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Gosangi B, Lang P, Johnson M, Zukerman R, Tu L, Traube L, Bader AS, Rubinowitz AN. Disorders with Ophthalmic and Thoracic Involvement. Radiographics 2024; 44:e230132. [PMID: 38870047 DOI: 10.1148/rg.230132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
A variety of systemic conditions involve the thorax and the eyes. While subtle or nonspecific eye symptoms can be the initial clinical manifestation of some disorders, there can be additional manifestations in the thorax that lead to a specific diagnosis and affect patient outcomes. For instance, the initial clinical manifestation of Sjögren syndrome is dry eye or xerophthalmia; however, the presence of Sjögren lung disease represents a fourfold increase in mortality. Likewise, patients with acute sarcoidosis can initially present with pain and redness of the eye from uveitis in addition to fever and parotitis. Nearly 90% of patients with sarcoidosis have thoracic involvement, and the ophthalmologic symptoms can precede the thoracic symptoms by several years in some cases. Furthermore, a diagnosis made in one system can result in the screening of other organs as well as prompt genetic evaluation and examination of family members, such as in the setting of Marfan syndrome or Ehlers-Danlos syndrome. Multimodality imaging, particularly CT and MRI, plays a vital role in identification and characterization of these conditions. While it is helpful for ophthalmologists to be knowledgeable about these conditions and their associations so that they can order the pertinent radiologic studies, it is also important for radiologists to use the clues from ophthalmologic examination in addition to imaging findings to suggest a specific diagnosis. Systemic conditions with thoracic and ophthalmologic manifestations can be categorized as infectious, inflammatory, autoimmune, neoplastic, or hereditary in origin. The authors describe a spectrum of these conditions based on their underlying cause. ©RSNA, 2024.
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Affiliation(s)
- Babina Gosangi
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Patrick Lang
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Michele Johnson
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Ryan Zukerman
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Long Tu
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Leah Traube
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Anna S Bader
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
| | - Ami N Rubinowitz
- From the Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (B.G., P.L., M.J., L. Tu, L. Traube, A.S.B., A.N.R.); and Department of Ophthalmology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (R.Z.)
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Moura J, Malaquias MJ, Jorge F, Pinto E, Sardoeira A, Laranjinha I, Oliveira V, Sousa AP, Damásio J, Maia L, Vila-Chã N, Samões R, Taipa R, Martins da Silva A, Santos E. Neurological Involvement in a Portuguese Cohort of IgG4-Related Disease. ACTA MEDICA PORT 2024; 37:429-435. [PMID: 38669036 DOI: 10.20344/amp.20767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/07/2024] [Indexed: 06/09/2024]
Abstract
INTRODUCTION Neurological involvement in immunoglobulin G4-related disease (IgG4-RD) is increasingly recognized. Its diagnosis can be challenging due to clinical mimics and difficulty in obtaining nervous system biopsies. The aim of this study was to describe a cohort of neurological IgG4-RD patients. METHODS Patients were recruited from a neuroimmunology tertiary center. Clinical, laboratory, neuroimaging and histological data were reviewed. RESULTS Fifteen patients (60% women), with a median age of 53 years (48.5 - 65.0) were included: 13 (86.7%) classified as possible IgG4-RD, one (6.7%) as probable and one (6.7%) as definitive. The most common neurological phenotypes were meningoencephalitis (26.7%), orbital pseudotumor (13.3%), cranial neuropathies (13.3%), peripheral neuropathy (13.3%), and longitudinally extensive transverse myelitis (LTEM) (13.3%). Median serum IgG4 concentration was 191.5 (145.0 - 212.0) mg/dL. Seven in 14 patients had CSF pleocytosis (50.0%) and oligoclonal bands restricted to the intrathecal compartment, while most cases presented elevated CSF proteins (64.3%). Magnetic resonance imaging abnormalities included white matter lesions in four (26.7%), hypertrophic pachymeningitis in two (13.3%), and LETM in two (13.3%). Two patients had biopsy-proven IgG4-RD in extra-neurological sites. CONCLUSION This study highlights the phenotypical variability of the neurological IgG4-RD. Biopsy inaccessibility reinforces the importance of new criteria for the diagnosis of this subset of patients.
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Affiliation(s)
- João Moura
- *Shared first co-authorship. Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Maria João Malaquias
- *Shared first co-authorship. Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Firmina Jorge
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Eduarda Pinto
- Neurorradiology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Ana Sardoeira
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Inês Laranjinha
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Vanessa Oliveira
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Ana Paula Sousa
- Neurophysiology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Joana Damásio
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto; Center for Predictive and Preventive Genetics (CGPP). Institute for Molecular and Cell Biology (IBMC). Instituto de Investigação e Inovação em Saúde (i3S). Universidade do Porto. Porto. Portugal
| | - Luís Maia
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Nuno Vila-Chã
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Raquel Samões
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Ricardo Taipa
- Portuguese Brain Bank. Centro Hospitalar Universitário de Santo António. Porto; Unit for Multidisciplinary Research in Biomedicine. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Ana Martins da Silva
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto; Unit for Multidisciplinary Research in Biomedicine. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Ernestina Santos
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto; Unit for Multidisciplinary Research in Biomedicine. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
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Huang Y, Liu Y. IgG4-related disease involving the cervical spinal cord. J Clin Neurosci 2024; 124:78-80. [PMID: 38669905 DOI: 10.1016/j.jocn.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/22/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Affiliation(s)
- Yanqi Huang
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou 510080, China.
| | - Yitong Liu
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 106 Zhongshan 2nd Road, Guangzhou 510080, China
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Inoue E, Kesumayadi I, Fujio S, Makino R, Hanada T, Masuda K, Higa N, Kawade S, Niihara Y, Takagi H, Kitazono I, Takahashi Y, Hanaya R. Secondary hypophysitis associated with Rathke's cleft cyst resembling a pituitary abscess. Surg Neurol Int 2024; 15:69. [PMID: 38468645 PMCID: PMC10927231 DOI: 10.25259/sni_947_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
Background Although rare, cases of hypophysitis resembling a pituitary abscess (PA) have been reported. Differential diagnosis between hypophysitis and PA is crucial as the two diseases require different treatments. Case Description A 38-year-old woman with headaches underwent head magnetic resonance imaging (MRI), which revealed an 11-mm mass lesion in the sella turcica. Due to breastfeeding, contrast-enhanced MRI was avoided. Pituitary adenomas and Rathke's cleft cyst (RCC) were suspected, and she was initially treated conservatively. Five months later, she acquired syndrome coronavirus two infections, and while the fever subsided with acetaminophen, the headache persisted. One month later, the headache worsened, followed by fever and diabetes insipidus. MRI revealed a pituitary cystic mass with ring-shaped contrast enhancement on T1-weighted MRI and increased signal intensity on diffusion-weighted imaging (DWI). PA was suspected, and emergency endoscopic transsphenoidal surgery was performed. The microbiological examination of the yellowish-brown content drained from the cystic mass was negative. Microscopically, the cystic lesion was covered with ciliated columnar epithelium and stratified squamous epithelium, with a dense inflammatory cell infiltrate consisting mainly of lymphocytes and plasma cells observed around the cyst. This supported the diagnosis of secondary hypophysitis associated with RCC without PA. Conclusion We report a case of hypophysitis secondary to RCC resembling PA with ring-shaped contrast enhancement on MRI and increased signal intensity on DWI. This case emphasizes the need for cautious diagnosis of secondary hypophysitis due to RCC in individuals with MRIs and clinical manifestations resembling an abscess.
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Affiliation(s)
- Eri Inoue
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Irfan Kesumayadi
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Department of Neurosurgery, Diponegoro University, Tembalang, Semarang, Indonesia
| | - Shingo Fujio
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Ryutaro Makino
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Tomoko Hanada
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Keisuke Masuda
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Nayuta Higa
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Shigeru Kawade
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
- Department of Diabetes and Endocrine Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuichiro Niihara
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
- Department of Obstetrics and Gynecology, Kagoshima University, Kagoshima, Japan
| | - Hirosuke Takagi
- Department of Hematology and Rheumatology, Kagoshima University, Kagoshima, Japan
| | - Ikumi Kitazono
- Department of Pathology, Kagoshima University, Kagoshima, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Nara, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
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Suezumi K, Uehara T, Taira A, Akamatsu N, Tanaka T, Hayashi Y, Komuta M, Shiomi T, Murai H. IgG4-related pachyleptomeningitis with inflammatory pseudotumor. eNeurologicalSci 2024; 34:100490. [PMID: 38229909 PMCID: PMC10789997 DOI: 10.1016/j.ensci.2023.100490] [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: 04/15/2023] [Revised: 06/23/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024] Open
Abstract
•We report the first case of IgG4-related pachyleptomeningitis.•Our case showed also an inflammatory pseudotumor on the side ipsilateral to the pachyleptomeningitis.•The pachyleptomeningitis is probably due to inflammation from the dural pseudotumor spreading along the adjacent meninges.
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Affiliation(s)
- Koki Suezumi
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Taira Uehara
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Akihiko Taira
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Naoki Akamatsu
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Yuichiro Hayashi
- Department of Anatomic Pathology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Mina Komuta
- Department of Anatomic Pathology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Takayuki Shiomi
- Department of Anatomic Pathology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
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Li CMF, Kim DD, Allen LH. Ophthalmoplegia With Isolated Extraocular Muscle Hypertrophy. JAMA Neurol 2024; 81:190-191. [PMID: 38190137 DOI: 10.1001/jamaneurol.2023.5056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
A 60-year-old man is experiencing diplopia but no problems with visual acuity, pain, or other symptoms. A magnetic resonance image of the head shows abnormal thickening and T2 hyperintensity of the right lateral rectus muscle. What is your diagnosis?
