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Shafiq I, Ghorab OKHA, Abuzakouk M, Mohammed S, Uzbeck MH, Wahla AS. IgG4-related lung disease mimicking lung cancer. Radiol Case Rep 2022; 17:931-934. [PMID: 35079315 PMCID: PMC8777243 DOI: 10.1016/j.radcr.2021.12.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/19/2022] Open
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Abstract
IgG4-related conditions affecting the digestive tract are part of a multi-organ fibro-inflammatory disorder termed IgG4-related disease (IgG4-RD), with autoimmune pancreatitis and IgG4-related cholangitis being the most prominent manifestations. Gastrointestinal symptoms include jaundice, weight loss, abdominal pain, biliary strictures, and pancreatic and hepatic masses that mimic malignant diseases. IgG4-RD manifestations occur less frequently elsewhere in the digestive tract, namely in the oesophagus, retroperitoneum or intestine. Evidence-based European guidelines frame the current state-of-the-art in the diagnosis and management of IgG4-related digestive tract disease. Diagnosis is based on histology (if available), imaging, serology, other organ involvement and response to therapy (HISORt criteria). Few biomarkers beyond serum IgG4 concentrations are reliable. The first-line therapy (glucocorticoids) is swiftly effective but disease flares are common at low doses or after tapering. Second-line therapy might consist of other immunosuppressive drugs such as thiopurines or rituximab. Further trials, for example, of anti-CD19 drugs, are ongoing. Although an association between IgG4-RD and the development of malignancies has been postulated, the true nature of this relationship remains uncertain at this time.
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153
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Moskalik A, Kercher M, Vitt J, Lee H, Waldau B. Chiari decompression for syringomyelia in the setting of IgG4-related hypertrophic pachymeningitis: A case-based update. Neurochirurgie 2022; 68:e97-e100. [DOI: 10.1016/j.neuchi.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/03/2022] [Accepted: 02/15/2022] [Indexed: 10/18/2022]
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154
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Rodriguez A, Klein CJ, Sechi E, Alden E, Basso MR, Pudumjee S, Pittock SJ, McKeon A, Britton JW, Lopez-Chiriboga AS, Zekeridou A, Zalewski NL, Boeve BF, Day GS, Gadoth A, Burkholder D, Toledano M, Dubey D, Flanagan EP. LGI1 antibody encephalitis: acute treatment comparisons and outcome. J Neurol Neurosurg Psychiatry 2022; 93:309-315. [PMID: 34824144 PMCID: PMC8862031 DOI: 10.1136/jnnp-2021-327302] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare acute treatment responses and long-term outcome in leucine-rich glioma-inactivated 1 (LGI1) antibody encephalitis. METHODS Retrospective case series of 118 patients with LGI1 antibody encephalitis evaluated at Mayo Clinic across all US sites from 1 May 2008 to 31 March 2019. Patient clinical data were identified and analysed through the neuroimmunology laboratory and electronic medical record. LGI1 antibody detection was by cell-based indirect immunofluorescence assay of serum, cerebrospinal fluid or both. Clinical outcomes were faciobrachial dystonic seizure (FBDS) resolution, modified Rankin Scale (mRS) score, Kokmen Short Test of Mental Status (STMS) score (0-38 point scale) and neuropsychometric testing results. RESULTS Compared with intravenous immunoglobulin (IVIg) (n=21), patients treated with single-agent acute corticosteroids (intravenous, oral or both) (n=49) were more likely to experience resolution of FBDS (61% vs 7%, p=0.002) and improvements in mRS score (ΔmRS score 2 vs 0, p=0.008) and median Kokmen STMS scores (ΔKokmen STMS score 5 points vs 0 points, p=0.01). In 54 patients with long-term follow-up (≥2 years), the median mRS score was 1 (range 0-6) and the median Kokmen STMS score was 36 (range 24-38) after all combinations of immunotherapy. Neuropsychometric testing in 32 patients with long-term follow-up (≥2 years) demonstrated short-term memory impairments in 37%. CONCLUSIONS Corticosteroids appeared more effective acutely than IVIg in improving LGI1 antibody encephalitis in this retrospective comparison of immunotherapies. While improvement with immunotherapy is typical and long-term outcome is favourable, short-term memory deficits are noted in approximately a third of the patients.
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Affiliation(s)
| | - C J Klein
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eva Alden
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael R Basso
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shehroo Pudumjee
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew McKeon
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Anastasia Zekeridou
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - B F Boeve
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Avi Gadoth
- Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Michel Toledano
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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155
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Ahmad M, Spandorfer R, Al Naqeeb J, Khosroshahi A. Mimickers of Immunoglobulin G4-Related Disease. J Clin Rheumatol 2022; 28:e647-e650. [PMID: 34670992 DOI: 10.1097/rhu.0000000000001796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Madiha Ahmad
- From the Department of Rheumatology, Emory University, Atlanta, GA
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The Role of Symptom Duration and Serologic Factors in the Relapse of IgG4-Related Ophthalmic Disease following Surgery: A Retrospective Cohort Study. DISEASE MARKERS 2022; 2022:5651506. [PMID: 35256891 PMCID: PMC8898119 DOI: 10.1155/2022/5651506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022]
Abstract
IgG4-related disease (IgG4-RD) affects multiple organs and is characterized by immune-mediated inflammation and fibrosis; IgG-RD affecting orbital tissue is known as IgG4-related ophthalmic disease (IgG4-ROD). This research is aimed at exploring whether symptom duration and common serologic factors, such as IgG, IgE, and eosinophils, are potential risk factors for IgG4-ROD patient relapse after surgery and identifying possible causes of the positive correlation between symptom duration and relapse. This retrospective cohort study included 40 IgG4-ROD patients after surgery. Auxiliary inspection results were obtained before surgery and during follow-up, and relapse risk factors were identified based on previous studies. We used the Spearman rank correlation test to reveal the relationship between symptom duration and relapse time and identified the optimal cutoff value for symptom duration by X-tile. Then, we divided the patients into the long-duration and short-duration groups. Kaplan–Meier survival analyses and log-rank tests were performed to identify the relationship between symptom duration and relapse using X-tile software. Finally, we studied the relationship between previously studied relapse risk factors and symptom duration. The survival curves of the long-duration and short-duration groups were obviously different, and the baseline serum IgG, IgE, and eosinophil levels and asthma concomitant rate were significantly different between the long-duration and short-duration groups. Furthermore, the baseline serum IgG (r = 0.485, P = 0.002), IgE (r = 0.350, P = 0.037), and eosinophil (r = 0.6535, P < 0.0001) levels were positively correlated with symptom duration. Our study shows that IgG4-ROD symptom duration is significantly positively correlated with relapse rate and negatively correlated with relapse time. Symptom duration was positively correlated with serum baseline IgG4, IgE, and eosinophil levels and asthma history, which were potential risk factors for disease relapse. We recommended that IgG4-ROD patients with symptom durations greater than 96 months continue to receive maintenance steroid therapy longer than 1 year postsurgery to reduce the relapse rate.
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157
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Two cases of refractory IgG4-related disease successfully treated with tocilizumab. Ann Hematol 2022; 101:1593-1594. [DOI: 10.1007/s00277-022-04787-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/01/2022]
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158
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Orchestration of Immune Cells Contributes to Fibrosis in IgG4-Related Disease. IMMUNO 2022. [DOI: 10.3390/immuno2010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This review summarizes recent progress in understanding the pathogenesis of IgG4-related disease (IgG4-RD), with a focus on fibrosis. Several studies reported that CD4+ T cells with cytotoxic activity promoted by the secretion of granzyme and perforin, cytotoxic CD4+ T cells (CD4+CTLs), and disease-specific activated B cells, infiltrated inflamed tissues and cooperated to induce tissue fibrosis in autoimmune fibrotic diseases such as IgG4-RD, systemic sclerosis, and fibrosing mediastinitis. An accumulation of cells undergoing apoptotic cell death induced by CD4+CTLs and CD8+CTLs followed by macrophage-mediated clearing and finally tissue remodeling driven by cytokines released by CD4+CTLs, activated B cells, and M2 macrophages may contribute to the activation of fibroblasts and collagen production. In IgG4-RD, this process likely involves the apoptosis of non-immune, non-endothelial cells of mesenchymal origin and subsequent tissue remodeling. In summary, CD4+CTLs infiltrate affected tissues where they may cooperate with activated B cells, CD8+CTLs, and M2 macrophages, to induce apoptosis by secreting cytotoxic cytokines. These immune cells also drive fibrosis by secreting pro-fibrotic molecules in IgG4-RD.
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159
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Achim A, Schmidt A, Mächler H, Sarocchi F, Marte W, Zweiker R, Zirlik A, Toth GG. A case report of recurrent acute myocardial infarction and cardiac arrest due to aortic dissection secondary to IgG4-related aortitis. Cardiovasc Pathol 2022; 59:107415. [PMID: 35143994 DOI: 10.1016/j.carpath.2022.107415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022] Open
Abstract
Occlusion of the right coronary artery is a relatively rare complication of type A aortic dissection and an example of type 2 myocardial infarction (MI) as well but when it occurs, it may have a fatal result for the patient. Aortic pseudoaneurysms are local type A dissections with a restricted extent in which the majority of the aortic wall has been breached and luminal blood is held in only by a thin rim of the remaining wall, mainly purely the adventitia. They typically occur from iatrogenic trauma by interventional procedures or previous cardiac surgery. We present a case of a 56-years-old patient who suffered an acute functional MI due to such pseudoaneurysm formed in the context of an undiagnosed aortitis. The etiology remained unclear until the surgical aortic prosthesis was deemed necessary, finding chronic IgG4 infiltrates in the aortic tissue. To our knowledge, this is the first case of IgG4-related aortitis causing functional MI and cardiogenic shock.
