Monoclonal origin of localised orbital amyloidosis detected by molecular analysis

Optic Nerve Amyloid Deposition Disguised as Optic Nerve Sheath Meningioma

Localized orbital amyloidosis is a rare clinical entity. Periocular and orbital amyloid deposits are mainly located at the lacrimal apparatus, eyelid, conjunctiva, ocular adnexa, extraocular muscles, and levator palpebrae muscle. In this article, the authors report an unusual case of optic nerve amyloid deposition in an 82-year-old African American woman who presented with vertical diplopia. MRI revealed an enhancing mass from the optic nerve sheath, and CT showed foci of calcifications suggestive of optic nerve meningioma. However, an incisional biopsy demonstrated lymphoproliferative disease with focal optic nerve sheath amyloid deposition confirmed by histologic Congo red staining and immunohistochemistry.

A case of bilateral amyloidosis localized to extraocular muscles mimicking thyroid eye disease

BACKGROUND

Amyloidosis is a rare condition characterized by the abnormal deposition of amyloid proteins in various tissues and organs. While systemic amyloidosis has been well-documented, amyloid deposition in extraocular muscles is an exceptionally rare occurrence, with only 35 reported cases. This case report sheds light on the importance of considering amyloidosis in the differential diagnosis of patients presenting with proptosis and diplopia, which are often associated with thyroid eye disease.

CASE PRESENTATION

A woman in her twenties sought medical attention due to a complaint of diplopia. Her ocular examination revealed almost normal findings except for exotropia and proptosis. Orbital magnetic resonance imaging displayed fusiform enlargement of nearly all eye muscles, a presentation typically observed in thyroid eye disease. However, despite corticosteroid therapy, her symptoms showed no improvement. Given the unusual lack of response to conventional treatment, and inhomogeneous enhancement of the muscle, an extraocular muscle biopsy was conducted. This biopsy yielded a unique finding-amyloid deposition within the muscle tissue. This discovery was particularly intriguing due to the extreme rarity of amyloidosis affecting extraocular muscles, with fewer than three dozen documented cases worldwide.

CONCLUSION

This unique case underscores the critical need for a comprehensive approach to diagnosing patients with proptosis and diplopia. While these symptoms are commonly attributed to thyroid eye disease, it is essential to consider alternative diagnoses such as amyloidosis, especially when standard treatments fail to yield results. The discovery of amyloid deposition in the extraocular muscles, although exceedingly rare, emphasizes the significance of a thorough differential diagnosis. In conclusion, this case report highlights the importance of vigilance in clinical practice, encouraging ophthalmologists to explore less common diagnostic possibilities when faced with challenging cases. Further research and clinical investigation are warranted to better understand the mechanisms and potential treatments for amyloidosis affecting the extraocular muscles.

Clinical and Radiological Features of Intramuscular Orbital Amyloidosis: A Case Series and Literature Review

PURPOSE

Orbital amyloidosis of the extraocular muscles (EOMs) is a rare condition, and its clinicoradiological features are not well elucidated. This study describes the characteristic clinical signs, MRI features, and potential treatment options.

METHODS

Retrospective multicenter case series and literature review of EOM amyloidosis.

RESULTS

Five cases were identified for inclusion. Common clinical findings were diplopia, ophthalmoplegia, and proptosis. Systemic amyloidosis was more likely to present with multiple muscle involvement, but no particular pattern was observed with localized disease. On MRI, amyloid deposition was characterized as a heterogeneous intramuscular mass with T2 hypointensity and post contrast enhancement. Management is dependent on the extent of disease and functional impairment; options include surgical debulking and radiation therapy.

CONCLUSION

EOM amyloidosis is uncommon. The combination of clinical and radiologic findings described in this study should lead to its clinical suspicion.

Postoperative amyloidosis of tongue base: Extremely rare complication after multilevel sleep surgery

Amyloidosis is to be considered in the differential diagnosis of postoperative edema of tongue base after its ablation. It might be triggered by surgical trauma. After establishment of diagnosis, cause of secondary amyloidosis should be excluded.

