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Yin X, Liu Y, Lv Z, Ding S, Ma L, Yang M, Yao M, Zhu L, Zhao S, Chen Y, Ge J, Tong H, Meng H, You L. scRNA-seq reveals the landscape of immune repertoire of PBMNCs in iMCD. Oncogene 2024:10.1038/s41388-024-03128-8. [PMID: 39147879 DOI: 10.1038/s41388-024-03128-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/31/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024]
Abstract
The etiology of idiopathic multicentric Castleman disease (iMCD) is poorly understood, and the identification of targetable disease mediators remains an unmet clinical need. Thus, we firstly employed single-cell RNA sequencing (scRNA-seq) to elucidate the landscape of the immune repertoire of peripheral blood mononuclear cells (PBMNCs) in iMCD and to identify additional driver cytokines/cells/pathways to address IL-6 blockade-refractory cases. We revealed that the inflammatory cytokine storm observed in iMCD was a significant phenomenon pervasive across all immune cells. B-plasma cell subsets was the main source of IL-6. The IL-6 signaling pathway was significantly activated across a spectrum of immune cells. Systemic upregulation of CXCL13 is mainly driven by peripheral helper T (Tph) and regulatory T (Treg) cells. Notably, a significant positive interaction was observed between CXCL13-expressing T cells and IL-6 signaling-activated B cells. This study provides an immune perspective on PBMNCs in iMCD at the single-cell level, unveiling pathways or targets characterized by atypical inflammatory expression that could potentially serve as promising candidates for therapeutic intervention in iMCD.
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Affiliation(s)
- Xuejiao Yin
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, Zhejiang, China
- Zhejiang University Cancer Center, Hangzhou, Zhejiang, China
| | - Yi Liu
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, Zhejiang, China
| | - Zuopo Lv
- Xinyuan Institute of Medicine and Biotechnology, School of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Shengnan Ding
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
| | - Liya Ma
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
| | - Min Yang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
| | - Meiqiu Yao
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
| | - Li Zhu
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China
| | - Shuqi Zhao
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yu Chen
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, Zhejiang, China
| | - Jiaying Ge
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Hongyan Tong
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China.
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, Zhejiang, China.
- Zhejiang University Cancer Center, Hangzhou, Zhejiang, China.
| | - Haitao Meng
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China.
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, Zhejiang, China.
- Zhejiang University Cancer Center, Hangzhou, Zhejiang, China.
| | - Liangshun You
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Provincial Clinical Research Center for Hematologic Diseases, Hangzhou, Zhejiang, China.
- Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, Zhejiang, China.
- Zhejiang University Cancer Center, Hangzhou, Zhejiang, China.
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Schmalzing M, Sander O, Seidl M, Marks R, Blank N, Kötter I, Tiemann M, Backhaus M, Manger B, Hübel K, Müller-Ladner U, Henes J. [Castleman's disease in the rheumatological practice]. Z Rheumatol 2024; 83:316-326. [PMID: 37624374 PMCID: PMC11058943 DOI: 10.1007/s00393-023-01393-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 08/26/2023]
Abstract
The term Castleman's disease encompasses a group of rare lymphoproliferative diseases that show histopathological similarities in lymph node biopsy. Diagnostic criteria and a specific ICD-10 code have been available for a few years. Case studies listed at the beginning illustrate that close cooperation between clinicians and pathologists is required to enable a reliable diagnosis. For an optimal histopathological assessment, the pathologist is also dependent on the removal of a complete lymph node. Before distinguishing a potentially fatal multicentric idiopathic Castleman's disease from the resectable unicentric form, which is important in terms of prognosis and treatment, early diagnosis presupposes that Castleman's disease is considered in the differential diagnosis. Various immune phenomena and overlaps with autoimmune diseases can increase the probability of misdiagnosis or undetected cases in the clinical routine of rheumatologists. The intention of the present overview is therefore to point out the similarities with autoimmune diseases that are relevant for differential diagnoses and to point out situations that justify a review of the previous diagnosis.
