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Daramjav Narantsatsral Division of Endocrinology and Metabolism, Department of Internal Medicine

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Takagi Junko Division of Endocrinology and Metabolism, Department of Internal Medicine

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Iwayama Hideyuki Department of Pediatrics, Aichi Medical University School of Medicine, Nagakute, Japan

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Inukai Daisuke Department of Otolaryngology, Aichi Medical University School of Medicine, Nagakute, Japan

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Takama Hiroyuki Department of Dermatology, Aichi Medical University School of Medicine, Nagakute, Japan

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Nomura Yuka Division of Endocrinology and Metabolism, Department of Internal Medicine

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Hirase Syo Division of Endocrinology and Metabolism, Department of Internal Medicine

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Morita Hiroyuki Division of Endocrinology and Metabolism, Department of Internal Medicine

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Otake Kazuo Division of Endocrinology and Metabolism, Department of Internal Medicine

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Ogawa Tetsuya Department of Otolaryngology, Aichi Medical University School of Medicine, Nagakute, Japan

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Takami Akiyoshi Department of Hematology, Aichi Medical University School of Medicine, Nagakute, Japan

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Summary

Dupilumab an inhibitor of the interleukin (IL)-4R-alpha subunit is used for the treatment of allergic diseases. The patient was a 49-year-old man who received dupilumab for the treatment of severe atopic dermatitis. He presented hyperthyroidism with elevated thyroglobulin and anti-thyroid antibody negativity at 4 months after the initiation of therapy. On scintigraphy, the thyroid radioiodine uptake was low. Ultrasonography showed a diffuse hypoechoic area in the thyroid gland. A pathological study revealed lymphocytic infiltration. The administration of dupilumab was continued because of his atopic dermatitis that showed an excellent response. The patient`s hyperthyroidism changed to hypothyroidism 3 weeks later. Six months later his thyroid function normalized without any treatment. We herein describe the case of a patient with atopic dermatitis who developed painless thyroiditis under treatment with dupilumab. To the best of our knowledge, this is the first report of this event in the literature.

Learning points:

  • Dupilumab, a fully human monoclonal antibody that blocks interleukin-4 and interleukin-13, has been shown to be effective in the treatment atopic dermatitis and asthma with eosinophilia.

  • Painless thyroiditis is characterized by transient hyperthyroidism and hypothyroidism and recovery without anti-thyroid treatment.

  • This is the first report of painless thyroiditis as an adverse effect of dupilumab, although conjunctivitis and nasopharyngitis are the main adverse effects of dupilumab.

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H Joshi Department of Endocrinology, Peterborough City Hospital, Peterborough, UK

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M Hikmat Department of Endocrinology, Peterborough City Hospital, Peterborough, UK

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A P Devadass Department of Histopathology, Addenbrookes Hospital, Cambridge, UK

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S O Oyibo Department of Endocrinology, Peterborough City Hospital, Peterborough, UK

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S V Sagi Department of Endocrinology, Peterborough City Hospital, Peterborough, UK

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Summary

IgG4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition which can affect various organs including the pituitary gland. The true annual incidence of this condition remains widely unknown. In addition, it is unclear whether IgG4 antibodies are causative or the end result of a trigger. With no specific biomarkers available, the diagnosis of IgG4-related hypophysitis remains a challenge. Additionally, there is a wide differential diagnosis. We report a case of biopsy-proven IgG4-related hypophysitis in a young man with type 2 diabetes mellitus.

Learning points:

  • IgG4-related hypophysitis is part of a spectrum of IgG4-related diseases.

  • Clinical manifestations result from anterior pituitary hormone deficiencies with or without diabetes insipidus, which can be temporary or permanent.

  • A combination of clinical, radiological, serological and histological evidence with careful interpretation is required to make the diagnosis.

  • Tissue biopsy remains the gold standard investigation.

  • Disease monitoring and long-term management of this condition is a challenge as relapses occur frequently.

