Immunoglobulins and amyloidosis. An immunologic study of sixty-two patients with biopsy-proved disease

Primary amyloidoma in epidural and paravertebral space of the lumbar spine

BACKGROUND CONTEXT

Localized amyloid deposits result in a mass, that is, so-called amyloidoma; it has been reported in every anatomic site, although systemic amyloid deposition is much more common. However, primary lumbar epidural amyloidoma without bony involvement is extremely rare. To the best of our knowledge, only one case has been reported previously.

PURPOSE

To report and review the clinical presentations, imaging studies, and treatment of epidural and paravertebral amyloidoma.

STUDY DESIGN

A case report and review of the literature.

METHODS

Lumbar epidural and paravertebral amyloidoma in a 75-year-old man with neurologic compromise is presented. Laminectomy with mass resection was performed.

RESULTS

After surgery, almost complete neurologic improvement was observed. Histologically, definite diagnosis was obtained only after the specific staining of tissue. No sign of local recurrence was evident 1 year after surgery.

CONCLUSIONS

Primary amyloidoma, although rare, should be included in the differential diagnosis of epidural mass of the spine. Diagnosis before surgery is difficult as there were no characteristic findings in clinical and imaging studies. Special histologic technique and stains are useful to make a definite diagnosis.

Amyloid goiter: a case of primary thyroid amyloid disease

Amyloid goiter is an atypical presentation of an already rare disease, amyloidosis, which uncommonly comes across in previous review of literature. A patient presented with respiratory distress, which aroused a dilemma on diagnosis because the presentation mimicked that of malignancy. A high index of attentiveness should be kept whenever amyloid deposits are seen on fine needle aspiration cytology, as they are also established in medullary carcinoma. Amyloid deposits have been traced in goiter; however, it was astonishing to observe this condition causing a rapidly growing goiter, large enough to cause respiratory distress. The confirmative diagnosis rested on the histopathology of the specimen.

Primary amyloidoma of the thoracic spine presenting with acute paraplegia

BACKGROUND

Primary solitary amyloidoma of the spine is a rare disease characterized by localized deposition of amyloid. To the best of our knowledge, there have been only 14 cases previously reported in the literature. Patients with focal spinal amyloidoma usually have relatively long symptomatic periods preoperatively, ranging from 3 weeks to 6 years (mean: 12 months). Only two reported patients had acute paraplegia. We add a third case of a thoracic spine amyloidoma presenting with acute paraplegia.

CASE DESCRIPTION

A 65-year-old man presented with a three-day history of progressive paraplegia and urinary retention. He was found to have severe cord compression at T2 on magnetic resonance imaging. He underwent emergent decompressive laminectomy with instrumentation for spinal stabilization. Histopathology revealed abundant amyloid deposits. A systemic work-up was negative for amyloidosis. The patient showed marked neurological improvement with residual mild spastic gait after 1 year.

CONCLUSIONS

Primary spinal amyloidoma with acute paraplegia is rare. One-stage surgery combining prompt decompression and stabilization of the spinal column is mandatory in cases of spinal amyloidoma with acute myelopathy, because primary solitary amyloidoma carries a good prognosis.

Amyloidoma of the thoracic spine. Case report

The authors report the case of a patient with amyloidoma of the thoracic spine. A 34-year-old man presented with a 2-month history of upper-back pain, bilateral lower-extremity weakness, and numbness below the nipple. A computerized tomography study revealed an extradural mass with destruction of the T-2 lamina and pedicle. Intraoperatively, there was a pinkish, partially suctionable mass infiltrating the muscle plane and causing destruction of the T-2 lamina. Histological examination showed typical amyloid masses that demonstrated apple-green double refraction on examination of the Congo red-stained section under polarized light. Amyloidomas are rare benign lesions that, unlike other forms of amyloidosis, have an excellent prognosis. A cure is possible with complete resection of the mass.

