IgG4-related Disease: Recent Topics on Immunological Aspects of This Disorder and Their Application in New Treatment Strategies

IgG4-related disease (IgG4-RD) is a systemic and chronic inflammatory disorder that can affect every part of the body. The formation of tertiary lymphoid tissues (TLT) in the affected organs may be a key phenomenon in understanding the pathogenesis of this disease because T follicular helper (Tfh) 2 cells play an important role in IgG4 class switching within TLT in the affected organs or tissues. TLT formation leads to the formation of masses or swelling of the affected organs. Interleukin (IL)-4 and IL-10 are critical cytokines for IgG4-class switching and are produced in TLT. Other factors, such as CD4-positive (CD4+) cytotoxic T cells, M2 macrophages, and LAG3+ Tfh cells, have been identified as disease-specific contributors to lesion formation. In this review, I describe the current knowledge necessary to understand the pathogenesis of this disease and recent developments in treatment strategies beyond B-cell depletion therapy.

Case Report: Immune dysregulation associated with long-lasting regression of a (pre)leukemic clone

Regression of leukemia in the absence of disease-modifying therapy remains poorly understood, although immunological mechanisms are thought to play a role. Here, we present a unique case of a 17-year-old boy with immune dysregulation and long-lasting regression of a (pre)leukemic clone in the absence of disease-modifying therapy. Using molecular and immunological analyses, we identified bone marrow features associated with disease control and loss thereof. In addition, our case reveals that detection of certain fusion genes with hardly any blasts in the bone marrow may be indicative of an accompanying oncogenic fusion gene, with implications for disease surveillance- and management in future patients.

Spontaneous remission of skull Langerhans cell histiocytosis that had developed by repeated head injury: illustrative case

BACKGROUND

Langerhans cell histiocytosis (LCH) was previously characterized as the proliferation of Langerhans-type histiocytes with a wide range of clinical presentations that arise mostly in children. The typical presentation is a gradually enlarging, painless skull mass. Rapid clinical deterioration is rare.

OBSERVATIONS

A 3-year-old boy who had incurred a right frontal impact head injury demonstrated no apparent neurological deficits. He subsequently bruised the same region multiple times. The right frontal swelling gradually increased over the course of 6 days after the initial injury. Skull radiography showed no bony lesion. The same site enlarged markedly 12 days after the initial injury. Magnetic resonance imaging revealed a frontal bony tumorous lesion associated with multiple subcutaneous cystic mass lesions. The patient underwent open biopsy of the skull lesion and evacuation of the subcutaneous lesions. Histopathological examination confirmed the diagnosis of LCH. Immunohistochemical evaluation revealed positivity for CD1a and langerin and no immunopositivity for BRAF V600E. The skull lesion spontaneously disappeared 30 days after the biopsy without recurrence.

LESSONS

Physicians should be aware of this rare clinical manifestation of LCH that developed by a repeat head injury.

Case report: Spontaneous remission in lung carcinoma with a late relapse after adjuvant immunotherapy: Exceptional tumor micro-environment

Spontaneous remission (SR) of local recurrence after adjuvant immunotherapy has rarely been reported, and the underlying mechanism is poorly understood. Herein, we reported a patient with stage cT2aN2M0 squamous cell lung carcinoma who received neoadjuvant and adjuvant treatment with nivolumab plus chemotherapy. The patient experienced a late relapse in the subcarinal lymph node seven months after the last dosage of treatment but achieved SR in the next three months without additional antitumor therapy. The complete response lasted for eleven months and counting. Notably, high copies of pathogenic microorganisms were detected in the patient's bronchoalveolar lavage fluid along with the recurrence but disappeared after SR. The patient also experienced a lymph node puncture-induced fever but had no other symptoms. A longitudinal analysis of infiltrated immune cells in the recurrent lymph node was performed by multiplex immunofluorescence and whole transcriptome sequencing, which revealed that CD8+ T cells were recruited during the initial relapse, specifically in the stromal area, then migrated into the tumor tissue, and continued to increase after elimination of tumor cells. Meanwhile, the initial recruitment of CD8+ T cells was coupled with a higher proportion of B cells, and the abundant neutrophil population was synchronous with the infiltration of CD8+ T cells into tumor cells. This is the first report on an Non-small cell lung cancer (NSCLC) patient with a late relapse after adjuvant immune checkpoint inhibitor (ICI) therapy who achieved SR. Our case highlights the complexity and plasticity of antitumor immunity and is expected to help find efficient strategies against the resistance of ICI treatment.

The Spontaneous Regression of Primary Gastrointestinal Malignancies: An Observational Review

The spontaneous regression or remission (SR) of cancer, often described as the partial or complete disappearance of a malignant tumor in the absence of all medical treatment and therapy, is a well-documented phenomenon. With efforts ongoing to establish cancer treatments that limit undesirable outcomes and adverse effects, these uncommon occurrences of SR carry significant implications for novel therapies and warrant further investigation. While several case studies have reported instances of SR in gastrointestinal (GI) malignancies, a comprehensive review of previous manifestations of SR in the GI tract remains lacking. The inclusion criteria for the rare phenomenon are also in need of an appropriate update that takes recent scientific advancements and emerging new medical technologies into account. Our analysis of 390 cases of SR in the GI tract focuses primarily on neoplasms of the hepatobiliary system and proposes an updated version of the older inclusion criteria for spontaneous regression.

Spontaneous Remission of Metastatic Castration-Resistant Prostate Cancer: Coley's Toxin Revisited?

Metastatic castration-resistant prostate cancer (mCRPC) is an incurable disease associated with poor survival outcomes. Immunotherapy was first pioneered by William Coley in the early 20th century with the injection of live and heat-killed bacteria. Despite the recent emergence of cancer immunotherapy, mCRPC remains an elusive immune target. Spontaneous remission of mCRPC following microbial infection has not been described in the literature to date. We present evidence of spontaneous biochemical and radiologic regression in a patient with mCRPC following multiple episodes of sepsis.

[Oncolytic Viruses in the Therapy of Lymphoproliferative Diseases]

Cancer is a leading causes of death. Despite significant success in the treatment of lymphatic system tumors, the problems of relapse, drug resistance and effectiveness of therapy remain relevant. Oncolytic viruses are able to replicate in tumor cells and destroy them without affecting normal, healthy tissues. By activating antitumor immunity, viruses are effective against malignant neoplasms of various nature. In lymphoproliferative diseases with a drug-resistant phenotype, many cases of remissions have been described after viral therapy. The current level of understanding of viral biology and the discovery of host cell interaction mechanisms made it possible to create unique strains with high oncoselectivity widely used in clinical practice in recent years.

