5 Questions with Dr. Anita Dhanrajani

Summary

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Podcast Summary:

Blood, Sweat and Smears - A Machaon Diagnostics Podcast
Episode Title: 5 Questions with Dr. Anita Dhanrajani
Host (for this episode): Bjorn (standing in for Dr. Brad Lewis)
Guest: Dr. Anita Dhanrajani, Pediatric Rheumatologist, New Orleans Children’s Hospital
Date: September 5, 2024

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Overview

In this concise and insightful “Five Questions” segment, Dr. Anita Dhanrajani, a pediatric rheumatologist, shares her perspectives on collaborative care for HLH/MAS patients, the pitfalls in rheumatologic testing, her favorite New Orleans spots, the profound challenges of treating lupus, and the unique relationship between hematology and rheumatology. The episode rounds out with a personal recommendation from Dr. Dhanrajani, blending clinical wisdom with the vibrancy of her adopted city.

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Key Discussion Points & Insights

1. Care Teams for HLH/MAS Patients ([01:45])

• Clarification of Terms:
  Dr. Dhanrajani distinguishes between HLH (Hemophagocytic Lymphohistiocytosis, often genetic/primary) and MAS (Macrophage Activation Syndrome, secondary to rheumatologic disease).
• Team Approach:
  • MAS in a child with known rheumatologic disease: rheumatology takes primary lead.
  • Possible new HLH/MAS diagnosis: consults go out to both rheumatology and hematology/oncology.
  • Infectious disease teams often involved (“some infectious diseases can also lead to secondary MAS”).
  • Allergy/immunology may be consulted if primary immunodeficiency is considered.
• Key Quote:

  “Short answer is, it’s very multidisciplinary. It’s a mix of heme, onc, rheumatology, ID and sometimes we would involve allergy immunology if there is consideration for a primary immunodeficiency disorder.”
  — Dr. Anita Dhanrajani ([03:33])

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2. Rheumatologic Tests: Misordered and Misunderstood ([03:53])

• Test Spotlight: ANA (Antinuclear Antibody)
  • Frequently misused as a general “rheumatologic screen.”
  • ANA is nonspecific; up to 30% of healthy individuals may have a positive result.
  • False positives also arise from infections or medications.
  • ANA is diagnostic only in context of high suspicion (e.g., strong clinical evidence of lupus).
• Key Quote:

  “There is no such thing as a rheumatologic screen, and ANA would be the worst possible test you could do if you wanted to do a rheumatologic screen.”
  — Dr. Anita Dhanrajani ([04:22])

• Advice:

  “…if you are ever considering doing an ANA test and you’re not sure… call your friendly rheumatologist and ask…”
  — Dr. Anita Dhanrajani ([05:32])

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3. Not-to-Miss in New Orleans ([05:45])

• City Park:
  • “Amazing place… long walks, biking, swan boats—lit up at night. Beautiful and close to nature.”
    — Dr. Anita Dhanrajani ([06:10])
• The Spotted Cat Cafe:
  • “Live music, jazz on Frenchmen Street… never been disappointed… always have a great time.”
    — Dr. Anita Dhanrajani ([06:36])
• Context:
  Dr. Dhanrajani considers herself “still a tourist” in the city despite living there for over a year.

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4. The Disease That Keeps Her Up at Night ([07:09])

• Lupus (Systemic Lupus Erythematosus):
  • Even with extra training and research, lupus’s unpredictability is daunting.
  • Flares, remissions, relapses, complications—including severe organ involvement and infection risks.
• Key Quote:

  “It’s so unpredictable when a patient can turn the wrong way for lupus, that that has to be the disease that keeps me up. And I suspect most rheumatologists up at night.”
  — Dr. Anita Dhanrajani ([07:44])

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5. What Hematologists Should Understand About Pediatric Rheumatology ([08:02])

• Contrast in Specialties:
  • Hematology/Oncology: “very protocol based… set guidelines and protocols.”
  • Rheumatology: “a very gray zone specialty”—lacking in diagnostic criteria and standardized recommendations.
  • Every patient may require an individualized approach; uncertainty is part of the field.
• Example: Lupus again highlighted as “disease of a thousand faces”—different in every patient.
• Key Quote:

  “Our field is a very gray zone specialty, if I can call it that. We don’t have a lot of diagnostic criteria, we don’t have a lot of set recommendations and guidelines… a lot of times we have to live with that uncertainty.”
  — Dr. Anita Dhanrajani ([08:43])

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Memorable Bonus Moment

Bonus: Something to Recommend ([09:57])

• Brené Brown (author/researcher on vulnerability and leadership)
  • Dr. Dhanrajani: “If anybody listening to this is not influenced by Brené Brown in their lives, they need to be.”
• Practical Impact:
  Dr. Dhanrajani credits Brown’s work for positively affecting her day-to-day life and work in medicine.

