Prevalence of Sjögren's syndrome in autoimmune diseases

Epidemiology of Sjögren syndrome

Sjögren syndrome is a phenotypically varied autoimmune disorder that can occur alone in primary Sjögren syndrome or in association with other connective tissue diseases (CTDs), including rheumatoid arthritis, systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). The estimation of the prevalence and incidence of Sjögren syndrome varies depending on diagnostic criteria and study design, making it difficult to estimate geographical and temporal trends. Nonetheless, disease phenotype is influenced by geographical origin, which is a risk factor for systemic activity. Whether mortality in primary Sjögren syndrome is increased compared with that of the general population is not yet known, but extra-glandular manifestations, in particular lymphomas, are clear risk factors for mortality. In CTDs associated with Sjögren syndrome, lymphoma risk seems higher than that of patients with CTD alone, and there is potentially lower disease activity in SLE with Sjögren syndrome and in SSc with Sjögren syndrome than in SLE or SSc alone.

Histopathological differences between primary Sjögren's syndrome and Sjögren's syndrome accompanied by scleroderma

Background

Investigation of morphological differences in relation with serological variables between primary versus secondary Sjögren's syndrome associated with systemic scleroderma (Scl-SS).

Materials and Methods

A total of 69 primary Sjögren's syndrome (pSS) and Scl-SS patients were grouped according to the American-European Consensus Group criteria. Serum autoantibody information was obtained from the patient records. Hematoxylin and eosin sections of the minor salivary gland biopsy were reevaluated, and the lymphocyte focus score (FS), plasma cell focus, and fibrosis rates were all evaluated.

Results

There were 43 pSS and 26 Scl-SS cases. Both biopsy and autoantibody were positive in 16 pSS cases while only biopsy was positive in 25 cases and only antibody in 1 case. Both biopsy and antibody were positive in 5 Scl-SS cases while only biopsy was positive in 18 and only antibody in 3 cases. The plasma cell focus was statistically significantly higher in pSS cases (P = 0.003). No difference was seen between Sjögren' syndrome (SS) subtypes in terms of lymphocyte FS, fibrosis, and autoantibody positivity.

Conclusion

We found that plasma cell focuses could be found more frequently in pSS than Scl-SS. In addition, our study reveals that the coexistence of SS and systemic scleroderma decreases the incidence of FS value ≥1 compared to pSS.

The management of autoimmunity in patients with cholestatic liver diseases

Cholestatic liver diseases are rare diseases that often lead to cirrhosis and its consequent complications. In addition to liver-related morbidity, patients with cholestatic liver diseases often suffer from autoimmune diseases that affect several organs and tissues. The robust and efficient data collection and collaboration between hepatologists and rheumatologists have led to significant advancements in understanding the relationship between the cholestatic liver diseases and associated autoimmune diseases. In this paper, we discuss the cholestatic liver diseases (primary biliary cirrhosis, primary sclerosing cholangitis and immunoglobulin G4 associated cholangitis) and associated autoimmune diseases.

Discrepancies in assessment of patients with rheumatoid arthritis and secondary Sjögren's syndrome by DAS28-ESR and DAS28-CRP

OBJECTIVES

To investigate whether a difference exists between DAS28 from CRP and DAS28 from ESR in patients with rheumatoid arthritis (RA) and secondary Sjögren's syndrome (sSS).

MATERIAL AND METHODS

One group comprised patients with RA and sSS, the control group comprised patients with RA. The inclusion criteria for the RA and sSS group have been specified as follows: presence of at least one symptom of dryness, and also presence of anti-SS-A and anti-SS-B or at least focus score of one in biopsy.

RESULTS

The disease activity score 28 (DAS28) was assessed using both ESR and CRP in 60 patients with RA and sSS and 59 patients with RA alone. However, concordance between these two methods was good (Cohen's κ coefficient κ = 0.60, 95% CI: 0.45-0.75 in the first group and κ = 0.71, 95% CI: 0.56-0.86 in the control group). In the group with RA and sSS, the mean value of DAS28-ESR = 5.2, whereas the mean value of DAS28-CRP = 4.7 (p < 0.0001). In the group with RA alone, mean DAS28-ESR = 4.7 while mean DAS28-CRP = 4.6; no significant difference was identified. Moreover, in RA patients with sSS, mean ESR = 39 mm/h compared with mean CRP at 25 mg/l. 79% of all patients demonstrated dysproteinaemia. There were connections between higher ESR and dysproteinaemia. In the control group there was no statistically significant difference between CRP and ESR.

