A clinicopathologic study of immunoglobulin G4-related disease of the femoral and popliteal arteries in the spectrum of immunoglobulin G4-related periarteritis

Immunoglobulin G4-related solitary aneurysm of the deep femoral artery

We have reported the case of an 83-year-old man with a rare immunoglobulin G4 (IgG4)-related solitary deep femoral artery aneurysm. The patient successfully underwent aneurysmectomy and vascular reconstruction with an expanded polytetrafluoroethylene graft. A definitive diagnosis was determined from the comprehensive diagnostic criteria, including histopathologic features of chronic inflammation indicated by massive infiltration of IgG4-positive plasma cells. IgG4-related aneurysmal diseases should be included in the differential diagnosis of deep femoral artery aneurysms, which have traditionally been considered to develop owing to previous trauma or surgery, intervention, infection, and autoimmune or collagen disease.

Exacerbation of immunoglobulin G4-related inflammatory abdominal aortic aneurysm after endovascular repair

A 78-year-old male was admitted to our hospital with lumbar pain and was found to have an abdominal aortic aneurysm (AAA) and femoral artery aneurysm (FAA). Initially, the patient underwent endovascular aneurysm repair (EVAR) for the AAA and aneurysmectomy for the FAA. The FAA was diagnosed by histology as immunoglobulin G4-related disease (IgG4-RD). The preoperative serum IgG4 level was within the normal range, although a slight serum interleukin-6 (IL-6) elevation was observed. Four years later, the AAA-sac diameter had expanded and the serum levels of both IgG4 and IL-6 levels had increased. Six years after the initial EVAR, aneurysmorrhaphy of AAA-sac was performed. The resected specimen revealed adventitial fibrosis and prominent lymphoplasmacytic infiltrate with regulatory T cells, satisfying histological diagnostic criteria for IgG4-RD. Immunoreactive matrix metalloproteinases (MMPs), particularly MMP-2 and MMP-9, and IL-6 were detected within numerous spindle cells in the adventitia of both the FAA and the AAA-sac. Five months after the aneurysmorrhaphy, the residual AAA-sac was again enlarged with a thickened wall that accumulated [¹⁸ F] fluoro-2-deoxy-D-glucose (FDG-PET) on positron emission tomography; these findings were paralleled by increased levels of serum IgG4 and IL-6. Therefore, persistent inflammation after EVAR may be attributed to the inflammatory sequelae of IgG4-RD.

[Raynaud phenomenon with arterial thromboses and IgG4-related disease]

INTRODUCTION

This is a clinical case illustrating a diagnosis of an IgG4 related-disease (IgG4-RD) diagnosed in a vascular context.

CASE REPORT

A 47-year-old man with no past medical history consulted for a recent and disabling Raynaud phenomenon without trophic disorder. Vascular examinations revealed multiple arterial thromboses with no abnormal finger and toe pressures. Secondly, weight loss and submandibular glands enlargement appeared, leading to the diagnosis of IgG4-RD without a link being able to be established with vascular involvement. This is the second observation of this association. A French translation of the new classification criteria for IgG4-RD published in 2019 by the American College of Rheumatology and European Ligue Against Rhumatism (ACR/EULAR) is offered with direct application to the clinical case.

CONCLUSION

A Raynaud phenomenon with distal arterial thrombosis is rarely observed in the IgG4-RD.

Vasculitis beyond aortitis in IgG4-related disease (IgG4-RD): case report and review of the literature