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Affiliation(s)
- Alexandru Achim
- University Heart Center Graz, Medical University Graz, Graz, Austria; "Niculae Stancioiu" Heart Institute, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Albrecht Schmidt
- University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Heinrich Mächler
- University Heart Center Graz, Medical University Graz, Graz, Austria
| | | | - Wolfgang Marte
- University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Robert Zweiker
- University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Andreas Zirlik
- University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Gabor G Toth
- University Heart Center Graz, Medical University Graz, Graz, Austria
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160
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Matza MA, Perugino CA, Harvey L, Fernandes AD, Wallace ZS, Liu H, Allard-Chamard H, Pillai S, Stone JH. Abatacept in IgG4-related disease: a prospective, open-label, single-arm, single-centre, proof-of-concept study. THE LANCET. RHEUMATOLOGY 2022; 4:e105-e112. [PMID: 35425928 PMCID: PMC9004478 DOI: 10.1016/s2665-9913(21)00359-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background There is strong rationale for interference with T cell co-stimulation in IgG4-related disease (IgG4-RD), but the literature to evaluate this is limited to a single case report. Methods We conducted a ten-subject proof-of-concept trial of abatacept in active IgG4-RD. All subjects met the ACR/EULAR Classification Criteria for IgG4-RD. Subjects received subcutaneous abatacept 125 mg weekly for 24 weeks. Concurrent glucocorticoid treatment was permitted but if used had to be discontinued by week four. The primary endpoint, complete remission at 24 weeks, was defined as an IgG4-RD Responder Index score of 0. Peripheral blood mononuclear cells were collected at baseline, four weeks, and 12 weeks. B and T cell subsets were quantified using a 25-parameter flow cytometry panel. Findings The subjects' median age was 68 years; seven subjects were male and nine were Caucasian. Baseline organ involvement was diverse with a median of 5 organs affected at the time of enrollment. The median serum IgG4 concentration was 597 mg/dL (IQR 304-913 mg/dL). Three subjects received concomitant prednisone at baseline. Six subjects (60%) had a disease response by week 12, five of whom maintained this response at week 24. Abatacept was stopped in the remaining five subjects (50%) due to flare (N = 1) or lack of response by week 12 (N = 4). Three subjects (30%) achieved the primary endpoint.Baseline proportions of unswitched memory B cells predicted responsiveness to abatacept. Reductions in serum IgE, circulating plasmablasts, and activated type 2 T follicular helper (TFH2) cells correlated with response to treatment. One adverse event (grade two thrombocytopenia) was attributed to abatacept. Interpretation Abatacept was associated with variable treatment responses in IgG4-RD. Half of the subjects achieved sustained treatment responses to abatacept alone, without glucocorticoids. Correlates of clinical response included reductions in serum IgE, circulating plasmablasts, and activated TFH2 cells. Response to abatacept was predicted by higher proportions of unswitched memory B cells at baseline.
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Affiliation(s)
- Mark A. Matza
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
| | - Cory A. Perugino
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
- Ragon Institute of MGH, MIT and Harvard. 400 Technology Square; Cambridge, MA 02139
| | - Liam Harvey
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
| | - Ana D. Fernandes
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
| | - Zachary S. Wallace
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
| | - Hang Liu
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
| | - Hugues Allard-Chamard
- Division of Rheumatology, Faculté de médecine et des sciences de la santé de l’ Université de Sherbrooke et Centre de Recherche Clinique Étienne-Le Bel, Sherbrooke, Québec, Canada
| | - Shiv Pillai
- Ragon Institute of MGH, MIT and Harvard. 400 Technology Square; Cambridge, MA 02139
| | - John H. Stone
- Division of Rheumatology, Allergy and Immunology. Massachusetts General Hospital. Harvard Medical School. 55 Fruit Street; Boston, MA 02114
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161
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Sabha M, Gryaznov A, Mayer R, Burke A, Doub JB. A Case of Persistent Aortic Graft and Retroperitoneal Enhancement on FDG PET/CT. Clin Infect Dis 2022; 74:359-362. [PMID: 35092440 DOI: 10.1093/cid/ciab297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marwa Sabha
- Division of Rheumatology and Clinical Immunology. University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anton Gryaznov
- Department of Diagnostic Radiology and Nuclear Medicine. University of Maryland, Baltimore, Maryland, USA
| | - Romana Mayer
- Department of Pathology. University of Maryland, Baltimore, Maryland, USA
| | - Allen Burke
- Department of Pathology. University of Maryland, Baltimore, Maryland, USA
| | - James B Doub
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Kamisawa T. Immunoglobulin G4-related Disease: A New Systemic Disease Emerging in Japan. JMA J 2022; 5:23-35. [PMID: 35224257 PMCID: PMC8826784 DOI: 10.31662/jmaj.2021-0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibro-inflammatory disease characterized by organ enlargement and elevated serum IgG4 levels. In 2003, IgG4-RD was proposed as a distinct form of IgG4-related systemic disease based on a histopathological study involving patients with autoimmune pancreatitis. IgG4-RD occurs mainly in older men and can affect almost any organ simultaneously or metachronously. Pathophysiologically, IgG4-RD occurs when an autoantigen triggers an immune response characterized by Th2 predominance with increased production of cytokines, such as interleukin 4 (IL-4), IL-5, IL-10, IL-13, and tumor growth factor-β (TGF-β), in the affected organ. IL-10 and TGF-β produced by the increased number of regulatory T cells induce a switch from B cells to IgG4-producing plasma cells and fibrosis, respectively. The characteristic histological features consist of dense infiltration of lymphocytes and IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. IgG4-RD is diagnosed based on a combination of clinical, serological, radiological, and histopathological findings. Differentiating IgG4-RD from malignant tumors or similar inflammatory diseases in the affected organs is important. The 2019 America College of Rheumatology/European League against Rheumatism classification criteria for IgG4-RD have high diagnostic sensitivity and specificity. IgG4-RD generally responds well to treatment with steroids, and a swift response is reassuring and provides further diagnostic confirmation. However, relapses are common during tapering or after cessation of steroids. In Japan, low-dose steroid maintenance therapy is usually given to prevent a relapse. B-cell depletion with rituximab is effective in patients resistant to or dependent on steroids. Most patients with IgG4-RD who receive steroid therapy show good short-term clinical, morphological, and functional outcomes. However, long-term outcomes, such as relapse, fibrosis development, and associated malignancies, have not been clearly defined. Therefore, novel treatment strategies, including rituximab, need to be tested in international randomized controlled clinical trials.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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163
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Update on classification, diagnosis, and management of immunoglobulin G4-related disease. Chin Med J (Engl) 2022; 135:381-392. [PMID: 34985023 PMCID: PMC8869566 DOI: 10.1097/cm9.0000000000001891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized chronic fibro-inflammatory autoimmune disease, and its recognition has been constantly increasing worldwide over the last few years. A correct and timely recognition, as well as appropriate intervention, is crucial for the treatment of IgG4-RD. For certain subtypes of IgG4-RD, organ-specific criteria are formulated to make the diagnosis more accurate. New biomarkers have emerged in the recent years to aid the disease diagnosis, its prognosis prediction, as well as therapy response monitoring. Although recurrence is very common in IgG4-RD, glucocorticoid is still the first-line treatment for the majority of patients. The factors that affect the likelihood of disease relapse are multifaceted. The selection strategy of various steroid-sparing agents is still being explored. Besides, when patients have special sites involvement leading to severe clinical conditions, surgical operation or interventional therapy should also be considered. An update on classification, diagnosis, and management of IgG4-RD is provided in the current study to fully elucidate the recommended clinical practice of this mysterious disease.
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164
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Duggal L, Singh BG, Patel J, Gupta M, Grover AK, Jain N. IgG4-Related Disease: A Clinical Case Series From a Tertiary Care Center in India. J Clin Rheumatol 2022; 28:e56-e62. [PMID: 33105313 DOI: 10.1097/rhu.0000000000001591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Immunoglobulin G4-related disease (IgG4-RD) is often an unrecognized, rare fibroinflammatory condition that can involve various organ systems. This study aimed to identify the different clinical patterns of this disease in a single center in North India. METHODS Patients were diagnosed on the basis of published diagnostic criteria for IgG4-RD. Patients' presenting complaints; epidemiologic profiles; and laboratory, radiologic, and histologic findings along with the treatment and outcomes were collected and analyzed. RESULTS In total, 70 patients were diagnosed with the disease. The female-to-male ratio was 0.94:1, and it increased with multiorgan involvement. The mean age of patients was 41.4 years, and the majority of the patients (65.7%) were younger than 50 years. Patients were diagnosed as possible (38.57%), probable (32.85%), and definite (28.57%) IgG4-RD. The incidence of the involvement of orbital and periorbital tissues was the highest (52.9%); however, 13% of the patients had multiple organ involvement. Patients with involvement of the retroperitoneal tissues and the lymph nodes were 8.5% and 5.7%, respectively. Increased serum IgG4 levels were found in 74.3% of the patients with single-organ involvement, whereas all patients with multiorgan involvement had increased IgG4 levels. The majority of patients (94.3%) required immunosuppressive medications along with corticosteroids. Azathioprine was the most commonly used (72.8%) immunosuppressive medication. Rituximab was used in 17.1% of the patients, of whom only one had multisystem involvement. CONCLUSIONS This study depicts the most common patterns of organ involvement, along with the epidemiologic, laboratory, histologic, and radiologic data and response to treatment, in IgG4-RD, with a definite ophthalmology referral bias.