CONCLUSIONS

Both DAS28-ESR and DAS28-CRP are useful outcome measures in RA. However, in patients with RA and sSS, DAS28 should be evaluated based on CRP.

The spectrum of orofacial manifestations in systemic sclerosis: a challenging management

Systemic sclerosis (SSc) is a rare multisystem connective tissue disorder characterized by the triad fibrosis, vasculopathy and immune dysregulation. This chronic disease has a significant impact on the orofacial region that is involved in more than two-thirds of the cases. SSc patients can show a wide array of oral manifestations, which are usually associated with a severe impairment of the quality of life. They often present a decreased the salivary flow and a reduced mouth opening that contribute substantially to the worsening of the oral health status. Therefore, SSc patients require specific and multidisciplinary interventions that should be initiated as early as possible. The identification of specific radiological and clinical signs at the early stage will improve the management of such patients. This study reviews the wide spectrum of orofacial manifestations associated with SSc and suggests clues for the oral management that remains challenging.

The coexistence of Sjögren's syndrome and primary biliary cirrhosis: a comprehensive review

Organ-specific and systemic autoimmune diseases share numerous features and often coexist in the same patient. Autoimmune cholangitis/primary biliary cirrhosis and Sjogren syndrome represent paradigmatic examples of the common grounds of different autoimmunity phenotypes based on similarities in clinical manifestations and immunopathogenesis. In fact, primary biliary cirrhosis and Sjogren's syndrome have both been coined as an autoimmune epithelitis in which apoptosis may be in both cases the key element to explain the organ-specific immune-mediated injury against the biliary and exocrine gland epithelia, respectively. Further, growing evidence supports in both diseases the view that B cells, T cytotoxic cells, and T helper cells are involved in chronic inflammation, likely via the altered expression of pro-inflammatory cytokines. The presence of estrogen receptors on the biliary and exocrine gland epithelia has been advocated as a key to the female predominance encountered in primary biliary cirrhosis and Sjogren's syndrome. Sadly, despite available data, therapeutic approaches remain largely unsatisfactory and recent studies with mechanistic approaches (as in the case of B cell depletion with rituximab) have been of partial benefit only. Future studies should focus on new molecular tools (single-cell transcriptomics, microRNA, epigenetics) to provide unique insights into common mechanisms.

Increased incidence of Sjogren's syndrome in systemic sclerosis: A nationwide population study

In the past, there were no studies to evaluate the incidence of Sjogren's syndrome and its relationship with sex and age in patients with systemic sclerosis. In this study, we enrolled 2217 patients with systemic sclerosis and 6485 controls from Taiwan's Registry of Catastrophic Illness database and National Health Insurance Research Database. Every patient with systemic sclerosis was matched to at most three controls by sex, age, month, and year of first diagnosis of systemic sclerosis. Standardized incidence ratio (SIR) of Sjogren's syndrome in patients with systemic sclerosis and 95% confidence interval (95% CI) were calculated. Cox hazard regression was used to calculate the hazard ratio (HR). Both male and female patients with systemic sclerosis had higher incidences of Sjogren's syndrome (SIR: 7.59, 95% CI = 2.97-19.51; SIR: 7.59, 95% CI = 5.56-10.42, respectively). The incidence of Sjogren's syndrome in patients with systemic sclerosis was still higher compared with control when stratified according to age. Age at diagnosis of Sjogren's syndrome was earlier in patients with systemic sclerosis in both male and female groups (p = 0.018; p < 0.001, respectively). Systemic sclerosis was associated with Sjogren's syndrome after adjusting for age, sex, and various autoimmune diseases (HR: 5.98, 95% CI = 4.79-7.47, p < 0.001). Common cytokines, overlapping antibodies, and similar risk alleles were all potential causes of increased incidence of Sjogren's syndrome in systemic sclerosis.

