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Hara S, Yoshida M, Sanada H, Suzuki Y, Sato Y, Mizushima I, Kawano M. Pediatric IgG4-related disease: a descriptive review. Expert Rev Clin Immunol 2024; 20:97-119. [PMID: 37874048 DOI: 10.1080/1744666x.2023.2274358] [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: 06/16/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION IgG4-related disease (IgG4-RD) is an immune-mediated systemic fibroinflammatory condition characterized by serum IgG4 elevation and IgG4-positive plasma cell infiltration into various organs. It generally occurs in elderly males. Pediatric cases have been reported, albeit rarely, accordingly lack of recognition of such cases could delay therapeutic intervention leading to poorer outcomes. AREAS COVERED The present review is a descriptive review of all published case reports, cohort studies, and reviews of pediatric IgG4-RD listed in PubMed. Characteristics of pediatric IgG4-RD were clarified, including sex, organ involvement, serological and histological findings, and treatment. We assessed how many published cases met current classification and comprehensive diagnostic criteria. EXPERT OPINION The characteristics of pediatricIgG4-RD differed from adult IgG4-RD in terms of sex and involved organs. There was no clear male dominance in numbers of cases, and surface organ involvement such as ophthalmic diseases were more common in the pediatric IgG4-RD. Organ involvement tended to be indolent and unilateral, causing difficulty in definitively diagnosing pediatric IgG4-RD. Only about 20% of published cases met IgG4-RD classification or comprehensive diagnostic criteria. Physicians should be careful in diagnosing pediatric IgG4-RD after excluding mimickers. International collaboration toward high-quality evidence to support diagnosis and treatment of pediatric IgG4-RD is advised.
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Affiliation(s)
- Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Misaki Yoshida
- Department of Nephrology and Urology, Fukui Red Cross Hospital, Fukui, Fukui, Japan
| | - Hajime Sanada
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Yasunori Suzuki
- Department of Nephrology and Urology, Fukui Red Cross Hospital, Fukui, Fukui, Japan
| | - Yasuharu Sato
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Kita-ku, Okayama, Okayama, Japan
| | - Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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Orozco-Gálvez O, Fernández-Codina A, Lanzillotta M, Ebbo M, Schleinitz N, Culver EL, Rebours V, D'Cruz DP, Della-Torre E, Martínez-Valle F. Development of an algorithm for IgG4-related disease management. Autoimmun Rev 2023; 22:103273. [PMID: 36682575 DOI: 10.1016/j.autrev.2023.103273] [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: 12/21/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVES IgG4-related disease (IgG4-RD) is a rare fibro-inflammatory condition affecting multiple organs lacking standardized management. In this article, we review the evidence available to provide European expert-based statements on the management of IgG4-RD which were integrated in a final algorithm. METHODS A panel of nine European experts in IgG4-RD from different specialties was asked to elaborate a set of consensus statements through a Delphi exercise. Three rounds of survey were taken. Consensus was reached when ≥75% of the responders agreed with a statement. RESULTS Thirty-one statements on induction treatment, maintenance treatment, non-pharmacological treatment, and general considerations were assessed. Patients should be treated promptly in situations when there is an immediate organ threatened, or when organ damage is anticipated. Glucocorticoids (GC) are considered the first line of treatment and should be progressively tapered. Maintenance treatment is recommended for patients with high disease activity or with risk factors for relapse. Rituximab is effective for induction and maintenance of remission, but its use can be limited by economics. Low dose GC with or without GC-sparing agents can be used for maintenance therapy. Stenting or surgery should be ancillary to pharmacological treatment. Follow up should be based on physical examination, blood works, and imaging studies. Furthermore, it should be tailored on individual patient clinical history. 18-fluorodeoxyglucose positron emission tomography/computerized tomography may provide additional information over other imaging modalities. CONCLUSIONS These new statements and algorithm reached a high degree of agreement and may help guiding the clinical management of IgG4-RD.
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Affiliation(s)
- Olimpia Orozco-Gálvez
- Division of Systemic Autoimmune Diseases, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andreu Fernández-Codina
- Division of Systemic Autoimmune Diseases, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Divisions of Rheumatology (London and Windsor campuses) and General Internal Medicine (Windsor Campus), Western University, London, Ontario, Canada
| | - Marco Lanzillotta
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, UNIRAR, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Mikael Ebbo
- Internal Medicine Department, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Nicolas Schleinitz
- Internal Medicine Department, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Emma L Culver
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; University of Oxford, Oxford, United Kingdom
| | - Vinciane Rebours
- Pancreatology Department, Beaujon Hospital, Clichy, Université de Paris, France
| | - David P D'Cruz
- Rheumatology Department, Louise Coote Lupus Unit, Guy's Hospital, London, United Kingdom
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, UNIRAR, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Fernando Martínez-Valle
- Division of Systemic Autoimmune Diseases, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Abstract
Lymphadenopathy occurring in patients with immunoglobulin G4 (IgG4)-related disease, termed IgG4-related lymphadenopathy, shows morphologic heterogeneity and overlap with other nonspecific causes of lymphadenopathy including infections, immune-related disorders, and neoplasms. This review describes the characteristic histopathologic features and diagnostic approach to IgG4-related disease and IgG4-related lymphadenopathy, with comparison to nonspecific causes of increased IgG4-positive plasma cells in lymph nodes, and with emphasis on distinction from IgG4-expressing lymphoproliferative disorders.
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Affiliation(s)
- Jacob R Bledsoe
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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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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Xu J, Bettendorf B, D'Oria M, Sharafuddin MJ. Multidisciplinary diagnosis and management of inflammatory aortic aneurysms. J Vasc Surg 2022:S0741-5214(22)02645-3. [PMID: 36565773 DOI: 10.1016/j.jvs.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inflammatory abdominal aortic aneurysms (IAAAs) are a variant involving a distinct immunoinflammatory process, with nearly one half believed to be associated with IgG4-related disease (IgG4-RD). METHODS MEDLINE and Google Scholar searches were conducted for English-language publications relevant to inflammatory aortic aneurysms from January 1970 onward. The search terms included inflammatory aortic aneurysms, aortitis, periaortitis, IgG4-related disease, and retroperitoneal fibrosis. Relevant studies were selected for review based on their relevance. RESULTS Morphologically, IAAAs are characterized by a thickened aneurysm wall often displaying contrast enhancement and elevated metabolic activity on fluorine-18 fluorodeoxyglucose-positron emission tomography imaging. A strong association exists with perianeurysmal and retroperitoneal fibrosis. Although the rupture risk appears lower with IAAAs than with noninflammatory abdominal aortic aneurysms (AAAs), the currently recommended diameter threshold for operative management is the same. Open repair has been associated with increased morbidity compared with noninflammatory AAAs, and a retroperitoneal approach or minimal dissection transperitoneal approach has been recommended to avoid duodenal and retroperitoneal structural injuries. Endovascular aneurysm repair has been increasingly used, especially for patients unfit for open surgery. It is important to exclude an infectious etiology before the initiation of immunosuppressive therapy or operative repair. Multimodality imaging follow-up is critical to monitor disease activity and secondary involvement of retroperitoneal structures by the associated fibrotic process. Maintenance of immunosuppressive therapy will be needed postoperatively for most patients with active systemic disease, especially those with IgG4-RD and those with persistent symptoms. Additional interventions aimed at ureteral decompression could also be required, and lifelong follow-up is mandatory. CONCLUSIONS Preoperative multimodality imaging is a diagnostic cornerstone for assessment of the disease extent and activity. IgG4-RD is an increasingly recognized category of IAAAs, with implications for tailoring adjunctive medical therapy. Open surgical repair remains the procedure of choice, although endovascular aneurysm repair is increasingly being offered. Maintenance immunosuppressive therapy can be offered according to the disease activity as assessed by follow-up imaging studies.
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Affiliation(s)
- Jun Xu
- Division of Vascular Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brittany Bettendorf
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Mel J Sharafuddin
- Division of Vascular Surgery, University of Iowa Carver College of Medicine, Iowa City, IA.
