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Cai XQ, Chen ZB, Chen HH, Zheng YQ, Yu XG. A case of IgG4-related interstitial nephritis with ureteral obstruction: case report and literature review. BMC Urol 2023; 23:67. [PMID: 37118801 PMCID: PMC10142501 DOI: 10.1186/s12894-023-01253-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 04/06/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a newly discovered systemic disease that can affect any organ or tissue in the body. IgG4-related kidney disease (IgG4-RKD) is relatively rare but essential to IgG4-RD. However, there are few reports of IgG4-RD mimicking malignant ureteral tumors leading to hydronephrosis. We report here a rare case of IgG4-RD involving the ureter. CASE PRESENTATION An 87-year-old man presented to our nephrology department with anorexia, nausea, and acute kidney injury in November 2020. Urinary computed tomography (CT) examination revealed a right lower ureter mass with right renal and ureter hydronephrosis. The serum level of IgG4 was 1890 mg/dL, and the concurrently renal biopsy revealed extensive infiltration of IgG4-positive plasma cells in renal interstitium, which was diagnosed as IgG4-associated tubule-interstitial nephritis(IgG4-TIN). The renal function improved significantly after double-J tube implantation of the right ureter and moderate-dose hormone therapy. The serum IgG4 decreased to the normal range, and the right lower ureter mass almost disappeared after one year of low-dose hormone maintenance therapy. CONCLUSION IgG4-RD can present as a mass in the renal pelvis and (or) ureter, leading to hydronephrosis. Therefore, early recognition of this disease is significant. Most patients respond well to hormonal therapy to avoid surgical treatment due to misdiagnosis as malignant tumors, causing secondary harm to patients.
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Affiliation(s)
- Xiao-Qing Cai
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, 325600, Zhejiang, China
| | - Zhi-Bin Chen
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, 325600, Zhejiang, China
| | - Huai-Huai Chen
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, 325600, Zhejiang, China
| | - Yan-Qiu Zheng
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, 325600, Zhejiang, China
| | - Xu-Guang Yu
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, 325600, Zhejiang, China.
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[A CASE OF IgG4-RELATED DISEASE OF THE URETER DIAGNOSED BY TRANSVAGINAL ULTRASOUND-GUIDED BIOPSY]. Nihon Hinyokika Gakkai Zasshi 2022; 112:38-44. [PMID: 35046235 DOI: 10.5980/jpnjurol.112.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
IgG4-related disease (IgG4-RD) is a chronic inflammatory disorder that systemically causes tissue fibrosis due to infiltration of IgG4-positive plasma cells. Here, we reported a rare case of ureteral IgG4-RD that formed a nodular lesion and diagnosed by trans-vaginal ultrasound-guided needle biopsy.A 72-year-old woman presented with loss of appetite. The patient underwent Computed Tomography (CT), and she was pointed out the thickening of the left side bladder wall. So we performed a transurethral bladder biopsy under lumber anesthesia, but histopathological findings were almost normal. After that, she developed pyelonephritis repeatedly. We performed CT again. A CT revealed a nodular lesion at the end of her left ureter and hydronephrosis. The tumor was gradually getting larger. So we performed placement the ureteral stent for urinary tract obstruction. Left ureteral urine cytology was classIIIa. We performed transvaginal ultrasound needle biopsy for the nodular lesion of the left ureter. Histopathological findings showed infiltration of lymphocytes and fibrosis and infiltration of IgG4 positive plasma cells: the ratio of IgG4/IgG positive cells>0.6, 30>IgG4 positive plasma cells/high power field. The serum IgG and IgG4 levels were also elevated 1,943 and 210 mg/dl. We finally diagnosed IgG4-RD of the ureter and started using steroid for her treatment. One month later, the tumor had reduced after steroid treatment. The ureteral stent was removed. Since then, recurrent ureteral obstruction of the left ureter has not occurred.IgG4-RD of the ureter with nodular type is rare, and the imaging findings are similar to malignant tumors. Accurate diagnosis is very important to rule out malignancy. In our case, transvaginal needle biopsy was helpful to reach final diagnosis.
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Ueki T, Miyake T, Narita M, Kojima M, Kaida S, Iida H, Shimizu T, Tani M. IgG4-related focal retroperitoneal fibrosis in ureter suggestive of colon cancer recurrence and resected laparoscopically: a case report. Surg Case Rep 2020; 6:197. [PMID: 32748129 PMCID: PMC7399002 DOI: 10.1186/s40792-020-00964-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a novel disease concept of unknown cause that is characterized by abundant infiltration of IgG4-positive cells, mass-forming lesions, and elevated serum IgG4 levels. The infiltration of IgG4-positive plasma cells and lymphocytes causes swelling, inflammation, fibrosis, and obliterative phlebitis in multiple organs. On the other hand, IgG4-RD occurring in the ureters has rarely been reported. To our knowledge, this is the first report of laparoscopic partial ureteral resection for IgG4-related focal retroperitoneal fibrosis in a ureter with suspected colon cancer recurrence. CASE PRESENTATION A 72-year-old man with a history of sigmoid colon cancer visited Shiga University of Medical Science Hospital for regular follow-up in December 2019. Enhanced abdominal computed tomography revealed a mass involving the left ureter. Furthermore, fluorine-18 fluorodeoxyglucose positron emission tomography showed significant accumulation of fluorodeoxyglucose uptake in the same region. Due to the possibility of colon cancer recurrence, a laparoscopic excisional biopsy with partial ureteral resection was performed. Histologically, IgG4-positive plasma cell infiltration exceeding 10 cells per high-power field and a high ratio of IgG4-positive/IgG-positive cells exceeding 40% were observed. The postoperative serum IgG4 level was 384 mg/dL. With the application of these findings to the diagnostic algorithm in the comprehensive diagnostic criteria for IgG4-RD, the mass-forming lesion was diagnosed as definitive IgG4-related focal retroperitoneal fibrosis. CONCLUSIONS IgG4-RD should be considered in the differential diagnosis of retroperitoneal lesions. Moreover, laparoscopic surgery may be useful for making the diagnosis in difficult-to-biopsy cases.
