Bessel's disease-the first report of an IgG4-related disorder

Many aspects of IgG4-related diseases were initially described during the late 19th and early 20th century. A variety of clinical presentations caused by this common pathology have been named after the researchers who first described the disorders, such as Mikulicz, Küttner, Riedel or Ormond. However, the initial description of retroperitoneal fibrosis dates back to even 50 years earlier, when in 1846, the Prussian private practitioner Raphael Jakob Kosch described a hitherto unknown constellation of symptoms and pathological findings in a famous patient. This celebrity was the mathematician and astronomer Friedrich Wilhelm Bessel, a close friend of Alexander von Humboldt and Carl Friedrich Gauss.

Minimally invasive ureterolysis and intraperitonealization of ureter for idiopathic retroperitoneal fibrosis; single center analysis of an erratic disease

INTRODUCTION

Idiopathic retroperitoneal fibrosis is a known cause of obstructive uropathy. Ureterolysis is done when medical management fails or the presentation is at an advanced stage. Conventionally ureterolysis without omental wrap has been considered incomplete. Our Institute has experience of laparoscopic or robotic ureterolysis with intraperitonealization of the ureter alone and no other adjunctive procedure. This study retrospectively assesses the result of the procedure with patients presenting with varying severity of disease.

METHODS

From 2008, all patients who underwent laparoscopic or robotic ureterolysis were analyzed retrospectively for pre-operative management, operative findings, and post operative outcomes.

RESULTS

We operated and released nine renal units in seven patients. Two of the nine cases were performed robotically completely and the rest was performed by laparoscopic approach. Median follow up was 60 months. All patients documented resolution of symptoms. The mean post-operative creatinine at 1 year was significantly decreased to 1.47 ± 0.49 mg/dl in comparison to preoperative creatinine (p < 0.05). The postoperative mean ESR decreased significantly from a preoperative value of 58.2 ± 19.41 mm to 15.8 ± 17.23. The nuclear scan revealed unobstructed drainage and radiological imaging revealed resolution of hydronephrosis and fibrosis in all. The mean GFR on the nuclear scan after 3 and 12 months of surgery was 36.3 ± 4.33 and 40 ± 3.77, respectively. Thus, there was significant increase noted in GFR at 3 and 12 months in comparison to preoperative GFR (p < 0.05).

CONCLUSION

Laparoscopic/robotic ureterolysis with intraperitonealization alone is secure and durable procedure for idiopathic retroperitoneal fibrosis needing surgical release.

A case of giant retroperitoneal lymphangioma and IgG4-positive fibrosis: Causality or coincidence?

Several chronic inflammatory diseases have been found to be a subtype of IgG4-related disease, all of which have a typical clinical and histological change, which is based in particular on an overexpression of IgG4 and subsequent fibrosis. At least a part of the retroperitoneal fibrosis, which was originally classified as idiopathic, seems to be assigned to IgG4-related disease. Lymphangiomas are benign, cystic tumors that rarely occur in adults. However, there is no firm association with IgG4-related disease described in the literature to date. This report is about a patient suffering from acute renal failure due to a giant retroperitoneal cyst. Surgical resection remains incomplete in the iliac vessel area due to severe fibrosis and histology revealed features of both lymphangioma and IgG4⁺ fibrosis. The case description is followed by a brief overview of IgG4-related disease and a consideration of whether lymphangiomas might be assigned to this topic.

Retroperitoneal fibrosis - a report of five cases

Retroperitoneal fibrosis (RPF) is a rare disease, characterized by inflammation and deposition of fibrotic tissue in the vicinity of the abdominal aorta and iliac arteries. We present a report of five patients admitted to our department between January 2014 and February 2017, diagnosed with RPF. Abdominal pain was the most common presenting symptom; however, in one patient, RPF was identified accidentally in routinely performed ultrasonography. In 4 cases, corticosteroids (CS) in combination with azathioprine were applied as first-line therapy, whereas one patient was treated with intravenous methylprednisolone pulses followed by oral CS. In this paper, clinical features as well as laboratory and radiographic findings together with management and treatment outcomes in patients with RPF are discussed. Given the rarity of the condition, it seems important to report every single case of RPF to help establish its management algorithm.

Retroperitoneal fibrosis - the state-of-the-art

Retroperitoneal fibrosis (RPF) is a rare disease, hallmarked by inflammation and deposition of fibrous tissue around the abdominal aorta. This process may spread contiguously and involve adjacent structures, leading to many complications, among which the most frequent and most severe is ureteral obstruction. The condition usually has idiopathic origin (idiopathic retroperitoneal fibrosis – IRF), but can also develop secondarily to a number of factors. The etiology of the disease remains unclear. Current research suggests that about half of the cases of IRF may be a symptom of a recently discovered, clinically heterogeneous immunoglobulin G4-related disease (IgG4-RD). Corticosteroids are the first-line treatment for IRF, but effective attempts to use immunosuppressants are also made. This paper presents the current state of knowledge on the etiopathogenesis, clinical presentation, diagnosis and therapeutic possibilities in different forms of RPF. Based on the latest research, an analysis of the relationship between IRF and IgG4-RD was performed.

