Sjögren''s syndrome: no demonstrable association by serology of secondary Sjögren''s syndrome with cytomegalovirus

The possible relationship between Sjögren's syndrome (SS) and cytomegalovirus (CMV) was examined using enzyme linked immunosorbent assay of serum antibodies. Patients with secondary SS did not have significantly different CMV antibodies compared with matched healthy controls.     

Comparison of salivary calmodulin binding proteins in Sjögren''s syndrome and healthy individuals

Background: Reduction in salivary secretion is the hallmark of Sjögren's syndrome (SS). Calmodulin (CaM) and calmodulin binding proteins (CaMBPs) play a key role in the secretory process of saliva. Recent studies have suggested that SS‐B, an autoantibody associated with SS, is a CaMBP. This finding suggests that CaMBP may contribute to the loss of saliva in SS. To better understand the role(s) of these proteins in SS, the purpose of this study was to compare salivary CaMBPs in Sjögren's patients and controls. Methods: Saliva samples were collected from 20 patients and 20 age‐, race‐, and gender‐matched controls. CaM overlay was used to identify CaMBPs in saliva of patients and controls. Results: Higher number of salivary CaMBPs was observed among patients than controls. Conclusions: The increased number of salivary CaMBPs in SS may suggest a potential role for these proteins in the pathogenesis of the disease.     

Assessment of SS-A and SS-B in parotid saliva of patients with Sjögren''s syndrome

Background: The purpose of this study was to compare the sensitivity of parotid saliva to that of serum in detecting anti‐SSA/Ro and anti‐SSB/La autoantibodies in patients with Sjögren's syndrome. Methods: Forty patients and 20 controls participated in the study; all patients met the 1993 European Community criteria for the diagnosis of Sjögren's syndrome. Healthy controls were age‐ and sex‐matched individuals with no signs or symptoms of Sjögren's syndrome. Serum and saliva samples were evaluated using AffiniTech SSA/Ro and SSB/La antibodies kits (AffiniTech, Ltd. Bentonville, AR, USA). The results were also compared with serological status of SS‐A and SS‐B as reported by an independent clinical laboratory. Results: Serum was significantly more sensitive than saliva in detecting SSA/Ro and SSB/La antibodies (P = 0.001). There was high agreement between the results with the AffiniTech kits and the independent laboratory (kappa = 0.80; P < 0.001). However, there was poor agreement between saliva and serum results (kappa = 0.174; P = 0.168). Conclusions: The overall results appear to support that serum analysis is effective method for evaluating the presence of SS‐A and SS‐B autoantibodies.     

Autoantibodies to keratin in Sjögren''s syndrome

In order to determine which components of the salivary duct cells are recognized by the antisalivary duct antibodies, sera of patients with Sjögren's syndrome were screened for immunoreactivity to keratin by using an ELISA test and a Western blot analysis. The autoantibodies which reacted with keratin were demonstrated in 8 of 9 definite cases of Sjögren's syndrome and in 3 of 6 probable cases, and they reacted with different keratin peptides in each case. The results suggest that the antisalivary duct antibodies include antibodies against keratin, which exists ubiquitously as a cytoskeleton in the salivary gland epithelial cells. Detection of antikeratin antibody might be a useful aid for diagnosis of Sjögren's syndrome.     

Analysis of the concentration and output of whole salivary constituents in patients with Sjögren's syndrome

In Sjögren's syndrome, salivary glands are affected, resulting in a diminished salivary flow. In the present study, the protein composition, sialic acid content and the amounts of calcium and phosphate of stimulated whole saliva from 43 patients with Sjögren's syndrome, were compared with those of control saliva samples from 17 healthy subjects. The absolute concentrations of albumin, cystatin C. cystatin S. total IgA and total protein, but not amylase, were increased significantly in both primary and secondary Sjögren's syndrome. The output/min of total protein, albumin, amylase, and IgA was, however, decreased in Sjögren patients. These results suggest that the diminished output of salivary defence factors, rather than their absolute concentrations, may be related to the oral health problems seen in Sjögren's syndrome patients.     

