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Yardimci GK, Arslan D, Babaoğlu B, Bolek EC, Kilic L, Saglam A, Tuncer A, Söylemezoğlu F, Gocmen R, Oguz KK, Tan E, Karadag O. IgG4-related pachymeningitis-Long term follow up and outcome of six patients. Int J Rheum Dis 2023; 26:1853-1860. [PMID: 37403944 DOI: 10.1111/1756-185x.14725] [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: 03/05/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Our understanding of IgG4-RD and pachymeningitis has grown substantially, but the optimal approach for diagnosis, management, and long-term outcomes is still an area of uncertainty. METHODS HUVAC is a database for IgG4-RD patients, this database was retrospectively evaluated for pachymeningeal disease. Demographic, clinical, serological, imaging, histopathological data, and treatment details were re-interpreted in patients with pachymeningitis. RESULTS Among 97 patients with IgG4-RD, 6 (6.2%) had pachymeningitis. None of these patients had extracranial features, and also, in most of the patients, serum IgG4 levels were normal. Tentorium cerebelli and transverse sinus dura were the most commonly involved in the posterior fossa. During 18 months of median follow-up on steroid+-rituximab, none of them relapsed as pachymeningitis. CONCLUSION Our patients were mainly older males with sole neurological involvement. Non-specific headache was the most common manifestation, and serum IgG4 levels were not useful for diagnosis. Typical radiology and tentorial thickening should suggest IgG4-RD and prompt an early biopsy. Moreover, accompanying hypophysitis could also be a clue. With steroids+ rituximab treatment, no relapse related to meningeal involvement was seen in long-term follow-up.
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Affiliation(s)
- Gozde Kubra Yardimci
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
| | - Doruk Arslan
- Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Berrin Babaoğlu
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ertuğrul Cagri Bolek
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
| | - Levent Kilic
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
| | - Arzu Saglam
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aslı Tuncer
- Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Figen Söylemezoğlu
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Rahşan Gocmen
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Kader K Oguz
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ersin Tan
- Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Vasculitis Research Centre, Hacettepe University, Ankara, Turkey
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Gader G, Atig FB, Jemel N, Bourgou M, Slimane A, Ghedira K, Badri M, Zammel I. Epiduritis related to IgG4 disease: A very rare cause for spinal cord compression. Surg Neurol Int 2023; 14:205. [PMID: 37404483 PMCID: PMC10316182 DOI: 10.25259/sni_400_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/27/2023] [Indexed: 07/06/2023] Open
Abstract
Background Inflammatory pseudotumors are rare, and those attributed to immunoglobulin G4 (IgG4) diseases are even less frequently encountered. Here, we reviewed 41 cases from the literature of spinal inflammatory pseudotumors due to IgG4 and have added our single new case. Case Presentation A 25-year-old male presented with progressive back pain, bilateral paraparesis, and sphincter dysfunction. His deficit was attributed to MR-documented posterolateral lesion between the T5 and T10 levels for which he levels underwent a T1-T1010 laminectomy. The pathology revealed an immunoglobulin G4-related inflammatory pseudotumor. Postoperatively, the patient additionally required systemic and epidural administration of glucocorticoids. Conclusion IgG4-related disease is an emerging clinical condition that rarely involves the central nervous system. Spinal inflammatory pseudotumors, including IgG4 disease, should be more commonly considered among the potential differential diagnoses of lesions compressing the spinal cord.
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Affiliation(s)
- Ghassen Gader
- Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
| | - Fatma Ben Atig
- Department of Neurosurgery, National Institute of Neurology, Tunis, Tunisia
| | - Nesrine Jemel
- Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
| | - Malek Bourgou
- Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
| | | | - Khalil Ghedira
- Department of Neurosurgery, National Institute of Neurology, Tunis, Tunisia
| | - Mohamed Badri
- Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
| | - Ihsèn Zammel
- Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
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3
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Sergio P, Alejandro R, Cristian F. Hypertrophic pachymeningitis due to IgG4-related disease (RD-IgG4). A case report. REUMATOLOGIA CLINICA 2023:S2173-5743(23)00090-4. [PMID: 37179159 DOI: 10.1016/j.reumae.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 11/22/2022] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Hypertrophic pachymeningitis (HP) is a clinico-radiological entity characterized by a thickening of the dura mater that may be focal or diffuse and manifested by a variety of neurological syndromes. Aetiologically, it is classified as infectious, neoplastic, autoimmune, and idiopathic. Many of these formerly idiopathic cases have been shown to fall into the spectrum of IgG4-related disease. OBJECTIVE To describe the case of a patient attended for neurological involvement due to hypertrophic pachymeningitis with initial diagnosis of inflammatory myofibroblastic tumour and final diagnosis of IgG4-related disease. CASE A 25-year-old woman with neurological symptoms of 3 years' evolution characterized initially by right hypoacusis, evolving with headache and diplopia. Magnetic resonance imaging (MRI) of the encephalon showed pachymeningeal thickening with involvement of vasculo-nervous structures in the tip of the cerebellum, cavernous sinus, ragged foramen, and optic chiasm. The patient presented for consultation with the result of an incisional biopsy that reported a proliferative lesion combining fibrous elements of fascicular or swirling arrangement with collagenized streaks with dense, lymphoplasmacytic infiltrate and some macrophages, with negative staining for ALK 1, with a diagnosis of inflammatory myofibroblastic tumour. Due to suspicion of IgG4-related disease (IgG4-RD) the biopsy was sent for review and pertinent complementary studies were requested. BIOPSY REVIEW Non storiform fibrosis, predominantly lymphoplasmacytic infiltrate, histiocytes, and polymorphonuclear infiltrate in sectors, without granulomas or atypia. Staining for germs negative. Immunohistochemistry with 50-60 IgG4+/HPF cells and range of 15%-20%, CD68+ in histiocytes, CD1a-, S100-. The patient presented deterioration of visual acuity due to ophthalmic nerve involvement, so glucocorticoid treatment was started in pulses and rituximab with regression of symptoms and imaging improvement of the lesions. CONCLUSION HP is a clinical imaging syndrome with variable symptoms and aetiologies that poses a diagnostic challenge. In this case the initial diagnosis was inflammatory myofibroblastic tumour, which is a neoplasm of variable behaviour, locally aggressive, and can metastasize; it is one of the main differential diagnoses of IgG4-related disease because they share anatomopathological features, including storiform fibrosis. IgG4-RD is an immune-mediated condition that can have single or multiple involvement. Its diagnosis is complex when it presents with single organ involvement or in non-typical organs (CNS, meninges) in which data are scarce, as in the case of our patient with single organ involvement of the CNS. Although there are classification criteria to guide non-specialists in the diagnosis, the sum of the clinical picture, imaging, laboratory, pathological anatomy, and immunohistochemistry will always be evaluated together for a definitive diagnosis.
