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Poo SX, Pepper RJ, Onwordi L, Ghufoor K, Sandhu G, Salama AD. Sirolimus use in patients with subglottic stenosis in the context of granulomatosis with polyangiitis (GPA), suspected GPA, and immunoglobulin G 4-related disease. Scand J Rheumatol 2020; 50:52-57. [PMID: 32865088 DOI: 10.1080/03009742.2020.1777324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Subglottic stenosis (SGS) is a severe, life-threatening disease found in immune-mediated diseases such as granulomatosis with polyangiitis (GPA) and in rare cases of immunoglobulin G4 (IgG4)-related disease. It can result in persistent airway compromise due to the fibrotic response following inflammation. Standard management involves repeated endoscopic interventions to dilate the airway, and tracheostomy is occasionally required. In addition, immunosuppression remains a cornerstone of therapy aimed at controlling the underlying inflammatory disease; however, cumulative dosing leads to significant adverse effects. We present five cases of predominantly anti-neutrophil cytoplasmic antibody-negative GPA and a case of IgG4-related disease with SGS, in whom we evaluated the long-term utility of sirolimus, which has beneficial anti-proliferative and fibrotic effects, in the management of their disease. Method: We conducted a retrospective review of a cohort of patients with SGS at a tertiary vasculitis unit. These patients were treated with sirolimus, in addition to conventional medical and endoscopic treatment. Clinical symptoms, frequency and time to endoscopic intervention pre- and post-treatment, additional rescue therapy, and any adverse effects were recorded and analysed. Results: Six patients were treated with sirolimus and followed for up to 9 years; two discontinued the drug owing to adverse effects, early on. In the remaining four patients, glucocorticoids were withdrawn, and the frequency of endoscopic intervention was reduced. One patient on sirolimus required rituximab therapy for disease flare. Conclusion: Sirolimus may be a therapeutic option for some patients with severe SGS, allowing steroid withdrawal and resulting in a positive adverse effect profile.
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Affiliation(s)
- S X Poo
- UCL Department of Renal Medicine, Royal Free Hospital , London, UK
| | - R J Pepper
- UCL Department of Renal Medicine, Royal Free Hospital , London, UK
| | - L Onwordi
- ENT Department, Charing Cross Hospital , London, UK
| | - K Ghufoor
- ENT Department, Barts and the London Hospitals , London, UK
| | - G Sandhu
- ENT Department, Charing Cross Hospital , London, UK
| | - A D Salama
- UCL Department of Renal Medicine, Royal Free Hospital , London, UK
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Poo SX, Tham CSW, Smith C, Lee J, Cairns T, Galliford J, Hamdulay S, Jacyna M, Levy JB, McAdoo SP, Roufosse C, Wernig F, Mason JC, Pusey CD, Tam FWK, Tomlinson JAP. IgG4-related disease in a multi-ethnic community: clinical characteristics and association with malignancy. QJM 2019; 112:763-769. [PMID: 31225617 DOI: 10.1093/qjmed/hcz149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/07/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Immunoglobulin-G4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory condition that can affect multiple organs. Despite growing interest in this condition, the natural history and management of IgG4-RD remain poorly understood. AIM To describe the clinical characteristics, treatment and outcomes of IgG4-RD in a multi-ethnic UK cohort, and investigate its possible association with malignancy. DESIGN Retrospective analysis of case-note and electronic data. METHODS Cases were identified from sub-specialty cohorts and a systematic search of an NHS trust histopathology database using 'IgG4' or 'inflammatory pseudotumour' as search terms. Electronic records, imaging and histopathology reports were reviewed. RESULTS In total, 66 identified cases of IgG4-RD showed a similar multi-ethnic spread to the local population of North West London. The median age was 59 years and 71% of patients were male. Presenting symptoms relating to mass effect of a lesion were present in 48% of cases and the mean number of organs involved was 2.4. Total of 10 patients had reported malignancies with 6 of these being haematological. 83% of those treated with steroids had good initial response; however, 50% had relapsing-remitting disease. Rituximab was administered in 11 cases and all achieved an initial serological response. Despite this, seven patients subsequently relapsed after a mean duration of 11 months and four progressed despite treatment. CONCLUSIONS We report a large UK-based cohort of IgG4-RD that shows no clear ethnic predisposition and a wide range of affected organs. We discuss the use of serum IgG4 concentrations as a disease marker in IgG4-RD, the association with malignant disease and outcomes according to differing treatment regimens.
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Affiliation(s)
- S X Poo
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, London North West Healthcare NHS Trust, Harrow, UK
| | - C S W Tham
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - C Smith
- Department of Medicine, Imperial College London, London, UK
| | - J Lee
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - T Cairns
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - J Galliford
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - S Hamdulay
- Department of Medicine, London North West Healthcare NHS Trust, Harrow, UK
| | - M Jacyna
- Department of Medicine, London North West Healthcare NHS Trust, Harrow, UK
| | - J B Levy
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - S P McAdoo
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - C Roufosse
- Department of Medicine, Imperial College London, London, UK
| | - F Wernig
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - J C Mason
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - C D Pusey
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - F W K Tam
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - J A P Tomlinson
- Department of Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Medicine, Imperial College London, London, UK
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