Clinical characteristics of IgG4-related retroperitoneal fibrosis versus idiopathic retroperitoneal fibrosis

Retroperitoneal fibrosis (RPF) is an uncommon condition characterized by inflammation and fibrosis in the retroperitoneal space. More than two-thirds of RPF are idiopathic, with the remaining stemed from a variety of secondary causes. It was suggested that IgG4-related RPF is a secondary form of RPF. We undertook this study to compare detailed demographic, clinical and laboratory characteristics of IgG4-related RPF and IRPF in a large Chinese cohort. We retrospectively reviewed the medical records of 132 RPF patients diagnosed at Peking University People’s Hospital between March 2010 and March 2018. Among the 132 patients, the mean age at disease onset was 54.8 years. IgG4-related RPF group showed greater male predominance compared to IRPF group. IgG4-related RPF patients showed a longer interval between symptom onset and diagnosis, and allergic diseases were more common in this group. Sixty-four patients (48.4%) had lower back pain, which was more common in IRPF group than that in IgG4-related RPF patients. In terms of organ involvement, although 42 of 47 patients (89.3%) with IgG4-related RPF had other organ involvement, there were no patients in the IRPF group with other organ involvement. In addition, the serum IgG4 level, elevated eosinophils counts and IgE level were significantly higher in IgG4-related RPF patients. We described the demographic, clinical and laboratory differences between IgG4-related RPF and IRPF patients, indicating their potential differences in pathogenesis, which was of great importance to diagnose and manage the two phenotypes.

Monitoring Disease Activity in Patients with Aortitis and Chronic Periaortitis Undergoing Immunosuppressive Therapy by Perfusion CT

RATIONALE AND OBJECTIVES

To evaluate the role of perfusion CT for monitoring inflammatory activity in patients with aortitis and chronic periaortitis undergoing immunosuppressive therapy.

MATERIALS AND METHODS

Seventeen symptomatic patients (median age 68.5 years) who underwent perfusion-based computed tomography (CT) monitoring after diagnostic contrast-enhanced CT were retrospectively included in this study. Blood flow (BF), blood volume (BV), volume transfer constant (k-trans), time to peak, and mean transit time were determined by setting circular regions of interest in prominently thickened parts of the vessel wall or perfused surrounding tissue at sites where the perfusion CT color maps showed a maximum BF value. Differences in CT perfusion and, morphological parameters, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were tested for significance during therapy.

RESULTS

In all patients BF and BV dropped at second perfusion CT (P < 0.05). In aortitis patients, CRP dropped from 3.86 ± 5.31 mg/dL to 0.9 ± 1.37 mg/dL and in periaortitis patients from 1.78 ± 2.25 mg/dL to 0.79 ± 1.55 mg/dL, whereas ESR dropped from 45.71 ± 37.59 seconds to 8.57 ± 3.1 seconds and 36.78 ± 34.67 seconds to 17.22 ± 21.82 seconds in aortitis and in periaortitis, respectively.

CONCLUSIONS

The course of perfusion CT parameters in aortitis and chronic periaortitis undergoing immunosuppressive therapy dropped at different extent after therapy.

Overlap of Post-obstructive Diuresis and Unmasked Diabetes Insipidus in a Case of IgG4-related Retroperitoneal Fibrosis and Tuberoinfundibular Hypophysitis: A Case Report and Review of the Literature

The clinical picture of IgG4-related disease (IgG4-RD) is diverse because various organs can be affected. We describe the case of a 56-year-old man with acute renal failure and tuberoinfundibular hypophysitis due to IgG4-RD. Steroid therapy lowered the serum IgG4 level and ameliorated renal dysfunction, bilateral hydronephrosis and retroperitoneal fibrosis. However, polyuria from post-obstructive diuresis and unmasked central diabetes insipidus ensued. The patient's polyuria continued despite the administration of a therapeutic dose of glucocorticoid; the patient's pituitary swelling and anterior pituitary dysfunction were partially ameliorated. The pituitary swelling recurred seven months later. In patients with IgG4-RD, the manifestation of polyuria after steroid therapy should prompt suspicion of post-obstructive diuresis and the unmasking of central diabetes insipidus.

Computed tomography parameters can be used as predictive markers for the improvement of renal function in patients with retroperitoneal fibrosis

OBJECTIVES

To discover the relationship between computed tomography (CT) parameters of retroperitoneal soft tissue of untreated retroperitoneal fibrosis patients and the variation of renal function after treatment.

