1
|
Skopec Z, Alsawas M, Maxwell T, Pelletier D, Brown-Joel Z, Bellizzi A, Liu V. Assessment of specificity of dermatopathologic criteria for IgG4-related skin disease. J Cutan Pathol 2024; 51:163-169. [PMID: 37853944 DOI: 10.1111/cup.14548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 08/16/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) represents a recently characterized multisystemic fibroinflammatory condition that can manifest a spectrum of skin findings (IgG4-related skin disease; IgG4-RSD). Histopathologic and immunohistochemical criteria have been proposed; however, the specificity of these criteria merits scrutiny given the potential histopathologic overlap of IgG4-RSD and both neoplastic and inflammatory skin conditions featuring lymphoplasmacytic infiltrates (IgG4-RSD mimics). This study sought to assess the specificity of the criteria by quantifying the frequency by which an expanded spectrum of IgG4-RSD mimics meet proposed thresholds. METHODS Following IRB approval, a total of 69 cases of IgG4-RD mimics, representing 14 different diagnoses featuring plasma cells, were reviewed and analyzed for the following histopathologic and immunohistochemical features: (i) maximum IgG4+ count/high-powered field (hpf) >200; (ii) IgG4/IgG ratio >0.4 averaged over 3 hpfs; (iii) IgG4+ count >10 per hpf. RESULTS Screening for IgG4-RSD by histopathologic criteria demonstrated the high frequency of lymphoplasmacytic infiltrates, contrasted with the rarity of storiform fibrosis (only one case of erythema elevatum diutinum [EED]) and obliterative phlebitis (0 cases). By immunohistochemical criteria, the analysis revealed that no cases exceeded 200 IgG4+ cells; 13% (9/69) cases demonstrated an IgG4/IgG ratio of >0.4 averaged over 3 hpfs; and 23% (16/69) cases demonstrated a mean IgG4+ count of >10 per hpf. CONCLUSION Application of proposed IgG4-RSD histopathologic criteria to an expanded spectrum of potential IgG4-RSD mimics (to include cutaneous marginal zone lymphoma, syphilis, necrobiosis lipoidica, lichen sclerosus, ALHE, psoriasis, lymphoplasmacytic plaque, EED, and erosive pustular dermatosis), highlights the relative nonspecificity of lymphoplasmacytic infiltrates contrasted with the stringency of storiform fibrosis and obliterative fibrosis. Furthermore, an IgG4+ cell count of >10 per hpf and an IgG4/IgG ratio of >0.4 are not specific to IgG4-RSD alone. In the appropriate clinical context for IgG4-RSD, histopathologic features still represent the entry threshold for diagnosis consideration, which then allows for further screening by immunohistochemical criteria.
Collapse
Affiliation(s)
- Zachary Skopec
- Department of Dermatology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mouaz Alsawas
- Department of Pathology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Timothy Maxwell
- Department of Dermatology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Daniel Pelletier
- Department of Pathology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Zoe Brown-Joel
- Department of Dermatology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Andrew Bellizzi
- Department of Pathology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Vincent Liu
- Department of Dermatology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Department of Pathology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| |
Collapse
|
2
|
Wang G, Tu P, Su J, Wu W, Zhang C, Wang W, Li W. An 8-year follow-up of IgG4-related skin disease presented with generalized ALHE-like eruptions: successful treatment of glucocorticoid and cyclophosphamide. J DERMATOL TREAT 2023; 34:2279899. [PMID: 38010938 DOI: 10.1080/09546634.2023.2279899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023]
Abstract
Immunoglobulin gamma (IgG) type 4-related disease (IgG4-RD) is a chronic immunologic systemic disorder that could affect multiple organs, which may cause irreversible organ damage or even death. Skin involvement is rare and associated especially with systemic disease. The dermatologist must be equipped to recognize IgG4-RD to prevent delayed identification and treatment. This case reports a very rare case of IgG4-related skin disease (IgG4-RSD) presenting with a generalized angiolymphoid hyperplasia with eosinophilia (ALHE)-like lesions in a middle-aged male patient with no other organ involvement. He was treated with oral glucocorticoid and cyclophosphamide, which resulted in complete remission. No relapse and disease progression were seen with a follow-up for 8 years.
