Vasculitis and Sjögren's syndrome with IgA-IgG cryoglobulinemia terminating in immunoblastic sarcoma

Cryoglobulinemia in primary Sjögren's syndrome: prevalence and clinical characteristics in a series of 115 patients

OBJECTIVES

To determine the prevalence and nature of cryoglobulins in a large series of patients with primary Sjögren's syndrome (SS) and identify the clinical and immunologic features related to their presence.

METHODS

In a cross-sectional study, we investigated 115 consecutive patients (107 women and eight men) with primary SS. All patients fulfilled four or more of the preliminary diagnostic criteria for SS proposed by the European Community Study Group in 1993. Serum cryoglobulinemia was measured in all patients. Serum samples were obtained at 37 degrees C, and cryoglobulinemia was estimated by centrifugation after incubation at 4 degrees C for 7 days. The type of cryoglobulinemia was identified by agarose gel electrophoresis and immunofixation.

RESULTS

Cryoglobulins were detected in the sera of 18 (16%) of our patients with primary SS; most were IgMkappa monoclonal/IgG polyclonal. When compared with patients without cryoglobulins, those with cryoglobulins presented a higher prevalence of leukocytoclastic cutaneous vasculitis (56% v8%, P < .001), hypocomplementemia (75% v 2%; P < 0.001) and antibodies to hepatitis C virus (HCV) (47% v8%, P < .001). Liver involvement (clinical signs, biochemical features, or ultrasound/histological data of liver disease) was present in all patients (100%) with cryoglobulins and HCV infection but in only 11% of patients with cryoglobulins without HCV infection (P < .001).

CONCLUSIONS

Leukocytoclastic cutaneous vasculitis, hypocomplementemia, and HCV infection are associated with the presence of cryoglobulins in the sera of patients with primary SS. Testing for HCV infection is recommended for patients with SS and cryoglobulinemia because of its high prevalence and its strong association with liver disease.

Vasculitis and lymphoproliferative diseases

Vasculitis as a complication of lymphoproliferative diseases is relatively uncommon. Cutaneous vasculitis is most commonly necrotizing and leukocytoclastic. Granulomatous vasculitis occurs rarely with lymphoproliferative diseases, and even less commonly T-cell lymphocytic vasculitis with eosinophilia. The most common systemic vasculitis is caused by cryoglobulinemia, due to either lymphocytic lymphoma or Waldenström's macroglobulinemia. Other unusual associations involving systemic vasculitides include polyarteritis nodosa and hairy cell leukemia, Wegener's granulomatosis and Hodgkin's disease, granulomatous angiitis of the central nervous system and lymphoma, temporal arteritis and lymphoma, and Henoch-Schönlein purpura and lymphoma. The vasculitis may predate the diagnosis of the lymphoproliferative disease, and patients with vasculitis should be screened and monitored for lymphoproliferative diseases.

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.

Cryoglobulinemia in autoimmune rheumatic diseases. Evidence of circulating monoclonal cryoglobulins in patients with primary Sjögren's syndrome

The incidence and nature of cryoglobulins, as well as their correlation with the clinical and serologic picture of Sjögren's syndrome (SS), were studied in the sera of 30 consecutive primary SS patients. Sera from 29 patients with systemic lupus erythematosus, 58 patients with rheumatoid arthritis, and 125 healthy blood donors were also studied. It was shown that one-third of the patients with SS had cryoglobulinemia. These cryoglobulins were mixed monoclonal IgM immunoglobulins, whereas those observed in systemic lupus erythematosus and rheumatoid arthritis patients were mixed polyclonal. The nature of the cryoglobulins was demonstrated using high-resolution electrophoresis combined with immunofixation. The presence of cryoglobulins in the sera of SS patients correlated with extraglandular disease and with antibodies to Ro (SS-A) and IgM rheumatoid factor. SS patients with cryoglobulins had lower serum C4 levels than did patients without cryoglobulins. These findings suggest that SS expresses, in addition to polyclonal B cell hyperreactivity, a monoclonal process in the absence of lymphoid neoplasia. Further, they show that the extraglandular manifestations of the syndrome may be due to an immune complex-mediated pathology.

Peripheral T-cell lymphomas: histologic, immunohistologic, and clinical characterization

A review of 40 cases of peripheral T-cell lymphoma identified at our institution between March 1983 and December 1985 revealed a clinically, histologically, and immunologically diverse group of neoplasms that were difficult to classify by conventional histomorphologic criteria for non-Hodgkin's lymphomas. These lymphomas were frequently extranodal at the time of initial manifestation (52%), and their clinical aggressiveness correlated with three major histologic categories--small lymphocytic, diffuse mixed, and large cell. Of the 40 lymphomas, 18 exhibited distinctive histologic features that allowed assignment of these cases into one of four subgroups: (1) angioimmunoblastic lymphadenopathy, (2) lymphomatoid granulomatosis, (3) Hodgkin's-like disease, and (4) Lennert's lymphoma (lymphoepithelioid lymphoma). Study of all our cases that fulfilled the morphologic criteria for lymphomatoid granulomatosis or angioimmunoblastic lymphadenopathy by using immunologic methods for identification of B-cell and T-cell antigens has shown these neoplasms to be peripheral T-cell lymphomas. Therefore, we now consider these earlier proposed entities to be distinct histologic variants of peripheral T-cell lymphoma.

