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Chen S, Zhang H, Fang F, Ye C, Zhang K. Characteristics of mass-forming autoimmune pancreatitis commonly misdiagnosed as a malignant tumor. Front Surg 2023; 10:1017621. [PMID: 36761026 PMCID: PMC9905684 DOI: 10.3389/fsurg.2023.1017621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023] Open
Abstract
Objective This study aimed to explore the clinical characteristics and differential diagnosis of patients with autoimmune pancreatitis (AIP) and pancreatic cancer to prevent misdiagnosis and mistreatment. Methods The clinical data of patients with AIP with suspected pancreatic or bile duct malignancy and pancreatic cancer were retrospectively analyzed. The risk factors and the diagnostic value of IgG4 and Tbil levels before treatment for AIP was investigated. Moreover, the imaging features and response to hormone therapy were analyzed. Results AIP was commonly observed in men. Compared to patients with pancreatic cancer, the incidence of poor appetite and weight loss and carbohydrate antigen 19-9 (CA19-9) level was lower in patients with AIP, while the immunoglobulin G4 (IgG4) level was higher (p < 0.05). After treatment, the IgG4 and CA19-9 levels in patients with AIP were decreased (p < 0.001). IgG4 level before treatment (OR = 2.452, 95%CI: 1.180-5.096, P = 0.016) and total bilirubin (Tbil) level before treatment (OR = 0.992, 95%CI: 0.985-0.998, P = 0.013) were independent risk factors of AIP. Furthermore, the diagnostic value of IgG4 level before treatment, Tbil level before treatment, IgG4/Tbil before treatment, and a combination of these indicators was high. Moreover, 15 (68.18%) patients with AIP had space-occupying lesions of the pancreas, and 16 (72.73%) had autoimmune cholangitis. Most patients with AIP were sensitive to hormone therapy. Conclusions The Tbil and IgG4 levels, imaging findings, and hormone therapy reactivity could differentiate AIP from pancreatic cancer. A combination of IgG4, Tbil, and IgG4/Tbil before treatment might be a promising diagnostic biomarker for AIP.
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Affiliation(s)
- Si Chen
- Department of Gastroenterology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China,Correspondence: Si Chen Kaiguang Zhang
| | - Hanlei Zhang
- Department of Gastroenterology, the Affiliated Provincial Hospital, Anhui Medical University, Hefei, China
| | - Fang Fang
- Department of Gastroenterology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chao Ye
- Department of Gastroenterology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Kaiguang Zhang
- Department of Gastroenterology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China,Correspondence: Si Chen Kaiguang Zhang
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2
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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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3
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Deng Y, Wang J, Zou G, Liu Z, Xu J. The characteristics and clinical significance of elevated serum IgG4/IgG levels in patients with Graves' disease. Endocrine 2022; 75:829-836. [PMID: 34773561 DOI: 10.1007/s12020-021-02935-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aims to further explore the clinical and laboratory characteristics of patients with GD with high serum IgG4 based on the IgG4/IgG ratio. METHODS This study is a prospective observational study. A total of 25 normal controls and 84 people newly diagnosed with GD were enrolled in this study. Taking the IgG4/IgG ratio of 8% as the cutoff value, the experimental groups were further divided into two subgroups: the high IgG4/IgG subgroup and the normal IgG4/IgG subgroup. We evaluated the differences in clinical characteristics and laboratory parameters between the groups. RESULTS The IgG4, IgG4/IgG, and IL-17 of the newly diagnosed GD group were significantly higher than those of the normal control group (P < 0.05). The differences in age, IL-1β, IL-17, and eosinophil count between the high IgG4/IgG subgroup and the normal IgG4/IgG subgroup were statistically significant (P < 0.05). After ATD treatment, some patients developed allergies; the high IgG4/IgG subgroup was significantly higher than the normal IgG4/IgG subgroup (χ2 = 4.424, P = 0.035). After 3 months of ATD treatment in patients with GD, the TRAb in the normal IgG4/IgG subgroup were significantly lower than before (P < 0.05), while the difference in the high IgG4/IgG subgroup was not statistically significant (P > 0.05). CONCLUSIONS A small portion of patients with GD harbored elevated serum IgG4/IgG levels. They are younger, have higher eosinophils, and are more prone to allergies; also, they have higher levels of cytokines IL-1β and IL-17 and their remission is not easily attained after treatment with ATD; this could be due to the instability of the Th17/Treg cell balance.
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Affiliation(s)
- Yuanyuan Deng
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China
| | - Jiao Wang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China
| | - Guilin Zou
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China
| | - Zelin Liu
- Department of Endocrinology and Metabolism, Fourth Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Jixiong Xu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China.
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Wu Q, Hang C, Li T, Wang B, Qin Y, Wang Y, Zhou X, Xia P, Sheng H, Huang P, Huang B. Establishment of time-resolved fluoroimmunoassay of IgG4 based on magnetic microspheres. J Clin Lab Anal 2021; 35:e23874. [PMID: 34125973 PMCID: PMC8373317 DOI: 10.1002/jcla.23874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The abnormal increase in serum IgG4 level is an important clinical symptom of IgG4-related disease (IgG4-RD), and the detection of serum IgG4 level is a powerful tool for the diagnosis of IgG4-RD. This study was conducted to establish a simple and rapid immunoassay for the determination of human serum IgG4 levels. METHODS Based on the competition method, a novel immunoassay was established for the determination of human serum IgG4 using a combination of time-resolved fluoroimmunoassay (TRFIA) and magnetic microspheres. IgG4 was coupled with magnetic microspheres and competed with IgG4 in the samples to bind the Eu3+ -labeled anti-IgG4 antibody. The immunocomplex was separated and washed in a magnetic field, and the fluorescence counts were measured according to the number of dissociated europium ions. RESULTS The analytical sensitivity of IgG4-TRFIA based on magnetic microspheres was 0.006 g/L, and the detection range was 0.006-20 g/L under optimal conditions. The precision, recovery, and specificity of this immunoassay were demonstrated to be acceptable. The clinical application of IgG4-TRFIA based on magnetic microspheres was evaluated and compared with that of immunonephelometry. The results showed that the two detection methods had a good correlation, with a correlation coefficient of .9871. CONCLUSION IgG4-TRFIA based on magnetic microspheres has the advantages of high sensitivity, wide detection range, and short analysis time and has the potential to become a useful tool for the diagnosis of IgG4-RD.
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Affiliation(s)
- Qingqing Wu
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
| | - Chen Hang
- Tong Ren HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ting Li
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
| | - Binrong Wang
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
| | - Yuan Qin
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
| | - Yigang Wang
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
| | - Xiumei Zhou
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
| | - Pengguo Xia
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
- College of PharmacyZhejiang Chinese Medical UniversityHangzhouChina
| | - Huiming Sheng
- Tong Ren HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Pei Huang
- Department of OncologyWuxi No. 2 Hospital Affiliated to Nanjing Medical UniversityWuxiChina
| | - Biao Huang
- College of Life Sciences and MedicineZhejiang Sci‐Tech UniversityHangzhouChina
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Umehara H, Okazaki K, Kawa S, Takahashi H, Goto H, Matsui S, Ishizaka N, Akamizu T, Sato Y, Kawano M. The 2020 revised comprehensive diagnostic (RCD) criteria for IgG4-RD. Mod Rheumatol 2021; 31:529-533. [PMID: 33274670 DOI: 10.1080/14397595.2020.1859710] [Citation(s) in RCA: 227] [Impact Index Per Article: 75.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
IgG4-related disease (IgG4-RD) is a fascinating clinical entity first reported in this century in Japan, and includes a wide variety of diseases, such as formerly named Mikulicz's disease (MD), autoimmune pancreatitis (AIP), interstitial nephritis, prostatitis and retroperitoneal fibrosis. The Japanese IgG4 team organized by the Ministry of Health, Labor and Welfare (MHLW) of Japan has published the first criteria, comprehensive diagnostic (CD) criteria for IgG-RD 2011. Thereafter, IgG4-RD has been accepted widely and many cases have been reported from all over the world. Several problems have arisen in clinical practice, however, including the difficulty obtaining biopsy samples, and the sensitivity and specificity in cut off level of serum IgG4 and impaired immunostaining of IgG4. Given these situations, the Japanese IgG4 team has updated the 2011 comprehensive diagnostic criteria for IgG4-RD and propose the 2020 revised comprehensive diagnostic (RCD) criteria for IgG4-RD, which consists of 3 domains; 1) Clinical and radiological features, 2) Serological diagnosis and 3) Pathological diagnosis. In addition, the new pathological diagnosis is composed by three sub-items including storiform fibrosis and obliterative phlebitis.
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Affiliation(s)
- Hisanori Umehara
- Center for RA and Autoimmune Diseases, Nagahama City Hospital, Shiga, Japan
| | - Kazuichi Okazaki
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Shigeyuki Kawa
- Faculty of Dentistry, Matsumoto Dental University, Nagano, Japan
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunolog, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Hiroshi Goto
- Department of Ophthalmology, Tokyo Medical University, Tokyo, Japan
| | - Shoko Matsui
- Health Administration Center,University of Toyama, Toyama, Japan
| | | | - Takashi Akamizu
- Department of Rheumatology and Clinical Immunology,Wakayama Medical University, Wakayama, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Ishikawa, Japan
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6
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Floreani A, Okazaki K, Uchida K, Gershwin ME. IgG4-related disease: Changing epidemiology and new thoughts on a multisystem disease. J Transl Autoimmun 2020; 4:100074. [PMID: 33490938 PMCID: PMC7806798 DOI: 10.1016/j.jtauto.2020.100074] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/19/2020] [Accepted: 12/10/2020] [Indexed: 02/07/2023] Open
Abstract
IgG4-related disease (IgG4-RD) represents an immune-mediated fibroinflammatory condition with peculiar histopathologic changes that can affect various organs. In 2012 its unified nomenclature was published, which allows to abandon other synonymous names. Up to now, only little is known about its epidemiology around the world. However, although it is generally considered a rare condition, the number of patients with IgG4-RD is increasing enormously. Likewise, the annual number of publications on this subject has increased progressively. The spectrum of clinical manifestations in IgG4-RD is highly variable, depending on the severity of the disease as well as the presence of organ(s) involvement. This review gives an overview on changing epidemiology of IgG4-RD focusing the attention on the large cohorts of patients published in the literature.
