Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?
Lupus anticoagulants are a heterogeneous group of antibodies that do not have uniform activity in all assays. Furthermore, testing procedures are not well-standardized. Since relevant clotting factor deficiencies have been ruled out and the long PTT does not correct with mixing, and since there is o...
Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?
Any bone that sustains a fragility fracture can result from osteoporosis. The definition for fragility fracture is a broken bone that occurs after a low-energy trauma, such as a fall from standing height or less, or lifting something light. They are a type of pathologic fracture, which means they ha...
What is your approach when surgeons want to stop hydroxychloroquine prior to surgery?
I would absolutely say "do NOT stop HCQ." This is most likely a case of the surgical team mistaking HCQ for an immunosuppressant drug rather than an immunomodulatory drug. I would write a tactful "Rheumatologic Perioperative Recommendations" note where I would specifically state not to stop it and t...
How would you treat a perineural IgG4-RD with persistent paresthesia?
Perineuritis is an uncommon manifestation of IgG4-related disease (IgG4-RD), but it does occur. In most cases, this is an incidental finding that is not associated with symptoms or nerve dysfunction. This is most often observed in branches of the trigeminal nerve (e.g., infraorbital nerve, frequentl...
Do you recommend osteoporosis medication in postmenopausal females on anastrozole with very low Vitamin D (4.5)?
A vitamin D level of 4 is very low and should be corrected before any osteoporosis therapy is considered. Severe low D is associated with decreased Ca absorption and sometimes low serum Ca. Giving an anti-resorptive could result in hypocalcemia. Sometimes D levels that low are associated with muscul...
How do you integrate next-generation sequencing with traditional culture methods to improve the identification of fungal pathogens, especially in cases where routine cultures are negative when evaluating suspected prosthetic joint infections?
To my knowledge, there is no evidence that molecular studies improve the detection of fungal pathogens in periprosthetic joint infections. The vast majority of fungal PJIs are caused by Candida species, while mold infections are rare and typically diagnosed through fungal cultures. If a PJI remains ...
How do you approach an asymptomatic patient with evidence of intense radiotracer activity at the left sternoclavicular joint on bone scan with a history of SAPHO syndrome on Humira?
Any other area light up? Bone scans are sometimes challenging to read as they can light up with degenerative changes or prior damage and do not always represent active disease. Can consider an MRI of the joint to better determine whether there's disease activity or only prior damage. If it's really ...
Is there a target alkaline phosphatase level for hypophosphatasia patients on asfotase alfa therapy?
The package insert states, “do not rely on serum alkaline phosphatase measurements for clinical decision making in patients treated with Strensiq”.
What is the appropriate interval to obtain a hydroxychloroquine level after making a dosage adjustment?
Hydroxychloroquine has an initial whole-blood half-life of around 5 days, while its terminal half-life is around 40 days (Costedeau-Chalumeau et al., PMID 27745934). The former is relevant to evaluating whole blood levels after a dose change.This was confirmed in the PLUS study (see figure 2 in Cost...
How do you counsel patients with non-statin associated inflammatory myopathies about statin use?
Patients with non-HMGCR-associated myositis could try statins, keeping in mind that they could develop statin-associated muscle symptoms (SAMS). Therefore, would start with fluvastatin/pravastatin/pitavastatin (that are less likely to cause SAMS) at a low dose and slowly escalate if there are no sid...