Preliminary Screening Questionnaire for Sjögren's Syndrome in the Rheumatology Setting

OBJECTIVE

Sjögren's syndrome (SS) is frequently undetected or misdiagnosed as other rheumatologic diseases. We aimed to develop an SS screening questionnaire for the rheumatology practice.

METHODS

We developed the Sjögren's Syndrome Screening Questionnaire (SSSQ) via secondary analysis of data from 974 participants referred by rheumatologists to the Sjögren's International Collaborative Clinical Alliance (SICCA) study. Participants answered 88 questions regarding symptoms, medical history, and demographics. They underwent ocular, dental, and serologic tests and were classified as SS or non-SS using the 2016 American College of Rheumatology/European League Against Rheumatism classification criteria. We conducted univariate and multivariate logistic regression to identify questions most discriminative of SS, from which we derived an individual's likelihood of SS ("SSSQ score").

RESULTS

Five questions were significantly discriminative of SS in the multivariate analysis (p < 0.05): (1) Can you eat a cracker without drinking a fluid/liquid? (no: odds ratio [OR], 1.39; 95% confidence interval [CI], 1.06-1.82]); (2) How would you describe your dental and oral health in general? (fair/poor: OR, 1.68; 95% CI, 1.04-2.75); (3) During the last week, have you experienced tearing? (none of the time: OR, 2.26; 95% CI, 1.23-4.34); (4) Are you able to produce tears? (no: OR, 1.62; 95% CI, 1.12-2.37); and (5) Do you currently smoke cigarettes? (no: OR, 2.83; 95% CI, 1.69-4.91). SSSQ score ≥7 (possible range, 0-11) distinguishes SS from non-SS patients with 64% sensitivity and 58% specificity (area under receiver operating characteristic curve, 0.65).

CONCLUSIONS

The SSSQ is a simple 5-item questionnaire designed to screen for SS in clinical practice, with a potential impact to reduce delays in diagnosis.

A New Screening Questionnaire to Identify Patients With Dry Eye With a High Likelihood of Having Sjögren Syndrome

PURPOSE

To develop a screening questionnaire to identify patients with dry eye with a high likelihood of having underlying Sjögren syndrome (SS).

METHODS

This was a cross-sectional study of participants with dry eye complaints who were self-referred or referred by an ophthalmologist to the Sjögren's International Collaborative Clinical Alliance study. Symptoms and ocular surface examination findings were candidate predictors. Univariable and multivariable logistic regression analyses were performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) for the association of a symptom and/or ocular sign with SS. Area under the receiver operating characteristic curve (AUC) was used to summarize the predictive ability of different regression models and the derived likelihood score.

RESULTS

Four questions were statistically significant in the final multivariable model: 1) Is your mouth dry when eating a meal? [Yes = OR 1.63 (1.18-2.26)]; 2) Can you eat a cracker without drinking a fluid or liquid? [No = OR 1.46 (1.06-2.01)]; 3) How often do you have excessive tearing? [None of the time = OR 4.06 (1.81-9.10)]; and 4) Are you able to produce tears? [No = OR 2.24 (1.62-3.09)]. The SS likelihood score had an AUC of 0.70 (95% CI, 0.66-0.73), and when including tear break-up time and conjunctival staining, it yielded an AUC of 0.79 (95% CI, 0.77-0.82).

CONCLUSIONS

This questionnaire can be used to identify patients with dry eye with a high likelihood of having SS. With future refinement and validation, this screening tool could be used alone or in combination with examination findings to identify patients with SS earlier, thereby facilitating better clinical outcomes.

Natural History and Predictors of Progression to Sjögren's Syndrome Among Participants of the Sjögren's International Collaborative Clinical Alliance Registry

OBJECTIVE

To explore changes in the phenotypic features of Sjögren's syndrome (SS), and in SS status among participants in the Sjögren's International Collaborative Clinical Alliance (SICCA) registry over a 2-3-year interval.

METHODS

All participants in the SICCA registry who were found to have any objective measures of salivary hypofunction, dry eye, focal lymphocytic sialadenitis in minor salivary gland biopsy, or anti-SSA/SSB antibodies were recalled over a window of 2 to 3 years after their baseline examinations to repeat all clinical examinations and specimen collections to determine whether there was any change in phenotypic features and in SS status.

RESULTS

As of September 15, 2013, a total of 3,514 participants had enrolled in SICCA, and among 3,310 eligible, 771 presented for a followup visit. Among participants found to have SS using the 2012 American College of Rheumatology (ACR) classification criteria, 93% again met the criteria after 2 to 3 years, and this proportion was 89% when using the 2016 ACR/European League Against Rheumatism (EULAR) criteria. Among those who did not meet ACR or ACR/EULAR criteria at baseline, 9% and 8%, respectively, had progressed and met them at followup. Those with hypergammaglobulinemia and hypocomplementemia at study entry were, respectively, 4 and 6 times more likely to progress to SS by ACR criteria than those without these characteristics (95% confidence interval 1.5-10.1 and 1.8-20.4, respectively).

