🧵 Think about this carefully.

You get an implant for cosmetic reasons.
The surgery goes well.
Nothing seems wrong.

Months later, you are tired all the time.
Your joints ache.
Your eyes feel dry.
Tests don’t give clear answers.

This situation has a name doctors should know: ASIA 👇

@DrAkhilX @IhabFathiSulima @nileshnolkha 1/9 Why this question matters

Modern medicine uses implants, fillers, meshes, and vaccines every day.
They help millions.

But doctors began noticing a pattern:

👉 some people developed delayed immune symptoms after exposure to immune-stimulating materials.

CRP in Lupus -Why I Don’t Use It to Measure Disease Activity and when I will use it

For decades, we’ve been taught:

Inflammation → CRP ↑

That rule works — except in lupus.

Here’s why 👇

1/6- Lupus inflammation is real -CRP silence is not reassurance

Active SLE can have:

• Nephritis
• Cytopenias
• CNS disease
• High anti-dsDNA
• Low complement

…and a normal CRP.

This is not paradoxical.
It is biologically expected.

#MedTwitter
#Rheumatology
#Lupus
#SLE
#ClinicalPearls @DrAkhilX @IhabFathiSulima @CelestinoGutirr @Urchilla01 @schowardjd 2/6. Lupus is not an IL-6 disease

It is a Type I interferon disease.

That distinction matters.

In RA:
IL-6 → liver → CRP ↑

In SLE:
IFN-α dominates — and IFN actively suppresses CRP transcription in hepatocytes.How ?

• IL-6 → STAT3 → CRP ON
• IFN-α → STAT1 → blocks STAT3
• CRP gene transcription → OFF

Inflammation continues.
CRP stays low.

What is new in lupus (2025) ?

We now understand lupus as a disease of TLR7 dysregulation.
Three key genetic mechanisms illustrate this.

🧵👇

TLR7 gain-of-function

TLR7 recognizes ssRNA in endosomes.
Gain-of-function variants → constitutive TLR7 signalling → excess type I interferon → lupus.

UNC93B1 mutations

UNC93B1 controls trafficking of TLR7 from ER to endosomes.
Pathogenic variants → increased endosomal TLR7 availability → amplified interferon signalling → lupus.

The new addition: PLD4

PLD4 is an endosomal exonuclease that degrades self ssRNA/ssDNA.
Loss-of-function → nucleic acid accumulation → failure to terminate TLR7/TLR9 activation.

The clinical insight

This pathway is not limited to childhood lupus.
Adult-onset disease (>40 years) has been reported.
Monogenic lupus can present late.

The therapeutic implication

TLR7-driven interferon excess → JAK inhibition is rational.

📉 Baricitinib reduces interferon hyperactivation.

Take-home message:
Different genes. Same pathway.
TLR7 overactivation is central to lupus.It is time for genetics-guided lupus care.

#SLE #TLR7 #UNC93B1 #PLD4 #TypeIInterferon #MonogenicLupus #JAKinhibitors #Rheumatology @DrAkhilX @IhabFathiSulima @CelestinoGutirr @DurgaPrasannaM1 1/3

10 Erythemas in Medicine You Must Know, because every rash is a diagnosis in disguise.

A quick, high-yield thread for busy clinicians. 👇🧵

@IhabFathiSulima @hemo_shk @MoarSahitoPTI
@MRCEMPREP
@DrBassemKurdi
@mohammadalmogbi @Dr_Alhatlani @DrAkhilX @CelestinoGutirr @Urchilla01 1/10

Erythema Nodosum

Tender nodular panniculitis on shins.

• TB, Streptococcus

• Sarcoidosis, IBD, Behçet’s

• Pregnancy

• Drugs – sulfa, penicillin, OCPs

Never ulcerates.

Image@dermatologyadvisor

🧵A must read

The rash that means “ischemia”
Painful, branching, non-blanching purple patches/plaques with central necrosis?

