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Lei Y, Zhang X, Liu H, Xu Z, Xu P. Amyotrophic lateral sclerosis associated with Sjögren's syndrome: a case report. BMC Neurol 2024; 24:300. [PMID: 39198773 PMCID: PMC11351767 DOI: 10.1186/s12883-024-03775-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/22/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Motor neuron disease (MND) is a chronic and progressive neurodegenerative disorder with an unknown cause. The development of amyotrophic lateral sclerosis (ALS) is believed to be linked to an immune response. Monocytes/macrophages and T cells are key players in the disease's advancement. Monitoring levels of cytokines in the blood can help forecast patient outcomes, while immunotherapy shows promise in alleviating symptoms for certain individuals. CASE PRESENTATION A 56-year-old male patient was admitted to the hospital due to progressive limb weakness persisting for eight months. The neurological examination revealed impairments in both upper and lower motor neurons, as well as sensory anomalies, without corresponding signs. Electrophysiological examination results indicated extensive neuronal damage and multiple peripheral nerve impairments, thereby the diagnosis was ALS. One month ago, the patient began experiencing symptoms of dry mouth and a bitter taste. Following tests for rheumatic immune-related antibodies and a lip gland biopsy, a diagnosis of Sjögren's syndrome (SS) was proposed. Despite treatment with medications such as hormones (methylprednisolone), immunosuppressants (hydroxychloroquine sulfate), and riluzole, the symptoms did not significantly improve, but also did not worsen. CONCLUSION It is recommended to include screening for SS in the standard assessment of ALS. Furthermore, research should focus on understanding the immune mechanisms involved in ALS, providing new insights for the diagnosis and treatment of ALS in conjunction with SS.
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Affiliation(s)
- Yihui Lei
- The Affiliated Hospital of Zunyi Medical University, No. 149, Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China
| | - Xiaoping Zhang
- The Affiliated Hospital of Zunyi Medical University, No. 149, Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China
| | - Haijun Liu
- The Affiliated Hospital of Zunyi Medical University, No. 149, Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China
| | - Zucai Xu
- The Affiliated Hospital of Zunyi Medical University, No. 149, Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China
| | - Ping Xu
- The Affiliated Hospital of Zunyi Medical University, No. 149, Dalian Road, Huichuan District, Zunyi City, Guizhou Province, China.
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Popescu A, Hickernell J, Paulson A, Aouhab Z. Neurological and Psychiatric Clinical Manifestations of Sjögren Syndrome. Curr Neurol Neurosci Rep 2024; 24:293-301. [PMID: 38981949 DOI: 10.1007/s11910-024-01352-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE OF REVIEW Sjögren Syndrome is a systemic autoimmune disorder that presents mainly with sicca symptoms, but frequently affects other body systems which can lead to a wide variety of manifestations. Understanding the neurological and psychiatric manifestations of Sjögren Syndrome can help with an earlier diagnosis of this disease and leads to better clinical outcomes. RECENT FINDINGS We provide an updated overview of the central neurological manifestations, peripheral neurological manifestations and psychiatric manifestations and their diagnosis when associated with primary Sjögren Syndrome. The epidemiology and clinical features of the neurological and psychiatric manifestations are derived from different cohort studies and review articles that were selected from PubMed searches conducted between January 2024 and March 2024. The absence of diagnostic criteria and the scarcity of large, robust studies makes the recognition of the neurological and psychiatric manifestations of Sjögren Syndrome more difficult. Maintaining a high index of suspicion in clinical practice and a close collaboration between the Neurologist and the Rheumatologist will facilitate the diagnosis and management of these patients.
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Affiliation(s)
- Alexandra Popescu
- Department of Rheumatology, Loyola University Medical Center, 2160 S. First Avenue, Maywood, Il, 60153, USA.
