Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do elevated neutrophils in the bronchoalveolar lavage of patients with sarcoidosis have any prognostic value?
Neutrophils in the alveolar space are uncommon in healthy non-smoking individuals, accounting for around 1% of cells in bronchoalveolar lavage (BAL). Macrophages compose 80–90% of the cells policing the alveolar surface, with the remaining cells being lymphocytes, rare eosinophils, and basophils. A ...
Would you stop romosozumab if a patient developed mild asymptomatic hypocalcemia while on treatment?
Mild hypocalcemia was noted during the pivotal clinical registration trials and thus is not too surprising. The reason for the hypocalcemia is not entirely clear but may have to do with blocking sclerostin's stimulatory effect on osteoclasts and/or calcium being "soaked up" by the massive rapid new ...
How do you counsel and manage patients with chronic pain conditions such as fibromyalgia or osteoarthritis who are taking centrally acting agents (gabapentin, duloxetine) and are planning to use or self administer psychedelics for symptom management?
Interesting query since some studies do suggest that psychedelics may be useful in treating chronic pain, and their mechanism of action regarding neuroplasticity is similar to approved centrally acting agents, like duloxetine. I would first review the limited role of medications in chronic pain and ...
How do you approach an isolated positive anti-Scl-70 antibody in a patient with no symptoms or exam findings suggestive of systemic sclerosis?
We see this often in the clinic, and it is usually a false-positive test. False-positive anti-topoisomerase I (Scl-70) results frequently occur with commercial immunoassays (ELISA/Multiplex), often leading to misdiagnosis of systemic sclerosis. In our practice, we repeat the test using immunodiffusi...
When, if ever, would you consider methotrexate over prednisone for first line therapy in patients with pulmonary sarcoidosis?
The PREDMETH trial supports the use of methotrexate for initial therapy for sarcoidosis. Future studies may identify subgroups that may benefit from the concurrent use of prednisone initially; it is unclear how soon methotrexate may provide symptomatic relief compared to the ability of an appropriat...
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...
Would you consider using avacopan in PR3+ mononeuritis multiplex without other systemic involvement?
I would certainly consider using avacopan in AAV mononeuritis multiplex. While we don't know the outcomes of mononeuritis in avacopan-treated patients specifically, ~20% of patients in the ADVOCATE trial (Jayne et al., PMID 33596356) had neuropathy and the outcomes overall suggest a robust response ...
Do you generally pursue a temporal artery biopsy in a patient who has a halo sign on ultrasound but has an atypical clinical presentation of GCA with normal inflammatory markers in the setting of persistent temporal headache?
This is an important question, and the answer would depend significantly on the details of the presentation. In general, with a highly atypical presentation such as this with normal inflammatory markers AND atypical symptoms, I would pursue TA biopsy and consider large vessel imaging if negative. Wh...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...