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Llamas-Molina JM, Velasco-Amador JP, De la Torre-Gomar FJ, Carrero-Castaño A, Ruiz-Villaverde R. Localized Cutaneous Nodular Amyloidosis: A Specific Cutaneous Manifestation of Sjögren's Syndrome. Int J Mol Sci 2023; 24:ijms24087378. [PMID: 37108553 PMCID: PMC10139233 DOI: 10.3390/ijms24087378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Primary localized cutaneous nodular amyloidosis (PLCNA) is a rare condition attributed to plasma cell proliferation and the deposition of immunoglobulin light chains in the skin without association with systemic amyloidosis or hematological dyscrasias. It is not uncommon for patients diagnosed with PLCNA to also suffer from other auto-immune connective tissue diseases, with Sjögren's syndrome (SjS) showing the strongest association. This article provides a literature review and descriptive analysis to better understand the unique relationship between these two entities. To date, 34 patients with PLCNA and SjS have been reported in a total of 26 articles. The co-existence of PLCNA and SjS has been reported, especially in female patients in their seventh decade of life with nodular lesions on the trunk and/or lower extremities. Acral and facial localization, which is a typical localization of PLCNA in the absence of SjS, seems to be much more unusual in patients with associated SjS.
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Affiliation(s)
- José María Llamas-Molina
- Department of Dermatology, Hospital Universitario San Cecilio, Avda Conocimiento 33, 18016 Granada, Spain
| | - Juan Pablo Velasco-Amador
- Department of Dermatology, Hospital Universitario San Cecilio, Avda Conocimiento 33, 18016 Granada, Spain
| | | | - Alejandro Carrero-Castaño
- Department of Pathological Anatomy, Hospital Universitario San Cecilio, Avda Conocimiento 33, 18016 Granada, Spain
| | - Ricardo Ruiz-Villaverde
- Department of Dermatology, Hospital Universitario San Cecilio, Avda Conocimiento 33, 18016 Granada, Spain
- Instituto Biosanitario de Granada (Ibs), 18014 Granada, Spain
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Yoneyama K, Tochigi N, Oikawa A, Shinkai H, Utani A. Primary Localized Cutaneous Nodular Amyloidosis in a Patient with Sjögren's Syndrome: A Review of the Literature. J Dermatol 2014; 32:120-3. [PMID: 15906542 DOI: 10.1111/j.1346-8138.2005.tb00728.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a 53-year-old Japanese woman with multiple, red, and elastic soft nodules on the left waist, left thigh, and right lower leg. She had had polyclonal hyperglobulinemia for one year, rheumatoid arthritis for 13 years, and Sjögren's syndrome (SjS) for 18 years. Histochemical examination of the nodule on the left thigh revealed a deposition of amyloid by Congo red staining. It was also positively stained with both anti-kappa and -lambda light chain antibodies. Moreover, the cytoplasm of the infiltrating plasma cells also positively reacted to both antibodies. The major amyloid proteins of primary localized cutaneous nodular amyloidosis (PLCNA) generally consist of monoclonal immunoglobulin light chains. A review of literature demonstrates 13 cases of PLCNA with SjS, in which immunoglobulin light chains were demonstrated in the amyloid in 5 cases. Amyloid in the 3 cases was composed of a single class immunoglobulin light chain and that in the 2 cases was composed of both kappa and lambda light chains. Polyclonal immunoglobulin amyloid has been reported only in PLCNA with SjS, which may be related to the fact that a certain population of SjS develops polyclonal B cell proliferation and hyperglobulinemia.
