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Primary Sjögren's syndrome: Recent advances
NZB/NZW mice. Clin. Exp. Immunol. 57:57 !-574. 19. Speck, B. et al. (1981). Treatment of severe aplastic anaemia with antilymphocyte globulin or bone-marrow
transplantation. Brit. Med. J. 282:860-863. 20. Vandenbroucke, J. P. et al. (1982). Oral contraceptives and rheumatoid arthritis. Further evidence for a preven-
tive effect. Lancet ii:839-842. 21. Verheul, II. A. M. et al. (1981). The effect of nandrolone, testosterone and their decanoate esters on murine lupus. Clin. Exp. Immunol 44:! i-17.
Primary Sj6gren's Syndrome: Recent Advances
most cases are diagnosed between 40 and 60 years of age.
ical histopathological changes can be demonstrated in minor salivary glands. When focus scoring is used, the focal sialoadenitis has been found to be the most disease-specific diagnostic criterion for the salivary gland component of SS (8).
R. Manthorpe, M.D. Mahn6 General Hospital Mabn6, Sweden A. Oxholm, M.D., and P. Oxholm, M.D. Rigshospitalet Copenhagen, Denmark J. U. Prause, M.D. University of Copenhagen Copenhagen, Demnark Primary Sj6gren's syndrome (primary SS) is a systemic chronic inflammatory connective tissue disease mainly affecting exocrine glands. However, symptoms and signs from other organs are to be seen. These are termed extraglandular manifestations of primary SS. The purpose of this communication is to present recent diagnostic and therapeutic developments regarding primary SS.
Definition Internationally accepted criteria do not at present exist, but the Copenhagen criteria introduced nearly a decade ago (10) have the advantage of being simple, reproducible, and objective. They can therefore be applied and repeated anywhere in the world. Primary SS is defined by the presence of keratoconjunctivitis sicca (KCS) and xerostomia, as defined below, in the absence of any other chronic inflammatory connective tissue disease.
Epidemiology Primary SS is considered the second most common of the chronic inflammatory connective tissue diseases (14). The female:male ratio is 9:1. Symptoms may develop at any time during life, even in childhood. However,
i 80
0197-1859/85/$0.00 + 02.20
O c u l a r Tests The dominant clinical sign of KCS is the presence of permanent dry spots on the cornea due to reduced tear aqueous. Observation of dry spots, as well as other ocular signs and tests, requires biomicroscopy, and patients suspected of having KCS should be examined by slit-lamp. As shown in Table 1, a battery of tests may be applied to detect KCS. For screening purposes, we define KCS as present if two of the three marked tests (Table 1) show pathologic values. O r a l Tests Xerostomia is the result of progressive destruction of major and minor salivary glands. The feeling of dry mouth is an unreliable diagnostic criterion for xerostomia. Therefore, only objective and reproducible tests should be used. We employ lower lip biopsy, unstimulated sialometry, and salivary gland scintigraphy. To establish the diagnosis, two of the three tests must give pathological results.
Lower Lip Biopsy By a small lower lip biopsy the typ-
Unstimulated Sialometry Salivary flow rates below 1.5 ml/15 min are considered abnormal (3). Salivary Gland Scintigraphy 99Tc-pertechnetate reveals reduced uptake, low spontaneous secretion, and lack of increased secretion after stimulation with citrus (7). Other Salivary Gland Tests Sialography may show sialoectasis, with disappearance of intraglandular ducts. Alterations in salivary proteins and electrolytes have been reported (33).
Histopathologic and Immunologic Findings Most information concerning the histopathologic changes of exocrine glands in SS originates from investigations of salivary glands. The typical histopathologic lesion is a focal sialoadenitis characterized by lympho-
Table 1 Tests for Keratoconjunctivitis Sicca
Test Schirmer l-test" Break-up time" Rose-bengal score" Cornea sensibility Tear lysozyme concentration Tear lactoferrin concentration Tear osmolarity Conjunctival imprints
Screenhlg limits -< 10 mm/5 min _-<10 sec >4 points >2.5 g/mm2 ] Reduced Reduced Increased "Snakelike" nuclear chromatin
Connnents Use correction for low flow 10 IJ.l 1% fluorescein/eye 10 p.l I% rose-bengal/eye
Show similar changes
References (15, 30) (26) (4) (6) (4, 15) (13, 15)
See Figure 1
(21)
" These three tests form the basis for the diagnosis of keratoconjunctivitissicca.
© 1985ElsevierSciencePublishingCo.. Inc.
