Abstract
Autoimmune pancreatitis (AIP) is a rare disorder often associated with multiple autoimmune diseases like rheumatoid arthritis, inflammatory bowel disease and Sjögren’s syndrome (SS). Although knowledge of AIP has grown over the last few years, little is certain about its cause and pathogenesis. Positive immunologic markers like antinuclear antibodies (ANA) or elevated serum levels of IgG4, systemic autoimmune disease association and positive response to oral steroid therapy strongly supports the idea of autoimmune mechanisms involved in the pathogenesis of AIP. We describe the first case reported on the literature of a patient with primary SS who developed relapsing AIP to steroids but responded successfully to Rituximab (RTX) therapy. New theories about the role of B-cells activity in SS and other autoimmune diseases has encourage the use of RTX, proving tolerance and efficacy especially in extra-glandular manifestations.




References
Sarles H, Sarles JC, Muratore R et al (1961) Chronic inflammatory sclerosis of the pancreas, an autonomous pancreatic disease? Am J Dig Dis 6:688–698. doi:10.1007/BF02232341
Yoshida K, Toki F, Takeuchi T et al (1995) Chronic pancreatitis caused by an autoimmune abnormality: proposal of the concept of autoimmune pancreatitis. Dig Dis Sci 40:1561–1568. doi:10.1007/BF02285209
Finkelberg DL, Sahani D, Deshpande V et al (2006) Autoimmune pancreatitis. N Engl J Med 355:2670–2676. doi:10.1056/NEJMra061200
Hayakawa T, Naruse S, Kitagawa M et al (2001) Clinical aspects of autoimmune pancreatitis in Sjögren’s syndrome. JOP J Pancreas Online 2(3):88–92
Uchida K, Okazaki K, Konishi Y et al (2000) Clinical analysis of autoimmunerelated pancreatitis. Am J Gastroenterol 95:2788–2794. doi:10.1111/j.1572-0241.2000.03187.x
Hirano K, Shiratori Y, Komatsu Y et al (2003) Involvement of the biliary system in autoimmune pancreatitis: a follow-up study. Clin Gastroenterol Hepatol 1:453–464. doi:10.1016/S1542-3565(03)00221-0
Ito T, Nakano I, Koyanagi S et al (1997) Autoimmune pancreatitis as a new clinical entity: three cases of autoimmune pancreatitis with effective steroid therapy. Dig Dis Sci 42:1458–1468. doi:10.1023/A:1018862626221
Pearson RK, Longnecker DS, Chari ST et al (2003) Controversies in clinical pancreatology: autoimmune pancreatitis: does it exist? Pancreas 27:1–13. doi:10.1097/00006676-200307000-00001
Zamboni G, Luttges J, Capelli P et al (2004) Histopathological features of diagnostic and clinical relevance in autoimmune pancreatitis: a study on 53 resection specimens and 9 biopsy specimens. Virchows Arch 445:552–563. doi:10.1007/s00428-004-1140-z
Yadav D, Notahara K, Smyrk TC et al (2003) Idiopathic tumefactive chronic pancreatitis: clinical profile, histology, and natural history after resection. Clin Gastroenterol Hepatol 1:129–135. doi:10.1053/cgh.2003.50016
Weber SM, Cubukcu-Dimopulo O, Palesty JA et al (2003) Lymphoplasmacytic sclerosing pancreatitis: inflammatory mimic of pancreatic carcinoma. J Gastrointest Surg 7:129–137, discussion 137–139. doi:10.1016/S1091-255X(02)00148-8
Okazaki K, Uchida K, Ohana M et al (2000) Autoimmune-related pancreatitis is associated with autoantibodies and a Th1/Th2-type cellular immune response. Gastroenterology 118:573–581. doi:10.1016/S0016-5085(00)70264-2
Kino-Ohsaki J, Nishimori I, Morita M et al (1996) Serum antibodies to carbonic anhydrase I and II in patients with idiopathic chronic pancreatitis and Sjogren’s syndrome. Gastroenterology 110:1579–1586. doi:10.1053/gast.1996.v110.pm8613065
Members of the Criteria Committee for Autoimmune Pancreatitis of the Japan Pancreas Society (2000) Diagnostic criteria for autoimmune pancreatitis by the Japan Pancreas Society. J Jpn Pan Soc 17:585–587
Aoki S, Nakazawa T, Ohara H et al (2005) Immunohistochemical study of autoimmune pancreatitis using anti-IgG4 antibody and patients’ sera. Histopathology 47:147–158. doi:10.1111/j.1365-2559.2005.02204.x
Zen Y, Harada K, Sasaki M et al (2004) IgG4-related sclerosing cholangitis with and without hepatic inflammatory pseudotumor, and sclerosing pancreatitis-associated sclerosing cholangitis: do they belong to a spectrum of sclerosing pancreatitis? Am J Surg Pathol 28:1193–1203. doi:10.1097/01.pas.0000136449.37936.6c
Deshpande V, Chicano S, Finkelberg D et al (2006) Autoimmune pancreatitis: a systemic immune complex mediated disease. Am J Surg Pathol 30:1537–1545. doi:10.1097/01.pas.0000213331.09864.2c
Song MH, Kim MH, Lee SK et al (2005) Regression of pancreatic fibrosis after steroid therapy in patients with autoimmune chronic pancreatitis. Pancreas 30:83–86. doi:10.1097/01.mpa.0000153211.64268.70
Pearson RK, Longnecker DS, Chari ST et al (2003) Controversies in clinical pancreatology: autoimmune pancreatitis: does it exist? Pancreas 27:1–13. doi:10.1097/00006676-200307000-00001