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Danielle R Bullock Division of Rheumatology, Department of Pediatrics

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Bradley S Miller Division of Endocrinology, Department of Pediatrics

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H Brent Clark Division of Neuropathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA

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Patricia M Hobday Division of Rheumatology, Department of Pediatrics

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Summary

IgG4-related hypophysitis is an important diagnostic consideration in patients with a pituitary mass or pituitary dysfunction and can initially present with headaches, visual field deficits and/or endocrine dysfunction. Isolated IgG4-related pituitary disease is rare, with most cases of IgG4-related disease involving additional organ systems. We report the case of a teenage female patient with isolated IgG4-related hypophysitis, diagnosed after initially presenting with headaches. Our patient had no presenting endocrinologic abnormalities. She was treated with surgical resection, prednisolone and rituximab with no further progression of disease and sustained normal endocrine function. This case, the youngest described patient with isolated IgG4-related hypophysitis and uniquely lacking endocrinologic abnormalities, adds to the limited reports of isolated pituitary disease. The use of rituximab for isolated pituitary disease has never been described. While IgG4-related hypophysitis has been increasingly recognized, substantial evidence concerning the appropriate treatment and follow-up of these patients is largely lacking.

Learning points:

  • IgG4-related hypophysitis most often occurs in the setting of additional organ involvement but can be an isolated finding. This diagnosis should therefore be considered in a patient presenting with pituitary abnormalities.

  • Most patients with IgG4-related hypophysitis will have abnormal pituitary function, but normal functioning does not exclude this diagnosis.

  • Corticosteroids have been the mainstay of therapy for IgG4-related disease, with other immunosuppressive regimens being reserved for refractory cases. Further research is needed to understand the effectiveness of corticosteroid-sparing regimens and whether there is utility in using these agents as first-line therapies.

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Leanne Hunt Sheffield Teaching Hospitals, Sheffield, UK

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Barney Harrison
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Matthew Bull
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Tim Stephenson
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Amit Allahabadia
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Summary

This case report reviews the rare condition of Riedel’s thyroiditis via a patient case. The report highlights the difficulties that one may encounter when managing such a case in regards to patient symptoms, side effects of medications and the relapsing nature of the condition. The case report also highlights novel treatment in the treatment of Riedel’s thyroiditis, rituximab, how this works and the resolution of symptoms that we have achieved with our patient on this treatment.

Learning points:

  • Riedel’s thyroiditis is characterised by chronic inflammation, which causes dense fibrosis in the thyroid gland.

  • Riedel’s thyroiditis can present with neck pain, dysphagia and dyspnoea with a firm, non-tender mass found on examination.

  • Riedel’s thyroiditis is part of the IgG4-related systemic disorders.

  • Rituximab is a monoclonal antibody that works against the protein CD20.

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Takatoshi Anno Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Fumiko Kawasaki Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Maiko Takai Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Ryo Shigemoto Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Yuki Kan Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Hideaki Kaneto Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki, Japan

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Tomoatsu Mune Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki, Japan

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Kohei Kaku Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Niro Okimoto Department of General Internal Medicine 1, Kawasaki Medical School, Okayama, Japan

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Summary

A 76-year-old man had a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism. Based on various findings including the swelling of the pituitary gland, increase of serum IgG4 level and abundant IgG4-positive plasma cell infiltration in immunostaining of the pituitary gland, we diagnosed this subject as IgG4-related hypophysitis. In general, a high-dose glucocorticoid treatment is effective for IgG4-related disease. His clinical symptom, laboratory data and adrenal insufficiency were almost improved without any therapy. The serum IgG4 level was decreased and pituitary size was normalized with hydrocortisone as physiological replacement. This case report provides the possibility that IgG4 level is decreased spontaneously or with physiological dose of glucocorticoid therapy.

Learning points:

  • We performed the pituitary gland biopsy and histochemical examination glucocorticoid therapy in a subject with IgG4-related hypophysitis.

