IgG4-related orbital inflammation presenting as unilateral pseudotumor

The Management of IgG4-Related Disease in Children: A Systematic Review

Background/Objectives: IgG4-related disease (IgG4-RD) is a multi-organ disease with greatly varying therapeutic approaches and a lack of specific treatment algorithms. This systematic review aimed to determine the therapeutic approaches for pediatric IgG4-RD in real-word practice. Methods: We searched PubMed and Google Scholar for articles on pediatric IgG4-RD cases published in English from 2012 to August 2024, focusing on treatments and outcomes. Study type, treatment(s), dose/regimen, age and sex, organ(s) involved, and treatment outcomes were manually extracted from each study. Results: Of the 219 studies identified, we analyzed 81 studies, including 114 pediatric IgG4-RD cases. Fifty-seven percent of patients suffered from multi-organ disease and required several treatment schemes. Around 75% received steroids, alone or in combination, regardless of the organ affected. The treatment outcomes were positive in most cases, although relapses occurred in approximately 30% of patients, usually upon steroid tapering. Other common therapeutic approaches included immunosuppressants, often used as steroid-sparing agents, with azathioprine and mycophenolate mofetil being the most common; surgery for localized disease; and biologics, mainly rituximab, used in more severe/refractory cases. Uncommon but effective therapies included adalimumab and ruxolitinib. Drug combinations seemed to be more efficacious than monotherapies across studies. Patients > 10 years old more frequently received aggressive approaches (surgery and rituximab) and more often experienced relapses. Relapse rates were higher among females. Conclusions: This review highlights the use of systemic steroids as an effective first-line treatment for pediatric IgG4-RD, but also underscores the use of non-steroid-based alternatives in combination with steroids or other immunosuppressants for the effective management of IgG4-RD.

IgG4-Related Dacryoadenitis With Fibrous Mass in a 19-Month-Old Child: Case Report and Literature Review

A 19-month-old boy presented with eyelid swelling, proptosis, and upgaze limitation in the OD. The radiological study showed a homogeneous mass enclosing the lacrimal gland. Near-total tumor excision revealed IgG4-related orbital disease. Eosinophilia, serum IgG4, and IgE elevations were detected without extraorbital involvement. The patient received oral prednisolone for 4 months postoperatively and remained relapse-free for 27 months. Among the 17 well-documented pediatric cases of IgG4-related orbital disease in the literature (including this case), 59% were female, and the median age was 10 years; 2 patients were under 2 years old. The disease was unilateral in 82% of the patients and caused a soft tissue mass in 88%, involving the lacrimal gland in 53%. Nine patients received immunosuppression only, 4 surgery and immunosuppression, and 2 only surgical excision. Treatment results were reported in 13 patients, and all were favorable. IgG4-related dacryoadenitis with a fibrous mass may occur in very young children, responding well to surgical excision and steroids. Although pediatric IgG4-related orbital disease is not well-characterized yet, it may manifest differently from its adult variant.

Pediatric IgG4-related disease: a descriptive review

INTRODUCTION

IgG4-related disease (IgG4-RD) is an immune-mediated systemic fibroinflammatory condition characterized by serum IgG4 elevation and IgG4-positive plasma cell infiltration into various organs. It generally occurs in elderly males. Pediatric cases have been reported, albeit rarely, accordingly lack of recognition of such cases could delay therapeutic intervention leading to poorer outcomes.

AREAS COVERED

The present review is a descriptive review of all published case reports, cohort studies, and reviews of pediatric IgG4-RD listed in PubMed. Characteristics of pediatric IgG4-RD were clarified, including sex, organ involvement, serological and histological findings, and treatment. We assessed how many published cases met current classification and comprehensive diagnostic criteria.

EXPERT OPINION

The characteristics of pediatricIgG4-RD differed from adult IgG4-RD in terms of sex and involved organs. There was no clear male dominance in numbers of cases, and surface organ involvement such as ophthalmic diseases were more common in the pediatric IgG4-RD. Organ involvement tended to be indolent and unilateral, causing difficulty in definitively diagnosing pediatric IgG4-RD. Only about 20% of published cases met IgG4-RD classification or comprehensive diagnostic criteria. Physicians should be careful in diagnosing pediatric IgG4-RD after excluding mimickers. International collaboration toward high-quality evidence to support diagnosis and treatment of pediatric IgG4-RD is advised.

IgG4 related pericardium and lung disease in pediatric patient complicated with fatal massive hemoptysis: a case report and review of literature

BACKGROUND

IgG4-related disease (IgG4-RD) is a progressive and sometimes fatal disease that rarely affects pediatric age group. It may affect the orbits, lacrimal and salivary glands, pancreas, kidneys, peritoneum and other organs. Lung and pleura are not commonly reported in IgG4-RD. We here present a rare case of pediatric IgG4-RD with rare involvement of pericardium, pleura and lungs.

CASE PRESENTATION

A 13-year-old girl presented with intrathoracic IgG4-RD with pleuropericardial involvement. She showed initial improvement on prednisolone. Azathioprine and then mycophenolate failed to control relapses during steroid tapering. Her last relapse was treated by rituximab however, the patient developed acute fatal massive hemoptysis.

