The influence of age on disease manifestations and serological characteristics in primary Sjögren's syndrome

Disease Duration Affects the Clinical Phenotype of Primary Sjögren Syndrome: A Medical Records Review Study of 952 Cases

OBJECTIVES

To investigate the impact of disease duration on clinical phenotypes in Chinese patients with primary Sjögren syndrome (pSS) and examine the correlation between clinical phenotypes and onset age, age at diagnosis, and disease duration.

METHODS

Data from 952 patients diagnosed with pSS in China between January 2013 and March 2022 were analyzed based on medical records. Patients were categorized into 3 groups based on disease duration: short (<5 years), moderate (≥5 and <10 years), and long (≥10 years) group. Clinical characteristics were compared among the 3 groups, and pSS patients with a long disease duration were compared with the other patients after matching age at diagnosis and age at onset.

RESULTS

Among the patients, 20.4% had a disease duration over 10 years. After matching for age at onset and age at diagnosis, pSS patients with a long disease duration exhibited a significantly higher prevalence of dry mouth ( p <0.001), dry eyes ( p <0.001), fatigue ( p <0.001), arthralgia ( p <0.001), and dental caries ( p <0.001) and higher rates of anti-Sjögren syndrome A ( p < 0.05), anti-Ro52 ( p < 0.05), and anti-SSB ( p < 0.05) positivity than their control groups, with prevalence increasing with disease duration ( ptrend < 0.001). However, no differences were noted in the prevalence of interstitial lung disease and leukopenia between different disease duration groups after matching for age at onset, although differences were shown when matching for age at diagnosis.

CONCLUSION

Longer disease duration in pSS patients correlates with increased prevalence of sicca symptoms, fatigue, and arthralgia and higher positivity of autoantibodies associated with pSS. However, the prevalence of interstitial lung disease and leukopenia did not correlate with disease duration after matching for age at onset.

Unveiling the age-related dynamics in Sjögren's syndrome: Insights from heart rate variability and autonomic function

BACKGROUND

Sjögren's Syndrome (SS), mainly affecting women in their midlife, is characterized by persistent inflammation in glands producing tears and saliva, often leading to significant complications. This study investigates the differences in autonomic system functioning between individuals with SS and healthy controls.

METHODS

From April 2019 to December 2022, 329 diagnosed primary SS (pSS) patients and 30 healthy controls were enrolled at Taipei Veterans General Hospital, Taipei, Taiwan. The study assessed autonomic nervous system functioning using various HRV metrics. Participants were divided based on age and AECG criteria, including salivary gland biopsy and autoantibody status.

RESULTS

Significant differences in Heart Rate Variability (HRV) were observed between pSS patients and healthy controls. The total power index was notably lower in pSS patients (4.98 ± 1.29) than in controls (5.54 ± 1.21, p = .022). Additionally, Vagal (VAG) activity was significantly reduced in the pSS group (4.95 ± 1.33) compared to the healthy control group (5.47 ± 1.19, p = .041). Age-stratified analysis highlighted that the ≤50 years pSS group had a higher heart rate (77.74 ± 10.42) compared to the >50 years group (73.86 ± 10.35, p = .005). This group also showed a higher total power index (5.78 ± 1.30) versus the >50 years group (4.68 ± 1.19, p < .001), and significantly lower VAG activity (4.70 ± 1.26, p = .007) compared to healthy controls. Furthermore, the Standard Deviation of Normal-to-Normal Intervals (SDNN) was greater in the ≤50 years SS group (44.45 ± 37.12) than in the >50 years group (33.51 ± 26.18, p = .007). In pSS patients, those positive for both salivary gland biopsy and autoantibodies demonstrated a lower Total Power (4.25 ± 1.32) and R-wave validity (93.50 ± 4.79, p < .05) than other groups, suggesting more severe autonomic imbalance. The R-R interval variation (RRIV) was also significantly higher in this dual-positive group (696.10 ± 975.41, p < .05). Additionally, the ESSPRI for dryness was markedly higher in the dual-positive group (8.10 ± 1.45, p < .05), indicating more severe symptoms. These findings reveal significant variations in autonomic function in SS patients, especially in those with dual-positive biopsy and autoantibody status.

CONCLUSION

This study demonstrates significant autonomic dysfunction in pSS patients compared to healthy controls, particularly in those positive for both salivary gland biopsy and autoantibodies. The age-stratified analysis further emphasizes the impact of aging on autonomic system functioning in pSS, suggesting a need for age-specific management approaches in pSS patient care.

Sex Difference in Primary Sjögren Syndrome: A Medical Records Review Study

OBJECTIVES

The aim of this study was to study clinical and biological differences between men and women with primary Sjögren syndrome (pSS) in China and perform a literature review to confirm if the clinical phenotypes are affected by sex in patients with pSS.

METHODS

Data from 961 patients with pSS treated at a tertiary hospital in China between January 2013 and March 2022 were analyzed based on medical records. Clinical characteristics, including disease manifestations and serological parameters of the disease, were compared between men and women with pSS using the Mann-Whitney U test and χ2 test.

RESULTS

This study included 140 (14.6%) men and 821 (85.4%) women with pSS. Women with pSS demonstrated a higher prevalence of dry mouth, dry eyes, arthralgia, and dental caries (p < 0.05); higher erythrocyte sedimentation rate and immunoglobulin M levels (p < 0.05); higher prevalence of leukopenia, neutropenia, anemia, low complement 3, and low complement 4 (p < 0.05); and higher titers of antinuclear antibody, anti-Sjögren syndrome A, anti-Ro52, and rheumatoid factor positivity (p < 0.05) than men, whereas men with pSS had a higher prevalence of parotid enlargement and interstitial lung disease (p < 0.05).

