Good's Syndrome: Time to Move on From Reviewing the Past

Pure Red Cell Aplasia in a Patient with Thymic Hyperplasia, Hypogammaglobulinemia and Adult T-cell Leukemia/Lymphoma

Acquired pure red cell aplasia (PRCA), caused by thymic hyperplasia, is extremely rare. We herein report a previously healthy 41-year-old man who presented with severe anemia, lymphadenopathy, an upper mediastinal mass, and hypogammaglobulinemia. The patient was eventually diagnosed with PRCA and adult T-cell leukemia/lymphoma (ATLL). The mediastinal mass was pathologically diagnosed as thymic hyperplasia without clear ATLL invasion. Although his anemia improved rapidly after thymectomy, PRCA recurred approximately 500 days later and was accompanied by ATLL exacerbation. The findings in this patient suggest that the Good's syndrome-like symptoms (thymic hyperplasia and hypogammaglobulinemia) in this patient and PRCA may have been paraneoplastic syndromes caused by ATLL.

Gastrointestinal pathology in Good's syndrome, thinking beyond common variable immunodeficiency: a clinicopathological observation

Good's syndrome (GS) is a rare immunodeficiency associated with thymoma, characterized by increased susceptibility to bacterial, viral, and fungal infections, along with autoimmune manifestations. Gastrointestinal symptoms are common in GS, yet its clinical and histopathological features remain underrecognized. Due to significant overlap in clinical presentation and immunological profiles, GS is frequently misdiagnosed as common variable immunodeficiency (CVID). While gastrointestinal pathology in CVID has been well-documented, data on gastrointestinal manifestations in GS are limited. In this study, we analyzed two cases of GS, both demonstrating marked reduction of plasma cells across multiple gastrointestinal sites, with variable intraepithelial lymphocytosis and mild to moderate villous blunting in the duodenum and features secondary to chronic norovirus infection in one case, and an invasive adenocarcinoma with notable depletion of lamina propria plasma cells in the other. Accurate recognition of GS is essential for pathologists and clinicians, given its poorer prognosis compared to CVID.

Diagnosis of Good Syndrome following Recurrent Coronavirus Disease-2019 Infections

Background

Good syndrome is defined as the co-occurrence of a thymoma and hypogammaglobulinemia.

Case

In this case report, we present a patient who was diagnosed with Good syndrome following recurrent infections with SARS-CoV-2. Of particular note was the patient's repeated presentation despite receiving outpatient treatment with nirmatrelvir-ritonavir. We describe the patient's presentation, diagnosis, and treatment - including robotic thymectomy and passive immunization with IVIG - and report the benefit to quality of life that the patient experienced.

Conclusion

This case highlights the importance of quantitative testing of immunoglobulins in patients with known thymomas who present with recurrent infections of SARS-CoV-2.

Unusual presentation of cytomegalovirus and varicella-zoster virus infection in a patient with good's syndrome: A case report

The co-infection of cutaneous cytomegalovirus (CMV) and varicella-zoster virus (VZV) is a rare occurrence, particularly in the context of Good's syndrome (GS). This report presents a unique case of a 56-year-old man with GS, characterized by a thymoma, who developed cutaneous CMV and VZV co-infections. We discuss the clinical characteristics, diagnostic process, and treatment of this uncommon manifestation. A 56-year-old man with a mediastinal mass identified as thymoma type A and pleural metastasis, presented with a three-week progressive, painful generalized skin lesions on his face, trunk, and extremities. Upon further examination, multiple extensive vesicles with reddened bases were distributed throughout all regions of his body, some exhibited hemorrhagic characteristics. The histopathologic assessment indicated a herpes virus infection and leukocytoclastic vasculitis. Additionally, Immunohistochemistry staining for CMV highlighted infected endothelial cells. The patient was diagnosed with disseminated cutaneous co-infection of CMV and VZV in the context of Good's syndrome. The patient responded well to a treatment regimen combining intravenous immunoglobulin (IVIG) and ganciclovir therapy, leading to the complete resolution of skin lesions. He was recommended prophylactic treatment and showed significant improvement upon follow-up, ultimately being discharged in a favorable clinical condition. By gaining a better understanding of this condition, healthcare professionals can improve their ability to recognize and treat Good's syndrome effectively. Early identification and effective treatment have a crucial role in enhancing the prognosis.

