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La Bella S, Vivarelli M, Di Ludovico A, Di Donato G, Chiarelli F, Breda L. Kidney manifestations of pediatric Sjögren's syndrome. Pediatr Nephrol 2024; 39:711-721. [PMID: 37638982 DOI: 10.1007/s00467-023-06135-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 08/29/2023]
Abstract
Approximately 1% of all patients with Sjögren's syndrome (SS) are children. Unlike the adult form, in which sicca syndrome is the main presentation, in children, the most common clinical finding is recurrent enlargement of the salivary glands. In pediatric SS, extraglandular manifestations represent a significant feature and, among these, kidney manifestations are relevant. Kidney involvement is observed in 5-20.5% of children with SS, most frequently tubulointerstitial nephritis. This injury can lead to serious phenotypes, including distal kidney tubular acidosis with the development of severe hypokalemia, which can lead to ECG abnormalities, weakness, and hypokalemic periodic paralysis. Kidney implications in pediatric SS also include nephrolithiasis, nephrocalcinosis, and various types of glomerular damage, which often require immunosuppressive therapies. Laboratory findings are usually comparable to adults, including hyperglobulinemia and high rates of antinuclear antibodies (ANA, 63.6-96.2%), and anti-Ro/SSA (36.4-84.6%). The current classification criteria for SS are inaccurate for the pediatric population, and more specific criteria are needed to improve the diagnostic rate. Due to the rarity of the disease, strong recommendations for treatment are lacking, and several therapeutic strategies have been reported, mostly based on glucocorticoids and disease-modifying antirheumatic drugs, with different outcomes. The aim of this paper is to provide an overview of the kidney implications of pediatric SS based on the latest evidence of the medical literature.
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Affiliation(s)
- Saverio La Bella
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy.
| | - Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Armando Di Ludovico
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Giulia Di Donato
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Luciana Breda
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
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2
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Shan H, Liu W, Li Y, Pang K. The Autoimmune Rheumatic Disease Related Dry Eye and Its Association with Retinopathy. Biomolecules 2023; 13:724. [PMID: 37238594 PMCID: PMC10216215 DOI: 10.3390/biom13050724] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
Dry eye disease is a chronic disease of the ocular surface characterized by abnormal tear film composition, tear film instability, and ocular surface inflammation, affecting 5% to 50% of the population worldwide. Autoimmune rheumatic diseases (ARDs) are systemic disorders with multi-organ involvement, including the eye, and play a significant role in dry eye. To date, most studies have focused on Sjögren's syndrome (one of the ARDs) since it manifests as two of the most common symptoms-dry eyes and a dry mouth-and attracts physicians to explore the relationship between dry eye and ARDs. Many patients complained of dry eye related symptoms before they were diagnosed with ARDs, and ocular surface malaise is a sensitive indicator of the severity of ARDs. In addition, ARD related dry eye is also associated with some retinal diseases directly or indirectly, which are described in this review. This review also summarizes the incidence, epidemiological characteristics, pathogenesis, and accompanying ocular lesions of ARD's related dry eye, emphasizing the potential role of dry eye in recognition and monitoring among ARDs patients.
