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Araújo DABS, Ribeiro RM, Lima PLGSB, de Queiroz DC, Pitombeira MS, Martins B, Coimbra PPA, Nogueira CD, Braga-Neto P, Silva GD, Nóbrega PR. Spinal cord compression by cystic IgG4-related spinal pachymeningitis mimicking neurocysticercosis: a case report. BMC Neurol 2024; 24:318. [PMID: 39237872 PMCID: PMC11375994 DOI: 10.1186/s12883-024-03817-7] [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: 11/18/2023] [Accepted: 08/21/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND To report a case of IgG4-related pachymeningitis presenting with cystic lesions mimicking neurocysticercosis. CASE PRESENTATION A 40-year-old female patient with tetraparesis, dysphagia and dysphonia was evaluated with clinical examination, magnetic resonance imaging, and meningeal biopsy. Magnetic resonance imaging (MRI) revealed diffuse pachymeningeal enhancement involving the cranial, cervical, thoracic, and lumbar segments with spinal cord compression and cystic lesions. CSF immunology was initially positive for cysticercus cellulosae. After disease progression a meningeal biopsy was compatible with IgG4 related disease. The patient had partial response to rituximab and needed multiple surgical procedures for spinal cord decompression and CSF shunting. CONCLUSIONS This case highlights the possibility of IgG4-related disease in patients with diffuse pachymeningitis causing spinal cord compression, even with cystic lesions on MRI. Diagnosis of IgG4-related pachymeningitis is paramount due to the possibility of treatment response to immunotherapy, particularly to anti-CD20 agents.
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Affiliation(s)
| | - Rodrigo Mariano Ribeiro
- Faculty of Medicine, Federal University of Ceara, Alexandre Baraúna St., 949, Fortaleza, 60430-160, Ceara, Brazil
| | | | - Dánton Campos de Queiroz
- Faculty of Medicine, Federal University of Ceara, Alexandre Baraúna St., 949, Fortaleza, 60430-160, Ceara, Brazil
| | - Milena Sales Pitombeira
- Department of Neurology, General Hospital of Fortaleza, Ávila Goularte St., 900, Fortaleza, 60150-160, Ceara, Brazil
| | - Bernardo Martins
- Rede SARAH de Hospitais de Reabilitação, SMHS - Área Especial, Qd 501, Asa Sul, Brasilia, Distrito Federal, Brazil
| | - Pablo Picasso Araújo Coimbra
- Department of Neurology, General Hospital of Fortaleza, Ávila Goularte St., 900, Fortaleza, 60150-160, Ceara, Brazil
| | | | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceara, Prof. Costa Mendes St., 1608, 4th Floor, Fortaleza, 60430-140, Ceara, Brazil
| | - Guilherme Diogo Silva
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Dr. Ovídio Pires de Campos St., 225, São Paulo, São Paulo, Brazil
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceara, Prof. Costa Mendes St., 1608, 4th Floor, Fortaleza, 60430-140, Ceara, Brazil.
- Centro Universitário Christus, Dom Luís Ave., 911, Fortaleza, 60160-230, Ceara, Brazil.
- , Hospital Universitário Walter Cantidio, Pastor Samuel Munguba St., 1290, Rodolfo Teófilo, Fortaleza, 60430-372, Ceara, Brazil.
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2
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Miglio M, Montanelli GA, Rossi FG, Maggioni M, Fiorelli EM. Connecting the dots in a case of multiple lymphadenopathies: IgG4-related disease or Castleman disease? Intern Emerg Med 2024:10.1007/s11739-024-03734-0. [PMID: 39120854 DOI: 10.1007/s11739-024-03734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/29/2024] [Indexed: 08/10/2024]
Affiliation(s)
- M Miglio
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - G A Montanelli
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - F G Rossi
- Division of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - M Maggioni
- Pathology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - E M Fiorelli
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
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Wei SJ, Xiong Q, Yao H, He QM, Yu PL. Is systemic lupus erythematosus linked to Immunoglobulin G4 Autoantibodies? Hum Immunol 2024; 85:110826. [PMID: 38954949 DOI: 10.1016/j.humimm.2024.110826] [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: 08/26/2023] [Revised: 04/26/2024] [Accepted: 05/21/2024] [Indexed: 07/04/2024]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder characterized by a hyperactive immune system with multiple abnormalities in B-cell proliferation, antibody production, T-cell regulation, and immune complex (IC) formation. In humans, Immunoglobulin (Ig) G is found in four subclasses. IgG1-IgG4, which are distinguished by both structural and biological differences. Fab-arm Exchange (FAE), specific biases in the IgG4 response repertoire, and a decreased capacity to induce effector functions mediated by interactions in the fragment crystallizable (Fc) region are just a few of the distinctive characteristics of IgG4. The recent finding of the presence of double-stranded DNA (dsDNA) and antinuclear antibody (ANA)-IgG4 has raised attention to this IgG subclass and its possible role in SLE. IgG4 was previously believed to just have anti-inflammatory effects by inhibiting immune responses, but recent studies have shown that these antibodies can also play a role in the onset and development of some clinical disorders. To consider the clinical effects of IgG4 presence, it is necessary to discuss its characteristics, which could underlie the potential role it can play in SLE. Therefore, this study aimed to comprehensively review the role of IgG4 in SLE to elucidate the collective incidence of high IgG4 levels reported in some SLE patients.
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Affiliation(s)
- Shu-Jun Wei
- Sichuan Police College, Longtouguan Road, Jiangyang District, Luzhou City, Sichuan Province, China
| | - Qian Xiong
- Chongqing Key Laboratory of Development and Utilization of Genuine Medicinal Materials in Three Gorges Reservoir Area, Chongqing Three Gorges Medical College, China
| | - Huan Yao
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan, China; Sichuan Provincial Engineering Research Center of Innovative Re-development of Famous Classical Formulas, Pengzhou 611930, China
| | - Qing-Man He
- Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Peng-Long Yu
- Chongqing Key Laboratory of Development and Utilization of Genuine Medicinal Materials in Three Gorges Reservoir Area, Chongqing Three Gorges Medical College, China.
