Idiopathic acquired agammaglobulinemia associated with thymoma. Report of two cases and review of the literature

Prevention of infectious diseases in patients with Good syndrome

PURPOSE OF REVIEW

Good syndrome is a profoundly immunocompromising condition with heterogeneous immune deficits characterized by the presence of thymoma, low-to-absent B-lymphocyte counts, hypogammaglobulinemia, and impaired cell-mediated immunity. Opportunistic infectious diseases associated with Good syndrome represent a diagnostic and therapeutic challenge, given their protean clinical manifestations. Although these infectious complications have been reviewed in prior publications, recommendations regarding their prevention have been lacking.

RECENT FINDINGS

Good syndrome usually occurs in adult patients between the ages of 40 and 70 years. Immunologically, it is characterized by low or absent peripheral blood B lymphocytes, hypogammaglobulinemia, and variable defects in cell-mediated immunity including low CD4 T counts, inverted CD4:CD8 T-lymphocyte ratio, and reduced T-lymphocyte mitogen proliferative responses. Patients with Good syndrome are susceptible to a variety of infectious diseases, of which the most common are recurrent bacterial sinopulmonary infections, mucocutaneous candidiasis, and CMV tissue-invasive disease. Preventive guidelines including targeted antimicrobial prophylaxis and vaccination strategies can mitigate infectious complications in patients with Good syndrome.

SUMMARY

Immunological deficits and infectious complications in Good syndrome have been described for over 60 years. Further research is needed to elucidate its exact pathogenesis and define the mechanistic relationship between thymoma and hypogammaglobulinemia. However, tailored prophylactic strategies can be recommended for patients with Good syndrome.

Good's Syndrome Patients Hospitalized for Infections: A Single-Center Retrospective Study

Good's syndrome (GS) is a rare combination of thymoma and hypogammaglobulinemia, resulting in immunodeficiency. Patients with GS are highly susceptible to bacterial infection, particularly encapsulated bacterial infection in upper and lower respiratory tracts. Good's syndrome patients with moderate-to- severe infection are often hospitalized. Clinical features of GS patients remain to be characterized.Patients with the discharge diagnosis of GS and simultaneous infection from Peking Union Medical College Hospital between January 2001 and July 2015 were retrospectively analyzed.Among 14 hospitalized GS patients, 12 of them were admitted for severe infections. Mean patient age was 56.7 + 10.1 years. Average concentrations of serum IgG, IgA, and IgM were 2.3 + 1.9 g/L, 0.28 + 0.28 g/L, and 0.06 + 0.07 g/L, respectively. Respiratory and intestinal tracts were the most common sites for infection, which occurred in 7 and 4 patients, respectively. Pathogens identified in 10 patients included cytomegalovirus in 5 patients, Pneumocystis jirovecii, Clostridium difficile in 2 patients, Klebsiella pneumonia in 2 patients, and Streptococcus pneumonia and Hemophilus influenza in 1 patient. Ten patients were treated with antibiotics and immunoglobulin replacement. Only 1 patient who was on immunosuppressant therapy died from P. jirovecii pneumonia.Infection was the most frequent cause for hospitalization of GS patients. Both respiratory and intestinal tracts were the most common sites of infection. Cytomegalovirus and P. jirovecii represented 2 common opportunistic pathogens isolated from hospitalized GS patients with infections.

Good's syndrome remains a mystery after 55 years: A systematic review of the scientific evidence

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.