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Affiliation(s)
| | | | | | - Kunpeng Pang
- Department of Ophthalmology, Qilu Hospital of Shandong University, Jinan 250012, China
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3
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Doolan G, Faizal NM, Foley C, Al-Obaidi M, Jury EC, Price E, Ramanan AV, Lieberman SM, Ciurtin C. Treatment strategies for Sjögren's syndrome with childhood onset: a systematic review of the literature. Rheumatology (Oxford) 2022; 61:892-912. [PMID: 34289032 PMCID: PMC8889300 DOI: 10.1093/rheumatology/keab579] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/29/2021] [Accepted: 07/11/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Georgia Doolan
- Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London
- Department of Rheumatology, University College London Hospital
| | - Nor Mohd Faizal
- Department of Applied Medical Sciences, University College London
| | - Charlene Foley
- Department of Paediatric Rheumatology, Great Ormond Street Hospital
| | | | - Elizabeth C Jury
- Centre for Rheumatology Research, Department of Medicine, University College London, London
| | - Elizabeth Price
- Department of Rheumatology, Great Western Hospitals NHS Foundation Trust, Swindon
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Scott M Lieberman
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London
- Department of Rheumatology, University College London Hospital
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4
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Abstract
Sjögren disease increasingly is recognized in pediatric patients. Clinical features, primarily parotitis and sicca symptoms, and results of diagnostic tests may be different from those in adult disease. Adult criteria fail to capture most pediatric patients. Pediatric-specific criteria are urgently needed to define the natural history of the disease, identify risk and prognostic factors, and evaluate the impact of therapeutics and other interventions on disease course in young patients.
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Affiliation(s)
- Rachel L Randell
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road Box #3212, Durham, NC 27705, USA.
| | - Scott M Lieberman
- Division of Rheumatology, Allergy, and Immunology, Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, 500 Newton Road, 2191 ML, Iowa City, IA 52242, USA
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5
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Lin J, Gadde JA, Flanagan E, Gombolay G. A Presentation of Pediatric Sjögren's Syndrome with Abducens Nerve Palsy. Neuropediatrics 2021; 52:394-397. [PMID: 33316834 DOI: 10.1055/s-0040-1715627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Sjögren's syndrome is a systemic autoimmune disease that classically presents with xerophthalmia and xerostomia. However, neurological manifestations occur in 10 to 60% of patients with Sjögren's syndrome and can often precede classic sicca symptoms in Sjögren's syndrome in some cases up to several years. Rarely, cranial neuropathy can be the initial presentation. Here, we present the first case of a 15-year-old girl with left abducens palsy in the setting of a new diagnosis of Sjögren's syndrome. Comprehensive evaluation revealed elevated Sjögren's syndrome-related antigen A-60 antibody. Cerebrospinal fluid analysis was unremarkable. Radiological studies demonstrated evidence of chronic parotitis. Acute treatment included high-dose methylprednisolone and rituximab, and symptoms resolved by follow-up at 2 weeks. The most common neurological disorder of Sjögren's syndrome is pure sensory neuropathy. In pediatric Sjögren's syndrome, neurological complications are rare but include aseptic meningoencephalitis, acute disseminated encephalomyelitis, transverse myelitis, optic neuritis, and cranial neuropathies. In the circumstance of a cranial neuropathy, the trigeminal nerve is most commonly involved but oculomotor nerves can occasionally be affected. Abducens palsies have been described in four patients with Sjögren's syndrome, typically women and all middle aged or older, with our patient being the first pediatric case. Thus, it is important to consider screening for Sjögren's syndrome in the evaluation of pediatric patients with new onset of isolated cranial neuropathy even in the absence of classic sicca symptoms.
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Affiliation(s)
- Jenny Lin
- Department of Pediatrics, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States.,Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Judith A Gadde
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States.,Department of Radiology, Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, Unites States
| | - Elaine Flanagan
- Department of Pediatrics, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States.,Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Grace Gombolay
- Department of Pediatrics, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, United States.,Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
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6
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Ciurtin C, Cho Y, Al-Obaidi M, Jury EC, Price EJ. Barriers to translational research in Sjögren's syndrome with childhood onset: challenges of recognising and diagnosing an orphan rheumatic disease. THE LANCET. RHEUMATOLOGY 2021; 3:e138-e148. [PMID: 38279369 DOI: 10.1016/s2665-9913(20)30393-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 01/28/2024]
Abstract
Sjögren's syndrome was considered for many years a disease of adulthood, characterised by immune infiltration of exocrine glands, leading to dryness (eg, dry mouth and eyes), which is a cardinal symptom. As of the last 20 years, it became apparent that although the disease is very rare in children, its clinical presentation differs from that of adults, posing substantial challenges to the recognition, diagnosis, and classification of patients with childhood-onset Sjögren's syndrome. This Viewpoint explores comparative classification criteria for children (not validated) and adults with Sjögren's syndrome, as well as differences in the clinical presentation of childhood-onset versus adult-onset Sjögren's syndrome, offering ideas about how we can improve the diagnosis of Sjögren's syndrome in children. A review of the role of medical history and clinical assessment, serology, glandular function assessment, and imaging, as well as salivary and lachrymal gland biopsy in the diagnosis of children with Sjögren's syndrome is included. Additionally, we provide suggestions about further research and registry data collection that is required to address the unmet needs of these patients.
