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Kawahara H, Mizushima I, Matsumoto Y, Sakata K, Takamura M, Inoue D, Kasashima S, Kawano M. Solitary recurrence of IgG4-related giant coronary aneurysm: Case report and review of the literature focusing on treatment strategies and complications. Mod Rheumatol Case Rep 2023; 8:182-194. [PMID: 37947034 DOI: 10.1093/mrcr/rxad065] [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: 08/31/2023] [Revised: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
Coronary periarteritis is a dangerous manifestation of IgG4-related disease, because it forms coronary artery aneurysms, which may cause sudden cardiac death. We report the case of a 78-year-old woman with IgG4-related coronary periarteritis and a coronary aneurysm, which showed progressive enlargement despite maintenance therapy for Type 1 autoimmune pancreatitis. This case was unique, in that coronary periarteritis was the only active lesion that recurred. Low-dose glucocorticoids suppressed the progression of periarterial lesions but led to rapid thinning of the aneurysmal wall and an increase in the size of mural thrombi, which pose a risk of myocardial infarction. Our systematic literature review including 98 cases of 86 articles was performed to examine its treatment strategies and complications. Among the cases in which the effect of immunosuppressive therapy could be followed radiologically, 33 of 37 (89.1%) cases showed improvement in wall thickening/periarterial soft tissue, while 6 of 13 (46.2%) showed worsening increase in the outer diameter of the coronary aneurysms. We propose a draft treatment algorithm and suggest that immunosuppressive therapy for IgG4-related coronary periarteritis with coronary aneurysms should be conducted only after the therapeutic benefit has been determined to outweigh the risks. Because coronary periarteritis can occur without other organ involvement, as in our case, all cases of IgG4-related disease require careful monitoring of coronary artery lesions.
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Affiliation(s)
- Hiroyuki Kawahara
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yasushi Matsumoto
- Department of Cardiovascular Surgery, National Hospital Organization Kanazawa Medical Center, Kanazawa, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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2
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Tang M, Zhang Z, Wang L, Qian H, Wu W, Liu Z, Shen Z, Chen H, Guo Z, Tian R, Zhang S. Coronary artery ectasia associated with IgG4-related disease: a case report and literature review. BMC Cardiovasc Disord 2023; 23:347. [PMID: 37438699 PMCID: PMC10339667 DOI: 10.1186/s12872-023-03369-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Coronary artery ectasia is defined as a local or diffuse dilatation of the coronary artery more than 1.5 times the diameter of the adjacent normal segment. The etiology of coronary artery ectasia is diverse, and rarely complicated with immunoglobulin G4-related disease (IgG4-related disease). A limited number of cases have been reported, with insidious onset, slow progression but poor prognosis. CASE PRESENTATION we report a patient with coronary artery ectasia combined with IgG4-related disease. He has been diagnosed with IgG4-related disease 5 years after his first percutaneous coronary intervention (PCI). Despite routine treatment with steroids, he develops a large coronary aneurysm and eventually died. CONCLUSIONS It is suggested that a thorough evaluation should be performed when coronary artery ectasia is diagnosed. The factors such as manifestations of coronary artery thickening, typical imaging features, other aortas involvement, increased serum IgG4 level, etc. should be considered for early diagnosis of key etiologies.
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Affiliation(s)
- Muyun Tang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Zhiyu Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Liang Wang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Hao Qian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Wei Wu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Zhenyu Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Zhujun Shen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Zhiwei Guo
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ran Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
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3
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Lin Z, Jia L, Yin D, Song W, Wang H, Dong Q, Gao G, Fu R, Yang F, Dou K. Current Evidence in the Diagnosis and Management of Coronary Arteritis Presenting as Acute Coronary Syndrome. Curr Probl Cardiol 2023; 48:101465. [PMID: 36261104 DOI: 10.1016/j.cpcardiol.2022.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Zhangyu Lin
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Lei Jia
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China.
| | - Dong Yin
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Weihua Song
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Hongjian Wang
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Qiuting Dong
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Guofeng Gao
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Rui Fu
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Feiran Yang
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
| | - Kefei Dou
- State Key Laboratory of Cardiovascular Disease, Beijing, Beijing, China; Cardiometabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China.
