We conclude that surgery of thymoma needs close and detailed pre- and postoperative myasthenia gravis examinations to screen for PTMG onset. post-thymectomy Myasthenia Gravis (PTMG); Sodium Danshensu however, its mechanism and risk factors remain unclear. Moreover, no case of PTMG with onset at Osserman stage III has been reported. Here, we present the first case of PTMG at Osserman stage III. CASE REPORT An 81-year-old woman was admitted to our hospital for examination and treatment of an abnormal shadow seen on chest radiograph. She had no symptoms on admission. Tumor markers were within the normal range. Acetylcholine receptor antibody (ARA) was unfavorable. Her lung function was normal. Chest computed tomography (CT) showed a bulky mediastinal tumor bulging outward into the left thoracic space (Physique 1). Open in a separate windows Fig. 1 Preoperative chest computed tomography (CT) showing a bulky mediastinal tumor bulging outward Sodium Danshensu into the left thoracic space and invading the pericardium and pleura. The tumor was diagnosed as a thymoma by tissue biopsy under CT guidance. The operative findings of the tumor was completely resected by performing thymothymectomy, left upper lobectomy, pericardial resection, and phrenicectomy with median sternotomy and superior longitudinal anterior mediastinotomy. The most a part of tumor had a place in the left pleural space and invaded the left superior lobe of the lung, pericardia and left phrenic nerve. Pathological examination of the tumor identified as a thymoma (Masaoka stage II). She was discharged 40 days after the surgery without postoperative complications. Two months after the surgery, the patient was admitted to our hospital for respiratory failure requiring mechanical ventilation. ARA level was remarkably elevated (220 nmol/L). Evoked electromyography showed waning. However, there was no evidence of tumor recurrence on imaging examination. We diagnosed the patient as Sodium Danshensu having PTMG with Osserman stage III and started steroid pulse therapy (prednisolone 1g/day for 3 days). Additionally, we treated the patient with immunoadsorption to shorten the duration of the steroid therapy. At three months after the admission, she was removed from the ventilator with a Sodium Danshensu drug regimen of 60 mg/day prednisolone. Moreover, the ARA level reduced to 43.5 nmol/L (Figure 2). Open in a separate windows Fig. 2 A chart showing the clinical course. DISCUSSION Here, we present the first case of myasthenia gravis onset with Osserman stage III after thymectomy. Studies have reported that this incidence of PTMG is usually 0.9C20% (1-6).However, we could not find reports of PTMG occurring at Osserman stage III. The current hypothesis of the pathogenic mechanism of PTMG includes: [1]thymoma recurrence (7,8); [2] surgical exposure to larval MG (2); and [3]activation of peripheral lymphocytes from thymoma after surgery (9,10). The risks of developing PTMG have been documented in various studies. However, these studies did not spotlight risks such as operative method that may be statistically significant. In this regard, Nakajima et al reported that all patients with Myasthenia Gravis before or after thymectomy had high ARA levels at the onset of Myasthenia Gravis. Thus, high ARA level might be a predictive indicator of PTMG (6). In our case, postoperative imaging examination and preoperative physical findings showed that PTMG did not develop because of the factors highlighted in hypotheses 1 and 2. PTMG onset was more likely to be caused by the factors described in hypothesis 3. The methods for evaluating the hypothesis 3 are currently available for clinical use. However, we regret that we evaluated ARA at an earlier date after the surgery. Moreover, after the medical procedures we might examine her about Myasthenia Gravis such as Harvey-Masland test. We experienced a case of PTMG onset at Osserman stage III with a negative preoperative ARA. We conclude that surgery of thymoma requires close and detailed pre- and postoperative myasthenia gravis examinations to screen for PTMG onset. We believe that this case may offer some useful information for patients with thymoma, be considered surgery. Recommendations 1. Namba T, Grunner NG, Grob D. Myasthenia gravis in patients with thymoma, with particular reference to onset after thymectomy. Medicine 1978;57:411C433 [PubMed] [Google Scholar] 2. Li J, Zhang DC, Wang LJ, Zhang DW, Zhang RG. Myasthenia gravis occurring after resection of thymoma. Zhonghua Wai Ke Za Zhi 2004;42:540C542 [PubMed] [Google Scholar] 3. Ohta M, Itoh M, Hara H, Itoh N, Nishitani H, Hyashi Sodium Danshensu K, et al. Anti-skeletal muscle and anti- TRK acetylcholine receptor antibodies in patients with thymoma.
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