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Sokol EV, Vasilyev VI, Palshina SG, Kokosadze NV, Probatova NA, Kovrigina AM, Safonova TN, Rodionova EB, Gaiduk IV, Selifanova EI. [Clinical and laboratory characteristics of IgG4-realated disease and its diagnostic algorithm]. TERAPEVT ARKH 2019; 91:40-48. [PMID: 32598675 DOI: 10.26442/00403660.2019.05.000236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 12/24/2022]
Abstract
AIM to propose diagnostic algorithm of IgG4-related disease (IgG4-RD). MATERIALS AND METHODS One center retrospective research. 52 pts with IgG4-RD were included. The diagnosis was proved histologically and immunohistochemically. 48 out of 52 pts received treatment. Treatment included one of the following schemes (along with low oral glucocorticoids): rituximab monotherapy, cyclophosphamide monotherapy or their combination. RESULTS The mean age was 47.4±5.9 years, the mean age of the disease onset was 43.9±16.0 years. Median time before the diagnosis was 24 months. The most often sites of IgG4-RD were lacrimal (63.5%), salivary (46.2%) glands, lungs (48%), lymph nodes (34.6%) and retroperitoneum (17.3%). In clinical picture the leading complain was organ enlargement, but not its dysfunction. Pain was characteristic for retroperitoneum localization. In 56.8% of pts with IgG4-related syalo - and/or dacryoadenitis there was association with ear - nose - throat organs affection. In 4 pts (7.7%) IgG4-RD was combined with some malignant disease, including MALT-lymphoma of lacrimal glands. Irreversible organ damage as an IgG4-RD outcome had 15.4% of pts. The main laboratory markers of IgG4-RD were ESR elevation (38.5%), blood eosinophilia (9.6%), immunological disturbances (serum total IgG and IgG4 elevation, IgE elevation, antinuclear antibodies, rheumatoid factor detection, hypocomplementemia). Serum IgG4 level >1.35 g/l was elevated in 88% of pts and correlated with the number of affected organs (Spearman correlation coefficient 0.39, Student's test, р=0.0056). Monoclonal serum secretion and B-cell clonality in the tissue was detected in 4 (23.5%) out of 17 pts, but not all of them had both signs. CONCLUSION Based on the analysis of clinical and laboratory characteristics of IgG4-RD a diagnostic algorithm was proposed that enhances the detection and examination of the patients with suspected IgG4-RD.
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Affiliation(s)
- E V Sokol
- V.A. Nasonova Scientific and Research Institute of Rheumatology
| | - V I Vasilyev
- V.A. Nasonova Scientific and Research Institute of Rheumatology
| | - S G Palshina
- V.A. Nasonova Scientific and Research Institute of Rheumatology
| | - N V Kokosadze
- N.N. Blokhin National Medical Research Centre of Oncology" of the Health Ministry of Russia
| | - N A Probatova
- N.N. Blokhin National Medical Research Centre of Oncology" of the Health Ministry of Russia
| | | | | | - E B Rodionova
- V.A. Nasonova Scientific and Research Institute of Rheumatology
| | - I V Gaiduk
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - E I Selifanova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)
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102
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Levraut M, Cohen M, Bresch S, Giordana C, Burel-Vandenbos F, Mondot L, Sedat J, Fontaine D, Bourg V, Martis N, Lebrun-Frenay C. Immunoglobulin G4-related hypertrophic pachymeningitis: A case-oriented review. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e568. [PMID: 31355304 PMCID: PMC6624094 DOI: 10.1212/nxi.0000000000000568] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/12/2019] [Indexed: 12/13/2022]
Abstract
Objective Meningeal involvement in Immunoglobulin G (IgG)-4-related disease is rare and only described in case reports and series. Because a review into the disease is lacking, we present 2 cases followed by a literature review of IgG4-related hypertrophic pachymeningitis (IgG4-HP). Methods Two IgG4-HP cases were reported, one involving the spinal cord and responding to surgical management and a second involving the brain and responding to Rituximab therapy. We then review clinical cases and case-series of histologically proven IgG4-HP that were published in the PubMed-NCBI database. Results Forty-two case reports and 5 case-series were studied (60 patients, 20 women). The median age was 53. Eighteen patients had systemic involvement and 24 had single-organ IgG4-HP. Fifty-five percent of patients had an elevated serum IgG4. Treatment was surgical in 20/53 cases. Steroid therapy and immunosuppressors were effective in 85% and more than 90% of the cases, respectively. The rate of disease relapse was 42.1% after steroid therapy was discontinued. Discussion/conclusion IgG4-HP is characterized by the lack of extra-neurologic organ-involvement and systemic signs. Histopathologic studies should be performed as it is crucial for diagnosis because serum markers are rarely informative. 18F-FDG positon tomography can be useful to characterize systemic forms. There is no specific CSF marker for IgG4-HP and the diagnostic value of CSF IgG4 levels needs to be studied with larger samples. We provide a treatment algorithm for IgG4-HP. Such treatment strategies rely on early surgery, steroids, and early immunosuppressive therapy to prevent neurologic complications.
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Affiliation(s)
- Michaël Levraut
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Mikaël Cohen
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Saskia Bresch
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Caroline Giordana
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Fanny Burel-Vandenbos
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Lydiane Mondot
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Jacques Sedat
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Denys Fontaine
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Véronique Bourg
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Nihal Martis
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Christine Lebrun-Frenay
- Service de Médecine Interne (M.L., N.M.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; Service de Cytologie Pathologique (F.B.-V.), Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur; and Service de Neurologie (M.C., S.B., C.G., V.B., C.L.-F.), Service de Radiologie (L.M.), Service de Radiologie Interventionnelle (J.S.), and Service de Neurochirurgie (D.F.), Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
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103
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Wehbeh L, Alreddawi S, Salvatori R. Hypophysitis in the era of immune checkpoint inhibitors and immunoglobulin G4-related disease. Expert Rev Endocrinol Metab 2019; 14:167-178. [PMID: 30939947 DOI: 10.1080/17446651.2019.1598260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/19/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hypophysitis is a rare disorder, defined as inflammation of the pituitary gland that may result in pituitary enlargement and varying anterior and posterior pituitary hormonal deficits. It involves different histopathological subtypes and variable etiologies, with considerable overlap between classification systems. Histopathology is the gold standard diagnostic approach. AREAS COVERED In this article, we will review the major histopathological subtypes of hypophysitis with a special focus on immunoglobulin G4 (IgG4)-related hypophysitis and immune checkpoint inhibitor-induced hypophysitis, given their recent appearance and increasing incidence. We will summarize the similarities and differences between the different subtypes as it relates to epidemiology, pathogenesis, presentation, diagnosis, and management. EXPERT OPINION Hypophysitis is a heterogeneous and wide term used to describe different, possibly distinct diseases often with poorly understood pathogenesis. It involves a wide range of subtypes with certain differences in incidence rates, pathogenesis, and management. Management usually focuses on relieving the mass effect symptoms and replacing the deficient pituitary hormones. Spontaneous recovery is possible but recurrence is not uncommon.
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Affiliation(s)
- Leen Wehbeh
- a Division of Endocrinology, Diabetes and Metabolism, and Pituitary Center , The Johns Hopkins University Hospital , Baltimore , MD , USA
| | - Sama Alreddawi
- b Medstar Health Internal Medicine Residency Program, Department of Medicine , Union Memorial Hospital , Baltimore , MD , USA
| | - Roberto Salvatori
- a Division of Endocrinology, Diabetes and Metabolism, and Pituitary Center , The Johns Hopkins University Hospital , Baltimore , MD , USA
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104
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Abstract
Hypophysitis is a rare entity characterized by inflammation of the pituitary gland and its stalk that can cause hypopituitarism and/or mass effect. Etiology can be categorized as primary or secondary to systemic disease, but may also be classified according to anatomical and hispathological criteria. Newly recognized causes of hypophysits have been described, mainly secondary to immunomodulatory medications and IgG4-related disease. Diagnosis is based on clinical, laboratory and imaging data, whereas pituitary biopsy, though rarely indicated, may provide a definitive histological diagnosis. For the clinician, obtaining a broad clinical and drug history, and performing a thorough physical examination is essential. Management of hypophysitis includes hormone replacement therapy if hypopituitarism is present and control of the consequences of the inflammatory pituitary mass (e.g. compression of the optic chiasm) using high-dose glucocorticoids, whereas pituitary surgery is reserved for those unresponsive to medical therapy and/or have progressive disease. However, there remains an unmet need for controlled studies to inform clinical practice.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona, United States.
| | - Vera Popovic
- Faculty of Medicine, University of Belgrade, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Peter J Trainer
- Department of Endocrinology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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105
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Mizushima I, Kasashima S, Fujinaga Y, Kawano M, Ishizaka N. IgG4-related periaortitis/periarteritis: An under-recognized condition that is potentially life-threatening. Mod Rheumatol 2019; 29:240-250. [DOI: 10.1080/14397595.2018.1546367] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ichiro Mizushima
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
- Department of Cardiovascular and Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Yasunari Fujinaga
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
- Department of Cardiovascular and Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
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Martín-Nares E, Ángeles-Ángeles A, Hernandez-Molina G. Major salivary gland enlargement in IgG4-related disease is associated with multiorgan involvement and higher basal disease activity. Mod Rheumatol 2019; 30:172-177. [DOI: 10.1080/14397595.2019.1572575] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Arturo Ángeles-Ángeles
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriela Hernandez-Molina
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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IgG4-related disease can present as recurrent spontaneous hemothorax: a case report. BMC Pulm Med 2019; 19:26. [PMID: 30709387 PMCID: PMC6359758 DOI: 10.1186/s12890-019-0785-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 12/18/2022] Open
Abstract
Background Immunoglobulin G4-related disease (IgG4-RD) encompasses a group of immune-mediated disorders that are gaining increasing recognition. Pulmonary presentations are common, with four types of patterns been described on radiography, including solid nodular, bronchovascular, ground glass opacities, and alveolar interstitial. Pleural thickening and pleural effusion have also been reported. However, there have been no reports of IgG4-RD that presents as spontaneous hemothorax. Case presentation A 61-year-old Chinese woman experienced recurrent right-sided chest pain and transient syncope. A significant decrease in her hemoglobin level and thick bloody pleural fluid demonstrated spontaneous hemothorax. The elevated serum IgG4 and histopathological analysis of the right pleura and intercostal lymph node specimens all supported the diagnosis of IgG4-RD in this patient. Further diagnostic evaluation did not reveal other causes for spontaneous hemothorax. She received steroids and no recurrent bleeding event occurred during a follow-up period of more than 1 year. Conclusion Recurrent spontaneous hemothorax can be a rare manifestation of IgG4-RD, with pleural involvement as the most probable mechanism.
