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Tsuge S, Fujii H, Tamai M, Tsujiguchi H, Yoshida M, Suzuki N, Takahashi Y, Takeji A, Horita S, Fujisawa Y, Matsunaga T, Zoshima T, Nishioka R, Nuka H, Hara S, Tani Y, Suzuki Y, Ito K, Yamada K, Nakazaki S, Hara A, Kawakami A, Nakamura H, Mizushima I, Iwata Y, Kawano M. Factors related to elevated serum immunoglobulin G4 (IgG4) levels in a Japanese general population. Arthritis Res Ther 2024; 26:156. [PMID: 39242517 PMCID: PMC11378454 DOI: 10.1186/s13075-024-03391-w] [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: 07/01/2024] [Accepted: 09/01/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Elevated serum immunoglobulin G4 (IgG4) concentrations are one of the characteristic findings in IgG4-related disease (IgG4-RD). This study investigated the frequency of elevated serum IgG4 levels and associated factors in a general Japanese population. METHODS Serum IgG4 concentrations were measured in 1,201 residents of Ishikawa prefecture who underwent general medical examinations. Factors associated with elevated serum IgG4 concentrations were assessed by logistic regression analysis. Participants with elevated serum IgG4 were subjected to secondary examinations. RESULTS The mean serum IgG4 concentration was 44 mg/dL, with 42 (3.5%) participants having elevated serum IgG4 levels. Age- and sex-adjusted logistic regression analyses showed that male sex, older age, and lower intake of lipids and polyunsaturated fatty acids and higher intake of carbohydrates in daily diet were associated with elevated serum IgG4 concentration. Subgroup analyses in men showed that older age, lower estimated glomerular filtration rates based on serum cystatin C (eGFR-cysC) levels, and higher hemoglobin A1c (HbA1c) levels were associated with elevated serum IgG4 concentration. Analyses in women showed that lower intake of lipids and fatty acids and higher intake of carbohydrates were significantly associated with elevated serum IgG4 concentration. One of the 15 participants who underwent secondary examinations was diagnosed with possible IgG4-related retroperitoneal fibrosis. CONCLUSIONS Elevated serum IgG4 levels in a Japanese general population were significantly associated with older age, male gender, and dietary intake of nutrients, with some of these factors identical to the epidemiological features of IgG4-RD.
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Affiliation(s)
- Shunsuke Tsuge
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hiroshi Fujii
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Mami Tamai
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiromasa Tsujiguchi
- Department of Hygiene and Public Health, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Misaki Yoshida
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Nobuhiro Suzuki
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yoshinori Takahashi
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Akari Takeji
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Shigeto Horita
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yuhei Fujisawa
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Takahiro Matsunaga
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Takeshi Zoshima
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Ryo Nishioka
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hiromi Nuka
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Satoshi Hara
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yukiko Tani
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yasunori Suzuki
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kiyoaki Ito
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kazunori Yamada
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | | | - Akinori Hara
- Department of Hygiene and Public Health, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroyuki Nakamura
- Department of Hygiene and Public Health, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Ichiro Mizushima
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
| | - Yasunori Iwata
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Mitsuhiro Kawano
- Department of Nephrology and Rheumatology, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
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Yinh JM, Ford JN, Jorge AM, Zonozi R. Case 7-2024: A 67-Year-Old Woman with Alternating Sixth Cranial Nerve Palsy. N Engl J Med 2024; 390:843-851. [PMID: 38416433 DOI: 10.1056/nejmcpc2312740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Janeth M Yinh
- From the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Massachusetts General Hospital, and the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Harvard Medical School - both in Boston; and Nephrology Associates of Northern Virginia, Fairfax, and Inova Fairfax Hospital, Falls Church - both in Virginia (R.Z.)
| | - Jeremy N Ford
- From the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Massachusetts General Hospital, and the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Harvard Medical School - both in Boston; and Nephrology Associates of Northern Virginia, Fairfax, and Inova Fairfax Hospital, Falls Church - both in Virginia (R.Z.)
| | - April M Jorge
- From the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Massachusetts General Hospital, and the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Harvard Medical School - both in Boston; and Nephrology Associates of Northern Virginia, Fairfax, and Inova Fairfax Hospital, Falls Church - both in Virginia (R.Z.)
| | - Reza Zonozi
- From the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Massachusetts General Hospital, and the Departments of Medicine (J.M.Y., A.M.J.) and Radiology (J.N.F.), Harvard Medical School - both in Boston; and Nephrology Associates of Northern Virginia, Fairfax, and Inova Fairfax Hospital, Falls Church - both in Virginia (R.Z.)
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Awadelkarim B, Vila J, Nayar MK, Leeds JS, Griffiths B, Oppong KW. Pancreaticobiliary versus head and neck presentation of immunoglobulin G4-related disease: different sides of the same coin? BMJ Open Gastroenterol 2023; 10:bmjgast-2022-000961. [PMID: 36707105 PMCID: PMC9884923 DOI: 10.1136/bmjgast-2022-000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/07/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND STUDY AIM Immunoglobulin G4-related disease (IgG4-RD) is a rare immune mediated fibroinflammatory condition. Pancreaticobiliary (PB) and head and neck (HN) are two of the most commonly involved anatomical sites. It has been postulated that PB IgG4-RD and HN IgG4-RD have distinct clinical phenotypes. Whether the optimum treatment regimen or response to therapy differs between them is unknown. We aimed to assess differences between PB and HN IgG4-RD in a cohort of IgG4 disease managed by an IgG4-RD multispecialty team. METHODS We performed a retrospective study of a prospectively maintained multidisciplinary IgG4-RD database to identify patients diagnosed with PB and HN IgG4-RD (based on initial presentation) between 2005 and 2019. The electronic patient records were reviewed. Use of immunosuppressive agents and clinical course was analysed. RESULTS 60 patients with PB IgG4-RD and 14 with HN IgG4-RD were included in the study. PB IgG4-RD was associated with older age at diagnosis 64 versus 51 years (p<0.001), higher serum IgG4 level as a multiple of upper limit of normal median (IQR) 2 (1-3.75) vs 1 (1-2), (p=0.04) and greater proportion with more than one organ involved 68% vs 33% (p=0.03). HN IgG4-RD was more likely to receive second-line therapy 71% versus 36% (p=0.03). Persistent elevation of serum IgG4 after therapy was more common in PB IgG4-RD 84% versus 43% (p=0.03). CONCLUSION These findings support the contention that PB IgG4-RD and HN IgG4-RD have different clinical profiles and represent distinct subtypes of IgG4-RD.
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Affiliation(s)
- Bidour Awadelkarim
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Josephine Vila
- Rheumatology Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Manu K Nayar
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John S Leeds
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Bridget Griffiths
- Rheumatology Department, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Kofi W Oppong
- HPB Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Lee SC, Yang CH, Chang CT, Yu KH. Diagnostic Utility of Serum IgG4 in Autoimmune Pancreatitis: An Updated Comprehensive Systematic Review and Meta-analysis. J Clin Gastroenterol 2022; 56:810-817. [PMID: 34516462 DOI: 10.1097/mcg.0000000000001612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/30/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Despite many studies suggesting an association between serum immunoglobulin G4 (sIgG4) and autoimmune pancreatitis (AIP), the evidence of utility in differentiation between AIP and pancreatic cancer (PC) remain uncertain. METHODS The analysis based on published studies. Data were pooled by means of a random-effects model, and sensitivity, specificity, diagnostic odds ratios (DOR), areas under summary receiver operating characteristic curves were calculated. RESULTS In the included thirteen studies, sIgG4 were measured in 594 patients with AIP and 958 patients with PC. The pooled sensitivity, specificity, DOR, and area under the curve were 0.72 [95% confidence interval (CI): 0.68-0.75], 0.93 (95% CI: 0.92-0.95), 51.37 (95% CI: 23.20-113.74), and 0.91 (95% CI: 0.87-0.95). Subgroup analyses of the DORs for region and year: Asia, (112.10; 95% CI: 27.72-453.32), non-Asia (26.01; 95% CI: 12.38-54.65), and year before 2011 (107.61; 95% CI: 39.30-294.68), year after 2011 (26.96; 95% CI: 9.78-74.32). Overall, sIgG4 was associated with AIP, the result revealed a moderate sensitivity 0.72 and high specificity 0.93. In the meta-analysis, the pooled DOR of sIgG4 levels of 2-fold upper limit 50.44 was similar with the DOR 51.37 when 1-fold cut-off value, but the summary receiver operating characteristic was 0.755 and 0.91. The higher specificity (from 93% to 98%) derived from the cut-off value (from 130-140 to 260-280 mg/dL) for sIgG4 occurred at a significant reduction in sensitivity (from 72% to 43%). CONCLUSIONS The study revealed sIgG4 is a good marker of AIP. Screening of sIgG4 may help clinicians differentiate between AIP and PC, and the best cut-off value should be 140 rather than 280 mg/dL.