Clinical ImmunologyNewsletter6:12,1985
cyte and plasma cell infiltration, acinar atrophy, glandular duct ectasia, myoepithelial cell proliferation, and interstitial fibrosis. T cells dominate the cellular infiltrates in salivary glands as well as in peripheral blood, the tnajority belonging to the helper-inducer subset (l). An increased prevalence of laantigen positive cells was demonstrated among salivary glandular T cells (>50% positive) compared with peripheral blood T cells (< 15% positive) (I). B cells constituted a minor proportion of the total lymphocyte population in both salivary glands and peripheral blood. Activated B cells, defined by the monoclonal antibody B 532, were present in salivary glandular tissue (5-20%), but absent from peripheral blood (1). This led Adamson et al. to hypothesize that salivary glandular lesions evolve by initial infiltration with activated T cells and a subsequent development of B cells in germinal centers. The glandular plasma cells and B lymphocytes are probably responsible for the polyclonal hypergammaglobulinemia and the various autoantibodies and immune complexes (l) (see Figure 1). Langerhans cells, which are considered immunoreactive with a high capacity for antigen presentation, have recently been demonstrated in cell infiltrates of minor salivary gland from primary SS (28). Salivary ductal and acinar epithelial cells close to lymphocytic infiltrates in patients with SS have furthermore been shown to express HLA-DR antigens, in contrast to normal controls (14). A decreased percentage of T cells with unchanged helper:suppressor ratio and an increase in B cells in peripheral blood have recently been demonstrated in patients with primary SS compared with normal controls (2), Quantitative immunofluorescence investigations on samples of peripheral blood indicated an increase in suppressor-cytotoxic cells expressing low antigen density (Leu-2a), suggesting abnormal differentiation of this T cell subset (2). Evidence for functional disturbances of lymphocyte-mediated immunity and disordered immunoregulation includes impaired delayed-type skin reactions,
Clinical Immunology Newsletter 6:12,1985
•
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Figure 1. Millipore filter imprhzt biopsy of limbal conjunctival cells (at the 12 o'clock position) of a patient with primao' SS. Note the characteristic snakelike appearance of nuclear chromatin. (Periodic acid-S&iff, x 1000.)
decreased response to mitogens, and decreased autologous mixed lymphocyte reaction (AMLR) (16, 32). Examination of peripheral blood has shown reduced activity of natural killer (NK) cells in patients with primary SS compared with normal controls (23). A defect in the Fc-receptor function of the mononuclear phagocyte system has been demonstrated only in patients with extraglandular manifestations (11). Extraglandular lymphocyte infiltration (e.g. in lungs and kidney) is seen in primary SS. Systemic vasculitis may occur and give rise to mucoeutaneous ulcerations. Deposits of IgG in the epidermis (probably intercellular) have recently been shown in 68% of patients with primary SS (p < 0.001), and in only 13% of patients with secondary SS (NS compared with healthy controls) (27). This finding differs from what is to be seen in other chronic inflammatory connective tissue diseases, in which granular deposits of IgM in the dermocpidermal junction zone are characteristic (29). The epidermal IgG depositions might be found to be of diagnostic help in primary SS, as was the lupus band test previously for the diagnosis of systemic lupus
© 1985 Elsevier Science Publishing Co., Inc.
erythematosus. Similar depositions of IgG and IgA have recently been found in the labial surface epithelium in patients with primary SS (P. Oxholm et al., unpublished data). Differential Diagnosis In clinical practice, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and myxedema are the three diseases that most resemble primary SS. In active, and often in inactive, SLE the anti-DNA antibodies are greatly raised, in contrast to primary SS, and usually CNS involvement and compromised functioning of the renal glomeruli are not seen in primary SS. RA differs from primary SS by erosions and destructions of bone in the hands and/or feet. These changes develop only rarely in primary SS. Myxedema and primary SS are probably the two diseases within internal medicine in which tiredness is the most repeated and annoying symptom without a concomitant severe anemia. The TSH value will distinguish the two diseases. In primary SS, tiredness appears to persist despite treatment, although in this respect reports on efamol appear to be promising (see below).
0197-1859;85/S0.00 + 02.20
181
Laboratory Findings Several hematological and serological abnormalities, including autoantibodies, are associated with primary SS and have recently been shown in tables (16). In clinical practice, it is important to note that pseudo-thrombocytopenia (17), immune complexes, hypergammaglobulinemia (and thus elevated erythrocyte sedimentation rate), ANA, complement C 3 - f i x i n g ANA, and Waaler test are usually positive, whereas the anti-DNA antibodies are within normal range. In patients with primary SS, tissue typing for the H L A - D region has shown an increased frequency of HLA-D2 and -D3 by cellular methods (18). Serological methods revealed the frequency of HLA-DR3 to be significantly raised and that of HLA-DR2 to be increased (Manthorpe et ai., unpublished data), in agreement with an earlier study (24). In a study of 75 patients with primary SS and appropriatecontrols, it was found that the Lewis L e ( a - b - ) frequency was raised,~probably due to a reduced L e ( a - b + ) frequency (19). In addition, the applied microhemagglutination technique indicated that a few patients had the virtually nonexistent Le(a + b + ) type. These results have, however, not yet been confirmed.
matory drugs are without effect. In several controlled clinical trials, bromhexine has been shown to improve tear production, provided the dose is 48 mg/day or more (10, 3 I). Furthermore, bromhexine reduces pathologically increased concentrations of saliva IgA, IgG, Na + (25), and IgM (31). It has been suggested that low body levels of prostaglandin precursors might induce development of SS (12). Treatment with ",/-linolenic a c i d - - a prostaglandin E l p r e c u r s o r - - m i g h t therefore improve the exocrine gland function. Recently, two uncontrolled studies have found treatment with efamol, which contains 9% ~-linolenic acid, to be effective (5, 12). However, another uncontrolled study did not confirm this (22). In a 3-wk double-blind investigation on 36 SS patients, we were able to demonstrate that efamol given in doses of 3 g per day improves tear production as estimated with the Schirmer l-test (20). At present, SS patients may be treated with either bromhexine or efamol systemically, and tear and saliva substitutes locally. The combination of systemic and local treatment is of importance, and both are without substantial side effects.