Think Retiform Purpura – a morphology that says:

“Blood vessels to the skin are compromised → ischemia → purpura → necrosis.”

Almost every case needs a systematic 6-step approach + biopsy.

A nice clinical trick 👇

A quick bedside hack: classify lesions as:

•Inflammatory → ≥2/3 erythema + ≤1/3 necrosis → vasculitis or infection

•Non-inflammatory → ≥2/3 necrosis + ≤1/3 erythema → occlusion/thrombotic

⚠️ But don’t be fooled

Cryoglobulinemia, sepsis, levamisole can hit both the vessel wall and lumen, causing overlap.

Read full 🧵👇
#RetiformPurpura #DermDetective #VascularRash #SkinCluesSaveLives
#RheumDerm #DICalert #HITteaching #ANCApearls
#MedEd #ClinicalPatterns #PatternToPunch #LupusMimics #IndiaMedEd @DrAkhilX @IhabFathiSulima @CelestinoGutirr @Urchilla01 🧵 2/7 – STEP 1: Morphology

✅ Define it first:

•Branching (reticular), non-blanching purpuric patch/plaque

•Persistent, often with frank or impending central necrosis/ulcer

🔍 Differentiate from other reticulate patterns:
•Livedo reticularis – complete rings, transient, temperature-related

•Livedo racemosa – broken, irregular fixed rings, rarely necrotic

@DrAkhilX @IhabFathiSulima @CelestinoGutirr

🧵 Can we have cardiac dysfunction despite a normal ejection fraction?

Even with a normal LV ejection fraction (LVEF), early myocardial damage can exist — especially in conditions like systemic sclerosis, lupus, or diabetes.

Let’s explore how we can detect it early — before symptoms appear.

Lets explore about Speckle Tracking Echocardiography (STE) 👇

#Cardiology #Rheumatology #Echo #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope #MedTwitter #RheumTwitter @CelestinoGutirr Tweet 2/6

The science behind it:

The LV myocardium has spiral architecture — fibers run longitudinally, circumferentially, and radially.
Each fiber layer contributes to a different “strain” during contraction.

When the myocardium weakens, strain changes before EF drops.

Image source-ecgwave

🧵 Have you ever heard of MGTS?
Let me tell you a story about a clotting disorder that doesn’t play by the rules 👇

@DrAkhilX @IhabFathiSulima @Janetbirdope #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/10

The patient who didn’t fit the pattern

A 55-year-old man came with repeated clots — in his legs, lungs, even the brain.
He was already on anticoagulants. Still, new thromboses appeared.

Platelets? Mostly normal.

No heparin. No recent vaccine.
Something didn’t add up.

🧵 Lupus Anticoagulant testing — explained like a story

Imagine you’re in the lab.

A patient’s APTT is prolonged.

Now the question begins:
Is it a factor deficiency or a Lupus Anticoagulant (LAC)?

There are 3 detective routes to solve this 🕵️‍♂️👇

@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/4

1️⃣ The Classic Detective

Starts simple — one clue at a time.
Screen → Mix → Confirm.
•If APTT prolonged → do a mixing test (add normal plasma).
•If it corrects → it’s a factor deficiency.
•If not → check with confirmatory test (extra phospholipid).
If it corrects now → LAC caught!

⚠️ Downside: weak LACs may hide; depends too much on the “normal plasma” used.

You think you know how to convert steroids into one another.

But if someone asks, you’ll be scrambling for the messy table or MDCalc 🤯

Here’s my own easy way to remember it… 🧵👇

#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/5

Steroid Equivalent Dose (Pred = 1)
PHMD → 1 / 4 / 0.8 / 0.16

🧠 PHMD = Pred • Hydrocortisone • Methylpred • Dexamethasone

👉 Pred 5 mg = HC 20 mg = Methylpred 4 mg = Dexa 0.75 mg

💡 Trick: 4 double = 8 → 0.8
8 double = 16 → 0.16
(don’t forget the dot!)

