Submitted:
11 September 2026
Posted:
14 September 2026
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Abstract
Objectives: Sjögren’s disease (SjD) and Hashimoto’s thyroiditis (HT) are closely associated autoimmune diseases. This study compared elastographic changes in the major salivary and thyroid glands of patients with SjD and HT. Methods: This cross-sectional study included 30 SjD and 31 HT patients. Ultrasonography and Shear Wave Elastography (SWE) were performed to evaluate the parotid, submandibular, and thyroid glands. Salivary gland structural changes were assessed using OMERACT scores, while thyroids were evaluated for heterogeneity and pseudonodular appearance. Results: Thyroid parenchymal heterogeneity was more frequent in HT patients, though 43% of SjD patients also exhibited HT-like thyroid features. In contrast, no HT patients showed SjD-like salivary gland changes (OMERACT score ≥3). Elastographic measurements of thyroid and salivary glands did not differ significantly between groups, even after age adjustment via ANCOVA. Furthermore, clinical disease activity (ESSDAI) did not correlate with elastographic findings in SjD. However, SjD patients with severe structural changes (OMERACT score ≥4) had significantly higher elastography indices exclusively in the left parotid gland (p=0.004). Conclusion: SjD is associated with thyroiditis-like changes in the thyroid, but HT lacks structural salivary gland involvement. Elastographic findings of these glands are similar in both diseases. Generally, ultrasonographically detected salivary gland parenchymal changes in SjD do not significantly affect glandular elasticity.
Keywords:
elastography
; Sjögren’s disease
; Hashimoto’s Thyroiditis
; ultrasonography
Introduction
Sjögren’s disease (SjD) is a chronic inflammatory autoimmune disorder of unknown etiology that results from immune-mediated damage to the salivary and lacrimal glands, leading to xerostomia and keratoconjunctivitis sicca. Because SjD primarily affects exocrine glands such as the salivary and lacrimal glands, it may also involve other organ systems, including the respiratory, gastrointestinal, neurological, and urogenital systems. It is therefore considered a complex multisystem disease that can present with involvement of virtually any organ system [1]. SjD predominantly affects women, with a female-to-male ratio of approximately 9:1 [2]. Although the disease is most commonly diagnosed in the fourth and fifth decades of life, symptoms may begin several years prior to diagnosis [3,4,5].
Hashimoto’s thyroiditis (HT), first described by Hakaru Hashimoto in 1912 as struma lymphomatosa, is characterized by lymphocytic infiltration and enlargement of the thyroid gland [6]. HT is more frequently observed in women, and its prevalence increases with age [4,7]. The prevalence of autoimmune thyroid diseases has been reported to be significantly higher in patients with SjD compared with the general population, and conversely, patients with HT exhibit an increased frequency of clinical and immunological features characteristic of SjD [8,9]. Moreover, both SjD and HT frequently coexist with other autoimmune diseases, including myasthenia gravis, systemic sclerosis, pernicious anemia, and autoimmune liver diseases [4,10].
SjD and HT share similar pathogenic mechanisms as autoimmune disorders. Their hallmark histopathological features include lymphocytic infiltration predominantly composed of CD4+ T lymphocytes and the formation of germinal center–like structures indicative of B-cell activation within the affected tissues [11]. From a genetic perspective, both thyroid and epithelial cells express the same class of HLA molecules, particularly HLA-B8 and HLA-DR3, and the presence of these haplotypes has been frequently identified in individuals affected by both SjD and autoimmune thyroid diseases [11]. One of the shared pathological mechanisms between SjD and autoimmune thyroid disease involves the role of epithelial cells in initiating and sustaining tissue inflammation through chemokine signaling, particularly interferon-γ–induced protein-10 (IP-10/CXCL10). CXCL10 exerts its effects via the chemokine (C-X-C motif) receptor-3 (CXCR3) [12]. CXCL10 is associated with a strong and aggressive inflammatory response in autoimmune-related thyroid diseases, while in SjD, CXCL10 produced by epithelial cells and CXCR3 expressed by CD3+ lymphocytes in periductal infiltrates are closely associated with salivary gland damage [13].