METHODS

Data were collected retrospectively from 42 patients with established diagnosis of retroperitoneal fibrosis, at the Department of Rheumatology in Peking University First Hospital from May 2009 to April 2015. The demographic information, clinical characteristics, laboratory data, treatment and general therapeutic response were collected. The CT parameters such as radial lines, Hounsfield unit values, radiographic classification at baseline before the initiation of therapy were measured. Then the correlations between baseline CT parameters and clinical data were analysed.

RESULTS

The Hounsfield unit values of venous phase and delayed phase at baseline were negatively correlated with the change of estimated glomerular filtration rate (eGFR) at the 12th month after the initiation of medications. The baseline transverse diameters of the retroperitoneal soft tissue were larger in the group of eGFR <60 ml/min/1.73 m² compared with the group of eGFR ≥ 60 ml/min/1.73 m² at the 12th month, while the vertical diameters and maximum cross-section thickness were not. The baseline transverse diameters were also significantly correlated with the duration of intubation.

CONCLUSIONS

The baseline Hounsfield unit values and baseline transverse diameters of soft tissue of untreated retroperitoneal fibrosis patients may be used to predict the renal function after 12 months of therapy.

[Ormond's disease complicated by infectious endocarditis]

A case of retroperitoneal fibrosis (Ormond's disease) is reported. It is known to be usually diagnosed at the late stages of renal complications Urinary infection ended in infectious endocarditis caused by E. faecium showing multiple resistance to antibiotics. Moderate immunosuppressive and modern antibacterial (daptomycin) therapy ensured remission of both Ormond's diseases and endocarditis.

Retroperitoneal fibroses: aetiopathogenesis and taxonomic assessment

Retroperitoneal fibrosis (RPF) is a chronic retroperitoneal inflammatory process that can entrap the retroperitoneal structures, mainly the ureters and the great vessels. Aetiology, clinical features and diagnostic appearance in several cases are protean. A true idiopathic form is present in any cases of RPF in which no potential aetiologic condition may be identified. The pathogenesis of the idiopathic RPF appears today to be related to IgG4 autoimmune mechanisms ("hyper-IgG4 disease"). Otherwise, RPF in the presence of aortic atheromatous inflammation (atheromatous aortitis), has been included, more than twenty years ago, among the secondary forms, since this condition appears to be elicited by antigen-acting oxidized-LDL and/or ceroid, that are present within the atheromatous plaque. Aetiology of other secondary RPFs refers to medications (drug-induced), infections, traumas, malignancies. Recent advances in imaging techniques (TC, RM, 18F-FDG/PET or hybrid TC/PET), together with laboratory findings (CRP, ESR, IgG, IgG4, autoantibodies, etc), allow to identify the active phases of the inflammatory process. The review focuses on the pathogenetic features of RPFs and some issues concerning their taxonomic assessment.

Combined Prednisone and Mycophenolate Mofetil Treatment for Retroperitoneal Fibrosis

PURPOSE

We determined the efficacy of a combination of corticosteroids and mycophenolate mofetil for retroperitoneal fibrosis.

MATERIALS AND METHODS

We performed a prospective observational study of the treatment of 7 patients with biopsy proven retroperitoneal fibrosis. Patients were treated with 40 mg prednisone daily with a gradual taper over 6 months. Mycophenolate mofetil was administered at a starting dose of 1,000 mg twice daily and continued for 6 months following resolution of systemic symptoms and extubation of affected ureters. Outcomes included normalization of laboratory evidence of inflammation, regression of fibrosis by computerized tomography and the ability to discontinue ureteral stents.

RESULTS

Seven patients were treated with mycophenolate mofetil and prednisone. Five of the 7 patients had bilateral ureteral obstruction and 1 had unilateral obstruction requiring ureteral stents. Baseline and followup laboratory values were C-reactive protein 8.9 and 1.3 mg/dl (p=0.07), hemoglobin 10.7 and 12.7 gm/dl (p=0.001), erythrocyte sedimentation rate 76 and 14.5 mm per hour (p=0.015) and serum creatinine 3.32 and 1.08 mg/dl (p=0.07), respectively. Six of the 7 patients had a mean 32% regression of the retroperitoneal mass on computerized tomography. Ten of the 11 obstructed ureters were free of obstruction following ureteral stent removal. The mean time to stent removal was 10.5 months. One patient had a distal ureteral stricture and continued to require decompression. There were no treatment related side affects.

CONCLUSIONS

Mycophenolate mofetil combined with prednisone was safe and efficacious in this small cohort of patients with retroperitoneal fibrosis. Larger trials are needed to confirm these results.