  • This case report provides the possibility that IgG4 level is decreased spontaneously or with a physiological dose of glucocorticoid therapy. We reported the clinical course of IgG4-related hypophysitis without a high-dose glucocorticoid treatment, although there were a few reports about the retrospective examination.

  • Although the patient had still higher IgG4 level compared to normal range, his clinical symptom disappeared and his laboratory data were improved.

  • We should keep in mind the possibility of IgG4-related hypophysitis when we examine one of the uncertain causes of a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism.

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Laila Ennazk Department of Endocrinology, Diabetology and Metabolic Diseases, Mohammed VI University Hospital of Marrakech, Caddi Ayyad University, Marrakech, Morocco

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Ghizlane El Mghari Department of Endocrinology, Diabetology and Metabolic Diseases, Mohammed VI University Hospital of Marrakech, Caddi Ayyad University, Marrakech, Morocco

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Nawal El Ansari Department of Endocrinology, Diabetology and Metabolic Diseases, Mohammed VI University Hospital of Marrakech, Caddi Ayyad University, Marrakech, Morocco

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Summary

Autoimmune pancreatitis is a new nosological entity in which a lymphocytic infiltration of the exocrine pancreas is involved. The concomitant onset of autoimmune pancreatitis and type 1 diabetes has been recently described suggesting a unique immune disturbance that compromises the pancreatic endocrine and exocrine functions. We report a case of type1 diabetes onset associated with an autoimmune pancreatitis in a young patient who seemed to present a type 2 autoimmune polyglandular syndrome. This rare association offers the opportunity to better understand pancreatic autoimmune disorders in type 1 diabetes.

Learning points:

  • The case makes it possible to understand the possibility of a simultaneous disturbance of the endocrine and exocrine function of the same organ by one autoimmune process.

  • The diagnosis of type 1 diabetes should make practitioner seek other autoimmune diseases. It is recommended to screen for autoimmune thyroiditis and celiac diseases. We draw attention to consider the autoimmune origin of a pancreatitis associated to type1 diabetes.

  • Autoimmune pancreatitis is a novel rare entity that should be known as it is part of the IgG4-related disease spectrum.

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Rayna Patel Department of Stroke Medicine, Addenbrooke’s Hospital, Cambridge, UK

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Waheed Mustafa Department of Orthopaedic Surgery, Basildon University Hospital, Nethermayne, Basildon, Essex, UK

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Michael T Sheaff Department of Pathology, St Bartholemew’s Hospital, London, UK

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Sami Khan Department of Radiology, Basildon University Hospital, Nethermayne, Basildon, Essex, UK

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Summary

IgG4-related disease (IgG4-RD) is a rare but increasingly recognised condition, emerging as a clinical entity following the observation of the associations of autoimmune pancreatitis. IgG4-RD is characterised by extensive infiltration of IgG4-positive plasma cells into multiple organs and raised serum IgG4 levels. Clinical manifestations of IgG4 disease classically include autoimmune pancreatitis, lacrimal or salivary gland infiltration (formerly known as Mikulicz disease) and retroperitoneal fibrosis. More rarely, IgG4 disease can cause pituitary hypophysitis. Although most frequently described in middle-aged males, the epidemiology and pathogenesis of the disease remain largely undefined. Nevertheless, an understanding of the wide variety of clinical manifestations of this multi-system condition is undeniably important given the often excellent outcomes following treatment. We describe an unusual presentation of IgG4 disease with isolated diabetes insipidus secondary to pituitary hypophysitis. The patient in question subsequently developed chest pain secondary to mediastinal lymphadenopathy and tubulo-interstitial nephritis leading to renal dysfunction. He was successfully treated with oral steroids and had regular follow-up, and remains well at follow-up 2 years later.

Learning points

  • IgG4 disease, although rare, is increasing in prevalence largely due to increased recognition of its clinical manifestations, including autoimmune pancreatitis, lacrimal or salivary gland infiltration, retroperitoneal fibrosis and, more rarely, lymphocytic hypophysitis presenting as diabetes insipidus.

