1.
Pediatric Sjogren Syndrome
Prof DR Dr Ariyanto Harsosno SpA(K)

2.
Introduction
• Sjögren syndrome, which is rare in pediatric patients, is a slowly
progressive inflammatory disorder that involves the exocrine
glands. Mikulicz and others recognized the findings of
keratoconjunctivitis and xerostomia as an entity in the late 1800s.
In 1933, Sjögren recognized the association of this symptom
complex with polyarthritis.
• Subsequent studies showed that Sjögren syndrome may be a
primary disorder or may be secondary to other autoimmune
disorders, such as systemic lupus erythematosus (SLE),
rheumatoid arthritis, scleroderma, and biliary cirrhosis.
Extraglandular manifestations may mimic these other
autoimmune disorders. The primary disorder is most common in
women in the fourth and fifth decades of life. Sjögren syndrome
may overlap with other pediatric autoimmune disorders and, less
commonly, may present as a primary condition.
Prof DR Dr Ariyanto Harsono SpA(K) 2

3.
Overlapping symptoms consistent with SLE include
neuropsychiatric manifestations, nephritis, and
severe Raynaud phenomenon. Severe systemic
manifestations may also develop without overt
features of other autoimmune disorders.
Prof DR Dr Ariyanto Harsono SpA(K) 3

4.
Etiology
Multiple etiologic factors are likely involved in the
pathogenesis of Sjögren syndrome. Lymphocytic
infiltration in the glandular lobules is the
characteristic abnormality in lacrimal or salivary
gland biopsy findings. The disorder appears to be
mediated by a complex cascade of immune events
and is often characterized as an autoimmune
exocrinopathy.
Prof DR Dr Ariyanto Harsono SpA(K) 4

5.
Etiology….
Epstein-Barr virus (EBV) replicates in the salivary glands
during primary infection and remains latent in these
organs. EBV deoxyribonucleic acid (DNA) is recovered
from the salivary glands and saliva of patients with
Sjögren syndrome. Its etiopathologic role cannot be
proven. Human immunodeficiency virus (HIV), human
T-cell leukemia-lymphoma virus type 1 (HTLV-1), and
cytomegalovirus (CMV) are also being studied as
possible inciting agents of the lymphoproliferation
observed in the end organs.
Prof DR Dr Ariyanto Harsono SpA(K) 5

6.
Etiology….
Multiple etiologic factors are likely involved in the
pathogenesis of Sjögren syndrome. Lymphocytic
infiltration in the glandular lobules is the
characteristic abnormality in lacrimal or salivary
gland biopsy findings. The disorder appears to be
mediated by a complex cascade of immune events
and is often characterized as an autoimmune
exocrinopathy.
Prof DR Dr Ariyanto Harsono SpA(K) 6

7.
Genetics
A higher incidence Sjögren syndrome is found in
family members of patients with the disease. The
association of Sjögren syndrome with human
leukocyte antigen (HLA)–B8, HLA-Dw3, HLA-DR3,
and the DQA1*0501 allele supports the notion of
genetic susceptibility.
Prof DR Dr Ariyanto Harsono SpA(K) 7

8.
Pathology
The predominant immune cells are activated memory
CD4+ T cells that express alpha/beta T-cell receptors,
suggesting a central role in the pathogenesis of this
disorder. Activated B cells are also found in the lesions,
which may be responsible for the production of the
autoantibodies to autoantigens Ro (SS-A) and La (SS-B).
Anti-Ro is found in 40-45% of adult patients with
Sjögren syndrome, and anti-La is found in 50% of these
patients. The presence of anti-Ro and anti-La is
associated with earlier onset, longer duration, and
more extensive extraglandular manifestations of
primary Sjögren syndrome.
Prof DR Dr Ariyanto Harsono SpA(K) 8

9.
Pathology…..
• Positivity in these antibodies appears to be higher in
children, according to a systematic review of the
literature rheumatoid factor, 66%; antinuclear
antibody, 78%; SS-A, 74%; SS-B, 65%). Because these
autoantibodies are also observed in other
autoimmune disorders, including SLE, further
diagnostic tools must be used for a more definitive
diagnosis.
• Researchers have found a high prevalence of anti-
Muscarinic-3 acetylcholine receptor autoantibodies
in Japanese children with primary Sjögren
syndrome.These antibodies are postulated to be
involved in defective glandular function.
Prof DR Dr Ariyanto Harsono SpA(K) 9

