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Jankowska K, Dudek P, Stasiek M, Suchta K. Autoimmune polyendocrine syndromes associated with autoimmune rheumatic diseases. Reumatologia 2023; 61:225-238. [PMID: 37745144 PMCID: PMC10515125 DOI: 10.5114/reum/170266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/02/2023] [Indexed: 09/26/2023] Open
Abstract
Autoimmune polyendocrine syndromes (APSs), also called autoimmune polyglandular syndromes, are a group of autoimmune diseases characterized by the co-occurrence of dysfunctions of several (at least two) endocrine glands. They develop under the influence of environmental factors in genetically predisposed people. Autoimmune polyendocrine syndromes may accompany autoimmune rheumatic diseases and worsen their course - APS-2 and APS-3 are the most common. The APS-2 includes the coexistence of, e.g. Hashimoto's disease, celiac disease and rheumatoid arthritis (RA). In APS-3, rheumatic diseases such as RA, systemic lupus erythematosus, and Sjögren's syndrome may coexist with Hashimoto's disease, type 1 diabetes and hypogonadism or other endocrinopathies. Undiagnosed endocrine diseases may be the reason for the intensification of metabolic disorders observed in the course of rheumatic diseases, cause the ineffectiveness of rheumatological treatment and also increase the frequency of bone fractures due to osteoporosis, cardiovascular complications and even miscarriages when coexistent, e.g. Hashimoto's disease with hypothyroiditis, which increases the risk of pregnancy loss. It is important to be able to conduct an extensive interview, paying attention to the symptoms of possible endocrinopathy as well as the features of other autoimmune disorders in the physical examination (e.g. vitiligo or darkening of the skin in Addison's disease). Depending on the history and physical examination, screening for various APSs is advised.
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Affiliation(s)
- Katarzyna Jankowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Piotr Dudek
- Biological Therapy Center, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Małgorzata Stasiek
- Biological Therapy Center, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Katarzyna Suchta
- Department of Gynaecological Endocrinology, Medical University of Warsaw, Poland
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Zhong H, Liu S, Wang Y, Xu D, Li M, Zhao Y, Zeng X. Primary Sjögren's syndrome is associated with increased risk of malignancies besides lymphoma: A systematic review and meta-analysis. Clin Exp Rheumatol 2022; 21:103084. [PMID: 35341972 DOI: 10.1016/j.autrev.2022.103084] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/23/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Patients with primary Sjögren's syndrome(pSS) have increased risk of non-Hodgkin lymphoma (NHL). However, whether pSS patients have increased risk of other malignancies is unclear. The aim of this study is to investigate the association between pSS and the risk of malignancy, with a focus on hematological malignancies besides lymphoma and solid tumors through a systematic review and meta-analysis. METHOD We searched PubMed and EMBASE by March 21st 2021. Inclusion criteria were as follows: (1) pSS was the exposure of interest; (2) newly developed malignancies were the outcome of interest; (3) standardized incidence ratio or relative risk with 95% confidence interval or essential data to calculate them were reported. (4) Study design was cohort study. Patient with other connective diseases were excluded. Quality assessment was conducted according to Newcastle-Ottawa Scale for cohort study. Random or fixed effect models were used to calculate the pooled SIR according to heterogeneity measured by I2. RESULTS A total of 1003 articles were found by a comprehensive search in PubMed and EMBASE. Twenty-eight articles were eligible. Four of them were from the same database, the one with longest observational span was chosen. Therefore, twenty-five articles were included for final analysis, which involved more than 47,607 pSS patients with the follow-up of more than 452,468 person-year. We found that pSS was significantly associated with increased risks of overall malignancy(pooled SIR 2.17, 95%1.57-3.00), hematological malignancy(pooled SIR 11.55, 95%CI 4.32-30.90) including NHL(pooled SIR 13.71, 95%CI 8.83-21.29), Hodgkin lymphoma(pooled SIR 8.84, 95%CI 5.00-15.61), multiple myeloma(pooled SIR 8.27, 95%CI 3.08-22.24), leukemia(pooled SIR 2.56, 95%CI 1.78-3.69) and solid tumors(pooled SIR 1.39, 95%CI 0.90-2.13) including lung cancer(pooled SIR 1.55, 95%CI 1.29-1.85), thyroid cancer(pooled SIR 2.05, 95%CI 1.20-3.48), non-melanoma skin cancer(pooled SIR 1.71, 95%CI 1.08-2.72), kidney/urinary tract cancer(pooled SIR 1.36, 95%CI 1.02; 1.81), liver cancer(pooled SIR 1.70, 95%CI 1.13-2.57) and prostate cancer(pooled SIR 1.50, 95%CI 1.02-2.22). CONCLUSION This meta-analysis showed that pSS patients had increased risk of overall cancer, which not only contributed by NHL, but also by other hematological malignancies and solid tumors.
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Affiliation(s)
- Hui Zhong
- Department of Rheumatology and Clinical Immunology of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Siyao Liu
- Department of Rheumatology and Clinical Immunology of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, PR China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Girón-Pïllado M, Cruz-Bautista I, Saavedra-González V, Atisha-Fregoso Y, Barraza G, Aguilar-Salinas CA, Hernández-Molina G. Autoimmune Thyroid Disease in Primary Sjögren's Syndrome: Real-Life Screening Practice and Clinical Outcomes. Curr Rheumatol Rev 2022; 18:272-277. [PMID: 35086454 DOI: 10.2174/1573397118666220127105546] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/15/2021] [Accepted: 11/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Notwithstanding the frequent coexistence of autoimmune thyroid disease (ATD) and primary Sjögren's Syndrome (SS), it is still unknown how often this association is studied along with its clinical impact. OBJECTIVE This study aimed to describe real-world screening practices for ATD in patients with SS and evaluate clinical outcomes of patients with both diagnoses using validated activity and chronicity indexes. METHODS It is a retrospective study of 223 patients with SS attending a tertiary referral center. Patients were under rheumatology surveillance and might have attended other clinics, including internal medicine and/or endocrinology. We registered glandular and extraglandular features, serology and scored the activity (ESSDAI) and the accrual damage (SSDDI) indexes. We also identified any thyroid function tests (TFT) performed, anti-thyroid antibodies, images, and histological thyroid examinations. A single endocrinologist reviewed all data. RESULTS One hundred forty-nine patients had at least one set of TFT. Younger age was associated with a lack of screening (OR 0.98, 95% CI 0.95-0.99, p=0.01). Sixty-nine patients had thyroid disease, with the most common diagnosis being ATD (n=24). Patients with ATD had a lower prevalence of Ro/SSA and anti-La/SSB antibodies but similar cumulative SS activity and damage scores. CONCLUSION At least one-third of our patients were not screened for thyroid disease, with these patients being the youngest. Thyroid disorders were found in about 40% of patients with SS, with ATD being the most common. Having SS/ATD did not confer the worst disease activity or damage accrual. These results highlight the importance of making treating physicians aware of screening for thyroid disease in this population.
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Affiliation(s)
- Mario Girón-Pïllado
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico City, Mexico
| | - Ivette Cruz-Bautista
- Department of Endocrinology and Metabolism, and Research Unit of Metabolic Diseases. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico
| | - Vanessa Saavedra-González
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico City, Mexico
| | - Yemil Atisha-Fregoso
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico City, Mexico
| | - Gustavo Barraza
- Department of Radiology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico City, Mexico
| | - Carlos A Aguilar-Salinas
- Department of Endocrinology and Metabolism, and Research Unit of Metabolic Diseases. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico
| | - Gabriela Hernández-Molina
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Mexico City, Mexico
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Pörings AS, Lowin T, Dufner B, Grifka J, Straub RH. A thyroid hormone network exists in synovial fibroblasts of rheumatoid arthritis and osteoarthritis patients. Sci Rep 2019; 9:13235. [PMID: 31519956 PMCID: PMC6744488 DOI: 10.1038/s41598-019-49743-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/28/2019] [Indexed: 01/08/2023] Open
Abstract
While patients with rheumatoid arthritis (RA) sometimes demonstrate thyroidal illness, the role of thyroid hormones in inflamed synovial tissue is unknown. This is relevant because thyroid hormones stimulate immunity, and local cells can regulate thyroid hormone levels by deiodinases (DIO). The study followed the hypothesis that elements of a thyroid hormone network exist in synovial tissue. In 12 patients with RA and 32 with osteoarthritis (OA), we used serum, synovial fluid, synovial tissue, and synovial fibroblasts (SF) in order to characterize the local thyroid hormone network using ELISAs, immunohistochemistry, imaging methods, tissue superfusion studies, cell-based ELISAs, flow cytometry, and whole genome expression profiling. Serum/synovial fluid thyroid hormone levels were similar in RA and OA (inclusion criteria: no thyroidal illness). The degradation product termed reverse triiodothyronine (reverse T3) was much lower in serum compared to synovial fluid indicating biodegradation of thyroid hormones in the synovial environment. Superfusion experiments with synovial tissue also demonstrated biodegradation, particularly in RA. Cellular membrane transporters of thyroid hormones, DIOs, and thyroid hormone receptors were present in tissue and SF. Density of cells positive for degrading DIOs were higher in RA than OA. TNF increased protein expression of degrading DIOs in RASF and OASF. Gene expression studies of RASF revealed insignificant gene regulation by bioactive T3. RA and OA synovial tissue/SF show a local thyroid hormone network. Thyroid hormones undergo strong biodegradation in synovium. While bioactive T3 does not influence SF gene expression, SF seem to have a relay function for thyroid hormones.
