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Ino K, Arinuma Y, Akiya M, Kajita S, Okina S, Sakamoto J, Tanaka T, Matsueda Y, Wada T, Tanaka S, Oku K, Yamaoka K. IgG4-related disease complicated with diffuse and chronic gastrointestinal inflammation leading to small intestinal perforation. Mod Rheumatol Case Rep 2024; 8:323-328. [PMID: 38547341 DOI: 10.1093/mrcr/rxae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/18/2024] [Accepted: 02/26/2024] [Indexed: 07/09/2024]
Abstract
Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a systemic inflammatory disease characterised by elevated serum IgG4, IgG4+ cell infiltration, storiform fibrosis, and obliterative phlebitis. While IgG4-RD can affect various organs, gastrointestinal tract involvement is less common. Here, we report a 70-year-old female with IgG4-RD complicated with diffuse and chronic gastrointestinal inflammation, which led to small intestinal perforation. She had been suffering from anorexia, abdominal pain, vomiting, and diarrhoea and hospitalised due to recurrent ileus. Consequently, she was referred due to small intestinal perforation required for surgical intervention. Pathology revealed acute and chronic inflammation with massive IgG4+ plasmacyte infiltration into mucosa of the small intestine and ischaemic change secondarily caused by chronic inflammation. Random biopsies from the mucosa of stomach, duodenum, ileum, and colon also revealed diffuse and massive IgG4+ plasmacyte infiltration in stomach, duodenum, small intestine, and colon. She was diagnosed with IgG4-RD based on the pathological findings and elevated serum IgG4 levels. Glucocorticoid rapidly ameliorated the symptoms. IgG4-RD may cause gastrointestinal manifestations, and histopathological assessment should be considered, even in the absence of specific characteristics of IgG4-RD.
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Affiliation(s)
- Kazuma Ino
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masashi Akiya
- Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Sabine Kajita
- Department of Pathology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sosei Okina
- Department of Hematology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Junichi Sakamoto
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Tomoki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yu Matsueda
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tatsuhiko Wada
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Sumiaki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
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冯 敏, 陈 哲, 程 永. [A case of duodenal ulcer as prominent manifestation of IgG4-related disease]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:1125-1129. [PMID: 38101799 PMCID: PMC10724000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 12/17/2023]
Abstract
A case of IgG4-related disease presented with a duodenal ulcer to improve the understan-ding of IgG4-related diseases was reported. A 70-year-old male presented with cutaneous pruritus and abdominal pain for four years and blackened stools for two months. Four years ago, the patient went to hospital for cutaneous pruritus and abdominal pain. Serum IgG4 was 3.09 g/L (reference value 0-1.35 g/L), alanine aminotransferase 554 U/L (reference value 9-40 U/L), aspartate aminotransferase 288 U/L (reference value 5-40 U/L), total bilirubin 54.16 μmol/L (reference value 2-21 μmol/L), and direct bilirubin 29.64 μmol/L (reference value 1.7-8.1 μmol/L) were all elevated. The abdominal CT scan and magnetic resonance cholangiopancreatography indicated pancreatic swelling, common bile duct stenosis, and secondary obstructive dilation of the biliary system. The patient was diagnosed with IgG4-related disease and treated with prednisone at 40 mg daily. As jaundice and abdominal pain improved, prednisone was gradually reduced to medication discontinuation. Two months ago, the patient developed melena, whose blood routine test showed severe anemia, and gastrointestinal bleeding was diagnosed. The patient came to the emergency department of Beijing Hospital with no improvement after treatment in other hospitals. Gastroscopy revealed a 1.5 cm firm duodenal bulb ulcer. After treatment with omeprazole, the fecal occult blood was still positive. The PET-CT examination was performed, and it revealed no abnormality in the metabolic activity of the duodenal wall, and no neoplastic lesions were found. IgG4-related disease was considered, and the patient was admitted to the Department of Rheumatology and Immunology of Beijing Hospital for further diagnosis and treatment. The patient had a right submandibular gland mass resection history and diabetes mellitus. After the patient was admitted to the hospital, the blood test was reevaluated. The serum IgG4 was elevated at 5.44 g/L (reference value 0.03-2.01 g/L). Enhanced CT of the abdomen showed that the pancreas was mild swelling and was abnormally strengthened, with intrahepatic and extrahepatic bile duct dilation and soft tissue around the superior mesenteric vessels. We pathologically reevaluated and stained biopsy specimens of duodenal bulbs for IgG and IgG4. Immunohistochemical staining revealed remarkable infiltration of IgG4-positive plasma cells into duodenal tissue, the number of IgG4-positive cells was 20-30 cells per high-powered field, and the ratio of IgG4/IgG-positive plasma cells was more than 40%. The patient was treated with intravenous methylprednisolone at 40 mg daily dosage and cyclophosphamide, and then the duodenal ulcer was healed. IgG4 related disease is an immune-medicated rare disease characterized by chronic inflammation and fibrosis. It is a systemic disease that affects nearly every anatomic site of the body, usually involving multiple organs and diverse clinical manifestations. The digestive system manifestations of IgG4-related disease are mostly acute pancreatitis and cholangitis and rarely manifest as gastrointestinal ulcers. This case confirms that IgG4-related disease can present as a duodenal ulcer and is one of the rare causes of duodenal ulcers.
