[The clinical characteristics of 346 patients with IgG4-related disease]

Radiomics Model Based on Enhanced Gradient Level Set Segmentation Algorithm to Predict the Prognosis of Endoscopic Treatment of Sinusitis

Methods

Computed tomography (CT) images of sinusitis in 91 patients were collected. By introducing boundary gradient information into the edge detection function, the sensitivity of the level set model to the boundary of different intensities of lesions was adjusted to obtain accurate segmentation results. After that, the segmented CT image was imported into Mazda texture analysis software for feature extraction. Three dimensionality reduction methods were used to screen the best texture features. Four analysis methods in the B11 module were used to calculate the misclassified rate (MCR).

Results

The segmentation algorithm based on an enhanced gradient level set has good segmentation results for sinusitis lesions. The radiomics results show that the raw data analysis method under the Fisher dimensionality reduction method has a low MCR (25.27%).

Conclusion

The enhanced gradient level set segmentation algorithm can segment sinusitis lesions accurately. The radiomics model effectively predicts the prognosis of endoscopic treatment of sinusitis.

Severe asthma as the initial clinical manifestation of IgG4-related disease: a retrospective clinical study

Background

Respiratory involvement is common in immunoglobulin G4-related disease (IgG4-RD). However, severe asthma as the initial clinical manifestation of IgG4-RD is rare and might be neglected by respiratory clinicians. We aimed to explore the clinical characteristics and prognoses of patients with immunoglobulin G4-related disease (IgG4-RD) manifesting as severe asthma.

Methods

A retrospective analysis of the clinical characteristics and prognoses of patients with severe asthma who were eventually diagnosed with IgG4-RD was performed in the Peking Union Medical College Hospital from 2013 to 2019.

Results

Twelve patients (5males, 7 females) were included. The mean age at enrollment and age of asthma onset were 59.4 ± 10.1 and 53.8 ± 10.4 years, respectively. The mean duration of asthma symptoms was 5.7 ± 2.0 years. In all patients, the proportion (25.1 ± 10.3%) and count (2.0 ± 1.1) × 10⁹/L of eosinophils in peripheral blood increased. Additionally, all patients exhibited elevated total immunoglobulin E [IgE, (1279.3 ± 1257.9) KU/L] and IgG4 (9155.8 ± 9247.6) mg/dL. Bronchial wall thickening (n = 11) and mediastinal/hilar lymphadenopathy (n = 11) were major chest CT manifestations. All were pathologically diagnosed through surgical biopsy; submandibular gland (n = 8), supraclavicular lymph node (n = 2), stomach (n = 1), rashes (n = 1), lacrimal gland (n = 1) and thoracoscopic lung (n = 1) biopsies were performed. Asthma was well controlled by oral glucocorticoids (GCs), but some patients relapsed during tapering (n = 11). The refractory condition was controlled after increasing the dosage of GCs and add-on immunosuppressants.

Conclusions

For patients with middle age-onset severe asthma with elevated eosinophils, total IgE and IgG4 levels and available salivary gland ultrasound imaging, ruling out IgG4-RD is recommended. GCs used in combination with immunosuppressants is recommended to prevent relapse.

Clinical Characteristics and CD4+ T Cell Subsets in IgG4-Related Disease

Objectives

To characterize the clinical features of IgG4-related disease (IgG4-RD) and analyze the peripheral T lymphocyte subsets and cytokine levels.

Methods

A total of 52 patients with newly diagnosed IgG4-RD were enrolled in the retrospective study. Baseline clinical characteristics and examinational findings were systematically reviewed.

