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Rosado F, Taveras P, Gayam V, Narendra N, Vigoda I. Intestinal Reactive Amyloid A (AA) Amyloidosis in a Patient With Multiple Myeloma: A Case Report and Literature Review. Cureus 2023; 15:e42906. [PMID: 37664311 PMCID: PMC10474897 DOI: 10.7759/cureus.42906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Amyloidosis is a rare group of disorders characterized by the extracellular deposition of misfolded protein aggregates that interfere with the function of the tissue affected. In some patients, the presenting symptom of monoclonal gammopathies, such as multiple myeloma, can be a gastrointestinal bleed with a further report of amyloidosis in gastrointestinal samples. In all the cases the pathology report is read as AL (light chain) amyloidosis. We present a case of a 57-year-old male patient with no medical history who debuted with gastrointestinal bleeding. A colonoscopy revealed a colonic ulcer with a pathologic diagnosis of amyloid A (AA) amyloidosis. Further investigation led to the finding of multiple myeloma (MM) with no evidence of systemic amyloidosis. Although there is little evidence in the literature of the association or even causative relationship between multiple myeloma and AA amyloidosis, our case highlights the importance of searching for an underlying monoclonal gammopathy like MM in a patient with a confirmed diagnosis of AA amyloidosis.
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Affiliation(s)
- Flor Rosado
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - Patxis Taveras
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - Vijay Gayam
- Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, USA
| | - Nithan Narendra
- Gastroenterology, St. Barnabas Hospital Health System, Bronx, USA
| | - Ivette Vigoda
- Hematology and Oncology, St. Barnabas Hospital Health System, Bronx, USA
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Iijima T, Sawa N, Nakayama Y, Oba Y, Ikuma D, Mizuno H, Yamanouchi M, Suwabe T, Wake A, Kono K, Hoshino J, Ubara Y, Ohashi K. Vincristine, Doxorubicin, and Dexamethasone Induction before Autologous Stem Cell Transplantation in Patients with AL Amyloidosis: A Retrospective Comparison with Frontline Stem Cell Transplantation. Intern Med 2022; 61:2853-2860. [PMID: 35228429 PMCID: PMC9593158 DOI: 10.2169/internalmedicine.9039-21] [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] [Indexed: 11/06/2022] Open
Abstract
Objective High-dose melphalan and autologous stem cell transplantation (ASCT) therapy for AL amyloidosis are now associated with reduced mortality based on the application of strict criteria. However, there is no long-term evidence concerning the performance of induction therapy with newer agents, such as bortezomib or daratumumab. Concerns regarding long-term relapse despite treatment with ASCT exist, and missing the opportunity to perform ASCT might occur if induction proves to not be efficacious and cardiac amyloidosis progression deprives the patients of a chance to receive ASCT. We herein report good amyloid control by vincristine, doxorubicin, and dexamethasone (VAD) induction therapy and argue the importance of induction therapy before ASCT. Methods We compared patients who underwent VAD induction and ASCT (VAD+ASCT) with patients who underwent frontline ASCT in our hospital. Patients A total of 26 patients with histologically proven AL amyloidosis were included (18 in the VAD+ASCT group and 8 in the frontline ASCT). Results In the VAD+ASCT group, the 10-year overall survival and renal response rates were 82% and 43%, respectively. The renal response rate at two years in the VAD+ASCT group was significantly better than that in the frontline ASCT group. Although there was no significant difference in the survival rates between the two groups, the time to next treatment or death was significantly better in the VAD+ASCT group than in the the frontline ASCT group. Acute kidney injury was the most frequent reason for failure to receive two courses of VAD, and early mortality was mainly due to gastrointestinal complications. Conclusion Considering that only those who underwent 2 courses of VAD experienced a 10-year renal response, induction therapy was deemed to be directly related to the long-term control of AL amyloidosis.
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Affiliation(s)
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yuki Nakayama
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Atsushi Wake
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
- Department of Hematology, Toranomon Hospital Kajigaya, Japan
- Department of Hematology, Toranomon Hospital, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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Anandan M, Ying L, Macisaac B, Kilner A, Laurie R, Naidoo UK. A rare case of gastrointestinal amyloidosis secondary to myeloma with predominant jejunal involvement. J Surg Case Rep 2022; 2022:rjab639. [PMID: 35096368 PMCID: PMC8791659 DOI: 10.1093/jscr/rjab639] [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: 11/22/2021] [Revised: 12/23/2021] [Indexed: 11/14/2022] Open
Abstract
Amyloidosis is a condition identified by the accumulation of abnormal proteins in various tissues and organs that eventually lead to impaired function. Systemic amyloidosis with gastrointestinal (GI) tract involvement is more common than localized GI amyloidosis, whereas predominant jejunal involvement is even more uncommon. We report a rare case of systemic amyloidosis with predominant jejunal involvement in a 76-year-old female who presented with lower abdominal bloating and lethargy.
