What is the diagnosis for a female patient with bilateral arthritis, arthralgia, severe dry eyes, and elevated erythrocyte sedimentation rate (ESR) with a negative anti-SSA (Anti-Sjögren's Syndrome A) test?

Diagnosis: Rheumatoid Arthritis (RA)

This patient most likely has rheumatoid arthritis rather than Sjögren's syndrome, given the prominent bilateral polyarticular arthritis involving PIP and MCP joints with elevated ESR, despite the presence of severe dry eyes and negative anti-SSA antibody.

Clinical Reasoning

Primary Presentation Favors RA

• The dominant clinical feature is bilateral polyarticular arthritis affecting multiple joints (PIP and MCP), which is the classic presentation of rheumatoid arthritis 1, 2
• The elevated ESR indicates active inflammatory disease, consistent with RA 2, 3
• Arthralgia and arthritis are common in both conditions, but when they are the presenting and most severe symptoms with multiple joint involvement in a symmetric pattern, RA is more likely the primary diagnosis 1, 2

Dry Eyes as Secondary Manifestation

• Dry eye syndrome occurs in 46.7% of patients with rheumatoid arthritis, making it a common secondary manifestation rather than indicating primary Sjögren's syndrome 2
• Secondary Sjögren's syndrome occurs in only 5.9-22.2% of RA patients, meaning most RA patients with dry eyes do NOT have secondary Sjögren's syndrome 2, 3
• The patient's severe dry eyes could represent either simple dry eye disease associated with RA or potentially secondary Sjögren's syndrome, but this does not change the primary diagnosis of RA 2, 3

Negative Anti-SSA Antibody

• The negative anti-SSA (anti-Ro) antibody significantly reduces the likelihood of Sjögren's syndrome, as anti-SSA positivity scores 3 points in the diagnostic criteria and is a key serological marker 4
• While not all Sjögren's patients test positive for anti-SSA (particularly in early disease), the absence of this antibody combined with the prominent arthritic presentation makes RA the more likely diagnosis 5, 6

Diagnostic Approach Moving Forward

Confirm RA Diagnosis

• Check rheumatoid factor (RF) and anti-CCP antibodies to confirm RA diagnosis 4, 2
• Obtain hand and foot radiographs to assess for erosive changes typical of RA 2
• Complete the ACR/EULAR classification criteria scoring 2, 3

Evaluate for Secondary Sjögren's Syndrome

• Perform additional objective tests for Sjögren's syndrome, including Schirmer test (≤5 mm/5 minutes scores 1 point), unstimulated salivary flow rate (≤0.1 ml/minute scores 1 point), and ocular surface staining score 4
• Check anti-SSB (anti-La) antibody, antinuclear antibody (ANA), and rheumatoid factor as part of the Sjögren's workup 4
• Consider newer biomarkers (salivary protein 1, carbonic anhydrase 6, parotid secretory protein) if traditional antibodies remain negative but clinical suspicion persists 4, 5
• A total score of ≥4 points on the classification criteria is required for Sjögren's syndrome diagnosis 4

Important Clinical Pitfall

• Do not assume that dry eyes in a patient with arthritis automatically equals Sjögren's syndrome - dry eye is extremely common in RA patients without meeting criteria for secondary Sjögren's syndrome 2, 3
• The presence of sicca symptoms (dry eyes/mouth) in RA patients shows a linear trend with aging and does not necessarily indicate secondary Sjögren's syndrome 3

Management Implications

Rheumatology Referral Essential

• Co-management with a rheumatologist is mandatory for both RA treatment and evaluation of potential secondary Sjögren's syndrome 4, 7
• If secondary Sjögren's syndrome is confirmed (score ≥4), patients require monitoring for lymphoproliferative disorders, as approximately 5% develop lymphoma 7, 8
• Decreased C4 levels at diagnosis indicate higher lymphoma risk and should be checked 4, 7

Treat the Dry Eyes Regardless

• Initiate symptomatic treatment for dry eyes with artificial tears and lubricants while the workup proceeds 4, 8
• For moderate to severe dry eye, consider topical anti-inflammatory therapy (cyclosporine) 4
• Hydroxychloroquine, commonly used for RA, may help with arthralgias but has limited evidence for treating dry eye specifically 4