Idiopathic and secondary forms of retroperitoneal fibrosis: a diagnostic approach

A Review on The Role of Environmental Exposures in IgG4-Related Diseases

PURPOSE OF REVIEW

Immunoglobulin G4-related diseases (IgG4-RDs) are immune-mediated fibroinflammatory multisystemic conditions identified by the presence of tumefactive lesions with a rich infiltrate of IgG4-positive plasma cells, and often by a high IgG4 serum concentration. IgG-RDs have a prevalence of at least 1 case every 100,000 persons, and they are mostly diagnosed after age 50, with a male to female ratio of about 3:1. IgG4-RD pathophysiology is still uncertain: it has been proposed that both genetic predisposition and chronic environmental exposures may play a role by triggering abnormal immune activation that perpetuates the disease. The purpose of this review is to summarize the evidences supporting the hypothesis that certain environmental/occupational exposures can trigger IgG4-RDs, focusing on the possible role of asbestos in an emerging IgG4-RD called idiopathic retroperitoneal fibrosis (IRF).

RECENT FINDINGS

Although some studies suggested a relationship between tobacco smoking and IgG4-RD risk, occupational exposures seem to have the most interesting effects. Positive history of blue-collar work increases the risk of developing an IgG4-RD, and mineral dusts and asbestos were the most strongly associated industrial compounds. Asbestos has been found to be a risk factor for IRF years before its classification as IgG4-RD, and later in two large case-control studies. In the most recent one, conducted on 90 patients and 270 controls, asbestos exposure conferred an increased IRF risk, quantified by odds ratios from 2.46 to 7.07. Further structured studies including serum IgG4 evaluation should be conducted to clarify the effect of asbestos on patients with confirmed diagnosis of IgG4-related IRF. Environmental exposures, especially of occupational origin, appear to play a role in the development of different types of IgG-RDs. In particular, although first suggested very recently, the relationship between asbestos and IRF deserves to be explored in more structured studies, especially because of the biological plausibility of the role of asbestos in IRF pathogenesis.

Investigating the Link Between Low Back Ache, Abdominal Discomfort and Oliguria: A Unique Case of Histopathology-Proven Retroperitoneal Fibrosis

Retroperitoneal fibrosis (RPF) is a rare condition characterized by systemic inflammation and the proliferation of fibroinflammatory tissues in the retroperitoneum. It may lead to the formation of a retroperitoneal mass and can encase the aorta, its branches and ureters. The pathogenesis of RPF is not fully known. We report a case of a 52-year-old male presented with low back ache, flank pain, swelling of legs, oliguria and features of obstructive uropathy, later diagnosed to be RPF. The mainstay of diagnosis includes blood workup, imaging and biopsy. The first line of treatment is corticosteroids. Surgical intervention is carried out when medical measures have failed or when contraindicated. Early diagnosis and prevention of complications is the key, and a high degree of suspicion is needed.

Are psychedelics the answer to chronic pain: A review of current literature

AIMS

We aim to provide an evidence-based overview of the use of psychedelics in chronic pain, specifically LSD and psilocybin.

CONTENT

Chronic pain is a common and complex problem, with an unknown etiology. Psychedelics like lysergic acid diethylamide (LSD) and psilocybin, may play a role in the management of chronic pain. Through activation of the serotonin-2A (5-HT2A) receptor, several neurophysiological responses result in the disruption of functional connections in brain regions associated with chronic pain. Healthy reconnections can be made through neuroplastic effects, resulting in sustained pain relief. However, this process is not fully understood, and evidence of efficacy is limited and of low quality. In cancer and palliative related pain, the analgesic potential of psychedelics was established decades ago, and the current literature shows promising results on efficacy and safety in patients with cancer-related psychological distress. In other areas, patients suffering from severe headache disorders like migraine and cluster headache who have self-medicated with psychedelics report both acute and prophylactic efficacy of LSD and psilocybin. Randomized control trials are now being conducted to study the effects in cluster headache Furthermore, psychedelics have a generally favorable safety profile especially when compared to other analgesics like opioids. In addition, psychedelics do not have the addictive potential of opioids.

IMPLICATIONS

Given the current epidemic use of opioids, and that patients are in desperate need of an alternative treatment, it is important that further research is conducted on the efficacy of psychedelics in chronic pain conditions.

Serum IgG4 Concentration Is a Potential Predictive Biomarker in Glucocorticoid Treatment for Idiopathic Retroperitoneal Fibrosis

Objectives: To evaluate the management and outcome of idiopathic retroperitoneal fibrosis (iRPF) in Japan, and to identify its clinical biomarker. Methods: We retrospectively analyzed 129 patients with iRPF treated between January 2008 and May 2018 at 12 university and related hospitals. Patients treated with glucocorticoid were analyzed to identify a predictive biomarker. These patients were classified into three groups according to overall effectiveness (no change: NC, complete response: CR, and partial response groups: PR), and each parameter was compared statistically. Results: Male–female ratio was 5:1, and median age at diagnosis was 69 (33–86) years. Smoking history was reported in 59.6% of the patients. As treatment, 95 patients received glucocorticoid therapy with an overall response rate of 84%. As a result, serum concentration of IgG4 was significantly decreased in NC group compared with the other two groups (56.6 mg/dL vs. 255 mg/dL, 206 mg/dL, p = 0.0059 and 0.0078). ROC analysis was performed between the nonresponder (NC) and responder groups (CR + PR) to identify the cut-off value of serum IgG4 as a predictive marker. As a result, AUC of 0.793 was confirmed. Conclusions: Pre-treatment serum IgG4 concentration may have potential as a predictive biomarker of steroid treatment.

Comparison of laparoscopic and open ureterolysis for retroperitoneal fibrosis: Results from a tertiary referral center

OBJECTIVES

To compare the surgical outcomes of open and laparoscopic ureterolysis procedures in patients requiring surgical treatment for ureteral obstruction caused by retroperitoneal fibrosis.

