The Clinicopathological Study On Involvement Of Submandibular Gland In Stevens-Johnson Syndrome

Stevens-Johnson syndrome(SJS)is a rare serious adverse drug reaction(ADR)involving skin and mucosa,which is a systemic disease involving multiple systems and dry mouth and dry eyes are common sequelae of SJS.Our previous preliminary study showed that in the patients with severe dry eye caused by SJS,the secretion function of SMG was damaged to some extent.Intraoperatively,the changes of glandular morphology are also distinct and the most prominent symptom in SJS patients was hypofunction of SMG.However,as one of the organs involved by SJS,the morphologic and functional characteristics of involved salivary glands require to be elucidated.In this study,we investigated the clinical and histopathologic characteristics of involved SMG in SJS patients in order to provide a basis for choosing the appreciate donor SMGs in transplantation of SMG for treatment of severe dry eyes,and for appreciate diagnosis and management of xerostomia.Part Ⅰ:Measurement of the weight and volume of submandibular gland in vitro and the evaluation of CT volume renderingEnlargement and atrophy of the submandibular glands are common clinical lesions in salivary gland diseases.However,the diagnosis of enlargement and atrophy was based solely on the subjective judgment of clinicians previously and lacks objective diagnostic criteria.It is well known that the pathological features of submandibular gland involvement in SJS patients are glandular atrophy.In order to objectively evaluate the incidence and severity of glandular atrophy,it is necessary to establish a reference standard for the mass and volume of normal submandibular gland.The description of normal submandibular gland weights is less common and specific study data are lacking.Our group has previously used CT volume rendering to measure the volume of submandibular glands and established a reference value for normal submandibular gland volume in different gender and age groups,which has been used to evaluate the diagnostic and therapeutic effects of IgG4-related sialadenitis(IgG4-RS).However,the actual situation of whether CT volume rendering can objectively reflect human submandibular gland volume is unknown.Selective neck dissection is often performed clinically for oral cancer patients with clinically negative cervical lymph nodes(N0),and the resected submandibular glands are mostly normal.In this study,we measured the weight and volume of normal submandibular gland by in vitro detection of glandular body,to compare with the measurement values of CT volume rendering to evaluate the consistency of the two methods,and to explore the related factors affecting the weight and volume of the submandibular gland.Evaluation of the reliability and feasibility of CT volume rendering also provides a basis for further study of SMG involvement in SJS patients.ObjectiveTo measure the weight and volume of normal submandibular gland by in vitro detection of glandular body,to compare with the measurement values of CT volume rendering to evaluate the consistency of the two methods,and to explore the related factors affecting the weight and volume of the submandibular gland.MethodsThe patients who underwent neck dissection due to oral cancer and were confirmed with normal submandibular gland by postoperative histopathology in Peking University School and Hospital of Stomatology from May 2019 to January 2020 were collected in this study and divided into 4 groups according to the age standards raised by the Society of Geriatrics Chinese Medical Association and WHO(2000)age standards.The submandibular gland was carefully dissected along with the capsule immediately after neck dissection.The weight and volume of submandibular gland were accurately measured by an integrated aseptic measuring device.The volume of submandibular gland was measured by CT volume rendering before operation and the consistency of the two methods was evaluated.The 95%confidence interval of the weight and volume of submandibular gland in the different groups of Chinese people,which were divided by gender and age,were calculated,and the correlation with age,gender,height,weight,body mass index(BMI)and other factors was analyzed.ResultsThe weight and volume of submandibular gland were measured in 220 