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Kanie K, Bando H, Iguchi G, Shiomi H, Masuda A, Fukuoka H, Nishizawa H, Fujita Y, Sakai A, Kobayashi T, Shiomi Y, Yoshida K, Matsumoto R, Suda K, Kodama Y, Ogawa W, Takahashi Y. IgG4-related hypophysitis in patients with autoimmune pancreatitis. Pituitary 2019; 22:54-61. [PMID: 30607745 DOI: 10.1007/s11102-018-00930-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE IgG4-related disease involves various organs including the pituitary and pancreas. The prevalence of IgG4-related hypophysitis is relatively rare compared with IgG4-related pancreatitis (autoimmune pancreatitis). Although several cases demonstrating both autoimmune pancreatitis and hypophysitis have been reported, the prevalence of IgG4-related hypophysitis in patients with autoimmune pancreatitis remains unknown. This study aimed at screening for IgG4-related hypophysitis to accurately determine its prevalence in patients with autoimmune pancreatitis. METHODS In this cohort study, we screened IgG4-related hypophysitis via pituitary magnetic resonance imaging (MRI) and endocrinological examination in 27 patients who were undergoing follow-up for autoimmune pancreatitis at Kobe University Hospital between 2014 and 2018. RESULTS Among 27 patients with autoimmune pancreatitis, 5 patients exhibited morphological abnormalities in the pituitary (18.5%). Among them, one patient (3.7%) met the criteria for hypophysitis with an enlarged pituitary and stalk concomitant with hypopituitarism. After glucocorticoid treatment, the enlarged pituitary shrank and became empty sella during the clinical course. Four patients (14.8%) revealed empty sella without obvious pituitary dysfunction. Four of 5 patients with morphological pituitary abnormalities showed multiple organ involvement in addition to pancreatic and pituitary involvement. Accordingly, multiple organ involvement was more prevalent in patients with morphological pituitary abnormalities (80%) compared to those without (48%). CONCLUSIONS Although a large-scale study is necessary to validate these results, these data suggest that the prevalence of hypophysitis in patients with autoimmune pancreatitis may be underestimated. Based on our findings, we recommend screening for hypophysitis, especially in patients with multiple organ involvement.
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Affiliation(s)
- Keitaro Kanie
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Hitoshi Nishizawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yasunori Fujita
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenichi Yoshida
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryusaku Matsumoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kentaro Suda
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
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Pérez-Sanz MT, Cervilla-Muñoz E, Alonso-Muñoz J, Marcelo-Ayala A, Pulfer MD, Galeano-Valle F. Retroperitoneal fibrosis associated with orbital pseudotumor without evidence of IgG4: A case report with review of literature. Intractable Rare Dis Res 2019; 8:29-35. [PMID: 30881855 PMCID: PMC6409117 DOI: 10.5582/irdr.2018.01075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Retroperitoneal fibrosis (RPF) is a rare disease characterized by chronic inflammation and periaortic fibrosis that affects retroperitoneal structures and often entraps the ureters. The idiopathic form has an incidence of 0.1-1.3/100,000 person-years. A substantial percentage of patients with idiopathic retroperitoneal fibrosis (IRF), as well as patients with orbital pseudotumor, is associated with IgG4-related disease (IgG4-RD). It is not clear what percentage of IRF is related to the spectrum of the IgG4-RD or if both represent different stages of the same disease (especially in those cases with extra-retroperitoneal involvement). Histopathological features such as storiform fibrosis, obliterative phlebitis and tissue infiltration of IgG4-positive plasma cells (ratio IgG4+/IgG higher than 0.4) are essential to identify this association. Extra-retroperitoneal manifestations are often presented among patients with IgG4-related RPF. About 90% of cases of IRF have a good prognosis, with adequate response to treatment. We report a case of a 59-year-old woman with history of past occupational asbestos exposure and smoking habit. She was diagnosed with RPF, periaortitis and orbital pseudotumor, without histopathologic or serologic features of IgG4- related disease. This could be related to the fact that the biopsy was done in a place with scarce inflammatory activity but high fibrosis. We want to emphasize the usual need to perform several biopsies or to be guided by positron emission tomography (PET-CT) in order to achieve a histopathological confirmation. Our case differs from the main IgG4 international cohorts in the involvement of the retroperitoneum, aorta and eye, whereas the usual involvement includes liver, pancreas, lymph nodes and salivary glands. Our patient had lower IgG4 serum levels than those described in the international cohorts. However, they were similar to those of the Spanish population.
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Affiliation(s)
- María-Teresa Pérez-Sanz
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Address correspondence to:Dr. María-Teresa Pérez-Sanz, Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain. E-mail:
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Kawano M, Saeki T, Nakashima H. IgG4-related kidney disease and retroperitoneal fibrosis: An update. Mod Rheumatol 2019; 29:231-239. [DOI: 10.1080/14397595.2018.1554321] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Hitoshi Nakashima
- Faculty of Medicine, Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
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Sireesha Y, Uppin MS, Ganti S, Alugolu R, Mudumba VS, Bhattacharjee S, Neeharika ML, Bastia J, Kanikannan MA. A Series of Biopsy-proven Patients with Immunoglobulin G4-related Neurological Disease. Ann Indian Acad Neurol 2019; 22:73-78. [PMID: 30692763 PMCID: PMC6327705 DOI: 10.4103/aian.aian_283_18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aim: To study the clinical presentation, radiological findings, and therapy responsiveness of patients with biopsy-proven immunoglobulin G4 (IgG4)-related neurological disease. Methods: The study was conducted between January 2016 and March 2018 from the Department of Neurology and Pathology of Nizam's Institute of Medical Sciences. Patients with neurological symptoms and biopsy suggestive of IgG4-related disease (IgG4-RD) were included. These patients were studied for their demographic pattern and clinical presentation. The presence of serological markers such as vasculitic profile and IgG4 levels was analyzed. Radiological findings were studied in detail. Therapeutic agents used and the response to therapy were assessed. Results: There were six cases with IgG4-related neurological disease which were all hypertrophic pachymeningitis. The age ranged from 35 to 64 (mean = 46) years. The clinical presentation was acute in one, subacute in two, and chronic in three patients. The most common presenting symptom was headache (4), followed by gait and/or urinary disturbances (2), paraparesis (1), and diplopia (1). IgG4 levels were elevated in 50% of them. Pseudotumor-like mass and sinovenous thrombosis, not described previously, were seen in one patient. All the patients were treated with oral or intravenous steroid. Rituximab was given in three patients; azathioprine was the steroid-sparing agent in one patient. Those with acute/subacute onset of presentation had an excellent response to steroids. All the patients with a chronic duration of their symptoms received empirical anti-tuberculous therapy before a definitive diagnosis of Ig G4-RD was made. Conclusions: The characterization of patients with IgG4-related neurological disease based on the understanding of the clinical spectrum increases the confidence in the clinician to resort to early immunosuppression, thereby having prognostic implications.
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Affiliation(s)
- Yareeda Sireesha
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Shridhar Ganti
- Department of Neurology, Sai Krishna Neuro Hospital, Hyderabad, Telangana, India
| | - Rajesh Alugolu
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Vijaya Saradhi Mudumba
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Suchanda Bhattacharjee
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | | | - Jogendra Bastia
- Department of Neurology, Sai Krishna Neuro Hospital, Hyderabad, Telangana, India
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Evans RD, Cargill T, Goodchild G, Oliveira B, Rodriguez-Justo M, Pepper R, Connolly J, Salama A, Webster G, Barnes E, Culver EL. Clinical Manifestations and Long-term Outcomes of IgG4-Related Kidney and Retroperitoneal Involvement in a United Kingdom IgG4-Related Disease Cohort. Kidney Int Rep 2019; 4:48-58. [PMID: 30596168 PMCID: PMC6308386 DOI: 10.1016/j.ekir.2018.08.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/15/2018] [Accepted: 08/27/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION IgG4-related disease (IgG4-RD) is a relapsing multisystem fibro-inflammatory disease, which may involve the kidney (IgG4-related kidney disease [IgG4-RKD]) and retroperitoneum (IgG4-related retroperitoneal fibrosis [IgG4-RPF]). The aim of this study was to describe IgG4-RKD and IgG4-RPF in the United Kingdom. METHODS We conducted a retrospective observational study of patients with IgG4-RKD and IgG4-RPF in a multicenter IgG4-RD cohort. Data were collected through review of medical records. We describe clinical parameters at baseline, histological and radiological findings, treatment, and patient outcomes. RESULTS Of 154 patients with IgG4-RD, 14 (9.1%) had IgG4-RKD, 10 (6.5%) had IgG4-RPF, and 4 (2.6%) had both. Patients were aged 58.2 ± 14.2 years, and 26 (92.9%) were male. Creatinine at presentation was worse in those with intrinsic renal disease (229 μmol/l vs. 110 μmol/l; P = 0.0076). Serum IgG4 was elevated in the majority of patients (87.5%), and hypocomplementemia was present in half of those with IgG4-RKD. Fifteen patients underwent renal biopsy; tubulointerstitial nephritis with abundant IgG4+ plasma cells was the most common finding (n = 14; 93.3%), and 4 (26.7%) patients had membranous nephropathy. Most patients (89.3%) were treated with corticosteroids, and 4 (16.0%) with additional azathioprine as initial management. Thirteen patients (46.4%) relapsed over 60 ± 48 months of follow-up, at median 18 (12-36) months after renal/RPF diagnosis; 61.5% of relapses were in the kidney. Renal function deteriorated in 5 patients (20.8%), including 2 (8.3%) who reached end-stage renal disease (ESRD). CONCLUSION IgG4-RKD and IgG4-RPF represent major organ manifestations of IgG4-RD, and should be identified early with prompt treatment to prevent progression to ESRD.
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Affiliation(s)
- Rhys D.R. Evans
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Tamsin Cargill
- Translational Gastroenterology Unit, John Radcliffe Hospital, and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - George Goodchild
- Gastroenterology Department, University College London Hospital NHS Trust, London, UK
| | - Ben Oliveira
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | | | - Ruth Pepper
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - John Connolly
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Alan Salama
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - George Webster
- Gastroenterology Department, University College London Hospital NHS Trust, London, UK
| | - Eleanor Barnes
- Translational Gastroenterology Unit, John Radcliffe Hospital, and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emma L. Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital, and Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Head and neck immunoglobulin G4 related disease: systematic review. The Journal of Laryngology & Otology 2018; 132:1046-1050. [PMID: 30558692 DOI: 10.1017/s0022215118002153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Immunoglobulin G4 related disease is a recently described systemic syndrome. The head and neck region is the second most common site for presentation after the pancreas. METHODS PubMed and the Cochrane Library were searched from 1995 to July 2017 for all the studies on immunoglobulin G4 related disease diagnosed in the head and neck compartment. Patient-specific data were extracted and basic statistical analysis was performed. RESULTS Ninety-one patients were identified. Treatment was specified in 76 patients. Twenty patients received surgical treatment, eight of them in association with medical therapy. Fifty-six patients received medical treatment. The disease recurred in 25 per cent of patients treated with surgical treatment alone, in 3.6 per cent of patients treated with medical treatment alone and in 12.5 per cent of patients treated with both. All medical treatment protocols contained high-dose corticosteroids. CONCLUSION Early and correct diagnosis can avoid unnecessary surgical treatment, and glucocorticoid therapy can improve the long-term prognosis.