Collapse
Affiliation(s)
- Guanyu Wang
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| | - Ping Tu
- Department of Dermatology, Peking University First Hospital, Beijing, China
| | - Jing Su
- Department of Pathology, Peking University Third Hospital, Beijing, China
| | - Wenting Wu
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| | - Chunlei Zhang
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| | - Wenhui Wang
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| | - Weiwei Li
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
3
|
Smith L, Yesudian PD, Murugusundaram S, Krishnakumar S, Yesudian P. IgG4-related skin disease responsive to thalidomide. Clin Exp Dermatol 2023; 48:290-292. [PMID: 36763743 DOI: 10.1093/ced/llac073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/27/2022] [Accepted: 11/11/2022] [Indexed: 01/22/2023]
Abstract
IgG4-related skin disease is a rare, immune-mediated disorder characterized by tissue infiltration with IgG4+ plasma cells, along with elevated serum IgG4. We describe a patient treated successfully with thalidomide.
Collapse
Affiliation(s)
- Lucy Smith
- Department of Dermatology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Wrexham, UK
| | - Paul Devakar Yesudian
- Department of Dermatology, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Wrexham, UK
| | | | | | | |
Collapse
|
4
|
Characteristics and prognosis of IgG4-related skin disease: A case report and systematic literature review. Autoimmun Rev 2021; 20:102805. [PMID: 33727155 DOI: 10.1016/j.autrev.2021.102805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022]
|
5
|
Abstract
Immunoglobulin-G4-related disease (IgG4-RD) is an autoimmune-mediated spectrum of diseases, characterized by infiltration of IgG4+ plasma cells into one or multiple organs, with the pancreas being the most commonly affected organ. The disease mostly affects middle-aged to elderly men. Diagnosis requires an integration of clinical, radiologic, pathologic, and serologic studies. Histologically, there is an increased infiltration of IgG4+ plasma cells, elevated ratio of IgG4+/IgG plasma cells of more than 40%, and a storiform pattern of fibrosis. There may be eosinophilia, along with elevated IgG4 levels. IgG4-RD can mimic several diseases and should be differentiated from inflammatory and neoplastic processes. Recently, there has been increased awareness of cutaneous involvement by IgG4-RD either as an isolated lesion or primary involvement or as a secondary involvement from a systemic disease. Clinically, cutaneous IgG4+-related disease presents as papules, plaques, and nodules involving the head and neck areas. We have provided a systematic review of the literature of this new and challenging entity of cutaneous IgG4-RD.
Collapse
|
6
|
Upregulated interleukins (IL-6, IL-10, and IL-13) in immunoglobulin G4-related aortic aneurysm patients. J Vasc Surg 2018; 67:1248-1262. [DOI: 10.1016/j.jvs.2016.12.140] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/16/2016] [Indexed: 12/18/2022]
|
7
|
Liu T, Guo F, Zhu X, He X, Xie L. Thalidomide and its analogues: A review of the potential for immunomodulation of fibrosis diseases and opthalmopathy. Exp Ther Med 2017; 14:5251-5257. [PMID: 29285050 DOI: 10.3892/etm.2017.5209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/14/2017] [Indexed: 12/11/2022] Open
Abstract
The US Food and Drug Administration approved thalidomide and its analogues for the treatment of erythema nodosum leprosum, in spite of the notoriety of reports of severe birth defects in the middle of the last century. As immunomodulatory drugs, thalidomide and its analogues have been used to effectively treat various diseases. In the present review, preclinical data about the effects of thalidomide and its analogues on the immune system are integrated, including the effects of cytokines on transdifferentiation, the anti-inflammatory effect, immune cell function regulation and angiogenesis. The present review also investigates the latest developments of thalidomide as a therapeutic option for the treatment of idiopathic pulmonary fibrosis, skin fibrosis, and ophthalmopathies.