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Affiliation(s)
- Shih-Ching Lee
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan
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American College of Rheumatology and the European League Against Rheumatism classification criteria for IgG4-related disease: an update for radiologists. Jpn J Radiol 2022; 40:876-893. [PMID: 35474439 DOI: 10.1007/s11604-022-01282-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/09/2022] [Indexed: 10/18/2022]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated, multiorgan, chronic inflammatory disease. The three-step classification criteria proposed in 2019 by the American College of Rheumatology and the European League Against Rheumatism (ACR/EULAR) encompass a wide range of clinical, radiological, serological, and histopathological findings. The ACR/EULAR proposed a three-step classification process, i.e., entry step, exclusion step, and scoring system. Radiologists need to know that the radiological findings observed in the five domains of the lacrimal and salivary glands, chest, pancreas and biliary ducts, kidney, and retroperitoneum are independently weighted with different points in the scoring system. A total score < 20 points indicates that the patient should not be classified as having IgG4-RD; conversely, a total score ≥ 20 points indicates that the patient should be classified as having IgG4-RD. In this review, the 2019 ACR/EULAR classification criteria are discussed, focusing on the interpretation of each radiological item, with the aim of applying them to the diagnosis of IgG4-RD in clinical practice.
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6
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Optic perineuritis: A Canadian case series and literature review. J Neurol Sci 2021; 430:120035. [PMID: 34717266 DOI: 10.1016/j.jns.2021.120035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Optic perineuritis (OPN) is a rare orbital inflammatory disorder that primarily involves the optic nerve sheath (ONS). This study aimed to describe the clinical features of idiopathic OPN as well as OPN secondary to other infectious and inflammatory conditions in a Canadian case series as current literature on secondary OPN in Western countries is mostly limited to case reports. METHODS Retrospective case series of all patients seen in a tertiary neuro-ophthalmology practice with a diagnosis of OPN from 2014 to 2020. RESULTS A total of 21 patients (14 women, mean age 55.8) corresponding to 29 eyes with OPN were identified. Fifteen cases were associated with inflammatory or infectious conditions and only 6 were idiopathic. All idiopathic cases were unilateral. The most common secondary causes of OPN were anti-myelin oligodendrocyte glycoprotein (MOG) antibody disease (n = 4), syphilis (n = 3), sarcoidosis (n = 3), and giant cell arteritis (n = 3). At initial presentation, best-corrected visual acuity (BCVA) was 20/20 or better in 24% (n = 7) and visual field mean deviation (VF MD) was better than -5 dB in 34% of eyes (10/29). Treatment consisted of intravenous penicillin for syphilitic OPN and high-dose corticosteroids followed by oral taper with or without immunosuppressive therapy for non-syphilitic OPN. BCVA improved in 34% (10/29) and VF MD improved in 45% (13/29) eyes. CONCLUSION OPN primarily occurred in association with systemic inflammatory conditions, especially in bilateral cases. Syphilis must be ruled out in all patients. Anti-MOG antibody disease is an important, newly recognized secondary cause of OPN, and serologic testing should be included in the investigation of all patients with OPN.
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Gökçay Canpolat A, Cinel M, Dizbay Sak S, Taşkaldıran I, Korkmaz H, Demir Ö, Ersoy R, Dağdelen S, Berker D, Dalva K, Bahçecioğlu Mutlu AB, Erdoğan MF. Long-Term Outcomes of Tamoxifen Citrate Therapy and Histo- and Immunopathological Properties in Riedel Thyroiditis. Eur Thyroid J 2021; 10:248-256. [PMID: 34178711 PMCID: PMC8216025 DOI: 10.1159/000512017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Riedel thyroiditis (RT) is a rare form of thyroiditis; thus, data about the disease course and treatment options are limited. Therefore, we aimed to assess the clinical, serological, radiological, and histopathological features, as well as short- and long-term follow-up of RT patients under glucocorticoid (GC) and tamoxifen citrate (TMX). Parameters related to IgG4-related diseases (IgG4-RD) were also investigated. METHODS Eight patients with RT diagnosed between 2000 and 2019 were enrolled. Data were collected in a retrospective and prospective manner. The diagnosis was confirmed with histopathological features in all patients. Results of the treatment with GCs on short- to mid-term, followed by TMX in the long term, were evaluated. RESULTS The mean age at diagnosis was 40.5 ± 6.8 years; female predominance was observed (F/M:7/1). Parameters related to IgG4-RD, like increase in IgG4 serum levels, total plasmablast counts, and IgG4+ plasmablasts, were negative in most of our patients in both active and inactive states of the disease. Likewise, an increased ratio of IgG4/IgG-positive plasma cells >40% could only be observed in 2 cases. GCs followed by TMX were given to the patients with an over-all median follow-up time of 67 (8-216) months. All the patients considerably improved clinically and had a reduction in the size of the mass lesion on GCs, followed by TMX therapy. None of the patients had a recurrence under TMX therapy for a median period of 18.5 (7-96) months. CONCLUSION Even though RT is suggested to be a member of IgG4-RD, serologic or histological evidence of IgG4 elevation or positivity is only useful for diagnosis and follow-up of RT. The diagnosis should be based on clinical and radiological evidence and confirmed by histopathology. GCs are effective for initial treatment, and TMX is a successful and safe therapeutic option for long-term maintenance therapy.
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Affiliation(s)
- Asena Gökçay Canpolat
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
- *Asena Gökçay Canpolat, Department of Endocrinology and Metabolism, School of Medicine, İbni-Sina Hospital, Ankara University, Altındağ, Ankara 06100 (Turkey),
| | - Murat Cinel
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
| | - Serpil Dizbay Sak
- Department of Pathology, School of Medicine, Ankara University, Ankara, Turkey
| | - Işılay Taşkaldıran
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Turkey
| | - Hakan Korkmaz
- Department of Endocrinology and Metabolism, School of Medicine, Süleyman Demirel University, Isparta, Turkey
| | - Özgür Demir
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
| | - Reyhan Ersoy
- Department of Endocrinology and Metabolism, School of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Selçuk Dağdelen
- Department of Endocrinology and Metabolism, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Dilek Berker
- Department of Endocrinology and Metabolism, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Klara Dalva
- Department of Haematology, School of Medicine, Ankara University, Ankara, Turkey
| | | | - Murat Faik Erdoğan
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
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A Follow-Up Study of a European IgG4-Related Disease Cohort Treated with Rituximab. J Clin Med 2021; 10:jcm10061329. [PMID: 33807051 PMCID: PMC8004657 DOI: 10.3390/jcm10061329] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES IgG4-related disease (IgG4-RD) is a chronic fibro-inflammatory disorder affecting virtually any organ. Type 1 autoimmune (type 1 AIP) is its pancreatic manifestation. To date, steroids are considered the first-line pancreatitis treatment. The CD20-binding antibody rituximab (RTX) appears a promising steroid-sparing therapy, although long-term data are lacking. We aimed to bridge this gap with a cohort of IgG4-RD patients treated with RTX and to assess the potential value of the Responder Index (RI) as a discriminatory score for disease activity. METHODS We retrospectively evaluated 46 patients from a tertiary referral centre who were diagnosed with IgG4-RD and/or type 1 AIP according to the International Consensus Diagnostic Criteria or Unifying-AIP criteria between June 2006 and August 2019. RESULTS Patients resembled previous cohorts in terms of characteristics, diagnosis, and therapeutic response. Thirteen of the 46 patients with IgG4-RD/type 1 AIP were treated with RTX pulse therapy due to relapse, adverse reactions to steroids, or high-risk constellations predicting a severe course of disease with multi-organ involvement. Median follow-up after diagnosis was 52 months for all subjects, and 71 months in IgG4-RD patients treated with RTX. While patients in the RTX group showed no significant response to an initial steroid pulse, clinical activity as measured by the RI significantly decreased in the short-term after RTX induction. Within 16 months, 61% of patients relapsed in the RTX group but responded well to re-induction. Clinical and laboratory parameters improved equally in response to RTX. CONCLUSION RTX therapy in patients with IgG4-RD is an effective and safe treatment to induce treatment response and possible long-term remission. Repeated RTX administration after 6-9 months may be of value in reducing the risk of relapse. The RI appears to be a reasonable index to assess disease activity and to identify patients with IgG4-related disease who may benefit from B-cell-depleting therapy.