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Affiliation(s)
- Annarosa Floreani
- Scientific Consultant IRCCS Negrar, Verona, Italy
- Senior Scholar, University of Padova, Italy
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Kazushige Uchida
- Department of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - M. Eric Gershwin
- Division of Rheumatology Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA, USA
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7
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Yoon SB, Moon SH, Kim JH, Song TJ, Kim MH. The use of immunohistochemistry for IgG4 in the diagnosis of autoimmune pancreatitis: A systematic review and meta-analysis. Pancreatology 2020; 20:1611-1619. [PMID: 33060017 DOI: 10.1016/j.pan.2020.10.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/01/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The diagnosis of autoimmune pancreatitis (AIP) remains challenging, especially when serum IgG4 is normal or imaging features are indeterminate. We performed a systematic review and meta-analysis to evaluate the performance of IgG4 immunostaining of pancreatic, biliary, and ampullary tissues as a diagnostic aid for AIP. METHODS A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted until February 2020. The methodological quality of each study was assessed according to the Quality Assessment of Diagnostic Accuracy Studies checklist. A random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy. RESULTS The meta-analysis included 20 studies comprising 346 patients with AIP and 590 patients with other pancreatobiliary diseases, including 371 pancreatobiliary malignancies. The summary estimates for tissue IgG4 in discriminating AIP and controls were as follows: diagnostic odds ratio 38.86 (95% confidence interval (CI), 18.70-80.75); sensitivity 0.64 (95% CI, 0.59-0.69); specificity 0.93 (95% CI, 0.91-0.95). The area under the curve was 0.939 for tissue IgG4 in discriminating AIP and controls. Subgroup analysis revealed no significant difference in diagnostic accuracy according to control groups (pancreatobiliary cancer versus other chronic pancreatitis) and sampling site (pancreas versus bile duct/ampulla). CONCLUSIONS Current data demonstrate that IgG4 immunostaining of pancreatic, biliary, and ampullary tissue has a high specificity but moderate sensitivity for diagnosing AIP. IgG4 immunostaining may be useful in supporting a diagnosis of AIP when AIP is clinically suspected, but a combination of imaging and serology does not provide a conclusive diagnosis.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea.
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea; Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Tae Jun Song
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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8
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Pelaez-Luna M, Soriano-Rios A, Lira-Treviño AC, Uscanga-Domínguez L. Steroid-responsive pancreatitides. World J Clin Cases 2020; 8:3411-3430. [PMID: 32913848 PMCID: PMC7457102 DOI: 10.12998/wjcc.v8.i16.3411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/03/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023] Open
Abstract
Autoimmune pancreatitis has received considerable attention, especially due to the marked effect of corticosteroid therapy on its clinical course. Knowledge, especially regarding type 1 autoimmune pancreatitis, has significantly increased over the last decades, and despite significant differences in pathophysiology and outcomes, both type 1 and 2 autoimmune pancreatitis are still considered different types of the same disease. Some have proposed a different nomenclature reflecting these differences. Although the term steroid-responsive pancreatitides may be interpreted as synonymous to type 1 and 2 autoimmune pancreatitis, these are not the only pancreatic conditions that show a response to steroid therapy. Acute pancreatitis caused by vasculitis and connective tissue diseases and acute pancreatitis secondary to checkpoint inhibitors or programmed cell death receptor antibody-mediated blockage cancer therapy may also benefit from steroid treatment. This review presents current concepts on these disorders, aiming to increase awareness, analyze similarities and differences, and propose a new nomenclature that reflects their specific particularities, clustering them under the term “steroid-responsive pancreatitides”.
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Affiliation(s)
- Mario Pelaez-Luna
- Research Division School of Medicine, Universidad Nacional Autonoma de México, Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubiran" Mexico City 14000, Mexico
| | - Andrea Soriano-Rios
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubiran" Mexico City 14000, Mexico
| | - Ana C Lira-Treviño
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubiran" Mexico City 14000, Mexico
| | - Luis Uscanga-Domínguez
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubiran" Mexico City 14000, Mexico
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9
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Mohapatra S, Charilaou P, Sharma A, Singh DP, Sah RP, Murray D, Majumder S, Topazian MD, Chari ST. Significance of peripheral eosinophilia for diagnosis of IgG4-related disease in subjects with elevated serum IgG4 levels. Pancreatology 2020; 20:74-78. [PMID: 31791884 DOI: 10.1016/j.pan.2019.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Saint Peter's University Hospital, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Paris Charilaou
- Department of Gastroenterology and Hepatology, Saint Peter's University Hospital, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Ayush Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dhruv Pratap Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Raghuwansh P Sah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Murray
- Department of Clinical Biochemistry and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suresh T Chari
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, USA.
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10
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Hegade VS, Sheridan MB, Huggett MT. Diagnosis and management of IgG4-related disease. Frontline Gastroenterol 2019; 10:275-283. [PMID: 31288262 PMCID: PMC6583577 DOI: 10.1136/flgastro-2018-101001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 09/09/2018] [Accepted: 09/29/2018] [Indexed: 02/04/2023] Open
Abstract
IgG subclass 4-related disease (IgG4-RD) is a rare but increasingly recognised fibroinflammatory condition known to affect multiple organs. IgG4-RD is characterised by unique histological features of lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. In this review we describe the pancreaticobiliary manifestations of IgG4-RD, with particular emphasis on type 1 autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-SC). AIP and IgG4-SC can pose diagnostic challenges to the clinician as they may mimic pancreatic cancer and primary sclerosing cholangitis, respectively. We discuss current knowledge, clinical diagnostic criteria and recent advances and summarise the evidence base for current therapeutic approaches for AIP and IgG4-SC.
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Affiliation(s)
- Vinod S Hegade
- Department of Gastroenterology, St James University Hospital, Leeds, UK
| | - Maria B Sheridan
- Department of Radiology, St James University Hospital, Leeds, UK
| | - Matthew T Huggett
- Department of Gastroenterology, St James University Hospital, Leeds, UK
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11
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Malluta ÉF, Maluf-Filho F, Leite AZDA, Ortiz-Agostinho CL, Nishitokukado I, Andrade AR, Lordello MLL, dos Santos FM, Sipahi AM. Pancreatic endosonographic findings and clinical correlation in Crohn's disease. Clinics (Sao Paulo) 2019; 74:e853. [PMID: 31166473 PMCID: PMC6542499 DOI: 10.6061/clinics/2019/e853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data. METHODS Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay. RESULTS Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations. CONCLUSION A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.
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Affiliation(s)
- Éverson Fernando Malluta
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fauze Maluf-Filho
- Departamento de Gastroenterologia, Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, SP, BR
| | - André Zonetti de Arruda Leite
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carmen Lucia Ortiz-Agostinho
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Iêda Nishitokukado
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Adriana Ribas Andrade
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Laura Lacava Lordello
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabiana Maria dos Santos
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Aytan Miranda Sipahi
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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12
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Native T1 mapping of autoimmune pancreatitis as a quantitative outcome surrogate. Eur Radiol 2019; 29:4436-4446. [DOI: 10.1007/s00330-018-5987-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/01/2018] [Accepted: 12/18/2018] [Indexed: 12/19/2022]
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13
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Lv H, Liu A, Zhao Y, Qian J. Comparison of clinical characteristics of radiological forms of autoimmune pancreatitis. HPB (Oxford) 2018; 20:1021-1027. [PMID: 29843984 DOI: 10.1016/j.hpb.2018.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is limited understanding of the clinical characteristics of different radiological forms of autoimmune pancreatitis (AIP). This retrospective study compared the clinical features of radiological forms of AIP. METHODS A retrospective review was conducted of patients with AIP treated from 2005 to 2015. Based on radiological features, these AIP cases were classified as diffuse (D) or focal (F), and the latter further stratified as head (H), or body and/or tail (B/T). The clinical characteristics and laboratory indices were compared. RESULTS Among the 119 patients, 66 (55.5%), 40 (33.6%), and 13 (10.9%) were respectively classified as D-, H-, and B/T-type. Compared with the others, the B/T-type patients were younger at onset, the percentage of men was lower, loss of appetite and weight were less common, and these patients had fewer extrapancreatic lesions (P < 0.05, each). Compared with the other groups, the B/T-type patients showed significantly lower levels of liver enzymes, direct bilirubin, and total bilirubin. No B/T-type patient displayed jaundice or pruritus. Three B/T-type patients progressed to D-type during the natural course of illness. CONCLUSIONS D-type and H-type AIP patients had similar clinical features. The B/T-type group differed significantly from the other two types. B/T-type can progress to D-type.