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Affiliation(s)
- 敏 冯
- />北京医院风湿免疫科, 国家老年医学中心, 中国医学科学院老年医学研究院, 北京 100730Department of Rheumatology, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - 哲 陈
- />北京医院风湿免疫科, 国家老年医学中心, 中国医学科学院老年医学研究院, 北京 100730Department of Rheumatology, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - 永静 程
- />北京医院风湿免疫科, 国家老年医学中心, 中国医学科学院老年医学研究院, 北京 100730Department of Rheumatology, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
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Sawada H, Czech T, Silangcruz K, Kozai L, Obeidat A, Wien EA, Nishimura MF, Nishikori A, Sato Y, Nishimura Y. Clinicopathological characteristics of gastric IgG4-related disease: Systematic scoping review. J Gastroenterol Hepatol 2022; 37:1865-1872. [PMID: 35949057 DOI: 10.1111/jgh.15980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/01/2022] [Accepted: 08/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Gastric IgG4-related disease (IgG4-RD) can mimic malignancy, submucosal tumors (SMT), and ulcers, leading to over-triage and unnecessary medical interventions such as gastrectomy. The variability in the clinicopathological presentation of IgG4-related disease is not yet well defined, posing a diagnostic challenge. METHODS Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including "gastritis," "stomach," "gastrointestinal stromal tumor," and "IgG4-RD" from their inception to December 28, 2021. RESULTS Thirty-nine articles, including 2 observational studies and 42 cases, were included in the systematic review. While bottom-heavy lymphoplasmacytic mucosal infiltration is a characteristic finding of gastric IgG4-RD, it was only present in less than half of the patients in the observational studies. Patients with gastric IgG4-RD were more likely to be diagnosed with gastrointestinal stromal tumor (GIST), gastric cancer, or peptic ulcer disease and their clinical course involved resection (51.3%) or even gastrectomy. Diagnosis of gastric IgG4-RD was most frequently made by post-operative pathological analysis. CONCLUSION This systematic review summarizes the current understanding of the characteristics of gastric IgG4-RD. Increased awareness of gastric IgG4-RD as a differential diagnosis of gastric SMT or ulcers among clinicians is crucial in order to reduce unnecessary high-risk, invasive interventions.
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Affiliation(s)
- Haruki Sawada
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Torrey Czech
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Krixie Silangcruz
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Landon Kozai
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Adham Obeidat
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Eric Andrew Wien
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.,Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Uchino K, Notohara K, Uehara T, Kuraishi Y, Itakura J, Matsukawa A. Utility of gastric biopsy in diagnosing IgG4-related gastrointestinal disease. Pathol Int 2020; 71:124-134. [PMID: 33378576 DOI: 10.1111/pin.13059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023]
Abstract
The utility of gastric biopsy for diagnosing immunoglobulin (Ig)G4-related gastrointestinal disease (IgG4-GID) remains unclear. Bottom-heavy plasmacytosis (BHP) is a distinct feature of IgG4-GID. To clarify the feasibility of using gastric biopsies to diagnose BHP in IgG4-GID, we analyzed the histological features and immunostaining of gastric biopsy specimens from 31 known IgG4-related disease (IgG4-RD) patients and we assessed the presence of BHP in 1696 consecutive routine gastric biopsies. Cases with both >10 IgG4-positive plasma cells per high-power field and an IgG4/IgG-positive ratio >40% were defined as IgG4-high. Ten of the 31 IgG4-RD patients were concluded to have IgG4-GID, in which IgG4-positive plasma cells were notably detected at the deeper part of the mucosa. Six cases displayed BHP whereas the remaining four cases showed transmural infiltration with concomitant Helicobacter pylori-associated gastritis. In addition to BHP, we identified two unique histologic features for IgG4-GID: plasmacytic aggregation in the muscularis mucosae and permeative plasmacytic infiltration between fundic glands in the non-atrophic mucosa. Six of the routine cases (0.35%) displayed BHP, including a case with IgG4-RD. IgG4-GID can be suspected by the presence of gastric biopsy specimens with characteristic histological features. Such cases are recommended to undergo further examinations to determine whether IgG4-RD is present.
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Affiliation(s)
- Kaori Uchino
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Takeshi Uehara
- Department of Laboratory Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yasuhiro Kuraishi
- Department of Gastroenterology, Shinshu University School of Medicine, Nagano, Japan
| | - Junya Itakura
- Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Akihiro Matsukawa
- Department of Pathology and Experimental Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Muto O, Tamakawa S, Takahashi K, Yokohama S, Takasoe A, Hirano F, Nishimura H, Saito H. IgG4-related Disease Manifesting as Gastroduodenal Ulcer Diagnosed by an Endoscopic Biopsy. Intern Med 2020; 59:2491-2497. [PMID: 32581158 PMCID: PMC7662039 DOI: 10.2169/internalmedicine.4483-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 26-year-old man was admitted to our hospital due to upper abdominal pain. He had previously been diagnosed with gastroduodenal ulcer at 23 and 25 years old and had been treated with proton-pump inhibitors. Endoscopic hemostasis and a biopsy were performed on the hemorrhagic gastroduodenal ulcers. Laboratory and pathologic examinations demonstrated elevated serum IgG4 levels and the infiltration of IgG4-positive plasma cells into the gastroduodenal tissues. Based on the clinicopathologic findings and after excluding other causes, he was diagnosed with IgG4-related gastroduodenal ulcer. We herein report a rare case of IgG4-related disease manifesting as a gastroduodenal ulcer diagnosed by an endoscopic biopsy.
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Affiliation(s)
- Osamu Muto
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Susumu Tamakawa
- Department of Pathology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Kenji Takahashi
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Japan
| | - Shiro Yokohama
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Ai Takasoe
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Fuminori Hirano
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hideo Nishimura
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
| | - Hiroki Saito
- Department of Gastroenterology, National Hospital Organization Asahikawa Medical Center, Japan
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Immunoglobulin G4-related gastric pseudotumor - An impostor: Case report. Int J Surg Case Rep 2020; 75:333-337. [PMID: 32980704 PMCID: PMC7522571 DOI: 10.1016/j.ijscr.2020.09.057] [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: 07/15/2020] [Revised: 08/16/2020] [Accepted: 09/05/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Gastric pseudotumors are rare entities whose clinical presentation resembles typical gastric neoplasias, often making them unrecognized unless other causes are considered. PRESENTATION OF CASE We present a case report of a patient that debuts with dysphagia, with an abdominal computed axial tomography (CAT) scan revealing a mass at the gastro-esophageal junction suggestive of malignant origin, with studies revealing it to be Immunoglobulin G4-related (IgG4). DISCUSSION The diagnosis and identification of IgG4-related gastric pseudotumors is very complicated, often and most commonly an incidental diagnosis upon histologic analysis, as is the situation in this case. CONCLUSION Understanding its clinical course and early diagnosis can reduce unwarranted surgical intervention in some patients with IgG4-related disease.
