Can Sjogren's (Sjogren's syndrome) cause loss of balance?

Can Sjögren's Syndrome Cause Loss of Balance?

Yes, Sjögren's syndrome can cause loss of balance through peripheral neuropathy, particularly sensory ataxic neuropathy and autonomic neuropathy, which are well-documented neurological manifestations of this disease.

Mechanism of Balance Impairment

Sjögren's syndrome causes loss of balance primarily through two neuropathic pathways:

• Sensory ataxic neuropathy results from large fiber loss in peripheral nerves, leading to impaired proprioception and coordination, which directly causes balance problems 1, 2
• Autonomic neuropathy can cause orthostatic hypotension and abnormal pupil reactions, contributing to dizziness and balance disturbances 1, 2
• The pathophysiology involves CD8-positive cytotoxic T lymphocyte infiltration of dorsal root ganglia and sympathetic ganglia, causing neuronal loss 1

Prevalence and Clinical Patterns

The neurological manifestations causing balance problems are common:

• Peripheral neuropathy occurs in approximately 15% of patients with primary Sjögren's syndrome 3
• Neurological symptoms are reported in 8.5-70% of pSS patients across various studies, making this one of the most common extraglandular manifestations 4
• Sensory ataxic neuropathy specifically presents with sensory symptoms without substantial motor involvement, but with prominent balance and coordination difficulties 1

Specific Neuropathy Types Affecting Balance

Multiple forms of Sjögren's-related neuropathy can impair balance:

• Sensory ataxic neuropathy - characterized by large fiber loss with prominent ataxia and balance impairment 1, 2
• Autonomic neuropathy - causes orthostatic hypotension, abnormal pupils, and balance problems particularly when standing 1, 2
• Multiple mononeuropathy - can cause asymmetric limb weakness affecting gait and balance 1
• Radiculoneuropathy - presents with motor impairment that can affect ambulation 1

Critical Diagnostic Considerations

When evaluating balance problems in the context of possible Sjögren's:

• Neuropathic symptoms precede or lead to Sjögren's diagnosis in 2:1 ratio, meaning balance problems may be the presenting complaint before sicca symptoms are recognized 3
• The majority of patients (93%) are diagnosed with Sjögren's syndrome after neurological symptoms appear 5
• Small-fiber neuropathy can cause non-length-dependent distribution of symptoms, affecting proximal areas and potentially causing balance issues through pain and proprioceptive dysfunction 2
• Skin biopsy assessing intraepidermal nerve fiber density is useful for diagnosing small-fiber neuropathies when electromyography is normal 2

Important Clinical Pitfalls

• Do not dismiss balance problems as unrelated to Sjögren's - peripheral neuropathy is a major neurological manifestation 6, 4
• Sjögren's-related neuropathy can present as pure motor syndrome in 11% of patients, which may be misdiagnosed as other causes of weakness affecting gait 5
• More than half of patients with severe Sjögren's neuropathy fulfill EFNS criteria for CIDP, making distinction challenging and requiring careful evaluation for underlying autoimmune disease 5
• The balanced 1:1 female-male ratio in severe neuropathy cases differs from the typical 20:1 female predominance of Sjögren's, so do not exclude the diagnosis in men with neuropathy 5

Management Approach

For patients with Sjögren's and balance problems:

• Co-management with a rheumatologist is essential due to the systemic nature and potential for multiple organ involvement 6, 7
• Glucocorticoids are the most commonly used treatment for Sjögren's-related peripheral neuropathy, particularly when associated with vasculitis 3
• Intravenous immunoglobulin is the second-line treatment option 3
• Differential therapeutic responses occur among various neuropathic forms, making accurate classification important 1
• Careful neurological evaluation combined with neurophysiological tests is recommended 4