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Affiliation(s)
- Anna-Sophia Pörings
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Torsten Lowin
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany.,W. & B. Hiller Research Center of Rheumatology, Life Science Center, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Bianca Dufner
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Joachim Grifka
- Department of Orthopedic Surgery, University Hospital Regensburg, Asklepios Clinic Bad Abbach, Bad Abbach, Germany
| | - Rainer H Straub
- Laboratory of Experimental Rheumatology and Neuroendocrine Immunology, Dept. of Internal Medicine, University Hospital Regensburg, Regensburg, Germany.
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High Prevalence of Antithyroid Antibodies in a New Zealand Cohort of Patients With Systemic Sclerosis. J Clin Rheumatol 2019; 24:264-271. [PMID: 29474198 DOI: 10.1097/rhu.0000000000000703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Autoimmune thyroid disease affects 1% of the general population, and autoimmune thyroid antibodies are noted in up to 15%. OBJECTIVE We hypothesized systemic sclerosis (SSc) is associated with higher prevalence of antithyroglobulin (anti-Tg) and anti-thyroid peroxidase (anti-TPO) antibodies) to justify monitoring of thyroid function for earlier detection and treatment. METHODS Waikato Hospital SSc clinic patients were prospectively tested for thyroid function tests and antithyroid antibodies (ATAs). RESULTS Of the 75 patients with SSc and 10 patients with SSc overlap syndrome (SOS) followed up in the SSc clinic, anti-Tg and anti-TPO were prospectively tested in 61 (70.6%) of the 85 patients. The cohort comprised 38 patients with limited cutaneous SSc (lcSSc), 15 with diffuse cutaneous SSc, and 8 with SOS.Anti-Tg and anti-TPO antibodies were found in 34.2% in lcSSc patients and 33.3% in diffuse cutaneous SSc patients, whereas in SOS they were found in 25% (Tg) and in 12.5% (TPO) of patients.At baseline, 10 patients (11.7%) had thyroid dysfunction: 8 (9.4%) with subclinical hypothyroidism and 1 each (1.2%) with subclinical hyperthyroidism and with clinical hyperthyroidism.After 18 months, 1 woman with lcSSc, positive for both ATAs, developed clinical hypothyroidism. CONCLUSIONS There is a higher prevalence of ATAs in SSc and SOS compared with the general population. Screening these patients for ATAs is a reasonable measure.
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Sun X, Lu L, Li Y, Yang R, Shan L, Wang Y. Increased risk of thyroid disease in patients with Sjogren's syndrome: a systematic review and meta-analysis. PeerJ 2019; 7:e6737. [PMID: 30918763 PMCID: PMC6430100 DOI: 10.7717/peerj.6737] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/07/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sjogren's syndrome (SS) is a chronic autoimmune epithelitis characterized by disruption of epithelial cells, ensuing lymphoplasmocytic infiltration of exocrine glands, and subsequent dryness of the mouth and eyes. Individuals with SS are more likely to have the thyroid disease. However, this association remains controversial. This meta-analysis aimed to evaluate the risk of thyroid disease in patients with SS. METHODS We performed this systematic review by searching both English and Chinese literature databases. Random- or fixed-effects models were used to summarize the association between thyroid disease and SS. The results were subjected to meta-analysis with odds ratios (ORs) and corresponding 95% confidence intervals (CIs). RESULTS The eight articles in this meta-analysis included 988 SS cases and 2,884 controls. Overall, the risk of thyroid disease in patients with SS was significantly increased compared with controls (OR, 3.29; 95% CI [2.08-5.21]). The risk of autoimmune thyroid disease (AITD) and non-AITD were also higher in patients with SS than in controls (OR, 3.48; 95% CI [1.59-7.63]; and OR, 2.90; 95% CI [1.51-5.57], respectively). CONCLUSIONS To the best of our knowledge, this systematic review is the first to demonstrate that the risk of thyroid disease was increased in SS compared to controls, suggesting that SS patients should be screened for thyroid disease.
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Affiliation(s)
- Xin Sun
- Department of Endocrinology and Metabolism, People's Hospital of Liaoning Province, Shenyang, China
| | - Li Lu
- Department of Endocrinology and Metabolism, People's Hospital of Liaoning Province, Shenyang, China
| | - Yanbin Li
- Department of Endocrinology and Metabolism, People's Hospital of Liaoning Province, Shenyang, China
| | - Rong Yang
- Department of Endocrinology and Metabolism, People's Hospital of Liaoning Province, Shenyang, China
| | - Ling Shan
- Department of Endocrinology and Metabolism, People's Hospital of Liaoning Province, Shenyang, China
| | - Yang Wang
- Department of Endocrinology and Metabolism, People's Hospital of Liaoning Province, Shenyang, China
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Matusiewicz A, Stróżyńska-Byrska J, Olesińska M. Polyautoimmunity in rheumatological conditions. Int J Rheum Dis 2018; 22:386-391. [PMID: 30548416 DOI: 10.1111/1756-185x.13454] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 10/12/2018] [Accepted: 11/08/2018] [Indexed: 12/14/2022]
Abstract
Co-occurrence of autoimmune diseases (ADs) within an individual is postulated to be a frequent phenomenon in rheumatic diseases. Similar clinical signs and symptoms, pathophysiological mechanisms, genetic factors within autoimmune diseases and aggregation of diverse ADs within families sustain the theory of shared pathogenesis of several ADs (autoimmune tautology). Polyautoimmunity (PA) is defined as the presence of more than one autoimmune disease in a single patient. When three or more autoimmune diseases coexist, this condition is called multiple autoimmune syndrome (MAS). This analysis summarizes an estimated prevalence of PA in the most common rheumatic diseases, the presumable risk factors for PA and influence of concomitant diseases on the course of disease.
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Affiliation(s)
- Agata Matusiewicz
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Joanna Stróżyńska-Byrska
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marzena Olesińska
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
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Sjögren’s Syndrome and Autoimmune Thyroid Disease: Two Sides of the Same Coin. Clin Rev Allergy Immunol 2018; 56:362-374. [DOI: 10.1007/s12016-018-8709-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sumida T, Azuma N, Moriyama M, Takahashi H, Asashima H, Honda F, Abe S, Ono Y, Hirota T, Hirata S, Tanaka Y, Shimizu T, Nakamura H, Kawakami A, Sano H, Ogawa Y, Tsubota K, Ryo K, Saito I, Tanaka A, Nakamura S, Takamura E, Tanaka M, Suzuki K, Takeuchi T, Yamakawa N, Mimori T, Ohta A, Nishiyama S, Yoshihara T, Suzuki Y, Kawano M, Tomiita M, Tsuboi H. Clinical practice guideline for Sjögren's syndrome 2017. Mod Rheumatol 2018; 28:383-408. [PMID: 29409370 DOI: 10.1080/14397595.2018.1438093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The objective of this study is to develop clinical practice guideline (CPG) for Sjögren's syndrome (SS) based on recently available clinical and therapeutic evidences. METHODS The CPG committee for SS was organized by the Research Team for Autoimmune Diseases, Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW), Japan. The committee completed a systematic review of evidences for several clinical questions and developed CPG for SS 2017 according to the procedure proposed by the Medical Information Network Distribution Service (Minds). The recommendations and their strength were checked by the modified Delphi method. The CPG for SS 2017 has been officially approved by both Japan College of Rheumatology and the Japanese Society for SS. RESULTS The CPG committee set 38 clinical questions for clinical symptoms, signs, treatment, and management of SS in pediatric, adult and pregnant patients, using the PICO (P: patients, problem, population, I: interventions, C: comparisons, controls, comparators, O: outcomes) format. A summary of evidence, development of recommendation, recommendation, and strength for these 38 clinical questions are presented in the CPG. CONCLUSION The CPG for SS 2017 should contribute to improvement and standardization of diagnosis and treatment of SS.