CONCLUSIONS

Women with pSS are associated with more dryness, cytopenia, hypocomplementemia, and autoantibody positivity. Although men with pSS probably have lighter sicca symptoms and lower immunoactivity and serologic responses, regular monitoring of interstitial lung disease in men is vital.

Age-related changes in ocular mucosal tolerance: Lessons learned from gut and respiratory tract immunity

The ocular surface is the part of the visual system directly exposed to the environment, and it comprises the cornea, the first refractive tissue layer and its surrounding structures. The ocular surface has evolved to keep the cornea smooth and wet, a prerequisite for proper sight, and also protected. To this aim, the ocular surface is a bona fide mucosal niche with an immune system capable of fighting against dangerous pathogens. However, due to the potential harmful effects of uncontrolled inflammation, the ocular surface has several mechanisms to keep the immune response in check. Specifically, the ocular surface is maintained inflammation-free and functional by a particular form of peripheral tolerance known as mucosal tolerance, markedly different from the immune privilege of intraocular structures. Remarkably, conjunctival tolerance is akin to the oral and respiratory tolerance mechanisms found in the gut and airways, respectively. And also similarly, this form of immunoregulation in the eye is affected by ageing just as it is in the digestive and respiratory tracts. With ageing comes an increased prevalence of immune-based ocular surface disorders, which could be related to an age-related impairment of conjunctival tolerance. The purpose of this review was to summarize the present knowledge of ocular mucosal tolerance and how it is affected by the ageing process in the light of the current literature on mucosal immunoregulation of the gut and airways.

The ocular surface immune system through the eyes of aging

Since the last century, advances in healthcare, housing, and education have led to an increase in life expectancy. Longevity is accompanied by a higher prevalence of age-related diseases, such as cancer, autoimmunity, diabetes, and infection, and part of this increase in disease incidence relates to the significant changes that aging brings about in the immune system. The eye is not spared by aging either, presenting with age-related disorders of its own, and interestingly, many of these diseases have immune pathophysiology. Being delicate organs that must be exposed to the environment in order to capture light, the eyes are endowed with a mucosal environment that protects them, the so-called ocular surface. As in other mucosal sites, immune responses at the ocular surface need to be swift and potent to eliminate threats but are at the same time tightly controlled to prevent excessive inflammation and bystander damage. This review will detail how aging affects the mucosal immune response of the ocular surface as a whole and how this process relates to the higher incidence of ocular surface disease in the elderly.

Primary Sjögren's Syndrome of Early and Late Onset: Distinct Clinical Phenotypes and Lymphoma Development

Objectives

To study the clinical, serological and histologic features of primary Sjögren’s syndrome (pSS) patients with early (young ≤35 years) or late (old ≥65 years) onset and to explore the differential effect on lymphoma development.

Methods

From a multicentre study population of 1997 consecutive pSS patients, those with early or late disease onset, were matched and compared with pSS control patients of middle age onset. Data driven analysis was applied to identify the independent variables associated with lymphoma in both age groups.

Results

Young pSS patients (19%, n = 379) had higher frequency of salivary gland enlargement (SGE, lymphadenopathy, Raynaud’s phenomenon, autoantibodies, C4 hypocomplementemia, hypergammaglobulinemia, leukopenia, and lymphoma (10.3% vs. 5.7%, p = 0.030, OR = 1.91, 95% CI: 1.11–3.27), while old pSS patients (15%, n = 293) had more frequently dry mouth, interstitial lung disease, and lymphoma (6.8% vs. 2.1%, p = 0.011, OR = 3.40, 95% CI: 1.34–8.17) compared to their middle-aged pSS controls, respectively. In young pSS patients, cryoglobulinemia, C4 hypocomplementemia, lymphadenopathy, and SGE were identified as independent lymphoma associated factors, as opposed to old pSS patients in whom SGE, C4 hypocomplementemia and male gender were the independent lymphoma associated factors. Early onset pSS patients displayed two incidence peaks of lymphoma within 3 years of onset and after 10 years, while in late onset pSS patients, lymphoma occurred within the first 6 years.

Conclusion

Patients with early and late disease onset constitute a significant proportion of pSS population with distinct clinical phenotypes. They possess a higher prevalence of lymphoma, with different predisposing factors and lymphoma distribution across time.

Primary Sjӧgren's syndrome with renal Fanconi syndrome: Good responses to treatment with glucocorticoids

BACKGROUND

Renal Fanconi syndrome (FS) is rare in primary Sjӧgren's syndrome (pSS). We aimed to describe the clinicopathological characteristics of pSS associated FS (pSS-FS) and its responses to treatment.

METHODS

We reported 25 cases of pSS-FS patients and retrospectively reviewed their clinical records, kidney pathology and follow-up data.

RESULTS

The 25 pSS-FS patients were mainly female (92.0%) and the mean age at diagnosis was 43.6±11.3 years. They showed different degrees of proximal tubular dysfunctions and eGFR decline (60.9±32.3 ml/min/1.73m²). Kidney pathology of pSS-FS patients showed tubulo-interstitial nephritis with defective brush border and lymphoplasmacytic infiltrates. After glucocorticoid treatment, the eGFR levels were significantly improved from 48.3±20.6 ml/min/1.73m² to 55.0±19.9 ml/min/1.73m² (P = 0.012) at the third month of follow-up. They also acquired good tubular (88.2%) and immunological (90.0%) responses. pSS-FS patients with young-onset pSS presented with a higher prevalence of positive anti-SSB antibody and hypocomplementemia, more severe hypokalemia, and better eGFR levels.

