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Soh BWT, Prendergast SC, Burke L, O’Connor CT, Ullah I, O’Brien JM, Hinchion JA, Arnous S, Kiernan TJ. Severe Aortic Valvular Incompetence From IgG4-Related Disease: An Unusual Entity. JACC Case Rep 2023; 24:102027. [PMID: 37869216 PMCID: PMC10589445 DOI: 10.1016/j.jaccas.2023.102027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/07/2023] [Accepted: 08/25/2023] [Indexed: 10/24/2023]
Abstract
IgG4-related disease (IgG4-RD) is a new clinical entity characterized by lymphoplasmacytic lesions rich in IgG4-positive plasma cells. Myocardial involvement is extremely rare and not a typical cardiovascular manifestation of IgG4-RD. We report a rare case of IgG4-RD-associated myocardial mass causing severe aortic incompetence, successfully treated with surgery and corticosteroids. (Level of Difficulty: Intermediate.).
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Affiliation(s)
| | | | - Louise Burke
- Department of Histopathology, Cork University Hospital, Cork, Ireland
| | - Cormac T. O’Connor
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Ihsan Ullah
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Julie M. O’Brien
- Department of Radiology, University Hospital Limerick, Limerick, Ireland
| | - John A. Hinchion
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - Samer Arnous
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Thomas J. Kiernan
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
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Elevated Serum Levels of IgG4 in Patients with Heart Failure with Reduced Ejection Fraction: A Prospective Controlled Study. BIOLOGY 2022; 11:biology11081168. [PMID: 36009795 PMCID: PMC9404706 DOI: 10.3390/biology11081168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022]
Abstract
(1) Background: Immunoglobulin gamma subclass 4 (IgG4) is a serum protein belonging to the immunoglobulin superfamily. It has a central role in certain immune-mediated conditions defined as IgG4-related disease. There is a paucity of data regarding the potential association of IgG4 and cardiovascular diseases. Our aim is to study the serum levels of IgG4 in patients with ischemic and non-ischemic dilated cardiomyopathy (DCM). (2) Methods: patients with ischemic and non-ischemic DCM were included in this study. Non-ischemic DCM was defined as a left ventricular ejection fraction (LVEF) < 40% without coronary artery disease (CAD). Ischemic DCM was defined as a LVEF < 40% and proven CAD. The serum concentrations of IgG4 were measured by turbidimetry. (3) Results: Overall 98 patients with cardiomyopathy had significantly higher levels of IgG4 compared with the control group (77.4 ± 64.0 vs. 50.3 ± 28.8 mg/dL, p < 0.01). Although there was no difference in the total IgG levels in patients with ischemic DCM, the serum concentrations of IgG4 were significantly higher than the corresponding values in the control group (89.8 ± 67.3 vs. 50.3 ± 28.8 mg/dL; interquartile ranges: 40.4−126.5 vs. 31.8−66.8 mg/dL, p < 0.01). This was altered by gender and smoking. (4) Conclusions: The patients with ischemic DCM had increased serum concentrations of IgG4. Future studies are warranted to explore the potential role of an IgG4-mediated process in patients with heart failure with reduced LVEF.
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Nomura S, Ishii W, Hara R, Nanasawa S, Nishiwaki K, Kagoshima M, Takano T, Satomi H, Usui T. IgG4-related Disease with a Cardiac Mass Causing Cerebral Infarction. Intern Med 2022; 61:1259-1264. [PMID: 34615822 PMCID: PMC9107975 DOI: 10.2169/internalmedicine.8049-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic inflammatory disease characterized by infiltration of extensive IgG4-positive plasma cells and lymphocytes. Although IgG4-RD has been observed in almost all organs, it rarely affects the myocardium. Cardiovascular lesions of IgG4-RD appear as aortic (aortic aneurysm and aortitis) and pericardial (constrictive pericarditis) lesions as well as pseudotumors around the coronary arteries. We herein report a case of IgG4-RD with a cardiac mass in the right atrium involving a sinus node. This condition caused arrhythmia and repeated strokes. We successfully treated the patient through resection of the cardiac mass, catheter ablation and immunosuppressive therapy.
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Affiliation(s)
- Shun Nomura
- Division of Rheumatology, Department of Internal Medicine, Nagano Red Cross Hospital, Japan
| | - Wataru Ishii
- Division of Rheumatology, Department of Internal Medicine, Nagano Red Cross Hospital, Japan
| | - Ryosuke Hara
- Division of Rheumatology, Department of Internal Medicine, Nagano Red Cross Hospital, Japan
| | | | - Kei Nishiwaki
- Division of Cardiology, Joetsu General Hospital, Japan
| | | | - Tamaki Takano
- Department of Cardiovascular Surgery, Nagano Red Cross Hospital, Japan
| | | | - Tatsuya Usui
- Department of Cardiology, Nagano Red Cross Hospital, Japan
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4
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Kondo N, Kasamatsu H, Nakazawa H, Tanaka H, Kuroiwa KK, Ide S. Is That a Real Tumor? J Cardiothorac Vasc Anesth 2021; 35:2530-2532. [PMID: 33875354 DOI: 10.1053/j.jvca.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/10/2021] [Accepted: 03/14/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Nami Kondo
- Department of Anesthesiology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano 380-8582, Japan.