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165
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Singh S, Pokhariyal S, Nandwani A, Duggal R. Diagnostic Dilemma: Cardiorenal Syndrome As an Unusual Presentation of IgG4-Related Disease. Indian J Nephrol 2022; 32:512-515. [PMID: 36568604 PMCID: PMC9775612 DOI: 10.4103/ijn.ijn_143_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/05/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022] Open
Abstract
IgG4-related kidney disease (IgG4 RKD) is a rare clinical entity characterized by lymphoplasmacytic infiltration rich in IgG4-positive plasma cells along with fibrosis affecting several organs. Tubulointerstitial nephritis is commonly the predominant finding on kidney biopsy. Our patient was admitted with a provisional diagnosis of cardiorenal syndrome of unknown etiology. The patient was dialysis dependent for around 45 days following which kidney biopsy revealed features of acute tubulointerstitial nephritis (ATIN) with IgG4-positive plasma cells and no glomerular involvement. Positron emission tomography-computed tomography was supportive of findings of sialadenitis along with myocarditis. Our patient responded to treatment with steroids with definitive improvement in both renal and cardiac functions. This case highlights the importance of IgG4 RKD as an important differential in patients with ATIN presenting as a clinical syndrome.
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Affiliation(s)
- Shailendra Singh
- Department of Nephrology, Manipal Hospitals, Dwarka, Delhi, India,Address for correspondence: Dr. Shailendra Singh, Department of Nephrology, Associate Consultant, Manipal Hospitals, Dwarka, Delhi, India. E-mail:
| | | | - Ashish Nandwani
- Department of Nephrology, Manipal Hospitals, Dwarka, Delhi, India
| | - Rajan Duggal
- Department of Histopathology and Cytopathology, BLK Super Specialty Hospital, Delhi, India
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166
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Langlois F, Varlamov EV, Fleseriu M. Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease. J Clin Endocrinol Metab 2022; 107:10-28. [PMID: 34528683 PMCID: PMC8684465 DOI: 10.1210/clinem/dgab672] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elena V Varlamov
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence: Maria Fleseriu, MD, Oregon Health & Science University, Mail Code CH8N, 3303 S Bond Ave, Portland, Oregon 97239, USA.
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167
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Muthuppalaniappan VM, Ball S. Acute Tubulointerstitial Nephritis. PRIMER ON NEPHROLOGY 2022:585-597. [DOI: 10.1007/978-3-030-76419-7_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Amendment of the Japanese consensus guidelines for autoimmune pancreatitis, 2020. J Gastroenterol 2022; 57:225-245. [PMID: 35192048 PMCID: PMC8938398 DOI: 10.1007/s00535-022-01857-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/28/2022] [Indexed: 02/04/2023]
Abstract
In response to the latest knowledge and the amendment of the Japanese diagnostic criteria for autoimmune pancreatitis (AIP) in 2018, the Japanese consensus guidelines for managing AIP in 2013 were required to be revised. Three committees [the professional committee for developing clinical questions (CQs) and statements by Japanese specialists; the expert panelist committee for rating statements by the modified Delphi method; and the evaluating committee of moderators] were organized. Twenty specialists in AIP extracted the specific clinical statements from a total of 5218 articles (1963-2019) from a search in PubMed and the Cochrane Library. The professional committee made 14, 9, 5, and 11 CQs and statements for the current concept and diagnosis, extra-pancreatic lesions, differential diagnosis, and treatment, respectively. The expert panelists regarded the statements as valid after a two-round modified Delphi approach with individually rating these clinical statements, in which a clinical statement receiving a median score greater than 7 on a 9-point scale from the panel was regarded as valid. After evaluation by the moderators, the amendment of the Japanese consensus guidelines for AIP has been proposed in 2020.
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169
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Rybakova MG, Mylnikova AA, Vlasova MT. [IgG4-related disease of the breast]. Arkh Patol 2022; 84:51-55. [PMID: 35880600 DOI: 10.17116/patol20228404151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
IgG4-related disease is an immune-mediated disorder with tumor-like multiorgan involvement, elevated serum IgG4 level and specific histopathological appearance (lymphoplasmacytic infiltrate rich in IgG4+ plasma cells and storiform fibrosis). The article presents rare clinical and morphological observations of IgG4-related mastopathy in women with suspected tumor process. A strategy for the treatment of IgG4-related disease should be based on the results of pre-surgery histopathological examination, which may help to avoid unreasonable surgical intervention and choose glucocorticoids or rituximab as the first-line treatment.
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Affiliation(s)
- M G Rybakova
- Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - A A Mylnikova
- Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - M T Vlasova
- Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
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170
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Adam Z, Dastych M, Čermák A, Doubková M, Skorkovská Š, Pour L, Řehák Z, Koukalová R, Adamová Z, Štork M, Krejčí M, Boichuk I, Král Z. Therapy of immunoglonuline IgG4 related disease (IgG4-RD). VNITRNI LEKARSTVI 2022; 68:15-22. [PMID: 36316207 DOI: 10.36290/vnl.2022.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Immunoglobulin IgG4 related disease (IgG4-RD) is a heterogeneous disorder with multi-organ involvement recognised as a separate entity at the beginning of this century only. Evolving therapy is reviewed in this paper. Glucocorticoids are first choice drug but long administration of glucocorticoids is connected with many adverse effects. In case of combination glucocorticoids and immunosuppressive agents lower doses of glucocorticoids are needed, the response rate is higher and therapy is better tolerated. Rituximab is drug, that is possible use as monotherapy or in combination with glucocorticoids and immunosuppressive drugs. Only one study compared two immunosuporessive drugs, mycophenolate mofetil and cyclophosphamide. The response rated was similar but remissions were longer after glucocorticoids with cyclophosphamide then glucocorticoids with mycofenolat mofetil. No other comparative study of combination of various imunossupressive drugs with glucocorticoids was published. Rituximab has high number (90 %) of response rate in monotherapy, but can be used in combination with glucocorticoids and immunosuppressives. Rituximab is now preferred and recommended for maintenance therapy administered in 6-month interval. In case of advanced disease, we prefer therefore combination of rituximab, cyclofosphamide and dexamethasone for initial therapy followed by maintenance with rituximab in 6 months interval. There are two new drugs under investigation abatacept and dupilimab with promising results. Although we have very intensive therapies for good results of therapy early diagnosis before irreversible fibrotic changes in IgG4-RD involved organs is still needed.
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171
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Akhrieva KM, Kogan EA, Tertychnyy AS, Zayratyants OV, Selivanova LS. [Immunohistochemical signs of IgG4-related disease in patients with inflammatory bowel diseases]. Arkh Patol 2022; 84:13-19. [PMID: 35880595 DOI: 10.17116/patol20228404113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine immunohistochemical features of IgG4-related disease in patients with inflammatory bowel diseases (IBD). MATERIAL AND METHODS Immunohistochemical testing of colonic biopsy material from 35 patients with IBD (24 cases of ulcerative colitis and 11 cases of Crohn's disease) was carried out using IgG, IgG4 and CD138 antibodies. The number of IgG4- and CD138-positive cells was counted in high power field of microscope (×400). Patient selection was random. RESULTS IgG4-positive cells were detected in the colonic mucosa of 5 patients with ulcerative colitis. The age of the patients ranged from 24 to 47 years. Two patients had a total, and three had a left-sided lesion of the colon. The anamnesis of the disease ranged from 3 to 13 years. The number of positively stained cells in the reaction with the antibody to IgG4 varied from 2 to 50 in high power field of microscope. We were able to detect over 10 IgG4-positive cells in 3 females aged 28, 30 and 31 years with a long history of ulcerative colitis (5, 4 and 3 years, respectively). Two patients had a total lesion of the colon, all three had an exacerbation of the disease, and a morphological study revealed chronic diffuse active erosive colitis. A high degree of histological activity and pronounced diffuse basal plasmacytosis were noted. In one of the cases, the infiltrate captured the muscular lamina of the mucosa and areas of the submucosa. CONCLUSIONS IgG4-positive cells in the inflammatory infiltrate, including those with an excess of more than 10 in the field of view of the microscope at high magnification, can be observed in patients with ulcerative colitis with severe and prolonged course of the disease. To classify this colitis as a manifestation of an IgG4-related disease, the results of immunohistochemical studies alone are not enough. It is required to accumulate a larger number of observations, as well as to search for other diagnostic criteria for an IgG4-related disease in these patients.