Quantification of plasma cells in labial salivary glands: increased expression of IgM in Sjögren''s syndrome

Plasma cells expressing IgG, IgA and IgM were quantified in labial salivary glands from patients with Sjögren's syndrome (SS) and compared with glands showing non-specific inflammatory changes and normal controls. In all glands the predominant isotype was IgA but in SS there was a significant increase in both the number and proportions of IgG and IgM positive cells (P> 0.002). In particular, all SS cases contained greater than 10% IgM positive cells (mean = 26.8± 15.5). The results suggest that accumulation of IgM positive plasma cells may be a specific finding in SS and support the concept that the glandular lesions may be a site of B-cell clonal expansion. Since most B-cell hyperproliferative states in SS, including lymphoma, are associated with synthesis of IgM simple quantification of plasma cells may have important diagnostic and prognostic significance.     

Epithelial HLA-DR expression in labial salivary glands in Sjögren''s syndrome and nonspecific sialadenitis

The expression of the Class II major histocompatibility antigen HLA-DR was quantified in the epithelial cells of labial salivary glands from patients with Sjögrens Syndrome (SS) and compared with similar expression in glands showing non-specific sialadenitis and normal controls. In all glands more duct cells were positive than acinar cells but only in sialadenitis and SS was strong epithelial staining seen. The proportions of duct and acinar cells expressing HLA-DR were increased between normals and sialadenitis (P < 0.01) and between sialadenitis and SS (P < 0.001). However, for all cases increased expression of HLA-DR correlated to the increased proportion of inflammatory cells in the gland (P < 0.01). The results indicate that although HLA-DR is expressed on the epithelial cells in the glandular lesions of SS, this is not specific as it is also seen in sialadenitis. This supports the view that such expression is secondary to an inflammatory infiltrate and may not be of importance in initiating autoimmune tissue damage.     

Coexistence of Sjögren''s syndrome and sarcoidosis: a report of five cases

Background: Sjögren's syndrome (SS) and sarcoidosis are diseases that can affect the salivary glands and result in the loss of salivary gland function. Most of the criteria used for the diagnosis of SS exclude sarcoidosis before establishing the diagnosis of SS. However, several reports have suggested the coexistence of both SS and sarcoidosis in the same patient. Objective: The purpose of this study was to present five cases that support a true coexistence of sarcoidosis and SS. Methods: Clinical and laboratory findings of patients with evidence of having both SS and sarcoidosis were reviewed. The diagnosis of SS was based on the European community criteria; the diagnosis of sarcoidosis was based on the presence of serological, radiographic and/or histopathologic findings that are consistent with sarcoidosis. Results: All patients fulfilled the criteria for the diagnosis of both diseases. Conclusion: Our findings appear to support a true coexistence of sarcoidosis with SS. Therefore, it is reasonable to suggest removing the exclusion of sarcoidosis from the diagnostic criteria for SS.     

Sjögren''s syndrome: the diagnostic potential of early oral manifestations preceding hyposalivation/xerostomia

Sjögren's syndrome (SS) is a systemic autoimmune exocrinopathy that affects mainly the salivary and lacrimal glands, leading to progressive reduction in saliva and tear flow. Although the underlying immuno‐mediated glandular destruction is thought to develop slowly over several years, a long delay from the start of the symptoms to final diagnosis has been frequently reported. A limited knowledge concerning SS natural history is among the major causes of the actual diagnostic delay. Although very few studies have been focused on the analysis of SS early clinical onset, a series of oral features preceding xerostomia/hyposalivation development in patients eventually diagnosed as having SS have been reported. Sialochemistry alterations, salivary gland swelling, early dental loss and sialorrhea have been observed before the onset of typical signs and symptoms (namely xerostomia and/or hyposalivation), which usually lead to SS clinical presentation and diagnosis. Here we suggest, after evaluating available data, that the traditional ‘untouchable’ association between SS and xerostomia/hyposalivation might probably be reconsidered, and that astute clinicians should not underestimate the possible presence or development of SS in patients without xerostomia/hyposalivation and presenting these atypical early oral features.     

