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

Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune disorder of the exocrine glands with associated lymphocytic infiltrates of the affected glands. Dryness of the mouth and eyes results from involvement of the salivary and lacrimal glands. The accessibility of these glands to biopsy enables study of the molecular biology of a tissue-specific autoimmune process. The exocrinopathy can be encountered alone (primary Sjögren's syndrome) or in the presence of another autoimmune disorder such as rheumatoid arthritis, systemic lupus erythematosus, or progressive systemic sclerosis. A new international consensus for diagnosis requires objective signs and symptoms of dryness including a characteristic appearance of a biopsy sample from a minor salivary gland or autoantibody such as anti-SS-A. Exclusions to the diagnosis include infections with HIV, human T-lymphotropic virus type I, or hepatitis C virus. Therapy includes topical agents to improve moisture and decrease inflammation. Systemic therapy includes steroidal and non-steroidal anti-inflammatory agents, disease-modifying agents, and cytotoxic agents to address the extraglandular manifestations involving skin, lung, heart, kidneys, and nervous system (peripheral and central) and haematological and lymphoproliferative disorders. The most difficult challenge in diagnosis and therapy is patients with symptoms of fibromyalgia (arthralgia, myalgia, fatigue) and oral and ocular dryness in the presence of circulating antinuclear antibodies.

Endothelıal dysfunctıon ın patıents wıth prımary Sjögren’s syndrome

The aim of this study was to determine the endothelial function in patients with primary Sjögren's syndrome (SS). We also aimed to determine whether endothelial (dys)function correlates with extraglandular manifestations, specific autoantibodies and the severity of salivary gland involvement of SS. Endothelium-dependent vasodilation and endothelium-independent vasodilation of the brachial artery were assessed by a high-resolution ultrasound on 25 patients with primary SS and on 29 healthy controls. Patients with primary SS had significantly less mean endothelium-dependent vasodilation than did controls (3.0 +/- 0.4% vs 4.2 +/- 0.3%; p = 0.012). Endothelium-independent vasodilation induced by sublingual glycerol trinitrate was not different between the two groups (12.9 +/- 1.4% vs 14.1 +/- 1.2%; p = 0.86). We concluded that endothelium-dependent vasodilation was impaired in primary SS patients, in particular those presenting with Raynaud's phenomenon, when compared with the healthy controls and this impairment was not associated with the presence of RF, ANA, anti-Ro/SS-A, anti-La/SS-B and with the other extraglandular manifestations of the disease.

Ultrasonographic contrast-enhanced study of sicca syndrome

OBJECTIVE

To assess the ability of US contrast-enhanced time-intensity curves to depict the changes connected with sicca syndrome, a fairly common condition that is often associated with autoimmune disorders such as Sjogren's syndrome or other diseases. Diagnostic criteria are complex and controversial and although no single test can be considered the gold standard, salivary gland scintigraphy and biopsy are reliable diagnostic methods.

MATERIALS AND METHODS

Sixty consecutive patients with sicca syndrome, 40 of whom had primary (n = 23) or secondary (n = 17) Sjogren's syndrome and 20 had non-Sjogren's sicca syndrome, selected according to European Community Study Group diagnostic criteria for Sjogren's syndrome and subjected to contrast-enhanced US imaging of the parotids using a second-generation contrast agent with analysis of time-intensity curves at rest and during salivary stimulation, Tc99m salivary gland scintigraphy and labial gland biopsy.

RESULTS

In the 40 Sjogren's patients, US enhancement values were significantly lower (P < 0.0001 and P < 0.00003, respectively) than in the 20 non-Sjogren's patients both at rest and during stimulation. In the 23 subjects with the primary syndrome, values during stimulation were significantly lower than in the 17 subjects with the secondary syndrome (P < 0.0006), whereas at rest differences were not significant. Contrast-enhanced US imaging allowed to discriminate Sjogren's from non-Sjogren's sicca patients with 87.5% sensitivity, 85% specificity and 86.7% accuracy and the primary from the secondary syndrome with 78.2% sensitivity, 70.5% specificity and 75% accuracy. Interestingly, in eight patients with the primary syndrome, i.e. those with the more severe gland involvement, enhancement values were lower during stimulation than at rest.

CONCLUSION

Preliminary results indicate that contrast-enhanced US imaging can provide useful information on sicca characterisation and severity.

Salivary hypofunction and xerostomia: diagnosis and treatment

Salivary gland hypofunction and complaints of xerostomia are common in elderly patients, irrespective of their living situation. Medication use is frequently related to dry mouth symptoms and reductions in salivary flow rates. Patients with reduced salivary flow are at increased risk for caries, oral fungal infections, swallowing problems, and diminished or altered taste. Oral health care providers should institute aggressive preventive measures and recommend palliative care for patients with significant reduction in salivary gland function. The systemic agents pilocarpine and cevimeline may help selected patients. Selective use of fluoride-releasing restorative materials and conservative treatment plans are recommended for this patient group.

Evaluation of oral manifestations and masticatory force in patients with polymyositis and dermatomyositis

BACKGROUND

The polymyositis (PM) and dermatomyositis (DM) complex encompasses a heterogeneous group of acquired autoimmune skeletal muscle diseases called idiopathic inflammatory myopathies (IIM). Despite their histological and immunopathological differences, the end result of the affected muscles in all of these entities is the triad of chronic inflammation, fibrosis and the loss of muscle fibres. The aim of this study was to perform a complete analysis of the orofacial abnormalities in 34 patients with PM and DM.

METHODS

Evaluation of subjective oral symptoms, measurement of whole resting saliva flow rate (WS) with the 'spitting method', a visual investigation of the oral soft tissue alterations, light- and electron microscopic analysis of the symptoms of capillary abnormalities or signs of focal infiltration in labial biopsy specimens were carried out. The number of decayed, missing and filled teeth (DMF-T) according to the WHO recommendations (1997), the periodontal probing depth (PPD), the plaque index (PI; Silness-Löe) and the gingival index (GI; Löe-Silness) were determined. For comparison with healthy controls the masticatory force (MF) and the force of the upper extremities' flexors were measured with a specially developed device. The SPSS version 11.0 for Windows software program, two-tailed Student's t-test and Mann-Whitney test were used to statistically analyse all data. Values were considered to be significant if P level was < or = 0.05.

RESULTS

Nine patients complained of subjective xerostomia, 11 showed the signs of salivary hypofunction (WS < or = 0.1 ml/min). The most prominent symptom of the oral mucosa and perioral tissues was the presence of telangiectasia, detected in seven cases. Fibrosis of the minor salivary glands was found in 12 patients, interstitial-perivascular infiltration was detected in eight cases, periductal infiltration in one case. The findings on dental and periodontal conditions indicate, that the patients with IIM diseases had significantly higher DMF-T scores (24.06 +/- 7.04 vs. 19.54 +/- 8.93, respectively; P = 0.002), they had less remaining teeth in average (15 vs. 20; P = 0.002), compared with the control group. Their oral hygiene was significantly worse (PI was 1.46 +/- 0.75 and 0.73 +/- 0.54, P = 0.001). GI was significantly higher in the patients (1.27 +/- 0.60 and 0.66 +/- 0.56, respectively, P = 0.0003), although we could not demonstrate any difference in the severity of the periodontal destruction between patients and controls. Masticatory force was significantly weaker in the first molar region on both sides in the patient group (309 +/- 213 N and 113 +/- 146 N, P = 0.0016 for the right side; 315 +/- 239 N and 123 +/- 76 N, P = 0.009 for the left side), but only the left hands showed to be weaker in the patient group (77 +/- 27 N and 59 +/- 20 N, P = 0.04).

CONCLUSION

In conclusion, the present study showed that, patients with IIM diseases have hyposalivation and mucosal alterations, mainly in the form of telangiectasia. They have increased prevalence of dental caries, which may be secondary to the hyposalivation. The masticatory and the upper extremity flexor forces indicate that the weakness of the masticatory muscles can manifest earlier than that of the arms.

