Inflammatory pseudotumors in multiple organs associated with elevated serum IgG4 level: recovery by only a small replacement dose of steroid

A 62-year-old man developed a fever, fatigue, anorexia and arthralgia. Central hypocorticoidism and central hypothyroidism were observed, and a low serum antidiuretic hormon level without symptoms of diabetes insipidus, as well. Images showed swelling of pituitary stalk, mediastinal and hilar lymphnodes and pancreas, pulmonary infiltrates and retroperitoneal mass. Serum CRP level was 20.6 mg/dL, and IgG4 level was 292 mg/dL. Lung biopsy revealed pseudotumor containing IgG4-positive plasmacytes, and obliterative vasculitis both in arterioles and venules. These features were similar to those of reported IgG4-related autoimmune disease. However, replacement steroid therapy for hypocorticoidism brought about almost complete recovery except that diabetes insipidus got apparent. This is the first report on the efficacy of only a small dose of steroid, and on features of pituitary stalk involvement and central hypocorcicoidism.

Inflammatory myofibroblastic tumor presenting as acute abdomen: report of one case

Inflammatory myofibroblastic tumor (IMT) is a very rare benign tumor composed of myofibroblastic spindle cells of uncertain etiology, which can occur at any age and affect any organ system. More and more cases of IMT in children have been described in pediatric literature in recent years. However, this tumor occurring intraabdominally in children has rarely been reported in Taiwan. Here we present a 1-year-9-month-old boy who had fever and abdominal pain only for 2 days, symptoms mimicking acute abdomen. After imaging study, a huge tumor nearly 10 cm in diameter was incidentally found over the right abdomen with unknown origin and nature. After surgical removal of the tumor, IMT was confirmed by the pathological findings. It is very difficult to make an accurate preoperative diagnosis on this tumor according to past experience, so the role of pathological diagnosis with immunohistochemical study becomes important. This case illustrates that IMT should be considered as a possible cause of intra-abdominal mass in children who have fever of unknown origin.

Pseudotumors due to IgG4 immune-complex tubulointerstitial nephritis associated with autoimmune pancreatocentric disease

Autoimmune pancreatitis (AIP) is a mass-forming chronic fibroinflammatory condition centered on the pancreatobiliary system and characterized by predominant immunoglobulin G4 (IgG4)-positive plasma cells. Recent reports have brought to light the multiorgan involvement of this disease. We describe a series of 5 cases of tubulointerstitial nephritis (TIN) associated with AIP and characterize the clinical, pathologic, ultrastructural, and immunopathologic features of TIN. The specimens consisted of 4 biopsies and 1 nephrectomy. The average patient age was 64 years (range 45 to 78) and the male to female ratio was 4:1. All had histologic and/or clinical and radiographic evidence of AIP, mass-forming sclerosing cholangitis, or both. The clinical impression in 4 patients was a renal mass or vasculitis. Two patients had renal insufficiency. Histologic preparations revealed a dense tubulointerstitial lymphoplasmacytic infiltrate. Eosinophils were often numerous. Tubulitis and tubular injury were present, along with tubular atrophy with focally thickened tubular basement membranes (TBMs). The histologic appearance ranged from a cellular, inflammatory pattern without tubular atrophy to a striking expansive interstitial fibrosis with tubular destruction. The nephrectomy specimen demonstrated a masslike nodular pattern of inflammation with normal renal tissue elsewhere. Glomeruli were uninvolved. By immunohistochemistry or immunofluorescence, numerous plasma cells in the infiltrate were positive for IgG4. TBM granular IgG deposits, predominantly of the IgG4 subclass, were detected in 4 of 5 cases by either immunofluorescence or immunohistochemistry. By electron microscopy, corresponding amorphous electron-dense deposits were present in the TBM in these cases. This type of TIN, typically characterized by a masslike lesion consisting of a lymphoplasmacytic infiltrate with eosinophils and prominent IgG4-positive plasma cells and immune-complex deposits in the TBM, may be part of a systemic IgG4-related disease, which we term "IgG4-associated immune complex Multiorgan Autoimmune Disease" (IMAD).