MATERIALS

This study was designed retrospectively. The clinical records of patients who underwent ureterolysis between January 2005 and April 2019 due to ureteral obstruction caused by retroperitoneal fibrosis were examined. According to the type of surgery, the patients were divided into two groups as Group 1 (open ureterolysis) and Group 2 (laparoscopic ureterolysis). Demographic features, preoperative-postoperative renal functions, duration of follow-up with ureteral stents, and perioperative-postoperative complications were examined. The requirement of ureteral stent placement during the follow-up period was accepted as unsuccessful ureterolysis.

RESULTS

Ureterolysis was performed in 13 patients and 23 renal units. Eleven of these patients were male and two were female. The median age of the patients was 54 (44-68) years. There were six patients and 12 renal units in Group 1 and seven patients and 11 renal units in Group 2. Postoperatively, a total of four patients (30%) had minor complications (Clavien-Dindo 1-2) and one patient had a major complication (Clavien-Dindo 3a). Ureterolysis was determined to be successful in 21 of the renal units (91%) [11/12 (92%) in Group 1 vs 10/11 (91%) in Group 2]. No statistically significant difference was found between the groups in terms of the success and complication rates (p=1 and p=0.529, respectively). Postoperative hospitalization length and recovery time to return to normal preoperative activities were significantly shorter in Group 2 than Group 1 (p=0.011 and p=0.041, respectively).

CONCLUSIONS

The success and complication rates were similar between the open and laparoscopic methods for ureterolysis. Laparoscopic approach was advantageous over open approach in terms of postoperative hospitalization length and recovery time to return to normal preoperative activities.

Retroperitoneal fibrosis is still underdiagnosed entity with poor prognosis

BACKGROUND

Retroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of inflammatory and fibrous retroperitoneal tissue that often encircles abdominal organs including aorta and ureters. Data on the incidence of this disease are limited.

SUMMARY

The disease may be idiopathic or secondary to infections, malignancies, drugs or radiotherapy. Idiopathic form is an immune-mediated entity and a part of the broader spectrum of idiopathic diseases termed chronic periaortitis, characterized by a morphologically similar fibroinflammatory changes in aorta and surrounding tissues. Taking into account the dominant symptoms and clinical charac-teristics of patients with periaortitis, two subtypes of disease could be distinguished. Vascular subtype include patients with non-dilated aorta or with inflammatory abdominal aortic aneu-rysm, both with and without involvement of adjacent structures and with numerous risk factors for atherosclerosis. In renoureteral subtype obstructive uropathy manifesting with hydronephro-sis and acute kidney injury is predominant finding. Due to the variety of symptoms, diagnosis of RPF remains challenging, difficult and often delayed. A series of diagnostic tests should be performed, in order to confirm the diagnosis idiopathic RPF. Laboratory work-up include eval-uation of inflammatory indices and immunological studies. A biopsy and histopathological evaluation may be necessary to confirm diagnosis and differentiate the disease. Computed to-mography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) are the modalities of choice for the diagnosis and follow-up of this disease. Management of ureteral obstruction, hydronephrosis, and aortic aneurysms often requires surgical evaluation and treatment. The pharmacological treatment of RPF has been evaluated in a few randomized trials and is mainly based on observational studies. Steroid therapy remains the gold standard of treatment. Key messages: Nowadays multidisciplinary team approach with clinical and diagnos-tic experience in both primary and secondary RPF as well as two major subtypes should be offered. Centers specialized in rare diseases with collaboration with other units and referral sys-tem yield the best possible outcomes.

Retroperitoneal fibrosis masquerading as pelvi-ureteric junction obstruction - Laparoscopic management

Introduction

Retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory condition which is characterized by development of extensive fibrosis throughout the retroperitoneum. It is classically centred over the anterior surface of the fourth and fifth lumbar vertebrae. It results in entrapment and extrinsic compression of retroperitoneal structures.

Presentation of the case

We present the case of a 69 years old man who was reported to have right pelvi - ureteric junction obstruction on computed tomography, but turned out to have RPF.

Discussion

Retroperitoneal fibrosis commonly causes obstructive uropathy (either unilateral, bilateral or progressing from unilateral to bilateral) and if untreated, renal failure. It has high response/remission rates to glucocorticoid therapy. However, relapse rates are also high. Hence, close surveillance with serial laboratory and imaging investigations, after achieving remission, is key to long term disease control.

Conclusion

Although classical imaging findings, supportive laboratory markers and suggestive/diagnostic histopathology appearances for RPF are well documented, its accurate preoperative diagnosis is not always an assured certainty.

•

This case is unique in that the original plan to perform a laparoscopic pyeloplasty, purportedly for right pelvi-ureteric junction obstruction; was aborted ‘on table’ and a laparoscopic ureterolysis performed, instead.

•

Though ureteral involvement is bilateral in most cases of retroperitoneal fibrosis, this case is rare and unique in that the patient had unilateral involvement of his ureter (right sided).

•

Periaortic fibro-inflammatory mass at the level of the lumbar vertebrae is the hallmark of primary / idiopathic retroperitoneal fibrosis. However in this case, no such imaging finding was noted. Instead, the patient had just obvious unilateral (ride sided) disease on pre-operative imaging.

Unique Presentation of Idiopathic Retroperitoneal Fibrosis in a Primary Care Setting

Patients with retroperitoneal fibrosis (RPF), a rare condition, present with nonspecific abdominal pain or flank pain that can be complicated by urologic obstruction and/or vascular compromise. Reporting rare entities that often elude prompt diagnosis will aid clinicians to consider the entity in their differential diagnosis and potentially lead to earlier recognition and appropriate management. Our case emphasizes the importance of not just the diagnosis and treatment of RPF but how to best monitor RPF patients to minimize complications from disease progression or treatment-related adverse events.

