A woman with rheumatoid arthritis, Sjögren's Syndrome, leg ulcer, and significant weight loss

A 46-year-old African American female presented with a 6-month history of swelling involving both hands and knees, with morning stiffness of 3 hours’ duration. She had difficulty extending both elbows and lifting her arms. She reported dryness of her eyes and mouth, but denied any dyspareunia. Despite a normal appetite, she reported a 49-pound weight loss over 6 months, but had no fever or night sweats and was without gastrointestinal symptoms. She had had a nonphotosensitive rash on her face for the past 3 months, but no alopecia or oral ulcers. Six weeks prior to presentation, she developed an enlarging painful ulcer over the right ankle.