A clinical study of the relationship between silicone breast implants and connective tissue disease

OBJECTIVE

This study was a blinded, concurrent assessment of a historical cohort derived from a provincial registry (1978 to 1986) of breast implant recipients (cosmetic, not reconstructive) and controls (other cosmetic surgery) to test the hypothesis that connective tissue disease (CTD) is increased in breast implant recipients.

METHODS

Women who underwent breast implant or other cosmetic surgery during the interval from 1978 to 1986 were contacted confidentially by Alberta Health and asked to participate in the study. Those willing to participate completed an extensive questionnaire and supplied a blood sample, subsequent to which all surgical records were reviewed to confirm implant type(s) or cosmetic surgery(ies). All participants with any suggestion of rheumatic disease were assessed blindly by a rheumatologist for CTD.

RESULTS

One thousand five hundred seventy-six breast implant recipients were recruited, including 1112 who had received silicone gel-filled implants (> 13,500 person yrs exposure). Seven hundred twenty-six controls were recruited. Prevalence rates adjusted for sex and age for rheumatoid arthritis, systemic lupus erythematosus, scleroderma, and Sjögren's syndrome (the principal targeted conditions) were consistent with published reports for Caucasian women. While breast implant recipients self-reported significantly greater rates of symptoms than controls, post-surgical diagnoses of the principal targeted conditions did not indicate an increased incidence of typical or atypical CTD.

CONCLUSION

The results of the study do not support the hypothesis that silicone gel-filled implants induce or promote CTD.

Altered frequency of type 1 cytokine secreting cells in the peripheral blood of patients with primary Sjögren's syndrome

OBJECTIVE

An imbalance in immunoregulatory cytokines may contribute to the etiopathogenesis of Sjogren's syndrome (SS). We investigated systemic abnormalities in cytokine production in the peripheral blood in patients with SS.

METHODS

ELISPOT assays were used to detect and enumerate cells spontaneously secreting interleukin 2 (IL-2), IL-6, IL-10, and interferon-gamma (IFN-gamma) in freshly isolated peripheral blood mononuclear cells from 20 patients with SS and 20 healthy controls.

RESULTS

The number of cells spontaneously secreting type 1 cytokines IL-2 and IFN-gamma was decreased in the peripheral blood of patients with SS compared to controls. There was no change observed in the number of cells spontaneously secreting IL-6 and IL-10. Cells spontaneously secreting IL-4 were too rare in peripheral blood to evaluate, although cells capable of secreting IL-4 in response to phytohemagglutinin did not differ from controls. Patients with severe extraglandular symptoms (such as vasculitis) had a significantly lower frequency of IFN-gamma secreting cells in their peripheral blood than those without extraglandular involvement.

CONCLUSION

These results suggest that decreased type 1 cytokine production may contribute to or reflect the pathogenesis of SS.

Cosmetic saline breast implants: a survey of satisfaction, breast-feeding experience, cancer screening, and health

Saline breast implants have been used for the past 30 years for cosmetic and reconstructive purposes. Data based on a large number of patients are needed to evaluate patient satisfaction, cancer screening practices, problems associated with breast-feeding, and health effects. We conducted a follow-up study of 292 cosmetic saline breast implant patients from Texas and Louisiana who consented to a telephone interview. Using a Likert scale, we measured the patients' degree of satisfaction with the implants. The results indicated that 80.5 percent were satisfied, 73.3 percent would recommend saline breast implants to others, and 65.1 percent felt that implants improved their quality of life. The extent of satisfaction was independent of the number of additional surgeries, age at implant, and follow-up time. Mammography use and breast self-examination were reported with high frequency in this survey. Ninety-one percent of study participants who were between 40 and 49 years of age at time of interview and 94 percent of those 50 or older reported having had at least one mammogram. Breast self-examination was practiced by 75 percent of the women, and 61 percent reported checking their breasts at least once a month. Of the 46 women who had children after augmentation, 28 reported breast-feeding and 8 (28.6 percent) reported having implant-related problems. The patients were asked to provide information regarding a series of conditions for which they sought medical attention. They reported: atypical rheumatoid syndrome (n = 1), Sjögren syndrome (n = 1), atypical autoimmune disorder (n = 1), and chronic fatigue syndrome (n = 2). Overall, women who elected to have saline breast implants were satisfied with their augmentations, had mammograms and performed breast self-examinations more often than nonaugmented women. A few had problems when breast-feeding that could be related to their implants. There were no reports of breast cancer, but five women reported autoimmune conditions.