Rheumatologic manifestations of cancer

A variety of musculoskeletal syndromes have been described in association with malignancy. The majority of such descriptions have dealt with the connective tissue disorder as a paraneoplastic syndrome, frequently the presenting feature of an otherwise occult malignancy. This may range from the well known syndrome of HOA, heralding lung cancer, to a lesser known association of pyogenic arthritis due to an unusual enteric pathogen, signaling colon cancer. Conversely, the connective tissue disorder may precede the malignancy, and by virtue of its pathophysiology or its therapy, foster the subsequent development of cancer. Awareness of these associations may lead to earlier cancer detection, and hence, potentially more effective therapy.

Monoclonal hypergammaglobulinemia without malignant transformation in angioimmunoblastic lymphadenopathy with dysproteinemia

A patient with angioimmunoblastic lymphadenopathy with dysproteinemia had a monoclonal IgG hypergammaglobulinemia. In contrast to previous reports, the development of a monoclonal paraprotein in the setting of angioimmunoblastic lymphadenopathy with dysproteinemia did not herald a transformation to malignancy. The patient improved clinically and the monoclonal gammopathy disappeared when the patient was treated with prednisone. The relationship of these findings to current concepts regarding the cause of angioimmunoblastic lymphadenopathy with dysproteinemia is discussed.

Monoclonal gammopathies in Japanese patients with Sjögren's syndrome

We report 10 Japanese patients with Sjögren's syndrome (SS) who developed monoclonal gammopathies (MG). One was of the IgG class, five of IgA, three of IgM, and one of IgG/IgM. The monoclonality of 7 of 10 M proteins was studied using antiidiotypic (Id) antibodies against M proteins. Four (three IgA and one IgM) of 10 M proteins had rheumatoid factor (RF) activity. Hemagglutination inhibition tests and enzyme-linked immunosorbent assays (ELISA) showed that the RF activity was inhibited by anti-Id antibodies in all four monoclonal RFs. In two patients examined, many cells infiltrating into the salivary glands were stained with anti-Id antibodies. Our review of 19 Japanese SS patients with MG revealed that the non-IgM class predominated (13/19). This contrasts with 19 reported non-Japanese SS patients, among whom 14 were IgM. In both Japanese and non-Japanese patients there was a higher incidence of MG in primary than in secondary SS. The difference in the dominant heavy-chain class may reflect a difference in the genetic factors affecting B cell differentiation in immunologically disordered states.

Military cold injury during the war in the Falkland Islands 1982: an evaluation of possible risk factors

Throughout the history of war, there have been many instances when the cold has ravaged armies more effectively than their enemies. Delineated risk factors are restricted to negro origins, previous cod injury, moderate but not heavy cigarette smoking and the possession of blood group O. No attention has been directed to the possibility that abnormal blood constituents could feasibly predispose to the development of local cold injury. This study considers this possibility and investigates the potential contribution of certain components of the circulating blood which might do so. Three groups of soldiers from two of the battalions who served during the war in the Falkland Islands in 1982 were investigated. The risk factors which were sought included the presence or absence of asymptomatic cryoglobulinaemia, abnormal total protein, albumin, individual gamma globulin or complement C3 or C4 levels, plasma hyperviscosity or evidence of chronic alcoholism manifesting as high haemoglobin, PCV, RBC, MCV or gamma glutamyl transpeptidase (GGT). No cases of cryoglobulinaemia were isolated and there was no haematological evidence to suggest that any of those men who had developed cold injury, one year before this study was performed, had abnormal circulating proteins, plasma hyperviscosity or indicators of alcohol abuse. Individual blood groups were not incriminated as a predisposing factor although the small numbers of negroes in this series fared badly. Although this investigation has excluded a range of potential risk factors which could contribute to the development of cold injury, the problem persists.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic immunopathology of the kidney biopsy in rheumatic diseases

Nephropathies found in systemic lupus erythematosus (SLE), progressive systemic sclerosis, rheumatoid arthritis, Sjögren's syndrome, and mixed connective tissue disease are discussed. Pathogenetic insights derived from the study of kidney tissue are highlighted and clinicopathologic correlations indicated. The question of whether to perform kidney biopsy in lupus patients is also addressed.

Angioimmunoblastic lymphadenopathy progressing to immunoblastic lymphoma with prominent gastric involvement

Two unusual cases of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD), with progression to immunoblastic lymphoma (IL) and prominent gastric involvement are presented, and detailed immunohistologic studies described. In one case, Bence Jones proteinuria of the kappa type was observed during the course of AILD and was identified immunohistochemically in lymph node biopsy specimens and at autopsy. The potential significance of an M component and the importance of recognizing gastric involvement by AILD are discussed.

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

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