Castleman's disease associated with myasthenia gravis

A Case Report of Subclinical Myasthenia Gravis Associated with Castleman's Disease

BACKGROUND Castleman's disease is defined as a benign lymphoproliferative disorder of uncertain origin. It is most commonly found in the area of mediastinum. Castleman's disease is classified based on pathological features into hyaline-vascular, plasma cell, and mixed variants, which the hyaline-vascular variant is the commonest in association with Myasthenia Gravis. Castleman's Disease have been very rarely reported in Myasthenia Gravis, as it is associated with various clinical abnormalities. The enlarged localized lymph node is mainly diagnosed by incidental radiological findings due to the enlargement of thymus gland or by compression symptoms. CASE REPORT Here we report a case revolves around a 31-year-old Saudi woman who presented with a 2 years history of exertional dyspnea associated with mouth and eye ulcers. There were no other associated symptoms such as muscular weakness, rapid fatigue or drooping of the eyelids. She was referred to our institution for further investigations and management. She was diagnosed with a mediastinal thymoma that was detected based on a positive serology of antibody anti-acetylcholine receptor (AChR) testing and a computed tomography (CT) scan findings, she eventually underwent a bilateral thoracoscopic thymectomy. CONCLUSIONS The aim of this case report is to add more to the literature by reporting a rare case of an asymptomatic subclinical Myasthenia Gravis associated with Castleman's disease. It highlights the importance of considering a Castleman's Disease in an asymptomatic case who presented with a mediastinal mass and in order to avoid an unusual intraoperative finding such as massive bleeding by performing a biopsy and an angiography preoperatively.

Dysphagia and Dysphonia, a Pairing of Symptoms Caused by an Unusual Pair of Diseases: Castleman's Disease and Myasthenia Gravis

OBJECTIVES

To describe a case of coincident Castleman's disease and myasthenia gravis that initially presented as rapidly progressive dysphagia and dysphonia and to review the unique pathophysiology of these two uncommon diagnoses.

METHODS

Case report and literature review.

RESULTS

Castleman's disease, angiofollicular or giant lymph node hyperplasia, is a rare benign lymphoid proliferation. Traditionally, the disease is classified based on histologic and clinical characteristics. Fewer than 10 cases with concurrent myasthenia gravis have been reported. Myasthenia gravis and thymic epithelial tumors are both associated with acetylcholine receptor antibody. While patients with isolated Castleman's disease are usually asymptomatic, those who have concurrent myasthenia gravis and undergo surgical treatment are at increased risk of postoperative myasthenic crisis. Both pre- and postoperative plasmapheresis are suggested to improve muscle strength and prevent severe postoperative complications.

CONCLUSIONS

In the setting of multiple cranial neuropathies including velopalatal insufficiency and bilateral ptosis it is important to consider myasthenia gravis. Castleman's disease occurs rarely in conjunction with myasthenia gravis but may increase the risk of myasthenic crisis.

Predominant Stroma-Rich Feature in Hyaline Vascular Variant of Castleman Disease Is Associated With Paraneoplastic Pemphigus

OBJECTIVES

We aimed to describe the clinical and histopathologic features of Castleman disease (CD), particularly emphasizing its associations with paraneoplastic pemphigus (PNP) and prognosis.

METHODS

We retrospectively enrolled 123 CD patients at our center. Clinical, pathologic, and laboratory data were reviewed.

RESULTS

Fifty percent of the patients had PNP. Compared with those without PNP, patients with PNP-associated CD had more hyaline vascular (HV) variants (83.9% vs 57.4%), fewer mixed cellular variants (16.1% vs 24.6%), and no plasmacytic variants (0% vs 18.0%). Thirty-eight of 87 patients with the HV variant of CD (HV-CD) had stroma-rich (SR) features, and the incidence rate was higher in those with PNP-associated CD than in those without PNP (48.4% vs 13.1%, P < .001). The SR variant was associated with higher PNP-associated IgG titers than SR absence before surgery (median 1:160 vs 1:80, P = .019) or after surgery (median 1:160 vs 1:40, P = .013). The SR variant was also an unfavorable prognostic factor for CD survival in univariate analysis. The 3-year survival rates were 47.5% among those with PNP and 87.7% among those without PNP (P < .001).

CONCLUSIONS

PNP is associated with specific subtypes of CD and affects survival. The SR variant of HV-CD positively correlates with the incidence of PNP.

