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

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.

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])

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])

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.

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])

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])

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.

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])

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

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.