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4
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Ito T, Fukui S, Kanie T, Tamaki H, Okada M. Immunoglobulin G4-related coronary periarteritis: a systematic literature review with a case series. Clin Rheumatol 2022; 41:2281-2295. [PMID: 35445950 DOI: 10.1007/s10067-022-06179-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/13/2023]
Abstract
We aimed to assess the clinical and radiological characteristics of immunoglobulin G4-related coronary periarteritis through a systematic literature review and from our case series. In the systematic literature review, we assessed English language manuscripts on immunoglobulin G4-related coronary periarteritis cases. Additionally, we identified patients with immunoglobulin G4-related coronary periarteritis at St. Luke's International Hospital in Tokyo, Japan, from 2014 to 2020. We summarized patients' demographics, immunoglobulin-G and -G4 titers, site and morphological features of the coronary lesion, and other organ involvements. We identified 38 cases from the literature and four patients from our institute. Coronary lesions were detected using coronary computed tomography in 40 (95.2%) patients. Mass-like or diffuse wall-thickening lesion was the most frequently observed type in 33 (78.6%) patients. No trends at the site of the coronary arteries were identified. Overall, 32 (76.1%) patients had multiple-organ involvement, of which the most common lesion was peri-aortitis in 21 (50.0%) patients. Ten (23.8%) patients with an isolated coronary lesion had significantly lower immunoglobulin-G4 titers than those with other organ involvements (immunoglobulin-G4: 261 [161.0, 564.0] vs. 1355.0 [320.8, 2480.0] mg/dL, p = 0.033). The wall-thickening lesions responded well to immunosuppressive treatments. Mass-like or diffuse wall-thickening on coronary computed tomography is a characteristic radiographic finding of immunoglobulin G4-related coronary periarteritis, which can occur in any branch. Immunoglobulin G4-related coronary periarteritis showed similar characteristics to other organ lesions, including its relatively low serum immunoglobulin-G4 level in patients with a single-organ disease and its high responsiveness to glucocorticoids.
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Affiliation(s)
- Takanori Ito
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan. .,Department of Emergency and General Medicine, Kyorin University, Tokyo, Japan.
| | - Takayoshi Kanie
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
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5
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Paratz ED, Ross L, Zentner D, Morgan N, Bouwer H, Lynch M, Parsons S, La Gerche A. Intracoronary IgG4-related disease as an unusual cause of sudden cardiac arrest: a case series. Eur Heart J Case Rep 2022; 6:ytac050. [PMID: 35187393 PMCID: PMC8851923 DOI: 10.1093/ehjcr/ytac050] [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] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 01/19/2022] [Indexed: 01/14/2023]
Abstract
Background IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition classically causing retroperitoneal fibrosis, aortitis, thyroiditis, or pancreatitis. Diagnosis includes the presence of lymphoplasmacytic infiltrate (with >40% ratio IgG4+:IgG plasma cells) and fibrosis. Cardiac involvement may include aortic, pericardial, or coronary disease. Coronary manifestations encompass obstructive intra-luminal lesions, external encasing pseudo-tumour on imaging, or lymphoplasmacytic arteritis. Case summary Case 1: A fit and healthy 50-year-old man was found deceased. His only known medical condition was treated Hashimoto’s thyroiditis. Post-mortem examination demonstrated an isolated severe stenosis of the left anterior descending (LAD) coronary artery without histopathological evidence of acute myocardial infarction. Coronary plaque histopathology showed florid IgG4-positive plasma cell infiltrate throughout all layers of the artery with dense fibrous tissue connective tissue stroma, all features consistent with coronary artery IgG4-RD. Case 2: A 48-year-old man collapsed at work. Computed tomography scan 1 week prior reported an ill-defined para-aortic retroperitoneal soft tissue density. No cardiac symptoms were reported in life. Post-mortem examination showed coronary arteritis and peri-arteritis with sclerosing peri-aortitis in the LAD. There was myocardial fibrosis of the anterior left ventricle and focal myocarditis of the right ventricle. Discussion IgG4-related disease presenting as sudden cardiac death without any preceding symptoms is very rare (six prior cases identified on literature review). Reported targeted successful interventions for intracoronary IgG4-RD diagnosed in life have included steroid therapy and B cell depleting therapy (i.e. rituximab). If cardiac symptoms are present in a patient with known IgG4-RD, cardiac investigations should be promptly arranged.
