Sjögren's syndrome: a review of aetiology, pathogenesis, diagnosis and management

Evidence of a Sjögren's disease-like phenotype following COVID-19 in mice and humans

Sjögren's Disease (SjD) is a systemic autoimmune disease characterized by lymphocytic inflammation of the lacrimal and salivary glands (SG), dry eyes and mouth, and systemic symptoms. SARS-CoV-2 may trigger the development or progression of autoimmune diseases. To test this, we used a mouse model of SARS-CoV-2 infection and convalescent patients' blood and SG in order to understand the development of SjD-like autoimmunity after infection. First, SARS-CoV-2-infected human angiotensin-converting enzyme 2 (ACE2) transgenic mice exhibited decreased salivation, elevated antinuclear antibodies (ANA), and lymphocytic infiltration in the lacrimal and SG. The sera from patients with COVID-19 sera showed increased ANA (i.e., anti-SSA [Sjögren's-syndrome-related antigen A]/anti-Ro52 and anti-SSB [SS-antigen B]/anti-La). Male patients showed elevated anti-SSA compared with female patients, and female patients exhibited diverse ANA patterns. SG biopsies from convalescent COVID-19 patients were microscopically similar to SjD SG with focal lymphocytic infiltrates in 4 of 6 patients and 2 of 6 patients exhibiting focus scores of at least 2. Lastly, monoclonal antibodies produced in recovered patients blocked ACE2/spike interaction and cross-reacted with nuclear antigens. Our study shows a direct association between SARS-CoV-2 and SjD. Hallmark features of SjD-affected SGs were histologically indistinguishable from convalescent COVID-19 patients. The results implicate that SARS-CoV-2 could be an environmental trigger for SjD.

Oxidative Stress and Epigenetics: miRNA Involvement in Rare Autoimmune Diseases

Autoimmune diseases (ADs) such as Sjögren’s syndrome, Kawasaki disease, and systemic sclerosis are characterized by chronic inflammation, oxidative stress, and autoantibodies, which cause joint tissue damage, vascular injury, fibrosis, and debilitation. Epigenetics participate in immune cell proliferation and differentiation, which regulates the development and function of the immune system, and ultimately interacts with other tissues. Indeed, overlapping of certain clinical features between ADs indicate that numerous immunologic-related mechanisms may directly participate in the onset and progression of these diseases. Despite the increasing number of studies that have attempted to elucidate the relationship between miRNAs and oxidative stress, autoimmune disorders and oxidative stress, and inflammation and miRNAs, an overall picture of the complex regulation of these three actors in the pathogenesis of ADs has yet to be formed. This review aims to shed light from a critical perspective on the key AD-related mechanisms by explaining the intricate regulatory ROS/miRNA/inflammation axis and the phenotypic features of these rare autoimmune diseases. The inflamma-miRs miR-155 and miR-146, and the redox-sensitive miR miR-223 have relevant roles in the inflammatory response and antioxidant system regulation of these diseases. ADs are characterized by clinical heterogeneity, which impedes early diagnosis and effective personalized treatment. Redox-sensitive miRNAs and inflamma-miRs can help improve personalized medicine in these complex and heterogeneous diseases.

Primary Sjögren syndrome-related peripheral neuropathy: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Primary Sjögren syndrome (pSS) is a chronic, systemic, autoimmune disorder characterized by lymphocytic infiltrates of the exocrine organs, leading to sicca symptoms and parotid enlargement. pSS has been linked to various neurological manifestations, including peripheral neuropathy (PN). We aimed to provide a comprehensive analysis of the currently available evidence regarding pSS-related PN.

METHODS

A literature search in the PubMed database was performed, and 49 papers were eligible to be included in this systematic review and meta-analysis.

RESULTS

The pooled prevalence of PN in pSS is estimated to be 15.0% (95% confidence interval = 10.7%-20.7%). The mean age of pSS patients at PN diagnosis is 59 years. Among the patients with pSS and PN, 83% are females. Neuropathic symptoms usually precede or lead to the pSS diagnosis at a 2:1 ratio in patients with pSS-related PN. The commonest type of pSS-related PN is distal axonal polyneuropathy (80% of patients with pSS-related PN), followed by sensory ganglionopathy. Peripheral and cranial mononeuropathies-particularly trigeminal-are also frequent. Risk factors for developing PN include increasing age and presence of vasculitis. Immune-mediated pathogenetic mechanisms are discussed. Glucocorticoids are the most commonly used treatment option for managing pSS-related PN, when associated with vasculitis, followed by the use of intravenous immunoglobulin.

CONCLUSIONS

PN is very common in pSS patients. Evidence on long-term prognosis of PN in pSS is limited, and further research is needed. Research into the use of immunosuppressive medication in nonvasculitic neuropathies in the context of pSS merits further consideration.

Systemic Diseases with Oral Manifestations and Their Impact on Health-Related Quality of Life

Health-related quality of life is a multidimensional concept established to evaluate the physical, psychological, and social impacts of health conditions on individuals’ well-being. Various tools for measuring health-related quality of life can be categorized into two subsets: generic and disease–specific instruments. The oral cavity can be stricken by a broad range of local and systemic diseases and their systemic treatment modalities. The most common systemic illnesses associated with oral lesions are hematologic disorders, endocrinopathies, neurological disorders, gastrointestinal conditions, mucocutaneous and rheumatic diseases, and neoplastic processes. Their manifestations in the oral cavity are, in most cases, rather nonspecific but should not be overlooked. Oral health is one of the most important parts of overall health, thus it has been proposed that poor oral health may affect health–related quality of life. The presence of oral manifestations of systemic diseases has a negative impact on the daily functioning of patients, decreasing their overall well-being. This article will review the most common systemic diseases with oral manifestations and their impact on the health–related quality of life. Oral health researchers should put a stronger emphasis on the patient-reported quality of life as a primary outcome in future clinical trials. The significance of this area has still not been widely understood in the current dental literature even though it could help improve patients’ health-related quality of life.

Evidence of a Sjögren's disease-like phenotype following COVID-19

Objectives

Sjögren's Disease (SjD) is a chronic and systemic autoimmune disease characterized by lymphocytic infiltration and the development of dry eyes and dry mouth resulting from the secretory dysfunction of the exocrine glands. SARS-CoV-2 may trigger the development or progression of autoimmune diseases, as evidenced by increased autoantibodies in patients and the presentation of cardinal symptoms of SjD. The objective of the study was to determine whether SARS-CoV-2 induces the signature clinical symptoms of SjD.

Methods

The ACE2-transgenic mice were infected with SARS-CoV-2. SJD profiling was conducted. COVID-19 patients' sera were examined for autoantibodies. Clinical evaluations of convalescent COVID-19 subjects, including minor salivary gland (MSG) biopsies, were collected. Lastly, monoclonal antibodies generated from single B cells of patients were interrogated for ACE2/spike inhibition and nuclear antigens.

Results

Mice infected with the virus showed a decreased saliva flow rate, elevated antinuclear antibodies (ANAs) with anti-SSB/La, and lymphocyte infiltration in the lacrimal and salivary glands. Sera of COVID-19 patients showed an increase in ANA, anti-SSA/Ro52, and anti-SSB/La. The male patients showed elevated levels of anti-SSA/Ro52 compared to female patients, and female patients had more diverse ANA patterns. Minor salivary gland biopsies of convalescent COVID-19 subjects showed focal lymphocytic infiltrates in four of six subjects, and 2 of 6 subjects had focus scores >2. Lastly, we found monoclonal antibodies produced in recovered patients can both block ACE2/spike interaction and recognize nuclear antigens.

Conclusion

Overall, our study shows a direct association between SARS-CoV-2 and SjD. Hallmark features of SjD salivary glands were histologically indistinguishable from convalescent COVID-19 subjects. The results potentially implicate that SARS-CoV-2 could be an environmental trigger for SjD.

