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Nguyen R, Gomez-Castillo L, Gonzales JA. Ocular manifestations of juvenile Sjögren's disease. Curr Opin Ophthalmol 2024:00055735-990000000-00180. [PMID: 38923442 DOI: 10.1097/icu.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
PURPOSE OF REVIEW This review aims to enhance understanding of juvenile Sjögren's disease (jSjD) by exploring diagnostic criteria, ocular clinical features, ancillary ophthalmic testing, and management strategies specific to this rare pediatric condition. RECENT FINDINGS Unlike adults, children with jSjD often present with recurrent parotitis and extra-glandular symptoms before developing sicca symptoms. Adult SjD classification criteria do not consider pediatric-specific symptoms and physiological differences. Underutilization of diagnostic tests such as the ocular staining score (OSS) and Schirmer I may result in an incomplete understanding of the prevalence of keratoconjunctivitis sicca in jSjD. SUMMARY Timely referral to an ophthalmologist can address perceived feasibility issues with respect to ocular features in jSjD. Management of keratoconjunctivitis sicca in jSjD includes improving ocular surface lubrication and decreasing inflammation. Recognition of pediatric-specific clinical features and development of universally accepted jSjD classification criteria will allow for better identification of potential participants for future jSjD studies.
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Affiliation(s)
- Robert Nguyen
- School of Medicine, University of Washington, Seattle, Washington
- Francis I. Proctor Foundation
| | | | - John A Gonzales
- Francis I. Proctor Foundation
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
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2
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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: 4] [Impact Index Per Article: 4.0] [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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3
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Doolan G, Faizal NM, Foley C, Al-Obaidi M, Jury EC, Price E, Ramanan AV, Lieberman SM, Ciurtin C. Treatment strategies for Sjögren's syndrome with childhood onset: a systematic review of the literature. Rheumatology (Oxford) 2022; 61:892-912. [PMID: 34289032 PMCID: PMC8889300 DOI: 10.1093/rheumatology/keab579] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/29/2021] [Accepted: 07/11/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES SS with childhood onset is a rare autoimmune disease characterized by heterogeneous presentation. The lack of validated classification criteria makes it challenging to diagnose. Evidence-based guidelines for treatment of juvenile SS are not available due to the rarity of disease and the paucity of research in this patient population. This systematic review aims to summarize and appraise the current literature focused on pharmacological strategies for management of SS with childhood onset. METHODS PubMed and MEDLINE/Scopus databases up to December 2020 were screened for suitable reports highlighting pharmacological treatment of SS with childhood onset using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 reporting checklist. Animal studies were excluded. RESULTS A total of 43 studies (34 case reports, 8 mini case series and 1 pilot study) were eligible for analysis. The studies retrieved included girls in 88% (120/137) of cases and had very low confidence levels. HCQ was prescribed for parotid swelling, as well as in association with MTX and NSAIDs in patients with arthritis and arthralgia. Corticosteroids such as long courses of oral prednisone and i.v. methylprednisolone were commonly prescribed for children with severe disease presentations. Rituximab was mainly indicated for mucosa-associated lymphoid tissue lymphoma and renal and nervous system complications. Other conventional DMARDs were prescribed in selected cases with extraglandular manifestations. CONCLUSION Various therapies are used for the management of juvenile SS and are prescribed based on expert clinician's opinion. There are currently no good-quality studies that allow clinical recommendations for treatment of SS with childhood onset.
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Affiliation(s)
- Georgia Doolan
- Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London
- Department of Rheumatology, University College London Hospital
| | - Nor Mohd Faizal
- Department of Applied Medical Sciences, University College London
| | - Charlene Foley
- Department of Paediatric Rheumatology, Great Ormond Street Hospital
| | | | - Elizabeth C Jury
- Centre for Rheumatology Research, Department of Medicine, University College London, London
| | - Elizabeth Price
- Department of Rheumatology, Great Western Hospitals NHS Foundation Trust, Swindon
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Scott M Lieberman
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London
- Department of Rheumatology, University College London Hospital
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4
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Pediatric Neuromyelitis Optica Spectrum Disorder: Case Series and Literature Review. Life (Basel) 2021; 12:life12010019. [PMID: 35054412 PMCID: PMC8779266 DOI: 10.3390/life12010019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/20/2022] Open
Abstract
Neuromyelitis Optica Spectrum Disorder (NMOSD) is a central nervous system (CNS) inflammatory demyelinating disease characterized by recurrent inflammatory events that primarily involve optic nerves and the spinal cord, but also affect other regions of the CNS, including hypothalamus, area postrema and periaqueductal gray matter. The aquaporin-4 antibody (AQP4-IgG) is specific for NMOSD. Recently, myelin oligodendrocyte glycoprotein antibodies (MOG-IgG) have been found in a group of AQP4-IgG negative patients. NMOSD is rare among children and adolescents, but early diagnosis is important to start adequate therapy. In this report, we present cases of seven pediatric patients with NMOSD and we review the clinical and neuroimaging characteristics, diagnosis, and treatment of NMOSD in children.
