1
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Lanzillotta M, Culver E, Sharma A, Zen Y, Zhang W, Stone JH, Della-Torre E. Fibrotic phenotype of IgG4-related disease. THE LANCET. RHEUMATOLOGY 2024; 6:e469-e480. [PMID: 38574746 DOI: 10.1016/s2665-9913(23)00299-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/13/2023] [Accepted: 10/31/2023] [Indexed: 04/06/2024]
Abstract
A prompt response to glucocorticoids is a clinical hallmark of IgG4-related disease. However, manifestations characterised by prominent tissue fibrosis on histological examination can be less responsive to glucocorticoid therapy than other types of IgG4-related disease. These manifestations include retroperitoneal fibrosis, fibrosing mediastinitis, Riedel thyroiditis, orbital pseudotumor, and hypertrophic pachymeningitis, among others. To explain this discrepancy, a preliminary distinction into proliferative and fibrotic phenotypes of IgG4-related disease has been proposed on the basis of clinical presentation, pathological features, and response to immunosuppressive therapy. Implications of this classification for patient management remain an important area of investigation. In this Series paper, we aim to dissect the pathophysiology of tissue fibrosis in IgG4-related disease and discuss how clinicians should approach the management of fibrotic manifestations of IgG4-related disease based on the most recent diagnostic and therapeutic developments.
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Affiliation(s)
- Marco Lanzillotta
- Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma Culver
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Amita Sharma
- Thoracic Imaging and Intervention Division, Massachusetts General Hospital, Boston, MA, USA
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital and King's College London, London, UK
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - John H Stone
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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2
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Caron P. Riedel's thyroiditis: report of 7 patients and review of literature. Endocrine 2024:10.1007/s12020-024-03853-w. [PMID: 38739225 DOI: 10.1007/s12020-024-03853-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/28/2024] [Indexed: 05/14/2024]
Abstract
Riedel's thyroiditis is a rare inflammatory-sclerosing thyroid disease, and its aetiology remains unknown. After a surgical biopsy to establish the diagnosis, the treatment of Riedel's thyroiditis is still challenging in most patients. The aim of this article is to report seven patients with Riedel's thyroiditis seen in a department of Endocrinology and Metabolic diseases over a period of 24 years, and based on the patient's data and the review of the literature to discuss the indications of surgery, glucocorticoids, tamoxifen and immunosuppressive drugs in the personalized treatment of patients with Riedel's thyroiditis.
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Affiliation(s)
- Philippe Caron
- Department of Endocrinology, Metabolic Diseases and Nutrition, Cardiovascular and Metabolic Unit, CHU Larrey, Toulouse, France.
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3
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Clifford LM, Joseph F. Difficulties in investigating and treating fibrosing thyroid disorder (overlap of fibrosing variant of Hashimoto's thyroiditis and Riedel's thyroiditis). BMJ Case Rep 2024; 17:e258917. [PMID: 38719258 PMCID: PMC11085981 DOI: 10.1136/bcr-2023-258917] [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] [Indexed: 05/13/2024] Open
Abstract
A gentleman in his 90s presented with a slowly enlarging goitre over 18 months, causing manifestations of superior vena cava obstruction, dysphagia and hoarseness of voice. Investigations were suggestive of a fibrosing thyroid pathology. Surgical management was avoided due to high surgical risk. Treatment included prednisolone and tamoxifen with palliative management in the event of further medical deterioration. This article illustrates the difficulties in diagnosing and managing fibrosing thyroid diseases.
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Affiliation(s)
| | - Flavian Joseph
- Endocrinology, Gosford Hospital, Gosford, New South Wales, Australia
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4
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O’Shea A, Crotty RK, Randhawa MK, Oliveira G, Perugino CA, Stone JH, Harisinghani MG, Wallace ZS, Hedgire SS. Multimodality Imaging Features of Immunoglobulin G4-related Vessel Involvement. Radiol Cardiothorac Imaging 2024; 6:e230105. [PMID: 38483247 PMCID: PMC11056752 DOI: 10.1148/ryct.230105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 12/11/2023] [Accepted: 01/30/2024] [Indexed: 05/01/2024]
Abstract
Immunoglobulin 4 (IgG4)-related disease is a chronic immune-mediated fibroinflammatory disorder. Involvement of the vascular system, including large- and medium-sized vessels, is increasingly recognized. The varied appearances of vascular involvement reflect the sequela of chronic inflammation and fibrosis and can include aortitis and periaortitis with resultant complications such as aneurysm formation and dissection. A diagnosis of IgG4-related large vessel involvement should be considered when there is known or suspected IgG4-related disease elsewhere. Other organs that are typically affected in IgG4-related disease include the lacrimal and salivary glands, thyroid, pancreas, biliary tree, lungs, kidneys, and meninges. Diagnosis typically requires careful correlation with clinical, imaging, serum, and pathologic findings. Patients may be managed with corticosteroid therapy or the anti-CD20 monoclonal antibody, rituximab, if needed. The varied clinical presentations and imaging features of large vessel involvement are discussed herein. Keywords: Vascular, Inflammation, Aorta, IgG4-related Vessel Involvement © RSNA, 2024.
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Affiliation(s)
- Aileen O’Shea
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - Rory K. Crotty
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - Mangun Kaur Randhawa
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - George Oliveira
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - Cory A. Perugino
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - John H. Stone
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - Mukesh G. Harisinghani
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - Zachary S. Wallace
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
| | - Sandeep S. Hedgire
- From the Departments of Radiology (A.O., M.K.R., M.G.H., S.S.H.),
Pathology (R.K.C.), and Rheumatology (C.A.P., J.H.S., Z.S.W.), Massachusetts
General Hospital, 55 Fruit St, White 217, Boston, MA 02114; and Radiology
Associates of South Florida, Miami, Fla (G.O.)
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5
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Bal M, Deshpande V. Advancements in diagnosing IgG4-related disease of the head and neck: Navigating diagnostic pitfalls. Semin Diagn Pathol 2024; 41:54-65. [PMID: 38185595 DOI: 10.1053/j.semdp.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/09/2024]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated condition affecting nearly any organ. This review focuses on the nuances of diagnosing IgG4-RD affecting the head and neck. Salivary gland involvement, especially of the submandibular glands, often permits a definitive diagnosis on biopsy. However, elevated IgG4+ plasma cells are nonspecific and can be seen in chronic sialadenitis, lymphoma, and other mimics. Careful correlation of clinical and pathological findings is essential. Given the significant overlap with chronic sinusitis, IgG4-RD of the sinonasal region is difficult to diagnose histologically. Laryngeal and pharyngeal involvement appears rare as an isolated finding of IgG4-RD. Mastoid disease is uncommon and remains a diagnosis of exclusion. Thyroid manifestations pose challenges given unclear diagnostic criteria - Riedel's thyroiditis likely represents IgG4-RD, but the fibrosing variant of Hashimoto's thyroiditis as a form of the so-called 'IgG4-related thyroiditis' requires better characterisation. Eosinophilic angiocentric fibrosis, despite histologic similarities, only partially overlaps with IgG4-RD. This review aims to guide diagnosing IgG4-RD in the head and neck through a systematic, organ-focused discussion of the clinical context, the utility of immunostaining, histological mimics, and controversial issues that pose diagnostic pitfalls. Increased awareness of the nuances and difficulties diagnosing IgG4-RD affecting the head and neck will improve recognition of this protean disease.
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Affiliation(s)
- Munita Bal
- Department of Pathology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharastra, India
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6
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Takahashi H, Kajita S, Katoh H, Matsumoto T, Inoue A, Sangai T, Saegusa M. Immunoglobulin G4-related thyroiditis associated with Graves' disease: A case report. Heliyon 2024; 10:e25843. [PMID: 38375285 PMCID: PMC10875452 DOI: 10.1016/j.heliyon.2024.e25843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/21/2024] Open
Abstract
We report a case of immunoglobulin (ig)-g4-related thyroiditis associated with graves' disease. a 45-year-old man was diagnosed with graves' disease due to asymptomatic enlarged thyroid gland and high serum levels of thyrotropin receptor antibodies and thyroid hormones. surgical resection of the thyroid gland was performed because of further thyroid gland enlargement and severe fluctuations in the thyroid hormonal levels, despite medical therapy with a combination of an antithyroid drug and a thyroid hormone preparation. macroscopic examination of the resected thyroid gland revealed a grayish-white diffuse swelling, and histopathological findings revealed follicular destruction, chronic inflammatory cell infiltration with diffuse igg4-positive plasma cells (IgG4/IgG >40%), storiform fibrosis, and phlebitis obliterans throughout the thyroid tissue. Additionally, there were small foci of high columnar follicular components with scalloping, resembling Graves' disease. We propose that all patients with Graves' disease should be evaluated for coexisting IgG4-related thyroiditis to detect ophthalmopathies as soon as possible.
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Affiliation(s)
- Hiroyuki Takahashi
- Department of Pathology, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan
| | - Sabine Kajita
- Department of Pathology, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Hiroshi Katoh
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Toshihide Matsumoto
- Department of Pathology, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan
| | - Akemi Inoue
- Department of Pathology, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan
| | - Takafumi Sangai
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Makoto Saegusa
- Department of Pathology, School of Medicine, Kitasato University, Kanagawa, Japan
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7
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Murata Y, Haneda M, Miyakawa N, Nishida S, Kajihara N, Maeda S, Ono K, Hanatani S, Igata M, Takaki Y, Motoshima H, Kishikawa H, Araki E. Autoimmune Polyglandular Syndrome Type 3 Complicated with IgG4-related Disease. Intern Med 2024; 63:425-431. [PMID: 37344441 PMCID: PMC10901709 DOI: 10.2169/internalmedicine.1270-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
A 52-year-old Japanese woman developed type 1 diabetes mellitus (type 1 DM) at 41 years old. She became complicated with Hashimoto's disease and showed swelling of both submandibular glands, which was diagnosed as IgG4-related disease (IgG4-RD). This is a rare case of a Japanese patient with autoimmune polyglandular syndrome type 3A (APS-3A) coexisting with autoimmune thyroid disease (AITD) and type 1 DM complicated by IgG4-RD. Bilateral submandibular gland resection was successfully performed without steroid therapy. We discuss the possibility that the immunological pathogenic mechanisms of APS-3A and IgG4-RD are related.
