IgG4-related retroperitoneal fibrosis induced by nivolumab and ipilimumab in a patient with non-small cell lung cancer: A case report

IgG4-related diseases are adverse events that occur after receiving treatment with immune checkpoint inhibitors (ICI). This study reports the first case of IgG4-related retroperitoneal fibrosis after the administration of chemotherapy with nivolumab and ipilimumab (NI therapy). An 80-year-old man developed lower abdominal pain eight months after NI therapy was initiated. Although the primary lesion maintained its reduced size on computed tomography, there was an increase in the soft tissue shadows intensity around the abdominal aorta, bladder, and seminal vesicles, suggesting retroperitoneal fibrosis. Blood tests showed elevated IgG4 levels. Computed tomography-guided biopsy of the retroperitoneum showed B cell-dominant lymphocyte infiltration consistent with IgG4-related retroperitoneal fibrosis and characteristic CD8-positive lymphocyte infiltration, suggestive of the involvement of cytotoxic T cells. Based on the clinical, imaging, and pathological findings, the patient was diagnosed with IgG4-related retroperitoneal fibrosis due to ICI. Immunotherapy discontinuation alone did not result in improvement; therefore, steroid therapy was initiated. In clinical practice, IgG4-related retroperitoneal fibrosis can occur as an immune-related adverse event when administering anti-PD-1 and anti-CTLA-4 antibodies for cancer immunotherapy. Early steroid therapy could be effective in controlling this immune-related adverse event.

The Onset of IgG4-related Retroperitoneal Fibrosis under Administration of a TNF Inhibitor in a Rheumatoid Arthritis Patient

An 80-year-old woman with rheumatoid arthritis during treatment with etanercept, a tumor necrosis factor (TNF) inhibitor, showed swelling of the salivary glands and retroperitoneal fibrosis, which was diagnosed as IgG4-related disease. Although some reports have shown the efficacy of TNF inhibitors for IgG4-related disease or retroperitoneal fibrosis, TNF inhibitors sometimes cause paradoxical reactions like psoriasis, and the mechanisms are considered to involve the upregulation of plasmacytoid dendritic cells and IFN-α, which is also common in patients with IgG4-related disease. This is a case report of IgG4-related retroperitoneal fibrosis with the possibility of a rare paradoxical reaction by a TNF inhibitor.

Retroperitoneal Fibrosis Complicating Intravesical Formalin Therapy

Two cases are reported of ureteric obstruction due to retroperitoneal fibrosis following the use of intravesical formalin. This particular complication of this treatment has not previously been described.

Drug-induced retroperitoneal fibrosis: short aetiopathogenetic note, from the past times of ergot-derivatives large use to currently applied bio-pharmacology

Among the secondary forms of retroperitoneal fibrosis (RPF), that drug-induced shows very intriguing aspects given both the broad range of involved pharmaceuticals and the considerable interest arisen from the related pathogenetic mechanisms. The particular incidence, in the last four decades past century, of the RPF due to long-term use of ergot alkaloid derivatives (ergotamine, methysergide, pergolide, bromocriptine, cabergoline) and specific L-dopa derived agents, such as methyldopa, as well as to different analgesics, came progressively down given that their long-term use for either the prevention of migraine attacks or the therapy of chronic pathologies (Parkinson's disease, prolactinoma, pain management, etc) has been, year after year, supplanted or even made unavailable in many countries. More recently, instead, the occurrence of the RPF has been sometimes identified with the use of antitumoral chemotherapeutics, such as carboplatin and methotrexate, and, just lately, as an unusual side-effect of certain biological agents, about which it is timely to go into specific pathogenetic problems in more depth.

