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Venkatesh SK, Hoodeshenas S, Venkatesh SH, Dispenzieri A, Gertz MA, Torbenson MS, Ehman RL. Magnetic Resonance Elastography of Liver in Light Chain Amyloidosis. J Clin Med 2019; 8:jcm8050739. [PMID: 31126105 PMCID: PMC6572504 DOI: 10.3390/jcm8050739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/21/2022] Open
Abstract
In this paper, we present our preliminary findings regarding magnetic resonance elastography (MRE) on the livers of 10 patients with systemic amyloidosis. Mean liver stiffness measurements (LSM) and spleen stiffness measurements (SSM) were obtained. Magnetic resonance imaging (MRI) images were analyzed for the distribution pattern of amyloid deposition. Pearson correlation analysis was performed in order to study the correlation between LSM, SSM, liver span, liver volume, spleen span, spleen volume, serum alkaline phosphatase (ALP), N-terminal pro b-type natriuretic peptide (NT pro BNP), and the kappa and lambda free light chains. An increase in mean LSM was seen in all patients. Pearson correlation analysis showed a statistically significant correlation between LSM and liver volume (r = 0.78, p = 0.007) and kappa chain level (r = 0.65, p = 0.04). Interestingly, LSM did not correlate significantly with SSM (r = 0.45, p = 0.18), liver span (r = 0.57, p = 0.08), or serum ALP (r = 0.60, p = 0.07). However, LSM correlated significantly with serum ALP when corrected for liver volume (partial correlation, r = 0.71, p = 0.03) and NT pro BNP levels (partial correlation, r = 0.68, p = 0.04). MRI review revealed that amyloid deposition in the liver can be diffuse, lobar, or focal. MRE is useful for the evaluation of hepatic amyloidosis and shows increased stiffness in hepatic amyloidosis. MRE has the potential to be a non-invasive quantitative imaging marker for hepatic amyloidosis.
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Affiliation(s)
- Sudhakar K Venkatesh
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Safa Hoodeshenas
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Sandeep H Venkatesh
- Department of Radiology, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886, Singapore.
| | - Angela Dispenzieri
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Morie A Gertz
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Michael S Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Primary Amyloidosis Manifesting as Cholestatic Jaundice after Laparoscopic Cholecystectomy. Case Rep Surg 2015; 2015:353818. [PMID: 26137342 PMCID: PMC4475520 DOI: 10.1155/2015/353818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/20/2015] [Indexed: 11/17/2022] Open
Abstract
A 71-year-old female patient with cholelithiasis who had undergone laparoscopic cholecystectomy was admitted with obstructive jaundice (total bilirubin ~6 mg/dL) three months later. An ERCP was performed, in which a gallstone was found, followed by a sphincterotomy and cleansing of the bile duct. Due to deterioration of jaundice (>25 mg/dL), a new, unsuccessful ERCP and stent placement was carried out. Because of ongoing cardiac failure, she underwent an echocardiogram which revealed restrictive cardiomyopathy possibly due to amyloidosis. A liver biopsy was performed, which was positive for amyloid deposits in the liver, and the diagnosis was confirmed by the detection of monoclonal λ IgG protein in urine. The patient's jaundice gradually deteriorated and she died one week later from hepatic insufficiency.