Treatment Treatment of this chronic, disabling, but usually nonfatal disease has long been frustrating. Two main lines of treatment are followed: topical and systemic. Topical use of tear substitutes (=>12 times a day) is still very important, and most patients observe a positive effect from frequent changes between a number of almost identical tear substitutes. Saliva substitutes play an equally important role, especially when applied as an aerosol. Patients often prefer an increased intake of water, together with the use of a juicy chewing gum. Anetholetrithione (Sialor), a sialogogue, has been shown in a recent clinical trial to increase the unstimulated saliva flow rate of patients with SS (9). Systemic treatment is restricted to two drugs, bromhexine and efamol, as most of the generally used antiinflam-
References
182
0197-1859/85/$0.00 + 02.20
1. Adamson, T. C. et al. (1983). Immunohistologic analysis of lymphoid infiltrates in primary_ Sj6g_ren's sy_ndrome using monoclonal antibodies. J. Immunol. 130:203-208. 2. Bakhshi, A. et al. (1983). Lymphocyte subsets in Sj6gren's syndrome: a quantitative analysis using monoelonal antibodies and the fluorescence-activated cell sorter. J. Clin. Lab. Immunol. 10:63-69. 3. Bertram U. (1967). Xerostomia. Clinical aspects, pathology and pathogenesis. Acta Odont. Scand. 25(Suppl 49): I - 126. 4. van Bijsterveld, O. P. (1969). Diagnostic tests in the sicca syndrome. Arch. Ophthalmol. 82:10-14. 5. Campbell, A. and C. G. MacEvan (1982). System treatment of Sj6gren's syndrome and the sicca syndrome with efamol (evening primrose oil), vitamin C and pyridoxine, pp. 129-137. hi D. F. Horrobin (ed.), Clinical uses of essential fatty acids. Eden Press, Montreal.
© 1985ElsevierSciencePublishingCo.. Inc.
6. Cochet, P. and R. Bonnet (1960). L'esth6sie com6enne. Clin. Ophthalmol. 4:2-27. 7. Cummings, N. A. et al. (1971). Sj6gren's syndrome--newer aspects of research, diagnosis and therapy. Ann. Intern. Med. 75:937-950. 8. Daniels, T. E. (1984). Labial salivary gland biopsy in Sj6gren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases. Arthritis Rheum. 27:147- i 56. 9. Epstein, J. B., W. E. Dceoteau, and A. Wilkinson (1983). Effect of sialor in treatment of xerostomia in Sj6gren's syndrome. Oral Surg. 56:495-499. 10. Frost-Larsen, K., It. Isager, and R. Manthorpe (1978). Sj6grcn's syndrome treated with bromhexine: a randomised clinical study. Brit. Med. J. i: 1569-1648. 11. Hamburger, M. I. et al. (1979). Sj6gren's syndrome: a defect in reticuloendothelial system Fc-receptor-specific clearance. Ann. Intem. Med. 91:534-538. 12. Horrobin, D. F. and A. Campbell (1980). SjOgrcn's syndrome and the sicca syndrome: the role of prostaglandin E I deficiency. Treatment with essential fatty acids and vitamin C. Med. Hypotheses 6:225-232. 13. Janssen, P. T. and O. P. van Bijsterveld (1983). The relations between tear fluid concentrations of lysozyme, tear-specific prealbumin and lactoferrin. Exp. Eye Res. 36:773-779. 14. Lindahl G. et al. (in press). Epithelial HLA-DR expression and T lymphocyte subsets in salivary glands in Sj6gren's syndrome. Clin. Exp. Med. 15. Maekie, I. A. and D. V. Seal (1984). Diagnostic implications of tear protein profiles. Br. J. Ophthalmol. 68:321324. 16. Manthorpe, R. et al. (1981). Sj6gren's syndrome. A review with emphasis on immunological features. Allergy 36:139-153. 17. Manthorpe, R. et al. (1981). Pseudothrombocytopenia. In vitro studies on the underlying mechanism. Scand. J. Haematol. 26:385-392. 18. Manthorpe, R. et al. (1981). HLA-D antigen frequencies in Sj~gren's syndrome. Differences between the primary and secondary form. Scand. J. Rheumatol. 10:124-128. 19. Manthorpe, R. et al. (in press). Lewis blood type frequency in patients with primary Sj6gren's syndrome. A prospective study including analyses for A~A2B0, secretor, MNSs, P, Duffy, KelI, Lutheran and rhesus blood group. Scand. J. Rheumatol. 20. Manthorpe, R., S. II. Petersen, and
Clinical ImmunologyNewsletter6:12,1985
21.
22.
23.
24.
J. U. Prause (in press). Primary Sj6gren's syndrome treated with efamol/ efavit. A double-blind cross-over investigation. Rheumatol. Int. Marner, K. (1980). "Snake-like" appearance of nuclear chromatin in conjunctival epithelial cells from patients with kerato-conjunctivitis sicca. Acta Ophthalmol. 58:849-853. McKendry, R. J. R. (1982). Treatment of Sj6gren's syndrome with essential fatty acids, pyridoxine and vitamin C. Prostaglandins, leukotrienes. Medicine (Baltimore) 8:403-408. Miyasaka, N. el al. (1983). Natural killing activity in Sj6gren's syndrome. An analysis of defective mechanisms. Arthritis Rheum. 26:954-960. Moutsopoulos, H. M. et al. (1979). Genetic differences between primary and secondary sicca syndrome. N. Engl. J. Med. 301:761-763.
