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Xu J, Zhou X, Wang Y, Liu W, Shan Y, Zhang D, Lv H, Zhao D, Dai T, Zhao Y, Li W, Liu F, Yan C. Skeletal muscle involvement in systemic amyloidosis is often overlooked. Neuropathol Appl Neurobiol 2024; 50:e12996. [PMID: 38982616 DOI: 10.1111/nan.12996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/05/2024] [Accepted: 06/22/2024] [Indexed: 07/11/2024]
Abstract
AIM Systemic amyloidosis is a condition in which misfolded amyloid fibrils are deposited within tissues. Amyloid myopathy is a rare manifestation of systemic amyloidosis. However, whether skeletal muscle involvement is underestimated and whether such deposition guarantees clinical and pathological myopathic features remain to be investigated. METHODS We retrospectively reviewed patients with systemic amyloidosis, in whom skeletal muscle biopsies were performed at our centre between January 2018 and June 2023. In total, 28 patients with suspected systemic amyloidosis were included. Among these, 21 presented with cardiomyopathy but lacked myopathic symptoms. The clinical and pathological data of these patients were further analysed. The amyloid type was confirmed by immunohistochemistry. RESULTS Twenty-eight patients with suspected systemic amyloidosis underwent muscle biopsy. Amyloid deposition in the skeletal muscle was confirmed in 24 patients, including 22 with light-chain amyloidosis (AL) and two with transthyretin amyloidosis (ATTR). Among the 24 patients, seven presented with muscle weakness and decreased muscle strength (Group 1, symptomatic myopathy), whereas the remaining 17 exhibited normal muscle strength (Group 2, asymptomatic myopathy). Group 1 included four patients with AL-λ, one with AL-κ and two with ATTR. Group 2 included 15 patients with AL-λ and two patients with AL-κ. In Group 1, six patients exhibited neuropathy, whereas only one patient in Group 2 presented with subclinical neuropathy on nerve conduction studies. Amyloid deposition in the interstitium was the most obvious change, observed in all 24 patients. Neuropathic changes, including denervation atrophy and muscle fibre grouping, were also common. Except for type 2 fibre atrophy, the other myopathic changes were mild and nonspecific. No sarcolemmal disruption was observed. Immunohistochemical analysis revealed marked positivity for MAC and MHC1 expression in the regions with amyloid deposits. Clinicopathological analysis revealed no significant differences in the extent of muscular amyloid deposition between the two groups. Nevertheless, patients in Group 1 displayed more pronounced neurogenic atrophy on skeletal muscle biopsies. CONCLUSIONS Our study indicates that amyloid deposition in skeletal muscle is commonly observed but rarely causes symptomatic myopathy in systemic amyloidosis.
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Affiliation(s)
- Jingwen Xu
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyu Zhou
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yingxin Wang
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenzhu Liu
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi Shan
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dong Zhang
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Huixia Lv
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Dandan Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tingjun Dai
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fuchen Liu
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Lashkari R, Loghman M, Aghaghazvini L, Saffar H, Ziaadini B, Shahriarirad R, Nekooeian M, Nejadhosseinian M, Alikhani M. Atypical Presentation of Amyloidosis in a Female Patient with Muscle Weakness. Case Rep Med 2023; 2023:1553163. [PMID: 37090743 PMCID: PMC10118899 DOI: 10.1155/2023/1553163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/26/2023] [Accepted: 03/17/2023] [Indexed: 04/25/2023] Open
Abstract
Muscle involvement represents a well-recognized but rare manifestation of amyloidosis. Here, we report a 40-year-old female who presented with muscle weakness, musculoskeletal pain, and proteinuria, which was eventually diagnosed as myopathic amyloidosis based on muscle biopsy results. A multidisciplinary approach appears to be the cornerstone of the diagnostic work up for recognizing the unusual amyloid myopathy.
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Affiliation(s)
| | - Maryam Loghman
- Department of Internal Medicine, School of Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Aghaghazvini
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hiva Saffar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Bentolhoda Ziaadini
- Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Shahriarirad
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Nekooeian
- Health and System Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Nejadhosseinian
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Alikhani
- Department of Internal Medicine, School of Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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3
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Draghici M, Jercan A, Badelita SN, Irimia RM, Bastian AE, Dobrea C, Popescu M, Coriu D. Muscle involvement with pseudohypertrophy in systemic light chain amyloidosis: Case report. Medicine (Baltimore) 2021; 100:e28267. [PMID: 34941106 PMCID: PMC8702120 DOI: 10.1097/md.0000000000028267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/25/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Muscle pseudohypertrophy is a rare manifestation of light chain amyloidosis (AL) amyloidosis. PATIENT CONCERNS A 63-year-old woman presented with a 2-year history of progressive asthenia, macroglossia, dysphonia, cachexia, hypotension, paresthesia, and lower limb muscle hypertrophy. DIAGNOSIS Free serum lambda light chains were increased, and fat pad biopsy demonstrated Congo red-positive deposits. Additionally, electromyography showed a myopathic pattern, whereas muscle biopsy revealed amyloid deposits. A diagnosis of λAL with cardiac, renal, nervous system, and skeletal muscle involvement was established. INTERVENTIONS AND OUTCOMES The patient received 3 subsequent lines of therapy over the following 23 months, with very slow hematological remission followed by resolution of organ dysfunction. LESSONS Despite its rarity, muscle involvement should be considered in patients diagnosed with AL amyloidosis associated with unexplained muscle hypertrophy or weakness associated with macroglossia or elevated troponin T levels in the absence of clear cardiac involvement.