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Affiliation(s)
- M Schmalzing
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - O Sander
- Klinik für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - M Seidl
- Institut für Pathologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - R Marks
- Klinik für Innere Medizin I, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - N Blank
- Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - I Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
- Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - M Tiemann
- Institut für HämatoPathologie Hamburg, Hamburg, Deutschland
| | - M Backhaus
- Abt. Innere Medizin - Rheumatologie und klinische Immunologie, Park-Klinik Weissensee (Berlin), Berlin, Deutschland
| | - B Manger
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - K Hübel
- Klinik I für Innere Medizin, Universitätsklinikum Köln, Köln, Deutschland
| | - U Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Kerckhoff Klinik Bad Nauheim, Bad Nauheim, Deutschland
| | - J Henes
- Medizinische Universitätsklinik Abt. II, Universitätsklinikum Tübingen, Tübingen, Deutschland
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Tsuge S, Mizushima I, Horita M, Kawahara H, Sanada H, Yoshida M, Takahashi Y, Zoshima T, Nishioka R, Hara S, Suzuki Y, Ito K, Kawano M. High serum IgA levels in patients with IgG4-related disease are associated with mild inflammation, sufficient disease-specific features, and favourable responses to treatments. Mod Rheumatol 2024; 34:621-631. [PMID: 37307433 DOI: 10.1093/mr/road056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/21/2022] [Accepted: 06/08/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Although elevated serum immunoglobulin A (IgA) levels are thought to exclude a diagnosis of IgG4-related disease (IgG4-RD), IgG4-RD has been definitively diagnosed in some patients despite elevated serum IgA levels. This study aimed to clarify the prevalence of elevated IgA levels in patients with IgG4-RD and to compare the clinical features of IgG4-RD patients with and without elevated IgA levels. METHODS The clinical features of 169 IgG4-RD patients were retrospectively compared among those with and without elevated serum IgA levels. RESULTS Of the 169 patients with IgG4-RD, 17 (10.1%) had elevated serum IgA levels. Those with elevated serum IgA levels showed higher serum C-reactive protein levels and lower prevalence of relapse than those without. Other clinical features did not differ significantly, including inclusion scores of the American College of Rheumatology/European League Against Rheumatism classification criteria. Cox regression analysis showed that elevated serum IgA levels were associated with a lower incidence of relapse. Moreover, patients with elevated serum IgA levels showed prompt improvement in response to glucocorticoids in the IgG4-RD responder index. CONCLUSIONS Some patients diagnosed with IgG4-RD have high serum IgA levels. These patients may form a subgroup, characterized by good response to glucocorticoids, less frequent relapse, mildly elevated serum C-reactive protein levels, and possible complications of autoimmune diseases.
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Affiliation(s)
| | | | - Makoto Horita
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Kawahara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hajime Sanada
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Misaki Yoshida
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | | | - Takeshi Zoshima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Yasunori Suzuki
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kiyoaki Ito
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
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4
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Cheuk W, Bledsoe JR. IgG4-related lymphadenopathy. Semin Diagn Pathol 2024; 41:108-115. [PMID: 38228439 DOI: 10.1053/j.semdp.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024]
Abstract
IgG4-related lymphadenopathy is a nodal manifestation of IgG4-related disease (IgG4RD) which is characterized by increased polytypic IgG4+ plasma cells and IgG4+/IgG+ plasma cell ratio in lymph nodes and morphologically manifested as various patterns of reactive lymphadenopathy: Castleman disease-like, follicular hyperplasia, interfollicular expansion, progressive transformation of germinal centers and inflammatory pseudotumor-like. It typically presents with solitary or multiple, mild to moderate lymph node enlargement in otherwise asymptomatic patients. The serum IgG4 level is frequently elevated but C-reactive protein often remains normal. In patients not having a history of IgG4RD or manifestation of extranodal IgG4RD, a diagnosis of IgG4-lymphadenopathy should only be made with great caution given the non-specific morphologic features that can overlap with ANCA-associated vasculitis, interleukin-6 syndromes, Rosai-Dorfman disease, inflammatory myofibroblastic tumor, syphilis, lymphoma, and plasma cell neoplasia. Elevated IgG4 parameters, appropriate morphologies, and clinical correlation are essential to make the diagnosis of IgG4-lymphadenopathy more specific and clinically meaningful.