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Chantada-de la Fuente D, San Miguel-Fraile MP, Serantes Combo A, Ortiz-Rey JA, Gándara-Cortés M, Fernández-Martín J. IgG4-related disease diagnosed in a paratesticular pseudotumor simulating malignancy, in a patient with retroperitoneal fibrosis. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2022; 55 Suppl 1:S2-S6. [PMID: 36075657 DOI: 10.1016/j.patol.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 06/15/2023]
Abstract
IgG4 related disease is a term used to describe a fibroinflammatory condition characterized by storiform fibrosis, inflammation with a dense lymphoplasmocytic infiltrate rich in plasma cells expressing IgG4, and often, if not always, raised serum levels of IgG4. We report a case of a patient with a past history of retroperitoneal fibrosis presenting with a swollen left testicle, who underwent an orchidectomy due to suspicion of malignancy. The surgical specimen revealed a paratesticular pseudotumor with histopathological and immunohistochemical characteristics of IgG4 related disease. To the best of our knowledge, just nine such cases have previously been reported, of which only three were manifestations of systemic disease, as in the present case. Whilst it is important to recognize the clinical and radiological features of this entity, histopathology is often essential in order to confirm the diagnosis.
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Pulmonary Manifestations of Primary Humoral Deficiencies. Can Respir J 2022; 2022:7140919. [PMID: 35440951 PMCID: PMC9013573 DOI: 10.1155/2022/7140919] [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: 02/12/2022] [Revised: 03/16/2022] [Accepted: 03/25/2022] [Indexed: 01/13/2023] Open
Abstract
Primary immunodeficiencies are a group of conditions characterized by developmental or functional alterations in the immune system caused by hereditary genetic defects. Primary immunodeficiencies may affect either the innate or the adaptive (humoral and cellular) immune system. Pulmonary complications in primary humoral deficiencies are frequent and varied and are associated with high morbidity and mortality rates. The types of complications include bronchiectasis secondary to recurrent respiratory infections and interstitial pulmonary involvement, which can be associated with autoimmune cytopenias, lymphoproliferation, and a range of immunological manifestations. Early detection is key to timely management. Immunoglobulin replacement therapy reduces the severity of disease, the frequency of exacerbations, and hospital admissions in some primary humoral deficiencies. Therefore, the presence of pulmonary disease with concomitant infectious and/or autoimmune complications should raise suspicion of primary humoral deficiencies and warrants a request for immunoglobulin determination in blood. Once diagnosis is confirmed; early immunoglobulin replacement therapy will improve the course of the disease. Further studies are needed to better understand the pathogenesis of pulmonary disease related to primary humoral deficiencies and favor the development of targeted therapies that improve the prognosis of patients.
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de Sainte Marie B, Ebbo M, Grados A, Rebours V, Reumaux H, Briantais A, Urbina D, Cury J, Morel N, Lhote F, Rohmer B, Lazaro E, Agbo-Kpati KP, Deroux A, Domont F, Delacroix I, Lavigne C, Perlat A, Kahn JE, Godeau B, Hamidou M, Launay D, Bader-Meunier B, Schleinitz N. A descriptive study of IgG4-related disease in children and young adults. Clin Exp Rheumatol 2022; 21:103035. [PMID: 34995766 DOI: 10.1016/j.autrev.2022.103035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/02/2022] [Indexed: 11/02/2022]
Affiliation(s)
- B de Sainte Marie
- Department of Internal Medicine, Timone Hospital, AP-HM, Aix-Marseille Université, 13005 Marseille, France.
| | - M Ebbo
- Department of Internal Medicine, Timone Hospital, AP-HM, Aix-Marseille Université, 13005 Marseille, France.
| | - A Grados
- Department of Internal Medicine, CH de Niort, 79000 Niort, France
| | - V Rebours
- Pancreatology Unit, Inserm, UMR 1149, Beaujon Hospital, 100, boulevard Gal-Leclerc, 92110 Clichy, France.
| | - H Reumaux
- Department of Pediatric Rheumatology and Emergency, Jeanne de Flandre Hospital, Lille, France.
| | - A Briantais
- Department of Internal Medicine, Timone Hospital, AP-HM, Aix-Marseille Université, 13005 Marseille, France
| | - D Urbina
- Pediatric Department, Children's, Nord Hospital, Chemin des Bourrelys, 13915 Marseille Cedex 20, France.
| | - J Cury
- Paris-Saclay University, CNRS, INRIA, Laboratory in Informatique Research, UMR 8623, Orsay, France.
| | - N Morel
- Pierre et Marie Curie-Paris 6 University, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, SNFMI, 75651 Paris Cedex 13, France.
| | - F Lhote
- Department of Internal Medicine, Saint-Denis Hospital, Saint-Denis, France.
| | - B Rohmer
- Pediatric Gastro-Enterology Department, Femme Mère Enfant Hospital, Groupement Hospitalier Est, 59, Boulevard Pinel, 69677 BRON Cedex, France.
| | - E Lazaro
- CHU Bordeaux, FHU ACRONIM, Place Amélie Raba Léon, 33076 Bordeaux, France.
| | - K P Agbo-Kpati
- Pediatric Department, Marne-La-Vallée Hospital, 2-4, cours de La-Gondoire, 77600 Jossigny, France.
| | - A Deroux
- Department of Internal Medicine, CHU de Grenoble, Grenoble, France.
| | - F Domont
- Department of Internal Medicine and Clinical Immunology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.
| | - I Delacroix
- Internal Medicine Department, Centre Hospitalier Intercommunal de Créteil, Creteil, France.
| | - C Lavigne
- Department of Internal Medicine and Vascular Diseases, CCMR, CHU Angers, Université Angers, 49000 Angers, France.
| | - A Perlat
- Department of Internal Medicine, Sud Hospital, CHU de Rennes, Rennes, France.
| | - J E Kahn
- Department of Internal Medicine Ambroise-Paré Hospital, Boulogne-Billancourt, Versailles Saint-Quentin-en-Yvelines University, France.
| | - B Godeau
- Department of Internal Medicine, Reference Center for Autoimmune Cytopenia, Henri Mondor University Hospital, Creteil, France.
| | - M Hamidou
- Department of Internal Medicine, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes, France.
| | - D Launay
- Department of Internal Medicine, CHU Lille, Lille, France.
| | - B Bader-Meunier
- Immunology-Hematology Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - N Schleinitz
- Department of Internal Medicine, Timone Hospital, AP-HM, Aix-Marseille Université, 13005 Marseille, France.
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Fernández-Codina A, Haig S, Pope JE, Barra L. IgG4-Related Disease, A Single-Center Experience. J Clin Rheumatol 2021; 27:S590-S591. [PMID: 30585995 DOI: 10.1097/rhu.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Orozco-Gálvez O, Fernández-Codina A, Simó-Perdigo M, Pinal-Fernández I, Martínez-Valle F. Response to Treatment in IgG4-Related Disease Assessed by Quantitative PET/CT Scan. Clin Nucl Med 2021; 46:e307-e311. [PMID: 33630792 DOI: 10.1097/rlu.0000000000003537] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The aim of this study was to assess disease activity by different PET/CT measurements in IgG4-related disease (IgG4-RD) flares and their correlation with the IgG4-RD responder index (IgG4-RI). PATIENTS AND METHODS Patients were retrospectively recruited from a single center in Barcelona, Spain. They all had IgG4-RD flares with an 18F-FDG PET/CT examination performed within the 2 first weeks of the flare onset and another one after at least 3 months of treatment between 2012 and 2018. Epidemiologic, clinical, laboratory, and therapeutic data were collected at baseline and at follow-up. Semiquantitative and volumetric measurements from PET/CT explorations were recorded. In addition, a 5-point visual scale was (adapted Deauville score) trialed. The IgG4-RI was used as the criterion standard to assess response before and after treatment. RESULTS Eighteen patients with a total of 23 flares were included. The median time to second PET/CT examination was 7 months. Remission (complete and partial) according to IgG4-RI was observed in 20 flares (87%). All PET/CT measurements (SUVmax and SUVmean, total lesion glycolysis, MTV, and adapted Deauville score) were statistically significantly lower on the follow-up evaluation, except for the size of the lesion. The correlation of all these parameters with the IgG4-RI was positive except for SUVmean and the size of the lesion. CONCLUSIONS Semiquantitative, volumetric, and visual parameters in PET/CT scans correlated with response to treatment assessed by IgG4-RI. Volumetric and visual items are less subject to variations and could be used to improve activity scores and treatment strategies.