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Affiliation(s)
- Mirela Draghici
- Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Jercan
- Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Ruxandra Maria Irimia
- Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania
| | - Alexandra Eugenia Bastian
- “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania
- Colentina Clinical Hospital, Bucharest, Romania
| | - Camelia Dobrea
- Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Daniel Coriu
- Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania
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4
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Ono E, Ishii A, Higashi Y, Koita N, Ayaki T, Tanigaki K, Takayanagi S, Kondo N, Sakai K, Endo S, Yokoi H, Matsubara T, Minamiguchi S, Nishino I, Takahashi R, Yanagita M. Monoclonal gammopathy of renal significance (MGRS)-related AL amyloidosis complicated by amyloid myopathy: a case report. BMC Nephrol 2021; 22:74. [PMID: 33639890 PMCID: PMC7916314 DOI: 10.1186/s12882-021-02272-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 02/18/2021] [Indexed: 12/05/2022] Open
Abstract
Background Lately, monoclonal gammopathy of renal significance (MGRS) has been defined as a group of renal disorders that are strongly associated with monoclonal protein, including amyloid immunoglobulin light chain (AL) amyloidosis. Amyloid myopathy is rare (1.5% of all patients with amyloidosis) and the prognosis is poor. Furthermore, only approximately 20% of patients with amyloid myopathy are reported to have renal involvement, indicating a lack of data in the literature. Case presentation Here, we report a rare case of MGRS-related AL amyloidosis complicated by amyloid myopathy that presented with muscle weakness in the upper and lower limbs, neck and fingers, and nephrotic syndrome. Blood, urine, and bone marrow examination revealed monoclonal gammopathy of undetermined significance (MGUS) (Bence Jones protein-lambda). Muscle biopsy of the vastus lateralis muscle demonstrated amyloid proteins in the sarcolemma and in the blood vessel walls on Congo red staining, suggesting amyloid myopathy, and tiny inclusions in fibers on modified Gomori trichrome stain. Although we thought they were reminiscent of nemaline bodies, we could not confirm the nature of this structure. Renal biopsy demonstrated amyloid proteins in the mesangial region, part of the capillary walls, and the blood vessel walls on direct fast scarlet staining. As these amyloid proteins were positive for p-component staining and negative for amyloid A staining, β2-microglobulin, and pre-albumin, and as lambda light chains were positive in the mesangial region, we diagnosed the patient with MGRS-related AL amyloidosis. Although he was treated with melphalan and dexamethasone, his symptoms did not improve. Conclusions AL amyloidosis involving the kidneys and muscles has a poor prognosis, and a delayed diagnosis of amyloid myopathy is common because of its rarity and frequent misdiagnosis, which increases organ function deterioration. Therefore, early detection, therapeutic intervention, and careful follow-up are crucial.
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Affiliation(s)
- Erina Ono
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akira Ishii
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Yoshiaki Higashi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Natsuko Koita
- Department of Neurology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takashi Ayaki
- Department of Neurology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Katsuya Tanigaki
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shunsuke Takayanagi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Naoya Kondo
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaoru Sakai
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shuichiro Endo
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideki Yokoi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawa-Higashi, Kodaira, Tokyo, 187-8502, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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5
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Kawazoe T, Uruha A, Mori-Yoshimura M, Saito Y, Ikeda SI, Saji M, Tanimura A, Amano T, Okamoto T, Oya Y, Murata M, Nishino I, Takahashi Y. A 67-Year-Old Man with Leg Weakness and Hypertrophic Cardiomyopathy. Brain Pathol 2021; 30:427-428. [PMID: 32100439 DOI: 10.1111/bpa.12824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Tomoya Kawazoe
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Akinori Uruha
- Department of Genome Medicine Development, Medical Genome Center, NCNP, Kodaira, Japan.,Department of Neuromuscular Research, National Institute of Neuroscience, NCNP, Kodaira, Japan.,Pierre and Marie Curie University - Paris VI, National Institute of Health and Medical Research (INSERM), Mixed Research Unit 974, Center of Research in Myology, Institute of Myology, Pitié-Salpêtrière University Hospital, Paris, France
| | - Madoka Mori-Yoshimura
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Yuko Saito
- Department of Neuropathology, National Center Hospital, NCNP, Kodaira, Japan
| | - Shu-Ichi Ikeda
- Intractable Disease Care Center, Shinshu University Hospital, Matsumoto, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Akira Tanimura
- Division of Hematology, Department of Internal Medicine, National Center for Global Health and Medicine, Shinjuku City, Japan
| | | | - Tomoko Okamoto
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Yasushi Oya
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Miho Murata
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Ichizo Nishino
- Department of Genome Medicine Development, Medical Genome Center, NCNP, Kodaira, Japan.,Department of Neuromuscular Research, National Institute of Neuroscience, NCNP, Kodaira, Japan
| | - Yuji Takahashi
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
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6
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Huser S, Loavenbruck A, Manousakis G. Wild-type Transthyretin Amyloid Myopathy With an Inclusion Body Myositis Phenotype. J Clin Neuromuscul Dis 2020; 22:53-57. [PMID: 32833725 DOI: 10.1097/cnd.0000000000000288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Senile systemic amyloidosis (SSA), or wild-type transthyretin (wtATTR) amyloidosis, is associated most commonly with cardiomyopathy and carpal tunnel syndrome. SSA-associated skeletal myopathy is rare. We describe the case of a patient with SSA who exhibited asymmetric quadriceps and finger flexor weakness, a phenotype usually seen in inclusion body myositis.
