A 44-Year-Old Man With Chronic Cough, Weakness, and a Mediastinum Mass

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1 [ Pulmonary, Critical Care, and Sleep Pearls ] A 44-Year-Old Man With Chronic Cough, Weakness, and a Mediastinum Mass Dimitrios Theofilos, MD ; Christina Triantafillidou, MD, PhD ; Athanasios Zetos, MD ; Danai Bisirtzoglou, MD, PhD ; Froso Konstantinou, MD ; Charalampos Marketos, MD ; and Georgios Politis, MD, PhD A 44-year-old white man presented with a 3-month history of dry cough and weakness. He had already been treated with antibiotics without any relief. He did not report dyspnea, fever, or expectoration. The patient s medical history was significant for mild arterial hypertension and autoimmune thyroiditis with normal thyroid hormone levels. He was a nonsmoker and had been in excellent health until symptom onset. CHEST 2015; 148 ( 3 ): e86 - e90 Physical Examination Findings Physical examination revealed a BP of 130/80 mm Hg, pulse of 80 beats/min, respiratory rate of 15 breaths/min, temperature of 36.7 C, and oxygen saturation of 98% on room air. Lung examination revealed normal breath sounds, and the rest of examination was normal. Diagnostic Studies The patient had a normal WBC count, hematocrit and platelet levels, coagulation study results, and urinanalysis. Complete metabolic panel values, ECG, spirometry, and diffusing capacity of lung for carbon monoxide were also normal. Chest radiograph was normal. Chest CT scan ( Fig 1 ) revealed a soft-tissue mass adjacent to the aortic arch with enlargement of the aortopulmonary window lymph nodes. The lung parenchyma appeared normal. Subsequent CT imaging of the abdomen was unremarkable. Fiber-optic bronchoscopy did not reveal pathologic endobronchial findings, and bacterial and fungal cultures and acid-fast staining of bronchial washing and aspirates were negative. A surgical biopsy of the mediastinal mass was performed, and pathologic examination revealed extensive fibrotic tissue Figure 1 Chest CT scan showing a soft-tissue mass adjacent to the aortic arch with enlargement of aortopulmonary window lymph nodes. infiltrating adipose tissue and regional vessels associated with dense polyclonal lymphoplasmacellular infiltration with more -positive ( 1 ) plasma cells ( Fig 2 ). Manuscript received November 30, 2014 ; revision accepted February 15, AFFILIATIONS: From the Pulmonary Department (Drs Theofilos, Triantafillidou, Zetos, Bisirtzoglou, Marketos, and Politis), Agios Savvas Anticancer-Oncology Hospital of Athens; and 6th Pulmonary Department (Dr Triantafillidou) and Internal Medicine Department (Dr Konstantinou), Sotiria General Hospital of Chest Diseases, Athens, Greece. CORRESPONDENCE TO: Christina Triantafillidou, MD, PhD, 6th Pulmonary Dept, Sotiria General Hospital of Chest Diseases, 2 Limnou St, Palaiopanagia-Peania, Athens, Greece; xristina. triantafyllidou@gmail.com 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: /chest e86 Pulmonary, Critical Care, and Sleep Pearls [ 148#3 CHEST SEPTEMBER 2015 ]

2 Figure 2 A, Mediastinal mass section obtained by thoracic surgery showing a storiform pattern of fibrosis and intense tissue infiltration by nonspecific-type inflammatory cells. Also showing are lymphoplasmatic infiltrate and obliterative phlebitis (hematoxylin-eosin, original magnification 3 200). B, Immunohistochemical stains showing diffuse and intense distribution of IgG4-positive plasma cells with local confluence of. 50 IgG4-positive plasma cells per high-power field (original magnification 3 200). Grocott methenamine silver staining was negative. Serum IgG4 level was increased (174 mg/dl [normal values, 135 mg/dl]). What is the diagnosis? journal.publications.chestnet.org e87

