Labial salivary gland biopsy in Sjögren's disease

Multinucleate giant cells in sublabial salivary gland tissue in Sjögren's syndrome. A diagnostic pitfall

The presence of multinucleate giant cells in the sublabial salivary gland tissue in Sjögren's syndrome is an unusual phenomenon which can give rise to differential diagnostic problems. We found in 4 cases of 55 patients with Sjögren's syndrome multinucleate giant cells. In 2 of these 4 patients epimyoepithelial islands were also present. The combination of both multinucleate giant cells as epimyoepithelial islands can mimic the histological picture of a non- caseating granulomatous disease. To discriminate between an epimyoepithelial island and an epithelioid granuloma the immunoperoxidase technique with antibodies directed against muramidase appeared an useful tool. The epithelioid cells contain muramidase whereas the cells in the epimyoepithelial island do not contain this enzyme. Thus, multinucleate giant cells are a rare phenomenon in Sjögren's syndrome, therefore restricting its diagnostic significance. When they occur in Sjögren's syndrome staining for muramidase can be of help to avoid a false positive diagnosis of diseases in which non- caseating granulomatous inflammation occur, such as in sarcoidosis.

Primary Sjögren's syndrome treated with Efamol/Efavit. A double-blind cross-over investigation

Thirty-six patients with primary Sjögren's syndrome participated in a randomised double-blind, cross-over, 3-week, study to compare the effect of Efamol (1500 mg X 2) with that of placebo. Efamol contains 9% of the prostaglandin-E1 precursor gamma-linolenic acid, which is presumed to occur in reduced levels in Sjögren's syndrome. Efamol treatment improved the Schirmer-I-test (P less than 0.03) while values of break-up time,-van Bijsterveld score, corneasensitivity, tear-lysozyme and nuclear chromatin in conjunctival epithelial cells did not reach the statistical 0.05 level.

A qualitative and quantitative study of the ageing human labial salivary glands

A series of 36 post-mortem labial salivary glands from both male and female subjects with ages ranging from 25 to 80 yr were examined histologically. Features such as acinar atrophy, fibrous replacement and ductal aberrations were noted in the aged glands. By the stereological method of point counting, the volume proportions of various defined gland constituents were calculated for individual glands in the series. An age-related decrease in acinar volume proportion and an increase in ductal and connective tissue volume proportion is recorded. These changes should be considered when diseased glands are studied.

Gastric plasmacytoma and multisystem autoimmune disease

A 54-year-old women with solitary gastric plasmacytoma, Ig M and kappa-light chain type, associated with multisystem autoimmune disease is described. The gastric plasmacytoma developed seven years after the diagnosis of Hashimoto's thyroiditis, primary biliary cirrhosis and Sjögren's syndrome. We speculate that this plasmacytoma developed in association with an immunodeficient and/or immunosuppressed state resulting from multisystem autoimmune disease and therapy.

Oral presentation of polyarteritis nodosa

A case of polyarteritis nodosa in a woman with oral manifestations and digital gangrene is presented. Oral lesions in this connective tissue disorder are rare, and few cases have previously been reported.

Autoantibodies to small nuclear ribonucleoproteins. A strong association between anti-SS-B(La), HLA-B8, and Sjögren's syndrome

The heterogeneity within multisystem autoimmune disease was evaluated according to the presence of antinuclear antibodies to ribonucleoproteins and the HLA-A1, B8, DR3 phenotype. Patients with various multisystem autoimmune diseases were tested by a highly sensitive radioimmunoassay for autoantibodies to the small nuclear ribonucleoproteins known as SS-B (La) and ribonucleoprotein (RNP), and HLA phenotypes were determined. The 210 patients included 64 with systemic lupus erythematosus (SLE), 11 with "atypical SLE", 41 with Sjögren's syndrome, 22 with mixed connective tissue disease (MCTD), 21 with rheumatoid arthritis (RA), 16 with primary biliary cirrhosis (PBC) and 35 with autoimmune chronic active hepatitis (A-CAH). Anti-SS-B (La) was present in high frequency in Sjögren's syndrome and was strongly associated with HLA-A1, B8, DR3. Anti-RNP was detected predominantly in MCTD and had no association with HLA-A1, B8, DR3. There were sharply defined serological and genetic differences between primary Sjögren's syndrome and Sjögren's syndrome associated with RA. Anti-SS-B (La) was present in 70% of patients with primary Sjögren's syndrome but in none with Sjögren's syndrome with RA, and the respective frequencies of HLA-A1, B8, and DR3 were 88%, 94% and 75% in the former compared with 38%, 29% and 14% in the latter. Thus primary Sjögren's syndrome differs immunogenetically from Sjögren's syndrome with RA. There was a notable absence of anti-SS-B (La) in PBC, an autoimmune disease associated with the Sjögren's syndrome. These findings illustrate the value of studying immunological and genetic markers in detecting heterogeneity within groups of diseases whose symptoms cannot be distinguished clinically.