Results

IgG4-RD patients had a male predominance, with an average age of 57.4 ± 10.3 years (range 27-81). The mean number of involved organs was 2.7 (range 1-8). Submandibular gland (57.7%) and lacrimal gland/orbit (40.4%) were the most commonly involved organs. Serum IgG4 increased in 97.9% of the patients, the median level was 1300 (585.25, 1975) mg/dl. Decreased C3 and C4 accounted for 77.8% and 55.6% of this patient cohort, respectively. Receiver operating characteristic (ROC) test indicated the possibility of lung/pleura involvement when C3 was less than 0.570 g/l (AUC = 0.788, P = 0.014), and kidney involvement when C3 was less than 0.545 g/l (AUC = 0.796, P = 0.014). Compared with healthy controls (HC), the absolute Th1 counts were higher in IgG4-RD patients (157.58 cells/μl vs. 130.54 cells/μl, P = 0.038), while the absolute counts of Th2, Th17 and T regulatory (Treg) cells, as well as Th17/Treg ratio were not statistically different. The levels of serum IL-4, IL-6, IL-10, IL-17, TNF-α, and IFN-γ were higher in patients with IgG4-RD as compared with HC (P < 0.001). Serum IL-10 was positively correlated with IL-4, TNF-α and IFN-γ, but uncorrelated with Treg cells. Serum IgG4 level was positively associated with the number of affected organs, eosinophil counts, and ESR, whereas inversely associated with C3, C4, IgM, and IgA.

Conclusion

Submandibular and lacrimal glands are the most commonly involved organs in IgG4-RD. Serum C3 level could be a predictor of lung/pleura and kidney involvement in the disease process. Elevated Th1 cells are probably related to chronic inflammation and fibrosis. Treg cells are unlikely to play an important role in the pathogenesis of IgG4-RD.

Clinicopathological Patterns and Predictors of the Functional Restoration of Immunoglobulin G4-Related Kidney Disease: A Chinese Single-Center Cohort Study

Background: Immunoglobulin G4-related disease (IgG4-RD) is a systemic immunoreactivity-based fibro-inflammatory disease. Immunoglobulin G4-related kidney disease (IgG4-RKD) is a frequently overlooked diagnosis. This study aimed to describe IgG4-RKD and examine the factors relevant to the renal outcomes of IgG4-RD.

Methods: We studied a prospective IgG4-RKD cohort between January 2012 and December 2020 with close follow-up. Clinicopathologic data at kidney biopsy were collected and analyzed. We aimed to explore independent risk factors for long-term renal outcome and disease relapse. Patients with an eGFR<45 ml/min per 1.73m² at 12 months were defined as having poor outcomes.

Results: The included 42 patients with IgG4-RKD had a mean age of 58.5 ± 8.7 years (male-to-female ratio = 5:1). The IgG4-RD responder index (RI) was 12.2 ± 3.3. A total of 66.7% of the patients presented with acute on kidney disease or acute on chronic kidney disease. Eight patients (19.0%) showed nephrotic-range proteinuria, and nine (21.4%) had high-titer IgG4-autoantibodies, including antineutrophil cytoplasmic antibody and anti-phospholipase A2 receptor. A kidney biopsy was conducted in 40 patients. Thirty-seven (90.0%) patients were diagnosed with IgG4-related tubulointerstitial nephritis, and 19 (47.5%) of them had concurrent glomerular diseases (membranous nephropathy [MN], n = 3; crescentic glomerulonephritis [CrGN], n = 11; diabetic kidney disease, n = 3; and both MN and CrGN, n = 2). IgG4-RD RI had a close relationship with serum C3 (R = −0.509, P = 0.001), C4 (R = −0.314, P = 0.049) levels, and peripheral blood eosinophil count (PBEC; R = 0.377, P = 0.024), factors that were not included in RI scores. Correlation analysis disclosed that IgG4-RD RI (R = 0.422, P = 0.007), organs involved (R = 0.452, P = 0.003), and C3 (R = −0.487, R = 0.002) were correlated with the percentage decrease of serum creatinine at 1 month. However, multivariate regression analysis failed to identify any clinicopathological parameters that could predict short-term renal restoration and IgG4-RKD relapse. Ten out of 29 variables, of most importance, were identified by the least absolute shrinkage and selection operator (LASSO) regression analysis. By multivariate logistic regression a higher serum IgG4 (OR = 0.671, P = 0.010), IgG1 (OR = 1.396, P = 0.049), IgG3 (OR = 19.154, P = 0.039), and erythrocyte sedimentation rate (ESR; OR = 1.042, P = 0.032) were found to be independent factors for poor long-term outcome. Conventional immunosuppressive medications and/or rituximab were prescribed, and in 83.3% of the patients, the kidney function improved. Repeat kidney biopsies confirmed the remission of interstitial inflammation in two patients under immunosuppressive therapy. However, the disease relapse rate was as high as 31.0%.

