Sjögren’s+syndrome


 * Sjögren’s syndrome(SS)

Quick diagnosis : ตาแห้ง ปากแห้ง ผิวแห้ง ต่อมน้ำลายพาโรติดโต**

เป็นโรคในกลุ่มความผิดปกติของระบบภูมิคุ้มกัน โดยมีความผิดปกติที่ต่อมมีท่อ (exocrine glands) เป็นหลัก การวินิจฉัยอาจล่าช้าเนื่องจากลักษณะที่ค่อยเป็นค่อยไปและไม่รุนแรงในช่วงแรก ทำให้ได้รับการรักษาตามอาการไปก่อน ไม่ทราบสาเหตุที่ชัดเจนแต่จากการศึกษา พบปัจจัยที่อาจเกี่ยวข้องดังนี้ พันธุกรรม (HLA-DR3,HLA-DQ2)  ฮอร์โมน ( พบมากในหญิง 40-50 ปี )  การติดเชื้อ (CMV,HepC,HTL V-1)  autoantibody( ตรวจพบ anti SSA/Ro,anti SSB/La) ความเสื่อม พบได้หลายระบบแต่ลักษณะเด่นคือ ความผิดปกติของ exocrine glands อาการที่เด่นที่ทางตาและปาก แบ่ง 2 กลุ่มอาการ  1. กลุ่มอาการที่เกิดจากความผิดปกติของ exocrine glands ทำหน้าที่ผิดปกติเนื่องจากมี lymphocyte <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ไปแทรกตัวอยู่ ทำให้มีอาการดังนี้ ปากแห้ง 98% <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ตาแห้ง 93% <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ผิวหนังแห้ง 31% <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ต่อมน้ำลาย parotid <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">โต 19% ocular test + 95% <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ฉีดสีต่อมน้ำลาย parotid + 77%, <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ตรวจพยาธิต่อมน้ำลาย + 74% <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 1.1  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ตา อาการตาแห้ง คือ เคืองตา ไม่สบายตา คล้ายมีเม็ดทรายในตา อาการมักค่อยๆเป็น และเป็นมากจนต้องพบแพทย์ ทั้งนี้ต้องดูสาเหตุอื่นด้วยเช่น ท่อน้ำตานตัน ได้ยาบางชนิด การตรวจเพิ่มเติมทางตา คือ การทำ Schirmer’s test <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ใช้กระดาษกรองวางที่หนังตาด้านในและวัดปริมาณที่น้ำตาไหลออกมาใน 5 <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">นาที วัดความยาวของน้ำตาที่กระดาษ ถ้าน้อยกว่า 5 mm <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ผิดปกติ 5-10mm <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ก้ำกึง มากกว่า 10mm <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ปกติ หรือใช้สี rose bengal dye <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ทดสอบ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 1.2  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ปาก ปากแห็งโดยเฉพาะกินอาหารพวกแป้ง ขนมปัง คุกกี้ จะติดที่กระพุ้งแก้ม เพดานปาก บางรายรู้สึกคอแห้งดื่มน้ำบ่อย รสชาติอาหารเปลี่ยนไป ตรวจร่างกายพบปากแห้ง ฟันผุ เหงือกผิดปกติ ลิ้นแดงอาจมีฝ้าขาวเป็นเชื้อรา การตรวจพบต่อมน้ำลายโตยิ่งทำให้คิดถึงมากขึ้น การตัดชิ้นเนื้อต่อมน้ำลายจาก lower lip <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">จะพบ lymphocyte <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">แทรกตัวอยู่มาก จะไม่ตัดจาก major salivary gland <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">เนื่องจากจะทำให้เกิด fistula <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">หรือติดเชื้อได้ง่าย <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 1.3  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ผิวหนัง แห้ง เหงื่อลดลง คัน ผิวแห้ง เกาคัน นอกจากนี้อาจพบผื่นนูน purpura <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ที่คลำได้และไม่ได้ โดยเฉพาะตามขา หากตัดไปตรวจจะพบ ลักษณะของ leukocytoclastic vasculitis (LCV) <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">นอกจากนี้ยังพบผื่นขนิดอื่นได้อีกเช่น erythema multiforme, macules, papules, <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">หรือ nodules <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ได้ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 1.4  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบสืบพันธุ์ เนื่องจากพบบ่อยในเพศหญิง อาการที่พบสารคัดหลั่งในช่องคลอดลดลง ช่องคลอดแห้งคัน เจ็บได้ขณะร่วมเพศ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 1.5  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบหายใจ สารคัดหลั่งลดลง ทำให้มีอาการไอแห้ง และอาการไอจาก hyper reactive airways <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ร่วมด้วย อาจมีการอุดตันของหลอดลมขนาดเล็ก การทำงานของปอดลดลง อาจพบภาวะ interstitial disease <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ร่วมด้วย อาจพบ nodule <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> ในปอดซึ่งต้องแยกจาก มะเร็งให้ได้ อาจมีน้ำในเยื่อหุ้มปอด ถ้าเจาะตรวจจะพบ lymphocyte <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">และ antiSSA/Ro <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">และ anti SSB/La <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ได้ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2. <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">กลุ่มอาการอื่นนอกเหนือจากต่อมไร้ท่อ (Extraglandular manifestation) <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2.1  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">กระดูกข้อและกล้ามเนื้อ พบได้บ่อย โดยมีอาการ ปวดเมื่อยกล้ามเนื้อ ปวดข้อ ข้ออักเสบ มักปวดหลายข้อและเป็นทั้ง 2 <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ข้าง การทำลายข้อน้อยกว่าโรครูมาตอยด์ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2.2  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบต่อมไรท่อ พบความผิดปกติของฮอร์โมนหลายตัว โดยเฉพาะที่เกี่ยวกับ HPA axis <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">อาจพบ ภาวะ hypothyroidism <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ได้ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2.3  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบประสาท ทั้งส่วนกลางและส่วนปลาย และระบบประสาทอัตโนมัติ เช่น  peripheral neuropathy <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">เป็นต้น <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2.4  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบไต  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">พบความผิดปกติของกระเพาะปัสสาวะได้บ้าง นิ่วในไต  distal RTA <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ได้ นอกจากนั้นยังพบ interstitial