Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
Is there a benefit to having a transition period in which a patient continues following with their previous pediatric rheumatologist while establishing care with a new adult rheumatologist?
Several pediatric to adult care models exist. Some models involve transition clinics in which adult and pediatric providers are both present and care may overlap between the two providers. Others are primarily focused on the pediatric side in preparing adolescents and young adults for care in the ad...
What is typical presentation and time course for belimumab infusion-related depression and/or hallucinations, and how do you approach management?
As the reported occurrence of severe depression AEs is rare (<0.5%), one can not really ascribe a 'typical' presentation to depression occurring in the context of treatment with belimumab infusions. The reasons/mechanisms underlying the consistently observed increased incidence of this AE in both th...
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...
Do you always get a baseline chest xray in patients who will be starting methotrexate?
I believe it is a good practice for screening CXR before Mtx to document baseline findings, which will help to register if there is some baseline issues.
Is there any role for immunosuppressive therapy in patients with primary Sjogren's disease with severe pulmonary artery hypertension without ILD findings?
PAH (WHO Class I PH) in/and SJD is not a common relation, and as such would Rx as we Rx regarding PAH in PSS? The pathophysiology of PSS is, at least in part, a vasculopathy that SJD may not share. The question is, however, specific regarding Primary SJD and the assumption then is that this is not a...
What is your approach to screening for malignancy in dermatomyositis patients who do not have a high risk antibody profile and whose disease responds well to treatment?
This is a great question and one that is very relevant to our clinical practice. Different myositis specific and associated antibodies seem to carry different risks in their associations with cancer. My colleague, Dr. Alexander Oldroyd, has written our current guidelines on cancer screening for pati...
In light of recent measles outbreaks, have you adjusted your vaccination counseling or preventive strategies for adult immunocompromised patients?
Check measles antibody (once) in individuals working in public places, especially when working with kids.
How would you approach the treatment of an SLE patient with refractory mucocutaneous ulcerations and lichenoid skin eruption despite treatment with MMF, Aza, Benlysta, Saphnelo, Rituximab, and JAK inhibitors?
This is an interesting case and the co-occurrence of SLE and Crohn's disease is rare but not unprecedented. The first issue is if the mucocutaneous lesions are related to SLE or the IBD and oral lesions are well described in Crohn's disease. Second, although cutaneous manifestations of Crohn's disea...
How would you approach management of a patient with sJIA that was previously well controlled on tocilizumab but is now having ongoing joint disease activity?
Not sure what specifically was the intolerance to methotrexate; I personally only give it subcutaneously (more effective, bypass liver first from GI tract, better and more consistently absorbed, less GI side effects). I really like methotrexate with IL-1 blockade, as a subset of kids with sJIA go on...