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Chawla RK, Chawla AK, Chaudhary G, Chawla MK, Sareen M. Sjogren's syndrome-An interesting case. Indian J Tuberc 2022; 69:109-112. [PMID: 35074142 DOI: 10.1016/j.ijtb.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/03/2020] [Accepted: 12/07/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To present a case of Sjogren syndrome with pulmonary manifestations in an adult female and discuss its assessment and management. DESIGN Case Report. SETTING Tertiary care hospital. PATIENT One. RESULTS A 50 yrs female admitted with complaints of dryness of eyes with decreased salivation causing difficulty in swallowing since last 3 years, with persistent dry cough since 10-15 days and progressive dyspnea since 4-5 days. Anti-nuclear antibody (ANA) profile revealed Anti- Ro/SS-A and Anti- La/SS-B Positive. Also, sub-lingual excisional biopsy was done which was consistent with findings of Sjogren's syndrome. Patient showed significant improvement after starting oral glucocorticoids, systemic anti inflammatory agents (Tab. HCQS), artificial tear drops, oral iron supplements and other supportive treatment. CONCLUSION Sjögren syndrome (SS) is a chronic inflammatory disorder characterized by diminished lacrimal and salivary gland function and associated with lymphocytic infiltration of exocrine glands, and can affect extraglandular organ systems including the skin, lung, heart, kidney, neural, and hematopoietic systems. We present a case of Sjogren syndrome in an adult female presenting with xerostomia and dyspnea and was diagnosed upon detection of anti-Ro and anti-La antibodies and confirmed by histopathological examination of lip biopsy. Patient was started on oral steroids and other supportive treatment, General condition improved significantly and is doing very well on regular follow-up.
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Affiliation(s)
- Rakesh K Chawla
- Department of Pulmonary Medicine, Critical Care and Sleep disorders, Jaipur Golden Hospital, Saroj Super Speciality Hospital, 36, Pocket: E-3, Sector-3, Rohini, New Delhi, 110085, India.
| | - Aditya K Chawla
- Department of Pulmonary Medicine, Critical Care and Sleep disorders, Jaipur Golden Hospital, Saroj Super Speciality Hospital, 36, Pocket: E-3, Sector-3, Rohini, New Delhi, 110085, India
| | - Gaurav Chaudhary
- Department of Pulmonary Medicine, Critical Care and Sleep disorders, Jaipur Golden Hospital, Saroj Super Speciality Hospital, 36, Pocket: E-3, Sector-3, Rohini, New Delhi, 110085, India
| | - Madhav K Chawla
- Department of Pulmonary Medicine, Critical Care and Sleep disorders, Jaipur Golden Hospital, Saroj Super Speciality Hospital, 36, Pocket: E-3, Sector-3, Rohini, New Delhi, 110085, India
| | - Manoj Sareen
- Department of Pulmonary Medicine, Critical Care and Sleep disorders, Jaipur Golden Hospital, Saroj Super Speciality Hospital, 36, Pocket: E-3, Sector-3, Rohini, New Delhi, 110085, India
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Connective Tissue Disease-Related Interstitial Lung Disease: Prevalence, Patterns, Predictors, Prognosis, and Treatment. Lung 2020; 198:735-759. [DOI: 10.1007/s00408-020-00383-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
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Abstract
Sjögren syndrome (SS) is a progressive autoimmune disease characterized by dryness, predominantly of the eyes and mouth, caused by chronic lymphocytic infiltration of the lacrimal and salivary glands. Extraglandular inflammation can lead to systemic manifestations, many of which involve the lungs. Studies in which lung involvement is defined as requiring the presence of respiratory symptoms and either radiograph or pulmonary function test abnormalities quote prevalence estimates of 9% to 22%. The most common lung diseases that occur in relation to SS are airways disease and interstitial lung disease. Evidence-based guidelines to inform treatment recommendations for lung involvement are largely lacking.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 836 W. Gates Building, Philadelphia, PA 19104, USA
| | - Chadwick Johr
- Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 3737 Market Street, 8th floor, Philadelphia, PA 19104, USA
| | - Maryl Kreider
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 836 W. Gates Building, Philadelphia, PA 19104, USA.
