Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach the work up of pulmonary artery aneurysm in the absence of other clinical features of Behcet’s?
While Behçet’s disease (BD) is one of the most well-recognized causes of pulmonary artery aneurysms (PAA), it may not be the most common one globally. In scenarios where a careful history, exam, and vascular imaging don’t reveal other BD-compatible findings, other conditions can be more likely. It i...
Do you routinely obtain baseline vascular imaging (CTA, MRA, PET) in patients with suspected GCA, but negative temporal artery biopsy?
Vascular imaging is particularly helpful in patients with large vessel giant cell arteritis. This patient subset may present with persistent constitutional symptoms, refractory polymyalgia rheumatica, fever of unknown origin, or with vascular signs/symptoms (for example arm claudication). These pati...
What is your approach for cancer screening for elderly onset RA?
For elderly onset RA, I would ensure that they had had all age-appropriate preventive malignancy screening with mammography, colonoscopy, PSA, and PAP smear, and in smokers or history of significant tobacco use, I would order low-dose CT screening for lung cancer. In those individuals with constitut...
Is there evidence for development of more severe autoimmune toxicities for young patients vs older patients on immune checkpoint inhibitors?
I am not aware of any. In my practice, I have realized that younger patients are getting more severe autoimmune toxicities like immune-related cardiomyopathy and adrenal insufficiency.
How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?
The distinction between pulmonary hypertension (PH) of the group 1 (pulmonary arterial hypertension (PAH)) and group 3 (pulmonary hypertension (PH) due to lung disease and/or hypoxia) is essential since the management is different. In group 1 PH we stratify the risk and treat with a variety of PAH-s...
Do you feel comfortable combining mycophenolate mofetil with azathioprine in patients with lupus?
Aggressive immunosuppression is occasionally indicated for patients with lupus. Examples include refractory lupus nephritis, lupus with secondary CAPS, refractory immune-mediated cytopenia, etc. Treatment options often consist of high-dose steroids with at least one other immunosuppressive agent. Ad...
In a pediatric patient diagnosed with orbital sarcoidosis (dacryoadenitis) on biopsy, would you recommend completing evaluation for pulmonary sarcoidosis and neurosarcoidosis?
Presumably, the biopsy reveals non-caseating granulomas. Chronic dacryoadenitis can be seen in a variety of settings, including ANCA-associated vasculitis, Sjogren, IgG4-related disease, Crohn's disease, Lyme disease, tuberculosis, EBV, etc. Additional sarcoidosis workup will in part depend on other...
What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?
The diagnosis of cardiac sarcoidosis (CS) can be challenging, as non-necrotizing granulomatous inflammation is frequently patchy, and as a result, may not be present on endomyocardial biopsy even in the setting of active cardiac disease. Many institutions, including ours, attempt to avoid endomyocar...
Is febuxostat a safe alternative for patients who are HLA-B*58:01 positive and of Han Chinese descent?
Cutaneous reactions to allopurinol range from the mild to the very severe and life-threatening such as Stevens-Johnson's Syndrome (SJS) and toxic epidermal necrolysis. The association of these reactions is so strong as to have its own acronym, AHS, for the allopurinol hypersensitivity syndrome.These...
Do you generally recommend low dose aspirin for patients with giant cell arteritis?
I generally do not use aspirin routinely in patients with GCA. While several retrospective series suggested a benefit to ASA for preventing ischemic complications in GCA (e.g. Nesher et al., PMID 15077317), this data is limited by its retrospective nature, small numbers, and significant confounding....