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Abstract
OBJECTIVE. The purpose of this article is to present the pathologic and clinical features of IgG4-related sclerosing cholangitis (ISC), illustrate the associated imaging findings, and discuss treatment of the disorder. CONCLUSION. ISC is an inflammatory disorder involving the biliary system and resulting in strictures. Although often associated with autoimmune pancreatitis, it may be an isolated disease. Differentiation of ISC from other forms of cholangitis and cholangiocarcinoma is difficult but necessary for management. Imaging is important in diagnosing and assessing the extent of disease and planning a management strategy.
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Mohapatra S, Sharma A, Chari ST. Pancreatobiliary Versus Head and Neck Manifestations in Immunoglobulin G4-related Disease: Distinct Subsets of the Same Disease? Pancreas 2019; 48:799-804. [PMID: 31210660 DOI: 10.1097/mpa.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We compared the clinical profiles and organ manifestations of the commonly encountered immunoglobulin G4-related diseases (IgG4-RDs) on either side of the diaphragm: head and neck (HN) versus pancreatobiliary (PB) in IgG4-RD. METHODS From the Mayo Clinic, Rochester, database, we identified 53 HN and 88 PB IgG4-RD based on the first affected organ manifestation. RESULTS Compared with HN IgG4-RD, subjects with PB IgG4-RD were likely to be older (median, 64.8 vs 50.2 years; P < 0.0001), male (83% vs 60.4%; P = 0.003), and with a shorter duration of follow-up (24.4 vs 48.7 months; P < 0.0001). In HN versus PB-IgG4-RD orbital, lacrimal gland, submandibular, parotid gland, asthma, and sinusitis manifestations were more common (77% vs 4.5%, 21% vs 0%, 32% vs 8%, 13% vs 0%, 36% vs 9%, and 51% vs 6.8%; P < 0.0001, respectively), whereas lung manifestations were similar (13.2% vs 5.6%; P = 0.12). In contrast, in PB versus HN IgG4-RD, pancreas and biliary were more frequent (98.8% vs 15%, 56.8% vs 3.7%; P < 0.0001), whereas renal lesions were similar (12.5% vs 7.5%; P = 0.36). CONCLUSION Pancreatobiliary and HN IgG4-RD have distinct clinical profiles. Proximity matters in other organ involvement in IgG4-RD, and organs involved tend to cluster close to each.
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Affiliation(s)
| | - Ayush Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN
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Miyabe K, Zen Y, Cornell LD, Rajagopalan G, Chowdhary VR, Roberts LR, Chari ST. Gastrointestinal and Extra-Intestinal Manifestations of IgG4-Related Disease. Gastroenterology 2018; 155:990-1003.e1. [PMID: 30012334 DOI: 10.1053/j.gastro.2018.06.082] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 12/13/2022]
Abstract
IgG4-related disease (IgG4-RD) is a chronic relapsing multi-organ fibro-inflammatory syndrome of presumed autoimmune etiology. It is characterized by increased serum levels of IgG4 and tissue infiltration by IgG4+ cells. Increased titers of autoantibodies against a spectrum of self-antigens and response to steroids have led to its characterization as an autoimmune disease. However, the pathognomonic antigens probably differ among manifestations, and different antigens or autoantibodies produce similar immune reactions in different organs. Little is known about the pathogenic effects, if any, of serum IgG4 or IgG4+ plasma cells in tissues. Despite several animal models of the disease, none truly recapitulates human IgG4-RD. Histologic analyses of tissues from patients with IgG4-RD reveal a dense lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis, although these features vary among organs. Typical presentation and imaging findings include mass-forming synchronous or metachronous lesions in almost any organ, but most commonly in the pancreas, bile duct, retroperitoneum, kidneys, lungs, salivary and lacrimal glands, orbit, and lymph nodes. In all organs, inflammation can be reduced by corticosteroids and drugs that deplete B cells, such as rituximab. Patients with IgG4-RD have relapses that respond to primary therapy. Intense fibrosis accompanies the inflammatory response, leading to permanent organ damage and insufficiency. Death from IgG4-RD is rare. IgG4-RD is a multi-organ disease with predominant pancreatico-biliary involvement. Despite its relapsing-remitting course, patients have an excellent prognosis.
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Affiliation(s)
- Katsuyuki Miyabe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yoh Zen
- Department of Laboratory Medicine and Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Lemaitre S, Esquerda GM, Guardiola AC, Agustin JT, Sanda N, González-Candial M. Colon cancer and IgG4-related disease with orbital inflammation and bilateral optic perineuritis: A case report. Medicine (Baltimore) 2018; 97:e12197. [PMID: 30278491 PMCID: PMC6181517 DOI: 10.1097/md.0000000000012197] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE Immunoglobulin G4-related disease (IgG4-RD) is an inflammatory condition of unknown cause. Cancer might be related to the development of certain IgG4-RD but to date, little literature documents it. PATIENT CONCERNS A 78-year old man presented with unilateral proptosis responsive to steroids, initially attributed to nonspecific orbital inflammation. DIAGNOSIS Right hemicolectomy was performed because of a suspicious lesion which turned out to be tubulovillous adenoma on histological analysis. Eight months after the surgery, a mass infiltrating the mesentery was found and biopsy revealed IgG4-RD. INTERVENTIONS Both the orbital inflammation and abdominal mass infiltrating the mesentery were responsive to steroids and rituximab administered to treat IgG4-RD. OUTCOMES In the course of IgG4-RD, the patient developed bilateral optic perineuritis, causing bilateral visual loss. Colon cancer with synchronous multiple liver metastases was found 1 year after rituximab treatment. LESSONS This case raises the possibility of IgG4-RD being a paraneoplastic syndrome in some patients. Cancer screening should probably be performed in some elderly patients diagnosed with IgG4-RD.
