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Sjogren's Syndrome

Sjogrens Syndrome

Sjogren's syndrome is a systemic autoimmune disease characterized by lymphocytic infiltrates in exocrine organs. It is named after Swedish ophthalmologist Henrik Sjögren.


Presentation

The early symptoms of Sjogren's syndrome can be easily overlooked. The main clinical presentation in adults is xerophthalmia and xerostomia. In children, bilateral swelling of the parotid glands is a common sign. Xerophthalmia and xerostomia are often described in the following way by affected individuals:

  • Unable to eat dry foods
  • Tongue sticks on the roof of the mouth
  • Unable to speak for long period
  • Increased cases of dental caries
  • Change in tastes
  • Painful mouth
  • Sandy sensation in the eyes
  • Persistent, dry cough

In addition to these sicca symptoms, various extraglandular manifestations may develop, including arthralgia, arthritis, myalgia, Raynaud phenomenon, pulmonary disease, gastrointestinal disease, pericarditis, pulmonary hypertension, lymphadenopathy, neuropathy, vasculitis, renal tubular acidosis, xeroderma, purpura, and urticaria. Late complications such as blindness, dental destruction, oral candidiasis, and non-Hodgkin lymphoma may occur [6].

Splenomegaly
  • On admission, she presented with anemia, elevated C-reactive protein levels, anasarca, and hepato-splenomegaly.[ncbi.nlm.nih.gov]
  • Clinical predictors of lymphoma development in SS include persistently enlarged parotid glands, with associated splenomegaly, lymphadenopathy, and cutaneous vasculitis (palpable purpura or leg ulcers).[rheumatologyadvisor.com]
Cough
  • Sjogren's syndrome is associated with chronic cough, but sicca symptoms are missing from cough evaluation guidelines. We evaluated patients with unexplained cough for undiagnosed Sjogren's syndrome.[ncbi.nlm.nih.gov]
  • Other symptoms can include joint swelling and pain, vaginal dryness, persistent dry cough and dry skin. It may also spread to other parts of the body such as blood vessels, nerves, lungs, kidneys and digestive system.[coloradoarthritis.com]
  • […] and irritation within the throat Difficulty swallowing and irritation of the stomach Vaginal dryness leading to irritation or pain during intercourse Glands Decrease in mucus can lead to coughing and irritation within the throat Difficulty swallowing[mollysfund.org]
  • […] in the following way by affected individuals: Unable to eat dry foods Tongue sticks on the roof of the mouth Unable to speak for long period Increased cases of dental caries Change in tastes Painful mouth Sandy sensation in the eyes Persistent, dry cough[symptoma.com]
  • In 2011, the elder Williams sister was diagnosed with Sjogren's syndrome, an autoimmune disease that dries out the mouth and eyes, and can also sap strength and cause joint and muscle pain, coughing, and limb numbness.[businessinsider.com]
Dry Cough
  • Other symptoms can include joint swelling and pain, vaginal dryness, persistent dry cough and dry skin. It may also spread to other parts of the body such as blood vessels, nerves, lungs, kidneys and digestive system.[coloradoarthritis.com]
  • […] described in the following way by affected individuals: Unable to eat dry foods Tongue sticks on the roof of the mouth Unable to speak for long period Increased cases of dental caries Change in tastes Painful mouth Sandy sensation in the eyes Persistent, dry[symptoma.com]
  • cough Prolonged fatigue Causes Sjogren's syndrome is an autoimmune disorder.[mayoclinic.org]
  • (The most frequent reason, in 80%, was persistent, dry cough periodically waking up patients at night). The chest HRCT scan revealed lung tissue changes in the course of 29% of all examined patients (of 68).[ncbi.nlm.nih.gov]
  • You may have a dry cough, hoarseness, a decreased sense of smell, and nosebleeds . It can also lead to pneumonia, bronchitis, and ear problems. Dryness of the vagina. This can cause painful intercourse. Fatigue. is a common complaint.[healthcentral.com]
Pneumonia
  • However her stay at hospital was complicated by severe hospital acquired pneumonia to which she succumbed.[ncbi.nlm.nih.gov]