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Affiliation(s)
- Wah Cheuk
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong, China SAR.
| | - Jacob R Bledsoe
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Nishikori A, Nishimura MF, Fajgenbaum DC, Nishimura Y, Maehama K, Haratake T, Tabata T, Kawano M, Nakamura N, Momose S, Sumiyoshi R, Koga T, Yamamoto H, van Rhee F, Kawakami A, Sato Y. Diagnostic challenges of the idiopathic plasmacytic lymphadenopathy (IPL) subtype of idiopathic multicentric Castleman disease (iMCD): Factors to differentiate from IgG4-related disease. J Clin Pathol 2024:jcp-2023-209280. [PMID: 38378248 DOI: 10.1136/jcp-2023-209280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/22/2024] [Indexed: 02/22/2024]
Abstract
AIMS AND METHODS Idiopathic multicentric Castleman disease (iMCD) is currently considered to be classified into three clinical subtypes, including idiopathic plasmacytic lymphadenopathy (IPL), thrombocytopaenia, anasarca, fever, reticulin fibrosis/renal dysfunction, organomegaly (TAFRO) and not otherwise specified (NOS). Among the three, iMCD-IPL closely mimics IgG4-related disease (IgG4-RD). In diagnosing IgG4-RD, it is sometimes challenging to distinguish iMCD-IPL patients that also meet the histological diagnostic criteria for IgG4-RD. In this study, we focused on the number of IgG4-positive cells in the lymph nodes and analysed the relationship with laboratory findings to distinguish iMCD-IPL from IgG4-RD. Thirty-nine patients with iMCD-IPL and 22 patients with IgG4-RD were included. RESULTS Among the cases considered to be iMCD-IPL, 33.3% (13/39) cases also met the histological diagnostic criteria for IgG4-RD and serum IgG4 levels were not different between the two groups. However, the serum IgG4/IgG ratio was significantly higher in IgG4-RD, with a cut-off value of 19.0%. Additionally, a significant positive correlation between serum IgG levels and the number of IgG4-positive cells was observed in iMCD-IPL (p=0.001). The serum IgG cut-off value for distinguishing iMCD-IPL meeting histological criteria for IgG4-RD from other iMCD-IPL was 5381 mg/dL. CONCLUSIONS iMCD-IPL cases with high serum IgG levels (>5000 mg/dL) were likely to meet the diagnostic criteria for IgG4-RD because of the numerous IgG4-positive cells observed. A combination of clinical presentations, laboratory values including the serum IgG4/IgG ratios and histological analysis is crucial for diagnosis of IgG4-RD and iMCD-IPL.