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Affiliation(s)
| | - E A Kogan
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A S Tertychnyy
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - O V Zayratyants
- Evdokimov Moscow State University of Medicine and Dentristry, Moscow, Russia
| | - L S Selivanova
- National Medical Research Center of Endocrinology, Moscow, Russia
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172
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Cai M, Voutnis D, Nair B. Immunoglobulin G4-Related ophthalmic disease and aortitis. ARCHIVES OF MEDICINE AND HEALTH SCIENCES 2022. [DOI: 10.4103/amhs.amhs_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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173
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IgG4-Related Sclerosing Cholangitis: Rarely Diagnosed, but not a Rare Disease. Can J Gastroenterol Hepatol 2021; 2021:1959832. [PMID: 34970512 PMCID: PMC8714375 DOI: 10.1155/2021/1959832] [Citation(s) in RCA: 4] [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: 08/10/2021] [Revised: 11/08/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022] Open
Abstract
IgG4-related sclerosing cholangitis, a biliary manifestation of an IgG4-related disease, belongs to the spectrum of sclerosing cholangiopathies which result in biliary stenosis. It presents with signs of cholestasis and during differential diagnosis it should be distinguished from cholangiocarcinoma or from other forms of sclerosing cholangitis (primary and secondary sclerosing cholangitis). Despite increasing information and recently established diagnostic criteria, IgG4-related sclerosing cholangitis remains underdiagnosed in routine clinical practice. The diagnosis is based on a combination of the clinical picture, laboratory parameters, histological findings, and a cholangiogram. Increased serum IgG4 levels are nonspecific but are indeed a part of the diagnostic criteria proposed by the Japan Biliary Association and the HISORt criteria for IgG4-SC. High serum IgG4 retains clinical utility depending on the magnitude of elevation. Approximately 90% of patients have concomitant autoimmune pancreatitis, while 10% present with isolated biliary involvement only. About 26% of patients have other organ involvement, such as IgG4-related dacryoadenitis/sialadenitis, IgG4-related retroperitoneal fibrosis, or IgG4-related renal lesions. A full-blown histological finding characterized by IgG4-enriched lymphoplasmacytic infiltrates, obliterative phlebitis, and storiform fibrosis is difficult to capture in practice because of its subepithelial localization. However, the histological yield is increased by immunohistochemistry, with evidence of IgG4-positive plasma cells. Based on a cholangiogram, IgG-4 related sclerosing cholangitis is classified into four subtypes according to the localization of stenoses. The first-line treatment is corticosteroids. The aim of the initial treatment is to induce clinical and laboratory remission and cholangiogram normalization. Even though 30% of patients have a recurrent course, in the literature data, there is no consensus on chronic immunosuppressive maintenance therapy. The disease has a good prognosis when diagnosed early.
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174
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Gan L, Luo X, Fei Y, Peng L, Zhou J, Li J, Lu H, Liu Z, Zhang P, Liu X, Zhang W. Long-Term Outcomes of IgG4-Related Ophthalmic Disease in a Chinese IgG4-Related Disease Cohort. Front Med (Lausanne) 2021; 8:784520. [PMID: 34977087 PMCID: PMC8718705 DOI: 10.3389/fmed.2021.784520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose: To define the treatment response and long-term outcomes of a large IgG4-related ophthalmic disease (IgG4-ROD) cohort. Methods: A total of 132 patients with a minimum follow-up of 1 year were included in this study. Demographic, clinical, and laboratory data were collected. Treatment response was assessed by the IgG4-RD responder index (IgG4-RD RI). Risk factors for relapse were analyzed with the multivariate Cox regression analysis. Results: The median follow-up time was 39 months. Lacrimal gland involvement was detected in 87.9% of cases. Extraocular muscles, the trigeminal nerve, and other soft tissue were affected in 25.8, 6.1, and 18.2% of patients. The relapse rate of watchful waiting, glucocorticoid monotherapy, immunosuppressant monotherapy, and combination therapy was 50.0, 51.7, 50.0, and 26.7% (p = 0.038), respectively. The combination therapy group exhibited shorter glucocorticoids therapy duration (36 vs. 48 months, p = 0.009) and maintenance period (24 vs. 42 months, p = 0.003). At the 6th month, the median IgG4-RD RI declined from 12 to 1 and 105 (79.5%) patients achieved complete response (CR). Relapse occurred in 49 (37.1%) patients. The multivariate Cox regression analysis exhibited that CR at the 6th month was an independent protective factor for relapse. Patients with multiple ocular lesions suffered from a higher risk of relapse. No patient had severe adverse reactions to the treatment in this study. Conclusion: Relapse was common in patients with IgG4-ROD. Patients receiving combination therapy showed a lower relapse rate and a shorter glucocorticoids therapy period. The presence of multiple ocular lesions was associated with a higher risk of relapse. CR at the 6th month might be a predictor for a better prognosis in IgG4-ROD. Thus, a more aggressive regimen should be prescribed for patients with a poor initial response.
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Affiliation(s)
- Linyang Gan
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuan Luo
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yunyun Fei
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Linyi Peng
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jieqiong Li
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui Lu
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zheng Liu
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Panpan Zhang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaowei Liu
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Xiaowei Liu
| | - Wen Zhang
- Department of Rheumatology, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Wen Zhang
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175
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Mayeku J, Deisch J, Lopez-Gonzalez MA. Immunoglobulin G4-related disease of the cavernous sinus with orbit invasion - A case report. Surg Neurol Int 2021; 12:557. [PMID: 34877043 PMCID: PMC8645509 DOI: 10.25259/sni_859_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/19/2021] [Indexed: 11/04/2022] Open
Abstract
Background Immunoglobulin G4-related disease (IgG4-RD) is a rare systemic disease of unknown etiology. It is characterized by tissue infiltration caused by IgG4 plasma cells and sclerosing inflammation of various body organs. At present, there are very few reported cases of IgG4-RD invasion of cavernous sinus and the orbit. Case Description A 56-year-old female with a history of rheumatoid arthritis was presented with a gradual onset of right oculomotor, abducens, and trigeminal nerve deficits. Four weeks after the onset of symptoms, the patient developed gradual visual deficit. Following this, a trial of steroids was administered to the patient. However, the treatment did not work as expected and patient's condition worsened. She progressed on to suffer complete visual loss in the right eye. Extensive work-up conducted on her turned out to be nondiagnostic. After this, the patient was referred to us for our evaluation. Neuroimaging revealed a right-sided cavernous sinus and orbital apex lesion. Given the lack of diagnosis and response to steroid treatment, we recommended surgical intervention and performed a modified pterional and pretemporal approach with extradural anterior clinoidectomy and transcavernous approach. We performed a lesion biopsy and cavernous sinus decompression, which helped in the partial recovery of visual function. The pathology report was consistent with IgG4-RD. Conclusion IgG4-RD is a rare disease that occurs even less in combination with cavernous sinus and orbit invasion. The rarity of the disease and the diverse presentation of symptoms have sometimes caused delayed diagnosis and intervention. Patients who failed to respond to conservative management and patients in the fibrotic stage of the disease without other organ involvement may benefit from surgical intervention if amenable. Early suspicion, diagnosis, and intervention can facilitate better prognosis.
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Affiliation(s)
- Julie Mayeku
- Department of General Surgery, Loma Linda University, California, United States
| | - Jeremy Deisch
- Department of Neuropathology and Human Anatomy, Loma Linda University, California, United States
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176
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Lecuit M, Aucouturier P, Abbas A, Cadranel J, Silvain C, Berthelot JM, Fauchais AL, Loubet P, Bachmeyer C, Montravers F, Dossier A, Nunes H, Cervera P, Coppo P. Overexpression of IgG2 in patients resembling IgG4-related disease with normal IgG4. Scand J Immunol 2021; 95:e13126. [PMID: 34877676 DOI: 10.1111/sji.13126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
IgG4-Related Disease (IgG4-RD) results from tissue infiltration by IgG4-expressing plasma cells and lymphocytes, leading to fibrosis and organomegaly. Clinical presentation is remarkably variable according to organ involvement, and high IgG4 serum concentration, initially considered a diagnostic hallmark of IgG4-RD, tends to be forgone as an indispensable criterion for its diagnosis; it can indeed be absent in some patients, highlighting the diversity of presentation of this dysimmune condition. Nevertheless, elevation of IgG4 serum concentration in suggestive settings remains an argument in favour of IgG4-RD, and while other IgG subclasses can be elevated, this biological feature lacks any diagnostic value. We retrospectively studied 9 patients (5 females, 4 males, 31-81 years old) for whom a diagnosis of IgG4-RD had been considered, based on clinical, imaging or histological criteria, but appeared to display abnormally high serum IgG2 while IgG4 levels were normal. Increased serum IgG1 in one case and increased IgG3 in another one were also noticed. Immunohistochemical analyses of intracellular immunoglobulins could be performed on tissue lymph node biopsies from 2 patients, which demonstrated strong infiltration with IgG2-expressing plasma cells. Thus, overexpression of IgG2 subclass may highlight cases of dysimmune disorders resembling IgG4-RD, although the disease trigger might be different, notably infectious. We suggest measuring all serum IgG subclass levels in patients with features consistent with IgG4-RD.