CONCLUSIONS

In pSS-FS patients, use of glucocorticoids could improve eGFR and tubular functions. The young-onset pSS group presented with a particular pattern in immunological features and kidney involvement.

Toward better outcomes in Sjögren's syndrome: The promise of a stratified medicine approach

Sjögren's syndrome is a systemic autoimmune disease defined by its targeted inflammation of the salivary and lacrimal glands, resulting in dry mouth and eyes in the majority and persistent or recurrent salivary gland enlargement in a minority of those affected. Involvement of major organs, an increased risk of lymphoma, and autoantibodies against ubiquitous cellular ribonucleoproteins define some of its systemic features. Those affected have a high symptom burden and the development of disease-modifying therapies is thus an urgent need. A stratified medicine approach offers promise as a means of targeting specific therapies to patients for whom the mechanism of action is most relevant. Implementation of this approach will require an understanding of the pathophysiological processes underlying different patient subsets, and then identifying or developing a drug that targets this pathway. Such therapies would be most effective if implemented early in the disease course before the advent of adverse outcomes or glandular damage. This review will provide a disease overview followed by an analysis of the feasibility of a stratified medicine approach, focusing on the disease heterogeneity, predictors of disease progression and adverse outcomes, and recent advances in the development of relevant outcome measures and new therapies.

Predicting lymphoma development in patients with Sjögren's syndrome

Introduction: The issue of predicting lymphoma in primary Sjögren's syndrome (pSS) starts from its clinical and biologic essence, i.e., an autoimmune exocrinopathy with sicca syndrome, inflammation and lymphoproliferation of MALT (mucosa-associated lymphoid tissue) in exocrine glands. Areas covered: The two major predictors to be firstly focused are persistent salivary gland (SG) swelling and cryoglobulinemic vasculitis with related features as purpura and low C4, or the sole serum cryoglobulinemia repeatedly detected. They are pathogenetically linked and reflect a heavier MALT involvement by histopathology, with the expansion of peculiar rheumatoid factor (RF)-positive clones/idiotypes. Other predictors include lymphadenopathy, splenomegaly, neutropenia, lymphopenia, serum beta2-microglobulin, monoclonal immunoglobulins, light chains, and RF. Composite indexes/scores may also predict lymphoma. Expert opinion: Prediction at baseline needs amelioration, and must be repeated in the follow-up. Careful clinical characterization, with harmonization and stratification of large cohorts, is a relevant preliminary step. Validated and new biomarkers are needed in biologic fluids and tissues. SG echography with automatic scoring could represent a future imaging biomarker, still lacking. Scoring MALT involvement in pSS, as an additional tool to evaluate disease activity and possibly to predict lymphoma, is welcomed. All these efforts are now ongoing within the HarmonicSS project and in other research initiatives in pSS.

Predictive markers of lymphomagenesis in Sjögren's syndrome: From clinical data to molecular stratification

Sjögren's syndrome (SS) is a chronic systemic autoimmune disease, affecting predominantly the exocrine glands, a large array of systemic manifestations and high risk of lymphoma development. The latter constitutes the major adverse outcome of SS contributing in the increased morbidity and mortality of the disease. The vast majority of lymphomas in SS are B-cell non-Hodgkin's lymphomas (NHL), primarily indolent mucosa-associated lymphoid tissue (MALT) lymphomas, followed by nodal marginal zone lymphomas (NMZL) and diffuse large B cell lymphomas (DLBCL). In the last 3 decades and due to the adverse impact of NHL in disease outcome, an effort has been undertaken to identify markers and models predicting patients with SS at high risk for lymphoma development. Several epidemiological, clinical, laboratory and histological parameters, some of which are evident at the time of SS diagnosis, were proved to independently predict the development of NHL. These include salivary gland enlargement, skin vasculitis/purpura, glomerulonephritis, peripheral neuropathy, Raynaud's phenomenon, lymphadenopathy, splenomegaly, cytopenias, hypocomplementemia, cryoglobulinemia, rheumatoid factor, anti-Ro/La autoantibodies, hypergammaglobulinemia, serum monoclonal gammopathy, biopsy focus score and organization of lymphocytic infiltrates in the salivary glands into ectopic germinal centers. Prediction models combining some of the afore-mentioned predictors have also been described. However, the identification of specific and sensitive molecular biomarkers, related to the process of lymphomagenesis is still pending. Recently, we described a novel biomarker the miR200b-5p micro-RNA. Low levels of this miRNA in the minor salivary glands, appears to discriminate with high specificity and sensitivity the SS patients who have from those who do not have NHL. miR200b-5p, being expressed years before the clinical onset of NHL, independently predicts NHL development with a predictive value higher than the previously published multifactorial models and has a possible role in the monitoring of therapeutic response. Thus, it is a strong candidate for the identification and follow-up of patients at risk.

Update on Sjögren Syndrome and Other Causes of Sicca in Older Adults

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypical disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Anti-citrullinated protein antibodies and arthritis in Sjögren's syndrome: a systematic review and meta-analysis

OBJECTIVE

The presence of anti-citrullinated protein antibodies (ACPAs) in primary Sjögren's syndrome (pSS) ranges from 3% to 9.9%; however, there is no agreement about their clinical significance. Our aim was to systematically review the literature regarding the association of arthritis and ACPAs in pSS and their role in the development of rheumatoid arthritis (RA).