10.
Pathology…..
An active area of research involves genetic
polymorphisms of cytokine genes, including IL10 and
TNFa. Associations with these polymorphisms might
implicate inappropriate regulation of the immune
response in Sjögren syndrome. Altered apoptotic
mechanisms have also been implicated in the
pathogenesis of Sjögren syndrome–related
exocrinopathies. Exocrine gland tissue damage and
chronic inflammation lead to fibrotic changes and
impaired glandular function. The pathophysiology of
extraglandular manifestations is thought to be due to
similar immune mechanisms.
Prof DR Dr Ariyanto Harsono SpA(K) 10

11.
Clinical Manifestations
Clinical manifestations of pediatric Sjögren
syndrome may vary more than those seen in adult
patients. The constellation of symptoms seen in
children (eg, lower frequency of sicca syndrome,
higher rates of parotid enlargement, higher
prevalence of immunologic markers) may be similar
to those found in young adult patients (ie, < 35 y).
Prof DR Dr Ariyanto Harsono SpA(K) 11

12.
Lower facial appearance of a 14-year-old adolescent girl with Sjogren
syndrome. She exhibits both parotid and submandibular gland enlargement
and chapped lips.
Prof DR Dr Ariyanto Harsono SpA(K) 12

13.
Clinical Manifestations…..
Sicca syndrome
• Symptoms of keratoconjunctivitis include dry eyes with reduced tear
production, gritty or sandy sensation under the lids, red eyes, and
photosensitivity. Keratoconjunctivitis is less prominent in primary juvenile
Sjögren syndrome. Lacrimal gland enlargement appears to be a feature in
primary and secondary pediatric Sjögren syndrome. The management of
keratoconjunctivitis includes the use of artificial tears and conservation of
natural tear flow.
• Symptoms of xerostomia include decreased saliva production and difficulties
with chewing, swallowing, and even speech; abnormality in taste and smell;
dental caries; mucosal burning sensation; sensitivity to spicy and acidic foods
and beverages; increased risk for oral candidiasis; hoarseness of voice, and
dysphonia (common in adults). Recurrent parotitis appears to be the most
common oroglandular manifestation in pediatric populations.
Prof DR Dr Ariyanto Harsono SpA(K) 13

14.
Intraoral view of a 14-year-old adolescent girl with Sjogren syndrome. Hyposalivation
results in erythema of the mucosa, gingivitis, decalcification or white spot lesions of
the teeth at the cervical margin, and dental caries with extensive restorations of the
posterior teeth.
Prof DR Dr Ariyanto Harsono SpA(K) 14

15.
Clinical Manifestations…..
Musculoskeletal symptoms
Symptoms include the following:
• Arthralgia (often noninflammatory),
morning stiffness, and nonerosive arthritis
• Myalgia and muscle weakness
Prof DR Dr Ariyanto Harsono SpA(K) 15

16.
Clinical Manifestations…..
Cutaneous findings
Symptoms include the following:
• Raynaud phenomenon
• Nonthrombocytopenic purpura, especially of
lower extremities
• Nasal, vaginal, and cutaneous dryness
Prof DR Dr Ariyanto Harsono SpA(K) 16

17.
Erythema of the labial mucosa with enlargement of the minor salivary glands
and superficial mucoceles.
Prof DR Dr Ariyanto Harsono SpA(K) 17

18.
Clinical Manifestations…..
Gastrointestinal symptoms
Symptoms include the following:
• Dysphagia, nausea, and epigastric and
abdominal pain
• Achalasia (in children)
• Achlorhydria and chronic atrophic gastritis
(adult patients)
• Primary biliary cirrhosis
Prof DR Dr Ariyanto Harsono SpA(K) 18

19.
The dorsal surface of the tongue demonstrates generalized atrophy of the
filiform papillae, mild fissuring, and median rhomboid glossitis.
Prof DR Dr Ariyanto Harsono SpA(K) 19

20.
Pulmonary findings
Symptoms include the following:
• Dyspnea due to mild interstitial disease
• Dry cough
Prof DR Dr Ariyanto Harsono SpA(K) 20

21.
A 14-year-old adolescent girl with Sjogren syndrome with painful unilateral
swelling of the knee and hyperpigmentation of the overlying skin.
Prof DR Dr Ariyanto Harsono SpA(K) 21

