[Influence of age on the clinical and biological characteristics of systemic scleroderma]

PURPOSE

The present study was aimed at assessing the influence of age on clinical and biological features of systemic sclerosis.

METHODS

This retrospective study included 151 consecutive patients with systemic sclerosis. The median age at diagnosis was 50.0 years (range: 10-84 years). Patients were divided into two groups according to their age (lower than 50.0 years of age: 73 patients, equal to or above 50 years of age: 78 patients). The following features were compared between the two groups: gender, disease duration, extent of skin sclerosis, Crest syndrome, lung fibrosis, secondary Sjögren's syndrome, antinuclear, anticentromere, and anti-Scl70 antibodies.

RESULTS

The disease duration was significantly higher in patients over 50 years of age (7.1 +/- 6.8 years vs 5.5 +/- 5.0 years, P < 0.05). Crest syndrome, secondary Sjögren's syndrome and anticentromere antibodies were significantly more common in patients over 50 years of age (17/73 vs 30/78, P < 10(-2); 9/73 vs 20/78, P < 10(-2), and 19/73 vs 31/78, P < 0.05; respectively). Anti-Scl70 antibodies were significantly more common in patients under 50 years of age (17/73 vs 10/78, P < 10(-2)). No significant difference was found in regard to the other features.

CONCLUSION

The clinical and biological patterns of systemic sclerosis are different according to the age at disease onset. Crest syndrome including anticentromere antibodies and Sjögren's syndrome is more common in elderly patients, while anti- Scl-70 antibodies are more common in younger patients. This suggests the involvement of various mechanisms in the pathogenesis of systemic sclerosis, and that these mechanisms may depend on the age.

[A case of Sjögren's syndrome with retrobulbar optic neuritis and cutaneous vasculitis]

A 52-year-old woman, diagnosed as having Sjögren's syndrome by parotid sialography and lip biopsy after a two years history of recurrent purpuric rashes on her lower extremities, was admitted to our hospital because of visual disturbance in March 1998. On presentation at the department of ophthalmology, her right visual acuity was light perception, and laboratory findings showed elevated levels of antinuclear antibody and anti-Ro/SS-A and anti-La/SS-B antibodies. Cerebrospinal fluid analysis showed mild pleocytosis and elevated levels of total protein and Q-albumin. The IgG-index was within normal level and no oligoclonal band was found. Magnetic resonance imaging showed increased signal intensity at the right optic nerve. After treatment with m-PSL pulse therapy, her visual acuity recovered to 0.08. When prednisolone was gradually tapered to the dose of 30 mg per day, she was transferred to our department because of high grade fever and pancytopenia. She also suffered from palpable purpura in her extremities extending the trunk, whose pathological diagnosis was leukocytoclastic vasculitis. The immunohistochemical examination showed depositions of IgG and C1q. After two additional cycles of mPSL pulse therapies, clinical improvement was achieved. The titers of von Willebrand factor and thrombomodulin correlated with her clinical improvement. Patients with Sjögren's syndrome can develop extra-grandular complications, including neurologic and cutaneus diseases, it is important to understand the role of SS-A-B antibodies in the immunopathogenesis of Sjögren's syndrome.

[Rheumatologic manifestations of chronic graft vs host disease. 4 case reports]

A description is given of four patients with the diagnosis of chronic graft-versus-host disease (cGVHD) who developed articular manifestations during the clinical course. One of the patients developed advanced lesions of scleroderma. The rheumatologic changes of the disease as well as other affections of organs, complications and prophylaxis are reviewed.

Sjögren's syndrome

Sjögren's syndrome is a rather common autoimmune disease primarily characterized by the dysfunction and destruction of exocrine glands associated with lymphocytic infiltrations. The disorder has a quite broad clinical presentation, ranging from glandular disease to systemic involvement and to the development of lymphoid malignancy. This article reviews the current aspects in clinical diagnosis and management and the immunopathogenesis of the disorder.

