Rohit Aggarwal
@docrota
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Rheumatologist, research in Myositis & Interstitial lung disease, medical director, Myositis Center, Professor of Medicine, @UPMC @pittrheum
Pittsburgh, PA
Joined December 2013
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My story: A journey from a resident presenting NEJM in journal club to 1st author NEJM. As FMG I was scared of research, had no experience or know how, but had a zeal to push my limits, curiosity n passion to learn and shear dedication n hard work. If I can do it …..any one can.
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#MyositisPearl
9: Have you seen a patient with increase in CK but nothing wrong with the patient. It’s called Asymptomatic HyperCKemia. Most patients don’t need beyond basic work up & most are Not
#Myositis
. This week I will address how to manage such patients.
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A big thanks to Myositis patients for NEJM paper on IVIG in Dermatomyositis. 🙏 to wife
@Nids_Aggarwal
, kids n family for unconditional support, mentors for wisdom, mentees for curiosity, colleagues for sharing knowledge,
@OctapharmaGroup
for trust in me.
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No place for hate in this Beautiful Pittsburgh
Light Up Night in
#Pittsburgh
always offers up some spectacular views, and I’m sure that tonight won’t be any different. This is a view of the fireworks from the roof of the Steel Building, with PPG Place reflecting the colorful display.
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Hot off the press! The best news Ever - for Myositis. FDA approved IVIG (Octagam 10%) by
@OctapharmaGroup
for adult Dermatomyositis. First & the only proven & approved tx for Myositis. History is made today. Congratulations & thanks to all patients and doctors and study staff.
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Hot off the Press: International Guidelines on Cancer Screening for Myositis are published. Start doing the risk based stratification and cancer screening for your myositis patient. Thanks to
@Dr_Alex_Oldroyd
for his scientific acumen and hard work.
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Dear Friends, happy to announce that we published our first ever book on myositis this week “Managing Myositis: A practical guide”. This comprehensive book serves as a guide in the day-to-day management of patients with PM, DM, IBM, Necrotizing myopathy.
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Spread positivity: 6 months ago she had stage IV metastatic ovarian cancer & severe Dermatomyositis failing chemotx. Her MDs didn’t want to start immune checkpoint inhibitors given DM. We advised to tx cancer with ICIs with SQIG for DM. Today neg CT/PET, CA125, & improving DM.
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Thanks to
@TheMyositisAssc
for an incredible recognition. Truly honored & humbled. Special thanks to Dr. Oddis for myositis, my wife for unwavering support & parents for encouragement, mentees, collaborators, staff & others, but above all my patients for teaching me all.
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Promoted to Professor of Medicine at
@UPMC
@PittDeptofMed
@PittRheum
I want thank so many friends, family, student n colleagues who have contributed to what I am today. It takes a village to raise a child is certainly true in my case - thanks to my wife kids parents brother n all
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It give me a great pleasure to announce the 1st ever ACGME Myositis fellowship in US for 1 year to improve education, research and patient care in Myositis.
@PittRheum
⭐️Happy to announce the 1st
#ACGME
recognized
#Myositis
fellowship to start July 2023!⭐️
Institution:
@UPMC
/
@PittRheum
Duration: 1 y
Eligibility: permanent residents & visa holders
Candidates:
#Rheumatology
,
#Neurology
, &
#Dermatology
trained
Program Director:
@docrota
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Anti-Synthetase Classification Criteria coming in early 2024. Stays tuned for news from CLASS project !
The CLASS project (
#antisynthetase
syndrome classification criteria): expected 2024:
@docrota
@Lollo7770
✅Jo-1 ab is the most 🎯 (other anti-synthetase abs (high false + and -)
✅anti-Ro52 and CYTOPLASMIC ANA are common
✅ Any form of ILD🫁
#ACR23
#rheumX
#pulmX
@ACRheum
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Dear Friends,
Sharing my myositis basics lecture for new rheumatology fellows covering the diagnosis and clinical phenotypes of different types of myositis. My 45 minutes lecture on Myositis starts at 1.02 hours onwards in this 2-hour series.