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Affiliation(s)
- Sara Huser
- Department of Neurology, University of Minnesota, Minnesota, MN; and
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7
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Yata T, Miwa T, Araki K, Kida T, Toyooka K, Nishino I, Tatsumi C. [A case of systemic AL amyloidosis diagnosed on muscle biopsy]. Rinsho Shinkeigaku 2019; 60:60-63. [PMID: 31852873 DOI: 10.5692/clinicalneurol.cn-001339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 69-year-old man was admitted to our hospital with a 1-year history of progressive easy fatigability while walking. He presented with proximal muscle weakness dominant in the lower extremities, hoarseness, and mild dysphagia. Muscle pseudo-hypertrophy was observed in the gastrocnemius. A biopsy specimen from the left deltoid muscle revealed amyloid deposition in the blood vessels and ring-like fibers. These findings suggested amyloid myopathy. The serum and urine immunofixation electrophoresis detected κ type Bence-Jones proteins, and bone marrow examination showed an increase in atypical plasma cells; thus, we established a diagnosis of multiple myeloma. Thereafter, he experienced frequent diarrhea, and the gastrointestinal endoscopy revealed extensive amyloid deposition in the upper and lower digestive tract. We started treatment with lenalidomide and dexamethasone; however, his condition worsened, and he died of aspiration pneumonia. Amyloid myopathy indicated systemic AL amyloidosis; therefore, muscle biopsy was necessary in this case.
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Affiliation(s)
- Tomohiro Yata
- Department of Neurology, Toyonaka Municipal Hospital.,Department of Neurology, Osaka Toneyama Medical Center
| | - Takashi Miwa
- Department of Neurology, Toyonaka Municipal Hospital.,Department of Neurology, Osaka University Graduate School of Medicine
| | - Katsuya Araki
- Department of Neurology, Toyonaka Municipal Hospital
| | - Toru Kida
- Department of Internal Medicine (Hematology), Toyonaka Municipal Hospital
| | - Keiko Toyooka
- Department of Neurology, Osaka Toneyama Medical Center
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP)
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8
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Hamaguchi M, Fujita H, Suzuki K, Nakamura T, Nishino I, Hirata K. [A male patient with adult-onset sporadic calpainopathy presenting with hypertrophy of the upper extremities]. Rinsho Shinkeigaku 2019; 59:740-745. [PMID: 31656265 DOI: 10.5692/clinicalneurol.cn-001330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 33-year-old man presented with slowly progressive weakness in the lower extremities over 8 years. At the age of 16 years, the elevation of serum creatine kinase level was detected. Physical examination revealed scapular winging, exaggerated lumbar lordosis and tendoachilles contracture. Gowers sign was positive and proximal dominant limb weakness was noted. Hypertrophy was observed in the upper limbs such as the biceps brachii and forearm flexor muscles. Muscle biopsy showed distinct differences in size of muscle fibers and regenerating and necrotic muscle fibers. A histological study revealed decreased calpain3 expression. Gene analysis of CAPN3 revealed two known gene mutations, leading to a diagnosis of calpainopathy (limb girdle muscular dystrophy 2A; LGMD2A). We here report our patient to discuss findings of upper limb hypertrophy, which are frequently missed compared to the lower limb, but important clinical findings.
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Affiliation(s)
| | | | | | | | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neurology, National Center of Neurology and Psychiatry.,Department of Clinical Genome Analysis, Medical Genome Center, National Center of Neurology and Psychiatry
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9
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Salvador B, Cypierre A, Allenbach Y, Liozon E, Fauchais A, Ly K, Jaccard A. Amylose AL : une autre grande simulatrice. Rev Med Interne 2019. [DOI: 10.1016/j.revmed.2019.03.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Sandoval CL, Acosta BJ, Contreras O, Vargas J. Multiple myeloma and light-chain amyloidosis: a rare presentation. CASE REPORTS 2018. [DOI: 10.15446/cr.v4n2.69047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. La amiloidosis sistémica primaria hace parte del espectro de neoplasias de células plasmáticas, donde las cadenas livianas de inmunoglobulina se depositan en múltiples órganos. El compromiso miopático con falla respiratoria y mieloma múltiple asociado es poco frecuente. Caso clínico. Se presenta el caso de un paciente con amiloidosis sistémica de cadenas livianas (AL) quien ingresó por miopatía con falla respiratoria e íleo adinámico, por lo que se llevó a la unidad de cuidados intensivos. Por histología se confirmó infiltración en piel y tracto digestivo y concomitantemente se presentó mieloma múltiple con lesiones óseas líticas y riñón de mieloma. El paciente tuvo buena respuesta al esquema CyBorD (ciclofosfamida, bortezomib, dexametasona), recuperó su función renal y tuvo disminución de las lesiones en piel. Sin embargo, el compromiso gastrointestinal y miopático fue difícil de manejar y se requirió soporte ventilatorio y nutrición parenteral. Discusión. El clínico puede pasar por alto esta patología, por lo que es probable llegar a fases avanzadas de la enfermedad. En la actualidad, con nuevos agentes de quimioterapia y trasplante autólogo, se puede aumentar la sobrevida de estos pacientes. Conclusión. La amiloidosis AL tiene un amplio espectro de manifestaciones y debe considerarse en los diagnósticos diferenciales a fin de hacer un diagnóstico precoz y hacerla una condición tratable.