Neuroendocrine host factors and inflammatory disease susceptibility

The etiology of autoimmune diseases is multifactorial, resulting from a combination of genetically predetermined host characteristics and environmental exposures. As the term autoimmune implies, immune dysfunction and dysregulated self-tolerance are key elements in the pathophysiology of all these diseases. The neuroendocrine and sympathetic nervous systems are increasingly recognized as modulators of the immune response at the levels of both early inflammation and specific immunity. As such, alterations in their response represent a potential mechanism by which pathologic autoimmunity may develop. Animal models of autoimmune diseases show pre-existing changes in neuroendocrine responses to a variety of stimuli, and both animal and human studies have shown altered stress responses in the setting of active immune activation. The potential role of the neuroendocrine system in linking environmental exposures and autoimmune diseases is 2-fold. First, it may represent a direct target for toxic compounds. Second, its inadequate function may result in the inappropriate response of the immune system to an environmental agent with immunogenic properties. This article reviews the relationship between autoimmune diseases and the neuroendocrine system and discusses the difficulties and pitfalls of investigating a physiologic response that is sensitive to such a multiplicity of environmental exposures.

Octreotide treatment of chronic intestinal pseudoobstruction secondary to connective tissue diseases

Chronic intestinal pseudoobstruction (CIPO) is a rare syndrome that may occur in association with connective tissue diseases (CTD). Effective management is a major challenge. We report 3 cases in which subcutaneous octreotide was efficacious in the treatment of digestive symptoms in CIPO. In 2 of the 3 cases, previous treatment with domperidone, cisapride, or erythromycin had been unsuccessful. All 3 patients underwent a regimen of oral antibiotics along with octreotide to stimulate small bowel motility. The effects of octreotide were evident within 48 hours after the first injection in all patients. In 2, the efficacy seemed to decrease after 1 week and 6 months respectively, but increasing the dosage led to another remission. CIPO in CTD is a severe condition that can evolve regardless of the underlying disease activity. Octreotide appears to be efficacious in improving both clinical symptoms and manometric patterns. When its therapeutic effect diminishes, increasing the dosage can be useful.

Dry eye and dry mouth in the elderly: a population-based assessment

BACKGROUND

Symptoms of dry eye and dry mouth are common in the elderly and are often debilitating. Previous research on small populations has been inconsistent regarding the contribution to sicca symptoms of autoimmune markers, medication use, and other factors. The objective of this study was to determine the population prevalence of symptoms of dry eye and dry mouth and to evaluate possible risk factors.

METHODS

This is a population-based study of 2481 individuals, aged 65 to 84 years, residing in Salisbury, Md, and identified by the Health Care Financing Medicare database. The main outcome measures included information on sicca symptoms, medical history, medication use, and joint examination results collected in a standardized manner. Autoimmune status was assessed in 1200 individuals by measuring antinuclear antibody, rheumatoid factor, and autoantibodies to the soluble nuclear antigens Ro/SS-A and La/SS-B by double immunodiffusion.

RESULTS

Approximately 27% of the population reported dry eye or dry mouth symptoms to be present often or all the time and 4.4% reported both. The prevalence of dry mouth (but not dry eye) symptoms increased with age, female sex, and white race. No association of sicca symptoms was found with rheumatoid arthritis, smoking, alcohol consumption, reproductive hormonal status, or the presence of autoantibodies. A strong, dose-response relationship was observed between sicca symptoms and the use of certain medication classes. The proportion of the population prevalence of sicca symptoms attributable to the use of drying medications was estimated at 62% for dry eye and dry mouth and 38% for dry eye or dry mouth symptoms.

CONCLUSIONS

Sicca symptoms are common in the elderly, and medication side effects appear to be a major underlying factor. Our results do not indicate an association between autoimmune status and sicca symptoms and do not support immunologic testing in persons with sicca symptoms in the absence of other important systemic features.

HTLV-I associated Sjögren's syndrome is aetiologically distinct from anti-centromere antibodies positive Sjögren's syndrome

OBJECTIVE

To investigate whether Sjögren's syndrome (SS) with anti-HTLV-I antibodies is aetiopathologically distinguishable from SS without these antibodies, the study compared prevalence of autoantibodies in serum samples of SS patients with or without anti-HTLV-I antibodies.