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Affiliation(s)
- Tomoyuki Ueki
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Mitsuhiro Narita
- Department of Urology, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Masatsugu Kojima
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Tomoharu Shimizu
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu-shi, Shiga, 520-2192 Japan
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Chen X, Sun W, Lin R, Huang Z, Chen W. IgG4+ plasma cell infiltration is correlated with the development of inflammatory bowel disease and can be regulated by TLR-4. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2018; 11:4537-4544. [PMID: 31949851 PMCID: PMC6962960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/07/2018] [Indexed: 06/10/2023]
Abstract
Immunoglobulin 4 (IgG4) is commonly considered a hallmark of autoimmune pancreatitis (AIP). Inflammatory bowel disease (IBD) is believed to play a substantial role in the setting of AIP. Toll-like receptor 4 (TLR4) plays an important role in inflammation. The relationship between IgG4 and TLR4 in the process of IBD is incompletely explored. Our study aimed to assess the expression of IgG4 and TLR4 in IBD patients and to find the role of IgG4 and TLR4 in the IBD process. A cohort of 68 IBD patients was enrolled in our study, and 20 healthy persons served as a control group. Intestinal IgG4 positive (IgG4+) plasma cell infiltration was measured by immunohistochemistry. Serum IgG4 and TLR4 levels were measured by ELISA. Fifteen additional features from the patients' general medical information and lab data were also collected to assess the risk factors of IBD activity by logistical analysis. BALB/c mice were used to build a rat IBD model with dextran sulfate sodium (DSS). The TLR4 inhibitor TAK242 was used to regulate the expression of TLR4. The expression of IgG4 and TLR4 in serum was detected by ELISA. The expression of IgG4 and TLR4 in the intestines were assayed with western blot. Our results revealed that the infiltration of IgG4+ plasma cells was higher in IBD patients (14/68 vs 0/20, P<0.05). The incidence of IgG4+ plasma cells in the IBD group (48.5%) was higher than in the control group (33/68 vs 0/20, P<0.05). Serum IgG4 and TLR4 levels in the IBD group were significantly higher compared with the control group (P<0.05). Based on our logistical analysis, three variables: IgG4+ plasma cell infiltration, CRP, and HB were identified as independent risk factors with odds ratios of 10.917, 1.031, and 0.923, respectively (P<0.05). After the TLR4 was suppressed, the infiltration of IgG4+ plasma cells in the intestines decreased significantly, and expression of IgG4 in the serum and intestines was suppressed. This study demonstrated that intestinal IgG4+ plasma cell infiltration was higher in IBD patients than in the control group. IgG4+ cell infiltration is significantly enhanced in ulcerative colitis patients. IgG4+ plasma cell infiltration can be regulated by TLR4, and an increase of IgG4+ plasma cell infiltration, CRP, and anemia are correlated with an increased risk of active IBD.
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Affiliation(s)
- Xiaowei Chen
- Department of Gastroenterology, The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu, P. R. China
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical UniversityWenzhou, Zhejiang, P. R. China
| | - Wenwen Sun
- Department of Pathology, The First Affiliated Hospital of Wenzhou Medical UniversityWenzhou, Zhejiang, P. R. China
| | - Risheng Lin
- Department of Pathology, The First Affiliated Hospital of Wenzhou Medical UniversityWenzhou, Zhejiang, P. R. China
| | - Zhiming Huang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical UniversityWenzhou, Zhejiang, P. R. China
| | - Weichang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu, P. R. China
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Fanidou D, Filippou N, Katseli A, Papadopoulos G, Skandalakis P, Filippou D. Autoimmune pancreatitis associated with retroperitoneal fibrosis mimicking cholangiocarcinoma. Oxf Med Case Reports 2018; 2018:omy056. [PMID: 30159151 PMCID: PMC6109199 DOI: 10.1093/omcr/omy056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/07/2018] [Accepted: 06/16/2018] [Indexed: 11/21/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare systematic autoimmune disease that causes chronic pancreatitis. Type 1-AIP (IgG4-related disease) may involve other organs as well. In this report we are presenting a case of a 74-year-old man with obstructive abdominal pain jaundice, mild and a history of retroperitoneal fibrosis and hydronephrosis. Labs were remarkable for hyperbilirubinemia, high serum IgG4 levels, mildly elevated CA 19–9, elevated rheumatoid factor and new onset diabetes. MRI revealed pancreatic enlargement, dilated intrahepatic bile ducts and stricture of the distal common bile duct concerning for cholangiocarcinoma. EUS-FNA biopsy was negative for malignancy but showed findings of pancreatitis. The diagnosis of type 1-AIP was made and the patient was treated with steroids. After one month of treatment jaundice and MRI findings resolved. It is important to include AIP in the differential diagnosis of pancreatic conditions causing obstructive jaundice, especially in the presence of other autoimmune conditions like retroperitoneal fibrosis.
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Affiliation(s)
- Domna Fanidou
- Surgical Department, General Hospital of Athens 'Giorgos Gennematas', Athens, Greece.,Surgical Anatomy, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Filippou
- Surgical Department, General Hospital of Athens 'Giorgos Gennematas', Athens, Greece.,Surgical Anatomy, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Katseli
- Surgical Department, General Hospital of Athens 'Giorgos Gennematas', Athens, Greece
| | - Georgios Papadopoulos
- Surgical Anatomy, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Plastic Surgery Department, Geniko Nosokomeio Evangelismou, Athens, Greece
| | - Panagiotis Skandalakis
- Surgical Anatomy, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Filippou
- Surgical Anatomy, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Han SY, Lee SI, Lee YH, Kim AJ, Lim HJ, Ro H, Chang JH, Lee HH, Chung W, Jung JY. IgG4-Related Systemic Disease Can Be Easily Mistaken as a Uroepithelial Tumor. Chonnam Med J 2015; 51:39-42. [PMID: 25914879 PMCID: PMC4406993 DOI: 10.4068/cmj.2015.51.1.39] [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: 10/24/2014] [Revised: 12/10/2014] [Accepted: 12/29/2014] [Indexed: 11/22/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized systemic syndrome characterized by elevated serum IgG4 concentrations and tumefaction or tissue infiltration by IgG4-positive plasma cells. We experienced a case of IgG4-RD involving multiple organs in a 64-year-old female who was referred for a suspected uroepithelial tumor. A mass biopsy confirmed dense lymphoplasmacytic infiltration with an increased number of IgG4-positive plasma cells. We discuss this case and review the literature to bring IgG4-RD to the attention to clinicians because it responds dramatically well to steroid therapy and should be kept in mind as a differential diagnosis to avoid unnecessary surgery.
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Affiliation(s)
- Song Yi Han
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Seung Ik Lee
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Yeon Hee Lee
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Ae Jin Kim
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Hye Jin Lim
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Han Ro
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea. ; Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Jae Hyun Chang
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea. ; Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Hyun Hee Lee
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea. ; Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Wookyung Chung
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea. ; Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Ji Yong Jung
- Division of Nephrology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea. ; Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
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Hara N, Kawaguchi M, Takeda K, Zen Y. Retroperitoneal disorders associated with IgG4-related autoimmune pancreatitis. World J Gastroenterol 2014; 20:16550-16558. [PMID: 25469023 PMCID: PMC4248198 DOI: 10.3748/wjg.v20.i44.16550] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 02/27/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
IgG4-related autoimmune pancreatitis is frequently accompanied by relevant lesions in the genitourinary tract and retroperitoneal organs, which cause various clinical problems, ranging from non-specific back pain or bladder outlet obstruction to renal failure. The diagnosis of IgG4-related retroperitoneal fibrosis requires a multidisciplinary approach, including serological tests, histological examination, imaging analysis, and susceptibility to steroid therapy. Radiological examinations are helpful to diagnose this condition, but surgical resection is occasionally unavoidable to exclude malignancy, particularly for patients with isolated retroperitoneal involvement. Steroid therapy is the treatment of choice for this condition, the same as for other manifestations of IgG4-related disease. For patients with severe ureteral obstruction, additional ureteral stenting needs to be considered prior to steroid therapy to preserve the renal function. Some papers have suggested that IgG4-related disease can affect male reproductive organs including the prostate and testis. IgG4-related prostatitis usually causes lower urinary tract symptoms, such as dysuria and pollakisuria. Patients sometimes state that corticosteroids given for IgG4-related disease at other sites relieve their lower urinary tract symptoms, which leads us to suspect prostatic involvement in this condition. Because of the limited number of publications available, further studies are warranted to better characterize IgG4-related disease in male reproductive organs.
