A case report of IgG4-RD involving bilateral renal pelvis and literature review.

RATIONALE: IgG4 related disease (IgG4-RD) is a systemic, and immune mediated chronic disease. IgG4-RD rarely presents as a bilateral renal pelvis soft tissue mass, which may be misdiagnosed as malignant urothelial tumor, leading to invasive surgical intervention and organ damage. Through the introduction of this rare case, the understanding of IgG-RD by clinicians can be increased, so as to reduce the misdiagnosis of tumor with space-occupying lesions in clinical practice, save medical resources, and reduce the unnecessary surgical burden of patients.

PATIENT CONCERNS: A 70-year-old male patient presented to our hospital with the chief complaint of "occupying bilateral renal lesions found on physical examination for 3 months." No visual hematuria, back pain or fever, no discomfort such as frequent, urgent or painful urination. Hypertension for 3 years, which is controlled by oral medication. No positive signs on physical examination.

DIAGNOSIS: IgG4-RD involving bilateral renal pelvis.

INTERVENTION: Computed tomography scan and magnetic resonance imaging incidentally discovered a mass located in the bilateral renal pelvis. The radiological examination results highly suggest malignant tumors. Therefore, the patient underwent right laparoscopic biopsy and the results showed that fibrous tissue hyperplasia with extensive plasma cell infiltration and lymphoid follicle formation. Immunohistochemical staining showed IgG4 positive plasma cells > 40/HPF, plasma cells IgG4/ IgG > 40%. The patient was treated with glucocorticoids in combination with immunosuppressive drugs.

OUTCOMES: Erythrocyte sedimentation rate and IgG4 returned to normal after first-line drugs treatment. The size of bilateral masses has been significantly decreased. The patient's kidney function is within the normal range.

LESSONS: In patients with bilateral renal pelvis masses, IgG4-RD should be considered in differential diagnosis to avoid unnecessary surgical intervention, and serum IgG4 level is the important biomarker. Glucocorticoids, immunosuppressive drugs, and biological agents are the first-line therapeutic medication for IgG4-RD.