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Background/Aims The COVID-19 pandemic has placed unprecedented pressures on NHS departments, with demand rapidly outstripping capacity. The British Society for Rheumatology ‘Rheumatology Workforce: a crisis in numbers (2021)’ highlighted the need to provide innovative ways of delivering rheumatology specialist care. At University College London Hospitals (UCLH) we created a rheumatology multidisciplinary team (MDT) clinic to meet rising demands on our service. The aims of the Rheumatology MDT clinic were to: reduce new appointment/follow-up waiting times, increase clinic capacity, incorporate musculoskeletal (MSK) point of care ultrasound, reduce number of hospital visits and add value to each clinic encounter. Methods We ran a 6-month pilot, supported by our outpatient transformation team, incorporating a Rheumatology Advanced Practice Physiotherapist (APP), Clinical Nurse Specialist (CNS) and MSK ultrasound within a Consultant clinic. The success of the pilot helped secure funding for a further 12 months. Over 18 months we have implemented: APP/Consultant enhanced triage - up to 40% of referrals were appropriate for APP assessment, including regional MSK problems and back pain. This increased capacity for consultant-led appointments. Standardisation of time-lapse between CNS and consultant follow-up appointments to ensure appropriate spacing between patient encounters. Facilitated overbooking of urgent cases afforded by additional capacity provided by the APP. MSK ultrasound embedded in the clinic template. ‘Zoom’ patient education webinars facilitated by MDT members and wider disciplines e.g. dietetics, to empower self-management and reduce the administrative burden of patient emails/phone calls occurring outside the clinic. Patient participation sessions and feedback to help shape the service. Results During the 6-month pilot we reduced our waiting time for follow-up appointments from 9 months to 2. We now have capacity to book 1-2 urgent cases each week. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision-making resulting in fewer appointments. Zoom webinar feedback has been positive. Patients value the broad expertise of allied health professionals which supports self-management. Embedding ultrasound allows for same day diagnostics, decreased referrals to radiology and reduced hospital visits. Conclusion Our MDT model has reduced waiting lists, decreased treatment delays and cut hospital attendances. Point of care ultrasound allows for same day decision making and abolishes the cost and diagnostic delay associated with referrals to radiology or outsourced providers. Shared decision-making adds value to outpatient attendances, which is reflected in patients’ positive feedback. The MDT model maximises the existing workforce skill set by enhancing the APP and CNS role, allowing patients immediate access to their expertise. Disclosure F. Higgs: None. D. Ludwig: None. N. Allotey: None. S. Begum: None. J. Burton: None.

Background/Aims Haemophagocytic lymphohistiocytosis (HLH) is a syndrome characterised by the presence of severe uncontrolled systemic inflammation due the overproduction of inflammatory cytokines and macrophage activation. The majority of adult patients have secondary HLH, triggered by either infection, haematological malignancy or rheumatic disease. Early recognition and initiation of definitive treatment is of vital importance as HLH leads to multi-organ failure and death if left untreated, with mortality of up to 80% in some cohorts. Methods Under-recognition of the disease and vast differences in the management of patients with HLH between specialities have been common problems. To address this, a Rheumatology-led HLH multi-disciplinary team (MDT) meeting was established at University College London Hospital (UCLH) in 2018. The MDT includes physicians from Rheumatology, Infectious Disease, Haematology, Intensive Care, Nephrology and Neurology and feeds into the national HLH group HASC - HLH Across Specialty Collaboration. The MDT is now held bimonthly, discussing between 2 and 4 cases each meeting. The MDT functions as a decision-making tool, while providing consensus on patient management, including collaboration on how to access urgent HLH-directed treatments such as Anakinra for secondary care centres without access. It also serves as a unique learning opportunity for trainees from different disciplines. Results Since the introduction of the MDT the number of patients diagnosed with HLH at ULCH has increased from an average of 6 per year in 2014-2016 to 12 per year in 2018-2020. In the last two years we have seen improved survival from years 2017/18 to 2019/20 (Table 1); survival was approximately 30% in 2017 and 75% in 2019. P018 Table 1:Outcomes of patients diagnosed with HLH (using ICD codes D761 and D762) at University College London Hospital since 2005.YEARALIVEDECEASED200511200601201021201111201220201334201442201525201641201737201839201993202095 Conclusion We believe that the HLH MDT has directly contributed to these improvements by encouraging earlier recognition and subspeciality collaboration. We encourage other sites to adopt a multi-disciplinary approach to managing patients with HLH to promote awareness of the condition and improve patient outcomes. Disclosure D.R. Ludwig: None. J. Manson: None. A. Jones: None. S. Mackenzie: None. N. Mccann: None.