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Affiliation(s)
- Asami Nishikori
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama, Japan
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
| | - Midori Filiz Nishimura
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama, Japan
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
| | - David C Fajgenbaum
- Department of Medicine, Center for Cytokine Storm Treatment & Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Castleman Disease Collaborative Network, Philadelphia, Pennsylvania, USA
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Medicine, University of Hawai'i, Honolulu, Hawai'i, USA
| | - Kanna Maehama
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Tomoka Haratake
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Tetsuya Tabata
- Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mitsuhiro Kawano
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Naoya Nakamura
- Department of Pathology, Tokai University School of Medicine, Isehara, Japan
| | - Shuji Momose
- Department of Pathology, Saitama Medical University, Saitama, Japan
| | - Remi Sumiyoshi
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomohiro Koga
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hidetaka Yamamoto
- Department of Pathology and Oncology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Frits van Rhee
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Atsushi Kawakami
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasuharu Sato
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama, Japan
- Research Program for Intractable Disease by Ministry of Health, Tokyo, Japan
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El Hussein S, Evans AG, Fang H, Wang W, Medeiros LJ. Unicentric Castleman Disease: Illustration of Its Morphologic Spectrum and Review of the Differential Diagnosis. Arch Pathol Lab Med 2024; 148:99-106. [PMID: 36920021 DOI: 10.5858/arpa.2022-0404-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 03/16/2023]
Abstract
CONTEXT.— Unicentric Castleman disease (UCD) is a dynamic entity with a wide spectrum of morphologic findings. UCD can be further subdivided into hyaline-vascular and mixed/plasmacytic variants. Hyaline-vascular UCD has both follicular and interfollicular (stromal) changes, and occasionally these lesions show a skewed representation of either the follicular or stromal compartments. Plasmacytosis is usually minimal in the hyaline-vascular variant. The mixed/plasmacytic variant of UCD is composed of sheets of plasma cells often associated with a variable number of follicles with regressive changes. OBJECTIVE.— To illustrate the differential diagnosis of UCD, as it is quite broad and includes lymphomas, plasma cell neoplasms, stromal neoplasms such as follicular dendritic cell sarcoma and vascular neoplasms, immunoglobulin G4-related disease, infections, and other rare lesions. An additional objective is to enhance awareness of the morphologic features of UCD in excisional and in small core-needle biopsy specimens, the latter of which may inadvertently target follicle- or stroma-rich areas, causing diagnostic challenges. DATA SOURCES.— In this review, we provide readers a concise illustration of the morphologic spectrum of UCD that we have encountered in our practice and a brief discussion of entities in the differential diagnosis. CONCLUSIONS.— UCD exhibits a broad spectrum of morphologic changes, and awareness of these morphologic variations is key to avoid misdiagnosis.
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Affiliation(s)
- Siba El Hussein
- From the Department of Pathology, University of Rochester Medical Center, Rochester, New York (El Hussein, Evans)
| | - Andrew G Evans
- From the Department of Pathology, University of Rochester Medical Center, Rochester, New York (El Hussein, Evans)
| | - Hong Fang
- the Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston (Fang, Wang, Medeiros)
| | - Wei Wang
- the Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston (Fang, Wang, Medeiros)
| | - L Jeffrey Medeiros
- the Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston (Fang, Wang, Medeiros)
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Ou Y, Zhang L, Ouyang R, Liang Q. Clinical characteristics of IgG4 -related disease with lung involvement in 14 patients. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:59-67. [PMID: 36935178 PMCID: PMC10930550 DOI: 10.11817/j.issn.1672-7347.2023.220274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Indexed: 03/21/2023]
Abstract
OBJECTIVES Immunoglobulin G4-related diseases (IgG4-RD) is a rare autoimmune disease, and there is no specific diagnostic test for patients with lung involvement yet. This study aims to summarize the clinical characteristics of IgG4-RD with lung involvement and improve the understanding and diagnosis of this disease. METHODS All patients diagnosed with IgG4-RD in the Second Xiangya Hospital from December 2014 to February 2022 were re-diagnosed according to the recommendations of Chinese Expert Consensus on the Diagnosis and Treatment of IGG4-Related Diseases in 2021. The clinical data of 14 IgG4-RD patients with pulmonary abnormalities were collected and analyzed. RESULTS Among the 14 patients, 11 were males and 3 were females, and the median age of diagnosis was 66 (22-82) years old. Six cases had respiratory symptoms such as cough, sputum and short breath. Extrapulmonary involvement was the most common in the glands of head and neck (6/14), followed by pancreas and bile duct (4/14). Elevated serum IgG4 level was found in all patients, and most (11/14) were accompanied by abnormal inflammatory markers. Patients' pulmonary imaging findings were diverse, the most common performances were mediastinal/hilar lymphadenopathy (12/14), followed by multiple pulmonary nodules (9/14), patchy density enhancement (7/14) and the increased broncho vascular bundles (6/14). Lung biopsy was performed in 9 patients, their pathology results showed lymphoplasmic cell infiltration, 5 cases of them had interstitial fibrosis, 2 cases with phlebitis, and extrapulmonary biopsy was performed in 8 patients. Immunohistochemical results of all the patients showed that the number of IgG4+ plasma cells was more than 10 per high magnification, and the ratio of IgG4/IgG was more than 40%. For treatment, 12 patients received hormone therapy, and 5 patients combined immunosuppressive therapy with hormone. 10 patients were in remission after treatment, while 2 patients were progressed. CONCLUSIONS IgG4-RD with lung involvement is rare and has no specific clinical manifestation. Its pulmonary imaging is diverse. Diagnosis for it should combine with serum IgG4 level and pathological examination. Glucocorticoid is the first line treatment, and combination with immunosuppressant can help prevent disease recurrence.