CONCLUSION

While there was stability over a 2-3-year period of both individual phenotypic features of SS and of SS status, hypergammaglobulinemia and hypocomplementemia at study entry were predictive of progression to SS.

Genome-Wide Association Analysis Reveals Genetic Heterogeneity of Sjögren's Syndrome According to Ancestry

OBJECTIVE

The Sjögren's International Collaborative Clinical Alliance (SICCA) is an international data registry and biorepository derived from a multisite observational study of participants in whom genotyping was performed on the Omni2.5M platform and who had undergone deep phenotyping using common protocol-directed methods. The aim of this study was to examine the genetic etiology of Sjögren's syndrome (SS) across ancestry and disease subsets.

METHODS

We performed genome-wide association study analyses using SICCA subjects and external controls obtained from dbGaP data sets, one using all participants (1,405 cases, 1,622 SICCA controls, and 3,125 external controls), one using European participants (585, 966, and 580, respectively), and one using Asian participants (460, 224, and 901, respectively) with ancestry adjustments via principal components analyses. We also investigated whether subphenotype distributions differ by ethnicity, and whether this contributes to the heterogeneity of genetic associations.

RESULTS

We observed significant associations in established regions of the major histocompatibility complex (MHC), IRF5, and STAT4 (P = 3 × 10^-42 , P = 3 × 10^-14 , and P = 9 × 10^-10 , respectively), and several novel suggestive regions (those with 2 or more associations at P < 1 × 10^-5 ). Two regions have been previously implicated in autoimmune disease: KLRG1 (P = 6 × 10^-7 [Asian cluster]) and SH2D2A (P = 2 × 10^-6 [all participants]). We observed striking differences between the associations in Europeans and Asians, with high heterogeneity especially in the MHC; representative single-nucleotide polymorphisms from established and suggestive regions had highly significant differences in the allele frequencies in the study populations. We showed that SSA/SSB autoantibody production and the labial salivary gland focus score criteria were associated with the first worldwide principal component, indicative of higher non-European ancestry (P = 4 × 10^-15 and P = 4 × 10^-5 , respectively), but that subphenotype differences did not explain most of the ancestry differences in genetic associations.

CONCLUSION

Genetic associations with SS differ markedly according to ancestry; however, this is not explained by differences in subphenotypes.

Sjogren's syndrome: Clinical aspects

Sjogren's syndrome (SS) is the 2nd most common chronic autoimmune rheumatic disease and associated with a high burden of illness. Morbidity arises not only from untreated xerostomia and keratoconjunctivitis sicca but also from extra-glandular manifestations including the development of non-Hodgkin's B cell lymphomas. Proper diagnosis of SS requires objective evidence of dry eyes and/or objective evidence of dry mouth as well as proof of autoimmunity. The recent development of new international classification criteria and clinical practice guidelines for SS should not only enhance the existing standards of care but also facilitate further studies to improve future diagnosis and outcomes.

Treatment Guidelines for Rheumatologic Manifestations of Sjögren's Syndrome: Use of Biologic Agents, Management of Fatigue, and Inflammatory Musculoskeletal Pain

OBJECTIVE

The Sjögren's Syndrome Foundation clinical practice guidelines (CPGs) are designed to improve quality and consistency of care in Sjögren's syndrome by offering recommendations for management.

METHODS

Management questions for the systemic manifestations of Sjögren's syndrome were posed by the CPG committee with input from patients and rheumatologists. Clinical questions were assigned to a topic review group that performed systematic reviews and data extraction and drafted guidelines. Quality of evidence and strength of recommendation were rated using the American Society of Clinical Oncology's modification of the Grading of Recommendations Assessment, Development, and Evaluation. Guideline recommendations were reviewed by a consensus expert panel (CEP) composed of 30-40 clinicians from academia and community practices, as well as registered nurses and patients, using a modified Delphi process. A CEP agreement level of 75% was set as a minimum for adoption of a guideline recommendation.

RESULTS

Consensus was achieved for 19 recommendations; for 11 additional modules, available data were insufficient to allow a recommendation to be formulated. Of the 19 recommendations, 15 required 1 Delphi round, 2 required 2 rounds, and 2 required 3 rounds.

CONCLUSION

Key recommendations include a decision tree for the use of oral disease-modifying antirheumatic drugs for inflammatory musculoskeletal pain, use of self-care measures and advice regarding exercise to reduce fatigue, and the use of rituximab in selected clinical settings for oral and ocular dryness and for certain extraglandular manifestations, including vasculitis, severe parotid swelling, inflammatory arthritis, pulmonary disease, and mononeuritis multiplex. The CPG committee strongly discouraged the use of tumor necrosis factor inhibitors for sicca symptoms and for the majority of clinical contexts in primary Sjögren's syndrome.

