Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?
As with most clinical scenarios, the short answer is 'it depends'. If a patient has cranial symptoms, elevated inflammatory markers, and suspicion for GCA is high, I do refer for temporal artery biopsy to help confirm the diagnosis. This is in line with guidelines from the American College of Rheuma...
How do you approach management of a patient with persistent EBV infection and MAS despite treatment with Rituximab, anakinra and canakinumab?
The (presumed) rationale for B cell depletion in EBV-associated MAS is to deplete infected B cells that are potential targets for cytotoxic T/NK cells that may have perforin pathway defects leading to excessive/prolonged cytokine release. Failure of the MAS to resolve with steroids/anakinra/rituxima...
Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?
I typically obtain both an ESR and a CRP in the workup of new onset or relapsing GCA. The CRP may be slightly more sensitive than the ESR based on Kermani et al., PMID 22119103 which demonstrated a sensitivity of 86.9% and 84.1% respectively for CRP and ESR, for a positive TAB. There is discordance ...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.
Do you routinely check G6PD level prior to initiation of hydroxychloroquine?
No, we do not routinely check G6PD levels prior to initiation of hydroxychloroquine (HCQ). The American College of Rheumatology does not recommend routine testing for G6PD prior to initiation of hydroxychloroquine (HCQ), but interestingly, package inserts often recommend caution in these patients. O...
Do you treat HIV/AIDS-associated CNS vasculitis with antiretrovirals alone or in combination with steroids?
This is a tough question and like most viral associated forms of vasculitis i.e., HCV, VZ, other... of unclear immunopathogenic mechanisms, it is approached empirically. Antiviral therapy is the cornerstone but at least short-term immunosuppression is generally needed in the acute phase as host medi...
How would you approach treating patients with RA refractory to cDMARDs and a prior history of MALT lymphoma?
If the concern is the risk of recurrence of lymphoma in a patient with RA requiring DMARD therapy, particularly biologic DMARD therapy, rituximab has not been associated with recurrence or even new onset lymphoma. Rituximab is a highly efficacious biologic DMARD for seropositive RA. This is consiste...
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
How would you approach initiating belimumab in a patient with serologic evidence of prior hepatitis B infection?
The patient in question is a patient who has serologic evidence of resolved hepatitis B infection. Of note, testing for hepatitis B is not a formal recommendation before starting belimumab. However, it is also important to point out that testing positive for hepatitis B was an exclusion criterion in...
Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?
I do not think there is a "right" answer to this question. First, I would want more evidence of distal renal tubular acidosis than urine chemistries. Specifically, I would do a urinary acidification test. If positive for distal RTA, and there is no other suggestion in the history or physical examina...