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Kawahara H, Mizushima I, Matsumoto Y, Sakata K, Takamura M, Inoue D, Kasashima S, Kawano M. Solitary recurrence of IgG4-related giant coronary aneurysm: Case report and review of the literature focusing on treatment strategies and complications. Mod Rheumatol Case Rep 2023; 8:182-194. [PMID: 37947034 DOI: 10.1093/mrcr/rxad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
Coronary periarteritis is a dangerous manifestation of IgG4-related disease, because it forms coronary artery aneurysms, which may cause sudden cardiac death. We report the case of a 78-year-old woman with IgG4-related coronary periarteritis and a coronary aneurysm, which showed progressive enlargement despite maintenance therapy for Type 1 autoimmune pancreatitis. This case was unique, in that coronary periarteritis was the only active lesion that recurred. Low-dose glucocorticoids suppressed the progression of periarterial lesions but led to rapid thinning of the aneurysmal wall and an increase in the size of mural thrombi, which pose a risk of myocardial infarction. Our systematic literature review including 98 cases of 86 articles was performed to examine its treatment strategies and complications. Among the cases in which the effect of immunosuppressive therapy could be followed radiologically, 33 of 37 (89.1%) cases showed improvement in wall thickening/periarterial soft tissue, while 6 of 13 (46.2%) showed worsening increase in the outer diameter of the coronary aneurysms. We propose a draft treatment algorithm and suggest that immunosuppressive therapy for IgG4-related coronary periarteritis with coronary aneurysms should be conducted only after the therapeutic benefit has been determined to outweigh the risks. Because coronary periarteritis can occur without other organ involvement, as in our case, all cases of IgG4-related disease require careful monitoring of coronary artery lesions.
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Affiliation(s)
- Hiroyuki Kawahara
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yasushi Matsumoto
- Department of Cardiovascular Surgery, National Hospital Organization Kanazawa Medical Center, Kanazawa, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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2
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Ito T, Fukui S, Kanie T, Tamaki H, Okada M. Immunoglobulin G4-related coronary periarteritis: a systematic literature review with a case series. Clin Rheumatol 2022; 41:2281-2295. [PMID: 35445950 DOI: 10.1007/s10067-022-06179-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/13/2023]
Abstract
We aimed to assess the clinical and radiological characteristics of immunoglobulin G4-related coronary periarteritis through a systematic literature review and from our case series. In the systematic literature review, we assessed English language manuscripts on immunoglobulin G4-related coronary periarteritis cases. Additionally, we identified patients with immunoglobulin G4-related coronary periarteritis at St. Luke's International Hospital in Tokyo, Japan, from 2014 to 2020. We summarized patients' demographics, immunoglobulin-G and -G4 titers, site and morphological features of the coronary lesion, and other organ involvements. We identified 38 cases from the literature and four patients from our institute. Coronary lesions were detected using coronary computed tomography in 40 (95.2%) patients. Mass-like or diffuse wall-thickening lesion was the most frequently observed type in 33 (78.6%) patients. No trends at the site of the coronary arteries were identified. Overall, 32 (76.1%) patients had multiple-organ involvement, of which the most common lesion was peri-aortitis in 21 (50.0%) patients. Ten (23.8%) patients with an isolated coronary lesion had significantly lower immunoglobulin-G4 titers than those with other organ involvements (immunoglobulin-G4: 261 [161.0, 564.0] vs. 1355.0 [320.8, 2480.0] mg/dL, p = 0.033). The wall-thickening lesions responded well to immunosuppressive treatments. Mass-like or diffuse wall-thickening on coronary computed tomography is a characteristic radiographic finding of immunoglobulin G4-related coronary periarteritis, which can occur in any branch. Immunoglobulin G4-related coronary periarteritis showed similar characteristics to other organ lesions, including its relatively low serum immunoglobulin-G4 level in patients with a single-organ disease and its high responsiveness to glucocorticoids.