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Affiliation(s)
- Olimpia Orozco-Gálvez
- From the Division of Systemic Autoimmune Diseases, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Marc Simó-Perdigo
- Department of Nuclear Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Iago Pinal-Fernández
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD
| | - Fernando Martínez-Valle
- From the Division of Systemic Autoimmune Diseases, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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11
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Liu Z, Zhang S, Zhang W, Feng J, Li M, Zeng X. Immunoglobulin G4-Related Disease Accompanied by Primary Myelofibrosis: Case Report. Front Med (Lausanne) 2021; 8:638794. [PMID: 34017840 PMCID: PMC8129158 DOI: 10.3389/fmed.2021.638794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a heterogeneous autoimmune fibrosing disorder that presents common pathologic features but with unclear etiology. We report a rare case of IgG4-RD accompanied by primary myelofibrosis that eventually transformed into acute myeloid leukemia. A 50-year-old woman suffered from progressive lacrimal and parotid gland enlargement, diaphoresis, and rapid weight loss. Important clinical findings included remarkable leukocytosis, hyperglobulinemia, and splenomegaly. IgG4-RD was confirmed by salivary gland biopsy. Meanwhile, myelofibrosis was diagnosed according to histopathological findings of bone marrow and genetic mutation test of peripheral blood. The patient was on corticosteroid treatment. However, she developed into acute myeloid leukemia (AML) in the 8th month of follow-up. Our case suggested that myeloproliferative neoplasm (MPN) may co-occur with IgG4-RD. Bone morrow aspiration and genetic tests are helpful for throughout evaluation. An active search for hematological malignancies is warranted at diagnosis and during follow-up for patients who present with unexplained leukocytosis, pancytopenia, splenomegaly, or weight loss.
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Affiliation(s)
- Ziwei Liu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Jun Feng
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
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Fernández-Codina A, Pinilla B, Pinal-Fernández I, Carballo I, Feijoo-Massó C, Toledano-Macías M, de Miguel-Campo B, Fonseca-Aizpuru E, Sáez-Comet L, López-Dupla M, Hernández-Rodríguez J, Martínez-Valle F. Performance of the 2019 ACR/EULAR classification criteria for IgG4-related disease and clinical phenotypes in a Spanish multicentre registry (REERIGG4). Rheumatology (Oxford) 2021; 60:217-223. [PMID: 32658963 DOI: 10.1093/rheumatology/keaa247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/15/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Several IgG4-related disease (IgG4-RD) phenotypes have been proposed and the first set of classification criteria have been recently created. Our objectives were to assess the phenotype distribution and the performance of the classification criteria in Spanish patients as genetic and geographical differences may exist. METHODS We performed a cross-sectional multicentre study (Registro Español de Enfermedad Relacionada con la IgG4, REERIGG4) with nine participating centres from Spain. Patients were recruited from November 2013 to December 2018. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria (AECC) were used. RESULTS We included 105 patients; 88% had Caucasian ethnicity. On diagnosis, 86% met the international pathology consensus while 92% met the Japanese comprehensive criteria. The phenotype distribution was head and neck 25%, Mikulicz and systemic (MS) 20%, pancreato-hepato-biliary (PHB) 13%, retroperitoneal and aorta (RA) 26%. Sixteen per cent had an undefined phenotype. Seventy-seven per cent of the cases met the AECC. From the 24 patients not meeting the AECC, 33% met exclusion criteria, and 67% did not get a score ≥20 points. Incomplete pathology reports were associated to failure to meet the AECC. CONCLUSIONS The PHB phenotype was rare among Spanish IgG4-RD patients. The MS phenotype was less frequent and the RA phenotype was more prevalent than in other, Asian patient series. An undefined phenotype should be considered as some patients do not fall into any of the categories. Three quarters of the cases met the 2019 AECC. Incomplete pathology reports were the leading causes of failure to meet the criteria.
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Affiliation(s)
- Andreu Fernández-Codina
- Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Rheumatology division and General Internal Medicine department-Windsor campus, University of Western Ontario, London, ON, Canada
| | - Blanca Pinilla
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Iago Pinal-Fernández
- Muscle Disease Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Iago Carballo
- Internal Medicine Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela
| | | | - María Toledano-Macías
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Luis Sáez-Comet
- Internal Medicine Department, Hospital Miguel Servet, Zaragoza
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Minh Thong P, Dang Luu V, Tra My TT, Xuan Hien N, Anh Tuan T, Minh Duc N. IgG4-Related Sclerosing Cholangitis Mimicking Cholangiocarcinoma. Case Rep Oncol 2021; 14:39-46. [PMID: 33776680 PMCID: PMC7983604 DOI: 10.1159/000513029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 11/19/2022] Open
Abstract
IgG4-related sclerosing cholangitis (IgG4-SC) is a relatively newly identified disease that is frequently associated with autoimmune pancreatitis. The differential diagnosis between cholangiocarcinoma, primary sclerosing cholangitis, and IgG4-SC can be challenging due to significant overlap among the clinical and imaging characteristics. We report the case of a 71-year-old woman who was diagnosed with IgG4-related disease based on increased serum IgG4 levels, imaging, and clinical presentation, which showed systemic involvement, including sclerosing cholangitis and kidneys. The patient presented with chronic jaundice. Magnetic resonance imaging revealed bile duct strictures and the dilatation of upstream bile ducts, smooth wall thickening with uniform enhancement in the delayed phase, and no vascular infiltration. Multiple low-density, wedge-shaped areas were identified in both kidneys, which were hypointense on T2-weighted images and hyperintense on diffusion-weighted images. The serum IgG4 levels of this patient were elevated to nearly 10-fold the normal upper limit. A diagnosis of IgG4-SC associated with IgG4-related kidney was made. Based on this case, pre-surgery IgG4 serum treatment in patients with non-malignant bile duct stenosis was recommended to exclude IgG4-SC.
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Affiliation(s)
- Pham Minh Thong
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam.,Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Vu Dang Luu
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam.,Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Thieu-Thi Tra My
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam
| | | | | | - Nguyen Minh Duc
- Department of Radiology, Ha Noi Medical University, Hanoi, Vietnam.,Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam.,Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Vietnam
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14
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Dragan AD, Weller A, Lingam RK. Imaging of IgG4-related disease in the extracranial head and neck. Eur J Radiol 2021; 136:109560. [PMID: 33524920 DOI: 10.1016/j.ejrad.2021.109560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/06/2020] [Accepted: 01/19/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE Immunoglobulin G4-related disease (IgG4-RD) is a newly defined fibro-inflammatory multisystemic condition defined by a triad of diagnostic criteria based on clinical presentation, biochemical and histopathological findings. Whereas some subsites of this disease have been well described in the literature so far (e.g. pancreas, kidneys, retroperitoneum, salivary glands), more recently identified anatomical sites of involvement in the head and neck are less well understood (e.g. nose, paranasal sinuses). METHOD This pictorial review details the imaging appearances of extracranial IgG4-RD in the Head & Neck. Multimodality imaging appearance and features are presented, with reference to the published literature to date. RESULTS Following a subsite-based approach, we present both the most common and the more rarely encountered imaging patterns of IgG4-RD in the extracranial head and neck, along with the relevant differential diagnoses to consider. Our institutional experience not only cements what is already known in the existing literature on this topic, but also reveals new imaging features of IgG4-RD, notably in the sinonasal tract. CONCLUSIONS This pictorial review of extracranial head & neck IgG4-RD will enable radiologists to recognise the features of this condition and propose it as a differential diagnosis to include alongside other probable entities. It establishes the place of the radiologist in the diagnosis and management of IgG4-RD.
