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COVID-19; Registries; Vaccination COVID-19; Registros; Vacunación COVID-19; Registres; Vacunació Vaccine hesitancy is considered a major barrier to achieving herd immunity against COVID-19. While multiple alternative and synergistic approaches including heterologous vaccination, booster doses, and antiviral drugs have been developed, equitable vaccine uptake remains the foremost strategy to manage pandemic. Although none of the currently approved vaccines are live-attenuated, several reports of disease flares, waning protection, and acute-onset syndromes have emerged as short-term adverse events after vaccination. Hence, scientific literature falls short when discussing potential long-term effects in vulnerable cohorts. The COVAD-2 survey follows on from the baseline COVAD-1 survey with the aim to collect patient-reported data on the long-term safety and tolerability of COVID-19 vaccines in immune modulation. The e-survey has been extensively pilot-tested and validated with translations into multiple languages. Anticipated results will help improve vaccination efforts and reduce the imminent risks of COVID-19 infection, especially in understudied vulnerable groups. HC is supported by the National Institution for Health Research Manchester Biomedical Research Centre Funding Scheme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Osteoarthritis (OA) is a common degenerative condition leading to significant pain, functional limitation, and economic loss. Generalized OA (GOA) is associated with greater morbidity and accounts for 5-25% of total OA cases depending on definition used. This paper aims to determine the frequency and pattern of GOA, compare clinical and laboratory parameters of GOA and non-GOA subjects, then identify independent associations of GOA among Nigerians with knee OA.A cross-sectional study of 180 knee OA patients with knee and generalized OA defined using ACR criteria. Questionnaire administration was followed by physical examination and appropriate radiographs. Data was summarized using tables and figures. Multivariate regression was done to identify independent GOA associations with statistical significance p0.05. Ethical approval was obtained for the study.There were 180 participants with mean age 59.7±9.1 years. Twenty-eight patients (15.6%) had GOA of which 26 were female. The hip/knee/spine pattern was the commonest while hand OA was rare. Comparisons showed that GOA patients were significantly older with longer pain duration, higher pain score, more Heberden's nodes, and greater fatigue. There were no significant differences between both groups in levels of inflammatory markers and other laboratory parameters. Further analysis identified joint stiffness as the only independent association of GOA (OR 3.34, p=0.01).A 15.6% frequency of GOA was identified among knee OA sufferers with the hip/knee/spine pattern most frequent. Nigerians with GOA are predominantly females with a large joint phenotype. Joint stiffness was the only independent association of GOA observed. Key Points • Generalized osteoarthritis occurs in 15.6% of Nigerian patients with knee osteoarthritis. • Females are predominantly affected with a large joint phenotype involving the hip/knee/spine. • Joint stiffness is an independent association of generalized osteoarthritis.

Interstitial lung disease (ILD) occurs in 15% of connective tissue disease (CTD) patients causing considerable morbidity and mortality. Data is scarce regarding its clinical characteristics and outcomes in Africa. We aim to study the frequency, clinico-radiological characteristics, and treatment outcomes of African CTD-ILD patients. A retrospective cross-sectional study of ILD among 318 CTD patients diagnosed using relevant ACR criteria at the rheumatology unit of Lagos State University Teaching Hospital (LASUTH), Lagos from 2012 to 2019. Socio-demographics, clinical features, radiological findings, and treatment outcomes were documented. Data was analyzed using SPSS version 21 with p < 0.05. The LASUTH ethics committee approved the study. Interstitial lung disease occurred in 31 (9.7%) of 318 CTD cases. Their mean age was 38.8 ± 13.3 years, range 19-68 years with 28 (90.3%) females. Proportions of CTD-ILD were Sjogren's syndrome (50%), UCTD (50%), systemic sclerosis (46.7%), MCTD (33.3%), PM/DM (25%), SLE (6.5%), and RA (2.6%). Commonest presentations were cough (93.5%) and bibasal inspiratory crackles (83.9%) with a restrictive pattern in 83.9%. Antinuclear antibody occurred in 100% and anti-ENA in 67.7%. Traction bronchiectasis (89.7%) and ground glass opacities (96.6%) were frequent HRCT findings. Treatments included pulse-dose prednisolone, cyclophosphamide, mycophenolate mofetil, pirfenidone, and rituximab. Outcomes were ambulatory oxygen therapy (12.9%) and mortality (16.1%) with 9.7% lost to follow-up. CTD-ILD is a female predominant disease occurring in 9.7% of CTD patients mostly those with Sjogren's syndrome and systemic sclerosis. Due to significant morbidity and mortality, we advocate routine ILD screening for all CTD patients including those with undifferentiated disease. Key Points: • Interstitial lung disease occurs in 9.7% of patients with underlying connective tissue disease. • Females are predominantly affected especially those with Sjogren's syndrome and systemic sclerosis. • Mortality occurs in roughly 1 in every 6 patients with CTD-ILD.

