Causal effects of endometriosis on SLE, RA and SS risk: evidence from meta-analysis and Mendelian randomization

BACKGROUND

Endometriosis is an underdiagnosed disorder that affects an estimated 6-10% of women of reproductive age. Endometriosis has been reported in epidemiological studies to be associated with autoimmune diseases. However, the relationship remains controversial.

METHODS

A meta-analysis of observational studies was undertaken to evaluate the risk of autoimmune diseases in patients with endometriosis. The relevant studies were retrieved via the databases Medline, Embase and Web of Science until July 20, 2023. Mendelian randomization (MR) was subsequently utilized to scrutinize the causal influence of genetic predisposition toward endometriosis on three autoimmune diseases.

RESULTS

The meta-analysis findings revealed a relationship between endometriosis and the onset of SLE (cohort studies: RR = 1.77, 95% confidence interval (CI): 1.47-2.13, I2 = 0%; Case-control and cross-sectional studies: OR = 5.23, 95% CI: 0.74-36.98, I2 = 98%), RA (cohort studies: RR = 2.18, 95% CI: 1.85-2.55, I2 = 92%; Case-control and cross-sectional studies: OR = 1.40, 95% CI: 1.19-1.64, I2 = 0%) and SS (cohort studies: RR = 1.49, 95% CI: 1.34-1.66, I2 = 0%). Similarly, in our MR study, the results of the inverse-variance-weighted (IVW) model suggested that genetic predisposition to endometriosis was causally associated with an increased risk for SLE (OR = 1.915, 95% CI: 1.204-3.045, p = 0.006) and RA (OR = 1.005, 95% CI: 1.001-1.009, p = 0.014).

CONCLUSIONS

Both our meta-analysis and MR study indicate that endometriosis increases the risk of autoimmune diseases. These findings not only broaden our understanding of the genetic mechanisms underlying the comorbidity of endometriosis and autoimmune diseases, but also offer a new strategy for autoimmune disease prevention.

Textural Analysis of Magnetic Resonance Images as an Additional Evaluation Tool of Parotid Glands in Sjögren-Primarily Findings

Magnetic Resonance Imaging (MRI) plays a leading role in diagnosing soft tissue pathologies, especially in the head and neck. It is increasingly popular for evaluating salivary gland issues like neoplasms and Sjogren's Syndrome. Advanced MRI methods, including MRI sialography and texture analysis, offer non-invasive alternatives, enhancing MRI's role. This study focused on the relationship between the apparent diffusion coefficient (ADC) and T2-weighted MRI sialography and texture analysis (TA) of parotid glands in children with and without Sjogren's Syndrome (SS). Using 3.0 Tesla MRI with DWI and T2-weighted imaging, expended texture analysis, first-order statistics (FSOs), second-order, and higher-order statistics were conducted. The results showed significant differences in parotid ADC values, with lower values in the SS group, particularly in cases of higher disease activity. Lower kurtosis values were associated with more severe Tonami Scale grades. FSO parameters correlated well with the texture analysis from T2-weighted images, indicating promise in grading parotid gland inflammation. However, further research is needed to understand the impact of variables like binning and region of interest (ROI) size. This study highlights the potential of texture analysis for assessing parotid gland inflammation and emphasizes the need for more investigations in this area.

Tear Cytokine Levels in Sicca Syndrome-Related Dry Eye: A Meta-Analysis

Sjogren's syndrome (SS) is an autoimmune disease that affects exocrine glands, mainly salivary and lacrimal glands. Several studies have investigated cytokine profiles in tears in order to understand the pathogenesis of SS and find additional diagnostic markers. This systematic review and meta-analysis aimed to analyze cytokines in tears of SS patients. A systematic literature search of the Cochrane, Medline via PubMed, Scopus, and Web of Science databases was conducted using key terms related to "Sjögren's syndrome" and "tears" combined with "biomarker", "cytokines", "interleukin", and "chemokines", following PRISMA guidelines. Article selection was subjected to certain eligibility criteria. A total of 17 articles (from 1998 and 2022) were selected for the quantitative and qualitative analysis. When compared to controls, concentrations of IFN-γ, TNF-α, IL-1α, IL-1 Ra, IL-4, IL-6, IL-8, IL-10, IL-17, IL-21 and IL-22 were consistently higher; however, IL-23 was significantly lower in patients with SS compared to the controls. Tear levels of some cytokines were significantly elevated among SS groups compared to control groups. Therefore, these cytokines could be potential biomarkers of SS. However, standardization of sample collection and analytical methods is necessary in order to translate these findings into clinical practice.

