Comparing Rheumatology Consultation Patterns Across Telehealth Platforms and Face-to-Face Clinic in the Military Health System.

OBJECTIVE: To compare patterns of rheumatology consultations and outcomes across four different platforms in the Military Health System (MHS): face-to-face, synchronous telehealth, and two asynchronous telehealth platforms. METHODS: We conducted a retrospective review comparing face-to-face rheumatology consults during 2019 with teleconsultations from three virtual systems in the MHS: an asynchronous email-based system from May 2006 to Feb 2018, a web-based platform from 2014 to 2018, and synchronous telehealth consults from March 2020 to March 2021. Consults were reviewed for diagnosis, and if medical evacuation was required for consults originating OCONUS or if face-to-face follow-up was required for synchronous teleconsults. Diagnoses of interest included inflammatory arthritis, noninflammatory arthritis, crystalline arthritis, myositis, lupus, vasculitis, fibromyalgia, antibody positivity without diagnosis, symptoms without specified diagnosis, and a composite of other rheumatic diseases. RESULTS: Leading diagnoses across platforms were inflammatory arthritis, noninflammatory arthritis, and a composite of other diagnoses. Consultation modality influenced the type of cases seen. Inflammatory arthritis accounted for significantly more consults in the synchronous telehealth (38.4%) and email-based (40.9%) models than in the web-based (23.7%) and face-to-face (32.0%) models. The composite of other diagnoses was the leading diagnosis for the asynchronous web-based model (32.9%), which was significantly more than the synchronous telehealth and face-to-face consults. Synchronous models saw significantly more cases of crystalline arthritis, vasculitis, and fibromyalgia.Email-based consultations resulted in medical evacuation in 25 cases and prevented evacuation in 5. Web-based consultations prompted medical evacuation in 100 cases. In the synchronous model, face-to-face follow-up was recommended in 142 (15%) cases. CONCLUSIONS: Modality of consultation influences the type of cases seen. Both synchronous and asynchronous telerheumatology models were able to answer the consult question without referral for face-to-face evaluation in 79.9-85.0% of consults, suggesting teleconsultation is a viable method to increase access to high-quality rheumatology care.

Hydroxychloroquine: An old drug with new relevance.

Hydroxychloroquine is an immunomodulatory drug that has been used for 60 years to treat malaria and autoimmune diseases such as systemic lupus erythematosus and inflammatory arthritis, and potential new uses and benefits continue to emerge. Toxicity concerns have been addressed with updated prescribing recommendations.

Autoimmunity Mimics: Infection and Malignancy.

Musculoskeletal rheumatic syndromes are commonly encountered in the primary care setting. A plethora of commonly encountered and rare infectious agents can produce osteoarticular and soft tissue manifestations. Likewise, malignancies may manifest rheumatic symptoms via direct tumor invasion or paraneoplastic effects. Awareness of these diseases and their clinical risk factors should result in improved screening and earlier recognition and intervention, leading to improved long-term outcomes and overall patient care.

Salmonella septic arthritis in a patient receiving etanercept: case report and review of the literature.

Antitumor necrosis factor alpha agents are known to increase the risk for severe and atypical infections. Numerous atypical organisms have been reported previously, however, there is a paucity of reports of Salmonella as a complication of these therapies. We report a case of a 69-year-old female who developed Salmonella septic arthritis of the pubic symphysis while taking etanercept that resolved with cessation of etanercept and antibiotic treatment and we review the literature regarding this complication. Awareness of susceptibility to Gram-negative intracellular organisms and reactivation of dormant infections due to the mechanism of action of antitumor necrosis factor alpha medications is vital.

A pain in the neck: carotid artery dissection presenting as vasculitis.

Spontaneous cervical artery dissection is increasingly recognized as a common cause of ischemic stroke in the young and middle-aged. Noninvasive imaging techniques such as magnetic resonance imaging and magnetic resonance angiography have widely replaced conventional angiography as the initial diagnostic study of extracranial dissections, allowing greater numbers of patients to be screened and thus leading to increased frequency of the diagnosis. We present a case of spontaneous carotid artery dissection in a previously healthy 48-year-old woman who presented with neck pain and elevated inflammatory markers. Marked gadolinium enhancement of the right extracranial internal carotid artery on magnetic resonance imaging led to an initial diagnosis of vasculitis. This case shows that the vessel injury associated with spontaneous carotid artery dissection is associated with an inflammatory response that can mimic vasculitis on highly sensitive imaging techniques, a phenomenon not well described previously. In this report, we review the nonvasculitic conditions that can mimic vasculitis and present clinicians complex diagnostic challenges. Recognition of these pseudovasculitic syndromes is important to avoid overdiagnosis resulting in unnecessary and potentially harmful immunosuppressive and cytotoxic treatments.

Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: clinical features and possible immunopathogenesis.

OBJECTIVE: The induction or exacerbation of psoriasis in patients treated with tumor necrosis factor (TNF) antagonists is a well-established phenomenon. The goals of this comprehensive literature analysis were to update currently available data regarding this adverse event, to identify any clinical patterns in the cohort of reported patients, and to review the possible immunopathogenesis. METHODS: A systematic literature review was performed utilizing PubMed and Medline databases (1996 to August 2009) searching the index terms "tumor necrosis factor alpha inhibitor," "TNF," "infliximab," "etanercept," "adalimumab," combined with the terms "psoriasis," "pustular," "skin," "rash," "palmoplantar," and "paradoxical." All relevant articles were reviewed. Patients who did not appear to meet accepted classification criteria for their treated disease, who had a more probable explanation or other likely diagnosis for their skin findings or known possible triggering factor for the skin eruption, including infection, were excluded from this analysis. RESULTS: Two hundred seven cases met inclusion criteria for review. Of these, 43% were diagnosed with rheumatoid arthritis, 26% with seronegative spondyloarthropathy, and 20% with inflammatory bowel disease. Mean patient age was 45 years and 65% were female. Fifty-nine percent were being treated with infliximab, 22% with adalimumab, and 19% with etanercept. Lesion morphology included pustular psoriasis in 56%, plaque psoriasis in 50%, and guttate lesions in 12%; 15% experienced lesions of more than 1 type. No statistically significant predisposing factors for the development of new-onset psoriasis were found. Sixty-six percent of patients were able to continue TNF antagonist therapy with psoriasis treatments. The pathogenesis appears to involve disruption of the cytokine milieu with production of unopposed interferon-α production by plasmacytoid dendritic cells in genetically predisposed individuals. Genetic polymorphisms may play a role in this paradoxical reaction to TNF blockade. CONCLUSIONS: TNF antagonist induced psoriasis is a well-described adverse event without any known predisposing risk factors. Most patients can be managed conservatively without drug withdrawal. Registry data reporting is necessary to define the true incidence and prevalence of this condition. Genomic studies of affected patients may assist with identification of predisposed patients and elucidation of the molecular trigger of this perplexing response.

Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: a literature review and potential mechanisms of action.

OBJECTIVE: Numerous reports of the induction or worsening of psoriasis in patients treated with tumor necrosis factor (TNF) antagonists indicate that this is not a rare phenomenon. The etiology of this paradoxical clinical response remains unclear. The aim of this study was to describe similar cases, conduct a comprehensive analysis of the literature, explore possible immunologic mechanisms of action of this perplexing reaction, and recommend management options. METHODS: A systematic literature review was performed using the PubMed and Medline databases (1996 to September 2007) searching the index terms "infliximab," "etanercept," "adalimumab," "tumor necrosis factor alpha inhibitor," and "TNF inhibitor," combined with the terms "psoriasis," "pustular," "skin," "rash," and "palmoplantar." All relevant articles in English were reviewed. Pertinent secondary references were also analyzed. RESULTS: According to the literature, new-onset psoriasis may occur any time after initiation of TNF antagonist therapy, is often of an uncommon morphology, may respond to psoriasis treatments, and usually resolves with TNF discontinuation. The pathogenesis of this response appears to involve a disruption in cytokine balance following TNF inhibition, resulting in the up-regulation of plasmacytoid dendritic cells and the subsequent production of unopposed interferon-alpha, following a triggering event in predisposed individuals. CONCLUSION: TNF antagonist-induced psoriasis is a newly recognized adverse effect of these medications that typically does not require therapy cessation. We recommend aggressive treatment of the skin disease and consideration of a change in the TNF antagonist if the lesions are unresponsive to conventional psoriasis treatment.