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Abstract
A 62-year-old man presented with pain in the upper abdomen persisting for 2 months. He had the clinical history of diabetes for approximately 10 years. CT and MRI showed a mass located in processus uncinatus of caput pancreatis. The laboratory tests, including pancreas-originated amylase, tumor marker, IgG, IgG4, and so on, were normal. For suspicion of pancreatic cancer, the patient underwent F-FDG PET/CT, which demonstrated focal and high radioactivity accumulation in processus uncinatus of pancreas, without extrapancreatic radioactivity uptake observed. Finally, the surgical pathology confirmed IgG4-related sclerosing pancreatitis.
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Abstract
(Case 1) A 63-year-old man was diagnosed as retroperitoneal fibrosis by the exploratory laparotomy for the pelvic mass with high IgG4 levels. (Case 2) A 64-year-old man had past medical history of autoimmune pancreatitis which was treated by steroid use. Three years later, he was diagnosed as IgG4-related gallbladder tumor by the cholecystectomy. And, then he was diagnosed as right hydronephrosis with high IgG4 levels. (Case 3) A 71-year-old man was diagnosed as left hydronephrosis and pelvic mass by computerized tomography with high IgG4 levels. We reported three cases of IgG4-related focal retroperitoneal fibrosis. All cases had pelvic mass with high IgG4 levels and were also treated effectively with steroid use. Those symptoms of the patients occurred in close association with IgG4 levels. It is necessary to acknowledge that retroperitoneal fibrosis may have aspects of IgG4-related systemic disease and that the measurement of serum IgG4 should be considered for diagnosing and treating the conditions.
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Camacho JF, Helú JC, Valenzuela A, Hidalgo JF. Retroperitoneal fibrosis: case report and literature review. Medwave 2013. [DOI: 10.5867/medwave.2013.08.5795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Increased immunoglobulin G4–positive plasma cells in collagenous sprue. Hum Pathol 2013; 44:1624-9. [DOI: 10.1016/j.humpath.2013.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/19/2013] [Accepted: 01/28/2013] [Indexed: 12/15/2022]
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Fujita A, Sakai O, Chapman MN, Sugimoto H. IgG4-related disease of the head and neck: CT and MR imaging manifestations. Radiographics 2013; 32:1945-58. [PMID: 23150850 DOI: 10.1148/rg.327125032] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Immunoglobulin G4 (IgG4)-related disease is a recently established systemic disease that commonly involves the head and neck, including the salivary glands, lacrimal glands, orbits, thyroid gland, lymph nodes, sinonasal cavities, pituitary gland, and larynx. Although the definitive diagnosis of IgG4-related disease requires histopathologic analysis, elevated serum IgG4 levels are helpful in making the diagnosis. Because of the proposed clinical diagnostic criteria for this disease, cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance (MR) imaging play an important diagnostic role. CT and MR imaging findings of IgG4-related disease are usually nonspecific. At CT, involved organs may demonstrate enlargement or decreased attenuation; at T2-weighted MR imaging, they may have relatively low signal intensity owing to their increased cellularity and amount of fibrosis. Some pathologic entities involving the head and neck are now considered to be part of the IgG4-related disease spectrum, including idiopathic orbital inflammatory syndrome (inflammatory pseudotumor), orbital lymphoid hyperplasia, Mikulicz disease, Küttner tumor, Hashimoto thyroiditis, Riedel thyroiditis, and pituitary hypophysitis. Because involvement of multiple sites is common in IgG4-related disease, radiologists should be familiar with manifestations of this systemic process outside the head and neck, in organs such as the pancreas, bile ducts, gallbladder, kidneys, retroperitoneum, mesentery, lungs, gastrointestinal tract, and blood vessels. Moreover, IgG4-related disease usually demonstrates a dramatic response to corticosteroid therapy, and radiologists should be familiar with its clinical and imaging manifestations to avoid a delay in diagnosis or unnecessary invasive interventions.
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Affiliation(s)
- Akifumi Fujita
- Department of Radiology, Jichi Medical University, School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.
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IgG4-related disease of the ureter: report of two cases and review of the literature. Virchows Arch 2013; 462:673-8. [PMID: 23666067 DOI: 10.1007/s00428-013-1421-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 04/16/2013] [Accepted: 04/29/2013] [Indexed: 12/18/2022]
Abstract
IgG4-related disease (IgG4-RD) is a recently recognized multi-organ fibro-inflammatory lesion characterized by elevated IgG4 serum levels and mass-forming lesions. This condition shows similar histological features independently of the site of origin including storiform fibrosis, obliterative phlebitis, and dense lymphoplasmacytic infiltrate with a conspicuous IgG4-positive plasma cell component. Since this disease has only recently been categorized as a single specific nosologic entity, lesions with these typical morphological features have previously been named in different ways, creating some confusion and making it difficult to identify cases published in the literature. Lesions with features suggesting IgG4-RDs have very rarely been reported in the ureter, and they have been named using the terms "inflammatory pseudotumor" and "idiopathic segmental ureteritis." Herein, we describe the clinicopathological features of ureteral IgG4-RD found in two different patients. An 82-year-old female and a 77-year-old male underwent ureteral resection due to severe ureteral wall thickness and lumen stenosis suggestive of urothelial carcinoma. However, histological examinations showed transmural fibro-inflammatory lesions, with abundant IgG4 plasma cells intermixed with histiocytes, lymphocytes, fibroblasts, and scattered eosinophils. We have also accurately reviewed the literature in order to identify, among lesions diagnosed with different names, examples of ureteral IgG4-related lesions to give the reader a comprehensive overview of this relatively rare inflammatory disease. We suggest using the name "ureteral IgG4-RD" for those lesions showing the same morphological features as IgG4-RDs located elsewhere.
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Chiba K, Kamisawa T, Tabata T, Hara S, Kuruma S, Fujiwara T, Kuwata G, Egashira H, Koizumi K, Koizumi S, Fujiwara J, Arakawa T, Momma K, Setoguchi K, Shinohara M. Clinical features of 10 patients with IgG4-related retroperitoneal fibrosis. Intern Med 2013; 52:1545-51. [PMID: 23857085 DOI: 10.2169/internalmedicine.52.0306] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To elucidate the clinical characteristics of IgG4-related retroperitoneal fibrosis (RF). METHODS IgG4-related RF was diagnosed when all of the following three criteria were fulfilled: retroperitoneal soft tissue masses surrounding the aorta and/or adjacent tissues, elevation of the serum IgG4 levels, and abundant infiltration of IgG4-positive plasma cells in at least one organ or site. Ten patients were diagnosed as having IgG4-related RF. RESULTS The mean age at diagnosis was 70.1 years, and the male-to-female ratio was 1:0.6. Only two patients had initial symptoms predominantly related to RF (back pain and edema of the lower extremities), while the remaining eight patients reported initial symptoms due to associated diseases. On laboratory examination, a severe inflammatory reaction was observed in one patient. Elevation of the levels of serum IgG and IgE, eosinophilia and positivity of antinuclear antibodies were detected in seven, five, two and seven patients, respectively. The retroperitoneal masses were detected primarily in the left renal hilus in four patients, in the periaortic region in five patients and in both regions in one patient. Hydronephrosis was present in five patients. The histological diagnosis was confirmed in the retroperitoneal masses (resection, n=1 biopsy, n=2) and extraretroperitoneal lesions (n=7). Twenty-four other IgG4-related diseases were found to be associated with IgG4-related RF in nine patients (autoimmune pancreatitis (n=2), sialadenitis (n=4), dacryoadenitis (n=5), lymphadenopathy (n=9), pulmonary pseudotumor (n=1) and pituitary pseudotumor (n=1)). Seven patients underwent steroid therapy, all of whom responded well and showed no instances relapse. CONCLUSION IgG4-related RF has several clinical characteristic features. Our diagnostic criteria may be helpful in obtaining a correct diagnosis.