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Affiliation(s)
- Elizabeth D Paratz
- Department of Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Road, Prahran, VIC 3181, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Prahran, VIC 3181, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, 41 Victoria Pde, Fitzroy. VIC 3065, Australia
| | - Laura Ross
- Department of Cardiology, St Vincent’s Hospital Melbourne, 41 Victoria Pde, Fitzroy. VIC 3065, Australia
- Department of Rheumatology, St Vincent’s Hospital Melbourne, 41 Victoria Pde, Fitzroy, VIC 3065, Australia
- Department of Medicine, The University of Melbourne at St Vincent’s, 41 Victoria Pde, Fitzroy, VIC 3065, Australia
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
- Department of Cardiology, Royal Melbourne Hospital Clinical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Natalie Morgan
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC 3006, Australia
| | - Heinrich Bouwer
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC 3006, Australia
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC 3006, Australia
| | - Matthew Lynch
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC 3006, Australia
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC 3006, Australia
| | - Sarah Parsons
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC 3006, Australia
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC 3006, Australia
| | - Andre La Gerche
- Department of Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Road, Prahran, VIC 3181, Australia
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Prahran, VIC 3181, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, 41 Victoria Pde, Fitzroy. VIC 3065, Australia
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6
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Yardimci GK, Ardali Duzgun S, Bolek EC, Kilic L, Canpolat U, Hazirolan T, Aytemir K, Karadag O. Coronary (peri)-arteritis in patients with IgG4-related disease: A case series from the Central Anatolia Region of Turkey. Int J Rheum Dis 2021; 24:1004-1013. [PMID: 34138520 DOI: 10.1111/1756-185x.14153] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/29/2021] [Accepted: 05/20/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized fibro-inflammatory disease which affects many systems, as well as the cardiovascular system. Identifying the coronary involvement like periaortitis, coronary periarteritis and pericarditis is important, as they often cause unfavorable outcomes. METHODS Eighty-one patients with IgG4-RD were retrospectively evaluated for symptomatic coronary artery involvement from Hacettepe University Vasculitis Research Center (HUVAC) database. The demographic, laboratory, radiologic and clinical characteristics of the patients were assessed. RESULTS Among 81 patients with IgG4-RD, 6 patients (M/F:5/1) had coronary artery involvement. The patients' median age was 57 and serum IgG4 levels were above normal except for one case. All patients with coronary arteritis revealed an increased coronary vessel wall thickening and stenotic lesions. The coronary aneurysm and pericarditis were observed in half of the patients. Immunosuppressive treatments were given to all the patients and most of them followed in stable condition. CONCLUSION Coronary arteritis is a rare but notable manifestation of IgG4-RD. Although coronary periarteritis can cause significant morbidity and mortality, it seems better results can be achieved with early diagnosis and treatment.
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Affiliation(s)
- Gozde Kubra Yardimci
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
| | - Selin Ardali Duzgun
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ertugrul Cagri Bolek
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
| | - Levent Kilic
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
| | - Ugur Canpolat
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tuncay Hazirolan
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
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Koo CY, Lim AYN, Chan KH. Recurrent Stent Thrombosis Secondary to Immunoglobulin G4-Related Disease. Can J Cardiol 2021; 37:1659-1660. [PMID: 34090981 DOI: 10.1016/j.cjca.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an insidiously progressive multiorgan disease. However, lack of familiarity with IgG4-RD results in patients often being undiagnosed and undertreated. IgG4-RD can affect any organ, and manifests as aortitis within the cardiovascular system. Cardiac involvement is less common, and myocardial infarction is rarely reported. We report the first case of a patient with multiple myocardial infarctions caused by recurrent stent thrombosis associated with IgG4-RD, which resolved upon treatment of IgG4-RD. This case highlights the importance for cardiologists to consider IgG4-RD as a rare but possible association with stent thrombosis.
