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Lan J, Deng C, Huang H, Rao P, Chen Y, Shi Y, Chen J, Shi G, Liu Y, Chen S. Seronegative primary Sjögren's syndrome, a distinct subtype of primary Sjögren's syndrome in Chinese patients. BMC Rheumatol 2024; 8:15. [PMID: 38627838 PMCID: PMC11020423 DOI: 10.1186/s41927-024-00384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND To investigate the clinical and immune characteristics of patients with primary Sjögren's syndrome (pSS) who were negative for anti-Sjögren's-syndrome-related antigen A antibodies (anti-SSA) and anti-Sjögren's-syndrome-related antigen B antibodies (anti-SSB) in Chinese population. METHODS A retrospective study were performed and 232 patients with pSS were analyzed. Patients positive for anti-SSA or/and anti-SSB were termed as seropositive pSS, and these negative for both anti-SSA and anti-SSB (non-antinuclear antibodies) as seronegative pSS. Clinical manifestations and laboratory findings were compared between the two groups. RESULTS Among the 232 patients with pSS, 192 (82.8%) were seropositive pSS and 40 (17.2%) were seronegative pSS. Compared to seropositive pSS, seronegative pSS were older and with higher percentage of low disease activity (ESSDAI < 5), xerostomia and xerophthalmia, with higher platelet count and level of creatine kinase. This subgroup was with lower levels of gamma globulin, immunoglobulin G, immunoglobulin A and autoantibodies including rheumatoid factor and antinuclear antibody in serum, and less immunoglobulin G deposition in labial gland. CONCLUSION Seronegative pSS was a distinct subtype of pSS different from seropositive pSS. Clinical manifestations in seronegative pSS subgroup were restricted to exocrine gland and less B lymphocyte activation, while seropositive pSS were prone to present with systemic involvement and high disease activity. Specific underlying pathogenesis mechanisms and therapeutic strategies in this subgroup needed to be further studied.
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Affiliation(s)
- Jingying Lan
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China
- Department of Rheumatology and Immunology, The First People's Hospital of Yibin, 644000, Yibin, Sichuan, China
| | - Chaoqiong Deng
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China
| | - Heqing Huang
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China
| | - Peishi Rao
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China
| | - Yangchun Chen
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China
| | - Yingying Shi
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China
| | - Jie Chen
- Department of Rheumatology and Clinical Immunology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 330006, Nanchang, China
| | - Guixiu Shi
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China.
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China.
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China.
| | - Yuan Liu
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China.
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China.
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China.
| | - Shiju Chen
- Department of Rheumatology and Clinical Immunology, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Zhenhai Rd. 55#, 361000, Xiamen, Fujian, China.
- Xiamen Municipal Clinical Research Center for Immune Diseases, 361000, Xiamen, Fujian, China.
- Xiamen Key Laboratory of Rheumatology and Clinical Immunology, 361000, Xiamen, Fujian, China.
