Lymphocytes suppressing both immunoglobulin production and erythroid differentiation in hypogammaglobulinaemia

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.

Urgent lung transplantation for thymic neoplasm-associated severe constrictive bronchiolitis with bronchiectasis and radiotherapy-induced organizing pneumonia: A case report

Here, we present the case of a 28-year-old woman who developed severe and progressive thymoma-associated constrictive bronchiolitis with bronchiectasis, despite undergoing thymectomy. The disease was further complicated by radiation-induced organizing pneumonia (RIOP), which developed after adjuvant radiotherapy (RT) for Masaoka stage II thymoma. The patient was successfully treated with an urgent lung transplantation (LTx) for irreversible respiratory failure.

Thymic epithelial tumor complicated by immunological abnormalities: results from a single-center retrospective study in China

Background

To describe the clinical manifestations, immunological features, treatments, and outcomes of patients with thymic epithelial tumor (TET) complicated by immunological abnormalities, and to improve knowledge on immunological abnormalities in this rare disease.

Methods

Patients with pathologically confirmed TET at Beijing Chaoyang Hospital between January 2013 and May 2018 were included in this study, and clinical data were analyzed retrospectively. Immunological abnormalities were classified into two groups as follows: Good syndrome (GS) and autoimmune disease (AD).

Results

Fifty-nine TET patients were enrolled; twenty-two patients (37.3%) had immune dysfunction. There were no gender, age, or histological type differences between groups with or without immunological abnormalities. Six patients had GS, of whom four patients were diagnosed after thymectomy. Recurrent respiratory infections, particularly opportunistic infections, were the most common manifestation. Three GS patients developed a second cancer (50%; P=0.011). Anti-infective therapy and immunoglobulin supplements effectively treated GS. Seventeen patients developed ADs, including myasthenia gravis (MG) (n=13), Hashimoto's thyroiditis (n=4), Sjogren's syndrome (n=1), rheumatoid arthritis (n=1), pemphigus (n=1), and Evans syndrome (n=1). One patient developed both MG and GS and 4 patients presented with two ADs. Three AD cases occurred after thymectomy. Pemphigus and 80% (8/10) of MG cases were resolved following thymectomy.

Conclusions

There is a strong association between immunological abnormalities and TET, which may present at any time point during the disease, even after thymectomy. In addition to infection, GS patients are more likely to develop a second cancer. Thymectomy may produce favorable outcomes for MG in this study, while surgery does not improve immunodeficiency in GS patients.

Thymic neoplasms patients complicated with bronchiectasis: Case series in a Chinese hospital and literature review

Background

Bronchiectasis is a rare complication in patients with thymic neoplasm. The aim of this study was to investigate the clinical and radiological manifestations, laboratory tests, pathologic features, and outcome of treatment of bronchiectasis in patients with thymic neoplasm.

Methods

From January 2000 to January 2018, 20 patients with a diagnosis of thymic neoplasm and bronchiectasis were hospitalized at the Peking Union Medical College Hospital. Clinical data was retrospectively analyzed.

Results

The prevalence of bronchiectasis in thymic neoplasms in our cohort was 1.56% (20/1279). Eighteen patients were diagnosed with thymoma, while two patients were diagnosed with thymic carcinoid. The duration from diagnosis of thymic neoplasm to bronchiectasis varied. Distributions of bronchiectasis were bilateral in 17 patients and unilateral in three patients. Four patients were previously diagnosed with diffuse panbronchiolitis and another two were suspected with diffuse panbronchiolitis. Twelve patients had various parathymic syndromes, including Good syndrome, myasthenia gravis, and aplastic anemia. Thymectomy was performed in all of these patients. Macrolide antibiotics were administered to 10 patients, and the symptoms improved in 8.

Conclusion

Bronchiectasis is a complication in thymic neoplasms, although prevalence is low. There may be multifactorial etiologies for bronchiectasis in patients with thymic neoplasms. Comprehensive treatment should be carried out to ensure optimal outcomes.

Humoral Immunity in Bronchiectasis: Finding Good's Syndrome

We present a case of a 37-year-old man with a past history of a surgically removed thymoma, who presented with recurrent pulmonary infections and bronchiectasis. On further testing, he was found to have low total immunoglobulin levels, a constellation of findings known as Good's syndrome. He responded well to immunoglobulin replacement, in addition to the usual treatments for bronchiectasis. We present this case to emphasize the association of bronchiectasis, low immunoglobulins, and thymomas and the role of immunoglobulin replacement as a treatment option.