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Abstract
Amyloidosis is characterized by extracellular deposition of abnormal protein. There are six types: primary, secondary, hemodialysis-related, hereditary, senile, and localized. Primary (AL) amyloidosis is associated with monoclonal light chains in serum and/or urine with 15% of patients having multiple myeloma. Secondary (AA) amyloidosis is associated with inflammatory, infectious, and neoplastic diseases. The presentation is protean, including macroglossia, a dilated and atonic esophagus, gastric polyps or enlarged folds, and luminal narrowing or ulceration of the colon. Amyloid deposition in the gastrointestinal (GI) tract is greatest in the small intestine. The symptoms include diarrhea, steatorrhea, or constipation. Pseudo-obstruction carries a particularly grave prognosis, often not responding to pro-motility agents. Hepatic involvement is common, but the clinical manifestations are usually mild with hepatomegaly and an elevated alkaline phosphatase level. Biopsies to diagnose amyloidosis can be taken from the fat, kidney, intestine, or bone marrow. The safety of liver biopsies is controversial. With Congo Red stain, amyloid appears red in normal light and apple-green in polarized light. Treatment for AL amyloidosis is chemotherapy and stem cell transplantation; treatment for AA amyloidosis is control of the underlying disease. Amyloidosis should be considered in patients with proteinuria, cardiomyopathy, hepatomegaly (with mildly abnormal liver tests), peripheral and autonomic neuropathy, weight loss, and GI symptoms.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 09803, USA
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Park MA, Mueller PS, Kyle RA, Larson DR, Plevak MF, Gertz MA. Primary (AL) hepatic amyloidosis: clinical features and natural history in 98 patients. Medicine (Baltimore) 2003; 82:291-8. [PMID: 14530778 DOI: 10.1097/01.md.0000091183.93122.c7] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The liver is a common site of amyloid deposition in primary systemic amyloidosis. We reviewed the clinical features and natural history of patients with primary systemic amyloidosis and biopsy-proven hepatic involvement who were evaluated at Mayo Clinic from January 1, 1975, to December 31, 1997. The median age of the study group (68 men; 30 women) was 58.5 years. Seventy-one patients (72%) had involuntary weight loss. Hepatomegaly was found in 79 patients (81%). Eighty-two patients (89%) had proteinuria, and 81 patients (86%) had elevated serum alkaline phosphatase levels. Seventy-six patients (83%) had either a serum or urine monoclonal protein. Before liver biopsy, clinicians considered amyloidosis in the differential diagnosis for only 14 patients (26%). None of our patients experienced hepatic rupture or death due to liver biopsy, and only 4 (4%) bled after liver biopsy. The median survival of the 98 patients was 8.5 months. Predictors of a poor prognosis were congestive heart failure, elevated concentrations of bilirubin, and a platelet count greater than 500 x 109/L. In conclusion, clinicians should consider the diagnosis of primary hepatic amyloidosis in patients who present with involuntary weight loss or hepatomegaly. Other clues to the diagnosis include an unexplained elevated serum alkaline phosphatase level, proteinuria, and evidence for hyposplenism (for example, Howell-Jolly bodies on peripheral blood smear). Liver biopsy was safe. Some patients benefit from systemic chemotherapy.
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Affiliation(s)
- Miguel A Park
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Iwai M, Ishii Y, Mori T, Harada Y, Kitagawa Y, Kashiwadani M, Ou O, Okanoue T, Kashima K. Cholestatic jaundice in two patients with primary amyloidosis: ultrastructural findings of the liver. J Clin Gastroenterol 1999; 28:162-6. [PMID: 10078828 DOI: 10.1097/00004836-199903000-00017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Two patients with primary amyloidosis (amyloid light chain case) and severe cholestatic jaundice are described. Liver biopsy in the preterminal stage demonstrated amyloid deposits in the perisinusoidal space and in portal tracts, and hepatocytes were atrophic because of compression by amyloid fibrils. Ultrastructural findings showed amyloid fibrils not only in Disse's space but also in the sinusoids, and the hepatocyte microvilli facing the amyloid fibrils were spicular. There were aggregates of lysosomal granules in the vicinity of bile canaliculi and some bile canaliculi were dilated with loss of microvilli. Amyloid fibrils in the portal tract compressed bile ductules, causing wide intercellular space and separated basement membranes from their epitheliums. These findings suggested disturbance in transporting not only of essential materials from sinusoids to hepatocytes but also of secretory vesicles into bile canaliculi and leakage of bile juice from small bile ductules in preterminal stage of primary amyloidosis.
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Affiliation(s)
- M Iwai
- Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, Japan
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Yamamoto T, Maeda N, Kawasaki H. Hepatic failure in a case of multiple myeloma-associated amyloidosis (kappa-AL). J Gastroenterol 1995; 30:393-7. [PMID: 7647907 DOI: 10.1007/bf02347517] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We report a case of kappa-AL amyloidosis which rapidly developed hepatic failure in a 79-year-old Japanese female who was admitted to our hospital because of abdominal distension and loss of appetite. Laboratory examination revealed a marked deterioration of liver function with cholestasis and monoclonal gammapathy. At the time that the diagnosis of IgG-kappa type multiple myeloma was made, jaundice was advanced, with continuous gastrointestinal bleeding. The patient died of hepatic failure 2 weeks after admission. Needle biopsy of the liver revealed a diffuse, massive deposition of amyloid protein.
