Immunoglobulin G4 (IgG4)-Related Sialadenitis and Dacryoadenitis With Chronic Rhinosinusitis

Immunoglobulin G4-related disease (IgG4-RD) is a new disease entity of rare and complex immune-mediated fibroinflammatory conditions that can affect any organ. The concomitance of IgG4 sclerosing sialadenitis and dacryoadenitis with rhinosinusitis is extremely rare. We report a case of IgG4 sclerosing sialadenitis and dacryoadenitis (Mikulicz's disease) diagnosed in a middle-aged African American man with a long-standing history of chronic rhinosinusitis who presented with progressively worsening bilateral salivary and lacrimal glands swelling. Imaging revealed pansinusitis, symmetric enlargement of the lacrimal glands, parotid glands, and submandibular glands. Serological IgG4 level was significantly elevated and the diagnosis of IgG4 sclerosing sialadenitis was confirmed by histopathology. A robust clinical response in the facial swelling and nasal manifestations was noted after the initiation of immunotherapy with corticosteroids.

Type 1 Autoimmune Pancreatitis in a Young Male

Autoimmune pancreatitis (AIP) is a rare entity leading to inflammation of the pancreas. It can be broadly categorized into two types. Type 1 AIP is more common and primarily presents with jaundice. Less commonly it can also progress to multiorgan involvement. Here we report a case of a 19-year-old male who presented to us with complaints of abdominal pain and vomiting. His laboratory investigations showed raised serum amylase and lipase. A contrast-enhanced CT revealed a diffuse enlargement of the pancreas with internal low-density foci. Due to the repeated episodes of pancreatitis, the patient's blood was tested for serum IgG4 (immunoglobulin type G4) which was markedly elevated pointing toward the diagnosis of AIP. Endoscopic ultrasound (EUS) showed a sausage-shaped pancreas with hyper- and hypoechoic strands. EUS-guided fine needle aspiration cytology of the lymph nodes performed in the celiac region showed a mixed population of lymphoid cells. Based on all the workup, our patient was diagnosed as type 1 AIP. He was managed with steroids and his condition progressively improved. This case is clinically significant because of the close resemblance of AIP with other pancreatic disorders like neoplasm. A timely diagnosis can prevent the unnecessary performance of invasive procedures in these patients.