Background: Haematological manifestations are common in SLE, but cytopenias are rarely the only abnormality at diagnosis. Case Summary: We report the case of a 40-year-old woman who was admitted for recurrent anaemia with a 2-month history of constitutional symptoms and no other complaints. Her Full Blood Count (FBC) showed bi-cytopenia, a Haemoglobin level of 4g/dl and a platelet level of 77x103/μl. An Autoimmune serology revealed a positive Antinuclear antibody (ANA) test at 1:2560 and positive SLE antibodies. The diagnosis of SLE was established using the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 classification criteria. She was commenced on steroids and Disease Modifying Anti-Rheumatic Drugs (DMARD), and there was a sustained increase in her Haemoglobin and platelet count. She subsequently required no further blood transfusions. Conclusion: SLE can present in a myriad of ways. It is, however, essential to note that haematological features may be the sole manifestation at the time of diagnosis. Early recognition and commencement of appropriate treatment often improve prognosis.

To determine the prevalence of depression and its determinants among Nigerian patients with knee osteoarthritis (OA). Two hundred and fifty patients satisfying the American College of Rheumatology classification criteria for knee OA were recruited from five centers. Pain was assessed using Western Ontario and McMaster Universities Index (WOMAC) pain subscale, functional status was determined by Steinbrokers criteria, radiographic knee OA was graded using Kellgren–Lawrence criteria, depression was determined using the Patient Health Questionnaire (PHQ-9), sleep quality by the Pittsburgh Sleep Quality Index (PSQI), and family functioning by Family APGAR (Adaptation, Partnership, Growth, Affection, and Resolve). Factors associated with depression in KOA following bivariate analyses were adopted as independent variables in logistic regression analysis to determine the predictors of depression in KOA. The study was approved by the Ethical Review Committee of each of the study centers. The mean age of patients was 59.90 ± 10.62 years and 209 (83.6%) were females. Their mean PHQ-9 score was 4.68 ± 4.19 with 105 (42%) having depression (PHQ-9 ≥ 5). Eighty-four (80%) of patients with depression had poor sleep quality (PSQI≥ 5.0). Depression was significantly associated with poor sleep, WOMAC pain scores, medial compartment KOA, lateral compartment KOA, and patellofemoral OA. Poor sleep quality was the best predictor of depression (OR 4.555, CI (2.241–9.257), p

ObjectivesTo identify the changes in rheumatology service delivery across the five regions of Africa from the impact of the COVID-19 pandemic.MethodsThe COVID-19 African Rheumatology Study Group created an online survey consisting of 40 questions relating to the current practices and experiences of rheumatologists across Africa. The CHERRIES checklist for reporting results of internet e-surveys was adhered to.ResultsA total of 554 completed responses were received from 20 countries, which include six in Northern Africa, six in West Africa, four in Southern Africa, three in East Africa and one in Central Africa. Consultant grade rheumatologists constituted 436 (78.7%) of respondents with a mean of 14.5 ± 10.3 years of experience. A total of 77 (13.9%) rheumatologists avoided starting a new biologic. Face-to-face clinics with the use of some personal protective equipment continued to be held in only 293 (52.9%) rheumatologists’ practices. Teleconsultation modalities found usage as follows: telephone in 335 (60.5%), WhatsApp in 241 (43.5%), emails in 90 (16.3%) and video calls in 53 (9.6%). Physical examinations were mostly reduced in 295 (53.3%) or done with personal protective equipment in 128 (23.1%) practices. Only 316 (57.0%) reported that the national rheumatology society in their country had produced any recommendation around COVID-19 while only 73 (13.2%) confirmed the availability of a national rheumatology COVID-19 registry in their country.ConclusionCOVID-19 has shifted daily rheumatology practices across Africa to more virtual consultations and regional disparities are more apparent in the availability of local protocols and registries.

