Positive salivary gland biopsy, Sjögren syndrome, and neuropathy: Clinical implications

Sjogren's syndrome: a neurological perspective

Sjogren's syndrome (SS) is a complex autoimmune disease characterized by lymphocytic infiltration of salivary and lacrimal glands, resulting in sicca symptoms. Additionally, SS presents with neurological manifestations that significantly impact the nervous system. This review aims to provide a comprehensive overview of the neurological aspects of SSj, covering both the peripheral and central nervous system involvement, while emphasizing diagnosis, treatment, and prognosis.

Peripheral Neuropathy in Systemic Autoimmune Rheumatic Diseases-Diagnosis and Treatment

Peripheral neuropathy (PN) is frequently observed in systemic rheumatic diseases and is a challenge in clinical practice. We aimed to review the evidence on the subject and proposed a comprehensive approach to these patients, facilitating diagnosis and management. We searched the MEDLINE database for the terms (and its respective Medical Subject Headings (MeSH) terms): "peripheral neuropathy" AND "rheumatic diseases" OR "systemic lupus erythematosus", "rheumatoid arthritis", "Sjogren syndrome", and "vasculitis" from 2000 to 2023. This literature review focuses on the diagnostic workup of PNs related to systemic lupus erythematosus, Sjögren's syndrome, rheumatoid arthritis, and systemic vasculitis. For every type of PN, we provide a pragmatic flowchart for diagnosis and also describe evidence-based strategies of treatment.

Bedside labial salivary gland biopsy (LSGBx: Lip biopsy): An update for rheumatologists

Retrieval of minor salivary glands from a labial submucosal site through a minimally invasive bedside procedure was first described nearly 60 years ago and remains an attractive alternative to more invasive surgical procedures to obtain salivary gland tissue for pathologic examination. Examination of glands for features of Sjögren's has constituted the primary use of this procedure but other systemic disorders can affect minor salivary glands and their diagnoses can be supported by biopsy. Performance of the procedure does not require specialized training in head and neck surgery or dentistry, only simple wound closure skills. Skill in performing the procedure enables the clinician to acquire potentially diagnostic material without the need for referral while offering immediate expert feedback to the patient being biopsied. Material obtained at biopsy can also be the focus of research investigations.

Complications after minor salivary gland biopsy: a retrospective study of 630 patients from two Swedish centres

OBJECTIVES

The aims of the study were to investigate the prevalence of impaired sensation after minor salivary gland biopsy (MSGB) in two Swedish centres [Karolinska University Hospital (KUH) and Skåne University Hospital (SUH)] and to assess its impact on quality of life (QoL) and associated risk factors.

METHOD

A questionnaire including questions regarding the presence of impaired sensation, impact on QoL, and impact on everyday life was sent to patients who had undergone MSGB between 2007 and 2016, and their medical notes were scrutinized.

RESULTS

The study included 630 patients (505 from KUH and 125 from SUH). In KUH the biopsies were performed by rheumatologists and in SUH by dentists or oral and maxillofacial surgeons (OMSs). Long-standing, probably permanent, impaired sensation after MSGB was reported by 21% of patients, and was associated with lower age and absence of anti-SSA antibodies. Patients with long-standing impaired sensation reported the inconvenience (1-10) of impaired sensation as 4.0 (2.0-7.0) [median (interquartile range)], and 32% reported an influence on their QoL, the reported influence (1-10) on everyday life being 3.0 (1.0-5.0). When comparing the outcomes from KUH and SUH, patients from SUH reported a significantly lower frequency of long-standing impaired sensation (14% vs 23%; p = 0.02).

CONCLUSION

A high frequency of long-standing impaired sensation after MSGB was found among patients who had undergone MSGB, although it had a low impact on everyday life. The complication frequency was less pronounced when a dentist or an OMS had performed the biopsy.

CNS demyelinating events in primary Sjögren's syndrome: A single-center case series on the clinical phenotype

Objective

The study aimed to assess the prevalence, clinical characteristics, and therapeutic outcomes of the central nervous system (CNS) demyelinating disease in a large cohort of primary Sjögren's syndrome (pSS).

Methods

This is an explorative cross-sectional study of patients with pSS seen in the departments of rheumatology, otorhinolaryngology, or neurology of a tertiary university center between January 2015 and September 2021.

