Corey Kershaw, MD, wants pulmonologists to know that although they may feel uncomfortable treating vasculitis, it’s possible through multidisciplinary help.
Vasculitis—a difficult and often complex array of diseases to diagnose and manage—bridges several specialties and is often over-looked or addressed in pulmonology. Dr. Kershaw and his co-presenters first bridged this gap at CHEST 2018, and due to popular demand, have brought the session Pulmonary Vasculitis Syndromes: A Case-Based Overview of Diagnosis and Treatment for the Pulmonologist back, modified for CHEST 2019. The Sunday session starts at 3:30 pm in room 277 of the convention center.
“Vasculitis is one of those uncomfortable topics for a lot of us pulmonologists,” said Dr. Kershaw, an associate professor in the department of internal medicine at UT Southwestern Medical Center and chair of the session. “We know how to quell somebody who has alveolar hemorrhage, but it’s what you have to do afterwards I think that gets people a little uneasy—the maintenance therapy. How do I achieve remission? How do I maintain remission and what do I do if there’s a recurrence?”
The session will break this topic down into three talks to make the condition more approachable.
The first talk, by John Fitzgerald, MD, also of UT Southwestern Medical Center, will provide an overview of the breadth of vasculitis, including alveolar hemorrhage syndromes. Many pulmonologists immediately think of granulomatosis with polyangiitis when vasculitis is mentioned, Dr. Kershaw said, so the presenters want to emphasize that there’s more to it than that.
“We’ll talk about how to classify these diseases,” Dr. Kershaw said. “Some may be more commonly encountered. For example, there’s antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), there’s immune complex vasculitis, and there’s drug-induced vasculitis. And these are but a few to remember.”
The second talk, by Sonye Danoff, MD, PhD, FCCP, from Johns Hopkins University School of Medicine, will explore brief cases of small- and large-vessel vasculitis, how patients present with these syndromes, and what you would expect to see if you suspect someone has vasculitis manifesting in the lungs.
Dr. Kershaw will finish up the session with the basic and advanced treatment of vasculitis, including maintenance of remission options and how to use some of the heavy-duty systemic immunosuppression needed for treatment.
“The role of total plasma exchange is a bit of an unknown, too,” Dr. Kershaw said. “I’m going to talk about some recent evidence in plasma exchange for alveolar hemorrhage, and I will discuss some of the advanced options for large vessel vasculitis you need to consider—sometimes it’s surgery or radiology intervention.”
Dr. Kershaw said these conditions are difficult to discuss because you often don’t know who is “captain of the ship.”
The typical scenario would be a patient arriving at the hospital coughing up blood and being sent to a pulmonologist. That patient would likely end up in the ICU to stop the bleeding with high-dose steroids and maybe plasma exchange.
“Those are very typical things you do upfront, but it’s the long-term management that can cause provider discomfort,” Dr. Kershaw said. “It requires medicines like rituximab or cyclophosphamide. I think for a lot of pulmonologists, that’s an area that they get a little bit uncomfortable with—coordinating an outpatient with infusion centers, knowing how to order the medicines, and how to monitor the patients on the medicine. You may need some help. You may need to ask rheumatology to help you, a nephrologist, or maybe a radiologist who does interventions. Know that you’re not alone. This is not something you have to do by yourself.”