Salivary gland immunoglobulin and rheumatoid factor synthesis in Sjögren's syndrome. Natural history and response to treatment

Immunopathogenesis of Sjogren's syndrome: "facts and fancy"

Sjogren's syndrome (Ss) is an ideal model to study the pathogenesis of both autoimmunity and malignancy. It occurs as an organ specific autoimmune disease, alone or in association with almost every other autoimmune disorder, as a systemic disorder, and finally it can evolve to B-cell-lymphoid malignancy. The most consistent finding in the syndrome, the B-cell-hyperreactivity, follows the same steps of evolution. It starts as polyclonal, but not random, since the autoantibody profile correlates with the disease subgroups and the systemic manifestations and it seems to be controlled by the MHC gene composition. Further, in the systemic form of the disease it presents as a poly-oligo-mono-clonal process and ends up to monoclonal (IgMk) B-lymphoid malignancy. Studies on the T-immunoregulatory subsets and function can not explain this B-cell hyperreactivity. The initial trigger is unknown. Estrogens, known as immunoenhancers possibly promote the B-cell hyperreactivity and certain genes controlling HLA class-II MHC molecules may represent susceptibility factors for the development of the disease. The discovery of lymphokines and particularly the B-cell growth and differentiation factors as well as the rapid development of the retro-virology field may give answers pertinent to the pathogenesis of Ss and to B-cell lymphoid malignancy.

T lymphocyte activation state in the minor salivary glands of patients with Sjögren's syndrome

Local lymphoplasmacytoid infiltration of the diseased exocrine glands is a cardinal sign of Sjögren's syndrome (SS). The state of T lymphocyte activation present in these local infiltrations was studied by three different techniques: determination of interleukin 2 (IL2) receptor (Tac) on cell surface membrane; autoradiography combined with immunoperoxidase staining of T cell epitopes; and electron microscopic analysis of the lymphoblast subclasses. Although 64 (SEM 4)% of the local inflammatory cells expressed Ia antigen, only 4 (SEM 1)% of them displayed the T cell activation antigen Tac. Autoradiography-immunoperoxidase double labelling showed that less than 1% of all T cells in situ were [3H]thymidine incorporating blasts. This finding suggests that although T lymphocyte is the dominant cell in situ, only a few of these cells have passed the G0/G1 interphase, and even fewer have been pushed to the S phase of the cell cycle by IL2. Transmission electron microscopy showed that few T blasts were present, even though there were many plasma cells. This result further confirms the impression that only a minor T cell subpopulation in situ is blast transformed despite the fact that many of the local T lymphocytes in the diseased salivary glands in SS are Ia positive.

Ultrastructural and immunocytochemical aspects of lymphocytic submandibulitis in the non-obese diabetic (NOD) mouse

The submandibular glands of female non-obese diabetic (NOD) mice (22-26 weeks of age) were studied by light and electron microscopy. Mononuclear cells consisting mostly of lymphocytes were recognized in and among the acini and secretory ducts. Some parts of the secretory ducts and mucous acini surrounded by lymphocytes showed destructive changes. In the secretory ducts lymphocytes invaded the duct epithelial lining and the duct lumen was occluded by these cells. The duct epithelial cells in such lesions were extremely distorted and tonofilament bundles running in various directions were present in the cytoplasm. Lymphocytes were in close contact with the duct epithelial cells. In the mucous acini some acinar cells, which appeared to be compressed by the infiltrating lymphocytes, showed degenerative changes. Immunocytochemical study revealed that both T- and B-lymphocytes were involved, T-lymphocytes tending to occupy the center of the infiltrate, while B-lymphocytes occupied the periphery. Although autoantibody against duct epithelial cells was identified, damage to duct epithelial cells was not correlated with the presence of this antibody. The morphological changes in the submandibular gland of the NOD mouse are very similar to those reported in the salivary gland of patients with Sjögren's syndrome.