[Mechanisms of amyloidosis and the proteins involved]

INTRODUCTION

Recent data in amyloid research have shed light on the amyloid substance and have broadened our knowledge on the mechanism of amyloid deposition.

CURRENT KNOWLEDGE AND KEY POINTS

Despite uniform physical properties relating to the presence of beta-pleates, amyloid deposits are chemically heterogeneous and have different origins; additional types will probably be described in the future. Immunohistochemical techniques using specific antisera for each of the major protein present in fibrils could help greatly to subclassify these disorders. In most circumstances, a circulating precursor protein may result from overproduction of either intact or aberrant molecule, a reduction in its degradation or excretion, or genetic abnormalities associated with variant proteins. The cleavage of protein precursor molecules of the protein component of amyloid fibrils characterizes amyloidogenesis, though it is not necessary for some amyloidosis forms. This review summarizes advances in the understanding of the nature of amyloid substances, the mechanism of amyloid deposition and the principal pathogenic hypothesis.

FUTURE PROSPECTS AND PROJECTS

SAP component is common in all amyloidosis and may be the target for future therapy.

Cervical amyloidoma of C2. Case report and review of the literature

STUDY DESIGN

Second published report of a patient with amyloidoma of the upper cervical spine.

OBJECTIVES

To describe a patient with rare radiculopathy to alert other physicians to consider amyloid tumor as a differential diagnosis of locally destructive spine lesions.

SUMMARY OF BACKGROUND DATA

Localized amyloid tumor of the bone is a rare disease. Only seven cases of spine involvement have been reported. Appropriate tissue sampling is required to establish the diagnosis. Histopathologic examination shows pathognomonic apple-green birefringence under polarized light. When bone is involved with amyloid, it is most commonly associated with multiple myeloma or other plasma cell-dyscrasias.

METHOD

This case was described, and pertinent literature was reviewed.

RESULTS

The patient showed persistent neurologic improvement after transoral complete tumor removal, followed by a secondary posterior stabilization procedure using transarticular C1-C2 screws.

CONCLUSIONS

Amyloidomas are benign lesions with no associated documented risk for the development of plasmocytoma-related diseases. The clinical and radiographic manifestations of this lesion are nonspecific. A cure is possible with complete resection of the tumor and no adjuvant management procedures.

Primary solitary amyloidosis of the spine: a case report and review of the literature

BACKGROUND

Amyloidosis is a term that encompasses a group of disorders that have as their common feature the intercellular deposition of the amyloid protein by several different pathogenetic mechanisms. Primary solitary amyloidosis, or amyloidoma, is a rare subset of amyloidosis in which the amyloid deposition is focal and not secondary to a systemic process or plasma cell dyscrasia. We present the second reported case of a cervical spine amyloidoma and discuss its presentation and management.

METHODS

This 58-year-old man presented with a 1-year history of intermittent chest pain that would radiate into both legs precipitated by valsalva maneuvers. A magnetic resonance imaging (MRI) of the cervical spine revealed a homogenously enhancing lesion focally involving the C-7 vertebral level with significant spinal cord compression. He underwent combined anterior and posterior decompressive procedures with instrumentation for spinal stabilization. Histopathology revealed amyloid deposits and a systemic work-up was negative for amyloidosis.

RESULTS

The patients is free of any tumor recurrence at 24 months and has a stable spine construct.

CONCLUSIONS

Primary solitary amyloidosis is a rare subtype of amyloidosis which, unlike other forms of amyloidosis, has an excellent prognosis with local resection. Diagnosis requires special stains and therefore a degree of suspicion for the disease. Management of vertebral amyloidoma involves aggressive local resection of the tumor when feasible and stabilization of the spine as mandated by the degree of tumor involvement. Complete evaluation for the diagnosis of systemic amyloidosis is essential for the management and prognostication of each case.