Non-Neoplastic and Benign Tumoral Lesions of the Thymic Gland: A Review and Update

The thymus is a dynamic organ that undergoes changes throughout life and can demonstrate a myriad of pathologic alterations. A number of benign entities of the thymus prove to be diagnostic dilemmas owing to their resemblance and association with true thymic tumors. These are usually discovered incidentally on routine imaging and most patients are either asymptomatic or present with signs and symptoms of compression of adjacent organs. The radiologic appearance of these lesions varies from simple cysts to complex masses that are suspicious for malignancy. The diagnosis is usually made purely on morphologic grounds, however, immunohistochemical stains can help rule out possible differential diagnoses. Surgical removal is usually curative in these lesions and recurrences are rare. The prognosis is excellent, however, some of these lesions may be associated with myasthenia gravis and/or thymomas. In this review, we describe non-neoplastic lesions and benign tumoral lesions of the thymus, with emphasis on the clinical, radiologic, and pathologic features. The differential diagnosis of each entity is also discussed.

Castleman Disease

Castleman disease (CD) is divided clinically into unicentric or multicentric type. Pathologically, CD is divided into hyaline-vascular and plasma cell variants. Unicentric CD is most common, about 75% of these cases are hyaline-vascular variant, and surgical excision is often curative. In contrast, there are a number of types of multicentric CD including HHV8-associated, idiopathic, and a subset of cases that arise in association with POEMS syndrome. Therapy is required for most patients with multicentric CD, but there is no consensus approach currently. As is evidence, the designation Castleman disease encompasses a heterogeneous group of diseases of varied pathogenesis and which require different therapies.

Castleman Disease Presenting with Pseudotumour Cerebri and Myasthenia Gravis: A Case Report and Literature Review

Castleman disease (CD) is a rare lymphoproliferative disorder that may present with various autoimmune, inflammatory, or neurologic syndromes. This is a case of a 21-year-old woman who presented with signs and symptoms of pseudotumour cerebri (PTC) who subsequently developed myasthenia gravis (MG), and was incidentally found to have a large mass in the posterior mediastinum. Upon resection, the mass was classified as unicentric CD involved with follicular dendritic cell sarcoma. Following treatment with IVIG in the setting of progressive weakness and dyspnea, she has had complete symptom resolution while maintained on a low dose of pyridostigmine for the last two years. There are 13 cases of MG and five cases of optic disc edema described as PTC associated with CD in the literature, but to our knowledge, this is the sole case reported of the intersection of all three conditions in one patient. Increased serum levels of interleukin-6 and vascular endothelial growth factor may provide clues as to the association of CD with these neurologic syndromes.

Atypical Lymphoproliferative Disorders: Castleman's Disease Case Report and Review of the Literature

Castleman's disease (CD) is a rare atypical lymphoproliferative disorder characterized by enlarged hyperplastic lymph nodes with striking vascular proliferations. CD is categorized as being either localized or disseminated and further subdivided into hyaline-vascular, plasma cell, or mixed histopathological patterns. Here we report a case of CD in a 15-year-old girl who presented with a solitary asymptomatic hyaline-vascular mass in the right supraclavicular space. In addition, we discuss the pathogenesis, clinical features and reported comorbidities of unicentric and multicentric CD and evaluate effective treatment strategies based on the results of lymph node biopsy and careful staging. Surgical excision is curative for the localized variants of CD, either hyaline-vascular or plasma cell type. If complete resection is not possible, partial resection or radiotherapy may be useful to control possible systemic manifestations. Multicentric CD, regardless of the histological subtype, is a more aggressive clinical entity, commonly with a chronic or rapidly fatal course. Patients with multicentric CD do not benefit from surgical treatment and should be candidates for systemic therapy (steroids, combination chemotherapy, novel therapies), although this is still in a fairly experimental phase.

Resection of unicentric interlobar Castleman disease with following adjuvant radiotherapy

A 22-year-old female patient with rare interlobar unicentric Castleman disease is presented. The tumour was discovered incidentally and thoracoscopic biopsy was planned to rule out malignancy. Due to dense adhesions to the adjacent anatomical structures and diffuse bleeding when mobilizing the tumour, a thoracoscopic approach was converted to thoracotomy. The tumour was removed without lung resection. Adjuvant radiotherapy was used to avoid possible recurrence of the disease. During the follow-up of 6 years, the patient remains free of any symptoms and evidence of recurrence.