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Yamada K, Mizushima I, Kawano M. New insights into the pathophysiology of IgG4-related disease and markers of disease activity. Expert Rev Clin Immunol 2018; 15:231-239. [PMID: 30557078 DOI: 10.1080/1744666x.2019.1560268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Recently, IgG4-related disease (IgG4-RD) has become a well-recognized clinical entity, although its causes are still not well understood. The pathophysiology of IgG4-RD has been reported from a variety of aspects. Areas covered: In this review, we outline a number of recent advances in our understanding of the pathogenesis of IgG4-RD, divided according to acquired immunology and innate immunology and other topics. Furthermore, we also focus on some proposed markers of disease activity of IgG4-RD. Expert commentary: One striking advance made recently is the identification of novel autoantigens of IgG4-RD. At the onset of IgG4-RD, various T cell side factors such as Tfh, Th2 cells are at work, in addition to B cell side factors like plasmablasts and plasma cells, and innate immunology via TLR and M2 macrophages. The efficacy of B cell depletion therapy using rituximab has been reported, with the establishment of steroid-sparing therapies targeting other molecules also anticipated.
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Affiliation(s)
- Kazunori Yamada
- a Division of Rheumatology, Department of Internal Medicine , Kanazawa University Graduate School of Medicine , Kanazawa , Japan.,b Department of Advanced Research in Community Medicine , Kanazawa University Graduate School of Medical Sciences , Kanazawa , Japan
| | - Ichiro Mizushima
- a Division of Rheumatology, Department of Internal Medicine , Kanazawa University Graduate School of Medicine , Kanazawa , Japan
| | - Mitsuhiro Kawano
- a Division of Rheumatology, Department of Internal Medicine , Kanazawa University Graduate School of Medicine , Kanazawa , Japan
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IgG4-Related Disease, the Malignancy Mimicker: Case Series from Bahrain. Case Rep Rheumatol 2018; 2018:4057024. [PMID: 30510832 PMCID: PMC6230411 DOI: 10.1155/2018/4057024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/14/2018] [Accepted: 09/25/2018] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease is an evolving immune-mediated condition. The hallmark of this condition is IgG4(+) plasma cells infiltration of the affected organs accompanied by a variable degree of fibrosis and occasionally elevated serum IgG4 level. It links many conditions that were once recognized as isolated unrelated idiopathic single organ disorders (e.g., autoimmune pancreatitis, Mikulicz syndrome, and retroperitoneal fibrosis) under one umbrella. It usually presents clinically as tumor-like swelling of the involved organs that can be misdiagnosed as neoplasia. In this case series, we present four cases that were considered as neoplasia but turned out to be IgG4-related disease, we demonstrate the protean manifestations of this condition and variable organs involvement, and we share our experience in using rituximab as the steroid sparing immunosuppressant agent to control this disease.
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116
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Gubbi S, Hannah-Shmouni F, Stratakis CA, Koch CA. Primary hypophysitis and other autoimmune disorders of the sellar and suprasellar regions. Rev Endocr Metab Disord 2018; 19:335-347. [PMID: 30547288 DOI: 10.1007/s11154-018-9480-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The pituitary gland and the hypothalamus can be affected by autoimmune-mediated structural and functional disruption. These autoimmune-mediated diseases occur more commonly in females and are often found during pregnancy or in the post-partum period. Autoimmune diseases can either affect parts of the pituitary or hypothalamus, or can involve both sellar and suprasellar structures. Most of these cases comprise primary hypophysitis (PRH). Over the years, there has been a tremendous increase in the number of reported PRH cases and related disorders, including hypophysitis induced by immune checkpoint inhibitors. With this increasing data, more light is being shed on the spectrum of clinical presentations, biochemical and imaging abnormalities of these disorders. Regardless, these disorders are still relatively rare. The clinical presentation can vary vastly, based on the type of pituitary cell or the area of the suprasellar region affected. The severity can range from clinically silent disease to progressive and rapid deterioration and death, likely due to unrecognized central adrenal insufficiency. Although biopsy remains a gold standard for diagnosing these disorders, the current standard of practice is biochemical assessment for hormonal deficiencies and imaging studies. In several instances, these disorders spontaneously resolve, but medical or surgical intervention might be necessary to treat symptomatic disease. Due to the subtlety and a vast spectrum of clinical manifestations which could often be asymptomatic, and the rarity of the occurrence of these diseases in clinical practice, the diagnosis can be easily missed which could potentially lead to substantial morbidity or mortality. Therefore, it is crucial to have a strong clinical suspicion and pursue timely biochemical and imaging studies to initiate prompt treatment. In this article, we review the various autoimmune conditions that affect the sellar and suprasellar structures, their diagnostic approach and management of these disorders.
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Affiliation(s)
- Sriram Gubbi
- Department of Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Christian A Koch
- Medicover GmbH, Berlin/Hannover, Germany.
- Carl von Ossietzky University, Oldenburg, Germany.
- Technical University of Dresden, Dresden, Germany.
- University of Louisville, Louisville, KY, USA.
- University of Tennessee Health Science Center, Memphis, TN, USA.
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Fernández-Codina A, Pinilla B, Pinal-Fernández I, López C, Fraile-Rodríguez G, Fonseca-Aizpuru E, Carballo I, Brito-Zerón P, Feijóo-Massó C, López-Dupla M, Cid MC, Martínez-Valle F. Treatment and outcomes in patients with IgG4-related disease using the IgG4 responder index. Joint Bone Spine 2018; 85:721-726. [DOI: 10.1016/j.jbspin.2018.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/31/2018] [Indexed: 12/26/2022]
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Oda R, Okuda K, Murase T, Watanabe T, Sakane T, Tatematsu T, Yokota K, Haneda H, Nakanishi R. Thymic inflammatory pseudotumor with multilocular thymic cyst caused by immunoglobulin G4-related disease. Thorac Cancer 2018; 10:116-119. [PMID: 30467988 PMCID: PMC6312835 DOI: 10.1111/1759-7714.12914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 12/24/2022] Open
Abstract
A 44-year-old man was referred to our hospital after an anterior mediastinal tumor was noted on computed tomography during follow-up observation after left testicular seminoma resection. Chest computed tomography revealed an enhanced mass measuring 33 x 16 x 15 mm at the anterior mediastinum. Chest magnetic resonance imaging revealed high signal intensity on T2-weighted imaging, and F18 fluorodeoxyglucose-positron emission tomography showed a maximum standardized uptake of 12.45. Laboratory tests revealed no elevated tumor markers, except for mildly elevated interleukin-2. Based on these results, complete resection was performed under suspicion of a malignant tumor, mediastinal metastasis of seminoma, or malignant lymphoma. An extended thymectomy with partial merger pericardial resection was performed using a subxiphoid approach. Small nodules and multiple thymic cysts were observed the thymus in addition to the main mass. Microscopic examination of the tumor revealed fibrosis, lymphocyte infiltration with lymphoid follicular hyperplasia, and hyperplasia of the thymus. Numerous immunoglobulin G4 (IgG4)-positive plasma cells were found on immunohistochemical staining. The ratio of IgG4 to total IgG was approximately 60%. We ultimately diagnosed the patient with a thymic inflammatory pseudotumor with multilocular cyst caused by IgG4-related disease.
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Affiliation(s)
- Risa Oda
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Katsuhiro Okuda
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takayuki Murase
- Department of Pathology and Molecular Diagnostics, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takuya Watanabe
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tadashi Sakane
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tsutomu Tatematsu
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Keisuke Yokota
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroshi Haneda
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ryoichi Nakanishi
- Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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119
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Medlicott SA, Oryschak A, Trpkov K. IgG4 prostatitis associated with prostatic adenocarcinoma: A case report and literature review. HUMAN PATHOLOGY: CASE REPORTS 2018. [DOI: 10.1016/j.ehpc.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Kang SR, Kim HR, Nam SJ, Hong S. Immunoglobulin G4-Related Disease Mimicking an Anterior Mediastinal Tumor. Ann Thorac Surg 2018; 105:e75-e77. [PMID: 29362197 DOI: 10.1016/j.athoracsur.2017.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/14/2017] [Accepted: 09/17/2017] [Indexed: 01/29/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated collection of disorders that were once thought to be unrelated but are increasingly being recognized as a single entity. The tumor-like swelling of the involved organ, a storiform pattern of fibrosis, and a serologic elevation of IgG4 can lead to the diagnosis of IgG4-RD. The usual organs affected are the pancreas, biliary tract, and salivary and lacrimal glands. There have been few reports of intrathoracic cases, which usually have pulmonary lesions. We here report a case of IgG4-RD of the anterior mediastinum in the form of a mass, a rare entity, the second such patient described in the literature to date.
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Affiliation(s)
- Seung Ri Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul.
| | - Soo Jeong Nam
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Winkel M, Lawton CD, Sanusi OR, Horbinski CM, Dahdaleh NS, Smith ZA. Neuro-surgical considerations for treating IgG4-related disease with rare spinal epidural compression. Surg Neurol Int 2018; 9:209. [PMID: 30488007 PMCID: PMC6213809 DOI: 10.4103/sni.sni_156_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Immunoglobulin G4-related disease (IgG4-RD) is a group of distinct autoimmune disorders affecting nearly every organ system in the body. Although central nervous system involvement is quite rare, it may present as hypertrophic pachymeningitis more frequently affecting the brain than the spine. In this study, we provide a case of spinal IgG4-RD pseudotumor resulting in cord compression, and a comprehensive review of the literature. Case Description: A patient presented with an extradural mass causing spinal cord compression at the L2-L3 level. Pathologically this proved to be an IgG4-RD pseudotumor. The patient was treated with thecal sac decompression and post-operative steroids that resulted in complete resolution of his symptoms. Conclusion: IgG4-RD is typically under-recognized and under-reported in the spinal literature. The clinical spinal presentation and non-surgical vs. surgical treatment are relatively straightforward. Although most cases can be managed with a course of steroids, surgical decompression may be required in patients presenting with spinal cord and/or nerve root compression. The differential diagnoses for these spinal tumors or pseudotumors should include IgG4-RD. Early detection and appropriate treatment can lead to satisfactory outcomes.