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Affiliation(s)
- Stephanie Lemaitre
- IDIBGI—Institut d’Investigació Biomèdica de Girona Dr. Josep Trueta (IDIBGI), Parc Hospitalari Martí i Julià de Salt—Edifici
- Ophthalmology Department, Oculoplastics
| | | | - Antoni Castro Guardiola
- Internal Medicine Department, Hospital Universitari de Girona Dr. Josep Trueta, Avinguda de França
| | - Jordi Teruel Agustin
- Radiology Department, Centre d’Atenció Primària (CAP) Güell, Carrer de Joan Pons, Girona, Spain
| | - Nicolae Sanda
- Neuroophthalmology, Hopitaux Universitaires de Geneve (HUG), Rue Gabrielle-Perret-Gentil, Geneva, Switzerland
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13
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Detlefsen S, de Vos JD, Tanassi JT, Heegaard NHH, Fristrup C, Schaffalitzky de Muckadell OB. Value of anti-plasminogen binding peptide, anti-carbonic anhydrase II, immunoglobulin G4, and other serological markers for the differentiation of autoimmune pancreatitis and pancreatic cancer. Medicine (Baltimore) 2018; 97:e11641. [PMID: 30075546 PMCID: PMC6081052 DOI: 10.1097/md.0000000000011641] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The diagnosis of autoimmune pancreatitis (AIP) and its differential diagnosis from pancreatic cancer (PC) can be challenging. In this retrospective study, we aimed to evaluate the value of anti-plasminogen binding peptide (a-PBP), immunoglobulin G4 (IgG4), and anti-carbonic anhydrase-II (a-CA-II), together with other serological markers whose value is not fully elucidated.The serum levels of a-PBP, IgG4, IgG, anti-nuclear antibodies (ANA), anti-lactoferrin (a-LF), a-CA-II, and rheumatoid factor (RF) were evaluated in patients with AIP (n = 29), PC (n = 17), pancreatic neuroendocrine neoplasm (P-NEN, n = 12), and alcoholic chronic pancreatitis (ACP, n = 41). ANCA were measured in the AIP patients.There was no statistically significant difference in mean a-PBP values in AIP compared with PC. A ROC curve showed that, when using a cut-off of 38.3 U, low values of a-PBP had a sensitivity and specificity of 45% and 71% for differentiating AIP from PC. The sensitivity and specificity of IgG4 (cut-off 1.4 g/L) for differentiating AIP from PC was 45% and 88%, but rose to 52% and 88% when using a cut-off of 1.09 g/L. When using this cut-off, the sensitivity and specificity for differentiating type 1 AIP from PC was 68% and 88%. None of the other markers were significantly changed in AIP versus PC. For differentiation of type 1 and type 2 AIP, the only significant differences were IgG4 in type 1 AIP (P < .01), with a sensitivity of 68% and a specificity of 80%, and c-ANCA elevations found in some type 2 AIP patients (P < .05).The only serological marker for which we found a statistically significant difference in mean values between AIP and PC was IgG4. However, the value of IgG4 for the distinction of AIP from PC was limited, probably in part due to the relatively high number of type 2 AIP patients in our study. In accord with recent publications, our data do not support a role of increased serum a-PBP for the diagnosis of AIP.
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Affiliation(s)
- Sönke Detlefsen
- Department of Pathology
- Odense Pancreas Center (OPAC), Odense University Hospital
- Institute of Clinical Research, University of Southern Denmark
| | - Jesper D. de Vos
- Institute of Clinical Research, University of Southern Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense
| | - Julia T. Tanassi
- Department of Autoimmunology and Biomarkers, Statens Serum Institute, Copenhagen
| | - Niels H. H. Heegaard
- Department of Autoimmunology and Biomarkers, Statens Serum Institute, Copenhagen
- Department of Clinical Biochemistry and Pharmacology
| | - Claus Fristrup
- Odense Pancreas Center (OPAC), Odense University Hospital
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ove B. Schaffalitzky de Muckadell
- Institute of Clinical Research, University of Southern Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense
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Cousin E, Cousin I, Aziz K, Chailloux P, Breton E. Autoimmune Pancreatitis and Ulcerative Rectocolitis in an Adolescent. Pediatrics 2018; 141:S456-S461. [PMID: 29610171 DOI: 10.1542/peds.2016-0765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 11/24/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is rare in teenagers and difficult to diagnose. There are no clear and established diagnostic criteria in the pediatric population to distinguish subtype 1 and subtype 2. Here, we report the case of a 16-year-old white French teenager admitted to the pediatric emergency service with more than 1 year's history of pain originating from the epigastric and the right hypochondriac regions, with bloody diarrhea. After exclusion of pancreatic cancer and other common causes of acute pancreatitis, the diagnosis of AIP was suspected. Biological analyses revealed acute pancreatitis with severe cholestasis and an elevated level of serum immunoglobulin G4. Magnetic resonance cholangiography revealed a voluminous pancreas presenting a typical "sausage-like" aspect. Anatomopathological analyses of the liver biopsy specimen revealed a biliary obstruction due to pancreatic involvement without the typical aspect of chronic destructive cholangitis. Corticotherapy and immunosuppressive treatment proved effective after 1 week of treatment. Without a pancreatic biopsy specimen, the distinction between AIP type 1 and 2 could not be made clearly in this case. The succession of clinical observations could allow clinicians to recognize, treat, and manage AIP in children.
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Affiliation(s)
| | - Ianis Cousin
- Department of Pediatric Surgery, Brest University Hospital, Brest, France
| | - Karim Aziz
- Gastroenterology, Saint-Brieuc Hospital, Saint-Brieuc, France; and
| | - Pascal Chailloux
- Gastroenterology, Saint-Brieuc Hospital, Saint-Brieuc, France; and
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15
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Martínez-Valle F, Orozco-Gálvez O, Fernández-Codina A. Update in ethiopathogeny, diagnosis and treatment of the IgG4 related disease. Med Clin (Barc) 2017; 151:18-25. [PMID: 29241876 DOI: 10.1016/j.medcli.2017.10.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 02/06/2023]
Abstract
IgG4 related disease (IgG4-RD) is probably an autoimmune pathology of unknown etiology. Diverse interactions participate in its pathogen between the adaptive and innate immune systems, activating lymphocytes B and T which trigger the inflammatory cascade, which culminates in fibrosis of the organs and their malfunction. It can affect a multitude of organs simultaneously. The diagnosis is based on the correlation of clinical findings with anatomopathological results (lymphoplasmocitary infiltrate, storiform fibrosis, obliterative phlebitis and IgG4+plasmatic cell count) and with the presence of elevated IgG4 in serum, depending on the criteria used. Corticoids and rituximab are among the few validated treatments available. There are multiple biomarkers and treatments in development. In this review, we aim to go over the principal pathogenic and clinical characteristics of IgG4-RD, as well as its handling, in accordance with the available scientific evidence.
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Affiliation(s)
- Fernando Martínez-Valle
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Vall Hebron, Universitat Autònoma de Barcelona, Barcelona, España; Vall d'Hebron Institut de Recerca, Barcelona, España.
| | - Olimpia Orozco-Gálvez
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Vall Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Andreu Fernández-Codina
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Vall Hebron, Universitat Autònoma de Barcelona, Barcelona, España; Vall d'Hebron Institut de Recerca, Barcelona, España; Rheumatology Division, Department of Medicine, University of Western Ontario, London, Ontario, Canadá
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16
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Heeringa JJ, Karim AF, van Laar JAM, Verdijk RM, Paridaens D, van Hagen PM, van Zelm MC. Expansion of blood IgG 4+ B, T H2, and regulatory T cells in patients with IgG 4-related disease. J Allergy Clin Immunol 2017; 141:1831-1843.e10. [PMID: 28830675 DOI: 10.1016/j.jaci.2017.07.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a systemic fibroinflammatory condition affecting various organs and has a diverse clinical presentation. Fibrosis and accumulation of IgG4+ plasma cells in tissue are hallmarks of the disease, and IgG4-RD is associated with increased IgG4 serum levels. However, disease pathogenesis is still unclear, and these cellular and molecular parameters are neither sensitive nor specific for the diagnosis of IgG4-RD. OBJECTIVE Here we sought to develop a flow cytometric gating strategy to reliably identify blood IgG4+ B cells to study their cellular and molecular characteristics and investigate their contribution in disease pathogenesis. METHODS Sixteen patients with histologically confirmed IgG4-RD, 11 patients with sarcoidosis, and 30 healthy subjects were included for 11-color flow cytometric analysis of peripheral blood for IgG4-expressing B cells and TH subsets. In addition, detailed analysis of activation markers and chemokine receptors was performed on IgG4-expressing B cells, and IgG4 transcripts were analyzed for somatic hypermutations. RESULTS Cellular and molecular analyses revealed increased numbers of blood IgG4+ memory B cells in patients with IgG4-RD. These cells showed reduced expression of CD27 and CXCR5 and increased signs of antibody maturation. Furthermore, patients with IgG4-RD, but not patients with sarcoidosis, had increased numbers of circulating plasmablasts and CD21low B cells, as well as TH2 and regulatory T cells, indicating a common disease pathogenesis in patients with IgG4-RD. CONCLUSION These results provide new insights into the dysregulated IgG4 response in patients with IgG4-RD. A specific "peripheral lymphocyte signature" observed in patients with IgG4-RD, could support diagnosis and treatment monitoring.
