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Martínez JC, Lichtman EI. Localized light chain amyloidosis: A self-limited plasmacytic B-cell lymphoproliferative disorder. Front Oncol 2022; 12:1002253. [PMID: 36457485 PMCID: PMC9705961 DOI: 10.3389/fonc.2022.1002253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/24/2022] [Indexed: 08/31/2023] Open
Abstract
Immunoglobulin light chain amyloidosis can be either systemic or localized. Although these conditions share a similar name, they are strikingly different. Localized light chain amyloidosis has been challenging to characterize due to its lower incidence and highly heterogeneous clinical presentation. Here, we review the emerging literature, emphasizing recent reports on large cohorts of patients with localized amyloidosis, and provide insights into this condition's pathology and natural history. We find that patients with localized amyloidosis have an excellent prognosis with overall survival similar to that of the general population. Furthermore, the risk of progression to systemic disease is low and likely represents initial mischaracterization as localized disease. Therefore, we argue for the incorporation of more sensitive techniques to rule out systemic disease at diagnosis. Despite increasing mechanistic understanding of this condition, much remains to be discovered regarding the cellular clonal evolution and the molecular processes that give rise to localized amyloid formation. While localized surgical resection of symptomatic disease is typically the treatment of choice, the presentation of this disease across the spectrum of plasmacytic B-cell lymphoproliferative disorders, and the frequent lack of an identifiable neoplastic clone, can make therapy selection a challenge in the uncommon situation that systemic chemotherapy is required.
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Affiliation(s)
- José C. Martínez
- Division of Hematology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Eben I. Lichtman
- Division of Hematology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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2
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Kakani RS, Goldstein AE, Meisher I, Hoffman C. Nodular Amyloidosis: Case Report and Literature Review. J Cutan Med Surg 2016. [DOI: 10.1177/120347540100500201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Amyloidosis refers to a group of depositional diseases that are classified into two main types: systemic and localized. Large nodules of localized cutaneous amyloidosis of the nasal ala and surrounding skin are rare and the treatment is often unsatisfactory. Objective: We report a case of rapidly enlarging, localized, nodular cutaneous amyloidosis of the nose and the surrounding skin with a brief review of the current literature regarding treatment of this rare disease. Conclusion: Nodular amyloidosis can be treated successfully with cold steel excision in combination with carbon dioxide laser. Close followup of these patients is warranted, as nodular amyloidosis may be the precursor to systemic amyloidosis.
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Affiliation(s)
- Rajesh S. Kakani
- Department of Otolaryngology, Albert Einstein College of Medicine, Bronx, New York 10461
| | - Amy E. Goldstein
- Department of Dermatology, St. Barnabas Hospital, Bronx, New York 10457
| | - Irina Meisher
- Department of Pathology, Coney Island Hospital, Brooklyn, New York 11235
| | - Cindy Hoffman
- Department of Dermatology, St. Barnabas Hospital, Bronx, New York 10457
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3
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Affiliation(s)
| | - Uday Khopkar
- Department of Dermatology, Seth GS Medical College and KEM Hospital, Mumbai, India
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4
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Gérard E, Ly S, Cogrel O, Pham-Ledard A, Fauconneau A, Penchet I, Ouhabrache N, Vergier B, Beylot-Barry M. [Primary localized cutaneous nodular amyloidosis: A diagnostic and therapeutic challenge]. Ann Dermatol Venereol 2015; 143:134-8. [PMID: 26724842 DOI: 10.1016/j.annder.2015.10.596] [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] [Received: 09/13/2015] [Revised: 10/12/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Nodular primary localized cutaneous amyloidosis (PLCA) is a rare subtype of localized cutaneous amyloidosis in which amyloid protein is derived from immunoglobulin light chains. Follow-up for progression to systemic amyloidosis or autoimmune disease is mandatory. No consensus exists regarding treatment. PATIENTS AND METHODS We report a case of nodular PLCA in a 49-year-old man, presenting as an asymptomatic nodule of the nose. Skin biopsy revealed diffuse deposition of amyloid associated with plasmocyte proliferation. Monotypic kappa light-chain restriction was observed. Extensive systemic evaluation, including bone marrow biopsy and PET scan, was negative. Protein electrophoresis and immunofixation in serum and urine were normal. The nodule was treated with radiotherapy but there was no response. Mohs micrographic surgery (MMS) was performed with no recurrence at 6 months of follow-up. No systemic progression was observed one year after the initial diagnosis. DISCUSSION Since nodular PLCA may have a cutaneous presentation similar to that of primary systemic amyloidosis, evaluation for systemic amyloidosis is necessary. Treatment of amyloidosis is difficult. Radiotherapy appears ineffective in treating this type of primary cutaneous amyloidosis, and surgical treatment, where possible, is a good option, especially with MMS, which allows both controlled excision and minimal margins.
