The history of difficulty swallowing suggests esophageal dysmotility. The image of the hand demonstrates ischemic necrosis along with a bluish-purple discoloration from Raynaud's phenomenon. The antinuclear antibody pattern in the Hep-2 cells is nucleolar. These findings suggest scleroderma. The limited form of this condition is called "CREST" syndrome (C=calcinosis; R=Raynaud's; E=esophageal dysmotility; S=sclerodactyly; T=telangiectasia) and is characterized by presence of anticentromere antibody and a more indolent course. Diffuse scleroderma is associated with antibody to DNA-topoisomerase I and a more severe course with widespread skin involvement and a greater risk for pulmonary fibrosis and restrictive lung disease. Fibrosis, rather than inflammatory cell infiltrates, appears more prominent in the lesions of scleroderma.