METHODS

The test group included 135 patients with primary SS and 97 patients with secondary SS. Serum samples of the patients were examined for the presence of anti-nuclear antibodies (ANA), anti-SS-A/Ro antibodies, anti-SS-B/La antibodies, anti-centromere antibodies (ACA), and anti-HTLV-I antibodies.

RESULTS

Anti-HTLV-I antibodies were detected in 25.0% of primary SS patients and in 29.2% of secondary SS patients. There were no significant differences in the mean age, sex, values of asparate aminotransferase, alanine aminotransferase, alkaline phosphatase, serum complements and IgG between HTLV-I seropositive and seronegative SS patients. The rheumatoid factor, ANA, anti-SS-A/Ro, and anti-SS-B/La antibodies in serum samples of SS patients were detected in 60.0%, 84.0%, 51.9%, and 12.0%, respectively. There was no significant difference in the prevalence of these antibodies between HTLV-I seropositive and seronegative SS patients. Using the indirect immunofluorescence test, 14.2% showed a discrete speckled staining pattern. All serum samples contained significant amounts of ACA determined by enzyme linked immunosorbent assay. These antibodies were detected in only 4% of HTLV-I seropositive SS patients but were present in 19.9% of HTLV-I seronegative SS patients. Furthermore, the prevalences of anti-SS-A/Ro and anti-SS-B/La antibodies in serum samples of ACA positive patients were significantly lower than those in ACA negative SS patients.

CONCLUSION

These results suggest that SS patients with anti-SS-A/Ro or anti-SS-B/La antibodies, or both, might be aetiopathologically distinct from SS patients with ACA. HTLV-I might be involved in the pathogenesis of SS in a subset of patients with anti-SS-A/Ro or anti-SS-B/La antibodies, or both, but not SS patients with ACA.

Sjogren's syndrome?

Dry eyes and mouth are just two of the many symptoms that can develop as a result of this common but little-known autoimmune disease that gradually destroys the exocrine glands. Because the effects are so far-reaching, it's important to familiarize yourself with diagnostic and treatment options as well as the special care needs of these patients.

Fas ligand-mediated exocrinopathy resembling Sjögren's syndrome in mice transgenic for IL-10

Although IL-10 has been implicated in the pathogenesis of several autoimmune diseases, the mechanisms by which this cytokine mediates inflammatory lesions remain to be elucidated. Exocrine gland destruction is an important early step in the development of Sjögren's syndrome. To better understand the role of IL-10 in Sjögren's syndrome, we made transgenic mice in which the mouse IL-10 gene was regulated by the human salivary amylase promoter. Transgenic expression of IL-10 induced apoptosis of glandular tissue destruction and lymphocyte infiltration consisting primarily of Fas-ligand (FasL)+ CD4+ T cells, as well as in vitro up-regulation of FasL expression on T cells. These data suggest that overexpression of IL-10 in the glands and their subsequent Fas/FasL-mediated bystander tissue destruction is a causal factor in the development of this disease.

Gender-specific medicine: the new profile of gynecology

The science of gynecology is undergoing a change and is swiftly turning into a holistic discipline, i.e. gender-specific medicine. The rationale for this is that the hormones of the ovary not only are responsible for reproduction but also perform a number of extragenital functions that extend far into other disciplines, giving rise to a different frequency of diseases in women than in men. For example, females are five times more likely to be affected by rheumatoid arthritis than males, the same also holding true for autoaggressive conditions. This phenomenon may be accounted for by the fact that physiological auto-aggression is involved in the reproductive process. Similarly, there is a difference between women and men with regard to the sicca phenomenon, or to such disorders as connective tissue weakness, cellulite, venous conditions or hypercholesterolemia. A cause-related treatment of such problems is now available through specific endocrine therapy. That is why gynecologists in future will increasingly have to adopt an interdisciplinary approach.