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Affiliation(s)
- Cathy Meng Fei Li
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | | | - Larry H Allen
- Department of Ophthalmology, Western University, London, Ontario, Canada
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Tsoumanis P, Kitsouli A, Stefanou C, Papathanakos G, Stefanou S, Tepelenis K, Zikidis H, Tsoumani A, Zafeiropoulos P, Kitsoulis P, Kanavaros P. Chronic Inflammatory Demyelinating Polyneuropathy and Evaluation of the Visual Evoked Potentials: A Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2160. [PMID: 38138263 PMCID: PMC10744621 DOI: 10.3390/medicina59122160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/02/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare autoimmune disorder characterised by the progressive demyelination of peripheral nerves, resulting in motor and sensory deficits. While much research has focused on clinical and electrophysiological aspects of CIDP, there is an emerging interest in exploring its impact on the visual system through visual evoked potentials (VEPs). This comprehensive review synthesises existing literature on VEP findings in CIDP patients, shedding light on their potential diagnostic and prognostic value. The review thoroughly examines studies spanning the last two decades, exploring VEP abnormalities in CIDP patients. Notably, VEP studies have consistently revealed prolonged latencies and reduced amplitudes in CIDP patients compared to healthy controls. These alterations in VEP parameters suggest that the demyelinating process extends beyond the peripheral nervous system to affect the central nervous system, particularly the optic nerve and its connections. The correlation between VEP abnormalities and clinical manifestations of CIDP, such as visual impairment and sensory deficits, underscores the clinical relevance of VEP assessment in CIDP management. Furthermore, this review addresses the potential utility of VEPs in aiding CIDP diagnosis and monitoring disease progression. VEP abnormalities may serve as valuable biomarkers for disease activity, helping clinicians make timely therapeutic decisions. Moreover, this review discusses the limitations and challenges associated with VEP assessment in CIDP, including variability in recording techniques and the need for standardised protocols. In conclusion, this review highlights the evolving role of VEPs as a non-invasive tool in CIDP evaluation. The consistent VEP abnormalities observed in CIDP patients suggest the involvement of the central nervous system in this demyelinating disorder. As our understanding of CIDP and its pathophysiology continues to evolve, further research in this area may lead to improved diagnostic accuracy and monitoring strategies, ultimately enhancing the clinical management of CIDP patients.
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Affiliation(s)
- Periklis Tsoumanis
- Department of Ophthalmology, University Hospital of Ioannina, 45500 Ioannina, Greece;
| | - Aikaterini Kitsouli
- Anatomy-Histology-Embryology, University of Ioannina, 45500 Ioannina, Greece; (A.K.); (P.K.); (P.K.)
| | - Christos Stefanou
- Department of Surgery, General Hospital of Filiates, 46300 Filiates, Greece;
| | | | - Stefanos Stefanou
- Department of Endocrine Surgery, Henry Dunant Hospital Center, 11526 Athens, Greece;
| | - Kostas Tepelenis
- Department of Surgery, General Hospital of Ioannina G. Hatzikosta, 45500 Ioannina, Greece;
| | - Hercules Zikidis
- Department of Neurology, University Hospital of Ioannina, 45500 Ioannina, Greece;
| | | | | | - Panagiotis Kitsoulis
- Anatomy-Histology-Embryology, University of Ioannina, 45500 Ioannina, Greece; (A.K.); (P.K.); (P.K.)
| | - Panagiotis Kanavaros
- Anatomy-Histology-Embryology, University of Ioannina, 45500 Ioannina, Greece; (A.K.); (P.K.); (P.K.)
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Zou D, Jiang L, Yang T, Cheng J, Ma Y. IgG4-associated hypophysitis coexisting with MALT lymphoma and gangliocytoma: first case report and literature review. Front Neurol 2023; 14:1253821. [PMID: 38020670 PMCID: PMC10666160 DOI: 10.3389/fneur.2023.1253821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
IgG4-related or IgG4-associated hypophysitis is a rare disease characterized by the infiltration of IgG4-positive plasma cells into pituitary gland tissue. Gangliocytomas in the sellar region are also extremely rare and are associated with pituitary adenomas in the majority of cases. Sellar mucosa-associated lymphoid tissue (MALT) lymphoma is an exceedingly rare condition. In this study, we present a case of IgG4-associated hypophysitis coexisting with MALT lymphoma and gangliocytoma. However, to elucidate the potential pathophysiological relationship, it is imperative to gather additional cases of IgG4-related hypophysitis accompanied by MALT lymphoma and gangliocytoma.
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Affiliation(s)
- Dongbo Zou
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
| | - Li Jiang
- Department of Rheumatology and Immunology, The Second People's Hospital of Chengdu, Chengdu, China
| | - Tao Yang
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
| | - Jingmin Cheng
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
| | - Yuan Ma
- Department of Neurosurgery, General Hospital of Western Theater Command, Chengdu, China
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Balaban DT, Hutto SK, Panzarini BP, O'Shea A, Varma A, Jones PS, Chwalisz BK, Stone JH, Venna N. Treatment of IgG4-related disease-associated hypertrophic pachymeningitis with intrathecal rituximab: a case report. Front Neurol 2023; 14:1189778. [PMID: 37292126 PMCID: PMC10244657 DOI: 10.3389/fneur.2023.1189778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
IgG4-related disease-associated hypertrophic pachymeningitis (IgG4RD-HP) is a fibroinflammatory autoimmune disorder in which diagnosis is difficult without biopsy. Guidance on management of disease refractory to glucocorticoids and intravenous rituximab is limited. We present the case of a 68-year-old woman with IgG4RD-HP who developed sensorineural hearing loss with associated bulky basilar pachymeningeal enhancement. Her cerebrospinal fluid was inflammatory and had an elevated IgG4 concentration, strongly suggestive of IgG4RD-HP. Biopsy of involved meninges was not possible due to surgical risk. Over years she developed bilateral optic neuropathies and hydrocephalus, requiring intravenous rituximab and ventriculoperitoneal shunt. Her disease was refractory to glucocorticoids. Despite maintenance intravenous rituximab, she developed slowly progressive symptoms of intracranial hypertension and hydrocephalus with persistently inflammatory spinal fluid. Switching to intrathecal rituximab therapy led to dramatic improvement in gait and headache and reduced pachymeningeal bulk and metabolic activity. In patients with IgG4RD-HP refractory to glucocorticoids and intravenous rituximab, intrathecal rituximab may be an efficacious therapy.
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Affiliation(s)
- Denis T. Balaban
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Spencer K. Hutto
- Division of Hospital Neurology, Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Bruno P. Panzarini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aileen O'Shea
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aditi Varma
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Pamela S. Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Bart K. Chwalisz
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuro-Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
| | - John H. Stone
- Department of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Nagagopal Venna
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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10
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Huynh KN, Kong MJ, Nguyen BD. Anatomic and Functional Imaging of Immunoglobulin G4-related Disease and Its Mimics. Radiographics 2023; 43:e220097. [PMID: 36821510 DOI: 10.1148/rg.220097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is an immune-mediated fibrosclerosing disease with tumefactive lesions infiltrated by IgG4-positive plasma cells. Initially described as autoimmune pancreatitis, IgG4-RD is now recognized as a discrete entity and is found to affect virtually any organ in the body. Common extrapancreatic sites include the biliary tree, salivary glands, periorbital tissue, lungs, kidneys, lymph nodes, aorta, retroperitoneum, and thyroid gland. Diagnosis-which relies on histopathologic, serologic, and radiologic features-can be challenging with the disease underdiagnosed, as IgG4-RD often mimics malignancy, infectious processes, or other immune-mediated conditions. Patients may present with signs of compression of nearby structures due to mass effect or with organ failure when the disease is left untreated. The clinical course is complex, with single- or multiorgan involvement and metachronous or synchronous occurrence of lesions. IgG4-RD responds well to glucocorticoid therapy, disease-modifying antirheumatic drugs, and B-cell-depleting biologic agents; prompt diagnosis is important to avoid delay in treatment and unnecessary pharmacologic or surgical intervention. While imaging features may not be specific for IgG4-RD, functional whole-body imaging with fluorine 18-fluorodeoxyglucose PET/CT is a useful adjunct for localizing extrapancreatic sites for biopsy, monitoring therapeutic response, and demonstrating disease relapse. The authors describe the pancreatic and extrapancreatic sites of involvement in IgG4-RD, with imaging features and patterns to aid in distinguishing IgG4-RD from its mimics through a multimodality approach with emphasis on functional imaging evaluation. ©RSNA, 2023 Quiz questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.
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Affiliation(s)
- Kenneth N Huynh
- From the Department of Radiological Sciences, University of California-Irvine, Orange, Calif (K.N.H.); and Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (M.J.K., B.D.N.)
| | - Min J Kong
- From the Department of Radiological Sciences, University of California-Irvine, Orange, Calif (K.N.H.); and Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (M.J.K., B.D.N.)
| | - Ba D Nguyen
- From the Department of Radiological Sciences, University of California-Irvine, Orange, Calif (K.N.H.); and Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (M.J.K., B.D.N.)
