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Grasso C, Giacchero F, Crivellari S, Bertolotti M, Maconi A. A Review on The Role of Environmental Exposures in IgG4-Related Diseases. Curr Environ Health Rep 2023; 10:303-311. [PMID: 37314670 DOI: 10.1007/s40572-023-00401-y] [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] [Accepted: 05/26/2023] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Chiara Grasso
- SC Infrastruttura Ricerca Formazione Innovazione, Dipartimento Attività Integrate Ricerca Innovazione, Azienda Ospedaliera "SS. Antonio E Biagio E Cesare Arrigo", Alessandria, Italy
| | - Fabio Giacchero
- SC Infrastruttura Ricerca Formazione Innovazione, Dipartimento Attività Integrate Ricerca Innovazione, Azienda Sanitaria Locale Alessandria, Alessandria, Italy
| | - Stefania Crivellari
- SC Infrastruttura Ricerca Formazione Innovazione, Dipartimento Attività Integrate Ricerca Innovazione, Azienda Ospedaliera "SS. Antonio E Biagio E Cesare Arrigo", Alessandria, Italy
| | - Marinella Bertolotti
- SC Infrastruttura Ricerca Formazione Innovazione, Dipartimento Attività Integrate Ricerca Innovazione, Azienda Ospedaliera "SS. Antonio E Biagio E Cesare Arrigo", Alessandria, Italy.
| | - Antonio Maconi
- SC Infrastruttura Ricerca Formazione Innovazione, Dipartimento Attività Integrate Ricerca Innovazione, Azienda Ospedaliera "SS. Antonio E Biagio E Cesare Arrigo", Alessandria, Italy
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Tanabe K, Homma T, Matsui S, Tsuchiya T, Saji H. Metachronous bilateral immunoglobulin G4-related pleuritis: A case report and literature review. Respirol Case Rep 2023; 11:e01204. [PMID: 37593372 PMCID: PMC10427978 DOI: 10.1002/rcr2.1204] [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: 05/26/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized disease, and therefore its clinical features are not yet fully understood. Here, we describe a surgical case of metachronous bilateral IgG4-related pleuritis and postoperative chylothorax. This case could provide key insights into the pathology of IgG4-RD from a surgical perspective. We present a 70-year-old woman who had a right pleural mass. Video-assisted thoracoscopic pleural mass resection was performed, and the patient was diagnosed with right-sided IgG4-related pleuritis. Two years later, she was also diagnosed with left-sided IgG4-related pleuritis. We suspected the presence of IgG4-positive plasma cell infiltration. Additionally, she experienced a complicated postoperative chylothorax on the left side. It is important to consider the altered course of lymphatic vessels when extensively removing the pleura near the right thoracic duct. The occurrence of metachronous bilateral IgG4-associated pleuritis has not been previously reported, making this case particularly significant for understanding the pathology of IgG4-RD from a surgical standpoint.
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Affiliation(s)
- Keitaro Tanabe
- Division of Thoracic SurgeryUniversity of ToyamaToyamaJapan
| | - Takahiro Homma
- Division of Thoracic SurgeryUniversity of ToyamaToyamaJapan
- Division of Thoracic SurgeryKurobe City HospitalKurobeJapan
- Department of Chest SurgerySt. Marianna University School of MedicineKawasakiJapan
| | - Shoko Matsui
- First Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | - Hisashi Saji
- Department of Chest SurgerySt. Marianna University School of MedicineKawasakiJapan
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Mizushina Y, Shiihara J, Nomura M, Ohta H, Ohyanagi F, Morishita Y, Tsubochi H, Tanaka A, Yamaguchi Y. Immunoglobulin G4-related Pleuritis Complicated with Minimal Change Disease. Intern Med 2022; 61:723-728. [PMID: 34483205 PMCID: PMC8943386 DOI: 10.2169/internalmedicine.7010-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 70-year-old woman with bilateral pleural effusion and respiratory failure was admitted to our hospital. Nephrotic syndrome due to minimal change disease had been diagnosed four months before admission. Because blood tests and a pleural fluid analysis did not reveal the etiology of her condition, we performed a video-assisted thoracoscopic pleural biopsy. No specific thoracoscopic findings were noted. The pathological findings revealed an increase in immunoglobulin G4 (IgG4)-positive cells; IgG4-related pleuritis was diagnosed. Her pleuritis improved with oral corticosteroid therapy. A further investigation was performed on previous kidney samples; however, the etiology of the nephrotic syndrome was not IgG4-related disease but minimal change disease.
