|LETTER TO EDITOR
|Ahead of print publication
IgG4 related disease in a middle-aged male having HLA-B27 positive unilateral sacroiliitis
Arun R Chogle
Department of Medicine, Division of Rheumatology, Sir H. N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
|Date of Submission||04-Jun-2020|
|Date of Acceptance||05-Jun-2020|
Arun R Chogle,
372, 3rd Floor, Jagannath Shankar Seth Road, Mumbai - 400 002, Maharashtra
Source of Support: None, Conflict of Interest: None
I refer to the case-based review by Varma S, Kurshid L, Voleti PR, Malviya AN published in Indian J Rheumatol 2020;15:141-4. They describe a 55-year-old male with IgG4-related disease (IgG4 RD) having HLA-B27 positive unilateral sacroiliitis.
The diagnosis of IgG4 RD in this case was based on serum IgG4 levels. In an elegant editorial published in annals of rheumatic disease in 2015, Fox and Fox have emphasized that specificity and positive predictive value of elevated serum IgG4 concentrations was only 60% and 34%, respectively.
Based on this, the patient was initiated on immunosuppressive treatment with oral steroids and injectable methotrexate after screening the patient for latent tuberculosis (TB). In TB endemic country like ours giving chemoprophylaxis for latent TB is a standard practice but there is no mention about this in the case report. Furthermore, histopathological examination of the sacroiliac joint was important in this context. However, the patient did not consent for this.
In this connection, I refer to a case published in Journal of Physician of India under the heading case of month from AIIMS, New Delhi. They describe an elderly male with TB contact in his wife who died 5 years back presenting with pyrexia and retroperitoneal soft-tissue swelling and diagnosed after investigations as a case of IgG4 RD.
The final point is regarding encasing of aortic root in their patient. The authors claim this is very uncommon and there are no reports describing the encasing of the aortic root in IgG4 RD.
- In this connection, I refer to one recent publication titled IgG4-related aortitis and periarteritis: a distinct spectrum of IgG4 RD. This enrolled 587 patients.
In this four types have been described type 1, type 2A, type 2c, and type 3; the patient described in the review had type 1 variety. Type 1 is the least common variety involves the ascending aorta.
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| References|| |
Fox RI, Fox CM. IgG4 levels and plasmablasts as a marker for IgG4-related disease (IgG4-RD). Ann Rheum Dis 2015;74:1-3.
Narang H, Ray A, Vyas S, Tripathi M, Damle N, Jadon RS, et al
. Undiagnosed fever in a TB contact patient: An unusual cause. J Assoc Physicians India 2019;67:74-6.
Peng L, Zhang P, Li J, Liu Z, Lu H, Zhu L,et al
. IgG4- related aortitis/periaortitis and periaortitis: A distinct spectrum of IgG4 related disease. Arthritis Res Ther 2020;22:103.