[Hepatitis C virus in rheumatic diseases]

HCV-infection is an important infectious disease in rheumatology. It is the cause of mixed cryoglobulinemia and other rheumatic manifestations develop frequently during HCV-infection. These comprise: Sicca-syndrome, thromboembolic events associated with anti-cardiolipin antibodies and fibromyalgia. Also associated with HCV-infection is a non-erosive polyarthritis. This synovitis often fulfills the ACR-criteria for rheumatoid arthritis, but the disease course is different with frequent remissions and non-erosive joint involvement. The following autoantibodies are associated with HCV-infection: Cryoglobulins, rheumatoid factor, antinuclear antibodies (ANA), antismooth muscle antibodies (SMA), anti-phospholipid-antibodies and anti-thyroid-antibodies. In HCV-associated sicca-syndrom, antibodies against Ro (SSA) and La (SSB) are not detected. The course of HCV-infection is often occult, without elevation of liver enzymes. We summarize the clinical and serological signs and symptoms when HCV-infection should be suspected and when HCV-testing should be performed in a rheumatological setting. The identification of HCV-infection in rheumatic patients is important to minimize the risk of aggravating hepatitis by prescription of hepatotoxic drugs and because of the availability of alpha-interferon as a potential virus eradicating agent.

[Rheumatic manifestations associated with infection by the hepatitis C virus]

The development in the past few years of laboratory test for hepatitis C virus allow us to associate it with a broad range of autoimmune manifestations such as cryoglobulinemia and Sjögren syndrome. As in other virus' infections, rheumatic manifestations have been described during VHC infection, but there are no large studies enough to know their true frequency and characteristic. The three reported patients in this issue presented and HCV related arthropathy once clinical picture, laboratory test and following, allowed us to exclude other diagnostics. Clinical manifestations ranged from arthralgias and intermittent arthritis to symmetric polyarthritis without any kind of join damage.

The role of T lymphocytes in Sjögren's syndrome

The exact role of T cells in the immunopathogenesis of Sjögren's syndrome (SS) is not well understood and is discussed herein. It seems plausible that this autoimmune disorder is associated strongly with the functions of autoantigen-specific CD4 cells. T cell receptor Vbeta gene usage appears to be unrestricted. Furthermore, elevated gene expression of T cell-derived cytokines such as IFN-gamma, IL-1, IL-6, IL-10 and IL-13 seen in salivary glands of SS patients and the animal models of this disorder suggests that the course of SS may be mediated by Th1 and Th2 cells. Defining the precise role of these CD4 cells subsets in SS would certainly provide insights into the establishment of immunotherapeutic bimodal.

Pathogenesis and treatment of Sjögren's syndrome

The criteria for diagnosis of primary Sjögren's syndrome continue to be controversial, leading to confusion in clinical practice and in the research literature. Among Sjögren's syndrome patients who fulfill the European criteria, only 15% of those would fulfill the San Diego criteria. This difference in disease classification leads to difficulty in evaluating clinical trials and in elucidating pathogenetic mechanisms, because different patient populations are evaluated. As a result of the ease and safety of minor salivary gland biopsy, Sjögren's syndrome serves as a prototype model to study the immunopathogenic features of a human organ-specific autoimmune disease. Critical features of pathogenesis include: 1) failure to "delete" autoimmune T cells at the level of thymic selection; 2) "homing" of autoimmune lymphocytes to salivary and lacrimal glands via high endothelial venules; 3) clonal expansion of autoimmune T cells in the glands; 4) upregulation of major histocompatibility antigens and adhesive molecules by epithelial cells in the glands; 5) secretion of proinflammatory cytokines by both lymphocytes and epithelial cells; 6) decreased neural innervation of the glands; 7) failure of residual glandular tissue express secretory functions; and 8) failure to remove autoimmune T cells by normal mechanisms of apoptosis. Each of these steps is regulated by cell-matrix interactions, cytokine and growth factor secretion, cell membrane receptor stimulation, "second" signals in the cytoplasm, and nuclear transcription factors. Recent studies on each of these steps in Sjögren's syndrome have suggested their role in pathogenesis and, consequently, their potential as sites for therapeutic intervention.