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11
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Dropped head syndrome with proximal myopathy revealing AL amyloidosis. Joint Bone Spine 2018; 85:779-781. [PMID: 29653282 DOI: 10.1016/j.jbspin.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/04/2018] [Indexed: 11/22/2022]
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12
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A Rare Case of Systemic AL Amyloidosis with Muscle Involvement: A Misleading Diagnosis. Case Rep Hematol 2018; 2018:9840405. [PMID: 29651353 PMCID: PMC5831914 DOI: 10.1155/2018/9840405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/27/2017] [Indexed: 02/03/2023] Open
Abstract
Muscle involvement in AL amyloidosis is a rare condition, and the diagnosis of amyloid myopathy is often delayed and underdiagnosed. Amyloid myopathy may be the initial manifestation and may precede the diagnosis of systemic AL amyloidosis. Here, we report the case of a 73-year-old man who was referred to our center for a monoclonal gammopathy of undetermined significance (MGUS) diagnosed since 1999. He reported a progressive weakness of proximal muscles of the legs with onset six months previously. Muscle biopsy showed mild histopathology featuring alterations of nonspecific type with a mixed myopathic and neurogenic involvement, and the diagnostic turning point was the demonstration of characteristic green birefringence under cross-polarized light following Congo red staining of perimysial vessels. Transmission electron microscopy (TEM) confirmed amyloid fibrils around perimysial vessels associated with collagen fibrils. A stepwise approach to diagnosis and staging of this disorder is critical and involves confirmation of amyloid deposition, identification of the fibril type, assessment of underlying amyloidogenic disorder, and evaluation of the extent and severity of amyloidotic organ involvement.
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13
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Monoclonal gammopathy with both nemaline myopathy and amyloid myopathy. Neuromuscul Disord 2017; 27:942-946. [PMID: 28606401 DOI: 10.1016/j.nmd.2017.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 04/23/2017] [Accepted: 05/05/2017] [Indexed: 11/23/2022]
Abstract
Monoclonal gammopathies due to plasma cell dyscrasias can induce diverse rare neuromuscular disorders. Deposition of monoclonal antibody light chains in skeletal muscle causes amyloid myopathy. Monoclonal gammopathy is occasionally associated with sporadic late-onset nemaline myopathy. Here we report a monoclonal gammopathy patient with both sporadic late-onset nemaline myopathy and amyloid myopathy. The diagnoses were based on immunofixation electrophoresis of urine, and serum for free light chain assay, Congo red staining and Thioflavin S staining of muscle biopsies, as well as immunohistochemical staining and electron-microscopic observation. Nemaline myopathy and amyloid myopathy can present in the same patient with monoclonal gammopathy.
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14
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Kawakami N, Katsuyama Y, Hagiwara Y, Yoshida H, Kim K, Harada K. A case of amyloid myopathy diagnosed during the treatment of myopathy associated with anti-signal recognition particle antibodies. Rinsho Shinkeigaku 2017; 57:168-173. [PMID: 28367947 DOI: 10.5692/clinicalneurol.cn-000974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 78-year-old man presented with subacute progressive proximal weakness and dysphagia. A biopsy specimen from the left biceps femoris revealed evidence of necrotic and regenerating muscle fibers, but lymphocyte infiltration was not noted. The patient was diagnosed with necrotizing myopathy with anti-signal recognition particle (SRP) antibodies. Concomitant therapy with prednisolone and azathioprine caused the serum CK level to return to normal and it caused clinical manifestations to abate. One year later, however, muscle weakness worsened. Immunoelectrophoresis of serum revealed IgG M protein, and muscle pathology revealed amyloid deposits in numerous blood vessels and at the periphery of a few muscle fibers, and deposits stained positive for anti-λ light chain antibody. The patient was diagnosed with amyloid myopathy, and therapy for systemic amyloid light chain amyloidosis caused muscle weakness to diminish. Amyloidosis is believed to be the primary pathology in this case based on the patient's response to treatment reaction, but the significance of a case involving both amyloid myopathy and necrotizing myopathy warranted examination.