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Affiliation(s)
- Yusuke Murata
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Masaki Haneda
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Nobukazu Miyakawa
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Saiko Nishida
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Nobuhiro Kajihara
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Sarie Maeda
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Japan
| | - Kaoru Ono
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
| | - Satoko Hanatani
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
| | - Motoyuki Igata
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
| | | | | | | | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Science, Kumamoto University, Japan
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8
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Comi S, Lanzolla G, Cosentino G, Maglionico MN, Posarelli C, Menconi F, Santini F, Elisei R, Marinò M. IgG4 serum levels in Graves' orbitopathy. J Endocrinol Invest 2023:10.1007/s40618-023-02265-3. [PMID: 38127192 DOI: 10.1007/s40618-023-02265-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) can involve many organs, including thyroid and orbital tissues. A link between IgG4, Graves' disease (GD) and Graves' orbitopathy (GO) has been proposed, but results are conflicting. Here we investigated the possible association between IgG4 and GO. METHODS Retrospective investigation in 297 patients with Graves' disease (GD), 152 with GO. PRIMARY OUTCOME prevalence of IgG4 ≥ 135 mg/dL (cut-off for IgG4-RD). SECONDARY OBJECTIVES (1) serum IgG4 concentrations; (2) IgG4/IgG ratio; (3) prevalence of IgG4/IgG ratio ≥ 8.0%; (4) relationship between IgG4 and eye features; (5) relationship between IgG4 and anti-TSH receptor antibodies (TRAbs). RESULTS Because GO patients had lower FT3 concentrations, we evaluated the main objectives in the second and third FT3 quartiles subpopulation, in which there were no relevant differences between patients with (n = 81) or without GO (n = 67) for baseline parameters. Within this population, the prevalence of IgG4 levels ≥ 135 mg/dL did not differ between patients without and with GO (17.9% vs 17.3%). No difference was observed concerning IgG4 concentrations, prevalence of IgG4/IgG ≥ 8.0%, and IgG4/IgG ratio. There was no relationship between IgG4 and eye features and no correlation between IgG4 levels and TRAb was found. CONCLUSIONS Our results suggest that, within GD, there is no relationship between serum IgG4 and GO.
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Affiliation(s)
- S Comi
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - G Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - G Cosentino
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M N Maglionico
- Department of Surgical, Medical and Molecular Pathology, Ophthalmology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - C Posarelli
- Department of Surgical, Medical and Molecular Pathology, Ophthalmology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Menconi
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Santini
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - R Elisei
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - M Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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9
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Uccella S, Dottermusch M, Erickson L, Warmbier J, Montone K, Saeger W. Inflammatory and Infectious Disorders in Endocrine Pathology. Endocr Pathol 2023; 34:406-436. [PMID: 37209390 PMCID: PMC10199304 DOI: 10.1007/s12022-023-09771-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
A variety of inflammatory conditions may directly involve the endocrine glands, leading to endocrine dysfunction that can cause severe consequences on patients' health, if left untreated. Inflammation of the endocrine system may be caused by either infectious agents or other mechanisms, including autoimmune and other immune-mediated processes. Not infrequently, inflammatory and infectious diseases may appear as tumor-like lesions of endocrine organs and simulate neoplastic processes. These diseases may be clinically under-recognized and not infrequently the diagnosis is suggested on pathological samples. Thus, the pathologist should be aware of the basic principles of their pathogenesis, as well as of their morphological features, clinicopathological correlates, and differential diagnosis. Interestingly, several systemic inflammatory conditions show a peculiar tropism to the endocrine system as a whole. In turn, organ-specific inflammatory disorders are observed in endocrine glands. This review will focus on the morphological aspects and clinicopathological features of infectious diseases, autoimmune disorders, drug-induced inflammatory reactions, IgG4-related disease, and other inflammatory disorders involving the endocrine system. A mixed entity-based and organ-based approach will be used, with the aim to provide the practicing pathologist with a comprehensive and practical guide to the diagnosis of infectious and inflammatory disorders of the endocrine system.
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Affiliation(s)
- Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanule, Milan, Italy
- Pathology Service IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lori Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
| | - Julia Warmbier
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathleen Montone
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Колодкина АА, Зубкова НА, Урусова ЛС, Бондаренко СП, Бровин ДН, Аникиев АВ, Безлепкина ОБ. [The clinical case of IgG4-related thyroid disease in a 6-year-old child]. PROBLEMY ENDOKRINOLOGII 2023; 70:94-102. [PMID: 38796766 PMCID: PMC11145568 DOI: 10.14341/probl13379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 05/29/2024]
Abstract
IgG4-related disease is a rare chronic pathology manifested by lymphoplasmacytic infiltration of one or more organs, the formation of storiform fibrosis, tissue edema, and an increase of IgG4 in the blood. This disease was singled out as an independent nosological unit only in 2001. The incidence is less than 1 in 100,000 people per year. Almost any organ can be affected in IgG4-related disease. The association of Riedel's thyroiditis with IgG4 was established in 2010. Riedel's thyroiditis is an extremely rare inflammatory disease of the thyroid gland, which diagnosis is complicated by an atypical course and the absence of characteristic symptoms. Less than 300 clinical cases of the disease have been described in the world, only two from them were in children. This article presents a clinical case of a 6-year-old boy with Riedel's thyroiditis.
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Affiliation(s)
- А. А. Колодкина
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. А. Зубкова
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. С. Урусова
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Д. Н. Бровин
- Национальный медицинский исследовательский центр эндокринологии
| | - А. В. Аникиев
- Национальный медицинский исследовательский центр эндокринологии
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11
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Czarnywojtek A, Pietrończyk K, Thompson LDR, Triantafyllou A, Florek E, Sawicka-Gutaj N, Ruchała M, Płazinska MT, Nixon IJ, Shaha AR, Zafereo M, Randolph GW, Angelos P, Al Ghuzlan A, Agaimy A, Ferlito A. IgG4-related sclerosing thyroiditis (Riedel-Struma): a review of clinicopathological features and management. Virchows Arch 2023; 483:133-144. [PMID: 37204493 PMCID: PMC10412505 DOI: 10.1007/s00428-023-03561-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
We present a thorough review of the literature on Riedel thyroiditis (RT) with emphasis on aetiology, diagnosis and management, using the PubMed, Sinomed, and China National Knowledge Infrastructure databases. Although the exact aetiology of RT remains obscure, the histopathological features are consistent with a localized form of IgG4-related systemic disease (IgG4-RSD). Nevertheless, IgG4-RSD as a systemic fibroinflammatory disorder per se rarely affects the thyroid in the context of multiorgan manifestations. The initial diagnosis of RT is based on clinical history and imaging, but confirmation by histopathological examination is mandatory. In contrast to the historical surgical approach, glucocorticosteroid therapy is currently considered first line therapy, in line with the RT currently being viewed as a manifestation of, or analogous to, IgG4-RSD. For disease relapse, immunomodulatory agents (azathioprine, methotrexate, rituximab) can be used.
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Affiliation(s)
- Agata Czarnywojtek
- Department of Pharmacology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
- Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | | | | | - Asterios Triantafyllou
- Department of Pathology, Liverpool Clinical Laboratories, School of Dentistry, University of Liverpool, Liverpool, L3 5PS UK
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, Dojazd 30 Street, 60-631 Poznan, Poland
| | - Nadia Sawicka-Gutaj
- Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Marek Ruchała
- Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | | | - Iain J. Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, NHS Lothian, Edinburgh, EH8 9YL UK
| | - Ashok R. Shaha
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065 USA
| | - Mark Zafereo
- Department of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX 77005 USA
| | - Gregory William Randolph
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA 02114 USA
| | - Peter Angelos
- Section of General Surgery and Surgical Oncology, Department of Surgery, The University of Chicago, Chicago, Illinois IL 60637 USA
| | - Abir Al Ghuzlan
- Department of Biology and Pathology, Gustave Roussy Cancer Campus, University Paris-Saclay, 91190 Villejuif, France
| | - Abbas Agaimy
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy
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12
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Carsote M, Nistor C. Reshaping the Concept of Riedel's Thyroiditis into the Larger Frame of IgG4-Related Disease (Spectrum of IgG4-Related Thyroid Disease). Biomedicines 2023; 11:1691. [PMID: 37371786 DOI: 10.3390/biomedicines11061691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Recently, Riedel's thyroiditis (RT) was assimilated into the larger spectrum of immunoglobulin IgG4-related disease (IgG4-RD) in addition to a particular frame of IgG4-related thyroid disease (IgG4-RTD), underlying IgG4-RT, IgG4-associated Hashimoto's thyroiditis (and its fibrotic variant), and IgG4-related Graves's disease. Our objective was to overview recent data on RT, particularly IgG4-RD and IgG4-RTD. The case and study- sample analysis (2019-2023) included 293 articles and selected 18 original studies: nine single case reports (N = 9, female/male = 2/1, aged: 34-79 years, 5/9 patients with serum IgG4 available data, 2/5 with high serum IgG4) and four case series (N = 21; 4/5 series provided data on IgG4 profile, 3/21 had serum IgG4 assays, and 2/3 had abnormally high values). IgG4-RD and thyroid findings were analyzed in three cohorts (N = 25). Another two studies (N = 11) specifically addressed IgG4-RTD components. On presentation, the patients may have hypothyroidism, transitory thyrotoxicosis, goiter, long-term history of positive anti-thyroid antibodies, and hypoechoic ultrasound thyroid pattern. The 5-year analysis (N = 66) showed the rate of serum IgG4 evaluation remained low; normal values do not exclude RT. Mandatory histological and immunohistochemistry reports point out a high content of IgG4-carrying plasma cells and IgG4/IgG ratio. Unless clinically evident, histological confirmation provides a prompt indication of starting corticoid therapy since this is the first-line option. Surgery, if feasible, is selective (non-responders to medical therapy, emergency tracheal intervention, and open/core needle biopsy). Current open issues are identifying the role of serum IgG4 assays in patients with IgG4-RD, finding out if all cases of RT are IgG4-mediated, applying IgG4-RTD criteria of differentiation among four entities, and providing an RT/IgG4-RTD guideline from diagnosis to therapy. It remains that the central aim of approaching RT in daily practice is the early index of suspicion in order to select patients referred for further procedures that provide enough histological/immunohistochemistry material to confirm RT and its high IgG4 burden.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy & Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 050474 Bucharest, Romania
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13
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Uversky VN, Redwan EM, Makis W, Rubio-Casillas A. IgG4 Antibodies Induced by Repeated Vaccination May Generate Immune Tolerance to the SARS-CoV-2 Spike Protein. Vaccines (Basel) 2023; 11:vaccines11050991. [PMID: 37243095 DOI: 10.3390/vaccines11050991] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Less than a year after the global emergence of the coronavirus SARS-CoV-2, a novel vaccine platform based on mRNA technology was introduced to the market. Globally, around 13.38 billion COVID-19 vaccine doses of diverse platforms have been administered. To date, 72.3% of the total population has been injected at least once with a COVID-19 vaccine. As the immunity provided by these vaccines rapidly wanes, their ability to prevent hospitalization and severe disease in individuals with comorbidities has recently been questioned, and increasing evidence has shown that, as with many other vaccines, they do not produce sterilizing immunity, allowing people to suffer frequent re-infections. Additionally, recent investigations have found abnormally high levels of IgG4 in people who were administered two or more injections of the mRNA vaccines. HIV, Malaria, and Pertussis vaccines have also been reported to induce higher-than-normal IgG4 synthesis. Overall, there are three critical factors determining the class switch to IgG4 antibodies: excessive antigen concentration, repeated vaccination, and the type of vaccine used. It has been suggested that an increase in IgG4 levels could have a protecting role by preventing immune over-activation, similar to that occurring during successful allergen-specific immunotherapy by inhibiting IgE-induced effects. However, emerging evidence suggests that the reported increase in IgG4 levels detected after repeated vaccination with the mRNA vaccines may not be a protective mechanism; rather, it constitutes an immune tolerance mechanism to the spike protein that could promote unopposed SARS-CoV2 infection and replication by suppressing natural antiviral responses. Increased IgG4 synthesis due to repeated mRNA vaccination with high antigen concentrations may also cause autoimmune diseases, and promote cancer growth and autoimmune myocarditis in susceptible individuals.
