PMC4462868_01
(A) PET/CT at the first admission showed FDG accumulation in the cervical, axillary, perigastric, portal, paraaortic, and inguinal lymph nodes and the salivary glands. (B) Follow-up PET/CT after corticosteroid therapy revealed decreased FDG accumulation.
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Positron- emission tomography/computed tomography (PET/CT) (Fig. 1) showed fluorodeoxyglucose (FDG) accumulation in the same lymph nodes as well as in the salivary glands.
Biopsy of an inguinal lymph node in the right side. The plasma cells were not atypical or blastic. No immunoglobulin light chain restriction was seen (kappa/lambda ratio = +2). Almost all plasma cells were IgG-positive, and the ratio of IgG4/IgG was 0.3.. Abbreviations: HE, hematoxylin-eosin; kappa-ish, kappa-in situ hybridization; lambda-ish, lambda-in situ hybridization.
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Almost all plasma cells were IgG-positive, and the IgG4/IgG ratio was 0.3 (Fig. 2).
Clinical course at the second admission.. Abbreviation: PSL, prednisolone sodium succinate.
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While the results for serum levels of intact PTH, parathyroid hormone-related protein (PTHrP), and 1-25(OH)2 vitamin D were awaited, treatment for hypercalcemia was initiated with IV fluids, bisphosphonate (pamidronate disodium hydrate 30 mg), calcitonin (elcatonin 80 U/day for three days), and IV corticosteroids (prednisolone sodium succinate 120 mg/day for three days, 20 mg/day for two days, and 10 mg/day for two days) (Fig. 3).
99mTc-MIBI parathyroid scintigraphy was negative, and no ectopic parathyroid glands were found.
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During the second admission, the serum level of intact PTH was 95 pg/mL (normal, 10-65 pg/mL) and PTHrP was <1.1 pmol/L (normal, <=1.1 pmol/L). 99mTc-MIBI parathyroid scintigraphy (Fig. 4) and parathyroid ultrasonography showed no abnormal findings, ruling out primary hyperparathyroidism.
Liver biopsy. Plasma cells infiltration was noted in Gleason's area; however, no active hepatitis or fibrosis was seen. The ratio of IgG4-positive/IgG-positive plasma cells was 0.4.
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The ratio of IgG4-positive and IgG-positive plasma cells was 0.4 (Fig. 5).