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Peng L, Nie Y, Zhou J, Wu L, Chen X, Wang F, Li J, Peng Y, Lu H, Zhao L, Li M, Zhao Y, Zeng X, Fei Y, Zhang W. Withdrawal of immunosuppressants and low-dose steroids in patients with stable IgG4-RD (WInS IgG4-RD): an investigator-initiated, multicentre, open-label, randomised controlled trial. Ann Rheum Dis 2024; 83:651-660. [PMID: 38216319 DOI: 10.1136/ard-2023-224487] [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: 05/27/2023] [Accepted: 12/22/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVES IgG4-related disease (IgG4-RD) is an immune-mediated, fibroinflammatory disease. Induction treatment with glucocorticoid (GC) is usually effective, but its tendency of relapse makes the strategy for maintenance treatment a challenge. The WInS IgG4-RD (withdraw immunosuppressants (IMs) and steroid in stable IgG4-RD) trial tested whether discontinuation of GC and IM was feasible in stable IgG4-RD. METHODS The WInS IgG4-RD trial was a multicentre, open-label, randomised controlled trial. Patients with IgG4-RD receiving GC+IM as maintenance treatment with clinically quiescent disease for at least 12 months were randomised (1:1:1) into three groups: group 1: withdraw GC+IM; group 2: withdraw GC but maintain IM; group 3: maintain GC+IM. The primary outcome was the relapse rate of disease within 18 months. The secondary outcomes included the changes of IgG4-RD Responder Index (RI), Physician's Global Assessment (PGA), serum IgG4 and IgG, as well as adverse events. RESULTS One hundred and forty-six patients were randomised, with 48 patients in group 1, 49 patients in group 2 and group 3, respectively. Within the 18-month follow-up period, disease relapse occurred in 25 out of 48 (52.1%) patients in group 1 vs 7 out of 49 (14.2%) in group 2 and 6 out of 49 (12.2%) in group 3 (p<0.001). The changes in RI and PGA were significantly higher in group 1 than in group 2 (p<0.001) or group 3 (p<0.001). CONCLUSIONS The maintenance of IMs, with or without low-dose GC, was found to be superior to withdraw GC+IM in preventing relapse for long-time stable IgG4-RD. TRIAL REGISTRATION NUMBER NCT04124861.
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Affiliation(s)
- Linyi Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Yuxue Nie
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Lijun Wu
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Clinical Research Center for Rheumatoid Arthritis, Urumqi, Xinjiang, China
| | - Xiaomei Chen
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Clinical Research Center for Rheumatoid Arthritis, Urumqi, Xinjiang, China
| | - Fang Wang
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Clinical Immunology Center, Chinese Academy of Medical Sciences, Beijing, China
| | - Jieqiong Li
- Department of Internal Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Yu Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Hui Lu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Lidan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Yunyun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, The Ministry of Education Key Laboratory, Beijing, China
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2
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Wallace ZS, Katz G, Hernandez-Barco YG, Baker MC. Current and future advances in practice: IgG4-related disease. Rheumatol Adv Pract 2024; 8:rkae020. [PMID: 38601138 PMCID: PMC11003820 DOI: 10.1093/rap/rkae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/28/2023] [Indexed: 04/12/2024] Open
Abstract
IgG4-related disease (IgG4-RD) is an increasingly recognized cause of fibroinflammatory lesions in patients of diverse racial and ethnic backgrounds and is associated with an increased risk of death. The aetiology of IgG4-RD is incompletely understood, but evidence to date suggests that B and T cells are important players in pathogenesis, both of which are key targets of ongoing drug development programmes. The diagnosis of IgG4-RD requires clinicopathological correlation because there is no highly specific or sensitive test. Glucocorticoids are highly effective, but their use is limited by toxicity, highlighting the need for studies investigating the efficacy of glucocorticoid-sparing agents. B cell-targeted therapies, particularly rituximab, have demonstrated benefit, but no randomized clinical trials have evaluated their efficacy. If untreated or under-treated, IgG4-RD can cause irreversible organ damage, hence close monitoring and consideration for long-term immunosuppression is warranted in certain cases.
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Affiliation(s)
- Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Guy Katz
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Yasmin G Hernandez-Barco
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew C Baker
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
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3
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Capurso G, Pedica F, Palumbo D, Della-Torre E. IgG4-related autoimmune liver disease. Minerva Gastroenterol (Torino) 2023; 69:23-49. [PMID: 33267565 DOI: 10.23736/s2724-5895.20.02794-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
The term IgG4-related autoimmune liver disease (AILD) refers to hepato-biliary manifestations of Immunoglobin G4-related disease (IgG4-RD) including IgG4-related sclerosing cholangitis and IgG4-related pseudotumor. The association of some forms of autoimmune hepatitis to IgG4-RD remains controversial. Although autoimmune phenomena have not been clearly observed in IgG4-AILD, perturbation of the adaptive immune system and activation of the humoral response represent established pathophysiological hallmarks and potential therapeutic targets. Clinical manifestations of IgG4-AILD are virtually indistinguishable from bile duct cancer or primary sclerosing cholangitis and are due to mass forming lesions and thickening of the biliary tract that progressively lead to biliary ducts obstruction. There are no current reliable biomarkers for IgG4-AILD and diagnosis should rely on the integration of clinical, serological, radiological, and histological findings. In analogy to most IgG4-RD manifestations, and in contrast to its major mimickers, IgG4-AILD promptly responds to glucocorticoids but frequently relapses, thus requiring long-term maintenance therapy to avoid progressive fibrosclerotic disease and liver cirrhosis. Accumulating evidence on the efficacy of B-cell depletion therapy in patients with systemic IgG4-RD is gradually changing the treatment paradigm of IgG4-AILD and biologics will be increasingly used also for gastroenterological manifestations of IgG4-RD to spare glucocorticoids and traditional immunosuppressive agents. Looking ahead, identification of reliable biomarkers and of mini-invasive strategies to obtain informative biopsies from the biliary tree represent unavoidable priorities to optimize diagnosis and management of IgG4-AILD.
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Affiliation(s)
- Gabriele Capurso
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy - .,Division of Pancreato-Biliary Endoscopy and Endosonography, IRCCS San Raffaele Hospital, Milan, Italy - .,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Hospital, Milan, Italy -
| | - Federica Pedica
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Unit of Pathology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Diego Palumbo
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Unit of Clinical and Experimental Radiology, Experimental Imaging Center, IRCCS San Raffaele Hospital, Milan, Italy
| | - Emanuel Della-Torre
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
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Chen Y, Li R, Luo X, Wu T, Li J, Liu Z, Peng Y, Lu H, Peng L, Zhou J, Zhao Y, Zeng X, Fei Y, Zhang W. Comparison of the efficacy and safety of leflunomide versus mycophenolate mofetil in treating IgG4-related disease: a retrospective cohort study. Clin Rheumatol 2023:10.1007/s10067-023-06528-5. [PMID: 36781683 DOI: 10.1007/s10067-023-06528-5] [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: 11/28/2022] [Revised: 01/07/2023] [Accepted: 01/27/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE Combination therapy of glucocorticoids (GCs) plus leflunomide (LEF) and GCs plus mycophenolate mofetil (MMF) was reported to have good efficacy and safety in the management of IgG4-RD. However, studies comparing the efficacy and safety of these two combination therapies were unavailable. Herein, this study aimed to compare the efficacy and safety of GCs plus LEF and GCs plus MMF in treating IgG4-RD. METHODS This study included 130 newly diagnosed IgG4-RD patients who received the therapy of GCs plus LEF (group I) and GCs plus MMF (group II). Clinical data at baseline and after treatment, treatment response, relapse rate, and adverse effects were recorded and analyzed. RESULTS Patients in both groups responded well to the treatment in the 1st-month follow-up, and 100% of patients achieved treatment response. However, at the 6th and 12th-month follow-up, the total response rate of group II was higher than that in group I (75.6 vs. 53.7%, p = 0.038 and 85.4% vs. 61.0%, p = 0.013, respectively). In addition, the duration of disease remission in group II was longer than that in group I (9 (6-9) vs. 6 (6-6) months, p = 0.014). Moreover, more patients in group I had adverse effects compared with group II (36.6 vs. 7.3%, p < 0.01); and the most common adverse events of LEF were rash (12.2%) and elevation of liver enzymes (9.8%). CONCLUSION The combination therapy of GCs plus low-dose MMF had better efficacy and safety in the management of IgG4-RD compared with the therapy of GCs plus LEF.