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Wan M, Xu X, Zhao X, You X, Zhang G, Long H, He P, Long J, Zhu J. Giant Ulcer with Necrosis on Right Vulva, Groin, and Thigh-- A Case of Necrotizing Fasciitis Associated with Erythematous Pemphigus. Clin Cosmet Investig Dermatol 2024; 17:103-110. [PMID: 38234694 PMCID: PMC10793116 DOI: 10.2147/ccid.s443374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/06/2024] [Indexed: 01/19/2024]
Abstract
Necrotizing fasciitis is a rare, severe, rapidly progressing disease with a high mortality rate. We report a case of a 72-year female with erythematous pemphigus who developed erythema, swelling and ulceration on right vulva, groin, and thigh. The early clinical manifestations of the patient were nonspecific and easily misdiagnosed as cellulitis. However, upon the occurrence of ulceration and necrosis, deep fungal infection, pyoderma gangrenosum or lymphoproliferative disorders were considered. The pathology suggested IgG4-related diseases, plasmacytoma et al. But at last, surgical exploration and postoperative pathology confirmed the diagnosis of necrotizing fasciitis. The patient recovered after multiple aggressive surgical debridement procedures and antibiotic therapy and the patient has been followed up for 2 years without recurrence. Clinicians should be vigilant about the possibility of necrotizing fasciitis in patients with erythema, pain, rapid ulceration of skin and soft tissue, particularly in immunocompromised individuals with long-term use of immunosuppressive agents. It is crucial for saving life by early multi-disciplinary consultation, prompt diagnosis, and aggressive treatment.
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Affiliation(s)
- Miao Wan
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Xiangrong Xu
- Department of Plastic Surgery of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Xiaojiao Zhao
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Xia You
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Guiying Zhang
- Department of Dermatovenerology of the Second Xiangya Hospital of Central South University, Changsha, 410000, People’s Republic of China
| | - Hai Long
- Department of Dermatovenerology of the Second Xiangya Hospital of Central South University, Changsha, 410000, People’s Republic of China
| | - Ping He
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Jian Long
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Jianjian Zhu
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
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Sahin MS, Gundogdu B, Vural G, Dogantekin B. IgG4 Positivity in Chronic Tonsillitis: A New Component of IgG4-Related Disease? J Craniofac Surg 2023; 34:e806-e810. [PMID: 37643125 DOI: 10.1097/scs.0000000000009654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Immunoglobulin G4-related disease (IgG4-RD) and chronic tonsillitis are both chronic fibroinflammatory diseases in which tissue atrophy is sometimes observed. In this study, the authors aimed to investigate the pathologic IgG4 positivity in tonsillectomy specimens and hypothesized to name it as a new clinical component of IgG4-RD if there is significant IgG4 positivity in chronic tonsillitis. METHODS A total of 73 patients who underwent tonsillectomy for chronic tonsillitis were included in this study. Of these, 31 patients had atrophic form chronic tonsillitis. Pathologic examinations and specific IgG4 immunohistochemical staining were performed by the same experienced pathologist in terms of IgG4-RD. RESULTS Sixty-three percent (n=46) of the cases were male, 37% (n=27) were female, their ages ranged from 3 to 51, and the mean age was 19.11±14.82. It was determined that 23.3% (n=17) of the cases participating in the study were IgG4-positive. When the pathologic grades of the cases were examined; it was observed that 13.7% (n=10) were Grade I, 65.8% (n=48) were Grade II, and 20.5% (n=15) were Grade III. A statistically significant difference was found between the pathology degrees of the cases according to the IgG4 groups ( P =0.001; P <0.01). CONCLUSION The authors concluded that as the histopathologic grades of chronic lymphoplasmacytic inflammation in tonsils specimen increase, IgG4 positivity rates also increase. Therefore, this clinical entity may be a new IgG4-related disease state in cases with chronic tonsillitis. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Murat S Sahin
- Department of Otolaryngology, Medicana Health Group Kadikoy Private Hospital
| | - Baris Gundogdu
- Department of Rheumatology, SBU Sultan Abdulhamid Han Research Hospital
| | - Gurcan Vural
- Department of Pathology, Istanbul Atlas University Medical Faculty
| | - Betul Dogantekin
- Department of Internal Medicine, SBU Sultan Abdulhamid Han Research Hospital, Kadiköy/İstanbul, Turkey
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Hess AO, Lobo BC, Leon ME, Duarte EM, Mulligan JK, Justice JM. Sinonasal IgG4-related sclerosing disease: A rare entity and challenging diagnosis. Laryngoscope Investig Otolaryngol 2022; 7:1725-1732. [PMID: 36544949 PMCID: PMC9764806 DOI: 10.1002/lio2.944] [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: 07/26/2022] [Revised: 09/09/2022] [Accepted: 09/21/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives To describe the rare presentation, imaging and histological findings, and treatments in patients with IgG4-related disease (IgG4-RD) and diagnostic pitfalls and difficulties. Methods Cases of sinonasal IgG4-RD were retrieved, and clinicopathological features were reviewed. Results Seven cases of sinonasal IgG4-RD were identified over an 11-year period, including four males and three females, with an age range of 19-66 years (median 58 years). Patients presented with symptoms related to the mass effect of the lesions or the destructive nature of the disease including fullness, swelling, obstruction, and pain. Serum IgG and IgG4 levels, IgG/IgG4 ratios, storiform fibrosis, obliterative phlebitis, and plasma cell infiltration were seen in varying proportions. Bony erosion and tissue inflammation were present in some cases. Conclusion Sinonasal IgG4-RD is exceedingly rare among other IgG4-RD and varied in its clinical presentation thus posing as a clinically difficult disease to diagnosis. Proper clinical, pathological, and immunohistopathological analysis is required for accurate diagnosis. Such disease should be considered in all cases of similar presentation to those in this study.Level of Evidence: 4.