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Affiliation(s)
- Kazuro Chiba
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Japan
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Novotný I, Dítě P, Trna J, Lata J, Husová L, Geryk E. Immunoglobulin G4-related cholangitis: a variant of IgG4-related systemic disease. Dig Dis 2012; 30:216-9. [PMID: 22722442 DOI: 10.1159/000336706] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IgG4-related sclerosing cholangitis as part of IgG4 systemic-related diseases is commonly associated with autoimmune pancreatitis. Major clinical manifestations of IgG4-related sclerosing diseases are apparent in the organs in which tissue fibrosis with obstructive phlebitis is pathologically induced. IgG4-related sclerosing cholangitis is included within the heterogeneous group of 'sclerosing cholangitis'. Sclerosing cholangitis may be associated with choledocholithiasis, infection or biliary malignancies. Sclerosing cholangitis of unknown etiology is called primary sclerosing cholangitis (PSC). Conservative therapy of PSC is usually unsuccessful, the disease involves extra- and/or intrahepatic biliary tree, and the end point of this disease is liver cirrhosis. Typically, PSC is identified at the age of 30 to 40 years, and the disease is frequently associated with inflammatory bowel diseases. On the other hand, IgG4-related sclerosing cholangitis is not associated with inflammatory bowel diseases. In patients with IgG4-related sclerosing cholangitis, a first symptom can be obstructive jaundice, whereas obstructive jaundice is rarely present in PSC. Clinically, patients with IgG4-related sclerosing cholangitis are older at diagnosis compared to patients with PSC. A typical diagnostic feature of IgG4-related sclerosing cholangitis is elevation of serum immunoglobulin G4. In patients with IgG4-related sclerosing cholangitis, response to steroid therapy is high; in patients with PSC corticosteroid therapy is unsuccessful. Histochemically abundant infiltration of IgG4-positive plasma cells is detected in the biliary duct wall. Histologically, we can identify dense lymphoplasmacytic infiltration of the bile duct wall, transmural fibrosis, lymphoplasmacytic infiltration and fibrosis in the periportal area of the liver - a typically obliterative phlebitis. The biliary epithelium is usually intact in contrast to PSC, where mucosal erosion is often present. Steroids are the first-choice therapy of IgG4-related sclerosing cholangitis. In the literature, cholangiocarcinoma in patients with IgG4- related sclerosing cholangitis was not described, whereas cholangiocarcinoma develops in up to 10-30% of patients with PSC.
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Affiliation(s)
- Ivo Novotný
- Department of Gastrointestinal Endoscopy, Masaryk Memorial Cancer Institute Brno, Czech Republic.
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Abe H, Morikawa T, Araki A, Shima T, Nakatsu H, Fukayama M, Suzuki Y. IgG4-related periureteral fibrosis presenting as a unilateral ureteral mass. Pathol Res Pract 2011; 207:712-4. [DOI: 10.1016/j.prp.2011.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 07/11/2011] [Accepted: 08/02/2011] [Indexed: 02/04/2023]
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Ito M, Naruke Y, Mihara Y, So K, Miyashita T, Origuchi T, Nakashima M, LiVolsi V. Thyroid papillary carcinoma with solid sclerosing change in IgG4-related sclerosing disease. Pathol Int 2011; 61:589-92. [DOI: 10.1111/j.1440-1827.2011.02701.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Singh K, Rajan KDA, Eberhart C. Orbital necrobiotic xanthogranuloma associated with systemic IgG4 disease. Ocul Immunol Inflamm 2011; 18:373-8. [PMID: 20716008 DOI: 10.3109/09273948.2010.490629] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The authors describe 2 cases of orbital xanthogranulomatous disease associated with an increase in IgG4-positive plasma cells, and also examine IgG4 in other types of orbital inflammation. METHODS Immunohistochemistry for total IgG and IgG4 was performed in 18 cases of orbital inflammation, including chronic dacryoadenitis (n=10), necrobiotic xanthogranuloma (n=2), xanthogranuloma (n=1), idiopathic orbital inflammation/pseudotumor (n=4), and fungal infection (n=1). RESULTS One patient presenting with necrobiotic xanthogranuloma had signs of systemic IgG4 disease. His orbital lesion showed an elevated number of IgG4 positive plasma cells (55%). An orbital xanthogranulomatous lesion in a second patient lacking systemic symptoms also contained a high percentage of IgG4-positive plasma cells (80%). Only 1 case of chronic dacryoadenitis contained prominent IgG4-positive plasma cells (mean 17/hpf). CONCLUSIONS IgG4-positive plasma cells are relatively rare in nonsclerosing orbital inflammatory lesions. However, systemic disease IgG4 can be associated with necrobiotic xanthogranuloma of the orbit.
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Zielonko J, Obołończyk Ł. Retroperitoneal fibrosis with pancreatic involvement - radiological appearance. Pol J Radiol 2011; 76:69-72. [PMID: 22802859 PMCID: PMC3389945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 01/31/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Retroperitoneal fibrosis or Ormond's disease is an uncommon process characterized by fibrous tissue proliferation in the retroperitoneum, usually involving the aorta, inferior vena cava and iliac vessels. Obstructive hydronephrosis is often observed due to ureteral entrapment. This report presents a case of the peripancreatic location of the disease. The role of CT and MRI in establishing diagnosis of retroperitoneal fibrosis in an atypical site is discussed. CASE REPORT A 52-year-old woman with Hashimoto's thyroiditis was admitted to hospital because of pain suggesting renal colic. The patient was subjected to ultrasound, CT, and MRI which did not confirm urolithiasis but revealed pancreatic infiltration. Partial pancreatectomy, left-sided adrenalectomy and splenectomy were performed. Retroperitoneal fibrosis was diagnosed in the histopathological examination. A few weeks after surgery, a complication such as pancreatitis developed. Repeat CT confirmed it and showed right hydronephrosis secondary to ureteral involvement by a mass adjacent to the common iliac artery (defined as a typical manifestation of retroperitoneal fibrosis). Nephrostomy and conservative treatment improved the clinical state of the patient. No progression of the process was observed in the follow-up examinations. CONCLUSIONS Atypical retroperitoneal fibrosis remains a diagnostic challenge. Imaging techniques CT and MRI are useful tools for evaluating the extent of Ormond's disease. An unusual distribution of the process (e.g. peripancreatic location reported in this study) requires histopathological assessment to establish the final diagnosis.
