Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you screen for cardiac disease in patients with dermatomyositis in the absence of symptoms?
I don't typically evaluate for cardiac disease in patients with dermatomyositis who are not symptomatic. There are subtypes of myositis patients where cardiac involvement is more common (such as those with antimitochondrial antibodies and anti-SRP antibodies), and there it may make sense to keep a c...
How do you approach the management of recurrent episcleritis in a patient with RA that is otherwise well-controlled?
The episclera lies on top of the sclera. The majority of patients with episcleritis do not have a systemic disease, although patients with rheumatoid arthritis are more prone to develop episcleritis. Episcleritis must be distinguished from scleritis, which is also associated with rheumatoid arthrit...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
How do you approach anticoagulation in a woman with SLE who is planning pregnancy, has persistently positive isolated anticardiolipin IgA and anti-β2 glycoprotein I IgA antibodies and a prior history of a provoked DVT after prolonged air travel?
Such a patient with IgA isotype APL antibodies would not meet EULAR – ACR classification criteria for antiphospholipid syndrome. However, there is evidence that IgA anti-Beta 2GP1 can be pathogenic. Therefore, this patient can meet less stringent disease classification and be considered a candidate ...
If a patient is legally blind and on hydroxychloroquine, do you still recommend follow up with ophthalmology to monitor for hydroxychloroquine retinal toxicity?
A patient who is legally blind but taking hydroxychloroquine absolutely needs to be monitored by an ophthalmologist. The usual definition of legal blindness in the United States is vision no better than 20/200 in the better-seeing eye. But 20/200 is far better than say counting fingers (the ability ...
In a patient with persistent symptoms of Lyme arthritis after initial treatment course with oral antibiotics, do you prefer a second course of oral antibiotics or do you frequently offer a course of IV ceftriaxone?
Patients diagnosed with Lyme arthritis should receive a 28-day course of oral antibiotics, preferably doxycycline. If patients achieve at least a partial response, a second course of oral antibiotics may be given. However, in patients with minimal to no response following the initial course of oral ...
How do you utilize tools such as MMT8 in clinical practice when evaluating myositis?
We test hip flexors in every patient as well as the traditional muscles tested in MMT-8. I agree that it is not ideal that MMT-8 does not include these muscles. In fact, we test all large muscle groups - UE and LE as well as the finger flexors and extensors for complete assessment - then extrapolate...
What is your approach to treating IgA nephropathy in patients who also have IgA vasculitis?
In a patient with known IgA Vasculitis [IgAV], IgA dominant pattern of injury in the kidney biopsy reflects IgA Vasculitis with Nephritis [IgAV-N]. Thus, it would not be appropriate to call it IgA nephropathy [IgAN] in IgAV. Though the histological features in IgAN and IgAV-N can be common in the ki...
Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?
Not all EDS is the same. Most commonly, an EDS patient these days is a clinically diagnosed patient with hypermobile joints, possibly stretchy skin, and possibly chronic pain syndrome. That is a very different picture from vascular EDS with a COL3A1 mutation, which is rare and would have the extreme...
When do you consider certolizumab for pregnant women with antiphospholipid syndrome with positive lupus anticoagulant?
Certolizumab is a TNF-α antagonist with minimal or no transfer across the placenta. It was evaluated in the phase 2, open-label IMPACT (Improve Pregnancy in APS with Certolizumab Therapy) trial to prevent placenta-mediated adverse outcomes in pregnant patients with antiphospholipid antibody syndrome...