Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach diagnosis in a patient with inflammatory joint symptoms and isolated bilateral CMC joint erosions on x-ray imaging?
This would be atypical for RA but not totally impossible. CPPD and psoriatic arthritis should be considered. In the absence of other joint involvement, erosive OA, although possible, seems unlikely. Is there a history of trauma or of peculiar activities? Is there evidence of psoriasis on either skin...
How do you interpret elevations in ESR and CRP in the setting of increased BMI?
Increases in BMI (overweight and obesity range) have been shown to be associated with elevated CRP and ESR, with stronger associations shown with CRP specifically. Interestingly, the association between elevated CRP and obesity seems to be stronger in female populations than in male patients.In the ...
How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?
This is a challenging scenario that we often see in clinical practice with our current multiplex assays. A great reference is the following ACR abstract: Clinical Significance of RNP Antibodies in Diagnosis of Systemic Autoimmune Rheumatic Disease When Detected By Multiplex Immunoassay. As demonstra...
How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?
Another important consideration is the methodology by which the anti-dsDNA antibody was assessed. Most commercial labs use EIA, which is sensitive but not as specific as Farr or Crithidia assays. Many positive EIA results are negative when checked by these more specific methodologies.
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...