Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Have you seen rheumatoid nodules or RA-ILD in patients with seronegative RA?
By definition, rheumatoid nodules are considered to be a highly specific manifestation of RA. Regarding the first part of the question, one should never see true rheumatoid nodules in someone who does not have seronegative RA. Though there are sporadic case reports of finding these nodules in people...
In light of findings from GOG 258, is the benefit of adjuvant RT in IIIC endometrial cancer worth the potential acute and late risks of RT in the setting of significant autoimmune disease?
I agree with the thoughtful answers of others in terms of tailoring therapy and balancing risk/benefit. In this case, however, GOG 258 answered the value of doing radiation on top of chemotherapy for any patient that met its criteria. And in this case, it included 75% that indeed had stage IIIC dise...
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...