LNSLNS

We would like to thank the authors of the correspondences for their constructive contributions.

We fully agree with Prof. Schmidt that Schirmer’s test is not a suitable examination for determining corneal damage. Rather, examinations carried out by ophthalmologists are necessary for this purpose, such as the local application of vital dyes (Lissamine green or fluorescein), as recommended in the new classification criteria cited. This also allows assessment of cornea and conjunctiva damage to be determined, which in turn plays a role in the classification criteria. We are especially grateful that additional causes of dry eyes’ challenges with intact aqueous phase were mentioned, due for instance to a disturbed lipid or mucin phase. For reasons of space, this was only shown for differential diagnoses purposes in Table 1 (1) of our article.

The working capacity of persons with Sjögren’s is reduced as compared to the normal population. In addition to sicca symptoms, fatigue, age, and the burden of fibromyalgia appear to be the most important predictors of this (2).

We thank Prof. Kiesewetter for pointing out that Raynaud’s phenomenon is frequent (although unspecific), occurring in 10% to 37% of persons with primary Sjögren’s syndrome (pSS). Fortunately, the symptoms are relatively mild; the available treatment options, including avoidance of cold and calcium channel blockers, were recently presented very extensively (3). Capillary microscopic changes are also described in pSS patients with and without Raynaud’s, as described for example in the publication by Corominas H. et al. cited by Kiesenwetter. However, no specific pattern for pSS has been detected. Immune complex glomerulonephritis with pronounced proteinuria can also occur in pSS and is most frequently associated with cryoglobulinemic vasculitis. However, glomerulonephritis is rare in pSS as compared to tubulointerstitial nephritides (differential diagnosis of systemic lupus erythematosus or overlap syndromes) (4). The therapeutic possibilities mentioned (bromelain and rutin) have not been supported by adequate trial data. Prophylactic anticoagulation is not necessarily indicated for mild skin vasculitis unless other risk factors for thromboembolic events, such as immobilization and hospitalization, are also present (5).

DOI: 10.3238/arztebl.2017.0660c

On behalf of the authors:

Dr. med. Ana-Luisa Stefanski

Charite Universitatsmedizin Berlin

Division of Rheumatology and Clinical Immunology

Ana-Luisa.Stefanski@charite.de

Conflict of interest statement

The authors of all contributions declare that no conflict of interest exists.

1.
Stefanski AL, Tomiak C, Pleyer U, Dietrich T, Burmester GR, Dörner T: The diagnosis and treatment of Sjögren‘s syndrome. Dtsch Arztebl Int 2017; 114: 354–61 VOLLTEXT
2.
Mandl T, Jørgensen TS, Skougaard M, Olsson P, Kristensen LE: Work disability in newly diagnosed patients with primary Sjogren syndrome. J Rheumatol 2017; 44: 209–15 CrossRef MEDLINE
3.
Wigley FM, Flavahan NA: Raynaud‘s phenomenon. N Engl J Med 2016; 375: 556–65 CrossRef MEDLINE
4.
Evans R, Zdebik A, Ciurtin C, Walsh SB: Renal involvement in primary Sjogren‘s syndrome. Rheumatology (Oxford) 2015; 54: 1541–8 CrossRef MEDLINE
5.
Encke A, Haas S, Kopp I, et al.: S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). AWMF 2015. www.awmf.org/leitlinien/detail/ll/003–001.html (last accessed on 27 July 2017).
1.Stefanski AL, Tomiak C, Pleyer U, Dietrich T, Burmester GR, Dörner T: The diagnosis and treatment of Sjögren‘s syndrome. Dtsch Arztebl Int 2017; 114: 354–61 VOLLTEXT
2.Mandl T, Jørgensen TS, Skougaard M, Olsson P, Kristensen LE: Work disability in newly diagnosed patients with primary Sjogren syndrome. J Rheumatol 2017; 44: 209–15 CrossRef MEDLINE
3.Wigley FM, Flavahan NA: Raynaud‘s phenomenon. N Engl J Med 2016; 375: 556–65 CrossRef MEDLINE
4.Evans R, Zdebik A, Ciurtin C, Walsh SB: Renal involvement in primary Sjogren‘s syndrome. Rheumatology (Oxford) 2015; 54: 1541–8 CrossRef MEDLINE
5.Encke A, Haas S, Kopp I, et al.: S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). AWMF 2015. www.awmf.org/leitlinien/detail/ll/003–001.html (last accessed on 27 July 2017).

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