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Affiliation(s)
- Yingying Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Rongli Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xuan Luo
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Tianmin Wu
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | - Jieqiong Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Zheng Liu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yu Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Hui Lu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yunyun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
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Jayachamarajapura Onkaramurthy N, Suresh SC, Theetha Kariyanna P, Jayarangaiah A, Prakash G, Raju B. IgG4 related disease and aortitis: an up-to-date review. Scand J Rheumatol 2023; 52:306-316. [PMID: 36763458 DOI: 10.1080/03009742.2022.2145744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Aortic involvement in immunoglobulin G4-related disease (IgG4-RD) is extremely rare and is often overlooked during the aortitis work-up. IgG4-related aortitis differs from non-IgG4-related aortitis in its histopathological features, site of involvement, laboratory markers, and treatment options. The histopathological examination of the vessel walls characteristically reveals adventitial thickening with intimal sparing, typically affecting the infrarenal abdominal aorta. In addition, inadequate knowledge about the disease often leads to delayed or missed diagnosis and undermanagement of a potentially treatable condition. Hence, in this paper, we review the unique clinical manifestations, laboratory markers, diagnostic features, current treatment strategies, and novel experimental therapeutic options in the management of IgG4-related aortitis.
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Affiliation(s)
| | - S C Suresh
- Department of Internal Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - P Theetha Kariyanna
- Division of Interventional Cardiology, Marshfield Clinic Health System, Marshfield, WI, USA
| | - A Jayarangaiah
- Department of Hematology and Oncology, Prevea Cancer Center at HSHS Sacred Heart Hospital, Eau Claire, WI, USA
| | - G Prakash
- Department of Hepatobiliary Surgery, New Jersey Medical College, Newark, NJ, USA
| | - B Raju
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, NJ, USA
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Fukui S, Nakai T, Kawaai S, Ikeda Y, Suda M, Nomura A, Tamaki H, Kishimoto M, Ohde S, Okada M. Advantages of an alternate-day glucocorticoid treatment strategy for the treatment of IgG4-related disease: A preliminary retrospective cohort study. Medicine (Baltimore) 2022; 101:e30932. [PMID: 36181016 PMCID: PMC9524883 DOI: 10.1097/md.0000000000030932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Alternate-day glucocorticoid (GC) therapy is a treatment option that can reduce GC-associated adverse events. We investigated the safety and efficacy of alternate-day GC therapy in patients with immunoglobulin G4-related disease (IgG4-RD). Medical records of patients with IgG4-RD who were followed for at least one year at St. Luke's International Hospital, Tokyo, Japan, from 2004 to 2020 were reviewed. Patients who fulfilled comprehensive IgG4-RD diagnostic criteria were divided into alternate-day or daily GC treatment groups based on their treatment protocol. The effect of alternate-day GC therapy on glucocorticoid toxicity index (GTI) score was evaluated using multilinear analysis with adjustments for cumulative GC doses until each assessment point and propensity scores (PS) for alternate-day GC therapy. Kaplan-Meier curves and Cox proportional hazard models were used to assess the efficacy of alternate-day GC therapy for disease control. Among the 67 patients with IgG4-RD, patients with alternate-day (n = 13) and daily (n = 31) GC treatments were analyzed after excluding 23 ineligible patients. The median (interquartile range) age was 64 (60-70) years, 29 (65.9%) were male patients, 26 (59.1%) patients had positive biopsy results, and the median follow-up period was 1643 days. Significantly more patients with alternate-day GC treatment used concomitant immunosuppressants (11 [84.6%] vs 11 [35.5%]; P = .007). The alternate-day strategy significantly lowered the GTI score after adjusting for cumulative GC dose until the assessment and PS (adjusted coefficient: -29.5 [-54.3, -4.8], P = .021 at 12 months; -20.0 [-39.8, -0.1], P = .049 at 24 months). Serious infections were numerically less frequent in the alternate-day group (incidence ratio [95% confidence interval [CI]: 0.45 [0.05, 3.63], P = .45). Most patients (92.3%) in the alternate-day GC treatment group and all patients in the daily GC treatment group showed treatment responses in the remission induction therapy. The PS-adjusted hazard ratio of alternate-day GC treatment for disease flares was not significant (1.55 [0.53, 4.51]; P = .43). The alternate-day treatment strategy significantly reduced GC-related adverse events regardless of the cumulative GC dose. Alternate-day GC treatment is a feasible option for patients with IgG4-RD, without a significant increase in disease flares particularly when combined with immunosuppressants.
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Affiliation(s)
- Sho Fukui
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
- Center for Clinical Epidemiology, St. Luke’s International University, Tokyo, Japan
- Department of Emergency and General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- *Correspondence: Sho Fukui, Immuno-Rheumatology Center, St. Luke’s International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan (e-mail: )
| | - Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
| | - Satoshi Kawaai
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
| | - Yukihiko Ikeda
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
| | - Masei Suda
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
- Department of Rheumatology, Suwa Chuo Hospital, Nagano, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
- Department of Rheumatology, JOJINKAI Ushiku Aiwa General Hospital, Ibaraki, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Sachiko Ohde
- Center for Clinical Epidemiology, St. Luke’s International University, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke’s International Hospital, Tokyo, Japan
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Chhabra N, Cebak JE, Schmitt A, Lal D, Rosenthal AC, Taylor CM, Thorwarth RM, Shah AA, Rodriguez-Pla A. Concomitant presentation of eosinophilic or oncocytic mucoepidermoid carcinoma, immunoglobulin G4-related disease, and adult-onset asthma and periocular xanthogranuloma: Case report of 3 uncommon clinical entities. Medicine (Baltimore) 2022; 101:e30067. [PMID: 35960078 PMCID: PMC9371478 DOI: 10.1097/md.0000000000030067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Immunoglobulin (Ig) G4-related disease (IgG4-RD) reportedly has a strong relationship with adult-onset asthma and periocular xanthogranuloma (AAPOX) and may be linked to sclerosing mucoepidermoid carcinoma (MEC). We present a rare case of IgG4-RD and AAPOX occurring in a patient with resected eosinophilic or oncocytic MEC. PATIENT CONCERNS A 52-year-old woman was referred to our rheumatology clinic in 2020 to be evaluated for suspected IgG4-RD. DIAGNOSES The patient had diagnoses of periorbital xanthelasmas, worsening glucocorticoid-dependent chronic rhinosinusitis and adult-onset asthma, and cervical lymphadenopathy persisting 2 years after resection of a low-grade MEC of a minor salivary gland. INTERVENTIONS Because the patient's symptomatic relief was glucocorticoid dependent, IgG4-RD was suspected, and she was referred to our medical center. Her amylase and lipase levels were elevated. Serum IgG4 levels were initially within normal limits, but IgG4-RD was diagnosed because of the presence of lymphadenopathy and evidence of pancreatitis, which was shown on positron emission tomography/computed tomography. Furthermore, the IgG4 levels later increased without explanation. After the patient began combination therapy with a glucocorticoid (prednisone) and methotrexate, her symptoms improved but recurred when the daily oral glucocorticoid dosage decreased below 10 mg. An excisional biopsy of her right submandibular gland in 2021 yielded results consistent with IgG4-RD. In addition, AAPOX was diagnosed, given the presence of periocular edema and plaques, adult-onset asthma, and rhinosinusitis. OUTCOME The patient was carcinoma free at last follow-up and was receiving medication to treat the other conditions. LESSONS The diagnosis of these 3 concomitant, uncommon entities required approximately 7 years of medical investigations. Clinicians should know that IgG4-RD, AAPOX, and MEC may occur together.
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Affiliation(s)
- Nikita Chhabra
- Department of Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona
| | - John E. Cebak
- Department of Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona
| | | | - Devyani Lal
- Department of Otorhinolaryngology, Mayo Clinic, Phoenix, Arizona
| | | | - Cullen M. Taylor
- Department of Otorhinolaryngology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Ryan M. Thorwarth
- Department of Otorhinolaryngology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Ami A. Shah
- Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
| | - Alicia Rodriguez-Pla
- Division of Rheumatology, Mayo Clinic, Scottsdale, Arizona
- *Correspondence: Alicia Rodriguez-Pla, Division of Rheumatology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (e-mail: )
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Aryasit O, Tiraset N, Preechawai P, Kayasut K, Sanghan N, Sittivarakul W. IgG4-related disease in patients with idiopathic orbital inflammation. BMC Ophthalmol 2021; 21:356. [PMID: 34625052 PMCID: PMC8499436 DOI: 10.1186/s12886-021-02115-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/17/2021] [Indexed: 01/13/2023] Open
Abstract
Background To identify the prevalence of positive IgG4 immunostaining in orbital tissue among patients previously diagnosed with nongranulomatous idiopathic orbital inflammation (IOI) and to compare the clinical characteristics of patients with and without IgG4-positive cells. Methods A retrospective review of all patients with a histopathologic diagnosis of IOI was performed. Immunohistochemical staining was performed to identify IgG-positive cells and IgG4-positive cells. Multivariate analysis was performed using likelihood ratio-test logistic regression on the differences between IgG4-related disease (IgG4-RD) and non-IgG4-RD. Results Of the 45 patients included, 21 patients (46.7%) had IgG4-positive cells, with 52.4% being male and a mean age of 55.9 ± 13.4 years. Bilateral ocular adnexal involvement (adjusted odds ratio [aOR] = 9.45; P = 0.016) and infraorbital nerve enlargement (aOR = 12.11; P = 0.008) were frequently found in IgG4-RD patients. Complete remission occurred in 23.8% of IgG4-RD patients and 41.7% of non-IgG4-RD patients. IgG4-RD patients had more frequent recurrent disease than non-IgG4-RD patients. Conclusions Nearly 50% of IgG4-RD patients were previously diagnosed with biopsy-proven IOI. IgG4-RD was more frequent in patients with bilateral disease and infraorbital nerve enlargement, showing the importance of tissue biopsy in these patients. Immunohistochemistry studies of all histopathology slides showing nongranulomatous IOI are highly recommended to evaluate for IgG4-RD.