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Affiliation(s)
| | - Pierre Aucouturier
- Département d'Immunologie Biologique, AP-HP.6, Paris, France.,Sorbonne Université, Paris, France.,Inserm, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Aicha Abbas
- Département d'Immunologie Biologique, AP-HP.6, Paris, France
| | - Jacques Cadranel
- Sorbonne Université, Paris, France.,Service de Pneumologie, AP-HP.6 and Constitutive Referent Center for Rare Pulmonary Diseases, Paris, France
| | - Christine Silvain
- Service d'Hépato-gastro-entérologie, CHU de Poitiers, Poitiers, France
| | | | | | - Paul Loubet
- Service de Maladies Infectieuses et Tropicales, AP-HP.7, Paris, France.,IAME, UMR 1137, Inserm, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | | | - Françoise Montravers
- Sorbonne Université, Paris, France.,Service de Médecine Nucléaire, AP-HP.6, Paris, France
| | - Antoine Dossier
- Service de Médecine Interne, AP-HP, Hôpital Bichat, Paris, France
| | - Hilario Nunes
- Service de Pneumologie, AP-HP, Hôpital Avicenne, Paris, France
| | | | - Paul Coppo
- Service d'Hématologie, AP-HP.6, Paris, France.,Sorbonne Université, Paris, France.,Centre de référence des Microangiopathies Thrombotiques, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
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177
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Suisa H, Soustiel JF, Grober Y. IgG4-related pachymeningitis masquerading as foramen magnum meningioma: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21398. [PMID: 36061082 PMCID: PMC9435580 DOI: 10.3171/case21398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated inflammatory condition with potential multiorgan involvement. Common manifestations include autoimmune pancreatitis and retroperitoneal fibrosis. Pathological analysis reveals lymphoplasmacytic infiltrate rich in IgG4-positive cells and characteristic storiform fibrosis. Early treatment with glucocorticoids may prevent progression to poorly responsive fibrotic disease. OBSERVATIONS A 63-year-old female patient presented with reports of left-sided headaches, nausea, and photophobia in addition to recently diagnosed chronic rhinosinusitis (CRS). Neurological examination revealed dysarthria secondary to left hypoglossal nerve palsy. Computed tomography (CT) revealed a contrast-enhancing extraaxial mass at the left craniocervical junction, CRS with secondary hyperostotic reaction, and multiple hypodense lesions involving the occipital bone. Magnetic resonance imaging revealed a dural-based lesion involving the foramen magnum and invading the left hypoglossal canal. The patient underwent a far-lateral craniotomy. Histopathological analysis revealed severe lymphoplasmacytic inflammation, storiform fibrosis and rich plasma-cell population positive for IgG4. Serum IgG4 was markedly elevated. Total-body CT showed no systemic involvement. The patient was diagnosed with IgG4-RD and was prescribed prednisone, with normalization of her IgG4 levels after 1 month. LESSONS IgG4-RD may mimic a variety of diseases, including skull-base meningiomas and CRS. Accurate diagnosis and expedited administration of steroids may prevent unnecessary interventions and progression to treatment-resistant fibrosis.
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Affiliation(s)
- Haggai Suisa
- Department of Neurosurgery, Galilee Medical Center, Nahariya, Israel; and
| | - Jean Francois Soustiel
- Department of Neurosurgery, Galilee Medical Center, Nahariya, Israel; and
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Yuval Grober
- Department of Neurosurgery, Galilee Medical Center, Nahariya, Israel; and
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178
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Asano Y, Kashiwagi S, Kawano Y, Tanaka S, Kuwae Y, Takashima T, Ohsawa M, Hirakawa K, Ohira M. IgG4-related mastitis requiring differentiation from breast cancer: a case report. J Surg Case Rep 2021; 2021:rjaa240. [PMID: 34858570 PMCID: PMC8634083 DOI: 10.1093/jscr/rjaa240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/13/2023] Open
Abstract
Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a group of chronic relapsing inflammatory conditions. Although IgG4-RD can occur in various organs, it is rarely observed in mammary glands. Here, we report a case of IgG4-related mastitis (IgG4-RM) that needed to be differentiated from breast cancer. A 54-year-old woman was examined for a tumor in her left breast. Mammary ultrasonography revealed an irregular hypoechoic tumor measuring 45.0 × 43.0 × 32.0 mm in size. A core-needle biopsy of the left breast tissue revealed a high degree of mixed T and B lymphocytic and plasma cell infiltration, as well as interstitial fibrosis. IgG4-RD was diagnosed based on hematological examination that revealed an abnormal IgG4 value of 332 mg/dl. All the clinical diagnostic criteria for IgG4 were met, resulting in a definitive diagnosis of IgG4-RM.
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Affiliation(s)
- Yuka Asano
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Shinichiro Kashiwagi
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yuko Kawano
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Sayaka Tanaka
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yuko Kuwae
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tsutomu Takashima
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masahiko Ohsawa
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Kosei Hirakawa
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masaichi Ohira
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
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179
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Noda S, Honda S, Hirota Y, Ito T, Hasegawa H, Kimura N, Matsuo Y, Iwai H, Kohsaka H, Yasuda S. Azathioprine Monotherapy for the Cases of Immunoglobulin G4-Related Disease With Contraindications to Glucocorticoids. J Clin Rheumatol 2021; 27:S327-S330. [PMID: 33998782 DOI: 10.1097/rhu.0000000000001717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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180
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Momoniat T, Jacob D, Duhli N, Jorna T. IgG4-related tubulointerstitial nephritis. BMJ Case Rep 2021; 14:e241942. [PMID: 34764107 PMCID: PMC8586881 DOI: 10.1136/bcr-2021-241942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/04/2022] Open
Abstract
A 67-year-old man was referred to the renal team following an episode of acute kidney injury on a background of chronic kidney disease. He had a 9-year history of steroid-sensitive arthritis, epigastric pain and isolated submandibular gland enlargement. He was noted to have a raised eosinophil count, total serum protein and total immunoglobulin G4 (IgG4) level as well as a serum hypocomplementaemia. A renal biopsy showed a tubulointerstitial nephritis with lymphoplasmacytic infiltrates, fibrosis and IgG4-positive plasma cells on immunohistochemistry. A diagnosis of IgG4-related disease was made based on clinical presentation and pathology. Renal function improved with glucocorticoids and the patient was successfully transitioned to azathioprine as a steroid-sparing agent.
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Affiliation(s)
| | - Deepa Jacob
- Histopathology Department, Hull Royal Infirmary, Hull, UK
| | | | - Tom Jorna
- Renal Department, Hull Royal Infirmary, Hull, UK
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181
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Nikolic S, Panic N, Hintikka ES, Dani L, Rutkowski W, Hedström A, Steiner C, Löhr JM, Vujasinovic M. Efficacy and safety of rituximab in autoimmune pancreatitis type 1: our experiences and systematic review of the literature. Scand J Gastroenterol 2021; 56:1355-1362. [PMID: 34410885 DOI: 10.1080/00365521.2021.1963837] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Autoimmune pancreatitis (AIP) is a special form of pancreatitis that responds well to glucocorticoid (GC) treatment. Relapses of AIP are common. The anti-CD20 antibody rituximab (RTX) has shown promising results in GC refractory cases, but long-term data are scarce. The study aims to determine the clinical and imaging response to RTX and summarize the existing data on RTX therapy in patients with AIP type 1 in the literature. PATIENTS AND METHODS Retrospective analysis of electronic medical records was conducted. Additionally, we conducted a systematic review of the literature concerning RTX use in AIP type 1. RESULTS Twelve (11.7%) of 103 patients with AIP type 1 were treated with RTX during the study period: eight (66.7%) achieved complete and four (33.3%) partial remission. RTX was discontinued in one patient who developed fever and reactivation of latent tuberculosis. None of the remaining 11 patients relapsed during a median follow-up of 17 months. No significant differences were detected in baseline clinical characteristics or history of relapse between the patients who obtained complete and partial remission. Altogether, eight studies with 110 AIP type-1 patients treated with RTX were analyzed. Adverse effects ranged from 11-43% and the relapse-free period during follow-up (range 2-173 months) ranged from 38-94%. CONCLUSIONS Our results confirm that RTX is efficacious in the treatment of AIP type 1 by inducing remission and preventing relapse. In addition, there are few adverse effects of the treatment.
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Affiliation(s)
- Sara Nikolic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, Division of Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Nikola Panic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Lara Dani
- Rheumatology Division, Department of Medicine, Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Wiktor Rutkowski
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Aleksandra Hedström
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Corinna Steiner
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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182
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Chen MX, Su HH, Shiao CY, Chang YT, Chang MC, Kao CC, Wang SY, Shih HC, Tsai IL. Affinity Purification Coupled to Stable Isotope Dilution LC-MS/MS Analysis to Discover IgG4 Glycosylation Profiles for Autoimmune Pancreatitis. Int J Mol Sci 2021; 22:ijms222111527. [PMID: 34768956 PMCID: PMC8584136 DOI: 10.3390/ijms222111527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 01/13/2023] Open
Abstract
Type 1 autoimmune pancreatitis (AIP) is categorized as an IgG4-related disease (IgG4-RD), where a high concentration of plasma IgG4 is one of the common biomarkers among patients. IgG Fc-glycosylation has been reported to be potential biosignatures for diseases. However, human IgG3 and IgG4 Fc-glycopeptides from populations in Asia were found to be isobaric ions when using LC-MS/MS as an analytical tool. In this study, an analytical workflow that coupled affinity purification and stable isotope dilution LC-MS/MS was developed to dissect IgG4 glycosylation profiles for autoimmune pancreatitis. Comparing the IgG4 and glycosylation profiles among healthy controls, patients with pancreatic ductal adenocarcinoma (PDAC), and AIP, the IgG4 glycosylations from the AIP group were found to have more digalactosylation (compared to PDAC) and less monogalactosylation (compared to HC). In addition, higher fucosylation and sialylation profiles were also discovered for the AIP group. The workflow is efficient and selective for IgG4 glycopeptides, and can be used for clinical biosignature discovery.