Collapse
Affiliation(s)
- Ting Liu
- Department of Ophthalmology, Daping Hospital and Research Institute of Surgery, The Third Military Medical University, People's Liberation Army, Chongqing 400042, P.R. China
| | - Feng Guo
- Department of Ophthalmology, Daping Hospital and Research Institute of Surgery, The Third Military Medical University, People's Liberation Army, Chongqing 400042, P.R. China
| | - Xiaomin Zhu
- Department of Ophthalmology, Daping Hospital and Research Institute of Surgery, The Third Military Medical University, People's Liberation Army, Chongqing 400042, P.R. China
| | - Xiangge He
- Department of Ophthalmology, Daping Hospital and Research Institute of Surgery, The Third Military Medical University, People's Liberation Army, Chongqing 400042, P.R. China
| | - Lin Xie
- Department of Ophthalmology, Daping Hospital and Research Institute of Surgery, The Third Military Medical University, People's Liberation Army, Chongqing 400042, P.R. China
| |
Collapse
|
8
|
Bennett AE, Fenske NA, Rodriguez-Waitkus P, Messina JL. IgG4-related skin disease may have distinct systemic manifestations: a systematic review. Int J Dermatol 2017; 55:1184-1195. [PMID: 27419384 DOI: 10.1111/ijd.13369] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/20/2016] [Accepted: 04/15/2016] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is an increasingly prevalent protean multisystem disorder characterized by single or multi-organ infiltration of IgG4-bearing plasma cells. Skin involvement has been recognized and is relevant to proper diagnosis. A systematic literature review of 50 cases involving the skin reveals that patients with IgG4-related skin disease show predominant involvement of the head and neck and have a distinct pattern of systemic involvement, also favoring the head and neck - lymphatics, orbit, salivary, and lacrimal glands - but generally lacking pancreaticobiliary involvement (16% of cases), which by contrast is a predominant manifestation in systemic IgG4-RD (60% with pancreaticobiliary involvement). We summarize clinical and pathologic descriptive data from this systematic review. We review differential diagnosis and propose a diagnostic scheme for stratifying probability of disease based upon comprehensive integration of clinical, histopathologic, and laboratory data. Plasmacyte infiltration and storiform fibrosis are prominent in IgG4-related skin disease, but obliterative venulitis is less common than in the prototypical IgG4-related disease manifestation of autoimmune pancreatitis. IgG4 tissue and serum values, with a mean (±95% CI) in the reviewed cases of 132.8 ± 32.6 IgG4-positive plasma cells per high-power field and 580 ± 183.8 mg/dl, respectively, are incorporated into the suggested criteria. The distinct set of manifestations identified by this systematic review and the proposed diagnostic considerations, while requiring further validation in prospective studies, highlight the need to consider that IgG4-related skin disease defines a unique systemic disease complex along the spectrum of IgG4-RD.
Collapse
Affiliation(s)
- Adam E Bennett
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Neil A Fenske
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paul Rodriguez-Waitkus
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Pathology and Cell Biology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jane L Messina
- Department of Dermatology and Cutaneous Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Pathology and Cell Biology, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| |
Collapse
|
9
|
|
10
|
Charrow A, Imadojemu S, Stephen S, Ogunleye T, Takeshita J, Lipoff JB. Cutaneous manifestations of IgG4-related disease (RD): A systematic review. J Am Acad Dermatol 2016; 75:197-202. [DOI: 10.1016/j.jaad.2016.01.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/18/2016] [Accepted: 01/20/2016] [Indexed: 02/07/2023]
|
11
|
Romero-Pérez D, Blanes Martínez M, Encabo-Durán B. Cutaneous Pseudolymphomas. ACTAS DERMO-SIFILIOGRAFICAS 2016; 107:640-51. [PMID: 27289134 DOI: 10.1016/j.ad.2016.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/16/2016] [Accepted: 05/01/2016] [Indexed: 11/19/2022] Open
Abstract
The term cutaneous pseudolymphoma refers to benign reactive lymphoid proliferations in the skin that simulate cutaneous lymphomas. It is a purely descriptive term that encompasses various reactive conditions with a varied etiology, pathogenesis, clinical presentation, histology, and behavior. We present a review of the different types of cutaneous pseudolymphoma. To reach a correct diagnosis, it is necessary to contrast clinical, histologic, immunophenotypic, and molecular findings. Even with these data, in some cases only the clinical course will confirm the diagnosis, making follow-up essential.
