Difference between revisions of "Sjögren syndrome"

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'''Sjögren syndrome''', also '''Sjögren disease''', is a disease that keeps [[rheumatology|rheumatologists]] busy.  Sjögren is also spelled '''Sjoegren''' and '''Sjogren'''.   
'''Sjögren syndrome''', also '''Sjögren disease''', is an uncommon disease that [[rheumatology|rheumatologists]] see.  Sjögren is also spelled '''Sjoegren''' and '''Sjogren'''.   


The syndrome may be part of another [[connective tissue disorder]], e.g. [[rheumatoid arthritis]], in which case it is called ''secondary Sjögren syndrome''.<ref name=pmid1703737>{{Cite journal  | last1 = Celenligil | first1 = H. | last2 = Kansu | first2 = E. | last3 = Ruacan | first3 = S. | last4 = Eratalay | first4 = K. | last5 = Irkeç | first5 = M. | title = Characterization of peripheral blood and salivary gland lymphocytes in secondary Sjögren's syndrome. | journal = Ann Dent | volume = 49 | issue = 2 | pages = 18-22 | month =  | year = 1990 | doi =  | PMID = 1703737 }}</ref>
The syndrome may be part of another [[connective tissue disorder]], e.g. [[rheumatoid arthritis]], in which case it is called ''secondary Sjögren syndrome''.<ref name=pmid1703737>{{Cite journal  | last1 = Celenligil | first1 = H. | last2 = Kansu | first2 = E. | last3 = Ruacan | first3 = S. | last4 = Eratalay | first4 = K. | last5 = Irkeç | first5 = M. | title = Characterization of peripheral blood and salivary gland lymphocytes in secondary Sjögren's syndrome. | journal = Ann Dent | volume = 49 | issue = 2 | pages = 18-22 | month =  | year = 1990 | doi =  | PMID = 1703737 }}</ref>
Pathologists are likely to see this condition as a ''[[labial salivary gland]]'' biopsy.
''Lip biopsy'' redirects here.


==General==
==General==
Line 9: Line 13:
*Dry eyes (xerophthalmia).
*Dry eyes (xerophthalmia).


Blood work:<ref name=pmid19323360>{{Cite journal  | title = Information from your family doctor. Sjögren syndrome. | journal = Am Fam Physician | volume = 79 | issue = 6 | pages = 472 | month = Mar | year = 2009 | doi =  | PMID = 19323360 | URL = http://www.aafp.org/afp/2009/0315/p465.html }}</ref>
===Diagnostic criteria===
*ANA +ve.
European criteria of 2002:<ref name=pmid12006334>{{Cite journal  | last1 = Vitali | first1 = C. | last2 = Bombardieri | first2 = S. | last3 = Jonsson | first3 = R. | last4 = Moutsopoulos | first4 = HM. | last5 = Alexander | first5 = EL. | last6 = Carsons | first6 = SE. | last7 = Daniels | first7 = TE. | last8 = Fox | first8 = PC. | last9 = Fox | first9 = RI. | title = Classification criteria for Sjögren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. | journal = Ann Rheum Dis | volume = 61 | issue = 6 | pages = 554-8 | month = Jun | year = 2002 | doi =  | PMID = 12006334 | PMC =1754137 }}
*Anti-SSA (Ro) +ve.
</ref>
*Anti-SSB (La) +ve.
{| class="wikitable sortable"
! Criteria
! Details
! Type
|-
| Oral symptoms
| any: (1) dry mouth > 3 months, (2) require fluids for swallowing, (3) swollen salivary glands (adults)
| history
|-
| Oral signs
| any: (1) low salivary flow test positive, (2) salivary scintigraphy positive (3) (parotid) sialography positive
| clinical test
|-
| Ocular symptoms
| any: (1) dry eye > 3 months, (2) need artifical tears >3x/day, (3) sand or gravel in the eyes sensation
| history
|-
| Ocular signs
| any: (1) Schirmer's test positive, (2) ocular dye test positive
| clinical test
|-
| Autoantibodies
| anti-SSA/Ro and/or anti-SSB/La
| serology
|-
| Histology
| labial minor salivary gland biopsy focus score >= 1.0/ 4 mm*mm; definition: multiple lymphocytic foci with >50 lymphocytes adjacent to mucinous acini, evaluated in 4 mm*mm of glandular tissue
| pathology
|}
The diagnosis is made if either:<ref name=pmid12006334/>
#Four of six criteria required, must include either autoantibodies or histology.
#Three of the four objective (non-history) criteria are met.
 