Chronic intestinal pseudo-obstruction due to lymphocytic intestinal leiomyositis: Case report and literature review

Lymphocytic intestinal leiomyositis is a rare entity, which causes chronic intestinal pseudo-obstruction (CIPO) in children. We present the first case of a boy who had pure red cell anemia 1 year before onset. Prolonged ileus developed after gastroenteritis and the patient was diagnosed using a biopsy of the intestinal wall. Findings from the present case indicate that there are three important factors for accurate diagnosis: history of enteritis, positive serum smooth muscle antibody, and lymphocyte infiltration with muscle destruction in the muscularis propria in the intestinal wall. Earlier diagnosis and induction of immunosuppressive therapy may be essential for a better outcome.

Thymoma in children: report of 2 cases and review of the literature

Thymoma is an uncommon and slow-growing neoplasm. It is derived from thymic epithelial cells and comprises about 20% to 30% of mediastinal masses in adults, but only about 1% in pediatric patients. Patients usually present with mass-associated respiratory symptoms, superior vena cava syndrome, or paraneoplastic syndrome including myasthenia gravis, pure red cell aplasia, or acquired hypogammaglobulinemia, and connective tissue disorders. Due to the limited number of cases, knowledge, and experience with thymoma in pediatric patients, the diagnosis and treatment are very challenging for this age group. In this article, we report 2 cases of thymoma in childhood and provide a comprehensive review and analysis of the reported pediatric cases in the past 30 years (total of 32 cases). We found that patients younger than age 10 years were predominantly male (M:F = 6:1) and had advanced tumor stage more frequent than patients older than age 10 (P = .03). There were also significant associations of male sex with more advanced tumor stage and less favorable outcome (P = .03). These findings suggest that age and sex may be additional potential prognostic contributors in pediatric patients with thymoma. The clinicopathologic features, differential diagnosis, and current therapeutic recommendations of this uncommon tumor in pediatric patients are also addressed.

Durable hypogammaglobulinemia associated with thymoma (Good syndrome)

Good syndrome, characterized by hypogammaglobulinemia and acquired immunodeficiency, is a rare condition associated with thymoma. A 67-year-old woman, who 4 months previously had a thymoma resected, presented with generalized hypogammaglobulinemia with a severely decreased B cell population as demonstrated by flow cytometry. She was diagnosed as having bacterial mediastinitis associated with Good syndrome. For the subsequent 6 years, she suffered from repeated serious bacterial infections. As this paraneoplastic syndrome is not resolved by tumor removal, careful management with intensive infection-control using antibiotics and intravenous immunoglobulins is required for the long term. Serum immunoglobulin levels should be evaluated for patients with thymoma and suspected vulnerability to infection.

Pure red cell aplasia--evidence for an inhibitory action of the bone marrow adherent cell layer

Evidence is presented for an inhibitory action of the bone marrow adherent cell layer on erythropoiesis in a case of pure red cell aplasia. Cultures of the patient's bone marrow with autologous and normal plasma showed normal numbers of CFU-C, but total absence of BFU-E. There was no inhibition of BFU-E when normal bone marrow was cultured with the patient's plasma. T-cell depletion of the patient's bone marrow did not affect these results, but after removal of the adherent cells, normal numbers of BFU-E were cultured. These observations suggest that the adherent cells, which are predominantly macrophages, were responsible for the inhibitory action on erythropoiesis.

Thymoma associated with pure red-cell aplasia: clinical features and prognosis

As information on the clinical features and prognosis of thymoma complicated by pure red-cell aplasia is limited, follow-up data on thymoma patients who had a thymectomy between 1954 and 1999 were analyzed retrospectively. Six of 166 cases were complicated by pure red-cell aplasia. In 3 of these, the pure red-cell aplasia appeared after surgical intervention. Remission was observed in 2 patients who underwent extended thymectomy. The other 4 patients subsequently died from pure red-cell aplasia. The outcome in patients with pure red-cell aplasia was poorer than that in the entire group of patients with thymoma and in those with thymoma complicated by myasthenia gravis. The possible onset of pure red-cell aplasia after thymectomy should be kept in mind during follow-up.

Late onset immunodeficiency in a patient with recurrent thymic carcinoma and myasthenia gravis

The most common autoimmune disease associated with thymoma is myasthenia gravis. In addition, cellular and humoral immune defects have been frequently reported in association with thymic neoplasms. Here we report the case of a patient with myasthenia gravis receiving long-term immunosuppression with azathioprine and recurrent well-differentiated thymic carcinoma who developed CD4+ T-cell depletion and CNS cryptococcosis after multiple courses of chemotherapy and mediastinal irradiation. We hypothesize that in thymectomized patients bone marrow suppression and abrogation of the peripheral T-cell pool can result in a delayed T-cell regeneration due to the lack of functional thymic epithelium.

