Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?
The frequency and timing of recurrent Scleroderma Renal Crisis are largely unknown. Majority of the reports available are from patients with ESRD that underwent renal transplant with recurrence in allograft - overall this is rare, with most occurring between 3 months to 2 years post-transplant, but ...
How would you treat a patient with necrotizing myopathy with positive anti-HMHCoR Ab unresponsive to standard therapies?
There are several questions raised by this scenario. I have personally never seen a patient with true HMGCR-antibody + necrotizing autoimmune myopathy fail a combination of 3 immunotherapies (high dose prednisone, IVIG, and either Rituximab or oral immunosuppression like Cellcept/azathioprine, etc),...
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
Would you consider a biologic or JAK inhibitor to manage active PsA in a patient on chronic antibiotic therapy if they had previously failed all conventional DMARDs (including apremilast)?
IL-23i such as guselkumab have not really shown a significantly higher incidence of infections or malignancies, so I would favor these over other biologics. Ustekinumab (IL-12,23i) also showed lower rates of infection compared with other biologics. However, something to consider is whether they have...
How would you approach a patient with GCA who develops necrotizing fasciitis and then flares because they are off of tocilizumab?
While recurrent necrotizing fasciitis is exceedingly rare, patients with necrotizing fasciitis may be at higher risk for other infections. Therefore, a careful risk/benefit analysis is warranted in such a case, similar to other cases of serious infections in patients on immunosuppression. The specif...
What is your approach to the management of patients with isolated cervical adenopathy related to sarcoidosis?
Establishing a diagnosis of sarcoidosis solely on the basis of isolated cervical adenopathy can present a challenge. Although thoracic adenopathy—alone or in combination with other extra-nodal clinical features—is part of the classic illness script for sarcoidosis, peripheral adenopathy as the exclu...
Would one year of steroids for JRA during teen years (with subsequently well-controlled autoimmune disease) be sufficient to explain a vertebral T score of -4.4 of a woman in her early 50s without any other risk factors?
This is a tough question. It is clear that teenage years with GCs would impact peak bone mass, however not to this extent. A T score of -4.4 is the result of a low peak bone mass, genetics, and factors that affect the bone mass between ages 25 to 30. I would put forth part of the low BMD is from GC ...
What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?
This is by far the hardest task assigned for a practicing rheumatologist. Inheriting a patient on a regimen you did not develop and are uncomfortable continuing poses a daunting challenge: you are challenging the patient’s relationship with the previous rheumatologist, the control of the patient’s d...
If a patient with relapsing remitting MS has comorbid Sjogren's syndrome and is on hydroxychloroquine (Plaquenil), how does that impact choice of DMT for MS?
A patient's pre-existing use of hydroxychloroquine (HCQ) has not impacted my decision on MS DMT. HCQ should not overlap with other DMT mechanisms of action, so the implication on more infections/malignancies is thought to be low. However, the need for additional immunomodulating agents for Sjogren's...
What additional therapies would you consider in a pregnant woman with Bechet's on an antiTNF and azathioprine who has uncontrolled non-pulmonary large vessel vasculitis?
BD often improves with pregnancy, so this scenario is not typical but certainly possible. Revising the diagnosis may still be worthwhile. In any case, checking anti-TNF through levels and testing for anti-anti-TNF antibodies seem reasonable as the first steps. Increasing the anti-TNF dose and dosing...