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Key article on safety of IVIG in Dermatomyositis. Always check for thromboembolic risk factors (HTN, DM, Obesity, Smoking, lipid Abn, heart failure, arrhythmia, obesity, etc). If >=3 use lower dose 1gm/kg; give over 4-5 days, or avoid. Max~ 0.04 ml/kg/min
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Congratulations to this young 1st medical student
@SrijanMittal29
who travelled all the way from India to present his research at prestigious
#ACR23
about education and awareness about myositis using social media.
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Our paper on cancer screening in myositis. Thanks to Sinan and
@LatikaGupta_
Check out our approach for high, moderate, and low risk for cancer in myositis. Not everyone needs extensive screening, but high-risk patients need careful monitoring.
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Dear Myositis and Autoimmune disease patients. Made 2 videos to help my pts with information about Covid vaccine in autoimmune disease and pts on immunosuppressive meds. Hope you like it. Here is part 1. Part 2 coming. Take Vaccine.
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Dear Twitter Friends
Next on the
#MyositisPearls
series, I will be covering the Lung 🫁 manifestations of
#myositis
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#MyositisPearls
51
Lung Involvement is common in
#myositis
. While interstitial lung disease (ILD) is the most common, there may be other presentations such as PAH, VTE, respiratory muscle weakness, pneumothorax aspiration and infections.
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Welcome anyone who would like to join this webinar by Myositis India
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Congratulations to
@DidemSayginMD
Hanna Kim, Lisa Rider et al. on proving that 2016 ACR/EULAR Myositis Response criteria truly works. It is being used in all Myositis clinical trials like ACR 20/50/70 for RA. Took us 3 years to complete. Effort pays off.
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#MyositisPearls
129-
Note that there are 5 muscle enzymes: CK, aldolase, LDH, AST, and ALT; all can be elevated in myositis.
- CK, aldolase are most specific, but AST and ALT are more often elevated JDM.
- LDH is less specific, but is 2nd most commonly elevated after CK. Also
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#MyositisPearls
57 :
Common lung manifestations other than ILD in myositis include -
🫁 Pneumomediastinum.
🫁 Pulmonary Arterial Hypertension (PAH).
🫁 Diaphragmatic Weakness.
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#MyositisPearl
for patient 12: If a patient has high CK levels without any symptoms, the doctor should first check for common causes before investigating neuromuscular causes: infections, medications like statins, thyroid disease, MacroCK, exercise, pregnancy, and other factors.
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On a personal note: Enjoyed being part of Bollywood dance group at 2023 Lunar New Year Parade in Pittsburgh. Loved dancing on our community street. I am hidden in back - which is good.
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#MyositisPearls
131 : Inflammatory Markers:
- Although inflammation is the hallmark of IIMs, inflammatory markers like Ferritin, ESR, and CRP are often nearly normal, except ASS and Anti-MDA5.
- ⬆️ CRP levels are predictive of bacterial infection.
-Ferritin is elevated in MDA5
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Thrilled to announce Eaman Al-Hassan as 2024 Myositis Fellow at UPMC & currently Rheum fellow at USC, LA. She got interested in Myositis in medical school, did her post-doc at Beth Israel prior to residency at Univ. of Maryland. Working on anti-MDA-5 & have impressive 25 papers.
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What a wonderful
#EULAR2024
! Great fun, laughs, food, music, dance, discussions and collaborations ! Feel like myositis work is a hobby due to lovely friends and colleagues. EULAR rejuvenated and motivated me to work towards finding cure for Myositis !
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Excited to collaborate with
@Samanthaprabhu2
as the brand ambassador for
#MyositisIndia
Together, we're stepping forward to raise awareness & make a difference in the lives of those battling myositis.
Join and support us!
