Editorial

The Rheumatology-Infectious Disease Clinic: A Much Needed Addition to Interprofessional Rheumatologic Care

This issue of Healio Rheumatology highlights the intersection of viral diseases and rheumatologic care, which is a topic near and dear to my heart. I hold a joint appointment in the department of infectious diseases at the Cleveland Clinic and continue to see patients of a select nature there on a weekly basis. I would like to share with you the story of how this came to be. I hope you find my story of interest and I also hope it helps convince you, if you are not convinced already, of the value of Rheum-ID collaboration.

Leonard H. Calabrese
Leonard H. Calabrese

In 1981, I had completed my rheumatology training and was working in the lab of Dr. John Clough who was recently minted from the NIH, and while practicing rheumatology at the clinic, was focused on the emerging field of primary immunodeficiency disorders. It was no coincidence that this became my passion as well, but there was just one problem: With the absence of genetic biomarkers and advanced laboratory immunologic testing in those early days, these patients were rarely diagnosed and thus genuinely rare.

Late in that year, I received a call from the medical intensive care unit about a complex patient and, remarkably, I remember this conversation very well. A young man was admitted and was critically ill with Pneumocystis carinii pneumonia (aka, Pneumocystis jiroveci pneumonia). He became stricken while traveling from New York and came through the ED. The team thought that perhaps this was a case of the new immune disease identified among gay men that did not yet have a name and, as of that time, the total number of cases reported could be counted on one’s fingers and toes.

I can remember the moment when I weighed the pros and cons of seeing the patient vs. shuttling him off (ie, turfing) to the ID team. I was aware of the MMWR reports and was intrigued by the recently published paper by Michael Gottlieb and colleagues and so I opted to go. Unfortunately, the fate of this poor young man was to experience a rapid demise. I attended his postmortem where ultimately a total of 11 serious and/or opportunistic infections were identified, including disseminated Kaposi’s sarcoma.

I made a fateful decision to make it known at the Clinic (a much smaller Cleveland Clinic) to call me in the event that we “ever” encountered another case of this suspected immune disease (“ever” because no one can recognize the first snowflake in an avalanche). This changed my career trajectory forever and I have never looked back.

Soon thereafter I met Dr. Michael Lederman, a young ID physician of literally the same age at Case Western Reserve School of Medicine who also was interested in this new disease. Little did I know that my new friend and colleague would ultimately become one of the leading HIV immunologists in the world. Our relationship has been remarkable as we have learned together, cried together and laughed a lot as we were taught lessons in immunology posed by both the mystery of as yet undiscovered HIV and challenges of the reaction, resistance and ultimate relative acceptance by society of the most formidable epidemic of our generation.

I cannot discount the immense impact of my HIV experience and I am quite serious when I say that any worth I have as rheumatologist today has been forged by this enduring part of my career above and beyond all others. Over the years I was taught, supported and graciously accepted by the ID department and learned the lessons of the diagnosis and management of serious and opportunistic infections through ‘on the job’ training. I became comfortable with managing most of these including the viral comorbidities of hepatitis B, hepatitis C, varicella-zoster and John Cunningham viral infections among others.

By the mid-to-late 90s and the dawn of biologic therapeutics, I was as ready as anyone in our field to help sort out the infectious complications that would ultimately be described. Fast forward to today and it seems only natural that my career is a fusion of many interests with an enduring focus on infections as etiologies, comorbidities and complications of our increasingly complex biologic armamentarium.

In terms of aligning this with rheumatology, I have been progressively convinced of the logic of combining both of these specialties as more patients with these types of problems were referred to me. In recent years, I have hired an outstanding young allergist/immunologist to join the Fasenmyer Center to focus on the growing field of adult primary immunodeficiency disorders that — somewhat ironically — are now increasingly recognized to have autoimmune and autoinflammatory manifestations!

To bolster this interprofessional collaboration with ID, we have developed an outstanding and popular core rotation for our fellows in ID that is an exemplar of interprofessional teaching. A few years ago, I reflected on this phase of my career and asked myself, in the absence of a new epidemic like HIV, how would rheumatologists like me be drawn into formal training in this area that I now refer to as the Rheum-ID connection?

I will close by telling you that I am extraordinarily excited to share with you that, with a half-million-dollar matching grant from the R.J. Fasenmyer Foundation, we have created the first formally vetted and approved Rheum-ID fellowship training program that will provide dual board eligibility after a total of 36 months of combined training. I am even more excited because the beta test subject of this new combined program is just now completing it and will be joining our department and my immunology center to formally establish the first Rheumatology-Infectious Disease Clinic dedicated to patients with all things infectious that may represent etiologies, comorbidities or complications of rheumatic diseases and their therapies. As many of you may also know this beta test subject is my daughter, Cassie, who is now in her seventh postgraduate year and is ready to lead the way. Of course, I could not be happier and also a little bit jealous, because her training has been designed the way it should be with dual board certifications as a result. We are now vetting the next candidate for this track and hope to achieve our philanthropic goal to endow this training position in perpetuity.

Well, that is my story and I would enjoy your comments. I will close by also asking you to share with me your views, experience and any efforts to work interprofessionally with our ID colleagues.

Thanks for reading Healio Rheumatology. Please send your comments by email to calabrl@ccf.org or to me on Twitter @LCalabreseDO.

Disclosure: Calabrese reports serving as an investigator and a consultant to Horizon Pharmaceuticals.

