1
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Tsuge S, Mizushima I, Horita M, Kawahara H, Sanada H, Yoshida M, Takahashi Y, Zoshima T, Nishioka R, Hara S, Suzuki Y, Ito K, Kawano M. High serum IgA levels in patients with IgG4-related disease are associated with mild inflammation, sufficient disease-specific features, and favourable responses to treatments. Mod Rheumatol 2024; 34:621-631. [PMID: 37307433 DOI: 10.1093/mr/road056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/21/2022] [Accepted: 06/08/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Although elevated serum immunoglobulin A (IgA) levels are thought to exclude a diagnosis of IgG4-related disease (IgG4-RD), IgG4-RD has been definitively diagnosed in some patients despite elevated serum IgA levels. This study aimed to clarify the prevalence of elevated IgA levels in patients with IgG4-RD and to compare the clinical features of IgG4-RD patients with and without elevated IgA levels. METHODS The clinical features of 169 IgG4-RD patients were retrospectively compared among those with and without elevated serum IgA levels. RESULTS Of the 169 patients with IgG4-RD, 17 (10.1%) had elevated serum IgA levels. Those with elevated serum IgA levels showed higher serum C-reactive protein levels and lower prevalence of relapse than those without. Other clinical features did not differ significantly, including inclusion scores of the American College of Rheumatology/European League Against Rheumatism classification criteria. Cox regression analysis showed that elevated serum IgA levels were associated with a lower incidence of relapse. Moreover, patients with elevated serum IgA levels showed prompt improvement in response to glucocorticoids in the IgG4-RD responder index. CONCLUSIONS Some patients diagnosed with IgG4-RD have high serum IgA levels. These patients may form a subgroup, characterized by good response to glucocorticoids, less frequent relapse, mildly elevated serum C-reactive protein levels, and possible complications of autoimmune diseases.
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Affiliation(s)
| | | | - Makoto Horita
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Kawahara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hajime Sanada
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Misaki Yoshida
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | | | - Takeshi Zoshima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Yasunori Suzuki
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kiyoaki Ito
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
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2
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Bateman AC, Culver EL. Challenges and pitfalls in the diagnosis of IgG4-related disease. Semin Diagn Pathol 2024; 41:45-53. [PMID: 38000975 DOI: 10.1053/j.semdp.2023.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023]
Abstract
IgG4-related disease (IgG4-RD) is a relatively novel fibroinflammatory condition characterized typically by dense lymphoplasmacytic inflammation, storiform fibrosis and obliterative venulitis, together with prominent IgG4+ plasma cells and an IgG4+/IgG+ plasma cell ratio of >40 %. The diagnosis is usually made on a combination of clinical and serological features together with characteristic radiological and histological appearances. The condition may be limited to a single tissue/organ (e.g., autoimmune pancreatitis) or may be multicentric in nature - four clinical 'patterns' of disease distribution have recently been described. The diagnosis of IgG4-RD can be challenging, particularly when the clinical presentation is unusual and/or when the histological features are not typical. A diagnosis of IgG4-RD may still be achieved in these situations, after careful clinicopathological discussion e.g., at a specialist multidisciplinary team meeting. However, a wide range of other conditions (neoplastic and non-neoplastic) can mimic IgG4-RD, clinically and/or on histological examination. The relationship between IgG4-RD and non-IgG4-RD associated conditions in some clinical situations is particularly complex. This review describes the role of histological examination in the diagnosis of IgG4-RD, discusses some of the practical difficulties that may be encountered and provides an insight into the range of non-IgG4-RD associated conditions that can mimic IgG4-RD on clinical and/or histological grounds. The requirement for interpretation of histological features in the context of the global clinical picture of the patient is highlighted and emphasized.
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Affiliation(s)
- Adrian C Bateman
- Department of Cellular Pathology, Southampton General Hospital, MP002, Level E, South Block, Tremona Road, Southampton SO16 6YD, UK.
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
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3
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Whitehair RM, Aguilera NS, Pramoonjago P, Craig JW. Increased IgG4+ plasma cells are common in excised lymph nodes from children and adolescents without IgG4-related disease. J Hematop 2023; 16:209-216. [PMID: 38175435 DOI: 10.1007/s12308-023-00565-4] [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: 09/18/2023] [Accepted: 10/30/2023] [Indexed: 01/05/2024] Open
Abstract
Lymphadenopathy is a common finding in patients with IgG4-related disease (IgG4-RD) and often associated with increased IgG4+ plasma cells in this setting. The histologic features of so-called IgG4-related lymphadenopathy (IgG4-LAD) have seldom been investigated in children and adolescents, and step-wise progression to extranodal IgG4-RD has not been described. This study was performed to further evaluate the frequency, pathologic features, and clinical significance of IgG4-LAD-like histologic changes in the pediatric setting. We analyzed 37 benign lymph nodes collected semi-consecutively from children aged 0-18 years at our institution for both absolute and relative IgG4+ plasma cell abundance and recurrent histomorphologic patterns associated with IgG4-LAD. The combination of IgG4+/IgG+ plasma cell ratio >40% and IgG4+ plasma cell count ≥50 were considered as IgG4-LAD-like per expert consensus guidelines. Seven cases (19%) met both diagnostic criteria. The dominant histomorphologic patterns were follicular hyperplasia (n = 6), interfollicular expansion (n = 3), and progressive transformation of germinal centers (n = 3). Extranodal manifestations of IgG4-RD were not identified in this cohort (38 months average follow-up). Instead, clinical and laboratory findings indicated that lymph node enlargement in most patients could likely be attributed to alternative processes including antecedent dentistry, concurrent infection, and incipient Crohn's disease. Our findings suggest that the histologic features of IgG4-LAD are likely much more common in children and adolescents than previously recognized, often existing in complex with common reactive lymphadenopathies. The diagnostic value of routine immunohistochemical assessment for IgG4+ plasma cells in benign lymph nodes from pediatric patients without established extranodal IgG4-RD and/or other supportive clinical and laboratory data is therefore uncertain.