[Retroperitoneal fibrosis associated with chronic use of ergotamine: report of one case]

Retroperitoneal fibrosis (RPF) associated with chronic use of ergotamine is a very rare disorder. We report a 45-year-old woman who presented with a RPf after using, almost daily for 23 years, ergotamine tartrate for migraine relief. FRP presented as a chronic inflammatory state, anemia, abdominal and lumbosacral pain and a hypogastric mass. A CT-Scan showed a periaortic mass and left hydronephrosis. A percutaneous biopsy was obtained and the patient was subjected to a surgical ureterolysis and tissue resection. The biopsy confirmed the presence of RPf. Due to persistent symptoms and increase in the volume of periaortic tissue, treatment with colchicine 1 mg/day and defazacort 30 mg/day was started, resulting in a rapid disappearance of symptoms, disappearance of inflammation and a significant reduction in the volume of the periaortic tissue. The patient remains in complete remission after 29 months of follow up.

Absence of major fibrotic adverse events in hyperprolactinemic patients treated with cabergoline

BACKGROUND

Cabergoline, a dopamine agonist used to treat hyperprolactinemia, is associated with an increased risk of fibrotic adverse reactions, e.g. cardiac valvular fibrosis, pleuropulmonary, and retroperitoneal fibrosis.

OBJECTIVE

This study evaluated the prevalence and risk of fibrotic adverse reactions during cabergoline therapy in hyperprolactinemic and acromegalic patients.

DESIGN

A cross-sectional study was conducted in a University Hospital.

PATIENTS

A total of 119 patients with hyperprolactinemia and acromegaly who were on cabergoline therapy participated in the study.

METHODS

All patients were requested to undergo a cardiac assessment, pulmonary function test, chest X-ray, and blood tests as recommended by the European Medicine Agency. Matched controls were recruited to compare the prevalence of valvular regurgitation. Cardiac valvular fibrosis was evaluated by assessing valvular regurgitation and the mitral valve tenting area (MVTa). The risk of pleuropulmonary fibrosis was assessed by a pulmonary function test, a chest X-ray, and if indicated, by additional imaging studies.

RESULTS

The prevalence of clinically relevant valvular regurgitation was not significantly different between cases (11.3%) and controls (6.1%; P=0.16). The mean MVTa was 1.27+/-0.17 and 1.24+/-0.21 cm(2) respectively (P=0.54). Both valvular regurgitation and the MVTa were not related to the cumulative dose of cabergoline. A significantly decreased pulmonary function required additional imaging in seven patients. In one patient, possible early interstitial fibrotic changes were seen. Lung function impairment was not related to the cumulative cabergoline dose.

CONCLUSION

Cabergoline, typically dosed for the long-term treatment of hyperprolactinemia or acromegaly, appears not to be associated with an increased risk of fibrotic adverse events.

Ergoline and non-ergoline derivatives in the treatment of Parkinson's disease

There are a large variety of dopamine agonists available. Especially de novo patients are treated with dopamine agonists to avoid dyskinesia. Dopamine agonists can be subdivided into ergoline and non-ergoline derivatives. This distinction raises the question whether there are differences in the effects to treat symptoms, not only in the side effects between the individual dopamine agonists but also between these two groups. Pergolide is now considered a second line drug because of its particularly high tendency towards valvular heart disease. Some authors claim that all ergoline-derivatives may cause this problem, while own results do not necessarily support this view. We recommend performing echocardiography on those patients being treated with an ergot-derivative. New data support the view that all dopaminergic drugs may cause somnolence and that there is no preference for non-ergots. It may be that the number of gamblers is slightly higher among patients treated with pramipexole than in others. Dopamine agonists with a high affinity to D3 receptors have a good anti-anhedonic potency. In cell culture all dopamine agonists studied so far show neuroprotective properties in cell culture. The introduction of a slow-release formulation for ropinirole and the rotigotine and lisuride patches have opened new ways of continuous dopamine receptor stimulation. Taken together, dopamine agonists show individual properties and there are differences between ergot and non-ergot derivatives.

Retroperitoneal fibrosis after chemotherapy

We report the case of a patient with a non-Hodgkin lymphoma, who after a standard chemotherapy protocol, developed retroperitoneal fibrosis (RPF) in the absence of radiotherapy or other known causes. The final diagnosis was reached with the microscopic examination of tissue obtained by fine-needle aspiration and true-cut biopsy of the retroperitoneal mass. RPF can be related to chemotherapy alone.

