Immunoglobulin G4-related masses surrounding coronary arteries: a case report

IgG4-related disease involving coronary and pulmonary arteries: a case report and literature review

Background

IgG4-related disease (IgG4-RD) is an inflammation-mediated autoimmune disease characterized by infiltration of IgG4 plasma cells in target organs, storiform fibrosis and obliterative phlebitis, accompanied by or without elevated serum IgG4 concentrations. Multiple sites can be involved, including large vessels. Coronary and pulmonary arteries are less involved, while simultaneous involvement of coronary and pulmonary arteries is less reported. This case is unique in terms of simultaneous involvement of coronary and pulmonary arteries in a female patient with possible IgG4-RD and the first review of relevant domestic literature.

Case Description

This case is a middle-aged female patient with both coronary artery and pulmonary artery involvement, with cardiac insufficiency as the main manifestation. Cardiac ultrasound revealed the cardiac insufficiency and abnormal wrapping of multiple arteries. Imaging examinations including coronary artery computed tomography angiography (CTA), pulmonary artery CTA and cardiac magnetic resonance imaging (MRI) further confirmed the lesions of the left main coronary artery, anterior descending branch, circumflex branch and pulmonary artery. Then the patient was diagnosed with possible IgG4-RD. After glucocorticoid treatment, the patient's clinical symptoms and cardiac function improved, and her serum IgG4 levels decreased.

Conclusions

When the arterial system is involved in IgG4 disease, it is known as IgG4-related artery disease. Combined with the case of this patient, this paper reviewed the literature on IgG4-related artery disease, and searched and summarized the related domestic literature on coronary/pulmonary artery disease to improve people's understanding of IgG4-related artery disease.

Reshaping the Concept of Riedel's Thyroiditis into the Larger Frame of IgG4-Related Disease (Spectrum of IgG4-Related Thyroid Disease)

Recently, Riedel's thyroiditis (RT) was assimilated into the larger spectrum of immunoglobulin IgG4-related disease (IgG4-RD) in addition to a particular frame of IgG4-related thyroid disease (IgG4-RTD), underlying IgG4-RT, IgG4-associated Hashimoto's thyroiditis (and its fibrotic variant), and IgG4-related Graves's disease. Our objective was to overview recent data on RT, particularly IgG4-RD and IgG4-RTD. The case and study- sample analysis (2019-2023) included 293 articles and selected 18 original studies: nine single case reports (N = 9, female/male = 2/1, aged: 34-79 years, 5/9 patients with serum IgG4 available data, 2/5 with high serum IgG4) and four case series (N = 21; 4/5 series provided data on IgG4 profile, 3/21 had serum IgG4 assays, and 2/3 had abnormally high values). IgG4-RD and thyroid findings were analyzed in three cohorts (N = 25). Another two studies (N = 11) specifically addressed IgG4-RTD components. On presentation, the patients may have hypothyroidism, transitory thyrotoxicosis, goiter, long-term history of positive anti-thyroid antibodies, and hypoechoic ultrasound thyroid pattern. The 5-year analysis (N = 66) showed the rate of serum IgG4 evaluation remained low; normal values do not exclude RT. Mandatory histological and immunohistochemistry reports point out a high content of IgG4-carrying plasma cells and IgG4/IgG ratio. Unless clinically evident, histological confirmation provides a prompt indication of starting corticoid therapy since this is the first-line option. Surgery, if feasible, is selective (non-responders to medical therapy, emergency tracheal intervention, and open/core needle biopsy). Current open issues are identifying the role of serum IgG4 assays in patients with IgG4-RD, finding out if all cases of RT are IgG4-mediated, applying IgG4-RTD criteria of differentiation among four entities, and providing an RT/IgG4-RTD guideline from diagnosis to therapy. It remains that the central aim of approaching RT in daily practice is the early index of suspicion in order to select patients referred for further procedures that provide enough histological/immunohistochemistry material to confirm RT and its high IgG4 burden.

Multimodality Imaging Evaluation of Coronary IgG4-Related Disease: A "Tumor-Like" Cardiac Lesion

Immunoglobulin G4-related disease (IgG4-RD) is a systemic immune-mediated fibro-inflammatory disorder. Coronary IgG4-RD has been scarcely reported and may present as "tumor-like" lesions. These pseudo-masses may be underdiagnosed mainly due to a vague clinical picture that can vary from complete lack of symptoms to acute coronary syndrome or sudden cardiac death. Early recognition of coronary IgG4-RD is essential to monitor disease activity and prevent life-threatening complications. We report a comprehensive non-invasive imaging evaluation of a patient affected by coronary IgG4-RD, which was diagnosed as an incidental finding during routine pre-laparoscopic cholecystectomy checkup. Non-invasive imaging revealed the presence of a peri-coronary soft-tissue mass that was stable at 12 months follow-up.