Immunoglobulin G4 related disease (IgG4-RD) is a rare multisystem inflammatory disease, in which one of the main gastrointestinal manifestations is autoimmune pancreatitis (AIP) type 1. AIP type 1 is correlated with a clinical presentation of obstructive jaundice, increased serum levels of IgG4 and suggestive pancreatic findings on radiologic imaging. Histo-pathology (HP) and immune-histochemistry (IHC) examinations obtained by biopsy are the gold standard for establishing the diagnosis. Several theories tried to elucidate the correlation between IgG4-RD and pancreatic or other extra-pancreatic malignancies. There are controversial opinions whether AIP type 1 serves as a premalignant state, or whether these two conditions are coexistent. We present a patient who had clinical, laboratory, radiologic and histologic findings that were consistent with a pancreatic space occupying lesion (SOL). As a result, he underwent a Whipple operation, but the IHC findings were compatible with AIP type 1. After 1 year of remission, the patient presented with a new pancreatic SOL that was diagnosed as adenocarcinoma.

Abstract Aim: To investigate the health care utilization and drug consumption of patients with fibromyalgia (FM). Materials and Methods: This is a cross-sectional study using the Clalit Health Care database. Clalit is the largest HMO in Israel, serving more than 4.4 million enrollees. We identified FM patients and age and sex-matched controls. Indicators of healthcare utilization and drug consumption were extracted and analyzed for both groups. Results: The study included 14,296 FM patients and 71,324 controls. The mean age was 56 years, with a female predominance of 92%. The mean number of visits across of all healthcare services (hospitalizations, emergency department visit, general practitioner clinic visits, rheumatology clinic visits and pain clinic visits) and the mean difference (MD) were significantly higher for FM patients compared to controls (MD 0.66, p<0.001; MD 0.23, p<0.001; MD 7.49, p<0.001; MD 0.31, p<0.001; MD 0.13, p<0.001), respectively. Drug use was significantly and consistently higher among FM patients compared to controls; NSAIDs (non-steroidal anti-inflammatory drugs) OR 2.56, P<0.001; Opioids OR 4.23, P<0.001; TCA (tricyclic antidepressants) OR 8.21, P<0.001; Gabapentinoids OR 6.31, P<0.001; SSRI (selective serotonin reuptake inhibitors) OR 2.07, P<0.001; SNRI (serotonin-norepinephrine reuptake inhibitor) OR 7.43, P<0.001. Conclusion: Healthcare utilization and drug use are substantially higher among patients with fibromyalgia compared to controls

Background: Fever of unknown origin (FUO) is a diagnostic challenge. Positron emission tomography with computed tomography (PET/CT) is expensive and not widely available. We aimed to evaluate the diagnostic yield of PET/CT in the workup of FUO, and identify the patients for whom this test is most useful. Methods: We reviewed the records of all patients admitted to Sheba Medical Center from 2013 to 2017 who were underwent PET/CT for the evaluation of FUO. Results: Of the 128 patients included, PET/CT was helpful in revealing the cause of FUO in 61 (48%). A final diagnosis was made in 95 (74%) patients. Of the 128 PET/CT tests conducted for the workup of FUO, 61 (48%) had true positive results, 25 (20%) false positive results, 24 (19%) true negative results, and 18 (14%) false negative results. In a multivariate analysis, helpfulness of PET/CT was independently associated with weight loss and low hemoglobin. The calculated test sensitivity was 77%, specificity was 49%, positive predictive value was 71% and negative predictive value was 57%. Conclusion: PET/CT is valuable in the diagnostic workup of FUO. When used as a complementary test, it was helpful in diagnosing almost half the patients, and especially in those with low hemoglobin and weight loss.

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease that leads to joint destruction and disability. Despite a significant progress in administration of biological agents for RA patients, there is still a need for improved therapy. Intravenous-immunoglobulins (IVIG) , a pooled polyspecific immunoglobulin-G (IgG) extracted from 20,000 healthy subjects, showed beneficial therapeutic effect in patients with immune-deficiency, sepsis, and autoimmune diseases. The current study aim to investigate the beneficial effect of treatment with IVIG in established collagen induced arthritis in DBA/1j mice. Murine arthritis was induced in DBA/1j mice. The treatment with IVIG started when the disease was established. The clinical score was followed twice a week until day 48. The mice were bled for plasma, the paws were H&E stained. Cytokine profile in the plasma was analyzed by Luminex technology, titers of circulating anti-collagen antibodies in the plasma was tested by ELISA. Our results show that treatment with IVIG in murine, significantly rreduced the clinical arthritis score (P<0.001). Moreover, mode of action show that IVIG significantly reduced circulating level of inflammatory cytokines (IFN, IL-1β, IL-17, IL-6, TNFα) (P<0.001), inhibit anti-collagen antibodies (P < 0.001) in the plasma of CIA mice. Importantly, histopathological examination revealed that IVIG treatment prevented the migration of inflammatory immune cells into the cartilage and synovium, reduced the extent of joint damage and preserved joint architecture. Our results proved for the first time the valuable anti-inflammatory treatment of IVIG in experimental RA. We propose IVIG therapy for a subgroup of patients with as rheumatological-related diseases.