Spontaneous regression of IgG4-related dacryoadenitis

Natural developing process of immunoglobulin G4-related sialadenitis after submandibular gland excision: a retrospective cohort study

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.

Spontaneous Regression of Swollen Submandibular Glands in IgG4-Related Disease

Background

IgG4-related disease is a new clinical entity frequently associated with swelling of the submandibular glands (SMGs). The long-term outcome of SMG swelling without steroid therapy remains unknown.

Objective

To examine whether swollen SMGs spontaneously regress without steroid therapy in the context of IgG4-related disease and to identify biomarkers that can predict the spontaneous regression of SMG swelling.

Methods

The SMG volume of 49 patients diagnosed with IgG4-related disease was calculated by measuring the axial and coronal planes of computed tomography scans. The change in SMG volume over time was measured and examined by treatment regimen, clinical data, and serum complement level.

Results

We found 28 of 49 (57%) IgG4-related disease patients to have swollen SMGs, with 15 of 20 (75%) of the swollen SMGs regressing without steroid therapy. The time required for the SMGs swelling to regress was significantly shorter in the steroid therapy group than in the no-steroid therapy group. Serum complement components at the initial visit were significantly lower in the regressed SMG group than in the nonregressed SMG group.

Conclusion

We observed 75% of swollen SMGs spontaneously regressed in patients with IgG4-related disease. The time required for the swollen SMGs to regress was longer in patients without steroid therapy than in those with steroid therapy. Serum complement level could be used as a predictor for the spontaneous regression of swollen SMGs in patients with IgG4-related disease.

A clinicopathological study on IgG4-related ophthalmic disease

AIM

To investigate clinicopathological features of immunoglobulin G4-related ophthalmic disease (IgG4-ROD), and analyze the recurrence rates following systemic corticosteroid administration.

METHODS

We retrospectively searched clinical features, laboratory and histological findings based on the medical records of 21 patients with IgG4-ROD. All the patients examined in this study underwent surgical resection in the ocular adnexal lesions and underwent histological evaluation. This study further investigated clinical and histopathological features of 15 patients who received systemic corticosteroid after the resection.

RESULTS

The mean age of the patients consisting of 7 males (33%) and 14 females (67%) was 61y. Fourteen patients were diagnosed as definitive, and 2 and 5 patients were probable and possible IgG4-ROD, respectively. Eyelid swelling was an initial symptom in 11 patients (52%) who did not show systemic involvements at a diagnosis. Fifteen patients received systemic corticosteroid administration, and all showed remission of inflammation. Among them, 10 patients did not recur, whereas 5 patients (33%) recurred during tapering. There were no significant difference between patients with or without recurrence in clinicopathological features.

CONCLUSION

In this study, female patients are more predominant in IgG4-ROD. While inflammation recurs in one-third of patients, this study do not identify factors associated with recurrence after systemic corticosteroid administration.

IgG4-related disease presenting as panuveitis without scleral involvement

BACKGROUND

The following case emphasizes the importance of including IgG4-related disease (RD) in the differential diagnosis of intraocular inflammation and multiple cranial nerve palsies.

RESULTS

A 33-year-old man, with a history of idiopathic bilateral panuveitis, presented with a new right pupillary-sparing partial third nerve palsy, which spontaneously resolved in 2 weeks, but was followed 1 month later, by a right sixth nerve palsy, which also resolved within a few weeks. Motility disturbance was accompanied by a decrease in the central acuity in the right eye. Magnetic resonance imaging/angiography (MRI/MRA) demonstrated a densely enhancing osteodestructive skull base process extending through the cavernous sinus and into the right superior orbital fissure. Biopsy of the lesion was consistent with IgG4-related disease (RD).

CONCLUSIONS

This is the first reported case of IgG4-RD associated panuveitis without scleral involvement, expanding the list of clinical manifestations of the IgG4-RD.

Methotrexate-associated orbital lymphoproliferative disorder in a patient with rheumatoid arthritis: a case report

PURPOSE

Lymphoproliferative disorders (LPDs) can develop in patients treated with methotrexate (MTX) and usually respond well to MTX withdrawal. Mucosa-associated lymphoid tissue (MALT) lymphoma is a relatively rare type of MTX-LPD. The development of MTX-LPD in the orbit has not been previously described. We here report a case of orbital MALT lymphoma that disappeared after MTX withdrawal in a patient treated with MTX for rheumatoid arthritis.

CASE

A 78-year-old woman who complained of swelling of the left upper eyelid had been treated with MTX for >8 years for rheumatoid arthritis. Slit-lamp examination revealed a temporal subconjunctival mass, salmon pink in color, in the left eye. Fundus photographs also suggested the presence of a temporal tumor in the left orbit. [(18)F]Fluorodeoxyglucose positron emission tomography-computed tomography revealed highly integrated lesions in the left inferotemporal orbit and a left external iliac lymph node, a left obturator lymph node, and an inguinal lymph node. Pathologic analysis of a tumor biopsy specimen showed small- and medium-sized lymphocytes positive for CD20, MIB-1, and bcl-2 and negative for CD10, CD3, bcl-1, IgG4, and EBV-ISH. On the basis of these findings, we diagnosed the tumor as MTX-induced MALT lymphoma. The subconjunctival and orbital masses disappeared gradually over 10 months after MTX withdrawal and did not recur within 2 years.

CONCLUSION

This case of orbital MTX-LPD suggests that the possibility of MTX-LPD should be considered even for ocular tumors in patients treated with MTX.