ObjectivesTo develop recommendations for the management of rheumatic and musculoskeletal diseases (RMDs) during the COVID-19 pandemic.MethodA task force comprising of 25 rheumatologists from the 5 regions of the continent was formed and operated through a hub-and-spoke model with a central working committee (CWC) and 4 subgroups. The subgroups championed separate scopes of the clinical questions and formulated preliminary statements of recommendations which were processed centrally in the CWC. The CWC and each subgroup met by several virtual meetings, and two rounds of voting were conducted on the drafted statements of recommendations. Votes were online-delivered and recommendations were pruned down according to predefined criteria. Each statement was rated between 1 and 9 with 1–3, 4–6 and 7–9 representing disagreement, uncertainty and agreement, respectively. The levels of agreement on the statements were stratified as low, moderate or high according to the spread of votes. A statement was retired if it had a mean vote below 7 or a ‘low’ level of agreement.ResultsA total of 126 initial statements of recommendations were drafted, and these were reduced to 22 after the two rounds of voting.ConclusionsThe preliminary statements of recommendations will serve to guide the clinical practice of rheumatology across Africa amidst the changing practices and uncertainties in the current era of COVID-19. It is recognized that further updates to the recommendations will be needed as more evidence emerges.Key Points• AFLAR has developed preliminary recommendations for the management of RMDs in the face of the COVID-19 pandemic.• COVID-19 is an unprecedented experience which has brought new concerns regarding the use of some disease-modifying anti-rheumatic drugs (DMARDs), and these recommendations seek to provide guidelines to the African rheumatologists.• Hydroxychloroquine shortage has become rampart across Africa as the drug is being used as prophylaxis against COVID-19 and this may necessitate a review of treatment plan for some patients with RMDs.• Breastfeeding should continue for as long as possible if a woman is positive for SARS-CoV-2 as there is currently no evidence that the infection can be transmitted through breast milk.

The onset of the COVID-19 pandemic has led to far-reaching changes in the delivery of healthcare services across Africa. A number of drugs used in the management of rheumatic diseases have been touted to have roles to play in the treatment and/or exacerbation of COVID-19 symptoms and this has resulted in significant changes in the practice of rheumatology. The global rheumatology community has risen to this challenge by demonstrating collaborative partnership, resulting in the establishment of the global rheumatology registry to collect data on rheumatic patients infected with COVID-19.1 In view of the study by Gianfrancesco et al ,2 an online survey consisting of 40 practice and experience questions ((online supplementary file 1) and (online supplementary file 2)) was created by the COVID-19 African Rheumatology Study Group which was formed through the network of the African League of Associations for Rheumatology (AFLAR). The aim of the study was to identify the changes in rheumatology practice and patient behaviour, as well as to highlight key concerns of rheumatologists across Africa resulting from the ongoing COVID-19 pandemic.### Supplementary data [annrheumdis-2020-218273supp001.pdf] ### Supplementary data [annrheumdis-2020-218273supp002.pdf] A total of 554 completed responses were received from 20 African countries. There were 431 (77.8%) responses from Northern Africa, 43 (7.8%) from West Africa, 6 (1%) from Central Africa, 20 (3.6%) from East Africa and 54 (9.8%) from Southern Africa. The scope of practice was adult only in 296 (53.4%), paediatric only in 15 (2.7%) and both in 243 (43.9%). A total of 288 (52.9%) of the respondents practised in academic institutions, while 162 (29.2%) practised primarily in a private setting. Forty-four (7.9%) were using hydroxychloroquine (HCQ) more than before, 19 (3.4%) admitted to have prescribed HCQ to prevent severe COVID-19 disease, 92 (16.6%) …