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Affiliation(s)
- Jorn J Heeringa
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - A Faiz Karim
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jan A M van Laar
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Robert M Verdijk
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Dion Paridaens
- Department of Oculoplastic & Orbital Surgery, The Rotterdam Eye Hospital, Rotterdam, The Netherlands
| | - P Martin van Hagen
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Menno C van Zelm
- Department of Immunology and Pathology, Central Clinical School, Monash University and Alfred Hospital, Melbourne, Australia.
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17
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Metachronous Involvement, Diagnostic Imprecision of Serum Immunoglobulin G4 Levels, and Discordance Between Clinical and Radiological Findings in Immunoglobulin G4–Related Pachymeningitis. J Clin Rheumatol 2017; 23:215-221. [DOI: 10.1097/rhu.0000000000000488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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18
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Gidwaney NG, Pawa S, Das KM. Pathogenesis and clinical spectrum of primary sclerosing cholangitis. World J Gastroenterol 2017; 23:2459-2469. [PMID: 28465630 PMCID: PMC5394509 DOI: 10.3748/wjg.v23.i14.2459] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/21/2017] [Accepted: 03/20/2017] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a disease of the biliary tract, which has been documented in the literature since 1867. This disease has a strong predilection for affecting men and can be seen in individuals as young as 2 years of age. PSC has a strong associated with inflammatory bowel disease, more commonly with ulcerative colitis, and is also part of the clinical spectrum of IgG4-related diseases. Small-duct PSC, a variant of PSC, also has an association with inflammatory bowel disease. The exact pathogenesis of PSC is not well understood at present, however, is likely a combination of a genetic predisposition with alteration of the molecular structure of the gut. Abnormal serum liver chemistry and presence of certain autoimmune markers are usually the first indicators leading to a diagnosis of PCS, however, these may often be normal in early stages of this disease. The diagnosis is made by cholangiography, which is now considered the gold standard. PSC is a known pre-malignant condition. Such patients have an increased risk of developing cholangiocarcinoma, gallbladder neoplasia, and colon cancer. Many new treatment modalities have emerged in the recent past, including anti-tumor necrosis factor- α and anti-integrins; however, liver transplantation is the only known cure for PSC. Despite past and present research, PSC remains an enigmatic biliary disease with few viable treatment options.
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Abstract
Retroperitoneal fibrosis (RPF) is a rare disease, hallmarked by inflammation and deposition of fibrous tissue around the abdominal aorta. This process may spread contiguously and involve adjacent structures, leading to many complications, among which the most frequent and most severe is ureteral obstruction. The condition usually has idiopathic origin (idiopathic retroperitoneal fibrosis – IRF), but can also develop secondarily to a number of factors. The etiology of the disease remains unclear. Current research suggests that about half of the cases of IRF may be a symptom of a recently discovered, clinically heterogeneous immunoglobulin G4-related disease (IgG4-RD). Corticosteroids are the first-line treatment for IRF, but effective attempts to use immunosuppressants are also made. This paper presents the current state of knowledge on the etiopathogenesis, clinical presentation, diagnosis and therapeutic possibilities in different forms of RPF. Based on the latest research, an analysis of the relationship between IRF and IgG4-RD was performed.
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20
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Chang DH, Wu PS, Wang YC, Lin CH, Li WY, Ma H, Perng CK. Clinicopathology of Immunoglobulin G4–Related Chronic Sclerosing Sialadenitis. Otolaryngol Head Neck Surg 2016; 155:974-981. [DOI: 10.1177/0194599816665603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/28/2016] [Accepted: 08/02/2016] [Indexed: 12/24/2022]
Abstract
Objectives To investigate the clinicopathologic characteristics of patients with immunoglobulin G4–related chronic sclerosing sialadenitis (IgG4-RCSS), a recently recognized disease. Study Design Case series with chart review and pathology study. Settings Tertiary care hospital. Subjects and Methods We evaluated chronic sialadenitis specimens obtained over 11 years using pathologic examination and IgG4 immunohistochemistry staining. The specimens were assigned a revised diagnosis of IgG4-RCSS or chronic sialadenitis not otherwise specified, and clinicopathologic data from each group were compared. Results Of the 84 patients, 21 were diagnosed with IgG4-RCSS and 63 with chronic sialadenitis not otherwise specified. IgG4-RCSS patients were older (68.2 ± 13.9 vs 54.2 ± 15.8 years, P = .001), predominantly male (85.7% vs 61.9%, P = .036), and more likely to present with painless swelling (75% vs 44.3%, P = .001) and bilateral involvement (52.4% vs 6.3%, P < .001). Ratio of IgG4-positive plasma cells to IgG-positive plasma cells in IgG4-RCSS tissues was 0.81 ± 0.14. The mean value of serum IgG4 in IgG4-RCSS patients was 918.8 mg/dL. Conclusion IgG4-RCSS is more common in older male patients and frequently presents with bilateral involvement. Informing head and neck surgeons of the clinical features of IgG4-RCSS and promoting a combined approach of clinical evaluation, imaging, and biopsy can improve the accuracy of preoperative diagnoses.
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Affiliation(s)
- Dun-Hao Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Pao-Shu Wu
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pathology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yu-Chen Wang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chin-Hsuan Lin
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pathology, Cheng Ching Hospital, Taichung City, Taiwan
| | - Wing-Yin Li
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsu Ma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chern-Kang Perng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming University, Taipei, Taiwan
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22
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Xu WL, Ling YC, Wang ZK, Deng F. Diagnostic performance of serum IgG4 level for IgG4-related disease: a meta-analysis. Sci Rep 2016; 6:32035. [PMID: 27558881 PMCID: PMC4997323 DOI: 10.1038/srep32035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/02/2016] [Indexed: 12/13/2022] Open
Abstract
An elevated serum IgG4 level is one of the most useful factors in the diagnosis of IgG4-related disease (IgG4-RD). In this study, we performed a meta-analysis of the published articles assessing the diagnostic accuracy of serum IgG4 concentrations for IgG4-RD. The databases of MEDLINE/PubMed, EMBASE and Web of Science were systematically searched for relevant studies. Sensitivities and specificities of serum IgG4 in each study were calculated, and the hierarchical summary receiver operating characteristic (HSROC) model with a random effects model were employed to obtain the individual and pooled estimates of sensitivities and specificities. In total, twenty-three studies comprising 6048 patients with IgG4-RD were included in the meta-analysis. The pooled sensitivity was 85% with a 95% confidence interval (CI) of 78-90%; the pooled specificity was 93% with a 95% CI of 90-95%. The HSROC curve for quantitative serum IgG4 lies closer to the upper left corner of the plot, and the area under the curve (AUC) was 0.95 (95% CI 0.93, 0.97), which suggested a high diagnostic accuracy of serum IgG4 for the entity of IgG4-RD. Our study suggests that serum IgG4 has high sensitivity and specificity in the diagnosis of IgG4-RD.
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Affiliation(s)
- Wen-Long Xu
- Department of Clinical Laboratory, Baoshan Branch of Shanghai Huashan Hospital, Baoshan Renhe Hospital, Shanghai 200431, China
| | - Ying-Chun Ling
- Department of Clinical Laboratory, Shaoxing Seventh People's Hospital, Zhejiang Shaoxing 312000, China
| | - Zhi-Kai Wang
- Department of Clinical Laboratory, Shanghai Family Planning Hospital, Shanghai 200032, China
| | - Fang Deng
- Department of Clinical Laboratory, Anhui Provincial Tumor Hospital, Anhui Hefei 230031, China
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Adult bile duct strictures: differentiating benign biliary stenosis from cholangiocarcinoma. Med Mol Morphol 2016; 49:189-202. [PMID: 27350291 DOI: 10.1007/s00795-016-0143-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/04/2016] [Indexed: 12/17/2022]
Abstract
Biliary epithelial cells preferentially respond to various insults under chronic pathological conditions leading to reactively atypical changes, hyperplasia, or the development of biliary neoplasms (such as biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct, and cholangiocarcinoma). Moreover, benign biliary strictures can be caused by a variety of disorders (such as IgG4-related sclerosing cholangitis, eosinophilic cholangitis, and follicular cholangitis) and often mimic malignancies, despite their benign nature. In addition, primary sclerosing cholangitis is a well-characterized precursor lesion of cholangiocarcinoma and many other chronic inflammatory disorders increase the risk of malignancies. Because of these factors and the changes in biliary epithelial cells, biliary strictures frequently pose a diagnostic challenge. Although the ability to differentiate neoplastic from non-neoplastic biliary strictures has markedly progressed with the advance in radiological modalities, brush cytology and bile duct biopsy examination remains effective. However, no single modality is adequate to diagnose benign biliary strictures because of the low sensitivity. Therefore, understanding the underlying causes by compiling the entire clinical, laboratory, and imaging data; considering the under-recognized causes; and collaborating between experts in various fields including cytopathologists with multiple approaches is necessary to achieve an accurate diagnosis.