Primary isolated amyloidosis in the extraocular muscle as a rare cause of ophthalmoplegia: A case report and literature review

Purpose

To report a case of external ophthalmoplegia due to an uncommon form of amyloidosis exclusively affecting the lateral rectus muscle, and to discuss the clinical manifestation, diagnostic challenges, and management pitfalls of isolated amyloidosis in the extraocular muscle.

Observations

A 64-year-old woman presented with diplopia in her left gaze lasting for six months. She had orthophoria in the primary position and abduction limitation in the left eye. Routine laboratory examinations were unremarkable. Orbital magnetic resonance imaging showed fusiform enlargement of the left lateral rectus muscle, without tendon involvement. Extraocular muscle biopsy was recommended to make a diagnosis, which revealed amyloid deposition in the lateral rectus muscle. A systemic work-up showed no evidence of systemic amyloidosis. Therefore, a diagnosis of primary isolated amyloidosis was made. Orthophoria in the primary position and diplopia in the lateral gaze persisted at the six-month follow-up.

Conclusions and importance

Atypical extraocular muscle enlargement should alert clinicians to the need for tissue biopsy to identify uncommon etiologies, such as amyloidosis. There are no pathognomonic or radiological features to distinguish localized from systemic amyloidosis. Therefore, if amyloidosis of the extraocular muscles is diagnosed, a systemic work-up is needed to rule out systemic amyloidosis, which is potentially life-threatening.

Systemic Amyloidosis and Extraocular Muscle Deposition

Isolated amyloid deposition in an extraocular muscle is a rare event but can be a presenting feature of systemic amyloidosis. A 67-year-old woman with an acquired exotropia and hypertropia was found to have unilateral diffuse extraocular muscle enlargement on magnetic resonance imaging. Owing to the progressive nature of her strabismus and the negative laboratory testing for thyroid disease, she underwent an extraocular muscle biopsy that revealed amyloid deposition. Further workup demonstrated a monoclonal gammopathy consistent with systemic amyloidosis. This case demonstrates the need to consider amyloidosis in the differential diagnosis of patients presenting with an atypical acquired strabismus. We review other reports of isolated amyloid deposition in extraocular muscles and its association with systemic amyloidosis, emphasizing the importance of the ophthalmologist in the early recognition of this disease to prevent irreversible, life-threatening end organ damage.

Amyloidosis and the lung

Amyloidosis is a disorder of protein folding in which normally soluble plasma proteins aggregate in an abnormal fibrillar form causing progressive disruption to tissue structure and organ function. This review covers systemic AA and AL amyloidosis which may arise as a consequence of chronic respiratory conditions; the manifestations of both systemic and of localised amyloid deposition within the respiratory tract and provides a summary of current approaches to diagnosis and management.

How to diagnose amyloidosis

Amyloidosis is a rare but devastating condition caused by deposition of misfolded proteins as aggregates in the extracellular tissues of the body, leading to impairment of organ function. High clinical suspicion is required to facilitate early diagnosis. Correct identification of the causal amyloid protein is absolutely crucial for clinical management in order to avoid misdiagnosis and inappropriate, potentially harmful treatment, to assess prognosis, and to offer genetic counselling if relevant. This review summarises the current evidence on which the diagnosis and subtyping of amyloidosis is based, outlines the limitations of various diagnostic techniques, particularly in an Australian and New Zealand context, and discusses optimal strategies for the diagnostic approach to these patients. Recommendations are provided for when particularly to suspect amyloidosis, what investigations are required, as well as an approach to accurate subtyping of amyloidosis.

Anterior orbit and adnexal amyloidosis

Purpose:

To describe six cases of anterior orbital and adnexal amyloidosis and to report on proteomic analysis to characterize the nature of amyloid in archived biopsies in two cases.

Materials and Methods:

The clinical features, radiological findings, pathology, and outcome of six patients with anterior orbit and adnexal amyloidosis were retrieved from the medical records. The biochemical nature of the amyloid was determined using liquid chromatography/mass spectroscopy archived paraffin-embedded tissue in two cases.