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Affiliation(s)
- Orapan Aryasit
- Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Nanida Tiraset
- Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Passorn Preechawai
- Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Kanita Kayasut
- Anatomical Pathology Unit, Department of Pathology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Nuttha Sanghan
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Wantanee Sittivarakul
- Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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9
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Mizushima I, Kawano M. Renal Involvement in Retroperitoneal Fibrosis: Prevalence, Impact and Management Challenges. Int J Nephrol Renovasc Dis 2021; 14:279-289. [PMID: 34349543 PMCID: PMC8328390 DOI: 10.2147/ijnrd.s239160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/23/2021] [Indexed: 01/01/2023] Open
Abstract
Retroperitoneal fibrosis (RPF) is a rare disorder consisting of idiopathic and various secondary forms and characterized by chronic inflammatory infiltrates and marked fibrosis in the retroperitoneal space. In idiopathic RPF (IRPF), 35–60% of cases have been reported to be IgG4-related RPF, the retroperitoneal lesions of IgG4-related disease (IgG4-RD). IRPF can frequently lead to renal insufficiency mediated by urinary tract obstruction and hydronephrosis irrespective of being IgG4-related or not. Clinical pictures, laboratory and imaging findings, and location of the urinary tract obstruction are generally similar in IgG4-related and non-IgG4-related IRPF although multiple organ involvement and serum IgG4 elevation may be characteristic of the IgG4-related forms. Periaortic/periarterial lesions are the most frequent cause of renal insufficiency. Although the response to glucocorticoids is generally good, relapse does occur in a considerable proportion of patients, and may require an additional immunosuppressive agent and/or urological intervention in cases with multiple relapses or refractory obstructive uropathy. In general, the prognosis of patients with IRPF is good, but careful attention needs to be paid to chronic kidney disease as a major complication and rupture of the affected aorta/artery as a life-threatening one. Further studies are necessary to better understand the pathogenesis of the disease and to establish the optimal diagnostic and therapeutic strategies for it.
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Affiliation(s)
- Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
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10
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Lanzillotta M, Fernàndez-Codina A, Culver E, Ebbo M, Martinez-Valle F, Schleinitz N, Della-Torre E. Emerging therapy options for IgG4-related disease. Expert Rev Clin Immunol 2021; 17:471-483. [PMID: 33689549 DOI: 10.1080/1744666x.2021.1902310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Awareness of IgG4-related disease (IgG4-RD) is increasing worldwide and specialists are now familiar with most of its clinical manifestations and mimickers. IgG4-RD promptly responds to glucocorticoids and repeated courses are typically used to induce and maintain remission because the disease relapses in most patients. If left untreated, it can lead to organ dysfunction, organ failure and death. Advancement in our understanding of IgG4-RD pathogenesis is leading to the identification of novel therapeutic targets and emerging treatments are now setting the stage for personalized therapies for the future. AREAS COVERED This review focuses on emerging treatment options for IgG4-RD based on our advancing understanding of disease pathophysiology. Research was performed in the English literature on Pubmed and clinicaltrials.gov databases. EXPERT OPINION Glucocorticoids remain the first-line induction treatment for the multi-organ manifestations of IgG4-RD. Alternative immunosuppressive agents for maintaining remission are warranted in order to avoid long-term steroid toxicity, and to offer a more mechanistic and personalized therapeutic strategy. Targeting B and T-lymphocyte activation represents the most promising approach, but randomized controlled trials are eagerly awaited to confirm positive preliminary experiences reported in case series and small cohort studies.
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Affiliation(s)
- Marco Lanzillotta
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (Unirar), IRCCS San Raffaele Scientific Institute, ss Milan, Italy
| | - Andreu Fernàndez-Codina
- Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Rheumatology Division and General Internal Medicine division-Windsor Campus, Western University, 268 Grosvenor St, D2-191, Rheumatology Centre, St. Joseph´s Health Care, London, Ontario, Canada
| | - Emma Culver
- Translational Gastroenterology Unit, University of Oxford, Oxford,UK.,Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mikael Ebbo
- Département De Médecine Interne, Centre De Référence Constitutif Des Cytopénies Auto-immunes De L'adulte (CERECAI), Hôpital De La Timone, Aix-Marseille Université, Assistance publique-Hôpitaux De Marseille, Marseille, France
| | | | - Nicolas Schleinitz
- Département De Médecine Interne, Centre De Référence Constitutif Des Cytopénies Auto-immunes De L'adulte (CERECAI), Hôpital De La Timone, Aix-Marseille Université, Assistance publique-Hôpitaux De Marseille, Marseille, France
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (Unirar), IRCCS San Raffaele Scientific Institute, ss Milan, Italy
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11
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Fukui S, Kawaai S, Nakai T, Suda M, Ikeda Y, Nomura A, Tamaki H, Kishimoto M, Ohde S, Okada M. Effectiveness and safety of Mizoribine for the treatment of IgG4-related Disease: A Retrospective Cohort Study. Rheumatology (Oxford) 2021; 60:5697-5704. [PMID: 33723568 DOI: 10.1093/rheumatology/keab235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/01/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Patients with IgG4-Related Disease (IgG4RD) usually require steroid-sparing agents due to relapse with tapering glucocorticoids (GC). The aim of this study was to determine the efficacy and safety of Mizoribine (MZR) among IgG4RD, which inhibits inosine monophosphate dehydrogenase, a rate-limiting enzyme in the de novo pathway of purine synthesis. METHODS We retrospectively reviewed records of IgG4RD patients at the Immuno-Rheumatology Center in St. Luke's International Hospital, Tokyo, Japan. Patients were classified into the MZR combination group, and those treated with GCs alone or with other immunosuppressants were included in the control group. Disease exacerbation, GC dose, IgG-IgG4 titre, and adverse events were evaluated using univariate analyses, including the Kaplan-Meier method. The Cox proportional hazard model was used to evaluate risk factors for exacerbation. RESULTS A total of 14 and 29 cases were included in the MZR combination and control groups, respectively. Multiple organ involvement (≥3 organs) was significantly more frequent in the MZR combination treatment group (10 [71.4%] vs 9 [31.0%], p= 0.021). Kaplan-Meier analysis revealed a significant reduction in exacerbation in patients with multiple organ involvement (p< 0.001), but not in total (p= 0.42). The adjusted hazard ratios of MZR use and multiple organ involvement for exacerbation were 0.34[0.12-1.01] (p= 0.052), and 3.51[1.29-9.51] (p= 0.014). The cumulative GC dose tended to be lower in the MZR combination group (1448[1003, 1642] vs 2179[1264, 3425]; p= 0.09). CONCLUSION MZR showed a significant steroid-sparing effect and decrease in exacerbation among IgG4RD patients with multi-organ involvement. MZR could be a treatment option for IgG4RD.
