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Hashiro W, Miyashita A, Kawaji-Kanayama Y, Okamoto H, Fujino T, Tsukamoto T, Mizutani S, Shimura Y, Kuroda J. Good's Syndrome With Pure Red Cell Aplasia and Subclinical Myasthenia Gravis: A Case Report and Review of Literature. Cureus 2024; 16:e59654. [PMID: 38836142 PMCID: PMC11147683 DOI: 10.7759/cureus.59654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2024] [Indexed: 06/06/2024] Open
Abstract
Good's syndrome is a pathologic condition characterized by thymoma and immunoglobulin disorder. Here, we report a rare case of a patient with Good's syndrome with simultaneous pure red cell aplasia (PRCA) and subclinical myasthenia gravis with detectable serum anti-acetylcholine receptor antibody (AChR Ab). While thymectomy did not result in the improvement of any paraneoplastic syndromes, cyclosporine A (CsA) treatment successfully improved PRCA; however, hypoglobulinemia was not recovered, and anti-AchR Ab did not disappear by CsA treatment in our case. A review of the literature on simultaneous Good's syndrome with PRCA also suggested the efficacy of CsA on PRCA but not hypoglobulinemia, suggesting the distinct underlying mechanisms between these two paraneoplastic symptoms with thymoma. Future research is needed to understand the mechanism underlying this rare pathologic condition and to generate appropriate treatment.
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Affiliation(s)
- Wakana Hashiro
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Akihiro Miyashita
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Yuka Kawaji-Kanayama
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Haruya Okamoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Takahiro Fujino
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Taku Tsukamoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Shinsuke Mizutani
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, JPN
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2
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Zhao J, Bhatnagar V, Ding L, Atay SM, David EA, McFadden PM, Stamnes S, Lechtholz-Zey E, Wightman SC, Detterbeck FC, Kim AW. A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases. J Thorac Cardiovasc Surg 2019; 160:306-314.e14. [PMID: 31982129 DOI: 10.1016/j.jtcvs.2019.11.052] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Paraneoplastic syndromes associated with thymomas remain incompletely understood. The objective was to examine the association between surgically resected thymomas and paraneoplastic syndromes over the past half century. METHODS A primary PubMed/MEDLINE search was used to identify published articles describing paraneoplastic syndromes associated with thymomas from 1960 to 2019. A secondary search identified additional articles referenced in the articles found in the primary search. Kaplan-Meier and log-rank test were used for time-to-event data analyses. RESULTS From 407 articles describing 507 patients, 123 different paraneoplastic syndromes were associated with thymoma. The 5 most common paraneoplastic syndromes were myasthenia gravis, pure red cell aplasia, lichen planus, Good syndrome, and limbic encephalitis. Complete or partial resolution of paraneoplastic syndrome symptoms after surgery was noted in 76% of patients, of whom 21% had a relapse or new paraneoplastic syndrome onset after surgery. The most common adjunctive therapy associated with resolution of paraneoplastic syndrome was corticosteroids (30%). For all patients after surgery, thymoma recurrence was observed in 17% of cases, whereas recurrence of paraneoplastic syndrome was observed in 34% of cases, and both were observed in approximately 11% of cases. The 5- and 10-year overall survivals were 78% and 66%, respectively. Improved overall survival was associated with patients who had total resolution from paraneoplastic syndrome. CONCLUSIONS A comprehensive assessment of publications over the past half century suggests that a multimodal treatment approach that includes surgical resection of thymomas is able to achieve paraneoplastic syndrome resolution in a majority of patients. Onset of new paraneoplastic syndromes after surgery is associated with the recurrence of the first paraneoplastic syndrome, and resolution of paraneoplastic syndrome is associated with improved overall survival.
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Affiliation(s)
- Jasmine Zhao
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Vikrant Bhatnagar
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Li Ding
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Scott M Atay
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Elizabeth A David
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - P Michael McFadden
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Stephanie Stamnes
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | | | - Sean C Wightman
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | | | - Anthony W Kim
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
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Wightman SC, Shrager JB. Non-Myasthenia Gravis Immune Syndromes and the Thymus: Is There a Role for Thymectomy? Thorac Surg Clin 2019; 29:215-225. [PMID: 30928003 DOI: 10.1016/j.thorsurg.2018.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Thymectomy has long been considered, performed, and discussed for many different nonmyasthenic immune syndromes. Thymectomy is now an established treatment for MG, and has been performed for other immune syndromes with varying degrees of improvement. Although numerous reports document immune syndromes' association with thymoma, few address the role of thymectomy in symptom resolution. This review assesses thymectomy in the various nonmyasthenic immune syndromes for which it has been tried. Based on this review, it seems appropriate to revisit a more active role for thymectomy in pure red cell aplasia, pemphigus, rheumatoid arthritis, autoimmune hemolytic anemia, and ulcerative colitis.
