¹Entesar N Etrug, ²Ahmed S Zayat,

¹University hospital Sharjah, ²University of Sharjah

Introduction: Since the Oral surveillance data, there has been some concern about MACE and thromboembolic adverse event in high risk patient.   There has been low attention on arterial thrombosis although oral surveillance data suggest that the IR is 0.4% (95% CI 0.3 to 0.5) for arterial thromboembolism (1).

Method(s): We report a 90 years old female with high BMI (42) but no other known history of VTE or MACE. The patient was wheelchair bound due to known lumber radiculopathy and complicated lumber laminectomy surgery.    She has no other background comorbidities such as hypertension or diabetes.  The patient was diagnosed as seronegative rheumatoid arthritis with negative CCP and RF but positive ANA 1:1000 and low positive smRNP (11 (0-100)), ESR (30-42mm/hr) and CRP of 11mg/ L.  She had a high DAS-28-CRP of 5.2.  Patient has strong family history of psoriasis and psoriatic arthritis and have high urate (461 umol/L) and is on allopurinol 100mg.  Patient originally presented with severe subacromial bursitis in the right side (Figure a) for which she had been diagnosed as polymyalgia rheumatica although she failed systemic steroid including prednisolone (up to 20mg) and Intramuscular methylprednisolone injections.  She continued to have huge subacromial collection of fluid in the subacromial bursa reach 300 ml on aspiration and failed all aspirations and corticosteroid injections and required monthly arthrocentesis.  Synovial aspirate was negative for crystals and cultures were negative.  after 12 months disease progressed to cause synovitis in wrists and MCP joints in a symmetrical pattern. Patient failed hydroxychloroquine 200mg daily.  In the final quarter of 2020 patient was prescribed Updadacitinib with the dose of 15mg daily (before the Oral surveillance data become widely accepted) as added to the ongoing treatment with hydroxychloroquine 200mg daily and her prednisolone was escalated from long-term 5mg to 20mg daily to treat the ongoing flare of disease.  As part of the screening the patient was found to have hepatitis B core antibodies positive but with negative HBV PCR.  She was given Entecavir 0.5mg as an antiviral prophylaxis.   Three weeks after starting Updadacitinib patient was admitted with severe right wrist and hand pain and on examination right hand was cold with absent radial pulse.

Result(s): Arterial Doppler ultrasonography of the left upper limp (Figure b)  where all examined arterial segments reveal diffuse atherosclerotic changes in the form of mild diffuse intimal medial thickening. There was Sudden interruption of the arterial flow is noted in the distal left brachial artery, just proximal to the cubital fossa, where a thrombus / embolus is seen completely occluding its lumen. No arterial flow is seen in the distal left brachial artery, to the radial and ulnar arteries at the level of the wrist

Left upper limb angiography showed brachial artery filling defect and occlusion at the elbow joint.  EKOS catheter was then introduced and 5 mg Alteplase was administered directly as a bolus. After 24 hours patient had check angiography of left brachial artery showed good improvement in the flow in the radial and ulnar arteries.  filling defect noted in the distal radial artery with abrupt cutoff. filling defect also noted in the origin of the left ulnar artery causing partial obstruction.2 mg alteplase and 5000 IU heparin was administered intraarterially. Aspiration thrombectomy of the filling defect in the ulnar artery was performed with 6 F guiding sheath. White clot was noted in the aspirate.

As a follow up investigation including protein C and S, B2 glycoprotein and anticardiolipin IgG and IM and lupus anticoagulant were normal.  Patient continued to do well after that and recovered well with return o blood flow in the left arm.  Upadacitinib was stopped after that.

Conclusion(s): Arterial thrombosis in a case of seronegative arthritis with the risk factors of old age, obesity, low mobility and corticosteroid use.  Although no direct causation could be established, but caution might be considered in the presence of the risk factors of low mobility and obesity in elderly with JAK inhibitors