Would you start hydroxychloroquine (or another DMARD) in a mid-20s female patient with positive ANA, SSA, SSB, and dsDNA, whose only clinical manifestation is intermittent parotid gland swelling?

Hmm... I think the better question to ask is, do you code as Sjogren's lupus overlap to get way more medication options? Certainly, HCQ is a reasonable DMARD and a place to start for both diseases. I would code as lupus and Sjogren's to have more options for the future. Hope someone can weigh in on Benlysta, Saphnelo in Sjogren's.

I absolutely would offer HCQ (using shared decision-making, of course, as recommended by Dr. @Dr. First Last). Though there is no strong data to show that HCQ prevents recurrent parotitis, after taking care of many patients with SLE/SjD overlap over the past 3 decades, I can say that those patients who had recurrent parotitis generally did very well on HCQ. I do not recall many instances in which I have had to add a more potent immunosuppressant. Of course, this is just anecdotal experience.

I do like Dr. @Dr. First Last's advice. It is not recommending that the patient be definitively diagnosed with SLE. However, it is excellent practical advice since we have no FDA-approved immunomodulators for SjD. I've seen some amazing results with be...

If there are absolutely no other clinical symptoms such as oral/ocular sicca (usually seen in Sjogren's) or other symptoms of SLE (photosensitive rashes, complement abnormalities, CBC abnormalities), I would keep an open differential diagnosis and consider alternative causes of intermittent parotid swelling, including ENT etiologies. If the anti-dsDNA is low positive, we would also consider a confirmatory Crithidae. Ultrasonography and/or salivary gland biopsy may be helpful to confirm Sjogren's, particularly if the patient does not have a sicca syndrome.

This case, in terms of the HCQ question, requires a risk-benefit discussion with the patient and hinges on some key points of how painful or functionally bothersome the intermittent paroti...

For a patient with dsDNA+, I would be considering SLE and probably associated Sjogren's with "intermittent parotid gland swelling. Pediatric Sjogren's colleagues use hydroxychloroquine (HC) in the setting of chronic parotitis. I would consider an HC trial (3-6 months) with patient discussion. I would also look for other serological markers, like inflammatory markers, C3/4, quantitative immunoglobulins, and maybe immunofixation and serum-free light chains.

Given the serologies, would follow for likely Sjogren's vs UCTD and would monitor for other organ involvement (of course) and also any other manifestations that may arise that are more likely to have potential response to HCQ (inflammatory arthralgia, rashes, +/- fatigue). Hydroxychloroquine is reasonable, but not sure how effective hydroxychloroquine is to prevent recurrent flares of parotitis in Sjogren's (hoping Sjogren's experts can weigh in), and it may not be necessary if the patient is otherwise asymptomatic. If the patient is having intermittent, self-limiting episodes of parotitis, cautious monitoring may be another alternative.

YES! This is parotitis and needs treatment it prevent long-term gland damage.