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Koslow M, Kivity S, Vishnevskia-Dai V, Ben-Dov I. Unexplained cough: it is time to rule out Sjogren's syndrome. Clin Rheumatol 2018; 37:1215-1222. [PMID: 29388084 DOI: 10.1007/s10067-018-3987-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/12/2018] [Indexed: 11/28/2022]
Abstract
Sjogren's syndrome is associated with chronic cough, but sicca symptoms are missing from cough evaluation guidelines. We evaluated patients with unexplained cough for undiagnosed Sjogren's syndrome. Patients referred to our pulmonary clinic (Sheba Medical Center, 2009 to 2012) with unexplained cough and concomitant dry eyes were selected for evaluation. Unexplained cough was defined as chronic cough of unknown etiology despite algorithm-based evaluation and treatment. Patients were evaluated in a dedicated clinic by a pulmonologist, rheumatologist, and ophthalmologist specializing in autoimmune disease. Patients completed the Leicester Cough Questionnaire, spirometry, antibody testing for anti Ro/La, ophthalmologic examination with visual acuity, eyelid, ocular surface fluorescein staining, tear break-up time and Schirmer's test, full slit lamp, and fundus examinations. Four-year follow-up was conducted by telephone questionnaire. We identified 24 patients among which 22 (21 females) agreed for evaluation. Eight patients (36%), seven initially, and one during follow-up were diagnosed with Sjogren's syndrome (SS) (six secondary and two primary SS). At 4-year follow-up, cough tended to persist and improve in only 37% with SS. These include 2 (Scl and RA) who received rituximab and 1 (stage 1 sarcoidosis) with spontaneous improvement. In contrast, cough improved in most (64%) patients without SS; the majority (eight/nine) report intensified disease-specific treatment (five allergic and three GERD). We describe patients in whom unexplained chronic cough was associated with dry eyes. Focused workup revealed undiagnosed Sjogren's syndrome in 36%. Dry eyes, with or without SS, is under-recognized and should be added to diagnostic algorithms for unexplained cough.
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Affiliation(s)
- Matthew Koslow
- The Pulmonary Medicine Institute, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel. .,Fellowship, Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA. .,Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st Street, SW, Rochester, MN, 55902, USA.
| | - Shaye Kivity
- The Department of Internal Medicine A, the Zabludovicz Center for Autoimmune Diseases, and The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2013, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Vicktoria Vishnevskia-Dai
- The Golschleger Eye Institute, Chaim Sheba Medical Center, Tel Hashomer, Sackler Medical School, Tel Aviv, Israel
| | - Issahar Ben-Dov
- The Pulmonary Medicine Institute, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel.,Division of Pulmonary, Critical Care and Sleep Medicine, Yale University Hospital, New Haven, CT, USA
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Ludviksdottir D, Valtysdottir ST, Hedenström H, Hällgren R, Gudbjörnsson B. Eight-year follow-up of airway hyperresponsiveness in patients with primary Sjögren's syndrome. Ups J Med Sci 2017; 122:51-55. [PMID: 27849141 PMCID: PMC5361432 DOI: 10.1080/03009734.2016.1239663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate in a longitudinal study the influence of airway hyperresponsiveness (AHR) on lung function in patients with primary Sjögren's syndrome (pSS). METHODS Lung function was studied over an eight-year period in 15 patients who fulfilled the Copenhagen criteria for primary Sjögren's syndrome and who were covered in our earlier published study on AHR in patients with Sjögren's syndrome. Standard spirometry and measurements of lung volumes, diffusing capacity (DLCO), and AHR to methacholine were performed. RESULTS A significant decline over time was found in total lung capacity (TLC), vital capacity (VC), forced vital capacity (FVC), functional residual capacity (FRC), and expiratory midflows (FEF50). A sign of small airway obstruction (decrease in FEF50) at entry correlated with VC at follow-up (r = .8, P < .003), and the individual change in FEF50 during the observation period correlated with the individual change in VC (r = .6, P < .05). Six patients had increased AHR, and three of them had decreased DLCO. Six of the patients progressively reduced DLCO over time, and five of them had spirometric signs of increased small airway obstruction. CONCLUSIONS During this eight-year follow-up we observed that one-third of the patients with pSS developed a significant reduction in lung function. Our findings suggest that small airways obstruction and AHR are associated with reduction of VC and development of impaired DLCO as a sign of interstitial lung disease in this group of patients.
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Affiliation(s)
- Dora Ludviksdottir
- Department of Allergy, University Hospital, Reykjavik, Iceland
- Department of Respiratory Medicine, University Hospital, Reykjavik, Iceland
- CONTACT Dora Ludviksdottir Department of Allergy and Respiratory Medicine, Landspitali, University Hospital, Reykjavik, Iceland
| | | | - Hans Hedenström
- Department of Clinical Physiology, Akademiska Sjukhuset, Uppsala University Hospital, Uppsala, Sweden
| | - Roger Hällgren
- Department of Medical Sciences, Akademiska Sjukhuset, Uppsala University Hospital, Uppsala, Sweden
| | - Björn Gudbjörnsson
- Centre for Rheumatology Research, University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Yeh JJ, Chen HJ, Li TC, Wong YS, Tang HC, Yeh TC, Kao CH. Association between Sjogren's syndrome and respiratory failure: put airway, interstitia, and vessels close together: a national cohort study. PLoS One 2014; 9:e110783. [PMID: 25350278 PMCID: PMC4211705 DOI: 10.1371/journal.pone.0110783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/15/2014] [Indexed: 12/31/2022] Open
Abstract
Objectives Few studies have evaluated the association between Sjogren's syndrome (SS) and respiratory failure (RF). Thus, we conducted a retrospective national cohort study to investigate whether Sjogren's syndrome (SS) increases the risk of respiratory failure (RF). Methods The cohort consisted of 4954 newly diagnosed patients with SS but without a previous diagnosis of RF, and 19816 patients as the comparison cohort from the catastrophic illnesses registry, obtained from the 2000–2005 period. All of the study participants were followed from the index date to December 31, 2011. We analyzed the association between the risk of RF and SS by using a Cox proportional hazards regression model, controlling for sex, age, and comorbidities. Results The overall incidence rate of RF showed a 3.21-fold increase in the SS cohort compared with the comparison cohort. The adjusted HR of RF was 3.04 for the SS cohort compared with the comparison cohort, after we adjusted for sex, age, and comorbidities. The HRs of RF for patients with primary SS and secondary SS compared with the comparison cohort were 2.99 and 3.93, respectively (P for trend <.001). The HRs of RF increased as the severity of SS increased, from 2.34 for those with no inpatient care experience to 5.15 for those with inpatient care experience (P for trend <.001). Conclusion This study indicates that clinical physicians should not only consider secondary SS but also primary SS as a critical factor that increases the risk of RF.