Characteristics of suppressor cell activity appearing in cocultures of two individuals with immunodeficiency with thymoma

Suppressor cell activity in two individuals (S1 and S2) with immunodeficiency with thymoma (ID-THY) was studied in peripheral blood mononuclear cells in pokeweed mitogen-stimulated single culture and cocultures. Secreted Ig was measured by radioincorporation and immunoprecipitation after 5-7 days. Control cocultures of normal/normal cells showed, in most cases, a percentage observed to expected ratio (% O/E) of cpm Ig near 100%. However, augmentation (% of O/E > 150) was often encountered, whereas suppression (% O/E < 50) was found only once in forty-two cocultures. In ID-THY/normal cell cocultures the degree of suppression by ID-THY cells varied widely when the same or different cocultivants were retested. This finding could be explained in part by an inverse correlation between the amount of secreted Ig produced by normal cells in single culture and the degree of suppression of the same normal by ID-THY cells in cocultures. A panel of normal cells were all suppressed when a range of S1 or S2/normal cell ratios were tested, weighing against genetic differences in suppressibility in the above system. ID-THY cells failed to block Ig secretion of human lymphoblastoid line cells, suggesting that the mechanism of suppression was related to a block in differentiation rather than interference with Ig synthesis per se. An experiment using cocultivants separated by a Millipore membrane showed that suppression was mediated by a humoral factor.

Thymomas associated with pure red cell aplasia. Histologic and follow-up studies

Seventeen cases of pure red cell aplasia (PRCA) with thymoma were studied clinically, histologically, and immunologically. Two cases were associated with myasthenia gravis (MG), and three with hypogammaglobulinemia. Coombs test and antinucleus antibody test were positive in five cases. All thymomas were spindle cell types, and the adjacent thymuses had no germinal center, but showed epithelial clusters frequently. All patients, except one whose tumor was unresectable, had thymo-thymomectomy. The operation was effective in six cases (37.5%), and the effects were not different between two operative procedures (simple and extended thymectomy). Myasthenic symptoms in two patients remitted after the operation, but effects on hypogammaglobulinemia were conincident with those on PRCA.

Autoreactive erythroid progenitor-T suppressor cells in the pure red cell aplasia associated with thymoma and panhypogammaglobulinemia

In vitro erythroid culture studies and lymphocyte markers were performed in a patient with a spindle cell thymoma who developed red cell aplasia, panhypogammaglobulinemia, and multiple opportunistic infections. At the time of presentation, erythroid progenitor cells (CFUe, BFUe) were markedly reduced when cultured from marrow mononuclear cells. Removal of T cells from bone marrow mononuclear cells by E-rosetting or complement-mediated lysis with OKT3 pan T cell monoclonal antibody increased growth of erythroid progenitor cells in vitro. Readdition of bone marrow or pleural fluid T cells derived from the thymoma suppressed autologous, but not allogenic, erythroid progenitor cell (CFUe, BFUe) proliferation in vitro. The erythroid progenitor suppressor T cells were predominantly OKT11+, OKT3+, OKT8+ and Ia+ consistent with activated suppressor T cells. Treatment of the patient with cyclophosphamide and corticosteroids reduced marrow lymphocytes fourfold, and a prompt reticulocytosis ensued. After recovery, erythroid progenitor cells were easily detectable. These studies provide new evidence for T cell-mediated suppression of erythropoiesis in a unique subset of patients with red cell aplasia associated with thymoma and hypogammaglobulinemia.

An antiemetic is antidotal to the satiety effects of cholecystokinin

Although cholecystokinin (CCK) has been proposed as a satiety agent, this property has been disputed by some who claim that the compound exerts its 'satiety' effects by inducing aversion. We considered that if CCK-induced reductions in food intake occur through the mechanism of normal satiety, CCK-induced satiety and normal satiety should respond in the same way to a pharmacological challenge. We demonstrate here that the administration of an antiemetic to rats significantly attenuates the food intake reduction caused by exogenously administered CCK but does not increase normal consumption. The effects of endogenous CCK are therefore quite different from those of exogenous CCK, making any previous study equating exogenous CCK effects with natural satiety problematic.

Pre-B cells in agammaglobulinemia: evidence for disease heterogeneity among affected boys

Six immunodeficient boys were found to have agammaglobulinemia and lack circulating B cells. These patients could be divided into two groups based on bone marrow findings and clinical course. In one group, pre-B cells and lymphocytes were present at normal frequencies and in normal absolute numbers. Recurrent serious infections were documented in the first few months of life in these patients, and this consequently led to early diagnosis. In the second group, pre-B cells were virtually undetectable. Patients in this group did not present with recurrent infections until the second year and were thus diagnosed later than were those in the first group. Childhood agammaglobulinemia with deficiency of both pre-B and B lymphocytes appears to be a different disease from X-linked infantile agammaglobulinemia. This disease may involve an arrest of B-lineage cell development at an earlier stage than that responsible for X-linked agammaglobulinemia.

