Mithu Maheswaranathan, MD @MithuRheum
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Rheumatologist at Duke University Creator of Rheum OnePagers ➡ RheumOnePagers.com Twitter: @MithuRheum ➡ https://twitter.com/MithuRheum
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ACR Guidelines for Vaccines in Patients with Rheumatic & Musculoskeletal Diseases 2022

Vaccine Guidance:
 • Expanded Indications
ACR Guidelines for Vaccines in Patients with Rheumatic & Musculoskeletal Diseases 2022 Vaccine Guidance: • Expanded Indications for Specific Vaccines • Multiple Vaccines in one Day • Non-Live vs Live Vaccinations By Mithu Maheswaranathan, MD @MithuRheum #Vaccine #vaccination #Guidelines #rheumatology #management #immunocompromised
Guidelines for Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip
Guidelines for Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty Continue or withhold prior to Surgery • DMARDS • Biologics • JAKi By Dr. Mithu Maheswaranathan, MD @MithuRheum #rheumatology #medications #hold #perioperative #guidelines #management #autoimmune #pharmacology #table
Myositis Specific Antibodies (MSAs)

Dermatomyositis: MDA5, TIF1y, NXP2, Mi-2, SAE
Anti-Synthetase Syndrome: Jo-1, PL7, PL12, EJ, OJ
Immune Mediated
Myositis Specific Antibodies (MSAs) Dermatomyositis: MDA5, TIF1y, NXP2, Mi-2, SAE Anti-Synthetase Syndrome: Jo-1, PL7, PL12, EJ, OJ Immune Mediated Necrotizing Myopathy (IMNM): HMGCR, SRP Inclusion Body Myositis (IBM) + others: NT5c1A/cN1A By Mithu Maheswaranathan, MD @MithuRheum #Myositis #Specific #Antibodies #MSAs #clinical #diagnosis #rheumatology #table
Scleroderma Renal Crisis (SRC)

Clinical Presentation of Scleroderma Renal Crisis:
1) Acute kidney injury
2) Abrupt onset of hypertension
3)
Scleroderma Renal Crisis (SRC) Clinical Presentation of Scleroderma Renal Crisis: 1) Acute kidney injury 2) Abrupt onset of hypertension 3) Abnormal urinalysis 3) microangiopathic hemolytic anemia (MAHA) Pathophysiology: • Precise pathogenesis is unknown but may involve vasculopathy, endothelial cell activation, ↓ perfusion • Biopsy → endothelial cell injury, arteriolar thickening, fibrinoid necrosis, fibrotic "onion-skinning" of arteries Management Pearls: • Hospitalization for BP control & Monitoring • Renal Biopsy to confirm diagnosis and rule out other pathology (e.g. pauci-immune GN) • Initiate ACEi (short-acting, e.g. captopril, to allow titration q6 hours) for initial therapy. • If uncontrolled with ACEi, add other BP meds • Refractory cases → consider PLEX (overlap TTP or aHUS), eculizumab, vasodilators (ERAs) By Mithu Maheswaranathan, MD @MithuRheum #SRC #Scleroderma #Renal #Crisis #rheumatology #nephrology #diagnosis #management
CNS Manifestations of Systemic Lupus Erythematosus (SLE)