  • A chronic autoimmune disease like Sjögren's syndrome can affect the entire body, causing dry eyes, dry mouth, dry skin, dental decay, joint pain, extreme fatigue, memory loss, pneumonia and abnormal liver function, among other things.[hospitals.jefferson.edu]
  • Drying in the lungs can result in lung infections or pneumonia . There may be a loss of hair on the body.[cedars-sinai.edu]
  • Inflammation can cause pneumonia, bronchitis or other problems in your lungs; lead to problems with kidney function; and cause hepatitis or cirrhosis in your liver. Lymph nodes.[mayoclinic.org]
  • It can also lead to pneumonia, bronchitis, and ear problems. Dryness of the vagina. This can cause painful intercourse. Fatigue. is a common complaint. You may get easily exhausted and feel tired and worn out. Other problems.[healthcentral.com]
Hoarseness
  • You may have a dry cough, hoarseness, a decreased sense of smell, and nosebleeds . It can also lead to pneumonia, bronchitis, and ear problems. Dryness of the vagina. This can cause painful intercourse. Fatigue. is a common complaint.[healthcentral.com]
  • […] secretions Extremely dry mouth and throat, causing: difficulty chewing and swallowing, especially dry food such as crackers decreased or altered sense of taste difficulty speaking increase in dental cavities and even tooth loss at early age dry cough or hoarseness[clevelandclinic.org]
  • The following is a list of potential symptoms associated with Sjogren's syndrome: Skin rashes Gland infections Excessive fatigue Difficulty speaking Extremely dry eyes Numbness or tingling Gastrointestinal issues Enlarged Parotid glands Dry cough or hoarseness[disabled-world.com]
  • Protect Your Voice You can develop hoarseness if their vocal cords become inflamed or become irritated from throat dryness or coughing. To prevent further strain on your vocal cords, try not to clear your throat before speaking.[niams.nih.gov]
  • You may have a dry cough hoarseness a decreased sense of smell and nosebleeds. It can also lead to pneumonia bronchitis and ear problems. Dryness of the vagina This can cause painful intercourse for women with Sjogren's syndrome.[orthop.washington.edu]
Chronic Cough
  • Unexplained cough was defined as chronic cough of unknown etiology despite algorithm-based evaluation and treatment.[ncbi.nlm.nih.gov]
  • Frequency (%) Arthralgia or nonerosive arthritis characterized by tenderness, swelling, or effusion of peripheral joints 37 to 75 Gastrointestinal symptoms (reflux, dyspepsia, diarrhea, constipation) 54 Autoimmune thyroiditis 15 to 33 Pulmonary disease (chronic[aafp.org]
  • Sjögren syndrome ( SjS , SS ) is a long-term autoimmune disease in which the moisture-producing glands of the body are affected. [4] This results primarily in the development of a dry mouth and dry eyes . [2] Other symptoms can include dry skin , a chronic[en.wikipedia.org]
Fatigue
  • […] systemic autoimmune disease that primarily affects the exocrine glands, resulting in dryness of the eyes and mouth due to lymphocytic infiltration of the salivary and lacrimal glands along with arthritis, kidney, liver, and lung involvement, chronic fatigue[ncbi.nlm.nih.gov]
  • Lewis, a registered nurse, found out at age 31 that her dry eyes, joint pain and extreme fatigue were caused by Sjogren’s syndrome. Ms. Lewis said that fatigue had been the worst part of living with Sjogren’s syndrome.[nytimes.com]
  • Open caused debilitating joint pain, swelling, numbness and fatigue, she told Good Morning America's Elizabeth Vargas today .[abcnews.go.com]
  • Debilitating fatigue and joint pain can seriously impair quality of life. It is one of the most prevalent autoimmune disorders, striking as many as four million Americans. Nine out of ten individuals with Sjögren's syndrome are women.[nationalhealthcouncil.org]
  • Fatigue and joint pain may occur as well, ranging in intensity from mild to disabling. Sjogren's can also affect the kidneys, digestive tract, lungs, liver, pancreas, or other internal organs.[winchesterhospital.org]
Fever
  • The patient was admitted due to dyspnea, fever, polyarthralgia, and generalized edema.[ncbi.nlm.nih.gov]
  • […] syndrome are: Two or more body systems or organs affected At least one system/function/organ affected to a moderate or severe level At least two of the following symptoms: weight loss (when not trying to lose weight), severe fatigue, malaise, chronic fever[disability-benefits-help.org]
