🧵 Giant Cell Arteritis — Save a Sight in 5 Minutes

The vision loss is often permanent—and preventable.
A zero-fluff checklist: who to treat before tests, when ultrasound beats biopsy, steroid start & taper, and the traps (normal ESR/CRP, “PMR only,” jaw pain without headache).
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @Janetbirdope @vascuk #MedTwitter #NEETPG Why this matters
•GCA is the most common primary vasculitis >50 years
•~15–20% develop vision loss — often before diagnosis
•Half lose the other eye within days if untreated
•Risk drops almost to zero with prompt steroids

🧵 C3 vs C4 — What the Pattern Really Means (in 30 seconds)

We order complements all the time.
But the pattern is the diagnosis.
Here’s the fast way to read C3/C4 without overthinking. 👇
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @DurgaPrasannaM1 @SarahSchaferMD @EMJNephrology #MedTwitter #Rheumatology 1) Quick primer
•C3 = shared hub (alternative + classical).
•C4 = classical pathway marker (C1q → C4).
Pattern > any single value.

🧵 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 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.

🧵 Drug Combinations That Can Kill — Interactions You Must Never Miss

We prescribe these daily.
Get the combination wrong → bleeding, rhabdomyolysis, bone marrow suppression, cardiac arrest.

Here are the 10 combinations you must always check for 👇
@DrAkhilX @IhabFathiSulima @CelestinoGutirr @Janetbirdope @DurgaPrasannaM1 @SarahSchaferMD @NeuroSjogrens #MedTwitter #RheumTwitter 1) Allopurinol or Febuxostat + Azathioprine or 6-Mercaptopurine
❌ Severe bone marrow suppression (xanthine oxidase inhibition).
✅ Avoid the combination; if unavoidable, drastically reduce azathioprine dose and monitor blood counts closely — but switching is safer.

🧵 Clues Your “Arthritis” Patient Doesn’t Actually Have RA

Not all swollen joints are rheumatoid arthritis.
Some look identical—but aren’t.
Here’s how to spot RA mimics before the label sticks forever 👇
@IhabFathiSulima @DrAkhilX @SarahSchaferMD @Janetbirdope #MedTwitter #Rheumatology 1. It’s asymmetric

RA loves symmetry.
If one side is swollen but the other is fine—think again.

🧵 When It’s Not Sepsis – Clues That It’s Actually Autoimmunity

Fever.
Tachycardia.
High CRP.
Looks like sepsis—but cultures stay negative, and antibiotics don’t work.

Let’s break down how to catch autoimmune mimicry of infection—before it’s too late. 👇
@IhabFathiSulima @DrIanWeissman @DrAkhilX @CelestinoGutirr @NeuroSjogrens @SarahSchaferMD @drkeithsiau #MedTwitter #RheumTwitter 1. The classic setup:

Patient has:
✅ Fever
✅ High CRP
✅ High neutrophils
✅ Looks toxic

But…
🧪 Cultures are negative
🧫 Antibiotics fail
🧠 Something’s not adding up

🧵 Thrombocytopenia – Not Always ITP

Low platelets aren’t always immune.
Sometimes they bleed.
Sometimes they clot.
Sometimes they’re screaming for help.

Let’s break down how to approach thrombocytopenia with clarity 👇
@IhabFathiSulima @DrAkhilX @drkeithsiau #MedTwitter #Hematology 1. First: Is it even real?

Some low counts are lab errors—not pathology.
Check for:
– Platelet clumps in EDTA
– Smear confirmation
– Citrate sample if unsure

🧵 Normocytic Anemia – When the MCV Looks Normal but Something’s Not Right

Hb is low.
MCV is normal.
Now what?

Let’s break down how to approach normocytic anemia — the subtle signal doctors often miss. 👇
@IhabFathiSulima @DrAkhilX @hemo_shk #MedTwitter 1. What is normocytic anemia?

🧪 Hb ↓
📏 MCV = 80–100 fL (normal)

The red cells are the right size—but not the right number.

🧵 Urea vs Creatinine in Rheumatology – Read Between the Lines

In lupus, vasculitis, RA—we check kidney function daily.
But urea and creatinine don’t always rise together.
Let’s decode what they mean—and when they mislead—in rheumatology. 👇
@IhabFathiSulima @CelestinoGutirr @ASNKidney @arvindcanchi @JasmineNephro #MedTwitter 1. First—Where Do They Come From?

🧪 Urea = from liver (protein metabolism)
🧪 Creatinine = from muscle breakdown

Both cleared by the kidney—but influenced by different factors.

🧵 Thread: “Steroid Unresponsive Arthritis? Don’t Miss This Mimic”

A young woman with “seronegative arthritis” is on steroids for 3 months.
Still flaring. No response.
Rheumatoid? Nope.
This was TB.
Let’s break down the great mimics of inflammatory arthritis. 🧵
#Rheumatology #MedTwitter @IhabFathiSulima @DrAkhilX @CelestinoGutirr @Janetbirdope @SidhaantNangia 1️⃣ Case:
28F with symmetrical arthritis, ESR 85, ANA negative.
Diagnosed as “seronegative RA.” Treated with steroids, MTX.
Symptoms persisted. Fever, weight loss, now chronic cough.

🧵 RF vs anti-CCP – Which Test Tells the Truth?

You ordered RF.
It came back positive.
But is it RA—or just rheumatoid confusion?

Let’s break down RF vs anti-CCP—and which one to actually trust 👇
@IhabFathiSulima @DrAkhilX @CelestinoGutirr @Janetbirdope @DurgaPrasannaM1 1. First: What are they?