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Affiliation(s)
- Michael X. Chen
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Victoria, BC V8Z6R5, Canada;
- Division of Medical Sciences, University of Victoria, Victoria, BC V8W2Y2, Canada
| | - Ho-Hsuan Su
- Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (H.-H.S.); (C.-Y.S.)
| | - Ching-Ya Shiao
- Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (H.-H.S.); (C.-Y.S.)
| | - Yu-Ting Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-T.C.); (M.-C.C.)
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Ming-Chu Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-T.C.); (M.-C.C.)
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan;
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei 11031, Taiwan
| | - San-Yuan Wang
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan;
- Master Program in Clinical Genomics and Proteomics, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsi-Chang Shih
- Genomics Research Center, Academia Sinica, Taipei 115, Taiwan;
| | - I-Lin Tsai
- Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (H.-H.S.); (C.-Y.S.)
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan;
- Master Program in Clinical Genomics and Proteomics, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- International Ph.D. Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Correspondence:
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183
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Recent Advances in Understanding the Role of TIGIT+ Follicular Helper T Cells in IgG4-Related Disease. IMMUNO 2021. [DOI: 10.3390/immuno1040026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a fibro-inflammatory disease characterized by elevated serum IgG4 levels and massive infiltration of IgG4+plasma cells. Although storiform fibrosis, obliterative phlebitis and IgG4+plasma cell infiltration are well described pathological features in this disease, the excessive formation of tertiary lymphoid organs (TLOs), particularly in the early phase of the disease lesions, has gained much attention. TLOs of IgG4-RD are orchestrated by specific immune cell subsets including follicular helper T cells (Tfh), CD20+ B cells, and CD21+ follicular dendritic cells (FDCs). Tfh is the key player of this disease because recent studies have suggested the pathological role of this immune cell subset in formation of TLOs, helping IgG4+plasma cell differentiation, inducing storiform fibrosis by secreting interleukin-4, and activating cytotoxic T cells by secreting interleukin-21. We have recently identified a new Tfh subset which expresses T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). TIGIT+Tfh efficiently produces interleukin-21 through OX40 signal, and the increase in peripheral TIGIT+Tfh cells reflects disease activity in IgG4-RD. TIGIT is important to mediate the retention and positioning of TIGIT+Tfh within TLOs through interaction with CD155 expressed on CD21+ FDCs. In this review, we summarize and discuss recent progress in understanding the pathogenesis of IgG4-RD, focusing on TIGIT+Tfh.
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184
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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185
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Koiwai A, Hirota M, Satoh M, Takasu A, Meguro T, Endo K, Kogure T, Murakami K, Murakami K, Satoh K. Immunoglobulin G4-Related Hepatic Inflammatory Pseudotumor Diagnosed with Endoscopic Ultrasound-Guided Fine-Needle Biopsy. Case Rep Gastroenterol 2021; 15:488-494. [PMID: 34616245 PMCID: PMC8454245 DOI: 10.1159/000516687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022] Open
Abstract
A 71-year-old man with obstructive jaundice was referred to our department. He underwent cholangiojejunostomy 15 years ago for palliative drainage. At that time, he had obstructive jaundice caused by an unresectable pancreatic head tumor. Contrast-enhanced computed tomography (CE-CT) now revealed a mass with low enhancement in the hepatic hilum that occluded the hilar bile duct and infiltrated extensively along the portal vein and hepatic artery. CE-CT also showed marked atrophy of the left hepatic lobe. No swelling or tumors were observed in the pancreas. Serum immunoglobulin G4 (IgG4) levels were as high as 465 mg/dL. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) was performed targeting the hepatic hilar lesion. Immunohistological results of the biopsy specimens suggested that the lesion was an IgG4-related hepatic inflammatory pseudotumor (IPT) with no atypical cells. Steroid treatment resulted in rapid clinical improvement. This case suggested the usefulness of EUS-FNB for diagnosing IgG4-related hepatic hilar IPT.
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Affiliation(s)
- Akinobu Koiwai
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Mari Satoh
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Atsuko Takasu
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takayoshi Meguro
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Katsuya Endo
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takayuki Kogure
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Keigo Murakami
- Division of Pathology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuhiro Murakami
- Division of Pathology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kennichi Satoh
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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186
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Mukai K, Nishida T, Adachi S, Matsumoto K, Osugi N, Sugimoto A, Nakamatsu D, Yamamoto M, Fukui K, Tamura H, Inada M. Immunoglobulin G4-Hepatopathy with Acute Hepatitis-Like Onset and Marked Centrilobular Necrosis: Clinicopathologically Unique Pattern of Hepatic Injury Related to Immunoglobulin G4-Related Disease. Case Rep Gastroenterol 2021; 15:720-728. [PMID: 34594172 PMCID: PMC8436635 DOI: 10.1159/000516313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/19/2021] [Indexed: 11/22/2022] Open
Abstract
A 69-year-old man presented with jaundice and appetite loss. Blood analyses showed elevated aminotransferase levels, hyperbilirubinemia, positivity for antinuclear antibody, elevated immunoglobulin (Ig) G4 levels, and negativity for hepatitis virus markers. Additionally, computed tomography revealed a focal enlargement of the pancreatic body and enhancement of the peripheral bile ducts. Liver biopsy showed interface hepatitis, supporting a clinical diagnosis of autoimmune hepatitis (AIH). Immunohistochemistry revealed that IgG4-bearing plasma cells accounted for more than 60% of the IgG-bearing plasma cells in the portal area. Then, we started oral prednisolone therapy. After tapering, serum transaminase levels became elevated again, and we had to adjust the dose. Azathioprine maintenance therapy was necessary to prevent relapse. We herein report a case of IgG4-hepatopathy with a clinical course similar to that of AIH with acute onset.
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Affiliation(s)
- Kaori Mukai
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Shiro Adachi
- Department of Pathology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Naoto Osugi
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Aya Sugimoto
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Koji Fukui
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Hiromi Tamura
- Department of Pathology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masami Inada
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
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187
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Li Y, Luo B, Zhang J, Zhou X, Shao S, Xu W, Yang Y, Yuan G. Clinical relevance of serum immunoglobulin G4 in glucocorticoid therapy of Graves' ophthalmopathy. Clin Endocrinol (Oxf) 2021; 95:657-667. [PMID: 33938028 DOI: 10.1111/cen.14493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 03/16/2021] [Accepted: 03/29/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Previous study suggested IgG4 levels were associated with the development of Graves' ophthalmopathy (GO). The aims of the present study were to investigate the role of IgG4 levels in glucocorticoid (GC) treatment in GO patients. DESIGN 69 GO patients were enrolled. Serum thyroid hormones, thyroid antibodies, IgG, IgG4, ophthalmological examinations and orbital MRI were performed. Furthermore, the clinical outcomes (a composite response endpoint including the clinical activity score (CAS), proptosis, vision, intraocular pressure, diplopia and lid width) after high-dose intravenous GC treatment in 32 active moderate-to-severe GO patients were compared. PATIENTS 69 consecutive patients with GO were asked to participate in the study. 32 of 69 GO patients were treated with high-dose intravenous GCs. MEASUREMENTS Measurement of serum IgG and IgG4, serum thyroid hormones and thyroid autoantibodies. An overall ophthalmic assessment was performed pretherapy (week 0) and post-therapy (week 12). RESULTS 33.3% of GO patients (23/69) had elevated IgG4 levels. IgG4 levels were positively correlated with the severity and activity of GO. After GC therapy, IgG4, IgG4/IgG, vision and CAS were significantly improved in GO patients. Patients with high IgG4 levels had a significantly reduced extraocular muscle area (EOMs) and better clinical outcomes than patients with normal IgG4 levels. CONCLUSIONS Our results suggest a possible subgroup of elevated IgG4 GO patients, with more severe ophthalmopathy and better response to GCs treatment compare with normal IgG4 GO patients.
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Affiliation(s)
- Yaling Li
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Wuhan Hospital of Traditional Chinese and Western Medical, Wuhan, China
| | - Ban Luo
- Department of Ophthalmology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Zhang
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Xinrong Zhou
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shiying Shao
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Weijie Xu
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Yang
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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188
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Liu J, Yin W, Westerberg LS, Lee P, Gong Q, Chen Y, Dong L, Liu C. Immune Dysregulation in IgG 4-Related Disease. Front Immunol 2021; 12:738540. [PMID: 34539675 PMCID: PMC8440903 DOI: 10.3389/fimmu.2021.738540] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/09/2021] [Indexed: 12/26/2022] Open
Abstract
Immunoglobin G4-related disease (IgG4-RD) is one of the newly discovered autoimmune diseases characterized by elevated serum IgG4 concentrations and multi-organ fibrosis. Despite considerable research and recent advances in the identification of underlying immunological processes, the etiology of this disease is still not clear. Adaptive immune cells, including different types of T and B cells, and cytokines secreted by these cells play a vital role in the pathogenesis of IgG4-RD. Antigen-presenting cells are stimulated by pathogens and, thus, contribute to the activation of naïve T cells and differentiation of different T cell subtypes, including helper T cells (Th1 and Th2), regulatory T cells, and T follicular helper cells. B cells are activated and transformed to plasma cells by T cell-secreted cytokines. Moreover, macrophages, and some important factors (TGF-β, etc.) promote target organ fibrosis. Understanding the role of these cells and cytokines implicated in the pathogenesis of IgG4-RD will aid in developing strategies for future disease treatment and drug development. Here, we review the most recent insights on IgG4-RD, focusing on immune dysregulation involved in the pathogenesis of this autoimmune condition.