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Affiliation(s)
- Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan.,Center for Clinical Epidemiology, St. Luke's International University, Tokyo, Japan
| | - Satoshi Kawaai
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Masei Suda
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan.,Department of Rheumatology, Suwa Chuo Hospital, Nagano, Japan
| | - Yukihiko Ikeda
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan.,Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Sachiko Ohde
- Center for Clinical Epidemiology, St. Luke's International University, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
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12
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Shakir A, Wheeler Y, Krishnaswamy G. The enigmatic immunoglobulin G4-related disease and its varied cardiovascular manifestations. Heart 2021; 107:790-798. [PMID: 33468575 DOI: 10.1136/heartjnl-2020-318041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/13/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterised by multiorgan lymphoplasmacytic infiltration, obliterative phlebitis and storiform fibrosis. It can be associated with cardiovascular pathology. The objective of this narrative review is to summarise the published literature on cardiovascular manifestations of IgG4-RD and to provide a basis for diagnosis and management of the condition by the practising cardiologist.We propose the following categorisations of cardiovascular IgG4-RD: aortitis, medium-vessel arteritis, pulmonary vascular disease, phlebitis, valvulopathy, pericarditis, myocardial disease and antineutrophilic cytoplasmic antibody-associated vasculitis. We also review herein developments in radiological diagnosis and reported medical and surgical therapies. Cardiovascular lesions frequently require procedural and/or surgical interventions, such as aortic aneurysm repair and valve replacement. IgG4-RD of the cardiovascular system results in serious complications that can be missed if not evaluated aggressively. These are likely underdiagnosed, as clinical presentations frequently mimic cardiovascular disease due to more common aetiologies (myocardial infarction, abdominal aortic aneurysm and so on). While systemic corticosteroids are the mainstay of IgG4-RD treatment, biological and disease-modifying agents are becoming more widely used. Cardiologists should be aware of cardiovascular IgG4-RD as a differential diagnosis, and understand the roles of corticosteroids, disease-modifying agents and biologicals, as well as their integration with surgical approaches. There are several knowledge gaps, including diagnosis, risk factors, pathogenesis and appropriate management in Ig4-RD of the cardiovascular system. Areas lacking well-conducted randomized trials include safety of steroids in the setting of vascular aneurysms and the role of disease-modifying drugs and biological agents in patients with established cardiovascular complications of this multifaceted enigmatic disease.
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Affiliation(s)
- Aamina Shakir
- Internal Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Guha Krishnaswamy
- Wake Forest University Department of Internal Medicine, Winston-Salem, North Carolina, USA .,Allergy, Asthma and Clinical Immunology, Bill Hefner VA Medical Center and affiliated institutions, Salisbury, North Carolina, USA
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13
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Wang Y, Zhao Z, Gao D, Wang H, Liao S, Dong C, Luo G, Ji X, Li Y, Wang X, Zhao Y, Li K, Zhang J, Jin J, Zhang Y, Zhu J, Zhang J, Huang F. Additive effect of leflunomide and glucocorticoids compared with glucocorticoids monotherapy in preventing relapse of IgG4-related disease: A randomized clinical trial. Semin Arthritis Rheum 2020; 50:1513-1520. [DOI: 10.1016/j.semarthrit.2020.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 02/08/2023]
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14
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Bakulina NV, Simanenkov VI, Vorobyev SL, Tikhonov SV, Lishchuk NB, Bakulin IG. The eosinophilic esophagitis and IgG4-related disease involving the esophagus. TERAPEVT ARKH 2020; 92:100-107. [DOI: 10.26442/00403660.2020.08.000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Indexed: 11/22/2022]
Abstract
The study of eosinophilic esophagitis has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Immunoglobulin G4 (IgG4)-related disease exhibits systemic involvement but very rarely involves the esophagus. The article presents a clinical case: the history of ulcer and stricture of the esophagus in a young man of 17 years. The patient was finally diagnosed with IgG4-related and eosinophilic esophagitis and showed a good response to corticosteroid therapy. We herein report a rare case of dysphagia associated with IgG4-related disease and eosinophilic. We presented a review of modern data on the relationship of eosinophilic esophagitis and pathological IgG4-response.
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15
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Malaviya AN. Does methotrexate cause interstitial lung disease in rheumatoid arthritis: What is the evidence? Int J Rheum Dis 2020; 23:713-716. [PMID: 32573124 DOI: 10.1111/1756-185x.13828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/30/2022]
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16
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Löhr JM, Beuers U, Vujasinovic M, Alvaro D, Frøkjær JB, Buttgereit F, Capurso G, Culver EL, de-Madaria E, Della-Torre E, Detlefsen S, Dominguez-Muñoz E, Czubkowski P, Ewald N, Frulloni L, Gubergrits N, Duman DG, Hackert T, Iglesias-Garcia J, Kartalis N, Laghi A, Lammert F, Lindgren F, Okhlobystin A, Oracz G, Parniczky A, Mucelli RMP, Rebours V, Rosendahl J, Schleinitz N, Schneider A, van Bommel EF, Verbeke CS, Vullierme MP, Witt H. European Guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations. United European Gastroenterol J 2020; 8:637-666. [PMID: 32552502 DOI: 10.1177/2050640620934911] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The overall objective of these guidelines is to provide evidence-based recommendations for the diagnosis and management of immunoglobulin G4 (IgG4)-related digestive disease in adults and children. IgG4-related digestive disease can be diagnosed only with a comprehensive work-up that includes histology, organ morphology at imaging, serology, search for other organ involvement, and response to glucocorticoid treatment. Indications for treatment are symptomatic patients with obstructive jaundice, abdominal pain, posterior pancreatic pain, and involvement of extra-pancreatic digestive organs, including IgG4-related cholangitis. Treatment with glucocorticoids should be weight-based and initiated at a dose of 0.6-0.8 mg/kg body weight/day orally (typical starting dose 30-40 mg/day prednisone equivalent) for 1 month to induce remission and then be tapered within two additional months. Response to initial treatment should be assessed at week 2-4 with clinical, biochemical and morphological markers. Maintenance treatment with glucocorticoids should be considered in multi-organ disease or history of relapse. If there is no change in disease activity and burden within 3 months, the diagnosis should be reconsidered. If the disease relapsed during the 3 months of treatment, immunosuppressive drugs should be added.
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Affiliation(s)
- J-Matthias Löhr
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Miroslav Vujasinovic
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division Pancreas Translational and Clinical Research Center IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Emanuel Della-Torre
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Enrique Dominguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nils Ewald
- Institute of Endocrinology, Diabetology and Metabolism, Johannes Wesling University hospital, Minden, Germany and Justus Liebig University Giessen, Giessen, Germany
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman, Ukraine
| | - Deniz Guney Duman
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nikolaos Kartalis
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Fredrik Lindgren
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | | | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrea Parniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insitute of Pediatrics, Budapest, Hungary
| | | | - Vinciane Rebours
- Pancreatology Department, Beaujon Hospital, Clichy, Université de Paris, France
| | - Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Nicolas Schleinitz
- Département de Médicine Interne Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Alexander Schneider
- Department of Gastroenterology and Hepatology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany
| | - Eric Fh van Bommel
- Department of Internal Medicine, Dutch National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | | | | | - Heiko Witt
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin, Paediatric Nutritional Medicine, Technische Universität München, Freising, Germany
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- See list at the end of this article
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Abstract
IgG4 related disease was recognized as a unified disease entity only 15 years ago. Awareness of IgG4 related disease has increased worldwide since then, and specialists are now familiar with most of its clinical manifestations. Involvement of the pancreato-biliary tract, retroperitoneum/aorta, head and neck, and salivary glands are the most frequently observed disease phenotypes, differing in epidemiological features, serological findings, and prognostic outcomes. In view of this multifaceted presentation, IgG4 related disease represents a great mimicker of many neoplastic, inflammatory, and infectious conditions. Histopathology remains key to diagnosis because reliable biomarkers are lacking. Recently released classification criteria will be invaluable in improving early recognition of the disease. IgG4 related disease is highly treatable and responds promptly to glucocorticoids, but it can lead to end stage organ failure and even death if unrecognized. Prolonged courses of corticosteroids are often needed to maintain remission because the disease relapses in most patients. Rapid advancement in our understanding of the pathophysiology of IgG4 related disease is leading to the identification of novel therapeutic targets and possible personalized approaches to treatment.
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Affiliation(s)
- Marco Lanzillotta
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaia Mancuso
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
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18
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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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19
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Li J, Peng Y, Zhang Y, Zhang P, Liu Z, Lu H, Peng L, Zhu L, Xue H, Zhao Y, Zeng X, Fei Y, Zhang W. Identifying clinical subgroups in IgG4-related disease patients using cluster analysis and IgG4-RD composite score. Arthritis Res Ther 2020; 22:7. [PMID: 31924265 PMCID: PMC6954570 DOI: 10.1186/s13075-019-2090-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/16/2019] [Indexed: 12/21/2022] Open
Abstract
Background To explore the clinical patterns of patients with IgG4-related disease (IgG4-RD) based on laboratory tests and the number of organs involved. Methods Twenty-two baseline variables were obtained from 154 patients with IgG4-RD. Based on principal component analysis (PCA), patients with IgG4-RD were classified into different subgroups using cluster analysis. Additionally, IgG4-RD composite score (IgG4-RD CS) as a comprehensive score was calculated for each patient by principal component evaluation. Multiple linear regression was used to establish the “IgG4-RD CS” prediction model for the comprehensive assessment of IgG4-RD. To evaluate the value of the IgG4-RD CS in the assessment of disease severity, patients in different IgG4-RD CS groups and in different IgG4-RD responder index (RI) groups were compared. Results PCA indicated that the 22 baseline variables of IgG4-RD patients mainly consisted of inflammation, high serum IgG4, multi-organ involvement, and allergy-related phenotypes. Cluster analysis classified patients into three groups: cluster 1, inflammation and immunoglobulin-dominant group; cluster 2, internal organs-dominant group; and cluster 3, inflammation and immunoglobulin-low with superficial organs-dominant group. Moreover, there were significant differences in serum and clinical characteristics among subgroups based on the CS and RI scores. IgG4-RD CS had a similar ability to assess disease severity as RI. The “IgG4-RD CS” prediction model was established using four independent variables including lymphocyte count, eosinophil count, IgG levels, and the total number of involved organs. Conclusion Our study indicated that newly diagnosed IgG4-RD patients could be divided into three subgroups. We also showed that the IgG4-RD CS had the potential to be complementary to the RI score, which can help assess disease severity.