Background/Aims Giant cell arteritis (GCA) is a systemic vasculitis affecting the temporal arteries and large vessels, including the aorta, in 25% of cases. Incidence of vertebral artery involvement is unknown likely owing to the reliance on conventional diagnostics including temporal artery biopsy (TAB) and temporal/axillary ultrasound which evade the vertebral arteries. These tests lose sensitivity soon after steroid initiation. Early specialist assessment and diagnostics, as part of a fast track pathway (FTP), can overcome this challenge. We present the first 12 months data from our FTP. To our knowledge this is the first GCA-FTP in the UK to utilise positron emission tomography - computed tomography (PET-CT) as an early diagnostic tool so we present a unique cohort of patients. Methods Cohort 1: 40 patients, diagnosed between 2015-2019, before FTP implementation. Time from steroid initiation to temporal artery ultrasound (TAUS) and TAB was recorded. Cohort 2: 35 patients referred after pathway implementation. 21 had a positive diagnosis. Time from steroid initiation to diagnostic test was recorded. Results Cohort 1: 26 (65%) patients had TAB; 3 (7.5%) had TAUS. The average time from starting steroid to investigation was 6 and 2 days respectively. Cohort 2: 17 (48%) had TAB, 30 (86%) had TAUS, 28 (80%) had PET-CT. In confirmed diagnoses, time from steroid initiation to investigations was 6.6 days, 1 day and 2.5 days respectively. In negative diagnoses time frames were 11.5, 1.5 and 2.3 days respectively. Table 1 shows sensitivity and specificity of these tests. Table 1. Sensitivity and specificity comparison between diagnostic tests Conclusion Combining TAUS and PET-CT allows for high diagnostic accuracy without the need for invasive biopsy. 24% of patients had negative or inconclusive ultrasound and/ or negative biopsy but confirmed vasculitis on PET-CT. 50% of this cohort had vertebral involvement only. PET-CT has an important role in detecting extracranial particularly vertebral arteritis, where biopsy and ultrasound are unreliable. Our pathway design with the inclusion of PET-CT, enables us to capture all patients with GCA and satisfy NHS England criteria for tocilizumab use in refractory GCA. Continued evaluation of PET-CT and its role in predicting vascular complications is required. Disclosure D.R. Ludwig: None. V. Morris: None. A. Shashidhara: None. S. Voo: None. R. Reshat: None.

The lead sepsis nurse, chief registrar and simulation team in a large London teaching hospital have developed a digital communication tool to improve and standardise the process of escalation and handover of deteriorating patients. The tool is designed for use by the multidisciplinary team (MDT). Poor communication is a frequently cited causative factor leading to adverse clinical events, particularly in relation to escalation and handover of care. UCLH uses ISBARD (Introduction, situation, background, assessment, recommendation and decision) to facilitate and improve how we escalate and handover deteriorating patients. Our trust switched to an electronic health record system last year using the software Epic. Since the introduction of Epic, we have had two serious incidents (SIs) related to miscommunication of escalation of NEWS2 scores. Investigation of these SIs concluded that the process of escalating a rising NEWS2 score could be improved by the use of an ISBARD tool creating a common language to escalate a deteriorating patient. Therefore, we have built a quick and intuitive ISBARD smart text in Epic to use when escalating a deteriorating patient. Teaching sessions are booked for the MDT over the next few months to train staff in the environment where they will use the tool to illustrate its use. We are working with the simulation team to embed the tool in clinical SIM training. We involved the MDT in design and implementation from the outset to optimise staff engagement. If we were starting again we would involve leaders of different staff groups at an earlier stage to help promote the importance and value of the tool. Our project is to streamline staff workload and help identify high risk wards where additional support may be needed. Our tool is designed to aid communication and empower clinicians to escalate their concerns safely and prioritise patient care.

