Spontaneous regression of lung lesions after excision of the submandibular gland in a patient with chronic sclerosing sialadenitis

Immunoglobulin G4-Related Lung Disease with Waxing and Waning Pulmonary Infiltrates: A Case Report

Immunoglobulin G4 (IgG4)-related lung disease can have various clinical courses. To our knowledge, reports of IgG4-related lung disease with waxing and waning pulmonary infiltrates only are very rare. A few lung nodules and ground glass opacities were incidentally found in a pre-operative evaluation in a 36-year-old female. The lung lesions showed waxing and waning in the follow-up chest CT. She underwent a surgical biopsy, and IgG4-related lung disease was confirmed.

Spontaneous regression of immunoglobulin G4-related dacryoadenitis and multiple organ involvement: A case report

PURPOSE

Immunoglobulin G4 (IgG4)-related dacryoadenitis is rarely resolved spontaneously without steroids. Here, we report a case of IgG4-related dacryoadenitis and extra-ophthalmic lesions with spontaneous regression.

METHODS

This is a clinical case report. A 56-years-old man had a 1-year and 7-month-old histories of neck and eyelid swelling, respectively. On the first examination, the lacrimal and submandibular glands were palpable bilaterally. Computed tomographic images showed enlargement of the lacrimal gland on both sides, right pulmonary hilar lymph node, and pancreas, and thickening of the abdominal aortic wall. Blood tests demonstrated elevated serum IgG4 level and positive hepatitis B surface antibody. Pathological examination of the biopsied lacrimal gland specimens revealed marked IgG4-positive plasma cell infiltration.

RESULTS

The patient was monitored carefully without steroid administration. Serum IgG4 level had gradually decreased during follow-up period and reached the normal range 3 years after the biopsy. At 4-year follow-up, the lacrimal and submandibular glands were not palpable on either side. Computed tomographic images demonstrated no enlargement of the lacrimal gland, submandibular gland, or lymph nodes, and improvement of the enlarged pancreas and thickened abdominal aortic wall.

CONCLUSION

Our case indicates that careful observation can be an option in selected cases with risks of steroid treatment or silent clinical course.

Update on classification, diagnosis, and management of immunoglobulin G4-related disease

Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized chronic fibro-inflammatory autoimmune disease, and its recognition has been constantly increasing worldwide over the last few years. A correct and timely recognition, as well as appropriate intervention, is crucial for the treatment of IgG4-RD. For certain subtypes of IgG4-RD, organ-specific criteria are formulated to make the diagnosis more accurate. New biomarkers have emerged in the recent years to aid the disease diagnosis, its prognosis prediction, as well as therapy response monitoring. Although recurrence is very common in IgG4-RD, glucocorticoid is still the first-line treatment for the majority of patients. The factors that affect the likelihood of disease relapse are multifaceted. The selection strategy of various steroid-sparing agents is still being explored. Besides, when patients have special sites involvement leading to severe clinical conditions, surgical operation or interventional therapy should also be considered. An update on classification, diagnosis, and management of IgG4-RD is provided in the current study to fully elucidate the recommended clinical practice of this mysterious disease.

Natural developing process of immunoglobulin G4-related sialadenitis after submandibular gland excision: a retrospective cohort study

OBJECTIVE

This study aimed to evaluate the long-term outcome and quality of life of IgG4-related sialadenitis (IgG4-RS) patients after submandibular gland (SMG) excision without immunomediate therapy.

MATERIALS AND METHODS

This retrospective review included patients with IgG4-RS who did not undergo further treatment following SMG excision. All patients diagnosed with IgG4-RS between January 1955 and December 2012 at the Department of Oral and Maxillofacial Surgery, Peking University School of Stomatology, were enrolled. The main outcome measures included postoperative IgG4-RS progression rate and differences between patients with and without recurrent disease. The degree of subjective oral dryness was evaluated using the summated xerostomia inventory (SXI); the objective secretory function was assessed by whole saliva flow rate measurements. Serological findings were analyzed during the follow-up.

RESULTS

SMG excision was adopted in all of the 83 patients. The median follow-up period was 108 (range 7-396) months. Clinical progression was observed in 54.2% of cases. Patients with other organ involvement (OOI) indicated higher progression rate to a significant extent (P = 0.015, HR = 2.108). The annual progression rate was 20.7% in the group with OOI and was 14.1% in the group without OOI. All cases showed higher levels of serum IgG4; the level was in positive correlation with follow-up time when no therapy was added. 82.4% of cases experienced xerostomia after the surgery, and the degree of dry mouth in patients underwent bilateral resection was significantly more severe than those in unilateral resection.

