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La Bella S, Vivarelli M, Di Ludovico A, Di Donato G, Chiarelli F, Breda L. Kidney manifestations of pediatric Sjögren's syndrome. Pediatr Nephrol 2024; 39:711-721. [PMID: 37638982 DOI: 10.1007/s00467-023-06135-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 08/29/2023]
Abstract
Approximately 1% of all patients with Sjögren's syndrome (SS) are children. Unlike the adult form, in which sicca syndrome is the main presentation, in children, the most common clinical finding is recurrent enlargement of the salivary glands. In pediatric SS, extraglandular manifestations represent a significant feature and, among these, kidney manifestations are relevant. Kidney involvement is observed in 5-20.5% of children with SS, most frequently tubulointerstitial nephritis. This injury can lead to serious phenotypes, including distal kidney tubular acidosis with the development of severe hypokalemia, which can lead to ECG abnormalities, weakness, and hypokalemic periodic paralysis. Kidney implications in pediatric SS also include nephrolithiasis, nephrocalcinosis, and various types of glomerular damage, which often require immunosuppressive therapies. Laboratory findings are usually comparable to adults, including hyperglobulinemia and high rates of antinuclear antibodies (ANA, 63.6-96.2%), and anti-Ro/SSA (36.4-84.6%). The current classification criteria for SS are inaccurate for the pediatric population, and more specific criteria are needed to improve the diagnostic rate. Due to the rarity of the disease, strong recommendations for treatment are lacking, and several therapeutic strategies have been reported, mostly based on glucocorticoids and disease-modifying antirheumatic drugs, with different outcomes. The aim of this paper is to provide an overview of the kidney implications of pediatric SS based on the latest evidence of the medical literature.
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Affiliation(s)
- Saverio La Bella
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy.
| | - Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Armando Di Ludovico
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Giulia Di Donato
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Luciana Breda
- Department of Pediatrics, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
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Kaeley N, Gangdev AM, Datta SS, Singh UP. Quadriparesis and Broad Complex Tachycardia Secondary to Severe Hypokalaemia Induced by Distal Renal Tubular Acidosis as the Initial Manifestation of Sjogren's Syndrome. Cureus 2023; 15:e38984. [PMID: 37378130 PMCID: PMC10292101 DOI: 10.7759/cureus.38984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 06/29/2023] Open
Abstract
Sjogren's syndrome is an autoimmune disorder characterized by lymphocytic infiltration of exocrine glands that typically manifests as dysfunction of the lacrimal or salivary glands. About one-third of Sjogren's syndrome patients exhibit systemic symptoms. In one-third of Sjogren's syndrome cases, renal tubular acidosis (RTA) is present. Hypokalemia is the most prevalent electrolyte disorder in patients with distal RTA. A middle-aged female presented to the emergency department with a complaint of sudden-onset quadriparesis followed by shortness of breath. Her arterial blood gas analysis revealed severe hypokalaemia and metabolic acidosis. ECG revealed broad complex tachycardia, which resolved after starting potassium infusion. On evaluating the cause of normal anion gap metabolic acidosis and hypokalaemia, she was found to have distal renal tubular acidosis (RTA). Furthermore, on evaluating the cause of distal RTA, her SSA/Anti Ro and SSB/Anti La levels came out to be elevated, and a probable diagnosis of Sjogren's syndrome was made. Severe hypokalaemia leading to hypokalaemia quadriparesis and broad complex tachycardia as the initial manifestation of distal RTA due to Sjogren's syndrome is uncommon. Timely recognition and prompt replacement of potassium are key to improved outcomes. It is also important to note that Sjogren's syndrome should be taken into account even in the absence of sicca symptoms, like in our case.
