A 66 year old white woman was referred to us for further evaluation of pulmonary nodules. Her medical history was as follows: in July 2001 multiple pulmonary nodules were recorded on a chest x ray examination as well as computed tomographic (CT) scan (fig 1). Cancer of unknown origin with multiple lung metastases was suspected. The patient showed no pulmonary symptoms at any time, was a non-smoker, and had not been exposed to any environmental toxins. She underwent an intensive search for the primary tumour, but all investigations were unsuccessful. Thus anterolateral thoracotomy was performed for histological evaluation of the nodules, which were classified as disseminated rheumatoid nodules (fig 2).

On presentation at our clinic, the patient reported extreme dryness of mouth and eyes, as well as Raynaud’s phenomenon. She did not have any history of fever, night sweats, weight loss, thrombosis, arthralgias, …