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Affiliation(s)
- Yoshiko Mizushina
- Division of Pulmonary Medicine, Saitama Medical Center, Jichi Medical University, Japan
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Japan
| | - Jun Shiihara
- Division of Pulmonary Medicine, Saitama Medical Center, Jichi Medical University, Japan
| | - Motoko Nomura
- Division of Pulmonary Medicine, Saitama Medical Center, Jichi Medical University, Japan
| | - Hiromitsu Ohta
- Division of Pulmonary Medicine, Saitama Medical Center, Jichi Medical University, Japan
| | - Fumiyoshi Ohyanagi
- Division of Pulmonary Medicine, Saitama Medical Center, Jichi Medical University, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hiroyoshi Tsubochi
- Division of Thoracic Surgery, Saitama Medical Center, Jichi Medical University, Japan
- Department of Thoracic Surgery, Jichi Medical University, Japan
| | - Akira Tanaka
- Department of Pathology, Saitama Medical Center, Jichi Medical University, Japan
| | - Yasuhiro Yamaguchi
- Division of Pulmonary Medicine, Saitama Medical Center, Jichi Medical University, Japan
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Sakata K, Kikuchi J, Emoto K, Kotaki T, Ota Y, Nishina N, Hanaoka H, Otomo K, Suzuki K, Kaneko Y, Takeuchi T. Refractory IgG4-related Pleural Disease with Chylothorax: A Case Report and Literature Review. Intern Med 2021; 60:2135-2143. [PMID: 33518567 PMCID: PMC8313917 DOI: 10.2169/internalmedicine.6313-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We herein report a rare case of a 66-year-old man with refractory chylothorax. Although he had been treated with moderate doses of prednisolone (PSL) on suspicion of pleuritis with Sjögren syndrome, the pleural effusion expanded after the reduction of PSL. Further workup including histopathological examinations of pleura led to the diagnosis of IgG4-RD with bilateral chylothorax without any leakage from the thoracic duct. Combination therapy with high-dose PSL plus rituximab successfully decreased the pleural effusion. This is a very rare case of IgG4-related pleuritis with chylothorax and the first report of its successful treatment with rituximab.
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Affiliation(s)
- Komei Sakata
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Katsura Emoto
- Division of Diagnostic Pathology, Keio University School of Medicine, Japan
| | - Tomomi Kotaki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuichiro Ota
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Naoshi Nishina
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Hironari Hanaoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Kotaro Otomo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Katsuya Suzuki
- 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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Abstract
Purpose of review The causes of exudative pleural effusions are diverse and frequently remain unclear despite exhaustive examinations. Recently recognized IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder that can affect nearly any organ including the lungs. This review will focus on the involvement of IgG4 in exudative pleural effusion of unknown cause. Recent findings IgG4 is found to be involved in a proportion of patients with undiagnosed pleural effusions. Pleural involvement in IgG4-RD can be seen in isolation or association with other organ disease. Pleural thickening and/or effusion are common clinical features of IgG4-related pleural lesions, and this condition is histologically characterized by a lymphoplasmacytic infiltrate enriched in IgG4-positive plasma cells in the pleura. Although the pathogenesis of IgG4-RD is poorly understood, there is a growing body of evidence that indicates an antigen-driven process requiring T-cell and B-cell interaction in which autoantibodies, plasmablasts, follicular helper T cells and CD4+ cytotoxic T lymphocytes participate. Summary The possibility of IgG4-related pleural lesion should be considered in patients with pleural effusion of unexplained cause when lymphoplasmacytic infiltration is seen in a pleural biopsy specimen. This condition is responsive to systemic steroid therapy.
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Okamoto S, Tsuboi H, Sato R, Terasaki M, Terasaki T, Toko H, Shimizu M, Honda F, Yagishita M, Ohyama A, Kurata I, Abe S, Takahashi H, Osada A, Hagiwara S, Kondo Y, Matsumoto I, Sumida T. IgG4-related pleural disease with aortitis and submandibular glands involvement successfully treated with corticosteroid: case-based review. Rheumatol Int 2020; 40:1725-1732. [PMID: 32206878 DOI: 10.1007/s00296-020-04555-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 03/13/2020] [Indexed: 12/25/2022]
Abstract
IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition characterized by increased serum IgG4 level, infiltration of lymphocytes and IgG4-positive (IgG4+) plasma cells and fibrosis. It can occur in almost all organs, commonly affecting the pancreas, biliary tract, salivary and lacrimal glands and kidneys. However, reports of IgG4-RD accompanied by pathologically confirmed, IgG4-related pleural disease are scarce. Here, we present a case of a 64-year-old man with suspected malignant pleural mesothelioma based on imaging findings but finally diagnosed with IgG4-RD (including pleuritis, periaortitis and bilateral submandibular gland enlargement) based on a high serum IgG4 level and pleural histopathological findings such as lymphoplasmacytic infiltration including IgG4+ plasma cells and fibrosis. Systemic corticosteroid therapy was effective at reducing serum IgG4, improving bilateral submandibular gland enlargement, and regressing pleural thickening and periaortic soft tissue. We also discuss clinical characteristics and pleural pathological features of previously reported cases with IgG4-related pleural disease based on a comprehensive literature review. Our case of IgG4-RD with pleura, aorta and submandibular gland involvement, pathologically confirmed by pleural specimen might be unique and very rare.