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Löhr JM, Beuers U, Vujasinovic M, Alvaro D, Frøkjær JB, Buttgereit F, Capurso G, Culver EL, de-Madaria E, Della-Torre E, Detlefsen S, Dominguez-Muñoz E, Czubkowski P, Ewald N, Frulloni L, Gubergrits N, Duman DG, Hackert T, Iglesias-Garcia J, Kartalis N, Laghi A, Lammert F, Lindgren F, Okhlobystin A, Oracz G, Parniczky A, Mucelli RMP, Rebours V, Rosendahl J, Schleinitz N, Schneider A, van Bommel EF, Verbeke CS, Vullierme MP, Witt H. European Guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations. United European Gastroenterol J 2020; 8:637-666. [PMID: 32552502 DOI: 10.1177/2050640620934911] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The overall objective of these guidelines is to provide evidence-based recommendations for the diagnosis and management of immunoglobulin G4 (IgG4)-related digestive disease in adults and children. IgG4-related digestive disease can be diagnosed only with a comprehensive work-up that includes histology, organ morphology at imaging, serology, search for other organ involvement, and response to glucocorticoid treatment. Indications for treatment are symptomatic patients with obstructive jaundice, abdominal pain, posterior pancreatic pain, and involvement of extra-pancreatic digestive organs, including IgG4-related cholangitis. Treatment with glucocorticoids should be weight-based and initiated at a dose of 0.6-0.8 mg/kg body weight/day orally (typical starting dose 30-40 mg/day prednisone equivalent) for 1 month to induce remission and then be tapered within two additional months. Response to initial treatment should be assessed at week 2-4 with clinical, biochemical and morphological markers. Maintenance treatment with glucocorticoids should be considered in multi-organ disease or history of relapse. If there is no change in disease activity and burden within 3 months, the diagnosis should be reconsidered. If the disease relapsed during the 3 months of treatment, immunosuppressive drugs should be added.
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Affiliation(s)
- J-Matthias Löhr
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Miroslav Vujasinovic
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division Pancreas Translational and Clinical Research Center IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Emanuel Della-Torre
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Enrique Dominguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nils Ewald
- Institute of Endocrinology, Diabetology and Metabolism, Johannes Wesling University hospital, Minden, Germany and Justus Liebig University Giessen, Giessen, Germany
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman, Ukraine
| | - Deniz Guney Duman
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nikolaos Kartalis
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Fredrik Lindgren
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | | | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrea Parniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insitute of Pediatrics, Budapest, Hungary
| | | | - Vinciane Rebours
- Pancreatology Department, Beaujon Hospital, Clichy, Université de Paris, France
| | - Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Nicolas Schleinitz
- Département de Médicine Interne Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Alexander Schneider
- Department of Gastroenterology and Hepatology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany
| | - Eric Fh van Bommel
- Department of Internal Medicine, Dutch National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | | | | | - Heiko Witt
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin, Paediatric Nutritional Medicine, Technische Universität München, Freising, Germany
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- See list at the end of this article
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Lim DY, Cheng LTE, Tan DMY, Al Jajeh I. Isolated IgG4-related gastric disease presenting as diffuse gastric wall thickening with ulcer. J Radiol Case Rep 2019; 12:9-20. [PMID: 30651919 DOI: 10.3941/jrcr.v12i9.3493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
An 81-year-old male presented with loss of appetite, early satiety and iron deficiency anaemia. A computed tomography (CT) scan of the abdomen and pelvis during initial work-up revealed diffuse gastric mural thickening associated with a large ulcer and adjacent gastro-hepatic lymphadenopathy. The CT appearances, together with the clinical features, were highly suspicious for an infiltrative type of gastric malignancy. Endoscopic biopsy however showed erosive inflammation, IgG4 plasmacytosis and fibrosis, raising the possibility of IgG4-related disease. A serologic assay for IgG showed normal IgG4 and elevated IgG2 serum levels. After appropriate steroid treatment, endoscopy and CT scan showed resolution of the ulcer and gastric wall thickening. This case shows yet another possible appearance of gastric involvement in IgG4-related disease on the current evolving spectrum of this disease presentation. Greater awareness and education of this disease would help in patient care, ensuring earlier diagnosis, prevention of severe organ damage and morbidity, as well as unnecessary surgery.
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Affiliation(s)
- David Yurui Lim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Damien Meng Yew Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Issam Al Jajeh
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
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Ileocecal IgG4-Related Disease: A Case Report Mimicking Malignancy. ACG Case Rep J 2018; 5:e84. [PMID: 30568972 PMCID: PMC6277136 DOI: 10.14309/crj.2018.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic mass-forming inflammatory disease characterized by fibroblastic proliferation and mixed inflammatory cell infiltration. IgG4-RD can involve one or multiple organs, and the most commonly affected organs include the pancreas, salivary glands, and the orbit. We present a case of a 66-year-old man, with a history of sarcoidosis, who presented with an obstructing ileocecal mass highly suspicious for malignancy. After surgical resection and pathological and serological evaluation, a diagnosis of IgG4-RD was rendered. In the absence of other manifestations, preoperative diagnosis is challenging, and IgG4-RD may continue to be a diagnostic pitfall.