Expression of aquaporin-5 in and fluid secretion from immortalized human salivary gland ductal cells by treatment with 5-aza-2'-deoxycytidine: a possibility for improvement of xerostomia in patients with Sjögren's syndrome

The aim of the present study was to investigate the possibility that ductal cells, which preferentially survive and/or proliferate in Sjögren's syndrome (SS) salivary glands of patients with SS, could acquire the functional expression of membrane water channel aquaporin-5 (AQP5). Thus, in this study, we demonstrate that an immortalized normal human salivary gland ductal cell (NS-SV-DC) line, lacking the expression of AQP5, acquires AQP5 gene expression in response to treatment with 5-aza-2'-deoxycytidine (5-Aza-CdR), a DNA demethylating agent. Confocal microscopic analysis revealed the localization of AQP5 expression mainly at the apical and lateral sides of the plasma membrane. The expressed AQP5 protein was functionally active because AQP5 expression resulted in a significant increase in the osmotically directed net fluid rate across monolayers of NS-SV-DC cells. By the analysis of bisulfite sequencing of CpG islands in the AQP5 promoter, hypermethylation within the consensus Sp1-binding sites was commonly observed in parental cell clones, whereas demethylation at the CGs, one in the second consensus Sp1 element and the other outside of the third consensus Sp1 element in the AQP5 promoter, was detected in NS-SV-DC cells after treatment with 5-Aza-CdR. By analyzing the luciferase activity of transfected AQP5 promoter vectors, it became evident that demethylation at the CGs cooperatively functions between these two sites to induce AQP5 expression. Our data, therefore, suggest that treatment of ductal cells with 5-Aza-CdR could result in the expression of the AQP5 gene, thereby leading to increased fluid secretion from ductal cells in SS salivary glands.

Lamivudine is not effective in primary Sjögren's syndrome

BACKGROUND

Retroviral infection has been implicated in the pathogenesis of primary Sjögren's syndrome.

OBJECTIVE

To examine the efficacy of the reverse transcriptase inhibitor lamivudine in patients with this syndrome.

METHODS

16 patients with primary Sjögren's syndrome were randomised to receive either lamivudine 150 mg twice daily or placebo for three months. Measures of lacrimal and salivary function, including minor salivary gland biopsies, were obtained before and after treatment.

RESULTS

Treatment with lamivudine did not result in significant improvement in the primary outcome measure of unstimulated whole salivary flow or other secondary measures, including minor salivary gland biopsy focus scores.

CONCLUSION

Lamivudine is not effective in patients with primary Sjögren's syndrome, suggesting either that a retroviral aetiology is not present or that it may be important only in early disease.

Multilevel examination of minor salivary gland biopsy for Sjogren's syndrome significantly improves diagnostic performance of AECG classification criteria

The recently observed low reproducibility of focus score (FS) assessment at different section depths in a series of single minor salivary gland biopsies highlighted the need for a standardized protocol of extensive histopathological examination of such biopsies in Sjögren's syndrome. For this purpose, a cumulative focus score (cFS) was evaluated on three slides cut at 200-μm intervals from each of a series of 120 salivary biopsies. The cFS was substituted for the baseline FS in the American–European Consensus Group (AECG) criteria set for Sjögren's syndrome classification, and then test specificity and sensitivity were assessed against clinical patient re-evaluation. Test performances of the AECG classification with the original FS and the score obtained after multilevel examination were statistically compared using receiver operating characteristic (ROC) curve analysis. The diagnostic performance of AECG classification significantly improved when the cFS was entered in the AECG classification; the improvement was mostly due to increased specificity in biopsies with a baseline FS ≥ 1 but <2. The assessment of a cFS obtained at three different section levels on minor salivary gland biopsies can be useful especially in biopsies with baseline FSs between 1 and 2.

Analysis of clinical questionnaire of Tokyo Metropolitan Government for Sjogren's syndrome

Sjögren's syndrome is not one of the forty-five diseases included in the incurable disease treatment research project funded by the government. However, it is approved as a designated incurable disease for government funded treatment in Tokyo. The criteria of approval are based on diagnostic criteria revised in 1999. Complications and other factors are taken into consideration in the recognition standard established independently in Tokyo. In this study we examined the recognition standard of approval and their significance by analyzing the clinical questionnaires of patients with Sjögren's syndrome in Tokyo through 2003. The major objective of the recognition standard (2003) appears to have been the approval of subjects with severe Sjögren's syndrome with such conditions as advanced glandular involvement xerosis affecting their daily lives and visceral complications. However, examinations using biopsy, salivary gland scintigraphy, and contrast sialography can only be performed at an institution with appropriate facilities. For an approval process that is impartial and accomplished with ease, we believe that combinations of simple multiple tests should be considered as auxiliary items which could be substituted for the aforementioned examinations. In addition, future investigation is necessary to examine the high cost incurred in requiring findings within six months for an approval application, performing of annual invasive tests, and the validity of the process for determining the approved or unapproved status using the present clinical questionnaire profiles.

Increased acinar damage of salivary glands of patients with Sjögren's syndrome is paralleled by simultaneous imbalance of matrix metalloproteinase 3/tissue inhibitor of metalloproteinases 1 and matrix metalloproteinase 9/tissue inhibitor of metalloproteinases 1 ratios

OBJECTIVE

Previous findings in labial salivary glands (LSGs) from patients with Sjögren's syndrome (SS) suggest that increased activity and expression of matrix metalloproteinase 9 (MMP-9) and MMP-3 trigger the destruction of acinar structures in these glands. Tissue inhibitors of matrix metalloproteinases (TIMPs) tightly control MMP activity, and TIMP expression is an important modulator of effects attributed to MMPs. This study was undertaken to investigate the correlation between the balance of MMPs/TIMPs in the LSGs of SS patients and the degree of inflammatory infiltration and acinar structure integrity.

METHODS

Three groups of SS patients classified according to focus score and residual tissue were studied. The expression of MMP-2, MMP-3, MMP-9, TIMP-1, and TIMP-2 was examined at the messenger RNA and protein levels. The ratio of MMP/TIMP expression (R value) was calculated. Focus score and acinar structure were evaluated by histologic analysis.

RESULTS

In SS patients the MMP-3/TIMP-1 ratio was higher than 1 and the MMP-9/TIMP-1 ratio was much higher than 1 whereas the MMP-2/TIMP-2 ratio nearly equaled 1, suggesting elevated proteolytic activity due mainly to MMP-9. R values were independent of the focus score of inflammatory cells, but correlated well with the dramatic changes observed in morphologic integrity of acini, as revealed mainly by the lack of nuclear polarity. Acinar changes were more evident when R values for both MMP-9/TIMP-1 and MMP-3/TIMP-1 were higher.

CONCLUSION

This study provides evidence that an altered balance between MMPs and their inhibitors is associated with acinar damage. Since salivary gland acinar cells express both MMPs and TIMPs, these cells may play an important role in extracellular matrix destruction and in the LSG pathophysiology in SS.

Immunohistochemistry of the B-Cell Component in Lower Lip Salivary Glands of Sjogren's Syndrome and Healthy Subjects

Serial sections of lower lip salivary gland (LSG) biopsies were examined by immunohistochemistry, using a battery of B- and partly T-related antibodies (CD5, CD20, CD21, CD27, CD38, CD45RO, CD79a, Bcl-2 and Bcl-6) in different groups of subjects: healthy controls and clinically verified smoking or nonsmoking cases of primary Sjögren's syndrome (SS). The purpose was to characterize the B-cell pattern of the lymphocytic foci and of the tiny perivascular infiltrates preceding the development of foci. Hyperplastic tonsil was used as stain control. In normal LSG, widely dispersed CD38+ and CD79a+ as well as some CD5+ cells are a normal constituent, with lack of staining with the other antibodies. In SS/LSG, the lymphocytic foci showed staining with all the antibodies, with variable degrees of overlapping or nonoverlapping. In SS/LSG of nonsmokers, CD20+ B cells make up a prominent part of the fully developed periductal lymphocytic foci, not overlapping with CD45RO. Also, CD20+ B cells did not overlap in the infiltrates with colocalized CD27+/CD38+ cells. CD20+ B cells and CD45RO+ T cells also occur as minute infiltrates perivascularly in areas of no foci in SS/LSG as well as in SS smokers lacking the typical foci. Smokers lack foci, but tiny infiltrates express CD20 as well CD45R0. Our findings suggest that CD20+ B cells and CD45RO+ T cells are early immigrants in the LSG of SS of smokers as well as nonsmokers and that another subgroup of CD27+/CD38+ B cells gradually mix with the first two to form the characteristic foci in SS/LSG. The simultaneous demonstration of CD20+ and CD27+ B cells in SS/LSG may constitute a significant diagnostic tool. Further, the findings suggest that the early immigrating lymphocytes may have been primed at a site remote from the glands before arriving via the blood to the gland tissue.