| | - John Hickernell
- Department of Rheumatology, Loyola University Medical Center, 2160 S. First Avenue, Maywood, Il, 60153, USA
| | - Anisha Paulson
- Department of Rheumatology, Loyola University Medical Center, 2160 S. First Avenue, Maywood, Il, 60153, USA
| | - Zineb Aouhab
- Department of Rheumatology, Loyola University Medical Center, 2160 S. First Avenue, Maywood, Il, 60153, USA
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Tanaka Y, Ikeda K, Kaneko Y, Ishiguro N, Takeuchi T. Why does malaise/fatigue occur? Underlying mechanisms and potential relevance to treatments in rheumatoid arthritis. Expert Rev Clin Immunol 2024; 20:485-499. [PMID: 38224064 DOI: 10.1080/1744666x.2024.2306220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 01/12/2024] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Fatigue and malaise are commonly associated with a wide range of medical conditions, including rheumatoid arthritis (RA). Evidence suggests that fatigue and malaise can be overwhelming for patients, yet these symptoms remain inadequately-managed, largely due to an incomplete elucidation of the underlying causes. AREAS COVERED In this assessment of the published literature relating to the pathogenesis of fatigue or malaise in chronic conditions, four key mechanistic themes were identified. Each theme (inflammation, hypothalamic-pituitary-adrenal axis, dysautonomia, and monoamines) is discussed, as well as the complex network of interconnections between themes which suggests a key role for inflammatory cytokines in the development and persistence of fatigue. EXPERT OPINION Fatigue is multifaceted, poorly defined, and imperfectly comprehended. Moreover, the cause and severity of fatigue may change over time, as a consequence of the natural disease course or pharmacologic treatment. This detailed synthesis of available evidence permits us to identify avenues for current treatment optimization and future research, to improve the management of fatigue and malaise in RA. Within the development pipeline, several new anti-inflammatory therapies are currently under investigation, and we anticipate that the next five years will herald much-needed progress to reduce the debilitating nature of fatigue in patients with RA.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kei Ikeda
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Lin HC, Yen CM, Chen WS, Hsu CC, Kung YY, Wu JH, Su YT, Chen KF, Chen HY, Lien CM, Wang MJ, Chang CM. Unveiling the age-related dynamics in Sjögren's syndrome: Insights from heart rate variability and autonomic function. Int J Rheum Dis 2024; 27:e15088. [PMID: 38454192 DOI: 10.1111/1756-185x.15088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Sjögren's Syndrome (SS), mainly affecting women in their midlife, is characterized by persistent inflammation in glands producing tears and saliva, often leading to significant complications. This study investigates the differences in autonomic system functioning between individuals with SS and healthy controls. METHODS From April 2019 to December 2022, 329 diagnosed primary SS (pSS) patients and 30 healthy controls were enrolled at Taipei Veterans General Hospital, Taipei, Taiwan. The study assessed autonomic nervous system functioning using various HRV metrics. Participants were divided based on age and AECG criteria, including salivary gland biopsy and autoantibody status. RESULTS Significant differences in Heart Rate Variability (HRV) were observed between pSS patients and healthy controls. The total power index was notably lower in pSS patients (4.98 ± 1.29) than in controls (5.54 ± 1.21, p = .022). Additionally, Vagal (VAG) activity was significantly reduced in the pSS group (4.95 ± 1.33) compared to the healthy control group (5.47 ± 1.19, p = .041). Age-stratified analysis highlighted that the ≤50 years pSS group had a higher heart rate (77.74 ± 10.42) compared to the >50 years group (73.86 ± 10.35, p = .005). This group also showed a higher total power index (5.78 ± 1.30) versus the >50 years group (4.68 ± 1.19, p < .001), and significantly lower VAG activity (4.70 ± 1.26, p = .007) compared to healthy controls. Furthermore, the Standard Deviation of Normal-to-Normal Intervals (SDNN) was greater in the ≤50 years SS group (44.45 ± 37.12) than in the >50 years group (33.51 ± 26.18, p = .007). In pSS patients, those positive for both salivary gland biopsy and autoantibodies demonstrated a lower Total Power (4.25 ± 1.32) and R-wave validity (93.50 ± 4.79, p < .05) than other groups, suggesting more severe autonomic imbalance. The R-R interval variation (RRIV) was also significantly higher in this dual-positive group (696.10 ± 975.41, p < .05). Additionally, the ESSPRI for dryness was markedly higher in the dual-positive group (8.10 ± 1.45, p < .05), indicating more severe symptoms. These findings reveal significant variations in autonomic function in SS patients, especially in those with dual-positive biopsy and autoantibody status. CONCLUSION This study demonstrates significant autonomic dysfunction in pSS patients compared to healthy controls, particularly in those positive for both salivary gland biopsy and autoantibodies. The age-stratified analysis further emphasizes the impact of aging on autonomic system functioning in pSS, suggesting a need for age-specific management approaches in pSS patient care.