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Affiliation(s)
- Rachel M Whitehair
- Department of Pathology, University of Virginia Health System, Charlottesville, VA, 22908-0904, USA
| | - Nadine S Aguilera
- Department of Pathology, University of Virginia Health System, Charlottesville, VA, 22908-0904, USA
| | - Patcharin Pramoonjago
- Department of Pathology, University of Virginia Health System, Charlottesville, VA, 22908-0904, USA
| | - Jeffrey W Craig
- Department of Pathology, University of Virginia Health System, Charlottesville, VA, 22908-0904, USA.
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4
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Abstract
Lymphadenopathy occurring in patients with immunoglobulin G4 (IgG4)-related disease, termed IgG4-related lymphadenopathy, shows morphologic heterogeneity and overlap with other nonspecific causes of lymphadenopathy including infections, immune-related disorders, and neoplasms. This review describes the characteristic histopathologic features and diagnostic approach to IgG4-related disease and IgG4-related lymphadenopathy, with comparison to nonspecific causes of increased IgG4-positive plasma cells in lymph nodes, and with emphasis on distinction from IgG4-expressing lymphoproliferative disorders.
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Affiliation(s)
- Jacob R Bledsoe
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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5
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Yoshida M, Mizushima I, Tsuge S, Takahashi Y, Zoshima T, Nishioka R, Hara S, Ito K, Kawano M. Development of IgG4-related pancreatitis and kidney disease 7 years after the onset of undiagnosed lymphadenopathy: A case report. Mod Rheumatol Case Rep 2023; 7:192-196. [PMID: 35950792 DOI: 10.1093/mrcr/rxac065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/17/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
This report describes a patient diagnosed with immunoglobulin G4 (IgG4)-related pancreatitis and kidney disease 7 years after the onset of undiagnosed lymphadenopathy. A 48-year-old Japanese woman presented with fatigue and leg oedema. Computed tomography showed perigastric lymphadenopathy, for which she underwent a laparoscopic biopsy of the perigastric lymph nodes. Although histopathological examination of the lymph nodes did not lead to a definitive diagnosis, serological tests revealed elevated serum IgG4 levels (558 mg/dl) and IgG4 immunostaining of the lymph nodes showed IgG4-positive plasma cell infiltration, leading to the suspicion of IgG4-related disease. Further workup revealed no organ lesion other than lymphadenopathy. At age 55 years, despite having no subjective symptoms, contrast-enhanced computed tomography showed low-density lesions in the tail of the pancreas and the left kidney. Histopathological examination showed lymphocyte infiltration, consisting of a mixture of plasma cells and eosinophils, in both organs and obliterative phlebitis in the pancreas. IgG4 immunostaining of the kidney specimens showed 160 IgG4-positive cells per high-powered field, with the IgG4+/IgG+ cell ratio being almost 100%, leading to a diagnosis of IgG4-related pancreatitis and kidney disease. Treatment with prednisolone for 2 months resulted in lesion improvement. Although the diagnosis of IgG4-related lymphadenopathy is often challenging in patients with lymphadenopathy alone, findings in the present patient emphasise the importance of long-term follow-up, as it may allow early detection of involvement of other organs by IgG4-related disease.
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Affiliation(s)
- Misaki Yoshida
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Shunsuke Tsuge
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | | | - Takeshi Zoshima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kiyoaki Ito
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
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6
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Unique Ultrasonographic Findings of Isolated IgG4-Related Lymphadenopathy. Diagnostics (Basel) 2021; 11:diagnostics11122213. [PMID: 34943450 PMCID: PMC8700604 DOI: 10.3390/diagnostics11122213] [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: 10/20/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 12/04/2022] Open
Abstract
IgG4-related disease is a rare immune-mediated disease that can involve many organs in the body. The lymph node is also where IgG4-related diseases occur, but its histological structure is different from that of other organs. For this reason, pathologists have difficulty diagnosing IgG4-related lymphadenopathy. If there were specific imaging findings of IgG4-related lymphadenopathy, it would be of great help to pathologists. A 64-year-old male visited our hospital with right ankle pain. On physical examination, the right lower extremity showed severe swelling with wound dehiscence, and infection was suspected. On CT (128-MDCT, Somatom Definition Flash, Siemens Healthcare) taken at the lower extremity, multiple enlarged lymph nodes were incidentally noted in the right inguinal area. On ultrasonography, a “starry night sign” resembling hyperechoic follicles was observed in the enlarged lymph node. A core needle biopsy was performed, and IgG4-related lymphadenopathy was diagnosed. Laboratory examination showed hypergammaglobulinemia with marked elevated serum IgG4, corresponding to IgG4-related disease. Chest and abdominal imaging were evaluated, but there was no extranodal IgG4-related disease. IgG4-related lymphadenopathy showed a very unique ultrasonography imaging finding. The cortex was filled with diffusely scattered hyperechoic foci and some bright foci gathered to form a follicle. This imaging finding may help diagnose IgG4-related lymphadenopathy.