METHOD

A comprehensive search of MEDLINE, ISI Web of Knowledge, and Cochrane Library from inception until June 2016 was undertaken using the combination of two or three of the keywords: primary Sjögren's syndrome, Sjögren's syndrome, arthritis, synovitis, arthropathy, anti-cyclic citrullinated peptide antibodies, and anti-citrullinated protein antibody - ACPA. No language restriction was used. Studies were included if they: assessed the association of arthritis and ACPAs, had sufficient data to construct a two-by-two table, tested immunoglobulin G ACPA by any method, and included patients with pSS according to a validated set of classification criteria. We used a random effects model and evaluated the heterogeneity and publication bias.

RESULTS

Ten studies were included (involving 1322 patients). We found a pooled odds ratio of 4.42 (95% confidence interval 1.15-16.94, p = 0.03). The test for heterogeneity was I² = 0.87. Publication bias was not observed. Based on data from three studies, 33 of 58 pSS patients with ACPAs (57%) developed RA compared with none of 598 pSS patients with negative ACPA (p < 0.000001).

CONCLUSION

Patients with pSS disclosing ACPAs are prone to arthritis as part of the clinical spectrum of the disease, but are also at risk of developing RA.

Sjögren Syndrome and Other Causes of Sicca in Older Adults

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypic disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Outcome of Reverse Shoulder Arthroplasty for Patients With Parkinson's Disease: A Matched Cohort Study

Parkinson's disease (PD) is a progressive neurologic disorder that affects the musculoskeletal system. Currently, the use of reverse shoulder arthroplasty (RSA) for patients with PD has not been adequately studied. The authors sought to determine if RSA provided similar functional outcomes for patients with PD compared with a matched cohort of patients without PD. Between 2004 and 2011, 10 patients with PD (4 men, 6 women) underwent RSA. Patients with PD were matched to patients without PD at a 1:4 ratio based on age (average, 76 years; range, 63-85 years), sex (16 men, 24 women), preoperative diagnosis, and length of follow-up (average, 43 months; range, 24-128 months). Outcome measures included range of motion, visual analog scale (VAS) score, Simple Shoulder Test (SST) score, American Shoulder and Elbow Society (ASES) score, and complication rates. Patients with PD had improvements in SST scores, ASES total scores, and forward flexion; however, they did not show statistically significant improvements in VAS scores, ASES function scores, or other range of motion parameters. There was a significant difference in postoperative functional outcome scores, SST scores, and internal/external rotation between the 2 groups, but no difference in postoperative pain scores, ASES total scores, forward flexion, or abduction. Complications occurred in 4 of 10 patients with PD and 6 of 40 patients without PD. Compared with the matched cohort, patients with PD achieved similar reduction of pain but inferior clinical function following RSA. Improvement in range of motion was less predictable and complication rates were significantly higher in patients with PD. [Orthopedics. 2017; 40(4):e675-e680.].

Cystic lung disease in Sjögren's syndrome: An observational study

OBJECTIVES

To analyze the prevalence, characteristics and outcome of cystic lung disease associated with Sjögren's syndrome (SS).

METHODS

From June 2010 to February 2015, 90 consecutive SS patients [60.1±14.8years; 88 (97.8%) female, 75 (83.3%) primary SS] had a systematic chest CT-scan. The presence of thin-walled cysts was analyzed by one experienced radiologist. Demographic data, clinical history, laboratory findings, and pulmonary function tests were extracted retrospectively from medical records.

RESULTS

Twenty-one (23.3%) patients had cysts on CT scan performed 40.5±54.5months after SS diagnosis. Cysts number ranged from 1 to 25 were often bilateral (52.4%) and mostly located in the middle lung zone (76.2%). Cysts were isolated (n=6, 28.6%) or associated with other lesions, including bronchiectasis (n=5, 23.8%), micronodules (n=5, 23.8%), ground-glass opacity (n=4, 19%) and/or air trapping (n=3, 14.3%). Most patients with cysts (57.1%) had no respiratory symptoms. When comparing SS patients with and without cysts, patients with cysts tended to be older (65.3±15.3 versus 58.5±14.4years, P=0.06). Smoking habits were similar in both groups. Anti-SSB antibodies were more frequently detected in patients with cysts (57.1% vs. 26.1%, P=0.02). Pulmonary function tests were normal or displayed only mild small airways obstruction and reduced diffusion capacity to carbon monoxide. Four (19%) patients with cysts had a past history of associated pulmonary disease, including interstitial lung disease. During follow-up (25.1±17.7months), no patient developed specific lung disease or lymphoproliferative disorders.

CONCLUSIONS

Cystic lung disease is frequent, benign, associated with anti-SSB/La antibodies and has no impact on outcome in SS.

Prediction of Sjögren's Syndrome Years Before Diagnosis and Identification of Patients With Early Onset and Severe Disease Course by Autoantibody Profiling

OBJECTIVE

Autoantibodies are highly characteristic of primary Sjögren's syndrome (SS) and represent important tools for studying its pathogenesis. Nonetheless, thus far, no systematic investigations have assessed the presence of autoantibodies before diagnosis. This study was undertaken to analyze how early and in what order autoantibodies appear, how predictive they are of primary SS, and whether they identify disease subsets.

METHODS

A nested case-control design linking data from the Malmö primary SS registry and 3 Swedish healthcare biobanks was applied. In all, 175 serum samples obtained from 117 individuals before diagnosis of primary SS and 1 serum sample from each of 117 matched controls were analyzed for antinuclear antibodies (ANAs), rheumatoid factor (RF), and antibodies against Ro 60/SSA, Ro 52/SSA, and La/SSB.

