Ask The Rheumatologist
@LastManStand85
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🩺 Rheumatologist & Internal Medicine | Education | Be Humble | Be Teachable | Grass is Green where you water it🪴 | Arsenal Fan 30 Years 🔴⚪️ | MSK Ultrasound
England, United Kingdom
Joined July 2023
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Steroids
2 mechanisms of action
1/ Genomic (activates @ 7.5mg-30mg Pred/day). Ceiling of saturation > 50mg. Limited additional anti-Inflammatory benefit beyond & ⬆️ Adverse
2/ NonGenomic. Act @ 100mg, Max sat 250-500mg & Less S/E as Shorter ⌛️
Less Is More! Great Slide 👇
4
77
201
EULAR Recommendations for the treatment for
#Sjogrens
disease
The systemic organ-specific therapeutic approaches summarised below 👇
#EULAR2024
#Rheumatology
#MedTwitter
3
175
480
The many causes of a positive ANA
Its not always
#Lupus
🏠
#Rheumatology
#MedTwitter
[Alotaibi et al]
3
147
440
A useful algorithm for the work up of connective tissue diseases based on antibody positivity
#Rheumatology
#MedTwitter
[Dr Sophie Fletcher,
#ILD
10 Topics]
5
131
396
How long can you be on
#steroids
and then stop them altogether (regardless of dose) without the risk of an adrenal crisis? Well this guidance from the 2024 European Endocrine society may shed some light👇
#Rheumatology
#MedTwitter
8
112
384
Updated EULAR recommendations for the Management of Systemic Sclerosis
Organ specific treatment approach Summary👇
[Prof F Del Galdo]
#EULAR24
#Rheumatology
#MedTwitter
1
114
314
Screening Algorithm for Latent/Active TB prior to starting biologic therapy👇
#Rheumatology
#MedTwitter
1
88
271
A Nice Summary of Recommendations for the treatment of Antiphospholipid Syndrome
#APS
[F.Bashal et al]
#Rheumatology
#MedTwitter
3
108
275
Treatment of Rheumatoid Arthritis (RA) associated Interstitial lung disease
#ILD
2023 ACR/Chest Guideline
#Rheumatology
#MedTwitter
5
77
239
#Myositis
mimics
🚩 Include very high CK’s > x100 ULN
🚩 “Seronegative Myositis”
🚩 No clinical response to therapy
🚩 Selective fatty replacement on muscle MRI
And Others👇
[Dr James Lilleker]
#Rheumatology
#MedTwitter
0
89
233
The differential diagnosis of foot/leg ulcers [Pearls & Myths
#Rheumatology
Stone 2023]
#Vasculitis
#MedTwitter
0
61
210
The differential diagnosis of a proximal myopathy👇
#Rheumatology
#MedTwitter
[H.Almoallim et al]
0
64
205
Autoimmune
#Hepatitis
(AIH) vs
#Lupus
Hepatitis
Can be tricky to tease out the differences between the 2 conditions both can be ANA+ etc
Histology essential to clinch diagnosis ‘Interface hepatitis’ or ‘Hepatic rosetting’ is pathognomonic of AIH
(Dr Amera Elzubeir)
#BSR24
0
93
203
Management of
#Behcets
The 2024 British Society for
#Rheumatology
& Dermatology ‘living guideline for managing people with Behcets’. Great Job!
#MedTwitter
1
73
205
13
74
200
A useful algorithm for the approach to potential haematological manifestations in
#Lupus
#SLE
👇
[N.Janoudi et al]
#Rheumatology
#Medtwitter
0
65
195
ESR vs CRP
Acute phase reactants are proteins whose serum conc ⬆️ by 25% during inflammatory states. Changes occur largely due to effects of cytokines IL6, IL1, TNF, IFG. Not specific, but helpful in reflecting intensity of inf.process and ofc other Dx
#Rheumatology
#MedTwitter
2
55
184
Lymphadenopathy in rheumatology
practice: a pragmatic approach 📜
A useful article to read 👇
#Rheumatology
#MedTwitter
A few Helpful diagrams below (bit of revision!)
