Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...
Have you utilized denosumab in treatment of erosive hand osteoarthritis?
I have not prescribed denosumab for patients with erosive hand osteoarthritis. While the 2024 double-blind placebo-controlled trial suggested that this RANK ligand inhibitor may have structure-modifying effects by inducing remodeling and preventing new erosions, the phase 2a study of 100 patients di...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
How do you treat a patient with new class V lupus nephritis and recent hx of breast cancer on tamoxifen?
The 2024 ACR and Kidney Disease Improving Global Outcomes (KDIGO) lupus nephritis treatment recommendations are excellent, and I tend to treat my patients similarly to their recommendations.NOTE: The KDIGO guidelines are excellent! Consider downloading them.Regarding the history of breast cancer and...
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
How do you manage inflammatory back pain when X-rays and MRI show no evidence of sacroiliitis?
While a normal MRI makes the diagnosis of axial spondyloarthritis unlikely, it doesn’t completely rule it out. This is specifically true in patients with inflammatory back pain or other features of spondyloarthritis. While classification criteria definitely should not be used for diagnosis, it is he...
Do you offer antibiotic therapy for patients with a chronic joint infection, with no plans for surgery, and with an open draining sinus tract?
I think this depends on (1) the organism, (2) the host - if he/she is immunocompromised or not, and (3) if the patient is symptomatic. Generally, if the patient has a draining sinus tract that is stable and is not causing any fevers, chills, leukocytosis, etc., then I would favor not treating, as tr...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
What is your approach to induction therapy and maintenance therapy for patients with autoimmune hepatitis?
Depending on the severity - if severe injury with jaundice, I admit for IV solumedrol. On an outpatient basis, will do prednisone 40mg daily - repeat labs in 1 week and if improved, start Imuran 2 mg/kg (up to 200 mg daily; TPMT testing has to be ok - otherwise will do MMF 500 mg daily and increase ...