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Affiliation(s)
- Takayuki Sumida
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan.,b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan
| | - Naoto Azuma
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,c Division of Rheumatology, Department of Internal Medicine , Hyogo College of Medicine , Hyogo , Japan
| | - Masafumi Moriyama
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,d Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences , Kyushu University , Fukuoka , Japan
| | - Hiroyuki Takahashi
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan.,b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan
| | - Hiromitsu Asashima
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan.,b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan
| | - Fumika Honda
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan
| | - Saori Abe
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan
| | - Yuko Ono
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan.,d Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences , Kyushu University , Fukuoka , Japan
| | - Tomoya Hirota
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan.,b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan
| | - Shintaro Hirata
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,e The First Department of Internal Medicine , School of Medicine, University of Occupational and Environmental Health, Japan , Fukuoka , Japan.,f Department of Clinical Immunology and Rheumatology , Hiroshima University Hospital , Hiroshima , Japan
| | - Yoshiya Tanaka
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,e The First Department of Internal Medicine , School of Medicine, University of Occupational and Environmental Health, Japan , Fukuoka , Japan
| | - Toshimasa Shimizu
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,g Unit of Translational Medicine, Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Hideki Nakamura
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,g Unit of Translational Medicine, Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Atsushi Kawakami
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,g Unit of Translational Medicine, Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Hajime Sano
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,c Division of Rheumatology, Department of Internal Medicine , Hyogo College of Medicine , Hyogo , Japan
| | - Yoko Ogawa
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,h Department of Ophthalmology , School of Medicine, Keio University , Tokyo , Japan
| | - Kazuo Tsubota
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,h Department of Ophthalmology , School of Medicine, Keio University , Tokyo , Japan
| | - Koufuchi Ryo
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,i Department of Pathology , Tsurumi University School of Dental Medicine , Kanagawa , Japan
| | - Ichiro Saito
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,i Department of Pathology , Tsurumi University School of Dental Medicine , Kanagawa , Japan
| | - Akihiko Tanaka
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,d Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences , Kyushu University , Fukuoka , Japan
| | - Seiji Nakamura
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,d Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences , Kyushu University , Fukuoka , Japan
| | - Etsuko Takamura
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,j Department of Ophthalmology , Tokyo Women's Medical University, School of Medicine , Tokyo , Japan
| | - Masao Tanaka
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,k Department of Advanced Medicine for Rheumatic Diseases , Kyoto University Graduate School of Medicine , Kyoto , Japan
| | - Katsuya Suzuki
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,l Division of Rheumatology, Department of Internal Medicine , School of Medicine, Keio University , Tokyo , Japan
| | - Tsutomu Takeuchi
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,l Division of Rheumatology, Department of Internal Medicine , School of Medicine, Keio University , Tokyo , Japan
| | - Noriyuki Yamakawa
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,m Department of Rheumatology and Clinical Immunology , Kyoto University Graduate School of Medicine , Kyoto , Japan.,n Department of Rheumatology , Kyoto-Katsura Hospital , Kyoto , Japan
| | - Tsuneyo Mimori
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,m Department of Rheumatology and Clinical Immunology , Kyoto University Graduate School of Medicine , Kyoto , Japan
| | - Akiko Ohta
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,o Division of Public Health, Department of Social Medicine , Saitama Medical University , Saitama , Japan
| | - Susumu Nishiyama
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,p Kurashiki Medical Center , Okayama , Japan
| | - Toshio Yoshihara
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,q Department of Otorhinolaryngology , Tokyo Women's Medical University , Tokyo , Japan
| | - Yasunori Suzuki
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,r Division of Rheumatology, Department of Cardiovascular and Internal Medicine , Kanazawa University Graduate School of Medicine , Ishikawa , Japan
| | - Mitsuhiro Kawano
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,r Division of Rheumatology, Department of Cardiovascular and Internal Medicine , Kanazawa University Graduate School of Medicine , Ishikawa , Japan
| | - Minako Tomiita
- b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan.,s Department of Allergy and Rheumatology , Chiba Children's Hospital , Chiba , Japan
| | - Hiroto Tsuboi
- a Department of Internal Medicine , University of Tsukuba , Ibaraki , Japan.,b Clinical Practice Guideline Committee for Sjögren's Syndrome, The Research Team for Autoimmune Diseases, The Research Program for Intractable Disease of the Ministry of Health, Labor and Welfare (MHLW) , Tokyo , Japan
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Baldini C, Ferro F, Mosca M, Fallahi P, Antonelli A. The Association of Sjögren Syndrome and Autoimmune Thyroid Disorders. Front Endocrinol (Lausanne) 2018; 9:121. [PMID: 29666604 PMCID: PMC5891591 DOI: 10.3389/fendo.2018.00121] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 03/09/2018] [Indexed: 12/13/2022] Open
Abstract
Sjögren's syndrome (SS) and autoimmune thyroid diseases (AITD) may frequently coexist in clinical practice, resulting in a complex overlapping disorder that represents a particular example of the expression of heterogeneity in patients with autoimmune disorders. Objective of this review was to describe the prevalence of the SS-AITD association in the most recent literature, exploring in particular to what extent the presence of AITD might influence the clinical expression of SS and vice versa. Moreover, we summarized some of the proposed genetic, biologic, and molecular mechanisms implied in the pathogenesis of AITD-SS association. Finally, we explored risk factors for lymphoma development in both AITD and SS. We performed a Medline search of English language articles published in the PubMed database in order to provide a critical overview of the recent literature on pathogenesis and clinical features of AITD-SS overlapping disease. All the articles were critically analyzed to select the most relevant contributions.
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Affiliation(s)
- Chiara Baldini
- Rheumatology Unit, University of Pisa, Pisa, Italy
- *Correspondence: Chiara Baldini,
| | | | - Marta Mosca
- Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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High Prevalence of Thyroid Disease and Role of Salivary Gland Scintigraphy in Patients with Xerostomia. Nucl Med Mol Imaging 2017; 51:169-177. [PMID: 28559942 DOI: 10.1007/s13139-016-0455-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/27/2016] [Accepted: 09/28/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Although Sjögren's syndrome (SS) is the most common disease causing xerostomia, autoimmune thyroid diseases can also affect the salivary glands. The aim of our study was to estimate the prevalence of thyroid diseases (TD) in subjects with symptoms of xerostomia and evaluate the efficacy of salivary gland scintigraphy (SGS) in the detection of TD in patients with SS and without SS. METHODS We retrospectively reviewed the SGS findings of 173 subjects (men:women, 29:144) with symptoms of xerostomia. Ejection fractions (EF) in the parotid and submandibular glands were calculated. Thyroid disease was diagnosed on the basis of the results of the visual assessment of tracer uptake in the thyroid gland on SGS images as well as serological thyroid function tests. RESULTS Based on the American-European Criteria, 94 patients were diagnosed with SS. Hashimoto's thyroiditis was diagnosed in 63 patients, subacute thyroiditis in 23, subclinical hypothyroidism in five, and Graves' disease in one. There were significant differences in the EF values of the parotid and submandibular glands between patients with TD and those with undetermined diagnoses. CONCLUSIONS More than half of patients with xerostomia exhibited TD. Thyroid assessment by SGS is feasible, and SGS appears to be useful for the patients with xerostomia caused by TD. SGS may be the first imaging modality capable of evaluating both salivary gland function and thyroid gland status in patients with xerostomia. This strategy would make the requirement for additional workup for thyroid disease.
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Brito-Zerón P, Kostov B, Fraile G, Caravia-Durán D, Maure B, Rascón FJ, Zamora M, Casanovas A, Lopez-Dupla M, Ripoll M, Pinilla B, Fonseca E, Akasbi M, de la Red G, Duarte-Millán MA, Fanlo P, Guisado-Vasco P, Pérez-Alvarez R, Chamorro AJ, Morcillo C, Jiménez-Heredia I, Sánchez-Berná I, López-Guillermo A, Ramos-Casals M. Characterization and risk estimate of cancer in patients with primary Sjögren syndrome. J Hematol Oncol 2017; 10:90. [PMID: 28416003 PMCID: PMC5392920 DOI: 10.1186/s13045-017-0464-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 04/05/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The purpose of this study is to characterize the risk of cancer in a large cohort of patients with primary Sjögren syndrome (SjS). METHODS We had analyzed the development of cancer in 1300 consecutive patients fulfilling the 2002 SjS classification criteria. The baseline clinical and immunological characteristics and systemic activity (ESSDAI scores) were assessed at diagnosis as predictors of cancer using Cox proportional hazards regression analysis adjusted for age at diagnosis and gender. The sex-and age-specific standardized incidence ratios (SIR) of cancer were estimated from 2012 Spanish mortality data. RESULTS After a mean follow-up of 91 months, 127 (9.8%) patients developed 133 cancers. The most frequent type of cancer was B-cell lymphoma (including 27 MALT and 19 non-MALT B-cell lymphomas). Systemic activity at diagnosis of primary SjS correlated with the risk of hematological neoplasia and cryoglobulins with a high risk of either B-cell or non-B-cell lymphoma subtypes. Patients with cytopenias had a high risk of non-MALT B-cell and non-B-cell cancer, while those with low C3 levels had a high risk of MALT lymphomas and those with monoclonal gammopathy and low C4 levels had a high risk of non-MALT lymphomas. The estimated SIR for solid cancer was 1.13 and 11.02 for hematological cancer. SIRs for specific cancers were 36.17 for multiple myeloma and immunoproliferative diseases, 19.41 for Hodgkin lymphoma, 6.04 for other non-Hodgkin lymphomas, 5.17 for thyroid cancer, 4.81 for cancers of the lip and oral cavity, and 2.53 for stomach cancer. CONCLUSIONS One third of cancers developed by patients with primary SjS are B-cell lymphomas. The prognostic factors identified at SjS diagnosis differed according to the subtype of B-cell lymphoma developed. Primary SjS is also associated with the development of some non-hematological cancers (thyroid, oral cavity, and stomach).