Primary amyloidoma of the chest wall

Primary amyloidoma of the chest wall presents as an aggressive tumor that causes local destruction. It is best treated with wide local excision and reconstruction as required, which usually is curative. A search for occult systemic disease also is recommended.

Extraction of amyloid-like fibrils from chronically inflamed periodontal tissues

Immunohistological studies have established an association between the deposition of the amyloid P protein and disease status in chronically inflamed periodontal tissues. The aim of this study was to determine if amyloid-like fibrils could be extracted from these tissues. Biopsies were homogenised and extracted exhaustively in saline before serial extraction in distilled water. Electrophoretic analysis revealed the presence of previously undetected protein bands in the fifth water extraction. These were probed and were found to react with antisera to kappa and lambda immunoglobulin light chains but not with antisera to mu, gamma or alpha heavy chains. Electron microscopic study indicated fibrils of 9.7 nm diameter. These bound Congo Red and exhibited green birefringence under polarised light. The results supported the presence of an amyloid-like matrix composed of immunoglobulin light chains in the lesions of chronic periodontitis. This could explain the persistence of foci of degenerate plasma cells and the paucity of granulation tissue formation in the disease process.

[IgM myeloma: 6 cases and a review of the literature]

IgM myeloma is a rare plasma cell neoplasia, with an estimated incidence of 0.5% in patients with myeloma. Approximately, between 2 and 3.3% of IgM monoclonal gammopathy are IgM myeloma. Six unpublished cases of IgM myeloma, association of an IgM monoclonal gammopathy and an exclusive plasma cell neoplasia, are reported. Forty-six other cases have been found in the literature. The initial clinical characteristics of these patients are: sex-ratio of 1.1, mean age of 62 years, fatigue in 95% of the cases, bone pain in 80%, osteolytic lesions in 78%, fever in 13%, hepatomegaly and splenomegaly in 8%, lymphadenopathy in 10%, hemorrhagic diathesis in 35% and neurologic involvement in 18%. Initial biological features are: anemia in 62% of the cases, creatininemia greater than 20 mg/l in 10%, calcemia greater than 120 mg/l in 24%. Mean serum IgM level is 33 g/l, mean medullary plasmocytosis is 52%. 80% of the patients presented with IgM kappa and only 20% with IgM lambda. Proteinuria with light chains are found in 65%. One-year survival is estimated at 82%, 2-year at 62%, 3-year at 46% with a median of 30 months. No prognostic factor is found. IgM myeloma with characteristics of both myeloma and macroglobulinemia appears well individualized among B-cell neoplasia. However, the distinction between Waldenström's macroglobulinemia and IgM myeloma can be difficult in case of lympho-plasmocytic bone marrow proliferation with osteolytic lesions.

Morphologic differences in the pattern of liver infiltration between systemic AL and AA amyloidosis

Biopsy and necropsy tissue from 31 unselected patients with systemic amyloidosis, in which there was histologic evidence of liver involvement, were reviewed with reference to the location and pattern of amyloid deposition in the liver. Amyloidosis was classified into AA and AL types on the basis of immunohistochemistry and permanganate reaction of the amyloid deposits. Nineteen were categorized as AA (secondary) and 12 as AL (primary) amyloidosis. Deposition of AA amyloid was limited to the walls of vessels in the portal tract, constituting a "vascular" pattern. In AL amyloidosis, the deposits exhibited a "sinusoidal" pattern in that they were seen along hepatic sinusoids as well as in vessel walls. This difference was statistically significant (P less than .001). The histologic pattern of liver infiltration offers a valuable clue in the classification of systemic amyloidosis and provides information that may be useful in the selection of patients for therapy.