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Affiliation(s)
- Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London, London, UK; Department of Rheumatology, University College London Hospital NHS Trust, London, UK.
| | - Youna Cho
- University College London Medical School, University College London, London, UK
| | - Muthana Al-Obaidi
- Department of Paediatric Rheumatology, Great Ormond Hospital for Children NHS Trust, London, UK
| | - Elizabeth C Jury
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
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7
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Marino A, Romano M, Giani T, Gaggiano C, Costi S, Singh R, Mehta JJ, Lieberman SM, Cimaz R. Childhood Sjogren's syndrome: An Italian case series and a literature review-based cohort. Semin Arthritis Rheum 2020; 51:903-910. [PMID: 33261821 DOI: 10.1016/j.semarthrit.2020.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Achille Marino
- Department of Pediatrics, Desio Hospital, ASST Monza. Via Mazzini 1, 20832 Desio (MB), Italy; ASST G.Pini-CTO, Via Gaetano Pini 9, 20122 Milan, Italy.
| | - Micol Romano
- ASST G.Pini-CTO, Via Gaetano Pini 9, 20122 Milan, Italy
| | - Teresa Giani
- Pediatric Rheumatology, Meyer Children's Hospital, Viale Gaetano Pieraccini, 24, 50139 Florence, Italy; Department of Medical Biotechnology, University of Siena, viale Mario Bracci, 16, Siena, Italy
| | - Carla Gaggiano
- Department of Pediatrics, University of Siena, viale Mario Bracci, 16, Siena, Italy
| | | | - Revika Singh
- Northwestern University, 633 Clark St, Evanston, IL 60208, USA
| | - Jay J Mehta
- Division of Rheumatology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104-4399, USA
| | - Scott M Lieberman
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Rolando Cimaz
- ASST G.Pini-CTO, Via Gaetano Pini 9, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, and Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Via della Commenda 19, 20122 Milan, Italy
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8
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Mittal GK, Mittal S, Kaur H, Stephen SR, Sekhar S, Sureshbabu S, Sandhya P. Anti-Sjögren's-syndrome-related antigen A autoantibodies (Anti-SSA antibody) and meningoencephalitis: Sjögren's syndrome waiting to be unveiled? A case series and review of literature. Rheumatol Int 2020; 41:1855-1866. [PMID: 33040168 DOI: 10.1007/s00296-020-04716-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
Aseptic meningoencephalitis (AME) constitutes a variable proportion of meningoencephalitis. Patients with AME are not routinely evaluated for autoimmune disorders. Primary Sjögren's syndrome (pSS) is a prevalent, but under suspected systemic autoimmune disease characterised by exocrinopathy, though sicca symptoms may not be the dominant or presenting feature. This study was undertaken to enumerate the clinical, radiological and laboratory features of meningoencephalitis related to pSS among the total cohort of meningoencephalitis admitted in our hospital. Retrospective patient records were screened for diagnosis of meningoencephalitis from April 2016 to March 2020. Those patients with anti-SSA positivity and clinical diagnosis of pSS were included. We have reviewed all cases of Sjögren's syndrome with meningoencephalitis available in literature. Four patients with meningoencephalitis with pSS were identified. Their clinical presentations, investigations, and good response to steroids have been described with special emphasis on evolving clinical features. In all patients, sicca features were absent. Anti-SSA was positive in all. The diagnosis of pSS was considered after ruling out all infectious and other autoimmune aetiologies. Two had extra-neurological organ manifestations and required addition of second line immunosuppressive agents for optimum disease control. Consistent with this case series, absent sicca symptoms have been described in pSS patients presenting with meningoencephalitis in literature. This case series is of special interest as it describes the initial presentation of pSS as meningoencephalitis with sicca features in absentia, thereby highlighting the need for a high index of suspicion and the need for workup for pSS in AME.
