Sleep disturbances, fibromyalgia and primary Sjögren's syndrome

OBJECTIVE

To investigate the association and prevalence of sleep disturbances and fibromyalgia (FM) in a group of patients with primary Sjögren's syndrome (pSS).

METHODS

Sixty-five patients with pSS were investigated. A 10-point Mini Sleep Questionnaire (MSQ) was completed focusing on sleep complaints. The same questionnaire was also used in three control groups: Group A-67 patients with rheumatoid arthritis. Group B-53 patients with rheumatoid arthritis (RA) and sicca symptoms; Group C-31 patients with osteoarthritis. All patients with pSS were also studied fro the presence of FM.

RESULTS

Moderate or severe sleep disturbances were reported by 49 out of 65 pSS patients (75%). This frequency was significantly higher than that reported by patients in the three control groups (p < 0.001). FM was present in 36 out of 65 pSS patients (55%) and was associated with sleep disturbances. FM or sleep disturbances were not associated with any clinical or laboratory parameters.

CONCLUSION

Our results suggest that sleep abnormalities and FM in pSS patients are frequent and their etiology might involve other mechanisms besides joint pain or sicca symptomatology.

Anti-heat-shock protein antibodies in rheumatic and autoimmune diseases

The heat-shock proteins (hsp) are a family of molecules that have different molecular weights and are thought to operate as scavengers that trap abnormal proteins and protect the stressed cells. These molecules, which have been conserved during evolution, have highly identical stretches of their amino acid sequence in bacteria as well as in humans. Experiments show that arthritis patients manifest T-cell responses to the hsp-65-kD molecule, as do rats with adjuvant arthritis. The B cell response to hsp has not been extensively studied. Autoantibodies against hsp 65, 70, and 90 have been detected in various rheumatic and autoimmune disorders such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and inflammatory bowel diseases. The frequency of these antibodies varies among studies and is mainly dependent on the methods of detection. Studies on sensitivity and specificity of these antibodies do not exist; therefore, their significance should be interpreted cautiously.

Salivary eicosanoid concentration in patients with Sjögren's syndrome

OBJECTIVE

To investigate eicosanoid concentrations in the saliva of patients with primary Sjögren's syndrome (SS).

METHODS

Whole mixed saliva of 36 subjects was assayed for eicosanoid concentrations using a radioimmunoassay. Patients with primary SS having positive lip biopsy served as the study group; their results were compared with data from patients with dry mouth and negative lip biopsy (dry mouth group), and with a group of normal healthy controls.

RESULTS

Concentrations of thromboxane B2 were significantly (p < 0.01) increased in 18 patients with primary SS compared with 10 patients with dry mouth and eight healthy normal controls (1.95 (SD 0.51) ng/ml saliva compared with 0.52 (0.1) ng/ml and 0.3 (0.1) ng/ml, respectively). Similarly, prostaglandin E2 concentrations were also significantly increased (p < 0.01) in 11 patients with primary SS compared with five patients with dry mouth and eight normal controls (3.75 (0.82) ng/ml saliva compared with 0.32 (0.1) ng/ml and 0.41 (0.1) ng/ml, respectively).

CONCLUSION

Salivary concentrations of eicosanoids are significantly increased in patients with primary SS, and this may prove helpful in the diagnosis of this disease.

Assessment of the European classification criteria for Sjögren's syndrome in a series of clinically defined cases: results of a prospective multicentre study. The European Study Group on Diagnostic Criteria for Sjögren's Syndrome

OBJECTIVE

To assess the recently proposed preliminary criteria for the classification of Sjögren's syndrome (SS) in a multicentre European study of a new series of clinically defined cases.

METHODS

The criteria included six items: I = ocular symptoms; II = oral symptoms; III = evidence of keratoconjunctivitis sicca; IV = focal sialoadenitis by minor salivary gland biopsy; V = instrumental evidence of salivary gland involvement; VI = presence of autoantibodies. Each centre was asked to provide five patients with primary SS, five with secondary SS, five with connective tissue diseases (CTD) but without SS, and five controls (patients with ocular or oral features that may simulate SS). The preliminary six item classification criteria set was applied to both the SS patients and the non-SS controls, and the performance of the criteria in terms of sensitivity and specificity was tested.