  • This may occur along with a fever. This affects about one-half of people with the disorder. Dental cavities. This is a common problem that results from a dry mouth. Saliva fights bacteria and defends against cavities.[healthcentral.com]
  • Patients with rare but serious systemic symptoms, such as fever, rashes, abdominal pain, or lung or kidney problems, may require treatment with corticosteroids such as prednisone (Deltasone and others) and/or immunosuppressive agents like methotrexate[rheumatology.org]
  • When I evaluate patients I’m looking for swollen lymph glands, new fevers or other clues that might tell us that lymphoma may be occurring.[med.unc.edu]
Anemia
  • As a result, patients with Sjogren’s syndrome can present with a variety of symptoms These may include: Dry eyes and/or dry mouth Burning and numbness of the extremities Pain with sexual intercourse Anemia or low white blood count Although Sjogren’s syndrome[hopkinssjogrens.org]
  • Blood tests may reveal elevated erythrocyte sedimentation rate and transaminase levels, anemia, leukopenia, eosinophilia, hypergammaglobulinemia, presence of antinuclear antibodies, anti–alpha-fodrin antibody and rheumatoid factor.[symptoma.com]
  • Patients with the RA and Sjögren’s combination were also more likely to have blood abnormalities, including decreased numbers of platelets (thrombocytopenia) and decreased numbers of red blood cells (anemia).[rheumatoidarthritis.net]
  • On admission, she presented with anemia, elevated C-reactive protein levels, anasarca, and hepato-splenomegaly.[ncbi.nlm.nih.gov]
  • Other nonspecific laboratory abnormalities that are commonly noted in SS are elevated erythrocyte sedimentation rates (a sign of inflammation), mild anemia, and low albumin levels.[resources.lupus.org]
Chronic Fatigue Syndrome
  • That's because the symptoms can overlap or look like those of other conditions, including chronic fatigue syndrome, fibromyalgia, lupus, rheumatoid arthritis, or even multiple sclerosis.[stlouischildrens.org]
Recurrent Sinusitis
  • sinusitis Mouth sores/ulcerations Swollen salivary glands Salivary gland stones Dental decay, dentures Problems with speech Problems with taste Dry, cracked lips that may peel Dry skin Dry hair Difficulty chewing Difficulty swallowing Esophagitis Reflux[migraine.com]
Constipation
  • Manifestations of Sjögren Syndrome Clinical signs and symptoms Frequency (%) Arthralgia or nonerosive arthritis characterized by tenderness, swelling, or effusion of peripheral joints 37 to 75 Gastrointestinal symptoms (reflux, dyspepsia, diarrhea, constipation[aafp.org]
Xerostomia
  • Despite symptomatic treatment, xerostomia, glossitis, and glossodynia were still present, at times marked, after 12 months when the ANA titer was unchanged.[ncbi.nlm.nih.gov]
  • Sjogren's syndrome(SS) is a chronic autoimmune disease, which damages exocrine glands especially salivary and lacrimal glands, with xerostomia and xerophthalmia as common symptoms. We report a case of a 49-year-old woman presented with pancytopenia.[ncbi.nlm.nih.gov]
  • After eighteen months and two years respectively, the patients were satisfied with function and aesthetics; restorations were comfortable, stable radiographic bone levels were noted and xerostomia was not reported to affect the function anymore.[ncbi.nlm.nih.gov]
  • The main clinical presentation in adults is xerophthalmia and xerostomia. In children, bilateral swelling of the parotid glands is a common sign.[symptoma.com]
  • Dryness affecting the eyes is sometimes referred to as keratoconjunctivitis sicca (KCS, for short) and dryness affecting the mouth is sometimes referred to as xerostomia.[rheumatoidarthritis.net]
Dental Caries
  • Xerophthalmia and xerostomia are often described in the following way by affected individuals: Unable to eat dry foods Tongue sticks on the roof of the mouth Unable to speak for long period Increased cases of dental caries Change in tastes Painful mouth[symptoma.com]
  • Further history revealed frequent dental caries, xerostomia and recent weight loss.[ncbi.nlm.nih.gov]