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Affiliation(s)
- Joanna Zielonko
- Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland,Author’s address: Joanna Zielonko, Department of Radiology, Medical University of Gdańsk, Dębinki 7 St., Gdańsk, Poland, e-mail:
| | - Łukasz Obołończyk
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Aortitis, periaortitis, and retroperitoneal fibrosis, as manifestations of IgG4-related systemic disease. Curr Opin Rheumatol 2011; 23:88-94. [PMID: 21037477 DOI: 10.1097/bor.0b013e3283412f7c] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Kamisawa T, Takuma K, Egawa N, Tsuruta K, Sasaki T. Autoimmune pancreatitis and IgG4-related sclerosing disease. Nat Rev Gastroenterol Hepatol 2010; 7:401-9. [PMID: 20548323 DOI: 10.1038/nrgastro.2010.81] [Citation(s) in RCA: 145] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Autoimmune pancreatitis (AIP) is a unique form of pancreatitis in which the pathogenesis is suspected to involve autoimmune mechanisms. AIP sometimes mimics pancreatic cancer in its presentation, but as AIP responds dramatically to steroid therapy, accurate diagnosis is necessary. AIP is currently diagnosed on the basis of a combination of characteristic clinical, serological, morphological and histopathological features. However, its diagnosis remains a clinical challenge and there are no internationally agreed diagnostic criteria. Another type of AIP called 'idiopathic duct-centric chronic pancreatitis' or 'AIP with granulocytic epithelial lesion' has been reported in Western countries. IgG4-related sclerosing disease is a systemic disease in which IgG4-positive plasma cells and T lymphocytes extensively infiltrate various organs. Organs with tissue fibrosis and obliterative phlebitis, such as the pancreas, salivary gland and retroperitoneum, show clinical manifestations; AIP seems to represent one manifestation of IgG4-related sclerosing disease. As a mass is formed in most cases of IgG4-related sclerosing disease, a malignant tumor is frequently suspected on initial presentation. Clinicians should consider IgG4-related sclerosing disease in the differential diagnosis to avoid unnecessary surgery.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
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Li Y, Nishihara E, Hirokawa M, Taniguchi E, Miyauchi A, Kakudo K. Distinct clinical, serological, and sonographic characteristics of hashimoto's thyroiditis based with and without IgG4-positive plasma cells. J Clin Endocrinol Metab 2010; 95:1309-17. [PMID: 20097712 DOI: 10.1210/jc.2009-1794] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT IgG4-related sclerosing disease is a new syndrome characterized by high serum IgG4 levels and increased IgG4-positive plasma cells in the involved organs. Recently the first description was made by our group of a subsection of Hashimoto's autoimmune thyroiditis (HT) patients showing indistinguishable histopathological features with IgG4-related sclerosing disease, which was termed as IgG4 thyroiditis. OBJECTIVE The objective of the study was analysis of the immunophenotypic features of IgG4 in 70 cases of HT patients and to clarify the histopathological and clinical characteristics of the patients with IgG4 thyroiditis. DESIGN Thyroid tissue samples were obtained from 70 patients with HT who were treated surgically. Quantitative analyses of the expression of IgG4 and IgG were performed. Statistical analyses of clinical and histopathological parameters were also conducted. RESULTS On the basis of immunohistochemistry of IgG4 and IgG4/IgG ratio, the 70 patients with HT were divided into two groups: IgG4 thyroiditis (19 cases) and non-IgG4 thyroiditis (51 cases). Histopathologically, IgG4 thyroiditis showed higher grade of stromal fibrosis, lymphoplasmacytic infiltration, and follicular cell degeneration than non-IgG4 thyroiditis. Moreover, these two groups were also demonstrated to be related with different clinical features, with IgG4 thyroiditis associated more with male gender, rapid progress, subclinical hypothyroidism, more diffuse low echogenicity, and higher level of circulating antibodies. CONCLUSIONS From both clinical and histopathological aspects, IgG4 thyroiditis and non-IgG4 thyroiditis were demonstrated to be distinct entities. Measuring serum IgG4 concentration provides a useful method of distinguishing IgG4 thyroiditis from non-IgG4 thyroiditis.
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Affiliation(s)
- Yaqiong Li
- Department of Human Pathology, Wakayama Medical University, Kimiidera 811-1, Wakayama, 641-8509, Japan
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Use of immunohistochemistry for IgG4 in the distinction of autoimmune pancreatitis from peritumoral pancreatitis. Hum Pathol 2010; 41:643-52. [PMID: 20149413 DOI: 10.1016/j.humpath.2009.10.019] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 10/17/2009] [Accepted: 10/22/2009] [Indexed: 12/24/2022]
Abstract
The patients with autoimmune pancreatitis usually present with jaundice and a pancreatic head mass, presumed to have pancreatic cancer, and they often undergo pancreatic resection. Elevated serum IgG4 levels (>135 mg/dL) help to distinguish autoimmune pancreatitis from pancreatic cancer. However, when the biopsy from a pancreatic mass shows dense chronic inflammation and fibrosis and the serum IgG4 level is not available, it presents a diagnostic dilemma whether it represents autoimmune pancreatitis or peritumoral pancreatitis. We performed IgG4 immunohistochemistry on 25 cases of autoimmune pancreatitis-lymphoplasmacytic sclerosing pancreatitis, 7 cases of autoimmune pancreatitis with granulocytic epithelial lesions, 8 cases of nonspecific pancreatitis, 15 cases of pancreatitis associated with pancreatic ductal adenocarcinoma, and 5 biopsies of pancreatic adenocarcinoma with variable inflammation. The distribution of IgG4-positive cells was noted in each case. Eighty-four percent (21/25) of autoimmune pancreatitis-LPSP cases showed diffuse and dense staining for IgG4, with more than 50 positive plasma cells per high-power field (range, 50-150 cells/hpf) in the highest density area. Most (5/7) cases of autoimmune pancreatitis-granulocytic epithelial lesions were negative for IgG4. Thirty-nine percent of nonspecific pancreatitis and peritumoral pancreatitis cases stained positive for IgG4, but the distribution was focal and none of the cases showed more than 50 IgG4-positive cells/hpf in the highest density area of IgG4 staining. IgG4-positive cells in peritumoral pancreatitis and nonspecific pancreatitis cases were closely associated with malignant glands and areas of acute inflammation in some cases. Using a cutoff of 50 IgG4-positive cells/hpf, the sensitivity of IgG4 staining for classical autoimmune pancreatitis-LPSP versus other types of pancreatitis was 84%, the specificity was 100%, and the P value was significant (<.0001). Hence, we conclude that diffuse and dense staining (>50 positive cells/hpf) for IgG4 is specifically seen in autoimmune pancreatitis-LPSP, and IgG4 staining along with the histologic features and serum IgG4 levels may be very helpful in diagnosing autoimmune pancreatitis.