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Gastrointestinal manifestation of immunoglobulin G4-related disease: clarification through a multicenter survey. J Gastroenterol 2018; 53:845-853. [PMID: 29222587 DOI: 10.1007/s00535-017-1420-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 11/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several reports on immunoglobulin (Ig)G4-related disease (IgG4-RD) with gastrointestinal involvement (IgG4-related gastrointestinal disease; IgG4-GID) have been published, although this entity has not been fully established clinicopathologically. Thus, we carried out a multicenter survey. METHODS Patients with possible IgG4-GID who underwent resection were collected. Histologic slides were reevaluated, and eight cases with diffuse lymphoplasmacytic infiltration but without numerous neutrophils, granulations or epithelioid granulomas were further analyzed. RESULTS Overall, the IgG4 counts (87-345/high-power field) and IgG4/IgG-positive ratio were high (44-115%). The demographic findings included advanced age among the patients (55-80 years) and male preponderance (six cases). Six lesions (five gastric, one esophageal), consisting of lymphoplasmacytic infiltration with neural involvement in the muscularis propria and/or bottom-heavy plasmacytosis in the gastric mucosa, were histologically regarded as highly suggestive of IgG4-RD. Storiform fibrosis and obliterative phlebitis were found in two cases, and the former gave rise to a 7-cm-sized inflammatory pseudotumor (IPT) in one case. Ulceration and carcinoma co-existed in three and two lesions, respectively. All the patients had other organ involvement (OOI), and serum IgG4 levels were markedly elevated (four of five patients). The remaining two cases with gastric IPTs featuring reactive nodular fibrous pseudotumor or nodular lymphoid hyperplasia were regarded as possible cases of IgG4-RD because of the histologic findings and lack of OOI. CONCLUSIONS IgG4-GID is found in the setting of IgG4-RD, often with ulceration or cancer. Characteristic histologic findings are observed in the muscularis propria and gastric mucosa. Cases with IPT may be heterogeneous, and there may be mimickers of IgG4-GID.
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Abstract
Immunoglobulin G4-related disease is a fibroinflammatory systemic disease that is characterized by focal or diffuse organ infiltration by immunoglobulin G4-bearing plasma cells. Immunoglobulin G4-related disease may affect any organ, and a high index of suspicion is necessary for early detection to avoid irreversible fibrosis, organ dysfunction, and death. Tumor-forming lesions are common radiological features of immunoglobulin G4-related disease that need to be differentiated from malignancies. The diagnostic approach requires the integration of clinical, biochemical, and radiographic manifestations with classic histopathologic features, which remain crucial to diagnosis. The histology of immunoglobulin G4-related disease is determined by a dense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis in the presence of increased immunoglobulin G4-positve plasma cells. Although immunoglobulin G4-related disease forms a distinct, clinically independent disease category, many questions and problems remain unanswered, especially on its pathogenesis and the role of immunoglobulin G4. Advances in the understanding of immunoglobulin G4-related disease are likely to change the diagnostic approach in the future and create potential targets for therapeutic purposes. Here we describe the concept of immunoglobulin G4-related disease and the most recent knowledge in the clinico-pathological characteristics on this emerging disease. This study can guide clinicians in early diagnosis and prevent unnecessary surgical resections.
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Affiliation(s)
| | | | - Metin Özdemirli
- Department of Pathology, Medstar Georgetown University Hospital, Washington, USA
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12
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Ciccone F, Ciccone A, Di Ruscio M, Vernia F, Cipolloni G, Coletti G, Calvisi G, Frieri G, Latella G. IgG4-Related Disease Mimicking Crohn's Disease: A Case Report and Review of Literature. Dig Dis Sci 2018; 63:1072-1086. [PMID: 29417330 DOI: 10.1007/s10620-018-4950-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/26/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Fabiana Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Antonio Ciccone
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Mirko Di Ruscio
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Filippo Vernia
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Gianluca Cipolloni
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Gino Coletti
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Calvisi
- Pathology Unit, San Salvatore Hospital, Via Lorenzo Natali, 1, Coppito, 67100, L'Aquila, Italy
| | - Giuseppe Frieri
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, Piazza S. Tommasi, 1, Coppito, 67100, L'Aquila, Italy.
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Seo HS, Jung YJ, Park CH, Song KY, Jung ES. IgG4-related Disease in the Stomach which Was Confused with Gastrointestinal Stromal Tumor (GIST): Two Case Reports and Review of the Literature. J Gastric Cancer 2018; 18:99-107. [PMID: 29629225 PMCID: PMC5881015 DOI: 10.5230/jgc.2018.18.e8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/12/2018] [Accepted: 03/21/2018] [Indexed: 12/13/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory disorder characterized by specific pathological findings and elevated serum IgG4 level. IgG4-RD in the stomach is rare, and occasionally diagnosed as gastric subepithelial tumor (SET) by endoscopy or computed tomography scan. Two female patients in the age group of 40–50 years were diagnosed with 4 cm sized gastric SET. One underwent laparoscopic gastric wedge resection. Another one had a history of subtotal gastrectomy for early gastric cancer and idiopathic thrombocytopenic purpura with oral steroids administration. She underwent a completion total gastrectomy with splenectomy for the gastric SET and ITP. The pathology showed storiform fibrosis, and IgG4 was positive in immunohistochemistry (IHC) stain. IgG4-RD is known as a medical disease that could be treated with oral steroids. The difficulty in preoperative diagnosis of the disease occasionally causes unnecessary gastric resection. Thus, preoperative diagnostic methods for IgG4-RD such as deep biopsy with IHC stain or magnetic resonance imaging are needed.
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Affiliation(s)
- Ho Seok Seo
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Yoon Ju Jung
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Cho Hyun Park
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Eun Sun Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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14
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Ileocecal IgG4-Related Disease: A Case Report Mimicking Malignancy. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805110-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Mori S, Tahashi Y, Uchida K, Ikeura T, Danbara N, Wakamatsu T, Kusuda T, Takahashi Y, Yanagawa M, Matsushita M, Ohe C, Michiura T, Inoue K, Kon M, Okazaki K. Sclerosing Esophagitis with IgG4-positive Plasma Cell Infiltration. Intern Med 2017; 56:3023-3026. [PMID: 29021429 PMCID: PMC5725855 DOI: 10.2169/internalmedicine.8095-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The patient was a 76-year-old woman who had noticed slight difficulty in swallowing in the 3 years prior to this presentation. Her dysphagia progressed while she was hospitalized following cervical cancer surgery. Esophagogastroduodenoscopy and an esophagram showed circumferential erosion and a stricture of the thoracic esophagus. Esophageal resection was performed; the resected specimens showed a stricture and wall thickening. Histologically, transmural hyperplasia, which consisted of inflammatory granulation tissue with the abundant infiltration of IgG4-positive plasma cells and lymphocytes, was observed. The patient was diagnosed with probable IgG4-related disease. IgG4-related esophageal disease presenting as esophageal lesions alone is a very rare condition.