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Zen Y, Kawakami H, Kim JH. IgG4-related sclerosing cholangitis: all we need to know. J Gastroenterol 2016; 51:295-312. [PMID: 26817943 DOI: 10.1007/s00535-016-1163-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 12/24/2015] [Indexed: 02/04/2023]
Abstract
Our knowledge and experience of IgG4-related sclerosing cholangitis (ISC) have expanded in the last decade. ISC is one of the common organ manifestations of IgG4-related disease (IgG4-RD); approximately 60 % of patients with this systemic condition have ISC in the proximal and/or distal bile ducts. ISC needs to be discriminated from primary sclerosing cholangitis, cholangiocarcinoma, and other rare forms of lymphoplasmacytic cholangiopathy (e.g., follicular cholangitis and sclerosing cholangitis with granulocytic epithelial lesions). Its diagnosis requires a multidisciplinary approach, in which serology, histology, and imaging play crucial roles. Treatments with high-dose corticosteroids typically lead to the rapid and consistent induction of disease remission. Another promising therapeutic approach is B-cell depletion with rituximab. Although disease relapse is relatively common, provided that appropriate treatments are administered, ISC is considered a "benign" disease with a low risk of liver failure and biliary malignancy. Its molecular pathology is characterized by Th2-dominant immune reactions, regulatory T-cell activation, and CCL1-CCR8 interactions. Particular subsets of B cells such as plasmablasts and regulatory B cells also expand. A recent global proteomic study demonstrated that three significantly activated immunological cascades in ISC were all B-cell- or immunoglobulin-related (Fc-gamma receptor-mediated phagocytosis, B-cell receptor signaling pathway, and Fc-epsilon receptor I signaling pathway), suggesting the crucial roles of B cells in the underlying immune reactions. Despite the expansion of our knowledge of the pathophysiology of ISC, the exact role of IgG4 remains unclear. A better understanding of its immunopathology will offer some potential drug targets for this emerging biliary disease.
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Affiliation(s)
- Yoh Zen
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Kobe, 650-0017, Japan.
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Jung Hoon Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
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Yu KH, Chan TM, Tsai PH, Chen CH, Chang PY. Diagnostic Performance of Serum IgG4 Levels in Patients With IgG4-Related Disease. Medicine (Baltimore) 2015; 94:e1707. [PMID: 26469909 PMCID: PMC4616795 DOI: 10.1097/md.0000000000001707] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The aim of this study is to study the clinical features and diagnostic performance of IgG4 in Chinese populations with IgG4-related diseases (IgG4-RDs).The medical records of 2901 adult subjects who underwent serum IgG4 level tests conducted between December 2007 and May 2014 were reviewed.Serum concentrations of IgG4 were measured in 2901 cases, including 161 (5.6%) patients with IgG4-RD and 2740 (94.4%) patients without IgG4-RD (non-IgG4-RD group). The mean age of the IgG4-RD patients was 58.4 ± 16.1 years (range: 21-87), and 48 (29.8%) were women. The mean serum IgG4 level was significantly much higher in IgG4-RD patients than in non-IgG4-RD (1062.6 vs 104.3 mg/dL, P < 0.001) participants. For IgG4 >135 mg/dL, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR)+, and LR- were 86%, 77%, 18%, 99%, 3.70, and 0.19, respectively. When the upper limit of normal was doubled for an IgG4 >270 mg/dL, the corresponding data were 75%, 94%, 43%, 98%, 12.79, and 0.26, respectively. For IgG4 >405 mg/dL (tripling the upper limit of normal), the corresponding data were 62%, 98%, 68%, 98%, 37.00, and 0.39, respectively. When calculated according to the manufacturer's package insert cutoff (>201 mg/dL) for the diagnosis of IgG4-RD, the corresponding sensitivity, specificity, PPV, NPV, LR+, and LR- were 80%, 89%, 29%, 99%, 7.00, and 0.23, respectively. For IgG4 >402 mg/dL (>2× the upper limit of the normal range), the corresponding data were 62%, 98%, 68%, 98%, 36.21, and 0.39, respectively. For IgG4 >603 mg/dL (>3× the upper limit of the normal range), the corresponding data were 50%, 99%, 84%, 97%, 90.77 and 0.51, respectively. The optimal cutoff value of serum IgG4 (measured by nephelometry using a Siemens BN ProSpec instrument and Siemens reagent) for the diagnosis of IgG4-RD was 248 mg/dL, the sensitivity and specificity were 77.6% and 92.8%, respectively.The present study demonstrated that 2 or 3 times the upper limit of the manufacturer's reference range of the IgG4 level was a useful marker for the diagnosis of various types of IgG4-RD and the optimal cutoff level was 248 mg/dL.
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Affiliation(s)
- Kuang-Hui Yu
- From the Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology (K-HY, T-MC, P-HT); Department of Laboratory Medicine, Chang Gung Memorial Hospital, and Department of Medical Biotechnology and Laboratory Science (C-HC, P-YC); and Chang Gung University, Tao-Yuan, Taiwan (K-HY, P-YC)
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Campochiaro C, Ramirez GA, Bozzolo EP, Lanzillotta M, Berti A, Baldissera E, Dagna L, Praderio L, Scotti R, Tresoldi M, Roveri L, Mariani A, Balzano G, Castoldi R, Doglioni C, Sabbadini MG, Della-Torre E. IgG4-related disease in Italy: clinical features and outcomes of a large cohort of patients. Scand J Rheumatol 2015; 45:135-45. [PMID: 26398142 DOI: 10.3109/03009742.2015.1055796] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe the clinical features, treatment response, and follow-up of a large cohort of Italian patients with immunoglobulin (Ig)G4-related disease (IgG4-RD) referred to a single tertiary care centre. METHOD Clinical, laboratory, histological, and imaging features were retrospectively reviewed. IgG4-RD was classified as 'definite' or 'possible' according to international consensus guidelines and comprehensive diagnostic criteria for IgG4-RD. Disease activity was assessed by means of the IgG4-RD Responder Index (IgG4-RD RI). RESULTS Forty-one patients (15 females, 26 males) were included in this study: 26 with 'definite' IgG4-RD and 15 with 'possible' IgG4-RD. The median age at diagnosis was 62 years. The median follow-up was 36 months (IQR 24-51). A history of atopy was present in 30% of patients. The pancreas, retroperitoneum, and major salivary glands were the most frequently involved organs. Serum IgG4 levels were elevated in 68% of cases. Thirty-six patients were initially treated with glucocorticoids (GCs) to induce remission. IgG4-RD RI decreased from a median of 7.8 at baseline to 2.9 after 1 month of therapy. Relapse occurred in 19/41 patients (46%) and required additional immunosuppressive drugs to maintain long-term remission. Multiple flares occurred in a minority of patients. A single case of orbital pseudotumour did not respond to medical therapy and underwent surgical debulking. CONCLUSIONS IgG4-RD is an elusive inflammatory disease to be considered in the differential diagnosis of isolated or multiple tumefactive lesions. Long-term disease control can be achieved with corticosteroids and immunosuppressive drugs in the majority of cases.