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Myositis Pearl
#1
Electromyography (EMG) is highly sensitive, but not specific for myositis, primarily serving to differentiate between myopathy & neuropathy. However, +ve fibrillation potential & positive sharp waves indicate active inflammation or necrosis - suggests myositis.
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Another excellent oral presentation from UPMC myositis center by Shiri Keret at
#EULAR2024
. She showed that many myositis patient may have normal CK despite muscle weakness. However, CK is associated with outcomes over time even in patients with normal or near normal CK,
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Congratulations to authors: much needed data on IVIG in Myositis-ILD
🆕🚨🔥IVIG for ILD of anti-MDA5+ve dermatomyositis
IVIG
IVIG led to a trend towards Greater
🔥 Remission at 3 and 6 months
🔥 Reduced Mortality at 3 and 6 months
🔥 Reduced steroid use at 6 months
early Encouraging data
#MedTwitter
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Time to use activity monitors for our
#myositis
patients to see treatment response, esp wrist device - ave. daily steps & cadence. Here is detailed review of the evidence for the utility of physical activity monitor (Actigraph, Fitbit, etc) use in myositis
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Dear All Rheum and Pulm folks in USA, please consider referring you myositis (clinical or autoantibody) and ILD patient for MINT clinical trial. This is a decentralized trial without requiring any visit to clinical trial site (from anywhere in USA).
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#MyositisPearl
8: A subtype of
#Myositis
is Immune Mediated Necrotizing Myopathy (
#IMMM
). It is about 20% of all
#IIM
. It is associated with anti-SRP (1/3rd) & anti-HMGCR (1/3rd) Myositis Antibody. 1/3rd Ab negative. Leads to severe muscle weakness, very high CK and disability.
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#MyositisPearls
55
Rapidly progressive ILD is a rare manifestation in
#myositis
, with fast progression over weeks to months.
💫Common in pt with anti-MDA5 & occasionally in Anti-Synthetase & overlap Myositis.
💫Associated with palmar papules, amyopathic DM & poor survival.
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#MyositisPearls
for Patients 49- Other characteristic skin lesions in DM
💫 Scaly, raised inflamed skin patches on scalp (can resemble dandruff and psoriasis)
💫 Hair loss without scarring
💫 Red rash on the chest- "V sign"
💫 Red rash on the back- "Shawl sign"
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Soon CD19 CAR T cell based therapy will be a reality in Myositis. I think it is a game changer for Myositis.
⚡️Wow ! A patient with an idiopathic inflammatory myopathy was successfully treated with CD19 CAR T cells
@TheLancet
.
Now cell therapies will be used for inflammatory myopathies
👉🏼Müller et al
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#MyositisPearls
42 - Think about a Myositis even in a patient presenting with polyarthritis as it can be first presentation in some patients especially anti-synthetase syndrome. Sometimes Anti-Synthetase patients are misdiagnosed as RA.
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#myositispearls
114
Myopathies with inflam. on muscle biopsy misdiag. as PM:
✨IBM
✨LGMD2B(dysferlinopathy)
✨Facioscapulohumeral dystrophy(FSHD)
✨LGMD2A(calpainopathy)
✨LGMD2I(Fukutin-rel. protein def.)
✨LGMD2E(betasarcoglycanopathy)
✨Autoimmune necrotizing myopathy
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Dear All - Try to restart my MyositisPearl twitter series...after inspiration from
@Janetbirdope
; Will start from very basics about myositis and slowly get into more advanced stuff.
#MyositisPearl
1: The cause of the IIM (
#Myositis
) is believed to be a combination of genetic susceptibility & environmental triggers. IIM affects pts. in 2 age peaks - adolescence & the sixth & seventh decades of life, & is more in females (70%). Ref:
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#MyositisPearl
4:There are 5 muscle enz abn in Myositis - CK, AST, ALT, Aldolase, LDH. AST, ALT, and LDH may be more abn than the CK or Aldolase in some. Mostly seen juvenile DM (40% of pts with LDH, aldolase, AST or ALT abn when CK is normal), but also in PM (10%) and DM (15%).
