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Graft‐versus‐host‐disease‐like disease in a patient with thymic lipomatosis

Dear Editor, Thymoma is well known to be associated with autoimmune disorders such as myasthenia gravis (MG), hypogammaglobulinemia, and red cell aplasia, amongst other diseases. Occasionally, thymoma patients with no history of hematopoietic stem cell transplant develop graftversushost disease (GVHD)like organ damage, involving the skin, intestine, or liver. This is collectively known as thymomaassociated multiorgan autoimmunity (TAMA).1 Thymic lipomatosis is a rare finding in patients with MG but has been reported.2 We report the first case in the literature of a patient with thymic lipomatosis developing MG and GVHDlike disease of the skin and gut. A 30yearold man with good past health was admitted for acute onset of ptosis, diplopia, muscle weakness, and respiratory failure. Investigations revealed positive antiacetylcholine receptor antibody (>20 nmol/L). Autoimmune markers, thyroid function, blood count, and biochemistry were unremarkable. Computed tomography of the thorax showed an anterior mediastinal mass measuring 55 mm × 43 mm × 53 mm (Figure 1a), and a thymectomy was planned. During hospitalization, he developed generalized erythematous nonpruritic scaly papules and plaques over the face, limbs, scalp, and trunk. (Figure 1b). The differentials included psoriasiform drug eruption, subacute cutaneous lupus erythematosus (SCLE), and erythrodermic psoriasis. He had no other features suggestive of psoriasis and SCLE. Medications for newly diagnosed diabetes mellitus and MG, including metformin, empagliflozin and azathioprine, were stopped but psoriasiform eruption persisted. A skin biopsy was performed on the abdomen which showed psoriasiform acanthosis, parakeratosis, hypergranulosis, frequent apoptotic keratinocytes, and occasional exocytosis of lymphocytes (Figure 1c). Direct immunofluorescence was negative. Clinicopathological correlation was compatible with skin GVHD. In addition, he suffered chronic diarrhea for 3 months. Stool microbiological investigations and plasma cytomegalovirus pp65 antigen were negative. Histological biopsies from colonoscopy showed chronic inflammation, with patchy neutrophilic and chronic inflammatory cells in the lamina propria. Thus, the diagnosis of thymic disorderassociated GVHDlike disorder involving the skin and gut was made.