Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with MPO-positive isolated peripheral nerve vasculitis?
AAV can present with a peripheral neuropathy as a first manifestation. The first question we're often facing is whether a biopsy is necessary. If the neuropathy pattern is one of mononeuritis multiplex and there are no atypical features or other atypical serologic findings, I sometimes forego nerve ...
How will you adjust your approach to steroid taper in patients with PMR also on sarilumab?
I would try to replicate the prednisone taper followed in the SAPHYR study that weaned patients off over 14 weeks, understanding that there may be patients that won’t be able to taper the prednisone so aggressively or may benefit, in the opinion of the treating physician, from longer tapers (e.g., 4...
In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?
How do you approach management of a patient with Sjogren's disease and lung mass biopsy revealing amyloidosis?
A lung mass showing amyloid in SjD may reflect systemic amyloid or local/focal amyloid. Interdisciplinary assessment is recommended (Fraenkel et al., PMID 34101376). Organ systems involved will guide the expertise needed.Immunohistochemistry and molecular studies are needed to define if there is an ...
What are the principal clinical and laboratory findings that lead a community rheumatologist to refer patients with scleroderma and lupus to a tertiary care center?
From the standpoint of scleroderma or lupus, tertiary care centers are more likely to get referrals from physicians caring for patients with complex, progressive, or refractory disease, though all consults are welcome. I will focus on the scleroderma (a.k.a. systemic sclerosis) aspect of this questi...
How would you approach the work up of a patient with nasal septal perforation, a negative infectious workup, and negative ANCA titers?
This clinical scenario can be difficult for the rheumatologist to evaluate, and close collaboration with colleagues in ENT would be essential. Causes of nasal septal perforation include trauma, infectious etiology, and autoimmune conditions such as granulomatosis with polyangiitis or microscopic pol...
Is whole body PET scan sufficient to rule out cardiac involvement in sarcoidosis?
Whole-body PET scans, particularly using 18F-fluorodeoxyglucose (FDG), play a significant role in evaluating sarcoidosis, including cardiac involvement. Recent studies have investigated the effectiveness of whole-body PET scans in diagnosing isolated cardiac sarcoidosis and assessing both cardiac an...
Would you use TNF inhibitors in patients with features of SLE, but active peripheral and axial spondylarthritis?
I can understand Dr. @Dr. First Last's hesitancy as there is no good literature to prove one way or the other. This is one of those questions which will have practitioners on both sides of the answer.However, I would not hesitate for several reasons:In the early 2000s, before we had better txs avail...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
How do you manage patients with early stage breast cancer with autoimmune disorders such as rheumatoid arthritis and collagen vascular disorders?
The historical perspective has been to treat in 180 cGy daily fractions to a total dose of 45 Gy with a tumor bed boost (assuming the need) to 50-55 Gy based on intrinsic increased radiosensitivity of normal and tumorous tissues. It is unclear whether this dose-fractionation schedule is effective be...