Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
Is there a benefit to having a transition period in which a patient continues following with their previous pediatric rheumatologist while establishing care with a new adult rheumatologist?
Several pediatric to adult care models exist. Some models involve transition clinics in which adult and pediatric providers are both present and care may overlap between the two providers. Others are primarily focused on the pediatric side in preparing adolescents and young adults for care in the ad...
What is typical presentation and time course for belimumab infusion-related depression and/or hallucinations, and how do you approach management?
As the reported occurrence of severe depression AEs is rare (<0.5%), one can not really ascribe a 'typical' presentation to depression occurring in the context of treatment with belimumab infusions. The reasons/mechanisms underlying the consistently observed increased incidence of this AE in both th...
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...
Do you always get a baseline chest xray in patients who will be starting methotrexate?
I believe it is a good practice for screening CXR before Mtx to document baseline findings, which will help to register if there is some baseline issues.
In light of recent measles outbreaks, have you adjusted your vaccination counseling or preventive strategies for adult immunocompromised patients?
Check measles antibody (once) in individuals working in public places, especially when working with kids.
How would you approach the treatment of an SLE patient with refractory mucocutaneous ulcerations and lichenoid skin eruption despite treatment with MMF, Aza, Benlysta, Saphnelo, Rituximab, and JAK inhibitors?
This is an interesting case and the co-occurrence of SLE and Crohn's disease is rare but not unprecedented. The first issue is if the mucocutaneous lesions are related to SLE or the IBD and oral lesions are well described in Crohn's disease. Second, although cutaneous manifestations of Crohn's disea...
How would you approach management of a patient with sJIA that was previously well controlled on tocilizumab but is now having ongoing joint disease activity?
Not sure what specifically was the intolerance to methotrexate; I personally only give it subcutaneously (more effective, bypass liver first from GI tract, better and more consistently absorbed, less GI side effects). I really like methotrexate with IL-1 blockade, as a subset of kids with sJIA go on...
Can giant cell arteritis present with a partial cranial neuropathy?
Giant cell arteritis (although giant cells on temporal artery biopsy are not a sine qua non) most typically presents to the neuro-ophthalmologist with ischemic optic neuropathy (usually anterior and sometimes posterior).Ophthalmoplegia is uncommon in GCA but has been attributed to oculomotor and abd...
What strategies or initiatives do you think could be most effective in addressing the rheumatology workforce shortage?
Addressing the current and future workforce shortage is a difficult task. The field of Rheumatology is not growing. It has not been growing for many years and we are at a phase where simply maintaining our current numbers would be considered a victory. New graduates entering the field barely offset ...