A case of autoimmune pancreatitis complicated with immune thrombocytopenia during maintenance therapy with prednisolone

Autoimmune Polyglandular Syndrome Type 3 Complicated with IgG4-related Disease

A 52-year-old Japanese woman developed type 1 diabetes mellitus (type 1 DM) at 41 years old. She became complicated with Hashimoto's disease and showed swelling of both submandibular glands, which was diagnosed as IgG4-related disease (IgG4-RD). This is a rare case of a Japanese patient with autoimmune polyglandular syndrome type 3A (APS-3A) coexisting with autoimmune thyroid disease (AITD) and type 1 DM complicated by IgG4-RD. Bilateral submandibular gland resection was successfully performed without steroid therapy. We discuss the possibility that the immunological pathogenic mechanisms of APS-3A and IgG4-RD are related.

Diagnostic imaging guide for autoimmune pancreatitis

The International Consensus Diagnosis Criteria for autoimmune pancreatitis (AIP) has been published internationally for the diagnosis of AIP. However, since the revisions in 2006 and 2011, the Clinical Diagnostic Criteria for Autoimmune Pancreatitis 2018 have been published. The criteria were revised based the Clinical Diagnostic Criteria 2011, and included descriptions of characteristic imaging findings such as (1) pancreatic enlargement and (2) distinctive narrowing of the main pancreatic duct. In addition, pancreatic duct images obtained by magnetic resonance cholangiopancreatography as well as conventional endoscopic retrograde pancreatography were newly adopted. The guideline explains some characteristic imaging findings, but does not contain descriptions of the imaging methods, such as detailed imaging parameters and optimal timings of dynamic contrast-enhanced computed tomography/magnetic resonance imaging. It is a matter of concern that imaging methods can vary from hospital to hospital. Although other characteristic findings have been reported, these findings were not described in the guideline. The present paper describes the imaging methods for obtaining optimal images and the characteristic imaging findings with the aim of standardizing image quality and improving diagnostic accuracy when radiologists diagnose AIP in actual clinical settings.

Immune thrombocytopenic purpura increased risk of subsequent pancreatitis: A Nationwide population cohort study

Immune thrombocytopenic purpura (ITP) is characterized by thrombocytopenia and bleeding diathesis. Pancreatitis is a very rare complication but may be fatal. We analyzed data of newly diagnosed ITP patients, excluding those with a history of splenectomy, unknown sex or date of birth, or preexisting pancreatitis at the time of ITP diagnosis, and compared these with selected age-, gender-, and index-year-matched controls, using the Taiwan National Health Insurance Research Database from 1996 to 2013. The study enrolled 100,177 ITP patients and 100,177 controls. We found that pancreatitis risk was higher in secondary ITP patients, regardless of age group, gender, baseline Charlson comorbidity index (CCI) score, history of biliary stone, hyperlipidemia, or alcoholism, than in the control population. Primary ITP patients with CCI score 1 and without biliary tract stone history also showed a higher pancreatitis risk than the controls. The incidence rate and cumulative incidence of pancreatitis were increased in primary, secondary, and unspecified ITP cases. These phenomena may be related to the presence of autoantibodies against glycoprotein IIb/IIIa, or to IgG4, microparticle obstruction, or sclerosis. We noted a direct association between ITP and the development of pancreatitis in Taiwan population.

Mikulicz's Disease With Immune Thrombocytopenia: A New Immunoglobulin G4-Mediated Disorder and Literature Review

Mikulicz's disease (MD), an immunoglobulin G4 (IgG4)-related disease, is a fibrosis-associated inflammatory disease characterized by painless bilat- eral swelling of lacrimal and salivary glands. Although thrombocytopenia is associated with many rheumatologic disorders, it is rare in IgG4-related MD. This novel study aims to report a rare case of IgG4-related MD complicated with severe autoimmune thrombocytopenia without any hemato- logical malignancies and review all cases of IgG4-related disease associated with thrombocytopenia in the literature.

IgG4-Related Pancreatitis and Immune Thrombocytopenia: A Case Report and Literature Review

A patient with a prior diagnosis of IgG4-related autoimmune pancreatitis (AIP) presented four years later with severe prednisone resistant immune thrombocytopenia (ITP). Her case is reported and the scant literature of the very unusual possible association of IgG4-related AIP and ITP is reviewed. It is suggested that investigation for IgG4-related disease be part of the work-up of ITP.