RESULTS

Considering all patients with primary SS who were autoantibody positive after diagnosis, at least one autoantibody specificity was detected in 81% up to 20 years (median 4.3-5.1 years) before diagnosis. Those found most often were ANAs, followed by RF, anti-Ro 60/SSA, anti-Ro 52/SSA, and anti-La/SSB. Anti-Ro/SSA and anti-La/SSB antibodies were strongly associated with the risk of developing primary SS, especially early-onset disease and a severe disease course. When Bayesian prior prevalence estimates for primary SS were included in the calculation, prediagnostic anti-Ro 60/SSA and anti-Ro 52/SSA had the highest positive predictive values (25% and 100%, respectively).

CONCLUSION

Our findings indicate that autoantibodies are present for up to 18-20 years before the diagnosis of primary SS, but we cannot exclude even earlier seropositivity, since for most patients, the earliest sample analyzed was positive. In families with multiple cases of autoimmune disease, autoantibody profiling, along with assessment of genetic risk, enables identification of susceptible individuals in a predisease state.

Primary Sjögren syndrome in Han Chinese: clinical and immunological characteristics of 483 patients

The epidemiological characteristics of Sjögren syndrome (SS) are significantly varied in different countries. We conducted the present study to survey the epidemiological characteristics of primary SS in China. We recruited 483 primary SS patients from 16 Chinese medical centers nationwide from January 2009 to November 2011 and assessed salivary and lacrimal gland dysfunction, organ involvement, and autoimmunity in these patients. The cohort included 456 women and 27 men (ratio, 17:1; mean age at onset, 42 ± 11 years; median age at diagnosis, 49 years; range, 41-56 years). Male patients showed a lower frequency of xerophthalmia (37.0% vs 60.7%) and a higher frequency of arthritis (40.7% vs 16.4%). Young-onset patients showed a higher frequency of low C3 levels (57.7% vs 36.3%) and pancytopenia (22.2% vs 8.8%). Patients with systemic involvement had a higher frequency of immunoglobulin A (IgA) (39.4% vs 22.5%) and immunoglobulin M (IgM) (12.4% vs 37.9%). Patients with pulmonary involvement had a higher parotid enlargement (21.4% vs 10.2%), purpura (12.1% vs 5.7%) and higher anti-La/SS-B (61.7% vs 41.8%), immunoglobulin G (IgG) (80.7% vs 64.6%) and IgA (48.9% vs 30.6%) levels. Patients with anti-Ro/SSA antibodies had more frequent exocrine gland symptoms and some extraglandular symptoms and immunological alterations. Compared with previous studies performed in other countries, SS patients in China showed particular clinical manifestation, systemic involvement, and immunological alterations.

[Primitive Sjögren syndrome in the elderly: clinical and immunological characteristics]

Les objectifs de notre étude est d’étudier les caractéristiques cliniques et immunologiques du syndrome de Gougerot Sjogren primitif (SGSp) du sujet âgé et les comparer à une population témoin plus jeune. Nous avons analysé rétrospectivement les dossiers de 60 patients atteints de SGSp consécutifs, suivis au service de Médecine interne du CHU Taher Sfar de Mahdia, en Tunisie, durant une période de 7 ans (janvier 2007 à décembre 2013). Les patients avec SGSp étaient classés en deux groupes selon l’âge de début de la maladie: groupe de sujets âgés (≥ 65 ans) et groupe de sujets jeunes (<65 ans). Chez 18 patients (30%), le SGSp a débuté après 65 ans. Il s'agissait de 17 femmes (94,5%) et un homme (5,5%). L’âge moyen du début du SGSp était de 70,5 ans ±3,1. Le délai moyen du diagnostic était de 38,6 mois ±26,8. Les manifestations glandulaires étaient constantes. La comparaison entre le groupe du SGSp du sujet âgé et celui du sujet jeune montrait que le délai moyen du diagnostic du SGSp était significativement plus long chez les sujets âgés. Les manifestations pulmonaires étaient significativement plus fréquentes chez les sujets âgés. En revanche, les fréquences des anticorps antinucléaires, anti-SSA et anti-SSB étaient significativement plus élevées chez les sujets jeunes. Bien que le SGSp soit une maladie typique d'adultes d’âge moyen, les cliniciens ne devraient pas ignorer que cette maladie peut être diagnostiquée aussi chez les patients âgés. Notre étude montre que l’âge du début avancé influence le profil clinique et immunologique du SGSp.

Sjögren's syndrome: an update on epidemiology and current insights on pathophysiology

Primary Sjögren's syndrome (pSS) is an autoimmune chronic inflammatory disorder affecting 0.2% to 3.0% of the population, with a 9:1 female to male ratio. Features are oral and ocular dryness, local and systemic autoantibody production, and progressive focal mononuclear cell infiltration in the affected salivary and lacrimal glands. Lymphoma is the most severe complication of pSS, occurring in 4% to 5% of patients. Genetic studies identified an association with HLA and susceptibility genes in cytokine genes and genes involved in B-cell differentiation. Genetic variations may help explain why disease manifestations differ among patients and supports the hypothesis of certain distinct disease phenotypes.

Early- versus late-onset systemic sclerosis: differences in clinical presentation and outcome in 1037 patients

Peak age at onset of systemic sclerosis (SSc) is between 20 and 50 years, although SSc is also described in both young and elderly patients. We conducted the present study to determine if age at disease onset modulates the clinical characteristics and outcome of SSc patients. The Spanish Scleroderma Study Group recruited 1037 patients with a mean follow-up of 5.2 ± 6.8 years. Based on the mean ± 1 standard deviation (SD) of age at disease onset (45 ± 15 yr) of the whole series, patients were classified into 3 groups: age ≤ 30 years (early onset), age between 31 and 59 years (standard onset), and age ≥ 60 years (late onset). We compared initial and cumulative manifestations, immunologic features, and death rates. The early-onset group included 195 patients; standard-onset group, 651; and late-onset, 191 patients. The early-onset group had a higher prevalence of esophageal involvement (72% in early-onset compared with 67% in standard-onset and 56% in late-onset; p = 0.004), and myositis (11%, 7.2%, and 2.9%, respectively; p = 0.009), but a lower prevalence of centromere antibodies (33%, 46%, and 47%, respectively; p = 0.007). In contrast, late-onset SSc was characterized by a lower prevalence of digital ulcers (54%, 41%, and 34%, respectively; p < 0.001) but higher rates of heart conduction system abnormalities (9%, 13%, and 21%, respectively; p = 0.004). Pulmonary hypertension was found in 25% of elderly patients and in 12% of the youngest patients (p = 0.010). After correction for the population effects of age and sex, standardized mortality ratio was shown to be higher in younger patients. The results of the present study confirm that age at disease onset is associated with differences in clinical presentation and outcome in SSc patients.

