A 54-Year-Old Woman with Cutaneous Nodules

Etiological study of polyclonal hypergammaglobulinemia in a French cohort of hospitalized patients and proposal of a diagnostic aid algorithm : Short title: polyclonal hypergammaglobulinemia in a French cohort of hospitalized patients

Serum protein electrophoresis can sometimes reveal polyclonal hypergammaglobulinemia. This electrophoretic abnormality can be caused by a variety of conditions and can be difficult to investigate. We sought to investigate screening practices in patients with hypergammaglobulinemia in order to establish diagnostic guidance strategies. We selected all patients with polyclonal hypergammaglobulinemia greater than or equal to 20 g/L over one year to identify the etiologies causing a significant increase in gammaglobulins in the absence of a monoclonal abnormality. We then selected patients who presented with this abnormality for the first time, with no known etiology. Clinical, medication, biological and imaging data were collected. In our study population with polyclonal hypergammaglobulinemia (n = 155), the main etiologies identified were infections (56%), autoimmune and autoinflammatory diseases (20%), liver diseases (18%) and hematological and non-hematological malignancies (6%). Once hypergammaglobulinemia was identified, the clinical examination provided diagnostic orientation but was not sufficient to make the diagnosis. The initial assessment must investigate the most common pathologies including analysis of liver function, viral status, the search for signs of intravascular haemolysis, inflammatory markers, and blood cell count. At the second time point (unless there were suggestive clinical signs at presentation), more specific biological and imaging analyses were required. Finally, we propose a diagnostic guideline for a current, rational and optimal medical practice to assist clinicians in the management of patients with hypergammaglobulinemia.

IgG4-related disease for the hematologist

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated disease with many important manifestations in hematopoietic and lymphoid tissue. IgG4 is the least naturally abundant IgG subclass, and the hallmark feature of IgG4-RD is markedly increased IgG4-positive plasma cells (with an IgG4 to IgG ratio >40%) in affected tissue, along with elevated polyclonal serum IgG and IgG4 in most patients. Histological diagnosis is essential, and other key features include storiform fibrosis, lymphoplasmacytic infiltrate, tissue eosinophilia, and obliterative phlebitis. The disease can present with predominantly proliferative features, such as swollen lacrimal and salivary glands, orbital pseudotumor, autoimmune pancreatitis, polyclonal hypergammaglobulinemia (PHGG), eosinophilia, and tubulointerstitial nephritis of the kidneys, or predominantly fibrotic disease, including mediastinal and retroperitoneal fibrosis, sclerosing mesenteritis, and hypertrophic pachymeningitis. This review focuses on 4 key hematological manifestations: PHGG, IgG4-positive plasma cell enriched lymphadenopathy (LAD), eosinophilia, and retroperitoneal fibrosis (RPF). These features are found in 70%, 60%, 40%, and 25% of IgG4-RD patients, respectively, but can also represent key hematological "mimickers" of IgG4-RD, including Castleman disease (PHGG, LAD), eosinophilic vasculitis (eosinophilia, PHGG, LAD), hypereosinophilic syndromes (eosinophilia, LAD, PHGG), and histiocyte disorders (PHGG, LAD, RPF). An organized approach to these 4 manifestations, and how to distinguish IgG4-RD from its mimickers, is explained. Proliferative manifestations typically respond very well to treatment corticosteroids, rituximab, and other immunosuppressives, whereas chronic fibrotic disease may not be reversible with current treatment modalities.

A primary Rosai-Dorfman-Destombes disease of the scalp: case report and literature review

Background

Rosai-Dorfman-Destombes disease (RDD) was first described in 1965 as a benign histiocytic proliferative disorder of unknown cause. Cases of RDD limited to cutaneous tissue have been reported over the past few decades, but single cutaneous RDD of the scalp is rare.

Case presentation

We report a 31-year-old male with a lump on the parietal scalp without extranodal lesion lasting 1 month with gradual enlargement. The surgical incision ruptured with purulent after the first resection. Then the patient was treated with plastic surgery after disinfection and antibiotic treatment. Finally, he recovered well and discharged after 20 days.

Conclusions

RDD of the scalp is rare. Surgical incision can cure the lesion but it may become infected because of increased lymphocytic infiltration. Early diagnosis and differential diagnosis of RDD are necessary. For treatment, individualized therapy is critical to patient prognosis.