Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you find MRI helpful to differentiate early erosive OA from psoriatic arthritis when early X-ray changes in both conditions may be hard to distinguish?
This is a great question to discuss. I do not in general let imaging dictate my decision about a diagnosis but factor it into the entire evaluation. I find the examination in conjunction with radiographs of the hands AND the feet help me sort out many of these issues. Symmetry, distribution, and par...
Do you use apremilast in combination with biologic DMARDs for psoriatic arthritis and/or psoriasis?
I have used apremilast in combination with a biologic in my practice. Monotherapy with biologics is not always effective in relevant treatment domains in patients with psoriasis and psoriatic arthritis. Then the choices are to switch to a different biologic agent, add a traditional DMARD or consider...
How would you approach management of incidentally identified unilateral retinal vasculitis with subsequent labs revealing +P-ANCA?
This anecdote raises at least 3 fascinating questions. First, how do you approach asymptomatic retinal vasculitis? Often a retinal vasculitis is defined by the dye, fluorescein, leaking from a retinal vessel on a study called a fluorescein angiogram. By this definition, pedal edema would be a pedal ...
Do you always aspirate effusions in patients with knee osteoarthritis prior to injecting hyaluronic acid?
There is strong biologic plausibility that one should always aspirate an effusion before injecting hyaluronic acid. Even a mildly inflammatory effusion will have an excess of white cells. White cells produce hyaluronidase. Hyaluronidase catalyzes the degradation of hyaluronic acid and renders it ina...
How do you manage a patient with severe RA or SLE that worsens after stopping immunosuppressants due to having chronic foot ulceration?
Fear the foot ulcer! These portals of entry for microorganisms can wreak havoc in immune-compromised patients. Rheumatologists must ensure that these lesions are being properly managed. Since healing can often be prolonged in some of our patients, the decision of whether and when to resume immune su...
Do you consider new onset autoimmune disease (e.g. seronegative rheumatoid arthritis) a few months after completing immunotherapy for cancer to be an immune-related adverse effect to the immunotherapy?
Yes, if there is no other features that suggest there is another etiology for the event. Immune-related adverse events (irAEs) can present after immunotherapy is stopped for at least one year and potentially longer. Consensus guidance (Naidoo et al., PMID 37001909) discusses delayed onset irAEs. If ...
What is your treatment approach for patients with MDA5-positive amyopathic dermatomyositis, who also have anti-CCP positive rheumatoid arthritis but no clinical lung involvement?
What clinical symptom or sign being treated is the key? If MDA-5 autoantibodies are associated with rash but no ILD or myositis, treatment should generally be directed at the skin. This is an active area of study. The presence of anti-CCP+ RA without ILD might prompt the use of rituximab given its p...
What is your approach to treating crowned dens syndrome?
Crowned dens syndrome is said to account for as much as 2% of acute neck pain. The diagnosis is mostly clinical. The patient will present with acute neck pain, elevated acute phase reactants, calcific deposits overlying the dens on x-ray or CT scan, and the lack of an alternative diagnosis. In >40 y...
What is your approach to management of chronic neutropenia in a patient with Sjogren’s who was recently diagnosed with metastatic endometrial cancer and plans to start chemotherapy?
With metastatic cancer, optimal treatment of the endometrial cancer is the priority. Heme/Onc consultant would likely be giving granulocyte stimulating products.Although neutropenia can occur in Sjogren's Disease (SjD), I rarely have found it to be clinically significant, and lymphopenia seems to oc...
Is there a reason to repeat HMGCR antibody level for monitoring disease activity once documented positive in patients with IMNM?
HMGCR antibody persists even when the disease is quiescent, and levels of the antibody correlate with the log of the CPK levels. Therefore, it is not a very sensitive marker for disease activity, so it is not a useful marker to follow longitudinally. Instead, CPK is a cheaper and more sensitive mark...