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Affiliation(s)
- Kei Yoneyama
- Department of Dermatology, School of Medicine, Chiba University, Japan
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Fox RI. Extraglandular Manifestations of Sjögren’s Syndrome (SS): Dermatologic, Arthritic, Endocrine, Pulmonary, Cardiovascular, Gastroenterology, Renal, Urology, and Gynecologic Manifestations. SJÖGREN’S SYNDROME 2011. [PMCID: PMC7124115 DOI: 10.1007/978-1-60327-957-4_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Wiegel NM, Mentele R, Kellermann J, Meyer L, Riess H, Linke RP. ALkappa(I) (UNK) - primary structure of an AL-amyloid protein presenting an organ-limited subcutaneous nodular amyloid syndrome of long duration. Case report and review. Amyloid 2010; 17:10-23. [PMID: 20146644 DOI: 10.3109/13506121003619328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Slowly progressing subcutaneous nodules all over the body were detected in 1994 in an otherwise healthy, now 66-year-old woman (UNK). A first biopsy was taken 10 years ago and revealed amyloid. Immunohistochemistry was suggestive for ALkappa. From a nodular excisate, performed in the same year for cosmetic reasons, amyloid fibrils were extracted. Protein separation according to their size revealed multiple protein fragments below the MW of an intact kappa-light chain. They were identified as kappa-fragments by Western blotting. The kappa-fragments were cleaved into overlapping peptides using tryptic, N-Asp and chymotryptic digests. Peptides were sequenced by Edman-degradation and mass spectrometry. The complete amino acid sequence of the variable region and most of the constant region of ALkappa (UNK) was identified in various fragments comprising positions 1 to 207 of a monoclonal kappa(I)-light chain. Four novel and several rare amino acid exchanges have been identified as compared to 17 amyloidogenic and >100 non-amyloidogenic kappa(I)-sequences published, leading to increased hydrophobicity of ALkappa (UNK). Sequence analysis of C-region peptides allowed one to determine the kappa-allotype as being invb(+). A rabbit antibody was produced against ALkappa(I) (UNK). It strongly reacted with amyloid on formalin-fixed paraffin embedded tissue sections of the same patient and detected ALkappa-amyloid of many other patients. In contrast, antibodies produced against kappaBJP of subclasses kappa(I)-kappa(IV) failed to label ALkappa (UNK) amyloid deposits. The patient continues to be free of systemic disease, already for 14 years until today.
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Secondary cutaneous nodular AA amyloidosis in a patient with primary Sjögren syndrome and celiac disease. J Clin Rheumatol 2008; 14:27-9. [PMID: 18431095 DOI: 10.1097/rhu.0b013e318163815f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We describe a 62-year-old female with primary Sjögren syndrome and myopathy, severe osteoporosis, and vertebral fractures that were attributed to celiac disease. A year after the diagnosis, she developed a skin nodule on the extensor surface of her right elbow, which was due to an amyloid deposit of AA type. Amyloidosis, although relatively common in some chronic inflammatory diseases, has been uncommon in Sjögren syndrome or celiac disease. Visceral amyloid was not found in this patient.
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Ramos-Casals M, Brito-Zerón P, Font J. Lessons from diseases mimicking Sjögren's syndrome. Clin Rev Allergy Immunol 2008; 32:275-83. [PMID: 17992594 DOI: 10.1007/s12016-007-8006-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sjögren's syndrome (SS) is a systemic autoimmune disease that mainly affects the exocrine glands and usually presents as persistent dryness of the mouth and eyes because of functional impairment of the salivary and lacrimal glands. The histological hallmark is a focal lymphocytic infiltration of the exocrine glands, and the spectrum of the disease extends from an organ-specific autoimmune disease (autoimmune exocrinopathy) to a systemic process with diverse extraglandular manifestations. In the absence of an associated systemic autoimmune disease, patients with this condition are classified as having primary SS. The differential diagnosis includes processes that specifically involve the exocrine glands. On the one hand, some chronic viral infections may induce lymphocytic infiltration of the exocrine glands, in some cases indistinguishable from that observed in primary SS. On the other hand, some processes may mimic the clinical picture of SS through nonlymphocytic infiltration of the exocrine glands. This review focuses on these two groups of diseases that mimic SS (infections and infiltrating processes).
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Affiliation(s)
- Manuel Ramos-Casals
- Servei de Malalties Autoimmunes, Hospital Clínic, C/Villarroel, 170, 08036 Barcelona, Spain.