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Affiliation(s)
- Nidhi Kaeley
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Anand M Gangdev
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Soumya Subhra Datta
- Emergency Medicine, AII India Institute of Medical Science, Rishikesh, Rishikesh, IND
| | - Utkarsh P Singh
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Osman O, Manzi S, Wasko MC, Clark BA. Case report: disease mechanisms and medical management of calcium nephrolithiasis in rheumatologic diseases. BMC Urol 2023; 23:42. [PMID: 36959633 PMCID: PMC10035194 DOI: 10.1186/s12894-023-01203-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/19/2023] [Indexed: 03/25/2023] Open
Abstract
Background Nephrolithiasis as a feature of rheumatologic diseases is under recognized. Understanding presenting features, diagnostic testing is crucial to proper management. Case presentation A 32 year old woman with a history of recurrent complicated nephrolithiasis presented to a rheumatologist for a several month history of fatigue, dry eyes, dry mouth, arthralgias. She had a positive double-stranded DNA, positive SSA and SSB antibodies. She was diagnosed with Systemic Lupus erythematosus (SLE) and Sjogren's syndrome and was started on mycophenalate mofetil. Of relevance was a visit to her local emergency room 4 years earlier with profound weakness with unexplained marked hypokalemia and a non-anion gap metabolic acidosis. Approximately one year after that episode she developed flank pain and nephrocalcinosis. She had multiple issues over the ensuing years with stones and infections on both sides. Interventions included extracorporeal shockwave lithotripsy as well as open lithotomy and eventual auto-transplantation of left kidney for recurrent ureteric stenosis. 24 h stone profile revealed marked hypocitraturia, normal urine calcium, normal urine oxalate and uric acid. She was treated with potassium citrate. Mycophenolate was eventually stopped due to recurrent urinary tract infections and she was started on Belimumab. Because of recurrent SLE flares, treatment was changed to Rituximab (every 6 months) with clinical and serologic improvement. Her kidney stone frequency gradually improved and no further interventions needed although she continued to require citrate repletion for hypocitraturia. Conclusions Nephrolithiasis can be a prominent and even presenting feature in Sjogrens syndrome as well as other rheumatologic diseases. Prompt recognition and understanding disease mechanisms is important for best therapeutic interventions for kidney stone prevention as well as treatment of underlying bone mineral disease.
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Affiliation(s)
- Omar Osman
- grid.417046.00000 0004 0454 5075Department of Medicine, Allegheny Health Network, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Susan Manzi
- grid.417046.00000 0004 0454 5075Department of Medicine, Allegheny Health Network, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Mary Chester Wasko
- grid.417046.00000 0004 0454 5075Department of Medicine, Allegheny Health Network, 320 East North Ave, Pittsburgh, PA 15212 USA
| | - Barbara A. Clark
- grid.417046.00000 0004 0454 5075Department of Medicine, Allegheny Health Network, 320 East North Ave, Pittsburgh, PA 15212 USA
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Fazal F, Ur Rehman ME, Tahir S, Ijaz AA, Ambreen S. Hypokalemic Quadriparesis As Initial Presentation of Secondary Sjogren Syndrome With Associated Autoimmune Thyroiditis: A Case Report. Cureus 2022; 14:e25420. [PMID: 35769685 PMCID: PMC9233982 DOI: 10.7759/cureus.25420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/05/2022] Open
Abstract
Sjögren's syndrome is an autoimmune disorder typically presenting as dry mouth and eyes (sicca syndrome). However, the disease can involve any organ, complicating diagnosis. Renal involvement may manifest as distal renal tubular acidosis, leading to hypokalemia. We report a case of a 25-year-old woman presenting with progressive quadriparesis and vomiting. She had severe hypokalemic paralysis due to distal renal tubular acidosis. The patient was diagnosed with secondary Sjögren syndrome with autoimmune thyroiditis. She recovered completely with potassium supplementation.
