This is the appearance of a middle-aged woman with ocular irritation.

a. What does the picture show?

Xerostomia (dry mouth).

b. What is the differential diagnosis?

• Pure sicca complex (keratoconjunctiva sicca and dry mouth) which may

occur in post menopausal woman or patients on medication. 
 
• Sjogren's syndrome.

This is an autoimmune disorder with cellular infiltration and destruction of exocrine glands chiefly lacrimal and salivary glands resulting in dry eyes and mouth.

In primary Sjogren's syndrome, the sicca complex (keratoconjunctiva sicca 
and xerostomia) has no systemic association but the blood test is positive for 
one or more of theses antibodies: anti-Ro or La, ANA (antinuclear antibody) and rheumatoid body.

In secondary Sjogren's syndrome, the sicca complex is associated with 
systemic diseases such as rheumatoid arthritis, systemic lupus erythematosus
and scleroderma

c. What systemic signs would you be looking for?

In Sjogren's syndrome there is an increased incidence of autoimmune disorders and the following signs may be present:

• hepatomegaly in association with primary biliary cirrhosis
• joints changes in association with rheumatoid arthritis
• anaemia in association with pernicious anaemia

In addition, there may be lymph node enlargement due to the increased incidence of lymphoma.

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