The Effect of Mesenchymal Stem Cells on Dry Eye in Sjogren Syndrome Mouse Model

Sjögren's syndrome (SS) is a systemic autoimmune disease delineated by chronic lymphocytic infiltrates into the lacrimal or salivary glands, leading to severe dry eye and dry mouth. Mesenchymal stem cells have been shown to be effective in treating numerous autoimmune diseases. This study aimed to illustrate the effects of mesenchymal stem cells on the attenuation of dry eyes (DE) through the inhibition of autophagy markers in a SS mouse model. NOD/ShiLtJ female mice with developed DE were treated with either subconjunctival or lacrimal gland injections of hMSCs (Catholic MASTER Cells). After maintenance for 14 days, clinical DE markers such as tear secretion and corneal staining were observed, as well as goblet cell counts in the conjunctiva, infiltration of inflammatory foci, B and T cells, and autophagy markers in the lacrimal glands. Proinflammatory cytokine expressions of the cornea and conjunctiva, as well as the lacrimal glands, were examined. Clinical markers, such as tear secretion and corneal stain scores, goblet cell counts in the conjunctiva, and foci infiltrations in the lacrimal glands were attenuated in mice treated with subconjunctival or lacrimal gland injections of hMSCs compared to the PBS-treated control group. B cell marker B220 decreased in the lacrimal glands of hMSCs-treated mice, as well as reduced proinflammatory cytokine expressions in the lacrimal glands and cornea. Notably, expression of autophagy markers ATG5 and LC3B-II, as well as HIF-1α and mTOR which play roles in the pathways of autophagy modulation, were shown to be attenuated in the lacrimal glands of hMSCs-treated mice compared to the PBS-treated control mice. Treatment with hMSCs by lacrimal gland or subconjunctival injection demonstrated the alleviation of DE through the repression of autophagy markers, suggesting the therapeutic potentials of hMSCs in a SS mouse model.

Case report: Unusual development of hepatocellular carcinoma during immunosuppressive treatments against rheumatoid arthritis overlapping Sjögren's syndrome; cirrhotic steatohepatitis with liver inflammation and fibrosis lurks in autoimmune disorders

The sequential progression from chronic liver disease to cirrhosis may be a risk factor for hepatocellular carcinoma (HCC) development. Although HCC originates from hepatitis B virus- or hepatitis C virus-associated liver cirrhosis, it has recently been reported in patients with non-alcoholic steatohepatitis (NASH) with advanced fibrosis. However, little is known about the pathophysiological mechanisms linking HCC to rheumatic disorders, including rheumatoid arthritis (RA). Herein, we describe the case of HCC with NASH complicated by RA and Sjögren's syndrome (SS). A fifty-two-year-old patient with RA and diabetes was referred to our hospital for further examination of a liver tumor. She received methotrexate (4 mg/week) for 3 years and adalimumab (40 mg/biweekly) for 2 years. On admission, laboratory data showed mild thrombocytopenia and hypoalbuminemia, with normal hepatitis virus markers or liver enzymes. Anti-nuclear antibodies were positive with high titers (x640), and anti-SS-A/Ro (187.0 U/ml; normal range [NR]: ≤6.9 U/mL) and anti-SS-B/La (320 U/ml; NR: ≤6.9 U/mL) antibodies were also high. Abdominal ultrasonography and computed tomography revealed liver cirrhosis and a tumor in the left lobe (S4) of the liver. She was diagnosed with HCC based on imaging findings, and elevated levels of protein induced by vitamin K absence- II (PIVKA-II) were detected. She underwent laparoscopic partial hepatectomy, and histopathological examination revealed steatohepatitis HCC with background liver cirrhosis. The patient was discharged on the 8^th day post-operation without any complications. At the 30 months follow-up, no significant evidence of recurrence was observed. Our case suggests that clinical screening for HCC is needed in patients with RA who are at a high risk of NASH, as they may progress to HCC even without elevated liver enzymes.