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Leboyan A, Esselin F, Bascou AL, Duflos C, Ion I, Charif M, Castelnovo G, Carra-Dalliere C, Ayrignac X, Kerschen P, Chbicheb M, Nguyen L, Maria ATJ, Guilpain P, Carriere M, de Champfleur NM, Vincent T, Jentzer A, Labauge P, Devaux JJ, Taieb G. Immune-mediated diseases involving central and peripheral nervous systems. Eur J Neurol 2023; 30:490-500. [PMID: 36366904 DOI: 10.1111/ene.15628] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/03/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND PURPOSE In addition to combined central and peripheral demyelination, other immune diseases could involve both the central nervous system (CNS) and peripheral nervous system (PNS). METHODS To identify immune-mediated diseases responsible for symptomatic combined central/peripheral nervous system involvement (ICCPs), we conducted a multicentric retrospective study and assessed clinical, electrophysiological, and radiological features of patients fulfilling our ICCP criteria. RESULTS Thirty patients (20 males) were included and followed during a median of 79.5 months (interquartile range [IQR] = 43-145). The median age at onset was 51.5 years (IQR = 39-58). Patients were assigned to one of four groups: (i) monophasic disease with concomitant CNS/PNS involvement including anti-GQ1b syndrome (acute polyradiculoneuropathy + rhombencephalitis, n = 2), checkpoint inhibitor-related toxicities (acute polyradiculoneuropathy + encephalitis, n = 3), and anti-glial fibrillary acidic protein astrocytopathy (subacute polyradiculoneuropathy and meningoencephalomyelitis with linear gadolinium enhancements, n = 2); (ii) chronic course with concomitant CNS/PNS involvement including paraneoplastic syndromes (ganglionopathy/peripheral hyperexcitability + limbic encephalitis, n = 4); (iii) chronic course with sequential CNS/PNS involvement including POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome (polyradiculoneuropathy + strokes, n = 2), histiocytosis (polyradiculoneuropathy + lepto-/pachymeningitis, n = 1), and systemic vasculitis (multineuropathy + CNS vasculitis/pachymeningitis, n = 2); and (iv) chronic course with concomitant or sequential CNS/PNS involvement including combined central and peripheral demyelination (polyradiculoneuropathy + CNS demyelinating lesions, n = 10) and connective tissue diseases (ganglionopathy/radiculopathy/multineuropathy + limbic encephalitis/transverse myelitis/stroke, n = 4). CONCLUSIONS We diagnosed nine ICCPs. The timing of central and peripheral manifestations and the disease course help determine the underlying immune disease. When antibody against neuroglial antigen is identified, CNS and PNS involvement is systematically concomitant, suggesting a common CNS/PNS antigen and a simultaneous disruption of blood-nerve and blood-brain barriers.
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Affiliation(s)
- Aurelie Leboyan
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Florence Esselin
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Anne-Laure Bascou
- Clinical Research and Epidemiology Unit, University Hospital Center, University of Montpellier, Montpellier, France
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, University Hospital Center, University of Montpellier, Montpellier, France
| | - Ioana Ion
- Department of Neurology, Caremeau University Hospital Center, Nîmes, France
| | - Mahmoud Charif
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | | | | | - Xavier Ayrignac
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Philippe Kerschen
- Department of Neurology, Luxembourg Hospital Center, Luxembourg City, Luxembourg
| | - Mohamed Chbicheb
- Department of Neurology, Narbonne Hospital Center, Narbonne, France
| | - Ludovic Nguyen
- Department of Neurology, Perpignan Hospital Center, Perpignan, France
| | - Alexandre T J Maria
- Department of Internal Medicine, Saint Eloi University Hospital Center, Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine, Saint Eloi University Hospital Center, Montpellier, France
| | - Mathilde Carriere
- Department of Neuroradiology, Gui de Chauliac University Hospital Center, Montpellier, France
| | | | - Thierry Vincent
- Department of Immunology, Saint Eloi University Hospital Center, Montpellier, France
| | - Alexandre Jentzer
- Department of Immunology, Saint Eloi University Hospital Center, Montpellier, France
| | - Pierre Labauge
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Jérôme J Devaux
- Institute of Functional Genomics, National Center for Scientific Research UMR5203, Montpellier, France
| | - Guillaume Taieb
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
- Institute of Functional Genomics, National Center for Scientific Research UMR5203, Montpellier, France
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12
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Raunio F, Kelppe J, Hafrén L. Malignant lymphoma presenting as bilateral sensorineural hearing loss—A case report. Clin Case Rep 2022; 10:e6711. [PMCID: PMC9748227 DOI: 10.1002/ccr3.6711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 09/12/2021] [Accepted: 09/27/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Frida Raunio
- Department of Otorhinolaryngology Helsinki University Hospital Helsinki Finland
| | - Jetta Kelppe
- Department of Pathology, HUS Diagnostic Center Helsinki University Hospital Helsinki Finland
| | - Lena Hafrén
- Department of Otorhinolaryngology Helsinki University Hospital Helsinki Finland
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13
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Narotam Jeena H, Afrogheh A, West J, van der Colff F, Brey N. A unique presentation of IgG4 disease with ocular, neurologic and mastoid involvement. BMJ Case Rep 2022; 15:e251736. [PMID: 36375856 PMCID: PMC9664293 DOI: 10.1136/bcr-2022-251736] [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] [Indexed: 11/16/2022] Open
Abstract
A man in his 20s presented with headache and acute deterioration in visual acuity. He was found to have panuveitis and raised intracranial pressure with papilloedema. MRI and F-fluorodeoxyglucose positron emission tomography confirmed a subclinical, but active, inflammatory mastoid process. Histology of the mastoid showed immunoglobulin G4 (IgG4) cells, plasma cells and storiform fibrosis.This presentation of IgG4 disease has not been previously described.Treatment with high-dose steroids was initiated, followed by long-term immunosuppressive therapy. The patient's symptoms improved, although he remains dependent on azathioprine and low dose oral steroids for symptom control. To date, there has been no progression of the disease.
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Affiliation(s)
- Heena Narotam Jeena
- Division of Neurology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
- Neurology, Tygerberg Hospital, Cape Town, Western Cape, South Africa
| | - Amir Afrogheh
- Anatomical Pathology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
- NHLS, Tygerberg Hospital, Cape Town, Western Cape, South Africa
| | - Joshua West
- Otorhinolaryngology, Tygerberg Hospital, Cape Town, Western Cape, South Africa
- Otorhinolaryngology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Freddie van der Colff
- Ophthalmology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
- Ophthalmology, Tygerberg Hospital, Cape Town, Western Cape, South Africa
| | - Naeem Brey
- Division of Neurology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
- Neurology, Tygerberg Hospital, Cape Town, Western Cape, South Africa
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14
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Chakales PA, Herman MC, Chien LC, Hutto SK. Pachymeningitis in Biopsy-Proven Sarcoidosis. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/6/e200028. [PMID: 36163175 PMCID: PMC9513981 DOI: 10.1212/nxi.0000000000200028] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/26/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives Meningeal inflammation is one of the most common manifestations of neurosarcoidosis, occurring in 16%–69% of affected patients. While the clinical and radiographic features of leptomeningitis in neurosarcoidosis are well known, those of pachymeningitis are far less clear. Our primary aim was to study the clinicoradiographic features of pachymeningeal involvement in neurosarcoidosis and its evolution over time in response to treatment. Methods Patients with a diagnosis of neurosarcoidosis seen at Emory University (January 2011–August 2021) were included if pachymeningeal involvement was evident by MRI and the patient's sarcoidosis was pathologically confirmed (from a CNS or non-CNS site). Results Twenty-six of 215 (12.1%) patients with neurosarcoidosis qualified for inclusion. Pathologic confirmation came from CNS tissue in 50%. The median age of onset was 43.5 years; most were male (16/26, 61.5%). Symptoms were primarily related to pachymeningitis in 20/26 (76.9%). Headache (19/26, 73.1%), visual dysfunction (12/26, 46.2%), and seizures (7/26, 26.9%) were the most common symptoms. All patients had cranial pachymeningitis; only a single patient undergoing spinal imaging (1/11, 9.1%) had spinal pachymeningitis. The falx cerebri (16/26, 61.5%) was the most commonly affected dural structure, but the anterior and middle cranial fossae and tentorium cerebelli were frequently involved (12/26 each, 46.2%). The pachymeningeal lesions were unifocal (11/26, 42.3%) or multifocal (15/26, 57.7%) in distribution, nodular morphologically (23/25, 92.0%), and homogeneously enhancing (24/25, 96.0%). Symptomatic improvement occurred with steroids initially in 22/25 (88.0%). Ultimately, 23/26 (88.5%) required initiation of steroid-sparing immunosuppressants, including 8/26 (30.8%) eventually undergoing TNF inhibition. Pachymeningeal relapses occurred in 7/26 (26.9%). The median clinical follow-up was 48 months. The median modified Rankin scale score at last follow-up improved to 1.0 from 2.0 at presentation. Discussion Pachymeningitis due to sarcoidosis often presents with headaches, visual dysfunction, and seizures; it usually affects the dura of the falx cerebri, anterior and middle cranial fossae, and tentorium cerebelli and tends to require steroid-sparing immunosuppressants. It has the potential to relapse, but the prospect for recovery is good.
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15
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Ohyama K, Tanaka M, Nosaki Y, Yokoi T, Iwai K. IgG4-related Inflammatory Pseudotumor with Imaging Findings Similar to Meningioma: A Case Report. Intern Med 2022. [PMID: 36223929 DOI: 10.2169/internalmedicine.9786-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IgG4-related inflammatory pseudotumor is a feature of IgG4-related disease and develops in various organs. Intracranial IgG4-related inflammatory pseudotumor is rare, and data on the clinical course and response to treatment are insufficient in the literature. We herein report a patient with IgG4-related inflammatory pseudotumor who had magnetic resonance imaging findings similar to meningioma. Tumorectomy was discontinued because of the intraoperative rapid diagnosis, which revealed the infiltration of lymphocytes and plasma cells. She received oral prednisolone therapy for IgG4-related inflammatory pseudotumor, and the tumor size had significantly decreased after six months of treatment.
