A 75-year-old woman was evaluated for an 18-year history of inflammatory joint pain in both hands. Symptoms of gastroesophageal reflux were present, but there was no history of Raynaud’s phenomenon. Physical examination revealed multiple palpable masses in the soft tissue overlying the extensor surfaces of the elbows, wrists, and hands. There was no skin thickening or digital pitting. Nailfold videocapillaroscopy performed in both hands (Panel A) showed dilated and tortuous capillary loops (arrow), severe capillary loss (arrowhead), and neovascularization (star) (a normal videocapillaroscopy is provided in the Supplementary Appendix, available with the full text of this article at NEJM.org). Laboratory examination revealed strongly positive reactions for serum antinuclear antibodies and anti polymyositis scleroderma (PM Scl) antibodies and negative results for anti Scl-70, anticentromere, and anti RNA polymerase III antibodies. Plain radiography of the right arm confirmed the presence of exuberant calcinosis cutis (Panel B, arrow). An axial computed tomographic image of the chest (Panel C) showed bilateral basilar reticular fibrosis (arrow), with ground-glass opacities suggesting an active alveolitis within the lung parenchyma (arrowhead). Pulmonary-function testing revealed slightly decreased carbon monoxide diffusing capacity. There was no evidence of myositis, hypertension, renal dysfunction, or pulmonary hypertension. The patient received a diagnosis of scleroderma, and low-dose corticosteroids were prescribed. There has been abatement in joint disease and alveolitis at 6-month follow-up.
Marisa Fernandes das Neves, M.D.
Susana Oliveira, M.D.
Fernando Fonseca Hospital, Amadora, Portugal