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Affiliation(s)
- Hong Lv
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ailing Liu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yixiao Zhao
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jiaming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Serum Immunoglobulin G4 in Discriminating Autoimmune Pancreatitis From Pancreatic Cancer: A Diagnostic Meta-analysis. Pancreas 2018; 47:280-284. [PMID: 29351121 DOI: 10.1097/mpa.0000000000000994] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Differentiation between autoimmune pancreatitis (AIP) and pancreatic cancer (PC) is a clinical challenge. Emerging published data on the accuracy of serum immunoglobulin G4 (IgG4) for the differential diagnosis between AIP and PC are inconsistent. The objective of our study was to perform a meta-analysis evaluating the clinical utility of serum IgG4 in the differential diagnosis between AIP and PC. METHODS We performed a systematic literature search of multiple electronic databases. The methodological quality of each study was assessed according to the Quality Assessment of Diagnostic Accuracy Studies checklist. Random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy. RESULTS Eleven studies comprising 523 AIP patients and 771 PC patients were included in the meta-analysis. The summary estimates for serum IgG4 in distinguishing AIP from PC were as follows: diagnostic odds ratio, 57.30 (95% confidence interval [CI], 23.17-141.67); sensitivity, 0.72 (95% CI, 0.68-0.76); specificity, 0.93 (95% CI, 0.91-0.94). The area under the curve of serum IgG4 in distinguishing AIP from PC was 0.9200. CONCLUSIONS Our meta-analysis found that serum IgG4 has high specificity and relatively low sensitivity in the differential diagnosis between AIP and PC. Therefore, serum IgG4 is useful in distinguishing AIP from PC.
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15
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Umehara H, Okazaki K, Nakamura T, Satoh-Nakamura T, Nakajima A, Kawano M, Mimori T, Chiba T. Current approach to the diagnosis of IgG4-related disease - Combination of comprehensive diagnostic and organ-specific criteria. Mod Rheumatol 2017; 27:381-391. [PMID: 28165852 DOI: 10.1080/14397595.2017.1290911] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IgG4-related disease (IgG4-RD) is a fascinating clinical entity proposed by Japanese investigators, and includes a wide variety of diseases, formerly diagnosed as Mikulicz's disease (MD), autoimmune pancreatitis (AIP), interstitial nephritis, prostatitis, retroperitoneal fibrosis, etc. Although all clinicians in every field of medicine may encounter this new disease, a unifying diagnostic criterion has not been established. In 2011, the Japanese IgG4 team, organized by the Ministry of Health, Labor and Welfare (MHLW) of Japan, published comprehensive diagnostic criteria for IgG4-RD. Several problems with these criteria have arisen in clinical practice, however, including the difficulty obtaining biopsy samples from some patients, and the sensitivity and the specificity of techniques used to measure serum IgG4 concentrations. Although serum IgG4 concentration is an important clinical marker for IgG4-RD, its diagnostic utility in differentiating IgG4-RD from other diseases, called IgG4-RD mimickers, remains unclear. This review describes the current optimal approach for the diagnosis of IgG4-RD, based on both comprehensive and organ-specific diagnostic criteria, in patients with diseases such as IgG4-related pancreatitis (AIP), sclerosing cholangitis, and renal, lung and orbital diseases.
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Affiliation(s)
- Hisanori Umehara
- a Division of RA and Autoimmune Diseases , Internal Medicine, Nagahama City Hospital , Shiga , Japan
| | - Kazuichi Okazaki
- b The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology , Kansai Medical University , Osaka , Japan
| | - Takuji Nakamura
- a Division of RA and Autoimmune Diseases , Internal Medicine, Nagahama City Hospital , Shiga , Japan
| | - Tomomi Satoh-Nakamura
- a Division of RA and Autoimmune Diseases , Internal Medicine, Nagahama City Hospital , Shiga , Japan
| | - Akio Nakajima
- c Division of Rheumatology , Internal Medicine, Kudo General Hospital , Ishikawa , Japan
| | - Mitsuhiro Kawano
- d Division of Rheumatology, Department of Internal Medicine, Graduate School of Medical Science , Kanazawa University , Ishikawa , Japan
| | - Tsuneyo Mimori
- e Department of Clinical Immunology, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Tsutomu Chiba
- f Department of Gastroenterology and Hepatology, Graduate School of Medicine , Kyoto University , Kyoto , Japan
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16
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Macinga P, Pulkertova A, Bajer L, Maluskova J, Oliverius M, Smejkal M, Heczkova M, Spicak J, Hucl T. Simultaneous occurrence of autoimmune pancreatitis and pancreatic cancer in patients resected for focal pancreatic mass. World J Gastroenterol 2017; 23:2185-2193. [PMID: 28405146 PMCID: PMC5374130 DOI: 10.3748/wjg.v23.i12.2185] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 01/31/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the occurrence of autoimmune pancreatitis (AIP) in pancreatic resections performed for focal pancreatic enlargement.
METHODS We performed a retrospective analysis of medical records of all patients who underwent pancreatic resection for a focal pancreatic enlargement at our tertiary center from January 2000 to July 2013. The indication for surgery was suspicion of a tumor based on clinical presentation, imaging findings and laboratory evaluations. The diagnosis of AIP was based on histology findings. An experienced pathologist specialized in pancreatic disease reviewed all the cases and confirmed the diagnosis in pancreatic resection specimens suggestive of AIP. The histological diagnosis of AIP was set according to the international consensus diagnostic criteria.
RESULTS Two hundred ninety-five pancreatic resections were performed in 201 men and 94 women. AIP was diagnosed in 15 patients (5.1%, 12 men and 3 women) based on histology of the resected specimen. Six of them had AIP type 1, nine were diagnosed with AIP type 2. Pancreatic adenocarcinoma (PC) was also present in six patients with AIP (40%), all six were men. Patients with AIP + PC were significantly older (60.5 vs 49 years of age, P = 0.045), more likely to have been recently diagnosed with diabetes (67% vs 11%, P = 0.09), and had experienced greater weight loss (15.5 kg vs 8.5 kg, P = 0.03) than AIP patients without PC. AIP was not diagnosed in any patients prior to surgery; however, the diagnostic algorithm was not fully completed in every case.
CONCLUSION The possible co-occurrence of PC and AIP suggests that preoperative diagnosis of AIP does not rule out simultaneous presence of PC.
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17
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Pelkmans LG, Hendriksz TR, Westenend PJ, Vermeer HJ, van Bommel EFH. Elevated serum IgG4 levels in diagnosis and treatment response in patients with idiopathic retroperitoneal fibrosis. Clin Rheumatol 2017; 36:903-912. [PMID: 28105551 DOI: 10.1007/s10067-017-3542-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/08/2017] [Accepted: 01/11/2017] [Indexed: 12/24/2022]
Abstract
Idiopathic retroperitoneal fibrosis (iRPF) may be a manifestation of IgG4-related disease. Measuring serum IgG4 (sIgG4) may be of value in monitoring iRPF, but this has scarcely been evaluated. It is unknown if tamoxifen (TMX) affects sIgG4 levels. We performed a prospective inception cohort study of 59 patients with untreated (re)active iRPF stratified by elevated (>1.4 g/L) or normal sIgG4 level. Changes in sIgG4 levels following TMX initiation and, if treatment failed, during subsequent corticosteroid (CS) treatment were analyzed. The median sIgG4 level was 1.1 g/L (interquartile range (IQR) 0.4-2.2); 24 patients (40%) had elevated sIgG4 level. Patients with elevated sIgG4 tended to present with higher ESR (46 vs. 34 mm/h; P = 0.08) and more frequent locoregional lymphadenopathy adjacent to the mass (41.7 vs. 20.0%; P = 0.08). sIgG4 also correlated with ESR (ρ = 0.26; P = 0.05) and serum creatinine (SC) (ρ = 0.26; P = 0.04). Following TMX initiation, sIgG4 level decreased, particularly when achieving treatment success (P < 0.01). Odds ratio for TMX treatment success in patients with elevated sIgG4 level was 0.77 (95% CI 0.53-1.14; P = 0.19). After adjusting for age, sex, and SC, the odds ratio was 0.78 (95% CI 0.51-1.18; P = 0.24). ROC curve analyses of sIgG4 on a continuous scale and treatment success showed an AUC of 0.62. Treatment success and concurrent sIgG4 decrease (P < 0.01) were achieved in 78% of patients who converted to CS therapy. Patients with elevated sIgG4 level may be more inflammatory than patients with normal sIgG4 level, but this needs further study. TMX affects sIgG4 levels, but to a lesser extent than CSs. sIgG4 cannot be used as an outcome prediction tool, irrespective of which cutoff value was chosen.
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Affiliation(s)
- L G Pelkmans
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer Hospital, PO Box 444, NL-3300 AK, Dordrecht, The Netherlands
| | - T R Hendriksz
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - P J Westenend
- Department of Pathology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - H J Vermeer
- Result Laboratory, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - E F H van Bommel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
- National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer Hospital, PO Box 444, NL-3300 AK, Dordrecht, The Netherlands.
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18
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Identification of Novel Serum Autoantibodies for Differential Diagnosis of Autoimmune Pancreatitis and Pancreatic Ductal Adenocarcinoma. Pancreas 2016; 45:1309-19. [PMID: 27623556 DOI: 10.1097/mpa.0000000000000647] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The lack of specific biochemical markers is a major drawback for the diagnosis of autoimmune pancreatitis (AIP). The aims were to characterize the autoantibody profiles in AIP and pancreatic ductal adenocarcinoma (PDAC) and to identify circulating autoantibodies that could be diagnostic markers differentiating PDAC and the AIP subtypes. METHODS Tissue lysates obtained from the resected pancreas of patients with AIP and patients with PDAC were separated by 2-dimensional polyacrylamide gel electrophoresis subsequently immunoblotted with autologous sera. The immunoreactive spots were subjected to nanoscale liquid chromatography-electrospray ionization tandem mass spectrometry to identify serum autoantibodies to tissue-derived autoantigens associated with AIP and PDAC. Autoantibody concentrations for selected autoantigens were assessed by enzyme-linked immunosorbent assays. RESULTS A total of 115 immunoreactive spots were identified by 2-dimensional polyacrylamide gel electrophoresis/immunobloting. Nanoscale liquid chromatography-electrospray ionization tandem mass spectrometry-based analysis revealed 68 autoantigens in AIP, 26 in PDAC, and 21 present in both diseases. Assessment of 13 selected AIP autoantibody serum levels revealed that 7 of them had significantly higher titers in AIP versus PDAC. IgG-directed against transaldolase could significantly differentiate between the 2 AIP subtypes. CONCLUSIONS The novel panel of AIP autoantibodies is promising to supplement the predictive tests for AIP of the currently known autoantigens and represent a basis for a combined blood test to differentiate AIP from PDAC in the future.