[Retroperitoneal fibrosis]

Retroperitoneal fibrosis is a rare clinical entity characterised by the presence of patologic collagen tissue in a retroperitoneal space. The fibrous mass covers abdominal organs causing their disfunctions. RPF was described at the begining of XX century but its etiology is not clear yet. Usually it causes an ureter obstuction and hydronephrosis, that is why most commonly is diagnosed by urologists and nephrologists. However, retroperitoneal fibrosis can be multifacial disease. In some patients localisation of fibrosis is atypical and manifestationns can be varied. Gastrological symptoms like jaundice, bowel obstuction, ascites can occure. Besides, some early signs of RPF are nonspecific and can imitate alarming symptoms of neoplasma, e.g.: weight loss, anemia, malaise, anorexia, fever. This force us to initiate gastrological investigation. The awareness of this disease is important. The early diagnosis and treatment improves prognosis and alows to avoid heavy complications. In typical cases radiology is often enough for diagnosis. However, histological examination is needed in many cases, especialy when patological mass is located atypical. A treatment is made up of farmacology and surgery. The first one is based on steroids, immunossuppressant and tamoxifen. Surgery is needed to eliminate organs obstruction.

Autoimmune aspects of chronic periaortitis

Chronic periaortitis (CP) includes idiopathic retroperitoneal fibrosis, inflammatory abdominal aortic aneurysms and perianeurysmal retroperitoneal fibrosis. These entities are characterised by a fibro-inflammatory tissue which develops around the abdominal aorta and the iliac arteries, and spreads into the surrounding retroperitoneum to entrap adjacent structures such as the ureters. CP often affects patients with advanced atherosclerosis, and several lines of evidence support the view that it could result from a local inflammatory reaction to antigens in the atherosclerotic plaques of the abdominal aorta such as oxidised-low density lipoproteins and ceroid. However, because most CP patients also suffer from constitutional symptoms and show elevated acute-phase reactant levels, positive autoantibodies and, in some cases, autoimmune diseases affecting other organs, CP may also be considered a manifestation of a systemic autoimmune disease. CP is usually diagnosed using computed tomography or magnetic resonance imaging, but retroperitoneal biopsy may also be necessary; positron emission tomography is useful in assessing the full extent of the disease and the metabolic activity of the retroperitoneal tissue. Ureterolysis and aneurysm repair are frequently performed, but the inflammatory and chronic-relapsing nature of the disease often compels the use of medical therapy, which is based on steroids and immunosuppressants.

Autoimmune pancreatitis: proposal of IgG4-related sclerosing disease

Autoimmune pancreatitis (AIP) is a peculiar type of pancreatitis of presumed autoimmune etiology. Many new clinical aspects of AIP have been clarified during the past 10 years, and AIP has become a distinct entity recognized worldwide. However, its precise pathogenesis or pathophysiology remains unclear. As AIP dramatically responds to steroid therapy, accurate diagnosis of AIP is necessary to avoid unnecessary surgery. Characteristic dense lymphoplasmacytic infiltration and fibrosis in the pancreas may prove to be the gold standard for diagnosis of AIP. However, since it is difficult to obtain sufficient pancreatic tissue, AIP should be diagnosed currently based on the characteristic radiological findings (irregular narrowing of the main pancreatic duct and enlargement of the pancreas) in combination with serological findings (elevation of serum gamma-globulin, IgG, or IgG4, along with the presence of autoantibodies), clinical findings (elderly male preponderance, fluctuating obstructive jaundice without pain, occasional extrapancreatic lesions, and favorable response to steroid therapy), and histopathological findings (dense infiltration of IgG4-positive plasma cells and T lymphocytes with fibrosis and obliterative phlebitis in various organs). It is apparent that elevation of serum IgG4 levels and infiltration of abundant IgG4-positive plasma cells into various organs are rather specific to AIP patients. We propose a new clinicopathological entity, "IgG4-related sclerosing disease", and suggest that AIP is a pancreatic lesion reflecting this systemic disease.

A new clinicopathological entity of IgG4-related autoimmune disease

BACKGROUND

Autoimmune pancreatitis (AIP) is occasionally associated with other autoimmune diseases.

METHODS

To investigate the pathophysiology of AIP, we immunohistochemically examined the pancreas and other organs in eight patients with AIP, and in controls, using anti-CD4-T and CD8-T cell subsets, as well as IgG4 antibodies.

