Sjögren's syndrome with rapidly progressive motor neuron disease: a case report

Foot Drop, Wrist Drop, and Digital Ischemia As Initial Manifestations in Sjögren's Disease

A 50-year-old Saudi woman, with a history of rheumatoid arthritis (RA), presented to the emergency room with a three-week history of progressive weakness. Her symptoms began with difficulty elevating her arms and standing up from a chair. Over the next two days, her weakness progressed, leading to bilateral wrist drop and foot drop, along with an inability to raise her hands or stand. She also reported sensory changes, including decreased sensation to touch and heat, most prominent in the lower limbs, and complaints of dry eyes and mouth. Additionally, the patient noted bluish discoloration of her right middle finger. Physical examination revealed bilateral wrist and foot drop, decreased distal strength, absent reflexes, and a black discoloration on the distal interphalangeal (DIP) joint of her right middle finger. The patient had a history of inflammatory polyarthritis diagnosed as RA two years prior. Her physical findings, along with dry eyes, mouth, and the characteristic sensory and motor deficits, raised concern for Sjögren's syndrome (SS). Diagnostic tests confirmed SS, showing positive salivary gland biopsy results with lymphocytic infiltration, a positive Schirmer test for dry eyes, and positive serum autoantibodies for anti-Ro, anti-La, and ANA. Nerve conduction studies revealed severe motor and sensory polyneuropathy. Treatment included a three-day pulse of steroids, followed by oral prednisone, and cyclophosphamide for six months. Additionally, the patient was treated for osteoporosis with teriparatide, then switched to denosumab, and managed with methotrexate and supportive therapies, including artificial tears and physiotherapy. The patient showed significant improvement in symptoms and responded excellently to the treatment.

Amyotrophic lateral sclerosis associated with Sjögren's syndrome: a case report

BACKGROUND

Motor neuron disease (MND) is a chronic and progressive neurodegenerative disorder with an unknown cause. The development of amyotrophic lateral sclerosis (ALS) is believed to be linked to an immune response. Monocytes/macrophages and T cells are key players in the disease's advancement. Monitoring levels of cytokines in the blood can help forecast patient outcomes, while immunotherapy shows promise in alleviating symptoms for certain individuals.

CASE PRESENTATION

A 56-year-old male patient was admitted to the hospital due to progressive limb weakness persisting for eight months. The neurological examination revealed impairments in both upper and lower motor neurons, as well as sensory anomalies, without corresponding signs. Electrophysiological examination results indicated extensive neuronal damage and multiple peripheral nerve impairments, thereby the diagnosis was ALS. One month ago, the patient began experiencing symptoms of dry mouth and a bitter taste. Following tests for rheumatic immune-related antibodies and a lip gland biopsy, a diagnosis of Sjögren's syndrome (SS) was proposed. Despite treatment with medications such as hormones (methylprednisolone), immunosuppressants (hydroxychloroquine sulfate), and riluzole, the symptoms did not significantly improve, but also did not worsen.

CONCLUSION

It is recommended to include screening for SS in the standard assessment of ALS. Furthermore, research should focus on understanding the immune mechanisms involved in ALS, providing new insights for the diagnosis and treatment of ALS in conjunction with SS.

Neuropsychiatric manifestations in primary Sjogren syndrome

INTRODUCTION

Neurologic manifestations in primary Sjogren´s Syndrome (pSS) are characterized by a heterogeneity of clinical manifestations. In clinical practice, physicians are challenged with the absence of diagnostic criteria and the lack of clinical trials to support treatment. In this article, we will review epidemiology, clinical and immunological characterization, diagnosis and treatment of neurologic events in pSS.

AREAS COVERED

This narrative review provides an overview of neurologic manifestations described in pSS, complementary investigations and treatment reported. Articles were selected from Pubmed searches conducted between December 2021 and February 2022.

EXPERT OPINION

Epidemiology and clinical features of neurologic manifestations are derived from different cohort studies. Our understanding of pathophysiology of neurologic manifestations in pSS has significantly increased in the past few years, especially regarding PNS. However, there are still many knowledge gaps on therapeutics. The few available data on therapy rely upon small case series, from experiences with other autoimmune disease, such as systemic lupus erythematosus or expert opinion. There is an urgent need for well-designed clinical trials.