Eosinophilic sialodochitis: redefinition of 'allergic parotitis' and 'sialodochitis fibrinosa'.

Sialodochitis fibrinosa and allergic parotitis have described rare patients with recurrent salivary gland swelling and mucus plugs, often with atopy. We have evaluated three patients with atopic disease, recurrent salivary gland swelling, and an eosinophilic sialodochitis. Two had eosinophil-rich mucus plugs. Fifty-six additional cases were identified in a medical literature database search, each defined by recurrent salivary gland swelling associated with eosinophil-rich mucus plugs or sialodochitis with periductal eosinophilic infiltration. The majority (78%) were reported from Japan. Females were predominantly affected (F:M = 2.3) with a median age of 47 years at evaluation. The parotid and submandibular glands were involved, respectively, in 71% and 46%. Allergic symptoms were present in 66%, atopic disease in 63% of those with reported allergy testing, and blood eosinophilia in 71%. Contrast sialography and other imaging modalities documented ductal dilatation in 82%. Treatments included anti-allergic medications (58%), systemic glucocorticoids (25%), duct cannulation with irrigation, steroid injection, and/or duct dilatation (36%), and glandular resection (19%). We recommend the diagnosis 'eosinophilic sialodochitis' be applied to patients who meet this case definition. The disease is a unique cause of chronic recurrent salivary gland swelling. Its likely allergic etiology may be amenable to current or future biologic therapies.

HCV Infection Alters Salivary Gland Histology and Saliva Composition.

Hepatitis C virus (HCV) infection is the most common blood-borne chronic infection in the United States. Chronic lymphocytic sialadenitis and sicca syndrome have been reported in chronic HCV infection. Up to 55% of these patients may have xerostomia; the mechanisms of the xerostomia and salivary gland (SG) hypofunction remain controversial. The objectives of this project are to establish if xerostomia associates with SG and HCV infection and to characterize the structural changes in SG and saliva composition. Eighteen HCV-infected patients with xerostomia were evaluated for SG dysfunction; 6 of these patients (patients 1-6) were further evaluated for SG histopathological changes and changes in saliva composition. The techniques used include clinical and laboratory assessment, SG ultrasonography, histological evaluation, sialochemical and proteomics analysis, and RNA in situ hybridization. All the HCV patients had low saliva flow, chronic sialadenitis, and SG fibrosis and lacked Sjögren syndrome (SS) characteristic autoantibodies. Further evaluation of a subgroup of 6 HCV patients (patients 1-6) demonstrated diffuse lymphocytic infiltrates that are predominantly CD8+ T cells with a significant increase in the number of inflammatory cells. Alcian Blue/periodic acid-Schiff staining showed significant changes in the ratio and intensity of the acinar secretory units of the HCV patients' minor SG. The submandibular glands showed significant ultrasonographic abnormalities in the parenchyma relative to the parotid glands. Significant changes were also observed in the concentration of sodium and mucin 5b. Although no significant correlation was observed between the lymphocytic infiltrates and the years of HCV chronic infection, a positive correlation was observed between HCV RNA-positive epithelial cells and the years of HCV infection. Consistent with the low saliva flow and xerostomia, patients showed changes in several markers of SG acinar and ductal function. Changes in the composition of the saliva suggest that HCV infection can cause xerostomia by mechanisms distinct from SS.

Relationship Between Neuromyelitis Optica Spectrum Disorder and Sjögren's Syndrome: Central Nervous System Extraglandular Disease or Unrelated, Co-Occurring Autoimmunity?

