Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your treatment approach to neurological Sjogrens disease with both peripheral neuropathy and transverse myelitis?
For transverse myelitis associated with Sjogren syndrome, many (if not the majority) test positive also for anti-AQP4 antibody. This is different from other autoimmune disorders such as Behcet in which the patients usually are seronegative. Therefore, I usually treat with rituximab for myelitis. As ...
What is your approach to the diagnosis and management of optic chiasmitis in systemic lupus erythematosus?
Optic nerve involvement occurs in SLE but not commonly. I am aware of two case reports about 20 years apart describing inflammation of the optic chiasm in lupus. Both appeared the Neuroophthalmology and the most recent was 16:117, 2020. I would be cautious about making the diagnosis of lupus if sero...
Is active rheumatoid arthritis (RA) a contraindication to hypofractionated breast irradiation?
Active RA with some sort of skin manifestation may make me consider delaying/deferring RT, but it would not change what fractionation I use.Here is recent data that shows no difference in toxicity across various fractionation schemes in patients with CVD.
What is your approach to long term lab monitoring for Sjogren's disease activity?
I do routinely monitor my Sjögren disease (SjD) population with labs. The frequency usually ranges from 3-6 months and depends on risk for moderate-severe SjD and for lymphoproliferation. Generally, risk is higher for patients with higher ESSDAI (systemic disease activity scores) and those with high...
How would you treat a recurrent endometrial cancer at the vaginal cuff that was initially FIGO 1A with no adj treatment, in a patient with actively treated scleroderma?
I would favor brachytherapy alone using MRI based planning with either a multichannel or hybrid applicator. Dose 6 Gy x 6 to CTV and higher dose (hot spots) to GTV.
How do you manage a patient with cervical cancer who has FDG uptake in bilateral ischial tuberosities with lytic areas on CT correlate, and also has a history suspicious for untreated polymyalgia rheumatica with chronic symptoms in the same anatomic locations?
I would be very interested in the opinion of a rheumatologist regarding the etiology of the lytic disease in the ischial tuberosities. A decision should be made on whether to biopsy one of these lesions. My suspicion is that it is unrelated to cervical cancer, but that possibility needs to be consid...
Do you wait until serum anti-GBM antibody titers are undetectable before hospital discharge in a patient with anti-GBM antibody disease with renal involvement who is receiving daily plasmapheresis, cyclophosphamide, and steroids?
If such a patient is responding to treatment, titers are declining, is otherwise doing well, and does not have extra-renal issues that would require hospitalization, for example, an ongoing oxygen requirement for lung involvement, they could be managed as an outpatient if pheresis can be arranged. I...
What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?
Great question, and one that comes up all the time in clinical practice. Unfortunately, the question gets a little bit complicated because of the heterogeneity of the musculodystrophies, metabolic myopathies, and neuropathies that can mimic myositis (not to mention the phenotypic variation between t...
How do you determine duration of therapy for patients who have responded well to voclosporin therapy?
Determining the duration of therapy for patients who have responded well to voclosporin therapy in lupus nephritis involves several considerations, including patient-specific factors, disease activity, and risk of relapse. Here is a suggested approach:The duration of therapy is determined by the ren...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.