Hi I'm studying a case study in regard of Rheumatology and I have some questions to ask I assume this patient has rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome, and Raynaud's disease Because he had pains in joints and abnormality in joints in x-ray, I thought he has rheumatoid arthritis. Also, he has dryness in eyes and mouth and positive result on anti salivary duct antibody test. so I thought he has Sjogren's syndrome. but my friend says he does not have rheumatoid arthritis and sjogren's syndrome. which one is right? or does he needs further investigations to confirm those disease? and are there any other diseases that can related to symptoms and test results? the case is below thank you Mr Black, aged 64, a retired process worker presented at his GP’s surgery with a fairly complex array of complaints and symptoms. He complained of general aches and pains in his joints over the last few months, mainly affecting his wrists and ankles. He had breathlessness and a persistent cough which had developed over several months. He had put this down to ‘arthritis and advancing years’. He then noticed that the tips of his fingers were becoming whitened and his fingers had begun to feel cold. He states that the skin on his fingers and hands seemed to becoming tighter, and the wrinkles seemed to be disappearing from his hands. In the last few weeks the fingers on his left hand had started to become at first discoloured and had become increasingly blackened. On further questioning by the doctor, Mr Black complained of dryness and soreness of the mouth and eyes, and reported an increasing difficulty in swallowing (dysphagia). He was also embarrassed to admit that he had become increasingly flatulent and had suffered fairly severe diarrhoea in the last few weeks, followed by spells of constipation, before his presentation at the surgery. A number of blood samples were taken for laboratory investigation and Mr Black was referred to the local hospital for X-ray investigation. At the hospital a skin biopsy sample was also taken for processing and investigation: Full blood count: All parameters were within the normal range Erythrocyte Sedimentation Rate: 35 mm/hr Serum electrophoresis: Indicated a marked, polyclonal, hypergammaglobulinaemia. Serum Immunoglobulin levels: IgG = 35 g/l, IgA = 8 g/l, IgM = 12 g/l X-Rays: ‘Arthritic’ joints showed a thickening of the periarticular soft tissues and juxta-articular osteoporosis. A grey mass was seen in the inferior lobe of the left lung. Urine examination: Proteinuria. Skin biopsy analysis: Shows a thinning of the epidermis with an accumulation of collagen within the reticular dermis. Arteriolar fibrosis was also evident. Also a lymphocytic infiltration was noted perivascularly (this was graded as mild). No further immunohistochemistry was done but these are assumed to be macrophages. Autoantibody screen: a)Anti Nuclear Antibody = Positive at a titre of 1/320. This antibody showed an anti-nucleolar pattern of staining on immunofluorescence. b) Anti Salivary Duct antibody: Positive