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韩 艺, 李 常, 陈 秀, 赵 金. [Comparison of clinical and immunological characteristics between primary Sjögren's syndrome patients with positive and negative anti-SSB antibody]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:1000-1006. [PMID: 38101780 PMCID: PMC10724006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To analyze the differences of clinical manifestations and laboratory features between primary Sjögren's syndrome (pSS) patients with positive and negative anti-Sjögren's syndrome type B (SSB) antibody. METHODS The clinical data of pSS patients hospitalized in Department of Rheumato-logy and Immunology, Peking University Third Hospital were retrospectively analyzed to investigate the differences of clinical and laboratory features between anti-SSB positive and negative groups. The t test, Mann-Whitney U test, Chi-square test and Fisher's exact probability were used for analysis. RESULTS A total of 142 pSS patients were enrolled in this study, including 137 females and 5 males with a mean age of (54.8±13.3) years. The anti-SSB positive group included 44 patients accounting for 31.0% of the pSS patients. The anti-SSB positive pSS patients were younger at disease onset and at visit [age at visit: (50.9±14.5) years vs. (56.5±12.4) years; age at onset: (42.2±14.8) years vs. (49.5±15.3) years, P < 0.05]. The patients with anti-SSB positive more frequently presented with rash (29.5% vs. 14.3%, P < 0.05), enlargement of parotid glands (27.3% vs. 8.2%, P < 0.05), renal tubular acidosis (15.9% vs. 4.2%, P < 0.05), immune thrombocytopenia (9.1% vs. 1.0%, P < 0.05), rheumatoid factor (RF) positive (85.0% vs. 49.4%, P < 0.05), higher RF and antinuclear antibody (ANA) titers (median: 89.8 IU/mL vs. 20.5 IU/mL; median: 320 vs. 160, P < 0.05), anti-Sjögren's syndrome type A (SSA) antibody positive (97.7% vs. 64.3%, P < 0.05), elevation of γ globulin (71.4% vs. 38.5%, P < 0.05), higher levels of IgG (median: 21.0 g/L vs. 15.6 g/L, P < 0.05), higher proportions of CD3-CD19+ cells [(21.0±11.9)% vs. (13.7±9.6)%, P < 0.05] and lower proportions of CD3+ cells [(67.2±14.4)% vs. (76.6%±13.1)%, P < 0.05] than those negative. However, the anti-SSB positive group was less likely to show anti-mitochondrial antibodies (AMA)-M2 positivity (10.5% vs. 35.6%, P < 0.05). Glucocorticoids (90.9% vs. 73.5%, P < 0.05) and immunosuppressants (54.5% vs. 36.7%, P < 0.05) were more frequently used in anti-SSB positive pSS patients than those negative. CONCLUSION The anti-SSB positive pSS patients were younger at disease onset while more frequently presenting with various symptoms, higher levels of other antibodies and activation of B cells than those negative. Glucocorticoids and immunosuppressants were more frequently used, indicating that anti-SSB positive group presented with a more severe clinal phenotype.
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Affiliation(s)
- 艺钧 韩
- 北京大学第三医院风湿免疫科, 北京 100191Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing 100191, China
| | - 常虹 李
- 北京大学第三医院风湿免疫科, 北京 100191Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing 100191, China
| | - 秀英 陈
- 北京大学第三医院延庆院区内科, 北京 102100Department of Internal Medicine, Yanqing Hospital, Peking University Third Hospital, Beijing 102100, China
| | - 金霞 赵
- 北京大学第三医院风湿免疫科, 北京 100191Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing 100191, China
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Jiang W, Yin X, Wang Y, Ding Y, Pan Y, Zheng G, Lv H, Chen K, Li S, Wang L, Shi Y, Li G, Zhang G. Establishment of a comprehensive diagnostic model for neuromyelitis optica spectrum disorders based on the analysis of laboratory indicators and clinical data. Neurol Sci 2023; 44:3647-3657. [PMID: 37191810 DOI: 10.1007/s10072-023-06853-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND To establish a comprehensive diagnostic model for neuromyelitis optica spectrum disorders (NMOSDs) based on laboratory indicators and clinical data. METHODS A retrospective method was used to query the medical records of patients with NMOSD from January 2019 to December 2021. At the same time, clinical data of other neurological diseases were also collected for comparison. Clinical data of the NMOSD group and non-NMOSD group were analyzed, and the diagnostic model was established based on these data. In addition, the model was evaluated and verified by the receiver operating curve. RESULTS A total of 73 patients with NMOSD were included, and the ratio of males to females was 1:3.06. The indicators that showed differences between the NMOSD group and non NMOSD group included neutrophils (P = 0.0438), PT (P = 0.0028), APTT (P < 0.0001), CK (P = 0.002), IBIL (P = 0.0181), DBIL (P < 0.0001), TG (P = 0.0078), TC (P = 0.0117), LDL-C (P = 0.0054), ApoA1 (P = 0.0123), ApoB (P = 0.0217), TPO antibody (P = 0.012), T3 (P = 0.0446), B lymphocyte subsets (P = 0.0437), urine sg (P = 0.0123), urine pH (P = 0.0462), anti-SS-A antibody (P = 0.0036), RO-52 (P = 0.0138), CSF simplex virus antibody I-IGG (P = 0.0103), anti-AQP4 antibody (P < 0.0001), and anti-MOG antibody (P = 0.0036). Logistic regression analysis showed that changes in ocular symptoms, anti-SSA antibody, anti-TPO antibody, B lymphocyte subsets, anti-AQP4 antibody, anti-MOG antibody, TG, LDL, ApoB, and APTT had a significant impact on diagnosis. The AUC of the combined analysis was 0.959. The AUC of the new ROC for AQP4- and MOG- antibody negative NMOSD was 0.862. CONCLUSIONS A diagnostic model was successfully established, which can play an important role in differential diagnosis of NMOSD.