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Affiliation(s)
- Maia Winkel
- Department of Neurological Surgery, Chicago Medical School At Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Cort D Lawton
- Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Olabisi R Sanusi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Craig M Horbinski
- Department of Neurological Surgery and Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Miyabe K, Zen Y, Cornell LD, Rajagopalan G, Chowdhary VR, Roberts LR, Chari ST. Gastrointestinal and Extra-Intestinal Manifestations of IgG4-Related Disease. Gastroenterology 2018; 155:990-1003.e1. [PMID: 30012334 DOI: 10.1053/j.gastro.2018.06.082] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 12/13/2022]
Abstract
IgG4-related disease (IgG4-RD) is a chronic relapsing multi-organ fibro-inflammatory syndrome of presumed autoimmune etiology. It is characterized by increased serum levels of IgG4 and tissue infiltration by IgG4+ cells. Increased titers of autoantibodies against a spectrum of self-antigens and response to steroids have led to its characterization as an autoimmune disease. However, the pathognomonic antigens probably differ among manifestations, and different antigens or autoantibodies produce similar immune reactions in different organs. Little is known about the pathogenic effects, if any, of serum IgG4 or IgG4+ plasma cells in tissues. Despite several animal models of the disease, none truly recapitulates human IgG4-RD. Histologic analyses of tissues from patients with IgG4-RD reveal a dense lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis, although these features vary among organs. Typical presentation and imaging findings include mass-forming synchronous or metachronous lesions in almost any organ, but most commonly in the pancreas, bile duct, retroperitoneum, kidneys, lungs, salivary and lacrimal glands, orbit, and lymph nodes. In all organs, inflammation can be reduced by corticosteroids and drugs that deplete B cells, such as rituximab. Patients with IgG4-RD have relapses that respond to primary therapy. Intense fibrosis accompanies the inflammatory response, leading to permanent organ damage and insufficiency. Death from IgG4-RD is rare. IgG4-RD is a multi-organ disease with predominant pancreatico-biliary involvement. Despite its relapsing-remitting course, patients have an excellent prognosis.
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Affiliation(s)
- Katsuyuki Miyabe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yoh Zen
- Department of Laboratory Medicine and Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Factors in glucocorticoid regimens associated with treatment response and relapses of IgG4-related disease: a multicentre study. Sci Rep 2018; 8:10262. [PMID: 29980706 PMCID: PMC6035219 DOI: 10.1038/s41598-018-28405-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/21/2018] [Indexed: 12/24/2022] Open
Abstract
Glucocorticoids (GC) are effective for treating IgG4-related disease (IgG4-RD); however, relapse is often observed. We conducted a retrospective multicentre study to investigate risk factors in GC regimens associated with relapses of IgG4-RD. Data on 166 patients with definitive IgG4-RD diagnosis were collected from 12 institutions. Comprehensive surveillance of clinical backgrounds and GC regimens as well as multivariate analysis of factors associated with treatment responses and relapses was performed. To determine the initial maximal GC dose, the patients were stratified into three groups depending on the initial prednisolone (PSL) dosage: <0.39, 0.4–0.69 and >0.7 mg/kg/day. The multivariate analysis extracted the disease duration and reduction speed of initial GC dose. Patients treated with initial GC <0.39 or >0.7 mg/kg/day of PSL showed higher relapse rates than those treated with 0.4–0.69 mg/kg/day. The relapse rates were significantly higher in patients with fast reduction of the initial dose (>0.4 mg/day) than in patients with slow reduction (<0.4 mg/day). To avoid relapse, 0.4–0.69 mg/kg/day of initial PSL with slow reduction speed (<0.4 mg/day) is needed in the early treatment of IgG4-RD.
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Lu JC, Shen JM, Hu XC, Peng LP, Hong ZW, Yao B. Identification and preliminary study of immunogens involved in autoimmune prostatitis in human males. Prostate 2018; 78:1092-1102. [PMID: 29947032 DOI: 10.1002/pros.23684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/14/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Experimental models have confirmed that autoimmunity is an important factor in the onset of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); however, there is no conclusive evidence on whether autoimmune prostatitis exists in human males. METHODS Rabbits were immunized with either human prostate tissue homogenates or normal saline and the antiserum was collected. Two-dimensional electrophoresis (2-DE) was performed on the homogenates and Western blotting was conducted on the sera. The identified human prostate tissue immunodominant antigens (HPTIAs) were detected by mass spectrometry. The serum immunoglobulin (Ig)G from the immunized rabbits was purified with protein A-agarose, and the purified IgG was linked with Sepharose to purify HPTIAs by affinity chromatography. Non-obese diabetic (NOD) mice were immunized with the purified HPTIAs, and the levels of serum antibodies, INF-γ, and histopathological changes in their prostate tissues were detected. The purified HPTIAs were coated into polystyrene pores and serum autoantibodies in CP/CPPS patients were detected by enzyme-linked immunosorbent assay (ELISA). Meanwhile, serum interleukin 2 (IL-2), interferon gamma (IFNγ), and tumor necrosis factor alpha (TNFα) levels in CP/CPPS patients were also determined by ELISA. RESULTS Sixteen HPTIAs were identified. Among them, three types were reported to be associated with prostatic diseases. Prostatitis was induced in mice immunized with the 16-HPTIA complex, with positive serum autoantibody and increased prostatic IFN-γ levels. The positive rate of serum autoantibodies against HPTIAs was significantly higher in CP/CPPS patients (23.1%, 18/78) than in the control (2.7%, 2/75). But there was no significant difference in serum TNFα, IFNγ, and IL-2 levels between the CPPS patients with positive and negative autoantibodies against HPTIAs. CONCLUSIONS Autoantibodies against HPTIAs exist in part in CP/CPPS patients, which implies that autoimmunity and the 16 HPTIAs are important factors in the onset of CP/CPPS. The detection of serum autoantibodies could be applied in clinical diagnoses of autoimmune prostatitis; treatment protocols might change. Additional studies are needed to determine which of the 16 HPTIAs is the most important.
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Affiliation(s)
- Jin-Chun Lu
- The Reproductive Medical Center, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
- Department of Laboratory Science, Nanjing Hospital, Jiangsu Corps, The Armed Police Force, PLA, Nanjing, Jiangsu, China
| | - Jia-Ming Shen
- The Reproductive Medical Center, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Xue-Chun Hu
- The Reproductive Medical Center, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Long-Ping Peng
- The Reproductive Medical Center, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Zhi-Wei Hong
- The Reproductive Medical Center, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Bing Yao
- The Reproductive Medical Center, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
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Huang X, Lu B, Li M, Fan Y, Zhang L. IgG4-related retroperitoneal fibrosis overlapping with primary biliary cirrhosis and primary Sjögren's syndrome: A case report. Medicine (Baltimore) 2018; 97:e11303. [PMID: 29953016 PMCID: PMC6039603 DOI: 10.1097/md.0000000000011303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE IgG4-related disease (IgG4-RD) is a chronic fibro-inflammatory disorder which is characterized by elevated levels of serum IgG4 and infiltration of IgG4-bearing plasma cells in the involved organs. Primary biliary cirrhosis (PBC) and Primary Sjögren's syndrome (pSS) are both distinct from IgG4-related disease. We herein describe a Chinese patient with IgG4-related RPF overlapping with PBC and pSS. PATIENT CONCERNS We report a case of 69-year-old male with recurrent lower abdominal pain for 10 months. Laboratory data showed elevated erythrocyte sedimentation rate and hepatobiliary enzymes, renal dysfunction, high titers of antinuclear antibody, anti-SS-A antibody and anti-mitochondrial type 2, high immunoglobulin (Ig) G levels and elevated serum IgG4 (9 g/L). Contrast-enhanced computed tomography and magnetic resonance imaging were suggestive of retroperitoneal fibrosis and unilateral ureteral occlusion. Immunohistochemical staining for IgG4 did not demonstrate infiltration of IgG4-positive plasma cells in the retroperitoneal mass, but revealed significant infiltration of lymphocytoplasma cells as well as fibrosis and fibrin accumulation. DIAGNOSES The patient was diagnosed with IgG4-related retroperitoneal fibrosis based on the International Consensus Diagnostic Criteria. He was also diagnosed with primary biliary cirrhosis and primary Sjögren's syndrome. INTERVENTIONS 250 mg ursodeoxycholic acid was administered twice daily, and prednisolone was initiated at a dose of 40 mg/day and then tapered to 25 mg after 45 days. OUTCOMES The size of the retroperitoneal soft tissue mass gradually reduced and the abnormal laboratory parameters were restored to normal. LESSONS This rare clinical condition has seldom been reported in the literature, which suggests that common immunogenetic factors may be involved in the development of IgG-related RPF, PBC and pSS.
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Wang L, Zhang P, Wang M, Feng R, Lai Y, Peng L, Fei Y, Zhang X, Zhao Y, Zeng X, Zhang F, Zhang W. Failure of remission induction by glucocorticoids alone or in combination with immunosuppressive agents in IgG4-related disease: a prospective study of 215 patients. Arthritis Res Ther 2018; 20:65. [PMID: 29636109 PMCID: PMC5894179 DOI: 10.1186/s13075-018-1567-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/14/2018] [Indexed: 12/24/2022] Open
Abstract
Background The aim of this study was to assess the outcomes of remission induction in patients with IgG4-related disease (IgG4-RD) in our cohort, and to investigate the characteristics, prognosis, and risk factors in the patients failed of remission induction. Methods We prospectively enrolled 215 newly diagnosed patients with IgG4-RD, who were initially treated with glucocorticoid (GC) alone or in combination with immunosuppressive agents (IM), and had at least 6 months of follow up. The therapeutic goals of remission induction were defined as fulfilling each of the following after the 6-month remission induction stage: (1) ≥ 50% decline in the IgG4-RD responder index (RI); (2) GC tapered to maintenance dose; and (3) no relapse during GC tapering. The patients not achieving the therapeutic goals were considered to have failed of remission induction. Results There were 26 patients in our cohort who failed of remission induction, including 16 (20.8%) on GC monotherapy, and 10 (7.2%) on combination therapy comprising GC and IM. The lacrimal gland and lung were most common sites of remission induction failure. Among the patients who relapsed during remission induction stage, 52.9% had secondary relapse during follow-up. Eosinophilia, higher baseline RI, more than five organs involved and dacryoadenitis were risk factors for remission induction failure with GC monotherapy, and the incidence of remission induction failure was 71.4% in the patients with more than three risk factors. After 6-month treatment, the patients who failed of remission induction had significantly higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and IgG4. Conclusion In our cohort, 20.8% of patients failed of remission induction with GC monotherapy, while 7.2% of patients failed of remission induction with combination therapy comprising GC and IM. Electronic supplementary material The online version of this article (10.1186/s13075-018-1567-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liwen Wang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China.,Tsinghua University School of Medicine, Beijing, 100086, China
| | - Panpan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Mu Wang
- Department of Stomatology, Peking Union Medical College Hospital, Beijing, China
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Yamin Lai
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Linyi Peng
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Yunyun Fei
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Xuan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Fengchun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China.