Amyloid and amyloidosis

Cutaneous lesions are present in up to 40% of patients with primary and myeloma-associated systemic amyloidosis and occur as a result of tissue deposition of immunoglobulin light chain material derived from a circulating paraprotein. The occurrence of waxy, purpuric mucocutaneous lesions provides a crucial early pointer to underlying occult plasma cell dyscrasia; the combination of the symptoms of the carpal tunnel syndrome, macroglossia, and specific mucocutaneous lesions is highly characteristic. Although secondary systemic (reactive) amyloidosis rarely gives rise to clinically evident cutaneous lesions, it may be etiologically related to a number of chronic dermatoses. Lesions of nodular primary localized cutaneous amyloidosis are indistinguishable from those of primary and myeloma-associated systemic amyloidosis, and they result from local plasma cell infiltration. Macular and papular (lichen amyloidosus) variants of primary localized cutaneous amyloidosis may have a familial or racial basis and are characterized by a tendency for keratinocytes to undergo filamentous degeneration and apoptosis. The prognosis of patients with plasma cell dyscrasia-related systemic amyloidosis remains poor, since there is little response to therapy with cytotoxic agents, colchicine, or dimethylsulfoxide. Colchicine is the drug of choice in the prevention and treatment of the renal amyloidosis associated with familial Mediterranean fever, and dimethylsulfoxide may be useful in the management of patients with secondary systemic amyloidosis. Macular amyloid and lichen amyloidosus generally follow a chronic course with intractable pruritus; there have been isolated reports of the beneficial effect of dermabrasion, topical dimethylsulfoxide, and therapy with the aromatic retinoid, etretinate.

An investigation of the protein components of amyloid using immunoperoxidase and permanganate methods on tissue sections

Amyloid deposits in tissue from 8 patients with generalized primary amyloidosis, 11 patients with generalized secondary amyloidosis, 11 nasopharyngeal carcinomas, 11 basal cell carcinomas, 4 islet cell tumours, 4 medullary carcinomas of the thyroid and 9 cases of lichen amyloidosis were studied using the indirect immunoperoxidase and peroxidase-antiperoxidase methods with specific antisera against Amyloid A (AA) protein and human immunoglobulin lambda and kappa light chains. The permanganate method of Wright was also applied to tissue sections. Positive staining for AA protein was observed only in secondary amyloidosis. There was excellent correlation between AA positivity and permanganate sensitivity. Positivity for immunoglobulin light chains was not observed in secondary amyloidosis but was noted in 5 (63%) cases of primary amyloidosis and 18-27% of intratumour amyloidosis. Lichen amyloidosis did not stain for AA protein or light chains. It is shown that assessment of the permanganate reaction and AA positivity of amyloid deposits can reliably differentiate secondary from primary amyloidosis and may contribute significantly to selection of patients for appropriate therapy.

Primary cardiovascular amyloidosis with benign monoclonal gammopathy

A 54-year-old woman is reported whose primary amyloidosis was diagnosed at autopsy. Amyloid deposits were found in the myocardium, the striated muscles, the smooth muscle layers of the gut and the wall of the blood vessels. The deposits showed resistance to induced proteolysis. A large number of mature plasma cells was demonstrated in the bone marrow, and immunocytochemical studies revealed a considerable increase in the proportion of plasma cells which were positive for kappa light chains of immunoglobulins, indicating a monoclonal gammopathy. This view was strongly supported by the unexpected finding that amyloid deposits were positive for kappa light chains. The relationship between the kappa positive reaction of amyloid and its resistance to induced proteolysis are discussed.

Localized amyloidosis in basal cell carcinoma. A pathologic study

Congo-red screening demonstrated intratumor deposits of amyloid in 35 of 53 unselected cases of basal cell carcinoma. Male subjects had a higher amyloid positivity rate than female subjects. The amyloid deposits were permanganate-resistant and located in the stroma between clumps of tumor cells, as well as abutting the advancing front of the neoplasm. Solar elastosis was often observed in the overlying and adjacent subepidermis. The relationship between amyloid positivity and the different histological subtypes of basal cell carcinoma, tumor ulceration, and density of the lymphoplasmacytic stromal infiltrate were also studied. The possibility that amyloid originates from the tumor cells and is a result of tumor apoptosis (degeneration) is discussed.

