Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When do you prefer bariatric surgery such as sleeve gastrectomy or gastric bypass over an initial trial of a GLP-1 receptor agonist in patients with severe obesity and painful knee or hip osteoarthritis?
I believe that this type of decision should be made by obesity specialists and not by rheumatologists. However, we can anticipate that the patient's choice is paramount: some prefer radical options such as surgery, while others cannot bear to hear about it. The decision should only be made through d...
How do you approach the management of inflammatory arthritis in a patient with Sjogren’s disease who is unable to tolerate or take methotrexate, leflunomide, or hydroxychloroquine?
Would consider a B-cell targeted agent. Currently, rituximab which was included in the 2017 MSK and biologic guidelines (Carsons et al., PMID 27390247) for SjD inflammatory arthritis.Serum level of BAFF is elevated in SjD, so an anti-BAFF agent, like belimumab, could be considered.Have avoided use o...
What immunosuppressant will you choose in a patient with necrotizing myopathy partially responding to IV steroids and IVIG with a history of non Hodgkins lymphoma?
The decision should be taken in collaboration with the patient’s oncologist; however, Rituximab would be a reasonable choice to add given that IMNM generally responds well to it (particularly anti-SRP) and that it has a favorable safety profile concerning malignancy.
Do you continue PJP prophylaxis indefinitely in patients on rituximab maintenance therapy?
Risk for PJP infection is usually in the context of moderate-high dose corticosteroid therapy or low T cell counts.
Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?
The answer is "Yes and No."@Dr. First Last: I am so glad you asked this question. I once observed a speaker give incorrect information on this topic with an answer of "yes."The quick answer, is that the AVISE Lupus Test (which uses EC4d and BC4d) result does NOT give a "yes" or "no" answer for someo...
In patients with anti-PL7 antibody–associated antisynthetase syndrome, can sacroiliitis occur as part of the inflammatory arthritis spectrum, or should alternative causes be considered?
A review of the literature on large cohorts of antisynthetase syndrome does not report sacroiliitis as a feature, but rather, inflammatory arthritis similar to rheumatoid arthritis (with or without RF and CCP) is described. Therefore: It is important to confirm whether the PL-7 result is truly posi...
Do you offer antibiotic therapy for patients with a chronic joint infection, with no plans for surgery, and with an open draining sinus tract?
This is a complex question that requires a nuanced answer. I am assuming this is a periprosthetic joint infection. If so, why is there no plan for surgical intervention—is this because the patient’s care is comfort-focused? How old is the patient? What is the microbial etiology, and is it even amena...
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...