IgG4-related disease (IgG4-RD) can affect almost every tissue/organ. Vascular involvement in the setting of IgG4-RD is increasingly being recognized with most of the cases pertaining patients with aortitis and/or periaortitis with or without aneurysm formation. However, it is now evident that other vessels like iliac arteries, coronary arteries, carotids, and others can also be affected being often underdiagnosed. Vascular involvement is expressed as vessel wall thickening, while aneurysm formation is also occasionally seen. Although histopathological findings are the cornerstone in the diagnosis of IgG4-RD, imaging modalities like magnetic resonance imaging (MRI) and positron emission tomography (PET) are similarly important when vascular involvement occurs, helping in the mapping of the disease and in identifying other, more accessible to biopsy, affected organs. Inflammation markers like erythrocyte sedimentation rate and C-reactive protein have also been described in IgG4-RD patients with vascular involvement. Herein, we present a case of a middle-aged man with long-term high inflammation markers who eventually diagnosed with IgG4-RD after an ascending aorta aneurysm operation, while a subsequent comprehensive magnetic resonance angiography revealed also involvement of the abdominal aorta and the left subclavian and left common carotid. Moreover, we sought to review the current literature about medium- and large-vessel involvement, beyond the aorta, in patients with IgG4-RD.

A Synchronous Ipsilateral True Superficial Femoral Artery and Profunda Femoris Artery Aneurysm With Rupture: A Case Report and Review of the Literature

Atherosclerotic true aneurysms of the superficial femoral artery (SFA) and profunda femoris artery (PFA) are rare and difficult to detect. The synchronous presence of SFA and PFA aneurysms is even rarer. Herein, we present a case with ipsilateral true SFA and PFA aneurysms diagnosed with rupture. A review of the international literature is made, and the diagnosis and treatment options of this rare condition are discussed. A 75-year-old male was admitted to our hospital with an aneurysm on the distal SFA and the ipsilateral PFA, as well as a hematoma around the PFA. It was difficult to determine the source of the rupture before surgery, even with proper imaging. Successful ligation of the PFA and an aneurysmectomy followed by a bypass grafting for the SFA were performed. An intraoperative examination revealed that the SFA aneurysm had ruptured. In elderly males with a history of ectasia or aneurysm on the aorta or peripheral arteries, a synchronous aneurysm on the SFA or the PFA should be suspected.

Efficacy and limitations of the histological diagnosis of type 1 autoimmune pancreatitis with endoscopic ultrasound-guided fine needle biopsy with large tissue amounts

OBJECTIVES

We examined the efficacy and limitations of acquiring large specimens by endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for diagnosing type 1 autoimmune pancreatitis (AIP).

METHODS

Patients from 12 institutions with non-neoplastic diseases or pancreatic ductal adenocarcinoma (PDAC) with large EUS-FNB specimens were investigated. Slides stained with hematoxylin-eosin, elastic, IgG4, and IgG stains were evaluated. The IgG4- and IgG-positive cell numbers were counted in three foci. The diagnoses were based on the Japan Pancreas Society 2011 (JPS 2011) criteria and the International Consensus Diagnostic Criteria (ICDC).

RESULTS

We analyzed 85 non-neoplastic (definite type 1 AIP in 73/85 based on the ICDC) cases and 64 PDAC cases. IgG4-positive cells were numerous (>10 in 85.9%), and the IgG4/IgG ratios were high (>40% in 81.2%). Plasma cell crushing by an artifact caused unsuccessful immunostaining, notably in smaller samples. Tissue lengths were an important factor for the presence of storiform fibrosis and obliterative phlebitis, but storiform fibrosis was equivocal even in large tissues. A definite or possible histological diagnosis was achieved in 45.9% (39/85) and 41.2% (35/85), respectively, and contributed to the definite final diagnosis of type 1 AIP in 33.3% (ICDC) and 55.6% (JPS 2011) in cases with segmental/focal lesions. In the PDAC group, >10 IgG4-positive cells was rare (2/58), but elastic stains revealed fibrous venous occlusions in 10.3% (6/58).

CONCLUSIONS

EUS-FNB with large tissue amounts was useful for diagnosing type 1 AIP, notably by facilitating successful IgG4 immunostaining, but definite diagnosis may not be achieved even in cases with large specimens.

