This morning we were treated to a fascinating Grand Rounds regarding the impact of inflammation on bone health by Dr. Ellen M. Gravallese of Harvard University and Brigham And Women’s Hospital. The talk discussed the mechanisms underlying the effect of inflammatory arthritis on bone physiology. Dr. Gravallese shared studies of mouse models to highlight the inflammatory pathways that affect osteoclast and osteoblast biology. She also discussed how the change in focus to early and aggressive treatment of inflammatory arthritis is necessary to prevent joints from destruction. The talk dived into the details of RANKL and sclerostin pathophysiology and the role of innate immune DNA sensors in bone homeostasis.
Missed the recording? You can view the recording of the presentation here:
Transitions of Care within Rheumatology: Dr Chira, from the Rady Children’s Hospital Department of Rheumatology, gave a session on Transitions of Care! Dr Chira emphasized the importance of a transition process for all children transferring care from the pediatric to adult health care system. He highlighted the 6 Core Elements of Transition from GotTransitions.org! The second half of the session was spent in small groups working through cases and building models to help us transition and welcome our young adult patients in our Internal Medicine clinics.
Health Disparities in Asthma: Dr Akuthota, from our Pulmonary & Critical Care Department, highlighted the high proportion of asthma and ER visits related to asthma in Latinx and Black ethnicities. These discrepancies between races are most likely multifactorial- SES, genetics, Vitamin D status, history of violence/stress, access to healthcare, environmental exposures.
Pregnancy and Autoimmunity: Dr Smith, from our Rheumatology Department, emphasized that a “planned pregnancy is the best pregnancy” with our patient with autoimmune diseases. Low risk medications during pregnancy include HCQ, NSAIDs, AZA, calcineurin inhibitors, sulfasalazine, TNF alpha inhibitors! Do NOT use MTX, MMF, cyclophosphamide in pregnancy! HCQ is also associated with better pregnancy outcome in patients with SLE!
Mystery Case: Today we interviewed a patient about his symptoms. He endorsed worsening back pain and stiffness starting in his early twenties. As time passed, his symptoms became worse and he started to notice decreased range of motion of his back. Pain was worse at night and was associated with considerable morning stiffness. What was the final diagnosis? Ankylosing Spondylitis! Thank you to Mr H for joining us and telling us your amazing story!
Intern Friday School
The interns had a separate session dedicated to the knee and shoulder exam! Dr Quan walked them through the exam with interactive videos with real patients to help illustrate many of the physical exam maneuvers we use in clinic!
This Friday at Friday school, in addition to the amazing journal fight club on the use of plasmapheresis for ANCA-associated vasculitis affecting the kidney (see Justin’s separate, awesome post), we ALSO learned about diagnosing and managing common musculoskeletal complaints (with Dr. Ken Vitale from sports medicine), crystal arthropathy (with gout guru and guideline author Dr. Robert Terkeltaub) and rheumatoid arthritis (with gifted clinician-educator Dr. Katherine Nguyen). YAY Rheumatology! The “smart guy” consult for multi-system disease!
Here are a few key take home points!
In the world of sports medicine age >40 (and in some cases >35) is OLD, and impacts the epidemiology of common causes for knee pain
Iliotibial band syndrome presents with diffuse, poorly localized lateral knee and distal thigh pain at the end of exercise involving knee flexion and extension . Running outdoors or downhill may worsen symptoms. On exam, there is often tenderness ~ 2-3 cm proximal to the lateral femoral condyle. Treat with abstinence from inciting activity, ice, followed by gradual return to activity, stretching, strengthening, and local massage.
Consider radial tunnel syndrome in patients with burning or numbness on the outside forearm and elbow, just distal to the lateral epicondyle.
Gold standard for diagnosis of acute gout is negatively birefringent, needle-like uric acid crystals within neutrophils in joint fluid.
Colchicine, NSAIDs, and glucocorticoids (intra-articular or systemic) are all options for treatment of acute gout; consider patient comorbidities (diabetes, kidney disease) and drug interactions when choosing.
The American College of Rheumatology recommends a “treat-to-target” approach, with a target serum urate <6.0 mg/dL . Allopurinol, started at a low dose (100mg/day for normal kidney function) and titrated up, is the 1st line therapy; check an HLAB58*01 first in those from high risk ethnic groups (Black & Asian) to avoid severe hypersensitivity skin reaction. Start anti-inflammatory prophylaxis to prevent flares.
Rheumatoid Arthritis (RA)
The most useful lab tests in the diagnosis of rheumatoid arthritis (RA) are rheumatoid factor and anti–cyclic citrullinated peptide (CCP) antibodies; anti-CCP antibodies have a specificity of 95% for RA.
Methotrexate is the anchor drug in rheumatoid arthritis; it is used as monotherapy and as a component of combination therapy.
Tumor necrosis factor α inhibitors are the most frequently used biologics to treat rheumatoid arthritis; they have a rapid onset of action and synergy with methotrexate.