Identification of Antigens in Immune Complexes B. Albini, M.D., P. Knoflach, M.D., E. Penner, M.D., and M. W. Stinson, Ph.D. Center for Studies on the Pathogenesis of Immune Complex-Mediated Diseases and Department of Microbiology State University of New York at Buffalo Buffalo, New York Recent years have seen a renewed discussion on basic concepts of pathogenesis mediated by immune complexes (IC) (see for example ref. 8). Many clinically relevant tenets of the past two decades have been questioned and are being reinvestigated: the definition of the term "immune complexes" in general; the participation of in situ formation of IC in disease; the importance of circulating IC (CIC) for the pathogenesis; the reliability of assays for CIC; and the immunohistological correlation of IC-mediated pathology and typical immunohistological staining patterns in tissue. In situ formation of immune complexes, an old concept, has been explored recently to a great extent, and new variants of this mechanism have been documented (8, 17). Both deposition of CIC (9) and in situ formation of IC
Clinical Immunology Newsletter 6:12,1985
26. Norn, M. S. (1983). External eye. Methods of examination. 2nd ed. p. 76. Scriptor, Copenhagen.
medical diseases. Acta Mcd. Scand. 205:333-338. 30. Prause, J. U. et al. (1982). Tear absorption into the filter-paper strip used in the Schirmer-l-test. A methodological study and a critical survey. Acta Ophthalmol. 60:70-78.
27. Oxholm, A., R. Manthorpe, and P. Oxholm (1984). Immunoglobin deposits in the epidermis of patients with primary Sj6gren's syndrome. Rheumatol. Int. 4:9-12.
31. Prause, J. U. et al. (1984). Lacrimal and salivary secretion in Sj6gren's syndrome: the effect of systemic treatment with bromhexine. Acta Ophthalmol. 62:489-497.
28. Oxholm, P., R. Manthorpe, and A. Oxholm (in press). Langerhans cells in labial minor salivary glands in primary Sj6gren's syndrome. Acta Path. Microbiol, lmmunol. Scand. Sect. A. 29. Pertain, II., F. Juhl, and A. Wiik (1979). Immunoglobin deposits in the dermo-epidermal junction zone. Nosographic occurrence in a number of
32. Sauvezie, B. el al. (1982). An increase in peripheral blood la-positive T cells in Sj6gren's syndrome correlated with a decrease in the autologous mixed lymphocyte response. Clin. Exp. lmmunol. 49:50-58.
(8) have been shown to occur in experimental models of IC disease. The validity of assays for CIC, troubled from the beginning with many technical pitfalls, occurrence of false positive and negative results, and difficulty in standardization, has been further weakened by the increasing awareness that indeed in situ formation of IC may be a major mode of pathogenesis in a number of IC-mediated diseases (1). In such cases, demonstration of CIC obviously would not be of prime pathogenic importance. Finally, the "rule of thumb" of immunohistology, namely that granular or " l u m p y bumpy" staining patterns suggest IC and linear patterns suggest antibody interactions with structural tissue or cell epitopes, has been greatly shaken by demonstrations of granular patterns with pathology induced by antibodies to structural antigens of the tissue or cells (8). To gain some insight into these and other problems of the pathogenesis of IC-mediated diseases, it seems essential to identify the antigens involved in IC, be it in circulation or in tissues.
specific" antibodies produced by hybridomas at our disposal. Unfortunately, in many cases the "direct" approach is not successful. Whereas bovine serum albumin (BSA) is easily demonstrable in IC by use of specific FITC-conjugated antisera, attempts to demonstrate other antigens, e.g., those of infectious agents or autoantigens, have had only moderate success. In many instances, the antigen is demonstrable not at all or only equivocally (21). These failures have been explained, e.g., by the concept of "blanketing" of ar~tigens in IC by antibodies, rheamatoid factor-like moieties, or complement (true blockage or steric bindrance); or by lack of sensitivity of the assays used, because of minimal amounts of epitopes available for reaction with the probing antibody. Nevertheless, in some instances these simple methods have been useful: the demonstration of DNA in kidneys of patients with systemic lupus erythematosus (SLE) (4), the demonstration of some infectious agents in tissue deposits in man (3) and experimental animals (2), and demonstration of the Hey mann antigen in experimentally induced glomerular IC (13). Sometimes, "adjunct" techniques--e.g., the partial elution of tissue sections ( 5 ) - - m a y enhance the direct demonstration of antigens.
25. Nahir, A. M. et al. (1979). Sialochemistry in evaluating bromhexine treatment of Sj6gren's syndrome. Br. Med. J. 280:833.
Direct Demonstration of Antigens in I C The simplest approach to the analysis of antigens in IC is the use of specific antibodies. We have "mono-
© 1985 Elsevier Scier, , ~'hlishing Co., Inc.