Current perspectives in the treatment of advanced prostate cancer

Prostate cancer (PC) continues to be an important world health problem for men. Patients with locally confined PC are treated with either radiotherapy or surgery. However, treatment of more advanced stages of the disease is problematic. Initially, androgen deprivation offers a period of clinical stability, which is however invariably followed by progression to non-responsiveness to hormonal manipulation. Current management of patients with androgen-independent prostate cancer (AIPC) displays modest response rates and achieves only short-term benefit. Recently, knowledge in the complex pathophysiology of advanced PC has led to the identification of mechanisms and target molecules permitting the introduction of new therapies. Consequently, many investigational treatments are ongoing for AIPC in Phase-II and Phase-III trials aiming at the combination of chemotherapeutic regimens along with immunotherapy targeting PC-associated antigens. Other attractive options are gene therapy, as well as the targeting of survival signaling, differentiation, and apoptosis of the malignant PC cells. Further treatment modalities are directed against the tumor microenvironment, bone metastasis, or both. Collectively, the aforementioned efforts introduce a new era in the management of advanced PC. Novel pharmaceutical compounds and innovative approaches, integrated into the concept of individualized therapy will hopefully, during the next decade, improve the outcome and survival for hundreds of thousands of men worldwide.

Thymoma with chronic diarrhea: report of two cases and review of the literature

Thymoma associated with hypogammaglobulinemia and profound susceptibility to recurrent and serious infections was first reported by Good in 1954, after whom it was named as Good's syndrome. Chronic diarrhea associated with thymoma is almost always seen in patients with hypogammaglobulinemia. However, chronic diarrhea in a setting of normal gammaglobulins have been rarely reported. We hereby report two cases of thymoma with normal immune functions, presenting with chronic diarrhea as the only symptom of thymic malignancy. We discussed the etiopathogenic relation between thymic pathology and diarrhea and review the cases of thymoma associated with chronic diarrhea in the English literature.

The fundamental contribution of Robert A. Good to the discovery of the crucial role of thymus in mammalian immunity

Robert Alan Good was a pioneer in the field of immunodeficiency diseases. He and his colleagues defined the cellular basis and functional consequences of many of the inherited immunodeficiency diseases. His was one of the groups that discovered the pivotal role of the thymus in the immune system development and defined the separate development of the thymus-dependent and bursa-dependent lymphoid cell lineages and their responsibilities in cell-mediated and humoral immunity.

Recurrent pneumonia post-thymectomy as a manifestation of Good syndrome

A 78-year-old woman presented with right lobar pneumonia. Six months before, the patient had undergone surgery due to a large mass that was found to be spindle cell thymoma. During the past 6 months, the patient had been admitted to the hospital several times with recurrent pneumonia in both lungs; this was treated successfully with antibiotics. Laboratory examinations revealed lymphopenia, eosinopenia, hypogammaglobulinemia, and a low count of CD4 T cells and an inverted CD4:CD8 T cell ratio, both on peripheral blood and bone marrow. History and laboratory findings were compatible with the diagnosis of the rare Good syndrome. This syndrome is discussed here.

Infections in patients with immunodeficiency with thymoma (Good syndrome). Report of 5 cases and review of the literature

Immunodeficiency with thymoma (Good syndrome, GS) is a rare, adult-onset condition that is characterized by thymoma, hypogammaglobulinemia, and low numbers of peripheral B cells. CD4+ T lymphopenia and an inverted CD4:CD8+ T-cell ratio may be present. Here we report 5 patients with GS and infectious complications who were seen at 3 institutions between 1983 and 1999. Three patients had recurrent sinopulmonary infections, 3 had severe cytomegalovirus (CMV) disease, and 1 had Pneumocystis carinii pneumonia. Review of the literature identified 46 other reports of infections in GS patients. The infections reported in all 51 patients included recurrent sinopulmonary infection (19 cases with documented respiratory pathogens), generally with encapsulated bacteria, most often Haemophilus influenzae (11 cases); CMV disease (5 cases); bacteremia (7 cases); oral or esophageal candidiasis (6 cases); persistent mucocutaneous candidiasis (5 cases); chronic diarrhea (5 cases with documented stool pathogens); urinary tract infections (4 cases); P. carinii pneumonia (3 cases); tuberculosis (2 cases); Kaposi sarcoma (1 case); disseminated varicella (1 case); candidemia (1 case); wound infection with Clostridium perfringens (1 case); Mycoplasma arthritis (1 case); and other infections. Patients with GS present with a spectrum of sinopulmonary infections and pathogens similar to common variable immunodeficiency (CVID). Compared with patients with CVID, opportunistic infections, including severe CMV disease, P. carinii pneumonia, and mucocutaneous candidiasis, appear to be more common in patients with GS, and patients with GS may have a worse prognosis. GS should be ruled out in patients with thymoma or CVID who develop severe, especially opportunistic, infections. Treatment with intravenous immune globulin is recommended for all patients with GS.

