Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 do you approach diagnosis and management of orbital myositis?
Orbital myositis is an umbrella diagnosis that includes a wide range of potential underlying conditions. Patients with this presentation are often first evaluated by neuro-ophthalmology to exclude causes such as isolated orbital myositis, myasthenia gravis, thyroid eye disease, infection, and diabet...
What treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
Colonic Behcet’s does not necessarily respond the way that IBD does. The evidence base for alternative therapies includes anti-interleukin-1, -6 and anti CD20. Anti Il-12/23 have also been used. Would discuss with a rheumatologist about which options are reasonable, depending on where else there are...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...
Can needle EMG or nerve conduction studies cause transient MRI abnormalities, such as apparent inflammation, edema, or enhancement of a nerve, that could be mistaken for neuritis on subsequent imaging?
Yes—needle EMG can create small, transient post-procedure MRI/MR-neurography abnormalities at needle insertion sites, including focal T2/STIR hyperintensity interpreted as edema and occasional small hematoma, which can potentially be mistaken for local pathology if the timing is not recognized. In a...
How do you envision incorporating CAR-T therapy into your clinical rheumatology practice?
This is an excellent question—one that, for now, might best be explored over a glass of white wine and some lively hand-waving. It’s a question I often find myself reflecting on every time I hear a presentation or read a new paper on the subject. Here’s a brief editorial response outlining how I env...
Is cellular therapy for autoimmune disease realistically scalable as a mainstream treatment, or is it more likely to remain reserved for a narrow, most-severe subset of patients?
The answer is that this remains very much a work in progress. Before we can meaningfully address scalability, we need greater certainty about several things: the magnitude and durability of clinical benefit; whether patients can remain drug-free or will require concomitant therapy after treatment; a...
When should CAR-T be considered in the treatment paradigm for SLE?
It should be considered after the failure of standard-of-care (SOC) therapy, including 1 or more biologics, for the given organ involvement with a connective tissue disease (CTD).