Concomitant occurrence of Mikulicz's disease and immunoglobulin G4-related chronic rhinosinusitis: a clinicopathological study of 12 cases

New insights into chronic rhinosinusitis associated with IgG4-related disease

IgG4-related disease (IgG4-RD) is a chronic inflammatory disorder characterized by elevated IgG4 serum levels, abundant IgG4-positive plasmacyte infiltration, and fibrosis of various organs, including the head and neck. We aimed to provide an overall review of IgG4-RD in the sinonasal region and propose a novel entity and criteria of chronic rhinosinusitis (CRS) associated with IgG4-RD as "IgG4-CRS," a distinct manifestation of IgG4-RD in the sinonasal region. Sinonasal involvement has been increasingly recognized; however, this region is not included in the classic IgG4-RD-affected organs. The clinical features of IgG4-CRS, including its prevalence and relationship with allergies and olfactory disturbances, have also been explored. Serum IgG4 levels and IgG4-positive plasma cell infiltrations, crucial diagnostic factors, have been discussed in association with IgG4-CRS pathogenesis. Fibrosis, a hallmark of IgG4-RD, is observed in sinonasal tissues; however, typical fibrosis, such as storiform fibrosis, is not usually found. Mimics or complications in eosinophilic CRS (ECRS) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are highlighted. Treatment often involves typically effective glucocorticoids. Organ-specific diagnostic criteria for the sinonasal region have not currently been established. Hence, this review aims to foster awareness and understanding of IgG4-CRS among ENT physicians and to provide a basis for future research and diagnostic refinement.

Implication of allergy and atopy in IgG4-related disease

Immunoglobulin G4-related disease (IgG4-RD) is a chronic multi-organic immune fibrosing disease. It affects preferentially men around middle age and almost any organs can be involved; however, lymph nodes, submandibular and lacrimal glands, pancreas, and retroperitoneum are the most affected. The mainstay treatment is corticosteroids, sometimes adjuncts with DMARDs or rituximab as steroid sparing agents. Th2 inflammation is implicated in the pathophysiology of the disease. Several reports indicate that allergy and/or atopy often affect patients with IgG4-RD. The frequency varies greatly between studies with allergies/allergic diseases reported in 18-76% while atopy is reported in 14-46%. In studies including both, they affect 42 and 62% of patients. Rhinitis and asthma are the most frequent allergic diseases. IgE and blood eosinophiles are often elevated and few studies report that basophils and mast cells could participate in the disease pathogenesis; however, the implication of allergy and atopy remain unclear. No common allergen has been identified and IgG4 production seems to be polyclonal. Although a direct causal effect is unlikely, they could potentially shape the clinical phenotype. Allergies/allergic diseases and/or atopy are reported to be more frequent in IgG4-RD patients presenting head, neck, and thoracic involvement, with higher IgE and eosinophils and less frequent in retroperitoneal fibrosis; however, studies regarding allergy and atopy in IgG4-RD are highly heterogenous. The aim of this article is to review what is currently known about the allergy and atopy in the context of Ig4-RD.

Chronic Upper Eyelid Oedema in a Young Boy: A Quiz

Abstract is missing (Quiz)

Serum immunoglobulin G4 has limited diagnostic value in immunoglobulin G4-related chronic rhinosinusitis

PURPOSE

To investigate the profiles and factors influencing serum IgG4 levels and evaluate the diagnostic value of serum IgG4 in IgG4-related CRS.

METHODS

This was a prospective study analyzing data from 288 hospitalized CRS patients who had undergone endoscopic sinus surgery from July 1, 2017 to August 31, 2018. Data were analyzed for correlations between elevated serum IgG4 concentrations (> 135 mg/dL) and clinical symptoms (nasal congestion, rhinorrhea, loss of smell, headache and/or facial pain), endoscopic presentation (Lund-Kennedy scores), allergic status (total and allergen-specific IgE), and pathological features (IgG4+ and IgG+ cells).