Results:

Of the six cases, three had unilateral localized anterior orbit and lacrimal gland involvement. Four of the six patients were female with an average duration of 12.8 years from the time of onset to presentation eyelid infiltration by amyloid caused ptosis in five cases. CT scan in patients with lacrimal gland involvement (n = 3) demonstrated calcified deformable anterior orbital masses and on pathological exmaintionamyloid and calcific deposits replaced the lacrimal gland acini. Ptosis repair was performed in three patients with good outcomes. One patient required repeated debulking of the mass and one patient had recurrenct disease. Proteomic analysis revealed polyclonal IgG-associated amyloid deposition in one patient and AL kappa amyloid in the second patient.

Conclusion:

Amyloidosis of the anterior orbit and lacrimal gland can present with a wide spectrum of findings with good outcomes after surgical excision. The nature of amyloid material can be precisely determined in archival pathology blocks using diagnostic proteomic analysis.

Amyloidosis

The term amyloid describes the deposition in the extracellular space of certain proteins in a highly characteristic, insoluble fibrillar form. Amyloidosis describes the various clinical syndromes that occur as a result of damage by amyloid deposits in tissues and organs throughout the body. The clinical significance of amyloid varies enormously, ranging from incidental asymptomatic deposits to localized disease through to rapidly fatal systemic forms that can affect multiple vital organs. Currently available therapy is focused on reducing the supply of the respective amyloid fibril precursor protein and supportive medical care, which together have greatly improved survival. Chemotherapy and anti-inflammatory treatment for the disorders that underlie AL and AA amyloidosis are guided by serial measurements of the respective circulating amyloid precursor proteins, i.e. serial serum free light chains in AL and serum amyloid A protein in AA type. Quality of life and prognosis of some forms of hereditary systemic amyloidosis can be improved by liver and other organ transplants. Various new therapies, ranging from silencing RNA, protein stabilizers to monoclonal antibodies, aimed at inhibiting fibril precursor supply, fibril formation or the persistence of amyloid deposits, are in development; some are already in clinical phase.

Macroglossia due to Systemic Amyloidosis: Is There a Role for Radiotherapy?

Background

Macroglossia due to amyloid depositions can cause cosmetic problems and functional disability, and can lead to life-threatening airway obstruction. Management of macroglossia in systemic amyloidosis is controversial, and the role of surgery is unclear.

Case Description

We present a case of a 66-year-old woman affected by macroglossia due to light chain amyloidosis who presented with eating and breathing difficulties. Because of prior successful results of radiotherapy for localized amyloid disease, our patient was treated with external beam radiation therapy (20 Gy in 10 fractions). The treatment was well tolerated by the patient. However, her systemic amyloidosis progressed, with a subclinical increase in tongue width.

Conclusions

This is the first reported use of radiotherapy for amyloidosis of the tongue. There was no evidence of benefit using a total dose of 20 Gy. This therapeutic modality is not recommended for the routine management of macroglossia.

The use of radiotherapy for the treatment of localized orbital amyloidosis

OBJECTIVE

To describe two patients with localized orbital amyloidosis and the response of their condition to surgical debulking followed by external beam radiotherapy.

DESIGN

Retrospective noncomparative interventional case series.

OUTCOME MEASURES

Stabilization or regression of orbital signs after treatment.

METHODS

Patients with biopsy-proven diagnosis of localized progressive orbital amyloidosis received 34 and 30 Gy fractionated external beam radiotherapy. The clinical case notes and histopathology for the two patients were reviewed.

RESULTS

A 69-year-old man with orbital amyloid deposition in association with localized MALT lymphoma had a marked improvement in orbital signs following surgical debulking and radiotherapy, with no recurrence over two years. A 59-year-old woman with localized orbital amyloidosis showed regression of disease after surgical debulking and radiotherapy, with no evidence of recurrence after six years of follow-up.

CONCLUSION

External beam radiotherapy following surgical debulking appears to halt the progression of localized orbital amyloidosis. Radiotherapy may be used in conjunction with surgical debulking of disease.