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Affiliation(s)
- Chieh Yang Koo
- Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Anita Yee Nah Lim
- Division of Rheumatology, Department of Medicine, National University Hospital Singapore, Singapore
| | - Koo Hui Chan
- Department of Cardiology, National University Heart Centre Singapore, Singapore
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8
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Tan M, Li Z, Tang H, Sun G, Xu Z. IgG4-Related Tumefactive Lesions at the Pulmonary Artery Causing Stenosis of Bilateral Primary Branches and Resultant Pulmonary Hypertension. Cardiology 2019; 143:136-144. [PMID: 31476758 DOI: 10.1159/000501741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
IgG4-related disease (IgG4-RD) is a newly recognized but rare entity involving multiple organs, with autoimmune pancreatitis, retroperitoneal mass, and the inflammation of glands being typical in most cases. IgG4-related perivascular lesions, although uncommon, have been increasingly reported in recent years. Diagnosis of IgG4-RD relies on comprehensive consideration of characteristic histopathological and immunostaining results, clinical and imaging findings, and serological results according to several widely recognized diagnostic criteria. This benign disorder frequently presenting tumefactive lesions should be distinguished from malignancy and other inflammatory mimics. Here we report a case of tumefactive mass at the bifurcation of the pulmonary trunk causing stenosis of the proximal left and right pulmonary artery (PA) and resultant pulmonary hypertension (PH). Bypass from the PA trunk to the right branch distal to stenosis was performed to resolve the obstructive hemodynamic disturbance and PH. Glucocorticoid monotherapy was performed after a diagnosis of definite IgG4-RD. Longitudinal disease activity assessment via imaging modalities, serological parameters, and IgG4-RD responder index verified no relapse during follow-up and the validity of the treatment strategy.
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Affiliation(s)
- Mengwei Tan
- Department of Cardiothoracic Surgery, Changhai Hospital, Naval Military Medical University (The Second Military Medical University), Shanghai, China
| | - Zhuodong Li
- Department of Cardiothoracic Surgery, Changhai Hospital, Naval Military Medical University (The Second Military Medical University), Shanghai, China.,Department of Chest Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
| | - Hao Tang
- Department of Cardiothoracic Surgery, Changhai Hospital, Naval Military Medical University (The Second Military Medical University), Shanghai, China
| | - Gaofeng Sun
- Department of Nuclear Medicine, Changhai Hospital, Naval Military Medical University (The Second Military Medical University), Shanghai, China
| | - Zhiyun Xu
- Department of Cardiothoracic Surgery, Changhai Hospital, Naval Military Medical University (The Second Military Medical University), Shanghai, China,
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9
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Akiyama M, Kaneko Y, Takeuchi T. Characteristics and prognosis of IgG4-related periaortitis/periarteritis: A systematic literature review. Autoimmun Rev 2019; 18:102354. [PMID: 31323364 DOI: 10.1016/j.autrev.2019.102354] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Immunoglobulin G4 (IgG4)-related disease is a systemic chronic fibroinflammatory disease that can affect almost every organ of the body. IgG4-related periaortitis/periarteritis is a newly recognized subset of IgG4-related disease, and its characteristics and prognosis remain unclear. We investigated the clinical characteristics and prognosis of IgG4-related periaortitis/periarteritis. METHODS We performed a systematic literature review of IgG4-related periaortitis/periarteritis. Additionally, we have summarized the characteristics and prognosis of IgG4-related coronary arteritis. RESULTS We investigated 248 patients with IgG4-related periaortitis/periarteritis. All studies reported the condition in elderly patients, and male predominance was observed. The infra-renal abdominal aorta and iliac arteries were the most commonly affected sites. Most reports showed the serum C-reactive protein elevation in this disease entity, in contrast to non-vascular IgG4-related disease. Based on radiological findings observed in 27 patients with IgG4-related coronary arteritis, vasculitic lesions were classified into 3 types: stenotic (67% of patients), aneurysmal (42%), and diffuse wall thickening type (92%). Serum IgG4 level, but not C-reactive protein level, was associated with the number of affected organs in IgG4-related coronary arteritis. Corticosteroid treatment with or without cardiac surgery or percutaneous coronary intervention was effective in most patients with IgG4-related coronary arteritis; however, 33% of patients showed an unfavorable clinical course including disease progression, relapse, or death. Pre-treatment stenosis and/or aneurysms were associated with progression of stenosis or aneurysm after corticosteroid treatment. CONCLUSION Most clinical characteristics were similar between the IgG4-related periaortitis/periarteritis and the non-vascular IgG4-related disease groups; however, serum C-reactive protein level elevation was observed only in the former. Although corticosteroid treatment was effective, this disease can be life-threatening secondary to myocardial infarction, aortic dissection, and aneurysmal rupture. Pre-treatment evaluation of stenosis or aneurysms is important for predicting progression of stenosis or aneurysm after corticosteroid treatment.
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Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan.