nephritis <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ได้ RTA <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">จะพบร่วมกับ systemic acidosis <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ทำให้เกิดความผิดปกติ ทำให้ระดับ calcium <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ในกระดูกลดลง เกิด hypercalciuria <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">และเกิดภาวะกระดูกพรุนได้ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2.5  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบโลหิต เช่นเม็ดเลือดชนิดต่างๆลดลง แต่ไม่มาก ซีดแบบ normocytic anemia <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">เกิดจาก anemia of chronic disease <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ภาวะมะเร็งต่อมน้ำเหลืองเป็นภาวะแทรกซ้อนที่พบได้ <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2.6  <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบบอื่นๆ ทั่วไปเช่น ไข้ อ่อนเพลีย ปวดเมื่อย ผอม น้ำหนักลด ต่อมน้ำเหลืองโต CBC <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">อาจต่ำทุกตัว, <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> ESR & CRP <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">สูง , <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> ANA positive <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ประมาณ 51-74%, anti SSA/Ro <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">และ anti SSB/La <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">บวกได้ 40% <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">และ 26% <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">การตรวจ antibody <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">อื่นไม่จำเป็น ยกเว้นในรายที่สงสัยโรคอื่นร่วมด้วย <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">อาศัยจากลักษณะทางคลินิกและผลตรวจทางห้องปฏิบัติการบางตัว โดยเกณฑ์การวินิจฉัยใช้ American-European consensus group <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ซึ่งยาวมาก [] <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ด้านล่าง จาก Sjögren’s syndrome <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> foundation
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ระบาดวิทยา **<span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> พบได้ทั่วโลก อุบัติการณ์สูงสุดในช่วงอายุ 40-50 <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ปี พบในหญิงมากกว่าชาย 9:1 <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ในไทยพบได้บ้างไม่บ่อยนัก ในจีนพบความชุก 0.33-0.77
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">สาเหตุและพยาธิกำเนิด **
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ลักษณะทางคลินิก **
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">การตรวจทางห้องปฏิบัติการ **
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">การวินิจฉัยโรค **

<span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ขึ้นกับอาการที่มาของผู้ป่วยในแต่ละราย โรคในกลุ่มภูมิแพ้ตนเอง โรคติดเชื้อเรื้อรัง โรคมะเร็ง โรคทางตา การรับยาบางชนิด <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">โดยทั่วไปเป็นการรักษาตามอาการมากกว่า ไม่มีการักษาที่เฉพาะเจาะจง <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 1. <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ตาแห้ง เลี่ยงฝุ่นละอองลม ใช้ยาหยอดตา น้ำตาเทียม การอุดท่อน้ำตาไม่ให้ไหลออก การรับประทานยาในกลุ่ม cholinergic agonist <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">อาจได้ประโยชน์สำหรับปากแห้งตาแห้ง <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 2. <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ปากแห้ง ดูแลสุขภาพปากและฟัน รวมถึงการติดเชื้อในช่องปากและเชื้อรา การใช้ลูกอมหมากฝรั่งที่ไม่มีน้ำตาลเพื่อกระตุ้นน้ำลายให้ไหลออกมา <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; msobidifontfamily: Calibri; msobidithemefont: minor-latin; msolist: Ignore;"> 3. <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">การรักษาตามอาการอื่นๆเช่น NSAIDs <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ลดอาการไข้ <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">ปวดเมื่อย การพยากรณ์โรค ไม่มีข้อมูลชัดเจน แต่โดยทั่วไป พบว่าเป็นโรคเรื้อรัง ค่อยเป็นค่อยไปโดยเริ่มจากทางต่อมมีท่อ แล้ว ตามไปด้วยอาการทางระบบทั่วไป การพยากรณ์โรคไม่ดีหากมีอาการทางระบบอื่นๆ นอกจากทาง exocrine gland <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">แล้ว การตรวจพบ autoantibody anti SSA/Ro <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">และ anti SSB/La <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">มีความเสี่ยงต่อมะเร็งต่อมน้ำเหลืองเพิ่มขึ้น <span style="display: none; font-family: Calibri; font-size: 12pt; mso-ansi-language: EN-GB; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; mso-hide: all; msoansilanguage: EN-GB; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman'; msohide: all;"> <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">The classification criteria for Sjögren’s syndrome (SS) currently used by clinicians and researchers around the world is the American-European Consensus Classification Criteria. Because many different criteria previously were used both within the U.S. and in other countries, the Sjögren’s Syndrome Foundation and members of the European Study Group on Classification Criteria brought international leaders in Sjögren’s together to develop consensus on one set of guidelines.1 Keep in mind that classification criteria is the strictest criteria available to prove a definitive diagnosis of Sjögren’s for research purposes. Physicians usually diagnose SS for clinical purposes on a more individual, medically intuitive and broader basis. **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">I. Ocular Symptoms **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';"> (at least one) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Dry eyes >3 months? <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Foreign body