Results

In a cohort of 194 pSS patients, 22 patients had a CNS manifestation. In this CNS group, 19 patients had a lesion pattern suggestive of demyelination. While there were no obvious differences in the patients' epidemiological disposition or rate of other extraglandular manifestations, the CNS group differed from the remaining patients with pSS by having less glandular manifestations but a higher seroprevalence for anti-SSA/Ro antibodies. Notably, patients with CNS manifestations were often diagnosed with multiple sclerosis (MS) and treated as such, although age and disease course were atypical of MS. Many first-line MS agents were ineffective in these "MS look-alikes"; however, the disease course was benign with B-cell-depleting agents.

Conclusion

Neurological symptoms of pSS are common and clinically manifest mainly as myelitis or optic neuritis. Notably, in the CNS, the pSS phenotype can overlap with MS. The prevailing disease is crucial since it has a major impact on the long-term clinical outcome and the choice of disease-modifying agents. Although our observations neither confirm pSS as a more appropriate diagnosis nor rule out simple comorbidity, physicians should consider pSS in the extended diagnostic workup of CNS autoimmune diseases.

Adverse post-operative events of salivary gland biopsies: A systematic review and meta-analysis

OBJECTIVES

The study aimed to perform a systematic review and meta-analysis of the complications following major and minor salivary gland biopsy.

MATERIALS AND METHODS

Observational studies assessing postoperative complications of minor salivary gland biopsy and indexed at Medline/PubMed, EMBASE, Cinahl, LILACS, or Scopus were selected. This review was registered under the protocol number: CRD42020211169. The level of significance considered was 0.05, and the R software (The R Foundation) was used for the meta-analysis.

RESULTS

Twenty-seven studies reporting 3208 patients were included in this review. The combined prevalence of postsurgical complications was 11% (95% CI, 8 to 13%, p = 0.01). The percentage of the combined prevalence of neurological complications was 3% (95% CI, 1-6%, p = 0.01). The surgical technique did not influence the frequency of overall and neurological complications.

CONCLUSION

Minor salivary gland biopsies are a safe and predictable procedure that should be performed on the lower lip. Postoperative complications are more common than previously reported, but permanent complaints are uncommon.

Antibody Testing for Suspected Autoimmune Autonomic Dysfunction and Small Fiber Neuropathies

SUMMARY

Autonomic dysfunction and small fiber neuropathies are heterogeneous disorders with a wide array of potential etiologies. As with other neurologic diseases, autoantibodies specific to neural tissue, either in the setting of cancer or systemic autoimmunity, may cause autonomic abnormalities. Given the complex and varied functions of the autonomic nervous system, however, the presentation of these conditions may be quite variable. This, in addition to pitfalls of autonomic testing especially for the novice, can lead to inaccuracies in recognizing and characterizing these conditions. We now have a large number of autoantibodies available for testing with more in the pipeline thanks to unprecedented developments in the field of neuroimmunology. Those have been very helpful in uncovering potentially treatable mechanisms of autonomic disease, but also pose a challenge to the clinician given their multiplicity and variable specificity. Growing knowledge regarding autoimmune autonomic implications and the autonomic specificities of each antibody, in addition to the increasing attention to the relevance of antibody titers are of utmost importance for clinicians concerned with autonomic neurology. This review attempts to shed a light on the frequently encountered antibodies in relation to autonomic dysfunction.

Peripheral nervous system manifestations of rheumatological diseases

Rheumatological diseases result in immune-mediated injury to not only connective tissue, but often components of the peripheral nervous system. These overlap conditions can be broadly categorized as peripheral neuropathies and overlap myositis. The peripheral neuropathies are distinctive as many have unusual presentations such as non-length-dependent, small fiber neuropathies and sensory neuronopathies (both due to dorsal root ganglia dysfunction), multiple mononeuropathies (e.g. vasculitic neuropathies), and even cranial neuropathies. Overlap myositis is increasingly recognized and is often associated with specific autoantibodies. Sarcoidosis also has widespread neurological manifestations and impacts both the peripheral nerves and muscle. Much work is needed to fully characterize the vast presentations of these overlap diseases. Given the rarity of these disorders, they are understudied, resulting in significant knowledge gaps with regards to their underlying pathophysiology and the best treatment approach. A basic knowledge of these disorders is mandatory for both practicing rheumatologists and neurologists as prompt recognition and early initiation of immunotherapy may prevent significant morbidity and permanent disability.

