Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
Would you consider a biologic or JAK inhibitor to manage active PsA in a patient on chronic antibiotic therapy if they had previously failed all conventional DMARDs (including apremilast)?
IL-23i such as guselkumab have not really shown a significantly higher incidence of infections or malignancies, so I would favor these over other biologics. Ustekinumab (IL-12,23i) also showed lower rates of infection compared with other biologics. However, something to consider is whether they have...
How would you approach a patient with GCA who develops necrotizing fasciitis and then flares because they are off of tocilizumab?
While recurrent necrotizing fasciitis is exceedingly rare, patients with necrotizing fasciitis may be at higher risk for other infections. Therefore, a careful risk/benefit analysis is warranted in such a case, similar to other cases of serious infections in patients on immunosuppression. The specif...
What is your approach to the management of patients with isolated cervical adenopathy related to sarcoidosis?
Establishing a diagnosis of sarcoidosis solely on the basis of isolated cervical adenopathy can present a challenge. Although thoracic adenopathy—alone or in combination with other extra-nodal clinical features—is part of the classic illness script for sarcoidosis, peripheral adenopathy as the exclu...
Would one year of steroids for JRA during teen years (with subsequently well-controlled autoimmune disease) be sufficient to explain a vertebral T score of -4.4 of a woman in her early 50s without any other risk factors?
This is a tough question. It is clear that teenage years with GCs would impact peak bone mass, however not to this extent. A T score of -4.4 is the result of a low peak bone mass, genetics, and factors that affect the bone mass between ages 25 to 30. I would put forth part of the low BMD is from GC ...
What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?
This is by far the hardest task assigned for a practicing rheumatologist. Inheriting a patient on a regimen you did not develop and are uncomfortable continuing poses a daunting challenge: you are challenging the patient’s relationship with the previous rheumatologist, the control of the patient’s d...
If a patient with relapsing remitting MS has comorbid Sjogren's syndrome and is on hydroxychloroquine (Plaquenil), how does that impact choice of DMT for MS?
A patient's pre-existing use of hydroxychloroquine (HCQ) has not impacted my decision on MS DMT. HCQ should not overlap with other DMT mechanisms of action, so the implication on more infections/malignancies is thought to be low. However, the need for additional immunomodulating agents for Sjogren's...
What additional therapies would you consider in a pregnant woman with Bechet's on an antiTNF and azathioprine who has uncontrolled non-pulmonary large vessel vasculitis?
BD often improves with pregnancy, so this scenario is not typical but certainly possible. Revising the diagnosis may still be worthwhile. In any case, checking anti-TNF through levels and testing for anti-anti-TNF antibodies seem reasonable as the first steps. Increasing the anti-TNF dose and dosing...
Would atypical fractures of the hip in a parent (treated with bisphosphonate) be considered when calculating the FRAX score for a patient with osteopenia?
There is no data regarding this question so my response is only my opinion. I would not include a parental hip fracture secondary to bisphosphonate use in the FRAX prediction model since such fractures are not (by definition), typical hip fractures (femoral neck or intertrochanteric regions). Howeve...
How would approach the management of a patient with significantly positive anticardiolopin and beta 2 glycoprotein antibodies in the absence of any clotting (including obstetric) history but with significant thrombocytopenia (but no other features of active connective tissue disease)?
I would first evaluate for other causes of thrombocytopenia (most of them can also result in positive APL antibodies): CTD, medications, liver disease, pregnancy, malignancy, splenomegaly, etc.I would not treat stable asymptomatic thrombocytopenia.If worsening/symptomatic, I would treat like any oth...