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Affiliation(s)
- Alina Denisa Dragan
- Radiology Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, London, HA1 3UJ, United Kingdom
| | - Alexander Weller
- Radiology Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, London, HA1 3UJ, United Kingdom
| | - Ravi Kumar Lingam
- Radiology Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, London, HA1 3UJ, United Kingdom.
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15
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Namas R, Elarabi M, Hegazin S, Joshi A, Salvo F, Jassim I, Ghosn M, Attallah N, Joshi P, Memisoglu E, Hassen W, Al-Saleh J, Abuzakouk M. Clinical characteristics of igG4-related disease in the United Arab Emirates: A retrospective single-center study. IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2021. [DOI: 10.4103/ijmbs.ijmbs_13_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]
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16
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Fernández-Codina A, Orozco-Gálvez O, Martínez-Valle F. Therapeutic Options in IgG4-Related Disease. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00147-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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17
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Jiang Z, Wang D, Jurkiewicz M, Langdon KD, Hammond R, Fernández-Codina A, Pope JE. Immunoglobulin G 4-related disease as a mimicker of granulomatosis with polyangiitis: a case report. Scand J Rheumatol 2019; 49:163-164. [PMID: 31631725 DOI: 10.1080/03009742.2019.1672088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Z Jiang
- Department of Medicine, Division of Rheumatology, St Joseph's Health Care, London, Ontario, Canada
| | - D Wang
- Department of Medical Imaging, London Health Sciences Centre, London, Ontario, Canada
| | - M Jurkiewicz
- Department of Medical Imaging, London Health Sciences Centre, London, Ontario, Canada
| | - K D Langdon
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - R Hammond
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - A Fernández-Codina
- Department of Medicine, Division of Rheumatology, St Joseph's Health Care, London, Ontario, Canada
| | - J E Pope
- Department of Medicine, Division of Rheumatology, St Joseph's Health Care, London, Ontario, Canada
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18
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Tsuchiya N, Kawasaki A. HLA-DRB1 and FCGR2B: highlights of the first genome-wide association study of IgG4-related disease. THE LANCET. RHEUMATOLOGY 2019; 1:e2-e3. [PMID: 38229355 DOI: 10.1016/s2665-9913(19)30015-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/17/2019] [Indexed: 01/18/2024]
Affiliation(s)
- Naoyuki Tsuchiya
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan.
| | - Aya Kawasaki
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan
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19
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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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20
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Abad S, Martin A, Héran F, Cucherousset N, Mouriaux F, Héron E, Sédira N, Zmuda M, Groh M, Abbas A, Saadoun D, Aucouturier P, Vicaut E, Dhote R. IgG4-related disease in patients with idiopathic orbital inflammation syndrome: data from the French SIOI prospective cohort. Acta Ophthalmol 2019; 97:e648-e656. [PMID: 30421562 DOI: 10.1111/aos.13968] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 10/11/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To better characterize IgG4-related disease (RD) in the setting of idiopathic orbital inflammation syndrome (IOIS). METHODS National, multicentre, prospective, observational cohort study. Among the patients consecutively included in the French multicentre SIOI cohort, we selected those who underwent orbital and/or adnexal biopsy. Clinical, morphological and pathological findings at diagnosis were blindly analysed. Serum IgG4 levels at inclusion were measured and all available biopsy specimens were immunostained for IgG4 and IgG. Biopsy samples with more than 10 IgG4-positive plasma cells per high-power field and a IgG4+/IgG+ plasma cell ratio above 40% were scored as positive. IgG4-positive patients were then screened for comprehensive diagnostic criteria for IgG4-RD. RESULTS Of the 87 patients included, 35 had histologically documented IOIS. Thirteen patients (37%) with a mean age at onset of 27 years (range 21-78) had IgG4-positive biopsies, among which 10 patients (77%) and 3 (23%, with IgG4 serum levels >1.35 g/L) were considered as having probable and definite IgG4-RD, respectively. The latter 13 patients more frequently fulfilled histological criteria for IgG4-RD (including plasmacytic infiltrate (p = 0.006), fibrosis (p = 0.0025) and periphlebitis (p = 0.075)) than IgG4-negative patients. Storiform fibrosis was exclusively found in orbital tissues from IgG4-positive patients (n = 3, 23%). Eosinophilia associated with recurrent sinusitis or asthma was a prominent feature in patients with definite IgG4-RD. CONCLUSIONS More than one-third of patients with biopsy-proven IOIS satisfied criteria for IgG4-RD, but only a few had a definite type.
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Affiliation(s)
- Sébastien Abad
- Service de Médecine Interne AP‐HP Hôpital Avicenne Bobigny France
- Faculté de Médecine SMBH Sorbonne Paris Cité Université Paris 13 Bobigny France
- Université Paris 13 Sorbonne Paris Cité UMR1125, LI2P Bobigny France
| | - Antoine Martin
- Faculté de Médecine SMBH Sorbonne Paris Cité Université Paris 13 Bobigny France
- Service d'Anatomopathologie AP‐HP Hôpital Avicenne Bobigny France
| | - Francoise Héran
- Service d'Imagerie Fondation Adolphe de Rothschild Paris France
| | - Nahla Cucherousset
- Faculté de Médecine SMBH Sorbonne Paris Cité Université Paris 13 Bobigny France
- Service d'Anatomopathologie AP‐HP Hôpital Avicenne Bobigny France
| | - Frédéric Mouriaux
- Service d'Ophthalmologie Centre Hospitalier Universitaire de Rennes Rennes France
- Faculté de Médecine Université Rennes 1 Rennes France
| | - Emmanuel Héron
- Service de Médecine Interne Hôpital des Quinze/vingts Paris France
| | - Neila Sédira
- Service de Médecine Interne Hôpital des Quinze/vingts Paris France
| | - Mathieu Zmuda
- Service de Chirurgie Oculoplastique Fondation Adolphe de Rothschild Paris France
| | - Matthieu Groh
- Centre National de Référence des Syndromes Hyperéosinophiliques (CEREO) Service de Médecine Interne Hôpital Foch Suresnes France
- Université Versailles St‐Quentin‐en‐Yvelines Versailles France
| | - Aïcha Abbas
- Département d'immunologie biologique AP‐HP Hôpital Saint‐Antoine Paris France
- Faculté de Médecine Université Pierre et Marie Curie Paris France
| | - David Saadoun
- Faculté de Médecine Université Pierre et Marie Curie Paris France
- Service de Médecine Interne AP‐HP Hôpital Pitié Salpétrière Paris France
- Université Pierre et Marie Curie Paris France
| | - Pierre Aucouturier
- Département d'immunologie biologique AP‐HP Hôpital Saint‐Antoine Paris France
- Faculté de Médecine Université Pierre et Marie Curie Paris France
- Inserm UMRS 938 Université Pierre et Marie Curie Paris France
| | - Eric Vicaut
- Unité de Recherche Clinique AP‐HP Hôpital Fernand Widal Paris France
- Faculté de Médecine Sorbonne Paris Cité Université Paris 7 Bobigny France
| | - Robin Dhote
- Service de Médecine Interne AP‐HP Hôpital Avicenne Bobigny France
- Faculté de Médecine SMBH Sorbonne Paris Cité Université Paris 13 Bobigny France
- Université Paris 13 Sorbonne Paris Cité UMR1125, LI2P Bobigny France
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21
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Kotsis GP, Peteinaki AP, Sakellaridis AC, Andriotis EE, Koufopoulos N. Immunoglobulin G4-related Disease: Presentation of the First Case with Isolated Pterygopalatine Fossa Involvement. Cureus 2019; 11:e4719. [PMID: 31355079 PMCID: PMC6650185 DOI: 10.7759/cureus.4719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Immunoglobulin G4-related disease is an immune-mediated fibroinflammatory disease with single or multiple organ involvement. Clinically it mimics several benign and malignant tumors, as well as infectious, and inflammatory disorders. It typically presents as multiple tumor-forming lesions. Histological and immunohistochemical findings are characteristic. Serum immunoglobulin G4 levels are usually increased. Systemic corticosteroid administration is the treatment of choice with good response, especially in early disease stages. We present the first case of immunoglobulin G4-related disease presenting as an isolated tumor forming lesion of the left pterygopalatine fossa. Imaging studies indicated a benign process. Histological findings were consistent with IgG4-related disease. The patient showed a good response to systemic corticosteroid treatment and remains free of symptoms 18 months following diagnosis.