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Kamisawa T, Takuma K, Anjiki H, Egawa N, Fujiwara J, Koizumi K, Sasaki T. 5. Extra-pancreatic Lesions and IgG4-related Sclerosing Disease. ACTA ACUST UNITED AC 2010; 99:97-101. [DOI: 10.2169/naika.99.97] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Li Y, Bai Y, Liu Z, Ozaki T, Taniguchi E, Mori I, Nagayama K, Nakamura H, Kakudo K. Immunohistochemistry of IgG4 can help subclassify Hashimoto's autoimmune thyroiditis. Pathol Int 2009; 59:636-41. [PMID: 19712131 DOI: 10.1111/j.1440-1827.2009.02419.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IgG4-related sclerosing disease has been recently recognized as a systemic disease entity characterized by an elevated serum IgG4 level, sclerosing fibrosis and diffuse lymphoplasmacytic infiltration by many IgG4-positive plasma cells. Similar histopathological features have often been noted in the fibrous variant of Hashimoto's autoimmune thyroiditis, but thyroid gland involvement has been only briefly mentioned with regard to IgG4, and no immunohistochemistry for IgG4 has been reported in Hashimoto's autoimmune thyroiditis. Herein, the purpose of the present study was to investigate the infiltration of IgG- and IgG4-positive plasma cells on immunohistochemistry for a panel of thyroiditis samples (Hashimoto's autoimmune thyroiditis, n= 13; subacute thyroiditis, n= 2; lymphocytic thyroiditis, n= 2). Cases of Hashimoto's thyroiditis could be classified into two groups based on immunostaining of IgG4: IgG4 thyroiditis (IgG4-related, IgG4-positive plasma cell-rich thyroiditis) and non-IgG4 thyroiditis (non-IgG4-related, IgG4-positive plasma cell-poor thyroiditis). IgG4 thyroiditis presents with severe lymphoplasmacytic infiltration, dense fibrosis, marked follicular cell degeneration, oxyphilic change and lymphoid follicle formation, while non-IgG4 thyroiditis presents with relatively mild or absent histopathological characteristics. In conclusion, immunostaining of IgG4 can help subclassify Hashimoto's thyroiditis; and IgG4 thyroiditis may have a close relationship with IgG4-related sclerosing disease.
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Affiliation(s)
- Yaqiong Li
- Department of Human Pathology, Wakayama Medical University, Wakayama 641-8509, Japan
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A case of IgG4-related sclerosing disease with retroperitoneal fibrosis, autoimmune pancreatitis and bilateral focal nephritis. Pancreas 2009; 38:825-32. [PMID: 19893455 DOI: 10.1097/mpa.0b013e318ac522f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 74-year-old male patient presented with progressive anorexia, cholestatic liver function tests, and a diffuse enlarged pancreas suggestive of a pancreatic carcinoma. There was a marked elevation of total immunoglobulin G4 (IgG4) in serum. Further investigation led to the diagnosis of IgG4-related sclerosing disease with involvement of the pancreas, retroperitoneal fibrosis, and bilateral focal nephritis. To our knowledge, this is the first report on these 3 clinical entities occurring in the same patient.A short review of the literature concerning autoimmune pancreatitis and retroperitoneal fibrosis is made, with special interest to the concept of IgG4-related pathology. This systemic disease can have several clinical manifestations: IgG4-positivity not only can be found in the pancreas, but also at the level of extrahepatic biliary ducts, gallbladder, salivary glands, retroperitoneal tissue, kidneys, ureters, and lymph nodes. Although further investigation is required to determine its exact pathophysiologic role, IgG4 seems to be an important key player.
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Fujinaga Y, Kadoya M, Kawa S, Hamano H, Ueda K, Momose M, Kawakami S, Yamazaki S, Hatta T, Sugiyama Y. Characteristic findings in images of extra-pancreatic lesions associated with autoimmune pancreatitis. Eur J Radiol 2009; 76:228-38. [PMID: 19581062 DOI: 10.1016/j.ejrad.2009.06.010] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 06/09/2009] [Indexed: 12/17/2022]
Abstract
PURPOSE Autoimmune pancreatitis is a unique form of chronic pancreatitis characterized by a variety of extra-pancreatic involvements which are frequently misdiagnosed as lesions of corresponding organs. The purpose of this study was to clarify the diagnostic imaging features of extra-pancreatic lesions associated with autoimmune pancreatitis. MATERIALS AND METHODS We retrospectively analyzed diagnostic images of 90 patients with autoimmune pancreatitis who underwent computer-assisted tomography, magnetic resonance imaging, and/or gallium-67 scintigraphy before steroid therapy was initiated. RESULTS AIP was frequently (92.2%) accompanied by a variety of extra-pancreatic lesions, including swelling of lachrymal and salivary gland lesions (47.5%), lung hilar lymphadenopathy (78.3%), a variety of lung lesions (51.2%), wall thickening of bile ducts (77.8%), peri-pancreatic or para-aortic lymphadenopathy (56.0%), retroperitoneal fibrosis (19.8%), a variety of renal lesions (14.4%), and mass lesions of the ligamentum teres (2.2%). Characteristic findings in CT and MRI included lymphadenopathies of the hilar, peri-pancreatic, and para-aortic regions; wall thickening of the bile duct; and soft tissue masses in the kidney, ureters, aorta, paravertebral region, ligamentum teres, and orbit. CONCLUSIONS Recognition of the diagnostic features in the images of various involved organs will assist in the diagnosis of autoimmune pancreatitis and in differential diagnoses between autoimmune pancreatitis-associated extra-pancreatic lesions and lesions due to other pathologies.
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Affiliation(s)
- Yasunari Fujinaga
- Department of Radiology, Shinshu University School of Medicine, Asahi, Matsumoto, Japan.
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F-18 FDG PET-CT findings in Mikulicz disease and systemic involvement of IgG4-related lesions. Clin Nucl Med 2009; 34:164-7. [PMID: 19352281 DOI: 10.1097/rlu.0b013e3181967568] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A 72-year-old woman with Mikulicz disease with pathogically proven sclerosing sialadenitis showed systemic abnormal F-18 FDG uptake in the bilateral lacrimal and submandibular glands, pancreas, abdominal aortic wall, and a retroperitoneal fibroid mass on PET/CT scan, with marked elevation of the serum IgG4 level. This case supports Mikulicz disease being included as 1 of the disorders associated with a new clinical entity of systemic IgG4-related plasmacytic syndrome. A whole-body FDG-PET/CT scan can be expected as a useful tool for detecting systemic involvement in systemic IgG4-related plasmacytic syndrome.
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Marumo K, Tatsuno S, Noto K. Elevated serum IgG4 may predict sensitivity to steroid therapy in retroperitoneal fibrosis. Int J Urol 2009; 16:427. [DOI: 10.1111/j.1442-2042.2009.02255.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Morselli-Labate AM, Pezzilli R. Usefulness of serum IgG4 in the diagnosis and follow up of autoimmune pancreatitis: A systematic literature review and meta-analysis. J Gastroenterol Hepatol 2009; 24:15-36. [PMID: 19067780 DOI: 10.1111/j.1440-1746.2008.05676.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
High circulating serum immunoglobulin G4 (IgG4) levels have been proposed as a marker of autoimmune pancreatitis (AIP). The aim of the present study was to review the data existing in the English literature on the usefulness of the IgG4 serum levels in the diagnosis and follow up of patients with AIP. A total of 159 patients with AIP and 1099 controls were described in seven selected papers reporting the usefulness of serum IgG4 in diagnosing AIP. In total, 304 controls had pancreatic cancer, 96 had autoimmune diseases, and the remaining 699 had other conditions. The summary receiver-operating characteristic curve analysis was carried out by means of Meta-DiSc open-access software. Serum IgG4 showed good accuracy in distinguishing between AIP and the overall controls, pancreatic cancer and other autoimmune diseases (area under the curve [+/- SE]: 0.920 +/- 0.073, 0.914 +/- 0.191, and 0.949 +/- 0.024, respectively). The studies analyzed showed significantly heterogeneous specificity values in each of the three analyses performed. The analysis of the four studies comparing AIP and pancreatic cancers also showed significantly heterogeneous values of sensitivities and odds ratios. Regarding the usefulness of IgG4 as a marker of efficacy of steroid treatment, a decrease in the serum concentrations of IgG4 was found in the four available studies. The serum IgG4 subclass is a good marker of AIP, and its determination should be included in the diagnostic workup of this disease. However, the heterogeneity of the studies published until now means that more studies are necessary in order to better evaluate the true accuracy of IgG4 in discriminating AIP versus other autoimmune diseases.