Key Messages

What is already known about this subject?SAR-CoV-2 has a tropism for the salivary glands. However, whether the virus can induce clinical phenotypes of Sjögren's disease is unknown.What does this study add?Mice infected with SAR-CoV-2 showed loss of secretory function, elevated autoantibodies, and lymphocyte infiltration in glands.COVID-19 patients showed an increase in autoantibodies. Monoclonal antibodies produced in recovered patients can block ACE2/spike interaction and recognize nuclear antigens.Minor salivary gland biopsies of some convalescent subjects showed focal lymphocytic infiltrates with focus scores.How might this impact on clinical practice or future developments?Our data provide strong evidence for the role of SARS-CoV-2 in inducing Sjögren's disease-like phenotypes.Our work has implications for how patients will be diagnosed and treated effectively.

Association between a History of herpes zoster and the risk of Sjögren's syndrome: a nationwide, population-based, case-control study

OBJECTIVE

Viral infection is an exogenous factor for Sjögren's syndrome (SS). The relationship between herpes zoster infection and the ensuring risk of SS has remained unclear. This study investigated the association between a history of herpes zoster infection and the risk of SS through a nationwide population-based case-control study.

DESIGN

Retrospective case-control study.

SETTING

General population of Taiwan.

DATA SOURCE

2003-2013 National Health Insurance Research Database of Taiwan.

PARTICIPANTS

We identified all patients with newly diagnosed SS between 1 January 2007 and 31 December 2012 without a history of rheumatoid arthritis or systemic lupus erythematosus as the SS group.

CONTROLS

We randomly selected patients without SS between 1 January 2003 and 31 December 2012 and matched 1:5 with controls based on index year, age and sex.

MAIN OUTCOME MEASURE

Conditional logistic regression analysis to examine the association between a history of herpes zoster and the risk of SS.

RESULTS

The study included 5751 patients with SS and 28 755 matched controls. The risk of SS was significantly associated with a history of herpes zoster (model A (adjusted for Charlson Comorbidity Index (CCI) (excluding connective tissue disease, CTD)): OR 1.89; 95% CI 1.71 to 2.08; model B (adjusted for comorbidities used to calculate CCI (excluding CTD)): OR 1.90; 95% CI 1.72 to 2.10), in particular if the interval from the last visit for herpes zoster infection to the index date was <3 months (model A: OR 3.09; 95% CI 2.20 to 4.34; model B: OR 3.13; 95% CI 2.20 to 4.45). Such associations remained robust using various definitions of herpes zoster.

CONCLUSION

This nationwide, population-based, case-control study revealed a significant association between a history of herpes zoster and the risk of SS.

Primary Sjögren's syndrome (pSS)-related cerebellar ataxia: a systematic review and meta-analysis

BACKGROUND

Primary Sjögren's syndrome (pSS) is a chronic autoimmune disorder characterized by lymphocytic infiltrates of the exocrine glands, particularly the salivary and lacrimal glands, resulting in oral and ocular dryness. pSS has been linked to various neurological manifestations, including cerebellar dysfunction. We aimed to provide a comprehensive analysis of the currently available evidence regarding pSS-related cerebellar ataxia.

METHODS

A systematic literature search in the PubMed database was performed and 19 papers were eligible to be included in this paper.

RESULTS

The pooled prevalence of cerebellar ataxia in pSS is estimated to be 1.5% (95% CI 0.3-6.8%). pSS patients with cerebellar involvement have a female-to-male ratio of 6:1. Although most of the patients are adults in their fifth decade of life when diagnosed, cases of children with pSS and cerebellar involvement have been reported. Typical cerebellar ataxia related to pSS manifests with vermian dysfunction, namely gait ataxia and/or cerebellar speech. Cerebellar ataxia due to pSS may also mimic degenerative cerebellar ataxia, especially when the onset is progressive.

CONCLUSIONS

The diagnostic approach to a patient with cerebellar ataxia of unknown etiology should include evaluation for an underlying pSS. A thorough history and clinical examination, antibody testing, brain MRI imaging and/or MRS of the cerebellum will assist in establishing the diagnosis. Setting up a joint neuro-rheumatology clinic can be valuable given that rheumatic and neurological diseases share comorbidities.

Reticular enhancement of the submandibular gland on contrast-enhanced magnetic resonance imaging in three cases with IgG4-related chronic sclerosing sialadenitis

The present case study reports contrast-enhanced magnetic resonance findings in three patients with histopathologically proven IgG4-related chronic sclerosing sialadenitis of the submandibular gland. All three patients presented with painless swelling of the submandibular region. The contrast-enhanced T1-weighted images showed reticular enhancement of the swollen submandibular gland. Radiological-pathological correlation revealed that the characteristic reticular enhancement corresponded to fibrosis and to inflammatory cell infiltration in the interlobular septa and in the periductal region of the submandibular gland.

The value of 68 Ga-PSMA-11 positron emission tomography/computerized tomography in evaluating the lacrimal and salivary glands function

OBJECTIVE

To investigate the value of ⁶⁸ Ga-PSMA-11 positron emission tomography/computerized tomography (PET/CT) in evaluating lacrimal and salivary glands function.

METHODS

Ten patients with pSS and 18 healthy volunteers were recruited in this study. All participants underwent ⁶⁸ Ga-PSMA-11 PET/CT, and the patients with pSS performed salivary gland scintigraphy the next day. The maximum standardized uptake value (SUVmax), average of the standard uptake value (SUVavg), the average CT value (CTavg), and volume (V) in the region of interest (ROI) of each lacrimal and salivary gland were analyzed in⁶⁸Ga-PSMA-11 PET/CT. The uptake ratio (UR) of the bilateral parotid gland and submandibular gland was calculated in salivary gland scintigraphy (SGS). Statistical analysis was processed by the SPSS software and the MedCalc software. A p-value of < 0.05 was considered as statistically significant.

RESULTS

Almost all the parameters of pSS were significantly lower than those of the control group (p < 0.05). The left parotid gland (PG) UR was positive correlation with left PG SUVmax (r = 0.758, p = 0.011) and left PG SUVavg (r = 0.770, p = 0.009); the right PGUR was positive correlation with right PG SUVmax (r = 0.721, p = 0.019) and right PG SUVavg (r = 0.721, p = 0.019). The SUVmax and SUVavg of both sides of acrimal and salivary glands had area under the receiver operating curve values greater than 0.5.

CONCLUSIONS

⁶⁸ Ga-PSMA-11 PET/CT can simultaneously enable the visualization of lacrimal glands and salivary glands and be used to evaluate the lacrimal and salivary glands function. Key Points • We have firstly investigated the value of 68 Ga-PSMA-11 PET/CT in evaluating lacrimal and salivary glands function in patients with pSS 68 Ga-PSMA-11 PET/CT can simultaneously allow the visualization of lacrimal glands and salivary glands. • The results of the present study imply that 68 Ga-PSMA-11 PET/CT can be used to evaluate the lacrimal and salivary glands function in patients with pSS meanwhile.

Oral microbiota in xerostomia patients - A preliminary study

Background/purpose

The estimated prevalence of xerostomia (lack of saliva) ranges from 10% to 50% of the general population. The oral cavity provides a multivariant environmental habitat to over 700 species of bacteria and fungi. We hypothesized that xerostomia will alter the composition of oral microbiota.

Material and methods

Nineteen xerostomia patients and 10 healthy normal volunteers were studied for the oral microbiota. Gingival plaques were collected and microbiota were detected using bacterial 16S ribosomal RNA and analyzed based on the levels of phylum and class.

Results

In all cases, phyla of Actinobacteria, Bacteroidetes, Firmicutes, Fusobacteria, and Proteobacteria make up to 100% of oral microbiota at phylum level. Analyzing individual phylum, presence of Bacteroidetes in xerostomia patients and normal subjects were 23.12 ± 2.56% and 23.23 ± 2.58%, respectively. Mean percentage presence of Firmicutes phylum in xerostomia patients and normal subjects were 18.94 ± 1.83% and 14.06 ± 0.98%, respectively. Statistically significant difference was not observed between xerostomia patients and normal subjects in this study.

Conclusion

These observations revealed obvious but not statistically significant changes in oral major microorganism phylum between xerostomia patients and normal subjects in this study. More samples are needed to verify the current results and to use oral microbiota as a tool in the diagnosis of xerostomia.

A meta-analysis of the effect of Sjögren's syndrome on adverse pregnancy outcomes

OBJECTIVE

This study aimed to assess the correlation between Sjögren's Syndrome (SS) and adverse pregnancy outcomes, with the aim of providing a basis for preconception and pregnancy interventions in women with SS.