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Affiliation(s)
- Takanori Ito
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan. .,Department of Emergency and General Medicine, Kyorin University, Tokyo, Japan.
| | - Takayoshi Kanie
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
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Yardimci GK, Ardali Duzgun S, Bolek EC, Kilic L, Canpolat U, Hazirolan T, Aytemir K, Karadag O. Coronary (peri)-arteritis in patients with IgG4-related disease: A case series from the Central Anatolia Region of Turkey. Int J Rheum Dis 2021; 24:1004-1013. [PMID: 34138520 DOI: 10.1111/1756-185x.14153] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/29/2021] [Accepted: 05/20/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized fibro-inflammatory disease which affects many systems, as well as the cardiovascular system. Identifying the coronary involvement like periaortitis, coronary periarteritis and pericarditis is important, as they often cause unfavorable outcomes. METHODS Eighty-one patients with IgG4-RD were retrospectively evaluated for symptomatic coronary artery involvement from Hacettepe University Vasculitis Research Center (HUVAC) database. The demographic, laboratory, radiologic and clinical characteristics of the patients were assessed. RESULTS Among 81 patients with IgG4-RD, 6 patients (M/F:5/1) had coronary artery involvement. The patients' median age was 57 and serum IgG4 levels were above normal except for one case. All patients with coronary arteritis revealed an increased coronary vessel wall thickening and stenotic lesions. The coronary aneurysm and pericarditis were observed in half of the patients. Immunosuppressive treatments were given to all the patients and most of them followed in stable condition. CONCLUSION Coronary arteritis is a rare but notable manifestation of IgG4-RD. Although coronary periarteritis can cause significant morbidity and mortality, it seems better results can be achieved with early diagnosis and treatment.
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Affiliation(s)
- Gozde Kubra Yardimci
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
| | - Selin Ardali Duzgun
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ertugrul Cagri Bolek
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
| | - Levent Kilic
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
| | - Ugur Canpolat
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tuncay Hazirolan
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Vasculitis Research Center, Hacettepe University, Ankara, Turkey.,Department of Cardiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Vasculitis Research Center, Hacettepe University, Ankara, Turkey
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Wallace ZS, Perugino C, Matza M, Deshpande V, Sharma A, Stone JH. Immunoglobulin G4-related Disease. Clin Chest Med 2020; 40:583-597. [PMID: 31376893 DOI: 10.1016/j.ccm.2019.05.005] [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] [Indexed: 12/14/2022]
Abstract
Immunoglobulin G4 (IgG4)-Related Disease (IgG4-RD) can cause fibroinflammatory lesions in nearly any organ and lead to organ dysfunction and irreversible damage. In addition to frequent involvement of the salivary glands, lacrimal glands, and/or pancreas, IgG4-RD often affects the chest. Thoracic manifestations include lung nodules and consolidations, pleural thickening, aortitis, and lymphadenopathy. The diagnosis is made after careful clinicopathologic correlation because there is no single diagnostic test with excellent sensitivity or specificity. Biopsy of pulmonary lesions can be useful for distinguishing IgG4-RD from common mimickers. Immunosuppressive regimens, such as glucocorticoids and/or glucocorticoid-sparing agents, form the cornerstone of treatment.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | - Cory Perugino
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Mark Matza
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Amita Sharma
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - John H Stone
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Borges T, Silva S. IgG4-related disease: How to place it in the spectrum of immune-mediated and rheumatologic disorders? Mod Rheumatol 2020; 30:609-616. [PMID: 31852351 DOI: 10.1080/14397595.2019.1705537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disorder that results from massive expansion of polyclonal IgG4-switched B and/or plasma cells. It can virtually affect all organs and its diagnosis relies on clinical, serological and histopathological criteria. The role of autoimmunity and adaptive immune system in IgG4-RD is reflected in plasmablast differentiation, germinal center formation and IgG4 production induced by CD4+ cells expressing CD40 ligand. IgG4-RD has been considered to be a Th2/Treg-driven disorder, but follicular helper T cells are important in driving the IgG subclass switch. Prompt clinical responses to rituximab, human leukocyte antigen (HLA) associations and the presence of autoantibodies also point to the importance of adaptive immune system. However, innate immunity may induce storiform fibrosis through T-cell independent responses as a consequence of toll-like receptors activation by microbe-and damage-associated molecular patterns, while macrophages and basophils also appear to have a significant role in IgG4-RD pathogenesis. Allergic mechanisms may drive IgG4-RD, but only a subgroup has elevated IgE serum levels and peripheral eosinophilia. Finally, the 2012 revised Chapel Hill Consensus Conference nomenclature pointed IgG4-RD as a cause of large-vessel vasculitis. This review aims to discuss how to place IgG4-RD in the spectrum of immune-mediated and rheumatologic disorders.
