A broader spectrum of Sjogren's syndrome and its pathogenetic implications

The Genesis of Sjögren

Henrik Sjögren was a Swedish ophthalmologist who wrote a dissertation (in German) consisting of a 131-page long monograph on patients who exhibited a constellation of keratitis sicca, xerostomia and arthritis. This article highlights several key moments of his life and work leading to the delineation of a new syndrome.

Eosinophilic vasculitis in connective tissue disease

BACKGROUND

Neutrophilic and lymphocytic vascular inflammation is common in vasculitis associated with connective tissue disease (CTD). We recently identified eight patients with CTD and eosinophilic vasculitis.

OBJECTIVE

The purpose of this study was to characterize a variant form of vasculitis in CTD with eosinophilic infiltration.

METHODS

Of 98 CTD patients with cutaneous necrotizing vasculitis, eight were found with predominantly eosinophilic vascular infiltration. Nine CTD patients with cutaneous neutrophilic vasculitis were identified for comparison. Clinical and laboratory findings were reviewed and compared. Indirect immunofluorescence for eosinophil granule major basic protein (MBP), neutrophil elastase, and mast cell tryptase was performed on lesional tissue. MBP levels and eosinophil survival enhancing activity were assayed in sera from three patients.

RESULTS

The patients with eosinophilic vasculitis had depressed serum complement levels and peripheral blood eosinophilia; MBP levels were elevated in serum and eosinophil survival was prolonged. Immunofluorescence of tissue showed marked angiocentric eosinophil MBP staining with peripheral neutrophil elastase staining; mast cell tryptase staining was notably absent. The patients with neutrophilic vasculitis were variably hypocomplementemic and did not have peripheral blood eosinophilia. Immunofluorescence showed marked angiocentric neutrophil elastase staining with scattered eosinophil MBP staining; mast cell tryptase staining showed normal mast cell numbers.

CONCLUSION

Patients with eosinophilic vasculitis, CTD, and hypocomplementemia show vessel wall destruction in association with vessel wall deposition of cytotoxic eosinophil granule MBP, which suggests that eosinophils mediate vascular damage in this disease process. In addition, perivascular mast cells appear diminished, thereby suggesting that mast cell degranulation occurs.

Neuropathy and myopathy in primary Sjögren's syndrome: neurophysiological, immunological and muscle biopsy results

Seventeen consecutive patients with primary Sjögren's syndrome (PSS) received neurophysiological examination, analysis of antibodies against peripheral nerve-myelin (PNM) and muscle biopsy, to show the prevalence and characteristics of peripheral neuropathy (PN) and myopathy; 3 PSS cases showed a clinical mild sensorimotor polyneuropathy, 1 of them had been treated with cytostatic drugs; 1 had mononeuropathia multiplex; and 1 clinical carpal tunnel syndrome. In these 5 patients neurophysiological investigation verified the clinical diagnosis of peripheral nerve involvement; 2 with PN had serum-antibodies against PNM; 1 of IgM-, and 1 of IgA-isotype. Muscle biopsies were taken from 15 PSS patients; 11 showed inflammatory myositis or inflammatory perivascular infiltrates and 3 showed signs of denervation. A combination of inflammation and morphological signs of myopathy, compatible with the biopsy diagnosis of polymyositis, was seen in 4, 1 of whom showed clinical signs of polymyositis. We conclude that the peripheral nervous and muscular systems are often involved in PSS, but commonly with relatively mild symptoms and laboratory findings. The common findings of inflammatory myopathy indicate an immune reaction in muscles in addition to other autoimmune manifestations of the disease.

Thyroid dysfunction in a prospectively followed series of patients with progressive systemic sclerosis

Thirty-nine patients with progressive systemic sclerosis (PSS) in stable clinical conditions were extensively evaluated for the presence of thyroid disease. Two patients had previously undetected hypothyroidism while 7 additional patients had normal serum thyroid hormone levels but an exaggerated TSH response to thyrotropin-releasing hormone (TRH) administration, consistent with subclinical hypothyroidism. Four of the 9 subjects with abnormal TRH responses had positive antithyroid antibodies and of the remaining 5, 4 had been on chlorambucil or prednisone. Basal TSH and TSH response to TRH were significantly higher in PSS patients as a group when compared to a control group and increased with increasing duration of PSS. Serum antithyroid antibodies (antithyroglobulin and/or antimicrosomal antibodies) were positive in 18% and thyroid scans were abnormal in 18% of the patients. The euthyroid sick syndrome was not seen. Our findings indicate an increased frequency of, sometimes previously unsuspected, clinical and subclinical hypothyroidism in stable PSS patients which appears to be autoimmune in nature and becomes more prevalent with increased PSS duration. Careful and regular monitoring of the thyroid function in PSS patients is advisable.

