Pain and fatigue in primary Sjögren's syndrome

Diagnostic Value of Labial Minor Salivary Gland Biopsy: Histological Findings of a Large Sicca Cohort and Clinical Associations

(1) Background: The aim of this study was to analyze labial minor salivary gland biopsy (MSGB) findings of a large sicca cohort and to examine their associations with Sjogren's syndrome (SS)-associated laboratory markers, phenotypic characteristics and systemic manifestations. Moreover, we sought to explore the ability of MSGB to identify SS patients among subjects with pre-diagnosed fibromyalgia (FM). (2) Methods: Included were all patients of three rheumatology departments having undergone a diagnostic MSGB within 9 years. Next to the examination of histological and immunohistochemical findings, we focused on activity and chronicity parameters of the underlying disease, autoantibodies, presence of systemic and hematologic involvement, as well as chronic pain and SS comorbidities. (3) Results: Among the 678 included patients, 306 (45.1%) had a positive focus score (FS). The remaining patients (n = 372) served as control subjects. There were significant correlations between FS and hypergammaglobulinemia (p < 0.001), ANA and rheumatoid factor positivity (both; p < 0.001), a weak significant correlation with erythrocyte sedimentation rate (rho = 0.235; p < 0.001) and a negative correlation with nicotine use (p = 0.002). Within the primary SS subgroup, FS was associated significantly with glandular enlargement (p = 0.007) and systemic hematologic manifestations (p = 0.002). Next to FS, CD20 cell staining showed an excellent diagnostic performance in the diagnosis of SS by an area under the curve of 0.822 (95%CI 0.780-0.864; p < 0.001). Interestingly, 42.1% of all patients with fibromyalgia (FM) having received an MSGB could be diagnosed with SS. (4) Conclusion: By examining one of the largest cohorts in the literature, we could show that MSGB histological and immunohistochemical findings not only play a key role in the classification and diagnosis of SS but could also provide important information regarding SS phenotype and systemic manifestations. Furthermore, MSGB may help differentiate patients with FM from patients with subclinical SS who suffer primarily from chronic pain.

Less, but not gone-gluten-free diet effects on fatigue in celiac disease: a prospective controlled study

Introduction

Fatigue is a frequent complaint in patients with celiac disease. A gluten-free diet is the only established treatment for celiac disease, but how this diet influences fatigue is uncertain. We aimed to investigate fatigue prevalence, severity, and associated factors in patients with celiac disease, at diagnosis and at 1 year after commencing a gluten-free diet.

Methods

78 patients with serologically and histologically verified celiac disease, 78 age- and sex-matched healthy subjects. Primary endpoints were Fatigue Visual Analog Scale (fVAS), Fatigue Severity Scale (FSS), and inverted Vitality subscale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36vs). Clinically relevant fatigue was defined as: FSS score ≥ 4, fVAS score ≥ 50 mm, or inverted SF-36vs score ≥ 65. Higher scores represented more fatigue.

Results

Fatigue was reduced after a 12-month gluten-free diet. Median scores changed from 3.8 (interquartile range [IQR]: 2.2 to 4.8) to 1.9 (IQR: 1.4 to 3.5) for FSS, from 44.5 (IQR: 18.8 to 66.0) to 15.5 (IQR: 7.8 to 43.3) for fVAS, and from 65 (IQR: 40 to 75) to 35 (IQR: 25 to 55) for inverted SF-36vs (p < 0.001 for all). Fatigue prevalence also declined after treatment. However, scores were significantly higher in patients compared to control subjects. Higher fatigue scores were associated with depression and pain, but not with signs of disease activity or nutritional deficiency.

Conclusion

At diagnosis, patients with celiac disease frequently had severe fatigue. Fatigue declined after a gluten-free diet, but it remained higher than that observed in healthy subjects.

Clinical trial registration

ClinicalTrials.gov, Identifier NCT01551563.

The Spectrum of Extraglandular Manifestations in Primary Sjögren's Syndrome

Extraglandular manifestations (EGMs) in primary Sjogren's syndrome (pSS) represent the clinical expression of the systemic involvement in this disease. EGMs are characterized by a wide heterogeneity; virtually any organ or system can be affected, with various degrees of dysfunction. The existing gaps of knowledge in this complex domain of extraglandular extension in pSS need to be overcome in order to increase the diagnostic accuracy of EGMs in pSS. The timely identification of EGMs, as early as from subclinical stages, can be facilitated using highly specific biomarkers, thus preventing decompensated disease and severe complications. To date, there is no general consensus on the diagnostic criteria for the wide range of extraglandular involvement in pSS, which associates important underdiagnosing of EGMs, subsequent undertreatment and progression to severe organ dysfunction in these patients. This review article presents the most recent basic and clinical science research conducted to investigate pathogenic mechanisms leading to EGMs in pSS patients. In addition, it presents the current diagnostic and treatment recommendations and the trends for future therapeutic strategies based on personalized treatment, as well as the latest research in the field of diagnostic and prognostic biomarkers for extraglandular involvement in pSS.