Polymorphous meningitis with atypical mononuclear cells in Sjögren's syndrome

Central nervous system complications in Sjögren's syndrome have been reported sporadically for years. We examined the nature and frequency of central nervous system abnormalities in 11 patients with clinically documented Sjögren's syndrome on whom postmortem examination was performed. In 9, characteristic mixed (polymorphous) inflammatory infiltrates containing large atypical mononuclear cells were observed in the leptomeninges, choroid plexus, or both; only 5 of the 9 neurological symptoms, however. Among patients with central nervous system lesions, 3 had definite vasculocentric inflammation and 1 had a necrotizing vasculitis with extensive subarachnoid hemorrhage. Four patients had evidence of chronic subarachnoid microhemorrhage associated with polymorphous meningitis. Atypical mononuclear cells in a polymorphous inflammatory exudate were observed in antemortem cerebrospinal fluid cytological specimens from 2 of the patients. The findings suggest that central nervous system involvement in Sjögren's syndrome is common and that neurological symptoms are related to polymorphous meningitis and vasculitis. Detection of atypical mononuclear cells in cerebrospinal fluid specimens may be of diagnostic value.

Quantitation of human salivary acidic proline-rich proteins in oral diseases

Acidic proline-rich proteins (APRP) were quantitated immunochemically in salivary secretions from groups of: caries-resistant (CR) and caries-susceptible (CS) subjects; heavy- and light-calculus-formers; and patients with Sjögren's Syndrome, drug-induced xerostomia, and recurrent parotitis. In all groups except the parotitis patients, there were comparable levels of APRP, about 40-50 mg%, with similar values in parotid and submandibular saliva. In chronic recurrent parotitis, the values were somewhat higher (about 60 mg%). There were no differences in the proportion of APRP-A to C in a subset of CR and CS. Taken as a whole, the data support the view that the secretion of APRP is stable and that caries status and propensity to calculus formation are not associated with abnormal levels of these phosphoproteins.

Immunological studies in two children with recurrent parotitis

In two children with recurrent parotitis, labial salivary gland biopsies showed chronic sialoadenitis. Immunofluorescence studies disclosed deposits of immunoglobulins and complement in juxta-acinar small vessels. Case 1 had gluten enteropathy, IgA deficiency and high titres of antinuclear antibodies (ANA), and in vivo fixation of ANA to nuclei of different cells in lip, skin and jejunum was present. Case 2 showed deposition of IgM in the dermo-epidermal junction of the skin. These findings suggest that autoimmune reactivity and immune complexes may play a role in the pathogenesis of this disorder.

Follicular lymphoid hyperplasia of the hard palate: a benign lymphoproliferative process

Follicular lymphoid hyperplasia of the hard palate is a reactive lymphoid proliferation which closely simulates the palatal lymphomas, both clinically and histologically. It is therefore imperative that the pathologist be familiar with the features that separate these two conditions. In equivocal cases like the present one, immunologic analysis would seem to be indicated to determine whether the lesion is monoclonal (neoplastic) or polyclonal (reactive).

