Primary Sjögren's Syndrome

Assessment of the potential impact of polymorphisms in the Foxp3 and CTLA-4 genes in immune balance and disease susceptibility of primary Sjögren's syndrome

BACKGROUND

Regulatory T (Treg) cell depletion-associated immune tolerance deficiency have been shown to play a key role in the pathogenesis of primary Sjögren's syndrome (pSS). Treg cells mainly express the transcriptional regulator Foxp3 and are characterized by constitutively high expression of inhibitory coreceptor CTLA-4 . Herein, the aim of this study was to investigate the potential association of single nucleotide polymorphisms (SNPs) in Foxp3 and CTLA-4 genes with the susceptibility to pSS.

METHOD

Ninety-nine pSS patients and 93 healthy controls were recruited into the retrospective study. Nuclear DNA was extracted from peripheral blood leukocytes, and SNP alleles were identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

RESULTS

For the Foxp3 gene, the T allele, the TT and GT genotype in rs3761548G/T, the A allele and AA genotype in rs3761549G/A, as well as the C allele and the TC genotype in rs2280883T/C, were preponderant in pSS. Polymorphisms of rs3761548G/T and rs3761549G/A were found to be associated with anemia or leukopenia, while rs2232365T/C was associated with neutropenia, and rs2280883T/C was demonstrated to have a correlation with anti-SSA(+). For the CTLA-4 gene, the C allele and the CC genotype in rs733618T/C were significantly more prevalent in pSS. rs733618T/C polymorphisms varied significantly in anti-SSA(+), anti-SSB(+) and leukopenia, and rs16840252T/C was associated with ANA(+). Patients with at least six risk alleles had higher Th17 cells and decreased Treg cell counts, accompanied by elevated Th1/Treg, Th2/Treg, and Th17/Treg ratios. And the phenomenon was also observed in patients with four or more variant genotypes.

CONCLUSION

Polymorphisms in Foxp3 and CTLA-4 genes were associated with the susceptibility to pSS. The greater number of mutant sites and variant genotypes an individual possessed, the more susceptible they became to immune dysregulation.

Sjögren's syndrome and pulmonary hypertension: Exploring the intricate link with interstitial lung disease

BACKGROUND

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease commonly presenting with sicca symptoms and, in approximately one-third of cases, extra-glandular manifestations, including pulmonary involvement. Pulmonary hypertension (pH) is a recognized, though less frequently studied, complication in pSS, particularly in patients with interstitial lung disease (ILD). This study evaluates the prevalence of PH in pSS and the relationship between ILD and cardiovascular risk in this population.

METHODS

This cross-sectional study included 63 patients with pSS, diagnosed according to ACR/EULAR criteria. Among them, 24 patients (38.1 %) had ILD, with 9 presenting pulmonary fibrosis. Comprehensive evaluations were conducted, including 2D/3D echocardiography, HRCT, and pulmonary function tests. Right heart catheterization confirmed PH when indicated. Patients were categorized into pSS-ILD and pSS-noILD groups for comparative analysis.

RESULTS

The cohort comprised 7 males (11.1 %) and 56 females (88.9 %), with a mean age of 69.1 ± 12.5 years. The prevalence of PH was low (1.6 %), with only one confirmed case via right heart catheterization, significantly below previous reports. Notably, pSS-ILD patients were older (77.1 ± 10.7 years) and diagnosed with pSS later (68.5 ± 12.6 years; p = 0.001) than pSS-noILD patients. Cardiovascular comorbidities, including arterial hypertension (32.8 %) and dyslipidemia (24.2 %), were more prevalent in pSS-ILD patients (p = 0.003 and p = 0.001, respectively). Pulmonary function tests revealed lower FVC (2.23 ± 0.70 vs. 2.98 ± 0.56; p = 0.004) and DLCO-Sb (3.87 ± 1.52 vs. 5.31 ± 1.26; p = 0.017) in pSS-ILD patients, indicating reduced lung function. Echocardiographic findings showed higher sPAP values (>35 mmHg) and reduced TAPSE/sPAP ratios in the pSS-ILD group (p = 0.028 and p = 0.026, respectively), suggesting early signs of right ventricular impairment.

CONCLUSIONS

PH prevalence in pSS is lower than previously reported, likely due to rigorous diagnostic criteria. Patients with pSS-ILD exhibit a higher risk of cardiovascular comorbidities and lung function decline. Echocardiographic monitoring of parameters like TAPSE/sPAP may aid in early PH detection, emphasizing the need for tailored management in pSS-ILD patients. Further studies are warranted to explore PH subtypes in diverse populations and to optimize follow-up protocols for at-risk patients.

Is high IgG level associated with disease activity and organ damage in patients with Sjögren's syndrome? A 3-year follow-up cohort study

Hypergammaglobulinemia is prevalent in primary Sjögren's syndrome (pSS) and is considered a marker of disease activity. However, limited data exist regarding its association with disease activity and organ damage. We enrolled patients with pSS from the Chinese Rheumatism Data Centre and categorized them into four groups based on the IgG levels over a 3-year follow-up: consistently high, consistently intermediate, consistently normal, and intermittent. Disease activity and organ damage at the end of the third year were compared across these groups. A total of 351 patients were included in this study, all females with a median age of 45 (IQR 35-53) years. The median baseline IgG was 17.2 (IQR 13.4-21.4) g/L. About 40% of the patients with elevated baseline IgG levels remained in the consistently high or intermediate IgG group. Compared to patients with consistently normal IgG levels, those with consistently high IgG levels had higher median SSDDI scores (2 vs. 1, p = 0.014), higher median ESSPRI scores (2.5 vs. 1.7, p = 0.005), more extra-glandular organ manifestations (IRR 2.34, 95%CI 1.48-3.7, p = < 0.001), and more extra-glandular organ damage (IRR 2.06, 95%CI 1.03-4.12, p = 0.040) at the third-year follow-up. No significant differences in extra-glandular involvement were found between the consistently intermediate IgG group and the consistently normal IgG group. The consistently high IgG level, but not the consistently intermediate level, was associated with a greater number of extra-glandular manifestations and increased extra-glandular organ damage.

Positive thyroid autoantibodies in primary Sjögren syndrome define a subset of patients with milder disease

OBJECTIVE

To investigate the prevalence, clinical and immune characteristics of patients with primary Sjögren syndrome (pSjS) with positive thyroid autoantibodies (TABs) in Chinese population.

METHODS

391 cases of pSjS were retrospectively analyzed. Patients with positive thyroid autoantibodies (TABs), the presence of either thyroglobulin antibody (TG-Ab), thyroid peroxidase antibody (TPO-Ab), or thyrotropin receptor antibody (TR-Ab), or any combination of these were defined as positive TABs group, and patients without any TABs were defined as negative TABs group. The clinical manifestations and laboratory results were compared between the two groups.

RESULTS

Among the 391 pSjS patients, the TABs were positive in 32.99% (129/391) patients. In the positive TABs group, the prevalence of Raynaud phenomenon was higher, the prevalence of interstitial lung disease (ILD) and low complement 4 (C4) level were significantly lower. Additionally, the levels of serum globulin, immunoglobulin (Ig) G and IgM were higher compared with patients with negative TABs. Age, ILD, RF and anti-SSA were negatively correlated with the coexistence of TABs, while C-reactive protein (CRP) was positively correlated.

CONCLUSION

PSjS was closely related to autoimmune thyroid abnormalities. The prevalence of autoimmune thyroid diseases (AITDs) and TABs in pSjS was high, pSjS patients with positive TABs might represent a milder subset of the disease with a better prognosis with low risk of ILD. Key Points • PSjS was closely related to autoimmune thyroid abnormalities, the prevalence of autoimmune thyroid diseases (AITDs) and TABs in pSjS were high. • The prevalence of interstitial lung disease (ILD) and low complement 4 (C4) level were significantly lower in the positive TABs group. PSjS patients with positive TABs may represent a milder subset of the disease with a better prognosis.

The Causal Relationship Between Serum Metabolites and Sjogren's Syndrome: A Mendelian Randomization Study

Aims/Background Sjogren's syndrome (SS) is a highly prevalent autoimmune disease with potentially serious consequences if left untreated, but methods for early detection and prevention of SS remain limited. This study aims to investigate the causal relationships between serum metabolites and SS using Mendelian randomization (MR), focusing on identifying key metabolic pathways and biomarkers that contribute to SS pathogenesis. Methods We used a two-sample MR approach to investigate the causal relationships between serum metabolites and SS. The primary method for estimating these causal effects was inverse variance weighting (IVW), with results presented alongside their corresponding 95% confidence intervals (CIs). Sensitivity analyses included the Cochran's Q statistical analysis and MR-Egger method. Furthermore, an enrichment analysis of metabolic pathways was applied to the identified metabolites. Results Thirty-seven serum metabolites that have causal links with SS, encompassing 7 metabolite ratios and 30 single metabolites (4 unknown and 26 known), were identified. Metabolite ratios, reflecting the balance between specific metabolites, were analyzed to identify metabolic shifts that may contribute to SS pathogenesis. Among the 26 known metabolites, 12 are protective factors and 14 are risk factors. The levels of cis-4-decenoate (cDA) (10:1n6) (odds ratio [OR] = 1.125; 95% CI = 1.026-1.233; p = 0.012) is positively correlated with the incidence of SS, whereas the levels of butyrate/isobutyrate (4:0) (OR = 0.822; 95% CI = 0.701-0.963; p = 0.016) are negatively correlated with the SS incidence. Most of these metabolites are associated with lipid and amino acid metabolism. Among lipids, the strongest risk-increasing factor was 2,3-dihydroxy-2-methylbutyrate (OR = 1.307; 95% CI = 1.054-1.621; p = 0.015), while the strongest risk-decreasing factor was hexadecadienoate (16:2n6) (OR = 0.774; 95% CI = 0.635-0.944; p = 0.011). Among amino acids, the strongest risk-increasing factor was N-acetylproline (OR = 1.178; 95% CI = 1.024-1.355; p = 0.022), and the strongest risk-decreasing factor was N-acetylserine (OR = 0.802; 95% CI = 0.694-0.926; p = 0.003). Furthermore, these metabolites are predominantly enriched in the arginine and proline metabolism pathway. Conclusion This study helped enhance our comprehension of the causal relationship between serum metabolites and SS, showing that some metabolites may influence the risk and development of this disease. These insights offer novel perspectives for the development of SS prediction and diagnosis.

