Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach patients referred for C1-2 pannus/erosions without clinical findings or serologies consistent with RA or CPPD arthropathy?
This is a most unusual clinical scenario. Rheumatologists are taught to image the C1-C2 area in patients with longstanding RA and persistent neck pain with or without accompanying myelopathic features. Therefore, a situation where the patient remains totally asymptomatic is quite uncommon. In addit...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...
What are your management strategies for patients with biopsy proven IgA nephropathy with rapidly progressive glomerulonephritis?
In adults, I believe these patients should be treated similarly to other patients with RPGN. I would start out with high dose steroids, then move to possibly rituximab versus possibly cyclophosphamide shortly afterwards if no response to steroids alone.
What is your treatment approach for a young female who has an idiopathic small right elbow effusion with synovial thickening that has resulted in limitation in her range of motion?
I might aspirate the joint, send for gram staining, cell count, culture, and crystals, check serology to rule out autoimmune like RA or lupus, tick-born disease, and X-ray the joint. If all is negative, consider a short course of steroids, even synovectomy.
What is your preferred add-on for membranous lupus nephritis (2.2 grams of protein, normal creatinine) in a young woman who is currently on hydroxychloroquine and mycophenolate 1500 mg 2x daily?
Persistent proteinuria in patients with any ISN/RPS class of LN is problematic recognizing goal is to achieve EULAR targets of uPCR < 25% at 3 months, < 50% at 6 months, and < 0.5 - 0.7 at 12 months compared to baseline. Proteinuria is renal tubulointerstitium toxic inducing pro-inflammatory and fib...
Is there a minimum work-up necessary in patients with an ANA greater than 1:160 and no clinical symptoms suggestive of lupus (i.e., specific antibodies, UA)?
My personal practice has been to get the "ANA subtypes" and a UA for prot/Cr ratio, but I do this with the idea of needing to have a complete picture. Clinical symptoms are still king.
What is your approach to evaluation in patients who present with erythromelalgia?
Erythromelalgia is a tough condition to treat. I usually break it down into diagnostic workup and treatment as follows: Diagnostic workup: I usually just get a CBC yearly to look for myeloproliferative disorders. Treatment: I have not had a lot of luck with topicals being too effective, so I usuall...
When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?
The evidence behind starting anti-fibrotic therapy for non-IPF ILD is largely based on the results of the INBUILD trial where patients who have non-IPF ILD who demonstrate progression (based on at least a 10% decline in FVC or a 5% decline in FVC with worsening symptoms or radiologic progression) ha...
If you have clinical suspicion for a paraneoplastic process (e.g. dermatomyositis or pemphigus), what work-up do you pursue?
This continues to be a topic of high interest. The first-ever evidence and consensus-based recommendations were recently drafted by an expert international committee under the auspices of the International Myositis Assessment and Clinical Studies (IMACS) group (in preparation). These recommendations...
How would you approach potentially tapering maintenance mycophenolate mofetil in a patient with a history of class IV LN that has been in remission for >5 years?
I would tell her, absolutely, and I'm sorry I did not consider this 2 years ago after being in remission for 3 years. ;-) I then proceed to explain the options and make a shared decision-making process. CHOICE 1 (my recommendation): A significant enough lupus nephritis patients are not in true patho...