Working Diagnosis:
Primary Sjogren's Syndrome with concurrent Fibromyalgia.

Treatment:
The patient was started on a trial of prednisone for 15mg for 14days, 10mg for 3 days, and 5mg for 3 days with symptomatic improvement that ceased once the treatment was completed. Patient began using Dextran 70-hypromellose artificial tear drops for temporary dry eye relief. Patient failed trial of amitriptyline 25mg due to medication side effects after the first two days of use.

Following Prednisone trial, hydroxychloroquine 200mg was given for Sjogren's Syndrome and Duloxetine 20mg for the Fibromyalgia component.

Outcome:
Following administration of Hydroxychloroquine and Duloxetine, the patient noted symptomatic improvement of pain and mood. The patient is currently on the waiting list to see Rheumatology. Based on current symptom severity, continued physical activity is encouraged.

Author's Comments:
Sjogren's Syndrome is an autoimmune disorder caused by destruction of the exocrine glands. The 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for Primary Sjogren's Syndrome Case Photo #1 was primarily established for research and can be impractical to test for all items in the clinic setting. However, these criteria offer great guidance towards establishing the diagnosis. Our patient's symptoms of dry eyes/mouth, fatigue, and arthritis along with laboratory results support a primary Sjogren's Syndrome diagnosis. The history of diffuse myalgia, muscle weakness, and depressed mood raised suspicion for Fibromyalgia, which has a higher incidence in Sjogren's Syndrome. Our patient meets the Modified 2016 Fibromyalgia diagnostic criteria by having a widespread pain index between 4-6 and Symptom Severity greater than or equal to 9.

Editor's Comments:
When evaluating patients with multiple symmetric joint complaints, we should be thinking about systemic causes for their presentation. In this case, the patient presented with bilateral shoulder and elbow pain, along with lumbar spine complaints. These symptoms and the report of fatigue prompted further laboratory investigations. While this work-up would ideally be done by a Rheumatologist, such specialists are not always easily available, and it is important for primary care providers to be comfortable with this diagnostic evaluation.

References:
Vivino, F. B. (2017). Sjogren's syndrome: clinical aspects. Clinical Immunology. 182: 48-54.

Return To The Case Studies List.