METHODS

A search of electronic databases in English and Chinese databases from January 2005 to December 2021, was conducted to collect the literature of case-control studies or cohort studies on the association between SS and pregnancy outcome studies. Literature inclusion and data extraction were performed according to established criteria, and the Newcastle-Ottawa scale was used to evaluate the quality of the literature. Stata 15 software was used for meta-analysis.

RESULTS

A total of nine papers were included in this study. Meta-analysis results showed that SS was associated with spontaneous abortion (RR = 8.85, 95% CI 3.10‒25.26), preterm birth (RR = 2.27, 95% CI 1.46‒3.52), low birth mass (RR = 1.99, 95% CI 1.34‒2.97), and birth defects (RR = 4.28, 95% CI 3.08‒5.96).

CONCLUSION

SS can increase the incidence of adverse pregnancy outcomes.

Egg White Alginate as a Novel Scaffold Biomaterial for 3D Salivary Cell Culturing

Saliva production by salivary glands play a crucial role in oral health. The loss of salivary gland function could lead to xerostomia, a condition also known as dry mouth. Significant reduction in saliva production could lead to further complications such as difficulty in speech, mastication, and increased susceptibility to dental caries and oral infections and diseases. While some palliative treatments are available for xerostomia, there are no curative treatments to date. This study explores the use of Egg White Alginate (EWA), as an alternative scaffold to Matrigel^® for culturing 3D salivary gland cells. A protocol for an optimized EWA was established by comparing cell viability using 1%, 2%, and 3% alginate solution. The normal salivary simian virus 40-immortalized acinar cell (NS-SV-AC) and the submandibular gland-human-1 (SMG-hu-1) cell lines were also used to compare the spheroid formation and cell viability properties of both scaffold biomaterials; cell viability was observed over 10 days using a Live–Dead Cell Assay. Cell viability and spheroid size in 2% EWA was significantly greater than 1% and 3%. It is evident that EWA can support salivary cell survivability as well as form larger spheroids when compared to cells grown in Matrigel^®. However, further investigations are necessary as it is unclear if cultured cells were proliferating or aggregating.

Headache and immunological/autoimmune disorders: a comprehensive review of available epidemiological evidence with insights on potential underlying mechanisms

Several lines of evidence support a role of the immune system in headache pathogenesis, with particular regard to migraine. Firstly, alterations in cytokine profile and in lymphocyte subsets have been reported in headache patients. Secondly, several genetic and environmental pathogenic factors seem to be frequently shared by headache and immunological/autoimmune diseases. Accordingly, immunological alterations in primary headaches, in particular in migraine, have been suggested to predispose some patients to the development of immunological and autoimmune diseases. On the other hand, pathogenic mechanisms underlying autoimmune disorders, in some cases, seem to favour the onset of headache. Therefore, an association between headache and immunological/autoimmune disorders has been thoroughly investigated in the last years. The knowledge of this possible association may have relevant implications in the clinical practice when deciding diagnostic and therapeutic approaches. The present review summarizes findings to date regarding the plausible relationship between headache and immunological/autoimmune disorders, starting from a description of immunological alteration of primary headaches, and moving onward to the evidence supporting a potential link between headache and each specific autoimmune/immunological disease.

Therapeutic Approaches for the Management of Autoimmune Disorders via Gene Therapy: Prospects, Challenges, and Opportunities

BACKGROUND

Autoimmune diseases are the diseases that result due to the overactive immune response, and comprise systemic autoimmune diseases like rheumatoid arthritis (RA), sjӧgren's syndrome (SS), and organ-specific autoimmune diseases like type-1 diabetes mellitus (T1DM), myasthenia gravis (MG), and inflammatory bowel disease (IBD). Currently, there is no long-term cure; but, several treatments exist which retard the evolution of the disease, embracing gene therapy, which has been scrutinized to hold immense aptitude for the management of autoimmune diseases.

OBJECTIVE

The review highlights the pathogenic mechanisms and genes liable for the development of autoimmune diseases, namely T1DM, type-2 diabetes mellitus (T2DM), RA, SS, IBD, and MG. Furthermore, the review focuses on investigating the outcomes of delivering the corrective genes with their specific viral vectors in various animal models experiencing these diseases to determine the effectiveness of gene therapy.

METHODS

Numerous review and research articles emphasizing the tremendous potential of gene therapy in the management of autoimmune diseases were procured from PubMed, MEDLINE, Frontier, and other databases and thoroughly studied for writing this review article.

RESULTS

The various animal models that experienced treatment with gene therapy have displayed regulation in the levels of proinflammatory cytokines, infiltration of lymphocytes, manifestations associated with autoimmune diseases, and maintained equilibrium in the immune response, thereby hinder the progression of autoimmune diseases.

CONCLUSION

Gene therapy has revealed prodigious aptitude in the management of autoimmune diseases in various animal studies, but further investigation is essential to combat the limitations associated with it and before employing it on humans.

Associations Between Air Pollution Exposure and Daily Pediatric Outpatient Visits for Dry Eye Disease: A Time-Series Study in Shenzhen, China

Objectives: This study aimed to investigate the associations between air pollution exposure and pediatric outpatient visits for dry eye disease (DED) in Shenzhen, China.

Methods: Generalized additive models were utilized to explore the acute effects of air pollution exposure on pediatric outpatient visits for DED.

Results: Single-day lag exposures to NO₂, O₃, PM_2.5, and PM₁₀ were associated with DED outpatient visits at lag days 0, 6, 4 and 2. Relative risks (RRs) for DED given a 10-μg/m³ increase in NO₂, O₃, PM_2.5, and PM₁₀ concentrations were 1.062[95% confidence interval (CI) 1.003, 1.123], 1.015(95% CI 1.001, 1.031), 1.052(95% CI 1.001, 1.115), and 1.038 (95% CI 1.002, 1.076), respectively. RR for DED given a 10-μg/m³ increase in NO₂ over cumulative lag days 0–1 was 1.075 (95% CI 1.009, 1.147), and RR for DED given a 10-μg/m³ increase in PM₁₀ over cumulative lag days 0–4 was 1.051 (95% CI 1.003, 1.102).

Conclusion: The observed associations between air pollution and outpatient visits for DED may provide evidence for policy makers to consider implementing measures to reduce the risk of DED owing to air pollution in China.

Role of ranulas in early diagnosis of Sjögren’s syndrome: A case report

BACKGROUND

Although the presentations of Sjögren’s syndrome (SS) are variable, ranging from mild dryness to wider systemic involvement, ranulas as early clinical signs were scarcely reported. Here, we present an adult patient with SS, who developed a unilateral simple ranula and was diagnosed primary SS 3 years later. We also provide a review of cases of SS and ranulas from 1980 to 2020.

CASE SUMMARY

A 22-year-old girl was found to have a left painless floor-of-mouth lesion 3 years ago, without obvious trauma or inducement. The diagnosis of a unilateral (left) simple ranula was made, and the ranula was surgically treated. Within 3 years after the ranula surgery, she developed acute lymphadenectasis in unilateral parotid twice without inducement, and ultrasonic examination revealed diffuse lesions in bilateral parotids and submandibular glands, which strongly suggested SS. Serologic tests and the unstimulated whole saliva flow rate confirmed the SS diagnosis.

CONCLUSION

Our study underlines that ranulas are early clinical signs of SS. As early diagnosis and early intervention of SS are important to obtain better outcomes, our findings underline the need for histopathological test after sublingual adenectomy and imaging detection of exocrine glands for the patients with ranulas.

Fatigue in Saudi Patients with Primary Sjögren's Syndrome and Its Correlation with Disease Characteristics and Outcome Measures: A Cross-Sectional Study

Background

Fatigue is a prevalent symptom affecting primary Sjögren's syndrome (pSS) patients. The purpose of this study is to determine the prevalence of fatigue in Saudi pSS patients and its correlation with disease features and outcome measures using a validated tool.

Methods

This is a cross-sectional study evaluating fatigue in pSS using the Arabic version of the fatigue severity scale (FSS). The EULAR Sjögren's syndrome disease activity index (ESSDAI) and EULAR Sjögren's syndrome patient reported index (ESSPRI) were calculated.