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Affiliation(s)
- Hong-Chun Lin
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Ming Yen
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Sheng Chen
- Division of Allergy, Immunology and Rheumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Chien Hsu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Ying Kung
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jin-Huang Wu
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Ting Su
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuo-Feng Chen
- Department of Chinese Medicine, Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan
| | - Hsin-Yuan Chen
- Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chien-Min Lien
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Section of Rehabilitation and Integrative Medicine, National Taiwan University Veterinary Hospital, Taipei, Taiwan
| | - Ming-Jen Wang
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Chinese Medicine, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Sokmen O, Temucin CM, Ayhan Seker C, Tan E. Immunotherapy Provides Electrophysiological Recovery and Excellent Clinical Response in Sjogren's Syndrome-Linked Quite Severe Autonomic Neuropathy. Neurologist 2023; 28:204-206. [PMID: 36223306 DOI: 10.1097/nrl.0000000000000468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The autonomic system is frequently affected in Sjogren's syndrome (SS), but presentation with severe autonomic neuropathy is infrequent. Herein, we present a patient with primary SS-linked autonomic neuropathy, which is significantly clinic and electrophysiological responsive to immunotherapy. CASE REPORT A 29-year-old female patient was admitted to our neurology department with recurrent syncope, postural light-headedness, and weight loss. Neurological examination revealed tonic pupils. The baseline composite autonomic symptom score-31 was 51 (0 to 75), and baseline functional ability score was 10 (0 to 100%). In the follow-up, syncope episodes that frequently develop during the day required the patient to lie in the supine position in bed all day and were triggered even by coming to a slightly sitting position. Neurophysiologic testing showed evidence of cardiovagal and sudomotor impairment. The patient was diagnosed with SS after detailed investigations. A 5-day course of intravenous immunoglobulin (IVIg) was given, and she continued IVIg once a month. After 6 months, she could walk long distances without support, and gastrointestinal complaints and syncopes had significantly decreased. After ~1.5 years, she had a composite autonomic symptom score-31 score of 11 and a functional ability score of 80%. Control heart rate variability analysis showed a significant improvement in the values of SD of the RR interval and root mean square of successive RR interval differences. CONCLUSIONS In SS-linked severe autonomic neuropathy, immunotherapy can provide electrophysiological recovery in addition to excellent clinical response.
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Affiliation(s)
| | | | - Cansu Ayhan Seker
- Department of Internal Medicine, Hacettepe University Hospital, Ankara,Turkey
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Casian M, Jurcut C, Dima A, Mihai A, Stanciu S, Jurcut R. Cardiovascular Disease in Primary Sjögren's Syndrome: Raising Clinicians' Awareness. Front Immunol 2022; 13:865373. [PMID: 35757738 PMCID: PMC9219550 DOI: 10.3389/fimmu.2022.865373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022] Open
Abstract
In the ever evolving landscape of systemic immune mediated diseases, an increased awareness regarding the associated cardiovascular system impairment has been noted in recent years. Even though primary Sjögren's Syndrome (pSS) is one of the most frequent autoimmune diseases affecting middle-aged individuals, the cardiovascular profile of this specific population is far less studied, at least compared to other autoimmune diseases. Traditional cardiovascular risk factors and disease specific risk factors are inextricably intertwined in this particular case. Therefore, the cardiovascular risk profile in pSS is a multifaceted issue, sometimes difficult to assess. Furthermore, in the era of multimodality imaging, the diagnosis of subclinical myocardial and vascular damage is possible, with recent data pointing that the prevalence of such involvement is higher in pSS than in the general population. Nevertheless, when approaching patients with pSS in terms of cardiovascular diseases, clinicians are often faced with the difficult task of translating data from the literature into their everyday practice. The present review aims to synthesize the existing evidence on pSS associated cardiovascular changes in a clinically relevant manner.