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19
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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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20
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Hasosah MY, Masawa L, Jan A, Alsaleem K. A Case Report of Childhood Recurrent Autoimmune Pancreatitis: A Rare Emerging Entity. J Clin Diagn Res 2016; 10:SD01-2. [PMID: 27504369 DOI: 10.7860/jcdr/2016/18437.7917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/19/2016] [Indexed: 01/15/2023]
Abstract
Autoimmune pancreatitis (AIP) is a rare entity in the paediatric population and its aetiology is unknown. Here, we report a 10-year-old girl with recurrent abdominal pain. A diagnosis of AIP was made based on elevated pancreatic enzymes, elevated IgG 4 and image findings. She responded to corticosteroid treatment. AIP should be considered in the differential diagnosis of recurrent pancreatitis. Correct diagnosis can help avert the consequences of progressive disease and unnecessary surgery.
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Affiliation(s)
- Mohammed Y Hasosah
- Assistant Professor, Department of Pediatric Gastroenterology, King Saud Bin Abdulaziz University for Health Sciences, National Guard Hospital , Jeddah, Saudi Arabia
| | - Lojain Masawa
- Paediatric Intern, Department of Pediatrics, King Saud Bin Abdulaziz University for Health Sciences, National Guard Hospital , Jeddah, Saudi Arabia
| | - Ajwan Jan
- Paediatric Intern, Department of Pediatrics, King Saud Bin Abdulaziz University for Health Sciences, National Guard Hospital , Jeddah, Saudi Arabia
| | - Khalid Alsaleem
- Consultant Gastroenterologist, Department of Pediatrics, Division of Gastroenterology, King Faisal Specialist Hospital and Research Center , Riyadh, Saudi Arabia
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21
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Egner W, Swallow K, Lock RJ, Patel D. Falsely low immunoglobulin (Ig)G4 in routine analysis: how not to miss IgG4 disease. Clin Exp Immunol 2016; 186:57-63. [PMID: 27125474 DOI: 10.1111/cei.12805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 12/16/2022] Open
Abstract
Immunoglobulin (Ig)G4 disease can have apparently 'normal' levels of IgG4 due to antigen excess conditions. IgG4 measurement therefore appears falsely low. UK National External Quality Assurance Scheme (UK NEQAS) data and other reports have suggested that this problem occurred despite pre-existing antigen excess detection steps. To determine the clinical relevance of the problem, we examined the prevalence and characteristics of prozoning in our laboratory and patient cohorts. We establish that the prevalence of raised IgG4 in routine IgG4 analysis is low (< 1%) using one of the two routine methods in use in the United Kingdom. We show that subsequent assay modification appears to have reduced the likelihood of misleading readings. However, the original version of the assay prozoned to low levels (below 0·64 g/l) in 41% of high IgG4 samples in our patients. This may explain the previous reports of low sensitivity of raised IgG4 for IgG4RD, and predictive values should be re-evaluated in this disease using modified prozone-resistant protocols. All laboratories providing IgG4 measurements should verify that their assays are fit for the clinical quality requirement of detection raised IgG4 levels and must verify the upper limit of their reference ranges and freedom from prozoning.
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Affiliation(s)
- W Egner
- Department of Immunology and Protein Reference Unit, Sheffield.,Immunochemistry and Allergy (IIA), Sheffield Teaching Hospitals NHS Trust, UK NEQAS Immunology, Sheffield
| | - K Swallow
- Department of Immunology and Protein Reference Unit, Sheffield
| | - R J Lock
- Immunology and Immunogenetics, North Bristol NHS Trust, Bristol
| | - D Patel
- Immunochemistry and Allergy (IIA), Sheffield Teaching Hospitals NHS Trust, UK NEQAS Immunology, Sheffield
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22
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Hybrid kappa\lambda antibody is a new serological marker to diagnose autoimmune pancreatitis and differentiate it from pancreatic cancer. Sci Rep 2016; 6:27415. [PMID: 27271825 PMCID: PMC4897619 DOI: 10.1038/srep27415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 05/18/2016] [Indexed: 12/12/2022] Open
Abstract
The only generally accepted serological marker currently used for the diagnosis of autoimmune pancreatitis (AIP) is IgG4. Our aim was mainly to determine whether hybrid κ\λ antibody can help to diagnose AIP and to differentiate it from pancreatic cancer. We established an enzyme-linked immunosorbent assay (ELISA) system to measure the levels of hybrid κ\λ antibodies in human sera. Sera were obtained from 338 patients, including 61 with AIP, 74 with pancreatic cancer, 50 with acute pancreatitis, 40 with ordinary chronic pancreatitis, 15 with miscellaneous pancreatic diseases, and 98 with normal pancreas. Our study showed levels of hybrid κ\λ antibodies in the AIP group were significantly higher than in the non-AIP group (P < 0.001). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of AIP were 80.3%, 91%, 66.2% and 95.5% respectively. Furthermore, the combined measurement of serum hybrid κ\λ antibody and IgG4 tended to increase the sensitivity although the difference was not statistically significant (90.2% vs. 78.7%, P = 0.08), compared to measurement of IgG4 alone. Our findings suggest that hybrid κ\λ antibody could be a new serological marker to diagnose AIP and differentiate it from pancreatic cancer.
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23
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Hao M, Liu M, Fan G, Yang X, Li J. Diagnostic Value of Serum IgG4 for IgG4-Related Disease: A PRISMA-compliant Systematic Review and Meta-analysis. Medicine (Baltimore) 2016; 95:e3785. [PMID: 27227950 PMCID: PMC4902374 DOI: 10.1097/md.0000000000003785] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Many studies about serum IgG4 for the diagnosis of IgG4-related disease (IgG4-RD) have been reported. However, these studies had relatively small sample sizes and the diagnostic accuracy values varied much between them.The aim of this study was to perform a meta-analysis to evaluate the diagnostic value of serum IgG4 for IgG4-RD.We conducted a search of relevant articles using MEDLINE, EMBASE, Web of Science, SCOPUS, and Cochrane Library databases published before December 2015.Studies those assessed the diagnostic accuracy of serum IgG4 for IgG4-RD and those provided the cut-off value for serum IgG4 were included.Data were synthesized using the random-effect model. Statistical analysis was performed using STATA with the MIDAS module and Meta-DiSc 1.4 software.A total of 9 case-control studies were analyzed, which included 1235 patients with IgG4-RD and 5696 overall controls. The pooled estimate, for a cut-off value ranged from 135 to 144 mg/dL, produced a sensitivity of 87.2% (95% CI, 85.2-89.0%) and a specificity of 82.6% (95% CI, 81.6-83.6%). The positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were 6.48 (95% CI, 3.98-10.57), 0.14 (95% CI, 0.09-0.21), and 45.15 (95% CI, 23.41-87.06), respectively. The area under the curve (AUC) of the summary receiver operating characteristic curve (SROC) was 0.94 (0.92-0.96). When a cut-off value of 2-fold the upper limit of normal was used (ranged from 270 to 280 mg/dL), the pooled sensitivity was 63% (95% CI, 60.0-66.0%), and the specificity was 94.8% (95% CI, 94.1-95.4%). The PLR, NLR, and DOR were 13.3 (95% CI, 7.39-24.0), 0.41 (95% CI, 0.29-0.58) and 33.42 (95% CI, 13.88-80.43), respectively. The AUC of the SROC was 0.92 (0.90-0.94).Only a relatively small number of studies were included, and significant heterogeneity was observed in this meta-analysis.Serum IgG4 is a modestly effective marker to diagnose IgG4-RD. Doubling the cut-off value for IgG4 could not improve the overall test characteristics. A high specificity inevitably accompanies with a significant sacrifice in sensitivity.
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Affiliation(s)
- Mingju Hao
- From the National Center for Clinical Laboratories (MH, GF, XY, JL), Beijing Hospital; Graduate School (MH, GF, XY, JL), Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing; Department of Clinical Laboratory (MH), Qianfo Mountain Hospital of Shandong University; and Department of Clinical Laboratory (ML), Jinan Dermatosis Prevention and Control Hospital, Jinan, People's Republic of China
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Culver EL, Sadler R, Simpson D, Cargill T, Makuch M, Bateman AC, Ellis AJ, Collier J, Chapman RW, Klenerman P, Barnes E, Ferry B. Elevated Serum IgG4 Levels in Diagnosis, Treatment Response, Organ Involvement, and Relapse in a Prospective IgG4-Related Disease UK Cohort. Am J Gastroenterol 2016; 111:733-43. [PMID: 27091321 DOI: 10.1038/ajg.2016.40] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Elevated serum immunoglobulin G4 (IgG4) levels have been associated with autoimmune pancreatitis and IgG4-related disease (IgG4-RD) for over a decade. However, an elevated serum IgG4 is not specific for the disease. There have been inconsistent reports of its use in diagnosis, as a marker of disease relapse, and its relationship to organ involvement in retrospective cohorts. The aims of this study were to ascertain conditions that are associated with an elevated serum IgG4 and to investigate the role of IgG4 in diagnosis, relapse, and organ involvement in a prospective cohort of patients with IgG4-RD. METHODS We evaluated serum IgG4 measurements in the Oxford Immunology Laboratory over 6 years. Patients in whom serum IgG4 was requested to differentiate IgG4-RD from other diseases were recruited into a longitudinal follow-up study to determine final diagnosis. In a prospective cohort of IgG4-RD patients, organ involvement, response to therapy, and disease relapse were determined. RESULTS Two thousand and sixty-seven samples from 1,510 patients had serum IgG4 measured. Of these, IgG4 was elevated (≥1.4 g l(-1)) in 243 (16.1%) patients. The main indication (85.6%) was to distinguish between IgG4-RD and non-IgG4-RD conditions. Only 5.1% of patients who had serum IgG4 measured for this purpose had a final diagnosis of IgG4-RD. Of those with an elevated serum IgG4, 22.4% met IgG4-RD diagnostic criteria. Serum IgG4 was elevated in 48 (82.8%) of IgG4-RD patients. An IgG4 cutoff of 1.4 g l(-1) gave a sensitivity of 82.8% and specificity of 84.7% to diagnose IgG4-RD. Increasing this to 2.8 g l(-1) increased specificity to 96.2% and negative predictive value to 97.7%, with a lower sensitivity of 56.9% and positive predictive value of 44.5%. Serum IgG4 levels fell with corticosteroid therapy, but this was not disease-specific. A serum IgG4 of ≥2.8 g l(-1) at diagnosis was associated with multi-organ involvement and risk of relapse. CONCLUSIONS Serum IgG4 levels are elevated in multiple non-IgG4-RD inflammatory and malignant conditions, with less than one-quarter of those with an elevated IgG4 meeting IgG4-RD diagnostic criteria. A serum IgG4 of ≥2.8 g l(-1) is useful in distinguishing between IgG4-RD and non-IgG4-RD diagnoses, predicting multiple-organ involvement and risk of relapse in IgG4-RD.