Pure red cell aplasia: relationship between inhibitory activity of T cells to CFU-E and erythropoiesis

T cell-mediated inhibition of autologous late erythroid colony formation was found in two patients with PRCA. Each patient was treated separately with immunosuppressive agents, ALG, bolus methylprednisolone or cyclophosphamide. Cyclophosphamide was the most effective among these immunosuppressive therapies. Peripheral blood T cells, which were taken serially from the patients during the course of the disease, were cryopreserved until use. The inhibitory activity of T cells was assayed after remission using autologous bone marrow. It was found that the decrease of inhibitory activity was closely correlated with clinical improvement and that the effectiveness of the immunosuppressive therapy on inhibitory activities of T cells differed between therapies. These findings suggest that T cell-mediated inhibition of erythropoiesis may be pathogenetic for PRCA in some patients.

Autoimmune pancytopenia. Lymphocyte inhibition of autologous but not allogenic bone marrow growth in vitro

A patient with autoimmune renal failure, cavitary lung lesions and arthritis experienced pancytopenia while prednisone therapy was being tapered. Utilizing semisolid culture techniques, a population of nonadherent peripheral blood mononuclear cells was demonstrated, which inhibited autologous but not allogeneic bone marrow erythroid colony-forming units (CFU-E) and myeloid colony-forming units (CFU-c) in vitro. No inhibition of CFU-E or CFU-c colony formation was seen when patient's serum or immunoglobulin G (IgG) was added to cultures. Reinstitution of prednisone therapy resulted in normalization of peripheral blood counts, which was accompanied by the loss of the hemopoietic inhibitor cell activity in the patient's peripheral blood. These results demonstrate the need for testing autologous marrow samples when looking for possible immune-mediated inhibition of hematopoiesis.

Serum inhibitors of myelopoiesis

A modification of the microcytotoxicity assay of Terasaki & McClelland was used to screen for serum inhibitors of myeloid progenitor cells (CFU-C). Sera from 104 patients with neutropenia or bone marrow failure and from 104 controls, including 30 normal subjects and 74 patients with various disorders or multiple transfusions, were studied. Inhibitors of CFU-C were found in 19 of the 104 patients with neutropenia or marrow failure: three with acquited neutropenia and 16 with aplastic anaemia. In 17 of the 19 patients the inhibitor was either complement dependent or chavincingly associated with clinical remission of disease in one patient. In another patient, the inhibitor was an IgG antibody directed against non-HL1 antigens present on CFU-C of all 50 normal target marrows tested; however, it was not clearly autoreactive. Inhibitors were also found in one of nine patients with lupus erythematosus, one with breast carcinoma, one patient with renal transplant rejection, and six of 46 multiply transfused patients without marrow failure. Our findings indicate that most serum inhibitors are associated with multiple transfusion: convincing evidence of pathogenetically important autoreactive antibody was present in only one of 19 patients with inhibitors.

Mucocutaneous candidiasis and thymoma

The clinical, pathologic and immunologic features of 27 patients with chronic mucocutaneous candidiasis and thymic tumors are reviewed. This form of chronic candidiasis is unique in that the infections do not occur until after the third decade and, in contrast to patients in whom candidiasis develops during infancy or childhood, it is not accompanied by failure of endocrine organs. Instead, the patients have the disorders that often accompany thymoma, such as myasthenia gravis, hypogammaglobulinemia, and abnormalities of the bone marrow and circulating blood elements. Evidence of impaired cell-mediated immunity was found in 16 of the 21 patients in whom studies were made. The pathogenesis of the immunodeficiency in these patients is unknown. Immunosuppressive activities in the plasma of four patients were found, but none of the five patients in whom the appropriate studies were made was found to have suppressor cells. The features of this disorder are unique enough that it should be considered a syndrome, and patients in whom candidiasis develops during their adult years should be studied for the presence of thymoma.

Immune suppression of hematopoiesis

Recent evidence suggests that immune mechanisms can injure proliferating hematopoietic precursor cells in the bone marrow. These may involve either humoral antibody or cell-mediated cytotoxic mechanisms. Immune injury can result in a variety of bone marrow failure syndromes. Immunologically induced abnormalities or blood cell production may be restricted to a single series, such as erythrocyte or granulocyte precursors, or may involve several hematopoietic lines; clinical manifestations reflect the cell line or lines that are injured. Immune suppression of hematopoiesis has now been described in pure red cell aplasia, immune panleukopenia, systemic lupus erythematosus, atypical cases of aplastic anemia and miscellaneous other hematologic diseases.