Hereditary transthyretin amyloidosis: a model of medical progress for a fatal disease

Hereditary amyloidogenic transthyretin (ATTRv) amyloidosis with polyneuropathy (also known as familial amyloid polyneuropathy) is a condition with adult onset caused by mutation of transthyretin (TTR) and characterized by extracellular deposition of amyloid and destruction of the somatic and autonomic PNS, leading to loss of autonomy and death. This disease represents a model of the scientific and medical progress of the past 30 years. ATTRv amyloidosis is a worldwide disease with broad genetic and phenotypic heterogeneity that presents a diagnostic challenge for neurologists. The pathophysiology of the neuropathy is increasingly understood and includes instability and proteolysis of mutant TTR leading to deposition of amyloid with variable lengths of fibrils, microangiopathy and involvement of Schwann cells. Wild-type TTR is amyloidogenic in older individuals. The main symptoms are neuropathic, but the disease is systemic; neurologists should be aware of cardiac, eye and kidney involvement that justify a multidisciplinary approach to management. Infiltrative cardiomyopathy is usually latent but present in half of patients. Disease-modifying therapeutics that have been developed include liver transplantation and TTR stabilizers, both of which can slow progression of the disease and increase survival in the early stages. Most recently, gene-silencing drugs have been used to control disease in the more advanced stages and produce some degree of improvement.

Sensory Neuronopathies

PURPOSE OF REVIEW

The sensory neuronopathies are sensory-predominant polyneuropathies that result from damage to the dorsal root and trigeminal sensory ganglia. This review explores the various causes of acquired sensory neuronopathies, the approach to diagnosis, and treatment.

RECENT FINDINGS

Diagnostic criteria have recently been published and validated to allow differentiation of sensory neuronopathies from other polyneuropathies. On the basis of serial electrodiagnostic studies, the treatment window for the acquired sensory neuronopathies has been identified as approximately 8 months. If treatment is initiated within 2 months of symptom onset, there is a better opportunity for improvement of the patient's condition. Even though sensory neuronopathies are rare, significant progress has been made regarding characterization of their clinical, electrophysiologic, and imaging features. This does not hold true, however, for treatment. There have been no randomized controlled clinical trials to guide management of these diseases, and a standard treatment approach remains undetermined.

Parotid Gland Biopsy, the Alternative Way to Diagnose Sjögren Syndrome

Salivary gland biopsy is a technique broadly applied for the diagnosis of Sjögren syndrome (SS), lymphoma in SS, and connective tissue disorders (sarcoidosis, amyloidosis). In SS characteristic histology findings are found, including lymphocytic infiltration surrounding the excretory ducts in combination with destruction of acinar tissue. In this article the main techniques are described for taking labial and parotid salivary gland biopsies with respect to their advantages, postoperative complications, and usefulness for diagnostic procedures, monitoring disease progression, and evaluation of treatment.

Immunotherapy Prospects for Painful Small-fiber Sensory Neuropathies and Ganglionopathies

The best-known peripheral neuropathies are those affecting the large, myelinated motor and sensory fibers. These have well-established immunological causes and therapies. Far less is known about the somatic and autonomic "small fibers"; the unmyelinated C-fibers, thinly myelinated A-deltas, and postganglionic sympathetics. The small fibers sense pain and itch, innervate internal organs and tissues, and modulate the inflammatory and immune responses. Symptoms of small-fiber neuropathy include chronic pain and itch, sensory impairment, edema, and skin color, temperature, and sweating changes. Small-fiber polyneuropathy (SFPN) also causes cardiovascular, gastrointestinal, and urological symptoms, the neurologic origin of which often remains unrecognized. Routine electrodiagnostic study does not detect SFPN, so skin biopsies immunolabeled to reveal axons are recommended for diagnostic confirmation. Preliminary evidence suggests that dysimmunity causes some cases of small-fiber neuropathy. Several autoimmune diseases, including Sjögren and celiac, are associated with painful small-fiber ganglionopathy and distal axonopathy, and some patients with "idiopathic" SFPN have evidence of organ-specific dysimmunity, including serological markers. Dysimmune SFPN first came into focus in children and teenagers as they lack other risk factors, for example diabetes or toxic exposures. In them, the rudimentary evidence suggests humoral rather than cellular mechanisms and complement consumption. Preliminary evidence supports efficacy of corticosteroids and immunoglobulins in carefully selected children and adult patients. This paper reviews the evidence of immune causality and the limited data regarding immunotherapy for small-fiber-predominant ganglionitis, regional neuropathy (complex regional pain syndrome), and distal SFPN. These demonstrate the need to develop case definitions and outcome metrics to improve diagnosis, enable prospective trials, and dissect the mechanisms of small-fiber neuropathy.