Exploration of the pathogenesis of Sjögren's syndrome via DNA methylation and transcriptome analyses

OBJECTIVES

Sjögren's syndrome (SS), a systemic autoimmune disorder, is characterized by dry mouth and eyes. However, SS pathogenesis is poorly understood. We performed bioinformatics analysis to investigate the potential targets and molecular pathogenesis of SS.

METHODS

Gene expression profiles (GSE157159) and methylation data (GSE110007) associated with SS patients were obtained from the Gene Expression Omnibus (GEO) database. Differentially methylated positions (DMPs) and differentially expressed genes (DEGs) were identified by the R package limma. The potential biological functions of DEGs were determined using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Key DMPs were selected by overlap and the shrunken centroid algorithm, and corresponding genes were identified as hub genes, with their diagnostic value assessed by receiver operating characteristic (ROC) curves. The potential molecular mechanisms of hub genes were analyzed by protein-protein interaction (PPI) networks and single-gene gene set enrichment analysis (GSEA). Peripheral blood mononuclear cells (PBMCs) were collected from control and SS patients at The Affiliated Hospital of Southwest Medical University and Dazhou Central Hospital. The mRNA levels of hub genes were verified by quantitative real-time polymerase chain reaction (qRT-PCR).

RESULTS

We identified 788 DMPs and 2457 DEGs between the two groups. Functional enrichment analysis suggested that the DEGs were significantly enriched in T cell activation, leukocyte cell-cell adhesion, and cytokine-cytokine receptor interaction. TSS200, TSS1500, and 1stExon were identified as highly enriched areas of differentially methylated promoter CpG islands (DMCIs). In total, 61 differentially methylated genes (DMGs) were identified by the overlap of 2457 DEGs and 507 genes related to DMPs (DMPGs), of which 21 genes located near TSS200, TSS1500, and 1stExon were selected. Then, three key DMPs and the corresponding hub genes (RUNX3, HLA-DPA1, and CD6) were screened by the shrunken centroid algorithm and calculated to have areas under the ROC curve of 1.000, 0.931, and 0.986, respectively, indicating good diagnostic value. The GSEA results suggested that all three hub genes were highly associated with the immune response. Finally, positive mRNA expression of the three hub genes in clinical SS samples was verified by qRT-PCR, consistent with the GSE157159 data.

CONCLUSIONS

The identification of three hub genes provides novel insight into molecular mechanisms and therapeutic targets for SS. Key Points • Hub genes were screened by DNA methylation and transcriptome analyses. • The relative expression of hub genes in peripheral blood samples was verified by qRT-PCR. • HLA-DPA1 was correlated with the pathogenic mechanism of SS.

Efficacy and safety of Tripterygium glycosides in Sjögren's syndrome treatment: evidence from 12 randomized controlled trials

BACKGROUND

Tripterygium glycosides (TGs) has been widely used in the treatment of Sjögren's syndrome (SS).

METHODS

Seven databases, PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Medical Database, China Science and Technology Journal Database, and the Chinese Biomedicine database, were selected to collect randomized controlled trials (RCTs) related to the treatment of SS with TGs alone or in combination. The participants, intervention, comparison, outcome, and study design principle were adopted for the inclusion of related studies. The risk of bias was assessed using the Cochrane Collaboration's tool. Meta-analysis was conducted using RevMan 5.3, with risk ratios (RRs) or standard mean differences (SMDs) and 95% confidence intervals (CIs).

RESULTS

Overall, 12 trials involving 668 patients were analyzed. The results of the meta-analysis showed that TGs in combination with total glucosides of paeony (TGP) had significantly lower symptom scores than TGs alone on dry eyes (SMD =-0.61, 95% CI: -1.12 to -0.10, P=0.02) or dry mouth (SMD =-1.29, 95% CI: -1.84 to -0.74, P<0.00001). The efficacy rates of TG + TGP vs. TGs (P<0.00001) and TG + HM vs. TGs (P=0.01) were significantly different. In addition, compared to hydroxychloroquine (HCQ), TGs could induce expression of C-reactive protein (P=0.007), globulin (P<0.00001), and immunoglobulin A (IgA) (P=0.006), whereas the TG + TGP group had lower levels of immunoglobulin G (IgG) (P<0.00001), immunoglobulin M (IgM) (P=0.02), and IgA (P<0.00001), as well as saliva flow rate (P<0.00001) and lacrimal gland function (P<0.00001). The adverse events between TGs and HCQ were not evident, and there was no increase in the risk of adverse reactions when combined with other drugs.