33. Scharf, J., Y. Scharf, and M. Nahir
(1982). Sj6gren's syndrome. Compr. Ther. 8:40-45.
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183
transplantation. Brit. Med. J. 282:860-863. 20. Vandenbroucke, J. P. et al. (1982). Oral contraceptives and rheumatoid arthritis. Further evidence for a preven-
tive effect. Lancet ii:839-842. 21. Verheul, II. A. M. et al. (1981). The effect of nandrolone, testosterone and their decanoate esters on murine lupus. Clin. Exp. Immunol 44:! i-17.
Primary Sj6gren's Syndrome: Recent Advances
most cases are diagnosed between 40 and 60 years of age.
ical histopathological changes can be demonstrated in minor salivary glands. When focus scoring is used, the focal sialoadenitis has been found to be the most disease-specific diagnostic criterion for the salivary gland component of SS (8).
R. Manthorpe, M.D. Mahn6 General Hospital Mabn6, Sweden A. Oxholm, M.D., and P. Oxholm, M.D. Rigshospitalet Copenhagen, Denmark J. U. Prause, M.D. University of Copenhagen Copenhagen, Demnark Primary Sj6gren's syndrome (primary SS) is a systemic chronic inflammatory connective tissue disease mainly affecting exocrine glands. However, symptoms and signs from other organs are to be seen. These are termed extraglandular manifestations of primary SS. The purpose of this communication is to present recent diagnostic and therapeutic developments regarding primary SS.
Definition Internationally accepted criteria do not at present exist, but the Copenhagen criteria introduced nearly a decade ago (10) have the advantage of being simple, reproducible, and objective. They can therefore be applied and repeated anywhere in the world. Primary SS is defined by the presence of keratoconjunctivitis sicca (KCS) and xerostomia, as defined below, in the absence of any other chronic inflammatory connective tissue disease.
Epidemiology Primary SS is considered the second most common of the chronic inflammatory connective tissue diseases (14). The female:male ratio is 9:1. Symptoms may develop at any time during life, even in childhood. However,
i 80
0197-1859/85/$0.00 + 02.20
O c u l a r Tests The dominant clinical sign of KCS is the presence of permanent dry spots on the cornea due to reduced tear aqueous. Observation of dry spots, as well as other ocular signs and tests, requires biomicroscopy, and patients suspected of having KCS should be examined by slit-lamp. As shown in Table 1, a battery of tests may be applied to detect KCS. For screening purposes, we define KCS as present if two of the three marked tests (Table 1) show pathologic values. O r a l Tests Xerostomia is the result of progressive destruction of major and minor salivary glands. The feeling of dry mouth is an unreliable diagnostic criterion for xerostomia. Therefore, only objective and reproducible tests should be used. We employ lower lip biopsy, unstimulated sialometry, and salivary gland scintigraphy. To establish the diagnosis, two of the three tests must give pathological results.
Lower Lip Biopsy By a small lower lip biopsy the typ-
Unstimulated Sialometry Salivary flow rates below 1.5 ml/15 min are considered abnormal (3). Salivary Gland Scintigraphy 99Tc-pertechnetate reveals reduced uptake, low spontaneous secretion, and lack of increased secretion after stimulation with citrus (7). Other Salivary Gland Tests Sialography may show sialoectasis, with disappearance of intraglandular ducts. Alterations in salivary proteins and electrolytes have been reported (33).
Histopathologic and Immunologic Findings Most information concerning the histopathologic changes of exocrine glands in SS originates from investigations of salivary glands. The typical histopathologic lesion is a focal sialoadenitis characterized by lympho-
Table 1 Tests for Keratoconjunctivitis Sicca
Test Schirmer l-test" Break-up time" Rose-bengal score" Cornea sensibility Tear lysozyme concentration Tear lactoferrin concentration Tear osmolarity Conjunctival imprints
Screenhlg limits -< 10 mm/5 min _-<10 sec >4 points >2.5 g/mm2 ] Reduced Reduced Increased "Snakelike" nuclear chromatin
Connnents Use correction for low flow 10 IJ.l 1% fluorescein/eye 10 p.l I% rose-bengal/eye
Show similar changes
References (15, 30) (26) (4) (6) (4, 15) (13, 15)
See Figure 1
(21)
" These three tests form the basis for the diagnosis of keratoconjunctivitissicca.
© 1985ElsevierSciencePublishingCo.. Inc.