subjects.The average weight and volume of submandibular gland were(11.69±2.45)g and(11.55±2.41)cm3 respectively.The volume of submandibular gland measured by CT volume rendering ranged from 70%to 82%of that measured by in vitro detection of glandular body,and the correlation coefficient between the two methods was 0.976(P<0.05).The gender difference of weight and volume of submandibular gland existed in the groups of youth,middle-aged and elderly groups,the values of males were obviously higher than those of females(P<0.05).There was no gender difference in weight and volume of submandibular gland in the adolescent group(P>0.05).The weight and volume of submandibular gland had a strong positive correlation with body height(P<0.05),a weak positive correlation with body weight(P<0.05),and no correlation with BMI(P>0.05).The female’s weight and volume of submandibular gland in the young elderly and elderly groups were significantly lower than those in the other three groups(P<0.05).ConclusionThe normal reference range of the weight and volume of submandibular gland in vitro were established in different age and gender groups of Chinese people.The volume of submandibular gland measured by CT volume rendering was 70%-82%of that measured by in vitro detection of the glandular body.The results of the two methods had a high degree of consistency.The weight and volume of submandibular gland were related to gender,body height and body weight.Part Ⅱ:Clinical and histopathologic characteristics of submandibular gland involved by Stevens-Johnson syndromeStevens-Johnson syndrome(S JS)is a rare serious adverse drug reaction(ADR)involving skin and mucosa,which is a systemic disease involving multiple systems and organs.It is reported that 40%of SJS survivors have "Sj?gren-like syndrome" showing dry mouth and dry eyes which demonstrated that SMG was involved in SJS.However,as one of the organs involved by SJS,the morphologic and functional characteristics of involved salivary glands require to be elucidated.Our group has developed transplantation of SMG for treatment of severe dry eye in the past 20 years,and SJS was the cause of severe dry eye in more than half of these patients,which creating favorable conditions for performing the clinicopathological study on involvement of SMG in SJS patients.Therefore,in this study,SJS patients who underwent transplantation of SMG for treatment of severe dry eye in our hospital were enrolled and non-SJS patients were enrolled as controls,and changed parameters in the morphological structure and secretory function of the SMG were used as indicators to investigate the clinicopathological characteristics of the SMG involvement in SJS patients and provide a basis for choosing the appreciate donor SMGs in transplantation of SMG for treatment of severe dry eyes,and for appreciate diagnosis and management of xerostomia.ObjectivesThis study aimed to investigate the clinical manifestations and pathologic appearances of the submandibular gland(SMG)involved by Stevens-Johnson syndrome(SJS).MethodsOne hundred and twenty patients who received transplantation of SMG for treatment of severe dry eye between March 1998 and May 2018 were enrolled in this study and divided into SJS group(70 cases)and non-SJS group(50 cases)according to the illness history of SJS.The weights and the CT volumes of SMG were calculated.The saliva flow rate was measured.Scintigraphy with 99mTc-pertechnetate was undertaken and the concentration index(CI)and secretion index(SI)were calculated.A small piece of SMG was harvested and stained with hematoxylin-eosin.At 20x magnification,three square areas were randomly selected from each gland and the maximum diameter of the acini,percentage of glandular parenchyma in the whole field and the proportion of serous to mucous acini were measured by Image J.ResultsThe volume and weight of submandibular gland in SJS group were significantly lower than those in non-SJS group and normal control group,but there was no significant difference between non SJS group and normal control group.34 out of 70(48.57%)SMG were shown decreased values of CT volumes and weights in SJS group,while only 1 out of 50(2%)were decreased in non-SJS group(P<0.01).The rest total salivary flow rate(P<0.05),acid stimulated total salivary flow rate(P<0.05),and rest salivary flow rate of