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Affiliation(s)
- Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Ross Sadler
- Clinical Immunology Department, Churchill Hospital, Oxford, UK
| | - Dawn Simpson
- Clinical Immunology Department, Churchill Hospital, Oxford, UK
| | - Tamsin Cargill
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Mateusz Makuch
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Adrian C Bateman
- Histopathology Department, Southampton General Hospital, Southampton, UK
| | - Anthony J Ellis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.,Gastroenterology, Horton Hospital, Banbury, UK
| | - Jane Collier
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Roger W Chapman
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - P Klenerman
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Eleanor Barnes
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Oxford NIHR and BRC, Oxford, UK
| | - Berne Ferry
- Clinical Immunology Department, Churchill Hospital, Oxford, UK
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Outcome of Long-term Maintenance Steroid Therapy Cessation in Patients With Autoimmune Pancreatitis: A Prospective Study. J Clin Gastroenterol 2016; 50:331-7. [PMID: 26565969 DOI: 10.1097/mcg.0000000000000440] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To predict the duration of steroid maintenance therapy required to achieve good prognosis in patients with autoimmune pancreatitis. PATIENTS AND METHODS The study sample comprised 21 patients with autoimmune pancreatitis who met the following criteria: (1) they received steroid therapy (ST) for at least 3 years without clinical relapse; and (2) immunoglobulin (Ig) G<1600 mg/dL was observed in the past year with a prednisolone maintenance dose ≤5 mg. All patients could be diagnosed with international consensus diagnostic criteria. Patients were prospectively followed up after tapering and cessation of steroids. Clinical relapse was defined as the need to resume ST. Serological relapse was defined as having an IgG level of >1600 mg/dL. RESULTS During the 43-month (range, 19 to 48 mo) follow-up period, clinical relapse occurred in 10 patients: pancreatic lesion in 4; coronary lesion in 2; submandibular lesion in 1; both pulmonary and renal lesions in 1; pulmonary, retroperitoneal, and submandibular lesions in 1; and bronchial asthma in 1. Serological relapse was observed in 12 patients. Although clinical and serological relapse occurred concomitantly in 3 patients, serological relapse preceded clinical relapse in 4 patients. Five patients experienced serological relapse alone, and no clinical or serological relapse occurred in 6 patients. According to Cox proportional hazard analysis, the duration of ST before tapering was a significant predictive parameter (hazard ratio, 0.969/month; 95% confidence interval, 0.940-0.998; P=0.038). CONCLUSIONS ST cessation resulted in a high rate of clinical relapses, even in patients with long-term maintenance therapy. Therefore, it appears desirable to continue steroid maintenance therapy for a period >3 years to prevent relapse.
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Wallace ZS, Mattoo H, Mahajan VS, Kulikova M, Lu L, Deshpande V, Choi HK, Pillai S, Stone JH. Predictors of disease relapse in IgG4-related disease following rituximab. Rheumatology (Oxford) 2016; 55:1000-8. [PMID: 26888853 DOI: 10.1093/rheumatology/kev438] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) is a relapsing-remitting condition responsible for fibroinflammatory lesions that can lead to organ damage and life-threatening complications at nearly any anatomical site. The duration of remission following treatment varies and predictors of relapse are unclear. The objectives of this study were to review our experience with rituximab as remission induction in IgG4-RD, to clarify the duration of efficacy and to identify predictors of flare following treatment. METHODS In this retrospective cohort study, all patients were treated with two doses of rituximab (1 g) separated by 15 days. Clinical, radiographic and laboratory data pertaining to rituximab response and disease relapse were collected from the electronic medical record. Kaplan-Meier curves were constructed to estimate the time to disease relapse. Log-rank analyses were performed to compare times to relapse among subgroups. Potential relapse predictors were evaluated with Cox regression analysis. RESULTS Fifty-seven of 60 patients (95%) had clinical responses to rituximab. Forty-one patients (68%) were treated without glucocorticoids. Twenty-one patients (37%) experienced relapses following treatment at a median time from the first infusion of 244 days. Baseline concentrations of serum IgG4, IgE and circulating eosinophils predicted subsequent relapses, with hazard ratios of 6.2 (95% CI: 1.2, 32.0), 8.2 (95% CI: 1.4, 50.0) and 7.9 (95% CI: 1.8, 34.7), respectively. The higher the baseline values, the greater the risk of relapse and the shorter the time to relapse. Only 10% of the patients had elevations of all three major risk factors, underscoring the importance of measuring all three at baseline. CONCLUSION Baseline elevations in serum IgG4, IgE and blood eosinophil concentrations all predict IgG4-RD relapses independently.
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Affiliation(s)
- Zachary S Wallace
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital
| | - Hamid Mattoo
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University
| | - Vinay S Mahajan
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University
| | - Maria Kulikova
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University
| | - Leo Lu
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Boston University School of Medicine
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shiv Pillai
- Massachusetts General Hospital Cancer Center, The Ragon Institute of the Massachusetts General Hospital, the Massachusetts Institute of Technology and Harvard University, Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Serum IgG4 and IgG for the diagnosis of autoimmune pancreatitis: A systematic review with meta-analysis. Clin Res Hepatol Gastroenterol 2016; 40:99-109. [PMID: 26160477 DOI: 10.1016/j.clinre.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/09/2015] [Accepted: 06/01/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE The correct diagnosis of autoimmune pancreatitis (AIP) is a clinical challenge. Emerging published data on the accuracy of serum IgG4 and IgG for diagnosing AIP are inconsistent. This study was performed to better elucidate the accuracy of serum IgG4 and IgG in diagnosing AIP. METHODS A comprehensive literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and some other databases was conducted before October 2014. The methodological quality of each study was assessed according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist. Random-effects model was used to summarize the sensitivity, specificity and other measures of accuracy. RESULTS Fifteen studies on IgG4 and 8 studies on IgG were included. The summary estimates for serum IgG4 in distinguishing AIP from the overall controls, pancreatic cancer and ordinary chronic pancreatitis were as follows: sensitivity 0.74 (0.70-0.77), 0.73 (0.69-0.77) and 0.76 (0.72-0.80), respectively, specificity, 0.94 (0.93-0.95), 0.93 (0.91-0.95) and 0.96 (0.95-0.97), respectively. The summary estimates for serum IgG in distinguishing AIP from the overall controls and pancreatic cancer were as follows: sensitivity, 0.53 (0.47-0.59) and 0.51 (0.44-0.57), respectively, specificity, 0.87 (0.85-0.89) and 0.94 (0.91-0.96), respectively. The area under the curve (AUC) of serum IgG in distinguishing AIP from ordinary chronic pancreatitis was 0.657. CONCLUSIONS Both serum IgG4 and IgG have high specificity and relatively low sensitivity for diagnosing AIP. Besides, they are useful for distinguishing AIP from pancreatic cancer and ordinary chronic pancreatitis. To better elucidate the usefulness of serum IgG4 and IgG, further studies are needed.
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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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Sánchez Castañón M, Zuliani V, Amodio A, Campagnola P, Granato A, Gabbrielli A, Benini L, López Hoyos M, Frulloni L. Role of Amylase-α2A Autoantibodies in the Diagnosis of Autoimmune Pancreatitis. Pancreas 2015; 44:1078-82. [PMID: 26335011 DOI: 10.1097/mpa.0000000000000417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Several serological markers have been reported in autoimmune pancreatitis (AIP) patients. However, only serum IgG4 (sIgG4) is available in clinical practice for AIP diagnosis. Antiamylase α antibodies (AMY-α Abs) have been proposed to diagnose AIP. This study evaluates the utility of AMY-α Abs and sIgG4 for AIP diagnosis. METHODS Twenty-five AIP patients, 84 disease control groups (31 chronic pancreatitis, 30 acute pancreatitis, 23 pancreatic adenocarcinoma), and 59 healthy donors were prospectively studied. The AMY-α Abs were determined by homemade enzyme-linked immunosorbent assay and sIgG4 by nephelometry. RESULTS Increased sIgG4 were detected to be present in 52% of AIP, 5% in control groups, and 0% in healthy donors, and AMY-α Abs, respectively, in 76%, 36%, and 2%. sIgG4 was elevated in 92% of the 13 patients with type 1 AIP, but in none of 3 with type 2 and of 8 with not otherwise specified AIP. The AMY-α Abs were present in 79%, 67%, and 75% of type 1, type 2, and not otherwise specified AIP, respectively. Sensitivity and specificity of AMY-α Abs were 76% and 78%, and of sIgG4 50% and 94%. By combining the 2 serological markers, sensitivity was 41%, and specificity was 99%. CONCLUSIONS The AMY-α Abs may help to diagnosis of AIP and to differentiate AIP subtypes.