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Affiliation(s)
- Jun-Jun Yeh
- Department of Family Medicine and Pulmonary Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
- Chia Nan University of Pharmacy and Science, Tainan, Taiwan
- Meiho University, Pingtung, Taiwan
| | - Hsuan-Ju Chen
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Tsai-Chung Li
- Graduate Institute of Biostatistics, College of Management, China Medical University, Taichung, Taiwan
- Department of Healthcare Administration, College of Health Science, Asia University, Taichung, Taiwan
| | - Yi-Sin Wong
- Department of Family Medicine and Pulmonary Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Hsien-Chin Tang
- Department of Family Medicine and Pulmonary Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Ting-Chun Yeh
- Department of Family Medicine and Pulmonary Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- * E-mail:
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Abstract
Sjögren syndrome is a slowly progressing autoimmune disease. Pulmonary manifestations are frequent in primary Sjögren syndrome but often not clinically significant; the most common are xerotrachea, interstitial lung diseases, and small airway obstruction. Pulmonary manifestations in Sjögren syndrome have a slow progression and favorable prognosis, with the exception of primary pulmonary lymphoma and pulmonary hypertension.
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Affiliation(s)
- Maria Kokosi
- 3rd Pulmonary Department, Sismanoglio General Hospital, Athens, Greece
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Bellido-Casado J, Plaza V, Díaz C, Geli C, Domínguez J, Margarit G, Torrejón M, Giner J. Bronchial inflammation, respiratory symptoms and lung function in Primary Sjögren's syndrome. Arch Bronconeumol 2011; 47:330-4. [PMID: 21429651 DOI: 10.1016/j.arbres.2011.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 01/04/2011] [Accepted: 01/07/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There is no information available regarding the relationship between the respiratory symptoms or lung function and bronchial inflammation, measured by induced sputum. OBJECTIVES Description of the clinical characteristics, radiographic images and lung function of patients suffering from Primary Sjögren Syndrome (PSS), and to assess the relationship with the inflammatory airway profile. METHODS We analysed clinical, radiology, lung function tests, bronchial hyperresponsiveness and inflammatory data in the induced sputum from 36 consecutive patients with PSS. RESULTS A total of 58% of patients had hoarseness and 42% had cough and dispnea. No lung dysfunction was observed, although 46% (n=16) had a positive bronchial response. Lymphocytosis >2.6% in induced sputum was observed in 69% of all sputa. There was chronic cough in 29% of patients with lymphocytosis (n=24), whereas 73% were normal (n=11) (P=.02). The duration time of cough was less for the former (P=.02). On the contrary a positive bronchial response was associated with lymphocytosis >2.6% (P=.02). Lipophages were present in 55% of pathological sputa (n=22) (index >15) versus 18% of the non-pathological ones (n=11) (P=.05). CONCLUSION Hoarseness, cough and dyspnea are frequent respiratory symptoms in PSS, although there is a wide variation in the relationship with bronchial responsiveness and airway inflammation. Lymphocytosis in the airways is another site of the infiltrative process in PSS, and the induced sputum is a complementary tool in the identification of active inflammatory process.
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9
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Hatron PY, Tillie-Leblond I, Launay D, Hachulla E, Fauchais AL, Wallaert B. Pulmonary manifestations of Sjögren's syndrome. Presse Med 2010; 40:e49-64. [PMID: 21194883 DOI: 10.1016/j.lpm.2010.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/12/2010] [Accepted: 11/15/2010] [Indexed: 10/18/2022] Open
Abstract
Sjögren's syndrome is a chronic inflammatory disorder characterized by lymphocytic infiltration of exocrine glands, mainly the lacrimal and salivary glands. However, extraglandular organ systems may frequently be involved, including the lungs. Although subclinical pulmonary inflammation exists in more than 50% of patients, clinically significant pulmonary involvement affects approximately 10% of patients and may be the first manifestation of the disease. The entire respiratory tract may be involved, with a wide spectrum of manifestations including xerotrachea and bronchial sicca, obstructive small airway disease, various patterns of interstitial lung disease, lymphoinfiltrative or lymphoproliferative lung disease, such as lymphoma (usually of MALT type), pulmonary hypertension, pleural involvement, lung cysts, and pulmonary amyloidosis.
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Affiliation(s)
- Pierre-Yves Hatron
- Service de médecine interne, Centre national de référence des maladies systémiques et auto-immunes rares (sclérodermie), université Lille2, CHRU de Lille, place de Verdun, 59037 Lille, France.