Pre-sarcopenia is associated with health-related quality of life in patients with primary Sjögren's syndrome

OBJECTIVES

Primary Sjögren's syndrome leads to pain and fatigue that may cause impaired muscle function and muscle mass. This study aimed to determine the presence of pre-sarcopenia and to clarify associated factors with pre-sarcopenia in primary Sjögren's syndrome patients.

METHOD

This cross-sectional study recruited 49 patients with primary Sjögren's syndrome and 49 age- and gender-matched healthy controls. Sarcopenia was assessed according to European Working Group on Sarcopenia in Older People in 2018 (EGSWOP2) criteria by evaluating muscle mass, gait speed, and grip strength. Physical function was also assessed with five times sit-to-stand (FTSTS) test. Quality of life (QoL), psychological symptoms, and nutritional status were evaluated using Sarcopenia Quality of Life (SarQoL) questionnaire, Hospital Anxiety and Depression Scale (HADS), and Mini Nutritional Assessment Long Form (MNA-LF), respectively.

RESULTS

Pre-sarcopenia was detected in 28.5% of patients with primary Sjögren's syndrome and 6.1% of healthy controls (p = 0.006). Patients with pre-sarcopenia were older and had worse scores in terms of depression, QoL, pain scores, grip strength, and gait speed compared with those without pre-sarcopenia. The SarQoL scores and grip strength were significantly correlated with gait speed, pain, FTSTS test, and depression. Logistic regression analyses identified that the independent predictive factor for pre-sarcopenia was QoL (OR: 0.79, 95% CI: 0.65-0.95; p = 0.015).

CONCLUSIONS

Maintaining adequate muscle mass and muscle function in patients with primary Sjögren's syndrome may contribute toward improving health-related QoL. Also, controlling depression and malnutrition risk may help to reduce the risk of development of sarcopenia. Key Points • Pre-sarcopenia is detected in 28.4% of the patients with primary Sjögren's syndrome which is higher than healthy controls. • Pre-sarcopenia is associated with health-related quality of life in primary Sjögren's syndrome. • Psychological symptoms and low physical performance are more common in pre-sarcopenic patients.

A randomized, phase II study of sequential belimumab and rituximab in primary Sjögren's syndrome

BACKGROUNDPrimary Sjögren's syndrome (pSS) is characterized by B cell hyperactivity and elevated B-lymphocyte stimulator (BLyS). Anti-BLyS treatment (e.g., belimumab) increases peripheral memory B cells; decreases naive, activated, and plasma B cell subsets; and increases stringency on B cell selection during reconstitution. Anti-CD20 therapeutics (e.g., rituximab) bind and deplete CD20-expressing B cells in circulation but are less effective in depleting tissue-resident CD20+ B cells. Combined, these 2 mechanisms may achieve synergistic effects.METHODSThis 68-week, phase II, double-blind study (GSK study 201842) randomized 86 adult patients with active pSS to 1 of 4 arms: placebo, s.c. belimumab, i.v. rituximab, or sequential belimumab + rituximab.RESULTSOverall, 60 patients completed treatment and follow-up until week 68. The incidence of adverse events (AEs) and drug-related AEs was similar across groups. Infections/infestations were the most common AEs, and no serious infections of special interest occurred. Near-complete depletion of minor salivary gland CD20+ B cells and a greater and more sustained depletion of peripheral CD19+ B cells were observed with belimumab + rituximab versus monotherapies. With belimumab + rituximab, reconstitution of peripheral B cells occurred, but it was delayed compared with rituximab. At week 68, mean (± standard error) total EULAR Sjögren's syndrome disease activity index scores decreased from 11.0 (1.17) at baseline to 5.0 (1.27) for belimumab + rituximab and 10.4 (1.36) to 8.6 (1.57) for placebo.CONCLUSIONThe safety profile of belimumab + rituximab in pSS was consistent with the monotherapies. Belimumab + rituximab induced enhanced salivary gland B cell depletion relative to the monotherapies, potentially leading to improved clinical outcomes.TRIAL REGISTRATIONClinicalTrials.gov NCT02631538.FUNDINGFunding was provided by GSK.