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Affiliation(s)
- Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital CIMA-Sanitas, Barcelona, Spain.,Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
| | - Belchin Kostov
- Transversal group for research in primary care, IDIBAPS, Consorci d'Atenció Primària de Salut Barcelona Esquerre (CAPSBE), Barcelona, Spain
| | - Guadalupe Fraile
- Department of Internal Medicine, Hospital Ramón y Cajal, Madrid, Spain
| | - Daniel Caravia-Durán
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Brenda Maure
- Department of Internal Medicine, Complejo Hospitalario Universitario, Vigo, Spain
| | | | - Mónica Zamora
- Department of Internal Medicine, Hospital Virgen de las Nieves, Granada, Spain
| | - Arnau Casanovas
- Department of Internal Medicine, Hospital Parc Taulí, Sabadell, Spain
| | | | - Mar Ripoll
- Department of Internal Medicine, Hospital Infanta Sofía, Madrid, Spain
| | - Blanca Pinilla
- Department of Internal Medicine, Hospital Gregorio Marañón, Madrid, Spain
| | - Eva Fonseca
- Department of Internal Medicine, Hospital de Cabueñes, Gijón, Spain
| | - Miriam Akasbi
- Department of Internal Medicine, Hospital Infanta Leonor, Madrid, Spain
| | - Gloria de la Red
- Department of Internal Medicine, Hospital Esperit Sant, Santa Coloma de Gramenet, Spain
| | | | - Patricia Fanlo
- Department of Internal Medicine, Hospital Virgen del Camino, Pamplona, Spain
| | - Pablo Guisado-Vasco
- Department of Internal Medicine, Complejo Hospitalario Ruber Juan Bravo, Madrid, Spain
| | | | - Antonio J Chamorro
- Department of Internal Medicine, Hospital de Salamanca, Salamanca, Spain
| | - César Morcillo
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital CIMA-Sanitas, Barcelona, Spain
| | | | - Isabel Sánchez-Berná
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Department of Internal Medicine, Hospital Virgen de las Nieves, Granada, Spain
| | | | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain. .,Department of Medicine, University of Barcelona, Barcelona, Spain.
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Zignego AL, Ramos-Casals M, Ferri C, Saadoun D, Arcaini L, Roccatello D, Antonelli A, Desbois AC, Comarmond C, Gragnani L, Casato M, Lamprecht P, Mangia A, Tzioufas AG, Younossi ZM, Cacoub P. International therapeutic guidelines for patients with HCV-related extrahepatic disorders. A multidisciplinary expert statement. Autoimmun Rev 2017; 16:523-541. [PMID: 28286108 DOI: 10.1016/j.autrev.2017.03.004] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 02/26/2017] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus (HCV) is both hepatotrophic and lymphotropic virus that causes liver as well extrahepatic manifestations including cryoglobulinemic vasculitis, the most frequent and studied condition, lymphoma, and neurologic, cardiovascular, endocrine-metabolic or renal diseases. HCV-extrahepatic manifestations (HCV-EHMs) may severely affect the overall prognosis, while viral eradication significantly reduces non-liver related deaths. Different clinical manifestations may coexist in the same patient. Due to the variety of HCV clinical manifestations, a multidisciplinary approach along with appropriate therapeutic strategies are required. In the era of interferon-free anti-HCV treatments, international recommendations for the therapeutic management of HCV-EHMs are needed. This implies the need to define the best criteria to use antivirals and/or other therapeutic approaches. The present recommendations, based on qualified expert experience and specific literature, will focus on etiological (antiviral) therapies and/or traditional pathogenetic treatments that still maintain their therapeutic utility.
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Affiliation(s)
- Anna Linda Zignego
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD Josep Font Autoimmune Lab, CELLEX-IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Clodoveo Ferri
- Chair and Rheumatology Unit, Medical School, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, 41124 Modena, Italy
| | - David Saadoun
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - Luca Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Dario Roccatello
- Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Center of Research of Immunopathology and Rare Diseases, and Nephrology and Dialysis Unit, San G. Bosco Hospital and University of Turin, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, Pisa 56126, Italy
| | - Anne Claire Desbois
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - Cloe Comarmond
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
| | - Laura Gragnani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Milvia Casato
- Department of Clinical Medicine, Sapienza University of Rome, Viale dell'Università 37, 00185 Rome, Italy.
| | - Peter Lamprecht
- Klinik für Rheumatologie Oberarzt, Ratzeburger Allee 160 (Haus 40), 23538 Lübeck, Germany.
| | - Alessandra Mangia
- Liver Unit, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy.
| | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, University of Athens, 75 M. Asias st, Building 16, Room, 32 11527 Athens, Greece.
| | - Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA; Beatty Liver and Obesity Program, Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Patrice Cacoub
- Sorbonne University, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France; INSERM, UMR S 959, Paris, France; CNRS, FRE3632, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
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Mlynáriková V, Mičeková D, Rovenský J, Šteňová E. Sjögren’s syndrome. ACTA FACULTATIS PHARMACEUTICAE UNIVERSITATIS COMENIANAE 2015. [DOI: 10.1515/afpuc-2015-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Sjögren’s syndrome is a slowly progressive, inflammatory autoimmune disease primarily affecting exocrine glands. Lymphocytic infiltrates replace functional epithelium and lead to decreased exocrine secretion of salivary and lacrimal glands - xerocrinopathy. Glands of intestinal system and pulmonary tract, skin and vaginal mucosa may also be affected. The most common extraglandular manifestations of primary Sjögren’s syndrome include skin vasculitis, Raynaud’s phenomenon, functional renal abnormalities, neuropathy and arthritis symptoms. This disorder may appear separately as a primary Sjögren’s syndrome or in connection with other inflammatory rheumatic diseases as secondary Sjögren’s syndrome. Treatment of the disease is based on topical ocular and oral therapy, extraglandular manifestations need to be treated with hydroxychloroquine and severe cases even with corticosteroid or immunosuppressive drugs.
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Abstract
Autoimmune thyroiditis (ATD) is generally regarded as a classic example of single organ autoimmunity with a high association with endocrine thyroid disorders. However, it is closely associated with several autoimmune diseases including rheumatologic syndromes and has long been known to have several rheumatic manifestations particularly in association with hypothyroidism. More recently, it has also been implicated in rheumatologic syndromes in the absence of hypothyroidism or subclinical hypothyroidism. There is also an emerging body of evidence that ATD is highly linked to chronic generalized pain syndromes including fibromyalgia. This review examines the rheumatic symptoms of ATD described in the current literature and discusses the clinical relevance of ATD in general rheumatology.
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Association of antithyroid peroxidase antibody with fibromyalgia in rheumatoid arthritis. Rheumatol Int 2015; 35:1415-21. [PMID: 25976307 DOI: 10.1007/s00296-015-3278-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/28/2015] [Indexed: 12/15/2022]
Abstract
To investigate how autoimmune thyroiditis (ATD) affects the clinical presentation of established rheumatoid arthritis (RA) with particular reference to fibromyalgia and chronic widespread pain (CWP). A cohort of 204 patients with RA for whom the presence or absence of autoimmune thyroid antibodies was documented was examined for the relationships between thyroid autoantibodies and fibromyalgia or CWP. We identified 29 % who tested positive for antithyroid peroxidase antibodies (TPOAb). The anti-thyroglobulin antibody (TgAb) was found in 24 %. Among the thyroid autoantibody-positive patients, 40 % had a diagnosis of fibromyalgia or CWP versus 17 % for antibody negative patients. Logistic regression analyses (adjusted by age, sex, diabetes and BMI) indicated that TPOAb-positive patients were more likely to have fibromyalgia or CWP, with an odds ratio (OR) of 4.641, 95 % confidence interval (CI) (2.110-10.207) P < .001. Adjusting for spinal degenerative disc disease did not change the association with fibromyalgia, OR 4.458, 95 % CI (1.950-10.191), P < .001. The OR between TgAb and fibromyalgia was not significant (P > .05). Additional logistic regression analyses (adjusted by age, sex and BMI) indicated a significant relationship between TPOAb and fibromyalgia or CWP in patients without diabetes and those without hypothyroidism (OR of 4.873, 95 % CI (1.877-12.653), P = .001 and OR of 4.615 95 % CI (1.810-11.770), P = .001, respectively). There may be a positive association between the ATD antibody TPOAb, and fibromyalgia syndrome and CWP in patients with established RA.
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Bourji K, Gatto M, Cozzi F, Doria A, Punzi L. Rheumatic and autoimmune thyroid disorders: a causal or casual relationship? Autoimmun Rev 2015; 14:57-63. [PMID: 25315745 DOI: 10.1016/j.autrev.2014.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 09/23/2014] [Indexed: 12/23/2022]
Abstract
A number of dysfunctions may affect the thyroid gland leading either to hyper- or hypothyroidism which are mediated by autoimmune mechanisms. Thyroid abnormalities may represent an isolated alteration or they may be the harbinger of forthcoming disorders as is the case of well-characterized polyendocrine syndromes. Also, they may precede or follow the appearance of rheumatic manifestations in patients affected with connective tissue diseases or rheumatoid arthritis. The mechanisms by which autoimmune thyroid disorders may be linked to systemic autoimmune diseases have not been fully unraveled yet, however alterations of common pathways are suggested by shared genetic variants affecting autoantigen presentation and regulation of the immune response. On the other hand, the higher prevalence of autoimmune thyroid disorders over rheumatic diseases compels the chance of a mere causal concomitancy in the same patient. The aim of our paper is to provide an overview of available data on thyroid involvement in different rheumatic diseases and to go over the main rheumatic manifestations in the context of autoimmune thyroid diseases.