Orbital Amyloidosis–induced Compressive Optic neuropathy Accompanied by Characteristic Eyelid Pigmentation

The deposition of amyloid protein in orbital tissue is called orbital amyloidosis. Orbital amyloidosis is a rare condition that usually affects older patients. Although the disease is slowly progressive, it rarely involves the optic nerve or threatens vision. We report a case of orbital amyloidosis that initially appeared as impressive eyelid pigmentation and blepharoptosis and then progressed to systemic amyloidosis. The orbital lesion induced compressive optic neuropathy. Surgical management enabled partial but not full recovery of vision.

Primary local orbital amyloidosis: biochemical identification of the immunoglobulin light chain kappaIII subtype in a small formalin fixed, paraffin wax embedded tissue sample

BACKGROUND

Amyloidosis refers to a heterogeneous group of disorders associated with the deposition of chemically distinct amyloid fibril proteins. Precise determination of chemical amyloid type has diagnostic, therapeutic, and prognostic relevance. Although immunohistochemical techniques are used routinely to determine the amyloid type, the results can be negative or inconclusive, so that biochemical characterisation is often required. The development and application of new biochemical microtechniques suitable for examination of extremely small tissue samples is essential for precise identification of the deposited amyloid proteins.

AIMS

To investigate biochemically the amyloid proteins present in a formalin fixed paraffin wax embedded orbital tissue from a patient with localised orbital amyloidosis in whom immunohistochemistry was not helpful in the determination of amyloid type.

METHODS

Extraction of amyloid proteins from fixed tissue and their identification was carried out by a recently developed microtechnique. An extremely small tissue sample was dewaxed and extracted with formic acid. The extracted material was analysed using electrophoresis, western blotting, and amino acid sequencing.

RESULTS

Biochemical examination of the extracted proteins showed the presence of immunoglobulin (Ig) derived amyloid proteins, which were composed of the N-terminal fragments of the Ig light chain kappaIII subtype (AL-kappaIII) (16, 8, and 3 kDa).

CONCLUSIONS

This is the first chemically proved AL case reported in association with primary localised orbital amyloidosis. The biochemical microtechnique used was useful in achieving a precise diagnosis of amyloid disease, in a case where the results of routine immunohistochemical examination of amyloid were inconclusive.

Kappa III immunoglobulin light chain origin of localized orbital amyloidosis

Isolated orbital amyloidosis is a rare condition in which intra-muscular deposits result in proptosis and restriction of eye movement. Previous reports have suggested an immunoglobulin origin of the amyloid fibrils, but this has not been proven biochemically. A case is presented in which initial unilateral orbital amyloidosis progressed to bilateral disease. Biochemical analysis of resected ocular muscle determined that the amyloid fibrils were derived from a kappa III immunoglobulin light chain. Questions of pathogenesis and tissue tropism are considered.

Ptosis from localized A-λ-amyloid deposits in the levator palpebrae muscle

PURPOSE

To describe a patient with unilateral ptosis caused by localized amyloid deposits of immunoglobulin lambda-light chains (A-lambda-amyloid) in the levator palpebrae muscle.

STUDY DESIGN

Case report and literature review.

PARTICIPANT

A 32-year-old otherwise healthy female with right-sided unilateral ptosis.

METHODS

The patient presented with right-sided unilateral ptosis without other ocular abnormalities. Palpebral fissures measured 5 mm on the right side and 8 mm on the left. Systemic evaluation, including neurologic and neuroradiologic examinations, was normal.

RESULTS

Several years after initial presentation, conjunctival amyloid deposits appeared. Ptosis surgery with resection of the levator muscle was performed, revealing massive deposits of A-lambda-amyloid in the excised tissue.

CONCLUSIONS

Our patient had unilateral ptosis due to localized A-lambda-amyloid deposits in the levator muscle. No other amyloid deposits were initially found. Visible conjunctival deposits developed only years later. Ocular amyloidosis with isolated initial involvement of the levator muscle is a rare condition. Localized monoclonal gammopathy may have been the cause of this unique presentation.

Analysis of plasma cell clonality in localized AL amyloidosis

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.