  • There may be evidence of infection including oral candidiasis and dental caries. Submandibular glands may be enlarged but more obvious is bilateral enlargement of the parotid glands.[patient.info]
  • caries Oral candidiasis Corneal abrasion or ulceration Mucosa-associated lymphoid tissue (MALT) lymphoma Parotid gland infection Please rate topic.[medbullets.com]
Cracked Lips
  • lips that may peel Dry skin Dry hair Difficulty chewing Difficulty swallowing Esophagitis Reflux Chronic or recurrent bronchitis Pneumonia Pleurisy Interstitial lung disease Malabsorption B12 and other vitamin deficiencies Stomach upset Gastroparesis[migraine.com]
Denture Problems
  • Problems with speech Problems with taste Dry, cracked lips that may peel Dry skin Dry hair Difficulty chewing Difficulty swallowing Esophagitis Reflux Chronic or recurrent bronchitis Pneumonia Pleurisy Interstitial lung disease Malabsorption B12 and[migraine.com]
Sore Mouth
  • Other symptoms may include: Contact lens discomfort Dry sinuses and frequent sinus infections or nosebleeds Sore mouth, tongue or throat Difficulty chewing or swallowing Dry or peeling lips Blepharitis Dry and sore skin Muscle pain without accompanying[allaboutvision.com]
Dry Eyes
  • Sjogren's syndrome is the leading cause for aqueous tear-deficiency dry eye. Little is known regarding the relationship between Sjogren's syndrome dry eye (SSDE) and patients' medical expenditure, clinical severity and psychological status changes.[ncbi.nlm.nih.gov]
  • Dry eyes, with or without SS, is under-recognized and should be added to diagnostic algorithms for unexplained cough.[ncbi.nlm.nih.gov]
  • Its cardinal symptoms include: Dry eyes Dry mouth Dental decay Systemic symptoms of fatigue and joint pain Dry eyes and dry mouth may also be caused by other diseases and certain medications.[hopkinssjogrens.org]
  • How Dry Eye From Sjogren's Syndrome Is Treated Dry eye resulting from Sjogren's syndrome may require ongoing treatment with artificial tears , ointments or other remedies.[allaboutvision.com]
  • She recommends seeing a dry eye specialist, especially one who is familiar with autoimmune disorders.[nytimes.com]
Lacrimal Gland Enlargement
  • Definition (CSP) symptom complex of unknown etiology, usually occurring in middle-aged or older women, marked by the triad of keratoconjunctivitis sicca with or without lacrimal gland enlargement, xerostomia with or without salivary gland enlargement,[fpnotebook.com]
  • The first clinical description of Sjögren syndrome was by Mikulicz, who described a 42-year-old with bilateral parotid and lacrimal gland enlargement in 1892.[eyewiki.org]
Red Eye
  • Since filamentary keratopathy is very symptomatic (mild to severe foreign body sensation that is exacerbated by blinking and is associated with photophobia, blepharospasm, and epiphora, red eye), it is worthwhile to describe the management of both filaments[eyewiki.org]
Urticaria
  • […] manifestations may develop, including arthralgia, arthritis, myalgia, Raynaud phenomenon, pulmonary disease, gastrointestinal disease, pericarditis, pulmonary hypertension, lymphadenopathy, neuropathy, vasculitis, renal tubular acidosis, xeroderma, purpura, and urticaria[symptoma.com]
  • Gastrointestinal disease Leukopenia Anemia Lymphadenopathy Neuropathy Vasculitis Renal tubular acidosis Lymphoma About 50% of patients with Sjögren syndrome have cutaneous findings, such as dry skin (xeroderma), palpable and nonpalpable purpura, and/or urticaria[emedicine.medscape.com]
Vaginal Dryness
  • There are vaginal lubricants available on an over-the-counter basis for women who experience vaginal dryness. These lubricants may ease vaginal dryness. Vaginal lubricants may also be considered for sexual intercourse.[disabled-world.com]
  • For vaginal dryness: Use lubricants made specifically to help vaginal dryness. Do not use petroleum jelly. Exercise and therapy Mild exercise such as walking or swimming can help keep joints and muscles flexible.[orthop.washington.edu]
  • Other symptoms can include joint swelling and pain, vaginal dryness, persistent dry cough and dry skin. It may also spread to other parts of the body such as blood vessels, nerves, lungs, kidneys and digestive system.[coloradoarthritis.com]
  • dryness, or persistent bronchitis.[blackdoctor.org]