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Affiliation(s)
- Andrew O. Hess
- Department of OtolaryngologyUniversity of FloridaGainesvilleFloridaUSA
| | - Brian C. Lobo
- Department of OtolaryngologyUniversity of FloridaGainesvilleFloridaUSA
| | - Marino E. Leon
- Department of Pathology, Immunology, and Laboratory MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Ernesto M. Duarte
- Department of Pathology, Immunology, and Laboratory MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Jennifer K. Mulligan
- Department of OtolaryngologyUniversity of FloridaGainesvilleFloridaUSA
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Jeb M. Justice
- Department of OtolaryngologyUniversity of FloridaGainesvilleFloridaUSA
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Ireifej B, Dhamrah U, Song D, Bitar J, Jaiswal V, Nepal G, Pathak N, Freijat M. Cerebellar infarction as the initial presentation of IgG4-related disease. Clin Case Rep 2022; 10:e05614. [PMID: 35340659 PMCID: PMC8931459 DOI: 10.1002/ccr3.5614] [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: 02/05/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/21/2022] Open
Abstract
Although IgG4-RD has CNS manifestations, cerebellar involvement has only been reported in three cases. Our patient presented with cerebellar symptoms, several cerebellar infarcts were evident on the brain MRI, and CT abdomen revealed retroperitoneal tumor. Endoscopic biopsy confirmed IgG4-RD. Steroids are the first-line therapy for IgG4-RD, but our patient was lost to follow-up before treatment.
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Affiliation(s)
- Branden Ireifej
- Department of Internal MedicineIcahn School of Medicine at Mount Sinai Elmhurst Hospital CenterNew York CityNew YorkUSA
| | - Umaima Dhamrah
- Department of Internal MedicineIcahn School of Medicine at Mount Sinai Elmhurst Hospital CenterNew York CityNew YorkUSA
| | - David Song
- Department of Internal MedicineIcahn School of Medicine at Mount Sinai Elmhurst Hospital CenterNew York CityNew YorkUSA
| | - Joyce Bitar
- Metropolitan Hospital CenterNew York CityNew YorkUSA
| | | | - Gaurav Nepal
- Department of Internal MedicineTribhuvan University Institute of MedicineKathmanduNepal
| | - Nibesh Pathak
- Department of Internal MedicineTribhuvan University Institute of MedicineKathmanduNepal
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Orchestration of Immune Cells Contributes to Fibrosis in IgG4-Related Disease. IMMUNO 2022. [DOI: 10.3390/immuno2010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This review summarizes recent progress in understanding the pathogenesis of IgG4-related disease (IgG4-RD), with a focus on fibrosis. Several studies reported that CD4+ T cells with cytotoxic activity promoted by the secretion of granzyme and perforin, cytotoxic CD4+ T cells (CD4+CTLs), and disease-specific activated B cells, infiltrated inflamed tissues and cooperated to induce tissue fibrosis in autoimmune fibrotic diseases such as IgG4-RD, systemic sclerosis, and fibrosing mediastinitis. An accumulation of cells undergoing apoptotic cell death induced by CD4+CTLs and CD8+CTLs followed by macrophage-mediated clearing and finally tissue remodeling driven by cytokines released by CD4+CTLs, activated B cells, and M2 macrophages may contribute to the activation of fibroblasts and collagen production. In IgG4-RD, this process likely involves the apoptosis of non-immune, non-endothelial cells of mesenchymal origin and subsequent tissue remodeling. In summary, CD4+CTLs infiltrate affected tissues where they may cooperate with activated B cells, CD8+CTLs, and M2 macrophages, to induce apoptosis by secreting cytotoxic cytokines. These immune cells also drive fibrosis by secreting pro-fibrotic molecules in IgG4-RD.
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Bushara O, Escobar DJ, Weinberg SE, Sun L, Liao J, Yang GY. The Possible Pathogenic Role of IgG4-Producing Plasmablasts in Stricturing Crohn's Disease. Pathobiology 2022; 89:187-197. [PMID: 35026755 DOI: 10.1159/000521259] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Crohn's disease (CD) is a condition on the spectrum of inflammatory bowel disease that affects up to 20 people per 100,000 in the US annually, and with incidence increasing. One of the most significant sources of morbidity in CD is the formation of strictures, with resultant intestinal blockage a common indication for hospitalization and surgical intervention in these patients. The pathophysiology of stricture formation is not fully understood. However, the fibroplasia that leads to fibrostenotic stricture formation may have shared pathophysiology with IgG4-related fibrosis. SUMMARY Initial intestinal inflammation recruits innate immune cells, such as neutrophils, that secrete IL-1β and IL-23, which induces a type 17 CD4+ T-helper T-cell (Th17)-mediated adaptive immune response. These CD4+ Th17 T cells also contribute to inflammation by secreting proinflammatory cytokines such as IL-17 and IL-21. IL-21 recruits and stimulates CD4+ T follicular helper (Tfh) cells, which secrete more IL-21. This causes ectopic germinal center formation, recruiting and stimulating naïve B cells. The IL-17 and IL-21 produced by Th17 cells and Tfh cells also induce IgG4 plasmablast differentiation. Finally, these IgG4-producing plasmablasts secrete platelet-derived growth factor (PDGF), which activates local PDGF-receptor expressing fibroblasts and myofibroblasts, resulting in uncontrolled fibroplasia.
