A 25-year-old woman with myasthenia gravis (generalised, anti-AChR antibody positive, MGFA Class IIb) has thymoma found on CT thorax. She is currently on pyridostigmine with incomplete control. What is the management sequence?

• A Pyridostigmine dose escalation alone without surgery
• B Rituximab as first-line immunotherapy without surgery
• C Thymectomy plus immunosuppression (prednisolone with steroid-sparing agent) ✓
• D Thymectomy followed by discontinuation of all immunotherapy

Explanation

In MG with thymoma, thymectomy is mandatory regardless of age or disease severity, as thymoma is a neoplasm and carries malignant potential. Postoperatively, immunosuppression with corticosteroids ± azathioprine or mycophenolate is maintained because thymoma-associated MG tends to have more severe and persistent disease. Pyridostigmine alone is symptomatic treatment insufficient for Class IIb generalised disease. Rituximab is used in refractory MuSK-antibody MG, not first-line for AChR-positive disease.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.