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Affiliation(s)
- Shigeo Mori
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Yoshiya Tahashi
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Kazushige Uchida
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Naoyuki Danbara
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | | | - Takeo Kusuda
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Yu Takahashi
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | - Masato Yanagawa
- Third Department of Internal Medicine, Kansai Medical University, Japan
| | | | - Chisato Ohe
- Department of Pathology and Laboratory Medicine, Kansai Medical University, Japan
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, Japan
| | - Masanori Kon
- Department of Surgery, Kansai Medical University, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Kansai Medical University, Japan
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Ortuño Moreno MI, Ferri Ñíguez B, Martínez Barba E, Fernández Hernández JÁ. An ulcerated gastric ulcer and pseudotumour with pancreatic affectation associated with immunoglobulin G4-related disease: a case report and literature review. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:870-874. [PMID: 29082738 DOI: 10.17235/reed.2017.4996/2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the case of a 67 year old male who presented with a nine year history of a gastric ulcer with symptoms of hematemesis and melena. Histological analysis identified fibrotic lesions and the accumulation of immunoglobulin G4-positive plasma cells with no evidence of malignancy. The lesion extended into the pancreas, where histological lesions and gastric lesions were also observed. This is a case of an ulcerated gastric ulcer and pseudo-tumor with pancreatic affection that is associated with immunoglobulin G4-related disease.
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Affiliation(s)
| | - Belén Ferri Ñíguez
- Anatomía patológica, Hospital Clínico Universitario Virgen de la Arrixaca, España
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18
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Yang J, Fan Z, Yang J, Yang C. IgG4-related disease with coronary arteritis. Int J Cardiol 2016; 222:1062-1063. [PMID: 26603648 DOI: 10.1016/j.ijcard.2015.10.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 10/18/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Jian Yang
- Department of Cardiology, the First College of Clinical Medical Sciences, China Three Gorges University, Yichang 443000, Hubei Province, China.
| | - Zhixing Fan
- Department of Cardiology, the First College of Clinical Medical Sciences, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Jun Yang
- Department of Cardiology, the First College of Clinical Medical Sciences, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Chaojun Yang
- Department of Cardiology, the First College of Clinical Medical Sciences, China Three Gorges University, Yichang 443000, Hubei Province, China
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19
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Otsuka R, Kano M, Hayashi H, Hanari N, Gunji H, Hayano K, Matsubara H. Probable IgG4-related sclerosing disease presenting as a gastric submucosal tumor with an intense tracer uptake on PET/CT: a case report. Surg Case Rep 2016; 2:33. [PMID: 27059471 PMCID: PMC4826359 DOI: 10.1186/s40792-016-0161-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/05/2016] [Indexed: 12/24/2022] Open
Abstract
A 44-year-old man consulted an internist because of abnormalities in an upper gastrointestinal series. It showed an elevated lesion with central depression in the greater curvature of the middle part of the stomach. Upper gastrointestinal endoscopy showed an elevated lesion with central depression, bridging hold, and no abnormalities of the gastric mucosa in the greater curvature of the middle part of the stomach. Endoscopic ultrasonography showed a submucosal tumor derived from the muscle layer of the stomach. Computed tomography showed a 22-mm tumor in the upper part of the stomach. Integrated position emission tomography/computed tomography (PET/CT) showed an intense tracer uptake by the tumor. Based on these findings, a gastrointestinal stromal tumor was suspected and laparoscopic endoscopic cooperative surgery was performed. A histopathological examination showed lymphoplasmacytic infiltration and fibrosis, and an immunohistochemical analysis showed the infiltration of IgG4-positive lymphoplasmacytic cells. The probable diagnosis was IgG4-related sclerosing disease of the stomach. We herein describe a rare case of probable IgG4-related sclerosing disease which presented as a gastric submucosal tumor. PET/CT is a useful imaging technique for the diagnosis and follow-up of this disease.
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Affiliation(s)
- Ryota Otsuka
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan.
| | - Masayuki Kano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hideki Hayashi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Naoyuki Hanari
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hisashi Gunji
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Koichi Hayano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
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20
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Cheong HR, Lee BE, Song GA, Kim GH, An SG, Lim W. Immunoglobulin G4-Related Inflammatory Pseudotumor Presenting as a Solitary Mass in the Stomach. Clin Endosc 2016; 49:197-201. [PMID: 26867551 PMCID: PMC4821516 DOI: 10.5946/ce.2015.074] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/26/2015] [Accepted: 07/11/2015] [Indexed: 12/24/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4RD) is a relatively recently recognized entity that is histopathologically characterized by an extensive infiltration of lymphocytes and IgG4-positive plasma cells with dense fibrosis. IgG4RD is now known to affect any organ system, and a few cases of gastrointestinal lesions have also been reported. However, solitary IgG4RD of the stomach is still very rare. Furthermore, as it can mimic malignant conditions, it is important to recognize this disease to avoid unnecessary surgery. Herein, we present a case of IgG4RD presenting as an isolated subepithelial mass in the stomach.