This issue of Healio Rheumatology highlights the intersection of viral diseases and rheumatologic care, which is a topic near and dear to my heart. I hold a joint appointment in the department of infectious diseases at the Cleveland Clinic and continue to see patients of a select nature there on a weekly basis. I would like to share with you the story of how this came to be. I hope you find my story of interest and I also hope it helps convince you, if you are not convinced already, of the value of Rheum-ID collaboration.

Leonard H. Calabrese
Leonard H. Calabrese

In 1981, I had completed my rheumatology training and was working in the lab of Dr. John Clough who was recently minted from the NIH, and while practicing rheumatology at the clinic, was focused on the emerging field of primary immunodeficiency disorders. It was no coincidence that this became my passion as well, but there was just one problem: With the absence of genetic biomarkers and advanced laboratory immunologic testing in those early days, these patients were rarely diagnosed and thus genuinely rare.

Late in that year, I received a call from the medical intensive care unit about a complex patient and, remarkably, I remember this conversation very well. A young man was admitted and was critically ill with Pneumocystis carinii pneumonia (aka, Pneumocystis jiroveci pneumonia). He became stricken while traveling from New York and came through the ED. The team thought that perhaps this was a case of the new immune disease identified among gay men that did not yet have a name and, as of that time, the total number of cases reported could be counted on one’s fingers and toes.

I can remember the moment when I weighed the pros and cons of seeing the patient vs. shuttling him off (ie, turfing) to the ID team. I was aware of the MMWR reports and was intrigued by the recently published paper by Michael Gottlieb and colleagues and so I opted to go. Unfortunately, the fate of this poor young man was to experience a rapid demise. I attended his postmortem where ultimately a total of 11 serious and/or opportunistic infections were identified, including disseminated Kaposi’s sarcoma.

I made a fateful decision to make it known at the Clinic (a much smaller Cleveland Clinic) to call me in the event that we “ever” encountered another case of this suspected immune disease (“ever” because no one can recognize the first snowflake in an avalanche). This changed my career trajectory forever and I have never looked back.

PAGE BREAK

Soon thereafter I met Dr. Michael Lederman, a young ID physician of literally the same age at Case Western Reserve School of Medicine who also was interested in this new disease. Little did I know that my new friend and colleague would ultimately become one of the leading HIV immunologists in the world. Our relationship has been remarkable as we have learned together, cried together and laughed a lot as we were taught lessons in immunology posed by both the mystery of as yet undiscovered HIV and challenges of the reaction, resistance and ultimate relative acceptance by society of the most formidable epidemic of our generation.

I cannot discount the immense impact of my HIV experience and I am quite serious when I say that any worth I have as rheumatologist today has been forged by this enduring part of my career above and beyond all others. Over the years I was taught, supported and graciously accepted by the ID department and learned the lessons of the diagnosis and management of serious and opportunistic infections through ‘on the job’ training. I became comfortable with managing most of these including the viral comorbidities of hepatitis B, hepatitis C, varicella-zoster and John Cunningham viral infections among others.

By the mid-to-late 90s and the dawn of biologic therapeutics, I was as ready as anyone in our field to help sort out the infectious complications that would ultimately be described. Fast forward to today and it seems only natural that my career is a fusion of many interests with an enduring focus on infections as etiologies, comorbidities and complications of our increasingly complex biologic armamentarium.

In terms of aligning this with rheumatology, I have been progressively convinced of the logic of combining both of these specialties as more patients with these types of problems were referred to me. In recent years, I have hired an outstanding young allergist/immunologist to join the Fasenmyer Center to focus on the growing field of adult primary immunodeficiency disorders that — somewhat ironically — are now increasingly recognized to have autoimmune and autoinflammatory manifestations!

To bolster this interprofessional collaboration with ID, we have developed an outstanding and popular core rotation for our fellows in ID that is an exemplar of interprofessional teaching. A few years ago, I reflected on this phase of my career and asked myself, in the absence of a new epidemic like HIV, how would rheumatologists like me be drawn into formal training in this area that I now refer to as the Rheum-ID connection?

PAGE BREAK

I will close by telling you that I am extraordinarily excited to share with you that, with a half-million-dollar matching grant from the R.J. Fasenmyer Foundation, we have created the first formally vetted and approved Rheum-ID fellowship training program that will provide dual board eligibility after a total of 36 months of combined training. I am even more excited because the beta test subject of this new combined program is just now completing it and will be joining our department and my immunology center to formally establish the first Rheumatology-Infectious Disease Clinic dedicated to patients with all things infectious that may represent etiologies, comorbidities or complications of rheumatic diseases and their therapies. As many of you may also know this beta test subject is my daughter, Cassie, who is now in her seventh postgraduate year and is ready to lead the way. Of course, I could not be happier and also a little bit jealous, because her training has been designed the way it should be with dual board certifications as a result. We are now vetting the next candidate for this track and hope to achieve our philanthropic goal to endow this training position in perpetuity.

Well, that is my story and I would enjoy your comments. I will close by also asking you to share with me your views, experience and any efforts to work interprofessionally with our ID colleagues.

Thanks for reading Healio Rheumatology. Please send your comments by email to calabrl@ccf.org or to me on Twitter @LCalabreseDO.

Disclosure: Calabrese reports serving as an investigator and a consultant to Horizon Pharmaceuticals.