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Affiliation(s)
- Omar Bushara
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Joseph Escobar
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Samuel Edward Weinberg
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Leyu Sun
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jie Liao
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kim D, Kim SH, Kim EH. Intracranial Tumors Associated With IgG4-Related Disease. Brain Tumor Res Treat 2021; 9:93-99. [PMID: 34725991 PMCID: PMC8561221 DOI: 10.14791/btrt.2021.9.e17] [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: 07/04/2021] [Revised: 09/11/2021] [Accepted: 09/23/2021] [Indexed: 12/03/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated inflammatory condition which is characterized by dense lymphoplasmacytic infiltrations with a predominance of IgG4 plasma cells in the affected tissue. Although pachymeninx and pituitary gland are the most common sites where IgG4-RD infiltrates, the associations with IgG4-RD and a true intracranial tumor have not been yet reported in literature. Herein, we report two cases with intracranial tumors associated with IgG4-RD; a 36-year-old male patient with a huge meningioma and another 54-year old woman with a pituitary macroadenoma. Pathological examination revealed their tumors were substantially infiltrated by IgG4 plasma cells indicating its possible relation with IgG4-RD.
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Affiliation(s)
- Dongkyu Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Se Hoon Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Pituitary Tumor Center, Severance Hospital, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea.
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Atienza-Mateo B, Díaz de Terán-López T, Gómez-Román J, Sánchez L, Mons-Lera R, Rubio-Suárez A, Cifrián JM, González-Gay MÁ. Atypical presentation of immunoglobulin G4-related disease as subglottic stenosis: a case-based review. Rheumatol Int 2021; 41:1161-1167. [PMID: 33834281 PMCID: PMC8079302 DOI: 10.1007/s00296-021-04816-4] [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: 01/05/2021] [Accepted: 02/16/2021] [Indexed: 12/02/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory pathology that has been reported to affect principally the retroperitoneum, hepatobiliary system, salivary glands, orbital structures or lymph nodes. However, IgG4-RD with laryngeal involvement is a very rare entity. Our aims were to describe a case of subglottic stenosis as first and only manifestation of IgG4-RD and review the literature. A patient with IgG4-RD affecting the larynx that presented as subglottic stenosis is described. A MEDLINE database search of IgG4-RD cases with laryngopharyngeal manifestations was also conducted. A 30-year-old Caucasian woman was referred to a tertiary care hospital for dyspnea on exertion, which had been increasing for the last 4 months. Medical and surgical procedures revealed a subglottic stenosis, with a histological finding of IgG4 positive plasma cell infiltration. There was no evidence of other organ involvement. She was successfully treated with oral glucocorticoids and rituximab infusions. Glucocorticoids were rapidly tapered and the rituximab regimen was optimized, with no evidence of relapses. In the literature review, we found a total of 12 reported cases with laryngopharyngeal involvement, two of them with subglottic stenosis. IgG4-RD of the larynx is rare but should be considered after excluding more common disorders.
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Affiliation(s)
- Belén Atienza-Mateo
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008, Santander, Spain.,Epidemiology, Genetics and Atherosclerosis Research Group On Systemic Inflammatory Diseases, IDIVAL, Santander, Spain
| | | | - Javier Gómez-Román
- Division of Pathology, Hospital Universitario Marqués de Valdecilla, Santander, Spain.,University of Cantabria - IDIVAL, Santander, Spain
| | - Laura Sánchez
- Division of Thoracic Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Roberto Mons-Lera
- Division of Thoracic Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Antonio Rubio-Suárez
- Division of Otorhinolaryngology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José Manuel Cifrián
- Epidemiology, Genetics and Atherosclerosis Research Group On Systemic Inflammatory Diseases, IDIVAL, Santander, Spain.,Division of Pulmonology, Hospital Universitario Marqués de Valdecilla, Santander, Spain.,University of Cantabria - IDIVAL, Santander, Spain
| | - Miguel Á González-Gay
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008, Santander, Spain. .,Epidemiology, Genetics and Atherosclerosis Research Group On Systemic Inflammatory Diseases, IDIVAL, Santander, Spain. .,University of Cantabria - IDIVAL, Santander, Spain. .,Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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12
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Hajsadeghi S, Pakbaz M, Hassanzadeh M, Sadeghipour A. A challenging case report of IgG4-related systemic disease involving the heart and retroperitoneum with a literature review of similar heart lesions. Echocardiography 2020; 37:1478-1484. [PMID: 32841427 DOI: 10.1111/echo.14828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/09/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022] Open
Abstract
The IgG4-related disease is a distinct, steroid-responsive fibro-inflammatory disorder of unknown etiology. This multiorgan disease is characterized by tumefactive lesions that contain rich infiltrations of IgG4-positive plasma cells, with the pancreas, and the salivary and lacrimal glands being the main involved. The more common cardiovascular involvements include inflammatory peri-aortitis, coronary arteritis, and pericarditis. Intra-cardiac tumefactive lesions are rarely reported. Herein, we describe a challenging case of IgG4-related disease with a long-time lag between initiation of symptoms to proper diagnosis with biopsy-proven cardiac and retroperitoneal and possible pituitary gland involvement. Concerning the rarity of the cardiac lesion in our case, we conducted a literature review of similar case reports.
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Affiliation(s)
- Shokoufeh Hajsadeghi
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology & Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Marziyeh Pakbaz
- Department of Cardiovascular Disease, Hazrat-e Rasool General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Morteza Hassanzadeh
- Department of Internal Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Sadeghipour
- Department of Pathology and Oncopathology Research Center, Iran University of Medical Sciences, Tehran, Iran
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Fragoulis GE, Evangelatos G, Tektonidou MG. Vasculitis beyond aortitis in IgG4-related disease (IgG4-RD): case report and review of the literature. Clin Rheumatol 2020; 40:1167-1173. [PMID: 32710295 DOI: 10.1007/s10067-020-05302-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/12/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
IgG4-related disease (IgG4-RD) can affect almost every tissue/organ. Vascular involvement in the setting of IgG4-RD is increasingly being recognized with most of the cases pertaining patients with aortitis and/or periaortitis with or without aneurysm formation. However, it is now evident that other vessels like iliac arteries, coronary arteries, carotids, and others can also be affected being often underdiagnosed. Vascular involvement is expressed as vessel wall thickening, while aneurysm formation is also occasionally seen. Although histopathological findings are the cornerstone in the diagnosis of IgG4-RD, imaging modalities like magnetic resonance imaging (MRI) and positron emission tomography (PET) are similarly important when vascular involvement occurs, helping in the mapping of the disease and in identifying other, more accessible to biopsy, affected organs. Inflammation markers like erythrocyte sedimentation rate and C-reactive protein have also been described in IgG4-RD patients with vascular involvement. Herein, we present a case of a middle-aged man with long-term high inflammation markers who eventually diagnosed with IgG4-RD after an ascending aorta aneurysm operation, while a subsequent comprehensive magnetic resonance angiography revealed also involvement of the abdominal aorta and the left subclavian and left common carotid. Moreover, we sought to review the current literature about medium- and large-vessel involvement, beyond the aorta, in patients with IgG4-RD.