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Abstract
PURPOSE The aim of this study was to review the frequency and types of inflammatory systemic diseases in a cohort of patients with dry eye, and identify clinical features suggesting the presence of these. METHODS Consecutive new patients with a primary diagnosis of dry eye evaluated at a tertiary dry eye center between January 2010 and December 2011 were reviewed retrospectively. Standardized questionnaires were used to obtain data regarding systemic symptoms, previous medical diagnoses, and family history. Dry eye evaluations included Schirmer testing, tear film break-up time, corneal fluorescein staining, and bulbar conjunctival lissamine green staining. Clinically significant dry eye was defined as having a Schirmer test score without anesthesia of ≤10 mm or conjunctival lissamine green staining of ≥1 using the Oxford scale. RESULTS A total of 228 new patients were analyzed. Of these, 47.4% (108/228) presented with a known diagnosis of inflammatory disease. Based on a review of systems and ocular examination, 81 patients (81/228) underwent a further work-up that revealed 25 additional diagnoses that were not known on presentation. The most common newly identified conditions included occult thyroid eye disease (n = 20), primary Sjögren Syndrome (4), and Sjögren Syndrome suspect (1). Female gender, family history of autoimmune disease, self-reported joint pain or dry mouth, external signs of orbital inflammation, and conjunctival chemosis were more common in patients with inflammatory systemic disease as compared with that in patients with no identifiable condition (P < 0.05 for all). CONCLUSIONS Systemic inflammatory diseases are frequently associated with dry eye in patients evaluated at a tertiary academic center. Diagnostic evaluations may help uncover previously undiagnosed significant conditions in about one-third of tested patients.
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Iikuni N, Hanzawa M, Ohta S, Nishinarita M. A rare case of systemic sclerosis complicated with multiple autoimmune diseases (Sjögren's syndrome, Graves' disease, and primary biliary cirrhosis). Mod Rheumatol 2014; 14:476-9. [DOI: 10.3109/s10165-004-0342-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Milic VD, Radunovic G, Boricic I, Ognjanovic S, Petrovic R, Radak-Perovic M, Vujasinovic-Stupar N, Damjanov N. High prevalence of autoimmune thyroid disease in subjects with sicca symptoms without Sjogren's syndrome. Rheumatology (Oxford) 2013; 52:754-5. [DOI: 10.1093/rheumatology/kes423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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The co-occurrence of Hashimoto thyroiditis in primary Sjogren's syndrome defines a subset of patients with milder clinical phenotype. Rheumatol Int 2012; 33:1271-5. [PMID: 23124734 DOI: 10.1007/s00296-012-2570-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 10/21/2012] [Indexed: 10/27/2022]
Abstract
To evaluate in a cohort of 100 consecutive patients affected by primary Sjogren's syndrome (pSS) the incidence of Hashimoto thyroiditis (HT) and to compare the clinical features and the laboratory parameters of patients affected by pSS with and without concomitant HT. In 100 consecutive patients affected by pSS, the occurrence of other autoimmune diseases was recorded and a full examination of thyroid function obtained. HT was associated with pSS in 27 cases. The comparison between pSS cases with and without HT showed that only patients with isolated pSS had low C4 level [p = 0.032, OR (IC 95 %) 230 (13.13-4,046)]. In addition, only patients affected by pSS without HT had evidence of cryoglobulins, cutaneous vasculitis with palpable purpura, peripheral neuropathy, and development of lymphoma, although all these manifestations were observed in a 4.1-8.2 % of the cases, without reaching statistical significance. The association of HT in patients suffering from pSS defines a subset of patients with milder disease and normal C4 levels.
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Amador-Patarroyo MJ, Arbelaez JG, Mantilla RD, Rodriguez-Rodriguez A, Cárdenas-Roldán J, Pineda-Tamayo R, Guarin MR, Kleine LL, Rojas-Villarraga A, Anaya JM. Sjögren’s syndrome at the crossroad of polyautoimmunity. J Autoimmun 2012; 39:199-205. [DOI: 10.1016/j.jaut.2012.05.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 05/20/2012] [Indexed: 12/26/2022]
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Mavragani CP, Fragoulis GE, Moutsopoulos HM. Endocrine alterations in primary Sjogren's syndrome: an overview. J Autoimmun 2012; 39:354-8. [PMID: 22695186 DOI: 10.1016/j.jaut.2012.05.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 05/20/2012] [Indexed: 11/25/2022]
Abstract
Involvement of several components of the endocrine system has been proposed as significant player in primary Sjogren's syndrome (SS) pathogenesis and clinical expression. Hypoactivity of the hypothalamic-pituitary-adrenal (HPA) axis has been previously demonstrated in patients with primary SS as a result either of a pituitary defect and/or of adrenal gland dysfunction. In support of the latter hypothesis, antibodies to 21-hydroxylase (OH)--a marker of autoimmune adrenal disease--have been detected in sera from approximately one fifth of primary SS patients, in association with B-cell activating cytokines and adrenal hyporesponsiveness. As a result of HPA hypofunction, adrenal androgens and particularly dehydroepiandrosterone-sulfate (DHEA-S) have been reportedly low in primary SS individuals. Epithelial salivary gland cells undergo apoptosis in lack of both estrogens and active androgens. In the absence of a compensatory action of the latter, menopausal status can lead to salivary gland apoptotic process triggering an aberrant immune response. On the other hand, given that salivary gland tissue remodeling has been shown to be under androgenic control, the observed androgen deficiency in these patients might account for the observed alterations in the salivary gland architecture. Heightened serum and salivary gland tissue prolactin levels in primary SS patients have been also suggested as contributors in disease pathogenesis. Finally, autoimmune thyroid disease (ATD) occurs quiet commonly in the setting of primary SS and subclinical hypothyroidism is the main functional abnormality observed in these patients.
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Affiliation(s)
- Clio P Mavragani
- Department of Experimental Physiology, School of Medicine, University of Athens, Athens, Greece.
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Rosas Gómez de Salazar J, Senabre Gallego JM, Santos Ramírez C. Manejo de las manifestaciones extraglandulares del síndrome de Sjögren primario. ACTA ACUST UNITED AC 2010; 6 Suppl 2:6-11. [DOI: 10.1016/j.reuma.2010.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 06/30/2010] [Indexed: 12/16/2022]
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Quantitative and visual evaluation of salivary and thyroid glands in patients with primary Sjögren's syndrome using salivary gland scintigraphy: relationship with clinicopathological features of salivary, lacrimal and thyroid glands. Nucl Med Commun 2010. [DOI: 10.1097/mnm.0b013e328339bdf6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Burbelo PD, Leahy HP, Issa AT, Groot S, Baraniuk JN, Nikolov NP, Illei GG, Iadarola MJ. Sensitive and robust luminescent profiling of anti-La and other autoantibodies in Sjogren's syndrome. Autoimmunity 2009; 42:515-24. [PMID: 19657778 PMCID: PMC3417760 DOI: 10.1080/08916930902911738] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Sjogren's syndrome (SjS) patients often have a variety of extraglandular manifestations including neurological and gastrointestinal involvement. In this study we evaluated the diagnostic performance of luciferase immunoprecipitation system (LIPS) that employs mammalian cell-produced recombinant antigens for analyzing SjS autoantibody responses. LIPS testing of mammalian cell-produced La, Ro60 and Ro52 recombinant antigens with defined commercial antibodies demonstrated highly specific immunoprecitation of each antigen without cross-reactivity. Next, sera from 57 SjS and 25 volunteers were evaluated by LIPS against a panel of human autoantigens. LIPS detected robust anti-La antibody levels in 43/57 SjS patients (75% sensitivity) and markedly outperformed an ELISA (46% sensitivity). Profiling of other SjS-associated autoantigens revealed the presence of anti-Ro60, anti-Ro52 in 63% and 61%, of SjS patients, respectively. Interestingly, a C-terminal fragment of Ro52 (Ro52-Delta2), a protein fragment not previously found to be antigenic by ELISA, also showed positive immunoreactivity in 42/57 SjS patients (65% sensitivity). Additional profiling of other autoantigens revealed that certain SjS patients also showed positive immunoreactivity with thyroid peroxidase (14%), AQP-4 (12%) and the H(+)/K(+) gastric ATPase (16%) suggesting potential autoantibody attack of thyroid, neuronal and gastric parietal cells, respectively. These heterogeneous autoantibody responses detected by LIPS in SjS will likely be useful for diagnosis and for evaluating extraglandular manifestations.
