Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat corneal melt (in the absence of peripheral arthritis) in rheumatoid arthritis?
Corneal melt is a rare, but serious complication of rheumatoid arthritis. It usually occurs in patients who are sero-positive with active joint disease. A viral infection such as herpes simplex could cause a corneal ulcer that would mimic an immune-mediated melt. It is critical to communicate with t...
How do you approach incidental NXP-2 antibody positivity in patients without current clinical evidence of myositis or systemic autoimmune disease?
A positive anti-NXP2 antibody in an asymptomatic patient may indicate either a false positive or a subclinical form of dermatomyositis. The initial step is to review the testing method (e.g., ELISA, immunoblot). If possible, confirm the result with a different assay, ideally immunoprecipitation, tho...
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
How do you approach management of rheumatoid vasculitis (in this era)?
We don't see rheumatoid vasculitis very often nowadays. When our drug options for RA were limited, most patients had smoldering ongoing disease, which predisposed them to the possible development of a rheumatoid arthritis related vasculitis, though even then, cases were uncommon. Nowadays, our abili...
In a patient with known APS (triple positive) and interstitial lung disease (NSIP), how do you distinguish APS associated lung involvement from connective tissue disease related ILD?
Patients with APS typically have vascular and thrombotic pulmonary disease, and very rarely has interstitial disease been ascribed to APS. The most common pulmonary manifestation of APS is pulmonary embolism, occurring in 14-16% of patients, followed by pulmonary hypertension often caused by chronic...
Do you offer adjuvant radiation therapy for a breast cancer patient with dermatomyositis?
This is an exceptionally important question for clinicians. I'm a little biased as I run an autoimmune Myositis Clinic, but here are my two cents: Paraneoplastic dermatomyositis (DM) is a fairly common occurrence (roughly about 15% of all DM cases, but up to 30-40% in some subtypes, such as adult pa...
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
Would you consider combining voclosporin and obinutuzumab for pure Class V lupus nephritis?
I agree with @Dr. First Last. Changing his regimen is indicated since target proteinuria (<700 mg/day by 1 year) has not been achieved, and renal biopsy shows ongoing active inflammatory class V (very smart to get that biopsy, by the way!).Obinituzumab (OBI) is the better choice than belimumab in pa...
How would you approach rituximab dosing in a patient with SLE-Myositis overlap with LN Class III, now with worsening UPCR and concern for worsening ILD 4 months post induction and incomplete B-Cell depletion on recent labs?
This is a challenging and concerning situation, as the patient is declining after rituximab. Without knowing which other medications have been tried, I would prioritize medications targeting life-threatening manifestations, i.e., the LN and ILD. In that case, I would start treatment with steroids, m...