- •Preface
- •Contents
- •Contributors
- •1 Introduction
- •1.1 Historical Background
- •1.2 Pitfalls in Diagnosis and Methodology
- •1.3 Methods to Assess Disease Activity
- •1.4 Summary
- •References
- •2.1 Introduction
- •2.4 Pearls of Wisdom
- •References
- •3.1 Background: Overall Approach to Patient Care
- •3.1.1 Pearl
- •3.1.2 Pearl
- •3.2 Diagnosis Criteria and Laboratory Tests
- •3.2.1 Myth
- •3.2.2 Pearl
- •3.2.3 Myth
- •3.2.4 Myth
- •3.2.5 Pearl
- •3.2.6 Pearl
- •3.2.7 Pearl
- •3.3 Myths and Pearls About Clinical Presentations
- •3.3.1 Pearl
- •3.3.2 Myth
- •3.3.3 Pearl
- •3.3.4 Pearl
- •3.3.5 Pearl
- •3.3.6 Pearl
- •3.3.7 Pearl
- •3.3.8 Pearl
- •3.3.9 Pearl
- •3.3.10 Pearl
- •3.3.11 Pearl
- •3.3.12 Pearl
- •3.3.13 Myth
- •3.3.14 Pearl
- •3.3.15 Pearl
- •3.3.16 Myth
- •3.4 Myths and Pearls About Pathogenesis
- •3.4.1 Myth
- •3.4.2 Pearl
- •3.4.3 Pearl
- •3.4.4 Myth
- •3.4.5 Pearl
- •3.5 Myths and Pearls About Treatment
- •3.5.1 Myth
- •3.5.2 Pearl
- •3.5.3 Pearl
- •3.5.4 Pearl
- •3.5.5 Pearl
- •3.5.6 Pearl
- •3.5.7 Pearl
- •References
- •4.1 Background and Overview
- •4.1.1 Need for Written Information
- •4.1.2 Use of Internet as a Method to Provide Information
- •4.1.3 Patient Access to Computers
- •4.1.4 Types of Information Supplied to Patients and Referring Physicians
- •4.2.1 Background: The Confusion Surrounding Criteria for Autoimmune Disorders
- •4.2.5 Criteria for Fibromyalgia
- •4.3 Laboratory Results for ANA Often Drive Clinical Diagnosis
- •4.5 Status of Biologic Drugs in SS Patients
- •4.6 Ocular Treatment
- •4.6.2 Blepharitis
- •4.7 Therapy of Oral Manifestations
- •4.7.1 Prevention of Dental Caries
- •4.7.2 Oral Candida Prevention and Treatment
- •4.8 Summary
- •References
- •5.1 Introduction
- •5.4 Outcome Measures in SS
- •5.4.1 Outcome Measures in SS: A Brief History
- •5.6 Outcome Measures in SS: The Italian Study
- •References
- •6.1 Introduction
- •6.2 Benign Lymphoepithelial Lesion in Salivary Glands
- •6.3.1.2 Ectopic Germinal Center Formation
- •6.3.1.3 Clinical Implications of Ectopic Germinal Center Formation
- •6.4 Late Breaking Update
- •References
- •7.1 Conventional Radiographs
- •7.1.1 Sialography
- •7.2 Computer Tomography
- •7.3 Ultrasound
- •7.4 Magnetic Resonance Imaging
- •7.5 Nuclear Medicine
- •7.5.1 Scintigraphy
- •7.6 Comparison of Nuclear Medicine, Ultrasound, and MRI
- •References
- •8.1 Introduction
- •8.2 Evidence Supporting a Genetic Component in SS
- •8.4 Lessons from SLE and Other Autoimmune Diseases
- •8.5 Genes Implicated in SS
- •8.7 Insights from Genomic and Proteomic Studies
- •8.8 Conclusion
- •References
- •9.1 Introduction
- •9.2.4 Antibodies to Nuclear Protein NA14
- •9.3.1 Initiation Phase
- •9.3.2 Recognition Phase
- •9.3.3 Establishment Phase: Autoreactive T and B Lymphocytes Dysregulation and Aberrant Cytokines Production
- •9.3.5 Effector Phase
- •References
