Secrets & Pearls of Rheumatology at ACR Convergence 2025

Labs in Connective Tissue Disease

Dr. Pope said it is important not to order an anti-nuclear antibody (ANA) test if there is low index of suspicion because it can generate false positive results. “This may not only generate patient concern, but is a waste of resources. And don’t repeat a positive ANA; that’s a waste of money,” Dr. Pope quipped.

The extractable nuclear antigen (ENA) test can only be positive in a negative ANA patient in positive Ro/SSA patients.⁵ “The other positive ENA tests are irrelevant if there is a negative ANA,” Dr. Pope said. “And don’t order a dsDNA [double-stranded DNA test] if the ANA is negative, as dsDNA can only be in the nucleus.”

Dr. Pope also advised to stop ordering dsDNA and complements in SLE patients if they have negative tests for several visits, unless clinically indicated.⁶ “The chance of converting to positive is very low if previously repeatedly negative,” she noted.

Raynaud’s Phenomenon

Dr. Pope highlighted a phone application called Magnifier that allows you to visualize nailfolds when evaluating patients with Raynaud’s phenomenon. “Abnormal nailfold capillaroscopy increases the chance of developing a future connective tissue disease,” Dr. Pope said.

Scleroderma

Interstitial lung disease in systemic sclerosis can occur at any time, in both the diffuse and limited subsets, though risk is highest in the first few years, Dr. Pope reviewed.

Sjögren’s Disease

“Repeatedly screening all patients with Sjögren’s disease for lymphoma is unnecessary,” Dr. Pope said. “This is a waste of money.” She suggested instead screening higher-risk patients, such as those with B symptoms or weight loss, or features like persistent salivary gland enlargement, low complement and positive cryoglobulins.⁷

Other Rheumatic Diseases

Dr. Chatham

Walter Winn Chatham, MD, professor of internal medicine, clinical immunology and rheumatology at the Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, spoke next about clinical pearls in other rheumatic diseases.

Crystalline Arthropathy

Calcium pyrophosphate disease (CPPD) was noted to be a mimic of giant cell arteritis or polymyalgia rheumatica. For example, an elderly patient may present with shoulder/hip girdle pain and high inflammatory markers with neck pain and occipital headache, but have the crowned dens sign of CPPD on radiographs.⁸

Additionally, patients with gout or CPPD may present with systemic inflammatory response syndrome (SIRS)–like phenotype and high C-reactive protein levels. “Consider gout and CPPD in the differential for nosocomial fever in elderly patients, especially after infection is ruled out,” Dr. Chatham said. “Crystalline arthritis can be highly inflammatory.”