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Affiliation(s)
- Paira Sergio
- Servicio de Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Reibaldi Alejandro
- Servicio de Reumatología, Hospital José María Cullen, Santa Fe, Argentina.
| | - Froullet Cristian
- Servicio de Diagnóstico por Imágenes, Hospital José María Cullen, Santa Fe, Argentina
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4
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Batani V, Lanzillotta M, Mahajne J, Pedica F, Palumbo D, Venturini E, Mapelli P, Bossi P, Dagna L, Della-Torre E. Association of IgG4-related disease and systemic rheumatic disorders. Eur J Intern Med 2023; 111:63-68. [PMID: 36935250 DOI: 10.1016/j.ejim.2023.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE Autoimmune disorders can occur together especially in genetically predisposed individuals. We here aimed to assess the occurrence of IgG4-related disease (IgG4-RD) in association with other systemic immune-mediated conditions. METHODS We retrospectively analyzed the clinical records of patients with IgG4-RD followed at the IgG4-RD Clinic of San Raffaele Hospital (Milan, Italy) for pre-existing or concomitant immune-mediated disorders. IgG4-RD was diagnosed based on histological findings and on the 2011 Comprehensive Diagnostic criteria. Associated immune-mediated disorders were diagnosed based on available classification and/or diagnostic criteria. RESULTS Two-hundred and thirty-four patients with a definitive diagnosis of IgG4-RD were included in this study. A pre-existing immune-mediated connective tissue disease was reported in 6/234 patients (3%): one case each of sarcoidosis, Takayasu arteritis (TA), eosinophilic granulomatosis with polyangitis (EGPA), and rheumatoid arthritis; and two cases of granulomatosis with polyangitis (GPA). Organs involved by IgG4-RD included the lungs, the pancreas, the peritoneum, lacrimal glands, meninges and orbits. Sarcoidosis, EGPA, and TA preceded the onset of IgG4-RD. GPA preceded IgG4-RD onset in one case and occurred simultaneously in the other case. Rheumatoid arthritis occurred together with IgG4-RD in one case. CONCLUSION Our observation suggests that "secondary" IgG4-RD can present in the context of pre-existing systemic immune-mediated disorders and complicate systemic autoimmune diseases as well as chronic granulomatous conditions. Further studies are needed to define whether this peculiar clinical scenario is associated with different genetic backgrounds, pathological bases, and long-term outcomes.
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Affiliation(s)
- Veronica Batani
- 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
| | - 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
| | - Jasmin Mahajne
- 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
| | - Federica Pedica
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Diego Palumbo
- Unit of Clinical and Experimental Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Venturini
- Unit of Clinical and Experimental Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Mapelli
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Bossi
- Pathology Department, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Lorenzo Dagna
- 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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5
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Yang F, Liu Z, Zhang Y, Li P, Zhu Y, Zhu Q, Zhang B. Case report: Clinical highlights and radiological classification of IgG4-related spinal pachymeningitis: A rare case series and updated review of the literature. Front Oncol 2023; 12:1035056. [PMID: 36703781 PMCID: PMC9873374 DOI: 10.3389/fonc.2022.1035056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Purpose Hypertrophic pachymeningitis associated with immunoglobulin G4-related disease (IgG4-RD) has been rarely reported, and there is little information and no clear consensus on the management of IgG4-related spinal pachymeningitis (IgG4-RSP). The present study described its possible clinical features, including the symptoms, imaging, treatment and prognosis of patients with IgG4-RSP. Methods We report three patients who presented with progressive neurological dysfunction due to spinal cord compression. Relevant articles were searched from the PubMed, Web of Science, and Embase databases, and the resulting literature was reviewed. Results The literature review provided a summary of 45 available cases, which included three cases from our center. Progressive worsening of neurological impairment was observed in 22 patients (48.9%). The lesions involved the thoracic spine (n=28, 62.2%), cervical spine (n=26, 57.8%), lumbar spine (n=9, 20.0%), and sacral spine (n=1, 2.2%). Furthermore, the lesions were located in the dura mater (n=18, 40.0%), epidural space (n=17, 37.8%), intradural-extramedullary space (n=9, 20.0%), and intramedullary space (n=1, 2.2%). On magnetic resonance imaging (MRI), the lesions generally appeared as striated, fusiform, or less often lobulated oval changes, with homogeneous (n=17,44.7%) and dorsal (n=15,39.5%) patterns being the most common. Thirty-five patients had homogeneous T1 gadolinium enhancement. Early surgical decompression, corticosteroid treatment, and steroid-sparing agents offered significant therapeutic advantages. A good therapeutic response to disease recurrence was observed with the medication. Conclusion The number of reported cases of IgG4-RSP remains limited, and patients often have progressive worsening of their neurological symptoms. The features of masses identified on the MRI should be considered. The prognosis was better with decompression surgery combined with immunosuppressive therapy. Long-term corticosteroid treatment and steroid-sparing agent maintenance therapy should be ensured. A systemic examination is recommended to identify the presence of other pathologies.
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6
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IgG4-Related Sclerosing Disease of the Temporal Bone: A Systematic Review. Otol Neurotol 2022; 43:856-863. [PMID: 35941671 DOI: 10.1097/mao.0000000000003614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) involving the temporal bone is an uncommon and underrecognized pathology often mistaken for malignancy. This systematic review is the first that aims to thoroughly analyze IgG4-RD of the temporal bone. DATABASES REVIEWED Ovid MEDLINE, EMBASE, Cochrane Library, and Google Scholar. METHODS We used the following search keywords: "lgG4-RD," "skull," "skull base," "cranial," "temporal bone," "inner ear." We additionally manually searched the bibliographies of relevant articles. The JBI Critical Appraisal Checklist for Case Reports and Case Series was used to assess the risk of bias; because of the scarcity of the reports, data were available through limited case series and reports; thus, data synthesis was not possible. RESULTS We identified 17 studies with 22 cases with temporal bone involvement. The most common presenting symptoms were hearing loss, otalgia, and headache. The mastoid and petrous bone were the most affected anatomical areas. Both computed tomography and magnetic resonance imaging were used. Biopsies showed the characteristic lymphoplasmacytic infiltrate in all cases, with histopathology being the diagnostic modality that set the diagnosis. Most patients were treated with corticosteroids ± surgery or a combination of corticosteroids and immunosuppressants with 95.5% symptomatic response and disease control. CONCLUSION IgG4-RD of the temporal bone radiologically manifests as space-occupying, lytic lesions; clinically, it presents with vague otological symptoms. Diagnosis involves a thorough workup, with histopathology being crucial in setting a definite diagnosis. IgG4-RD tends to respond well to systemic corticosteroids, whereas surgery is mostly required for diagnostic purposes.