22.
Renal symptoms
Symptoms include the following:
• Interstitial nephritis
• Renal tubular acidosis
Prof DR Dr Ariyanto Harsono SpA(K) 22

23.
Prognosis
• Patients with primary Sjögren syndrome usually have
a good prognosis unless severe, extraglandular
manifestations develop. The prognosis of secondary
Sjögren syndrome depends on the primary
autoimmune disorder.
• Although most adult patients have a mild and benign
course, they often experience painful eye irritation,
severe dental caries, and dyspareunia. Pediatric
patients often do not have early sicca syndrome
symptomatology but often have recurrent parotitis.
Because of the insidious nature of these symptoms,
patients often do not seek medical attention until more
severe symptoms appear years later.
Prof DR Dr Ariyanto Harsono SpA(K) 23

24.
Prognosis…..
The time from disease onset until diagnosis is often 9
years in adults and perhaps as long as 3 years in
pediatric patients. In a multicenter, retrospective
review of 40 patients, few major complications were
reported from time of onset (follow-up, 0-7.5
y). According to another small report of pediatric
patients with at least 3 years’ follow-up, minimal
progression in disease status was reported. Some
pediatric patients may develop systemic features that
involve the nervous system, kidney, and lungs.
Prof DR Dr Ariyanto Harsono SpA(K) 24

25.
Prognosis…..
Lymphoproliferative disorders increase 40-fold in adult
Sjögren syndrome. Although significant
lymphoproliferation usually remains confined to the
salivary and lacrimal glands, extraglandular
lymphoproliferation (eg, lymphadenopathy,
hepatosplenomegaly) sometimes resembles lymphoma
(eg, pseudolymphoma) and may herald frank
malignancies, including non-Hodgkin lymphoma,
Waldenström macroglobulinemia, and B-cell
lymphoma. Associations with lymphoproliferative
diseases are not well described in pediatric populations.
Prof DR Dr Ariyanto Harsono SpA(K) 25

26.
Additional findings
The following symptoms may also be seen in
Sjögren syndrome:
• Fatigue
• Depression
• Insomnia
• Cognitive impairment
Prof DR Dr Ariyanto Harsono SpA(K) 26

27.
Physical Examination
The following may be noted on physical examination:
• Parotid gland enlargement and recurrent parotitis
(most prominent feature in pediatric populations)
• Corneal ulceration, vascularization, and uveitis
• Vasculitic lesions - Purpura and erythema nodosum
• Lymphadenopathy
• Autoimmune thyroiditis
• Nervous system manifestations - Peripheral
sensorimotor neuropathy; central nervous system disorders
such as cognitive impairment, movement disorder,
transverse myelopathy, encephalopathy, aseptic meningitis,
dementia, optic neuropathy, and cranial neuropathies (in
both adult and pediatric patients)
Prof DR Dr Ariyanto Harsono SpA(K) 27

28.
Physical Examination…..
Musculoskeletal manifestations - Intermittent synovitis, chronic nonerosive
oligoarticular or polyarthritis (Jaccoud arthropathy is observed in adults),
and myalgias
Oral cavity manifestations of Sjögren syndrome may include the following:
• Mild erythema and thinning of the mucosa
• Dental caries
• Traumatic erosions and ulcers, angular cheilitis, and chapped lips
• Frothy, ropey, and thickened saliva
• Erythema, fissuring, coating, and depapillation of the dorsal tongue
• Halitosis
• Gingivitis/periodontitis
• Superficial mucoceles
Prof DR Dr Ariyanto Harsono SpA(K) 28

29.
Differential Diagnosis
Conditions to consider in the differential diagnosis
of Sjögren syndrome include the following:
• Medications that cause sicca symptoms
(anticholinergic agents)
• Recurrent juvenile parotitis
• Oropharyngeal candidiasis
• Gingivitis/periodontitis
• Retrograde bacterial sialadenitis
• Halitosis
• Superficial mucoceles
Prof DR Dr Ariyanto Harsono SpA(K) 29

30.
Differential Diagnosis…..
Compromised nutrition
• Dryness of the nasal and vaginal mucosa and
skin
• Pregnancy complications due to
autoantibodies
• Mumps
• Sarcoidosis
• SLE
• Systemic sclerosis
• Hepatitis C
Prof DR Dr Ariyanto Harsono SpA(K) 30