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7
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Nishikori A, Nishimura MF, Nishimura Y, Notohara K, Satou A, Moriyama M, Nakamura S, Sato Y. Investigation of IgG4-positive cells in idiopathic multicentric Castleman disease and validation of the 2020 exclusion criteria for IgG4-related disease. Pathol Int 2021; 72:43-52. [PMID: 34762752 PMCID: PMC9299129 DOI: 10.1111/pin.13185] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 01/09/2023]
Abstract
Patients with plasma cell type idiopathic multicentric Castleman disease (PC-iMCD) often show elevated serum IgG4 levels and IgG4-positive cell infiltration in tissues due to overproduction of interleukin-6, and may meet the diagnostic criteria for IgG4-related disease (IgG4-RD). Although PC-iMCD has been listed as a major exclusion disease for IgG4-RD, distinguishing between these diseases is challenging due to a lack of highly specific diagnostic biomarkers. In 2020, we proposed exclusion criteria of IgG4-RD mimickers. In this paper, we validated the accuracy of the criteria in excluding one of the mimickers, PC-iMCD, from IgG4-RD. Validation was performed on 57 PC-iMCD patients (39 presenting lymph node lesions and 19 with lung lesions) and 29 IgG4-RD patients (22 presenting lymph node lesions and seven with lung lesions). According to our results, 20.5% of the PC-iMCD patients with lymph node lesions and 42.1% of those with lung lesions met the diagnostic criteria for IgG4-RD. All these patients with PC-iMCD were excluded from a diagnosis of IgG4-RD by the proposed criteria. Additionally, 6.9% of IgG4-RD patients met the exclusion criteria. Thus, if the exclusion criteria are met, diagnosis should be made based on a combination of findings including organ distribution of disease, response to steroid therapy, and other pathological findings.
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Affiliation(s)
- Asami Nishikori
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan
| | - Midori Filiz Nishimura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii, USA
| | - Kenji Notohara
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Akira Satou
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Surgical Pathology, Aichi Medical University Hospital, Aichi, Japan
| | - Masafumi Moriyama
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Seiji Nakamura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Yasuharu Sato
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-Related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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8
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IgG4-related Lymphadenopathy: A Comparative Study of 41 Cases Reveals Distinctive Histopathologic Features. Am J Surg Pathol 2021; 45:178-192. [PMID: 32889888 DOI: 10.1097/pas.0000000000001579] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Lymphadenopathy is common in patients with immunoglobulin G4-related disease (IgG4-RD). However, the described histopathologic features of IgG4-related lymphadenopathy have been shown to be largely nonspecific. In an attempt to identify features specific for nodal IgG4-RD we examined the histopathologic features of lymph nodes from 41 patients with established IgG4-RD, with comparison to 60 lymph nodes from patients without known or subsequent development of IgG4-RD. An increase in immunoglobulin (Ig) G4-positive plasma cells >100/HPF and IgG4/IgG ratio >40% was identified in 51% of IgG4-RD cases and 20% of control cases. Localization of increased IgG4-positive plasma cells and IgG4/IgG ratio to extrafollicular zones was highly associated with IgG4-RD, particularly when identified in regions of nodal fibrosis (P<0.0001; specificity: 98.3%), or in the context of marked interfollicular expansion (P=0.022; specificity: 100%). Other features characteristic of IgG4-RD included frequent eosinophils associated with IgG4-positive plasma cells, phlebitis (P=0.06), and perifollicular granulomas (P=0.16). The presence of an isolated increase in intrafollicular IgG4-positive plasma cells and IgG4/IgG ratio was more frequently present in control cases than IgG4-RD (P<0.0001). This study confirms that increased IgG4-positive plasma cells and IgG4/IgG ratio are neither sensitive nor specific for the diagnosis of IgG4-related lymphadenopathy, and most described morphologic patterns are nonspecific. In contrast, nodal involvement by IgG4-rich fibrosis akin to extranodal IgG4-RD or diffuse interfollicular expansion by IgG4-positive plasma cells are highly specific features of true IgG4-related lymphadenopathy. Our findings provide for a clinically meaningful approach to the evaluation of lymph nodes that will assist pathologists in distinguishing IgG4-related lymphadenopathy from its mimics.
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9
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Nishimura MF, Igawa T, Gion Y, Tomita S, Inoue D, Izumozaki A, Ubara Y, Nishimura Y, Yoshino T, Sato Y. Pulmonary Manifestations of Plasma Cell Type Idiopathic Multicentric Castleman Disease: A Clinicopathological Study in Comparison with IgG4-Related Disease. J Pers Med 2020; 10:jpm10040269. [PMID: 33321725 PMCID: PMC7768369 DOI: 10.3390/jpm10040269] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023] Open
Abstract
Plasma cell type idiopathic multicentric Castleman disease (PC-iMCD) occasionally manifests as parenchymal lung disease. This study aimed to elucidate the detailed clinicopathological features of lung lesions in PC-iMCD and compare the findings with those in immunoglobulin (Ig) G4-related disease (IgG4-RD), the most difficult differential diagnosis of PC-iMCD. We analyzed the clinicopathological findings and immunohistochemical expression patterns of interleukin-6 (IL-6) and Igs in lung specimens from 16 patients with PC-iMCD and 7 patients with IgG4-RD. Histologically, pulmonary PC-iMCD could not be differentiated from IgG4-RD based on lesion distribution patterns, the number of lymphoid follicles and obliterative vasculitis, or fibrosis types. The eosinophil count was higher in the IgG4-RD group than in the PC-iMCD group (p = 0.004). The IgG4/IgG-positive cell ratio was significantly higher in the IgG4-RD group (p < 0.001). The IgA-positive cell count and IL-6 expression intensity were higher in the PC-iMCD group than in the IgG4-RD group (p < 0.001). Based on these findings, we proposed a new diagnostic approach to differentiate lung lesions of PC-iMCD and IgG4-RD. Our approach can be utilized to stratify patients with suspected lung-dominant PC-iMCD to identify candidates for strong immunosuppressive treatment, including IL-6 blockade, at an early stage.
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Affiliation(s)
- Midori Filiz Nishimura
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (M.F.N.); (T.I.); (T.Y.)
| | - Takuro Igawa
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (M.F.N.); (T.I.); (T.Y.)
| | - Yuka Gion
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan;
| | - Sakura Tomita
- Department of Pathology, Tokai University School of Medicine, Kanagawa 259-1193, Japan;
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Ishikawa 920-8641, Japan; (D.I.); (A.I.)
| | - Akira Izumozaki
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Ishikawa 920-8641, Japan; (D.I.); (A.I.)