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Affiliation(s)
- Jiachen Liu
- Department of Pathogen Biology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Yin
- Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lisa S Westerberg
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Pamela Lee
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Quan Gong
- Department of Immunology, School of Medicine, Yangtze University, Jingzhou, China
| | - Yan Chen
- The Second Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chaohong Liu
- Department of Pathogen Biology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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189
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Chen L, Almudaires A, Alzahrani M, Qumosani K, Chakrabarti S. IgG4-related disease as a rare cause of gastric outlet obstruction: a case report and literature review. BMC Gastroenterol 2021; 21:349. [PMID: 34544364 PMCID: PMC8454001 DOI: 10.1186/s12876-021-01927-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 11/22/2022] Open
Abstract
Background IgG4-related disease involvement of the digestive tract is very rare. In few reported cases of isolated gastric/duodenal IgG4-related disease, none of which resulted in luminal obstruction. Case presentation A 59 years old female presented with longstanding gastrointestinal symptoms. CT showed mural thickening of the proximal duodenum. Gastroscopy showed antral ulcer extending into the duodenum with outlet obstruction and biopsy showed acute on chronic duodenitis. Whipple’s procedure was performed and IgG4-related disease was diagnosed on final pathology. Symptoms were revolved on mycophenolate mofetil and prednisone with no recurrence. Conclusions Our case is the only reported case with gastric outlet obstruction secondary to gastroduodenal IgG4-related disease. The diagnosis should be considered in the differential diagnosis of unexplained duodenal stricture, gastric outlet obstruction or gastrointestinal ulceration. IgG4-related disease usually responds to steroids but long-term response rates to steroid-sparing agents, especially in the subset of patients with luminal IgG4-related disease remains to be determined.
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Affiliation(s)
- Lina Chen
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - Abdulaziz Almudaires
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - May Alzahrani
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - Karim Qumosani
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Western University, London, ON, Canada
| | - Subrata Chakrabarti
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre and Western University, London, ON, Canada.
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190
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Pyae PK, Cama R, Nicholson AG, Vancheeswaran R. Curious case of the unexplained exudative pleural effusion. BMJ Case Rep 2021; 14:e245796. [PMID: 34544724 PMCID: PMC8454451 DOI: 10.1136/bcr-2021-245796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/03/2022] Open
Abstract
We report a case of a 74-year-old male patient who was referred to the respiratory clinic with an incidental finding of a left sided pleural effusion. He was initially being treated by the general practitioner for chest infection with productive cough that had limited resolution after course of oral antibiotics. At the pleural clinic, 1.5 L of serosanguineous fluid was drained and sent for diagnostics. However, the diagnosis only reached as far as idiopathic exudative effusion with lymphocytes and plasma cells. He was then referred for video-assisted thoracoscopic surgery pleural biopsy and pleurodesis. It revealed black pleura with abundant IgG4 positive cells. He is followed up in respiratory clinic where further discussion and treatment has commenced.
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Affiliation(s)
- Phyoe Kyaw Pyae
- Respiratory Medicine, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Rigers Cama
- Respiratory Medicine, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Andrew G Nicholson
- Department of Histopathology, Royal Brompton and Harefield NHS Trust, London, UK
| | - Rama Vancheeswaran
- Respiratory Medicine, West Hertfordshire Hospitals NHS Trust, Watford, UK
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191
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Akazawa T, Sekido M, Adachi K, Aihara Y, Myojo R. A tumor of IgG4-related skin disease on a forehead with relapse 3 years after resection. JAAD Case Rep 2021; 16:9-11. [PMID: 34504926 PMCID: PMC8413660 DOI: 10.1016/j.jdcr.2021.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Toshifumi Akazawa
- Department of Plastic and Reconstructive Surgery, Tsukuba Gakuen Hospital, Tsukuba, Ibaraki, Japan
| | - Mitsuru Sekido
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Koji Adachi
- KANEKI Dermatology Clinic, Iwaki, Fukushima, Japan
| | - Yukiko Aihara
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Risa Myojo
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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192
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Sharzehi K. Hepatic Manifestations of Immunoglobulin G4-Related Disease. Clin Liver Dis (Hoboken) 2021; 18:81-84. [PMID: 34584673 PMCID: PMC8450467 DOI: 10.1002/cld.1087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/30/2020] [Accepted: 12/06/2020] [Indexed: 02/04/2023] Open
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193
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Olmos RD, Rodrigues MAVM, Ferreira CR, Etrusco RDCF, Romagnolli C. IgG4-related Disease: a diagnostic challenge. Autops Case Rep 2021; 11:e2021312. [PMID: 34458180 PMCID: PMC8387082 DOI: 10.4322/acr.2021.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/25/2021] [Indexed: 11/23/2022]
Abstract
Immunoglobulin IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition with a characteristic histopathological appearance that can affect almost any organ. The clinical features result from a focal or diffuse appearance of a tumor-like swelling of the affected organs, identified by physical and/or imaging examination. Herein, we report the case of a 38-year-old male complaining of a worsening chronic right lumbar pain associated with legs and scrotum edema. He also had itchy and erythematous cutaneous lesions on the abdominal wall over the last 8 months, and complained of a diffuse and mild to moderate abdominal discomfort. On examination, the liver was firmly enlarged and tender. His legs had 2+ symmetrical pitting edema extending from his feet to just above the knees. An abdominal computed tomography scan showed a large mass (10 x 8 x 4cm) involving the abdominal infrarenal aorta and the iliac arteries, and compressing the inferior vena cava, with dilated iliac veins, raising the possibility of lymphoproliferative disease. During the initial investigation, the laboratory workup revealed anemia, without other marked changes. A laparoscopic-guided biopsy of the peri-aortic mass was undertaken. The histological report associated with IgG4 immunoglobulin measurement rendered the diagnosis of IgG4-RD. The patient had a favorable outcome after the use of glucocorticoids with the abdominal mass remission.
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Affiliation(s)
- Rodrigo Díaz Olmos
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division, São Paulo, SP, Brasil
- Universidade de São Paulo (USP), Hospital Universitário, Faculty of Medicine, Internal Medicine Department, São Paulo, SP, Brasil
| | - Marcelo Arlindo Vasconcelos Miranda Rodrigues
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division, São Paulo, SP, Brasil
- Universidade São Caetano do Sul (USCS), Faculty of Medicine, São Paulo, SP, Brasil
| | - Cristiane Rúbia Ferreira
- Universidade de São Paulo (USP), Hospital Universitário, Anatomic Pathology Service, São Paulo, SP, Brasil
| | | | - Carla Romagnolli
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division, São Paulo, SP, Brasil
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194
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Vanhomwegen C, Mestrez F, Faverly D, Holz S, Taylor S, Rossi C. Indolent renal involvement with BRAF V600E mutation: Erdheim-Chester, a rare disease with a wide spectrum of clinical manifestations. Clin Case Rep 2021; 9:e04683. [PMID: 34466245 PMCID: PMC8385182 DOI: 10.1002/ccr3.4683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/06/2021] [Accepted: 07/18/2021] [Indexed: 12/02/2022] Open
Abstract
We present the case of a patient with three-year indolent bilateral ureteral and perirenal masses. Clinical presentation, radiological context, and histopathological findings with detection of BRAF V600E mutation confirmed the diagnosis of Erdheim-Chester disease (ECD). A review of current knowledge regarding diagnosis, clinical assessment, management, and treatment of ECD is also presented.
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Affiliation(s)
| | - Fabienne Mestrez
- Nephrology DepartmentAmbroise Paré Hospital Université Libre de BruxellesBruxellesBelgium
| | - Daniel Faverly
- Pathology DepartmentAmbroise Paré Hospital Université Libre de BruxellesBruxellesBelgium
| | - Serge Holz
- Urology DepartmentAmbroise Paré Hospital Université Libre de BruxellesBruxellesBelgium
| | - Stephen Taylor
- Radiology UnitAmbroise Paré Hospital Université Libre de BruxellesBruxellesBelgium
| | - Camelia Rossi
- Infectious Disease DepartmentAmbroise Paré Hospital Université Libre de BruxellesBruxellesBelgium
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195
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Faizi Z, Humayun A, Matto M, White Z, Sajja S. Idiopathic Aortitis With Retroperitoneal Fibrosis Course and Its Treatment. Cureus 2021; 13:e17366. [PMID: 34567905 PMCID: PMC8454988 DOI: 10.7759/cureus.17366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 11/05/2022] Open
Abstract
Aortitis is an inflammatory phenomenon involving one or more layers of the aorta and can have infectious or noninfectious etiologies. Complications of aortitis include aneurysm, dissection, and rupture, which can lead to ischemic organs and ultimately death. Noninfectious aortitis is often secondary to trauma or results from a systemic inflammatory process. It is further categorized based on clinical characteristics, laboratory findings, and imaging. There are some cases in which the etiology cannot be determined and is, therefore, idiopathic in nature. We present a case of a 67-year-old male who presented with malaise, abdominal pain, anorexia, and significant weight loss for several months. Imaging revealed retroperitoneal fibrosis and aortitis. After an extensive workup, we diagnosed idiopathic aortitis and treated the patient with high-dose corticosteroids that led to symptom improvement.