DISCUSSION

TGs are potentially effective for treating SS without increasing the risk of adverse events. High-quality, multi-center, and large-scale RCTs are required.

TLR7 Signaling Drives the Development of Sjögren's Syndrome

Sjögren’s syndrome (SS) is a chronic systemic autoimmune disease that affects predominately salivary and lacrimal glands. SS can occur alone or in combination with another autoimmune disease like systemic lupus erythematosus (SLE). Here we report that TLR7 signaling drives the development of SS since TLR8-deficient (TLR8ko) mice that develop lupus due to increased TLR7 signaling by dendritic cells, also develop an age-dependent secondary pathology similar to associated SS. The SS phenotype in TLR8ko mice is manifested by sialadenitis, increased anti-SSA and anti-SSB autoantibody production, immune complex deposition and increased cytokine production in salivary glands, as well as lung inflammation. Moreover, ectopic lymphoid structures characterized by B/T aggregates, formation of high endothelial venules and the presence of dendritic cells are formed in the salivary glands of TLR8ko mice. Interestingly, all these phenotypes are abrogated in double TLR7/8-deficient mice, suggesting that the SS phenotype in TLR8-deficient mice is TLR7-dependent. In addition, evaluation of TLR7 and inflammatory markers in the salivary glands of primary SS patients revealed significantly increased TLR7 expression levels compared to healthy individuals, that were positively correlated to TNF, LT-α, CXCL13 and CXCR5 expression. These findings establish an important role of TLR7 signaling for local and systemic SS disease manifestations, and inhibition of such will likely have therapeutic value.

Double lung transplantation for Sjögren's syndrome-related interstitial lung disease: a case report and review of literature

In this study, we present a case of 65-year-old male patient with suspected Sjögren's syndrome-related interstitial lung disease (SS-ILD) with initial symptoms of limb edema and acute respiratory failure. He was treated with immunosuppressor, respiratory support, dialysis, immunomodulatory, and anti-inflammatory medications. However, no significant response was shown to anti-fibrotic treatments and his respiratory function deteriorated. Double lung transplantation was thus indicated considering the irreversible interstitial changes in both lungs. The surgical procedure was complicated, and the role of enhanced recovery after surgery (ERAS) for this critical patient was discussed. The patient experienced hemorrhage, pulmonary infection, and peripheral neuropathy after surgery, but he was cured by the multidisciplinary team. He had a satisfactory quality of life at 1-year follow-up. This case report describes the details of double lung transplantation in a patient with advanced SS-ILD. Important considerations include the indications for and timing of transplantation, the effects of long-term immunosuppression on wound healing, and extrapulmonary organ dysfunction. Based on a review of the published literature and a consideration of the short-term outcomes, lung transplantation for this individual with an autoimmune disease appears to be safe and feasible. SS-ILD should not be a contraindication to transplantation; however, patients with advanced pulmonary involvement should be carefully selected after a multidisciplinary evaluation. More long-term follow-up and further comparative studies are needed in the future.

Diagnostic value of major salivary gland ultrasonography in primary Sjögren's syndrome: the role of grey-scale and colour/power Doppler sonography

Primary Sjögren's syndrome (pSS) is an autoimmune connective tissue disease characterized primarily by chronic inflammatory involvement of the exocrine glands, particularly the salivary glands. The use of ultrasound in the study of salivary glands (SGUS) has expanded considerably in recent years. The ultrasound can document structural alterations that can be visualized as hyperechogenic and hypoechogenic areas, or as areas with non-homogeneous echogenicity. To date, several systems of SGUS scoring systems of abnormalities during pSS are available. From the studies published in recent decades, it has been possible to document the high sensitivity and specificity of the pathological findings that can be documented by SGUS. SGUS can also provide added value in identifying patients at risk for developing disease complications such as lymphoma. The Doppler technique can also supply information about glandular tissue vascularization, which is very useful for diagnostic and differential purposes. In this review we will present the state of the art of SGUS, with a prevailing focus on diagnostic use and possible future developments.