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Affiliation(s)
- Mihnea Casian
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- 2 Internal Medicine Department, Central Military University Emergency Hospital, Bucharest, Romania
| | - Ciprian Jurcut
- 2 Internal Medicine Department, Central Military University Emergency Hospital, Bucharest, Romania
| | - Alina Dima
- Department of Rheumatology, Colentina Clinical Hospital, Bucharest, Romania
| | - Ancuta Mihai
- 2 Internal Medicine Department, Central Military University Emergency Hospital, Bucharest, Romania
- Rheumatology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Silviu Stanciu
- Cardiac Noninvasive Laboratory, Central Military University Emergency Hospital, Bucharest, Romania
- Internal Medicine Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Ruxandra Jurcut
- Cardiology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Department of Cardiology, Expert Center for Rare Genetic Cardiovascular Diseases, Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
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Flessa CM, Zampeli E, Evangelopoulos ME, Natsis V, Bodewes ILA, Huijser E, Versnel MA, Moutsopoulos HM, Mavragani CP. Genetic Variants of the BAFF Gene and Risk of Fatigue Among Patients With Primary Sjögren's Syndrome. Front Immunol 2022; 13:836824. [PMID: 35371038 PMCID: PMC8964489 DOI: 10.3389/fimmu.2022.836824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background/Purpose Primary Sjögren's Syndrome (SS) is characterized by B lymphocyte hyperactivity with B cell activating factor (BAFF) acting as an important regulator. Single Nucleotide Polymorphisms (SNPs) of the BAFF gene have been implicated in the pathogenesis of several autoimmune diseases characterized by heightened fatigue levels, including primary SS. We aimed to explore potential associations between BAFF SNPs and fatigue status of primary SS patients. Methods Fatigue status was assessed in 199 consecutive primary SS patients (Greek cohort) using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) scale. Clinical, histological, laboratory, psychometric and personality data were also collected. DNA extracted from peripheral blood of all patients underwent evaluation for the presence of five BAFF SNPs (rs9514827, rs1041569, rs9514828, rs1224141, rs12583006) by PCR. To confirm our findings, an independent replicative cohort of 62 primary SS patients (Dutch cohort) was implemented. Finally, 52 multiple sclerosis (MS) patients were served as disease controls (MS cohort). Analysis of BAFF SNPs in association with fatigue levels was performed by the online platforms SNPStats and SHEsis and the SPSS 26 and Graph Pad Prism 8.00 software. Results TT genotype of the rs9514828 BAFF polymorphism was significantly less frequent in the fatigued primary SS patients of the Greek cohort compared to the non-fatigued (14.1% vs 33.3%). The corresponding ORs [95%CI] in the dominant and overdominant models were 0.33 [0.15-0.72], p=0.003 and 0.42 [0.23-0.78], p=0.005 respectively. The association remained significant after adjustment for the variables contributing to fatigue in the univariate analysis (OR [95% CI]: 0.3 [0.1-0.9], p=0.026). Accordingly, in the Dutch cohort, there was a trend of lower mental fatigue among patients carrying the TT rs9514828 BAFF genotype compared to their CC counterparts (4.1 ± 2.4 vs 6.0 ± 2.2 respectively, p=0.06). The rs9514828 BAFF SNP was not significantly associated with fatigue in the MS cohort. Conclusions We report a novel association between genetic makeup and primary SS-associated fatigue with the rs9514828 TT genotype decreasing the likelihood of fatigue development among these patients. These findings need validation in multi-center studies.
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Affiliation(s)
- Christina-Maria Flessa
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Maria-Eleftheria Evangelopoulos
- 1st Department of Neurology, Multiple Sclerosis and Demyelinating Disease Unit, Eginition University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilis Natsis
- 1st Department of Neurology, Multiple Sclerosis and Demyelinating Disease Unit, Eginition University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Iris L A Bodewes
- Department of Immunology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Erika Huijser
- Department of Immunology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marjan A Versnel
- Department of Immunology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Clio P Mavragani
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Fourth Department of Internal Medicine, Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Takahashi J, Umehara T, Mitsumura H, Murakami H, Iguchi Y. Hyperadrenergic Orthostatic Hypotension With Pure Peripheral Sympathetic Denervation Associated With Sjogren's Syndrome. Cureus 2021; 13:e17805. [PMID: 34660015 PMCID: PMC8497279 DOI: 10.7759/cureus.17805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/21/2022] Open
Abstract
Hyperadrenergic orthostatic hypertension (hyper OH), defined as OH with elevated levels of upright plasma norepinephrine (NE), is assumed to be a clinical expression of peripheral sympathetic denervation (PSD). Primary Sjogren’s syndrome (pSS) is an autoimmune disease that not only affects the exocrine glands but also develops autonomic neuropathy with PSD. We present a hyper OH with PSD possibly associated with pSS and successfully treated with intravenous immunoglobulin (IVIg). The case was a 60-year-old man who developed recurrent syncope on rapid standing from a sitting position. Head-up tilt test and NE infusion test showed hyper OH with PSD. This case report raises the possible associations between hyper OH and autonomic neuropathy as pSS developed.