Prevalence of myasthenia gravis and associated autoantibodies in paraneoplastic pemphigus and their correlations with symptoms and prognosis

BACKGROUND

Paraneoplastic pemphigus (PNP) involves multiple organs, but little is known about its neurological involvement.

OBJECTIVES

To investigate the symptoms, prognosis and profiles of associated autoantibodies in myasthenia gravis (MG), and their correlations in patients with PNP.

METHODS

Fifty-eight patients with PNP were assessed for myasthenic symptoms and laboratory evidence. Serum autoantibodies against acetylcholine receptor (AChR), acetylcholinesterase (AChE), titin, ryanodine receptor (RyR) and muscle-specific kinase (MuSK) were measured by enzyme-linked immunosorbent assay. Patients with pemphigus vulgaris (PV), pemphigus foliaceus (PF), connective tissue disease (CTD) and non-PNP MG (NP-MG), and healthy donors, served as controls. These autoantibodies in PNP were also compared in the presence or absence of dyspnoea or muscle weakness. Cox regression and log-rank tests were used for survival analysis.

RESULTS

Overall 39% of patients with PNP experienced muscle weakness, and 35% were diagnosed with MG. Moreover, 35% had positive anti-AChR and 28% had anti-AChE antibodies, similarly to NP-MG (33% and 17%, respectively, P > 0·05). However, both were negative in all patients with PV, PF and CTD and healthy donors (P < 0·005). No other antibodies showed significant differences among groups. Anti-AChR and anti-AChE antibody levels were significantly increased in patients with PNP with dyspnoea, while anti-AChR, anti-titin and anti-RyR were significantly increased in patients with PNP with muscle weakness (P < 0·05). Nevertheless, levels and positive rates of these autoantibodies showed no significant differences between PNP with Castleman disease and thymoma. Although anti-AChE levels impacted survival duration (P  =  0·027, odds ratio 3·14), MG complications did not affect the overall survival percentage in PNP.

CONCLUSIONS

MG is a complication of PNP. Anti-AChR and anti-AChE antibodies are prominent in patients with PNP, especially those with dyspnoea.

A case report of retroperitoneal pararenal Castleman's disease associated with myasthenia gravis

Background

Castleman’s disease (CD) is a relatively rare disorder characterized by the benign proliferation of lymphoid tissue. The combination of an occurrence of retroperitoneal pararenal CD with myasthenia gravis (MG) is extremely rare.

Case presentation

The patient was admitted to our hospital for investigation of a retroperitoneal pararenal tumor which had been coincidentally diagnosed at a local hospital where he was admitted because of MG. The patient subsequently underwent an exploratory laparotomy and suffered from postoperative myasthenic crisis. Pathological examination revealed a left retroperitoneal mass of CD (hyaline vascular type). There was no recurrence of disease found after 7 months.

Conclusions

CD with MG is a rare condition. Postoperative myasthenic crisis is a severe complication. The possibility of its occurrence must be in physicians’ minds and the risk of postoperative myasthenic crisis must be carefully considered when evaluating MG patients undergoing surgery.

A case of Castleman's disease with myasthenia gravis

A rare case of Castleman's disease with myasthenia gravis is reported. A 55-year-old woman with bilateral ptosis, speech impairment, and severe dyspnea had been previously diagnosed with myasthenia gravis. Computed tomography showed a 5 cm × 3 cm paratracheal mass in the mediastinum, thought to be an ectopic thymoma. Two days after surgical resection, the patient suddenly developed dyspnea. Postoperative myasthenic crisis was diagnosed, and plasmapheresis was performed. Her general condition improved, and her subsequent course was uneventful. The final pathological diagnosis was mediastinal solitary Castleman's disease, hyaline vascular type. Castleman's disease with myasthenia gravis is especially rare. One of the serious complications is postoperative myasthenic crisis. For patients with myasthenia gravis, the rate of postoperative myasthenic crisis seems significantly higher in Castleman's disease patients than in patients with thymic epithelial tumors. Castleman's disease with myasthenia gravis is discussed along with a review of the literature.

Myasthenia gravis, Castleman disease, pemphigus, and anti-phospholipid syndrome

INTRODUCTION

Myasthenia gravis is an autoimmune disease marked by neuromuscular transmission failure at the neuromuscular junction. Castleman disease is a rare lymphoproliferative disease characterized by non-cancerous angiofolicular hyperplasia of lymphatic tissue.

