Foot Drop, Wrist Drop, and Digital Ischemia As Initial Manifestations in Sjögren's Disease.

A 50-year-old Saudi woman, with a history of rheumatoid arthritis (RA), presented to the emergency room with a three-week history of progressive weakness. Her symptoms began with difficulty elevating her arms and standing up from a chair. Over the next two days, her weakness progressed, leading to bilateral wrist drop and foot drop, along with an inability to raise her hands or stand. She also reported sensory changes, including decreased sensation to touch and heat, most prominent in the lower limbs, and complaints of dry eyes and mouth. Additionally, the patient noted bluish discoloration of her right middle finger. Physical examination revealed bilateral wrist and foot drop, decreased distal strength, absent reflexes, and a black discoloration on the distal interphalangeal (DIP) joint of her right middle finger. The patient had a history of inflammatory polyarthritis diagnosed as RA two years prior. Her physical findings, along with dry eyes, mouth, and the characteristic sensory and motor deficits, raised concern for Sjögren's syndrome (SS). Diagnostic tests confirmed SS, showing positive salivary gland biopsy results with lymphocytic infiltration, a positive Schirmer test for dry eyes, and positive serum autoantibodies for anti-Ro, anti-La, and ANA. Nerve conduction studies revealed severe motor and sensory polyneuropathy. Treatment included a three-day pulse of steroids, followed by oral prednisone, and cyclophosphamide for six months. Additionally, the patient was treated for osteoporosis with teriparatide, then switched to denosumab, and managed with methotrexate and supportive therapies, including artificial tears and physiotherapy. The patient showed significant improvement in symptoms and responded excellently to the treatment.