Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
Would atypical fractures of the hip in a parent (treated with bisphosphonate) be considered when calculating the FRAX score for a patient with osteopenia?
There is no data regarding this question so my response is only my opinion. I would not include a parental hip fracture secondary to bisphosphonate use in the FRAX prediction model since such fractures are not (by definition), typical hip fractures (femoral neck or intertrochanteric regions). Howeve...
How would approach the management of a patient with significantly positive anticardiolopin and beta 2 glycoprotein antibodies in the absence of any clotting (including obstetric) history but with significant thrombocytopenia (but no other features of active connective tissue disease)?
I would first evaluate for other causes of thrombocytopenia (most of them can also result in positive APL antibodies): CTD, medications, liver disease, pregnancy, malignancy, splenomegaly, etc.I would not treat stable asymptomatic thrombocytopenia.If worsening/symptomatic, I would treat like any oth...
Would you add voclosporin to mycophenolate for refractory proteinuria in a patient with low EF?
There are two major potential concerns in a lupus nephritis patient with systolic dysfunction and a left ventricular ejection fraction (LVEF) of only 30%: QTc prolongation potential worsening leading to acute cardiac death Exacerbation of hypertension leading to worse LVEF and CHF However, with prop...
How do you approach pre-conception counseling in males who are on medications for which there is limited or no data such as Jak inhibitors, apremilast, or belimumab?
I am transparent about the lack of data, but discuss the differences in mechanism of action between cyclophosphamide and thalidomide (the only medications we recommend against conception with a partner) and JAKi, Apremilast, and Benlysta. Prior data has demonstrated a clinically insignificant amount...
How do you differentiate active vasculitis from pregnancy complications such as pre-eclampsia and HELLP in a patient with AAV?
Differentiating preeclampsia from autoimmune kidney disease in patients with rheumatic disease is often challenging due to the obvious overlap in clinical and serologic features. While most discussions about preeclampsia versus flare focus on SLE patients given that SLE is more common in women of re...