Destructive bone lesions in primary amyloidosis

Onset of Chronic Expanding Hematoma 25 Years After Total Hip Arthroplasty

Chronic expanding hematoma (CEH) is a rare anatomical condition that gradually expands due to trauma or surgery. We report the case of a 56-year-old woman who developed CEH 25 years after metal-on-polyethylene total hip arthroplasty. She presented with swelling and radiating pain in the right inguinal region. Tocilizumab was administered for treating rheumatoid arthritis and renal amyloid A amyloidosis. Diagnostic imaging and partial resection revealed a soft tissue mass and a CEH, respectively. The symptoms recurred 6 months later; dialysis was initiated, and the CEH was resected under general anesthesia, leading to improvement. This case report emphasizes the importance of prompt diagnosis and intervention in CEH management for preventing further complications and improving the patient's quality of life.

Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis with Kidney Involvement in a Patient with AL Amyloidosis

Antineutrophil cytoplasmic autoantibody (ANCA) vasculitis has occasionally been associated with other systemic glomerulonephritis, such as anti-glomerular basement membrane disease. Here, we report the first clinical case of ANCA-associated crescentic glomerulonephritis with AL amyloidosis. An 81-years-old gentleman presented to the hospital with acute kidney injury (serum creatinine 4.7 mg/dL) on a background of chronic kidney disease and volume overload. Autoimmune serology was remarkable for p-ANCA and myeloperoxidase positivity. A renal biopsy confirmed pauci-immune glomerulonephritis and lambda light-chain amyloid deposition (confirmed on liquid chromatography and tandem mass spectrometry). The patient was initially managed with rituximab and subsequently transitioned to bortezomib-based chemotherapy but died due to decompensated heart failure. This case report promotes greater awareness of the unusual presentation of amyloidosis and guides future research and treatment.

Atypical immunoglobulin light chain amyloidosis: Spontaneous vertebral compression fracture, liver involvement, and bone marrow involvement report of 3 cases and review of the literature

BACKGROUND

Primary immunoglobulin light chain amyloidosis (AL amyloidosis) is a plasma cell disorder which mainly affects heart, kidneys, liver, and peripheral nervous system. Cases of atypical AL amyloidosis presented as spontaneous vertebral compression fractures have been rarely reported, and data about the management and clinical outcomes of the patients are scarce.

METHODS

Herein, we present 3 new cases of AL amyloidosis with spontaneous vertebral compression fracture and review 13 cases retrieved from the literature.

RESULTS

Moreover, we observed overrepresentations of liver involvement and bone marrow involvement in AL amyloidosis with spontaneous vertebral compression fracture.

CONCLUSION

We believe that better awareness of the rare clinical presentation as spontaneous vertebral compression fracture of AL amyloidosis can facilitate earlier diagnosis and earlier treatment.

Osteoprotegerin is a significant prognostic factor for overall survival in patients with primary systemic amyloidosis independent of the Mayo staging

Bone metabolism has not been systematically studied in primary (AL) amyloidosis. Thus we prospectively evaluated bone remodeling indices in 102 patients with newly diagnosed AL amyloidosis, 35 healthy controls, 35 newly diagnosed myeloma and 40 monoclonal gammopathy of undetermined significance patients. Bone resorption markers (C-telopeptide of type-1 collagen, N-telopeptide of type-1 collagen) and osteoclast regulators (soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteoprotegerin (OPG)) were increased in AL patients compared with controls (P<0.01), but bone formation was unaffected. Myeloma patients had increased bone resorption and decreased bone formation compared with AL patients, while sRANKL/OPG ratio was markedly decreased in AL, due to elevated OPG in AL (P<0.001). OPG correlated with N-terminal pro-brain natriuretic peptide (P<0.001) and was higher in patients with cardiac involvement (P=0.028) and advanced Mayo stage (P=0.001). OPG levels above the upper value of healthy controls was associated with shorter survival (34 versus 91 months; P=0.026), while AL patients with OPG levels in the top quartile had very short survival (12 versus 58 months; P=0.024). In Mayo stage 1 disease, OPG identified patients with poor survival (12 versus >60 months; P=0.012). We conclude that increased OPG in AL is not only a compensation to osteoclast activation but may also reflect early cardiac damage and may identify patients at increased risk of death within those with earlier Mayo stage.

Vertebral compression fractures as the initial presentation of AL amyloidosis: case series and review of literature

The clinical presentation of AL amyloidosis is highly variable. In this series, we describe five cases of AL amyloidosis with vertebral compression fractures as initial presentation. All five patients had evidence of bone marrow replacement on magnetic resonance imaging and bone marrow biopsies demonstrating diffuse interstitial amyloid deposition. Hepatomegaly and elevated liver enzymes, consistent with liver involvement with amyloidosis, were also seen in each case. All five patients responded well to anti-plasma cell chemotherapy, with normalization of serum free light chain levels, reduction in alkaline phosphatase and improvement in pain and functional status. Although rare, AL amyloidosis should be considered in the differential diagnosis of selected patients with spontaneous vertebral compression fractures. Moreover, there seems to be an association of vertebral compression fractures with liver involvement in AL amyloidosis.

