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Cheuk W, Bledsoe JR. IgG4-related lymphadenopathy. Semin Diagn Pathol 2024; 41:108-115. [PMID: 38228439 DOI: 10.1053/j.semdp.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024]
Abstract
IgG4-related lymphadenopathy is a nodal manifestation of IgG4-related disease (IgG4RD) which is characterized by increased polytypic IgG4+ plasma cells and IgG4+/IgG+ plasma cell ratio in lymph nodes and morphologically manifested as various patterns of reactive lymphadenopathy: Castleman disease-like, follicular hyperplasia, interfollicular expansion, progressive transformation of germinal centers and inflammatory pseudotumor-like. It typically presents with solitary or multiple, mild to moderate lymph node enlargement in otherwise asymptomatic patients. The serum IgG4 level is frequently elevated but C-reactive protein often remains normal. In patients not having a history of IgG4RD or manifestation of extranodal IgG4RD, a diagnosis of IgG4-lymphadenopathy should only be made with great caution given the non-specific morphologic features that can overlap with ANCA-associated vasculitis, interleukin-6 syndromes, Rosai-Dorfman disease, inflammatory myofibroblastic tumor, syphilis, lymphoma, and plasma cell neoplasia. Elevated IgG4 parameters, appropriate morphologies, and clinical correlation are essential to make the diagnosis of IgG4-lymphadenopathy more specific and clinically meaningful.
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Affiliation(s)
- Wah Cheuk
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong, China SAR.
| | - Jacob R Bledsoe
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Sakai M, Ohno Y, Kozuki N, Kawasaki Y, Yoshida M, Ikeda H, Konishi J, Maeda T, Sugano M, Kawakami S, Ito I, Yamaguchi A, Naiki H, Notohara K, Akamizu T, Kawano M, Yoshida H. A case of immunoglobulin G4-related retroperitoneal fibrosis and hypophysitis with antecedent respiratory disease followed by spontaneous remission and recurrence. Mod Rheumatol Case Rep 2023; 8:163-171. [PMID: 37417460 DOI: 10.1093/mrcr/rxad040] [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: 06/01/2023] [Revised: 06/24/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
A 65-year-old man presented with apparent bronchopneumonia. After treatment with antibiotics, he showed eosinophilia. Computed tomography (CT) imaging revealed bilateral consolidation, ground-glass opacities with nodular consolidations, and pleural effusion. Lung biopsy showed organising pneumonia with lymphoplasmacytic infiltration in the alveolar septa and in the thickened pleura and interlobular septa. All pulmonary abnormalities spontaneously went into remission within 12 months. At 73 years old, a follow-up CT scan revealed small nodules in both lungs and the review of the head CT scan showed thickening of the pituitary stalk in studying prolonged headache. Two years later, he visited the hospital complaining of severe oedema on the lower extremities with high serum immunoglobulin (Ig)G4 186 mg/dl. A whole-body CT scan showed retroperitoneal mass surrounding aortic bifurcation and compressing inferior vena cava, pituitary stalk thickening and gland swelling, and enlarged pulmonary nodules. Anterior pituitary stimulation tests showed central hypothyroidism, central hypogonadism, and adult growth hormone deficiency with partial primary hypoadrenocorticism. Retroperitoneal mass biopsy showed storiform fibrosis and obliterative phlebitis with marked lymphoplasmacytic infiltration with moderate IgG4-positivity. Immunostaining of the former lung specimen revealed dense interstitial infiltration of IgG4-positive cells. These findings indicated metachronous development of IgG4-related disease in lung, hypophysis, and retroperitoneum, according to the recent comprehensive diagnostic criteria of IgG4-related disease. Glucocorticoid therapy ameliorated oedema, on the other hand, unmasked partial diabetes insipidus at the initial dose of the treatment. Hypothyroidism and retroperitoneal mass regressed at 6 months of the treatment. This case warns us that long-term follow-up from prodromal to remission is necessary for the treatment of IgG4-related disease.
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Affiliation(s)
- Masato Sakai
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Yuta Ohno
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Nana Kozuki
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Yuki Kawasaki
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Michiko Yoshida
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Hiroyuki Ikeda
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Junji Konishi
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Toshiki Maeda
- Department of Surgery, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Motoki Sugano
- Department of Surgery, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Satoshi Kawakami
- Department of Diagnostic Radiology, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
| | - Isao Ito
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
- Department of Respiratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Aina Yamaguchi
- Department of Anatomic and Clinical Pathology, Fukui University Hospital, Fukui, Japan
| | - Hironobu Naiki
- Division of Molecular Pathology, Fukui University Hospital, Fukui, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Takashi Akamizu
- Department of Internal Medicine, Kuma Hospital, Kobe, Hyogo, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Haruyoshi Yoshida
- Department of Internal Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Fukui, Japan
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