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Affiliation(s)
| | - Tadashi Umehara
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hidetaka Mitsumura
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Hidetomo Murakami
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, JPN
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Cardiac involvement in primary Sjӧgren's syndrome. Rheumatol Int 2021; 42:179-189. [PMID: 34387735 DOI: 10.1007/s00296-021-04970-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Primary Sjӧgren's syndrome (pSS) is an autoimmune-mediated, inflammatory, and systemic connective tissue disease (CTD), especially in middle-aged women, which often involves multiple systems and organs of the body. In fact, the heart is an important target organ in patients with pSS. In recent years, it has been confirmed that the morbidity of cardiac involvement has increased in patients with pSS, and cardiovascular disease (CVD) is one of the main causes of death. The increased risk of CVD in pSS patients is associated with a great variety of risk factors, such as age, gender, hypertension, diabetes mellitus, dyslipidemia, disease duration, extra-glandular manifestations, therapeutic drugs of pSS, and so on. Early recognition and effective treatment of CVD may play a crucial role in improving adverse cardiovascular prognosis. Whereas cardiac involvement is closely related to patient prognosis and survival, the cardiac involvement of patients with pSS remains poorly studied. Therefore, this article reviews the cardiovascular risk factors, clinical manifestations of cardiac involvement, cardiovascular biomarkers, and therapeutic strategies of pSS patients.
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Davies K, Ng WF. Autonomic Nervous System Dysfunction in Primary Sjögren's Syndrome. Front Immunol 2021; 12:702505. [PMID: 34381453 PMCID: PMC8350514 DOI: 10.3389/fimmu.2021.702505] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) is an autoimmune disease which primarily affects the exocrine glands, but can also affect other organs, including the nervous system. Many studies have reported evidence of autonomic nervous system (ANS) dysfunction in pSS which may contribute to a wide range of symptoms and functional burden. Symptoms of ANS dysfunction are common and widespread among patients with pSS and are associated with other features of the disease, particularly fatigue. Accumulating data on the inter-relationship between the ANS and the immune system via the vagus nerve have been reported. Vagus nerve stimulation (VNS) has also been associated with improvement in fatigue in patients with pSS. Taken together, these data suggest that the ANS may be a potential treatment target for pSS, in particularly those with fatigue being a predominant symptom. Future research to dissect the link between the ANS, immune dysregulation and clinical manifestations in pSS and to evaluate the potential of VNS as a therapy for pSS is warranted.
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Affiliation(s)
- Kristen Davies
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Wan-Fai Ng
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health Research (NIHR) Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals National Health Service (NHS) Foundation Trust, Newcastle upon Tyne, United Kingdom
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Borensztejn I, Ansari H, Siami-Namini K, Newman KA. Sjögren's Syndrome: an undiagnosed etiology for facial pain Case series with review of neurological manifestation of Sjögren syndrome. Autoimmun Rev 2021; 20:102762. [PMID: 33515728 DOI: 10.1016/j.autrev.2021.102762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/10/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Ignacio Borensztejn
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
| | - Hossein Ansari
- University of California, San Diego (UCSD), Department of Neurology, 4510 Executive Dr., San Diego, CA 92121, United States of America
| | - Koushan Siami-Namini
- Eisenhower Health, Department of Pathology, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
| | - Kam A Newman
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America; University of California, Riverside (UCR), Eisenhower Health, Internal Medicine Residency Program, Division of Rheumatology, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
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Melissaropoulos K, Bogdanos D, Dimitroulas T, Sakkas LI, Kitas GD, Daoussis D. Primary Sjögren's Syndrome and Cardiovascular Disease. Curr Vasc Pharmacol 2020; 18:447-454. [PMID: 31995009 DOI: 10.2174/1570161118666200129125320] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/19/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
Sjögren's syndrome is a rheumatic autoimmune disease that primarily affects middle-aged women and runs a slowly progressing course with sicca symptoms being the prevalent manifestation. Premature atherosclerosis and increased cardiovascular (CV) morbidity and mortality are frequently encountered in rheumatic diseases characterized by significant systemic inflammation, such as the inflammatory arthritides, systemic vasculitides and systemic lupus erythematosus. In the same context, chronic inflammation and immune aberrations underlying Sjögren's syndrome are also reported to be associated with augmented risk of atherosclerosis. Increased CV disease (CVD) frequency has been found in recent meta-analyses. The involvement of the CV system is not a common feature of Sjögren's syndrome; however, specific manifestations, such as autoantibody-mediated heart block, pericarditis, pulmonary arterial hypertension and dysautonomia, have been described. This review focuses on studies addressing CV morbidity in Sjögren's syndrome and presents current data regarding distinct CV features of the disease.