Sjögren's syndrome. Controversies and progress

Diagnostic criteria for Sjögren's syndrome (SS) are required by both physicians and patients to (1) provide a rational basis for their symptoms, assess their prognosis, and guide therapy; (2) identify a group of patients who are most likely to share a common etiopathogenesis, in order to identify those genetic and environmental factors that are crucial in pathogenesis; (3) fill out the myriad medical insurance forms that require a diagnosis code; and (4) serve as a "shorthand" code that alerts specialists in different fields (oral medicine, ophthalmology, and a variety of specialists in internal medicine) to search for particular clinical problems found in the SS patient. The key question in this article is whether the term "Sjögren's syndrome" should apply to a rather restricted group of individuals (those with an autoimmune basis for exocrinopathy) or to a rather large group of individuals who share a similar symptom complex of dry eyes and mouth. Primary SS, as defined by San Diego criteria, is a systemic autoimmune disease that is characterized by keratoconjunctivitis sicca and xerostomia resulting from lymphocytic infiltrates of the lacrimal and salivary glands. The criteria for the diagnosis of SS continues to be controversial, leading to confusion in the clinical and research literature. It is important to distinguish SS (an idiopathic autoimmune process) from other processes including hepatitis C infection, retroviral infection, lymphoma, autonomic neuropathy, depression, primary fibromyalgia, and drug side effects that can result in sicca symptoms. Recent studies on pathogenesis of SS in human and animal models have examined the clonality of the T-cell infiltrates, the production of cytokines by lymphocytes and glandular epithelial cells, neuroendocrine and hormonal factors that affect glandular secretion, and the fine structure of antigens recognized by T cells and B cells. Studies in SS have allowed comparison of lymphocytes in blood and in the glandular tissue lesions; important differences in the gland microenvironment play an important role in the initiation and perpetuation of the autoimmune process. For example, apoptotic death depends on the balance of Fas, Fas ligand, nuclear factors (such as bcl-2, bax, and myc), cytokines, neuropeptides, and cell membrane interactions with extracellular matrix. Although increased rates of apoptosis may be present in the blood T cells of SS patients, some glandular T cells are resistant to apoptosis. Recent advances have led to improved understanding of signal transduction in response to cytokines and hormones that play a role in the local and systemic manifestations of SS.

Scaling lichenoid eruptions and Sjögren-like syndrome: manifestations of nonfatal postoperative transfusion-associated graft-versus-host disease?

We report a case of an 81-year-old woman in whom lichenoid eruptions and Sjögren-like sicca syndrome developed 45 days after cholecystectomy. During surgery, one unit (130 ml) of unirradiated packed red blood cells from a male donor was transfused. The lichenoid eruptions cleared up with exfoliation: however, sicca symptoms remained during the follow-up period of four years. Histological examinations of both skin and lip biopsy specimens were in agreement with those of graft-versus-host disease (GVHD). A Y-chromosomal body was identified in the lymphocytes in the skin lesion by staining with quinacrine dihydrochloride and in the lip lesion by a method with in situ hybridization. The findings suggest that this case demonstrated the manifestations of non-fatal transfusion-associated GVHD.

[Study of apoptosis in Sjögren's syndrome]

To clarify the role of apoptosis in the pathogenesis of Sjögren's syndrome (SS), we investigated apoptosis and apoptosis-related molecules in peripheral blood lymphocytes (PBL) and salivary glands (SG) from SS patients and normal controls. In PBL, SS T lymphocytes showed accelerated in vitro apoptosis, and CD4+ T cells showed increased Fas expression compared to those in normal controls. Interestingly, SS T cells also showed increased Bcl-2 expression. The acinar epithelial cells in SS were Fas+ and FasL+, and these cells died by apoptosis. The majority of infiltrating lymphocytes in SS were Fas+ and Bcl-2+, while few lymphocytes expressed FasL. In situ detection of apoptosis showed minimal cell death among lymphocytes, particularly in dense periductal foci. Bax seemed to be expressed in apoptotic acinar cells. In conclusion, blocked apoptosis of SG infiltrating lymphocytes as well as enhanced apoptosis of peripheral T cells may be characteristics of SS. SS acinar cells may die by apoptosis, and this may ultimately lead to SG destruction in SS patients.