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Igawa T, Nakashima H, Sadanaga A, Masutani K, Miyake K, Shimizu S, Takeda A, Hamano S, Yoshida H. Deficiency in EBV-induced gene 3 (EBI3) in MRL/lpr mice results in pathological alteration of autoimmune glomerulonephritis and sialadenitis. Mod Rheumatol 2008; 19:33-41. [PMID: 18779924 DOI: 10.1007/s10165-008-0117-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 07/17/2008] [Indexed: 11/28/2022]
Abstract
MRL/lpr mice develop a systemic autoimmune disease that is reminiscent of systemic lupus erythematosus (SLE) and Sjögren's syndrome in humans. To investigate the role of IL-27 in the development of autoimmune disorders in MRL/lpr mice, we disrupted the EBV-induced gene 3 (EBI3), which is a subunit of IL-27. Consequently, the pathophysiology of glomerulonephritis and sialadenitis, which develops in MRL/lpr mice, was drastically changed. EBI3-/- MRL/lpr mice developed disease that resembles human membranous glomerulonephritis (MGN), not diffuse proliferative glomerulonephritis (DPGN), with a predominance of IgG1 in glomerular deposits, and different type sialadenitis from Sjögren's syndrome, with IgG1 producing plasma cell infiltration in salivary glands, accompanied by increased IgG1 and IgE in the sera. T cells in these mice displayed significantly reduced IFN-gamma production along with elevated IL-4 expression. Loss of EBI3 thus favors Th2-type autoimmune responses, suggesting that the Th1/Th2 balance may be a pivotal determinant of phenotypes of human autoimmune diseases.
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Affiliation(s)
- Takashi Igawa
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
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Ito H, Kaizaki Y, Noda Y, Fujii S, Yamamoto S. IgG4-related inflammatory abdominal aortic aneurysm associated with autoimmune pancreatitis. Pathol Int 2008; 58:421-6. [PMID: 18577110 DOI: 10.1111/j.1440-1827.2008.02247.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
An association between autoimmune pancreatitis (AIP) and inflammatory abdominal aortic aneurysm (AAA) has never been reported. Reported herein is a case of IgG4-related inflammatory AAA accompanying metachronous AIP. A 77-year-old man presented with malaise and intermittent lower abdominal pain. Radiological examination showed inflammatory AAA and right hydronephrosis caused by retroperitoneal fibrosis. Surgical correction of the AAA was performed, but high levels of systemic inflammatory markers persisted. Four months after surgery, the patient presented with epigastric pain, backache, and jaundice. His serum IgG4 concentration was high (571 mg/mL), and he was diagnosed with AIP, based on clinical and radiological findings. Corticosteroid therapy resulted in improvement of the clinical findings and lowered his serum IgG4 levels. Subsequent histological examination of a specimen from the aortic wall showed irregular proliferation of fibroblastic and myofibroblastic cells, severe lymphoplasmacytic infiltration, and obliterative phlebitis in the adventitia. Furthermore, on immunohistochemistry many plasma cells within the lesion were found to be positive for IgG4. These findings suggest that inflammatory AAA has a pathological process similar to that of AIP, and that some cases of inflammatory AAA and retroperitoneal fibrosis may be aortic and periaortic lesions of an IgG4-related sclerosing disease.
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Affiliation(s)
- Homare Ito
- Department of Surgery, Tannan Public Hospital, Sabae, Fukui, Japan.
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Abstract
Based on histological and immunohistochemical examination of various organs of patients with autoimmune pancreatitis (AIP), a novel clinicopathological entity of IgG4-related sclerosing disease has been proposed. This is a systemic disease that is characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of various organs. Clinical manifestations are apparent in the pancreas, bile duct, gallbladder, salivary gland, retroperitoneum, kidney, lung, and prostate, in which tissue fibrosis with obliterative phlebitis is pathologically induced. AIP is not simply pancreatitis but, in fact, is a pancreatic disease indicative of IgG4-related sclerosing diseases. This disease includes AIP, sclerosing cholangitis, cholecystitis, sialadenitis, retroperitoneal fibrosis, tubulointerstitial nephritis, interstitial pneumonia, prostatitis, inflammatory pseudotumor and lymphadenopathy, all IgG4-related. Most IgG4-related sclerosing diseases have been found to be associated with AIP, but also those without pancreatic involvement have been reported. In some cases, only one or two organs are clinically involved, while in others, three or four organs are affected. The disease occurs predominantly in older men and responds well to steroid therapy. Serum IgG4 levels and immunostaining with anti-IgG4 antibody are useful in making the diagnosis. Since malignant tumors are frequently suspected on initial presentation, IgG4-related sclerosing disease should be considered in the differential diagnosis to avoid unnecessary surgery.
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Abstract
Autoimmune pancreatitis is the pancreatic manifestation of a systemic disorder that affects various organs, including the bile duct, retroperitoneum, kidney, and parotid and lacrimal glands. It represents a recently described subset of chronic pancreatitis that is immune mediated and has unique histologic, morphologic, and clinical characteristics. A hallmark of the disease is its rapid response to corticosteroid treatment. Although still a rare disease, autoimmune pancreatitis is increasingly becoming recognized clinically, leading to evolution in the understanding of its prognosis, clinical characteristics, and treatment.
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Affiliation(s)
- Timothy B Gardner
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
In this review article, we will briefly describe the main characteristics of autoimmune pancreatitis and then we will concentrate on our aim, namely, evaluating the clinical characteristics of patients having recurrence of pain from the disease. In fact, the open question is to evaluate the possible presence of autoimmune pancreatitis in patients with an undefined etiology of acute pancreatitis and for this reason we carried out a search in the literature in order to explore this issue. In cases of recurrent attacks of pain in patients with “diopathic”pancreatitis, we need to keep in mind the possibility that our patients may have autoimmune pancreatitis. Even though the frequency of this disease seems to be quite low, we believe that in the future, by increasing our knowledge on the subject, we will be able to diagnose an ever-increasing number of patients having acute recurrence of pain from autoimmune pancreatitis.