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10
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Utility of Bronchoalveolar Lavage in Evaluation of Patients with Connective Tissue Diseases. Clin Chest Med 2010; 31:423-31. [DOI: 10.1016/j.ccm.2010.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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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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Abstract
Sjögren's syndrome (SS) is a systemic disease with a predilection for the exocrine glands. It also is considered to be an autoimmune epitheliitis, and, as the respiratory system is lined throughout with epithelial cells, it should not be surprising that patients who have SS may develop pulmonary disease. This article describes these manifestations.
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Affiliation(s)
- Ann L Parke
- Division of Rheumatology, Saint Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105-1208, USA
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Archimandriti DT, Dalavanga YA, Cianti R, Bianchi L, Manda-Stachouli C, Armini A, Koukkou AII, Rottoli P, Constantopoulos SH, Bini L. Proteome Analysis of Bronchoalveolar Lavage in Individuals from Metsovo, Nonoccupationally Exposed to Asbestos. J Proteome Res 2008; 8:860-9. [DOI: 10.1021/pr800370n] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Dimitra T. Archimandriti
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Yotanna A. Dalavanga
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Riccardo Cianti
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Laura Bianchi
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Carmen Manda-Stachouli
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Alessandro Armini
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Anna-I. I. Koukkou
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Paola Rottoli
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Stavros H. Constantopoulos
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
| | - Luca Bini
- Department of Pneumonology, Medical School, University of Ioannina, Ioannina, Greece, Laboratory of Anatomy, Medical School, University of Ioannina, Ioannina, Greece, Functional Proteomics Laboratory, Department of Molecular Biology, University of Siena, Siena, Italy, Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, Ioannina, Greece, and Respiratory Diseases, Department of Clinical Medicine and Immunological Sciences, University of Siena, Siena, Italy
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14
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Interstitial lung disease and Sjögren's syndrome in primary biliary cirrhosis: a causal or casual association? Clin Rheumatol 2008; 27:1299-306. [PMID: 18512115 DOI: 10.1007/s10067-008-0917-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 04/17/2008] [Accepted: 04/21/2008] [Indexed: 12/16/2022]
Abstract
Interstitial lung disease (ILD) has been reported in patients with primary biliary cirrhosis (PBC); however, its frequency and pathogenesis are still poorly documented. Sjogren's syndrome (SS) is fairly common among patients with PBC, but the relationship between SS and PBC also remains controversial. To determine whether ILD and SS in PBC is a causal or casual association, whether SS accompanying PBC, could be considered secondary to or associated with PBC. One hundred and nine consecutive PBC cases were analyzed, and the differences of clinical features, histological stages, and serum autoantibodies between the PBC patients with and without SS were compared. There were 46 PBC patients with SS and 63 without SS, and 11 patients met the criteria of ILD. SS is associated with PBC in the form of secondary SS. The frequency of ILD in PBC patients with SS was 21.7% while only 1.6% in PBC patients without SS (P<0.0001). ILD in PBC was related to SS, with Spearman's rank coefficient of 0.330 (P=0.000). The association of SS with PBC, significantly higher in patients with than without ILD, which supports the hypothesis that ILD and SS in PBC, may be a causal, not casual, association.
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Tomashefski JF, Cagle PT, Farver CF, Fraire AE. Collagen Vascular Diseases and Disorders of Connective Tissue. DAIL AND HAMMAR’S PULMONARY PATHOLOGY 2008. [PMCID: PMC7120184 DOI: 10.1007/978-0-387-68792-6_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The collagen vascular diseases, also referred to as connective tissue diseases, are a diverse group of systemic inflammatory disorders thought to be immunologically mediated. The concept of collagen vascular disease began to take shape in the 1930s, when it was recognized that rheumatic fever and rheumatoid arthritis can affect connective tissues throughout the body.1,2 During the following decade, as conditions such as systemic lupus erythematosus (SLE) and scleroderma came to be viewed as systemic diseases of connective tissue, the terms diffuse connective disease and diffuse collagen disease were proposed.3,4 During the same period, the designation of diffuse vascular disease was proposed for diseases such as scleroderma, polymyositis, SLE, and polyarteritis nodosa, which featured widespread vascular involvement.5 With the realization that many of these entities can exhibit both systemic connective tissue manifestations and vascular abnormalities, the unifying designation of collagen vascular disease was introduced.6
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Affiliation(s)
- Joseph F. Tomashefski
- grid.67105.350000000121643847Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH USA ,grid.411931.f0000000100354528Department of Pathology, MetroHealth Medical Center, Cleveland, OH USA
| | - Philip T. Cagle
- grid.5386.8000000041936877XDepartment of Pathology, Weill Medical College of Cornell University, New York, NY ,grid.63368.380000000404450041Pulmonary Pathology, Department of Pathology, The Methodist Hospital, Houston, TX USA
| | - Carol F. Farver
- grid.239578.20000000106754725Pulmonary Pathology, Department of Anatomic Pathology, The Cleveland Clinic Foundation, Cleveland, OH USA
| | - Armando E. Fraire
- grid.168645.80000000107420364Department of Pathology, University of Massachusetts Medical School, Worcester, MA USA
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Ostojic P, Cerinic MM, Silver R, Highland K, Damjanov N. Interstitial lung disease in systemic sclerosis. Lung 2007; 185:211-20. [PMID: 17717851 DOI: 10.1007/s00408-007-9012-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We reviewed the literature concerning pathogenesis, clinical features, diagnosis and treatment of interstitial lung disease (ILD) in patients with systemic sclerosis (SSc). ILD is detectable in approximately 70% of patients at autopsy. Nonspecific interstitial pneumonia (NSIP) is the most common pathologic finding. The earliest phase of ILD in SSc is characterized by microvascular injury and alveolitis. Endothelial lesions, activation of coagulation proteases, especially thrombin, fibroblast proliferation, and differentiation of normal lung fibroblasts to a myofibroblasts phenotype are hallmarks of ILD in SSc. Diagnostic procedures used to detect ILD are chest X-ray, high-resolution computed tomography, bronchoalveolar lavage, lung function tests, and sometimes thoracoscopic lung biopsy. Novel and potentially useful methods to diagnose ILD in SSc are induced sputum and technetium-labeled diethylenetriamine pentaacetate (99mTC-DTPA) clearance time. Cyclophosphamide seems to be relatively effective to treat ILD in the earliest phase, but the effects of other immunosuppressive drugs on the lungs are less convincing.