Collapse
Affiliation(s)
- D Romero-Pérez
- Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, España
| | - M Blanes Martínez
- Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, España.
| | - B Encabo-Durán
- Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, España
| |
Collapse
|
12
|
Ingen-Housz-Oro S, Ortonne N. [Surface membrane markers (clusters of differentiation) used in dermatopathology (2): Inflammatory infiltrates]. Ann Dermatol Venereol 2016; 143:311-7. [PMID: 26988384 DOI: 10.1016/j.annder.2016.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/05/2016] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
Affiliation(s)
- S Ingen-Housz-Oro
- Service de dermatologie, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France.
| | - N Ortonne
- Département de pathologie, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| |
Collapse
|
13
|
Bhabha FK, Turner JJ, Bleasel K, Sladden MJ. Immunoglobulin Type Gamma 4-Related Disease Presenting with Cutaneous Plaques. Australas J Dermatol 2016; 57:74. [DOI: 10.1111/ajd.12240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Friyana Keiku Bhabha
- Department of Dermatology; Peter MacCallum Hospital; Melbourne Victoria Australia
| | - Jennifer J Turner
- Department of Medicine; Australian School of Advanced Medicine; Macquarie University; Sydney New South Wales Australia
| | - Karl Bleasel
- Hampden Road Specialist Centre; Hobart Tasmania Australia
| | - Michael J Sladden
- Department of Dermatology; University of Tasmania; Launceston Tasmania Australia
| |
Collapse
|
14
|
Kottler D, Barète S, Quéreux G, Ingen-Housz-Oro S, Fraitag S, Ortonne N, Deschamps L, Rybojad M, Flageul B, Crickx B, Janin A, Bagot M, Battistella M. Retrospective Multicentric Study of 25 Kimura Disease Patients: Emphasis on Therapeutics and Shared Features with Cutaneous IgG4-Related Disease. Dermatology 2015; 231:367-77. [DOI: 10.1159/000439346] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/11/2015] [Indexed: 11/19/2022] Open
|
15
|
Mitteldorf C, Palmedo G, Kutzner H, Kauer F, Prestin M, Schuster C, Hübscher E, Kirsch A, Tronnier M, Kempf W. Diagnostic approach in lymphoplasmacytic plaque. J Eur Acad Dermatol Venereol 2015; 29:2206-15. [PMID: 26370335 DOI: 10.1111/jdv.13213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lymphoplasmacytic plaque (LPP) is a recently described rare skin disease characterized by a dense dermal lymphohistiocytic infiltrate with polyclonal plasma cells. The clinical picture is distinct with reddish to brownish plaque with a predilection for the lower leg. LPP typically affects children. OBJECTIVE To define clinical and histologic criteria of LPP and to develop a diagnostic flow chart. METHODS We investigated six of our own LPP cases. Immunoglobulin light chains, IgG, IgG4, CD31, CD163 as a histiocytic marker were examined by immunohistochemistry. PCR-based molecular studies were conducted for borrelia sp., mycobacterial and leishmania sp. Moreover, 10 cases, which have been reported in the literature, were checked for the same features. RESULTS We could differentiate three main histological patterns (superficial band-like only, [deep] dermal only and mixed). Acanthosis and interface dermatitis are key features in cases with a superficial band-like or mixed infiltrate. Granulomas and giant cells could be only found in about 30% of the cases. The number of plasma cells was variable accounting for 5-40% of the infiltrate. The number of blood vessels was increased in the majority of the cases. 'Free-floating' collagen bundles surrounded by histiocytes (pseudorosettes) were identified as a new histological feature. An infectious agent could be excluded in all cases. CONCLUSIONS LPP is a long-standing skin disease, which may also occur in adults and in other body regions than the lower leg. Reproducible clinical and histological criteria allow delineating a diagnostic work-up for LPP.