Multimodalities Imaging of Immunoglobulin 4-related Cardiovascular Disorders

Immunoglobulin 4 (IgG4)-related systemic disease (IgG4-RSD) is a systemic inflammatory disease characterized by elevation of serum IgG4. IgG4-RSD can affect any organ in the body, and the list of organs associated with this condition is growing steadily. IgG4-related cardiovascular disease affects the coronary arteries, heart valves, myocardium, pericardium, aorta, pulmonary and peripheral vessels. Echocardiography is the most commonly used non-invasive imaging method. Computed tomography angiography (CTA) can assess aortitis, periarteritis and coronary aneurysms. Coronary CTA is fast, offers high spatial resolution and a wide coverage field of view. Cardiac magnetic resonance imaging (CMR) offers a comprehensive evaluation of the cardiovascular system including cardiac function, extent of myocardial fibrosis, characterise cardiac masses with different pulse sequences and guide to further treatment. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) can provide important information about the extent of disease, the presence of active inflammation and the optimum biopsy site. In general, the role of diagnostic imaging includes establishing the diagnosis, detecting complications, guiding biopsy and documenting response to therapy.

Protective effect of rivaroxaban on arteriosclerosis obliterans in rats through modulation of the toll-like receptor 4/NF-κB signaling pathway

The aim of the present study was to explore the pharmacological role of rivaroxaban in rats with arteriosclerosis obliterans (ASO) and the potential mechanism of its action. A total of 60 adult male Sprague Dawley (weighing 210–250 g) were randomly assigned into either the sham group, model group or Riv group. Rats in the sham group were fed a normal diet, whereas those in model group and Riv group were fed a high-fat diet for 8 weeks. After establishment of the ASO model, rats in the Riv group were intragastrically administered 10 mg/kg rivaroxaban, whereas those in the sham group and the model group were administrated with the same volume of 0.9% saline for 4 weeks. At the end of animal procedures, a blood sample and the femoral artery of the rats were harvested. The results of the present study revealed that rats in the model group presented with an irregularly narrowed femoral artery lumen, disordered endothelial cells, internal elastic plates and smooth muscle cells. By comparison, the arterial wall structure and stenosis of the femoral artery of rats in Riv group recovered and all the pathological changes were alleviated after rivaroxaban treatment. Levels of total cholesterol, triglycerides and low-density lipoproteins decreased, whereas the level of high-density lipoproteins increased in the Riv group compared with the model group. Rivaroxaban treatment significantly reduced serum levels of interleukin-1, tumor necrosis factor-α and monocyte chemoattractant protein-1 (MCP-1), and increased the serum level of transforming growth factor-β (TGF-β). Rats in the Riv group had reduced expression of toll-like receptor 4 (TLR4), NF-κB and MCP-1, and increased expression of TGF-β in femoral artery tissues compared with the model group. Therefore rivaroxaban may have exerted its anti-atherosclerotic effects by regulating the expression of genes in the TLR4/NF-κB signaling pathway and the activation of the downstream molecules.

IgG4-aortitis among thoracic aortic aneurysms

Objective

The incidence of aortitis in patients with thoracic aortic diseases is not well established. The aim of this study was to analyse the frequency and clinical course of patients with aortitis in a surgical series.

Methods

320 consecutive patients with ascending aorta/aortic arch aneurysm or acute aortic syndrome who underwent surgery from 2012 to 2017 in a single tertiary referral hospital were retrospectively reviewed. Epidemiological data, clinical course and variables related to diagnosis, treatment and follow-up were collected from patients with histologically proven aortitis.

Results

From 320 examined aortic samples, 279 (87.2%) thoracic aneurysms and 41 acute aortic syndromes (12.8%), 9 (2.8%) were aortitis: 3 cases of Takayasu’s arteritis, 3 of IgG4-related aortitis, 2 of giant cell, and 1 classified as idiopathic. Median age at surgery was 53.4 (51–69.2) years and six cases were female. Seven patients presented with non-specific symptoms and the diagnosis was made at pathology. Surgery was elective in eight patients and emergent in one case of IgG4-related aortitis. 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) was performed for disease extension study and as a monitoring technique during the follow-up of five patients, with just one case performed presurgically. All the patients with IgG4-related disease showed extrathoracic aortic involvement. There were no deaths, neither in-hospital nor during the 1.7 years of median follow-up.

