Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Patients with primary Sjögren syndrome have up to a 44-fold increased incidence of lymphoma and should be monitored closely for lymphadenopathy.Therefore, transthoracic echocardiography would not be warranted in this patient. However, infective endocarditis is unlikely in a patient with no cardiac abnormalities negative blood culture results and an absence of associated vascular phenomena or risk factors for this condition.
Infective endocarditis may manifest as fever, fatigue, and lymphadenopathy, and transthoracic echocardiography can help to diagnose this condition. In addition, her constitutional symptoms may be manifestations of malignancy and not Sjögren syndrome. Prednisone may help to treat constitutional symptoms associated with Sjögren syndrome but would not address this patient’s more urgent enlarged left axillary lymph node. Because this patient has clinical evidence of Sjögren syndrome, salivary gland biopsy is not necessary furthermore, this study would not help to evaluate this patient’s enlarged axillary lymph node. This patient’s firm enlarged left axillary lymph node and pancytopenia particularly raise suspicion of lymphoma, and an excisional axillary lymph node biopsy is the most appropriate next step in this patient’s management.Ī minor (labial) salivary gland biopsy would help to confirm the diagnosis of Sjögren syndrome and would reveal increased lymphocytic infiltration. Patients with primary Sjögren syndrome have up to a 44-fold increased incidence of lymphoma, particularly non-Hodgkin lymphoma, and should be monitored closely for lymphadenopathy. Sjögren syndrome also may occur secondary to another autoimmune disease, such as rheumatoid arthritis or systemic lupus erythematosus. Her fatigue, arthralgia, Raynaud phenomenon, and low-grade fever also are consistent with this condition. This patient’s symptoms of keratoconjunctivitis sicca (dry eyes and dry mouth) the presence of antinuclear, anti-Ro/SSA, and anti-La/SSB antibodies and an elevated rheumatoid factor level are characteristic of primary Sjögren syndrome.
This item is available to MKSAP 15 subscribers as item 79 in the Rheumatology section. The correct answer is A) Excisional axillary lymph node biopsy.
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