Prevalence of Sjogren's syndrome in ambulatory patients according to the American-European Consensus Group criteria

OBJECTIVE

To estimate the prevalence of Sjögren's syndrome (SS) in ambulatory patients attending a tertiary care centre, according to the American-European Consensus Group criteria, using a structured approach.

METHODS

Three hundred patients from rheumatology and internal medicine clinics were randomly chosen. During the screening phase, a face-to-face interview, a screening questionnaire, a Schirmer-I test and a wafer test were carried out in all patients. During the second phase, patients with positive screening had confirmatory tests including fluorescein staining test, non-stimulated whole salivary flow and autoantibody testing. Confirmatory tests were also done in 13 patients with negative screening. In the last phase, lip biopsy was proposed to those patients who met pre-established criteria.

RESULTS

Females constituted 79% of the study population. The mean age of the subjects was 42.8+/-15.7 yr. Two hundred and twenty patients (73%) had positive screening. Fifty-five (27%) out of 204 patients evaluated showed keratoconjunctivitis sicca and 28 (13%) out of 215 patients xerostomia. One hundred and sixty-eight patients met criteria for lip biopsy and it was performed in 80 subjects who accepted the procedure. Focal sialoadenitis was demonstrated in 39 patients (49%), but only 28 of them met criteria for SS. In total, 40 patients were classified as SS. The minimum prevalence of SS in the population studied was 13.3% (95% CI 9.5-17.1%). The structured approach used in this study allowed 24 (60%) undiagnosed cases of SS to be identified.

CONCLUSION

SS is common among ambulatory patients attending a tertiary care centre and in most of them it is undiagnosed.

Histopathological investigation of salivary glands in the asymptomatic elderly

The significance of labial gland biopsies (LGBs) in the diagnosis of Sjögren's syndrome (SS) in the elderly has been a controversial subject since it is complicated by age-related histopathological changes. In an attempt to clarify the appropriateness of LGBs in present diagnosis criteria, we evaluated the specificity of LGBs using autopsied tissues. This was done by taking labial, sublingual and submandibular salivary glands from 53 autopsy subjects (24 males and 29 females) with an average age of 84 years, and testing them histopathologically with reference to a previously reported grading system. None had any sicca symptoms (oral dryness or dry eye). In subjects up to 75 years old, acinar atrophy was more frequent in labial glands than in the two major salivary glands (P=0.0098 for sublingual and P=0.0009 for submandibular glands). Also, while there were significant differences in frequency of such atrophy between the sublingual and submandibular salivary glands of subjects younger and older than 75, the labial glands showed no such variation. Taking grade 3 (focus score of 1) as the diagnosis criterion, two subjects were determined to have SS in which case the specificity was 95%. Using contemporaneous serological test results for anti-SSA/Ro antibodies as a diagnostic criterion raised specificity to 98%. For both major and minor glands, these appeared to be no relationship between degree of lymphocytic infiltration and age. Our results thus suggest that it is appropriate to adopt a focus score of 1 as a diagnostic criterion for SS in the elderly, and that serological test results can improve specificity.

Manometric assessment of esophageal motility in patients with primary Sjögren's syndrome

OBJECTIVE

The aim of this study was to assess the esophageal motility by manometry in patients with primary Sjögren's syndrome.

METHODS

Esophageal manometry was carried out in 40 patients with primary Sjögren's syndrome (SS), 15 with rheumatoid arthritis (RA), 15 with RA and secondary SS, and 21 healthy volunteers.

RESULTS

We found that the mean lower esophageal sphincter (LES) pressures measured by station pull-through and rapid pull-through techniques were significantly higher in primary SS patients than with healthy controls and RA patients with or without SS (P<0.05). Our study did not show any major differences when comparing the three patient groups (P>0.05). However, peristaltic contraction velocity was lower and peristaltic contraction duration significantly higher at the middle and lower thirds of the esophagus in primary SS patients than in healthy controls (P<0.05).

CONCLUSION

The results of our study support the view that various esophageal motility disorders can be found in patients with primary SS which could be related to an increase in LES pressure. We also found no correlation of the esophageal abnormalities with other factors studied, suggesting that the cause of dysphagia is multifactorial in nature.

The oral component of Sjögren's syndrome: pass the scalpel and check the water

The labial salivary gland biopsy is a diagnostic test for the oral component of Sjögren's syndrome (SS) that has been the subject of controversy and re-examination for many years. Despite multiple recent challenges to the significance of this test, when correctly done, it remains one of the most informative, specific, and technically simple tests available for the oral component of SS. Because of compromised salivary gland function, patients with SS are at risk for dental caries. Within the past decade, a paradigm shift has occurred within the field of caries research. The caries process was previously thought irreversible once initiated. Research has shown that the "early" carious lesion can be remineralized. Thus, the "early" carious lesion may be prevented and even repaired. The process of remineralization requires appropriate conditions to occur, and one of those conditions is pH. Because water is often the preferred wetting agent/beverage for patients with SS, the data show that, with regard to pH, not all waters are created equal.

Quantitative ultrasonography and magnetic resonance imaging of the parotid gland: can they replace the histopathologic studies in patients with Sjogren’s syndrome?

OBJECTIVE

To assess the diagnostic value of parotid gland quantitative assessment using ultrasound (US) as well as magnetic resonance imaging (MRI) in patients with Sjogren's syndrome (SS) and to evaluate the possibility of using such modalities as a predictor of the histopathologic score of salivary gland biopsy in this group of patients.

METHODS

Sonographic and MRI studies were performed on the parotid glands of 47 patients diagnosed to have primary SS, 20 healthy control subjects of matched sex and age, and 20 subjects with sicca symptoms but without any evidence of SS. The patients and the control subjects were scored according to the structural changes seen in both radiologic modalities. In addition, sialography and labial gland biopsy were done for all patients as well as the control subjects and scored according to the degree of affection.

RESULTS

Parenchymal inhomogenity (PIH) was seen in 93.6% of the patients studied by US, while nodular pattern was seen in 97.8% in the MRI study. The US and MRI results correlated significantly with the histopathologic score of the minor salivary glands (r = 0.82, 0.84, respectively) as well as sialography score (r = 0.69, 0.60, respectively). There was good agreement between US and MRI findings (r = 0.87) in both SS cases and control subjects.

CONCLUSION

US and MRI are equally sensitive tools for the diagnosis of salivary involvement in patients with SS. Quantitative assessment of US and MRI images seem to represent an advance in the diagnosis of SS as they offer a good prediction of the pathology score of the salivary gland. MRI seems unnecessary as a routine diagnostic tool and should be considered as the second option in case of normal US.

Salivary gland disease in HIV/AIDS and primary Sjögren's syndrome: analysis of collagen I distribution and histopathology in American and African patients

BACKGROUND

Salivary gland disease (SGD) in HIV/AIDS is clinically and histopathologically very similar to Sjögren's Syndrome (SS), although the mechanism of tissue damage is unknown. The aim of this study is to determine the prevalence of SGD in primary SS and in HIV/AIDS in USA and in West African patients, and to seek distinguishing histopathologic features that may help to elucidate underlying mechanisms.

METHODS

Histologic sections of minor salivary glands from 164 HIV-positive and -negative patients from Cameroon and the US, and from 17 US patients with primary SS, were evaluated following salivary gland biopsy for inflammatory changes. To confirm the presence of fibrosis, collagen I, which is the most abundant collagen type, was assessed immunohistochemically in H&E-stained sections.

RESULTS

Forty-eight per cent of patients with HIV from Cameroon had severe SGD, while it was only in 6% of patients from the US. Patients with HIV in the US had less fibrosis and collagen I deposits than Cameroonians. Seventy-six per cent of US HIV-positive patients had received anti-retroviral therapy, while none of the African patients had. SS and AIDS patients had a tendency for lymphocytes to locate in a perivascular rather than in a periductal distribution.

CONCLUSIONS

The prevalence of SGD and the presence of fibrosis and collagen I in Cameroonians with HIV is significantly higher than in HIV-positive American patients, and is similar to US patients with primary SS. The impact of patient selection, anti-retroviral therapy, and pathogenic mechanisms on salivary gland pathology is discussed.

Enhanced degradation of proteins of the basal lamina and stroma by matrix metalloproteinases from the salivary glands of Sjögren's syndrome patients: correlation with reduced structural integrity of acini and ducts

OBJECTIVE

To determine the effect of matrix metalloproteinase (MMP) activity from the labial salivary glands (LSGs) of Sjögren's syndrome (SS) patients on proteins of the extracellular matrix (ECM) that form the basal lamina and stroma, and to compare this effect with the structural integrity of acini and ducts as well as the functionality of the LSGs.

