Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you reduce the risk of contralateral fracture in a patient with atypical femur fracture from prolonged bisphosphonate use?
While there are no published clinical trials treating AFF with anabolics, we have considerable experience taking care of AFF's. Between myself and two ANP's doing strictly bone health with a large group of orthos who manage a large percentage of fractures in the Phoenix valley, we unfortunately stil...
Do you correct the synovial fluid white blood cell count for red blood cells, and if so, is there a rough approximation/equation you use?
In a rheumatology practice, under most circumstances, there is no need to make a correction of the synovial fluid white blood cell count. The fluid is either translucent, transparent, or opaque and the count will help to establish the presence or absence of an infectious or inflammatory process and ...
What are the current treatment options for progressive multifocal leukoencephalopathy in patients without HIV/AIDS?
It depends on the underlying cause of the immunodeficiency that led to the PML. In cases of natalizumab-induced PML, this would involve stopping the drug immediately. There is controversy over whether or not to perform plasma exchange to hasten this. In some cases, this has provoked IRIS while in ot...
Would you use romosozumab in a patient with a cardiovascular event more than 2 years prior?
Frankly, knowing the data fairly well, I think the decision is a matter of style. Recall that the enhanced cardiovascular risk was only seen in the ARCH trial when romosozumab was compared to alendronate (leaving open the interpretation that alendronate reduces CV events, rather than romo increasing...
How would you interpret a temporal artery biopsy demonstrating focal chronic inflammation in the adventitia associated with small adventitial vessels and nerves without inflammation of the intima and media and without giant cells?
Peri-adventitial inflammation seen in temporal artery biopsies is generally a non-specific finding. This was demonstrated nicely in a recent histopathological study from Mayo Clinic evaluating temporal artery samples from autopsy cases. Over 40% of temporal arteries from older individuals (with no h...
At what point is a skin biopsy indicated in patients with neuropathy?
Skin biopsy is indicated when small fiber neuropathy is suspected- that is, a patient with usually painful paresthesias- positive sensory symptoms, and less often negative sensory symptoms alone, and normal EMG/NCS. Clinical exam usually, but not always, will show some signs of small fiber involveme...
What is your approach to monitoring for hepatic fibrosis in chronic methotrexate use?
Historically, in lower-risk patients (e.g. rheumatoid arthritis patients who are less likely to have metabolic syndrome and are treated with lower doses), guidance has been to proceed with liver biopsy if repeated tests show elevated liver enzymes or hypoalbuminemia. In higher risk patients, (e.g. p...
Do you have concerns with the use of oral contraceptives in patients on JAK inhibitors given the black box warning for thromboembolic events?
I would be concerned with the use of estrogen-containing OC especially in patients who are smokers, obese, and/or with a strong family history of CV disease. However, I know many rheumatologists who would still cautiously prescribe JAK inhibitors to these patients, particularly in the absence of add...
What suspected myositis manifestations drive you to start empiric therapy before the work-up is complete?
When evaluating a patient with myositis, I would consider starting immediate therapy when 1) my suspicion of myositis is high (i.e. characteristic rashes, compatible constellation of symptoms, very high CPK) and 2) the symptoms are severe. It would be the severity of the symptoms that would drive ho...
What is your approach to elevated CK in patients without clinical or serologic evidence of immune mediated myopathy?
Thanks for your great question: This is especially important because we are much more likely to see patients sent for "elevated" CPK than patients with myositis.Unfortunately, I think that the answer to the approach depends a lot the circumstances, including (1) how elevated is the CPK, and (2) how ...