Abnormal immunoglobulin and rheumatoid factor synthesis by blood lymphocytes in patients with primary Sjögren's syndrome

Peripheral blood B lymphocytes from patients with primary Sjögren's syndrome showed significantly higher spontaneous synthesis of IgG, IgM, and IgM rheumatoid factor in vitro, compared with B lymphocytes from healthy controls. Lymphocytes from patients also showed higher IgM rheumatoid factor production after mitogen stimulation. Patients had competent suppressor activity for IgG, but not for IgM synthesis. Pre-irradiation of T cells, but not depletion of OKT8+ cells, markedly enhanced IgG synthesis in cocultures with autologous B cells; therefore, the T lymphocyte responsible for this effect is radiosensitive and is not identified by OKT8. OKT8+ lymphocytes from patients did not suppress Ig synthesis by autologous B plus T cell cocultures. However, OKT8+ cells from normal controls down-regulated Ig synthesis by B plus T cells from patients. The abnormal proportion of helper and suppressor cells suggests that there is altered redistribution of regulatory subpopulations in peripheral blood from Sjögren's syndrome patients.

Sjögren's syndrome: clinical and laboratory features, immunopathogenesis, and management

Sjögren's syndrome may be accompanied by local oral problems such as dry mouth, rampant caries, candidosis, or sialadenitis, but it is a systemic autoimmune disorder with wide repercussions, including a small premalignant potential. This article reviews the clinical and immunopathogenic features, as well as the etiology, of Sjögren's syndrome and discusses the diagnosis and management of oral complications.

Expression of histocompatibility antigen HLA-DR by salivary gland epithelial cells in Sjögren's syndrome

Recent studies have suggested that the induction of HLA-DR antigens on epithelial cells plays an important role in the pathogenesis of autoimmune endocrine-exocrine disorders. We found that salivary gland epithelial cells (i.e., acinar and ductal cells) in salivary gland biopsy specimens from patients with primary Sjögren's syndrome (keratoconjunctivitis sicca) expressed high levels of HLA-DR antigen, which were detected by staining frozen tissue sections with monoclonal antibodies and immunoperoxidase technique. In contrast, salivary gland epithelial cells from normal subjects did not express this antigen. Lymphocytes eluted from the salivary gland biopsy specimens of patients who had Sjögren's syndrome produced a soluble factor that stimulated HLA-DR synthesis by a salivary gland-derived cell line (Sal-1). These tissue culture supernatants contained gamma-interferon, and their ability to induce HLA-DR synthesis was blocked by monoclonal anti-gamma-interferon antibody. These results demonstrate the presence of HLA-DR antigen on salivary gland epithelial cells and suggest that local production of gamma-interferon plays a role in this induction.

Primary Sjogren syndrome: clinical and immunopathologic features

Primary Sjogren syndrome is an autoimmune condition in which dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia) result from lymphocytic infiltration of lacrimal and salivary glands. Clinical and laboratory features of 60 primary Sjogren syndrome patients seen at our clinic during the past three years are presented. These patients illustrate the wide spectrum of extraglandular features that may occur as a result of lymphoid infiltration of lung, kidney, skin, stomach, liver, and muscle. They further emphasize the difficulty in classifying a patient as primary or secondary Sjogren syndrome (ie, sicca symptoms associated with systemic lupus erythematosus, rheumatoid arthritis, or scleroderma), particularly early in the disease course. As an initial step in understanding the pathogenesis, the lymphocytes that infiltrate the salivary glands and lymph nodes were characterized by using monoclonal antibodies that recognize distinct lymphocyte subsets and by using in vitro functional assays. These studies have demonstrated that affected tissues have infiltrates of T cells with helper/inducer activity and with a high frequency of "activation antigens." The immunohistologic techniques are useful in differentiating "benign" and "pseudolymphoma" lesions (both due predominantly to T cells) from non-Hodgkin lymphoma (usually due to B-cell infiltrates). Although there is no "cure" for primary Sjogren syndrome patient's symptoms may be significantly improved by measures aimed at prevention of ocular and dental complications and by the recognition of extraglandular features that may be amenable to specific treatment.