Spinal cord compression by amyloid tissue

Spinal cord compression by a mass of amyloid tissue arising from the thoracic vertebrae is described in a 72-year-old female. Investigations failed to provide a primary cause for this amyloid tissue.

Intracellular immunoglobulin distribution of bone marrow plasma cells as a diagnostic aid for primary amyloidosis

In order to classify the underlying disorder in four patients with biopsy-proven amyloidosis without overt monoclonal gammopathy, the cytoplasmic immunoglobulin (Ig) distribution of bone marrow plasma cells was evaluated using direct immunofluorescence microscopy. This procedure revealed the presence of a monoclonal proliferation of light chain containing plasma cells, and thus led to the diagnosis of immunoglobulin-related amyloidosis.

Nodular pulmonary amyloidosis associated with benign hypergammaglobulinemic purpura

A 59-year-old woman, who had had benign hypergammaglobulinemic purpura for three years, developed a solitary amyloid nodule of the lung. The benign hypergammaglobulinemia was associated with an IgG band of restricted heterogeneity and IG2-IgG3 subclass containing complexes of intermediate size with rheumatoid factor activity. Serum levels of IgA and IgM were also increased. Autopsy after death from an unrelated cause revealed no amyloid in the remainder of the lungs or other organs and no evidence of lymphoproliferative disorder.

Pseudotumoral (para-articular) amyloidosis in non-myelomatous monoclonal gammopathy

A case of non-myelomatous monoclonal gammopathy, with the unusual presenting features of recurrent "pseudotumoral" localized amyloid deposits in intimate relation with the shoulder joints, is described. The peculiar anatomo-clinical features, which make this case quite different from the most reported ones of amyloid arthropathy and of localized amyloidosis, are discussed. The pathogenetic implications are analyzed with special reference to the various known mechanisms, none of which seems to provide a completely satisfactory explanation of the genesis of this form.

Primary amyloidosis, pure red cell aplasia, and Kaposi's sarcoma in a single patient

A patient who developed primary amyloidosis, pure red cell aplasia, and Kaposi's sarcoma is described. This is the second reported coincidence of Kaposi's sarcoma and pure red cell aplasia and the first coincidence of Kaposi's sarcoma and primary amyloid, thus enlarging the spectrum of plasma cell and immunoglobulin abnormalities seen in Kaposi's sarcoma. Because immunologic abnormalities have been described in all these diseases, it is felt that some primary immune dysfunction is the underlying cause of the three diseases in this patient.

Pleomorphic reticulum cell sarcoma, monoclonal gammopathy and amyloidosis: an immunoperoxidase study

Pleomorphic reticulum cell sarcoma, a histologic variant of the histiocytic lymphomas, presented as an abdominal mass in a 52-year-old woman. Extensive amyloid deposition was present within the tumor mass and an M-component (IgG Lambda) was identified in the serum. Direct immunoperoxidase staining of tissue sections demonstrated the same monoclonal immunoglobulin to be present within the neoplastic cells, presumptive evidence of their ability to both synthesize and secrete immunoglobulin. The presence of amyloid within this patient was probably the direct result of the tissue deposition of this monoclonal immunoglobulin and may be related to the amyloidogenic nature of Lambda light chains. Immunoglobulin production is a specific property of the B lymphocyte series. Transforming B lymphocytes and their differentiating progeny are engaged in active immunoglobulin synthesis and thus may be distinguished from morphologically identical but functionally distinct cells. The demonstration of cytoplasmic monoclonal immunoglobulin within these "malignant reticulum cells" strongly supports the assertion that at least some "histiocytic lymphomas" are neoplastic analogues of transformed B lymphocytes, and are not derived from phagocytic histiocytes, as previously believed.