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
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10
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Sudden unexpected death due to coronary thrombosis associated with isolated necrotizing vasculitis in the coronary arteries of a young adult. Forensic Sci Med Pathol 2019; 15:252-257. [PMID: 30810977 DOI: 10.1007/s12024-019-00099-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2019] [Indexed: 12/18/2022]
Abstract
Coronary arteritis is an uncommon cause of sudden death in non-atherosclerotic coronary diseases, and is mostly associated with systemic vasculitis or systemic autoimmune diseases; therefore, sudden death due to isolated coronary arteritis rarely occurs. The case described in this report is that of a 34-year-old man with no significant personal medical history who died suddenly after presenting with nausea. Postmortem examination revealed a significant infiltration of lymphocytes predominantly on the adventitia and periadventitial tissues of the coronary arteries in the epicardium. The lymphocytic infiltrate partially extended to the thickened intima with fibrosis, destructing the media and internal elastic lamina, and the lumen was occluded by a thrombus in the left main stem and left anterior descending branch. The arterial walls exhibited focal fibrinoid necrosis with regression in the intima and fibrous scars with angiogenesis in the media and adventitia. Focal myocardial infarction was detected in the left ventricle as a fibrotic change of the myocardium. No findings associated with vasculitis were discerned in the aorta, other peripheral arteries, or major organs. Laboratory tests of postmortem blood samples returned negative results for antinuclear antibodies, cryoglobulin, immunoglobulin G4, and cytoplasmic anti-neutrophil cytoplasmic antibodies for myeloperoxidase and proteinase 3. These autopsy findings suggest that the sudden death was caused by isolated necrotizing vasculitis that is assumed to be polyarteritis nodosa localized at the coronary arteries. However, pathological characteristics may not be exactly the same between isolated necrotizing vasculitis in the coronary arteries and polyarteritis nodosa.
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11
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Zhou Y, Shao L, Ruan W, Jin J, Xu H, Ying K, Wu X. Pulmonary vascular involvement of IgG4-related disease: Case series with a PRISMA-compliant systemic review. Medicine (Baltimore) 2019; 98:e14437. [PMID: 30732204 PMCID: PMC6380675 DOI: 10.1097/md.0000000000014437] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 12/29/2018] [Accepted: 01/16/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized, immune-mediated chronic fibrotic inflammation that can involve almost all organs, causing tumefaction and dysfunction. Its presence in pulmonary circulation is underestimated and has not yet been investigated. OBJECTIVES We describe a representative IgG4-RD patient with pulmonary artery stenosis and pulmonary embolism, leading to reversible pulmonary hypertension. Literature review of IgG4-RD with pulmonary circulation involvement was conducted. DATA SOURCES References for this review were identified through searches via PubMed, EBSCO, and Web of Science for published articles before November 2016. RESULTS There were 15 published cases of IgG4-RD with pulmonary vascular involvement, 3 with pulmonary arteritis, 2 with pulmonary artery aneurysm, 3 with pulmonary artery stenosis, 1 with obliterative phlebitis, and 1 with pulmonary embolism. Possible immunity and inflammation mechanisms were summarized. CONCLUSIONS IgG4-RD with pulmonary vascular involvement is rare. Echocardiogram and contrast-enhanced chest CT are helpful to screen the disease. Clinical manifestations were found from asymptomatic to dyspnea or even syncope. And nearly all cases had more than 1 organ affected, with significantly increased serum IgG4 levels. PET/CT aided in identifying affected organs and determining candidate biopsy sites. More awareness is urged to evaluate the pulmonary vascular manifestations of this disease.