0
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1
67
175
Frequency of ANCA positivity in different conditions. Atypical ANCAs w/negative PR3 or MPO can be found in a range of nonvasculitic conditions (inflammatory bowel disease, autoimmune disease, malignancy & chronic infection)
[D.Geetha et al]
#Vasculitis
#Rheumatology
#MedTwitter
6
57
171
The serologic variability in
#SLE
relationship between dsDNA and Complement
The “Serologically Active Clinically Quiescent” patients…Monitor these pts very closely 🚨
#Lupus
#MedTwitter
1
58
163
0
56
158
1
47
156
Treatment Pathway for the treatment of Psoriatic Arthritis 👇
#PsA
#MedTwitter
#Rheumatology
#EULAR24
3
49
154
Treatment of
#Behcets
Disease
10 Topics in Rheumatology 2024
#Rheumatology
#MedTwitter
#Vasculitis
Great talk by [Prof H Direskeneli]👇
1
48
150
A 2024 Updated Summary of
#Rheumatology
medication that’s compatible (and not) with pregnancy & lactation👇
Presented by [Dr Frauke Forger]
#EULAR24
#MedTwitter
2
52
150
Algorithmic approach for hyperferritinemia with pancytopenia in patients with rheumatic diseases
#MAS
#HLH
#Rheumatology
#MedTwitter
0
61
150
Behcets Disease
The 2024 Updated Summary of organ specific management/recommendations.
[Presented by Dr Robert Moots, BSR24]
#Rheumatology
#MedTwitter
#Vasculitis
2
45
149
The work up/differential in a patient with cutaneous vasculitis in whom a skin biopsy showed the presence of leukocytoclastic
#vasculitis
👇
[L&M Size Vasculitis, C.Salvarani 2021]
#Rheumatology
#MedTwitter
2
53
138
Catastrophic
#APS
treatment
1st Line Rx 🚩
💉Heparin, Steroid, Plasma Exchange or IVIG
If Relapse 🔄
⬆️ Risk factors: Triple Positive Abs, Low Plt or Severe disease
💉 Consider B Cell Depletion or Complement Inhibition
References on the slide👇
#Rheumatology
#MedTwitter
2
48
133
“Doctor I feel weak all over”
The clinical approach to Weakness 💪🦵
[Skills in
#Rheumatology
, Almoallim et al]
#MedTwitter
2
38
134
Systemic Sclerosis associated antibodies and their associated cutaneous and SSc complications [S.R Johnson et al]
#Rheumatology
#MedTwitter
3
62
132
Fever of unknown origin in
#Rheumatology
🌡️ 38.3 & >3/52
One multi-centre quoted FUO in terms of distribution CTD 22%, Infection 16%, Malignancy 7% MISC 4% No Diagnosis 51%. Empiric treatment with Abx/Steroids not recommended as may muddy the waters & delay diagnosis (M.Cheikh)
0
42
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#Scleroderma
organ specific associated antibodies.
#systemicsclerosis
& Antibodies associated w/overlap SSc
Extracted from Textbook Scleroderma From Pathogenesis to Comprehensive management 2024
#Rheumatology
#MedTwitter
👇
2
49
126
Treatment Algorithm for systemic sclerosis-
#ILD
based on evidence based recommendations & clinical experiences
*Freq of screening guided by risk of ILD progression & Sx
*P-ILD = FVC ⬇️10% or DLCO⬇️15% at 12M from baseline
HRCT > 20% Extensive Dx
👇
#Rheumatology
#MedTwitter
2
51
125
Differentiating features of scleroderma-like disorders (mimics) and scleroderma
👇
#MedTwitter
#Rheumatology
[A.Tyndall]
0
49
125
#Scleroderma
specific autoantibodies in predicting prognosis/survival
➡️ almost all
#ANA
positive
📈 Best survival in anticentromere group
📉 Diffuse subtype carries a worse prognosis especially Anti-Scl70, anti-RNA polymerase III & If 🫁 ILD present
[AL Herrick]
0
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#Scleroderma
mimics
From Textbook Scleroderma From Pathogenesis to Comprehensive management. Chapter 11 (Hummers et Tyndall) 2024 👇
#Rheumatology
#MedTwitter
3
35
122
Medication that can safely be continued in men when family planning/during conception 👇
[Frauke Forger]
#EULAR24
#MedTwitter
#Rheumatology
1
44
122
Immune-Related Adverse Events from Cancer Immunotherapy👇
#Rheumatology
#MedTwitter
Clinical Innovation in Rheumatology [J.Liebowitz et P.Seo]
1
41
123
Differences among Intestinal
#Behcets
