Objective To test the hypothesis that the formation of ectopic germinal center (GC)–like structures in Sjögren's syndrome (SS) is associated with the ectopic expression of the constitutive lymphoid tissue–homing chemokines B cell–attracting chemokine 1 (BCA‐1; or, CXCL13) and stromal cell–derived factor 1 (SDF‐1; or, CXCL12). Methods Immunohistochemical and immunofluorescence analysis was used to determine the expression of the constitutive chemokines BCA‐1 (CXCL13) and SDF‐1 (CXCL12) in salivary glands from 5 SS patients and 3 non‐SS patients. In addition, the expression of their respective receptors (CXCR5 and CXCR4) was examined on infiltrating lymphocytes. Human tonsil was used as a positive control for secondary lymphoid tissue. Results BCA‐1 (CXCL13) was expressed within lymphoid aggregates in SS, which shared many structural features with GCs in tonsil. BCA‐1 (CXCL13) was completely absent in control biopsy samples from patients who did not have SS. High levels of BCA‐1 (CXCL13) were also found on endothelial cells in salivary glands from SS patients. Diseased SS tissue was infiltrated by CXCR5‐expressing B cells which organized into GC‐like clusters. In complete contrast, SDF‐1 (CXCL12), a constitutive chemokine involved in leukocyte retention within lymphoid tissue, was expressed by epithelial cells in both diseased and control samples. The chemokine receptor for SDF‐1, CXCR4, was expressed on T cells that accumulated in a periductal distribution in diseased tissue. Conclusion The ectopic expression of BCA‐1 (CXCL13) on endothelial cells and within GC‐like structures, together with the strong expression of SDF‐1 (CXCL12) on ductal epithelial cells, is a unique feature of inflamed glands in SS. By creating a local microenvironment supportive of focal B cell aggregation and differentiation, with structural features that are remarkably similar to GCs, BCA‐1 (CXCL13) and SDF‐1 (CXCL12) may contribute to the excessive production of high‐affinity, class‐switched autoantibodies and to the high incidence of B cell lymphomas classically associated with SS.

This is the first double blind study of rituximab in pSS to show benefit; further studies are justified.

Our data support previous studies suggesting a prevalence of PSS in the community of 0.1-0.6% rather than those suggesting a higher figure.

Although lichen planus is a relatively common mucocutaneous disorder in adults, it has only rarely been described in children. Moreover, even less data has been published regarding mucosal lesions in children. Six case reports of childhood oral lichen planus are presented and the available literature reviewed. It is believed that this paper documents the largest series of cases of childhood oral mucosal lichen planus to be reported in the literature to date. Lichen planus should be considered in the differential diagnosis of oral mucosal white patches in children, particularly those of Asian origin.

Background Heterogeneity is a major obstacle to developing effective treatments for patients with primary Sjögren's syndrome. We aimed to develop a robust method for stratification, exploiting heterogeneity in patient-reported symptoms, and to relate these differences to pathobiology and therapeutic response. MethodsWe did hierarchical cluster analysis using five common symptoms associated with primary Sjögren's syndrome (pain, fatigue, dryness, anxiety, and depression), followed by multinomial logistic regression to identify subgroups in the UK Primary Sjögren's Syndrome Registry (UKPSSR). We assessed clinical and biological differences between these subgroups, including transcriptional differences in peripheral blood. Patients from two independent validation cohorts in Norway and France were used to confirm patient stratification. Data from two phase 3 clinical trials were similarly stratified to assess the differences between subgroups in treatment response to hydroxychloroquine and rituximab. FindingsIn the UKPSSR cohort (n=608), we identified four subgroups: Low symptom burden (LSB), high symptom burden (HSB), dryness dominant with fatigue (DDF), and pain dominant with fatigue (PDF). Significant differences in peripheral blood lymphocyte counts, anti-SSA and anti-SSB antibody positivity, as well as serum IgG, κ-free light chain, β2-microglobulin, and CXCL13 concentrations were observed between these subgroups, along with differentially expressed transcriptomic modules in peripheral blood. Similar findings were observed in the independent validation cohorts (n=396). Reanalysis of trial data stratifying patients into these subgroups suggested a treatment effect with hydroxychloroquine in the HSB subgroup and with rituximab in the DDF subgroup compared with placebo.Interpretation Stratification on the basis of patient-reported symptoms of patients with primary Sjögren's syndrome revealed distinct pathobiological endotypes with distinct responses to immunomodulatory treatments. Our data have important implications for clinical management, trial design, and therapeutic development. Similar stratification approaches might be useful for patients with other chronic immune-mediated diseases.