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Affiliation(s)
- Jieqiong Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Yu Peng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Beijing, China
| | - Panpan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Zheng Liu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Hui Lu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Linyi Peng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Liang Zhu
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China
| | - Yunyun Fei
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China.
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Ministry of Health, Beijing, China.
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Malaviya A, Verma S, Khurshid L, Voleti P. Immunoglobulin G4-related disease, constitutional symptoms, human leukocyte antigen b27 positivity, and sacroiliitis. INDIAN JOURNAL OF RHEUMATOLOGY 2020. [DOI: 10.4103/injr.injr_1_20] [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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Omar D, Chen Y, Cong Y, Dong L. Glucocorticoids and steroid sparing medications monotherapies or in combination for IgG4-RD: a systematic review and network meta-analysis. Rheumatology (Oxford) 2019; 59:718-726. [PMID: 31511884 DOI: 10.1093/rheumatology/kez380] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/02/2019] [Indexed: 12/22/2022] Open
Abstract
Abstract
Objective
To assess the safety and efficacy of glucocorticoids (GCs), immunosuppressive agents (IM) and rituximab (RTX), alone or in combination, for the treatment of IgG4-RD.
Methods
Relevant articles published were searched in the databases with relevant key words. Network meta-analysis was conducted, with various outcomes including relapse rate, remission rate and adverse events. Data were calculated with odds ratio (ORs) and 95% CI. P-score was used to rank the treatments.
Results
A total of 15 studies involving 1169 patients were included. Network meta-analysis indicated that RTX maintenance therapy had the lowest relapse rate of all treatments (OR = 0.10, 95% CI [0.01, 1.63]), whereas GCs + IM was associated with a lower relapse rate compared with GCs alone (OR = 0.39, 95% CI [0.20, 0.80]). Further, patients treated with GCs + IM had a higher remission rate than those given GCs (OR= 3.36, 95% CI [1.44, 7.83]), IM (OR= 55.31, 95% CI [13.73, 222.73]) monotherapies or RTX induction therapy only (OR= 7.38, 95% CI [1.56, 34.94]). The rate of adverse events was comparable among the different treatment groups.
Conclusion
Treatment of IgG4-RD patients with GCs and IM was associated with higher remission rates and lower relapse rates, as well as comparable safety profiles compared with GC, IM and RTX induction therapy. RTX maintenance therapy had a larger reduction in the relapse rate compared with GC and IM. The current evidence should be carefully scrutinized as the included studies were observational in design. Larger randomized controlled trials are needed to confirm.
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Affiliation(s)
- Dina Omar
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yu Chen
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ye Cong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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22
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Detiger SE, Karim AF, Verdijk RM, van Hagen PM, van Laar JAM, Paridaens D. The treatment outcomes in IgG4-related orbital disease: a systematic review of the literature. Acta Ophthalmol 2019; 97:451-459. [PMID: 30734497 DOI: 10.1111/aos.14048] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/12/2019] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
| | - A. Faiz Karim
- Departments of Internal Medicine and Immunology Section Clinical Immunology Erasmus MC Rotterdam the Netherlands
- Department of Internal Medicine Groene Hart Hospital Gouda the Netherlands
| | - Robert M. Verdijk
- Department of Pathology Section Ophthalmic Pathology Erasmus MC Rotterdam the Netherlands
| | - P. Martin van Hagen
- Departments of Internal Medicine and Immunology Section Clinical Immunology Erasmus MC Rotterdam the Netherlands
| | - Jan A. M. van Laar
- Departments of Internal Medicine and Immunology Section Clinical Immunology Erasmus MC Rotterdam the Netherlands
| | - Dion Paridaens
- The Rotterdam Eye Hospital Rotterdam the Netherlands
- Department of Ophthalmology Erasmus MC Rotterdam the Netherlands
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Fernández-Codina A, Pinilla B, Pinal-Fernández I, López C, Fraile-Rodríguez G, Fonseca-Aizpuru E, Carballo I, Brito-Zerón P, Feijóo-Massó C, López-Dupla M, Cid MC, Martínez-Valle F. Treatment and outcomes in patients with IgG4-related disease using the IgG4 responder index. Joint Bone Spine 2018; 85:721-726. [DOI: 10.1016/j.jbspin.2018.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/31/2018] [Indexed: 12/26/2022]
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25
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Abstract
IgG4-related disease is a heterogeneous immune-mediated fibroinflammatory condition that can affect every single organ. This disease is more prevalent in the elderly (the mean age of patients is above 60 years) and the prevalence rate is estimated to be over 4.6 per 100,000 population. Before making a diagnosis, the exclusion of malignancies, lymphoma, anti-neutrophil cytoplasmic antibody-associated vasculitis, multicentric Castleman disease, and other mimickers is crucial for appropriate treatment. Broad management guidelines have been published emphasizing the need for prompt treatment and the use of glucocorticoids as first-line drug therapy for induction of remission. However, the toxic effects of glucocorticoids are problematic because IgG4-related disease is more prevalent in patients above 60 years of age, a population with frequent comorbid conditions and polypharmacy. Immunosuppressants (cyclophosphamide, methotrexate, leflunomide, and tacrolimus) and targeted immunomodulators (rituximab, XmAb5871, and abatacept) are appealing to overcome potential toxic effects of glucocorticoids and as emerging glucocorticoid-sparing and/or maintenance treatments. In this review, we provide an overview of our understanding of the pathophysiology of the disease (T follicular helper cells, CD4+ cytotoxic T cells, plasmablasts, and alternatively activated M2 macrophages) and clinical characteristics, and highlight the potential targets for treatment intervention.
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Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
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26
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Bledsoe JR, Della-Torre E, Rovati L, Deshpande V. IgG4-related disease: review of the histopathologic features, differential diagnosis, and therapeutic approach. APMIS 2018; 126:459-476. [PMID: 29924455 DOI: 10.1111/apm.12845] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an uncommon disorder that demonstrates characteristic clinicopathologic features including sclerosing lesions with storiform fibrosis, increased IgG4+ plasma cells with an increased IgG4+/IgG+ plasma cell ratio, obliterative phlebitis, and often an increased serum IgG4 level. This review summarizes the characteristic histopathologic and clinical features of IgG4-RD with detailed discussion of the histopathologic characteristics of the most commonly involved anatomic sites. We also present recent advances in our understanding of the pathophysiologic mechanisms of IgG4-RD and discuss updates on the treatment, prognosis, and outcomes of this rare disease, including discussion of the possible association between IgG4-RD and malignancy.
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Affiliation(s)
- Jacob R Bledsoe
- Department of Pathology, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA, USA
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Università Vita-Salute San Raffaele - San Raffaele Scientific Institute, Milan, Italy.,Ragon Institute of MGH, MIT, and Harvard University, Cambridge, MA, USA
| | - Lucrezia Rovati
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Università Vita-Salute San Raffaele - San Raffaele Scientific Institute, Milan, Italy.,Ragon Institute of MGH, MIT, and Harvard University, Cambridge, MA, USA
| | - Vikram Deshpande
- The James Homer Wright Pathology Laboratories of the Massachusetts General Hospital, Boston, MA, USA
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27
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Kita T, Araya T, Ichikawa Y, Terada N, Kawashima A, Kasashima S, Kasahara K. IgG4-Related Pleuritis With No Other Organ Involvement. Am J Med Sci 2018; 356:487-491. [PMID: 30055756 DOI: 10.1016/j.amjms.2018.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 05/02/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
A 65-year-old man was admitted for productive cough and dyspnea. Bilateral pleural effusions were observed on chest X-ray. Although the bilateral pleural effusions were exudative with an increased number of lymphocytes, bacterial culture and polymerase chain reaction analysis for Mycobacterium tuberculosis were negative. Immunological examinations showed high levels of immunoglobulin G4 (IgG4) in both serum and pleural effusion fluid. Pathologic evaluation of a left pleural biopsy specimen using hematoxylin and eosin staining and immunohistochemical staining showed fibrosis-associated lymphoplasmacytic infiltration, 50 IgG4-positive plasma cells per high-power field, and an IgG4/IgG ratio of 40%. Thus, a diagnosis of IgG4-related pleuritis without other systemic manifestations was established. The bilateral pleural effusion improved following corticosteroid therapy. This is a rare case of IgG4-related pleuritis with no other organ involvement.