Development of salivary gland organoids derived from patient biopsies: a functional model of Sjögren's disease

OBJECTIVES

Salivary gland epithelial cells (SGECs) play a key role in Sjögren's disease (SjD) as an active contributor to the pathogenesis. Current models lack clear epithelial readouts. Our aim was to establish a more advanced model by developing salivary gland organoids (SGOs) from labial salivary gland biopsies (LSGBs) of SjD patients and sicca controls.

METHODS

We included SjD patients fulfilling the American College of Rheumatology/European League Against Rheumatism 2016 criteria and sicca controls. LSGBs were dissociated, encapsulated in extracellular matrix, and submerged in growth expansion medium for long-term culture. SGOs were primarily cultured in differentiation medium and then transferred to a low attachment plate to form differentiated SGOs (DIF-SGOs).

RESULTS

We included 13 SjD and 15 controls. In both groups, SGOs were formed, demonstrating long-term culture viability and comparable self-renewal capacity (3.3 ± 1.7 months). DIF-SGOs comparably exhibited mature acinar (aquaporin 5, amylase), ductal (cytokeratins 5 and 7) and myoepithelial (α-smooth muscle actin) markers in both groups. DIF-SGOs were responsive to inflammation by expressing BAFF, CXCL10 and IL7 upon stimulation with poly(I:C) and interferon-α. DIF-SGOs also demonstrated a swelling response to cholinergic stimulation by pilocarpine. We observed significant differences between SjD- and control-derived SGOs. Notably, SjD-derived DIF-SGOs consistently maintained a persistent interferon signature throughout long-term culture. In addition, the swelling capacity was reduced in SjD-derived DIF-SGOs compared to control. However, treatment with tofacitinib enhanced the swelling ability, suggesting a potential effect on saliva production.

CONCLUSIONS

We successfully developed SGOs from LSGBs of SjD patients, allowing long-term culture and faithfully recapitulating the disease phenotype. This model holds promise as a valuable tool for drug screening.

Cancer in connective tissue disease

The association between cancer and autoimmunity is well-recognized, as represented by the increased incidence of cancer among patients with systemic autoimmune diseases; however, the underlying mechanisms remain only partially understood. On the one hand, malignancy may trigger a breakdown of immune tolerance in predisposed individuals, as autoimmune syndromes often emerge shortly after cancer diagnosis, suggesting that tumor antigens might initiate an autoimmune response. However, by involving persistent responses and the creation of a pro-inflammatory environment, the chronic immune activation characteristic of autoimmunity may promote oncogenesis. This scenario is further complicated by the use of immunosuppressive therapies for autoimmune conditions, which, as seen in transplant immunology, are associated with a higher risk of cancer, although data in rheumatology have not yielded definitive conclusions. Connective tissue diseases include systemic lupus erythematosus, primary Sjögren syndrome, idiopathic inflammatory myopathies, systemic sclerosis, mixed connective tissue disease, and undifferentiated forms. These conditions have been variably associated with an increased risk of cancer, both at the time of disease onset and in patients with long-standing autoimmune conditions, providing a paradigm for investigating this complex interplay. Despite recent progress, many unmet needs remain that warrant further research.

Integrated stress response inhibition restores hsa-miR-145-5p levels after IFN-β stimulation in salivary gland epithelial cells. Association between cellular stress and miRNA biogenesis in Sjögren's disease

Labial salivary glands (LSG) from Sjögren's disease (SjD) patients are characterized by increased levels of pro-inflammatory cytokines, such as type I interferons (IFN-I). These LSG also show activation of the integrated stress response (ISR) with overexpression of protein kinase R (PKR), a known IFN-stimulated gene. In vitro, IFN-I stimulation reproduces the downregulation of hsa-miR-145-5p, which is associated with TLR4 overexpression observed in LSG of SjD patients. MicroRNA levels depend on its biogenesis, which is a multi-step process involving several protein complexes. It is not known whether altered miRNA biogenesis is associated with the activation of the ISR induced by IFN-I in LSG from SjD. The aim of this study was to characterize the expression and localization of components of the miRNA biogenesis machinery in LSG of SjD patients, to assess the effect of pro-inflammatory cytokines on these components, and to test whether inhibition of the IFN-β-induced ISR restores the levels of hsa-miR-145-5p. In LSG from 12 SjD patients and 11 non-SjD sicca controls, we determined mRNA fold changes, relative protein levels, and the localization of the ISR and miRNA biogenesis machinery components by RT-qPCR, Western blot, and immunofluorescence, respectively. Pro-inflammatory cytokines, the ISR inhibitor ISRIB, and the PKR inhibitor C16 were used for in vitro assays. In LSG from SjD patients, PKR and its activator PACT colocalized in the cytoplasm, whereas the PKR inhibitor TRBP was observed in the nuclei. IFN-β activates PKR, increases p-eIF2α and ATF4 levels, and increases PACT and AGO2 detection in stress granules. C16 inhibits PKR phosphorylation but increases ATF4 by activating GCN2. ISRIB restores levels of hsa-miR-145-5p and its target TLR4 mRNA upon IFN-β stimulation. These findings suggest an association between inflammation, cellular stress, and miRNA biogenesis, where modulation of the ISR emerges as a potential strategy to restore cellular homeostasis in LSG from SjD patients.

Clinical targeted treatment in Sjogren's disease: A systematic literature review for an evidence-based medicine approach

Sjögren's disease is a systemic autoimmune disease that primarily affects the exocrine glands, causing the main symptoms of xerostomia and xerophthalmia. In about half of the patients, it also causes systemic symptoms, which can potentially involve any organ or system. To date, the management of these patients is particularly complex due to the lack of recognized and approved therapies for the disease, except for medications used as symptomatic treatment for dryness. Due to the limited evidence available, therapeutic decisions in daily practice are frequently based on a combination of expert opinions and personal experience, which can vary significantly between clinicians. On these bases, we performed as systematic literature review critically analyzing the results of the previous trials, unpacking the single domains of ESSDAI, to evaluate if there are treatments significantly effective in some manifestations of the disease.

Integrative gut microbiota, metabolomics and proteomics studies unraveled the mechanism of Shaoteng decoction in treating Sjogren's syndrome

BACKGROUND

Sjögren's syndrome (SS) is a complicated autoimmune disorder, encompassing multifaceted pathogenesis of inflammatory response, immune dysregulation and metabolic abnormalities. Shaoteng Decoction (STD) is a type of traditional Chinese medicine preparation that has been shown to effectively improve inflammatory damage and immune dysfunction in patients with SS. Nevertheless, the exact mechanism has not been unspecified.

PURPOSE

This work aims to determine the mechanism of STD treatment on SS, identifying potential therapeutic targets and their relationships.

METHODS

Non-obese diabetic mice served as a disease model. This study analyzes potential signaling pathways of STD treatment for SS through network pharmacology, and assesses the role of STD in reducing inflammatory damage using pathological staining, ELISA, and immunohistochemistry. Additionally, the study apply gut microbiota, metabolomics, and proteomics analyses to identify the key microbiota, metabolites and proteins, aiming to find potential action targets of STD. We use Western blotting and immunohistochemistry to verify the authenticity of the relevant targets and study the interactions among gut microbiota, metabolites, and proteins.

RESULTS

Proteobacteria is the important intestinal bacteria, Bile Acid Biosynthesis is the main metabolic pathway, IfI30, Ndufv3, and Ndufs6 are the crucial differential expressed proteins. Moreover, there is a strong correlation among the three. STD treats SS by reducing the abundance of Proteobacteria, increasing Bile Acid Biosynthesis, decreasing IfI30 expression, and increasing the expression of Ndufv3 and Ndufs6.

CONCLUSION

STD inhibits inflammatory responses, improves immune dysregulation and energy metabolism abnormalities, and prevents the progression of SS through regulating the gut microbiota, enhancing Bile Acid Biosynthesis, and modulating proteins expression levels.

Clinical Progress in Mesenchymal Stem Cell Therapy: A Focus on Rheumatic Diseases

BACKGROUND

Rheumatic diseases are chronic immune-mediated disorders affecting multiple organ systems and significantly impairing patients' quality of life. Current treatments primarily provide symptomatic relief without offering a cure. Mesenchymal stem cells (MSCs) have emerged as a promising therapeutic option due to their ability to differentiate into various cell types and their immunomodulatory, anti-inflammatory, and regenerative properties. This review aims to summarize the clinical progress of MSC therapy in rheumatic diseases, highlight key findings from preclinical and clinical studies, and discuss challenges and future directions.

METHODOLOGY

A comprehensive review of preclinical and clinical studies on MSC therapy in rheumatic diseases, including systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteoporosis, Sjögren's syndrome, Crohn's disease, fibromyalgia, systemic sclerosis, dermatomyositis, and polymyositis, was conducted. Emerging strategies to enhance MSC efficacy and overcome current limitations were also analyzed.

RESULTS AND DISCUSSION

Evidence from preclinical and clinical studies suggests that MSC therapy can reduce inflammation, modulate immune responses, and promote tissue repair in various rheumatic diseases. Clinical trials have demonstrated potential benefits, including symptom relief and disease progression delay. However, challenges such as variability in treatment response, optimal cell source and dosing, long-term safety concerns, and regulatory hurdles remain significant barriers to clinical translation. Standardized protocols and further research are required to optimize MSC application.

CONCLUSION

MSC therapy holds promise for managing rheumatic diseases, offering potential disease-modifying effects beyond conventional treatments. However, large-scale, well-controlled clinical trials are essential to establish efficacy, safety, and long-term therapeutic potential. Addressing current limitations through optimized treatment protocols and regulatory frameworks will be key to its successful integration into clinical practice.