Workup

No single examination is sufficiently sensitive or specific in the diagnosis of the disorder. Blood tests may reveal elevated erythrocyte sedimentation rate and transaminase levels, anemia, leukopenia, eosinophilia, hypergammaglobulinemia, presence of antinuclear antibodies, anti–alpha-fodrin antibody and rheumatoid factor. Rose Bengal test measures the function of the lacrimal glands and Schirmer's test the production of tears.

Radiological procedures such as sialography and scintigraphy or a salivary gland biopsy may be recommended to aid in the diagnosis of Sjogren’s syndrome [7] [8] [9].

Lymphocytic Infiltrate
  • Sjogren's syndrome (SS) is a systemic autoimmune disease that primarily affects the exocrine glands, resulting in dryness of the eyes and mouth due to lymphocytic infiltration of the salivary and lacrimal glands along with arthritis, kidney, liver, and[ncbi.nlm.nih.gov]
  • Sjogren's syndrome is a chronic inflammatory disorder characterized by salivary insufficiency and lymphocytic infiltrates in exocrine organs.[symptoma.com]
  • Valve pathology showed nodular calcification and hyaline degeneration, but lymphocyte infiltration was not evident.[ncbi.nlm.nih.gov]
  • Sjogren's syndrome is a chronic autoimmune syndrome characterized by lymphocyte infiltration of salivary glands, resulting in symptomatic eye and mouth dryness.[news-medical.net]
  • It is an autoimmune disease characterized by features of systemic autoimmunity, dysfunction, and inflammation in the exocrine glands (mainly salivary and lacrimal glands) and lymphocytic infiltration of exocrine glands.[ncbi.nlm.nih.gov]
HLA-B8
  • These "histocompatibility antigens" may include HLA-B8 and HLA-DR3.[resources.lupus.org]
  • DRB1*03:01 alleles were identified as risk factors , while DQA1*02:01, DQA1*03:01 and DQB1*05:01 alleles were found to be protective factors for the disease. [59] The relationship between alleles and specific race was also established. [60] HLA-DQ2 and HLA-B8[en.wikipedia.org]
  • In white persons, for instance, the condition is linked to human leukocyte antigen (HLA)–DR3, HLA-DQ2, and HLA-B8, [10] whereas the linkage is to HLA-DRB1*15 in Spanish persons [ 11 ] and to HLA-DR5 in Greek and Israeli persons. [12] Some evidence indicates[emedicine.medscape.com]
HLA-DR3
  • These "histocompatibility antigens" may include HLA-B8 and HLA-DR3.[resources.lupus.org]
  • […] that the true association of Sjögren syndrome may be with HLA-DQA1, which is in linkage disequilibrium with HLA-DR3 and HLA-DR5. [ 13 ] These HLA associations appear restricted to individuals with Sjögren syndrome who have antibodies to the antigens[emedicine.medscape.com]

Treatment

Treatment of the disorder is generally symptomatic and supportive. It depends on the manifestations and varies for every patient. Moisturizing treatments, nonsteroidal anti-inflammatory drugs and low-dose glucocorticoids are most commonly used.

Prognosis

The prognosis of primary Sjogren's syndrome is generally good, but for secondary cases, the prognosis is closely related to the associated disease.

Etiology

Sjogren's syndrome exists as a primary or as a secondary disease. The two forms occur in similar frequency. The secondary form of the disease is associated with disorders such as system lupus erythematosus, polyarteritis nodosa, scleroderma, cryoglobulinemia, and systemic sclerosis. Regardless of whether the syndrome is primary or secondary, the parotid glands, the lungs, eyes, the mouth, the nervous systems, and the skin are affected.

The exact etiology of the disease is currently unknown. So far, it has been established that the pathogenesis is multifactorial. Environmental and hormonal factors are thought to trigger inflammation in individuals with a genetic predisposition to the disorder.

Viruses have been poised as being the number one candidates in possible environmental triggers. Some of the viruses that may play a role include HIV, HTLV-1, human hepersvirus 6, Epstein-Barr virus, cytomegalovirus, and hepatitis C virus [3].

Epidemiology

Sjogren's syndrome is ranked as the second most common rheumatologic disorder behind systemic lupus erythematosus. The disorder affects about 0.1% to 4% of the population in the United States. The wide range reflects the lack of a standard diagnosis method [2].

Globally, the disease has shown to remain homogenous among various ethnic groups and environments. The majority of cases occur in individuals above 40 years of age and mainly women are affected [1].

Sex distribution
Age distribution

Pathophysiology

Sjogren's syndrome is a chronic inflammatory disorder characterized by salivary insufficiency and lymphocytic infiltrates in exocrine organs. Even though the mechanism of its pathology has been studied since the discovery, the roles of different populations of immune cells in the pathogenesis remain inconclusive [4] [5].

Prevention

There are no guidelines for prevention of Sjogren's syndrome.

