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Case Study

Sara is a 40-year-old woman whose busy life is at a standstill. She has severe fatigue and tight, itchy skin on her face, arms, hands and trunk. She spends most of her days sitting up in the lounger in the living room to help with the fatigue and gastroesophageal reflux disease (GERD). She describes a dwindling appetite with worsening of her nutritional status.

Sara is always cold and her fingertips and nails often are severely hyperemic. There are two small, painful digital ulcers on her right hand. Her fingers are beginning to curl, making it difficult for her to perform her ADLs and household duties.

She has seen quite a few specialists about her complaints, including a psychologist, and none of them could be definitive about the diagnosis. (Patients often report a period of 1-3 years from first signs and symptoms to actual diagnosis.)

Sara finally is referred to a rheumatologist at a nearby university medical department, who diagnoses systemic sclerosis. She and her husband are frightened, especially when she is prescribed methotrexate, which they know is a drug used to treat cancer. She types scleroderma into her computer search engine and discovers ads for herbal remedies, the Scleroderma Foundation site and scary articles in various magazines.

Discuss the pathophysiological changes that occur with scleroderma.

What factors from Sara’s history and physical validate her diagnosis?

Give a justification for the use of methotrexate for this patient

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