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...
Is there any expanded diagnostic workup that you pursue for a young female patient with gout?
In 45 years of practice, and with a strong focus on gout, I can count the number of premenopausal women with gout I’ve seen (or, perhaps better stated, recognized) on one hand. Of the last two, one had chronic renal failure due to acute kidney injury incurred secondary to an alcoholic binge a few ye...
Is there any role for immunosuppressive therapy in patients with primary Sjogren's disease with severe pulmonary artery hypertension without ILD findings?
PAH (WHO Class I PH) in/and SJD is not a common relation, and as such would Rx as we Rx regarding PAH in PSS? The pathophysiology of PSS is, at least in part, a vasculopathy that SJD may not share. The question is, however, specific regarding Primary SJD and the assumption then is that this is not a...
How do you time concurrent therapy with rituximab and IVIG?
Rituximab has about the same half-life as regular IgG. If the regular IVIG treatment can be delayed, it will be less likely to increase the catabolism of Rituximab. If the regular IgG is given at 3-4 week intervals, I would give the Rituxan halfway between IVIG doses. Complement is needed for optima...
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
What biomarkers or patient characteristics do you feel best predict response to B cell depleting therapies in a patient with Sjogren's?
At present, it may depend on the Sjogren's phenotype being treated with B-cell depleting therapies. If it is vasculitis with or without cryo, cryoglobulins, rheumatoid factor, and complements are helpful, along with inflammatory markers (ESR/CRP). I also note the level of total IgG, if elevated, may...
When is the ideal time in the disease course to offer radiotherapy for Dupuytren's disease for the most optimal outcomes?
Radiotherapy is most effective when fibroblasts are actively proliferating, i.e., during the cellular or proliferative phase of the disease, when there is a palpable, progressive nodule or cord but no fixed contracture.Prospective German trials show that treating during this biologically active peri...
Would you consider re-irradiation for recurrence of Dupuytren's Contracture?
Agree with @Dr. First Last, especially since the total doses used for treatment are widely variable (as low as 10 Gy all the way to 40 Gy), with clinical study evidence supporting a minimum dose of 21 Gy. Seegenschmiedt et al., PMID 11172962Due to dose constraints for the hand being about 60 Gy (no ...
What factors do you consider when advising a patient with lupus nephritis on the safety of becoming pregnant?
I agree with Dr. @Dr. First Last's excellent suggestions (with just one exception!). I don't increase prednisone prophylactively for lupus pregnancy - I would only add or increase steroid if there is a flare. The risks of steroid in pregnancy impact both maternal and pregnancy outcomes, so we try to...
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 ...