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Affiliation(s)
- Yanru Ou
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha 410011.
| | - Lianhua Zhang
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha 410011
| | - Ruoyun Ouyang
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha 410011.
| | - Qingchun Liang
- Department of Pathology, Second Xiangya Hospital, Central South University, Changsha 410011, China.
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Nishikori A, Nishimura MF, Nishimura Y, Otsuka F, Maehama K, Ohsawa K, Momose S, Nakamura N, Sato Y. Idiopathic Plasmacytic Lymphadenopathy Forms an Independent Subtype of Idiopathic Multicentric Castleman Disease. Int J Mol Sci 2022; 23:ijms231810301. [PMID: 36142213 PMCID: PMC9499480 DOI: 10.3390/ijms231810301] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is a type of Castleman disease that is not related to KSHV/HHV8 infection. Currently, iMCD is classified into iMCD-TAFRO (thrombocytopenia, anasarca, fever, reticulin fibrosis, and organomegaly) and iMCD-NOS (not otherwise specified). The former has been established as a relatively homogeneous disease unit that has been recently re-defined, while the latter is considered to be a heterogeneous disease that could be further divided into several subtypes. In 1980, Mori et al. proposed the concept of idiopathic plasmacytic lymphadenopathy (IPL), a disease presenting with polyclonal hypergammaglobulinemia and a sheet-like proliferation of mature plasma cells in the lymph nodes. Some researchers consider IPL to be a part of iMCD-NOS, although it has not been clearly defined to date. This is the first paper to analyze iMCD-NOS clinicopathologically, to examine whether IPL forms a uniform disease unit in iMCD. Histologically, the IPL group showed prominent plasmacytosis and the hyperplasia of germinal centers, while the non-IPL group showed prominent vascularity. Clinically, the IPL group showed significant thrombocytosis and elevated serum IgG levels compared to the non-IPL group (p = 0.007, p < 0.001, respectively). Pleural effusion and ascites were less common in the IPL group (p < 0.001). The IPL group was more likely to have an indolent clinical course and a good response to the anti-IL-6 receptor antibody, while the non-IPL counterpart frequently required more aggressive medical interventions. Thus, the IPL group is a clinicopathologically uniform entity that forms an independent subtype of iMCD.
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Affiliation(s)
- Asami Nishikori
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan
| | - Midori Filiz Nishimura
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan
- Department of Pathology, Okayama University Hospital, Okayama 700-8558, Japan
- Correspondence: (M.F.N.); (Y.S.); Tel.: +81-86-235-7150 (Y.S.)
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
- Department of Medicine, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI 96813, USA
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Kanna Maehama
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan
| | - Kumiko Ohsawa
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama 350-8550, Japan
| | - Shuji Momose
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama 350-8550, Japan
| | - Naoya Nakamura
- Department of Pathology, Tokai University School of Medicine, Kanagawa 259-1193, Japan
| | - Yasuharu Sato
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan
- Correspondence: (M.F.N.); (Y.S.); Tel.: +81-86-235-7150 (Y.S.)