Diagnostic and clinical significance of anti-centromere antibodies in primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is an autoimmune disease of the liver characterised by biochemical evidence of cholestasis, elevated alkaline phosphatase levels and the presence of the highly disease specific anti-mitochondrial autoantibodies. Extra-hepatic autoimmune manifestations are common, including rheumatic disorders, such as systemic sclerosis (SSc). Notably, PBC is the most frequent autoimmune liver disease in SSc patients. Based on skin lesion extension, two major SSc disease subgroups are recognised: limited cutaneous SSc (lSSc) and diffuse cutaneous SSc. Anti-centromere antibody (ACA) positivity is highly characteristic of SSc, with up to 90% prevalence in lSSc patients. ACA has also been found in up to 30% of PBC patients and 80% of patients with a PBC/SSc overlap syndrome. The diagnostic and clinical significance of ACA positivity in patients with PBC without SSc has recently been under investigation, with several studies highlighting links to severe bile duct injury and portal hypertension. This review discusses the diagnostic and clinical relevance of ACA in patients with PBC, with or without SSc.

Discovery of putative salivary biomarkers for Sjögren's syndrome using high resolution mass spectrometry and bioinformatics

The purpose of the current study was to determine if saliva contains biomarkers that can be used as diagnostic tools for Sjögren's syndrome (SjS). Twenty seven SjS patients and 27 age-matched healthy controls were recruited for these studies. Unstimulated glandular saliva was collected from the Wharton's duct using a suction device. Two µl of salvia were processed for mass spectrometry analyses on a prOTOF 2000 matrix-assisted laser desorption/ionization orthogonal time of flight (MALDI O-TOF) mass spectrometer. Raw data were analyzed using bioinformatic tools to identify biomarkers. MALDI O-TOF MS analyses of saliva samples were highly reproducible and the mass spectra generated were very rich in peptides and peptide fragments in the 750-7,500 Da range. Data analysis using bioinformatic tools resulted in several classification models being built and several biomarkers identified. One model based on 7 putative biomarkers yielded a sensitivity of 97.5%, specificity of 97.8% and an accuracy of 97.6%. One biomarker was present only in SjS samples and was identified as a proteolytic peptide originating from human basic salivary proline-rich protein 3 precursor. We conclude that salivary biomarkers detected by high-resolution mass spectrometry coupled with powerful bioinformatic tools offer the potential to serve as diagnostic/prognostic tools for SjS.

The value of antinuclear antibodies in primary biliary cirrhosis

OBJECTIVE

Although autoantibodies have been used for the diagnosis of primary biliary cirrhosis (PBC), their role has not been clarified. In this study, we try to explore the value of gp210 antibody and anti-centromere antibodies (ACA) in PBC.

METHODS

Anti-gp210 and ACA were tested in 140 PBC patients by ELISA and indirect immunofluorescence respectively. Their association with clinical, pathological data and prognosis was analysed.

RESULTS

30.5% of PBC patients had positive anti-gp210 antibody and 29.2% had ACA. The anti-gp210 antibody positive group had higher Mayo risk scores and lower serum albumin levels compared to the negative one. Patients with positive anti-gp210 antibody were more likely to develop hepatic failure (p<0.05, OR=9.8460, 95% CI: 1.067-90.901) than patients with negative anti-gp210 antibody. More patients with positive ACA developed portal hypertension than patients with negative ACA (p<0.05, OR=9.259; 95% CI: 1.027-88.410). Furthermore, concurrent Sjögren's syndrome (SjS) and PBC was significantly more likely in the ACA positive group than in the negative ones (68.4% in ACA positive group, 20.7% in ACA negative group p<0.001).

CONCLUSIONS

Both anti-gp210 antibody and ACA are related to severe disease course and poor prognosis. For PBC patients with positive ACA, further examinations should be made to detect underlying SjS.

Association between rheumatoid arthritis and primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is an autoimmune disease, characterized by chronic biliary duct destruction, which mainly affects women aged between 35 and 45 years. Prolonged liver inflammation can cause scarring, leading to cirrhosis. The most common first clinical manifestations are pruritus, asthenia or jaundice, but most patients remain asymptomatic. PBC can be associated by itself with arthralgia, but polyarthritis and synovitis are exceptional. PBC is often associated with other non-hepatic autoimmune diseases, especially primary Sjogren's syndrome, which may favour articular involvement. PBC and rheumatoid arthritis (RA) have been suggested to coexist in 1.8 to 5.6% of patients with PBC, but data supporting this association are scarce. We report two cases of such an association. Both of these patients presented severe erosive RA. We discuss the therapeutic management of these patients, taking into account hepatic involvement and drug toxicity.