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Affiliation(s)
- Zaheer Faizi
- General Surgery, Crozer-Chester Medical Center, Upland, USA
| | | | - Marissa Matto
- Surgery, Drexel University College of Medicine, Philadelphia, USA
| | - Zeyn White
- Surgery, Trinity School of Medicine, Kingstown, VCT
| | - Sai Sajja
- Vascular Surgery, Crozer-Chester Medical Center, Upland, USA
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196
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Tanaka A, Notohara K. Immunoglobulin G4 (IgG4)-related autoimmune hepatitis and IgG4-hepatopathy: A histopathological and clinical perspective. Hepatol Res 2021; 51:850-859. [PMID: 34165225 DOI: 10.1111/hepr.13683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022]
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a chronic inflammatory disease that simultaneously or consecutively involves multiple organs of the body. It is characterized by elevated serum IgG4 levels and massive infiltration of IgG4+ plasma cells in the damaged tissues. IgG4-related autoimmune hepatitis (IgG4-AIH) and IgG4-hepatopathy are relatively new entities that have been proposed as a phenotype of IgG4-RD in the liver. Immunoglobulin G4-AIH is defined as a disorder with serological, histopathological, and clinical features of both IgG4-RD and AIH, simultaneously satisfying the diagnostic criteria of both classical AIH and IgG4-RD. Although there are several case reports and studies of IgG4-AIH among the published works, no consensus regarding the histopathological characteristics of IgG4-AIH has been established, and its clinical implications remain obscure. Immunoglobulin G4-hepatopathy is defined as a comorbidity of IgG4-RD in the liver, and patients not meeting the diagnostic criteria of classical AIH could be diagnosed with IgG4-hepatopathy. Numerous issues regarding these diseases, especially their epidemiology, histopathological and clinical characteristics, and treatment response to corticosteroids, remain unsolved, and need to be determined to establish the disease concepts of IgG4-AIH and IgG4-hepathopathy.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
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197
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Zhang KF, Hong X, Li W, Gao Y, Chen Y, Zhang YY, Su JZ, Peng X, Yu GY. Natural developing process of immunoglobulin G4-related sialadenitis after submandibular gland excision: a retrospective cohort study. Clin Rheumatol 2021; 40:4969-4976. [PMID: 34275056 DOI: 10.1007/s10067-021-05859-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study aimed to evaluate the long-term outcome and quality of life of IgG4-related sialadenitis (IgG4-RS) patients after submandibular gland (SMG) excision without immunomediate therapy. MATERIALS AND METHODS This retrospective review included patients with IgG4-RS who did not undergo further treatment following SMG excision. All patients diagnosed with IgG4-RS between January 1955 and December 2012 at the Department of Oral and Maxillofacial Surgery, Peking University School of Stomatology, were enrolled. The main outcome measures included postoperative IgG4-RS progression rate and differences between patients with and without recurrent disease. The degree of subjective oral dryness was evaluated using the summated xerostomia inventory (SXI); the objective secretory function was assessed by whole saliva flow rate measurements. Serological findings were analyzed during the follow-up. RESULTS SMG excision was adopted in all of the 83 patients. The median follow-up period was 108 (range 7-396) months. Clinical progression was observed in 54.2% of cases. Patients with other organ involvement (OOI) indicated higher progression rate to a significant extent (P = 0.015, HR = 2.108). The annual progression rate was 20.7% in the group with OOI and was 14.1% in the group without OOI. All cases showed higher levels of serum IgG4; the level was in positive correlation with follow-up time when no therapy was added. 82.4% of cases experienced xerostomia after the surgery, and the degree of dry mouth in patients underwent bilateral resection was significantly more severe than those in unilateral resection. CONCLUSIONS Surgical excision of involved SMG cannot control the disease progression, which is not recommended for treatment of IgG4-RS. Differential diagnosis is crucial in order to prevent irreversible organ loss and relevant salivary gland dysfunction. Key Points • Surgical excision of involved SMG cannot control progression of IgG4-RS.
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Affiliation(s)
- Ke-Fu Zhang
- Department of Oral & Maxillofacial Surgery, Peking University School of Stomatology, Beijing, 100081, China
| | - Xia Hong
- Center for Stomatology, Peking University Shenzhen Hospital, Shenzhen, People's Republic of China
| | - Wei Li
- Department of Oral & Maxillofacial Surgery, Peking University School of Stomatology, Beijing, 100081, China
| | - Yan Gao
- Department of Oral Pathology, Peking University School of Stomatology, Beijing, China.,National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing, People's Republic of China
| | - Yan Chen
- Department of Oral Pathology, Peking University School of Stomatology, Beijing, China.,National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing, People's Republic of China
| | - Yan-Yan Zhang
- Department of Oral & Maxillofacial Surgery, Peking University School of Stomatology, Beijing, 100081, China
| | - Jia-Zeng Su
- Department of Oral & Maxillofacial Surgery, Peking University School of Stomatology, Beijing, 100081, China
| | - Xin Peng
- Department of Oral & Maxillofacial Surgery, Peking University School of Stomatology, Beijing, 100081, China
| | - Guang-Yan Yu
- Department of Oral & Maxillofacial Surgery, Peking University School of Stomatology, Beijing, 100081, China. .,Center for Stomatology, Peking University Shenzhen Hospital, Shenzhen, People's Republic of China.
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198
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Kim Y, Choi HY. [Immunoglobulin G4-Related Disease in the Thorax: Imaging Findings and Differential Diagnosis]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:826-837. [PMID: 36238052 PMCID: PMC9514412 DOI: 10.3348/jksr.2021.0078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 01/13/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic inflammatory condition involving multiple organs, including the salivary or lacrimal glands, orbit, pancreas, bile duct, liver, kidney, retroperitoneum, aorta, lung, and lymph nodes. It is histologically characterized by tissue infiltration with lymphocytes and IgG4-secreting plasma cells, storiform fibrosis, and obliterative phlebitis. In the thoracic involvement of IgG4-RD, mediastinal lymphadenopathy and perilymphangitic interstitial thickening of the lung are the most common findings. Peribronchovascular and septal thickening and paravertebral band-like soft tissue are characteristic findings of IgG4-RD. Other findings include pulmonary nodules or masses, ground-glass opacity, alveolar interstitial thickening, pleural effusion or thickening, mass in the chest wall or mediastinum, and arteritis involving the aorta and coronary artery. Radiologic differential diagnosis of various malignancies, infections, and inflammatory conditions is needed. In this review, we describe the imaging findings of IgG4-RD and the radiologic differential diagnoses in the thorax.
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199
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Abstract
BACKGROUND The IgG4-related systemic disease as well as the homonymous variant IgG4-related orbital disease were first described less than 15 years ago. The mostly subacute clinical symptoms can be multifarious and the classical case is characterized by an orbital inflammatory condition with a bilateral enlargement of the lacrimal glands; however, any other orbital tissue with the exception of the eyeball can be affected by the lymphocytic inflammatory infiltration. MATERIAL AND METHODS Based on the current literature the clinical picture, epidemiology, pathogenesis and treatment options are described. A focus is on the differential diagnostic demarcation from other inflammatory processes of the orbit. CONCLUSION The IgG4-related orbital disease is an important differential diagnosis of inflammatory diseases of the orbit. The condition can exhibit considerable clinical and imaging similarity to idiopathic inflammation of the orbit, to the specific inflammations seen in systemic diseases, to Graves' orbitopathy and to lymphoproliferative diseases and lymphoma. After histopathologic confirmation the interdisciplinary clarification and treatment consensus are indispensable.
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Affiliation(s)
- Susanne Pitz
- Bürgerhospital, Augenklinik - Orbitazentrum, Nibelungenallee 37-41, 60318, Frankfurt, Deutschland.
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200
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Tanaka Y, Takikawa T, Kume K, Kikuta K, Hamada S, Miura S, Yoshida N, Hongo S, Matsumoto R, Sano T, Ikeda M, Unno M, Masamune A. IgG4-related Diaphragmatic Inflammatory Pseudotumor. Intern Med 2021; 60:2067-2074. [PMID: 33518577 PMCID: PMC8313910 DOI: 10.2169/internalmedicine.6589-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] Open
Abstract
A 71-year-old man underwent surgery for a pancreatic neuroendocrine tumor. Follow-up imaging showed swelling of the remnant pancreas, and he was histologically diagnosed with autoimmune pancreatitis based on endoscopic ultrasonography-guided fine-needle aspiration specimens. After two years, a tumor appeared on the liver surface. Although we planned to perform laparoscopic partial hepatectomy, the intraoperative findings showed that the tumor was located in the diaphragm. Partial resection of the diaphragm was performed, and the final diagnosis was an immunoglobulin G4-related inflammatory pseudotumor in the diaphragm. To our knowledge, this is the first reported case of an immunoglobulin G4-related diaphragmatic inflammatory pseudotumor.
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Affiliation(s)
- Yu Tanaka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tetsuya Takikawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kiyoshi Kume
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kazuhiro Kikuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Shin Hamada
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Shin Miura
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Naoki Yoshida
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Seiji Hongo
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Ryotaro Matsumoto
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Takanori Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Mio Ikeda
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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