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Affiliation(s)
- Yong Zhou
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Thoracic Oncology Program, Department of Surgery, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, CA
| | - Lingyan Shao
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wenjing Ruan
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Joy Jin
- Thoracic Oncology Program, Department of Surgery, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, CA
| | - Hangdi Xu
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Kejing Ying
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaohong Wu
- Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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12
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Betancur-Vásquez L, Gonzalez-Hurtado D, Arango-Isaza D, Rojas-Villarraga A, Hernandez-Parra D, Carmona S, Díaz-Coronado JC. IgG4-related disease: Is rituximab the best therapeutic strategy for cases refractory to conventional therapy? Results of a systematic review. ACTA ACUST UNITED AC 2019; 16:195-202. [PMID: 30665856 DOI: 10.1016/j.reuma.2018.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/16/2018] [Accepted: 11/29/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION IgG4 related disease is a fibroinflammatory condition characterised by lymphoplasmocytic infiltration with predominance of IgG4+ plasma cells, fibrosis, and in most cases elevated IgG4 serum levels. It can affect any organ and result in varying clinical manifestations. Steroids are the cornerstone of treatment, however there is a high percentage of relapse. Recent studies have demonstrated favourable effects with rituximab. OBJECTIVE To evaluate effectiveness related to the response to treatment with rituximab in patients with IgG4 related disease refractory to steroids and other immunosuppressant therapies. MATERIALS AND METHODS We undertook a systematic search of the specialist databases EMBASE, LILACS, PUBMED and OVID-Cochrane for publications up until December 2017. RESULTS After the quality analysis, we selected 27 articles (264 patients in total) for the final review, of which 23 were case reports and case series (105 patients), 3 were observational follow-up cohort studies (129 patients), and there was one clinical trial (30 patients). IgG4 related disease presents predominantly in male patients aged between 50 and 70 years on average. Multiple organs are compromised with an average of 3.5 compromised organs. Orbital, glandular and lymph-node compromise is most frequent. Patients in the different studies we included had received various treatments prior to starting rituximab, including glucocorticoids and disease-modifying anti-rheumatic drugs. There was 90.7% response in the cases where rituximab was used as second line therapy; rituximab was used as first line treatment for 10% of the patients with a 100% response rate. CONCLUSION The use of rituximab for patients refractory to first-line treatments was associated with a high response percentage and less dependence on glucocorticoids.
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Affiliation(s)
| | | | | | | | | | - Samuel Carmona
- Grupo de información clínica, Artmedica IPS, Medellín, Colombia
| | - J C Díaz-Coronado
- Departamento de medicina interna, Universidad CES, Medellín, Colombia; Departamento de investigación en medicina, Universidad CES, Medellín, Colombia; Grupo de información clínica, Artmedica IPS, Medellín, Colombia
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Oyama-Manabe N, Yabusaki S, Manabe O, Kato F, Kanno-Okada H, Kudo K. IgG4-related Cardiovascular Disease from the Aorta to the Coronary Arteries: Multidetector CT and PET/CT. Radiographics 2018; 38:1934-1948. [DOI: 10.1148/rg.2018180049] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Noriko Oyama-Manabe
- From the Department of Diagnostic and Interventional Radiology (N.O.M., S.Y., F.K., K.K.) and Department of Surgical Pathology (H.K.O.), Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Japan 060-8638; and Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan (O.M.)
| | - Satoshi Yabusaki
- From the Department of Diagnostic and Interventional Radiology (N.O.M., S.Y., F.K., K.K.) and Department of Surgical Pathology (H.K.O.), Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Japan 060-8638; and Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan (O.M.)
| | - Osamu Manabe
- From the Department of Diagnostic and Interventional Radiology (N.O.M., S.Y., F.K., K.K.) and Department of Surgical Pathology (H.K.O.), Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Japan 060-8638; and Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan (O.M.)
| | - Fumi Kato
- From the Department of Diagnostic and Interventional Radiology (N.O.M., S.Y., F.K., K.K.) and Department of Surgical Pathology (H.K.O.), Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Japan 060-8638; and Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan (O.M.)
| | - Hiromi Kanno-Okada
- From the Department of Diagnostic and Interventional Radiology (N.O.M., S.Y., F.K., K.K.) and Department of Surgical Pathology (H.K.O.), Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Japan 060-8638; and Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan (O.M.)
| | - Kohsuke Kudo
- From the Department of Diagnostic and Interventional Radiology (N.O.M., S.Y., F.K., K.K.) and Department of Surgical Pathology (H.K.O.), Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Japan 060-8638; and Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan (O.M.)