Nodular malignant lymphoma and amyloidosis. A case report

A case of long-standing, nodular malignant lymphoma of lymphocytic type associated with nephrotic syndrome and systemic amyloidosis is presented. Review of literature revealed only six previously reported cases of systemic amyloidosis complicating non-Hodgkin's lymphomas. Recent studies have revealed that all of the nodular lymphomas are B-lymphocyte malignancies; that nodular lymphomas have high incidence (46-64%) of abnormality of intracellular immunoglobulin synthesis; that abnormality of serum immunoglobulin in such patients in uncommon (0-8%); and that at least one type of amyloid fibrils is made up of immunoglobulin light chains. These findings would suggest that there is an etiologic relationship between nodular lymphoma and systemic amyloidosis.

Primary diffuse pulmonary amyloidosis with monoclonal gammopathy

A rare case of primary diffuse amyloidosis of the lung with an abnormal monoclonal protein is described. The diagnosis was confirmed by an open-lung biopsy. The different classifications of amyloidosis as well as the relationship between the immunoglobulins and the pathogenesis of amyloid disease is discussed.

Primary amyloidosis and myelomatosis associated with excessive fibrinolytic acitivty

A case of primary amyloidosis is described in association with Bence-Jones myeloma and increased fibrinolytic activity. Epsilon aminocaproic acid reversed the fibrinolytic activity and clinical improvement was maintained with melphalan and prednisolone.

Amyloidosis and Light Chain Plasmocytoma

Nine cases of light chain plasmocytomas, 6 type λ and 3 type k, have been studied in reference to amyloid presence and localisation. Bone marrow plasmocytosis, light chains in serum and/or in the urine, and osteolytic lesions were demonstrated in all the patients. Initial symptoms, i.e., macroglossia and lymphadenopathy, were secondary to amyloid deposits in two patients; the absence of overt evidence of plasmocytoma had previously led to the diagnosis of « primary » amyloidosis in one case. Amyloidosis may therefore be associated with concealed plasmocytomas, evident only after a certain period of time. Amyloidosis was not detected in the sites where it was clinically suspected in two cases. However, on bone marrow aspirates, amyloid was present in seven patients where thioflavine T appeared as homogeneous, amorphous, intercellular substance localised in small areas.

Comprehensive study of humoral and cellular immune abnormalities in 26 patients with systemic amyloidosis

Serum immunoglobulin abnromalities in nonfamilial and systemic primary amyloidosis are distinct from those seen in multiple myeloma and more closely resemble those seen in benign monoclonal gammopathy. Surface lymphocyte characteristics also differentiate amyloid patients with or without monoclonal immunoglobulins from those with malignant B-cell dyscrasias. In vitro lymphocyte transformation with phytohemagglutinin and pokeweed mitogen is normal in amyloidosis, but T-cell function is significantly depressed in both primary and secondary amyloid disease as measured by concanavalin A responses.

Manifestations of systemic light chain deposition

In two patients with terminal renal failure, manifestations of disease developed in multiple organ systems. One had a previous diagnosis of multiple myeloma with kappa light chain proteinemia and proteinuria. The other had idiopathic lobular glomerulonephritis. Hepatic and neurologic abnormalities developed in both; in the latter gastrointestinal, cardiac and endocrine disease developed as well. Clinical and pathologic correlations suggest that the retention and tissue deposition of light chains produced the organ dysfunction, inasmuch as free kappa light chain determinants were demonstrated histologically in the clinically affected organs. The deposition in these patients may be an extreme example of a common but previously unrecognized form of plasma cell dyscrasia.

Amyloidosis associated with dermatomyositis and features of multiple myeloma. The progression of amyloidosis associated with corticosteroid and cytotoxic drug therapy

Described here is a 59 year old man with dermatomyositis and hypogammaglobulinemia. His muscle power improved after corticosteroid therapy, but extensive amyloidosis and repeated infections appeared. Bone marrow morphology suggested multiple myeloma, but treatment with cytotoxic drugs had no beneficial effect on the amyloidosis. Because of rapid progression of the amyloidosis and further infections, cytotoxic drug therapy was stopped, corticosteroid dosage was decreased, and supplementary immunoglobulin therapy was instituted. The infections occurred less frequently and the amyloidosis appeared to regress. This case suggests that immunosuppressive therapy may exacerbate amyloidosis. The literature is reviewed, and the possible role of humoral immunodeficiency in the pathogenesis of amyloidosis is discussed. It is suggested that supplementary immunoglobulin may be beneficial in amyloidosis.