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Affiliation(s)
- Vladimir N Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer's Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Elrashdy M Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, P.O. Box 80203, Jeddah 21589, Saudi Arabia
- Therapeutic and Protective Proteins Laboratory, Protein Research Department, Genetic Engineering and Biotechnology Research Institute, City for Scientific Research and Technology Applications, New Borg EL-Arab, Alexandria 21934, Egypt
| | - William Makis
- Cross Cancer Institute, Alberta Health Services, 11560 University Avenue, Edmonton, AB T6G 1Z2, Canada
| | - Alberto Rubio-Casillas
- Autlan Regional Hospital, Health Secretariat, Autlan 48900, Jalisco, Mexico
- Biology Laboratory, Autlan Regional Preparatory School, University of Guadalajara, Autlan 48900, Jalisco, Mexico
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14
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Sadacharan D, Ahmed A, Smitha S, Mahadevan S, Vimala R, Prasad H. Our Uncommon Experience with 6 Cases of Riedel's Thyroiditis (Woody Thyroiditis). Indian J Otolaryngol Head Neck Surg 2022; 74:1757-1762. [PMID: 36452560 PMCID: PMC9702193 DOI: 10.1007/s12070-019-01783-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022] Open
Abstract
Riedel's thyroiditis is a rare form of thyroiditis. Estimated prevalence is 1.06/100,000 population and is reported in 0.05% of thyroidectomy specimens. It has 38% association with systemic fibrotic conditions. We retrospectively reviewed 6 cases of Riedel's thyroiditis at a tertiary care centre in south India, from 2011 through 2019 with special emphasis on demography, clinical presentation, workup, management, intraoperative findings, postoperative outcomes and follow up. There were 4 females and 2 males of which we reported a rare presentation in paediatric age group which was probably never reported before. Presenting symptoms included dysphagia and compressive symptoms in neck. 5 out of 6 cases underwent surgical management- 4 total thyroidectomy and 1 hemithyroidectomy. Postoperative complications noted were temporary hypoparathyroidism, unilateral vocal cord palsy and temporary bilateral vocal cord palsy One case was medically managed with oral corticosteroids. There was no evidence of extra cervical fibrosis on follow up in all patients. There was no cause-specific mortality, and the fibrotic process stabilized or resolved in all patients. Riedel's thyroiditis is a fibroinflammatory disorder presenting with compressive symptoms mandating surgical intervention mainly decompression in the form of isthmectomy. However since extensive interventions are associated with complications it is less favoured approach. Long term follow up of these cases are necessary for detecting evidence of extra cervical fibrosis.
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Affiliation(s)
| | - Althaf Ahmed
- Resident Department of Endocrine Surgery, Madras Medical College, Chennai, India
| | - S. Smitha
- Resident Department of Endocrine Surgery, Madras Medical College, Chennai, India
| | | | | | - Hemchand Prasad
- Consultant Paediatric Endocrinologist, Dr Mehta’s Hospital, Chennai, India
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15
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Salama OH, Ibrahim ENA, Hussein MO, Alkady AMM, Abd El-Salam ME, Ghanem S. IgG4-Related Dacryoadenitis in Egyptian Patients: A Retrospective Study. Clin Ophthalmol 2022; 16:2765-2773. [PMID: 36039106 PMCID: PMC9419724 DOI: 10.2147/opth.s378583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To report clinical, serological, and histopathological findings in Egyptian patients with dacryoadenitis associated with ImmunoglobulinG4-related disease (IgG4-RD). Methods We retrospectively revised medical records of patients presented to Al-Azhar University Hospitals with lacrimal gland (LG) swelling between June 2016 and February 2022. We included patients with definite IgG4-related disease (IgG4-RD) diagnosis and excluded those with possible, probable, or unlikely IgG4-RD based on The Japanese Ministry of Health, Labour, and Welfare’s 2011 guidelines. Results Sixteen cases were included in the study (Fourteen females and two males, mean age 39.2±12.2 years); Seven cases met the criteria of Mikulicz disease, and nine cases met full clinical, serological, and histopathological criteria. Mean reported serum IgG was 1792.5 ± 313.7 (range 1063–2134) mg/dl, mean serum IgG4 was 576.25±215.3 (range 112–841) mg/dl, and mean Serum IgG4/IgG ratio was 31.9 ± 12.4%. The mean number of IgG4+ plasma cells/HPF was 74 ± 21.2, and the mean IgG4+ plasma cell percentage was 55 ± 9.7%. Serum IgG4 level showed a positive correlation to tissue IgG4+plasma cell percentage, while serum IgG4/IgG ratio positively correlated to both percentage and number of IgG4+plasma cells. Steroids had a good initial response, but recurrences were common. Conclusion A considerable proportion of patients with lacrimal gland swelling fall within the range of IgG4-RD. Proper diagnosis requires clinical, serological, and histopathologic correlation. Patients require long follow-up periods.
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Affiliation(s)
- Omar Hassan Salama
- Ophthalmology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Correspondence: Omar Hassan Salama, Lecturer of Ophthalmology, Faculty of Medicine, Al Azhar University, El Hussain University Hospital, Gawhar Al Qaed Street, Al Darrasah, Cairo, 11561, Egypt, Tel +201146316323, Email
| | | | | | | | | | - Saad Ghanem
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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16
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Sharma Khatiwada A, Choudhury N. IgG4-positive Hashimoto thyroiditis and its association with IgG4-related sclerosing disease. BMJ Case Rep 2022; 15:e249181. [PMID: 35793849 PMCID: PMC9260794 DOI: 10.1136/bcr-2022-249181] [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] [Indexed: 11/04/2022] Open
Abstract
A woman in her 50s was referred with suspected thyroid malignancy and underwent total thyroidectomy. Immunohistochemical analysis revealed IgG4-positive Hashimoto's thyroiditis. IgG4-related thyroid disease is poorly understood, and thought to encompass various entities including IgG4-positive Hashimoto's thyroiditis, Fibrosing Variant of Hashimoto's thyroiditis, Reidel's thyroiditis and Graves' disease with elevated IgG4 levels. Furthermore, it may be associated with a systemic fibrosing condition called 'IgG4-related sclerosing disease'. The clinical significance of IgG4-positive thyroid disease, however, remains unclear.
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Affiliation(s)
| | - Natasha Choudhury
- Department of Otolaryngology, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
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17
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T Cell Roles and Activity in Chronic Sclerosing Sialadenitis as IgG4-Related Disease: Current Concepts in Immunopathogenesis. Autoimmune Dis 2022; 2022:5689883. [PMID: 35769404 PMCID: PMC9236833 DOI: 10.1155/2022/5689883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
IgG4-related disease is a multiorgan immunological fibroinflammatory disorder characterized by lymphoplasmacytic infiltration and fibrosis in multiple organs accompanied by high serum IgG4 levels. The salivary glands are the most common organs involved in this disease. Recently, chronic sclerosing sialadenitis affecting salivary glands, formerly known as Küttner's tumor, and Mikulicz's disease have been classified as a class of IgG4-related diseases. The etiopathobiology of IgG4-related disease is not fully understood. It has recently been hypothesized that the inflammatory and fibrotic process and the increased serum IgG4+ levels in IgG4-related disease are the result of an interaction between B cells and T helper cells, suggesting that T cells may play a key role in the pathogenesis of this disease. The aim of this review is to discuss the proposed roles of different T cell subsets in the pathogenesis of IgG4-related disease focusing on their roles in immunopathogenesis of IgG4-related sialadenitis.
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18
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Jin M, Kim B, Jang A, Jeon MJ, Choi YJ, Lee YM, Song DE, Kim WG. Immunoglobulin G4-Related Thyroid Disease: A Single-Center Experience and Literature Review. Endocrinol Metab (Seoul) 2022; 37:312-322. [PMID: 35504602 PMCID: PMC9081308 DOI: 10.3803/enm.2021.1318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Immunoglobulin G4 (IgG4)-related disease is an entity that can involve the thyroid gland. The spectrum of IgG4-related thyroid disease (IgG4-RTD) includes Hashimoto thyroiditis (HT) and its fibrotic variant, Riedel thyroiditis, as well as Graves' disease. The early diagnosis of IgG4-RTD is important because it is a medically treatable disease, and a delay in the diagnosis might result in unnecessary surgery. We present a case series of IgG4-RTD with a review of the literature. METHODS We retrospectively reviewed the clinical presentation and the radiological and pathological findings of patients diagnosed with IgG4-RTD between 2017 and 2021 at a tertiary medical center in Korea. We also conducted a literature review of IgG4-RTD. RESULTS Five patients were diagnosed with IgG4-RTD during the study period. The patients' age ranged from 31 to 76 years, and three patients were men. Most patients visited the clinic for a neck mass, and hypoechogenic nodular lesions were observed on neck ultrasonography. Three patients had IgG4 HT, and two patients had IgG4 Riedel thyroiditis. All patients developed hypothyroidism that necessitated L-thyroxine replacement. The diagnosis of IgG4-RTD was confirmed after a pathological examination of the surgical specimen in the first two cases. However, the early diagnosis was possible after a core needle biopsy in three clinically suspected patients. CONCLUSION The diagnosis of IgG4-RTD requires clinical suspicion combined with serology and histological analyses using IgG4 immunostaining. The early diagnosis of IgG4-RTD is difficult; thus, biopsy with IgG4 immunostaining and serum IgG4 measurements will help diagnose patients suspected of having IgG4-RTD.
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Affiliation(s)
- Meihua Jin
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bictdeun Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ahreum Jang
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Ji Jeon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Jun Choi
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Eun Song
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Gu Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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19
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Deng Y, Wang J, Zou G, Liu Z, Xu J. The characteristics and clinical significance of elevated serum IgG4/IgG levels in patients with Graves' disease. Endocrine 2022; 75:829-836. [PMID: 34773561 DOI: 10.1007/s12020-021-02935-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aims to further explore the clinical and laboratory characteristics of patients with GD with high serum IgG4 based on the IgG4/IgG ratio. METHODS This study is a prospective observational study. A total of 25 normal controls and 84 people newly diagnosed with GD were enrolled in this study. Taking the IgG4/IgG ratio of 8% as the cutoff value, the experimental groups were further divided into two subgroups: the high IgG4/IgG subgroup and the normal IgG4/IgG subgroup. We evaluated the differences in clinical characteristics and laboratory parameters between the groups. RESULTS The IgG4, IgG4/IgG, and IL-17 of the newly diagnosed GD group were significantly higher than those of the normal control group (P < 0.05). The differences in age, IL-1β, IL-17, and eosinophil count between the high IgG4/IgG subgroup and the normal IgG4/IgG subgroup were statistically significant (P < 0.05). After ATD treatment, some patients developed allergies; the high IgG4/IgG subgroup was significantly higher than the normal IgG4/IgG subgroup (χ2 = 4.424, P = 0.035). After 3 months of ATD treatment in patients with GD, the TRAb in the normal IgG4/IgG subgroup were significantly lower than before (P < 0.05), while the difference in the high IgG4/IgG subgroup was not statistically significant (P > 0.05). CONCLUSIONS A small portion of patients with GD harbored elevated serum IgG4/IgG levels. They are younger, have higher eosinophils, and are more prone to allergies; also, they have higher levels of cytokines IL-1β and IL-17 and their remission is not easily attained after treatment with ATD; this could be due to the instability of the Th17/Treg cell balance.