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Affiliation(s)
- Predrag Ostojic
- Institute of Rheumatology, University of Belgrade, Belgrade, Serbia.
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Crestani B, Schneider S, Adle-Biassette H, Debray MP, Bonay M, Aubier M. Manifestations respiratoires au cours du syndrome de Gougerot-Sjögren. Rev Mal Respir 2007; 24:535-51. [PMID: 17468709 DOI: 10.1016/s0761-8425(07)91575-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Sjogren's syndrome is a common auto-immune disease. BACKGROUND Clinically significant pulmonary involvement affects approximately 10% of patients and may be the first manifestation of the disease, putting the respiratory physician in a position to suspect and confirm the diagnosis. Besides interstitial lung disease and bronchial disorders, cough is a common symptom of the disease and particularly difficult to treat. Lung cysts and amyloid deposits, sometimes associated with lymphoma, have recently been described. The development of a primary pulmonary lymphoma, usually from MALT, is a major complication of the disease. VIEWPOINT Characterisation of the pathophysiology of pulmonary involvement in Sjogren's syndrome and the institution of specific treatment merits the interest of the respiratory physician. CONCLUSION The respiratory physician should consider the diagnosis of Sjogren's syndrome in many different clinico-pathological situations.
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Affiliation(s)
- B Crestani
- Service de Pneumologie A, APHP, Hôpital Bichat, Paris, France.
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18
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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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Dalavanga YA, Voulgari PV, Georgiadis AN, Leontaridi C, Katsenos S, Vassiliou M, Drosos AA, Constantopoulos SH. Lymphocytic alveolitis: A surprising index of poor prognosis in patients with primary Sjogren's syndrome. Rheumatol Int 2005; 26:799-804. [PMID: 16344933 DOI: 10.1007/s00296-005-0092-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 11/20/2005] [Indexed: 10/25/2022]
Abstract
Twelve years ago we reported that lymphocytic alveolitis [or bronchoalveolar lavage (BAL) lymphocytosis] correlates with clinical pulmonary involvement in primary Sjogren's syndrome (pSS). Our thesis was based on subtle clinical and functional evidence of interstitial lung disease (ILD) in pSS patients with "high lymphocytic alveolitis" (>15% lymphocytes in BAL). This report is a follow-up study of these patients. Basic clinical and functional re-evaluation of the 22 patients with pSS, studied in 1991, emphasized the differences between those with alveolitis and those without alveolitis. There was no significant functional decline. There were, however, two statistically significant differences between the two groups: (1) only patients with BAL lymphocytosis had to be treated with steroids (5/12 vs. 0/10, P < 0.05) and (2) only patients with BAL lymphocytosis had died in the mean time (6/12 vs. 0/10, P < 0.01). The causes of death were various. On only two occasions were they related to respiratory infections while there were no deaths from respiratory failure secondary to ILD. BAL lymphocytosis appears to be a surprisingly serious index of dismal prognosis in patients with pSS. We offer no unifying pathophysiologic mechanism for it and, therefore, all we propose is that BAL is performed early, in as many patients with pSS as possible. These patients should then be followed up systematically, in order to evaluate if BAL lymphocytosis has any pathophysiologic importance in the development of clinically serious pSS, which is serious enough to lead to death.
