Let’s Discuss: Insights from the ACR Convergence 2025 Review Course

Dr. Ardoin also discussed the situation in which a patient’s laboratory studies and physical exam look good, but they feel poorly. In such cases, she recommended that the rheumatologist consider different etiologies of the patient’s not feeling well, including medication side effects, fibromyalgia/amplified musculoskeletal pain syndrome, depression, adrenal insufficiency, other medical conditions that may arise secondary to the effects of SLE and life stressors.

Inflammatory Brain Diseases

Dr. Muscal

The next talk was delivered by Eyal Muscal, MD, MS, division chief, pediatric rheumatology, Pawelek Endowed Chair of Pediatric Rheumatology, Texas Children’s Hospital, Houston, and the topic was inflammatory brain diseases. Dr. Muscal provided a systematic approach to the evaluation of these patients, and he noted four tools at the disposal of clinicians.

Tool #1 is the ability of rheumatologists to listen to the stories that patients and their family members tell about their symptoms and tease out if there are clues to a specific process that ought to be considered. The stories may indicate if an infectious or malignant process is at play, or may hint at features of a systemic disease that clinicians can be searching for, such as with manifestations involving the skin, eyes, kidneys, lungs or other organs beyond the nervous system. Dr. Muscal implored clinicians to consider the possibility of an ischemic or focal process, or the possibility of the acute onset of a neurodegenerative disease. He noted that, although rheumatologists are trained to deal with implications of immune dysregulation in the periphery, a variety of cells can break the blood brain barrier and disrupt normal functioning. For example, certain monocytes and macrophages can take the appearance of microglia in the brain and cause issues.

Tool #2 is imaging, namely computed tomography of the head to look for hemorrhage and magnetic resonance imaging (MRI) of the brain and spinal cord to clearly define the anatomy of the patient’s disease process. Before pursuing imaging, the clinician should have a good sense of if the neurologic process is involving the central nervous system (CNS), the peripheral nervous system, or both, but the results of imaging are still very useful. A black blood MRI of the brain uses specialized sequences that suppress the signal from flowing blood, making blood vessels appear dark (black) on images and thus enhancing the visibility of adjacent structures, such as vessel walls, thrombi and parenchymal lesions. This imaging technique can be helpful in looking for certain forms of inflammatory brain disease, such as that which involves the small vessels.