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Stearns K, Vuppuluri B, Lininger R, Berry LK. IgG4-related disease in the pelvis: A mimicker of gynecologic malignancy. Gynecol Oncol Rep 2024; 54:101428. [PMID: 38912387 PMCID: PMC11190480 DOI: 10.1016/j.gore.2024.101428] [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: 05/02/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/25/2024] Open
Abstract
This report describes a unique case of IgG4-related disease in a 36-year-old woman who presented with a pelvic mass. Although CT and MR imaging initially suggested a malignant process, further work-up including sigmoidoscopy and surgical exploration revealed no evidence of malignancy. The final pathology indicated an inflammatory process, leading to the diagnosis of IgG4-related disease. After receiving appropriate systemic treatment, the patient's symptoms significantly improved. This case underscores the limitations of current imaging studies and emphasizes the importance of considering a wide range of potential diagnoses when dealing with pelvic masses of uncertain etiology.
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Affiliation(s)
- Kristen Stearns
- Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Binathi Vuppuluri
- Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Ruth Lininger
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Laurel K. Berry
- Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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Czerniak S, Rao A, Mathur M. Multimodality pictorial review of IgG4-related disease in the abdomen and pelvis. Abdom Radiol (NY) 2023; 48:3147-3161. [PMID: 37407744 DOI: 10.1007/s00261-023-03996-w] [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] [Received: 04/13/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a systemic, immune-mediated disease that can affect multiple organs, including the orbits, salivary glands, thyroid gland, lungs, aorta, pancreas, bile ducts, lymph nodes, and retroperitoneum. While timely diagnosis is particularly important given the efficacy of glucocorticoid treatment for IgG4-RD, accurate recognition can prove a challenge given the overlap between the imaging features of this disease and other entities. PURPOSE After a review of the epidemiology, pathophysiology, and clinical considerations (including treatment) associated with IgG4-RD, this pictorial review will showcase the variable imaging manifestations of this disease in the abdomen and pelvis. Post-treatment imaging appearance of these entities will be reviewed and mimickers of this disease in the abdomen and pelvis will be presented. CONCLUSION The presence of mass-like soft tissue with radiographic characteristics of fibrosis affecting multiple organs should raise suspicion for IgG4-RD, although definite diagnosis can only be made with appropriate clinical, serological, and pathologic data.
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Affiliation(s)
- Suzanne Czerniak
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA.
| | - Aditya Rao
- Diagnostic Radiology Resident, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mahan Mathur
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA
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Huynh KN, Kong MJ, Nguyen BD. Anatomic and Functional Imaging of Immunoglobulin G4-related Disease and Its Mimics. Radiographics 2023; 43:e220097. [PMID: 36821510 DOI: 10.1148/rg.220097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is an immune-mediated fibrosclerosing disease with tumefactive lesions infiltrated by IgG4-positive plasma cells. Initially described as autoimmune pancreatitis, IgG4-RD is now recognized as a discrete entity and is found to affect virtually any organ in the body. Common extrapancreatic sites include the biliary tree, salivary glands, periorbital tissue, lungs, kidneys, lymph nodes, aorta, retroperitoneum, and thyroid gland. Diagnosis-which relies on histopathologic, serologic, and radiologic features-can be challenging with the disease underdiagnosed, as IgG4-RD often mimics malignancy, infectious processes, or other immune-mediated conditions. Patients may present with signs of compression of nearby structures due to mass effect or with organ failure when the disease is left untreated. The clinical course is complex, with single- or multiorgan involvement and metachronous or synchronous occurrence of lesions. IgG4-RD responds well to glucocorticoid therapy, disease-modifying antirheumatic drugs, and B-cell-depleting biologic agents; prompt diagnosis is important to avoid delay in treatment and unnecessary pharmacologic or surgical intervention. While imaging features may not be specific for IgG4-RD, functional whole-body imaging with fluorine 18-fluorodeoxyglucose PET/CT is a useful adjunct for localizing extrapancreatic sites for biopsy, monitoring therapeutic response, and demonstrating disease relapse. The authors describe the pancreatic and extrapancreatic sites of involvement in IgG4-RD, with imaging features and patterns to aid in distinguishing IgG4-RD from its mimics through a multimodality approach with emphasis on functional imaging evaluation. ©RSNA, 2023 Quiz questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.
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Affiliation(s)
- Kenneth N Huynh
- From the Department of Radiological Sciences, University of California-Irvine, Orange, Calif (K.N.H.); and Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (M.J.K., B.D.N.)
| | - Min J Kong
- From the Department of Radiological Sciences, University of California-Irvine, Orange, Calif (K.N.H.); and Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (M.J.K., B.D.N.)
| | - Ba D Nguyen
- From the Department of Radiological Sciences, University of California-Irvine, Orange, Calif (K.N.H.); and Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (M.J.K., B.D.N.)