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Affiliation(s)
- Yuanyuan Deng
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China
| | - Jiao Wang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China
| | - Guilin Zou
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China
| | - Zelin Liu
- Department of Endocrinology and Metabolism, Fourth Affiliated Hospital of Nanchang University, Nanchang, PR China.
| | - Jixiong Xu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, 330006, PR China.
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20
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IgG4-related pseudotumours: a series of 12 cases and a review of the literature. Pathology 2022; 54:563-572. [DOI: 10.1016/j.pathol.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/11/2021] [Accepted: 11/18/2021] [Indexed: 11/22/2022]
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21
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Cai M, Voutnis D, Nair B. Immunoglobulin G4-Related ophthalmic disease and aortitis. ARCHIVES OF MEDICINE AND HEALTH SCIENCES 2022. [DOI: 10.4103/amhs.amhs_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Wallwork R, Perugino CA, Fu X, Harkness T, Zhang Y, Choi HK, Stone JH, Wallace ZS. The association of smoking with immunoglobulin G4-related disease: a case-control study. Rheumatology (Oxford) 2021; 60:5310-5317. [PMID: 33751033 PMCID: PMC8783539 DOI: 10.1093/rheumatology/keab172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/03/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate the association between cigarette smoking and the odds of IgG4-related disease (IgG4-RD). METHODS We performed a case-control study of patients with IgG4-RD compared in a 1:5 ratio with age-, race- and sex-matched controls. We included cases evaluated at the Massachusetts General Hospital, a hospital within the Mass General Brigham (MGB) System. Controls were identified from the MGB Biobank. Smoking status at the date of IgG4-RD diagnosis or corresponding index date was determined. Conditional logistic regression was used to estimate the association between cigarette smoking and the odds of having IgG4-RD. RESULTS There were 234 IgG4-RD cases and 1170 controls. The mean age (59 years), sex (62% male) and race (75% white) were well balanced. IgG4-RD cases were more likely to be current smokers compared with controls [25 (11%) vs 70 (6%); odds ratio (OR) 1.79 (95% CI 1.08, 2.95)]. This association was strongest among female cases [13 (14%) vs 19 (4%);, OR 3.79 (95% CI 1.71, 8.39)] and those with retroperitoneal fibrosis [RPF; 13 (28%) vs 13 (6%);, OR 6.93 (95% CI 2.78, 17.26)] or normal IgG4 concentrations [21 (21%) vs 21 (4%); OR 6.22 (95% CI 3.09, 12.49)]. When RPF cases were excluded, there was no longer an association between current smoking and the odds of having IgG4-RD [12 (6%) vs 57 (6%); OR 0.95 (95% CI 0.49, 1.86)]. CONCLUSION Being a current smoker is associated with greater odds of having IgG4-RD, especially among women and those with RPF or normal IgG4 concentrations. Current smoking is the first recognized modifiable risk factor for IgG4-RD.
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Affiliation(s)
- Rachel Wallwork
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
| | - Cory A Perugino
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
| | - Xiaoqing Fu
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
- Division of Rheumatology, Allergy, and Immunology, Clinical Epidemiology Program, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
| | - Tyler Harkness
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
| | - Yuqing Zhang
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
- Division of Rheumatology, Allergy, and Immunology, Clinical Epidemiology Program, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
| | - Hyon K Choi
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
- Division of Rheumatology, Allergy, and Immunology, Clinical Epidemiology Program, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
- Division of Rheumatology, Allergy, and Immunology, Clinical Epidemiology Program, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
| | - Zachary S Wallace
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology
- Division of Rheumatology, Allergy, and Immunology, Clinical Epidemiology Program, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, USA
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic immune-mediated fibroinflammatory disease. Since its discovery nearly two decades ago, our understanding of its pathophysiology and clinical manifestations has grown substantially. Early diagnosis and treatment of this elusive disease can prevent substantial organ damage from end-stage fibrosis, emphasizing the need for prompt recognition and accurate characterization of IgG4-RD. The classification criteria endorsed by the American College of Rheumatology and the European Alliance of Associations for Rheumatology in 2019 provide a framework for establishing the diagnosis in the clinical setting. This process involves recognizing the typical manifestations of the disease and incorporating clinical, radiological, serological, and histopathological information as well as excluding disease mimickers. Glucocorticoids and rituximab are effective at inducing remission in IgG4-RD in most patients, but the optimal approach to long-term management of IgG4-RD remains an area of active clinical research. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Guy Katz
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA;
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA;
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Li Y, Luo B, Zhang J, Zhou X, Shao S, Xu W, Yang Y, Yuan G. Clinical relevance of serum immunoglobulin G4 in glucocorticoid therapy of Graves' ophthalmopathy. Clin Endocrinol (Oxf) 2021; 95:657-667. [PMID: 33938028 DOI: 10.1111/cen.14493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 03/16/2021] [Accepted: 03/29/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Previous study suggested IgG4 levels were associated with the development of Graves' ophthalmopathy (GO). The aims of the present study were to investigate the role of IgG4 levels in glucocorticoid (GC) treatment in GO patients. DESIGN 69 GO patients were enrolled. Serum thyroid hormones, thyroid antibodies, IgG, IgG4, ophthalmological examinations and orbital MRI were performed. Furthermore, the clinical outcomes (a composite response endpoint including the clinical activity score (CAS), proptosis, vision, intraocular pressure, diplopia and lid width) after high-dose intravenous GC treatment in 32 active moderate-to-severe GO patients were compared. PATIENTS 69 consecutive patients with GO were asked to participate in the study. 32 of 69 GO patients were treated with high-dose intravenous GCs. MEASUREMENTS Measurement of serum IgG and IgG4, serum thyroid hormones and thyroid autoantibodies. An overall ophthalmic assessment was performed pretherapy (week 0) and post-therapy (week 12). RESULTS 33.3% of GO patients (23/69) had elevated IgG4 levels. IgG4 levels were positively correlated with the severity and activity of GO. After GC therapy, IgG4, IgG4/IgG, vision and CAS were significantly improved in GO patients. Patients with high IgG4 levels had a significantly reduced extraocular muscle area (EOMs) and better clinical outcomes than patients with normal IgG4 levels. CONCLUSIONS Our results suggest a possible subgroup of elevated IgG4 GO patients, with more severe ophthalmopathy and better response to GCs treatment compare with normal IgG4 GO patients.
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Affiliation(s)
- Yaling Li
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Wuhan Hospital of Traditional Chinese and Western Medical, Wuhan, China
| | - Ban Luo
- Department of Ophthalmology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Zhang
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Xinrong Zhou
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shiying Shao
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Weijie Xu
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Yang
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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Arora K, Kulkarni A, Pankaj A, Desai N, Deshpande V. IgG4 Related Disease is characterized by the overexpression of Immunomodulatory proteins. Histopathology 2021; 81:486-495. [PMID: 34506637 DOI: 10.1111/his.14564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION IgG4 related disease (IgG4-RD) is a multisystem disease, characterized by tumefactive lesions and a swift response to immunosuppressive therapy. Although elevated serum and tissue IgG4 are characteristic, T-cells appear to be the primary driver of this immunologically mediated disease. The overarching goal was to examine the role of immunomodulatory cells in IgG4-RD. METHODS Biopsies from patients with IgG4-RD (n=39) and mimics of this disease (n=78) were evaluated for IgG4, IgG, CD8, PD-L1 and a subset (n=18) evaluated for CD4, PU.1, Foxp3, PD-L1, PD-1, IDO1 and LAG3. Data pertaining to demographics and laboratory findings at baseline evaluation was extracted from electronic medical records. RESULTS When compared to mimics, IgG4-RD showed increased numbers of PD-L1 (p=0.0001), PD-1 (p=0.001), IDO1 (p=0.03), LAG3 (p=0.04) and Foxp3 (p=0.04) positive immune cells. The PD-L1 positive cells were enriched within aggregates of CD4 and CD8 positive T-cells. 31 of 39 (80%) IgG4-RD cases showed greater than 5 PD-L1 positive cells per HPF, while 4 of 78 (5%) mimics of this disease exceeded this cut point. In IgG4-RD PD-L1 positive macrophages correlated with PD-1 (p=0.002), LAG3 (p=0.001) and IDO1 positive cells (p=0.001); a positive correlation was also noted between IgG4/IgG ratio and PD-L1, PD-1, and IDO1 positive cells. CONCLUSIONS IgG4-RD shows expansion of mechanisms that maintain peripheral tolerance. The spatial and temporal relationship between T-cells and the PD-L1-PD1 axis, and the upregulation of multiple immunomodulatory proteins suggests that these immunoregulatory mechanisms play a significant role in IgG4-RD.
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Affiliation(s)
- Kshitij Arora
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02478, USA
| | - Anupriya Kulkarni
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02478, USA
| | - Amaya Pankaj
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02478, USA
| | - Niyati Desai
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02478, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02478, USA
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Amirbaigloo A, Esfahanian F, Mouodi M, Rakhshani N, Zeinalizadeh M. IgG4-related hypophysitis. Endocrine 2021; 73:270-291. [PMID: 33837927 DOI: 10.1007/s12020-021-02714-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/23/2021] [Indexed: 12/13/2022]
Abstract
Hypophysitis is a rare pituitary inflammatory disorder classified in different ways. Immunoglobulin G4-related disease (IgG4-RD), also a rare disease is a systemic fibro-inflammatory condition characterized by infiltration of tissue with IgG4-positive plasma cells; however prevalence of both of them probably is underestimated. In this paper, we present an Iranian patient with biopsy-proven IgG4-related hypophysitis and then review the clinical characteristics, laboratory, imaging, pathologic findings and therapeutic management as well as prognosis of 115 published cases of hypophysitis secondary to IgG4-related disease.