Overlap of IgG4-related Disease and Primary Biliary Cirrhosis Complicated with Autoimmune Thrombocytopenia

A 63-year-old woman was referred to Fukushima Red Cross Hospital with an enlargement of the left submandibular gland and subcutaneous bleeding in the chest and legs. A diffuse enlargement of the pancreas was also detected by abdominal computed tomography, and laboratory data showed severe thrombocytopenia. She was diagnosed with IgG4-related disease (IgG4-RD) complicated with autoimmune thrombocytopenia and was treated with methylprednisolone, after which the number of platelets favorably increased. Further investigation for liver dysfunction revealed underlying primary biliary cirrhosis (PBC). We herein report a rare case of IgG4-RD overlapping PBC complicated with autoimmune thrombocytopenia.

A case of IgG4-related sclerosing cholangitis overlapped with primary biliary cirrhosis

IgG4-related sclerosing cholangitis (IgG4-SC) and primary biliary cirrhosis (PBC) can both cause liver dysfunction. While IgG4-SC is associated with IgG4-related diseases such as autoimmune pancreatitis, PBC is associated with various autoimmune diseases. However, there is only one case report of an association between IgG4-SC and PBC, and this association has not been elucidated further. The treatments for these two diseases are different, i.e., corticosteroid treatment is performed for IgG4-SC and ursodeoxycholic acid is given for PBC. We report a case of IgG4-SC overlapping with PBC in a 45-year-old man who was successfully treated by combination therapy with prednisolone and ursodeoxycholic acid.

Usefulness of serum IgG4 in the diagnosis and follow up of autoimmune pancreatitis: A systematic literature review and meta-analysis

High circulating serum immunoglobulin G4 (IgG4) levels have been proposed as a marker of autoimmune pancreatitis (AIP). The aim of the present study was to review the data existing in the English literature on the usefulness of the IgG4 serum levels in the diagnosis and follow up of patients with AIP. A total of 159 patients with AIP and 1099 controls were described in seven selected papers reporting the usefulness of serum IgG4 in diagnosing AIP. In total, 304 controls had pancreatic cancer, 96 had autoimmune diseases, and the remaining 699 had other conditions. The summary receiver-operating characteristic curve analysis was carried out by means of Meta-DiSc open-access software. Serum IgG4 showed good accuracy in distinguishing between AIP and the overall controls, pancreatic cancer and other autoimmune diseases (area under the curve [+/- SE]: 0.920 +/- 0.073, 0.914 +/- 0.191, and 0.949 +/- 0.024, respectively). The studies analyzed showed significantly heterogeneous specificity values in each of the three analyses performed. The analysis of the four studies comparing AIP and pancreatic cancers also showed significantly heterogeneous values of sensitivities and odds ratios. Regarding the usefulness of IgG4 as a marker of efficacy of steroid treatment, a decrease in the serum concentrations of IgG4 was found in the four available studies. The serum IgG4 subclass is a good marker of AIP, and its determination should be included in the diagnostic workup of this disease. However, the heterogeneity of the studies published until now means that more studies are necessary in order to better evaluate the true accuracy of IgG4 in discriminating AIP versus other autoimmune diseases.

IgG4-related sclerosing disease

Based on histological and immunohistochemical examination of various organs of patients with autoimmune pancreatitis (AIP), a novel clinicopathological entity of IgG4-related sclerosing disease has been proposed. This is a systemic disease that is characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of various organs. Clinical manifestations are apparent in the pancreas, bile duct, gallbladder, salivary gland, retroperitoneum, kidney, lung, and prostate, in which tissue fibrosis with obliterative phlebitis is pathologically induced. AIP is not simply pancreatitis but, in fact, is a pancreatic disease indicative of IgG4-related sclerosing diseases. This disease includes AIP, sclerosing cholangitis, cholecystitis, sialadenitis, retroperitoneal fibrosis, tubulointerstitial nephritis, interstitial pneumonia, prostatitis, inflammatory pseudotumor and lymphadenopathy, all IgG4-related. Most IgG4-related sclerosing diseases have been found to be associated with AIP, but also those without pancreatic involvement have been reported. In some cases, only one or two organs are clinically involved, while in others, three or four organs are affected. The disease occurs predominantly in older men and responds well to steroid therapy. Serum IgG4 levels and immunostaining with anti-IgG4 antibody are useful in making the diagnosis. Since malignant tumors are frequently suspected on initial presentation, IgG4-related sclerosing disease should be considered in the differential diagnosis to avoid unnecessary surgery.