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Bertoni M, Giani A, Tozzini S, Di Natale ME. Sclerosing Mesenteritis as an Uncommon Site of Involvement of IgG4-Related Disease: A Case Report With an Updated Review of the Literature. Cureus 2022; 14:e25041. [PMID: 35719809 PMCID: PMC9199380 DOI: 10.7759/cureus.25041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 11/05/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an uncommon immune-mediated disorder most commonly involving the pancreas, lacrimal, and salivary glands. Immunoglobulin G4-related sclerosing mesenteritis (IgG4-RSM) is a rare site of involvement that usually mimics the imaging characteristics of mesenteric malignancies. Herein, we report a case of IgG4-RSM followed by an updated and comprehensive review of the literature. A 73-year-old woman presented with colicky abdominal pain in the right hypochondrium. The findings on contrast medium computed tomography (CMCT) showed a swelling of the mesenteric root with vascular structures surrounded by slightly contrast-impregnated tissue and irregular margins. The 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET) showed an area of inhomogeneous and intense hypermetabolism of the mesenteric root. Hence, laparoscopic resection of the mesenteric root was performed to distinguish such masses from malignant tumors, obtaining specimens for histopathologic examination. The latter exhibited tissue infiltration with lymphocytes, IgG4-positive plasma cells, and fibrosis, indicating a diagnosis of IgG4-RSM in the presence of both elevated serum IgG4 levels and the aforementioned imaging findings. With steroid therapy, no clinical signs of re-exacerbation within a one-year follow-up were observed and serum IgG4 levels returned to normality. Aiming to evaluate the real frequency of IgG4-RSM in view of the 2017 Comprehensive Diagnostic Criteria (CDC) of IgG4-RD, we undertook a complete MEDLINE, EMBASE, Web of Science, and Scopus database search of all case reports of IgG4-RSM published so far. Such criteria were met in only six cases with a definite diagnosis. This case highlights the mesentery as a rare site of involvement of IgG-RD and allows us to advance knowledge of IgG4-RSM.
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Ichikawa S, Onishi H. Imaging findings of immunoglobulin G4-related disease: from the head to the pelvis. Singapore Med J 2022; 62:574-581. [PMID: 35001118 DOI: 10.11622/smedj.2021226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
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López-Fernández J, García Plaza G, García Martín CM, de la Cruz Cuadrado C, Larrea Y Olea FJ, Hernández Hernández JR. IgG4-related cholecystitis mimicking gallbladder carcinoma; the challenge of a preoperative diagnosis. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45 Suppl 1:64-66. [PMID: 34023474 DOI: 10.1016/j.gastrohep.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 11/19/2022]
Affiliation(s)
- José López-Fernández
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España.
| | - Gabriel García Plaza
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - Carlos M García Martín
- Servicio de Anatomía Patológica, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - Cristina de la Cruz Cuadrado
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - Francisco J Larrea Y Olea
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - Juan R Hernández Hernández
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
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Manger B, Schett G. Jan Mikulicz-Radecki (1850-1905): return of the surgeon. Ann Rheum Dis 2020; 80:8-10. [PMID: 32988841 DOI: 10.1136/annrheumdis-2020-218843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Bernhard Manger
- Department of Medicine 3, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Georg Schett
- Department of Medicine 3, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
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Bhattad PB, Joseph DL, Peterson E. IgG4-Related Disease Manifesting as Hypocomplementemic Tubulointerstitial Nephritis: A Rare Case Report and Literature Review. J Investig Med High Impact Case Rep 2020; 8:2324709620952213. [PMID: 32830581 PMCID: PMC7448130 DOI: 10.1177/2324709620952213] [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: 07/08/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic fibrosing inflammatory systemic disorder that has been recognized relatively recently in the medical literature. Little is known about the exact disease pathogenesis and epidemiology. IgG4-RD may be asymptomatic or may have minimal symptoms or involve multiple organs with overt symptoms. The different phenotypes of IgG4-RD can lead to delayed or incorrect diagnosis. We report the case of a 66-year-old male with coal worker's pneumoconiosis who presented with progressive kidney disease and was diagnosed with tubulointerstitial nephritis due to IgG4-RD. The patient was noted to have progressive kidney disease, skin involvement, worsening interstitial lung disease, complete vision loss in the left eye, and retroperitoneal fibrosis. Serologic workup revealed elevated inflammatory markers, IgG4 and IgG1 levels, and hypocomplementemia. A tissue biopsy helped us establish a definitive diagnosis of IgG4-RD and initiate treatment with glucocorticoids to prevent further progression of kidney disease and other end-organ damage.
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Affiliation(s)
| | - David L. Joseph
- James H. Quillen Veterans Affairs Medical Center, Johnson City, TN, USA
| | - Eric Peterson
- James H. Quillen Veterans Affairs Medical Center, Johnson City, TN, USA
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