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Affiliation(s)
- Ken Ohyama
- Department of Neurology, Okazaki City Hospital, Japan
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Maki Tanaka
- Department of Neurology, Toyohashi Municipal Hospital, Japan
- Department of Internal Medicine, Sakurakai Hospital, Japan
| | - Yasunobu Nosaki
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Takamasa Yokoi
- Department of Neurology, Toyohashi Municipal Hospital, Japan
| | - Katsushige Iwai
- Department of Neurology, Toyohashi Municipal Hospital, Japan
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16
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Qing P, Lu C, Yan B, Liu C, Fox DA, Zhao Y, Liu Y, Tan C. Case report: IgG4-related intracranial lesions mimicking multiple sclerosis in a 14-year-old girl. Front Neurol 2022; 13:1007153. [PMID: 36247763 PMCID: PMC9554464 DOI: 10.3389/fneur.2022.1007153] [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: 07/30/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives IgG4-related disease (IgG4-RD) is distinguished by the infiltration of IgG4-positive plasma cells in a variety of tissues and organs. Even so, central nervous system lesions associated with IgG4-RD are scarce. We present a case of IgG4-related brain parenchymal lesions that mimics multiple sclerosis in a young girl. Methods The patient was followed by our neurology and rheumatology teams. Clinical information was recorded, and the brain was screened using magnetic resonance imaging (MRI). During follow-up, we examined serum IgE, IgG and IgG4 and lymph node biopsy. Results Here, we presented details of a 14-year-old Chinese girl suffering from diplopia, left eyelid ptosis, right facial numbness, and right lower limb weakness admitted to our institute. Brain MRI revealed multiple sclerosis-like lesions in the brain parenchyma and spinal cord. During the follow-up, she developed lymphadenopathy. Elevation of serum, IgG, IgG4 and IgE and lymph node biopsy favors a diagnosis of IgG4-RD. The patient had a good response to glucocorticoids and mycophenolate mofetil. The literature review summarized eight previously reported IgG4-RD involving brain parenchyma. Discussion Our case expands the known age spectrum of IgG4-RD. The intracranial IgG4-RD is rare and could mimic multiple sclerosis. Careful examination and dynamic review of disease history are crucial in the differential diagnosis.
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Affiliation(s)
- Pingying Qing
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Chenyang Lu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Bing Yan
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Chang Liu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - David A. Fox
- Division of Rheumatology, Clinical Autoimmunity Center of Excellence, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Yi Zhao
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China,Laboratory of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Chunyu Tan
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Chunyu Tan
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17
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Lv K, Cao X, Geng DY, Zhang J. Imaging findings of immunoglobin G4-related hypophysitis: A case report. World J Clin Cases 2022; 10:9440-9446. [PMID: 36159431 PMCID: PMC9477681 DOI: 10.12998/wjcc.v10.i26.9440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/04/2022] [Accepted: 08/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Immunoglobin G4 (IgG4)-related hypophysitis (IgG4-RH) is a rare form of IgG4-related disease (IgG4-RD), which often manifests as a single organ disease and is easily misdiagnosed as a pituitary tumor clinically and by imaging. There are few reports of imaging findings of IgG4-RH. Therefore, we describe a case of IgG4-RH, which mimicked a pituitary macroadenoma, that was detected by computed tomography (CT) and magnetic resonance imaging (MRI), and review the previous literature in order to further the understanding of IgG4-RH.
CASE SUMMARY A 47-year-old man presented with a history of blurred vision for more than 2 mo, without other symptoms. A preoperative unenhanced CT scan revealed a slightly hyperdense mass in the sellar region measuring 2.5 cm × 2.3 cm × 1.8 cm, with a CT value of 45 HU. T1-weighted imaging (T1WI) and T2-weighted imaging showed iso-hypointensity, and gadolinium contrast-enhanced T1WI showed obvious homogeneous enhancement. The MRI revealed involvement of the pituitary gland and stalk. Preoperative laboratory tests revealed abnormal pituitary hormone levels, including an increased prolactin level, and decreased levels of insulin-like growth factor, dehydroepiandrosterone, and testosterone. The lesion was surgically resected. Postoperative histopathological examination of a tissue sample and an elevated serum IgG4 level confirmed the diagnosis of IgG4-RH. The patient was treated with cortisone acetate postoperatively and made a good recovery without developing any neurological deficit.
CONCLUSION An elevated serum IgG4 concentration is the main clue for diagnosis of IgG4-RD. Imaging combined with laboratory testing is useful for preoperative diagnosis of IgG4-RH.
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Affiliation(s)
- Kun Lv
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Research, Science and Technology Commission of Shanghai Municipality, Shanghai 200003, China
- Institute of Intelligent Imaging Phenomics, International Human Phenome Institutes (Shanghai), Shanghai 200433, China
| | - Xin Cao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Research, Science and Technology Commission of Shanghai Municipality, Shanghai 200003, China
- Institute of Intelligent Imaging Phenomics, International Human Phenome Institutes (Shanghai), Shanghai 200433, China
| | - Dao-Ying Geng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Research, Science and Technology Commission of Shanghai Municipality, Shanghai 200003, China
- Institute of Intelligent Imaging Phenomics, International Human Phenome Institutes (Shanghai), Shanghai 200433, China
| | - Jun Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Research, Science and Technology Commission of Shanghai Municipality, Shanghai 200003, China
- Institute of Intelligent Imaging Phenomics, International Human Phenome Institutes (Shanghai), Shanghai 200433, China
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18
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Haj Mohamad Ebrahim Ketabforoush A, Bahadorinia M, Dolatshahi E, Nozarian Z, Abbasi Khoshsirat N. IgG4
‐related disease associated with the primary manifestation of recurrent cerebral venous thrombosis: A rare case report. Clin Case Rep 2022; 10:e6324. [PMID: 36177072 PMCID: PMC9474911 DOI: 10.1002/ccr3.6324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/08/2022] Open
Abstract
Nervous system involvement in IgG4‐related systemic disease (IgG4‐RD) is rarely reported and manifests as hypertrophic pachymeningitis and hypophysitis. In this report, a 33‐year‐old woman with neurological manifestations was diagnosed with IgG4‐RD by biopsy. The patient showed improvement in symptoms after treatment.
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Affiliation(s)
| | - Mahsa Bahadorinia
- Student Research Committee Alborz University of Medical Sciences Karaj Iran
| | - Elahe Dolatshahi
- Department of Rheumatology Clinical Research Development Unit (CRDU) of Shahid Rajaei Hospital Alborz University of Medical Sciences Karaj Iran
| | - Zohreh Nozarian
- Department of Pathology Farabi Eye Hospital Tehran University of Medical Sciences Tehran Iran
| | - Nahid Abbasi Khoshsirat
- Department of Neurology Clinical Research Development Unit (CRDU) of Shahid Rajaei Hospital Alborz University of Medical Sciences Karaj Iran
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19
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Abe F, Michishita Y, Saito M, Nara M, Wakui H, Takahashi N. Refractory IgG4-related disease complicated with organising pneumonia and hypertrophic pachymeningitis. Mod Rheumatol Case Rep 2022; 6:278-281. [PMID: 35355069 DOI: 10.1093/mrcr/rxac025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/12/2022] [Accepted: 03/18/2022] [Indexed: 06/14/2023]
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) involves multiple organs, including the lungs and central nervous system. Lung lesions are frequently reported as mass lesions or non-specific interstitial pneumonia, whereas organising pneumonia (OP) due to IgG4-RD is rare. Furthermore, limited information is currently available on hypertrophic pachymeningitis (HP). We herein report a case of IgG4-RD complicated with OP and HP. The diagnosis was confirmed based on the serum concentration of IgG4 and the results of salivary gland and transbronchial lung biopsies. HP did not respond to steroid monotherapy and was also resistant to rituximab and intravenous cyclophosphamide; however, the combination therapy of methotrexate and dexamethasone was effective.
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Affiliation(s)
- Fumito Abe
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Masaya Saito
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Mizuho Nara
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hideki Wakui
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
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20
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Shroff GS, Wu CC, Ocazionez D, Carter BW, Shivaprasad A, Chai T, Supsupin EP, Truong MT, Shroff S. It's Not All in Your Head: Thoracic Manifestations of Neurologic Diseases and Disorders. Acad Radiol 2022; 29:736-747. [PMID: 32622741 PMCID: PMC7329291 DOI: 10.1016/j.acra.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
Myriad conditions may affect both the neurologic system and the thorax, while other diseases primarily affecting the thorax may manifest with neurologic abnormalities. Correlation of signs, symptoms, and imaging findings in the neurological system with those in the thorax can help diagnose certain conditions and/or guide further diagnostic work-up and treatment. We will review and illustrate the imaging appearance of several systemic/neurological diseases with thoracic manifestations as well as discuss conditions in the thorax that can lead to neurologic symptoms.
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Affiliation(s)
- Girish S Shroff
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX.
| | - Carol C Wu
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Brett W Carter
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Thomas Chai
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Mylene T Truong
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
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21
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An YQ, Ma N, Liu Y. Immunoglobulin G4-related disease involving multiple systems: A case report. World J Clin Cases 2022; 10:2543-2549. [PMID: 35434077 PMCID: PMC8968596 DOI: 10.12998/wjcc.v10.i8.2543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/16/2021] [Accepted: 01/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND IgG4-related disease (IgG4-RD), an immune-mediated chronic progressive fibroinflammatory disease, can affect the functions of several organs. Some common characteristics can be observed in different IgG4-RDs, such as higher prevalence in middle-aged and elderly male patients, raised serum IgG4 levels, abundant infiltration of IgG4-positive cells and fibrosis, diffuse or localized swelling of the affected organs, and good response to glucocorticoids treatment.
CASE SUMMARY A 72-year-old man complained of left upper abdominal pain 3 mo ago, and he was diagnosed with acute onset of chronic cholecystitis and acute pancreatitis in the local hospital. Pain improved after relevant treatment. Several days ago, his abdominal pain worsened, and he was admitted to our hospital for further treatment. Doppler ultrasound showed that the pancreas presented with sausage-like swelling and the parenchymal echo was diffusely reduced. Gallbladder volume was increased, while the wall was rough and thickened with bilateral signs. Furthermore, the left submandibular gland was enlarged, accompanied with significantly increased blood flow signals. Finally, we found that the adventitia of the abdominal aorta and right iliac artery was thickened locally. Serum IgG4 was elevated to 12600 mg/L. Therefore, the patient was diagnosed with IgG4-RD. After treatment with methylprednisolone, he had an uneventful course and was discharged in good condition.
CONCLUSION IgG4-RD can involve almost any organs. Ultrasound has a significant role in timely and accurately diagnosis.
