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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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Thangatorai R. Pure Red Cell Aplasia Associated With Thymoma. Cureus 2023; 15:e39387. [PMID: 37362458 PMCID: PMC10286678 DOI: 10.7759/cureus.39387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
A 27-year-old male with thymoma presented with recurrent severe anemia which required multiple transfusions. Bone marrow biopsy showed pure red cell aplasia with normal other cell lineages. He was diagnosed with pure red cell aplasia associated with thymoma and treatment with cyclosporine A was begun. After 12 weeks of treatment, his hemoglobin improved to 11.3 g/dL and the patient remained transfusion independent.
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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: 5] [Impact Index Per Article: 1.0] [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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Dong JP, Gao W, Teng GG, Tian Y, Wang HH. Characteristics of Good's Syndrome in China: A Systematic Review. Chin Med J (Engl) 2017; 130:1604-1609. [PMID: 28639577 PMCID: PMC5494925 DOI: 10.4103/0366-6999.208234] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Good's syndrome (GS) is a rare disease characterized by thymoma, hypogammaglobulinemia, low or absent B-cells, decreased T-cells, an inverted CD4+/CD8+ T-cell ratio and reduced T-cell mitogen proliferative responses. GS is difficult to diagnose preoperatively due to its rarity and lack of typical symptoms, the characteristics of Chinese GS patients are still lacking. This study aimed to systematically review all the clinical, laboratory, and immunologic findings of reported cases of Chinese patients with GS. METHODS We searched for case reports and articles up to January 2017 using PubMed, China National Knowledge Infrastructure, Wangfang database and China Science and Technology Journal Database with the following words in combinations as key words: "thymoma," "hypogammaglobulinemia," and "Good's syndrome." The text words and MeSH terms were entered depending on the databases characteristics. The reference lists from retrieved articles were also screened for additional applicable studies. The authors were restricted to Chinese. There was no language restriction. RESULTS Forty-seven patients were reported in 27 studies. We found that GS has a nationwide distribution and that most cases (83%) have been described on the mainland of China. The initial clinical presentation is varied, ranging from symptoms related to the thymoma to infections resulting from immunodeficiency. Type AB (50%) is the most common histologic type of thymomas in Chinese GS patients according to the World Health Organization classification of thymomas. With respect to infection, sinopulmonary infection (74%) is the most common type, followed by skin infection (10%) and intestinal tract infection (10%). Diarrhea was presented in 36% of patients, and autoimmune manifestations were presented in 36% of patients. CONCLUSIONS GS is a rare association of thymoma and immunodeficiency with a poor prognosis. Astute clinical acumen and increased awareness of the clinical and immunological profile of GS are needed to increase early diagnosis, that would benefit improved therapeutic effects.
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Affiliation(s)
- Jin-Pei Dong
- Department of Gastroenterology, Peking University First Hospital, Beijing 100034, China
| | - Wen Gao
- Department of Gastroenterology, Peking University First Hospital, Beijing 100034, China
| | - Gui-Gen Teng
- Department of Gastroenterology, Peking University First Hospital, Beijing 100034, China
| | - Yu Tian
- Department of Gastroenterology, Peking University First Hospital, Beijing 100034, China
| | - Hua-Hong Wang
- Department of Gastroenterology, Peking University First Hospital, Beijing 100034, China
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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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Briones J, Iruretagoyena M, Galindo H, Ortega C, Zoroquiain P, Valbuena J, Acevedo F, Ocqueteau M, Sánchez C. Thymoma associated with hypogammaglobulinaemia and pure red cell aplasia. Ecancermedicalscience 2013; 7:364. [PMID: 24171048 PMCID: PMC3797656 DOI: 10.3332/ecancer.2013.364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Indexed: 11/30/2022] Open
Abstract
Thymomas are neoplasias that begin in the thymus and develop in the anterior mediastinum. They are commonly associated with a variety of systemic and autoimmune disorders, such as pure red cell aplasia, hypogammaglobulinaemia, pancytopaenia, collagen diseases, and, most commonly, myasthenia gravis. The presence of inter-current infections, especially diarrhoea and pneumonia, in the presence of lymphocyte B depletion and hypogammaglobulinaemia is known as Good’s syndrome and may affect up to 5% of patients with thymoma. While anaemia is present in 50%–86% of patients with Good’s syndrome, only 41.9% of cases present pure red cell aplasia. Concomitance of these two conditions has only been rarely studied. We report on the case of a 55-year-old man diagnosed with advanced thymoma, who, during the progression of his disease, developed signs and symptoms suggesting Good’s syndrome and pure red cell aplasia. We also performed a brief review of the literature concerning this association, its clinical characteristics, and treatment.
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Affiliation(s)
- Juan Briones
- Department of Hematology-Oncology, School of Medicine, Pontifical Catholic University of Chile, Chile 8330024
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Chen J, Yang Y, Zhu D, Chen G, Wei S, Qiu X, Zhou Q. Thymoma with pure red cell aplasia and Good's syndrome. Ann Thorac Surg 2011; 91:1620-2. [PMID: 21524480 DOI: 10.1016/j.athoracsur.2010.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Revised: 09/28/2010] [Accepted: 10/05/2010] [Indexed: 10/18/2022]
Abstract
Thymoma patients with pure red cell aplasia (PRCA) or hypogammaglobulinemia (Good's syndrome) are rare, whereas those with both PRCA and Good's syndrome are even rarer. Here we present the case report of a 70-year-old woman with invasive thymoma and simultaneous PRCA and Good's syndrome, who achieved complete PRCA remission after thymectomy.
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Affiliation(s)
- Jun Chen
- Department of Lung Cancer Surgery, Tianjin Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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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: 166] [Impact Index Per Article: 11.9] [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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