Experimental autoallergic sialadenitis in mice. Histopathological and ultrastructural studies

Experimental autoallergic sialadenitis was induced in SL/Ni mice by one or two injections of syngeneic submandibular gland homogenate emulsified with adjuvant. Light microscopically, there were marked lymphoid cell infiltration in the submandibular glands with high incidence and proliferation of duct epithelia. Furthermore complete alteration of whole glandular lobules in some cases was observed. Ultrastructurally, small and medium sized lymphocytes and plasma cells constituted a major portion of the infiltrating cells, and lymphocytes were frequently observed inside the basal lamina of ductal and acinar regions, especially observed in the small ductal region. In the aggregates of infiltrating cells, the cell remnants of salivary gland epithelia were scattered. Furthermore some of the epithelial cell remnants in aggregates of infiltrating cells could be recognized as epithelial masses which were composed of proliferated duct epithelial cells, though no typical structure of epimyoepithelial islands seen in Sjögren's syndrome was found. Antisalivary duct antibody was detected in only one case.

Architecture of minor salivary gland duct/lymphoid follicle associations and possible antigen-recognition sites in the monkey Macaca fascicularis

In Macaca fascicularis, lymphoid follicles with germinal centres related to minor salivary gland ducts are frequently found in the mucosa of lips, cheeks and the soft palate. Three semi-three-dimensional reconstructions, each based on 3 sets of 230-300 serial Epon sections, of such duct/follicle-assemblies (2 in the soft palate and 1 in the lip) and electron microscopic observations were made. These revealed that (1) these structures were about 0.05-0.1 mm3 in size, (2) they were found preferentially at sites where small interlobular ducts fused to form a pelvis-like basin from which blind duct portions protruded into the surrounding lymphoid tissue and (3) they often included a germinal centre which partly embraced blind ducts. The walls of such blind ducts were heavily infiltrated by lymphocytes and in part blast-forming T-cells. Portions of the walls of interlobular and main secretory ducts, passing directly or peripherally through follicles, were also infiltrated with lymphocytes. The duct lumen within the follicles contained clusters of Gram-negative bacteria, probably rods. Based on these findings, it is argued that gland duct/follicle assemblies represent physiological entities, either formed and re-formed temporarily or of long-standing nature, which may provide the locus (i.e. tonsillar microcrypt-like pouches) and the structural matrix necessary for local antigen recognition. The antigens (bacteria, macromolecules in salivary fluid, etc.) might enter the above structure by way of the secretory ducts. Such matrices may also exist in man.

Histologic and sialochemical findings indicating sicca syndrome in patients with systemic lupus erythematosus

Twenty unselected patients with systemic lupus erythematosus (SLE) were investigated with respect to symptoms and signs of salivary gland involvement. Eight of them complained of xerostomia. Whole salivary flow was measured, parotid saliva was analyzed chemically, and palatal biopsy was performed to assess the degree of inflammatory infiltration in minor salivary glands. All but one of the patients showed signs of involvement on at least one of the tests and, as a group, the patients with SLE had significantly reduced values for salivary flow and increased concentrations of sodium, protein, and carbohydrates as compared to matched healthy controls.

Structure and function of salivary glands in psoriatics

A total of 28 psoriatics and the same number of age-and sex-matched healthy individuals as controls were subjected to clinical, histopathologic, and salivary flow rate studies to assess whether structural and functional disturbances attributable to psoriasis vulgaris are detectable in their salivary glands, i.e., whether they have sicca syndrome or not. The oral status of the patients in the two series proved to be normal, and no clinical signs of impaired tear and salivary secretion were notable, as determined by Schirmer test I and stimulated parotid flow rate measurement, respectively. In labial biopsy, the degree of salivary gland inflammation, fatty infiltration, and fibrosis were equal in both series. These results, seemingly contradictory to those of earlier workers, are discussed in the light of the newly introduced concept on MALT (mucosal associated lymphatic tissue), and the conclusion is drawn that salivary glands are not affected by psoriasis vulgaris nor complicated by arthritis. The latter seems to be required to initiate the inflammatory reaction within MALT, in which synovial tissue and salivary glands are included. The necessity of an age- and sex-matched control series is emphasized whenever salivary gland changes in association with systemic diseases are studied.