Clinical features of dipeptidyl peptidase-4 inhibitor-associated bullous pemphigoid in Japan: A nationwide retrospective observational study

Many cases of bullous pemphigoid (BP) have been reported in patients taking dipeptidyl peptidase-4 inhibitors (DPP-4i), which are the most widely used antidiabetic drug for type 2 diabetes mellitus. However, no large-scale survey has been conducted in Japan. This retrospective study investigated the incidence, clinical presentation, and clinical course of DPP-4i-associated BP (DPP-4i-BP) using epidemiological data from a nationwide registry for BP. In 2016, 713 new BP patients at 94 dermatological institutes were registered, 243 (34.1%) with DPP-4i-BP and 461 (64.7%) with non-DPP-4i-BP. The male-to-female ratio was 1.9 and 0.84, respectively. Patients with DPP-4i-BP were predominantly male. Non-inflammatory BP was more common in DPP-4i-BP (33.3%) than in non-DPP-4i-BP (14.6%), while inflammatory BP was common in both. No specific subtype or difference in disease severity was evident in DPP-4i-BP. The most common gliptins administered to DPP-4i-BP patients were vildagliptin (37.2%) and linagliptin (23.8%). DPP-4i intake was discontinued in 79.9% of cases after diagnosis. Some DPP-4i-BP patients (17.6%) achieved spontaneous remission after discontinuing DPP-4i without requiring the use of systemic corticosteroids and/or adjuvant therapy. Mean duration to achieve disease control was 2.87 months. The odds ratio for non-inflammatory BP requiring systemic corticosteroids and/or adjuvant therapy was low (0.52), suggesting that remission was achieved easily with supportive care in that phenotype. Non-inflammatory and mild cases of DPP-4i-BP may resolve spontaneously with supportive care, including the discontinuation of DPP-4i and no oral corticosteroid therapy.

Giant cell arteritis with spontaneous remission

The case of a 75-year-old woman diagnosed with polymyalgia rheumatica (PMR), treated with low doses of prednisone, and with clinical and analytical remission is reported. Two years later, she presented with a clinical picture of giant cell arteritis (GCA), including headache, diplopia, jaw pain, feeling of swelling in both temples, and elevation of acute phase reactants. Symptoms spontaneously subsided 2 weeks later, while analytical parameters improved without any treatment. A high-resolution colour Doppler ultrasound showed thickening of the intima-media complex with 'halo' sign in the right temporal artery. A biopsy of the right temporal artery was performed, although it was not successful, as no artery could be found, and the procedure became more complicated with an eyebrow ptosis due to a lesion in the frontal branch of the facial nerve. GCA diagnosis was based on the clinical, laboratory, and ultrasound findings. The patient was treated with prednisone and methotrexate, without clinical or analytical relapse. Comments are presented on the described cases of GCA with spontaneous remission, and the most appropriate treatments in these cases are discussed. Other peculiarities of the case, such as the progression to GCA more than 2 years after the onset of PMR, and the complications from the temporal artery biopsy are also mentioned.

Oncolytic Viruses in the Therapy of Lymphoproliferative Diseases

Cancer is a leading causes of death. Despite significant success in the treatment of lymphatic system tumors, the problems of relapse, drug resistance and effectiveness of therapy remain relevant. Oncolytic viruses are able to replicate in tumor cells and destroy them without affecting normal, healthy tissues. By activating antitumor immunity, viruses are effective against malignant neoplasms of various nature. In lymphoproliferative diseases with a drug-resistant phenotype, many cases of remissions have been described after viral therapy. The current level of understanding of viral biology and the discovery of host cell interaction mechanisms made it possible to create unique strains with high oncoselectivity widely used in clinical practice in recent years.

Spontaneous reduction age for ovarian hernia in early infancy

BACKGROUND

Many articles recommend early surgery for ovarian hernia to avoid the risk of ovarian torsion. However, while ovarian hernia is known to undergo spontaneous reduction (SR) in early infancy, few reports have described the timing of SR. We therefore investigated the clinical features of SR for ovarian hernia in early infancy.

METHODS

A total of 610 girls were diagnosed with inguinal hernia between 2008 and 2018. We focused on infants who had an ovarian hernia onset in the first 3 months of age. We reviewed the age retrospectively at the onset of hernia and age at SR. The data were compared statistically using the Kaplan-Meier method.

RESULTS

Sixty-one infants with inguinal hernia were included in this study. Thirty-nine patients (64%) had ovarian hernia. The mean age at the onset of hernia was 44 ± 17 days of age. Thirty cases underwent SR (77%). A Kaplan-Meier analysis showed that 75% of ovarian hernias underwent SR by 6 months of age. There were no cases of ovarian torsion.

CONCLUSIONS

Most cases of ovarian hernia underwent SR, so patients with ovarian hernia in early infancy might be treated by elective surgery after 6 months of age.

Monitoring anti-PLA2R antibody titres to predict the likelihood of spontaneous remission of membranous nephropathy

Background

In anti-phospholipase A2 receptor (PLA2R) membranous nephropathy (MN) there is controversy whether spontaneous remission (SR) can be predicted using a single titre or by assessing the dynamic changes in anti-PLA2R antibody (ab) titres. The study objective was to identify the optimal dynamics of anti-PLA2Rab titres to predict SR in MN.

Methods

A total of 127 nephrotic patients with anti-PLA2R-MN were prospectively followed up for 6 months under conservative treatment. Anti-PLA2Rabs and proteinuria were assessed at diagnosis and monthly thereafter. The primary endpoint (PEP) was a reduction of proteinuria ≥50% at 6 months. Logistic models with baseline and evolutive anti-PLA2Rab titres were developed to predict the PEP.

Results

A total of 28 patients (22%) reached the PEP. These patients were more frequently female and had significantly lower baseline proteinuria and anti-PLA2Rab titres. An anti-PLA2R titre ≤97.5 RU/mL at diagnosis had a sensitivity of 71% and a specificity of 81% to predict the PEP. The model including baseline anti-PLA2Rabs and a reduction ≥15% at 3 months predicted the PEP with a sensitivity of 93% and a specificity of 80%, with an area under the curve that was significantly greater than that obtained with relative changes of proteinuria in the same period of time {odds ratio [OR] 0.95 [95% confidence interval (CI) 0.91–0.98 versus OR 0.79 [95% CI 0.70–0.88], respectively; P = 0.0013}.

Conclusions

Combining the baseline anti-PLA2Rab titres with their relative changes at 3 months after diagnosis gives the earliest prediction for achieving a reduction of urinary protein excretion ≥50% at 6 months in MN, thereby shortening the observation period currently recommended to make individualized decisions to start immunosuppressive therapy.

Spontaneous Remission of Thrombospondin Type-1 Domain-Containing-Associated Membranous Nephropathy

Membranous nephropathy often achieves spontaneous remission. However, there are scarce reports of spontaneous remission of thrombospondin type-1 domain-containing 7A (THSD7A)-associated membranous nephropathy. A 64-year-old female presented with nephrotic syndrome and edema of the lower extremities. We diagnosed membranous nephropathy by kidney biopsy and confirmed positive THSD7A on immunofluorescence using frozen sections; serum THSD7A antibodies were also detected. Thirty-four months after the initial diagnosis, she achieved a spontaneous complete remission without immunosuppressive therapy. With the complete remission, no serum THSD7A levels were detected. In this study, we describe serial examinations of kidney biopsies and serum THSD7A antibodies.