The clinical spectrum of light chain myeloma. A study of 35 patients with special reference to the occurrence of amyloidosis

During a 40 month interval, 35 patients were seen with a plasma cell dyscrasia in which the only detectable monoclonal immunoglobulin abnormality consisted of excess production of either type kappa or type lambda light chains (Bence Jones protein). This group constituted 17.3 per cent of the total number of patients with plasma cell dyscrasias and 25.7 per cent of the patients with myeloma identified during the same period. Variable initial clinical presentation, the absence of a typical monoclonal serum spike and the unreliability of commonly used urine protein tests made recognition of the disorder difficult in many patients. Sulfosalicylic acid and p-toluene sulfonic acid proved valuable in screening for ueine protein. Definition of "proteinuria" by quantitative, electrophoretic and immunochemical studies was essential for diagnosis. Bence Jones proteinemia was present in 80 per cent of the patients; panhypogammaglobulinemia and lytic bone lesions were demonstrable in more than 60 per cent. Although no specific morphologic abnormality of marrow plasma cells was evident by light microscopy, the absence of rouleau on peripheral blood smear was a helpful diagnostic clue. Although patients with lambda light chains presented with more Bence Jones proteinuria, this did not correlate with the severity of initial renal functional impairment or with survival when compared to patients with kappa light chains. No other clinical or laboratory observation differentiated the groups with kappa light chains from those with lambda light chains. Amyloid was identified in seven patients. Their course was dominated by the features of primary systemic amyloidosis instead of the usual findings of classic myeloma. Patients with amyloidosis had lower initial serum albumin levels, fewer lytic bone lesions and reduced survival compared to patients without amyloidosis.

Multiple nodular pulmonary amyloidosis. A case report and comparison with diffuse alveolar-septal pulmonary amyloidosis

A case of multiple nodular pulmonary amyloidosis in a 54-year-old Caucasian man is presented. Discrete symptomless radiodensities had developed in this patient's lungs within a period of three years, leading to a suspicion of a neoplastic process. The amyloid nature of these nodules was demonstrated by biopsy. In this case, as in others previously reported, there was no evidence of systemic disease, and immunoglobulins were normal. Local factors probably play an important part in the pathogenesis of this disease. This entity is to be distinguished from the diffuse type of pulmonary amyloidosis, which has a far graver prognosis. Diffuse alveolar septal amyloidosis is usually associated with primary systemic amyloidosis or multiple myeloma and leads rapidly to respiratory distress.

Neuropathy, M components, and amyloid

Of eighty-seven patients with nonhereditary systemic amyloidosis, ten had evidence of peripheral neuropathy. There was median-nerve neuropathy due to infiltration of the flexor retinaculum with amyloid in six patients. Two patients had diffuse sensorimotor neuropathy and two patients had sensory loss without evidence of motor impairment--three of these cases had amyloid deposition demonstrated by nerve biopsy. Neurological manifestations in all ten patients preceded other evidence of amyloidosis by 6 months-4 years (mean, 1 to 5 years). Neuropathy occurred in six of thirty-eight patients with primary amyloidosis and four of fourteen with amyloidosis associated with malignant B-cell dyscraias; and all patients with neuropathy had either a serum-M-component or Bence-Jones proteinuria. In contrast, neuropathy was not noted in any of the fifty-six patients in this series who had no evidence of a monoclonal gammopathy (thirty-five with secondary and twenty-one with primary amyloidosis).