Sjögren's syndrome in a child

Innovations in the care of childhood interstitial lung disease associated with connective tissue disease and immune-mediated disorders

Childhood interstitial lung disease (chILD) associated with connective tissue and immune mediated disorders is the second most common chILD diagnostic category. As knowledge of the molecular and genetic underpinnings of these rare disorders advances, the recognized clinical spectrum of associated pulmonary manifestations continues to expand. Pulmonary complications of these diseases, including ILD, confer increased risk for morbidity and mortality and contribute to increased complexity for providers tasked with managing the multiple organ systems that can be impacted in these systemic disorders. While pulmonologists play an important role in diagnosis and management of these conditions, thankfully they do not have to work alone. In collaboration with a multidisciplinary team of subspecialists, the pulmonary and other systemic manifestations of these conditions can be managed effectively together. The goal of this review is to familiarize the reader with the classic patterns of chILD and other pulmonary complications associated with primary immune-mediated disorders (monogenic inborn errors of immunity) and acquired systemic autoimmune and autoinflammatory diseases. In addition, this review will highlight current, emerging, and innovative therapeutic strategies and will underscore the important role of multidisciplinary management to improving outcomes for these patients.

Pulmonary manifestations of childhood-onset primary Sjogren's syndrome (SS) masquerading as reactive airways disease in a male patient and review of interstitial lung disease associated with SS

BACKGROUND

Sjogren's syndrome (SS) is a rare chronic autoimmune disease involving exocrine glands presenting with sicca syndrome, recurrent parotitis and other extraglandular stigmata. SS is well characterized in the adult population with classification criteria; however, primary SS presenting in childhood is poorly defined and rare in males. Recurrent parotitis is the most common presenting symptom in children with primary SS; however, clinical phenotype in children appears more variable than in adults. The lungs are a common extraglandular location for manifestations of primary SS. However, interstitial lung disease (ILD) is rare in children with primary SS. There are only four published reports of ILD associated with primary SS in female children. Here, we present a very rare case of primary SS in a pediatric male with pulmonary manifestations and review of the literature on ILD in childhood-onset primary SS.

CASE PRESENTATION

A 14-year-old White male with a history of chronic severe asthma, recurrent parotitis and idiopathic intracranial hypertension was referred to pediatric rheumatology for evaluation of a positive ANA. In early childhood, he was diagnosed with persistent asthma recalcitrant to therapy. At age 8, he developed recurrent episodes of bilateral parotitis despite multiple treatments with sialoendoscopy. At age 14, respiratory symptoms significantly worsened prompting reevaluation. Lab workup was notable for positive ANA and Sjogren's Syndrome A and B antibodies. Pulmonary function tests showed only a mild obstructive process. Computed tomography of chest was significant for small airway disease, and lung biopsy was positive for mild interstitial lymphocytic inflammation presenting a conflicting picture for ILD. The constellation of findings led to the diagnosis of primary SS with associated pulmonary manifestations. He was treated with hydroxychloroquine, mycophenolate mofetil and oral corticosteroids with resolution of symptoms.

CONCLUSIONS

Primary SS is a rare disease in the pediatric population that is poorly characterized. This case is the very rare presentation of childhood-onset primary SS with pulmonary manifestations in a male patient. ILD associated with primary SS is also very rare with only four pediatric patients reported in the literature. Collaborative effort is needed to develop pediatric specific diagnostic and treatment guidelines in this rare condition.

Treatment strategies for Sjögren's syndrome with childhood onset: a systematic review of the literature

OBJECTIVES

SS with childhood onset is a rare autoimmune disease characterized by heterogeneous presentation. The lack of validated classification criteria makes it challenging to diagnose. Evidence-based guidelines for treatment of juvenile SS are not available due to the rarity of disease and the paucity of research in this patient population. This systematic review aims to summarize and appraise the current literature focused on pharmacological strategies for management of SS with childhood onset.

METHODS

PubMed and MEDLINE/Scopus databases up to December 2020 were screened for suitable reports highlighting pharmacological treatment of SS with childhood onset using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 reporting checklist. Animal studies were excluded.