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9
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Yoshimura Y, Suwabe T, Ikuma D, Oba Y, Yamanouchi M, Sekine A, Mizuno H, Hasegawa E, Hoshino J, Kono K, Kinowaki K, Ohashi K, Sawa N, Ubara Y. Renal Cell Carcinoma-Associated Diabetes Mellitus Due to Paraneoplastic Syndrome in Maintenance Hemodialysis: A Case Report. Kidney Med 2022; 4:100477. [PMID: 35637924 PMCID: PMC9142673 DOI: 10.1016/j.xkme.2022.100477] [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] [Indexed: 11/24/2022] Open
Abstract
A 59-year-old Japanese woman with a 22-year history of long-term hemodialysis was admitted to our hospital for further examination of hyperglycemia and anemia. Five months before hospitalization, her fasting plasma glucose value was 99 mg/dL and her glycated hemoglobin was 5.7%. On admission, her fasting plasma glucose value was 873 mg/dL, glycated hemoglobin was 16.2%, C-peptide reactivity was 22.3 ng/mL (reference range, 0.5-3.0), and homeostasis model assessment of insulin resistance (HOMA-IR) was 10.6 (reference range, <2.0); the high HOMA-IR indicated high insulin resistance. Intensive insulin therapy was started for hyperglycemia, which required more than 40 units/day. Computed tomography showed a hypervascular lesion 2.2 cm in diameter on the right kidney; therefore, right nephrectomy was performed. Complete resection was confirmed, and the lesion was diagnosed as a clear cell type of renal cell carcinoma (RCC). Immediately after nephrectomy, glycemic control normalized and administration of insulin was discontinued. Fourteen days after nephrectomy, the HOMA-IR decreased to 2.96. RCC that develops in patients receiving long-term hemodialysis has been reported to be dialysis-related RCC, but there have been no reports suggesting a relationship between dialysis-related RCC and diabetes. To our knowledge, this is the first report of RCC presenting with the paraneoplastic syndrome of acute-onset diabetes because of insulin resistance.
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Affiliation(s)
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | | | - Akinari Sekine
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Eiko Hasegawa
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
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10
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Nishimura MF, Nishimura Y, Nishikori A, Yoshino T, Sato Y. Historical and pathological overview of Castleman disease. J Clin Exp Hematop 2022; 62:60-72. [PMID: 35474035 PMCID: PMC9353854 DOI: 10.3960/jslrt.21036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Castleman disease consists of several lymphoproliferative subtypes that share some histological features in the lymph nodes. On the other hand, numerous clinical findings and etiologies make the disease challenging to understand. The origin of the disease is the hyaline vascular-type unicentric Castleman disease (UCD), first reported by Benjamin Castleman et al. in 1954. Although UCD is characterized by localized lesions and lack of symptoms, multicentric Castleman disease (MCD) with multiple lesions and systemic symptoms was reported by Frizzera in 1983. MCD is further divided according to KSHV/HHV8 infection status. In KSHV/HHV8-related MCD, viral infection signals lead to excessive cytokine production, and cause clinical and pathologic abnormalities. Some cases of plasma cell-type KSHV/HHV8-negative MCD can be found in association with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-proteins, and skin changes), which is a paraneoplastic syndrome. The others are idiopathic MCD, which are currently considered a heterogeneous group of diseases with overlapping pathological and clinical features. In this article, we summarize the historical evolution of Castleman disease to help understand the disease concept. We also review the latest ideas and definitions of the subtypes within the MCD spectrum and summarize the histopathological findings.
