Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you treat idiopathic acute anterior uveitis that recurs immediately after a course of topical corticosteroids?
Anterior uveitis has many known causes that include HLA-B27-associated (often with ankylosing spondylitis); viral such as herpes simplex, CMV, or zoster; or as part of a syndrome that includes interstitial nephritis; or as a manifestation of juvenile arthritis. Labeling it acute means that it starts...
How long do you continue PJP prophylaxis in a patient with GPA who is able to wean steroids and remains only on rituximab for maintenance therapy?
Great question! For my ANCA patients and the OSU vasculitis clinic, we leave them all on Bactrim for the life of the disease. Less about PJP, and more about helping minimize infections due to the sinus and respiratory inflammation creating a nice environment for bacteria to live. Also, there is some...
Would you consider the use of doxycycline or minocycline in the management of RA?
When faced with an issue of a TNF side effect or an infectious complication, I have used minocycline for the management of RA. This is based on an observation of minocycline’s effectiveness in early RA. A patient of mine developed optic neuritis while administering adalimumab, and Opthalmology (appr...
What is your workup and treatment approach for cranial neuropathies in patients with lupus?
Pretty much the same as is done for SLE patients presenting with acute or chronic inflammatory peripheral neuropathies with the additional concern for leptomeningeal inflammation. Evaluation: Cranial MR, CSF studies (cell count, albumin, IgG level with accompanying serum levels to determine IgG Inde...
How would you manage a patient with CKD4 due to lupus nephritis of unknown class who develops AKI requiring hemodialysis and nephrotic range proteinuria and is found to have atrophic kidneys on imaging?
The decision to biopsy a kidney is not based just on size. The operator should look at the kidney size compared to the height of the patient and the echogenicity on ultrasound.If the patient is short with a normal/near-normal echogenicity, even a <9cm kidney can yield useful information. This is rel...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Is there a concern for the potential of future congenital malformations in offspring when preservation of eggs and sperm is done AFTER cyclophosphamide treatment given that it is an alkylating agent?
No, there is not a significant risk of congenital malformations in embryos created with cryopreserved gametes or unassisted pregnancies AFTER cyclophosphamide use. While alkylating agents lead to both male and female infertility, congenital malformations from cyclophosphamide occur when conception h...
How do you reduce the risk of contralateral fracture in a patient with atypical femur fracture from prolonged bisphosphonate use?
While there are no published clinical trials treating AFF with anabolics, we have considerable experience taking care of AFF's. Between myself and two ANP's doing strictly bone health with a large group of orthos who manage a large percentage of fractures in the Phoenix valley, we unfortunately stil...
Do you correct the synovial fluid white blood cell count for red blood cells, and if so, is there a rough approximation/equation you use?
In a rheumatology practice, under most circumstances, there is no need to make a correction of the synovial fluid white blood cell count. The fluid is either translucent, transparent, or opaque and the count will help to establish the presence or absence of an infectious or inflammatory process and ...
What are the current treatment options for progressive multifocal leukoencephalopathy in patients without HIV/AIDS?
It depends on the underlying cause of the immunodeficiency that led to the PML. In cases of natalizumab-induced PML, this would involve stopping the drug immediately. There is controversy over whether or not to perform plasma exchange to hasten this. In some cases, this has provoked IRIS while in ot...