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7
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Friedrich M, Kehl N, Engelke N, Kraus J, Lindner K, Münch P, Mildenberger I, Groden C, Gass A, Etminan N, Fatar M, von Deimling A, Reuss D, Platten M, Bunse L. Intrathecal activation of CD8 + memory T cells in IgG4-related disease of the brain parenchyma. EMBO Mol Med 2021; 13:e13953. [PMID: 34254741 PMCID: PMC8350898 DOI: 10.15252/emmm.202113953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/21/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder signified by aberrant infiltration of IgG4-restricted plasma cells into a variety of organs. Clinical presentation is heterogeneous, and pathophysiological mechanisms of IgG4-RD remain elusive. There are very few cases of IgG4-RD with isolated central nervous system manifestation. By leveraging single-cell sequencing of the cerebrospinal fluid (CSF) of a patient with an inflammatory intracranial pseudotumor, we provide novel insights into the immunopathophysiology of IgG4-RD. Our data illustrate an IgG4-RD-associated polyclonal T-cell response in the CSF and an oligoclonal T-cell response in the parenchymal lesions, the latter being the result of a multifaceted cell-cell interaction between immune cell subsets and pathogenic B cells. We demonstrate that CD8+ T effector memory cells might drive and sustain autoimmunity via macrophage migration inhibitory factor (MIF)-CD74 signaling to immature B cells and CC-chemokine ligand 5 (CCL5)-mediated recruitment of cytotoxic CD4+ T cells. These findings highlight the central role of T cells in sustaining IgG4-RD and open novel avenues for targeted therapies.
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Affiliation(s)
- Mirco Friedrich
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Niklas Kehl
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Niko Engelke
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Josephine Kraus
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Katharina Lindner
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Philipp Münch
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Iris Mildenberger
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Achim Gass
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas von Deimling
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.,DKTK CCU Neuropathology, DKFZ, Heidelberg, Germany
| | - David Reuss
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.,DKTK CCU Neuropathology, DKFZ, Heidelberg, Germany
| | - Michael Platten
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Helmholtz Institute of Translational Oncology (HI-TRON), Mainz, Germany.,Immune Monitoring Unit, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Lukas Bunse
- DKTK Clinical Cooperation Unit (CCU) Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Neurology, MCTN, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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8
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Hutto SK, Maher MD, Miloslavsky EM, Venna N. Nodular Pachymeningitis Associated With Relapsing Polychondritis and Crohn Disease Responsive to Adalimumab and Prednisone. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/5/e1022. [PMID: 34078656 PMCID: PMC8176555 DOI: 10.1212/nxi.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022]
Abstract
Objectives To review the previous literature on the associations of pachymeningitis with Crohn disease (CD) and relapsing polychondritis (RP) and to describe a new case occurring in association with both in addition to highlighting its positive response to steroid and adalimumab treatment. Methods We review the patient's clinical presentation, diagnostic workup (serum and CSF testing), and MRI findings in detail and chronicle the response of the pachymeningitis to intensive immunotherapy. We contrast this case against previous reports of pachymeningitis occurring in association with RP and inflammatory bowel disease that were found on PubMed. Results Only 2 cases of ulcerative colitis and 5 cases of RP were found in association with pachymeningitis; there were no cases in association with CD. Our patient presented with symptoms isolated to a steroid-responsive headache in the setting of normal neurologic and rheumatologic examinations. Her preceding history was notable for long-standing CD and increasingly active symptoms referable to RP. Focal nodular pachymeningitis was seen overlying the left hemisphere on brain MRI. An extensive serum and CSF workup and body fluorodeoxyglucose-PET scan failed to identify an alternative etiology beyond her underlying autoimmune inflammatory disorders. After adding prednisone and adalimumab to her preexisting treatment of methotrexate, she responded dramatically both clinically and radiographically. Conclusions Although exceptionally rare, pachymeningitis may occur as a neuroinflammatory complication of CD and RP.
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Affiliation(s)
- Spencer K Hutto
- From the Division of Neuroimmunology and Neuroinfectious Diseases (S.K.H., N.V.), Department of Neurology, Massachusetts General Hospital, Boston; Division of Neuroradiology (M.D.M), Department of Radiology, Massachusetts General Hospital, Boston; and Division of Rheumatology, Allergy and Immunology (E.M.M), Department of Medicine, Massachusetts General Hospital, Boston.
| | - Mary D Maher
- From the Division of Neuroimmunology and Neuroinfectious Diseases (S.K.H., N.V.), Department of Neurology, Massachusetts General Hospital, Boston; Division of Neuroradiology (M.D.M), Department of Radiology, Massachusetts General Hospital, Boston; and Division of Rheumatology, Allergy and Immunology (E.M.M), Department of Medicine, Massachusetts General Hospital, Boston
| | - Eli M Miloslavsky
- From the Division of Neuroimmunology and Neuroinfectious Diseases (S.K.H., N.V.), Department of Neurology, Massachusetts General Hospital, Boston; Division of Neuroradiology (M.D.M), Department of Radiology, Massachusetts General Hospital, Boston; and Division of Rheumatology, Allergy and Immunology (E.M.M), Department of Medicine, Massachusetts General Hospital, Boston
| | - Nagagopal Venna
- From the Division of Neuroimmunology and Neuroinfectious Diseases (S.K.H., N.V.), Department of Neurology, Massachusetts General Hospital, Boston; Division of Neuroradiology (M.D.M), Department of Radiology, Massachusetts General Hospital, Boston; and Division of Rheumatology, Allergy and Immunology (E.M.M), Department of Medicine, Massachusetts General Hospital, Boston
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9
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Utility of the "2019 ACR/EULAR classification criteria" for the management of patients with IgG4-related disease. Semin Arthritis Rheum 2021; 51:761-765. [PMID: 34144386 DOI: 10.1016/j.semarthrit.2021.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/03/2021] [Accepted: 04/09/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The 2019 ACR/EULAR Classification Criteria for IgG4-related disease (IgG4-RD) represent a fundamental tool for patient enrollment in research studies and in clinical trials but their usefulness in daily clinical practice remains unknown. OBJECTIVE To validate the 2019 ACR/EULAR Classification Criteria for IgG4-RD in a real-life setting and to anticipate their utility for orienting disease diagnosis and patient management. METHODS Four experts were asked to classify 200 patients diagnosed with IgG4-RD according to the 2019 ACR/EULAR Classification Criteria for IgG4-RD. Agreement between experts was calculated and the Classification score of each patient was correlated with the following variables and outcomes: serum IgG4 and IgE; inflammatory markers; eosinophils; plasmablasts; IgG4-RD responder index; diabetes, osteoporosis, relapses; and use of rituximab. RESULTS Among the 157/200 cases equally rated by at least three experts, 94 (59.9%) achieved IgG4-RD classification and 63 (40.1%) did not. Strong agreement among IgG4-RD experts was observed in classifying patients (k = 0.711, p<0.0001). Clinical presentations not included in the classification algorithm and lack of informative histology were the most common reasons for not achieving classification. In patients achieving classification, the Classification score did not correlate with variables of disease activity and was not associated with specific outcomes. CONCLUSIONS The ACR/EULAR Classification Criteria represent a replicable instrument for classifying patients and a useful framework for orienting diagnosis but are of limited utility for assessing IgG4-RD activity, for predicting disease outcomes, and for defining personalized therapeutic approaches.
