Autoimmune hemolytic anemia and myasthenia gravis associated with thymoma

A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases

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.

Non-Myasthenia Gravis Immune Syndromes and the Thymus: Is There a Role for Thymectomy?

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.

Autoimmune haemolytic anaemia associated with a thymoma: case report and review of the literature

A 67-year-old female presents with a small mass in the anterior mediastinum on chest computed tomography. A biopsy proves the mass to be a spindle-cell-type or type A thymoma. Subsequently the patient develops fever and severe Coombs-positive haemolytic anaemia. She is initially treated with oral corticosteroids. Because of persistence of the haemolysis subsequent thymectomy is performed. Haemolysis disappears almost instantly and does not return after discontinuation of the oral corticosteroids. Review of the literature reveals only 17 other cases of thymoma-associated autoimmune haemolytic anaemia.

Autoimmune thrombocytopenic purpura, autoimmune hemolytic anemia and gastric cancer appeared in a patient with myasthenia gravis

We report a case of myasthenia gravis (MG) associated with autoimmune thrombocytopenic purpura (AITP) and autoimmune hemolytic anemia (AIHA), and after that gastric cancer appeared. A 51-year-old man began to suffer from fluctuated muscle weakness in 1985. Muscle weaknesses became exacerbated, and he was admitted to our hospital in 1989. He was diagnosed as MG associated with AITP. After a thymectomy (hyperplasia), prednisolone therapy was started, subsequently his condition was satisfactory. In March 1995, he developed severe anemia and icterus. He was diagnosed as Evans' syndrome (AIHA and AITP) with MG. High-doses of immunoglobulin administration improved the anemia, but thrombocytopenia continued. In November 2002, he suffered marked petechia; the platelet count decreased to 1000/microl. Methylprednisolone pulse therapy and platelet transfusion were started. Gastrofiberscopy was performed and biopsy specimens revealed signet cell-type adenocarcinoma. On December 19, 2002, subtotal gastrectomy and splenectomy were performed. After that, his condition has remained satisfactory, without MG symptoms or thrombocytopenia. This is the first such case report in the literature.

Myasthenia gravis

Adult-onset myasthenia gravis is an acquired autoimmune disorder of neuromuscular transmission in which acetylcholine receptor antibodies attack the postsynaptic membrane of the neuromuscular junction. Although the cause of this disease is unknown, the role of immune responses in its pathogenesis is well established. Circulating acetylcholine receptor antibodies are present in 80% to 90% of patients with the generalized form of myasthenia gravis. Most patients have ptosis, diplopia, dysarthria and dysphagia. The weakness and fatigue worsen on exertion and improve with rest. Respiratory muscle and limb weakness are rare at the onset of the disease. For the past two decades, there has been considerable progress in understanding the diagnosis and management of myasthenia gravis. The diagnosis is based on clinical presentation, neurologic examination, and confirmation by means of electrophysiologic testing and immunologic studies. Myasthenia gravis mimics many neuromuscular diseases and even illnesses such as depression and chronic fatigue syndrome. One should always exclude drug-induced myasthenia gravis for all patients. With the introduction of new modalities of treatment, particularly immunosuppressive or immunomodulating drugs, plasma exchange and thymectomy, the morbidity and mortality of myasthenia gravis have decreased dramatically to the point that myasthenia gravis should not be considered as serious a disease as it once was. Although the several therapeutic options are usually effective and have meant independence in daily life to many patients with myasthenia gravis, well-designed, controlled, prospective studies are still lacking.

Absence of cellular hypersensitivity to muscle and thymic antigens in myasthenia gravis

Humoral antibodies to skeletal muscle and its components and to thymus have been demonstrated in the sera of patients with myasthenia gravis. A role for cellular hypersensitivity to similar antigens in the pathogenesis of the disease has been suggested by some reports of the presence of cellular immunity. A detailed immunological study using muscle and thymic antigens, including those prepared from the patients' own tissues, failed to confirm these findings. It is suggested that previous reports of cellular hypersensitivity represent the demonstration of an epiphenomenon.

Study of Five Cases of Autoimmune Hemolytic Anemia in the Course of Hemoblastosis

Five cases of AHA in the course of different hemoblastosis (lymphosarcoma, Hodgkin's disease, CLL, AML) are described. Three cases presented no reticulocytosis and no hemolysis, ascribed to erythropoietic insufficiency due to neoplastic proliferation and/or cytostatic therapy in two cases and myeloid aplasia, probably due to the fixation to the bone marrow cells by erythrocytes and platelet autoantibodies in another case. In the two lymphosarcoma cases erythrocyte autoantibodies were found in the course of pretransfusion crossmatching. It may be inferred that systematic immunological tests can reveal erythrocyte autoimmunization in the course of anemia due to a hemoblastosis, even when there are no signs of hemolysis. Erythrocyte-fixed antibodies were of the IgG, IgA, IgM types in various combinations in different patients; the two cases with lymphosarcoma presented a high titer of cold anti I hemoagglutinins. In view of the frequency of both AHA and lymphoproliferative disorders in patients with immunological disorders, it is suggested that neoplasms and autoimmune diseases are independent phenomena, both conditioned by an immunological deficiency, influencing autoantibody synthesis and/or neoplastic growth.

Multiple sclerosis associated with defects in neuromuscular transmission

Three patients with multiple sclerosis characterized by exacerbations and remissions of nervous system signs and symptoms disseminated in time and space also had the kind of easy fatiguability seen in myasthenia gravis. In each case abnormal decrements to repetitive stimulation were electromyographically demonstrated and treatment with ephedrine or anticholinesterase drugs increased the patient's functional capacity while improving the electromyographic abnormality. The suggestion is that these patients represent an overlap syndrome, analogous to the overlap syndrome existing between systemic lupus erythematosus and rheumatoid arthritis where clinical and laboratory features of two diseases coexist in the same patient at the same time. Presumably some patients with multiple sclerosis have deficient production of acetylcholine, just like patients with myasthenia, and treatment with agents useful in myasthenia is able partially to correct the symptoms caused by the deficiency. The cases illustrate how in neurology greater attention to the more immediate cause of clinical symptoms, in the absence of a known aetiology, may result in benefit to the patients.