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Affiliation(s)
| | - Dimitrios Bogdanos
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41 110, Greece
| | - Theodoros Dimitroulas
- 4th Department of Internal Medicine Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lazaros I Sakkas
- Department of Rheumatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41 110, Greece
| | - George D Kitas
- Department of Rheumatology, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, United Kingdom
| | - Dimitrios Daoussis
- Department of Rheumatology, Patras University Hospital, University of Patras Medical School, Patras, Greece
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Kaur D, Tiwana H, Stino A, Sandroni P. Autonomic neuropathies. Muscle Nerve 2020; 63:10-21. [PMID: 32926436 DOI: 10.1002/mus.27048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Autonomic neuropathies represent a complex group of disorders that preferentially target autonomic fibers and can be classified as either acute/subacute or chronic in onset. Acute-onset autonomic neuropathies manifest with such conditions as paraneoplastic syndromes, Guillain-Barre syndrome, Sjögren syndrome, infection, or toxins/chemotherapy. When the presentation is acute, immune-mediated, and without a secondary cause, autoimmune autonomic ganglionopathy is likely, and should be considered for immunotherapy. Of the chronic-onset forms, diabetes is the most widespread and disabling, with autonomic impairment portending increased mortality and cardiac wall remodeling risk. Acquired light chain (AL) and transthyretin (TTR) amyloidosis represent two other key etiologies, with TTR amyloidosis now amenable to newly-approved gene-modifying therapies. The COMPASS-31 questionnaire is a validated outcome measure that can be used to monitor autonomic severity and track treatment response. Symptomatic treatments targeting orthostatic hypotension, among other symptoms, should be individualized and complement disease-modifying therapy, when possible.
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Affiliation(s)
- Divpreet Kaur
- Department of Neurology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Harmanpreet Tiwana
- Department of Neurology, Dartmouth-Hitchcok Medical Center, Lebanon, New Hampshire, USA
| | - Amro Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Ganglionic Acetylcholine Receptor Antibodies and Autonomic Dysfunction in Autoimmune Rheumatic Diseases. Int J Mol Sci 2020; 21:ijms21041332. [PMID: 32079137 PMCID: PMC7073227 DOI: 10.3390/ijms21041332] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Autonomic neuropathy has been reported in autoimmune rheumatic diseases (ARD) including Sjögren’s syndrome, systemic sclerosis, rheumatoid arthritis, and systemic lupus erythematosus. However, the pathophysiological mechanism underlying autonomic dysfunction remains unknown to researchers. On the other hand, autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder, which causes dysautonomia that is mediated by autoantibodies against ganglionic acetylcholine receptors (gAChRs). The purpose of this review was to describe the characteristics of autonomic disturbance through previous case reports and the functional tests used in these studies and address the importance of anti-gAChR antibodies. We have established luciferase immunoprecipitation systems to detect antibodies against gAChR in the past and determined the prevalence of gAChR antibodies in various autoimmune diseases including AAG and rheumatic diseases. Autonomic dysfunction, which affects lower parasympathetic and higher sympathetic activity, is usually observed in ARD. The anti-gAChR antibodies may play a crucial role in autonomic dysfunction observed in ARD. Further studies are necessary to determine whether anti-gAChR antibody levels are correlated with the severity of autonomic dysfunction in ARD.