Detection of HHV-8 sequences and antigens in a MALT lymphoma associated with Sjögren''s syndrome

We describe the case of a bilateral parotid mucosa‐associated lymphoid tissue (MALT) lymphoma associated with 2 years history of Sjögren's syndrome (SS), which was linked to human herpes virus 8 (HHV‐8) infection. Using polymerase chain reaction (PCR) assay HHV‐8 sequences were detectable in the lymphoma tissue of both sides. Serologic testing of the patient revealed HHV‐8 antibodies in enzyme‐linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA). Immunohistologic staining with two antibodies against open reading frame (ORF) 26 and v‐cyclin homologues of HHV‐8 revealed positive staining of the salivary acinic cells whereas the lymphoma cells were negative. The potential influence of HHV‐8 infection for MALT lymphoma development in this case and possible parallels to gastric MALT lymphoma are discussed.     

Reproducibility of biopsy grade in Sjögren's syndrome

Abstract: The purpose of this study was to examine the reproducibility of biopsy grades at various tissue depths in Sjögren’s syndrome. The biopsy grades of 38 minor salivary gland biopsies were examined at 6 μm, 50 μm, 100 μm, 150 μm, 200 μm, and 250 μm tissue depths. Tissue sections were stained with routine hematoxylin and eosin, graded I–IV, and compared with the initial “baseline” biopsy grade. The majority of the biopsies showed a wide range of grade variability at all depths. No tissue depth was consistently reproducible for any grade (P0.41, 0.64, 0.91, and 0.20, respectively). The difference between baseline grades and grades of deeper sections was sufficient to impact the diagnosis of Sjögren’s syndrome in approximately 60% of the biopsies (P<0.001). The overall result of this study suggests that examination of multiple sections of minor salivary gland biopsies is advisable to improve the reliability of the grade when evaluating Sjögren’s syndrome.     

Oral pilocarpine HCl stimulates labial (minor) salivary gland flow in patients with Sjögren's syndrome

Pilocarpine HCl has been shown to stimulate parotid and submandibular gland salivary flow. The purpose of this study was to determine whether this cholinergic-muscarinic drug also stimulates labial (minor) salivary gland (LSG) flow and to relate that with whole unstimulated salivary (WUS) flow rateS. Subjects diagnosed with primary Sjögren's syndrome (SS-1; n = 9) or secondary Sjögren's syndrome (SS-2; n = 9) were enrolled in this study after meeting stringent enrollment criteria. An age-gender matched control group was also enrolled. The labial saliva was collected in a standardized manner on Per-iopaper® for 5 min and the volume was analysed by the Periotron®.Whole unstimulated salivary samples were collected for 5 min by the method of Mandel and Wot-man (1976).Each subject was dosed with pilocarpine HCl (5 mg; tablets; p.o.).After 60 min the LSG flow as well as the WUS flow was determined again as previously. The results indicated a significant (>180%) increase in both labial salivary gland flow as well as whole salivary flow in the SS-1 and SS-2 subjects (mean ± S. e.m.): [SS-1: WUS = 0.1080 ± 0.03 vs 0.2242 ± 0.03 ml per 5 min; LSG = 93.1 ± 22.2 vs 167.8 ± 15.9 μl/5 min; P < 0.001; SS-2: WUS = 0.1384 ± 0.02 vs 0.2775 ± 0.09 ml per 5 min; LSG = 97.7 ± 20.2 vs 182.8 ± 17.9 μl per 5 min; P < 0.001]. These results indicate a significant increase in labial salivary gland flow as well as whole salivary flow as stimulated by pilocarpine HCI in Sjögren's syndrome patients.     