sensation in the eyes? <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Use of artificial tears >3x per day? **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">II. Oral Symptoms **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';"> (at least one) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Dry mouth >3 months? <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Recurrent or persistently swollen salivary glands? <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Need liquids to swallow dry foods? **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">III. Ocular Signs **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">(at least one) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">Schirmer's test, (without anesthesia) <span style="font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">≤ <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">5 mm/5 minutes <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">Positive vital dye staining (van Bijsterveld <span style="font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">≥ <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">4) (focus score <span style="font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">≥ <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">1 per 4 mm2)2 <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';"> **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">V. Oral Signs **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">(at least one) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">Unstimulated whole salivary flow ( <span style="font-size: 12pt; mso-bidi-font-family: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman';">≤ <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">1.5 mL in 15 minutes) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Abnormal parotid sialography3 <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Abnormal salivary scintigraphy4 **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">VI. Autoantibodies **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';"> (at least one) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Anti-SSA (Ro) or Anti-SSB (La) **a.** Any 4 of the 6 criteria, must include either item IV (Histopathology) or VI (Autoantibodies) In patients with another well-defined major connective tissue disease, the presence of one symptom (I or II) plus 2 of the 3 objective criteria (III, IV and V) is indicative of secondary SS. **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">Exclusion Criteria **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';"> <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Past head and neck radiation treatment <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Hepatitis C infection <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Acquired immunodeficiency syndrome (AIDS) <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Pre-existing lymphoma <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Sarcoidosis <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Graft versus host disease <span style="font-family: Symbol; font-size: 10pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol; msobidifontfamily: Symbol; msobidifontsize: 12.0pt; msofareastfontfamily: Symbol; msolist: Ignore;">· <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Current use of anticholinergic drugs REFERENCES <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';"> || <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">การวินิจฉัยแยกโรค **
 * <span style="font-family: 'Cordia New','sans-serif'; font-size: 14pt; line-height: 115%; mso-ansi-font-size: 11.0pt; mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: 'Cordia New'; mso-bidi-theme-font: minor-bidi; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">การรักษา **
 * **<span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Diagnosis Criteria ** ||
 * **<span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">American-European Consensus Sjögren’s Syndrome Classification Criteria **
 * <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">IV. Histopathology ** <span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';"> Lip biopsy showing focal lymphocytic sialoadenitis
 * <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">For a primary Sjögren’s syndrome diagnosis: **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">
 * b.** Any 3 of the 4 objective criteria (III, IV, V, VI)
 * <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">For a secondary Sjögren’s syndrome diagnosis: **<span style="font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman';">
 * 1) <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, Daniels TE, Fox PC, Fox RI, Kassan SS, Pillemer SR, Talal N, Weisman MH, European Study Group on Classification Criteria for Sjögren’s Syndrome. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002 Jun;61(6):554-8.
 * 2) <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Daniels TE, Whitcher JP. Association of patterns of labial salivary gland inflammation with keratoconjunctivitis sicca. Analysis of 618 patients with suspected Sjögren’s syndrome. //Arthritis Rheum.// 1994;37:869-877.
 * 3) <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Rubin H, Holt M. Secretory sialography in diseases of the major salivary glands. //AJR Am J Roentgenol.// 1957;77:575-598.
 * 4) <span style="font-family: Calibri; font-size: 12pt; mso-bidi-font-family: 'Angsana New'; mso-fareast-font-family: 'Times New Roman'; msobidifontfamily: 'Angsana New'; msofareastfontfamily: 'Times New Roman';">Shall GL, Anderson LG, Wolf RO, Herdt JR, Tarpley TM Jr, Cummings NA, et al. Xerostomia in Sjögren’s syndrome: evaluation by sequential scintigraphy. //JAMA//. 1971;216:2109-2116.