Conclusions

In surgically treated thoracic aorta pathology, the frequency of aortitis is low; IgG4-related disease is among the most common aetiologies with a frequency similar to other types of aortitis, such as Takayasu’s and giant cell arteritis, and clinical manifestations are non-specific making presurgical diagnosis difficult. 18F-FDG PET/CT allows a better assessment of disease extension and therapeutic response. Surgery can be successfully performed and corticosteroid therapy ensures a good mid-term follow-up.

Hybrid treatment of an isolated immunoglobulin G4-related internal thoracic artery aneurysm

True aneurysms of the internal thoracic artery (ITA) are rare and are associated with vasculitides, connective tissue diseases, and infections. We report a case of a 3-cm immunoglobulin G4-positive ITA aneurysm that was excised by a hybrid approach involving open ligation of the ITA origin and video-assisted thoracoscopic aneurysmectomy. This novel technique was able to acquire tissue for histopathologic diagnosis through a minimally invasive means.

Superficial temporal artery aneurysm associated with immunoglobulin G4-related disease

A 68-year-old man was admitted because of a pulsatile mass and pain in the left temporal region, and computed tomography demonstrated the superficial temporal artery aneurysm. He underwent aneurysmectomy, and pathologic investigation revealed marked thickness of the adventitia with substantial plasmacyte infiltration. On immunoglobulin G4 (IgG4) immunohistochemistry, IgG4-positive lymphocytes were scattered in the adventitia, and biochemical tests revealed elevation of IgG4 (200 mg/dL). The case satisfied the criteria for both giant cell arteritis and IgG4-related disease (IgG4-RD). This case report suggested that IgG4-RD can occur in the superficial temporal artery and that IgG4-RD may partially overlap with a subtype of giant cell arteritis.

IgG4-Related Arterial Disease

Immunoglobulin G4-related diseases (IgG4-RD) are systemic inflammatory conditions, characterized by high serum IgG4 concentrations, and pathologically IgG4-positive plasmacytes infiltrations and storiform fibrosis. We described IgG4-related inflammatory abdominal aortic aneurysm in 2008, and revealed the existence of vascular lesions. IgG4-related vascular lesions frequently occur in the aorta and branching medium-sized arteries with or without aneurysmal change. The inflammatory lesion mainly involves in the adventitia, indicating remarkable adventitial fibrous thickening with infiltration of inflammatory cells. Clinical symptoms associated with IgG4-related vascular lesions might be fever, abdominal pain, hydronephrosis, or few subjective symptoms. Comprehensive diagnostic criteria is applied according to image findings of thickening lesions, high serum IgG4 levels, and histopathological findings. As a treatment, open surgical repair or endovascular aneurysm repair is performed for the aneurysmal cases, and steroid administration is used for the cases with strong inflammation. This disease can lead to a lethal situation due to the rupture following aneurysmal formation, thus special attention is needed unlike IgG4-RD occupying in the other organs. (This is a translation of Jpn J Vasc Surg 2017; 26: 129–134.)

Clinical features of IgG4-related periaortitis/periarteritis based on the analysis of 179 patients with IgG4-related disease: a case-control study

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized systemic condition characterized by high serum immunoglobulin G4 (IgG4) concentration and IgG4-bearing plasma cell infiltration in affected organs. Although it has become evident that IgG4-RD also involves the systemic aortic/arterial system, the precise details of this condition remain unclear. The present study sought to clarify the clinical features of IgG4-related periaortitis/periarteritis.

METHODS

Among 223 patients with IgG4-RD, 179 (131 male, median onset age 67 years) were recruited for this study. Periaortitis/periarteritis was defined as vessel wall thickness with circumferential enhancement on contrast-enhanced computed tomography.

