A 42 yo F with no known past medical history presents with dry eyes.
Questions to Ask
- Duration? Symptom severity?
- Other exocrine gland symptoms: dry mouth, parotid or salivary gland enlargement
- Any arthritis, Raynaud’s, rashes, or other concerning symptoms?
- Use of contacts?
- Any smoking history?
- Contributing medications
- Infectious risk factors
Clinical Presentation & History
- Dry eyes for the past 2 yrs
- Describes a gritty, burning sensation
- No longer able to wear her contacts
- Mild dry mouth, no parotid gland swelling
- Diffuse myalgia and arthralgia, no swelling
- Medications: multivitamin
- Social history:
- Married
- Drinks coffee daily
- No alcohol or smoking
Diagnostic Workup
- Recommended labs:
Referrals
- For rheumatology serology abnormality, refer to rheumatology
- Refer to ophthalmology for objective testing (e.g., Schirmer’s test or ocular surface staining)
Treatment & Management
- Recommend over-the-counter artificial tears for dry eyes
- For mild dry mouth, try over-the-counter saliva substitute
- Counsel on limiting coffee consumption and increasing hydration
A 66 yo M with past medical history of hypertension reports progressive numbness and tingling in both feet.
Questions to Ask
- Any comorbidities that cause neuropathy: diabetes, vitamin B12 deficiency, hypothyroid, or other?
- Social history: history of alcohol abuse, vegan/vegetarian?
- Infectious risk factors: neurosyphilis, Lyme, or other?
Clinical Presentation & History
- Distal tingling, numbness present for 1 yr
- Started in toes and progressed to mid-shin
- Worse with activity, pain limiting activity
- Noticed fingers turn purple/white with cold
- No ulcerations, rashes, skin changes
- Minimal dry mouth and mild dry eyes with gritty sensation in morning
- No history of diabetes, no dietary restrictions
- Social history: denies alcohol, married, sexually active 1 partner
Diagnostic Workup
- Recommended labs:
- Procedures/imaging:
- EMG/NCV
- Small fiber neuropathy will not be picked up on EMG/NCV and will
necessitate skin biopsy (usually done by neuro)
Referrals
- Neurology for the neuropathic symptoms
- Rheumatology given late onset Raynaud’s, even if serologies are unrevealing
- Ophthalmology for the xerophthalmia
Treatment & Management
- Biotene mouthwash for xerostomia/dry mouth
- Artificial tears for xerophthalmia
- Symptomatic treatment with gabapentin or pregabalin
- Consider CCB for concern of Raynaud’s
- Remove any toxins (if smoker, coffee drinker, etc.)
- Replete any vitamin deficiencies
- Treat any contributing comorbidities
- Ensure up-to-date with age-appropriate malignancy screening
- Sjogren’s associated peripheral neuropathy may need systemic steroids and/or IVIg for
improvement – collaborate with neurology