Differential diagnosis of the manifestations of Sjögren's disease

	Examples
Dry eyes
Aqueous-deficient form
Lacrimal gland inflammation	Sarcoidosis Lymphoma IgG4-related disease Graft-versus-host disease HCV infection
Lacrimal gland duct obstruction	Trachoma Stevens-Johnson syndrome Ocular cicatricial pemphigoid
Age-related glandular fibrosis
Reflex hyposecretion secondary to ocular sensory loss	Corneal surgery (eg, laser-assisted in situ keratomileusis [LASIK]) Chronic contact lens wear Diabetes mellitus
Idiopathic^[1]
Medications	Tricyclic and other antidepressants; antihistamines
Evaporative form
Meibomian gland dysfunction	Acne rosacea Seborrheic dermatitis Atopic dermatitis Isotretinoin therapy Menopause
Impaired lid closure	Thyroid ophthalmopathy
Low blink rate	Parkinson disease Working at a computer monitor^[2,3]
Ocular surface disorders	Vitamin A deficiency^[4-6] Topical drugs and preservatives Contact lens wear Allergic conjunctivitis
Dry mouth
Drugs	Antidepressants Antihistamines Anticholinergics Diuretics Neuroleptics
Systemic diseases	Amyloidosis Sarcoidosis HIV and HCV infection Uncontrolled diabetes mellitus
Psychogenic	Anxiety
Radiation therapy	External beam for head and neck cancers Iodine-131 for thyroid cancer
Dehydration
Salivary gland enlargement
Usually unilateral
Acute	Bacterial infection Actinomycosis^[7] Obstruction
Chronic	Chronic sialadenitis Primary neoplasm (adenoma, adenocarcinoma, lymphoma, mixed salivary gland tumors)
Usually bilateral
Acute	Acute viral infections (EBV, mumps, CMV, coxsackie A)
Chronic	Chronic viral infections (HIV, HCV) IgG4-related sialadenitis Amyloidosis Granulomatous diseases (sarcoidosis, tuberculosis)^[8,9] HIV infection Hyperlipidemia Diabetes mellitus^[10] Alcoholism^[10] Malnutrition Acromegaly^[11,12] Anorexia and bulimia^[13,14]

IgG4: immunoglobulin G4; HCV: hepatitis C virus; HIV: human immunodeficiency virus; EBV: Epstein-Barr virus; CMV: cytomegalovirus.

References:

Whitcher JP, Shiboski CH, Shiboski SC, et al. A simplified quantitative method for assessing keratoconjunctivitis sicca from the Sjögren's Syndrome International Registry. Am J Ophthalmol 2010; 149:405.
Wolkoff P, Nøjgaard JK, Franck C, Skov P. The modern office environment desiccates the eyes? Indoor Air 2006; 16:258.
Sheedy JE, Gowrisankaran S, Hayes JR. Blink rate decreases with eyelid squint. Optom Vis Sci 2005; 82:905.
Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: A Delphi approach to treatment recommendations. Cornea 2006; 25:900.
Bowman SJ. Collaborative research into outcome measures in Sjögren's syndrome. Update on disease assessment. Scand J Rheumatol Suppl 2002; 116:23.
Corrales RM, Stern ME, De Paiva CS, et al. Desiccating stress stimulates expression of matrix metalloproteinases by the corneal epithelium. Invest Ophthalmol Vis Sci 2006; 47:3293.
Hensher R, Bowerman J. Actinomycosis of the parotid gland. Br J Oral Maxillofac Surg 1985; 23:128.
Janmeja AK, Das SK, Kochhar S, Handa U. Tuberculosis of the parotid gland. Indian J Chest Dis Allied Sci 2003; 45:67.
Ramos-Casals M, Brito-Zerón P, García-Carrasco M, Font J. Sarcoidosis or Sjögren syndrome? Clues to defining mimicry or coexistence in 59 cases. Medicine (Baltimore) 2004; 83:85.
Kim D, Uy C, Mandel L. Sialosis of unknown origin. N Y State Dent J 1998; 64:38.
Manetti L, Bogazzi F, Brogioni S, et al. Submandibular salivary gland volume is increased in patients with acromegaly. Clin Endocrinol (Oxf) 2002; 57:97.
Thomson JA, McCrossan J, Mason DK. Salivary gland enlargement in acromegaly. Clin Endocrinol (Oxf) 1974; 3:1.
Buchanan JA, Fortune F. Bilateral parotid enlargement as a presenting feature of bulimia nervosa in a post-adolescent male. Postgrad Med J 1994; 70:27.
Vavrina J, Müller W, Gebbers JO. Enlargement of salivary glands in bulimia. J Laryngol Otol 1994; 108:516.

Adapted from: The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:75.

Graphic 77821 Version 6.0

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Differential diagnosis of the manifestations of Sjögren's disease