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Abstract
Sjogren's Syndrome (SS) is a systemic autoimmune disease characterized by dry eyes (keratoconjunctivis sicca) and dry mouth (xerostomia). To fulfill diagnostic criteria, patients must have objective signs of dryness on examination and laboratory confirmation of an autoimmune process as evidenced by a positive autoantibody to SS-A antigen or a characteristic lip biopsy. SS may exist as a primary condition or in association with other systemic autoimmune disorders (termed secondary SS) such as rheumatoid arthritis, systemic lupus erythematous (SLE), progressive systemic sclerosis (scleroderma), or dermatomyositis. Exclusions to the diagnosis include pre-existing lymphoma, hepatitis C or HIV infection. Pathogenesis involves both genetic (especially HLA-DR) and environmental factors. Both T-cells and B-cells are involved in the generation of cytokines and chemokines within the glands. The epithelial cells of the glands also play a role in pathogenesis. The dermatologic manifestations range from drynessness (sicca) and its complications to vasculitis. There is a significant overlap in the clinical manifestations, as well as treatment, of SS and SLE. However, SS patients require special attention to the complications of ocular dryness (keratocojunctivitis sicca and blepharitis) and oral dryness (rapid tooth loss and oral candidiasis) SS patients have a markedly increased risk of lymphoma and enlarged lymph nodes or persistently enlarged parotid/submandibular glands that require further evaluation.
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Affiliation(s)
- Robert I Fox
- Rheumatology Clinic Scripps Memorial Hospital and Research Foundation, La Jolla, CA 92037, USA.
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Ooms V, Decupere M, Lerut E, Vanrenterghem Y, Kuypers DRJ. Secondary Renal Amyloidosis due to Long-Standing Tubulointerstitial Nephritis in a Patient With Sjögren Syndrome. Am J Kidney Dis 2005; 46:e75-80. [PMID: 16253713 DOI: 10.1053/j.ajkd.2005.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Accepted: 07/11/2005] [Indexed: 01/17/2023]
Abstract
A 53-year-old patient with long-standing primary Sjögren syndrome presented with acute renal failure and nephrotic syndrome caused by secondary (AA) renal amyloidosis. Ten years before, he had been admitted because of exacerbation of the systemic disease. At that time, a pseudolymphoma of the kidney was diagnosed. To our knowledge, this is the first report of a patient with primary Sjögren syndrome and secondary (AA) amyloidosis with amyloid deposition in the kidneys causing nephrotic syndrome.
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Affiliation(s)
- Vanessa Ooms
- Department of Nephrology, University Hospitals Leuven, Belgium
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Ramos-Casals M, Anaya JM, García-Carrasco M, Rosas J, Bové A, Claver G, Diaz LA, Herrero C, Font J. Cutaneous vasculitis in primary Sjögren syndrome: classification and clinical significance of 52 patients. Medicine (Baltimore) 2004; 83:96-106. [PMID: 15028963 DOI: 10.1097/01.md.0000119465.24818.98] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To analyze the different clinical and histologic types of cutaneous vasculitis in patients with primary Sjögren syndrome (SS), we investigated the clinical and immunologic characteristics of 558 consecutive patients with primary SS from our units and selected those with clinical evidence of cutaneous lesions, excluding drug reactions and xeroderma. All patients fulfilled 4 or more of the diagnostic criteria for SS proposed by the European Community Study Group in 1993. A total of 89 (16%) patients presented with cutaneous involvement (88 female patients and 1 male; mean age, 51.8 yr). The main cutaneous involvement was cutaneous vasculitis, present in 52 (58%) patients. There were 51 (98%) female patients and 1 (2%) male, with a mean age at diagnosis of cutaneous vasculitis of 51 years (range, 20-80 yr). Fourteen presented with cryoglobulinemic vasculitis, 11 with urticarial vasculitis, and the remaining 26, with cutaneous purpura not associated with cryoglobulins. A skin biopsy specimen was obtained in 38 patients (73%). Involvement of small-sized vessels was observed in 36 (95%) patients (leukocytoclastic vasculitis), while the remaining 2 (5%) presented with medium-sized vessel vasculitis (necrotizing vasculitis). Patients with cutaneous vasculitis had a higher prevalence of articular involvement (50% vs 29%, p = 0.044), peripheral neuropathy (31% vs 4%, p < 0.001), Raynaud phenomenon (40% vs 15%, p = 0.008), renal involvement (10% vs 0%, p = 0.028), antinuclear antibodies (88% vs 60%, p = 0.002), rheumatoid factor (78% vs 48%, p = 0.004), anti-Ro/SS-A antibodies (70% vs 43%, p = 0.011), and hospitalization (25% vs 4%, p = 0.005) compared with SS patients without vasculitis. Six (12%) patients died, all of whom had multisystemic cryoglobulinemia.In conclusion, cutaneous involvement was detected in 16% of patients with primary SS, with cutaneous vasculitis being the most frequent process. The main characteristics of SS-associated cutaneous vasculitis were the overwhelming predominance of small versus medium vessel vasculitis and leukocytoclastic versus mononuclear vasculitis, with a higher prevalence of extraglandular and immunologic SS features. Small vessel vasculitis manifested as palpable purpura, urticarial lesions, or erythematosus maculopapules, with systemic involvement in 44% of patients in association with cryoglobulins in 30%. Life-threatening vasculitis was closely related to cryoglobulinemia.