Clinical analysis of primary Sjögren's syndrome complicating anemia

This is a cross-sectional study to assess the prevalence and causes of anemia in the primary Sjögren's syndrome (pSS). One hundred and thirty-two consecutive patients with pSS were enrolled into the study. Standard hematological and immunological tests and examination of bone marrow were performed. Anemia occurred in 45 (34.1%) patients. The causes of anemia included anemia of chronic disease (69%), autoimmune hemolytic anemia (AIHA, 18%), iron deficiency anemia (9%) and other causes (4%), of which AIHA caused the most severe anemia. The prevalence of ANA, anti-Ro/SSA, and anti-La/SSB was much higher in patients with anemia than those without anemia. Anticardiolipin antibodies were most commonly detected in AIHA; the prevalence of IgG and hypocomplementemia in AIHA was much higher in patients without anemia. Abnormal bone marrow changes were observed in two cases with anemia, one with morphological changes in the myeloid, megakaryocytic, and erythroid lineages and one with hypocellularity in the erythroid lineage. Therefore, pSS patients with anemia may be associated with destruction of peripheral mature blood cells, impaired red cells production, and hematopoietic abnormalities due to an immune mechanism, although the concrete pathogenesis is still unclear.

Cytokine and autoantibody profiling related to histopathological features in primary Sjogren's syndrome

OBJECTIVE

To investigate a potential correlation between circulating cytokine and autoantibody levels and histopathological features in subgroups of patients with primary SS (pSS).

METHODS

Minor salivary gland biopsies from a cohort of 141 patients fulfilling the American-European consensus classification criteria for pSS were re-examined and grouped according to focus score (FS) and germinal centre (GC) status; serum samples were analysed for autoantibodies, chemokines and cytokines.

RESULTS

Of the 115 available biopsies, 18 (16%) lacked characteristic focal mononuclear cell infiltrates [FS < 1 (FS-)] but patients were positive for Ro/SSA and/or La/SSB. IL-17, IL-1RA, IL-15, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta, eotaxin, IFN-alpha and IL-4 levels were significantly increased in the 27 (23%) patients with ectopic GC formation (GC+) in the salivary glands compared with the GC- patients (n = 70). In addition, minor differences in cytokine levels were found when comparing age groups.

CONCLUSION

Degenerative changes observed in the minor salivary glands of patients with pSS may represent 'burned out' inflammation. The elevated levels of IL-4 found in these patients may influence the reduced salivary flow observed in GC+ patients. Increased titres of Th17-associated cytokines, IL-17, IL-1beta and the IL-23 subunit IL-12p40, may indicate a higher activity of these cells in GC+ patients. Differences in cytokine levels may be utilized when sub-grouping the SS patients into disease phases and may consequently have implications for treatment.

Estimating the prevalence among Caucasian women of primary Sjögren's syndrome in two general practices in Birmingham, UK

OBJECTIVE

To establish the prevalence among women of primary Sjögren's syndrome (PSS) in Birmingham, UK.

METHODS

Eight hundred and forty-six female Caucasians from two general practitioner lists were invited to complete a questionnaire that included a screening question on dry eyes and mouth. Individuals who responded positively were evaluated further.

RESULTS

Overall, 65/% of individuals who were sent a questionnaire responded. Two had possible PSS, but were negative for anti-Ro/La antibodies. Our estimates of the prevalence of PSS ranged from < 0.1% up to 0.4%, depending on the assumptions used.

CONCLUSION

Our data support previous studies suggesting a prevalence of PSS in the community of 0.1-0.6% rather than those suggesting a higher figure.

Possible importance of immunoglobulin E in foetal loss by mothers with anti‐SSA antibody

OBJECTIVE

The incidence of foetal loss and/or adverse foetal outcomes, including congenital heart block (CHB), has been investigated in mothers with anti-SSA antibody detected by immunodiffusion or counter-immunoelectrophoresis methods. We investigated the relationship between several serum parameters (such as autoantibodies and immunoglobulins) and foetal loss in patients with anti-SSA antibody, measured by enzyme-linked immunosorbent assay (ELISA).

MATERIAL AND METHODS

Thirty-seven women who showed positivity for anti-SSA antibody and had a history of pregnancy were included in this study. Immunoglobulins and several autoantibodies were assayed by routine laboratory methods at our hospital.

RESULTS

Our data indicated that immunoglobulin E (IgE) levels were significantly higher in the anti-SSA antibody positive women with foetal loss than in those without, and that a strong positive correlation between IgE and anti-SSA antibody levels was observed in the former group, but not in the latter.

CONCLUSION

The serum IgE level seems to be an important factor in the occurrence of foetal loss in mothers with anti-SSA antibody detected by ELISA.

