Presenting Complaint
The patient describes persistent tiredness that has gradually worsened over the past year. What is the medical term for this symptom?
Fatigue
The patient is a 51-year-old woman. Why is her demographic relevant when considering autoimmune disease?
Many autoimmune diseases have a marked female predominance; this is particularly relevant to the eventual diagnosis.
Her oral mucosa appears unusually dry on examination. What would you expect to find if this has been present for some time?
Dental caries, cracked lips/tongue, oral candidiasis and reduced/absent pooled saliva.
FBC demonstrates a mild normocytic anaemia. Is this finding specific for a particular diagnosis?
No. It is non-specific and may occur with chronic inflammatory or autoimmune disease.
The patient has significant ocular discomfort. Which simple treatment would be appropriate initially?
Artificial tears or ocular lubricants
She reports aching and stiffness affecting several small joints, but there is no significant joint deformity. What type of musculoskeletal symptom is this most consistent with?
Arthralgia / inflammatory joint symptoms
She reports that she frequently wakes during the night to have a drink. What does this suggest about the underlying problem?
Persistent thirst/dryness
Both parotid glands are visibly enlarged but are not particularly tender. What type of process could cause persistent bilateral enlargement?
Chronic inflammatory or infiltrative or autoimmune disease.
ESR is raised but CRP is only mildly elevated. What does this tell you?
There is evidence of an inflammatory process, but the result is non-specific.
What advice would you give to reduce the risk of dental complications in this patient?
Excellent oral hygiene, regular dental review, fluoride treatment and measures to stimulate saliva
She says that eating foods such as crackers and bread has become increasingly difficult unless she has a drink alongside them. What physiological process could explain this?
Reduced salivary secretion (Xerostomia)
She has developed several dental cavities despite previously having good oral hygiene. What change in normal physiology could predispose her to this?
Reduced saliva, which normally helps protect teeth and maintain oral health.
The conjunctivae appear mildly red, and the patient frequently blinks during the examination. What structure should you assess to investigate the cause?
The tear film / lacrimal glands and ocular surface.
ANA is positive. What does this result tell you?
It supports an autoimmune process but is not diagnostic of a specific autoimmune disease.
The patient continues to have troublesome oral symptoms despite simple measures. Which medication can stimulate exocrine secretion?
Pilocarpine.
She has recently found that her eyes become uncomfortable when reading or using a computer for prolonged periods. What normal physiological function may be impaired?
Adequate tear production and maintenance of the tear film
(Dry eyes/keratoconjunctivitis sicca)
She describes episodes where her fingers become pale and then blue when exposed to cold. What phenomenon is this?
Raynaud's phenomenon
The patient has no obvious joint deformities, but several joints are tender on palpation. What does this suggest about the nature of her musculoskeletal symptoms?
Arthralgia/inflammatory musculoskeletal involvement rather than established destructive joint disease.
The patient has reduced tear production on objective testing. What bedside test could have demonstrated this?
Schirmer test
The patient develops significant systemic inflammatory symptoms affecting multiple organs. Would management remain purely symptomatic?
No. Systemic disease may require immunomodulatory treatment, depending on the organs involved and severity
She reports that she has recently developed persistent swelling around both sides of her jaw. What structures could be responsible for this finding?
Salivary glands, particularly the parotid glands
She has a past medical history of rheumatoid arthritis. Why should this be relevant when considering the cause of her current symptoms?
Autoimmune diseases can coexist, and some patients develop features of another autoimmune connective tissue disease alongside rheumatoid arthritis.
On examination, you find persistent cervical lymphadenopathy alongside the bilateral parotid enlargement. Why is this finding particularly important in this patient?
It raises concern for lymphoproliferative disease, particularly lymphoma, in the context of a chronic autoimmune disorder
Blood tests reveal antibodies directed against Ro/SSA and La/SSB. What does this pattern suggest?
An autoimmune connective tissue disease
A patient with this condition develops persistent unilateral parotid enlargement and lymphadenopathy. What is the appropriate next step?
Urgent specialist assessment/investigation for possible lymphoma or other malignancy