[Ergoline-induced retroperitoneal fibrosis]

A 69-year-old man presented with anaemia, swelling of the legs and scrotum, weight gain and fatigue. MR scan and laboratory findings initiated a search for cancer, but eventually retroperitoneal fibrosis (RF) was suspected. A medical review revealed that an ergoline-based drug known to be associated with RF had been used for eight years. The drug was withdrawn, and in short time the patient substantially recovered, with the disappearance of almost all abnormal findings. This case emphasises the importance of awareness of side effects of drug therapy.

Pergolide-Associated Valvular Heart Disease

Pergolide is an ergot derivative dopamine agonist used in the treatment of Parkinson's disease and restless legs syndrome. Ergot derivatives are known to be associated with fibrotic conditions, including a carcinoid-like, fibrotic, valvular heart disease (VHD). Recently, pergolide was identified in association with the development of VHD. This article includes a summary of the literature published on pergolide-associated VHD, a description of the potential mechanisms of drug-induced VHD, and the clinical implications for the management of patients taking pergolide.

Retroperitoneal Fibrosis With Periaortic and Pericardial Involvement

A 66-year old man, who had been diagnosed with dilated cardiomyopathy and felt a progressive shortness of breath and fatigability, was admitted to hospital. Computed tomography showed a thickening of the aortic wall from the aortic arch to the aortic bifurcation, as well as mild pleural and pericardial effusion. Intravenous pyelography showed severe ureteral stenosis, along with hydronephrosis, of the left side. There was a marked increase in C-reactive protein and the erythrocyte sedimentation rate, but the serology for connective tissue disease and perinuclear antineutrophil cytoplasmic antibodies was negative. Retroperitoneal fibrosis (RPF) with intrathoracic extension was diagnosed. After confirming the absence of malignant disease, an oral predonisolone treatment of 30 mg/day was started, and this ameliorated the ureteral obstruction, aortic wall thickening and pericardial effusion. The patient had been taking 300 mg of loxoprofen sodium for headaches every day for 16 years. The relationship between loxoprofen, cardiomyopathy and RPF remains unclear. There is a possibility of RPF in the patients with a thickening of thoracic aortic wall, as in this case.

Retroperitoneal fibrosis caused by pergolide in a patient with Parkinson's disease

Retroperitoneal fibrosis (RPF) is an uncommon disorder that may cause ureteric obstruction with renal damage. Pergolide, a dopaminergic agonist used in the treatment of Parkinson's disease, has rarely been related to the development of RPF. We report on a 78-year-old woman with Parkinson's disease who presented with hydroureteronephrosis and developed RPF and serosal fibrosis during treatment with pergolide. Following discontinuation of pergolide therapy and placement of a double-J stent, her renal function improved. Inflammatory markers returned to normal limits within two months and the retroperitoneal fibrotic mass became smaller.

Diagnosis and management of pergolide-induced fibrosis

We report on 2 patients treated with pergolide, 1 of whom developed pleural fibrosis and the other retroperitoneal fibrosis. In both cases, an extensive diagnostic evaluation and surgical intervention were required to reach a diagnosis. Based on our experience with these patients and a review of cases of pergolide-induced fibrosis in the English-language literature, we propose guidelines for the diagnosis and management of this rare complication.

[Severe pleuropericarditis induced by long-term bromocriptin therapy, report of a case and review of the literature]

INTRODUCTION

Bromocriptin, member of the class of ergolines, is commonly prescribed as treatment of Parkinson's disease. Apart from vascular, digestif, neurologic and psychic disorders, the authors report cases of retroperitoneal fibrosis and pleural effusion, as adverse reactions related to the bromocriptin.

SYNTHESIS

About 40 cases of skin, pleural, lung and retroperitoneal attacks were described after long term and high doses of bromocriptin. More ten years ago, the first case of constrictive pericarditis was cited in the medical literature, and the bromocriptin was incriminated as responsible. Since then, two other cases were cited. Our observation is a constrictive pericarditis, found in a 72 years old patient treated with bromocriptin for Parkinson's disease since five years (cumulative dose intake 73 grams). Investigations aimed to establish etiology were negative. Bromocriptin is suspected and the treatment is discontinued. As in the three other cases, cardiac and neurologic conditions markedly improved after bromocriptin's withdrawal. A pericardic thickening persists at the echography.