Ultrasonography (US) is an effective imaging modality for evaluating the structural characteristics of both salivary and thyroid glands. In a study conducted by Wierzbicka et al. [14]., parotid gland elastography was used to assess parotid diseases associated with chronic inflammation, and patients with SjD demonstrated significantly increased tissue stiffness on elastography despite the absence of fibrotic changes on conventional ultrasonography. A meta-analysis has demonstrated that shear wave elastography (SWE) is a strong supportive imaging tool for the diagnosis of pediatric HT, particularly when used in conjunction with conventional ultrasonography for early diagnosis, assessment of disease severity, and follow-up [15]. In a study by Baltacıoğlu et al. [16]. investigating the role of SWE in the diagnosis of HT, thyroid elastography findings were found to correlate with pulsatility and resistance indices obtained from thyroid Doppler ultrasonography. Increased stiffness values on thyroid SWE, together with decreased peak systolic and end-diastolic velocities on Doppler US, have been identified as strong diagnostic indicators.
Given the frequent coexistence and shared autoimmune mechanisms of SjD and HT, this study aims to investigate and compare ultrasonographic and elastographic alterations in the major salivary and thyroid glands of patients with SjD and HT.
Method
Study Population
Between November 2024 and May 2025, a total of 30 patients diagnosed with SjD according to the 2016 ACR–EULAR classification criteria [17]. and 31 patients diagnosed with Hashimoto’s thyroiditis (HT) were enrolled from the Rheumatology Clinic of Antalya Training and Research Hospital. The diagnosis of HT was based on the presence anti–thyroid peroxidase (anti-TPO) and/or anti–thyroglobulin (anti-Tg) antibodies and/or hypoecogenity, parenchymal heterogeneity and pseudonodular appearance on thyroid ultrasonography.
Ethical approval for the study was obtained from the Clinical Research Ethics Committee of Antalya Training and Research Hospital (Approval No: 2025-142).
Demographic characteristics of all patients, including age, sex as well as types of clinical involvement (arthralgia/arthritis, cutaneous manifestations, pulmonary involvement, renal involvement, serosal involvement, and central nervous system involvement), sicca symptoms, and ocular dryness were recorded. In addition, salivary gland biopsy results, immunosuppressive treatments used, and disease activity scores were documented.
Laboratory evaluations included antinuclear antibody (ANA), anti-Ro52, anti-SSA, anti-SSB, rheumatoid factor (RF), anti–thyroid peroxidase (anti-TPO), anti-thyroglobulin antibodies, presence of proteinuria, immunoglobulin levels, and complement (C3 and C4) levels. Anemia was defined as hemoglobin <12 g/dL, leukopenia as a white blood cell count <4,000/mm3, and thrombocytopenia as a platelet count <100,000/mm3.
Ultrasonography
To ensure consistency, all ultrasound examinations were carried out by the same radiologist. The radiologist who performed the ultrasonography and elastography examinations was blinded to the patients’ clinical diagnoses and laboratory results.
All ultrasonography and elastography examinations were performed using a Canon Aplio 500 ultrasound system (Canon Medical Systems, Otawara, Japan). A convex transducer (e.g., 1–6 MHz) was used for the evaluation of abdominal organs, and a linear transducer (e.g., 5–14 MHz) was used for the assessment of the salivary glands. Prior to shear wave elastography (SWE) acquisition, a conventional B-mode ultrasound examination was conducted to evaluate parenchymal echotexture, homogeneity, presence of focal lesions, and proximity to conspicuous vascular structures and/or ductal anatomy. When exclusion of vascular structures within the planned measurement area was required, color Doppler ultrasonography was used to assess vascularity.
Shear wave elastography is a quantitative ultrasound technique used to assess the mechanical properties of tissues. The system generates a short-duration, low-amplitude acoustic radiation force impulse within the selected region, producing microscopic tissue displacement and inducing transversely propagating shear waves. The shear wave propagation velocity (m/s) is related to tissue stiffness, with faster propagation observed in stiffer tissues. The system tracks shear wave propagation at high frame rates, calculates shear wave velocity, and typically converts this parameter into kilopascals (kPa) as an estimate of Young’s modulus (approximately E ≈ 3ρc2, where ρ represents tissue density and c represents shear wave velocity). In this study, SWE measurements were recorded as provided by the device in kPa and/or m/s.
Pre-Measurement Standardization (Artifact Reduction)
To minimize technical factors that could influence measured tissue elasticity, the following standardized conditions were applied:
- Adequate coupling gel was used, and minimal transducer compression was applied to avoid artificial tissue stiffening.
- Measurements were planned, whenever feasible, within homogeneous parenchymal regions away from the capsule and septal structures.
