Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What baseline work-up do you do for patients with suspected palindromic rheumatism?
I'm sure this varies a lot by rheumatologists. For someone with a pattern of recurrent and episodic arthritis that sounds inflammatory, I think the differential diagnosis should include rheumatoid arthritis, gout, and calcium pyrophosphate deposition disease, polymyalgia rheumatica, and perhaps some...
Are there any clinical situations in which checking for anti-chromatin antibodies is helpful?
Chromatin is the native complex of histones and DNA found in the cell nucleus of eukaryotes. The prevalence of anti-chromatin (nucleosome) antibodies in systemic lupus erythematosus (SLE) varies from 50% to 90%, being similar to that of the historic LE cell.The question is whether this provides addi...
How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?
Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most c...
How do you manage severe vaginal dryness and vulvodynia refractory to topical lubricants in patients with Sjogren's syndrome?
Exclude candida, vestibular gland blockage, and lichen sclerosis.First-line treatment option is vaginal estrogens (cream, ring) or low-dose systemic estrogen (tablet, patch).Second-line options include vaginal DHEA or vaginal testosterone.The severe vaginal dryness in Sjogren's is associated with ly...
Are there any features that help differentiate Sjogren's-related CNS demyelinating plaques from multiple sclerosis in a patient with primary Sjogren's syndrome?
This differentiation can be very difficult but the modified Barkhof's MRI criteria, perivenular lesions, and T2 lesions larger than 6 mm can be helpful in this regard. Helpful references:Kim et al., PMID 23736535Maggi et al., PMID 29328521
Is there a role for tocilizumab in treatment of polymyalgia rheumatica in patients who do not have features of giant cell arteritis or rheumatoid arthritis?
In select PMR patients with multiple relapses as corticosteroids are tapered or who have significant steroid toxicity, additional "steroid-sparing" agents may be considered. I do think in this setting tocilizumab may be useful. IL-6 has long been appreciated as a pivotal cytokine in PMR. Two studies...
Does serologic activity (e.g., high titer dsDNA, low complements) without clinical disease activity in a pregnant lupus patient affect maternal or fetal outcomes?
Not specifically. High titers of anti-dsDNA and low C3 and/or low C4, especially those that are adversely trending, are predictors of renal involvement which could adversely affect outcomes especially if the renal involvement mandates a change in therapy, but otherwise no. If these biomarkers are ab...
How do you interpret granulomatous features on a muscle biopsy?
The differential for granulomatous myopathies is quite wide and depends on the clinical scenario. The most common diagnosis would still be sarcoidosis, but can also be seen with Crohn's disease, myopathy associated with anti-mitochondrial antibodies, rheumatoid arthritis, GPA/EGPA, rheumatoid arthri...
Are subcutaneous RA therapies less effective in obese patients?
Subcutaneous therapies may be less effective for RA in obese patients in some cases. The literature is mixed: no effect with subcutaneous abatacept but worse response in people with higher BMI with subcutaneous methotrexate.From personal experience, some obese patients or men with higher body weight...
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...