IgG4-Related Disease With Tuberculosis: A Case Report and Retrospective Review of Patients in a Single Center

Abstract

BackgroundIgG4-related disease (IgG4-RD) is a recently recognized systemic fibro-inflammatory disease of unknown cause involving many organs including pancreas, salivary glands, and lymph nodes. Chronic tuberculosis (TB) infection has been reported in IgG4-RD, but the prevalence of TB infection has not been evaluated in IgG4-RD.MethodsCharacterization of a patient with IgG4-RD by physical examination, laboratory tests, magnetic resonance imaging (MRI) and histological examination. TB infection was evaluated by medical history, radiological examinations, sputum examinations, tubercular skin test (TST) and interferon gamma (IFN-γ) release assay test (IGRA). Medical records of IgG4-RD patients were reviewed in our institute from February 2015 to September 2020 to explore the prevalence of TB infection in IgG4-RD.ResultsWe described a 40-year-old Chinese man presented with headache and diplopia. Physical examination revealed bitemporal hemianopsia and limited abduction of both eyes. MRI revealed uniformly enhancing mass overlying clivus with dural tail sign. Laboratory data revealed elevation of IgG4 (1.9g/L), and TB-IGRA demonstrated significantly elevated IFN-γ (414.21 pg/ml). The clivus lesion was subtotally removed and IgG4 was strongly positive on immunohistochemical staining. The diagnosis of IgG4-RD was established, and the patient received treatment of corticosteroids, methotrexate, and cyclophosphamide with isoniazid prophylaxis. Consequently, the mass shrank remarkably within 3 months. A similar concurrence of TB disease or latent TB infection (LTBI) and IgG4-RD was present in 17/47 (36.2%) patients in our institute.ConclusionHigh frequency of TB/LTBI presented in patients with IgG4-RD. Patients with IgG4-RD and LTBI should be closely monitored for resurgence of TB. Whether TB represents a risk for IgG4-RD should be further investigated in prospective cohort.

Autoimmune pancreatitis associated with inflammatory bowel diseases: A retrospectively bidirectional case–control study in China

“…Only a few cases have reported the coexistence of TB and AIP as well as the potential mechanism, most of whom had type 1 AIP or IgG4-related diseases. [38][39][40] A study identified crosstalk between T-helper 17 cells and neutrophils mediated through interleukin (IL)-17A as a potential mechanism for the recruitment and subsequent destruction of neutrophils into ductal and glandular blast cells, which may be the pathognomonic for type 2 AIP. 41 TB also causes an imbalance of T-and B-lymphocytes and up to 96.7% of differentially expressed genes in TB overlap with autoimmune diseases.…”

“…All TB infections in our study were detected before the diagnosis of IBD, which excluded opportunistic infections due to medical treatment. Only a few cases have reported the coexistence of TB and AIP as well as the potential mechanism, most of whom had type 1 AIP or IgG4‐related diseases 38–40 . A study identified crosstalk between T‐helper 17 cells and neutrophils mediated through interleukin (IL)‐17A as a potential mechanism for the recruitment and subsequent destruction of neutrophils into ductal and glandular blast cells, which may be the pathognomonic for type 2 AIP 41 .…”

The unique diagnostic and management challenge of a patient with concomitant anti-interferon-gamma autoantibody associated immunodeficiency syndrome, IgG4-related disease, and treatment refractory, disseminated mycobacterium avium complex infection

“…Some have suggested that IgG4-RD is precipitated by a likely unknown antigen that causes B cell differentiation into IgG4 producing plasma cells leading to the increased expression of T helper 2 (Th2) cells and cytokines [17,18]. The immune mediated response of IgG4-RD shares a similar response to tuberculosis infection as the activation of Helper T cells and the expression of similar cytokines in IgG4-RD have a crucial role in our immune mediated defense against tuberculosis infection [19,20]. As disseminated mycobacterial disease has been shown to increase a Th2 immune mediated response, it has been suggested that prolonged opportunistic infections due to underlying AOID results in activation of Th2 cells and repeated antigen exposure causes increased IgG4 production [6,21].…”

Respiratory Failure With Aspergillus submaranianii and Lymphoplasmacystic Vasculitis

“…Serum galactomannan was detected eventually, suggestive of eventual invasive pulmonary Aspergillus, despite lack of pathological evidence of fungal invasion on biopsy. Furthermore, infections associated with IgG4-related disease have been reported with tuberculosis, 6 Necator americanus, 7 Helicobacter pylori, 8 and Paragonimus westermani. 9 It is unclear in this case if IgG4-related pulmonary disease was triggered by A subramanianii infection, or if IgG4-related disease came first, and A subramanianii infection was an infectious sequalae.…”