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Affiliation(s)
- Manoj Anandan
- Correspondence address. Department of General Surgery, Western District Health Service, Hamilton Victoria 3300, Australia. Tel: +61481751086; E-mail:
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Duan G, Qi M, Guo Q, Song Z. Primary amyloidosis involving the gastrointestinal tract, mesentery and omentum: A case report. Exp Ther Med 2021; 22:1145. [PMID: 34504590 PMCID: PMC8393627 DOI: 10.3892/etm.2021.10579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 09/11/2020] [Indexed: 11/05/2022] Open
Abstract
Amyloidosis, a systemic disease characterized by the deposition of misfolded protein, is difficult to rapidly diagnose due to its wide range of symptoms. The present study reported on a case of primary amyloidosis (AL) with involvement of the gastrointestinal tract, mesentery and omentum in a 66-year-old male presenting with recurrent diarrhoea and abdominal distension. Oesophagogastroduodenoscopy and enteroscopy revealed multiple gastric ulcers and multiple protuberant lesions in the colon. Laparotomy indicated multiple nodules in the mesentery of the small intestine. Contrast-enhanced CT revealed dilation of the small bowel with pneumatosis intestinalis and positive Congo red staining of gastric mucosa and mesentery biopsy specimens confirmed amyloid deposition. Therefore, the patient was diagnosed with AL. In this case, the clinical manifestation of mesentery amyloidosis was multiple nodules and extensive peritoneal adhesions, which, to the best of our knowledge, has not been reported by any previous study.
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Affiliation(s)
- Guihua Duan
- Department of Gastroenterology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan 650032, P.R. China
| | - Min Qi
- Department of Radiology, The Third People's Hospital of Kunming City, The Sixth Affiliated Hospital of Dali University, Kunming, Yunnan 650041, P.R. China
| | - Qiang Guo
- Department of Gastroenterology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan 650032, P.R. China
| | - Zhengji Song
- Department of Gastroenterology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan 650032, P.R. China
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Chan R, Carpentier S. Gastric amyloidosis presenting as acute upper gastrointestinal bleeding: a case report. BMC Gastroenterol 2021; 21:300. [PMID: 34325671 PMCID: PMC8323269 DOI: 10.1186/s12876-021-01882-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022] Open
Abstract
Background Amyloidosis is characterized by extracellular tissue deposition of fibrils, composed of insoluble low-molecular-weight protein subunits. The type, location, and extent of fibril deposition generates variable clinical manifestations. Gastrointestinal (GI) bleeding due to amyloid deposition is infrequent. Previous literature describes upper GI bleeding (UGIB) in patients with known amyloid disease. Here, we describe a case of recurrent UGIB that ultimately led to a diagnosis of GI amyloidosis and multiple myeloma in a patient with no history of either. Case presentation A 76-year-old male presented to the emergency department with frank hematemesis, melena, and a decreased level of consciousness. Management required intensive care unit (ICU) admission with transfusion, intubation, and hemodynamic support. Upper endoscopy revealed gastritis with erosions and nodularity in the gastric cardia and antrum. Hemostasis of a suspected bleeding fundic varix could not be achieved. Subsequently, the patient underwent computerized tomography (CT) angiography and an interventional radiologist completed embolization of the left gastric artery to address potentially life-threatening bleeding. Complications included development of bilateral pleural effusions and subsegmental pulmonary emboli. Pleural fluid was negative for malignancy. He was transferred to a peripheral hospital for continued care and rehabilitation. Unfortunately, he began re-bleeding and was transferred back to our tertiary center, requiring re-admission to the ICU and repeat endoscopy. Repeat biopsy of the gastric cardial nodularity was reported as active chronic gastritis and ulceration. However, based on the unusual endoscopic appearance, clinical suspicion for malignancy remained high. He exhibited symptoms of congestive heart failure following standard resuscitation. Transthoracic echocardiogram (TTE) demonstrated a reduced ejection fraction of 35–40% and a strain pattern with apical sparing. Following discussions between the treating gastroenterologist, consulting cardiologist, and pathologist, Congo Red staining was performed, revealing submucosal amyloid deposits. Hematology was consulted and investigations led to diagnosis of multiple myeloma (MM) and immunoglobulin light-chain (AL) amyloidosis. The patient was treated for MM for four months prior to cessation of therapy due to functional and cognitive decline. Conclusions GI amyloidosis can present with various non-specific clinical symptoms and endoscopic findings, rendering diagnosis a challenge. This case illustrates GI amyloidosis as a potential—albeit rare—etiology of UGIB.