Successful treatment of autoimmune pancreatitis complicated with autoimmune thrombocytopenia and interstitial pneumonia by prednisolone

We report the second patient diagnosed with autoimmune pancreatitis complicated with autoimmune thrombocytopenia and interstitial pneumonia. The patient was treated with prednisolone and responded favorably. We demonstrated that anti-platelet (PLT) antibody of the patient was IgG4 and that it may react with HLA, not specific antigen, on both pancreas and PLT.

Difficulty in diagnosing autoimmune pancreatitis by imaging findings

BACKGROUND

Autoimmune pancreatitis (AIP) presents as diffuse enlargement of the pancreas and as diffuse irregular narrowing of the main pancreatic duct. However, some AIP cases are difficult to diagnose because of atypical imaging findings.

OBJECTIVE

To clarify a variety of imaging findings of AIP and the reason for its misdiagnosis.

DESIGN

We examined the imaging findings of 37 AIP cases and also examined misdiagnosed cases of AIP to determine their reasons for misdiagnosis.

PATIENTS

A total of 37 patients with AIP who reported to our hospital or its affiliate over a 17-year period (1989 to May 2005).

RESULTS

Patients in 15 AIP cases showed segmental narrowing of the main pancreatic duct. There were 6 patients with focal enlargement of the pancreas, whereas 3 patients showed no enlargement. There were 3 cases of calcification of the pancreas. Pancreatic cysts were detected in 2 patients. Abdominal US showed multiple low-echoic masses in 1 case and a single mass in 3 cases. Sixteen patients had stenosis of the bile duct at the hilar hepatic lesion and/or the intrahepatic duct. Only 7 patients had typical AIP findings. Six patients were misdiagnosed with pancreatic cancer and 2 with bile-duct cancer. Seven cases were surgically treated. Five cases were misdiagnosed because of the nonexistence of, or the unfamiliarity with, the concept of AIP and sclerosing cholangitis with AIP. Another 3 cases were diagnosed with pancreatic cancer because of segmental stenosis of the main pancreatic duct and no or focal enlargement of the pancreas.

CONCLUSIONS

The results of this study suggest that AIP presents a variety of imaging findings. The most important diagnostic factor is clinician awareness of the concept of AIP and the diverse nature of imaging findings.

Hyper-IgG4 disease: report and characterisation of a new disease

BACKGROUND

We highlight a chronic inflammatory disease we call 'hyper-IgG4 disease', which has many synonyms depending on the organ involved, the country of origin and the year of the report. It is characterized histologically by a lymphoplasmacytic inflammation with IgG4-positive cells and exuberant fibrosis, which leaves dense fibrosis on resolution. A typical example is idiopathic retroperitoneal fibrosis, but the initial report in 2001 was of sclerosing pancreatitis.

METHODS

We report an index case with fever and severe systemic disease. We have also reviewed the histology of 11 further patients with idiopathic retroperitoneal fibrosis for evidence of IgG4-expressing plasma cells, and examined a wide range of other inflammatory conditions and fibrotic diseases as organ-specific controls. We have reviewed the published literature for disease associations with idiopathic, systemic fibrosing conditions and the synonyms: pseudotumour, myofibroblastic tumour, plasma cell granuloma, systemic fibrosis, xanthofibrogranulomatosis, and multifocal fibrosclerosis.

RESULTS

Histology from all 12 patients showed, to varying degrees, fibrosis, intense inflammatory cell infiltration with lymphocytes, plasma cells, scattered neutrophils, and sometimes eosinophilic aggregates, with venulitis and obliterative arteritis. The majority of lymphocytes were T cells that expressed CD8 and CD4, with scattered B-cell-rich small lymphoid follicles. In all cases, there was a significant increase in IgG4-positive plasma cells compared with controls. In two cases, biopsies before and after steroid treatment were available, and only scattered plasma cells were seen after treatment, none of them expressing IgG4. Review of the literature shows that although pathology commonly appears confined to one organ, patients can have systemic symptoms and fever. In the active period, there is an acute phase response with a high serum concentration of IgG, and during this phase, there is a rapid clinical response to glucocorticoid steroid treatment.