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Affiliation(s)
- Peter D Burbelo
- Neurobiology and Pain Therapeutics Section, Laboratory of Sensory Biology, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
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Zeher M, Horvath IF, Szanto A, Szodoray P. Autoimmune thyroid diseases in a large group of Hungarian patients with primary Sjögren's syndrome. Thyroid 2009; 19:39-45. [PMID: 19119981 DOI: 10.1089/thy.2007.0398] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Previous studies on relatively small populations of patients with primary Sjögren's syndrome (pSS) suggested an association between pSS and Hashimoto's thyroiditis (HT). As some findings in the literature regarding the relationship between pSS and thyroid disease are contradictory, and there is little information on the sequence of pSS and HT, we conducted a study with a population of patients with pSS that was about three times larger than previously studied populations. Our objective was to determine the prevalence of HT and Graves' disease (GD) in patients with pSS and to assess the sequence of pSS and autoimmune thyroid diseases. METHODS A total of 479 patients with pSS were retrospectively studied. Thyroid ultrasound and scintigraphy were performed, and serum thyrotropin, free triiodothyronine, free thyroxine, antithyroid peroxidase antibody (TPOAb), and anti-thyroglobulin autoantibody (TgAb) measurements were carried out. Solitary thyroid nodules were investigated by fine-needle aspiration biopsy. RESULTS Thyroid dysfunction was found in 95 patients (21.25%). Thirty of these patients had HT and 18 had GD. HT predated pSS in eight patients, developed at approximately the same time in seven patients, and followed pSS in 15 patients. Almost all (90%) patients with HT had persistently elevated serum TgAb or TPOAb titers. CONCLUSIONS An association between HT and pSS was found based on the fact that the frequency of HT was greater among pSS patients (6.26%) than in the general population (1-2%). In contrast, no association between GD and pSS was found. We noted that both HT and GD can appear either before or after the onset of pSS. Since most cases of pSS predate the appearance of autoimmune thyroid diseases it is important to determine if pSS is a predisposing factor for the development of autoimmune thyroiditis.
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Affiliation(s)
- Margit Zeher
- Division of Clinical Immunology, Medical and Health Science Center, University of Debrecen , Debrecen, Hungary
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Rodríguez-Espinosa J, Díaz-López C, Guinot M, Geli C, de Llobet JM, Rodríguez de la Serna A. [Thyroid dysfunction in women with suspected fibromyalgia]. ACTA ACUST UNITED AC 2008; 2:70-7. [PMID: 21794307 DOI: 10.1016/s1699-258x(06)73025-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Accepted: 01/11/2006] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Due to its prevalence, morbidity, and frequency rate, fibromyalgia (FM) represents a health problem and produces high healthcare resource utilization. Serum thyrotropin (TSH) measurement is recommended as a first-line laboratory test to exclude hypothyroidism as a cause of FM syndrome. The aim of this study was to analyze the prevalence of thyroid dysfunction (TD), the frequency of TSH measurement, the effect of levothyroxine treatment, and whether screening for TD is justified in women with suspected FM. PATIENTS AND METHODS A cross-sectional descriptive study was performed in 400 consecutive female outpatients with suspected FM and in 384 controls from January 2001 to October 2004. TSH measurement was used as the first line test to detect TD. RESULTS The prevalence of TD in patients with suspected FM (40/400; 10%; 95% CI: 7-13%) and controls was similar (46/384; 12%; 95% CI: 9-15%). No differences were found in the types and grades of TD. The prevalence of TD was higher in patients with suspected FM and connective tissue diseases (12%) than in those without these diseases (5%). The most frequent TD was subclinical hypothyroidism (5.5% in suspected FM and 6.7% in controls), and in 93% of these cases TSH concentrations were <10 mIU/L. FM persisted in all women with hypothyroidism even after euthyroidism was achieved with levothyroxine. A total of 870 TSH determinations were performed in 360 euthyroid patients with suspected FM. CONCLUSIONS The prevalence of TD in women with suspected FM does not differ from that in the general population. Screening for TD does not appear to be justified in women without diseases that increase their risk. In many cases the request for thyroid function tests is excessive. Treatment for hypothyroidism does not affect FM.
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Affiliation(s)
- J Rodríguez-Espinosa
- Servei de Bioquímica Clínica. Hospital de la Santa Creu i Sant Pau. Barcelona. España
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31
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Lundström IMC, Lindström FD. Iron and vitamin deficiencies, endocrine and immune status in patients with primary Sjögren's syndrome. Oral Dis 2008. [DOI: 10.1034/j.1601-0825.2001.70302.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tzioufas AG, Voulgarelis M. Update on Sjögren's syndrome autoimmune epithelitis: from classification to increased neoplasias. Best Pract Res Clin Rheumatol 2008; 21:989-1010. [PMID: 18068857 DOI: 10.1016/j.berh.2007.09.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Sjögren's syndrome is a chronic inflammatory process that primarily involves the exocrine glands. Its clinical manifestations range from autoimmune exocrinopathy to extraglandular (systemic) involvement affecting the lungs, kidneys, blood vessels, and muscles; it can occur alone (primary Sjögren's syndrome) or in association with other autoimmune diseases (secondary Sjögren's syndrome). In recent years, clinical and laboratory observations have highlighted the central role of the epithelial cell and it has been suggested that the etiological name of the disease should be 'autoimmune epithelitis'. The extraglandular manifestations of the disease are divided in two groups: (1) lung, kidney (interstitial nephritis), and liver involvement as a result of lymphocytic invasion in epithelial tissues; and (2) skin vasculitis, peripheral neuropathy, and glomerulonephritis, with low C4 levels, which is the result of immune complex disease, are associated with increased morbidity and high risk for lymphoma. The diagnosis of the disease is based on the classification criteria, raised by the American-European Study Group and which have been built on the European preliminary classification criteria, developed in 1992. The association of Sjögren's syndrome with lymphoma is well documented as in approximately 5% of patients the benign autoimmune process is transformed into a lymphoid malignancy. The salivary extranodal marginal zone B-cell lymphomas of the mucosa-associated lymphoid tissue type are the most common lymphoma in Sjögren's syndrome. These tumors are antigen-stimulated B-cell lymphomas and are characterized by localized stage, indolent clinical course, and recurrence in other extranodal sites. Among the clinical and serological parameters that have been associated with lymphoma development in patients with Sjögren's syndrome, the presence of palpable purpura, low C4 and mixed monoclonal cryoglobulinemia constitute the main predictive markers; patients displaying these risk factors should be monitored closely. The purpose of this review is to discuss the clinical picture, the diagnostic procedure, and the malignant lymphoproliferation in the disease.
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33
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Pillemer SR. Sjögren's syndrome. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fuertes I, Espinosa G, Ramos-Casals M, Cervera R. Asociación de síndrome de Sjögren, tiroiditis autoinmune, sarcoidosis, cirrosis biliar primaria y amiloidosis primaria en una misma paciente. Rev Clin Esp 2007; 207:376. [PMID: 17662210 DOI: 10.1157/13107956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jara LJ, Navarro C, Brito-Zerón MDP, García-Carrasco M, Escárcega RO, Ramos-Casals M. Thyroid disease in Sjögren's syndrome. Clin Rheumatol 2007; 26:1601-6. [PMID: 17558463 DOI: 10.1007/s10067-007-0638-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Revised: 04/07/2007] [Accepted: 04/16/2007] [Indexed: 11/24/2022]
Abstract
From 1960 to 2007, an important number of patients with primary Sjögren's syndrome (pSS) along with thyroid disease diagnosed by laboratory data and clinical presentation were reported. The most common thyroid disorder found was autoimmune thyroiditis and the most common hormonal pattern was subclinical hypothyroidism. The coexistence of SS and thyroiditis is frequent and suggests a common genetic or environmental factor predisposition with similar pathogenic mechanisms. pSS was ten times more frequent in patients with autoimmune thyroid disease and autoimmune thyroiditis was nine times more frequent in pSS. Therefore, SS should be studied in patients with thyroid disease and vice versa. Antigens are shared by both thyroid and salivary glands, which could be responsible for the association between both diseases. Immunogenetic studies had suggested that both diseases have a common genetic predisposition. pSS and thyroid disease patients were mostly women with positive antithyroglobulin, antiparietal cell and antithyroid peroxidase antibodies. Thyroid dysfunction is frequent in pSS patients and those prone to develop thyroid disorders are identified by thyroid-related autoantibodies or by rheumatoid factor and anti-Ro/SSA activity. Patients with pSS have an increased tendency to develop other autoimmune diseases. Hypothyroidism was the most common autoimmune disease developed in pSS patients during follow-up of 10.5 years. Lymphomas are also associated with SS and thyroiditis and a 67-fold increased risk for thyroid mucosa-associated lymphoid tissue (MALT) lymphoma and a 44-fold increased risk for parotid lymphoma is being attributed to autoimmune thyroiditis and pSS. It is suggested that immune mechanism deficiency is a causal factor for B cell lymphoma in pSS and autoimmune thyroid disease. Other studies are necessary to clarify the shared pathogenesis mechanism in SS and autoimmune thyroid disease and to understand this fascinating autoimmune association.
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Affiliation(s)
- Luis J Jara
- Direction of Education and Research, Hospital de Especialidades, Centro Médico La Raza, IMSS, Seris y Zaachila s/n C.P., 02990, Mexico City, México.