The role of the thymus in development of immunologic capacity in rabbits and mice

In rabbits, complete thymectomy before the age of 5 days produced immunologic deficiency in the adult animals, as indicated by reduced antibody production to bovine serum albumin and bacteriophage T(2). Homotransplantation immunity was unaffected, however. In an inbred strain of mice, complete neonatal thymectomy resulted in complete inability of the 60-day-old animals to form antibody to bacteriophage T(2). Inbred mice, completely thymectomized at birth, had a deficient homograft response, indicated by acceptance of skin homografts from strains differing in both the weaker and stronger (H-2) histocompatibility antigens. Tumor transplants (mammary adenocarcinoma) were also successful across the H-2 genetic barrier in mice thymectomized at birth. Neonatal thymectomy also eliminated the Eichwald-Silmser phenomenon, rendering female mice capable of accepting isografts of male skin. Transplantation immunity in mice was also affected by later thymectomy, at 30 days of age, in certain strain combinations involving weak histocompatibility differences. Spleen and lymph node cells from mice thymectomized at birth or at 6 days of age, and sacrificed 2 months later, did not produce a graft versus host reaction in appropriate F(1) hybrid recipients, indicating that such cells are immunologically inactive. Neonatal thymectomy of F(1) hybrid mice, and in one strain combination thymectomy at 40 days of age, produced animals with inordinate susceptibility to runt disease (homologous disease) following injection of parent strain spleen cells 35 days (neonatal surgery) and 10 days (surgery at 40 days) later. Mice thymectomized at birth also showed growth failure and were short-lived. Studies of newborn mice indicated that they have true lymphocytes only in the thymus, and lack such cells in the spleen, lymph nodes, and gut. In normal mice, adult lymphoid structure develops gradually, beginning during the 1st week of life and continuing for the next month. In contrast, mice thymectomized at birth do not develop mature lymphoid structure: the lymph nodes and spleens tend to be small and poorly organized, and show a quantitative deficiency in lymphoid cells. It is our current working hypothesis that the thymus makes a major contribution toward the centrifugal distribution of lymphoid cells which, in turn, is essential to the full expression of immunologic capacity.

Orofacial manifestations in the primary immunodeficiency disorders

Primary immunodeficiencies are increasingly recognized yet there is little data concerning the oral manifestations of such disorders. This article reviews the current literature and details the oral aspects of well-characterized primary immunodeficiencies.

T-cell chronic lymphocytic leukemia in a patient with invasive thymoma in remission with chemotherapy

This is a case report of a patient with invasive thymoma. Subsequently to radiotherapy and steroids, a combination chemotherapy of cis-platinum (CDDP) and doxorubicin was tested with good results. The patient later developed a chronic lymphocytic leukemia (CLL); morphologically and cytochemically a T-CLL with skin localizations, hepatomegaly, and a high leukocyte count.

Treatment and prognosis of thymoma: a review of 25 cases

Experience of 25 patients with thymoma is reported. Based on the presence or absence of gross invasion 17 tumors were regarded as benign, 8 as malignant. All patients were operated on. Twenty-two had a complete excision, 2 a palliative excision, and 1 a biopsy only. Five patients received post-operative radiotherapy and 2 patients were given cytotoxic chemotherapy. None of the 17 patients with a benign thymoma had a recurrence or death due to thymoma during the follow-up. The five- and ten-year survival rates for malignant thymoma were 50% and 17%, respectively. Excision is the treatment of choice for all thymomas, since the prognosis for benign tumor is excellent and the malignancy can only by determined at exploration. Post-operative radiotherapy seems to be indicated in malignant thymoma. Myasthenia gravis and histologic features of thymoma have some value in predicting prognosis.

