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Kobza A, Keenan M, Ivory C. Mixed connective tissue disease after thymectomy in refractory myasthenia gravis. Rheumatol Int 2021; 42:2077-2084. [PMID: 34432146 DOI: 10.1007/s00296-021-04976-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
Connective tissue diseases, including systemic lupus erythematosus (SLE) and systemic sclerosis are classic models of autoimmunity; diseases with large-scale loss of tolerance and subsequent development of pathogenic autoreactive lymphocytes and tissue targeting autoantibodies. Here we report a case of mixed connective tissue disease, with features of systemic lupus erythematosus and systemic sclerosis developing in a patient 10 years post thymectomy for myasthenia gravis. The patient developed acute cutaneous lupus, Raynaud's with digital ulcers, arthritis and lymphopenia. Her myasthenia continued to be resistant to treatment and her rheumatic disease progressed despite aggressive therapy. We performed a database search of MEDLINE, EMBASE, Scopus, and Web of Science for articles of similar cases post thymectomy from inception to August 2021, using the terms "systemic lupus erythematosus" (or systemic sclerosis, or connective tissue disease) and "myasthenia gravis" and "thymectomy". We identified 41 cases, 28 of SLE post thymectomy, 8 related to systemic sclerosis, 5 with mixed connective tissue disease and highlighted their different presentation and serology. We explore the role of the thymus, tolerance and myasthenia gravis in the development of connective tissue disease. This highlights the complexity of concurrent autoimmune diseases and their autoantibodies.
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Affiliation(s)
- Alexandra Kobza
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Marissa Keenan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Rheumatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Catherine Ivory
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Division of Rheumatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Mollaeian A, Haas C. A tale of autoimmunity: thymoma, thymectomy, and systemic lupus erythematosus. Clin Rheumatol 2020; 39:2227-2234. [PMID: 32277368 PMCID: PMC7295737 DOI: 10.1007/s10067-020-05061-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022]
Abstract
The thymus plays an integral role in immune system regulation, modulating the development, diversity, and selection of T lymphocytes, a critical feature for the prevention of T cell-mediated autoimmunity. Thymoma is a rare tumor of the thymus. Autoimmune diseases and paraneoplastic syndromes such as myasthenia gravis, pure red blood cell aplasia, and systemic lupus erythematosus, although relatively uncommon, have been described in association with thymomas. Rare cases of post-thymectomy autoimmune related diseases, including systemic lupus erythematosus and pure red cell aplasia, have been reported in the literature. Here, we present the case of a 65-year-old male who developed systemic lupus erythematosus 2 years after thymectomy in the setting of thymoma-associated pure red cell aplasia.
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Affiliation(s)
- Arash Mollaeian
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.
| | - Christopher Haas
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.,Georgetown University School of Medicine, Washington, DC, USA
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Iijima T, Hoshino J, Takaichi K, Kohno T, Fujii T, Ohashi K, Ubara Y. Lupus Nephritis with Thymoma Managed by Thoracoscopic Surgery and Prednisolone. Intern Med 2017; 56:3311-3316. [PMID: 29249764 PMCID: PMC5790719 DOI: 10.2169/internalmedicine.8966-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 48-year-old woman was admitted to our hospital to undergo evaluation for fatigue, severe weight loss, and nephrotic range proteinuria. Light microscopy of a renal biopsy specimen revealed class III (A) lupus nephritis, while immunofluorescence and electron microscopy only showed sparse immune deposits with findings that were not typical of lupus nephritis. Computed tomography revealed a mass in the anterior mediastinum, which was resected. The examination of the surgical specimen revealed type A noninvasive thymoma. In combination with thymomectomy, postoperative steroid therapy achieved the prompt remission of lupus nephritis. In this patient, thymoma-related autoimmunity may have contributed to the exacerbation of lupus nephritis.