"Burnt-out" progressive multifocal leukoencephalopathy in idiopathic CD4+ lymphocytopenia

Progressive multifocal leukoencephalopathy (PML) is a fatal disease caused by John Cunningham virus (JCV) infection; however, a growing number of PML patients now survive longer and achieve remission, largely due to the advent of combination antiretroviral therapy. Several reports have suggested that the pathology in such patients presents only chronic demyelination without characteristic cellular changes, being referred to as "burnt-out" PML. On the other hand, our knowledge of "burnt-out" PML is still substantially limited, especially in patients with non-human immunodeficiency virus infection. Here, we report a case of PML associated with idiopathic CD4⁺ lymphocytopenia (ICL) who presented with spontaneous remission and survived for 11 years after onset. Notably, postmortem examination revealed surprisingly broad "burnt-out" lesions lacking the classic histopathological findings. However, pathogenic JCV-specific DNA sequences was still present in the autopsied brain tissue. This case suggests that complete remission can be achieved with a persistent presence of JCV-specific pathogenic sequences, even after a catastrophic infection. Considering that there have been a few reported cases of PML with ICL with long survival, the long-term survival of our case may share a favorable immunological response that is unique to a subgroup of ICL.

Acute Pulmonary Graft-Versus-Host Disease in a Patient with Adult T-cell Leukemia-Lymphoma Diagnosed by a Cryobiopsy

A 51-year-old woman with adult T-cell leukemia-lymphoma was hospitalized in order to undergo allogeneic hematopoietic stem-cell transplantation. On day 29 after transplantation, she began to experience hypoxia upon exertion. Chest computed tomography revealed centrilobular granular shadows, and pulmonary function tests revealed a remarkable obstructive ventilatory impairment compared to before transplantation. A histopathological analysis following a transbronchial lung cryobiopsy revealed acute graft-versus-host disease (GVHD). We herein report a rare case of histopathologically diagnosed acute pulmonary GVHD with spontaneous remission.

Spontaneous Remission of Acromegaly After Pituitary Apoplexy in a Middle-Aged Male

Background: Pituitary apoplexy results from hemorrhage, infarction, or hemorrhagic infarction within a pituitary tumor. Subclinical or clinical apoplexy is not uncommon in acromegaly, owing to the large size of the tumor at initial detection. Growth hormone excess in acromegaly often persists following surgery. However, in rare instances, pituitary apoplexy may present a spontaneous cure to growth hormone excess.

Case Report: A 40-year-old male presented with holocranial headache for the past 16 years that had worsened in severity during the prior year. Two months before presentation, he experienced a severe headache that he described as the worst headache of his life. The patient had prominent acromegaloid features that he ignored, as they seemed to cause no harm. The patient had no signs of clinically active disease. Magnetic resonance imaging of the brain revealed a pituitary macroadenoma with evidence of hemorrhage. Serum insulin-like growth factor 1 and oral glucose–suppressed serum growth hormone levels were normal, suggestive of inactive or silent disease. Pituitary apoplexy causing spontaneous remission of acromegaly was diagnosed, and close follow-up was planned for the evolution of hypopituitarism.

Conclusion: This case highlights a rare presentation of acromegaly in which an episode of symptomatic pituitary apoplexy revealed the diagnosis of pituitary adenoma and led to the cure of growth hormone hypersecretion.

Clinical Phenotypes and Predictors of Remission in Primary Membranous Nephropathy

(1) Background: We sought to investigate the clinical outcome and to identify the independent predictors of clinical remission in a prospectively followed cohort of patients with primary membranous nephropathy (pMN). (2) Methods: We conducted a prospective, observational, non-interventional study that included 65 consecutive patients diagnosed with pMN between January 2015 and December 2019 at our department and followed for at least 24 months. The primary outcomes evaluated during the follow-up period were the occurrence of immunological and clinical remission (either complete or partial remission). Univariate and multivariate Cox proportional hazard regression analyses were performed to identify independent predictors of clinical remission. (3) Results: In the study cohort, 13 patients had a PLA2R-negative pMN, while, of those with PLA2R-associated pMN, 27 patients had a low anti-PLA2R antibody titer (<200 RU/mL), and 25 patients had a high anti-PLA2R antibody titer at baseline (≥200 RU/mL). The clinical outcome was better in patients with PLA2R-negative pMN compared to patients with PLA2R-positive pMN. These patients had a higher percentage of complete remissions (46.2%, compared to 33.3% in those with low anti-PLA2R antibody titer or 24% in those with high anti-PLA2R antibody titer), a faster decline of 24 h proteinuria and lower time to complete remission. In multivariate Cox regression analysis, patients with PLA2R-negative pMN had a 3.1-fold and a 2.87-fold higher chance for achieving a complete or partial remission compared to patients with high anti-PLA2R antibody titer or to all PLA2R-positive patients, respectively. Additionally, patients with a baseline 24 h proteinuria of less than 8 g/day and with an immunological remission at 24 months had a 2.4-fold (HR, 2.4; 95%CI, 1.19-4.8) and a 2.2-fold (HR, 2.26; 95%CI, 1.05-4.87), respectively, higher chance of achieving a clinical response. By contrary, renal function at diagnosis, type of therapeutic intervention or anti-PLA2R antibody titer did not predict the occurrence of clinical remission. (4) Conclusions: We identified a different clinical phenotype between PLA2R-positive and PLA2R-negative pMN. Additionally, we have shown that baseline proteinuria seems to be a more important predictor of clinical outcome than anti-PLA2R-ab titer.

Unexpected remission of hyperparathyroidism caused by hemorrhage due to the use of fine-needle aspiration biopsy: two cases report

Hyperparathyroidism is not a rare disease; if a parathyroid adenoma is confirmed, the treatment of choice is the surgical resection. Diagnostic use of fine-needle aspiration biopsy (FNAB) for histological confirmation in patients with hyperparathyroidism is controversial. And spontaneous remission of hyperparathyroidism caused by bleeding or infarction of the adenoma rarely occurs. Here we have reported two cases of hyperparathyroidism in which spontaneous remission occurred due to the use of FNAB for diagnosis. The remission was confirmed after surgical removal and pathological review of the adenoma. The first patient diagnosed with primary hyperparathyroidism (PHPT) had neck pain and severe swelling 4 days after FNAB, and spontaneous remission due to intracapsular hemorrhage was confirmed after surgery. In the second patient receiving hemodialysis treatment for end-stage renal disease, hyperparathyroidism spontaneously resolved after FNAB and the parathyroid hormone (PTH) levels normalized after surgery. The first patient maintained a normal level of PTH for 6 years, and the second patient received kidney transplantation 6 years after surgery, and the normal level of PTH was confirmed for 13 years. Caution is needed while performing FNAB for diagnosis of hyperparathyroidism and during decision making regarding whether to observe the patient or perform surgery after spontaneous remission due to bleeding or infarction.

Course of tic disorders over the lifespan

PURPOSE OF REVIEW

To summarize and update information on the course of tic disorders from childhood through later life.

RECENT FINDINGS

Tics tend to improve substantially over the first year after they appear. However, contrary to widespread opinion, tics usually last longer than one year, though usually at minimal severity. Tics often wane to clinical insignificance over the teen years, possibly resurging occasionally over the lifespan. However, in an important minority of patients, tics remain clinically relevant throughout life. Tics rarely first come to clinical attention later in adulthood, but new reports describe additional such cases.

