Paraneoplastic Neurologie Syndrome and Autoimmune Addison Disease in a Patient with Thymoma

Adrenal crisis and acute exacerbation of interstitial lung disease after thymoma needle biopsy: a case report and literature review

Thymoma is the most common paraneoplastic syndrome–associated tumor. It is related to a variety of autoimmune diseases including myasthenia gravis, systemic lupus erythematosus, and hypogammaglobulinemia. Only a few reports of thymoma associated with Addison’s disease have been reported to date. Herein, we report a novel case of thymoma complicated with autoimmune Addison’s disease and interstitial lung disease. The patient developed adrenal crisis with persistent hypotensive shock and heart block after needle biopsy. Acute exacerbation of the interstitial lung disease was also observed, accompanied by severe respiratory failure. After treatment with glucocorticoids, somatostatin, and temporary pacemaker implantation, the patient’s condition improved, and the thymoma had shrunk in size. Finally, he underwent transsternal extended thymectomy and lymph node dissection. Hydrocortisone was given intravenously before surgery, on the operation day and after the surgery. The operation was uneventful, and no hypotension or fever occurred. Cortisol and ACTH were still obviously abnormal at 1 month post-surgery. The clinical manifestations of Addison’s disease and interstitial lung disease are hidden and can be easily overlooked. However, in the postoperative period, Addison’s disease can lead to adrenal crisis developing, which can progress to life-threatening shock, arrhythmia, and acute respiratory failure. Therefore, clinicians should be aware of this phenomenon and consider a regimen combining proactive glucocorticoid replacement therapy with somatostatin to preserve the life of such patients.

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.

Myasthenia gravis and autoimmune Addison disease in a patient with thymoma

The association of thymoma with myasthenia gravis has been well documented. However, the relationship between these two syndromes and Addison disease are very rarely encountered in clinical practice. We report on a 32-year-old man who underwent a resection for thymoma 48 months ago. The diagnosis of Addison disease was made followed by a diagnosis of myasthenia gravis on the basis of a high titer of acetylcholine receptor levels. The treatment of oral prednisolone 7.5 mg/day and oral prostigmine 180 mg/day was initiated. His symptoms and physical signs were improved after this treatment. To our knowledge, this is the fourth reported case of thymoma synchronously associated with myasthenia gravis and Addison disease.