METHODS AND RESULTS

We describe a young man with rapid, successive manifestations of myasthenia gravis, a solitary form of Castleman disease, pemphigus vulgaris, and anti-phospholipid syndrome, which resulted in 2 ischemic cerebrovascular events that caused a severe central neurological deficit.

DISCUSSION

We were unable to find a similar case in the literature, but we hypothesize that the temporal concidence of these clinical entities may be related to a common immunological pathway, such as B-cell activation. Therefore, we treated the patient with an immunosuppressant and anticoagulant treatment, as well as rituximab, a monoclonal antibody therapy against CD20+.

Castleman's Disease with Myasthenia Gravis

Castleman's disease is a rare disorder characterized by benign tumors that may develop in the lymph node tissue throughout the body. Castleman's disease associated with myasthenia gravis is an especially rare disease. Only less than 10 cases have been reported in the world literature. The cause of Castleman's disease is associated with immune mediated reaction, and myasthenia gravis also develops due to an antibody-mediated process. The cause of myasthenia gravis is the immune activity of Castleman's disease, which may be the promoter of the antibody-mediated process. We report here a case of Castleman's disease, which was incidentally found in a patient diagnosed with myasthenia gravis.

Successful treatment of autoimmune hemolytic anemia associated with multicentric Castleman disease by anti-interleukin-6 receptor antibody (tocilizumab) therapy

We describe herein the successful treatment of severe autoimmune hemolytic anemia (AIHA) in a patient with multicentric Castleman disease (MCD) by humanized anti-interleukin-6 (IL-6) receptor antibody (tocilizumab) therapy. Inflammatory anemia is commonly reported; however, AIHA is a very rare complication of MCD. In 1996, a 45-year-old Japanese woman was referred to our hospital because of generalized lymphadenopathy, anemia and skin eruptions. Lymph node biopsy demonstrated MCD. She was treated with prednisolone (1 mg/kg/day), which improved the anemia and skin eruptions. In 2009, she suddenly developed Coombs-positive hemolytic anemia. The blood count was as follows: hemoglobin 4.7 g/dl, platelets 490 × 10(9)/l and white blood cell count 9.8 × 10(9)/l. Both direct and indirect Coombs' tests were strongly positive. She was treated with 8 mg/kg tocilizumab every 2 weeks. One month later, her hemoglobin levels rose dramatically to 10.9 g/dl and her haptoglobin level, hypergammaglobulinemia and clinical symptoms had also markedly improved. To the best of our knowledge, this is the first report of the efficacy of tocilizumab in AIHA associated with MCD. The well-established role of IL-6 in the pathogenesis of MCD may have been responsible for the improvement in the AIHA associated with MCD. Anti-IL-6 receptor antibody treatment could be an attractive therapeutic approach for AIHA associated with MCD.

Doença de Castleman associada a sarcoma de células dendríticas foliculares e miastenia gravis

A doença de Castleman é um distúrbio linfoproliferativo atípico, de etiologia desconhecida, que pode estar associada a uma série de condições clínicas, inclusive doenças de caráter autoimune e neoplasias malignas. No presente relato, uma paciente de 72 anos foi encaminhada ao serviço de cirurgia torácica do Hospital Universitário Getúlio Vargas, localizado na cidade de Manaus (AM) para a ressecção de um tumor de mediastino posterior. Três meses antes, havia sido internada em UTI com um quadro de dispneia intensa, ocasião na qual foi diagnosticada miastenia gravis. Após a ressecção da massa mediastinal, a análise histopatológica revelou doença de Castleman hialino-vascular complicada por sarcoma de células dendríticas foliculares. Até o momento da redação deste estudo, a paciente utilizava um anticolinesterásico e corticoides para o controle da miastenia gravis.

[Thoracic manifestations of Castleman's disease]

INTRODUCTION

Castleman's disease is a rare orphan disease. The prevalence is estimated at less than 1/100 000. Respirologists may encounter this disease when its thoracic manifestations occur.