Conclusions: We strongly recommend a kidney biopsy in active IgG4-RD, especially when there is proteinuria and renal dysfunction, because concurrent glomerular involvement and active interstitial inflammation should be assessed. A higher serum IgG1, IgG3, and ESR were independent factors for the poor long-term renal outcome; however, elevated IgG4 predicted a good renal prognosis, and appropriate and timely immunosuppressive therapy can help achieve a better prognosis.

Immunoglobulin G4-related lacrimal sac dacryocystocele: A novel case report

Purpose

Immunoglobulin G4-related disease is a systemic fibroinflammatory disease of unknown etiology. Immunoglobulin G4-related ophthalmic disease (IgG4-ROD) can manifest in multiple ways, but lacrimal sac involvement is rare. We present the first case in Chinese population of lacrimal sac IgG4-ROD.

Observations

Lacrimal sac IgG4-ROD is rare, and only 9 cases were reported in literature. Despite reported cases in Asian population, mainly in Japan, there was none from the Chinese population or South Asia. Our index case is a 67-year-old Chinese male, who presented with a left insidious nasolacrimal duct swelling mimicking dacryocystocele. Lacrimal sac IgG4-ROD was diagnosed with radiological, serological, pathological and immunohistochemical evidence. The under-reporting of this disease entity may suggest a benign course of such.

Conclusions and importance

This is the first reported case of biopsy proven lacrimal sac definite IgG4-ROD in Chinese patient on English literature. With the limited cases reported in literature, the pathology of Immunoglobulin G4 immune process in lacrimal sac demands further investigation.

Immunoglobulin G4-related hypertrophic pachymeningitis: A case-oriented review

Objective

Meningeal involvement in Immunoglobulin G (IgG)-4-related disease is rare and only described in case reports and series. Because a review into the disease is lacking, we present 2 cases followed by a literature review of IgG4-related hypertrophic pachymeningitis (IgG4-HP).

Methods

Two IgG4-HP cases were reported, one involving the spinal cord and responding to surgical management and a second involving the brain and responding to Rituximab therapy. We then review clinical cases and case-series of histologically proven IgG4-HP that were published in the PubMed-NCBI database.

Results

Forty-two case reports and 5 case-series were studied (60 patients, 20 women). The median age was 53. Eighteen patients had systemic involvement and 24 had single-organ IgG4-HP. Fifty-five percent of patients had an elevated serum IgG4. Treatment was surgical in 20/53 cases. Steroid therapy and immunosuppressors were effective in 85% and more than 90% of the cases, respectively. The rate of disease relapse was 42.1% after steroid therapy was discontinued.

Discussion/conclusion

IgG4-HP is characterized by the lack of extra-neurologic organ-involvement and systemic signs. Histopathologic studies should be performed as it is crucial for diagnosis because serum markers are rarely informative. 18F-FDG positon tomography can be useful to characterize systemic forms. There is no specific CSF marker for IgG4-HP and the diagnostic value of CSF IgG4 levels needs to be studied with larger samples. We provide a treatment algorithm for IgG4-HP. Such treatment strategies rely on early surgery, steroids, and early immunosuppressive therapy to prevent neurologic complications.