CONCLUSIONS

Pediatric IgG4-RD is a rare entity with pericardio-pulmonary affection as the rare of the rare. Usual treatment of prednisolone and steroid sparing agents should be used, with rituximab used as a rescue therapy, but fatal complications may occur.

Clinicopathologic Characterization of IgG4-Rich Pediatric Head and Neck Lesions

CONTEXT.—

Immunoglobulin G4 (IgG4)-related disease is rare but well characterized in adults; however, the clinical and histologic manifestations in children may differ.

OBJECTIVE.—

To review the clinical and histologic features of IgG4-rich head and neck lesions in a pediatric population.

DESIGN.—

Retrospective search for cases with IgG4 immunohistochemical staining performed at our institution from 2011 to 2019. Review of clinical courses, serology profiles, histologic patterns, and immunohistochemical staining patterns.

RESULTS.—

Four pediatric IgG4-rich lesions were identified and showed distinct histologic patterns from adult IgG4-related disease, including absence of pathognomonic findings associated with the latter. One case showed intralesional immunoglobulin light-chain restriction. Clinical review showed serum IgG4 elevation in 2 of 4 cases, presence of additional autoantibody positivity, and a generally benign/treatment-responsive clinical course.

CONCLUSIONS.—

Pediatric IgG4-related disease shows distinct clinical, serologic, and histologic features from its adult counterpart. Pediatric IgG4-related disease involving the orbit has unique clinical characteristics, including frequently normal serum IgG4 levels and female predominance. Awareness and evaluation for these features may improve diagnosis and treatment.

Tumour of the orbit and pterygopalatine fossa: delayed recognition of possible IgG4-related disease

Introduction

IgG4-related disease (IgG4-RD) is a systemic fibrotic-inflammatory disease characterised by elevated serum concentration of IgG4 and tissue infiltration by plasma cells. IgG4-RD is a newly recognised fibro-inflammatory condition, characterised by organ mass lesions, special histopathological appearance, and - often but not always - elevated serum IgG4 concentrations. IgG4-RD is a separate, clinically distinct disease entity, but, due to its heterogeneous manifestation, it is a subject of interest of physicians of various specialties. Histopathological examination is the gold standard in the diagnosis.

Case report

In the paper we discuss the case of a 13-year-old patient who had been diagnosed with fully symptomatic IgG4-RD nine years after initial manifestation. Although IgG4-RD is diagnosed markedly more often in adults than in children, in this case report we would like to emphasise that the disease may also occur in paediatric patients, and it constitutes both a diagnostic and therapeutic challenge in this age group.

Conclusions

IgG4-RD is a poorly recognised disease, especially in the paediatric population. To the best of our knowledge, case reports on IgG4-RD in paediatric patients available in the literature are sparse. The non-specific and heterogeneous manifestation may hinder the diagnostic process, and in some cases the disease is diagnosed accidentally, especially when it is asymptomatic. Since 2015, the first-line treatment in IgG4-RD has been glucocorticoids; however, combination therapies should not be underestimated as another method to achieve permanent remission.

The treatment outcomes in IgG4-related orbital disease: a systematic review of the literature

IgG4-related disease (IgG4-RD) is an immune-mediated systemic fibro inflammatory disease. Treatment of IgG4-related orbital disease (IgG4-ROD) is often indicated to relieve the symptoms and to prevent complications. For IgG4-ROD, no international formal treatment guidelines are available and the optimal treatment strategy is uncertain. In this systematic review, we describe the efficacy of conventional and biologic disease-modifying antirheumatic drugs (DMARDs) in IgG4-ROD. A systematic search of Embase, Medline, Web-of-Science, PubMed publisher, Cochrane and Google Scholar was performed for treatment outcomes in IgG4-ROD. Relevant articles on treatment of IgG4-ROD were retrieved to last date of inclusion 3 January 2018. The following inclusion criteria were used: articles in English or English translation, studies evaluating the use of DMARDs (conventional and biologic) in the treatment of IgG4-ROD. Meta-analysis and review articles were excluded. A final selection after full-text evaluation was made by independent reviewers, based on treatment of IgG4-ROD with DMARDs and the availability of treatment outcomes. With this systematic review, we identified 35 studies and case reports/series on IgG4-ROD, describing 95 patients, treated with conventional and/or biologic DMARDs. The success of conventional DMARDs varies between 36% and 75% in patients with IgG4-ROD, while rituximab is successful in the majority (93%) of the patients. Based on this systematic review, rituximab is the most effective DMARD in IgG4-ROD, while the efficacy of conventional DMARDs is limited. We propose early initiation of rituximab in case of refractory and organ- or life-threatening disease.