ObjectivesTo highlight common precipitants and co-morbidities of gout in Nigerians; determine the frequency of chronic kidney disease (CKD) in Nigerian gout patients, as well as identify significant associations of CKD in gout patients.Material and methodsRetrospective cross-sectional study of gout cases seen at the Rheumatology Clinic of the Lagos State University Teaching Hospital over five years from January 2011 to December 2015. Gout was diagnosed using the 1977 American Rheumatism Association (ARA) criteria. Clinical and laboratory data were extracted and examined for the presence of CKD defined using Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines as estimated glomerular filtration rate (eGFR, CKD-EPI) < 60 mls/min/1.73 m2 body surface area for > 3 months.ResultsOne hundred and six gout patients were identified representing 4.5% out of a total of 2330 cases seen during the study period. There were 94 males and 12 females. Oligoarthritis was most frequent (41.5%) with the knee mostly affected (20.1%). Diuretic use was the most frequent precipitant (37.9%) with hypertension the commonest co-morbidity (62.9%). Of 70 patients with complete results, 29 had eGFR (CKD-EPI) < 60 mls/min (41.4%). Age, proteinuria, body mass index (BMI) and packed cell volume (PCV) were significant associations of CKD. Gout patients with CKD were significantly older (61.79 vs. 54.41 years, p = 0.003) with a significantly higher proportion developing proteinuria (15 vs. 4 patients, p  0.0001) compared to those without CKD. In contrast, those with CKD had a significantly lower BMI (27.31 vs. 29.65 kg/m2, p = 0.026) and PCV (31.97 vs. 37.95%, p = 0.005).ConclusionsThiazide diuretic use is the most common precipitant while hypertension is the commonest comorbidity in Nigerian gout patients. About two in five Nigerian gout patients had chronic kidney disease at presentation with age, proteinuria, BMI and PCV as significant associations. It is thus imperative to screen for chronic kidney disease when managing gout patients.

Musculoskeletal (MSK) conditions are more frequently found among patients with diabetes mellitus (DM) than in the non-diabetics. Despite several reports outside Africa, they have been under-studied among Africans. This study aimed to assess the overall prevalence and predictors of MSK conditions in Nigerian with types 2 diabetes mellitus (T2DM). A total of 268 adult with T2DM and 268 non-diabetic controls were recruited. All study subjects had their socio-demographics and clinical parameters obtained using interviewer-administered questionnaire. Musculoskeletal conditions among study subjects were classified using validated criteria and case definitions. Musculoskeletal disorders (MSKD) were significantly more frequent amongst subjects with DM (56% vs 22%, OR=4.5 p=0.001). Osteoarthritis (9.3% vs 4.1%, p=0.016), lumbosacral spondylosis (5.6% vs 2.2%, p=0.045), limited joint mobility (13.8% vs 5.6%, p-0.001), adhesive capsulitis (4.5% vs 1.5%, p-0.042) and rotator cuff tendinitis (3.7% vs 0.4%, p=0.006) were more frequent in DM subjects than in controls. Logistic regression showed that age (OR=2.1, CI=1.5-2.6) and waist circumference (OR=3.0, CI=2.6- 3.4) are independent predictors of MSKD among patients with diabetes. This study found higher prevalence of MSKD among diabetic subjects. It also identified certain factors associated with MSKD among patients with diabetes mellitus.

Juvenile systemic lupus erythematosus (JSLE) is a complex multisystemic autoimmune disorder of unknown cause. It accounts for about one in five cases of SLE. The tendency for SLE to run a fulminant course when it starts in childhood has made JSLE a potentially more severe disease than adult SLE. Reports of JSLE from sub-Saharan Africa are scanty in spite of the increasing reports of adult SLE. We conducted a 4-year retrospective study of JSLE cases seen at the Lagos State University Teaching Hospital between January 2010 and December 2014. Out of the 12 patients studied, eight were girls and four were boys. All patients had positive antinuclear antibody and extractable nuclear antibody tests. Anti-dsDNA antibody was positive in 10 patients. Eight patients had renal disease while four patients had neuropsychiatric manifestations. Haematological abnormalities and constitutional symptoms were present in all patients. Patients were treated with pulse methylprednisolone, oral prednisolone, hydroxychloroquine and azathioprine. Three patients also received rituximab. In conclusion, JSLE exists in Nigeria and exhibits clinical and immunological characteristics similar to its pattern in other parts of the world. It is, however, diagnosed late and is possibly being underdiagnosed as there is no paediatric rheumatologist in the country.