Plasma cell granuloma of the thyroid gland mimicking carcinoma: A case report and review of the literature

Plasma cell granulomas (PCG) are rare tumor-like lesions consisting of sheets of polyclonal plasma cells admixed with numerous lymphocytes and other inflammatory cells surrounded by fibrous stroma. They usually appear in the lung, but involvement of diverse extrapulmonal sites has been described. PCGs occurring in the thyroid are very uncommon. Since 1981, only 11 cases have been described in the English literature. Here, we present the case of a 50-year-old Arabic man who noticed an enlargement of his thyroid gland during the previous 2 years, and he developed swallowing disturbances and a feeling of narrowness in the neck. A nearly total resection of the thyroid gland was made because of clinical suspicion of carcinoma. On histologic examination, PCG of the thyroid associated with Hashimoto's thyroiditis (HT) was diagnosed. This is the first case in which molecular pathological analyses for EBV and HHV8 DNA were made. As these were negative, distinct etiological features were suggested.

Inflammatory pseudotumor of the middle ear masquerading as Bell's palsy

We describe the case of a 28-year-old woman who presented with an acute dense left facial paralysis. Magnetic resonance imaging demonstrated enhancement of the labyrinthine portion of the facial nerve, and Bell's palsy was the presumed initial diagnosis. After 2 months without recovery despite receiving steroid and antiviral therapy, the patient underwent further workup. Computed tomographic scan demonstrated a mass lesion adjacent to the tympanic portion of the facial nerve, and electromyography showed active denervation and prominent fibrillation potentials. Surgical excision of the tumor was performed with decompression and sparing of the facial nerve. Histologically, the tumor proved to be an inflammatory pseudotumor (IPT). At the 3-year follow-up, the patient had an improvement in her facial nerve function, progressing to a House-Brackman grade III. An IPT can masquerade as Bell's palsy with sudden complete facial paralysis. Failure to obtain even slight recovery in Bell's palsy should prompt further workup, including appropriate imaging, to assess for a mass lesion. Confusion of an IPT with a nerve-based tumor on frozen section and imaging could lead to inappropriate resection and cable grafting of the facial nerve. Therefore, the relationship between an IPT and facial nerve paralysis is vital and must be recognized for treatment and to maximize postoperative facial nerve function.

Inflammatory pseudotumor: a rare cause of hematuria and shock

We report the clinical, radiologic, and pathologic findings of a case of inflammatory pseudotumor in an otherwise healthy 44-year-old woman, who presented with dysuria and hematuria causing hemodynamic instability. Computed tomography revealed a 4.3-cm by 3.5-cm densely enhancing mass arising from the anterior bladder wall. Pathologic examination showed spindle-shaped cells with mild nuclear pleomorphism, rare mitotic activity, and a strong reaction to vimentin, with focal positivity to alpha-actin and S100 protein. Monokeratin, CK7, and CK20 were negative. After two transurethral resections, the patient underwent partial cystectomy.

Concomitant inflammatory pseudotumor of the temporal bone and lung: a case report

Inflammatory pseudotumors are histologically benign but locally destructive lesions that are usually found in the lung, although some cases of temporal bone involvement have been reported. To the best of our knowledge, no case of simultaneous involvement of the temporal bone and the lung has been previously reported in the literature. We describe such a case in a 39-year-old man. The temporal bone lesion was removed in its entirety, and the lung lesion was treated with steroid therapy. At the 2-month follow-up, the size of the lung mass on chest x-ray was significantly reduced, and at 1 year, the patient was asymptomatic.

Intradural cervical inflammatory pseudotumor mimicking epidural hematoma in a pregnant woman: case report and review of the literature

BACKGROUND

Inflammatory pseudotumors usually affect the lung and the orbit. They occur extremely rarely in the spine. We encountered a case of intradural extramedullary IPT of the cervical spine in a pregnant woman that initially presented as an epidural hematoma in MRI.

CASE DESCRIPTION

This is a case of a 30-year-old, HIV-negative, full-term pregnant lady presenting with 2-month history of progressive quadriparesis with rapid worsening of power in all 4 limbs for 3 days. Magnetic resonance imaging scanning revealed cervical extramedullary compressive lesion likely to be epidural bleed from its imaging characteristics. Intraoperatively, intradural extramedullary granulomatous lesion was found with dural thickening. Gross total excision was accomplished; histopathologic study assessed an IPT. The patient improved after surgery excision and is doing well at 6-month follow-up with remarkable neurological recovery.

