A Rare Hematologic Presentation of a Patient with Myasthenia Gravis Status Post Thymectomy
Ayesha Quadri1, Hafiz El-Sayed Fadl3, Scott Cooper2
1Morehouse School of Medicine, 2Department of Internal Medicine, Morehouse School of Medicine, 3Department of Internal Medicine, Grady Memorial Hospital
Background:
Hematological side effects of a thymectomy are important to consider in myasthenia gravis (MG) patients who are candidates for thymoma resection. We report a case of a patient with MG who underwent a thymectomy and presented to the emergency department (ED) about one year later with low hemoglobin and a normocellular bone marrow with suspected developing pure red cell aplasia (PRCA) versus autoimmune related peripheral destruction of red blood cells.
Design/Methods:
Patient was a 52-year-old male with a history of MG on pyridostigmine status post thymectomy 1 year ago, presenting to the ED with complaints of 2 weeks of shortness of breath, cough, and found to be severely anemic with a hemoglobin of 2.4 g/dL. Physical exam was notable for conjunctival pallor and jugular venous distention. Treatment upon admission included transfusion of packed red blood cells with IV Lasix, pyridostigmine, and high dose prednisone.
Results:
Labs showed Hemoglobin 2.4 g/dL, MCV 120 fL, reticulocyte count 0.29%, LDH 370 U/L, total iron 202 µg/dL, iron saturation 61%, Ferritin 398 µg/dL, and TIBC 129 µg/dL. B12 and B9 within normal limits (WNL). Chest CT showed trace hazy soft tissue stranding across mediastinum representing residual thymic tissue versus post-surgical changes. Direct Coombs Test was negative, IgG and IgA (WNL), and IgM low normal. Urine protein electrophoresis was normal and kappa/lambda was 1.73. Antinuclear antibodies and antimitochondrial antibodies were negative. Peripheral blood smear showed concern for possible hairy cell. MDS FISH panel was negative. EGD/colonoscopy showed no source of bleeding. Bone marrow biopsy showed concern for early evolving PRCA due to decreased erythroid precursors.
Conclusions:
With thymectomy becoming more common in the treatment of MG, this case provides insight into potential hematological sequelae post-surgery. Prior studies have highlighted the occurrence of aplastic anemia after thymectomy, but other postoperative hematological manifestations have not been explored.
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