METHODS

Gelatinase activity was determined by zymography. The digestion pattern of extracellular matrix (ECM) macromolecules was detected by gel electrophoresis and quantified by densitometry. The structural integrity of acini and ducts was evaluated by light and electron microscopy. Secretory function was evaluated by measuring unstimulated salivary flow and by scintigraphy.

RESULTS

LSG extracts showed increased levels of proteolytic activity toward purified proteins of the basal lamina (laminin and type IV collagen) and stroma (types I and III collagen and fibronectin). Enhanced degradation was most evident for fibronectin, laminin, and type IV collagen. Analysis of the ultrastructure of the acinar and ductal basal lamina revealed abnormalities ranging from disorganization to disappearance of this ECM structure. These changes were paralleled by an important loss of microvilli on the apical surface, as well as decreased unstimulated salivary flow. Interestingly, the results were similar in LSGs from all SS patients, regardless of the proximity of infiltrating mononuclear cell foci.

CONCLUSION

Our observation that the proteolytic action of MMPs toward ECM macromolecules is increased in SS patients provides a rationale for understanding the dramatic changes in the structural organization observed in the basal lamina and apical surface of acini in these patients. The results provide new evidence that acinar and ductal cells from the LSGs of SS patients display a molecular potential, with increased capacity to markedly disorganize their ECM environment and, thus, damage their architecture and functionality.

Histopathological analysis and demonstration of EBV and HIV p-24 antigen but not CMV expression in labial minor salivary glands of HIV patients affected by diffuse infiltrative lymphocytosis syndrome

BACKGROUND

The diffuse infiltrative lymphocytosis syndrome (DILS) in HIV patients is characterized by the persistence of CD8-circulating lymphocytes and lymphocytic infiltration, predominantly in salivary glands.

METHODS

We examined seven HIV-positive patients with bilateral parotid enlargement and sicca symptoms. Minor labial salivary gland biopsies were performed in all patients and submitted for histopathological analysis and immunohistochemistry for CD4, CD8, cytomegalovirus (CMV), LMP-EBV protein, and HIV p-24 protein.

RESULTS

In all cases, lymphocytic infiltration of the minor salivary glands, mainly periductal, was found. Acinar atrophy, ductal ectasia, and mild to moderate fibrosis were also observed. We noticed strong immunohistochemical reaction for LMP-EBV and p-24 proteins in ductal cells in all cases, while staining for CMV was consistently negative. The lymphocytes were positive for CD8, but consistently negative for CD4.

CONCLUSIONS

A role of Epstein-Barr virus (EBV) and HIV, but not CMV, in the pathogenesis of DILS, is suggested by our immunohistochemical findings.

The diagnostic applications of saliva--a review

This review examines the diagnostic application of saliva for systemic diseases. As a diagnostic fluid, saliva offers distinctive advantages over serum because it can be collected non-invasively by individuals with modest training. Furthermore, saliva may provide a cost-effective approach for the screening of large populations. Gland-specific saliva can be used for diagnosis of pathology specific to one of the major salivary glands. Whole saliva, however, is most frequently used for diagnosis of systemic diseases, since it is readily collected and contains serum constituents. These constituents are derived from the local vasculature of the salivary glands and also reach the oral cavity via the flow of gingival fluid. Analysis of saliva may be useful for the diagnosis of hereditary disorders, autoimmune diseases, malignant and infectious diseases, and endocrine disorders, as well as in the assessment of therapeutic levels of drugs and the monitoring of illicit drug use.

Clinical and imaging findings of lymphoma in patients with Sjögren syndrome

OBJECTIVE

To describe and correlate the clinical and imaging findings of lymphomas in patients with Sjögren syndrome.

METHODS

The authors reviewed the medical and imaging records of 27 cases of lymphoma from among a total of 463 patients with Sjögren syndrome. The estimated prevalence of lymphoma in patients with Sjögren syndrome was 5.8%. There were 22 women and 5 men. Histopathologically, 26 of the 27 neoplasms were non-Hodgkin lymphoma, including 6 mucosa-associated lymphoid tissue lymphomas, and the other neoplasm was Hodgkin lymphoma. The clinical and imaging findings of lymphomas were analyzed.

RESULTS

No obvious correlations were present between the duration or severity of Sjögren syndrome and the lymphoma development. At the initial diagnosis, extranodal involvement was observed in 14 (52%) of the 27 patients, including the salivary gland (n = 9), lacrimal gland (n = 2), lung (n = 2), and thyroid gland (n = 1), mostly in the neck organs. On the other hand, nodal involvement was observed in 21 (78%) of the 27 patients. Of these 21 patients, 19 had at least cervical lymph node involvement.

CONCLUSION

Patients with Sjögren syndrome are at increased risk of lymphoma development. Because most lymphomas initially involve the neck organs, including the lymph nodes, meticulous imaging studies mainly focused on the cervical regions are recommended in the follow-up of patients with Sjögren syndrome.

An anatomical study of the cutaneous branches of the mental nerve

Minor surgical procedures to the inner (mucosal) aspect of the lower lip may occasionally cause numbness of the overlying skin. This study was designed to find, by means of dissection and computerized three-dimensional reconstruction, why surgical interference with nerve fibres in the deep aspect of the lip can cause neurological deficit in the superficial layers. Thirteen cadaveric lips were examined by dissection under a surgical microscope (9 lips) or serial sectioning and computerized three-dimensional reconstruction (4 lips). Muscle mass, minor labial salivary glands and nerve fibres were identified and traced. Three patterns of mental nerve distribution were seen on dissection and two on computerized reconstruction; these latter corresponded to two of the patterns seen on dissection. Fibres passing close to the labial minor salivary gland mass were seen to travel towards the superficial aspect of the lip, terminating in the dermis. It is clear that there is no safe anatomical space for minor surgical procedures to the inner (mucosal) aspect of the lower lip if avoidance of cutaneous numbness is an important consideration. However, we describe a technique that may minimize the possibility of cutaneous numbness.

Decreased salivary gland function in patients with autoimmune thyroiditis

BACKGROUND/AIMS

It has been speculated that impaired salivary flow contributes to autoimmune thyroiditis (chronic thyroiditis, Hashimoto's thyroiditis). To test this hypothesis, salivary function was measured by quantitative salivary scintigraphy in autoimmune thyroiditis patients, as well as in age- and gender-matched controls for comparison.

METHODOLOGY

One hundred and twenty patients with an autoimmune thyroiditis history of more than 10 years each and 36 healthy controls were enrolled in the study. All the 120 autoimmune thyroiditis patients had good blood sugar control. None had autonomic neuropathy. These 120 autoimmune thyroiditis patients were separated into two subgroups: group 1, 60 patients with xerostomia; and group 2, 60 patients without xerostomia. After intravenous injection of 5 mCi Tc-99m pertechnetate, sequential images at 1 min/frame were acquired for 30 min. The first- and 15th-minute uptake ratios (UR) were calculated from the tracer uptakes in the four major salivary glands over the background regions of interest (ROIs). Saliva excretion was stimulated by 1 tablet of 200 mg ascorbic acid given orally 15 min after injection of the tracer. Then, the maximal excretion ratios (ER) of the four major salivary glands after sialagogue stimulation were calculated.

RESULTS

Impaired salivary function, represented by significantly decreased UR and ER values, in autoimmune thyroiditis patients with xerostomia was demonstrated in this study. In addition, there was a significantly higher prevalence of salivary gland dysfunction in group 1 patients than in group 2 patients.

CONCLUSIONS

Significantly poorer salivary function was found in autoimmune thyroiditis patients with xerostomia compared with autoimmune thyroiditis patients without xerostomia and healthy controls by means of objective and quantitative salivary scintigraphy.

Do autoantibodies predict autoimmune liver disease in primary Sjögren's syndrome? Data of 180 patients upon a 5 year follow-up

OBJECTIVE

To evaluate the clinical value of autoantibodies as serological markers to predict autoimmune liver diseases in primary Sjögren's syndrome (SS).

MATERIALS AND METHODS

180 patients who met the European diagnostic criteria for SS but without a history of liver disease were studied upon a 5 year follow-up. Sera taken at enrolment were evaluated by immunofluorescence analysis (IF-AMA) on rat liver, stomach and kidney sections, enzyme-linked immunosorbent assay using rat mitochondrial, microsomal and soluble liver antigens and Western blot (WB) analysis using rat mitochondrial antigens.