RESULTS

Overall, 43/288 (14.9%) CRS patients had elevated serum IgG4 levels > 135 mg/dL. Comparison of the clinical parameters between patients with elevated and normal serum IgG4 levels demonstrated serum total IgE levels to be significantly different (P = 0.003) between the two groups; and significantly correlated with serum IgG4 level in CRS subjects (P = 0.000; r = 0.232), particularly CRS patients with nasal polyps (P = 0.000; r = 0.259). In contrast, the ratio of plasmocyte/inflammatory cells and IgG4+ cells/IgG+ plasmocytes, and IgG4+ plasma cells/HPF in sinus mucosa were not significantly different between the groups and no patient with elevated serum IgG4 demonstrated ratio of IgG4+ /IgG+ cells > 40% or > 10 IgG4+ plasma cells/HPF.

CONCLUSION

Serum IgG4 concentration is not related to the clinical phenotype of CRS and is likely to be of limited value when used alone in the diagnosis of IgG4-related CRS.

The prevalence of extra-salivary gland complications in immunoglobulin G4-related sialadenitis

OBJECTIVES

To estimate the prevalence of extra-glandular lesions in patients with immunoglobulin G4-related sialadenitis (IgG4-RS).

METHODS

Six electronic databases (PubMed, EMBASE, Science Direct, Scopus, Web of Science, and China National Knowledge Infrastructure) were systematically searched from the date of inception of each database to March 2021. The Strengthening the Reporting of Observational Studies in Epidemiology statement was used to conduct methodological quality assessment, and a random-effect meta-analysis model was applied to estimate the prevalence. Publication bias was visually assessed using a funnel plot and calculated via Begg's and Egger's tests. The Stata 15 software was used to perform data analysis.

RESULTS

A total of 43 articles comprising 1,864 patients with IgG4-RS were considered to be eligible for this study. The pooled prevalence of extra-salivary gland lesions in IgG4-RS was 76.53% with a confidence interval (CI) of (69.39%, 83.04%). A higher prevalence was associated with studies published before or during 2015 (84.38%, CI [74.23%, 92.58%]) than those published after 2015 (68.55%, CI [58.44%, 77.88%]). Lacrimal gland involvement (54.68%, CI [45.61%, 63.60%]) and lymph node swelling (56.96%, CI [48.16%, 65.56%]) were the most frequent lesions.

CONCLUSIONS

Extra-glandular lesions were common in patients with IgG4-RS. More high-quality prospective studies with less heterogeneity are required to determine the accurate prevalence.

Immunoglobulin G4 (IgG4)-Related Sialadenitis and Dacryoadenitis With Chronic Rhinosinusitis

Immunoglobulin G4-related disease (IgG4-RD) is a new disease entity of rare and complex immune-mediated fibroinflammatory conditions that can affect any organ. The concomitance of IgG4 sclerosing sialadenitis and dacryoadenitis with rhinosinusitis is extremely rare. We report a case of IgG4 sclerosing sialadenitis and dacryoadenitis (Mikulicz's disease) diagnosed in a middle-aged African American man with a long-standing history of chronic rhinosinusitis who presented with progressively worsening bilateral salivary and lacrimal glands swelling. Imaging revealed pansinusitis, symmetric enlargement of the lacrimal glands, parotid glands, and submandibular glands. Serological IgG4 level was significantly elevated and the diagnosis of IgG4 sclerosing sialadenitis was confirmed by histopathology. A robust clinical response in the facial swelling and nasal manifestations was noted after the initiation of immunotherapy with corticosteroids.

Five Cases of IgG4-related Disease with Nasal Mucosa and Sinus Involvement

We herein report five patients with nasal mucosa and sinus involvement who were diagnosed with immunoglobulin G4-related disease (IgG4-RD). In all cases, the lacrimal, parotid, and submandibular glands were swollen; biopsies of these glands were risky, so the labium and nasal mucosa were instead targeted. All patients tested positive through these biopsies, suggesting alternative sites for confirming IgG4-RD. These five patients had first been diagnosed and unsuccessfully treated for allergic rhinitis or chronic sinusitis. After the IgG4-RD diagnosis, they were administered corticosteroid therapy, which drastically improved the nasal mucosa and sinus involvement. When refractory allergic rhinitis or sinusitis is detected, IgG4-RD should be considered.