OBJECTIVE: Sjögren's syndrome (SS) patients may be affected by the neuromyelitis optica spectrum disorder (NMOSD), a severe demyelinating syndrome associated with anti-aquaporin 4 antibodies (anti-AQP-4 antibodies). The relationship between SS and NMOSD has been a sustained focus of investigation. Among SS patients, anti-AQP-4 antibodies have been detected exclusively in those with NMOSD. It has therefore been speculated that NMOSD is not a neurologic complication of SS. However, such studies evaluated small numbers of SS patients, often mixed with other inflammatory disorders. METHODS: We compared frequencies of anti-AQP-4 and SS-associated antibodies in 109 SS patients, including 11 with NMOSD, 8 with non-NMOSD demyelinating syndromes, and 90 without demyelinating syndromes. RESULTS: When assessed using a fluorescence-activated cell sorting (FACS) assay, anti-AQP-4 antibodies were seen exclusively in those SS patients with NMOSD (72.7%), but not in SS patients without NMOSD (P < 0.01). In contrast, anti-Ro 52, anti-Ro 60, and other autoantibodies were not more prevalent in SS patients with NMOSD versus those without. Anti-AQP-4 antibodies were detected more frequently among NMOSD patients by FACS assay than with a commercial immunohistochemical assay (72.7% versus 54.5%), despite assessment after a more prolonged period of immunosuppressive therapy (median 38 months versus 5 months; P < 0.01). CONCLUSION: The syndrome-specificity of anti-AQP-4 antibodies, along with an otherwise similar antibody profile in SS NMOSD patients, indicates that NMOSD is not a direct central nervous system manifestation of SS. Anti-AQP-4 antibodies can persist and be refractory to prolonged immunosuppressive therapy.

Stereospecificity of the hydroxyeicosatetraenoic and hydroxyoctadecadienoic acids produced by cultured bovine endothelial cells.

Characterization of the stereospecificity of the derivatives of arachidonic acid and linoleic acid produced by endothelial cells is needed to define the enzymatic origin of these compounds and their role in vascular physiology. In studies utilizing two bovine endothelial cell lines (CPAE and AG04762), both free 15-hydroxyeicosatetraenoic acid (15-HETE) and 11-hydroxyeicosatetraenoic acid (11-HETE) were generated during incubations with exogenous arachidonic acid and both free 9-hydroxyoctadecadienoic acid (9-HODE) and 13-hydroxyoctadecadienoic acid (13-HODE) were generated during incubations with exogenous linoleic acid. Esterification of 15-HETE, 9-HODE and 13-HODE during these incubations was demonstrated. The analyses included reversed-phase high performance liquid chromatography of the free acid and its methyl ester and chiral separation of the methyl ester on straight phase chiral columns. The ratio of 9-HODE/13-HODE averaged 2.7 in the chromatographic analyses of the extracts of the incubations with linoleic acid. The combined production of 13-HODE and 9-HODE from linoleic acid was four times greater than that of 15-HETE and 11-HETE from arachidonic acid. With regard to the products of the CPAE endothelial cell line, the S/R ratio of the stereoisomers averaged 1.5 for free 15-HETE, 5.7 for free 13-HODE and 0.2 for free 9-HODE. The 11-HETE had strict (R) stereospecificity. The products from the AG04762 endothelial cell line had similar stereochemistry. All these stereochemical findings point to the activity of a cyclooxygenase rather than that of a lipoxygenase.

Epidermal fatty acid oxygenases are activated in non-psoriatic dermatoses.

The extent of epidermal fatty acid oxygenase activation in non-psoriatic dermatoses and the nature of these oxygenases are not known. The monohydroxylated fatty acid derivatives produced in vivo and trapped in skin scales or produced in vitro by oxygenases preserved in scales were analyzed by high performance liquid chromatography in 10 patients with non-psoriatic dermatoses. Evidence for 15-lipoxygenase activation included the finding of 15(S)-hydroxyeicosatetraenoic acid (HETE) in scales from seven patients and the production of 15(S)-[14C]HETE and 13(S)-[14C]hydroxyoctadecadienoic acid (HODE) during scale incubations, respectively, with [14C]arachidonic and [14C]linoleic acid. Evidence for the activation of an arachidonic acid 12(R)-oxygenase included the finding of 12(R)-HETE in scales from eight patients and the production of 12(R)-[14C]HETE during scale incubations with [14C]arachidonic acid. 13-HODE was the predominant fatty acid derivative present in scale extracts; its lack of enantiopurity (mean S/R = 3.1) and the substantial formation of 9-HODE (mean S/R = 0.6; 9/13-HODE = 0.43) suggest its derivation from 15-lipoxygenase and a second oxygenase. The levels of 15(S)-HETE and 12(R)-HETE had a 125- to 144-fold range and were highest in scales from a patient with erythroderma and in three psoriatic scale samples similarly analyzed. These findings indicate that 15-lipoxygenase, most likely of keratinocyte origin, and an arachidonic acid 12(R)oxygenase of unknown type and cell origin are activated in diverse dermatoses.