The role of fatty acid metabolism on B cells and B cell-related autoimmune diseases

Fatty acid metabolism plays a critical role in regulating immune cell function, including B cells, which are central to humoral immunity and the pathogenesis of autoimmune diseases. Emerging evidence suggests that fatty acid metabolism influences B cell development, activation, differentiation, and antibody production, thereby impacting B cell-related autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and multiple sclerosis (MS). In this review, we discuss the mechanisms by which fatty acid metabolism modulates B cell biology, including energy provision, membrane composition, and signaling pathways. We highlight how alterations in fatty acid synthesis, oxidation, and uptake affect B cell function and contribute to autoimmune pathogenesis. Additionally, we explore the therapeutic potential of targeting fatty acid metabolism in B cells to treat autoimmune diseases. Understanding the interplay between fatty acid metabolism and B cell immunity may provide novel insights into the development of precision therapies for B cell-mediated autoimmune disorders.

CCR5 + T cells as a potential biomarker for primary Sjögren's disease based on bioinformatics analysis

OBJECTIVE

To identify and verify potential biomarkers for primary Sjögren's disease (pSjD) using bioinformatics analysis and explore the molecular immune mechanisms of biomarkers.male-to-female ratio of 1:9 METHODS: The pSjD datasets were downloaded from the Gene Expression Omnibus (GEO) database. Differential expression analysis, weighted gene co-expression network analysis (WGCNA) and functional analysis were conducted. PPI network analysis was performed and the hub genes were screened by Cytoscape software. The diagnostic value was assessed by receiver operating characteristic (ROC) analysis. To explore biomarker-immune cell relations, we used CIBERSORT for cell-type identification, combined with scRNA-seq data. Lastly, we validated the expression of the biomarker in human samples.

RESULTS

A total of 96 overlapping genes, including 1 downregulated and 95 upregulated genes, were obtained. Based on the enrichment analysis, these overlapping genes were mapped to terms related to the functions and regulation of the immune system. CCR5 was identified as a critical biomarker and demonstrated high diagnostic accuracy for pSjD. From CIBERSORT analysis, CCR5 was significantly associated with diverse immune cells. Further scRNA-seq analysis indicated that CCR5 was specifically upregulated in T cells of pSjD salivary gland tissues, which was confirmed in pSjD patients.

CONCLUSION

Our findings show the role of CCR5 in pSjD, mediated by immune mechanisms. CCR5 is localized in T cells of pSjD salivary glands. Elevated CCR5 expression may be a key biomarker, and increased CCR5 + T cells could aid future diagnosis, prognosis, and treatment of pSjD.

Route of Application and Dose Evaluation of Dental Pulp Stem Cells for the Treatment of Sialadenitis Caused by Sjögren's Syndrome: A Preclinical Study

Background: Sjögren's syndrome (SS) is an autoimmune disorder characterized by sicca syndrome and/or systemic manifestations. In this study, non-obese diabetic (NOD) mice were used as an animal model for studying SS, to evaluate the optimal administration route and dose range of dental pulp stem cells (DPSCs) in the treatment of sialadenitis caused by SS. Methods: Different doses of DPSCs were transplanted into the submandibular glands (SMGs) of 14-week-old NOD mice through two different methods: injection or retrograde perfusion through the catheter orifice into the SMG. At 21 weeks of age, the saliva flow rate (SFR), ectopic lymphocytes, and CD4+ T-cell infiltration were measured. Tumor necrosis factor-alpha (TNF-α) and interferon-gamma (IFN-γ) in the glandular tissues were also quantitatively detected. Results: Compared with untreated and PBS-injected controls, different-dose groups of the two administration methods showed an increased saliva flow rate of NOD mice to varying degrees, reduced infiltration of lymphocytes and CD4+ T cells in the SMG, and decreased IFN-γ/TNF-α levels. Finally, we compared these two administration routes and found that the perfusion of 2 × 105 DPSCs presents good therapeutic effects. Conclusions: DPSC perfusion through the catheter orifice is a simple and effective treatment method, which is worthy of further investigation through clinical trials.

Overlap Syndrome of Primary Sjögren Syndrome with Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis Based on the American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) Criteria

Background/Objectives: The overlap syndrome of primary Sjögren syndrome (pSS) with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) (OvSD/pSS/AAV) has been reported in other studies. This study applied the new criteria for AAV proposed by the American College of Rheumatology/European Alliance of Associations for Rheumatology in 2022 (the ACR/EULAR criteria) to patients with pSS presenting signs and symptoms suggestive of small- and medium-vessel vasculitis. It also investigated the overall frequency of OvSD/pSS/AAV and the major contributing factors to its reclassification. Methods: This study included 116 patients with pSS from March 2005 to December 2020, according to the inclusion criteria, and defined signs and symptoms suggestive of small- or medium-vessel vasculitides as lung parenchymal lesions supporting AAV, peripheral neuropathy, and suspected renal vasculitis. The classification could be made when the total scores for microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are ≥5 points and the eosinophilic GPA (EGPA) score is ≥6 points. Results: The median age of the patients was 56.0 years, and 101 patients (87.1%) were women. In total, 95, 12, and 37 patients had lung parenchymal lesions supporting AAV, peripheral neuropathy, and suspected renal vasculitis, respectively. According to the ACR/EULAR criteria for AAV, 35 of 116 (30.2%) patients were reclassified as having OvSD/pSS/AAV. Among these 35 patients, 4 were reclassified as having both OvSD/pSS/MPA and OvSD/pSS/GPA and 1 as having both OvSD/pSS/MPA and OvSD/pSS/EGPA simultaneously. The major contributing factor to the reclassification of OvSD/pSS/AAV was ANCA positivity. Conclusions: The overall frequency of the reclassification of OvSD/pSS/AAV was 30.2% in pSS patients presenting signs and symptoms suggestive of small- and medium-vessel vasculitis. Its likelihood increased according to ANCA positivity.

Hydroxychloroquine dose-dependently reduces the risk of incident diabetes in primary Sjögren syndrome patients on glucocorticoids: a nationwide population-based cohort study

BACKGROUND

Hydroxychloroquine (HCQ) is commonly used to treat Sjögren syndrome (SS). Glucocorticoids, which are commonly applied for managing primary SS (pSS), can disrupt glucose metabolism and increase diabetes mellitus (DM) risk. HCQ reduces DM risk in systemic lupus erythematosus and rheumatoid arthritis.

OBJECTIVE

This study aimed to investigate the relationship between HCQ and glucocorticoids in the incidence of new-onset diabetes in pSS.

METHODS

This nationwide population-based cohort study identified patients diagnosed with pSS from the Taiwan's National Health Insurance Research Database from 2006 to 2015. Multivariate and stratified analyses, Kaplan-Meier method, and Cox proportional hazard regression were used to evaluate DM risk associated with the use of HCQ and glucocorticoid, both individually and in combination.

RESULTS

Among pSS patients (4,874 HCQ users and 2,437 HCQ nonusers), 497 patients developed DM over an average follow-up of 4.89 years. Multivariate analysis revealed significantly lower adjusted hazard ratios (aHRs) for DM in HCQ users in the 151-350 cumulative defined daily dose (cDDD) and ≥ 351 cDDD subgroups (0.600, 95% CI: 0.454-0.794 and 0.326, 95% CI: 0.246-0.433, respectively) compared with HCQ nonusers. High-dose glucocorticoids (≥ 151 cDDD) were linked to increased DM risk (aHR: 1.833, 95% CI: 1.410-2.383). However, high-dose HCQ (> 350 cDDD) mitigated this risk, even the risk caused by the use of high-dose glucocorticoids (≥ 151 cDDD) (aHR: 0.632, 95% CI: 0.421-0.948, P < 0.01).

CONCLUSIONS

Our study demonstrated that HCQ exposure significantly reduces the risk of developing diabetes in patients with pSS. While higher doses of glucocorticoids are associated with an increased diabetes risk, concurrent HCQ use mitigates this risk in a dose-dependent manner.

Value of combined application of the OMERACT scoring system and shear wave elastography for primary Sjögren's syndrome

OBJECTIVE

To assess diagnostic efficiency when introduce the OMERACT scoring system and shear wave elastography (SWE) into ACR/EULAR criteria for primary Sjögren's syndrome (pSS).

METHODS

One hundred fifteen patients with suspected pSS were enrolled, including 71 pSS and 44 non-pSS patients. Salivary gland ultrasonography (SGUS) was performed on parotid glands (PG) and submandibular glands to obtain the OMERACT scores (range 0-3 for single gland) and SWE values, and diagnostic efficiency was evaluated.

RESULTS

Receiver operating characteristic curves showed that the total OMERACT score of four glands and PG SWE had optimal predictive value for pSS (area under the curve (AUC) = 0.848, 0.852), with cutoff values of 8 and 6.8 kPa, sensitivities of 76.1% and 80.3%, specificities of 86.4% and 81.8%. In addition, the total OMERACT score of 10 and PG SWE value of 9.1 kPa were chosen to get high specificities (97.7% for both). By combining SGUS with current items except labial salivary gland biopsy (LSGB), a modified model was proposed. The modified model significantly distinguished pSS patients form non-pSS patients (AUC = 0.963), provided a sensitivity of 97.2% and specificity of 84.1%. It showed an excellent agreement with ACR/EULAR criteria (Kappa = 0.831, p < 0.001), and no statistical difference in diagnostic performance was observed (p = 0.180).

CONCLUSION

An ultrasound-integrated diagnosis model with comparable diagnostic efficiency was established by introducing the OMERACT scoring system and SWE. SGUS is a viable non-invasive adjunct for pSS and has potential to reduce reliance on LSGB for patients with negative anti-SSA/Ro. Key Points • Introducing the OMERACT scoring system and SWE into ACR/EULAR criteria had no negative effect on efficiency. • Inclusion of SGUS in the classification criteria may help reduce invasive LSGB.