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Affiliation(s)
| | - Sumidha Mittal
- Department of Rheumatology, St. Stephen's Hospital, Delhi, 110054, India
| | - Harleen Kaur
- Department of Neurology, St. Stephen's Hospital, Delhi, 110054, India
| | | | - Shilpa Sekhar
- Department of Neurology, St. Stephen's Hospital, Delhi, 110054, India
| | - Sachin Sureshbabu
- Department of Neurology, Aster Malabar Institute of Medical Sciences, Calicut, Kerela, India
| | - Pulukool Sandhya
- Department of Rheumatology, St. Stephen's Hospital, Delhi, 110054, India
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Zhao J, Chen Q, Zhu Y, Zhao M, Liu J, Zhang Z, Gong X. Nephrological disorders and neurological involvement in pediatric primary Sjogren syndrome:a case report and review of literature. Pediatr Rheumatol Online J 2020; 18:39. [PMID: 32448292 PMCID: PMC7245745 DOI: 10.1186/s12969-020-00431-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/06/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Sjögren syndrome (SS) is a rare disease in pediatrics, and little attention has been paid to the clinical feature in these patients. To date, there are few cases concern about neurological and nephrological disorders in childhood Sjögren syndrome. We describe a case of Sjögren syndrome in a 12-year-old girl who developed neurological disorders and interstitial nephritis and review the literature currently available on this topic. CASE PRESENTATION A 12-year-old girl was admitted to our hospital for arthritis and glucosuria. She was required to do labial gland and renal biopsy, because the positive for anti-nuclear antibody and anti-Sjögren syndrome B (anti-SSB) antibody. Then the biopsy was performed revealing the lymphocytic infiltrate in the small area and renal tubular interstitial damage,thus the diagnosis of Sjögren syndrome with tubular interstitial damage was made. Three months later, she presented again with headache, fever, nausea, vomiting and was recovered without drug therapy. Based on the patient's medical history, laboratory and imaging examination, and treatment, we speculate that the disorders of the nervous system were caused by the Sjögren syndrome. The girl has stable renal function and no residual nervous system damage in the next 1.5 years, but she underwent low dose prednisone therapy because of persistent renal glucosuria. CONCLUSIONS Nephrological disorders and neurological involvement are rare manifestations of Sjögren syndrome in children, and rarely presented as the initial symptoms. It should be suspected in children presenting with unexplained renal diseases, neurological abnormalities, or unexplained fever. Although there is no guidelines on the diagnosis and treatment of children Sjögren syndrome are currently available, early recognition and the appropriate treatment of renal damage and neurologic involvement would improve prognosis and prevent complications.
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Affiliation(s)
- Jingya Zhao
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Qin Chen
- Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012, People's Republic of China.