RESULTS

A total of 43 studies (34 case reports, 8 mini case series and 1 pilot study) were eligible for analysis. The studies retrieved included girls in 88% (120/137) of cases and had very low confidence levels. HCQ was prescribed for parotid swelling, as well as in association with MTX and NSAIDs in patients with arthritis and arthralgia. Corticosteroids such as long courses of oral prednisone and i.v. methylprednisolone were commonly prescribed for children with severe disease presentations. Rituximab was mainly indicated for mucosa-associated lymphoid tissue lymphoma and renal and nervous system complications. Other conventional DMARDs were prescribed in selected cases with extraglandular manifestations.

CONCLUSION

Various therapies are used for the management of juvenile SS and are prescribed based on expert clinician's opinion. There are currently no good-quality studies that allow clinical recommendations for treatment of SS with childhood onset.

Childhood Sjogren's syndrome: An Italian case series and a literature review-based cohort

OBJECTIVE

Sjogren's syndrome (SS) is a chronic autoimmune disease with a highly variable presentation. This study aims to describe childhood SS (cSS) features to help guide clinicians in their consideration of and workup for cSS.

METHODS

We retrospectively reviewed medical records of patients with cSS referred to three Italian pediatric rheumatology centers from 2015 to 2019 and we conducted a literature review of cSS. Statistical analysis was performed to detect associations between clinical/laboratory features.

RESULTS

We reviewed 12 cases (9 female) followed in 3 Italian centers and 240 cases (191 female) in the published literature reporting individual information. The median age at disease onset was 10 years for both cohorts. The most frequently reported clinical SS-specific feature was parotitis in both cohorts (67% each). Extraglandular manifestations were very common and joint involvement was the most frequent. In the cluster analysis, we identified a significant association between parotitis and younger patients (< 11 years). We verified the presence of the main SS features (exocrine gland inflammation, exocrine gland dysfunction, and presence of autoantibodies) in the Italian cohort and the literature review-based cohort: 92% and 80% of the cohorts, respectively, had at least 2/3 main characteristics.

CONCLUSION

We described cSS features with relative frequencies and we found that parotid involvement was related to cSS in younger patients. The majority of patients showed various combinations of exocrine gland inflammation, exocrine gland dysfunction, and presence of autoantibodies giving a theoretical basis for future research to pave the way for the development of cSS specific diagnostic criteria.

Clinical practice guidance for Sjögren's syndrome in pediatric patients (2018) - summarized and updated

There are a considerable number of pediatric patients with Sjögren's syndrome (SS); however, SS is generally considered rare among children. Pediatric patients with SS report fewer sicca symptoms; therefore, many are under-diagnosed and cannot access appropriate medical management. Therefore, we propose a newly developed guidance for the diagnosis, treatment, and management of pediatric SS, including epidemiology, clinical features, and diagnostic examination methodology. The aim of this guidance was to standardize the medical care of pediatric SS in Japan, and we published the Japanese version by YODOSHA in 2018. This article is the English version, which is summarized and updated. This guidance will need to be revised in the near future as additional clinical data become available.

Primary Sjögren syndrome in the paediatric age: a multicentre survey

Primary Sjögren syndrome (SS) is very rare in childhood. We collected a series of primary paediatric SS cases from different centres. A data collection form was prepared and sent to rheumatologists who were willing to participate. Data on 40 cases of primary SS with onset before the 16th birthday were collected. Almost all patients (35/40) were females, age at onset varied from 9.3 to 12.4 years (mean 10.7 years). Signs and symptoms at disease onset were mainly recurrent parotid swelling followed by sicca symptoms. Abnormal laboratory tests were found in the majority of cases. Regarding treatment, 22 patients were treated at some time with oral corticosteroids, seven with non-steroidal anti-inflammatory drugs, and five with hydroxychloroquine; two patients needed cyclosporine and one cyclophosphamide. Follow-up varied from 0 to 7.5 years from onset, without major complications in the majority of patients.

CONCLUSION

recurrent parotid swelling is a common feature of primary Sjögren syndrome in childhood and often occurs as a presenting feature. Sicca symptoms may be rarer.