- Vessels, ductal structures, calcifications, prominent fibrotic bands, and lesion margins were excluded from the region of interest (ROI).
- Given that the reliability of SWE measurements may decrease with increasing depth, the ROI was placed in artifact-free and relatively superficial parenchymal regions.
- To reduce motion artifacts, patients were provided with respiratory instructions, and the transducer was held stable during image acquisition.
SWE Acquisition Window and ROI Placement
After activation of the SWE mode, the elastography color map (elastogram) was overlaid on the B-mode image. Measurements were obtained when the elastogram was stable and the system’s quality indicators were deemed adequate.
For each organ, an approximately 1 cm (≈10 mm) region of interest (ROI) was defined:
- A circular ROI was used when permitted by the system, targeting an approximate diameter of 10 mm.
- For each acquisition, the ROI was positioned within homogeneous-appearing parenchyma on B-mode imaging, while heterogeneous or artifact-prone regions on the elastogram were excluded.
- When available, the system’s quality and/or propagation maps were utilized; areas demonstrating smooth and uninterrupted shear wave propagation (e.g., parallel and undistorted contours) were preferred, and frames showing clearly distorted propagation were not included for analysis.
Parotid Gland
Parotid gland SWE measurements were performed using a linear transducer over the superficial lobe. A region representative of homogeneous glandular parenchyma was selected, and the ROI was positioned away from conspicuous vascular and ductal structures as well as potential intraparotid lymph nodes. Minimal transducer pressure was applied to reduce artifacts. Measurements were recorded separately for the right and left parotid glands.
Submandibular Gland
Submandibular gland SWE measurements were performed using a linear transducer in the submandibular region. The ROI was placed within a homogeneous area of glandular parenchyma, avoiding Wharton’s duct and vascular structures. Measurements were obtained bilaterally.
Ultrasonographic Scoring
Parenchymal heterogeneity, hypoecogenity and pseudonodular appearance on thyroid ultrasonography were considered indicative of Hashimoto’s thyroiditis. The parotid and submandibular salivary glands were classified according to the OMERACT major salivary gland ultrasonography scoring system [18], in which a score of 0 represents a normal gland and a score of 3 indicates marked heterogeneity characterized by hypoechoic/anechoic areas involving the entire glandular surface. In each patient, four anatomical regions (right and left parotid glands and right and left submandibular glands) were evaluated separately, yielding a total OMERACT score ranging from 0 to 12. Ultrasonographic evaluation was performed using the OMERACT scoring system, wherein each of the four salivary glands was graded separately. A cumulative global score was then calculated for each participant by aggregating the individual scores of all four glands.
Statistical Analysis
Statistical analyses were performed using SPSS software version 23.0. Continuous variables were presented as mean ± standard deviation, and categorical variables were expressed as percentages (%). Variables with a normal distribution were compared using Student’s t-test, whereas non-normally distributed variables were compared using the Mann–Whitney U test. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. A p value <0.05 was considered statistically significant. Age-adjusted comparisons of elastography parameters were conducted using ANCOVA to eliminate the confounding effect of the baseline age difference between the groups. To control for the inflation of Type I error rate due to multiple comparisons in the sub-analyses of elastographic parameters, post-hoc statistical corrections were applied. Both the conservative Bonferroni correction and the Benjamini-Hochberg False Discovery Rate (FDR) procedure were conducted across the eight independent hypothesis tests performed for the major salivary glands. The adjusted significance thresholds were rigorously calculated to confirm the robustness of the primary findings. Both the conservative Bonferroni correction and the Benjamini-Hochberg False Discovery Rate (FDR) procedure were conducted across the eight independent hypothesis tests performed for the major salivary glands. The adjusted significance thresholds were rigorously calculated to confirm the robustness of the primary findings. A post-hoc power analysis was conducted using G*Power software (version 3.1.9.7). For the primary outcome comparing elastographic parameters between SjD (n = 30) and HT (n = 31) groups, the study had lower statistical power (< 20%) to detect small effect sizes (Cohen’s d<0.30), supporting the finding that tissue stiffness parameters did not inherently differ between the two autoimmune cohorts. Conversely, for the subgroup analysis within the SjD cohort regarding left parotid elasticity according to OMERACT scores (score ≥4 vs. <4 ), the calculated effect sizes were exceptionally large ( d=1.18 for pressure and d=1.25 for shear wave velocity). Consequently, the statistical power to detect left parotid stiffness differences in advanced ultrasonographic stages reached 88.4% and 92.1% at alfa=0.05, respectively, confirming the robustness of this significant association despite the modest sample size
Results
Female sex was predominant in both the SjD and HT groups. The mean age of patients with SjD was significantly higher than that of the HT group (53.07 ± 13.51 vs. 36.2 ± 16.95 years, p = 0.014). Similarly, the age at diagnosis was higher in the SjD group (50.3 ± 12.57 vs. 36.2 ± 16.95 years, p = 0.036). Positivity for ANA, anti-Ro52, and anti-La antibodies was more frequent in patients with SjD, whereas autoantibodies associated with autoimmune thyroiditis (anti-TPO and anti-Tg) were more prevalent in the HT group. No significant differences were observed between the two groups with respect to other laboratory parameters (Table 1).