Hypocomplementemic urticarial vasculitis syndrome. Clinical and serologic findings in 18 patients.

We identify and describe clinical findings in hypocomplementemic urticarial vasculitis syndrome (HUVS), an uncommon to rare illness related to systemic lupus erythematosus (SLE). A patient with recurrent, idiopathic urticaria-like lesions was diagnosed as having HUVS if a lesional biopsy showed leukocytoclastic vasculitis, the serum C1q was markedly decreased, and antibody to C1q was detected in the patient's serum. The clinical characteristics, serologic findings, and outcome of patients who met these criteria were determined from prospective and retrospective data, including hospital and office records, patient interviews, previously banked serum samples, and freshly drawn sera. Eighteen patients with HUVS were identified, and high incidences of angioedema, ocular inflammation, glomerulonephritis, and obstructive pulmonary disease were found. Renal and lung biopsies showed mesangial or membranoproliferative glomerulonephritis and severe pulmonary emphysema without vasculitis. Pulmonary function was measured in 17 patients, 11 of whom had dyspnea. All dyspneic patients had moderate to severe airflow obstruction, which progressed in all 11 and subsequently improved in only 1. Six of these 11 patients died of respiratory failure, 1 underwent lung transplantation, and 3 of the remaining 4 have moderately severe to life-threatening respiratory insufficiency. Treatment did not appear to alter the progression of obstructive lung disease. In contrast, renal insufficiency improved with treatment in 2 of 2 patients. Angioedema, ocular inflammation, obstructive lung disease, and glomerulonephritis appear to be common in HUVS, and lung disease causes substantial morbidity and mortality. The pathogenesis of HUVS may involve humoral autoimmunity, although it is not clear how autoimmunity would participate in development of obstructive lung disease. Cigarette smoking appears to be a risk factor for fatal lung disease in HUVS. All patients with HUVS should be made aware of this possibility and should be advised, encouraged, and helped to avoid tobacco smoke.

Left ventricular dysfunction induced by cold exposure in patients with systemic sclerosis.

Raynaud's phenomenon and cardiac abnormalities are frequent in patients with systemic sclerosis. Radionuclide ventriculograms were obtained in 16 patients with Raynaud's phenomenon and systemic sclerosis or the related CREST syndrome and in 11 normal volunteers in order to evaluate changes in left ventricular function that might be induced by exposure to cold. Left ventricular regional wall motion abnormalities developed in nine of 16 patients during cooling compared with only one of 11 control subjects, despite a comparable rise in mean arterial pressure (p less than 0.02). The abnormalities occurred in seven of 11 patients with systemic sclerosis, one of four with CREST syndrome, and one with Raynaud's disease. To test the potential protective effect of nifedipine, radionuclide ventriculograms were then obtained during cooling after sublingual nifedipine (20 mg). Only five of 13 patients had wall motion abnormalities, and the severity of the abnormalities was significantly less than during the first cooling period (p = 0.03). Five of eight patients who had cold-induced wall motion abnormalities during the first cooling period had none after nifedipine, whereas two other patients demonstrated small abnormalities only during the second cooling period after treatment with nifedipine. It is concluded that cold induces segmental myocardial dysfunction in patients with systemic sclerosis and that nifedipine may blunt the severity of this abnormal response.

The pathogenesis of anemia in rheumatoid arthritis: a clinical and laboratory analysis.

Principal concepts concerning the anemia of RA are summarized in Tables 7 and 8. These concepts have been validated by our analysis of 93 anemic RA patients and by our review of the literature. The fact that anemia in RA may have one or more etiologies, occasionally in the same patient, mandates a reasoned approach to the analysis of anemia in every RA patient in whom it may occur. In particular, iron deficiency is common and determination of bone marrow iron content via an aspirate may be required for a definitive diagnosis. In those RA patients with anemia of chronic disease, the best therapy remains control of the underlying disease, most commonly with second line drugs and/or corticosteroids. The place for recombinant erythropoietin in the therapy of this anemia has not been defined; one specific role for erythropoietin may be in the preparation of RA patients for elective surgery, particularly hip arthroplasty, where correction of the anemia may either obviate the need for transfusion or may allow for donation of blood for purposes of autologous transfusion perioperatively. The pathogenesis of the anemia of chronic disease, as seen in RA anemia, is not completely understood. Inflammatory mediators, particularly the cytokines, appear to be important factors in the impairment of erythropoiesis. The mechanism by which these cytokines impair erythroid progenitor growth and hemoglobin production in developing erythrocytes is an important area for future study.