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#MyositisPearls
83
-Digital nail fold abnormality are common
-Use ophthalmoloscope/dermatscope
-Features: dilatation & tortuosity of capillary loops, areas of capillary dropout & hemorrhage
-Associated with active disease
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Dear Friends, next on
#MyositisPearls
, I would be covering- Making the diagnosis of
#Myositis
: Muscle Biopsy and Interpretation.
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Dear Twitter Friends, Next on
#MyositisPearls
, I would be covering a short tutorial series on Manual Muscle Testing (MMT), one of the core set measures of disease assessment in
#myositis
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#MyositisPearl
1: The cause of the IIM (
#Myositis
) is believed to be a combination of genetic susceptibility & environmental triggers. IIM affects pts. in 2 age peaks - adolescence & the sixth & seventh decades of life, & is more in females (70%). Ref:
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#MyositisPearls
for Patients 50 :
Scaling and cracking of the skin of the hands due to ⬆️⬆️ keratin deposition is called Mechanic’s hands. Skin resembles coarse hands of industrial workers. Seen most commonly in Anti-Synthetase syndrome.
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Myositis Pearl # 3 When evaluating muscle weakness, these clinical features should point away from polymyositis: Asymmetrical weakness, sensory loss, neuropathy, fasciculations, cramping, very high/low muscle enzymes > 100x ULN or < 3-5x ULN, lack of response, early atrophy, etc.
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#MyositisPearls
for Patients 80
💫Gottron papules are red or violet patches that can be seen on the back of the hand in JDM. Gottron sign is same rash but they are not raised. Hides on elbows and knees as well.
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#MyositisPearls
120:
- MRI is a useful tool to exclude several myositis mimics by recognising patterns of muscle involvement
- Although EMG is the standard of care to guide muscle biopsy MRI provides a more non-invasive approach for selecting site of muscle biopsy
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#MyositisPearls
45
Think about a Myositis (order Myositis antibodies) even in a patient presenting with just ILD as it can be first presentation in some patients especially anti-synthetase syndrome. Sometimes Anti-Synthetase patients are misdiagnosed as IPF or IPAF.
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#MyositisPearl
11: For asymptomatic HyperCKemia: Work up is recommended only if the serum CK > 1.5 times the upper limit of normal (ULN). ULN is as per 97.5%ile of gender & ethnicity = 200 for white🧍♀️,300–400 for black 🧍🏾♀️, 500 for white 🧍and 800 for black 🧍🏾.
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Congratulations to Tanya Chandra, the Silent Brightest Budding Star of Myositis for successfully completing first of its kind ACGME recognized Myositis Fellowship in the world
@UPMC
/
@PittRheum
Myositis community is grateful for your commitment to myositis patient and research.
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Happy Holi: Today is a festival of holi - an Indian festival of color which celebrate rising above any differences we may have among our friends, family or enemies. It makes me rise above differences in color, gender, religion, race, language & country. Let’s be a human first.
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MyositisPearls 52 :
💫ILD can sometimes be the presenting and predominant symptom in myositis.
💫In any pt with ILD, myositis must be kept in the differential.
💫 Occasionally ILD is the only features of Myositis without any muscle involvement (known by positive Myositis).
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#MyositisPearl
for patients 1:
#Myositis
is a disease that affects muscles & has 2 age groups where it's more common - teenagers & people in their 60s or 70s. It's believed that a combination of genes & environmental factors may cause it. Myositis is more common in women 70%.
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#MyositisPearl
10: Patients with asymptomatic hyperCKemia should have repeat CK testing after avoiding exercise for 7 days. Also, CK elevation should be based of 97.5% for gender & ethnicity; NOT the lab’s upper limit of normal. CK in healthy is skewed towards higher levels.