Chinese Society of Allergy and Chinese Society of Otorhinolaryngology-Head and Neck Surgery Guideline for Chronic Rhinosinusitis

The current document is based on a consensus reached by a panel of experts from the Chinese Society of Allergy and the Chinese Society of Otorhinolaryngology-Head and Neck Surgery, Rhinology Group. Chronic rhinosinusitis (CRS) affects approximately 8% of Chinese adults. The inflammatory and remodeling mechanisms of CRS in the Chinese population differ from those observed in the populations of European descent. Recently, precision medicine has been used to treat inflammation by targeting key biomarkers that are involved in the process. However, there are no CRS guidelines or a consensus available from China that can be shared with the international academia. The guidelines presented in this paper cover the epidemiology, economic burden, genetics and epigenetics, mechanisms, phenotypes and endotypes, diagnosis and differential diagnosis, management, and the current status of CRS in China. These guidelines-with a focus on China-will improve the abilities of clinical and medical staff during the treatment of CRS. Additionally, they will help international agencies in improving the verification of CRS endotypes, mapping of eosinophilic shifts, the identification of suitable biomarkers for endotyping, and predicting responses to therapies. In conclusion, these guidelines will help select therapies, such as pharmacotherapy, surgical approaches and innovative biotherapeutics, which are tailored to each of the individual CRS endotypes.

Significance of peripheral eosinophilia for diagnosis of IgG4-related disease in subjects with elevated serum IgG4 levels

OBJECTIVES

In this study, we aim to assess the diagnostic utility of elevated serum IgG4 (sIgG4) concentration alone and in combination with peripheral eosinophilia (PE) for IgG4-related disease (IgG4-RD).

METHODS

From the Mayo Clinic, Rochester electronic medical record database we identified 409 patients with above normal levels of sIgG4 (reference range 121-140 mg/dL) who had sIgG4 measured to differentiate IgG4-RD from another disease.

RESULTS

Among 409 patients with any elevation in sIgG4 levels, 129 (31.5%) had a definite diagnosis of IgG4-RD. The prevalence of PE increased with increasing sIgG4 levels and was more likely to be seen in subjects with IgG4-RD vs. non-IgG4-RD at ≥1X (n = 35/120, 29.2% vs. n = 23/258, 8.9%; p < 0.001), ≥2X (n = 23/64, 35.9% vs. n = 5/54,9.3%; p = 0.001) and ≥3X (n = 18/42, 42.9% vs. n = 0/9, 0%; p = 0.015) of sIgG4 upper limit of normal (ULN), respectively. After adjusting for gender and age, sIgG4 levels ≥ 2X ULN with PE as a predictor, had a higher positive predictive value in predicting IgG4-RD (72.2% vs. 65.9%) with an Area Under the Receiver Operatic Characteristic Curve (AUC) of 0.776, compared to sIgG4 ≥ 2X ULN without PE predictor (AUC = 0.74), p = 0.016. PE, sIgG4≥2X ULN, male gender, and age independently predicted the disease with odds ratio of 4.89 (95% CI:2.51-9.54), 3.78 (95% CI:2.27-6.28), 2.78 (95% CI:1.55-4.97), and 1.03 (95% CI:1.02-1.05), respectively.

CONCLUSION

Even in subjects in whom IgG4-RD is suspected, only a minority (∼30%) with elevated sIgG4 levels have IgG4-RD. sIgG4 by itself is more specific at higher levels, though never diagnostic. PE increases with increasing sIgG4 and adds diagnostic value at higher sIgG4 levels.

IgG4-related disease: association between chronic rhino-sinusitis and systemic symptoms

PURPOSE

The objective of this study is to analyze the relationship between chronic rhino-sinusitis (CRS) and systemic symptoms in patients with IgG4-related disease (IgG4-RD).