SUMMARY

Recent publications have shown tics to persist past a few months more often than previously thought, though often at minimal severity, and recurrence after an asymptomatic period is common. The safety and efficacy of behavior therapy for tics, together with prospective indicators of early prognosis, make feasible the possibility of bettering the lifetime course of tic disorders with early intervention.

Case Report: Spontaneous Remission of an Infraorbital Follicular B-Cell Lymphoma: Case Report and Review of the Literature

Non-Hodgkin lymphomas comprise a heterogeneous group of malignancies, with a wide scope of clinical, radiological and histological presentations. In this paper, a case is presented of a 59-year-old white male with an infraorbital follicular B-cell lymphoma, which appeared as a painless mass in the left cheek. The lymphoma achieved spontaneous remission five and a half months after his diagnostic incision biopsy. The literature is reviewed, focusing on this rare site of presentation and spontaneous remission. In literature, only four cases have been reported with a follicular B-cell lymphoma of the cheek or infraorbital region, and only 26 cases of spontaneous remission of an extracranial non-Hodgkin lymphoma in the head and neck region have been described. To the authors’ best knowledge, this is the first time spontaneous remission of an infraorbital follicular lymphoma could be observed. The nature of the processes inducing spontaneous remission remains obscure. It is important to recognize this phenomenon as this might prevent unnecessary treatment.

Spontaneously Resolved Atopic Dermatitis Shows Melanocyte and Immune Cell Activation Distinct From Healthy Control Skin

Atopic dermatitis (AD) typically starts in infancy or early childhood, showing spontaneous remission in a subset of patients, while others develop lifelong disease. Despite an increased understanding of AD, factors guiding its natural course are only insufficiently elucidated. We thus performed suction blistering in skin of adult patients with stable, spontaneous remission from previous moderate-to-severe AD during childhood. Samples were compared to healthy controls without personal or familial history of atopy, and to chronic, active AD lesions. Skin cells and tissue fluid obtained were used for single-cell RNA sequencing and proteomic multiplex assays, respectively. We found overall cell composition and proteomic profiles of spontaneously healed AD to be comparable to healthy control skin, without upregulation of typical AD activity markers (e.g., IL13, S100As, and KRT16). Among all cell types in spontaneously healed AD, melanocytes harbored the largest numbers of differentially expressed genes in comparison to healthy controls, with upregulation of potentially anti-inflammatory markers such as PLA2G7. Conventional T-cells also showed increases in regulatory markers, and a general skewing toward a more Th1-like phenotype. By contrast, gene expression of regulatory T-cells and keratinocytes was essentially indistinguishable from healthy skin. Melanocytes and conventional T-cells might thus contribute a specific regulatory milieu in spontaneously healed AD skin.

Spontaneous regression of central nervous system posttransplant lymphoproliferative disease: A case report

RATIONALE

Primary central nervous system (CNS) posttransplant lymphoproliferative disease (PTLD) is a very rare entity. Patients may respond to reduction of immunosuppression or other therapies, but the prognosis is still pessimistic.

PATIENT CONCERNS

Herein, we report a 40-year-old female with a history of renal transplantation developed brain masses 4 years ago. Although brain biopsy was performed, PTLD was underdiagnosed then. No relevant treatment was administered. However, the lesions resolved spontaneously. After 4 years, new lesion appeared in a different brain region.

DIAGNOSES

The history of renal transplantation raised the suspicion of PTLD. Reexamination of previous brain sections confirmed the diagnosis of polymorphic PTLD (P-PTLD). A second biopsy of the new lesion also demonstrated P-PTLD.

INTERVENTIONS

She was referred to hematology department to receive rituximab.

OUTCOMES

After 4 rounds of treatment, the lesion resolved satisfactorily.

LESSONS

This case demonstrates the natural history of primary CNS P-PTLD. Although self-remission and recurrence is possible, aggressive measures should be taken to this condition.

Spontaneous Remission After a Hypercalcemic Crisis Caused by an Intracystic Hemorrhage of Bilateral Parathyroid Adenomas: A Case Report and Literature Review

BACKGROUND

Hyperparathyroidism is a common cause of hypercalcemia; however, spontaneous remission after a hypercalcemic crisis caused by an intracystic hemorrhage of parathyroid adenomas is very rare. The question, then, is "What is the best treatment strategy for this type of case?"

METHOD

A 47-year-old male patient with primary hyperparathyroidism and a hypercalcemic crisis is reported. Hypercalcemia was spontaneously relieved thereafter. Postoperative paraffin pathology results indicated an intracystic hemorrhage of bilateral parathyroid adenomas.

RESULTS

After the case report, a literature review is also included to summarize the clinical features of this patient and to provide special reference for clinical diagnosis and treatment of similar cases.

CONCLUSIONS

The choice of surgical timing for such cases can be made based on the comprehensive consideration of clinical symptoms and changes in parathyroid function.

Spontaneous Remission and Concomitant Progression in a Patient with DLBCL

Diffuse large B-cell lymphoma (DLBCL) is the most common type of lymphoma. Although DLBCL can be cured in more than half of all patients, up to 50% of patients become refractory to initial treatment or relapse after complete remission. We present a case of complete spontaneous remission of some tumors and concomitant newly developed tumors observed in a patient with relapsed DLBCL. Spontaneous remission of lymphoma without treatment is a rare phenomenon and can occur at baseline as well as in relapsed DLBCL. However, most patients who initially experience spontaneous remission later develop relapse. Thus, careful follow-up is required, and fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) allows monitoring of multiple lesions.

Spontaneous remission of untreated primary amyloidosis of the bladder after transurethral resection biopsy: a case report and literature review

We herein present a case involving a 23-year-old woman with gross hematuria. Cystoscopy revealed abnormal areas of the mucosa along the anterior and posterior bladder walls. These abnormalities were suspicious for neoplasia; however, a diagnosis was not established by subsequent biopsy. The patient underwent transurethral resection biopsy in which an isolated lesion along the anterior wall was completely resected and the others were left untreated. Pathologic examination and special staining led to a diagnosis of amyloidosis, and the patient elected to undergo transurethral surgery 1 month later. During the operation, the intravesical lesions were found to have significantly improved in both the treated and untreated sites. The operation was cancelled, follow-up was arranged, and no other treatment was administered. Repeat cystoscopy examinations at 3 and 9 months after surgery showed that the lesions had almost completely disappeared.

Idiopathic Membranous Nephropathy: Glomerular Pathological Pattern Caused by Extrarenal Immunity Activity

Idiopathic membranous nephropathy (IMN) is a pathological pattern of glomerular damage caused by an autoimmune response. Immune complex deposition, thickness of glomerular basement membrane, and changes in the podocyte morphology are responsible for the development of proteinuria, which is caused by the targeted binding of auto-antibodies to podocytes. Several auto-antigens have recently been identified in IMN, including M-type receptor for secretory phospholipase A2 (PLA2R1), thrombospondin type-1 domain-containing 7A (THSD7A), and neural epidermal growth factor-like 1 protein (NELL-1). The measurement of peripheral circulating antibodies has become an important clinical reference index. However, some clinical features of IMN remain elusive and need to be further investigated, such as the autoimmunity initiation, IgG4 predominance, spontaneous remission, and the unique glomerular lesion. As these unresolved issues are closely related to clinical practice, we have proposed a hypothetical pathogenesis model of IMN. Induced by environmental stimuli or other causes, the PLA2R1 antigen and/or THSD7A antigen exposed to extrarenal tissues, such as lungs, then produce the auto-antibodies that target and cause damage to the podocytes in circulation. In this review, we highlighted the potential association between environmental stimuli, immune activity, and glomerular lesions, the underlying basis for spontaneous immune and proteinuria remission.

