesA*2oral only441stIVIG given 3 weeks after symptom onsetB*2IV/PO22deceased, MI secondary to thrombusC21IV/PO1.10treated with Infliximab and then Methotrexate,post infliximab psoriasis,D51IV/PO0.32treated with Infliximab and then Methotrexate,multiple infections in hospital; BCG reactivation while on InfliximabE92no1.42.7UTI, AIHA, lost to follow upF33IV/PO0.712.5post Infliximab psoriasis, multiple infections in hospitalG72oral only70lost to follow up

*patients A & B had recurrent KD episodes interspersed with short periods of symptom resolution

Conclusion:

While transthoracic echocardiograms remain imaging investigation of choice, for children with recalcitrant or recrudescent KD, especially in the setting of delayed CRP resolution of >2 weeks; an MRA should be considered.

References:

[1]McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017 Apr 25;135(17):e927-e999.

Disclosure of Interests:

None declared

AB1004 JUVENILE DERMATOMYOSITIS (JDM) IN SOUTHEAST ASIA: A 20-YEAR SINGAPORE EXPERIENCE

Background:

Juvenile dermatomyositis (JDM) is a multisystem inflammatory disease of childhood with variable demographics, clinical features and outcomes. No studies have described the characteristics of JDM patients from Southeast Asia population.

Objectives:

To describe the clinical characteristics and outcomes of JDM patients in Singapore over a 20-year period.

Methods:

Patients diagnosed with JDM from 1999 to 2019 at KK Women’s and Children’s Hospital, Singapore, were recruited. Nonparametric descriptive statistics were used to described data. Kaplan-Meier analyses were used to estimate the probability of remission. Multivariate logistic and Cox regression analyses were used to determine predictors as appropriate. The significant level was set at < 0.05.

Results:

32 JDM were identified. Clinical characteristics and treatment used are shown in Table 1.

All (n=32)Monophasic (n=17)Polyphasic (n=14)Male14 (43.8)7 (41.2)7 (50.0)Age at onset (yrs)*6.4 (4.5 – 9.8)5.4 (4.1 – 8.5)7.4 (5.6 – 12.3)Lag period (mo)*3.5 (1.0 – 12.5)2.0 (1.0 – 16.8)6.8 (1.2 – 15.8)Heliotrope16 (50)9 (52.9)7 (50)Gottron papule23 (71.9)12 (70.6)11 (78.6)Malar rash19 (61.3)9 (52.9)10 (71.4)Vasculitic rash19 (61.3)8 (47.1)11 (78.6)Arthritis10 (31.3)3 (17.6)7 (50)Nailfold changes28 (87.5)15 (88.2)13 (92.9)Calcinosis9 (28.1)4 (23.5)5 (35.7)Positive ANA17 (53.1)10 (58.8)7 (50)Positive Myositis antibodies4 (12.5)2 (11.8)2 (14.3)Laboratory at diagnosis, U/L* CK324 (134 – 2229)746 (139 – 2965)351 (155 – 2622) LDH650 (450 – 943)650 (398 – 1015)714 (512 – 944) ALT28 (16 – 106)35 (18 – 109)38 (15 – 104) AST50 (30 -108)50 (31 – 113)85 (36 – 215) Aldolase13.7 (8.1 – 28.0)14.2 (8.4 – 26.6)16.3 (8.6 – 38.5)CMAS score at diagnosis29 (21 – 43)28 (21 – 35)35 (11 – 43)

*median (IQR), otherwise - n (%)

Pulse methylprednisolone (pMP) was used in 53.1% of patients after diagnosis. Median time to inactive disease (ID) was 5.3 months (IQR 2.8 – 12.8). Male, older age and patients on pMP (p = 0.003-0.044) achieved ID sooner. Older patients also developed disease flare sooner after achieving ID (p =0.024). No clinical features nor lab investigations predicted JDM disease course. Malay patients was associated with higher risk of calcinosis (p = 0.017).

Compared to adult dermatomyositis patients in Singapore1, our cohort had more cutaneous manifestations including malar rash, vasculitic rash and nailfold changes. Table 2 shows the time for each muscle enzymes to normalise.

CK1.49 (0.69 – 3.53)LDH4.53 (2.35 – 25.04)ALT1.71 (0.90 – 4.13)AST0.97 (0.53 – 3.12)Aldolase3.12 (2.35 – 8.30)

median in months (IQR)

Conclusion:

Our cohort of JDM patients had more calcinosis compared to other Asian population2. Malay population is at higher risk of this complication. It is crucial to achieve ID state in the shortest time possible to avoid significant morbidity. Our study suggests that early treatment with pMP is associated with shorter time to ID. There is no predictor identified for disease course, similar to previous studies3.

References:

[1]Liu, Wen Chun, et al. “An 11-year review of dermatomyositis in Asian patients.” Annals Academy of Medicine Singapore 39.11 (2010): 843.

[2]Sun, Chi, et al. “Juvenile dermatomyositis: a 20-year retrospective analysis of treatment and clinical outcomes.” Pediatrics & Neonatology 56.1 (2015): 31-39.

[3]Stringer, Elizabeth, Davinder Singh Grewal, and Brian M. Feldman. “Predicting the course of juvenile dermatomyositis: significance of early clinical and laboratory features.” Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 58.11 (2008): 3585-3592.

Disclosure of Interests:

None declared