A 67-year-old woman presented with dry eyes, dry mouth, intermittent polyarticular nonerosive arthropathy, bronchial and bronchiolar involvement with bronchiectasis, peripheral sensory neuropathy, cryoglobulinemic vasculitis (IgM |gk paraprotein), pronounced hypergammaglobulinemia (|gg-globulin fraction, 28.6 g/L; reference interval, 8.0–13.5 g/L), and rheumatoid factor positivity (rheumatoid arthritis latex test, 728 IU/mL; reference interval, ≤40 IU/mL). Both parotid glands were enlarged, especially on the left side (Fig. 1). Puncture of a parotid cyst revealed benign material suggestive of a sialocoele (salivary cyst). The results of antinuclear antibody testing were negative (indirect immunofluorescence, screening dilution 1:40).Magnetic resonance image showing cystic enlargement of the left parotid gland (arrow).

 Magnetic resonance image showing cystic enlargement of the left parotid gland (arrow).

  1. What is the most likely diagnosis?
  2. Which result is inconsistent with the clinical picture?
  3. What could be done to investigate the inconsistent results?

What Is Your Guess? Read the article by Xavier Bossuyt, et al., here ​​for the answers.