Notes:
*ANA<ref name=pmid19323360>{{Cite journal  | title = Information from your family doctor. Sjögren syndrome. | journal = Am Fam Physician | volume = 79 | issue = 6 | pages = 472 | month = Mar | year = 2009 | doi =  | PMID = 19323360 | URL = http://www.aafp.org/afp/2009/0315/p465.html }}</ref> and RF<ref name=pmid12022353>{{Cite journal  | last1 = Vivino | first1 = FB. | last2 = Gala | first2 = I. | last3 = Hermann | first3 = GA. | title = Change in final diagnosis on second evaluation of labial minor salivary gland biopsies. | journal = J Rheumatol | volume = 29 | issue = 5 | pages = 938-44 | month = May | year = 2002 | doi =  | PMID = 12022353 }}</ref> were criteria in the past; they are no longer considered important in the diagnosis.


==Microscopic==
==Microscopic==
Features ([[salivary gland]]):<ref name=pmid19323360/>
Features ([[salivary gland]]):<ref name=pmid19323360/>
*Lymphocytic infiltration - '''key feature'''.
*"Significant lymphocytic infiltrate" adjacent to viable [[salivary gland]] (or [[lacrimal gland]]) acini - '''key feature'''.
**"Benign lymphoepithelial lesion"<ref name=pmid15956090/> - intraepithelial lymphocytes.
**"Significant lymphocytic infiltrate": cluster of >= 50 lymphocytes - '''important'''.
*Viable [[salivary gland]] or [[lacrimal gland]] acini.
***Lymphocytes may be perivascular or periductular.<ref name=pmid12022353/><ref name=pmid8003059>{{Cite journal  | last1 = Daniels | first1 = TE. | last2 = Whitcher | first2 = JP. | title = Association of patterns of labial salivary gland inflammation with keratoconjunctivitis sicca. Analysis of 618 patients with suspected Sjögren's syndrome. | journal = Arthritis Rheum | volume = 37 | issue = 6 | pages = 869-77 | month = Jun | year = 1994 | doi =  | PMID = 8003059 }}</ref>
*+/-[[Plasma cell]]s.
***[[Plasma cell]]s should not exceed 10% of the inflammatory infiltrate.<ref name=pmid12022353/>
***May have "benign lymphoepithelial lesions"<ref name=pmid15956090/> - intraepithelial lymphocytes.
*+/-Fibrosis.
*+/-Fibrosis.


DDx:
DDx:
*[[MALT lymphoma]].
*[[MALT lymphoma]].
*[[Chronic sialadenitis]] - mixed inflammatory infiltrate.


Note:
Note:
*Diagnosis is based on clinicopathologic correlation; the histology alone is insufficient.
*Diagnosis is based on clinicopathologic correlation; the histology alone is insufficient.
*Perivascular lymphocytes ''not'' important.


Images:
===Images===
<gallery>
Image:Sjogren_syndrome_%281%29.jpg | SS - low mag. (WC)
Image:Sjogren_syndrome_%282%29.jpg | SS - high mag. (WC)
</gallery>
www:
*[http://img.medscape.com/pi/emed/ckb/rheumatology/329097-1339496-332125-1582482.jpg Sjögren syndrome (medscape.com)].<ref>URL: [http://emedicine.medscape.com/article/332125-workup#aw2aab6b5b6aa http://emedicine.medscape.com/article/332125-workup#aw2aab6b5b6aa]. Accessed on: 24 July 2012.</ref>
*[http://img.medscape.com/pi/emed/ckb/rheumatology/329097-1339496-332125-1582482.jpg Sjögren syndrome (medscape.com)].<ref>URL: [http://emedicine.medscape.com/article/332125-workup#aw2aab6b5b6aa http://emedicine.medscape.com/article/332125-workup#aw2aab6b5b6aa]. Accessed on: 24 July 2012.</ref>
*[http://commons.wikimedia.org/wiki/File:Sjogren_syndrome_%281%29.jpg SS - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Sjogren_syndrome_%282%29.jpg SS - high mag. (WC)].