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Affiliation(s)
- Wencan Jiang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
- NMPA Key Laboratory for Quality Control for In Vitro Diagnostic, Beijing, China
| | - Xiaoxuan Yin
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yufei Wang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yaowei Ding
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yu Pan
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Guanghui Zheng
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- NMPA Key Laboratory for Quality Control for In Vitro Diagnostic, Beijing, China
| | - Hong Lv
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Kelin Chen
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Siwen Li
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Lijuan Wang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Yijun Shi
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Guoge Li
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China
| | - Guojun Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
- National Engineering Research Centre for Beijing Biochip Technology, Beijing, China.
- NMPA Key Laboratory for Quality Control for In Vitro Diagnostic, Beijing, China.
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Hoshina Y, Wong KH, Galli J, Bacharach R, Klein J, Lebiedz-Odrobina D, Rose JW, Trump B, Hull C, Greenlee JE, Clardy SL. Neurologic involvement in seronegative primary Sjögren's syndrome with positive minor salivary gland biopsy: a single-center experience. Front Neurol 2023; 14:1174116. [PMID: 37360347 PMCID: PMC10289021 DOI: 10.3389/fneur.2023.1174116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Objective To assess the demographics, neurologic manifestations, comorbidities, and treatment of patients with seronegative primary Sjögren's syndrome (pSS). Patients and methods We conducted a retrospective chart review on patients with seronegative pSS evaluated by a neurologist at the University of Utah Health between January 2010 and October 2018. The diagnosis was based on characteristic symptoms, positive minor salivary gland biopsy according to the American-European Consensus Group 2002 criteria, and seronegative antibody status. Results Of 45 patients who met the study criteria, 42 (93.3%) were Caucasian, and 38 (84.4%) were female. The patients' mean age at diagnosis was 47.8 ± 12.6 (range 13-71) years. Paresthesia, numbness and dizziness, and headache were noted in 40 (88.9%), 39 (86.7%), and 36 patients (80.0%), respectively. Thirty-four patients underwent brain magnetic resonance imaging. Of these, 18 (52.9%) showed scattered nonspecific periventricular and subcortical cerebral white matter T2/fluid-attenuated inversion recovery hyperintense foci. Twenty-nine patients (64.4%) presented to the neurology clinic prior to pSS diagnosis, and the median delay in diagnosis from the first neurology clinic visit was 5 (interquartile ranges 2.0-20.5) months. Migraine and depression were the most common comorbidities in 31 patients (68.9%). Thirty-six patients received at least one immunotherapy, and 39 were on at least one medication for neuropathic pain. Conclusion Patients often display various nonspecific neurological symptoms. Clinicians should express a high degree of skepticism regarding seronegative pSS and consider minor salivary gland biopsy to avoid delaying diagnosis, as undertreatment can affect patients' quality of life.
