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Presentation of Case

Dr. Kyle Staller (Medicine): A 62-year-old woman was admitted to this hospital because of renal failure.

The patient had an autoimmune overlap syndrome with polymyositis, treated with prednisone and mycophenolate mofetil, but had been in her usual health until 6 weeks before admission, when she noted increasing skin tightness around her mouth, dry mouth, difficulty swallowing, worsening gastroesophageal reflux, hair loss, and discoloration of her fingers, which were ash-colored, painful, and cool. Prednisone was increased from 10 to 20 mg daily, without improvement. Four days before admission, the patient was found on the floor of her bathroom, . . .

Presented at the Internal Medicine Comprehensive Review and Update 2010; course director, Ravi Thadhani, M.D., Massachusetts General Hospital; sponsored by the Harvard Medical School Department of Continuing Education, Boston.

Dr. Cunningham reports receiving consulting fees from Abbott, Amgen, Ineos, Shire, Leo, Genzyme, and Fresenius; grant support from Amgen and Abbott; and payment for the development of educational presentations, including service on speakers' bureaus, from Amgen, Fresenius, Shire, and Abbott.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

No other potential conflict of interest relevant to this article was reported.

We thank Dr. Robert B. Colvin for contributing to the preparation of an earlier draft of the pathological discussion.

Source Information

From the Centre for Nephrology, Royal Free and University College London Medical School, London (J.C.); the Departments of Radiology (M.G.H.) and Pathology (D.T.), Massachusetts General Hospital, Boston; and the Departments of Radiology (M.G.H.) and Pathology (D.T.), Harvard Medical School, Boston.

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