Neurology of rheumatologic disorders

Rheumatologic diseases encompass autoimmune and inflammatory disorders of the joints and soft tissues that often involve multiple organ systems, including the central and peripheral nervous systems. Common features include constitutional symptoms, arthralgia and arthritis, myalgia, and sicca symptoms. Neurological manifestations may present in patients with preexisting rheumatologic diagnoses, occur concurrently with systemic signs and symptoms, or precede systemic manifestations by months to years. Rheumatic disorders presenting as neurological syndromes may pose diagnostic challenges. Advances in immunosuppressive treatment of rheumatologic disease have expanded the treatment armamentarium. However, serious neurotoxic effects have been reported with both old and newer agents. Familiarity with neurological manifestations of rheumatologic diseases, diagnosis, and potential nervous system consequences of treatment is important for rapid diagnosis and appropriate intervention. This article briefly reviews the diverse neurological manifestations and key clinical features of rheumatic disorders and the potential neurological complications of agents commonly used for treatment.

A convenient and less invasive technique of labial minor salivary gland biopsy using a minimal incision with a needle tip

Objectives

This study was to show the technique and to compare the usefulness and complications of biopsy using a minimal incision with a needle tip of the labial minor salivary glands with those of conventional incisional lip biopsy in the diagnosis of Sjögren's syndrome.

Methods

We retrospectively reviewed the medical records of the patients who had the labial minor salivary gland biopsy for the diagnosis of Sjögren's syndrome between January 2005 and December 2008. One hundred forty-three patients were enrolled in this study. The yields of diagnostic salivary tissues and complications of the biopsy using a minimal incision with a needle tip and the conventional incisional lip biopsy were compared.

Results

Out of 143 patients, 56 patients underwent the conventional incisional lip biopsy and 87 patients received the biopsy using a minimal incision with a needle tip. In the biopsy using a minimal incision with a needle tip group, adequate salivary gland tissues were obtained in 85 patients out of 87 patients (97.7%). In the conventional incisional lip biopsy group, adequate specimens were acquired in 44 patients out of 56 patients (78.6%). There was no complication after the biopsy using a minimal incision with a needle tip, whereas there was one patient complained transient numbness of the lip after the conventional incisional lip biopsy.

Conclusion

The less invasive labial minor salivary gland biopsy using a minimal incision with a needle tip was easy to perform and safe and showed the better result than the conventional incisional lip biopsy in terms of the adequate specimen in the diagnosis of Sjögren's syndrome. So it might be a good alternative to the conventional incisional lip biopsy.

Neurological adverse events related to lip biopsy in patients suspicious for Sjögren's syndrome: a systematic review and prevalence meta-analysis

OBJECTIVE

The aim of this study was to compare the prevalence of neurological complications related to lip biopsy for SS diagnosis using conventional vs minimally invasive techniques.

METHODS

We performed a systematic review and prevalence meta-analysis using the search strategy [(salivary gland biopsy OR labial biopsy OR lip biopsy) AND (Sjögren)] in the MEDLINE, EMBASE and Web of Science Conference Proceedings Citation Index databases. Studies were selected if they included original data for minor salivary gland biopsy, sample size, exposure of interest (technique description), number of complications and number of affected patients. The prevalence of total and permanent neurological adverse effects was calculated. Both fixed-effects and random-effects pooled estimates were assessed. Heterogeneity was calculated using an adaptation of the DerSimonian and Laird Q test.

RESULTS

Sixteen articles were selected for the study. In the minimally invasive group (n = 3), the pooled prevalence of total adverse events is almost four times higher than that in the linear incision group (n = 12) (4.73% vs. 1.20%). In contrast, the pooled prevalence of the permanent or potentially permanent neurological adverse events is 8.5 times lower in the minimally invasive technique group than in the studies using linear incisions (0.17% vs. 1.45%).

CONCLUSION

With the limitations intrinsic to the potential biases in the studies included in this meta-analysis, we conclude that the minimally invasive lip biopsy technique for SS diagnosis induces fewer permanent neurological complications than conventional approaches with large linear incisions in the lower lip.