Tracheobronchial amyloidosis. The Boston University experience from 1984 to 1999

Tracheobronchial amyloidosis (TBA), an idiopathic disorder characterized by deposition of fibrillar proteins in the tracheobronchial tree, occurred in 10 patients referred to the Amyloid Program at Boston University over the past 15 years. Fewer than 100 cases of TBA have been described; only 1 series encompassed more than 3 patients. We analyzed our experience with biopsy-proven TBA to define better its natural history. Follow-up averaged approximately 8 years and was obtained in all cases, making this outcome reporting the largest and most complete to date. Three of these patients were prospectively studied for up to 24 months to examine the utility of bronchoscopy, computerized tomography (CT) imaging, and pulmonary function tests (PFTs) in monitoring disease progression. No patient with TBA developed signs or symptoms of systemic amyloidosis during the period reviewed. Conversely, tracheobronchial disease was not diagnosed in 685 patients with primary systemic (AL) amyloidosis during the 15-year study period at Boston University. Bronchoscopy proved most useful in establishing the diagnosis by biopsy. Narrowing of major airways limited its inspection of the tracheobronchial tree, however. In contrast, CT imaging provided quantitative assessment of airway narrowing and mural thickening--2 major consequences of amyloid infiltration. These CT features, in the presence of mural calcifications sparing the posterior tracheal membrane, have been reported in few disorders other than TBA. The ability of CT to map airway involvement and identify extraluminal manifestations of TBA made it the study of choice for establishing disease extent. Three patterns of disease were evident by CT imaging and bronchoscopic examination: proximal, mid, and distal airways involvement. Those with severe proximal disease had significantly decreased air flows, air trapping, and fixed upper airway obstruction on PFTs. Patients with distal disease had normal airflows. PFTs could not clearly distinguish proximal from severe mid airways disease. Thirty percent of patients died within 7-12 years after diagnosis, all having proximal or severe mid airways disease. Repeated rigid bronchoscopic debridement and laser treatments did not prevent progressive airways narrowing in patients dying from TBA. Most patients with mid airways involvement, and all distal airway cases, had either stagnant disease or slowly increasing amyloid deposits when followed for up to 14 years. In a small subset of patients followed prospectively, serial PFTs were most sensitive to disease progression. CT-derived measures of airway lumen diameter and wall thickness did not change significantly despite marked improvements in airflow after rigid bronchoscopy. Our experience suggests that serial PFTs and CT imaging together offer the best assessment of airway involvement and disease progression in patients with TBA. In the future, radiation therapy may provide more definitive treatment of TBA than debulking procedure have to date.

Nonthyroid causes of extraocular muscle disease

Extraocular muscle involvement in orbital disease is most frequently seen as a feature of thyroid orbitopathy (Graves' disease). However, a wide range of other conditions may alter the size, shape, and function of these muscles, with characteristic clinical manifestations or abnormalities visible on orbital imaging. The differential diagnosis of muscle disease can be narrowed by careful analysis of clinical features and ancillary tests. Imaging facilitates recognition in many cases, but in some instances, accurate diagnosis requires biopsy. This review highlights the differential diagnoses for diseases of extraocular muscles based on the clinical and investigative records of 103 patients at our institution combined with data from the world literature. We found that the most common nonthyroid causes of muscle disease were inflammatory, vascular, and neoplastic processes (in decreasing order of frequency). Emphasis is placed on investigations that provide a logical approach to, and appropriate management of, disease of the extraocular muscles.

Conjunctival AL amyloidosis associated with a low-grade B-cell lymphoma

A rare case of localized amyloidosis associated with a low-grade B-cell lymphoma involving the conjunctiva is described. Although infiltrating small lymphocytes and plasma cells showed little cytological atypia, molecular genetic examination revealed a prominent B-cell clonal immunoglobulin heavy chain (IgH) gene rearrangement in the tumor tissue. Immunoelectronmicroscopic examination showed immunoglobulin lambda light chain specificity in the amyloid deposit and Russell bodies in the surrounding plasma cells. We concluded that the immunoglobulin lambda light chain, produced by the tumor's differentiated plasma cells, is the precursor protein of the localized amyloidosis found in this case.

Amyloid deposition in the extraocular muscles

Orbital involvement is frequent in generalised amyloidosis. However, primary localised amyloid in the orbit is rare and requires systemic investigation. We present a case with amyloid deposits localised to one extraocular muscle in whom systemic investigation has been negative.