Letter to the Editor
Etiology of sicca syndrome in a consecutive series of 199 patients with chronic fatigue syndrome
Etiología del síndrome seco en una serie consecutiva de 199 pacientes con síndrome de fatiga crónica
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It is characterized by prolonged generalized and abnormal fatigue post-exercise (98%), recurrent headache (90%) and problems of concentration and memory (85%) that have lasted for at least 6 months. It is accompanied by such other symptoms as tender lymph nodes (80%), musculoskeletal pain (75%) and psychiatric problems (65%).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The prevalence of CFS is estimated to be between 0.5 and 2.5%, predominantly in women (4:1).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Many patients with CFS also complain of sicca symptoms in up to 30–87%, and are more likely to have thyroid disorder and sleep disruption;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> that may suggest an underlying role of the immune system in these patients. Primary Sjögren’ syndrome (PSS) is a systemic autoimmune disease, that presents chronic exocrine glands hypofunction leading to xerostomia and/or xerophthalmia, and extraglandular involvement, of which autoimmune hypothyroidism (AIHT) is the most common autoimmune disease developed<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. Patients with PSS, also experience CFS-like musculoskeletal and neurocognitive symptoms more than 50%, and the two disorders share some similar immunologic defects.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The purpose of this study was to determine the causality of sicca symptoms in 199 consecutive patients diagnosed as having CFS, and the possible association with PSS, although few studies that have examined this association (between 2010 and 2012 in our chronic fatigue unit of Joan XXIII University Hospital) according to the Fukuda’ criteria of 1994. One hundred sixty-seven patients (84%) were women. The age of onset of symptoms was 41<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10 years. Mucosal sicca symptoms were complained by 160 patients (80.4%): 11/160 (6.8%) patients were diagnosed with PSS (9 patients were incomplete PSS and 2 patients were complete PSS by positive lower lip biopsy that had MSG focus score >1, using the American-European criteria 2002<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>). 110/160 patients (68.75%) were mainly duo to xerogenic medications. Severe obstructive sleep apnea syndrome (OSAS) was diagnosed in 6/160 patients (3.75%) (according to the American Academy of Sleep Medicine, Chicago Criteria 1999) by polysomnographic analysis. Thirty-eight (23.75%) patients were sero-positive for thyroperoxidase antibody (TPO-Ab) and/or thyroglobulin antibody (Tg-Ab) (of these patients 33/160 (20.6%) were diagnosed as having AIHT), 15 (10.2%) had a positive antinuclear antibody (ANA) assay (titer count >1:160), and 5 (3.5%) had a positive parietal cell antibody (titer count >1:160). All were sero-negative for anti-Ro/SS-A and anti-La/SS-B. In previous studies mucosal sicca symptoms were described as one of the common clinical manifestations of CFS<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> as seen in our serie. Nishikai et al. and Sirois et al. had found sicca symptoms in 73% and 52% of their series respectively.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> As possible causes in our study, we determined that the prevalence of sicca symptoms (especially xerostomia) induced by psychotropic medications with anticholinergic side effects (amitriptyline, clonazepam, etc.) was high as described in several studies. Drugs with anticholinergic actions decrease salivary gland secretion by neurochemical blockade. It is usually dose related and reversible when medication is discontinued.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> We also found a group of CFS patients with sicca symptoms that may be attributed to AIHT and OSAS. This suggests that these two disorders share common pathophysiological features with CFS. Interestingly, in patients with OSAS, CFS symptoms were improved by using continuous nasal positive airway pressure (CPAP). Any potential relationship between CFS and PSS is complicated by the lack of a sensitive test or agreement regarding the diagnostic criteria for PSS. Nishikai et al. examined a group of 75 seronegative patients diagnosed with CFS and found that 22 (29%) met the European criteria 1993 for PSS.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Sirois et al. also examined 25 patients diagnosed with CFS and found that 32% met diagnostic criteria for PSS according to the European criteria 1993.