New Treatment Guidelines for Sjögren's Disease

Sjögren's disease is associated with a high burden of illness, diminished quality of life, and increased health care costs. The Sjögren's Syndrome Foundation developed the first US clinical practice guidelines for management of the oral, ocular, and rheumatologic or systemic manifestations. Guideline recommendations were reviewed by a consensus expert panel using a modified Delphi process. This initiative should improve the quality and consistency of care for Sjögren's disease in the United States, guide insurance reimbursement, and define areas for future study. Guidelines will be periodically reviewed and revised as new information becomes available.

Features of childhood Sjögren's syndrome in comparison to adult Sjögren's syndrome: considerations in establishing child-specific diagnostic criteria

OBJECTIVES

To describe the clinical features of childhood Sjögren's syndrome (SS) in comparison to adult SS and to evaluate possible child-specific modifications to existing adult criteria for use in diagnosing childhood SS.

METHODS

We retrospectively identified children (age <18 years) with SS and compared the clinical, laboratory, and histopathological features of these children based on presence or absence of parotitis. We compared these features to adults with SS and evaluated the applicability of existing classification criteria in diagnosing childhood SS. Child-specific modifications to existing criteria were evaluated.

RESULTS

Twenty-six children were included in our childhood SS group. Sixteen children had parotitis at or before presentation. Absence of parotitis was associated with greater degree of organ damage based on SS disease damage index. Compared to 413 adult SS patients, childhood SS was more commonly associated with parotitis, positive serologies, neurologic and nephrologic manifestations, and non-specific features (fever, lymphadenopathy) but less commonly associated with dry mouth and dry eyes. Only a minority of these children met previously established criteria for adult SS. Inclusion of child-specific features such as parotitis and the presence of any focal lymphocytic sialadenitis on minor salivary gland biopsy increased the proportion of children meeting these criteria.

CONCLUSIONS

Childhood SS features may be different than adult SS features necessitating child-specific criteria for better diagnosis of childhood SS, a key step towards better understanding the features, prognosis, and outcomes in this disease.

Clinical practice guidelines for oral management of Sjögren disease: Dental caries prevention

BACKGROUND

Salivary dysfunction in Sjögren disease can lead to serious and costly oral health complications. Clinical practice guidelines for caries prevention in Sjögren disease were developed to improve quality and consistency of care.

METHODS

A national panel of experts devised clinical questions in a Population, Intervention, Comparison, Outcomes format and included use of fluoride, salivary stimulants, antimicrobial agents, and nonfluoride remineralizing agents. The panel conducted a systematic search of the literature according to pre-established parameters. At least 2 members extracted the data, and the panel rated the strength of the recommendations by using a variation of grading of recommendations, assessment, development, and evaluation. After a Delphi consensus panel was conducted, the experts finalized the recommendations, with a minimum of 75% agreement required.

RESULTS

Final recommendations for patients with Sjögren disease with dry mouth were as follows: topical fluoride should be used in all patients (strong); although no study results link improved salivary flow to caries prevention, the oral health community generally accepts that increasing saliva may contribute to decreased caries incidence, so increasing saliva through gustatory, masticatory, or pharmaceutical stimulation may be considered (weak); chlorhexidine administered as varnish, gel, or rinse may be considered (weak); and nonfluoride remineralizing agents may be considered as an adjunct therapy (moderate).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The incidence of caries in patients with Sjögren disease can be reduced with the use of topical fluoride and other preventive strategies.

The SSB-positive/SSA-negative antibody profile is not associated with key phenotypic features of Sjögren's syndrome

OBJECTIVE

To determine whether the Sjögren's syndrome B (SSB)-positive/Sjögren's syndrome A (SSA)-negative antibody profile is associated with key phenotypic features of SS.

METHODS

Among registrants in the Sjögren's International Collaborative Clinical Alliance (SICCA) with possible or established SS, we compared anti-SSA/anti-SSB reactivity profiles against concurrent phenotypic features. We fitted logistic regression models to explore the association between anti-SSA/anti-SSB reactivity profile and each key SS phenotypic feature, controlling for potential confounders.

RESULTS

Among 3297 participants, 2061 (63%) had negative anti-SSA/anti-SSB, 1162 (35%) had anti-SSA with or without anti-SSB, and 74 (2%) anti-SSB alone. Key SS phenotypic features were more prevalent and had measures indicative of greater disease activity in those participants with anti-SSA, either alone or with anti-SSB, than in those with anti-SSB alone or negative SSA/SSB serology. These between-group differences were highly significant and not explained by confounding by age, race/ethnicity or gender. Participants with anti-SSB alone were comparable to those with negative SSA/SSB serology in their association with these key phenotypic features. Among SICCA participants classified with SS on the basis of the American-European Consensus Group or American College of Rheumatology criteria, only 2% required the anti-SSB-alone test result to meet these criteria.