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Affiliation(s)
- Hong Ryeol Cheong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Sung Gyu An
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Won Lim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
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21
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Sarkar A, Pitchumoni CS. The protean manifestations of IgG4-RD in gastrointestinal disorders. Dis Mon 2015; 61:493-515. [DOI: 10.1016/j.disamonth.2015.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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22
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Tsuchiya T, Yagi T, Tsukamoto M, Fukushima Y, Shimada R, Nakamura K, Fujii S, Nozawa K, Matsuda K, Kikuchi Y, Saito K, Hashiguchi Y. A case of IgG4-related disease coexisted with rectal cancer. Surg Case Rep 2015; 1:118. [PMID: 26943442 PMCID: PMC4658344 DOI: 10.1186/s40792-015-0120-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/19/2015] [Indexed: 01/12/2023] Open
Abstract
A 67-year-old man was referred to our hospital with suspicion of rectal tumor, hilar tumor, and urinary tumor. Colonoscopic findings were intermittent nodular lesions with redness which were atypical to primary rectal cancer. Endoscopic retrograde cholangiopancreatography showed narrowing of the bilateral intrahepatic bile duct. However, the findings were improved 1 month later. Blood biochemistry showed high level of serum IgG4 up to 1140 mg/dl. The patient matched to comprehensive diagnostic criteria for IgG4-related disease as a possible diagnostic case. Laparoscopic low anterior resection with creation of ileostomy was performed for rectal cancer. Histological findings revealed cancer cells spread horizontally at submucosal layer and subserosal layer. There was marked infiltration of the plasma cells and lymphocytes at tumor stroma, and more than half of the plasma cells were positive for IgG4. After surgery, the level of serum IgG4 was decreased to 597 mg/dl. Although the association with IgG4-related disease and colorectal disease is unclear, the tumor progression was atypical for rectal cancer. Some report that the disease may rise up the risk of a malignant disease. It is necessary to perform systemic examination keeping in mind for concurrence of malignancy.
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Affiliation(s)
- Takeshi Tsuchiya
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Takahiro Yagi
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Mitsuo Tsukamoto
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yoshihisa Fukushima
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Ryu Shimada
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keisuke Nakamura
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Shoichi Fujii
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keijiro Nozawa
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Keiji Matsuda
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yoshinao Kikuchi
- The Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Koji Saito
- The Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
| | - Yojiro Hashiguchi
- The Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-0003, Japan.
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Kawano H, Ishii A, Kimura T, Takahashi T, Hironaka H, Kawano M, Yamaguchi M, Oishi K, Kubo M, Matsui S, Notohara K, Ikeda E. IgG4-related disease manifesting the gastric wall thickening. Pathol Int 2015; 66:23-8. [DOI: 10.1111/pin.12364] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/20/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Hiroo Kawano
- Department of Laboratory Science, Faculty of Health Science; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Aya Ishii
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Tokuhiro Kimura
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | | | - Hideharu Hironaka
- Department of Surgery; Saiseikai Yamaguchi Hospital; Yamaguchi Japan
| | - Michitaka Kawano
- Department of Internal Medicine; Saiseikai Yamaguchi Hospital; Yamaguchi Japan
| | - Michiya Yamaguchi
- Department of Dermatology; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Keiji Oishi
- Department of Internal medicine; Ube Medical Center; Ube Japan
| | - Makoto Kubo
- Department of Medicine and Clinical Science; Yamaguchi University Graduate School of Medicine; Ube Japan
| | - Shoko Matsui
- Health Administration Center; Toyama University; Toyama Japan
| | - Kenji Notohara
- Department of Anatomic Pathology; Kurashiki Central Hospital; Kurashiki Japan
| | - Eiji Ikeda
- Department of Pathology; Yamaguchi University Graduate School of Medicine; Ube Japan
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24
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Woo CG, Yook JH, Kim AY, Kim J. IgG4-Related Disease Presented as a Mural Mass in the Stomach. J Pathol Transl Med 2015; 50:67-70. [PMID: 26420251 PMCID: PMC4734962 DOI: 10.4132/jptm.2015.07.28] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/28/2015] [Indexed: 02/07/2023] Open
Abstract
Isolated gastric IgG4-related disease (IgG4-RD) is a very rare tumefactive inflammatory condition, with only a few cases reported to date. A 48-year-old woman was incidentally found to have a subepithelial tumor in the stomach. Given a presumptive diagnosis of gastrointestinal stromal tumor or neuroendocrine tumor, she underwent wedge resection. The lesion was vaguely nodular and mainly involved the submucosa and proper muscle layer. Microscopically, all classical features of type I autoimmune pancreatitis including lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and numerous IgG4-positive plasma cells were seen. She had no evidence of IgG4-RD in other organs. Although very rare, IgG4-RD should be considered one of the differential diagnoses in the setting of gastric wall thickening or subepithelial mass-like lesion. Deep biopsy with awareness of this entity might avoid unnecessary surgical intervention.
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Affiliation(s)
- Chang Gok Woo
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hwan Yook
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah Young Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea ; Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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25
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Arnason T, Brown IS, Goldsmith JD, Anderson W, O'Brien BH, Wilson C, Winter H, Lauwers GY. Collagenous gastritis: a morphologic and immunohistochemical study of 40 patients. Mod Pathol 2015; 28:533-44. [PMID: 25234289 DOI: 10.1038/modpathol.2014.119] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 07/14/2014] [Accepted: 07/22/2014] [Indexed: 12/13/2022]
Abstract
Collagenous gastritis is a rare condition defined histologically by a superficial subepithelial collagen layer. This study further characterizes the morphologic spectrum of collagenous gastritis by evaluating a multi-institutional series of 40 patients (26 female and 14 male). The median age at onset was 16 years (range 3-89 years), including 24 patients (60%) under age 18. Twelve patients (30%) had associated celiac disease, collagenous sprue, or collagenous colitis. Hematoxylin and eosin slides were reviewed in biopsies from all patients and tenascin, gastrin, eotaxin, and IgG4/IgG immunohistochemical stains were applied to a subset. The distribution of subepithelial collagen favored the body/fundus in pediatric patients and the antrum in adults. There were increased surface intraepithelial lymphocytes (>25 lymphocytes/100 epithelial cells) in five patients. Three of these patients had associated celiac and/or collagenous sprue/colitis, while the remaining two had increased duodenal lymphocytosis without specific etiology. An eosinophil-rich pattern (>30 eosinophils/high power field) was seen in 21/40 (52%) patients. Seven patients' biopsies demonstrated atrophy of the gastric corpus mucosa. Tenascin immunohistochemistry highlighted the subepithelial collagen in all 21 specimens evaluated and was a more sensitive method of collagen detection in biopsies from two patients with subtle subepithelial collagen. No increased eotaxin expression was identified in 16 specimens evaluated. One of the twenty-three biopsies tested had increased IgG4-positive cells (100/high power field) with an IgG4/IgG ratio of 55%. In summary, collagenous gastritis presents three distinct histologic patterns including a lymphocytic gastritis-like pattern, an eosinophil-rich pattern, and an atrophic pattern. Eotaxin and IgG4 were not elevated enough to implicate these pathways in the pathogenesis. Tenascin immunohistochemistry can be used as a sensitive method of collagen detection.