Results

Forty-one patients met the sample criteria and were involved in the final report. There were predominantly females (78%) with a mean (±SD) age and disease duration of 58.76±12.7 and 4.6±2.28 years, respectively. Based on the FSS, 18 (43.9%) patients had a positive test with a mean score of 5.43±0.76. The mean ESSDAI was 9.95±7.73, while the mean EESPRI was 5.17±2.4 with individual component scores were dryness (5.23±2.62), fatigue (5.4±2.88), and pain (4.88±3.31). The FSS had a significant correlation with PGA (r=0.559; p<0.001), PhGA (r=0.671; p<0.001), ESSDAI (r=0.402; p=0.01), ESSPRI fatigue component (r=0.0.621; p<0.001), ESSPRI pain component (r=0.558; p<0.001), and missed significance for the ESSPRI dryness component (r=0.289; p=0.071). There was no correlation between the total ESSPRI score and presence of fatigue (r=-0.261; p=0.104) nor the FSS score (r=-0.136; p=0.409).

Conclusion

Fatigue is prevalent in Saudi pSS patients. FSS correlated with ESSDAI and ESSPRI components but not its total score signaling other unmeasured factors contributing to fatigue development.

Infections as Risk Factor of Sjögren's Syndrome

Purpose

Sjögren's syndrome (SS) is an autoimmune disease targeting exocrine glands, leading to low body fluids production, especially on the salivary and lacrimal glands. Due to the low saliva and tear production, the common symptoms of Sjögren's syndrome are dry eyes and dry mouth, later on leading to uncomfortable sensations on the eye surface, cornea destruction, dental caries, and oral cavity infections. Several infections are known to cause similar side-effects to Sjögren's syndrome symptoms, including low saliva flow; therefore, infection is hypothesized as one of the risk factors of Sjögren's syndrome.

Results

Based on our literature research, there are several infectious agents which cause similar disease manifestations to Sjögren's syndrome, including infections of hepatitis C virus, Epstein-Barr virus, cytomegalovirus, and human T-lymphotropic virus-1 (HTLV-1), and these four agents are found to cause persistent infection on the salivary gland after the first infection and later lead to organ destruction, thus causing sicca syndrome in the oral cavity. Other findings show possible Heliobacter pylori infection might lead on the increasing level of anti-Ro/SSA and anti-La/SSB of infected individuals.

Conclusion

Some research has shown persistent infection could trigger autoimmune disorders due to continuous T-cells and B-cells activation in an attempt of infected cells eradication, leading to autoimmune reaction and high autoreactive cells concentration around the healthy cells causing the immune cells to eradicate the healthy cells nearby. However, the results in this literature study found persistent infection is not the only risk factor of Sjögren's syndrome but there are various unknown factors that trigger infection to develop into Sjögren's syndrome.

miR-744-5p contributes to ocular inflammation in patients with primary Sjogrens Syndrome

In primary Sjögren’s syndrome (pSS) the exocrine glands become infiltrated with lymphocytes instigating severe damage to the salivary and lacrimal glands causing dry eyes and dry mouth. Previous investigations have suggested that dysregulated localized and systemic inflammation contributes to the development and pathogenesis of pSS. A miR microarray performed in primary human conjunctival epithelial cells (PECs) demonstrated significant differences in miR expression at the ocular surface between pSS patients and healthy controls. MicroRNA-744-5p (miR-744-5p) was identified as being of particular interest, as its top predicted target is Pellino3 (PELI3), a known negative regulator of inflammation. Validation studies confirmed that miR-744-5p expression is significantly increased in PECs from pSS patients, whilst PELI3 was significantly reduced. We validated the miR-744 binding site in the 3’ untranslated region (UTR) of PELI3 and demonstrated that increasing PELI3 levels with a miR-744-5p antagomir in an inflammatory environment resulted in reduced levels of IFN dependent chemokines Rantes (CCL5) and CXCL10. These results reveal a novel role for miR-744-5p in mediating ocular inflammation via Pellino3 expression in pSS patients and suggest that miR-744-5p may be a potential therapeutic target for the management of severe dry eye disease and ocular inflammation in pSS patients.

Sjögren's syndrome and ranula development

OBJECTIVES

We hypothesized that the extravasation of saliva from damaged ducts with lymphocytic infiltration in patients with Sjögren's syndrome causes ranulas. There are too many uncertainties to support this hypothesis. The aim of this study was to investigate whether there is an association between Sjögren's syndrome and ranulas.

MATERIALS AND METHODS

We observed three cases of patients with ranulas who were also diagnosed with Sjögren's syndrome at the same facility. These cases led to the question of whether there are other such cases, and thus, an exhaustive literature search was conducted.

RESULTS

Three cases in two case reports of mucocele of the floor of the mouth associated with adult Sjögren's syndrome were noted. Including our cases, until now, there have been six cases of ranula with adult Sjögren's syndrome.

CONCLUSIONS

It could be useful to investigate whether patients presenting with a ranula are also affected by Sjögren's syndrome and, conversely, investigate patients with Sjögren's syndrome longitudinally to see whether they develop ranulas.

Laryngological manifestations of Sjögren's syndrome

Sjögren’s syndrome (SS) is a systemic autoimmune disease characterized by lymphocytic infiltration of exocrine glands and a range of extra-glandular features. The most common and earliest symptoms are oral and ocular dryness. The aim of this study is to present the most common otolaryngological manifestations of SS, their pathomechanism and possible aetiology. The most common oral signs and symptoms are xerostomia, tooth decay, fungal infections, traumatic oral lesions, dysphagia, dysgeusia, and inflammation of the salivary glands. The salivary glands of SS patients are characterised by chronic inflammation. The presence of foci is thus a hallmark of SS. A biopsy can be taken from either the labial or the parotid salivary gland. The most significant complication of SS is the development of lymphoproliferative malignancy, which occurs in about 5% of SS patients. The ultrasonic greyscale scoring system, glandular volume measurement, and intraglandular power Doppler ultrasonography are specific ultrasound parameters of SS.

Detection of SSA and SSB Antibodies Associated with Primary Sjögren's Syndrome Using Enzyme-Linked Immunosorbent Assay

Antibodies to Ro52/Ro60 (SSA) and La (SSB) are strongly associated to the autoimmune disease primary Sjögren's syndrome and are important in the serologic diagnosis of the disease. Several methods for detection of these antibodies exist such as indirect immunofluorescence, commercial western blot kits, in-house assays, and numerous commercial enzyme-linked immunosorbent assays (ELISAs). Dependent on the type of assay, sensitivity and specificity may vary notably. Especially ELISAs, where the antibody reactivity to synthetic peptides, recombinant or native proteins are determined, are often applied. This chapter describes detection of SSA and SSB antibodies by ELISA.

Cerebellar degeneration in primary Sjӧgren syndrome

Neurological manifestations are reported as a consequence of primary Sjӧgren syndrome (PSS). Any part of the brain and peripheral nervous system can be involved in PSS. However, cerebellar degeneration and atrophy associated with PSS have been rarely reported. Our report describes a 22-year-old woman who presented with cerebellar ataxia, arthritis and arthralgia. Evaluation of her symptoms, autoantibodies and salivary gland pathology was in favour of the diagnosis of Sjögren syndrome. Also, her brain MRI revealed cerebellar degeneration. There are only four patients reported to be affected by cerebellar atrophy associated with PSS. Administration of high doses of methylprednisolone and cyclophosphamide leads to substantial improvement in the cerebellar symptoms of this case. In addition, after 2 months of follow-up, the patient's ataxia recovered significantly. It could be concluded that in addition to neurological degenerative disorders, in some cases cerebellar atrophy could also be associated with autoimmune conditions such as PSS.

Autoimmune Diseases and Their Manifestations on Oral Cavity: Diagnosis and Clinical Management

Oral signs are frequently the first manifestation of autoimmune diseases. For this reason, dentists play an important role in the detection of emerging autoimmune pathologies. Indeed, an early diagnosis can play a decisive role in improving the quality of treatment strategies as well as quality of life. This can be obtained thanks to specific knowledge of oral manifestations of autoimmune diseases. This review is aimed at describing oral presentations, diagnosis, and treatment strategies for systemic lupus erythematosus, Sjögren syndrome, pemphigus vulgaris, mucous membrane pemphigoid, and Behcet disease.