COVID-19 has had a significant impact on specialty training. All training days were cancelled and the majority of trainees were redeployed to general medicine. By early May 2020, there was a shift in the focus back towards specialty training as COVID-19 related hospital admissions continued to decrease. With the help of the team from King’s College London, a remote rheumatology training programme was developed and accessible to trainees from four different regions – South London, North West London, North East/North Central London and Kent/Surrey/Sussex. The collaboration between different regions gave access to a greater pool of speakers and reduced the administrative workload. Subsequent collaboration with the British Society for Rheumatology facilitated the delivery of the webinars on a national level, supporting other regions that had not yet set up any remote training. Feedback was particularly important for this innovative programme in order to understand how this experience could be optimised for trainees. There were no additional difficulties related to the training taking place online, with one trainee responding that it was ‘very easy to log on’. There was also positive feedback regarding the recording – ‘[it] was great to have a link to the recording to watch it later’. By having a shared vision for change, we were able to work across regions and organisations, delivering a high quality training programme on a national scale, benefitting a greater number of trainees. Remote training has the additional benefit of removing the need to travel between hospitals. Therefore, there may be a push towards blended learning (a combination of online and face-to-face learning) in the future. Using a robust feedback mechanism, we are confident that the programme will continue to improve as it evolves alongside the pandemic, aiming to at least in part, satisfy the speciality rheumatology training needs within our regions.

BACKGROUND: The COVID-19 pandemic presents a significant infection prevention and control challenge. The admission of large numbers of patients with suspected COVID-19 disease risks overwhelming the capacity to protect other patients from exposure. The delay between clinical suspicion and confirmatory testing adds to the complexity of the problem. METHODS: We implemented a triage tool aimed at minimizing hospital-acquired COVID-19 particularly in patients at risk of severe disease. Patients were allocated to triage categories defined by likelihood of COVID-19 and risk of a poor outcome. Category A (low-likelihood; high-risk), B (high-likelihood; high-risk), C (high-likelihood; low-risk) and D (low-likelihood; low-risk). This determined the order of priority for isolation in single-occupancy rooms with Category A the highest. Patients in other groups were cohorted when isolation capacity was limited with additional interventions to reduce transmission. RESULTS: Ninety-three patients were evaluated with 79 (85%) receiving a COVID-19 diagnosis during their admission. Of those without a COVID-19 diagnosis: 10 were initially triaged to Category A; 0 to B; 1 to C and 4 to D. All high-risk patients requiring isolation were, therefore, admitted to single-occupancy rooms and protected from exposure. Twenty-eight (30%) suspected COVID-19 patients were evaluated to be low risk (groups C and D) and eligible for cohorting. No symptomatic hospital-acquired infections were detected in the cohorted patients. DISCUSSION: Application of a clinical triage tool to guide isolation and cohorting decisions may reduce the risk of hospital-acquired transmission of COVID-19 especially to individuals at the greatest of risk of severe disease.

Introduction Idiopathic inflammatory myopathies (IIM) have long been diagnosed using a defined number of clinical criteria (Bohan and Peter). The emergence of new myositis specific antibodies (MSAs) and their relation to specific disease phenotypes may be useful in establishing a new clinical-serological diagnostic criteria for different disease presentations and thus help to determine management and prognosis. We present a case of dermatomyositis (DM) where limb subcutaneous oedema; a rare manifestation of the disease, and severe dysphagia were prominent clinical features in addition with the presence of anti-small ubiquitin-like modifier activating enzyme (SAE) antibodies. Case description A 63-year-old Pakistani male presented with weight loss, anorexia, odynophagia, and a rash over his scalp, chest, face and flexor surfaces. Initial blood results revealed hypoalbuminaemia, CRP 7mg/L and ESR 37mm/h. A CT chest revealed an anterior mediastinum soft tissue mass suggestive of necrosis, with multiple ill-defined nodes throughout the lungs. An endoscopy revealed severe gastritis. Oropharyngeal examination revealed pooling of saliva and mucositis. Ceftriaxone was commenced for a presumed infective aetiology. Video fluoroscopy confirmed pharyngeal dysphagia with aspiration. Examination demonstrated a non-fatigable bulbar sounding dysarthria. There was no tongue wasting or fasciculations. Power was globally