IVIG for thymoma-associated pseudo-obstruction: report of successful treatment.

At our institution ophthalmology, neuro-ophthalmology, neurology, and gastroenterology consults were initiated. A radionucleotide gastric emptying study confirmed complete immotility. Evaluation of diplopia with prism testing revealed fluctuating levels of exotropia and hypertropia in the left eye. CT of the chest, abdomen, and pelvis revealed a 6 ! 6 ! 3 cm anterior mediastinal mass which was found to be a stage 1 thymoma. His postoperative course was complicated by a hemothorax and hypotension. Cosyntropin stimulation testing on postoperative day 1 revealed relative adrenal insufficiency for which he received intravenous hydrocortisone 100 mg three times per day for 7 days. His symptoms persisted postoperatively and he continued to require parenteral fluids and nutrition. Results of a gastric emptying examination on postoperative day 11 were unchanged. Repeat prism testing after IM injection of neostigmine 1.5 mg and atropine 2 mg resulted in mild improvement in ocular discordance. Pyridostigmine 60 mg every 8 h was started. The only improvement after 2 days was a mild reduction in diplopia. We believed our patient had thymomaassociated pseudo-obstruction. This was first reported in 1983 in a patient presenting with altered mental status and antibodies against the nicotinic acetylcholine receptor (N-AChR) [1] . Thymectomy can Dear Sir, We report the case of a 36-year-old white male from rural Alaska with severe idiopathic gastroparesis and intolerance to oral nutrition who was referred to our institution. His primary concern was for his gastrointestinal symptoms which included abdominal fullness, nausea, vomiting, and stools as infrequent as every 3 weeks. Other symptoms over the preceding 7 months included intermittent diplopia, dysgeusia, and sicca symptoms. Radiologic evaluations including chest and abdominal plain films, CT scans of the sinuses, abdomen, pelvis, and MRI of the brain had been normal. A radionucleotide gastric emptying study showed 100% of the radiotracer retained in the stomach at 90 min. EGD and colonoscopy were notable only for mild gastritis without evidence of Helicobacter pylori . Repetitive peripheral nerve stimulation testing and an extensive laboratory evaluation were normal. Therapies for his GI symptoms, including histamine blockers and osmotic and stimulant laxatives, were minimally effective. He lost over 50 lb and required multiple admissions for intravenous fluids and parenteral nutrition. Received: September 29, 2006 Accepted: December 28, 2006 Published online: June 13, 2007