Ocular manifestations of IgG4-related disease in children. More common than anticipated? Review of the literature and case report

IgG4-related disease (IgG4-RD) is an entity with various clinical manifestations. Histopathologically, it is characterized by lymphoplasmacytic infiltrates enriched in IgG4 (+) plasmacytes and usually fibrosis of the affected tissue. Most of the patients have also increased IgG4 serum levels and they respond to glucocorticosteroids. In children, due to its rare occurrence, IgG4-RD is ill defined. From the published studies, so far, it appears that ocular manifestations are very common in the paediatric population with IgG4-RD. Herein, we describe a new case of a child with IgG4-RD with ocular involvement manifested with orbit and eyelid swelling, successfully treated with steroids. In addition, we review the clinical, laboratory, histopathologic and radiologic characteristics of the published paediatric cases with IgG4-RD and ocular involvement, critically comparing them with the characteristics of the adult population. It seems that ocular manifestations are more frequently observed in children than in adults. Also, the pattern of involvement is different, with extraocular muscles and soft tissues being more commonly affected than the lacrimal glands.

IgG4-related inflammatory pseudotumor: A systematic review of histopathological features of reported cases

OBJECTIVES

There is marked inconsistency in reporting the key features of IgG4-related inflammatory pseudotumor (IPT) cases. We aimed to analyze the various aspects of IgG4-related IPTs and to test the performance of the consensus criteria for their diagnosis.

METHODS

PubMed database was searched for IgG4-related IPT cases. The data regarding patient demographics, clinical presentation, laboratory findings, histopathological features, and treatment response are extracted and are presented here in a descriptive manner.

RESULTS

The study included 40 papers describing the clinicopathological features of 83 IPTs in 80 patients. Seventeen cases were diagnosed on biopsies; while remaining were diagnosed on excision specimens. Among these, 50 cases were categorized as highly suggestive and 24 cases as probable for IgG4RD; while nine cases had insufficient histopathological evidence of IgG4RD. Two cases diagnosed on biopsies having insufficient evidence of IgG4RD showed partial or no response to steroids; while 12/14 cases (85.71%) diagnosed on biopsies that were histologically suggestive or probable for IgG4RD showed prompt response to steroids.

CONCLUSION

Many reports have not specifically mentioned the full histopathological findings of IgG4-related IPTs that may hinder in refining the diagnostic criteria of IgG4RD. The IgG4-related IPTs diagnosed on biopsies with requisite features showed prompt response to steroids indicating specificity of histopathological findings in predicting treatment response.

IgG4-related disease: a systematic review of this unrecognized disease in pediatrics

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibro-inflammatory condition with an unclear pathophysiological mechanism affecting different parts of the body. If untreated, the disease can lead to fibrosis and irreversible organ damage. IgG4-RD mostly has been described in adults, hence it is generally unknown among pediatricians. This systematic search of the literature provides an overview of all reports published on IgG4-RD in children in order to create awareness of IgG4-RD in pediatrics and to emphasize the broad clinical presentation of this disease.

METHODS

A systematic literature search of Embase, Medline, Web-of-Science, PubMed publisher, Cochrane and Google Scholar was performed for case reports on IgG4-RD in children.

RESULTS

Of total 740 articles identified by the search, 22 case reports including 25 cases of IgG4-RD in children were found. The median age of the children was 13 years, of which 64 % were girls. IgG4-related orbital disease (44 %) and autoimmune pancreatitis type 1/IgG4-related pancreatitis (12 %) predominantly occurred. Less frequently, other manifestations as pulmonary manifestation, cholangitis and lymphadenopathy were also found. Almost all cases were histologically proven. Prednisone was the first choice of treatment leading to favorable clinical response in 83 % of the cases. Maintenance therapy with steroid sparing agents was required in 43 % of the cases needing therapy. Rituximab was successful in all 4 cases, whereas, the disease modifying rheumatic drugs (DMARDs) mycophenolate mofetil, azathioprine and methotrexate were effective in almost 50 % of the cases.

CONCLUSION

IgG4-RD in children is a generally unknown disease among pediatricians, but several pediatric cases have been described. Prednisone is the first choice of treatment leading to disease remission in the majority of the cases. DMARDs and rituximab are alternative effective steroid sparing agents with more positive evidence for the latter.

Structural properties of adenovirus DNA's

The current study presents the case of a 9-year-old Chinese boy who presented with eosinophilia and elevated serum levels of immunoglobulin G4 (IgG4). A bone marrow puncture identified an elevated eosinophil rate of 23% (normal range, <5%), which indicated eosinophilia. However, gene analysis, fluorescent in situ hybridization and other examinations, including bone marrow aspiration, blood routine, auto-antibody tests and parasitic and allergens screening, contradicted a diagnosis of secondary or clonal eosinophilia. Furthermore, the patient exhibited multiple lymph node swelling and a lymph biopsy strongly indicted a pathological diagnosis of IgG4-related disease (IgG4-RD). His peripheral blood flow cytometry confirmed an elevated count of plasmablasts, which is specific to IgG4-RD. The patient responded well to therapy with prednisone and remained healthy in all follow-ups. By taking all these factors into consideration, the boy was diagnosed with IgG4-RD. It is difficult to distinguish IgG4-RD from hypereosinophilic syndrome and the potential association between the two remains unclear. However, the present case study serves as a reminder that IgG4-RD may occur in children and medical professionals should not neglect this possibility.