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Affiliation(s)
- María Sánchez Castañón
- From the *Immunology Service, Hospital Universitario Marqués de Valdecilla-IFIMAV, Santander, Spain; and †Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
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Li M, Zhou Q, Yang K, Brigstock DR, Zhang L, Xiu M, Sun L, Gao RP. Rare case of Helicobacter pylori-positive multiorgan IgG4-related disease and gastric cancer. World J Gastroenterol 2015; 21:3429-3434. [PMID: 25805956 PMCID: PMC4363779 DOI: 10.3748/wjg.v21.i11.3429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/17/2014] [Accepted: 12/22/2014] [Indexed: 02/06/2023] Open
Abstract
A 61-year-old male from Northeast China presented with a 2-mo history of abdominal distension, pruritus and jaundice. Laboratory testing revealed an elevated serum IgG4 level. A computed tomography scan showed a typical feature of autoimmune pancreatitis (AIP) and cholecystocholangitis. Early gastric cancer was incidentally discovered when endoscopic untrasound-guided fine needle aspiration (EUS-FNA) of the pancreas was carried out. The patient underwent radical subtotal gastrectomy for gastric cancer combined with cholecystectomy. Helicobacter pylori (H. pylori) and IgG4-positive plasmacytes were detected in gastric cancer tissue, pancreatic EUS-FNA sample and resected gallbladder specimen by immunohistochemistry. The patient was diagnosed with H. pylori-positive IgG4-related AIP and sclerosing cholecystocholangitis as well as H. pylori-positive gastric cancer. He responded well to steroid therapy and remains healthy with no signs of recurrence at one year follow-up. We speculate that H. pylori might act as a trigger via direct or indirect action in the initiation of onset of gastric cancer and multiorgan IgG4-related disease.
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Talar-Wojnarowska R, Gąsiorowska A, Olakowski M, Dranka-Bojarowska D, Lampe P, Śmigielski J, Kujawiak M, Grzegorczyk J, Małecka-Panas E. Utility of serum IgG, IgG4 and carbonic anhydrase II antibodies in distinguishing autoimmune pancreatitis from pancreatic cancer and chronic pancreatitis. Adv Med Sci 2014; 59:288-92. [PMID: 25194335 DOI: 10.1016/j.advms.2014.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 08/02/2014] [Accepted: 08/12/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Autoimmune pancreatitis (AIP) can mimic pancreatic cancer in its clinical presentation, imaging features and laboratory parameters. The aim of our study was to compare IgG, IgG4 and anti-CAIIAb serum levels in patients with AIP, pancreatic adenocarcinoma (PA) and chronic pancreatitis (CP) and to assess their clinical significance and utility in differential diagnosis of pancreatic diseases. PATIENT/METHODS The study included 124 patients: 45 with PA, 24 with AIP and 55 with CP. Peripheral venous blood samples were obtained from all analyzed patients at the time of hospital admission and total IgG, IgG4 and anti-CAIIAB serum levels were measured using ELISA tests. RESULTS Serum levels of IgG, IgG4 and anti-CAIIAb were significantly higher in patients with AIP compared to PA and CP patients (p<0.001). In AIP patients the median IgG levels were 19.7 g/l, IgG4 levels - 301.9 mg/dl and anti-CAIIAb - 81.82 ng/ml, compared to 10.61 g/l, 123.2mg/dl and 28.6 ng/ml, respectively, in PA patients. IgG4 for the cut-off 210 mg/dl showed the best sensitivity and specificity (83.8% and 89.5%) in AIP diagnosis compared to IgG (69.3% and 87.3%, respectively) and anti-CAIIAb (45.3% and 74.3%). However, 16 (35.5%) patients with PA and 14 (25.4%) patients with CP had IgG4 levels greater than 140 mg/dl. Moreover, in 3 (6.67%) patients with pancreatic cancer those values were greater than 280 mg/dl. No patients with CP had IgG4 more than 280 mg/dl. CONCLUSIONS IgG4 at cut-off 210 mg/dl showed the best sensitivity and specificity in AIP diagnosis compared to IgG and anti-CAIIAb, however elevations of serum IgG4 may be seen in subjects without AIP, including pancreatic cancer.
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Affiliation(s)
| | - Anita Gąsiorowska
- Department of Digestive Tract Diseases, Medical University of Lodz, Poland
| | - Marek Olakowski
- Department of Digestive Tract Surgery, Silesian Medical University, Katowice, Poland
| | | | - Paweł Lampe
- Department of Digestive Tract Surgery, Silesian Medical University, Katowice, Poland
| | - Jacek Śmigielski
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, Poland
| | - Magdalena Kujawiak
- Department of Microbiology and Laboratory Medical Immunology, Faculty of Medicine, Medical University of Lodz, Poland
| | - Janina Grzegorczyk
- Department of Microbiology and Laboratory Medical Immunology, Faculty of Medicine, Medical University of Lodz, Poland
| | - Ewa Małecka-Panas
- Department of Digestive Tract Diseases, Medical University of Lodz, Poland
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Chang MC, Liang PC, Jan IS, Yang CY, Tien YW, Wei SC, Wong JM, Chang YT. Comparison and validation of International Consensus Diagnostic Criteria for diagnosis of autoimmune pancreatitis from pancreatic cancer in a Taiwanese cohort. BMJ Open 2014; 4:e005900. [PMID: 25138812 PMCID: PMC4139642 DOI: 10.1136/bmjopen-2014-005900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/12/2014] [Accepted: 07/18/2014] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The International Consensus Diagnostic Criteria (ICDC) designed to diagnosis autoimmune pancreatitis (AIP) has been proposed recently. The diagnostic performance of ICDC has not been previously evaluated in diffuse-type and focal-type AIP, respectively, in comparison with the revised HISORt and Asian criteria in Taiwan. DESIGN Prospective, consecutive patient cohort. SETTING Largest tertiary referred centre hospital managing pancreatic disease in Taiwan. PARTICIPANTS 188 patients with AIP and 130 with tissue proofed pancreatic adenocarcinoma were consecutively recruited. INTERVENTIONS The ICDC, as well as revised HISORt and Asian criteria, was applied for each participant. Each diagnostic criterion of ICDC was validated with special reference to levels 1 and 2 in diffuse-type and focal-type AIP. OUTCOMES Sensitivity, specificity and accuracy. Each diagnostic criterion of ICDC was validated with special reference to levels 1 and 2 in AIP and focal-type AIP. RESULTS The sensitivity, specificity and accuracy of ICDC for all AIP were the best: 89.4%, 100% and 93.7%, respectively, in these three criteria. The sensitivity, specificity and accuracy of ICDC for focal-type AIP (84.9%, 100% and 93.8%) were also the best among these three criteria. The area under the curve of receiver-operator characteristic of ICDC was 0.95 (95% CI 0.92 to 0.97) in all AIP and 0.93 (95% CI 0.88 to 0.97) in focal-type AIP. CONCLUSIONS The sensitivity, specificity and accuracy of ICDC are higher than the revised HISORt and Asian criteria. The sensitivity, specificity and accuracy of each criterion are higher in diffuse-type AIP compared with focal-type AIP. Under the same specificity, the sensitivity and accuracy of ICDC are higher than other diagnostic criteria in focal-type AIP. ICDC has better diagnostic performance compared with previously proposed diagnostic criteria in diffuse-type and focal-type AIP.
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Affiliation(s)
- Ming-Chu Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Po-Chin Liang
- Department of Radiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - I-Shiow Jan
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Ting Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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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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Increase diagnostic accuracy in differentiating focal type autoimmune pancreatitis from pancreatic cancer with combined serum IgG4 and CA19-9 levels. Pancreatology 2014; 14:366-72. [PMID: 25278306 DOI: 10.1016/j.pan.2014.07.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES To distinguish autoimmune pancreatitis (AIP), especially focal type, from pancreatic cancer, is a greatest challenge for clinician. The aim of the study is to compare the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of combined serum IgG4 and CA19-9 levels to differentiate AIP from pancreatic cancer by HISORt, Asian and international consensus diagnostic criteria. METHODS We measured serum IgG4, CEA, and CA19-9 levels in 188 AIP patients, 86 non-AIP chronic pancreatitis patients, and 130 pancreatic cancer patients. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were compared with different diagnostic criteria. We also compared the diagnostic performance in patients with or without jaundice. RESULTS The serum level of IgG4 was significantly higher in AIP than those in non-AIP chronic pancreatitis and pancreatic cancer. The optimal cutoffs of IgG4 and CA19-9 to differentiate AIP from pancreatic cancer were 175 mg/dL and 85.0 U/ml based on ROC analysis. Combining IgG4 level over 280 mg/dL and CA19-9 below 85.0 U/ml could yield a best diagnostic accuracy (85.6%) to distinguishing AIP from pancreatic cancer in all of the HISORt, Asian and international consensus diagnostic criteria. With the combination of serological test, focal type AIP could be diagnosed with comparable accuracy as diffuse type AIP. CONCLUSIONS Our study demonstrated that combined use of serum IgG4 (over 280 mg/dL) and CA19-9 9 (below 85.0 U/ml) together increases the diagnostic accuracy to distinguish AIP from pancreatic cancer non-invasively, especially in focal type autoimmune pancreatitis.
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Fritz S, Bergmann F, Grenacher L, Sgroi M, Hinz U, Hackert T, Büchler MW, Werner J. Diagnosis and treatment of autoimmune pancreatitis types 1 and 2. Br J Surg 2014; 101:1257-65. [DOI: 10.1002/bjs.9574] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 01/31/2014] [Accepted: 04/24/2014] [Indexed: 01/05/2023]
Abstract
Abstract
Background
Autoimmune pancreatitis (AIP) is characterized by diffuse or focal swelling of the pancreas. AIP has been divided into types 1 and 2. The aim of the study was to evaluate and compare the clinicopathological characteristics, therapy and outcome of patients with AIP.