Salivary gland function and changes in patients with oral lichen planus

Saliva analysis, sialography and histopathologic examination of labial salivary glands were performed on patients with oral lichen planus. Diseases connected with salivary gland function were also recorded. Saliva analysis regarding secretion rate, pH and buffer capacity in unstimulated and stimulated saliva was performed on 39 patients. 87% of the patients exhibited a low or very low unstimulated secretion rate, the mean value being 0.14 ml/min. The rate of stimulated saliva, pH and buffer capacity did not deviate from normal reference values. Sialographic examination was performed on 18 patients, corresponding to 36 major salivary glands. Radiologic changes were seen in 89% of the patients. Histopathologic examination was performed on 15 patients. Lymphocytic infiltration, acinar atrophy, fibrosis, fatty degeneration or ductal changes were observed in the minor glands of all patients. Different degrees of acinar atrophy were present in 93% of the patients. Lymphocytic infiltration was seen in 12 patients (80%) of whom three exhibited focal accumulation as in Sjögren's syndrome. Since decreased salivary secretion and symptoms of joint diseases and keratoconjunctivitis sicca were frequently present, over a third of the patients showed clinical signs comparable to those of Sjögren's syndrome. A high frequency of gastrointestinal and endocrine diseases was also recorded, which suggests that a general exo and endocrine influence may be present in patients with oral lichen planus.

Predictive value of SS-B precipitating antibodies in Sjoögren's syndrome

As part of a screening programme several patients were identified with antibodies to the nuclear antigen SS-B. Fifteen were examined and 11 found to have Sjögren's syndrome, though this had not been suspected by most of the referring physicians. In contrast, among a group of 17 patients with overt Sjögren's syndrome, most of whom also had rheumatoid arthritis, only one had antibodies to SS-B. Patients presenting with polyarthralgia found to be SS-B positive may be likely to develop Sjögren's syndrome but unlikely to develop rheumatoid arthritis. The detection of SS-B antibodies may antedate clinical evidence of Sjögren's syndrome by months or even years. These results emphasise the clinical heterogeneity of Sjögren's syndrome.

Immunohistologic studies of cytoplasmic immunoglobulins in rheumatic diseases including two patients with monoclonal patterns and subsequent lymphoma

Tissue specimens from five patients with rheumatic disease who developed lymphadenopathy were studied by an immunoperoxidase method; available biopsy material was examined for cytoplasmic immunoglobulin determinants. Three patients had follicular hyperplasia of lymph nodes with polyclonal patterns. Two patients with Sjogren's syndrome had monoclonal patterns; both of these patients subsequently developed lymphoma with similar monoclonal patterns. Implications of the monoclonal patterns with regard to the biology of these lymphoproliferative disorders are discussed.

Airway disease in a subset of nonsmoking rheumatoid patients. Characterization of the disease and evidence for an autoimmune pathogenesis

Previous investigations of airway disease in rheumatoid patients have been oriented toward establishing the prevalence of the disease, but the pathogenesis and the time course of the airflow obstruction in rheumatoid disease are still unclear. In this study, we analysed the clinical, serial pulmonary function and histopathologic data of six rheumatoid patients who had never smoked but who had airflow limitations documented repeatedly up to 10 years previously. We have attempted to characterize the site, nature and evolution of the chronic airway disease in this group of patients. Bronchiectasis was excluded in all patients by bilateral bronchography. Clinical and histopathologic evidence of the Sjörgen autoimmune exocrinopathy was documented in five of the patients, and the sixth patient had lymphoplasmocytic infiltrates of the labial glands without obstruction of the lumen or destruction. By pulmonary function tests and histopathologic examination of four open lung biopsies, the airway disease was found to be located predominantly in the peripheral airways of the lung. On each biopsy, the lesions were in different stages of activity, but on all specimens there was a definite predilection for selective bronchiolar injury. Early stage lesions were characterized by mononuclear cell infiltrates of the peribronchiolar tissue which led to deformation of airway lumen, focal mucosal extension and ulceration. Subsequently, the inflammatory reaction was replaced by fibroblastic proliferation, and in the end stage of the disease, there was complete obliteration of many bronchioles by collagenized fibroblastic tissue. From regression analyses of serial pulmonary function tests of these patients, it was concluded that (1) the airway disease in our patients who did not smoke progressed inevitably but not uniformly and (2) deterioration of pulmonary functions was more rapid in our patients than it was in the cigarette smokers who had chronic obstructive lung disease. This study also documents major dysfunctions of the chest wall mechanics which appear to contribute to the restriction of lung volumes in some rheumatoid patients.

