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Autonomic Nervous System Dysfunction Involving the Gastrointestinal and the Urinary Tracts in Primary Sjögren’S Syndrome

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Autonomic Nervous System Dysfunction Involving the Gastrointestinal and the Urinary Tracts in Primary Sjögren’S Syndrome Autonomic nervous system dysfunction involving the gastrointestinal and the urinary tracts in primary Sjögren’s syndrome L. Kovács1, M. Papós2, R. Takács3, R. Róka2, Z. Csenke4, A. Kovács1, T. Várkonyi3, L. Pajor5, L. Pávics2, G. Pokorny1 Department of Rheumatology1, Department of Nuclear Medicine2, 1st Department of Internal Medicine3 and Department of Urology5, University of Szeged, Faculty of Medicine, Szeged; Division of Urology, Municipial Clinic, Szeged, Hungary4 Abstract Objective Antibodies reacting with the m3 subtype muscarinic acetylcholine receptor appear to be an important patho- genic factor in primary Sjögren’s syndrome (pSS). As this receptor subtype is functionally important in the gastrointestinal and urinary tracts, and very little is known about the autonomic nervous system function in these organs in pSS patients, the occurrence and clinical significance of an autonomic nervous system dysfunction involving the gastrointestinal and urinary tracts were investigated. Methods Data on clinical symptoms attributable to an autonomic dysfunction were collected from 51 pSS patients. Gastric emptying scintigraphy and urodynamic studies were performed on 30 and 16 patients, respectively, and the results were correlated with patient characteristics and with the presence of autonomic nervous system symptoms. Results Gastric emptying was abnormally slow in 21 of the 30 examined patients (70%). Urodynamic findings compatible with a decreased detrusor muscle tone or contractility were found in 9 of the 16 patients tested (56%). Various symptoms of an autonomic nervous system dysfunction were reported by 2-16% of the patients. Conclusion Signs of an autonomic nervous system dysfunction involving the gastrointestinal and the urinary systems can be observed in the majority of pSS patients. This high occurrence is rarely associated with clinically significant symptoms. The authors presume a role of autoantibodies reacting with the m3 muscarinic acetylcholine receptor in the elicitation of the autonomic dysfunction. Key words Primary Sjögren’s syndrome, anti-muscarinic acetylcholine receptor antibodies, gastric emptying scintigraphy, urodynamic studies, autonomic dysfunction. Clinical and Experimental Rheumatology 2003; 21: 697-703. Autonomic dysfunction in Sjögren’s syndrome / L. Kovács et al. László Kovács, Assistant Professor; Introduction autonomic dysfunction can be detected Miklós Papós, Associate Professor; Primary Sjögren’s syndrome (pSS) is a in the GI and the urinary tracts. Róbert Takács, Resident; Richárd Róka, systemic autoimmune disease charac- Resident; Zoltán Csenke, Head Physician; terised by a lymphocytic infiltration Patients and methods Attila Kovács, Assistant Professor; Tamás Várkonyi, Assis-tant Professor; and a subsequent functional impair- Study patients László Pajor, Professor; László Pávics, ment of various exocrine glands. There From among the cohort of pSS patients Professor; Gyula Pokorny, Professor. is increasing evidence that, in addition followed up at the Department of The work was supported by National to the structural damage to the involved Rheumatology at the University of Scientific Research Fund of Hungary grant glands caused by a lymphocytic infil- Szeged, all those who did not have dia- OTKA038303 and Health Care Scientific tration, decreased stimulation by the betes mellitus, chronic renal failure or Council of the Ministry of Health Care of autonomic nervous system of the glands any other disease that may cause an Hungary grant ETT214/2001 plays an important role in the elicita- autonomic neuropathy, and who were Please address correspondence to: tion of the exocrine dysfunction (1). We younger than 75 years, were asked to László Kovács, MD, Department of have found that pSS patients demon- complete a questionnaire relating to Rheumatology, Faculty of Medicine, strate an impaired microvascular re- symptoms which may potentially be University of Szeged, Kossuth Lsgt. 42, 6724 Szeged, Hungary. sponse to cholinergic stimuli as com- caused by an autonomic dysfunction. E-mail: [email protected] pared with healthy individuals (2). The Fifty-one patients (48 women) satisfied Received on February 10, 2003; accepted presence of antibodies reacting with th e the above-mentioned criteria (average in revised form on July 1, 2003. rodent and human muscarinic acetyl- age: 53 [range 31-71] years, and aver- © Copyright CLINICAL AND EXPERIMEN- choline receptor subtype 3 (m3AchR), age time since the appearance of the TAL RHEUMATOLOGY 2003. the predominant receptor subtype in first symptom of pSS: 14 [range 2-31] the lachrymal and salivary