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Affiliation(s)
- Yu-Qiong An
- Heart Center, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
| | - Ning Ma
- Heart Center, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
| | - Yong Liu
- Department of Ultrasound, Beijing-Shijitan Hospital, Capital Medical University, Beijing 100038, China
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22
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Studies on anti-rabphilin-3A antibodies in 15 consecutive patients presenting with central diabetes insipidus at a single referral center. Sci Rep 2022; 12:4440. [PMID: 35292721 PMCID: PMC8924241 DOI: 10.1038/s41598-022-08552-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 03/09/2022] [Indexed: 12/11/2022] Open
Abstract
Central diabetes insipidus (CDI) is a rare condition caused by various underlying diseases including inflammatory and autoimmune diseases, and neoplasms. Obtaining an accurate definitive diagnosis of the underlying cause of CDI is difficult. Recently, anti-rabphilin-3A antibodies were demonstrated to be a highly sensitive and specific marker of lymphocytic infundibuloneurohypophysitis (LINH). Here, we report a detailed case series, and evaluated the significance of anti-rabphilin-3A antibodies in differentiating the etiologies of CDI. A prospective analysis was conducted in 15 consecutive patients with CDI from 2013 to 2020 at a single referral center. Anti-rabphilin-3A antibodies were measured and the relationship between antibody positivity and the clinical/histopathological diagnoses was evaluated. Among 15 CDI patients, the positive anti-rabphilin-3A antibodies were found in 4 of 5 LINH cases, 3 of 4 lymphocytic panhypophysitis (LPH) cases, one of 2 sarcoidosis cases, and one intracranial germinoma case, respectively. Two Rathke cleft cyst cases and one craniopharyngioma case were negative. This is the first report of anti-rabphilin-3A antibodies positivity in CDI patients with biopsy-proven LPH. Measurement of anti-rabphilin-3A antibodies may be valuable for differentiating CDI etiologies.
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Martín-Nares E, Hernández-Molina G, Baenas DF, Paira S. IgG4-Related Disease: Mimickers and Diagnostic Pitfalls. J Clin Rheumatol 2022; 28:e596-e604. [PMID: 34538846 DOI: 10.1097/rhu.0000000000001787] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The tendency of IgG4-related disease (IgG4-RD) to form pseudotumors, as well as its multisystemic nature, makes it the perfect mimicker of many conditions. Moreover, some clinical, serological, radiological, or histological features of the disease might be shared with some mimickers.Recently, 4 clinical phenotypes have been identified, and patients grouped in each phenotype have distinctive demographic, clinical, and serological features and outcomes, and, as expected, for each phenotype, a set of differential diagnoses should be considered. SUMMARY OF THE LITERATURE The main differential diagnoses for the pancreato-hepato-biliary phenotype are pancreatic adenocarcinoma and cholangiocarcinoma. Other differential diagnoses include type 2 autoimmune pancreatitis and primary sclerosing cholangitis. In patients with retroperitoneal/aortic phenotype, inflammatory conditions such as idiopathic retroperitoneal fibrosis and large vessel vasculitides should be ruled out, and most of the time, a biopsy will be needed to exclude malignancies. In head and neck limited phenotype, autoimmune conditions (eg, granulomatosis with polyangiitis, Graves orbitopathy, sarcoidosis), malignancies, and histiocytosis should be ruled out, whereas the main differential diagnoses of the Mikulicz/systemic phenotype are Sjögren syndrome, granulomatosis with polyangiitis, and multicentric Castleman disease. CONCLUSIONS Approaching a patient with probable IgG4-RD through a clinical phenotype framework will ease the diagnostic algorithm and facilitate the prompt recognition of the disease. There are certain clinical, serological, radiological, and histological features in each clinical phenotype that, if present, increase the likelihood that a patient may have IgG4-RD instead of the mimicker condition. Those clues that point toward IgG4-RD diagnosis should be actively sought in the workup of patients.
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Affiliation(s)
- Eduardo Martín-Nares
- From the Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriela Hernández-Molina
- From the Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Sergio Paira
- Sección de Reumatología, Hospital José María Cullen, Santa Fe, Argentina
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24
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Optic perineuritis: A Canadian case series and literature review. J Neurol Sci 2021; 430:120035. [PMID: 34717266 DOI: 10.1016/j.jns.2021.120035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Optic perineuritis (OPN) is a rare orbital inflammatory disorder that primarily involves the optic nerve sheath (ONS). This study aimed to describe the clinical features of idiopathic OPN as well as OPN secondary to other infectious and inflammatory conditions in a Canadian case series as current literature on secondary OPN in Western countries is mostly limited to case reports. METHODS Retrospective case series of all patients seen in a tertiary neuro-ophthalmology practice with a diagnosis of OPN from 2014 to 2020. RESULTS A total of 21 patients (14 women, mean age 55.8) corresponding to 29 eyes with OPN were identified. Fifteen cases were associated with inflammatory or infectious conditions and only 6 were idiopathic. All idiopathic cases were unilateral. The most common secondary causes of OPN were anti-myelin oligodendrocyte glycoprotein (MOG) antibody disease (n = 4), syphilis (n = 3), sarcoidosis (n = 3), and giant cell arteritis (n = 3). At initial presentation, best-corrected visual acuity (BCVA) was 20/20 or better in 24% (n = 7) and visual field mean deviation (VF MD) was better than -5 dB in 34% of eyes (10/29). Treatment consisted of intravenous penicillin for syphilitic OPN and high-dose corticosteroids followed by oral taper with or without immunosuppressive therapy for non-syphilitic OPN. BCVA improved in 34% (10/29) and VF MD improved in 45% (13/29) eyes. CONCLUSION OPN primarily occurred in association with systemic inflammatory conditions, especially in bilateral cases. Syphilis must be ruled out in all patients. Anti-MOG antibody disease is an important, newly recognized secondary cause of OPN, and serologic testing should be included in the investigation of all patients with OPN.
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25
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Wang CC, Liu B, Li XL, Yang B, Li YB, Duan RS. Chronic inflammatory demyelinating polyneuropathy-like neuropathy in IgG4-related disease. CNS Neurosci Ther 2021; 28:172-174. [PMID: 34697896 PMCID: PMC8673700 DOI: 10.1111/cns.13747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Cong-Cong Wang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Institute of Neuroimmunology, Jinan, China
| | - Bin Liu
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Institute of Neuroimmunology, Jinan, China
| | - Xiao-Li Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Institute of Neuroimmunology, Jinan, China
| | - Bing Yang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Institute of Neuroimmunology, Jinan, China
| | - Yan-Bin Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Institute of Neuroimmunology, Jinan, China
| | - Rui-Sheng Duan
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Institute of Neuroimmunology, Jinan, China
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26
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Jin L, Liu Y. Clinical Manifestations, Pathogenesis, Diagnosis and Treatment of Peripheral Neuropathies in Connective Tissue Diseases: More Diverse and Frequent in Different Subtypes than Expected. Diagnostics (Basel) 2021; 11:diagnostics11111956. [PMID: 34829303 PMCID: PMC8618211 DOI: 10.3390/diagnostics11111956] [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: 09/06/2021] [Revised: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose of review: To discuss and summarize recent findings in peripheral neuropathy (PN) related to connective tissue diseases (CTD) including its prevalence, clinical manifestations, pathogenesis, diagnosis and treatment. Recent findings: Although PN is a common complication in CTD and has been well studied, recent research has shown that PN is more diverse and frequent in different subtypes of CTD than was expected. The incidence of PN in Sjögren’s syndrome and rheumatoid arthritis (RA) varies according to different disease subtypes, and the pathogenesis of neuropathic pain in different subtypes of eosinophilic granulomatosis with polyangiitis (EGPA) may also differ. Neurogenic inflammation, autoantibody-mediated changes, ischemia of the vascular wall and metabolic mechanisms have been shown to contribute to the pathogenesis of PN in CTD. Moreover, allergic inflammation has been recently identified as a possible new mechanism producing peripheral neuropathic pain associated with MPO-ANCA negative EGPA patients. Glucocorticoids are routinely used to relieve pain caused by PN. However, these steroids may cause hyperalgesia, exacerbate neuropathic pain, and activate the early phase of pain induction and produce hyperalgesia. Recently, neuroactive steroids, such as progesterone, tetrahydroprogesterone and testosterone, have been shown to exert protective effects for several PN symptoms, and in particular neuropathic pain. Neuroactive steroids will be an interesting topic for future research into PN in CTD. Summary: It is essential for the diagnosis and treatment of PN in CTD to be updated. Timely diagnosis, appropriate treatments, and multidisciplinary care are essential to minimize morbidity and decrease the risk of permanent neurologic deficits. Further studies are needed to guide diagnosis and treatment.
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Affiliation(s)
| | - Yu Liu
- Correspondence: ; Tel.: +86-139-1671-8761
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27
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic immune-mediated fibroinflammatory disease. Since its discovery nearly two decades ago, our understanding of its pathophysiology and clinical manifestations has grown substantially. Early diagnosis and treatment of this elusive disease can prevent substantial organ damage from end-stage fibrosis, emphasizing the need for prompt recognition and accurate characterization of IgG4-RD. The classification criteria endorsed by the American College of Rheumatology and the European Alliance of Associations for Rheumatology in 2019 provide a framework for establishing the diagnosis in the clinical setting. This process involves recognizing the typical manifestations of the disease and incorporating clinical, radiological, serological, and histopathological information as well as excluding disease mimickers. Glucocorticoids and rituximab are effective at inducing remission in IgG4-RD in most patients, but the optimal approach to long-term management of IgG4-RD remains an area of active clinical research. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Guy Katz
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA;
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA;
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28
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Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2021; 35:152-169. [PMID: 34490814 DOI: 10.1177/19714009211042879] [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] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
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Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
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29
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Urushida Y, Ishikawa D, Yanaizumi M, Nakamura T, Amari M, Kawarabayashi T, Tosaka M, Ikeda Y, Takatama M, Shoji M. IgG4-related hypothalamo-hypophysitis. eNeurologicalSci 2021; 24:100362. [PMID: 34466672 PMCID: PMC8385281 DOI: 10.1016/j.ensci.2021.100362] [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: 06/04/2021] [Revised: 07/16/2021] [Accepted: 07/25/2021] [Indexed: 12/02/2022] Open
Abstract
A patient exhibited IgG4-related hypothalamo-hypophysitis. Prominent high-signal areas of swelling were observed in the hypothalamus, tuber cinereum, infundibulum, and bilateral optic nerve systems. MRI T1WI with contrast media demonstrated enhanced neurohypophysis and cystic swelling, and compressed anterior pituitary. MRI findings improved rapidly after 4 days of steroid therapy.
