Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What maintenance regimen do you use for a patient with lupus cerebritis?
I prefer a mycophenolate analogue (MPA, usually mycophenolate mofetil, MMF, but prefer mycophenolic acid if on a PPI, which causes reduced MMF bioavailability, or if MMF intolerant) over azathioprine (AZA) for maintenance.Reasoning is that MPAs have shown better efficacy in improving outcomes and pr...
What factors drive you to prioritize treatments that inhibit T cells vs B cell depletion when choosing therapies for patients with refractory SLE?
Other than for immune cytopenias that are likely primarily autoAb mediated it is difficult to know the relative extent to which T cell vs humoral immunity effects lupus disease activity. As such, the main driver for me to target T-cell activation currently would be organ complications not known to b...
Do elevated neutrophils in the bronchoalveolar lavage of patients with sarcoidosis have any prognostic value?
Neutrophils in the alveolar space are uncommon in healthy non-smoking individuals, accounting for around 1% of cells in bronchoalveolar lavage (BAL). Macrophages compose 80–90% of the cells policing the alveolar surface, with the remaining cells being lymphocytes, rare eosinophils, and basophils. A ...
Would you stop romosozumab if a patient developed mild asymptomatic hypocalcemia while on treatment?
Mild hypocalcemia was noted during the pivotal clinical registration trials and thus is not too surprising. The reason for the hypocalcemia is not entirely clear but may have to do with blocking sclerostin's stimulatory effect on osteoclasts and/or calcium being "soaked up" by the massive rapid new ...
How do you counsel and manage patients with chronic pain conditions such as fibromyalgia or osteoarthritis who are taking centrally acting agents (gabapentin, duloxetine) and are planning to use or self administer psychedelics for symptom management?
Interesting query since some studies do suggest that psychedelics may be useful in treating chronic pain, and their mechanism of action regarding neuroplasticity is similar to approved centrally acting agents, like duloxetine. I would first review the limited role of medications in chronic pain and ...
How do you approach an isolated positive anti-Scl-70 antibody in a patient with no symptoms or exam findings suggestive of systemic sclerosis?
We see this often in the clinic, and it is usually a false-positive test. False-positive anti-topoisomerase I (Scl-70) results frequently occur with commercial immunoassays (ELISA/Multiplex), often leading to misdiagnosis of systemic sclerosis. In our practice, we repeat the test using immunodiffusi...
Do you generally pursue a temporal artery biopsy in a patient who has a halo sign on ultrasound but has an atypical clinical presentation of GCA with normal inflammatory markers in the setting of persistent temporal headache?
This is an important question, and the answer would depend significantly on the details of the presentation. In general, with a highly atypical presentation such as this with normal inflammatory markers AND atypical symptoms, I would pursue TA biopsy and consider large vessel imaging if negative. Wh...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
How do you approach selecting optimal muscle biopsy site when evaluating a patient for suspected inflammatory myopathy?
There are a few things to consider when formulating your approach to this, which include 1) the clinical exam, 2) ease of biopsy of muscle, and 3) potential confounders of diagnosis. The goal is to get a specimen from a muscle that is undergoing active inflammation. These muscles will generally be w...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...