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Affiliation(s)
- George E Fragoulis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Gerasimos Evangelatos
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Maritati F, Peyronel F, Vaglio A. IgG4-related disease: a clinical perspective. Rheumatology (Oxford) 2020; 59:iii123-iii131. [DOI: 10.1093/rheumatology/kez667] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/10/2019] [Indexed: 12/11/2022] Open
Abstract
AbstractIgG4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory disorder that can affect almost any organ. Common presentations include major salivary and lacrimal gland enlargement, orbital disease, autoimmune pancreatitis, retroperitoneal fibrosis and tubulointerstitial nephritis. The main histopathological features are a dense, polyclonal, lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, storiform fibrosis and obliterative phlebitis. The precise pathogenic mechanisms of IgG4-RD are still unclear. CD4+ T and B cells, including IgG4-expressing plasmablasts, constitute the major inflammatory cell populations and are believed to cause organ damage and tissue fibrosis. The diagnosis of the disease may be challenging and should be based on specific histopathological findings, typical laboratory and radiological aspects and an appropriate clinical context. The first-line treatment of IgG4-RD is based on glucocorticoids, which are usually efficacious. However, B cell depletion induced by rituximab has also been found to induce remission in steroid-resistant disease or has been used as steroid-sparing agent for relapsing disease. This review provides an update on clinical and therapeutic aspects of IgG4-RD.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti, AnconaItaly
| | | | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children’s University Hospital, Florence, Italy
- Department of Biomedical Clinical and Experimental Sciences, University of Firenze, Firenze, Italy
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15
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Nódulos pulmonares cavitados con relación a la enfermedad por depósito de IgG4. Arch Bronconeumol 2020; 56:127-128. [DOI: 10.1016/j.arbres.2019.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 11/18/2022]
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16
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Vashi B, Khosroshahi A. IgG4-Related Disease with Emphasis on Its Gastrointestinal Manifestation. Gastroenterol Clin North Am 2019; 48:291-305. [PMID: 31046976 DOI: 10.1016/j.gtc.2019.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IgG4-related disease is an immune-mediated fibroinflammatory condition with a diverse spectrum of organ involvement, commonly in the pancreas and bile ducts among other organs such as salivary and lacrimal glands. Classic histopathologic findings are the gold standard for confirmation of diagnosis, although diagnosis remains challenging, as biomarkers to date are neither sufficient nor necessary. Glucocorticoids are the most effective initial treatment, generally having a dramatic response, although limited clinical evidence exists regarding effective maintenance therapy. This review summarizes key GI manifestations of this condition for the practicing gastroenterologist and addresses the pathology, disease mechanism, and current therapeutic recommendations.
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Affiliation(s)
- Bijal Vashi
- Department of Medicine, Emory University, 200 Whitehead Building, 615 Michael Street, Atlanta, GA 30322, USA
| | - Arezou Khosroshahi
- Department of Medicine, Emory University, 244 Whitehead Building, 615 Michael Street, Atlanta, GA 30322, USA.
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Aortitis as a Harbinger of Occult Malignancy. Case Rep Rheumatol 2019; 2019:8385630. [PMID: 30937207 PMCID: PMC6413356 DOI: 10.1155/2019/8385630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/31/2018] [Accepted: 02/12/2019] [Indexed: 12/02/2022] Open
Abstract
Noninfectious aortitis can be associated with an occult malignancy. Although glucocorticosteroids are often used, there is no clear evidence-based therapy and there is little consensus regarding treatment. Identifying and treating an underlying trigger is the most efficacious therapy. We present an unusual case initially concerning acute bacterial endocarditis of the native mitral valve; however, aseptic ischemic valvitis manifested on pathology. Concurrent aortitis was diagnosed with angiography. Occult colon adenocarcinoma was discovered during diagnostic abdominal imaging. Treatment of this underlying malignancy was associated with dynamic mitigation of inflammation affecting the entire aorta and a reduction in associated symptoms. This is an unusual case of a paraneoplastic secondary large vessel vasculitis involving the entire aorta, a diagnosis of exclusion but a consideration that can have dramatic impact on both morbidity and mortality.
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18
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Hide and seek. Surv Ophthalmol 2018; 65:109-115. [PMID: 30521818 DOI: 10.1016/j.survophthal.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 11/22/2018] [Accepted: 11/28/2018] [Indexed: 11/22/2022]
Abstract
A 51-year-old woman with a previous history of rheumatoid arthritis experienced painless progressive visual loss in the left eye for 3 weeks. Fundus examination revealed optic disk pallor in her left eye. Magnetic resonance imaging of the brain and orbits showed enhancement of the pachymeninges and hypersignal at the left optic nerve. Meningeal biopsy was performed. Immunohistochemical staining for IgG4 revealed several IgG4-positive plasma cells, which in some areas reached the number of 50 cells/high-power field. In this case, the clinical and histopathological features of the patient met diagnostic criteria for rheumatoid arthritis and IgG4-related disease, respectively. Rheumatoid arthritis sometimes occurs with abundant IgG4 plasma cells and fulfills the histological diagnostic criteria for IgG4-related disease. This case demonstrates that overlapping features of IgG4-RD and rheumatoid arthritis may present in a single patient.