Spontaneous remission of the micronodular pattern in cryptogenic organizing pneumonia

Organizing pneumonia (OP) is a common interstitial lung disease, pathologically characterized by polypoid granulation tissue in the alveolar ducts and alveoli. In clinical practice, OP occasionally presents as non-resolving pneumonia. The typical radiographic pattern of OP is characterized by dense consolidation with ground-glass opacities. Diffuse micronodular pattern of OP (MNOP) is a rare radiographic manifestation that mimics non-resolving bronchiolar diseases such as pulmonary tuberculosis or hypersensitivity pneumonitis. Steroid therapy is usually effective for MNOP; however, spontaneous remission in MNOP has never been reported. Herein, we report a case of a diffuse micronodular form of cryptogenic OP (COP) that was diagnosed via transbronchial biopsy (TBB) and resolved spontaneously within a few months. Our case highlights that MNOP may resolve spontaneously similar to other forms of OP, and mild cases may be under-recognized. Furthermore, careful observation could be an option for managing MNOP with mild and non-progressive symptoms.

A "Wait-and-See" Approach to Quiescent Single-System Langerhans Cell Histiocytosis to Spare Children From Chemotherapy

Background: Langerhans Cell Histiocytosis (LCH) is a childhood disorder of histiocytes that is generally treated with systemic chemotherapy. Spontaneous resolution has been previously reported in Single System LCH (SS-LCH), which is less aggressive than multisystem disease. However, there are no clear guidelines on which patients can be safely spared from systemic chemotherapy. Here, we propose a risk stratification framework based on disease quiescence as determined by clinical and biochemical features of inflammation, to identify low risk patients who may be potentially spared from chemotherapy through a conservative "wait-and-see" approach. Methods: Retrospective analysis in a single institution was conducted in children with SS-LCH, comparing features of inflammation and outcomes of those who received chemotherapy vs. those with quiescent disease, who were managed conservatively. Results: Of 44 children with SS-LCH, only patients without risk-organ involvement were considered for conservative management. A "wait-and-see" approach was adopted for patients with quiescent disease as defined by clinical and biochemical evidence of disease activity. Following 2 weeks of watchful observation, decisions were made to either start treatment or continue conservative management. Based on data collected at diagnosis, patients with quiescent disease had a lower mean platelet count 339 × 10⁹/L (95%C.I: 285-393) vs. 482 × 10⁹/L (95% C.I: 420-544) p < 0.01, a lower mean white cell count 9.3 × 10⁹/L (95%C.I: 7.5-11.1) vs. 13.1 × 10⁹/L (95%C.I: 11-15.2) p < 0.01 and lower Erythrocyte-Sedimentation-Rate (ESR) 8.2 mm/h (95%C.I: 5.4-11) vs. 53.7 mm/h (95%C.I: 11-96.3) p = 0.04, suggesting that these are potential biochemical markers of disease activity. Other features of disease quiescence noted were rapid progression, functional disability, presence of a skull depression rather a lump and the lack of fever. Conclusions: Further studies are required to validate our proposed framework to determine disease activity in SS-LCH. Within the limits of this current analysis, it appears that low-risk patients with clinically and biochemically quiescent SS-LCH, may potentially be spared from chemotherapy with good long-term outcomes.

Spontaneous resolution of untreated diffuse large B-cell lymphoma of maxillary bone after incisional biopsy

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous group of lymphomas which require multiagent therapy for remission induction and are associated with relapse in more than 40% of patients. Spontaneous remission of diffuse large B-cell lymphoma (DLBCL) is a rare occurrence.

Analysis of 59 cases of congenital leukemia reported between 2001 and 2016

Congenital leukemia (CL), defined as manifestations of leukemia within the first 4 weeks of life, is a rare condition with an estimated incidence of only 1 to 5 per million live births. Despite extensive research and the clinical application of new therapies, the prognosis of CL remains poor. Few large-scale studies have investigated the factors affecting the outcomes of infants with CL. Here, we conducted a retrospective study and analysis of CL cases published in the English language from 1 January 2001 to 1 May 2016. Our goal was to provide updated information about this rare disease and to investigate factors that may affect the outcomes of patients with CL.

Methotrexate-associated Classical Hodgkin Lymphoma Shows Distinct Clinicopathological Features but Comparable Clinical Outcomes With Sporadic Cases

BACKGROUND/AIM

Methotrexate (MTX)-associated classical Hodgkin lymphoma (CHL) is a rare disease, and its prognosis remains unclear.

MATERIALS AND METHODS

Our study retrospectively compared clinicopathological features and clinical outcomes of patients with MTX-CHL (n=6) and sporadic CHL (n=40).

RESULTS

MTX-CHL was more frequently the mixed cellularity subtype and positive for Epstein-Barr virus, but less frequently positive for CD20 than sporadic CHL. Clinically, MTX-CHL was more frequent in advanced stage than sporadic CHL and often associated with extranodal disease. After the cessation of MTX, transient spontaneous regression was observed in two MTX-CHL cases. Eventually, all patients with MTX-CHL required chemotherapy, which gave similar complete remission rates at 2 years compared to sporadic CHL. Patients with MTX-CHL tended to have a higher incidence of grade 3 or more neutropenia.

CONCLUSION

The present study revealed differences in clinicopathological features but similarities in clinical outcomes of MTX-CHL and sporadic CHL.

Spontaneous remission of West syndrome following a human herpesvirus 7 infection in a Chinese infant: A case report

RATIONALE

West syndrome (WS) is an age-dependent epileptic encephalopathy that is characterized by intractable epileptic seizures, hypsarrhythmia, and observed through electroencephalogram (EEG) and significant neurodevelopmental regression. The spontaneous remission of epileptic seizure is clinically rare and has not previously been reported in a Chinese infant. Herein, we reported a Chinese infant with WS whose seizures disappeared following a human herpesvirus 7 (HHV-7) infection.

PATIENT CONCERNS

The male Chinese infant was born at the gestational age of 36 weeks with a birth weight of 1.65 kg and an Apgar score of 7 at the first minute. At the age of 6 months, the infant developed seizures that manifested as flexor spasms with trunk involvement and mental regression.

DIAGNOSIS

Brain magnetic resonance imaging revealed leukomalacia of the posterior horn and a reduction in the size of the periventricular of the bilateral ventricle and the corpus callosum. An EEG revealed hypsarrhythmia and typical spasm seizures. Therefore, the infant was diagnosed with symptomatic WS.

INTERVENTIONS

The infant was treated with adequate vitamin B6 intravenous drip and oral treatment with topiramate and levetiracetam.

OUTCOMES

The observed seizures disappeared spontaneously 40 days after onset, without any changes in the anti-epileptic drug treatment, following a febrile rash due to a HHV-7 infection.