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Myth: Myositis is weakness without pain.
@TheMyositisAssc
@MyositisSupport
See our paper on pain in myositis by Anjana Pillai. Pain is common in myositis & associated with muscle weakness & disease activity; however residual pain is due to muscle damage.
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Pass on the good Karma (Selfless). I was flying with my family but due to last min flight changes my seat got separated from family (wife n 2 kids). A lady graciously agreed to exchange her seat so we could be together. Then the seat she got from us was upgraded to business.
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#MyositisPearl
18: Weakness Vs. Myalgia- if muscle pain without weakness is the main symptom - it’s a major red flag in the diagnosis of
#Myositis
and points towards fibromyalgia or PMR or other metabolic myopathies/neuropathies. Myalgia commonly seen with weakness in Myositis.
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#MyositisPearls
47-
Most characteristic rash in DM:
💫Gottron Papules-
- Red, Raised, plaques of the knuckles of the dorsum of the hand.
- In severe cases - with erosions, ulcerations.
- tough to detect in darker skin tones - erythema looks like hyperpigmentation.
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Getting wisdom of being a scientist and mentorship from super mentor Dr. Najaraju and celebrating my mentee’s bday
@DidemSayginMD
at 1 am at GCOM
@MyoDiscovery
@DidemSayginMD
@EmilyTh95218879
@LatikaGupta_
@PatelAarat
@NataliyaSlater
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Congratulations to UPMC myositis fellow
@ChandraTanya
on functional assessment of myositis patients using sit to stand, timed up and go and 6MWD at
#ACR23
. These are simple tests that can be used patients at home and clinicians in clinics for myositis monitoring & Tx response.
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#MyositisPearls
37- 5. Muscle weakness in IBM- assymetrically involves distal and proximal muscles esp. severe involvement of finger flexors & quadriceps, often with early atrophy.
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#MyositisPearls
43 -
Muscle biopsy may not be required in a classic Dermatomyositis with muscle weakness, classic rashes, elevated muscle enzyme, MRI/EMG consistent and positive Myositis Antibodies. However is must in all Non-DM Myositis like NM, PM or IBM.
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Excited to announce that
@ChandraTanya
a rheum fellow from
@Georgetown
Univ. will be joining
#Myositis
team at
@PittRheum
as our 1st myositis fellow this July!
Her passion for helping those with myositis is truly inspiring & we can’t wait to see the positive impact she will make
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Excellent Study By Chris Mecoli and Hopkins group about yield of CT scan in Myositis screening. Highly recommend doing Pan CT in high risk Myositis patients at diagnosis like DM, TIF 1 gamma antibody, age > 40 and other risk factors.
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#MyositisPearls
122: Types of muscle MRI
✨ Thigh muscle MRI are convenient as thigh muscles are most frequently involved in myositis & are feasible targets for biopsy sites
✨ Although whole body MRI protocol dictates 45 mins of procedure duration it offers comprehensive
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#MyositisPearls
121 : MRI in IIM
- T1-weighted sequences are used in muskuloskeletal MRI and in IIM they exhibit muscle edema, fat replacement and muscle atrophy
- Fat suppressed T2w and fluid sensitive sequences help to monitor disease activity and target muscle for biopsy.
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Oral presentation at
#EULAR2024
by Eduardo Dourado from Portugal on classification of anti-Synthetase Syndrome from
#CLASS
project. Spoke eloquently and made a complex topic easy.
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Dear Friends, as promised - here is the first video for myositis patients explaining - What is Myositis? In
#Myositis101
series I will post 1 myositis video each week to promote myositis awareness. Subscribe to YouTube channel Myositis101 for the updates.
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#MyositisPearl
for patients 14: When your doctor has ruled out common causes of high CK levels without symptoms they may do genetic testing followed by EMG or MRI & muscle biopsy for neuromuscular causes. Note chances of diagnosis is low & no treatment for most. It’s your choice.