CONCLUSIONS

The presence of anti-SSB, without anti-SSA antibodies, had no significant association with SS phenotypic features, relative to seronegative participants. The solitary presence of anti-SSB antibodies does not provide any more support than negative serology for the diagnosis of SS. This serological profile should thus be interpreted cautiously in clinical practice and potentially eliminated from future classification criteria.

EULAR Sjögren's syndrome disease activity index (ESSDAI): a user guide

The EULAR Sjögren's syndrome (SS) disease activity index (ESSDAI) is a systemic disease activity index that was designed to measure disease activity in patients with primary SS. With the growing use of the ESSDAI, some domains appear to be more challenging to rate than others. The ESSDAI is now in use as a gold standard to measure disease activity in clinical studies, and as an outcome measure, even a primary outcome measure, in current randomised clinical trials. Therefore, ensuring an accurate and reproducible rating of each domain, by providing a more detailed definition of each domain, has emerged as an urgent need. The purpose of the present article is to provide a user guide for the ESSDAI. This guide provides definitions and precisions on the rating of each domain. It also includes some minor improvement of the score to integrate advance in knowledge of disease manifestations. This user guide may help clinicians to use the ESSDAI, and increase the reliability of rating and consequently of the ability to detect true changes over time. This better appraisal of ESSDAI items, along with the recent definition of disease activity levels and minimal clinically important change, will improve the assessment of patients with primary SS and facilitate the demonstration of effectiveness of treatment for patients with primary SS.

Comparison of the discontinuation rates and side-effect profiles of pilocarpine and cevimeline for xerostomia in primary Sjögren's syndrome

OBJECTIVES

There are currently no head-to-head comparisons of sialagogues for Primary Sjögren's syndrome (pSS). We compared the tolerability and side effect profile of pilocarpine and cevimeline in patients with pSS and determined clinical, laboratory and pathological variables associated with therapeutic failure.

METHODS

We retrospectively reviewed the use of pilocarpine and cevimeline in 118 patients with pSS who fulfilled the 2002 American European Consensus Group criteria in a University-based setting. Clinical, laboratory and pathological baseline variables were collected. Failure of therapy was defined as the clinician or patient's decision to stop treatment either due to lack of efficacy or side effects.

RESULTS

Cevimeline was associated with lower failure rates compared to pilocarpine among first-time users: 27% vs. 47% (p=0.02), and all users: 32% vs. 61% (p<0.001). Severe sweating was the most frequent side effect leading to cessation of therapy and occurred more frequently in pilocarpine (25%) than cevimeline (11%) users (p=0.02). Patients who previously failed one secretagogue were less likely to discontinue treatment with the other agent, 52% of first-time users vs. 27% of second-time users (p=0.004). Only ANA positivity was associated with failure: [59% vs. 38%] (p=0.03).

CONCLUSIONS

pSS patients were more likely to continue cevimeline than pilocarpine long-term due to fewer reported side effects with cevimeline. Therapeutic failure of one secretagogue did not predict similar results with the other since second time users were more likely to continue long-term treatment.

Comparison of Labial Minor Salivary Gland Biopsies from Childhood Sjögren Syndrome and Age-matched Controls

Objective.

To determine an appropriate focus score cutoff for childhood Sjögren syndrome (SS).

Methods.

Labial salivary gland tissue from specimens from children with SS and age-matched controls was retrospectively identified and reviewed by a blinded oral pathologist.

Results.

The presence of any focal sialadenitis (focus score > 0 foci/4 mm2) was common among childhood SS samples but present in only 1 of 8 control samples.

Conclusion.

The presence of any focal lymphocytic sialadenitis in minor labial salivary gland tissue is suggestive of childhood SS and should be included in future childhood SS-specific diagnostic or classification criteria.

Rituximab therapy for primary Sjögren's syndrome: an open-label clinical trial and mechanistic analysis

OBJECTIVE

To study the safety and clinical efficacy of rituximab therapy for primary Sjögren's syndrome, as well as to investigate its mechanisms.

METHODS

Patients with primary Sjögren's syndrome were enrolled in an open-label trial, were given rituximab (1 gm) infusions on days 1 and 15, and were monitored through week 52. The primary end point was safety, with secondary end points evaluating clinical and biologic efficacy. Blood was obtained for enumeration of lymphocyte subsets, measurement of serum autoantibody and BAFF levels, and analysis of gene expression.

