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A 23-year-old woman with near vision difficulty
Digital Journal of Ophthalmology 2007
Volume 13, Number 5
January 9, 2007
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H. Ozden Sener | Departments of Neurology and Ophthalmology, Ankara University School of Medicine
Mine H. Sorgun | Department of Neurology, Ankara University School of Medicine
Huban Atilla | Department of Ophthalmology, Ankara University School of Medicine
Canan Yucesan | Department of Neurology, Ankara University School of Medicine
Diagnosis and Discussion
This young woman had bilateral Adie’s pupil and delayed gastric emptying as well as leukopenia and mild anemia. The mentioned smooth muscle related dysfunctions seem to be a consequence of autonomic involvement primarily affecting the pupillary parasympathetics. Unilateral Adie’s pupil is usually a benign condition (1). It can also be associated with neoplastic processes (2,3,4). Bilateral Adie’s pupil may be due to dysautonomia, polyneuropathy, Sjogren’s syndrome, or syphilis (5,6,7). Recently, two cases of small cell lung cancer have been reported with bilateral Adie’s pupil (4). Together with the anti-Hu positivity, the authors suggested that the ophthalmological abnormality was paraneoplastic.

Thymoma associated neurological paraneoplastic syndromes include myasthenia gravis, autonomic neuropathy, myositis, encephalitis, limbic encephalitis, Isaac’s syndrome, and hearing loss (8). A unilateral Adie’s pupil associated solitary thymoma has been reported previously (9). It has been diagnosed with CT but not confirmed histologically.

To our knowledge, the patient reported here is the first reported bilateral Adie’s pupil associated with histologically proven thymoma. Her Ach receptor (muscle) binding antibody, striational antibody, Ach receptor (muscle) modulating antibody, ganglionic Ach receptor antibody, and GAD65 antibody levels were elevated. These antibodies are associated with thymic abnormalities (8). Vernino and Lennon reported thymoma associated autoantibodies and their clinical significance (8). A high titer of ganglionic Ach receptor antibody has been detected in the sera of three out of ten gastrointestinal dysautonomic patients with thymoma although they found no difference in seroprevalance of this antibody compared with patients without a neurological diagnosis.

Together with the detected thymoma and existing autoantibodies associated with thymic abnormalities, the autonomic involvement in this patient seems to be paraneoplastic.