Pulmonary function in familial amyloidosis with polyneuropathy

Vocal Cord Paralysis and Hypercapnic Respiratory Failure in a Patient with Familial Amyloidotic Polyneuropathy

We herein report a patient case with familial amyloidotic polyneuropathy (FAP) who presented with vocal cord paralysis (VCP). A 60-year-old man with FAP (Gly89Gln) presented with hoarseness and snoring for the previous two years. A chest X-ray demonstrated cardiomegaly and bilateral diaphragmatic elevation. The findings of a restrictive pattern on spirometry and daytime hypercapnia were consistent with respiratory muscle weakness related to neuropathy [forced expiratory volume (FEV1): 38%, forced vital capacity (FVC): 39%, FEV1/FVC: 77, partial pressure of arterial oxygen (PaO2): 80 mmHg, partial pressure of carbon dioxide in arterial blood (PaCO2): 52 mmHg]. An ear-nose-throat examination showed VCP. Polysomnography revealed severe obstructive sleep apnea (OSA). FAP may cause OSA by VCP and hypercapnic respiratory failure by respiratory muscle weakness. Therefore, an ear-nose-throat examination, spirometry, arterial blood gases analysis and polysomnography are important for these patients.

Hemodynamic and angiocardiographic observations in familial amyloidosis with polyneuropahy

Eleven patients with familial amyloidosis with polyneuropathy were studied by heart catheterization; eight of them also by right and left ventriculography and selective coronary angiography. Signs of congestive heart failure, often reported as typical of cardiac amyloidosis, were found in only one patient. The systolic function was relatively unimpaired, but in several patients hemodynamic data suggested restrictive cardiomyopathy. Six patients showed signs of right or left ventricular outflow tract obstruction. Thus, no uniform hemodynamic pattern could be identified, but the changes found indicate impaired diastolic function.

Echocardiographic features in familial amyloidosis with polyneuropathy

Twenty-two patients with the Swedish variant of familial amyloidosis with polyneuropathy were studied by M-mode and two-dimensional echocardiography. These patients had few symptoms consistent with cardiac disease but, nevertheless, echocardiograms of only two of them, both with a short history of the disease, were considered normal in all aspects. The most common abnormality was increased thickness of the interventricular septum found in 20 (91%) of the patients. This septal hypertrophy was asymmetric in 12 (55%) of them. Two-dimensional echocardiography revealed a characteristic hyperrefractile appearance of the myocardium in 15 (68%) of the patients. Thus, echocardiography showed a characteristic pattern in these patients. This study also indicates that cardiac amyloidosis can be diagnosed in the preclinical, asymptomatic state by M-mode and two-dimensional echocardiography.

Pulmonary manifestations of POEMS syndrome: case report and literature review

Phrenic nerve paresis is an unusual complication of POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein spike and skin changes) syndrome. In this report, we describe a case of POEMS syndrome in which a 56-year-old woman presented with dyspnea and ventilatory failure due to bilateral phrenic nerve paralysis. To our knowledge, only one other case of phrenic neuropathy in POEMS syndrome has been reported.

Assessment of hypothalamic-pituitary function in patients with familial amyloidotic polyneuropathy

This study was performed to evaluate hypothalamic-pituitary hormone regulation in patients with familial amyloidotic polyneuropathy. Twenty-two patients without clinically overt endocrinological dysfunction were studied. A thyrotropin-releasing hormone test revealed abnormal growth hormone regulation in 9 of 17 (53%) patients, and abnormal prolactin regulation in 9 of 18 (50%) patients. Abnormalities in either growth hormone or prolactin regulation were found in 12 of 17 (71%) patients. Serum somatomedin C levels were normal in all 22 patients. In 3 of 18 (17%) patients the plasma arginine vasopressin levels were low relative to the serum osmolality levels. Thus abnormalities in hypothalamic-pituitary hormone regulation may be common in familial amyloidotic polyneuropathy.

Assessment of thyroid and adrenal function in patients with familial amyloidotic polyneuropathy

This study was performed to evaluate thyroid and adrenal function in patients with familial amyloidotic polyneuropathy. Twenty-four patients without any clinical overt endocrinological dysfunction were studied. None of the patients showed laboratory evidences of hypo- or hyperthyroidism. A short ACTH-stimulation test was performed in 17 of the patients. A low cortisol response to ACTH stimulation, suggesting adrenocortical insufficiency, was found in four (24%) of the patients, and an intermediate response interpreted as suspected hypofunction was found in three (18%) patients. Low serum dehydroepiandrosterone sulphate levels, suggesting adrenal hypofunction, were found in six (25%) of the patients. We believe that the possibility of glucocorticoid insufficiency should always be considered in patients with familial amyloidotic polyneuropathy.

