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Ito M, Vaidya A, Kakizaki H, Takahashi Y. Spontaneous regression of immunoglobulin G4-related dacryoadenitis and multiple organ involvement: A case report. Medicine (Baltimore) 2023; 102:e32618. [PMID: 36607859 PMCID: PMC9829289 DOI: 10.1097/md.0000000000032618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Immunoglobulin G4 (IgG4)-related dacryoadenitis is rarely resolved spontaneously without steroids. Here, we report a case of IgG4-related dacryoadenitis and extra-ophthalmic lesions with spontaneous regression. METHODS This is a clinical case report. A 56-years-old man had a 1-year and 7-month-old histories of neck and eyelid swelling, respectively. On the first examination, the lacrimal and submandibular glands were palpable bilaterally. Computed tomographic images showed enlargement of the lacrimal gland on both sides, right pulmonary hilar lymph node, and pancreas, and thickening of the abdominal aortic wall. Blood tests demonstrated elevated serum IgG4 level and positive hepatitis B surface antibody. Pathological examination of the biopsied lacrimal gland specimens revealed marked IgG4-positive plasma cell infiltration. RESULTS The patient was monitored carefully without steroid administration. Serum IgG4 level had gradually decreased during follow-up period and reached the normal range 3 years after the biopsy. At 4-year follow-up, the lacrimal and submandibular glands were not palpable on either side. Computed tomographic images demonstrated no enlargement of the lacrimal gland, submandibular gland, or lymph nodes, and improvement of the enlarged pancreas and thickened abdominal aortic wall. CONCLUSION Our case indicates that careful observation can be an option in selected cases with risks of steroid treatment or silent clinical course.
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Affiliation(s)
- Mayari Ito
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Aric Vaidya
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Kirtipur Eye Hospital, Kathmandu, Nepal
| | - Hirohiko Kakizaki
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Yasuhiro Takahashi
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, Nagakute, Aichi, Japan
- * Correspondence: Yasuhiro Takahashi, Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan (e-mail: )
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Singh S, Selva D. Non-infectious Dacryoadenitis. Surv Ophthalmol 2021; 67:353-368. [PMID: 34081929 DOI: 10.1016/j.survophthal.2021.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Dacryoadenitis is an inflammation of the lacrimal gland that may have various etiologies with similar presentations. Despite more recent elucidation of specific causes, the management has remained largely unchanged. Hence, the condition remains under biopsied with the rationale that empirical treatment with corticosteroids is effective for many of the causes. Dacryoadenitis, however, dacryoadenitis can be the presenting sign of an undiagnosed systemic disease and a mimick for lymphoma; hence, tissue diagnosis and systemic investigations play a vital role. A significant proportion of dacryoadenitis has a specific etiology, and IgG4-related dacryoadenitis is more frequently identified as a cause. We summarize the different types of immune-mediated dacryoadenitis, their clinical findings, histopathology, management, and prognosis. We have also highlighted and formulated practice guidelines for diagnosis and effective treatment based on the underlying systemic disease.
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Affiliation(s)
- Swati Singh
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Telangana, Hyderabad, India.
| | - Dinesh Selva
- Department of Ophthalmology, Royal Adelaide Hospital, South Australia, Adelaide, Australia
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Abstract
IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition characterized by lymphoplasmacytic infiltrates rich in IgG4-positive plasma cells, often with elevated serum IgG4. Multiple organs may be affected. Coronary arteritis may be one form of fatal involvement in IgG4-RD. IgG4-RD can manifest as periocular lesions, called IgG4-related ophthalmic disease (IgG4-ROD). Here, the authors describe a patient with asymptomatic coronary arteritis detected after the diagnosis of IgG4-ROD. A 58-year-old male complained of eyelid swelling and diplopia without systemic symptoms. Swelling of bilateral lacrimal glands and infraorbital nerves, high serum IgG4 levels, and histopathology of lacrimal gland tissue fulfilled diagnostic criteria for IgG4-ROD. After diagnosis, systemic and coronary CT showed coronary lesions and coronary artery stenosis. After prednisolone at 40 mg/day was administered, swelling of the lacrimal glands, diplopia, and coronary lesions improved. This case emphasizes the importance of systemic screening, even if initial symptoms are solely associated with periocular regions.