- •10.1 Introduction
- •10.2.1 Ro/La RNP Particles
- •10.2.3 The Ro60 Autoantigen
- •10.2.4 The Ro52 Autoantigen
- •10.2.5 The Multifunctional Chaperone Calreticulin
- •10.4.2 Early Epitope Recognition in Autoimmune Diseases and Epitope Spreading
- •References
- •11.2 Acinar Cell
- •11.3 Neuropeptides
- •11.3.1 Acinotrophic Neurogenic Stimuli
- •11.4 Sex Steroids
- •11.4.1 Steroidogenesis in Adrenal Glands
- •11.4.2 Regulation of the Adrenal Steroidogenesis
- •11.4.4 Peripheral Intracrine Synthesis of Sex Steroids
- •11.4.5 Intracrine Sex Steroids Production in pSS and sSS
- •11.4.7 Putative Mechanism of Action of the Intracrine Processing Defect
- •11.5.1 General Histopathology
- •11.5.2 T Lymphocytes
- •11.5.3 B Lymphocytes
- •11.5.4 Chemokines
- •11.5.5 Adhesion Molecules
- •11.5.6 Cytokines
- •References
- •12.1 Background
- •12.2 Incidence, Symptomatic Presentation, and Impact on Quality of Life
- •12.3 Diagnostic Screening Examination
- •12.4 Overview of Dry Eye Management
- •12.4.1 Dry Eyes Deserve Respect and Careful Monitoring
- •12.4.2 Four Levels of Severity Differentiation
- •12.4.2.1 Level 1
- •12.4.2.2 Level 2
- •12.4.2.3 Level 3
- •12.4.2.4 Level 4
- •12.5.2 General Guidelines for the Dry Eye Patient
- •12.6 Additional Types of Therapy
- •12.7 Moisture Preservation and Oral Medications
- •12.7.2 Punctal Plugs
- •12.8 Oral Medications and Supplements
- •12.8.1 Dietary Fatty acids (Flaxseed Oil) and Dry Eyes
- •12.8.2 Oral Medications
- •12.9 Complications Associated with Ophthalmologic Cosmetic Procedures
- •12.10 Summary
- •References
- •13.1 Introduction
- •13.2 The Lacrimal Functional Unit (LFU)
- •13.3 The General Role of the LFU in Normal and Pathological Situation
- •13.4 Innervation of the Lacrimal Functional Unit
- •13.5 Efferent Structures
- •13.5.1 Lacrimal Glands
- •13.5.2 Goblet Cells
- •13.5.3 Meibomian Glands
- •13.6 Maintenance of the Lacrimal Functional Unit
- •13.6.1 Hormonal
- •13.6.2 Immunological
- •13.8 The Normal Ocular Surface Environment
- •13.9 The Makeup of the Tear Film
- •13.9.1 Hydrated Mucin Gel
- •13.9.3 Aqueous Components
- •13.10 The Pathophysiology of Dry Eye
- •13.10.1 Loss of Hormonal Support
- •13.10.2.1 Afferent Arm
- •13.10.2.2 Efferent Arm
- •13.11 Loss of Ocular Surface Homeostasis
- •13.11.1 Alterations of the Mucin, Lipid, and Aqueous Composition
- •13.11.2 Mucins
- •13.11.3 Lipids
- •13.12 The Ocular Surface Immunosuppressive Environment
- •13.14 Late-Breaking Additions
- •References
- •14.1 Saliva in Oral Health and Disease
- •14.1.1 Saliva in Dental and Mucosal Defense
- •14.1.2 Assessment of Oral Dryness
- •14.1.2.2 Objective Measurements of Hyposalivation
- •14.2 Saliva as a Diagnostic Fluid
- •14.2.1 Biomarker Analyses in Saliva
- •14.3 Complications of Oral Dryness
- •14.3.1 Management of Xerostomia
- •14.3.2 Caries Preventive Measures
- •14.3.2.3 Dietary Advice