CONCLUSION

Cervical intradural IPT is a very rare issue in the spine. Diagnosis can be confused with a neoplastic lesion like an "en plaque meningioma" or as epidural bleed like in the present case.

Inflammatory myofibroblastic tumor on intercostal nerve presenting as paraneoplastic pemphigus with fatal pulmonary involvement

Inflammatory myofibroblastic tumors (IMTs) are benign neoplasms that can occur at different anatomic sites with nonspecific clinical symptoms. A 48-yr-old woman presented with a 2-month history of a relapsed oral ulcer, progressive dyspnea, and a thoracic pain induced by breathing. A tumorous mass was noticed in the right costodiaphragmatic recess on chest computed tomography and magnetic resonance imaging, and the patient underwent a right costotransversectomy with excision of the tumor, which originated from the 12th intercostal nerve. Histology and immunohistochemistry showed that the tumor was an IMT of the intercostal nerve. The patient's postoperative course was not favorable; dyspnea persisted after surgery, and a progressive pulmonary compromise developed. The cause of the respiratory failure was found to be bronchiolitis obliterans, which in this case proved to be a fatal complication of paraneoplastic pemphigus associated with an IMT. This case of IMT of the spinal nerve in the paravertebral region is unique in terms of its location and presentation in combination with paraneoplastic pemphigus, which is rare. A brief review of the heterogeneous theories concerning the pathogenesis, clinicopathological features, and differential diagnosis of this disease entity is presented.

Cardiac Inflammatory Myofibroblastic Tumor: A “Benign” Neoplasm That May Result in Syncope, Myocardial Infarction, and Sudden Death

Cardiac tumors other than myxomas are rare. We report a series of 10 intracavitary polypoid myofibroblastic proliferations in children and young adults emphasizing gross, histologic, and clinical features. There were 6 females and 4 males, with a mean age of 10 years (range 5 wk to 21 y). All lesions were endocardial-based, located in the right atrium (1), right ventricular inflow/tricuspid valve (1), right ventricular outflow (3), mitral valve (3), aortic valve/left coronary sinus (1), and left ventricular free wall (1). Symptoms included shortness of breath or dyspnea (3), syncope (2), chest pain (1), transient ischemic attacks (1), and fever with myalgias (1). All tumors were surgical resections, except 1 tumor that resulted in sudden coronary death and that was diagnosed at autopsy, and 1 tumor that embolized into the coronary artery and was treated by cardiac transplant. Two tumors, present in the aortic and mitral valves, respectively, caused cardiac ischemia. The tumors were polypoid or filiform and histologically resembled inflammatory myofibroblastic tumors of extracardiac sites, with loose spindle cell growth with sparse inflammation. Although there were frequent collagen bundles interspersed among the tumor cells, there were no large areas of dense fibrosis. Surface fibrin was present on the polypoid projections in 7 cases. Symptoms resulted from prolapse into coronary ostia or embolization, but no patient developed metastasis. Long-term follow-up in 2 patients demonstrated no evidence of disease or recurrence. Although metastatic potential was not identified, these tumors may result in serious symptoms, including myocardial infarct, syncope, and sudden death. These cardiac myofibroblastic tumors are readily distinguished from other endocardial-based cardiac tumors, including papillary fibroelastoma and myxoma, which may present clinically in the same manner.

Plasma cell granuloma associated with pulmonary actinomycosis: a case report

Plasma cell granuloma (PCG) of the lung is a rare disease that usually presents as a pulmonary nodule or mass on incidental radiographic examination without symptoms. Although the etiology of PCG is still controversial, many findings have lent support to the lesion being a reactive inflammatory process rather than a neoplastic one. We describe a 53-yr-old male who presented with a hemoptysis and have a lung mass at the left upper lobe on chest radiograph. The lung mass was primarily diagnosed as PCG by percutaneous needle aspiration and biopsy, and the patient was treated with oral steroid because he and relatives refused the operation. However, the size of the lung mass did not change and open thoracotomy and lobectomy were done therefore. He was confirmed as having pulmonary actinomycosis with PCG after surgery. To our knowledge, this is the first report of PCG associated with actinomycosis in Korea.