Thymoma with recurrent opportunistic infections-a case report

Good's syndrome (GS) is a rare adult-onset thymoma associated with acquired combined B-cell and T-cell immunodeficiency. It has similarities with Common variable immunodeficiency (CVID) in terms of hypogammaglobulinemia and significant risk of invasive bacterial and opportunistic infections. We still have a long way to go in understanding the pathogenesis of Good's syndrome. Here, we describe a case of a middle-aged female with thymoma and recurrent opportunistic infections. Clinico-laboratory evaluation led to a diagnosis of GS and she showed good response to intravenous immunoglobulin. Clinicians should be aware that thymoma can precede the onset of immunodeficiency.

Oral Diseases as a Manifestation of Inborn Errors of Immunity

Oral findings such as inflammation, ulcerations, or lesions can indicate serious systemic diseases and should prompt suspicion of acquired chronic conditions or inborn errors of immunity (IEIs). Currently, there are approximately 500 disease entities classified as IEIs, with the list expanding annually. The awareness of the existence of such conditions is of paramount importance, as patients with these disorders frequently necessitate the utilization of enhanced diagnostic techniques. This is exemplified by patients with impaired antibody production, in whom conventional serological methods may prove to be undiagnostic. Patients with IEI may require distinct therapeutic approaches or antimicrobial prophylaxis throughout their lives. An accurate diagnosis and, more importantly, early identification of patients with immune deficiencies is crucial to ensure the quality and longevity of their lives. It is important to note that the failure to establish a proper diagnosis or to provide adequate treatment could also have legal implications for medical professionals. The article presents IEIs, which may manifest in the oral cavity, and their diagnosis alongside therapeutic procedures.

Good's syndrome combined with CMV gastroenteritis: A case report and literature review

Key Clinical Message

Good's syndrome (GS) presents with thymoma, hypogammaglobulinemia, and recurrent infection. The manifestations of patients diagnosed with GS and Cytomegalovirus (CMV) gastroenteritis are rare and non-specific. Early diagnosis and treatment can improve the prognosis of the rare disease.

Abstract

Good's syndrome (GS), a rare acquired immunodeficiency condition, is characterized by thymoma, hypogammaglobulinemia, and low peripheral B-lymphocyte count. GS tends to occur in individuals aged 40-60 years, resulting in increased risk of recurrent infections with various conditional pathogenic bacteria, viruses, and fungi. Cytomegalovirus (CMV) can cause pneumonia, retinitis, encephalitis, and enteritis in GS patient, but CMV infection in the alimentary tract is usually underestimated, delayed diagnosed and misdiagnosed. In this study, we reported a female patient with GS and chronic diarrhea due to CMV infection and reviewed the literature to conclude the characteristics of this rare condition to improve the clinical diagnosis and prognosis of CMV gastroenteritis in patients with GS.

Good syndrome and cytomegalovirus retinitis: A literature review

Good syndrome (GS) is a rare primary immunodeficiency in adults consisting of hypogammaglobulinemia and thymoma that affects both cellular and humoral immunity. It usually appears in patients between the 4th and 6th decade of life and affects both genders equally. Ophthalmological clinical presentation is highly variable; associations with herpetic keratitis, toxoplasmosis, and cytomegalovirus retinitis (CMVR) have been described. GS associated with CMVR is uncommon. Ophthalmologists may be the first to diagnose systemic disease and change the outcome. Only18 cases of CMVR have been described, most of them unilateral with poor visual outcomes. We discuss the clinical features of CMVR in patients with reported GS, pathogenesis, and outline a work-up for diagnosis. CMVR in an apparently healthy patient should encourage the clinician to search for human immunodeficiency virus (HIV) and non-HIV-associated immunosuppression.