Primary Sjögren syndrome in Spain: clinical and immunologic expression in 1010 patients

We conducted the current study to characterize the clinical presentation of primary Sjögren syndrome (SS) in a large cohort of Spanish patients and to determine whether epidemiologic, clinical, and analytical features modulate disease expression. Patients were from the GEMESS Study group, which was formed in 2005 and included 12 Spanish reference centers. By March 2007, the database included 1010 consecutive patients, recruited since 1994, both incident and prevalent cases. The cohort included 937 women and 73 men (ratio, 13:1), with a mean age of 53 years at diagnosis and 59 years at inclusion in the registry. Multivariate analysis showed that male patients had a lower frequency of thyroiditis, Raynaud phenomenon, and antinuclear antibodies. Young-onset patients had a low degree of sicca involvement (xerostomia and parotid enlargement) and a high frequency of immunologic markers (anti-Ro/SS-A and low C4 levels). Patients with disease duration of more than 10 years had a higher prevalence of xerophthalmia, parotid enlargement, lung involvement, and peripheral neuropathy in comparison with incident cases. The subset of patients with anti-Ro/La antibodies had the highest prevalence of most systemic, hematologic, and immunologic alterations (higher frequency of Raynaud phenomenon, altered parotid scintigraphy, positive salivary gland biopsy, peripheral neuropathy, thrombocytopenia, and rheumatoid factor). Hypocomplementemia was associated with a higher frequency of vasculitis and lymphoma, and cryoglobulins with a higher frequency of parotid enlargement, vasculitis, and leukopenia.Epidemiologic, clinical, and analytical features have a significant impact on the clinical presentation of primary SS, influencing the results of the main diagnostic tests, the prevalence and diversity of extraglandular involvement, and the frequency of the main immunologic markers. Primary SS should be considered as a systemic autoimmune disease that can express in many guises beyond sicca involvement.

Primary Sjögren's syndrome: new clinical and therapeutic concepts

Sicca features are the central clinical manifestations of Sjögren's syndrome (SS), but recent studies have confirmed that primary SS has a systemic expression, including extraglandular manifestations. Patients with a predominantly extraepithelial expression should be managed differently from patients with predominantly periepithelial or sicca limited disease. In coming years treatment will be based on muscarinic agonists for sicca features and immunosuppressive/biological agents for extraglandular features.

Systemic autoimmune diseases in elderly patients:

The possible consequences of the progressive 'ageing' of the immune system are the increase in autoimmune phenomenon, incidence of neoplasia and predisposition to infections. This review analyses the clinical expression of the systemic autoimmune diseases in older patients, focusing on three specific characteristics: the frequent atypical presentation of autoimmune diseases in the elderly, the higher morbidity and mortality of these patients and the frequent association with neoplasic processes. The study of autoimmune manifestations in elderly populations should be considered a priority for future medical research because of increasing life expectation, especially in developed countries.

Histopathological investigation of salivary glands in the asymptomatic elderly

The significance of labial gland biopsies (LGBs) in the diagnosis of Sjögren's syndrome (SS) in the elderly has been a controversial subject since it is complicated by age-related histopathological changes. In an attempt to clarify the appropriateness of LGBs in present diagnosis criteria, we evaluated the specificity of LGBs using autopsied tissues. This was done by taking labial, sublingual and submandibular salivary glands from 53 autopsy subjects (24 males and 29 females) with an average age of 84 years, and testing them histopathologically with reference to a previously reported grading system. None had any sicca symptoms (oral dryness or dry eye). In subjects up to 75 years old, acinar atrophy was more frequent in labial glands than in the two major salivary glands (P=0.0098 for sublingual and P=0.0009 for submandibular glands). Also, while there were significant differences in frequency of such atrophy between the sublingual and submandibular salivary glands of subjects younger and older than 75, the labial glands showed no such variation. Taking grade 3 (focus score of 1) as the diagnosis criterion, two subjects were determined to have SS in which case the specificity was 95%. Using contemporaneous serological test results for anti-SSA/Ro antibodies as a diagnostic criterion raised specificity to 98%. For both major and minor glands, these appeared to be no relationship between degree of lymphocytic infiltration and age. Our results thus suggest that it is appropriate to adopt a focus score of 1 as a diagnostic criterion for SS in the elderly, and that serological test results can improve specificity.

Young age of onset is associated with increased prevalence of circulating IgM rheumatoid factor and antinuclear antibodies at presentation in women with rheumatoid arthritis

In 200 patients, 143 women and 57 men, with rheumatoid arthritis (RA), age at onset was related to the presence of IgM rheumatoid factor (RF) and antinuclear antibodies (ANA) in serum at presentation. The patients were stratified into bands of age at onset: <40 years, 40- 60 years, and >60 years. In women, the prevalences of ANA (1:160) were 63.0%, 45.5%, and 31.1% in the respective age bands ( p=0.002), and the prevalences of IgM RF were 85.2%, 72.7% and 66.4%, respectively ( p=0.03). The prevalences of ANA and IgM RF among men were, respectively, 35% and 86% with no association with age at onset. The findings may indicate interactive effects between gender and various pathogenetic factors.

Autoimmunity and geriatrics: clinical significance of autoimmune manifestations in the elderly

The immune system undergoes continuous morphologic and functional changes throughout the years, and it is now believed that the immune response has its peak function in puberty and gradually decreases with age (immunosenescence). Recent studies in healthy octogenarian patients suggest that the immune system, instead of suffering a generalized deterioration, undergoes a remodelling/readjustment of its major functions. Increase in two contrasting phenomena coexist in immunosenescence: on the one hand, a decrease in the capacity of the immune response and, on the other hand autoantibody production. The possible consequences of this progressive 'ageing' of the immune system are the increase in autoimmune phenomena, incidence of neoplasia and predisposition to infections. The study of autoimmune manifestations in elderly populations should be considered a priority for future medical research because of increasing life expectancy, especially in developed countries. This review analyses the main immune disorders associated with immunosenescence, the prevalence and clinical significance of autoantibodies in the elderly and the clinical expression of the main autoimmune diseases in older patients.

