Primary Sjogren's syndrome: a great masquerader

Primary Sjögren's syndrome without ocular manifestation: a case report

Introduction and importance

Sjögren's Syndrome is a systemic immune disorder, manifested in dry eyes and mouth. Primary Sjögren's syndrome without ocular manifestation is seldom mentioned in the literature.

Case presentation

The authors report a case of a 48-year-old female who complained of dryness of mouth and dysphagia for 6 months. Physical examinations showed dry lips with angular cheilitis, an erythematous tongue, and dry buccal mucosa, with multiple carious teeth. The salivary flow was scanty from the Stenson's and Wharton's ducts on both sides. Her ophthalmological examination was normal. Laboratory tests revealed leukopenia, anemia, thrombocytopenia, elevated levels of C-reactive protein and erythrocyte sedimentation rate, a strongly positive antinuclear antibody, anti-SS-A, anti-SS-, and rheumatic factor. Hyperechoic nodules in both parotids were shown by Ultrasonography. Salivary gland biopsy showed lymphocytic infiltration. Diagnosis of primary Sjögren's syndrome was made. She was treated with Pilocarpine 5 mg for 3 months, Vitamin C, and artificial saliva for oral dryness. She is under continuous follow-up with 50-60% relief, without any systemic complications.

Discussion

Sjögren's Syndrome affects the exocrine glands causing dry mouth and eyes, and can cause systemic symptoms, including fatigue and joint pain. The incidence of ocular involvement among the reported cases is 86.1%, whereas our patient did not have any ocular involvement, and this represents a rare condition. The differential diagnosis included diabetes mellitus, hypothyroidism, chronic virology infection, and some medications that cause dryness, which were very much ruled out. Treatment of sicca symptoms involves artificial tears and medications that stimulate saliva flow while treatment of systemic disease includes corticosteroids, and various DMARDs, Rituximab. this disease has an increased relative risk for the development of B-cell non-Hodgkin's lymphoma. Therefore, patients need to be monitored, especially in the presence of risk factors.

Conclusion

It is very important to diagnose this disorder early, using the various diagnostic criteria.

Clinical characteristics of Guillain-Barré syndrome in patients with primary Sjögren's syndrome

To investigate the clinical characteristics of Guillain-Barré syndrome (GBS) in patients with primary Sjögren's syndrome (SS). Records of patients with positive anti-SSA antibodies hospitalized in the Beijing Tiantan Hospital between December 2011 and May 2020 were retrieved. Patients who fulfilled the criteria for diagnosis of GBS and primary SS were included, and their clinical data were analyzed. Among the 785 patients with positive anti-SSA, 52 patients were identified in this study. They were 27 males and 25 females with median age of 59 years old. Besides anti-SSA antibodies, multiple autoantibodies were detected in these patients including antinuclear antibody, anti-Ro52, anti-mitochondrial M2, anti-thyroid peroxidase and anti-thyroglobulin autoantibodies. Preceding infection was reported in 42 patients. Hyporeflexia/areflexia and limbs weakness were the most common manifestation and 35 patients presented cranial nerve injuries. GBS disability score of 3, 4 and 5 was scaled in 28 (53.8%), 15 (28.8%) and 3 (5.8%) patients respectively. Forty-six patients received intravenous immunoglobulin (IVIG) monotherapy, 5 patients were treated by IVIG plus glucocorticoids, and 51 patients improved during hospitalization. The frequency of male gender among the patients with both GBS and primary SS suggests an independent onset of GBS and the co-existence of these autoimmune diseases in patients with multiple autoantibodies. Majority of patients with GBS and primary SS experience benign disease course.

A case report of hypokalemic periodic muscular weakness secondary to Sjögren's syndrome with distal renal tubular acidosis

Key Clinical Message

An underlying autoimmune condition should be suspected in patients who presented with periodic muscular weakness secondary to distal RTA that leads to hypokalemia because distal RTA is commonly associated with autoimmune disorders such as Sjögren's syndrome.

Abstract

A 22-year-old female presented with a sudden onset of bilateral weakness in both upper and lower limbs. The patient had a history of muscular weakness secondary to hypokalemia and dryness of the eyes for the last 3 years. Laboratory investigations revealed decreased potassium and metabolic acidosis. Further investigations confirmed distal renal tubular acidosis (RTA) and Sjögren's syndrome. A diagnosis of distal RTA secondary to Sjögren's syndrome was made. Her potassium levels were replaced, and she was discharged with oral potassium supplements, steroids, and artificial tears.