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Key Words
- ACE, angiotensin converting enzyme
- ACTH, adrenocorticotropic hormone
- AQP4, aquaporin-4
- BP, blood pressure
- CT, computed tomography
- DDAVP, 1-desamino-8-D-arginine vasopressin
- FLAIR, fluid attenuated inversion recovery
- FSH, follicle stimulating hormone
- IgG4-related hypothalamo-hypophysitis
- LH, luteinizing hormone
- MPO-ANCA, myeloperoxidase-antineutrophil cytoplasmic antibody
- MRI, magnetic resonance imaging
- Neurohypophysitis
- Optic tract edema
- PR3-ANCA, proteinase-3-antineutrophil cytoplasmic antibody
- Rapid recovery
- T1WI, T1 weighted image
- T2WI, T2 weighted image
- sIL-2R, soluble interleukin 2 receptor
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Affiliation(s)
- Yuki Urushida
- Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
- Corresponding author.
| | - Daisuke Ishikawa
- Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | - Mayuri Yanaizumi
- Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | - Takumi Nakamura
- Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masakuni Amari
- Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
| | | | - Masahiko Tosaka
- Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yoshio Ikeda
- Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Mikio Shoji
- Neurology, Geriatrics Research Institute and Hospital, Maebashi, Japan
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30
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Singh VK, Kalita J, Misra UK, Kumar S. Cerebral Venous Sinus Thrombosis and Pachymeningitis in IgG4 Related Disease: Report of Two Cases and Review of Literature. Ann Indian Acad Neurol 2021; 24:432-436. [PMID: 34447016 PMCID: PMC8370182 DOI: 10.4103/aian.aian_411_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Varun K Singh
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Sunil Kumar
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
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31
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Friedrich M, Kehl N, Engelke N, Kraus J, Lindner K, Münch P, Mildenberger I, Groden C, Gass A, Etminan N, Fatar M, von Deimling A, Reuss D, Platten M, Bunse L. Intrathecal activation of CD8 + memory T cells in IgG4-related disease of the brain parenchyma. EMBO Mol Med 2021; 13:e13953. [PMID: 34254741 PMCID: PMC8350898 DOI: 10.15252/emmm.202113953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/21/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder signified by aberrant infiltration of IgG4-restricted plasma cells into a variety of organs. Clinical presentation is heterogeneous, and pathophysiological mechanisms of IgG4-RD remain elusive. There are very few cases of IgG4-RD with isolated central nervous system manifestation. By leveraging single-cell sequencing of the cerebrospinal fluid (CSF) of a patient with an inflammatory intracranial pseudotumor, we provide novel insights into the immunopathophysiology of IgG4-RD. Our data illustrate an IgG4-RD-associated polyclonal T-cell response in the CSF and an oligoclonal T-cell response in the parenchymal lesions, the latter being the result of a multifaceted cell-cell interaction between immune cell subsets and pathogenic B cells. We demonstrate that CD8+ T effector memory cells might drive and sustain autoimmunity via macrophage migration inhibitory factor (MIF)-CD74 signaling to immature B cells and CC-chemokine ligand 5 (CCL5)-mediated recruitment of cytotoxic CD4+ T cells. These findings highlight the central role of T cells in sustaining IgG4-RD and open novel avenues for targeted therapies.
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Affiliation(s)
- Mirco Friedrich
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Niklas Kehl
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Niko Engelke
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Josephine Kraus
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Katharina Lindner
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Philipp Münch
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Iris Mildenberger
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Achim Gass
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.,DKTK CCU Neuropathology, DKFZ, Heidelberg, Germany
| | - David Reuss
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.,DKTK CCU Neuropathology, DKFZ, Heidelberg, Germany
| | - Michael Platten
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Helmholtz Institute of Translational Oncology (HI-TRON), Mainz, Germany.,Immune Monitoring Unit, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Lukas Bunse
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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32
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Kawazoe T, Inoue T, Tobisawa S, Sugaya K, Shimizu T, Miyamoto K, Goto M, Yokogawa N, Azuma S, Itagaki S, Nishida K, Morita Y, Nagao M, Isozaki E. Immunoglobulin G4-related Disease Accompanied by Peripheral Neuropathy: A Report of Two Cases. Intern Med 2021; 60:1941-1947. [PMID: 33456044 PMCID: PMC8263177 DOI: 10.2169/internalmedicine.6461-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Due to its rarity and the limited literature, the clinicopathological characteristics of peripheral nerve involvement in immunoglobulin G4 (IgG4)-related disease are unknown. We present two cases of IgG4-related disease, accompanied by peripheral neuropathy, presenting as unilateral ptosis (case 1) and sclerosing cholangitis (case 2), respectively. In both cases, sural nerve biopsy indicated vasculitis as the underlying pathophysiology; the peripheral neuropathy was refractory to corticosteroid therapy. In contrast to the previously proposed pathomechanism of IgG4-related neuropathy (direct lymphoplasmacytic infiltration), the pathological findings in our cases suggest that vasculitis occurs secondary to systemic autoimmune conditions.
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Affiliation(s)
- Tomoya Kawazoe
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Tomoyuki Inoue
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Shinsuke Tobisawa
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Toshio Shimizu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Kazuhito Miyamoto
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Manaka Goto
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Japan
| | - Sanami Azuma
- Department of Otolaryngology-Head and Neck Surgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Shingo Itagaki
- Department of Pathology, Tokyo Metropolitan Tama Medical Center, Japan
| | - Kenji Nishida
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yasuhiro Morita
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Japan
| | - Masahiro Nagao
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Eiji Isozaki
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
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33
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Neuroimaging findings in rheumatologic disorders. J Neurol Sci 2021; 427:117531. [PMID: 34130065 DOI: 10.1016/j.jns.2021.117531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/12/2021] [Accepted: 06/02/2021] [Indexed: 01/06/2023]
Abstract
Patients with rheumatological diseases may present with neurological manifestations of peripheral and/or central nervous system (CNS). Symptoms may be related to underlying rheumatological disease or CNS effects of immune-modulating drugs. Early diagnosis and therapy may help prevent serious complications. Magnetic resonance imaging (MRI), given its excellent soft tissue details, is the preferred imaging modality when evaluating patients with rheumatological disease and suspected CNS involvement. We present a review of the neuroimaging manifestations of various rheumatic diseases with emphasis on the imaging findings on MRI.
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34
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Hahner S, Ross RJ, Arlt W, Bancos I, Burger-Stritt S, Torpy DJ, Husebye ES, Quinkler M. Adrenal insufficiency. Nat Rev Dis Primers 2021; 7:19. [PMID: 33707469 DOI: 10.1038/s41572-021-00252-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/25/2022]
Abstract
Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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Affiliation(s)
- Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephanie Burger-Stritt
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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35
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Vasaitis L, Wikström J, Ahlström S, Gudjonsson O, Kumlien E, Edén Engström B, Casar-Borota O. Histopathological findings in the landscape of IgG4-related pathology in patients with pituitary dysfunction: Review of six cases. J Neuroendocrinol 2021; 33:e12942. [PMID: 33615590 DOI: 10.1111/jne.12942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/05/2021] [Accepted: 01/19/2021] [Indexed: 12/18/2022]
Abstract
IgG4-related hypophysitis (IgG4-RH) is increasingly being reported as an isolated entity or, less frequently, as a manifestation of a multiorgan IgG4-related disease (IgG4-RD), in which typical histopathology is a cornerstone for the diagnosis. We aimed to describe the histopathological changes in the surgical specimens from patients with clinical signs of pituitary disease that fulfilled the current diagnostic criteria for IgG4-RH. Histopathological features were correlated with clinical and radiological findings. Of 19 patients with pituitary dysfunction and inflammatory changes in the surgical pituitary specimen operated on during 2011-2019, we identified five patients with typical IgG4-related pathology (lymphoplasmacytic infiltration with more than 10 IgG4-positive plasma cells per one high power microscopic field, representing at least 40% of all plasma cells and at least focal storiform fibrosis). One patient with diabetes insipidus and pachymeningitis with IgG4-related changes in a biopsy from the dura was also included. Additional histopathological changes that typically are not part of the IgG4-RH were observed: Rathke's cleft cyst in four and granulomatous changes in two patients. One patient had an elevated serum IgG4 level and systemic manifestations that could be associated with the systemic IgG4-RD. Our findings indicate that pure IgG4-RH is uncommon. All patients with pituitary dysfunction, beyond typical IgG4-related pathology, had other pathological findings that could trigger the secondary IgG4-response. Both primary pathology and secondary IgG4-related features should be reported in patients with pituitary dysfunction because their co-occurrence may cause atypical clinical and imaging features, and unexpected response to surgical and pharmacological treatment. The current criteria for the diagnosis of IgG4-RH can lead to overdiagnosis of IgG4-RH if additional pathological changes are not taken into consideration. The classification criteria of IgG4-RD proposed by the American College of Rheumatology/European League Against Rheumatism could help classify patients more properly as IgG4-RH if applied to the pituitary gland.