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Affiliation(s)
- Sean C Wightman
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Hospitals and Clinics, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Hospitals and Clinics, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Solano-Genesta M, Lome-Maldonado C, Orozco-Pelayo A, Morgan-Villela G, Zuloaga-Fernández del Valle C, Cortés-Flores A, García-González L, Miranda-Ackerman R, Carballo-Uribe A, Morgan-Ochoa E, Navarro-Fernández C, Rubio-Macías F, González-Ojeda A. Good syndrome associated with pure red cell aplasia in a patient with a history of thymoma: A case report and literature review. MEDICINA UNIVERSITARIA 2017. [DOI: 10.1016/j.rmu.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Muzamil J, Shiekh AA, Bhat GM, Lone AR, Bhat S, Nabi F. Thymoma masquerading as transfusion dependent anemia. Indian J Med Paediatr Oncol 2017; 37:296-299. [PMID: 28144099 PMCID: PMC5234169 DOI: 10.4103/0971-5851.195729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a known entity in clinical medicine. Patients are often transfusion dependent for their whole life. Ascertaining its etiology is always a herculean task. We received a similar transfusion-dependent patient, who on evaluation was found to have thymoma as an etiological factor. Thymoma presenting as PRCA is seen in 2%–5% patients and evaluating PRCA for thymoma is seen in 5%–13% patient. As per the WHO histopathological classification, thymoma has six types and Type A is associated with PRCA and Type B is associated with myasthenia gravis. This correlation was not seen in our patient, who had Type B thymoma. Surgical resection of thymus improves 30% of PRCA and rest needs immunosuppression. Our patient was not the surgical candidate, and hence he was put on chemotherapy.
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Affiliation(s)
- Javvid Muzamil
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Aejaz Aziz Shiekh
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Gull Mohammad Bhat
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Lone
- Department of Medical Oncology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shuaeb Bhat
- Department of Clinical Hematology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Firdousa Nabi
- Department of Prosthodonsia, Government Dental College, Srinagar, Jammu and Kashmir, India
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Kim SY, Kim JH, Hwang HW, Kim KY, Park S, Hwang YI, Jang SH, Jung KS. Opportunistic lung infections as a manifestation of Good's syndrome. ALLERGY ASTHMA & RESPIRATORY DISEASE 2015. [DOI: 10.4168/aard.2015.3.5.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Suk Yeon Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ha Won Hwang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kwang Youn Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sunghoon Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Young Il Hwang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Seung Hun Jang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ki-Suck Jung
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Antar AI, Otrock ZK, Kharfan-Dabaja MA, Mahfouz RA, Alameddine RS, El-Majzoub NMW, Salem ZM. Thymoma with Concomitant Pure Red Cell Aplasia, Good's Syndrome and Myasthenia Gravis Responding to Rituximab. Indian J Hematol Blood Transfus 2014; 32:219-22. [PMID: 27408396 DOI: 10.1007/s12288-014-0478-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 11/19/2014] [Indexed: 11/27/2022] Open
Abstract
Thymomas are often associated with a variety of autoimmune diseases, mostly myasthenia gravis. The association of thymomas with both pure red cell aplasia (PRCA) and Good's syndrome is exceedingly rare. To the best of our knowledge, the combination of a thymoma with manifestations of myasthenia gravis, PRCA, and Good's syndrome, as in our case herein, has not been described before in the medical literature. We present a 90-year-old man initially diagnosed with an asymptomatic thymoma. Later, he developed generalized muscle weakness and was found to have severe anemia. He was diagnosed with PRCA, myasthenia gravis and Good's syndrome. He responded to rituximab with restoration of bone marrow erythroid maturation and stabilization of red blood cell counts.