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Ramos-Casals M, Khamashta MA. Advances in Lupus and Sjogren's Syndrome: A Tribute to Josep Font. Ann N Y Acad Sci 2007; 1108:51-63. [PMID: 17893970 DOI: 10.1196/annals.1422.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Dr. Josep Font (Barcelona, 1953-2006) devoted his professional career to the care of patients with systemic autoimmune diseases (SAD). In 1995, he created the Department of Autoimmune Diseases at the Hospital Clinic in Barcelona, a pioneering unit in Europe specifically dedicated to the clinical management of these patients. The research output of Dr. Font has been prodigious, with a total of over 500 scientific articles published in 25 years, and was especially focused on the clinical and immunological characterization of systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (SS). This review briefly analyzes some of the main contributions of Josep Font to our current knowledge about these diseases. In SLE, the research was centered on the epidemiological and clinical characterization, the study of cardiovascular and vasculitic involvements, and the investigation of the etiopathogenic role of the innate immunity. In primary SS, basic research conducted by Dr. Font contributed to a better understanding of the autoimmune etiopathogenesis of the disease, while the clinical research expanded our knowledge about the systemic and immunological expression of the disease and its frequent association with lymphoma, other SAD, and chronic viral infections.
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Abstract
The expression 'autoimmune epithelitis' has been proposed as an alternative for Sjögren's syndrome (SS) based on data pointing out the central role of the epithelial cell in the pathogenesis of the syndrome. Clinically, apart from exocrine glands that are the main target, the epithelial component of the other organs such as kidneys, liver, lungs or thyroid is commonly affected resulting in various extraglandular manifestations. On the other hand, at the molecular and cellular level, the epithelial cell plays a major role in the initiation and perpetuation of the autoimmune lesion. Mechanisms such as antigen presentation, apoptosis, chemokine production or germinal center formation lie in the center of SS pathogenesis and the epithelial cell has a very important role. Herein, we present both aspects, review the data that support the proposed terminology and finally, suggest a unifying theory for the pathogenesis of SS.
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Affiliation(s)
- D I Mitsias
- Department of Pathophysiology, School of Medicine, National University of Athens, Athens, Greece
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38
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Scofield RH, Bruner GR, Harley JB, Namjou B. Autoimmune thyroid disease is associated with a diagnosis of secondary Sjögren's syndrome in familial systemic lupus. Ann Rheum Dis 2006; 66:410-3. [PMID: 16984944 PMCID: PMC1856020 DOI: 10.1136/ard.2006.055103] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Autoimmune thyroid disease is common in systemic lupus erythematosus (SLE). About 20% of patients with SLE have secondary Sjögren's syndrome. METHODS Families with more than one patient with SLE were identified. All patients met the revised classification criteria, although SLE-unaffected relatives were confirmed not to satisfy these criteria. Diagnosis of autoimmune thyroid disease and Sjögren's syndrome was made on the basis of a review of medical records, interview and questionnaire administered to patients with SLE, and by a questionnaire administered to SLE-unaffected subjects. RESULTS Of a total of 1138 patients with SLE, 169 had a diagnosis of Sjögren's syndrome. Of these 50 (29.6%) patients also had autoimmune thyroid disease. Of the 939 patients with SLE with no diagnosis of Sjögren's syndrome, 119 (12.7%) had autoimmune thyroid disease (chi2 = 20.1, p = 0.000009). There was no association of a diagnosis of hypertension with secondary Sjögren's syndrome (42% vss 47%). Among 2291 SLE-unaffected relatives, 44 had diagnosed primary Sjögren's syndrome and 16 (36.3%) of these also had autoimmune thyroid disease. 265 of 2247 (11.8%) subjects had autoimmune thyroid disease but no Sjögren's syndrome (chi2 = 24.2, p<0.001). CONCLUSIONS Autoimmune thyroid disease is found in excess among patients with SLE with a diagnosis of secondary Sjögren's syndrome, as well as among their SLE-unaffected relatives with a diagnosis of primary Sjögren's syndrome.
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Affiliation(s)
- R Hal Scofield
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
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39
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Nakamura T, Higashi SI, Tomoda K, Tsukano M, Sugi K. Primary biliary cirrhosis (PBC)-CREST overlap syndrome with coexistence of Sjögren's syndrome and thyroid dysfunction. Clin Rheumatol 2006; 26:596-600. [PMID: 16496080 DOI: 10.1007/s10067-005-0178-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 12/04/2005] [Accepted: 12/04/2005] [Indexed: 10/25/2022]
Abstract
Calcinosis, Raynaud's phenomenon, oesophageal dysmotility, sclerodactyly, telangiectasia (CREST) syndrome, a limited form of systemic sclerosis, is sometimes complicated by primary biliary cirrhosis (PBC). A 52- and 61-year-old Japanese woman with PBC-CREST overlap syndrome accompanied by Sjögren's syndrome, and Hashimoto's thyroiditis, and Graves' disease, respectively, are reported. They had suffered from Raynaud's phenomena, sclerodactyly, morning stiffness, arthralgia, and sicca symptoms during these several years. They exhibited an increased level of alkaline phosphatase, gamma-glutamyl transpeptidase, positive antibodies against mitochondria and centromere, and hyperglobulinemia without any cholestatic symptoms. Histological findings from liver biopsy specimens were consistent with those of PBC. Clinically, they were diagnosed as both asymptomatic PBC and incomplete CREST syndrome. Their human leukocyte antigen typing showed both DR4 and DR8 positive. The association of the four autoimmune conditions is clinically and etiologically important. Although a combination of these diseases is rare, it is of importance to keep in mind that various autoimmune diseases could occur simultaneously. Of critical importance is that an active diagnostic attitude towards them is admirable, and that early diagnosis and therapy are needed.
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Affiliation(s)
- Tadashi Nakamura
- Section of Internal Medicine and Rheumatology, Kumamoto Center for Arthritis and Rheumatology, 1-15-7 Kuhonji, Kumamoto 862-0976, Japan.
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40
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Biró E, Szekanecz Z, Czirják L, Dankó K, Kiss E, Szabó NA, Szucs G, Zeher M, Bodolay E, Szegedi G, Bakó G. Association of systemic and thyroid autoimmune diseases. Clin Rheumatol 2005; 25:240-5. [PMID: 16247581 DOI: 10.1007/s10067-005-1165-y] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2003] [Revised: 06/22/2005] [Accepted: 06/22/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There are few large cohort studies available on the association of systemic and thyroid autoimmune diseases. In this study, we wished to determine the association of Hashimoto's thyroiditis (HT) and Graves' disease (GD) with systemic autoimmune diseases. METHODS One thousand five hundred and seventeen patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), mixed connective tissue disease (MCTD), Sjögren's syndrome (SS) and polymyositis/dermatomyositis (PM/DM) were included in the study. The HT and GD were diagnosed based on thorough clinical evaluation, imaging and fine-needle aspiration cytology (FNAC). The frequency of HT and GD in these diseases was assessed. In addition, 426 patients with HT or GD were assessed and the incidence of SLE, RA, SSc, MCTD, SS and PM/DM among these patients was determined. Prevalence ratios indicating the prevalences of GD or HT among our autoimmune patients in comparison to prevalences of GD or HT in the general population were calculated. RESULTS Altogether 8.2% of systemic autoimmune patients had either HT or GD. MCTD and SS most frequently overlapped with autoimmune thyroid diseases (24 and 10%, respectively). HT was more common among MCTD, SS and RA patients (21, 7 and 6%, respectively) than GD (2.5, 3 and 1.6%, respectively). The prevalences of HT in SLE, RA, SSc, MCTD, SS and PM/DM were 90-, 160-, 220-, 556-, 176- and 69-fold higher than in the general population, respectively. The prevalences of GD in the same systemic diseases were 68-, 50-, 102-, 76-, 74- and 37-fold higher than in the general population, respectively. Among all thyroid patients, 30% had associated systemic disease. In particular, 51% of HT and only 16% of GD subjects had any of the systemic disorders. MCTD, SS, SLE, RA, SSc and PM/DM were all more common among HT patients (20, 17, 7, 4, 2 and 2%, respectively) than in GD individuals (2, 5, 5, 1, 2 and 1%, respectively). CONCLUSION Systemic and thyroid autoimmune diseases often overlap with each other. HT and GD may be most common among MCTD, SSc and SS patients. On the other hand, these systemic diseases are often present in HT subjects. Therefore it is clinically important to screen patients with systemic autoimmune diseases for the co-existence of thyroid disorders.
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Affiliation(s)
- Edit Biró
- 3rd Department of Medicine, University of Debrecen Medical and Health Sciences Center, 22 Moricz street, 4004 Debrecen, Hungary
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41
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Szyper-Kravitz M, Marai I, Shoenfeld Y. Coexistence of thyroid autoimmunity with other autoimmune diseases: friend or foe? Additional aspects on the mosaic of autoimmunity. Autoimmunity 2005; 38:247-55. [PMID: 16126513 DOI: 10.1080/08916930500050194] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Autoimmunity encompasses a wide spectrum of diseases from organ-specific diseases like Hashimoto thyroiditis, to systemic diseases such as systemic lupus erythematosus. These diseases are characterized by inflammation and the production of a wide range of autoantibodies directed against multiple autoantigens. Although their etiology is still poorly understood, genetic, immunological, hormonal, and environmental factors are major predisposing and triggering factors. These multiple factors, like pieces in a mosaic, may interplay in different forms, leading to the expression of various autoimmune manifestations and diseases. This phenomenon, which has been referred by us as the "mosaic of autoimmunity", illuminates the diversity of autoimmune manifestations among susceptible individuals. From this theoretical framework we conducted a wide search of the literature, on the prevalence of thyroid autoimmunity, the commonest of the autoimmune conditions, among other autoimmune diseases, and discuss the possible clinical significance of this association.