🔑 Explanation:

•Pred is the reference = 1
•HC needs 4× the dose
•Methyl is slightly stronger (0.8× Pred)
•Dexa is very potent (only 0.16× Pred)

Did you know histiocytoses are not a single disease but a family of >100 rare entities?

New classification reshapes them into 5 groups (L, C, R, M, H)—each with its own biology, pathology, and treatment implications. Let’s unpack 👇

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@drkeithsiau @CelestinoGutirr Tweet 2/7

L group = Langerhans cell histiocytosis (LCH), Erdheim–Chester disease (ECD), Indeterminate CH, Mixed forms

👉 Most cases carry clonal MAPK pathway mutations

How to manage Antiphospholipid Syndrome (APS)? 🤔

It’s not one-size-fits-all. Management depends on 3 key scenarios:

1️⃣ Asymptomatic carrier
2️⃣ With thrombosis
3️⃣ In pregnancy

Here’s the algorithmic roadmap 🧵

#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2- Asymptomatic carrier

How do you manage an asymptomatic aPL-positive patient? 🤔

Not everyone needs anticoagulation.

👉 Key:
• Identify CVD risks—>statin
• Look for autoimmune disease—->HCQ
• LDA only for high-risk profiles

APS management begins with risk stratification, not blanket treatment.

❓How can one tiny chemical edit in your proteins — replacing arginine with citrulline — trigger rheumatoid arthritis (RA)?

Here’s the story of citrullination and ACPA 🧵👇

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter
@CelestinoGutirr Tweet 2:

Proteins contain the amino acid arginine.
Enzymes called PAD (peptidyl arginine deiminases) convert arginine → citrulline.

This calcium-dependent reaction is called citrullination (or deimination).
It’s a normal post-translational modification — but in RA it goes wrong.

🧵How Clinical Trials Revolutionized ANCA Vasculitis Maintenance 💥

From cyclophosphamide to rituximab — this is the journey of evidence, one trial at a time. 🔁
Facts. Timelines. Game-changers.

📚 A must-read for every physician, rheumatologist, nephrologist, pulmonologist & ophthalmologist.
This is how science shaped the standard of care 👇
@rheum_doctor @zach_wallace_md @VasculitisOrg @ACRheum @EULAR_org @vasculitis_UK @LoyolaRheum @DrChrisWincup
#ANCAVasculitis #Vasculitis #Rheumatology #MedTwitter #Autoimmune #NephTwitter #Immunology #SteroidSparing #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter

Thank you to George Deva Raja for the brilliant image design 1/
📍Why we needed trials
In the 90s, patients with ANCA vasculitis had to stay on oral cyclophosphamide (CYC) even after remission.
🧨 Yes, it worked — but came with…
• Infections
• Infertility
• Cancer risks

We needed safer maintenance options. Let’s see what trials found 👇

🧵She was 17. Her fingers turned white in the cold.

A doctor ordered an ANA.
It came back positive.
She stopped sleeping.
She was sure she had an autoimmune disease.
Then she met me.
Here’s what I told her—and why it matters👇

#VEDOSS #Raynauds #Rheumatology #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 1/
She had:
Raynaud’s (cold-induced finger color change)
No pain, ulcers, disability
ANA: Positive

Google made her believe she had Scleroderma.

But the truth?
Not every ANA-positive Raynaud’s means disaster.
Let me explain.

🧵 PAH in Systemic Sclerosis: What You Don’t See Can Kill

1/
A 45-year-old man with SSc asked me in clinic:
“Am I at risk for pulmonary hypertension? How will we catch it early?”

This is how I approach that critical question 👇

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter 2/ Definition of PAH

Confirmed via right heart catheterization:
•mPAP ≥ 20 mmHg
•PCWP ≤ 15 mmHg
•PVR ≥ 2 Wood units

Why it matters:
🔴 PAH is a leading cause of death in SSc
📊 PHAROS registry:
•3-year survival ~75%
•5-year survival ~63%
•8-year survival ~49%

🕒 Early detection is key.

