Pathogenesis of follicular thymic hyperplasia associated with rheumatoid arthritis

Lymphoproliferative disorders may occur in patients with rheumatoid arthritis (RA) who are treated with methotrexate. However, follicular thymic hyperplasia (FTH) associated with RA (FTH‐RA) is generally not considered a lymphoproliferative disorder. To investigate the pathogenesis of FTH‐RA, we examined 12 cases of FTH involving thymic enlargement, four of FTH involving RA and eight of FTH involving myasthenia gravis (MG). Increased numbers and larger germinal center (GC) size were observed in FTH‐RA group. The percentage of distorted GCs was 13.3% in FTH‐RA group and 3.25% in FTH associated with MG (FTH‐MG) group. A greater meshwork of follicular dendritic cells was observed in the GCs of FTH‐RA group. Positive indices of CD27(+) cells and PD‐1(+) cells per GC in FTH‐RA group were significantly higher than those in FTH‐MG group, though positive indices of CD68(+) cells and CD163(+) cells were similar. Myoid cell proliferation, as evaluated by α‐SMA, tenascin‐C, and l‐caldesmon expression, was significantly increased in the FTH‐RA group compared with the FTH‐MG group. These results suggest that FTH should be considered in patients with RA treated with methotrexate. The pathogenesis of FTH‐RA includes GC expansion and increased numbers of memory B cells, follicular helper T cells, and myoid cells, indicating humoral immunity activation.