Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What do you include in differential diagnosis when evaluating a patient with calcinosis cutis?
When evaluating the patient with calcinosis cutis, I first make sure that the patient indeed has calcinosis cutis. In general, there are two types of ectopic calcifications in soft tissues: metastatic and ectopic. Metastatic calcifications occur in the setting of abnormal. serum calcium and/or phosp...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
This is an interesting question. Just to provide a little context, I used to have a sarcoidosis-focused clinic where one day each week I would see only sarcoidosis patients. I also had a day of seeing only neurosarcoidosis patients once per month, together with neuroimmunology. To be honest, since I...
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
Do you routinely check HLA-B*58:01 allele status in patients of Vietnamese descent before starting allopurinol? Would you check it if they've already been tolerating it for years?
Of asian or african ameican descent
How would you approach management of a patient who develops squamous cell skin cancer while on abatacept?
I would discontinue abatacept. Several studies now have reported an increased risk of squamous cell cancer/non-melanoma skin cancers in patients on abatacept (Wadstrom et al., PMID 28975211, Simon et al., PMID 37932010) and in someone who actually develops this malignancy on the drug, I would hesita...
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 ...
What is your approach to management of a patient with sarcoidosis who is asymptomatic, but demonstrates progressively enlarging mediastinal lymphadenopathy and rising soluble IL-2 receptor levels?
My concern here would be whether such a patient does not have 'asymptomatic sarcoidosis' but has CVID (often associated with multifocal non-caseating granulomas) with an associated B-cell lymphoma (for which such patients have a 30-fold Relative Risk) with developing mHLH (elevated sIL-2 being an as...
Do you start low dose aspirin for preeclampsia prevention in patients with myositis planning pregnancy?
I generally favor low-dose aspirin for preeclampsia prophylaxis in pregnant patients with idiopathic inflammatory myopathy (IIM), barring contraindications and in collaboration with maternal–fetal medicine. I discuss the plan before conception but typically begin 81 mg daily at 12 weeks’ gestation, ...
How do you determine osteoporosis treatment response when patients have discrepant DEXA scan results during monitoring (eg improved BMD of the hip and spine but worsening BMD of the femoral neck)?
This is not all that uncommon. The first thing I do is ask if they have fractured since we started the therapy. If not, I relax a little. This is a nice scenario for using bone turnover markers as part of initial work up. If PINP goes up by >10 I am happy that an anabolic drug is working... more you...