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Immunoglobulin G4-Related Disease Presenting as Bilateral Arthritis of the Hip Joints. J Clin Rheumatol 2018; 24:398-401. [PMID: 29389686 DOI: 10.1097/rhu.0000000000000705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Hong X, Zhang YY, Li W, Liu YY, Wang Z, Chen Y, Gao Y, Sun ZP, Peng X, Su JZ, Cai ZG, Zhang L, He J, Ren LM, Yang HY, Li ZG, Yu GY. Treatment of immunoglobulin G4-related sialadenitis: outcomes of glucocorticoid therapy combined with steroid-sparing agents. Arthritis Res Ther 2018; 20:12. [PMID: 29382364 PMCID: PMC5791187 DOI: 10.1186/s13075-017-1507-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/28/2017] [Indexed: 12/24/2022] Open
Abstract
Background Immunoglobulin G4-related sialadenitis (IgG4-RS) is a newly recognized immune-mediated systemic disease. Despite its good response to steroid therapy, its treatment protocol is not standardized and the long-term outcome is controversial. The study was conducted to determine the short-term and long-term outcomes of IgG4-RS patients treated with glucocorticoids and steroid-sparing immunosuppressive agents, to analyze secretory function, serological and radiological changes in salivary glands and to assess the usefulness of serum IgG4 level as an indicator of disease activity. Methods IgG4-RS patients who were treated for more than 3 months were enrolled. Serological tests, salivary gland function assessment and computed tomography (CT) were performed before treatment and during follow up. The treatment outcomes in the short and the long term were evaluated, and the relationship between serum IgG4 level and salivary gland volume was analyzed. Results Glucocorticoids were used in all 43 patients and steroid-sparing immunosuppressive agents in 38 patients (88.4%). The follow-up period was 24.6 ± 14.9 months. Clinical remission was achieved in all patients after induction therapy. During short-term observation, salivary gland secretion significantly increased, and the serum IgG4 levels, the volumes and CT values of submandibular and parotid gland decreased significantly (P < 0.001). For long term, relapse occurred in 32.5% patients within 55 months in the regularly treated group, while all seven irregularly treated patients relapsed. However, the relapse-free survival curves were not significantly different between the steroid monotherapy and the combination therapy groups (P = 0.566). Submandibular glands, lacrimal glands, sublingual glands, nasal and paranasal cavity were commonly relapsing organs. In clinically stable patients, a serologically unstable condition occurred in 54.9% patients within 55 months and medication adjustment was performed accordingly. Volume changes in the submandibular and parotid glands were associated with serum IgG4 levels and time of follow up (R2adjusted = 0.905, P < 0.0001 and R2adjusted = 0.9334, P < 0.0001, respectively). Conclusions The combination of glucocorticoid and steroid-sparing agents could be effective for treating IgG4-RS, and restoring salivary gland function. Serum IgG4 levels could predict disease activity. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1507-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xia Hong
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China.,Center for Stomatology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yan-Yan Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Wei Li
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Yan-Ying Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, China
| | - Zhen Wang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Yan Chen
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, Beijing, China
| | - Yan Gao
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, Beijing, China
| | - Zhi-Peng Sun
- Department of Oral Radiology, Peking University School and Hospital of Stomatology, Beijing, China
| | - Xin Peng
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Jia-Zeng Su
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Zhi-Gang Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China
| | - Jing He
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, China
| | - Li-Min Ren
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, China
| | - Hong-Yu Yang
- Center for Stomatology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhan-Guo Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Beijing, 100044, China.
| | - Guang-Yan Yu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Street, Beijing, 100081, China. .,Center for Stomatology, Peking University Shenzhen Hospital, Shenzhen, China.
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Liu Y, Wang L, Zhang W, Pan H, Yang H, Deng K, Lu L, Yao Y, Chen S, Chai X, Feng F, You H, Jin Z, Zhu H. Hypophyseal Involvement in Immunoglobulin G4-Related Disease: A Retrospective Study from a Single Tertiary Center. Int J Endocrinol 2018; 2018:7637435. [PMID: 29755523 PMCID: PMC5883929 DOI: 10.1155/2018/7637435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/08/2017] [Accepted: 10/18/2017] [Indexed: 12/20/2022] Open
Abstract
This study aims to outline the clinical features and outcomes of IgG4-related hypophysitis (IgG4-RH) patients in a tertiary medical center. We reviewed clinical manifestations and imaging and pituitary function tests at baseline, as well as during follow-up. Ten patients were included. The mean age at diagnosis of IgG4-RH was 48.4 (16.0-64.0) years. An average of 3 (0-9) extrapituitary organs were involved. Five patients had panhypopituitarism, three had only posterior hypopituitarism, one had only anterior hypopituitarism, and one had a normal pituitary function. One patient in our study had pituitary mass biopsy, lacking IgG4-positive cells despite lymphocyte infiltration forming an inflammatory pseudotumor. Five patients with a clinical course of IgG4-RH less than nine months and a whole course of IgG4-RD less than two years were managed with glucocorticoids, while three patients with a longer history were administered glucocorticoids plus immunosuppressive agents. One patient went through surgical excision, and one patient was lost to follow-up. All patients showed a prompt response clinically, but only three patients had normalized serum IgG4 levels. Two patients who took medications for less than six months relapsed. Conclusions. IgG4-RD is a broad disease, and all physicians involved have to be aware of the possibility of pituitary dysfunction. Younger patients should be expected. The histopathological feature of pituitary gland biopsy could be atypical. For patients with a longer history, the combination of GC and immunosuppressive agents is favorable. Early and adequate courses of treatment are crucial for the management of IgG4-RH. With GC and/or immunosuppressant treatment, however, pituitary function or diabetes insipidus did not improve considerably.
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Affiliation(s)
- Yang Liu
- Department of Neurosurgery, Peking Union Medical College, Beijing 100730, China
| | - Linjie Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College, Beijing 100730, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Hongbo Yang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College, Beijing 100730, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College, Beijing 100730, China
| | - Shi Chen
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Xiaofeng Chai
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Zimeng Jin
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College, Beijing 100730, China
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Yamada K, Yamamoto M, Saeki T, Mizushima I, Matsui S, Fujisawa Y, Hara S, Takahashi H, Nomura H, Kawa S, Kawano M. New clues to the nature of immunoglobulin G4-related disease: a retrospective Japanese multicenter study of baseline clinical features of 334 cases. Arthritis Res Ther 2017; 19:262. [PMID: 29191210 PMCID: PMC5709928 DOI: 10.1186/s13075-017-1467-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 11/07/2017] [Indexed: 12/24/2022] Open
Abstract
Background The aim was to further characterize immunoglobulin G4-related disease (IgG4-RD) by a large-scale multicenter study of its clinical and laboratory features conducted by multidisciplinary physicians of IgG4-RD in Japan. Methods Various specialists retrospectively evaluated IgG4-RD patients diagnosed between 1996 and 2015 in five hospitals by analyzing their baseline clinical features, laboratory, imaging, and pathological test findings, and treatment. Results Of the 334 patients listed, 205 were male and median age at diagnosis was 65 years. The mean number of organs involved was 3.2 at diagnosis. The most frequently affected organs were the salivary glands, followed by the lacrimal glands, lymph nodes, pancreas, retroperitoneum/periaorta, kidneys, and lungs. The mean serum level of IgG4 was 755 mg/dl, and more than 95% of patients had elevated serum IgG4 levels. The median serum level of C-reactive protein (CRP) was 0.1 mg/dl and the level was less than 1 mg/dl in 90% of patients. A total of 34.7% of patients had low serum levels of C3. Serum levels of C3 and non-IgG4 IgG, calculated as the total IgG minus IgG4, showed an inverse correlation in patients with kidney lesions, while serum IgG4 levels were not correlated with serum C3 levels. Corticosteroid was administered in 78.0% of patients, and was effective in all. Conclusions The serum CRP level is generally low and the serum IgG4 level is elevated in most Japanese IgG4-RD patients, in contrast to western patients. These original findings suggest that these two parameters in IgG4-RD differ in some interesting ways from those hitherto reported in western populations. Additional studies, especially international comparative ones, are needed to elucidate the extent and significance of these differences between populations. Attention will also have to be paid to whether the existence of such differences requires consideration when devising international classification criteria. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1467-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kazunori Yamada
- Division of Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.,Department of Advanced Research in Community Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Motohisa Yamamoto
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Ichiro Mizushima
- Division of Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, Toyama, Japan
| | - Yuhei Fujisawa
- Division of Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Satoshi Hara
- Division of Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hideki Nomura
- Health Administration Center, University of Toyama, Toyama, Japan.,Division of General Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
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Ebbo M, Grados A, Samson M, Groh M, Loundou A, Rigolet A, Terrier B, Guillaud C, Carra-Dallière C, Renou F, Pozdzik A, Labauge P, Palat S, Berthelot JM, Pennaforte JL, Wynckel A, Lebas C, Le Gouellec N, Quémeneur T, Dahan K, Carbonnel F, Leroux G, Perlat A, Mathian A, Cacoub P, Hachulla E, Costedoat-Chalumeau N, Harlé JR, Schleinitz N. Long-term efficacy and safety of rituximab in IgG4-related disease: Data from a French nationwide study of thirty-three patients. PLoS One 2017; 12:e0183844. [PMID: 28915275 PMCID: PMC5600376 DOI: 10.1371/journal.pone.0183844] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/11/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To assess efficacy and safety of rituximab (RTX) as induction therapy, maintenance of remission and treatment of relapses in a cohort of IgG4-related disease (IgG4-RD) patients. METHODS Nationwide retrospective multicenter study of IgG4-RD patients treated with at least one course of RTX. Clinical, biological and radiological response, relapse rate and drug tolerance were analyzed. Kaplan-Meier curves were plotted and risk factors for relapse studied with a Cox regression model. RESULTS Among 156 IgG4-RD patients included in the French database, 33 received rituximab. Clinical response was noted in 29/31 (93.5%) symptomatic patients. Glucocorticoids withdrawal was achieved in 17 (51.5%) patients. During a mean follow-up of 24.8 ±21 months, 13/31 (41.9%) responder patients relapsed after a mean delay of 19 ±11 months after RTX. Active disease, as defined by an IgG4-RD Responder Index >9 before RTX, was significantly associated with relapse (HR = 3.68, 95% CI: 1.1, 12.6) (P = 0.04), whereas maintenance therapy with systematic (i.e. before occurrence of a relapse) RTX retreatment was associated with longer relapse-free survival (41 versus 21 months; P = 0.02). Eight severe infections occurred in 4 patients during follow-up (severe infections rate of 12.1/100 patient-years) and hypogammaglobulinemia ≤5 g/l in 3 patients. CONCLUSION RTX is effective for both induction therapy and treatment of relapses in IgG4-RD, but relapses are frequent after B-cell reconstitution. Maintenance therapy with systematic RTX infusions is associated with longer relapse-free survival and might represent a novel treatment strategy. Yet, the high rate of infections and the temporary effect of RTX might be hindrances to such strategy.
