Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When would you administer the next maintenance dose of rituximab in a patient with ANCA glomerulonephritis who last received an infusion six months ago and has low immunoglobulin levels and an undetectable CD-19 cell count?
If an ANCA vasculitis patient is in remission and has no infections, I usually in clinical practice do not check Immunoglobulin levels or CD19/20 levels either. They should only be done in patients with recurrent sinus infections or Pneumonia. If the patient with recurrent infections has low Immunog...
What is your treatment approach for pregnant patients with IgA nephropathy who have worsening proteinuria during the first trimester?
Difficult question to answer without more details, but I would consider the following factors: One is whether it appears that the IgA is active. When was the last biopsy, and how much hematuria is present? Two would be if this is 'worsening proteinuria' is really just the first time proteinuria has ...
How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?
This is a complex problem for which any response clearly is not data-driven. Disseminated VZV is a profound illness and is linked to JAKi exposure. While the majority of VZV is 'mild' all complications are increased in this setting and dissemination is among the most serious and potentially fatal co...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?
The answer is "Yes and No."@Dr. First Last: I am so glad you asked this question. I once observed a speaker give incorrect information on this topic with an answer of "yes."The quick answer, is that the AVISE Lupus Test (which uses EC4d and BC4d) result does NOT give a "yes" or "no" answer for someo...
After completing 12 months romosozumab, what is the next best treatment option for patients with severe osteoporosis, high risk for fracture, and normal kidney function?
Zoledronic acid is my clear-cut first choice in this setting.
What features on CTA/MRA are most helpful for differentiating large vessel vasculitis from atherosclerosis?
While calcified plaque is not typically mistaken for large vessel vasculitis, distinguishing non-calcified atherosclerotic lesions from large vessel vasculitis is challenging. An experienced vascular radiologist is an invaluable resource in such situations if available. The first step is to assess ...
How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?
This is an unusual but anxiety-inducing situation. Remember that an "indeterminate" Quantiferon is not an "intermediate" Quantiferon. It's not half-positive, it's uninterpretable. The result provides absolutely no reason to be more or less concerned that the patient has lTB, latent or otherwise. I a...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
What is your approach for disease activity monitoring in patients with sarcoidosis?
Disease activity monitoring is useful in managing therapy and prognostication in sarcoidosis. Since the disease activity can vary across different organ systems, it can be a challenge. Broadly, good bio-markers of overall disease activity are lacking in this disease.ACE level lacks the sensitivity b...