Clinical ImmunologyNewsletter6:12,1985
cyte and plasma cell infiltration, acinar atrophy, glandular duct ectasia, myoepithelial cell proliferation, and interstitial fibrosis. T cells dominate the cellular infiltrates in salivary glands as well as in peripheral blood, the tnajority belonging to the helper-inducer subset (l). An increased prevalence of laantigen positive cells was demonstrated among salivary glandular T cells (>50% positive) compared with peripheral blood T cells (< 15% positive) (I). B cells constituted a minor proportion of the total lymphocyte population in both salivary glands and peripheral blood. Activated B cells, defined by the monoclonal antibody B 532, were present in salivary glandular tissue (5-20%), but absent from peripheral blood (1). This led Adamson et al. to hypothesize that salivary glandular lesions evolve by initial infiltration with activated T cells and a subsequent development of B cells in germinal centers. The glandular plasma cells and B lymphocytes are probably responsible for the polyclonal hypergammaglobulinemia and the various autoantibodies and immune complexes (l) (see Figure 1). Langerhans cells, which are considered immunoreactive with a high capacity for antigen presentation, have recently been demonstrated in cell infiltrates of minor salivary gland from primary SS (28). Salivary ductal and acinar epithelial cells close to lymphocytic infiltrates in patients with SS have furthermore been shown to express HLA-DR antigens, in contrast to normal controls (14). A decreased percentage of T cells with unchanged helper:suppressor ratio and an increase in B cells in peripheral blood have recently been demonstrated in patients with primary SS compared with normal controls (2), Quantitative immunofluorescence investigations on samples of peripheral blood indicated an increase in suppressor-cytotoxic cells expressing low antigen density (Leu-2a), suggesting abnormal differentiation of this T cell subset (2). Evidence for functional disturbances of lymphocyte-mediated immunity and disordered immunoregulation includes impaired delayed-type skin reactions,
Clinical Immunology Newsletter 6:12,1985
•
..
S•./
.
-,.
.
g
-
,. _
'$
qp
%" .Z
¢" .~"
,.
P
:,,,,, , ~
Figure 1. Millipore filter imprhzt biopsy of limbal conjunctival cells (at the 12 o'clock position) of a patient with primao' SS. Note the characteristic snakelike appearance of nuclear chromatin. (Periodic acid-S&iff, x 1000.)
decreased response to mitogens, and decreased autologous mixed lymphocyte reaction (AMLR) (16, 32). Examination of peripheral blood has shown reduced activity of natural killer (NK) cells in patients with primary SS compared with normal controls (23). A defect in the Fc-receptor function of the mononuclear phagocyte system has been demonstrated only in patients with extraglandular manifestations (11). Extraglandular lymphocyte infiltration (e.g. in lungs and kidney) is seen in primary SS. Systemic vasculitis may occur and give rise to mucoeutaneous ulcerations. Deposits of IgG in the epidermis (probably intercellular) have recently been shown in 68% of patients with primary SS (p < 0.001), and in only 13% of patients with secondary SS (NS compared with healthy controls) (27). This finding differs from what is to be seen in other chronic inflammatory connective tissue diseases, in which granular deposits of IgM in the dermocpidermal junction zone are characteristic (29). The epidermal IgG depositions might be found to be of diagnostic help in primary SS, as was the lupus band test previously for the diagnosis of systemic lupus
© 1985 Elsevier Science Publishing Co., Inc.
erythematosus. Similar depositions of IgG and IgA have recently been found in the labial surface epithelium in patients with primary SS (P. Oxholm et al., unpublished data). Differential Diagnosis In clinical practice, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and myxedema are the three diseases that most resemble primary SS. In active, and often in inactive, SLE the anti-DNA antibodies are greatly raised, in contrast to primary SS, and usually CNS involvement and compromised functioning of the renal glomeruli are not seen in primary SS. RA differs from primary SS by erosions and destructions of bone in the hands and/or feet. These changes develop only rarely in primary SS. Myxedema and primary SS are probably the two diseases within internal medicine in which tiredness is the most repeated and annoying symptom without a concomitant severe anemia. The TSH value will distinguish the two diseases. In primary SS, tiredness appears to persist despite treatment, although in this respect reports on efamol appear to be promising (see below).
0197-1859;85/S0.00 + 02.20
181
Laboratory Findings Several hematological and serological abnormalities, including autoantibodies, are associated with primary SS and have recently been shown in tables (16). In clinical practice, it is important to note that pseudo-thrombocytopenia (17), immune complexes, hypergammaglobulinemia (and thus elevated erythrocyte sedimentation rate), ANA, complement C 3 - f i x i n g ANA, and Waaler test are usually positive, whereas the anti-DNA antibodies are within normal range. In patients with primary SS, tissue typing for the H L A - D region has shown an increased frequency of HLA-D2 and -D3 by cellular methods (18). Serological methods revealed the frequency of HLA-DR3 to be significantly raised and that of HLA-DR2 to be increased (Manthorpe et ai., unpublished data), in agreement with an earlier study (24). In a study of 75 patients with primary SS and appropriatecontrols, it was found that the Lewis L e ( a - b - ) frequency was raised,~probably due to a reduced L e ( a - b + ) frequency (19). In addition, the applied microhemagglutination technique indicated that a few patients had the virtually nonexistent Le(a + b + ) type. These results have, however, not yet been confirmed.
matory drugs are without effect. In several controlled clinical trials, bromhexine has been shown to improve tear production, provided the dose is 48 mg/day or more (10, 3 I). Furthermore, bromhexine reduces pathologically increased concentrations of saliva IgA, IgG, Na + (25), and IgM (31). It has been suggested that low body levels of prostaglandin precursors might induce development of SS (12). Treatment with ",/-linolenic a c i d - - a prostaglandin E l p r e c u r s o r - - m i g h t therefore improve the exocrine gland function. Recently, two uncontrolled studies have found treatment with efamol, which contains 9% ~-linolenic acid, to be effective (5, 12). However, another uncontrolled study did not confirm this (22). In a 3-wk double-blind investigation on 36 SS patients, we were able to demonstrate that efamol given in doses of 3 g per day improves tear production as estimated with the Schirmer l-test (20). At present, SS patients may be treated with either bromhexine or efamol systemically, and tear and saliva substitutes locally. The combination of systemic and local treatment is of importance, and both are without substantial side effects.