PATIENTS AND METHODS

The patients with IgG4-RD, confirmed by restrict association with clinical and histopathological manifestations between March 2013 and July 2016, were enrolled and followed-up for 1 year at the Tongren Hospital, Capital Medical University. The patients were divided into two groups: the case group included IgG4-RD patients with CRS confirmed by clinical and imaging, while the control group included IgG4-RD patients without CRS confirmed by clinical and imaging. Age, gender, clinical manifestations, the percentage of eosinophils in peripheral blood, sedimentation (ESR), C-reaction protein, serum IgE and IgG4 levels, histopathology, and treatment drugs at the baseline and 1 year of follow-up were compared between the two groups.

RESULTS

A total of 46 cases met the diagnostic criteria for IgG4-RD. A total of 30 patients (65.2%) had IgG4-RD complicated with CRS, and were aged 49.7 ± 13.4 years, with male:female ratio = 2:1. The disease duration in the case group was longer than that in the control group (3.0 versus 0.8, p = 0.009). The ratio of ocular involvement was higher (86.7 versus 60%, p < 0.001), and allergic manifestations including drug allergy, asthma, and allergic skin were more common (56.5 versus 20%, p = 0.004), with a higher percentage of eosinophils in peripheral blood (8.5 versus 3.3%, p = 0.018) and more sensitive to glucocorticoids (6.0 versus 3.5, p = 0.004) than those in the control group.

CONCLUSIONS

CRS in patients with IgG4-RD was closely associated with IgG4-related ocular lesions, which was more prone to allergic manifestations accompanied by raised percentage of eosinophils in peripheral blood. The treatment of patients with IgG4-RD complicated with CRS was more effective than those with IgG4-RD without CRS.

Immunoglobulin G4-related chronic rhinosinusitis: a pitfall in the differential diagnosis of granulomatosis with polyangiitis, Rosai-Dorfman disease, and fungal rhinosinusitis

Immunoglobulin G4 (IgG4)-related chronic rhinosinusitis (CRS) has recently been proposed to be a new clinical entity of nasal disease, with no consensually agreed criteria for diagnosis. Moreover, the pathological features of IgG4-related CRS often overlap with other sinonasal inflammatory and autoimmune diseases such as granulomatosis with polyangiitis (GPA), Rosai-Dorfman disease (RDD) and fungal rhinosinusitis (FRS). We aimed to explore the specific similarities and differences in clinicopathologic features between IgG4-related CRS, and GPA, RDD and FRS, in order that these conditions can be diagnosed more accurately. Biopsy specimens collected from nasal mucosa of 20 IgG4-related CRS, 10 GPA, 10 RDD and 10 FRS patients were assessed by hematoxylin and eosin staining and immunohistochemical techniques for specific histochemical differences. The number of IgG4-positive plasma cells /high-power fields (HPF) in biopsies from IgG4-related CRS patients (mean=79.6±51.59; range=15/HPF to 230/HPF) was significantly higher than in biopsies from GPA (mean=13±9.428; P<.0001) and RDD (mean=12.5± 8.267; P<.0001) patients, but not from FRS (mean=47.4±26.48; P>.05) patients. Similarly, the ratio of IgG4/IgG-positive plasmacytes was >40% in 90% (18/20) of IgG4-related CRS patients, compared to >40% in 10% (1/10) of GPA patients, 20% (2/10) of RDD patients and 20% (2/10) of FRS patients. The sinonasal diseases GPA, RDD and FRS might present with similar histopathologic features such as the increased numbers of plasma cells and fibrosis, which are characteristic of IgG4-related CRS. A comprehensive consideration combining the clinical signs and symptoms with a histopathological assessment of IgG4-positive plasma cells may provide accurate diagnoses of these conditions.

Imaging of IgG4-related disease of the head and neck

IgG4-related disease is a systemic, inflammatory disorder typically involving multiple organ systems. Several eponymous conditions described previously in the clinical and radiology literature are now recognised to be part of the IgG4-related disease spectrum. This includes multiple manifestations in the head and neck region, which are the subject of this review. Imaging can occasionally suggest the specific diagnosis of IgG4 disease. More commonly, it will be included in a limited differential diagnosis that requires clarification with the aid of image-guided biopsy. There are strict histopathological criteria for the diagnosis of IgG4-related disease.

Recent advances in knowledge regarding the head and neck manifestations of IgG4-related disease

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.