CONCLUSIONS

Surgical excision of involved SMG cannot control the disease progression, which is not recommended for treatment of IgG4-RS. Differential diagnosis is crucial in order to prevent irreversible organ loss and relevant salivary gland dysfunction. Key Points • Surgical excision of involved SMG cannot control progression of IgG4-RS.

The prevalence of extra-salivary gland complications in immunoglobulin G4-related sialadenitis

OBJECTIVES

To estimate the prevalence of extra-glandular lesions in patients with immunoglobulin G4-related sialadenitis (IgG4-RS).

METHODS

Six electronic databases (PubMed, EMBASE, Science Direct, Scopus, Web of Science, and China National Knowledge Infrastructure) were systematically searched from the date of inception of each database to March 2021. The Strengthening the Reporting of Observational Studies in Epidemiology statement was used to conduct methodological quality assessment, and a random-effect meta-analysis model was applied to estimate the prevalence. Publication bias was visually assessed using a funnel plot and calculated via Begg's and Egger's tests. The Stata 15 software was used to perform data analysis.

RESULTS

A total of 43 articles comprising 1,864 patients with IgG4-RS were considered to be eligible for this study. The pooled prevalence of extra-salivary gland lesions in IgG4-RS was 76.53% with a confidence interval (CI) of (69.39%, 83.04%). A higher prevalence was associated with studies published before or during 2015 (84.38%, CI [74.23%, 92.58%]) than those published after 2015 (68.55%, CI [58.44%, 77.88%]). Lacrimal gland involvement (54.68%, CI [45.61%, 63.60%]) and lymph node swelling (56.96%, CI [48.16%, 65.56%]) were the most frequent lesions.

CONCLUSIONS

Extra-glandular lesions were common in patients with IgG4-RS. More high-quality prospective studies with less heterogeneity are required to determine the accurate prevalence.

IgG4-related disease: a clinical perspective

IgG4-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.

IgG4-related disease in the head and neck

PURPOSE OF REVIEW

To summarize current evidence regarding the pathophysiology, diagnostic criteria, and management of IgG4 disease in the head and neck.

RECENT FINDINGS

The anti-CD20 antibody, rituximab is being used increasingly as a primary treatment modality in cases with a definitive diagnosis. Despite the favorable prognosis, it is now recognized that the incidence of cancer development within 3 years of diagnosis is higher than that of the general population.

SUMMARY

IgG4-related disease is a sclerosing, chronic inflammatory disease, that is benign, and usually occurs in middle-aged to elderly individuals. Definitive diagnosis of IgG4-related disease requires radiological confirmation of enlargement of the affected organ, elevated serum IgG4 levels, and characteristic histopathological findings. Treatment is primarily with systemic corticosteroids or the monoclonal anti-CD20 antibody rituximab, surgical excision, or a combination of treatment modalities. Prognosis is good with complete remission in up to 90% of patients.

Spontaneous Regression of Swollen Submandibular Glands in IgG4-Related Disease

Background

IgG4-related disease is a new clinical entity frequently associated with swelling of the submandibular glands (SMGs). The long-term outcome of SMG swelling without steroid therapy remains unknown.

Objective

To examine whether swollen SMGs spontaneously regress without steroid therapy in the context of IgG4-related disease and to identify biomarkers that can predict the spontaneous regression of SMG swelling.

Methods

The SMG volume of 49 patients diagnosed with IgG4-related disease was calculated by measuring the axial and coronal planes of computed tomography scans. The change in SMG volume over time was measured and examined by treatment regimen, clinical data, and serum complement level.

Results

We found 28 of 49 (57%) IgG4-related disease patients to have swollen SMGs, with 15 of 20 (75%) of the swollen SMGs regressing without steroid therapy. The time required for the SMGs swelling to regress was significantly shorter in the steroid therapy group than in the no-steroid therapy group. Serum complement components at the initial visit were significantly lower in the regressed SMG group than in the nonregressed SMG group.

