Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?
This is a complex problem for which any response clearly is not data-driven. Disseminated VZV is a profound illness and is linked to JAKi exposure. While the majority of VZV is 'mild' all complications are increased in this setting and dissemination is among the most serious and potentially fatal co...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
After completing 12 months romosozumab, what is the next best treatment option for patients with severe osteoporosis, high risk for fracture, and normal kidney function?
Zoledronic acid is my clear-cut first choice in this setting.
What features on CTA/MRA are most helpful for differentiating large vessel vasculitis from atherosclerosis?
While calcified plaque is not typically mistaken for large vessel vasculitis, distinguishing non-calcified atherosclerotic lesions from large vessel vasculitis is challenging. An experienced vascular radiologist is an invaluable resource in such situations if available. The first step is to assess ...
How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?
This is an unusual but anxiety-inducing situation. Remember that an "indeterminate" Quantiferon is not an "intermediate" Quantiferon. It's not half-positive, it's uninterpretable. The result provides absolutely no reason to be more or less concerned that the patient has lTB, latent or otherwise. I a...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
What is your approach for disease activity monitoring in patients with sarcoidosis?
Disease activity monitoring is useful in managing therapy and prognostication in sarcoidosis. Since the disease activity can vary across different organ systems, it can be a challenge. Broadly, good bio-markers of overall disease activity are lacking in this disease.ACE level lacks the sensitivity b...
Is it safe to continue administering Prolia per schedule for osteoporosis treatment shortly after a patient has undergone extensive spinal surgery?
There is no evidence that spine surgery is a contraindication to receiving Prolia. If the bone was incised, Prolia could help healing.
What is your approach to maintenance treatment in a patient with Sjogren's who received rituximab for mononeuritis multiplex?
The data supporting the use of maintenance DMARDs, in this scenario, is limited. On the other hand, there is some evidence that relapse is common. Therefore, agents such as Azathioprine, MFM or maintenance Rituximab, should be considered, akin to the management approach for ANCA vasculitis. Managing...
Is there any role for IVIG or steroids in viral myositis complicated by severe rhabdomyolysis, diffuse compartment syndrome, DIC, and AKI?
There is no evidence to support the use of immunosuppression in the case of viral myositis, besides supportive measures for rhabdomyolysis, and a review of the patient's medication list and habits to rule out other toxins that could contribute.