BACKGROUND Psoriatic arthritis (PsA) is an extracutaneous manifestation of psoriasis occurring in 6% to 42% of patients. Both conditions are common among whites but rarely reported among black Africans.Few African studies, however, have reported PsA frequencies of 0% to 4.6%, with a previous case report of 2 patients from a Nigerian rheumatology clinic. METHODS Case records of PsA patients from the Lagos State University Teaching Hospital Rheumatology Clinic seen over a 5-year period from January 2012 to December 2016 were retrieved and documented.Psoriatic arthritis was diagnosed using the Classification Criteria for Psoriatic Arthritis. Data on demography, clinical features, laboratory parameters, imaging, and treatment were extracted from case records. RESULTS Twelve PsA cases were identified out of 2330 patients (0.5%) seen during the study period. There were 9 males and 3 females. Age range was 24 to 67 years (mean, 45.3 ± 15.1 years). Duration of psoriasis ranged between 11 and 96 months (mean, 46.8 ± 33.6 months), whereas median duration of arthritis at presentation was 15 months (range, 4-72 months).Oligoarthritis was the commonest presentation (58.3%). Dactylitis (66.7%) and enthesitis (44.7%) were frequent extra-articular features. All patients were negative for rheumatoid factor and human immunodeficiency virus. HLAB27 was negative in 5 patients tested.Treatment was mostly with nonsteroidal anti-inflammatory drugs (100%) and methotrexate (75%). Only 1 patient received the biologic etanercept. Eight subjects (66.6%) showed initial improvement in skin and joint symptoms, of which 6 had a relapse within 6 to 12 months. CONCLUSIONS Psoriatic arthritis is rare among Nigerians and predominantly affects males in their fourth decade. Oligoarthritis is common, and extra-articular manifestations are frequent.

Eosinophilic granulomatosis with polyangiitis (EGPA), previously called Churg-Strauss Syndrome, is a systemic autoimmune disease that is usually associated with asthma and eosinophilia. It is a rare condition associated with antineutrophil cytoplasmic antibodies (ANCA). We report a case of a 52-year-old Nigerian woman who presented with bilateral leg swelling with multiple ulcers, background history of allergic rhinitis and chronic sinusitis since adolescence. There were also associated symptoms of peripheral neuropathy, weight loss, peripheral blood eosinophilia and positive perinuclear ANCA and she was previously managed for rheumatoid arthritis and asthma. She fulfilled the American College of Rheumatology criteria for EGPA and was treated with glucocorticoids and methotrexate which led to significant improvement of her symptoms.