CONCLUSION

The responsibility of bromocriptin in the etiology of constrictive pericarditis is seldom discussed, because it remains an exclusion diagnosis. Periodic chest X-ray and echocardiography should be considered in patients with long-term bromocriptin treatment.

Urologic complications of nonurologic medications

A physician must be aware of common drug side effects and interactions before prescribing a certain agent. In addition to the drugs that we, as urologists, prescribe, we must also be aware of the urologic side effects of drugs that are commonly prescribed by nonurologists. The mechanisms of the pharmacologic causes for voiding dysfunction, erectile and sexual dysfunction, infertility, and urolithiasis are often mutifactorial and incompletely understood. The recognition and association of a particular drug's potential side effects may save valuable time and money involved in the workup of a patient with a new urologic complaint. It is incumbent on the practicing urologist to be able to recognize the common, and sometimes subtle, urologic complications of medications that are used for nonurologic conditions.

Pergolide-induced pleuropulmonary fibrosis

Pleuropulmonary fibrosis is a rare, but well-recognized adverse effect of ergot alkaloids. We report on four patients who developed pleural and/or pulmonary fibrosis during treatment with pergolide and give characteristics of 87 cases with one or more symptoms of serosal fibrosis. Retroperitoneal and pleuropulmonary fibrosis are serious conditions, which are often irreversible after drug withdrawal. Increased awareness may help to diagnose these complications at an earlier stage and to minimize any permanent damage to the patient.

Pergolide-induced retroperitoneal fibrosis

Retroperitoneal fibrosis is a rare complication of pergolide therapy. This complication can be easily missed, so it is essential to have a high index of suspicion. We describe a case of well controlled Parkinson's disease who presented with shortness of breath and oedema.

Treatment of Parkinson's disease with ropinirole after pergolide-induced retroperitoneal fibrosis

Pergolide is a dopaminergic agonist used to treat Parkinson's disease but is associated with the development of retroperitoneal fibrosis (RPF). Newer nonergot agents (pramipexole, ropinirole) may not carry this same risk. A patient with a history of pergolide-induced RPF was treated successfully with ropinirole for 1 year without complications.

Pericardial, retroperitoneal, and pleural fibrosis induced by pergolide

Three patients with Parkinson's disease are described who developed pericardial, retroperitoneal, and pleural fibrosis associated with pergolide treatment. Surgical intervention was required in all three cases, either to reach a tissue diagnosis or for potentially life threatening complications. Symptoms emerged on average 2 years after the institution of treatment, and were sufficiently non-specific to cause significant delays in diagnosis in all cases. The erythrocyte sedimentation rate (ESR) was raised in the two patients in whom it was measured. Serosal fibrosis is a rarely reported adverse effect of pergolide treatment, although it is well described with other dopamine agonists. We suggest that patients with Parkinson's disease who receive pergolide treatment should be regularly monitored for the development of such complications.

Methysergide-induced retroperitoneal fibrosis: successful outcome and two new laboratory features

A 25-year-old woman sought medical attention because of iliocaval manifestations of retroperitoneal fibrosis while she was taking methysergide. Laboratory studies yielded substantially increased serum procollagen III levels and anticardiolipin antibodies accompanied with anti-beta(2) glycoprotein I, findings not previously described with this disorder. Clinical and laboratory manifestations resolved after cessation of methysergide therapy.

[Retroperitoneal fibrosis secondary to treatment with L-dopa analogues for Parkinson disease]

OBJECTIVES

The present study describes two patients with retroperitoneal fibrosis following prolonged use of bromocriptine and pergolide for Parkinson's disease. Both patients also presented severe atheromatosis.

METHODS

Similar cases reported in the literature are reviewed and the possible relationship between the use of the ergotamine derivate and severe atheromatosis is discussed.

