1
|
De Michieli L, Sinigiani G, De Gaspari M, Branca A, Rizzo S, Basso C, Trentin L, Iliceto S, Perazzolo Marra M, Cipriani A, Berno T. Light-chain cardiac amyloidosis for the non-expert: pearls and pitfalls. Intern Emerg Med 2023; 18:1879-1886. [PMID: 37338717 PMCID: PMC10543940 DOI: 10.1007/s11739-023-03335-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
Cardiac amyloidosis (CA) is an uncommon, progressive, and fatal disease; the two main forms that can affect the heart are transthyretin CA and light chain CA (AL-CA). AL-CA is a medical urgency for which a diagnostic delay can be catastrophic for patients' outcome. In this manuscript, we focus on the pearls and pitfalls that are relevant to achieve a correct diagnosis and to avoid diagnostic and therapeutical delays. Through the aid of three unfortunate clinical cases, some fundamental diagnostic aspects are addressed, including the following: first, a negative bone scintigraphy does not exclude CA, with patients with AL-CA frequently showing no or mild cardiac uptake, and its execution should not delay hematological tests; second, fat pad biopsy does not have a 100% sensitivity for AL amyloidosis and, if negative, further investigations should be performed, particularly if the pre-test probability is high. Third, Congo Red staining is not sufficient to reach a definitive diagnosis and amyloid fibrils typing with mass spectrometry, immunohistochemistry, or immunoelectron microscopy is crucial. To achieve a timely and correct diagnosis, all the necessary investigations must be performed, always considering the yield and diagnostic accuracy of each examination.
Collapse
Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
| | - Monica De Gaspari
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Antonio Branca
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Stefania Rizzo
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Tamara Berno
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| |
Collapse
|
2
|
Staron A, Mendelson LM, Joshi T, Ruberg FL, Sanchorawala V. Factors affecting the accuracy of amyloidosis identification and referral to a specialty centre. Amyloid 2023; 30:297-302. [PMID: 36718932 DOI: 10.1080/13506129.2023.2171787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Diagnostic algorithms for amyloidosis have evolved over the past decade, particularly with the incorporation of imaging-based techniques to detect amyloid cardiomyopathy. We sought to identify the key sources of amyloidosis misidentification in the community, which lead to false positive referrals to a tertiary centre. METHODS We conducted a retrospective review of all referrals to the Amyloidosis Centre from 2010 to 2021 and identified cases lacking amyloid pathology upon final adjudication after extensive assessment at the centre. Factors for false positive referrals were examined. RESULTS Among 2409 referrals of suspected amyloidosis, 147 (6%) demonstrated an absence of amyloid pathology. This percentage increased over time from 4% in 2010 to 13% in 2021. False positive referrals consisted of more people of colour. The most frequent source of inaccuracy was the erroneous staining of tissue specimens with Congo red, followed by suggestive findings on cardiac imaging. In recent years, misinterpretation of 99mtechnetium- pyrophosphate scintigraphy emerged as a major source of false positive referrals. CONCLUSION Recognising these potential sources of diagnostic error in the workup of amyloidosis can improve patient care. Referral to a centre of excellence for amyloidosis helps confirm an accurate diagnosis and avoid mistreatment.
Collapse
Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa M Mendelson
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| |
Collapse
|
3
|
Moriyama H, Kitakata H, Endo J, Ikura H, Sano M, Tasaki M, Sakai S, Ueda M, Fukuda K. Step‐by‐step typing for the accurate diagnosis of concurrent light chain and transthyretin cardiac amyloidosis. ESC Heart Fail 2022; 9:1474-1477. [PMID: 35060353 PMCID: PMC8934961 DOI: 10.1002/ehf2.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/09/2021] [Accepted: 12/02/2021] [Indexed: 11/11/2022] Open
Abstract
While 99mTc‐pyrophosphate scintigraphy is clearly useful in diagnosing transthyretin amyloid cardiomyopathy (ATTR‐CM), it is necessary to know the pitfalls of this test for proper use. We present a rare case of concurrent ATTR‐CM and amyloid light chain (AL) cardiomyopathy. The patient showed congestive heart failure with left ventricular hypertrophy. 99mTc‐pyrophosphate scintigraphy revealed abnormal cardiac uptake of Grade 3, a typical feature for ATTR‐CM. However, the patient showed renal impairment with proteinuria and the presence of monoclonal gammopathy, which rather suggested AL amyloidosis. Endomyocardial biopsy, immunohistochemistry, and proteomic analysis by laser microdissection with liquid chromatography‐coupled tandem mass spectrometry were performed, which finally confirmed both ATTR‐CM and AL cardiomyopathy. This case implicates the importance of combining examinations and precisely interpreting the results to diagnose cardiac amyloidosis accurately.