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Affiliation(s)
- Lilian Vasaitis
- Department of Medical Sciences, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Sengul Ahlström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
| | | | - Eva Kumlien
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University, Uppsala, Sweden
| | - Olivera Casar-Borota
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
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Immunoglobulin G4-related disease presenting with peripheral neuropathy: a case report. BMC Neurol 2021; 21:41. [PMID: 33509108 PMCID: PMC7845096 DOI: 10.1186/s12883-021-02069-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/21/2021] [Indexed: 01/12/2023] Open
Abstract
Background Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition characterized by high serum IgG4 concentrations and tissue infiltration by IgG4-positive plasma cells. Reports have demonstrated that IgG4-RD affects various organs, including the pancreas, kidney, lung, thyroid, and lacrimal and salivary glands. In the nervous system, hypertrophic pachymeningitis and hypophysitis are mainly related to IgG4-RD; however, the peripheral neuropathy involvement is unusual. Case presentation We report on a 69-year-old woman with multiple mononeuropathy, weight loss and kidney mass in the setting of IgG4-RD. Biopsies of the kidney mass showed lymphoplasmacytic sclerosing inflammation with numerous IgG4-positive plasma cells. IgG4 and IgG4/IgG ratios in the blood were elevated. The patient was treated with high dose methylprednisolone with improvement in her neuropathy. Conclusions IgG4-RD is a relatively recently reported systemic fibrous inflammatory disease caused by the infiltration of IgG4-positive plasma cells in various organs. In the nervous system, symptomatic peripheral nerve invasion is very rare. However, as demonstrated in our case, IgG4-RD may present with primarily peripheral nerve disease.
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Abrantes FF, Moraes MPMD, Rezende Filho FM, Pedroso JL, Barsottini OGP. A clinical approach to hypertrophic pachymeningitis. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:797-804. [PMID: 33295420 DOI: 10.1590/0004-282x20200073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms. OBSERVATIONS HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor. CONCLUSION HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.
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Affiliation(s)
- Fabiano Ferreira Abrantes
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Flávio Moura Rezende Filho
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | - José Luiz Pedroso
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
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Zhan L, Fan M, Cai N, Cai B. Combination of autoimmune pancreatitis and peripheral neuropathy on an IgG4-related disease patient with 4 years following-up. J Neuroimmunol 2020; 348:577378. [PMID: 32949993 DOI: 10.1016/j.jneuroim.2020.577378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022]
Abstract
Type1 autoimmune pancreatitis (AIP) is the first recognized and the most common manifestation of IgG4-related disease. However, AIP patient presented with neuropathy in the extremities have not been reported previously. We reported a rare combination of autoimmune pancreatitis and peripheral neuropathy on an IgG4-related disease patient based on histological features to expand the clinical spectrum of IgG4-related disease.
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Affiliation(s)
- Lingling Zhan
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, China
| | - Mengting Fan
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, China
| | - Naiqing Cai
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, China
| | - Bin Cai
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou 350005, China.
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Altintas A, Dargvainiene J, Schneider-Gold C, Asgari N, Ayzenberg I, Ciplea AI, Junker R, Leypoldt F, Wandinger KP, Hellwig K. Gender issues of antibody-mediated diseases in neurology: (NMOSD/autoimmune encephalitis/MG). Ther Adv Neurol Disord 2020; 13:1756286420949808. [PMID: 32922516 PMCID: PMC7450460 DOI: 10.1177/1756286420949808] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD), autoimmune encephalitis (AE), myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) are antibody-mediated neurological diseases. They have mostly female predominance, affecting many women during childbearing age. Interactions between the underlying disease (or necessary treatment) and pregnancy can occur in every of these illnesses. Herein, we present the characteristics of NMOSD, AE, MG and LEMS in general, and review published data regarding the influence of the different diseases on fertility, pregnancy, puerperium, treatment strategy during pregnancy and post-partum period, and menopause but also male factors. We summarise key elements that should be borne in mind when confronted with such cases.
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Affiliation(s)
- Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Justina Dargvainiene
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Schleswig-Holstein, Germany
| | | | - Nasrin Asgari
- Department of Neurology, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital Bochum, Ruhr University of Bochum, Germany
| | - Andrea I Ciplea
- Department of Neurology, St. Josef Hospital Bochum, Ruhr University of Bochum, Germany
| | - Ralf Junker
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Schleswig-Holstein, Germany
| | - Frank Leypoldt
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Schleswig-Holstein, Germany
| | - Klaus-Peter Wandinger
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Schleswig-Holstein, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital Bochum, Ruhr University of Bochum, Gudrunstrasse 56, Bochum, 44791, Germany
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is rare disease entity and has recently been recognized as an inflammatory disorder with the tendency to affect multiple organs. Pachymeningitis of spine caused by IgG4-related disease is extremely rare. Neck pain and spinal cord compression symptoms consist of usual presentation of IgG4-related spinal pachymeningitis; however, polyarthritis is an unusual presentation of this disease, and it was reported in only one case that mimicked psoriatic arthritis. In this report, we describe a case of IgG4-related spinal pachymeningitis in a middle-age male who presented initially with neck pain and rheumatoid arthritis-like symptoms and later on developed both right upper and lower limb weakness. He was found to had pachymeningeal thickening on a cervical magnetic resonance image (MRI) and elevated serum IgG4 levels. He was treated with glucocorticoids and rituximab, which led to a significantly positive radiological response.
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Affiliation(s)
- Mousa N Alrashdi
- Department of Medicine, Collage of Medicine, Qassim University, Al Qassim, Kingdom of Saudi Arabia. E-mail.
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41
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Vakrakou AG, Evangelopoulos ME, Boutzios G, Tzanetakos D, Tzartos J, Velonakis G, Toulas P, Anagnostouli M, Andreadou E, Koutsis G, Stefanis L, Fragoulis GE, Kilidireas C. Recurrent myelitis and asymptomatic hypophysitis in IgG4-related disease: case-based review. Rheumatol Int 2020; 40:337-343. [PMID: 31898763 DOI: 10.1007/s00296-019-04502-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/11/2019] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a disorder with various clinical manifestations. Central nervous system (CNS) involvement is well recognized, with hypertrophic pachymeningitis and hypophysitis being the most common manifestations. Spinal cord involvement is an extremely rare manifestation. We present the first case of an IgG4-RD patient with spinal cord parenchymal disease and concurrent hypophysitis. We review also the current literature about CNS parenchymal involvement in the context of IgG4-RD. A young female presented with clinical symptoms of myelitis. Cervical spinal cord magnetic resonance imaging (MRI) displayed features of longitudinally extensive transverse myelitis (LETM). Brain MRI showed a small number of high-intensity lesions in the deep white matter and enlargement of hypophysis with homogeneous gadolinium enhancement (asymptomatic hypophysitis). Diagnostic workup revealed elevated IgG4 serum levels (146 mg/dL). Our patient fulfilled the organ-specific diagnostic criteria of IgG4-hypophysitis. Treatment with intravenous glucocorticoids led to rapid clinical response, and to the substantial resolution of imaging findings. Azathioprine was used as a maintenance treatment. One relapse occurred 2 years after the initial diagnosis and patient was re-treated with glucocorticoids. Three years after relapse, patient is in remission with azathioprine. We present the first case of myelitis with radiological features of LETM associated with increased IgG4 serum levels and the simultaneous presence of asymptomatic IgG4-related hypophysitis.
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Affiliation(s)
- Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece.
| | - Maria-Eleptheria Evangelopoulos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Boutzios
- Endocrine Unit, Department of Pathophysiology, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitrios Tzanetakos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - John Tzartos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Velonakis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Panagiotis Toulas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Elissavet Andreadou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Koutsis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - George E Fragoulis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
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Comai G, Cuna V, Fabbrizio B, Sabattini E, Leone O, Tondolo F, Angeletti A, Cappuccilli M, Liguori R, La Manna G. A case report of IgG4-related disease: an insidious path to the diagnosis through kidney, heart and brain. BMC Nephrol 2019; 20:418. [PMID: 31752722 PMCID: PMC6868811 DOI: 10.1186/s12882-019-1587-4] [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: 03/27/2019] [Accepted: 10/13/2019] [Indexed: 11/22/2022] Open
Abstract
Background IgG4-related disease, described around the years 2000 as a form of autoimmune pancreatitis, is now increasingly accepted as a systemic syndrome. The diagnosis is based on both comprehensive and organ-specific criteria. For the kidney, Mayo clinic classification and the guidelines of the Japanese Nephrology Society are used. Ultimately, together with parameters that characterize every organ or apparatus involved, the key element is the confirmation of growing levels of IgG4 in blood or in tissues. Case presentation We describe a male patient with chronic renal failure associated to hypertension without proteinuria. IgG4-related disease was diagnosed through renal biopsy. After an initial positive response to steroids, he presented tinnitus, and histological assessment showed cerebral and subsequently cardiac damage, both IgG4-related. This case appears unique for the type of histologically documented cardiac and neurological parenchymal involvement, and at the same time, exemplifies the subtle and pernicious course of the disease. Frequently, blurred and non-specific signs prevail. Here, kidney damage was associated with minimal urinary findings, slowly progressive renal dysfunction and other factors that can be equivocated in the differential diagnosis. Neurological involvement was represented by tinnitus alone, while cardiac alterations were completely asymptomatic. Conclusions This report is representative of the neurological and cardiac changes described in the literature for IgG4-related disease, which may be correlated or not with the renal form and highlights the need, in some cases, of targeted therapeutic approaches. In addition to glucocorticoids, as in this case, rituximab may be necessary.
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Affiliation(s)
- Giorgia Comai
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Vania Cuna
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Benedetta Fabbrizio
- Unit of Oncology and Transplant Pathology, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 18), 40138, Bologna, Italy
| | - Elena Sabattini
- Unit of Hemolymphopathology, Department of Hematology & Oncology, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 8), 40138, Bologna, Italy
| | - Ornella Leone
- Unit of Oncology and Transplant Pathology, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 18), 40138, Bologna, Italy
| | - Francesco Tondolo
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Andrea Angeletti
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Maria Cappuccilli
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Rocco Liguori
- IRCCS Institute of Neurological Sciences of Bologna and Department of Biomedical and Neuromotor Sciences, University of Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Gaetano La Manna
- Unit of Nephrology, Dialysis and Transplantation, Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, S. Orsola Malpighi Hospital, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy.