Collapse
Affiliation(s)
- C Mitteldorf
- Department of Dermatology, HELIOS Klinikum Hildesheim GmbH, Hildesheim, Germany
| | - G Palmedo
- Dermatopathologie Friedrichshafen Bodensee, Bodensee, Germany
| | - H Kutzner
- Dermatopathologie Friedrichshafen Bodensee, Bodensee, Germany
| | - F Kauer
- Medizinisches Versorgungs-Zentrum Charlottenburg, Berlin, Germany
| | - M Prestin
- Hautzentrum Dr. Martin Kägi, MD, Zürich, Switzerland
| | - C Schuster
- Dermatology Practice, St. Gallen, Switzerland
| | | | - A Kirsch
- Dermatology Unit, Kantonsspital Lucerne, Lucerne, Switzerland
| | - M Tronnier
- Department of Dermatology, HELIOS Klinikum Hildesheim GmbH, Hildesheim, Germany
| | - W Kempf
- Kempf und Pfaltz, Research Unit, Histologische Diagnostik, Zürich, Switzerland
| |
Collapse
|
16
|
Ingen-Housz-Oro S, Ortonne N. [Surface membrane markers (clusters of differentiation) used in dermatopathology (1): The lymphocyte markers]. Ann Dermatol Venereol 2015; 142:598-606. [PMID: 26169897 DOI: 10.1016/j.annder.2015.04.167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 04/07/2015] [Accepted: 04/24/2015] [Indexed: 12/22/2022]
Affiliation(s)
- S Ingen-Housz-Oro
- Service de dermatologie, hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de Lattre-de-Tassigny, 94010 Créteil, France.
| | - N Ortonne
- Département de pathologie, hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| |
Collapse
|
17
|
Islam AD, Selmi C, Datta-Mitra A, Sonu R, Chen M, Gershwin ME, Raychaudhuri SP. The changing faces of IgG4-related disease: Clinical manifestations and pathogenesis. Autoimmun Rev 2015; 14:914-22. [PMID: 26112170 DOI: 10.1016/j.autrev.2015.06.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 02/08/2023]
Abstract
Since the earliest reports in 2001, immunoglobulin G4 (IgG4)-related disease has been defined as an autoimmune systemic disease characterized by the lymphoplasmacytic infiltration of affected tissues leading to fibrosis and obliterative phlebitis along with elevated serum IgG4 levels. Prior to this unifying hypothesis, a plethora of clinical manifestations were considered as separate entities despite the similar laboratory profile. The pathology can be observed in virtually all organs and may thus be a challenging diagnosis, especially when the adequate clinical suspicion is not present or when obtaining a tissue biopsy is not feasible. Nonetheless, the most frequently involved organs are the pancreas and exocrine glands but these may be spared. Immunosuppressants lead to a prompt clinical response in virtually all cases and prevent histological sequelae and, as a consequence, an early differential diagnosis from other conditions, particularly infections and cancer, as well as an early treatment should be pursued. We describe herein two cases in which atypical disease manifestations were observed, i.e., one with recurrent neck lymph node enlargement and proptosis, and one with jaundice. Our understanding of the pathogenesis of IgG4-related disease is largely incomplete but data support a significant role for Th2 cytokines with the contribution of innate immunity factors such as Toll-like receptors, macrophages and basophils. Further, macrophages activated by IL4 overexpress B cell activating factors and contribute to chronic inflammation and the development of fibrosis. We cannot rule out the possibility that the largely variable disease phenotypes reflect different pathogenetic mechanisms and the tissue microenvironment may then contribute to the organ involvement.
Collapse
Affiliation(s)
- Arshia Duza Islam
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA; VA Medical Center Sacramento, Mather, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy; BIOMETRA Department, University of Milan, Italy
| | | | - Rebecca Sonu
- Department of Pathology and Laboratory Medicine, University of California Davis, School of Medicine, Davis, CA, USA
| | - Mingyi Chen
- Department of Pathology and Laboratory Medicine, University of California Davis, School of Medicine, Davis, CA, USA
| | - M Eric Gershwin
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - Siba P Raychaudhuri
- Department of Internal Medicine, Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA; VA Medical Center Sacramento, Mather, CA, USA.