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Affiliation(s)
- Martine Szyper-Kravitz
- Center for Autoimmune Diseases and Department of Medicine B, Sheba Medical Center Tel- Hashomer, Sackler Faculty of Medicine, Tel Aviv University
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42
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Tunc R, Gonen MS, Acbay O, Hamuryudan V, Yazici H. Autoimmune thyroiditis and anti-thyroid antibodies in primary Sjogren's syndrome: a case-control study. Ann Rheum Dis 2004; 63:575-7. [PMID: 15082490 PMCID: PMC1755005 DOI: 10.1136/ard.2003.010058] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the frequency of antithyroid antibodies and the presence of autoimmune thyroiditis among patients with primary Sjögren's syndrome. DESIGN A case-control study. METHODS 53 consecutive patients with primary Sjögren's syndrome, 30 with rheumatoid arthritis, 12 with secondary Sjögren's syndrome associated with rheumatoid arthritis, 17 with autoimmune thyroiditis, and 53 apparently healthy controls were studied for anti-TG and anti-TPO antibodies as well as serum thyroid hormones and TSH levels. RESULTS The overall frequencies of thyroid antibodies were 6/53 (11%) in primary Sjögren's syndrome, 2/30 (7%) in rheumatoid arthritis, 2/12 (17%) in secondary Sjögren's syndrome, 4/53 (8%) in healthy controls, and 16/17 (94%) in autoimmune thyroiditis. There was no difference in the frequency of the thyroid antibodies among the groups if patients with autoimmune thyroiditis were excluded (p = 0.415 for anti-TPO; p = 0.275 for anti-TG; p = 0.696 for either anti-TG and/or anti-TPO). Only two patients with primary Sjogren's syndrome had clinical hypothyroidism associated with autoimmune thyroiditis. CONCLUSIONS In this Turkish population, no association between primary Sjögren's syndrome and autoimmune thyroiditis was found.
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Affiliation(s)
- R Tunc
- Department of Internal Medicine, Division of Rheumatology, Meram School of Medicine, Selcuk Universitesi, Konya, Turkey.
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D'Arbonneau F, Ansart S, Le Berre R, Dueymes M, Youinou P, Pennec YL. Thyroid dysfunction in primary Sjögren's syndrome: a long-term followup study. ACTA ACUST UNITED AC 2004; 49:804-9. [PMID: 14673967 DOI: 10.1002/art.11460] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the prevalence of thyroid dysfunction and related autoantibodies in patients with primary Sjögren's syndrome (pSS), and to determine whether these abnormalities develop over time. METHODS pSS patients (n = 137) and controls (n = 120) were investigated for thyroid dysfunction and for the presence of anti-thyroid peroxidase antibody (anti-TPO) and antithyroglobulin antibody (ATG). Followup time for patients was 1-16 years, and 72 of the 120 controls were reevaluated 3 years after initial evaluation. RESULTS Thyroid disease was more frequent in the pSS patients than in the controls (30% versus 4%; P < 10(-4)), as were anti-TPO and ATG (11% versus 3%; P < 0.02, and 3% versus 1%, not significant). Ten of 107 euthyroid pSS patients dropped out of the study, and thyroid dysfunction became apparent at followup in 12 of the remaining 97. Most of the patients with thyroid-related autoantibodies at entry developed autoimmune thyroid disease thereafter. CONCLUSION Thyroid dysfunction is frequent in pSS patients, and those prone to develop thyroid disorders are identified by thyroid-related autoantibodies, or by rheumatoid factor and anti-Ro/SSA activity.
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Affiliation(s)
- Frédérique D'Arbonneau
- Laboratory of Immunology, Brest University Medical School Hospital, F-29609 Brest Cedex, France
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44
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Abstract
Autoimmune thyroid disease (AITD) is common and occurs frequently in conjunction with other diseases. Many putative disease associations have been suggested for AITD but the validity of these associations is not clear in all cases. It is important to define disease associations correctly because this may offer a means to rationally screen for true associations, may shed light on shared pathophysiologic mechanisms and may be important if the associated disease impacts on patient management. This review has examined the evidence base for a large number of the suggested associations.
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Affiliation(s)
- Richard C Jenkins
- University of Sheffield, Clinical Sciences Centre, Northern General Hospital, Sheffield, United Kingdom
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45
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Ramos-Casals M, García-Carrasco M, Brito Zerón MP, Cervera R, Font J. Viral etiopathogenesis of Sjögren's syndrome: role of the hepatitis C virus. Autoimmun Rev 2002; 1:238-43. [PMID: 12849002 DOI: 10.1016/s1568-9972(02)00057-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patients with hepatitis C virus (HCV) chronic infection present some extrahepatic manifestations that may mimic the clinical, immunologic and histological manifestations of primary Sjögren's syndrome (SS). Thus, HCV patients with sicca symptomatology and positive autoantibodies could be misdiagnosed as a 'primary' SS. Nevertheless, there are several clinical and immunologic features that could help us differentiate both processes.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, C/Villaroel 170, Hospital Clínic, Institut Clínic d'Infeccions i Immunologia, 08036 Barcelona, Catalonia, Spain.
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46
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García-Carrasco M, Ramos-Casals M, Rosas J, Pallarés L, Calvo-Alen J, Cervera R, Font J, Ingelmo M. Primary Sjögren syndrome: clinical and immunologic disease patterns in a cohort of 400 patients. Medicine (Baltimore) 2002; 81:270-80. [PMID: 12169882 DOI: 10.1097/00005792-200207000-00003] [Citation(s) in RCA: 242] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Mario García-Carrasco
- Department of Autoimmune Diseases, Clinical Institute of Infections and Immunology, Barcelona, Spain
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Ramos-Casals M, Font J, Garcia-Carrasco M, Brito MP, Rosas J, Calvo-Alen J, Pallares L, Cervera R, Ingelmo M. Primary Sjögren syndrome: hematologic patterns of disease expression. Medicine (Baltimore) 2002; 81:281-92. [PMID: 12169883 DOI: 10.1097/00005792-200207000-00004] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, Clinical Institute of Infections and Immunology, Barcelona, Spain.
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Taura SI, Murata Y, Aung W, Ishida R, Zhang L, Hossain M, Takahashi Y, Okada N, Shibuya H. Decreased thyroid uptake of Tc-99m pertechnetate in patients with advanced-stage Sjögren syndrome: evaluation using salivary gland scintigraphy. Clin Nucl Med 2002; 27:265-9. [PMID: 11914666 DOI: 10.1097/00003072-200204000-00006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The authors assessed the uptake of Tc-99m pertechnetate in the thyroid using salivary gland scintigraphy in patients with Sjögren syndrome and in healthy controls. MATERIALS AND METHODS Salivary gland scintigraphy and a labial biopsy were performed in 73 patients with Sjögren syndrome. Based on the labial biopsy findings, 32 patients with a histopathologic grade of 1 or 2 were regarded as having early-stage Sjögren syndrome and 41 patients with a grade of 3 or 4 were regarded as having an advanced stage. After the administration of 370 MBq (10 mCi) Tc-99m pertechnetate, dynamic salivary gland scintigraphy was performed for 50 minutes. Lemon juice was used to stimulate the salivary glands, and the thyroid gland was included in the imaging area. Scintigraphy was also performed in an age- and sex-matched control group of 25 healthy persons. The thyroid uptake ratio was calculated for the scintigraphic images and compared among the three groups: healthy controls, patients with early-stage Sjögren syndrome, and those with advanced-stage Sjögren syndrome. RESULTS When compared with the control group, the thyroid uptake ratio of the early-stage Sjögren syndrome group was not significantly different, whereas that of the advanced-stage group was significantly lower. CONCLUSIONS Thyroid uptake of Tc-99m pertechnetate was less in patients with advanced-stage Sjögren syndrome than in patients with early-stage Sjögren syndrome or in healthy controls. Measuring the thyroid uptake of Tc-99m pertechnetate using salivary gland scintigraphy is an easy and useful method for assessing thyroid disorders in Sjögren syndrome and thus should be performed routinely.
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Affiliation(s)
- Shin-ichi Taura
- Department of Radiology, Faculty of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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Ramos-Casals M, García-Carrasco M, Font Franco J, Ingelmo Morín M. Manifestaciones clínicas e inmunológicas asociadas a la infección crónica por el virus de la hepatitis C. Rev Clin Esp 2002. [DOI: 10.1016/s0014-2565(02)71033-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Enfermedad de Crohn en paciente diagnosticada de tiroiditis de Hashimoto y síndrome de Sjögren. Med Clin (Barc) 2002. [DOI: 10.1016/s0025-7753(02)73323-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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