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Joshi MN, Whitelaw BC, Carroll PV. MECHANISMS IN ENDOCRINOLOGY: Hypophysitis: diagnosis and treatment. Eur J Endocrinol 2018; 179:R151-R163. [PMID: 29880706 DOI: 10.1530/eje-17-0009] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/06/2018] [Indexed: 12/19/2022]
Abstract
Hypophysitis is a rare condition characterised by inflammation of the pituitary gland, usually resulting in hypopituitarism and pituitary enlargement. Pituitary inflammation can occur as a primary hypophysitis (most commonly lymphocytic, granulomatous or xanthomatous disease) or as secondary hypophysitis (as a result of systemic diseases, immunotherapy or alternative sella-based pathologies). Hypophysitis can be classified using anatomical, histopathological and aetiological criteria. Non-invasive diagnosis of hypophysitis remains elusive, and the use of currently available serum anti-pituitary antibodies are limited by low sensitivity and specificity. Newer serum markers such as anti-rabphilin 3A are yet to show consistent diagnostic value and are not yet commercially available. Traditionally considered a very rare condition, the recent recognition of IgG4-related disease and hypophysitis as a consequence of use of immune modulatory therapy has resulted in increased understanding of the pathophysiology of hypophysitis. Modern imaging techniques, histological classification and immune profiling are improving the accuracy of the diagnosis of the patient with hypophysitis. The objective of this review is to bring readers up-to-date with current understanding of conditions presenting as hypophysitis, focussing on recent advances and areas for future development. We describe the presenting features, investigation and diagnostic approach of the patient with likely hypophysitis, including existing conventional techniques and those in the research/development arena. Hypophysitis usually results in acute and persistent pituitary hormone deficiency requiring long-term replacement. Management of hypophysitis includes control of the inflammatory pituitary mass using a variety of treatment strategies including surgery and medical therapy. Glucocorticoids remain the mainstay of medical treatment but other immunosuppressive agents (e.g. azathioprine, rituximab) show benefit in some cases, but there is a need for controlled studies to inform practice.
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Affiliation(s)
- Mamta N Joshi
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Benjamin C Whitelaw
- Department of Endocrinology, Kings College Hospital NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
| | - Paul V Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
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20
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Infrequent organ involvement of IgG4-related diseases: a literature review. Clin Rheumatol 2018; 37:1153-1159. [PMID: 29502226 DOI: 10.1007/s10067-018-4048-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/30/2018] [Accepted: 02/19/2018] [Indexed: 01/28/2023]
Abstract
IgG4-related disease (IgG4-RD) is a chronic and systemic disease that can involve multiple organs. The most commonly involved organs include the salivary glands, orbital adnexal structures, paranasal sinus, thyroid, lungs, breasts, aorta, pancreas, biliary ducts, kidneys, retroperitoneum, lymph nodes, prostate, pituitary, and endocranium. Due to increased disease research, several new site-specific nuances of IgG4-RD have been described. The authors have reviewed the recent literature and briefly summarize the infrequent organ involvement of IgG4-RD.
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21
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Dua P, Shinder R, Laskar DB, Lazzaro DR, Rizzuti AE. A case of hypertrophic herpes simplex virus affecting the eyelid and cornea masquerading as IgG4-related disease. Am J Ophthalmol Case Rep 2017; 9:68-71. [PMID: 29468223 PMCID: PMC5786855 DOI: 10.1016/j.ajoc.2017.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 11/22/2022] Open
Abstract
Purpose To report a case of hypertrophic herpes simplex virus (HSV) of the eyelid and cornea masquerading as IgG4-related disease. Observations A 37-year old African American female with a past medical history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and a recent history of treated genital herpes, presented with an ulcerative lesion of the left upper and lower eyelids, and severe ocular inflammation with symblepharon. Initially, eyelid biopsy revealed findings consistent with IgG4-related disease, and the patient was treated with high dose oral prednisone. After one week of therapy, there was no improvement in the patient's symptoms, and she subsequently developed a corneal epithelial defect which progressed to chronic ulceration. Repeat biopsy and corneal cultures revealed herpes simplex virus type 2. The patient was treated with high dose acyclovir, and the lid lesion improved. The conjunctival inflammation and corneal epithelial defect resolved but symblepharon restricting her eye movement remained. She also developed corneal vascularization and opacification causing severe vision loss. Conclusions and importance Chronic hypertrophic herpes simplex virus infection is a rare condition reported in patients with HIV. While there have been few reports of hypertrophic HSV affecting the eyelid, this is the first reported case of hypertrophic HSV affecting the eye, resulting in severe vision loss.
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Affiliation(s)
- Prachi Dua
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Derek B Laskar
- Department of Pathology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Douglas R Lazzaro
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Allison E Rizzuti
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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IgG4-Related Kidney Disease: Report of a Case Presenting as a Renal Mass. Case Rep Surg 2017; 2017:9690218. [PMID: 28912998 PMCID: PMC5585603 DOI: 10.1155/2017/9690218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/02/2017] [Accepted: 07/20/2017] [Indexed: 12/12/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a nosological entity defined as a chronic immune-mediated fibro-inflammatory condition characterized by a tendency to form tumefactive, tissue-destructive lesions or by organ failure. Urologic involvement in IgG4-RD has been described in some short series of patients and in isolated case reports, most often involving the kidneys in so-called IgG4-related kidney disease (IgG4-RKD). The disease can occasionally mimic malignancies and is at risk of being misdiagnosed due to its rarity. We report the case of a 56-year-old man presenting with a right renal mass suspected of being malignant. Laboratory tests showed normal creatinine levels, a high erythrocyte sedimentation rate, and high levels of C-reactive protein and microalbuminuria. The patient underwent radical right nephroureterectomy and histopathologic examination revealed features proving IgG4-RKD. He was therefore referred to immunologists. Typical clinical presentation of IgG4-RKD includes altered renal function with inconstant or no radiologic findings. Conversely, in the case we presented, a single nodule was detected upon imaging evaluation, thus mimicking malignancy. This raises the issue of a proper differential diagnosis. A multidisciplinary approach can be useful, although in clinical practice the selection of patients suspected of having IgG4-RKD is critical in the cases presenting with a renal mass that mimics malignancy.