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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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Cler SJ, Sharifai N, Baker B, Dowling JL, Pipkorn P, Yaeger L, Clifford DB, Dahiya S, Chicoine MR. IgG4-Related Disease of the Skull and Skull Base-A Systematic Review and Report of Two Cases. World Neurosurg 2021; 150:179-196.e1. [PMID: 33746107 DOI: 10.1016/j.wneu.2021.03.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE IgG4-related disease (IgG4-RD) is an inflammatory process that uncommonly can present in the skull base and calvarium and mimic a tumor but the nature of this condition is not well summarized in the neurosurgical literature. METHODS A review was performed of 2 cases of IgG4-RD in the skull base highlighting the diagnostic challenges with assessment of these skull base lesions, and a systematic review of relevant literature was carried out. RESULTS A systematic review of the literature conducted in accordance with PRISMA guidelines identified 113 articles, with 184 cases of IgG4-RD in the skull base or calvarium. The most commonly affected locations include the meninges, cavernous sinus, base of the posterior fossa, clivus, and mastoid bone. Headache, visual and auditory disturbances, cranial nerve dysfunction, and seizures were the most common presenting symptoms. Medical treatment was highly successful and most commonly consisted of corticosteroids coadministered with immunosuppressive agents such as rituximab. Prevalence seemed to be equal between sexes, and serum IgG4 levels were increased in 61% of patients. Delayed diagnosis and a need for multiple biopsies were reported in numerous cases. Two cases of skull base IgG4-RD from the authors' institution show the variable presentations of this disease. More invasive surgical biopsies were required in both cases, and corticosteroid treatment led to significant clinical improvement. CONCLUSIONS IgG4-RD is an uncommon condition with an increasing body of reported cases that can affect the skull base and calvarium and should be in the differential diagnosis, because delay in diagnosis and treatment may be common.
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Affiliation(s)
- Samuel J Cler
- Department of Neurosurgery, Washington University School of Medicine, Washington, D.C., USA.
| | - Nima Sharifai
- Department of Pathology and Immunology, Washington University School of Medicine, Washington, D.C., USA
| | - Brandi Baker
- Department of Neurology, Washington University School of Medicine, Washington, D.C., USA
| | - Joshua L Dowling
- Department of Neurosurgery, Washington University School of Medicine, Washington, D.C., USA
| | - Patrik Pipkorn
- Department of Otolaryngology, Washington University School of Medicine, Washington, D.C., USA
| | - Lauren Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, Washington, D.C., USA
| | - David B Clifford
- Department of Neurology, Washington University School of Medicine, Washington, D.C., USA; Department of Infectious Disease, Washington University School of Medicine, Washington, D.C., USA
| | - Sonika Dahiya
- Department of Pathology and Immunology, Washington University School of Medicine, Washington, D.C., USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, Washington, D.C., USA
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12
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Rampi A, Lanzillotta M, Mancuso G, Vinciguerra A, Dagna L. IgG4-Related Disease of the Oral Cavity. Case Series from a Large Single-Center Cohort of Italian Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218179. [PMID: 33167472 PMCID: PMC7663930 DOI: 10.3390/ijerph17218179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022]
Abstract
A series of destructive and tumefactive lesions of the oral cavity are increasingly recognized as part of the IgG4-related disease (IgG4-RD) spectrum. We herein examined the clinical, serological, radiological, and histological features of a series of patients referred to our clinic because of oral cavity lesions ultimately attributed to IgG4-RD. In particular, we studied 6 consecutive patients out of 200 patients referred to the immunology outpatient unit who presented with erosive and/or tumefactive lesions of the oral cavity. All patients underwent serum IgG4 measurement, nasal endoscopy, radiological studies, and histological evaluation of tissue specimens. The histological studies included immunostaining studies to assess the number of IgG4+ plasma cells/High-Power Field (HPF) for calculation of the IgG4+/IgG+ plasma cell ratio. Six patients (3% of the entire cohort) were diagnosed with IgG4-RD of the oral cavity based on histological evaluation. A major complaint at presentation was oral discomfort due to bulging mass. A mild to no increase in serum IgG4 was observed. Different patterns of organ involvement were associated with oral lesions. Five patients were treated with immunosuppressive therapy and two patients promptly responded to B-cell depletion with rituximab. Watchful waiting was decided in one patient with no major clinical symptoms. Involvement of the oral cavity is an infrequent manifestation of IgG4-RD but should be taken into consideration as a possible differential diagnosis of tumefactive or erosive lesions once neoplastic conditions are excluded. A histological examination of biopsy samples from the oral cavity represents the mainstay for diagnosis of IgG4-RD.
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Affiliation(s)
- Andrea Rampi
- Otorhinolaryngology Unit, Division of Head and Neck Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (A.R.); (A.V.)
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.); (L.D.)
| | - Marco Lanzillotta
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.); (L.D.)
- Division of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Correspondence:
| | - Gaia Mancuso
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.); (L.D.)
- Division of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Alessandro Vinciguerra
- Otorhinolaryngology Unit, Division of Head and Neck Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (A.R.); (A.V.)
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.); (L.D.)
| | - Lorenzo Dagna
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.); (L.D.)
- Division of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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13
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Sbeih I, Darwazeh R, Shehadeh M, Al-Kanash R, Abu-Farsakh H, Sbeih A. Immunoglobulin G4-Related Hypertrophic Pachymeningitis of the Spine: A Case Report and Systematic Review of the Literature. World Neurosurg 2020; 143:445-453. [PMID: 32777395 DOI: 10.1016/j.wneu.2020.07.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spinal immunoglobulin G4-related hypertrophic pachymeningitis (IgG4-HP) is a rare disease. Little information is known regarding the diagnosis, management, and prognosis of patients with spinal IgG4-HP. METHODS The authors present a case of spinal IgG4-HP with a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies (up to April 2020) that reported patients with spinal IgG4-HP, based on the criteria of Japan College of Rheumatology, were identified from the PubMed and Cochrane Library databases. RESULTS This systematic review identified 33 patients, including the present case, of whom 21 were male and 12 were female. The mean value of age was 51.2 (±12.6) years. Eight patients had systemic involvement. In addition, among 33 patients, 13 patients had an elevated serum IgG4. Surgery was performed in 31 patients. Steroid therapy alone and steroid therapy with immunosuppressants were effective in 94% and 100% of the cases, respectively. Furthermore, 31 of 33 patients reported improved outcomes, 1 patient died due to infection, and in 2 patients the data were not available. CONCLUSIONS Spinal IgG4-HP is a rare entity. In addition, it should be considered in the differential diagnosis of space-occupying lesions around the spinal cord. Histopathology with immunohistochemistry results provides the most reliable evidence for diagnosis. Steroid therapy is the first line of treatment. Surgical decompression may be required in patients presenting with nerve root and/or spinal cord compression. Long-term follow-up is necessary for patients with spinal IgG4-HP.