| |
Collapse
|
18
|
Dermatologic disorders in 118 patients with autoimmune (immunoglobulin G4-related) pancreatitis: a retrospective cohort analysis. Am J Clin Dermatol 2015; 16:125-30. [PMID: 25575835 DOI: 10.1007/s40257-014-0109-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autoimmune pancreatitis is the prototypical manifestation of immunoglobulin G4-related disease, a fibroinflammatory syndrome that can affect virtually any organ. Rarely, skin involvement has been reported in immunoglobulin G4-related disease. Isolated case reports have described other distinct associated dermatoses. OBJECTIVE Our objective was to determine the frequency and nature of dermatologic manifestations of immunoglobulin G4-related disease in patients with autoimmune pancreatitis. METHODS Retrospective analysis of dermatologic conditions of patients with autoimmune pancreatitis. RESULTS Among the 118 identified patients, 31 (26.3%) had a dermatologic diagnosis [mean (standard deviation; SD) follow-up 5.9 (4.6) years]. Two patients (1.7%) had necrobiotic xanthogranuloma; three (2.5%) had another xanthomatous or xanthogranulomatous process. One patient (0.8%) had pemphigus erythematosus. No patient had immunoglobulin G4-related skin disease. CONCLUSION Skin involvement in immunoglobulin G4-related disease appears to be rare. A disproportionately high number of patients had xanthomatous or xanthogranulomatous processes, including necrobiotic xanthogranuloma. It remains unclear whether the association between immunoglobulin G4-related disease and necrobiotic xanthogranuloma or other xantho(granulo)matous processes represents shared pathophysiology, a mutual underlying driver, or coincidence, though the results of this study cast doubt on the latter. Although pemphigus was not reported in immunoglobulin G4-related disease previously, the prominent role of the immunoglobulin G4 subclass in each condition makes this association intriguing.
Collapse
|
19
|
Lowe GC, Bogner RR, el-Azhary RA, Gonzalez-Santiago TM, Kindle SA, Lehman JS, Gibson LE. Cutaneous manifestations of immunoglobulin G4-related disease: what dermatologists need to know. Int J Dermatol 2015; 54:377-82. [DOI: 10.1111/ijd.12953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | - Julia S. Lehman
- Department of Dermatology; Mayo Clinic; Rochester MN USA
- Division of Anatomic Pathology; Mayo Clinic; Rochester MN USA
| | - Lawrence E. Gibson
- Department of Dermatology; Mayo Clinic; Rochester MN USA
- Division of Anatomic Pathology; Mayo Clinic; Rochester MN USA
| |
Collapse
|
20
|
Tokura Y, Yagi H, Yanaguchi H, Majima Y, Kasuya A, Ito T, Maekawa M, Hashizume H. IgG4‐related skin disease. Br J Dermatol 2014; 171:959-67. [DOI: 10.1111/bjd.13296] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Y. Tokura
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - H. Yagi
- Section of Dermatology Shizuoka General Hospital 4‐27‐1 Kita‐Andou Aoi‐ku Shizuoka 420‐8527 Japan
| | - H. Yanaguchi
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - Y. Majima
- Section of Dermatology Shizuoka General Hospital 4‐27‐1 Kita‐Andou Aoi‐ku Shizuoka 420‐8527 Japan
| | - A. Kasuya
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - T. Ito
- Department of Dermatology Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - M. Maekawa
- Laboratory Medicine Hamamatsu University School of Medicine 1‐20‐1 Handayama Higashi‐ku Hamamatsu 431‐3192 Japan
| | - H. Hashizume
- Section of Dermatology Shimada Municipal Hospital 1200‐5 Noda Shimada 427‐8502 Japan
| |
Collapse
|
21
|
Infiltration cutanée : une grande galère après 4 biopsies…. Rev Med Interne 2014; 35:686-9. [DOI: 10.1016/j.revmed.2014.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 05/13/2014] [Indexed: 02/07/2023]
|
22
|
Kempeneers D, Hauben E, De Haes P. IgG4-related skin lesions: case report and review of the literature. Clin Exp Dermatol 2014; 39:479-83. [PMID: 24758575 DOI: 10.1111/ced.12325] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a systemic disease, mostly affecting the pancreas. It presents as accumulation of IgG4-producing plasma cells in various tissues. Other possible affected organs include the lacrimal glands, salivary glands, lungs, kidneys, liver, bile duct, retroperitoneum, breast, aorta, pituitary gland and prostate. A cutaneous presentation has also been described in the literature, and might be the initial presenting feature of IgG4-RD. We describe a 73-year-old white man who presented with two infiltrated, erythematous nodules on his abdomen. The histopathological characteristics were highly suggestive of IgG4-related cutaneous disease. Immunohistochemical stains were positive for IgG4. In the past, the patient's other organs had also been affected by IgG4-RD. Cutaneous presentation of IgG4-RD has been described previously in the literature but only in Asian patients (both East and South Asian). We also provide an overview of previously reported cutaneous manifestations of IgG4-RD.