- •14.3.2.4 The Time Factor
- •References
- •15.1.1 Endothelial Cells
- •15.1.2 Epithelial Cells
- •15.1.3 T cells
- •15.1.4 B cells
- •15.2 Mechanisms Mediating Salivary Gland Dysfunction
- •15.2.1 Acinar Cell Innervation and Humoral Immunity
- •15.2.3 Fluid Movement in the Salivary Glands and Aquaporins
- •15.3.1 Environmental Factors
- •15.3.2 Secondary Signals
- •15.3.3 Apoptosis, Autoantigens, and Potential Danger Signals in the Salivary Glands
- •15.3.4 Immunoregulation
- •15.3.5 B-cell-Activating Factor
- •15.3.6 Hormones
- •15.3.7 Microchimerism
- •References
- •16.1 Introduction
- •16.2 Diagnosis
- •16.3 Head and Neck Manifestations
- •16.3.1 Ophthalmic
- •16.3.2 Oral
- •16.3.3 Otologic
- •16.3.4 Rhinologic
- •16.3.5 Laryngeal
- •16.3.6 Esophageal
- •16.3.7 Thyroid
- •16.3.8 Neurological
- •16.4 Treatment
- •16.5 Conclusion
- •16.6 Patient Handout
- •References
- •17.1 Introduction
- •17.2 Cutaneous/Dermatologic Manifestations
- •17.4 Endocrinopathic/Pancreatic Manifestations
- •17.4.1 Hypothyroidism
- •17.4.2 Adrenal
- •17.4.3 Pancreas
- •17.5 Pulmonary Manifestations
- •17.5.1 Interstitial Pneumonitis
- •17.6.1 Pericarditis
- •17.6.2 Autonomic Manifestations
- •17.6.3 Congenital Heart Block
- •17.6.4 Accelerated Atherosclerosis
- •17.7 Gastrointestinal Manifestations
- •17.8 Hepatic and Pancreatic Manifestations
- •17.9 Renal/Urological Manifestations
- •17.10 Hematologic Manifestations
- •17.11 Obstetrical/Gynecological Manifestations
- •17.12 Vasculitis
- •17.12.1 CNS Arteritis in the SS Patient
- •17.13 Differential Diagnosis of Extraglandular Manifestations of SS
- •17.13.1 Medications and Other Metabolic Disorders
- •17.14 Manifestations and Differential Diagnosis in the Pediatric Population
- •17.15 Summary
- •17.16 Late-Breaking Updates
- •References
- •18.1 Introduction
- •18.2 Treatment and Management of Cutaneous Manifestations
- •18.2.1 Treatment of Dry Skin
- •18.3 Arthralgia/Arthritis
- •18.4.1 Chronic Cough
- •18.5 Renal Manifestations
- •18.5.1 Interstitial Nephritis
- •18.5.1.1 Glomerular Disease
- •18.6 Gastrointestinal Manifestations
- •18.6.1 Mesenteric Vasculitis
- •18.6.2 Primary Biliary Cirrhosis
- •18.7 Urologic
- •18.8 Therapeutic Management of Obstetrical/Gynecological Manifestations
- •18.9 Special Precautions at the Time of Surgery
- •18.10 Vaccinations in the SS Patient
- •18.11 Summary
- •18.12 Late-Breaking Updates
- •References
- •19.1 Introduction
- •19.3.1 Fatigue
- •19.3.2 Musculoskeletal
- •19.3.4 Gastrointestinal Manifestations
- •19.3.5 Liver Involvement
- •19.3.6 Lung Involvement
- •19.3.7 Kidney Involvement
- •19.3.8 Neurologic Involvement
- •19.3.9 Hematologic Involvement
- •19.4 Conclusions
- •References
- •20.1 Introduction
- •20.2 Diagnosis
- •20.3 Staging and Evaluation of Treatment Response
- •20.4 Treatment
- •20.5 Summary/Pearls
- •References
- •21.1 Introduction
- •21.2 What Is Fatigue?