Treatment Treatment of this chronic, disabling, but usually nonfatal disease has long been frustrating. Two main lines of treatment are followed: topical and systemic. Topical use of tear substitutes (=>12 times a day) is still very important, and most patients observe a positive effect from frequent changes between a number of almost identical tear substitutes. Saliva substitutes play an equally important role, especially when applied as an aerosol. Patients often prefer an increased intake of water, together with the use of a juicy chewing gum. Anetholetrithione (Sialor), a sialogogue, has been shown in a recent clinical trial to increase the unstimulated saliva flow rate of patients with SS (9). Systemic treatment is restricted to two drugs, bromhexine and efamol, as most of the generally used antiinflam-
References
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1. Adamson, T. C. et al. (1983). Immunohistologic analysis of lymphoid infiltrates in primary_ Sj6g_ren's sy_ndrome using monoclonal antibodies. J. Immunol. 130:203-208. 2. Bakhshi, A. et al. (1983). Lymphocyte subsets in Sj6gren's syndrome: a quantitative analysis using monoelonal antibodies and the fluorescence-activated cell sorter. J. Clin. Lab. Immunol. 10:63-69. 3. Bertram U. (1967). Xerostomia. Clinical aspects, pathology and pathogenesis. Acta Odont. Scand. 25(Suppl 49): I - 126. 4. van Bijsterveld, O. P. (1969). Diagnostic tests in the sicca syndrome. Arch. Ophthalmol. 82:10-14. 5. Campbell, A. and C. G. MacEvan (1982). System treatment of Sj6gren's syndrome and the sicca syndrome with efamol (evening primrose oil), vitamin C and pyridoxine, pp. 129-137. hi D. F. Horrobin (ed.), Clinical uses of essential fatty acids. Eden Press, Montreal.
© 1985ElsevierSciencePublishingCo.. Inc.
6. Cochet, P. and R. Bonnet (1960). L'esth6sie com6enne. Clin. Ophthalmol. 4:2-27. 7. Cummings, N. A. et al. (1971). Sj6gren's syndrome--newer aspects of research, diagnosis and therapy. Ann. Intern. Med. 75:937-950. 8. Daniels, T. E. (1984). Labial salivary gland biopsy in Sj6gren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases. Arthritis Rheum. 27:147- i 56. 9. Epstein, J. B., W. E. Dceoteau, and A. Wilkinson (1983). Effect of sialor in treatment of xerostomia in Sj6gren's syndrome. Oral Surg. 56:495-499. 10. Frost-Larsen, K., It. Isager, and R. Manthorpe (1978). Sj6grcn's syndrome treated with bromhexine: a randomised clinical study. Brit. Med. J. i: 1569-1648. 11. Hamburger, M. I. et al. (1979). Sj6gren's syndrome: a defect in reticuloendothelial system Fc-receptor-specific clearance. Ann. Intem. Med. 91:534-538. 12. Horrobin, D. F. and A. Campbell (1980). SjOgrcn's syndrome and the sicca syndrome: the role of prostaglandin E I deficiency. Treatment with essential fatty acids and vitamin C. Med. Hypotheses 6:225-232. 13. Janssen, P. T. and O. P. van Bijsterveld (1983). The relations between tear fluid concentrations of lysozyme, tear-specific prealbumin and lactoferrin. Exp. Eye Res. 36:773-779. 14. Lindahl G. et al. (in press). Epithelial HLA-DR expression and T lymphocyte subsets in salivary glands in Sj6gren's syndrome. Clin. Exp. Med. 15. Maekie, I. A. and D. V. Seal (1984). Diagnostic implications of tear protein profiles. Br. J. Ophthalmol. 68:321324. 16. Manthorpe, R. et al. (1981). Sj6gren's syndrome. A review with emphasis on immunological features. Allergy 36:139-153. 17. Manthorpe, R. et al. (1981). Pseudothrombocytopenia. In vitro studies on the underlying mechanism. Scand. J. Haematol. 26:385-392. 18. Manthorpe, R. et al. (1981). HLA-D antigen frequencies in Sj~gren's syndrome. Differences between the primary and secondary form. Scand. J. Rheumatol. 10:124-128. 19. Manthorpe, R. et al. (in press). Lewis blood type frequency in patients with primary Sj6gren's syndrome. A prospective study including analyses for A~A2B0, secretor, MNSs, P, Duffy, KelI, Lutheran and rhesus blood group. Scand. J. Rheumatol. 20. Manthorpe, R., S. II. Petersen, and
Clinical ImmunologyNewsletter6:12,1985
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J. U. Prause (in press). Primary Sj6gren's syndrome treated with efamol/ efavit. A double-blind cross-over investigation. Rheumatol. Int. Marner, K. (1980). "Snake-like" appearance of nuclear chromatin in conjunctival epithelial cells from patients with kerato-conjunctivitis sicca. Acta Ophthalmol. 58:849-853. McKendry, R. J. R. (1982). Treatment of Sj6gren's syndrome with essential fatty acids, pyridoxine and vitamin C. Prostaglandins, leukotrienes. Medicine (Baltimore) 8:403-408. Miyasaka, N. el al. (1983). Natural killing activity in Sj6gren's syndrome. An analysis of defective mechanisms. Arthritis Rheum. 26:954-960. Moutsopoulos, H. M. et al. (1979). Genetic differences between primary and secondary sicca syndrome. N. Engl. J. Med. 301:761-763.