31.
Work Up
Criteria for pediatric patients have been proposed
but not prospectively validated. Only 76%
sensitivity has been noted in studies of
retrospective patients. The clinical judgment of a
pediatric rheumatologist is the criterion standard.
However, the proposed pediatric criteria appear
more sensitive than adult AECG criteria in
classifying primary pediatric Sjögren syndrome.
Diagnosis is based on the presence of 4 or more of
the following proposed pediatric diagnostic criteria:
Prof DR Dr Ariyanto Harsono SpA(K) 31

32.
Work Up…..
• Exclusion of all other autoimmune diseases
• Oral symptoms - Dry mouth, parotitis, and
parotid gland enlargement
• Ocular symptoms - Recurrent conjunctivitis
and keratoconjunctivitis sicca
• Other mucosal symptoms - Recurrent vaginitis
or vulvovaginitis
• Systemic symptoms - Fever of unknown origin,
noninflammatory arthralgias, and hypokalemic
paralysis
Prof DR Dr Ariyanto Harsono SpA(K) 32

33.
• Presence of anti-Ro (SS-A), anti-La (SS-B), high
titer ANA, or RF
• Elevated serum amylase levels
• Leukopenia and high erythrocyte sedimentation
rate
• Polyclonal hyperimmunoglobulinemia
• Renal tubular acidosis
• Histologic proof of lymphocytic infiltration of
salivary gland or other organs
Prof DR Dr Ariyanto Harsono SpA(K) 33
Work Up…..

34.
Objective documentation of parotid gland enlargement
- Sialography findings
On a complete blood count with differential, mild
anemia and leukopenia are often present in patients
with Sjögren syndrome. Elevated erythrocyte
sedimentation rate is observed in 80-90% of patients,
which may be related to hypergammaglobulinemia;
however, C-reactive protein levels are usually within the
reference range. Hypergammaglobulinemia, up to
several grams of immunoglobulin G, is observed in 70-
80% of pediatric and adult patients.
Prof DR Dr Ariyanto Harsono SpA(K) 34
Work Up…..

35.
ANTIBODIES
ANA and rheumatoid factor RF levels are usually
elevated in children. Anti-Ro (SS-A) and anti-La (SS-B)
are also usually present in children.
Various autoantibodies may be found in patients with
Sjögren syndrome; however, the clinical or diagnostic
implication is often unclear. Autoantibodies include
thyroglobulin, thyroid microsomal, mitochondrial,
smooth muscle, parietal, peroxisomal, muscarinic
receptors, and salivary duct (often present in adults
with Sjögren syndrome) autoantibodies. Cryoglobulins
and, occasionally, antiphospholipid antibodies are
noted.
Prof DR Dr Ariyanto Harsono SpA(K) 35
Work Up…..

36.
Histologic findings
The characteristic histopathologic findings of the minor
salivary glands include an inflammatory infiltrate
adjacent to normal-appearing acinar structures. The
inflammatory infiltrate consists of primarily
lymphocytes and fewer plasma cells. Most of the
infiltrating lymphocytes are activated CD4+ memory T
lymphocytes. A focal periductal pattern is initially
observed, with eventual confluence of the
inflammatory infiltrate that replaces the acini.
Periductal and perivascular hyaline deposits may be
observed.
Prof DR Dr Ariyanto Harsono SpA(K) 36

37.
Low-power photomicrograph of a minor salivary gland lobule showing
multiple lymphocytic foci that are replacing the acinar structures
(hematoxylin-eosin, 40 X).
Prof DR Dr Ariyanto Harsono SpA(K) 37

38.
Intermediate-power photomicrograph demonstrating a chronic inflammatory
aggregate of more than 50 lymphocytes and plasma cells with a periductal pattern.
The inflammatory focus is adjacent to normal appearing acini (hematoxylin-eosin, 200
X)
Prof DR Dr Ariyanto Harsono SpA(K) 38

39.
High-power photomicrograph of the chronic inflammatory aggregate consists
of lymphocytes and plasma cells around a ductal structure (hematoxylin-
eosin, 400 X).
Prof DR Dr Ariyanto Harsono SpA(K) 39

