Secrets & Pearls of Rheumatology at ACR Convergence 2025

Seronegative Syndromes

“Consider seronegative spondyloarthritis if a patient has joint tenderness of the great toe IP [interphalangeal] joint,” Dr. Chatham said, noting it is often a signal enthesal focus. He discussed how polyenthesal tenderness points can sometimes be confused with fibromyalgia.

Patients with psoriatic disease commonly have sicca features including ocular sicca and xerostomia, which is often underappreciated, Dr. Chatham said.⁹

Medications

ANA positivity can commonly develop in patients on anti-tumor necrosis factor (TNF) therapy, and, rarely, drug-induced lupus can occur. The incidence of drug-induced lupus in patients on TNF inhibitors is estimated at 0.2–2%.¹⁰

“When using intravenous immunoglobulin [IVIg], passive antibody transfer with IVIg can have significant impacts that are important to recognize,” Dr. Chatham said. “This includes interfering with autoantibody results due to false positives from passive antibody transfer.” He explained how IVIg can also cause an immune complex vasculitis in patients with cryoglobulin syndrome or immune complexes that contain rheumatoid factor.

Other Miscellaneous Problems

Refractory greater trochanteric bursa pain syndromes are often due to unrecognized or undertreated innominate pelvic rotation and sometimes altered mechanics from genu varum/valgus, Dr. Chatham pointed out.

Acalculous cholecystitis is noted as a bellwether for possible underlying autoimmunity.^11,12 “This is not an uncommon complication of patients with SLE, Sjögren’s and systemic sclerosis,” Dr. Chatham added. “And importantly, this can antedate the diagnosis of these disorders and occur in healthy patients and is not only seen in critical illness.”

Malignancy Pearls

In older adult patients, it is important to recognize IgA vasculitis in the absence of an infectious trigger has a high association with malignancy.¹³ Similarly, macrophage activation syndrome or secondary hemophagocytic lymphohistiocytosis (HLH) phenotype in patients older than 60 years is most likely due to malignancy, requiring malignant HLH to be evaluated thoroughly.¹⁴

Mithu Maheswaranathan, MD, is an assis­tant professor of medicine in the Division of Rheumatology at Duke University School of Medicine, Durham, N.C. and can be followed on X/Twitter @MithuRheum.

References

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