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Affiliation(s)
- Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, USA
| | - Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
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11
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Martín-Nares E, Hernández-Molina G, Baenas DF, Paira S. IgG4-Related Disease: Mimickers and Diagnostic Pitfalls. J Clin Rheumatol 2022; 28:e596-e604. [PMID: 34538846 DOI: 10.1097/rhu.0000000000001787] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The tendency of IgG4-related disease (IgG4-RD) to form pseudotumors, as well as its multisystemic nature, makes it the perfect mimicker of many conditions. Moreover, some clinical, serological, radiological, or histological features of the disease might be shared with some mimickers.Recently, 4 clinical phenotypes have been identified, and patients grouped in each phenotype have distinctive demographic, clinical, and serological features and outcomes, and, as expected, for each phenotype, a set of differential diagnoses should be considered. SUMMARY OF THE LITERATURE The main differential diagnoses for the pancreato-hepato-biliary phenotype are pancreatic adenocarcinoma and cholangiocarcinoma. Other differential diagnoses include type 2 autoimmune pancreatitis and primary sclerosing cholangitis. In patients with retroperitoneal/aortic phenotype, inflammatory conditions such as idiopathic retroperitoneal fibrosis and large vessel vasculitides should be ruled out, and most of the time, a biopsy will be needed to exclude malignancies. In head and neck limited phenotype, autoimmune conditions (eg, granulomatosis with polyangiitis, Graves orbitopathy, sarcoidosis), malignancies, and histiocytosis should be ruled out, whereas the main differential diagnoses of the Mikulicz/systemic phenotype are Sjögren syndrome, granulomatosis with polyangiitis, and multicentric Castleman disease. CONCLUSIONS Approaching a patient with probable IgG4-RD through a clinical phenotype framework will ease the diagnostic algorithm and facilitate the prompt recognition of the disease. There are certain clinical, serological, radiological, and histological features in each clinical phenotype that, if present, increase the likelihood that a patient may have IgG4-RD instead of the mimicker condition. Those clues that point toward IgG4-RD diagnosis should be actively sought in the workup of patients.
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Affiliation(s)
- Eduardo Martín-Nares
- From the Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriela Hernández-Molina
- From the Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Sergio Paira
- Sección de Reumatología, Hospital José María Cullen, Santa Fe, Argentina
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12
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Hao FY, Yang FX, Bian HY, Zhao X. Immunoglobulin G4-related lymph node disease with an orbital mass mimicking Castleman disease: A case report. World J Clin Cases 2021; 9:10999-11006. [PMID: 35047610 PMCID: PMC8678879 DOI: 10.12998/wjcc.v9.i35.10999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/25/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immunoglobulin (Ig) G4-associated diseases are a group of systemic diseases involving multiple organs and are also known as IgG4-associated sclerosing diseases. IgG4-associated lymphadenopathy occurring in the lymph nodes is characterized by a lack of specificity due to its clinicopathological characteristics and must be differentiated from a variety of lesions, such as Castleman disease, lymphatic follicular reactive hyperplasia, and lymphoma.
CASE SUMMARY A 65-year-old male patient, with Guillain-Barre syndrome for 5 years, presented to our hospital complaining of bilateral orbital mass for 2 years. After hospitalization, the results of the patient’s laboratory tests showed that immunoglobulin subgroup IgG4 was 33.90 g/L and IgG was 30.30 g/L, but serum interleukin-6 was normal. The pathological morphology of orbital mass and cervical lymph node were consistent, which showed that a large number of plasma cells and eosinophils were observed in the lymphatic follicles, and the interstitial fibrous tissue was proliferative. Immunohistochemistry showed that CD20 (B cells) (+), CD3 (T cells) (+), CD38 (+), IgG (+), IgG4 positive cells > 100/high powered field, and IgG4/IgG > 40%. Combined with clinical and immunohistochemical results, lymphadenopathy was consistent with Castleman disease-like IgG4-associated sclerosing disease. Prednisone acetate treatment was given at 40 mg/d. After 2 wk, the superficial lymph nodes and orbital masses shrank, and the IgG4 level decreased. As prednisone acetate was regularly used at a reduced dosage, no recurrence of the disease has been observed.
CONCLUSION This case suggested that it is necessary to proceed cautiously in clinical practice with such patients, and immunoglobulin, complement, interleukin-6, C-reactive protein, and other examinations should be performed to confirm the diagnosis.