RESULTS

At presentation, 152 (84%) sera had autoantibodies. Antinuclear antibodies (ANA) were expressed in 58% of patients and displayed three distinct patterns (speckled, homogenous and anticentromere). Smooth muscle autoantibodies (SMAs) and parietal cell autoantibodies were found in 39 and 4.5% of patients, respectively. Three patients presented antimitochondrial antibodies by IF-AMA, and two of them developed symptomatic primary biliary cirrhosis (PBC). Two patients without IF-AMA and without evidence of cholestasis had PBC-specific AMA (anti-PDC-E2 and anti-BCKADC-E2). However, these two patients and the third IF-AMA-positive woman remained free from symptoms and biochemical signs of PBC. Autoimmune hepatitis (AIH) (n = 2), 'overlap syndrome' of AIH and chronic hepatitis C (n = 1) and autoimmune cholangiopathy (AIC) (n = 1) were diagnosed in four patients.

CONCLUSIONS

Patients with IF-AMA usually develop symptomatic PBC upon a 5 year follow-up. Our findings support the idea that patients without IF-AMA, who express PBC-specific AMA, are in early, asymptomatic stage of the disease. High-titre SMA and IF-AMA are the most specific indicators for AIH and PBC.

[Diagnosis of the Mikulicz-Sjogren syndrome using biopsy of the minor salivary glands]

BACKGROUND

Sjögren's syndrome (SS) represents autoimmune disease characterized by chronic inflammation, destruction and insufficiency of exocrine glands, particularly salivary and lacrimal glands, accompanied by dryness of mouths and eyes. Diagnostic work-up involves clinical laboratory tests, radiography, scintigraphy and bioptic histopathological examination. Examination of small salivary glands in the biopsy of the lower lip represents a "golden standard" of diagnosis of SS, concerning the fact that the growth and the disfunction of salivary and lacrimal glands occurs in different pathologic states.

METHODS

Resected specimens of the lower lip were obtained from 47 patients with clinical diagnosis of SS. After standard histopathological treatment, slices were hematoxylin and eosin stained. Immunohistochemistry against smooth muscle actin was performed using LSAB+ method (AHSMA-M7558, DAKO 1:50). On the basis of generally accepted histopathological diagnostic criteria the results were categorized as: findings suspicious for SS; findings compatible with the diagnosis of SS (mild, moderate and high degree of inflammation); nonspecific inflammatory reaction and nonrepresentative biopsy samples.

RESULTS

Diagnosis of SS was confirmed in 32% of cases. In 2% of cases findings were suspected for SS, in 36% of cases findings were compatible with the diagnosis of nonspecific inflammation, and in 30% of cases material was not representative.

CONCLUSIONS

By the biopsy of salivary glands of the lower lip the diagnosis of SS was confirmed in 50-60% of cases. Upon the precise diagnostic criteria it was also possible to determine the intensity of inflammation and tissue destruction in SS and identify other pathological conditions, which justified the biopsy. Surgical technique had to be adequate in order to obtain representative number of small salivary glands. In the presented material 30% of specimens were nonrepresentative which was very high percentage compared with literature data. This was most probably the reason why the diagnosis of SS was confirmed in only 32% of cases, i.e., in every third patient.

Prevalence and clinical significance of lymphocytic foci in minor salivary glands of healthy volunteers

OBJECTIVE

To determine the prevalence and severity of focal lymphocytic sialadenitis in minor salivary glands of healthy, asymptomatic individuals, in whom Sjögren's syndrome (SS) has been excluded.

METHODS

Charts of 54 healthy volunteers who had salivary gland biopsies at the National Institutes of Health from January 1992 to August 1998 were reviewed. The healthy volunteers served as control subjects in various studies of salivary dysfunction. Significant medical conditions including SS were excluded. A biopsy with a focus score (FS) >1 was regarded as positive. Descriptive statistics were used to summarize the population's characteristics.

RESULTS

The frequency of focal lymphocytic infiltration in the healthy volunteers was about 15% (8 of 54). None of these individuals had subjective xerostomia or dry eyes. The positive FS ranged from 2 to 6. FS did not correlate with age, smoking, serologic findings, or salivary flow in these patients.

CONCLUSION

Lymphocytic infiltration in minor salivary glands is not uncommon among individuals without a history of salivary gland dysfunction. This finding is in agreement with the result of a previous autopsy survey study, indicating that focal sialadenitis may occur in the absence of SS.

Use of the dry eye questionnaire to measure symptoms of ocular irritation in patients with aqueous tear deficient dry eye

PURPOSE

To demonstrate the ability of the Dry Eye Questionnaire (DEQ) to characterize the frequency of ocular surface symptoms and their diurnal intensity in patients with Sjögren's syndrome (SS), keratoconjunctivitis sicca (KCS), and age-matched controls.

METHODS

One hundred patients with tear-deficient dry eye from Toronto Western Hospital were mailed the DEQ and the McMonnies' questionnaire (MQ). Age- and gender-matched controls were selected from an historical data set. The DEQ measured the habitual frequency, intensity, and impact of common ocular surface symptoms and asked questions about computer use, medications, and allergies.

RESULTS

Sixty-two dry eye subjects responded; 30 with SS and 32 with KCS. Compared with controls, SS subjects consistently reported the highest frequency and intensity of symptoms, followed by non-KCS subjects. The intensity of symptoms was significantly greater in the evening than in the morning among SS subjects for all symptoms except dryness and light sensitivity (p < 0.05). Sixty percent of SS subjects reported the need to stop daily activities and close their eyes due to dryness, burning, and light sensitivity.

CONCLUSIONS

Symptoms of ocular irritation were frequent and intense among SS and KCS subjects. These symptoms often increased in intensity over the day, suggesting that open-eye conditions affect the progression of symptoms. Measurement of symptom frequency and diurnal intensity by the DEQ provides a sensitive tool that may be useful in clinical treatment trials for dry eye.

Objective evidence of decreased salivary function in patients with autoimmune thyroiditis (chronic thyroiditis, Hashimoto's thyroiditis)

Impaired salivary flow is found in Sjögren's syndrome, which is a common, chronic, autoimmune, inflammatory connective tissue disease, mainly affecting the exocrine glands. Histopathologically, lymphocytic infiltrations of the salivary glands are found in Sjögren's syndrome that are similar to those of the thyroid gland in autoimmune thyroiditis (chronic thyroiditis, Hashimoto's thyroiditis). To test this hypothesis by Daniels et al ., salivary function was measured by quantitative salivary scintigraphy in autoimmune thyroiditis patients, as well as in age- and sex-matched controls. Forty patients, each with a history of autoimmune thyroiditis of over 10 years, and 61 healthy controls were enrolled in the study. All of the 40 autoimmune thyroiditis patients had good blood sugar control. None presented autonomic neuropathy. They were separated into two subgroups: patient group 1, 20 patients with xerostomia; patient group 2, 20 patients without xerostomia. Two control groups of healthy subjects were included for comparison: control group 1, 36 subjects without xerostomia; control group 2, 25 subjects with xerostomia. After intravenous injection of 5 mCi (99m)Tc-pertechnetate, sequential images at 1 min per frame were acquired for 30 min. The first and 15th minute uptake ratios (URs) were calculated from the tracer uptakes in the four major salivary glands relative to the background regions of interest (ROIs). Saliva excretion was stimulated by one tablet of 200 mg ascorbic acid given orally 15 min after injection of the tracer. The maximal excretion ratios (ERs) of the four major salivary glands after sialagogue stimulation were calculated. Impaired salivary function, represented by significantly decreased UR and ER values, in autoimmune thyroiditis patients with xerostomia was demonstrated in this study. Significantly poorer salivary function was found in autoimmune thyroiditis patients with xerostomia, when compared with autoimmune thyroiditis patients without xerostomia and healthy controls with or without xerostomia, via objective and quantitative salivary scintigraphy. However, a larger series of autoimmune thyroiditis patients is necessary to confirm our findings.

