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Diagnostic and Therapeutic Challenges of Vasculitis. Can J Cardiol 2022; 38:623-633. [DOI: 10.1016/j.cjca.2022.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/17/2022] Open
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2
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Mahmoud R, Ianculovici C, Kleinman S, Peleg O. IgG4-related sialadenitis - a rare bilateral submandibular gland enlargement: case report. Oral Maxillofac Surg 2022; 26:673-677. [PMID: 35028774 DOI: 10.1007/s10006-021-01020-3] [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: 08/30/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition of unknown etiology. Although the salivary glands are currently considered among the most commonly affected among them, oral and maxillofacial surgeons are generally not familiar with the condition. Enlargement of the major salivary glands may be the first identifiable sign of IgG4-RD. A salivary gland biopsy along with IgG4 serum level assessment may help differentiate IgG4-related sialadenitis (IgG4-RS) from malignancies, infectious diseases, and obstructive conditions. Greater knowledge and higher levels of awareness of IgG4-RS may contribute to the expansion of differential diagnostic and treatment approaches. This case report describes a patient with bilateral submandibular salivary gland swelling who was diagnosed as having IgG4-RS on the basis of the histopathologic findings of a submandibular salivary gland biopsy and subsequent IgG4 levels.
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Affiliation(s)
- Reema Mahmoud
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel.
| | - Clariel Ianculovici
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Shlomi Kleinman
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Oren Peleg
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
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Mathew J, Padiyar S, Manwatkar A, Ganapati A, Roy S. Overlap of IgG4-Related disease with autoimmune rheumatic diseases: Report of 2 cases and review of literature. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_265_21] [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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Bakulina NV, Simanenkov VI, Vorobyev SL, Tikhonov SV, Lishchuk NB, Bakulin IG. The eosinophilic esophagitis and IgG4-related disease involving the esophagus. TERAPEVT ARKH 2020; 92:100-107. [DOI: 10.26442/00403660.2020.08.000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Indexed: 11/22/2022]
Abstract
The study of eosinophilic esophagitis has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Immunoglobulin G4 (IgG4)-related disease exhibits systemic involvement but very rarely involves the esophagus. The article presents a clinical case: the history of ulcer and stricture of the esophagus in a young man of 17 years. The patient was finally diagnosed with IgG4-related and eosinophilic esophagitis and showed a good response to corticosteroid therapy. We herein report a rare case of dysphagia associated with IgG4-related disease and eosinophilic. We presented a review of modern data on the relationship of eosinophilic esophagitis and pathological IgG4-response.
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Fernandez-Flores A. La biopsia cutánea en el contexto de la enfermedad sistémica. ACTAS DERMO-SIFILIOGRAFICAS 2019; 110:710-727. [DOI: 10.1016/j.ad.2019.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 02/07/2023] Open
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Fathala A. Multimodalities Imaging of Immunoglobulin 4-related Cardiovascular Disorders. Curr Cardiol Rev 2019; 15:224-229. [PMID: 30652646 PMCID: PMC6719394 DOI: 10.2174/1573403x15666190117101607] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 01/27/2023] Open
Abstract
Immunoglobulin 4 (IgG4)-related systemic disease (IgG4-RSD) is a systemic inflammatory disease characterized by elevation of serum IgG4. IgG4-RSD can affect any organ in the body, and the list of organs associated with this condition is growing steadily. IgG4-related cardiovascular disease affects the coronary arteries, heart valves, myocardium, pericardium, aorta, pulmonary and peripheral vessels. Echocardiography is the most commonly used non-invasive imaging method. Computed tomography angiography (CTA) can assess aortitis, periarteritis and coronary aneurysms. Coronary CTA is fast, offers high spatial resolution and a wide coverage field of view. Cardiac magnetic resonance imaging (CMR) offers a comprehensive evaluation of the cardiovascular system including cardiac function, extent of myocardial fibrosis, characterise cardiac masses with different pulse sequences and guide to further treatment. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) can provide important information about the extent of disease, the presence of active inflammation and the optimum biopsy site. In general, the role of diagnostic imaging includes establishing the diagnosis, detecting complications, guiding biopsy and documenting response to therapy.