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Meena DS, Kumar D, Bohra GK, Bhambu SK. Hypokalemic paralysis as an initial presentation of Sjogren syndrome. Ann Afr Med 2020; 19:147-149. [PMID: 32499473 PMCID: PMC7453953 DOI: 10.4103/aam.aam_34_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sjogren syndrome (SS) is a systemic autoimmune disorder with predominant exocrine gland involvement leading to sicca symptoms. Among extraglandular manifestations, renal disease is the most common. Tubular interstitial nephritis and renal tubular acidosis (RTA) are the common presentations. Mild hypokalemia associated with distal RTA is common in SS, however, severe hypokalemia causing paralysis is unusual. We report the case of a 26-year-old female who presented with hypokalemic paralysis. On evaluation, distal RTA was diagnosed. Further evaluation showed positive SS-a/SS-b antibodies in high titer, which confirms the diagnosis of primary SS. Our report illustrates that SS is a rare but important cause of hypokalemic paralysis.
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Affiliation(s)
- Durga Shankar Meena
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Deepak Kumar
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Gopal Krishana Bohra
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sunil Kumar Bhambu
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Bruns N, Finkelberg I, Al-Attrach I, Hoyer PF, Büscher R. Unusual Presentation of Polyautoimmunity and Renal Tubular Acidosis in an Adolescent With Hashimoto's Thyroiditis and Central Pontine Myelinolysis. Front Endocrinol (Lausanne) 2020; 11:548877. [PMID: 33162932 PMCID: PMC7591671 DOI: 10.3389/fendo.2020.548877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Hashimoto's thyroiditis is frequently associated with other autoimmune diseases and may include renal involvement. Case description: A 17-year-old female with previously diagnosed Hashimoto's thyroiditis and vitiligo was admitted to a pediatric intensive care unit with hypokalemic paralysis and acidosis, after having suffered from recurrent muscular weakness for approximately one year. A few days later she developed central pontine myelinolysis. After initial stabilization she was also diagnosed with distal renal tubular acidosis (dRTA) and tubular proteinuria which can occur in Sjögren's syndrome. Extended screening for autoimmune diseases additionally revealed celiac disease. Treatment with Prednisone and substitution of potassium quickly lead to the resolution of proteinuria and dRTA, but unilateral paralysis of the sixth nerve as a result of central pontine myelinolysis was irreversible. Conclusions: This is the rare case of polyautoimmunity including autoimmune thyroiditis, Sjögren's syndrome, vitiligo and celiac disease in an adolescent with few disease-specific symptoms. The diagnoses were made via a complicating nephritis causing dRTA and proteinuria. Delay in diagnosis lead to permanent neurological damage. This case highlights the need for pediatricians to be aware of rare accompanying diseases and their complications in "common" pediatric autoimmune diseases like Hashimoto's thyroiditis and celiac disease.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
- *Correspondence: Nora Bruns
| | - Ilja Finkelberg
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Ibrahim Al-Attrach
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Peter F. Hoyer
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Rainer Büscher
- Department of Pediatrics II, Pediatric Nephrology, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
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Seeliger T, Prenzler NK, Gingele S, Seeliger B, Körner S, Thiele T, Bönig L, Sühs KW, Witte T, Stangel M, Skripuletz T. Neuro-Sjögren: Peripheral Neuropathy With Limb Weakness in Sjögren's Syndrome. Front Immunol 2019; 10:1600. [PMID: 31354737 PMCID: PMC6637792 DOI: 10.3389/fimmu.2019.01600] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/26/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: Sjögren's syndrome is a heterogeneous inflammatory disorder frequently involving peripheral nerves with a wide spectrum of sensory modalities and distribution patterns. The objective of this cross-sectional study was to determine characteristics of Sjögren's syndrome as a cause for severe neuropathy with limb weakness. Methods: One hundred and eighty four patients with polyneuropathy associated with limb weakness underwent routine diagnostics including investigations for Sjögren's syndrome. Forty-four patients with Sjögren's syndrome (ACR-EULAR classification criteria) and severe neuropathy were identified. Results: Sjögren's syndrome was found at a median age of 63 years and the gender distribution showed a balanced female-male ratio of 1:1. Anti-SSA(Ro) antibodies were detected in 48% while seronegative patients were diagnosed with Sjögren's syndrome based on sialadenitis on minor salivary gland biopsy with a focus score ≥1. The majority of patients (93%) were diagnosed with Sjögren's syndrome after neurological symptoms appeared. Limbs were symmetrically involved in 84% of patients (57% tetraparesis, 27% paraparesis). Sensory function was not affected in 11% of patients indicating that Sjögren's syndrome associated neuropathy can present as a pure motor syndrome. Electrophysiological measurements did not reveal pathognomonic findings (23% demyelinating pattern, 36% axonal pattern, 41% both demyelinating and axonal damage signs). More than half of our patients fulfilled the European Federation of Neurological Societies (EFNS) diagnostic criteria for CIDP indicating that distinction between Neuro-Sjögren and other causes of neuropathy such as CIDP is challenging. Interpretation: Our findings show that severe neuropathy with limb weakness is often associated with Sjögren's syndrome. This is of great importance in identifying and understanding the causes of immune mediated polyneuropathy.