The distribution of clinical features among the patient cohort was as follows: articular involvement in 25 patients, sicca symptoms in 22 patients, pulmonary involvement in two patients, and pleural and renal involvement in one patient each
The therapeutic profile of the study cohort showed that hydroxychloroquine was the most common medication, used by 25 patients for joint involvement. Concomitant glucocorticoid treatment was reported in seven patients, prescribed for ILD (n=2), TIN (n=1), articular symptoms (n=2), pleuritis (n=1) and autoimmune hemolytic anemia (n=1). Other immunosuppressive and immunomodulatory agents included methotrexate (n=3) and sulfasalazine (n=2) for articular involvement, azathioprine (n=1) for TIN, and mycophenolate mofetil (n=2) for lung involvement. Secretagogue therapy with pilocarpine was managed in two patients for dryness symptoms. No patients were treated with rituximab or cyclophosphamide.
Ultrasonographic Findings
Parenchymal alterations of the major salivary glands were significantly more pronounced in patients with SjD. In the SjD group, 13 patients (43%) had a total OMERACT score ≥3, and 12 patients (40%) had a score ≥4. In contrast, none of the patients in the HT group reached an OMERACT score ≥3. Thyroid parenchymal heterogeneity and pseudonodular appearance were observed significantly more frequently in patients with HT compared with those with SjD (24 [77%] vs. 13 [43%], p = 0.006).
Elastographic Assessments
Elastographic measurements of the thyroid, parotid, and submandibular glands were compared separately between groups. Although mean stiffness values (kPa) were higher in the parotid glands of the SjD group and in the thyroid and submandibular glands of the HT group, no statistically significant differences were detected between the two groups (Table 1). Age-adjusted analysis (ANCOVA) resulted in slight variations in p-values without altering the significance of the results, confirming that the observed parity in elastographic measurements is independent of age (Table 2).
Among patients with SjD, those with an OMERACT ultrasound score ≥4 demonstrated significantly higher pressure and shear wave velocity values in the left parotid gland (p = 0.004 and p = 0.002, respectively). To address the multiplicity of the eight separate glandular comparisons, these results were subjected to multiple testing corrections. Under the strict Bonferroni correction (adjusted threshold alfa=0.00625), both left parotid velocity (p= 0.002) and left parotid pressure (p= 0.004) maintained their statistical significance. Furthermore, application of the Benjamini-Hochberg procedure confirmed that both parameters remained highly significant below their respective false discovery rate thresholds (0.00625 and 0.0125 respectively), validating the independent clinical relevance of left parotid stiffness in advanced ultrasonographic stages. No significant differences were observed in elastographic parameters of the right parotid gland, bilateral submandibular glands, or thyroid gland (Table 3). Furthermore, no significant association was found between salivary gland elastography findings and an ESSDAI score >4 in patients with SjD (Table 4).
Discussion
In this study, we evaluated parenchymal and elasticity-related changes in glandular structures affected by two distinct autoimmune diseases involving exocrine and endocrine glands. Our findings demonstrate that the thyroid gland is also affected in patients with SjD, with 43% of patients exhibiting ultrasonographic changes resembling thyroiditis, although without corresponding alterations in thyroid elasticity. In contrast, no structural or elastographic changes were observed in the exocrine glands of patients with HT. These results support the concept that HT is an organ-specific autoimmune disease, whereas SjD is a systemic autoimmune disorder capable of affecting multiple tissues and organs, including the thyroid gland.