Vertebra collapse due to primary amyloidosis causing neurological compromise

In primary amyloidosis (AL), a fibrillar protein (amyloid light chain) is deposited in many organs; however, it is rare to have involvement of the vertebral bodies. Multiple myeloma is a well-known systemic amyloid disease that frequently has vertebral involvement. However, the pathology of vertebral involvement of these two clinical entities differs significantly. We report a patient with L4 vertebral collapse because of primary AL, causing neurological compromise that improved with surgical treatment. Deposition of amyloid and following demineralisation caused the vertebral collapse. Primary AL needs to be taken into consideration as a cause of pathological vertebral fracture.

Soft tissue, joint, and bone manifestations of AL amyloidosis: clinical presentation, molecular features, and survival

OBJECTIVE

To characterize symptoms and signs of AL amyloidosis that may bring patients to the attention of rheumatologists, evaluate Ig V(L) gene usage in this subgroup of patients, and assess the impact of soft tissue and bone involvement and V(L) gene usage on survival.

METHODS

Clinical features of soft tissue and bone involvement were assessed in 191 patients with AL amyloidosis. V(L) gene sequencing was carried out to determine light-chain family, rate of somatic mutation, and evidence of antigen selection. The association of soft tissue and bone involvement with V(L) gene usage was assessed by logistic regression analysis, and survival time was analyzed using log rank tests and Cox regression models.

RESULTS

Soft tissue and bone involvement occurred in 42.9% of the patients, and 9.4% had dominant soft tissue and bone involvement. The most common manifestations were submandibular gland enlargement, macroglossia, and carpal tunnel syndrome. Dominant soft tissue and bone involvement was significantly associated with V(L)kappaI gene usage. Mutation rate and evidence of antigen selection in the V(L) genes were not found to be confounding factors, providing evidence against a contribution of autoimmunity in this type of AL amyloidosis. Survival time was initially longer in patients with dominant soft tissue and bone involvement than in patients with other dominant organ involvement; however, this difference diminished over time.

CONCLUSION

Amyloid infiltration into soft tissue, joints, periarticular structures, and bones can bring patients with AL amyloidosis to the attention of rheumatologists. Recognition of the presenting symptoms is essential for accurate diagnosis and appropriate treatment, since the long-term outlook for untreated patients with dominant soft tissue and bone involvement is not better than that for patients with other dominant features of AL amyloidosis.

An unusual complication of familial Mediterranean fever: protracted arthritis with bilateral coxarthrosis and intraosseous amyloidosis of femoral head

Protracted arthritis is uncommon in familial Mediterranean fever (FMF) and rarely may result in degenerative joint damage, a well-known complication of FMF, usually affecting kidneys. We present an unusual case of FMF involving severe bilateral coxarthrosis leading to residual incapacity that was treated by total hip arthroplasty, and an unusual presentation of amyloidosis - intraosseous amyloidosis of the femoral head.

Bone mineral density in familial amyloid polyneuropathy and in other neuromuscular disorders

Neuromuscular diseases are a known risk factor for immobilization-induced osteoporosis. The aim of the study was to analyse bone mineral density (BMD) in patients with familial amyloid polyneuropathy (FAP) type I (Val30 Met) and to compare them with a population of patients with other neuromuscular disorders. We studied 24, ambulatory, neuromuscular patients, all men and premenopausal women. We included 12 FAP patients (GI) and 12 patients with other disorders (GII). Clinical data included age, sex, height, weight, alcohol intake, smoking, calcium intake, physical activity and history of fractures. Serum and urinary calcium, osteocalcin, bone alkaline phosphatase, parathyroid hormone, thyroid stimulating hormone and urinary N-telopeptide cross-linked type 1 collagen were determined in all patients. Bone mineral density of lumbar spine, hip and wrist were determined by dual energy X-ray absorptiometry scan. No statistical differences were found in clinical or analytic data between the two groups, except for body mass index and calciuria, which were lower in GI. In GI, 54.5% were osteoporotic, against 23.1% in GII (P = 0.04). Bone mineral density was lower in GI when compared with GII, and tended to decrease with disease duration. Decreased BMI and the early autonomic involvement in GI probably explain the results. The prevention and early treatment of osteoporosis, in FAP patients should be considered a priority.

Haemarthrosis due to fracture through amyloid deposits in bone in Portuguese familial amyloidosis

A patient with Portuguese familial amyloid polyneuropathy who developed haemarthroses secondary to pathological fractures is described. Amyloid material was demonstrated on bone biopsy and confirmed immunohistochemically to be transthyretin (prealbumin). Although amyloid deposits in bone have been described in other types of amyloid, this is believed to be the first proved case of amyloid deposition resulting in pathological fracture in familial amyloidosis.

Role of amyloid in dialysis-related arthropathies. A morphological analysis of 23 cases

The role of beta 2-microglobulin-related amyloidosis in the articular syndromes associated with long-term haemodialysis was analysed in a series of 23 haemodialysed patients from whom 43 amyloid-containing osteoarticular specimens were obtained. Patients with clinical arthropathy had more intense and deep synovial involvement by amyloid than asymptomatic ones. Amyloid proved to be an agent for bone destruction, causing bone cysts and cortical erosions. Amyloid deposition in cartilage was found constantly, leading to fissures and irregularities in the articular surface. From our observations, amyloid seems to be the main pathogenetic factor involved in articular swelling, destructive arthropathies and pathological fractures occurring in haemodialysed patients, although other disturbances related to haemodialysis could play a role.