RESULTS

Twelve female patients with primary Sjögren's syndrome were administered rituximab. They had a median age of 51 years (range 34-69 years) and a median disease duration of 8.0 years (range 2-18 years). We observed no unexpected toxicities from the rituximab therapy. Modest improvements were observed at week 26 in patient-reported symptoms of fatigue and oral dryness, with no significant improvement in the objective measures of lacrimal and salivary gland function. The recovery of blood B cells following the nadir from rituximab therapy was characterized by a predominance of transitional B cells and a lack of memory B cells. While blood B cell depletion was associated with an increase in serum BAFF levels, no significant changes were observed in the levels of serum anti-Ro/SSA, anti-La/SSB, and anti-type 3 muscarinic acetylcholine receptor autoantibodies or in the blood interferon signature.

CONCLUSION

In patients with primary Sjögren's syndrome, a single treatment course of rituximab was not associated with any unexpected toxicities and led to only modest clinical benefits despite effective depletion of blood B cells.

Primary Sjögren's syndrome as a systemic disease: a study of participants enrolled in an international Sjögren's syndrome registry

OBJECTIVE

To study the prevalence of extraglandular manifestations in primary Sjögren's syndrome (SS) among participants enrolled in the Sjögren's International Collaborative Clinical Alliance (SICCA) Registry.

METHODS

A total of 1,927 participants in the SICCA registry were studied, including 886 participants who met the 2002 American-European Consensus Group (AECG) criteria for primary SS, 830 "intermediate" cases who had some objective findings of primary SS but did not meet AECG criteria, and 211 control individuals. We studied the prevalence of immunologic and hematologic laboratory abnormalities, specific rheumatologic examination findings, and physician-confirmed thyroid, liver, and kidney disease, as well as lymphoma among SICCA participants.

RESULTS

Laboratory abnormalities, including hematologic abnormalities, hypergammaglobulinemia, and hypocomplementemia, frequently occurred among primary SS cases and were more common among the intermediate cases than among control participants. Cutaneous vasculitis and lymphadenopathy were also more common among primary SS cases. In contrast, the frequency of physician-confirmed diagnoses of thyroid, liver, and kidney disease and lymphoma was low and only primary biliary cirrhosis was associated with primary SS case status. Rheumatologic and neurologic symptoms were common among all SICCA participants, regardless of case status.

CONCLUSION

Data from the international SICCA registry support the systemic nature of primary SS, manifested primarily in terms of specific immunologic and hematologic abnormalities. The occurrence of other systemic disorders among this cohort is relatively uncommon. Previously reported associations may be more specific to select patient subgroups, such as those referred for evaluation of certain neurologic, rheumatologic, or other systemic manifestations.

Primary Sjögren's Syndrome: health experiences and predictors of health quality among patients in the United States

Objective

To assess the health related quality of life of patients with primary Sjögren's Syndrome (PSS) in a large US sample.

Methods

Questionnaires were mailed to 547 patients with a confirmed diagnosis of PSS (PhysR-PSS) and all active members of the Sjögren's Syndrome Foundation USA (SSF-PSS), half of whom identified a friend without PSS to also complete the survey.

Results

277 PhysR-PSS patients were compared to 606 controls. The mean age was 62 years in the PhysR-PSS group and 61 years in the control group. 90% in both groups were women. Time from first symptom to diagnosis of PSS was a mean of 7 years. Sicca related morbidity, fatigue severity, depression and pain (assessed by validated questionnaires, PROFAD-SSI, FACIT-F, CES-D, BPI) were significantly greater, and all eight SF-36 domains were significantly diminished, in patients compared to controls. Somatic fatigue was the dominant predictor of physical function and of general health. Depression was the dominant predictor of emotional well being. Health care utilization was higher in patients than controls, including out of pocket dental expenses (mean: PhysR-PSS = $1473.3, controls = $503.6), dental visits (mean: PhysR-PSS = 4.0, controls = 2.3), current treatments (mean: PhysR-PSS = 6.6, controls = 2.5), and hospitalizations (53% PhysR-PSS, vs. 40% controls).

Conclusion

Diminished health quality and excess health costs are prevalent among PSS patients. Health experiences and functional impact of PSS is similar among US and European patients. Delayed diagnosis, sicca related morbidity, fatigue, pain and depression are substantial suggesting unmet health needs and the importance of earlier recognition of PSS.

Hydralazine-induced autoimmune disease: comparison to idiopathic lupus and ANCA-positive vasculitis

We report two cases of hydralazine-induced vasculitis with rare complications: pulmonary renal syndrome and digital gangrene. We also review 68 published cases of hydralazine-induced vasculitis. Hydralazine-induced vasculitis mimics idiopathic antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis. However, it also produces other autoantibodies, such as antinuclear antibodies, antihistone antibodies, anti-dsDNA antibodies, and antiphospholipid antibodies. Patients with hydralazine-induced vasculitis typically have a more severe course than those with hydralazine-induced lupus, predominantly due to renal vasculitis, and require a more aggressive treatment.