Subconjunctival dendrimer-drug therapy for the treatment of dry eye in a rabbit model of induced autoimmune dacryoadenitis

PURPOSE

To investigate the efficacy of a single subconjunctival injection of dendrimer-dexamethasone conjugate in a rabbit model of induced autoimmune dacryoadenitis (AID).

METHODS

Dendrimer biodistribution after subconjunctival injection in AID animals was evaluated using Cy5-labelled dendrimer (D-Cy5) and confocal microscopy. Diseased animals were treated with free dexamethasone (Free-Dex), dendrimer-dexamethasone (D-Dex), or saline via a single subconjunctival injection. The efficacy was evaluated using various clinical evaluations, such as Schirmer's test, tear breakup time (TBUT), and fluorescein and rose Bengal staining. Histopathology was evaluated by H&E staining and immunostaining. Levels of inflammatory cytokines and aquaporin proteins in the LGs were determined by real-time PCR.

RESULTS

Subconjunctivally administered dendrimers selectively localized in the inflamed LGs, and were taken up by the infiltrating cells. At two weeks post single dose-treatment, the D-Dex group showed improved clinical evaluations. No significant changes were observed in other groups. H&E staining demonstrated less inflammatory cell infiltration and fewer atrophic acini in D-Dex group, compared to those treated with saline or Free-Dex. Immunohistochemistry demonstrated that the intensity of CD-18 (+) and RTLA (+) was weaker in LGs in the D-Dex group than in other treatment groups. Pro-inflammatory gene expression levels of MMP9, IL6, IL8, and TNFα were significantly decreased in the D-Dex group compared to the Free-Dex and saline group.

CONCLUSIONS

The dendrimer exhibits pathology-dependent biodistribution in the inflamed LGs. Subconjunctivally administered D-Dex suppressed LG inflammation, leading to partial recovery of LG function with clinical improvement in induced AID. Sjögren's patients may benefit from this targeted nanomedicine approach.

Contemporary management and full mouth rehabilitation of a patient with Sjögren syndrome

Sjögren syndrome is a chronic autoimmune disorder with xerostomia, increased tooth wear, high rates of caries, and repeated failure of dental restorations as the main oral symptoms. These render the prosthetic treatment challenging. This clinical report describes a contemporary approach to the treatment of a patient with Sjögren syndrome using translucent multilayered monolithic zirconia restorations and focuses on the treatment protocols before, during, and after the prosthetic treatment.

Patient burden of Sjögren's: a comprehensive literature review revealing the range and heterogeneity of measures used in assessments of severity

CONTEXT

The severity of Sjögren's syndrome has been evaluated using a wide variety of clinical measures and patient-reported outcomes (PROs). This may contribute to the lack of clarity concerning the burden of Sjögren's from the patient perspective.

OBJECTIVE

To perform a comprehensive peer-reviewed literature analysis of the patient aspects of Sjögren's, focusing on PROs, to investigate the complexity underlying the evaluation of the syndrome and to elucidate the discordance between the different measures.

METHODS

We searched Embase for articles published between January 2005 and September 2015. Research articles, clinical and diagnostic reviews, and validation studies with a focus on patient aspects of Sjögren's were selected as the primary information source.

RESULTS

157 articles met the eligibility criteria. A wide variety of assessment measures used to evaluate glandular, extraglandular and functional domains were observed. Many different, non-validated Visual Analogue Scales, with a wide range of anchor words, were used in the quantification of Sjögren's disease burden, impeding comparisons between studies. Relatively few clinical trials of drug therapies used validated scales: European League Against Rheumatism Sjögren's Syndrome Patient Reported Index was used most often for symptom assessment and 36 Item Short Form Survey for quality of life (QoL).

CONCLUSION

A wide range and diversity of measures are used to evaluate the patient burden of Sjögren's; most are not validated for use in this disease. PRO endpoints, validated specifically in Sjögren's, that demonstrate improvement are needed. These measures should focus on QoL aspects important to patients and will most likely involve gauging change in function rather than patient-reported symptoms.

Rapamycin Eye Drops Suppress Lacrimal Gland Inflammation In a Murine Model of Sjögren's Syndrome

Purpose

To evaluate the efficacy of topical rapamycin in treating autoimmune dacryoadenitis in a mouse model of Sjögren's syndrome.

Methods

We developed rapamycin in a poly(ethylene glycol)-distearoyl phosphatidylethanolamine (PEG-DSPE) micelle formulation to maintain solubility. Rapamycin or PEG-DSPE eye drops (vehicle) were administered in a well-established Sjögren's syndrome disease model, the male nonobese diabetic (NOD) mice, twice daily for 12 weeks starting at 8 weeks of age. Mouse tear fluid was collected and tear Cathepsin S, a putative tear biomarker for Sjögren's syndrome, was measured. Lacrimal glands were retrieved for histological evaluation, and quantitative real-time PCR of genes associated with Sjögren's syndrome pathogenesis. Tear secretion was measured using phenol red threads, and corneal fluorescein staining was used to assess corneal integrity.

Results

Lymphocytic infiltration of lacrimal glands from rapamycin-treated mice was significantly (P = 0.0001) reduced by 3.8-fold relative to vehicle-treated mice after 12 weeks of treatment. Rapamycin, but not vehicle, treatment increased tear secretion and decreased corneal fluorescein staining after 12 weeks. In rapamycin-treated mice, Cathepsin S activity was significantly reduced by 3.75-fold in tears (P < 0.0001) and 1.68-fold in lacrimal gland lysates (P = 0.003) relative to vehicle-treated mice. Rapamycin significantly altered the expression of several genes linked to Sjögren's syndrome pathogenesis, including major histocompatibility complex II, TNF-α, IFN-γ, and IL-12a, as well as Akt3, an effector of autophagy.

Conclusions

Our findings suggest that topical rapamycin reduces autoimmune-mediated lacrimal gland inflammation while improving ocular surface integrity and tear secretion, and thus has potential for treating Sjögren's syndrome–associated dry eye.

Seasonality and autoimmune diseases: The contribution of the four seasons to the mosaic of autoimmunity

Autoimmune diseases (ADs) are a heterogeneous groups of diseases that occur as a results of loss of tolerance to self antigens. While the etiopathogeneis remain obscure, different environmental factors were suggested to have a role in the development of autoimmunity, including infections, low vitamin D levels, UV radiation, and melatonin. Interestingly, such factors possess seasonal variation patterns that could influence disease development, severity and progression. Vitamin D levels which reach a nadir during late winter and early spring is correlated with increased disease activity, clinical severity as well as relapse rates in several disease entities including multiple sclerosis (MS), non-cutaneous flares of systemic lupus erythematosus (SLE), psoriasis, and rheumatoid arthritis (RA). Additionally, immunomodulatory actions of melatonin secretion ameliorate the severity of several ADs including MS and SLE. Melatonin levels are lowest during spring, a finding that correlates with the highest exacerbation rates of MS. Further, melatonin is postulated to be involved in the etiopathogenesis of inflammatory bowel diseases (IBD) through it influence on adhesion molecule and therefore transcription factor expression. Moreover, infections can mount to ADs through pro-inflammatory cytokine release and human antigen mimicry. Seasonal patterns of infectious diseases are correlated with the onset and exacerbation of ADs. During the winter, increased incidence of Epstein-Barr virus (EBV) infectious are associated with MS and SLE flares/onset respectively. In addition, higher Rotavirus infections during the winter precedes type 1 diabetes mellitus onset (T1DM). Moreover, Escherichia coli (E. coli) infection prior to primary biliary cirrhosis (PBC) and T1DM disease onset subsequent to Coxachievirus infections are seen to occur during late summer, a finding that correlate with infectious agents' pattern of seasonality. In this review, the effects of seasonality on the onset, relapses and activity of various ADs were discussed. Consideration of seasonal variation patterns of ADs can possibly provide clues to diseases pathogenesis and lead to development of new approaches in treatment and preventative care.