RESULTS

Both patients, a 67-year-old male and a 62-year-old female, improved after discontinuing bromocriptine, despite severe damage of renal function.

CONCLUSIONS

Retroperitoneal fibrosis may develop in patients with bilateral ureteral obstruction, especially those who have received drugs that have been reported to cause the foregoing condition.

Retroperitoneal fibrosis in a patient with Parkinson's disease treated with pergolide

We describe a 68-year-old patient with Parkinson's disease who developed retroperitoneal fibrosis during pergolide treatment. Because pergolide is an ergot derivative, it could be related to the development of this complication.

[Retroperitoneal fibrosis due to ergotamine. Apropos a case]

OBJECTIVES

This paper reviews retroperitoneal fibrosis secondary to ergotamine and evaluated the current tools in its diagnosis.

METHODS/RESULTS

A well documented case of a young patient with retroperitoneal fibrosis resulting from chronic use of ergotic agents is presented. The fibrous plaque remitted after withdrawal of the causal agent.

CONCLUSIONS

The importance of contrast-enhanced CT in the diagnosis of retroperitoneal fibrosis is widely accepted. The usefulness of this technique in determining the extent of the lesion and for subsequent follow up is underscored.

[Retroperitoneal fibrosis due to barium]

The authors report two cases of retroperitoneal fibrosis secondary to rectal perforation occurring during barium enema. In view of the variable interval between the radiological accident and the urological complications, a long patient follow-up is recommended. If ureteric obstruction occurs, ureteric catheterisation is a temporary alternative, but surgery is the treatment of choice. When ureterolysis cannot be performed, the authors propose ureteroileoplasty to restore continuity of the urinary tract.

Obstructive jaundice due to retroperitoneal fibrosis involving the head of the pancreas

A 51-year-old man with no history of liver disease had acute severe jaundice, with a serum level of total bilirubin of 27.4 mg/dl and an alkaline phosphatase level of 731 IU/L due to distal common bile duct compression from peripancreatic head fibrosis associated with retroperitoneal fibrous. Other obstructive phenomena in this patient included bilateral hydronephrosis from ureteral fibrosis encasement and testicular swelling from fibrous encasement of vessels draining the scrotum. Autopsy demonstrated massive retroperitoneal fibrosis, with angulation and compression of the distal common bile duct by fibrosis covering the head of the pancreas. The intrahepatic biliary tree was dilated because of the distal choledochal obstruction, but the proximal common bile duct was not dilated due to mural fibrosis.

Carboplatin and retroperitoneal fibrosis

A patient treated for ovarian epithelial cancer by total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), total omentectomy and five courses of single agent carboplatin chemotherapy, developed retroperitoneal fibrosis. This was diagnosed at exploratory laparotomy 6 months after completing treatment. No predisposing drug history existed in this patient. We believe that there have been no previous reports of an association between retro peritoneal fibrosis and carboplatin treatment.

Retroperitoneal fibrosis in two patients with Parkinson's disease treated with bromocriptine

Retroperitoneal fibrosis has been observed in two patients with Parkinson's disease treated with bromocriptine. The patients complained of abdominal or lower back pain and presented with various degrees of renal insufficiency, with anuria in one. Laboratory evaluation furthermore showed an increased sedimentation rate and inflammatory anemia. Computerized tomography disclosed marked retroperitoneal thickening, and biopsy was performed in one patient. The symptoms appeared eighteen months and five years after treatment was started, at doses of 20 and 22.5 mg of bromocriptine daily. The medication was discontinued in both patients and steroid therapy was initiated, with resolution of all clinical, biological and radiological evidence of disease. This potential but rare complication of a widely prescribed drug warrants monitoring of renal function and sedimentation rate in patients undergoing bromocriptine treatment.

Retroperitoneal fibrosis in a patient with macroprolactinoma treated with bromocriptine

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Hydralazine, hydrochlorothiazide and ampicillin associated with retroperitoneal fibrosis: case report

A case of retroperitoneal fibrosis possibly associated with hydralazine, hydrochlorothiazide and ampicillin therapy is reported.