Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you typically get muscle MRI in patients with symptoms of myopathy?
Not routinely, but there are some scenarios where MRI is useful. Selection of muscle to biopsy in a chronic progressive myopathy. In the past, we used to select muscles based on the degree of weakness on the MRC scale and the EMG findings. One would avoid muscles with MRC strength of 3/5 or less or...
How do you counsel patients about the malignancy risk associated with azathioprine?
Malignancy with the use of AZA (Imuran) was documented many decades ago in a renal transplant population, not in rheumatoid patients. Are they equivalent? Overall I consider Imuran a pretty safe DMARD. In fact, it can be used in pregnant patients with lupus, with mothers and babies doing just fine.
Is there any role of sympathectomy in Raynaud’s disease?
Sympathectomy was once considered to be the treatment of last resort for severe, refractory Raynaud's. Though severe Raynaud's remains a challenging disorder to manage, nowadays, sympathectomy rarely if ever enters the therapeutic discussion. Though most patients with Raynaud's phenomenon observed a...
What is your approach to therapy for pulmonary sarcoidosis resistant to methotrexate?
The first question I ask myself in any situation dealing with "refractory" sarcoidosis is "Am I sure active inflammation from sarcoidosis is the cause of their symptoms?". Oftentimes, I will see patients referred for refractory disease who end up having other causes of their symptoms. If I am confid...
How do you approach evaluation of hypocomplementemia in a patient with arthralgias and a history of Hodgkin's lymphoma treated in the past?
There are both acquired disorders - more common - of the complement system and inherited disorders - less common - of the complement system. Although rheumatologists commonly deal with autoimmune/acquired disorders of the immune system, they should be aware that certain inherited deficiencies of the...
How do you approach differentiating infectious vs inflammatory tenosynovitis?
Infectious tenosynovitis is boggy and very tender. Inflammatory tenosynovitis is less tender.
How would you manage scleritis perforans in a patient with seropositive rheumatoid arthritis/scleroderma overlap?
Scleromalacia perforans is a rare but sight-threatening disease that is often associated with seropositive RA. It has become less common, presumably due to more aggressive management of RA and newer medication options. Prior to biologics, it was often managed with oral prednisone and/or cyclophospha...
Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?
There seems not to be a consensus literature on this topic, so my answer is based on common sense rather than science. The first step is a detailed history (including family history) and physical examination looking for evidence of inflammatory joint disease with/without other findings that might fo...
Do you use anti-DFS70 Ab to help reduce the posttest probability of ANA-positive patients having a systemic autoimmune disease if other autoantibodies are negative?
I agree with Dr. Dixit that any lab test, especially an autoantibody test, has to be taken in context with the clinical features and other lab features. Our laboratory does not run this test as part of our serologic profiles. It may be reassuring to the clinician and patient that it is likely they d...
How do you specifically counsel patients on conservative measures such as hand warming in the treatment of SSc associated digital ulceration?
While Raynaud’s is nearly universal in Systemic sclerosis, digital ulcerations occur in approximately 30% of these patients yearly and tend to recur, with 2/3rd developing another one despite the use of vasodilators. Irreversible tissue loss, osteomyelitis, gangrene, and amputation are unfortunate c...