The interplay between cognition, depression, anxiety, and sleep in primary Sjogren's syndrome patients

Primary Sjögren’s syndrome (pSS) is an autoimmune disease with frequent neurological involvement. Memory complaints are common, but their precise patterns remain unclear. We wanted to characterize patterns of neurocognitive profiles in pSS patients with cognitive complaints. Only pSS patients with memory complaints were included, prospectively. Cognitive profiles were compiled through a comprehensive cognitive evaluation by neuropsychologists. Evaluations of anxiety, depression, fatigue, sleep disorders and quality of life were performed for testing their interactions with cognitive profiles. All 32 pSS patients showed at least borderline cognitive impairment, and 17 (53%) exhibited a pathological cognitive profile: a hippocampal profile (37%), a dysexecutive profile (22%), and an instrumental profile (16%) (possible overlap). Regarding the secondary objectives: 37% of patients were depressed, and 48% exhibited a mild-to-severe anxiety trait. Sleep disorders were frequent (excessive daytime sleepiness (55%), high risk for sleep apnea (45%), and insomnia (77%)). Cognitive impairments could not be explained alone by anxiety, depression or sleep disorders. Fatigue level was strongly associated with sleep disorders. Our study highlights that cognitive complaints in pSS patients are supported by measurable cognitive impairments, apart from frequently associated disorders such as depression, anxiety or sleep troubles. Sleep disorders should be screened.

Fatigue: a frequent and biologically based phenomenon in newly diagnosed celiac disease

Fatigue is increasingly recognized as a major complaint in patients with chronic inflammatory and autoimmune diseases. Although fatigue is assumed to represent a significant problem in celiac disease, existing knowledge is scarce, and opinions are conflicting. This study aimed to investigate the prevalence and severity of fatigue in patients with newly diagnosed celiac disease and compare it with healthy control subjects. Ninety patients with newly diagnosed celiac disease were compared with 90 age- and sex-matched healthy subjects. The primary endpoints were fatigue severity as measured by: the fatigue Visual Analog Scale (fVAS), the Fatigue Severity Scale (FSS), and the inverted Vitality subscale of the MOS36 (SF-36vs). Higher scores indicate more severe fatigue. Clinically relevant fatigue was determined using predefined cut-off values. Secondary endpoints were the associations between fatigue, and sex, age, depression, pain, and selected biochemical variables. The median (IQR) fVAS-scores were 43.0 (18.0–64.5) in patients, and 9.0 (2.0–16.0) in the control group (p < 0.001); and the FSS scores 3.8 (2.0–4.8) in patients, and 1.4 (1.0–1.9) in control subjects (p < 0.001). Inverted SF-36vs scores had a mean (SD) value of 58.8 (23.6) in patients, and 29.7 (14.3) in healthy subjects (p < 0.001). The presence of clinically relevant fatigue ranged from 41 to 50% in patients. Increased fatigue severity was associated with female sex, younger age, and elevated pain and depression scores, but not with levels of selected biochemical variables, including hemoglobin. Fatigue is a severe and frequent phenomenon in patients with untreated celiac disease.

Fatigue and expression of heat shock genes in plaque type psoriasis

BACKGROUND

Chronic fatigue is common in psoriasis, and heat shock proteins (HSP) have been postulated to influence fatigue.

OBJECTIVE

To evaluate gene expression patterns of selected HSPs in psoriasis patients with high versus low fatigue.

METHODS

Fatigue was assessed using the fatigue Visual Analoge Scale and disease activity by the Psoriasis Area and Severity Index. Peripheral blood transcriptional profiles (RNA-seq) of HSP genes from 10 patients with high fatigue were compared with 10 patients with low fatigue. HSPB11, HSPBAP1, HSPA14, HSPA9P1, HSP90B1 and HSP90AB1 contributed most to separation of the two groups in a principal component analysis. Four of these genes (HSPB11, HSPA14, HSP90B1, HSP90AB1) were further investigated by reverse transcription quantitative real-time polymerase reaction (RT-qPCR) in 20 patients with high and 20 with low fatigue scores.

RESULTS

Both RNA-seq and RT-qPCR analyses revealed a tendency to higher expression levels of HSPB11 and lower expression of HSP90B1 in the high fatigue group versus the low fatigue group. Psoriasis disease activity had no influence on the expression levels of the studied HSP genes.

CONCLUSION

Overall, the results suggest that some HSPs are involved in generation of fatigue in psoriasis supporting the hypothesis that downregulatory innate immune responses influence fatigue.

