🧵 CRP vs Procalcitonin – Inflammation vs Infection? Both rise in systemic illness. But they don’t speak the same language. Let’s break down when to use CRP, when to trust Procalcitonin—and when both lie. 👇 @IhabFathiSulima @DrAkhilX @Janetbirdope @emcrit @andrewsuleh @Lupusreference #MedTwitter

Latest targeted therapies in systemic lupus erythematosus. The management of lupus is increasingly moving toward targeted immunologic therapies. Recent advances focus on key immune pathways involved in disease pathogenesis. Current and emerging approaches include: • BAFF inhibition with belimumab • Type I interferon pathway blockade with anifrolumab • Next-generation B-cell targeting therapies • BTK inhibitors under investigation • CD40–CD40L pathway modulation • Cellular therapies such as CAR-T in refractory disease These developments highlight a shift toward precision immunomodulation and reduced reliance on broad immunosuppression. #Rheumatology #Lupus #ClinicalImmunology #MedicalEducation #AutoimmuneDisease @IhabFathiSulima @docakx

MYOSITIS MIMICS Not every elevated CK represents inflammatory myositis. A wide range of endocrine, metabolic, genetic, neurologic, toxic, and critical illness–related conditions can present with proximal weakness and elevated CK levels. Before diagnosing inflammatory myopathy, consider important mimics such as hypothyroid myopathy, muscular dystrophy, metabolic and mitochondrial myopathies, motor neuron disease, myasthenia gravis, drug-induced myopathy, vitamin D deficiency, and critical illness myopathy. The diagnosis of myositis requires more than an elevated CK. Clinical pattern, medication history, autoantibodies, EMG, muscle MRI, and sometimes muscle biopsy are essential. Which myositis mimic do you find most challenging in clinical practice? Infographic by Dr. Aravind Palraj #Rheumatology #Myositis #InflammatoryMyopathy #MedicalEducation #MedEd #FOAMed #Neurology #InternalMedicine #MuscleDisease #ClinicalReasoning #RheumTwitter #MedTwitter #AutoimmuneDisease #DMRheumatology #MedX @docakx @IhabFathiSulima

🧠 RHEUMATOLOGY CHALLENGE A 28-year-old woman with systemic lupus erythematosus presents with: • Proteinuria 3.8 g/day • Creatinine 1.1 mg/dL • Low C3 and C4 • Strongly positive anti-dsDNA Kidney biopsy shows Class V lupus nephritis with nephrotic-range proteinuria. Which of the following is the MOST appropriate initial treatment? A. Hydroxychloroquine alone B. Mycophenolate mofetil glucocorticoids C. Azathioprine glucocorticoids D. Rituximab monotherapy 👇 Comment your answer and reasoning. Dr. Aravind Palraj #Rheumatology #SLE #LupusNephritis #MedEd #ClinicalPearls @docakx @IhabFathiSulima @Renalpathsoc

VASCULITIS MIMICS Not every purpura is vasculitis. Before labeling a patient as having primary vasculitis and initiating immunosuppression, consider important mimics such as infective endocarditis, cholesterol embolization syndrome, antiphospholipid syndrome, thrombotic microangiopathy, calciphylaxis, atrial myxoma, fibromuscular dysplasia, levamisole-associated vasculopathy, septic emboli, and malignancy-associated vasculitis-like syndromes. Recognizing the red flags can prevent diagnostic errors, unnecessary immunosuppression, and potentially life-threatening consequences. Which vasculitis mimic have you found most challenging in clinical practice? Infographic by Dr. Aravind Palraj #Rheumatology #Vasculitis #ANCA #MedicalEducation #MedEd #FOAMed #InternalMedicine #Nephrology #ClinicalReasoning @IhabFathiSulima @docakx #AutoimmuneDisease #MedTwitter #RheumTwitter #MedX #Medicine #MedEdCommunity