reduced, with marked proximal upper and lower limb weakness. Nerve conduction studies revealed normal sensation, and most motor nerves had normal conduction velocities with small nerve responses. Electromyography showed areas with denervation. With no improvement in the patient’s condition, anti-tuberculosis and anti-fungal therapy were commenced, with pulsed methylprednisolone for three days followed by 80mg daily to cover for an organizing pneumonia. Subsequent cultures were negative. Progressive weight loss with muscle wasting ensued and later, facial hyperpigmentation was noted in addition to the development of facial, lip and arms swelling. He was rheumatoid factor positive >500 iu/ml, with a raised IgE 2912 g/L and IgG 37.6 g/L. A CT-PET scan revealed intense uptake in the muscles posterior of the neck, tongue and masticators. An MRI scan of his arms revealed several abnormal signals around the shoulder girdle, long muscles of the back, and upper arm, which guided the site for muscle biopsy. This revealed highly abnormal skeletal muscle with frequent atrophic and necrotic fibres overrun by macrophages and T-cell rich inflammation. These findings in addition to serology reporting the presence of anti-SAE antibodies confirmed the diagnosis. Pulsed methylprednisolone, immunoglobulin therapy, and azathioprine were initiated with reducing prednisolone dose. Discussion This case of DM with a generalised rash, severe dysphagia and limb subcutaneous oedema were salient features in addition to the presence of anti-SAE antibodies. Anti-SAE has been shown to be present exclusively in DM patients where rash and severe dysphagia are common clinical findings. Our patient presented with severe dysphagia, which can be difficult to manage requiring enteral feeding. Video fluoroscopy was particularly useful in this case helping to stratify the severity of dysphagia and we would urge other clinicians to use this tool when investigating patients with suspected dermatomyositis to avoid potential complications of poor swallow including aspiration pneumonia. The additional imaging modality of PET-CT in our case confirmed the involvement of the muscles of mastication thus could prove a useful tool when investigating involvement of swallowing muscles in patients with anti-SAE DM. Skin features are another common finding in the anti-SAE group and our patient had a heliotrophic rash and shawl sign, which responded poorly to treatment. We describe the additional feature of severe subcutaneous limb and facial oedema, a rare manifestation of the disease, described in only a few other cases. Limb subcutaneous oedema is thought to reflect underlying severe muscle disease, is difficult to treat, and often is unresponsive to conventional treatment. Our case, and several other cases with the presence of limb oedema as reported in a literature search, required treatment with intravenous immunoglobulin and glucocorticoids, in addition with azathioprine and methotrexate. This is the first reported case to our knowledge of a patient with positive ANA, RF, anti-ccp, and anti-small ubiquitin-like modifier activating enzyme (anti-SAE) antibodies. Key learning points The finding of anti-SAE in our case where severe dysphagia was present provides further weight to this antibody being a useful serological marker to identify this subgroup of DM patients. Identifying this antibody may be helpful in creating management strategies for these patients and determining disease progression and prognosis. The presence of limb and facial oedema may be an overlying feature of the anti-SAE group; however, previous cases of limb oedema have not identified this antibody as the SAE test was unavailable. The presence of severe dysphagia and subcutaneous oedema suggests the presence of anti-SAE lends itself to a clinical phenotype of DM that is particularly severe and requires multidisciplinary input. Conflicts of interest The authors have declared no conflicts of interest.

Background: :Giant Cell Arteritis (GCA) is a common primary systemic vasculitis (1). Its predilection for the temporal artery can result in permanent visual loss if left untreated. Over 25% of patients have involvement of large vessels, such as the aorta, resulting in an increased risk of aneurysm formation and dissection. (3)Diagnosis of GCA is largely clinical and temporal artery biopsy (TAB) has long been the gold standard for diagnosis. In recent years temporal artery ultrasound (TAUS) has emerged as an effective, non-invasive tool to aid diagnosis. Positron-emission tomography (PET) can also be utilised to detect the presence of large vessel involvement but is currently not used in many centres for diagnostic purposes and requires further standardisation and validation (2). The challenge arises from these investigations losing sensitivity in the days following steroid treatment, meaning that rapid access is key to confirm diagnosis.Objectives:To evaluate the impact of the introduction of a fast track pathway (FTP) on prompt diagnostics and treatment.To improve our understanding of the use of PET at diagnosis and compare