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Suzuki M, Nakamaru Y, Takagi D, Honma A, Suzuki T, Takakuwa E, Morita S, Vreugde S, Homma A. Spontaneous Regression of Swollen Submandibular Glands in IgG4-Related Disease. ALLERGY & RHINOLOGY (PROVIDENCE, R.I.) 2019; 10:2152656718816738. [PMID: 35141000 PMCID: PMC8819756 DOI: 10.1177/2152656718816738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background IgG4-related disease is a new clinical entity frequently associated with
swelling of the submandibular glands (SMGs). The long-term outcome of SMG
swelling without steroid therapy remains unknown. Objective To examine whether swollen SMGs spontaneously regress without steroid therapy
in the context of IgG4-related disease and to identify biomarkers that can
predict the spontaneous regression of SMG swelling. Methods The SMG volume of 49 patients diagnosed with IgG4-related disease was
calculated by measuring the axial and coronal planes of computed tomography
scans. The change in SMG volume over time was measured and examined by
treatment regimen, clinical data, and serum complement level. Results We found 28 of 49 (57%) IgG4-related disease patients to have swollen SMGs,
with 15 of 20 (75%) of the swollen SMGs regressing without steroid therapy.
The time required for the SMGs swelling to regress was significantly shorter
in the steroid therapy group than in the no-steroid therapy group. Serum
complement components at the initial visit were significantly lower in the
regressed SMG group than in the nonregressed SMG group. Conclusion We observed 75% of swollen SMGs spontaneously regressed in patients with
IgG4-related disease. The time required for the swollen SMGs to regress was
longer in patients without steroid therapy than in those with steroid
therapy. Serum complement level could be used as a predictor for the
spontaneous regression of swollen SMGs in patients with IgG4-related
disease.
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Affiliation(s)
- Masanobu Suzuki
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Surgery - Otorhinolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Yuji Nakamaru
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Dai Takagi
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Aya Honma
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takayoshi Suzuki
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Surgical Pathology, Hokkaido University Hospital, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Emi Takakuwa
- Department of Surgical Pathology, Hokkaido University Hospital, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shinya Morita
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sarah Vreugde
- Department of Surgery - Otorhinolaryngology Head and Neck Surgery, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Akihiro Homma
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Najem K, Derzko-Dzulynsky L, Margolin EA. IgG4-related disease presenting as panuveitis without scleral involvement. J Ophthalmic Inflamm Infect 2017; 7:7. [PMID: 28243891 PMCID: PMC5328900 DOI: 10.1186/s12348-017-0125-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/16/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The following case emphasizes the importance of including IgG4-related disease (RD) in the differential diagnosis of intraocular inflammation and multiple cranial nerve palsies. RESULTS A 33-year-old man, with a history of idiopathic bilateral panuveitis, presented with a new right pupillary-sparing partial third nerve palsy, which spontaneously resolved in 2 weeks, but was followed 1 month later, by a right sixth nerve palsy, which also resolved within a few weeks. Motility disturbance was accompanied by a decrease in the central acuity in the right eye. Magnetic resonance imaging/angiography (MRI/MRA) demonstrated a densely enhancing osteodestructive skull base process extending through the cavernous sinus and into the right superior orbital fissure. Biopsy of the lesion was consistent with IgG4-related disease (RD). CONCLUSIONS This is the first reported case of IgG4-RD associated panuveitis without scleral involvement, expanding the list of clinical manifestations of the IgG4-RD.
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Affiliation(s)
- Kinda Najem
- Department of Ophthalmology, Université de Montréal, 5415 de l’Assomption Boulevard, Montreal, Quebec H1T 2M4 Canada
| | - Larissa Derzko-Dzulynsky
- Department of Ophthalmology, University of Toronto, 340 College Street Suite 501, Toronto, Ontario M5T 3A9 Canada
| | - Edward A. Margolin
- Department of Ophthalmology, University of Toronto, 340 College Street Suite 501, Toronto, Ontario M5T 3A9 Canada
- 801 Eglinton Avenue West, Suite 301, Toronto, Ontario M5N 1E3 Canada
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Clinical Features and Treatment Outcomes of Orbital Inflammatory Disease in Singapore: A 10-Year Clinicopathologic Review. Ophthalmic Plast Reconstr Surg 2017; 33:182-188. [DOI: 10.1097/iop.0000000000000690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Methotrexate-associated orbital lymphoproliferative disorder in a patient with rheumatoid arthritis: a case report. Jpn J Ophthalmol 2016; 60:212-8. [PMID: 27018050 DOI: 10.1007/s10384-016-0439-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 01/24/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE Lymphoproliferative disorders (LPDs) can develop in patients treated with methotrexate (MTX) and usually respond well to MTX withdrawal. Mucosa-associated lymphoid tissue (MALT) lymphoma is a relatively rare type of MTX-LPD. The development of MTX-LPD in the orbit has not been previously described. We here report a case of orbital MALT lymphoma that disappeared after MTX withdrawal in a patient treated with MTX for rheumatoid arthritis. CASE A 78-year-old woman who complained of swelling of the left upper eyelid had been treated with MTX for >8 years for rheumatoid arthritis. Slit-lamp examination revealed a temporal subconjunctival mass, salmon pink in color, in the left eye. Fundus photographs also suggested the presence of a temporal tumor in the left orbit. [(18)F]Fluorodeoxyglucose positron emission tomography-computed tomography revealed highly integrated lesions in the left inferotemporal orbit and a left external iliac lymph node, a left obturator lymph node, and an inguinal lymph node. Pathologic analysis of a tumor biopsy specimen showed small- and medium-sized lymphocytes positive for CD20, MIB-1, and bcl-2 and negative for CD10, CD3, bcl-1, IgG4, and EBV-ISH. On the basis of these findings, we diagnosed the tumor as MTX-induced MALT lymphoma. The subconjunctival and orbital masses disappeared gradually over 10 months after MTX withdrawal and did not recur within 2 years. CONCLUSION This case of orbital MTX-LPD suggests that the possibility of MTX-LPD should be considered even for ocular tumors in patients treated with MTX.
