IgG4-Related Chronic Sinonasal Pseudotumor with Refractory Nasal Bleeding: A Case Report

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibro-inflammatory and idiopathic autoimmune disorder. IgG4-RD can be characterized by the presence of pseudotumors. Inflammatory pseudotumors may involve any part of a human organ. There are few reports of sinus lesions in IgG4-RD. An 82-year-old man has a history of chronic sinusitis for the last several years and no remarkable family history. Two years before disease presentation, the patient experienced intermittent nasal bleeding, stuffy nose, dizziness, and fatigue. Blood test revealed positive (160X) antinuclear antibody with a mixed speckled and nucleolar pattern, IgG level of 1370 mg/dL, and IgG4 level of 99.7 mg/dL. Computed tomography (CT) of the sinus revealed several calcifications in the sphenoid sinus. Surgical findings revealed tumor-like materials. Pathological examination of the soft tissues revealed acute and chronic granulomatous inflammation. Immunohistochemical analysis demonstrated high levels of positive-affinity markers of IgG, IgG4, and CD138 and a IgG4/IgG ratio > 40%. IgG4-RD with pseudotumor was diagnosed. The initial treatment was intravenous methylprednisolone 120 mg daily for three days and oral prednisolone 10 mg twice a day and azathioprine 50 mg daily. The efficacy of the treatment was insufficient, and nasal bleeding did not decrease. Subsequently administered intravenous rituximab 1000 mg monthly for 2 months. Following this treatment, nasal bleeding stopped. CT revealed reduction in nasal mucosal swelling compared with that in a previous scan. This report highlights that in cases with an inflammatory mass mimicking malignancy, IgG4RD should always be considered, and rituximab treatment is recommended upon failure of steroid and azathioprine therapy.