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LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1094-1095

Association of Multilocular Thymic Cyst with Myasthenia Gravis


Department of Neurology, Command Hospital (Central Command), Lucknow, Uttar Pradesh, India

Date of Submission08-Jul-2020
Date of Decision15-Jul-2020
Date of Acceptance23-Sep-2020
Date of Web Publication2-Sep-2021

Correspondence Address:
Shaman Gill
Department of Neurology, Command Hospital (Central Command), Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325305

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How to cite this article:
Gill S, Dhull P. Association of Multilocular Thymic Cyst with Myasthenia Gravis. Neurol India 2021;69:1094-5

How to cite this URL:
Gill S, Dhull P. Association of Multilocular Thymic Cyst with Myasthenia Gravis. Neurol India [serial online] 2021 [cited 2021 Sep 27];69:1094-5. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1094/325305




Dear Editor,

Thymic cysts are uncommon lesions of the anterior mediastinum and may be unilocular or multilocular. They account for 1%–5% of anterior mediastinal masses and may be congenital or acquired. Association of multilocular thymic cysts with Myasthenia Gravis (MG) is rare.

We present a case of myasthenia gravis who was found to have a multilocular thymic cyst on evaluation, underwent thoracoscopic thymectomy and excision of the cyst and had improvement in symptoms after surgery.

54 years old male with no known comorbidities presented with complaints of fluctuating ptosis, intermittent fatigable diplopia of two months duration and history of fatigable proximal limb weakness of one month duration. Clinically, patient had partial ptosis left eye with enhanced ptosis in right eye. He had grade 4 power proximally in upper and lower limbs. He was diagnosed as a case of Myasthenia gravis and diagnosis was confirmed by acetyl choline receptor antibody (40.8 nmol/L), positive ocular cooling test and a decremental response on repetitive nerve stimulation test. CECT chest revealed 8 cm × 6 cm loculated cystic space occupying lesion in anterior mediastinum predominantly on right side with peripheral rim of calcification along with internal septa and calcification suggestive of anterior mediastinal cystic mass likely thymic cyst [Figure 1].
Figure 1: CECT chest showing thymic cyst

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He was planned for thymectomy as thymectomy has been a proven therapy for patients with MG.[1] Also, since thymic cyst has an association with thymoma,[2] patient was subjected to thymectomy after one month of initial treatment and initial stabilization. He underwent video assisted thoracoscopic thymectomy and excision of thymic cyst. Histopathological examination of the excised cyst revealed multilocular cystic area filled with cheesy yellow color material. Microscopic exam revealed thymic cyst focally lined by flattened cuboidal epithelium with underlying fibro collagenous tissue with mild lymphoplasmacytic infiltrate, cholesterol granuloma and clefts and speckles of calcification. Margins were free of any tumor. Findings were suggestive of multilocular thymic cyst [Figure 2].
Figure 2: Scanner and high power view showing thymic cyst

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Patient was managed initially with tablet pyridostigmine 60 mg TDS along with oral steroids (Prednisolone 20 mg daily). He had gradual symptomatic improvement over next one month. He was given Intravenous Immunoglobin preoperatively and underwent thoracoscopic thymectomy with excision of the cyst. Postoperative period was uneventful. On subsequent follow up, patient had persistent symptomatic improvement after surgery. The steroids were gradually tapered and steroid sparing agent (Azathioprine) was added. Over next 6 months of follow up, patient had sustained response to therapy.

MG association with multilocular thymic cyst is extremely rare. There have been very few cases reported in literature [Table 1] and most of these have association with unilocular cysts.[7]>/sup>
Table 1: Previous case reports on association of thymic cysts with Myasthenia Gravis

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Multilocular thymic cyst, though extremely rare, should be included in the spectrum of MG-associated thymic conditions. Also, its association with thymoma and thymic carcinoma merits thymectomy and cyst excision. The response of patient to surgery confirms its involvement in the pathophysiology of myasthenia gravis.

Acknowledgement

Department of Oncosurgery, Command Hospital (CC).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, et al. Randomized trial of thymectomy in Myasthenia Gravis N Engl J Med 2016;375:511-22.  Back to cited text no. 1
    
2.
Shen X, Jin Y, Shen L, Sun Y, Chen H, Li Y. Thymoma and thymic carcinoma associated with multilocular thymic cyst: A clinicopathologic analysis of 18 cases. Diagn Pathol 2018;13:41.  Back to cited text no. 2
    
3.
Fongi EG, Gotlieb D, Vaamonde CA, Buzzi A, Machado E, Perianes I. Myasthenia gravis following excision of a thymic cyst; study of electrolytes during a myasthenic attack. Prensa Med Argent 1957;27:3754-60.  Back to cited text no. 3
    
4.
Peacey SR, Belchetz PE. Graves' disease: Associated ocular myasthenia gravis and a thymic cyst. J R Soc Med 1993;83:297-8.  Back to cited text no. 4
    
5.
Okumura S, Ohta T, Fujioka M, Nakabayashi H. A case of multilocular thymic cyst with myasthenia gravis. Nihon Kyobu Geka Gakkai Zasshi 1995;43:917-21.  Back to cited text no. 5
    
6.
Mishra AK, Agarwal SK, Pradhan S, Agarwal A. Association of unilocular thymic cyst and myasthenia gravis. Neurol India 2012;60:103-5.  Back to cited text no. 6
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7.
Morollón N, Guerrero P, Duarte J. Quiste tímico asociado a miastenia gravis. Neurología 2018;33:405-7.  Back to cited text no. 7
    


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