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Affiliation(s)
- Ibrahim Sbeih
- Neurosurgery Department, Farah Medical Campus, Amman, Jordan.
| | - Rami Darwazeh
- Neurosurgery Department, Farah Medical Campus, Amman, Jordan
| | | | - Rasha Al-Kanash
- Endoscopic Spine Department, Razi Spine Clinic, Amman, Jordan
| | | | - Aseel Sbeih
- Neurosurgery Department, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
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14
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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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15
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Melenotte C, Seguier J, Ebbo M, Kaphan E, Bernit E, Saillier L, Audoin B, Feyeux D, Daniel L, Roche PH, Graillon T, Dufour H, Boutière C, Girard N, Closs-Prophette F, Guillaud C, Tieulié N, Regent A, Harlé JR, Hamidou M, Mekinian A, Grados A, Schleinitz N. Clinical presentation, treatment and outcome of IgG4-related pachymeningitis: From a national case registry and literature review. Semin Arthritis Rheum 2019; 49:430-437. [DOI: 10.1016/j.semarthrit.2019.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 03/13/2019] [Accepted: 05/06/2019] [Indexed: 12/31/2022]
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16
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Spinal IgG4-Related Hypertrophic Pachymeningitis with Spinal Cord Compression: Case Report and Literature Review. World Neurosurg 2019; 130:65-70. [DOI: 10.1016/j.wneu.2019.06.130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/18/2019] [Indexed: 12/24/2022]
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17
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Goodchild G, Pereira SP, Webster G. Immunoglobulin G4-related sclerosing cholangitis. Korean J Intern Med 2018; 33:841-850. [PMID: 30045615 PMCID: PMC6129623 DOI: 10.3904/kjim.2018.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/06/2018] [Indexed: 12/22/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory condition of which IgG4-related sclerosing cholangitis (IgG4-SC) is the biliary manifestation. In this review, we provide an overview of IgG4-RD, with a focus on the biliary manifestations. In particular, we describe the important differential diagnoses of IgG4-SC, namely, primary sclerosing cholangitis and cholangiocarcinoma, outline diagnostic criteria for IgG4-SC, provide insight into possible pathophysiological mechanisms underlying the disease and discuss short and long-term management options of this recently described disease.
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Affiliation(s)
- George Goodchild
- Department of Gastroenterology, University College Hospital, London, UK
| | | | - George Webster
- Department of Gastroenterology, University College Hospital, London, UK
- Correspondence to George Webster, M.D. Department of Gastroenterology, University College Hospital, 250 Euston Rd, London NW1 2PG, UK Tel: +44-2034567890 Fax: +44-2034479218 E-mail:
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18
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Abstract
IgG4 autoimmune diseases are characterized by the presence of antigen-specific autoantibodies of the IgG4 subclass and contain well-characterized diseases such as muscle-specific kinase myasthenia gravis, pemphigus, and thrombotic thrombocytopenic purpura. In recent years, several new diseases were identified, and by now 14 antigens targeted by IgG4 autoantibodies have been described. The IgG4 subclass is considered immunologically inert and functionally monovalent due to structural differences compared to other IgG subclasses. IgG4 usually arises after chronic exposure to antigen and competes with other antibody species, thus "blocking" their pathogenic effector mechanisms. Accordingly, in the context of IgG4 autoimmunity, the pathogenicity of IgG4 is associated with blocking of enzymatic activity or protein-protein interactions of the target antigen. Pathogenicity of IgG4 autoantibodies has not yet been systematically analyzed in IgG4 autoimmune diseases. Here, we establish a modified classification system based on Witebsky's postulates to determine IgG4 pathogenicity in IgG4 autoimmune diseases, review characteristics and pathogenic mechanisms of IgG4 in these disorders, and also investigate the contribution of other antibody entities to pathophysiology by additional mechanisms. As a result, three classes of IgG4 autoimmune diseases emerge: class I where IgG4 pathogenicity is validated by the use of subclass-specific autoantibodies in animal models and/or in vitro models of pathogenicity; class II where IgG4 pathogenicity is highly suspected but lack validation by the use of subclass specific antibodies in in vitro models of pathogenicity or animal models; and class III with insufficient data or a pathogenic mechanism associated with multivalent antigen binding. Five out of the 14 IgG4 antigens were validated as class I, five as class II, and four as class III. Antibodies of other IgG subclasses or immunoglobulin classes were present in several diseases and could contribute additional pathogenic mechanisms.
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Affiliation(s)
- Inga Koneczny
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
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19
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IgG4-related hypertrophic pachymeningitis of the spine with MPO-ANCA seropositivity. Clin Imaging 2017; 46:108-112. [DOI: 10.1016/j.clinimag.2017.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/24/2022]
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20
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Zheng K, Teng F, Li XM. Immunoglobulin G4-related kidney disease: Pathogenesis, diagnosis, and treatment. Chronic Dis Transl Med 2017; 3:138-147. [PMID: 29063068 PMCID: PMC5643773 DOI: 10.1016/j.cdtm.2017.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 12/19/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized clinical entity that often involves multiple organs; it is characterized by high levels of serum immunoglobulin G4 (IgG4), dense infiltration of IgG4+ cells, and storiform fibrosis. Cellular immunity, particularly T cell-mediated immunity, has been implicated in the pathogenesis of IgG4-RD. The most frequent renal manifestations of IgG4-RD are IgG4-related tubulointerstitial nephritis, membranous glomerulonephropathy (MGN), and obstructive nephropathy secondary to urinary tract obstruction due to IgG4-related retroperitoneal fibrosis, prostatitis, or ureter inflammation. Kidney function impairment can be acute or chronic. In IgG4-MGN, proteinuria can be in the nephrotic range. The diagnosis of IgG4-related kidney disease should not be based solely on serum IgG4 levels or the number of tissue-infiltrating IgG4+ plasma cells. Diagnosis should be based on specific histopathological findings, confirmed by tissue immunostaining and an appropriate clinical context. Steroid treatment is the first-line therapy. For relapsing or refractory cases, immunosuppressants could be combined with steroids. In hydronephrosis patients, appropriate immunosuppressive therapy could preclude the implantation of a double J ureteral catheter.