Multiple sclerosis: diagnosis, differential diagnosis, and clinical presentation

The diagnosis of multiple sclerosis (MS) is based on demonstrating evidence of inflammatory-demyelinating injury within the central nervous system that is disseminated in both time and space. Diagnosis is made through a combination of the clinical history, neurologic examination, magnetic resonance imaging and the exclusion of other diagnostic possibilities. Other so-called "paraclinical" tests, including the examination of the cerebrospinal fluid, the recording of evoked potentials, urodynamic studies of bladder function, and ocular coherence tomography, may be helpful in establishing the diagnosis for individual patients, but are often unnecessary. Differential diagnosis in MS must be guided by clinical presentation and neurologic localization. While the list of conditions that can mimic MS clinically or radiologically is long, in clinical practice there are few conditions that truly mimic MS on both fronts. A positive test for a putative MS "mimic" does not unto itself exclude the diagnosis of MS. Typical symptoms of MS include discrete episodes ("attacks" or "relapses") of numbness, tingling, weakness, vision loss, gait impairment, incoordination, imbalance, and bladder dysfunction. In between attacks, patients tend to be stable, but may experience fatigue and heat sensitivity. Some MS patients go on to experience, or only experience, an insidious worsening of neurologic function and accumulation of disability ("progression") that is not associated with discrete relapse activity. Progression accounts for most of the long-term disability in MS. Diagnostic criteria for MS have evolved over the past several decades, with each revision impacting the apparent prevalence and prognosis of the disorder - the result has been to encourage earlier diagnosis without compromising accuracy.

Minor salivary gland biopsy in Sjögren's syndrome: a review and introduction of a new tool to ease the procedure

Objectives: To review the existing techniques for minor salivary gland biopsy (MSGB) in the lip and to suggest a new approach to ease the procedure and reduce post-operative complications. Study Design: A comprehensive literature review and a descriptive study of a new surgical technique. Results: Diverse incisions have been suggested for MSGB with different designs (ellipse, circular, linear), different directions (parallel, oblique, vertical) and a wide range of lengths (from 1 mm up to 3 cm), but no comparative studies supporting the advantages of a particular type of incision over the others could be retrieved. A variety of features of the existing techniques for MSGB are linked to undesired events and surgical complications which could be minimized by modifying certain aspects of these procedures. The technique described, together with the use of the S forceps, represents a significant improvement over the already described chalazion forceps because it allows for a better access and positioning of the lower lip, improves the ergonomic conditions of the assistant, and facilitates the identification of lip areas with more superficial gland lobules. Conclusions: The suggested approach for lip MSGB includes a specifically designed instrument whose performance during lip biopsy may contribute to minimize post-operative complications.

Key words:Sjögren’s syndrome, diagnosis, minor salivary gland biopsy, surgical technique, lower lip.

Comparison of two different labial salivary gland biopsy incision techniques: a randomized clinical trial

Objectives: To compare the reliability of two different labial salivary gland biopsy (LSGB) incision techniques (vertical versus horizontal incision techniques) and to report the related complications and discomfort. Study Design: 163 patients who underwent LSGB were included in this study. Patients were randomly divided as vertical incision group (n=81) and horizontal incision group (n=82). Demographic and clinical information of each patient were recorded. A questionnaire was prepared and applied together with Visual Analog Scale (VAS) on the subjects verbally at the 7th day, postoperatively. Intraoperative, short- term and delayed complications were evaluated. Results: The mean age of patients (117 female, 46 male) was 47.3 years (range 19-79 years). Vertical incision technique was associated with less pain (p<0.001), less swelling (p<0.05), less scar formation (p<0.05) and less difficulty in eating (p<0.05) when compared with horizontal incision technique. No statistically significant differences were observed between the 2 groups in terms of hematoma, parasthesia and speech difficulty (p>0.05). Additionally, two subjects in the horizontal incision group revealed permanent paresthesia during the follow-up period of two years. Conclusions: This prospective study demonstrated that the subjects in the vertical incision group had less complication rates and discomfort after labial salivary gland procedure than those in the horizontal incision group.

Key words:Salivary gland, biopsy, incision.

Sjögren Syndrome-Associated Small Fiber Neuropathy: Characterization From a Prospective Series of 40 Cases