  • IgG4 disease is highly treatable, and symptoms may show complete resolution with administration of steroids, highlighting the importance of correct and timely diagnosis.

  • Causes of lymphocytic hypophysitis are varied and not distinguishable radiologically. Given the difficulty in biopsying the pituitary, careful attention must be paid to the systemic clinical presentation to provide clues as to the underlying disorder.

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Hiroto Minamino The First Department of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan
Department of Diabetes and Endocrinology, Wakayama Red Cross Hospital, Wakayama, Japan

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Hidefumi Inaba The First Department of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan

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Hiroyuki Ariyasu The First Department of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan

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Hiroto Furuta The First Department of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan

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Masahiro Nishi The First Department of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan

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Takashi Yoshimasu Department of Dermatology, Wakayama Medical University, Wakayama, Japan

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Akinori Nishikawa Department of Hematology, Wakayama Medical University, Wakayama, Japan

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Masanori Nakanishi Department of Respiratory Medicine & Medical Oncology, Wakayama Medical University, Wakayama, Japan

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Shigeki Tsuchihashi Department of Otolaryngology, Wakayama Medical University, Wakayama, Japan

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Fumiyoshi Kojima Department of Human Pathology, Wakayama Medical University, Wakayama, Japan

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Shin-ichi Murata Department of Human Pathology, Wakayama Medical University, Wakayama, Japan

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Gen Inoue Department of Diabetes and Endocrinology, Wakayama Red Cross Hospital, Wakayama, Japan

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Takashi Akamizu The First Department of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8509, Japan

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Summary

A 73-year-old man with Hashimoto's thyroiditis (HT) suffered from purpura on the lower legs. He was diagnosed with IgG4-related disease (IgG4-RD) with serum IgG4 elevation and dacryo-sialadenitis confirmed histologically. Serum Th2 and Treg cytokines, interleukin 7 (IL7), IL8 and Th2 chemokine levels were elevated, while skewed Th1 balance was seen in fluorescence-activated cell sorting (FACS). Therefore, preferential Th1 balance in HT appeared to be followed by IgG4-RD characterized with Th2 and Treg polarization. The commencement of steroid therapy dramatically exacerbated clinical manifestations including IgG4-RD-associated HT. The measurement of cytokine and chemokine levels as well as FACS analysis in the development of IgG4-RD seemed to be beneficial. In conclusion, an innovative association of HT, IgG4-RD and vasculitis was observed. This report also offers novel diagnostic and therapeutic approaches for IgG4-RD.

Learning points

  • Recently, a subtype of HT has been considered to be a thyroid manifestation of IgG4-RD, although the etiology of IgG4-RD is not established yet.

  • Immunologically a close association between HT and vasculitis was reported.

  • Leukocytoclastic vasculitis is a rare skin presentation of IgG4-RD.

  • In the current case, during the course of HT, IgG4-RD and leukocytoclastic vasculitis occurred; thus, innate immunity and acquired immunity seem to be involved in the development of IgG4-RD.

  • The measurement of cytokine and chemokines appeared to be beneficial in the development of IgG4-RD.

  • Remarkably, effectiveness of steroid therapy for HT suggested presence of IgG4-RD-associated HT. Therefore, this report highlights the pathogenesis of IgG4-RD and proposes novel therapeutic mechanisms. Clinicians should pay attention to the development of IgG4-RD and vasculitis during long course of HT.