Collapse
Affiliation(s)
- D Kempeneers
- Department of Dermatology, UZ Leuven, Leuven, Belgium
| | | | | |
Collapse
|
23
|
Lehman JS, Smyrk TC, Pittelkow MR. Increased immunoglobulin (Ig) G4-positive plasma cell density and IgG4/IgG ratio are not specific for IgG4-related disease in the skin. Am J Clin Pathol 2014; 141:234-8. [PMID: 24436271 DOI: 10.1309/ajcptmwtcn04gsjh] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES Immunoglobulin (Ig) G4-related disease (IgG4-RD), a fibroinflammatory condition that can affect multiple organs, is suggested by lymphoplasmacytic inflammation, fibrosis, phlebitis, and increased IgG4+ plasma cell (PC) tissue density. In patients with suspected IgG4-RD and skin changes, skin biopsy may serve as a diagnostic screen or to supplement nondiagnostic visceral biopsy specimens. We aimed to determine whether increased cutaneous IgG4+ PCs or IgG4/IgG ratio is specific for IgG4-RD. METHODS We examined 50 mucocutaneous specimens representing seven PC-rich dermatoses and reactive PC-rich infiltrates with IgG and IgG4 immunohistochemical stains. RESULTS IgG4+ density exceeded 10 cells per high-power field in 22 (44%) of 50 specimens, representing six of seven diagnoses and reactive infiltrates. In five specimens (10%), the IgG4/IgG ratio exceeded 0.40. CONCLUSIONS Moderately elevated IgG4+ PC density or IgG4/IgG ratio is a nonspecific finding in the skin. In cutaneous biopsy specimens showing increased IgG4+ PCs, careful consideration should be given to clinical, serologic, and other histopathologic features before attributing clinical changes to IgG4-RD.
Collapse
Affiliation(s)
- Julia S. Lehman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
- Department of Dermatology, Mayo Clinic, Rochester, MN
| | - Thomas C. Smyrk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
24
|
Primary cutaneous marginal zone lymphomas with plasmacytic differentiation show frequent IgG4 expression. Mod Pathol 2013; 26:1568-76. [PMID: 23765244 DOI: 10.1038/modpathol.2013.106] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 05/03/2013] [Accepted: 05/03/2013] [Indexed: 12/24/2022]
Abstract
The expression of IgG4 in malignant B-cell lymphomas has only partially been studied. Recent reports described single cases of marginal zone lymphomas arising in the ocular adnexae that express IgG4. Moreover, a subset of dura-associated marginal zone lymphomas appear to express IgG4 as well. We investigated IgG4 expression in a more systematic manner in a large cohort of marginal zone lymphoma specimens derived from the archive of our institute. Overall, we examined 169 marginal zone lymphomas of various primary sites that displayed a distinct plasmacytic differentiation and light chain restriction, allowing for a detailed investigation of the immunoglobulin heavy chain expression in these tumors by immunohistochemistry. Unexpectedly, primary cutaneous marginal zone lymphomas showed frequent IgG4 expression. Although only 1 out of 120 noncutaneous marginal zone lymphomas, located in the ocular adnexae, expressed IgG4, 19 of 49 (39%) primary cutaneous marginal zone lymphomas showed this feature, constituting the highest expression rate of IgG4 reported to date in any B-cell lymphoma. None of the IgG4-positive cutaneous marginal zone lymphomas with available clinical data showed evidence of a preexisting systemic IgG4-related disease, suggesting a localized immunologic IgG4-driven pathogenetic process at early stages of the disease. IgG4-positive and IgG4-negative primary cutaneous marginal zone lymphomas did not significantly differ in architectural features of the infiltrate or the composition of the reactive T-cell infiltrate as determined by analysis of T-cell content, CD4/CD8 ratio, and content of FOXP3- and PD1-positive T cells. Although the pathogenetic role of IgG4 expression in a significant subset of primary cutaneous marginal zone lymphomas with plasmacytic differentiation remains unclear at present, the demonstration of IgG4 expression in a marginal zone lymphoma involving the skin might be a helpful clue in the routine diagnostic setting, as these tumors will almost invariably be of primary cutaneous origin with an extremely low risk of spread to noncutaneous sites and an excellent prognosis.
Collapse
|
25
|
Quoi de neuf en médecine interne? Ann Dermatol Venereol 2013; 140 Suppl 3:S263-72. [DOI: 10.1016/s0151-9638(13)70142-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|