Sjogren Syndrome - Musculoskeletal Manifestations

Dry eyes and dry mouth - sicca - with a symmetric small-joint arthralgia suggests Sjogren syndrome, a chronic autoimmune exocrinopathy caused by lymphocytic infiltration of the lacrimal and salivary glands, which can be primary, occurring alone, or secondary, accompanying another connective-tissue disease such as rheumatoid arthritis or lupus. Musculoskeletal involvement is among the commonest extraglandular features: arthralgia is very common and there is often an inflammatory arthritis in a rheumatoid-like symmetric small-joint distribution. The key difference from rheumatoid arthritis is that the Sjogren arthritis is usually non-erosive - it does not cause the same destructive joint damage - and it is defined by anti-Ro, or SSA, and anti-La, or SSB, antibodies rather than anti-CCP, with the prominent sicca pointing to the diagnosis. I would confirm with serology, including ANA, rheumatoid factor and IgG, and assess gland involvement. I would also keep in mind the most serious complication, an increased risk of B-cell, MALT, lymphoma, so persistent salivary-gland swelling or new lymphadenopathy must be investigated. Management is symptomatic for the sicca, and for the inflammatory musculoskeletal disease I would use NSAIDs and hydroxychloroquine, with other DMARDs or immunosuppression for significant systemic involvement, coordinated with rheumatology. From an orthopaedic standpoint, the main point is to recognise Sjogren as the systemic disease behind a seropositive, usually non-erosive arthritis.