Enumeration of T cell subsets with monoclonal antibodies in minor salivary glands of patients with rheumatoid arthritis

Labial salivary glands of 51 patients with rheumatoid arthritis and those of 25 control patients were examined by the ANAE (acid alpha-naphthyl acetate esterase) technique to determine the percentages of B- and T-lymphocytes and mononuclear phagocytes (MPS cells). Using monoclonal antibodies (OKT3 for all T cells, OKT4 for helper/inducer T cells, OKT6 for thymocytes, and OKT8 for suppressor/cytotoxic T cells) T cell subsets were enumerated. B-lymphocytes predominated in both series of salivary glands, and the percentages of B and T cells were equal in both series. The absolute cell counts in the salivary glands of rheumatics were significantly higher (P less than 0.001) than in those of healthy controls. The number of OKT4+ cells was increased in rheumatics, leading to an elevated OKT4+/OKT8+ ratio when compared with that in controls (P less than 0.01). The results suggest that the basic phenomenon behind the B cell hyperactivity noticed in rheumatics might be due to increased activity of T helper cells rather than reduced number of T suppressor cells, which were shown to remain almost unaffected in the salivary glands of patients with rheumatoid arthritis.

An immunohistological study of secondary Sjögren's syndrome

The labial biopsies from 13 patients with secondary Sjögren's syndrome (SS) and four disease controls were examined with a panel of monoclonal antibodies to human leucocyte antigens. Large numbers of T cells were found in most of the biopsies. In seven SS patients the T helper/inducer subset was found to be predominant. Antibody to HLA class I antigens consistently stained leucocytes, but other cell types stained more variably. Although the staining with antibody to HLA class II antigen was often weak, approximately as many cells stained with this antibody as with an antileucocyte antibody, implying that the T cells were activated. Anti-IgD revealed membrane staining of a corona of IgD-positive cells in structures resembling germinal centres. Isolated cells throughout the sections also showed strong cytoplasmic staining with anti-IgD. These results suggest a role for T-cell-dependent local antibody synthesis in the pathogenesis of the disease.

Labial salivary gland biopsy in Sjögren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases

Xerostomia is an unsatisfactory diagnostic criterion for the salivary component of Sjögren's syndrome (SS). To determine the diagnostic usefulness of the presence of focal sialadenitis in labial salivary gland (LSG) biopsy specimens, 362 patients suspected of having SS prospectively underwent a unique LSG biopsy procedure. The pattern and severity of LSG inflammation were compared with measurements of parotid flow rate, and the presence or absence of symptomatic xerostomia, major salivary gland enlargement, keratoconjunctivitis sicca (KCS), and other connective tissue diseases (CTD). LSG biopsy focus scores of greater than 1 correlated more closely with the diagnoses of KCS alone and with KCS plus a CTD than did either reduced parotid flow rate or symptoms of xerostomia (P less than 0.0005 and P less than 0.05, respectively). Focal sialadenitis in an adequate LSG specimen is an objective criterion and a more disease-specific feature of SS than xerostomia or any other feature of salivary disease. The salivary component of SS should be redefined as the presence of LSG focal sialadenitis.

Sjögren's syndrome in systemic lupus erythematosus and rheumatoid arthritis: immune effector cells in salivary glands

A simultaneously capturing azo dye method for acid alpha-naphthyl acetate esterase was used to characterize the cellular infiltrate in labial salivary glands in 25 patients with Sjögren's syndrome (SS). There was no significant difference in the T-pattern lymphocyte percentage in situ between the untreated group with SS and the group treated with 10 +/- 2 mg prednisone/day. There was a significant correlation (P less than 0.05) between the T-pattern lymphocyte percentage in situ and the focus-score value. In secondary (2 degrees) SS in cases of systemic lupus erythematosus (SLE) and rheumatoid arthritis, respectively, 55% +/- 4% (range 41-69) and 43% +/- 7% (range 15-80) of all inflammatory cells in the periductal lymphocyte-rich infiltrates were T-pattern lymphocytes. In other SS patients the corresponding value was 28% +/- 7% (range 4-50). The T-pattern lymphocyte percentage in situ was dependent on the disorder associated with SS (P = 0.07). The present results indicate the dominance of T-lymphocytes in situ in 2 degrees SS with SLE and suggest that there are differences in cell-mediated immunity in different clinical subgroups of SS.