Methods
The medical records of patients diagnosed with AIP between January 2003 and July 2011 were reviewed. Characteristics of patients with AIP types 1 and 2 were compared with those of patients with pancreatic ductal adenocarcinoma (PDAC).
Results
AIP was classified as type 1 in 40 patients and type 2 in 32 according to the HISORt (Histology, Imaging, Serology, Other organ involvement, Response to therapy) criteria. Patients with histologically confirmed AIP type 2 were younger than those with type 1 (P = 0·005). Some 30 of 32 patients with AIP type 2 were found to have a localized tumour-like pancreatic mass and underwent pancreatectomy, compared with only 16 of 40 with type 1 (P < 0·001). Three of 25 patients with AIP type 2 presented with raised serum levels of IgG4 compared with 21 of 38 with type 1 (P < 0·001). There was no difference in symptoms and involvement of other organs between AIP types 1 and 2. Presentation with weight loss was more common among patients with PDAC than those with AIP, but there was no difference in pain or jaundice between the groups. Raised serum carbohydrate antigen 19-9 levels were more prevalent in patients with PDAC.
Conclusion
Patients with AIP type 2 frequently present with abdominal pain and a tumour-like mass. Differentiating AIP from PDAC is difficult, so making the clinical decision regarding operative versus conservative management is challenging.
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Affiliation(s)
- S Fritz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - F Bergmann
- Department of Pathology, University of Heidelberg, Heidelberg, Germany
| | - L Grenacher
- Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - M Sgroi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - U Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - J Werner
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University of Munich, Munich, Germany
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Singla V, Garg PK. Role of diagnostic and therapeutic endoscopic ultrasonography in benign pancreatic diseases. Endosc Ultrasound 2014; 2:134-41. [PMID: 24949381 PMCID: PMC4062252 DOI: 10.7178/eus.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 07/20/2013] [Indexed: 12/21/2022] Open
Abstract
Standard imaging of pancreas is generally obtained by computed tomography and magnetic resonance imaging. However endoscopic ultrasound (EUS) has become an indispensable tool for the diagnosis of various pancreatic diseases. Because of the close proximity of the EUS probe to the pancreas, EUS provides excellent images of the pancreas. In this review, we discuss the role of EUS in the clinical management of patients with benign pancreatic diseases, i.e., various forms of pancreatitis.
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Affiliation(s)
- Vikas Singla
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Ikeura T, Manfredi R, Zamboni G, Negrelli R, Capelli P, Amodio A, Caliò A, Colletta G, Gabbrielli A, Benini L, Okazaki K, Vantini I, Frulloni L. Application of international consensus diagnostic criteria to an Italian series of autoimmune pancreatitis. United European Gastroenterol J 2014; 1:276-84. [PMID: 24917972 DOI: 10.1177/2050640613495196] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 05/21/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND International consensus diagnostic criteria (ICDC) have been proposed to classify autoimmune pancreatitis (AIP) in type 1, type 2, or not otherwise specified. OBJECTIVE Aim was to apply the ICDC to an Italian series of patients to evaluate the incidence and clinical profiles among different subtypes of AIP. METHODS we re-evaluated and classified 92 patients diagnosed by Verona criteria, according to the ICDC. RESULTS Out of 92 patients, 59 (64%) were diagnosed as type 1, 17 (18%) as type 2, and 15 (16%) as not otherwise specified according to the ICDC. A significant difference between type 1 and type 2 were found for age (54.5 ± 14.5 vs. 34.4 ± 13.9 respectively; p < 0.0001), male sex (76 vs. 47%; p = 0.007), jaundice (66 vs. 18%; p = 0.002) and acute pancreatitis (9 vs. 47%; p < 0.0001), elevated serum IgG4 levels (85 vs. 7%; p < 0.0001), inflammatory bowel disease (8 vs. 82%; < 0.0001), and relapse of the disease (34 vs. 6%; p = 0.058). Imaging and response to steroids in the not-otherwise-specified group were similar to type 1 and 2. CONCLUSIONS Type 1 has a different clinical profile from type 2 autoimmune pancreatitis. The not-otherwise-specified group has peculiar clinical features which are shared both with type 1 or type 2 groups.
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Hardy TG, McNab AA, Rose GE. Enlargement of the Infraorbital Nerve. Ophthalmology 2014; 121:1297-303. [DOI: 10.1016/j.ophtha.2013.12.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 12/24/2022] Open
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Immunoglobulin G4-related pancreatic and biliary diseases. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:523-30. [PMID: 24078937 DOI: 10.1155/2013/180461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Autoimmune pancreatitis and autoimmune cholangitis are new clinical entities that are now recognized as the pancreatico-biliary manifestations of immunoglobulin (Ig) G4-related disease. OBJECTIVE To summarize important clinical aspects of IgG4-related pancreatic and biliary diseases, and to review the role of IgG4 in the diagnosis of autoimmune pancreatitis (AIP) and autoimmune cholangitis (AIC). METHODS A narrative review was performed using the PubMed database and the following keywords: "IgG4", "IgG4 related disease", "autoimmune pancreatitis", "sclerosing cholangitis" and "autoimmune cholangitis". A total of 955 articles were retrieved; of these, 381 contained relevant data regarding the IgG4 molecule, pathogenesis of IgG-related diseases, and diagnosis, management and long-term follow-up for patients with AIP and AIC. Of these 381 articles, 66 of the most pertinent were selected. RESULTS The selected studies demonstrated the increasing clinical importance of both AIP and AIC, which can mimic pancreatic cancer and cholangiocarcinoma, respectively. IgG4 titration in tissue or blood cannot be used alone to diagnose all IgG4-related diseases; however, it is often a useful adjunct to clinical, radiological and histological features. AIP and AIC respond to steroids; however, relapse is common and long-term maintenance treatment often required. CONCLUSIONS A review of the diagnosis and management of both AIC and AIP is timely and pertinent to clinical practice because the amount of information regarding these conditions has increased substantially in the past few years, resulting in significant impact on the clinical management of affected patients.
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Pezzilli R. Immunosuppressive drugs for the treatment of autoimmune pancreatitis. Immunotherapy 2014; 6:477-83. [DOI: 10.2217/imt.14.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Autoimmune pancreatitis is one of the few diseases of the pancreas characterized by the possibility of curing the illness using immunosuppressant drugs. In this paper, the therapeutic approach used to treat autoimmune pancreatitis patients and the clinical outcome related to each treatment modality were reviewed. Steroids are useful in alleviating the symptoms of the acute presentation of autoimmune pancreatitis, but some questions remain open, such as a shared definition of the disease’s remission as well as autoimmune pancreatitis relapse, the dosage of steroids in the symptomatic phase of the disease and the duration of steroid therapy. Finally, it should be determined if other immunosuppressive nonsteroidal drugs could become first-line therapy in patients with autoimmune pancreatitis without jaundice and without atrophic pancreas.
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Affiliation(s)
- Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases & Internal Medicine, Sant’Orsola-Malpighi Hospital, Bologna, Italy
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Pezzilli R, Pagano N. Pathophysiology of autoimmune pancreatitis. World J Gastrointest Pathophysiol 2014; 5:11-17. [PMID: 24891971 PMCID: PMC4024516 DOI: 10.4291/wjgp.v5.i1.11] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 11/05/2013] [Accepted: 11/16/2013] [Indexed: 02/06/2023] Open
Abstract
Autoimmune pancreatitis (AIP) is a recently discovered form of pancreatitis and represents one of the diseases of the pancreas which can be cured and healed medically. International consensus diagnostic criteria have been developed, and the clinical phenotypes associated with the histopathologic patterns of lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-centric pancreatitis should be referred to as type 1 and type 2 AIP, respectively. Most importantly, in type 1 AIP, the pancreatic manifestations are associated with other extrapancreatic disorders, resembling an immunoglobulin G4 (IgG4)-related disease. In addition, the pancreas of a patient with AIP is often infiltrated by various types of immune cells; the cluster of differentiation (CD) 4 or CD8 T lymphocytes and IgG4-bearing plasma cells have been found in the pancreatic parenchyma and other involved organs in AIP and factors regulating T-cell function may influence the development of AIP. From a genetic point of view, it has also been reported that DRB1*0405 and DQB1*0401 mutations are significantly more frequent in patients with AIP when compared to those with chronic calcifying pancreatitis, and that only DQB1*0302 had a significant association with the relapse of AIP. Finally, it has been found that the polymorphic genes encoding cytotoxic T lymphocyte-associated antigen 4, a key negative regulator of the T-cell immune response, are associated with AIP in a Chinese population. Even if these data are not concordant, it is possible that physiological IgG4 responses are induced by prolonged antigen exposure and controlled by type 2 helper T cells. We reviewed the current concepts regarding the pathophysiology of this intriguing disease, focusing on the importance of the humoral and cellular immune responses.