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Affiliation(s)
- E Gérard
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, rue Jean-Burguet, 33076 Bordeaux, France
| | - S Ly
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, rue Jean-Burguet, 33076 Bordeaux, France
| | - O Cogrel
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, rue Jean-Burguet, 33076 Bordeaux, France
| | - A Pham-Ledard
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, rue Jean-Burguet, 33076 Bordeaux, France
| | - A Fauconneau
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, rue Jean-Burguet, 33076 Bordeaux, France
| | - I Penchet
- Service d'anatomopathologie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - N Ouhabrache
- Service de radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - B Vergier
- Service d'anatomopathologie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - M Beylot-Barry
- Service de dermatologie, hôpital Saint-André, CHU de Bordeaux, rue Jean-Burguet, 33076 Bordeaux, France.
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5
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Westermark P. Localized Amyloidoses and Amyloidoses Associated with Aging Outside the Central Nervous System. CURRENT CLINICAL PATHOLOGY 2015. [DOI: 10.1007/978-3-319-19294-9_7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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6
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Abstract
Concepts and semantics are crucial for good communication between clinicians and pathologists. Amyloidosis was described more than 150 years ago. Therefore, the terminology related to it is abundant, varied, and sometimes complex. In this report, we intend to discuss several terms related to the disease, with special emphasis on cutaneous amyloidosis. We present a review, from Virchow to present, of the concepts related to amyloidosis: its nature, the classification of cutaneous forms of the disease, and the techniques used in its diagnosis.
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7
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Kendler M, Helbig D, Paasch U, Kutzner H, Simon JC, Wetzig T. Nodular localized primary cutaneous amyloidosis and primary marginal zone B-cell lymphoma on the nose: treatment with microscopically controlled surgery. Int J Dermatol 2011; 50:458-61. [PMID: 21413960 DOI: 10.1111/j.1365-4632.2010.04524.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Michael Kendler
- Department of Dermatology, Venereology and Allergology, Leipzig University Medical Center, Philipp Rosenthalstr, Leipzig, Germany.
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8
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Nodular Amyloidosis: Differentiation From Colloid Milium by Electron Microscopy. Am J Dermatopathol 2009; 31:472-4. [DOI: 10.1097/dad.0b013e31818c5cd3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Feito-Rodríguez M, García-Macarrón J, Pagán-Muñoz B, Mariño-Enríquez A, Vidaurrázaga-Díaz y Arcaya C, Díaz-Díaz R, Casado-Jiménez M. Amiloidosis cutánea primaria localizada nodular con patrón diseminado. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s0001-7310(08)74762-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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11
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Koh M, Kwok CYK, Tan HW, Mancer JFK. A rare case of primary cutaneous nodular amyloidosis of the face. J Eur Acad Dermatol Venereol 2008; 22:1011-2. [DOI: 10.1111/j.1468-3083.2007.02541.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Koba S, Inoue T, Otu M, Miura Y, Misago N, Narisawa Y. The occurrence of two types of amyloid in the same patient. Br J Dermatol 2008; 158:860-2. [PMID: 18241258 DOI: 10.1111/j.1365-2133.2007.08432.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Feito-Rodríguez M, García-Macarrón J, Pagán-Muñoz B, Mariño-Enríquez A, Vidaurrázaga-Díaz y Arcaya C, Díaz-Díaz R, Casado-Jiménez M. Disseminated Nodular Primary Localized Cutaneous Amyloidosis. ACTAS DERMO-SIFILIOGRAFICAS 2008. [DOI: 10.1016/s1578-2190(08)70333-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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14
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Early rheumatoid arthritis in a patient with Sjögren's syndrome and pulmonary nodular amyloidosis: clinical implication of early limited use of infliximab. Mod Rheumatol 2007; 17:500-6. [PMID: 18084704 DOI: 10.1007/s10165-007-0617-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Accepted: 06/04/2007] [Indexed: 10/22/2022]
Abstract
Infliximab, an anti-tumor necrosis factor alpha antibody, is among the most effective therapies for rheumatoid arthritis (RA). In this study, we report a patient with early RA of 6 months who has Sjögren's syndrome and pulmonary nodular lesions concomitantly. The patient did not respond to methotrexate (MTX, 6;Smg per week) for 3 months. When introduction of infliximab therapy is considered, we need to exclude the possibility of pulmonary granulomatous infection and malignancy. With the use of computed tomography-guided percutaneous needle biopsy and subsequent histological examinations, this case was rapidly and confidently diagnosed as localized pulmonary nodular amyloidosis. Immunochemical staining showed light chain type nodular amyloidosis by a deposition of immunoglobulin kappa light chains, which is a rare condition in a patient with Sjögren's syndrome. We started combination therapy of infliximab (200;Smg per infusion) and MTX (6;Smg per week). Because of severe systemic eruption, this therapy was stopped halfway through the third infusion of infliximab, and MTX monotherapy was continued. Despite the withdrawal of infliximab therapy, the C-reactive protein values were decreased to an undetectable level at week 14, and the disease activity score for 28 joints was 3.1 at week 22. Clinical remission has been maintained more than 14 months with MTX alone. Infliximab has been used only for patients with recalcitrant RA, because the cost of its lifelong use would be an economic burden in most cases. An optimal and affordable strategy for the treatment of early RA should be developed. Our findings may support the idea that the combination therapy of infliximab and MTX for early RA alters the course of the disease.