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Affiliation(s)
- Shota Okamoto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hiroto Tsuboi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryota Sato
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Mayu Terasaki
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Toshihiko Terasaki
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hirofumi Toko
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Masaru Shimizu
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Fumika Honda
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Mizuki Yagishita
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ayako Ohyama
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Izumi Kurata
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Saori Abe
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hiroyuki Takahashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Atsumu Osada
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinya Hagiwara
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yuya Kondo
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Isao Matsumoto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Takayuki Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
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7
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Yasokawa N, Shirai R, Tanaka H, Kurose K, Oga T, Oka M. Thoracoscopic Findings in IgG4-related Pleuritis. Intern Med 2020; 59:257-260. [PMID: 31554752 PMCID: PMC7008034 DOI: 10.2169/internalmedicine.3031-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/15/2019] [Indexed: 12/20/2022] Open
Abstract
A 46-year-old Japanese man was admitted to our hospital with a 1-year history of dyspnea and persistent right-dominant bilateral pleural effusions. Chest and abdominal computed tomography (CT) revealed no notable findings apart from the bilateral pleural effusions. 2-deoxy-2-[18F]-fluoro-D-glucose (FDG) positron emission tomography-CT showed no accumulation of FDG in the thorax and abdomen. Thoracoscopy revealed numerous small (approximately 2-3 mm in size), blister-like nodules on the left parietal pleura extending from the lower third of the chest wall to the diaphragm. A pathological examination revealed lymphocyte and plasma cell infiltrates with increasing numbers of IgG4-positive plasma cells in the fibrotic pleura, indicating IgG4-related pleuritis.
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Affiliation(s)
- Naoya Yasokawa
- Department of Respiratory Medicine, Kawasaki Medical School, Japan
| | - Ryo Shirai
- Department of Respiratory Medicine, Kawasaki Medical School, Japan
| | - Hitomi Tanaka
- Department of Respiratory Medicine, Kawasaki Medical School, Japan
| | - Koji Kurose
- Department of Respiratory Medicine, Kawasaki Medical School, Japan
| | - Toru Oga
- Department of Respiratory Medicine, Kawasaki Medical School, Japan
| | - Mikio Oka
- Department of Immuno-Oncology, Kawasaki Medical School, Japan
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Murata Y, Aoe K, Mimura-Kimura Y, Murakami T, Oishi K, Matsumoto T, Ueoka H, Matsunaga K, Yano M, Mimura Y. Association of immunoglobulin G4 and free light chain with idiopathic pleural effusion. Clin Exp Immunol 2017; 190:133-142. [PMID: 28617941 DOI: 10.1111/cei.12999] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/24/2022] Open
Abstract
The cause of pleural effusion remains uncertain in approximately 15% of patients despite exhaustive evaluation. As recently described immunoglobulin (Ig)G4-related disease is a fibroinflammatory disorder that can affect various organs, including the lungs, we investigate whether idiopathic pleural effusion includes IgG4-associated etiology. Between 2000 and 2012, we collected 830 pleural fluid samples and reviewed 35 patients with pleural effusions undiagnosed after pleural biopsy at Yamaguchi-Ube Medical Center. Importantly, IgG4 immunostaining revealed infiltration of IgG4-positive plasma cells in the pleura of 12 patients (34%, IgG4+ group). The median effusion IgG4 level was 41 mg/dl in the IgG4+ group and 27 mg/dl in the IgG4- group (P < 0·01). The light and heavy chains of effusion IgG4 antibodies of patients in the IgG4+ group were heterogeneous by two-dimensional electrophoresis, indicating the absence of clonality of the IgG4 antibodies. Interestingly, the κ light chains were more heterogeneous than the λ light chains. The measurement of the κ and λ free light chain (FLC) levels in the pleural fluids showed significantly different κ FLC levels (median: 28·0 versus 9·1 mg/dl, P < 0·01) and κ/λ ratios (median: 2·0 versus 1·2, P < 0·001) between the IgG4+ and IgG4- groups. Furthermore, the κ/λ ratios were correlated with the IgG4+ /IgG+ plasma cell ratios in the pleura of the IgG4+ group. Taken together, these results demonstrate the involvement of IgG4 in certain idiopathic pleural effusions and provide insights into the diagnosis, pathogenesis and therapeutic opportunities of IgG4-associated pleural effusion.
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Affiliation(s)
- Y Murata
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan.,The Department of Respiratory Medicine, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan.,Division of Cardiology, The Department of Medicine and Clinical Science, Ube, Japan
| | - K Aoe
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan
| | - Y Mimura-Kimura
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan
| | - T Murakami
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan
| | - K Oishi
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan.,The Department of Respiratory Medicine, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan.,Division of Cardiology, The Department of Medicine and Clinical Science, Ube, Japan
| | - T Matsumoto
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan
| | - H Ueoka
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan
| | - K Matsunaga
- The Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - M Yano
- Division of Cardiology, The Department of Medicine and Clinical Science, Ube, Japan
| | - Y Mimura
- The Department of Clinical Research, National Hospital Organization Yamaguchi-Ube Medical Center, Ube, Japan
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