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Affiliation(s)
| | - Fatemeh Esfahanian
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
| | - Marjan Mouodi
- Department of Endocrinology and Metabolism, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Rakhshani
- Department of Pathology, Firoozgar Hospital, Iran University of medical sciences, Tehran, Iran
| | - Mehdi Zeinalizadeh
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Han X, Zhang P, Li J, Liu Z, Lu H, Luo X, Pan B, Lian X, Zeng X, Zhang W, Zeng X. Clinical features and treatment efficacy for IgG4-related thyroiditis. Orphanet J Rare Dis 2021; 16:324. [PMID: 34289855 PMCID: PMC8293477 DOI: 10.1186/s13023-021-01942-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/02/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study aimed to clarify the clinical features of and evaluate the treatment efficacy for IgG4-related thyroiditis. METHODS Fourteen IgG4-related thyroiditis patients and 42 randomly matched IgG4-related disease (IgG4-RD) patients without thyroiditis in a prospective cohort at the Peking Union Medical College Hospital (PUMCH) were enrolled from 2011 to 2019. Patient demographics, clinical characteristics, laboratory parameters and treatment efficacy were analysed. RESULTS The prevalence of IgG4-related thyroiditis in our cohort was 2.0%. The average patient age was 42.8 ± 14.9 years, and the male: female ratio was 1:1. Goiter (14, 100.0%), hard thyroid (14, 100.0%) and neck compression (5, 35.7%) were the most prevalent onset symptoms observed. IgG4-related thyroiditis was characterized by asymmetric diffuse thyroid enlargement on ultrasound. Thirteen (92.9%) patients had hypothyroidism, and all patients had significantly elevated circulating thyroid antibodies. Compared with patients without thyroiditis, patients with IgG4-related thyroiditis had less submandibular gland involvement and lacrimal gland involvement and lower serum IgG4 and T-IgE levels (P = 0.019, P = 0.022, P = 0.004, and P = 0.006, respectively) and more single-organ involvement (P = 0.011). After treatment, the symptoms were relieved, while the size of the thyroid gland did not change significantly, and levothyroxine as a supplemental therapy was still needed. CONCLUSIONS IgG4-related thyroiditis is a distinct subtype of IgG4-RD characterized by positive circulating thyroid antibodies and a high rate of hypothyroidism. Although compression symptoms could be relieved with treatment, the thyroid size did not change significantly, and the damage to thyroid function was often irreversible.
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Affiliation(s)
- Xinxin Han
- Department of General Practice, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, People’s Republic of China
| | - Panpan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
| | - Jieqiong Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
| | - Zheng Liu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
| | - Hui Lu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
| | - Xuan Luo
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
| | - Boju Pan
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, People’s Republic of China
| | - Xiaolan Lian
- Department of Endocrine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, People’s Republic of China
| | - Xuejun Zeng
- Department of General Practice, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, People’s Republic of China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, State Key Laboratory of Complex Severe and Rare Diseases, Ministry of Education and National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), No.1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730 People’s Republic of China
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IgG4 as a Biomarker in Graves' Orbitopathy. Mediators Inflamm 2021; 2021:5590471. [PMID: 34220335 PMCID: PMC8213474 DOI: 10.1155/2021/5590471] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/29/2021] [Indexed: 12/26/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic inflammatory disorder associated with fibrosis and abundant tissue lymphoplasmacytic infiltrations. It typically affects the pancreas, the salivary glands, and the retroperitoneal space. However, it might also involve multiple other organs, including the orbit and the thyroid. Recent studies have suggested that IgG4 plays a role in the pathophysiology of autoimmune thyroid diseases. This ultimately led to the establishment of new clinical entities called IgG4-related thyroid disease and thyroid disease with an elevation of IgG4. The aim of this paper is to describe the pathophysiological, histopathological, and clinical features of Graves' Disease (GD) and Graves' Orbitopathy (GO) with elevated IgG4 levels. Multiple studies have demonstrated higher IgG4 serum concentrations in GD patients than in healthy euthyroid controls. Depending on the studied population, elevated serum IgG4 levels occur in 6.4-23% (average: 10.3%) of all patients with GD, 8.3-37.5% (average: 17.6%) of patients with GO, and 0-9.8% (average: 5.4%) of patients with GD without GO, while GO patients comprise 37.5-100% (average: 65.8%) of all GD patients with elevated IgG4 levels. Characteristic features of GD with elevated IgG4 levels include lower echogenicity of the thyroid gland on ultrasound examination, peripheral blood eosinophilia, higher prevalence of orbitopathy, and better response to antithyroid drugs with a tendency to develop hypothyroidism when compared to patients with GD and normal levels of IgG4. Typical signs of GO accompanied by increased concentration of IgG4 include younger age at diagnosis, and more severe course of the disease with a higher Clinical Activity Score (CAS).. We strongly recommend considering the diagnosis of GO with elevated IgG4 in patients with an established diagnosis of GD, elevated serum IgG4 levels, and clinical features of ophthalmic disease overlapping with those of IgG4-related orbital disease.
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Gökçay Canpolat A, Cinel M, Dizbay Sak S, Taşkaldıran I, Korkmaz H, Demir Ö, Ersoy R, Dağdelen S, Berker D, Dalva K, Bahçecioğlu Mutlu AB, Erdoğan MF. Long-Term Outcomes of Tamoxifen Citrate Therapy and Histo- and Immunopathological Properties in Riedel Thyroiditis. Eur Thyroid J 2021; 10:248-256. [PMID: 34178711 PMCID: PMC8216025 DOI: 10.1159/000512017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Riedel thyroiditis (RT) is a rare form of thyroiditis; thus, data about the disease course and treatment options are limited. Therefore, we aimed to assess the clinical, serological, radiological, and histopathological features, as well as short- and long-term follow-up of RT patients under glucocorticoid (GC) and tamoxifen citrate (TMX). Parameters related to IgG4-related diseases (IgG4-RD) were also investigated. METHODS Eight patients with RT diagnosed between 2000 and 2019 were enrolled. Data were collected in a retrospective and prospective manner. The diagnosis was confirmed with histopathological features in all patients. Results of the treatment with GCs on short- to mid-term, followed by TMX in the long term, were evaluated. RESULTS The mean age at diagnosis was 40.5 ± 6.8 years; female predominance was observed (F/M:7/1). Parameters related to IgG4-RD, like increase in IgG4 serum levels, total plasmablast counts, and IgG4+ plasmablasts, were negative in most of our patients in both active and inactive states of the disease. Likewise, an increased ratio of IgG4/IgG-positive plasma cells >40% could only be observed in 2 cases. GCs followed by TMX were given to the patients with an over-all median follow-up time of 67 (8-216) months. All the patients considerably improved clinically and had a reduction in the size of the mass lesion on GCs, followed by TMX therapy. None of the patients had a recurrence under TMX therapy for a median period of 18.5 (7-96) months. CONCLUSION Even though RT is suggested to be a member of IgG4-RD, serologic or histological evidence of IgG4 elevation or positivity is only useful for diagnosis and follow-up of RT. The diagnosis should be based on clinical and radiological evidence and confirmed by histopathology. GCs are effective for initial treatment, and TMX is a successful and safe therapeutic option for long-term maintenance therapy.
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Affiliation(s)
- Asena Gökçay Canpolat
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
- *Asena Gökçay Canpolat, Department of Endocrinology and Metabolism, School of Medicine, İbni-Sina Hospital, Ankara University, Altındağ, Ankara 06100 (Turkey),
| | - Murat Cinel
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
| | - Serpil Dizbay Sak
- Department of Pathology, School of Medicine, Ankara University, Ankara, Turkey
| | - Işılay Taşkaldıran
- Department of Endocrinology and Metabolism, Ankara Training and Research Hospital, Ankara, Turkey
| | - Hakan Korkmaz
- Department of Endocrinology and Metabolism, School of Medicine, Süleyman Demirel University, Isparta, Turkey
| | - Özgür Demir
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
| | - Reyhan Ersoy
- Department of Endocrinology and Metabolism, School of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
| | - Selçuk Dağdelen
- Department of Endocrinology and Metabolism, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Dilek Berker
- Department of Endocrinology and Metabolism, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Klara Dalva
- Department of Haematology, School of Medicine, Ankara University, Ankara, Turkey
| | | | - Murat Faik Erdoğan
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
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Yu Y, Liu J, Yu N, Zhang Y, Zhang S, Li T, Gao Y, Lu G, Zhang J, Guo X. IgG4 immunohistochemistry in Riedel's thyroiditis and the recommended criteria for diagnosis: A case series and literature review. Clin Endocrinol (Oxf) 2021; 94:851-857. [PMID: 33301600 DOI: 10.1111/cen.14390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Riedel's thyroiditis (RT) is a very rare chronic fibrosing thyroiditis that is often associated with multifocal fibrosclerosis. Although the relationship of RT and IgG4-related disease (IgG4-RD) has been suggested, the expression of IgG and IgG4 in thyroid tissues of patients with RT has seldom been studied. DESIGN A case series and literature review. PATIENTS AND MEASUREMENTS We searched our hospital's pathology database and identified five cases of RT between 2000 and 2019. The expression levels of IgG4 and IgG in thyroid tissues were detected by immunohistochemistry. We also performed a literature search of the electronic databases PubMed/MEDLINE, Web of Science and China National Knowledge Internet (CNKI). Eight papers were included in this study. RESULTS According to immunohistochemistry, the numbers of IgG4+ plasma cells per high-power field (HPF) of the five RT patients at our hospital were 80, 8, 50, 10 and 22, and the respective IgG4+/IgG+ ratios were 76%, 80%, 43%, 19% and 28%. In the literature, 15 RT patients with confirmed IgG4 and IgG immunohistochemical findings were identified. Only seven of them fulfilled the IgG4-RD diagnostic criteria in terms of immunohistochemistry (IgG4+ > 10/HPF, IgG4+/IgG+ > 40%). In order to ensure that most RT cases can meet the IgG4 immunohistochemical criteria, an organ-specific cut-off value (≥10 IgG4+ plasma cells/HPF and ≥ an IgG4+/IgG ratio of 20%) was finally selected in our study. CONCLUSION Our findings of IgG4 expression in patients with RT suggest that a cut-off of 10 IgG4+ plasma cells/HPF and an IgG4+/IgG ratio of 20% are more suitable diagnostic criteria for RT in IgG4-RD.
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Affiliation(s)
- Yang Yu
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Jumei Liu
- Department of Pathology, Peking University First Hospital, Beijing, China
| | - Nan Yu
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Yang Zhang
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Shuang Zhang
- Department of Pathology, Peking University First Hospital, Beijing, China
| | - Ting Li
- Department of Pathology, Peking University First Hospital, Beijing, China
| | - Ying Gao
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Guizhi Lu
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Junqing Zhang
- Department of Endocrinology, Peking University First Hospital, Beijing, China
| | - Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing, China
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31
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Matos T, de Almeida MM, Batista L, do Vale S. IgG4-related disease of the thyroid gland. BMJ Case Rep 2021; 14:14/3/e238177. [PMID: 33649038 PMCID: PMC7929855 DOI: 10.1136/bcr-2020-238177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
IgG4-thyroid-related disease (TRD) represents an uncommon spectrum of diseases, with four subcategories established so far, IgG4-related Hashimoto's thyroiditis, fibrosing variant of Hashimoto's thyroiditis, Riedel's thyroiditis and Graves disease with elevated IgG4 levels. We report the case of a 59-year-old woman presenting with painless cervical swelling and hypothyroidism. Thyroid gland was enlarged and distinctively very hard, with reduced mobility. Neck ultrasonography showed multiple nodularity and diffuse thyroid enlargement, which on CT scan conditioned slight deviation of the airway. Fine-needle aspiration of the biggest nodule was suggestive of lymphocytic thyroiditis. She developed compressive symptoms and was submitted to total thyroidectomy. Histology of the thyroid revealed extensive areas of fibrosis, oncocytic cells and lymphoplasmacytic infiltrates. Immunohistochemistry confirmed the predominance of IgG4-secreting plasma cells. IgG4-TRD is characterised by a rapidly progressive and destructive thyroiditis process. Typical presentation can often mimic malignancy; hence, an opportune recognition of IgG4-TRD may avoid unnecessary burdens.