Retroperitoneal Fibrosis as a presentation with masked multiorgan involvement of IgG4-related disease-demystifying the diagnosis: A case report from Nepal

The timely diagnosis of the disease helps in preventing the progression of RF and unnecessary interventions that may mislead the diagnosis. Biopsy and serum IgG4 both can be non-specific.

A case of idiopathic retroperitoneal fibrosis presenting as gallbladder carcinoma

Background

Retroperitoneal fibrosis (RPF) is a rare disease with a poor prognosis characterized by systemic inflammation and fibroinflammatory tissue. Idiopathic RPF (IRPF) accounts for approximately two-thirds of RPF cases.

Case presentation

A 56-year-old female patient with abdominal distension was admitted to Changxing Hospital. Laboratory tests revealed mild anemia and elevated CA125, while IgG4 and autoantibodies were within the normal ranges. Computed tomography (CT) revealed a gallbladder-occupying lesion, pancreatic cyst and retroperitoneal mass, which may have contributed to bilateral ureteral compression and hydronephrosis. The initial diagnosis was gallbladder carcinoma with lymph node metastasis. Then, abdominal adhesiolysis, cholecystectomy and partial hepatectomy were performed. Histologically, there were fibrosis and inflammation in the retroperitoneal tissue without any malignant cells in the retroperitoneal or gallbladder tissue. Finally, we confirmed the diagnosis of idiopathic retroperitoneal fibrosis, chronic cholecystitis and pancreatic cyst. The patient recovered well following the CT scan, in which dilatation of the bile duct was reduced, and effusion of the bilateral upper ureter was no longer significant.

Conclusion

This atypical case illustrates that RPF can be combined with other biliary tract diseases. The coexistence of other diseases conceals the symptoms of RPF, which increases the difficulty of image identification. A high degree of suspicion is necessary for routine clinical work. As more cases are reported, further advances in the diagnosis and treatment of RPF can be expected.

IgG4-Related Retroperitoneal Fibrosis: A Rare Association With Riedel's Thyroiditis

Idiopathic retroperitoneal fibrosis is a rare fibro-inflammatory disease that can be associated with other IgG4-related diseases (IgG4-RDs). It is exceedingly uncommon to encounter this condition in a patient with Riedel's thyroiditis (RT), another disease in the IgG4-RD family. We present the case of a 53-year-old man with a history of RT who presented for severe localized lower abdominal and suprapubic pain due to obstructive uropathy from extensive retroperitoneal fibrosis. The biopsy of the mass demonstrated fibro-inflammatory tissue, and its immunohistochemistry was notable for IgG4-positive plasma cells. This case highlights the challenge associated with the diagnosis and management of this rare manifestation of IgG4-RD. In a patient with a history of any form of IgG4-RDs, providers should be vigilant for any signs or symptoms that suggest the development of fibrosis in other organs.

[Retroperitoneal fibrosis at the Ibn Sina University Hospital of Rabat: about 18 cases]

La fibrose rétropéritonéale (FRP) est une pathologie rare caractérisée par la formation d´une plaque fibro-inflammatoire dans l´espace rétropéritonéale en avant de l´aorte abdominale, responsable d´un engainement des uretères. Le tableau clinique n´est pas spécifique et la pathologie est souvent révélée par une uropathie obstructive. Nous avons mené une étude descriptive rétrospective étendue sur 10 ans, de janvier 2006 à décembre 2016, réalisée dans les services d´urologie B et de néphrologie du Centre Hospitalier Universitaire Ibn Sina. Nous avons inclus 18 patients dans l´étude dont 11 hommes et 7 femmes, avec un âge moyen de 51,4 ans ± 11,2. Le diagnostic a été révélé par des douleurs lombaires chez 14 patients. L´insuffisance rénale obstructive était présente chez 15 de nos patients et le diagnostic de FRP a été posé par l´uroscanner. Le bilan étiologique notait des antécédents de néoplasies pour 2 patients, de pathologies inflammatoires pour 2 autres patients et une chirurgie rétropéritonéale chez un patient. On notait l´association de prises médicamenteuses chroniques chez plus de la moitié des patients. Le traitement comportait un double volet: une sonde double J systématique chez tous les patients et un traitement systémique par de la corticothérapie et des immunosuppresseurs selon le profil évolutif. Le traitement par urétérolyse a été réalisé d´emblée chez 3 patients. L´évolution a été favorable avec une nette amélioration de la fonction rénale chez 12 patients. La rechute est survenue chez 2 patients après 2 ans de suivi. L´association de signes généraux à une insuffisance rénale obstructive doit faire évoquer le diagnostic de FRP. La recherche de causes secondaires devrait être systématique, avec un accent particulier à mettre sur le syndrome d´hyper IgG4 et les pathologies néoplasiques.

Into Clinical Practice: Diagnosis and Therapy of Retroperitoneal Fibrosis

PURPOSE OF THE REVIEW

We aim to review the most relevant diagnostic features and treatment options of retroperitoneal fibrosis, in order to provide a useful guide for clinical practice.

RECENT FINDINGS

The recent literature highlights the role of imaging studies such as computed tomography, magnetic resonance imaging and positron emission tomography as useful tools for the diagnosis of retroperitoneal fibrosis, with retroperitoneal biopsy being reserved to atypical cases. The treatment approach is mainly conservative and is based on the use of medical therapies plus urological interventions. Medical therapies essentially comprise glucocorticoids and immunosuppressants-either traditional or biological agents such as rituximab. Surgical ureterolysis is only left for refractory cases. Recent findings in retroperitoneal fibrosis highlight the possibility of a non-invasive diagnostic approach and a conservative treatment strategy.