RESULTS

In AIP patients, severe or moderate infiltration of IgG4-positive plasma cells associated with CD4- or CD8-positive T lymphocytes was detected in the peripancreatic tissue (6/6), bile duct (8/8), gallbladder (8/8), portal area of the liver (3/3), gastric mucosa (5/7), colonic mucosa (2/2), salivary glands (1/2), lymph nodes (6/6), and bone marrow (2/2), as well as in the pancreas (8/8). There were few IgG4-positive plasma cells at the same sites in controls.

CONCLUSIONS

These results suggest that AIP is not simply pancreatitis but that it is a pancreatic lesion involved in IgG4-related systemic disease with extensive organ involvement. We propose a new clinicopathological entity, of a systemic IgG4-related autoimmune disease in which AIP and its associated diseases might be involved. Autoimmune pancreatitis (AIP) is occasionally associated with other autoimmune diseases.

Clinical and radiological evolution of a case of idiopathic retroperitoneal fibrosis treated with Tamoxifen

The authors report a case of retroperitoneal fibrosis conservatively treated with Tamoxifen. The computerized tomography (TC) control at ten months showed the persistence of a slight residual of peri-aortic fibrotic tissue. This result allowed removal of the double J catheter.

[Idiopathic retroperitoneal fibrosis: a clinical analysis of 7 cases]

OBJECTIVE

To investigate the clinical characteristics of idiopathic retroperitoneal fibrosis.

METHODS

The clinical manifestations, laboratory examination, and CT and MIR features of seven patients with idiopathic retroperitoneal fibrosis were analyzed.

RESULTS

(1) The initial symptoms were nonspecific and variable and included abdominal pain, low back pain, and weigh loss. Later symptoms, depending on the organs affected, included abdominal mass, ascites, urinary symptoms, and and intestinal obstruction. (2) Diagnosis of IRF could be based on elevated erythrocyte sedimentation rate and gamma globulin and positive findings by CT and MIR. For masses in retroperitoneal space and adhesion of abdominal organs, CT was more sensitive than B mode ultrasonography. However, for hydronephrosis and lesions in ureter, B mode ultrasonography was the first choice. (3) Steroid and immunosuppressant were effective during the early stage of IRF. In the advanced stage, operation was necessary.

CONCLUSION

Imaging examination is important for diagnosis of IRF. However, the final diagnosis depends on pathological examination. Treatment depends on the stage of disease. The prognosis is optimistic.

Idiopathic retroperitoneal fibrosis: prompt diagnosis preserves organ function

Prompt diagnosis of idiopathic retroperitoneal fibrosis improves chances of preserving renal function, preventing involvement of other organs, and relieving symptoms. Computed tomography or magnetic resonance imaging helps to exclude secondary causes, but open biopsy remains the gold standard for diagnosis. Management typically includes surgery (ureterolysis, stent placement), and drug treatment (corticosteroids), or a combination of both. However, no surgical or medical therapy has been tested in a randomized, controlled trial.

Retroperitoneal fibrosis with duodenal stenosis

Retroperitoneal fibrosis is a rare disease characterized by the formation of dense plaque of fibrous tissue covering the retroperitoneal structures. This disease is commonly presented as ureteral obstruction, but the involvement of duodenum is rare. We report a case of retroperitoneal fibrosis which was complicated with duodenal stenosis and was successfully treated with corticosteroids. A 58-yr-old man, who had history of aorto-iliac bypass graft due to arteriosclerosis obliterans with infrarenal aortic occlusion was admitted to the hospital with abdominal pain and a mass. Abdominal CT scan revealed the periaortic soft tissue mass encircling grafted aorta and stenosis of duodenal third portion. Retroperitoneal fibrosis with duodenal stenosis was diagnosed and prednisolone therapy was initiated. Follow-up CT scan showed that the patient responded to prednisolone therapy with eased pain, shrinking periaortic mass, and reduced duodenal stenosis.

[Clinical thinking and decision making in practice. A patient with flank pain and anuria]

A 49-year-old man was admitted because of acute anuria. He had bilateral loin pain and was said to have been suffering from renal calculi seven years earlier. He used diclofenac as a pain killer. The renal pyela were mildly dilated. Eventually it became clear that the patient suffered from retroperitoneal fibrosis. This case illustrates (a) ureteral patency does not ensure actual urine flow; (b) non-steroidal anti-inflammatory drugs (NSAIDs) are a frequent cause of renal function loss, but only if there is an additional renal disease causing increased renal prostaglandin synthesis; (c) pattern recognition and verification are clinically relevant diagnostic tools.