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Affiliation(s)
- Georgios P Kotsis
- Otorhinolaryngology / Head & Neck Surgery, "Saint Savvas" General Anti-Cancer and Oncological Hospital of Athens, Athens, GRC
| | | | - Athanasios C Sakellaridis
- Otorhinolaryngology / Head & Neck Surgery, "Saint Savvas" General Anti-Cancer and Oncological Hospital of Athens, Athens, GRC
| | - Efthymios E Andriotis
- Interventional Radiology, "Saint Savvas" General Anti-Cancer and Oncological Hospital of Athens, Athens, GRC
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22
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Lee CM, Alalwani M, Prayson RA, Gota CE. Retrospective single-centre analysis of IgG4-related disease patient population and treatment outcomes between 2007 and 2017. Rheumatol Adv Pract 2019; 3:rkz014. [PMID: 31432002 PMCID: PMC6649925 DOI: 10.1093/rap/rkz014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/18/2019] [Indexed: 12/24/2022] Open
Abstract
Objective The aim was to gain a better understanding of the prevalence, organ involvement, clinical characteristics and long-term outcomes of medical and surgical treatments of IgG4-related disease (IgG4-RD). Methods Query of the Cleveland Clinic pathology database for IgG4 plasma cell staining between 2007 and 2017 yielded 1481 results, of which 57 cases were identified as highly likely (n = 28; 49%) or probable (n = 29; 51%) IgG4-RD by histopathological criteria and IgG4 serum concentrations. Patient demographics, type of treatment and outcomes were retrieved from medical records. Patients were designated as being in remission if indicated in the chart and/or symptom- and objective finding-free for >6 months, relapsed if symptoms/findings recurred after remission, active if no remission was achieved during follow-up, and as unable to determine if the duration of follow-up was <60 days or they were lost to follow-up. Results Of all patients who met the IgG4 staining criteria (n = 119), half (n = 57) satisfied the IgG4-RD histopathological criteria; 63% were males, age 57.9 ± 14.8 years. The average follow-up was 2.7 ± 2.2 years. The pancreas was the most affected organ in our cohort (26.4%). Almost half of the patients (45.6%; n = 26) were managed surgically, 21.1% (n = 12) medically, and 24.6% (n = 14) received both types of treatment. Medical treatment included prednisone (45.6%), MTX (5.3%), AZA (7%) and rituximab (8.8%). Remission was achieved by 77% of patients receiving surgical, 67% receiving medical and 72% receiving both treatments. Conclusion A histological diagnosis of IgG4-RD could be made in half of the patients who had IgG4+ plasma cells ≥10/high-power field or IgG4+/IgG+ ratio >40%. In our cohort, surgical treatment compared with medical treatment had a higher proportion of remission according to our outcome classification.
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Affiliation(s)
- Chan Mi Lee
- The Education Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Mohamed Alalwani
- Department of Rheumatologic and Immunologic Disease, Orthopaedic and Rheumatologic Institute, Cleveland Clinic
| | - Richard A Prayson
- The Education Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Carmen E Gota
- The Education Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.,Department of Rheumatologic and Immunologic Disease, Orthopaedic and Rheumatologic Institute, Cleveland Clinic
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23
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Ron R, Ruz-Caracuel I, García E, Montes-Ramírez ML. IgG4-related disease in a patient with HIV infection. BMJ Case Rep 2019; 12:12/4/e226809. [PMID: 30988103 DOI: 10.1136/bcr-2018-226809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A 47-year-old HIV-positive man with good immune and virological status presented with chronic multiple enlarged lymph nodes, lung disease and eosinophilia. Radiologic tests showed enlarged cervical, thoracic and axillary lymph nodes, with interstitial lung damage. After several non-specific histologic studies, an elevated serum IgG4 level led us to request immunohistochemistry of a lymph node sample. The test confirmed the diagnosis of IgG4-related disease.
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Affiliation(s)
- Raquel Ron
- Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | | | - Eugenia García
- Pathology- IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
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24
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Chowsilpa S, Chowsilpa S, Teeranoraseth T, Roongrotwattanasiri K. Temporal bone involvement of IgG4-related disease: a rare condition misleading to petrous apicitis causing lateral rectus palsy. BMJ Case Rep 2019; 12:12/2/e228550. [PMID: 30814106 DOI: 10.1136/bcr-2018-228550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease (IgG4-RD) of temporal bone is rare and clinical manifestation mimics infection. A 19-year-old female presented with progressive left earache and intermittent left nasal obstruction. Then, she rapidly developed left lateral rectus palsy. The physical examination revealed mild redness of left tympanic membrane and a small nasal polyp from the left middle meatus. CT scan showed left petrous apicitis and enhancing sinonasal mucosa. Therefore, Gradenigo's syndrome was first considered. The empirical intravenous antibiotic was immediately prescribed and surgery was performed. The intraoperative pale soft tissue mass in middle ear and polyp in the left nasal cavity were sent for pathological examination and found positive immunohistochemical stains for IgG4 in plasma cells. Systemic corticosteroid, the first-line treatment, was started and her symptoms were finally recovery.
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Affiliation(s)
- Sanathorn Chowsilpa
- Department of Otolaryngology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sayanan Chowsilpa
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Martínez-Valle F, Riveiro-Barciela M, Salcedo MT, Merino-Casabiel X, Fernández-Codina A, Torres ID, Esteban R, Buti M. Sclerosing Cholangitis Related to IgG4: Not Always a Curable Entity. Ann Hepatol 2019; 18:215-219. [PMID: 31113593 DOI: 10.5604/01.3001.0012.7916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/06/2017] [Indexed: 02/04/2023]
Abstract
IgG4-related disease is a recently-described fibro-inflammatory condition with characteristic histopathological findings in the organs involved. The most commonly affected organs are pancreas, lymph nodes, and retroperitoneum. Liver disease usually involves bile structures and therefore IgG4-related disease is considered a cause of secondary sclerosing cholangitis. One out of three patients with IgG4 sclerosing cholangitis also presents autoimmune pancreatitis, although it can be associated with manifestations in other organs. One of the main features of IgG4-related disease is its good prognosis due to the great response to glucocorticoid therapy. However, relapse of the disease is not uncommon, especially when steroid therapy is decreased or stopped. Rituximab seems to be an effective treatment to achieve remission of the disease. We report the case of a 74 year-old man diagnosed with IgG4-related disease based on increase of serum IgG4 levels, imaging and histopathological findings, with systemic involvement including sclerosing cholangitis. Despite the absence of liver fibrosis at onset, the early use of glucocorticoids and rituximab therapy, the patient presented clinical and analytical deterioration, leading to secondary biliary cirrhosis. In conclusion, this clinical case highlights the importance of prompt diagnosis and therapeutics for sclerosing cholangitis secondary to IgG4-related disease in order to avoid progression of the disease and development of liver cirrhosis, as well as the refractory, aggressive nature of the disease in some cases as this one.