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14
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Affiliation(s)
- Yoshio Misawa
- Division of Cardiovascular Surgery, Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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15
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Huang HL, Fong W, Peh WM, Niraj KA, Lam WW. The Utility of FDG PET/CT in IgG4-Related Disease with a Focus on Coronary Artery Involvement. Nucl Med Mol Imaging 2017; 52:53-61. [PMID: 29391913 DOI: 10.1007/s13139-017-0494-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/24/2017] [Accepted: 09/03/2017] [Indexed: 11/27/2022] Open
Abstract
Purpose Our case series aims to study the growing use of FDG PET/CT in diagnostic evaluation and follow up of IgG4-RD with emphasis on patients presenting with coronary artery involvement. Methods We conducted a search on the nuclear medicine and rheumatology service databases and identified patients with histologically proven IgG4-RD with FDG PET/CT performed at the Singapore General Hospital. The radiological, clinical, and laboratory findings of these patients were analyzed retrospectively. Results The series included ten male and two female patients. The commonest organ involved (five patients) was the pancreas. In three patients, coronary artery involvement manifested as soft tissue masses surrounding the arterial lumens. In these patients, histological diagnosis was established from alternative biopsy sites with abnormal metabolic activity on FDG PET/CT.Correlation between laboratory and metabolic imaging findings was not statistically significant in our series.Four patients had follow-up FDG PET/CT; three showed interval reduction in metabolic activity to baseline. One showed persistent abnormal metabolic activity before a rise in IgG4 levels. The metabolic imaging response was used to guide steroid dose. Conclusions FDG PET/CT is a useful tool in evaluation and follow-up of IgG4-RD, particularly in identifying alternative biopsy sites in patients who present with coronary artery involvement. Hypermetabolic coronary artery masses on FDG PET/CT should raise clinical suspicion of IgG4-RD. As the coronary artery masses may not show decrease in size after treatment, FDG PET/CT is also useful for metabolic response assessment.
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Affiliation(s)
- Hian L Huang
- 1Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, 1 Outram Road, Bukit Merah, 169608 Singapore
- 2Duke-NUS Medical School, Singapore, Singapore
| | - Warren Fong
- 2Duke-NUS Medical School, Singapore, Singapore
- 3Department of Rheumatology and Immunology, Singapore General Hospital, Bukit Merah, Singapore
- 4Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee M Peh
- 1Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, 1 Outram Road, Bukit Merah, 169608 Singapore
| | - Kasat A Niraj
- 1Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, 1 Outram Road, Bukit Merah, 169608 Singapore
| | - Winnie W Lam
- 1Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, 1 Outram Road, Bukit Merah, 169608 Singapore
- 2Duke-NUS Medical School, Singapore, Singapore
- 4Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Characteristics of immunoglobulin G4-related aortitis/periaortitis and periarteritis on fluorodeoxyglucose positron emission tomography/computed tomography co-registered with contrast-enhanced computed tomography. EJNMMI Res 2017; 7:20. [PMID: 28244022 PMCID: PMC5328898 DOI: 10.1186/s13550-017-0268-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/18/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We aimed to assess the positivity, distribution, quantitative degree of vessel inflammation, and clinical characteristics of IgG4-related aortitis/periarteritis and periarteritis (IgG4-aortitis), and to examine the difference in these characteristics between cases with and without IgG4-aortitis, using fluorodeoxyglucose positron-emission tomography/computed tomography (FDG-PET/CT) co-registered with contrast-enhanced CT (CECT). We retrospectively evaluated 37 patients with IgG4-related disease (IgG4-RD) who underwent both FDG-PET/CT and CECT. The arterial SUVmax and its value normalized to the background venous blood pool (BP)-the target-to-background ratio (TBR) in the entire aorta and the major first branches-were measured. Active vascular inflammation was considered in cases with a higher FDG uptake than BP and a thickened arterial wall (>2 mm). RESULTS Fifteen (41%) patients exhibited IgG4-aortitis. Most patients (80%) showed multiple region involvement. The entire aorta, including the major first branches, were involved, typically showing a thickened wall and high FDG uptakes. The most common site was the iliac arteries (35%), followed by the infrarenal abdominal aorta (33%), thoracic aorta (8%), first branches of the thoracic aorta (8%), suprarenal abdominal aorta (6%), and the first branches of the abdominal aorta (5%). The IgG4-aortitis-positive vessel regions were thickened, with an average maximal wall thickness of 6.3 ± 2.9 mm. The SUVmax and TBR values were significantly higher in the IgG4-aortitis-positive regions (median 3.7 [1.6-5.5] and 2.1 [1.4-3.7], respectively) than in the IgG4-aortitis-negative regions (median 2.1 [1.2-3.7] and 1.3 [0.9-2.3], respectively; p < 0.0001). The IgG4-aortitis-positive group patients were older (69.5 ± 6.0 vs. 63.3 ± 12.6 years, respectively) and had a higher male predominance (80 vs. 55%, respectively) than the negative group, although the differences were not significant (p = 0.17 and p = 0.06, respectively). CONCLUSIONS We investigated the image characteristics of IgG4-aortitis. The entire aorta and major branches can be involved with more than 2-fold higher FDG uptake than the venous background pool, and with wall thickening. The most common involved site is the iliac arteries, followed by the infrarenal abdominal aorta.
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