| | - Yunyun Zhu
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Meng Zhao
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Jun Liu
- grid.417168.d0000 0004 4666 9789Department of Pathology, Tongde Hospital of Zhejiang Province, Hangzhou, People’s Republic of China
| | - Zhenzhong Zhang
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Xiaoting Gong
- grid.417168.d0000 0004 4666 9789Department of Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, People’s Republic of China
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Means C, Aldape MA, King E. Pediatric primary Sjögren syndrome presenting with bilateral ranulas: A case report and systematic review of the literature. Int J Pediatr Otorhinolaryngol 2017; 101:11-19. [PMID: 28964279 DOI: 10.1016/j.ijporl.2017.07.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/13/2017] [Accepted: 07/16/2017] [Indexed: 01/01/2023]
Abstract
CONTEXT Primary Sjögren syndrome is uncommon in children, and the standard clinical criteria used in diagnosis of adult Sjögren syndrome will miss many children with the disease. Floor of mouth ranulas have not been described in Sjögren syndrome. OBJECTIVE This study aims to describe a novel presentation of juvenile primary Sjögren syndrome, and to present a comprehensive systematic review of the literature regarding the presentation and diagnosis of Sjögren syndrome in children. DATA SOURCES Ovid MEDLINE. STUDY SELECTION A MEDLINE literature search was performed using the following search terms: primary, Sjögren, disease, and children. Results were limited to human subjects and articles written in English between 1981 and 2014. Applicable articles were reviewed and qualitatively summarized. DATA EXTRACTION Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRIMA). RESULTS Initial MEDLINE search yielded 146 articles, 80 of which were excluded as not clinically pertaining to Sjögren syndrome. An additional 25 were excluded due to lack of pediatric-specific data. Systematic review of the literature revealed no reports of ranula in association with Sjögren syndrome. 6 papers were manually included from review of reference lists of included articles. Our review indicated that recurrent parotitis is the most commonly reported presenting symptom in children, followed by ocular and oral symptoms, musculoskeletal, and renal symptoms. Compared to adults, children are less likely to present with dry eyes and mouth. LIMITATIONS All studies were retrospective chart reviews, case series or case reports. CONCLUSION This is the first report of a child presenting with floor of mouth ranulas in association with Sjögren syndrome. While recurrent parotitis is the most common presentation in children, other salivary gland and extra-salivary manifestations may be seen, and the clinician must maintain a high index of suspicion for underlying Sjögren syndrome.
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Affiliation(s)
- Casey Means
- Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, PV01, Portland, OR 97239, United States.
| | - Mark A Aldape
- Department of Pathology, Kaiser Permanente Northwest, United States.
| | - Ericka King
- Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, PV01, Portland, OR 97239, United States.
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11
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Matsui Y, Takenouchi T, Narabayashi A, Ohara K, Nakahara T, Takahashi T. Childhood Sjögren syndrome presenting as acute brainstem encephalitis. Brain Dev 2016; 38:158-62. [PMID: 26006751 DOI: 10.1016/j.braindev.2015.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/27/2015] [Accepted: 05/11/2015] [Indexed: 11/17/2022]
Abstract
Sjögren syndrome is an autoimmune disease characterized by dry mouth and eyes, known as sicca symptoms. The exact spectrum of neurological involvement, especially of the central nervous system, in childhood Sjögren syndrome has not been well defined. We report a girl who presented with acute febrile brainstem encephalitis. In retrospect, she had exhibited a preceding history of recurrent conjunctivitis and strong halitosis that could be considered as sicca symptoms. The histopathology results of a minor salivary biopsy, the presence of anti-SSA/Ro antibody, and keratoconjunctivitis confirmed the diagnosis of Sjögren syndrome. Commonly observed features in previously reported patients with childhood Sjögren syndrome and central nervous system complications have included fever at the time of neurologic presentation, cerebrospinal fluid pleocytosis, abnormal neuroimaging, and positivity for several specific antibodies. In children presenting with unknown acute febrile encephalopathy, Sjögren syndrome should be included in the differential diagnosis, especially when sicca symptoms are present.