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Affiliation(s)
- Yoji Hoshina
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Ka-Ho Wong
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Jonathan Galli
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Rae Bacharach
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- Department of Neurology, Penn State Health, Hershey, PA, United States
| | - Julia Klein
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Dorota Lebiedz-Odrobina
- Department of Medicine, Division of Rheumatology, University of Utah, Salt Lake City, UT, United States
| | - John W. Rose
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Bryan Trump
- School of Dentistry, University of Utah, Salt Lake City, UT, United States
| | - Christopher Hull
- Department of Dermatology, University of Utah, Salt Lake City, UT, United States
| | - John E. Greenlee
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Stacey L. Clardy
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, United States
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Mihai A, Chitimus DM, Jurcut C, Blajut FC, Opris-Belinski D, Caruntu C, Ionescu R, Caruntu A. Comparative Analysis of Hematological and Immunological Parameters in Patients with Primary Sjögren's Syndrome and Peripheral Neuropathy. J Clin Med 2023; 12:jcm12113672. [PMID: 37297866 DOI: 10.3390/jcm12113672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Primary Sjögren syndrome (pSS) is a multisystem disorder of autoimmune etiology, frequently involving peripheral nerves. Early detection of peripheral neuropathy (PN) manifestations might improve prognosis and disease control. The purpose of the study was to evaluate the predictive potential of hematological and immunological parameters associated with PN development in pSS patients. METHODS This single-center retrospective study included patients with pSS who were divided into two groups, according to the occurrence of neurological manifestations throughout the follow-up period. RESULTS From the total of 121 pSS patients included in the study, 31 (25.61%) developed neurological manifestations (PN+ group) during the follow-up period. At the moment of pSS diagnosis, 80.64% of PN+ patients exhibited increased disease activity, with ESSDAI scores above 14 (p = 0.001), and significantly higher values for VASp score (p = 0.001), with a mean value of 4.90 ± 2.45, compared to 1.27 ± 1.32 in the PN- group. The hematological assessment at the moment of pSS diagnosis revealed that neutrophils and neutrophil-to-lymphocyte ratio (NLR) were significantly higher in the PN+ group (p = 0.001), while lymphocytes, monocytes and monocyte-to-lymphocyte ratio (MLR) were significantly lower (p = 0.025, p = 0.13 and p = 0.003, respectively). Immuno-inflammatory parameters-gammaglobulins, complement fractions C3, C4, total proteins and vitamin D were significantly lower in the PN+ patients' group. In multivariate analysis, the independent predictive character for PN development in pSS patients was confirmed for NLR (95% CI 0.033 to 0.263, p = 0.012), MLR (95% CI -1.289 to -0.194, p = 0.008), gammaglobulins (95% CI -0.426 to -0.088, p < 0.003), complement fraction C4 (95% CI -0.018 to -0.001, p < 0.030) and vitamin D (95% CI -0.017 to -0.003, p < 0.009). CONCLUSIONS Readily available and frequently used hematological and immunological markers, such as NLR, MLR, gammaglobulins, C4 and vitamin D could be helpful in predicting the neurological involvement in pSS patients. These biological parameters might become useful tools for clinicians to monitor disease progression and identify potentially severe extraglandular manifestations in pSS patients.
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Affiliation(s)
- Ancuta Mihai
- Department of Internal Medicine, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Rheumatology, Faculty of General Medicine, Titu Maiorescu University, 031593 Bucharest, Romania
| | - Diana Maria Chitimus
- Department of Neurology, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
| | - Ciprian Jurcut
- Department of Internal Medicine, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
| | - Florin Cristian Blajut
- Department of General Surgery, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Medical-Surgical Specialties, "Titu Maiorescu" University of Bucharest, 040441 Bucharest, Romania
| | - Daniela Opris-Belinski
- Internal Medicine and Rheumatology Department, Sfanta Maria Clinical Hospital, 011172 Bucharest, Romania
- Internal Medicine and Rheumatology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Constantin Caruntu
- Department of Physiology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Dermatology, Prof. N.C. Paulescu National Institute of Diabetes, Nutrition and Metabolic Diseases, 011233 Bucharest, Romania
| | - Ruxandra Ionescu
- Internal Medicine and Rheumatology Department, Sfanta Maria Clinical Hospital, 011172 Bucharest, Romania
| | - Ana Caruntu
- Department of Oral and Maxillofacial Surgery, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Titu Maiorescu University, 031593 Bucharest, Romania