Chemical analysis of parotid saliva and lacrimal fluid in psoriatics

A total of 28 psoriatics and the same number of healthy individuals as controls were subjected to chemical analyses of their lacrimal fluid and parotid saliva to assess whether any functional disturbances attributable to psoriasis were detectable, i.e. if they have sicca syndrome (SS) or not. The stimulated parotid flow rate and Schirmer test I proved to be normal in both series. A significant elevation of salivary IgA, alpha-amylase, and Na+ was found in psoriatics when compared with the controls. On the other hand, salivary lysozyme values in psoriatics were markedly lowered. There was a distinct interrelationship between salivary IgA, beta 2-microglobulin, and lysozyme detectable in both series. The findings are discussed in terms of the increased immunological activity in psoriasis, and the possible role of cAMP and neural regulation in the causation of elevated amylase and Na+ levels in psoriatics is hypothesized. These alterations in salivary constituents might provide a protective system for oral mucous membranes against this skin disease.

Histological and immunological study in patients with rheumatoid arthritis showing isolated abnormalities of salivary scintigraphy

We report the histological and immunological findings in 20 rheumatoid arthritis (RA) patients with impaired salivary scintigraphy but without sicca complex. This condition was stable over 2-5 years and associated with mild infiltrates on lip biopsies. Increased levels of IgG, immune complexes, and antinuclear antibodies were found in seven patients (35 vs 69% in secondary Sjögren's syndrome). Two of the seven patients later developed xerostomia. The above-mentioned immunological abnormalities may increase the likelihood of developing a clinical impairment of salivary function in patients with an abnormal salivary scintiscan, the latter being a frequent, yet often isolated, finding in RA. Antisalivary duct antibodies were not related to any other parameter of salivary gland involvement.

Use of monoclonal antibodies to analyze peripheral blood and salivary gland lymphocyte subsets in Sjögren's syndrome

Using monoclonal antibodies to cell surface antigens, we studied lymphocyte subsets in 15 patients with primary Sjögren's syndrome. The absolute number of OKT8-positive cells (reactive with T suppressor/cytotoxic cells) was significantly decreased in such patients (353 +/- 186/mm3) compared to age-matched controls (631 +/- 150/mm3) (P less than 0.001). The number of OKT4-positive cells (reactive with T helper/inducer cells) was comparable in both groups (932 +/- 588/mm3 versus 1.073 +/- 290/mm3). The ratio of OKT4/OKT8-reactive peripheral blood lymphocytes was increased (greater than 2.4) in 67% of these patients and ranged from 1.0 to 6.4 (normal = 1.8 +/- 0.3). OKT4-positive cells were the predominant subset in lip biopsy specimens stained with immunofluorescence or immunoperoxidase techniques; the OKT4/OKT8 ratio exceeded 3.0 in all 5 patients examined. In 1 patient with pseudolymphoma, a lymph node biopsy specimen contained 80% T cells with an OKT4/OKT8 ratio of 3.2. Thus, OKT4-positive cells predominated in the peripheral blood lymphocytes as well as in sites of inflammation in primary Sjögren's syndrome. The decreased number of OKT8-positive cells in primary Sjögren's syndrome was probably not caused by circulating autoantibody, since patients' sera did not react with normal OKT8-positive cells. Functional studies using pokeweed mitogen demonstrated that T helper cell activity for immunoglobulin synthesis was contained in the OKT4-positive subset in both normal and patients' peripheral blood lymphocytes. Removal of OKT8-positive cells by complement-mediated lysis did not lead to increased immunoglobulin synthesis or production of rheumatoid factor. The identification of peripheral blood lymphocyte subsets by use of monoclonal antibodies and the relationship of these subsets to tissue infiltrates and autoantibody production provide further insight into the pathogenesis of primary Sjögren's syndrome.

