Sjogren's syndrome and the sicca syndrome: the role of prostaglandin E1 deficiency. Treatment with essential fatty acids and vitamin C

Lack of adequate synthesis of prostaglandin (PG) E1 may be the key factor in Sjogren's syndrome. PGE1 is important for lacrimal and salivary gland secretion and for T lymphocyte function: a deficiency could therefore account for the main features of Sjogren's syndrome and the sicca syndrome. PGE1 could also account for many of the other features often associated with these syndromes. These include the Raynaud's phenomenon, the abnormalities of renal function and the precipitation of the syndrome by vitamin C deficiency. Vitamin C is important in PGE1 biosynthesis. PGE1 treatment has been shown to correct the immunological abnormalities in the NZB/W mouse, the animal model of Sjogren's syndrome. An attempt to treat humans with Sjogren's syndrome by raising endogenous PGE1 production by administration of essential fatty acid PGE1 precursors, of pyridoxine and of vitamin C was successful in raising the rates of tear and saliva production.

Cutaneous manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic illness defined and classified according to strict criteria of the American Rheumatism Association. Cutaneous disease may complicate RA or the drugs used in its treatment. Cutaneous vasculitis is potentially a prognostic factor in patients with RA. Controversy exists regarding the role of corticosteroids in the development of rheumatoid vasculitis. Two illustrative cases of RA with cutaneous complications are presented and the joint and cutaneous manifestations are reviewed herein.

[Systemic lupus erythematosus--clinical aspects and laboratory findings]

In a retrospective multicenter study 106 patients with systemic lupus erythematosis were analyzed who had had the disease for an average of 8.6 years, and from whom an average of 8 sera were tested within 3 years for current immunologic parameters. Cumulative clinical data showed arthropathies in 86% of the patients, exanthema (67%), cytopenia (58%), and involvement of the kidney (45%), lung (43%) and heart (24%). In at least 1 serum per patient the following immune abnormalities were found: antinuclear antibodies (98%), anti-native DNA (92%), low C3 (71%), low C4 (82%), circulated immunocomplexes (70%) and cold lymphocytotoxins (46%). A clinical score and an immunological score was introduced and the two items were compared: the immune data from a single serum do not provide long-range prognostic information. The present disease state is best reflected by the total immune score, C3 and C4 with, however, many exceptions. Within the disease course of some SLE patients, periods were observed during which no pathological immune serologic data are measureable. This phenomenon may pose diagnostic problems.

Immunoblastic sarcoma with features of Sjögren's syndrome and systemic lupus erythematosus in a patient with immunoblastic lymphadenopathy

A patient with immunoblastic lymphadenopathy and features of Sjögren's syndrome and systemic lupus erythematosus is presented. Clinical features included generalized lymphadenopathy, rash, alopecia, and synovitis, with associated laboratory abnormalities of a positive antinuclear factor and double-stranded DNA antibodies, positive lupus band test, and hemolytic anemia. Symptoms of Sjögren's syndrome included dry eyes and mouth and swollen parotid gland; biopsy results of the accessory salivary glands were positive. At autopsy immunoblastic sarcoma was found that involved the myocardium, which stained for both kappa and lambda light chains by immunoperoxidase techniques.

The regulation of prostaglandin E1 formation: a candidate for one of the fundamental mechanisms involved in the actions of vitamin C

Vitamin C stimulates the formation of PGE1 in human platelets. The effect occurs over the physiologically relevant range of concentrations. PGE1 is required for T lymphocyte function and plays a major part in the regulation of immune responses. PGE1 is also important in the regulation of collagen and ground substance metabolism, in cholesterol metabolism and in regulation of responsiveness to insulin. It is proposed that defective formation of PGE1 could account for many of the features of scurvy and for many of the reported therapeutic effects of vitamin C. If correct, vitamin C will be of value only in conjunction with an adequate supply of dihomogammalinolenic acid, the precursor of PGE1. Essential fatty acids, pyridoxine and zinc are all required to achieve this.