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Affiliation(s)
| | | | | | | | - Kang Kim
- Department of Neurology, Shizuoka General Hospital
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Guduru Z, Purohit A, Pu C, Rana S. Amyloid myopathy as the presenting feature of lymphoplasmacytic lymphoma. Ann Indian Acad Neurol 2017; 20:77-78. [PMID: 28298851 PMCID: PMC5341277 DOI: 10.4103/0972-2327.194303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Zain Guduru
- Department of Neurology, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Abhishek Purohit
- Department of Neurology, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Cunfeng Pu
- Department of Neuropathology, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Sandeep Rana
- Department of Neurology, Allegheny General Hospital, Allegheny Health Network, Drexel University College of Medicine, Philadelphia, PA, USA
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Takahashi N, Glockner J, Howe BM, Hartman RP, Kawashima A. Taxonomy and Imaging Manifestations of Systemic Amyloidosis. Radiol Clin North Am 2016; 54:597-612. [DOI: 10.1016/j.rcl.2015.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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17
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Muscle Hypertrophy in a Patient with Immunoglobulin D Multiple Myeloma. J Gen Intern Med 2016; 31:583-4. [PMID: 26450278 PMCID: PMC4835386 DOI: 10.1007/s11606-015-3528-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Miopatía amiloidea como causa de insuficiencia respiratoria. Med Clin (Barc) 2016; 146:e25-6. [DOI: 10.1016/j.medcli.2015.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 08/12/2015] [Accepted: 09/03/2015] [Indexed: 11/23/2022]
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Tanabe H, Maki Y, Urabe S, Higuchi I, Obayashi K, Hokezu Y. Myopathy in a patient with systemic AA amyloidosis possibly induced by psoriasis vulgaris: An autopsy case. Muscle Nerve 2015; 52:1113-7. [DOI: 10.1002/mus.24771] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Hajime Tanabe
- Department of Neurology; Oita Prefectural Hospital; 476 Bunyo Oita 870-0855 Japan
| | - Yoshimitsu Maki
- Department of Neurology; Oita Prefectural Hospital; 476 Bunyo Oita 870-0855 Japan
| | - Shogo Urabe
- Department of Clinical Laboratory; Oita Prefectural Hospital; Oita Japan
| | - Itsuro Higuchi
- School of Health Sciences, Faculty of Medicine, Kagoshima University; Kagoshima Japan
| | - Konen Obayashi
- Diagnostic Unit for Amyloidosis; Department of Laboratory Medicine; Kumamoto University Hospital; Kumamoto Japan
| | - Youichi Hokezu
- Department of Neurology; Oita Prefectural Hospital; 476 Bunyo Oita 870-0855 Japan
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Matsumura E, Yamaguchi T, Tomidokoro Y, Ishii A, Tamaoka A. [A representative case of joint contracture as a main feature of AL amyloid deposits identified in the skeletal muscles]. Rinsho Shinkeigaku 2015; 54:907-10. [PMID: 25420566 DOI: 10.5692/clinicalneurol.54.907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 68-year-old man, with a history of type 2 diabetes mellitus and chronic kidney impairment, had been suffering from progressive knee joint contracture and dysesthesia of the lower extremities for 4 years. When he walked, his knees remained bent owing to contracture of the knee joints. There was no evidence of muscle pseudohypertrophy, intramuscular nodules, or muscle weakness. Clinical examination revealed IgA λ M-protein, reticular high-signal intensity lesions demonstrated by magnetic resonance T2-short TI IR(STIR) imaging of the lower extremity muscles, and a mixture of neurogenic and myogenic changes demonstrated by needle electromyography. A biopsy specimen from the vastus lateralis muscle identified Aλ amyloid deposits around the vessels, establishing a diagnosis of amyloid myopathy based on systemic AL amyloidosis. This case demonstrated that joint contracture and reticular lesions shown by magnetic resonance STIR imaging of the muscles can alert the physician to consider muscle biopsy to investigate deposition of amyloid in the skeletal muscles even in the absence of muscle pseudohypertrophy or weakness, both of which are characteristic of amyloid myopathy.
