Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
What guides your choice between prophylactic, intermediate, and full therapeutic dosing of enoxaparin in a woman with APLS and prior fetal loss with no hx of thromboembolic disease?
First, it is essential to confirm that patients meet criteria for obstetric antiphospholipid antibody syndrome (OAPS), based on the 2023 ACR/EULAR classification criteria. This includes persistently positive laboratory criteria (confirmed on repeat testing >12 weeks apart), plus otherwise unexplaine...
How do you approach management of mucinous cysts associated with hand osteoarthritis?
These cysts develop dorsally between the distal interphalangeal (DIP) joint and the proximal nail fold, are filled with synovial fluid associated with inflammation and damage to the joint capsule. Fluid escapes and accumulates, communicating with the adjacent joint. While they are often asymptomatic...
What additional workup would you perform to evaluate a new onset of spontaneous hemarthrosis?
The workup that you've outlined is essentially complete. Would rule out any possible medication/supplement effects, Would consider the possibility of a vascular fragility syndrome (EDS) or other connective tissue disease, Would rule out vitamin C deficiency, If there is other bleeding that clinical...
How long do you treat retroperitoneal fibrosis with immunosuppression?
I normally treat for 9 months to a year depending on response. I have found PET CT useful in determining if there is active ongoing inflammation.
What is your approach to using pegloticase in patients with congestive heart failure?
Clinical trial data show developing CHF exacerbation in 2% of patients while on Pegloticase treatment, while real-world data show higher numbers (6.4%), so careful patient selection and stabilization of CHF are necessary before starting treatment, and need close monitoring while receiving treatment....
What findings on routine monitoring PFTs prompt you to pursue HRCT in your patients with SARDs?
That’s an excellent question, and the strategy might vary somewhat by the specific SARD, but in general, in any SARD patient undergoing annual PFTs, the presence of any of these should prompt an HRCT to evaluate for the development of ILD. FVC drop ≥ 10% DLCO drop ≥ 15% Moderate decline in FVC (5-9...
How would you advise a CKD patient who asks about oral NSAIDs for management of chronic pain if they have a contraindication to taking acetaminophen?
This depends on the severity of the CKD/eGFR, age, course of disease, available alternatives to NSAIDs, severity of pain and impact on QoL, frequency with which NSAIDs might be taken. I have advised patients whose QoL is adversely affected by pain to take occasionally if needed but to keep to minimu...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...