IgG4 related disease as a cause of isolated retroperitoneal fibrosis with no other organ involvement; Case report

Introduction and importance

Retroperitoneal fibrosis (RPF) is a rare disease characterized by the replacement of normal tissue with fibrosis and inflammation. We present the case of a 40-years-old gentleman with RPF whose presenting complaints were bilateral flank pain and weight loss and was found to have IgG4 related disease. To the best of our knowledge, IgG4-related disease with isolated retroperitoneal involvement is a very rare occurrence.

Case presentation

The diagnosis of IgG4-Related retroperitoneal fibrosis was made based on clinical, radiological and histopathological criteria. Imaging revealed isolated retroperitoneal involvement and the patient was started on oral steroids with a good clinical response after ten days. Repeated imaging months later showed significant regression in the fibrosis.

Clinical discussion

RPF can occur due to many etiologies and is categorized to idiopathic and secondary. Factors associated with secondary RPF include medications, autoimmune disease, malignancy and IgG4 related disease. Almost all the reported cases of IgG4 related disease had evidence of multifocal involvement such as the pancreas, aorta and kidneys. Our patient was diagnosed with isolated RPF due to IgG4 disease. He met all the suggested diagnostic criteria, was started on oral steroids and had an excellent clinical outcome.

Conclusion

IgG4 related disease can present with isolated retroperitoneal fibrosis without involvement of other organ systems. The diagnosis should be based on specific criteria. Treatment with corticosteroids can lead to remission both clinically and radiographically.

[IgG4-related disease: Diagnostic criteria evolution toward the 2019 ACR/EULAR classification criteria]

The concept of IgG4-related disease (IgG4-RD) has recently been individualized in the early 2000s, but most of the organ involvements are known since more than 100 years. IgG4-RD is a non-malignant fibroinflammatory disorder, characterized by peculiar immunological and pathological abnormalities, which can affect virtually all organs or tissues. Diagnostic criteria have been proposed and have evolved rapidly, with general or organ specific criteria. An international and multidisciplinary group assembled by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) has recently developed and validated a set of classification criteria called 2019 ACR/EULAR classification criteria for IgG4-related disease. The objective of this review is to discuss the evolution from organ specific and general diagnostic criteria toward the 2019 ACR/EULAR classification criteria, as well as respective benefits and limits of these criteria. The use of the 2019 ACR/EULAR classification criteria will help to better define homogeneous group of IgG4-RD patients in future clinical, epidemiological and basic science research studies on the disease.

Standardized approach to idiopathic retroperitoneal fibrosis: a comprehensive review of the literature

BACKGROUND

Idiopathic retroperitoneal fibrosis (iRPF) is a rare fibro-inflammatory disease, characterized by inflammation of the abdominal aorta and its surrounding structures. The exact pathophysiology remains unclear. Diagnosis is often troublesome due to the non-specific and highly variable clinical presentation. Standardized treatment protocols are lacking.

OBJECTIVE

This article presents a review on iRPF, addressing clinical and diagnostic modalities as well as its pathophysiology and the possible inclusion within the IgG4-related disease (IgG4-RD) spectrum. Finally, a diagnostic-therapeutic algorithm for a standardized approach to iRPF is proposed.

METHODS

The PubMed Internet database was searched. Articles were selected based on the relevance of abstract, article type and impact of the journal.

RESULTS

iRPF and IgG4-RD share a common autoimmune aetiology. Diagnostics are multimodal and based on imaging. Ruling out malignancy should be of primary concern. Complications are mostly of renal or vascular origin due to compression of retroperitoneal structures. Corticosteroids remain the first-line treatment regimen and are mostly successful, but evidence supporting alternative immunosuppressive and anti-inflammatory treatments is growing. Long-term therapy, as well as follow-up, is paramount in this chronic and often relapsing disease.

Metallic ureteral stent in restoring kidney function: Nine case reports

BACKGROUND

Retroperitoneal fibrosis is an exceptionally rare disease characterized by proliferation of fibrous tissue and inflammation in the retroperitoneum. It features many symptoms in the kidneys and in other organs and usually leads to ureteral obstruction.

CASE SUMMARY

Here we present 9 consecutive cases of idiopathic retroperitoneal fibrosis (IRPF) in patients who presented to the Department of Nephrology or Department of Rheumatology, Xuanwu Hospital, Capital Medical University, Beijing, China, between January 2012 and June 2017 with ureteral obstruction due to external compression of the ureter that led to hydronephrosis and kidney dysfunction. Computed tomography imaging was used to identify hydronephrosis and ureteral obstruction and to evaluate kidney function. Each patient was diagnosed with IRPF based on clinical observation and computed tomography examination results. To restore kidney function, a retrograde metallic stent was placed in the ureter under X-ray guidance 2 d after each patient’s admission. No perioperative complications occurred in any patient, but postoperative complications occurred in two patients as follows: Patient 2 had stent migration and repeated metallic stent infections that resolved with treatment; and patient 4 had postoperative hematuria because he resumed normal activities too soon after stent placement (contrary to instruction). Placement of the metallic ureteral stents provided relief from ureteral obstruction and restored kidney function in all patients.

CONCLUSION

Our 9-case series underscores the utility and efficacy of applying the Resonance^® metallic ureteral stent to treat ureteral obstruction in patients with IRPF. For all retroperitoneal fibrosis cases in our series, ureteral stents provided effective relief and were shown to reduce the incidence rate of perioperative and postoperative complications.