glands, has years). An answer was considered posi- been demonstrated in pSS patients (3- tive when no other medical condition 5). potentially attributable to the elicitation The m3AchR is also the functionally of the symptom was present in the dominant acetylcholine-receptor in the given patient. All of them fulfilled the gastrointestinal (GI) and the genito-uri- American-European classification cri- nary (GU) tracts (6,7), where it medi- teria for pSS (16). For the clinical tests, ates contraction of the parietal smooth further exclusion criteria were defined, muscles and relaxation of the sphincter as discussed later; the numbers of muscles (7). An impairment of these patients participating in the individual mechanisms, most commonly as a con- clinical examinations was therefore sequence of an autonomic neuropathy, smaller. The protocol was accepted by leads to significant morbidity as evi- the Medical Ethics Committee of the denced in patients with diabetes melli- University of Szeged. tus (8). Although a cardiovascular auto- nomic neuropathy has been described Examination of gastric emptying in pSS (9-15), data are scarce or lack- The gastrointestinal autonomic nervous ing as concerns autonomic neuropathy function was examined by assessment involving other organs, including the of the gastric motility with gastric emp- GI and the GU tracts. tying scintigraphy. The examination With regard to the emerging impor- was performed in the morning after an tance of anti-m3AchR autoantibodies overnight fast. The patients ingested a in pSS, and the fact that very little is radiolabelled meal (2 hard-boiled eggs known about the autonomic function in labelled with 20 MBq 9 9 mTc - h u m a n the GI and the urinary systems in this serum albumin macroaggregate + one disease, we designed a clinical study bread roll and 200 ml water). A dynam- among pSS patients to examine the ic scintigraphic study was performed autonomic nervous system function in about the gastric region. Digital images these organ systems. We hypothesised were taken at a frequency of 1 minute/ that anti-m3AchR antibodies bind to frame for 2 hours. As a parameter of receptors not only located in the sali- gastric emptying, the emptying half- vary and the lachrymal glands, but also time (t1/ 2 ), i.e. the time until the radioac- in other organs where the m3AchR su b - tivity in the stomach had decreased to type predominates, and thereby cause an half the initial value, was determined. autonomic dysfunction. Our aim was to Two of the 51 patients had a condition attempt to clarify whether signs of an that may influence gastric emptying 698 Autonomic dysfunction in Sjögren’s syndrome / L. Kovács et al. (previous surgical polypectomy and Table I. The occurrences of the most important organ manifestations and serological para- pernicious anaemia, respectively), and meters in the 51 pSS patients enrolled in the study.A labial biopsy was performed in 35 of they were therefore considered ineligi- the 51 patients. ble for this examination. Of the remain- Organ involvement/laboratory abnormality No. (%) ing patients, 30 consecutive subjects (27 women) participated in this exami- Articular involvement* 42 (82) nation. The patients did not have any Raynaud’s phenomenon 20 (39) sign of an organic upper gastrointesti- Purpura 11 (22) nal disease; moreover, gastroscopic Renal involvement** 11 (22) examinations on 23 of the patients did Pulmonary fibrosis 3 (6) not reveal such abnormalities either. Non-Hodgkin’s lymphoma 3 (6) The use of prokinetics or other drugs Antinuclear antibody positivity 35 (69) which influence the autonomic nervous Anti-SSA 42 (82) system or smooth muscle contractility Anti-SSB 26 (51) was suspended at least 3 days before Minor salivary gland focus score ³ 1 30 (86) the examination. During the validation process for this procedure, the cut-off *Articular involvement: arthralgia not due to degenerative joint disease, or arthritis. **Renal involvement: renal tubular acidosis or biopsy-proven tubulointerstitial nephritis. value for an abnormal t1/2 was deter- mined as the average + 1 SD of the t1/ 2 values for 7 healthy individuals (6 and were excluded from the urodynam- The correlation of the t1/2 values with women) with an average age similar to ic examinations. The administration of the patient parameters was examined that of the pSS patients. Thus, a t1/2 va l u e drugs influencing the autonomic ner- with linear regression analysis or with >74 minutes was considered abnormal. vous system or the function of the blad- Pearson’s correlation test. The relation- der was suspended an appropriate peri- ships between the urodynamic vari- Urodynamic examinations od before the measurements. Six pa- ables and the various patient data were For assessment of the autonomic neural tients refused to participate; of the re- analysed with Spearman’s rank correla- ef fects on the urinary tract, standard
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