🧠 RHEUMATOLOGY CHALLENGE A 42-year-old woman with rheumatoid arthritis has been in sustained clinical remission for 2 years on: • Methotrexate 20 mg/week • Adalimumab 40 mg every 2 weeks She reports no symptoms, has no swollen joints, and inflammatory markers remain normal. She asks whether treatment can be reduced. According to current treat-to-target principles, what is the MOST appropriate next step? A. Stop both therapies immediately B. Continue both therapies indefinitely without reassessment C. Discuss cautious tapering with close monitoring for relapse D. Discontinue methotrexate and continue adalimumab indefinitely 👇 Comment your answer and explain your reasoning. Dr. Aravind Palraj #Rheumatology #RheumatoidArthritis #TreatToTarget #MedEd #ClinicalPearls @IhabFathiSulima @docakx

Not every ANA-positive patient has lupus. Many disorders can closely mimic SLE, including Sjögren disease, MCTD, drug-induced lupus, viral infections, adult-onset Still disease, ANCA-associated vasculitis, sarcoidosis, tuberculosis, infective endocarditis, and fibromyalgia. Recognizing the clues against SLE is just as important as recognizing the clues for it. Which lupus mimic has challenged you the most in practice? #Rheumatology #Lupus #SLE #AutoimmuneDisease #MedEd #FOAMed #RheumTwitter #MedTwitter #ClinicalReasoning #InternalMedicine @IhabFathiSulima @docakx

Not every RF-positive or symmetric polyarthritis patient has rheumatoid arthritis. Before labeling a patient as RA, consider important mimics such as psoriatic arthritis, SLE, viral arthritis, crystal arthropathy, hepatitis C arthropathy, palindromic rheumatism, reactive arthritis, adult-onset Still disease, sarcoidosis, and osteoarthritis. Recognizing the clinical pattern and identifying red flags can prevent misdiagnosis and inappropriate treatment. Which RA mimic have you encountered most often in practice? #Rheumatology #RheumatoidArthritis #MedicalEducation #MedEd #FOAMed #InternalMedicine #ClinicalReasoning #RheumTwitter #MedTwitter #AutoimmuneDisease @docakx @IhabFathiSulima

Not every sacroiliitis is #SpA. Before diagnosing axial spondyloarthritis, consider important mimics such as osteitis condensans ilii, infectious sacroiliitis, TB sacroiliitis, DISH, fibromyalgia, crystal arthropathies, oxalosis, SAPHO syndrome, and hyperparathyroidism. Recognizing red flags can prevent misdiagnosis and inappropriate treatment. #Rheumatology #AxialSpA #Sacroiliitis #MedEd #FOAMed #MedTwitter #RheumTwitter #InternalMedicine @IhabFathiSulima @docakx

Most cases of relapsing polychondritis are not VEXAS. But when an older man develops: • Recurrent chondritis • Macrocytic anemia • Unexplained systemic inflammation Stop and think. Could this be VEXAS syndrome? Early recognition can change management. #VEXAS #Rheumatology #MedTwitter #Hematology #AutoInflammation #RareDisease #InternalMedicine #MedicalEducation #MedEd #FOAMed @IhabFathiSulima @docakx

🧠 RHEUMATOLOGY CHALLENGE A 54-year-old woman with long-standing seropositive rheumatoid arthritis develops neutropenia and splenomegaly. Peripheral blood flow cytometry demonstrates a clonal CD3 CD8 T-cell population. What is the MOST likely diagnosis? A. Felty syndrome B. Large granular lymphocytic leukemia C. Macrophage activation syndrome D. Drug-induced neutropenia 👇 Comment your answer Dr. Aravind Palraj #Rheumatology #RheumatoidArthritis #LGLLeukemia #MedEd #ClinicalPearls @Janetbirdope @IhabFathiSulima @docakx

What’s the single biggest impact this man had on medicine? 👇 #MedTwitter @IhabFathiSulima

🧠 RHEUMATOLOGY CHALLENGE A 31-year-old woman presents with recurrent oral ulcers, genital ulcers, erythema nodosum, and episodic blurred vision. Fundus examination reveals occlusive retinal vasculitis. Despite high-dose glucocorticoids and azathioprine, vision continues to worsen. Which biologic is MOST appropriate to achieve rapid control of ocular inflammation? A. Rituximab B. Tocilizumab C. Infliximab D. Abatacept 👇 Comment your answer Dr. Aravind Palraj #Rheumatology #BehcetDisease #Uveitis #MedEd #ClinicalPearls @IhabFathiSulima