Effect of mesenchymal stem cells on Sjögren-like mice and the microRNA expression profiles of splenic CD4+ T cells

Mesenchymal stem cells (MSCs) serve immuno-regulatory functions and offer a promising novel treatment for certain autoimmune diseases. The present study investigated the therapeutic effect of mice bone marrow (BM)-MSCs on mice with relatively late stage of Sjögren-like disease and the impact of BM-MSCs on the microRNA (miRNA) expression profiles of splenic CD4+ T cells. Female NOD/Ltj mice were randomized into two groups: The disease group (n=8) and the MSC-treated group (n=8). Female ICR mice served as the healthy control group (n=8). The MSC-treated group received an injection of MSCs when they were 26 weeks old. Water intake, blood glucose and salivary flow rate were measured and submandibular glands were resected and stained with hematoxylin and eosin to calculate the focus score. The concentrations of interleukin (IL)-2, IL-6, hepatocyte growth factor, interferon γ, IL-10, prostaglandin E2, transforming growth factor β1 and tumor necrosis factor-α in serum were measured using ELISA. The expression of miRNAs in splenic CD4+ T cells were measured using deep sequencing. The results demonstrated that treatment with BM-MSCs prevented a decline in the salivary flow rate and lymphocyte infiltration in the salivary glands of NOD mice, indicating that MSC-treatment had a therapeutic effect on NOD mice with relatively late stage of Sjögren-like disease. ELISA and deep sequencing results showed that the three groups of mice had different serum concentrations of cytokines/growth factors and different miRNA expression profiles of splenic CD4+ T cells. This implies that the alteration in serum levels of cytokines/growth factors and miRNA expression profiles of splenic CD4+ T cells may explain the therapeutic effect MSCs have on Sjögren's syndrome.

Delivery of Bone Marrow-Derived Mesenchymal Stem Cells Improves Tear Production in a Mouse Model of Sjögren's Syndrome

The purpose of the present study was to test the potential of mouse bone marrow-derived mesenchymal stem cells (BD-MSCs) in improving tear production in a mouse model of Sjögren's syndrome dry eye and to investigate the underlying mechanisms involved. NOD mice (n = 20) were randomized to receive i.p. injection of sterile phosphate buffered saline (PBS, control) or murine BD-MSCs (1 × 10⁶ cells). Tears production was measured at baseline and once a week after treatment using phenol red impregnated threads. Cathepsin S activity in the tears was measured at the end of treatment. After 4 weeks, animals were sacrificed and the lacrimal glands were excised and processed for histopathology, immunohistochemistry, and RNA analysis. Following BD-MSC injection, tears production increased over time when compared to both baseline and PBS injected mice. Although the number of lymphocytic foci in the lacrimal glands of treated animals did not change, the size of the foci decreased by 40.5% when compared to control animals. The mRNA level of the water channel aquaporin 5 was significantly increased following delivery of BD-MSCs. We conclude that treatment with BD-MSCs increases tear production in the NOD mouse model of Sjögren's syndrome. This is likely due to decreased inflammation and increased expression of aquaporin 5.

Sjögren's syndrome is associated with negatively variable impacts on domains of health-related quality of life: evidence from Short Form 36 questionnaire and a meta-analysis

PURPOSE

The purpose of this article was to systematically review the literature to identify the impact of primary Sjögren's syndrome (pSS) on specific health-related quality of life (HRQoL) domains.

METHODS

A meta-analysis was performed, and the related articles were searched in Medline, Embase, Cochrane Library, China National Knowledge Infrastructure, China Biology Medicine, and Web of Science databases and in reference lists of articles and systematic reviews. Score of the Short Form 36 (SF-36) questionnaire was used as the outcome measurement, and mean differences (MD) with 95% confidence intervals (CIs) were calculated.

RESULTS

Seven studies were included, comprising 521 patients with pSS and 9,916 healthy controls. The SF-36 questionnaire score of each domain (physical function, role physical [RP] function, emotional role function, vitality, mental health, social function, body pain, general health, physical component scale, mental component scale) was lower in patients with pSS than in healthy controls, especially the score in the dimension of RP function.

CONCLUSION

This meta-analysis showed that patients had lower pSS score in each dimension of the SF-36, mostly in the RP function. This demonstrated that targeted interventions should be carried out to improve the HRQoL of pSS patients.

Present and future of biologic drugs in primary Sjögren's syndrome

INTRODUCTION

Primary Sjögren's (pSS) syndrome is a chronic, autoimmune, and systemic disease characterized by xerostomia, xerophthalmia, muscle pain and fatigue. The disease may be complicated by a systemic involvement, such as a pulmonary fibrosis or the development of lymphoma which severely worsens the prognosis. Actually, there are no recommendations for the management of pSS. However, recent advances in the understanding of its pathogenesis have uncovered some pathways that have potential as therapeutic targets. Areas covered: In this review, the authors present the biologic drugs potentially valuable to the treatment of pSS in light of its physiopathology with a 'bird's eye' view of future prospects. The authors took into account relevant studies published from 2004 to 2016. Expert opinion: Biological treatment in pSS is a promising opportunity to potentially control disease activity and prevent its complication. Currently, inhibition of B-cell and IL-17 pathways seem to be the most promising avenues. New achievements in the knowledge of pSS pathophysiology are necessary in order to try to simultaneously predict the predominant pathogenic pathway, the kind of patients at major risk to develop a more severe disease, and the appropriate biological therapy to use.

Evaluation of different diagnostic criteria of diseases manifesting the oral cavity - A review. Part-1

There are many disorders affecting the oral cavity, which can cause difficulty in diagnosis for an oral physician. A criterion is defined as 'a principle or standard by which something may be judged or decided'. Several criteria have been given by different authors or committee, which further aids in diagnosis of certain disease. This article encompasses a collection and analysis of all the criteria of diseases affecting the oral cavity, which will be beneficial for an oral physician in their routine clinics.

The lived experience of Sjögren's Syndrome

BACKGROUND

Sjögren's Syndrome is an autoimmune exocrinopathy characterised by lymphocytic infiltration of exocrine glands in multiple sites, with dry mouth as a primary presenting symptom. Although quantitative studies have shown the negative impact of both dry mouth and Sjögren's Syndrome on patients' quality of life, no qualitative diary and interview study has been undertaken to examine the lived experience of dry mouth for Sjögren's Syndrome sufferers. The aim of this qualitative study was to provide clinicians with insight into how dry mouth can impact on the daily lives of Sjögren's Syndrome patients.

METHODS

The American-European Consensus Group (AECG) Revised International Classification criteria were used to identify participants from patients seen in an oral medicine clinic. After pilot study work to test the approach, the 10 main study participants were recruited. Diary entries and semi-structured interviews were used to explore how dry mouth affects their lives. Owing to the exploratory nature of the research, thematic content analysis was applied, allowing the themes to arise naturalistically from the data without bias or elicitation.

RESULTS

The data showed that it is unrealistic to understand the experience of a single symptom, but that the disease as a whole needs to be taken into perspective. The empirical evidence supported four main themes that depicted the lived experience of Sjögren's Syndrome. These included: (1) the journey to diagnosis; (2) disease impact spectrum (of dry mouth amid other symptoms); (3) interactions with healthcare professionals; and (4) the positive coping process.

CONCLUSIONS

The findings revealed patients' perspectives on diagnosis, coping with dry mouth and Sjögren's Syndrome, and interaction with healthcare professionals. Dry mouth is not a trivial symptom for Sjögren's Syndrome sufferers; it has considerable impact on their day-to-day lives. Healthcare professionals need to understand patients as individuals in their environment in order to be part of the Sjögren's journey.