Suppression of tumor necrosis factor alpha-induced matrix metalloproteinase 9 production in human salivary gland acinar cells by cepharanthine occurs via down-regulation of nuclear factor kappaB: a possible therapeutic agent for preventing the destruction of the acinar structure in the salivary glands of Sjögren's syndrome patients

OBJECTIVE

Our previous results suggested that suppression of tumor necrosis factor alpha (TNFalpha)-induced matrix metalloproteinase 9 (MMP-9) could prevent the destruction of acinar tissue in the salivary glands of patients with Sjögren's syndrome (SS). The present study was undertaken to investigate the effect of cepharanthine on the suppression of TNFalpha-induced MMP-9 production in NS-SV-AC, an SV40-immortalized normal human acinar cell clone.

METHODS

After pretreatment with or without cepharanthine, NS-SV-AC cells were treated with TNFalpha alone or with a combination of TNFalpha and cepharanthine. The expression of MMP-9 was then examined at the protein and messenger RNA levels. In addition, the effect of cepharanthine on the morphogenetic behavior of NS-SV-AC cells cultured on type IV collagen-coated dishes in the presence of TNFalpha was examined.

RESULTS

Although TNFalpha induced the production of MMP-9 in NS-SV-AC cells, this production was greatly suppressed when cells were pretreated with cepharanthine, followed by treatment with both TNFalpha and cepharanthine. In addition, cepharanthine suppressed the TNFalpha-stimulated NF-kappaB activity by partly preventing the degradation of IkappaBalpha protein in NS-SV-AC cells. When NS-SV-AC cells were seeded on type IV collagen-coated dishes in the presence of both TNFalpha and plasmin, type IV collagen interaction with the cells was lost and the cells entered apoptosis. However, pretreatment with cepharanthine restored the aberrant in vitro morphogenesis of the NS-SV-AC cells.

CONCLUSION

These results may indicate a molecular mechanism by which cepharanthine is able to protect against the destruction of the acinar structure in salivary glands from patients with SS.

Current issues in Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune and rheumatic disorder with prominent sicca complaints from the mucous membranes because of lack of proper exocrine secretions. There is no straightforward and simple diagnostic test for Sjögren's syndrome, although several classification criteria have been designed including several oral diagnostic tests. A new set of classification criteria in a joint effort by research groups in Europe and USA has recently been presented. A large number of autoantibodies have been reported in Sjögren's syndrome where, in some cases, the antibodies are correlated with the extent and severity of disease. The finding of serum autoantibodies directed against the muscarinic M3 receptor is an important advance in understanding the pathogenesis of not only the impaired glandular function but also associated features of autonomic dysfunction in some patients. The treatment of primary Sjögren's syndrome is still mainly symptomatic.

Risk factors for positive minor salivary gland biopsy findings in Sjögren's syndrome and dry mouth patients

OBJECTIVE

To investigate risk factors for positive minor salivary gland biopsy results in Sjögren's syndrome (SS) and dry mouth patients.

METHODS

A total of 289 patients with dry mouth symptoms were evaluated. Potential risk factors for positive minor salivary gland biopsy results (>1 focus of lymphocytes) were studied in 2 phases. In phase 1, predictor variable candidates were identified for the test study (phase 2). Odds ratios were calculated for predictor variables.

RESULTS

IgG, IgA, keratoconjunctivitis sicca, and sex, identified as the best predictor variables from phase 1 data, were included in a logistic regression model using phase 2 data. Only IgG demonstrated association with biopsy results (chi(2) = 20.4, P = 0.0001). An elevated IgG level (>1,482 mg/dl) had a high specificity (97% and 97%), high positive predictive value (PPV) (97% and 97%), but poor sensitivity (40% and 45%) in predicting positive biopsy results and SS, respectively.

CONCLUSION

Elevated serum IgG levels best predicted a positive biopsy result and SS with high PPV and specificities.

Agranulocytosis in Sjögren's syndrome: two case reports and analysis of 11 additional reported cases

OBJECTIVES

To report 2 patients who presented with agranulocytosis that was found to be immune-mediated and associated with occult primary Sjögren's syndrome (primary SS) and to identify and study similar cases reported in the literature.

METHODS

Two patients encountered in 2 large medical centers over a period of 5 years were studied in detail. All reported cases of agranulocytosis in primary SS identified through a MEDLINE search were reviewed.

RESULTS

Two patients presented with marked systemic symptoms alone or associated with recurrent infections. Agranulocytosis with either a pattern of maturation arrest or a hypercellular reactive bone marrow was found and was associated with "acute phase" markers, hypergammaglobulinemia, a small paraprotein peak, and high rheumatoid factor titers. A diagnosis of immune-mediated agranulocytosis associated with an occult primary SS was established and was successfully treated with intravenous immunoglobulins or prednisone. Both patients subsequently developed skin vasculitis. This rare association of agranulocytosis and Sjögren's syndrome was identified in 11 other cases and was the presenting manifestation of primary SS in 10 of 13 (77%) patients.

CONCLUSIONS

Agranulocytosis should be recognized as a rare but well-established association of primary SS. Bone marrow neutrophil production may be affected, or neutrophils may be destroyed in the circulation, by both humoral and cellular immune-mediated mechanisms. Agranulocytosis or neutropenia should be added to the varied hematologic manifestations of primary SS and may be its presenting feature and an important clue to diagnosis.

[Primary Gougerot-Sjögren syndrome in a 13-year-old girl]

Sjögren's syndrome is uncommon in children, and occurs most often in association with autoimmune diseases (secondary Sjögren's syndrome). We describe the clinical and biological features of a 13-year-old girl with primary Sjögren's syndrome, revealed by recurrent parotitis.

CASE REPORT

This adolescent girl was referred for investigation of multiple episodes of bilateral parotid swelling since age nine, without systemic symptoms. Examination was unremarkable except for enlarged and painless parotid glands. Laboratory investigations, measurement of saliva production, parotid sialography, labial salivary gland biopsy, revealed Sjögren's syndrome without associated disease. Hydroxychloroquine was prescribed with clinical improvement.

CONCLUSION

Recurrent parotitis in children is an uncommon condition. The onset of parotid swelling at five years or over deserves screening for dysimmune disorders, sarcoidosis or Sjögren's syndrome. Diagnosis of Sjögren's syndrome is based on laboratory evidence of autoimmune disorders and minor salivary gland biopsy.

Minor Salivary Gland Punch Biopsy for Evaluation of Sjögren’s Syndrome

Incisional biopsy of labial salivary glands has been a valuable technique for diagnosis of Sjögren's syndrome. This report describes a new technique using punch biopsies that requires fewer resources and appears to be equally effective. Fifty patients evaluated by punch biopsy all yielded adequate pieces averaging 6 glands per specimen. Two patients had transient numbness of the lip. There were no other complications. Classical findings of Sjögren's histopathology were demonstrable with these specimens. This technique is safe, less expensive, and is proposed as a reliable alternative to incisional biopsy.

Use of muscarinic agonists in the treatment of Sjögren's syndrome

Two muscarinic agonists (pilocarpine and cevimeline) have recently been approved for the treatment of symptoms of xerostomia in Sjögren's syndrome (SS). These agents stimulate the M1 and M3 receptors present on salivary glands, leading to increased secretory function. The use of these agents emphasizes the importance of neuroendocrine mechanisms in SS, which is considered an autoimmune disorder. We review recent studies on the release of cytokines and metalloproteinases in SS-affected glands and their influence on the release of and response to neurotransmitters. Also, we review the structure and function of muscarinic receptors as they may relate to SS and the potential use of novel muscarinic agonists in SS.

Magnetic resonance imaging and magnetic resonance sialography of parotid glands in primary Sjogren's syndrome

OBJECTIVE

To look for structural parotid gland changes on magnetic resonance (MR) imaging and MR sialography of primary Sjögren's syndrome (SS) patients and healthy control subjects and to compare these methods with each other.

METHODS

MR imaging and MR sialography of both parotid glands were performed on 26 patients and 7 healthy controls. Bilateral surface coils were used to obtain high spatial resolution.

RESULTS

Twenty-two of the 26 patients had abnormalities on MR imaging. Twenty-one had a nodular or dendritic parenchymal pattern, 5 had cavities, and 6 had duct dilatations. On MR sialography, 25 of the 26 patients had abnormalities of the ducts, and 16 of them also had cavities. One patient and all 7 controls had normal results with both methods. The structural appearance of the parotid glands on MR images had marginal linear association with the duct system changes but no correlation with the cavitary changes seen on MR sialography. Furthermore, duct system abnormalities did not correlate with cavitary changes. Both parenchymal and sialographic abnormalities were associated with the presence of Ro/SSA antibodies but not with age of the patient, disease duration, salivary flow rate, or the presence of hypergammaglobulinemia or extraglandular manifestations.

