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Ruacho G, Kvarnström M, Zickert A, Oke V, Rönnelid J, Eketjäll S, Elvin K, Gunnarsson I, Svenungsson E. Sjögren Syndrome in Systemic Lupus Erythematosus: A Subset Characterized by a Systemic Inflammatory State. J Rheumatol 2019; 47:865-875. [PMID: 31523050 DOI: 10.3899/jrheum.190250] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE An often-neglected subset of patients with systemic lupus erythematosus (SLE) is those with secondary Sjögren syndrome (SLE-sSS). Further, primary SS overlaps and can be difficult to delineate from SLE. To shed light on the SLE-sSS subset, we investigated a large and well-characterized SLE cohort, comparing patients with SLE-sSS and SLE patients without SS (SLE-nonsSS) and controls. METHODS We included 504 consecutive patients with SLE, fulfilling the 1982 revised American College of Rheumatology criteria, and 319 controls from the general population, matched for age and sex to the first 319 patients. SLE-sSS was defined according to the American-European Consensus Criteria (AECC). A thorough clinical examination, including subjective and objective quantifications of sicca symptoms, was performed in all participants. Autoantibodies and 20 selected cytokines were measured by luminex and multiplex analysis, respectively. RESULTS SLE-sSS, as defined by AECC, occurred in 23% of the patients with SLE. In comparison to SLE-nonsSS, the SLE-sSS group was older and more frequently female. Leukopenia and peripheral neuropathy were more frequent and nephritis less frequent. Circulating levels of 6/20 investigated proinflammatory cytokines [tumor necrosis factor-α, interleukin (IL) 6, monocyte chemoattractant protein 4, macrophage inflammatory protein 1β, IL-12/IL-23p40, and interferon γ-induced protein 10], total IgG, anti-SSA/Ro52, anti-SSA/Ro60, anti-SSB/La antibodies, and rheumatoid factor (IgM and IgA) were higher in the SLE-sSS group (p < 0.05 for all comparisons). CONCLUSION The frequency of SLE-sSS increased with age and affected roughly one-quarter of all patients with SLE. Despite less internal organ involvement, a systemic inflammatory state with high levels of proinflammatory cytokines is present in the SLE-sSS subgroup. This is a novel observation that may affect future understanding and treatment of the SLE-sSS subset.
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Affiliation(s)
- Guillermo Ruacho
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Marika Kvarnström
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Agneta Zickert
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Vilija Oke
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Johan Rönnelid
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Susanna Eketjäll
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Kerstin Elvin
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Iva Gunnarsson
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden.,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital
| | - Elisabet Svenungsson
- From the Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm; Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Centre (KI-AZ ICMC), Stockholm; Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm; Center for Clinical Research, Uppsala University, Sörmland; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala; Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Huddinge, Sweden. .,G. Ruacho, DMD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Center for Clinical Research, Uppsala University; M. Kvarnström, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; A. Zickert, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; V. Oke, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; J. Rönnelid, MD, PhD, Department of Immunology, Genetics and Pathology, Uppsala University; S. Eketjäll, PhD, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca, and KI-AZ ICMC; K. Elvin, MD, PhD, Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet and Karolinska University Hospital; I. Gunnarsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital; E. Svenungsson, MD, PhD, Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, and Karolinska University Hospital.
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