LESSONS

Spontaneous remission of epileptic seizures can occur following viral infection of HHV-7 in children with WS. The mechanism behind this spontaneous remission warrants further research.

Spontaneous remission of giant cell arteritis: possible association with a preceding acute respiratory infection and seropositivity to Chlamydia pneumoniae antibodies

Recent epidemiological or immunopathological studies demonstrate the possible association between giant cell arteritis and infectious agents including Chlamydia pneumoniae. A 62-year-old Japanese man with type 1 diabetes mellitus developed biopsy-proven giant cell arteritis after acute upper respiratory infection. Serological examination indicated concurrent re-infection with C. pneumoniae. Clinical manifestations of the vasculitis subsided within a month without any immunosuppressive therapy, and no relapse was observed for the following 12 months. The natural history of this disease is unclear and spontaneous remission is rarely reported. The self-limiting nature of the infection could contribute to this phenomenon.

Linking Individual Natural History to Population Outcomes in Tuberculosis

Background

Substantial individual heterogeneity exists in the clinical manifestations and duration of active tuberculosis. We sought to link the individual-level characteristics of tuberculosis disease to observed population-level outcomes.

Methods

We developed an individual-based, stochastic model of tuberculosis disease in a hypothetical cohort of patients with smear-positive tuberculosis. We conceptualized the disease process as consisting of 2 states—progression and recovery—including transitions between the 2. We then used a Bayesian process to calibrate the model to clinical data from the prechemotherapy era, thus identifying the rates of progression and recovery (and probabilities of transition) consistent with observed population-level clinical outcomes.

Results

Observed outcomes are consistent with slow rates of disease progression (median doubling time: 84 days, 95% uncertainty range 62–104) and a low, but nonzero, probability of transition from disease progression to recovery (median 16% per year, 95% uncertainty range 11%–21%). Other individual-level dynamics were less influential in determining observed outcomes.

Conclusions

This simplified model identifies individual-level dynamics—including a long doubling time and low probability of immune recovery—that recapitulate population-level clinical outcomes of untreated tuberculosis patients. This framework may facilitate better understanding of the population-level impact of interventions acting at the individual host level.

Anti-phospholipase A2 receptor antibody and spontaneous remission in membranous nephropathy

Membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in native kidney biopsies from adults. In 2009, antibodies to the M-type receptor of phospholipase A2 (anti-PLA2R) were identified in idiopathic MN patients, both within the kidney and in the circulation. The clinical course of idiopathic MN is variable and ranges from spontaneous remission to end-stage renal disease. Clinical variables such as proteinuria levels, patient sex, age and renal function at diagnosis have been associated with renal MN progression. In this editorial, we update the importance of anti-PLA2R levels as a prognostic marker in idiopathic MN at the diagnosis of the disease.

Association of 18F-FDG PET or PET/CT results with spontaneous remission in classic fever of unknown origin: A systematic review and meta-analysis

BACKGROUND

Spontaneous remission is common in patients with undiagnosed classic fever of unknown origin (FUO). Although identifying reliable predictors of spontaneous remission in such diagnostically challenging cases could improve their management strategies, few studies have assessed such clinical factors. Recently, studies have reported that F-fluorodeoxyglucose positron emission tomography (F-FDG PET) alone and integrated with computed tomography (PET/CT) were useful in localizing the source of FUO. In this systematic review and meta-analysis, we assessed the association of results of these imaging modalities with spontaneous remission in patients with classic FUO.

METHODS

We searched PubMed and Scopus from inception until June 30, 2018, and studies that evaluated the PET or PET/CT results of ≥10 adult or adolescent patients with classic FUO who were followed up for at least 3 months were included. At least 2 investigators extracted data and rated quality using the QUIPS-2 tool. We used a random-effects meta-analysis to calculate summary risk ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

Nine studies of PET/CT results (418 patients) and 4 studies of standalone PET results (128 patients) were eligible. None explicitly specified the incidence of spontaneous remission as the primary or secondary outcomes of interest. The risk of bias was considered high in all studies because patients received subsequent diagnostic workup based on imaging results. Patients with negative PET/CT results were significantly more likely to present with spontaneous regression than those with positive results (summary RR = 5.6; 95% CI: 3.4-9.2; P < .001; I = 0%). In contrast, no significant association was found between standalone PET results and spontaneous remission. The random-effects study-level meta-regression found that PET/CT results [relative RR (rRR) = 7.4; 95% CI: 2.5-21.3; P = .002], compared with standalone PET results, and publication year (rRR = 1.2 per 1 year; 95% CI: 1.0-1.3; P = .013) were significantly associated with spontaneous remission.

CONCLUSION

Limited data suggest that undiagnosed classic FUO patients with negative PET/CT results had a high likelihood of spontaneous remission after a series of unsuccessful investigations for fever workup. Prospective studies should validate these results.

Spontaneous Remission in Paroxysmal Nocturnal Hemoglobinuria-Return to Health or Transition Into Malignancy?

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired syndrome characterized by intravascular hemolysis, thrombosis, and bone marrow failure. The disease is caused by a mutation in the PIG-A gene that leads to the lack of glycosylphosphatidylinositol-anchored complement regulatory molecules CD55 and CD59 on affected blood cell surfaces. In previous studies, spontaneous clinical remissions have been described. The disease manifestations are very heterogeneous, and we wanted to examine if true remissions and disappearance of the clone occur. In a follow-up of a nation-wide cohort of 106 Finnish patients with a PNH clone, we found six cases, where the clone disappeared or was clearly diminished. Two of the patients subsequently developed leukemia, while the other four are healthy and in clinical remission. According to our data, spontaneous remissions are not as frequent as described earlier. Since the disappearance of the PNH cell clone may indicate either a favorable or a poor outcome—remission or malignancy—careful clinical monitoring in PNH is mandatory. Nevertheless, true remissions occur, and further studies are needed to understand the immunological background of this phenomenon and to obtain a better understanding of the natural history of the disease.

Spontaneous regression of locally advanced nonsmall cell lung cancer: A case report

RATIONALE

Spontaneous regression of non-small cell lung cancer is exceptionally rare.

PATIENT CONCERNS

Treatment-related toxicity.

DIAGNOSES

We report a case of a patient diagnosed with locally advanced non-small cell lung cancer.

INTERVENTIONS

The patient declined potentially curative treatment, and did not receive any anti-cancer treatment.

OUTCOMES

He has survived more than two years since his initial diagnosis, maintaining his good performance status. Serial imaging with computed tomography scans showed tumour regression and near-complete resolution of his disease.

LESSONS

Spontaneous regression of non-small cell lung cancer, by virtue of its scarcity, has not been well-studied and is poorly understood. Further studies are required, in order to clarify the mechanisms by which spontaneous regression occurs, and possibly identify new targets for cancer treatment.

The prognostic value of phospholipase A2 receptor autoantibodies on spontaneous remission for patients with idiopathic membranous nephropathy: A meta-analysis

BACKGROUND

The presence of antibodies against phospholipase A2 receptor (PLA2R-Abs) in serum at diagnosis is reported to be related to the rate of spontaneous remission in patients with idiopathic membranous nephropathy (IMN); however, there is still lack of enough samples to illustrate this problem. Here, we conducted a comprehensive meta-analysis to investigate the prognostic value of PLA2R-Abs on spontaneous remission for IMN patients in the absence of immunosuppressive therapy.