Decreased salivary gland function in patients with autoimmune thyroiditis

BACKGROUND/AIMS

It has been speculated that impaired salivary flow contributes to autoimmune thyroiditis (chronic thyroiditis, Hashimoto's thyroiditis). To test this hypothesis, salivary function was measured by quantitative salivary scintigraphy in autoimmune thyroiditis patients, as well as in age- and gender-matched controls for comparison.

METHODOLOGY

One hundred and twenty patients with an autoimmune thyroiditis history of more than 10 years each and 36 healthy controls were enrolled in the study. All the 120 autoimmune thyroiditis patients had good blood sugar control. None had autonomic neuropathy. These 120 autoimmune thyroiditis patients were separated into two subgroups: group 1, 60 patients with xerostomia; and group 2, 60 patients without xerostomia. After intravenous injection of 5 mCi Tc-99m pertechnetate, sequential images at 1 min/frame were acquired for 30 min. The first- and 15th-minute uptake ratios (UR) were calculated from the tracer uptakes in the four major salivary glands over the background regions of interest (ROIs). Saliva excretion was stimulated by 1 tablet of 200 mg ascorbic acid given orally 15 min after injection of the tracer. Then, the maximal excretion ratios (ER) of the four major salivary glands after sialagogue stimulation were calculated.

RESULTS

Impaired salivary function, represented by significantly decreased UR and ER values, in autoimmune thyroiditis patients with xerostomia was demonstrated in this study. In addition, there was a significantly higher prevalence of salivary gland dysfunction in group 1 patients than in group 2 patients.

CONCLUSIONS

Significantly poorer salivary function was found in autoimmune thyroiditis patients with xerostomia compared with autoimmune thyroiditis patients without xerostomia and healthy controls by means of objective and quantitative salivary scintigraphy.

Objective evidence of decreased salivary function in patients with autoimmune thyroiditis (chronic thyroiditis, Hashimoto's thyroiditis)

Impaired salivary flow is found in Sjögren's syndrome, which is a common, chronic, autoimmune, inflammatory connective tissue disease, mainly affecting the exocrine glands. Histopathologically, lymphocytic infiltrations of the salivary glands are found in Sjögren's syndrome that are similar to those of the thyroid gland in autoimmune thyroiditis (chronic thyroiditis, Hashimoto's thyroiditis). To test this hypothesis by Daniels et al ., salivary function was measured by quantitative salivary scintigraphy in autoimmune thyroiditis patients, as well as in age- and sex-matched controls. Forty patients, each with a history of autoimmune thyroiditis of over 10 years, and 61 healthy controls were enrolled in the study. All of the 40 autoimmune thyroiditis patients had good blood sugar control. None presented autonomic neuropathy. They were separated into two subgroups: patient group 1, 20 patients with xerostomia; patient group 2, 20 patients without xerostomia. Two control groups of healthy subjects were included for comparison: control group 1, 36 subjects without xerostomia; control group 2, 25 subjects with xerostomia. After intravenous injection of 5 mCi (99m)Tc-pertechnetate, sequential images at 1 min per frame were acquired for 30 min. The first and 15th minute uptake ratios (URs) were calculated from the tracer uptakes in the four major salivary glands relative to the background regions of interest (ROIs). Saliva excretion was stimulated by one tablet of 200 mg ascorbic acid given orally 15 min after injection of the tracer. The maximal excretion ratios (ERs) of the four major salivary glands after sialagogue stimulation were calculated. Impaired salivary function, represented by significantly decreased UR and ER values, in autoimmune thyroiditis patients with xerostomia was demonstrated in this study. Significantly poorer salivary function was found in autoimmune thyroiditis patients with xerostomia, when compared with autoimmune thyroiditis patients without xerostomia and healthy controls with or without xerostomia, via objective and quantitative salivary scintigraphy. However, a larger series of autoimmune thyroiditis patients is necessary to confirm our findings.