Bowman SJ, Ibrahim GH, Holmes G et al (2004) Estimating the prevalence among Caucasian women of primary Sjögren’s syndrome in two general practices in Birmingham, UK. Scand J Rheumatol 33:39–43. doi:10.1080/03009740310004676
Strand V, Talal N (1980) Advances in the diagnosis and concept of Sjögren’s syndrome (autoimmune exocrinopathy). Bull Rheum Dis 30:1046–1052
Moutsopoulus HM (1994) Sjögren’s syndrome: autoimmune epithelitis. Clin Immunol Immunopathol 72:162–165. doi:10.1006/clin.1994.1123
Nagaraju K, Cox A, Casciola-Rosen L et al (2001) Novel fragments of the Sjögren’s syndrome autoantigens α-fodrin and type 3 muscarinic acetylcholine receptor generated during cytotoxic lymphocyte granule-induced cell death. Arthritis Rheum 44:2376–2386. doi:10.1002/1529-0131(200110)44:10<2376::AID-ART402>3.0.CO;2-E
Nakamura H, Kawakami A, Eguchi K (2006) Mechanisms of autoantibody production and the relationship between autoantibodies and the clinical manifestations in Sjögren’s syndrome: translational research. J Lab Clin Med 148:281–288
Bave U, Nordmark G, Lovgren T et al (2005) Activation of the type I interferon system in primary Sjögren’s syndrome: a possible etiopathogenic mechanism. Arthritis Rheum 52:1185–1195. doi:10.1002/art.20998
Looney RJ (2007) Will targeting B cells be the answer for Sjögren’s syndrome? Arthritis Rheum 56:1371–1377. doi:10.1002/art.22604
Anaya JM, Talal N (1997) Sjögren’s syndrome and connective tissue diseases associated with other immunologic disorders. In: Koopman W (ed) Arthritis and allied conditions, 13th edn. Williams and Wilkins, Baltimore, pp 1561–1580
Nishimori I, Okazaki K, Yamamoto Y et al (1993) Specific cellular immune responses to pancreatic antigen in chronic pancreatitis and Sjögren’s syndrome. J Clin Immunol 13:265–271. doi:10.1007/BF00919385
Akahane C, Takei Y, Horiuchi A et al (2002) A primary Sjögren’s syndrome patient with marked swelling of multiple exocrine glands and sclerosing pancreatitis. Intern Med 41:749–753. doi:10.2169/internalmedicine.41.749
Chira P, Sandborg CI (2003) Novel therapies in pediatric rheumatic diseases. Curr Opin Pediatr 15:579–585. doi:10.1097/00008480-200312000-00007
Omdal R, Wildhagen K, Hansen T et al (2005) Anti-CD20 therapy of treatment-resistant Wegener’s granulomatosis: favorable but temporary response. Scand J Rheumatol 34:229–232. doi:10.1080/02813430510015269
Van Vollenhoven RF, Gunnarsson I, Welin-Henriksson E et al (2004) Biopsy-verified response of severe lupus nephritis to treatment with rituximab (anti-CD20 monoclonal antibody) plus cyclophosphamide after biopsy-documented failure to respond to cyclophosphamide alone. Scand J Rheumatol 33:423–427. doi:10.1080/03009740410010227
Kneitz C, Wilhelm M, Tony HP (2004) Improvement of refractory rheumatoid arthritis after depletion of B cells. Scand J Rheumatol 33:82–86. doi:10.1080/03009740310004379
Gottenberg JE, Guillevin L, Lambotte O et al (2005) Tolerance and short-term efficacy of rituximab in 43 patients with systemic autoimmune diseases. Ann Rheum Dis 64:913–920. doi:10.1136/ard.2004.029694
Silverman GJ, Weisman S (2003) Rituximab therapy and autoimmune disorders. Arthritis Rheum 48:1484–1492. doi:10.1002/art.10947
Zaja F, De Vita S, Russo D et al (2002) Rituximab for the treatment of type II mixed cryoglobulinemia. Arthritis Rheum 46:2252–2254. doi:10.1002/art.10345
Pijpe J, Van Imhoff G, Spijkervet F et al (2005) Rituximab treatment in patients with primary Sjogren’s syndrome. An open-label phase II study. Arthritis Rheum 52:2740–2750. doi:10.1002/art.21260
Somer BG, Tsai DE, Downs L et al (2003) Improvement in Sjogren’s syndrome following therapy with rituximab for marginal zone lymphoma. Arthritis Rheum 49:394–398. doi:10.1002/art.11109
Ramos-Casals M, Lopez-Guillermo A, Brito-Zeron P (2004) Treatment of B-cell lymphoma with rituximab in two patients with Sjogren’s syndrome associated with hepatitis C virus infection. Lupus 13:969–971. doi:10.1191/0961203304lu2049xx
Pijpe J, Van Imhoff G, Vissink A et al (2005) Changes in salivary gland immunohistology and function after rituximab mono-therapy in a patient with Sjogren’s syndrome and associated MALT-lymphoma. Ann Rheum Dis 64:958–960. doi:10.1136/ard.2004.030684
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Rueda, J.C., Duarte-Rey, C. & Casas, N. Successful treatment of relapsing autoimmune pancreatitis in primary Sjögren’s syndrome with Rituximab: report of a case and review of the literature. Rheumatol Int 29, 1481–1485 (2009). https://doi.org/10.1007/s00296-009-0843-5
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DOI: https://doi.org/10.1007/s00296-009-0843-5