The coexistence of Sjögren's syndrome and primary biliary cirrhosis: a comprehensive review

Organ-specific and systemic autoimmune diseases share numerous features and often coexist in the same patient. Autoimmune cholangitis/primary biliary cirrhosis and Sjogren syndrome represent paradigmatic examples of the common grounds of different autoimmunity phenotypes based on similarities in clinical manifestations and immunopathogenesis. In fact, primary biliary cirrhosis and Sjogren's syndrome have both been coined as an autoimmune epithelitis in which apoptosis may be in both cases the key element to explain the organ-specific immune-mediated injury against the biliary and exocrine gland epithelia, respectively. Further, growing evidence supports in both diseases the view that B cells, T cytotoxic cells, and T helper cells are involved in chronic inflammation, likely via the altered expression of pro-inflammatory cytokines. The presence of estrogen receptors on the biliary and exocrine gland epithelia has been advocated as a key to the female predominance encountered in primary biliary cirrhosis and Sjogren's syndrome. Sadly, despite available data, therapeutic approaches remain largely unsatisfactory and recent studies with mechanistic approaches (as in the case of B cell depletion with rituximab) have been of partial benefit only. Future studies should focus on new molecular tools (single-cell transcriptomics, microRNA, epigenetics) to provide unique insights into common mechanisms.

Increased utilisation of eye disorder-related ambulatory medical services prior to the diagnosis of Sjögren's syndrome in female patients: a longitudinal population-based study in Taiwan

OBJECTIVES

To investigate the utilisation of eye disorder-related ambulatory medical services prior to the diagnosis of primary Sjögren's syndrome in female Taiwanese patients.

DESIGN

A nationwide, population-based case-control study.

SETTING

Taiwan's National Health Insurance Research Database.

PARTICIPANTS

A total of 347 patients with a diagnosis of primary Sjögren's syndrome from 2005 to 2010 and 1735 controls frequency matched on 10-year age interval and index year were identified from Taiwan's National Health Insurance Research Database. Diagnoses of eye disorder (International Classification of Diseases, Ninth Revision, clinical modification (ICD-9-CM) codes from 360 to 370) were retrospectively screened to 1997.

MAIN OUTCOME MEASURE

The utilisation of eye disorder-related medical service over different intervals prior to diagnosis of Sjögren's syndrome between cases and controls were compared using generalised estimating equations with negative binomial distribution and log link function.

RESULTS

A significantly higher proportion of patients with Sjögren's syndrome (7.5%) utilised eye disorder-related ambulatory medical services over an 8-year interval prior to the diagnosis of the disease compared with controls (4.8%). The annual frequency of utilisation of eye disorder-related ambulatory medical services increased significantly faster when closer to the index date in patients with Sjögren's syndrome compared with controls (interaction effect, p=0.010). Subgroup analyses indicated that the changes over time in the utilisation of services related to disorders of lacrimal system (interaction effect, p=0.019) and conjunctiva (interaction effect, p=0.066) were significantly greater in patients with Sjögren's syndrome compared with controls.

CONCLUSIONS

An increase in the utilisation of eye disorder-related ambulatory medical services was observed in patients with Sjögren's syndrome several years prior to the diagnosis of the disease. General practitioners and ophthalmologists can play an important role by including Sjögren's syndrome in the diagnostic evaluation of their patients afflicted with relevant symptoms.

Type I IFN signature in primary Sjögren's syndrome patients

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease characterized by lymphocytic infiltrates in salivary and lacrimal glands. Clinical manifestations range from ocular and oral dryness to vasculitis and severe fatigue. pSS is a disease with heterogeneous symptoms and a variable response to the available treatment. Recently, a key role for Interferon (IFN) type I has been implicated in the pathogenesis of pSS. As type I IFN consists of 17 different subtypes, it cannot be easily assessed using a conventional ELISA. Therefore the expression of type I IFN inducible genes--the so-called type I IFN signature--is assessed in salivary gland tissue and blood from patients as a readout for type I IFN activity. In this review we discuss the potential of type I IFN as a novel biomarker for disease activity, subclassification of patients, prediction of therapy response and most importantly as a target for therapeutic intervention.

Neurological involvement in primary Sjögren syndrome: a focus on central nervous system

Objectives

Sjögren syndrome is an autoimmune disease involving mainly salivary and lacrimal glands. Beyond widely described PNS involvement, high variable prevalence of CNS manifestations ranging from 2.5 and 60% of all pSS patients has been reported, without specific syndrome definition. The aim of this cohort study was to evaluate the prevalence of CNS signs and symptoms in pSS patients and to identify possible biomarkers of CNS damage.

Methods

120 patients with pSS diagnosis according to the 2002 American-European Consensus Group criteria were enrolled after exclusion of secondary causes. All patients underwent to a wide neurological, neuropsychological, psychiatric, neuroradiological and ultrasonographic evaluation.

Results

Central and peripheral nervous system involvement was observed in 81 patients with a prevalence of 67.5%. The prevalence of CNS involvement was significantly higher than PNS disease (p 0.001). 68 patients (84%) shown non-focal CNS symptoms and 64 (79%) focal CNS deficits with headache as the most common feature (46.9%), followed by cognitive (44.4%) and mood disorders (38.3%). Particularly, we observed a high prevalence of migraine without aura, subcortical frontal executive functions and verbal memory impairment and apathy/alexythimia. MR spectroscopy revealed a reduction of NAA levels or NAA/Cr ratio decrease in subcortical frontal and basal ganglia white matter, while ultrasonography showed an impairment of microvasculature response. At multivariate analysis, headache, cognitive disorders and psychiatric symptoms was significantly associated to serological markers (anti-SSA), MRS and ultrasonographic features.

Conclusions

The higher prevalence of MWO-mimic headache, cognitive dys-esecutive syndrome and mood disorders observed in this series confirmed previous evidences of a higher diffused CNS compromission rather than focal involvement such as SM-like clinical course or NMO-like syndrome. The association with immunological biomarkers, metabolic cerebral dysfunction and microvascular damage suggests a possible endothelial dysfunction of the cerebral microcirculation or a potential inflammation-mediated shift of the neurovascular coupling.

Treatment for salivary gland hypofunction at both initial and advanced stages of Sjögren-like disease: a comparative study of bone marrow therapy versus spleen cell therapy with a 1-year monitoring period

BACKGROUND AIMS

Non-obese diabetic mice (NOD) exhibit autoimmune Sjögren-like disease (SS-like). We reported previously that a combined-therapy consisting of immuno- and cell-based therapy rescued NOD from SS-like. However, therapies tested to date on NOD mice were aimed at the initial phase of SS-like. It is unknown whether therapies are effective in restoring salivary function when given at an advanced phase of SS-like.

METHODS

The efficacy of two therapies (bone marrow versus spleen cells) was compared head-to-head for halting/reversing salivary hypofunction at two critical time points of SS-like (7-week-old NOD with normal saliva output and 20-week-old NOD with minimal saliva). NOD mice were divided into four groups: (i) control, (ii) complete Freund's adjuvant (CFA), (iii) bone marrow transplants with CFA or (iv) spleen cell transplants with CFA. Mice were monitored 8-12 months after therapy.

RESULTS

Both cell therapies were effective during the initial phase of SS-like; salivary flow rates were maintained between 80-100% of pre-symptomatic levels. Spleen cell therapy was better than bone marrow when administered in the initial phase of SS-like. When cell therapies were given at an advanced phase of SS-like (20 weeks and older), salivary flow rates improved but were at best 50% of pre-symptomatic levels. Both cell therapies decreased tumor necrosis factor-α, transforming growth factor-β1 levels and T and B cells while increasing epidermal growth factor and regulatory T cells. Elevated serum epidermal growth factor levels were measured in spleen-treated mice.

CONCLUSIONS

A therapeutic effect in advanced phase disease, albeit in mice, holds promise for humans in which Sjögren syndrome is generally not diagnosed until a late stage.

Characterization of cognitive dysfunction in Sjögren's syndrome patients

Sjögren's syndrome is an autoimmune disorder primarily affecting women, with decreased saliva and tear production as the principal characteristic. Cognitive, neurological, and psychiatric disorders also are associated with Sjögren's. The present study addressed the hypothesis that patients with Sjögren's syndrome differ significantly from matched controls in the prevalence and impact of a number of neuropsychiatric abnormalities. Sjögren's patients and controls (n = 37 per group) underwent medical and psychiatric evaluation, demographic assessments, quality of life and symptom evaluation, and extensive testing of cognitive function and memory. Patients and controls were closely matched for age, gender distribution, verbal IQ, marital status, educational level, employment status, and current/past medical or psychiatric history. On most subjective self-ratings, Sjögren's patients reported greater fatigue, impaired physical functioning, feeling depressed, and autonomic symptomatology compared to controls. Impaired memory was described mainly as loss of thought continuity in the midst of a task or activity. However, the majority of objective measures of cognition, psychomotor function, and memory showed minimal differences between groups. Sjögren's patients rate themselves as impaired on multiple ratings of emotional, cognitive, and physical function, but objective measures of cognition reveal fewer substantive differences between patients and matched controls. Sjögren's patients perceive deteriorated physical function over time, but they achieve a level of functioning comparable to controls despite the burden of their illness.