this to the gold standard TAB, and to TAUS, in our institution.Methods:Cohort 1: 32 patients, all presenting before FTP implementation, identified from outpatient clinics and referrals to the Rheumatology team. Time taken from steroid initiation to TAUS/TAB was extracted from clinical records. Outcomes for this group included number of years on steroid (steroid burden).Cohort 2: 21 patients all referred after implementation of a new GCA FTP. This group contains all patients referred as query GCA, not just those with positive diagnoses. Time from steroid initiation to TAUS/TAB was recorded. The FTP included the addition of PET imaging within 72 hours.Results:Cohort 1: 20 (63%) patients had TAB and 3 (9%) had TAUS. The average time from starting steroid to investigation was 5.2 days and 2 days respectively. The average steroid burden in patients with no confirmatory test was 11 years. If patients had just a single diagnostic test this value dropped to 3 years.Cohort 2: 11 (52%) had TAB, 10 (48%) had TAUS and 11 (52%) had PET. In positive GCA diagnoses, time from steroid start to investigations was 7.2 days, 1 day and 3.2 days respectively. In patients with a negative diagnosis the time frames were 13 days, 1 day and 1.7 days respectively. Sensitivity for TAB was 45.5% and TAUS 40%. Specificity for TAB and TAUS was 100%. These results are comparable to similar studies (4). PET sensitivity was 63.6% and specificity 100%.Table 1.Sensitivity, specificity, predictive valuesTABTAUSPET CTSensitivity (%)45.540.063.6Specificity (%)100100100PPV (%)100100100NPV (%)33.357.155.6Conclusion:Prompt diagnostics, best facilitated through a FTP, can reduce steroid burden in GCA even if only one confirmatory test is available. Patients with a low clinical suspicion of GCA and negative TAUS or a high clinical suspicion and positive TAUS stand little to gain from TAB. These findings summarise the first 6 months of our GCA FTP. Continued evaluation of PET in our FTP is needed to understand its role in diagnosis, particularly in patients at risk of vascular complications.References:[1]Crowson CS, Matteson EL. Contemporary prevalence estimates for giant cell arteritis and polymyalgia rheumatica 2015. Semin Arthritis Rheum. 2017; 47 (2) 253–6[2]Camellino D, Dejaco C. Should 18 F FDG PET imaging be used in the diagnosis of GCA? Nature Reviews Rheumatology 2019; 15 (7) 388–90[3]Nuenninghoff DM et al. Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large artery stenosis) in patients with giant cell arteritis: a population-based study over 50 years. Arthritis Rheum 2003; 48:3522-3531[4]Luqmani, R. et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): A Diagnostic Accuracy and Cost-Effectiveness Study. Health Technol Assess 2016; 20 (90) 1-238Disclosure of Interests:None declared

Background:Giant cell arteritis (GCA) may affect both cranial and extra-cranial vessels; where the latter occurs, it can be termed large-vessel GCA (LV-GCA). Large vessel involvement is common: histological evidence has been seen in 80% of autopsies of patients with known GCA, and imaging studies suggest large vessel involvement in over 80%1. LV-GCA is important to diagnose due to the risks of vascular complications such as occlusion and ischaemic stroke. The clinical diagnosis can be challenging, and the American College of Rheumatology (ACR) GCA classification criteria often underperform in cases of LV-GCA1. F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been found to be useful in the detection of extra-cranial involvement to support the diagnosis of LV-GCA.2Objectives:To appreciate the variability in presentation of cases of LV-GCA, and to further characterise a subgroup of patients with vertebral arteritis.To explore the use of FDG-PET imaging in GCA patients in addition to or in place of traditional diagnostic tools (temporal artery ultrasound / biopsy).Methods:Through evaluation of the new GCA fast-track pathway implemented at UCLH, a subgroup of patients diagnosed with vertebral arteritis was identified. The history and presentation of these patients were analysed.Results:Three patients were diagnosed with vertebral arteritis. All three were male, Caucasian and aged over 70. All were investigated for GCA due to a history of severe headache (frontal in one, occipital in one, bi-temporal in one) with associated red flag symptoms. Two had a history of jaw claudication and visual disturbances (unilateral visual loss in one, transient diplopia in the other). Both of these patients had positive temporal artery biopsies. The third patient had no ischaemic symptoms but a strong history of prominent polymyalgic features and a positive temporal artery ultrasound. Inflammatory markers were raised in two, and normal in one, of the patients. Only one had systemic symptoms (weight loss). All three proceeded to FDG-PET scans which showed vertebral arteritis and were commenced on immunosuppressive treatment.Conclusion:The cases discussed illustrate the heterogeneity of the presentation of LV-GCA, and the diagnostic challenge this poses. FDG-PET imaging is useful in confirming extra-cranial involvement and therefore guiding treatment.References:[1]Large-vessel giant cell arteritis: diagnosis, monitoring and management.Matthew J Koster, Eric L Matteson, Kenneth J Warrington.2018, Rheumatology, Vol. 57, pp. 32-42.[2]EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice.Dejaco C, Ramiro S, Duftner C, et al.2018, Annals of the Rheumatic Diseases, Vol. 77, pp. 636-643.Disclosure of Interests: :None declared

