The Sjögren lymphoma questions take ninety seconds

Lymphoid malignancy is one of the four causes of excess death in Sjögren disease, and unlike the other three it has a set of well-described warning features that are almost never systematically asked about. They are cheap to check and they do not change.

Ask and examine for persistent or recurrent parotid or submandibular swelling - the single most reported predictor - and for new lymphadenopathy or splenomegaly. Check the bloods you probably already have: a low C4, a persistently low complement generally, cryoglobulins, a monoclonal band, lymphopenia. Ask about purpura on the legs, which in this context is a vasculitic sign rather than a dermatological one. And note if the salivary glands that used to be enlarged have become firm or asymmetrical.

None of these on its own is a reason to investigate for lymphoma. Several together, or a persistently enlarged gland, is. The point of running the list is that it converts a vague background worry into either a documented negative or a specific reason to image - and in a clinic where the presenting complaint is always dryness and fatigue, the list will not come up unless you bring it.

• Persistent or recurrent major salivary gland swelling - ask and palpate at every review
• Low C4, cryoglobulins, a monoclonal band, lymphopenia - check what is already in the file
• Palpable purpura on the legs is a vasculitic sign here, not a rash
• New lymphadenopathy or splenomegaly on examination
• Document the negatives; they are what makes a later change meaningful

Why it matters

The lymphoma risk in Sjögren is well known and almost never systematically screened for in a clinic organised around dryness.

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