IgG4-related prostatitis manifesting as urinary obstruction in a 28-year-old male

Imaging findings in inflammatory disease of the genital organs

This review focuses on inflammatory diseases of female and male genital organs and discusses their epidemiology, pathogenesis, clinical presentation, and imaging findings. The female section covers pelvic inflammatory disease (PID) primarily caused by sexually transmitted infections (STIs) that affect the uterus, fallopian tubes, and ovaries. Unusual causes such as actinomycosis and tuberculosis have also been explored. The male section delves into infections affecting the vas deferens, epididymis, testes, prostate, and seminal vesicles. Uncommon causes such as tuberculosis, and Zinner syndrome have also been discussed. In addition, this review highlights other conditions that mimic male genital tract infections such as vasculitis, IgG4-related diseases, and sarcoidosis. Accurate diagnosis and appropriate management of these inflammatory diseases are essential for preventing serious complications and infertility. Imaging modalities such as ultrasound, magnetic resonance imaging, and computed tomography play a crucial role in diagnosis. Understanding the diverse etiologies and imaging findings is vital for the effective management of inflammatory diseases of the genital organs.

Multimodality pictorial review of IgG4-related disease in the abdomen and pelvis

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a systemic, immune-mediated disease that can affect multiple organs, including the orbits, salivary glands, thyroid gland, lungs, aorta, pancreas, bile ducts, lymph nodes, and retroperitoneum. While timely diagnosis is particularly important given the efficacy of glucocorticoid treatment for IgG4-RD, accurate recognition can prove a challenge given the overlap between the imaging features of this disease and other entities.

PURPOSE

After a review of the epidemiology, pathophysiology, and clinical considerations (including treatment) associated with IgG4-RD, this pictorial review will showcase the variable imaging manifestations of this disease in the abdomen and pelvis. Post-treatment imaging appearance of these entities will be reviewed and mimickers of this disease in the abdomen and pelvis will be presented.

CONCLUSION

The presence of mass-like soft tissue with radiographic characteristics of fibrosis affecting multiple organs should raise suspicion for IgG4-RD, although definite diagnosis can only be made with appropriate clinical, serological, and pathologic data.

Focal IgG4-related periprostatic "PI-RADS 5" pseudotumor mimicking prostatic adenocarcinoma

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterized by raised serum IgG4 levels and tumefactive inflammation affecting multiple organ systems, typically involving the pancreas and biliary tree. Though rare, prostatic involvement has been reported in a few cases and is suspected to be an underreported entity. Our patient is a 63-year-old gentleman who has presented with an incidental "PI-RADS 5" (Prostate Imaging Reporting & Data System) prostate lesion and perivascular soft tissue cuffing of the superior rectal vessels on MRI rectum performed for surveillance of rectal neuroendocrine tumor. He had a history of lacrimal gland IgG4-RD. The lentiform prostate lesion subtly indents the prostate capsule, reminiscent of a periprostatic rather than an intraprostatic lesion. Perivascular cuffing of superior rectal vessels suggest inflammatory vasculitis of IgG4-RD. Differential diagnosis of periprostatic inflammatory IgG4-RD was considered, subsequently proven on MRI-ultrasound fusion targeted biopsy. Reported radiological findings of prostate IgG4-RD typically show diffuse chronic inflammation of the prostate, with a minority of the reports describing focal involvement, often mimicking focal prostate adenocarcinoma. Focal periprostatic involvement of IgG4-RD is an unusual manifestation which should be considered in patients with IgG4-RD who present with a periprostatic pseudotumor. IgG4-RD of the prostate usually responds well to steroid treatment without the need for surgery.

Anatomic and Functional Imaging of Immunoglobulin G4-related Disease and Its Mimics

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is an immune-mediated fibrosclerosing disease with tumefactive lesions infiltrated by IgG4-positive plasma cells. Initially described as autoimmune pancreatitis, IgG4-RD is now recognized as a discrete entity and is found to affect virtually any organ in the body. Common extrapancreatic sites include the biliary tree, salivary glands, periorbital tissue, lungs, kidneys, lymph nodes, aorta, retroperitoneum, and thyroid gland. Diagnosis-which relies on histopathologic, serologic, and radiologic features-can be challenging with the disease underdiagnosed, as IgG4-RD often mimics malignancy, infectious processes, or other immune-mediated conditions. Patients may present with signs of compression of nearby structures due to mass effect or with organ failure when the disease is left untreated. The clinical course is complex, with single- or multiorgan involvement and metachronous or synchronous occurrence of lesions. IgG4-RD responds well to glucocorticoid therapy, disease-modifying antirheumatic drugs, and B-cell-depleting biologic agents; prompt diagnosis is important to avoid delay in treatment and unnecessary pharmacologic or surgical intervention. While imaging features may not be specific for IgG4-RD, functional whole-body imaging with fluorine 18-fluorodeoxyglucose PET/CT is a useful adjunct for localizing extrapancreatic sites for biopsy, monitoring therapeutic response, and demonstrating disease relapse. The authors describe the pancreatic and extrapancreatic sites of involvement in IgG4-RD, with imaging features and patterns to aid in distinguishing IgG4-RD from its mimics through a multimodality approach with emphasis on functional imaging evaluation. ^©RSNA, 2023 Quiz questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

How I manage bacterial prostatitis

BACKGROUND

Bacterial prostatitis is a highly prevalent infection responsible for significant morbidity among men. The diagnosis and treatment for bacterial prostatitis remains complicated. The difficulty in diagnosis is in part owing to the paucity of high-quality evidence that guides a clinician's interpretation of patients' history, physical examination, and laboratory findings. Treatment is challenging because of the few antimicrobials capable of prostate penetration, growing antimicrobial resistance limiting effective treatment options, and the high risk of recurrence.

OBJECTIVES

We aimed to provide a useful resource for clinicians in effectively diagnosing and managing acute bacterial prostatitis (ABP) and chronic bacterial prostatitis (CBP).

SOURCES

A PubMed literature search on prostatitis was performed with no restrictions on publication date.

CONTENT

The epidemiology, pathophysiology, diagnosis, and treatment for ABP and CBP are explored using a clinical vignette as relevant context.

IMPLICATIONS

Bacterial prostatitis can be diagnosed through a focused history and microbiological investigations. The Meares-Stamey 4-glass test or modified 2-glass test can help confirm the diagnosis if uncertainty exists. Typical uropathogens are common contributors to bacterial prostatitis but there is growing interest in exploring the role atypical and traditional non-pathogenic organisms may have. Fluoroquinolones remain first-line therapy, followed by trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline if the pathogen is susceptible. Fosfomycin has emerged as a repurposed and useful agent because of the increasing incidence of multidrug-resistant pathogens. Selection of appropriate antimicrobial regimens can be challenging and is dependent on the host, chronicity of symptoms, uropathogens' susceptibilities, antimicrobials' side effect profile, and the presence of prostatic abscesses or calcifications. ABP can typically be treated similar to other complicated urinary tract infections. However, CBP requires prolonged therapy, with a minimum of 4 weeks and up to 12 weeks of therapy.