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Immunoglobulin G4-Related disease, constitutional symptoms, human leukocyte antigen b27 positivity, and sacroiliitis – Reply

1 Fellow in Rheumatology, ISIC Superspeciality Hospital, New Delhi, India
2 Consultant Physician, Medanta Hospital, Gurgaon, India
3 Consultant Rheumatologist, ISIC Superspeciality Hospital, New Delhi, India

Date of Submission02-Aug-2020
Date of Acceptance02-Aug-2020

Correspondence Address:
AN Malaviya,
Consultant Rheumatologist, ISIC Superspeciality Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_211_20

How to cite this URL:
Verma S, Khurshid L, Voleti P R, Malaviya A N. Immunoglobulin G4-Related disease, constitutional symptoms, human leukocyte antigen b27 positivity, and sacroiliitis – Reply. Indian J Rheumatol [Epub ahead of print] [cited 2020 Oct 27]. Available from:

Dear Editor,

We are thankful to Dr. Arun R. Chogle for his comments on our IgG4-related case-based review.[1] He has raised certain queries that we shall like to answer. Hisfirst question is regarding the diagnosis if IgG4-related disease (IgG4-RD). He has correctly mentioned that it cannot be based only the blood levels of IgG4, and we fully agree with this statement. This is why a nodule in parotid gland was biopsied that confirmed the diagnosis of IgG4-RD. Dr. Chogle seems to have missed reading the sentence “A biopsy of the parotid gland nodule showed focal periductal chronic inflammation and plasma cells that were positive for IgG as well as for IgG4[Figure 3].” The diagnosis was confirmed by appropriate histopathological examination. The second point he raised was the initiation of “immunosuppressive” drug methotrexate (MTX) with glucocorticoid. It is very unfortunate that MTX at the doses used in rheumatology practice is often wrongly labeled as being “immunosuppressive.” In this regard, in a very recent paper published on June 11, 2020 (on-line).[2] Issacs and Burmester have forcefully emphasized that widespread mistake is being committed because of confusion among many rheumatologists and physicians between drugs that are immunomodulatory versus those that are immunosuppressive. Low-dose MTX (LD-MTX; up to 20–25 mg/week) is classified as immunomodulator and not as immunosuppressive.[2] Therefore, giving chemoprophylaxis for latent tuberculosis (TB) infection (LTBI) in a patient who is not on immunosuppressive drug, would not be right. Otherwise, almost every patient with rheumatoid arthritis taking LD-MTX would have to be given LTBI chemoprophylaxis; and that is not the practice or recommendation anywhere in the world by any recognized national or international guidelines. The reference to a case published from AIIMS by Dr. Chogle is not relevant because there was no such history of TB contact in our patient. The last point made by Dr. Chogle about the rarity of encasing of aortic root that was mentioned under “Discussion” of our report. We did not find any figures or numbers in Dr. Chogle's rejoinder that refutes our statement.{Figure 3}

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  References Top

Verma S, Khurshid L, Voleti PR, Malaviya AN. Immunoglobulin G4-related disease, constitutional symptoms, human leukocyte antigen b27 positivity, and sacroiliitis. J Rheumatol 2020;15:141-4.  Back to cited text no. 1
Isaacs JD, Burmester GR. Smart battles: Immunosuppression versus immunomodulation in the inflammatory RMDs. Ann Rheum Dis 2020;79:991-3.  Back to cited text no. 2


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