Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you screen for cardiac disease in patients with dermatomyositis in the absence of symptoms?
I don't typically evaluate for cardiac disease in patients with dermatomyositis who are not symptomatic. There are subtypes of myositis patients where cardiac involvement is more common (such as those with antimitochondrial antibodies and anti-SRP antibodies), and there it may make sense to keep a c...
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...
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
In patients with SLE do you have concerns about using trimethoprim-sulfamethoxazole (Bactrim) because of a potential risk of lupus flare?
I have had two patients hospitalized with lupus flares after being placed on TMP/SMX by ER physicians, and two others who had diffuse skin eruptions. The med residents who saw the flares and cared for the patients in the hospitals told me how impressed they were with the flares.
For patients with definite UIP and MPO-ANCA-associated vasculitis limited to the lungs (without systemic manifestations), what is the role of immunosuppression?
I think in these subjects (as opposed to UIP in RA), immune suppression would be my first agent. The data are limited; there is some suggestion on biopsy that they have significant inflammation (Arnold et al., PMID 38574743). I would start with immunosuppression and have a low threshold to add anti-...
How do you approach the management of recurrent episcleritis in a patient with RA that is otherwise well-controlled?
The episclera lies on top of the sclera. The majority of patients with episcleritis do not have a systemic disease, although patients with rheumatoid arthritis are more prone to develop episcleritis. Episcleritis must be distinguished from scleritis, which is also associated with rheumatoid arthrit...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
What is the difference between P155/140 and TIF1-γ antibodies on the ARUP myositis panel?
TIF1g is the name of the protein itself, whereas "p155/140" refers to the IP (immunoprecipitation) finding of 2 distinct bands at 155 kDa (TIF1g) and 140 kDa (TIF1a), indicative of an anti-TIF1g antibody response. Until recently, ARUP (like most commercial laboratories) used immunoblotting, as it is...
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 ...
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...