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Affiliation(s)
- Fernando Martínez-Valle
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | - Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Xavier Merino-Casabiel
- Abdominal Imaging Unit, Radiology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Andreu Fernández-Codina
- Systemic Autoimmune Diseases Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Inés de Torres
- Pathology Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - María Buti
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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26
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Schroeder HW, Imboden JB, Torres RM. Antigen Receptor Genes, Gene Products, and Coreceptors. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Fernández-Codina A, Pinilla B, Pinal-Fernández I, López C, Fraile-Rodríguez G, Fonseca-Aizpuru E, Carballo I, Brito-Zerón P, Feijóo-Massó C, López-Dupla M, Cid MC, Martínez-Valle F. Treatment and outcomes in patients with IgG4-related disease using the IgG4 responder index. Joint Bone Spine 2018; 85:721-726. [DOI: 10.1016/j.jbspin.2018.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/31/2018] [Indexed: 12/26/2022]
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Abstract
PURPOSE OF REVIEW IgG4-related disease (IgG4-RD) is increasingly recognized as a fibroinflammatory disease with a plethora of organ-specific manifestations but a particular predilection for head and neck tissues, including the nervous system. This review discusses general features and organ-specific presentations of IgG4-RD as well as treatment considerations, particularly emphasizing features of neuro-ophthalmic interest. RECENT FINDINGS IgG4-RD is emerging as a common cause of several fibroinflammatory disorders in the head and neck that were previously considered idiopathic, such as sclerosing orbital pseudotumor, orbital myositis, hypophysitis, and hypertrophic pachymeningitis. New and unusual presentations continue to be described, including a number of vascular manifestations. Substantial progress has been made in elucidating the cell types involved in IgG4-RD, and new pathogenic models are being proposed. Although clinicopathologic correlation remains the cornerstone of diagnosis, ancillary tests such as flow cytometry for circulating plasmablasts and PET-computed tomography have high sensitivity, and certain radiologic features are recognized to be particularly suggestive, such as infraorbital nerve enlargement in IgG4-RD orbitopathy. IgG4-RD often responds to steroids but incomplete responses and relapses are common. Rituximab is emerging as a promising new therapy. SUMMARY The current review summarizes manifestations of IgG4RD that are of particular relevance to neuro-ophthalmic practice.
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Xiao X, Lian M, Zhang W, Eric Gershwin M, Ma X. The Immunologic Paradoxes of IgG4-Related Disease. Clin Rev Allergy Immunol 2018; 54:344-351. [PMID: 29460058 DOI: 10.1007/s12016-018-8679-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IgG4-related disease (IgG4-RD), which usually occurs in middle-aged and elderly men, is a newly recognized fibroinflammatory condition characterized by swelling and sclerosis of involved organs, increased IgG4-positive plasma cell infiltration in lesions, and elevated IgG4 concentration in serum. Despite growing interest in the research, the pathophysiological mechanism remains elusive. Most IgG4-RD patients respond well to steroid therapy initially, but recurrent and refractory cases are common, especially in advanced fibrotic stage. Recent studies have documented the heterogeneity of the B cell lineages, which suggests their multiple functions in IgG4-RD beyond IgG4 production, such as cytokine secretion, antigen presentation, autoantibody production, and modulation of T and B cell interactions. Thus, a critical balance exists between pathogenic and regulatory B subsets to prevent immunopathology. A prompt response to B cell depletion therapy reported in recent cases strongly suggests the imbalance within B cell lineages in IgG4-RD. A more precise understanding of the pathogenesis of IgG4-RD will open up new perspectives for therapeutic strategy. With a particular emphasis on the novel B cell-targeted therapeutic strategies, this review highlights the immunologic features of IgG4-RD and the possible roles of B cell lineages in the pathogenesis of IgG4-RD.
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Affiliation(s)
- Xiao Xiao
- Division of Gastroenterology and Hepatology, Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.,Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai JiaoTong University; Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai JiaoTong University; Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.,Renji Hospital, School of Medicine, Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China
| | - Min Lian
- Division of Gastroenterology and Hepatology, Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.,Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai JiaoTong University; Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.,State Key Laboratory for Oncogenes and Related Genes, Shanghai JiaoTong University; Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.,Renji Hospital, School of Medicine, Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China
| | - Weici Zhang
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
| | - M Eric Gershwin
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA.
| | - Xiong Ma
- Division of Gastroenterology and Hepatology, Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China. .,Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai JiaoTong University; Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China. .,State Key Laboratory for Oncogenes and Related Genes, Shanghai JiaoTong University; Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China. .,Renji Hospital, School of Medicine, Shanghai JiaoTong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai, 200001, China.
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Bledsoe JR, Della-Torre E, Rovati L, Deshpande V. IgG4-related disease: review of the histopathologic features, differential diagnosis, and therapeutic approach. APMIS 2018; 126:459-476. [PMID: 29924455 DOI: 10.1111/apm.12845] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an uncommon disorder that demonstrates characteristic clinicopathologic features including sclerosing lesions with storiform fibrosis, increased IgG4+ plasma cells with an increased IgG4+/IgG+ plasma cell ratio, obliterative phlebitis, and often an increased serum IgG4 level. This review summarizes the characteristic histopathologic and clinical features of IgG4-RD with detailed discussion of the histopathologic characteristics of the most commonly involved anatomic sites. We also present recent advances in our understanding of the pathophysiologic mechanisms of IgG4-RD and discuss updates on the treatment, prognosis, and outcomes of this rare disease, including discussion of the possible association between IgG4-RD and malignancy.
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Affiliation(s)
- Jacob R Bledsoe
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA, USA
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Università Vita-Salute San Raffaele - San Raffaele Scientific Institute, Milan, Italy.,Ragon Institute of MGH, MIT, and Harvard University, Cambridge, MA, USA
| | - Lucrezia Rovati
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Università Vita-Salute San Raffaele - San Raffaele Scientific Institute, Milan, Italy.,Ragon Institute of MGH, MIT, and Harvard University, Cambridge, MA, USA
| | - Vikram Deshpande
- The James Homer Wright Pathology Laboratories of the Massachusetts General Hospital, Boston, MA, USA
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Gao Y, Zheng M, Cui L, Chen N, Wang YN, Zhan YT, Wang ZG. IgG4-related disease: association between chronic rhino-sinusitis and systemic symptoms. Eur Arch Otorhinolaryngol 2018; 275:2013-2019. [PMID: 29948263 DOI: 10.1007/s00405-018-5013-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/23/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE The objective of this study is to analyze the relationship between chronic rhino-sinusitis (CRS) and systemic symptoms in patients with IgG4-related disease (IgG4-RD). PATIENTS AND METHODS The patients with IgG4-RD, confirmed by restrict association with clinical and histopathological manifestations between March 2013 and July 2016, were enrolled and followed-up for 1 year at the Tongren Hospital, Capital Medical University. The patients were divided into two groups: the case group included IgG4-RD patients with CRS confirmed by clinical and imaging, while the control group included IgG4-RD patients without CRS confirmed by clinical and imaging. Age, gender, clinical manifestations, the percentage of eosinophils in peripheral blood, sedimentation (ESR), C-reaction protein, serum IgE and IgG4 levels, histopathology, and treatment drugs at the baseline and 1 year of follow-up were compared between the two groups. RESULTS A total of 46 cases met the diagnostic criteria for IgG4-RD. A total of 30 patients (65.2%) had IgG4-RD complicated with CRS, and were aged 49.7 ± 13.4 years, with male:female ratio = 2:1. The disease duration in the case group was longer than that in the control group (3.0 versus 0.8, p = 0.009). The ratio of ocular involvement was higher (86.7 versus 60%, p < 0.001), and allergic manifestations including drug allergy, asthma, and allergic skin were more common (56.5 versus 20%, p = 0.004), with a higher percentage of eosinophils in peripheral blood (8.5 versus 3.3%, p = 0.018) and more sensitive to glucocorticoids (6.0 versus 3.5, p = 0.004) than those in the control group. CONCLUSIONS CRS in patients with IgG4-RD was closely associated with IgG4-related ocular lesions, which was more prone to allergic manifestations accompanied by raised percentage of eosinophils in peripheral blood. The treatment of patients with IgG4-RD complicated with CRS was more effective than those with IgG4-RD without CRS.