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23
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Baptista B, Casian A, Gunawardena H, D'Cruz D, Rice CM. Neurological Manifestations of IgG4-Related Disease. Curr Treat Options Neurol 2017; 19:14. [PMID: 28374231 PMCID: PMC5378735 DOI: 10.1007/s11940-017-0450-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. Early recognition of IgG4-RD is important to avoid permanent organ dysfunction and disability. Neurological involvement by IgG4-RD is relatively uncommon, but well recognised-hypertrophic pachymeningitis and hypophysitis are the most frequent manifestations. Although the nervous system may be involved in isolation, this more frequently occurs in conjunction with involvement of other systems. Elevated circulating levels of IgG4 are suggestive of the condition, but these are not pathognomonic and exclusion of other inflammatory disorders including vasculitis is required. Wherever possible, a tissue diagnosis should be established. The characteristic histopathological changes include a lymphoplasmacytoid infiltrate, storiform fibrosis and obliterative phlebitis. IgG4-RD typically responds well to treatment with glucocorticoids, although relapse is relatively common and treatment with a steroid-sparing agent or rituximab may be required. Improved understanding of the pathogenesis of IgG4-RD is likely to lead to the development of more specific disease treatments in the future.
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Affiliation(s)
| | - Alina Casian
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Harsha Gunawardena
- Department of Rheumatology, Brunel Building, Southmead Hospital, Bristol, UK
- Musculoskeletal Research Unit, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - David D'Cruz
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
- Division of Immunology, Infection and Inflammatory Diseases, King's College London, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Claire M Rice
- School of Clinical Sciences, Level 1, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Department of Neurology, Brunel Building, Southmead Hospital, Bristol, UK.
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24
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Recent advances in knowledge regarding the head and neck manifestations of IgG4-related disease. Auris Nasus Larynx 2016; 44:7-17. [PMID: 27956101 DOI: 10.1016/j.anl.2016.10.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/31/2016] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a chronic inflammatory disorder, characterized by elevated serum IgG4 levels as well as abundant infiltration of IgG4-positive plasmacytes and fibrosis in various organs, including the head and neck region. In particular, the salivary glands, orbit, and thyroid are common sites of disease involvement. IgG4-RD is diagnosed based on various clinical, serological, and histopathological findings, none of which are pathognomonic. Hence, various differential diagnoses, which exhibit elevated serum IgG4 levels and infiltration of IgG4-postive cells into tissues, need to be excluded, especially malignant diseases and mimicking disorders. Systemic corticosteroids are generally effective in inducing IgG4-RD remission; however, recurrent or refractory cases are common. In addition, although the pathogenic mechanisms of IgG4-RD remain unclear, an antigen-driven inflammatory condition is believed to be involved. Recent studies have indicated the important pathogenic role of B cell/T cell collaboration and innate immunity in this disease. Nevertheless, additional research and discussions are needed to resolve many remaining questions. In this review, we provide an overview of the recent insights on the history, clinical features, diagnosis, and treatment of IgG4-RD in the head and neck region. Furthermore, we have also addressed the pathogenesis of this disease.
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Abstract
Hypophysitis is the acute or chronic inflammation of the pituitary gland. The spectrum of hypophysitis has expanded in recent years with the addition of two histologic subtypes and recognition as a complication of treatment with immune checkpoint inhibitors. Despite the increased number of published cases, the pathogenesis of hypophysitis is poorly understood, and treatment strategies are diverse and controversial. The diagnosis of hypophysitis generally requires histopathologic confirmation. The presentation and clinical course of hypophysitis varies. Hypophysitis can resolve spontaneously, relapse may occur, and some cases can be refractory to treatment.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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26
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Peng T, Hu Z, Xie T, Jiang B, Zhen J, Yang X. IgG4-related disease: a case report with duration of more than 16 years and review of literature. SPRINGERPLUS 2016; 5:804. [PMID: 27390645 PMCID: PMC4916074 DOI: 10.1186/s40064-016-2537-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 06/08/2016] [Indexed: 12/24/2022]
Abstract
Introduction IgG4-related disease was first reported in 2001 and was officially named in 2010. It is now considered as a systemic disease that might affect any organ system. The characteristic pathological changes of IgG4-related disease are extensive infiltration of IgG4-positive plasma cells. IgG4-related disease is a kind of benign lesions, but there has not been well-defined standard treatment so far. Patients usually respond well to corticosteroids. The prognosis of IgG4-related disease is perhaps good as long as early detection and treatment. Case description We report one case of IgG4-related disease with a 16-years anamnesis with multi-pseudotumor masses. He was diagnosed with chronic kidney disease with wide interstitial renal fibrosis. And he received glucocorticoids therapy. After 2 month therapy, the serum creatinine, erythrocyte sedimentation rate, and serum IgG4 decreased significantly. The discussion includes presentation, clinical course, diagnosis, and prognosis of IgG4-related disease. The case and discussion highlight the importance of diagnosis and the good prognosis of IgG4-related diseases. Discussion and evaluation Our case highlights the importance of diagnosis and the good prognosis of IgG4-related diseases. IgG4-related disease is a systemic fibro-inflammatory immune-mediated disorder and now recognized in almost every major organs. Characteristics of the disease is multiple lymph nodes and the response to glucocorticoids therapy is well. In such case, he had a history of 16 years with multi-pseudotumor masses and misdiagnosed for 16 years, if the doctors were not awareness of higher serum immunoglobulin G4 (IgG4) than normal, the correct diagnosis may be missed or delayed. Consequently, appropriate treatment for IgG4-related disease would also be delayed or not provided and likely result in increased morbidity and mortality. Conclusions IgG4-related disease is a systemic fibro-inflammatory immune-mediated disorder and progresses slowly. In the present patient the course of IgG4-related disease appears to be benign. The prognosis of IgG4-related disease depend on early diagnosis and treatment.