Aortitis and periaortitis: The puzzling spectrum of inflammatory aortic diseases

Aortitis and periaortitis are inflammatory diseases of the aorta and its main branches; they differ in the extension of inflammation, which is confined to the aortic wall in aortitis, and spreads to the periaortic space in periaortitis. Aortitis is classified as non-infectious or infectious. Non-infectious aortitis represents a common feature of large-vessel vasculitides but can also be isolated or associated with other rheumatologic conditions. Periaortitis can be idiopathic or secondary to a wide array of etiologies such as drugs, infections, malignancies, and other proliferative diseases. Notably, both aortitis and periaortitis may arise in the context of IgG4-related disease, a recently characterised fibro-inflammatory systemic disease. Prompt recognition, correct diagnosis and appropriate treatment are essential in order to avoid life-threatening complications.

Current approach to diagnosis and management of retroperitoneal fibrosis

Retroperitoneal fibrosis is characterized by fibrotic lesions around the abdominal aorta and common ileac artery causing ureteral obstruction. Secondary retroperitoneal fibrosis is associated with malignant disease, drugs, exposure to radiation and surgery. In contrast, the majority of retroperitoneal fibrosis is classified into idiopathic retroperitoneal fibrosis, for which immunological etiology has been suggested. Recently, idiopathic retroperitoneal fibrosis has been considered to be a spectrum of immunoglobulin G4-related disease, a systemic inflammatory disease, the concept of which has been developed during the past decade. In the management of retroperitoneal fibrosis, assessment of systemic lesions associated with immunoglobulin G4-related disease and the exclusion of secondary retroperitoneal fibrosis is mandatory. Histological examination of retroperitoneal lesions is desired for accurate diagnosis and management. Laparoscopic or open biopsy is often beneficial, although it is more invasive than needle biopsy. Treatment for idiopathic retroperitoneal fibrosis consists of meticulous glucocorticoid therapy based on that for immunoglobulin G4-related disease, which is expected to be highly effective. Ureteral obstruction is usually managed with conservative procedures, such as ureteral stenting or percutaneous nephrostomy. The goal of treatment for retroperitoneal fibrosis should be freedom from the stent/nephrostomy with withdrawal of the glucocorticoid in addition to salvage of renal function; however, conservative management does not always provide favorable outcomes. In contrast, aggressive surgical treatment, such as ureterolysis, can achieve the goal; however, the procedure is associated with high morbidity. Establishment of a consensus about treatment for idiopathic retroperitoneal fibrosis, including the optimal indications for the invasive surgical procedure and conservative management, is desired.

Medical Challenge Posed by Retroperitoneal Fibrosis: Case Reports and Literature Review

Idiopathic retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory disease, with a low incidence worldwide, which occurs around the abdominal aorta and the iliac arteries. It spreads through the retroperitoneum causing ureteral obstruction with associated renal failure and obstruction of other adjacent structures. RPF can be idiopathic or secondary to neoplastic processes, infections, or medications. RPF is considered part of the spectrum of the disease related to immunoglobulin G4 (IgG4) and other autoimmune disorders. Occupational exposure to asbestos and tobacco smoke are important risk factors for the development of idiopathic RPF. The clinical picture is nonspecific, from pain to symptoms due to ureteral compression, this being the main complication associated.

Imaging studies are essential in the diagnosis; computed tomography (CT) and magnetic resonance imaging (MRI) are the most reliable imaging modalities. The goal of treatment is to stop the progression of the fibroinflammatory reaction. The first line of treatment is usually with medical management. Biological agents, such as rituximab and infliximab, have also been used, even with scarce data in the literature. Surgery is usually performed to improve a ureteral obstruction and should always be accompanied by systemic steroid treatment. The conservative approach given by systemic therapy and ureteral stent placement or nephrostomies has been recommended, thus reserving surgical treatment for refractory cases.

We present two clinical cases of idiopathic RPF, one of them associated with IgG4.

Emergence of a lymphoma imitating an infectious infiltration surrounding the infrarenal aorta after EVAR

Primary retroperitoneal localization of non-Hodgkin's lymphoma is rare but should be considered, even if the circumstances surrounding its emergence point to other direction. We present a case of an appearance of periaortic infiltration after successful endovascular treatment which turned out to be of malignant origin.

Listeria monocytogenes infectious periaortitis: a case report from the infectious disease standpoint

Background

Endograft infection is a rare but extremely dangerous complication of aortic repair (25–100% of mortality). We describe here the first case of Listeria monocytogenes abdominal periaortitis associated with a vascular graft. We also discuss the differential diagnosis of periaortitis and provide a literature review of L. monocytogenes infectious aortitis.

Case presentation

Nine months after endovascular treatment of an abdominal aortic aneurysm (abdominal stent graft), a 76-year-old man was admitted for severe abdominal pain radiating to the back. Laboratory tests were normal apart from elevated C-reactive protein (CRP). Injected abdominal computed tomography (CT) showed infiltration of the fat tissues around the aortic endoprosthesis and aneurysmal sac expansion; positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro- D-glucose integrated with computed tomography (18F-FDG PET/CT) showed a hypermetabolic mass in contact with the endoprosthesis. Blood cultures were negative. At surgical revision, an infra-renal peri-aortic abscess was evident; post-operative antibiotic therapy with ciprofloxacin and doxycycline was started. Cultures of intraoperative samples were positive for L. monocytogenes. Results were further confirmed by a broad-range polymerase chain reaction (PCR) and next-generation sequencing. Antibiotic treatment was switched to intravenous amoxicillin for 6 weeks. Evolution was uneventful with decrease of inflammatory parameters and regression of the abscess.

Conclusion

An etiologic bacterial diagnosis before starting antibiotic therapy is paramount; nevertheless, culture-independent methods may provide a microbiological diagnosis in those cases where antimicrobials are empirically used and when cultures remain negative.

Rheumatic manifestations as initial presentation of malignancy: A case series from a tertiary care center in India

OBJECTIVE

Malignant neoplasms can be associated with a wide variety of rheumatological manifestations that may be caused by direct tumor invasion into bones and joints, as a paraneoplastic syndrome, and through altered immune surveillance. To identify the relationship between rheumatic manifestations in various malignancies.