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Affiliation(s)
- Y A Dalavanga
- Department of Anatomy, Medical School, University of Ioannina, 45110 Ioannina, Greece
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Nishinarita S, Kinoshita S, Kaneko M, Shimizu T, Son K, Aoki M, Kitamura N, Matsukawa Y, Hiranuma M, Horie T. Subclinical renal tubular acidosis in patients with primary and secondary Sjögren's syndrome: a possible marker of disease progression. Mod Rheumatol 2002; 12:318-22. [PMID: 24383999 DOI: 10.3109/s101650200056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract To clarify the prevalence of subclinical renal tubular acidosis (RTA) and its association with clinical and laboratory parameters in primary and secondary Sjögren's syndrome (SS), an acid-loading test was conducted. Subclinical RTA was found in 32% of patients with SS. The prevalence of subclinical RTA in primary and secondary SS was about the same (31.6% and 33.3%, respectively). Significant longer duration of illness, more severely decreased salivary excretion, decreased lymphocyte number, higher serum levels of IgG and IgA, and higher frequency of anti-SS-A (Ro) and SS-B (La) antibodies were found in patients with subclinical RTA. These results suggested that subclinical RTA may be a characteristic manifestation both in primary and secondary SS, along with the progression of immunologic dysfunction, when the illness seemed to be indolent.
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Affiliation(s)
- S Nishinarita
- Department of Internal Medicine, Nihon University School of Medicine , 30 Oyaguchi, Itabashi-ku, Tokyo 173-8610 , Japan
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22
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Galani V, Constantopoulos S, Manda-Stachouli C, Frangou-Lazaridis M, Mavridis A, Vassiliou M, Dalavanga Y. Additional proteins in BAL fluid of Metsovites environmentally exposed to asbestos: more evidence of "protection" against neoplasia? Chest 2002; 121:273-8. [PMID: 11796462 DOI: 10.1378/chest.121.1.273] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Inhabitants of Metsovo in northwest Greece have been exposed to asbestos from use of a tremolite-containing whitewash ("luto" soil). As a result, they have increased incidence of malignant pleural mesothelioma and pleural calcifications (PCs). However, subjects with calcifications have a much lower incidence of mesothelioma than those without. A previous study of the two groups with BAL revealed higher proportional lymphocytosis among subjects with calcifications. We suggested that BAL lymphocytosis may be somehow correlated with "protection" against neoplasia. METHODS The present report is a study of the liquid phase of BAL in the two groups. BAL specimens of 43 Metsovites (13 subjects with PCs and 30 subjects without PCs) and two control groups were examined. We measured total protein, albumin, IgG, IgA, and interleukin-6. Proteins were analyzed with sodium dodecyl sulfate-polyacrylamide gel electrophoresis and two-dimensional electrophoresis and further characterized using an appropriate computer program. RESULTS The most interesting finding was the presence of two additional protein spots corresponding to the electrophoretic site of Ig heavy chain and C(4) component of complement. The two proteins were present in all Metsovites with PCs but in none without PCs and also in none of the control groups. CONCLUSION This study further separates two groups of Metsovites with different reaction to asbestos, possibly as a result of different activation of alveolar macrophages. This difference leads the first group to the formation of PCs, BAL fluid lymphocytosis, and relative "protection" against malignancy, and the second group to no calcifications, no lymphocytosis, but also no protection against malignancy.
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Affiliation(s)
- Vassiliki Galani
- Department of Pneumonology, University of Ioannina, Medical School, Ioannina, Greece
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Alhamad EH, Lynch JP, Martinez FJ. Pulmonary function tests in interstitial lung disease: what role do they have? Clin Chest Med 2001; 22:715-50, ix. [PMID: 11787661 DOI: 10.1016/s0272-5231(05)70062-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pulmonary function tests have been widely accepted and utilized in the management of interstitial lung diseases. Although the tests performed have changed little over the past several decades, extensive literature has been published highlighting their clinical role in the diagnosis, staging, prognostication, and follow-up of patients with a wide variety of interstitial lung diseases.
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Affiliation(s)
- E H Alhamad
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, USA
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 17-2001. A 42-year-old man with multiple pulmonary cysts and recurrent respiratory infections. N Engl J Med 2001; 344:1701-8. [PMID: 11386270 DOI: 10.1056/nejm200105313442208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- G Semenzato
- Padua University School of Medicine, Department of Clinical and Experimental Medicine, Italy
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Abstract
Sjögren's syndrome is one of the most common systemic rheumatic diseases. Pulmonary disease is prevalent in Sjögren's syndrome; respiratory manifestations include chronic cough, obstructive airways disease, pulmonary lymphoma, and interstitial lung disease that may progress to severe pulmonary fibrosis.