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Abstract
Sjögren disease increasingly is recognized in pediatric patients. Clinical features, primarily parotitis and sicca symptoms, and results of diagnostic tests may be different from those in adult disease. Adult criteria fail to capture most pediatric patients. Pediatric-specific criteria are urgently needed to define the natural history of the disease, identify risk and prognostic factors, and evaluate the impact of therapeutics and other interventions on disease course in young patients.
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Affiliation(s)
- Rachel L Randell
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road Box #3212, Durham, NC 27705, USA.
| | - Scott M Lieberman
- Division of Rheumatology, Allergy, and Immunology, Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, 500 Newton Road, 2191 ML, Iowa City, IA 52242, USA
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Fang GL, Fang W, Zheng Y, Zhang YX. Neuromyelitis optica spectrum disorder complicated with Sjögren's syndrome: first pediatric case responsive to mycophenolate mofetil treatment. Acta Neurol Belg 2021; 121:1065-1067. [PMID: 33136271 DOI: 10.1007/s13760-020-01530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
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Ciurtin C, Cho Y, Al-Obaidi M, Jury EC, Price EJ. Barriers to translational research in Sjögren's syndrome with childhood onset: challenges of recognising and diagnosing an orphan rheumatic disease. THE LANCET. RHEUMATOLOGY 2021; 3:e138-e148. [PMID: 38279369 DOI: 10.1016/s2665-9913(20)30393-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 01/28/2024]
Abstract
Sjögren's syndrome was considered for many years a disease of adulthood, characterised by immune infiltration of exocrine glands, leading to dryness (eg, dry mouth and eyes), which is a cardinal symptom. As of the last 20 years, it became apparent that although the disease is very rare in children, its clinical presentation differs from that of adults, posing substantial challenges to the recognition, diagnosis, and classification of patients with childhood-onset Sjögren's syndrome. This Viewpoint explores comparative classification criteria for children (not validated) and adults with Sjögren's syndrome, as well as differences in the clinical presentation of childhood-onset versus adult-onset Sjögren's syndrome, offering ideas about how we can improve the diagnosis of Sjögren's syndrome in children. A review of the role of medical history and clinical assessment, serology, glandular function assessment, and imaging, as well as salivary and lachrymal gland biopsy in the diagnosis of children with Sjögren's syndrome is included. Additionally, we provide suggestions about further research and registry data collection that is required to address the unmet needs of these patients.
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Affiliation(s)
- Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London, London, UK; Department of Rheumatology, University College London Hospital NHS Trust, London, UK.
| | - Youna Cho
- University College London Medical School, University College London, London, UK
| | - Muthana Al-Obaidi
- Department of Paediatric Rheumatology, Great Ormond Hospital for Children NHS Trust, London, UK
| | - Elizabeth C Jury
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
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Marino A, Romano M, Giani T, Gaggiano C, Costi S, Singh R, Mehta JJ, Lieberman SM, Cimaz R. Childhood Sjogren's syndrome: An Italian case series and a literature review-based cohort. Semin Arthritis Rheum 2020; 51:903-910. [PMID: 33261821 DOI: 10.1016/j.semarthrit.2020.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Sjogren's syndrome (SS) is a chronic autoimmune disease with a highly variable presentation. This study aims to describe childhood SS (cSS) features to help guide clinicians in their consideration of and workup for cSS. METHODS We retrospectively reviewed medical records of patients with cSS referred to three Italian pediatric rheumatology centers from 2015 to 2019 and we conducted a literature review of cSS. Statistical analysis was performed to detect associations between clinical/laboratory features. RESULTS We reviewed 12 cases (9 female) followed in 3 Italian centers and 240 cases (191 female) in the published literature reporting individual information. The median age at disease onset was 10 years for both cohorts. The most frequently reported clinical SS-specific feature was parotitis in both cohorts (67% each). Extraglandular manifestations were very common and joint involvement was the most frequent. In the cluster analysis, we identified a significant association between parotitis and younger patients (< 11 years). We verified the presence of the main SS features (exocrine gland inflammation, exocrine gland dysfunction, and presence of autoantibodies) in the Italian cohort and the literature review-based cohort: 92% and 80% of the cohorts, respectively, had at least 2/3 main characteristics. CONCLUSION We described cSS features with relative frequencies and we found that parotid involvement was related to cSS in younger patients. The majority of patients showed various combinations of exocrine gland inflammation, exocrine gland dysfunction, and presence of autoantibodies giving a theoretical basis for future research to pave the way for the development of cSS specific diagnostic criteria.