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Affiliation(s)
- Tânia Matos
- Endocrinology, Diabetes, and Metabolism Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
| | | | - Lucas Batista
- Surgery Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal,Endocrinology Department, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Sónia do Vale
- Endocrinology, Diabetes, and Metabolism Department, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal,Endocrinology Department, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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32
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Takeshima K, Li Y, Kakudo K, Hirokawa M, Nishihara E, Shimatsu A, Takahashi Y, Akamizu T. Proposal of diagnostic criteria for IgG4-related thyroid disease. Endocr J 2021; 68:1-6. [PMID: 33311000 DOI: 10.1507/endocrj.ej20-0557] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with IgG4-related disease (IgG4-RD) are diagnosed in Japan by comprehensive or organ-specific diagnostic criteria. To date, organ-specific criteria have been established for several organs, but not for the thyroid. We attempted to establish diagnostic criteria for IgG4-related thyroid disease (IgG4-RTD) based on IgG4-RD research by The Research Program on Intractable Diseases from the Ministry of Health, Labour and Welfare of Japan. These criteria have been publicly reported to members of both the Japan Endocrine Society and the Japan Thyroid Association. Thyroid diseases associated with IgG4 include Hashimoto's thyroiditis, Graves' disease and Riedel's thyroiditis. As a comprehensive definition that includes both systematic and organ-specific forms, we use the broad term 'IgG4-related thyroid disease'. Diagnostic criteria for IgG4-RTD comprise the following five items: I) enlargement of the thyroid, II) hypoechoic lesions in the thyroid by ultrasonography, III) elevated serum IgG4 levels, IV) histopathological findings in the thyroid lesion (IgG4+ plasma cells >20/HPF and IgG4+/IgG+ plasma cell ratio >30%) and V) involvement of other organs. "Definitive" diagnosis of IgG4-RTD is made when I, II, III and IV are all fulfilled, while "probable" diagnosis of IgG4-RTD is when I, II, and IV or V are fulfilled. Patients who fulfill I, II and III criteria are considered as "possible" IgG4-RTD. We believe that the proposed diagnostic criteria contribute to more accurate diagnosis of IgG4-RTD as well as exclusion of mimicry. Furthermore, they may lead to better understanding of the clinical implications and underlying pathogenesis of IgG4-RTD.
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Affiliation(s)
- Ken Takeshima
- First Department of Internal Medicine, Wakayama Medical University, Wakayama 641-8509, Japan
| | - Yaqiong Li
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong, 250021, China
| | - Kennichi Kakudo
- Department of Pathology and Thyroid Disease Center, Izumi City General Hospital, Izumi 594-0073, Japan
| | | | - Eijun Nishihara
- Department of Internal Medicine, Kuma Hospital, Kobe 650-0011, Japan
| | - Akira Shimatsu
- Advanced Medical Care Center, Kusatsu General Hospital, Kusatsu 525-8585, Japan
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University Hospital, Nara 634-8522, Japan
| | - Takashi Akamizu
- First Department of Internal Medicine, Wakayama Medical University, Wakayama 641-8509, Japan
- Department of Internal Medicine, Kuma Hospital, Kobe 650-0011, Japan
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Behzadi F, Suh CH, Jo VY, Shanmugam V, Morgan EA, Guenette JP. Imaging of IgG4-Related Disease in the Head and Neck: A Systematic Review, Case Series, and Pathophysiology Update. J Neuroradiol 2021; 48:369-378. [PMID: 33516733 DOI: 10.1016/j.neurad.2021.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022]
Abstract
This systematic review aims to clarify and comprehensively detail the sometimes variable published imaging features as well as the pathogenesis, clinical diagnostic criteria, and treatment options of IgG4-Related Diseases (IgG4-RD) in the head and neck to aid the radiologist in diagnosing relapse and new sites of disease. A literature search in PubMed and EMBASE for reported cases of IgG4-RD was performed in December 2019. Case reports or series of IgG4-RD in the head and neck in adults that included sufficient imaging and pathology findings were included. This yielded 50 reports. IgG4-RD locations included the orbits, thyroid, pituitary gland, paranasal sinuses, salivary and parotid glands, larynx, pharynx, cervical lymph nodes, meninges, and skull base. Most lesions demonstrated non-specific homogenous CT attenuation, diffuse enhancement, isointense/low T2 signal intensity, and low T1 signal intensity. 6 cases from our institution followed previously reported imaging patterns.
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Affiliation(s)
- Fardad Behzadi
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Vickie Y Jo
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vignesh Shanmugam
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Morgan
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey P Guenette
- Division of Neuroradiology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition that often causes the formation of tumefactive lesions. The discovery of IgG4-RD linked many well-known isolated conditions as a distinct multi-organ disease, and started an era of promoting investigation and treatment in relevant fields. In the thyroid gland, a subcategory of Hashimoto thyroiditis (HT) with IgG4-rich inflammation was first discovered and named IgG4 thyroiditis by our group. This subtype of HT presents with rapidly progressive clinical manifestations and destructive histopathological features underlying thyroid dysfunction, which are significantly different from the common type of HT. Moreover, other IgG4-rich thyroid conditions in patients with Graves' disease and systemic IgG4-RD have been described. These observations are most frequently reported in the Asian population for unknown reasons. Although recent studies demonstrated that IgG4 thyroiditis is a specific entity independent from IgG4-RD, recognition of this unique subset of thyroid disease has yielded important insights into understanding its pathogenesis and the development of novel therapeutic approaches.
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Affiliation(s)
- Yaqiong Li
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Keiko Inomata
- Department of Clinical and Laboratory Medicine, Yamashita Thyroid Hospital, Fukuoka, Japan
| | | | - Kennichi Kakudo
- Department of Pathology and Thyroid Disease Center, Izumi City General Hospital, Izumi, Japan
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35
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Cho MJ, Moon HS, Lee HS, Park JH, Kim JS, Kang SH, Lee ES, Kim SH, Sung JK, Lee BS, Jeong HY. Immunoglobulin G4-related disease in the stomach presenting as a gastric subepithelial tumor: Case report. Medicine (Baltimore) 2020; 99:e22078. [PMID: 32899079 PMCID: PMC7478664 DOI: 10.1097/md.0000000000022078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disorder characterized by specific pathologic findings and often, but not in all cases, elevated serum IgG4 concentration. Although it can virtually involve every organ system, cases involving the gastrointestinal tract and especially gastric mass lesions have rarely been reported. PATIENT CONCERNS A 45-year-old man, who was incidentally discovered asymptomatic subepithelial tumor (SET), by endoscopy, on the greater curvature of the upper gastric body, was referred to our hospital for further evaluation. DIAGNOSIS The patient was postoperatively diagnosed with IgG4-RD by histopathologic results. INTERVENTIONS The patient underwent laparoscopic wedge resection. OUTCOMES The patient is presently followed up annually in our clinic and had no problems and showed no signs of recurrence in examination. CONCLUSION We reported a rare case of IgG4-RD presenting as a gastric SET. The first line treatment of IgG4-RD is glucocorticoid administration. However, because pathologic examination is challenging owing to the lesion location, preoperative diagnosis is difficult and may lead to unnecessary gastric resection. Thus, using alternative preoperative diagnostic methods such as endoscopic ultrasound-guided fine-needle biopsy or the biopsy unroofing technique could spare the patient from unnecessary surgical treatment.
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Zala A, Berhane T, Juhlin CC, Calissendorff J, Falhammar H. Riedel Thyroiditis. J Clin Endocrinol Metab 2020; 105:5873864. [PMID: 32687163 DOI: 10.1210/clinem/dgaa468] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/15/2020] [Indexed: 01/10/2023]
Abstract
CONTEXT Riedel thyroiditis (RT) is a rare inflammatory autoimmune disease that is often a clinically diagnostic dilemma because of its insidious presentation and nonspecific symptoms. OBJECTIVE The aim of the present systematic review and meta-analysis is to clarify the presentation, management, and outcomes of RT. STUDY SELECTION A systematic search of PubMed/MEDLINE and Web of Science was conducted to identify relevant reports published up to September 2019. DATA EXTRACTION First author, country, patient sex, ethnicity, presentation, biochemical status, duration of symptoms, histology, treatment, follow-up duration, and short- and long-term outcomes. DATA SYNTHESIS Data from 212 RT patients were retrieved. The mean age was 47 years with a predominantly female population (81%). Neck swelling (89%), dyspnea (50%), and neck pain (41%) were the most common presenting symptoms. Inflammatory markers were elevated in 70% to 97% and thyroid antibody positivity was present in less than 50%. Up to 82% underwent surgical intervention, with the most common being total thyroidectomy in 34% of individuals. Glucocorticoids were used in 70% of individuals with median duration 3 months. Prognosis was reasonable with 90% having resolution or improvement of symptoms. CONCLUSIONS This analysis is the largest and most comprehensive to date of RT and provides clinicians with vital information on the common presentation features that may alert to the diagnosis and highlight management options.
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Affiliation(s)
- Aakansha Zala
- Department of Endocrinology, Royal Darwin Hospital, Northern Territory, Australia
- Department of Endocrinology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Thomas Berhane
- Department of Endocrinology, Royal Darwin Hospital, Northern Territory, Australia
| | - C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Northern Territory, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, Northern Territory, Australia
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Lintusaari J, Vesaniemi E, Kalfert D, Ilvesaro J, Ludvíková M, Kholová I. IgG4-positive plasma cells in Hashimoto thyroiditis: IgG4-related disease or inflammation-related IgG4-positivity? APMIS 2020; 128:531-538. [PMID: 32578252 DOI: 10.1111/apm.13067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/11/2020] [Indexed: 12/24/2022]
Abstract
Despite the interest of researchers in IgG4-related disease (IgG4-RD), many questions still remain unanswered regarding the thyroid gland. We aimed to clarify the relationship between IgG4-positive plasma cells and the histopathological pattern in the Hashimoto thyroiditis (HT) in a Finnish series. HT specimens (n = 280) were retrieved from the Department of Pathology, Fimlab Laboratories. After re-evaluation, 82 (29%) cases (72 females and 10 males, 52 ± 17 years) with significant fibrosis were selected. CD38, IgG and IgG4 positivity in plasma cells was evaluated by immunohistochemistry. Adjusted IgG4-positive plasma cells per HPF > 20 and IgG4- to IgG-positive plasma cell ratio > 30% were adopted as threshold criteria and related to other morphological features. IgG4-positive HT group included 13 cases (15% from fibrotic HT, 4.6% from all HT, 50 ± 15 years, 11 females) with adjusted HPF count 30 ± 5 (23-40) IgG4-positive cells. IgG4-positivity significantly correlated with the presence of lobulation, oncocytic metaplasia and certain type of fibrosis, fibrosis spread outside the gland, lymphocytes/plasma cells epithelial penetration, the predominance of microfollicles and follicular atrophy in the present study. Despite the persisting uncertainty whether HT is IgG4-RD, HT with IgG4-positive plasma cells is histopathologically distinct entity with some geographic variability.
