Mass: The Conundrum in Spine

Immunoglobulin (Ig)G4-related disease belongs to a rare compilation of conditions in rheumatology and may involve a multitude of organs. Amidst the central nervous system (CNS) presentation, involvement of spinal cord is rarer still.

Case 1: A 50-year-old male came with chief complaints of tingling sensation over both soles since 2 months associated with lower back ache and gait disturbance in the form of spastic gait. X-rays of spine were suggestive of a growth at the level of D10-D12 compressing the spinal cord with no focal sclerotic/lytic lesions, and MRI dorsolumbar spine showed dural tail sign. The patient underwent excision of dural mass, and histopathology revealed majority of plasma cells positive for IgG4. Case 2: A 65-year-old female came with complaints of cough, shortness of breath, and fever on and off since 2 months. No history of hemoptysis, purulent sputum, weight loss. On examination: There were bilateral rhonchi in the left upper zone. MRI spine showed focal erosion with soft-tissue thickening at the right paravertebral region extending from D5-9. The patient underwent surgery (fusion D6-8 and ostectomy D7 posterior rib resection D7 right side) with the right pleural biopsy and transpendicular intracorporal biopsy D7. Histopathology was compatible with findings of IgG4 disease.

IgG4 tumors presenting in CNS itself is rare and rarer in spinal cord. Histopathological examination is central to diagnose and prognosticate the disease further as IgG4-related disease manifestations may recur without proper treatment.