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Chen J, He Q, Yang J, Wu T, Huang Z, Zhang Y, Liao J, Zhang L, Yu X, Yao C, Luo J, Tao Q. Anti-SSA/SSB-negative primary Sjögren's syndrome showing different clinical phenotypes: a retrospective study of 934 cases. Adv Rheumatol 2023; 63:21. [PMID: 37189182 DOI: 10.1186/s42358-023-00304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/07/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Currently, only a few studies have described the general characteristics of patients with primary Sjögren's syndrome (pSS) who tested negatives for anti-SSA and anti-SSB antibodies. We aimed to further investigate the clinical characteristics of these patients in a large sample. METHODS Data from patients with pSS who were treated at a tertiary hospital in China between 2013 and 2022 were retrospectively analyzed. Clinical characteristics of the patients were compared between those with and without anti-SSA and anti-SSB antibody negativity. Factors associated with anti-SSA and anti-SSB negativity were identified by logistic regression analysis. RESULTS Overall, 934 patients with pSS were included in this study, among whom 299 (32.0%) tested negative for anti-SSA and anti-SSB antibodies. Compared with patients testing positive for anti-SSA or anti-SSB antibodies, that testing negative for the two antibodies had a lower proportion of females (75.3% vs. 90.6%, p < 0.001) and thrombocytopenia (6.7% vs. 13.6%, p = 0.002), but a higher proportion of abnormal Schirmer I tests (96.0% vs. 89.1%, p = 0.001) and interstitial lung disease (ILD) (59.2% vs. 28.8%, p = 0.001). Anti-SSA and anti-SSB negativity was positively associated with male sex (odds ratio [OR] = 1.86, 95% confidence interval [CI]: 1.05, 3.31), abnormal Schirmer I tests (OR = 2.85, 95% CI: 1.24, 6.53), and ILD (OR = 2.54, 95% CI: 1.67, 3.85). However, it was negatively related to thrombocytopenia (OR = 0.47, 95% CI: 0.24, 0.95). CONCLUSION Approximately one third of pSS patients had anti-SSA and anti-SSB negativity. pSS patients testing negative for anti-SSA and anti-SSB showed a higher risk of abnormal Schirmer I tests and ILD, but a lower risk of thrombocytopenia.
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Affiliation(s)
- Jiaqi Chen
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Qian He
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Jianying Yang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - TzuHua Wu
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Ziwei Huang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Yan Zhang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Jiahe Liao
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Lining Zhang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Xinbo Yu
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Chuanhui Yao
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Jing Luo
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China.
- Beijing Key Laboratory of Immune Inflammatory Disease, Beijing, China.
| | - Qingwen Tao
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China.
- Beijing Key Laboratory of Immune Inflammatory Disease, Beijing, China.
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Immunological, Clinical, and Epidemiological Features of Guillain-Barré Syndrome Associated with SARS-CoV-2 Infection. Acta Neurol Scand 2023. [DOI: 10.1155/2023/5380946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Objectives. There is a growing interest in understanding the association between Guillain-Barré syndrome (GBS) and SARS-CoV-2 infection. The aim of this study was to analyse various characteristics of GBS before and after the pandemic outbreak and thus identify possible distinctive features of GBS associated with SARS-CoV-2 (GBS-S). Material and Methods. In our centre, we retrospectively reviewed the records of patients diagnosed with GBS between January 2018 and March 2022. Epidemiological, clinical, and immunological data were analysed and compared between patients with GBS according to the time of diagnosis and antecedent events. Results. Thirty-nine patients with GBS were included: nine (23.1%) were diagnosed with GBS-S. GBS-S was most frequent in 2020 (6/13, 46.1%). Most of these patients developed a postinfectious classic demyelinating variant (4/9, 44.4%) with frequent bilateral facial paralysis (4/9, 44.4%). Serum antiganglioside antibodies (AGAs) were found in 1/9 patients with GBS-S. Serum anti-SSA/Ro60 antibodies were highly prevalent in GBS-S (7/9 (77.8%) vs. 3/11 (27.3%),
). Three cases associated with SARS-CoV-2 vaccination (GBS-V) were detected. Of note, two had bilateral facial paralysis and anti-SSA/Ro60 antibodies. Conclusion. Our findings suggest that SARS-CoV-2 has become an important antecedent event associated with GBS in our setting. GBS-S shows a postinfectious demyelinating immune-mediated profile with negative serological testing for AGAs. Serum anti-SSA/Ro60 antibodies were found frequently in these patients. Bilateral facial paralysis stands out as a possible characteristic clinical feature both in GBS-S and GBS-V. Larger, prospective studies are needed for a better understanding of its immunopathogenesis.