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Affiliation(s)
- Rachael Chan
- Department of Medicine, Dalhousie University and Nova Scotia Health, QEII Health Sciences Centre, VG Site, Suite 442 Bethune Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.
| | - Stephanie Carpentier
- Department of Medicine, Dalhousie University and Nova Scotia Health, QEII Health Sciences Centre, VG Site, Suite 442 Bethune Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.,Division of Gastroenterology, Saint John Regional Hospital, 400 University Avenue, Saint John, NB, E2L 4L2, Canada
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Secondary Amyloidosis Presenting as Ischemic Proctitis. Case Rep Gastrointest Med 2021; 2021:6663391. [PMID: 33927906 PMCID: PMC8052136 DOI: 10.1155/2021/6663391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 11/25/2022] Open
Abstract
A 49-year-old man presented with abdominal pain and rectal bleeding for two days associated with a 50-pound unintentional weight loss. History was notable for hypertension, chronic kidney disease, obesity, gout, and acute cholecystitis status post cholecystectomy. Computed tomography (CT) of the abdomen and pelvis showed rectal wall thickening. Colonoscopy showed proctitis with superficial ulcerations. In the setting of renal insufficiency, malabsorption, and low-voltage QRS complexes on electrocardiogram (ECG), amyloidosis was considered in the differential diagnosis. Rectal and renal biopsies with subsequent retrospective staining of gallbladder tissue confirmed amyloid deposition. Gastrointestinal involvement of amyloidosis is relatively uncommon. Particularly, amyloid deposition in the gallbladder and rectum is very rare. The development of AA amyloidosis in our patient may have been related to gout, obesity, and the presence of a heterozygous complex variant for the MEFV (familial Mediterranean fever) gene. Awareness of this atypical presentation of amyloidosis is important, as additional staining of biopsy samples is necessary, and diagnosis allows for directed treatment.
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Systemic manifestations - do not forget the small bowel. Curr Opin Gastroenterol 2021; 37:234-244. [PMID: 33606400 DOI: 10.1097/mog.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out. SUMMARY SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.
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Muacevic A, Adler JR. Amyloidosis Presenting with Macroglossia. Cureus 2018; 10:e3185. [PMID: 30364871 PMCID: PMC6199138 DOI: 10.7759/cureus.3185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Macroglossia is an uncommon condition that causes cosmetic and functional disabilities. We present a case of a 67-year-old patient with the past medical history of vitamin B12 deficiencies who presented with macroglossia and was found to have amyloidosis. She had an enlarged tongue with multiple ulcerations secondary to traumatic injury from dentation along with difficulty swallowing. Laboratory workup was unremarkable apart from elevated C reactive protein (CRP) and low complement 3 (C3) levels. On the second day of admission she had gastrointestinal bleed; computed tomography (CT) scan of the abdomen with oral contrast was performed which revealed nodular thickening of the stomach suspicious for gastric malignancy. Endoscopy was postponed as there was concern that macroglossia could comprise the airway. A biopsy of the tongue was performed and histological staining was positive suggestive of the amyloidosis. We discuss here the probable underlying causes of macroglossia and amyloidosis.
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Abstract
PURPOSE OF REVIEW The goal of this paper is to review the literature on small bowel amyloidosis. Our review focuses on the underlying etiology, histopathology, clinical features, endoscopic and radiologic findings, and the mainstay of management. RECENT FINDINGS The latest research shows changing epidemiological trends of different types of amyloidosis. It also reveals a better understanding of its pathophysiology and shows improvement in treatment outcomes. Amyloidosis is a group of diseases of multiple etiologies and clinical presentations. It is characterized by pathological deposition of insoluble fibrillar proteins within various organs leading to disruption of their structure and function. The classification of amyloidosis includes primary, secondary, dialysis-related, senile, and hereditary. Amyloidosis can be systemic or localized. The incidence of AA amyloidosis is declining in frequency. If the gastrointestinal (GI) tract is involved, the small intestine is the most commonly affected site. Overall, outcomes among patients with newly diagnosed amyloidosis have improved. This article focuses on small bowel amyloidosis.
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Affiliation(s)
- Raghav Bansal
- Division of Gastroenterology and Hepatology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Room D3-24D, 79-01 Broadway, Elmhurst, NY, 11373, USA
| | - Umer Syed
- Division of Gastroenterology and Hepatology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Room D3-24D, 79-01 Broadway, Elmhurst, NY, 11373, USA
| | - Jacob Walfish
- Department of Medicine, NYU School of Medicine, NYU Langone Health, 101 Broadway, Suite 301, Brooklyn, NY, 11249, USA
| | - Joshua Aron
- Division of Gastroenterology and Hepatology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Room D3-24D, 79-01 Broadway, Elmhurst, NY, 11373, USA
| | - Aaron Walfish
- Division of Gastroenterology and Hepatology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Room D3-24D, 79-01 Broadway, Elmhurst, NY, 11373, USA.
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