Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are the principal clinical and laboratory findings that lead a community rheumatologist to refer patients with scleroderma and lupus to a tertiary care center?
From the standpoint of scleroderma or lupus, tertiary care centers are more likely to get referrals from physicians caring for patients with complex, progressive, or refractory disease, though all consults are welcome. I will focus on the scleroderma (a.k.a. systemic sclerosis) aspect of this questi...
How would you approach the work up of a patient with nasal septal perforation, a negative infectious workup, and negative ANCA titers?
This clinical scenario can be difficult for the rheumatologist to evaluate, and close collaboration with colleagues in ENT would be essential. Causes of nasal septal perforation include trauma, infectious etiology, and autoimmune conditions such as granulomatosis with polyangiitis or microscopic pol...
Is whole body PET scan sufficient to rule out cardiac involvement in sarcoidosis?
Whole-body PET scans, particularly using 18F-fluorodeoxyglucose (FDG), play a significant role in evaluating sarcoidosis, including cardiac involvement. Recent studies have investigated the effectiveness of whole-body PET scans in diagnosing isolated cardiac sarcoidosis and assessing both cardiac an...
Would you use TNF inhibitors in patients with features of SLE, but active peripheral and axial spondylarthritis?
I can understand Dr. @Dr. First Last's hesitancy as there is no good literature to prove one way or the other. This is one of those questions which will have practitioners on both sides of the answer.However, I would not hesitate for several reasons:In the early 2000s, before we had better txs avail...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
How do you manage patients with early stage breast cancer with autoimmune disorders such as rheumatoid arthritis and collagen vascular disorders?
The historical perspective has been to treat in 180 cGy daily fractions to a total dose of 45 Gy with a tumor bed boost (assuming the need) to 50-55 Gy based on intrinsic increased radiosensitivity of normal and tumorous tissues. It is unclear whether this dose-fractionation schedule is effective be...
Do you consider APBI a reasonable alternative to mastectomy for women with early stage breast cancer and collagen vascular diseases?
As to the appropriateness of using APBI via a balloon catheter system for patients with CVD, data are limited to just small case series and individual case reports (e.g., Brachytherapy 10:121-127,2011; Brachytherapy 10:486-490,2011). Further, most patients reported in these series have been classifi...
Is hypofractionation ever appropriate in women with early stage breast cancer and latent lupus who have never experienced skin symptoms in their lifetime?
Short answer: Yes. I do offer HFRT to such patients. No. I would not advise a "wait-and-see" approach. Long answer: There are actually two categories of considerations here: First, are you comfortable treating patients with autoimmune/collagen vascular disease (CVD)? If so, are you a "lumper" or a ...
In which patients with stage IV NSCLC and PD-L1 TPS >50% plus concomitant autoimmune disease is it considered safe to give immune checkpoint blockers?
Given the adverse events of special interest noted with immune checkpoint blockers - specifically immune related AEs (or irAEs), the safety (and efficacy) of using these drugs in patients with pre-existing autoimmune disorders is not entirely clear. To date, most (if not all) studies have excluded p...
How would the presence of active rheumatoid arthritis on methotrexate impact your choice of fractionation for a patient with prostate cancer?
It depends on the dose of MTX. For 7.5-10 mg weekly doses have not changed volume or dose but if on a higher dose of MTX then I would discuss with rhematologist for possible holding or decreasing dose of MTX (as in that range has known radiosensitizing effect)