SMG(P<0.001)decreased in the SJS group.The percentages of patients with normal CI(37.5%vs 96.67%,P<0.001)and normal SI(35%vs 96.67%,P<0.001)of SMG decreased in SJS group.The reduction of glandular parenchyma,widening of acinar space,and increase of fat content were observed in SMG of SJS patients.ConclusionsAtrophic and degenerative changes occur in the SMG of SJS patients.Decreased salivary secretion function occur in more than half of the patients.Part Ⅲ:Association between human leucocyte antigen alleles and co-trimoxazoleinduced Stevens-Johnson syndrome with severe ocular complications in Han ChineseIt is reported that the incidence of SJS varies significantly among different ethnic groups.With advances in pharmacogenomics,several human leukocyte antigen(HLA)alleles have been identified to contribute to the pathogenesis of SJS.Recent studies showed that the pathogenic genes of SJS with severe ocular complications(SOCs)had characteristics,but most of them were focused on HLA alleles association of SJS with SOCs induced by cold medicine(CM)and non steroidal anti-inflammatory drugs(NSAID).Our group performed the technique of SMG transplantation for treatment of severe dry eye in the past 20 years,and SJS was the cause of severe dry eye in more than half of these patients and most of the SJS with SOCs were induced by co-trimoxazole.Co-trimoxazole is one of the most commonly used sulfonamides antibiotics.Whether there is an association between co-trimoxazole-induced SJS with SOCs and HLA allele is lack of in-depth research.In this study,the patients who received submandibular gland transplantation in our hospital for treatmen of SJS with SOCs were collected and divided into two groups according to whether the SJS with SOCs induced by cotrimoxazole or not.The HLA alleles were detected and their frequencies were compared between two groups,and took the HLA alleles frequency in the major histocompatibility complex(MHC)database of Chinese Han population as the normal control.The association between HLA alleles and co-trimoxazole-induced SJS with SOCs was preliminarily investigated,to provide a reference for the prevention of co-trimoxazole-induced SJS with SOCs.ObjectiveThe aims of this study were to investigate the frequencies of HLA alleles in patients with co-trimoxazole-induced SJS with SOCs and compared those with non co-trimoxazole-induced SJS with SOCs group and normal control group,and to investigate the association between HLA alleles and co-trimoxazole-induced SJS with SOCs.MethodsA total of 14 patients who were followed-up after transplantation of SMG for treatment of severe dry were enrolled in this study,including co-trimoxazole-induced SJS(n=8)and non co-trimoxazole-induced SJS(n=6).Patients’ blood was collected and DNA was extracted.Next-generation sequencing(NGS)was performed using Illumina TruSight HLA V2 Sequencing Panel,which covered whole gene for HLA-A,B,C.Selected cases were retrospectively analyzed using Conexio Assign software(IMGT library 3.26-3.33)for identifying genotype.Web based NCBI dbSNP GeneView section was used to verify the genomic coordinate.Each allele was mapped and assigned as low-or high-expressionResultsIn patients with co-trimoxazole-induced SJS with SOCs,the allele frequencies of HLAA*02:03(OR=9.24,95%CI=2.63 to 32.52,P=0.006),HLA-B*38:02(OR=11.86,95%CI=3.37 to 41.8,P=0.003)and HLA-B*44:03(OR=7.95,95%CI=2.26 to 27.97,P=0.011)were higher than those in control group and those in non co-trimoxazole-induced SJS with SOCs.There was no overlap with these three HLA alleles in the co-trimoxazole-induced SJS group and non co-trimoxazole-induced SJS group.In all patients with SJS with SOCs,the allele frequency of HLA-A*02:03(OR=4.80,95%CI=1.45 to 15.96,P=0.03),HLAA*02:07(OR=3.45,95%CI=1.40 to 8.51,P=0.014),HLA-B*38:02(OR=6.17,95%CI=1.86 to 20.51,P=0.016)and HLA-B*44:03(OR=4.13,95%CI=1.24 to 13.73,P=0.044)were higher than that in controls.ConclusionsThe frequencies of HLA-A*02:03,HLA-B*38:02 and HLA-B*44:03 alleles in patients with co-trimoxazole-induced SJS with SOCs in Han population were higher than those in normal Han population and other medicine-induced SJS with SOCs patients,which may be related to the pathogenesis of co-trimoxazole-induced SJS with SOCs.Our findings demonstrate the genetic diversity in SJS pathogenesis among different ethnic groups.