- •21.3 Potential Causes of Fatigue in pSS
- •21.3.1 Biological
- •21.3.1.1 Cytokines
- •21.3.1.2 Neuroendocrine
- •21.3.1.3 Sleep
- •21.3.2 Psychosocial
- •21.3.2.1 Depression
- •21.3.2.2 Fibromyalgia
- •21.4 Measurement of Fatigue and Other Extraglandular Symptoms
- •21.6 Potential Approaches to Treatment of Fatigue and Other Extraglandular Symptoms
- •21.7 Measurement of Dryness (Sicca) Symptoms
- •21.8 Data from Existing Clinical Studies Addressing Dryness in pSS
- •21.9 Conclusion: Clinical Trial Outcomes
- •References
- •22.1 Introduction
- •22.2 Clinical Evaluation of Neurological Findings in SS
- •22.3.1 Role of Cell-Mediated Immunity
- •22.3.2 The Role of Antibodies Associated with Neurological Manifestations of SS
- •22.4 Investigations
- •22.4.1 Neurophysiology
- •22.4.2 Autonomic Studies
- •22.4.3 MR Imaging of the Spinal Cord
- •22.5 Peripheral Clinical Manifestations
- •22.6 Painful Sensory Neuropathies
- •22.6.1 Differential Diagnosis
- •22.7 Sensory Ataxic Neuropathy
- •22.7.1 Differential Diagnosis
- •22.8 Neuromuscular Weakness
- •22.8.1 Differential Diagnosis
- •22.9 Neuromuscular Pain
- •22.9.1 Differential Diagnosis
- •22.10 Autonomic Neuropathy
- •22.10.1 Differential Diagnosis
- •22.11 Trigeminal Neuropathy and Other Cranial Neuropathies
- •22.12 Central Nervous System Manifestations
- •22.12.2 Cognitive Impairment
- •22.12.3 Movement Disorders
- •22.12.4 Aseptic meningitis and Meningoencephalitis
- •22.12.5 Other Neurological Disorders
- •22.13 Investigations of Central Nervous System Manifestations
- •22.13.1 Serology
- •22.13.2 Spinal Fluid
- •22.13.4 Nuclear Brain Imaging Studies
- •22.13.5 Cerebral Angiography
- •22.14 The Puzzling Neurological Manifestations of Fibromyalgia
- •22.15 Interpretation of ANA in the Patient with Neurological Symptoms
- •22.16 Treatment
- •22.16.1 Peripheral Nervous System Treatment: Overview
- •22.16.2 Painful Sensory Neuropathies
- •22.16.3 Ataxic Neuropathy
- •22.16.4 Motor and Sensory Neuropathies
- •22.16.5 Central Nervous System Treatment
- •22.16.6 Side Effects of Immunosuppressive Therapy
- •22.17 Summary of Special Points to Neurologists
- •22.17.3 Relationship of Neurological Symptoms to Sicca Manifestations
- •22.18 Summary for Rheumatologists
- •References
- •23.1 Introduction
- •23.3.1 Labial Minor Salivary Gland Biopsy
- •23.3.2 Sialography
- •23.4 The Application of a Bite Guard
- •References
- •24.1 Introduction
- •24.2 How to Provide the Essential Tear Components to the Ocular Surface
- •24.3 Use of Autologous Serum Eye Drops for the Treatment of Dry Eye
- •24.4 Ongoing Research with Autologous Serum Eye Drops
- •24.5 Preparation of Autologous Serum Eye Drops
- •24.8 Conclusion
- •References
- •References
- •27.1 A Disease of Antiquity in Ancient China
- •References
- •References
- •References
- •30.1 Introduction
- •30.2 Evaluation of Systemic Features of Primary SS
- •30.2.4 Comparisons of Systemic Disease Activity Scores
- •30.3.1 The SSI: Sicca Symptoms Inventory
- •30.4 Conclusion
- •References
- •31.1 Clinical Practice Guidelines
- •31.2 Clinical Trials Consortium
- •31.3 Professional Education and Awareness
- •31.4.1 Rheumatology Working Group
- •31.4.2 Ocular Working Group
- •31.4.3 Oral Working Group
- •31.4.5 Facilitator for Both Initiatives
- •32.1 Introduction
- •32.2 For Which Patients Should Biological Therapy Be Considered?