No significant association was observed between salivary gland elasticity and disease activity scores in patients with SjD. However, evidence suggests that patients with more advanced ultrasonographic parenchymal changes may exhibit decreased elasticity and increased stiffness in the parotid glands.
D’Arbonneau et al. [19] reported an initial prevalence of HT of 14.5% in 137 patients with SjD, which increased to 21.8% after a mean follow-up of 5.3 years. Similarly, Caramaschi et al. [ 20] reported an HT prevalence of 27% among patients with SjD and identified isolated anti-TPO and anti-thyroglobulin antibody positivity in a small subset of patients. Other studies have also demonstrated associations between SjD and autoimmune thyroid diseases [21,22,23].
Wierzbicka et al. [14] evaluated parotid gland elastography in four chronic inflammatory conditions affecting the parotid glands such as SjD, Stensen duct stenosis, sialolithiasis, and found significantly higher mean and median stiffness values in SjD compared with the other conditions. The presence of marked tissue stiffness on elastography even in the absence of fibrotic changes on conventional ultrasonography highlights the diagnostic relevance of elastographic measurements in SjD. In another study, the elasticity modulus of the parotid gland demonstrated a high diagnostic accuracy (AUC = 0.937; 95% CI: 0.901–0.973), with a sensitivity of 93.2% and specificity of 83.3%, indicating the high diagnostic value of SWE assessment of both parotid and submandibular glands [24]. Conversely, studies comparing patients diagnosed with SjD according to AECG criteria and healthy controls have reported no significant differences between B-mode ultrasonography and elastography findings on ROC analysis [25].
Baltacıoğlu et al. [26] reported a weak correlation between TSH levels and SWE findings, but a strong correlation between anti-TPO levels and SWE measurements. Another study demonstrated that thyroid SWE could quantify the degree of fibrosis in patients with HT and showed a positive correlation between SWE results and thyroid autoantibody levels, and a negative correlation with echogenicity [27]. In that study, optimal cut-off values for diagnosing HT were identified as 29.45 kPa or 2.77 m/s.
Zhong et al. [28] found that patients with active SjD exhibited significantly higher rates of hyperechoic bands and increased SWE values in the lacrimal glands compared with patients in remission. Lacrimal gland elasticity scores were correlated with ESSPRI, but not with parotid gland elasticity findings [29]. Other studies have reported that patients with elevated parotid sonoelastography values experienced greater tooth loss and that parotid gland scores correlated with disease duration, whereas no significant association was observed between bilateral parotid and submandibular gland elastography scores and ESSDAI [30]. Consistent with these findings, Özer et al. [24] also reported no significant association between SWE findings, ultrasonographic features, and disease activity scores. In contrast, Hayama et al. [31] demonstrated a significant correlation between B-mode ultrasonography and SWE findings (τ = 0.53, P = 0.001) and reported that SWE findings correlated with unstimulated salivary flow rate, ESSDAI, glandular ESSDAI, and salivary CXCL13 and CXCL10 levels, but not with age or fibrosis. These findings suggest that SWE may reflect chronic glandular inflammatory processes rather than fibrotic changes.
In the study by Özer et al. [24] patients with SjD and a gray-scale ultrasonography score >1 exhibited significantly higher SWE values (p < 0.01). It was also suggested that elastography findings obtained from the right parotid and right submandibular glands did not provide additional diagnostic value beyond B-mode ultrasonography for the diagnosis of SjD [32]. In contrast, our study demonstrated a significant correlation between an OMERACT score ≥4 and increased stiffness and shear wave velocity in the left parotid gland (p = 0.002 and p = 0.004). Although SjD is generally characterized by bilateral and symmetrical involvement, we observed a statistically significant difference between left and right parotid gland SWE findings, with a significant association between an OMERACT score >4 and left parotid gland elastography values.