===Grading===
===Focus score===
Lesions can be graded with the ''Chisholm-Mason classification''.<ref name=pmid15956090>{{Cite journal  | last1 = Ramos-Casals | first1 = M. | last2 = Font | first2 = J. | title = Primary Sjögren's syndrome: current and emergent aetiopathogenic concepts. | journal = Rheumatology (Oxford) | volume = 44 | issue = 11 | pages = 1354-67 | month = Nov | year = 2005 | doi = 10.1093/rheumatology/keh714 | PMID = 15956090 | url = http://rheumatology.oxfordjournals.org/content/44/11/1354.long }}</ref> It is based on assessing 4 mm<sup>2</sup> area of salivary gland tissue and depends on the abundance and aggregation of lymphocytes as follows:<ref>{{Cite journal  | last1 = Chisholm | first1 = DM. | last2 = Mason | first2 = DK. | title = Labial salivary gland biopsy in Sjögren's disease. | journal = J Clin Pathol | volume = 21 | issue = 5 | pages = 656-60 | month = Sep | year = 1968 | doi =  | PMID = 5697370 | PMC = 473887 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC473887/?tool=pubmed }}</ref>
Features:<ref name=pmid12022353/>
*This is nothing more than a count of significant lymphocytic foci per 4 mm*mm.
**Significant: >= 50 lymphocytes, adjacent to (viable) [[salivary gland]] acini.
**A ''focus score'' of one or more is considered significant.<ref name=pmid12006334/>
 
Calculating the focus score (fs):
# Count the significant foci (n).
# Estimate the sample area in mm<sup>2</sup> (a).
 
:<math>fs = { n  \over a } \times 4 \ mm^2</math>
 
====Grading====
In the past lesions were graded with the ''Chisholm-Mason classification''.<ref name=pmid15956090>{{Cite journal  | last1 = Ramos-Casals | first1 = M. | last2 = Font | first2 = J. | title = Primary Sjögren's syndrome: current and emergent aetiopathogenic concepts. | journal = Rheumatology (Oxford) | volume = 44 | issue = 11 | pages = 1354-67 | month = Nov | year = 2005 | doi = 10.1093/rheumatology/keh714 | PMID = 15956090 | url = http://rheumatology.oxfordjournals.org/content/44/11/1354.long }}</ref><ref>{{Cite journal  | last1 = Chisholm | first1 = DM. | last2 = Mason | first2 = DK. | title = Labial salivary gland biopsy in Sjögren's disease. | journal = J Clin Pathol | volume = 21 | issue = 5 | pages = 656-60 | month = Sep | year = 1968 | doi =  | PMID = 5697370 | PMC = 473887 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC473887/?tool=pubmed }}</ref> The ''Chisholm-Mason classification'' is based on assessing 4 mm<sup>2</sup> area of salivary gland tissue and depends on the abundance and aggregation of lymphocytes. 
 
It is compares to Daniels-Whitcher grading as follows:
{| class="wikitable sortable"  
{| class="wikitable sortable"  
!Grade
! Lymphocytes
!Lymphocytes
! Daniels-Whitcher <br>grade
! Chisholm-Mason <br>grade
|-
|-
| 0
| absent
|-
| 1
| slight infiltrate
| slight infiltrate
| mild
| 1
|-
|-
| moderate infiltrate or less than one focus †
| intermediate
| 2
| 2
| moderate infiltrate or less than one focus †
|-
|-
| one focus †
| severe
| 3
| 3
| one focus †
|-
|-
| more than one focus †
| severe
| 4
| 4
| more than one focus †
|}
|}
† Focus = aggregrate of 50 lymphocytes.
† Focus = an aggregrate of 50 lymphocytes or more.


==Sign out==
==Sign out==
===Suggestive===
<pre>
<pre>
LOWER LIP, BIOPSY:
LOWER LIP, BIOPSY:
- SQUAMOUS MUCOSA WITH PARAKERATOSIS.
- MINOR SALIVARY GLAND WITH FOCAL LYMPHOCYTIC SIALADENITIS, SEE COMMENT.
- SALIVARY GLAND WITH A MINIMAL LYMPHOCYTIC INFILTRATE, SEE COMMENT.
- SQUAMOUS MUCOSA WITH PARAKERATOSIS, MILD.


