A case of autoimmune pancreatitis with metachronous appearance of idiopathic thrombocytopenic purpura

Autoimmune Polyglandular Syndrome Type 3 Complicated with IgG4-related Disease

A 52-year-old Japanese woman developed type 1 diabetes mellitus (type 1 DM) at 41 years old. She became complicated with Hashimoto's disease and showed swelling of both submandibular glands, which was diagnosed as IgG4-related disease (IgG4-RD). This is a rare case of a Japanese patient with autoimmune polyglandular syndrome type 3A (APS-3A) coexisting with autoimmune thyroid disease (AITD) and type 1 DM complicated by IgG4-RD. Bilateral submandibular gland resection was successfully performed without steroid therapy. We discuss the possibility that the immunological pathogenic mechanisms of APS-3A and IgG4-RD are related.

Steroid Therapy and Steroid Response in Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP), a unique subtype of pancreatitis, is often accompanied by systemic inflammatory disorders. AIP is classified into two distinct subtypes on the basis of the histological subtype: immunoglobulin G4 (IgG4)-related lymphoplasmacytic sclerosing pancreatitis (type 1) and idiopathic duct-centric pancreatitis (type 2). Type 1 AIP is often accompanied by systemic lesions, biliary strictures, hepatic inflammatory pseudotumors, interstitial pneumonia and nephritis, dacryoadenitis, and sialadenitis. Type 2 AIP is associated with inflammatory bowel diseases in approximately 30% of cases. Standard therapy for AIP is oral corticosteroid administration. Steroid treatment is generally indicated for symptomatic cases and is exceptionally applied for cases with diagnostic difficulty (diagnostic steroid trial) after a negative workup for malignancy. More than 90% of patients respond to steroid treatment within 1 month, and most within 2 weeks. The steroid response can be confirmed on clinical images (computed tomography, ultrasonography, endoscopic ultrasonography, magnetic resonance imaging, and 18F-fluorodeoxyglucose-positron emission tomography). Hence, the steroid response is included as an optional diagnostic item of AIP. Steroid treatment results in normalization of serological markers, including IgG4. Short- and long-term corticosteroid treatment may induce adverse events, including chronic glycometabolism, obesity, an immunocompromised status against infection, cataracts, glaucoma, osteoporosis, and myopathy. AIP is common in old age and is often associated with diabetes mellitus (33-78%). Thus, there is an argument for corticosteroid therapy in diabetes patients with no symptoms. With low-dose steroid treatment or treatment withdrawal, there is a high incidence of AIP recurrence (24-52%). Therefore, there is a need for long-term steroid maintenance therapy and/or steroid-sparing agents (immunomodulators and rituximab). Corticosteroids play a critical role in the diagnosis and treatment of AIP.

Immune thrombocytopenic purpura increased risk of subsequent pancreatitis: A Nationwide population cohort study

Immune thrombocytopenic purpura (ITP) is characterized by thrombocytopenia and bleeding diathesis. Pancreatitis is a very rare complication but may be fatal. We analyzed data of newly diagnosed ITP patients, excluding those with a history of splenectomy, unknown sex or date of birth, or preexisting pancreatitis at the time of ITP diagnosis, and compared these with selected age-, gender-, and index-year-matched controls, using the Taiwan National Health Insurance Research Database from 1996 to 2013. The study enrolled 100,177 ITP patients and 100,177 controls. We found that pancreatitis risk was higher in secondary ITP patients, regardless of age group, gender, baseline Charlson comorbidity index (CCI) score, history of biliary stone, hyperlipidemia, or alcoholism, than in the control population. Primary ITP patients with CCI score 1 and without biliary tract stone history also showed a higher pancreatitis risk than the controls. The incidence rate and cumulative incidence of pancreatitis were increased in primary, secondary, and unspecified ITP cases. These phenomena may be related to the presence of autoantibodies against glycoprotein IIb/IIIa, or to IgG4, microparticle obstruction, or sclerosis. We noted a direct association between ITP and the development of pancreatitis in Taiwan population.

Concurrent Autoimmune Neutropenia and Idiopathic Thrombocytopenic Purpura Associated with IgG4-related Diease

IgG4-related disease (IgG4RD) is a multi-organ disorder characterized by an elevated serum IgG4 level and IgG4-positive plasma cell infiltration of the affected organs, accompanied by tissue fibrosis and sclerosis. Although it can affect any organ, to our knowledge, no cases involving concurrent autoimmune neutropenia and thrombocytopenia have been reported. A 62-year-old man visited our hospital and was diagnosed with IgG4RD accompanied by interstitial pneumonitis, lymphadenopathy, and interstitial nephritis. During his clinical course, he developed autoimmune neutropenia and idiopathic thrombocytopenic purpura. Our case, invoving multiple hematological abnormalities, might help deepen our understanding of the pathophysiology of IgG4RD.