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Yanagisawa N, Haruta I, Shimizu K, Furukawa T, Higuchi T, Shibata N, Shiratori K, Yagi J. Identification of commensal flora-associated antigen as a pathogenetic factor of autoimmune pancreatitis. Pancreatology 2014; 14:100-6. [PMID: 24650962 DOI: 10.1016/j.pan.2014.01.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/30/2013] [Accepted: 01/24/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Autoimmune pancreatitis (AIP) is a chronic fibro-inflammatory disease of the pancreas constituting, in part, a recently defined nosological entity of IgG4-related systemic sclerosing diseases. The pathogenetic factors of AIP have not been fully elucidated. We previously established a mouse model of AIP using chronic exposure to a commensal bacteria, Escherichia coli. METHODS To determine the pathogenetically relevant antigen of E. coli, the outer membrane fractions of E. coli were subjected to two-dimensional gel electrophoresis followed by immunoblotting against sera from the AIP model. Immunoreactive spots were determined using MALDI TOF/MS and Mascot search. The recombinant protein of the identified antigen was examined for their ability to induce AIP-like disorder in C57BL/6 mice. Furthermore, the antibody titer against that antigen was determined in AIP patients. RESULTS One representative spot reacting with sera from E. coli-inoculated mice was identified as FliC from E. coli, based on the results of TOF/MS. The repeated inoculation of recombinant FliC in C57BL/6 mice induced AIP-like pancreatitis and higher titers of anti-lactoferrin and anti-carbonic anhydrase II. Sera from patients with AIP had the highest antibody titer, while those from patients with pancreatic diseases other than AIP had a higher antibody titer against E. coli and FliC, compared with pancreatic disease-free controls. CONCLUSIONS FliC from E. coli may pathogenetically generate an AIP-like inflammation status. A reconsideration of the importance of commensal bacteria as an environmental factor(s) capable of inducing autoimmunity could provide insight to overcoming AIP.
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Affiliation(s)
- Naoko Yanagisawa
- Department of Microbiology and Immunology, Tokyo Women's Medical University, Japan
| | - Ikuko Haruta
- Department of Microbiology and Immunology, Tokyo Women's Medical University, Japan; Department of Gastroenterology and Medicine, Tokyo Women's Medical University, Japan.
| | - Kyoko Shimizu
- Department of Gastroenterology and Medicine, Tokyo Women's Medical University, Japan
| | - Toru Furukawa
- Institute for Integrated Medical Sciences, Tokyo Women's Medical University, Japan
| | - Tomoaki Higuchi
- Department of Microbiology and Immunology, Tokyo Women's Medical University, Japan
| | - Noriyuki Shibata
- Department of Pathology, Tokyo Women's Medical University, Japan
| | - Keiko Shiratori
- Department of Gastroenterology and Medicine, Tokyo Women's Medical University, Japan
| | - Junji Yagi
- Department of Microbiology and Immunology, Tokyo Women's Medical University, Japan
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Abstract
: Restorative proctocolectomy with ileal pouch-anal anastomosis is commonly used in the management of ulcerative colitis. Inflammation of the ileal pouch reservoir, or pouchitis, is a common complication of ileal pouch-anal anastomosis that is incompletely understood. Risk factors including nonsmoker status and primary sclerosing cholangitis have been linked with pouchitis development, but the etiopathogenesis of pouchitis remains poorly defined. Pouchitis is more commonly a complication of ileal pouch-anal anastomosis performed in patients with ulcerative colitis, and similar to ulcerative colitis, chronic pouchitis is associated with extraintestinal manifestations and other diseases of immune origin, suggesting overlap in the disease pathogenesis. It is becoming apparent that pouchitis encompasses clinically distinct subtypes based on the response or lack of response to antibiotic therapy. There is also emerging evidence of the role of autoimmunity in a subgroup of patients with pouchitis, including patients with concurrent primary sclerosing cholangitis, seropositivity for immunoglobulin G4, or infiltration of immunoglobulin G4-expressing plasma cells in the pouch mucosa. The identification of underlying autoimmunity may have important clinical implications in the diagnosis, subclassification, and management of pouchitis.
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Pezzilli R, Morselli-Labate AM. The concept of autoimmune pancreatitis and its immunological backgrounds. Expert Rev Clin Immunol 2014; 6:125-36. [DOI: 10.1586/eci.09.68] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Khosroshahi A, Cheryk LA, Carruthers MN, Edwards JA, Bloch DB, Stone JH. Brief Report: Spuriously Low Serum IgG4 Concentrations Caused by the Prozone Phenomenon in Patients With IgG4-Related Disease. Arthritis Rheumatol 2013; 66:213-7. [DOI: 10.1002/art.38193] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 09/05/2013] [Indexed: 12/24/2022]
Affiliation(s)
- Arezou Khosroshahi
- Emory University School of Medicine, Atlanta, Georgia, and Massachusetts General Hospital and Harvard Medical School; Boston
| | | | | | | | - Donald B. Bloch
- Massachusetts General Hospital and Harvard Medical School; Boston
| | - John H. Stone
- Massachusetts General Hospital and Harvard Medical School; Boston
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Abstract
IgG4-related disease is a systemic fibroinflammatory syndrome of unknown etiology characterized by local inflammatory swelling and tumefactive lesions in one or several organs. It unifies several diseases previously thought to be unrelated. Recently, diagnostic criteria for the disease have been formulated and were complemented by an international consensus on histopathological assessment. In general, the disease activity can be rapidly controlled by high doses of prednisolone (0.6 mg/kg body weight); however, relapses, either local or in other regions, are frequent during tapering of the steroid dose. Commonly used steroid-sparing agents are only partially effective. Persistent local inflammatory activity may result in permanent organ damage. In refractory cases rituximab treatment has been used with good success. In the long-term care of affected patients a probable increased risk of malignancies (e.g. solid tumors and lymphoma) requires attention.
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Affiliation(s)
- J Loock
- Klinik für Rheumatologie und klinische Immunologie, Schön Klinikum Hamburg Eilbek, Dehnhaide 120, 22081, Hamburg, Deutschland.
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Sun W, Gao RF, Chen Y, Su YY, Dong LL. Measurement of serum IgG4 levels by an established ELISA system and its clinical applications in autoimmune diseases. ACTA ACUST UNITED AC 2013; 33:611-614. [PMID: 23904386 DOI: 10.1007/s11596-013-1167-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 03/21/2013] [Indexed: 12/11/2022]
Abstract
IgG4-related disease (IgG4-RD) is a novel and rare autoimmune disease entity. Elevated serum IgG4 level is strongly suggestive of IgG4-RD. But it is still unknown whether serum IgG4 elevation commonly occurs in other autoimmune diseases. In this study, the serum IgG4 levels were detected by an established enzyme-linked immunosorbent assay (ELISA) in a variety of autoimmune diseases including systemic lupus erythematosus (SLE), Sjogren's syndrome (SS), polymyositis or dermatomyositis (PM/DM) and IgG4-RD. To evaluate the reliability of this ELISA system, some of our samples were sent to a lab in Kanazawa Medical University, Japan, and detected by using the nephelometric assay. The results showed that our findings were consistent with theirs. Moreover, it was found that the serum IgG4 levels were 0.23±0.16 g/L in 53 healthy controls, 0.16±0.15 g/L in 103 SLE patients, 0.22±0.18 g/L in 41 SS patients and 0.40±0.32 g/L in 21 PM/DM patients. No significant difference in the serum IgG4 level was observed among these groups (P>0.05). The serum IgG4 levels of two cases of IgG4-RD were 1.63 and 4.65 g/L respectively, and both decreased markedly after treatment with glucocorticoids. These data indicated that this established ELISA system can be used for detecting serum IgG4 levels. Elevated serum IgG4 levels help diagnose IgG4-RD and evaluate the curative effect of this condition rather than other autoimmune diseases.
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Affiliation(s)
- Wei Sun
- Department of Stomatology, Union Hospital, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Rong-Fen Gao
- Department of Rheumatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yu Chen
- Department of Rheumatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yu-Ying Su
- Department of Rheumatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ling-Li Dong
- Department of Rheumatology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Abstract
GOALS To determine the prevalence of ulcerative colitis (UC) in autoimmune pancreatitis (AIP) patients in a tertiary referral hospital and to compare the clinical and pathologic characteristics and outcomes of UC associated with AIP (AIP-UC) and UC patients. BACKGROUND Recently, it was suggested that UC is associated with AIP. However, the prevalence of UC in AIP, together with the clinical characteristics and outcomes of AIP-UC are not clear. STUDY We retrospectively reviewed the medical records of AIP patients diagnosed at the Asan Medical Center. RESULTS Of the 104 patients with AIP, 6 (5.8%) were also diagnosed with UC. Serum immunoglobulin G (IgG) and IgG4 were elevated in 1 patient (16.7%), respectively, and 4 (66.7%) showed idiopathic duct-centric pancreatitis (type 2 AIP). Compared with 24 matched patients with UC only, AIP-UC patients had a lower body mass index (P=0.003), higher C-reactive protein levels (P=0.048), and higher Mayo scores (P=0.006) at diagnosis of UC. Two AIP-UC patients (33.3%), but none with UC only showed increased infiltration of IgG4-positive cells into the colonic tissues (P=0.006). During follow-up, 2 AIP-UC patients (33.3%) underwent colectomy and 1 (16.7%) died, but no colectomies or deaths occurred in the UC only group. CONCLUSIONS AIP patients seem to have a higher risk of UC compared with the general population. The increased IgG4-positive cellular infiltration in the colonic tissue suggests that UC may be an extrapancreatic manifestation of AIP.
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Abstract
Autoimmune pancreatitis (AIP) is a rare, heterogeneous, fibroinflammatory disorder of the pancreas. It has gained increasing recognition due to a presentation that can mimic difficult-to-treat disorders such as pancreatic cancer, cholangiocarcinoma and primary sclerosing cholangitis. In contrast, autoimmune pancreatitis is a benign disease that is very responsive to therapy with corticosteroids. There are two types of AIP. Type 1 disease is the most common worldwide and is associated with extrapancreatic manifestations and elevated levels of IgG4-positive cells. Type 2 AIP is characterized by a paucity of IgG4-positive cells and is more difficult to diagnose. This review provides an update on the diagnosis, pathophysiology and treatment of AIP, with special emphasis on the two subtypes.
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Affiliation(s)
- Gyanprakash A. Ketwaroo
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sunil Sheth
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Deshpande V, Khosroshahi A. Diagnostic guidelines for IgG4-related disease with a focus on histopathological criteria. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.mpdhp.2013.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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