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Affiliation(s)
- Jarkko Lintusaari
- Pathology, Fimlab Laboratories, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Eini Vesaniemi
- Pathology, Fimlab Laboratories, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - David Kalfert
- Department of Otorhinolaryngology and Head and Neck Surgery, First Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | | | - Marie Ludvíková
- Department of Biology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ivana Kholová
- Pathology, Fimlab Laboratories, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Maritati F, Peyronel F, Vaglio A. IgG4-related disease: a clinical perspective. Rheumatology (Oxford) 2020; 59:iii123-iii131. [DOI: 10.1093/rheumatology/kez667] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/10/2019] [Indexed: 12/11/2022] Open
Abstract
AbstractIgG4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory disorder that can affect almost any organ. Common presentations include major salivary and lacrimal gland enlargement, orbital disease, autoimmune pancreatitis, retroperitoneal fibrosis and tubulointerstitial nephritis. The main histopathological features are a dense, polyclonal, lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, storiform fibrosis and obliterative phlebitis. The precise pathogenic mechanisms of IgG4-RD are still unclear. CD4+ T and B cells, including IgG4-expressing plasmablasts, constitute the major inflammatory cell populations and are believed to cause organ damage and tissue fibrosis. The diagnosis of the disease may be challenging and should be based on specific histopathological findings, typical laboratory and radiological aspects and an appropriate clinical context. The first-line treatment of IgG4-RD is based on glucocorticoids, which are usually efficacious. However, B cell depletion induced by rituximab has also been found to induce remission in steroid-resistant disease or has been used as steroid-sparing agent for relapsing disease. This review provides an update on clinical and therapeutic aspects of IgG4-RD.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti, AnconaItaly
| | | | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children’s University Hospital, Florence, Italy
- Department of Biomedical Clinical and Experimental Sciences, University of Firenze, Firenze, Italy
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40
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Boharoon H, Tomlinson J, Limback-Stanic C, Gontsorova A, Martin N, Hatfield E, Meeran K, Nair R, Mendoza N, Levy J, McAdoo S, Pusey C, Wernig F. A Case Series of Patients with Isolated IgG4-related Hypophysitis Treated with Rituximab. J Endocr Soc 2020; 4:bvaa048. [PMID: 32537540 PMCID: PMC7278280 DOI: 10.1210/jendso/bvaa048] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
Context The acute presentation of immunoglobulin G4 (IgG4)-related hypophysitis can be indistinguishable from other forms of acute hypophysitis, and histology remains the diagnostic gold standard. The high recurrence rate necessitates long-term immunosuppressive therapy. Rituximab (RTX) has been shown to be effective in systemic IgG4-related disease (IgG4-RD), but experience with isolated pituitary involvement remains limited. Case Description We report 3 female patients with MRI findings suggestive of hypophysitis. All patients underwent transsphenoidal biopsy and fulfilled diagnostic criteria for IgG4-related hypophysitis. Treatment with glucocorticoids (GCs) resulted in good therapeutic response in Patients 1 and 2, but the disease recurred on tapering doses of GCs. GC treatment led to emotional lability in Patient 3, necessitating a dose reduction. All 3 patients received RTX and Patients 2 and 3 received further courses of treatment when symptoms returned and B-cells repopulated. Patient 3 did not receive RTX until 12 months from the onset of symptoms. Patient 1 was not able to have further RTX treatments due to an allergic reaction when receiving the second dose. Rituximab treatment resulted in sustained remission and full recovery of anterior pituitary function in Patients 1 and 2, with complete resolution of pituitary enlargement. By contrast, Patient 3 only showed a symptomatic response following RTX treatment, but pituitary enlargement and hypofunction persisted. Conclusion Rituximab treatment for IgG4-related hypophysitis resulted in sustained remission in 2 patients treated early in the disease process but only achieved partial response in a patient with chronic disease, suggesting that early therapeutic intervention may be crucial in order to avoid irreversible changes.
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Affiliation(s)
- Hessa Boharoon
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - James Tomlinson
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clara Limback-Stanic
- Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Niamh Martin
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Emma Hatfield
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Karim Meeran
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Ramesh Nair
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel Mendoza
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy Levy
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Steve McAdoo
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Pusey
- Renal Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Florian Wernig
- Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Satou A, Notohara K, Zen Y, Nakamura S, Yoshino T, Okazaki K, Sato Y. Clinicopathological differential diagnosis of IgG4-related disease: A historical overview and a proposal of the criteria for excluding mimickers of IgG4-related disease. Pathol Int 2020; 70:391-402. [PMID: 32314497 DOI: 10.1111/pin.12932] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
IgG4-related disease (RD) is a relatively new entity, which was first proposed in 2001. Since then, clinical and pathological characteristics of the disease have been investigated. As IgG4-RD has been studied extensively, the diagnostic criteria for IgG4-RD of each organ and the comprehensive diagnostic criteria for IgG4-RD have also been developed. However, one of the biggest challenges in the field is distinguishing between IgG4-RD and mimickers, which show overlapping features with IgG4-RD. It is now known that some non-IgG4-RDs may meet the diagnostic criteria of IgG4-RD and can be misdiagnosed as IgG4-RD. However, accurate diagnosis is crucial, as the treatments for IgG4-RD and those for other diseases that may be misdiagnosed as IgG4-RD are different. This prompted us to create and propose comprehensive exclusion criteria for IgG4-RD. In this review, we have described the comprehensive exclusion criteria for IgG4-RD, with a historical overview of the disease. These exclusion criteria were recently created by the Research Program for Intractable Disease of the Ministry of Health, Labor, and Welfare of Japan, All Japan IgG4 team, to support correct and accurate diagnosis of IgG4-RD.
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Affiliation(s)
- Akira Satou
- Department of Surgical Pathology, Aichi Medical University Hospital, Aichi, Japan.,The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan
| | - Kenji Notohara
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Anatomic Pathology, Kurashiki Central Hospital, Okayama, Japan
| | - Yoh Zen
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Institute of Liver Studies, King's College Hospital & King's College London, London, UK
| | - Shigeo Nakamura
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Aichi, Japan
| | - Tadashi Yoshino
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Kazuichi Okazaki
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Yasuharu Sato
- The Research Program for Intractable Disease by Ministry of Health, Labor and Welfare, Japanese Pathology Study Group of IgG4-related Disease, Tokyo, Japan.,Department of Pathology, Okayama University Graduate School of Medicine, Okayama, Japan.,Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
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42
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Maehara T, Moriyama M, Nakamura S. Review of a novel disease entity, immunoglobulin G4-related disease. J Korean Assoc Oral Maxillofac Surg 2020; 46:3-11. [PMID: 32158675 PMCID: PMC7049757 DOI: 10.5125/jkaoms.2020.46.1.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/06/2020] [Indexed: 12/20/2022] Open
Abstract
Immunoglobulin G4 (IgG4)-related dacryoadenitis and sialoadenitis (IgG4-DS) are part of a multiorgan fibroinflammatory condition of unknown etiology termed IgG4-related disease (IgG4-RD), which has been recognized as a single diagnostic entity for less than 15 years. Histopathologic examination is critical for diagnosis of IgG4-RD. CD4+ T and B cells, including IgG4-expressing plasma cells, constitute the major inflammatory cell populations in IgG4-RD and are thought to cause organ damage and tissue fibrosis. Patients with IgG4-RD who have active, untreated disease exhibit significant increase of IgG4-secreting plasmablasts in the blood. Considerable insight into the immunologic mechanisms of IgG4-RD has been achieved in the last decade using novel molecular biology approaches, including next-generation and single-cell RNA sequencing. Exploring the interactions between CD4+ T cells and B lineage cells is critical for understanding the pathophysiology of IgG4-RD. Establishment of pathogenic T cell clones and identification of antigens specific to these clones constitutes the first steps in determining the pathogenesis of the disease. Herein, the clinical features and mechanistic insights regarding pathogenesis of IgG4-RD were reviewed.
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Affiliation(s)
- Takashi Maehara
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Masafumi Moriyama
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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43
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Li Y, Wang X, Liu Z, Ma J, Lin X, Qin Y, Nishihara E, Miyauchi A, Kakudo K. Hashimoto's Thyroiditis with Increased IgG4-Positive Plasma Cells: Using Thyroid-Specific Diagnostic Criteria May Identify Early Phase IgG4 Thyroiditis. Thyroid 2020; 30:251-261. [PMID: 31861966 DOI: 10.1089/thy.2019.0063] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: A subset of Hashimoto's thyroiditis (HT), reported as immunoglobulin G4 (IgG4) thyroiditis, is characterized by IgG4+ plasma cell-rich inflammation and marked sclerotic changes, which suggests a close relationship with immunoglobulin G4-related disease (IgG4-RD). However, to date, there is no consensus regarding the cutoff values used to define a significant IgG4+ plasma cell count in thyroid inflammation. We, therefore, sought to validate both the cutoff value of the comprehensive diagnostic criteria (CVC) and the cutoff value of thyroid-specific diagnostic criteria (CVT) for diagnosing IgG4 thyroiditis. Methods: One hundred twenty cases of HT were retrospectively reviewed. According to the CVC (IgG4+ plasma cells >10/HPF (high-power field) and IgG4+/IgG+ plasma cell ratio >40%) and the CVT (IgG4+ plasma cells >20/HPF and IgG4+/IgG+ plasma cell ratio >30%), cases were subclassified as IgG4 thyroiditis or non-IgG4 thyroiditis. Clinical, serological, sonographic, and histopathological characteristics of the two subsets, and the cases diagnosed as IgG4 thyroiditis using different thresholds were compared. Results: Both the CVC and CVT identified the same set of distinct clinical, laboratory, and sonographic features of the cases diagnosed as IgG4 thyroiditis. All 120 cases of HT were able to be divided into four distinct groups. Group A included the 25 cases who were assigned as IgG4 thyroiditis by both the CVC and CVT, whereas Group D included the 85 cases who did not meet either of the cutoff values. Group B and Group C comprised the borderline cases who only met one of the two thresholds. Based on histological evaluation, the cases in Group B who met the CVT demonstrated similar histological features of IgG4 thyroiditis. Conclusions: Although both of the cutoff values can efficiently distinguish IgG4 thyroiditis from its non-IgG4 counterpart, the thyroid-specific cutoff value (CVT, IgG4+ plasma cells >20/HPF, and IgG4+/IgG+ plasma cell ratio >30%) can better identify borderline cases of HT with more fibrotic changes, which may represent an early phase lesion of IgG4 thyroiditis. We propose a new series of clinical and pathological diagnostic clues for both endocrinologists and pathologists to improve the early recognition of IgG4 thyroiditis.
