A 65-year-old woman comes to the office with a 6-month history of dry mouth. She says that she feels dry all day long and has to drink water. She also has had a sandy sensation in her eyes, especially after watching television for a while. Medical history is significant for long-term hypertension that is controlled with metoprolol. She does not smoke or consume alcohol. Her recent fasting blood glucose level was normal. Physical examination findings are within normal limits. Which of the following is the best next step in the management of this patient?

Question

A 65-year-old woman comes to the office with a 6-month history of dry mouth.  She says that she feels dry all day long and has to drink water.  She also has had a sandy sensation in her eyes, especially after watching television for a while.  Medical history is significant for long-term hypertension that is controlled with metoprolol.  She does not smoke or consume alcohol.  Her recent fasting blood glucose level was normal.  Physical examination findings are within normal limits.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca). These sicca symptoms are extremely common, especially in the elderly (prevalence ~30%), where they may be due to medication usage or to age-related atrophy of tissues that secrete saliva and tears; they are also commonly associated with Sjogren syndrome, an infiltrative autoimmune condition that can affect multiple organ systems (eg, musculoskeletal pain, cutaneous manifestations, interstitial lung disease, hematologic abnormalities). In patients with sicca symptoms, the choice of appropriate diagnostic modalities depends on the patient's age, past medical history, associated findings, and overall pretest probability of Sjogren syndrome. The initial evaluation can include ophthalmologic evaluation, including Schirmer test (slit-lamp examination to assess tear break-up time), as well as autoantibody screening with anti-Ro/SSA, anti-La/SSB, antinuclear antibodies, and rheumatoid factor. Evidence of systemic autoimmunity (eg, positive autoantibodies) can support the diagnosis of Sjogren syndrome. (Choice B) Although labial salivary gland biopsy is the gold standard for diagnosing Sjogren syndrome, it is typically not the first test that is performed. It helps confirm the diagnosis, especially in young patients with aggressive disease but with no evidence of systemic autoimmunity. (Choice C) Low-dose corticosteroids are not typically used to treat sicca symptoms alone. Initial measures for xerostomia include salivary flow stimulation (mechanical, topical) and artificial saliva. (Choice D) Imaging modalities may be helpful in assessing the structure and function of the salivary glands. Ultrasonography and MR imaging are commonly used. Parotid gland sialography requires cannulation of the glands with injection of contrast material; it is associated with a risk of rupture and is not routinely performed. (Choice E) It is necessary to use appropriate diagnostic tools in order to diagnose Sjogren syndrome or to identify other conditions that may present as sicca syndrome (eg, sarcoidosis). Educational objective: A reasonable initial approach to sicca symptoms (eg, dry mouth, dry eyes) is confirming a secretory deficiency (eg, Schirmer test) and obtaining an autoantibody screen to evaluate for Sjogren syndrome.

A 65-Year-Old Woman Comes to the Office with a 6-Month