IgG4-related Diseases - A Rare Polycystic Form of Ormond's Disease

Currently, Ormond's disease is classified among IgG4-associated diseases. Its clinical manifestation varies and is characterized by the presence of fibrous retroperitoneal tissue that often affects the ureters or abdominal aorta and iliac arteries. We present a unique case of the polycystic form of Ormond's disease, imitating tumour in the retroperitoneal space. At the time of diagnosis, the disease was not metabolically active and did not require immunosuppressive therapy. The polycystic mass was removed surgically. There has been no exacerbation of the disease during the last 12 months.

Combination of Steroids and Azathioprine in the Treatment of Ormond's Disease--A Single Centre Retrospective Analysis

We present a retrospective analysis of patients treated in our Department of Clinical Biochemistry, Haematology and Immunology, Na Homolce Hospital, during 1997-2013 for Ormond's disease. We analyse the clinical history, diagnostic approaches, surgical, and immunosuppressive therapies and their subsequent effect on our patients. 28 patients treated for Ormond's disease were included. Patients with established disease activity (26 patients) were given immunosuppressive treatment, using corticosteroids in combination with azathioprine. Treatment response was evaluated using clinical symptomatology, inflammatory parameters and imaging methods. In the cohort as a whole, immunosuppressive therapy was applied in 26 patients; in two patients it was not used as no inflammatory activity was found with the disease. In all 26 patients, computed tomography showed that immunosuppressive treatment resulted in partial or complete regression of inflammatory infiltrate. Out of the total number of 26 patients, two patients experienced disease exacerbation 7 and 16 months after the immunosuppressive treatment was discontinued. The longest follow-up period was 16 years; the shortest one was 21 months. Idiopathic retroperitoneal fibrosis--Ormond's disease--is a disease with serious complications. Standard treatment involves a combination of surgery and immunosuppressive treatment. The combination of corticosteroids and azathioprine represents a potentially safe and useful method of treatment.

Ormond's Disease--IgG4-related Disease

Ormond's disease is a relatively rare disease with unclear etiology, characterized by chronic periaortitis and retroperitoneal fibrosis. The inflammatory process affects the infrarenal part of the abdominal aorta and the iliac arteries, and the presence of infiltrates encasing the ureters and inferior vena cava. This disease is currently classed as an IgG4-related disease. In our review we analyse the clinical history, diagnostic approaches, surgical and immunosuppressive therapies.

Extensive primary retroperitoneal fibrosis (Ormond's disease) with common bile duct and ureteral obstruction: A rare case report

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Retroperitoneal fibrosis is a rare inflammatory fibrotic process causing compression of retroperitoneal structures particularly the ureters.

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Ormond’s disease may involve the perirenal tissue, mesentery and biliary system in extremely uncommon situations defining the extensive RPF.

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We describe an unusual case of retroperitoneal fibrosis presenting as a malignant tissular bile duct stricture (hilar cholangiocarcinoma).

Introduction

Idiopathic retroperitoneal fibrosis (Ormond’s disease) may involve the perirenal tissue, mesentery and biliary system in extremely uncommon situations in addition to classical compression of retroperitoneal structures particularly the ureters.

Presentation of case

We report the case of a 60 year’s old man with clinical manifestation of obstructive jaundice, due to the common bile duct narrowing caused by a primary retroperitoneal fibrosis. Magnetic resonance cholangiopancreatography (MRCP) showed the presence of intrahepatic bile duct obstruction, suggesting the diagnosis of a hilar cholangiocarcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) showed strictures in the proximal common bile duct. A biliary endoprosthesis was inserted at ERCP. Histological investigations as well as CT-scan were compatible with retroperitoneal fibrosis.

Discussion

The main clinical presentation of the Ormond’s disease is compression of the ureters, and less commonly blood vessels and nerves. Our patient presented with obstructive jaundice, due to the common bile duct (CBD) compression, which was unusual. The first description of the extrahepatic biliary obstruction secondary to retroperitoneal fibrosis was made in 1964 and since then only 13 cases have been reported in the medical literature.

Conclusion

Retroperitoneal fibrosis can cause compression of the CBD and therefore mimic a cholangiocarcinoma. Patients can be successfully managed with long-term CBD stent placement.

An aid to decision-making in therapy of retroperitoneal fibrosis: dynamic enhancement analysis of gadolinium MRI

Background

Idiopathic retroperitoneal fibrosis (IRF) as an uncommon cause of obstructive uropathy is often primarily treated medically by the attending urologist. We evaluated dynamic enhancement analysis (DEA) as a possible predictor of response to medical treatment and for treatment monitoring.

Methods

From 2007, 24 patients with fibrosis were assessed by magnetic resonance imaging (MRI) with DEA. The dynamic enhancement quotient (DEQ) was measured before therapy with prednisone (n = 12) or tamoxifen (n = 12) and in follow-up investigations after 3 and 6 months. Response to medical treatment was recorded by changes in the retroperitoneal mass on MRI and possible relief of ureteral obstruction, which was monitored by intravenous pyelogram and/or MAG3 scan after removal of DJ stents.

Results

Treatment groups did not differ significantly as to age, gender, or laboratory values, and response to medical treatment showed no significant difference between agents. Overall there were no cases of progression, 2 cases of stable disease, 11 cases of mild fibrotic regression, and 11 of significant or complete regression. DJ stents could successfully be removed in 21 of 35 renal units (60.0%). In a total of 61 DEAs the DEQ was significantly higher (P < 0.001) in patients with a good response (DEQ = 4.02) than in those with an average response (3.11) or none (2.14).

Conclusions

DEA was able to distinguish between patients with different response rates to medical treatment of IRF and may be useful to individualize therapeutic decision-making.