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*Sarthak Manchanda

*Post Graduate Resident, Department of Medicine, LHMC

A 39 year old female, resident of Sadar Bazaar, New Delhi, working as a nanny at school, educated up to class 12 presented to the Rheumatology OPD with chief complaints of:

Progressive skin changes since last 15 years
Shortness of breath and fatigue since last 12 years
Joint pain since last 8 years
Difficulty in swallowing since last 2 years

General physical examination reveals dryness of skin with pigmentation over skin of the face. Tightness of skin bilaterally up to mid of forearm with decrease range of motion of wrist, fingers and arms was also noted along grade 2 clubbing of both hands. Mouth opening was observed to be up to 2 finger breadths. Rest general examination was unremarkable.

Systemic examination revealed decreased respiratory movements over whole lung field bilaterally with bilateral biphasic fine crepitation present in infrascapular, infraaxiallary and interscapular areas.

A provisional clinical diagnosis of Systemic Sclerosis with sicca symptoms was made on the basis of history, general physical examination and systemic examination findings. Patient’s routine investigations suggested ANA positivity with peripheral rim pattern. Nail fold capillaroscopy showed capillary dilations and hemorrhages. Diagnosis of systemic sclerosis was made and patient was put on DMARD’s and antifibrotics.

Salt and pepper skin pigmentation Reduced mouth opening