Disease,
#crohnsdisease
and Intestinal tuberculosis👇
#Rheumatology
#MedTwitter
(GI & Hepatic Manifestations of Rheumatic diseases H.Ohira 2019)
0
37
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Lupus Enteritis & the classical imaging soecific for
#SLE
✔️ Comb’ Sign 🪮
✔️ Halo/Target Sign 🎯
✔️ 3 Pointed Star Sign (Mercedes) 🚗
These features differentiate it from a Mesenteric Vasculitis SLE Serology can be Normal. Rare, Good Response & 98% Recover Rx GC & IS
#MedTwitter
5
52
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The spectrum of clinical presentations of a vasculitic neuropathy
#vasculitis
#neurology
#Rheumatology
#MedTwitter
👇
1
38
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Hypereosinophilia 📔
➡️Disorders often delayed
➡️Average delay 5Y
➡️Prolonged disease activity = irreversible organ damage & mortality
🚩 I always say dont forget the 3W’s
Wheeze 🫁 Worms 🪱 & The Weird 🧠 i.e rare immune rheumatic, Hyper IgE
(F.Anwer)
#MedTwitter
#Rheumatology
0
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Induction regimes in severe ANCA
#Vasculitis
Note Majority of trials have excluded patients with eGFR <15ml/min. 26% of pts have an eGFR <15 or require dialysis at presentation. Excellent outcomes in the imperial observational study w/⬇️ in dialysis.
[D.Greetha]
#Rheumatology
0
48
105
A Summary of the current ANCA
#Vasculitis
treatment options
➡️ Severe vs Non-Severe/Limited disease
➡️ Remission Induction & Maintenance
👇
#MedEd
#MedTwitter
1
40
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How long do we continue immunosuppressive treatment in
#Lupus
Nephritis patients that have achieved a complete response?👇
@goKDIGO
[Dr I Ayoub]
#Rheumatology
#SLE
0
33
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Happy 75th Anniversary to
#Steroids
still going strong 🎂 💊 in the treatment of the spectrum of rheumatic disease
Some of the highlights and benefits (dare I say) of low dose steroid 5mg daily…
👇
(Joseph Smolen)
#EULAR24
#Rheumatology
#MedTwitter
1
34
102
#Methotrexate
protects against
#ILD
50% Reduction in ILD if taking MXT vs Not. There is absolutely no need to stop the methotrexate it’s not associated with worsening ILD. An acute pneumonitis is different which you may need to stop.Treating the arthritis is key!
#Rheumatology
2
31
95
✅ The differential diagnosis of a proximal myopathy.
✅ Toxin induced myopathies
✅ Correlation between findings and suggestive diagnosis of weakness
✅ Common signs with specific myopathies
#Rheumatology
#MedTwitter
#Myositis
[H.Almoallim et al] 👇
2
35
98
Rheumatoid associated lung disease
ILD but don’t forget Airway & Pleural disease [Dr Sophie Fletcher]
#10topics24
#Rheumatology
#Medtwitter
0
42
98
Features differentiating sporadic inclusion body myositis (sIBM) from Polymyositis/Dermatomyositis
#Myositis
[Immune mediated Myopathies, B.Gaspar 2024]
#Rheumatology
#MedTwitter
1
36
95
Phenotypic comparison between anti-HMGCR and anti-SRP immune mediated necrotising
#myositis
Extract from textbook Immune mediated Myopathies [B.Gaspar] 2024
#Rheumatology
#MedTwitter
0
31
94
Potential investigations to consider for the diagnosis of Neuropsychiatric
#SLE
#Lupus
I find the Q-Albumin ratio especially helpful..
BUT Nothing replaces a good detailed history as part of your clinical work up 📑
#MedTwitter
#Rheumatology
[Table from T.Yoshio et Okamoto]
4
29
93
Macrophage Activation Syndrome
#MAS
#HLH
The 3 Fs
➡️ Fever 🌡️
- Due to Persistent activation of macrophages by other macrophages
➡️ Falling Counts ⬇️
- Consumption by immune system. Plts usually first to drop
➡️ Ferritin highly elevated ⬆️
- Usually >10,000
#RheumTwitter
#MedEd
0
34
93
HLAB27 🧬 & Axial
#SpA
#AS
➡️ Frequently asked questions⁉️
Some helpful clinical pearls & percentages which may assist you in clinic👇
[Clinical
#Rheumatology
R.Handa]
#MedTwitter
0
30
89
Feltys syndrome vs LGL Leukemia.