🧪 Rheumatoid Factor (RF) = an autoantibody against the Fc portion of IgG
🧪 anti-CCP = antibody against cyclic citrullinated peptides

Both are used in diagnosing Rheumatoid Arthritis (RA)—but they behave very differently.

🧵 CRP vs Procalcitonin in Fever Workup 🔍
Flare? Infection? Both? Let’s break it down clinically — one step at a time.👇
#MedTwitter #Rheumatology #Infection @IhabFathiSulima @DrAkhilX @CelestinoGutirr 1.CRP rises in almost everything:
🔥 Infection
🦠 Autoimmune flare
💥 Trauma
🛌 Post-op
…but it’s NOT specific.
It just says, “Something’s wrong.” 😐

🧵D-Dimer – Diagnostic Hero or Misleading Villain?

We’ve all ordered D-Dimer.
But do we really understand what it’s telling us?
Let’s break down when D-Dimer helps—and when it just adds confusion👇
@IhabFathiSulima @DrAkhilX @drkeithsiau @CelestinoGutirr @Janetbirdope @nirmalregency @Lupusreference #MedTwitter #NEETPG 1. What is D-Dimer, really?

🧬 It’s a fibrin degradation product.
If you see it, it means the body formed and broke down a clot.

But: That doesn’t always mean pathology.

🧵 Ferritin vs CRP – When High Iron Means High Fire

CRP goes up in inflammation.
Ferritin does too—but sometimes, it explodes.
Let’s break down how ferritin behaves differently, and when to worry. 👇
@IhabFathiSulima @DrAkhilX @emcrit @Janetbirdope @Lupusreference #MedTwitter #NEETPG 1. First—What is Ferritin, really?

Ferritin stores iron.
But it’s also an acute-phase reactant.
So it rises in inflammation.
But unlike CRP, it skyrockets in cytokine storms.

🧵 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 1. First, the Basics

🩸 CRP = C-reactive protein
🧬 PCT = Procalcitonin
Both are acute phase reactants—but with different triggers.

🧵 Vasculitis is Not One Disease – It’s a Spectrum
It’s not a diagnosis.
It’s a mechanism.
From small-vessel purpura to large-vessel aneurysms, here’s how to recognize and reason through the vasculitis spectrum👇
@Amansharmapgi @DurgaPrasannaM1 @12VRavindran @Kanjivellam @IhabFathiSulima @DrAkhilX #MedTwitter 1️⃣ Start With the Vessel Size

🔹 Large vessel: aorta and branches
🔸 Medium vessel: muscular arteries
🔻 Small vessel: arterioles, venules, capillaries
Your clues lie in which organ is hit—and how.

🧵 Thread: ESR vs CRP – Friends? Foes? Or Just… Different?

They’re both inflammatory markers—but they don’t always agree.
Let’s break down how they differ, overlap, and mislead.
#MedTwitter @IhabFathiSulima @DrAkhilX @CelestinoGutirr 1️⃣ Different Tests. Different Rules.

🧪 CRP: Liver makes it via IL-6
🧫 ESR: RBC settling rate in plasma
Both track inflammation—but work very differently.

🧵 CRP in Rheumatology – When It Lies, Lags, or Leads You Astray
Because inflammation is complex—and so is CRP.
@IhabFathiSulima @DrAkhilX @ACRheum #NEETPG #MedTwitter 1️⃣ CRP: Not the Oracle

CRP is helpful—but don’t worship it.
🔸 It can be normal in active disease
🔸 Or elevated in non-inflammatory states
Interpret in clinical context only.

🧵 Neuro-Sjögren’s: Not Just Dryness

Sicca may be the start—but neuro symptoms can be the storm.
Peripheral neuropathy, CNS signs, and fatigue demand more than eye drops.

Let’s talk treatment. 💊
#NeuroSjögren #NeuroRheum #MedTwitter @IhabFathiSulima @DrAkhilX @nirmalregency @NeuroSjogrens @SjogrensCa @SjogrensForum @SjogrensOrg @elisa_comer @SarahSchaferMD 1️⃣ Start With the Basics

✅ Exclude other causes: B12, diabetes, paraproteins, vasculitis
🧪 Rule out cryoglobulins, HBV/HCV, and lymphoma

Sjögren’s can be small fiber hell or central confusion.

Neuropathy ≠ always antibody-driven
Treat what you see. Not just what glows.

📌 Neuro-Sjögren is a diagnosis of inclusion, not exclusion.

🧵 1/ ILD in CTDs – What Every Clinician Must Know

Not all crackles are IPF.
Not all NSIP is idiopathic.

This is a thread on interstitial lung disease in connective tissue diseases — the subtle signs, red flags & real-world insights.👇
#Rheumatology #ILD @IhabFathiSulima @DrAkhilX @andrewsuleh 2/ Rule 1: If you hear crackles, HRCT.

🔊 Velcro crackles in RA, SSc, myositis?
🫁 Don’t wait for a fall in PFTs
📌 HRCT is more sensitive
📉 DLCO drop alone ≠ enough

🧵 1/ Things I Wish I Knew Earlier in Rheumatology

Some lessons aren’t in the guidelines.
You learn them the hard way—through missed patterns, wrong calls, or watching mentors.

Here’s a list I’d give my younger self.👇
#Rheumatology #MedTwitter @IhabFathiSulima @nileshnolkha @Janetbirdope 2/ ACPA is not just for RA.

You’ll see it in ILD with no arthritis.
You’ll see it in elderly with nothing else.
You’ll even see it in cancer.

📌 Don’t overtreat the lab. Follow the joints, not the titres.