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Notable Quotes

• “For the best weather (and festivals) in New Orleans, I would pick early March… but book early!”
  — Dr. Anita Dhanrajani ([01:20])

• “The uncertainty would be the biggest thing I would say is different between rheumatology and hematology.”
  — Dr. Anita Dhanrajani ([09:13])

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Timestamps of Key Segments

• [01:45] The care team for HLH/MAS at New Orleans Children’s
• [03:53] Most misunderstood rheumatologic test: ANA
• [05:45] Dr. Dhanrajani’s “not-to-miss” New Orleans recommendations
• [07:09] The one condition that causes the most worry: Lupus
• [08:02] What pediatric hematologists should know about rheumatology
• [09:57] Bonus: Life advice—Brené Brown

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Tone and Takeaways

Dr. Dhanrajani offers an approachable, thoughtful, and practical lens on complex pediatric care, marked by collaboration, humility, and an embrace of the unknown (“the gray zone”). She brings both clinical expertise and personal recommendations, making this episode equally suited for clinicians seeking nuanced practice pearls and listeners looking for life wisdom—or even travel tips for New Orleans.

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Transcript

[Podcast Host]

Hello, and welcome to Blood, Sweat, and Smears, a podcast produced by Macheon Diagnostics. In this podcast series, we will be discussing thrombosis and hemostasis from the perspective of our host benign hematologist and medical director of Macheon Diagnostics, Dr. Brad Lewis. Please remember to subscribe and leave a review. With that, I'll turn it over to Dr. Lewis. Brad, take it away.

[Bjorn]

Hi, my name is Bjorn, and I'm sitting in for Dr. Lewis for our series called Five Questions, where we pose five questions to physicians in and around the disease areas we work in. We hope you find these short interviews interesting, maybe even the most interesting thing you've heard today. Today I'm joined by Dr. Anita Dhanrajani, pediatric rheumatologist at New Orleans Children's Hospital, where she specializes in caring for children with autoimmune diseases. Thank you for joining us today, Dr. Dhanrajani.

[Dr. Anita Dhanrajani]

Thanks for having me.

[Bjorn]

We have a lab in New Orleans, and I've probably been to New Orleans over 20 times, and I'm rather taken with it at all. This is not one of the official questions, but which month do you think is the best weather wise for folks to come to New Orleans?

[Dr. Anita Dhanrajani]

So my personal favorite is March, and it's a bit contentious because you could say that October is better than March, but honestly, if you want the best of the weather and the best of all the festivals and all the activities that go on in New Orleans, I would pick to come in early March. Fair warning, though, you might want to do your reservations, like, a year in advance because the prices are really jacked up at that time.

[Bjorn]

Yeah. All right, now we have real questions. Here's our first one. Question number one at New Orleans Children's, when you have a suspected HLH or MAS patient, who's involved, who's on the team, and how do you work together?

[Dr. Anita Dhanrajani]

Yeah, I think that's a great first question. Thank you for asking that. I think I would like to start by clarifying the difference between HLH and mas, and that kind of determines who is more significantly involved in the care of the patient. So a lot of people in the audience probably already know this, but HLH is when you have primary HLH and usually due to a genetic cause, whereas if you have an underlying rheumatologic condition, for instance, systemic GIA or systemic lupus, if you then develop hlh, then we call it mas. So that's a little bit of a difference in terminology. But if there is a patient with MAS that already has an existing diagnosis of a rheumatologic condition, then obviously rheumatologists would be primarily involved in the care of the patient when they get admitted with mas, Whereas if it is a new patient where a diagnosis of HLH MAS is being considered, then I think that what happens is the primary team would send out consults to both rheumatology and hemong to kind of determine which way this might go. At the same time, I think infectious diseases can be pretty closely involved in the diagnosis of these patients because as again, some of you probably know that some infectious diseases can also lead to secondary MAs. So I think short answer is it's very multidisciplinary. It's a mix of heme, onc, rheumatology, ID and sometimes we would involve allergy immunology if there is consideration for a primary immunodeficiency disorder.

[Bjorn]

Question number two. What is one rheumatologic test you think is often ordered but understood rarely?

[Dr. Anita Dhanrajani]

This is one of my pet peeves, one of my absolute favorite things to talk about. I'm going to try to really keep it brief here. I think that ANA or the anti nuclear antibody test is a very largely misunderstood test and a misused test, unfortunately. And this is not just me that says this, choosing wisely. Guidelines very strongly recommend not to do ANA testing for a patient for screening purposes. There is no such thing as a rheumatologic screen and ANA would be the worst possible test you could do if you wanted to do a rheumatologic screen. And the reason for that is ANA is a very non specific test. 30% of the normal population can have a positive ANA and not have any disease. On top of that, there are a lot of conditions other than rheumatologic conditions such as infections or medications that can lead to a transiently positive ana. So testing the ANA if you don't have actual signs and symptoms of lupus is just not a great thing to do. It is not going to help you with the diagnosis unless you actually already have a strong suspicion of what is going on with the patient. So if you were to ask me, I would say that for pediatricians, for hematologists, oncologists, if you are ever considering doing an ANA test and you're not sure if you want to order it or not, if you're not sure how to interpret it, I would say call your friendly rheumatologist and ask them if it is a valid test to be sent or not.