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These results were not similar to ours in the study we present (11 patients if we included patients with incomplete PSS) as we described previously (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In searching of causes of this poor association, several considerations have to be taken into account in our study. 1st, in our study we used the 2002 criteria that require mandatory: (1) a positive salivary gland biopsy (only done in 5 patients), or (2) the presence of antibodies to SSA/Ro and/or to SS-B/La (negative in all patients). The serological item was also met in the 1993 criteria (used by Nishikai et al. and Sirois et al.,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a>) but only if a test for rheumatoid factor or ANA was positive. This condition has probably increased the prevalence of PSS in their studies. 2nd, symptoms or signs of PSS do not always begin at the same time and that patients with incomplete SS may be will met the diagnostic criteria 2002 at some point in the future. In summary, in our study about 70% of CFS patients with sicca syndrome are related to be drug-induced. Therefore, xerogenic medications, as possible cause, must be excluded. However, we recommend that patients who have been diagnosed with CFS and manifest mucosal sicca symptoms should be also screened for SS, AIHT and/or OSAS; and should be regarded as a comorbidity of CFS, not a diagnostic exclusion criterion.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Causes of sicca symptoms in chronic fatigue syndrome’ patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">N°. patients (%): 160 (80.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Xerogenic medications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 (68.75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Autoimmune hypothyroidism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (20.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary Sjögren syndrome (incomplete/complete) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (6.8)(9/2 patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstructive sleep apnea syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (3.75) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab520495.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Causes of sicca symptoms in chronic fatigue syndrome’ patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myalgic encephalomyelitis: International Consensus Criteria" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.M. Carruthers" 1 => "M.I. Van de Sande" 2 => "K.L. De Meirleir" 3 => "N.G. Klimas" 4 => "G. Broderick" 5 => "T. Mitchell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2796.2011.02428.x" "Revista" => array:6 [ "tituloSerie" => "J Intern Med" "fecha" => "2011" "volumen" => "270" "paginaInicial" => "327" "paginaFinal" => "338" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21777306" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic fatigue syndrome: study of a consecutive series of 824 cases assessed in two specialized units" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Ruiz" 1 => "J. Alegre" 2 => "A.M. Garcia Quintana" 3 => "L. Aliste" 4 => "A. blazquez" 5 => "T. Fernandez de Sevilla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2011.02.013" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2011" "volumen" => "211" "paginaInicial" => "385" "paginaFinal" => "390" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21794854" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influence of immediate hypersensitivity skin reactions on delayed reactions in patients with chronic fatigue syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Steinberg" 1 => "A. Pheley" 2 => "P.K. Peterson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Allergy Clin Immunol" "fecha" => "1996" "volumen" => "98" "paginaInicial" => "1126" "paginaFinal" => "1128" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8977518" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatigue in primary Sjögren's syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.J. Barendregt" 1 => "M.R.M. Visser" 2 => "E.M.A. Smets" 3 => "J.H.M. Tulen" 4 => "A.H. Van den Meiracker" 5 => "F. Boomsma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "1998" "volumen" => "57" "paginaInicial" => "291" "paginaFinal" => "295" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9741313" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification criteria for