Sjögren's syndrome: pathogenesis

Sjögren's syndrome is a chronic inflammatory disease of the lacrimal and salivary gland with subsequent keratoconjunctivitis sicca and xerostomia. Histopathologic findings include damaged acini of the lacrimal and salivary glands with mononuclear cell infiltrates of lymphocytic and plasma cell type. The cause of the damage is cell-mediated cytotoxicity. The pathogenesis of Sjögren's syndrome is still unknown. The role of viral infections failed to show a causative effect. On the other hand, tissue destruction was shown to be mediated by activated T cells of CD4+ type that home into the lacrimal gland. This process is signal-mediated through the T-cell receptor that interacts with class II antigen on the epithelial cells of exocrine glands. This, in turn, induces the expression of Fas/APO-1 and Fas-mediated apoptosis of acinar cells. Granzyme A and perforin are cytolytic enzymes secreted by activated T lymphocytes that seem to participate in acinar cell destruction.

An alternative perspective to the immune response in autoimmune exocrinopathy: induction of functional quiescence rather than destructive autoaggression

Sjögren's syndrome is characterized by dryness of the eyes and the mouth due to mononuclear cell infiltration of the lacrimal and salivary glands. The aetiology is unknown but autoimmunity is considered to play a significant role in the pathogenesis. Recent studies have focused on the fact that tear and salivary flow involves an entire functional system that includes the mucosal surfaces with adnexes (the site of inflammation), efferent nerve signals sent to the midbrain (lacrimal and salivary response region), and afferent neural signals from the brain to the acinar/ductal epithelial structures in the gland. Mononuclear cell infiltration in exocrine glands can lead to glandular destruction, suggested to be mediated through apoptosis. However, the functional impairment of exocrine glands could be regulated by cytokines and/or antibodies against the muscarinic M3 receptor by inhibiting the neural stimulation of the residual glands. This review discusses the possibility that the pathogenesis of Sjögren's syndrome comprises aberrant immune-mediated neuro-hormonal events.

Murine cytomegalovirus induces a Sjögren's syndrome-like disease in C57Bl/6-lpr/lpr mice

OBJECTIVE

To analyze Fas and tumor necrosis factor receptor I (TNFRI) apoptosis pathways in salivary gland inflammatory disease induced by murine cytomegalovirus (MCMV) infection.

METHODS

Four different strains of mice (C57BI/6 [B6]-+/+, Fas-deficient B6-lpr/lpr, TNFRI-deficient B6-tnfr1(0/0), and B6-tnfr1(0/0)-lpr/lpr mice) were infected intraperitoneally with the Smith strain of MCMV (1 x 10(5) plaque-forming units). Viral load was determined by a plaque assay, inflammation and apoptosis by immunohistochemistry and staining with terminal dUTP nickend labeling, and autoantibodies by enzyme-linked immunosorbent assay.

RESULTS

Infectious MCMV was not detectable by day 100. Although all MCMV-infected mice developed acute sialadenitis by day 28, a chronic (>100 days), severe salivary gland inflammation and anti-Ro and anti-La antibodies developed only in the B6-lpr/lpr mice. Apoptotic cells were detected during the acute, but not the chronic, phase of inflammation.

CONCLUSION

Both Fas- and TNFRI-mediated apoptosis contribute to the clearance of MCMV-infected cells in the salivary glands. However, because Fas-mediated apoptosis is necessary for the down-modulation of the immune response, a defect in this process can lead to a postinfection, chronic inflammatory response that resembles Sjögren's syndrome.

Kininogen-kallikrein-kinin system in plasma and saliva of patients with Sjögren's syndrome

OBJECTIVE

To evaluate variables of the kininogen-kallikrein-kinin system (KKKS) simultaneously in plasma and saliva of patients with Sjögren's syndrome (SS).

METHODS

We studied a group of 20 female patients with SS aged 37-75 years, 7 with primary SS (SS1) and 13 with SS secondary to rheumatoid arthritis (SS2), and 20 healthy individuals. Total kininogen and high and low molecular weight kininogen (HKg and LKg, respectively) levels were evaluated by ELISA. The activity of plasma and tissue kallikreins was determined by enzyme activity on selective chromogenic substrates.

RESULTS

The plasma levels of total kininogen, HKg, and LKg, and the activity of plasma kallikrein observed in patients were not significantly different from controls. The tissue kallikrein-like activity in plasma and the active tissue kallikrein in saliva were significantly increased in patients with SS, whereas the total salivary tissue kallikrein activity in patients was not significantly different from controls. The concentration of protein in the saliva of patients was significantly increased, and a positive correlation between salivary protein levels and the active tissue kallikrein was observed.