Sicca symptoms, saliva and tear production, and disease variables in 636 patients with rheumatoid arthritis

OBJECTIVES

(1) To estimate the prevalence of ocular and oral sicca symptoms (SISY) or reduced saliva and tear production; (2) to relate SISY and sicca signs to measures of disease activity, damage, and health status; and (3) to examine the relation between symptoms and objective signs of tear and saliva production in a large sample of representative patients with rheumatoid arthritis (RA).

METHODS

From an unselective county RA register 636 patients (age 20-70 years) were examined with Schirmer-I test (ST), unstimulated whole saliva (UWS), questions on SISY and measures of disease activity, damage and health status.

RESULTS

Ocular sicca symptoms were reported in 38%, oral sicca symptoms in 50%, and a combination of both in 27%. Reduced tear production was present in 29%, and reduced saliva production in 17%. The minimum frequency of secondary Sjögren's syndrome was 7%. Measurements of exocrine disease manifestations were to variable extents bivariately correlated to disease activity measures, physical disability, pain, fatigue, and use of xerogenic drugs, but were not related to deformed joint count. Multivariate analyses revealed significant associations between disease activity and reduced saliva production. Only weak associations between SISY and tear or saliva production were observed.

CONCLUSION

SISY, reduced tear and saliva production were frequent extra-articular manifestations in RA, but were only weakly intercorrelated. High disease activity and at least two SISY were independent predictors of reduced saliva production, but ocular and oral dryness did not seem to be closely related to disease duration, disease activity, damage or health status.

Characteristics of rheumatoid arthritis patients with self-reported sicca symptoms: evaluation of medical, salivary and oral parameters

OBJECTIVES

To examine the prevalence of sicca symptoms in rheumatoid arthritis (RA)-patients, and to evaluate medical, salivary, and oral parameters in matched subgroups of patients with and without sicca symptoms as well as in healthy controls.

PATIENTS AND METHODS

The prevalence of self-reported sicca symptoms was examined by a postal questionnaire in a representative cohort of RA-patients (n = 105, aged 52-74 years, disease duration 10-20 years, 77% females, 56% RF-positive). Patient subgroups and controls (9-10 in each group) underwent examinations of disease activity, blood analyses, tests of tear and salivary secretion, and examination of oral mucosa and microflora. Analyses of salivary acidic proline-rich proteins (PRPs), statherin and histatins were performed.

RESULTS

One or more sicca symptoms were reported by 65% of RA-patients. Sicca patients (having > or = 4 sicca symptoms) had a more active and severe disease with higher scores for disability, fatigue and tender joints than patients without such symptoms. Other significant findings in the sicca group were lower values of unstimulated whole saliva, output of PRPs, statherin and histatins in submandibular saliva, and higher counts of oral Candida species.

CONCLUSIONS

Sicca symptoms were prevalent in RA. Qualitative and quantitative salivary tests distinguished between sicca and non-sicca RA-patients, though overlap was considerable for some parameters.

Assessment of anti-endothelial cell antibodies in systemic sclerosis and Sjögren's syndrome

OBJECTIVES

Anti-endothelial cell antibodies (AECA) have been detected in 19 to 30% of patients with systemic sclerosis (SSc). The objective of this study was first to assess the role of a secondary Sjögren's syndrome (SS) in the occurrence of AECA in SSc. Secondly, we researched AECA in patients with primary SS, and investigated whether AECA were associated with vascular manifestations (Raynaud's phenomenon and vasculitis).

METHODS

IgG-AECA were tested by an ELISA method in serum samples from 50 patients with SSc (16 of them had also a secondary SS), 50 patients with primary SS, and 50 healthy controls.

RESULTS

AECA levels were significantly higher in patients with SSc or primary SS than in healthy controls (p < 0.01 and p < 0.01, respectively). In patients with SSc, AECA values were significantly higher in patients with secondary SS (p < 10(-5)). In patients with primary SS, AECA levels were significantly higher in patients with Raynaud's phenomenon (p < 0.01), but not in patients with vasculitis.

CONCLUSION

In patients with SSc, AECA are associated with a secondary SS. In patients with primary SS, AECA are associated with Raynaud's phenomenon, but not with vasculitis.