CONCLUSION

We believe that hyper-IgG4 disease is an important condition to recognise, as the diagnosis can be readily verified and the outcome with treatment is very good.

Autoimmune pancreatitis: proposal of IgG4-related sclerosing disease

Autoimmune pancreatitis (AIP) is a peculiar type of pancreatitis of presumed autoimmune etiology. Many new clinical aspects of AIP have been clarified during the past 10 years, and AIP has become a distinct entity recognized worldwide. However, its precise pathogenesis or pathophysiology remains unclear. As AIP dramatically responds to steroid therapy, accurate diagnosis of AIP is necessary to avoid unnecessary surgery. Characteristic dense lymphoplasmacytic infiltration and fibrosis in the pancreas may prove to be the gold standard for diagnosis of AIP. However, since it is difficult to obtain sufficient pancreatic tissue, AIP should be diagnosed currently based on the characteristic radiological findings (irregular narrowing of the main pancreatic duct and enlargement of the pancreas) in combination with serological findings (elevation of serum gamma-globulin, IgG, or IgG4, along with the presence of autoantibodies), clinical findings (elderly male preponderance, fluctuating obstructive jaundice without pain, occasional extrapancreatic lesions, and favorable response to steroid therapy), and histopathological findings (dense infiltration of IgG4-positive plasma cells and T lymphocytes with fibrosis and obliterative phlebitis in various organs). It is apparent that elevation of serum IgG4 levels and infiltration of abundant IgG4-positive plasma cells into various organs are rather specific to AIP patients. We propose a new clinicopathological entity, "IgG4-related sclerosing disease", and suggest that AIP is a pancreatic lesion reflecting this systemic disease.

Lymphoplasmacytic infiltration of multiple organs with immunoreactivity for IgG4: IgG4-related systemic disease

We report three elderly men with high serum IgG4 concentrations and multiple lymphoplasmacytic inflammation of the salivary glands, lymph nodes, pancreas, and renal interstitium. The infiltrating plasma cells had strong immunoreactivity for IgG4, even in patients without pancreatic lesions. These cases show that IgG4 is associated not only with autoimmune pancreatitis, but also with other systemic lymphoplasmacytic disease.

Systemic extrapancreatic lesions associated with autoimmune pancreatitis

OBJECTIVES

Autoimmune pancreatitis (AIP) is often associated with systemic extrapancreatic lesions. We studied 31 cases of AIP to clarify the diversity of associated systemic extrapancreatic lesions and the differences between AIP with and without systemic extrapancreatic lesions.

METHODS

The clinical features and courses were compared by age, sex, and blood chemistry between those with and without systemic extrapancreatic lesions. In addition, we reviewed the available literature on systemic extrapancreatic lesions with AIP.

RESULTS

Seven of the 31 cases of AIP had associated systemic extrapancreatic lesions, which were diagnosed simultaneously with AIP; however, 1 case presenting with various extrapancreatic lesions was diagnosed independently of the AIP lesion. Patients with systemic extrapancreatic lesions needed maintenance steroid therapy for AIP in 4 cases and systemic extrapancreatic lesions in 2 cases; the ratio of cases requiring maintenance steroid therapy was significantly higher among those with systemic extrapancreatic lesions (6/8) than those without (7/23). There were no significant differences between groups with regard to age, sex, extent of narrowing of the main pancreatic duct, and enlargement of the pancreas. gamma-globulin, IgG, and IgG4 levels were significantly higher in patients with AIP with systemic extrapancreatic lesions than those without. The systemic extrapancreatic lesions associated with AIP found in the literature were Sjögren syndrome, ulcerative colitis, retroperitoneal fibrosis, sialadenitis, thyroiditis, and idiopathic thrombocytopenic purpura.

CONCLUSIONS

The results of this study suggest that, when encountering a case of AIP with elevated levels of gamma-globulins, IgG, and IgG4, an effort should be made to detect other systemic extrapancreatic abnormalities and initiate steroid administration.