A 68 year-old female came to your office complaining of dry eyes, dry mouth, painful oral sores, nausea, vomiting, wheezing and vaginal dryness and irritation. She is especially sensitive to hot or spicy foods. Her urine looks dark brown colored and her stools look pale and clay-colored. She also developed a rash which is itchy and irritating. She used some hydrocortisone cream but it is not seeming to help her much. It is hard to open mouth and extend her elbows. Her past medical history is remarkable for aplastic anemia for which she received a matched, related allogeneic stem cell transplant from her brother approximately 10 months prior to this presentation. During the physical examination you noticed that her sclera looks yellow. There are several fluid-filled cysts on the inner surface of her mouth. You noticed grayish white lines on the palate. In the auscultation of her lungs, you noticed bilateral wheezing. She has abdominal tenderness in the right upper quadrant. As you were examining the range of motion, the patient put her palms together and had difficulty extending her elbows and fingers. There are deep pigmentation changes over her shoulders and back. She has a rash on her trunk which is made up of small, discolored dots covered with scaly patches. Her nails looked hard and brittle with some dystrophy. You noticed the loss of hair on her head. To investigate her condition further, you ordered some routine labs which are significant for the following values: Total serum bilirubin is 7.9 mg/dl Alanine aminotransferase (ALT) …….175 U/L Aspartate aminotransferase (AST)……..145 U/L and alkaline phosphatase of 440 U/L Antinuclear antibodies….Positive Rheumatoid factor………Positive What is the most likely diagnosis in this patient?