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Affiliation(s)
- Thomas Arnason
- 1] Gastrointestinal Pathology Service, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA [2] Division of Anatomical Pathology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Ian S Brown
- 1] Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia [2] Envoi Pathology, Brisbane, QLD, Australia
| | - Jeffrey D Goldsmith
- Department of Pathology, Children's Hospital Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Claire Wilson
- Providence Alaska Medical Center, Anchorage, AK, USA
| | - Harland Winter
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory Y Lauwers
- Gastrointestinal Pathology Service, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Frydman J, Grunner S, Kluger Y. IgG4-related disease manifesting as an acute gastric-pericardial fistula. World J Gastroenterol 2014; 20:16782-16785. [PMID: 25469052 PMCID: PMC4248227 DOI: 10.3748/wjg.v20.i44.16782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/10/2014] [Accepted: 07/25/2014] [Indexed: 02/06/2023] Open
Abstract
IgG4-related disease is a recently recognized entity linked initially to autoimmune pancreatitis and has been subsequently described in nearly every organ system. Men over the age of 50 represent the most affected demographic group and a comprehensive set of diagnostic criteria has been developed to aid treating clinicians. Though elevated levels of IgG4 in the serum are suggestive of the disease, definitive diagnosis is made on histopathology. Treatment is tailored to the clinical presentation with corticosteroid therapy known to have proven efficacy. Gastric manifestations of the IgG4-related disease primarily come in two varieties, notably chronic ulceration or pseudotumor formation. Autoimmune pancreatitis conveys increased risk for IgG4-related disease of the stomach, which is independent of Helicobacter pylori status. In this case report, we present an acute gastric-pericardial fistula secondary to IgG4-related disease that required urgent operative management. To our knowledge, this is the first report in the medical literature describing this complication of IgG4-related disease.
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Na KY, Sung JY, Jang JY, Lim SJ, Kim GY, Kim YW, Park YK, Lee JH. Gastric nodular lesion caused by IgG4-related disease. Pathol Int 2014; 62:716-8. [PMID: 23005600 DOI: 10.1111/j.1440-1827.2012.02859.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Hiyoshi Y, Oki E, Zaitsu Y, Ando K, Ito S, Saeki H, Morita M, Yamamoto H, Baba H, Maehara Y. IgG4-related disease of the ileocecal region mimicking malignancy: A case report. Int J Surg Case Rep 2014; 5:669-72. [PMID: 25194601 PMCID: PMC4189076 DOI: 10.1016/j.ijscr.2014.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/04/2014] [Accepted: 08/04/2014] [Indexed: 12/24/2022] Open
Abstract
The colonic IgG4-RD is rare. We report the case of a74-year-old female with IgG4-RD of the ileocecal region. The patient was diagnosed asmalignant lymphoma and underwent right-hemi colectomy. Postoperative pathologicalexamination revealed IgG4-RD of the ileocecal region. Surgical resection for IgG4-RDis necessary for cases with concerns of malignancy.
INTRODUCTION Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease characterized by chronic fibrosing inflammation with abundant IgG4-positive plasma cells, and responds well to steroids. Previous reports of IgG4-RD have focused on pancreatic and extrapancreatic including the gastrointestinal tract, however, the colonic IgG4-RD is rare. PRESENTATION OF CASE We herein report the case of a 74-year-old female with edematous wall thickening of the terminal ileum to the lower ascending colon confirmed by several preoperative imaging studies, who underwent right hemi-colectomy for suspected malignant lymphoma. The resected specimen showed an irregular wall thickness with subserosal sclerosis, and the lesion was 10 cm in length from the terminal ileum to the ascending colon. The patient was diagnosed with IgG4-RD by pathological examinations, which demonstrated an increased number of IgG4-positive plasma cells (150/HPF), and an elevated IgG4/IgG ratio (50%). DISCUSSION Gastrointestinal IgG4-RD appears to be difficult to diagnose prior to surgical resection because of its rarity, and the similarity of its features to malignancy. The measurement of the serum IgG4 levels, immunohistochemical examination of biopsy specimens and use of several imaging modalities might help us to diagnose the disease without surgical resection, and this disease can generally be treated with steroid therapy. However, surgical resection for IgG4-RD may still be also necessary for patients with concerns regarding malignancy or with intractable gastrointestinal obstruction caused by this disease. CONCLUSION Gastrointestinal IgG4-RD often mimics malignancy, and we should therefore consider this disease in the differential diagnosis of colonic lesions in order to optimize the treatment.