Recurrent swellings of the parotid gland, sialectasis and Mikulicz's syndrome

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Sicca syndrome associated with idiopathic haemochromatosis

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Ankylosing spondylitis with subsequent development of rheumatoid arthritis, Sjögren's syndrome, and rheumatoid vasculitis

Twelve years after the onset of ankylosing spondylitis, a patient developed severe seropositive rheumatoid arthritis with subcutaneous nodules. This was subsequently complicated by Sjögren's syndrome and rheumatoid vasculitis. The literature is reviewed, and the nature of the association between ankylosing spondylitis and rheumatoid arthritis is discussed.

Sjögren-type syndrome after allogeneic bone-marrow transplantation

Four patients, treated for hematologic disorders with bone-marrow transplants from HLA-identical siblings, spontaneously complained of dry eyes 8 to 12 months after transplantation. Four allograft recipients and two recipients of autologous bone-marrow transplants were evaluated for xerophthalmia and xerostomia. Three allogeneic marrow recipients had evidence of keratoconjunctivitis sicca, and two had decreased parotid gland function. All four allograft recipients had minor salivary gland histopathology identical to that of Sjögren's syndrome. The severity of symptoms and histologic lesions corresponded with the severity of chronic graft-versus-host disease. In addition, one patient developed sclerodermatous skin changes, another had discoid lupus erythematosus, and two patients had laboratory evidence of cholestasis. None of the patients had autoantibodies but all had hypergammaglobulinemia. In contrast, none of the recipients of autologous bone marrow had clinical, laboratory, or histologic findings resembling Sjögren's syndrome.

Scleroderma, Sjögren-like syndrome, and chronic graft-versus-host disease

A patient with acute myelogenous leukemia treated with an allogeneic bone marrow transplant developed acute graft-versus-host disease manifested by severe diarrhea, hepatitis, and a cutaneous eruption. As the graft-versus-host disease progressed to the chronic phase, the patient developed marked cutaneous sclerosis and symptoms of xerophthalmia and xerostomia. Biopsy of his indurated skin showed features of both graft-versus-host disease and scleroderma. Results of Schirmer's tests, corneal fluorescent studies, parotid flow-rate testing, and a lip biopsy were consistent with Sjögren's syndrome. Possibly, activated lymphocytes may have a role in the pathogenesis of graft-versus-host disease, scleroderma, and Sjögren's syndrome.

Ultrastructure of lymphoid interstitial pneumonia: virus-like particles in bronchiolar epithelium of a patient with Sjögren's syndrome

Ultrastructural studies of an open lung biopsy of a patient who had lymphoid interstitial pneumonia, Sjögren's syndrome, and a highly elevated level of immunoglobulin M in the serum disclosed the presence in bronchiolar epithelium of numerous round electron-dense particles 70-120 nm in diameter. These were closely reminiscent of the oncogenic type-A viral particles associated with tumors of laboratory and wild mice. In the inflammatory infiltrate the morphology of some small lymphocytes was suggestive of germinative activity, although no germinal centers were found. Plasma cells, which were numerous in the vicinity of the bronchiolar epithelium, contained varying amounts of electron-dense material, probably immunoglobulin, which was also deposited in the irregulary thickened epithelial basal lamina. The observations support the theory that viral infection may be the stimulus to the immunologic abnormalities observed in patients with lymphoid interstitial pneumonia and Sjögren's syndrome.

Sjögren's syndrome

Sjögren's syndrome is a multisystemic connective tissue disease. The syndrome is associated with other major connective tissue disorders, such as rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis and others, Reticulo-endothelial malignances have repeatedly been reported in patients with Sjögren's syndrome. A clinical study of 20 patients with Sjögren's syndrome was performed in the Department of otolaryngology, Rikshospitalet, Oslo, Norway. A considerable complexity of symptoms was seen. One patient with malignant lymphoma and one with a thyroid carcinoma were encountered.

Keratoconjunctivitis sicca

KCS in man is often associated with a systemic disease whose pathogenesis is still obscure. A spontaneous animal model resembling Sjögren's syndrome has been developed in the NZB and NZB-NZW mouse. Other spontaneous animal models analagous to lupus erythematosis and polyarteritis have been found in dogs and Aleutian mink, respectively. Studies of the eyes and lacrimal glands in such animals, and in dogs with distemper, should be pursued. A viral etiology is implicated in each of the models. The roles of both the main and accessory lacrimal glands in normal and KCS eyes have been discussed, as well as drug-induced KCS and opportunities for its further investigation and treatment.