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Affiliation(s)
- Erika Matsumura
- Department of Neurology, University of Tsukuba Faculty of Medicine
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Lam L, Margeta M, Layzer R. Amyloid polyneuropathy caused by wild-type transthyretin. Muscle Nerve 2015; 52:146-9. [DOI: 10.1002/mus.24563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/18/2014] [Accepted: 12/23/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Lynda Lam
- Department of Neurology; Kaiser Permanente Medical Center; San Rafael California USA
| | - Marta Margeta
- Department of Pathology; University of California; San Francisco California USA
| | - Robert Layzer
- Department of Neurology; University of California; San Francisco California USA
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Vilela VS, Prieto-González S, Milisenda JC, Selva-O´Callaghan A, Grau JM. Polymyositis, a very uncommon isolated disease: clinical and histological re-evaluation after long-term follow-up. Rheumatol Int 2014; 35:915-20. [DOI: 10.1007/s00296-014-3198-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 12/19/2014] [Indexed: 11/28/2022]
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Misumi Y, Doki T, Ueda M, Obayashi K, Tasaki M, Tamura A, Ando Y. Myopathic phenotype of familial amyloid polyneuropathy with a rare transthyretin variant: ATTR Ala45Asp. Amyloid 2014; 21:216-7. [PMID: 24953234 DOI: 10.3109/13506129.2014.932277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Yohei Misumi
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University , Kumamoto , Japan
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Ohtsuka Y, Yasui N, Sekiguchi K, Kowa H, Nishino I, Kanda F, Toda T. [Case of amyloidosis with amyloid deposition detected only in skeletal muscles]. Rinsho Shinkeigaku 2013; 52:739-43. [PMID: 23064623 DOI: 10.5692/clinicalneurol.52.739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 75-year-old man was admitted to our hospital with progressive weakness in the lower extremities for 7 months. Immunoelectrophoresis of serum detected IgA λ type M protein and bone marrow examination detected an increase in monoclonal plasma cells, thus leading to a diagnosis of IgA λ type multiple myeloma. Subsequent muscular CT scan showed severe fatty infiltration of vastus lateralis muscles, and histopathological examinations of biopsied muscle specimens an abundance of abnormal "ring-fiber-like" appearance, positive staining by Congo red and the presence of anti-λ light chain antibody. This led to a diagnosis of amyloid myopathy. No depositions were seen in rectal mucosa, cardiac muscle, or sural nerve. The results of double immunohistochemical staining using anti-dystrophin antibody and anti-λ light chain antibody suggested the possibility of direct injury by amyloid to muscle fibers. The case presented here was thus amyloidosis confirmed by deposition of amyloid only in muscles. In conclusion, when amyloidosis is suspected and there is evidence of muscle injury, muscle biopsy should be performed.
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Affiliation(s)
- Yoshihisa Ohtsuka
- Department of Neurology, Kobe University Graduate School of Medicine
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Rezania K, Pytel P, Smit LJ, Mastrianni J, Dina MA, Highsmith WE, Dogan A. Systemic transthyretin amyloidosis in a patient with bent spine syndrome. Amyloid 2013; 20:131-4. [PMID: 23638719 DOI: 10.3109/13506129.2013.792248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Wild-type and mutant transthyretin (TTR) are implicated in systemic amyloidosis (ATTR). Myopathy is a rare complication of ATTR amyloidosis, however no patient with bent spine syndrome secondary to ATTR amyloidosis has been reported so far. We present the first case of bent spine syndrome in a patient with wild-type ATTR amyloidosis who also had concomitant Alzheimer's disease.
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Affiliation(s)
- Kourosh Rezania
- Department of Neurology, The University of Chicago Medical Center, Chicago, IL, USA.
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Manoli I, Kwan JY, Wang Q, Rushing EJ, Tsokos M, Arai AE, Burch WM, Dispenzieri A, McPherron AC, Gahl WA. Chronic myopathy due to immunoglobulin light chain amyloidosis. Mol Genet Metab 2013; 108:249-54. [PMID: 23465863 PMCID: PMC3608108 DOI: 10.1016/j.ymgme.2013.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 01/25/2013] [Indexed: 11/19/2022]
Abstract
Amyloid myopathy associated with a plasma cell dyscrasia is a rare cause of muscle hypertrophy. It can be a challenging diagnosis, since pathological findings are often elusive. In addition, the mechanism by which immunoglobulin light-chain deposition stimulates muscle overgrowth remains poorly understood. We present a 53-year old female with a 10-year history of progressive generalized muscle overgrowth. Congo-red staining and immunohistochemistry revealed perivascular lambda light chain amyloid deposits, apparent only in a second muscle biopsy. The numbers of central nuclei and satellite cells were increased, suggesting enhanced muscle progenitor cell formation. Despite the chronicity of the light chain disease, the patient showed complete resolution of hematologic findings and significant improvement of her muscle symptoms following autologous bone marrow transplantation. This case highlights the importance of early diagnosis and therapy for this treatable cause of a chronic myopathy with muscle hypertrophy.
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Affiliation(s)
- Irini Manoli
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA.
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Ostrow LW, Corse AM, Morrison BM, Huff CA, Carrino JA, Hoke A, Mammen AL. Expanding the spectrum of monoclonal light chain deposition disease in muscle. Muscle Nerve 2012; 45:755-61. [PMID: 22499107 DOI: 10.1002/mus.23287] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The diagnosis of amyloid myopathy is delayed when monoclonal gammopathies are not detected on initial testing and muscle biopsies are nondiagnostic, and the EMG and symptoms can mimic an inflammatory myopathy. METHODS Case report of a patient presenting with severe progressive muscle weakness of unclear etiology despite an extensive workup including two nondiagnostic muscle biopsies. RESULTS Directed by MRI, a third biopsy revealed amyloid angiopathy and noncongophilic kappa light chain deposition in scattered subsarcolemmal rings and perimysial regions. A serum free light chain (FLC) assay revealed a kappa monoclonal gammopathy, which was not detected by multiple immunofixations. CONCLUSIONS The spectrum of immunoglobulin deposition in muscle is similar to other organs. It comprises a continuum that includes parenchymal amyloid deposition, amyloid angiopathy, and noncongophilic Light Chain Deposition Disease (LCDD). We recommend including the FLC assay in the routine investigation for monoclonal gammopathies. This case also highlights the value of MRI-guided muscle biopsy.
