Dr. Jack Cush and guests discuss complex rheumatology cases including RA with TB, relapsing polychondritis, ICI induced RA in breast cancer, sarcoidosis in the maxilla, and acute onset monoarthritis in a young woman. They explore unique treatment approaches, challenges, and diagnostic strategies for these rare cases.
Resuming RA therapy is crucial in active TB patients to prevent complications and TNF inhibitors can be used safely.
Imaging techniques like CT and MRI are recommended for assessing severe relapsing polychondritis with traditional inflammation markers being unhelpful.
Using TNF inhibitors or DMARDs is advised to control inflammatory arthritis in metastatic breast cancer patients, ensuring minimal impact on primary cancer.
Deep dives
Treatment Recommendations for Rheumatoid Arthritis and Tuberculosis
The podcast discusses two cases involving patients with rheumatoid arthritis and tuberculosis. In the first case, a 42-year-old female with rheumatoid arthritis and Crohn's disease was hospitalized with symptoms of fever, cough, and shortness of breath. She was diagnosed with active tuberculosis and is currently being treated with anti-TB medication while her RA therapy is temporarily on hold. The speaker recommends resuming her RA therapy to prevent complications and emphasizes that TNF inhibitors can be used safely. In the second case, a 74-year-old male with rheumatoid arthritis and a positive TB test but no symptoms is considered to have latent tuberculosis. The speaker recommends treating him with INH for 6-9 months to prevent reactivation and assures that he can safely resume his RA therapy once on treatment.
Monitoring and Treatment of Inflammatory Activity in Debilitating Rheumatic Disease
The podcast addresses the challenges of monitoring and treating inflammatory activity in a patient with severe relapsing polychondritis. The patient has experienced extensive tissue damage over time, resulting in various complications. Traditional markers of inflammation may not be helpful in this case. The speaker recommends using imaging techniques like CT, MRI, and FDG PET to assess the extent of damage and determine if inflammation is present. If inflammation is confirmed, treatment options include methotrexate, leflunomide, azathioprine, and TNF inhibitors. The speaker emphasizes the importance of controlling the disease to prevent long-term complications and advises consulting with a specialist in sarcoidosis to guide management decisions.
Management of Inflammatory Arthritis in Patients with Metastatic Breast Cancer
The podcast discusses the management of inflammatory arthritis in a patient with metastatic breast cancer who developed the condition after receiving checkpoint inhibitor therapy. The patient is currently on a high dose of steroids but wants to get pregnant and avoid methotrexate. The speaker suggests using TNF inhibitors or other DMARDs to control the disease and reduce dependency on steroids. The speaker reassures that treating the inflammatory arthritis will not adversely affect the primary cancer and emphasizes that the oncologist should monitor the cancer while the rheumatologist focuses on managing the arthritis. The goal is to achieve disease control before considering pregnancy.
Monitoring and Treatment of Bone Involvement in Sarcoidosis
The podcast addresses the challenges of monitoring and treating sarcoidosis affecting the bone, specifically the maxilla. The case involves a 21-year-old woman who developed bone destruction near a dental implant and subsequent biopsies revealed granulomas consistent with sarcoidosis. The speaker suggests involving a sarcoid clinic or specialist to manage the patient. Recommended treatment options include infliximab, high-dose azathioprine, and other immunosuppressive medications. The speaker highlights the importance of considering tissue involvement and damage rather than relying solely on lab tests, and underlines the value of imaging techniques like CT, MRI, and FDG PET in assessing the extent of sarcoidosis and guiding treatment decisions.
Diagnostic Approach and Treatment for a Young Woman with Acute Monarthritis
The podcast presents a case of a 17-year-old woman presenting with acute monarthritis of the knee. The speaker highlights the importance of performing a joint tap to rule out infection. The differential diagnosis includes gonococcal reactive arthritis, pseudogout, and spondyloarthritis. Further evaluation reveals that the patient also has Crohn's disease, which is likely the underlying cause of the arthritis. Treating the colitis leads to resolution of the arthritis symptoms. The speaker emphasizes the common occurrence of arthritis as an extra intestinal manifestation of Crohn's disease, particularly in younger individuals.
Dr. Jack Cush answers audience clinical case questions sent by email or "ask Cush anything". Cases and questions from:
Dr. William Hong - RA management in the setting of active TB or latent TB (LTBI)
Dr. Vrishali Dalvi - relapsing polychondritis monitoring
Dr. Ken Stark - ICI induced RA; management and breast cancer considerations
Dr. Nada Skaf - Sarcoidosis in the maxilla
Dr. Cush - acute onset (knee) monarthritis
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