# IgG4-Related Disease of Mastoid Presenting as Headache: A Case Report

## TL;DR

A rare case of IgG4-related disease presented as headache and was successfully treated with surgery and steroids.

## Contribution

This case report highlights IgG4-related disease as a differential diagnosis for persistent middle ear symptoms.

## Key findings

- The patient's symptoms were caused by IgG4-related mastoiditis, pachymeningitis, and cerebral venous thrombosis.
- Histopathology confirmed IgG4-related disease with plasma cell-rich inflammation and storiform fibrosis.
- The patient responded well to surgical intervention and steroid treatment.

## Abstract

IgG4-related disease (IgG4-RD) is a complex multi-system inflammatory disorder that can affect various organs in the body. This condition is characterized by elevated levels of immunoglobulin G subclass 4 (IgG4) and the presence of specific histopathological features. While neurological involvement is not as common as in other organs, when it occurs, it can lead to hypertrophic pachymeningitis and hypophysitis.

Here, we present a case of a 53-year-old male with right-sided hemicranial headache and diplopia. Computed tomography revealed a soft tissue density lesion in the middle ear cavity and mastoid antrum with the destruction of the mastoid septae. Magnetic resonance imaging revealed a lesion in the right middle ear cavity associated with pachymeningitis and right sigmoid and transverse sinus thrombosis. Tissue pathology revealed dense plasma cell-rich chronic inflammation with storiform fibrosis. Immunohistochemistry was positive for IgG4. Hence, a diagnosis of IgG4-related disease causing mastoiditis, pachymeningitis and cerebral venous thrombosis was made. The patient was successfully operated and treated with steroids. IgG4-RD remains a rare but serious condition. It is crucial to identify and treat this condition promptly as it can lead to permanent organ damage. When patients continue to experience middle ear symptoms after an infection has been treated and cancer has been ruled out, it is important to consider inflammatory conditions as a differential diagnosis.