Background Paediatric rheumatology service in Sub-Sahara African is virtually not available as there is a shortage of paediatric rheumatologists and other rheumatology health professionals. We aim to describe the clinical spectrum and the frequencies of paediatric rheumatic diseases (PRDs) in Lagos State University Teaching Hospital (LASUTH), Lagos, Nigeria. Methods This is a retrospective review of patients with PRDs seen over a five year period (March 2010 to February 2016) at the rheumatology clinic and children ward of LASUTH. We reviewed the folders of 57 patients from our records. The demographics, baseline laboratory features, clinical diagnosis, treatment patterns and patient outcomes were extracted and analyzed. Clinical and laboratory characteristics between patients with Juvenile idiopathic arthritis (JIA) and patients with juvenile connective tissue diseases (JCTD) were compared using Fisher’s exact test. Results Fifty seven patients were studied with a female to male ratio of 3 to 1 (Female: 43; M: 14). The mean age at presentation in years was 14 ± 4.4 years (range: 1.5–22 years). The mean duration of symptoms before diagnosis was 18.4 ± .9 months (range: 2–60 months). The diagnostic types of PRDs included 28(49.1%) cases of JIA. These were made up of 14 cases of polyarticular JIA, nine cases of oligoarticular JIA and 5 cases of systemic onset JIA. Others were 18 (24.6%) cases of juvenile systemic lupus erythematosus (JSLE), 3 (5.3%) cases of joint hypermobility syndrome, 2 (3.5%) cases of juvenile systemic sclerosis, 2 (3.5%) cases of fibromyalgia, 2 (3.5%) cases of plantar fasciitis, 1 (1.6%) case of juvenile dermatomyositis (JDM), 1 (1.6%) case of juvenile polymyositis-systemic lupus erythematosus (PM-SLE) overlap, 1 (1.6%) case of secondary bilateral knee osteoarthritis from Blount disease, 1 (1.6%) case of secondary osteoporosis from childhood leukemia and 1 (1.6%) case of Osgood-Schlatter’s disease. Constitutional symptoms and extra-articular diseases were significantly more frequent among JCTD cases than among the JIA cases (Constitutional symptoms: 100% vs 83.3%, p = 0.003; extra-articular disease: 100% vs 10.7%, p = 0.001). The percentage mortality in this study was 10.5% while 20 (35.1%) of the patients were lost to clinic follow up. Conclusion The pattern of PRDs observed in this study is similar to that described in South African and North American series but it differs from patterns reported in Asian series. Although hitherto largely unrecognized, PRDs may constitute a substantial cause of morbidity and mortality in black Africans.

Background: In occult hepatitis B virus (HBV) infection, the HBV DNA is present in the blood or liver tissue in patients negative for hepatitis B surface antigen (HBsAg) with or without anti-HBV antibodies. Thus, the absence of HBsAg in the blood only reduces the risk of transmission and is not sufficient enough to ensure the absence of HBV infection. Aim: This study was aimed at determining the prevalence of occult HBV infection among blood donors in Lagos. Study Designs: A cross-sectional study was done among 101 consenting blood donors at Lagos State University Teaching Hospital, Ikeja, between November 2016 and January 2017. Materials and Methods: HBV DNA analysis and viral load were done at the Molecular Laboratory of National Sickle Cell Centre, Idi Araba, Lagos, for all the HBsAg negative blood donors screened by rapid kit at Ikeja. Results: The prevalence of occult HBV DNA among the participants was 3% consisting of 3% prevalence of HBV DNA surface antigen and 0% prevalence for precore and core of the HBV DNA. Conclusion: The low prevalence (3%) of occult HBV seen in our study does not make it cost-effective to routinely screen blood donors or the general population for HBV infection using DNA polymerase chain reaction.

Pulmonary air leak syndromes are extremely rare complications of systemic autoimmune connective tissue diseases and the occurrence of spontaneous subcutaneous emphysema (SSE) from pulmonary leak in the absence of pneumothorax or pneumomediastinum is even rarer. We report a case of recurrent SSE in a patient with rheumatoid arthritis and interstitial lung disease. The SSE was managed conservatively each time and it resorbed over several days. There has been no previous documented report of SSE in the absence of pneumomediastinum, pneumothorax or pulmonary nodules in a patient with RA.

Juvenile dermatomyositis is an autoimmune connective tissue disease occurring in children less than 16 years old. It is part of a heterogeneous group of muscle diseases called idiopathic Iiflammatory myopathies. It had previously been reported in black Africans resident in UK. However, there is no documented case reported from Africa. The index sign of heliotrope rashes is often difficult to visualise in the black skin. An 11-year-old Nigerian girl presenting with clinical, laboratory and histopathological features of juvenile dermatomyositis is presented here. It is hoped that this case will heighten the index of suspicion of this condition among medical practitioners in Africa.

Systemic lupus erythematosus (SLE) has rarely been reported among African blacks. However, recent reports may indicate otherwise. Digital gangrene in lupus patients has been reported in different populations and has mostly been seen in patients with long-standing lupus. Digital gangrene as the initial presentation of SLE has rarely been reported, even among African blacks. Two cases of digital gangrene as the initial presentation in Nigerian lupus patients are hereby presented. The medical and surgical managements, as well as relevant literature are hereby discussed.