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Abstract
We report a unique case of a 69-year-old man who presented with a 1-year history of pink nodules and plaques limited to the anterior plantar surface of the right foot and a 30-year history of a callus on the right heel. Histologic examination findings of both areas showed deposits of amorphous, eosinophilic material and an infiltrate of plasma cells in the dermis. Congo red-stained deposits exhibited apple-green birefringence with polarized light. Results of an extensive clinical and laboratory evaluation showed no evidence of systemic amyloidosis. The diagnosis of nodular primary localized cutaneous amyloidosis (PLCA) was made. Nodular PLCA isolated to pedal or strictly plantar surfaces is an unusual presentation of PLCA. The origin and the clinical and histopathologic features of nodular PLCA are reviewed.
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Hagari Y, Hagari S, Kambe N, Kawaguchi T, Nakamoto S, Mihara M. Acral pseudolymphomatous angiokeratoma of children: immunohistochemical and clonal analyses of the infiltrating cells. J Cutan Pathol 2002; 29:313-8. [PMID: 12100634 DOI: 10.1034/j.1600-0560.2002.290510.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acral pseudolymphomatous angiokeratoma of children (APACHE) is a disorder characterized clinically by red nodules and histopathologically by a massive subepidermal lymphohistiocytic infiltrate. Although it was initially thought to be a vascular nevus, it has never been regarded as a pseudolymphoma. CASE REPORT We report a 7-year-old-girl with small red nodules on the dorsum of the right foot and a 73-year-old man with asymptomatic brown-red nodules on the lower extremities. RESULTS Histopathologic examination revealed a massive lymphohistiocytic infiltrate with plasma cells, some eosinophils, or a multinucleated giant cell immediately beneath the epidermis. Thick-walled vessels were observed in the infiltrate. These characteristics are identical to those of acral pseudolymphomatous angiokeratoma of children. The infiltrate was composed mainly of equal numbers of CD4+ or CD8+ T cells and equal numbers of B cells stained for kappa or lambda light chains. PCR amplification of rearranged immunoglobulin heavy chain genes or T-cell receptor gamma genes showed no evidence of clonality, suggesting that these infiltrates were polyclonal both for B and T cells. CONCLUSIONS Our data support the idea that this disorder represents a reactive process. The modified term 'papular angiolymphoid hyperplasia' would define this disorder more appropriately.
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Affiliation(s)
- Yoshitaka Hagari
- Department of Dermatology, Faculty of Medicine, Tottori University, Yonago, Japan.
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Abstract
We present long-term follow-up data on patients with nodular localized primary cutaneous amyloidosis (NLPCA) seen at the St John's Institute of Dermatology between 1968 and 1999. This is the largest clinical follow-up study of this type of amyloid to date. Based on these cases we estimate the rate of progression of NLPCA to systemic amyloidosis to be only 7%, much lower than the 50% rate currently quoted in the literature.