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Affiliation(s)
- Ahmed Fathala
- Department of Radiology, King Fasial Hospital, Riyadh, Saudi Arabia
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Fernandez García D, León Fábregas M, Mancheño Franch N, Benavent Corai V. Enfermedad relacionada con IgG4 con afectación pulmonar. Arch Bronconeumol 2019; 55:165-166. [DOI: 10.1016/j.arbres.2018.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/13/2018] [Accepted: 05/14/2018] [Indexed: 11/28/2022]
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Wick MR, O’Malley DP. Lymphadenopathy associated with IgG4-related disease: Diagnosis & differential diagnosis. Semin Diagn Pathol 2018; 35:61-66. [DOI: 10.1053/j.semdp.2017.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Obiorah I, Hussain A, Palese C, Azumi N, Benjamin S, Ozdemirli M. IgG4-related disease involving the esophagus: a clinicopathological study. Dis Esophagus 2017; 30:1-7. [PMID: 28881885 DOI: 10.1093/dote/dox091] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/13/2017] [Indexed: 12/11/2022]
Abstract
Immunoglobulin G4 (IgG4)-related disease is a recently coined systemic disease characterized by specific histopathologic findings of an intense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis in the presence of predominant IgG4-positive plasma cells. Although IgG4-related disease has been described in many organs, involvement of the esophagus is very rare. In this study, we describe the clinicopathologic characteristics of eight patients with IgG4-related esophagitis. We evaluated chronic esophagitis specimens with lymphoplasmacytic infiltrate obtained over the past 6 years (from January 2011 to February 2017) using a chart review, pathologic examination, and IgG4 immunohistochemical staining. The diagnoses of the specimens were either confirmed as IgG4-related esophagitis (IgG4-RE) or chronic esophagitis, not otherwise specified (CENOS), and the clinicopathologic data from each group were compared. Eight patients were diagnosed with IgG4-RE and 10 controls were identified and diagnosed with CENOS. In the IgG4-RE group, esophageal strictures were identified in three patients, two patients had postmyotomy treated achalasia, one patient had erosive esophagitis and another presented with an esophageal nodule. Only one patient had an unremarkable mucosa on endoscopy. In the CENOS group, four patients had esophageal strictures, six had erosive esophagitis, one patient had mild esophagitis. The IgG4-RE group had significantly higher numbers of IgG4-positive plasma cells (66.9 ± 21.9 vs. 4.7 ± 2.4 per high power field; P< 0.001) and a greater IgG4: IgG ratio 0.76 ± 0.13 vs. 0.06 ± 0.05; P< 0.001) when compared to CENOS patients. Two of the patients with recurrent esophageal strictures in the IgG4-RE group showed initial response to steroid therapy and are currently on immunosuppressive therapy which has significantly reduced the need for multiple esophageal dilatations. The presentation of IgG4-related esophageal disease can vary and the key to diagnosis is dependent on histopathology. These observations highlight the need for IgG4 immunohistochemical staining of esophageal biopsies especially in patients with mucosal ulceration, chronic inflammation, and plasmacytosis on biopsy. This will prevent unwarranted esophagectomies and failed medical treatment due to lack of recognition of this entity.
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Affiliation(s)
| | - A Hussain
- Division of Gastroenterology, Department of Internal Medicine, Medstar Georgetown University Hospital, Washington DC, USA
| | - C Palese
- Division of Gastroenterology, Department of Internal Medicine, Medstar Georgetown University Hospital, Washington DC, USA
| | | | - S Benjamin
- Division of Gastroenterology, Department of Internal Medicine, Medstar Georgetown University Hospital, Washington DC, USA
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Abstract
Immunoglobulin G4-related lymphadenopathy (IgG4-RLAD) occurs in the setting of extranodal IgG4-related disease (IgG4-RD), an immune-mediated process described in many organ systems characterized by lymphoplasmacytic infiltrates with abundant IgG4-positive plasma cells and fibrosis. Although the morphologic features in the lymph node sometimes resemble those seen at the extranodal sites, 5 microscopic patterns have been described, most of which resemble reactive lymphoid hyperplasia. This morphologic variability leads to unique diagnostic challenges and a broad differential diagnosis. As IgG4-RD may be exquisitely responsive to steroids or other immunotherapy, histologic recognition and inclusion of IgG4-RLAD in the differential diagnosis is vital.