40.
TREATMENT
• Many of the symptoms associated with Sjögren syndrome
can impair an individual's quality of life. In addition to sicca
syndrome, concerns about facial appearance, depression,
chronic fatigue, and joint pain must be addressed. Parotid
enlargement and weight gain (if corticosteroids are used to
manage the disease) may be problematic in adolescents.
Artificial tears and conservation of natural tear flow are used
in the management of keratoconjunctivitis.
• Close attention must be paid to emotional and cognitive
functioning of the adolescent coping with a chronic disease
such as Sjögren syndrome.
• Medical care for children with primary Sjögren syndrome is
primarily based on strategies used for adults. No controlled
studies in children with this disorder have been reported.
Prof DR Dr Ariyanto Harsono SpA(K) 40

41.
TREATMENT…..
Discourage patients from smoking. Instruct patients
to avoid windy and low-humidity environments. The
family dwelling should be well humidified. Support
normal school attendance and academic functioning
in patients with juvenile Sjögren syndrome.
Prof DR Dr Ariyanto Harsono SpA(K) 41

42.
Xerostomia
Means of addressing xerostomia include stimulation
of salivary flow with sialagogues, such as pilocarpine
(shown to be effective in increasing salivary flow in
placebo-controlled, randomized adult trials) or
cevimeline; mechanical stimulation of salivary flow
with sugarless chewing gum or lozenges; and topical
tissue hydration or lubrication with drinking water
or artificial saliva. These measures are supportive
and have only been well studied in adults, yet they
may improve quality of life in patients of all ages.
Prof DR Dr Ariyanto Harsono SpA(K) 42
TREATMENT…..

43.
In Sjögren syndrome, calcium is leeched from teeth because
of a reduction in saliva and as a result of the interaction
between simple sugars and acidogenic bacteria. Therefore,
good oral hygiene is necessary for caries control. Patients
should avoid mouth rinses that contain alcohol, because they
desiccate the mucosa.
Dental plaque reduction measures include twice-daily
cleaning of the teeth with a toothbrush, using a fluoride-
containing dentifrice, the daily use of dental floss, and
increasing the number of professional cleanings to 3-4 times
a year if carious lesions develop. Daily home use of topical
fluorides, especially gel or toothpaste that contains 1.1%
sodium fluoride or remineralizing gel with 0.05% sodium
fluoride, sodium phosphate, and calcium carbonate, is
recommended.
Prof DR Dr Ariyanto Harsono SpA(K) 43
TREATMENT…..

44.
If the patient has severe xerostomia, use custom
fluoride trays or carriers to apply the topical
fluorides. Use chlorhexidine gluconate oral rinse
concurrently for 2-week periods when high numbers
of Streptococcus mutans are found in the saliva (>1
X 106/mL saliva). Limit the intake of sugary food and
beverages between meals. Use sweetener
alternatives, if tolerated, such as aspartame,
saccharin, sorbitol, and xylitol.
Prof DR Dr Ariyanto Harsono SpA(K) 44
TREATMENT…..

45.
For the prevention of oral mucosal lesions such as chapped
lips, use water- or lanolin-based lip moisturizers. Avoid lip
products that are medicated with menthol or phenol,
because they cause further drying. For traumatic erosions
and ulcers, frequently hydrate and use artificial saliva or oral
moisturizing agents, especially under removable oral
prostheses.
For oropharyngeal candidiasis, recommend good oral
hygiene, frequent oral hydration and lubrication, and nightly
removal and cleaning of dental prostheses. The intermittent
use of topical or systemic antifungal agents may be necessary
to prevent recurrent infection. If topical antifungal agents are
used, consultation with a compounding pharmacist is
recommended in order to formulate sucrose-free
suspensions or lozenges.
Prof DR Dr Ariyanto Harsono SpA(K) 45
TREATMENT…..

46.
Diet
• A nutritious well-balanced diet with the appropriate servings from
the basic food groups is recommended. Patients should drink plenty
of fluids with meals to aid in chewing, tasting, and swallowing. If
tolerated, encourage the intake of dairy products, especially low-fat
milk, yogurt, and cheese. Milk provides increased oral lubrication,
while cheese has a beneficial anticaries effect.
• Recommend that patients avoid dry, crunchy foods, because they
are too difficult to swallow and may irritate the mucosa. Patients
should also avoid spicy or acidic foods and beverages. In addition,
avoiding simple carbohydrates, such as sucrose, and refined, highly
processed foods, such as pastries and cookies, is important, to
decrease the risk of dental caries. Alcoholic beverages and
caffeinated drinks, such as coffee, tea, and cola, increase oral
dryness.
Prof DR Dr Ariyanto Harsono SpA(K) 46
TREATMENT…..