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa 213-0015, Japan;
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (M.F.N.); (T.I.); (T.Y.)
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; (M.F.N.); (T.I.); (T.Y.)
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama 700-8558, Japan;
- Correspondence: ; Tel.: +81-86-235-7150
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10
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Mancera N, Bajric J, Margo CE. IgG4-rich reactive lymphoid hyperplasia of the lacrimal gland. Orbit 2020; 39:285-288. [PMID: 31724473 DOI: 10.1080/01676830.2019.1687735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/27/2019] [Indexed: 06/10/2023]
Abstract
We describe an otherwise healthy 24-year-old woman with reactive lymphoid hyperplasia of one lacrimal gland. She was found to have modest elevation of serum IgG4 and high density of IgG4+ plasma cells in her lacrimal gland, ranging from 40% to 60% of IgG+ plasma cells. The patient transiently responded to systemic corticosteroids before treatment with rituximab. IgG4-rich reactive lymphoid hyperplasia of the lacrimal gland is neither an established part of IgG4-related disease spectrum nor a known precursor lesion to lymphoma. Although there is a plausible risk of transforming to IgG4-related disease or to lymphoma, the biological potential and natural history of IgG4-rich reactive lymphoid hyperplasia remains to be determined.
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Affiliation(s)
- Norberto Mancera
- Department of Ophthalmology, University of South Florida , Tampa, Florida, USA
| | - Jasmina Bajric
- Department of Ophthalmology, University of South Florida , Tampa, Florida, USA
| | - Curtis E Margo
- Department of Ophthalmology, University of South Florida , Tampa, Florida, USA
- Department of Pathology and Cell Biology, Morsani Collage of Medicine, University of South Florida , Tampa, Florida, USA
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11
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Satou A, Notohara K, Zen Y, Nakamura S, Yoshino T, Okazaki K, Sato Y. Clinicopathological differential diagnosis of IgG4-related disease: A historical overview and a proposal of the criteria for excluding mimickers of IgG4-related disease. Pathol Int 2020; 70:391-402. [PMID: 32314497 DOI: 10.1111/pin.12932] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
IgG4-related disease (RD) is a relatively new entity, which was first proposed in 2001. Since then, clinical and pathological characteristics of the disease have been investigated. As IgG4-RD has been studied extensively, the diagnostic criteria for IgG4-RD of each organ and the comprehensive diagnostic criteria for IgG4-RD have also been developed. However, one of the biggest challenges in the field is distinguishing between IgG4-RD and mimickers, which show overlapping features with IgG4-RD. It is now known that some non-IgG4-RDs may meet the diagnostic criteria of IgG4-RD and can be misdiagnosed as IgG4-RD. However, accurate diagnosis is crucial, as the treatments for IgG4-RD and those for other diseases that may be misdiagnosed as IgG4-RD are different. This prompted us to create and propose comprehensive exclusion criteria for IgG4-RD. In this review, we have described the comprehensive exclusion criteria for IgG4-RD, with a historical overview of the disease. These exclusion criteria were recently created by the Research Program for Intractable Disease of the Ministry of Health, Labor, and Welfare of Japan, All Japan IgG4 team, to support correct and accurate diagnosis of IgG4-RD.
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Affiliation(s)
- Akira Satou
- Department of Surgical Pathology, Aichi Medical University Hospital, Aichi, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan
| | - Kenji Notohara
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Yoh Zen
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Institute of Liver Studies, King's College Hospital & King's College London, London, UK
| | - Shigeo Nakamura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Aichi, Japan
| | - Tadashi Yoshino
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Kazuichi Okazaki
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Yasuharu Sato
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Okayama, Japan.,Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
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12
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Yamada C, Oguro E, Tsuji S, Kudo-Tanaka E, Teshigawara S, Ohshima S, Hashimoto J, Saeki Y, Horiuchi T, Iizuka N, Tomita Y, Hoshida Y. Pathological assessment of the lymph node biopsies for lymphadenopathy in rheumatoid arthritis. Mod Rheumatol 2019; 30:835-842. [DOI: 10.1080/14397595.2019.1675260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Chika Yamada
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Eri Oguro
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Soichiro Tsuji
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Eriko Kudo-Tanaka
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Satoru Teshigawara
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Shiro Ohshima
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Jun Hashimoto
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Yukihiko Saeki
- Department of Rheumatology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | - Tetsuya Horiuchi
- Department of Surgery, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
| | | | - Yasuhiko Tomita
- Department of Pathology, International University of Health and Welfare, Japan
| | - Yoshihiko Hoshida
- Department of Pathology, National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan
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13
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Bledsoe JR, Della-Torre E, Rovati L, Deshpande V. IgG4-related disease: review of the histopathologic features, differential diagnosis, and therapeutic approach. APMIS 2018; 126:459-476. [PMID: 29924455 DOI: 10.1111/apm.12845] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an uncommon disorder that demonstrates characteristic clinicopathologic features including sclerosing lesions with storiform fibrosis, increased IgG4+ plasma cells with an increased IgG4+/IgG+ plasma cell ratio, obliterative phlebitis, and often an increased serum IgG4 level. This review summarizes the characteristic histopathologic and clinical features of IgG4-RD with detailed discussion of the histopathologic characteristics of the most commonly involved anatomic sites. We also present recent advances in our understanding of the pathophysiologic mechanisms of IgG4-RD and discuss updates on the treatment, prognosis, and outcomes of this rare disease, including discussion of the possible association between IgG4-RD and malignancy.