The entrenchment of NLRP3 inflammasomes in autoimmune disease-related inflammation

Autoinflammation and autoimmunity are almost "opposite" phenomena characterized by chronic activation of the immune system, 'innate' in the first and 'adaptive' in the second, leading to inflammation of several tissues with specific protean effectors of tissue damage. The mechanism of involvement of multiprotein complexes called 'inflammasomes' within autoimmune pictures, differently from autoinflammatory conditions, is yet undeciphered. In this review we provide a comprehensive overview on NLRP3 inflammasome contribution into the pathogenesis of some autoimmune diseases. In response to autoantibodies against nucleic acids or tissue-specific antigens the NLRP3 inflammasome is activated within dendritic cells and macrophages of patients with systemic lupus erythematosus. Crucial is NLRP3 inflammasome to amplify tissue inflammation with interleukin-1 overexpression and matrix metalloproteinase production at the joint level in rheumatoid arthritis. A deregulated NLRP3 inflammasome activation occurs in the serous acini of salivary and lacrimal glands prone to Sjogren's syndrome, but also in the inflammatory process involving endothelial cells, leucocyte recruitment, and platelet plugging of vasculitides. Furthermore, organ-specific autoimmune diseases such as thyroiditis and hepatitis may display hyperactive NLRP3 inflammasomes at the level of resident immune cells within thyroid or liver, respectively. Therefore, it is not unexpected that preclinical studies have shown how specific inflammasome inhibitors may significantly overthrow the severity of different autoimmune diseases and slow down their trend towards an ominous progression. Specific markers of inflammasome activation could also reveal subclinical inflammatory components escaping conventional diagnostic approaches or improve monitoring of autoimmune diseases and personalizing their treatment.

Pro-Inflammatory Properties of Salivary Gland-Derived Fibroblasts-Implications in Sjögren's Disease

Salivary gland dysfunction is a hallmark of Sjögren's disease (SjD). Here, we investigated the pro-inflammatory properties of salivary gland-derived fibroblasts (SGF) that were cultured from minor salivary gland (MSG) tissues of patients with SjD and controls. SGF from patients with SjD exhibited higher rates of proliferation compared to controls. RNA sequencing revealed pronounced pro-inflammatory properties of SGF in response to stimulation with IL1 and polyI:C, with an activation of "interferon responses", "JAK STAT", and "NF-kappa B" signaling, as well as "complement" pathways. In addition to encoding pro-inflammatory transcripts, stimulated SGF featured increased expression of a number of non-coding enhancer RNAs (eRNAs) that we originally identified in TNF-stimulated synovial fibroblasts (FLS) by CAGE sequencing. We confirmed the expression of selected eRNAs in SGF and FLS through time-course experiments upon stimulation with different pro-inflammatory stimuli using real-time PCR. Furthermore, we detected eRNAs for IL6 (eIL6) and IL8 (eIL8#3) in MSG tissues. Treatment of SGF with the bromodomain inhibitor I-BET suppressed IL1- and LPS-induced expression of all eRNAs tested, as well as their associated pro-inflammatory coding transcripts. Transfection of SGF with antisense nucleotides targeting eCCL20 reduced the LPS-induced expression of this eRNA, as well as CCL20 expression and secretion. Together, our data highlight similarities between SGF and FLS regarding their activation under inflammatory conditions.

Identification of Crosstalk Genes Between Primary Sjögren's Syndrome and Primary Biliary Cirrhosis by Transcriptome Analysis

BACKGROUND

Growing evidence points a connection between Primary Sjögren's Syndrome (pSS) and Primary Biliary Cholangitis (PBC). This study seeks to identify the crosstalk genes between them.

METHOD

Transcriptomic datasets for pSS (GSE66795) and PBC (GSE119600) were sourced from the Gene Expression Omnibus (GEO) database. Common genes between these two conditions were detected using Differential Expression Analysis and Weighted Gene Co-expression Network Analysis (WGCNA). Potential crosstalk genes were pinpointed through Least Absolute Shrinkage and Selection Operator (LASSO) regression. Validation of these genes were performed through single-sample gene set enrichment analysis (ssGSEA), multivariable logistic regression, and single-cell transcriptome analysis.

RESULT

Differential expression analysis showed 339 commonly upregulated DEGs in both pSS and PBC. WGCNA analysis revealed 11 modules associated with pSS and 7 modules associated with PBC. Subsequently, 56 core genes were found to overlap between the genes identified by differential expression analysis and WGCNA. LASSO regression identified CX3CR1, ELF1, CUL1, PARP3, DDX60, SP140L, and MUC1 as pivotal crosstalk genes for both pSS and PBC. Moreover, ssGSEA analysis and multivariable logistic regression underscored the potential of these 7 genes as crosstalk genes. Single-cell analyses revealed higher proportions of NK cells, CD4+ T cells, and CD8+ T cells in pSS patients, with prominent expression of CX3CR1, ELF1, CUL1, PARP3, DDX60, SP140L, and MUC1 in these cells.

CONCLUSION

Our study identified CX3CR1, ELF1, CUL1, PARP3, DDX60, SP140L and MUC1 as crosstalk genes between pSS and PBC, and highlighted the critical role of NK cells, CD4+ T cells and CD8+ T cells in disease mechanisms.

Deep learning in the precise assessment of primary Sjögren's syndrome based on ultrasound images

OBJECTIVES

This study aimed to investigate the value of a deep learning (DL) model based on greyscale ultrasound (US) images for precise assessment and accurate diagnosis of primary Sjögren's syndrome (pSS).

METHODS

This was a multicentre prospective analysis. All pSS patients were diagnosed according to 2016 ACR/EULAR criteria. A total of 72 pSS patients and 72 sex- and age-matched healthy controls recruited between January 2022 and April 2023, together with 41 patients and 41 healthy controls recruited from June 2023 to February 2024 were used for DL model development and validation, respectively. The DL model was constructed based on the ResNet 50 input with preprocessed all participants' bilateral submandibular glands (SMGs), parotid glands (PGs), and lacrimal glands (LGs) greyscale US images. Diagnostic performance of the model was compared with two radiologists. The accuracy of prediction and identification performance of DL model were evaluated by calibration curve.

RESULTS

A total of 864 and 164 greyscale US images of SMGs, PGs, and LGs were collected for development and validation of the model. The area under the ROC (AUCs) of DL model in the SMGs, PGs, and LGs were 0.92, 0.93, 0.91 in the model cohort, and were 0.90, 0.88, 0.87 in the validation cohort, respectively, outperforming both radiologists. Calibration curves showed the prediction probability of the DL model was consistent with the actual probability in both model cohort and validation cohort.

CONCLUSION

The DL model based on greyscale US images showed diagnostic potential in the precise assessment of pSS patients in the SMGs, PGs and LGs, outperforming conventional radiologist evaluation.

Clinical value of salivary gland ultrasonography in evaluating secretory function, disease activity, and lymphoma risk factors in primary Sjögren's syndrome

INTRODUCTION/OBJECTIVES

Salivary gland ultrasonography (SGUS) has been investigated for its diagnostic usefulness in replacing invasive minor salivary gland biopsy (MSGB) in primary Sjögren's syndrome (pSS). However, its broader clinical value remains unclear. This study aimed to assess the clinical significance of SGUS in evaluating secretory function, disease activity, and lymphoma risk factors in pSS.

METHOD

One hundred fifty pSS patients who visited Seoul St. Mary's Hospital between January 2019 and July 2023 were included. Parameters related to secretory function, disease activity, and lymphoma risk factors were obtained. Associations between SGUS grades and secretory function or disease activity parameters were determined. Subgroup analyses based on SGUS grade or the presence of lymphadenopathy (LAP) in SGUS were also performed.

RESULTS

SGUS grades correlated significantly with parameters of salivary gland secretory function and disease activity. Higher SGUS grades were associated with higher scores of overall EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI), ESSDAI glandular domain, EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) dryness domain, and physician or patient global assessment. Patients with the highest SGUS grade (overall score = 6) showed higher prevalence of laboratory risk factors or extraglandular manifestations related to lymphoma development than others. Detection of LAP by SGUS was associated with reduced salivary flow rates and higher ESSDAI, ESSPRI scores, and patient global assessments.

CONCLUSIONS

Our results suggest that SGUS grades and the presence of LAP in SGUS findings are associated with clinical parameters representing secretory function and disease activity in pSS. High SGUS grades are associated with risk factors for lymphoma development. Key Points • SGUS grades showed significant correlations with clinical parameters related to salivary gland function and disease activity in patients with pSS. • pSS patients with the highest SGUS grade exhibited a higher prevalence of laboratory risk factors or extraglandular manifestations potentially related to lymphoma development compared to others. • These associations were more pronounced in the parotid gland than in the submandibular gland. • LAP identified by SGUS showed significant associations with clinical parameters related to the quality of life of patients with pSS.

Plasma extracellular vesicles promote follicular T helper cell expansion in primary Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a prevalent autoimmune disease characterized by exocrine gland dysfunction, with hallmarks of B cell and T cell overactivation, whose underlying mechanism remains largely unknown. Herein, we show that pSS plasma contained more extracellular vesicles (EVs) than HC plasma, which promoted CD4+ T cell activation, Th1, and follicular T helper cell (Tfh) differentiation, aggravating pSS immunopathology. Notably, pSS plasma EVs were enriched with miR-501-3p, mediating CD4+ T cell activation and Tfh cell differentiation. Furthermore, miR-501-3p downregulated special AT-rich sequence-binding protein-1 (SATB1) to promote Tfh differentiation. These findings suggested pSS plasma EVs as an important contributor to pSS pathogenesis, which was of potential clinical interest in managing pSS.

Anti-SSA/SSB antibody double-negative Sjögren's disease patients: a comprehensive clinical study and immune profile

INTRODUCTION/OBJECTIVES

Anti-Sjögren's syndrome A (SSA/Ro60) and anti-Sjögren's syndrome B (SSB/La) antibodies are not present in up to 25% of patients with primary Sjögren's disease (SjD). Our observational study aims to provide a clinical perspective on the presentation, extra-glandular manifestations, as well as the immune profile of anti-SSA/SSB antibody double-negative SjD patients.

METHOD

A total of 615 SjD patients of age 53.21 (± 0.59) were enrolled without acute infection or ongoing treatment that could affect the immune system. Of our participants, 254 (41.3%) were seronegative for both SSA (Ro60) and SSB (La) autoantibodies (SSA/SSB double-negative). A 1:1 propensity score matching was performed to balance age at diagnosis, disease duration, and gender for extra-glandular involvement analyses and immune profiling. Peripheral blood mononuclear cells (PBMCs) were derived from all patients. Flow cytometry was performed to further define the immune cell subsets.

