LAUSR

or intake of immunosuppressants or antiviral agents. Physical examination demonstrated normal complexity, no oral lesions, no surface lymph node swelling, and no thyroid goiter. Her heart and lung sounds were normal. Her abdomen was flat with no tenderness, resistance, or signs of a tumor, and bowel sound was also normal. She had no edema, skin rash, nail abnormality, or purpura. She had increased levels of serum pancreatic enzymes including pancreatic amylase (p-amylase), lipase, trypsin, elastase 1, and pancreatic phospholipase A2 (Table 1). The tumor markers carbohydrate antigen 19-9 and Span 1 werewithin normal limits. Abdominal computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography showed no abnormal findings in the pancreas, gallbladder, or biliary tract (Fig. 1). The endoscopic examination after the eradication of H. pyroli infection showed reflux esophagitis (grade M), short-segment Barrett esophagus, and atrophic gastritis, and there was no active disease of the upper gastric tract. Her amylase-creatinine clearance ratio was 2.4%, indicating that macroamylasemia was unlikely (data not shown). At the initial assessment, antinuclear antibodies (29.9; reference range, <20.0 arbitrary units by enzyme immunosorbent assay) and anti-SS-A antibodies (1080 U/mL by the Ouchterlony method) were positive; therefore, shewas referred to a rheumatologist. She said that she had been under observation for leucopenia for several years without any conclusive diagnosis. She had no complaints or episodes of fever, arthralgia, myalgia, skin rash, photosensitivity, or the Raynaud phenomenon; however, she experienced dryness of eyes and mouth. The presence of anti-SS-A/Ro antibodies and elevated levels of immunoglobulin G (IgG, 2087 mg/dL) were confirmed, whereas the SS-B/La antibody and Saxon test for the quantification of salivary secretion (3.7 g/2 min) were negative. The level of IgG4 was within the reference range (Table 1), making the possibility of IgG4-related pancreatitis unlikely. Tests for cryoglobulin, soluble interleukin 2 receptor,