47.
• If sweetener substitutes are used, monitor their
intake, because some products may cause
abdominal distress.
• Recommend that patients eat foods at moderate
temperatures. Foods can be liquefied or pureed if
swallowing is a problem. If an increase in calories
is needed because of an eating disorder, consider
liquid nutritional supplements.
Prof DR Dr Ariyanto Harsono SpA(K) 47
TREATMENT…..

48.
Primary Sjögren syndrome usually follows a benign course in
adult patients, and conservative management is indicated.
Therapeutic approaches may include increasing lubrication
with artificial tears, stimulating salivary flow with sugar-free
gum or lozenges, and using vaginal lubricants. Saliva
substitutes (eg, carboxymethylcellulose) are not usually
effective. Cholinergic agonists have been shown to help
increase salivary secretion and are approved by the US Food
and Drug Administration (FDA) for this use. The treatment of
secondary Sjögren syndrome is determined by the severity of
the overlapping autoimmune disorder and may include the
use of additional agents, such as methotrexate,
cyclophosphamide, rituximab, and mycophenolate.
Prof DR Dr Ariyanto Harsono SpA(K) 48
TREATMENT…..

49.
Pilocarpine (Salagen)
Pilocarpine is a muscarinic M3 receptor agonist.
Cevimeline (Evoxac)
Cevimeline is a muscarinic M3 agonist. It has 40-fold less binding affinity to M2
receptors and therefore has the theoretical benefit of causing less stimulation of
cardiac tissues. This agent has a longer duration of action than pilocarpine.
These agents are used to treat extraglandular disease (ie, interstitial pneumonitis,
glomerulonephritis, polyarthritis, vasculitis, pseudolymphoma, neurologic
manifestations).
Prof DR Dr Ariyanto Harsono SpA(K) 49
TREATMENT…..

50.
Prednisone
Prednisone is a corticosteroid with salt-retention properties
used for its potent anti-inflammatory effects.
The use of NSAIDs in Sjögren syndrome is similar to agents
used for juvenile arthritis. These agents may be used to treat
polyarthritis associated with Sjögren syndrome.
Ibuprofen (Motrin, Advil, Caldolor)
Ibuprofen is the drug of choice for patients with mild to
moderate pain. It inhibits inflammatory reactions and pain by
decreasing prostaglandin synthesis. It also has anti-
inflammatory and antipyretic properties. Ibuprofen is available
in 200-, 400-, 600-, and 800-mg doses.
Prof DR Dr Ariyanto Harsono SpA(K) 50
TREATMENT…..

51.
Naproxen (Aleve, Naprosyn, Naprelan)
Naproxen is used for the relief of mild to moderate
pain. It inhibits inflammatory reactions and pain by
decreasing the activity of cyclooxygenase, which is
responsible for prostaglandin synthesis.
These agents are used for polyarthritis not
controlled with nonsteroidal anti-inflammatory
drugs (NSAIDs).
Prof DR Dr Ariyanto Harsono SpA(K) 51
TREATMENT…..

52.
Methotrexate (Trexall, Rheumatrex)
Methotrexate has been shown to be effective in managing polyarthritis.
Methotrexate has an unknown mechanism of action in the treatment of inflammatory reactions
(although it may involve adenosine receptors). The drug, which may affect immune function,
ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Adjust the dose gradually
to attain a satisfactory response.
Other DMARDs, such as hydroxychloroquine, may be synergistic when coadministered with
methotrexate.
Antimalarials agents
These agents may inhibit chemotaxis of eosinophils and the locomotion of neutrophils and may
impair complement-dependent antigen-antibody reactions.
Hydroxychloroquine sulfate (Plaquenil)
The mechanism of action for this drug is unclear; in the treatment of inflammatory arthritis, the
mechanism of action is unknown. Hydroxychloroquine sulfate may inhibit chemotaxis of
eosinophils and the locomotion of neutrophils and impairs complement-dependent antigen-
antibody reactions.
Prof DR Dr Ariyanto Harsono SpA(K) 52
TREATMENT…..

53.
Refference
• Muscal E, Jung LK, FlaitzCM: Pediatrics Sjogren
Syndrome.http://emedicine.medscape.com/articl
e/1008536-overview
Prof DR Dr Ariyanto Harsono SpA(K) 53

54.
Prof DR Dr Ariyanto Harsono SpA(K) 54Thankyou