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Affiliation(s)
- Christine E Bookhout
- Department of Pathology and Laboratory Medicine, University of North Carolina, Campus Box 7525, Brinkhous-Bullitt Building, Chapel Hill, NC 27599-7525, USA
| | - Marian A Rollins-Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Campus Box 7525, Brinkhous-Bullitt Building, Chapel Hill, NC 27599-7525, USA.
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Li X, Duan W, Zhu X, Xu J. Immunoglobulin G4-related acquired hemophilia: A case report. Exp Ther Med 2016; 12:3988-3992. [PMID: 28105131 PMCID: PMC5228537 DOI: 10.3892/etm.2016.3898] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/22/2016] [Indexed: 12/24/2022] Open
Abstract
Acquired hemophilia A (AHA) is a relatively rare and life-threatening bleeding disorder whose pathogenesis is not completely understood. The present study reports a rare case of immunogubulin (IgG)4-related AHA with multisystemic involvement. A 55-year old male patient presented with symptoms of bronchial asthma and multiple subdermal hematomas. Chest computed tomography showed multiple diffuse nodular lesions with thickening of bronchovascular bundles, and scattered high-density spots in both lung lobes. Laboratory investigations showed increased activated partial prothrombin time (120.0 sec), a markedly decreased factor VIII (FVIII) activity (0.5%), a high-titer of FVIII inhibitor (27.2 Bethesda units/ml) and a marked increase in serum IgG4 (>4.03 g/l) level. Left inguinal lymph node biopsy revealed capsular thickening with marked lymphoplasmacytic infiltration, occlusive phlebitis and irregular fibrosis. Immunostaining revealed numerous IgG4-positive plasma cells (>100 cells/human plasma fibronectin) in the nodular lesions, with an IgG4/IgG ratio of >40%. The symptoms were markedly alleviated following corticosteroid therapy. The current study presents the first reported case of a rare IgG4-related AHA that presented with unusual clinical features and multisystemic involvement. The patient responded well to corticosteroid therapy. Documentation of such rare cases will help in characterizing the pathogenesis, and prompt recognition and timely treatment of this rare disorder.
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Affiliation(s)
- Xiaoyan Li
- Department of Respiratory Medicine, Shanxi DAYI Hospital of Shanxi Medical University, Taiyuan, Shanxi 030032, P.R. China
| | - Wei Duan
- Department of Respiratory Medicine, Shanxi DAYI Hospital of Shanxi Medical University, Taiyuan, Shanxi 030032, P.R. China
| | - Xiang Zhu
- Department of Pathology, Peking University Third Hospital, Beijing 100191, P.R. China
| | - Jianying Xu
- Department of Respiratory Medicine, Shanxi DAYI Hospital of Shanxi Medical University, Taiyuan, Shanxi 030032, P.R. China
- Correspondence to: Dr Jianying Xu, Department of Respiratory Medicine, Shanxi DAYI Hospital of Shanxi Medical University, 99 Longcheng Avenue, Taiyuan, Shanxi 030032, P.R. China, E-mail:
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Charrow A, Imadojemu S, Stephen S, Ogunleye T, Takeshita J, Lipoff JB. Cutaneous manifestations of IgG4-related disease (RD): A systematic review. J Am Acad Dermatol 2016; 75:197-202. [DOI: 10.1016/j.jaad.2016.01.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/18/2016] [Accepted: 01/20/2016] [Indexed: 02/07/2023]
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Oka S, Uramoto H, Yamada S, Tanaka F. Sclerosing mediastinitis of unknown origin: Report of a case. Int J Surg Case Rep 2015; 10:5-7. [PMID: 25770698 PMCID: PMC4429944 DOI: 10.1016/j.ijscr.2015.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/04/2015] [Accepted: 03/05/2015] [Indexed: 11/08/2022] Open
Abstract
Sclerosing mediastinitis, also known as fibrosing mediastinitis, is a rare disease. We experienced a case of sclerosing mediastinitis without IgG4-related disease. This case did not fit the criteria for IgG4-related disease, and it was therefore unclear whether steroid therapy should be used for this case. We will continue to carefully follow up this patient’s residual lesion, and there have been no changes in the lesion at present.
