Question

A 32 year old woman comes to her primary care provider for a return visit with the chief complaint of joint pain and swelling for several months. At first the pain involved the left wrist and elbow and the right knee, but gradually became bilateral and now involves the metacarpophalangeal and proximal interphalangeal joints. Every morning, she has stiffness that slowly gets better after a couple of hours, but the generalized fatigue and weakness lasts all day. Her eyes often feel gritty and dry. She has had some weight loss over the past few months. There is no skin rash or oral ulcers. However, the oral cavity appears overly dry. There is no history of fever or diarrhea. On examination, the affected joints are bilaterally warm, swollen and tender. The rest of her physical exam is unremarkable.

NEW INFORMATION:

The constellation of her signs and symptoms points to an autoimmune disease. The involved joints make rheumatoid arthritis more likely than other conditions such as SLE or scleroderma. Her CBC reveals normochromic normocytic anemia. Her ESR and CRP are both elevated. She is negative for antinuclear antibodies (ANA), but highly positive for rheumatoid factor (RF). Serum creatinine is normal.

1. Which other autoimmune disease may be present along with RA in this patient?
2. What additional tests would be helpful in confirming her diagnosis?

Answer 1

Ans ) sjogrens syndrome

Since the patient has high rheumatoid factor (RF) and dry mouth its rheumatoid arthritis with sjogrens syndrome.

Secondary sjogrens syndrome occurs along with an autoimmune disorder such as as rheumatoid arthritis, polyareteritis nodosa , scleroderma , billiary cirrhosis , thyroiditis , polymyositis , connectivectissue disorders , lymphoma ,chronic active hepatitis C , vasculitis , miced cryoglobulinemia etc.

( Primary sjogrens syndrome patients present with only dry eyes and dry mouth called as sicca syndrome . )

tests for sjogren syndrome include .

Lab findings would show raised RF factors ,ANA , immunoglobulin antibofies etc.

Schirmers test - filter paper is uaef to assess tear production ,more than 10mm oroupto 15mm moisture on filter paper in 5 minutes is normal .

Less than 15mm suggests sjogrens .

Sialography with injection of a fontrast dye into salivary gland duct and exposed to x rays . Produces branchless fruit laden tree or cherry vlossoms appearence due to filling defects.

Rose bengal staining of the corneal tissue to differentiate between keratoconjunctivitis sicca and sjogrens .

Biospy of lip glands would ahow infiltration by lymphocytes replacing all acinar structures , or there may be oroliferation of epimyoepthlial cells or atrophy of gland sequential to lymphocytic infiltration.

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