🧵 Rheumatoid Factor (RF): When Antibodies Turn on Each Other

In a healthy immune system, antibodies target foreign invaders.
But sometimes, antibodies start targeting each other.

That’s the beginning of the story of Rheumatoid Factor (RF) — an autoantibody directed against the Fc portion of IgG.

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/
So why would the immune system make RF?
It may not be a mistake.

Originally, RF evolved as a clearance mechanism to remove immune complexes by making them larger and stickier → easier for the system to eliminate.

🧵1/
Yesterday, I saw a young woman with SLE & lupus nephritis, on steroids + mycophenolate, who came in with sudden right hip pain radiating to the knee.

She could barely walk.

What’s your first thought?

👉 AVN – Avascular Necrosis of the femoral head.

AVN is common in:
• SLE
• Patients on long-term steroids
• Also seen with alcohol, trauma, transplant, HIV

🦴 Most common site?
→ Femoral head (due to precarious blood supply).
Let’s decode AVN step by step 🔍

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/

🎯 Key X-ray Features of AVN:

📍Early:
• Normal or subtle geographic lucency
• Flattening of the articular surface

📍Advanced:
• Collapse of femoral head
• Thinning of acetabular cortex
• Joint space narrowing
Image -Radiology masterclass

1/
Today, I saw a patient in OPD—referred from Pulmonology to rule out CTD-ILD.
On history and examination, there were no overt features of connective tissue disease.
What to do now? Let’s walk through the clues.
#MedTwitter #RheumTwitter #ILD #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/
Sometimes ILD (Interstitial Lung Disease) can precede other CTD features.
This is called forme fruste ILD—when lung involvement is the first or only manifestation.
So, yes, we must still keep CTD on the radar.

Do you know why inflammatory arthritis flares with maximum stiffness in the early morning?
Why prednisolone is best taken at 2 AM?
Or why vaccines work better in the morning?
It all comes down to your circadian rhythm.
Let’s explore the science.
#MedTwitter #Chronobiology #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter Tweet 2:
Our body runs on a ~24-hour cycle called the circadian rhythm, controlled by genes like:
•CLOCK
•BMAL1
•PER (Period)
•CRY (Cryptochrome)

These regulate sleep, hormones, immune responses, and even inflammation.

1/
Starting a new series: How to interpret MSK X-rays using the ABCDE-S approach!

A systematic method every rheumatologist, radiologist, & learner should know.

Simple. Visual. High yield.
Let’s dive in!

#Radiology #Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History
@DrAkhilX @IhabFathiSulima @Janetbirdope @Lupusreference @RheumNow #MedTwitter #RheumTwitter 2/
What is ABCDE-S?

A structured tool to read joint radiographs:

A – Articular (erosions: marginal / subchondral)
B – Bone
  ▶️ Productive: osteophytes, sclerosis, enthesophytes, syndesmophytes
  ▶️ Diminished: osteoporosis, cysts, focal osteolysis
C – Cartilage: joint space narrowing
D – Distribution: symmetry, joint pattern, small vs large joints
E – Extras: systemic clues (labs, age, sex)
S – Soft tissue

Today’s focus: Articular Erosions

🧵 Methotrexate: A Drug Born from Mistakes That Changed Medicine Forever

1/ When you hear Methotrexate (MTX), you probably think of Farber or Gubner. But the story actually begins in 1945 with Subbarow, an Indian-American scientist most people have never heard of.

#Rheumatology #Immunology
#Sullysrounds #MedX #Medtwitter #Mnemonics #Medicine #History But few know about the brilliant scientist who paved the way for its success—Dr. Yellapragada SubbaRow. Let’s uncover his story. 👇

2/ Born in rural India (1895), Dr. SubbaRow’s life was full of struggles.
•He studied at Madras Medical College, but due to his ties with the Indian independence movement, he was denied a full MBBS degree.
•Instead, he received a lesser Licentiate of Medicine & Surgery.