Case presentation
A 58-year-old female presented with pallor and fatigue for the last
month. She was diagnosed with sceroderma 10 years ago according to the
American College of Rheumatology criteria for SSc(4),and was treated
with methotrexate7.5mg/week for 5 years without adherence. Her past
medical history was significant for breast cancer 15 years ago that was
treated with surgery, chemotherapy, radiation and hormonal therapy for 5
years, with total remission.
On physical examination patient had thickened tight skin all over the
extremities (Figure 1), and telangiectasia on her face and
hands(Figure2,3).
Laboratory tests showed Haemoglobin 7.8 g/mL, total leucocyte count
5.7×109/L and platelet count
258×109/L. The erythrocyte sedimentation rate was 122
in the 1st hour and the C-reactive protein was
7.8mg/dl. Blood glucose, serum creatinine and electrolytes (including
calcium) were within the reference ranges. Serology immune profile
showed positive antinuclear antibodies (ANA) and SCL70 . The 25-Hydoxy
vitamin D was low (<5 ng/mL; normal 9–37.6 ng/mL)and the
parathyroid hormone level was normal (21.15 pg/mL; normal 15–65 pg/mL).
On serum protein electrophoresis, a dense monoclonal band of 3.03 g/dL
.No monoclonal proteins were detected in urine.
Immunoglobulin subtype evaluation showed significant high levels of IgG
and Kappa light chain as demonstrated in (table 1)