Today was our first day of the Rheumatology Friday School Block and part of our Resident As Clinician Educator for All (RACE 4 All) curriculum!
From 1-3pm, RACE Track Director, Dr. Supraja Thota shared tips on how to be an amazing team leader and teach on rounds. She included a mini-workshop on the “holdover game,” helping residents to make holdovers into a rich, interactive cognitive reasoning exercise that can help avoid anchoring!
From 3-5pm, residents and interns gathered in small groups to come up with creative questions to test their co-residents on the clinical manifestations, work up and treatment of SLE! Dr Maripat Corr from our Rheumatology Department then reviewed SLE with us! With her help, and the help of our new resident experts in SLE, we were able to answer all the fun (but difficult) questions made by each small group! While we were able to cover a lot, learning about SLE is not restricted to Friday School! Check out this amazing article on SLE for the internist in the Annals of Internal Medicine! Click Here!
Today our wonderful R2 Dr. Susan Seav lead us through a diagnostic reasoning exercise of a man in his 40’s who presented with an acute generalized tonic-clonic seizure. We began by reminding ourselves of other conditions that could mimic seizures and went through why we would put our money down on this being a presentation of seizure. We then went through the updated classification/descriptors for seizures.
We next walked through our diagnostic schema for seizures and based on the physical exam findings of polyarticular joint pain and rash, and elevated inflammatory markers, we narrowed the differential to an autoimmune cause of the seizures. Further serologic studies revealed that the patient likely had neuropsychiatric lupus (NPSLE) based on the new clinical criteria!
Our rheumatology expert discussant, Dr. Soo In Choi, advised us regarding the sensitivities and specificities of diagnostic studies we could order. We ended by briefly going through the proposed pathophysiology for NPSLE syndromes.
Thank you again to Dr. Seav for such an exciting case and to Dr. Choi for lending your expertise!
R3 Allen Jiang and CMR Robert Thomas led us (and our awesome applicants) through a fascinating case with LOTS of twists and turns. This included a diagnostic schema for postprandial abdominal pain, imaging and labs suggestive of vasculitis, and whole genome sequencing searching for a mutation to explain the patient’s findings. Robert got us out of our seats to place various vasculitis diagnoses in their appropriate categories of small, medium and large vessel. Dr. Arnold Ceponis (Fellowship PD, Rheumatology) was our expert discussant.
REMINDER: Recruitment AM Reports will be held in the Hillcrest Auditorium on the 1st floor, near the West Wing. Come early to grab coffee and bagels before AM report!
Today we discussed a patient who presented with acute onset right hip pain, unable to ambulate or range the joint. The patient was afebrile but exhibited leukocytosis and an elevated CRP. Synovial fluid was obtained by our colleagues in MSK-radiology. The fluid looked purulent, the WBC count was greater than 50,000, and the patient started broad spectrum antibiotics. Ultimately, synovial fluid analysis demonstrated calcium pyrophosphate crystals and cultures were negative. After clinical improvement, antibiotics were stopped and he recovered from his pseudogout flare on colchicine. Remember that gout or pseudogout can both present with bacterial superinfection. Treat with antibiotics early, and make sure you call the right colleagues about synovial fluid sampling. In this case, MSK-radiology saved the day!
Today we had a case of a man in his 30’s who came in with shortness of breath and chest pain with exertion and found to be volume overloaded, with labs and exam concerning for pericarditis. He had a vague history of joint pain for 5 years that he ignored and but was found to have symmetric polyarticular joint swelling, pain and subcutaneous nodules highly concerning untreated rheumatoid arthritis! His RF and anti-CCP ab were quite elevated, and he was ultimately diagnosed with constrictive pericarditis as a sequelae of his arthritis.
Dr. Corr, our expert discussant from Rheumatology, reminded us that Rheumatoid Arthritis can be diagnosed largely from a careful history and physical alone. Remember to check about smoking history as it is a large risk factor, and counsel about cessation if the patient happens to be a smoker! Flares can be treated with steroids, but first line therapy is methotrexate, with other non-biologic and biologic DMARDs as adjunct therapies. Our patient ultimately had improvement of his pericarditis symptoms with diuresis, colchicine and steroids and methotrexate.
Today we discussed a case of a young woman who initially presented to her PCP with fatigue and dark urine. We walked through a differential on the board of the causes of dark urine, specifically for gross hematuria. Our nephrology expert discussant, Dr. Rifkin helped us review the components of the urinalysis and reminded us why it is important to go spin the urine and look under the microscope for dysmorphic cells and casts. The patient ultimately was diagnosed with lupus nephritis and got a kidney biopsy. We went over the classifications of lupus nephritis and the implications for treatment. Our patient was found to have class IV +V lupus nephritis and sent out of steroids.
Thank you Dr. Rifkin for your teaching and clinical pearls !