IgG4-Related Pancreatitis and Immune Thrombocytopenia: A Case Report and Literature Review

A patient with a prior diagnosis of IgG4-related autoimmune pancreatitis (AIP) presented four years later with severe prednisone resistant immune thrombocytopenia (ITP). Her case is reported and the scant literature of the very unusual possible association of IgG4-related AIP and ITP is reviewed. It is suggested that investigation for IgG4-related disease be part of the work-up of ITP.

Transpapillary biliary stenting is a risk factor for pancreatic stones in patients with autoimmune pancreatitis

BACKGROUND AND STUDY AIM

Pancreatic stones occasionally develop in autoimmune pancreatitis (AIP), often worsen endocrine and exocrine functions, and occasionally cause pain attacks. However, the risks of pancreatic stones in AIP have been poorly studied. The aim of this study was to analyze the risk factors associated with pancreatic stone formation in cases of AIP.

PATIENTS AND METHODS

In total, 50 patients with AIP (39 males, 11 females; mean age 64.0 years), followed up for at least a year, were analyzed for their demographic and clinical findings and pancreatic stone occurrence.

RESULTS

In total, 50 patients were followed up for an average of 59.7 (12 - 120) months, with steroid treatment in 44 patients (88 %); pancreatic stones occurred in 14 (28 %) patients after the diagnosis of AIP and endoscopic treatment was needed in one patient with pain attack. The pancreatic stones appeared only in patients with long follow-up period (P < 0.001, 83.9 months vs. 49.6 months), biliary stenting (odds ratio [OR]: 8.40, P = 0.010), relapse (OR: 6.20, P = 0.023), jaundice (OR: 5.40, P = 0.019), and swelling of the duodenal major papilla (OR: 4.67, P = 0.040). Biliary stenting was placed for an average of 9.9 months in 27 patients. Multivariate analysis revealed a significant association only with biliary stenting (P = 0.011). The stones appeared relatively earlier in patients with stones in the main pancreatic duct or Santorini duct (22.1 months) than in patients where pancreatic stones developed elsewhere (53.4 months) (P = 0.018).

CONCLUSIONS

The risk of pancreatic stone development should be taken into account when a biliary stent is placed in patients with AIP.

Diagnosis of autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is a distinct form of chronic pancreatitis that is increasingly being reported. The presentation and clinical image findings of AIP sometimes resemble those of several pancreatic malignancies, but the therapeutic strategy differs appreciably. Therefore, accurate diagnosis is necessary for cases of AIP. To date, AIP is classified into two distinct subtypes from the viewpoints of etiology, serum markers, histology, other organ involvements, and frequency of relapse: type 1 is related to IgG4 (lymphoplasmacytic sclerosing pancreatitis) and type 2 is related to a granulocytic epithelial lesion (idiopathic duct-centric chronic pancreatitis). Both types of AIP are characterized by focal or diffuse pancreatic enlargement accompanied with a narrowing of the main pancreatic duct, and both show dramatic responses to corticosteroid. Unlike type 2, type 1 is characteristically associated with increasing levels of serum IgG4 and positive serum autoantibodies, abundant infiltration of IgG4-positive plasmacytes, frequent extrapancreatic lesions, and relapse. These findings have led several countries to propose diagnostic criteria for AIP, which consist of essentially similar diagnostic items; however, several differences exist for each country, mainly due to differences in the definition of AIP and the modalities used to diagnose this disease. An attempt to unite the diagnostic criteria worldwide was made with the publication in 2011 of the international consensus diagnostic criteria for AIP, established at the 2010 Congress of the International Association of Pancreatology (IAP).

Determination of steroid response by abdominal ultrasound in cases with autoimmune pancreatitis

BACKGROUND

Abdominal ultrasound is the most convenient modality for examining the morphology of the pancreas without physical stress. Steroid response is one of the key features of autoimmune pancreatitis; however, visualizing this response has not been evaluated using ultrasonography.