We conducted the current study to analyze the clinical, immunologic, and neurophysiologic features of primary Sjögren syndrome (pSS)-associated sensory small fiber neuropathies (SFNs). Forty consecutive pSS patients with SFN were included. SFN was defined by the presence of suggestive sensory painful symptoms with normal nerve conduction studies and abnormal neurophysiologic tests for small nerve fibers or a low intraepidermal nerve fiber density at skin biopsy. Included patients were compared to 100 pSS patients without peripheral neuropathy.SFN patients were mainly female (92.5%). Age at pSS diagnosis was 55.3 ± 13.1 years, and at SFN diagnosis, 58.9 ± 11.8 years, with a median time to SFN diagnosis after symptom onset of 3.4 years. Clinical symptoms included burning pains (90%), numbness (87.5%), tingling (82.5%), pins and needles (72.5%), electric discharges (70%), and allodynia (55%). Dysautonomia included vasomotor symptoms (66%) and hyperhidrosis (47%). Abnormal neurophysiologic tests included laser evoked potentials (97.5%), thermal quantitative sensory testing (67.5%), and sympathetic skin reflex (40%). A skin biopsy revealed low intraepidermal nerve fiber density in 76% of the 17 tested patients.Compared to the 100 pSS patients without peripheral neuropathy, the 40 pSS-SFN patients were older at pSS diagnosis (55.3 ± 13.1 vs. 49.5 ± 14.9 yr; p = 0.03), and more often had xerostomia (97.5% vs. 81%; p = 0.01) and arthralgia (82.5% vs. 65.0%; p = 0.04). Immunologically, they were characterized by a lower prevalence of serum B-cell activation markers, that is, antinuclear antibodies (65% vs. 85%; p = 0.01), anti-SSA (42.5% vs. 71%; p = 0.002), and anti-SSB (17.5% vs. 39%; p = 0.017); rheumatoid factor (32.5% vs. 66%; p = 0.0005); and hypergammaglobulinemia (35% vs. 62%; p = 0.005).In conclusion, we report the main features of SFN in patients with pSS, the first such study to our knowledge. Our results show that patients with pSS-associated SFN are characterized by an older age at pSS diagnosis and a distinctive immunologic profile hallmarked by a lower frequency of serum B-cell activation markers.

Autoimmune neuromuscular disorders

Autoimmune neuromuscular disorders affecting peripheral nerves, neuromuscular junction or muscle have a wide clinical spectrum with diverse pathogenetic mechanisms. Peripheral nervous system may be targeted in the context of complex immune reactions involving different cytokines, antigen-presenting cells, B cells and different types of T cells. Various immunomodulating and cytotoxic treatments block proliferation or activation of immune cells by different mechanisms attempting to control the response of the immune system and limit target organ injury. Most treatment protocols for autoimmune neuromuscular disorders are based on the use of corticosteroids, intravenous immunoglobulins and plasmapheresis, with cytotoxic agents mostly used as steroid-sparing medications. More recently, development of specific monoclonal antibodies targeting individual cell types allowed a different approach targeting specific immune pathways, but these new treatments are also associated with various adverse effects and their long-term efficacy is still unknown.

Sensory neuropathies, from symptoms to treatment

PURPOSE OF REVIEW

The present review focuses on recent developments in diagnosis and treatment of sensory neuropathies. It does not seek to establish a comprehensive classification of sensory neuropathies, nor treatment guidelines per se.

RECENT FINDINGS

Diagnostic criteria and guidelines have been developed for distal symmetric polyneuropathies, small fiber sensory neuropathies and sensory neuronopathies. Novel diagnostic tools such as skin biopsies now allow diagnosis of small fiber sensory neuropathies. Genetic testing has defined new subtypes of mitochondrial neuropathies and inherited neuropathies with sensory involvement. Intravenous immunoglobulin and tumor necrosis factor-alpha inhibitors show promise for some dysimmune sensory neuropathies or neuronopathies. Additional options for management of neuropathic pain are emerging.

SUMMARY

Diagnostic methods for both acquired and hereditary sensory neuropathies have progressed in recent years, leading to earlier and more specific diagnoses and a better understanding of disease mechanisms. Much progress remains to be made regarding symptomatic and disease-modifying therapy for a range of sensory neuropathies, including those due to diabetes, HIV infection and from dysimmune or hereditary causes.

Salivary gland biopsy: a comprehensive review of techniques and related complications

OBJECTIVE

This study proposes a revision of the literature on the current techniques employed in salivary gland biopsy.

METHODS

A systematic review of the literature between January 1990 and January 2010 was conducted using MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. The search terms were: 'biopsy AND parotid AND Sjögren'; 'biopsy AND sublingual salivary gland AND Sjögren'; 'biopsy AND minor salivary gland AND Sjögren'; 'biopsy AND labial salivary gland AND Sjögren' and 'biopsy AND salivary glands AND connective disorders'.

RESULTS

No study reporting submandibular salivary gland biopsy was found; 3 studies reported sublingual salivary gland biopsy; 1 study reported palate biopsy; 4 studies reported parotid gland biopsy and 21 studies reported minor salivary gland biopsy.

CONCLUSION

Biopsy of salivary glands must be performed as last investigation and only when the other items are not complete enough to satisfy the diagnosis. The knowledge of complications and sequelae may be useful in order to minimize the risk.