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Affiliation(s)
- Mikael Ebbo
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | - Aurélie Grados
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - Matthieu Groh
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université René-Descartes Paris V, Sorbonne Paris Cité, Paris, France
| | - Anderson Loundou
- Unité d'Aide Méthodologique, Aix-Marseille Université, AP-HM, Marseille, France
| | - Aude Rigolet
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital La Pitié-Salpêtrière; DHUI2B, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université René-Descartes Paris V, Sorbonne Paris Cité, Paris, France
| | - Constance Guillaud
- Department of Internal Medicine, Hôpital Henri Mondor, AP-HP, Créteil, France
| | | | - Frédéric Renou
- Department of Internal Medicine, CHU La Réunion site Félix Guyon, Saint-Denis, La Réunion, France
| | - Agnieszka Pozdzik
- Department of Nephrology, Erasme Hospital, Cliniques Universitaires de Bruxelles, Bruxelles, Belgium
| | - Pierre Labauge
- Department of Neurology, CHRU de Montpellier, Montpellier, France
| | - Sylvain Palat
- Department of Internal Medicine, CHU Limoges, Limoges, France
| | | | | | - Alain Wynckel
- Department of Nephrology, CHU de Reims, Reims, France
| | - Céline Lebas
- Department of Nephrology, CHRU de Lille, Lille, France
| | - Noémie Le Gouellec
- Department of Nephrology and Internal Medicine, CH Valenciennes, Valenciennes, France
| | - Thomas Quémeneur
- Department of Nephrology and Internal Medicine, CH Valenciennes, Valenciennes, France
| | - Karine Dahan
- Department of Nephrology, Hôpital Tenon, AP-HP, Paris, France
| | - Franck Carbonnel
- Department of Gastro-enterology, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Gaëlle Leroux
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital La Pitié-Salpêtrière; DHUI2B, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Antoinette Perlat
- Department of Internal Medicine, Hôpital Sud, CHU de Rennes, Rennes, France
| | - Alexis Mathian
- Department of Internal Medicine, Hôpital Pitié-Salpêtrière, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital La Pitié-Salpêtrière; DHUI2B, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Eric Hachulla
- National Referral Centre for Auto-immune and Systemic Diseases, Department of Internal Medicine, Huriez Hospital, Université de Lille, Lille, France
| | - Nathalie Costedoat-Chalumeau
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université René-Descartes Paris V, Sorbonne Paris Cité, Paris, France
| | - Jean-Robert Harlé
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | - Nicolas Schleinitz
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
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132
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Uzunhan Y, Jeny F, Kambouchner M, Didier M, Bouvry D, Nunes H, Bernaudin JF, Valeyre D. The Lung in Dysregulated States of Humoral Immunity. Respiration 2017; 94:389-404. [PMID: 28910817 DOI: 10.1159/000480297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In common variable immunodeficiency, lung manifestations are related to different mechanisms: recurrent pneumonias due to encapsulated bacteria responsible for diffuse bronchiectasis, diffuse infiltrative pneumonia with various patterns, and lymphomas, mostly B cell extranodal non-Hodgkin type. The diagnosis relies on significant serum Ig deficiency and the exclusion of any primary or secondary cause. Histopathology may be needed. Immunoglobulin (IgG) replacement is crucial to prevent infections and bronchiectasis. IgG4-related respiratory disease, often associated with extrapulmonary localizations, presents with solitary nodules or masses, diffuse interstitial lung diseases, bronchiolitis, lymphadenopathy, and pleural or pericardial involvement. Diagnosis relies on international criteria including serum IgG4 dosage and significantly increased IgG4/IgG plasma cells ratio in pathologically suggestive biopsy. Respiratory amyloidosis presents with tracheobronchial, nodular, and cystic or diffuse interstitial lung infiltration. Usually of AL (amyloid light chain) subtype, it may be localized or systemic, primary or secondary to a lymphoproliferative process. Very rare other diseases due to nonamyloid IgG deposits are described. Among the various lung manifestations of dysregulated states of humoral immunity, this article covers only those associated with the common variable immunodeficiency, IgG4-related disease, amyloidosis, and pulmonary light-chain deposition disease. Autoimmune connective-vascular tissue diseases or lymphoproliferative disorders are addressed in other chapters of this issue.
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133
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Qi R, Chen LYC, Park S, Irvine R, Seidman MA, Kelsall JT, Collins D, Yin V, Slack GW, Mattman A, Lam E, Carruthers MN. Utility of Serum IgG4 Levels in a Multiethnic Population. Am J Med Sci 2017; 355:61-66. [PMID: 29289265 DOI: 10.1016/j.amjms.2017.08.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/02/2017] [Accepted: 08/21/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a recently recognized condition defined by characteristic histopathologic findings in affected organs. Serum IgG4 concentration is often but not always elevated. The sensitivity and specificity of serum IgG4 vary greatly across studies and has been anecdotally associated to ethnicity. Our study was conducted to investigate the difference in serum IgG4 levels between Asian and non-Asian patients with IgG4-RD. METHODS This is a single-center retrospective study of 26 Asian and 10 non-Asian patients with histologically confirmed IgG4-RD. Serum IgG4 levels, clinical features and other laboratory findings were compared between the 2 groups, 31 Asian and 11 non-Asian patients with non-IgG4-RD rheumatic diseases were randomly identified to evaluate test characteristics of serum IgG4 measurement. RESULTS Median serum IgG4 at time of diagnosis was significantly higher in Asian (median = 11.2g/L, interquartile range: 4.6-19.7) than non-Asian patients (median = 2.9g/L, interquartile range: 0.7-5.4, P = 0.0094), as well as the median serum IgG and total protein. Asian patients had more eosinophilia and polyclonal hypergammaglobulinemia than non-Asian patients (P = 0.016 and 0.001, respectively). Test sensitivity was higher in Asian (96%) than non-Asian patients (67%), whereas test specificity was higher in non-Asian patients (91% versus 71%). CONCLUSION Asian patients with IgG4-RD have more exuberant serum IgG4, IgG and polyclonal hypergammaglobulinemia than non-Asian patients; the mechanism of this difference requires further study. These findings have significant clinical importance and must be accounted for in the diagnostic workup of patients in multiethnic settings.
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Affiliation(s)
- Ruyu Qi
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Luke Y C Chen
- Division of Hematology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sujin Park
- Division of Hematology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Irvine
- Division of Otolaryngology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A Seidman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John T Kelsall
- Division of Rheumatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Collins
- Division of Rheumatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vivian Yin
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Graham W Slack
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andre Mattman
- Adult Metabolic Disease Clinic, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Lam
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mollie N Carruthers
- Division of Rheumatology, University of British Columbia, Vancouver, British Columbia, Canada.
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Yunyun F, Yu C, Panpan Z, Hua C, Di W, Lidan Z, Linyi P, Li W, Qingjun W, Xuan Z, Yan Z, Xiaofeng Z, Fengchun Z, Wen Z. Efficacy of Cyclophosphamide treatment for immunoglobulin G4-related disease with addition of glucocorticoids. Sci Rep 2017; 7:6195. [PMID: 28733656 PMCID: PMC5522435 DOI: 10.1038/s41598-017-06520-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 06/14/2017] [Indexed: 12/24/2022] Open
Abstract
Aim to evaluate the efficacy and safety of glucocorticoid monotherapy vs combination therapy of cyclophosphamide (CYC) for IgG4 related disease (IgG4-RD). 102 newly diagnosed IgG4-RD patients were enrolled and assigned to 2 groups: Group I was prednisone monotherapy (0.5-1.0 mg/kg.d, tapered gradually) and Group II was glucocorticoid and CYC (50-100 mg per day). Patients were assessed at different periods. Primary end point was relapse rate; secondary end points included response, remission rate and adverse effects. 52 patients were in Group I and 50 in Group II. At 1 month, both groups achieved obvious improvement. Accumulated relapse rate during 1 year was 38.5% in Group 1, including 12 cases with clinical relapse and 8 patients manifesting only serological relapse; whereas there was 12.0% of relapse in Group 2, only 1 with clinical relapse and other 5 patients got serological relapse. The mean flare time in Group II was significantly longer than that in Group I. All relapsing patients in Group I were sensitive to immunosuppressants. Most patients involving more than 6 organs in Group I relapsed during 1 year. IgG4 levels of relapse cases were significantly higher than non-relapsing patients at baseline. Bile duct, lacrimal glands and lymph nodes were commonly relapsed organs in Group I.
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Affiliation(s)
- Fei Yunyun
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Chen Yu
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhang Panpan
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Chen Hua
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Wu Di
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhao Lidan
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Peng Linyi
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Wang Li
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Wu Qingjun
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhang Xuan
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhao Yan
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zeng Xiaofeng
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhang Fengchun
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Zhang Wen
- Departments of Rheumatology, Peking Union Medical College Hospital, Clinical Immunology Center, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China.
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Zheng K, Teng F, Li XM. Immunoglobulin G4-related kidney disease: Pathogenesis, diagnosis, and treatment. Chronic Dis Transl Med 2017; 3:138-147. [PMID: 29063068 PMCID: PMC5643773 DOI: 10.1016/j.cdtm.2017.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 12/19/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized clinical entity that often involves multiple organs; it is characterized by high levels of serum immunoglobulin G4 (IgG4), dense infiltration of IgG4+ cells, and storiform fibrosis. Cellular immunity, particularly T cell-mediated immunity, has been implicated in the pathogenesis of IgG4-RD. The most frequent renal manifestations of IgG4-RD are IgG4-related tubulointerstitial nephritis, membranous glomerulonephropathy (MGN), and obstructive nephropathy secondary to urinary tract obstruction due to IgG4-related retroperitoneal fibrosis, prostatitis, or ureter inflammation. Kidney function impairment can be acute or chronic. In IgG4-MGN, proteinuria can be in the nephrotic range. The diagnosis of IgG4-related kidney disease should not be based solely on serum IgG4 levels or the number of tissue-infiltrating IgG4+ plasma cells. Diagnosis should be based on specific histopathological findings, confirmed by tissue immunostaining and an appropriate clinical context. Steroid treatment is the first-line therapy. For relapsing or refractory cases, immunosuppressants could be combined with steroids. In hydronephrosis patients, appropriate immunosuppressive therapy could preclude the implantation of a double J ureteral catheter.
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Bennett AE, Fenske NA, Rodriguez-Waitkus P, Messina JL. IgG4-related skin disease may have distinct systemic manifestations: a systematic review. Int J Dermatol 2017; 55:1184-1195. [PMID: 27419384 DOI: 10.1111/ijd.13369] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/20/2016] [Accepted: 04/15/2016] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is an increasingly prevalent protean multisystem disorder characterized by single or multi-organ infiltration of IgG4-bearing plasma cells. Skin involvement has been recognized and is relevant to proper diagnosis. A systematic literature review of 50 cases involving the skin reveals that patients with IgG4-related skin disease show predominant involvement of the head and neck and have a distinct pattern of systemic involvement, also favoring the head and neck - lymphatics, orbit, salivary, and lacrimal glands - but generally lacking pancreaticobiliary involvement (16% of cases), which by contrast is a predominant manifestation in systemic IgG4-RD (60% with pancreaticobiliary involvement). We summarize clinical and pathologic descriptive data from this systematic review. We review differential diagnosis and propose a diagnostic scheme for stratifying probability of disease based upon comprehensive integration of clinical, histopathologic, and laboratory data. Plasmacyte infiltration and storiform fibrosis are prominent in IgG4-related skin disease, but obliterative venulitis is less common than in the prototypical IgG4-related disease manifestation of autoimmune pancreatitis. IgG4 tissue and serum values, with a mean (±95% CI) in the reviewed cases of 132.8 ± 32.6 IgG4-positive plasma cells per high-power field and 580 ± 183.8 mg/dl, respectively, are incorporated into the suggested criteria. The distinct set of manifestations identified by this systematic review and the proposed diagnostic considerations, while requiring further validation in prospective studies, highlight the need to consider that IgG4-related skin disease defines a unique systemic disease complex along the spectrum of IgG4-RD.