Fatigue in inflammatory rheumatic diseases: current knowledge and areas for future research

Fatigue is a complex phenomenon and an important health concern for many people with chronic inflammatory rheumatic diseases, such as rheumatoid arthritis, psoriatic arthritis, primary Sjögren syndrome and systemic lupus erythematosus. Although some clinical trials have shown the benefits of cognitive behavioural therapy in fatigue management, the effect of this approach is relatively modest, and no curative treatment has been identified. The pathogenesis of fatigue remains unclear. Despite many challenges and limitations, a growing body of research points to roles for the immune system, the central and autonomic nervous systems and the neuroendocrine system in the induction and maintenance of fatigue in chronic diseases. New insights indicate that sleep, genetic susceptibility, metabolic disturbances and other biological and physiological mechanisms contribute to fatigue. Furthermore, understanding of the relationships between psychosocial factors and fatigue is increasing. However, the interrelationships between these diverse mechanisms and fatigue remain poorly defined. In this Review, we outline various biological, physiological and psychosocial determinants of fatigue in inflammatory rheumatic diseases, and propose mechanistic and conceptual models of fatigue to summarize current understanding, stimulate debate and develop further research ideas.

Analysis of Tweets Containing Information Related to Rheumatological Diseases on Twitter

Background: Tweets often indicate the interests of Twitter users. Data from Twitter could be used to better understand the interest in and perceptions of a variety of diseases and medical conditions, including rheumatological diseases which have increased in prevalence over the past several decades. The aim of this study was to perform a content analysis of tweets referring to rheumatological diseases. Methods: The content of each tweet was rated as medical (including a reference to diagnosis, treatment, or other aspects of the disease) or non-medical (such as requesting help). The type of user and the suitability of the medical content (appropriate content or, on the contrary, fake content if it was medically inappropriate according to the current medical knowledge) were also evaluated. The number of retweets and likes generated were also investigated. Results: We analyzed a total of 1514 tweets: 1093 classified as medical and 421 as non-medical. The diseases with more tweets were the most prevalent. Within the medical tweets, the content of these varied according to the disease (some more focused on diagnosis and others on treatment). The fake content came from unidentified users and mostly referred to the treatment of diseases. Conclusions: According to our results, the analysis of content posted on Twitter in regard to rheumatological diseases may be useful for investigating the public’s prevailing areas of interest, concerns and opinions. Thus, it could facilitate communication between health care professionals and patients, and ultimately improve the doctor–patient relationship. Due to the interest shown in medical issues it seems desirable to have healthcare institutions and healthcare workers involved in Twitter.

COVID-19 infection among autoimmune rheumatic disease patients: Data from an observational study and literature review

The impact of SARS-CoV-2 infection in patients with autoimmune/auto-inflammatory rheumatic diseases (AARD) under immunomodulatory treatment has been a focus of interest during the COVID-19 pandemic. In this observational study, demographic data, disease related features and comorbidities, COVID-19 manifestations and outcome as well as antibody responses to SARS-CoV-2 were recorded among 77 consecutive patients with underlying AARD infected by SARS-CoV-2. Analysis of data was performed using univariate and multivariate models. Most patients (68.8%) had a mild COVID-19 course. The predominant clinical manifestations were fatigue (58.4%), low grade fever (45.4%) and upper respiratory tract symptoms (68.8%). About a quarter of patients required hospitalization (23.3%) and the mortality rate was 1.3%. Regarding COVID-19 severity, prior treatment with corticosteroids, mycophenolate mofetil or rituximab was more common in patients who developed a more serious disease course (60.0 vs 29.9%, p = 0.003, 40.0 vs 7.5%, p = 0.003, 10.0 vs 0.0%, p = 0.009, respectively). When disease related features and comorbidities were considered in multivariate models, older age and lung disease in the context of the AARD were found to be independent predictive factors for hospitalization (OR [95%]: 1.09 [1.03-1.15] and 6.43 [1.11-37.19]). Among COVID-19 related features, patients with shortness of breath and high-grade fever were more likely to get hospitalized (OR [95%]: 7.06 [1.36-36.57], 12.04 [2.96-48.86]), while anosmia was independently associated with lower hospitalization risk (OR [95%]: 0.09 [0.01-0.99]). Though the majority of AARD patients displayed a mild COVID-19 course, certain underlying disease features and COVID-19 related manifestations should prompt alertness for the physician to identify patients with AARD at high risk for severe COVID-19 and need for hospitalization.