CONCLUSION

MR imaging and MR sialography are noninvasive methods that provide definitive information of morphologic changes in parotid glands and can be used as diagnostic indicators of primary SS. Because these methods give information on different aspects of glandular pathology, both should be performed when evaluating parotid glands of SS patients. MR sialography is more sensitive, but conventional MR imaging gives complementary information on the progressive pathologic changes of glandular parenchyma.

Focal sialadenitis in patients with ankylosing spondylitis and spondyloarthropathy: a comparison with patients with rheumatoid arthritis or mixed connective tissue disease

OBJECTIVES

To investigate the occurrence of and risk factors for focal sialadenitis in patients with rheumatoid arthritis (RA), mixed connective tissue disease (MCTD), ankylosing spondylitis (AS), and spondyloarthropathy (SpA).

METHODS

A total of 85 patients (25 with RA, 19 with MCTD, 19 with AS, 22 with SpA) participated in the study. Each patient filled out a questionnaire for eye and oral symptoms and for the use of medication, and was interviewed; other tests included Schirmer's test, laboratory tests, collection of unstimulated and stimulated whole saliva, and minor salivary gland biopsy. A focus score of > or =1 was regarded as an indicator of focal sialadenitis.

RESULTS

Focal sialadenitis was observed in 68% (57/84) of all patients. It affected 80% (20/25) of the patients with RA, 94% (17/18) of those with MCTD, 58% (11/19) of those with AS, and 41% (9/22) of those with SpA (chi(2) test, p=0.0013). Salivary secretion correlated negatively with the focus scores-that is, severity of focal sialadenitis. Patients with focal sialadenitis had both decreased salivary secretion and decreased tear secretion significantly more often than did patients without (chi(2) test, p=0.0074 and p=0.048 respectively). Patients with positive rheumatoid factor (RF), antinuclear antibodies (ANA), or SSA or SSB antibodies had sialadenitis significantly more often than did patients with negative antibodies. In the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and the presence of these antibodies.

CONCLUSION

In addition to patients with RA or MCTD, focal sialadenitis also affects a very high proportion of patients with AS or SpA. Focus scores are significantly higher in patients with RA or MCTD than in those with AS or SpA. A significant association exists between focal sialadenitis and RF, ANA, SSA and SSB. However, in the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and serological markers or clinical symptoms.

Acetylcholine-evoked calcium mobilization and ion channel activation in human labial gland acinar cells from patients with primary Sjögren's syndrome

Recent evidence has indicated that the salivary gland dysfunction associated with Sjögren's syndrome (SjS) is not necessarily due to immune-mediated destruction of acinar tissue. SjS sufferers may possess substantial reserves of acinar tissue but nevertheless be incapable of maintaining salivary flow rates in the normal range. We have investigated the ability of isolated labial gland acinar cells from SjS patients to fluid secrete by measuring agonist-evoked changes in intracellular Ca(2+) ([Ca(2+)](i)) using fura-2 microfluorimetry and activation of K(+) and Cl(-) channels using the patch-clamp whole cell technique. We can confirm that stimulation with a super-maximal dose of acetylcholine (ACh) increased [Ca(2+)]i equally in both control acinar cells and those derived from SjS patients. However, at submaximal concentrations, the dose-response curve for ACh was shifted to the right by approximately one order of magnitude in acinar cells from SjS patients compared to control acinar cells. Patch-clamp measurements consistent with the presence of Ca(2+)-activated K(+) and Cl(-) conductances were obtained from both control acinar cells and those obtained from SjS patients. Dose-dependent activation of the ion channels by acetylcholine was also right-shifted in acinar cells from SjS patients compared to control cells. Our data show that labial gland acinar cells from SjS patients were capable of responding to agonist stimulation by mobilizing [Ca(2+)](i) and activating K(+) and Cl(-) channels consistent with the requirements of fluid secretion. However, the persistent loss of sensitivity to ACh observed in from SjS patients may account for the lack of saliva production observed in these patients in vivo.

Possible involvement of EBV-mediated alpha-fodrin cleavage for organ-specific autoantigen in Sjogren's syndrome

A cleavage product of alpha-fodrin may be an important organ-specific autoantigen in the pathogenesis of Sjogren's syndrome (SS), but the mechanisms of alpha-fodrin cleavage remain unclear. Since EBV has been implicated in the pathogenesis of SS, we determined whether EBV activation could induce the SS-specific 120-kDa autoantigen alpha-fodrin. ZEBRA mRNA expression, a marker for activation of the lytic cycle of EBV, was found in the salivary gland tissues from SS patients, but not in those from control individuals. ZEBRA-expressing lymphoid cells were also found in the SS glands in double-stained immunohistochemistry. Furthermore, a significant link between production of Abs against 120-kDa alpha-fodrin and reactivated EBV Ag was found in sera from patients with SS, but not in those from control individuals. EBV-activated lymphoid cells showed specific alpha-fodrin cleavage to the expected 120-kDa fragments in vitro. Pretreatment with caspase inhibitors inhibited cleavage of alpha-fodrin. Thus, an increase in apoptotic protease activities induced by EBV reactivation may be involved in the progression of alpha-fodrin proteolysis in the development of SS.

A comparative study between MR sialography and salivary gland scintigraphy in the diagnosis of Sjögren syndrome

PURPOSE

The purpose of this work was to compare the diagnostic accuracy of MR sialography with that of salivary gland scintigraphy in Sjögren syndrome.

METHOD

One hundred thirty patients clinically suspected of having Sjögren syndrome were examined by MR sialography and salivary gland scintigraphy. A labial gland biopsy was performed in all patients. Imaging findings of MR sialography and salivary gland scintigraphy were compared with the results of labial gland biopsy.

RESULTS

From the results of labial gland biopsy, the diagnosis of Sjögren syndrome was established in 80 patients. Abnormally high T2 signal intensity areas on MR sialography and decreased uptake and delayed excretion of [(99m)Tc]pertechnetate on salivary gland scintigraphy were well seen in patients with Sjögren syndrome. For the diagnosis of Sjögren syndrome, salivary gland scintigraphy showed higher sensitivity than MR sialography. On the other hand, MR sialography showed higher specificity and positive predictive value (PPV) than salivary gland scintigraphy. Overall diagnostic accuracy was 83% for MR sialography and 72% for salivary gland scintigraphy.

CONCLUSION

The high PPV of MR sialography suggests that MR sialography is the preferred imaging modality in patients suspected of having Sjögren syndrome.

A simple method to estimate the secretion of saliva from minor salivary glands using iodine-starch reaction

OBJECTIVE/HYPOTHESIS

This study was undertaken to detect the faculty of secretion of saliva from minor salivary glands by analyzing a color reaction on a test tape containing iodine and starch that was applied on the lower lip.

STUDY DESIGN

A study involving 63 patients with oral dryness, 7 patients with Sjogren syndrome, and 70 healthy individuals was performed.

METHODS

A test tape (1 x 1 cm) containing iodine and starch was set on the mucosal area anterior to the labia frenulum for 30 seconds. Because the number of blue spots was considered to correspond to the number of ostia of the salivary gland on the lower lip that was examined, the number of blue spots occurring as a reaction of iodine and starch on the test tape was counted and was compared among three groups. In addition, the relationship between the histopathological findings and the number of spots was analyzed.

RESULTS

The average number of spots in the patients with oral dryness (4.52+/-3.18 [mean +/- SD]) was lower than that in healthy individuals (9.49+/-2.52, P <.01), and that in the patients with Sjögren syndrome (2.14+/-1.35) was the lowest among all groups in the study. Moreover, this reduction in the number of spots in those patients was accompanied by histopathological changes of the minor salivary glands.

CONCLUSION

These findings suggest that this simple, noninvasive method can be successfully used for the estimation of the faculty of secretion of saliva from the minor salivary glands.