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Affiliation(s)
- Manuel Ramos-Casals
- From the Departments of Autoimmune Diseases (MR-C, MG-C, AB, GC, JF), Clinical Institute of Infections and Immunology, and Dermatology (CH), Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain; Rheumatology Unit (JR), Hospital de la Vila-Joiosa, Vila-Joiosa, Alacant, Spain; and Department of Rheumatology (J-MA, L-AD), Unidad de Biología Celular e Inmunogenética, Corporación para Investigaciones Biomédicas, and Clínica Universitaria Bolivariana, Medellín, Colombia
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Nguyen TU, Oghalai JS, McGregor DK, Janssen NM, Huston DP. Subcutaneous nodular amyloidosis: a case report and review of the literature. Hum Pathol 2001; 32:346-8. [PMID: 11274647 DOI: 10.1053/hupa.2001.22742] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Amyloidosis typically manifests with disseminated infiltration of multiple organ systems. Rarely, amyloidosis may be localized. We report a patient with localized subcutaneous nodular amyloidosis, without systemic amyloid involvement or myeloma, whose presenting symptom was multiple discrete neck nodules. Immunohistochemical analysis showed the amyloid deposits to be derived from lambda light chains. Twenty-four month follow-up showed minimal disease progression. A literature review showed only 5 reported cases of subcutaneous nodular amyloidosis. This is the first description of a patient with subcutaneous nodular amyloidosis derived from lambda light chains. HUM PATHOL 32:346-348.
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Affiliation(s)
- T U Nguyen
- Immunology Allergy and Rheumatology Section, Department of Medicine, Baylor College of Medicine, Houston, TX 77030-3498, USA
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Affiliation(s)
- R I Fox
- Allergy and Rheumatology Clinic, Scripps Memorial Hospital and Research Foundation, La Jolla, California 92037, USA
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Abstract
The cutaneous deposition disorders are a group of unrelated conditions characterized by the presence of either endogenous or exogenous substances within the dermis or the subcutis. Part I of this two-part series will focus on metabolic processes involved in the endogenous deposition in the various forms of amyloidosis, porphyria, colloid milium, and lipoid proteinosis. We will also review the clinical, histologic, biochemical, and ultrastructural findings relevant to each disorder. Basic mechanisms of pathogenesis, diagnostic modalities, and treatment options are also discussed.
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Affiliation(s)
- D M Touart
- Dermatology Service, Walter Reed Army Medical Center, Washington DC, USA
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Pablos JL, Carreira PE, Morillas L, Montalvo G, Ballestin C, Gomez-Reino JJ. Clonally expanded lymphocytes in the minor salivary glands of Sjögren's syndrome patients without lymphoproliferative disease. ARTHRITIS AND RHEUMATISM 1994; 37:1441-4. [PMID: 7945468 DOI: 10.1002/art.1780371006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine whether clonally expanded B cells are present in the early infiltrates of minor labial salivary glands (LSG) of Sjögren's syndrome (SS) patients. METHODS Available paraffin-embedded LSG biopsies from 14 patients with primary SS were studied. DNA from LSG tissue was amplified by a polymerase chain reaction directed toward rearranged immunoglobulin gene DNA. RESULTS All LSG specimens showed oligoclonal or monoclonal B cell expansion. In one patient with plasma cell neoplasm, tumor and LSG specimens obtained at the same operation displayed different immunoglobulin gene rearrangements. CONCLUSION Clonal expansion is characteristic of primary SS, and it is uniformly found in the early LSG infiltrates of patients who do not experience further progression to pseudolymphoma or lymphoma (mean followup 4.1 years after biopsy). This feature, together with the clonal discordance between the LSG and the B cell neoplasm found in one patient, suggests that additional steps are critical for the progression to malignancy.
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