Primary biliary cirrhosis, sicca complex, and dysphagia

We investigated symptoms suggestive of swallowing problems in patients with primary biliary cirrhosis, some of whom displayed features of sicca complex. A prospective study of 95 consecutive patients with primary biliary cirrhosis was conducted at a single teaching hospital using a questionnaire administered over the telephone. Some symptoms of sicca complex (dry mouth and/or dry eyes) were found in 65 patients (68.4%). Subjective xerostomia alone was present in 45 patients (47.4%). The questionnaire revealed an increase in incidence of dysphagia in xerostomia subjects, affecting 21 of 45 patients, compared with 6 of 50 non-xerostomia patients. Multivariate logistic regression analysis showed that confounding factors such as age, obesity, cigarette smoking, and medications associated with a dry mouth could not explain these findings. Twenty-eight patients complained of hoarseness, 23 of coughing, and 14 of wheezing, all of which were significantly more frequent than in the 50 patients without xerostomia. Heartburn affected 17 xerostomia patients and 15 non-xerostomia patients, indicating no difference in frequency between these two groups, even after age, obesity, cigarette smoking, and medications associated with heartburn were considered in the multivariate analysis. Acid regurgitation, nausea, and vomiting were also similar in frequency between patients with and without xerostomia. Swallowing problems, manifested primarily as dysphagia, are common in primary biliary cirrhosis patients who have subjective xerostomia.

Differential immunological aberrations in patients with primary and secondary Sjögren's syndrome

The aim of the present study was to analyse possible differences in immunological features between patients with primary and secondary Sjögren's syndrome (SS). Ten patients with primary SS and 10 patients with secondary SS also suffering from rheumatoid arthritis, were identified according to established criteria for SS. Ten healthy, age-matched women served as controls. The authors analysed the phenotypic characteristics of lymphocytes in peripheral blood as well as in focal inflammatory infiltrates of minor salivary gland biopsies. Functional analyses of T lymphocytes were performed after stimulation with mitogens and antigen. B cell activity was determined at the single cell level by spontaneous and mitogen induced immunoglobulin production. Serum levels of IL-4, IL-6 and IFN-gamma were also analysed. Patients with primary SS displayed a significantly higher degree of salivary gland inflammation and reduced salivary flow than did patients with secondary SS. Decreased in vitro T cell responses to antigen and mitogens were evident in both patient groups. The CD4/CD8 ratios in both peripheral blood and salivary gland lesions were significantly lower in primary SS compared with secondary SS patients. Polyclonal B cell activation, measured as the frequency of spontaneous immunoglobulin producing cells, was most prominent in primary SS, whereas a diminished response to poke-weed mitogen (PWM), a T cell dependent B cell mitogen, was more pronounced in secondary SS. The results reveal certain immunological aberrations in the whole group of patients with SS. In addition, the authors demonstrated distinct differences in immune dysfunction between patients with primary and secondary SS, indicating that they may constitute separate entities.

Sjögren's syndrome: a challenge for dentistry

Sjögren's syndrome presents dentists with many challenges, from diagnosis to therapy. The secondary effects of xerostomia cause a spectrum of oral problems, including caries, candidal infection, and inflammation of the oral mucosa. The oral signs and symptoms may be the first manifestations of systemic aspects of the disease. Sjögren's syndrome requires both dental and medical management, and a program of home care.

Assessment of anti-endothelial cell antibodies in systemic sclerosis and Sjögren's syndrome

OBJECTIVES

Anti-endothelial cell antibodies (AECA) have been detected in 19 to 30% of patients with systemic sclerosis (SSc). The objective of this study was first to assess the role of a secondary Sjögren's syndrome (SS) in the occurrence of AECA in SSc. Secondly, we researched AECA in patients with primary SS, and investigated whether AECA were associated with vascular manifestations (Raynaud's phenomenon and vasculitis).

METHODS

IgG-AECA were tested by an ELISA method in serum samples from 50 patients with SSc (16 of them had also a secondary SS), 50 patients with primary SS, and 50 healthy controls.

RESULTS

AECA levels were significantly higher in patients with SSc or primary SS than in healthy controls (p < 0.01 and p < 0.01, respectively). In patients with SSc, AECA values were significantly higher in patients with secondary SS (p < 10(-5)). In patients with primary SS, AECA levels were significantly higher in patients with Raynaud's phenomenon (p < 0.01), but not in patients with vasculitis.

CONCLUSION

In patients with SSc, AECA are associated with a secondary SS. In patients with primary SS, AECA are associated with Raynaud's phenomenon, but not with vasculitis.