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Raina A, Krasinskas AM, Greer JB, Lamb J, Fink E, Moser AJ, Zeh III HJ, Slivka A, Whitcomb DC. Serum Immunoglobulin G Fraction 4 Levels in Pancreatic Cancer: Elevations Not Associated With Autoimmune Pancreatitis. Arch Pathol Lab Med 2008; 132:48-53. [DOI: 10.5858/2008-132-48-sigfli] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2007] [Indexed: 01/04/2023]
Abstract
Abstract
Context.—Autoimmune pancreatitis is an uncommon, inflammatory disease of the pancreas that presents with clinical features, such as painless jaundice and a pancreatic mass, similar to those caused by pancreatic cancer. Patients with autoimmune pancreatitis frequently have elevated serum immunoglobulin G fraction 4 (IgG4) levels, and their pancreatic tissue may show IgG4-positive plasma cell infiltration. It is imperative to differentiate autoimmune pancreatitis from pancreatic cancer because autoimmune pancreatitis typically responds to corticosteroid treatment. A previous Japanese study reported that serum IgG4 greater than 135 mg/dL was 97% specific and 95% sensitive in predicting autoimmune pancreatitis.
Objective.—To prospectively measure serum IgG4 levels in pancreatic cancer patients to ascertain whether increased levels might be present in this North American population.
Design.—We collected blood samples and phenotypic information on 71 consecutive pancreatic cancer patients and 103 healthy controls who visited our clinics between October 2004 and April 2006. IgG4 levels were determined using a single radial immunodiffusion assay. A serum IgG4 level greater than 135 mg/dL was considered elevated.
Results.—Five cancer patients had IgG4 elevation, with a mean serum IgG4 level of 160.8 mg/dL. None of our cancer patients with plasma IgG4 elevation demonstrated evidence of autoimmune pancreatitis. One control subject demonstrated elevated serum IgG4 unrelated to identified etiology.
Conclusions.—As many as 7% of patients with pancreatic cancer have serum IgG4 levels above 135 mg/dL. In patients with pancreatic mass lesions and suspicion of cancer, an IgG4 level measuring between 135 and 200 mg/dL should be interpreted cautiously and not accepted as diagnostic of autoimmune pancreatitis without further evaluation.
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Affiliation(s)
- Amit Raina
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - Alyssa M. Krasinskas
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - Julia B. Greer
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - Janette Lamb
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - Erin Fink
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - A. James Moser
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - Herbert J. Zeh III
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - Adam Slivka
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
| | - David C. Whitcomb
- From the Departments of Medicine (Drs Raina, Greer, Lamb, Slivka, and Whitcomb and Ms Fink), Pathology (Dr Krasinskas), and Surgical Oncology (Drs Moser and Zeh), University of Pittsburgh Medical Center; Cell Biology & Physiology and Human Genetics, University of Pittsburgh (Dr Whitcomb); University of Pittsburgh Cancer Institute (Drs Zeh and Whitcomb); and University of Pittsburgh Medical Center
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Pickartz T, Mayerle J, Lerch MM. Autoimmune pancreatitis. ACTA ACUST UNITED AC 2007; 4:314-23. [PMID: 17541445 DOI: 10.1038/ncpgasthep0837] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 03/05/2007] [Indexed: 12/16/2022]
Abstract
Autoimmune pancreatitis is a rare systemic fibrotic inflammatory disorder that can affect organs such as the bile ducts, salivary glands, and retroperitoneal lymph nodes, in addition to the pancreas. Morphological characteristics of autoimmune pancreatitis include a diffusely enlarged 'sausage-shaped' pancreas and an irregularly narrowed duct of Wirsung. According to the revised Japan Pancreas Society criteria, the diagnosis of autoimmune pancreatitis requires that one or more secondary serologic or histologic criteria are also met: the presence of autoantibodies, elevated levels of gamma-globulins, IgG or IgG(4), a lymphoplasmacytic infiltrate, or pancreatic fibrosis. The presence in any affected organ of a lymphoplasmacytic inflammatory infiltrate containing greater than 10 IgG(4)-positive cells per high-power field is pathognomonic for autoimmune pancreatitis. Precise data on the incidence and prevalence of autoimmune pancreatitis are currently not available because most reports involve either limited patient series or resection specimen cohorts. New diagnostic tools and further studies of the underlying pathophysiology and prognosis of autoimmune pancreatitis are needed for adequate and effective treatment strategies to be developed. The most crucial issue when caring for patients with suspected autoimmune pancreatitis is to differentiate autoimmune pancreatitis from pancreatic carcinoma, because pancreatic carcinoma requires surgery, whereas autoimmune pancreatitis responds well to steroid treatment.
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Affiliation(s)
- Tilman Pickartz
- Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt Universität Greifswald, Greifswald, Germany
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Kuwatani M, Kawakami H, Makiyama H, Onodera M, Matsumoto K, Karasawa G, Asaka M. Autoimmune pancreatitis with retroperitoneal fibrosis which responded to steroid therapy but was complicated with refractory renal dysfunction. Intern Med 2007; 46:1557-64. [PMID: 17878642 DOI: 10.2169/internalmedicine.46.0164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 58-year-old male had been diagnosed as having autoimmune pancreatitis (AIP) from the results of serological examinations and image findings. He was treated with prednisolone (PSL) for 3.5 months. Fifteen months later, follow-up CT revealed the main pancreatic duct (MPD) dilatation in the pancreas body to tail and right hydronephrosis caused by complicated retroperitoneal mass. We diagnosed him as having recurrent AIP with retroperitoneal fibrosis, and restarted PSL treatment. After one month, Examinations indicated amelioration of the MPD dilatation and right hydronephrosis, but not the right renal failure. This case indicates the importance of maintenance of PSL treatment.
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Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo.
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Kamisawa T, Okamoto A. Autoimmune pancreatitis: proposal of IgG4-related sclerosing disease. J Gastroenterol 2006; 41:613-25. [PMID: 16932997 PMCID: PMC2780632 DOI: 10.1007/s00535-006-1862-6] [Citation(s) in RCA: 376] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 06/20/2006] [Indexed: 02/06/2023]
Abstract
Autoimmune pancreatitis (AIP) is a peculiar type of pancreatitis of presumed autoimmune etiology. Many new clinical aspects of AIP have been clarified during the past 10 years, and AIP has become a distinct entity recognized worldwide. However, its precise pathogenesis or pathophysiology remains unclear. As AIP dramatically responds to steroid therapy, accurate diagnosis of AIP is necessary to avoid unnecessary surgery. Characteristic dense lymphoplasmacytic infiltration and fibrosis in the pancreas may prove to be the gold standard for diagnosis of AIP. However, since it is difficult to obtain sufficient pancreatic tissue, AIP should be diagnosed currently based on the characteristic radiological findings (irregular narrowing of the main pancreatic duct and enlargement of the pancreas) in combination with serological findings (elevation of serum gamma-globulin, IgG, or IgG4, along with the presence of autoantibodies), clinical findings (elderly male preponderance, fluctuating obstructive jaundice without pain, occasional extrapancreatic lesions, and favorable response to steroid therapy), and histopathological findings (dense infiltration of IgG4-positive plasma cells and T lymphocytes with fibrosis and obliterative phlebitis in various organs). It is apparent that elevation of serum IgG4 levels and infiltration of abundant IgG4-positive plasma cells into various organs are rather specific to AIP patients. We propose a new clinicopathological entity, "IgG4-related sclerosing disease", and suggest that AIP is a pancreatic lesion reflecting this systemic disease.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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