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Affiliation(s)
- C Campochiaro
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - G A Ramirez
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - E P Bozzolo
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - M Lanzillotta
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - A Berti
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - E Baldissera
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - L Dagna
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - L Praderio
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - R Scotti
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - M Tresoldi
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - L Roveri
- c Division of Gastroenterology and Gastrointestinal Endoscopy , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - A Mariani
- d Pancreas Unit, Department of Surgery , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - G Balzano
- e Pathology Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - R Castoldi
- e Pathology Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - C Doglioni
- e Pathology Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - M G Sabbadini
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - E Della-Torre
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
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Theofilos D, Triantafillidou C, Zetos A, Bisirtzoglou D, Konstantinou F, Marketos C, Politis G. A 44-Year-Old Man With Chronic Cough, Weakness, and a Mediastinum Mass. Chest 2015; 148:e86-e90. [DOI: 10.1378/chest.14-2982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Abstract
PURPOSE OF REVIEW There are two distinct steroid responsive chronic fibro-inflammatory diseases of the pancreas, called type 1 and type 2 autoimmune pancreatitis (AIP). We review recent progress in this field. RECENT FINDINGS It has recently been suggested that the term AIP be used to describe type 1 AIP and the term idiopathic duct-centric chronic pancreatitis (IDCP) be used for type 2 AIP. Clinical features and long-term outcomes of AIP and IDCP are well characterized and prognosis of both diseases is excellent. Diagnostic strategies tailored to regional practice patterns have emerged with the application of International Consensus Diagnostic Criteria for AIP. Although corticosteroids remain the mainstay of treatment, management of relapses and strategies for preventing multiple relapses are better understood, including the role of maintenance therapy and B-cell depletion therapy with rituximab. Association studies with malignancies have yielded conflicting results regarding risk of cancer in AIP. SUMMARY The treatment, follow-up guidelines and associations continue to evolve with our increasing experience with both AIP and IDCP. In AIP, rituximab can be used for both induction and maintenance of remission. IDCP responds to steroids without need for maintenance therapy. Both AIP and IDCP have excellent prognosis.
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Hart PA, Zen Y, Chari ST. Recent Advances in Autoimmune Pancreatitis. Gastroenterology 2015; 149:39-51. [PMID: 25770706 DOI: 10.1053/j.gastro.2015.03.010] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/26/2015] [Accepted: 03/03/2015] [Indexed: 12/14/2022]
Abstract
Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that is characterized clinically by frequent presentation with obstructive jaundice, histologically by a dense lymphoplasmacytic infiltrate with fibrosis, and therapeutically by a dramatic response to corticosteroid therapy. Two distinct diseases, type 1 and type 2 AIP, share these features. However, these 2 diseases have unique pancreatic histopathologic patterns and differ significantly in their demographic profiles, clinical presentation, and natural history. Recognizing the popular and long-standing association of the term "AIP" with what is now called "type 1 AIP," we suggest using "AIP" solely for type 1 AIP and to acknowledge its own distinct disease status by using "idiopathic duct-centric chronic pancreatitis" (IDCP) for type 2 AIP. AIP is the pancreatic manifestation of immunoglobulin G4-related disease (IgG4-RD). The etiopathogenesis of AIP and IgG4-RD is largely unknown. However, the remarkable effectiveness of B-cell depletion therapy with rituximab in patients with AIP and IgG4-RD highlights the crucial role of B cells in its pathogenesis. IDCP is less commonly recognized, and little is known about its pathogenesis. IDCP has no biomarker but is associated with inflammatory bowel disease in ~25% of patients. Recently, the international consensus diagnostic criteria for AIP identified combinations of features that are diagnostic of both diseases. Both AIP and IDCP are corticosteroid responsive; however, relapses are common in AIP and rare in IDCP. Therefore, maintenance therapy with either an immunomodulator (eg, azathioprine, 6-mercaptopurine, or mycophenolate mofetil) or rituximab is often necessary for patients with AIP. Long-term survival is excellent for both patients with AIP and patients with IDCP.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yoh Zen
- Department of Diagnostic Pathology, Kobe University, Kobe, Japan
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Hong X, Sun ZP, Li W, Chen Y, Gao Y, Su JZ, Wang Z, Cai ZG, Li TT, Zhang L, Liu XJ, Liu YY, He J, Li ZG, Yu GY. Comorbid diseases of IgG4-related sialadenitis in the head and neck region. Laryngoscope 2015; 125:2113-8. [PMID: 25994602 DOI: 10.1002/lary.25387] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Xia Hong
- Department of Oral and Maxillofacial Surgery
| | | | - Wei Li
- Department of Oral and Maxillofacial Surgery
| | - Yan Chen
- Department of Oral Pathology; Peking University School and Hospital of Stomatology; Beijing China
| | - Yan Gao
- Department of Oral Pathology; Peking University School and Hospital of Stomatology; Beijing China
| | - Jia-Zeng Su
- Department of Oral and Maxillofacial Surgery
| | - Zhen Wang
- Department of Oral and Maxillofacial Surgery
| | | | | | - Lei Zhang
- Department of Oral and Maxillofacial Surgery
| | | | - Yan-Ying Liu
- Department of Rheumatology and Immunology; Peking University People's Hospital; Beijing China
| | - Jing He
- Department of Rheumatology and Immunology; Peking University People's Hospital; Beijing China
| | - Zhan-Guo Li
- Department of Rheumatology and Immunology; Peking University People's Hospital; Beijing China
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Serum IgG4 elevation in pancreatic cancer: diagnostic and prognostic significance and association with autoimmune pancreatitis. Pancreas 2015; 44:557-60. [PMID: 25785724 DOI: 10.1097/mpa.0000000000000297] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Serum IgG4 (sIgG4) elevation, more common to autoimmune pancreatitis (AIP), occurs in some patients with pancreatic cancer (PaC). We investigated whether sIgG4 could differentiate AIP from PaC, its role in prognostication, and the concomitant occurrence of AIP and PaC. METHODS We identified all patients with PaC (n = 548) and with type 1 AIP (n = 99) with sIgG4 measurements from 2001 to 2011. We compared demographics and sIgG4 profiles in these groups. Among patients with PaC, we compared resectability and mortality with and without elevated sIgG4. We reviewed AIP and PaC tissue specimens to identify concomitant occurrence of both diseases. RESULTS Patients with AIP were more likely to have elevation in sIgG4 (65% vs 10.4%, P < 0.001) and sIgG4 more than 2 times upper limit of normal (40% vs 2.4%, P < 0.001). Patients with PaC with sIgG4 elevation were more commonly male compared with those with normal sIgG4 (81% vs 53%). Both groups were similarly aged with similar rates of resectability and mortality. No evidence of concurrent PaC and AIP was found. CONCLUSIONS Mild elevations in sIgG4 cannot distinguish AIP from PaC. Elevations more than 2 times upper limit of normal appear more commonly in AIP. Serum IgG4 elevation has no prognostic significance in PaC. We could not identify a relationship between AIP and PaC.
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Su Y, Sun W, Wang C, Wu X, Miao Y, Xiong H, Bai L, Dong L. Detection of serum IgG4 levels in patients with IgG4-related disease and other disorders. PLoS One 2015; 10:e0124233. [PMID: 25885536 PMCID: PMC4401680 DOI: 10.1371/journal.pone.0124233] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/28/2015] [Indexed: 12/31/2022] Open
Abstract
Objective Elevated serum IgG4 levels are an important hallmark for diagnosing IgG4-related disease (IgG4-RD), but can also be observed in other diseases. This study aimed to compare two different testing methods for IgG4: ELISA and nephelometric assay. Both assays were used to measure serum IgG4 concentrations, and to assess the prevalence of high serum IgG4 levels in both IgG4-RD and non-IgG4-RD diseases. Methods A total of 80 serum samples were tested using the nephelometric assay and ELISA method that we established. Serum IgG4 concentrations were determined by ELISA for 957 patients with distinct diseases, including 12 cases of IgG4-RD and 945 cases of non-IgG4-RD. Results IgG4 levels from 80 selected serum samples examined by ELISA were in agreement with those detected using the nephelometry assay. Meanwhile, the serum IgG4 concentrations measured by ELISA were also consistent with the clinical diagnoses of patients with IgG4-RD during the course of disease. The Elevated levels of serum IgG4 (>1.35 g/L) were detected in all IgG4-RD (12/12) patients, and the prevalence of high IgG4 serum levels was 3.39% in non-IgG4-RD cases. Among them, the positive rates of serum IgG4 were 2.06% in patients with carcinoma and 6.3% in patients with other non-IgG4 autoimmune diseases. Conclusion Our established ELISA method is a reliable and convenient technique, which could be extensively used in the clinic to measure serum IgG4 levels. High levels of IgG4 were observed in IgG4-RD. However, this phenomenon could also be observed in other diseases, such as carcinomas and other autoimmune diseases. Thus, a diagnosis of IgG4 disease cannot only be dependent on the detection of elevated serum IgG4 levels.