Primary Sjögren's syndrome: salivary gland function and clinical oral findings

OBJECTIVE: To evaluate salivary gland function, saliva composition and oral findings in patients with primary Sjogren's syndrome (pSS) subdivided into patients with and without focus score ≤1 (FS) and/or antibodies to SSA/SSB (AB) as well as in healthy controls. SUBJECTS AND METHODS: Unstimulated (UWS) and chewing stimulated (SWS) whole saliva, and stimulated parotid saliva (SPS) were collected in 16 patients fulfilling the European classification criteria for pSS subdivided into those with FS and/or AB (n= 8) and those without FS and AB (n= 8), and in age-matched (n= 14) and young healthy controls (n= 13).UWS and SWS were analysed for Na⁺ and K⁺.SPS was analysed for Na⁺, K⁺, statherin, and proline-rich proteins (PRPs).Sicca symptoms, DMFT/DMFS, plaque (PI) and gingival (GI) scores, periodontal pocket depth (PPD), and mucosal status were recorded. RESULTS: The young healthy controls had lower UWS as compared to the aged controls (P= 0.03).However, the aged controls had higher DMFT/DMFS (P < 0.001) and PI, GI and PPD (P < 0.01).Patients with FS and/or AB generally had lower saliva secretory rates than patients without FS and/or AB (P= 0.01 for UWS and SPS) and age-matched healthy controls (P= 0.001). There was no significant difference in the content of Na⁺ and K⁺, statherin and PRPs between groupS. Patients with FS and/or AB had the highest frequency of oral mucosal changes and higher DMFT/DMFS than patients without FS and/or AB and healthy controls (P < 0.01).However, PI, GI, and PPD did not differ significantly. CONCLUSION: Patients with FS and/or AB had lower salivary secretory rates, higher DMFT/DMFS, and more oral mucosal changes than patients without FS and/or AB.Additionally, data suggest that salivary gland function in healthy individuals do not decrease with age.     

The development and initial validation of the Liverpool sicca index to assess symptoms and dysfunction in patients with primary Sjögren''s syndrome

Background: A validated measure to assess sicca‐related symptoms in patients with primary Sjögren's syndrome (1°SS) is required for clinical studies. Methods: A self‐administered questionnaire was developed to assess sicca‐related symptoms and dysfunction in 1°SS. This was administered to three groups of 40 respondents to measure construct validity: 1°SS patients, non‐SS patients reporting xerostomia and a non‐patient group. The frequency of scores and the mean score for each question were calculated for each group. Reliability was assessed by test/retest. Results: The measure consisted of 28 items divided into five domains. Scores for questions in domains were generally worse (higher) for 1°SS patients than for patients with xerostomia. The non‐patient group reported the best (lowest) scores for all questions. The Kappa statistic for all but four questions was greater than 0.6, suggesting good reliability. Conclusion: Questionnaire showed good construct validity and reliability. The Liverpool sicca index needs to be further validated in larger, multicentre studies.     

The minor salivary gland proteome in Sjögren's syndrome

Objective:  To identify the global protein expression (the proteome) in the minor salivary glands from primary Sjögren's syndrome (pSS) patients and non-SS controls.
Materials and methods:  Minor labial salivary glands were obtained from six pSS patients and from six age-matched non-SS controls, lysed in SDS buffer and pooled into two groups, respectively. The lysates were analysed by liquid chromatography electrospray ionization combined with tandem mass spectrometry. Also, the proteins were separated by two-dimensional polyacrylamide gel electrophoresis and protein spots were subjected to mass spectrometry.
Results:  Heat shock proteins, mucins, carbonic anhydrases, enolase, vimentin and cyclophilin B were among the proteins identified. The differences in the proteomes of minor salivary glands from pSS patients and non-SS controls were mainly related to ribosomal proteins, immunity and stress. Alpha-defensin-1 and calmodulin were among six proteins exclusively identified in pSS patients.
Conclusion:  We have identified several minor salivary gland proteins that may have implications for clarifying the SS pathophysiology. This experiment adds to the knowledge of proteins produced in salivary glands in health and disease, and may form the basis of further studies on biomarkers of prognostic and diagnostic value.     

