Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...
How would you approach treatment of active inflammatory arthritis in a patient with MCTD (+RNP/+Chromatin) and stable ILD who has failed MMF, azathioprine and methotrexate?
I'd think about Actemra to treat both ILD (with the scleroderma approval) and arthritis.
Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?
We don't have any evidence that immunosuppression (assuming that is what you are referring to) would play a role in the treatment of the esophageal disease or the Raynaud phenomenon. Also, we don't have any data to suggest that this would have any overall long-term "disease-modifying" effects. So in...
How would you treat a young patient who presents with coronary vasculitis and aortitis with persistently positive MPO but no other features of AAV?
Once infectious causes such as syphilis have been excluded, the most common causes of the combination of aortitis and coronary vasculitis would be Takayasu arteritis and IgG4RD. However, AAV can cause both aortitis and coronary vasculitis (albeit infrequently). Therefore, if there are no features of...
How would you approach rheumatoid arthritis treatment for widespread large rheumatoid nodules but no active synovitis or subjective joint pain?
One needs also to consider drug-induced accelerated nodulosis. I used to see it more often in the 1990s from methotrexate, but since then, it has also been described with other drugs like TNF inhibitors and leflunomide (Patatanian & Thompson, PMID 12222551, Ahmed et al., PMID 11470988, Akiyama et al...
How would you approach a patient with new temporal headache, temporal artery tenderness and TA biopsy with mild thickening, but normal inflammatory markers?
Some more information is needed. Is this bilateral or unilateral and if the latter is there a potential other cause? Was this patient started on prednisone for presumed GCA prior to obtaining the temporal artery biopsy and if so how long before? When were the “inflammatory markers” measured relative...
How would you manage a case of subcutaneous panniculitis-like T cell lymphoma (A/B) who is already on steroids and methotrexate for autoimmune disease?
First, I would want to be assured that the diagnosis is truly panniculitis T cell lymphoma and not lupus profundus. The two can be hard to differentiate microscopically with T cell gene rearrangement positive in the lymphoma. If the diagnosis is lupus profundus, this would be managed as per rheumato...
In which patients with suspected IgA nephropathy and microalbuminuria would you recommend a kidney biopsy?
There are no guidelines to answer this question. This is my approach. In proteinuric patients, with intact kidney function, threshold proteinuria (UPCR) of 0.5 g/g, or UACR <300 mg/g would be an indication to biopsy. In diseases such as IgA Nephropathy, treatment is driven by the degree of proteinur...