METHODS

Twenty patients with various malignancies presenting with rheumatic conditions in our tertiary medical care were studied retrospectively from case records at the Kalinga Institute of Medical Sciences from 2013 to 2018.

RESULTS

In the present study, total of 20 patients including 12 males and 8 females with mean age at diagnosis of was 46.3±22.2 years with various malignancy associated rheumatic diseases were included. In total 20% of patients with were current smokers. Seven (35%) had hematological malignancies whereas 13 (65%) had solid malignancies. Most common presenting feature was arthritis (40%), followed by weight loss (20%), skin rash (10%), fever (15%) and muscle weakness (10%) at the time of diagnosis. All of them developed malignancy within 24 months of diagnosis. Among the autoantibodies, only 6 patients (30%) were positive for both ANA (n= 4, 20%) and RF (n=2, 10%), other antibodies were negative. The patients in the hematological malignancies had significantly higher serum levels of LDH, Mean±SD U/L compared to solid malignancy group (716.8±169.6 vs. 249.9±161.6, p<0.001).

CONCLUSION

In our cohort, all the patients developed malignancies within 2 years of diagnosis of rheumatic condition. Higher serum LDH levels helpful to differentiates between hematological and solid malignancies. Hence early detection of malignancy is of major importance in these patients.

Retroperitoneal fibrosis after chemo-radiotherapy for cervical cancer: A case report

Retroperitoneal fibrosis (RPF) is a rare disease characterized by proliferation of fibro-inflammatory tissue in the retroperitoneum. Multiple studies have reported on the idiopathic cases of the disease, but reports of RPF secondary to irradiation are very limited. Herein, we report the case of a 47-year-old woman who complained of lower abdominal pain 14 months after chemo-radiotherapy for cervical cancer. Computed tomography showed a soft-tissue mass spreading in the presacral space. Biopsy of the lesion revealed fibro-inflammatory tissue without malignancy. Retrospective imaging findings showed that the lesion was consistent with the irradiation field. We diagnosed the patient with RPF caused by radiotherapy. We started oral administration of prednisolone at a dose of 30 mg/day. After 3 months, scans showed a remarkable reduction in lesion size. Prednisolone was tapered to a maintenance dose of 5 mg/day, which is ongoing. The patient is doing well with no recurrence to date.

Retroperitoneal fibrosis associated with orbital pseudotumor without evidence of IgG4: A case report with review of literature

Retroperitoneal fibrosis (RPF) is a rare disease characterized by chronic inflammation and periaortic fibrosis that affects retroperitoneal structures and often entraps the ureters. The idiopathic form has an incidence of 0.1-1.3/100,000 person-years. A substantial percentage of patients with idiopathic retroperitoneal fibrosis (IRF), as well as patients with orbital pseudotumor, is associated with IgG4-related disease (IgG4-RD). It is not clear what percentage of IRF is related to the spectrum of the IgG4-RD or if both represent different stages of the same disease (especially in those cases with extra-retroperitoneal involvement). Histopathological features such as storiform fibrosis, obliterative phlebitis and tissue infiltration of IgG4-positive plasma cells (ratio IgG4+/IgG higher than 0.4) are essential to identify this association. Extra-retroperitoneal manifestations are often presented among patients with IgG4-related RPF. About 90% of cases of IRF have a good prognosis, with adequate response to treatment. We report a case of a 59-year-old woman with history of past occupational asbestos exposure and smoking habit. She was diagnosed with RPF, periaortitis and orbital pseudotumor, without histopathologic or serologic features of IgG4- related disease. This could be related to the fact that the biopsy was done in a place with scarce inflammatory activity but high fibrosis. We want to emphasize the usual need to perform several biopsies or to be guided by positron emission tomography (PET-CT) in order to achieve a histopathological confirmation. Our case differs from the main IgG4 international cohorts in the involvement of the retroperitoneum, aorta and eye, whereas the usual involvement includes liver, pancreas, lymph nodes and salivary glands. Our patient had lower IgG4 serum levels than those described in the international cohorts. However, they were similar to those of the Spanish population.

Retroperitoneal fibrosis; a single-centre case experience with literature review

Objective

We present 13 patients with retroperitoneal fibrosis, focusing on clinical features, radiological characteristics, treatments and their outcomes.

Methods

Retrospective review of the medical records was performed of all retroperitoneal fibrosis patients diagnosed and treated in our department between 2012 and 2017.

Results

Twelve patients were male, with a median age of 64 years. Eleven patients presented with abdominal pain or back pain or both. Aetiologies varied from idiopathic to malignancy and vasculitis. Twelve patients had PET scans. These showed ¹⁸F-fluorodeoxyglucose-avid retroperitoneal soft tissue around the abdominal aorta in the vast majority, with five scans also demonstrating localized or generalized uptake by the aorta. In all cases except one, glucocorticoids were applied as the first-line therapy. Further immunosuppressive therapy was required in 10 cases.

Conclusion

Our patients were male and older in age compared with the existing literature. PET scans were very helpful in diagnosis of retroperitoneal fibrosis. Rituximab was found to be an effective treatment in six of our patients.

[Diseases of connective tissue in IgG4-associated autoimmune diseases]

The IgG4-associated diseases of connective tissue are caused by allergen-mediated autoimmune processes. The retroperitoneum, mesentery and mediastinum as well as other less common localizations, such as the neck, orbit and periarticular connective tissue can be affected. Inflammatory fibrosis is initially dominated by a lymphocytic and plasma cell-rich infiltrate and later by cell-poor storiform fibrosis. Stenosis and occlusion of vessels, ureters and intestines can cause severe complications. Computed tomography (CT) and magnetic resonance imaging (MRI) can be implemented in the diagnostic algorithm to narrow the differential diagnosis, delineate the distribution of fibrosis and reveal complications.