Prevalence of eyelid dermatitis in primary Sjögren's syndrome

BACKGROUND

The eyelid dermatitis seen in elderly patients is a relatively heterogenous and troublesome disease. Most cases seem to be idiopathic and show resistance to standard dermatologic therapy.

METHODS

Fifty-two patients with primary definite Sjögren's syndrome (4 men, 48 women, mean age 54 years) were enrolled in this study, and the prevalence of eyelid dermatitis was investigated. Diagnostic criteria for Sjögren's syndrome were based on the criteria proposed by the Japanese Ministry of Health and Welfare. Patch test was performed using ICDRG-European standard allergens and/or eye drops, hair dye, and cosmetics.

RESULTS

Of the 52 patients, 22 showed eyelid dermatitis. These changes were much more frequent in elderly patients and showed a good correlation with the presence of ocular dry sensation. No significant difference was observed in clinical and other laboratory findings between patients with or without eyelid dermatitis. Although 8 of the 13 patients showed positive patch test reaction to various allergens, no close relationship existed between the use of a suspected substance and the onset or severity of eyelid dermatitis.

CONCLUSIONS

These results suggest that the presence of rubbing dermatitis of the eyelid may be one of the cutaneous manifestations of Sjögren's syndrome.

Giant mucocele of oral cavity as a mucocutaneous manifestation of Sjögren syndrome

Two cases of Sjögren syndrome who developed a giant mucocele on the floor of the oral cavity are reported. Histological analysis revealed the dense infiltration of lymph-plasmacytic infiltration around the dilated salivary duct. Similar findings were observed in the biopsied specimens of the labial salivary gland which were consistent with the grade 4 score proposed by Chisholm and Mason's criteria. Mucocele is a common mucocutaneous disease of unknown etiology except for traumatic origin and Sjögren syndrome might be one of the important underlying disease which causes giant mucocele, especially in elderly female patients.

Salivary gland involvement in autoimmune thyroiditis, with special reference to the degree of association with Sjögren's syndrome

From a total of 63 patients with autoimmune thyroiditis, 19 cases were further investigated to determine the degree of concomitant morphologic and functional salivary gland changes. For comparison, 21 of a total of 28 cases of primary Sjögren's syndrome were also examined. Of the 19 cases of autoimmune thyroiditis, 11 showed various degrees of salivary gland involvement on the basis of an analysis of lower lip salivary gland biopsy specimens, scintigraphy of the parotid, and unstimulated whole sialometry. Six of these cases fulfilled the criteria of primary Sjögren's syndrome. A remarkably high proportion of dark-staining acini was observed in the lower lip biopsy specimens of our patients with thyroiditis (8 of 19, 42%) and less among our patients with primary Sjögren's syndrome (5 of 21, 24%). We conclude that significant involvement of salivary glands may occur in cases of autoimmune thyroiditis, which indicates that common mechanisms may frequently be operative in the development of thyroid and salivary gland immune disease.

Sjögren's syndrome: a stepwise approach to the use of diagnostic tests

One hundred and forty two patients (62 with definite Sjögren's syndrome, 24 with probable Sjögren's syndrome, and 56 in whom Sjögren's syndrome was finally ruled out) were studied. Schirmer's test and rose bengal staining for the diagnosis of keratoconjunctivitis sicca and salivary scintigraphy and a labial biopsy sample for the diagnosis of xerostomaia were studied in all patients. Rose bengal staining showed high specificity (98%) but low sensitivity (55%). All patients with positive rose bengal staining results had associated xerostomia. In the rose bengal staining positive patients, scintigraphy had 100% specificity. A labial biopsy sample showed high sensitivity in the rose bengal staining, salivary scintigraphy positive group, and high specificity in the rose bengal staining positive, salivary scintigraphy negative group. In patients with negative rose bengal staining, salivary scintigraphy showed 96% specificity and 36% sensitivity. A labial biopsy sample had a sensitivity and specificity greater than 90% in rose bengal staining negative patients. Only 29 biopsy samples were needed to achieve a diagnosis of Sjögren's syndrome in 142 patients (20%). Hence the suggested approach may make it unnecessary to take biopsy samples in approximately 80% of patients with suspected Sjögren's syndrome. Using the stepwise approach of first rose bengal staining, then salivary scintigraphy, and eventually a labial biopsy sample in patients with suspected Sjögren's syndrome, the diagnosis is relatively simple.