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Affiliation(s)
- Jacob R Bledsoe
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA, USA
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Università Vita-Salute San Raffaele - San Raffaele Scientific Institute, Milan, Italy.,Ragon Institute of MGH, MIT, and Harvard University, Cambridge, MA, USA
| | - Lucrezia Rovati
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Università Vita-Salute San Raffaele - San Raffaele Scientific Institute, Milan, Italy.,Ragon Institute of MGH, MIT, and Harvard University, Cambridge, MA, USA
| | - Vikram Deshpande
- The James Homer Wright Pathology Laboratories of the Massachusetts General Hospital, Boston, MA, USA
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Lymphomas in IgG4-related disease: clinicopathologic features in a Western population. Virchows Arch 2017; 472:839-852. [PMID: 29285637 DOI: 10.1007/s00428-017-2286-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/10/2017] [Accepted: 12/18/2017] [Indexed: 12/21/2022]
Abstract
Lymphomas that occur in the setting of IgG4-related disease (IgG4-RD) are uncommon. Most reported cases derive from Asia and are MALT lymphomas occurring in orbital IgG4-RD. The spectrum of lymphomas among IgG4-RD patients in the Western world remains poorly defined. The aim of this study was to report our experience with lymphomas occurring in IgG4-RD. Eight cases were identified from the pathology and consultation files. The median age was 61 years (range 22-68) at IgG4-RD diagnosis and 63.5 years (range 33-79) at lymphoma diagnosis, with a M:F ratio of 4:4. The diagnosis of lymphoma and IgG4-RD was concurrent in three cases and asynchronous in five (interval 4.3-16.4 years). Concurrent cases included a MALT lymphoma and a diffuse large B cell lymphoma (DLBCL) occurring with IgG4-related sialadenitis and a follicular lymphoma occurring with orbital IgG4-RD. Asynchronous cases included a lymphoplasmacytic lymphoma with large cell transformation and intervening IgG4-related pancreatitis, a MALT lymphoma after lacrimal IgG4-RD, two DLBCLs after multiorgan IgG4-RD, and a DLBCL after IgG4-related sialadenitis. Our findings suggest that lymphomas in IgG4-RD are more varied in location and type than the experience reported from Asia to date. Pathologists should be aware of the potential for lymphoma to develop in patients with IgG4-RD and should have a high degree of suspicion when lymphadenopathy or extranodal masses persist despite appropriate therapy for IgG4-RD. The co-occurrence of IgG4-RD and lymphoma that is reported here and previously suggests a possible etiologic association.
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15
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Bledsoe JR, Wallace ZS, Deshpande V, Richter JR, Klapman J, Cowan A, Stone JH, Ferry JA. Atypical IgG4+ Plasmacytic Proliferations and Lymphomas: Characterization of 11 Cases. Am J Clin Pathol 2017; 148:215-235. [PMID: 28821195 DOI: 10.1093/ajcp/aqx067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To report the clinicopathologic features of monotypic immunoglobulin G4+ (IgG4+) lymphoid and plasmacytic proliferations. METHODS Cases were identified from the pathology files. Pathology and clinical materials were reviewed. RESULTS Eleven cases of monotypic IgG4+ proliferations were identified at nodal, orbital, or salivary sites. Six cases (three men, three women; age, 57-94 years) met criteria for lymphoma or plasma cell neoplasia. Most contained frequent Mott cells. Five cases (three men, two women; age, 40-80 years) had restricted proliferations of atypical/monotypic IgG4+ plasma cells in a background of reactive lymphoid hyperplasia or inflammation. CONCLUSIONS Monotypic IgG4+ proliferations include lymphomas, plasmacytic neoplasms, and a previously uncharacterized group of proliferations not meeting criteria for conventional hematolymphoid neoplasia. Distinct features included prominent Mott cells and/or monotypic plasma cells within follicles. The proliferations were infrequently associated with IgG4-related disease (IgG4-RD). Our findings raise questions regarding the relationship between clonal IgG4+ proliferations, reactive/inflammatory processes, and IgG4-RD.
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Affiliation(s)
- Jacob R Bledsoe
- Department of Pathology, UMass Memorial Medical Center,Worcester, MA
| | | | - Vikram Deshpande
- The James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Boston
| | - Joshua R Richter
- The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Jason Klapman
- Gastrointestinal Tumor Program, Moffitt Cancer Center, Tampa, FL
| | - Andrew Cowan
- Division of Medical Oncology, University of Washington, Seattle
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology
| | - Judith A Ferry
- The James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Boston
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16
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Li C, Cao Y, Xu W, Zhang W. Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome with remarkably elevated serum IgG4. EUR J INFLAMM 2017. [DOI: 10.1177/1721727x17708940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare inflammatory disorder with unknown etiology, while the evidence of the association between IgG4 and inflammatory disorders is accumulating. We present the first report of a patient with SAPHO syndrome with remarkably elevated serum IgG4. The clinical features of this 45-year-old male patient included pain of the anterior chest wall and right elbow, bone marrow edema in the ulna suggested by magnetic resonance imaging (MRI), the “bull’s head” sign on the bone scintigraphy, and remarkably increased IgG4 and interleukin-6. This report may indicate a spectrum of diseases with serum IgG4 elevation broader than previously reported. Moreover, it also provides information on the underlying abnormal immune response in SAPHO syndrome.