RESULTS

Our study revealed that anti-SSA/SSB seronegative patients had a delayed onset by an average of 7.43 years and exhibited a lower prevalence of parotid gland enlargement compared to the seropositive group (50.8% vs. 59%, p < 0.05). In terms of extra-glandular involvement, seronegative patients exhibited a lower prevalence of white blood cell (WBC), hemoglobin (HGB), and platelet (PLT) reduction (OR 0.406, 95% CI 0.314-0.523; OR 0.751, 95% CI 0.587-0.959; OR 0.56, 95% CI 0.383-0.818, respectively) compared to anti-SSA/SSB antibody-positive group. Additionally, the double-negative group tended to hold higher CD4 + T helper cells and lower CD8 + T cell proportions compared with the anti-SSA/SSB-positive group (40.52% vs. 37.38%, p < 0.001; 28.25% vs. 32.55%, p < 0.001 respectively). Higher proportions of NK cells (13.05% vs. 10.32%, p < 0.001) and CD161 + Treg cells (13.69% vs. 12.03%, p < 0.001) were found in the double-negative group.

CONCLUSION

The observed higher frequency of CD161 + Tregs and NK cells, as well as the lower frequency of CD8 + T cells and B cells, in anti-SSA/SSB antibody double-negative patients suggests a potential role of innate immunity in this subgroup of Sjögren's syndrome. Our findings hint at the importance of serological and immune profiles in tailoring personalized management strategies for these patients. Key Points • Our analyses suggested a potential role of innate immunity in anti-SSA/SSB antibody double-negative SjD patients in comparison to seropositive counterparts. • Higher frequencies of CD4 + T cells, CD161 + Tregs, and NK cells were observed in the peripheral blood of double-negative patients, alongside lower proportions of CD8 + T cells and B cell subsets. • Double-negative patients exhibited a lower prevalence of reductions in white blood cell counts, hemoglobin level, and platelet level.

TAFRO-like Symptoms in a Sjögren's Syndrome Patient with HTLV-1 Infection

A 58-year-old woman was admitted to our hospital with anasarca and generalized lymphadenopathy. Laboratory data showed serum creatinine 1.48 mg/dL, C-Reactive Protein 2.38 mg/dL, platelet 102,000/μL, and anti-SS-A antibodies. A lymph node biopsy revealed a regressed germinal center and hypervascularization in the interfollicular area. The patient was diagnosed with TAFRO-like symptoms occurring with Sjögren's syndrome and human T-cell leukemia virus type 1 (HTLV-1) infection, and 80 mg of methylprednisolone and tocilizumab 8 mg/kg biweekly were initiated. Her body weight decreased from 59.4 to 41 kg, and pleural effusion disappeared 8 weeks later. This case suggests that TAFRO-like symptoms may occur in patients with Sjögren's syndrome with HTLV-1 infection.

miRNA let-7f-5p-encapsulated labial gland MSC-derived EVs ameliorate experimental Sjögren's syndrome by suppressing Th17 cells via targeting RORC/IL-17A signaling axis

Sjögren's syndrome (SS) is an autoimmune disease primarily affecting salivary glands, with xerostomia as a distinct clinical manifestation. This disease also poses a significantly increased risk of lymphoma, severely impacting patients' quality of life. The imbalance between Th17 and Treg cells plays a critical role in SS progression, driving severe immune dysregulation, chronic inflammation, and escalating tissue dysfunction. However, current clinical treatments for SS still remain limited, and it continues to be recognized as a refractory disease. Therefore, the development of novel and effective therapeutic strategies is a pressing demand in clinical research. In recent years, extracellular vesicle (EV) therapy has emerged as a promising approach for autoimmune disease treatment, showing encouraging outcomes in modulating immune balance and alleviating symptoms. EVs carry diverse cargo, among which microRNAs (miRNAs) are highly abundant and play critical roles. These small RNAs are essential for EV-mediated functions, particularly in regulating gene expression and modulating the immune microenvironment. Our research team first isolated labial gland mesenchymal stem cells (LGMSCs) and their derived EVs (LGMSC-EVs), which offer potential therapeutic advantages in SS due to their salivary gland origin. Then we screened and identified the highly enriched miRNA let-7f-5p as a key regulator through miRNA profiling analysis. To achieve better therapeutic outcomes, we transfected exogenous miRNA let-7f-5p into LGMSC-EVs to upregulate its expression, thereby constructing let-7f-5p-encapsulated LGMSC-EVs. These modified EVs were subsequently tested in an experimental SS mouse model to evaluate their therapeutic potential. The upregulation of miRNA let-7f-5p in LGMSC-EVs significantly enhanced their therapeutic effects, resulting in clinical improvements such as increased salivary flow and reduced lymphocytic infiltration. Mechanistically, let-7f-5p-encapsulated LGMSC-EVs suppressed Th17 cells by directly targeting the 3'-untranslated region (3'UTR) of RORC, inhibiting the RORC/IL-17A signaling axis, and reducing IL-17A production, thereby restoring Th17/Treg balance and promoting an anti-inflammatory profile. Collectively, this let-7f-5p-encapsulated LGMSC-EV therapy offers a promising target-driven approach for the treatment of SS, achieving improved clinical outcomes and immune rebalance after modification with miRNA let-7f-5p, which presents new potential for the clinical treatment of SS.

Association of killer cell immunoglobulin-like receptor genes with primary Sjögren's syndrome among Chinese population

BACKGROUND

Primary Sjögren's syndrome (pSS) is a chronic and common autoimmune disorder which is caused by inflammatory infiltration of the exocrine glands salivary glands and lacrimal glands are the main sites of involvement. Killer cell immunoglobulin-like receptors (KIRs), are crucial for the development and function of natural killer (NK) cells. Moreover, the activity of NK cells is affected by the interaction of KIRs with HLA class I ligands. The pathogenesis of autoimmune diseases has been linked to some KIR genes. Further research on the relationship between KIR and these autoimmune diseases is of great significance for the diagnosis and treatment of these diseases. This study aimed to detect and analyze the connection between the polymorphism of the KIR and HLA-Cw genes and the pathogenesis of pSS.

METHODS

We took 56 pSS patients as the study group and 32 healthy people as the control group. Blood samples were collected to perform a polymerase chain reaction with sequence specific primers (PCR-SSP). Then a comparative analysis of gene frequencies of 16 KIR genes and HLA-Cw in the two groups was performed.

RESULTS

The genotype frequencies of both KIR2DS3 (P = 0.0027) and KIR3DS1 (P = 0.006) were significantly lower in patients with pSS compared to healthy individuals, indicating a negative correlation of these two activating KIR genes. There were more individuals who had more than three activating KIR genes in the control group than in the patient group (P = 0.004). And the KIR2DL1/HLA-C2 gene combination (P = 0.022) was significantly more in pSS group than in controls.

CONCLUSION

Our results may imply that via influencing the activity, development, capacitation, and functionality of NK cells, NKT cells, and part T cells, the decrease of activated KIR genes and the increase of the frequency of the inhibitory KIR and its specific ligand gene combination（KIR2DL1/HLA-C2) may contribute to the pathogenesis of pSS.

Association of increased serum I-309 with phenotypes, disease activity, and cytokine pattern in primary Sjögren's syndrome

The aim of this study was to determine serum I-309 levels in primary Sjögren's syndrome (pSS) patients, as well as the association with disease phenotype, systemic activity, and T helper cell-related cytokines. A total of 58 pSS patients and 30 healthy controls (HC) were enrolled in this study. The concentrations of serum I-309, interleukin-4 (IL-4), IL-6, IL-9, IL-13, IL-17, IL-22, IL-23, tumor-necrosis factor-α (TNF-α), interferon-γ (IFN-γ), IFN-α, and IFN-β were measured with multiplex immunoassay. The relationships between I-309 and various clinical and laboratory variables were analyzed. The serum concentrations of I-309 were significantly increased (median, IQR, 14.24, 10.99--20.35, pg/ml) in pSS patients compared with HC (median, IQR, 8.27, 6.74--9.62, pg/ml) (P < 0.001). Serum I-309 is increased in pSS, and may be associated with systemic inflammation, Th1-, Th17,- and Th9 cells, type Key Points • Serum I-309 levels are increased in pSS patients. • Increased I-309 may be associated with systemic rather than local manifestations in pSS. • Increased I-309 may be associated with Th1, Th17 and Th9 other than Th2 in pSS. • There may be close relationships between I-309 and type land type II IFNs in pSS.

Increased risk of dementia in patients with primary Sjogren's syndrome: a nationwide population-based cohort study

BACKGROUND/AIMS

This nationwide cohort study aimed to evaluate (1) whether primary Sjogren's syndrome (pSS) can contribute to the development of dementia and (2) whether the use of hydroxychloroquine (HCQ) can decrease the incidence of dementia in patients with pSS using the Health Insurance Review and Assessment database.

METHODS

We established a cohort between 2008 and 2020 of 20,160 patients with pSS without a history of dementia. The control group comprised sex- and age-matched individuals with no history of autoimmune disease or dementia. Cox proportional hazard analyses were performed to identify the association between pSS and dementia development. We also assessed the hazard ratio (HR) of dementia in early users of HCQ (within 180 days of the diagnosis of pSS) compared to non-users, adjusted for age, sex, and comorbidities.

RESULTS

The incidence of dementia was 0.68 (95% CI 0.64-0.72) cases per 100 person-years in pSS, and it was 0.58 (0.56-0.60) in the controls. The adjusted HR (aHR) of developing dementia was 1.16 (1.09-1.25) times greater in the pSS group than in the controls. The risk of dementia did not increase in HCQ users (aHR 1.07 [0.94-1.21]), but HCQ non-users had a 1.22 (1.12-1.33) higher risk of developing dementia than the matched controls. The use of HCQ lowered the risk of dementia in comparison with non-users in patients with pSS (aHR 0.82 [0.71-0.94]).

CONCLUSION

Our results suggest that pSS is associated with an increased risk of dementia. HCQ may prevent dementia in patients with pSS.