RESULTS

The criteria set was tested on a total of 278 cases (157 SS patients and 121 non-SS controls) collected from 16 centres in 10 countries. At least four of the six items in the criteria set (limiting item VI to the presence of Ro(SS-A) or La(SS-B) antibodies) were present in 79 of 81 patients initially classified as having primary SS (sensitivity 97.5%), but in only seven of 121 non-SS controls (specificity 94.2%). When the presence of item I or II plus any two of items III-V of the criteria set was considered as indicative of secondary SS, 97.3% (71 of 73) of the patients initially defined as having this disorder and 91.8% (45 of 49) of the control patients with CTD without SS were correctly classified.

CONCLUSION

This prospective study confirmed the high validity and reliability of the classification criteria for SS recently proposed by the European Community Study Group.

Primary Sjögren's syndrome and primary biliary cirrhosis: differences and similarities in the autoantibody profile

Sera from 61 patients with primary biliary cirrhosis (PBC) and 23 patients with primary Sjögren's syndrome (pSS) were tested for the presence of autoantibodies to 15 different antigens (PDH, RNP, SS-A, SS-B, Sm, Scl-70, H2AH2B, Jo-1, collagen-type I, GBM, GM <--> 1, Sulf, GD1b, MPO, PR3). Patients with pSS had significantly (p < 0.01) higher frequencies of antibodies to SS-A, SS-B and RNP (78%, 52%, 22% vs 29%, 20%, 5%, respectively) when compared to patients with PBC. On the other hand, patients with PBC had significantly (p < 0.01) higher frequencies of antibodies to PDH, Sm, Jo-1, collagen and MPO (80%, 34%, 26%, 52%, 67% vs 13%, 9%, 13%, 13%, 9%, respectively) as compared with patients with pSS. For all the other autoantibodies, no significant differences were found between PBS and pSS patients. These data on the similarities in autoimmunity between two diseases with different clinical presentations shed more light on the mosaic of autoimmunity.

Anti-neuronal antibodies in antiphospholipid syndrome with central nervous system involvement: the difference from systemic lupus erythematosus

The presence of antineuronal antibodies was compared in 43 patients with primary aPLS and 57 patients with neuropsychiatric SLE. Fifty-eight patients with Guillain-Barré syndrome and 72 normal healthy donors served as control groups. Seventeen patients in the study group had aPLS associated with CNS involvement. Antineuronal antibodies were studied in the sera employing a novel flow cytometric assay. The frequency of antineuronal antibodies in patients with aPLS and CNS involvement was not significantly different from that of patients with aPLS without CNS disease or from that found in the control groups (12%, 19% and 7%, respectively). However, it was significantly different from that found in SLE patients with CNS involvement (60%) (P < 0.001). Our results provide further evidence that unlike CNS-SLE, the major mechanism of CNS involvement in patients with primary aPLS might not be autoantibody (antineuronal) mediated, but rather 'thrombotic' in origin, or due to yet unknown factors.

Skin ulcer as the presenting symptom of primary antiphospholipid syndrome--resolution with anticoagulant therapy

A 51-year-old woman with unilateral foot ulcers as the presenting symptom of primary antiphospholipid syndrome is described. Therapy with anticoagulants resulted in complete disappearance of the ulcers.

Effect of spa therapy in Tiberias on patients with ankylosing spondylitis

Fourteen patients with ankylosing spondylitis (AS) were treated in a pilot study for two weeks at a Tiberias spa with a combination of hot mineral water baths and mud packs. A significant improvement was noticed in morning stiffness, finger to floor distance and the overall well-being assessment both by the patient and the physician. A significant reduction in the use of analgesics and NSAIDs was also noted in most of the patients. Improvement in all parameters began after one week of treatment and was still present at three months.