A rapamycin-binding protein polymer nanoparticle shows potent therapeutic activity in suppressing autoimmune dacryoadenitis in a mouse model of Sjögren's syndrome

Sjögren's syndrome (SjS) is a chronic autoimmune disease characterized initially by lymphocytic infiltration and destruction of exocrine glands, followed by systemic organ damage and B-cell lymphoma. Conventional treatment is based on management of symptoms and there is a shortage of therapies that address the underlying causes of inflammation at source exocrine tissue. The aim of this study was to test a novel protein polymer-based platform consisting of diblock copolymers composed from Elastin-like Polypeptides (ELPs) fused with FKBP12, to deliver a potent immunosuppressant with dose-limiting toxicity, rapamycin (Rapa) also known as Sirolimus, and evaluate its effects on the inflamed lacrimal gland (LG) of non-obese diabetic mouse (NOD), a classic mouse model of SjS. Both soluble and diblock copolymer ELPs were fused to FKBP12 and characterized with respect to purity, hydrodynamic radii, drug entrapment and release. Both formulations showed successful association with Rapa; however, the nanoparticle formulation, FSI, released drug with nearly a 5 fold longer terminal half-life of 62.5h. The strong interaction of FSI nanoparticles with Rapa was confirmed in vivo by a shift in the monoexponential pharmacokinetic profile for free drug to a biexponential profile for the nanoparticle formulation. When acutely administered by injection into NOD mice via the tail vein, this FSI formulation significantly suppressed lymphocytic infiltration in the LG relative to the control group while reducing toxicity. There was also a significant effect on inflammatory and mammalian target of Rapamycin (mTOR) pathway genes in the LG and surprisingly, our nanoparticle formulation was significantly better at decreasing a proposed tear biomarker of SjS, cathepsin S (CATS) compared to free drug. These findings suggest that FSI is a promising tool for delivering Rapa for treatment of SjS in a murine model and may be further explored to meet the unmet medical challenge of SjS.

Sjögren's syndrome, the old and the new

Sjögren's syndrome is a chronic autoimmune disease characterised by progressive injury to exocrine glands accompanied by diverse extra-glandular manifestations. The spectrum of Sjögren's manifestations expanded in recent years to include new symptoms and signs such as small fibre neuropathy, and also well-defined activity and prognostic indexes. Similar to other non-organ-specific autoimmune diseases, a mosaic of factors have been linked with the development and appearances of Sjögren's syndrome. Progress has been made unravelling those factors, including susceptibility genes, immunological parameters and various environmental factors in the last decade, some of which may enable targeted therapies, biological and non-biological ones, for patients suffering from this disease. Thus, herein we review the postulated aetiologies, pathogenesis and new insights related to Sjögren's syndrome.

A study of the effects of saliva stimulation by nizatidine on dry mouth symptoms of primary biliary cirrhosis

AIM

To elucidate the effect of saliva stimulation by nizatidine on oral symptoms of primary biliary cirrhosis (PBC) by administering it to PBC cases.

METHODS

From among 73 cases that had been definitively diagnosed as PBC at our hospital by February 2010, we selected 27 cases of PBC, 4 males and 23 females, as subjects. We obtained subjects' consent after giving them a full explanation of the administration of nizatidine. Nizatidine 150 mg was administered internally twice daily, after morning and evening meals. To observe changes in the quantity of saliva secreted, chewing gum tests were carried out four times: before the initial dose, and after 6 mo, 12 mo and 24 mo of administration. For subjective dry mouth symptoms, a visual analog scale (VAS) method was used to assess their feelings of oral dryness and eating difficulty, five times: before the initial dose, and after 1, 6, 12 and 24 mo of administration in 8 cases. The nutritional condition and the hepatic functional reserve were compared between before and after the nizatidine treatment.

RESULTS

The result of a chewing gum test on the subjects before the administration of nizatidine showed that 50% produced less than 10 mL of saliva, i.e., the standard under which cases are considered to have hyposalivation. The results of these tests showed that the quantity of saliva secreted was 10.5 ± 6.8 mL before administration of nizatidine, 10.9 ± 6.0 mL after 6 mo, 10.6 ± 4.9 mL after 12 mo, and 11.8 ± 6.8 mL after 24 mo administration. Thus, there was a slowly increasing trend in the quantity of saliva in the whole group. The percentage of subjects with saliva production above 10 mL was 45.8% after 6 mo administration of nizatidine, that is, only a slight change from before its administration, but it was 64.3% after 12 mo, that is, a significant increase. The saliva secretion by subject patients was examined before the beginning of administration of nizatidine, 12 mo later, and 24 mo later, and Fisher's combined probability test was used to examine the results for increases in saliva secretion. The analysis yielded P values of 0.51 and 0.53 for 12 mo later and 24 mo later, respectively. Thus, although there was no statistically significant increase, it was confirmed that saliva secretion tended to increase. A VAS method was employed to study the intensities of subjective symptoms of oral dryness and eating difficulty. Almost every case indicated some improvement of subjective oral dryness on the VAS early in the administration, i.e., one month after. We also studied the effects of the administration of nizatidine on nutritional condition, hepatic functional reserve, and long-term prognosis of PBC. No significant improvements in cholinesterase (ChE) level, albumin (Alb) level, or Child-Pugh score were found during the period of observation from the beginning to the end of administration of nizatidine, nor in comparison with the non-administration group. A comparative analysis between before administration and 24 mo later yielded P values of 0.41 for Alb, 0.56 for ChE, and 0.59 for the Child-Pugh scores.

CONCLUSION

It was confirmed that administering nizatidine to cases of PBC with dry mouth increased the secretion of saliva and improved the symptoms.

Sarcoidosis and Sjögren's syndrome: clinical and salivary evaluation

BACKGROUND

Sarcoidosis and Sjögren's syndrome are two different diseases; however, when affecting the salivary glands, both diseases exhibit similar clinical signs and symptoms, which often complicates the diagnosis. The purpose of this study was to investigate the possibility of using salivary electrophoresis to differentiate between the two diseases.

METHODS

Saliva was collected from patients with sarcoidosis and patients with Sjögren's syndrome. Salivary flow rate, total protein, and electrophoretic profiles were examined.

RESULTS

Mean salivary flow rate was 0.41 ± 0.07 ml/min/gland vs. 0.43 ± 0.07 ml/min/gland; total salivary protein was 130.0 ± 29.2 mg% vs. 104.0 ± 8.8 mg% for sarcoidosis vs. Sjögren's syndrome, respectively. No differences were observed in salivary flow rate, total salivary protein, or electrophoretic profile between patients with sarcoidosis and patients with Sjögren's syndrome (P = 0.768, 0.718, and 1.000, respectively).

CONCLUSIONS

Salivary protein electrophoresis does not appear to be useful to differentiate between sarcoidosis and Sjögren's syndrome.

Novel autoantibodies in Sjogren's syndrome

Sjogren's syndrome (SS) is defined by autoantibodies to Ro and La. The current studies identified additional autoantibodies in SS to salivary gland protein 1 (SP-1), carbonic anhydrase 6 (CA6) and parotid secretory protein (PSP). These autoantibodies were present in two animal models for SS and occurred earlier in the course of the disease than antibodies to Ro or La. Patients with SS also produced antibodies to SP-1, CA6 and PSP. These antibodies were found in 45% of patients meeting the criteria for SS who lacked antibodies to Ro or La. Furthermore, in patients with idiopathic xerostomia and xerophthalmia for less than 2 years, 76% had antibodies to SP-1 and/or CA6 while only 31% had antibodies to Ro or La. Antibodies to SP-1, CA6 and PSP may be useful markers for identifying patients with SS at early stages of the disease or those that lack antibodies to either Ro or La.