Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider rituximab in a patient with severe GI dysmotility caused by scleroderma?
Severe GI dysmotility due to scleroderma remains refractory to most therapies. The rationale for recommending rituximab (RTX) in this setting is based on its use in rare cases of autoimmune gastrointestinal dysmotility syndrome (AGID) that appear to have a paraneoplastic basis. There are scattered c...
How would you approach management of a patient with checkpoint inhibitor induced psoriatic arthritis?
We will often try a short course of steroids if this is new psoriatic arthritis due to immune checkpoint inhibitor therapy. We then consider a DMARD like methotrexate or biologic. If biologics are needed, we will typically choose an IL-12/23 or IL-23 inhibitor or a TNF inhibitor.
Do you ever consider discontinuing hydroxychloroquine in patients with SLE in longstanding remission except in cases of overt toxicity?
I’ll assume that this question is only for SLE patients who are tolerating it well, have been in remission, and are not on steroids or other immunosuppressants (since hydroxychloroquine, HCQ, is safer than all of these).Since very few things in medicine are 100%, the answer must be “yes.” However, 9...
Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?
Joint replacement surgery can be done in patients with Paget's disease. There should be no problem particularly if the patient has been treated to suppress disease activity. The best treatment is a 5 mg intravenous infusion of Recast which can suppress disease activity for 5 years or more.
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.
How would you approach additional workup and management of a patient with active Crohn’s disease, who has multiple lung and brain nodules, with lung pathology demonstrating necrotizing granulomatous inflammation and brain biopsy with granulomatous inflammation and medium-large vessel vasculitis?
This is a great question and a challenging case. Further workup would depend on the clinical presentation and the risk factors of this particular patient, however, I will outline some broad considerations centered around questions I would consider in a similar case. Has Crohn's disease been definit...
How do you approach treating mild hypercalcemia in patients with sarcoidosis?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Pulmonary hypertension (PH) associated with sarcoidosis presents a complex clinical challenge. The decision to use corticosteroids in sarcoidosis-associated pulmonary hypertension depends on several factors: Underlying Cause of PH: It's crucial to determine whether the pulmonary hypertension is dir...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.
How do you dose steroids in neurosarcoidosis patients with a worsening clinical symptoms or MRI findings?
The route of dosing of glucocorticoids for neurosarcoidosis typically depends on the severity of illness and symptoms. For example, significant CNS involvement on imaging or patients presenting with AMS, weakness, vision changes/loss, or seizures would benefit from IV methylprednisolone followed by ...