Treatment of xerostomia: a double-blind trial in 108 patients with Sjögren's syndrome

The first-ever controlled study of a therapeutic modality for xerostomia is reported. A recently described formulation for saliva substitute (SS) has been tested against a glycerine mouthwash as a control saliva substitute (placebo) in a double-blind clinical trial in 108 patients with varying grades of xerostomia of Sjögren's syndrome. The results indicate that SS offered significant relief of nocturnal oral discomfort (p less than 0.02) and more patients reported "excellent" improvement (p less than 0.01) on a five-point graded response. In all other respects, the SS was not significantly better than the placebo. Significant adverse effects were not reported. It is suggested that any such current and future therapeutic modalities for Sjögren's syndrome be subjected to similar critical appraisal of their worth.

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.

Immune complexes in Sjögren's syndrome

Sera from 48 patients with Sjögren's syndrome were examined for immune complexes by the Raji cell assay. There was no correlation between levels of immune complexes and the degree of lymphocytic infiltration of the labial salivary glands. Serum complement levels were normal. Five patients were serially followed during the development of pseudolymphoma or malignant lymphoma. Immune complex levels in 4 of the 5 patients were generally unchanged throughout the illness and did not parallel disease activity, rheumatoid factor, or SS-A and SS-B concentrations. Possible roles for immune complexes in Sjögren's syndrome are discussed.

Immunology in dentistry

Implications of immunology in dental treatment are explained through discussion of the basic scientific principles of allergy, autoimmunity, immunization, immune dysfunction, tumor immunology, immunosuppression, and transplantation immunobiology.

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.

Polyclonal hyperviscosity syndrome

The clinical course of two patients who presented with polyclonal hyperviscosity syndrome is described. Polymerizing IgG rheumatoid factors were isolated from the serum of both patients. The presence of these polymers with their extraordinary rheologic properties was the principal determinant of the abnormal rheological properties of the plasma. Neither patient had a discrete rheumatic disease. In both, a lymphoproliferative syndrome was present with features suggestive of the "pseudolymphoma" of Sjögren's syndrome.

Improvement in lacrimal and salivary secretions after alkali therapy in Sjøgren's syndrome with renal tubular acidosis

A patient with Sjøgren's syndrome developed renal tubular acidosis which led to systemic acidosis and potassium depletion. Treatment with Shohl's solution and potassium supplements was followed by subjective improvement in tear flow, salivary flow, and by disappearance of bronchitic symptoms. Detailed objective assessments were then made during the next year, twice on treatment and twice without. These confirmed the subjective impression of improvement.

Sialochemistry in Sjögren's syndrome

The value of sialochemistry in the study of Sjögren's syndrome was explored by comparative examination of a spectrum of parotid components in twelve subjects with a positive diagnosis of the disease and twelve control subjects with normal gland function. The subjects with Sjögren's syndrome all exhibited a marked reduction in flow rate and phosphate concentration and a marked elevation in sodium and chloride concentration. The concentration of IgA was somewhat elevated (commensurate with reduced flow rate); the levels of IgG, IgM, and albumin were normal. The major functional abnormality in the parotid gland in Sjögren's syndrome appears to be luminal transport in the ductal region; leakage of serum components is minimal. Sialochemistry can be helpful in differentiating Sjögren's disease from other diseases of the salivary gland and in assessing degree of pathologic change.

HL-A in Sjögren's syndrome

HL-A phenotype frequencies were studied in 36 patients with Sjögren's syndrome and compared with those of 350 healthy individuals from the same geographical area. Patients suffering from Sjögren's syndrome had a significantly higher frequency of HL-A8 (P corrected less than 0.01). The relative risk of developing Sjögren's syndrome is 3.96 for HL-A8 positive individuals.

Minor salivary glands as a major source of secretory immunoglobin A in the human oral cavity

Secretory immunoglobulin A is the predominant immunoglobulin in labial minor salivary gland secretions. Its mean concentration is four times higher in these secretions than in parotid gland secretion. The minor salivary glands can produce 30 to 35 percent of the immunoglobulin A that enters the oral cavity. This, together with the potential accessibility of these glands to antigenic stimulation, suggest that they may be an important source of the immune factors that are involved in the regulation of the microorganisms in the oral environment.