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Affiliation(s)
- Chen Li
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yihan Cao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenrui Xu
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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17
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Manabe A, Igawa T, Takeuchi M, Gion Y, Yoshino T, Sato Y. Immunohistochemical analysis of IgA expression differentiates IgG4-related disease from plasma cell-type Castleman disease. Med Mol Morphol 2016; 50:34-41. [PMID: 27438709 DOI: 10.1007/s00795-016-0145-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/14/2016] [Indexed: 12/19/2022]
Abstract
Plasma cell-type Castleman disease (PCD) is often encountered when differentiating IgG4-related disease (IgG4-RD). Given that serum IgA is often elevated in Castleman disease, we investigated whether IgA expression levels in histological specimens can be used to differentiate between the two diseases. Lymph node lesions obtained from 12 IgG4-RD and 11 PCD patients were analysed by immunohistochemistry with anti-IgG, -IgG4, and -IgA antibodies. In addition to all 12 cases of IgG4-RD, 8/11 cases (72.7 %) of PCD also met the diagnostic criteria of IgG4-RD (serum IgG4 ≥135 mg/dl and IgG4/IgG-positive cells ≥40 %). IgA-positive cells were sparsely and densely distributed in IgG4-RD and PCD cases, respectively. The median number of IgA-positive cells ± SD in all 12 cases of IgG4-RD was 31 ± 37 cells per three high-powered fields (3HPFs) (range 4-118 cells/3HPFs). In contrast, the median number of IgA-positive cells, which was significantly higher in all 11 cases of PCD, was 303 ± 238 cells/3HPFs (range 74-737 cells/3HPFs) (P < 0.001). In conclusion, our findings indicate that in cases where serum analysis-based data are unavailable, anti-IgA immunostaining can be used for differential diagnosis of IgG4-RD.
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Affiliation(s)
- Akihiro Manabe
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
- Department of Clinical Laboratory, Fukuyama City Hospital, Fukuyama, Japan
| | - Takuro Igawa
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Mai Takeuchi
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yuka Gion
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
- Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan.
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18
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Nakamura M, Iwamoto O, Chino T, Todoroki K, Kusukawa J. Diagnostic dilemma of IgG4-related primary localized cervical lymphadenopathy associated with aberrant IL-6 expression level. Diagn Pathol 2016; 11:43. [PMID: 27142509 PMCID: PMC4855418 DOI: 10.1186/s13000-016-0493-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/22/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized inflammatory condition with single- or multi-organ involvement. The disease is characterized by tumefactive lesions with dense IgG4 plasmacytic infiltration (an elevated IgG4(+)/IgG(+) cell ratio of > 40 %), storiform fibrosis, and obliterative phlebitis, with or without elevated serum IgG4 levels. The diagnostic criteria for IgG4-RD, proposed in 2011, were quite comprehensive and practical; however, it is important to remember that other diseases, such as hyper-interleukin (IL)-6 syndromes, may have common histopathological findings. Therefore, the histopathology of suspected IgG4-RD is occasionally not diagnostic. Here, we report a case of IgG4-related primary localized cervical lymphadenopathy without any other organ involvement. To our knowledge, there have been no previous reports of this. Additionally, the disease was associated with a 20-fold increase in IL-6 levels compared to that of the normal range. CASE PRESENTATION We report the case of a 52-year-old Japanese man who presented with a painless, somewhat diffuse swelling in the left submandibular region. Although the case fulfilled diagnostic criteria for IgG4-RD, the diagnosis was not straightforward due to abnormally high levels of serum IL-6. After systematic evaluation of the patient, a final diagnosis of IgG4-RD was established. Since then, a specialist in connective tissue disorders has evaluated the patient on a regular basis. Two years after his initial visit, no disease progress or systemic involvement has been noted. CONCLUSION We present a case of an IgG4-related primary localized cervical lymphadenopathy mimicking hyper-IL-6 syndrome. This case can serve as an excellent reminder that the definitive diagnosis of IgG4-RD should be established using a systematic approach, in particular when it appears as an atypical manifestation.
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Affiliation(s)
- Moriyoshi Nakamura
- Dental and Oral Medical Center, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan.
| | - Osamu Iwamoto
- Dental and Oral Medical Center, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Takahiro Chino
- Department of Biomedical Sciences, University of the Pacific, Arthur A. Dugoni School of Dentistry, 155 fifth St, San Francisco, CA, 94103, USA
| | - Keita Todoroki
- Dental and Oral Medical Center, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Jingo Kusukawa
- Dental and Oral Medical Center, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
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19
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Brito-Zerón P, Bosch X, Ramos-Casals M, Stone JH. IgG4-related disease: Advances in the diagnosis and treatment. Best Pract Res Clin Rheumatol 2016; 30:261-278. [DOI: 10.1016/j.berh.2016.07.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/17/2016] [Indexed: 02/08/2023]
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20
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Ohyama K, Koike H, Takahashi M, Kawagashira Y, Iijima M, Watanabe H, Sobue G. Immunoglobulin G4-related pathologic features in inflammatory neuropathies. Neurology 2015; 85:1400-7. [DOI: 10.1212/wnl.0000000000002039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/25/2015] [Indexed: 12/20/2022] Open
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21
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Liang L, Zhou J, Chen L. Perifollicular granulomas with IgG4 plasmacytosis: A case report and review of literature. World J Clin Cases 2015; 3:650-654. [PMID: 26244157 PMCID: PMC4517340 DOI: 10.12998/wjcc.v3.i7.650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/13/2015] [Accepted: 05/18/2015] [Indexed: 02/05/2023] Open
Abstract
Perifollicular granuloma is a unique histologic feature and whether it is associated with immunoglobulin G4 (IgG4)-related disease is controversial. We report a case of a 38-year-old man who presented with worsening left eye pain, proptosis, tearing, gritty sensation, blurred vision and multiple lymphadenopathy. An axillary lymph node resection showed reactive follicular and interfollicular lymph node hyperplasia, and increased eosinophils and plasma cells (at least 80% of IgG+ plasma cells were positive for IgG4). A distinct feature was the presence of multifocal, perifollicular histiocytic granulomas, which formed a wreath around the entire follicles. The human herpes virus 8 was not detected by immunohistochemistry. In addition, an extensive panel of special stains, immunohistochemistry, and flow cytometry was negative for lymphoma, fungal, or mycobacterial infection. The findings were suggestive of IgG4-related sclerosing disease-associated lymphadenopathy. Further laboratory testing showed a significant increase of serum immunoglobulin E (> 23000 IU/mL) and slight increase of total IgG, but normal serum IgG4. Even though perifollicular granuloma is a nonspecific histopathologic feature and can be seen in other diseases, such as nodular lymphocyte predominant Hodgkin lymphoma, IgG4-related lymphadenopathy should be listed in the differential diagnoses of benign reactive lymph nodes, especially when perifollicular granuloma and plasmacytosis coexist.