Annular erythema. A comparative study of Sjögren syndrome with subacute cutaneous lupus erythematosus

Annular erythema developed in 22 patients with Sjögren syndrome. Clinically, the annular erythema was subdivided into three forms: Sweet disease-like annular erythema with an elevated border (14 cases); subacute cutaneous lupus erythematosus (SCLE)-like marginally scaled erythema (5 cases); and papular erythema (3 cases). Histopathologically, features commonly seen in annular erythema are deep perivascular and/or periappendageal infiltration of the lymphocytes with an admixture of neutrophils or plasma cells and less frequent epidermal changes suggestive of cutaneous lupus erythematosus. Immunoglobulin or complement deposition along the dermoepidermal junction of lesional skin was observed in 8 of 18 cases, and most of the dermal infiltrates consisted of CD4(+), 4B4(+) cells. The appearance of anti-SS-A(Ro) (100%) and anti-SS-B(La) (77%) was significantly higher in patients with annular erythema. These results suggest that patients with Sjögren syndrome might have a distinct annular erythematous lesion that is both clinically and histopathologically different from SCLE, although close immunologic abnormalities exist in these two diseases.

Clinical and histological analysis of labial lip biopsy in Sjögren syndrome

Labial lip biopsy findings from 52 patients with Sjögren syndrome (SjS) and cutaneous manifestations were clinically analyzed. Findings of the labial lip biopsy with more than one focus (a cluster of at least 50 lymphocytes) were positive in 52% (28/52). Sixteen patients who presented with oral dryness had negative labial lip biopsy findings with less than one focus score and five patients without oral dryness had positive results. Cells infiltrating into the salivary gland were categorized as plasma cell rich (Group 1), lymphocyte rich (Group 3), intermediate (Group 2), or no gland in biopsied specimens (Group 4). Sicca complaint and the grade of lip biopsy score were significantly higher in Group 3 than in Group 1; no differences were observed in laboratory findings between Groups 1 and 3. The patterns of age distribution and salivary flow rate were also not statistically significant in these two groups. The patients with plasma cell rich infiltrate presented oral dryness, although their clinical and grade of lip biopsy scores were relatively low; most of these patients have secondary SjS. Some of the patients in Group 4 showed an advanced stage of the disease through their lip biopsy score was grade 1 with atrophic or no gland. These data suggest that labial lip biopsy is a useful screening method for the diagnosis of Sjögren syndrome and that clinical manifestations may differ in parallel with the type of infiltrating cell.

A postmortem study of focal adenitis in salivary and lacrimal glands

Investigations were carried out on 102 consecutive medicolegal post-mortem subjects to identify signs of focal adenitis in labial, submandibular, and lacrimal glands. There were 19 subjects (18.6%) with focus scores exceeding 1 in one or two of the types of glands. Among the 19, five had had a disease which is generally associated with Sjögren's syndrome or is autoimmune in nature. In another 63 subjects occasional lymphocytic foci were found in one, two, or all three types of gland. Fibrosis, atrophy, and fatty change had occurred most often in the labial salivary glands in those over 50 years of age with or without high focus scores. Fibrosis, atrophy, and fat infiltration had hardly ever occurred in the lacrimal glands, although this is the type of gland in which high focus scores occur most often. The results suggest that there may be a common autoimmune basis for Sjögren's syndrome and other diseases, the mechanisms of which are still incompletely understood. A focus score exceeding 1 may be an indicator of Sjögren's syndrome, but the diagnosis should not be established on the biopsy findings alone.

Annular erythema: a possible association with primary Sjögren's syndrome

In four patients with primary Sjögren's syndrome a distinct annular erythema developed, which was characterized by a wide, elevated border (which can be likened to a doughnut ring) and central pallor. Histologically, there was a coat sleeve-like infiltration of lymphocytes around blood vessels and nuclear debris in the connective tissue. Vasculitis or epidermal changes suggestive of lupus erythematosus were not observed, and there was no immunoglobulin deposition along the basement membrane zone. This annular erythema may be a cutaneous manifestation of Sjögren's syndrome.