Update on Sjögren Syndrome and Other Causes of Sicca in Older Adults

Abstract

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypical disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Keywords: Aging; Dry eye; Salivary hypofunction; Sjögren syndrome; Xerostomia.

Fig. 1

Histopathology of minor labial salivary glands. The sections are from biopsies of a 28-year-old woman (A) and a 65-year-old woman (B), shown at the same magnification. Neither had Sjögren syndrome. (A) This histopathologic section shows normal tissue, with confluent mucous acini and normal-sized intralobular ducts. (B) In contrast, this section shows extensive acinar loss, interstitial fibrosis, ductal dilatation, and fatty replacement. These changes are often seen to varying degrees in older patients (H&E stain, original magnification ×100).

Fig. 2

Imaging techniques in Sjögren syndrome. This patient has bilateral symmetric parotid gland enlargement, seen best on the T2 fat-suppressed MR images (A). Note the multiple T2-hyperintense foci scattered throughout both glands, a characteristic finding. With ultrasonography (B), multiple hypoechoic rounded lesions with convex borders are noted throughout the glandular parenchyma. In normal parotid gland tissue, the parenchyma has a homogeneous appearance with ultrasonography.

Fig. 3

Focal lymphocytic sialadenitis. This section of a labial minor salivary gland biopsy shows the typical features of focal lymphocytic sialadenitis. Note the tightly aggregated lymphocytes surrounding ducts and adjacent to normal-appearing mucous acini. At least 3 foci are evident (H&E stain, original magnification ×100).

Fig. 4

Potential misinterpretation of labial gland biopsies. (A) The lymphocytic focus is typical of that seen in focal lymphocytic sialadenitis, being centered on a duct and adjacent to normal-appearing mucus-secreting acini. (B) In contrast, the lymphocytic focus here is present within a gland lobule marked by interstitial fibrosis, ductal dilatation, and marked acinar loss. This focus should not be interpreted as representative of Sjögren syndrome (H&E stain, original magnification ×100).