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Affiliation(s)
- Feng-Yun Hao
- Department of Pathology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Feng-Xia Yang
- Department of Abdominal Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Hai-Yan Bian
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Xia Zhao
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
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13
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Nishikori A, Nishimura MF, Nishimura Y, Notohara K, Satou A, Moriyama M, Nakamura S, Sato Y. Investigation of IgG4-positive cells in idiopathic multicentric Castleman disease and validation of the 2020 exclusion criteria for IgG4-related disease. Pathol Int 2021; 72:43-52. [PMID: 34762752 PMCID: PMC9299129 DOI: 10.1111/pin.13185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 01/09/2023]
Abstract
Patients with plasma cell type idiopathic multicentric Castleman disease (PC-iMCD) often show elevated serum IgG4 levels and IgG4-positive cell infiltration in tissues due to overproduction of interleukin-6, and may meet the diagnostic criteria for IgG4-related disease (IgG4-RD). Although PC-iMCD has been listed as a major exclusion disease for IgG4-RD, distinguishing between these diseases is challenging due to a lack of highly specific diagnostic biomarkers. In 2020, we proposed exclusion criteria of IgG4-RD mimickers. In this paper, we validated the accuracy of the criteria in excluding one of the mimickers, PC-iMCD, from IgG4-RD. Validation was performed on 57 PC-iMCD patients (39 presenting lymph node lesions and 19 with lung lesions) and 29 IgG4-RD patients (22 presenting lymph node lesions and seven with lung lesions). According to our results, 20.5% of the PC-iMCD patients with lymph node lesions and 42.1% of those with lung lesions met the diagnostic criteria for IgG4-RD. All these patients with PC-iMCD were excluded from a diagnosis of IgG4-RD by the proposed criteria. Additionally, 6.9% of IgG4-RD patients met the exclusion criteria. Thus, if the exclusion criteria are met, diagnosis should be made based on a combination of findings including organ distribution of disease, response to steroid therapy, and other pathological findings.
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Affiliation(s)
- Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan
| | - Midori Filiz Nishimura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii, USA
| | - Kenji Notohara
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Akira Satou
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Surgical Pathology, Aichi Medical University Hospital, Aichi, Japan
| | - Masafumi Moriyama
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Seiji Nakamura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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14
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Sasaki T, Akiyama M, Kaneko Y, Takeuchi T. IgG4-related disease and idiopathic multicentric Castleman's disease: confusable immune-mediated disorders. Rheumatology (Oxford) 2021; 61:490-501. [PMID: 34363463 DOI: 10.1093/rheumatology/keab634] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/13/2021] [Accepted: 08/02/2021] [Indexed: 11/13/2022] Open
Abstract
IgG4-related disease (IgG4-RD) and idiopathic multicentric Castleman's disease (iMCD) are both rare systemic immune-mediated disorders. However, pathogenesis differs markedly between the two diseases, and differing therapeutic strategies are adopted: IgG4-RD is treated using a moderate dose of glucocorticoids or rituximab, while iMCD therapy involves an interleukin (IL)-6 targeted approach. Nonetheless, some clinical features of IgG4-RD and iMCD overlap, so differential diagnosis is sometimes difficult, even though the classification and diagnostic criteria of the diseases require careful exclusion of the other. The key findings in IgG4-RD are high IgG4/IgG ratio, allergic features, and germinal centre expansion involving T follicular helper cells, while iMCD involves polyclonal antibody production (high IgA and IgM levels), sheet-like mature plasma cell proliferation, and inflammatory features driven by IL-6. The distribution of organ involvement also provides important clues in both diseases. Particular attention should be given to differential diagnosis using combined clinical and/or pathological findings, because single features cannot distinguish IgG4-RD from iMCD. In the present review, we discuss the similarities and differences between IgG4-RD and iMCD, as well as how to distinguish the two diseases.
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Affiliation(s)
- Takanori Sasaki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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