Identification of Antigens in Immune Complexes B. Albini, M.D., P. Knoflach, M.D., E. Penner, M.D., and M. W. Stinson, Ph.D. Center for Studies on the Pathogenesis of Immune Complex-Mediated Diseases and Department of Microbiology State University of New York at Buffalo Buffalo, New York Recent years have seen a renewed discussion on basic concepts of pathogenesis mediated by immune complexes (IC) (see for example ref. 8). Many clinically relevant tenets of the past two decades have been questioned and are being reinvestigated: the definition of the term "immune complexes" in general; the participation of in situ formation of IC in disease; the importance of circulating IC (CIC) for the pathogenesis; the reliability of assays for CIC; and the immunohistological correlation of IC-mediated pathology and typical immunohistological staining patterns in tissue. In situ formation of immune complexes, an old concept, has been explored recently to a great extent, and new variants of this mechanism have been documented (8, 17). Both deposition of CIC (9) and in situ formation of IC
Clinical Immunology Newsletter 6:12,1985
26. Norn, M. S. (1983). External eye. Methods of examination. 2nd ed. p. 76. Scriptor, Copenhagen.
medical diseases. Acta Mcd. Scand. 205:333-338. 30. Prause, J. U. et al. (1982). Tear absorption into the filter-paper strip used in the Schirmer-l-test. A methodological study and a critical survey. Acta Ophthalmol. 60:70-78.
27. Oxholm, A., R. Manthorpe, and P. Oxholm (1984). Immunoglobin deposits in the epidermis of patients with primary Sj6gren's syndrome. Rheumatol. Int. 4:9-12.
31. Prause, J. U. et al. (1984). Lacrimal and salivary secretion in Sj6gren's syndrome: the effect of systemic treatment with bromhexine. Acta Ophthalmol. 62:489-497.
28. Oxholm, P., R. Manthorpe, and A. Oxholm (in press). Langerhans cells in labial minor salivary glands in primary Sj6gren's syndrome. Acta Path. Microbiol, lmmunol. Scand. Sect. A. 29. Pertain, II., F. Juhl, and A. Wiik (1979). Immunoglobin deposits in the dermo-epidermal junction zone. Nosographic occurrence in a number of
32. Sauvezie, B. el al. (1982). An increase in peripheral blood la-positive T cells in Sj6gren's syndrome correlated with a decrease in the autologous mixed lymphocyte response. Clin. Exp. lmmunol. 49:50-58.
(8) have been shown to occur in experimental models of IC disease. The validity of assays for CIC, troubled from the beginning with many technical pitfalls, occurrence of false positive and negative results, and difficulty in standardization, has been further weakened by the increasing awareness that indeed in situ formation of IC may be a major mode of pathogenesis in a number of IC-mediated diseases (1). In such cases, demonstration of CIC obviously would not be of prime pathogenic importance. Finally, the "rule of thumb" of immunohistology, namely that granular or " l u m p y bumpy" staining patterns suggest IC and linear patterns suggest antibody interactions with structural tissue or cell epitopes, has been greatly shaken by demonstrations of granular patterns with pathology induced by antibodies to structural antigens of the tissue or cells (8). To gain some insight into these and other problems of the pathogenesis of IC-mediated diseases, it seems essential to identify the antigens involved in IC, be it in circulation or in tissues.
specific" antibodies produced by hybridomas at our disposal. Unfortunately, in many cases the "direct" approach is not successful. Whereas bovine serum albumin (BSA) is easily demonstrable in IC by use of specific FITC-conjugated antisera, attempts to demonstrate other antigens, e.g., those of infectious agents or autoantigens, have had only moderate success. In many instances, the antigen is demonstrable not at all or only equivocally (21). These failures have been explained, e.g., by the concept of "blanketing" of ar~tigens in IC by antibodies, rheamatoid factor-like moieties, or complement (true blockage or steric bindrance); or by lack of sensitivity of the assays used, because of minimal amounts of epitopes available for reaction with the probing antibody. Nevertheless, in some instances these simple methods have been useful: the demonstration of DNA in kidneys of patients with systemic lupus erythematosus (SLE) (4), the demonstration of some infectious agents in tissue deposits in man (3) and experimental animals (2), and demonstration of the Hey mann antigen in experimentally induced glomerular IC (13). Sometimes, "adjunct" techniques--e.g., the partial elution of tissue sections ( 5 ) - - m a y enhance the direct demonstration of antigens.
25. Nahir, A. M. et al. (1979). Sialochemistry in evaluating bromhexine treatment of Sj6gren's syndrome. Br. Med. J. 280:833.
Direct Demonstration of Antigens in I C The simplest approach to the analysis of antigens in IC is the use of specific antibodies. We have "mono-
© 1985 Elsevier Scier, , ~'hlishing Co., Inc.
33. Scharf, J., Y. Scharf, and M. Nahir
(1982). Sj6gren's syndrome. Compr. Ther. 8:40-45.
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