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Abstract
PURPOSE OF REVIEW To review the spectrum of lacrimal gland inflammation, with particular reference to the old condition, idiopathic dacryoadenitis, and the new, immunoglobulin G4 (IgG4)-related dacryoadenitis. RECENT FINDINGS Idiopathic dacryoadenitis remains the most common inflammatory lesion of the lacrimal gland, for which surgical treatment is successful. There is mounting evidence that the presence of IgG4-positive plasma cells in a lacrimal gland specimen is nonspecific, for being found in other inflammatory lacrimal gland lesions, even lymphoproliferative ones. To identify IgG4-related dacryoadenitis, particularly when there is no documented disease elsewhere, the criteria have been strengthened toward abundant IgG4-positive plasma cell counting. SUMMARY The gold standard of diagnosis of noninfectious lacrimal gland inflammation is tissue biopsying, which is commonly therapeutic in the case of idiopathic dacryoadenitis. Although it was initially suggested that IgG4-related dacryoadenitis is a possible cause of idiopathic dacryoadenitis, it becomes obvious that it has more resemblance to the lymphoproliferative tumors.
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Grados A, Ebbo M, Jean E, Bernit E, Harlé JR, Schleinitz N. [IgG4-related disease treatment in 2014: Update and literature review]. Rev Med Interne 2015; 36:395-404. [PMID: 25595874 DOI: 10.1016/j.revmed.2014.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/27/2014] [Accepted: 11/23/2014] [Indexed: 02/08/2023]
Abstract
IgG4-related disease is an inflammatory disorder characterized by a polyclonal lymphoplasmacytic tissue infiltrate, with numerous IgG4+ plasmocytes, evolving toward fibrosis. The disease is heterogeneous and affects several tissues and organs synchroneously or metachroneously. Both the fibrosis and the tumor forming characteristics of the disease can be responsible of irreversible tissue damage. For these reasons treatment is usually necessary. A dramatic response is usually observed with steroid treatment but relapses are frequent. Immunosuppressive agents and rituximab are used as second line treatments. We review here previous studies on treatment and suggest general recommendations for the treatment and follow up of patients with IgG4-related disease.
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Affiliation(s)
- A Grados
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| | - M Ebbo
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France.
| | - E Jean
- Service de médecine interne, hôpital Nord, AP-HM, Aix-Marseille université, 13915 Marseille, France
| | - E Bernit
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| | - J-R Harlé
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
| | - N Schleinitz
- Service de médecine interne, hôpital de la Timone, AP-HM, Aix-Marseille université, 264, rue Saint-Pierre, 13385 Marseille, France
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Abstract
IgG4-related disease is characterized by elevated serum IgG4 and tissue infiltration by IgG4-positive plasma cells. We herein report a case of lacrimal sac diverticulitis with marked IgG4-positive plasma cell infiltration. An 89-year-old woman presenting with right lower eyelid mass. Imaging modalities demonstrated a cystic orbital mass located beneath the globe and adjacent to enlarged lacrimal sac. Serological tests showed high IgG4 and normal IgG levels, measuring 242 and 1603 mg/dl, respectively. The orbital mass was surgically excised. Histologically, the excised tissue demonstrated marked inflammation with fibrosis surrounded by mononuclear epithelial cells. A variety of IgG and IgG4-positive plasma cells infiltrated the stroma. This patient was diagnosed as an IgG4-related lacrimal sac diverticulitis, based on current diagnostic criteria of IgG4-related disease. It is likely that IgG4-related inflammation occurs in a lacrimal sac diverticulum, which should be considered a differential diagnosis in inferior orbital tumors.
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Affiliation(s)
- Satoru Kase
- Department of Ophthalmology, Teine Keijinkai Hospital , Maeda 1-12, Teine-ku, Sapporo , Japan
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