The clinical features of Sjögren's syndrome in Japanese children

Sjögren's syndrome (SS) is thought to be uncommon in children. An epidemiological study to describe the clinical features distinguishing SS in Japanese children was performed by sending questionnaires to hospitals. A total of 61 cases of SS were reported from 1290 hospitals. The diagnosis of SS was based on histopathological changes and/or sialographic changes in the salivary glands. Forty-two cases had primary SS and 19 were secondary SS with other autoimmune disorders. Fourteen cases (65%) of secondary SS were associated with systemic lupus erythematosus. In primary SS, the initial symptoms were systemic manifestations (fever, exanthema, arthralgia, etc) except for sicca symptoms. In laboratory studies, antinuclear antibodies, elevated serum IgG, rheumatoid factor, anti-Ro/SS-B antibodies were frequently observed.

Complications of childhood Sjögren syndrome

Sjögren syndrome (SS) is a common disorder in adults and involves both glandular and extraglandular systems. We report here four cases of childhood SS complicated by chronic thyroiditis, interstitial nephritis or sweat gland inflammation. Additionally, in one of these cases, the central nervous system was involved. All of these complications are common in adult cases.

CONCLUSION

Childhood SS is a systemic "ductilitis" or "exocrinopathy" with complications which are commonly observed in adult cases.

Central nervous system disease in a child with primary Sjögren syndrome

A 9-year-old girl had hemiparesis, and a diagnosis of primary Sjögren syndrome was made. The neurologic dysfunction was multifocal, involving both the brain and spinal cord, and was recurrent; the findings mimicked multiple sclerosis. Corticosteroid treatment during episodes of acute neurologic dysfunction appeared to be beneficial.

Primary Sjogren's syndrome and rampant dental caries in a 5-year-old child

A 5-year-old boy of Pakistani parents first presented with rampant dental caries and later developed bilateral parotid gland enlargement accompanied by intermittent nocturnal fever, anorexia, lethargy and weight loss. Investigations revealed anaemia, hypergammaglobulinaemia, elevated non-specific indices of inflammation, a reduced Schirmer's test value, lymphocytic infiltration and some atrophy of the parotid gland. The parotid gland enlargement, low Schirmer's test value and salivary gland biopsy showing non-focal lymphocytic infiltration led to the diagnosis of primary Sjogren's syndrome. The present case report highlights the need for health professionals to be aware that Sjogren's syndrome is a possible, if rare, predisposing cause of rampant dental caries in children.

Sjögren's syndrome in the adolescent. Report of four cases

We report three cases of Sjögren's syndrome and a case with a probable diagnosis of Sjögren's syndrome at the ages of 16 (2 cases), 17, and 18 years. Two patients were affected by systemic lupus erythematosus. All four patients showed periductal lymphocytic infiltration in the labial glands. Two of the three patients underwent parotid sialography that revealed punctate or globular sialectasis. A decrease in stimulated parotid flow rate was noted in three of the cases compared with age-matched healthy females, whereas only one patient was diagnosed as having keratoconjunctivitis sicca.

Sjogren syndrome in childhood: report of two cases

A 12-year-old boy who developed primary Sjogren syndrome and a girl, whose diagnosis of secondary Sjogren syndrome was established at the age of 3, are reported. The importance of some unusual manifestations at disease onset and possible differences in expression between children and adults are briefly discussed.

Recurrent parotid gland enlargement as an initial manifestation of Sjögren syndrome in children

Recurrent parotid gland enlargement is a common disorder in children, while that of auto-immune aetiology is rare. Three children with recurrent parotid swelling had autoantibodies including antinuclear antibody, anti-SS-A (Sjögren syndrome-A), SS-B (Sjögren syndrome-B) antibodies and rheumatoid factor, abnormal sialograms and lymphocytic infiltration of salivary glands, which were consistent with Sjögren syndrome. Initially, all three lacked symptoms of keratoconjunctivitis sicca. During follow up, two patients developed xerostomia and were diagnosed as having primary Sjögren syndrome. Recurrent parotid enlargement appears to be important as an initial manifestation of Sjögren syndrome in children.

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

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