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21
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Une pachyméningite révélatrice d’une maladie associée aux IgG4. Rev Med Interne 2017. [DOI: 10.1016/j.revmed.2017.03.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Abstract
PURPOSE OF REVIEW Remarkable insights have been gleaned recently with regard to the pathophysiology of IgG4-related disease (IgG4-RD). These findings have direct implications for the development of targeted strategies for the treatment of this condition. RECENT FINDINGS Oligoclonal expansions of cells of both the B and T lymphocyte lineages are present in the blood of patients with IgG4-RD. Oligoclonal expansions of plasmablasts are a good biomarker for disease activity. An oligoclonally expanded population of CD4+ cytotoxic T lymphocytes is found not only in the peripheral blood but also at tissue sites of active disease. This cell elaborates cytokines that may drive the fibrosis characteristic of IgG4-RD. T follicular helper cells (Tfhc), particularly the Tfhc2 subset, appear to play a major role in driving the class switch to IgG4 that typifies this disease. The relationship between malignancy and IgG4-RD remains an area of interest. SUMMARY Advances in understanding the pathophysiology of IgG4-RD have proceeded swiftly, leading to the identification of a number of potential targeted treatment strategies. The completion of classification criteria for IgG4-RD, an effort supported jointly by the American College of Rheumatology and the European League Against Rheumatism, will further facilitate studies on this disease.
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23
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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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24
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De Virgilio A, de Vincentiis M, Inghilleri M, Fabrini G, Conte M, Gallo A, Rizzo MI, Greco A. Idiopathic hypertrophic pachymeningitis: an autoimmune IgG4-related disease. Immunol Res 2016; 65:386-394. [DOI: 10.1007/s12026-016-8863-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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25
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Lu Z, Tongxi L, Jie L, Yujuan J, Wei J, Xia L, Yumin Z, Xin L. IgG4-related spinal pachymeningitis. Clin Rheumatol 2015; 35:1549-53. [PMID: 26567899 DOI: 10.1007/s10067-015-3104-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/04/2015] [Accepted: 10/20/2015] [Indexed: 12/24/2022]
Abstract
The aim of this study is to study the clinical, laboratory, imaging pathology, and prognosis features of IgG4-related spinal pachymeningitis. We worked with a 55-year-old man suffering from IgG4-related spinal pachymeningitis who had the most widespread lesion in his dura mater. We also review previous related studies and discuss the clinical characteristics of this rare disease. In total, eight IgG4-related spinal pachymeningitis patients have been reported in the literature since 2009. They were mostly male patients, 51.7 ± 11.9 years old on average. Cervical and thoracic vertebrae were the most common sites for lesions. The most prominent symptom was varying numbness and weakness of the limbs and/or body associated with spinal cord compression. There was one patient (1/5) with elevated serum IgG4 levels and three patients (3/3) with increased cerebrospinal fluid (CSF) IgG4 index. Positive histopathologic findings are the strongest basis for a diagnosis. All the patients with IgG4-related spinal pachymeningitis responded well to glucocorticoid therapy. IgG4-related spinal pachymeningitis is an orphan disease that mainly occurs in cervical and thoracic vertebrae. Older males are the most susceptible group. Serum IgG4 levels were consistently normal in these cases, so analysis of CSF for IgG4 production (IgG4 index) could become a useful tool. Pathological findings remain the gold standard for diagnosis. Most patients responded favorably to glucocorticoid treatment.
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Affiliation(s)
- Zhang Lu
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Liu Tongxi
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Luo Jie
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Jiao Yujuan
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Jiang Wei
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Liu Xia
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Zheng Yumin
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China
| | - Lu Xin
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029, Beijing, China.
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26
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Nishikawa S, Kawaguchi N, Fujimori J. [Case of Takayasu arteritis accompanying hypertrophic pachymeningitis]. Rinsho Shinkeigaku 2015; 55:940-2. [PMID: 26511027 DOI: 10.5692/clinicalneurol.cn-000759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 71-year-old woman was referred to our department for evaluation of a right temporal headache. She had been diagnosed with Takayasu arteritis in her twenties but did not receive steroid therapy. A brain MRI scan detected thickened dura mater with abnormal enhancement on the right cerebral hemisphere. She was diagnosed with hypertrophic pachymeningitis, but she refused to be treated with steroids. Three months later, she noticed periorbital pain and blurred vision in her left eye, although the right temporal headache was reduced. A brain MRI scan detected thickened dura mater with abnormal enhancement on the left cerebral hemisphere adjacent to the left orbit and a swelled left superior rectus muscle with abnormal enhancement. However, the MRI results also showed that the thickening of the dura mater on the right cerebral hemisphere had improved. The new symptoms and the abnormalities revealed with imaging were resolved following steroid therapy. Takayasu arteritis mainly affects the large vessels, but can involve small and systemic vessels. This case presents a rare but possible link between hypertrophic pachymeningitis and Takayasu arteritis.
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Affiliation(s)
- Shohei Nishikawa
- Department of Neurology, Tohoku Pharmaceutical University Hospital
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27
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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: 96] [Impact Index Per Article: 10.7] [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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Fernández-Codina A, Hernández-González M, Solans-Laquè R, Bujan-Rivas S, Vilardell-Tarrés M, Martínez-Valle F. Alteration of IgG4 levels in cerebrospinal fluid in IgG4-related disease. Int J Rheum Dis 2015; 20:1865-1867. [DOI: 10.1111/1756-185x.12739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Andreu Fernández-Codina
- Systemic Autoimmune Diseases Unit; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Manuel Hernández-González
- Immunology Department; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Roser Solans-Laquè
- Systemic Autoimmune Diseases Unit; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Segundo Bujan-Rivas
- Systemic Autoimmune Diseases Unit; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Miquel Vilardell-Tarrés
- Systemic Autoimmune Diseases Unit; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Fernando Martínez-Valle
- Systemic Autoimmune Diseases Unit; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
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29
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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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30
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Della-Torre E, Feeney E, Deshpande V, Mattoo H, Mahajan V, Kulikova M, Wallace ZS, Carruthers M, Chung RT, Pillai S, Stone JH. B-cell depletion attenuates serological biomarkers of fibrosis and myofibroblast activation in IgG4-related disease. Ann Rheum Dis 2014; 74:2236-43. [PMID: 25143523 DOI: 10.1136/annrheumdis-2014-205799] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/02/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Fibrosis is a predominant feature of IgG4-related disease (IgG4-RD). B-cell depletion induces a prompt clinical and immunological response in patients with IgG4-RD, but the effects of this intervention on fibrosis in IgG4-RD are unknown. We used the enhanced liver fibrosis (ELF) score to address the impact of rituximab on fibroblast activation. The ELF score is an algorithm based on serum concentrations of procollagen-III aminoterminal propeptide, tissue inhibitor of matrix metalloproteinase-1 and hyaluronic acid. METHODS Ten patients with active, untreated IgG4-RD were enrolled. ELF scores were measured and correlated with the IgG4-RD Responder Index, serum IgG4, circulating plasmablasts and imaging studies. Through immunohistochemical stains for CD3, CD20, IgG4 and α-smooth muscle actin, we assessed the extent of the lymphoplasmacytic infiltration and the degree of fibroblast activation in one patient with tissue biopsies before and after rituximab. RESULTS The ELF score was increased in patients with IgG4-RD compared with healthy controls (8.3±1.4 vs 6.2±0.9; p=0.002) and correlated with the number of organs involved (R(2)=0.41; p=0.04). Rituximab induced significant reductions in the ELF score, the number of circulating plasmablasts and the IgG4-RD Responder Index (p<0.05 for all three parameters). Rituximab reduced both the lymphoplasmacytic infiltrate and myofibroblast activation. IgG4-RD relapse coincided with recurrent increases in the ELF score, indicating reactivation of collagen deposition. CONCLUSIONS The ELF score may be a clinically useful indicator of active fibrosis and the extent of disease in IgG4-RD. B-cell depletion has the potential to halt continued collagen deposition by attenuating the secretory phenotype of myofibroblasts in IgG4-RD lesions.