CONCLUSION

Comparisons between the total and the active tissue kallikrein in saliva of patients with SS showed that most of the tissue kallikrein was in its active form. In addition, we observed a concomitant increase of the tissue kallikrein-like activity in plasma. These results suggest increased activation of the KKKS in plasma and saliva of patients with SS.

Collagen disease: the enemy within

Surprisingly, the autoimmune diseases predominate in women of childbearing years. Recent evidence suggests that these diseases are the result of some interaction of the hypothalamic-gonadal axis with the immune system. The median age for rheumatoid arthritis is 45 years, the median age for lupus erythematosus is 25. Other illnesses, which are autoimmune in character, such as Sjögren syndrome, scleroderma and the vasculitides, are also more commonly found in women. There is no link that ties these illnesses together, except for gender and various disparate immune manifestations such as autoantibodies. The etiopathogenesis of these diseases is reviewed. These diseases are notoriously difficult to diagnose; they mimic other illnesses in their early presentations. Accompanying illnesses such as migraine headaches, Hashimoto's thyroiditis, and fibromyalgia are discussed as related entities. Immunosuppression of diseases like rheumatoid arthritis and lupus erythematosus, is discussed. Various methods of management are considered, such as the use of steroids, cytotoxic agents, and new experimental agents, such as DHEA and IVIG.

Evolving concepts of diagnosis, pathogenesis, and therapy of Sjögren's syndrome

Differences in diagnostic criteria for Sjögren's Syndrome (SS) have led to confusion in the research literature and in clinical practice. A particular challenge is the clinical diagnosis of the patients with sicca symptoms, fibromyalgia, chronic fatigue, vague cognitive defects, and a low titer antinuclear antibody. Until recently, many of these patients would have been classified as primary SS using the European criteria. A suggested revision of the European criteria will require inclusion of anti SS-A antibody or characteristic minor salivary gland biopsy, leading to greater agreement between European and San Diego criteria. Recent studies have emphasized that lacrimal and salivary gland flow involves an entire "functional" unit that includes the mucosal surface (the site of inflammation), efferent nerve signals sent to the midbrain (lacrimatory and salvatory nucleus), efferent neural signals from the brain, and acinal/ductal structures in the gland. Thus, symptoms of dryness or pain can result from interferences with any part of this functional unit. The initiating antigens in SS remain unknown, but immune reactivity against SS-A, SS-B, fodrin, alpha- amylase, and carbonic anhydrase have been demonstrated in patients with established disease. The inflammatory process in the gland releases metalloproteinases that alter the relationship of epithelial cells to their matrix, an interaction that is necessary for glandular function and survival. Therapies for SS remain inadequate. In SS patients with immune-mediated extraglandular manifestation (ie, lung, kidney, skin, nerve), the therapeutic approach is similar to systemic lupus erythematosus, although these therapies have relatively little effect on tear or saliva flow.

[Clinical and laboratory characteristics of patients with Sjogren's disease lasting from young age]

AIM

Characterization of Sjogren's disease (SD) with onset at early age basing on the comparison of two patient groups--with the disease onset at the age under 30 and over 50.

MATERIALS AND METHODS

Clinical, ophthalmological and stomatological examinations were performed in 31 SD patients who developed the disease at the age under 30 (group 1) and over 50 (group 2).

RESULTS

In group 1 the disease started with parotitis in 42.8% of cases, dysfunction of secreting epithelial glands was rare, functional activity of exocrine glands was normal, dysproteinemia (high total protein levels, hypergammaglobulinemia, hypoalbuminemia) and immunological defects (high levels of circulating immune complexes, rheumatoid factor, antinuclear factor) were more pronounced. At retrospective analysis not only a decline of functional activity of the salivary and lacrimal glands but also appearance of systemic symptoms were registered.

CONCLUSION

Development of systemic SD symptoms at young age necessitates early pathogenetic therapy employing corticosteroid, cytostatic and other drugs.