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Huanyu Ding Department of Endocrinology and Metabolism, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China

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Yang Li Department of Pathology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China

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Caishun Ruan Department of Endocrinology and Metabolism, Longyan People Hospital, Longyan, 364000, People's Republic of China

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Yuan Gao Department of General Practice, Community Health Center of Qianjin Street, Tianhe District, Guangzhou, 510660, People's Republic of China

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Hehua Wang Department of Hematology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China

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Xiangsong Zhang Department Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China

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Zhihong Liao Department of Endocrinology and Metabolism, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China

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Summary

Erdheim-Chester disease (ECD), one type of systemic non-Langerhans cell histiocytosis, has been rarely seen and is characterized by the accumulation of foamy CD68+CD1a- histiocytes. We reported a case of ECD and reviewed the clinical features of 13 cases of ECD reported so far in China. A 53-year-old male was diagnosed with central diabetes insipidus in March 2014, followed by fever, splenomegaly and anemia in July 2014. His initial pituitary magnetic resonance imaging (MRI) revealed the absence of high signal at T1-weighted image in posterior pituitary without any lesion. A further positron emission tomography/computer tomography (PET/CT) images showed elevated metabolic activity of 18F-2-fluro-D-deoxy-glucose (FDG) and low 13N-NH3 uptake in the posterior pituitary, and multi-organ involvement. Biopsy at right femur lesion revealed that granulomatous infiltration of foamy histiocytes and Touton giant cells surrounded by fibrosis tissues. Immunohistochemistry stain was positive for CD68, negative for CD207/Langerin and S-100. The diagnosis of ECD was confirmed and the treatment with pegylated interferon was effective. ECD was a possible immune-related disorder concluding from the IgG4 immunohistochemistry results. We summarized the pathological manifestations for ECD and its differential diagnosis from Langerhans cell histiocytosis (LCH) and Rosai-Dorfman disease (RDD). ECD should be considered by both pathologists and clinicians in the differential diagnosis when central diabetes insipidus is accompanied with multi-organ involvement, especially skeletal system involvement, or recurrent fever.

Learning points

  • ECD should be considered when central diabetes insipidus is accompanied with multisystem involvement, especially symmetric/asymmetric bone lesions, or recurrent fever.

  • PET/CT scanning was helpful for locating pituitary lesion, discovering multiple system involvement and indicating the biopsy sites.

  • Conducting proper immunohistochemistry stains was important for diagnosing ECD. ECD might be correlated with immune disorder.

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Milena S Pandrc Department of Internal Medicine, Militar Medical Academy, Crnotravska 1711000, Belgrade, Serbia

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Stanko Petrović Department of Gastroenterology, Militar Medical Academy, Crnotravska 1711000, Belgrade, Serbia

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Vanja Kostovski Clinic for Thoracic Surgery, Militar Medical Academy, Crnotravska 1711000, Belgrade, Serbia

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Marijana Petrović Department of Nephrology, Militar Medical Academy, Crnotravska 1711000, Belgrade, Serbia

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Miloš Zarić Department of Pathology, Militar Medical Academy, Crnotravska 1711000, Belgrade, Serbia

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Summary

Immunoglobulin (Ig)G4-related sclerosing disease (IgG4-RSD) is a new disease entity first proposed with regard to autoimmune pancreatitis. A 67-year-old male patient was examined because of weight loss and an abdominal pain. Based on the clinical characteristics, laboratory parameters and ultrasound features, we identified the diagnosis of the IgG4-related systemic disease (IgG4-RSD), that was confirmed by the histopathological analysis after the biopsy of the head of pancreas. After confirmation, we started with the corticosteroid therapy with a good clinical, biochemical and morphological response. During the previous therapy, the disturbance of glucoregulation appeared, so we had to change the modality of treatment. We decided to add Azathioprine to the therapy in a dose of 150 mg/day. We achieved a stable phase of the disease with IgG 4.37 g/l and IgG4 0.179 g/l, and with no side effects from the therapy.

Learning points

  • There are potential clinical applications of identifying subsets of patients with IgG4 thyroiditis (FVHT and Riedel thyroiditis).

  • A trial of immunosuppressive therapy should be included if a resection is deemed inadvisable.

  • In particular, cases of FVHT that mimic malignancy, tissue and serum IgG4 may provide supportive diagnostic information.

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