Sjogren's syndrome in Israel: primary versus secondary disease

Sixty Israeli patients, 30 with primary Sjögren's syndrome (SS) and 30 with rheumatoid arthritis (RA) and secondary SS, were evaluated. The Schirmer-1 test and a positive labial salivary gland biopsy were found to be the most helpful tools in assessing the diagnosis of SS. Extraglandular features such as Raynaud's phenomenon, lymphadenopathy and CNS involvement as well as parotid gland enlargement (p < 0.05) were more common in primary SS. Antinuclear antibodies, especially anti-Ro (SSA) and anti-La (SSB) were also more common in primary SS (p < 0.05). Our results are in accord with those of many European centers, despite the different genetic background.

Anti-Ro(SSA) antibodies in patients with rheumatoid arthritis--a possible marker for gold induced side effects

OBJECTIVE

To determine whether anti-Ro antibodies are associated with gold induced side effects.

METHODS

A retrospective chart review of 208 patients with rheumatoid arthritis (RA) and examination of sera for the presence of anti-Ro antibodies by enzyme linked immunosorbent assay.

RESULTS

Anti-Ro antibodies were detected in 44 (21%) of our patients with RA and their presence correlated with positive rheumatoid factor, antinuclear antibody, and secondary Sjögren's syndrome. Thirty-three out of 48 patients with gold induced side effects (69%) were anti-Ro positive in contrast to 11 patients (7.5%) with positive antibodies with no side effects (p < 0.001). Mucocutaneous reactions had the only significant correlation (p < 0.01) with the presence of anti-Ro antibodies.

CONCLUSION

Patients with RA with anti-Ro antibodies are prone to develop mucocutaneous side effects to gold salts.

Jaccoud's arthropathy and psoriatic arthritis

A patient with long-standing psoriatic arthritis developed an arthropathy of the hands characterized by subluxations of the metacarpophalangeal joints without erosive changes. This is to the best of our knowledge the first reported case describing Jaccoud's arthropathy associated with psoriatic arthritis.

Long-term experience with low dose methotrexate in rheumatoid arthritis

One hundred twenty-six patients with rheumatoid arthritis (RA) were treated with weekly low doses of methotrexate (MTX) for a mean period of 36.8 months (range 13-110 months). The overall probability of continuing with MTX therapy was 72% at 2 and 3 years, 67% at 4 years and 65% at 5-7 years. Seronegative patients had a higher probability of continuing therapy than seropositive patients (P < 0.05). Out of the whole group, 8% showed no improvement, 16% showed mild improvement, 30% showed moderate improvement, and 45% experienced marked improvement. Eight patients (6%) of the latter group achieved complete clinical remission. In the course of the follow-up period there was a significant decrease in the mean daily dosage of prednisone and NSAIDs. Minor side effects were common (68%), but therapy was discontinued in only 27 patients (21%) because of major complications. In most of them (25 out of 27) these occurred within the first 24 months of therapy. Although malignancy was revealed in 5 patients during the follow-up period, its occurrence did not differ from expected rates.

Methotrexate treatment of rheumatoid arthritis: is a fortnightly maintenance schedule enough?

In 15 patients with rheumatoid arthritis who were in clinical remission the weekly regimen of methotrexate treatment was changed to fortnightly without a change in dose. A total of 13 patients completed a 12 month trial. No change in clinical or laboratory parameters occurred. There was no change in the use of analgesics or non-steroidal anti-inflammatory drugs and the patients remained in remission. Two patients had to be withdrawn after two and four months respectively because of a flare in disease activity. It is suggested that in most patients with rheumatoid arthritis who are treated with methotrexate and whose disease activity is stable a fortnightly regimen can be permitted without affecting drug efficacy.