3 Diagnosis: -related fibrosing mediastinitis Discussion -related disease ( -RD) encompasses a spectrum of fibroinflammatory conditions once regarded as entirely separate diseases associated with elevated circulating levels of, which can potentially affect almost every organ system. Since the first reports of increased in autoimmune pancreatitis in 2001, knowledge has been rapidly growing about the pathogenesis, clinical features, histopathology, and treatment strategies of these novel lymphoproliferative disorders, leading to a growing number of new entities now recognized as -RD. Pancreas, liver, thyroid, salivary, and lacrimal glands are the most frequently affected organs. The clinical picture depends on the organ affected; thus, it is highly heterogeneous. An international symposium on -RD convened in 2011 established comprehensive diagnostic criteria for -RD. The diagnosis of -RD is supported by the combined presence of the characteristic histopathologic appearance, more -staining plasma cells in the biopsy specimen of a patient with either localized or diffuse edema or mass or dysfunction in single or multiple organs, and a hematologic examination showing elevated serum concentrations. Histopathologic features comprise a dense lymphoplasmatic infiltrate, a storiform pattern of fibrosis, and obliterative phlebitis. immunostaining is an essential test for diagnosis; at least 10 1 cells per high-power field or a ratio of 1 cells to total IgG 1 plasma cells exceeding 0.4 to 0.5 is required for a definite diagnosis. The positive predictive value of an elevated serum level is poor, being in the range of 34% in one recent study. Conversely, the negative predictive value has been demonstrated to be. 95%. Normal concentrations of serum are mainly noticed among patients with -RD with single-organ involvement, whereas the mean level among patients with multiorgan disease is higher compared with those with single-organ disease. Probable and possible cases are also recognized according to criteria ( Table 1 ). The first reports of -related lung disease included patients with autoimmune pancreatitis and diffuse interstitial lung disease or pulmonary nodules. Since, a wide and heterogeneous spectrum of intrathoracic abnormalities has been reported, with mediastinal and hilar lymphadenopathy being the most common manifestations. However, patterns of pulmonary involvement in -RD of the lung can take the form of solitary or multiple lung masses and nodules, ground glass opacities, diffuse infiltrates or consolidation, interstitial lung disease, airway stenosis and obstruction, bronchiectasis, and pleural disease (pleural effusion, thickening and nodular pleural lesions). In a cross-sectional study of 114 patients with -RD, 14% were given a diagnosis of lung or pleural involvement, whereas in another retrospective study, approximately one-half of patients with -related autoimmune pancreatitis had evidence of pulmonary disease on imaging studies. Fibrosing mediastinitis is an unusual manifestation of -RD because only a few cases of -related fibrosing mediastinitis have been reported in the literature. Interestingly, in a retrospective study of 15 cases of histologically confirmed fibrosing mediastinitis, three patients were given a diagnosis of definite -RD, a fact that may reflect the possible underestimation of this combined entity. The rarity of fibrosing mediastinitis in association with -RD stands in contrast to retroperitoneal fibrosis, which is much more common within the spectrum of -RD. Mediastinal fibrosis or fibrosing mediastinitis is a benign but potentially progressive and life-threatening disorder characterized by an excessive storage of dense fibrous tissue within the mediastinum. Many cases of fibrosing mediastinitis are idiopathic, but most cases in the United States are believed to be a sequence of abnormal immunologic response to Histoplasma capsulatum infection. The disease progresses slowly over years and does not respond to antifungal, corticosteroid, or other antiinflammatory agents. However, in Greece, no data exist regarding the isolation of H capsulatum from soil and animals, and the few H capsulatum infections reported are considered imported. Fibrosing mediastinitis may be asymptomatic until the disease has progressed to cause damage to any organ or tissue of the mediastinum, leading to signs and symptoms of obstruction or compression of the affected organ, such as superior vena cava syndrome, dyspnea, pericarditis, thoracic pain, and dysphagia. Corticosteroids are considered the mainstay of treatment of -RD, and for many of its manifestations, response to therapy is favorable. The usual regimen consists of prednisolone or prednisone at a dose of between 30 mg/d and 1 mg/kg/d, but the optimal dose and duration of corticosteroid therapy remains to be defined. A number of other immunosuppressant drugs, such as azathioprine, mycophenolate mofetil, cyclophosphamide, and methotrexate, have also been e88 Pulmonary, Critical Care, and Sleep Pearls [ 148#3 CHEST SEPTEMBER 2015 ]