Extreme efficacy of intravenous immunoglobulin therapy for severe burning pain in a patient with small fiber neuropathy associated with primary Sjögren's syndrome

Neurological involvement occurs in approximately 20% of patients with primary Sjögren's syndrome. Although neurological symptoms can affect the peripheral nervous system and the central nervous system, the most frequent symptom is polyneuropathy. Small fiber neuropathy (SFN) is a form of painful peripheral polyneuropathy that is common in patients with diabetic neuropathy, but may also occur in toxic, infectious, or immune-mediated neuropathy. We show here a patient with Sjögren's syndrome who developed SFN and was treated with intravenous immunoglobulin (IVIG) therapy, which was immediately and extremely effective. Because of the efficacy of IVIG therapy, we propose that direct immune-mediated mechanisms may be involved in the pathogenesis of SFN complicated by Sjögren's syndrome.

Diagnosis and Treatment of Chronic Immune-mediated Neuropathies

The chronic autoimmune neuropathies are a diverse group of disorders, whose diagnosis and classification is based on the clinical presentations and results of ancillary tests. In chronic inflammatory demyelinating polyneuropathy, controlled therapeutic trials demonstrated efficacy for intravenous gamma-globulins, corticosteroids, and plasmaphereis. In multifocal motor neuropathy, intravenous gamma-globulins have been shown to be effective. In the other immune-mediated neuropathies, there are no reported controlled therapeutic trials, but efficacy has been reported for some treatments in non-controlled trials on case studies. Choice of therapy in individual cases is based on reported efficacy, as well as severity, progression, coexisting illness, predisposition to developing complications, and potential drug interactions.

Peripheral neuropathy in an outpatient cohort of patients with Sjögren's syndrome

Peripheral neuropathy is common in patients with Sjögren's syndrome (SS), but its precise prevalence is unknown. Most prior studies were conducted at neurology or rheumatology specialty clinics and likely selected for a more severely affected population. We evaluated 22 SS patients and 10 controls for evidence of neuropathy in an outpatient setting at a regional meeting of the Sjögren's Syndrome Foundation. We performed neurological examinations and nerve conduction studies (NCSs) and measured serum antinuclear antibody (ANA) and SS-A and SS-B antibody levels. Participants filled out a questionnaire pertaining to symptoms, diagnosis, and treatment. We found that signs and symptoms related to small axons were more common in patients with SS than in controls. Complaints of painful distal paresthesias in the feet were noted in 59% of patients but in only 10% of controls, and of abnormal sweating in 41% and 0%, respectively. Examination revealed decreased pinprick sensation in 64% of patients with SS, but in only 30% of controls. Overall, 45% of the patients but none of the controls were thought to have an isolated small-fiber neuropathy. Large-fiber dysfunction (as measured by testing vibration, deep tendon reflexes, and NCSs) was similar between the two groups. We conclude that small-fiber neuropathy is common in patients with SS.

Painful small-fiber neuropathy in Sjogren syndrome

Of 20 consecutive patients with Sjögren neuropathy, 16 (80%) presented with burning feet and 12 (60%) with non-length-dependent sensory symptoms. Leg and thigh skin biopsies, performed in 13 patients, including 7 with normal electrophysiology, showed either reduced epidermal nerve fiber (ENF) density or abnormal morphology. ENF loss was frequently non length dependent, suggesting that patients with this disorder commonly have a small-fiber sensory neuronopathy rather than a "dying-back" axonopathy.

Inflammatory neuropathies: an update on evaluation and treatment

Inflammatory neuropathies are a diverse group of illnesses sharing the pathologic characteristic of inflammation surrounding nerve fibers. They may be autoimmune, granulomatous, infectious, paraneoplastic, or paraproteinemic in origin. All can result in significant morbidity and rarely, death. It is critical to correctly diagnose these illnesses, as many respond well to treatment. In this paper, the diagnosis and latest developments in the treatment of the most common inflammatory neuropathies (Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, neurosarcoidosis, anti-myelin-associated glycoprotein neuropathy, Sjögren's syndrome, paraneoplastic neuronopathy, and vasculitic neuropathies) will be discussed.

Antiganglion neuron antibodies correlate with neuropathy in Sj??gren??s syndrome

To investigate the possible implication of antibodies against dorsal root ganglion neuron in the pathogenesis of sensory neuropathy with Sjögren's syndrome, we examined the pathogenic role of antiganglion neuron antibodies by immunoblotting, immunohistochemistry and immunoreactive assay. Sjögren's syndrome patients without neuropathy, patients with vasculitic neuropathy and normal volunteers were evaluated as controls. Antiganglion neuron antibodies recognizing certain proteins of several different molecular weights were detected only in patients of sensory neuropathy with Sjögren's syndrome. Those antibodies labeled specific-sized neurons in the fixed ganglion and isolated ganglion neurons under the culture condition, each of which corresponded well to clinical manifestations. These results suggest that antiganglion neuron antibodies may contribute to the pathogenesis of sensory neuropathy with Sjögren's syndrome.