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Affiliation(s)
- Yuying Su
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Sun
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chenqiong Wang
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xuefen Wu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ye Miao
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hui Xiong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lin Bai
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail:
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Carruthers MN, Topazian MD, Khosroshahi A, Witzig TE, Wallace ZS, Hart PA, Deshpande V, Smyrk TC, Chari S, Stone JH. Rituximab for IgG4-related disease: a prospective, open-label trial. Ann Rheum Dis 2015; 74:1171-7. [PMID: 25667206 DOI: 10.1136/annrheumdis-2014-206605] [Citation(s) in RCA: 422] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 01/06/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the efficacy of rituximab (RTX) in IgG4-related disease (IgG4-RD) in an open-label pilot trial. METHODS We treated 30 IgG4-RD patients with two doses of RTX (1000 mg each). The participants were either treated with RTX alone (n = 26; 87%) or required to discontinue baseline glucocorticoids (GC) within 2 months (n = 4; 13%). Disease activity was measured by the IgG4-RD Responder Index (IgG4-RD RI) and physician's global assessment (PGA). Disease response was defined as the improvement of the IgG4-RD RI by two points. The primary outcome, measured at 6 months, was defined as: (1) decline of the IgG4-RD RI ≥2 points compared with baseline; (2) no disease flares before month 6; and (3) no GC use between months 2 and 6. Complete remission was defined as an IgG4-RD RI score of 0 with no GC use. RESULTS Disease responses occurred in 97% of participants. The baseline IgG4-RD RI and PGA values, 11±7 and 63±22 mm, respectively, declined to 1±2 and 11±16 mm at 6 months (both p<0.00001). The primary outcome was achieved by 23 participants (77%). Fourteen (47%) were in complete remission at 6 months, and 12 (40%) remained in complete remission at 12 months. Among the 19 with elevated baseline serum IgG4, IgG4 concentrations declined from a mean of 911 mg/dL (range 138-4780 mg/dL) to 422 mg/dL (range 56-2410 mg/dL) at month 6 (p<0.05). However, only 8 (42%) of the 19 achieved normal values. CONCLUSIONS RTX appears to be an effective treatment for IgG4-RD, even without concomitant GC therapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT01584388.
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Affiliation(s)
- Mollie N Carruthers
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Arezou Khosroshahi
- Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas E Witzig
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachary S Wallace
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Philip A Hart
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Thomas C Smyrk
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Hart PA, Smyrk TC, Chari ST. Lymphoplasmacytic sclerosing pancreatitis without IgG4 tissue infiltration or serum IgG4 elevation: IgG4-related disease without IgG4. Mod Pathol 2015; 28:238-47. [PMID: 25081756 DOI: 10.1038/modpathol.2014.91] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 12/24/2022]
Abstract
Type 1 autoimmune pancreatitis can be diagnosed by and is synonymous with its pathognomonic histopathologic appearance called lymphoplasmacytic sclerosing pancreatitis. Type 1 autoimmune pancreatitis, also called IgG4-related pancreatitis, is the pancreatic manifestation of IgG4-related disease. However, the role of IgG4 in the pathogenesis of IgG4-related disease is unclear. We describe patients with LPSP without serum or tissue IgG4 abnormalities. From the Mayo Clinic database of autoimmune pancreatitis patients, we identified three patients with histologically confirmed type 1 autoimmune pancreatitis (lymphoplasmacytic sclerosing pancreatitis) who had normal serum IgG4 and no increase in IgG4-positive plasma cells in tissue. We reviewed original clinical records and pathologic specimens, and describe the clinical and histologic features of these three patients. All patients (age/gender: 63/F, 70/M and 68/M) had normal serum IgG and IgG4 levels, and multiple sections of pancreatic histology did not show increased IgG4-positive plasma cells. Two patients were diagnosed retrospectively following pancreatic surgery, one relapsed in another organ and one has remained relapse free. Another patient was diagnosed by pancreatic core biopsy and has suffered multiple relapses that have been controlled by rituximab. These cases highlight the fact that although the currently agreed upon name for type 1 autoimmune pancreatitis is IgG4-related pancreatitis, serum and tissue IgG4 abnormalities are best considered characteristic, but not essential for the diagnosis of this enigmatic condition.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Thomas C Smyrk
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Yun J, Wienholt L, Adelstein S. Poor positive predictive value of serum immunoglobulin G4 concentrations in the diagnosis of immunoglobulin G4-related sclerosing disease. Asia Pac Allergy 2014; 4:172-6. [PMID: 25097853 PMCID: PMC4116044 DOI: 10.5415/apallergy.2014.4.3.172] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/10/2014] [Indexed: 01/01/2023] Open
Abstract
Background Immunoglobulin G4 (IgG4)-related sclerosing disease is a recently described clinicopathological entity with diverse manifestations including, amongst others, autoimmune pancreatitis, sclerosing cholangitis, sclerosing sialadenitis and retroperitoneal fibrosis. Elevated serum IgG4 concentration has been described as the hallmark of this condition with reported good sensitivity and specificity. Objective We sought to establish the utility of serum IgG4 concentrations in the diagnosis of IgG4-related sclerosing disease by determining how many serum samples with elevated IgG4 from an unselected population would originate from patients who fulfilled criteria for this diagnosis. Methods The clinical features and laboratory characteristics of patients whose serum IgG4 concentration was greater than 1.30 g/L were analysed retrospectively from a total of 1,258 IgG subclass measurements performed in a tertiary hospital diagnostic laboratory. Results Eighty patients (6.4%) had elevated IgG4 concentrations greater than 1.30 g/L. Nine of 61 patients had the diagnosis of IgG4-related sclerosing disease, giving a poor positive predictive value of 15%. The median serum IgG4 concentrations of those with and without IgG4-related sclerosing disease were 2.16 g/L and 1.86 g/L, respectively (p = 0.22). Conclusion Serum IgG4 concentration has poor positive predictive value in the diagnosis of IgG4-related sclerosing disease and, therefore, the clinical significance of elevated serum IgG4 concentration alone must be interpreted with caution.
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Affiliation(s)
- James Yun
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Louise Wienholt
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Stephen Adelstein
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
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Pieringer H, Parzer I, Wöhrer A, Reis P, Oppl B, Zwerina J. IgG4- related disease: an orphan disease with many faces. Orphanet J Rare Dis 2014; 9:110. [PMID: 25026959 PMCID: PMC4223520 DOI: 10.1186/s13023-014-0110-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/03/2014] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin G4- related disease (IgG4-RD) is a rare systemic fibro-inflammatory disorder (ORPHA284264). Although patients have been described more than 100 years ago, the systemic nature of this disease has been recognized in the 21st century only. Type 1 autoimmune pancreatitis is the most frequent manifestation of IgG4-RD. However, IgG4-RD can affect any organ such as salivary glands, orbits, retroperitoneum and many others. Recent research enabled a clear clinical and histopathological description of IgG4-RD. Typically, lymphoplasmacellular inflammation, storiform fibrosis and obliterative phlebitis are found in IgG4-RD biopsies and the tissue invading plasma cells largely produce IgG4. Elevated serum IgG4 levels are found in many but not all patients. Consequently, diagnostic criteria for IgG4-RD have been proposed recently. Treatment is largely based on clinical experience and retrospective case series. Glucocorticoids are the mainstay of therapy, although adjunctive immunosuppressive agents are used in relapsing patients. This review summarizes current knowledge on clinical manifestations, pathophysiology and treatment of IgG4-RD.
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