Both share HLADR4
?Part of the same spectrum
Both ANA & RF +
✅ 1/3 of LGL pts also have
#Rheumatoid
Arthritis, Neutropenia & ⬆️ Spleen
✅ RA precedes onset in LGL
FS: Postive response to splenectomy
LGL: Progression to Leukaemia
#MedTwitter
2
29
89
A useful table with a few clinical pearls & therapeutic tips when managing the elderly RA patient [Rheumatic diseases in geriatrics, G Slobodin]
#Rheumatology
#MedTwitter
2
25
88
Possible signs and symptoms in systemic
#Vasculitis
with corresponding investigations to consider 👇
[R.Micheletti et P.Merkel]
#Rheumatology
#MedTwitter
0
27
85
Factors to consider with the new combination therapies in
#SLE
#Lupus
MMF +
1/ Voclosporin (Proteinuria >3g) Cautious if eGFR <45
Or
2/ Belimumab (CKD, Proteinuria <3g)
#MedTwitter
@goKDIGO
#Rheumatology
(J Mejia-Vilet & Ayoub)
1
43
86
The 10 Top Takeaways for Clinicians for the Management of Lupus Nephritis 2024
@goKDIGO
Guidelines
#Lupus
#SLE
#Rheumatology
0
34
86
Salivary gland biopsy
✅ Sensitivity 80-92%
✅ Specificity 88-97%
Complication rate low if done by someone experienced
➡️ Risk of 1/300 of permanent numbness around the site of the scar
Recommended for Diagnosis & Prognosis BSR 2024 Guidelines
#Sjogrens
disease
[Dr E Price]
2
32
86
A lovely table summarising the Systemic Sclerosis associations including the phenotypic features with specific autoantibodies👇
{Pearls & Myths
#Rheumatology
, Stone et al}
#MedTwitter
0
29
84
Management of
#Stills
disease by the Danish Delphi Panel 2024
Key messages
1/ Steroids effective in AOSD but use should be minimised due to ⬆️ S/E
2/ Early initiation of biologics preferred over Methotrexate
3/ Important role for early use of IL-1 & IL-6 blockers
[Leavis et al]
1
32
81
0
30
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0
20
81
Nice overview & summary slide from Prof Liz Lightstone for the treatment of
#Lupus
nephritis
#SLE
10 topics in
#Rheumatology
#MedTwitter
2
23
81
A helpful algorithm in Managing difficult to treat psoriatic arthritis [Dr Kaul, 10 Topics]
#Rheumatology
#MedTwitter
0
32
80
Systematic review for Rx of calcinosis. Remains a major challenge in patients with
#SSc
.Several💊 have been tried with variable results.None have regulatory approval.Small studies,no validated outcome mesures & needs prolonged obvservation
#Rheumatology
#MedTwitter
(L.Chang et al)
1
36
79
Don’t forget viral
#arthritis
in your DDx of an acute Polyarthritis. Varies depending on demographics. Includes Hepatitis B/C, HIV, Parvovirus B19, Dengue and of course Chikungunya which belongs to the alphavirus👇below is its clinical course and treatments [
#Rheumatology
, Handa]
2
14
80
#Myositis
specific & associated antibodies
Table of the 8 known Anti-synthetase (AS) antibodies & their clinical associations
Pulmonary function & low threshold for HRCT in all patients especially AS antibodies & anti-MDA5 rapidly progressive
#ILD
#Rheumatology
#MedTwitter
0
36
79
A summary of cardiac involvement in systemic immune mediated inflammatory diseases. Clinical presentations can be so heterogenous👇
Essential🫀investigations are part of your work up!