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Affiliation(s)
| | | | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tadashi Kohno
- Department of Chest Surgery, Toranomon Hospital, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Pathology, Yokohama City University, Graduate School of Medicine, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
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Abe K, Takahashi A, Sato Y, Okai K, Katsushima F, Monoe K, Kanno Y, Saito H, Ohira H. Case of idiopathic portal hypertension complicated with autoimmune hepatitis. Hepatol Res 2013; 43:984-90. [PMID: 23675841 DOI: 10.1111/hepr.12038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 11/28/2012] [Accepted: 11/30/2012] [Indexed: 12/23/2022]
Abstract
We report a case of idiopathic portal hypertension (IPH) complicated with autoimmune hepatitis. A 60-year-old woman was admitted to our hospital with esophageal and gastric varices in February 2010. Abdominal ultrasonography and computed tomography showed splenomegaly and collateral veins without evidence of liver cirrhosis. Laboratory examinations and liver biopsy indicated that the esophageal and gastric varices were caused by IPH. She underwent endoscopic injection sclerotherapy and partial splenic embolization. Two years after these therapies, laboratory examinations showed liver dysfunction with elevated levels of aspartate aminotransferase (180 IU/L), alanine aminotransferase (190 IU/L), γ-glutamyl transpeptidase (159 IU/L) and immunoglobulin G (2609 mg/dL). The titer of antinuclear antibodies was 1:320 and its pattern was homogeneous and speckled. Histological examination revealed plasma cell/lymphocyte infiltration and interface hepatitis in the portal tract. Based on these findings, a diagnosis of autoimmune hepatitis accompanied by IPH was made. After treatment with prednisolone (20 mg/day), liver functions were normalized immediately. Overlapping of IPH and AIH is extremely rare, but the present case is interesting considering the etiology of IPH because an autoimmune mechanism is thought to be involved in the pathogenesis of IPH.
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Affiliation(s)
- Kazumichi Abe
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
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Agrawal M, Rahmani R, Nakkala K, Fiel MI, Schiano T. Hepatoportal sclerosis (obliterative portal venopathy) and nodular regenerative hyperplasia in a patient with myasthenia gravis: A case report and review of the published work. Hepatol Res 2013; 43:999-1003. [PMID: 23675894 DOI: 10.1111/hepr.12045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 11/29/2012] [Accepted: 12/13/2012] [Indexed: 12/14/2022]
Abstract
Nodular regenerative hyperplasia (NRH) and hepatoportal sclerosis, also known as obliterative portal venopathy (OPV), are two causes of non-cirrhotic portal hypertension (NCPH). NCPH is an increasingly recognized entity that can be seen in association with collagen vascular diseases and with the use of medications such as azathioprine and didanosine, but oftentimes the etiology remains unidentified. We herein report a case of NCPH occurring due to OPV and NRH in a 64-year-old woman with myasthenia gravis (MG), status post-thymectomy. Portal hypertension was diagnosed incidentally on computed tomography in the absence of predisposing factors. Extensive work-up to determine the etiology of any underlying liver disease was unrevealing. NRH and OPV were identified on liver biopsy. Subsequently, the patient had variceal bleeding that necessitated transjugular intrahepatic portosystemic shunt placement. A few similar cases of NCPH occurring in the setting of MG have been previously reported, suggesting that the immunological mechanisms involved in the pathogenesis of myasthenia may also have contributed to the development of NCPH.