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Affiliation(s)
- Lyle W Ostrow
- Department of Neurology, Johns Hopkins School of Medicine, 733 N. Broadway, Baltimore, Maryland 21205, USA
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Chuquilin M, Al-Lozi M. Primary amyloidosis presenting as "dropped head syndrome". Muscle Nerve 2011; 43:905-9. [PMID: 21607974 DOI: 10.1002/mus.22049] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A 77-year-old man, with a history of lymphoma, presented with isolated neck extensor weakness and a 2-year history of bilateral carpal tunnel syndrome (CTS). Needle electromyography showed myopathic changes, and biopsy of cervical paraspinal muscles showed amyloid deposition in blood vessels. Amyloidosis should be considered in the differential diagnosis of dropped head syndrome.
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Affiliation(s)
- Miguel Chuquilin
- Department of Neurology, Washington University, 660 South Euclid Avenue, Box 8111, St. Louis, Missouri 63110, USA
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Prashantha DK, Taly AB, Sinha S, Yasha TC, Gayathri N, Kovur JME, Vijayan J. Familial amyloidotic polyneuropathy with muscle, vitreous, leptomeningeal, and cardiac involvement: phenotypic, pathological, and MRI description. Ann Indian Acad Neurol 2010; 13:142-4. [PMID: 20814501 PMCID: PMC2924515 DOI: 10.4103/0972-2327.64642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 02/03/2009] [Accepted: 04/07/2009] [Indexed: 11/04/2022] Open
Abstract
Familial amyloidotic polyneuropathy (FAN type 1) is a rare systemic disease that causes severe and disabling peripheral neuropathy. We describe the phenotypic, radiological, and pathological characteristics of a patient with familial amyloid polyneuropathy type 1 who had evidence of motor-sensory-autonomic neuropathy, ocular vitreous deposits, diffuse leptomeningeal involvement, and hypertrophic cardiomyopathy. Muscle involvement, an infrequently reported feature, was also observed. Early recognition of the disease has significant therapeutic implications.
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Affiliation(s)
- D K Prashantha
- Departments of Neurology, Neuroimaging and Interventional Radiology, Bangalore, India
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Amyloid myopathy: a therapeutic trial for the rare and underdiagnosed myopathy with bortezomib. J Neurol 2010; 257:2091-3. [DOI: 10.1007/s00415-010-5642-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 06/19/2010] [Accepted: 06/24/2010] [Indexed: 10/19/2022]
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Abstract
Amyloidosis comprises a group of diseases characterized by the extracellular deposition of insoluble fibrillar proteins. This mechanism generates different clinical syndromes depending on the site and extent of organ involvement. Amyloidosis is classified into categories of systemic and localized disease. Systemic amyloidosis is further subdivided into a hereditary familial form (for example, ATTR amyloidosis), a reactive form (AA amyloidosis), dialysis-related (Abeta(2)M) amyloidosis and immunoglobulin light chain (AL) amyloidosis. Treatment can be symptomatic, directed at the affected organ, or can be directed at reducing the production of the abnormal proteins with different strategies. Despite advances in treatment, the prognosis is still poor and depends on the underlying disease as well as the type and degree of dysfunction in involved organs. Early diagnosis is essential because patients with advanced disease are generally unable to undergo intensive therapy. Patients with systemic amyloidosis often present to a rheumatologist not only because the disease can include musculoskeletal and articular symptoms but also because it can be associated with chronic rheumatic diseases. This Review discusses the clinical features of amyloidosis and its rheumatic manifestations. The various types of amyloidosis, as well their prognosis and treatment, are also presented.
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Tuomaala H, Kärppä M, Tuominen H, Remes AM. Amyloid myopathy: a diagnostic challenge. Neurol Int 2009; 1:e7. [PMID: 21577365 PMCID: PMC3093221 DOI: 10.4081/ni.2009.e7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 06/08/2009] [Accepted: 06/11/2009] [Indexed: 01/09/2023] Open
Abstract
Amyloid myopathy (AM) is a rare manifestation of primary systemic amyloidosis (AL). Like inflammatory myopathies, it presents with proximal muscle weakness and an increased creatine kinase level. We describe a case of AL with severe, rapidly progressive myopathy as the initial symptom. The clinical manifestation and muscle biopsy were suggestive of inclusion body myositis. AM was not suspected until amyloidosis was seen in the gastric mucosal biopsy. The muscle biopsy was then re-examined more specifically, and Congo red staining eventually showed vascular and interstitial amyloid accumulation, which led to a diagnosis of AM. The present case illustrates the fact that the clinical picture of AM can mimic that of inclusion body myositis.