Cardiac arrhythmias in familial amyloid polyneuropathy during anaesthesia

There is an increased risk of anaesthetic complications in patients with myocardial disorders. The present paper concerns seven patients with familial amyloid polyneuropathy, who developed severe bradycardia or heart block during anaesthesia. Amyloid infiltration of the cardiac conducting tissues probably increases their susceptibility to anaesthetic agents. Dysfunction of autonomic nerves may also diminish cardiac impulse formation and conduction. In addition, the possibility of contributing succinylcholine-induced hyperkalaemia cannot be excluded. There was a prompt response to infusion of isoproterenol in all patients so treated, but the insertion of a temporary pacemaker prior to anaesthesia should, nevertheless, be seriously considered in this group of patients.

Electrophysiologic evaluation of the cardiac conduction system and its autonomic regulation in familial amyloid polyneuropathy

A high incidence of cardiac conduction disturbances is a salient feature in familial amyloid polyneuropathy (FAP) and amyloid infiltration of the conduction system has been found. In patients with FAP autonomic nervous dysfunction involving gastrointestinal, urogenital and cardiovascular systems has been described. However, the present study is the first to evaluate the results of autonomic tests and pharmacologic intervention in the autonomic nervous regulation of the cardiac conduction system during an invasive electrophysiologic study. Seven patients with FAP and severe disturbances of the conduction system, evaluated concerning indications for pacemaker treatment, were studied; in 3 of them the parasympathetic regulation was found to be abolished. In 1 patient the observations indicated either vagal overactivity or denervation oversensitivity of the receptors. The function of the beta adrenoceptors was intact in all patients, but a disturbance of sympathetic innervation could not be excluded. Dysfunction of autonomic nervous regulation of the cardiac conduction system was thus found in 4 of 7 patients. However, most conduction abnormalities were irreversible, indicating amyloid infiltration of the conduction system as the predominant pathophysiologic mechanism, in accordance with the findings of pathoanatomic studies.

Non-invasive assessment of the presence and severity of cardiac amyloidosis. A study in familial amyloidosis with polyneuropathy by cross sectional echocardiography and technetium-99m pyrophosphate scintigraphy

Twelve patients with familial amyloidosis with polyneuropathy were examined both by cross sectional echocardiography and by technetium-99m pyrophosphate scintigraphy to assess involvement of the heart non-invasively. All 12 patients had echocardiographic abnormalities. The most prominent findings were highly refractile myocardial echoes, thickened heart valves, and increased thickness of the heart walls. Four patients had abnormal myocardial uptake of technetium-99m pyrophosphate. The remaining eight had equivocal or no myocardial uptake and were considered to have normal scintigrams. A certain amount of amyloid is probably required to produce an abnormal scintigram, although lesions with less amyloid can evidently be identified by echocardiography. Neither the duration of polyneuropathy nor its severity showed any relation to the echocardiographic or scintigraphic findings. It is concluded that cross sectional echocardiography is superior to technetium-99m pyrophosphate scintigraphy in detecting cardiac involvement in familial amyloidosis with polyneuropathy and that these results may also be applicable to other forms of amyloidosis.

Pacemaker treatment in familial amyloidosis with polyneuropathy

Involvement of the heart is common in familial amyloidosis with polyneuropathy (FAP) and is manifested by disturbances of atrioventricular and intraventricular conduction and dysfunction of the sinus node. Pacemaker implantation was performed in 20 patients with FAP in northern Sweden between 1968 and 1983 for the following indications: complete heart block (11), second degree heart block (1), sinus node dysfunction (5), and atrial fibrillation with a slow ventricular rate (3). There was a prompt improvement of symptoms attributable to a slow heart rate. Dislodgement of the electrode occurred in four patients; no other serious complications were observed. From our experience we conclude that at least one out of ten patients with FAP will eventually require pacemaker treatment. Cardiac pacing is an effective adjunct in the symptomatic treatment of FAP, although the ultimate prognosis depends mainly on the underlying disease.

Disturbances of cardiac rhythm and conduction in familial amyloidosis with polyneuropathy

Sixteen consecutive patients with familial amyloidosis with polyneuropathy of varying duration and severity underwent 24 hour ambulatory electrocardiographic monitoring. A high incidence of sinus node dysfunction, supraventricular and ventricular arrhythmias, and disturbances of atrioventricular conduction was found. Considerably more arrhythmias and disturbances of conduction were detected by long term electrocardiographic monitoring than by conventional 12 lead electrocardiograms. During a follow up period of three to 14 months five patients needed treatment by a pacemaker, three of them because of symptomatic complete heart block, one because of second degree heart block with heart failure, and one because of symptomatic dysfunction of the sinus node. The tachyarrhythmias did not require specific treatment. Long term electrocardiographic monitoring is a useful adjunct in the evaluation of patients with familial amyloidosis with polyneuropathy as it may detect otherwise unrecognised symptomatic disturbances of heart rhythm. The results may be valid also for other forms of amyloidosis involving the heart.