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Affiliation(s)
- A Woollons
- St John's Institute of Dermatology, The Guy's, King's College and St Thomas' Medical and Dental Schools, University of London, UK
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Mochizuki H, Kamakura K, Masaki T, Hirata A, Tokuda T, Yazaki M, Motoyoshi K, Ikeda S. Nodular cutaneous amyloidosis and carpal tunnel syndrome due to the amyloidogenic transthyretin His 114 variant. Amyloid 2001; 8:105-10. [PMID: 11409031 DOI: 10.3109/13506120109007352] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This is the second report of transthyretin (TTR) amyloidosis in a patient who had ATTR Tyr114His diagnosed by mass spectrometry and gene analysis. This case had some clinical features that differed from those of the first reported cases. The patient, 73-year-old man, complained of generalized cutaneous tubercula that had started at age 68. These tubercula gradually increased in size and became generalized. He felt a slight numbness in his extremities. Clinical and electrophysiological examinations revealed that he had bilateral carpal tunnel syndrome (CTS), whereas there was no clear evidence of sensory and/or motor polyneuropathy. Autonomic symptoms were not present. Biopsy studies revealed that both his tuberculum and his sural nerve contained TTR-related amyloid. In his sural nerve, amyloid deposits were observed mainly in the perineurium, not in the endoneurium, and there was no significant depletion of myelinated fibers. The features of this patient were clinically characterized by generalized cutaneous amyloid deposits and late-onset CTS with a lack of overt polyneuropathy and autonomic dysfunction. The unique clinical features in this case seemed to be consistent with the distribution of amyloid deposits.
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Affiliation(s)
- H Mochizuki
- Third Department of Internal Medicine, National Defense Medical College, 3-2, Namiki, Tokorozawa, Saitama 359-8513, Japan
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Kakani RS, Goldstein AE, Meisher I, Hoffman C. Nodular amyloidosis: case report and literature review. J Cutan Med Surg 2001; 5:101-4. [PMID: 11443480 DOI: 10.1007/bf02737862] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Amyloidosis refers to a group of depositional diseases that are classified into two main types: systemic and localized. Large nodules of localized cutaneous amyloidosis of the nasal ala and surrounding skin are rare and the treatment is often unsatisfactory. OBJECTIVE We report a case of rapidly enlarging, localized, nodular cutaneous amyloidosis of the nose and the surrounding skin with a brief review of the current literature regarding treatment of this rare disease. CONCLUSION Nodular amyloidosis can be treated successfully with cold steel excision in combination with carbon dioxide laser. Close followup of these patients is warranted, as nodular amyloidosis may be the precursor to systemic amyloidosis.
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Affiliation(s)
- R S Kakani
- Department of Otolaryngology, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Abstract
AL amyloidosis is characterized by fibrillar tissue deposits composed of monoclonal immunoglobulin light chains(IgLs). It has been speculated that clonal expansion of plasma cells may occur locally and produce amyloidogenic IgLs. Both immunohistochemistry and molecular genetics are useful for examining plasma cell clonality from paraffin-embedded tissue sections, which are easy to obtain. We evaluated plasma cell clonality in 16 biopsy cases of localized AL amyloidosis using these two methods. A clonal excess of plasma cells was detected in 6 (37.5%) cases immunohistochemically, in 10 (62.5%) cases molecularly, and in 13 (81.3%) cases by at least one of the two methods. These results support local synthesis of the light chain proteins in localized AL amyloidosis.
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Affiliation(s)
- M Setoguchi
- Department of Surgical Pathology, Yamaguchi University Hospital, Japan.
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Miyamoto T, Kobayashi T, Makiyama M, Kitada S, Fujishima M, Hagari Y, Mihara M. Monoclonality of infiltrating plasma cells in primary pulmonary nodular amyloidosis: detection with polymerase chain reaction. J Clin Pathol 1999; 52:464-7. [PMID: 10562817 PMCID: PMC501436 DOI: 10.1136/jcp.52.6.464] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS To investigate the relation between localised amyloidosis and immunocytic dyscrasia. METHODS Open lung biopsy specimens from a 72 year old man with multiple nodules in the right middle and lower lung were stained with haematoxylin-eosin, Congo red, and antibodies against IgG, IgA, IgM, and kappa and lambda light chains. Semi-nested PCR amplification for the immunoglobulin heavy chain (IgH) gene was performed using consensus primers for the VDJ region of the IgH gene, FR3A, LJH, and VLJH. RESULTS The biopsy specimens contained eosinophilic amorphous material stained with Congro red and anti-kappa light chain, and surrounded by inflammatory cells intermingled with plasma cells. Plasma cells in the adjacent amorphous material showed cytoplasmic staining with anti-kappa. Polymerase chain reaction revealed a discrete amplified band of apparently uniform size with background smear. CONCLUSIONS Primary AL type localised amyloidosis involves local accumulation of monoclonal plasma cells and their secreted products, as in nodular cutaneous amyloidosis. Localised AL type nodular amyloidosis is a separate entity in amyloidosis.
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Affiliation(s)
- T Miyamoto
- Department of Dermatology, Tsuyama Central Hospital, Japan
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