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Affiliation(s)
- Achille Marino
- Department of Pediatrics, Desio Hospital, ASST Monza. Via Mazzini 1, 20832 Desio (MB), Italy; ASST G.Pini-CTO, Via Gaetano Pini 9, 20122 Milan, Italy.
| | - Micol Romano
- ASST G.Pini-CTO, Via Gaetano Pini 9, 20122 Milan, Italy
| | - Teresa Giani
- Pediatric Rheumatology, Meyer Children's Hospital, Viale Gaetano Pieraccini, 24, 50139 Florence, Italy; Department of Medical Biotechnology, University of Siena, viale Mario Bracci, 16, Siena, Italy
| | - Carla Gaggiano
- Department of Pediatrics, University of Siena, viale Mario Bracci, 16, Siena, Italy
| | | | - Revika Singh
- Northwestern University, 633 Clark St, Evanston, IL 60208, USA
| | - Jay J Mehta
- Division of Rheumatology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104-4399, USA
| | - Scott M Lieberman
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Rolando Cimaz
- ASST G.Pini-CTO, Via Gaetano Pini 9, 20122 Milan, Italy; Department of Clinical Sciences and Community Health, and Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Via della Commenda 19, 20122 Milan, Italy
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Zhao J, Chen Q, Zhu Y, Zhao M, Liu J, Zhang Z, Gong X. Nephrological disorders and neurological involvement in pediatric primary Sjogren syndrome:a case report and review of literature. Pediatr Rheumatol Online J 2020; 18:39. [PMID: 32448292 PMCID: PMC7245745 DOI: 10.1186/s12969-020-00431-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/06/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Sjögren syndrome (SS) is a rare disease in pediatrics, and little attention has been paid to the clinical feature in these patients. To date, there are few cases concern about neurological and nephrological disorders in childhood Sjögren syndrome. We describe a case of Sjögren syndrome in a 12-year-old girl who developed neurological disorders and interstitial nephritis and review the literature currently available on this topic. CASE PRESENTATION A 12-year-old girl was admitted to our hospital for arthritis and glucosuria. She was required to do labial gland and renal biopsy, because the positive for anti-nuclear antibody and anti-Sjögren syndrome B (anti-SSB) antibody. Then the biopsy was performed revealing the lymphocytic infiltrate in the small area and renal tubular interstitial damage,thus the diagnosis of Sjögren syndrome with tubular interstitial damage was made. Three months later, she presented again with headache, fever, nausea, vomiting and was recovered without drug therapy. Based on the patient's medical history, laboratory and imaging examination, and treatment, we speculate that the disorders of the nervous system were caused by the Sjögren syndrome. The girl has stable renal function and no residual nervous system damage in the next 1.5 years, but she underwent low dose prednisone therapy because of persistent renal glucosuria. CONCLUSIONS Nephrological disorders and neurological involvement are rare manifestations of Sjögren syndrome in children, and rarely presented as the initial symptoms. It should be suspected in children presenting with unexplained renal diseases, neurological abnormalities, or unexplained fever. Although there is no guidelines on the diagnosis and treatment of children Sjögren syndrome are currently available, early recognition and the appropriate treatment of renal damage and neurologic involvement would improve prognosis and prevent complications.
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Affiliation(s)
- Jingya Zhao
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Qin Chen
- Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012, People's Republic of China.
| | - Yunyun Zhu
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Meng Zhao
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Jun Liu
- grid.417168.d0000 0004 4666 9789Department of Pathology, Tongde Hospital of Zhejiang Province, Hangzhou, People’s Republic of China
| | - Zhenzhong Zhang
- grid.417168.d0000 0004 4666 9789Department of Nephrology, Tongde Hospital of Zhejiang Province, Gucui Road, No.234, Hangzhou, 310012 People’s Republic of China
| | - Xiaoting Gong
- grid.417168.d0000 0004 4666 9789Department of Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, People’s Republic of China
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Gmuca S, Lieberman SM, Mehta J. Pediatric Neuromyelitis Optica Spectrum Disorder and Sjögren Syndrome: More Common Than Previously Thought? J Rheumatol 2018; 44:959-960. [PMID: 28572479 DOI: 10.3899/jrheum.160978] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Sabrina Gmuca
- Department of Pediatrics, Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Scott M Lieberman
- Stead Family Department of Pediatrics, Division of Rheumatology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Jay Mehta
- Department of Pediatrics, Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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