Clinical Manifestations: Demyelinating Syndrome, Headache, Movement disorders, Seizure disorders, Aseptic
CNS Manifestations of Systemic Lupus Erythematosus (SLE) Clinical Manifestations: Demyelinating Syndrome, Headache, Movement disorders, Seizure disorders, Aseptic Meningitis, Myelopathy, Encephalopathy, Cognitive Dysfunction, Cerebrovascular Disease, PRES Pathophysiology: Pathogenesis involves the formation of autoantibodies that will cause ischemia and/or inflammation, leading to vasculopathy, thrombosis and/or blood-brain barrier permeability Diagnosis of Lupus Cerebritis: Labs, Imaging, Lumbar Puncture, EEG Treatment: • Inflammatory Pathway - Lupus Cerebritis Induction Rx: high-dose glucocorticoids + cyclophosphamide • Ischemic Pathway - Aspirin, anticoagulants (for secondary APS), Secondary prevention (statin for CVA) By Dr. Gabriela Figueiredo Pucci @gabifpucci (@neudrawlogy) and Mithu Maheswaranathan, MD @MithuRheum (@RheumOnePagers) #Systemic #Lupus #Erythematosus #SLE #CNS #neurology #rheumatology #cerebritis #diagnosis #management #treatment
Systemic Sclerosis (Scleroderma)
Multi-system autoimmune disease characterized by vasculopathy and progressive fibrosis of skin and internal organs
3
Systemic Sclerosis (Scleroderma) Multi-system autoimmune disease characterized by vasculopathy and progressive fibrosis of skin and internal organs 3 Subtypes of Scleroderma (SSc): • Limited cutaneous systemic sclerosis (LcSSc) - distal skin thickening, distal to elbows/wrists and knees • Diffuse systemic sclerosis (DcSSc; diffuse) - skin thickening extends proximally to arms, thighs, and/or trunk • Systemic Sclerosis sine scleroderma (ssSSc) - fibrosing internal organ involvement without skin thickening Signs and Symptoms: • Cardiac: myocardial fibrosis, pericarditis • Hepatic: PBC (primary biliary cholangitis) overlap • Gastrointestinal: GERD, dysmotility, SIBO, GAVE, pseudoobstruction • Cutaneous ("salt and pepper" skin changes): skin thickening, sclerodactyly, telangiectasias, poikiloderma, calcinosis • Pulmonary: ILD (interstitial lung disease), PAH (pulmonary arterial HTN) • Renal: scleroderma renal crisis (SRC) • Musculoskeletal: joint involvement, acro-osteolysis, myositis overlap • Vascular: Raynaud's, digital ulcers Mithu Maheswaranathan, MD @MithuRheum #Systemic #Sclerosis #Scleroderma #SSc #rheumatology #diagnosis #signs #symptoms #testing #workup
Scleroderma Mimics
 • Scleredema
 • Scleromyxedema (papular mucinosis)
 • Eosinophilic Fasciitis
 • Nephrogenic Systemic Fibrosis
 •
Scleroderma Mimics • Scleredema • Scleromyxedema (papular mucinosis) • Eosinophilic Fasciitis • Nephrogenic Systemic Fibrosis • POEMS Syndrome • Diabetic Cheiroarthropathy • Environmental Exposures By Mithu Maheswaranathan, MD @MithuRheum #Scleroderma #Mimics #rheumatology #differential #diagnosis
Lupus Nephritis Primer
Class I - Minimal Mesangial
Class II - Mesangial Proliferative
Class Ill - Focal Proliferative
Class IV
Lupus Nephritis Primer Class I - Minimal Mesangial Class II - Mesangial Proliferative Class Ill - Focal Proliferative Class IV - Diffuse Proliferative Class V - Membranous Class VI - Advanced Sclerosing By Mithu Maheswaranathan, MD @MithuRheu and Dr. Caitlyn Vlasschaert @DrFlashHeart #Lupus #Nephritis #SLE #Classification #Classes #differential #diagnosis #management #nephrology
Aortitis - Differential Diagnosis Framework
Non-Infectious Aortitis:
 • Vasculitides: Giant Cell Arteritis (GCA), Takayasu's arteritis, Cogan's Syndrome,
Aortitis - Differential Diagnosis Framework Non-Infectious Aortitis: • Vasculitides: Giant Cell Arteritis (GCA), Takayasu's arteritis, Cogan's Syndrome, Relapsing polychondritis, Behcet's Disease, Polyarteritis Nodosa (PAN), ANCA associated vasculitis (rare) • Rheumatic Diseases: IgG4-Related Disease (IgG4-RD), Rheumatoid Arthritis (RA), Systemic lupus erythematosus (SLE), Sarcoidosis, HLA-B27-related spondyloarthropathies (SPA) • Other Causes: Cancer, Histiocytic disorders (Erdheim-Chester), Immune Checkpoint Inhibitors (irAEs) (rare), Idiopathic Infectious Aortitis: • Most common bacterial causes include: Staphylococcus spp., Salmonella spp., Streptococcus pneumoniae • Mycobacterial Causes: M.tuberculosis, M. bovis • Fungi: Candida, Cryptococcus, Aspergillus, Histoplasma, Paracoccidioides • Viruses: HIV, VZV By Mithu Maheswaranathan, MD @MithuRheu and Dr. Sara Dong @swinndong #Aortitis #Differential #Diagnosis #rheumatology
Rheumatoid Arthritis Summary
Overview: chronic, inflammatory symmetric polyarthritis involving small joints of hands/feet, knees, shoulders
Signs & Symptoms:
Rheumatoid Arthritis Summary Overview: chronic, inflammatory symmetric polyarthritis involving small joints of hands/feet, knees, shoulders Signs & Symptoms: • early AM stiffness, >1 hour • sx improve with activity (inflammatory) • joint pain / swelling Physical Exam • synovitis; joint swelling or tenderness • joint deformities, rheumatoid nodules, joint effusions, reduced ROM Laboratory Studies • RF (rheumatoid factor) • anti-CCP (cyclic citrullinated peptide) - ↑ specificity than RF • ESR/CRP - ↑ inflammatory marker Imaging: • XRay (erosions, joint space narrowing) • Ultrasound Diagnosis: CLINICAL DIAGNOSIS based on history, exam and imaging Treatment: • steroids (prednisone), ideally limit for acute flare • intra-articular corticosteroid injections • DMARDs: Methotrexate (MTX), Sulfasalazine (SSZ), Hydroxychloroquine (HCQ), Leflunomide (LEF) • JAKi / Small Molecules: Tofacitinib, Baracitinib, Upadacitinib • Biologics: Anti-TNF (Adalimumab, Etanercept, Infliximab, Certolizumab, Golimumab), IL-6 (tocilizumab), Abatacept By Mithu Maheswaranathan, MD @MithuRheum via @RheumOnePagers #Rheumatoid #Arthritis #diagnosis #management #rheumatology