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Affiliation(s)
- Yuan Gao
- Department of Rheumatology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ming Zheng
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Li Cui
- Department of Rheumatology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Nan Chen
- Department of Rheumatology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yan-Ni Wang
- Department of Rheumatology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yu-Tao Zhan
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| | - Zhen-Gang Wang
- Department of Rheumatology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Abstract
Immunoglobulin G4-related disease is a fibroinflammatory systemic disease that is characterized by focal or diffuse organ infiltration by immunoglobulin G4-bearing plasma cells. Immunoglobulin G4-related disease may affect any organ, and a high index of suspicion is necessary for early detection to avoid irreversible fibrosis, organ dysfunction, and death. Tumor-forming lesions are common radiological features of immunoglobulin G4-related disease that need to be differentiated from malignancies. The diagnostic approach requires the integration of clinical, biochemical, and radiographic manifestations with classic histopathologic features, which remain crucial to diagnosis. The histology of immunoglobulin G4-related disease is determined by a dense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis in the presence of increased immunoglobulin G4-positve plasma cells. Although immunoglobulin G4-related disease forms a distinct, clinically independent disease category, many questions and problems remain unanswered, especially on its pathogenesis and the role of immunoglobulin G4. Advances in the understanding of immunoglobulin G4-related disease are likely to change the diagnostic approach in the future and create potential targets for therapeutic purposes. Here we describe the concept of immunoglobulin G4-related disease and the most recent knowledge in the clinico-pathological characteristics on this emerging disease. This study can guide clinicians in early diagnosis and prevent unnecessary surgical resections.
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Affiliation(s)
| | | | - Metin Özdemirli
- Department of Pathology, Medstar Georgetown University Hospital, Washington, USA
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Tong X, Bai M, Wang W, Han Q, Tian P, Fan H. IgG4-related disease involving polyserous effusions with elevated serum interleukin-6 levels: a case report and literature review. Immunol Res 2018; 65:944-950. [PMID: 28710703 DOI: 10.1007/s12026-017-8934-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently described immune-mediated fibroinflammatory disease with a characteristic histopathologic appearance that can affect various organs. We report a 43-year-old Chinese female patient with IgG4-RD involving polyserous effusions with reports of worsening exertional dyspnea for 3 months. Laboratory blood tests revealed that serum interleukin (IL)-6, carbohydrate antigens (CA-199 and CA-125), and alpha-fetoprotein levels were significantly increased, but serum IgG4 levels were normal. Repeat pleural effusion and ascite analysis showed lymphocyte-predominant exudates. In addition, computed tomography scan showed massive pleural effusion in the right pleural cavity, abdominal effusion, and some pericardial effusion with a partial compression atelectasis. Further, medical thoracoscopy was performed to examine the pleural cavity and found multiple nodules on the pleura and partly thickened pleura with a reddish color. Histopathologic and immunohistochemical examination revealed marked lymphocytes and IgG4-positive plasma cell infiltration. The patient was finally diagnosed with IgG4-RD according to the comprehensive diagnostic criteria, although the patient presented similar serological and pathological manifestations of Castleman disease (CD). Our case suggests that IgG4-RD may be one of the causes of polyserous effusions and shows the difficulties in differentiating between IgG4-RD and CD.
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Affiliation(s)
- Xiang Tong
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China
| | - Min Bai
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China
| | - Weiya Wang
- Department of Pathology, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Qingbing Han
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China
| | - Panwen Tian
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China. .,Lung Cancer Center, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, 610041, China.
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China.
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Goulabchand R, Delicque J, Gallo M, Le Quellec A, Guilpain P. Comment on the article entitled “Antineutrophil cytoplasmic antibody-associated vasculitides and IgG4-related disease: A new overlap syndrome” ( Autoimmunity Reviews 16 ( 2017 ) 1036–1043 ). Autoimmun Rev 2018; 17:431-433. [DOI: 10.1016/j.autrev.2017.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/09/2017] [Indexed: 12/12/2022]
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Tan L, Guan X, Zeng T, Wu S, Zheng W, Fu H, Long T, Wang Q, Meng Y, Tian Y, Yu J, Chen J, Li H, Cao L. The significance of serum IgG 4 and CA19-9, autoantibodies in diagnosis and differential diagnosis of IgG 4-related sclerosing cholangitis. Scand J Gastroenterol 2018; 53:206-211. [PMID: 29272982 DOI: 10.1080/00365521.2017.1416159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the value of serum levels of IgG4 and CA19-9, and autoantibodies in the diagnosis of IgG4-related sclerosing cholangitis (IgG4-SC). METHODS We detected the serum IgG4 and CA19-9 of 45 IgG4-SC patients, 173 non-IgG4-SC patients and 48 healthy controls by immunoassay and chemiluminescence, respectively, with antinuclear antibody (ANA), anti-neutrophil antibody (ANCA), anti-smooth muscle antibody (SMA) and anti-mitochondrial antibody (AMA) level detected by indirect immunofluorescence. Then analyze the detection results. RESULTS (1) The positive rates of ANA, ANCA, SMA and AMA in patients with IgG4-SC were 40%, 6.67%, 0 and 2.22%. Among them, the positive rate of ANA was significantly higher than that of the healthy control group (p < .01), and the positive rate of ANA, ANCA, SMA and AMA were significantly different from that of the non-IgG4-SC group (p < .05). (2) Serum levels of IgG4 and CA19-9 increased significantly in patients with IgG4-SC compared with the healthy controls (p < .01). The areas under the ROC curve (AUC) of IgG4 and CA19-9 were 0.9750 and 0.6498, respectively (p < .05). CONCLUSION The high levels of serum IgG4 and CA19-9, and autoantibodies detections are of great important clinical value in diagnosis and differential diagnosis of IgG4-SC.
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Affiliation(s)
- Liming Tan
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Xiaolin Guan
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Tingting Zeng
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Sifan Wu
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Wei Zheng
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Huiying Fu
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Tingting Long
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Qiaohua Wang
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Yimei Meng
- b College of Public Health , Nanchang University , Nanchang , Jiangxi , China
| | - Yongjian Tian
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Jianlin Yu
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Juanjuan Chen
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Hua Li
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
| | - Liping Cao
- a Key Laboratory of Laboratory Medicine in Jiangxi Province, Department of the Clinical Laboratory , The Second Affiliated Hospital of Nanchang University , Nanchang , Jiangxi , China
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Martínez-Valle F, Orozco-Gálvez O, Fernández-Codina A. Update in ethiopathogeny, diagnosis and treatment of the IgG4 related disease. Med Clin (Barc) 2017; 151:18-25. [PMID: 29241876 DOI: 10.1016/j.medcli.2017.10.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 02/06/2023]
Abstract
IgG4 related disease (IgG4-RD) is probably an autoimmune pathology of unknown etiology. Diverse interactions participate in its pathogen between the adaptive and innate immune systems, activating lymphocytes B and T which trigger the inflammatory cascade, which culminates in fibrosis of the organs and their malfunction. It can affect a multitude of organs simultaneously. The diagnosis is based on the correlation of clinical findings with anatomopathological results (lymphoplasmocitary infiltrate, storiform fibrosis, obliterative phlebitis and IgG4+plasmatic cell count) and with the presence of elevated IgG4 in serum, depending on the criteria used. Corticoids and rituximab are among the few validated treatments available. There are multiple biomarkers and treatments in development. In this review, we aim to go over the principal pathogenic and clinical characteristics of IgG4-RD, as well as its handling, in accordance with the available scientific evidence.