METHODS

A systematic search of the PubMed, EMBASE, and Cochrane Central databases was performed for relevant original articles published until October 2017. All studies focus on spontaneous remission rates in IMN patients associated with PLA2R-Abs, the endpoint of interest is spontaneous remission rate. Risk ratio (RR) and corresponding 95% confidence intervals (CI) were carried out using a fixed or random effects model. The data were analyzed by Review Manager 5.3 software.

RESULTS

A total of 5 articles involving 190 patients were included in this meta-analysis. There were significant differences between the 2 groups in spontaneous remission rate. The seropositive of PLA2R-Abs measured at the time of diagnosis was negatively correlated with the likelihood of spontaneous remission (RR = 0.69; 95% CI, 0.56-0.87; P = .001).

CONCLUSION

In PLA2R-Abs seronegative patients, the spontaneous remission rate is higher than that of PLA2R-Abs seropositive patients during symptomatic treatment. Therefore, in order to avoid malignant events caused by immunosuppressive therapy, maybe it is more beneficial to adopt conservative treatment for PLA2R-Abs seronegative patients at initial treatment.

Advancing alcohol research and treatment: contentions and debates about treatment intensity, goals and outcomes in the 1970s and 1980s

AIMS

This narrative exploration of alcohol treatment research focuses on key contentions and advances in alcohol treatment during the critical 1970s and 1980s.

METHODS

Papers and books which signal some of the major debates and advances in alcohol treatment research were selected from the 1970s and 1980s. The selection process was based on significant debate during this period, and included those that influenced the field in general and this author in particular.

RESULTS

This was a period where challenges to traditional models and concepts, and the perceived universal need for long-term treatment, were accompanied by contention but also advances in research and treatment approaches. The debates and advances resonate today. These include the recognition that: intensive and long-term treatment is not always required; for dependent drinkers, relapse is a common treatment outcome meriting specific treatment approaches to prevent and reduce this risk; controlled drinking is a treatment option, especially for younger and less dependent drinkers; and an important contributor to enduring change is access to, and realization of, improvements in the quality of life.

CONCLUSIONS

Pioneering research and publications in the 1970s and 1980s, sometimes conducted and produced in contentious contexts, influenced significantly conceptualizations of alcohol-related problems, and laid the foundations for treatment hypotheses and research, improving access to a broader range of evidence-based treatment. These underpinning works influenced the development of stepped-up care from brief to intensive interventions, relapse prevention and treatment options not limited to abstinence, and they identified the need to include a stronger focus on quality of life.

Stigmatization Is Associated With Increased PTSD Risk After Traumatic Stress and Diminished Likelihood of Spontaneous Remission-A Study With East-African Conflict Survivors

Studies in conflict population have repeatedly documented that the number of traumatic event types experienced (trauma load) increases the risk to develop posttraumatic stress disorder (PTSD) in a dose-dependent manner. Misconceptions about survivors' experiences and actions during the war, as well as mental health symptoms frequently lead to stigmatization by their own families and the community, which might render them even more vulnerable for PTSD development and prevent successful recovery. We therefore investigated whether stigmatization affects trauma-related psychopathology beyond the well-known effect of trauma load. The study sample comprised N = 1131 survivors of the rebel war led by the Lord's Resistance Army (LRA) in Northern Uganda, including a large proportion of formerly abducted individuals and child soldiers. We investigated how the experience of stigmatization affects PTSD risk and the likelihood of spontaneous remission, taking trauma load into account. Further, the association of stigmatization with treatment outcome was determined in a subsample of N = 284 individuals with PTSD who received trauma-focused psychotherapy. More than one third of the total sample, and almost two-thirds of the therapy subsample, reported experiences of stigmatization. The main reasons for stigmatization were related to an association with a rebel group (e.g., being called a rebel), followed by mental health problems/PTSD symptoms and HIV/AIDS. Stigmatization was strongly associated with a higher prevalence of lifetime and current PTSD, a diminished probability of spontaneous remission and higher PTSD symptoms before and after trauma-focused psychotherapy, beyond the effect of trauma load. In sum, our results support the assumption that stigmatization aggravates trauma-related psychopathology and impede symptom improvement. In post-conflict regions, community and family interventions which aim at reducing stigmatization and discrimination might therefore complement individual psychotherapy in order to allow survivors to recover and reintegrate into society.

[Membranous nephropathy in a Russian population]

AIM

To analyze the clinical and morphological manifestations of membranous nephropathy (MN) and to evaluate the efficiency of its therapy.

MATERIAL AND METHODS

MN cases in 2009 to 2016 were retrospectively detected with a subsequent analysis of patients with primary MN (PMN). The titer of IgG-autoantibodies to phospholipase A2 receptor (anti-PLA2R Ab) was determined by an indirect immunofluorescence assay. Treatment outcomes, such as the time course of changes in proteinuria, nephrotic syndrome (NS), and the development of complete and partial remissions (CR and PR), were assessed.

RESULTS

MN was detected in 201 cases; the secondary etiology of the disease was established in 24.9%. The prevalence of MN among morphologically confirmed glomerulopathies was 14%; that of PMN was 10.4%. The median period to diagnosis PMN was 8 (5; 19) months. 150 patients with PMN (66.7% were men; age was 50±15 years) were distributed according to the following morphological stages: Stages I (23.9%), II (48.5%), III (26.1%), and IV (1.5%). Elevated anti-PLA2R Ab levels were found in 51.6% of cases; NS in the presence of proteinuria was detected in 85.6% of patients. An estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 was seen in 25% of cases. Treatment outcomes were evaluated in 80 cases; the median follow-up period was 19 (8; 40) months. 68% of cases had CR (32%) or PR (36%) with a median follow-up of 26 (13; 44) months. Spontaneous CRs or PRs were observed in 7.5% of the patients. Multivariate analysis showed that the probability of CR or PR increased 3.2-fold in the use of cyclophosphamide and/or cyclosporine and decreased as eGFR dropped.

CONCLUSION

In Russia, PMN is a common type of glomerulopathy, the specific features of which should include the low rates of spontaneous remissions and detection of anti-PLA2R Abs. For renal protection, the majority of patients with PMN require timely diagnosis and treatment; individualization of the choice of treatment and its enhanced efficiency call for further investigations.

Primary diffuse large B-cell lymphoma of the CNS: a rare case of spontaneous remission

There is no consensus on the optimal therapy for primary CNS lymphoma. Conventional treatment modalities include chemotherapy and radiation therapy, which carry significant risks of morbidity and mortality. In systemic lymphomas, there are situations where non-Hodgkin lymphomas have resolved spontaneously. We now report the case of a nonimmunocompromised patient with primary CNS lymphoma who underwent a spontaneous remission with a durable response. This case suggests that not all patients with primary CNS lymphomas require aggressive treatment with chemotherapy and radiation therapy.

