Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?
This could easily be a person with early (evolving) ANA-negative SLE (depending on the dsDNA titer) or early UCTD. If the dsDNA titer is low my concerns are somewhat diminished. I certainly would not assign a diagnosis of SLE given the information provided, with special reference to the person's anx...
How would you approach the management of dry corneal melt in a patient requiring high dose systemic steroids and no apparent underlying systemic autoimmune disease?
A corneal melt is a rare condition in which the cornea thins, usually at its periphery, which is the junction between the cornea and the sclera. A healthy cornea is avascular, but an array of antigen-presenting cells (APCs) is present at the corneal-scleral junction, presumably acting like guards to...
How would you manage a patient with severe deforming seronegative RA who has failed or been intolerant to DMARDs, TNFi, abatacept, Jak inhibitors, IL-6 and IL-1 agents in addition to Rituxan and moderate dose prednisone?
I would potentially be referring such a patient for implantable vagal nerve stimulation when the device is available (potentially later this year). Importantly, in the RESET RA trial, patients with multiple drug failures tended to do better than “easier to control” RA.
How would you manage a patient with progressive/refractory molluscum contagiosum who is well controlled on methotrexate for seropositive rheumatoid arthritis?
Molluscum can be more challenging to treat when a pt is taking any immunosuppressive. In treating that patient, I would attempt to use cimetidine 400 mg TID along with a topical retinoid such as Retin A 0.1% bid to each individual molluscum. If there are only a few remaining, recalcitrant lesions, I...
What is your approach to evaluation and management of a patient with Blau Syndrome and GI manifestations?
Blau syndrome is certainly an unusual diagnosis, as noted by @Dr. First Last. I've also only cared for one patient with this. However, it's important to first confirm the diagnosis of Blau. Did the patient have arthritis, dermatitis, and uveitis? Did you get a biopsy that revealed noncaseating granu...
How would you recommend dosing the MMR or other live vaccines for patients with rheumatoid arthritis on immunosuppressive medications such as DMARDs and anti-TNF alpha therapy?
It is rarely necessary for any live virus vaccine to be mandatory as most employers will accept waiver letters, as will most countries requiring yellow fever vaccination to enter. The risk of disease exposure, illness must be balanced against disease flare holding therapy. Fortunately, with the adve...
In a patient with active spondylarthritis and uveitis who cannot take TNF inhibitors, what is your next agent of choice?
Uveitis and typically acute anterior uveitis is commonly associated with Axial spondyloarthritides (SpA) but also other spondyloarthritides and is usually recurrent with exacerbation and resolution. The approach to the management of uveitis in my opinion is similar to patients without an underlying ...
How do you approach choosing between subcutaneous and IV actemra for RA?
This question has been studied using data collected by eight European RA registries. The aim of the study was to compare the proportions of patients achieving Clinical Disease Activity Index (CDAI) remission and low disease activity (LDA) at 1 year. There were no statistical differences observed and...
How would you approach a patient with anti-scl70 ab positive sine scleroderma complicated by ILD who also has seropositive RA with active arthritis?
This scenario can be looked at in different ways. For example, does this patient have scleroderma that explains the ILD and seropositive RA to explain the arthritis? Or, does this patient have seropositive RA which explains both the arthritis and the ILD? I favor the latter explanation. In this scen...
Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?
Hx of prior radiation was never a contraindication, it was a warning due to the known increase in osteosarcoma in patients who had prior radiation. A contraindication requires proof of harm. There was no data that radiation plus a PTH anabolic increased the risk of osteosarcoma. With the review of 1...