Clinicopathologic Utility of Minor Salivary Gland Biopsy in Suspected Sjögren syndrome: Experience from a Single Center in Libya

Sjögren syndrome (SS) is a chronic systemic autoimmune disease characterized by lymphocytic infiltration and progressive dysfunction of exocrine glands, primarily affecting salivary and lacrimal glands. Diagnosis remains challenging because of overlapping sicca symptoms, variable serologic findings, and diverse clinical presentations. Minor salivary gland biopsy (MSGB) remains an important component of the 2016 ACR/EULAR classification criteria as it provides direct histopathological evidence of focal lymphocytic sialadenitis and helps support the diagnosis, especially in patients with non-specific clinical manifestations or negative serological findings. To evaluate the clinicopathologic utility of minor salivary gland biopsy in patients with suspected Sjögren syndrome at Al Hilal University Hospital, Misrata, Libya. This retrospective single-center case series was conducted at Al Hilal University Hospital, Misrata, Libya, between October 2025 and April 2026. Patients who underwent labial minor salivary gland biopsy for suspected Sjögren syndrome were included. Clinical presentation, serological findings, and histopathological features were reviewed from available medical records. Histopathological examination focused on the presence of focal lymphocytic sialadenitis, focus score assessment, acinar atrophy, stromal fibrosis, and ductal epithelial changes. Six patients were included in this series, with ages ranging from 48 to 85 years (median age: 64 years). Most patients were female (5/6, 83.3%). Dry mouth was reported in all cases, while dry eyes were present in five patients. Two patients showed positive autoimmune serology, including ANA and/or anti-Ro antibodies, whereas the remaining patients were seronegative despite clinical suspicion of Sjögren syndrome. Biopsy findings consistent with Sjögren syndrome, defined by focal lymphocytic sialadenitis with a focus score ≥1 focus/4 mm², were identified in four cases (67%). The main microscopic findings included dense periductal lymphocytic infiltrates, acinar atrophy, and mild stromal fibrosis. The remaining two biopsies showed only mild chronic inflammatory changes without definite diagnostic lymphocytic foci and were interpreted as non-specific chronic sialadenitis. One patient showed systemic autoimmune involvement with chronic renal impairment, positive ANA and anti-Ro antibodies, and renal biopsy findings consistent with chronic diffuse lupus nephritis associated with marked chronic tubulointerstitial nephritis, suggesting possible secondary Sjögren syndrome overlap associated with systemic lupus erythematosus. Minor salivary gland biopsy continues to play an important role in the evaluation of patients with suspected Sjögren syndrome, particularly in cases with negative serology or unclear clinical findings. In our experience, histopathological examination provided valuable diagnostic information and helped support disease classification when clinical and serological findings alone were insufficient. Close collaboration between pathologists and rheumatologists remains essential for accurate diagnosis and appropriate patient management, especially in resource-limited settings.