Prevalence of thyroid disease and abnormal thyroid function test results in patients with systemic lupus erythematosus

Although thyroid disease has been associated with other autoimmune conditions, it is not well recognized in systemic lupus erythematosus (SLE) patients. We found that in 332 SLE patients hospitalized during a 5-year period, the overall prevalence of diagnosed thyroid disease (7.5%) was similar to that in other female populations, but the prevalence of diagnosed hypothyroidism (6.6%) was unexpectedly high. There was also a high frequency of abnormal thyroid function test results in 175 SLE patients without diagnosed thyroid disease who underwent laboratory screening. More than 45% of these patients had elevated levels of thyroid-stimulating hormone, 34% had low T3 determinations, and 18% had high antimicrosomal antibody titers. When patients were categorized into "functional groups," some showed evidence of the "euthyroid sick syndrome" (15%), but many more had laboratory test results suggestive of true (5%) or incipient (39%) primary hypothyroidism. We conclude that abnormal thyroid function test results are common in patients with SLE and that hypothyroidism, especially, should be considered when evaluating symptoms and signs in SLE patients.

Studies on the sicca syndrome in patients with rheumatoid arthritis

Secretion from the parotid and the lacrimal glands has been studied in two similar groups of 48 subjects, one consisting of RA patients, the other a control group. Sialometry and sialography has been performed as regards the parotid glands; the secretion of the lacrimal glands has been measured with Schirmer's test I and the occurrence of conjunctival and corneal epithelial defects stainable with Rose-Bengal has been studied. It has been shown that lacrimal and parotid secretion was significantly reduced in the RA group as compared with the control group; that epithelial defects typical for KCS occurred significantly more often in the RA group; that parenchymal changes, sialodochiectasias, existed in the RA group but that sialodochiectasias were completely absent in the control group; that there was no significant co-variation in the RA group between lacrimal and salivary secretion or lacrimal secretion and sialodochiectasias; that criteria for Sjögren's syndrome were fulfilled by 15 subjects in the RA group. The results of the study indicate that Sjögren's syndrome is to be regarded as part of the RA complex.

Salivary content of patients with subjective symptoms resembling galvanic pain

Analyses of whole and parotid saliva were performed in ten patients with subjective symptoms resembling galvanic pain and in their eight asymptomatic counterparts. Salivary flow rates, protein, IgA, lysozyme, sodium, potassium, chloride, calcium phosphate, copper, and magnesium contents were measured. The concentrations of protein, sodium, chloride, and phosphate in the whole saliva of the patients with symptoms were significantly higher, but concentrations of calcium, magnesium, and IgA were lower than in the asymptomatic controls. In parotid saliva, too, protein, lysozyme, and calcium concentrations were significantly altered in patients with oral symptoms. The analysis of free amino acids serine, proline, glutamic acid + glutamine, and glycine in the whole saliva did not show any significant differences between the two groups studied. The results suggest the importance of salivary contents in the development of oral soreness. Such changes in the salivary constituents could modulate the amount and character of the salivary macromolecules absorbed onto the teeth. This could lead to passivation or activation of the surfaces in metallic restorations and consequently to the onset of the intraoral electric currents.

Angioimmunoblastic lymphadenopathy progressing to immunoblastic lymphoma with prominent gastric involvement

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

Hand flexor tenosynovitis in rheumatoid arthritis. Prevalence, distribution, and associated rheumatic features

Tenosynovitis of one or more flexor tendons of the hand (mean 3.1 tendons per patient) was noted in 55% of 100 patients with rheumatoid arthritis (RA) examined periodically during a mean period of 5 years. The third flexor tendon was involved most frequently (71% of patients), followed by the second (62%), fourth (53%), fifth (27%), and first (13%). Patients with flexor tendonitis (FT) had a significantly higher prevalence of rheumatoid nodules (56% vs 33%), carpal tunnel syndrome (47% vs 13%), wrist extensor tenosynovitis (47% vs 9%), and elbow epicondylitis (22% vs 7%) than patients without FT. Dupuytren's contracture, DeQuervain's tenovaginitis, flexor carpi radialis and ulnaris tendonitis, and Achilles tendonitis were found exclusively in patients with FT. A control group of 50 non-RA patients with FT had statistically fewer diseased tendons per patient (mean 1.5) and a different digital distribution, the thumb being affected more frequently (P less than 0.05) than in RA patients.