Age and Risk of Pulmonary Arterial Hypertension in Scleroderma*

STUDY OBJECTIVES

To investigate whether age at disease onset is a risk factor for pulmonary arterial hypertension (PAH) in scleroderma.

SETTING

Scleroderma center.

PATIENTS

Seven hundred nine consecutive scleroderma patients who underwent echocardiography.

MEASUREMENTS

The risk of PAH associated with age at disease onset was modeled as both a continuous and categorical variable. Risk estimates were adjusted for sex, race, scleroderma subtype, disease duration, smoking status, FVC, anticentromere and antitopoisomerase I antibody status.

RESULTS

Overall, 274 patients (38.6%), 272 patients by Doppler echocardiography and 2 patients by M-mode echocardiography, had PAH at baseline or during follow-up. There were 114 patients with mild PAH (right ventricular systolic pressure [RVSP], 36 to 45 mm Hg), 66 patients with moderate PAH (RVSP, 46 to 55 mm Hg), and 92 patients with severe PAH (RVSP > or =56 mm Hg). A 52% increase in risk of PAH was demonstrated for every 10 years of age at disease onset (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.31 to 1.76). In addition, there was a twofold greater risk of PAH (OR, 2.30; 95% CI, 1.32 to 3.99) for late-onset (age > or =60 years) vs earlier-onset (< 60 years) disease. These associations remained evident and were somewhat strengthened when the analyses were restricted to patients with moderate and severe PAH.

CONCLUSIONS

We identified increasing age at scleroderma onset as a risk factor for PAH. Vigilance among these high-risk patients may provide an opportunity to intervene prior to development of irreversible pulmonary vascular disease.

Fungal load and candidiasis in Sjögren's syndrome

OBJECTIVE

We sought to investigate the prevalence of Candida carriage and the relationships between salivary flow rates and oral Candida load in patients with Sjögren's syndrome (SS).

METHODS

The oral Candida load of patients with SS was evaluated by culturing oral rinse (swish and spit) samples. Culture, Gram stain, and wet-mount test results were reported.

RESULTS

One hundred three patients (96 women) met European criteria for SS (91 with primary SS and 12 with secondary SS). The mean age (95% confidence interval) was 55 years (range, 51-57 years). Oral rinse cultures were positive in 77% of subjects. The total stimulated salivary flow rate was inversely correlated with oral Candida load (r = -0.47; P </=.0001). The oral rinse samples yielded gram-positive results in 38% of patients with SS, and the Fungi-Fluor assay (wet mount) results were positive in 49%.

CONCLUSIONS

The prevalence of Candida carriage varies according to the methods used to determine the presence of the organism and is similar to that reported in the literature. A low stimulated salivary flow rate-not a low unstimulated flow rate-was associated with Candida carriage.

Is the relationship between spondyloarthropathy and Sjögren's syndrome in women coincidental? A study of 13 cases

OBJECTIVE

To determine the prevalence of Sjogren's syndrome (SS) in women with spondyloarthropathy (SpA).

METHODS

Forty-one women with SpA manifesting as inflammatory back pain and/or peripheral arthritis were diagnosed as having ankylosing spondylitis, undifferentiated spondyloarthropathy, psoriatic arthritis, or enteropathic arthropathy based on accepted criteria. A validated questionnaire was used to look for sicca symptoms in the SpA group and in 102 controls with degenerative rheumatic diseases. Women with SpA and sicca symptoms and/or positive antinuclear antibodies (ANA) were investigated for SS by minor salivary gland biopsy. In the SpA group, the following tests were done: HLA B27; HLA DR, DQ; ENA; and serology for CMV, EBV, HIV, hepatitis B, and hepatitis C.

RESULTS

Thirteen women (31.7%) met European criteria for SS, compared to three (2.9%) of the controls. Of the 41 women with SpA, 16 (39%) were ANA-positive. ANA were detected in eight of the 16 (50%) patients with SS. HLA B27 was present in 11 of the 13 (84.6%) SS patients. HLA DR 04.04 and DQ 03.03 seemed more common in SS patients, but the difference was not statistically significant.

CONCLUSION

SS was far more common in the women with SpA (31.7%) than in the controls (2.9%), suggesting that the SpA-SS association may not be coincidental.

Monitoring the disease activity

Primary Sjögren's syndrome is a chronic systemic rheumatic disease characterized as an autoimmune exocrinopathy or autoimmune epithelitis thereby suggesting a pathogenesis leading to tissue specific autoimmune lesion. The development of internationally approved criteria for the classification and diagnosis of Sjögren's syndrome has been a major scientific task for nearly two decades with consensus now approaching. In contrast, an international dialogue on how to develop additional common criteria for the assessment of disease activity, organ damage and outcome in Sjögren's syndrome has just recently been initiated. Such assessment criteria would provide useful measures for patient management and are mandatory for comparing efficacy between different clinical trials. The lack of common assessment criteria may be explained by missing uniform diagnostic criteria, by the multispeciality and systemic nature of the disease and the difficulties in separating out what is activity and what is damage in Sjögren's syndrome. Attempts are now made to overcome these problems. The purpose of this paper is to give a brief introduction to the concepts of disease activity, damage and outcome in Sjogren's syndrome with reference to the results obtained from a recent workshop on assessment tools in Sjögren's syndrome held in Oxford, England in March 2000.