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Wu Z, Wang D, Chen L, Xianyu K, Yang H. Analysis of clinical features and risk factors of peripheral neuropathy in patients with primary Sjögren's syndrome. Eur J Med Res 2023; 28:54. [PMID: 36717930 PMCID: PMC9885688 DOI: 10.1186/s40001-023-01013-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/12/2023] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To observe the clinical features and efficacy of immunosuppressive therapy in patients with primary Sjögren's syndrome (PSS) combined with peripheral neuropathy (PN) syndrome and to explore the risk factors for PN in patients with PSS. METHODS Sixty consecutive patients with PSS admitted to the Department of Rheumatology and Immunology, Wuhan No. 1 Hospital, from January 2014 to June 2020 were analysed retrospectively. Patients were divided into a PN group (N = 15) and a non-PN group (N = 45). The clinical characteristics of the two groups were compared, and the independent risk factors for PN combined with PSS were analysed by multivariate logistic regression. The patients with PSS combined with PN were followed up to observe the effect of immunosuppressive therapy. RESULTS The patients with PN had a longer course of disease than those without PN (z = - 3.225, P = 0.001), and the incidence of Raynaud's phenomenon, anti-SSB antibody, rheumatoid factor and hyperglobulinaemia was higher (all P < 0.05) in patients with PN than in those without PN. Multivariate logistic regression analysis showed that hyperglobulinaemia, RF and anti-SSB antibodies were independent risk factors for PN with PSS (P < 0.05). Fourteen patients with PSS-PN were treated with immunosuppressants. The clinical symptoms of 10 patients were relieved, and mRS scores of 10 patients were decreased. CONCLUSION PN is a common complication in PSS patients. Patients with PSS combined with PN have a longer course of disease and a significantly higher percentage of Raynaud's phenomenon, positive anti-SSB antibody, positive RF and hyperglobulinaemia. Immunosuppressive therapy was effective for partial remission of PN with PSS.
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Affiliation(s)
- Zhihong Wu
- grid.33199.310000 0004 0368 7223Department of Rheumatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dong Wang
- grid.33199.310000 0004 0368 7223Department of Cardiology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lirong Chen
- grid.33199.310000 0004 0368 7223Department of Rheumatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kaipu Xianyu
- grid.33199.310000 0004 0368 7223Department of Rheumatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huiqing Yang
- grid.33199.310000 0004 0368 7223Department of Rheumatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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9
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Liampas A, Parperis K, Erotocritou MF, Nteveros A, Papadopoulou M, Moschovos C, Akil M, Coaccioli S, Hadjigeorgiou GM, Hadjivassiliou M, Zis P. Primary Sjögren syndrome-related peripheral neuropathy: A systematic review and meta-analysis. Eur J Neurol 2023; 30:255-265. [PMID: 36086910 PMCID: PMC10087501 DOI: 10.1111/ene.15555] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Primary Sjögren syndrome (pSS) is a chronic, systemic, autoimmune disorder characterized by lymphocytic infiltrates of the exocrine organs, leading to sicca symptoms and parotid enlargement. pSS has been linked to various neurological manifestations, including peripheral neuropathy (PN). We aimed to provide a comprehensive analysis of the currently available evidence regarding pSS-related PN. METHODS A literature search in the PubMed database was performed, and 49 papers were eligible to be included in this systematic review and meta-analysis. RESULTS The pooled prevalence of PN in pSS is estimated to be 15.0% (95% confidence interval = 10.7%-20.7%). The mean age of pSS patients at PN diagnosis is 59 years. Among the patients with pSS and PN, 83% are females. Neuropathic symptoms usually precede or lead to the pSS diagnosis at a 2:1 ratio in patients with pSS-related PN. The commonest type of pSS-related PN is distal axonal polyneuropathy (80% of patients with pSS-related PN), followed by sensory ganglionopathy. Peripheral and cranial mononeuropathies-particularly trigeminal-are also frequent. Risk factors for developing PN include increasing age and presence of vasculitis. Immune-mediated pathogenetic mechanisms are discussed. Glucocorticoids are the most commonly used treatment option for managing pSS-related PN, when associated with vasculitis, followed by the use of intravenous immunoglobulin. CONCLUSIONS PN is very common in pSS patients. Evidence on long-term prognosis of PN in pSS is limited, and further research is needed. Research into the use of immunosuppressive medication in nonvasculitic neuropathies in the context of pSS merits further consideration.
