A 37-year-old woman first presented in the beginning of 2019 complaining of arthralgias, sicca symptoms, tiredness, and fatigue. Her personal history revealed that she was a non-smoker without prior allergies. She had been diagnosed with HT and vitamin D deficiency since 2012, but she was taking vitamin D irregularly. Family history suggested a strong autoimmune disease background: her mother had SLE and Sjogren's syndrome, and her grandmother had cutaneous lupus and pernicious anemia. In 2017, the patient had a cosmetic SBI. However, a seroma was found repeatedly in the right breast that required drainage on three occasions. At that point, no seroma analysis was performed. She was treated by a plastic surgeon and periodically received short corticosteroid courses and antibiotics. Prednisone therapy led to some symptoms' relief and seroma reduction, but the symptoms re-emerged after the corticosteroid therapy was discontinued. In 2018, magnetic resonance imaging (MRI) showed right breast capsulitis; a year later, breast ultrasound showed no signs of rupture and contractures ( Figure 1 ).
At her first visit at our clinic in 2019, her erythrocyte sedimentation rate was 48 mm/h, complete blood count, CRP, D-dimer, and complete biochemistry (Blood urea nitrogen (BUN), creatinine, Na, K, Cl, total protein, albumin, bilirubin, aspartate transferase (AST), ALT, alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), creatine kinase (CK), and lactate dehydrogenase (LDH)) were normal, as well as urine analysis. The TSH and FT4 levels were in the reference range. The 25 (OH) vitamin D level was low:22 nmol/L indicating deficiency). The physical examination was unremarkable. Immunological analysis showed a positive ANA homogenous/nucleolar pattern on the Hep2 cells substrate in the titter 1:640, positive anticardiolipin (aCL) IgG, and anti-SSA antibodies. Ophthalmological testing was normal, as were nailfold capillaroscopy and abdominal ultrasound. The unstimulated salivary flow rate was 0.2 ml/min. The diagnosis of ASIA was made based on clinical presentation (arthralgias, sicca symptoms, tiredness, and fatigue), immunological tests (+ ANA, + anti SSA antibodies, and aCL IgG), the co-occurrence of AID (HT), a family history of AID, and time correlation between SBI and clinical presentation.
The removal of SBI was suggested, and vitamin D therapy was introduced. Also, salivary gland biopsy was indicated for suspected Sjogren's syndrome and genetic testing as well. However, the tests were not completed due to the COVID-19 outbreak, and the patient missed her follow-up visits.
Almost 2 years since the first visit, she returned with similar symptoms, but some new ones have appeared in the meantime, such as skin and vaginal dryness and tingling in extremities. Also, hypothyroidism was diagnosed in 2020 and levothyroxine therapy was introduced. The seroma in the right breast was found once again. An ultrasound revealed right breast intracapsular rupture and contracture in 2021. The immunological analysis of seroma was positive for ANA (indirect immunofluorescence, IIF) of centromere pattern in the titer 1:640 and anticentromere (ELISA) antibodies. There were no malignant cells in seroma, and bacteriological and mycological findings were normal. Immunological testing in the serum showed + ANA on Hep-2 cell substrate (IIF) centromere pattern 1:640. Her laboratory work was normal, as well as her serum vitamin D level. In the following months, an extensive diagnostic workup was done. Keratoconjunctivitis, the unspecific nailfold capillaroscopic changes, and reduced diffusing capacity of the lungs for carbon monoxide (67%) were found. There were no abnormalities in her spirometry, chest CT, heart ultrasound, electroneuromyography, and color Doppler ultrasound of lower extremities.
There was an evolution of the patient's symptoms over the years, alongside with the change of autoantibodies profile from 2012 to 2021 as shown in  Figure 2 . We treated the patient with corticosteroid therapy (prednisone 20 mg daily initially with tapering) and antimalarial (hydroxychloroquine sulfate 2 x 200 mg), and vitamin D supplementation was continued. The therapy led to the reduction of most symptoms, except for the persistence of sicca symptoms. The explanation of SBI was indicated, but the patient was reluctant to accept it.