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Hoshi A, Ebitani M, Tanaka G, Nakamura K, Shibano K, Matsuda N, Abe M, Ugawa Y. Amyloid myopathy with external ophthalmoparesis. J Neurol 2009; 256:676-8. [PMID: 19444542 DOI: 10.1007/s00415-009-0138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 10/16/2008] [Accepted: 10/30/2008] [Indexed: 10/20/2022]
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Hoffman-Snyder C, Smith BE. Neuromuscular Disorders Associated with Paraproteinemia. Phys Med Rehabil Clin N Am 2008; 19:61-79, vi. [DOI: 10.1016/j.pmr.2007.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Prokaeva T, Spencer B, Kaut M, Ozonoff A, Doros G, Connors LH, Skinner M, Seldin DC. Soft tissue, joint, and bone manifestations of AL amyloidosis: clinical presentation, molecular features, and survival. ACTA ACUST UNITED AC 2007; 56:3858-68. [PMID: 17968927 DOI: 10.1002/art.22959] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To characterize symptoms and signs of AL amyloidosis that may bring patients to the attention of rheumatologists, evaluate Ig V(L) gene usage in this subgroup of patients, and assess the impact of soft tissue and bone involvement and V(L) gene usage on survival. METHODS Clinical features of soft tissue and bone involvement were assessed in 191 patients with AL amyloidosis. V(L) gene sequencing was carried out to determine light-chain family, rate of somatic mutation, and evidence of antigen selection. The association of soft tissue and bone involvement with V(L) gene usage was assessed by logistic regression analysis, and survival time was analyzed using log rank tests and Cox regression models. RESULTS Soft tissue and bone involvement occurred in 42.9% of the patients, and 9.4% had dominant soft tissue and bone involvement. The most common manifestations were submandibular gland enlargement, macroglossia, and carpal tunnel syndrome. Dominant soft tissue and bone involvement was significantly associated with V(L)kappaI gene usage. Mutation rate and evidence of antigen selection in the V(L) genes were not found to be confounding factors, providing evidence against a contribution of autoimmunity in this type of AL amyloidosis. Survival time was initially longer in patients with dominant soft tissue and bone involvement than in patients with other dominant organ involvement; however, this difference diminished over time. CONCLUSION Amyloid infiltration into soft tissue, joints, periarticular structures, and bones can bring patients with AL amyloidosis to the attention of rheumatologists. Recognition of the presenting symptoms is essential for accurate diagnosis and appropriate treatment, since the long-term outlook for untreated patients with dominant soft tissue and bone involvement is not better than that for patients with other dominant features of AL amyloidosis.
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Affiliation(s)
- Tatiana Prokaeva
- Boston University School of Medicine, Boston, Massachusetts 02118-2526, USA.
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Friedman Y, Paul JT, Turley J, Hazrati LN, Munoz D. Axial myopathy due to primary amyloidosis. Muscle Nerve 2007; 36:542-6. [PMID: 17405139 DOI: 10.1002/mus.20777] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 74-year-old man presented with progressive weakness involving only his back muscles. Serum protein electrophoresis revealed the presence of a monoclonal gammopathy. Muscle biopsy of affected muscles demonstrated amyloid light chain deposition surrounding individual muscle fibers as well as in the walls of blood vessels in association with vasculitis. Selective involvement of axial muscles in isolated amyloid myopathy has not been previously described. We report the occurrence of axial myopathy with associated vasculitis as a presenting feature of primary (AL) amyloidosis. Amyloidosis should be considered in the differential diagnosis of focal myopathies, since the condition may be responsive to chemotherapy.
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Affiliation(s)
- Yael Friedman
- Division of Neurology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Hilton-Jones D. Miscellaneous myopathies. HANDBOOK OF CLINICAL NEUROLOGY 2007; 86:397-409. [PMID: 18809012 DOI: 10.1016/s0072-9752(07)86020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Myopathie amyloïde à propos de quatre observations. Rev Med Interne 2006. [DOI: 10.1016/j.revmed.2006.10.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rodolico C, Mazzeo A, Toscano A, Pastura C, Maimone D, Musumeci O, Musolino C, Vita G. Amyloid myopathy presenting with rhabdomyolysis: evidence of complement activation. Neuromuscul Disord 2006; 16:514-7. [PMID: 16919949 DOI: 10.1016/j.nmd.2006.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 06/12/2006] [Accepted: 06/14/2006] [Indexed: 10/24/2022]
Abstract
At age of 57 years, a man experienced an episode of rhabdomyolysis. On that occasion muscle biopsy was not performed, however monoclonal gammopathy of undetermined significance (MGUS) was diagnosed. Further he developed a moderate proximal muscle weakness with CK level persistently elevated (1000-1200U/l). When he came to our observation, at age 67, a muscle biopsy revealed an amyloid myopathy and multiple myeloma was at the same time disclosed. Terminal complement complex C5b9 (membrane attack complex) deposits were found in the vessel walls and muscle fibers surface depicted by amyloid. Our case suggests to keep in mind the possibility that amyloid myopathy may begin as an isolate episode of rhabdomyolysis. The detection of complement complex C5b9 suggests that complement cascade is implicated in the muscular damage of amyloid myopathy.
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Affiliation(s)
- C Rodolico
- Department of Neurosciences, Psychiatry and Anaesthesiology, University of Messina, Messina, Italy.
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Ikeda SI. Unusual clinical manifestations of primary systemic AL amyloidosis: are myasthenic symptoms and dilated cardiomyopathy caused by muscular or myocardial amyloid angiopathy? Intern Med 2006; 45:123-4. [PMID: 16508223 DOI: 10.2169/internalmedicine.45.0139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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What's in the Literature? J Clin Neuromuscul Dis 2005; 6:180-187. [PMID: 19078771 DOI: 10.1097/01.cnd.0000166394.90546.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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