Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...
Can needle EMG or nerve conduction studies cause transient MRI abnormalities, such as apparent inflammation, edema, or enhancement of a nerve, that could be mistaken for neuritis on subsequent imaging?
Yes—needle EMG can create small, transient post-procedure MRI/MR-neurography abnormalities at needle insertion sites, including focal T2/STIR hyperintensity interpreted as edema and occasional small hematoma, which can potentially be mistaken for local pathology if the timing is not recognized. In a...
When should CAR-T be considered in the treatment paradigm for SLE?
It should be considered after the failure of standard-of-care (SOC) therapy, including 1 or more biologics, for the given organ involvement with a connective tissue disease (CTD).
Do you refer for autonomic testing or manage symptomatically when dysautonomia symptoms complicate chronic musculoskeletal pain?
Great question. Dysautonomia is very common in patients with chronic overlapping pain conditions (e.g., ME/CFS & post-acute infectious syndromes), and it can be disabling. This is more of a clinically salient phenomenon in pt w/ ME/CFS, in my experience, whereas rheumatic patients with RA/SS/SLE, et...
Would you escalate treatment for a clinically stable/asymptomatic lupus patient with persistent leukopenia/neutropenia, already on hydroxychloroquine?
The short answer is it depends on several variables most importantly, whether the patient has been experiencing recurrent infections. Additionally, the presence or absence of coincidental lymphocytopenia can be relevant. Worth mentioning that the most common hematologic manifestations in lupus are a...
Do you recommend a particular antiresorptive/anabolic agent for patients who are at high risk for fractures but have high risk of osteonecrosis of the jaw?
Teriparatide has improved bone healing in patients with osteonecrosis of the jaw, so would be a good choice for patients at high risk of ONJ.
What should a minimum adequate follow-up protocol look like for patients following CAR-T therapy, and who should be responsible for it once a patient is years out from infusion and asymptomatic?
A minimum adequate follow-up protocol after CAR-T therapy should be structured, risk-adapted, and jointly managed by rheumatology and the cellular-therapy center. During the first 30–100 days, the cellular-therapy team should lead monitoring for cytokine release syndrome, immune effector cell–associ...
How do you approach osteoporosis screening in men?
While osteoporosis is more prevalent in postmenopausal women, it is often under-recognized in men. The risk of mortality after hip fracture is higher in men, and that risk may extend over 10 years after injury. Men who sustain a wrist fracture are more likely to have severe osteoporosis and a higher...