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Affiliation(s)
- Andreas Liampas
- Medical School, University of Cyprus, Nicosia, Cyprus.,Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | | | | | | | - Marianna Papadopoulou
- Department of Physiotherapy, Laboratory of Neuromuscular and Cardiovascular Study of Motion, University of West Attica, Egaleo, Greece
| | - Christos Moschovos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Mohammed Akil
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Stefano Coaccioli
- European League Against Pain, Zurich, Switzerland.,Department of Internal Medicine, Perugia University, Perugia, Italy
| | - Georgios M Hadjigeorgiou
- Medical School, University of Cyprus, Nicosia, Cyprus.,Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus
| | | | - Panagiotis Zis
- Medical School, University of Cyprus, Nicosia, Cyprus.,Department of Neurology, Nicosia General Hospital, Nicosia, Cyprus.,Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Medical School, University of Sheffield, Sheffield, UK
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10
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Appenzeller S, Andrade de Oliveira S, Bombini MF, Sepresse SR, Reis F, Cavalcante França Junior M. Neuropsychiatric manifestations in primary Sjogren syndrome. Expert Rev Clin Immunol 2022; 18:1071-1081. [PMID: 36001085 DOI: 10.1080/1744666x.2022.2117159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Neurologic manifestations in primary Sjogren´s Syndrome (pSS) are characterized by a heterogeneity of clinical manifestations. In clinical practice, physicians are challenged with the absence of diagnostic criteria and the lack of clinical trials to support treatment. In this article, we will review epidemiology, clinical and immunological characterization, diagnosis and treatment of neurologic events in pSS. AREAS COVERED This narrative review provides an overview of neurologic manifestations described in pSS, complementary investigations and treatment reported. Articles were selected from Pubmed searches conducted between December 2021 and February 2022. EXPERT OPINION Epidemiology and clinical features of neurologic manifestations are derived from different cohort studies. Our understanding of pathophysiology of neurologic manifestations in pSS has significantly increased in the past few years, especially regarding PNS. However, there are still many knowledge gaps on therapeutics. The few available data on therapy rely upon small case series, from experiences with other autoimmune disease, such as systemic lupus erythematosus or expert opinion. There is an urgent need for well-designed clinical trials.
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Affiliation(s)
- Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas
| | | | | | | | - Fabiano Reis
- Department of Radiology, School of Medical Science, University of Campinas
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Lenti MV, Rossi CM, Melazzini F, Gastaldi M, Bugatti S, Rotondi M, Bianchi PI, Gentile A, Chiovato L, Montecucco C, Corazza GR, Di Sabatino A. Seronegative autoimmune diseases: A challenging diagnosis. Autoimmun Rev 2022; 21:103143. [PMID: 35840037 DOI: 10.1016/j.autrev.2022.103143] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/10/2022] [Indexed: 12/19/2022]
Abstract
Autoimmune diseases (AID) are increasingly prevalent conditions which comprise more than 100 distinct clinical entities that are responsible for a great disease burden worldwide. The early recognition of these diseases is key for preventing their complications and for tailoring proper management. In most cases, autoantibodies, regardless of their potential pathogenetic role, can be detected in the serum of patients with AID, helping clinicians in making a definitive diagnosis and allowing screening strategies for early -and sometimes pre-clinical- diagnosis. Despite their undoubted crucial role, in a minority of cases, patients with AID may not show any autoantibody, a condition that is referred to as seronegative AID. Suboptimal accuracy of the available laboratory tests, antibody absorption, immunosuppressive therapy, immunodeficiencies, antigen exhaustion, and immunosenescence are the main possible determinants of seronegative AID. Indeed, in seronegative AID, the diagnosis is more challenging and must rely on clinical features and on other available tests, often including histopathological evaluation and radiological diagnostic tests. In this review, we critically dissect, in a narrative fashion, the possible causes of seronegativity, as well as the diagnostic and management implications, in several AID including autoimmune gastritis, celiac disease, autoimmune liver disease, rheumatoid arthritis, autoimmune encephalitis, myasthenia gravis, Sjögren's syndrome, antiphospholipid syndrome, and autoimmune thyroid diseases.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Carlo Maria Rossi
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Federica Melazzini
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Serena Bugatti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Unit of Rheumatology, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Mario Rotondi
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
| | - Paola Ilaria Bianchi
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Antonella Gentile
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Luca Chiovato
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Pavia, Italy
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Unit of Rheumatology, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy.