Localization of antimicrobial peptides human β-defensins in minor salivary glands with Sjögren's syndrome

Sjögren's syndrome is a common systemic autoimmune disease associated with inflammatory cells that infiltrate exocrine glands. The antimicrobial peptides human β-defensin-1, human β-defensin-2, and human β-defensin-3 are expressed in various human epithelial cells and in normal salivary glands. Antimicrobial peptides provide local protection against infection and participate in inflammatory responses. Because of the presence of inflammation, we hypothesized that human β-defensin expression in minor salivary glands may be increased in subjects with Sjögren's syndrome. However, the expression of human β-defensins 1 and 2 was decreased in salivary glands affected by Sjögren's syndrome in comparison with the human β-defensin expression patterns in salivary glands from normal subjects. In addition, the reduction in expression of human β-defensin-2 was greater than the reduction in expression of human β-defensin-1. The aforementioned result suggests that the reduction in expression of human β-defensin-2 may occur earlier than the reduction in expression of human β-defensin-1, which may lead to a greater decrease in human β-defensin-2 than in human β-defensin-1 during disease progression.     

Anti-salivary antibodies in primary Sjögren's syndrome

Earlier studies have described an antibody that recognized salivary ductal epithelium in sera from 15–50% of patients with primary Sjögren's syndrome; however, the specific salivary antigen in those studies was not identified. The present study further investigated this unknown salivary antigen. Twenty-nine of 31 patients (94%) with primary Sjögren's syndrome demonstrated IgG antinuclear antibodies that bound to an epithelial cell line with ductal characteristics derived from a human salivary gland. Seventy-seven percent of these patients had serum antibodies that bound to ductal cells of normal human parotid tissue after formalin fixation. Western blots of cell extracts, immunofluorescence, and adsorption studies indicated that SS-A/Ro and SS-B/La were the antigens recognized in the salivary cell line. The pattern of fluorescence seen when anti-SS-B/La bound to normal parotid tissue was identical to the fluorescence pattern of the anti-salivary ductal antibodies described in earlier literature.     

Minor salivary gland immunohistology in the diagnosis of primary Sjögren's syndrome

Background:  Focal lymphocytic infiltrates of minor salivary glands are considered target-organ related signs of Sjögren's syndrome. The percentages of plasma cells expressing IgA, IgG and IgM in minor salivary gland biopsies have also been suggested as useful in establishing a diagnosis of Sjögren's syndrome, and this study aimed at evaluating this method.
Methods:  All biopsies from patients under investigation for Sjögren's syndrome ( n  = 210) at our department during 4 years were analyzed for IgA, IgG and IgM producing cells by immunohistochemistry, and related to Sjögren classification parameters.
Results:  A focus score ≥1 was observed in 67/210 patients and the frequency of IgA producing cells was <70% in 42/210 patients. Sufficient clinical data for classification of disease were available for 57/210 patients. Patients were classified as having primary Sjögren's syndrome (pSS) ( n  = 9), secondary Sjögren's syndrome (sSS) ( n  = 12) or non-Sjögren's syndrome (non-SS) ( n  = 36). IgA expressing cells were significantly decreased ( P  < 0.01) and IgG expressing cells significantly increased ( P  < 0.02) in patients with pSS compared to non-SS. Also, increased numbers of salivary gland IgG producing plasma cells correlated with increased IgG serum levels ( P  < 0.001). However, there was no significant difference between sSS and non-SS with regard to IgA, IgG or IgM expressing cells in the glands.
Conclusions:  Our results support previous reports indicating the relevance of quantitative evaluation of Ig isotype expression in plasma cells in the clinical investigation of Sjögren's syndrome and further indicate a difference in plasma cell populations between pSS and sSS.