A 48-year-old Caucasian woman comes to the physician because of a 1 week history of a lump in her neck. She has muscle pains and body aches. Upon further questioning, she adds that she often experiences a "gritty, burning sensation in both of my eyes, and sometimes they get red and inflamed." She does not wear contact lenses. She has not had fever, chills, weight loss, dysphagia, cough, hemoptysis, muscle weakness, or joint swelling. She has fibromyalgia, depression, and cholelithiasis. She has extensive caries of her teeth and has been visiting a dentist regularly. She does not use tobacco, alcohol, or drugs. Her only medication is fluoxetine. Her temperature is 37.0 C (98.6 F) , blood pressure is 122/80 mm Hg, pulse is 76/min, and respirations are 14/min. Her BMI is 27 kg/m2. Examination shows a mobile, non-tender 2x2 cm right-sided submandibular mass. Item 1 of 2
Which of the following is the most appropriate next step in management?

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Quizplus · Accepted Answer

Explanation: The most likely diagnosis in this patient is Sjogren's syndrome, a chronic, autoimmune inflammatory condition that primarily affects the lacrimal and salivary glands. The "gritty, burning sensation" and conjunctival irritation described by this patient are typical manifestations of keratoconjunctivitis sicca secondary to abnormal tear production by the lacrimal glands. Keratoconjunctivitis sicca may also present with prominent bulbar blood vessels and stringy discharge from the eyes. Dental caries may be a manifestation of xerostomia (decreased saliva production). Anti-Ro/SSA and anti-La/SSB antibodies are associated with Sjogren's syndrome - 50% of patients with Sjogren's syndrome test positive for one of the above antibodies. Because there is no definitive diagnostic test, these antibodies can be helpful to confirm the clinical diagnosis of Sjogren's syndrome. (Choice B) Tuberculosis can produce necrotic lymph nodes (sometimes referred to as scrofula). However, this patient's overall presentation is more consistent with Sjogren's syndrome. (Choice C) Sjogren's syndrome results in very few symptoms referable to the paranasal sinuses. MRI could be considered for evaluation of the submandibular mass - not for evaluation of the sinuses. (Choice D) Nasopharyngeal endoscopy should be considered if there was concern for nasopharyngeal carcinoma. While a metastatic lymph node is in the differential for the submandibular mass, this is unlikely to be secondary to nasopharyngeal carcinoma in this particular patient. (Choice E) Thyroid abnormalities would not explain this patient's symptoms. Educational objective: The combination of ocular symptoms consistent with keratoconjunctivitis sicca and oral symptoms consistent with xerostomia should lead one to suspect a diagnosis of Sjogren's syndrome. Anti-Ro-SSA and anti-La/SSB antibodies are commonly present and can be helpful to confirm one's clinical suspicion of Sjogren's syndrome, as no true diagnostic test is available. References: Anti-Ro (SS-A) and anti-La (SS-B) in patients with Sjögren's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/3485431)

A 48-Year-Old Caucasian Woman Comes to the Physician Because of a 1