[Bjorn]

All right, switching gears here a little bit for Question three. What is one place not to miss on a trip to New Orleans?

[Dr. Anita Dhanrajani]

Oh, okay. Yeah, that is a switch. One place not to miss is hard. I'm going to go with my two top favorites. I have been in New Orleans for just over a year, and I think I still consider myself a tourist because I'm still exploring a lot of places here. My top favorite one in New Orleans is the City Park. Now, if you are a person that loves nature, that just loves being surrounded by green and lakes and bodies of water, City park is an amazing place for you. We love going on long walks there. You can bike there. They even have all this touristy stuff like the swan boats, which they light up at night, by the way. So it's really, really beautiful, really touristy, but also just very brings you closer to nature kind of place. And then my second one is the exact opposite of City Park. That would be. This is a live music, jazz kind of place on Frenchman Street. It's called the Spotted Cat Cafe. They have the best, you know, selection of musicians that come and perform there. I have never been disappointed when I visited that place. Whether it's about their choice on their menu or it's about who's performing, I always have a great time there. So those would be my top two.

[Bjorn]

Question number four. What's the one disease or condition that keeps you up the most?

[Dr. Anita Dhanrajani]

So I would have to say lupus. Even though lupus is the disease that I am most comfortable treating and I have additional training in treating lupus and I do research work in lupus, I think the inherent nature of the disease is just so unpredictable. You can have flare ups, you can have remissions, you can have relapses, you can have complications such as infections, you can have major organ involvement. And some of these kids get extremely sick. And like I said, it's so unpredictable when a patient can turn the wrong way for lupus, that that has to be the disease that keeps me up. And I suspect most rheumatologists up at Nate.

[Bjorn]

Question 5. What do you wish pediatric hematologists understood better about pediatric rheumatology?

[Dr. Anita Dhanrajani]

Great question. Again, I have to preface that one by saying that when I was doing my pediatrics training, I almost chose to do a hemonc fellowship. I was very closely involved in treating some hemonc patients because my mentor was a hematologist oncologist, and I was very, very attracted to that field. And so one of the major differences that strikes me me about hematology versus rheumatology is that hema ONC is very protocol based, which is a great thing. Hematologists deal with a lot more serious and life threatening conditions than we do in rheumatology. And having set guidelines and protocols is so important. And yet that is a very extreme contrast from what we deal with in pediatric rheumatology. So our field is a very, is a very gray zone specialty, if I can call it that. We don't have a lot of diagnostic criteria, we don't have a lot of set recommendations and guidelines for treating some of our major conditions. And a lot of times we have to live with that uncertainty for a lot of our patients, whether it is related to diagnostic uncertainty or whether it is related to what kind of management protocol would we pick for the patient? Because it can really vary from patient to patient. As an example, talk to me about lupus. Lupus is called disease of thousand faces and it can really look different in every patient that I see. So I think that uncertainty would be the biggest thing I would say is different between rheumatology and hematology. And that would be something I would want everybody to know.

[Bjorn]

So that wraps up our five questions and now we have our bonus question which is what's something you would recommend? And it can be absolutely anything.

[Dr. Anita Dhanrajani]

Oh yay, bonus question. I think that if you are not anybody listening to this is not influenced by Brene Brown in their lives. I think they need to be. So that is my very, very strong generic recommendation to absolutely anybody in the world. If you guys don't know Brene Brown, she is a researcher, I believe Houston, Texas. She is a writer and author of several books and she also does podcasts on Spotify. So what she talks about or researches is a little bit unconventional. Talks about vulnerability, she talks about shame, she talks about unconventional leadership methods. I for one have been very influenced by some of her writings and I have been able to incorporate some of that in my day to day life and in my work. And I feel like every single person should get at least a little taste of what is Brene Brown about. So that would be my recommendation.

[Bjorn]

Thank you so much. And as Brene Brown would say, courage starts with showing up and letting ourselves be seen. So thank you Dr. Dhanrajani, for showing up today, letting yourself be seen.

[Dr. Anita Dhanrajani]

Thank you so much for having me. Really enjoyed it.

[Bjorn]

Our pleasure.

[Podcast Host]

That's it for us here at Blood, Sweat and Smears, a podcast produced by Matrion Diagnostics, your reference lab and CRO specializing in thrombosis, hemostasis and rare disease. Thank you for listening. And if you have a question or comment or there's a topic you'd like Dr. Lewis to speak to, please send us an email to Blood, Sweat and Smearsay that's M A C H A O N diagnostics.com youm can follow Macheon at Twitter at matriondx. Be sure to subscribe to Stay in the know. Share this podcast with clinicians you think might appreciate it, and we hope you'll join us next time here at Blood, Sweat and Smears.