Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient with longstanding Sjogren’s disease (+SSA/SSB and RF with polyclonal hypergammaglobulinemia) who develops new asymmetric parotid fullness what is your preferred initial imaging modality to further evaluate?
I would usually start with ultrasound in this case, specifically looking for signs of lymphoma, and let the results guide any further workup necessary. I have often seen benign parotid swelling in these patients, but an asymmetric presentation such as this requires further workup and potentially bio...
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
How would you approach rituximab dosing in a patient with SLE-Myositis overlap with LN Class III, now with worsening UPCR and concern for worsening ILD 4 months post induction and incomplete B-Cell depletion on recent labs?
This is a challenging and concerning situation, as the patient is declining after rituximab. Without knowing which other medications have been tried, I would prioritize medications targeting life-threatening manifestations, i.e., the LN and ILD. In that case, I would start treatment with steroids, m...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
How would you approach managing severe, functionally disabling steroid induced edema that is refractory to treatment with chlorthalidone or bumetanide?
This is a difficult issue - I'm assuming the patient is unable to taper steroids at this time. The edema results from the mineralocorticoid activity of the steroid, so attempting to change to a low or negligible mineralocorticoid corticosteroid may be helpful if possible - dexamethasone, betamethaso...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
How would you treat active SLE with high level crithidia dsDNA abs and recurrent pleuritis with effusions still requiring corticosteroids despite combination therapy with full doses of mycophenolate, hydroxychloroquine, and Benlysta for over 6 months after no response to Saphnelo for 6 months?
There are no controlled trials of different therapies for treating refractory pleuritis in lupus as the primary manifestation. Due to refractory pleuritis being relatively uncommon, the trials of benlysta and anifrolumab did not have enough patients to assess response. In the literature, there are a...