Immunometabolic shifts in autoimmune disease: Mechanisms and pathophysiological implications

Autoimmune diseases occur when the immune system abnormally attacks the body's normal tissues, causing inflammation and damage. Each disease has unique immune and metabolic dysfunctions during pathogenesis. In rheumatoid arthritis (RA), immune cells have different metabolic patterns and mitochondrial/lysosomal dysfunctions at different disease stages. In systemic lupus erythematosus (SLE), type I interferon (IFN) causes immune cell metabolic dysregulation, linking activation to metabolic shifts that may worsen the disease. In systemic sclerosis (SSc), mitochondrial changes affect fibroblast metabolism and the immune response. Idiopathic inflammatory myopathies (IIMs) patients have mitochondrial and metabolic issues. In primary Sjögren's syndrome (pSS), immune cell metabolism is imbalanced and mitochondrial damage can lead to cell/tissue damage. Metabolic reprogramming links cellular energy needs and immune dysfunctions, causing inflammation, damage, and symptoms in these diseases. It also affects immune cell functions like differentiation, proliferation, and secretion. This review discusses the potential of targeting metabolic pathways to restore immune balance, offering directions for future autoimmune disease research and treatment.

Impact of disease duration on systemic clinical profile in Sjogren's syndrome

BACKGROUND

Primary Sjogren's Syndrome (pSS) is a systemic autoimmune disorder characterized by lymphocyte infiltration of the exocrine glands. Disease duration plays a pivotal role in evaluating the development of SS. In this study, we aimed to clarify the clinical manifestations of pSS across various stages of its progression, thereby offering critical insights for early diagnosis and targeted management strategies for Sjogren's Syndrome.

METHODS

We conducted a retrospective analysis involving 3,978 patients with primary Sjogren's Syndrome (mean [SD] age: 53.1[24] years) from Peking University People's Hospital between January 2015 and December 2022. We classified patients into five distinct groups based on the duration of the syndrome: T0 (≤ 1 year), T1 (> 1 year, ≤ 5 years), T2 (> 5 years, ≤ 10 years), T3 (> 10 years, ≤ 20 years), and T4 (> 20 years).

RESULTS

We observed a statistically significant increase in the percentage of pSS patients with white blood cell (WBC) decrease, specifically: T0 (9.23%), T1 (15.40%), T2 (22.62%), T3 (20.22%), T4 (26.45%). The decreases in hemoglobin (HGB) and platelet (PLT) were also robustly associated with extended disease duration (p < 0.0001). Simultaneously, systemic involvements aggravated with disease progression as incidence rates of skin, joint, lung, and nervous system were strikingly increased in each group. The findings also indicated that patients with long-term pSS exhibit a higher likelihood of developing comorbid conditions, such as diabetes and tumors. In summary, disease duration serves as a crucial determinant for the prognosis of patients with pSS.

CONCLUSIONS

Therefore, early identification of symptoms and initiation of therapies are imperative for mitigating the risk of significant complications in pSS patients.

Acute Coronary Syndrome and Rheumatic Disease

Patients with rheumatic disease and immune disorders have been noted to show an earlier development of atherosclerosis and to present with acute coronary syndrome. These diseases disproportionately affect women, and patients frequently have a higher number of comorbidities and other risk factors. Inflammation has long been known to play a role in the development of coronary artery disease. Early studies have shown some benefit in treatment targeting inflammation. While this has not been realized for all populations, there remains potential in treatment with targeted and individualized therapies. Especially since these diseases are associated with a worse prognosis, management benefits from the multidisciplinary expertise of cardiologists, rheumatologists, and other providers. However, the prevention and treatment of underlying rheumatic disease remains essential. This review will seek to highlight prior studies and future directions in the treatment of acute coronary syndrome in patients with rheumatologic disease.

A biopsychosocial questionnaire for patients with primary Sjögren's syndrome: The BETY-Biopsychosocial Questionnaire

OBJECTIVE

The BETY-Biopsychosocial Questionnaire (BETY-BQ) is a scale developed to assess the biopsychosocial domains of patients with rheumatic diseases under a single roof. The study aimed to determine the validity and reliability of the BETY-BQ in patients with primary Sjögren's syndrome (pSS).

METHODS

At enrollment and 1 week, 91 patients with pSS completed the BETY-BQ. Construct validity was measured by correlating the BETY-BQ total score responses with the Health Assessment Questionnaire, Hospital Anxiety and Depression Scale, 36-Item Short-Form Health Survey, EULAR Sjögren's Syndrome Patient-Reported Index, EULAR Sjögren's Syndrome Disease Activity Index, Primary Sjögren's Syndrome Quality of Life questionnaire, and Euro-QoL 5D.

RESULTS

The BETY-BQ correlated high to moderate with Health Assessment Questionnaire, bodily pain subscale of 36-Item Short-Form Health Survey, Euro-Qol 5D, Primary Sjögren's Syndrome Quality of Life questionnaire, Hospital Anxiety and Depression Scale, and EULAR Sjögren's Syndrome Patient-Reported Index (0.776 to 0.557, P < .05). Spearman's correlation coefficients between BETY-BQ total scores at baseline and average 1 week were very high (rho = 0.98, P < .001) and indicated substantial agreement between test-retest scores (intraclass correlation coefficient = 0.99, P < .001). Internal consistency reliability at baseline was 0.91 for the BETY-BQ.

CONCLUSIONS

BETY-BQ is valid and reliable for assessing biopsychosocial status in patients with pSS and can be used to measure outcomes in pSS.

Sexual experience and functioning in male and female patients with Sjögren's disease: a qualitative study

OBJECTIVE

Sjögren's disease (SjD) can have a major impact on sexual functioning, but this topic has received limited attention in research and clinical practice. This qualitative study investigated how SjD affects sexual experience and functioning in both women and men.

METHOD

Reflexive thematic analysis was performed based on in-depth interviews with patients with SjD. Sexual functioning was measured using the Female Sexual Function Index and International Index of Erectile Function questionnaire.

RESULTS

11 female and 9 male patients with SjD, aged between 24 and 65 years, were included. According to questionnaire scores, 64% of female and 67% of male participants reported sexual dysfunction. In both sexes, six themes were identified as important in sexual experience and functioning: chronic stress in life, symptoms of SjD (affecting sexual experience), invisible suffering of SjD, impact of illness perception on coping strategies for sexuality-related symptoms, quality of (sexual) partner relationship and taboo of sexuality. These themes interact with each other and together shape the sexual experience.

CONCLUSION

SjD plays a crucial role in the quality of sexual experience. Many participants reported an unmet need for support, advice and treatment of sexuality-related symptoms related to SjD. The themes generated provide valuable insights into understanding the factors that shape sexual experience and underscore the importance of addressing sexuality-related symptoms as part of holistic care for patients with SjD. Due to the complexity of sexual experience and functioning, future research should focus on the patient as a whole person, and not solely on physical sexual functions.

Risk Allele rs117026326-Mediated Alternative Splicing of GTF2I Promotes B Cell Proliferation in Primary Sjögren's Syndrome

Objectives: Primary Sjögren's syndrome (pSS) is associated with a risk allele T of rs117026326 located at a potential splicing enhancer within the intronic region of general transcription factor II-I (GTF2I). This study aimed to explore the rs117026326-regulated alternative splicing of GTF2I and its role in B cell overactivation in pSS. Methods: GTF2I isoform expressions and rs117026326 genotypes of pSS peripheral blood mononuclear cells (PBMCs) were examined using quantitative PCR and Sanger sequencing, respectively. GTF2IΔ was overexpressed in B cells, T cells, and macrophages using plasmid transfection. Proliferation of B cells and T cells was determined using Cell Counting Kit-8 (CCK8) assay. CD4+ T cell differentiation was inspected using flow cytometry. Proinflammatory cytokine production of macrophages was investigated using quantitative PCR. c-FOS expression in GTF2IΔ-transfected B cells was tested by quantitative PCR, and proliferation of GTF2IΔ-transfected B cells treated with c-FOS siRNA or c-FOS inhibitor was interrogated using CCK8 assay. Results: pSS patients with risk allele of rs117026326 expressed higher levels of GTF2IΔ and GTF2Iζ isoforms. GTF2IΔ expression was correlated with serum immunoglobulin G (IgG). GTF2IΔ promoted B cell proliferation and upregulated c-FOS expression. Knocking down or inhibition of c-FOS reversed B cell proliferation driven by GTF2IΔ. Conclusion: pSS risk allele of rs117026326 modulates alternative splicing of GTF2I and upregulates GTF2IΔ isoform, which promotes B cell proliferation through enhancing binding and transcription of c-FOS.

Identification of novel autoantibodies in Sjögren's disease

Introduction

The diagnosis of Sjögren's disease (SjD) in patients without autoantibodies against Ro/SSA is a major challenge. We aimed to identify novel autoantibodies in SjD that may facilitate the diagnostic procedure for Ro/SSA negative SjD.

Methods

IgG and IgA autoantibody reactivity of 94 potential candidate autoantigens for SjD, selected from a discovery screen of 1,629 human antigens coupled to Luminex beads and prior knowledge about potential biological relevance, were examined in serum of SjD patients (n=347) using Luminex and ELISA technology. Healthy (HC, n=118) and non-Sjögren's sicca syndrome (NSS, n=44) individuals served as controls. To assess disease specificity, the novel autoantibodies were also measured in serum of patients with Rheumatoid Arthritis (RA, n=50), Systemic Lupus Erythematosus (SLE, n=49), and Systemic Sclerosis (SSc, n=37).

Results

45 novel autoantibodies were significantly (p ≤ 0.05) more prevalent in SjD than in HC and were detected in up to 19% of the SjD cohort. The most common autoantibodies were against CCL4, M5, TMPO and OAS3. Some of the novel autoantibodies were associated with extraglandular disease manifestations, such as anti-TONSL or anti-IL6 with pulmonary involvement. We have developed a three and five marker panel for the detection of Ro/SSA negative patients, consisting of anti-FNBP4, anti-SNRPC, anti-CCL4, anti-M3 and anti-KDM6B, which had a sensitivity of up to 46% with a specificity of 95% (SjD vs. HC). Both panels discriminate these patients from HC, whereas the three-marker more effectively differentiates between Ro/SSA negative patients and NSS.

Discussion

Novel autoantibodies will facilitate the diagnosis of Ro/SSA negative patients with SjD, in particular our predictive panel will be useful in the diagnosis and differentiation of these patients from healthy and NSS individuals in a clinical context. In addition, the autoantibodies may also be useful for risk stratification of extraglandular manifestations.