Understanding Fatigue in Sjögren's Syndrome: Outcome Measures, Biomarkers and Possible Interventions

Sjögren’s syndrome (SS) is an autoimmune disease affecting the salivary and lacrimal glands. Symptoms range from dryness to severe extra-glandular disease involving manifestations in the skin, lungs, nervous system, and kidney. Fatigue occurs in 70% of patients, characterizing primary SS (pSS) and significantly impacting the patient’s quality of life. There are some generic and specific instruments used to measure fatigue in SS. The mechanisms involved with fatigue in SS are still poorly understood, but it appears fatigue signaling pathways are more associated with cell protection and defense than with pro-inflammatory pathways. There are no established pharmacological treatment options for fatigue in pSS. So far, exercise and neuromodulation techniques have shown positive effects on fatigue in pSS. This study briefly reviews fatigue in pSS, with special attention to outcome measures, biomarkers, and possible treatment options.

Higher Risk for Sjögren's Syndrome in Patients With Fibromyalgia: A Nationwide Population-Based Cohort Study

Objectives

Clinically, associations have been observed between Sjögren's syndrome and fibromyalgia. Nonetheless, population-based evidence evaluating the risk of Sjögren's syndrome in fibromyalgia patients is lacking. The main purpose of this retrospective cohort study was to determine the association between fibromyalgia and subsequent development of Sjögren's syndrome.

Methods

This retrospective cohort study extracted data from the Longitudinal Health Insurance Database (LHID) of the Taiwan National Health Insurance (NHI). During 2000-2012, patients with newly-diagnosed fibromyalgia (International Classification of Diseases, Ninth Revision, Clinical Modification code 729.1) were defined as the exposure cohort. Age- and gender-matched individuals without fibromyalgia were used as the comparison cohort. The adjusted hazard ratios (aHR) for the occurrence of Sjögren's syndrome in those with fibromyalgia were evaluated along with stratified analyses of different subgroups.

Results

Of the 149,706 subjects whose data were extracted from the LHID, 74,853 subjects had coded fibromyalgia and 74,853 control subjects were without fibromyalgia. Compared to the control group, patients with fibromyalgia had an aHR of 2.00 (95% Confidence Interval [CI], 1.52-2.61) for developing Sjögren's syndrome. In fibromyalgia patients aged 20-49 years, the aHR for future Sjögren's syndrome was 3.07 (95% CI, 1.92-4.89).

Conclusion

Patients with fibromyalgia, both males and females, have a higher risk for developing Sjögren's syndrome than those without fibromyalgia, especially those aged 20-49 years. While managing patients, clinicians should be aware of the bidirectional association between the two diseases, which helps to understand the impact of the association on disease activity and diagnosis.

Genetic contributors and soluble mediators in prediction of autoimmune comorbidity

Comorbidities including subclinical atherosclerosis, neuropsychological aberrations and lymphoproliferation represent a major burden among patients with systemic autoimmune diseases; they occur either as a result of intrinsic disease related characteristics including therapeutic interventions or traditional risk factors similar to those observed in general population. Soluble molecules recently shown to contribute to subclinical atherosclerosis in the context of systemic lupus erythematosus (SLE) include among others B-cell activating factor (BAFF), hyperhomocysteinemia, parathormone (PTH) levels and autoantibodies against oxidized lipids. Variations of the 5, 10- methylenetetrahydrofolate reductase (MTHFR) gene -the main genetic determinant of hyperhomocystenemia in humans-as well the interferon regulatory factor-8 (IRF8), FcγRIIA and BAFF genes have been all linked to subclinical atherosclerosis in SLE. BAFF variants have been also found to confer increased risk for subclinical atherosclerosis and lymphoma development in Sjogren's syndrome (SS) patients. Other genes shown to be implicated in SS lymphoproliferation include genes involved a. in inflammatory responses such as the NFκB regulator Tumor necrosis factor alpha-induced protein 3 (TNFAIP3) and the Leukocyte immunoglobulin-like receptor A3 (LILRA3) immunoreceptor, b. B cell activation and signaling (BAFF/BAFF-receptor), c. type I IFN pathway such as three-prime repair exonuclease 1 (TREX1), d. epigenetic processes including DNA methylation (MTHFR rs1801133, 677T allele) and e. genomic instability (MTHFR rs1801131, 1298C allele). Emerging soluble biomarkers for SS related lymphoma include mediators of B cell growth and germinal center formation such as BAFF, FMS-like tyrosine kinase 3 ligand (Flt-3L) and CXCL13 as well as inflammatory contributors such as inteleukin (IL)-17, IL-18, ASC, LILRA3 and the extracellular lipoprotein-associated phospholipase A2 (Lp-PLA2). In regard to fatigue and neuropsychologic features in the setting of SS, contributing factors such as BAFF variants, antibodies against neuropeptides, proteins involved in nervous system function as well as inflammatory cytokines have been reported.