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Affiliation(s)
| | | | | | | | - Atsuhiro Kawashima
- Department of Pathology, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | | | - Kazuo Kasahara
- Department of Respiratory Medicine, Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
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28
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Wang L, Zhang P, Wang M, Feng R, Lai Y, Peng L, Fei Y, Zhang X, Zhao Y, Zeng X, Zhang F, Zhang W. Failure of remission induction by glucocorticoids alone or in combination with immunosuppressive agents in IgG4-related disease: a prospective study of 215 patients. Arthritis Res Ther 2018; 20:65. [PMID: 29636109 PMCID: PMC5894179 DOI: 10.1186/s13075-018-1567-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/14/2018] [Indexed: 12/24/2022] Open
Abstract
Background The aim of this study was to assess the outcomes of remission induction in patients with IgG4-related disease (IgG4-RD) in our cohort, and to investigate the characteristics, prognosis, and risk factors in the patients failed of remission induction. Methods We prospectively enrolled 215 newly diagnosed patients with IgG4-RD, who were initially treated with glucocorticoid (GC) alone or in combination with immunosuppressive agents (IM), and had at least 6 months of follow up. The therapeutic goals of remission induction were defined as fulfilling each of the following after the 6-month remission induction stage: (1) ≥ 50% decline in the IgG4-RD responder index (RI); (2) GC tapered to maintenance dose; and (3) no relapse during GC tapering. The patients not achieving the therapeutic goals were considered to have failed of remission induction. Results There were 26 patients in our cohort who failed of remission induction, including 16 (20.8%) on GC monotherapy, and 10 (7.2%) on combination therapy comprising GC and IM. The lacrimal gland and lung were most common sites of remission induction failure. Among the patients who relapsed during remission induction stage, 52.9% had secondary relapse during follow-up. Eosinophilia, higher baseline RI, more than five organs involved and dacryoadenitis were risk factors for remission induction failure with GC monotherapy, and the incidence of remission induction failure was 71.4% in the patients with more than three risk factors. After 6-month treatment, the patients who failed of remission induction had significantly higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and IgG4. Conclusion In our cohort, 20.8% of patients failed of remission induction with GC monotherapy, while 7.2% of patients failed of remission induction with combination therapy comprising GC and IM. Electronic supplementary material The online version of this article (10.1186/s13075-018-1567-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liwen Wang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China.,Tsinghua University School of Medicine, Beijing, 100086, China
| | - Panpan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Mu Wang
- Department of Stomatology, Peking Union Medical College Hospital, Beijing, China
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Yamin Lai
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Linyi Peng
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Yunyun Fei
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Xuan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Fengchun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (West Campus), Chinese Academy of Medical Science & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.41 Da Mu Cang, Western District, Beijing, 100032, People's Republic of China.
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Obiorah I, Hussain A, Palese C, Azumi N, Benjamin S, Ozdemirli M. IgG4-related disease involving the esophagus: a clinicopathological study. Dis Esophagus 2017; 30:1-7. [PMID: 28881885 DOI: 10.1093/dote/dox091] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/13/2017] [Indexed: 12/11/2022]
Abstract
Immunoglobulin G4 (IgG4)-related disease is a recently coined systemic disease characterized by specific histopathologic findings of an intense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis in the presence of predominant IgG4-positive plasma cells. Although IgG4-related disease has been described in many organs, involvement of the esophagus is very rare. In this study, we describe the clinicopathologic characteristics of eight patients with IgG4-related esophagitis. We evaluated chronic esophagitis specimens with lymphoplasmacytic infiltrate obtained over the past 6 years (from January 2011 to February 2017) using a chart review, pathologic examination, and IgG4 immunohistochemical staining. The diagnoses of the specimens were either confirmed as IgG4-related esophagitis (IgG4-RE) or chronic esophagitis, not otherwise specified (CENOS), and the clinicopathologic data from each group were compared. Eight patients were diagnosed with IgG4-RE and 10 controls were identified and diagnosed with CENOS. In the IgG4-RE group, esophageal strictures were identified in three patients, two patients had postmyotomy treated achalasia, one patient had erosive esophagitis and another presented with an esophageal nodule. Only one patient had an unremarkable mucosa on endoscopy. In the CENOS group, four patients had esophageal strictures, six had erosive esophagitis, one patient had mild esophagitis. The IgG4-RE group had significantly higher numbers of IgG4-positive plasma cells (66.9 ± 21.9 vs. 4.7 ± 2.4 per high power field; P< 0.001) and a greater IgG4: IgG ratio 0.76 ± 0.13 vs. 0.06 ± 0.05; P< 0.001) when compared to CENOS patients. Two of the patients with recurrent esophageal strictures in the IgG4-RE group showed initial response to steroid therapy and are currently on immunosuppressive therapy which has significantly reduced the need for multiple esophageal dilatations. The presentation of IgG4-related esophageal disease can vary and the key to diagnosis is dependent on histopathology. These observations highlight the need for IgG4 immunohistochemical staining of esophageal biopsies especially in patients with mucosal ulceration, chronic inflammation, and plasmacytosis on biopsy. This will prevent unwarranted esophagectomies and failed medical treatment due to lack of recognition of this entity.
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Affiliation(s)
| | - A Hussain
- Division of Gastroenterology, Department of Internal Medicine, Medstar Georgetown University Hospital, Washington DC, USA
| | - C Palese
- Division of Gastroenterology, Department of Internal Medicine, Medstar Georgetown University Hospital, Washington DC, USA
| | | | - S Benjamin
- Division of Gastroenterology, Department of Internal Medicine, Medstar Georgetown University Hospital, Washington DC, USA
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Ebbo M, Grados A, Samson M, Groh M, Loundou A, Rigolet A, Terrier B, Guillaud C, Carra-Dallière C, Renou F, Pozdzik A, Labauge P, Palat S, Berthelot JM, Pennaforte JL, Wynckel A, Lebas C, Le Gouellec N, Quémeneur T, Dahan K, Carbonnel F, Leroux G, Perlat A, Mathian A, Cacoub P, Hachulla E, Costedoat-Chalumeau N, Harlé JR, Schleinitz N. Long-term efficacy and safety of rituximab in IgG4-related disease: Data from a French nationwide study of thirty-three patients. PLoS One 2017; 12:e0183844. [PMID: 28915275 PMCID: PMC5600376 DOI: 10.1371/journal.pone.0183844] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/11/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To assess efficacy and safety of rituximab (RTX) as induction therapy, maintenance of remission and treatment of relapses in a cohort of IgG4-related disease (IgG4-RD) patients. METHODS Nationwide retrospective multicenter study of IgG4-RD patients treated with at least one course of RTX. Clinical, biological and radiological response, relapse rate and drug tolerance were analyzed. Kaplan-Meier curves were plotted and risk factors for relapse studied with a Cox regression model. RESULTS Among 156 IgG4-RD patients included in the French database, 33 received rituximab. Clinical response was noted in 29/31 (93.5%) symptomatic patients. Glucocorticoids withdrawal was achieved in 17 (51.5%) patients. During a mean follow-up of 24.8 ±21 months, 13/31 (41.9%) responder patients relapsed after a mean delay of 19 ±11 months after RTX. Active disease, as defined by an IgG4-RD Responder Index >9 before RTX, was significantly associated with relapse (HR = 3.68, 95% CI: 1.1, 12.6) (P = 0.04), whereas maintenance therapy with systematic (i.e. before occurrence of a relapse) RTX retreatment was associated with longer relapse-free survival (41 versus 21 months; P = 0.02). Eight severe infections occurred in 4 patients during follow-up (severe infections rate of 12.1/100 patient-years) and hypogammaglobulinemia ≤5 g/l in 3 patients. CONCLUSION RTX is effective for both induction therapy and treatment of relapses in IgG4-RD, but relapses are frequent after B-cell reconstitution. Maintenance therapy with systematic RTX infusions is associated with longer relapse-free survival and might represent a novel treatment strategy. Yet, the high rate of infections and the temporary effect of RTX might be hindrances to such strategy.