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Lin L, Hang H, Zhang J, Lu J, Chen D, Shi J. Clinical significance of anti-SSA/Ro antibody in Neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 2022; 58:103494. [PMID: 35051897 DOI: 10.1016/j.msard.2022.103494] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/19/2021] [Accepted: 01/01/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune inflammatory disease of the central nervous system (CNS), also described as CNS autoimmune astrocytopathy, due to the production of pathogenic antibodies against aquaporin-4 (AQP4) expressed on the foot of astrocytes. NMOSD coexists with autoimmune diseases and related autoantibodies [anti-Sjogren's syndrome A (anti-SSA)/Ro antibody, anti-Sjogren's syndrome B (anti-SSB)/La antibody, anti-nuclear (anti-ANA) antibodies, anti-double-stranded DNA (anti-dsDNA) antibody, anti-thyroglobulin antibody, and anti-thyroid peroxidase antibody]. OBJECTIVES No precise conclusion has been drawn on the role of the anti-SSA/Ro antibody in NMOSD. Therefore, the aim of this work was to evaluate whether the anti-SSA/Ro antibody has an impact on the clinical manifestation or prognosis of NMOSD. METHODS Data were retrospectively collected from 102 patients with NMOSD diagnosed by experienced neurologists. The study population was divided into two groups based on the serum anti-SSA/Ro antibody status: NMOSD with or without anti-SSA/Ro antibody. The clinical, neuroimaging and laboratory parameters were compared between the two groups, including the neurological symptoms, MRI results, frequency of systemic autoantibodies, Expanded Disability Status Scale (EDSS), and NMOSD relapse rate. The EDSS and relapse were applied as measures of the NMOSD patient prognostic value. Cox regression analysis was used to evaluate the prognostic impact of anti-SSA/Ro antibody on NMOSD. RESULTS Among the 102 NMOSD patients, striking differences were observed in the positive rate of AQP4-IgG (89.2% vs. 72.3%, p = 0.046) between those patients with and without the anti-SSA/Ro antibody. In addition, NMOSD patients with anti-SSA/Ro antibody showed the presence of more frequent anti-ANA antibodies (p = 0.002), anti-SSB/La antibody (p < 0.001), anti-dsDNA antibody (p < 0.002), Sjogren's syndrome (SS, p < 0.001) and systemic lupus erythematosus (SLE, p = 0.045). Univariate and multivariate Cox regression analysis were performed to confirm that the anti-SSA/Ro antibody affected the EDSS score and the relapse of NMOSD patients. The analysis of the survival curve revealed that the EDSS score in the NMOSD patients positive for the anti-SSA/Ro antibody reached 4.0 (p = 0.035) and relapsed (p = 0.039) earlier than in the negative group. CONCLUSION The anti-SSA/Ro antibody could be associated with disease activity and severe disability in NMOSD.
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Affiliation(s)
- Liuyu Lin
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hailun Hang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jihong Zhang
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jie Lu
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China.
| | - Daowen Chen
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jingping Shi
- Department of Neurology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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