[Caforio et al]
#Rheumatology
#MedTwitter
#Cardiology
2
30
77
The wide spectrum of Cardiovascular involvement in
#Rheumatology
👇🫀 [R.A.Ali et Al]
#SLE
#Vasculitis
#Inflammation
0
17
76
Clinical features of immune
#checkpoint
inhibitor induced inflammatory arthritis and its Management👇
MDT discussion with oncology critical when forming a plan. Screening for infection (esp TB) even w/DMARD (higher risk w/CI) & ✅ Bone health!
#Rheumatology
(Cappelli et al)
0
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0
23
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The 2024 KDIGO Guidelines For The Management of ANCA
#Vasculitis
@goKDIGO
#Rneumatology
Induction treatment 👇
3
24
73
The Treatment spectrum of
#Behcets
A Few treatment Caveats:
➡️ Cyclosporin may increase CNS involvement 🧠
➡️ TOC may exacerbate skin findings
➡️ ETN may not work in Uveitis 👁️
➡️ Thalidomide may increase the risk of venous thrombosis
#Vasculitis
#Rheumatology
#MedTwitter
0
23
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0
23
70
#bDMARD
&
#tsDMARD
in the treatment of spondyloarthritis
+
#IBD
Efficacy Vs No Efficacy in the disease
#Rheumatology
#MedTwitter
👇
0
28
70
#Behcets
versus
#Crohns
disease
Can be very similar in their clinical features presentations with some overlap👇
But Behcets:
➡️Vascular Involvement🫀
➡️Neurologic 🧠
➡️Pathergy reaction 💉
Colonoscopy helpful in viewing ulcer: Diffuse (IBD) vs Focal
#Vasculitis
#Rheumatology
0
31
66
Diagnostic approach to patient with rash and a neuropathy. When neuropathy either mononeuropathy, mono-neuritis multiplex or peripheral neuropathy occurs in a setting of skin rash, vasculitis should be considered as an etiological factor 👇
#Rheumatology
#MedTwitter
0
21
67
0
25
66
#AxialSpA
vs
#AxialPsA
vs DISH
You can categorise the pure AS Phenotype (PT), The Mixed Overlapping AS PT & The True Axial PsA PT which then merges into DISH and True DISH👇
#BSR24
(Prof D McGonagle)
#Rheumatology
0
43
67
Pulmonary function test made easy
Pulmonary HTN 🫀vs Lung Fibrosis 🫁
DLCO & FVC Ax essential to put on the PFT request…
Of course a Right Heart Catheter is the ‘gold standard’ for PHTH diagnosis & HRCT for ILD
#Rheumatology
#MedTwitter
0
22
65
Systemic Sclerosis
#EULAR24
recommendations/treatments based on organ involvement
[Fransceso Del Gado]
#Rheumatology
#MedTwitter
0
22
66
#Infection
&
#Vasculitis
The association between infection and vasculitis has been well documented & recognised for many years. Should always be considered in your initial work up 🔬
Can affect any size vessel: Large, Medium & Small👇
#Rheumatology
#MedTwitter
#Diagnosis
2
31
66
The
#Myositis
specific antibodies. MSAs can play a role in identifying subsets
of patients with specific phenotypes early in the disease course
and help guide prognostication and treatment decisions
#MedTwitter
[R.Shahin et al]
0
31
66
The
@goKDIGO
2024 clinical practice guidelines for the management of IgA Nephropathy
#Vasculitis
[Draft Version Currently]
#Rheumatology
#MedTwitter
0
26
65
Very early diagnosis of systemic sclerosis (VEDOSS) EUSTAR project aims to identify features that may precede skin thickening and internal organ
involvement
⬆️ risk:
🚩 Raynauds Phenomenon and/or Puffy hands who are ANA positive
🚩 Abnormal Capillaroscopy
🚩 SSc specific abs
0
37
62
The 4 clinical disease phenotypes of IgG4-Related Disease & The 2020 Diagnostic Criteria👇
#MedTwitter
#Rheumatology
#IgG4
0
17
63
The BSR treatment guidelines for Psoriatic arthritis
#PsA
10 Topics in
#Rheumatology
#MedTwitter
[Dr A Kaul]
0
20
62
A summary of disease associations/complications with
#diabetes
and rheumatic diseases including investigations & treatment options
#Rheumatology
#MedTwitter
(A.Monjed)👇
0
26
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A nice summary of Rituximab related adverse reactions & complications and how to manage them👇
#Rheumatology
#MedTwitter
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0
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