Background:Joint hypermobility is a common, although largely ignored physical sign. It is often asymptomatic but can be associated with significant musculoskeletal symptoms. Joint hypermobility may also be a feature of an underlying genetic disorder and patients may present with arthralgia, recurrent soft tissue injuries and intermittent joint swelling due to mechanical instability and poor proprioception. At University College London Hospital, we run a national service for the diagnosis and management of patients with hypermobility related disorders including hypermobility spectrum disorders, Ehlers-Danlos syndromes and Marfan syndrome. Over the years we observed that a significant number of our patients had been referred to the early arthritis clinics years prior to the recognition of their hypermobility. For example, one patient with a vascular type of Ehlers-Danlos syndrome EDS (confirmed COL3A mutation) presented to 3 different hospitals over a 5-year period, with possible inflammatory arthritis prior to the EDS diagnosis. Several studies have shown that a significant proportion of patients attending early arthritis clinics do not have inflammatory rheumatic diseases. In our experience, heritable disorders of connective tissue and hypermobility spectrum disorders are often overlooked and should be included in the differential diagnosis in patients seen in the early arthritis clinics.Objectives:We aimed to audit the outcome of patients who were seen in the early arthritis clinics focusing on those who were not found to have inflammatory rheumatic diseases and to explore if joint hypermobility was considered as a possible cause of patient’s symptoms.Methods:A retrospective analysis of medical records was conducted of patients attending the early arthritis clinics at University College London Hospital between May 2018 and December 2019.Results:279 patients (90 males, 189 females) were seen in the early arthritis clinics with a mean age of 48 (range 19-91). 131 patients (47%) did not have inflammatory rheumatic diseases. Sixty-three of these patients (48%) were not given any diagnosis and joint hypermobility was not assessed during the appointment. Eleven patients (8%) had features of hypermobility, 11 patients (8%) were diagnosed with fibromyalgia, 20 patients (15%) received a diagnosis of osteoarthritis, and 27 patients (21%) were given other diagnoses including tendonitis and soft tissue pathology.Conclusion:Almost 50 % of patients who were seen in the early arthritis clinics did not have inflammatory rheumatic diseases and 21 % of patients were discharged without a clear diagnosis. In these patients, hypermobility was not assessed and this is consistent with our observation. In our experience recognising joint hypermobility as a cause of arthralgia and intermittent joint swelling usually reassures patients and motivates them to follow appropriate treatment protocols including physiotherapy and occupational therapy thus allowing a more efficient utilization of early arthritis clinic resources towards those with true inflammatory rheumatic diseases. Going forward, we have planned to embed a cognisant attitude towards hypermobility within the relevant clinics to ensure that patients who do not have inflammatory arthritis are assessed for hypermobility and directed towards appropriate management.References:[1]Castori M, Hakim A. Contemporary approach to joint hypermobility & related disorders. Current Opinion in Pediatrics. 2017;29(6):640-649.[2]Emma Connelly, Alan Hakim, Sally Davenportc & Jane Simmonds, A study exploring the prevalence of Joint Hypermobility Syndrome in patients attending a Musculoskeletal Triage Clinic. Physiotherapy Practice & Research 36 (2015) 43–53[3]Feuchtenberger M, Nigg A, Kraus M, Schäfer A. Rate of Proven Rheumatic Diseases in a Large Collective of Referrals to an Outpatient Rheumatology Clinic under Routine Conditions. Clin Med Insights Arthritis Musculoskelet Disord. 2016; 9: 181–187.Disclosure of Interests:None declared

A significant proportion of patients with pyrexia of unknown origin (PUO) are found to have a rheumatological cause. The mainstay of treatment for rheumatic disease is immunosuppression, and therefore, accurate diagnosis is crucial given the risks associated with these drugs. In this review, we analyse the rheumatological conditions that most commonly present with fever and illustrate clinical cases demonstrating some of the challenges in the workup of these patients. With this in mind, we propose an evidence-based algorithm for investigating PUO from a rheumatological perspective, with the aim that it will aid clinicians when approaching these clinical scenarios.