Conclusion

We observed 75% of swollen SMGs spontaneously regressed in patients with IgG4-related disease. The time required for the swollen SMGs to regress was longer in patients without steroid therapy than in those with steroid therapy. Serum complement level could be used as a predictor for the spontaneous regression of swollen SMGs in patients with IgG4-related disease.

Recent advances in knowledge regarding the head and neck manifestations of IgG4-related disease

IgG4-related disease (IgG4-RD) is a chronic inflammatory disorder, characterized by elevated serum IgG4 levels as well as abundant infiltration of IgG4-positive plasmacytes and fibrosis in various organs, including the head and neck region. In particular, the salivary glands, orbit, and thyroid are common sites of disease involvement. IgG4-RD is diagnosed based on various clinical, serological, and histopathological findings, none of which are pathognomonic. Hence, various differential diagnoses, which exhibit elevated serum IgG4 levels and infiltration of IgG4-postive cells into tissues, need to be excluded, especially malignant diseases and mimicking disorders. Systemic corticosteroids are generally effective in inducing IgG4-RD remission; however, recurrent or refractory cases are common. In addition, although the pathogenic mechanisms of IgG4-RD remain unclear, an antigen-driven inflammatory condition is believed to be involved. Recent studies have indicated the important pathogenic role of B cell/T cell collaboration and innate immunity in this disease. Nevertheless, additional research and discussions are needed to resolve many remaining questions. In this review, we provide an overview of the recent insights on the history, clinical features, diagnosis, and treatment of IgG4-RD in the head and neck region. Furthermore, we have also addressed the pathogenesis of this disease.

IgG4-related disease: current challenges and future prospects

Immunoglobulin G4-related disease (IgG4-RD) represents an immune-mediated fibroinflammatory condition with a characteristic histopathological appearance that can affect various organs. Although numerous single-organ manifestations have been described more than a century ago, its systemic nature and unique features were only discovered in the last 2 decades, when IgG4-RD emerged as a new entity of disease. IgG4-RD is usually considered a rare disease, but its true epidemiology has not yet been fully clarified. Also, despite recent advances in the identification of the underlying immunological processes, its pathophysiology is only incompletely understood till now. The diagnostic workup of IgG4-RD is complex and usually requires a combination of clinical examination, imaging, histological, and serological analyses. However, no finding alone is specific for IgG4-RD. Therefore, its diagnosis requires careful interpretation of examination results in context with the patient’s clinical appearance as well as the exclusion of a broad variety of differential diagnoses. The past years brought rapid advances concerning this novel disease entity: diagnostic criteria, further insights into the underlying immunological processes, new biomarkers, and novel therapeutic approaches were proposed and widened the knowledge in the field of IgG4-RD. Still, a greater number of questions remain unanswered, and many recent developments require further discussion and proof from clinical trials. This review should give an overview on current knowledge and future perspectives in epidemiology, pathophysiology, diagnosis, and therapy of IgG4-RD.

IgG4-related disease of the head and neck

IgG4-related disease is an uncommon sclerosing and inflammatory mass-forming disease that may affect a single organ or be systemic. The prototypical example of the disease is type 1 autoimmune pancreatitis. After the pancreatobiliary system, the head and neck is the next most common site for involvement by IgG4-related disease. Here, we describe the clinicopathologic features of the head and neck involvement by this disease process with particular attention to involvement of the major salivary glands, the lacrimal glands and periorbital tissues, the upper aerodigestive tract, the thyroid gland, lymph nodes, the ear, and the skin and soft tissues.

Spontaneous regression of IgG4-related dacryoadenitis

This is the first report showing the clinical course of a patient with bilateral IgG4-related dacryoadenitis, which spontaneously regressed after excision of the left lacrimal gland. A 65-year-old female had been aware of bilateral eyelid swelling without pain for 5 years. Magnetic resonance imaging revealed enlargement of bilateral lacrimal gland. Laboratory tests showed high IgG4 concentrations, measuring 394 mg/dl. The biopsied specimen of the left lacrimal gland revealed marked lymphoplasmacytic infiltration with mild fibrosis. Marked IgG and IgG4-positive plasma cells surrounded the lymphoid follicles. Although the patient did not wish to undergo any treatments, lacrimal gland lesions showed gradual remission. This case highlights the potential of spontaneous improvement in IgG4-related dacryoadenitis, indicating that careful observation may be one of the therapeutic options for such patients.