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Affiliation(s)
- Manasi Agrawal
- Department of Internal Medicine, Division of Gastroenterology, Maimonides Medical Center, Brooklyn
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The association of systemic lupus erythematosus and myasthenia gravis: a series of 17 cases, with a special focus on hydroxychloroquine use and a review of the literature. J Neurol 2011; 259:1290-7. [PMID: 22160434 DOI: 10.1007/s00415-011-6335-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/16/2011] [Accepted: 11/17/2011] [Indexed: 01/19/2023]
Abstract
The coexistence of systemic lupus erythematosus (SLE) and myasthenia gravis (MG) is rarely reported, and most of the published studies are case reports. Hydroxychloroquine, an antimalarial agent, is an essential treatment in patients with SLE but special caution is recommended when used in MG patients. We retrospectively analyzed the clinical features, laboratory findings, and outcome of 17 patients with both diseases with a special focus regarding hydroxychloroquine use and with a review of the literature. All patients were women. The mean age at MG onset and SLE diagnosis was 34.5 [14-64] and 37.8 [18-72] years, respectively. The presenting symptoms of MG were limb weakness (94%), ocular (88%) and bulbar involvement (53%). Autoantibodies against the acetylcholine receptor were positive in 94% of cases. The main manifestations of SLE included arthritis (88%), cytopenias (53%) and skin rash (41%). Treatment of SLE required hydroxychloroquine (94%), steroids (47%) and immunosuppressive drugs (18%). Among eight patients (47%) who developed MG after initiation of hydroxychloroquine, the question of induction of MG by hydroxychloroquine was raised in one patient. On the other hand, an exacerbation of myasthenic symptoms was only seen in one of the eight patients who received hydroxychloroquine after the diagnosis of MG. Including our cases, we reviewed a total of 70 patients with SLE and MG. Compared with a large series of 1,000 unselected SLE patients, those with associated MG were older, had lower incidence of cutaneous, renal, and neurological manifestations, and higher frequency of anticardiolipin antibodies and lupus anticoagulant. In conclusion, the clinical pattern of patients with SLE and MG seems to be characterized by a less severe course of SLE and higher frequency of antiphospholipid antibodies. Hydroxychloroquine treatment appears to be safe in this setting.
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Ohira H, Abe K, Takahashi A. Involvement of the liver in rheumatic diseases. Clin J Gastroenterol 2011; 5:9-14. [DOI: 10.1007/s12328-011-0271-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 01/15/2023]
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Hrycek A. A sequence of pathologic events in a patient after thymectomy for myasthenia gravis. Rheumatol Int 2009; 32:245-8. [DOI: 10.1007/s00296-009-1301-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 11/29/2009] [Indexed: 11/27/2022]
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Wani AM, Hussain WM, Fatani MI, Bafaraj MG, Showkat K, Hanif S, Qadmani A, Akhtar M, Maimani GA. Analgesics are not always the culprits: isolated gastric fundal varices as the cause of recurrent upper GI bleed in a patient with SLE, rheumatoid arthritis and polymyositis overlap syndrome. BMJ Case Rep 2009; 2009:bcr06.2009.1967. [PMID: 21829425 PMCID: PMC3027918 DOI: 10.1136/bcr.06.2009.1967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The most common cause of upper gastrointestinal bleeding in patients with systemic rheumatic diseases is non-steroidal drug use; this is the case with COX-2 inhibitors, especially when used concomitantly with corticosteroids. Bleeding from varices is unusual in the absence of liver disease. We present an interesting case of a patient with systemic lupus erythematosus, rheumatoid arthritis and polymyositis overlap syndrome with recurrent upper gastrointestinal bleeds from isolated fundal gastric varices and a normal liver.
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Affiliation(s)
- Abdul Majid Wani
- Hera General Hospital, Medicine, 4a/201, Hera General, Hospital, Makkah, Western, 21955, Saudi Arabia
| | - Waleed Mohd Hussain
- Hera General Hospital, Medicine, 4a/201, Hera General, Hospital, Makkah, Western, 21955, Saudi Arabia
| | - Mohamad Ibrahim Fatani
- Hera General Hospital, Medicine, 4a/201, Hera General, Hospital, Makkah, Western, 21955, Saudi Arabia
| | - Mazen G Bafaraj
- Hera General Hospital, Hera General Hospital, Makkah, 21955, Saudi Arabia
| | - Khalid Showkat
- Hera General Hospital, Hera General Hospital, Makkah, 21955, Saudi Arabia
| | - Sadia Hanif
- Hera General Hospital, Hera General Hospital, Makkah, 21955, Saudi Arabia
| | - Ahmad Qadmani
- Hera General Hospital, Hera General Hospital, Makkah, 21955, Saudi Arabia
| | - Mubeena Akhtar
- Hera General Hospital, Medicine, 4a/201, Hera General, Hospital, Makkah, Western, 21955, Saudi Arabia
| | - Ghassan Al Maimani
- Umul Qurah University, Umul Qurah University, Makkah, 21955, Saudi Arabia
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