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Affiliation(s)
- Emanuel Della-Torre
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA Unit of Medicine and Clinical Immunology, IRCCS-San Raffaele Scientific Institute, Università Vita-Salute San Raffaele, Milan, Italy
| | - Eoin Feeney
- Liver Center and Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hamid Mattoo
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Vinay Mahajan
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Maria Kulikova
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mollie Carruthers
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond T Chung
- Liver Center and Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shiv Pillai
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
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31
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Yonekawa T, Murai H, Utsuki S, Matsushita T, Masaki K, Isobe N, Yamasaki R, Yoshida M, Kusunoki S, Sakata K, Fujii K, Kira JI. A nationwide survey of hypertrophic pachymeningitis in Japan. J Neurol Neurosurg Psychiatry 2014; 85:732-9. [PMID: 24273222 DOI: 10.1136/jnnp-2013-306410] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To clarify the prevalence, frequent causes and distinct features of hypertrophic pachymeningitis (HP) according to background conditions in a nationwide survey in Japan. METHODS The study began with a preliminary survey to determine the approximate number of HP patients diagnosed from 1 January 2005 to 31 December 2009, and was followed by a questionnaire survey for clinical and laboratory findings. HP was defined as a condition with thickening of the cranial or spinal dura mater with inflammation, evidenced by MRI or histology. RESULTS Crude HP prevalence was 0.949/100 000 population. The mean age at onset was 58.3±15.8 years. Among 159 cases for whom detailed data were collated, antineutrophil cytoplasmic antibody (ANCA)-related HP was found in 54 cases (34.0%) and IgG4/multifocal fibrosclerosis (MFS)-related HP in 14 cases (8.8%). Seventy cases (44.0%) were classified as 'idiopathic' and 21 (13.2%) as 'others'. ANCA-related HP cases showed a female preponderance, a higher age of onset, and higher frequencies of otological symptoms and elevated systemic inflammatory biomarkers, but lower frequencies of diplopia compared with idiopathic HP. IgG4/MFS-related HP cases showed a marked male predominance; all had cranial HP while none had isolated spinal HP or decreased sensation. CONCLUSIONS HP is not extremely rare. ANCA-related HP is the most frequent form, followed by IgG4/MFS-related HP. Both forms have unique features, which may help to differentiate background causes.
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Affiliation(s)
- Tomomi Yonekawa
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Murai
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Utsuki
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Katsuhisa Masaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriko Isobe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryo Yamasaki
- Department of Neurological Therapeutics, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Susumu Kusunoki
- Department of Neurology, School of Medicine, Kinki University, Osaka, Japan
| | - Kiyomi Sakata
- Department of Hygiene and Preventive Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Kiyotaka Fujii
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Jun-ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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32
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Della-Torre E, Passerini G, Furlan R, Roveri L, Chieffo R, Anzalone N, Doglioni C, Zardini E, Sabbadini MG, Franciotta D. Cerebrospinal fluid analysis in immunoglobulin G4-related hypertrophic pachymeningitis. J Rheumatol 2014; 40:1927-9. [PMID: 24187161 DOI: 10.3899/jrheum.130678] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Emanuel Della-Torre
- Università Vita-Salute San Raffaele, School of Medicine, and Unit of Medicine and Clinical Immunology, San Raffaele Scientific Institute, Milan
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33
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Takeuchi S, Osada H, Seno S, Nawashiro H. IgG4-Related Intracranial Hypertrophic Pachymeningitis : A Case Report and Review of the Literature. J Korean Neurosurg Soc 2014; 55:300-2. [PMID: 25132941 PMCID: PMC4130960 DOI: 10.3340/jkns.2014.55.5.300] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 07/14/2013] [Accepted: 05/15/2014] [Indexed: 11/27/2022] Open
Abstract
Hypertrophic pachymeningitis is an uncommon disorder that causes a localized or diffuse thickening of the dura mater. Recently, the possibility that IgG4-related sclerosing disease may underlie some cases of intracranial hypertrophic pachymeningitis has been suggested. We herein report the tenth case of IgG4-related intracranial hypertrophic pachymeningitis and review the previous literature. A 45-year-old male presented with left-sided focal seizures with generalization. Magnetic resonance imaging (MRI) revealed a diffuse thickening and enhancement of the right convexity dura matter and falx with focal nodularity. The surgically resected specimens exhibited the proliferation of fibroblast-like spindle cells and an infiltration of mononuclear cells, including predominantly plasma cells. The ratio of IgG4-positive plasma cells to the overall IgG-positive cells was 45% in the area containing the highest infiltration of plasma cells. On the basis of the above findings, IgG4-related sclerosing disease arising from the dura mater was suspected. IgG4-related sclerosing disease should be added to the pachymeningitis spectrum.