Acute myeloid leukemia in the setting of low dose weekly methotrexate therapy for rheumatoid arthritis.

Methotrexate is in widespread use as second-line therapy for rheumatoid arthritis. Treatment with methotrexate in this and other settings has not been associated with the development of therapy-related leukemias. Four patients with rheumatoid arthritis are reported who developed acute myeloid leukemia (AML) while receiving low dose weekly methotrexate therapy in the absence of previous or concomitant treatment with known leukemogenic agents. AML in these four patients was of different morphologic subtypes and was associated with heterogeneous cytogenetic abnormalities, cell surface marker expression and multidrug resistance protein expression. None of the recognized features of therapy-related leukemia were present in these four nor in five previously-reported patients. It is likely that the occurrence of AML in patients with rheumatoid arthritis in the setting of methotrexate therapy represents the coincidence of these two diseases, and does not reflect a causal relationship.

Saturability of esterification pathways of major monohydroxyeicosatetraenoic acids in rat basophilic leukemia cells.

The principal monohydroxyeicosatetraenoic acids (HETEs), 5-, 12-, and 15-HETE, which can be produced by rat basophilic leukemia (RBL-1) cells, are also esterified by these cells. Exogenously added 5-, 12-, and 15-HETE were rapidly incorporated as esters in RBL cells, reaching plateau levels within 25 min. In incubations in culture medium with protein added, all three HETEs were essentially completely metabolized within 24 h. 5-HETE was esterified more rapidly and to a greater extent than 12-HETE or 15-HETE when these were incubated together with RBL cells, indicating some degree of selectivity in the esterification pathways. When arachidonic acid (AA) was incubated in increasing concentrations with constant concentrations of 15-HETE and RBL cells, the free 15-HETE concentration increased and esterified 15-HETE concentration decreased markedly at AA: 15-HETE molar ratios above 9. 15-HETE esterification in RBL cells was also markedly inhibited by the polyunsaturated fatty acids, eicosatetraynoic and eicosapentanoic acids, but not by oleic or linoleic acids. In separate experiments with unlabeled and radiolabeled substrates, the extent of incorporation of esterified HETE in RBL cells decreased at higher concentrations of 15-HETE and AA, which showed that the pathway was saturable. The shapes of the curves for these fatty acid inhibitors suggest a concentration-dependent two-compartment pathway of esterification. These data indicate that the HETEs and other 20 carbon fatty acid substrates probably compete for activity of a specific arachidonyl-CoA synthetase, which is the first and rate-limiting step for esterification of arachidonic acid by many human cells. Esterified 15-HETE was found to be predominantly in the phosphatidylethanolamine fraction of RBL cell lipids.

Reversible posterior leukoencephalopathy syndrome in systemic lupus erythematosus.

Reversible posterior leukoencephalopathy syndrome (RPLS) is an acute form of cerebrovascular injury that has been described recently in the setting of uncontrolled hypertension, puerperal eclampsia, or treatment with certain immunosuppressive drugs, including cyclosporine. It is reversible if treated promptly. Two patients with systemic lupus erythematosus (SLE), renal failure, and uncontrolled hypertension developed acute cerebrovascular symptoms; one had seizures and the other had headache and blurred vision. Both patients showed abnormal predominantly posterior lobe findings on neuroimaging films. The patients' symptoms and imaging abnormalities resolved completely with prompt correction of their hypertension and concomitant treatment with corticosteroids. RPLS should be recognized in SLE patients with uncontrolled hypertension and renal failure who present with headaches, seizures, cortical blindness, and other visual abnormalities. Prompt treatment with control of hypertension and withdrawal of precipitating drugs may be most important and can prevent permanent neurologic damage.

American College of Rheumatology classification criteria for Sjögren's syndrome: a data-driven, expert consensus approach in the Sjögren's International Collaborative Clinical Alliance cohort.