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Abstract
PURPOSE OF REVIEW This article discusses an approach to imaging in patients with neuro-ophthalmologic disorders, with emphasis on the clinical-anatomic localization of lesions affecting afferent and efferent visual function. RECENT FINDINGS Advances in MRI, CT, ultrasound, and optical coherence tomography have changed how neuro-ophthalmic disorders are diagnosed and followed in the modern clinical era. SUMMARY The advantages, disadvantages, and indications for various imaging techniques for neuro-ophthalmologic disorders are discussed, with a view to optimizing how these tools can be used to enhance patient care.
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Lin J, Zheng L, Zhou D, Hong Z. Immunoglobulin G4–related disease involving both cerebral parenchyma and spinal cord: A case report. J Neuroimmunol 2019; 335:577018. [DOI: 10.1016/j.jneuroim.2019.577018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/01/2019] [Accepted: 08/01/2019] [Indexed: 01/05/2023]
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Soares C, Martins DF, Pestana-Silva R, Honavar M, Faria O, Abreu P, Costa A. Intrathecal rituximab in immunoglobulin G4-hypertrophic pachymeningitis. J Neuroimmunol 2019; 334:576997. [DOI: 10.1016/j.jneuroim.2019.576997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 05/29/2019] [Accepted: 06/17/2019] [Indexed: 12/24/2022]
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Bunschoten C, Jacobs BC, Van den Bergh PYK, Cornblath DR, van Doorn PA. Progress in diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy. Lancet Neurol 2019; 18:784-794. [DOI: 10.1016/s1474-4422(19)30144-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 02/05/2019] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
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Fujino Y, Saito K, Maezono K, Kasai T, Mizuno T. [A case of hypertrophic pachymeningitis associated with probable sarcoidosis with increased serum IgG4]. Rinsho Shinkeigaku 2019; 59:436-441. [PMID: 31243250 DOI: 10.5692/clinicalneurol.cn-001275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We report a 54-year-old man, who presented with an acute onset of diplopia and ptosis on the left side. On admission, neurological examination showed left oculomotor and abducens nerve palsy. Brain MRI showed thickening of the left parieto-temporal dura mater with gadolinium enhancement. Whole-body CT revealed a mass lesion in the right submandibular gland, diffuse goiter, and bilateral hilar lymph node enlargement. Initially, IgG4-related disease was considered because of an elevated serum IgG4 level (240 mg/dl); however, biopsy of the submandibular gland showed non-caseating epithelioid cell granulomas that suggested sarcoidosis, which could be associated with the intracranial lesions causing his neurological manifestation. In cases of hypertrophic pachymeningitis, especially with increased serum IgG4 including our case, a careful assessment with pathological examination is critical for identifying various underlying conditions.
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Affiliation(s)
- Yuzo Fujino
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kozo Saito
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Keiko Maezono
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takashi Kasai
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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Newman JH, Shaver A, Sheehan JH, Mallal S, Stone JH, Pillai S, Bastarache L, Riebau D, Allard‐Chamard H, Stone WM, Perugino C, Pilkinton M, Smith SA, McDonnell WJ, Capra JA, Meiler J, Cogan J, Xing K, Mahajan VS, Mattoo H, Hamid R, Phillips JA. IgG4-related disease: Association with a rare gene variant expressed in cytotoxic T cells. Mol Genet Genomic Med 2019; 7:e686. [PMID: 30993913 PMCID: PMC6565556 DOI: 10.1002/mgg3.686] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Family screening of a 48-year-old male with recently diagnosed IgG4-related disease (IgG4-RD) revealed unanticipated elevations in plasma IgG4 in his two healthy teenaged sons. METHODS We performed gene sequencing, immune cell studies, HLA typing, and analyses of circulating cytotoxic CD4+ T lymphocytes and plasmablasts to seek clues to pathogenesis. DNA from a separate cohort of 99 patients with known IgG4-RD was also sequenced for the presence of genetic variants in a specific gene, FGFBP2. RESULTS The three share a previously unreported heterozygous single base deletion in fibroblast growth factor binding protein type 2 (FGFBP2), which causes a frameshift in the coding sequence. The FGFBP2 protein is secreted by cytotoxic T-lymphocytes and binds fibroblast growth factor. The variant sequence in the FGFBP2 protein is predicted to form a disordered random coil rather than a helical-turn-helix structure, unable to adopt a stable conformation. The proband and the two sons had 5-10-fold higher numbers of circulating cytotoxic CD4 + T cells and plasmablasts compared to matched controls. The three members also share a homozygous missense common variant in FGFBP2 found in heterozygous form in ~40% of the population. This common variant was found in 73% of an independent, well characterized IgG4-RD cohort, showing enrichment in idiopathic IgG4-RD. CONCLUSIONS The presence of a shared deleterious variant and homozygous common variant in FGFBP2 in the proband and sons strongly implicates this cytotoxic T cell product in the pathophysiology of IgG4-RD. The high prevalence of a common FGFBP2 variant in sporadic IgG4-RD supports the likelihood of participation in disease.
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Affiliation(s)
- John H. Newman
- Vanderbilt Center for Undiagnosed DiseaseVanderbilt UniversityNashvilleTennessee
| | - Aaron Shaver
- Department of Pathology, Microbiology and of ImmunologyVanderbilt UniversityNashvilleTennessee
| | - Jonathan H. Sheehan
- Department of Biochemistry and Center for Structural BiologyVanderbilt UniversityNashvilleTennessee
| | - Simon Mallal
- Department of MedicineCenter for Translational Immunology and Infectious DiseasesVanderbilt UniversityNashvilleTennessee
| | - John H. Stone
- Department of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusetts
| | - Shiv Pillai
- Ragon Institute of MGHMIT and Harvard Medical SchoolBostonMassachusetts
| | - Lisa Bastarache
- BioVUVanderbilt University Medical CenterVanderbilt UniversityNashvilleTennessee
| | - Derek Riebau
- Department of NeurologyVanderbilt UniversityNashvilleTennessee
| | | | - William M. Stone
- Ragon Institute of MGHMIT and Harvard Medical SchoolBostonMassachusetts
| | - Cory Perugino
- Ragon Institute of MGHMIT and Harvard Medical SchoolBostonMassachusetts
| | - Mark Pilkinton
- Department of MedicineCenter for Translational Immunology and Infectious DiseasesVanderbilt UniversityNashvilleTennessee
| | - Scott A. Smith
- Department of MedicineCenter for Translational Immunology and Infectious DiseasesVanderbilt UniversityNashvilleTennessee
| | - Wyatt J. McDonnell
- Department of MedicineCenter for Translational Immunology and Infectious DiseasesVanderbilt UniversityNashvilleTennessee
| | - John A. Capra
- Department of Biochemistry and Center for Structural BiologyVanderbilt UniversityNashvilleTennessee
| | - Jens Meiler
- Department of Biochemistry and Center for Structural BiologyVanderbilt UniversityNashvilleTennessee
| | - Joy Cogan
- Vanderbilt Center for Undiagnosed DiseaseVanderbilt UniversityNashvilleTennessee
- Department of PediatricsDivision of Medical GeneticsVanderbilt UniversityNashvilleTennessee
| | - Kelly Xing
- Ragon Institute of MGHMIT and Harvard Medical SchoolBostonMassachusetts
| | - Vinay S. Mahajan
- Ragon Institute of MGHMIT and Harvard Medical SchoolBostonMassachusetts
| | - Hamid Mattoo
- Ragon Institute of MGHMIT and Harvard Medical SchoolBostonMassachusetts
| | - Rizwan Hamid
- Vanderbilt Center for Undiagnosed DiseaseVanderbilt UniversityNashvilleTennessee
- Department of PediatricsDivision of Medical GeneticsVanderbilt UniversityNashvilleTennessee
| | - John A. Phillips
- Vanderbilt Center for Undiagnosed DiseaseVanderbilt UniversityNashvilleTennessee
- Department of PediatricsDivision of Medical GeneticsVanderbilt UniversityNashvilleTennessee
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Pucar PA, Nolan J, Hissaria P. Immunoglobulin G 4 related disease: a single-centre experience from South Australia. Intern Med J 2019; 49:1099-1104. [PMID: 31059167 DOI: 10.1111/imj.14331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 04/16/2019] [Accepted: 04/27/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND IgG4 related disease (IgG4RD) is a newly described multisystem fibro-inflammatory disorder. There is a paucity of literature describing the Australian experience of this rare condition. AIMS To characterise the Royal Adelaide Hospital IgG4RD cohort with biopsy-proven disease. METHODS A search of the Frome Road SA Pathology database was performed for all tissue biopsies containing the phrase 'IgG4 positive'. Case notes were reviewed for clinical details, laboratory and radiology results. Histological features according to the Boston Criteria were used. Patients with available case notes, highly suggestive or probable histology and clinical features to suggest IgG4RD were included. RESULTS Twenty patients had definite or probable IgG4RD and suggestive clinical features; median age 59 (20-76), male : female 1.5:1. There was considerable delay in diagnosis (median diagnosis at 64 months). Organ involvement included: 11 exocrine gland, seven pancreatobiliary, seven nodal, seven soft tissue, five retro-orbital, three retroperitoneal fibrosis and two renal. Systemic symptoms at diagnosis were seen in eight patients. Seven (35%) had an elevated serum IgG4 (>1.35 g/L) at diagnosis. Only 12 (60%) required immunosuppressive treatment (corticosteroids); of these, four (20%) required a steroid-sparing agent and four (20%) required B-cell depleting therapy (rituximab). The median duration of follow up was 18 months. CONCLUSIONS This is the first characterised Australian cohort with generalised IgG4RD, a rare, relatively indolent and under-recognised multisystem disorder. Diagnosis is difficult given lack of awareness of this rare condition among physicians, its presentation as a great disease mimic, challenges with histopathological assessment and the absence of a suitable serum biomarker.
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Affiliation(s)
- Phillippa A Pucar
- Immunology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Immunology Department, SA Pathology, Adelaide, South Australia, Australia
| | - James Nolan
- Department of Anatomical Pathology, SA Pathology, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Immunology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Immunology Department, SA Pathology, Adelaide, South Australia, Australia
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