Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach differentiating infectious vs inflammatory tenosynovitis?
Infectious tenosynovitis is boggy and very tender. Inflammatory tenosynovitis is less tender.
How would you manage scleritis perforans in a patient with seropositive rheumatoid arthritis/scleroderma overlap?
Scleromalacia perforans is a rare but sight-threatening disease that is often associated with seropositive RA. It has become less common, presumably due to more aggressive management of RA and newer medication options. Prior to biologics, it was often managed with oral prednisone and/or cyclophospha...
Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?
There seems not to be a consensus literature on this topic, so my answer is based on common sense rather than science. The first step is a detailed history (including family history) and physical examination looking for evidence of inflammatory joint disease with/without other findings that might fo...
Do you use anti-DFS70 Ab to help reduce the posttest probability of ANA-positive patients having a systemic autoimmune disease if other autoantibodies are negative?
I agree with Dr. Dixit that any lab test, especially an autoantibody test, has to be taken in context with the clinical features and other lab features. Our laboratory does not run this test as part of our serologic profiles. It may be reassuring to the clinician and patient that it is likely they d...
How do you specifically counsel patients on conservative measures such as hand warming in the treatment of SSc associated digital ulceration?
While Raynaud’s is nearly universal in Systemic sclerosis, digital ulcerations occur in approximately 30% of these patients yearly and tend to recur, with 2/3rd developing another one despite the use of vasodilators. Irreversible tissue loss, osteomyelitis, gangrene, and amputation are unfortunate c...
What is your approach to checking IgG levels post vaccination to detect common variable immunodeficiency in patients with systemic lupus?
I recommend that this type of workup for primary immunodeficiency disorders be done as soon as a diagnosis of systemic lupus erythematosus (SLE) is made. In other words, order quantitative immunoglobulins (IgA, IgM, IgG) plus IgG subclasses during your initial workup.Reasons being: Some primary immu...
How do you approach the usage of hydroxychloroquine in patients with rheumatologic conditions and baseline cardiomyopathy or heart failure?
This is an excellent and difficult question that parallels the recent posted question about the use of hydroxychloroquine (HCQ) in someone with an abnormal visual field. There is no question that HCQ can cause cardiomyopathy. There is no question that HCQ can prolong the QT interval. Fortunately, ca...
In a patient with APS and obesity during pregnancy when switched to LMWH, do you cap the dose of dalteparin as per manufacturers labeling at 18,000U per day or do you use weight based dosing?
Hi @Dr. First Last, We use enoxaparin in our institution, but the general principle that we follow is that we do not cap LMWH dose at a set threshold. I am assuming that you're referring to thromboprophylaxis and not the management of a VTE in the past 6 months. We monitor anti-Xa levels in obese p...
What is your approach for induction therapy in dual positive anti-GBM/PR3 disease with ESRD presenting with recurrent DAH previously treated with cyclophosphamide?
Most patients who are double positive for ANCA and anti-GBM antibodies relapse with AAV rather than anti-GBM disease. The rate of relapse in single positive anti-GBM disease is very low, estimated at around 2% by some experts. This is in contrast to double-positive patients who have a relapse rate s...
What is your approach to treatment of skin-limited cryoglobulinemic vasculitis in patients with Sjogren's syndrome who lack evidence of neurological or renal involvement?
I have given this patient Rituximab prior with success.