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Abstract
PURPOSE OF REVIEW Autonomic disorders sometimes occur in the context of systemic autoimmune disease or as a direct consequence of autoimmunity against the nervous system. This article provides an overview of autonomic disorders with potential autoimmune etiology. RECENT FINDINGS Recent evidence highlights a close association between the autonomic nervous system and inflammation. The autonomic nervous system regulates immune function, and autonomic manifestations may occur in a number of systemic autoimmune diseases. In a few instances, autoimmunity directly influences autonomic function. Autoimmune autonomic ganglionopathy is the prototypic antibody-mediated autonomic disorder. Over time, a better understanding of the clinical spectrum of autoimmune autonomic ganglionopathy, the significance of ganglionic nicotinic acetylcholine receptor antibodies, other immune-mediated autonomic neuropathies, and autonomic manifestations of other systemic or neurologic autoimmune disorders has emerged. SUMMARY Autoimmune autonomic disorders may be challenging, but correct identification of these conditions is important. In some cases, potential exists for effective immunomodulatory treatment.
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Brunetta E, Shiffer D, Mandelli P, Achenza S, Folci M, Zumbo A, Minonzio M, Cairo B, Jacob G, Boccassini L, Puttini PS, Porta A, Furlan R. Autonomic Abnormalities in Patients With Primary Sjogren's Syndrome - Preliminary Results. Front Physiol 2019; 10:1104. [PMID: 31551801 PMCID: PMC6736624 DOI: 10.3389/fphys.2019.01104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) is an autoimmune disease affecting exocrine glands and extra-glandular organs. There are conflicting reports on the presence of autonomic dysfunction in pSS and no data are available on the functional status of sympathetic outflow to the vessels and baroreceptor [baroreflex sensitivity (BRS)] control mechanisms. We investigated the cardiac (cBRS) and sympathetic (sBRS) baroreceptor modulation in both time and frequency domains and the cardiovascular autonomic profile in pSS patients compared to healthy controls. Autonomic symptoms were quantified by the Composite Autonomic Symptom Scale (COMPASS31) three-item questionnaire. The EULAR Sjogren's syndrome patient reported index (ESSPRI) questionnaire evaluated the magnitude of pSS clinical symptoms, i.e., fatigue, pain, and sicca symptoms. Electrocardiogram, beat-by-beat arterial pressure (AP) and respiratory activity were continuously recorded in 17 pSS patients and 16 healthy controls, while supine and during 75° head-up tilt. In seven patients and seven controls, muscle sympathetic nerve activity (MSNA) was measured. Spectrum analysis of RR variability provided markers of cardiac vagal modulation (HFRR nu) and sympatho-vagal balance [low frequency (LF)/high frequency (HF)]. The power of LF (0.1 Hz) oscillations of systolic arterial pressure (SAP) variability (LFSAP) evaluated the vasomotor response to sympathetic stimulation. Compared to controls, pSS patients scored higher in total COMPASS31 (p < 0.0001) and all ESSPRI subdomains (fatigue, p = 0.005; pain, p = 0.0057; dryness, p < 0.0001). Abnormal scialometry (<1.5 ml/15 min) and Schirmer tests (<5 mm/5 min) were found in pSS patients and salivary flow rate was negatively associated with ESSPRI dryness (p = 0.0014). While supine, pSS patients had lower SEQcBRS index of cardiac baroreceptor sensitivity, higher HFRRnu (p = 0.021), lower LF/HF (p = 0.007), and greater MSNA (p = 0.038) than controls. No differences were observed in LFSAP between groups. During orthostatic challenge, although LFSAP increased similarly in both groups, MSNA was greater in pSS patients (p = 0.003). At rest pSS patients showed lower cBR control and greater parasympathetic modulation. Furthermore, greater sympathetic nerve activity was observed in pSS patients while supine and in response to gravitational challenge. We hypothesized that such enhanced sympathetic vasoconstrictor activity might reflect an attempt to maintain blood pressure in a setting of likely reduced vascular responsiveness.