Fas-induced apoptosis is a rare event in Sjögren's syndrome

The aim of this study was to perform a controlled in situ analysis on the incidence of apoptosis, investigate the expression of apoptosis-mediating proteins, and determine the frequency of apoptotic CD4+ and CD8+ T cells in Sjögren's syndrome (SS). The study was extended to patients with atrophy-fibrosis (AF) not related to SS, as well as to a control group. Immunohistochemistry and the terminal deoxynucleotidyl transferase mediated dUTP digoxigenin nick end labeling (TUNEL) method were applied to study the Fas and FasL expression and the incidence of apoptosis in salivary glands (SG) from patients with primary and secondary SS, AF, and controls. These methods were also combined to enable simultaneous detection of apoptotic and CD4+ or CD8+ T cells. Despite abundant expression of Fas and FasL in SS SG, apoptotic cells were not exceeding 1% in the foci of infiltrating mononuclear cells (IMC). Double staining showed that the frequency of apoptosis was low among both CD4+ and CD8+ T cells. Only a few TUNEL+ epithelial cells were found in all patient groups. Fas was expressed predominantly on SS IMC, single SS epithelial cells, and a few normal acinar cells, but not in AF SG. Although FasL was present on SS and AF IMC and epithelial cells, it was rarely detected in normal tissue. Consequently we demonstrate that Fas-induced apoptosis among SS SG is a rare event. Our findings support an earlier hypothesis indicating that IMC seem to be able to escape apoptosis, resulting in foci of inflammatory cells. Notably, however, no obvious correlation can be drawn to previous studies where a high incidence of apoptosis of epithelial cells was proposed as an important mechanism leading to decreased glandular function, which is a hallmark of SS.

Xerostomia, xerophthalmia, and plasmacytic infiltrates of the salivary glands (Sjögren's-like syndrome) in a cat

A 2.5-year-old domestic shorthair cat was evaluated because of dysphagia and weight loss of 4 weeks' duration. MIld blepharospasm and conjunctival hyperemia were evident in both eyes, oral mucous membranes were tacky on palpation, and salivary glands were enlarged. Results of a Schirmer tear test were 0 mm/min for both eyes. Administration of atropine did not cause salivation or caused secretion fo thick rope-like saliva. Examination of biopsy specimens of salivary glands revealed a plasmacytic infiltrate. Sjögren's syndrome (SS) was diagnosed. Oral administration of prednisone was instituted but was discontinued after a minimal positive response was evident 6 weeks after initiation of treatment. Palliative treatment with a 6% solution of pilocarpine 4 to 5 times/d, cyclosporine, hylan A, and neomycin-polymyxin-bacitracin ophthalmic ointment resulted in clinical improvement in the cat. Although reported rarely in animals, SS may be more common than currently is recognized. Most treatment regimens for SS are aimed at alleviating clinical signs.

Characteristics of salivary diffuse infiltrative lymphocytosis syndrome in West Africa

OBJECTIVE

To determine the prevalence of diffuse infiltrative lymphocytosis syndrome (DILS) in the minor salivary glands of 30 African Cameroonian adults with the acquired immunodeficiency syndrome (AIDS).

DESIGN

Salivary gland tissue was analyzed using a modified classification system that was developed to aid the diagnosis of Sjögren syndrome. The advantages and disadvantages of this approach are discussed.

MATERIALS AND METHODS

Formalin-fixed, paraffin-embedded, hematoxylin-eosin-stained biopsy sections were prepared for 30 patients with AIDS, 26 healthy individuals who declined human immunodeficiency virus (HIV) testing, and 4 seronegative healthy controls. Tissues were immunostained for CD4/CD8+ lymphocytes and cytomegalovirus (CMV), and transmission electron microscopy was performed to locate viral particles. Patients were tested for HIV-1 and HIV-2 by the HIV/Chek System 3 or CAMSTIX-HIV-1 and HIV-2 assay.

RESULTS

Severe salivary ductal atypia (96%) was the feature most strongly associated with AIDS, and the lymphocytic focus score was the second histologic feature most strongly correlated with AIDS. Forty-eight percent of patients with HIV-1 infection had more than 1 lymphocytic focus in a minor salivary gland. These lymphocytes were primarily CD8+. We report, to the best of our knowledge, the first case of multinucleated salivary duct epithelial cells in minor salivary glands also containing enveloped virus particles. All cases were negative for CMV.

CONCLUSIONS

The prevalence of DILS in West Africans with AIDS appears higher than the prevalence reported in whites from the United States and Europe and in blacks from the United States, a group that has been reported to have a greater incidence of DILS than whites. This discrepancy may be related to differences in patient selection criteria. The determination of lymphocytic focus score, as used in the diagnosis of Sjögren syndrome, with the adjunct of ductal atypia is useful for assessing DILS. The impact of patient selection, drug therapy, and parasites on salivary gland pathology is discussed.

Leukocytes infiltrating the submandibular glands of NOD mice express E-cadherin

Sjögren's syndrome [SS] is typified by infiltration of mononuclear cells [MNC] into the salivary and lacrimal glands, although the biological role of these infiltrating cells remains unclear. We report here that E-cadherin, which mediates cell-cell adhesion and regulates differentiation, proliferation, and apoptosis of epithelial cells, is expressed ectopically by MNC in the salivary glands in the NOD mouse model of SS. Flow cytometric analysis of CD45(+)cells from NOD submandibular glands revealed that over 90% express E-cadherin. More detailed phenotypic analyses demonstrated that E-cadherin expression is high (>90%) among mature T cells (CD3(+)), B cells (CD19(+)), NK cells (DX5(+)), and monocyte/macrophages (CD11b(+)) within the infiltrates. Expression of other surface antigens, such as CD90 and CD117, above expected values suggests the presence of immature leukocytes, possibly of the T cell lineage, within the foci. We also present evidence that E-cadherin-expressing T cells in the glands do not exhibit normal proliferative responses to immobilized anti-CD3 antibody. While infiltrating MNC are not likely to be the direct cause of salivary hypofunction, the expression of E-cadherin by these cells may have implications for the progression of disease.

The changing spectrum of rheumatic disease in human immunodeficiency virus infection

CONTEXT

Although it has been known for over 15 years that a number of rheumatic diseases occur in patients with human immunodeficiency virus (HIV) infection, increasing knowledge about these disorders and advances in HIV treatment need to be considered in approaching patients with HIV-associated rheumatic disease.

OBJECTIVE

To examine the clinical, pathologic, and therapeutic features of HIV-associated rheumatic diseases in the context of what is known about the immunology of HIV infection.

DATA SOURCES

The author's own extensive collection of references, supplemented by PubMed Medline searches for articles in English-language journals published between 1985 and 2000. The indexing term HIV and the following coindexing terms were used for searching: arthritis, Reiter's syndrome, psoriatic arthritis, rheumatoid arthritis, osteonecrosis, vasculitis, pulmonary hypertension, myositis, myopathy, fibromyalgia, septic arthritis, parotid enlargement, diffuse infiltrative lymphocytosis syndrome, systemic lupus erythematosus, septic arthritis, mycobacterial arthritis, fungal arthritis, autoantibodies, anti-cardiolipin antibodies, and anti-neutrophilic cytoplasmic antibodies.

STUDY SELECTION

All papers identified in the literature search were reviewed. Studies presenting data that merely confirmed previous studies were not included in the analysis.

DATA EXTRACTION

All identified papers were abstracted by the author. Letters to the editor were included only if a new observation had been made.

DATA SYNTHESIS

This was a qualitative review of papers published, with new knowledge about these disorders summarized and presented.

RESULTS

Despite new treatments for HIV, reports of rheumatic diseases presenting in AIDS patients persist, especially in HIV-associated arthritis, diffuse infiltrative lymphocytosis syndrome, HIV-associated vasculitis, and polymyositis. However, new HIV treatments may ameliorate these diseases.

CONCLUSIONS

The spectrum of HIV-associated rheumatic disease remains a diagnostic and therapeutic challenge for the clinician. The impact of changes in HIV treatment on these disorders requires further assessment.

Expression of cyclooxygenase-1 (COX-1) in labial salivary glands of Sjögren's syndrome

COX plays an important role in inflammatory diseases such as rheumatoid arthritis. To determine the role of COX in Sjögren's syndrome (SS), we examined COX expression in the salivary glands of SS patients. We examined 15 patients with SS and two normal subjects. Labial salivary gland tissue samples were analysed immunohistochemically using anti-COX-1 and COX-2 antibodies. All biopsy samples from 15 patients with SS were stained for COX-1. In contrast, COX-1 immunostaining was not detected in normal salivary gland tissues. Co-expression of COX-1 and CD68 was confirmed by mirror section technique and double antibody immunostaining. This finding indicated that COX-1-expressing cells in SS salivary glands were infiltrating macrophages. In contrast to COX-1 staining, only a little COX-2 immunostaining was observed in salivary gland tissues from SS patients. These data suggest that COX-1 expression on infiltrating macrophages may contribute to the inflammatory process of salivary glands in SS.