Autoimmunity in thymic epithelial tumors: a not yet clarified pathologic paradigm associated with several unmet clinical needs

Thymic epithelial tumors (TETs) are rare mediastinal cancers originating from the thymus, classified in two main histotypes: thymoma and thymic carcinoma (TC). TETs affect a primary lymphoid organ playing a critical role in keeping T-cell homeostasis and ensuring an adequate immunological tolerance against "self". In particular, thymomas and not TC are frequently associated with autoimmune diseases (ADs), with Myasthenia Gravis being the most common AD present in 30% of patients with thymoma. This comorbidity, in addition to negatively affecting the quality and duration of patients' life, reduces the spectrum of the available therapeutic options. Indeed, the presence of autoimmunity represents an exclusion criteria for the administration of the newest immunotherapeutic treatments with checkpoint inhibitors. The pathophysiological correlation between TETs and autoimmunity remains a mystery. Several studies have demonstrated the presence of a residual and active thymopoiesis in adult patients affected by thymomas, especially in mixed and lymphocytic-rich thymomas, currently known as type AB and B thymomas. The aim of this review is to provide the state of art in regard to the histological features of the different TET histotype, to the role of the different immune cells infiltrating tumor microenvironments and their impact in the break of central immunologic thymic tolerance in thymomas. We discuss here both cellular and molecular immunologic mechanisms inducing the onset of autoimmunity in TETs, limiting the portfolio of therapeutic strategies against TETs and greatly impacting the prognosis of associated autoimmune diseases.

Unraveling the Natural History of Good's Syndrome: A Progressive Adult Combined Immunodeficiency

BACKGROUND

Good's syndrome (GS) is a rare immune deficiency described almost 6 decades ago. Despite numerous published individual case reports and data collected in cross-sectional studies of small cohorts, the natural history and long-term outcomes of this disease remain unknown.

OBJECTIVE

We aimed to determine the clinical and laboratory evolution of 8 adults diagnosed with GS and consecutively evaluated between 1983 and 2023.

METHODS

In this prospective, longitudinal cohort study, newly diagnosed patients with GS were followed through repeated measures of clinical, immune, and hematologic changes, as well as targeted genetic screening.

RESULTS

All patients reported a healthy childhood and adolescence with symptom onset during the third or fourth decade of life. All presented to our center with recurrent bacterial sinopulmonary infections, thymoma, hypogammaglobulinemia, and absence of B cells. The median age of GS diagnosis was 57 years. During follow-up, immunoglobin replacement therapy effectively minimized sinopulmonary infections. However, the majority experienced severe and systemic viral or fungal infections, 3 developed basal cell carcinomas, and 5 had progressive bronchiectasis and persistent splenomegaly. The most notable clinical feature was opportunistic infections and in vitro evidence of cellular immune deficiency, which resulted in the death of 2 individuals. We also report a statistically significant, multidecade progressive decline in lymphocytes, platelets, hemoglobin, and red blood cells in our cohort, suggesting gradual bone marrow failure.

CONCLUSIONS

Knowledge of the unique phenotype and temporal evolution of GS has allowed us to develop a more comprehensive diagnostic framework. It can be investigated as part of broader research into disease pathophysiology.

Good Syndrome in a Young Woman: An Unusual Presentation

Good Syndrome is a rare disease that comprises the presence of a thymoma, immunodeficiency, and recurrent opportunistic infections. We report the case of a young woman who was diagnosed with Good Syndrome, who had a long-term history of recurrent infections, often due to atypical agents, and who also had a previous history of immunodeficiency and a B1 thymoma invading the large vessels, lung, and pericardium (Masaoka stage IV). She underwent surgical resection of the mediastinal mass, requiring vena cava superior reconstruction due to the extent of invasion, followed by adjuvant radiotherapy and immunoglobulin G supplementation. Despite relative stability in the subsequent years, without serious infections, after three years she had a thymoma recurrence requiring a new therapeutic approach. This case highlights the importance of a thorough investigation of the underlying causes of recurrent infections, which may be the result of an immunodeficiency secondary to malignancy. In young patients, early diagnosis is crucial to avoid disease progression and to reduce mortality rates. To achieve such outcomes, a multidisciplinary team and a comprehensive therapeutic strategy are necessary.