COMMENT:
COMMENT:
Clinical and serologic correlation is required. The inflammation corresponds
The histologic findings are compatible with those seen in Sjoegren's disease
to Chisholm-Mason classification grade 3.
(focus score >= 1).
 
SALIVARY GLAND - SUMMARY:
Glandular area: 8 mm*mm.
Interstitial fat: not apparent.
Plasma cells: not apparent.
Fibrosis: none apparent (0% of salivary gland area).
Ductular dilation: not apparent.
Gross foci: 4.
Focus score (foci/4 mm*mm): 2.
 
This result needs to be combined with the clinical and serologic criteria used
to diagnose Sjoegren's disease.
</pre>
 
===Not suggestive===
<pre>
Minor Salivary Gland, Biopsy:
- Benign minor salivary gland with one focus of chronic lymphocyte
  predominant inflammation.
- Focus score less than one; not suggestive of Sjoegren's disease.
 
Comment:
Estimated area of salivary gland: 50 mm*mm.
Number of foci (~50 lymphocytes): 1.
Plasma cells: few (<10%).
Fibrosis: none/minimal.
Focus score (number of foci / area x 4 mm*mm) = < 1.
 
The findings do not exclude Sjoegren's disease. Clinical and serologic  
correlation is required.
</pre>
</pre>



Latest revision as of 21:45, 2 March 2023

Sjögren syndrome, also Sjögren disease, is an uncommon disease that rheumatologists see. Sjögren is also spelled Sjoegren and Sjogren.

The syndrome may be part of another connective tissue disorder, e.g. rheumatoid arthritis, in which case it is called secondary Sjögren syndrome.[1]

Pathologists are likely to see this condition as a labial salivary gland biopsy.

Lip biopsy redirects here.

General

Clinical - classically:

  • Women in 50s.
  • Dry mouth (xerostomia).
  • Dry eyes (xerophthalmia).

Diagnostic criteria

European criteria of 2002:[2]

Criteria Details Type
Oral symptoms any: (1) dry mouth > 3 months, (2) require fluids for swallowing, (3) swollen salivary glands (adults) history
Oral signs any: (1) low salivary flow test positive, (2) salivary scintigraphy positive (3) (parotid) sialography positive clinical test
Ocular symptoms any: (1) dry eye > 3 months, (2) need artifical tears >3x/day, (3) sand or gravel in the eyes sensation history
Ocular signs any: (1) Schirmer's test positive, (2) ocular dye test positive clinical test
Autoantibodies anti-SSA/Ro and/or anti-SSB/La serology
Histology labial minor salivary gland biopsy focus score >= 1.0/ 4 mm*mm; definition: multiple lymphocytic foci with >50 lymphocytes adjacent to mucinous acini, evaluated in 4 mm*mm of glandular tissue pathology

The diagnosis is made if either:[2]

  1. Four of six criteria required, must include either autoantibodies or histology.
  2. Three of the four objective (non-history) criteria are met.

Notes:

  • ANA[3] and RF[4] were criteria in the past; they are no longer considered important in the diagnosis.

Microscopic

Features (salivary gland):[3]

  • "Significant lymphocytic infiltrate" adjacent to viable salivary gland (or lacrimal gland) acini - key feature.
    • "Significant lymphocytic infiltrate": cluster of >= 50 lymphocytes - important.
      • Lymphocytes may be perivascular or periductular.[4][5]
      • Plasma cells should not exceed 10% of the inflammatory infiltrate.[4]
      • May have "benign lymphoepithelial lesions"[6] - intraepithelial lymphocytes.
  • +/-Fibrosis.

DDx:

Note:

  • Diagnosis is based on clinicopathologic correlation; the histology alone is insufficient.

Images

www:

Focus score

Features:[4]

  • This is nothing more than a count of significant lymphocytic foci per 4 mm*mm.
    • Significant: >= 50 lymphocytes, adjacent to (viable) salivary gland acini.
    • A focus score of one or more is considered significant.[2]

Calculating the focus score (fs):

  1. Count the significant foci (n).
  2. Estimate the sample area in mm2 (a).

Grading

In the past lesions were graded with the Chisholm-Mason classification.[6][8] The Chisholm-Mason classification is based on assessing 4 mm2 area of salivary gland tissue and depends on the abundance and aggregation of lymphocytes.