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Affiliation(s)
- Yoriko Matsui
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Toshiki Takenouchi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.
| | | | - Kentaro Ohara
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Tadaki Nakahara
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Takao Takahashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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12
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Colaci M, Cassone G, Manfredi A, Sebastiani M, Giuggioli D, Ferri C. Neurologic Complications Associated with Sjögren's Disease: Case Reports and Modern Pathogenic Dilemma. Case Rep Neurol Med 2014; 2014:590292. [PMID: 25161786 PMCID: PMC4139080 DOI: 10.1155/2014/590292] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/14/2014] [Accepted: 07/18/2014] [Indexed: 12/14/2022] Open
Abstract
Objectives. Sjögren's syndrome (SS) may be complicated by some neurological manifestations, generally sensory polyneuropathy. Furthermore, involvement of cranial nerves was described as rare complications of SS. Methods. We reported 2 cases: the first one was a 40-year-old woman who developed neuritis of the left optic nerve as presenting symptom few years before the diagnosis of SS; the second was a 54-year-old woman who presented a paralysis of the right phrenic nerve 7 years after the SS onset. An exhaustive review of the literature on patients with cranial or phrenic nerve involvements was also carried out. Results. To the best of our knowledge, our second case represents the first observation of SS-associated phrenic nerve mononeuritis, while optic neuritis represents the most frequent cranial nerve involvement detectable in this connective tissue disease. Trigeminal neuropathy is also frequently reported, whereas neuritis involving the other cranial nerves is quite rare. Conclusions. Cranial nerve injury is a harmful complication of SS, even if less commonly recorded compared to peripheral neuropathy. Neurological manifestations may precede the clinical onset of SS; therefore, in patients with apparently isolated cranial nerve involvement, a correct diagnosis of the underlying SS is often delayed or overlooked entirely; in these instances, standard clinicoserological assessment is recommendable.
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Affiliation(s)
- Michele Colaci
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Giulia Cassone
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Andreina Manfredi
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Dilia Giuggioli
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Clodoveo Ferri
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
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Abstract
INTRODUCTION Pediatric stroke, while increasingly recognized among practitioners as a clinically significant, albeit infrequent entity, remains challenging from the viewpoint of clinicians and researchers. DISCUSSION Advances in neuroimaging have revealed a higher prevalence of pediatric stroke while also provided a safer method for evaluating the child's nervous system and vasculature. An understanding of pathogenic mechanisms for pediatric stroke requires a division of ages (perinatal and childhood) and a separation of mechanism (ischemic and hemorrhagic). This article presents a review of the current literature with the recommended divisions of age and mechanism. CONCLUSION Guidelines for treatment, though limited, are also discussed.
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Reiff A. Ocular complications of childhood rheumatic diseases: nonuveitic inflammatory eye diseases. Curr Rheumatol Rep 2009; 11:226-32. [PMID: 19604468 DOI: 10.1007/s11926-009-0031-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ocular involvement is common in pediatric rheumatologic diseases, supporting the concept that these conditions do not manifest in isolation but are components of a multisystem inflammatory process. It remains unclear why the eye and its adjacent tissues become a target during paninflammatory disease. Pediatric rheumatologists must recognize ocular disorders, as these conditions significantly concern the treatment team managing serious cases of inflammatory eye disease. Close collaboration between the treating rheumatologist and ophthalmologist is required to prevent potentially devastating outcomes. Therapeutic interventions, such as topical steroids, systemic immunosuppressants, and biologics, must balance the necessity of controlling ocular inflammation and treatment-related adverse effects. This article-the second in a series on ocular complications of childhood rheumatic diseases-reviews the presentation and management of the more common nonuveitic inflammatory ocular manifestations of childhood rheumatologic disease.
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Affiliation(s)
- Andreas Reiff
- Division of Rheumatology, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 60, Los Angeles, CA 90027 USA.
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15
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16
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Riou EM, Amlie-Lefond C, Echenne B, Farmer M, Sébire G. Cerebrospinal fluid analysis in the diagnosis and treatment of arterial ischemic stroke. Pediatr Neurol 2008; 38:1-9. [PMID: 18054685 DOI: 10.1016/j.pediatrneurol.2007.09.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 07/27/2007] [Accepted: 09/10/2007] [Indexed: 01/04/2023]
Abstract
With the advent of magnetic resonance imaging as a rapid and accurate way to diagnose arterial ischemic stroke, cerebrospinal fluid assessment is rarely performed, unless infectious or inflammatory processes are obvious. Recent advances in the understanding of the pathophysiology of childhood stroke have implicated a growing list of discrete or occult infectious and inflammatory conditions which may involve intracranial arteries and neighboring structures. Cerebrospinal-fluid assessment may allow the detection of markers identifying processes (including infectious, inflammatory, metabolic, and traumatic) potentially involved in cerebral vasculopathy and stroke. The analysis of cerebrospinal fluid in arterial ischemic strokes, including apparently idiopathic strokes, may yield essential information on pathophysiology, allowing for optimal therapeutic decisions and prognostic considerations.