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Abstract
IgG4-related disease (IgG4-RD) is a recently recognized systemic disease characterized by tumefactive lesions in various organ systems. The list of organs that can be involved continues to expand, and recently computed tomography (CT) descriptions of the pulmonary lesions found in the disease have been described. The clinical symptoms are nonspecific and may include cough, dyspnea, chest pain, and fever. The appropriate clinical presentation along with elevated serum IgG4 concentrations and pathologic evidence of lymphoplasmacytic infiltrates with abundant IgG4-positive plasma cells and storiform fibrosis is consistent with the disease. Steroids are used to treat this disease in addition to immunosupressives such as cyclosporine or rituxumab for steroid refractory disease. The pulmonary manifestations and imaging features can often mimic malignancy, and as such knowledge of the diagnostic, clinicopathologic, and radiographic features of the disease is required in order to provide appropriate diagnostic workup and treatment.
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23
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Kawano M, Suzuki Y, Yamada K, Mizushima I, Matsumura M, Nakajima K, Yamagishi M, Yamaguchi Y. Primary Sjögren's syndrome with chronic tubulointerstitial nephritis and lymphadenopathy mimicking IgG4-related disease. Mod Rheumatol 2013; 25:637-41. [PMID: 24252015 DOI: 10.3109/14397595.2013.844303] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We describe a 62-year-old woman with Sjögren's syndrome (SS) presenting with tubulointerstitial nephritis (TIN) and lymphadenopathy mimicking IgG4-related disease (IgG4-RD). Computed tomography revealed multiple swollen lymph nodes. Biopsy of the largest lymph node showed reactive lymphadenopathy with dense IgG4 positive plasma cell (IgG4 + PC) infiltration. Renal biopsy showed chronic plasma cell-rich TIN with IgG4 + PC infiltration. This case suggests that Immunoglobulin G4 immunostaining does not always support the diagnosis of IgG4-RD in the differential diagnosis between SS and IgG4-RD.
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Affiliation(s)
- Mitsuhiro Kawano
- Division of Rheumatology, Kanazawa University Hospital , Kanazawa, Ishikawa , Japan
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24
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Sato Y, Takeuchi M, Takata K, Ohno K, Iwaki N, Orita Y, Goto N, Hida AI, Iwamoto T, Asano N, Ito T, Hanakawa H, Yanai H, Yoshino T. Clinicopathologic analysis of IgG4-related skin disease. Mod Pathol 2013; 26:523-32. [PMID: 23174935 DOI: 10.1038/modpathol.2012.196] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IgG4-related disease is a recently recognized systemic syndrome characterized by mass-forming lesions with lymphoplasmacytic infiltration, increase in the number of IgG4(+) cells in affected tissues and elevation of serum IgG4 levels. In 2009, we were the first to report skin lesions in patients with IgG4-related disease, but no large case series has been reported and clinicopathological findings remain unclear. To clarify these features, we herein report 10 patients (9 men and 1 woman; median age, 64 years; age range, 46-81 years) with IgG4-related skin disease. All patients had erythematous and itchy plaques or subcutaneous nodules on the skin of the head and neck, particularly in the periauricular, cheek, and mandible regions, except for one patient, whose forearm and waist skin were affected. In addition, eight patients had extracutaneous lesions: these were found on the lymph nodes in six patients, the lacrimal glands in three patients, the parotid glands in three patients, and the kidney in one patient. Histologically examined extracutaneous lesions were consistent with IgG4-related disease; five of six lymph node lesions showed progressively transformed germinal centers-type IgG4-related lymphadenopathy. Cases of IgG4-related skin disease were classified into two histological patterns: those exhibiting a nodular dermatitis pattern and those with a subcutaneous nodule pattern. The infiltrate was rich in plasma cells, small lymphocytes, and eosinophils; the majority of the plasma cells were IgG4(+). The IgG4(+) cell count was 49-396 per high-power field (mean±s.d., 172±129), with an IgG4(+)/IgG(+) cell ratio ranging from 62 to 92%. Serum IgG4 levels were elevated in all examined patients. In conclusion, patients with IgG4-related skin disease had uniform clinicopathology. Lesions were frequently present on the skin of the periauricular, cheek, and mandible regions, and were frequently accompanied by IgG4-related lymphadenopathy.