Baltacıoğlu et al. [26] reported mean elastography values of 24.34 ± 18.97 kPa in the right thyroid lobe and 24.77 ± 17.12 kPa in the left thyroid lobe in patients with HT, with no significant difference between sides. In healthy controls, corresponding values were 6.46 ± 3.32 kPa and 8.22 ± 3.76 kPa, respectively. Total thyroid SWE values were significantly higher in patients with HT compared with healthy controls (24.56 ± 18.04 kPa vs. 7.34 ± 3.54 kPa, p = 0.0132). In our study, thyroid elastography values in patients with SjD were comparable to those reported for HT in the study by Baltacıoğlu et al. (right thyroid: 20.55 ± 13.5 kPa; left thyroid: 17.09 ± 14.06 kPa). Kara et al. [27]. identified optimal cut-off values of 15.46 kPa and 2.15 m/s for predicting HT. In our cohort, 13 of 30 patients with SjD had thyroid ultrasonography findings compatible with HT, and 6 of these patients were positive for thyroid autoantibodies. SWE results in all 13 patients were consistent with the cut-off values reported for previously undiagnosed HT, suggesting that asymptomatic thyroid fibrosis may have already begun in approximately 43% of patients with SjD.
Özer et al. [24] reported mean elasticity modulus values of 20.21 ± 6.9 kPa for the submandibular glands and 21.64 ± 7.44 kPa for the parotid glands, which were significantly higher than those of healthy controls (p < 0.001). Corresponding shear wave velocities were 2.50 ± 0.41 m/s for the submandibular glands and 2.58 ± 0.42 m/s for the parotid glands. In our study, each parotid and submandibular gland was evaluated separately, and elasticity modulus values were 13.29 ± 7.9 kPa for the right submandibular gland, 13.25 ± 5.1 kPa for the left submandibular gland, 35.45 ± 28.6 kPa for the right parotid gland, and 47.11 ± 31.3 kPa for the left parotid gland.
Caramaschi et al. [20] reported isolated anti-TPO and anti-thyroglobulin antibody positivity in four patients whose thyroid ultrasonography findings were not compatible with HT. Zeher et al. [21] emphasized the importance of monitoring thyroid function tests and clinical features in patients with SjD, given the increased likelihood of developing HT even after the diagnosis of SjD. Further studies are needed to identify predictors of HT development in patients with SjD. In our study, anti-TPO antibody positivity was detected in 47% of patients with SjD, and anti-thyroglobulin positivity in 2%. Among patients with ultrasonographic findings compatible with HT, six were positive for thyroid autoantibodies.
In patients with autoimmune thyroid disease, SjD-specific autoantibodies (anti-Ro and anti-La) have been reported at rates of 16.5% and 12.5%, respectively [23]. Multivariate analyses have identified anti-La positivity, ultrasonographic changes, and elevated second-hour erythrocyte sedimentation rate as predictors of SjD development in patients with HT. In contrast, none of the patients with HT in our study exhibited parenchymal changes in the parotid or submandibular salivary glands. In our cohort, ANA positivity was observed in three patients with HT, anti-Ro positivity in one patient, and RF positivity in one patient, while no patients were positive for anti-La antibodies. Thyroid ultrasonography findings compatible with HT were observed in 43% of patients with SjD. The presence of thyroid autoantibodies remains an important risk factor for the subsequent development of autoimmune thyroid disease during follow-up [19].
Consistent with standard ultrasound imaging, operator dependency is a limitation of this study, which was mitigated by having all scans performed by a single radiologist who was blinded to the patients’ diagnoses. Another limitation is the baseline age disparity between the cohorts; while adjusted for in the statistical analysis, the residual confounding effect of age on fibrosis cannot be completely excluded. Although the overall sample size was modest, post-hoc power analysis confirmed that the main significant finding—increased left parotid stiffness in advanced OMERACT stages—retained high statistical power (>88%) due to the large effect sizes observed (d>1.18). Finally, despite immunosuppressive treatments not being targeted at sicca symptoms, we cannot completely exclude their potential influence on tissue elastography due to systemic disease management in SjD.
Conclusions
In conclusion, this study demonstrates that patients with SjD exhibit thyroid gland involvement in addition to exocrine gland involvement, whereas exocrine glands are not affected in patients with Hashimoto’s thyroiditis. Elastographic findings of endocrine and exocrine glands were comparable between patients with SjD and HT, supporting the systemic nature of SjD and the organ-specific nature of HT.
Author Contributions
VY and BA designed the study. Data collection was performed by BA, SG, and ASA. Data analysis and interpretation were conducted by VY. BA drafted the initial version of the manuscript, and all authors contributed to the final version. All authors have read and approved the final and revised manuscript.
Funding
The authors received no financial support for the research and/or authorship of this article.
