Sjögren syndrome (SS) is a common autoimmune disease evidenced by broad organ-specific and systemic manifestations, the most prevalent being diminished lacrimal and salivary gland function, xerostomia, keratoconjunctivitis sicca, and parotid gland enlargement. Primary SS presents alone, and secondary SS occurs in connection with autoimmune rheumatic diseases. In addition, symptoms do not always present concurrently. This diversity of symptomatic expression adds to the difficulty in initial diagnosis. Armed with the recently refined criteria for diagnosis, specialists, such as rheumatologists, primary care physicians, ophthalmologists, and dentists, who would otherwise focus only on those symptoms that encompass their areas of expertise, can get a comprehensive image of the presenting patient, leading to earlier identification and treatment of SS.

The risk of cancer was ascertained in 136 women with sicca syndrome followed at the National Institutes of Health (NIH). Seven patients developed non-Hodgkin's lymphoma from 6 months to 13 years after their first admission to NIH. This was 43.8 times (P less than 0.01) the incidence expected from the rates of cancer prevailing among women of the same age range in the general population during this time. In addition, three cases of Waldenström's macroglobulinemia occurred in this study group. Eight patients developed cancers other than lymphoma, similar to the number expected based on the rates prevailing in the general population. Patients with a history of parotid enlargement, splenomegaly, and lymphadenopahy had an increased risk of lymphoma. These clinical conditions did not appear to be early manifestations of undiagnosed lymphoma but rather seemed to identify a subgroup of patients with sicca syndrome with marked lymphoid reactivity, who had a particularly high risk of subsequently developing lymphoma.

Key recommendations include a decision tree for the use of oral disease-modifying antirheumatic drugs for inflammatory musculoskeletal pain, use of self-care measures and advice regarding exercise to reduce fatigue, and the use of rituximab in selected clinical settings for oral and ocular dryness and for certain extraglandular manifestations, including vasculitis, severe parotid swelling, inflammatory arthritis, pulmonary disease, and mononeuritis multiplex. The CPG committee strongly discouraged the use of tumor necrosis factor inhibitors for sicca symptoms and for the majority of clinical contexts in primary Sjögren's syndrome.

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Ha, a soluble nuclear protein, was purified from calf thymus nuclear extract by successive application of fractional ammonium sulfate precipitation (60 to 80% saturation), DEAE-Sephadex chromatography (eluted between 0.26 and 0.38 M NaCl in 0.05 M Tris HCl buffer, pH 7.2), and affinity chromatography utilizing an immunoabsorbent column of Sepharose coupled to IgG from a patient with a high titer of antibody to Ha. The Ha antigen could be iodinated by the method of Bolton and Hunter but not by the chloramine-T or lactoperoxidase methods indicating the absence of tyrosine and histidine. The iodinated material was passed through a Sephadex G-100 column to remove minor contaminants. The final product migrated as a single band in polyacrylamide gel electrophoresis. The 125I-Ha antigen was utilized to measure specific antibody by the ammonium sulfate method. Elevated serum-binding capacity was observed in 73% of patients with sicca syndrome in the absence of another connective tissue disease and 85% of patients with sicca syndrome associated with systemic lupus erythematosus. It was infrequent in sicca syndrome associated with rheumatoid arthritis (6%) and in systemic lupus erythematosus without sicca syndrome (3%). Anti-Ha antibodies were not found in patients with other connective tissue diseases or normal controls. Antibody to Ha characterizes a subset of patients with sicca syndrome.

The in vitro antibody-forming cell response of mouse spleen cells to the thymic independent synthetic polymer, TNP-Ficoll, was found to require the presence of either macrophages or 2-mercaptoethanol. The TNP-Ficoll response and that to the thymic dependent antigen, sheep erythrocytes, demonstrated the same degree of macrophage dependence. However, macrophage-depleted spleen cells which did not produce plaque-forming cells responded normally to T and B cell mitogens. Comparison of the antibody-forming cell response of macrophage-depleted spleen cells in the presence and absence of 2-mercaptoethanol indicated that either macrophages function 10 to 100 times more efficiently in its presence or that 2-mercaptoethanol partially replaces the function of macrophages.

We have developed a highly specific and sensitive “two-site” immunoradiometric assay for murine IgM in which antigen bound to immobilized antibody reacts with affinity-purified radiolabeled antibody. We utilized the sensitivity of this assay to study the rate of IgM secretion in short-term cultures by spleen cells from the autoimmune strains, New Zealand Black (NZB) and New Zealand Black by New Zealand White F1 hybrid (BW), and from normal (C57BL/6, DBA/2, NZW) mice. The temperature dependence of IgM secretion in short-term cultures, its pentameric structure, and the similar viability of NZB and normal strain spleen cells indicate that active IgM synthesis is being measured. We observed that the splenic B lymphocytes of NZB and BW mice, in contrast to normal strains, produce IgM in vitro at birth. By 6 to 8 weeks of age NZB and BW spleen cells produce 40 times more IgM than spleen cells from normal strains of mice. The IgM produced in vitro by splenic lymphocytes from NZB and BW mice is not absorbed by syngeneic or allogeneic thymocytes or erythrocytes.