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Affiliation(s)
- Mikael Ebbo
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | - Aurélie Grados
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - Matthieu Groh
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université René-Descartes Paris V, Sorbonne Paris Cité, Paris, France
| | - Anderson Loundou
- Unité d'Aide Méthodologique, Aix-Marseille Université, AP-HM, Marseille, France
| | - Aude Rigolet
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital La Pitié-Salpêtrière; DHUI2B, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université René-Descartes Paris V, Sorbonne Paris Cité, Paris, France
| | - Constance Guillaud
- Department of Internal Medicine, Hôpital Henri Mondor, AP-HP, Créteil, France
| | | | - Frédéric Renou
- Department of Internal Medicine, CHU La Réunion site Félix Guyon, Saint-Denis, La Réunion, France
| | - Agnieszka Pozdzik
- Department of Nephrology, Erasme Hospital, Cliniques Universitaires de Bruxelles, Bruxelles, Belgium
| | - Pierre Labauge
- Department of Neurology, CHRU de Montpellier, Montpellier, France
| | - Sylvain Palat
- Department of Internal Medicine, CHU Limoges, Limoges, France
| | | | | | - Alain Wynckel
- Department of Nephrology, CHU de Reims, Reims, France
| | - Céline Lebas
- Department of Nephrology, CHRU de Lille, Lille, France
| | - Noémie Le Gouellec
- Department of Nephrology and Internal Medicine, CH Valenciennes, Valenciennes, France
| | - Thomas Quémeneur
- Department of Nephrology and Internal Medicine, CH Valenciennes, Valenciennes, France
| | - Karine Dahan
- Department of Nephrology, Hôpital Tenon, AP-HP, Paris, France
| | - Franck Carbonnel
- Department of Gastro-enterology, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Gaëlle Leroux
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital La Pitié-Salpêtrière; DHUI2B, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Antoinette Perlat
- Department of Internal Medicine, Hôpital Sud, CHU de Rennes, Rennes, France
| | - Alexis Mathian
- Department of Internal Medicine, Hôpital Pitié-Salpêtrière, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Hôpital La Pitié-Salpêtrière; DHUI2B, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Eric Hachulla
- National Referral Centre for Auto-immune and Systemic Diseases, Department of Internal Medicine, Huriez Hospital, Université de Lille, Lille, France
| | - Nathalie Costedoat-Chalumeau
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Centre National de Référence Maladies Systémiques et Auto-immunes Rares, Université René-Descartes Paris V, Sorbonne Paris Cité, Paris, France
| | - Jean-Robert Harlé
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
| | - Nicolas Schleinitz
- Department of Internal Medicine, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France
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Abstract
PURPOSE OF REVIEW IgG4-related disease (IgG4-RD) is an immune-mediated disease of unknown cause. It predominantly affects the biliary tract [IgG4-associated cholangitis (IAC)] and pancreas [autoimmune pancreatitis (AIP)] of mostly elderly men. Accurate diagnostic tests are lacking. Patients benefit from predniso(lo)ne treatment. However, disease relapse is often seen. This review will address pathophysiological aspects and advances in diagnostic and therapeutic strategies. RECENT FINDINGS The role of IgG1 and IgG4 in the pathophysiology of IgG4-RD was studied in mice which showed more intense organ damage of pancreas and salivary glands when IgG1 rather than IgG4 of patients with IgG4-RD was injected. Coadministration of IgG1+IgG4 led to dampening of IgG1-mediated injury supporting the view that IgG4 exerts immune-dampening effects. IgG4+ B-cell receptor clones identified by next-generation sequencing and the IgG4/IgG RNA ratio in human blood assessed by quantitative PCR were able to accurately distinguish IAC/AIP from primary sclerosing cholangitis or pancreatobiliary malignancies. Long-term treatment with low-dose prednisolone was safe and reduced the number of flare-ups in patients with AIP. SUMMARY Early diagnosis by a novel accurate and easy-to-use qPCR test may prevent life-threatening complications, unnecessary interventions and fatal course because of misdiagnosis. Prednisolone treatment remains the standard of care in patients with IgG4-RD.
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Wang Y, Li K, Gao D, Luo G, Zhao Y, Wang X, Zhang J, Jin J, Zhao Z, Yang C, Zhu J, Zhang J, Huang F. Combination therapy of leflunomide and glucocorticoids for the maintenance of remission in patients with IgG4-related disease: a retrospective study and literature review. Intern Med J 2017; 47:680-689. [PMID: 28321964 DOI: 10.1111/imj.13430] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/07/2017] [Accepted: 03/08/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Yiwen Wang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Kunpeng Li
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Dai Gao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Gui Luo
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Yurong Zhao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Xiuru Wang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jie Zhang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jingyu Jin
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Zheng Zhao
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Chunhua Yang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jian Zhu
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Jianglin Zhang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
| | - Feng Huang
- Department of Rheumatology; Chinese PLA General Hospital; Beijing China
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33
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Ardila-Suarez O, Abril A, Gómez-Puerta JA. Enfermedad relacionada con IgG4: revisión concisa de la literatura. ACTA ACUST UNITED AC 2017; 13:160-166. [DOI: 10.1016/j.reuma.2016.05.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/12/2016] [Accepted: 05/13/2016] [Indexed: 12/24/2022]
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34
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Baptista B, Casian A, Gunawardena H, D'Cruz D, Rice CM. Neurological Manifestations of IgG4-Related Disease. Curr Treat Options Neurol 2017; 19:14. [PMID: 28374231 PMCID: PMC5378735 DOI: 10.1007/s11940-017-0450-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. Early recognition of IgG4-RD is important to avoid permanent organ dysfunction and disability. Neurological involvement by IgG4-RD is relatively uncommon, but well recognised-hypertrophic pachymeningitis and hypophysitis are the most frequent manifestations. Although the nervous system may be involved in isolation, this more frequently occurs in conjunction with involvement of other systems. Elevated circulating levels of IgG4 are suggestive of the condition, but these are not pathognomonic and exclusion of other inflammatory disorders including vasculitis is required. Wherever possible, a tissue diagnosis should be established. The characteristic histopathological changes include a lymphoplasmacytoid infiltrate, storiform fibrosis and obliterative phlebitis. IgG4-RD typically responds well to treatment with glucocorticoids, although relapse is relatively common and treatment with a steroid-sparing agent or rituximab may be required. Improved understanding of the pathogenesis of IgG4-RD is likely to lead to the development of more specific disease treatments in the future.
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Affiliation(s)
| | - Alina Casian
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Harsha Gunawardena
- Department of Rheumatology, Brunel Building, Southmead Hospital, Bristol, UK
- Musculoskeletal Research Unit, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - David D'Cruz
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
- Division of Immunology, Infection and Inflammatory Diseases, King's College London, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Claire M Rice
- School of Clinical Sciences, Level 1, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Department of Neurology, Brunel Building, Southmead Hospital, Bristol, UK.
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35
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Martínez-Valle F, Fernández-Codina A, Pinal-Fernández I, Orozco-Gálvez O, Vilardell-Tarrés M. IgG4-related disease: Evidence from six recent cohorts. Autoimmun Rev 2017; 16:168-172. [DOI: 10.1016/j.autrev.2016.12.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/09/2016] [Indexed: 12/24/2022]
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36
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Yamamoto M. New strategies for the treatment of IgG4-related disease. ACTA ACUST UNITED AC 2017; 39:485-490. [PMID: 28049956 DOI: 10.2177/jsci.39.485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
IgG4-related disease is a chronic and fibroinflammatory disorder, which is characterized with elevated levels of serum IgG4, and prominent infiltration of IgG4-bearing plasma cells in the involved organs. It often affects with lacrimal glands, salivary glands, pancreas, kidneys, lungs, and retroperitoneal cavity. Now, the first line of the induction therapy for IgG4-related disease is glucocorticoid, but almost patients need the maintenance treatment and experience the relapse. It is recently reported that biologic agents, including rituximab and abatacept, are effective for the relapse of IgG4-related disease. It is clear that the tapering effect of glucocorticoid is better than conventional oral immunosuppressants. We can use it in safely if we choose the appropriate cases. The investigator-initiated trial of rituximab for IgG4-related disease is scheduled in Japan. This article reviews the new strategies for the treatment of IgG4-related disease with our data of SMART registry, and discuss the problems of each biologic agents for IgG4-related disease.