Good's syndrome: brief overview of an enigmatic immune deficiency

Good's syndrome, an infrequent adult-onset immunodeficiency is characterized by the triad of thymoma, hypogammaglobulinemia, and increased susceptibility to recurrent infections. The clinical presentation is highly variable, with a spectrum ranging from recurrent bacterial and opportunistic infections to concomitant autoimmune diseases and, sometimes malignant pathologies. Due to heterogeneous clinical phenotypes and the lack of adequate diagnostic criteria, its recognition is often challenging, even delaying it by years. It is one of the most unusual, less studied form of the immune deficiency syndromes with a still unknown pathophysiology. It was initially considered a thymoma-associated variant of primary antibody deficiencies with a reduced or absent number of mature B cells, but it later emerged that significant defects of T cell-mediated immune functions are the underlying cause of opportunistic infections. On the basis of current evidence, Good's syndrome is evaluated as a distinct acquired form of combined immunodeficiency states and classified as a phenocopy of primary immunodeficiency diseases. Epigenetic and acquired genetic factors can play an ultimate role in its evolution.

In-depth blood immune profiling of Good syndrome patients

Introduction

Good syndrome (GS) is a rare adult-onset immunodeficiency first described in 1954. It is characterized by the coexistence of a thymoma and hypogammaglobulinemia, associated with an increased susceptibility to infections and autoimmunity. The classification and management of GS has been long hampered by the lack of data about the underlying immune alterations, a controversy existing on whether it is a unique diagnostic entity vs. a subtype of Common Variable Immune Deficiency (CVID).

Methods

Here, we used high-sensitive flow cytometry to investigate the distribution of up to 70 different immune cell populations in blood of GS patients (n=9) compared to age-matched CVID patients (n=55) and healthy donors (n=61).

Results

All 9 GS patients displayed reduced B-cell counts -down to undetectable levels (<0.1 cells/μL) in 8/9 cases-, together with decreased numbers of total CD4+ T-cells, NK-cells, neutrophils, and basophils vs. age-matched healthy donors. In contrast, they showed expanded TCRγδ+ T-cells (p ≤ 0.05). Except for a deeper B-cell defect, the pattern of immune cell alteration in blood was similar in GS and (age-matched) CVID patients. In depth analysis of CD4+ T-cells revealed significantly decreased blood counts of naïve, central memory (CM) and transitional memory (TM) TCD4+ cells and their functional compartments of T follicular helper (TFH), regulatory T cells (Tregs), T helper (Th)2, Th17, Th22, Th1/Th17 and Th1/Th2 cells. In addition, GS patients also showed decreased NK-cell, neutrophil, basophil, classical monocyte and of both CD1c+ and CD141+ myeloid dendritic cell counts in blood, in parallel to an expansion of total and terminal effector TCRγδ+ T-cells. Interestingly, those GS patients who developed hypogammaglobulinemia several years after the thymoma presented with an immunological and clinical phenotype which more closely resembled a combined immune humoral and cellular defect, with poorer response to immunoglobulin replacement therapy, as compared to those in whom the thymoma and hypogammaglobulinemia were simultaneously detected.

Discussion

Our findings provide a more accurate definition of the immune cell defects of GS patients and contribute to a better discrimination among GS patients between those with a pure B-cell defect vs. those suffering from a combined immunodeficiency with important consequences on the diagnosis and management of the disease.