Retroperitoneal fibrosis - a report of five cases

Retroperitoneal fibrosis (RPF) is a rare disease, characterized by inflammation and deposition of fibrotic tissue in the vicinity of the abdominal aorta and iliac arteries. We present a report of five patients admitted to our department between January 2014 and February 2017, diagnosed with RPF. Abdominal pain was the most common presenting symptom; however, in one patient, RPF was identified accidentally in routinely performed ultrasonography. In 4 cases, corticosteroids (CS) in combination with azathioprine were applied as first-line therapy, whereas one patient was treated with intravenous methylprednisolone pulses followed by oral CS. In this paper, clinical features as well as laboratory and radiographic findings together with management and treatment outcomes in patients with RPF are discussed. Given the rarity of the condition, it seems important to report every single case of RPF to help establish its management algorithm.

Retroperitoneal fibrosis associated with immunoglobulin IgG4-related disease in the differential diagnosis in retroperitoneal tumors. Case report

The patient was a 55-year-old woman with a 4-month history of pain in left flank that irradiated to the lumbar region. Computed tomography revealed a cystic tumor in the retroperitoneal region that compresses the ureter and left renal pelvis in contact with pancreatic body and tail. Surgery was performed and the definitive pathological report diagnosed nodular retroperitoneal fibrosis associated with IgG4; Ki67-positive in germinal centers (5%) and IgG4-positive (40 plasma cells in 3 fields of 40x) by immunohistochemistry. Retroperitoneal fibrosis is a rare disease, that develops gradually and has an excellent response to steroid management. Surgical treatment is reserved for cases that compromise adjacent structures. Thus, identifying it when studying a retroperitoneal tumor leads to better prognosis and survival.

Differentiation of Lymphoma Presenting as Retroperitoneal Mass and Retroperitoneal Fibrosis: Evaluation with Multidetector-row Computed Tomography

Background:

Retroperitoneal fibrosis (RPF) and lymphoma presenting as retroperitoneal mass may closely resemble each other and misdiagnosis may occur. This study investigated the differential imaging features of RPF and lymphoma which presented as a retroperitoneal soft tissue using multidetector-row computed tomography (MDCT).

Methods:

The 42 consecutive patients were included in this retrospective review, including 19 RPF patients (45.2%; including 13 males and 6 females; mean age: 56.7 ± 6.2 years) and 23 patients with lymphoma (54.8%; including 14 males and 9 females; mean age: 57.4 ± 12.3 years). An array of qualitative computed tomography (CT) features of lesions in 42 consecutive patients with newly diagnosed untreated RPF and lymphoma were retrospectively analyzed. The quantitative size of the lesion at the para-aortic region and attenuation in the precontrast, arterial, and portal phases were calculated in regions of interest and compared between the patients with newly diagnosed untreated RPF and with lymphoma. Receiver operating characteristic curve analysis was used to assess the potential diagnostic value of each quantitative parameter. Inter-reader concordance was also calculated.

Results:

Mean ages between patients with RPF and lymphoma were not significantly different (56.7 ± 6.2 years vs. 57.4 ± 12.3 years P = 0.595). Compared to those in patients with lymphoma, homogeneous enhancement (65.2% vs. 94.7%, P = 0.027) and pelvic extension (52.2% vs. 89.5%, P = 0.017) were significantly more common while the involvement of additional nodes (78.3% vs. 5.3%, P < 0.001), suprarenal extension (60.9% vs. 15.8%, P = 0.004), and aortic displacement (43.5% vs. 5.3%, P = 0.006) were significantly less common in patients with RPF. Lesion size at the para-aorta was significantly greater in patients with lymphoma, compared with RPF patients (3.9 ± 1.2 cm vs. 1.8 ± 0.6 cm; P < 0.001). The attenuation values in three phases were not significantly different between patients with RPF and lymphoma. Inter-reader concordance for subjective features ranged from very good to excellent (range: 85.7–100.0%).

Conclusions:

This study showed that MDCT can help differentiate between untreated RPF and lymphoma on the basis of qualitative CT features and lesion sizes. Differentiating RPF from lymphoma on the basis of attenuation values in the precontrast, arterial, and portal phases was difficult to accomplish.

Idiopathic retroperitoneal fibrosis and its overlap with IgG4-related disease

Retroperitoneal fibrosis (RPF) is a rare disease characterised by fibrous tissue proliferation in the retroperitoneum, with encasement of the ureters and large vessels of the abdomen as the most destructive of potentially severe complications. It can either be idiopathic, or secondary to infections, malignancies, or the use of certain drugs. The idiopathic form accounts for approximately 75% of the cases, and is usually responsive to immunosuppressive therapy. In recent years, the emergence of a new clinical entity, IgG4-related disease (IgG4-RD), shed light on many fibro-inflammatory disorders once thought to be separate clinical entities, although frequently associated in the so-called multifocal fibrosclerosis. Among these, together with sclerosing pancreatitis and cholangitis, pseudotumour of the orbit, idiopathic mediastinal fibrosis and other conditions, is idiopathic retroperitoneal fibrosis (IRF). Both IRF and IgG4-RD can be associated with a wide variety of disorders, usually governed by immune-mediated (and particularly auto-immune) mechanisms. In our review, we discuss the clinical and therapeutic challenges IRF presents to the internist, as well as the meaning of its recent inclusion in the IgG4-RD spectrum from a clinical practice standpoint.