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Affiliation(s)
- Tabea Seeliger
- Department of Neurology, Hanover Medical School, Hanover, Germany
| | - Nils K. Prenzler
- Department of Otolaryngology, Hanover Medical School, Hanover, Germany
| | - Stefan Gingele
- Department of Neurology, Hanover Medical School, Hanover, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hanover Medical School, Hanover, Germany
| | - Sonja Körner
- Department of Neurology, Hanover Medical School, Hanover, Germany
| | - Thea Thiele
- Department of Clinical Immunology and Rheumatology, Hanover Medical School, Hanover, Germany
| | - Lena Bönig
- Department of Neurology, Hanover Medical School, Hanover, Germany
| | | | - Torsten Witte
- Department of Clinical Immunology and Rheumatology, Hanover Medical School, Hanover, Germany
| | - Martin Stangel
- Department of Neurology, Hanover Medical School, Hanover, Germany
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Vasquez-Rios G, Westrich DJ, Philip I, Edwards JC, Shieh S. Distal renal tubular acidosis and severe hypokalemia: a case report and review of the literature. J Med Case Rep 2019; 13:103. [PMID: 31023369 PMCID: PMC6485144 DOI: 10.1186/s13256-019-2056-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/15/2019] [Indexed: 12/29/2022] Open
Abstract
Background Distal renal tubular acidosis is a relatively infrequent condition with complex pathophysiology that can present with life-threatening electrolyte abnormalities. Case presentation We describe a case of a 57-year-old Caucasian woman with previous episodes of hypokalemia, severe muscle weakness, and fatigue. Upon further questioning, symptoms of dry eye and dry mouth became evident. Initial evaluation revealed hyperchloremic metabolic acidosis, severe hypokalemia, persistent alkaline urine, and a positive urinary anion gap, suggestive of distal renal tubular acidosis. Additional laboratory workup and renal biopsy led to the diagnosis of primary Sjögren’s syndrome with associated acute tubulointerstitial nephritis. After potassium and bicarbonate supplementation, immunomodulatory therapy with hydroxychloroquine, azathioprine, and prednisone was started. Nonetheless, her renal function failed to improve and remained steady with an estimated glomerular filtration rate of 42 ml/min/1.73 m2. The literature on this topic was reviewed. Conclusions Cases of renal tubular acidosis should be carefully evaluated to prevent adverse complications, uncover a potentially treatable condition, and prevent the progression to chronic kidney disease. Repeated episodes of unexplained hypokalemia could be an important clue for diagnosis.
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Affiliation(s)
- George Vasquez-Rios
- Department of Internal Medicine, St. Louis University School of Medicine, St. Louis, MO, USA.
| | - David John Westrich
- Department of Internal Medicine, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Isaac Philip
- St. Louis University School of Medicine, St. Louis, MO, USA
| | - John C Edwards
- Nephrology Division, Department of Internal Medicine, St. Louis University, St. Louis, MO, USA
| | - Stephanie Shieh
- Nephrology Division, Department of Internal Medicine, St. Louis University, St. Louis, MO, USA.,Division of Nephrology, VA St. Louis Health Care System, St. Louis, MO, USA
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