Biclonal immunoglobulin M dysglobulinaemia: evolving aspects in a case of primary Sjögren's syndrome

The observation of suggestive clinical symptoms in a patient suffering from a Gougerot-Sjögren syndrome led to a search for a cryoglobulin. Unusual physico-chemical features of this cryoglobulin were discovered, using standard electrophoresis, immunoelectrophoresis, immunofixation and electroimmunotransfer. The main unusual finding was that the cryoprecipitate was made up of a biclonal IgM kappa associated to polyclonal IgG. Therefore, we suggest that this new form of cryoglobulin be classified as a subtype IIb, thus distinguishing two subtypes in the usual classification.

Sicca syndrome and silicoproteinosis in a dental technician

Secondary sicca syndrome has been described in silicotic and exposed nonpneumoconiotic individuals. Systemic autoimmune pathogenic mechanisms have been thought to be responsible. Salivary gland mineral deposition has not so far been implicated. We describe the case of a dental technician who sand-blasted dental prostheses and developed silicoproteinosis and sicca syndrome. Immunological studies were negative. Scanning electron microscopy study and energy-dispersive X-ray analysis were carried out in the patient's lung and salivary gland and in two salivary glands from nonexposed individuals diagnosed with sicca syndrome. High peaks of silicon and aluminium were detected in the patient's lung and salivary gland. Silicon/sulphur and aluminium/sulphur ratios were higher in the patient's glands (0.612 and 0.402, respectively) than in the two control salivary glands (0.193 and 0 and 0.127 and 0, respectively). We suggest that, in this case, sicca syndrome could have been caused by inorganic deposition.

High prevalence of Sjögren's syndrome in patients with HTLV-I associated myelopathy

OBJECTIVE

A high seroprevalence of HTLV-I in female Sjögren's syndrome (SS) patients has been reported in Nagasaki, Japan, an area that is heavily endemic for HTLV-I infection. Salivary IgA class antibodies to HTLV-I were common among HTLV-I seropositive patients with SS. This study was undertaken to elucidate the pathogenesis of SS caused by HTLV-I infection.

METHODS

The clinical features and histological findings of SS and the prevalence of serum autoantibodies in 10 patients with HTLV-I associated myelopathy (HAM) who were consecutively admitted into Nagasaki University School of Medicine, were compared with those of 20 HTLV-I seropositive and 20 HTLV-I seronegative patients with SS.

RESULTS

Ocular and oral manifestations of SS were commonly detected in HAM patients. These patients also had extraglandular manifestations including recurrent uveitis, arthropathy, interstitial pneumonitis, Raynaud's phenomenon, and inflammatory bowel disease. All patients with HAM histologically showed a mononuclear cell infiltration in the labial salivary glands. Six of 10 patients had a mononuclear cell infiltration with a focus score of 1 or greater. According to the preliminary criteria for SS proposed by the European Community, definitive SS was diagnosed in six patients and probable SS in two patients. Serum gamma globulin and IgG values were increased in HAM patients. Patients with HAM had lower prevalence of rheumatoid factor, antinuclear antibody, and anti-SS-A (Ro) antibody than those of HTLV-I seropositive and HTLV-I seronegative SS patients. However, there was no significant difference in the prevalence of these antibodies among HAM patients with definitive SS, HTLV-I seropositive and HTLV-I seronegative SS patients. The CD3+CD4+ T cells preferentially infiltrated into the salivary glands in HAM patients as well as the salivary glands of patients with HTLV-I seropositive and seronegative patients. It seems probable that peripheral blood mononuclear cells from HAM patients preferentially infiltrated into the salivary glands, and that these cells produced the autoantibodies as well as anti-HTLV-I antibody.

CONCLUSION

The results strongly support the idea that HTLV-I is involved in the pathogenesis of the disease in a subset of patients with SS in endemic areas.

[Hepatitis C virus infection and Sjögren's syndrome]

Various immunologic and clinical abnormalities have been described in patients with chronic hepatitis C: mixed cryoglobulins, autoimmune thyroiditis, pulmonary fibrosis, polymyositis, and vasculitis. Moreover, laboratory immunologic changes have been reported in this type of infection, such as rheumatoid factor and antinuclear antibodies. The association of primary Sjögren's syndrome with hepatitis C virus infection has been suggested. We will discuss different clinical and laboratory aspects of this association.