The relationship of defective cell-mediated immunity to visceral disease in systemic sclerosis

Phytohaemagglutinin-induced lymphocyte transformation and circulating thymus-dependent (T) lymphocyte numbers were studied in twenty-eight patients with systemic sclerosis (SS), in fifty normal controls and eleven elderly controls. Patients with SS were found to have impaired lymphocyte transformation responses which showed a positive correlation with both the number of circulating T lymphocytes and the extent of visceral involvement by the disease. This defect of cell-mediated immunity could not be attributed to the effects of increasing age, corticosteroid treatment, iron and folate deficiency or inhibitory serum factors and may have pathogenetic implications for the disorder.

Oral swelling in Sjögren's syndrome

A case is reported of a 69-year-old female with Sjögren's syndrome who presented with a problem of interest to the oral surgeon. The clinical features and cryosurgical management of a rare cause of palatal swelling are described. The confusion that exists in the literature concerning the nomenclature of chronic inflammatory salivary gland lesions is discussed.

[Clinical aspects of non-tumorous diseases of the salivary glands]

The vast field encompassed by the non-tumorous diseases of the salivary glands poses difficult problems for their diagnosis and therapy. In order to facilitate comprehension of the pathological processes and the therapeutical possibilities for their treatment, physiological and biochemical aspects of salivary gland function are presented in the introduction. There are also mentioned in detail most of the diagnostic methods clinically applied today and stress is laid on their respective diagnostic values. In contrast to the opinion of many authors, exploratory excision and puncture are shown to be very important diagnostic tools in salivary gland pathology. The specific application of these methods is often the only means for a reliable diagnosis. The classification of the diseases follows Seifert's (1971) proposal. The chronic diseases of the salivary glands are specifically mentioned with the chronic recurrent and the chronic myoepithelial sialoadenitis taking first place. The sialoses are presented in a larger chapter. An attempt was made to correlate clinical and experimental results, to establish working hypotheses concerning the development of sialoses, to suggest therapeutical possibilities and, last not least, to give an idea of the many clinical and patho-anatomical difficulties to be overcome for a satisfactory understanding of such pathological processes. Finally, various forms of salivary gland fistulas and their treatment are mentioned. The long list of references merely gives an approximation of the abundance of publications dealing with the problems of this field.

Parietal cell antibodies. Part II. Cytotoxic activities of parietal cell antibodies. Experiment 1. The observations on cytotoxic activities of parietal cell antibodies to normal human parietal cells in vitro. Experiment 2. The histochemical changes of rat stomach after administrations of rabbit anti-rat gastric mucosa sera

Cytotoxic activities of P.C.A. to normal parietal cells were demonstrated in vitro. The changes were very similar to those of thyroid cells provoked by Hashimoto serum. The cytotoxic component was found to be immunoglobulin G. Complement was not added. Rabbit anti-rat gastric mucosa sera had no effects on the gastric secretion in rats, but histochemical changes were demonstrated. The changes were transient and returned to the normal state 60 minutes after injection of Anti-RGM sera. Activities of succinic dehydrogenase were most affected, particularly 3 minutes after injection. Decrease of activities gradually recovered to the normal condition. The comparison of C.A.G. with C.Th. was made. By the comparison between C.A.G. and C.Th., and by the results of experiments, the author considers that C.A.G. has the immunologically identical aspects with C.Th.. The author also considers that some immunological mechanisma are playing a role in the pathogenesis of C.A.G.

Methotrexate therapy in polymyositis

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Sjögren's syndrome, dysimmunoglobulinaemia and malignant disease

The occurrence of carcinoma in situ in the stomach and dysimmunoglobulinaemia in a patient who had Sjögren's syndrome is described. This is believed to be the first report of such a case to be found in the literature.

Although carcinoma has occasionally been described, in this syndrome its occurrence is probably coincidental and not part of the disease process. There is a greater incidence of lymphoid tumours in Sjögren's syndrome than in the general population. Corticosteroid therapy favourably influenced the immunoglobulin abnormalities and some of the clinical manifestations of the disease.

A brief review of the literature concerning Sjögren's syndrome, auto-immunity and malignant disease is included.

Oral mycoplasmas in Sjögren's syndrome

Mycoplasmas were sought in the salivary secretions and minor salivary gland tissue of 26 patients with Sjögren's syndrome or the allied sicca complex. A mycoplasma (M. orale type 1) was recovered from the stimulated parotid saliva of only one case. Possible mechanisms of mycoplasmal cell damage in this and allied disorders are considered and some future lines of investigation are suggested.