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Affiliation(s)
- Emilie M Riou
- Division of Pediatric Neurology, Montreal Children's Hospital-McGill University Health Center, Montreal, Quebec, Canada
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17
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Arabshahi B, Pollock AN, Sherry DD, Albert DA, Kreiger PA, Pessler F. Devic disease in a child with primary Sjögren syndrome. J Child Neurol 2006; 21:285-6. [PMID: 16900921 DOI: 10.1177/08830738060210040701] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bita Arabshahi
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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18
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Pessler F, Monash B, Rettig P, Forbes B, Kreiger PA, Cron RQ. Sjögren syndrome in a child: favorable response of the arthritis to TNFα blockade. Clin Rheumatol 2006; 25:746-8. [PMID: 16391885 DOI: 10.1007/s10067-005-0042-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Accepted: 04/14/2005] [Indexed: 10/25/2022]
Abstract
Tumor necrosis factor alpha (TNFalpha) blockade has recently been found to be ineffective in treating glandular and extraglandular manifestations of adult Sjögren syndrome (SS), including arthralgia and arthritis. We report a girl who developed purpura, polyarthritis, uveitis, and severe dental caries in the first year of life and optic neuritis by age three. SS was diagnosed at 11 years of age, when severe hypokalemic renal tubular acidosis developed during infliximab treatment for arthritis. In contrast to her other disease manifestations, the arthritis responded remarkably well to TNFalpha blockade, suggesting that TNFalpha blockers may have a role in the treatment of arthritis with pediatric SS.
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Affiliation(s)
- F Pessler
- Division of Rheumatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3405 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Nishio M, Suzuki T, Oshida E, Matsumoto Y, Chikuda M. A Case of Primary Sjögren's Syndrome Presenting Various Visual Field Changes. Neuroophthalmology 2006. [DOI: 10.1080/01658100600817366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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20
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Abstract
PURPOSE OF THE REVIEW To summarize the current literature on central nervous system vasculitis in childhood because this condition remains a diagnostic and therapeutic challenge. RECENT FINDINGS Central nervous system vasculitis in childhood may be primary or secondary to a variety of conditions including infections, collagen vascular diseases, systemic vasculitides, and malignancies. Conditions that result in vasospasm or are associated with noninflammatory vasculopathies may mimic the features of central nervous system vasculitis. Recent studies have described the clinical spectrum of CNS vasculitis in childhood. The most common presenting features are headaches and focal neurologic deficits. The diagnosis of central nervous system vasculitis remains particularly difficult because the available investigative modalities have limited sensitivities and specificities. The most helpful diagnostic tests include cerebrospinal fluid analysis, MRI of the brain, and angiography. However, brain biopsy may be required to diagnose small vessel vasculitis. SUMMARY This review summarizes recent data on primary central nervous system vasculitis and some of the secondary CNS vasculitides in children. Awareness of the presenting clinical features of CNS vasculitis should lead to consideration of the diagnosis. Awareness of the sensitivity and specificity of the various diagnostic tests should lead to the more prudent use of invasive diagnostic tests including angiography and brain biopsy.