Introduction We herein describe a rare case of a sclerosing mediastinitis without IgG4-related disease. This case was clearly excluded from IgG4-related disease, because this patient’s serum IgG4 level was not elevated. Specifically, this patient’s serum IgG4 level was 7.9 mg/dl (4.8–105). Presentation of case A 61-year-old Japanese female presented at our hospital due to an abnormal chest X-ray that showed a growing shadow in the mediastinum. Chest computed tomography (CT) showed an 80 × 75 × 75 mm tumor, which located in the anterior mediastinum. This large tumor surrounded the thoracic aorta, left brachiocephalic vein and superior vena cava. It was difficult to obtain a definitive diagnosis. We tried to perform three biopsies, and eventually performed a partial resection of the tumor. Discussion This case did not fit the criteria for IgG4-related disease, and it was therefore unclear whether steroid therapy should be used for this case. We will continue to carefully follow up this patient’s residual lesion, and there have been no changes in the lesion at present. Conclusion Sclerosing mediastinitis and IgG4-related disease should be included in the differential diagnosis of patients presenting with a mediastinal tumor. However, sclerosing mediastinitis is difficult to diagnose, and it is important to obtain a sufficient amount of tissue to ensure an accurate diagnosis.
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Affiliation(s)
- Soichi Oka
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Hidetaka Uramoto
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Sohsuke Yamada
- Department of Pathology and Cell Biology, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Fumihiro Tanaka
- Second Department of Surgery, University of Occupational and Environmental Health, Kitakyushu, Japan
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Pieringer H, Parzer I, Wöhrer A, Reis P, Oppl B, Zwerina J. IgG4- related disease: an orphan disease with many faces. Orphanet J Rare Dis 2014; 9:110. [PMID: 25026959 PMCID: PMC4223520 DOI: 10.1186/s13023-014-0110-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/03/2014] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin G4- related disease (IgG4-RD) is a rare systemic fibro-inflammatory disorder (ORPHA284264). Although patients have been described more than 100 years ago, the systemic nature of this disease has been recognized in the 21st century only. Type 1 autoimmune pancreatitis is the most frequent manifestation of IgG4-RD. However, IgG4-RD can affect any organ such as salivary glands, orbits, retroperitoneum and many others. Recent research enabled a clear clinical and histopathological description of IgG4-RD. Typically, lymphoplasmacellular inflammation, storiform fibrosis and obliterative phlebitis are found in IgG4-RD biopsies and the tissue invading plasma cells largely produce IgG4. Elevated serum IgG4 levels are found in many but not all patients. Consequently, diagnostic criteria for IgG4-RD have been proposed recently. Treatment is largely based on clinical experience and retrospective case series. Glucocorticoids are the mainstay of therapy, although adjunctive immunosuppressive agents are used in relapsing patients. This review summarizes current knowledge on clinical manifestations, pathophysiology and treatment of IgG4-RD.
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Uehara T, Hamano H, Suga T, Kawa S, Yoshizawa A, Kobayashi Y, Murata K, Oki K, Sano K, Onodera R, Ota H. Inflammation of colon adenoma in the setting of type 1 autoimmune pancreatitis. Pathol Int 2014; 64:67-74. [DOI: 10.1111/pin.12139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 01/19/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Takeshi Uehara
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Hideaki Hamano
- Division of Medical Informatics; Shinshu University Hospital; Matsumoto Japan
| | - Tomoaki Suga
- Gastroenterology, Department of Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Shigeyuki Kawa
- Center for Health, Safety and Environmental Management; Shinshu University; Matsumoto Japan
| | - Akihiko Yoshizawa
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Yukihiro Kobayashi
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Kazuya Murata
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Keiko Oki
- Department of Laboratory Medicine; Shinshu University Hospital; Matsumoto Japan
| | - Kenji Sano
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Rie Onodera
- Department of Biomedical Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
| | - Hiroyoshi Ota
- Department of Laboratory Medicine; Shinshu University School of Medicine; Matsumoto Japan
- Department of Laboratory Medicine; Iwate Medical University School of Medicine; Morioka Japan
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Sekiguchi H, Horie R, Aksamit TR, Yi ES, Ryu JH. Immunoglobulin G4-related disease mimicking asthma. Can Respir J 2013; 20:87-9. [PMID: 23616963 PMCID: PMC3630040 DOI: 10.1155/2013/619453] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Immunoglobulin (Ig) G4-related disease (also known as 'IgG4-related sclerosing disease', 'IgG4-related systemic disease' or 'hyper-IgG4-disease') is a recently recognized systemic fibroinflammatory disease associated with IgG4-positive plasma cells in tissue lesions. IgG4-related disease was initially described as autoimmune pancreatitis, but it is now known to affect virtually any organ. The authors describe a patient presenting with multi-organ manifestations, including airway inflammation mimicking asthma, pulmonary parenchymal infiltrates, intrathoracic lymphadenopathy, submandibular gland swelling and a kidney mass.