A primary care approach to Sjögren's syndrome. Helping patients cope with sicca symptoms, extraglandular manifestations

Sjögren's syndrome is a chronic, systemic, autoimmune inflammatory disorder characterized by lymphocytic infiltration of exocrine glands, most notably the salivary and lacrimal glands. It results in loss of functional epithelium, diminished exocrine function, and gradual onset of dryness of the eyes, mouth, and other body parts (sicca syndrome). Because most patients with Sjögren's syndrome are female, this syndrome also represents a major women's health problem that is often misdiagnosed and undertreated. In this article, Drs Derk and Vivino review the criteria for diagnosis, common signs and symptoms, and strategies for increasing patient comfort.

Inclusion body myositis in connective tissue disorders: case report and review of the literature

We report a patient with systemic lupus erythematosus (SLE) and secondary Sjögren's syndrome (SS) who developed inclusion body myositis (IBM) which, contrary to the typical presentation of this disorder, was symmetrical in nature although the diagnosis was only made after electron microscopy was performed. Therapy with increased doses of methotrexate proved to be beneficial, with the patient having full recovery after 8 months of therapy. It appears that a subset of IBM may be related to autoimmune disorders, an issue that was disputed in the past, and these patients may have a better prognosis than typical IBM patients. This is the first case report of IBM in a patient who had the dual diagnosis of SLE and SS.

Sjögren's syndrome--implications for perioperative practice

Sjögren's syndrome (SS) is a chronic autoimmune rheumatic disorder in which lymphocytes invade the exocrine glands, leading to destruction of the glandular tissue. Systemic inflammation also may occur and involve multiple organs. Ninety percent of patients with SS are female, Caucasian, and middle-aged. The characteristic symptoms of xerostomia and xerophthalmia often are trivialized, and the disorder is significantly underdiagnosed. Early diagnosis and management can prevent devastating oral and ocular complications and internal organ damage. Treatment modalities are aimed at providing comfort and preventing complications and progression of the disease. In the perioperative practice setting, nurses play an important role in the health care team involved in providing surgical care to patients with SS.

Change in final diagnosis on second evaluation of labial minor salivary gland biopsies

OBJECTIVE

We evaluated the diagnostic accuracy of labial salivary gland specimens from a group of patients with symptoms or signs of dry mouth and/or dry eyes referred for assessment of possible Sjögren's syndrome (SS).

METHODS

Fifty-eight individuals (52 women, 6 men; median age 54.5 yrs, range 19-90) had previously undergone one (n = 58) or 2 (n = 2) labial salivary gland biopsies, serologic studies, and objective tests for dry eyes and/or dry mouth to diagnose possible SS. Patients were referred to our institution for a second opinion regarding diagnosis and/or management of SS. All biopsy specimens underwent blinded review to measure aggregate glandular area, identify lymphocytic foci, and calculate focus scores that might verify the submitted diagnoses. Results were classified according to accepted histologic criteria: chronic sialadenitis, focal lymphocytic sialadenitis, indeterminate, insufficient tissue for diagnosis, and within normal limits. Institutional sources of submitted diagnoses included university hospitals (n = 26), university affiliates (n = 9), community hospitals (n = 18), commercial laboratories (n = 6), and a governmental agency (n = 1).

RESULTS

Upon reexamination, 32 of 60 accessions (53%) sustained a revision of the initial diagnosis. Application of the focus scoring system combined with clinical features to reveal 12 hitherto undocumented cases of SS and refuted the diagnosis of SS in 8 instances. The principal reason for inaccurate initial interpretation was failure to apply the focus scoring system in 58 of 60 instances. Median diagnostic delay for the 12 SS cases was 302 days (range 55-2821).

CONCLUSION

It is possible that widespread cross-institutional failure to apply the focus scoring system in the interpretation of labial salivary gland biopsies may delay the recognition and/or treatment of SS.

The treatment of Sjögren's syndrome patients with pilocarpine-tablets

Therapeutic progress in Sjögren's syndrome has lagged behind our recognition and understanding of clinical manifestations and disease pathogenesis. Past treatment of sicca symptoms with immunosuppressives has been unsuccessful. The use of secretagogues (e.g. pilocarpine-HCl) to stimulate flow from exocrine glands represents a novel approach that has dramatically altered our management strategy for Sjögren's syndrome. Clinical studies with pilocarpine (Salagen) tablets in the United States have demonstrated significant subjective and objective benefit for xerostomia and related oral symptoms at doses of 20 mg/day or more. Symptomatic relief of xerophthalmia and other xeroses due to Sjögren's syndrome may also occur. Data from human and animal models suggest that regular use of pilocarpine may not only improve patient quality of life but potentially prevent complications as well. Better methods of patient selection for therapy are needed since clinical response to pilocarpine cannot be predicted based on the duration of patient symptoms.