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Affiliation(s)
- Adam E Bennett
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Neil A Fenske
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paul Rodriguez-Waitkus
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Pathology and Cell Biology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jane L Messina
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Pathology and Cell Biology, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Wang Y, Li K, Gao D, Luo G, Zhao Y, Wang X, Zhang J, Jin J, Zhao Z, Yang C, Zhu J, Zhang J, Huang F. Combination therapy of leflunomide and glucocorticoids for the maintenance of remission in patients with IgG4-related disease: a retrospective study and literature review. Intern Med J 2017; 47:680-689. [PMID: 28321964 DOI: 10.1111/imj.13430] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/07/2017] [Accepted: 03/08/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Yiwen Wang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Kunpeng Li
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Dai Gao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Gui Luo
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Yurong Zhao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Xiuru Wang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jie Zhang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jingyu Jin
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Zheng Zhao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Chunhua Yang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jian Zhu
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jianglin Zhang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Feng Huang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
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Abstract
Pathologists are likely to encounter IgG4-related disease in several organ systems. This article focuses on helping pathologists diagnose IgG4-related disease in the hepatobiliary system. Missing the diagnosis can result in unnecessary organ damage and/or unnecessary surgical and cancer therapy. In the liver, tumefactive lesion(s) involving the bile ducts with storiform fibrosis and an IgG4-enriched lymphoplasmacytic infiltrate are highly concerning for IgG4-related disease. The recent identification of oligoclonal populations of T cells and B cells in IgG4-related disease may lead to molecular tests, new therapeutics, and a greater mechanistic understanding of the disease.
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Affiliation(s)
- Jonathan H Chen
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 01224, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 01224, USA.
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Wu Q, Chang J, Chen H, Chen Y, Yang H, Fei Y, Zhang P, Zeng X, Zhang F, Zhang W. Efficacy between high and medium doses of glucocorticoid therapy in remission induction of IgG4-related diseases: a preliminary randomized controlled trial. Int J Rheum Dis 2017; 20:639-646. [PMID: 28556584 DOI: 10.1111/1756-185x.13088] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Qingjun Wu
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Jie Chang
- Department of Rheumatology; The Fourth Affiliated Hospital; Zhejiang University School of Medicine; Yiwu Zhejiang China
| | - Hua Chen
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Yu Chen
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Hongxian Yang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Yunyun Fei
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Panpan Zhang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Xiaofeng Zeng
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Fengchun Zhang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Wen Zhang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
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Addition of second-line steroid sparing immunosuppressants like mycophenolate mofetil improves outcome of Immunoglobulin G4-related disease (IgG4-RD): a series from a tertiary care teaching hospital in South India. Rheumatol Int 2017; 38:203-209. [DOI: 10.1007/s00296-017-3730-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/22/2017] [Indexed: 12/24/2022]
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141
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Baptista B, Casian A, Gunawardena H, D'Cruz D, Rice CM. Neurological Manifestations of IgG4-Related Disease. Curr Treat Options Neurol 2017; 19:14. [PMID: 28374231 PMCID: PMC5378735 DOI: 10.1007/s11940-017-0450-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. Early recognition of IgG4-RD is important to avoid permanent organ dysfunction and disability. Neurological involvement by IgG4-RD is relatively uncommon, but well recognised-hypertrophic pachymeningitis and hypophysitis are the most frequent manifestations. Although the nervous system may be involved in isolation, this more frequently occurs in conjunction with involvement of other systems. Elevated circulating levels of IgG4 are suggestive of the condition, but these are not pathognomonic and exclusion of other inflammatory disorders including vasculitis is required. Wherever possible, a tissue diagnosis should be established. The characteristic histopathological changes include a lymphoplasmacytoid infiltrate, storiform fibrosis and obliterative phlebitis. IgG4-RD typically responds well to treatment with glucocorticoids, although relapse is relatively common and treatment with a steroid-sparing agent or rituximab may be required. Improved understanding of the pathogenesis of IgG4-RD is likely to lead to the development of more specific disease treatments in the future.
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Affiliation(s)
| | - Alina Casian
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Harsha Gunawardena
- Department of Rheumatology, Brunel Building, Southmead Hospital, Bristol, UK
- Musculoskeletal Research Unit, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - David D'Cruz
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
- Division of Immunology, Infection and Inflammatory Diseases, King's College London, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Claire M Rice
- School of Clinical Sciences, Level 1, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Department of Neurology, Brunel Building, Southmead Hospital, Bristol, UK.
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Chen Y, Zhao JZ, Feng RE, Shi JH, Li XM, Fei YY, Shi Y, Zhang W, Zhang FC. Types of Organ Involvement in Patients with Immunoglobulin G4-related Disease. Chin Med J (Engl) 2017; 129:1525-32. [PMID: 27364787 PMCID: PMC4931257 DOI: 10.4103/0366-6999.184459] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized systemic disease that can involve multiple organs and various clinical phenotypes. The purpose of this study was to analyze different types of organ involvement in IgG4-RD patients in China. Methods: We conducted a prospective cohort study on IgG4-RD patients to analyze the clinical manifestations and rare features of IgG4-RD. Patients were grouped into different types according to organ involvement regarding organ number and organ site. The constituent ratio in different types was also analyzed. Results: A total of 200 IgG4-RD patients, with a male:female ratio of 2.08:1, were grouped into different types. Cases having involvement of two or three organs were the most common whereas the fewest number of patients had multi-organ (≥4) involvement. Serum IgG4 and IgE levels, IgG4/IgG ratio, and percentage of eosinophils increased as the number of involved organs increased. In addition, constituent ratio analysis revealed that patients with salivary gland/lacrimal gland swelling, who also constituted the largest number of IgG4-RD patients, had higher serum IgG4 concentrations and IgG4/IgG values, had higher percentage of Eos, and were more likely to have had a history of allergies relative to patients with internal organ involvement. Conclusions: The characteristic feature of IgG4-RD is multiple organ involvement with various clinical manifestations and different types. Although serum IgG4 levels increased with the number of involved organs, serum IgG4 levels were higher for those patients with salivary gland/lacrimal gland swelling compared with those with internal organ involvement. Thus, valuable clues to the differential diagnosis of IgG4-RD could be obtained by examining the clinical patterns of organ involvement.
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Affiliation(s)
- Yu Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100032, China
| | - Ji-Zhi Zhao
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Rui-E Feng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ju-Hong Shi
- Department of Respiratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xue-Mei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yun-Yun Fei
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100032, China
| | - Yang Shi
- Department of Rheumatology, Traditional Chinese Medicine Hospital, Capital Medical University, Beijing 100010, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100032, China
| | - Feng-Chun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100032, China
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143
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Cao L, Chen YB, Zhao DH, Shi WF, Meng S, Xie LX. Pulmonary function tests findings and their diagnostic value in patients with IgG4-related disease. J Thorac Dis 2017; 9:547-554. [PMID: 28449462 DOI: 10.21037/jtd.2017.02.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disorder that can affect most organs. To date, there have been no detailed assessments of pulmonary function in patients with IgG4-RD. In this study, we investigated pulmonary function in IgG4-RD patients and evaluated the value of pulmonary function tests (PFTs) in diagnosing IgG4-related respiratory disease (IgG4-RRD). METHODS This was a retrospective study of 17 patients with IgG4-RD. The patients were divided into two groups: IgG4-RRD group and IgG4-related disease extrapulmonary involvement (IgG4-RDEI) group. The PFT results were compared between the two groups. RESULTS All patients in the IgG4-RRD group had pulmonary dysfunction. Five of 8 (62.5%) patients in the IgG4-RDEI group had pulmonary dysfunction, despite having normal thoracic computed tomography scans and no respiratory symptoms. Patients in both groups showed restrictive ventilatory dysfunction and abnormal diffusing capacity, and two patients in the IgG4-RRD group had obstructive ventilatory dysfunction. The incidence of diffusing capacity of the lung for carbon monoxide per liter of alveolar volume (DLCO/VA) decrease were significantly higher in the IgG4-RRD group than in the IgG4-RDEI group (P=0.029). DLCO/VA were significantly higher in the IgG4-RDEI than in the IgG4-RRD group (P=0.044), but otherwise, there were no significant differences. We report the first finding of a negative correlation between pulmonary diffusing capacity and total serum concentrations of IgG and IgG subclasses (IgG4, IgG3 and IgG2). CONCLUSIONS DLCO/VA plays an important role for detecting lung involvement in IgG4-RD patients. The patient with high serum IgG may be more prone to respiratory involvement.
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Affiliation(s)
- Lu Cao
- Department of Pulmonary & Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Yi-Bing Chen
- Department of Pulmonary & Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Da-Hui Zhao
- Department of Pulmonary & Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Wen-Fang Shi
- Department of Pulmonary & Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Song Meng
- Department of Pulmonary & Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Li-Xin Xie
- Department of Pulmonary & Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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Ebbo M, Patient M, Grados A, Groh M, Desblaches J, Hachulla E, Saadoun D, Audia S, Rigolet A, Terrier B, Perlat A, Guillaud C, Renou F, Bernit E, Costedoat-Chalumeau N, Harlé JR, Schleinitz N. Ophthalmic manifestations in IgG4-related disease: Clinical presentation and response to treatment in a French case-series. Medicine (Baltimore) 2017; 96:e6205. [PMID: 28272212 PMCID: PMC5348160 DOI: 10.1097/md.0000000000006205] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is characterized by variable tissue or organ involvements sharing common pathological findings. Orbital or orbital adnexa involvement of the disease has been reported in a few case series. The aim of our study was to characterize and analyze ophthalmic manifestations from a nationwide French case-series.Patients with IgG4-RD and orbital or orbital adnexa involvement included in the French multicentric IgG4-RD case-registry were identified. Only patients fulfilling "modified" comprehensive diagnostic criteria with pathological documentation were retained for the study. Clinical, biological, pathological, radiological findings and data regarding the response to treatment were retrospectively analyzed.According to our data registry, the frequency of IgG4-related ophthalmic disease (IgG4-ROD) was 17%. Mean age at diagnosis was 55.1 ± 7.1 years with a male/female ratio of 2.2. The 19 cases of IgG4-ROD consisted of lacrimal gland (68.4%), soft tissue (57.9%), extra-ocular muscles (36.8%), palpebral (21.1%), optical nerve (10.5%), orbital bone (10.5%), and mononeuritis (V1 and/or V2, 10.5%) involvements. IgG4-ROD was bilateral in 57.9% of cases. Extra-ophthalmic manifestations were reported in 78.9% of cases. All patients responded to prednisone but two-thirds of patients relapsed within a mean (SD) of 9.8 (3.5) months and 72.2% required long-term glucocorticoids and/or immunosuppressive agents. Eight patients were treated by rituximab with a favorable response in 87.5% of cases.Lacrimal involvement is the most frequent ophthalmic manifestation of IgG4-RD and is frequently associated with extra-orbital manifestations. Despite initial favorable response to steroids, the long-term management of relapsing patients needs to be improved.