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Affiliation(s)
- Tiago Borges
- Department of Internal Medicine, Trofa Saúde Hospital Privado de Gaia, Vila Nova de Gaia, Portugal
| | - Sérgio Silva
- Department of Internal Medicine, Trofa Saúde Hospital Privado de Gaia, Vila Nova de Gaia, Portugal
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Akiyama M, Kaneko Y, Takeuchi T. Characteristics and prognosis of IgG4-related periaortitis/periarteritis: A systematic literature review. Autoimmun Rev 2019; 18:102354. [PMID: 31323364 DOI: 10.1016/j.autrev.2019.102354] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Immunoglobulin G4 (IgG4)-related disease is a systemic chronic fibroinflammatory disease that can affect almost every organ of the body. IgG4-related periaortitis/periarteritis is a newly recognized subset of IgG4-related disease, and its characteristics and prognosis remain unclear. We investigated the clinical characteristics and prognosis of IgG4-related periaortitis/periarteritis. METHODS We performed a systematic literature review of IgG4-related periaortitis/periarteritis. Additionally, we have summarized the characteristics and prognosis of IgG4-related coronary arteritis. RESULTS We investigated 248 patients with IgG4-related periaortitis/periarteritis. All studies reported the condition in elderly patients, and male predominance was observed. The infra-renal abdominal aorta and iliac arteries were the most commonly affected sites. Most reports showed the serum C-reactive protein elevation in this disease entity, in contrast to non-vascular IgG4-related disease. Based on radiological findings observed in 27 patients with IgG4-related coronary arteritis, vasculitic lesions were classified into 3 types: stenotic (67% of patients), aneurysmal (42%), and diffuse wall thickening type (92%). Serum IgG4 level, but not C-reactive protein level, was associated with the number of affected organs in IgG4-related coronary arteritis. Corticosteroid treatment with or without cardiac surgery or percutaneous coronary intervention was effective in most patients with IgG4-related coronary arteritis; however, 33% of patients showed an unfavorable clinical course including disease progression, relapse, or death. Pre-treatment stenosis and/or aneurysms were associated with progression of stenosis or aneurysm after corticosteroid treatment. CONCLUSION Most clinical characteristics were similar between the IgG4-related periaortitis/periarteritis and the non-vascular IgG4-related disease groups; however, serum C-reactive protein level elevation was observed only in the former. Although corticosteroid treatment was effective, this disease can be life-threatening secondary to myocardial infarction, aortic dissection, and aneurysmal rupture. Pre-treatment evaluation of stenosis or aneurysms is important for predicting progression of stenosis or aneurysm after corticosteroid treatment.
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Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan.
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Japan
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7
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Affiliation(s)
- Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Fan Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Mizushima I, Kasashima S, Fujinaga Y, Kawano M, Ishizaka N. IgG4-related periaortitis/periarteritis: An under-recognized condition that is potentially life-threatening. Mod Rheumatol 2019; 29:240-250. [DOI: 10.1080/14397595.2018.1546367] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ichiro Mizushima
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
- Department of Cardiovascular and Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Yasunari Fujinaga
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
- Department of Cardiovascular and Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
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Blazekovic R, Planinc M, Catic J, Baric D, Unic D, Manojlovic L, Holzer S. Immunoglobulin G4 Inflammatory Aortic Aneurysm Mimicking Acute Aortic Syndrome. Ann Thorac Surg 2019; 108:e179-e181. [PMID: 30771330 DOI: 10.1016/j.athoracsur.2019.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
Immunoglobulin-G4-related disease (IgG4RD) is a novel clinical entity characterized by lymphoplasmacytic infiltrates presenting as an excessive fibrosis such as retroperitoneal inflammatory pseudotumor but rarely affecting the heart or the aorta. We describe a case of IgG4RD with multifocal aortic involvement presenting as an acute aortic syndrome.
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Affiliation(s)
- Robert Blazekovic
- Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia; Faculty of Medicine, "J.J. Strossmayer" University of Osijek, Osijek, Croatia
| | - Mislav Planinc
- Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia.
| | - Jasmina Catic
- Faculty of Medicine, "J.J. Strossmayer" University of Osijek, Osijek, Croatia; Department of Cardiology, Dubrava University Hospital, Zagreb, Croatia
| | - Davor Baric
- Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia
| | - Daniel Unic
- Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia
| | - Luka Manojlovic
- Department of Clinical and Experimental Pathology, Dubrava University Hospital, Zagreb, Croatia
| | - Sabrina Holzer
- Department of Orthopedics and Trauma Surgery, General Hospital of Vienna, Austria
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