RESULTS

Periaortitis/periarteritis was identified in 65 (36.3%; 53 male) of 179 IgG-RD patients. The distribution of IgG4-related periaortitis/periarteritis could be broadly classified into five types, with the most prevalent Type 2 (44.6%) being localized at the infra-renal artery portion of the abdominal aorta and continuing to the iliac arteries. The infra-renal artery region of the abdominal aorta was most frequently involved (>80%) among IgG4-related periaortitis/periarteritis cases. Comparisons of clinical parameters between IgG4-RD patients with and without periaortitis/periarteritis revealed significantly higher propensities for older IgG4-RD onset age and highly active disease state featuring elevated serum IgG, IgG4, circulating immune complex, and soluble interleukin-2 receptor. All patients showed improvement of wall thickening after steroid therapy, although nine patients (20.9%) exhibited worsening of luminal dilatation. The main risk factor for this manifestation was prior luminal dilatation according to multivariate analysis.

CONCLUSION

IgG4-related periaortitis/periarteritis predominantly occurred at the infra-renal artery portion of the abdominal aorta, affected older IgG4-RD onset patients, and was prevalent in highly active disease states. As reported previously, the main risk factor for worsening luminal dilation after corticosteroid therapy was the existence of luminal dilation beforehand.

Clinical course after corticosteroid therapy in IgG4-related aortitis/periaortitis and periarteritis: a retrospective multicenter study

Introduction

Immunoglobulin G4 (IgG4)–related aortitis/periaortitis and periarteritis are vascular manifestations of IgG4-related disease. In this disease, the affected aneurysmal lesion has been suspected to be at risk of rupture. In this study, we aimed to clarify the clinical course after corticosteroid therapy in IgG4-related aortitis/periaortitis and periarteritis.

Methods

We retrospectively evaluated clinical features, including laboratory data, imaging findings and the course after corticosteroid therapy, in 40 patients diagnosed with IgG4-related aortitis/periaortitis and periarteritis on the basis of periaortic/periarterial radiological findings, satisfaction of the comprehensive diagnostic criteria or each organ-specific diagnostic criteria, and exclusion of other diseases.

Results

The patients were mainly elderly, with an average age of 66.4 years and with a marked male predominance and extensive other organ involvement. Subjective symptoms were scanty, and only a small proportion had elevated serum C-reactive protein levels. The affected aorta/artery were the abdominal aortas or the iliac arteries in most cases. Thirty-six patients were treated with prednisolone, and the periaortic/periarterial lesions improved in most of them during the follow-up period. Two (50.0%) of four patients with luminal dilatation of the affected lesions before corticosteroid therapy had exacerbations of luminal dilatation after therapy, whereas none of the twenty-six patients without it had a new appearance of luminal dilatation after therapy.

Conclusions

The results of this retrospective multicenter study highlight three important points: (1) the possibility of latent existence and progression of periaortic/periarterial lesions, (2) the efficacy of corticosteroid therapy in preventing new aneurysm formation in patients without luminal dilatation of periaortic/periarterial lesions and (3) the possibility that a small proportion of patients may actually develop luminal dilatation of periaortic/periarterial lesions in IgG4-related aortitis/periaortitis and periarteritis. A larger-scale prospective study is required to confirm the efficacy and safety of corticosteroid therapy in patients with versus those without luminal dilatation and to devise a more useful and safe treatment strategy, including administration of other immunosuppressants.

IgG4- related disease: an orphan disease with many faces

Immunoglobulin G4- related disease (IgG4-RD) is a rare systemic fibro-inflammatory disorder (ORPHA284264). Although patients have been described more than 100 years ago, the systemic nature of this disease has been recognized in the 21^st century only. Type 1 autoimmune pancreatitis is the most frequent manifestation of IgG4-RD. However, IgG4-RD can affect any organ such as salivary glands, orbits, retroperitoneum and many others. Recent research enabled a clear clinical and histopathological description of IgG4-RD. Typically, lymphoplasmacellular inflammation, storiform fibrosis and obliterative phlebitis are found in IgG4-RD biopsies and the tissue invading plasma cells largely produce IgG4. Elevated serum IgG4 levels are found in many but not all patients. Consequently, diagnostic criteria for IgG4-RD have been proposed recently. Treatment is largely based on clinical experience and retrospective case series. Glucocorticoids are the mainstay of therapy, although adjunctive immunosuppressive agents are used in relapsing patients. This review summarizes current knowledge on clinical manifestations, pathophysiology and treatment of IgG4-RD.