It is compares to Daniels-Whitcher grading as follows:

Lymphocytes Daniels-Whitcher
grade
Chisholm-Mason
grade
slight infiltrate mild 1
moderate infiltrate or less than one focus † intermediate 2
one focus † severe 3
more than one focus † severe 4

† Focus = an aggregrate of 50 lymphocytes or more.

Sign out

Suggestive

LOWER LIP, BIOPSY:
- MINOR SALIVARY GLAND WITH FOCAL LYMPHOCYTIC SIALADENITIS, SEE COMMENT.
- SQUAMOUS MUCOSA WITH PARAKERATOSIS, MILD.

COMMENT:
The histologic findings are compatible with those seen in Sjoegren's disease
(focus score >= 1).

SALIVARY GLAND - SUMMARY:
Glandular area: 8 mm*mm.
Interstitial fat: not apparent.
Plasma cells: not apparent.
Fibrosis: none apparent (0% of salivary gland area).
Ductular dilation: not apparent.
Gross foci: 4.
Focus score (foci/4 mm*mm): 2.

This result needs to be combined with the clinical and serologic criteria used
to diagnose Sjoegren's disease.

Not suggestive

Minor Salivary Gland, Biopsy:
- Benign minor salivary gland with one focus of chronic lymphocyte 
  predominant inflammation.
- Focus score less than one; not suggestive of Sjoegren's disease.

Comment:
Estimated area of salivary gland: 50 mm*mm. 
Number of foci (~50 lymphocytes): 1.
Plasma cells: few (<10%).
Fibrosis: none/minimal.
Focus score (number of foci / area x 4 mm*mm) = < 1.

The findings do not exclude Sjoegren's disease. Clinical and serologic 
correlation is required.

See also

References

  1. Celenligil, H.; Kansu, E.; Ruacan, S.; Eratalay, K.; Irkeç, M. (1990). "Characterization of peripheral blood and salivary gland lymphocytes in secondary Sjögren's syndrome.". Ann Dent 49 (2): 18-22. PMID 1703737.
  2. 2.0 2.1 2.2 Vitali, C.; Bombardieri, S.; Jonsson, R.; Moutsopoulos, HM.; Alexander, EL.; Carsons, SE.; Daniels, TE.; Fox, PC. et al. (Jun 2002). "Classification criteria for Sjögren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group.". Ann Rheum Dis 61 (6): 554-8. PMC 1754137. PMID 12006334. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754137/.
  3. 3.0 3.1 "Information from your family doctor. Sjögren syndrome.". Am Fam Physician 79 (6): 472. Mar 2009. PMID 19323360.
  4. 4.0 4.1 4.2 4.3 Vivino, FB.; Gala, I.; Hermann, GA. (May 2002). "Change in final diagnosis on second evaluation of labial minor salivary gland biopsies.". J Rheumatol 29 (5): 938-44. PMID 12022353.
  5. Daniels, TE.; Whitcher, JP. (Jun 1994). "Association of patterns of labial salivary gland inflammation with keratoconjunctivitis sicca. Analysis of 618 patients with suspected Sjögren's syndrome.". Arthritis Rheum 37 (6): 869-77. PMID 8003059.
  6. 6.0 6.1 Ramos-Casals, M.; Font, J. (Nov 2005). "Primary Sjögren's syndrome: current and emergent aetiopathogenic concepts.". Rheumatology (Oxford) 44 (11): 1354-67. doi:10.1093/rheumatology/keh714. PMID 15956090. http://rheumatology.oxfordjournals.org/content/44/11/1354.long.
  7. URL: http://emedicine.medscape.com/article/332125-workup#aw2aab6b5b6aa. Accessed on: 24 July 2012.
  8. Chisholm, DM.; Mason, DK. (Sep 1968). "Labial salivary gland biopsy in Sjögren's disease.". J Clin Pathol 21 (5): 656-60. PMC 473887. PMID 5697370. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC473887/?tool=pubmed.