Long-lasting response to cis-platinum in recurrent malignant thymoma: case report

A patient who had received irradiation for inoperable invasive thymoma was treated with cis-platinum after mediastinal and endothoracic recurrence two years from diagnosis. A quick and long-lasting response was observed, which is still present. Systematic phase II trials with cis-platinum in invasive thymoma are suggested.

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.

Pulmonary manifestations of hypogammaglobulinaemia

Fifty-five patients with late-onset idiopathic immunoglobulin deficiency were studied and upper or lower respiratory tract infections were encountered in about 90%. Cylindrical bronchiectasis was shown in all of the 21 patients in whom bronchograms were done. A thymoma was found in four patients. Three patients had diffuse interstitial pulmonary disease--two with proved and one with presumed lymphocytic interstitial pneumonitis. Five patients had no evidence of pulmonary disease, including two patients with long-standing late-onset immunoglobulin deficiency who had essentially no serum immunoglobulins. This small subgroup of patients with immunoglobulin dificiency without severe pulmonary infections cannot be explained in the context of current understanding of immunoglobulin deficiency. Thirty-two patients were followed up for long enough for the response to treatment to be assessed.

Idiopathic late-onset immunoglobulin deficiency. Clinical observations in 50 patients

Fifty patients with late-onset idiopathic immunoglobulin deficiency were studied and the frequency of various clinical associations and complications was observed. Men and women were equally affected, although the age at onset in men peaked in the third decade whereas it was more uniformly distributed in women. Sinobronchopulmonary infections were common and were caused by Haemophilus influenzae. Diplococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus: bronchiectasis occurred in 28 per cent. Thirty patients (60 per cent) had diarrhea, which was often associated with steatorrhea, giardiasis, achlorhydria, abnormal Schilling tests and morphologic abnormalities on small bowel biopsy specimens, including nodular lymphoid hyperplasia; three patients had pernicious anemia. In the 20 patients without diarrhea these abnormalities were not observed except for giardiasis in one patient and achlorhydria in two patients. Cholelithiasis occurred in both groups in about a third of the patients tested. A high degree of susceptibility to neoplasia was noted. Thyroid abnormalities, including primary hypothyroidism and Graves' disease, were observed in six patients. Additional occasional findings were vitiligo, keratoconjunctivitis sicca and arthritis. Splenomegaly occurred in 14 (28 per cent) patients. The percentage of B lymphocytes in the blood was determined in 10 patients; it was normal or slightly decreased in eight patients and low in two patients.

Thymoma metastasizing to extrathoracic sites. A case report

In the case presented, metastases to extrathoracic sites developed in a 53-year-old man four years after the diagnosis of inoperable thymoma had been established. The appearance of metastases was preced by an extensive intrathoracic invasion of the tumour. The thymoma was of epithelial subtype which was the most common (67 percent) type also in the previously published 29 cases of thymomas metastasizing to extrathoracic sites.

Chemotherapy of invasive thymoma

Despite conventional therapy, including surgery and radiation, 5-year survival for invasive thymoma remains poor. Chemotherapeutic agents, including cisdiamminedichloroplatinum, prednisone, adriamycin and nitrogen mustard-vincristine-vinblastine-procarbazine, and bleomycin-adriamycin-CCNU-vincristine have produced short-term remissions. In view of the small number of cases seen in any one institution, a cooperative study to evaluate chemotherapeutic efficacy in malignant thymoma would seem worthwhile.

Thymoma: a clinical and pathological study of 65 cases

A clinicopathologic study of 65 patients with thymomas was performed. The most significant prognostic feature of the thymomas was the presence or absence of gross invasion of adjacent tissue. None of 37 patients with non-invasive thymomas died of tumor or had a recurrence. Invasive thymomas resulted in the death of 3 of 17 patients. Two others are alive with unresectable tumor, and one other patient died of myasthenia gravis with recurrent thymoma. The histologic type of thymoma had no value in predicting prognosis. Thirty-five patients had possibly associated syndromes. These syndromes, particularly myasthenia gravis and red cell hypoplasia, affected survival to an equal or greater extent than did the direct effects of the tumors.