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Affiliation(s)
- Tao Peng
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, 250012 China
| | - Zhao Hu
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, 250012 China
| | - Tingting Xie
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, 250012 China
| | - Baodong Jiang
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, 250012 China
| | - Junhui Zhen
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, 250012 China
| | - Xiangdong Yang
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, 250012 China
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Brito-Zerón P, Bosch X, Ramos-Casals M, Stone JH. IgG4-related disease: Advances in the diagnosis and treatment. Best Pract Res Clin Rheumatol 2016; 30:261-278. [DOI: 10.1016/j.berh.2016.07.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/17/2016] [Indexed: 02/08/2023]
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28
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Li J, Ge X, Ma JM. Relationship between dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor and paranasal sinusitis. Int J Ophthalmol 2016; 9:444-7. [PMID: 27158618 DOI: 10.18240/ijo.2016.03.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 06/08/2015] [Indexed: 11/23/2022] Open
Abstract
AIM To determine the clinical features of the dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor and its relationship with paranasal sinusitis. METHODS A retrospective analysis of 46 patients who received surgical treatment at the Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University for the dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor from October 2010 to December 2012. Each patient underwent magnetic resonance imaging (MRI) of the orbits and the 4 paranasal sinuses. Disease status and the level of serum immunoglobulin G4 (IgG4) was measured before and 6mo after surgery. RESULTS The initial clinical feature of the idiopathic dacryoadenitis type of orbital inflammatory pseudotumor was redness or swelling of the eyelids. Masses were palpated in the area of the lacrimal gland in some patients. Of the 46 patients, 16 also suffered from sinusitis (34.8%), with 14 cases of ethmoid sinusitis, 8 cases of maxillary sinusitis, 9 cases of sphenoid sinusitis, and 8 cases of frontal sinusitis. Of the 16 patients with sinusitis, 4 patients had a medical history of rhinitis (range: 10mo to 15y previously), 10 patients had occasional nasal congestion, and 2 patients had no nasal congestion. Thirteen of the 46 patients had elevated serum IgG4 levels. Nine of these 13 patients had MRI signs of sinusitis. All patients (n=46) received oral glucocorticoid treatment for approximately 3mo after surgery. No sign of recurrence was found in the orbital MRI 6mo after surgery. Of the 16 patients with sinusitis, 9 cases of elevated serum IgG4 levels improved after treatment with decreased serum IgG4 level and 7 cases of normal serum IgG4 levels remained unchanged. CONCLUSION Some patients with the dacryoadenitis subtype of idiopathic orbital inflammatory pseudotumor may also suffer from paranasal sinusitis. The incidence of paranasal sinusitis was much higher in patients with IgG4-elevated dacryoadenitis subtype orbital inflammatory pseudotumor than in those with normal IgG4 levels. Dacryoadenitis subtype orbital inflammatory pseudotumor and paranasal sinusitis may both the clinical manifestations of IgG4-related disease involved in different locations.
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Affiliation(s)
- Jing Li
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100730, China
| | - Xin Ge
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100730, China
| | - Jian-Min Ma
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100730, China
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IgG4-related disease: what urologists should know. Int Urol Nephrol 2016; 48:301-12. [DOI: 10.1007/s11255-015-1189-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 12/13/2015] [Indexed: 12/24/2022]
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30
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A small subgroup of Hashimoto’s thyroiditis is associated with IgG4-related disease. Virchows Arch 2015; 468:321-7. [DOI: 10.1007/s00428-015-1893-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/05/2015] [Accepted: 11/25/2015] [Indexed: 12/24/2022]
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31
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McMahon BA, Novick T, Scheel PJ, Bagnasco S, Atta MG. Rituximab for the Treatment of IgG4-Related Tubulointerstitial Nephritis: Case Report and Review of the Literature. Medicine (Baltimore) 2015; 94:e1366. [PMID: 26266393 PMCID: PMC4616672 DOI: 10.1097/md.0000000000001366] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/18/2015] [Accepted: 07/20/2015] [Indexed: 12/18/2022] Open
Abstract
Immunoglobulin type gamma 4 (IgG4)-related disease is a relatively newly described clinical entity characterized by a distinctive histopathological appearance, increased numbers of IgG4 positive plasma cells and often, but not always, elevated serum IgG4 concentrations. The most common renal manifestation of IgG4-related disease is tubulointerstitial nephritis marked with proteinuria, hematuria, decreased kidney function, hypocomplementemia, and radiologic abnormalities. Renal biopsy characteristics include dense lymphoplasmacytic tubulointerstitial nephritis that stains for IgG4, storiform fibrosis, and immune complex deposition in the interstitium and along tubule basement membranes. Treatment traditionally consists of prolonged glucocorticoids but cases refractory to glucocorticoids have been reported.We report a case of a 58-year-old Caucasian man who presented with fatigue, 50 pound weight loss, dyspnea, lymphadenopathy, and nephromegaly. The patient was first misdiagnosed as chronic interstitial nephritis secondary to renal sarcoid and was treated with repeated doses of prednisone. On his third relapse, he underwent a repeat renal biopsy and a diagnosis of IgG4-tubulointerstitial nephritis was confirmed. He was refractory to treatment with prednisone. The patient received Rituximab and had prompt sustained improvement in renal function. At 1 year post Rituximab treatment, his serum creatinine remains at baseline and imaging study revealed reduction in his kidney size.This is the first case report using Rituximab as a steroid sparing option for refractory IgG4-tubulointerstitial nephritis. More information is needed on the long-term effects of using of B-cell depleting agents for glucocorticoid resistant IgG4-tubulointerstitial nephritis.
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Affiliation(s)
- Blaithin A McMahon
- From the Division of Nephrology (BAM, PJS, MGA); Osler Medical Residency Program (TN); and Division of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland (SB)
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