Beta2 microglobulin and lymphocytic infiltration in Sjögren's syndrome

We measured salivary beta2 microglobulin concentrations in 49 patients evaluated for Sjögren's syndrome with a labial salivary-gland biopsy. The salivary concentration was elevated and a significant correlation (P less than 0.001) was found between the concentration and the degree of inflammation seen in the biopsy. Serum concentrations were increased in 135 patients with Sjögren's syndrome. Striking elevations were seen in patients with associated renal or lymphoproliferative complications. Three patients have an increase in serum beta2 microglobulin concentration in association with exacerbation of their disease, and six a decrease after clinically efficacious therapy. These data indicate that determination of beta2 microglobulin in saiva may provide a simple, noninvasive technic for estimation of the degree of local inflammation in autoimmune disease.

Immunologic characterization of the mononuclear cell infiltrates in rheumatoid synovia, in rheumatoid nodules, and in lip biopsies from patients with Sjögren's syndrome

Two subcutaneous rheumatoid nodules and 8 rheumatoid synovia from patients with rheumatoid arthritis (RA); and 2 parotid glands, 1 "pseudolymphoma," and 6 lip biopsies from patients with Sjogren's syndrome (SS) were studied to identify mononuclear cells. The palisading mononuclear cells in subcutaneous nodules had a surface membrane receptor for complement. B lymphocytes surrounded by larger numbers of non-B lymphocytes were found in RA synovium and between salivary ducts of SS lip biopsies. A "pseudolymphoma" obtained from a patient with SS consisted primarily of B lymphocytes. The predominant mononuclear cell in rheumatoid synovia and salivary glands in patients with RA and SS do not have surface membrane receptors from complement and are thus probably T lymphocytes or null cells.

The oral component of Sjögren's syndrome

This study reports the results of an interdisciplinary approach to the diagnosis of Sjögren's syndrome in 100 patients. Ocular and systemic diagnoses and oral features from the history and physical examination are correlated with measurements of stimulated parotid flow rate and labial salivary gland histopathology. A new diagnostic criterion is introduced whereby labial salivary gland focus scores are used to establish the presence of the oral component of Sjögren's syndrome in place of the subjective evaluation of xerostomia. The differential diagnosis of the oral clinical features of Sjögren's syndrome and the clinical management of the oral component of this disease are discussed.

Elevated salivary and synovial fluid beta2-microglobulin in Sjogren's syndrome and rheumatoid arthritis

Beta2-Microglobulin is normally present in low concentrations in serum and other bodily fluids. By use of a radioimmunoassay, elevated concentrations of beta2--microglobulin were found in saliva and synovial fluid from patients with Sjogren's syndrome and rheumatoid arthritis, autoimmune inflammatory diseases that attack and destroy the salivary glands and articular tissues, respectively. Elevated beta2-microglobulin concentrations decreased in the saliva of two patients who simultaneously showed a clinical response to systemic treatment. Measurement of beta2-microglobulin in inflammatory fluids may offer a simple method of quantifying local activity in autoimmune states.

T and B lymphocytes in peripheral blood and tissue lesions in Sjögren's syndrome

Lymphocyte heterogeneity was studied in peripheral blood and salivary gland lesions in 24 patients with Sjögren's syndrome. Peripheral blood B cells, measured by immunofluorescence with specific antiserum to immunoglobulins or by rosette assay with complementcoated erythrocytes, were increased in most patients. Peripheral blood T cells, measured by immunofluorescence with rabbit antiserum to human thymocytes or by rosette assay with sheep erythrocytes, were reduced in eight patients. Three had associated rheumatoid arthritis, two had a generalized lymphoproliferative disorder, and one each had scleroderma, systemic lupus erythematosus, and neuropathy. The salivary gland lymphocytic infiltrates present in labial biopsy specimens were compared in 10 patients using an indirect immunofluorescent method with anti-human T cell serum and a quantitative focus-scoring method. In general, there was a correlation between the number of T cells and the extent of the infiltrate. Striking accumulations of T cells were present in some patients, but clusters of presumed B cells were also seen. These results indicate an increase in peripheral blood B cells in most patients, a decrease in T cells in some, and a mixed T and B cell infiltrate in the salivary gland lesions.