[67Ga scintigraphy in retroperitoneal fibrosis (RPF): indications, application and clinical relevance--report of five patients]

AIM

The aim of the study was to evaluate the indication for 67Ga-citrate imaging and its clinical impact on patients with retroperitoneal fibrosis (RPF).

METHOD

The scanning with ventral and dorsal projections was done 48 an 72 h after i.v.-injection of 370 Mbq 67Ga-citrate.

RESULTS

In the 5 patients with idiopathic RPF included in the study, there was a remarkably high correlation between the clinical symptoms, the surgical and histologic findings, the activity of the disease and the results of 67Ga-scintigraphy.

CONCLUSION

While CT and--maybe even better--MRI might perfectly show the extension, shape and contour of the fibrotic tissue, Gallium-67 scan appears to be superior in assessing the intensity and activity of the disease process.

Magnetic resonance imaging in idiopathic retroperitoneal fibrosis: measurement of T1 relaxation time

Magnetic resonance imaging at 0.08 Tesla was performed in nine patients with proven idiopathic retroperitoneal fibrosis. A total of 11 scans was performed. Three patients were scanned before diagnosis; one of these also had two follow-up scans. A further six patients were scanned a variable time after diagnosis and treatment. On each scan, a periaortic soft-tissue mass was readily identified, the distribution corresponding to that seen on computed tomography. There was no difference in the mean T1 relaxation time of the mass between patients scanned before diagnosis and those scanned after treatment. However, the patient followed with serial scans showed a progressive reduction in the T1 value of the mass with time. Comparison with results obtained in patients with lymphoma suggests that the T1 values in retroperitoneal fibrosis are lower than in lymphoma, particularly non-Hodgkin's lymphoma.

Lymphoid hypophysitis in a patient with lymphoid thyroiditis, lymphoid adrenalitis, and idiopathic retroperitoneal fibrosis

We describe the autopsy findings in a 24-year-old woman with a clinical picture of pituitary and adrenal insufficiency which had its onset shortly after a normal pregnancy and delivery of a normal infant, two years before the mother's death. There were heavy lymphocytic infiltrations of the adenohypophysis, thyroid, and adrenals as well as diffuse retroperitoneal fibrosis with numerous perivascular lymphocytic infiltrates. It is concluded that lymphoid hypophysitis probably represents the hypophyseal counterpart of other endocrine autoimmune disorders and that immune mechanisms may also play a role in the pathogenesis of the so-called idiopathic retroperitoneal fibrosis.

Retroperitoneal fibrosis. A follow-up study

13 patients with retroperitoneal fibrosis (RPF) were reviewed. 10 patients had idiopathic disease and in 3 patients the disease was secondary to temporal arteritis, aortic aneurysm and ergotamine ingestion. Ureterolysis was performed in all patients. 4 patients were reoperated due to problems arising from RPF progression. A total of 24 ureters were lysed. 23 of these functioned in the early postoperative period. 22 ureters were available for follow-up 4 months to 20 years later. 19 kidneys had a free outflow, 2 kidneys were removed and 1 left in situ without function. A review is presented on the etiology, pathogenesis and treatment of this disease. Percutaneous nephrostomy is recommended when the patient presents with severely elevated plasma creatinine, pyonephrosis or urosepsis.

Positive Ga-67 citrate scan in retroperitoneal fibrosis

A patient with retroperitoneal fibrosis was evaluated by Ga-67 citrate imaging. The radionuclide study accurately demonstrated the location and extent of the disease.

[Reaction of synovial membranes in knee joint with primary extra-articular systemic diseases (author's transl)]

Postmortal histologic examinations of the synovial membrane of both knee joints were conducted in 85 selected cases. The following conditions were given priority: diabetes mellitus, advanced renal insufficiency, liver cirrhosis with ascites, chronic insufficiency of the right heart, vericose syndrome of the lower extremities, tumours compressing organs of the pelvis minor as well as a few rare infectious and tumerous diseases. Comparison of the histomorphologic findings revealed consistancies such as pronounced ultravillous branching of the synovial membrane with villous hyalinosis in diabetes mellitus, increased, coarse villi formation in renal insufficiency and liver cirrhosis, edema of the synovial membrane in chronic insufficiency of the right heart and renal insufficiency as well as a number of nonspecific reactions of the synovial membrane in obstruction of venous drainage. In the context of generalized fibrotic processes such as in Ormond's disease and scleroderma, similar reactions of the synovial membrane are pronounced. Arthralgic complaints and secondary arthroses in those systemic diseases not primarily involving joints can be at least partially clarified by histomorphologic findings.