Impaired Seroconversion After Severe Acute Respiratory Syndrome Coronavirus 2 mRNA Vaccine in Patients With Thymic Epithelial Tumors

INTRODUCTION

Thymic epithelial tumors (TETs) are rare malignancies associated with dysregulation of the immune system and humoral- and cell-mediated immunity abnormalities. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine is effective in preventing coronavirus disease 2019 morbidity and mortality. The aim of this study was to evaluate the seroconversion in patients with TET after two doses of mRNA vaccine.

METHODS

This is a prospective study in which consecutive patients with TET were enrolled before receiving the first dose of SARS-CoV-2 mRNA vaccine (BNT162b2 by Pfizer-BioNTech). SARS-CoV-2 spike-binding immunoglobulin (Ig)G antibody serologic levels were analyzed at different time points, including before first vaccine dose (T0), 1 month after the second dose (T2), and 3 months after the second dose (T3).

RESULTS

Overall, 39 patients were included in the analysis. All patients had negative antibody titer results at T0. There were 19 patients (48.7%) in the follow-up with no residual tumor lesion/s (referred as no evidence of disease), and 20 (51.3%) had evidence of disease (ED) and were receiving systemic treatment. Dysregulations of the immune system were diagnosed in 29 patients (74.4%) with Good syndrome (GS) being the most frequent immune disorder (48.7%). At univariate analysis, lack of seroconversion at T2 was significantly associated with ED (p < 0.001) and with GS (p = 0.043). A significant association with impaired seroconversion was confirmed at multivariate analysis for ED (p = 0.00101) but not for GS (p = 0.625).

CONCLUSIONS

Our data revealed that patients with TET with ED had substantially higher probability of impaired seroconversion after SARS-CoV-2 mRNA vaccine as compared with patients with no evidence of disease.

[Good syndrome: a rare, unusual immunodeficiency condition]

Good syndrome is an infrequent and unique clinical entity of associated thymoma and immunodeficiency, first described almost 70 years ago. It is characterized by increased susceptibility to recurrent invasive bacterial and opportunistic infections as well as autoimmune and malignant diseases with an omnious prognosis. The affected patients are mainly middle-aged persons. The most consistent immunological abnormalities are hypogammaglobulinemia and reduced/absent B cells. More recently it was classified as an acquired combined (T, B) immunodeficiency and labelled as a phenocopy. This complex immunocompromised condition can lead to heterogenous clinical phenotypes, making the diagnosis rather challenging. The thymoma is mainly benign, and an incidental finding. Since the thymus plays a critical role in the development of the immune system, the altered tissue structure and microenvironment in thymoma can both predispose to manifestation of immunodeficiency and autoimmunity. The etiopathogenesis of the disease is still unclear, but it is assumed that epigenetic and acquired genetic factors can be highly responsible for its evolvement. Currently there is no specific therapy for Good syndrome. In addition to thymectomy, control of infections, possibly secondary prevention, and regular immunoglobulin replacement are recommended. Orv Hetil. 2023; 164(22): 859-863.

Insights from a Case of Good's Syndrome (Immunodeficiency with Thymoma)

Immunodeficiency with thymoma was described by R.A. Good in 1954 and is also named after him. The syndrome is characterized by hypogammaglobulinemia associated with thymoma and recurrent infections, bacterial but also viral, fungal and parasitic. Autoimmune diseases, mainly pure red cell aplasia, other hematological disorders and erosive lichen planus are a common finding. We describe here a typical case exhibiting all these clinical features and report a detailed immunophenotypic assessment, as well as the positivity for autoantibodies against three cytokines (IFN-alpha, IL-6 and GM-CSF), which may add to known immune abnormalities. A review of the published literature, based on case series and immunological studies, offers some hints on the still unsolved issues of this rare condition.

Cellular mechanisms and clinical applications for phenocopies of inborn errors of immunity: infectious susceptibility due to cytokine autoantibodies

INTRODUCTION

With a growing knowledge of Inborn error immunity (IEI), immunological profiling and genetic predisposition to IEI phenocopies have been developed in recent years.