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Affiliation(s)
- Mikael Ebbo
- Médecine Interne, Groupe Hospitalier Timone, AP-HM, Aix-Marseille Université, Marseille
| | - Matthieu Patient
- Médecine Interne, Groupe Hospitalier Timone, AP-HM, Aix-Marseille Université, Marseille
| | - Aurelie Grados
- Médecine Interne, Groupe Hospitalier Timone, AP-HM, Aix-Marseille Université, Marseille
| | - Matthieu Groh
- Médecine Interne, Hopital Cochin, Université Paris-Descartes, Paris
| | | | - Eric Hachulla
- CHRU—Hôpital Claude Huriez, Université de Lille, Lille
| | - David Saadoun
- Médecine Interne, Groupe hospitalier Pitie Salpêtrière AP-HP, Université Pierre et Marie Curie, Paris
| | - Sylvain Audia
- Médecine interne, CHU le Bocage, Université de Bourgogne, Dijon
| | - Aude Rigolet
- Médecine Interne, Groupe hospitalier Pitie Salpêtrière AP-HP, Université Pierre et Marie Curie, Paris
| | - Benjamin Terrier
- Médecine Interne, Hopital Cochin, Université Paris-Descartes, Paris
| | | | | | | | - Emmanuelle Bernit
- Médecine Interne, Groupe Hospitalier Timone, AP-HM, Aix-Marseille Université, Marseille
| | | | - Jean-Robert Harlé
- Médecine Interne, Groupe Hospitalier Timone, AP-HM, Aix-Marseille Université, Marseille
| | - Nicolas Schleinitz
- Médecine Interne, Groupe Hospitalier Timone, AP-HM, Aix-Marseille Université, Marseille
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145
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Ferreira da Silva RC, Lieberman SM, Hoffman HT, Policeni B, Bashir A, Smith RJH, Sato TS. IgG4-related disease in an adolescent with radiologic-pathologic correlation. Radiol Case Rep 2017; 12:196-199. [PMID: 28228909 PMCID: PMC5310240 DOI: 10.1016/j.radcr.2016.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4–related disease (IgG4RD) is an immune-mediated condition characterized by lymphoplasmacytic infiltrates and fibrosis of affected organs. IgG4RD may affect many different organs either individually or together in a multiorgan condition and, thus, incorporates a wide range of fibroinflammatory phenotypes with shared pathologic features. Although IgG4RD most commonly occurs in late adulthood, it may affect children and adolescents. Only one case of IgG4RD presenting as isolated submandibular gland involvement has been reported in the pediatric population. Radiographic features of IgG4RD are often nonspecific making diagnosis challenging, but it is important for radiologists to be familiar with this diseased as its inclusion the differential for diffuse salivary enlargement may be the first step in making an accurate diagnosis. Here, we report a case of a child presenting with bilateral submandibular gland swelling to increase awareness of this condition in the pediatric population. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
| | - Scott M Lieberman
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Henry T Hoffman
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Bruno Policeni
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Amani Bashir
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Richard J H Smith
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - T Shawn Sato
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA
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146
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Lin W, Zhang P, Chen H, Chen Y, Yang H, Zheng W, Zhang X, Zhang F, Zhang W, Lipsky PE. Circulating plasmablasts/plasma cells: a potential biomarker for IgG4-related disease. Arthritis Res Ther 2017; 19:25. [PMID: 28183334 PMCID: PMC5301376 DOI: 10.1186/s13075-017-1231-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/12/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a multisystem fibroinflammatory disease. We previously reported that a circulating cell population expressing CD19+CD24-CD38hi was increased in patients with IgG4-RD. In this study, we aimed to document that this cell population represented circulating plasmablasts/plasma cells, to identify the detailed phenotype and gene expression profile of these IgG4-secreting plasmablasts/plasma cells, and to determine whether this B-cell lineage subset could be a biomarker in IgG4-related disease (IgG4-RD). METHODS A total of 42 untreated patients with IgG4-RD were evaluated. Peripheral B-cell subsets, including CD19+CD24-CD38hi plasmablasts/plasma cells, CD19+CD24+CD38- memory B cells, CD19+CD24intCD38int naïve B cells, and CD19+CD24hiCD38hi regulatory B cells, were assessed and sorted by flow cytometry. Microarray analysis was used to measure gene expression of circulating B-cell lineage subsets. Further characterization of CD19+CD24-CD38hi plasmablasts/plasma cells was carried out by evaluating additional surface markers, including CD27, CD95, and human leukocyte antigen (HLA)-DR, by flow cytometric assay. In addition, various B-cell lineage subsets were cultured in vitro and IgG4 concentrations were measured by cytometric bead array. RESULTS In untreated patients with IgG4-RD, the peripheral CD19+CD24-CD38hi plasmablast/plasma cell subset was increased and positively correlated with serum IgG4 levels, the number of involved organs, and the IgG4-related Disease Responder Index. It decreased after treatment with glucocorticoids. Characterization of the plasmablast/plasma cell population by gene expression profiling documented a typical plasmablast/plasma cell signature with higher expression of X-box binding protein 1 and IFN regulatory factor 4, but lower expression of paired box gene 5 and B-cell lymphoma 6 protein. In addition, CD27, CD95, and HLA-DR were highly expressed on CD19+CD24-CD38hi plasmablasts/plasma cells from patients with IgG4-RD. Furthermore, CD19+CD24-CD38hi plasmablasts/plasma cells secreted more IgG4 than other B-cell populations. CONCLUSIONS Circulating CD19+CD24-CD38hi plasmablasts/plasma cells are elevated in active IgG4-RD and decreased after glucocorticoid treatment. This IgG4-secreting plasmablast/plasma cell population might be a potentially useful biomarker for diagnosis and assessing response to treatment.
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Affiliation(s)
- Wei Lin
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.,Department of Rheumatology, Hebei General Hospital, Shijiazhuang, China
| | - Panpan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Hua Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yu Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Hongxian Yang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Wenjie Zheng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xuan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Fengxiao Zhang
- Department of Rheumatology, Hebei General Hospital, Shijiazhuang, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
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Martínez-Valle F, Fernández-Codina A, Pinal-Fernández I, Orozco-Gálvez O, Vilardell-Tarrés M. IgG4-related disease: Evidence from six recent cohorts. Autoimmun Rev 2017; 16:168-172. [DOI: 10.1016/j.autrev.2016.12.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/09/2016] [Indexed: 12/24/2022]
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148
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Bernreuther C, Illies C, Flitsch J, Buchfelder M, Buslei R, Glatzel M, Saeger W. IgG4-related hypophysitis is highly prevalent among cases of histologically confirmed hypophysitis. Brain Pathol 2017; 27:839-845. [PMID: 27864854 DOI: 10.1111/bpa.12459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/17/2016] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease is an immune-mediated disease with manifestations in most organ systems among them the pituitary gland. To date, few cases of histologically confirmed cases of IgG-related hypophysitis have been reported. The aim of this study was to retrospectively determine the prevalence of IgG4-related hypophysitis among cases previously diagnosed as primary hypophysitis (lymphocytic hypophysitis, granulomatous hypophysitis and hypophysitis not otherwise specified). Histological and immunohistochemical analysis revealed that 12 of 29 cases (41.4%) previously diagnosed as primary hypophysitis fulfilled the criteria for IgG4-related disease and, thus, IgG4-related hypophysitis should always be considered in the differential diagnosis of primary hypophysitis. All cases of IgG4-related hypophysitis showed a dense lymphoplasmacytic infiltrate with more than 10 IgG4-positive cells per high power field and a ratio of IgG4/IgG-positive cells of more than 40%, whereas storiform fibrosis was an inconsistent histological feature and was also seen in few cases of non-IgG-related hypophysitis, thus lacking sensitivity and specificity. Obliterative phlebitis was not seen in any case. Thus, histological criteria defined for IgG4-related disease in other organs should be modified for IgG4-related hypophysitis, accordingly.
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Affiliation(s)
- Christian Bernreuther
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christopher Illies
- Department of Pathology, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Rolf Buslei
- Institute of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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149
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Bellastella G, Maiorino MI, Bizzarro A, Giugliano D, Esposito K, Bellastella A, De Bellis A. Revisitation of autoimmune hypophysitis: knowledge and uncertainties on pathophysiological and clinical aspects. Pituitary 2016; 19:625-642. [PMID: 27503372 PMCID: PMC7088540 DOI: 10.1007/s11102-016-0736-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE This publication reviews the accepted knowledges and the findings still discussed on several features of autoimmune hypophysitis, including the most recently described forms, such as IgG4 and cancer immunotherapy- related hypophysitis. METHODS The most characteristic findings and the pending controversies were derived from a literature review and previous personal experiences. A single paragraph focused on some atypical examples of the disease presenting under confounding pretences. RESULTS Headache, visual field alterations and impaired pituitary secretion are the most frequent clinical findings of the disease. Pituitary biopsy, still considered the gold diagnostic standard, does not always receive consent from the patients. The role of magnetic resonance imaging is limited, as this disease may generate images similar to those of other diseases. The role of antipituitary and antihypothalamus antibodies is still discussed owing to methodological difficulties and also because the findings on the true pituitary antigen(s) are still debated. However, the low sensitivity and specificity of immunofluorescence, one of the more widely employed methods to detect these antibodies, may be improved, considering a predetermined cut-off titre and a particular kind of immunostaining. CONCLUSION Autoimmune hypophysitis is a multifaceted disease, which may certainly be diagnosed by pituitary biopsy. However, the possible different clinical, laboratory and imaging features must be considered by the physician to avoid a misdiagnosis when examining a possibly affected patient. Therapeutic choice has to be made taking into account the clinical conditions and the degree of hypothalamic-pituitary involvement, but also considering that spontaneous remissions can occur.
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Affiliation(s)
- Giuseppe Bellastella
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, Naples, Italy
| | - Maria Ida Maiorino
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, Naples, Italy
| | - Antonio Bizzarro
- Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Dario Giugliano
- Endocrinology and Metabolic Diseases Unit, Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Second University of Naples, Naples, Italy
| | - Katherine Esposito
- Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Antonio Bellastella
- Endocrinology and Metabolic Diseases Unit, Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy.
| | - Annamaria De Bellis
- Endocrinology and Metabolic Diseases Unit, Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy
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Abstract
Retroperitoneal fibrosis (RPF) is a rare disease, hallmarked by inflammation and deposition of fibrous tissue around the abdominal aorta. This process may spread contiguously and involve adjacent structures, leading to many complications, among which the most frequent and most severe is ureteral obstruction. The condition usually has idiopathic origin (idiopathic retroperitoneal fibrosis – IRF), but can also develop secondarily to a number of factors. The etiology of the disease remains unclear. Current research suggests that about half of the cases of IRF may be a symptom of a recently discovered, clinically heterogeneous immunoglobulin G4-related disease (IgG4-RD). Corticosteroids are the first-line treatment for IRF, but effective attempts to use immunosuppressants are also made. This paper presents the current state of knowledge on the etiopathogenesis, clinical presentation, diagnosis and therapeutic possibilities in different forms of RPF. Based on the latest research, an analysis of the relationship between IRF and IgG4-RD was performed.
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