[Gougerot-Sjögren syndrome in patients with sarcoidosis]

Three patients with eye and salivary dryness presenting the scintigraphic and histological features of Sjogren's syndrome and also suffering from sarcoïdosis, are reported. The authors stress the rarity of clinically indentifiable dry oculo-salivary syndromes whilst routine scintigraphy of the principle salivary glands using technetium 99 m often reveals altered salivary function. They consider that the primary feature in the development of this dry salivary syndrome consists of fibro-inflammatory lesions of the glandular interstitium, seen in specimens of the glands of the labial mucosae, which are sequelae of the initial sarcoid infiltration. They point out that Sjogren's syndrome occurring in relation with sarcoïdosis has certain special features. These include its appearance in relatively young subjects, the minimal symptoms, the non-essential presence of inflammatory signs and the absence of associated connective tissue disorder.

[The salivary glands during rheumatoid arthritis]

Salivary gland lesions were studied in 65 non-selected, confirmed rheumatoid polyarthritis patients. The investigations included a careful clinical study, the Schirmer test, sialography, sequential scintigraphy with Technetium 99, and a histological study of the sublingual glands. Tests were also made for salivary gland anti-epithelium antibodies. The frequency of sialography and scintigraphy anomalies is emphasized. In different degrees, two of of three patients presented anatomical or functional anomalies of the salivary glands. These disturbances were not related to the duration, the functional severity, or the treatment of the disease or to the presence of anti-salivary gland antibodies. On the other hand, there was a clear relation with both the presence of anti-nuclear antibodies and an increase in the serum gammaglobulin levels. The limits of the Gougerot syndrome are discussed and it is proposed that there is a need for a second nosological class grouping the minor scintigraphic and sialographic anomalies related to rheumatoid arthritis that has been suggested by several authors.

Coeliac disease: a cause of various associated diseases?

Deposition in other organs of immune complexes originating from the small-intestinal musosa is suggested as a possible reason, in some patients, for the described association between coeliac disease and a range of "autoimmune" diseases.

Immunological and virological studies of cultured labial biopsy cells from patients with Sjögren's syndrome

Labial salivary gland tissues from twenty-five patients were cultured in vitro for virus studies and for use as target cells in cellular and antibody-mediated cytotoxicity assays. Fourteen patients had definite Sjögren's Syndrome (SS), four had possible SS and seven did not have SS. No evidence for the presence of a virus in the cultured cells or after chemical treatment of the cultured cells was obtained. Tubuloreticular structures were present in three of the original biopsies but were not seen in the corresponding cultured cells, although in two of these cell lines rare bundles of intranuclear microfibrils occurred. The significance of these structures is unknown. Autologous serum and autologous lymphocytes were not cytotoxic for the cultured cells.

Cell-mediated immune reactivity in liver disease

Cell-mediated immunity has been investigated using the leucocyte migration test in 32 patients with chronic active hepatitis or primary biliary cirrhosis. Twenty-six (75%) showed reactivity to liver extract. At least two antigens are involved. Cell-mediated reactivity was confirmed in some cases using lymphocyte ;blast' transformation. There was no correlation with the presence of auto-antibodies.Cell-mediated immunity to parotid extract was shown in 10 cases (28%). This is in accord with the occurrence of the sicca syndrome in liver disease, which has been confirmed in this study.

The spectrum of benign to malignant lymphoproliferation in Sjögren's syndrome

Clinical and pathological evidence suggests that a wide spectrum of lymphoproliferation exists in Sjögren's syndrome (SS), from benign disease with lymphoid infiltrates confined to glandular tissue on the one end, to widespread lymphoreticular malignancy on the other. In the middle of the spectrum are patients threatened by extraglandular extension of lymphoproliferation which is not clinically or histologically malignant and which apparently has the potential to regress with appropriate therapy or to progress to frank neoplasia. Illustrative patients are described. Over thirty other case reports associating SS with pseudolymphoma, Waldenstrom's macroglobulinaemia, reticulum cell sarcoma, or other lymphomas appear in the literature. Similar lymphoproliferative processes have been observed in other autoimmune diseases, in certain immune deficiency states, with hydantoin and other anticonvulsant drugs, and in experimental animal models. In SS, as in these other conditions, it seems likely that a combination of genetic, immunologic, and viral or other unknown environmental factors plays a role in pathogenesis.