Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you routinely apply the 2010/2011 ACR symptom-based diagnostic criteria for fibromyalgia in your practice, or do you continue to use the 1990 tender point examination to make the diagnosis?
I don’t use tender point counts in my practice: they were discarded after the 1990 criteria for many reasons, including poor inter-rater reliability and the sort of nebulous nature of what was really being measured. The ACR 2016 criteria reference this very issue, noting that some have described ten...
How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?
As rheumatologists, we are accustomed to managing people with rare diseases. Eosinophilic fasciitis (EF) ranks among the rarest of the rare, so it is understandable that there are no carefully designed trials assessing the efficacy of the various immune-modulating drugs. Clearly, corticosteroids are...
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
What is your approach to the management of nodular regenerative hyperplasia of the liver in patients with SLE?
There are no large studies regarding the treatment of nodular regenerative hyperplasia (NRH) in systemic lupus erythematosus (SLE). It is rarely recognized, and the vast majority of reported cases are single-case reports, literature reviews, and a few very small case series. A Japanese autopsy serie...
How do you decide between initiating systemic immunotherapy versus local treatment for uveitis with associated HLA-B27 and spondyloarthropathy?
I find that most, but not all, HLA-B27 iritis can be controlled with topical therapies. To do so requires eliminating other causes of inflammation. Many patients have GI inflammation due to gluten and dairy, despite not having classic celiac disease or lactose intolerance. Reducing their intake, mod...
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...
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...