Corneal melt as the initial presentation of primary Sjögren's syndrome

Corneal melting is a rare complication of S ogren's syndrome (SS). Previously reported cases of corneal ulceration occurred in patients with established SS, usually secondary to RA. We describe the first case of corneal ulceration with stromal melting as the initial presentation of primary SS. A 79-year-old man without prior sicca symptoms developed a large sterile corneal ulcer that required extensive treatment over several months with ocular lubricants, systemic immunosuppressives, and surgical repair. Evaluation for an underlying connective tissue disease revealed positive antinuclear antibodies (1:640 speckled) and anti-SSA antibody. A lip biopsy established the diagnosis of SS. Ulceration later occurred in the contralateral eye. Two years after the last corneal ulcer and no longer taking prednisone, the patient's ocular disease remained quiescent taking azathioprine 175 mg and hydroxychloroquine 400 mg daily. This case highlights the potential for primary SS to present with serious ocular complications despite lack of a priori sicca symptoms, as well as the importance of immunosuppressive therapy in the treatment of this complication.

Scintigraphic features of chronic sialadenitis and Sjögren's syndrome: a comparison

An abnormal salivary scintigram is an accepted objective criterion in the diagnosis of primary and secondary Sjögren's syndrome, an immune-mediated disorder characterized by xerostomia and kerato-conjunctivitis sicca. However, chronic sialadenitis constitutes a major differential diagnostic consideration in the xerostomic population. We investigated 39 cases of biopsy-confirmed chronic sialadenitis and 152 individuals with first- or second-degree Sjögren's syndrome, according to international classification criteria. We analysed scintigraphic defects in terms of glands per patient, distribution patterns, kinetics and severity. Relative to Sjögren's syndrome, chronic sialadenitis showed significantly fewer defective glands per patient, less frequent dual parotid-submandibular defects, fewer combined deficits of uptake and discharge, and milder uptake failure. No statistically significant differences were found in the frequency of single gland abnormality, predilection for submandibular involvement, and respective proportions of uptake-only and discharge-only defects. Unevaluable discharge due to low uptake, although comprising only 34% of test-positive cases, appeared to be a highly specific but insensitive scintigraphic marker for Sjögren's syndrome. In non-irradiated xerostomic populations, scintigraphy provides specific, albeit limited, diagnostic information. The procedure's ability to distinguish uptake failure from secretory failure may be a useful asset in guiding clinical management strategies and estimating outcomes.

Diagnostic accuracy of salivary scintigraphic indices in xerostomic populations

PURPOSE

Three decades of work to enhance the diagnostic accuracy of salivary scintigraphy have generated various plausible decision criteria. This study evaluates four commonly cited numeric indices in studies of xerostomic populations and how accurately they identify Sjögren's syndrome, chronic sialadenitis, radiation sialadenitis, and drug effects and distinguish each from the other.

METHODS

Stimulated dynamic salivary scintigraphy was performed on 295 xerostomic patients and on 31 controls. The nonparametric area under the receiver operating characteristic curves expressed the diagnostic accuracy of the following scintigraphic indices: the parotid:submandibular ratio of unstimulated glandular activity, the peak:baseline uptake ratio, its time of occurrence, and the stimulated excretion fraction.

RESULTS

The stimulated excretion fraction distinguished Sjögren's syndrome and radiation sialadenitis from healthy states with respective accuracies of 0.78 and 0.90. The maximum diagnostic payoff in Sjögren's syndrome occurred at a cutoff of 73%, yielding a 73% rate of test sensitivity and a 73% rate of specificity. The other three indices were not useful. Even the stimulated excretion fraction performed indifferently or poorly in most other diagnostic tasks.

CONCLUSIONS

In the scintigraphic examination of xerostomic and healthy populations, an acceptable diagnostic utility of the stimulated excretion fraction was evident only in Sjögren's syndrome and radiation sialadenitis. When presented with differential diagnostic alternatives not involving radiation sialadenitis, none of the four numeric indices performed acceptably.

Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group

BACKGROUND

Patients with Sjögren syndrome (SS) experience slowly progressive infiltration of lacrimal and salivary glands by mononuclear cells. This leads to diminished secretions, with resultant symptoms of xerostomia and xerophthalmia. Although pilocarpine hydrochloride tablets are currently indicated for the treatment of radiation-induced xerostomia, their effects on dry mouth or dry eyes in patients with SS are unclear.

OBJECTIVE

To assess the safety and efficacy of pilocarpine (Salagen) tablets as symptomatic treatment for dry mouth and dry eyes caused by SS in a multicenter, doubleblind, placebo-controlled trial.

METHODS

After providing written informed consent, 373 patients with primary or secondary SS and clinically significant dry mouth and dry eyes were randomized to receive 2.5-mg pilocarpine, 5-mg pilocarpine, or placebo tablets 4 times daily for 12 weeks. Symptoms were assessed by questionnaires with visual analog scales or categorical checkboxes. Whole-mouth salivary flow rates were measured.