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Affiliation(s)
- Enrico Brunetta
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Dana Shiffer
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Pietro Mandelli
- Department of Pathophysiology and Transplantation, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Sara Achenza
- Department of Nephrology, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Marco Folci
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Aurora Zumbo
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Maura Minonzio
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy
| | - Beatrice Cairo
- Department of Biomedical Sciences for Health, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Giris Jacob
- Department of Internal Medicine F, J. Recanati Autonomic Dysfunction Center, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Laura Boccassini
- Reumathology Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Piercarlo Sarzi Puttini
- Reumathology Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Alberto Porta
- Department of Biomedical Sciences for Health, Faculty of Medicine and Surgery, University of Milan, Milan, Italy.,Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Raffaello Furlan
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Milan University, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Golden EP, Vernino S. Autoimmune autonomic neuropathies and ganglionopathies: epidemiology, pathophysiology, and therapeutic advances. Clin Auton Res 2019; 29:277-288. [DOI: 10.1007/s10286-019-00611-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/03/2019] [Indexed: 12/12/2022]
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18
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Miyamoto ST, Lendrem DW, Ng WF, Hackett KL, Valim V. Managing fatigue in patients with primary Sjögren's syndrome: challenges and solutions. Open Access Rheumatol 2019; 11:77-88. [PMID: 31118841 PMCID: PMC6503647 DOI: 10.2147/oarrr.s167990] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) patients identify fatigue as their most important symptom and the one most difficult to cope with, but there are still many challenges and few solutions to manage this debilitating symptom. Promising pharmacological treatments, such as rituximab, have failed in more stringent tests including randomized controlled trials (RCTs) and meta-analysis. While non-pharmacological interventions may be safer, less costly, and address other common comorbidities, to date only aerobic exercise seems to be effective at reducing fatigue in pSS. All interventions, pharmacological or not, need to be tested in high-quality RCTs. The aim of this review is to provide an overview of fatigue management in pSS and discuss potential opportunities for future research.
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Affiliation(s)
- Samira Tatiyama Miyamoto
- Department of Integrated Education in Health, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Dennis William Lendrem
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University and NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.,NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Trust, , Newcastle upon Tyne, UK
| | - Wan-Fai Ng
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University and NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.,NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Trust, , Newcastle upon Tyne, UK
| | - Katie Louise Hackett
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University and NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Trust, , Newcastle upon Tyne, UK.,Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Valéria Valim
- Department of Medical Clinic, Universidade Federal do Espírito Santo, Vitória, Brazil.,Rheumatology Outpatient Clinic, Hospital Universitário Cassiano Antônio de Moraes (HUCAM), Vitória, Brazil
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19
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Immunoresponsive Autonomic Neuropathy in Sjögren Syndrome—Case Series and Literature Review. Am J Ther 2019; 26:e66-e71. [DOI: 10.1097/mjt.0000000000000583] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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20
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de Oliveira FR, Fantucci MZ, Adriano L, Valim V, Cunha TM, Louzada-Junior P, Rocha EM. Neurological and Inflammatory Manifestations in Sjögren's Syndrome: The Role of the Kynurenine Metabolic Pathway. Int J Mol Sci 2018; 19:ijms19123953. [PMID: 30544839 PMCID: PMC6321004 DOI: 10.3390/ijms19123953] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/16/2022] Open
Abstract
For decades, neurological, psychological, and cognitive alterations, as well as other glandular manifestations (EGM), have been described and are being considered to be part of Sjögren's syndrome (SS). Dry eye and dry mouth are major findings in SS. The lacrimal glands (LG), ocular surface (OS), and salivary glands (SG) are linked to the central nervous system (CNS) at the brainstem and hippocampus. Once compromised, these CNS sites may be responsible for autonomic and functional disturbances that are related to major and EGM in SS. Recent studies have confirmed that the kynurenine metabolic pathway (KP) can be stimulated by interferon-γ (IFN-γ) and other cytokines, activating indoleamine 2,3-dioxygenase (IDO) in SS. This pathway interferes with serotonergic and glutamatergic neurotransmission, mostly in the hippocampus and other structures of the CNS. Therefore, it is plausible that KP induces neurological manifestations and contributes to the discrepancy between symptoms and signs, including manifestations of hyperalgesia and depression in SS patients with weaker signs of sicca, for example. Observations from clinical studies in acquired immune deficiency syndrome (AIDS), graft-versus-host disease, and lupus, as well as from experimental studies, support this hypothesis. However, the obtained results for SS are controversial, as discussed in this study. Therapeutic strategies have been reexamined and new options designed and tested to regulate the KP. In the future, the confirmation and application of this concept may help to elucidate the mosaic of SS manifestations.
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Affiliation(s)
- Fabíola Reis de Oliveira
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Marina Zilio Fantucci
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Leidiane Adriano
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Valéria Valim
- Espírito Santo Federal University, Vitoria, ES 29075-910, Brazil.
| | - Thiago Mattar Cunha
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Paulo Louzada-Junior
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Eduardo Melani Rocha
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
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