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#ACR20
Join me for a Major Breaking News of the myositis world - First-ever positive Phase 3 clinical trial. At 10 am ET Saturday. Join Abstracts Session: Muscle Biology, Myositis & Myopathies Myositis.
@didemsayginmd
@drhectorchinoy
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#MyositisPearl
5: Top environmental risk factors are: UV radiation for DM and Smoking for anti-synthetase. The prevalence of DM, as a proportion of DM/PM, and # anti-Mi-2+ DM, increases from north to south with latitudinal gradient. No consistent infection risk.
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#MyositisPearls
49- Other characteristic skin lesions in DM
💫 Scaly, psoriasiform plaques on scalp (diff from seborrheic dermatitis and psoriasis)
💫 non-scarring alopecia
💫 Erythema and poikiloderma on the chest- "V sign"
💫 Erythema and poikiloderma on the back- "Shawl sign"
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Dear Friends: Here is my 4thd video on
#Myositis101
for patient - in this video discussing on common triggers of Myositis. Few key risk or triggers of myositis - smoking, UV light, statin, cancer as well as talk about infection risk of myositis.
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PROMIS PROs are really awesome with several advantages over others. Congratulations to Shiri Keret,
@RaisaLomanto
@ChandraTanya
for publishing the reliability, validity & responsiveness of PROMIS physical function 20 in Myositis. Use in myositis trials.
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#MyositisPearl
3: Inclusion Body Myositis (
#IBM
) is a severe and disabling subtype of IIM (
#myositis
) that leads to muscle inflammation & degeneration. More common in older (>50) & Males. Huge unmet need as there is no treatment except exercise.
Ref:
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#MyositisPearls
21 - MMT: More key points to remember-
💪 The examiner must stand close to the patient on the side of the target muscle;
💪 All non-axial muscles must be tested bilaterally, one muscle at a time.
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#MyositisPearls
36- Muscles commonly affected in Myositis are deltoid (shoulder and arm) > hand/wrist; and Hip (flexors and gluteal muscles) > ankle/foot. Also neck flexor weaker than extensor. Also core muscles.
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Friends, 5th Myositis 101 video is here - Making Diagnosis of Myositis, where I am explaining how a doctor makes an accurate diagnosis of myositis. Next week - the differences between muscle weakness, muscle pain, and muscle fatigue. Welcome feedback.
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#MyositisPearls
93 :EULAR/ACR
Classification Criteria
📘 data & consensus driven new myositis classif. criteria made by experts
📘 overcomes limitations of all other criterias
📘 based on two steps: to identify
a) myositis pt vs non-myositis pt
b)subgroups of myositis
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#MyositisPearl
for Patients 18- If muscle pain (called myalgia) without muscle weakness is the main symptom - then this may point towards neuropathy or other muscle disorders including metabolic myopathy or muscle dystrophies, fibromyalgia, or PMR, etc.
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Dear Friends sharing a myositis101 for patient video on how myositis and muscle disease patients can use this simple test to check their own muscle strength and monitor it over time.
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#MyositisPearls
: 91 - When to suspect
#myositis
📘 Muscle weakness (low endurance), mm. Enzyme⬆️
📘Seronegative polyarthritis
📘Typical rashes/palmar papules
📘ILD with Raynaud's/Mechanic's hands/fever/arthritis
📘Dysphagia
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#MyositisPearls
132 - Role of Myositis Specific Antibodies
-Myositis Specific Autoantibodies (MSAs) and Myositis Associated Autoantibodies (MAAs) are powerful predictive tools for treatment response, phenotyping and prognosis.
-MSA are highly specific (95%) but each MSA has
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#MyositisPearls
for Patients 44- Doctors should consider Myositis and order Myositis Antibodies in patients with shortness of breath or cough due to ILD because ILD alone can be the first sign of Myositis; especially in Anti synthetase syndrome (a type of Myositis).
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