- •32.7 BAFF Inhibition
- •32.8 Interferon Inhibition
- •32.9 Gene Therapy
- •32.10 Other Targets for Biologic Therapy
- •32.11 Conclusions and Future Directions
- •References
- •33.1 Overview of the Pathogenesis of pSS
- •33.1.1 Initial Steps
- •33.1.1.1 Breach of Self-tolerance
- •33.1.1.2 Activation of Innate Immunity and Interferon Pathways
- •33.1.1.4 Regulation of BAFF Secretion
- •33.1.1.6 Other Cytokines, Chemokines, and Adhesion Molecules Are Involved in the Pathogenesis of the Disease
- •33.1.3 Glandular Hypofunction Rather Than Glandular Destruction
- •33.2 Emerging Therapies
- •33.2.1 Prerequisite for the Development of New Drugs in pSS
- •33.2.1.1 Disease Activity Score
- •33.2.1.2 Selection of Patients
- •33.2.3.1 Inhibition of the Triggering Factors of IFN Activation
- •33.2.3.2 IFN Blockade
- •33.2.3.3 Antagonists of BAFF and APRIL
- •33.2.3.4 B-cell Depletion
- •33.2.3.5 Other B-cell-Targeted Therapy: Other Anti-CD20 and Anti-CD22
- •33.3 Other Therapeutic Perspectives
- •33.3.1 Inhibition of Other Cytokines and Chemokines
- •33.3.3 Gene Therapy
- •33.4 Conclusion
- •References
- •34.1 Introduction
- •34.5 Conclusion
- •References
- •Index
3 Myths, Pearls, and Tips Regarding Sjögren’s Syndrome |
25 |
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of reproductive capacity, low testosterone, and abnormal XXY karyotype).
These Þndings are interesting in view of the Þnding of translocation of a Toll receptor in the BXSB mouse involving a portion of the X chromosome to the Y chromosome, since this is the only male mouse model to develop SS-like or SLE-like features.
3.3.12 Pearl
Pulmonary hypertension may develop in SS patients.
Comments: Although dyspnea is most frequently associated with scleroderma, pulmonary hypertension needs to be considered in the SS patient.
A recent study reviewed an unexpected 9 cases of PAH [66] in a cohort of 500 SS patients. The rheumatologist should make sure that the cardiac echo is performed (i.e., valves imaged) and interpretation being speciÞcally read for PAH since most technicians perform the study to evaluate left heart function rather than a detailed examination of the tricuspid valve and the estimated pulmonary pressure. Further, in the real world of the busy cardiologist, the echocardiograms are read as a ÒstringÓ of different studies where the cardiologists are concentrating on left ventricular function (without recognizing that the ordering rheumatologist wanted information on PAH).
If PAH is detected, then the patient also needs to be evaluated for occult pulmonary emboli and the occurrence of circulating anticoagulants.
3.3.13 Myth
Cutaneous vasculitis in SS is usually a lymphocytic vasculitis.
Comment: In fact, cutaneous vasculitis in SS is usually a leukocytoclastic vasculitis, the most common feature of which is palpable purpura [67]. In up to 30% of cases of vasculitis associated with SS, cryoglobulinemia (occurring as part and parcel of the SS) is also present.
Other prominent features of vasculitis in SS are
¥Urticarial lesions in approximately 25% of those with vasculitis
¥Medium-vessel disease mimicking PAN in <5% (but bearing a bad prognosis when it presents) [67]
3.3.14 Pearl
More than 25% of patients with primary SS have sensorineural hearing loss.
Comment: Sensorineural hearing loss was detected in 38 (27%) of 140 patients with primary SS included in 4 studies [68Ð71]. An association with immunologic parameters such as aPL, ANA, Ro, or La has been suggested. Boki et al. [71] found that primary SS is associated with sensorineural hearing loss preferentially affecting the high frequencies, although clinically signiÞcant deÞcits are not common, with no evidence of retrocochlear disease or increased vestibular involvement [71, 72].
3.3.15 Pearl
Urinary tract symptoms and cystitis are underdiagnosed in primary SS.
Comment: Two recent studies have investigated lower urinary tract symptoms in primary SS. Walker et al. [73] found severe urological symptoms (increased frequency, urgency, and nocturia) in 61% of patients, with biopsy-proven interstitial cystitis being found in some cases [5, 6]. Similar results have recently found that 5% of Finnish SS patients fulÞlled the criteria for interstitial cystitis [74]. Using a different approach, a high percentage of patients were identiÞed as having a biomarker associated with interstitial cystitis (APF, antiproliferative factor made by bladder epithelial cells) and clinical features of SS among an Australian cohort [75].
3.3.16 Myth
Muscular biopsy is a key tool in the diagnosis of muscular involvement in SS.