OBJECTIVE: We propose new classification criteria for Sjögren's syndrome (SS), which are needed considering the emergence of biologic agents as potential treatments and their associated comorbidity. These criteria target individuals with signs/symptoms suggestive of SS. METHODS: Criteria are based on expert opinion elicited using the nominal group technique and analyses of data from the Sjögren's International Collaborative Clinical Alliance. Preliminary criteria validation included comparisons with classifications based on the American­European Consensus Group (AECG) criteria, a model-based "gold standard"obtained from latent class analysis (LCA) of data from a range of diagnostic tests, and a comparison with cases and controls collected from sources external to the population used for criteria development. RESULTS: Validation results indicate high levels of sensitivity and specificity for the criteria. Case definition requires at least 2 of the following 3: 1) positive serum anti-SSA and/or anti-SSB or (positive rheumatoid factor and antinuclear antibody titer >1:320), 2) ocular staining score >3, or 3) presence of focal lymphocytic sialadenitis with a focus score >1 focus/4 mm2 in labial salivary gland biopsy samples. Observed agreement with the AECG criteria is high when these are applied using all objective tests. However, AECG classification based on allowable substitutions of symptoms for objective tests results in poor agreement with the proposed and LCA-derived classifications. CONCLUSION: These classification criteria developed from registry data collected using standardized measures are based on objective tests. Validation indicates improved classification performance relative to existing alternatives, making them more suitable for application in situations where misclassification may present health risks.

Occult systemic lupus erythematosus in elderly men.

Systemic lupus erythematosus (SLE) is often not suspected in elderly men with a debilitating illness, particularly when pleuropericarditis is not prominent. Five elderly men with SLE were initially seen with a systemic illness, marked by fever, weight loss, and arthritis. The diagnosis of SLE was established after considerable delay with extensive diagnostic evaluations and was supported by the presence of DNA antibodies in four patients. Treatment with corticosteroids was effective in three patients. Early testing for DNA antibodies may be cost effective in the evaluation of the elderly patient with a debilitating illness.

Lipid laden macrophages in synovial fluid: a late finding in traumatic arthritis.

A 66-year-old man presented with arthritis of the right knee of 3 months' duration. Cytologic examination of synovial fluid (SF) showed numerous lipid laden macrophages. Radiographs and a nuclear scintigram established the presence of a fracture of the lateral tibial plateau. The diagnostic significance of lipid laden macrophages in SF is reviewed.

Staphylococcal infection of the subacromial/subdeltoid bursa.

A patient with a Staphylococcus aureus infection of the subacromial/subdeltoid bursa is described. Instillation of radiocontrast dye into the purulent cavity provided evidence that the infection was localized to the subacromial/subdeltoid bursa. The use of bursography/arthrography to define the site and extent of shoulder infections may help to determine the optimal duration of antibiotic therapy and the prognosis for cartilage and/or bone destruction.

Cyclooxygenase activity of cultured human mesothelial cells.

The fatty acid oxygenase activity of mesothelial cells and its role in inflammatory and neoplastic diseases of the mesothelium have not been defined. Techniques permitting in vitro cultivation of human mesothelial cells shed into serous cavities have permitted analysis of their specific metabolic capacities. The principal products of incubations of cultured human mesothelial cells with polyunsaturated fatty acids were analyzed using high performance liquid chromatography on reversed-, straight-, and chiral-phase columns and gas-liquid chromatography/mass spectrometry. The products included 6-keto-PGF1 alpha, 15-hydroxyeicosatetraenoic acid (S/R = 3.5), 11-hydroxyeicosatetraenoic acid, and 12-hydroxyheptadecatrienoic acid from arachidonic acid; 9- and 13-hydroxyoctadecadienoic acids (molar ratio of 9/13-hydroxyoctadecadienoic acids = 3.5, S/R ratios = 0.3 and 2.8, respectively) from linoleic acid; and 12-hydroxyheptadecadienoic acid from homo-gamma-linolenic acid. These products are indicative of a cyclooxygenase whose activation in vivo may play a significant role in serosal cavity pathology.

Cytochrome P-450 mediated metabolism in active murine systemic lupus erythematosus.