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Affiliation(s)
- Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hideo Osada
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Soichiro Seno
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hiroshi Nawashiro
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
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34
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Della-Torre E, Mattoo H, Mahajan VS, Deshpande V, Krause D, Song P, Pillai S, Stone JH. IgG4-related midline destructive lesion. Ann Rheum Dis 2014; 73:1434-6. [PMID: 24651619 DOI: 10.1136/annrheumdis-2014-205187] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Emanuel Della-Torre
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA Unit of Medicine and Clinical Immunology, Università Vita-Salute San Raffaele, Milan, Italy
| | - Hamid Mattoo
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vinay S Mahajan
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donald Krause
- Rheumatology Service, St. Joseph Healthcare, Bangor, Maine, USA
| | - Philip Song
- Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shiv Pillai
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John H Stone
- Division of Rheumatology, Allergy, & Immunology, Massachusetts General Hospital, Boston, Massachusetts, USA
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35
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Gru AA, Kolar G, Wagner-Johnston ND, Schmidt R, Yaseen NR. A 54 Year-Old Man with Progressive Vision and Hearing Loss. Brain Pathol 2014; 24:197-200. [DOI: 10.1111/bpa.12124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- AA Gru
- Dept of Pathology & Immunology; Washington University School of Medicine; St. Louis MO 63110
| | - G Kolar
- Dept of Pathology & Immunology; Washington University School of Medicine; St. Louis MO 63110
| | - ND Wagner-Johnston
- Division of Hematology and Oncology in Dept of Internal Medicine; Washington University School of Medicine; St. Louis MO 63110
| | - R Schmidt
- Dept of Pathology & Immunology; Washington University School of Medicine; St. Louis MO 63110
| | - NR Yaseen
- Dept of Pathology & Immunology; Washington University School of Medicine; St. Louis MO 63110
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36
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Takahashi H, Yamashita H, Morooka M, Kubota K, Takahashi Y, Kaneko H, Kano T, Mimori A. The utility of FDG-PET/CT and other imaging techniques in the evaluation of IgG4-related disease. Joint Bone Spine 2014; 81:331-6. [PMID: 24568886 DOI: 10.1016/j.jbspin.2014.01.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/15/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVES This study aimed to evaluate the utility of imaging techniques, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), in immunoglobulin (IgG)4-related disease (IgG4-RD). METHODS We reviewed eight IgG4-RD patients who were referred to our hospital between August 2006 and April 2012. All cases underwent FDG-PET/CT and brain magnetic resonance imaging (MRI) and endobronchial ultrasonography (EBUS) were also performed in five cases and one case, respectively. RESULTS Although nearly all patients with IgG4-RD in this study were negative for CRP (mean 0.22 mg/dL), various organ involvement sites were detected by FDG-PET/CT. In the active phase in two autoimmune pancreatitis (AIP) cases, FDG-PET/CT showed longitudinal and heterogeneous FDG accumulation in the pancreas with FDG uptake in the hilar or mediastinal lymph nodes. Follow-up FDG-PET/CT after therapy in one case revealed that the abnormal FDG uptake in all affected lesions had completely disappeared. In two cases, brain MRI revealed asymptomatic hypertrophic pachymeningitis. In one case, EBUS imaging of mediastinal lymph node swelling was consistent with tortuous vessels with high Doppler signals and hyperechoic strands between lymph nodes. CONCLUSIONS When FDG-PET/CT shows FDG accumulation, characteristic of IgG4-RD in organs, without evidence of an associated inflammatory reaction, a diagnosis of IgG4-RD can be made. Treatment effects can be assessed by the disappearance of FDG uptake. A routine brain MRI is useful for detecting asymptomatic hypertrophic pachymeningitis. EBUS may also be useful for differentiating among the etiologies of lymphadenopathy with characteristic sonographic imaging findings.
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Affiliation(s)
- Hiroyuki Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan.
| | - Miyako Morooka
- Department of Radiology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Kazuo Kubota
- Department of Radiology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Yuko Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Toshikazu Kano
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Akio Mimori
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
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Kume K, Ikeda K, Deguchi K, Kamada M, Okada M, Tamiya T, Touge T, Masaki T. Advantage of 11C-methionine positron emission tomography for assessing IgG4-related central nervous system lesions. J Neurol 2014; 261:625-7. [PMID: 24532202 DOI: 10.1007/s00415-014-7269-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/23/2014] [Accepted: 01/28/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Kodai Kume
- Department of Gastroenterology and Neurology, Kagawa University Faculty of Medicine, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, Japan
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38
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Diagnostic value of IgG4 Indices in IgG4-Related Hypertrophic Pachymeningitis. J Neuroimmunol 2014; 266:82-6. [DOI: 10.1016/j.jneuroim.2013.10.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 10/16/2013] [Indexed: 12/24/2022]
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39
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Diffuse large B-cell lymphoma/follicular lymphoma arising in a background of IgG4-related pachymeningitis. Pathology 2013; 45:696-8. [DOI: 10.1097/pat.0000000000000016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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40
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LIPTON SARAH, WARREN GARTH, POLLOCK JEFFREY, SCHWAB PASCALE. IgG4-related Disease Manifesting as Pachymeningitis and Aortitis. J Rheumatol 2013; 40:1236-8. [DOI: 10.3899/jrheum.121545] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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41
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Wallace ZS, Carruthers MN, Khosroshahi A, Carruthers R, Shinagare S, Stemmer-Rachamimov A, Deshpande V, Stone JH. IgG4-related disease and hypertrophic pachymeningitis. Medicine (Baltimore) 2013; 92:206-216. [PMID: 23793110 PMCID: PMC4553969 DOI: 10.1097/md.0b013e31829cce35] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hypertrophic pachymeningitis (HP) is an inflammatory condition in which the dura mater of the cranium or spine becomes thickened, leading to symptoms that result from mass effect, nerve compression, or vascular compromise. The differential diagnosis of HP includes immune-mediated conditions such as rheumatoid arthritis and vasculitis, malignancies, and infections. Many times, no diagnosis is reached; in such cases, the disease has been described as idiopathic HP. IgG4-related disease (IgG4-RD) is a recently described inflammatory condition known to cause tumefactive lesions at myriad anatomical locations. Both IgG4-RD and idiopathic HP share similar demographics, histopathology, and natural history. We hypothesized that IgG4-RD is a common cause of idiopathic HP.To investigate this hypothesis, we identified all pathology specimens diagnosed as noninfectious HP during 25 years at our institution. Fourteen cases had stained slides and paraffin blocks to permit review of the original hematoxylin and eosin stained slides as well as immunostaining of cell blocks. Recently published consensus guidelines describing characteristic histopathology and the necessary quantity of IgG4+ plasma cell infiltrate were used to diagnose IgG4-RD.Four cases (66.6%) that had been regarded previously as representing idiopathic HP were diagnosed as IgG4-RD; of all the reviewed cases, IgG4-RD represented 29% of cases. Of the remaining cases, 3 cases were associated with granulomatosis with polyangiitis (GPA), 2 with lymphoma, and 1 each with rheumatoid arthritis, giant cell arteritis, and sarcoidosis. Two of the cases could not be diagnosed more precisely and were classified as undifferentiated HP. Clinical history, serologic tests, cerebrospinal fluid studies, and radiology alone could not identify the cause of HP. Rather, biopsy with histopathology and immunostaining was necessary to reach an accurate diagnosis. Significant IgG4+ plasma cell infiltrates were observed in rheumatoid arthritis, granulomatosis with polyangiitis, and lymphoma, underscoring the importance of histopathology in making the diagnosis of IgG4-RD.This case series demonstrates that IgG4-RD may be the most common etiology of noninfectious HP and highlights the necessity of biopsy for accurate diagnosis.
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Affiliation(s)
- Zachary S Wallace
- From Department of Medicine (ZSW, MNC, AK, JHS); Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology (MNC, AK, JHS); Department of Neurology (RC); and Department of Pathology (SS, ASR, VD); Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Sen Hee Tay
- Division of Rheumatology, University Medicine Cluster, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, Singapore
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