Hooked on Rheum with Jonathan D. Krant, MD
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In my third year of medical school, I had the privilege of spending a month at Good Samaritan Hospital, on Loch Raven Blvd. in Baltimore, then the home of the rheumatology service at Johns Hopkins.
My supervisor was Dr. Thomas Zizic and I was encouraged to assemble clinical impressions of patients to present to Dr. Mary Betty Stevens at the end of my clinical rotation. I had the good fortune of diagnosing a patient with Sjögren’s syndrome, myxedema and myotonic dystrophy, and presented her as an unknown to a crowded field of attendings, residents and fellows at the end of my brief tenure on service. The interest was intense and the questions were withering, but I knew I was onto something — and my career, nascent as a student, took flight.
One year later, I was a sub-intern on the medical service of Moffitt Hospital at the University of California, San Francisco, and admitted a 19-year-old patient in scleroderma renal crisis. The fellow at the time was Dr. David Hellmann and we worked incessantly to reverse her course and to save her life. Nothing worked. It was crushing to lose a young woman to an inexorably progressive disease and I vowed to make scleroderma my focus.
That launched me into my career as a clinical investigator. I returned to UCSF as a clinical fellow 3 years later. In between, I did my internal medicine training at Dartmouth and cared for a young Raynaud’s patient with limited scleroderma and advancing skin disease. She was admitted to cardiology with an evolving myocardial infarction, received tissue plasminogen activator by infusion and survived her MI. Remarkably, her skin cleared after one infusion of thrombolytic therapy, and I scoured the literature for supportive case material.
There was one report by Dr. Marvin Fritzler suggesting a role for thrombolytic therapy in scleroderma, and I was off to the races. I called Genentech with hopes of exploring this approach to managing scleroderma skin disease but was diverted by the birth of our firstborn son, and the concept died on the vine. Years later, I ran into Dr. Hellmann at the American College of Rheumatology meeting and mentioned our mutual patient who died 2 weeks into her hospital admission, and he dropped his scotch!
It has taken decades for new candidate therapies to become commercial assets in the autoimmune space — witness the advent of voclosporin (Lupkynis, Aurinia) in lupus nephritis, anifrolumab (Saphnelo, AstraZeneca) in systemic lupus erythematosus and avacopan (Tavneos, Amgen) in ANCA-associated vasculitis as examples — and there is hope on the horizon for scleroderma patients as well.
My admiration for the many mentors I have had in the management of autoimmune disease — Michelle Petri, MD, Kenneth E. Sack, MD, David Wofsy, MD, Ronald B. Anderson, MD, and many others — has made me think twice about every prescription written, balancing the Scylla and Charybdis of safety and efficacy, as well as the cost burdens and difficulties with access from the Adirondacks to Appalachia.
We are a very small subset of internal medicine, yet the passion for our patients, drive to develop targeted therapeutics and assure affordability makes rheumatology the most compelling of choices for those “bitten by the bug” early in their careers.
I recently met the daughter of the farmer whose livestock and property were destroyed by Dupont’s release of C8 (perfluorooctanoic acid) into landfills abutting their property. She has Raynaud’s disease and erythromelalgia — years after a bucolic childhood tending cattle in rural West Virginia. Our world is small and vulnerable, and rheumatologists do make a difference.
Jonathan D. Krant <strong),>
Section Chief of Rheumatology
Marietta Health Systems
Marietta, Ohio</strong),>