Sjögren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Vitali" 1 => "S. Bombardieri" 2 => "R. Jonsson" 3 => "H.M. Moutsopoulos" 4 => "E.L. Alexander" 5 => "S.E. Carsons" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "2002" "volumen" => "61" "paginaInicial" => "554" "paginaFinal" => "558" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12006334" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seronegative Sjögren's syndrome manifested as a subset of chronic fatigue syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Nishikai" 1 => "K. Akiya" 2 => "T. Tojo" 3 => "N. Onoda" 4 => "M. Tani" 5 => "K. Shimizu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Rheumatol" "fecha" => "1996" "volumen" => "35" "paginaInicial" => "471" "paginaFinal" => "474" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8646439" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinicopathological findings consistent with primary Sjögren’ syndrome in a subset of patients diagnosed with chronic fatigue syndrome: preliminary observations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.A. Sirois" 1 => "B. Natelson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Rheumatol" "fecha" => "2001" "volumen" => "28" "paginaInicial" => "126" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11196514" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001000000004/v1_201406280041/S2173574314001075/v1_201406280041/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001000000004/v1_201406280041/S2173574314001075/v1_201406280041/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574314001075?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 36 | 30 | 66 |
| 2024 September | 43 | 22 | 65 |
| 2024 August | 47 | 52 | 99 |
| 2024 July | 47 | 34 | 81 |
| 2024 June | 50 | 31 | 81 |
| 2024 May | 50 | 27 | 77 |
| 2024 April | 39 | 23 | 62 |
| 2024 March | 38 | 40 | 78 |
| 2024 February | 34 | 30 | 64 |
| 2024 January | 34 | 20 | 54 |
| 2023 December | 24 | 27 | 51 |
| 2023 November | 33 | 17 | 50 |
| 2023 October | 42 | 32 | 74 |
| 2023 September | 31 | 32 | 63 |
| 2023 August | 31 | 21 | 52 |
| 2023 July | 37 | 24 | 61 |
| 2023 June | 39 | 22 | 61 |
| 2023 May | 46 | 24 | 70 |
| 2023 April | 32 | 6 | 38 |
| 2023 March | 40 | 22 | 62 |
| 2023 February | 47 | 31 | 78 |
| 2023 January | 14 | 12 | 26 |
| 2022 December | 41 | 27 | 68 |
| 2022 November | 38 | 26 | 64 |
| 2022 October | 35 | 20 | 55 |
| 2022 September | 28 | 54 | 82 |
| 2022 August | 41 | 51 | 92 |
| 2022 July | 24 | 36 | 60 |
| 2022 June | 23 | 30 | 53 |
| 2022 May | 39 | 38 | 77 |
| 2022 April | 38 | 29 | 67 |
| 2022 March | 39 | 35 | 74 |
| 2022 February | 58 | 16 | 74 |
| 2022 January | 75 | 35 | 110 |
| 2021 December | 31 | 39 | 70 |
| 2021 November | 30 | 40 | 70 |
| 2021 October | 50 | 41 | 91 |
| 2021 September | 33 | 38 | 71 |
| 2021 August | 56 | 27 | 83 |
| 2021 July | 31 | 21 | 52 |
| 2021 June | 20 | 40 | 60 |
| 2021 May | 27 | 37 | 64 |
| 2021 April | 72 | 81 | 153 |
| 2021 March | 46 | 22 | 68 |
| 2021 February | 30 | 23 | 53 |
| 2021 January | 29 | 21 | 50 |
| 2020 December | 16 | 17 | 33 |
| 2020 November | 26 | 18 | 44 |
| 2020 October | 16 | 10 | 26 |
| 2020 September | 18 | 22 | 40 |
| 2020 August | 18 | 19 | 37 |
| 2020 July | 24 | 26 | 50 |
| 2020 June | 16 | 15 | 31 |
| 2020 May | 24 | 12 | 36 |
| 2020 April | 20 | 24 | 44 |
| 2020 March | 10 | 14 | 24 |
| 2020 February | 2 | 0 | 2 |
| 2019 May | 1 | 0 | 1 |
| 2018 December | 2 | 2 | 4 |
| 2018 May | 3 | 0 | 3 |
| 2018 April | 31 | 6 | 37 |
| 2018 March | 51 | 6 | 57 |
| 2018 February | 14 | 3 | 17 |
| 2018 January | 14 | 4 | 18 |
| 2017 December | 26 | 4 | 30 |
| 2017 November | 23 | 5 | 28 |
| 2017 October | 27 | 5 | 32 |
| 2017 September | 19 | 4 | 23 |
| 2017 August | 29 | 9 | 38 |
| 2017 July | 25 | 6 | 31 |
| 2017 June | 35 | 10 | 45 |
| 2017 May | 32 | 10 | 42 |
| 2017 April | 24 | 5 | 29 |
| 2017 March | 18 | 3 | 21 |
| 2017 February | 23 | 4 | 27 |
| 2017 January | 22 | 5 | 27 |
| 2016 December | 41 | 13 | 54 |
| 2016 November | 26 | 2 | 28 |
| 2016 October | 33 | 6 | 39 |
| 2016 September | 34 | 7 | 41 |
| 2016 August | 24 | 3 | 27 |
| 2016 July | 22 | 7 | 29 |
| 2016 April | 2 | 0 | 2 |
| 2016 March | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 9 | 6 | 15 |
| 2015 June | 14 | 5 | 19 |
| 2015 May | 32 | 6 | 38 |
| 2015 April | 10 | 8 | 18 |
| 2015 March | 12 | 7 | 19 |
| 2015 February | 9 | 6 | 15 |
| 2015 January | 18 | 14 | 32 |
| 2014 December | 15 | 8 | 23 |
| 2014 November | 17 | 13 | 30 |
| 2014 October | 17 | 10 | 27 |
| 2014 September | 17 | 8 | 25 |
| 2014 August | 26 | 26 | 52 |
| 2014 July | 31 | 22 | 53 |
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