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I have inflammatory arthritis, auto immune thyroid and hepatitis. I have very dry mucosa in eyes, nose and mouth, ulceration and white spots on mouth. I also have skin breakdown on arms and legs and ulceration on my foot. I am not diabetic.
My mother had scleroderma and pbc.

Photos of my nailfolds are they abnormal?

I am concerned about scleroderma, sjogrens or vasculitis. I also am being investigated for peripheral neuropathy.

Many thanks.

Category: Rheumatologist

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Category: Internal Medicine Specialist
Dr. Bimlesh Dhar Pandey is online now

Expert:  Dr. Bimlesh Dhar Pandey replied 4 Days.

Thank you for your query at DoctorSpring.com
As far as working diagnosis is concerned I would label it as Sjogren Syndrome with vasculitis and associated auto immune hepatitis and auto immune thyroiditis.
I would be extremely important to have ESR, CRP, CBC LFT and TSH levels kindly post the recent reports to assess the activity in general and ANA by Immunoflurorsence method and ANA profile by ENA or LIA method or specific Anti Ro ( both the fraction Kilo dalton 60 and 52) anti La also called as Anti SS-A and Anti SS-B.
so my diagnosis is overlap syndrome( auto immune hepatitis and thyroiditis and probable Sjogren Syndrome with vasculitis).
Getting work up for hepatitis C and B is essential, probably done if not please get it done and serum croglobulin work up is also required.
Thanks for the query and do feel comfortable to ask if you have query.

Patient replied :

I am getting a skin biopsy tomorrow but most of the lesions have healed. Where would be the best place to take a biopsy from? I am getting a dry eye assessment done next week and as my husband is a retired facial maxillary surgeon, we have done a salivary flow test which was 0.3 mls/min (with parotid stimulation) at best. I have had a sialogran for an infected gland two years old patientago. The duct was tiny and the gland described to me as damaged. Is there anything else that I need to do? Thank you for your answer. It is a great relief to have an opinion to cite to consultants who are not looking at the whole picture.

Expert:  Dr. Bimlesh Dhar Pandey replied 3 Days.

In suspected cases of sicca especially sjogren syndrome what works the best is to have minor salivary gland biopsy and get a focus score to demonstrate inflammatory cell chiefly lymphocytes in the salivary gland and also score it accordingly. the second best to have ANA and Rheumatoid factor as well as Anti RO anti LA. The third would be Ultrasound of the salivary gland which is easy to do but requires trained person to interpret salivary gland ultrasound.
with these three it is more than sufficient for work up of sjogren syndrome as on today. the sialogram and salivary flow over the time will become redundant because external factors affecting the result. now comes role of biopsy if they are healing or healed there wont be anything contributory from the biopsy other chronic inflammatory cell and various cell types in different stages of cell death i.e cell derbies.the meaning of biopsy would be difficult to interpret.
I order only in fresh lesion from normal to abnormal junction area and very easy procedure of not more than 5 minutes. So the patient are informed to come with lesion which are fresh i.e approximately 48 hours to see all the cell types at pathological sites.
I don't know whether you have the system where the doctors office is willing to do biopsy without prior appointment.we have what is called open appointment for the biopsy.

Patient replied :

Thankyou, I will get these tests done privately and then go back to my GP.

Dr. Bimlesh Dhar Pandey
Category: Internal Medicine Specialist
Senior Residency: Rhematology, All India Institute of Medical Schiences, New Delhi, 2009
Post Graduate, Junior Residency: MD (Internal Medicine), Rajendra Institute of Medical Sciences, Jharkhand, 2006
Residency: Physiology, Institute of Medical Science, Banaras Hindu University, Varanasi, 2003
Internship: Government Medical College, Trichur, 2001
Medical School: MBBS, Calicut University, 2001
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