*Corresponding author: Makki H Fayadh, Advanced center for day care sur- gery, Abu Dhabi, UAE, Tel: +971 6227700; E-mail: makkihf@yahoo.com Citation: Fayadh MH, Awadh S (2019) High IgG4 in a Patient with, Diabetes Mellitus, Ulcerative Colitis, Liver Cirrhosis with Papillary Thyroid Cancer. J Clin Stud Med Case Rep 6: 072. Received: August 07, 2019; Accepted: September 16, 2019; Published: Sep- tember 23, 2019 Copyright: © 2019 Fayadh MH and Awadh S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background IgG4-Related Disease (IgG4 RD) is a clinical entity including a wide variety of diseases, formerly diagnosed as Mikulicz’s disease, Autoimmune Pancreatitis (AIP), interstitial nephritis, prostatitis an- dretroperitoneal fbrosis [1-4]. Characteristics common to all forms of IgG4-RD include elevat- ed serum IgG4 concentration and tissue infltration by IgG4-positive plasma cells, accompanied by tissue fbrosis and sclerosis. As increased serum concentrations of IgG4 have been observed in several diseases with aberrant immunological condition unrelated to IgG4-RD, such as malignant tumors, autoimmune diseases especially rheumatoid arthritis and allergic diseases, increased IgG4 concentra- tion is not a specifc marker for IgG4-RD [2]. Since this complex multisystem disease represented a single pathogenetic disorder manifesting in a variety of target organs, the diagnosis of IgG4-RD is largely based on biopsy results showing en- hanced infltration by IgG4-positive plasma cells, storiform fbrosis, obliterative phlebitis and moderate eosinophilia, all of which are fre- quently observed in the affected tissues of these patients [1-8]. A high number of IgG4-positive plasma cells in tissue is a hall- mark of IgG4-RD, even when serum IgG4 concentrations are below the cut-off level [4]. IgG4-RD tends to be both under diagnosed and over diagnosed [1-8]. Each criterion contains organ-specifc clinical symptom and char- acteristic radiological fndings of IgG4-RD, even with steroidal trial in some. We reportedour initial experience in the United Arab Emirate on high IGG4 associated with pachymenigitis, infammatory bowel diseases, celiac disease, thyroiditis, retroperitoneal fbrosis, auto im- mune pancreatitis & sclerosing cholangitis [6]. Case Study A Male 55 years old with BMI 25, with strong family history of diabetes mellitus & myocardial infarctions in brothers and father. His diabetes mellitus started 1997 treated with oral hypoglycemic with poor control, insulinstarted 2005, and developed left sided ulcerative- colitis 2015 treated with mesalazine 3.2 g, azathioprine 200mg and courses of budesonide 9 mg. Frequent relapses of colitis with positive ameba and another re- lapse with positive clostridium diffcile infection treated with metro- nidazole successfully (Figures 1&2). January 2016 because of the colitis frequent relapses, adalimumab started but 6 months later developed recurrent deep vein thrombosis lower limbs and discovered to have factor V Leiden mutation, treated with oral anti-coagulants. Hematuria developed, ultrasound showed small bilateral kidney stones with large prostate. 2018 because of darkening of the skin and Fayadh MH and Awadh S, J Clin Stud Med Case Rep 2019, 6: 72 DOI: 10.24966/CSMC-8801/100072 HSOA Journal of Clinical Studies and Medical Case Reports Case Report Makki H Fayadh* and Salim Awadh Advanced Center for Day Care Surgery, Abu Dhabi, UAE High IgG4 in a Patient with, Diabetes Mellitus, Ulcerative Colitis, Liver Cirrhosis with Papillary Thyroid Cancer Abstract Objectives: As increased serum concentrations of IgG4 have been observed in several diseases with aberrant immunological condition such as malignant tumors, autoimmune diseases especially rheuma- toid arthritis and allergic. We describe a patient with high IgG4, liver cirrhosis, the ulcer- ative colitis, diabetes mellitus, prostatitis, venous thrombosis and thyroid cancer.The relationship between elevated IgG4 and these diseases is discussed. Case study: A 56 years old male with diabetes mellitus on insulin, ulcerative colitis on azathioprine & adalimumab developed deep skin pigmentation and liver enzymes elevation with portal hypertension and liver cirrhosis followed by portal vein thrombosis with persistent- ly elevated IgG4, azathioprine & adalimumab were stopped. Goli- mumab started but after 3 infusions,papillary thyroid cancer devel- oped, total thyroidectomy followed by radio iodine. Ulcerativecolitis was treated with vedolizumab with good re- sponse. Liver disease progressed with bleeding varices and portal vein thrombosis with factor Leiden V mutation. IgG4 was high which may high direct or indirect relation to liver cirrhosis, diabetes melli- tus and thyroid cancer. The safety of immunosuppressive & biologic agents in patients with high IgG4 need to be reviewed. Awareness is needed about the relationship between high IgG4 and multiple complex diseases is needed Conclusion: A patient with elevated IgG4, liver cirrhosis, diabetes mellitus, and ulcerative colitis developed skin pigmentation and pap- illary thyroid cancer, the role of IgG4 is questioned. Keywards: Diabetes mellitus; Diseases; IgG4; Liver cirrhosis; Thy- roid cancer