Dr. Mohamad Ali Rida
Rheumatology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I am a 55-year-old male who has had asthma since childhood. It got severe during covid last year, and I recovered fully. Last seven months, I have been healthy. Three months back, I came down with flu-like symptoms, generalized muscle pain, and bone pain. I lost 20 pounds of weight and had severe malaise. My autoimmune panel was normal, ANCA was negative, one bout of eosinophilia, and the doctor put me on a tablet of Prednisone 60 mg, thinking polymyalgia rheumatica. It did not work. Eosinophil count has been normal. Renal biopsy concerning Churg Strauss but no autoimmune diseases, just thrombi and vasculitis, with eosinophils were seen. Currently on seven days of tablet Prednisolone 60 mg. Bone pain is back, but I feel 70 % better. Every six weeks, I get these purple small skin lesions on my face that rupture, bleed, and heal. No rashes on the legs, and kappa light chains are mildly elevated. Viral testing turned negative.
Please help, doctor.
Thank you.
Hi,
Welcome to icliniq.com.
Your symptoms suggest Churg Strauss; however, we should also consider other diseases with negative antineutrophil cytoplasmic antibodies (ANCA) and occasional eosinophilia. Also, your history of asthma is pertinent for Churg Strauss.
For now, I can call your disease small vessel vasculitis. The treatment is, of course, tablet Prednisolone. However, I would consider bridging to a steroid-sparing agent over the next few weeks, such as a tablet Azathioprine (consult with a specialist doctor, talk with him or her, and take medicine with their consent). A biopsy of the skin lesion will also help.
Thank you.
Patient's Query
Hi doctor,
Thanks for your response.
Here is something interesting. For all the hospitalizations (because or not because of asthma), I have never had eosinophilia. I have looked through the past five years of medical history. I have done dozens of CBC tests. Is it possible I have non-eosinophilic asthma and, therefore, a poor producer of eosinophils? Even with allergies, I have no eosinophils. I only had eosinophilia three months back this year. The doctor put me on tablet Prednisone, thinking my symptoms were polymyalgia rheumatica, but I got worse, and the renal values worsened. He stopped the steroids, and the eosinophils have not returned in six weeks.
Thank you.
Hi,
Welcome back to icliniq.com.
This is why I labeled you as small vessel vasculitis instead of Churg Strauss. We need to have severe eosinophilia for Churg Strauss. Nevertheless, the initial treatment is the same for all small vessel vasculitis, including ANCA vasculitis, which is tablet Prednisone. The aim is to protect you from end-organ damage, most importantly kidney disease. Once stabilized, we go for maintenance therapy. I do not see the link between eosinophilia and polymyalgia rheumatica that your doctor said before. But certainly, you do not have polymyalgia rheumatica. At this point, you need to be on tablet Prednisone and then monitor kidney function.
Thank you.
Patient's Query
Hi doctor,
I just got results back from antiphospholipid antibody reflexive tests. I am concerned that I had been on tablet Prednisone 60 mg daily for a week before the test. Could that alter the results or anything? The cardiolipin antibody IgM came back as high (20).
Please help, doctor.
Thank you.
Hi,
Welcome back to icliniq.com.
Yes, a high dose of tablet Prednisone will affect the tests. I suggest repeating antiphospholipid ab in 12 weeks as per guidelines (you need to have positive titers on two occasions at least 12 weeks apart). This is because of the high rate of false-positive Antiphospholipid antibodies, which are affected by any other disease or medication.
Thank you.
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Rheumatology
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