Collapse
Affiliation(s)
- Hidenori Moriyama
- Department of Cardiology Keio University School of Medicine 35 Shinanomachi, Shinjuku‐ku Tokyo 160‐8582 Japan
| | - Hiroki Kitakata
- Department of Cardiology Keio University School of Medicine 35 Shinanomachi, Shinjuku‐ku Tokyo 160‐8582 Japan
| | - Jin Endo
- Department of Cardiology Keio University School of Medicine 35 Shinanomachi, Shinjuku‐ku Tokyo 160‐8582 Japan
| | - Hidehiko Ikura
- Department of Cardiology Keio University School of Medicine 35 Shinanomachi, Shinjuku‐ku Tokyo 160‐8582 Japan
| | - Motoaki Sano
- Department of Cardiology Keio University School of Medicine 35 Shinanomachi, Shinjuku‐ku Tokyo 160‐8582 Japan
| | - Masayoshi Tasaki
- Department of Neurology, Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
- Department of Morphological and Physiological Sciences, Graduate School of Health Sciences Kumamoto University Kumamoto Japan
| | - Shunta Sakai
- Department of Cardiology Showa General Hospital Tokyo Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences Kumamoto University Kumamoto Japan
| | - Keiichi Fukuda
- Department of Cardiology Keio University School of Medicine 35 Shinanomachi, Shinjuku‐ku Tokyo 160‐8582 Japan
| |
Collapse
|
4
|
Shintani-Domoto Y, Ishino K, Naiki H, Sakatani T, Ohashi R. Autopsy case with concurrent transthyretin and immunoglobulin amyloidosis. Pathol Int 2021; 72:65-71. [PMID: 34637570 DOI: 10.1111/pin.13179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
An 85-year-old man with a history of aortic dissection suddenly fainted, underwent cardiac heart arrest, and died. An autopsy was performed, but the cause of death was not grossly identified. Congo red staining detected amyloid deposits in systemic organs, including the heart, lungs, liver, and kidneys. Immunohistochemical (IHC) analysis revealed immunoglobulin (Ig) λ light chain (-λ) in systemic blood vessels and transthyretin (TTR) in the heart and lungs. Ig-λ was predominantly positive in the blood vessels of the lungs, while TTR was detected in the alveolar septum. In the heart, Ig-λ was positive in the endocardium and blood vessels, and TTR was positive in nodular deposits between cardiomyocytes. The concurrent deposition of Ig-λ and TTR in the heart was further substantiated by laser microdissection (LMD)-liquid chromatography-tandem mass spectrometry (LC-MS/MS) at each deposition site. Despite systemic deposition of Ig-λ, bone marrow biopsy findings were not diagnostic for multiple myeloma. In summary, we present an autopsy case of concurrent Ig-λ and TTR deposition as revealed by IHC and LC-MS/MS. When Congo red staining and IHC results are indeterminate due to the deposition of multiple amyloid proteins, LMD-LC-MS/MS is useful for determining the precursor protein.
Collapse
Affiliation(s)
| | - Kousuke Ishino
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Tokyo, Japan
| | - Hironobu Naiki
- Department of Molecular Pathology, University of Fukui, Fukui, Japan
| | - Takashi Sakatani
- Department of Diagnostic Pathology, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Hospital, Tokyo, Japan.,Department of Integrated Diagnostic Pathology, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
5
|
Staron A, Connors LH, Zheng L, Doros G, Sanchorawala V. Race/ethnicity in systemic AL amyloidosis: perspectives on disease and outcome disparities. Blood Cancer J 2020; 10:118. [PMID: 33173025 PMCID: PMC7655813 DOI: 10.1038/s41408-020-00385-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/01/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023] Open
Abstract
In marked contrast to multiple myeloma, racial/ethnic minorities are underrepresented in publications of systemic light-chain (AL) amyloidosis. The impact of race/ethnicity is therefore lacking in the narrative of this disease. To address this gap, we compared disease characteristics, treatments, and outcomes across racial/ethnic groups in a referred cohort of patients with AL amyloidosis from 1990 to 2020. Among 2416 patients, 14% were minorities. Non-Hispanic Blacks (NHBs) comprised 8% and had higher-risk sociodemographic factors. Hispanics comprised 4% and presented with disproportionately more BU stage IIIb cardiac involvement (27% vs. 4-17%). At onset, minority groups were younger in age by 4-6 years. There was indication of more aggressive disease phenotype among NHBs with higher prevalence of difference between involved and uninvolved free light chains >180 mg/L (39% vs. 22-33%, P = 0.044). Receipt of stem cell transplantation was 30% lower in Hispanics compared to non-Hispanic White (NHWs) on account of sociodemographic and physiologic factors. Although the age/sex-adjusted hazard for death among NHBs was 24% higher relative to NHWs (P = 0.020), race/ethnicity itself did not impact survival after controlling for disease severity and treatment variables. These findings highlight the complexities of racial/ethnic disparities in AL amyloidosis. Directed efforts by providers and advocacy groups are needed to expand access to testing and effective treatments within underprivileged communities.
Collapse
Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
- Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
| | - Lawreen H Connors
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
| | - Luke Zheng
- Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA, USA
| | - Gheorghe Doros
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA.
- Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA.
| |
Collapse
|