Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your differential for a patient presenting with multiple digits affected by flexor tenosynovitis, dupuytren's, and no evidence of peripheral inflammatory arthritis?
Other than idiopathic Dupuytren's and recreational or occupational flexor tenosynovitis, I would look for underlying thyroid disorders that can induce trigger finger with some palmar fascia and tendon thickening, and also diabetic cheiroarthropathy. There are several musculoskeletal complications se...
What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?
This is an interesting question. We need to clarify what this phrase means "who do not have potential to improve". It may be easier to identify patients who may benefit from therapy.ILD physicians work under the motto, 'stability is success'. Thus, improvement may mean 'did not deteriorate'. Minimal...
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
Is it ever reasonable to switch to a different TNFi as opposed to switching to an agent in a different class in a case of TNFi induced lupus or psoriasis?
This is a very interesting question where the answer continues to evolve. I would also like to answer the question separately. Both Psoriatic skin lesions and lupus or lupus-like conditions can be induced by anti-TNF-alpha therapy. The pathogenesis may involve changes in cytokine balance.Regarding P...
How long would you treat with antimycobacterials before starting biologic DMARD in a patient with latent TB and active rheumatoid arthritis?
This is a common question rheumatologists ask their ID colleagues. Given the diversity of patient presentations, though, there isn't a blanket answer. One reason there's no blanket answer is because it is so hard to study LTBI risks, due to infrequent conversion to active TB, which is a fortunate th...
How would you approach a patient with refractory polymyositis (elevated CK, weakness) despite MMF, IVIG, and moderate dose prednisone?
This is a tricky question as true "polymyositis" is exceedingly rare. In most cases, inflammatory myositis without a rash can be further categorized as an immune-mediated necrotizing myopathy, antisynthetase/overlap myositis, or IBM. So when faced with a refractory polymyositis, the first thing I wo...
Are there circumstances when you may consider imaging enthesitis in patients with psoriatic arthritis?
If you already know that there is "enthesitis", then there may not be a reason for imaging. However, there are a few circumstances to consider imaging entheses in a patient with psoriatic arthritis:1) When there is concomitant widespread pain syndrome and the enthesis is tender but not swollen on ph...
What is your approach to differentiating SLE flare in pregnancy vs pre-eclampsia?
Differentiating SLE flare in pregnancy from pre-eclampsia is challenging. This is particularly so because SLE patients have a higher risk of developing pre-eclampsia during pregnancy. There are no hard and fast rules, and often time as a provider, you are never 100% certain if a patient is having a ...
In which patients with autoimmune or inflammatory conditions are you recommending a 3rd dose of the mRNA COVID vaccine?
We found that many of the patients on immune suppressive medications do not have an appropriate response to the initial 2 doses of mRNA COVID19 vaccines. At this point, I recommend a 3rd dose to all the patients on immune suppressive medications, prioritizing the ones with known low titers of SARS-C...
What is your approach to a patient with rheumatoid arthritis and moderate disease activity on 25 mg of PO methotrexate?
Switching to sub cu may work for low disease activity, but not moderate.