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Affiliation(s)
- Fernando Martínez-Valle
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Vall Hebron, Universitat Autònoma de Barcelona, Barcelona, España; Vall d'Hebron Institut de Recerca, Barcelona, España.
| | - Olimpia Orozco-Gálvez
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Vall Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Andreu Fernández-Codina
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Vall Hebron, Universitat Autònoma de Barcelona, Barcelona, España; Vall d'Hebron Institut de Recerca, Barcelona, España; Rheumatology Division, Department of Medicine, University of Western Ontario, London, Ontario, Canadá
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Yang H, Wei R, Liu Q, Shi Y, Li J. Frequency and distribution of CD4+CXCR5+ follicular B helper T cells within involved tissues in IgG4‑related ophthalmic disease. Mol Med Rep 2017; 16:9512-9520. [PMID: 29039547 PMCID: PMC5780010 DOI: 10.3892/mmr.2017.7780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 08/22/2017] [Indexed: 12/24/2022] Open
Abstract
Immonoglobulin G4-related ophthalmic disease (IgG4-ROD) is a IgG4-RD and exhibits two main characteristics: Fibrosis that is not necessarily marked histopathologically; and frequent formation of germinal centers (GCs). Follicular B helper T (Tfh) cells are now recognized as the true helper cells for B cells in antibody responses. In the present study, the profile and distribution of Tfh cells in involved tissues from patients with IgG4-ROD was compared to those of type 1 autoimmune pancreatitis (AIP) and patients with IgG4-related lymphadenopathy (IgG4-RL). A total of 7 patients with IgG4-ROD, 7 patients with type 1 AIP or IgG4-RL and 7 IgG4-negative controls were evaluated. The expression of Tfh-cell immunological proteins, the inducible T-cell costimulator, B-cell lymphoma 6 protein, C-X-C chemokine receptor type 5 (CXCR5) and interleukin-21 (IL-21) in affected tissues was analyzed using immunohistochemical staining and dual immunofluorescence. It was demonstrated that patients with IgG4-RD exhibited a significantly increased number of CD4+CXCR5+ Tfh cells compared with the IgG4-negative controls. Furthermore, CD4+CXCR5+ Tfh cells were detected in and outside of GCs in patients with IgG4-ROD and IgG4-RLF, whereas CD4+CXCR5+ Tfh cells were randomly distributed in areas demonstrating type 1 AIP. Fewer CD4+CXCR5+ Tfh cells were observed in patients with type 1 AIP compared with patients with IgG4-ROD and IgG4-RL. In addition, increased expression of IL-21 was observed in patients with IgG4-ROD and IgG4-RL compared with type 1 AIP. IL-21 expression was positively correlated with the IgG4/IgG ratio in immunohistochemically-positive cells. The results of the present study indicate that Tfh cells are involved in the histopathological pathogenesis of IgG4-RD and may serve a different role in IgG4-ROD and type 1 AIP. Tfh cells may serve a direct role in the IL-21-mediated pathogenesis of IgG4-ROD.
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Affiliation(s)
- Huimin Yang
- Department of Ophthalmology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai 200127, P.R. China
| | - Ruili Wei
- Department of Ophthalmology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
| | - Qiang Liu
- Department of Pathology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai 200127, P.R. China
| | - Yongheng Shi
- Department of Pathology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai 200127, P.R. China
| | - Jin Li
- Department of Ophthalmology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai 200127, P.R. China
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Uzunhan Y, Jeny F, Kambouchner M, Didier M, Bouvry D, Nunes H, Bernaudin JF, Valeyre D. The Lung in Dysregulated States of Humoral Immunity. Respiration 2017; 94:389-404. [PMID: 28910817 DOI: 10.1159/000480297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In common variable immunodeficiency, lung manifestations are related to different mechanisms: recurrent pneumonias due to encapsulated bacteria responsible for diffuse bronchiectasis, diffuse infiltrative pneumonia with various patterns, and lymphomas, mostly B cell extranodal non-Hodgkin type. The diagnosis relies on significant serum Ig deficiency and the exclusion of any primary or secondary cause. Histopathology may be needed. Immunoglobulin (IgG) replacement is crucial to prevent infections and bronchiectasis. IgG4-related respiratory disease, often associated with extrapulmonary localizations, presents with solitary nodules or masses, diffuse interstitial lung diseases, bronchiolitis, lymphadenopathy, and pleural or pericardial involvement. Diagnosis relies on international criteria including serum IgG4 dosage and significantly increased IgG4/IgG plasma cells ratio in pathologically suggestive biopsy. Respiratory amyloidosis presents with tracheobronchial, nodular, and cystic or diffuse interstitial lung infiltration. Usually of AL (amyloid light chain) subtype, it may be localized or systemic, primary or secondary to a lymphoproliferative process. Very rare other diseases due to nonamyloid IgG deposits are described. Among the various lung manifestations of dysregulated states of humoral immunity, this article covers only those associated with the common variable immunodeficiency, IgG4-related disease, amyloidosis, and pulmonary light-chain deposition disease. Autoimmune connective-vascular tissue diseases or lymphoproliferative disorders are addressed in other chapters of this issue.
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Lian M, Li B, Xiao X, Yang Y, Jiang P, Yan L, Sun C, Zhang J, Wei Y, Li Y, Chen W, Jiang X, Miao Q, Chen X, Qiu D, Sheng L, Hua J, Tang R, Wang Q, Eric Gershwin M, Ma X. Comparative clinical characteristics and natural history of three variants of sclerosing cholangitis: IgG4-related SC, PSC/AIH and PSC alone. Autoimmun Rev 2017; 16:875-882. [PMID: 28564616 DOI: 10.1016/j.autrev.2017.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 12/17/2022]
Abstract
There is increased interest and recognition of the clinical variants of Sclerosing Cholangitis (SC) namely IgG4-SC, PSC/AIH overlap and PSC. For most Centers, the characteristic of IgG4-SC has not been thoroughly clinically compared with other sclerosing cholangitis variants. Further there are relatively few PSC/AIH overlap patients and the clinical outcome is not well characterized, especially for the PSC/AIH overlap syndrome. Our objective herein is to clarify the differences and similarities of the natural history of IgG4-SC, the PSC/AIH overlap and PSC alone. We also place in perspective the diagnostic value of serum IgG4 for IgG4-SC and investigate biomarkers for predicting the prognosis of sclerosing cholangitis. In this study, we took advantage of our large and well-defined patient cohort to perform a retrospective cohort study including 57 IgG4-SC, 36 PSC/AIH overlap patients, and 55 PSC patients. Firstly, as expected, we noted significant differences among immunoglobulin profiles and all patients exhibited similar cholestatic profiles at presentation. Cirrhotic events were found in 20 of total 57 IgG4-SC, 15 of 36 PSC/AIH overlap, and 18 of 55 PSC patients. Serum IgG4 was elevated in 92.65% of IgG4-SC patients with an 86% sensitivity and 98% specificity for diagnosis. IgG4-SC patients had a better treatment response at 6-month and 1-year than PSC/AIH patients, while the latter responded better with steroids than PSC patients. Importantly the adverse outcome-free survival of IgG4-SC patients was reduced, unlike earlier reports, and therefore similar to the PSC/AIH overlap syndrome. Serum IgG and total bilirubin were useful to predict long-term survival of IgG4-SC and PSC/AIH, respectively. In conclusion, serum IgG4≧1.25 ULN shows an excellent predictability to distinguish IgG4-SC among SC patients. IgG4-SC appears to be immune-mediated inflammatory process, while PSC/AIH overlap more tends to be cholestatic disease.
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Affiliation(s)
- Min Lian
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Bo Li
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Xiao Xiao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Yue Yang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Pan Jiang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Li Yan
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Chunyan Sun
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Jun Zhang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Yiran Wei
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Yanmei Li
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Weihua Chen
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Xiang Jiang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Qi Miao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Xiaoyu Chen
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Dekai Qiu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Li Sheng
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Jing Hua
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Ruqi Tang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China
| | - Qixia Wang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China.
| | - M Eric Gershwin
- Division of Rheumatology, Department of Medicine, Allergy and Clinical Immunology, University of California at Davis, Davis, CA, USA.
| | - Xiong Ma
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, State Key Laboratory for Oncogenes and Related Genes, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, 145 Middle Shandong Road, Shanghai 200001, China.
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KARADAĞ Ö, ERDEN A, AYHAN EA, BÖLEK EÇ, KALYONCU U, ARMAĞAN B, SARI A, KILIÇ L, AKDOĞAN A, HAZIROLAN T, AKDOĞAN B, APRAŞ BİLGEN ŞŞ, BAYDAR D, KİRAZ S, ERTENLİ Aİ. The clinical features and outcomes of Turkish patients with IgG4-related disease:a single-center experience. Turk J Med Sci 2017; 47:1307-1314. [DOI: 10.3906/sag-1704-150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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