[Neurological manifestations in Sjögren syndrome]

PURPOSE

To describe clinical and physiopathological aspects of neurological involvement in neurological Sjögren syndrome (SS) and to overview biological markers and therapeutical aspects.

CURRENT KNOWLEDGE AND KEY POINTS

Neurological complications during SS may occur between 8.5 and 70%. Peripheral nervous system (PNS) involvement is well none but data concerning central nervous system (CNS) symptoms have been rarely described. In the present study we detail more precisely the heterogeneity of the neurological manifestation in SS. Recently new biological of SS such as alpha-fodrin antibodies have been described but there interest remain controversial. Furthermore, therapeutical data are scarce and there is to date no consensual guidelines for the therapeutical approach.

PERSPECTIVE

Recent data concerning neurological involvement in SS confirm the heterogeneity of clinical presentations that may mimic stroke or multiple sclerosis. They underline the need for new biological markers. Furthermore, multicentric, randomized trials should be assessed in order to give us some therapeutical guidelines.

Nuclear-targeting autoantibodies induced nuclear PARP cleavage accompanied by more pronounced decrease of peripheral white blood cells than Ro/SSA and La/SSB antigen-targeting autoantibodies

Autoantibody production and leukocytopenia may be linked in patients with lupus erythematosus (LE). Unclear is the ability of different autoantibody species to induce apoptosis and cell loss. Laboratory routine analyses (white blood cell counts, autoantibody detection), and flow cytometry (annexin V, CD3, CD4, CD8) have been performed in 126 consecutive LE-patients. Nuclei of PBMC were investigated flow cytometrically for the presence of the 85 kDa poly-(ADP-ribose)-polymerase (PARP) fragment. Peripheral total white blood cells (WBC), lymphocytes, T-cells, CD3+ CD4+, and CD3+ CD8+ cells were significantly decreased in patients with LE (P from 1.2 x 10(-14) to P < .0008). In the presence of either antinuclear (P from 1.2 x 10(-14) to P < .0008) or anti-dsDNA antibodies (P from 2.9 x 10(-12) to P < .007) were significantly diminished. Differences in cell numbers in LE patients with versus without anti-Ro/SSA were less pronounced: significant differences could be only obtained in lymphocytes and T-cells (P < .02). Anti-La/SSB antibodies were accompanied by significant increased leukocytes (P < .02). PARP cleavage (85 kDa) in nuclei was preferentially observed in cases with nuclear targeting autoantibodies. These results indicate that nuclear targeting autoantibodies are associated to lower peripheral blood cells counts than Ro/SSA, and La/SSB cytoplasmic targeting autoantibodies. This provides an explanation for the pathogenesis of cytopenias associated with SLE.

Clinical features and pathophysiological basis of sensory neuronopathies (ganglionopathies)

Sensory ganglionopathies have a frequent association with neoplastic disorders (paraneoplastic subacute sensory neuronopathy, or SSN) or dysimmune disorders (Sjögren's syndrome, SS; Miller Fisher syndrome; and Bickerstaff's brainstem encephalitis, BBE), with drugs, such as cisplatin or pyridoxine, and with inherited disorders with degeneration of dorsal root ganglion cells. Unsteady gait and pseudoathetoid movements of the hand are the distinctive signs encountered in these disorders. The chronic disorders are characterized by non-length-dependent abnormalities of sensory nerve action potentials (SNAPs) and differ from other sensory neuropathies in showing a global, rather than distal, decrease in SNAP amplitudes. This review focuses on recent advances in defining the mechanisms involved in sensory ganglionopathies. Specific topics include a summary of their clinical features, pathological findings, and immunopathology. In SSN, early diagnosis by the detection of anti-Hu antibodies and early treatment of the cancer gives the best chance of stabilizing the disorder. In SS sensory ganglionitis, response to treatment has been disappointing, but immunomodulating treatments are emerging. The immunological profile common to BBE and Fisher syndrome supports a common pathogenesis. In toxic sensory neuronopathy, no treatment is available. The differential diagnosis involves separating sensory ganglionopathies from other ataxic polyneuropathies, such as infectious neuropathies, sensory neuropathies with various autoantibodies, and the neuropathies seen in celiac disease.