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Affiliation(s)
- T Yamamoto
- Second Department of Internal Medicine, Tottori University Faculty of Medicine, Yonago, Japan
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Peters RA, Koukoulis G, Gimson A, Portmann B, Westaby D, Williams R. Primary amyloidosis and severe intrahepatic cholestatic jaundice. Gut 1994; 35:1322-5. [PMID: 7959246 PMCID: PMC1375717 DOI: 10.1136/gut.35.9.1322] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Liver involvement in systemic amyloidosis is frequent but is rarely of clinical importance. Five patients with severe cholestatic jaundice are described and an additional 20 from published reports are reviewed. The most frequent presenting symptoms were lethargy and abdominal pain, which were present for a median of 11 months before the onset of jaundice. Hepatomegaly, usually marked, was present in 92%, with ascites in 56% of the cases. The serum bilirubin concentration was noticeably high and the serum globulin low. Histology of the liver showed considerable perisinusoidal deposition with a slight predilection for the periportal area. Two patients presented with predominant centrilobular deposition. Congo red staining was not uniformly positive. A variety of treatment regimens was tried but median survival was only three months from the onset of jaundice.
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Affiliation(s)
- R A Peters
- Institute of Liver Studies, King's College School of Medicine and Dentistry, King's College Hospital, London
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Terada T, Hirata K, Hisada Y, Hoshii Y, Nakanuma Y. Obstructive jaundice caused by the deposition of amyloid-like substances in the extrahepatic and large intrahepatic bile ducts in a patient with multiple myeloma. Histopathology 1994; 24:485-7. [PMID: 8088723 DOI: 10.1111/j.1365-2559.1994.tb00560.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Obstructive jaundice has rarely been reported in liver amyloidosis. We report here an autopsy of a 55-year-old woman with multiple myeloma and obstructive jaundice due to the deposition of amyloid-like substances in the walls and lumina of the extrahepatic bile duct and intrahepatic large bile ducts, resulting in obstruction and narrowing of the bile ducts. The amyloid-like deposits were negative with Congo red stain, and were negative immunohistochemically for IgG, IgA, IgM, kappa chain, beta-2-microglobulin, and amyloid A and P components. However, they were positive for lambda chain, and ultrastructurally composed of non-branching filaments with a diameter of 7-10 nm. This is the first case of obstructive jaundice due to histologically confirmed amyloid-like deposits in the biliary system.
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Affiliation(s)
- T Terada
- Department of Pathology (II), Kanazawa University School of Medicine, Japan
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Dohmen K, Nagano M, Iwakiri R, Yamano Y, Kikuchi Y, Mizoguchi M, Iwata Y, Mori Y, Ishibashi H. A case of prominent hepatic cholestasis developing to hepatic failure in lambda-AL amyloidosis. GASTROENTEROLOGIA JAPONICA 1991; 26:376-81. [PMID: 1889693 DOI: 10.1007/bf02781928] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report a case of lambda-AL amyloidosis which manifested prominent hepatic cholestasis. The patient was a 71-year-old Japanese male who was admitted to our hospital because of abdominal distension and jaundice. Laboratory examination revealed a marked deterioration of liver function with cholestasis. Gastric biopsy revealed amyloid deposition. Under a diagnosis of primary amyloidosis he was treated with corticosteroid and dimethylsulfoxide. However, jaundice progressed, renal function deteriorated rapidly, and he died two weeks after admission. Autopsy revealed a profound deposition of lambda-AL amyloid not only in the liver but also in the kidneys, spleen, lungs, heart and intestine.