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Affiliation(s)
- Yukiharu Hiyoshi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Eiji Oki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoko Zaitsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Koji Ando
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Shuhei Ito
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hiroshi Saeki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan
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Affiliation(s)
- Miyu Tajima
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
- Department of Cardiology, Sakakibara Heart Institute
| | | | - Yukio Hiroi
- Department of Cardiology, National Center for Global Health and Medicine
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MURAKAWA K, SAITO T, TSUTAHO A, YAMAMURA Y, KOINUMA J, ONO K, KIKUCHI K. Probable IgG4-related Sclerosing Disease Presenting as a Submucosal Tumor of the Stomach. ACTA ACUST UNITED AC 2014. [DOI: 10.3919/jjsa.75.394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Koizumi S, Kamisawa T, Kuruma S, Tabata T, Chiba K, Iwasaki S, Endo Y, Kuwata G, Koizumi K, Shimosegawa T, Okazaki K, Chiba T. Immunoglobulin G4-related gastrointestinal diseases, are they immunoglobulin G4-related diseases? World J Gastroenterol 2013; 19:5769-5774. [PMID: 24124321 PMCID: PMC3793131 DOI: 10.3748/wjg.v19.i35.5769] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/30/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
In immunoglobulin G4 (IgG4)-related disease (RD), organ enlargement or nodular lesions consisting of abundant infiltration of lymphocytes and IgG4-positive plasma cells and fibrosis are seen in various organs. Although infiltration of many IgG4-positive plasma cells is detected in the gastric and colonic mucosa and major duodenal papilla of patients with autoimmune pancreatitis, it cannot be diagnosed as a gastrointestinal lesion involved in IgG4-RD, because none of the following is observed in these lesions: a mass-like formation; dense fibrosis; or obliterative phlebitis. Based on our review of the literature, there appear to be two types of IgG4-related gastrointestinal disease. One is a gastrointestinal lesion showing marked thickening of the wall of the esophagus and stomach, consisting of dense fibrosis with abundant infiltration of IgG4-positive plasma cells, which usually show submucosal spreading. The other is an IgG4-related pseudotumor occurring in gastrointestinal regions such as the stomach, colon, and major duodenal papilla, showing polypoid or mass-like lesions. Most solitary IgG4-related gastrointestinal lesions that are not associated with other IgG4-RD appear to be difficult to diagnose. It is of utmost importance to rule out malignancy. However, these lesions may respond to steroid therapy. To avoid unnecessary resection, IgG4-related gastrointestinal diseases should be considered in the differential diagnosis.
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Regional portal hypertension, systemic lymphadenopathy, and splenomegaly associated with autoimmune pancreatitis. Clin Res Hepatol Gastroenterol 2013; 37:e75-80. [PMID: 23333230 DOI: 10.1016/j.clinre.2012.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 12/06/2012] [Indexed: 02/04/2023]
Abstract
Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis, characterised by elevated serum IgG4 levels. AIP is associated with many other diseases, including retroperitoneal fibrosis, sclerosing cholangitis, and sialoadenitis. Here, we report an interesting case of a 45-year-old male who presented with haematemesis, melena, and fever, accompanied by hepatosplenomegaly, systemic lymphadenopathy, diffuse swelling of the pancreas, portal hypertension, and multiple enlarged retroperitoneal lymph nodes on abdominal computed tomography (CT). The patient did not have a history of viral hepatitis or cirrhosis. Laboratory testing revealed an elevated IgG (3000 mg/dL). He underwent surgery for uncontrolled active upper gastrointestinal bleeding. We found splenomegaly, with a plump pancreas and involved peripheral lymph nodes, so a splenectomy was performed, and the pancreatic tail and some of the lymph nodes were biopsied. All of the resected tissues were infiltrated by large numbers of IgG4-positive plasma cells. Therefore, this patient was diagnosed with AIP associated with portal hypertension, systemic lymphadenopathy, and splenomegaly. The patient received no other treatment after the splenectomy. By the 6-month follow-up, the patient had recovered, the serum IgG had decreased to normal, and enhanced CT showed a normal pancreas. We speculate that splenectomy may be a new method of treating AIP.
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Fujita K, Naganuma M, Saito E, Suzuki S, Araki A, Negi M, Kawachi H, Watanabe M. Histologically confirmed IgG4-related small intestinal lesions diagnosed via double balloon enteroscopy. Dig Dis Sci 2012; 57:3303-6. [PMID: 22695887 DOI: 10.1007/s10620-012-2267-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 05/30/2012] [Indexed: 01/27/2023]
Affiliation(s)
- Kyohei Fujita
- Departments of Gastroenterology and Hepatology, School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Are Classification Criteria for IgG4-RD Now Possible? The Concept of IgG4-Related Disease and Proposal of Comprehensive Diagnostic Criteria in Japan. Int J Rheumatol 2012; 2012:357071. [PMID: 22690221 PMCID: PMC3368488 DOI: 10.1155/2012/357071] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 03/25/2012] [Indexed: 02/07/2023] Open
Abstract
Recent studies suggest simultaneous or metachronous lesions in multiorgans characterized by elevated serum levels of IgG4 and abundant infiltration of IgG4-positive plasma cells with various degrees of fibrosis. Two Japanese research committees for IgG4-RD, one from fibrosclerosis (Okazaki team) and the other from lymph proliferation (Umehara team) supported by the “Research Program for Intractable Disease” of the Ministry of Health, Labor, and Welfare of Japan, have agreed with the unified nomenclature as “IgG4-RD” and proposed the comprehensive diagnostic criteria (CDC) for IgG4-RD. Validation of the CDC demonstrated satisfactory sensitivity for the practical use of general physicians and nonspecialists but low sensitivity in the organs to be difficult in taking biopsy specimens such as type1 autoimmune pancreatitis (IgG4-related AIP), compared with IgG4-related sialadenitis/dacryoadenitis (Mikulicz's disease) and IgG4-related kidney disease. Although the diagnostic criteria covering all IgG4-RD are hard to be established, combination with the CDC and organ-specific diagnostic criteria should improve sensitivity.
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Clinicopathological findings of immunoglobulin G4-related kidney disease. Clin Exp Nephrol 2011; 15:810-9. [DOI: 10.1007/s10157-011-0526-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/12/2011] [Indexed: 12/24/2022]
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IgG4-related sclerosing esophagitis: a case report. Gastrointest Endosc 2011; 73:834-7. [PMID: 21067736 DOI: 10.1016/j.gie.2010.08.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 08/11/2010] [Indexed: 02/08/2023]
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