In a comparison of NZB/NZW female mice either with active systemic lupus erythematosus (SLE) (28-33 weeks of age) or without overt SLE (7-13 weeks), the hepatic microsomal activities of ethoxycoumarin O-deethylation and aminopyrine N-demethylation were decreased 32% (p less than 0.05) and 28% (p less than 0.03), respectively, and cytochrome P-450 levels were decreased 34% (p less than 0.01) in the mice with active SLE. These changes were not associated with age differences alone in 2 nonautoimmune strains. Active murine SLE is thus associated with significant depressions in both hepatic cytochrome P-450 levels and microsomal enzyme activities. The metabolism of drugs and endogenous substrates may thus be impaired in active SLE.

Estrogen metabolism in the (New Zealand black x New Zealand white)F1 murine model of systemic lupus erythematosus.

Hepatic microsomal estrogen metabolism was analyzed in the (New Zealand black x New Zealand white)F1 ([NZB x NZW]F1) murine model of systemic lupus erythematosus. Both the estrogen 2-hydroxylase activity (per mg microsomal protein) and the hepatic cytochrome P-450 content were higher in premorbid (NZB x NZW)F1 mice, as compared with similarly aged nonautoimmune mice. However, these differences were not associated with alterations in the relative formation of the 2-hydroxylated and the 16 alpha-hydroxylated metabolites. The development of overt nephritis was associated with a decrease in estrogen metabolic activity, but not with any alteration in the distribution of estrogen metabolites. Thus, estrogen metabolism was not altered in premorbid (NZB x NZW)F1 mice in a manner that would result in abnormal retention of hormonally active metabolites.

Fatty acid oxygenase activity of human hair roots.

The extent to which fatty acid oxygenases are activated in the normal epidermis is not known. Characterization of the regio- and stereospecificity of the monohydroxylated derivatives of arachidonic and linoleic acid produced by human hair roots is needed to define the enzymatic origin of these compounds and to define a possible role for fatty acid oxygenases in growth, differentiation, and pathology of human hair. Hair roots epilated from normal human volunteers were incubated with radiolabeled arachidonic acid or linoleic acid and the monohydroxylated derivatives produced in vitro were characterized. Incubation of hair roots with 14C]arachidonic acid resulted in the production of 15(S)-[14C]hydroxyeicosatetraenoic acid and 12(S,R)-[14C]hydroxyeicosatetraenoic acid (mean S/R ratio, 2.5). 13(S)-[14C]hydroxyoctadecadienoic acid was the principal product of incubations with [14C]linoleic acid. No radiolabeled products were derived from incubations with heat-denatured hair roots. The fatty acid oxygenase activity of anagen hair roots was inhibited by nordihydroguaiaretic acid and was greatest in the hair root bulb. The strict S-stereospecificity and the regiospecificity of the n-6 oxygenase are strong evidence for the presence of a 15-lipoxygenase in human hair roots, similar to that identified in cultured human keratinocytes. The stereospecificity of the 12-HETE produced by human hair roots is not compatible with the sole action of 12-lipoxygenase.

Free and esterified 13(R,S)-hydroxyoctadecadienoic acids: principal oxygenase products in psoriatic skin scales.

Characterization of the chemical form and stereo-specificity of the fatty acid derivatives of arachidonic and linoleic acid in psoriatic epidermis is needed to define the enzymatic origin of these compounds and their possible role in pathogenesis. In an analysis of psoriatic skin scales, both free and esterified 13-hydroxyoctadecadienoic acids were the principal fatty acid derivatives, present in mean concentrations of 115 and 17 ng/mg scales, respectively. The analysis included reversed-phase high performance liquid chromatography of the free acid and of its methyl ester, gas chromatography, gas-liquid chromatography-mass spectrometry of the methyl ester derivatives, and chiral separation. The free and esterified 13-hydroxyoctadecadienoic acids isolated from the psoriatic scales contained a mixture of the S/R stereoisomers, averaging 1.9:1 for free 13- hydroxyoctadecadienoic acid. These findings are not compatible with the strict S-stereospecificity for oxygen insertion exhibited by mammalian lipoxygenase but rather could point to the action of a cyclooxygenase. The demonstration that a hydroxylated fatty acid derivative is esterified in vivo in psoriatic keratinocytes suggests that the physiology of these cells may be altered early in the process of keratinization.