Aravind Palraj Profile picture
Aug 10 12 tweets 4 min read Read on X
🧵 CK Can Lie — Catching Myositis When Creatine Kinase Is Normal

Myalgia + weakness.
CK is normal.
Everyone relaxes.
That’s how dangerous myositis gets missed. Let’s fix it. 👇
@IhabFathiSulima @DrAkhilX @CelestinoGutirr #MedTwitter Image
1) First principle
Normal CK ≠ no muscle disease. CK reflects muscle necrosis, not strength. Patchy disease, low muscle mass, or perimysial-predominant injury can keep CK normal. Image
2) When CK is often normal (or only mildly ↑)
•Dermatomyositis (esp. MDA5 phenotype)
•Steroid myopathy (treatment complication, not inflammation)
•Inclusion body myositis (>50 yrs; finger flexors/quads)
•Early/patchy disease, chronic burnt-out myositis Image
3) Red flags that trump a normal CK
•True proximal weakness (chair rise, comb hair, neck flexors)
•Dysphagia/aspiration, nasal speech, weak cough
•Dyspnea or rapid desaturation (think RP-ILD)
•Pathognomonic rashes: heliotrope, Gottron papules, mechanic’s hands
•Dark urine (heme-positive, no RBCs)Image
4) What to order next (CK normal but you’re worried)
•Aldolase, LDH, AST/ALT, GGT
•AST/ALT high with normal GGT → likely muscle source
•Urine dip: heme + / RBC − → myoglobinuria
•Ferritin (very high with MDA5/RP-ILD or MAS)
•If breathless: CXR/HRCT ± PFTs Image
5) Pattern pearls
•CK normal + Aldolase high → perimysial process (think dermatomyositis, overlap)
•AST ≫ ALT, GGT normal → muscle, not liver
•LDH high supports muscle injury but is nonspecific Image
6) Don’t confuse with steroid myopathy
•Timing: weeks after starting/high-dose steroids
•Painless proximal weakness, CK normal
•Plan: taper steroids, add physio, use steroid-sparing agent for underlying rheum disease. Image
7) Statin story (two different beasts)
•Simple statin myalgia: CK normal or mild ↑; resolves on stopping
•Immune-mediated necrotizing myopathy (anti-HMGCR): very high CK, weakness persists after stopping → needs immunosuppression Image
8) Inclusion body myositis (don’t overtreat like PMR/RA)
•Men >50, finger-flexor and quadriceps weakness, falls, CK normal–mild
•Poor steroid response; think biopsy, rehab, assist devices. Image
9) The lethal miss: MDA5-Dermatomyositis with RP-ILD
•Minimal/normal CK, sky-high ferritin, hand ulcers or palmar papules
•Rapidly progressive ILD → treat early (high-dose steroids + calcineurin inhibitor ± cyclophosphamide/rituximab; center-specific) Image
10) 30-second algorithm
Weakness ± myalgia + CK normal →
→ Check aldolase, AST/ALT, LDH, GGT, urine heme
→ Look for DM rash / IBM pattern / steroid exposure / ILD signs
→ If positive: myositis panel (MDA5, TIF1-γ, NXP2, SAE1, HMGCR, SRP, Jo-1, etc), EMG/MRI, and early rheum/pulm referral.Image
📌 Takeaway
CK can lie. Muscles don’t.
If your exam and the story say “myositis,” keep digging even with a normal CK.

If this thread prevents one missed myositis or RP-ILD, share it. Someone will thank you later. 🔁 Image

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More from @Rheumat_Aravind

Aug 17
🧵 ANA (Antinuclear Antibody): What Every GP Needs To Know—2025 Guide

1/ What is ANA—and Why Test It?
ANA is a blood test that helps detect autoantibodies against cell nuclei, seen in autoimmune diseases like lupus, Sjögren’s, and more. It’s NOT a screening test for general complaints. Use it when history or exam genuinely points to autoimmune disorders
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @Janetbirdope @SarahSchaferMD @NeuroSjogrens #MedTwitter #RheumatXImage
2/ Who Should Be Tested?
Test ANA only when you see signs such as:
•Unexplained, non-infectious joint pain/swelling
•Persistent rash, especially photosensitive
•Raynaud’s phenomenon
•Sicca symptoms (dry eyes/mouth)
•Multi-system symptoms (e.g., nephritis, serositis) Image
3/ How To Interpret ANA Results
•Negative ANA: Very low likelihood of connective tissue disease, but rarely rules out all autoimmune illness.
•Positive ANA: Means autoantibodies were detected, but CAUTION! Many healthy people, especially elderly and women, can test positive. Image
Read 8 tweets
Aug 16
🧵 Red Flag Symptoms NOT to Miss in Rheumatic Diseases