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Affiliation(s)
- K Dohmen
- Department of Internal Medicine, Kyushu Koseinenkin Hospital, Kitakyushu, Japan
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Faa G, Van Eyken P, De Vos R, Fevery J, Van Damme B, De Groote J, Desmet VJ. Light chain deposition disease of the liver associated with AL-type amyloidosis and severe cholestasis. J Hepatol 1991; 12:75-82. [PMID: 1901075 DOI: 10.1016/0168-8278(91)90913-v] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A 67-year-old man with a 3-month history of jaundice presented with hepatomegaly. Laboratory studies revealed abnormal liver tests with raised bilirubin. Renal function was normal. Endoscopic retrograde cholangiopancreatography revealed normal extrahepatic bile ducts. Liver biopsy showed severe bilirubinostasis and a typical bile infarct. Laminar and globular deposits of PAS-positive diastase-resistant non-congophilic material were observed in the sinusoidal walls. In addition, congophilic material was detected in the portal tracts. Immunohistochemistry revealed the presence of lambda-light chain deposits both in the sinusoids and in the portal tracts. Collagens type I and IV and fibronectin appeared markedly increased in the perisinusoidal space. On electron microscopy, the deposited material in the Disse spaces was mainly composed of fibrils indistinguishable from amyloid, admixed with small amounts of granular electron-dense material. The similarities of light chain deposition disease and AL amyloidosis are discussed.
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Affiliation(s)
- G Faa
- Laboratorium voor Histo- en Cytochemie, Dienst Pathologische Ontleedkunde II, U.Z. St. Rafael, Leuven, Belgium
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Affiliation(s)
- R A Kyle
- Mayo Medical School, Rochester, Minnesota
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Blendis LM. Jaundice in systemic disease. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1989; 3:431-45. [PMID: 2655763 DOI: 10.1016/0950-3528(89)90009-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
PURPOSE We wished to study patients with a premortem diagnosis of primary hepatic amyloidosis to determine what clinical and laboratory features might assist in recognizing the disease and assessing prognosis. PATIENTS AND METHODS A group of 80 patients with liver biopsy proven primary hepatic amyloidosis was followed from diagnosis to death. RESULTS At presentation, 77 percent of the group had an associated nephrotic syndrome, congestive heart failure, peripheral neuropathy, or orthostatic hypotension. Certain clues suggested the diagnosis of hepatic amyloidosis in patients with liver disease, including the following: (1) proteinuria (88 percent); (2) abnormal serum protein electrophoresis (monoclonal protein or hypogammaglobulinemia, 64 percent); (3) hyposplenism on the peripheral blood smear (62 percent), defined by the presence of Howell-Jolly bodies; and (4) hepatomegaly disproportional to the liver enzyme abnormalities. Liver function tests were not sensitive or specific. Hepatomegaly from amyloid was frequently seen, with normal levels of alkaline phosphatase, aspartate aminotransferase, and bilirubin (32 percent). Myeloma was diagnosed in 11 patients but had no effect on the clinical course. In vitro coagulation abnormalities were common, bleeding was infrequent, and liver biopsy carried a slightly increased risk. The median survival of the entire group was nine months, and projected five- and 10-year survival rates were 13 and 1 percent, respectively. CONCLUSION Because survival is poor and no clinical features permit prospective recognition of those patients in whom the disease is likely to have an indolent course, a trial of therapy is warranted in all patients.
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Affiliation(s)
- M A Gertz
- Dysproteinemia Clinic, Mayo Clinic, Rochester, Minnesota 55905
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 50-1987. A 43-year-old woman with hepatic failure after renal transplantation because of amyloidosis. N Engl J Med 1987; 317:1520-31. [PMID: 3317049 DOI: 10.1056/nejm198712103172407] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
Clinically significant liver involvement in systemic amyloidosis, especially with cholestasis, is rare. We report a case of primary amyloidosis with severe intrahepatic cholestasis leading to terminal liver failure. The present case is the first of its kind reported involving Lambda light chains only as the associated paraprotein. Conventional treatment and a therapeutic trial with dimethyl sulphoxide were unsuccessful.
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Affiliation(s)
- F Konikoff
- Department of Internal Medicine E, Beilinson Medical Center, Petah Tiqva, Israel
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Calomeni JA, Smith JR. Obstructive jaundice from hepatic amyloidosis in a patient with multiple myeloma. Am J Hematol 1985; 19:277-9. [PMID: 4014227 DOI: 10.1002/ajh.2830190309] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A patient with multiple myeloma is described who developed severe intrahepatic cholestasis secondary to hepatic deposition of amyloid. This is the first reported case of this complication's developing in a patient with multiple myeloma.
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