Benign lymphoepithelial lesion and malignancy

Whereas most patients with benign lymphoepithelial lesion suffer from the involvement of a major salivary gland a number evolve into a clinical form of Sjögren's syndrome or Mikulicz's disease. In a small number development of malignant lymphomas, especially non-Hodgkin's lymphomas, have been described. Therefore, regular follow-up and appropriate histological evaluation of suspected areas in all patients with a benign lymphoepithelial lesion is indicated. Histologically, diagnosis of a non-Hodgkin's lymphoma may be difficult. Demonstration of a cell pattern, monoclonal for cytoplasmic Ig by means of the immunoperoxidase technique may facilitate the diagnosis. In this report we present the history of two cases out of our series with benign lymphoepithelial lesion who developed a non-Hodgkin's lymphoma.

Pulmonary involvement in primary biliary cirrhosis

The association of pulmonary fibrosis and primary biliary cirrhosis (PBC) remains controversial. To determine the frequency of pulmonary fibrosis in PBC, a carefully selected series of 14 PBC patients, seven patients with Sicca complex, and 14 control subjects have been studied. Seven of the 14 patients with PBC had Sjögren's syndrome, four of whom had some clinical evidence of pulmonary disease. Evaluation of ventilatory capacity, gas transfer factor, arterial blood gases, and lung mechanics were performed. Gas transfer was reduced in patients with PBC associated with Sjögen's syndrome and in patients with the Sicca complex. These results suggest that the respiratory, clinical, ad functional abnormalities found in PBC are related to the presence of an associated Sjögen's syndrome.

In situ characterization of the cellular infiltrate in labial and palatine glands in Sjögren's syndrome

The inflammatory cells in the minor salivary glands in situ in 11 patients with Sjögren's syndrome were characterized by using intracellular markers for T lymphocytes, plasma cells, mononuclear phagocytes and granulocytes. The methods used to demonstrate the markers were optimized histochemical and immunoperoxidase techniques which did not disturb the simultaneous morphological study of the marker-positive cells. Acid alpha-naphthyl acetate esterase (ANAE)-positive T lymphocytes accounted for 33 +/- 22%, mononuclear phagocytes for 8 +/- 4% and ANEA-negative (B) lymphocytes for 59 +/- 23% of all cells in the periductal lymphocyte-rich infiltrates, indicating great variations between individual patients. However, variations between labial and palatine glands in individual patients were usually less than 10%, indicating that the disease was at the same stage. Plasma cells were located peripherally to the lymphocytic foci and situated between the glandular acini. Equal proportions of plasma cells containing kappa-light chains (34 +/- 8%) and lambda-light chains (31 +/- 10%) were seen in individual patients, indicating polyclonal B lymphocyte activation. The results indicate differences in the local pathogenetic mechanisms or stage of disease in individual patients with Sjögren's syndrome.

Lip biopsy in connective tissue diseases. A review and study of seventy cases

The labial salivary glands from seventy patients with systemic lupus erythematosus (twenty cases), systemic progressive sclerosis (twenty-two cases), rheumatoid arthritis (twenty-three cases), and Sjögren's syndrome (five cases) and from fifty subjects without connective tissue diseases were studied by means of light and fluorescence microscopy. The availability of the lip biopsy as a diagnostic tool is stressed, but a differential diagnosis between the different connective tissue diseases was not achieved. Yet some of the latter disclosed peculiar lesions. The role of the inflammatory and degenerative components, as well as the pathogenesis of the lesions, is discussed.

Impairment of lachrymal and salivary secretion and cellular immune responses to salivary antigens in rheumatoid arthritis

During a systematic investigation of 100 unselected outpatients with rheumatoid arthritis, 58 were found to have reduced lachrymal or salivary secretion. No correlation could be detected between the presence or absence of secretory abnormalities and the age or sex of the patient, the presence of nodules or salivary duct antibody, or the occurrence of vasculitis. However, there was a significant correlation between diminished salivary of lachrymal flow and the occurrence of cellular immune responses to a protein fraction of normal human saliva, sensitisation being found in 94% of those with impairment of salivary and lachrymal secretion as compared with 33% of those without.

Sjögren's syndrome (sicca complex)

A case of sicca complex Sjögren's syndrome in a 41-year-old woman is presented. Symptoms related to xerophthalmia and xerostomia were severe but, ironically, served to confuse the clinical impressions of medical personnel managing this patient, resulting in a diagnostic dilemma. Biopsy of a labial minor salivary gland followed by histopathologic examination of the tissue provided invaluable information which, together with the clinical picture, aided in the establishment of the delayed diagnosis.