Immune reconstitution inflammatory syndrome presenting as sinusitis with inflammatory pseudotumor in an HIV-infected patient: a case report and review of the literature

Immune reconstitution inflammatory syndrome (IRIS) encompasses a variety of conditions that occur among HIV-infected patients in a temporal relationship with increases in CD4 cell count as a result of highly active antiretroviral therapy (HAART). Most conditions associated with IRIS are infectious. Malignancies, such as Kaposi's sarcoma, have also been reported. We report a case of sinusitis with presumptive inflammatory pseudotumor as a manifestation of IRIS that occurred 20 weeks after the initiation of HAART.

Inflammatory myofibroblastic tumor of the orbit with associated enhancement of the meninges and multiple cranial nerves

Inflammatory myofibroblastic tumor (IMT), Tolosa-Hunt syndrome (THS), and idiopathic hypertrophic pachymeningitis (IHP) seem to be part of a spectrum of disorders that have diverse locations but similar histologic and imaging findings. We report a case of a 50-year-old man presenting with multiple progressive cranial nerves palsies with leptomeningeal cranial nerve enhancement on MRI (II, V1-V3, and X), orbital and infraorbital masses, prominence within the left cavernous sinus, and diffuse dural enhancement. Biopsies of the orbital lesion and infraorbital nerve revealed IMT. The patient's lesions, symptoms, and dural enhancement quickly improved with steroid administration and nearly resolved over multiple subsequent scans over the next few months. This case illustrates a rare case of pseudotumor mimicking a more aggressive appearance that would usually portend a case of malignancy. There is a potential association of IMT, THS, and IHP, which may have existed in a concomitant fashion in this patient. The case also describes the unique finding of enhancement of the cisternal segments of multiple cranial nerves (simulating leptomeningeal malignant involvement), which may be related to inflammatory perineural edema or ischemic neuropathy.

Calcifying fibrous pseudotumor of the myocardium

Calcifying fibrous pseudotumor is an uncommon tumor first described in 1988 as a childhood fibrous tumor with psammoma bodies. The typical pathological findings are those of a densely collagenized fibrous tumor with psammomatous and dystrophic calcification accompanied by a lymphoplasmacytic infiltrate. To date these tumors are reported in subcutaneous and deep soft tissues of the extremities and trunk, groin, scrotum, pleura, mediastinum, paratracheal region, peritoneum, neck, mesentery, omentum, serosa, lung, bone, and gallbladder. We describe a 17-year-old girl with a myocardial calcifying fibrous tumor, and we review the English literature.

[A case of hepatic inflammatory pseudotumor developed with peripheral cholangiocarcinoma]

Inflammatory pseudotumor is an uncommon mass which develops most frequently in the lung of young adults. It is characterized by localized fibrous proliferations with chronic inflammatory cell infiltration. Due to its rarity and similarity in radiologic appearance with malignant hepatic tumors, hepatic inflammatory pseudotumor (HIPT) is often misdiagnosed and resected accidentally. We report a case of HIPT which was unnecessarily resected due to synchronous small peripheral cholangiocarcinoma located on the other segment of liver.

Inflammatory myofibroblastic tumor with thrombocytosis and a unique chromosomal translocation With ALK rearrangement

We describe a case of inflammatory myofibroblastic tumor with an unusual constellation of clinical, pathologic, and genetic findings. A 7-year-old girl had an 11-cm abdominopelvic mass accompanied by thrombocytosis, anemia, elevated erythrocyte sedimentation rate, and elevated C-reactive protein. The inflammatory myofibroblastic tumor displayed unusual histologic features of zonal coagulative necrosis, high cellularity with a herringbone pattern, and tumor-associated osteoclast-like giant cells. The complex tumor karyotype included a translocation t(1;2)(q21; p23). Following resection, the laboratory abnormalities resolved. The patient is well and free of recurrence at 3 years following resection. This case raises interesting questions about clinical, pathologic, prognostic, and molecular genetic interrelationships in inflammatory myofibroblastic tumor.