4 TABLE 1 ] Comprehensive Clinical Diagnostic Criteria for -RD Criterion 1. Localized or diffuse edema or mass or dysfunction in single or multiple organs 2. Elevated serum concentration ( 135 mg/dl) 3. Characteristic histopathologic appearance: Dense lymphoplasmatic infiltrate and fibrosis Tissue infiltrate: /IgG ratio. 40% and. 10 -positive cells per high-power field Criteria as proposed in 2011 by Umehara et al: definite, ; probable, 1 1 3; possible, RD 5 -related disease. used as corticosteroid-sparing agents. Additionally, successful treatment of -RD has been reported with bortezomib and rituximab. For treatment of - related fibrosing mediastinitis in particular, evidence for efficacy is anecdotal and based mainly on case reports. In three previous case reports of IgG4-related fibrosing mediastinitis, patients improved after steroid therapy, a noticeable event because mediastinal fibrosis is considered resistant to pharmacologic treatment. Specifically, two patients presented with symptoms from extrathoracic disease, whereas one patient complained of exertional dyspnea. In all patients, the size of mediastinal mass decreased after initiation of corticosteroids, and the patient with dyspnea showed remission of symptoms. A few other cases have been described in terms of retrospective analysis without information regarding treatment outcome. Figure 3 Chest CT scan 1 mo after treatment showing a significant reduction in the size of the mediastinum mass. Clinical Course The patient met criteria for definite diagnosis of -RD. Specifically, the patient had documented organ involvement, an elevated serum level. 135 mg/dl, and compatible histopathologic features. He was treated with prednisolone 0.6 mg/kg/d. One month after treatment was initiated, the patient was asymptomatic, and his new chest CT scan was significantly improved (Fig 3 ). Clinical Pearls 1. -related fibrosing mediastinitis is a rare but likely underdiagnosed entity and, thus, requires a high clinical and pathologic suspicion to be diagnosed with certainty. 2. The diagnosis of -RD is supported by the combined presence of the characteristic histopathologic appearance and more -staining plasma cells in the biopsy specimen of a patient with either localized or diffuse edema or a mass or dysfunction in single or multiple organs and hematologic examination showing elevated serum concentrations. 3. -related fibrosing mediastinitis may respond to steroid therapy in contrast to other forms of fibrosing mediastinitis, which do not typically respond to steroids or other antiinflammatory agents. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Suggested Readings Hamano H, Kaw a S, Hor iu ch i A, e t a l. Hi g h s e r u m Ig G 4 concentrations in patients with sclerosing pancreatitis. N Engl J Med ;344 (10 ): Kapotsis GE, Daniil Z, Malagari K, et al. A young male with chest pain, cough and fever. Eur Respir J ;24 (3 ): Taniguchi T, Kobayashi H, Fukui S, Ogura K, Saiga T, Okamoto M. A case of multifocal fibrosclerosis involving posterior mediastinal fibrosis, retroperitoneal fibrosis, and a left seminal vesicle with elevated serum IgG4. Hum Pathol ;37 (9 ): Inoue M, No s e N, Nish i k aw a H, Ta k a hash i M, Z e n Y, Kaw ag u ch i M. Successful treatment of sclerosing mediastinitis with a high serum level. Gen Thorac Cardiovasc Surg ;55 (10 ): Pei ker t T, Sh re st ha B, Aubr y MC, et a l. Histop at hol og ic ove rl ap b et we en fibrosing mediastinitis and -related disease. Int J Rheumatol ; 2012 : Ryu JH, Sekiguchi H, Yi ES. Pulmonary manifestations of immunoglobulin G 4 -related sclerosing disease. Eur Respir J ; 39 ( 1 ): journal.publications.chestnet.org e89

5 Umehara H, Okazaki K, Masaki Y, et al. Comprehensive diagnostic criteria for -related disease ( -RD), Mod Rheumatol ;22(1): Fuj imor i N, Ito T, Ig ar ash i H, et a l. R et rop er itone a l fibrosis associated with immunoglobulin G 4 -related disease. World J Gastroenterol ;19(1): Ngwa TN, Law R, Murray D, Chari ST. Serum immunoglobulin G 4 level is a poor predictor of immunoglobulin G 4 -related disease. Pancreas ;43 (5 ): C ar r ut hers M N, K ho s ro sha h i A, Au g ust i n T, D e shp and e V, Stone J H. The diagnostic utility of serum IgG4 concentrations in IgG4-related disease. Ann Rheum Dis ;74 (1 ): e90 Pulmonary, Critical Care, and Sleep Pearls [ 148#3 CHEST SEPTEMBER 2015 ]