METHODS

Thirty-three consecutive autoimmune pancreatitis cases were retrospectively investigated for pancreatic and extrapancreatic lesions by ultrasonography before steroid therapy (n=33) and at two weeks (n=28) and one month (n=19) after starting oral steroid treatment.

RESULTS

Steroid treatment resulted in obvious shrinkage of the pancreatic lesion in 86% of the cases at two weeks and in 97% until one month. The maximum thickness of the pancreatic lesion was reduced from 28 to 22 mm in two weeks (P<0.0001), and pancreatic echographic findings improved in one month. Swelling of the peripancreatic lymph node was recognized in 48% and the aortic wall thickness in 12%, mostly reduced in two weeks (P=0.005). One case of definitive autoimmune pancreatitis revealed a steroid response only by following endoscopic retrograde cholangiopancreatography but not by ultrasonography or computed tomography.

CONCLUSIONS

Abdominal ultrasound revealed a steroid response in most cases of autoimmune pancreatitis within two weeks. Ultrasonography is suitable for initial confirmation of a steroid response; however, atypical cases showing insufficient response or not fulfilling criteria should undergo further examination.

Reduction of splenic volume by steroid therapy in cases with autoimmune pancreatitis

OBJECTIVES

Splenomegaly is sometimes recognized in autoimmune diseases and chronic pancreatitis; however, it has not yet been studied in autoimmune pancreatitis (AIP). The current study analyzed splenic volume and its associated factors in cases with AIP.

METHODS

Splenic volume was measured using computed tomography (CT) volumetric analysis in 46 cases with AIP and compared with 92 age- and gender-matched controls, and 46 disease controls (liver cirrhosis). Forty-six cases of chronic pancreatitis were also analyzed. Cases with AIP were investigated for factors associated with splenic volume and splenic volume change in response to steroid therapy.

RESULTS

Splenic volume was significantly larger in AIP (149 ± 86 ml) than in controls (97 ± 38 ml) and in CP (108 ± 79 ml) (P < 0.0001 and 0.0002), and was smaller than in disease controls (222 ± 134 ml) (P = 0.003). In AIP cases, splenic volume was associated with age and gender (P = 0.04 and 0.02), and splenomegaly was recognized in 20 % (9/46) of cases. Abnormal uptake of (18)F-fluorodeoxyglucose was not detected in the spleen by positron emission tomography. Splenic vein (SpV) was frequently involved in AIP (67 %), but was all recanalized after steroid therapy. Splenic volume in cases with AIP was minimized to 77 % of the original (122 ± 40 ml) (P < 0.0001) and this trend was remarkable in cases with splenomegaly (66 %). In AIP, high serum IL-2 receptor level, diffuse pancreatic enlargement, and SpV stenosis were significantly associated with splenic shrinkage due to steroid treatment (P = 0.002, 0.02, and 0.03).

CONCLUSIONS

Splenomegaly was sometimes recognized in cases with AIP; however, these cases can be treated with steroids, especially in cases with diffuse pancreatic swelling and SpV stenosis.

Characteristics of autoimmune pancreatitis based on serum IgG4 level

BACKGROUND

Autoimmune pancreatitis is categorized as an IgG4-related autoimmune disease, mostly associated with serological alterations, however characteristics of autoimmune pancreatitis based on serum markers have not been fully evaluated.

METHODS

We evaluated demographics, symptoms, imaging and therapeutic outcome in 27 cases of autoimmune pancreatitis stratified by serum IgG4 level.

RESULTS

Twenty patients (74%) had elevated serum IgG4 and 7 (26%) had normal IgG4 levels. Compared to patients with normal serum IgG4 levels, patients with elevated IgG4 had higher incidence of jaundice at onset (14.3% vs. 80%, respectively; P=0.002), more frequent diffuse pancreatic enlargement at imaging (14.3% vs. 60%, respectively; P=0.04), significantly higher 18F-2-fluoro-2-deoxy-d-glucose uptake of pancreatic lesions (SUV max: 4.0 vs. 5.7, respectively; P=0.02), more frequent extrapancreatic lesions (42.9% vs. 85%, respectively; P=0.03). Response to steroids was recognized regardless of serum IgG4 level, however maintenance therapy was required more frequently amongst patients with elevated compared to normal IgG4 (85.7% vs. 33.3%, respectively; P=0.04).

CONCLUSIONS

Clinical features of autoimmune pancreatitis are different based on level of serum IgG4. Further studies are needed to clarify if normal serum IgG4 cases are a precursor of active type 1 or type 2 autoimmune pancreatitis.