Musculoskeletal Manifestations in Sjogren's Syndrome: An Orthopedic Point of View

Idiopathic avascular necrosis of the scaphoid (Preiser's disease): a case report and review of the literature

Idiopathic avascular necrosis of the scaphoid bone, Preiser's disease, was originally described as a deteriorative pathology whereby the osseous structure necroses due to loss of blood supply. It may present with multifactorial etiology, which is still largely not well understood. We describe a case of Preiser's disease in a 70-year-old female, with worsening pain and loss of range of motion in her right wrist over a two-year period. Past medical history was significant for Sjogren's disease, fibromyalgia, and dystonia. Pain began several months following traumatic right dorsal wrist injury. Diagnosis of traumatic scaphoid fracture was originally suspected. Conservative treatment was unsuccessful. Radiographs did not demonstrate evidence of primary fracture. CT scan and MRI demonstrated osteonecrosis of the proximal pole of the scaphoid, but no evidence of fracture, either residual or healing, was found. Proximal row carpectomy was performed for avascular necrosis of the scaphoid. Histology confirmed diagnosis and verified absence of fracture. Postoperatively, the patient's pain and range of motion improved. This report combines histological findings of Preiser's disease with radiographic images which may ameliorate understanding of the clinical pathophysiology. We describe an unusual manifestation of Preiser's disease whereby a single traumatic event, in the absence of fracture, led to idiopathic scaphoid avascular necrosis, which may have been associated with Sjogren's syndrome and fibromyalgia. These conditions may have negatively impacted microvasculature and decreased bone mineral density, inversely correlated with the production of fatty marrow, facilitating the onset of osteonecrosis in the scaphoid.

Salivary nitrate prevents osteoporosis via regulating bone marrow mesenchymal stem cells proliferation and differentiation

Background

Nitrate, a key component of saliva, has been shown widely physiological functions in the human body. But its function on bone metabolism remains unclear. The aim of this study was to investigate the function and mechanism of saliva nitrate on osteoporosis and the function of bone marrow mesenchymal stem cells (BMSCs).

Methods

Saliva nitrate removal or supplemental interventions were performed for 1 month in ovariectomized (OVX) osteopenia mice. The nitrate levels in saliva and serum were detected. The bone formation and bone microarchitecture in the OVX mouse model were investigated by quantitative Micro--computed tomography imaging, histological staining and serum bone biomarker analysis. The effects of nitrate on the functional homeostasis of BMSCs in OVX mice were explored by Ki67 immunofluorescence staining, Ki67 flow staining, alizarin red staining, qPCR and western blotting. Finally, downstream signaling pathways were screened by proteomics and verified by western blotting.

Results

The results showed that nitrate deficiency exacerbated osteoporosis, while nitrate administration prevent osteoporosis in OVX mice. Nitrate increased the expression of PINP, a biomarker of bone formation, in OVX mice. Besides, nitrate enhanced the proliferative capacity and osteogenic function of BMSCs in OVX mice in vitro and in vivo. In addition, nitrate upregulated the expression levels of osteogenesis-related genes ALP, Run2 and OPN of BMSCs. EGFR and mTOR signaling were screened as the key downstream of nitrate, and phosphorylated protein levels of its subfamily members AKT, ERK and S6K were significantly upregulated by nitrate.

Conclusion

The present results showed saliva nitrate preventively protects against osteoporosis through enhances the proliferation and osteogenic differentiation potential of BMSCs. The effects of nitrate on bone homeostasis are closely related to the EGFR/AKT/ERK and mTOR/S6K signaling axes.

The translational potential of this article

Our study provides experimental evidence for the use of saliva nitrate as an effective candidate for the prevention of osteoporosis and maintenance of bone homeostasis.

Neurological Involvement in Patients with Primary Sjögren's Syndrome: A Retrospective Cross-Sectional Study

Background

To determine the rate and types of neurological involvement in patients with primary Sjögren's syndrome (pSS) and to evaluate predictive clinical and immunologic features of neurological involvement.

Methods

We retrospectively assessed 2127 patients with an ICD-10 code for Sjögren recorded in the hospital database. Among these patients, those meeting the pSS classification criteria and having neurological symptoms and an objective evaluation accordingly were enrolled. After comparing the patients with and without neurological involvement, peripheral and central involvement subtypes were also compared within themselves.

Results

A total of 199 pSS patients were enrolled and neurological involvement was found in 31.6%. Peripheral nervous system (PNS) involvement was found in 23.5% of the patients, and central nervous system (CNS) involvement was found in 34.3%. Patients with neurological involvement had a higher frequency of Schirmer's test, anti-Ro/SS-A and anti-La/SS-B positivity and the presence of interstitial lung disease, articular involvement, lymphadenopathy, anemia and hypocomplementemia than patients without those. In multivariate regression analysis, only articular involvement had a higher risk for the development of neurologic involvement [OR 10.01 (4.18-23.97), P 0.0001]. Among the patients with PNS, the frequency of anti-Ro/SS-A positivity, low C3 and Schirmer's test positivity were statistically increased compared to those who were not in PNS (P = 0.032, P = 0.044, and P = 0.029, respectively). When compared in terms of CNS involvement, patients with CNS involvement were younger, had a shorter disease duration, and had a higher frequency of anti-Ro/SS-A positivity than patients without those (P = 0.041, P = 0.027, and P = 0.046, respectively).

Conclusions

In our study, it was shown that one third of the symptomatic pSS patients had objective neurological involvement. The presence of neurological symptoms should be considered, especially in patients with articular involvement in pSS.

The Spectrum of Extraglandular Manifestations in Primary Sjögren's Syndrome

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

Sjogren's Syndrome: Recent Updates

Primary Sjögren's syndrome (SS) is a chronic systemic autoimmune disorder affecting primarily perimenopausal women [...].