Unraveling the Genetics of Shared Clinical and Serological Manifestations in Patients With Systemic Inflammatory Autoimmune Diseases

OBJECTIVE

Systemic inflammatory autoimmune diseases (SIADs) such as systemic lupus erythematosus (SLE), primary Sjögren disease (pSS), and idiopathic inflammatory myopathies (myositis) are complex conditions characterized by shared circulating autoantibodies and clinical manifestations, including skin rashes, among others. This study was aimed at elucidating the genetics underlying these common features.

METHODS

We performed targeted DNA sequencing of coding and regulatory regions from approximately 1,900 immune-related genes in a large cohort of 2,292 well-characterized Scandinavian patients with SIADs with SLE, pSS, and myositis as well as 1,252 controls. A gene-based functionally weighted genetic score for aggregate testing of all genetic variants, including rare variants, was complemented by in silico functional analyses and in vitro reporter experiments.

RESULTS

Case-control association analysis detected known and potentially novel genetic loci in agreement with previous genetic and transcriptomics findings linked to the SIAD autoimmune background. Intriguingly, case-case comparisons between patient subgroups with and without specific autoantibodies revealed that the subgroups defined by antinuclear antibodies and anti-double-stranded DNA antibodies have unique genetic profiles reflecting their heterogeneity. When focusing on clinical features, we overall showed that dual-specificity phosphatase 1 (DUSP1) protective genetic variants lead to increased gene expression and potentially to anti-inflammatory effects on the SIAD-associated skin phenotype. This is consistent with recent genetic findings on eczema and with the previously reported down-regulation of the MAPK signaling-related gene DUSP1 in other skin disorders.

CONCLUSION

Together, this suggests common molecular mechanisms potentially underlying overlapping clinical manifestations shared among different disorders and informs clinical heterogeneity, which could be translated to improve disease diagnostic and treatment, also in more generalized disease frameworks.

Cerebral venous thrombosis as a rare complication of Sjögren's syndrome: case series and literature review

OBJECTIVE

As few cerebral venous thrombosis (CVT) patients with primary Sjögren's syndrome (pSS) have been reported, little is known about the characteristics of this rare complication. This study is aimed at describing the clinical features, treatment, and outcome of CVT combined with pSS.

MATERIALS AND METHODS

We reported five patients of CVT and pSS admitted to our hospital and searched the relevant case reports in PubMed for literature review.

RESULTS

We reviewed a total of twelve patients with pSS and CVT. Among them, five patients were from our report in the present paper, and seven other patients were from the case reports searched in PubMed. In total twelve patients, eleven patients were female. The twelve patients had an average age of 43.7 ± 8.3 years (age range, 26-57 years). The symptoms of pSS included multiple caries (50%), dry mouth (41.7%), dry eyes (33.3%), arthritis symptoms (16.7%), and parotid gland swelling (8.3%). Headache was the most common neurological symptom in all patients. Four patients (33.3%) had no clinical symptoms associated with pSS. Anti-SSA antibodies were positive in all patients. Antiphospholipid antibodies (aPLs) were positive in 33.3% of patients. Unilateral transverse sinus (75.0%) was the most commonly involved venous sinus. All patients received anticoagulant therapy. Hydroxychloroquine was also administered to the patients. Seven patients were treated with glucocorticoids. All patients recovered completely with no clinical or radiological recurrence.

CONCLUSION

pSS combined with CVT is a rare condition. Middle-aged women with pSS should be alert to the presence of CVT. It is of great importance to screen for autoimmune diseases during the clinical course of CVT, especially in patients with unilateral transverse sinus thrombosis. Effective treatment strategies require further study. Key Points • Patients combined with CVT are very rare. • Screening for autoimmune diseases in CVT patients is great important. • Patients may have good prognosis when effective treatment is administrated.

Sjogren's Syndrome Complicated by Naso-Orbito-Cerebral Mucormycosis: A Case Report

Background: Sjogren's syndrome (SS) is a chronic inflammatory autoimmune disease characterized by exocrine gland dysfunction. Mucormycosis is a rare yet life-threatening opportunistic fungal infection caused by Mucor species, with a high mortality rate. In patients undergoing long-term immunosuppressive therapy or corticosteroid use, especially when compounded by conditions such as diabetes or hyperlipidemia, Mucor can become pathogenic. Medical Record Description: We retrospectively analyzed the clinical data of a patient with Sjogren's syndrome complicated by rhinocerebral mucormycosis, focusing on its clinical presentation and progression. The patient was admitted to the hospital 20 days prior with symptoms of a "nasal infection" caused by a furuncle on the nose. The condition progressively worsened, resulting in nasofacial skin ulceration and necrosis, with black eschar formation around the affected area. Upon admission, comprehensive evaluations, including rapid histopathological and fungal tests, confirmed the diagnosis of mucormycosis. Despite surgical intervention under general anesthesia and antifungal therapy, the clinical outcome was ultimately fatal. Conclusion: Mucor infections commonly occur in patients with immunodeficiency and severe underlying diseases. The clinical manifestations are diverse, often presenting with skin tissue necrosis and the formation of black eschar. Fungal culture and histopathological examination remain the gold standards for diagnosing mucormycosis, while imaging studies are crucial for evaluating the extent of fungal dissemination and bone involvement. Given the rapid progression of the disease, early diagnosis and prompt treatment are critical for improving survival rates.

Systemic disease activity measured with ESSDAI varies largely over 5 years in a prospective, longitudinal cohort of patients with Sjögren's disease

OBJECTIVES

The objectives are to evaluate variation in systemic disease activity (European Alliance of Associations For Rheumatology (EULAR) Sjögren's Syndrome Disease Activity Index (ESSDAI)) over time at group and individual patient level and to assess associations of ESSDAI low disease activity (LDA) with other outcome measures in a standard-of-care cohort of patients with Sjögren's disease (SjD).

METHODS

Patients with SjD participating in a prospective longitudinal study (REgistry of Sjögren Syndrome LongiTudinal cohort) fulfilling the 2016 American College of Rheumatology/EULAR classification criteria with ≥2 years of follow-up were included. ESSDAI was assessed at least yearly, up to 5 years. Patient-reported, objective glandular and laboratory outcomes were compared between patients with ESSDAI LDA (score<5) for <75% vs ≥75% of time.

RESULTS

Of 265 included patients with SjD, 236 (89%) were women, median disease duration was 6 years (IQR 2-10) and 114 (43%) received immunosuppressive treatment at some point during follow-up. At group level, median ESSDAI decreased slightly, from 4 (IQR 2-7) at baseline to 3 (IQR 2-5) at year 5, with a concomitant decrease in variation, indicating regression to the mean. At the individual patient level, ESSDAI varied in the majority of patients: 50/102 (49%) untreated patients with ESSDAI<5 at baseline changed to ESSDAI≥5 at least once during follow-up. Of the untreated patients with ESSDAI≥5 at baseline, 41/45 (91%) changed to ESSDAI<5. Patients with ESSDAI LDA for ≥75% of time showed better outcomes on saliva production.

CONCLUSIONS

In this cohort of patients with SjD, overall ESSDAI slightly decreased during 5 years of follow-up, whereas at individual patient level, large variation was seen over time for the majority of patients. Longer time in ESSDAI LDA was associated with better salivary gland outcomes.

Is There a Difference Between Seropositive and Seronegative Sjögren Disease Dry Eye?

PURPOSE

The study aims to compare dry eye disease (DED) prevalence and severity between seropositive and seronegative Sjögren disease (SjD).

METHODS

Prospective, consecutive, comparative cross-sectional cohort study. A total of 160 eyes of 80 patients with SjD by The American College of Rheumatology and the European League Against Rheumatism 2016 criteria were included: 55 seropositive and 25 seronegative SjD. Associated SjD was excluded. Patients had dry eye tests performed. Generalized estimating equations were used to account for intereye correlation of the same participant.

RESULTS

Mean age was 52.2 ± 12.7, 96.3% were women, no differences were observed between groups (P > 0.05). Seronegative SjD had positive minor salivary gland biopsy more often (100% vs. 82%, P = 0.024), but with lower focus score (2.0 ± 1.2 vs. 4.1 ± 3.5, P = 0.006) than seropositive SjD group. DED prevalence was similar in seropositive and seronegative SjD (92.7% and 84%; P = 0.088). Only noninvasive break-up time (NIBUT) average was significantly reduced in seropositive SjD (6.6 ± 3.2 vs. 8.8 ± 2.4, P = 0.011), and the rest of the evaluated DED tests were not significant. In the seropositive group, nonstatistically significant trends toward more severe DED signs, including matrix metalloproteinase-9, osmolarity, Schirmer I without anesthesia, fluorescein tear break-up time, NIBUT first, and Sicca Ocular Staining Score, were observed. Both groups were highly symptomatic in ocular surface disease index score (43 ± 23 vs. 46 ± 30, P = 0.779) and had a reduction in quality of life in National Eye Institute visual health questionnaire-25 test (72 ± 21 vs. 70 ± 24, P = 0.650).

CONCLUSIONS

Patients with seropositive SjD showed significantly reduced NIBUT and a trend of more severe DED signs. Patients with seronegative and seropositive SjD were similarly highly symptomatic, experienced important reductions in vision-related quality of life, and had similar DED prevalence.

Diversity of central nervous system manifestations in Sjogren's Disease: a case-based review

Sjogren's disease (SjD) is a chronic and disabling autoimmune disease, predominantly characterized by dryness of the mouth and eyes, resulting from lymphocytic infiltration of exocrine glands. While these are the most prominent symptoms, extra-glandular manifestations are also common. Studies suggest that up to 70% of SjD patients experience neurological symptoms, which interestingly often precede the hallmark dryness. Although every structure of the nervous system can be affected, disorders of peripheral nervous system (PNS) are more common than central nervous system (CNS) involvement. The CNS manifestations can range from subtle to severe, with some patients experiencing a rapid progression of symptoms. The literature documents cases where patients initially diagnosed with Creutzfeldt-Jakob disease, neurosarcoidosis, temporary hemiplegia, neuromyelitis optica, or epilepsy were ultimately diagnosed as having SjD. Here, we present five SjD patient cases, each with a different manifestation of CNS involvement, along with an overview of the current understanding of CNS disorders in the course of the disease. In four cases, the neurological manifestations appeared before the onset of sicca symptoms. In one patient, diagnosis was delayed by 15 years due to an atypical presentation. After receiving immunosuppression, all patients experienced notable alleviation of their symptoms.