Risk of asthma in patients with primary Sjögren's syndrome: a retrospective cohort study

Background

Sjögren’s syndrome (SS) has been associated with bronchial hyperresponsiveness and asthma; however, no population-based cohort study has been performed. We evaluated the risk of asthma in patients with primary SS in a nationwide population.

Methods

We conducted a retrospective cohort study using data from the National Health Insurance Research Database in Taiwan. The primary SS group included 4725 adult patients diagnosed between 2000 and 2006. Each patient was frequency-matched with four people without SS by sex, age and year of diagnosis. The occurrence and hazard ratio (HR) of asthma was monitored by the end of 2011.

Results

The overall incidence density of asthma was 1.62-fold higher in the primary SS group than in the non-SS group (9.86 vs. 6.10 per 1000 person-years), with a multivariable Cox proportional hazards model measured adjusted HR of 1.38 [95% confidence interval (CI) = 1.21–1.58]. Stratified analyses by sex, age group, and presence of comorbidity revealed that asthma incidences were all higher in the primary SS group than in the non-SS group, and the relative HRs of asthma associated with primary SS were significant in all subgroups.

Conclusion

Patients with primary SS are associated with an increased risk of developing asthma. We should pay more attention to this group of individuals and provide them with appropriate support.

Effect of paeoniflorin on the calcium ion concentration in salivary gland cells using confocal laser scanning microscopy

OBJECTIVE

To investigate the effects of paeoniflorin, the main monomer component of Jinxueyuan granules, on the Ca²⁺ concentrations in salivary gland cells to further explore the salivation-promoting mechanism and effective monomer components of Jinxueyuan granules.

METHODS

The salivary gland cells of suckling rats were cultured in vitro and loaded with a Fluo-3AM fluorescent probe, and changes in the intracellular Ca²⁺ concentrations were observed using a confocal laser scanning microscope.

RESULTS

No significant changes in the intracellular Ca²⁺ concentrations were demonstrated (P>0.05) in the paeoniflorin-free Hank's media treatment group or in the higher-dose paeoniflorin (10^-2 mol/L) Hank's media treatment group; however, a significant increase in the intracellular Ca²⁺ concentration in the lower-dose paeoniflorin (10^-4 mol/L) treatment group was observed (P=0.001). Further study showed that treatment with the calcium channel blocker verapamil hydrochloride or with Ca²⁺-free D-Hank's media did not block the paeoniflorin-induced (10^-4 mol/L) increase in intracellular Ca²⁺ (P<0.05).

CONCLUSION

Paeoniflorin promotes the release of endogenous calcium to upregulate the intracellular Ca²⁺ concentration. Further studies should be performed to investigate the association between paeoniflorin and the Ca²⁺ concentration in salivary gland cells and to elucidate the corresponding functional pathways.

The Prevalence of Dry Eye Syndrome's and the Likelihood to Develop Sjögren's Syndrome in Taiwan: A Population-Based Study

BACKGROUND

Dry eye syndrome (DES) is one of the key clinical features and possibly an early clinical presentation of Sjögren's syndrome (SS). We explore DES prevalence and assess the likelihood of DES patients to develop SS in Taiwan through the National Health Insurance Research Database (NHIRD).

METHODS

Through a cohort comparison study, longitudinal data from the NHIRD (2000 to 2008) in Taiwan was used to probe the prevalence of DES and the odds that DES patients would later develop SS.

RESULTS

The prevalence of DES in the present study is 4.87%. The incidence rates of developing SS were 4.8% for the DES group and 1.5% for comparison group. The median age and interquartile range of DES and comparison patients was 49.8 (10) and 48.7 (15) years old, respectively. The crude hazard ratio (with 95% confidence interval) for DES patients to develop SS was 3.13 (3.10-3.50) for the DES group, and the adjusted hazard ratio (with 95% confidence interval) was 3.64 (3.43-3.87). The observation period and interquartile range for DES and comparison patients to develop SS later were 1418 (781-2316) versus 1641 (971-2512) days respectively.

CONCLUSIONS

DES patients carried a higher risk for developing SS (hazard ratio 3.13) and presented for SS 3.88 years earlier than comparison group patients in this study.