Institutional Review Board Statement
All procedures performed in this study were conducted in accordance with the ethical standards of the institutional and national research committees and with the principles of the Declaration of Helsinki. The study was approved by the Clinical Research Ethics Committee of Antalya Training and Research Hospital (Approval No: 2025-142). Artificial intelligence based tools (e.g., Gemini, ChatGPT and Grammarly) were used solely to assist with language editing, grammar correction, and improvement of readability. These tools did not generate scientific content, analyze data, or influence the study design, results, or interpretation. All final decisions regarding the content and wording of the manuscript were made by the authors, who take full responsibility for the integrity and accuracy of the work.
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Table 1.
General Characteristics of the Study Groups.
|
SjD (n:30) |
HT (n:31) |
p-value | |
| Sex (Female; n, %) | 28 (93.0) | 30 (97.0) | 0.534 |
| Age (years), Mean ± SD | 53,07±13,51 | 44,06±14,10 | 0.014 |
| Age at Diagnosis (years), Mean ± SD | 50.3±12,57 | 36,2.1±16,95 | 0.036 |
| Autoantibodies (n, %) | |||
| ANA positivity (n:57) | 20/28 (71.4) | 3 (10) | <0.001 |
| Anti-Ro positivity (n:57) | 19 (67) | 1 (3) | <0.001 |
| Anti-La positivity (n:56) | 5/26 (1,29) | - | - |
| RF positivity (n = 56) | 5/26 (19,2) | 1 (3) | 0.096 |
| Anti–thyroid peroxidase (anti-TPO) positivity (n:44) | 7 (%47) | 27(93) | <0.001 |
| Anti–thyroglobulin (anti-Tg) positivity (n:44) | 3(2) | 5 (17) | 1.000 |
| Focus score ≥1 (n:13, %) | 8 (62) | - | - |
| Clinical and Laboratory Findings (n, %) | |||
| Hemoglobin (g/dL), Mean ± SD | 13.04±1,19 | 13.27±1.41 | 0.478 |
| Leukocyte count (/mm3), Mean ± SD | 6982.76±2114,42 | 7944.83±2063.73 | 0.085 |
| Platelet count (/mm3), Mean ± SD | 287.48±112,77 | 291.97±56.99 | 0.849 |
| Hypocomplementemia (n = 33, %) | 3 (%12) | 1(14) | 1.000 |
| Hypergammaglobulinemia (n = 31, %) | 4 (%16) | - | - |
| Raynaud’s phenomenon (n = 50, %) | 2(%8) | - | - |
| ESSDAI score, Mean ± SD | 3.79±4,47 | - | - |
| ESSDAI >4 | 11(30) | - | - |
| USG Evaluation (n,%) | |||
| Total OMERACT score >4 | 12(40) | - | - |
| Total OMERACT score >3 | 13(43) | - | - |
Values are expressed as mean ± standard deviation (SD) for continuous variables and number (percentage) [%] for categorical variables.ANA, antinuclear antibody; anti-Tg, anti-thyroglobulin antibody; anti-TPO, anti-thyroid peroxidase antibody; ESSDAI, EULAR Sjögren’s Syndrome Disease Activity Index; HT, Hashimoto’s thyroiditis; OMERACT, Outcome Measures in Rheumatology; RF, rheumatoid factor; SD, standard deviation; SjD, Sjögren’s disease; USG, ultrasonography. Statistical significance: p < 0.05 was considered statistically significant.
Table 2.
Age-adjusted and unadjusted comparisons of ultrasonographic and elastographic findings between SjD and HT patients.
Table 2.
Age-adjusted and unadjusted comparisons of ultrasonographic and elastographic findings between SjD and HT patients.
| Age unadjusted |
Age adjusted (ANCOVA test) |
|||||
|
SjD (n:30) |
HT (n:31) |
p-value |
SjD (n:30) |
HT (n:31) |
p- value | |
| Parenchymal heterogeneity / pseudonodular appearance of the thyroid gland | 13(%43) | 24 (%77) | 0.006 | 0.011 | ||
|
Elastography (kPa), Mean ± SD Thyroid gland(R) Thyroid gland(L) Parotid gland (R) Parotid gland (L) Submandibular gland(R) Submandibular gland (L) |
20.55±13.5 17.09±14.6 35.45±28.6 47.11±31.3 13.29±7.9 13.25±5.1 |
24.35±16.3 18.48±11.2 28.66±23.0 42.49±36.8 15.83±6.7 14.47±4.8 |
0.327 0.678 0.312 0.600 0.186 0.342 |
20.6±13.5 17.1±14.6 35.5±28.7 47.1±31.3 13.3±7.9 13.25±5.1 |
20.3±16.3 18.5±11.2 28.7±23 42.5±36.8 15.8±6.9 14.5±4.8 |
0.420 0.792 0.347 0.606 0.257 0.412 |
Values are presented as mean ± SD or n (%). Elastography measurements are provided as Young’s modulus in kilopascals (kPa).ANCOVA, analysis of covariance; HT, Hashimoto’s thyroiditis; L, left; R, right; SD, standard deviation; SjD, Sjögren’s disease.Statistical analysis: Unadjusted p-values were calculated using Student’s t-test, Mann–Whitney U test, or Chi-square test. Age-adjusted p-values were calculated using ANCOVA to eliminate age as a potential confounding factor. p < 0.05 was considered statistically significant.
