Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In older male patients with a history of underlying autoimmune disease, what clinical manifestations would prompt you to evaluate for VEXAS Syndrome?
Hello!!!Skin lesions, elevated MCV, elevated inflammatory markers.
How would you counsel a patient with relapsing polychondritis who is considering a turbinectomy for nasal obstruction regarding potential risks and disease-related complications?
Thank you so much for thinking so carefully about this!!.<3 <3 When I talk with a patient who has relapsing polychondritis and is considering a turbinectomy for nasal obstruction, I try to acknowledge how difficult and frustrating these symptoms can be, while also making sure we keep their safety a...
What biologic or conventional/synthetic DMARD would you use as a steroid sparing agent in a patient with GCA and a history of diverticulitis?
This is an important question. Both IL-6 inhibitors and JAK inhibitors have a risk of bowel perforation which is increased in patients with a history of diverticulitis, therefore, these agents must be used with great caution in such patients and alternative therapies are often preferred.First, it's ...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...
What is your approach to patients with SLE who develop a rash after hydroxychloroquine initiation?
First, I diagnose the type of rash. If it is a severe cutaneous reaction, e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), or if it is a more persistent type of reaction like a lichenoid reaction, I stop hydroxychlor...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you approach inflammatory arthralgias without synovitis in a patient with psoriasis?
When a patient with psoriasis presents with inflammatory arthralgias, the approach should be centered on a prompt evaluation to differentiate psoriatic arthritis (PsA) from other causes of joint pain or non-inflammatory arthralgias. Clinical history and physical exam are the key. A good clinical his...
Are there patients with SLE associated inflammatory arthritis in whom you recommend TNF inhibitors as a treatment option?
In patients who have inflammatory arthritis due to SLE and other causes have been excluded, such as infection, gout, and CPPD, I avoid TNFi therapy due to the concern of flaring lupus disease activity. Alternatively, I tend to add therapy for which there is evidence-based data to support their use, ...