Alterations in lactoferrin in salivary gland disease

During the active phase of chronic recurrent parotitis there is a marked elevation in the parotid concentration of lactoferrin (Lf), and iron-binding glycoprotein with antibacterial properties. The Lf concentration decreases during the recovery period, but still remains above normal levels. The changes of Lf in parotitis parallel recent findings in mastitis and pancreatitis. Elevations in Lf were also noted in five of six subjects with Sjögren's disease, but not in subjects with sarcoidosis, diabetes or "dry mouth" without sialographic changes. The source of the Lf has not been determined; it could arise in part from disrupting polymorphonuclear leucocytes and in part from epithelial cells that synthesize Lf in the salivary glands. Inflammatory stimulation of Lf synthesis would suggest a basic protective mechanism in exocrine glands and should be fully explored.

Serum beta-2-microglobulin in Sjögren's syndrome

The serum concentration of beta-2-microglobulin was determined with a radioimmunoassay in 52 patients with keratoconjunctivitis sicca, 29 of whom had Sjögren's syndrone. Eleven (38%) of the patients with Sjögren's syndrome had high serum values. These cases had a higher mean age and a higher frequency of the complete triad of Sjögren's and of antinuclear antibodies than had the lower value cases. The sicca components per se did not seem to influence the serum concentration of beta-2-microglobulin. Most of the few complications occurred in patients with high values.

Tear physiology and dry eyes

The conditions of tear film formation and stability are governed by the surface chemical characteristics of the tear film system and by the proper functioning of the lacrimal apparatus. The tear film has to remain continuous between blinks in order to fulfill it function. The presence of an abnormal tear film results in dry eye states that can be detrimental to vision. The diagnostic tests presently available are limited mainly to approximately determining tear secretion rate and estimating epithelial damage by staining techniques. The only test that directly measures tear film stability is one which determines tear film breakup time. The treatment modalities depend on the type of irregularity causing the dry eye state and range from the application of artificial tear substitutes or the obstruction of the puncta to surgical alterations of the lacrimal system.

Oral swelling in Sjögren's syndrome

A case is reported of a 69-year-old female with Sjögren's syndrome who presented with a problem of interest to the oral surgeon. The clinical features and cryosurgical management of a rare cause of palatal swelling are described. The confusion that exists in the literature concerning the nomenclature of chronic inflammatory salivary gland lesions is discussed.

Cellular immune responses to salivary antigens in autoimmune liver disease with sicca syndrome

Twenty-six patients with primary biliary cirrhosis (PBC) and twenty-two with active chronic hepatitis (ACH) were examined for evidence of the sicca syndrome (keratoconjunctivitis sicca, xerostomia). Measurements of tear flow and total saliva flow showed that at least one sicca feature was present in twenty (77%) of the patients with PBC and ten (45%) of those with ACH. Examination of cellular immune responses to a protein fraction of normal human saliva using the leucocyte migration test showed sensitization to the saliva protein in twenty-three of the thirty cases with sicca syndrome but in only two of the eighteen in whom sicca features were not detected. Antisera raised in guinea-pigs against the saliva protein gave specific immunofluorescent staining of bile duct epithelial cells in sections of normal human liver. These findings suggest that damage to structures in the liver may lead to sensitization to various self-antigens which cross-react with other tissues in which a similar disease process may be consequently be initiated.

Familial Sjögren's syndrome with associated primary salivary gland lymphoma

Primary salivary gland lymphoma has been rarely documented in patients with or without Sjögren's syndrome. The association of disseminated lymphoreticular neoplasms with Sjögren's syndrome has been recognized, and the malignancy is usually widespread at the time of diagnosis. Familial occurrence of Sjögren's syndrome is likewise infrequently observed. In the present report we describe a patient with Sjögren's syndrome in whom a primary parotid gland lymphoma subsequently developed. In addition to the propositus, two of four siblings had definite evidence of Sjögren's syndrome and a third had several abnormal studies commonly associated with the disease. This observation suggests that genetic influence alone or in conjunction with other factors may facilitate the development of Sjögren's syndrome.