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Affiliation(s)
- Motohisa Yamamoto
- Department of Rheumatology, Sapporo Medical University School of Medicine
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37
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Della-Torre E, Stone JH. “How I manage” IgG4-Related Disease. J Clin Immunol 2016; 36:754-763. [DOI: 10.1007/s10875-016-0331-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/29/2016] [Indexed: 12/18/2022]
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38
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Vasaitis L, Sundström C, Backlin C, Nordmark G, Baecklund E. Sporadic occurrence of non-diagnosed IgG4-related disease in lymphoma patients with a previous Sjögren's syndrome diagnosis. Acta Oncol 2016; 55:1139-1144. [PMID: 27196149 DOI: 10.1080/0284186x.2016.1182644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory disorder, which may affect many organs, and often comes to clinical attention due to tumor-like organ swelling or is identified incidentally by specific biopsy findings. Typical histopathology of IgG4-RD is lymphoplasmacytic infiltration rich in IgG4 + plasma cells (PCs), storiform fibrosis, and obliterative phlebitis. Patients with sicca symptoms can be misdiagnosed as primary Sjögren's syndrome (pSS) instead of IgG4-RD because of clinical and histopathological similarities. Moreover, an association with lymphoma development is described in both diseases. This study investigated signs of IgG4-RD in a population-based cohort of patients diagnosed with pSS complicated by lymphoma. METHODS Patients with pSS and lymphoma diagnoses and available lymphoma specimens were identified by linkage with the Swedish Patient Register 1964-2007 and the Cancer Register 1990-2007 (n = 79). Clinical data and lymphomas were reviewed and the diagnoses evaluated. All lymphoma tissues and available minor salivary gland biopsies (n = 11) were immunostained for IgG4 + PCs and evaluated for other histopathological signs of IgG4-RD. In a case with specific findings of IgG4-RD, other available tissue specimens of the same patient were investigated for IgG4-RD. RESULTS Only one patient of 79 (1.3%) had >10 IgG4 + PCs/high power field (HPF) in the lymphoma tissue, an unspecified low-grade B-cell lymphoma localized in the submandibular gland. This patient also had other histopathological features of IgG4-RD in the lymphoma and a surgical lung biopsy taken five years before lymphoma diagnosis and, therefore, fulfilled the criteria for IgG4-RD. Occasional IgG4 + PCs (<10/HPF) without signs of IgG4-RD were observed in another six lymphomas. No IgG4 + PCs were identified in the minor salivary gland biopsies. CONCLUSION Histopathological findings of IgG4-RD may co-exist with low malignant B-cell lymphoma in patients with initially suspected pSS and may be associated with an underlying IgG4-RD.
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Affiliation(s)
- Lilian Vasaitis
- Section of Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Christer Sundström
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Carin Backlin
- Section of Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunnel Nordmark
- Section of Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Eva Baecklund
- Section of Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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39
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Malaviya AN. Landmark papers on the discovery of methotrexate for the treatment of rheumatoid arthritis and other systemic inflammatory rheumatic diseases: a fascinating story. Int J Rheum Dis 2016; 19:844-51. [DOI: 10.1111/1756-185x.12862] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anand N. Malaviya
- A&R Clinic for Arthritis and Rheumatism and Department of Rheumatology; ISIC Superspeciality Hospital; Vasant Kunj New Delhi India
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40
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Gajewska ME, Rychwicka-Kielek BA, Sørensen K, Kubik M, Hilberg O, Bendstrup E. Immunoglobulin G4-related pleuritis - A case report. Respir Med Case Rep 2016; 19:18-20. [PMID: 27408782 PMCID: PMC4925619 DOI: 10.1016/j.rmcr.2016.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 05/23/2016] [Indexed: 12/11/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic disease that presents with inflammation and fibrosis of involved tissue. It encompasses several disorders previously described using different terms, but all disorders are characterised by IgG4-positive plasma cells and lymphocytes infiltration of tissues. We report a rare case of a 58-year-old man with IgG4-related pleural disease without other systemic manifestations. The diagnosis was based on characteristic changes on PET-CT and typical histopathology in a pleural specimen. The patient’s condition improved following immunosuppressive therapy.
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Affiliation(s)
- Marta E Gajewska
- Dept. of Respiratory Diseases and Allergy, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark
| | | | - Kathina Sørensen
- Dept. Pathology, Aalborg University Hospital, Ladegårdsgade 3, 9000 Aalborg, Denmark
| | - Magdalena Kubik
- Dept. of Nuclear Medicine, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Ole Hilberg
- Dept. of Respiratory Diseases and Allergy, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark
| | - Elisabeth Bendstrup
- Dept. of Respiratory Diseases and Allergy, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark
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41
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Brito-Zerón P, Bosch X, Ramos-Casals M, Stone JH. IgG4-related disease: Advances in the diagnosis and treatment. Best Pract Res Clin Rheumatol 2016; 30:261-278. [DOI: 10.1016/j.berh.2016.07.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/17/2016] [Indexed: 02/08/2023]
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42
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Campochiaro C, Ramirez GA, Bozzolo EP, Lanzillotta M, Berti A, Baldissera E, Dagna L, Praderio L, Scotti R, Tresoldi M, Roveri L, Mariani A, Balzano G, Castoldi R, Doglioni C, Sabbadini MG, Della-Torre E. IgG4-related disease in Italy: clinical features and outcomes of a large cohort of patients. Scand J Rheumatol 2015; 45:135-45. [PMID: 26398142 DOI: 10.3109/03009742.2015.1055796] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe the clinical features, treatment response, and follow-up of a large cohort of Italian patients with immunoglobulin (Ig)G4-related disease (IgG4-RD) referred to a single tertiary care centre. METHOD Clinical, laboratory, histological, and imaging features were retrospectively reviewed. IgG4-RD was classified as 'definite' or 'possible' according to international consensus guidelines and comprehensive diagnostic criteria for IgG4-RD. Disease activity was assessed by means of the IgG4-RD Responder Index (IgG4-RD RI). RESULTS Forty-one patients (15 females, 26 males) were included in this study: 26 with 'definite' IgG4-RD and 15 with 'possible' IgG4-RD. The median age at diagnosis was 62 years. The median follow-up was 36 months (IQR 24-51). A history of atopy was present in 30% of patients. The pancreas, retroperitoneum, and major salivary glands were the most frequently involved organs. Serum IgG4 levels were elevated in 68% of cases. Thirty-six patients were initially treated with glucocorticoids (GCs) to induce remission. IgG4-RD RI decreased from a median of 7.8 at baseline to 2.9 after 1 month of therapy. Relapse occurred in 19/41 patients (46%) and required additional immunosuppressive drugs to maintain long-term remission. Multiple flares occurred in a minority of patients. A single case of orbital pseudotumour did not respond to medical therapy and underwent surgical debulking. CONCLUSIONS IgG4-RD is an elusive inflammatory disease to be considered in the differential diagnosis of isolated or multiple tumefactive lesions. Long-term disease control can be achieved with corticosteroids and immunosuppressive drugs in the majority of cases.
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Affiliation(s)
- C Campochiaro
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - G A Ramirez
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - E P Bozzolo
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - M Lanzillotta
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - A Berti
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - E Baldissera
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - L Dagna
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - L Praderio
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - R Scotti
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - M Tresoldi
- b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - L Roveri
- c Division of Gastroenterology and Gastrointestinal Endoscopy , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - A Mariani
- d Pancreas Unit, Department of Surgery , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - G Balzano
- e Pathology Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - R Castoldi
- e Pathology Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - C Doglioni
- e Pathology Unit , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - M G Sabbadini
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - E Della-Torre
- a Unit of Medicine and Clinical Immunology , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Department of Neurology , IRCCS San Raffaele Scientific Institute , Milan , Italy
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43
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Della-Torre E, Lanzillotta M, Doglioni C. Immunology of IgG4-related disease. Clin Exp Immunol 2015; 181:191-206. [PMID: 25865251 DOI: 10.1111/cei.12641] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 04/03/2015] [Accepted: 04/08/2015] [Indexed: 12/12/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition that derives its name from the characteristic finding of abundant IgG4(+) plasma cells in affected tissues, as well as the presence of elevated serum IgG4 concentrations in many patients. In contrast to fibrotic disorders, such as systemic sclerosis or idiopathic pulmonary fibrosis in which the tissues fibrosis has remained largely intractable to treatment, many IgG4-RD patients appear to have a condition in which the collagen deposition is reversible. The mechanisms underlying this peculiar feature remain unknown, but the remarkable efficacy of B cell depletion in these patients supports an important pathogenic role of B cell/T cell collaboration. In particular, aberrant T helper type 2 (Th2)/regulatory T cells sustained by putative autoreactive B cells have been proposed to drive collagen deposition through the production of profibrotic cytokines, but definitive demonstrations of this hypothesis are lacking. Indeed, a number of unsolved questions need to be addressed in order to fully understand the pathogenesis of IgG4-RD. These include the identification of an antigenic trigger(s), the implications (if any) of IgG4 antibodies for pathophysiology and the precise immunological mechanisms leading to fibrosis. Recent investigations have also raised the possibility that innate immunity might precede adaptive immunity, thus further complicating the pathological scenario. Here, we aim to review the most recent insights on the immunology of IgG4-RD, focusing on the relative contribution of innate and adaptive immune responses to the full pathological phenotype of this fibrotic condition. Clinical, histological and therapeutic features are also addressed.
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Affiliation(s)
- E Della-Torre
- Università Vita-Salute San Raffaele, Milan, Italy.,Unit of Medicine and Clinical immunology, Milan, Italy
| | - M Lanzillotta
- Università Vita-Salute San Raffaele, Milan, Italy.,Unit of Medicine and Clinical immunology, Milan, Italy
| | - C Doglioni
- Università Vita-Salute San Raffaele, Milan, Italy.,Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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