CASE REPORT

The authors report two cases of Castleman's disease with two different thoracic involvements. The first patient was a 20-year-old man without a previous medical history. A chance chest X-ray revealed right basal opacity. A lung biopsy demonstrated giant lymph node polyclonal hyperplasia leading to the diagnosis of a thoracic form of Castleman's disease. Since the patient was completely symptom free, no treatment was proposed. The patient was stable after 10months of medical supervision. The second patient, a 34-year-old woman, had a medical history of myasthenia gravis, autoimmune thrombopenic purpura and haemolytic anaemia. Her general condition deteriorated and upper mediastinal enlargement was noted. A diagnosis of multicentric Castleman's disease was established by means of the biopsy of an axillary lymph node. As the symptoms persisted, she was treated by rituximab. The clinical response was dramatic.

CONCLUSION

The authors call to mind the difficult diagnostic features and therapeutic strategies of Castleman's disease, a rare disease which may involve the thorax.

HIV-associated multicentric Castleman's disease

Multicentric Castleman's disease (MCD), a relatively rare lymphoproliferative disorder that presents with heterogenous symptoms including fevers, anemia, and multifocal lymphadenopathy, is today most commonly observed in individuals infected with human immunodeficiency virus type-1 (HIV). In such individuals, a lymph node biopsy typically identifies cells that stain for Kaposi's sarcoma-associated herpesvirus proteins, and most HIV-associated MCD features can be attributed to the presence of this gamma-herpesvirus. Surgery and antiviral therapies including highly active antiretroviral therapy, interferon-alpha, foscarnet, ganciclovir, and antibodies to interleukin-6 have proved largely ineffective, and chemotherapy in HIV positive individuals is complicated by limited efficacy and pronounced toxicity. While no randomized trials have been performed, more recently the use of the anti-CD20 monoclonal antibody rituximab in large single center cohorts has been associated with prolonged remissions, radiologic responses, as well as hematologic and serum chemistry normalization of the inflammatory picture observed, at the expense of B cell depletion and flare of Kaposi's sarcoma. MCD represents a model of disease at the interplay between tumor biology, infection, and immunology.

Detection of low avidity desmoglein 3-reactive T cells in pemphigus vulgaris using HLA-DR beta 1*0402 tetramers

In the present study, we developed a HLA class II tetramer-based detection system utilizing DRB1*0402 tetramers loaded with recently identified immunodominant peptides of desmoglein 3 (Dsg3), the major autoantigen of pemphigus vulgaris (PV). Initial experiments demonstrated staining of a Dsg3-reactive T cell hybridoma which was derived from HLA-DR0402-transgenic mice with loaded PE-labeled DRbeta1*0402 tetramers. However, staining of autoreactive T cell clones (TCC) derived from PV patients resulted only in positive staining by addition of exogenous peptides to the staining reactions. There was a dose-dependent specific binding of TCC to the tetramers with the agonistic Dsg3 peptide which was not altered by exogenous unrelated Dsg3 peptide. Noteworthy, the TCC did not stain with HLA-DR4 tetramers complexed with unrelated Dsg3 peptides. The findings of this study suggest that HLA class II tetramers may provide a highly specific approach to monitor ex vivo the T cellular autoimmune response against Dsg3 in patients with PV.

A Diagnostic and Management Dilemma

BACKGROUND

Neuromuscular junction disorders are usually categorized as either presynaptic or postsynaptic. The most frequently encountered disorder of the postsynaptic neuromuscular junction is acquired myasthenia gravis. Lambert-Eaton myasthenic syndrome is a well-known prototype of the presynaptic autoimmune disorders of neuromuscular transmission. These major disorders of neuromuscular transmission are relatively common and distinctly recognized, but co-occurrence of these disorders (overlap myasthenic syndrome) is rare and has so far attracted little attention.

REVIEW SUMMARY

This report describes a patient with acquired myasthenia gravis and immunologic coexistence of Lambert-Eaton myasthenic syndrome (overlap myasthenic syndrome) in association with abdominal/uterine leiomyosarcoma. The patient presented with acute respiratory failure, making identification and management of her illness challenging. A general overview of the complexities associated with overlap between myasthenia gravis and Lambert-Eaton myasthenic syndrome is provided and this patient's complicated clinical course and response to therapy are discussed.

CONCLUSION

To our knowledge, this is the first report of overlap myasthenic syndrome in conjunction with abdominal leiomyosarcoma. The immunologic coexistence of acquired myasthenia gravis and Lambert-Eaton myasthenic syndrome in a patient with a malignant smooth-muscle tumor is intriguing and suggests that a common paraneoplastic process targeting 2 different onconeural antigens was the underlying pathogenic mechanism in this patient.