🧠 RHEUMATOLOGY CHALLENGE A 27-year-old woman presents with recurrent oral ulcers, genital ulcers, erythema nodosum, and posterior uveitis. MRI brain confirms cerebral venous sinus thrombosis. Antiphospholipid antibodies are negative. Which treatment targets the primary mechanism responsible for thrombosis in this disease? A. Warfarin B. High-dose glucocorticoids C. Aspirin D. Intravenous immunoglobulin 👇 Comment your answer Dr. Aravind Palraj #Rheumatology #BehcetDisease #Vasculitis #MedEd #ClinicalPearls @IhabFathiSulima

🧠 RHEUMATOLOGY CHALLENGE A 48-year-old woman with rheumatoid arthritis has been in sustained clinical remission for 18 months on methotrexate and a TNF inhibitor. According to current EULAR treat-to-target recommendations, which strategy is MOST appropriate? A. Continue both therapies indefinitely without reassessment B. Stop methotrexate and continue TNF inhibitor monotherapy immediately C. Consider cautious tapering of the biologic while maintaining close monitoring D. Discontinue all DMARD therapy because remission has been achieved 👇 Comment your answer before checking the explanation. Dr. Aravind Palraj #Rheumatology #RheumatoidArthritis #TreatToTarget #MedEd #ClinicalPearls @IhabFathiSulima

The cervical spine is the only spinal region commonly affected in rheumatoid arthritis. Key points: • Anterior atlantoaxial subluxation is most common • Cranial settling is most dangerous • Occipital pain may be the earliest clue • PADI <14 mm predicts neurological risk • Cervical myelopathy is a medical emergency Early recognition can prevent catastrophic neurological injury. #Rheumatology #RheumatoidArthritis #MedEd #FOAMed #MedTwitter @IhabFathiSulima @docakx @DrNikhilMD @Neuroptimist23 @NeuroJediMaster

🧠 RHEUMATOLOGY CHALLENGE A 32-year-old woman, 10 weeks postpartum, presents with fever, photosensitive rash, oral ulcers, arthralgia, and pleuritic chest pain. Labs: • Hb 9.2 g/dL • WBC 2,800/mm³ • Platelets 68,000/mm³ • Urine: 3 protein, RBC casts • Creatinine: 1.6 mg/dL • Low C3, Low C4 • ANA positive (1:1280) • Anti-dsDNA strongly positive She had a healthy baby and has no history of thrombosis. Which statement regarding future pregnancy is MOST appropriate? A. Pregnancy is contraindicated due to high risk of flare and poor fetal outcomes B. She should avoid pregnancy until the disease is quiescent for at least 6 months and proteinuria is <500 mg/day C. Hydroxychloroquine should be stopped before conception to avoid fetal toxicity D. Low-dose aspirin alone is sufficient prophylaxis in future pregnancy 👇 Comment your answer #Rheumatology #SLE #LupusNephritis #MedEd #ClinicalPearls @IhabFathiSulima

🧠 RHEUMATOLOGY CHALLENGE A 24-year-old woman, 10 days postpartum, presents with fever, pleuritic chest pain, and shortness of breath. CT pulmonary angiography shows multiple segmental pulmonary arterial thromboses. Labs: • Platelets 68,000/µL • Hb 9.2 g/dL (falling) • LDH elevated • Haptoglobin low • Peripheral smear: schistocytes No history of heparin exposure. What is the MOST appropriate next step in management? A. Start anticoagulation with heparin B. Start plasma exchange immediately C. Start high-dose corticosteroids D. Start caplacizumab plasma exchange 👇 Comment your answer @IhabFathiSulima @docakx #Rheumatology #MedEd #FOAMed #ClinicalPearls #MedQuiz #MedTwitter

The microbiome may influence autoimmune disease. Your gut contains trillions of microbes that interact with the immune system every day. In rheumatology, some of the most exciting research isn’t happening in the joints - it’s happening in the gut. #rheumatoidarthritis #rheumatology @IhabFathiSulima @docakx #MedTwitter