| | - Haruka Kasamatsu
- Department of Anesthesiology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano 380-8582, Japan
| | - Haruka Nakazawa
- Department of Anesthesiology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano 380-8582, Japan
| | - Hidenori Tanaka
- Department of Anesthesiology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano 380-8582, Japan
| | - Kaori Kimura Kuroiwa
- Department of Anesthesiology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano 380-8582, Japan
| | - Susumu Ide
- Department of Anesthesiology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano 380-8582, Japan
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Shakir A, Wheeler Y, Krishnaswamy G. The enigmatic immunoglobulin G4-related disease and its varied cardiovascular manifestations. Heart 2021; 107:790-798. [PMID: 33468575 DOI: 10.1136/heartjnl-2020-318041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/13/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterised by multiorgan lymphoplasmacytic infiltration, obliterative phlebitis and storiform fibrosis. It can be associated with cardiovascular pathology. The objective of this narrative review is to summarise the published literature on cardiovascular manifestations of IgG4-RD and to provide a basis for diagnosis and management of the condition by the practising cardiologist.We propose the following categorisations of cardiovascular IgG4-RD: aortitis, medium-vessel arteritis, pulmonary vascular disease, phlebitis, valvulopathy, pericarditis, myocardial disease and antineutrophilic cytoplasmic antibody-associated vasculitis. We also review herein developments in radiological diagnosis and reported medical and surgical therapies. Cardiovascular lesions frequently require procedural and/or surgical interventions, such as aortic aneurysm repair and valve replacement. IgG4-RD of the cardiovascular system results in serious complications that can be missed if not evaluated aggressively. These are likely underdiagnosed, as clinical presentations frequently mimic cardiovascular disease due to more common aetiologies (myocardial infarction, abdominal aortic aneurysm and so on). While systemic corticosteroids are the mainstay of IgG4-RD treatment, biological and disease-modifying agents are becoming more widely used. Cardiologists should be aware of cardiovascular IgG4-RD as a differential diagnosis, and understand the roles of corticosteroids, disease-modifying agents and biologicals, as well as their integration with surgical approaches. There are several knowledge gaps, including diagnosis, risk factors, pathogenesis and appropriate management in Ig4-RD of the cardiovascular system. Areas lacking well-conducted randomized trials include safety of steroids in the setting of vascular aneurysms and the role of disease-modifying drugs and biological agents in patients with established cardiovascular complications of this multifaceted enigmatic disease.
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Affiliation(s)
- Aamina Shakir
- Internal Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Guha Krishnaswamy
- Wake Forest University Department of Internal Medicine, Winston-Salem, North Carolina, USA .,Allergy, Asthma and Clinical Immunology, Bill Hefner VA Medical Center and affiliated institutions, Salisbury, North Carolina, USA
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6
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Diamond JE, Marboe C, Palmeri N, Cook JR, Bijou R, Restaino S, Lin E. Isolated Immunoglobulin G4-Related Disease Myocarditis Treated With Heart Transplantation. Circ Heart Fail 2020; 13:e007204. [PMID: 32894982 DOI: 10.1161/circheartfailure.120.007204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Jamie E Diamond
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
| | - Charles Marboe
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
| | - Nicholas Palmeri
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
| | - Joshua R Cook
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
| | - Rachel Bijou
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
| | - Susan Restaino
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
| | - Edward Lin
- Beth Israel Deaconess Medical Center, Boston, MA (J.E.D., N.P.).,NewYork Presbyterian Hospital/Columbia University Medical Center, New York, NY (C.M., J.R.C., R.B., S.R., E.L.)
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Hajsadeghi S, Pakbaz M, Hassanzadeh M, Sadeghipour A. A challenging case report of IgG4-related systemic disease involving the heart and retroperitoneum with a literature review of similar heart lesions. Echocardiography 2020; 37:1478-1484. [PMID: 32841427 DOI: 10.1111/echo.14828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/09/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022] Open
Abstract
The IgG4-related disease is a distinct, steroid-responsive fibro-inflammatory disorder of unknown etiology. This multiorgan disease is characterized by tumefactive lesions that contain rich infiltrations of IgG4-positive plasma cells, with the pancreas, and the salivary and lacrimal glands being the main involved. The more common cardiovascular involvements include inflammatory peri-aortitis, coronary arteritis, and pericarditis. Intra-cardiac tumefactive lesions are rarely reported. Herein, we describe a challenging case of IgG4-related disease with a long-time lag between initiation of symptoms to proper diagnosis with biopsy-proven cardiac and retroperitoneal and possible pituitary gland involvement. Concerning the rarity of the cardiac lesion in our case, we conducted a literature review of similar case reports.
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Affiliation(s)
- Shokoufeh Hajsadeghi
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology & Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Marziyeh Pakbaz
- Department of Cardiovascular Disease, Hazrat-e Rasool General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Morteza Hassanzadeh
- Department of Internal Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Sadeghipour
- Department of Pathology and Oncopathology Research Center, Iran University of Medical Sciences, Tehran, Iran
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