Spontaneous remission of acute lymphoblastic leukemia: A case report

Spontaneous remission (SR) in acute lymphoblastic leukemia (ALL) is a rare phenomenon, but the disease course and its underlying processes are of basic and clinical interest. Herein is reported the case of a pregnant, 31-year-old patient who developed ALL, followed by septic shock and SR of ALL. Information is summarized from earlier case reports and incidences of SR in ALL, to identify common patterns. Furthermore, the phenomenon of SR is compared with another disease variant of ALL, termed prodromal or preceding-ALL (pre-ALL). SR and the aleukemic phase in pre-ALL are associated with fever and/or sepsis and have similar kinetics and epidemiology. Therefore, pre-ALL not only closely resembles SR in ALL, but both conditions may represent a single disease entity. Production of pro-inflammatory cytokines and immune cell effects may induce temporary remission of ALL and the suppression of hematopoiesis. In contrast to SR in other types of cancer, all documented cases of SR in ALL were only transient. However, the disease can still be effectively treated with standard ALL therapies following relapse.

Clinicopathological analysis of methotrexate-associated lymphoproliferative disorders: Comparison of diffuse large B-cell lymphoma and classical Hodgkin lymphoma types

Patients with rheumatoid arthritis often develop methotrexate‐associated lymphoproliferative disorders (MTX‐LPD) during MTX treatment. MTX‐LPD occasionally regresses spontaneously after simply discontinuing MTX treatment. In patients without spontaneous regression, additional chemotherapy is required to avoid disease progression. However, the differences between spontaneous and non‐spontaneous regression have yet to be elucidated. To clarify the factors important for spontaneous regression, we analyzed the clinicopathological features of 51 patients with rheumatoid arthritis who developed MTX‐LPD (diffuse large B‐cell lymphoma [DLBCL]‐type [n = 34] and classical Hodgkin lymphoma [CHL]‐type [n = 17]). We examined the interval from MTX discontinuation to the administration of additional chemotherapy. The majority of DLBCL‐type MTX‐LPD patients (81%) exhibited remission with MTX discontinuation alone. In contrast, the majority of CHL‐type MTX‐LPD patients (76%) required additional chemotherapy. This difference was statistically significant (P = 0.001). However, overall survival was not significantly different between DLBCL‐type and CHL‐type (91% vs 94%, respectively; P > 0.05). Thus, the morphological differences in the pathological findings of MTX‐LPD may be a factor for spontaneous or non‐spontaneous regression after discontinuation of MTX.

Anti-phospholipase A2 receptor antibody levels at diagnosis predicts spontaneous remission of idiopathic membranous nephropathy

Background: The diagnostic role of circulating anti-phospholipase A2 receptor antibodies (anti-PLA2R Abs) is now well recognized in idiopathic membranous nephropathy (iMN). These Abs could also be interesting as predictors of clinical outcome. In this study, we explored the prognostic value of anti-PLA2R Abs measured in a cohort of iMN patients, with a special focus on their ability to detect patients achieving spontaneous remission.

Methods: All adult patients with biopsy-proven iMN diagnosed between 1978 and 2007 were retrospectively screened in our centre. Using a validated enzyme-linked immunosorbent assay, levels of anti-PLA2R Abs were measured from serum samples obtained at the time of renal biopsy and stored at −80°C until processing. Clinical data on disease activity, treatments and outcomes were collected by reviewing patients’ medical records. The association between anti-PLA2R Ab titres and clinical activity/outcome was assessed by Cox proportional hazard and Kaplan–Meier methods.

Results: In this retrospective study, 68 patients were included in the final analysis (median follow-up of 81 months). No significant association was found between anti-PLA2R Ab titres at diagnosis with baseline proteinuria, baseline estimated glomerular filtration rate or chronic kidney disease progression. Spontaneous remission was observed in 22% of patients. Ab titres were significantly and gradually correlated in a dose–response manner with the likelihood of spontaneous remission.

Conclusions: While Ab titres measured at diagnosis were not found to predict the activity of iMN, evaluation of anti-PLA2R Ab titres might prove useful in the early identification of patients likely to achieve spontaneous remission.

Intrascrotal and osseous sarcoidosis mimicking intrascrotal organ cancer and bony metastasis

We report a case of sarcoidosis with concomitant epididymis, testes, and phalanxes involvement mimicking intrascrotal organ cancer and metastatic bony disease. A 23-year-old man developed blurred vision and hyperemia of the left eye, and was diagnosed as having left iritis. A chest computed tomography scan detected bilateral hilar lymphadenopathy and lung nodular shadows. A transbronchial lung biopsy revealed a non-caseating granuloma and he was diagnosed with sarcoidosis. One year after the onset of his eye symptoms, he noticed enlargement of his right scrotum. Magnetic resonance imaging detected lesions of the right epididymis, bilateral testes, and bilateral phalanxes. A technetium-99m scintigram revealed a high accumulation in the bilateral bones of extremities. These radiological findings mimicked intrascrotal organ cancer and metastatic bony disease. Pathologic evaluation following the right epididymectomy revealed non-caseating granulomas compatible with sarcoidosis. Three and half years after the appearance of intrascrotal and bony lesions, they improved spontaneously. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 373-376).

Pathologically Proven Spontaneous Remission of IgG4-related Retroperitoneal Fibrosis

Some forms of idiopathic retroperitoneal fibrosis (RF) have recently been considered to be a part of the spectrum of immunoglobulin G4 (IgG4)-related disease. This case report is the first description of a spontaneous remission in a patient with pathologically proven IgG4-related RF. Although the pathogenesis and long-term disease behavior of IgG4-related RF remains unknown, we believe that an initial assessment consisting of only careful monitoring might be one important strategy, especially in asymptomatic IgG4-related RF patients without nephropathy, while carefully monitoring these patients for the risk of recurrence.

HBsAg spontaneous seroclearance in a cohort of HBeAg-seronegative patients with chronic hepatitis B virus infection

Loss of hepatitis B surface antigen (HBsAg) is considered to reflect the resolution of a hepatitis B virus (HBV) infection. Patient characteristics and various seromarkers were evaluated to characterize factors predicting spontaneous HBsAg loss in a cohort of HBeAg-seronegative patients with presumed chronic HBV infection. Relationships between seromarkers and HBsAg loss were assessed annually and after 6 years using binary logistic regression. Among the 634 participants, 117 (18.45%) cleared HBsAg after 6 years, with a 3.08% annual seroclearance rate. Baseline HBsAg levels and platelet (PLT) counts were predictors of HBsAg seroclearance. The HBsAg level predicted HBsAg seroclearance better than the PLT count (area under the receiver operating characteristic curve (AUROC): HBsAg, 0.965 (95%CI, 0.947-0.980) versus PLT count, 0.617 (95%CI, 0.561-0.669); P < 0.001). A cutoff HBsAg level of 10 IU/ml at baseline predicted spontaneous HBsAg seroclearance at 6 years with a diagnostic accuracy of 93.4%, a sensitivity of 87.2%, a specificity of 94.8%, a positive predictive value of 79.1%, and a negative predictive value of 97.0%. HBsAg seroclearance may occur more commonly than expected. A serum HBsAg level <10 IU/ml and PLT count were accurate predictors of clearance.