Introduction: Extra‐articular involvement (EAI) in rheumatoid arthritis (RA) is rare, severe and usually presents after years of joint involvement. Onset of RA as lung involvement has been published. We describe a series of three patients with strongly positive anti‐citrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) positive in the absence of joint symptoms, but with significant EAI.Methods: This is a descriptive case series of three patients evaluated in an academic medical center rheumatology clinic.Results: A 50‐year‐old female presented with severe recurrent scleritis in the background of strongly positive ACPA, but no joint involvement. Her ocular disease responded well to rituximab. Four years later, she developed peripheral inflammatory arthritis consistent with RA. A 74‐year‐old male presented after developing recurrent steroid‐dependent serositis (pleuro‐pericarditis) and interstitial lung disease (ILD). Serology was notable for strongly positive ACPA, but no joint involvement. Serositis responded well to adalimumab. Two years after initial symptoms, he developed peripheral joint involvement after holding adalimumab. A 56‐year‐old female presented with an isolated, biopsy‐proven subcutaneous rheumatoid nodule. Subsequently, she developed pancytopenia and fatigue. She tested strongly positive for ACPA and RF. Bone marrow biopsy was negative for malignancy and she had no evidence of infection. She responded to steroids and hydroxychloroquine and had not developed joint involvement after 2 years of follow‐up.Conclusion: EAI as an onset of RA is a complex and not easily recognized entity if typical joints involvement is not yet present. Early diagnosis may help guide specific therapy and prevent sequelae and co‐morbidities.

Retinal vasculitis is an uncommon but potentially sight-threatening manifestation of systemic lupus erythematosus (SLE). The most common findings include retinal hemorrhage, “cotton-wool” spots, and vasoocclusion1,2. While the exact pathogenesis is unclear, it is thought that antiphospholipid antibodies, immune complex deposition, and complement activation are involved1. Systemic corticosteroids and cyclophosphamide are established treatment options for vasculitis, but case studies show promise with rituximab and plasma exchange3,4,5. A …

Objective The current study was designed to evaluate the translation of clinical trial outcomes and clinical guidelines for the treatment of fibromyalgia (FM) into an intensive multicomponent clinical program embedded in routine care delivery. The study aimed to assess the adaptation of these recommended strategies into routine clinical care while evaluating their effectiveness and durability in improving functional status and level of distress in a large clinical sample of FM patients. Methods Four hundred eighty-nine patients with FM completed a 2-day program that incorporated best practice recommendations for the treatment of FM. Patients completed the Fibromyalgia Impact Questionnaire–Revised, the Center for Epidemiologic Studies Depression Scale, and the Pain Catastrophizing Scale at admission to the program and at follow-up on average 5 months posttreatment. Results Significant improvements were seen in functional status (p < 0.0001), depressive symptoms (p < 0.0001), and pain catastrophizing (p < 0.0001) after participation in the intensive multicomponent treatment program. Conclusions The present study shows that an intensive multicomponent treatment program embedded in routine care delivery is effective in significantly improving functional status and psychological distress in a large sample of FM patients. The significant improvements were durable and maintained at follow-up.

To the Editor: Giant cell arteritis (GCA) has been associated with extracranial involvement, usually affecting large- and medium-sized vessels. Involvement of the female genitourinary tract is rare, with < 30 cases reported in the literature1,2,3. Here, we discuss 2 cases of incidentally discovered uterine GCA ultimately found to also involve the aorta on positron emission tomography (PET) scan. Ethics board approval was not required according to the authors’ institution (Mayo Clinic, Jacksonville, Florida, USA). Both patients gave written permission to publish the material. Case 1 involved a 73-year-old female with a history of polymyalgia rheumatica (PMR) 5 years prior and presented to rheumatology after surgical uterine pathology following hysterectomy for symptomatic uterine prolapse. The patient demonstrated GCA involving small and medium-sized vessels. In the months preceding hysterectomy, she … Address correspondence to Dr. R.R. Butendieck Jr., Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA. E-mail: butendieck.ronald{at}mayo.edu