Radiological diagnosis of perinephric pathology: pictorial essay 2015

The perinephric space, shaped as an inverted cone, sits between the anterior and posterior renal fasciae. It can play host to a variety of clinical conditions encountered daily in the reporting schedule for a radiologist. Lesions may be classified and diagnosed based on their imaging characteristics, location and distribution. A broad range of differential diagnoses can be attributed to pathology sitting within this space, often without clinical signs or symptoms. An understanding of commonly encountered conditions affecting the perinephric space, along with characteristic imaging findings, can illustrate and often narrow the likely diagnosis. The aim of this essay is to describe commonly encountered neoplastic and non-neoplastic entities involving the perinephric space and to describe their key imaging characteristics.

TEACHING POINT

• Despite often a bulky disease, perinephric lymphoma does not produce obstruction or stenosis. • In primarily fatty masses, defects within the renal capsule likely represent angiomyolipoma. • Consider paraganglioma if biopsy is planned; biopsy may lead to catecholamine crisis.

Retroperitoneal Fibrosis Due to Opium Abuse: A Case Series and Literature Review

Retroperitoneal fibrosis (RPF) is a rare condition with an unclear etiology, presenting with the development of aberrant chronic nonspecific fibroinflammatory tissue in the retroperitoneal space, which can result in entrapment and obstruction of the retroperitoneal structures. RPF is a subtype of chronic periaortitis, and can be divided into two types: primary (or idiopathic) and secondary. RPF is usually idiopathic, but can also be secondary to malignancies, certain drugs, infections, surgery, and trauma. The systemic clinical manifestations are nonspecific and include low-grade fever, fatigue, anorexia, weight loss, and myalgia. We report five patients admitted to our hospital with clinical, laboratory, imaging, and pathologic findings compatible with RPF, and we describe their treatment and follow-up. We were suspicious that the impurities of some types of opium have an important role in the pathogenesis of RPF. Some of our patients used opium again after the follow-up period; however, they used a different type with a different origin, and we were surprised to see that RPF did not form again.

Staphylococcus aureus aortitis and retroperitoneal fibrosis: A case report and literature review

An infected aortic aneurysm is a process with high mortality rate. Survival is dependent on an early diagnosis and surgical management. This case report details a rare presentation of aortitis with persistent methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, which initially presented as retroperitoneal fibrosis and was ultimately fatal.

Juxta-vertebral lesions in granulomatosis with polyangiitis

OBJECTIVES

To describe the clinical, pathological, serological, and radiological characteristics of juxta-vertebral masses occurring in patients with granulomatosis with polyangiitis (GPA).

METHODS

We analyzed the clinical records of patients with juxta-vertebral lesions from our GPA study cohort and reviewed the English literature for other cases of GPA with juxta-vertebral localization.

RESULTS

Out of 74 patients in our GPA study cohort, six (8%) had juxta-vertebral lesions. We found 10 cases of juxta-vertebral GPA described in the English literature. Overall, juxta-vertebral lesions were detected at GPA onset in 11/16 (69%) patients, and preferentially occurred on the right side of the spine (12/15 patients, 80%). Fifteen patients (94%) with juxta-vertebral lesions had systemic GPA. Juxta-vertebral lesions were associated with back pain at GPA onset in 8/16 (50%) patients. In all of them juxta-vertebral lesions resolved or improved after treatment.

CONCLUSIONS

Preference for the right-anterior side of the spine, increased ¹⁸FDG uptake on PET scan, low or absent invasiveness of the surrounding tissues, and occurrence in the context of systemic disease were the main features of juxta-vertebral GPA. Symptomatic lesions showed a better response to immunosuppressive therapies.

Characterisation of an epigenetically altered CD4(+) CD28(+) Kir(+) T cell subset in autoimmune rheumatic diseases by multiparameter flow cytometry

Objectives

Antigen-specific CD4⁺ T cells epigenetically modified with DNA methylation inhibitors overexpress genes normally suppressed by this mechanism, including CD11a, CD70, CD40L and the KIR gene family. The altered cells become autoreactive, losing restriction for nominal antigen and responding to self-class II major histocompatibility complex (MHC) molecules without added antigen, and are sufficient to cause a lupus-like disease in syngeneic mice. T cells overexpressing the same genes are found in patients with active lupus. Whether these genes are co-overexpressed on the same or different cells is unknown. The goal of this study was to determine whether these genes are overexpressed on the same or different T cells and whether this subset of CD4⁺ T cells is also present in patients with lupus and other rheumatic diseases.

Methods

Multicolour flow cytometry was used to compare CD11a, CD70, CD40L and KIR expression on CD3⁺CD4⁺CD28⁺ T cells to their expression on experimentally demethylated CD3⁺CD4⁺CD28⁺ T cells and CD3⁺CD4⁺CD28⁺ T cells from patients with active lupus and other autoimmune diseases.

Results

Experimentally demethylated CD4⁺ T cells and T cells from patients with active lupus have a CD3⁺CD4⁺CD28⁺CD11a^hiCD70⁺CD40L^hiKIR⁺ subset, and the subset size is proportional to lupus flare severity. A similar subset is found in patients with other rheumatic diseases including rheumatoid arthritis, systemic sclerosis and Sjögren's syndrome but not retroperitoneal fibrosis.

Conclusions

Patients with active autoimmune rheumatic diseases have a previously undescribed CD3⁺CD4⁺CD28⁺CD11a^hiCD70⁺CD40L^hiKIR⁺ T cell subset. This subset may play an important role in flares of lupus and related autoimmune rheumatic diseases, provide a biomarker for disease activity and serve as a novel therapeutic target for the treatment of lupus flares.

[Secondary retroperitoneal fibrosis in a 39-year-old man after rectal cancer]

A 39-year-old man had been treated for rectal cancer 6 years ago by lower anterior resection of the rectum and perioperative radiochemotherapy. Since then follow-up had been unremarkable but now the patient presented with unspecific lower abdominal pain. The cause of the pain was identified as paraneoplastic retroperitoneal fibrosis secondary to metachronous pulmonary metastases of the rectal cancer.