RESULTS

A significantly greater proportion of patients in the 5-mg pilocarpine group showed improvement compared with the placebo group (P< or =.01) in global assessments of dry mouth, dry eyes, and other symptoms of dryness (P< or =.05). Salivary flow was significantly increased 2- to 3-fold (P<.001) after administration of the first dose and was maintained throughout the 12-week study. The most common adverse effect was sweating, and no serious drug-related adverse experiences were reported.

CONCLUSION

Administration of 5-mg pilocarpine tablets 4 times daily (20 mg/d) was well tolerated and produced significant improvement in symptoms of dry mouth and dry eyes and other xeroses in patients with SS.

Variability of quantitative scintigraphic salivary indices in normal subjects

Several quantitative measures of salivary uptake and discharge have been proposed recently in the scintigraphic evaluation of xerostomia. We investigated the scatter of four time-activity curve C(TAC)-derived indices in a group of volunteer subjects who met extensive inclusionary and exclusionary criteria of salivary normalcy.

METHODS

Thirty-one adult volunteers underwent dynamic salivary scintigraphy with gustatory stimulation. Any candidates with subjective xerostomia, conditions or medications associated with dry mouth, salivary gland enlargement or pregnancy were excluded from study. All subjects had normal oral exams, xerostomia scores and unstimulated whole-mouth salivary flow rates. After the intravenous administration of 99mTcO-4, scintigraphy was performed with generation of TACs derived from regions of interest centered about the four major salivary glands and the oral cavity. At 45 min postinjection, hard lemon candy was given for 15 min as a gustatory stimulus. The following functional indices were calculated for each gland: partitioned percentage (PP) of total prestimulated activity, maximum net uptake ratio (NUR) and its time of occurrence (TNUR) and percentage stimulated discharge fraction (DF).

RESULTS

The following ranges were observed: parotid PP, 22%-49%; submandibular PP, 4%-31%; parotid NUR, 2.2-16.0; submandibular NUR, 1.4-16.2; parotid TNUR, 8-45 min; submandibular TNUR, 2-45 min; parotid DF, 20%-99%; and submandibular DF, 27%-98%. Every subject except one 91-yr-old man showed frequent periodic unstimulated oral transfer of salivary activity with a rising oral TAC and responded to gustatory stimulation.

CONCLUSION

So-called quantitative indices may perform poorly in the scintigraphic evaluation of xerostomic patients because the effects of normal simultaneous glandular trapping, uptake, oral discharge and possible vascular washout combine to widen reference limits. Coordinated analysis of oral cavity and glandular activities, glandular index averaging and better temporal resolution may help improve diagnostic performance.

Histologic and electron microscopic characterization of the antiperinuclear factor antigen

The presence of the antiperinuclear factor, an autoantibody that recognizes cytoplasmic antigens, was detected in sera from patients with rheumatoid arthritis (59%), seronegative rheumatoid arthritis (36%), systemic lupus erythematosus (46%), systemic sclerosis (26%), and in nonautoimmune controls (10%). The antigenic perinuclear granules were found in the stratum intermedium layer of the buccal mucosa. Granules exhibited histologic features of nucleoproteins, stained for ribonucleoprotein, and showed the ultrastructural characteristics of aggregated rough endoplasmic reticulum. The antiperinuclear factor may recognize a common autoantigen in connective tissue disease.

Synovial fluid characteristics and the lupus erythematosus cell phenomenon in drug-induced lupus. Findings in three patients and review of pertinent literature

The characteristics of synovial fluid obtained from 3 patients with drug-induced lupus erythematosus are described. Two patients had "inflammatory" counts of synovial leukocytes, in the range of 2,500-39,000/mm3, with mononuclear predominance in 1 patient and neutrophil predominance in the other. The third patient had "noninflammatory" fluid, with mononuclear predominance. Lupus erythematosus cells formed in vivo were observed in the synovial fluid of 2 of the patients. Biopsy of the synovium of 1 patient showed nonspecific chronic inflammatory changes. Our findings in these patients with drug-induced lupus are indistinguishable from those previously described in patients with idiopathic lupus erythematosus.

Nuclear imaging and clinical features of childhood reflex neurovascular dystrophy: comparison with adults

Reflex neurovascular dystrophy (RND) is less common in children than in adults, and differences in onset, clinical course, response to treatment, and degree of disability suggest a different pathogenesis. We have assessed the usefulness of nuclear imaging in 15 children with RND who were evaluated from March 1983 to September 1985. Abnormal findings on 3-phase bone scans were observed in 14 children, with diffusely decreased bone uptake at the symptomatic site being the most common observation. This contrasts sharply with previous reports of diffusely increased uptake in most adults with RND.