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Affiliation(s)
- H C Cain
- Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Lois M, Roman J, Holland W, Agudelo C. Coexisting Sjögren's syndrome and sarcoidosis in the lung. Semin Arthritis Rheum 1998; 28:31-40. [PMID: 9726334 DOI: 10.1016/s0049-0172(98)80026-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
CONTEXT Sjögren's syndrome (SS) and sarcoidosis are diseases of unknown origin that are considered to result from abnormal regulation of the immune system. Pulmonary involvement by SS and sarcoidosis may have similar clinical and radiographic manifestations, making it difficult for the clinician to distinguish between these diseases. OBJECTIVES This study was undertaken to analyze the characteristics of SS and sarcoidosis in the lung to identify distinguishing features that may assist clinicians in the differentiation of these conditions. DESIGN We present two cases with severe pulmonary impairment in which the distinction between SS and sarcoidosis required lung tissue biopsy. The literature regarding the pulmonary manifestations of these diseases is reviewed. RESULTS The clinical, pathological, radiographic, and physiological characteristics of lung disease in the setting of SS and sarcoidosis can be very similar, preventing a diagnosis solely on clinical grounds. This is exemplified in the two cases reported. In one patient who carried the diagnosis of sarcoidosis, examination of lung tissue revealed lymphocytic interstitial pneumonitis consistent with SS. In the other patient, who had previously been diagnosed with SS on clinical grounds, examination of lung tissue showed lymphocytic interstitial pneumonitis with scattered noncaseating granulomas, suggesting the possibility of coexisting SS and sarcoidosis. A literature review indicated that lung involvement by SS may be difficult to distinguish from that of sarcoidosis. Furthermore, several cases have been reported in which both diseases coexisted. CONCLUSIONS Because SS and sarcoidosis may coexist and present with similar pulmonary manifestations, aggressive evaluation including tissue biopsy may be required. However, even tissue biopsy may not distinguish between these entities unless noncaseating granulomas are seen (in the case of sarcoidosis) or isolated lymphocytic interstitial pneumonitis is detected (in the case of SS). When both features (ie; noncaseating granuloma and lymphocytic interstitial pneumonitis) are encountered in the same organ, we believe these diseases are coexisting. Distinguishing both conditions may have prognostic implications, because sarcoidosis may present as an autolimiting process and frequently resolves spontaneously without significant residual functional impairment. In contrast, pulmonary involvement with SS often leads to permanent defects and may progress to incapacitating disease.
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Affiliation(s)
- M Lois
- Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Papiris SA, Saetta M, Turato G, La Corte R, Trevisani L, Mapp CE, Maestrelli P, Fabbri LM, Potena A. CD4-positive T-lymphocytes infiltrate the bronchial mucosa of patients with Sjögren's syndrome. Am J Respir Crit Care Med 1997; 156:637-41. [PMID: 9279251 DOI: 10.1164/ajrccm.156.2.9610076] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To investigate the degree and the type of inflammation in the bronchial mucosa in patients with Sjögren's syndrome, we examined lobar bronchial biopsies obtained from 10 patients with Sjögren's syndrome (six with primary and four with secondary) and eight control subjects. Histochemistry with hematoxylin-eosin was performed both to identify the number of mononuclear cells and eosinophils and to measure the thickness of the basement membrane. Immunohistochemistry was performed to identify neutrophils (neutrophil-elastase), macrophages (CD68), and T-lymphocyte subpopulations (CD4 and CD8) in the submucosa. Subjects with Sjögren's syndrome presented a greater number of CD4-positive T-lymphocytes than did the normal control subjects (p = 0.0129). Instead, eosinophils, neutrophils, macrophages, CD8 positive T-lymphocytes, and basement membrane thickness were similar in the two groups. There were no differences in cell counts between patients with primary and those with secondary Sjögren's syndrome and between symptomatic and asymptomatic patients. No correlation was found between cell counts, symptoms, lung volumes, and disease duration. This study has shown that patients with Sjögren's syndrome have an increased number of CD4 positive T-lymphocytes in the bronchial mucosa outside of the bronchial glands, supporting the concept that, in the airways. Sjögren's syndrome involves also extraglandular tissues.
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Affiliation(s)
- S A Papiris
- Department of Pulmonary Diseases, University of Padova, Italy
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Kadota J, Kusano S, Kawakami K, Morikawa T, Kohno S. Usual interstitial pneumonia associated with primary Sjögren's syndrome. Chest 1995; 108:1756-8. [PMID: 7497800 DOI: 10.1378/chest.108.6.1756] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
We describe the first case, to our knowledge, of usual interstitial pneumonia (UIP) as the pulmonary manifestation in primary Sjögren's syndrome (SjS). A 45-year-old woman was admitted to our hospital because of a dry cough and an interstitial shadow on a chest roentgenogram. Labial biopsy and sialogram confirmed a diagnosis of SjS. BAL fluid analysis revealed lymphocytosis with a decreased CD4/CD8 ratio compatible with bronchiolitis obliterans organizing pneumonia or lymphoid interstitial pneumonia. Open-lung biopsy specimen, however, showed evidence of UIP. Open-lung biopsy was a useful and necessary examination to determine the nature of the pulmonary complication in primary SjS. Conservative treatment without corticosteroids maintained a stable condition for a follow-up period of 3 years.