1/ Systemic (Whole-Body) Red Flags
•Fever, unexplained weight loss, night sweats, loss of appetite, persistent fatigue
•Malaise or feeling generally unwell, lymph node swelling, new pallor
These often signal serious underlying inflammation, infection, or even malignancy.
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @SarahSchaferMD @NeuroSjogrens #MedTwitter #RheumatologyImage
2/ Pain and Swelling Not Acting Like “Usual Arthritis”
•Acute, severe, or rapidly increasing joint pain (especially a single hot, swollen joint)
•Bone pain, deep/throbbing—not just joint tenderness
•Recurrent or migratory joint pain, especially with redness or heat. Image
3/ Night Pains & Persistent Symptoms
•Pain waking you up at night and not eased with usual pain relief
•Stiffness that lasts more than an hour in the morning or after inactivity. Image
Read 8 tweets
Aug 16
1/ 🧵 Most people think Sjögren’s disease means dry eyes and mouth—but did you know it can also affect your kidneys? Kidney problems in Sjögren’s are serious but often missed. Here’s everything you need to know. 👇
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @JasmineNephro @arvindcanchi @SarahSchaferMD @NeuroSjogrens @elisa_comer @SjogrensIrl @SjogrensForum @SjogrensOrg @SjogrensCa #MedTwitter #RheumatologyImage
2/ Renal involvement in Sjögren’s can take many forms, from mild lab abnormalities to full-blown kidney disease. Early detection is key to prevent lasting damage. Image
3/ Common kidney-related symptoms and signs include:
•Excess protein or blood in urine
•Excessive thirst and urination
•Muscle weakness due to low potassium
•Fatigue and swelling
•Sometimes no symptoms, only abnormal lab tests Image
Read 11 tweets
Aug 16
🧵 Unlocking Rheumatology: What Every Joint, Patient & Clinician Should know👇

Tweet 1/5: The Anatomy of Arthritis
Ever wondered what sets a healthy joint apart from one with rheumatoid arthritis?
🔹 Healthy knees have smooth cartilage and clean bone architecture.
🔸 RA knees show swelling, inflamed synovium (the joint lining), and bone erosion—key targets for early intervention!
@IhabFathiSulima @DrAkhilX @CelestinoGutirr #MedTwitterImage
Tweet 2/5: Morning Struggles
Stiff, aching joints first thing in the morning? You’re not alone.
For many with RA and similar diseases, getting out of bed is the hardest part. Targeted therapy and gentle movement can really help. Image
Tweet 3/5: Medication, Planning, & Progress
Managing rheumatic disease can feel like a juggling act: pills, injections, calendars, and appointments!
Organization, reminders, and open conversations with your doctor lead to the best outcomes. Image
Read 5 tweets
Aug 14
💡 “When Joint Pain Is NOT Arthritis” — The 7 Red Flags Every Doctor Should Know

Tweet 1:
“Not every swollen or painful joint is arthritis. Missing the real cause can delay life-saving treatment.
Here are 7 red flags that should make you think beyond rheumatology 👇”
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @SarahSchaferMD @NeuroSjogrens #MedTwitterImage
Tweet 2:
1️⃣ Fever + Acute Monoarthritis
•Think septic arthritis until proven otherwise
•Don’t start steroids until infection is ruled out Image
Tweet 3:
2️⃣ Joint Pain + Rash + Low Platelets
•Could be dengue or other viral fevers
•ESR/CRP may be high but steroids can be dangerous Image
Read 9 tweets
Aug 13
🧵 The Gut–Joint Connection: How Your Microbiome Influences Arthritis

🦠🤔 Could your gut bacteria be making your arthritis worse?
Emerging science says YES.
Your gut microbiome can shape your immune system… and may even trigger autoimmune joint disease.
Let’s connect the gut to the joints 👇
#MedTwitter #guthealthmatters @DurgaPrasannaM1 @nileshnolkha @IhabFathiSulima @DrAkhilX @CelestinoGutirr @drkeithsiau @SarahSchaferMDImage
The microbiome’s hidden role
Your gut hosts trillions of microbes.
When balanced → they help digestion & immunity.
When imbalanced (“dysbiosis”) → they can mis-train the immune system, sparking inflammation far beyond the gut. Image
RA and specific bacteria
🔍 Studies show Prevotella copri is more common in new RA patients.
It’s thought to activate immune pathways that attack joints.
A 2023 study found Eggerthella lenta may cause autoantibodies YEARS before symptoms. Image
Read 8 tweets

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