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Affiliation(s)
- Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Wong PCW, Fung AT, Gerrie AS, Moloney G, Maberley D, Rossman D, White V, Collins D, Coupland R, Chen LYC. IgG4-related disease with hypergammaglobulinemic hyperviscosity and retinopathy. Eur J Haematol 2013; 90:250-6. [PMID: 23278107 DOI: 10.1111/ejh.12059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2012] [Indexed: 12/24/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently described entity with protean manifestations. We describe a novel case of IgG4-RD with hypergammaglobulinemic hyperviscosity responsive to fludarabine and rituximab. A 33-year-old Asian man developed bilateral lacrimal gland and submandibular salivary gland swelling with cervical lymphadenopathy. Biopsies of the affected tissues revealed reactive follicular hyperplasia. Seven years later, he presented with bilateral retinal hemorrhages due to hyperviscosity syndrome from profound polyclonal increase in IgG, including marked IgG4 elevation. Despite plasmapheresis, overproduction of IgG continued and he was refractory to systemic steroids, azathioprine, interferon alpha, and cyclophosphamide. IgG4-RD was suspected following a myocardial infarction and detection of aneurysmal coronary arteries indicating large vessel vasculitis. Review of the cervical lymph node and lacrimal gland biopsies with immunohistochemical staining for IgG4-positive plasma cells confirmed IgG4-RD. B-cell depletion with rituximab produced a partial response, but clinical symptoms and elevated protein levels persisted. Fludarabine was added to rituximab to suppress T-cell activity, and this resulted in an excellent clinical and biochemical response. Combination therapy with fludarabine and rituximab in IgG4-RD has not previously been reported and can be considered in patients with severe refractory disease.
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Affiliation(s)
- Patrick C W Wong
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
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Sekiguchi H, Horie R, Suri RM, Yi ES, Ryu JH. Constrictive pericarditis caused by immunoglobulin G4-related disease. Circ Heart Fail 2012; 5:e30-1. [PMID: 22438527 DOI: 10.1161/circheartfailure.111.966408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, the Division of Cardiovascular Surgery, and the Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
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Histopathologic Overlap between Fibrosing Mediastinitis and IgG4-Related Disease. Int J Rheumatol 2012; 2012:207056. [PMID: 22654916 PMCID: PMC3357960 DOI: 10.1155/2012/207056] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 02/16/2012] [Accepted: 02/20/2012] [Indexed: 12/21/2022] Open
Abstract
Fibrosing mediastinitis (FM) and IgG4-related disease (IgG4-RD) are two fibroinflammatory disorders with potentially overlapping clinical and radiological features. In this paper, we looked for histopathologic features of IgG4-RD and enumerated infiltrating IgG4-positive plasma cells within mediastinal tissue biopsies from FM patients. We identified 15 consecutive FM surgical mediastinal tissue biopsies between 1985 and 2006. All patients satisfied the clinical and radiological diagnostic criteria for FM. All patients had either serological or radiological evidence of prior histoplasmosis or granulomatous disease, respectively. Formalin-fixed paraffin-embedded tissue sections of all patients were stained for H&E, IgG, and IgG4. Three samples met the predefined diagnostic criteria for IgG4-RD. In addition, characteristic histopathologic changes of IgG4-RD in the absence of diagnostic numbers of tissue infiltrating IgG4-positive plasma cells were seen in a number of additional cases (storiform cell-rich fibrosis in 11 cases, lymphoplasmacytic infiltrate in 7 cases, and obliterative phlebitis/arteritis in 2 cases). We conclude that up to one-third of histoplasmosis or granulomatous-disease-associated FM cases demonstrate histopathological features of IgG4-RD spectrum. Whether these changes occur as the host immune response against Histoplasma or represent a manifestation of IgG4-RD remains to be determined. Studies to prospectively identify these cases and evaluate their therapeutic responses to glucocorticoids and/or other immunosuppressive agents such as rituximab are warranted.
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