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Affiliation(s)
- Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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Tasaki T, Matsuyama A, Tabata T, Suzuki H, Yamada S, Sasaguri Y, Hisaoka M. Sclerosing mucoepidermoid carcinoma with eosinophilia of the salivary gland: Case report and review of the literature. Pathol Int 2013; 63:125-31. [DOI: 10.1111/pin.12035] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 01/17/2013] [Indexed: 12/24/2022]
Affiliation(s)
- Takashi Tasaki
- Department of Pathology and Cell Biology; University of Occupational and Environmental Health; Kitakyushu; Japan
| | - Atsuji Matsuyama
- Department of Pathology and Oncology; University of Occupational and Environmental Health; Kitakyushu; Japan
| | - Takahisa Tabata
- Department of Otorhinolaryngology; University of Occupational and Environmental Health; Kitakyushu; Japan
| | - Hideaki Suzuki
- Department of Otorhinolaryngology; University of Occupational and Environmental Health; Kitakyushu; Japan
| | - Sohsuke Yamada
- Department of Pathology and Cell Biology; University of Occupational and Environmental Health; Kitakyushu; Japan
| | - Yasuyuki Sasaguri
- Department of Pathology and Cell Biology; University of Occupational and Environmental Health; Kitakyushu; Japan
| | - Masanori Hisaoka
- Department of Pathology and Oncology; University of Occupational and Environmental Health; Kitakyushu; Japan
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26
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Cheuk W, Chan JKC. Lymphadenopathy of IgG4-related disease: an underdiagnosed and overdiagnosed entity. Semin Diagn Pathol 2012; 29:226-34. [PMID: 23068302 DOI: 10.1053/j.semdp.2012.07.001] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lymphadenopathy is a common occurrence in IgG4-related disease; it can appear before, concurrent with, or after the diagnosis of this disease, which is characterized by tumefactive sclerosing inflammatory lesions predominantly affecting extranodal sites, such as the pancreas, salivary gland, and lacrimal gland. Although multiple lymph node groups are commonly involved, constitutional symptoms are absent. The lymph nodes can show a broad morphologic spectrum, including multicentric Castleman disease-like (type I), follicular hyperplasia (type II), interfollicular expansion (type III), progressive transformation of germinal centers (type IV), and inflammatory pseudotumor-like (type V). All are characterized by an increase in IgG4+ plasma cells (>100 per high power field) and IgG4/IgG ratio (>40%). IgG4-related lymphadenopathy is both an underdiagnosed and overdiagnosed entity. The former is because of the fact that this entity has not been characterized until recently, while the latter results from pathologists' enthusiasm in diagnosing "new" entities and the lack of specificity of the morphologic and immunophenotypic features of IgG4-related lymphadenopathy. It is prudent to render this diagnosis only for patients with known IgG4-related disease or in the presence of corroborating clinical and laboratory findings (such as elderly men, systemic lymphadenopathy, elevated serum IgG4, IgG, and IgE but not IgM and IgA, and low titers of autoantibodies). Outside these circumstances, a descriptive diagnosis of "reactive lymphoid hyperplasia with increased IgG4+ cells" accompanied by a recommendation for follow-up will be appropriate because IgG4-related disease will likely ensue only in a minority of such patients.
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Affiliation(s)
- Wah Cheuk
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong, SAR, China
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27
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Takeuchi M, Sato Y, Takata K, Kobayashi K, Ohno K, Iwaki N, Orita Y, Yoshino T. Cutaneous multicentric Castleman's disease mimicking IgG4-related disease. Pathol Res Pract 2012; 208:746-9. [PMID: 23102767 DOI: 10.1016/j.prp.2012.09.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/12/2012] [Accepted: 09/22/2012] [Indexed: 12/20/2022]
Abstract
Castleman's disease, an uncommon lymphoproliferative disorder, can be difficult to differentiate from immunoglobulin (Ig) G4-related disease. The latter is typically characterized by elevated serum IgG4 levels and abundant IgG4-positive cells. However, multicentric Castleman's disease can also have elevated serum IgG4 levels and even fulfill the histological diagnostic criteria for IgG4-related disease. We present a case of cutaneous multicentric Castleman's disease mimicking IgG4-related disease. A 55-year-old Japanese woman developed erythematous and brown plaques on her back. Skin biopsy revealed regressive follicles with interfollicular plasmacytosis, and many plasma cells were positive for IgG4 (mean 263.67±79.19, range 214-355 per high power field). The IgG4-/IgG-positive cell ratios were 35.6%, 36.2%, and 48.4%, respectively, with an average of 40.6%, thus fulfilling the histological diagnostic criteria for IgG4-related disease. Furthermore, serum IgG4 level was significantly elevated (1490 mg/dl; normal range: 4.8-105 mg/dl). However, laboratory findings of anemia, hypoalbuminemia, polyclonal gammaglobulinemia, high C-reactive protein level, and elevated serum interleukin-6 level were consistent with hyper-IL-6 syndrome. Hence, the diagnosis of cutaneous multicentric Castleman's disease was made. In conclusion, IgG4-related disease cannot be differentiated from hyper-IL-6 syndromes on histology alone. Instead, laboratory analyses are necessary to distinguish between the two diseases.
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Affiliation(s)
- Mai Takeuchi
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
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Abstract
Lymphadenopathy is frequently observed in patients with immunoglobulin G4-related disease (IgG4-RD) and sometimes appears as the first manifestation of the disease. The diagnosis of IgG4-related lymphadenopathy is complicated owing to a great histological diversity, with at least 5 histological subtypes. Indeed, lymph node biopsy may be performed under the suspicion that the lymphadenopathy is a malignant lymphoma or other lymphoproliferative disorder. The diagnosis of IgG4-RD is characterized by both elevated serum IgG4 (>135 mg/dL) and histopathological features, including a dense lymphoplasmacytic infiltrate rich in IgG4(+) plasma cells (IgG4(+)/IgG(+) plasma cell ratio >40%). However, patients with hyper-interleukin (IL-) 6 syndromes such as multicentric Castleman's disease, rheumatoid arthritis, and other immune-mediated conditions frequently show lymph node involvement and often fulfill the diagnostic criteria for IgG4-RD. Owing to these factors, IgG4-RD cannot be differentiated from hyper-IL-6 syndromes on the basis of histological findings alone. Laboratory analyses are crucial to differentiate between the 2 diseases. Hyper-IL-6 syndromes are characterized by elevated serum levels of IgG, IgA, IgM, and C-reactive protein (CRP); thrombocytosis; anemia; hypoalbuminemia; hypocholesterolemia. In contrast, IgG4-RD does not share any of these characteristics. Therefore, the diagnosis of IgG4-RD requires not only pathological findings but also clinical and laboratory analyses.
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