I have intermittent swelling of the finger joints with episodic purple discoloration (Raynaud phenomenon) that has become more frequent over the past few months, alternating between hands, no toe involvement, and daily hip pain after prolonged sitting; what is the likely diagnosis and what evaluation and management should be pursued?

Likely Diagnosis: Secondary Raynaud's Phenomenon with Possible Underlying Connective Tissue Disease

Based on the episodic purple discoloration (Raynaud's phenomenon) with joint swelling that has become more frequent, alternating between hands, you most likely have secondary Raynaud's phenomenon associated with an early connective tissue disease, and require urgent rheumatologic evaluation with specific autoimmune serologies. 1, 2

Key Clinical Features Supporting Secondary Raynaud's

Your presentation has several concerning features that distinguish this from benign primary Raynaud's:

• Joint swelling with Raynaud's phenomenon strongly suggests secondary Raynaud's associated with connective tissue disease, particularly systemic sclerosis, systemic lupus erythematosus, or rheumatoid arthritis 2, 3
• Increasing frequency over recent months is a red flag for progression from primary to secondary Raynaud's or evolution of underlying connective tissue disease 1, 3
• Asymmetric or alternating hand involvement (switching from hand to hand) may suggest secondary Raynaud's rather than the typical symmetric pattern of primary disease 1
• The absence of toe involvement does not exclude secondary Raynaud's, as digital involvement can be variable 2, 3

Critical Diagnostic Workup Required Immediately

You need the following laboratory tests to rule out connective tissue diseases:

• Complete blood count with differential to assess for cytopenias associated with autoimmune disease 1, 2
• Erythrocyte sedimentation rate (ESR) as an inflammatory marker 1, 2
• Antinuclear antibodies (ANA) as the primary screening test for connective tissue diseases 1, 2
• Rheumatoid factor to evaluate for rheumatoid arthritis 1, 2
• Anticentromere antibodies and anti-Scl-70 antibodies to screen for systemic sclerosis, which is the most common connective tissue disease associated with secondary Raynaud's 2, 3
• Anticardiolipin antibodies and lupus anticoagulant to assess for antiphospholipid syndrome 2, 3

Differential Diagnosis Considerations

Most Likely: Early Connective Tissue Disease

• Systemic sclerosis (scleroderma) is the most common cause of secondary Raynaud's, and Raynaud's phenomenon is the initial manifestation in 70% of systemic sclerosis patients, often preceding other symptoms by years 2, 3, 4
• Look for subtle skin thickening, telangiectasias, or calcinosis on examination 1
• Digital ulcers occur in 22.5% of systemic sclerosis patients, making early diagnosis critical 1, 3

Other Possibilities

• Systemic lupus erythematosus commonly presents with Raynaud's phenomenon and arthritis 2, 3
• Rheumatoid arthritis can cause both Raynaud's phenomenon and joint swelling, though the joint pattern (DIP, PIP involvement) would help differentiate 5, 2
• Mixed connective tissue disease should be considered with overlapping features 3

Less Likely Given Your Presentation

• Hand osteoarthritis typically affects patients over 40 with bony enlargement (Heberden's and Bouchard's nodes) at DIP and PIP joints, but would not explain the purple discoloration 5
• Adult-onset Still's disease presents with high spiking fevers (>39°C), salmon-pink rash, and arthritis, which does not match your presentation 5
• Gout causes acute monoarticular arthritis with severe pain, not the pattern you describe 5

Hip Pain Consideration

Your daily hip pain with prolonged sitting is likely a separate musculoskeletal issue (possibly trochanteric bursitis or hip osteoarthritis) rather than part of a systemic inflammatory process, given the mechanical nature of the symptoms. However, polyarticular hand osteoarthritis patients have increased risk of hip osteoarthritis 5, and inflammatory arthritis can affect the hip 5.

Urgent Red Flags to Monitor

Seek immediate medical attention if you develop:

• Digital ulcers, tissue necrosis, or gangrene - these occur in 22.5% of systemic sclerosis patients and require urgent intervention 1, 3
• Severe, painful episodes beyond typical discomfort 1, 3
• Systemic symptoms including weight loss, malaise, fatigue, fever, photosensitivity, dry eyes/mouth, or difficulty swallowing 1, 3
• Skin thickening or tightening of the fingers or hands 1

Initial Management While Awaiting Workup

Non-Pharmacological Measures (Start Immediately)

• Absolute smoking cessation if you smoke - this is critical as smoking dramatically worsens Raynaud's and is associated with thromboangiitis obliterans 1, 2
• Avoid cold exposure and wear protective clothing including mittens (not gloves), insulated footwear, coat, and hat in cold conditions 1, 2
• Avoid triggering medications including beta-blockers, ergot alkaloids, and clonidine if you are taking any 1, 2
• Limit cold water immersion to maximum 10 minutes, 4 times daily 1

Pharmacological Treatment

If symptoms significantly affect your quality of life while awaiting rheumatology evaluation:

• Nifedipine 30-90 mg daily is first-line therapy and reduces both frequency and severity of Raynaud's attacks in approximately two-thirds of patients 1, 2
• Other dihydropyridine calcium channel blockers can be used if nifedipine is not tolerated 2

Follow-Up Timeline

• Immediate rheumatology referral given the combination of Raynaud's phenomenon with joint swelling and increasing frequency 1, 2
• Reassess in 4-6 weeks if starting pharmacological therapy to evaluate response and tolerability 1
• Immediate reassessment required if any digital ulcers, tissue necrosis, or new systemic symptoms develop 1

Common Pitfalls to Avoid

• Do not dismiss this as simple "poor circulation" - the combination of Raynaud's phenomenon with joint swelling requires thorough autoimmune evaluation 1, 2, 3
• Do not delay workup - early connective tissue disease can be treated more effectively, and systemic sclerosis can lead to serious complications including digital ulcers and internal organ involvement 1, 2, 3
• Do not assume absence of toe involvement rules out serious disease - Raynaud's distribution varies and does not predict severity 2, 3