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Affiliation(s)
- Yaqiong Li
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xinli Wang
- Department of Pathology, Affiliated Hospital of Taishan Medical University, Taian, China
| | - Zhiyan Liu
- Department of Pathology, Shandong University Cheeloo College of Medicine, Jinan, China
| | - Jiwei Ma
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xiaoyan Lin
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yejun Qin
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | | | | | - Kennichi Kakudo
- Department of Pathology and Laboratory Medicine, Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
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Riedel's Thyroiditis: Report of Two Cases and Literature Review. Case Rep Endocrinol 2019; 2019:5130106. [PMID: 31929916 PMCID: PMC6942777 DOI: 10.1155/2019/5130106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/24/2019] [Indexed: 12/24/2022] Open
Abstract
Riedel's thyroiditis is a rare entity consisting of a fibrotic process of the thyroid which can generate gland destruction, infiltration of cervical structures and even airway obstruction. It has been associated with systemic fibrotic disorders, autoimmune diseases, and more recently with spectrum of diseases related to excess of Immunoglobulin G type 4 (IgG4). Two cases of Riedel's thyroiditis by IgG4, confirmed by immunohistochemistry and was managed surgically with favorable results during the follow-up time, are presented. These case descriptions highlight the diagnostic challenge of this disease, describe the response with surgical management, and make a brief update on the subject.
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45
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Inaba H, Ariyasu H, Takeshima K, Iwakura H, Akamizu T. Comprehensive research on thyroid diseases associated with autoimmunity: autoimmune thyroid diseases, thyroid diseases during immune-checkpoint inhibitors therapy, and immunoglobulin-G4-associated thyroid diseases. Endocr J 2019; 66:843-852. [PMID: 31434818 DOI: 10.1507/endocrj.ej19-0234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Various thyroid diseases are associated with autoimmunity. Major autoimmune thyroid diseases are Graves' disease (GD) and Hashimoto's thyroiditis (HT). Thyrotropin receptor is an autoantigen in GD, and its immunogenicity has been examined. Immune-checkpoint inhibitor (ICI) is recently widely used for treatment of malignant tumors, but cases of thyroid diseases during ICI treatment have been increasing. Thyroid diseases during ICI therapy have been investigated in immunological and clinical aspects, and their Japanese official diagnostic guidelines were established. In addition, serum and tissue immunoglobulin-G4 levels have been examined in association with clinicopathological characteristics in GD, HT, and Riedel's thyroiditis. We review these diseases associated with thyroid autoimmunity and comprehensively discuss their potential application in future research and therapeutic options.
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Affiliation(s)
- Hidefumi Inaba
- The First Department of Medicine, Wakayama Medical University, Wakayama, 641-8509, Japan
| | - Hiroyuki Ariyasu
- The First Department of Medicine, Wakayama Medical University, Wakayama, 641-8509, Japan
| | - Ken Takeshima
- The First Department of Medicine, Wakayama Medical University, Wakayama, 641-8509, Japan
| | - Hiroshi Iwakura
- The First Department of Medicine, Wakayama Medical University, Wakayama, 641-8509, Japan
| | - Takashi Akamizu
- The First Department of Medicine, Wakayama Medical University, Wakayama, 641-8509, Japan
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46
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Patil PA, DeLellis RA. Plasma Cell Granuloma of the Thyroid: Review of an Uncommon Entity. Arch Pathol Lab Med 2019; 142:998-1005. [PMID: 30040458 DOI: 10.5858/arpa.2017-0068-rs] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Plasma cell granuloma (PCG) is characterized by proliferation of polyclonal plasma cells with associated fibrosis and is often considered part of the heterogeneous group of inflammatory myofibroblastic tumors (IMTs). The thyroid is rarely affected by PCG. A patient having PCG associated with Hashimoto thyroiditis (HT) prompted our literature search that revealed 18 cases of PCG, 55% (n = 10) of which occurred together with HT. The etiopathogenesis of PCG is unknown and there is no specific treatment except surgical excision for compressive symptoms. This entity has an excellent prognosis with no evidence of recurrence or metastasis. Lesions of the thyroid with infiltrating plasma cells include HT, fibrous variant of HT, plasmacytoma, plasma cell myeloma, Riedel thyroiditis, IgG4 (immunoglobulin G4)-related disease, IMT, and PCG. Inflammatory myofibroblastic tumor has ALK gene rearrangements and is considered a neoplasm as opposed to PCG, which is a reactive polyclonal plasma cell proliferation. We believe IMT and PCG are distinct entities and consensus definitions are required for avoiding confusion in the literature.
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Affiliation(s)
| | - Ronald A DeLellis
- From the Department of Pathology, Warren Alpert Medical School of Brown University, Lifespan Academic Medical Center, Providence, Rhode Island
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47
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Affiliation(s)
- Yuki Ishikawa
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Chikashi Terao
- Center for Investigative Medical Sciences, RIKEN, Yokohama, Japan
- Clinical Research Center, Shizuoka General Hospital, Shizuoka, Japan
- Department of Applied Genetics, The School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
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48
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Rotondi M, Carbone A, Coperchini F, Fonte R, Chiovato L. DIAGNOSIS OF ENDOCRINE DISEASE: IgG4-related thyroid autoimmune disease. Eur J Endocrinol 2019; 180:R175-R183. [PMID: 30889549 DOI: 10.1530/eje-18-1024] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Abstract
IgG4-related disease (IgG4-RD) is fibro-inflammatory, immune-mediated, systemic disease recognized as a defined clinical condition only in 2001. The prevalence of IgG4-RD is 6/100 000, but it is likely to be underestimated due to insufficient awareness of the disease. The diagnostic approach is complex because of the heterogeneity of clinical presentation and because of rather variable diagnostic criteria. Indeed, high concentrations of IgG4 in tissue and serum are not a reliable diagnostic marker. The spectrum of IgG4-RD also includes well-known thyroid diseases including Riedel's thyroiditis, Hashimoto's thyroiditis and its fibrotic variant, Graves' disease and Graves' orbitopathy. Results from clinical studies indicate that a small subset of patients with the above-mentioned thyroid conditions present some features suggestive for IgG4-RD. However, according to more recent views, the use of the term thyroid disease with an elevation of IgG4 rather than IgG4-related thyroid diseases would appear more appropriate. Nevertheless, the occurrence of high IgG4 levels in patients with thyroid disease is relevant due to peculiarities of their clinical course.
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Affiliation(s)
- Mario Rotondi
- Unit of Internal Medicine and Endocrinology, ICS Maugeri I.R.C.C.S., University of Pavia, Pavia, Italy
| | - Andrea Carbone
- Unit of Internal Medicine and Endocrinology, ICS Maugeri I.R.C.C.S., University of Pavia, Pavia, Italy
| | - Francesca Coperchini
- Unit of Internal Medicine and Endocrinology, ICS Maugeri I.R.C.C.S., University of Pavia, Pavia, Italy
| | - Rodolfo Fonte
- Unit of Internal Medicine and Endocrinology, ICS Maugeri I.R.C.C.S., University of Pavia, Pavia, Italy
| | - Luca Chiovato
- Unit of Internal Medicine and Endocrinology, ICS Maugeri I.R.C.C.S., University of Pavia, Pavia, Italy
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Mammen SV, Gordon MB. SUCCESSFUL USE OF RITUXIMAB IN A CASE OF RIEDEL THYROIDITIS RESISTANT TO TREATMENT WITH PREDNISONE AND TAMOXIFEN. AACE Clin Case Rep 2019; 5:e218-e221. [PMID: 31967038 DOI: 10.4158/accr-2018-0352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/16/2019] [Indexed: 01/13/2023] Open
Abstract
Objective Riedel thyroiditis (RT) is a rare disorder with high morbidity and limited treatment options. We describe a case resistant to conventional treatment with corticosteroids and tamoxifen, which subsequently responded to rituximab. Methods Surgical pathology with hematoxylin and eosin staining was initially performed to confirm diagnosis, followed by IgG4 immunostaining and IgG4 serology in the setting of refractory RT, given its association with IgG4-related disease. Response to treatment was monitored subjectively as well as objectively with serial computed tomography scans. Results A 51-year-old female with history of Hashimoto thyroiditis presented with compressive neck symptoms. Imaging was suggestive of a multinodular goiter with a large right thyroid nodule. Total thyroidectomy was planned, however intraoperative findings of a densely adherent thyroid with disruption of resection planes led to early termination of surgery. Biopsies obtained during surgery showed benign thyroid tissue with chronic lymphocytic thyroiditis, dense fibrous scar tissue, and benign lymph nodes, confirming the diagnosis of RT. The patient had minimal symptomatic improvement with chronic prednisone as high as 60 mg daily with tamoxifen at 30 mg twice a day. She subsequently received 4 doses of intravenous rituximab at 375 mg/m2 every 3 weeks, resulting in significant subjective improvement of her compressive symptoms as well as an objective decrease in size of the thyroid mass as seen on a subsequent computed tomography scan. Conclusion Evidence regarding etiology and management of RT is limited. We present a case of refractory RT treated with rituximab with resultant symptomatic improvement, thus providing further evidence for use of rituximab in resistant cases.
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Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently established systemic disease that is characteristically associated with elevated serum immunoglobulin G4 (IgG4) levels and believed to be caused by autoimmune mechanisms. The clinical features of IgG4-RD include (i) systemic distribution, (ii) imaging findings of swelling, nodules, and/or wall thickening, (iii) high serum IgG4 levels, (iv) abundant IgG4-bearing plasma cell infiltration and fibrosis in affected organs, (v) a favorable response to corticosteroid therapy, and (vi) coexistence with other IgG4-RD manifestations simultaneously or in a metachronous fashion. The concept of IgG4-RD was established based on the culmination of specific discoveries. Specifically, a close association between autoimmune pancreatitis (AIP) and high serum IgG4 levels, massive IgG4-bearing plasma cell infiltration in pancreatic tissues affected by AIP, and systemic other organ involvements in AIP with similar IgG4-bearing plasma cell features opened the gateway from AIP to IgG4-RD. The systemic distribution of IgG4-RD seems to be capable of affecting every organ, causing well-established members including AIP, lacrimal and salivary gland lesions such as Mikulicz’s disease, respiratory diseases, sclerosing cholangitis, kidney diseases, and retroperitoneal fibrosis. IgG4-RD has been diagnosed worldwide, and international collaboration efforts on the disease have led to consensus publications on its nomenclature, pathology findings, and management approach. The algorithms developed for the comprehensive diagnostic criteria for IgG4-RD have remarkably increased detection sensitivity. Oral glucocorticoids are the first-line agents for remission induction, and certain patients with high disease activity may benefit from maintenance therapy afterwards. Originally, IgG4-RD had been considered reversible and to have a good prognosis; however, long-term afflictions sometimes result in transition to advanced-stage conditions with dysfunction and/or complicating malignancy. The immunological abnormalities in IgG4-RD have been reported in both innate and adaptive immune systems; however, it remains unclear whether IgG4 has a pathogenic role or a protective one in disease onset and progression.
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Affiliation(s)
- Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
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