Elderly-onset inflammatory myopathy associated with Sjögren's syndrome following SARS-CoV-2 vaccination

As vaccination against SARS-CoV-2 has progressed, various autoimmune diseases, including inflammatory myopathies, have been reported to develop after vaccination. Sjögren's syndrome (SS) sometimes presents as extra-glandular manifestations including inflammatory myopathy. In this report, we describe a case of inflammatory myopathy associated with SS that occurred in an atypically elderly patient after receiving the first dose of the SARS-CoV-2 mRNA vaccine (BNT162b2). The inflammatory myopathy was pathologically classified into non-specific myositis and characterised by predominant infiltration of the B cell lineage in this case. Combined treatment with glucocorticoid, intravenous immunoglobulin, and immunosuppressant resulted in an improvement in swallowing function and muscle strength. While we recognise the efficacy and safety of SARS-CoV-2 vaccines, we also emphasise the importance of recognising that individuals with an immunogenetic predisposition such as positivity of anti SS-A antibody may show disease activity including inflammatory myopathy following vaccination in SS, even at an atypically old age.

Analysis of the relationships between interferon-stimulated genes and anti-SSA/Ro 60 antibodies in primary Sjögren's syndrome patients via multiomics and machine learning methods

BACKGROUND

Primary Sjögren's syndrome (pSS) is a chronic systemic autoimmune disease characterized by lymphocyte infiltration of the exocrine glands. Interferon-stimulated genes (ISGs) are often upregulated in patients with pSS, and anti-SSA/Ro 60 antibodies are among the main items detected in pSS. However, the relationship between ISGs and anti-SSA/Ro 60 antibodies in pSS remains unclear. Therefore, our study aimed to explore the relationships between ISGs and anti-SSA/Ro 60 antibodies and identify key genes involved in pSS.

METHODS

Transcriptome sequencing and microarray data of PBMC, parotid and labial glands tissues from pSS patients (1341 samples) were downloaded from the GEO database and used in this analysis. A linear model was used to analyze the relationship between ISGs and anti-SSA/Ro 60 antibodies. ELISA was used to measure the levels of anti-SSA/Ro 60 antibodies in the whole blood of pSS patients. Machine learning methods were used to construct a diagnostic model, and further validation was conducted with external datasets and RT-qPCR.

RESULTS

After differential analysis of the PBMCs and tissues, 22 and 160 DEGs, respectively, were identified. There was a positive correlation between ISGs and anti-SSA/Ro 60 antibodies in the PBMCs of pSS patients, and there was a significant positive correlation between ISG expression in the PBMCs and tissues of pSS patients. The expression levels of ISGs were increased in the PBMCs and tissues of pSS patients with positive anti-SSA/Ro 60 antibody results, and the ESSDAI, focus scores and CD45 levels were increased. Finally, the expression of EPSTI1, EIF2AK2, IFI44, RSAD2, and OAS2 in PBMCs can be used to diagnose pSS.

CONCLUSION

In patients with pSS, a positive correlation was observed between ISGs and anti-SSA/Ro 60 antibodies. The expression of ISGs reflects the disease severity and pathology scores of pSS patients. Through bioinformatics analysis combined with our clinical data, we identified five key genes with potential diagnostic value for pSS.

Clinical and laboratory characteristics of salivary gland ultrasonography-positive patients with primary Sjögren's syndrome

OBJECTIVE

This study aimed to investigate the clinical and laboratory characteristics of salivary gland ultrasonography (SGUS)-positive patients with primary Sjögren's syndrome (pSS) compared to SGUS-negative patients and to analyse the diagnostic value of SGUS and labial salivary gland biopsy (LSGB) grading in pSS.

METHODS

A retrospective analysis of patients admitted to the Affiliated Hospital of Yangzhou University between May 2019 and November 2023 was conducted. According to the OMERACT scoring system, patients with pSS were divided into an SGUS-negative group (score <2) and an SGUS-positive group (score ≥2). The patient's age, gender, clinical symptoms, laboratory parameters and diagnostic examinations were compared and analysed, and Spearman correlation analysis was used to analyse the correlation between SGUS, LSGB and influencing factors.

RESULTS

There was no significant difference in dry mouth, dry eyes, tooth loss, fever, joint pain, fatigue, interstitial lung disease or renal tubular acidosis between the two groups, although there were more patients with salivary gland enlargement in the SGUS-positive group (p < 0.05). In terms of high levels of immunoglobulin G (IgG), high levels of rheumatoid factor (RF), anti-nuclear antibody ≥1:320, anti-Sjögren's syndrome A-52KD and anti-Sjögren's syndrome B, the number of cases in the SGUS-positive group was greater than that in the SGUS-negative group (p < 0.05). LSGB samples were graded per the Chisholm-Mason system with significant differences between multiple groups. SGUS score negatively correlated with age and positively correlated with LSGB grade.

CONCLUSION

This study showed that the SGUS score positively correlated with LSGB grade in pSS patients and negatively correlated with patient age. Thus, SGUS and LSGB are consistent in the diagnosis of pSS to reflect the degree of salivary gland involvement, and patients who are SGUS positive have high RF and IgG levels, a variety of autoantibodies positive and a tendency toward salivary gland enlargement.

Headaches in Sjogren's disease: A narrative review

OBJECTIVE

To review the most common types of primary and secondary headaches that are associated with Sjogren's disease (SjD).

BACKGROUND

Sjogren's disease is a chronic systemic autoimmune disease that typically presents with xerophthalmia, xerostomia, and arthralgias. Sensory and motor neuropathies are commonly reported neurological complications with SjD. Primary and secondary headaches are also frequent neurological complications associated with SjD, which may be under-recognized.

METHODS

In this study, researchers conducted a literature review through the platforms of PubMed and Google Scholar with the keywords: (1) Sjogren's syndrome, (2) Sjogren's disease, (3) headache, (4) migraine, (5) tension-type headache, (6) aseptic meningitis, (7) cerebral venous sinus thrombosis, and (8) idiopathic intracranial hypertension. Included articles involved a study population of patients with both SjD and headache. There were no exclusion criteria. A total of 54 articles were identified, and 31 articles were utilized for study analysis.

RESULTS

In patients with SjD, headaches were a frequently reported neurological complaint. The most common types of primary headaches associated with SjD were found to be migraine and tension-type headache. Patients with SjD were more likely to report severe, debilitating headaches compared to the general population. Furthermore, patients with SjD have been found to experience dangerous types of secondary headaches, including aseptic meningitis and cerebral venous sinus thrombosis.

CONCLUSIONS

Headaches are a common neurological complication in patients with SjD. Current literature suggests that there is an increased risk of both primary and secondary headaches in individuals with SjD compared to the general population and that headaches may occur throughout the clinical course of the disease. There are also reports of patients who experience the onset of primary and secondary headaches prior to the diagnosis of SjD. SjD has been linked to dangerous, life-threatening conditions that cause headaches, which require urgent recognition and treatment. Therefore, it is important to have a higher index of suspicion for patients who present with headaches and clinical symptoms of SjD, such as xerophthalmia and xerostomia. Utilizing a detailed history, physical examination, and neuroimaging can assist clinicians to recognize and diagnose types of headaches in patients with SjD to prevent dangerous complications.

Dry eye and systemic diseases

Tear film instability and reduced tear production initiate a vicious circle where hyperosmolarity, ocular inflammation, and apoptosis may induce a damage of the ocular surface including keratitis which is all included in a common condition called dry eye disease (DED). DED can be apparently an isolated ocular surface condition; however, multiple ocular and systemic risk factors have been identified. The association with systemic diseases such as autoimmune diseases, hormonal imbalance, dietary imbalance, metabolic diseases, infections, psychological conditions, and aging together with external causative factors may act independently or interacting each other to initiate and/or perpetuate signs and symptoms typical of this very common ocular surface disease. Rheumatological disorders are most typically associated with dry eye; therefore, strict interaction with rheumatologists is important for the diagnosis and management of DED patients. In the present narrative review, we highlight associations between DED and some of the systemic disorders that may be implicated in the development of the disease.

Mortality and Survival Analysis in Patients With Cancer Occurrence After Sjögren's Syndrome: A Long-Term Cohort Study in China

OBJECTIVE

This study aimed to investigate the mortality, survival rates, and prognostic indicators of cancer occurrence after Sjögren's syndrome (SS-CA).

METHODS

The medical records of patients with SS-CA at the Peking Union Medical College Hospital (PUMCH) between January 2010 and August 2022 were retrieved. Clinical data and survival outcomes were compared to controls. The standard mortality ratio (SMR) versus the general population was calculated, and the survival and predictive markers of prognosis were analyzed using Kaplan-Meier curves and Cox regression.

RESULTS

In total, 114 SS-CA patients were included, with a median follow-up time of 105.1 (57.3-168.0) months. Non-Hodgkin lymphoma (32, 28.1%) was the most common cancer in patients with SS-CA. The SMR of SS-CA patients was 2.61 (95% confidence interval [CI] 1.73-3.77). Patients with SS-CA exhibited significantly inferior outcomes compared to controls (p = 0.010), with 5- and 10-year overall survival rates of 91.2% and 83.2%, respectively. SS patients with a diagnostic interval between SS and cancer (SS-CA diagnostic interval) ≤ 3 years or with hematological malignancies had poorer survival compared to those with a diagnostic interval > 3 years (p < 0.001) or with solid tumors (p = 0.019). Multivariate Cox regression analysis identified the prognosis-associated factors of SS-CA as age at SS diagnosis > 50 years (HR 3.129, 95% CI 1.224-7.998; p = 0.017), SS-CA diagnostic interval ≤ 3 years (HR 7.754, 95% CI 1.953-30.781; p = 0.004), and hematological malignancies (HR 2.648, 95% CI 1.201-5.838; p = 0.016).

CONCLUSION

Malignant comorbidities constituted a poor prognosis in patients with SS, wherein the SS-CA diagnostic interval and the types of cancer were associated with survival.