Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Does significant eosinophilia (8-44%) in a patient with suspected granulomatosis with polyangiitis (GPA) based on sinusitis, pulmonary nodules and positive PR3 change your management approach?
This is an important question because at times the distinction between GPA and EGPA can be difficult to make. In general, I would rely on clinical symptoms as a key distinguisher. For example, sinusitis in GPA differs from that of EGPA, with the former often causing crusting, erosions/necrosis on EN...
Do you expect a different response rate to neradomilast depending on the ILD phenotype?
As a rheumatologist, I am particularly interested in the autoimmune ILD subtype and reviewed with great interest the subgroup analysis published in the Annals of Rheumatic Diseases by Anna-Maria Hoffman-Vold et al., PMID 42062162, which reports specifically on the 324 patients with autoimmune ILDs (...
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
I am not an RA expert; however, I am well-versed in the use of IM steroids for flares.After Dr. Petri's FLOAT study in SLE (Danowski et al., PMID 16395750), we have utilized IM steroids instead of daily PO prednisone as our "go-to" treatment of choice as much as we can over Medrol dose packs and QD ...
What is your approach to management of patients with recurrent nephrolithiasis and osteoporosis who are receiving teriparatide?
Bones and calcium containing kidney stones can interact. I find it interesting that patients who have primary hyperparathyroidism are prone to predominantly calcium phosphate kidney stones, since the action of parathyroid hormone on renal tubes is to reabsorb urine calcium. That’s why people with hy...
In a patient with recurrent episodes of GCA that flare shortly after steroid tapering, how do you differentiate between steroid-dependent inflammatory relapse, an alternative autoimmune vasculitic process, and a paraneoplastic phenomenon?
Paraneoplastic disease rarely behaves like GCA with ischemic manifestations. If a non-GCA vasculitis is suspected, perhaps repeat biopsy or serologic testing for other markers could be done. I'm not sure of the value of these tests, however, given that the treatment approach with immunosuppression w...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
When do you consider genetic testing for autoinflammatory diseases in patients with recurrent pericarditis and fever, particularly when symptoms are highly responsive to IL-1 blockade?
Yesterday ;-). About 10% of patients with recurrent pericarditis have genes that may increase their risk of pericarditis. If you're already managing the patient with IL-1 inhibition, I would strongly encourage you to conduct genetic testing. Just my 2 cents...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
In an article by the Yale group, Gallegos et al., PMID 33997256 give a nice summary of the literature cited options for managing cardiac sarcoidosis (Non-steroidal treatment of cardiac sarcoidosis: A systematic review.Options cited here that have not been discussed include cyclophosphamide, cyclospo...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
How would you approach a patient referred for esophageal aperistalsis with a longstanding history of Raynaud’s phenomenon, but without other clinical features or serologic findings suggestive of systemic sclerosis?
Scleroderma esophagus (distal aperistalsis/absent contractility + hypotensive LES) is a manometric finding, not a diagnosis. There are multiple causes of this finding, including other autoimmune diseases, neuropathic conditions, and metabolic causes.In addition, RP is seen in 3-8% of the population....