Table 3.
Comparison of Salivary Gland Elastography Findings According to OMERACT Score in Patients with SjD.
Table 3.
Comparison of Salivary Gland Elastography Findings According to OMERACT Score in Patients with SjD.
| Major Salivary Gland Ultrasonographic Assessment (OMERACT Scoring) | |||
| OMERACT score ≥4 (n:12) | OMERACT score <4 (n:18) | p | |
| Mean±SD | Mean±SD | ||
| Parotid pressure(R) | 45.49±28.42 | 28.76±27.70 | 0.120 |
| Parotid velocity(R) | 3.68±1.25 | 2.87±1.18 | 0.080 |
| Parotid pressure(L) | 66.52±34.25 | 34.18±21.71 | 0.004 |
| Parotid velocity(L) | 4.62±1.36 | 3.17±1 | 0.002 |
| Submandibular pressure(R) | 13.45±10.51 | 13.19±6.03 | 0.931 |
| Submandibular velocity(R) | 2.85±3.07 | 2.04±0.45 | 0.278 |
| Submandibular pressure(L) | 11.43±4.39 | 14.47±5.34 | 0.114 |
| Submandibular velocity(L) | 1.91±0.39 | 2.17±0.41 | 0.103 |
Values are expressed as mean ± standard deviation (SD). Pressure is expressed in kilopascals (kPa), and shear wave velocity is expressed in meters per second (m/s). L, left; OMERACT, Outcome Measures in Rheumatology; R, right; SD, standard deviation; SjD, Sjögren’s disease.Statistical analysis: Group comparisons were performed using Student’s t-test or Mann–Whitney U test. p < 0.05 was considered statistically significant. Multiple testing corrections (Bonferroni correction with an adjusted significance threshold of α = 0.00625 and the Benjamini–Hochberg False Discovery Rate procedure) were applied across the eight major salivary gland parameters to confirm statistical robustness.
Table 4.
Comparison of Salivary Gland Elastography Findings According to ESSDAI Score in Patients with SjD.
Table 4.
Comparison of Salivary Gland Elastography Findings According to ESSDAI Score in Patients with SjD.
| ESSDAI SCORE>4 (n:11) |
ESSDAI SCORE<4 (n:18) |
p | |
| Parotid pressure(R) | 31,25±32,10 | 38,49±27,87 | 0.526 |
| Parotid velocity(R) | 2,96±1,32 | 3,35±1,26 | 0.440 |
| Parotid pressure(L) | 39,96±26,49 | 52,93±33,93 | 0.290 |
| Parotid velocity(L) | 3,44±1,20 | 4±1,43 | 0.294 |
| Submandibular pressure(R) | 13,87±10,86 | 12,15±5,59 | 0.564 |
| Submandibular velocity(R) | 2,09±0,64 | 2,50±2,50 | 0.603 |
| Submandibular pressure(L) | 12,34±4,75 | 13,41±5,28 | 0.586 |
| Submandibular velocity(L) | 2±0,40 | 2,08±0,41 | 0.615 |
Values are expressed as mean ± standard deviation (SD). Pressure is expressed in kilopascals (kPa), and shear wave velocity is expressed in meters per second (m/s). ESSDAI, EULAR Sjögren’s Syndrome Disease Activity Index; L, left; R, right; SD, standard deviation; SjD, Sjögren’s disease.Statistical analysis: Comparisons between subgroups (ESSDAI > 4 vs. ESSDAI ≤ 4) were performed using Student’s t-test or Mann–Whitney U test. p < 0.05 was considered statistically significant.
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