Increased incidence of urinary tract infection in patients with rheumatoid arthritis and secondary Sjögren's syndrome

The incidence of lower urinary tract infection in 120 women with rheumatoid arthritis and secondary Sjögren's syndrome was evaluated retrospectively. Thirty one patients (26%) had secondary Sjögren's syndrome. Recurrent urinary tract infection was significantly more common in these patients (11/31) than in patients without Sjögren's syndrome (4/89). Habitual leucocyturia was also more common in patients with secondary Sjögren's syndrome (18/31) than in patients with rheumatoid arthritis without Sjögren's syndrome (8/89). Of seven patients with vaginal sicca symptoms, six had recurrent urinary tract infection. Urinary 24 hour mucopolysaccharide excretion in 20 patients with Sjögren's syndrome was similar to the excretion in 10 patients without Sjögren's syndrome. These results show that recurrent urinary tract infection is significantly more common in women with rheumatoid arthritis and secondary Sjögren's syndrome. A local deficit in protective urinary mucosal secretion or other immune mechanisms may be responsible for this susceptibility.

A prospective analysis of liver biopsies in rheumatoid arthritis patients receiving long term methotrexate therapy

Baseline and sequential liver biopsies were performed in ten patients with rheumatoid arthritis (RA) treated with methotrexate (MTX) for more than 4 years. Liver biopsies were performed in all patients before the initiation of MTX therapy and were repeated after reaching a cumulative dose of 1500 mg or more. In four patients a third biopsy was performed 3 years after the first one. No significant worsening of hepatic architecture was found in any of our patients after 4 to 7 1/2 years of MTX therapy. No correlations between histologic findings and various clinical or pharmacological variables could be found. Our results suggested that prolonged MTX administration in RA patients did not cause severe hepatic abnormalities.

Genetic studies of anti-Ro (SSA) antibodies in families with rheumatoid arthritis

Forty-nine members of 4 families with multiple cases of rheumatoid arthritis (RA) were investigated. Nine patients with RA, one patient with primary Sjögren's syndrome (SS) and one patient with systemic lupus erythematosus (SLE) were detected among them. Anti-Ro (SSA) antibodies were found in 11 members (22%) of the investigated group; 6 suffered from RA, SLE or primary SS, and 5 were healthy first degree relatives. Anti-La (SSB) antibodies were detected in only one family member with primary SS. Secondary SS was evident in 5 patients with RA, 3 of whom had anti-Ro antibodies; HLA-DR4 was present in 7 of 9 patients with RA (78%) but in only 7 of 26 asymptomatic relatives (27%) (p less than 0.05). All patients with RA and their relatives who had anti-Ro antibodies were found to have HLA-DR4. Our results demonstrate that anti-Ro antibodies are present in relatives of patients with RA and are strongly associated with HLA-DR4.

Effect of spa therapy in Tiberias on patients with rheumatoid arthritis and osteoarthritis

Forty-one patients with rheumatoid arthritis were treated for 2 weeks at a Tiberias spa hotel. Randomized into 2 groups, Group 1 received a combination of mineral baths and mud packs, and Group 2 had tap water baths only. Both groups had a significant but temporary improvement in Ritchie index. Group 1 showed a significant improvement in grip strength. No improvement was noticed in morning stiffness, 15 meter walk time and laboratory variables of disease activity in either group. Twelve patients with osteoarthritis (OA) received 2 weeks of treatment with mineral baths and mud packs. Statistically significant improvement for a period of 6 months was noticed in night pain, pain on passive motion, tenderness on palpation and in the index of severity of OA of the knee.

Pure red cell aplasia caused by D-penicillamine treatment of rheumatoid arthritis

A 40 year old woman with rheumatoid arthritis developed pure red cell aplasia after treatment with D-penicillamine 500 mg/day. D-Penicillamine was stopped and short term treatment with steroids resulted in complete recovery of bone marrow.

Synovial and serum levels of methotrexate during methotrexate therapy of rheumatoid arthritis

Methotrexate (MTX) levels were studied following intravenous MTX in both serum and synovial fluid (SF) of rheumatoid arthritis patients. Two hours after injection serum MTX levels were higher than those of SF. At 24 hours SF levels of MTX exceeded those of the serum, while at 72 hours both blood and SF concentrations were undetectable. The localization of parenteral MTX in the SF may have importance in the understanding of its mechanism and site of action in rheumatoid arthritis.