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Affiliation(s)
- Susanne Benseler
- Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Ontario, Canada M5G1X8
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21
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Cimaz R, Casadei A, Rose C, Bartunkova J, Sediva A, Falcini F, Picco P, Taglietti M, Zulian F, Ten Cate R, Sztajnbok FR, Voulgari PV, Drosos AA. Primary Sjögren syndrome in the paediatric age: a multicentre survey. Eur J Pediatr 2003; 162:661-5. [PMID: 12898241 DOI: 10.1007/s00431-003-1277-9] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2003] [Revised: 06/02/2003] [Accepted: 06/03/2003] [Indexed: 11/24/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Rolando Cimaz
- Clinica Pediatrica, Istituti Clinici di Perfezionamento, Via Commenda 9, 20122 Milano, Italy.
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22
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Chang CP, Shiau YC, Wang JJ, Ho ST, Kao A. Abnormal regional cerebral blood flow on 99mTc ECD brain SPECT in patients with primary Sjögren's syndrome and normal findings on brain magnetic resonance imaging. Ann Rheum Dis 2002; 61:774-8. [PMID: 12176800 PMCID: PMC1754217 DOI: 10.1136/ard.61.9.774] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Technetium-99m ethyl cysteinate dimer (99mTc ECD) single photon emission computed tomography (SPECT) of the brain was used to detect abnormal regional cerebral blood flow (rCBF) in patients with primary Sjögren's syndrome (pSS) and normal findings on brain magnetic resonance imaging (MRI). METHODS (99m)Tc ECD brain SPECT was performed to detect brain lesions showing hypoperfusion in 32 female patients with pSS and definite neuropsychiatric symptoms or signs. Seventeen female patients with pSS without neuropsychiatric symptoms and signs were included as a control group for comparison. All of the 49 patients with pSS had normal findings on brain MRI. RESULTS 99mTc ECD brain SPECT showed brain regions with hypoperfusion in 18 (56.3%) of the 32 patients, and parietal lobes were the most common areas with such lesions. By contrast, 99mTc ECD brain SPECT showed brain regions with hypoperfusion in only three (17.6%) of the 17 patients with pSS without neuropsychiatric symptoms or signs. CONCLUSION This study suggests that 99mTc ECD SPECT is a sensitive tool for detecting regions of hypoperfusion in the brains of patients with pSS and neuropsychiatric symptoms or signs and normal findings on brain MRI. However, a review of the literature showed that the (99m)Tc ECD SPECT findings in patients with pSS were non-specific.
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Affiliation(s)
- C P Chang
- Division of Allergy, Immunology, and Rheumatology, Changhua Christian Hospital, Changhua, Taiwan
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23
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Gottfried JA, Finkel TH, Hunter JV, Carpentieri DF, Finkel RS. Central nervous system Sjögren's syndrome in a child: case report and review of the literature. J Child Neurol 2001; 16:683-5. [PMID: 11575610 DOI: 10.1177/088307380101600911] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe a case of pediatric Sjögren's syndrome with progressive neurologic involvement. At age 4 years, she had been diagnosed with Melkersson-Rosenthal syndrome. After being stable with facial diplegia and swelling for 5 years, she acutely presented with diplopia, vertigo, and ataxia. Cranial magnetic resonance imaging (MRI) showed a left dorsal midbrain lesion. Serologic and histopathologic findings confirmed primary Sjögren's syndrome. She responded well to intravenous methylprednisolone, with subsequent clinical improvement and MRI resolution. This report reviews the pediatric literature and underscores the importance of considering Sjögren's syndrome in a child with unexplained facial weakness and in the differential diagnosis of pediatric stroke.
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Affiliation(s)
- J A Gottfried
- Division of Neurology, The Children's Hospital of Philadelphia, The University of Pennsylvania, 19104, USA
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DeGuzman M, Fishman MA, Lewis RA, McCluggage C, Warren RW, Finegold MJ. Chronic neurologic disease with visual, gait, and bladder problems in a male teenager. J Pediatr 1998; 132:742-7. [PMID: 9580783 DOI: 10.1016/s0022-3476(98)70373-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- M DeGuzman
- Department of Pediatrics, Texas Children's Hospital, Houston 77030, USA
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