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Affiliation(s)
- Ahmad I Antar
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Zaher K Otrock
- Department of Pathology and Immunology, Barnes-Jewish Hospital, Washington University, St. Louis, MO USA
| | | | - Rami A Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Raafat S Alameddine
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Nadim M W El-Majzoub
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad M Salem
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
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Thongprayoon C, Tantrachoti P, Phatharacharukul P, Buranapraditkun S, Klaewsongkram J. Associated Immunological Disorders and Cellular Immune Dysfunction in Thymoma: A Study of 87 Cases from Thailand. Arch Immunol Ther Exp (Warsz) 2012; 61:85-93. [DOI: 10.1007/s00005-012-0207-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 09/21/2012] [Indexed: 02/07/2023]
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Myelodysplasia followed by Good's Syndrome: a unique manifestation associated with thymoma. Kaohsiung J Med Sci 2012; 28:236-40. [PMID: 22453074 DOI: 10.1016/j.kjms.2011.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 02/16/2011] [Indexed: 11/24/2022] Open
Abstract
Good's syndrome, also known as thymoma with combined immunodeficiency, is rare. The immunodeficiency may precede, arise concurrently with or follow the diagnosis of thymoma. In addition to myasthenia gravis and Good's syndrome, paraneoplastic syndromes associated with thymoma can also be manifested with hematological disorders, such as pure red cell aplasia, aplastic anemia, agranulocytosis, hemolytic anemia, pernicious anemia, and paroxysmal nocturnal hemoglobinuria. Myelodysplastic syndrome is a group of clonal hematopoietic stem cell diseases characterized by cytopenia(s), dysplasia in one or more lineages, ineffective hematopoiesis, and potential precursors of acute leukemia. One proposed pathogenesis of myelodysplasia is autoantibodies that directly reject against hematopoietic cells, but this situation is rare in thymoma. Herein, we report a thymoma patient with unique paraneoplastic syndromes who developed myelodysplasia prior to Good's syndrome. Early and accurate diagnosis of myelodysplastic syndrome is important for disease management, especially in patients whose myelodysplastic syndrome is possibly derived from autoimmunity. For thymoma patients with recurrent infections, comprehensive immunologic studies to exclude the possibility of Good's syndrome and prophylactic intravenous immunoglobulin infusion in suitable candidates are warranted.
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Kelesidis T, Yang O. Good's syndrome remains a mystery after 55 years: A systematic review of the scientific evidence. Clin Immunol 2010; 135:347-63. [PMID: 20149753 DOI: 10.1016/j.clim.2010.01.006] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Accepted: 01/17/2010] [Indexed: 11/17/2022]
Abstract
Good syndrome (GS) is a rare association of thymoma and immunodeficiency first described more than 50 years ago. However, this syndrome still remains a mystery to clinicians. We systematically reviewed all the clinical, laboratory and immunologic findings from 152 patients with Good syndrome. The syndrome has a worldwide distribution and approximately half of the cases (47%) have been described in Europe. The diagnosis of thymoma preceded the diagnosis of hypogammaglobulinemia, infection, or diarrhea in 42% of patients whereas in 38% of patients the diagnoses were made almost simultaneously within 2 months of each other. We found significant mortality in patients with this syndrome (44.5%). Astute clinical acumen and increased awareness about the clinical and immunological profile of this syndrome may increase early recognition of this syndrome and prevent mortality. Further studies are needed to elucidate this clinical entity.
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Affiliation(s)
- Theodoros Kelesidis
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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11
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de Jesus NPF, Carvalho PMS, Dias FMG, Gaspar EMF, de Moura JJA. Dementia in a patient with Thymoma and hypogammaglobulinaemia (Good's syndrome). CASES JOURNAL 2008; 1:90. [PMID: 18700970 PMCID: PMC2527547 DOI: 10.1186/1757-1626-1-90] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 08/13/2008] [Indexed: 11/18/2022]
Abstract
Good's syndrome is extremely rare and refers to an acquired B and T cell immunodeficiency in thymoma patients. The authors of this article present a case report of a 75-year-old, caucasian male patient previously subjected to examinations for secondary dementia and recurrent infections, which revealed paraneoplastic syndrome arose from thymoma. He underwent thymectomy, while his immunodeficiency syndrome sustained with frequent opportunistic infections, constantly requiring intravenous immunoglobulin treatment.
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Affiliation(s)
- Nelson Pedro Ferreira de Jesus
- Hospitais da Universidade Coimbra, Serviço de Medicina II, Av, Bissaya Barreto e Praceta Prof, Mota Pinto, 3000-075, Coimbra, Portugal.
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