Summary

Sjogren's syndrome is a chronic inflammatory disorder marked by salivary insufficiency and lymphocytic infiltrates in exocrine organs. It is a relatively common disease, although often under-diagnosed.

In 1933, Dr. Henrik Sjögren published an article describing a group of women in a small Swedish town presenting with keratoconjunctivitis, lymphoid infiltrations of the conjunctiva, cornea, lacrimal glands, and parotid glands, a history of arthritis, swelling of the salivary glands, and dryness of the oronasopharynx. Two years later the observation was connected with Mikulicz’s disease and together formed the basis for this syndrome. In 1936, Duke Elder honored Sjögren by naming the disease Sjogren’s syndrome.

The disorder can occur either primary or secondary. Secondary Sjogren's syndrome appears several years after other associated disorders such as scleroderma, rheumatoid arthritis, and primary billiary cirrhosis.

Sjogren's syndrome is common among women above the age of 40 years. The female-to-male ratio is 9:1. There are no geographical differences in the prevalence of Sjogren's syndrome [1].

The disorder is complicated by the fact that there is no sufficiently sensitive or specific test in the diagnosis of Sjogren's syndrome. Moreover, so far there is no known cure for the disease. Symptomatic treatments control the severity of the symptoms associated with the disease.

Patient Information

Once diagnosed with Sjogren's syndrome, the main challenge is not having the disorder, but not knowing what to do next to live positively with it. The good news is that Sjogren’s syndrome does not have to impede your normal lifestyle.

Several remedies are used to treat Sjogren’s syndrome effects. Artificial tears are effective in remedying against dry eye. Tears in normal eyes are drained through tear ducts. Through surgery, these ducts can be sealed with small plugs. Therefore, the little tears formed in the eyes are not drained hence stay for longer. The process is known as punctual occlusion and it is recommended only after the other possible alternatives have failed.

Possible treatments for dry mouth:

  • Consumption of more liquid
  • Suckling of ice cubes that keeps the mouth moist and lubricated
  • Regular rising of the mouth to protect against infections as well as sooth the mouth
  • Maintenance of good oral hygiene to prevent tooth decay and gum diseases
  • Stop smoking for those who smoke as smoking evaporates the mouth as well as causes an irritation
  • Chewing of sugar free gums which stimulates the production of saliva
  • Use of saliva substitutes

Vaginal dryness can be treated with lubricants, hormone replacement therapy, and estrogen creams. Joint and muscle aching can be relieved with non-steroidal anti-inflammation drugs. Systemic corticosteroids or immunosuppressive agents have been used for various extraglandular symptoms, such as vasculitis, lung involvement and kidney involvement.

References

Article

  1. Mavragani CP, Moutsopoulos HM. The geoepidemiology of Sjogren's syndrome. Autoimmunity Reviews 9 2010, A305-A310
  2. Helmick CG, Felson DT, Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. Jan 2008;58(1):15-25.
  3. Jonsson R, Vogelsang P, Volchenkov R, Espinosa A. The complexity of Sjogren's syndrome: Novel aspects on pathogenesis. Immunol. Lett. 141 2011, 1; 1-9; 9
  4. Voulgarelis M, Tzioufas AG. Pathogenetic mechanisms in the initiation and perpetuation of Sjogren's syndrome. Nature Reviews Rheumatology 6 2010, 529-537.
  5. Nocturne G, Mariette X. Advances in understanding the pathogenesis of primary Sjögren's syndrome. Nature Reviews Rheumatology 9 2013, 544-556.
  6. Tzioufas AG, Voulgarelis M. Update on Sjögren's syndrome autoimmune epithelitis: from classification to increased neoplasias. Best Pract Res Clin Rheumatol. Dec 2007;21(6):989-1010.
  7. Montaño-Loza AJ, Crispín-Acuña JC, Remes-Troche JM, Uribe M. Abnormal hepatic biochemistries and clinical liver disease in patients with primary Sjögren's syndrome. Ann Hepatol. Jul-Sep 2007;6(3):150-5.
  8. Daniels TE. Labial salivary gland biopsy in Sjögren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases. Arthritis Rheum. Feb 1984;27(2):147-56.
  9. García-Carrasco M, Ramos-Casals M, Rosas J, et al. Primary Sjögren syndrome: clinical and immunologic disease patterns in a cohort of 400 patients. Medicine (Baltimore). Jul 2002;81(4):270-80.

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Last updated: 2018-06-22 07:21