AREAS COVERED

Here we summarized the correlation between various pathogen invasions, autoantibody profiles, and corresponding clinical features in the context of patients with IEI phenocopies. It has been extensively evident that patients with anti-cytokine autoantibodies underly impaired anti-pathogen immune responses and lead to broad unregulated inflammation and tissue damage. Several hypotheses of anti-cytokine autoantibodies production were summarized here, including a defective negative selection of autoreactive T cells, abnormal germinal center formation, molecular mimicry, HLA class II allele region, lack of auto-reactive lymphocyte apoptosis, and other possible hypotheses.

EXPERT OPINION

Phenocopies of IEI associated with anti-cytokine autoantibodies are increasingly recognized as one of the causes of acquired immunodeficiency and susceptibility to certain pathogen infections, especially facing the current challenge of the COVID-19 pandemic. By investigating clinical, genetic, and pathogenesis autoantibodies profiles associated with various pathogens' susceptibilities, we could better understand the IEI phenocopies with anti-cytokine autoantibodies, especially for those that underlie life-threatening SARS-CoV-2.

Good's syndrome and COVID-19: case report and literature review

Background

Good's syndrome (GS) is an adult-onset acquired immunodeficiency, in which patients present with thymoma and hypogammaglobulinemia (HGG). GS is characterized by low to absent peripheral B cells and impaired T-cell mediated immunity, often resulting in various (opportunistic) infections and concurrent autoimmune disorders. In this case report, we present a case of a patient with GS and coronavirus disease 2019 (COVID-19) infection after surgical removal of a thymoma. The simultaneous occurence of these two entities is extremely rare.

Case Description

A 55-year-old man presented with oral lichen planus and cutaneous lesions. Additional symptoms included a weight loss of 5 kilograms in the last six months. Computed tomography (CT) and positron emission tomography (PET) of the chest showed a large anterior mediastinal mass with a maximum diameter of 10 centimetres. A core needle biopsy was performed, which led to a pathological diagnosis of thymoma type AB. In addition to these earlier findings, laboratory analysis revealed HGG. The combination of a thymoma and HGG led to a diagnosis of GS. Induction chemotherapy with cisplatin-etoposide was started, however, the patient developed COVID-19 after 2 cycles. Treatment with remdesivir was initiated and, subsequently, a thymectomy via sternotomy was performed. Final pathology confirmed a thymoma type AB of 14 centimetres, fully encapsulated, and without invasion. Resection margins were negative and the tumour was classified as pT1aN0, R0 resection. The patient has received immunoglobulin treatments every 4 weeks for his GS and has not developed any new infections since the start of this therapy.

Conclusions

Patients with GS are prone to developing (pulmonary) infections. Clinicians should be aware of the possible clinical effects of COVID-19 infections in this patient population.

Relapsing cellulitis associated with Campylobacter coli bacteremia in a Good’s syndrome patient: a case report

Background

Good’s syndrome (GS) is characterized by immunodeficiency, and patients diagnosed with GS are susceptible to infection or even bacteremia, which is the most evident complication. Campylobacter coli (C. coli) rarely causes bacteremia or extraintestinal infection. We report herein a case with GS in which right leg cellulitis associated with C. coli bacteremia occurred three times over one and a half years.

Case presentation

A 41-year-old Chinese male with GS was diagnosed with C. coli infection. He presented with swelling and redness of right lower leg and developed bacteremia due to C. coli repeatedly. Bacteremia was confirmed by bacteriological examination. Adding long-term oral antibiotic treatment with amoxicillin/clavulanate potassium and gentamicin following intravenous meropenem and amikacin was very effective. The blood cultures became negative and the patient has been free from any symptoms encountered for more than one year without relapse of bacteremia.

Conclusions

Patients with GS and their physicians should carefully consider the antibacterial treatment options against C. coli bacteremia. Combined anti-infective therapy involving aminoglycoside is preferred in the treatment of C. coli bacteremia in GS patients.