A 49-year-old woman comes to the office due to difficulty swallowing solid food. The patient's symptoms are worse with breads and crackers, but she has no difficulty with liquids, and she uses sips of water to help with swallowing. She thinks that she may have lost weight. The patient's medical history is significant for hypertension and hypothyroidism treated with amlodipine and levothyroxine, respectively. She also uses over-the-counter saline eye drops for eye dryness. The patient has never used tobacco or alcohol. Family history is negative for cancer. She has been monogamous with her husband for 15 years. Blood pressure is 140/90 mm Hg and pulse is 60/min. BMI is 19 kg/m². Physical examination shows oral thrush, prominent dental caries, and bilateral, firm submandibular nodules. There is no lymphadenopathy. Cardiopulmonary examination shows no abnormalities. Abdomen is soft and nontender with no organomegaly. There is no peripheral edema. Which of the following is the best next step to confirm this patient's diagnosis?

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Explanation: 11ec25c8_d525_6f90_bc81_79fcf65847f9_MD0003_00 Sjögren syndrome (SS) is an autoimmune disorder characterized by inflammation of exocrine glands, with a greatest incidence in middle-aged women. Patients can have severe dry mouth (xerostomia) with dysphagia (difficulty swallowing), thrush, and dental caries. Involvement of lacrimal glands causes keratoconjunctivitis sicca (eg, dry eyes). Extraglandular features include arthritis, Raynaud phenomenon, cutaneous vasculitis, interstitial lung disease, and increased risk for non-Hodgkin lymphoma. The diagnosis of SS is made in patients with ocular or oral dryness when there is: Evidence of dry mouth and eyes. In the Schirmer test, a sterile strip of filter paper is placed under the lower eyelid, and the area moistened by the absorbed fluid is measured after 5 minutes. Either histologic evidence of lymphocytic infiltration of the salivary glands or presence of serum autoantibodies directed against SSA (Ro) and/or SSB (La). Antinuclear antibodies and rheumatoid factor are less specific but helpful when positive. (Choice B) Autoimmune sialoadenitis in SS causes enlargement of the salivary glands visible on MRI or ultrasound. CT scan of the neck can be used to evaluate for malignancy, which is less likely to explain this patient's dry eyes, bilateral submandibular nodules, thrush, or prominent caries. (Choice C) Bulimia can cause dental caries and transient salivary gland hypertrophy but is less likely to cause dysphagia or dry eyes. (Choice D) The evaluation of patients with suspected esophageal dysphagia can include CT scan (extrinsic compression) and esophageal endoscopy (intrinsic obstruction). However, these patients typically have a sensation of food sticking in the chest following large unchewed food boluses (eg, meat) and frequently have a history of smoking. Endoscopy with biopsy can also diagnose Barrett esophagus in patients with chronic gastroesophageal reflux. (Choice E) Biopsy of salivary glands can confirm the diagnosis of SS if other evaluations are nondiagnostic. However, samples are usually taken from the minor glands of the lip rather than submandibular glands. (Choice F) A videofluoroscopic swallowing study is used to evaluate oropharyngeal and esophageal function in patients with suspected neuromuscular dysphagia. In SS, patients may have a delayed swallow and decreased upper esophageal contractility, but the results are nonspecific and not needed for diagnosis or management. Educational objective: The diagnosis of Sjögren syndrome requires evidence of dry mouth and eyes (eg, positive Schirmer test result for decreased lacrimation) with either histologic evidence of lymphocytic infiltration of the salivary glands or serum autoantibodies against SSA (Ro) and/or SSB (La). References: Diagnosis and management of Sjögren syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19323359)

A 49-Year-Old Woman Comes to the Office Due to Difficulty