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Affiliation(s)
- J Kadota
- Second Department of Internal Medicine, Nagasaki University School of Medicine, Japan
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Orens JB, Martinez FJ, Lynch JP. PLEUROPULMONARY MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS. Rheum Dis Clin North Am 1994. [DOI: 10.1016/s0889-857x(21)00230-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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AUTOANTIBODIES, AUTOIMMUNE DISEASES, AND VASCULITIS IN THE AGED. Immunol Allergy Clin North Am 1993. [DOI: 10.1016/s0889-8561(22)00420-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Walters EH. Investigation of lung disease in rheumatic disorders. BAILLIERE'S CLINICAL RHEUMATOLOGY 1993; 7:183-207. [PMID: 8519076 DOI: 10.1016/s0950-3579(05)80276-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- E H Walters
- Department of Respiratory Medicine, Alfred Hospital and Monash Medical School, Melbourne, Victoria, Australia
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Abstract
Significant abnormalities in pulmonary function are encountered in about 24% of patients with primary Sjögren's syndrome. The most common cause of dyspnoea is interstitial fibrosis, with a prevalence of around 8%, but a number of other pathologies may be encountered in the lungs of these patients (Table 1). Lymphoproliferative disorders are relatively uncommon, but these apparently benign lesions may harbour malignant potential. Interstitial fibrosis and the lymphoproliferative disorders may be responsive to corticosteroids or cytotoxic agents, and it is therefore important to establish an accurate diagnosis at an early stage. On the basis of our experience we would recommend the investigative strategy outlined below. Patients should be screened for significant lung disease by taking a careful history of respiratory symptoms followed by standard pulmonary function testing (including measurement of carbon monoxide diffusing capacity) and chest radiography. High resolution computed tomography is a non-invasive technique that should prove superior to chest radiography in the detection of early cases of interstitial fibrosis. When the disease is patchy it may be useful in identifying areas of maximal involvement for subsequent biopsy. Bronchoalveolar lavage is a sensitive tool in the non-smoker, but lacks the specificity to command a significant role in the investigation of pulmonary pathology in these patients. One exception to this may be in the investigation of the clonality of lymphocytes which may allow early and specific diagnosis of lymphomatous proliferation. The application of techniques such as the polymerase chain reaction may assist in the investigation of the role of the Epstein-Barr virus in the causation of lymphoproliferative lesions. In most patients with significant symptoms and abnormalities of pulmonary function a tissue diagnosis will be required, either by transbronchial biopsy or by open lung biopsy. Both bronchial and interstitial lung tissue should be obtained where possible. Histological confirmation is probably mandatory when there is a recent history of parotid enlargement, weight loss or the appearance of a monoclonal gammopathy. Advances in our understanding of the mechanisms of the MALT system may provide the key to unlocking some of the mysteries of 'autoimmune' diseases such as Sjögren's syndrome. The response of lymphoproliferative disorders to immunosuppressive therapy provides hope that if the diagnosis of sicca syndrome can be made earlier lymphocyte induced tissue damage may be halted or reversed.
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Affiliation(s)
- P Gardiner
- Department of Rheumatology, Musgrave Park Hospital, Belfast, Northern Ireland
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Dalavanga YA, Constantopoulos SH, Zerva LB, Trekli MM, Kotoulas OO, Moutsopoulos HM. Liquid phase characteristics of bronchoalveolar lavage in primary Sjögren's syndrome. Chest 1992; 102:1805-7. [PMID: 1446492 DOI: 10.1378/chest.102.6.1805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We have previously reported that alveolitis correlates with clinical, roentgenologic, and functional parameters of pulmonary involvement in primary Sjögren's syndrome (1SS). In the present study, we analyzed the liquid phase characteristics of bronchoalveolar lavage (BAL) in the same 19 patients with 1SS. Our results show that patients with "high alveolitis" (group A, BAL lymphocytes > 15.2 percent) have increased values of total protein, albumin, IgA, and IgG and in their BAL fluid compared with patients with "low alveolitis" (group B) and control subjects. Also interleukin 2 (IL-2) was detected in more "high alveolitis" patients while IgM, IL-2R, and interferon gamma (IFN-gamma) were detected only in this group. There were no differences between the two groups in serum values of all above factors as well as in the presence of rheumatoid factor, extractable nuclear antibodies, and antinuclear antibodies. The increased values of immunoglobulins and cytokines in the BAL fluid of patients with intense alveolitis, in the absence of serum differences, speak for their local production and suggest activation of local immune mechanism.
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Affiliation(s)
- Y A Dalavanga
- Department of Medicine (Rheumatology/Immunology and Pulmonary Section), Medical School of Ioannina, Greece
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Constantopoulos SH, Dalavanga YA, Sakellariou K, Goudevenos J, Kotoulas OB. Lymphocytic alveolitis and pleural calcifications in nonoccupational asbestos exposure. Protection against neoplasia? THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1992; 146:1565-70. [PMID: 1456576 DOI: 10.1164/ajrccm/146.6.1565] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Inhabitants of the Metsovo area in Northwest Greece (population, 4,000) have been exposed to asbestos through the use of whitewash containing tremolite. This has resulted in endemic pleural calcifications (PCs) and increased incidence of malignant pleural mesothelioma (MPM). In order to evaluate the lung response to the fiber, bronchoalveolar lavage (BAL) was performed in 25 Metsovites; 14 with PCs, three with PCs and neoplasia, five without PCs, and three without PCs but with established neoplasia. There were no differences between the four groups with regard to age or exposure. Twelve Metsovites had lymphocytic alveolitis (BAL lymphocytes > 15%). Eleven belonged to the group with PCs and one belonged to the group without PCs. None of those with neoplasia had alveolitis. The lymphocytes were mainly helper T-cells, and activation markers were more frequent among those with PCs. We have previously reported on the relative absence of PCs in Metsovites with malignant pleural mesothelioma. This observation and the results of the present study suggest that lymphocytic alveolitis correlates with pleural calcifications, whereas both are rarely present in patients with neoplasia.
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