Diffuse parenchymal pulmonary amyloidosis associated with multiple myeloma: a case report and systematic review of the literature

Pulmonary Amyloidoma: A Case Report and Brief Review of the Literature

We report the case of a 59-year-old female patient, a former smoker, who was diagnosed with bilateral pulmonary nodules. Extensive medical investigations were conducted, including a surgical lung biopsy, which led to the diagnosis of pulmonary amyloidoma. The diagnostic process was guided by the presence of a persistent, polymorphic, and nonspecific clinical picture, strengthened by imaging findings characterized by mixed nodular lesions and the addition of interstitial involvement, along with partial deterioration of the pulmonary parenchyma architecture. Although it is recognized as a benign tumor, pulmonary amyloidoma requires special care in order to rule out systemic involvement, association with lymphomas, or systemic amyloidosis. This case highlights the comprehensive investigations required in the presence of multiple pulmonary nodules and the wide range of possible diagnoses. It underscores the pivotal role of surgical lung biopsy and histopathological examination. The case is instructive, addressing a rare pathology, on the border between specialties, while also emphasizing potential evolving challenges and providing further insights into the clinical course of this disease.

Pulmonary manifestations of amyloidosis

Amyloidosis is caused by abnormal protein deposition in various tissues, including the lungs. Pulmonary manifestations of amyloidosis may be categorized by areas of involvement, such as parenchymal, large airway and pleural involvement. We describe four distinct manifestations of amyloidosis involving the lung and review their clinical, radiological and pathological features and summarize the evidence for treatment in each of these presentations. We describe alveolar-septal amyloidosis, cystic amyloid lung disease, endobronchial amyloidosis and pleural amyloidosis.

Implications of Extra-cardiac Disease in Patient Selection for Heart Transplantation: Considerations in Cardiac Amyloidosis

Disease-modifying therapies in both light chain and transthyretin amyloidosis have improved patient functional status and survival. Conceivably, as heart failure may progress despite amyloid therapies, more patients may be considered for heart transplantation. In earlier eras, extra-cardiac amyloid deposits significantly reduced post-heart transplant patient survival and functional status compared to the non-amyloid population. In the modern era, transplant centres have reported improved outcomes in amyloidosis as patient selection has grown more stringent. Importantly, systematic candidate evaluation should assess the degree of extra-cardiac involvement, the effectiveness of disease-modifying therapies and downstream effects on patients' nutrition and frailty. This review outlines such an overall approach while also considering that organ-specific selection criteria may vary between individual transplant centres. A methodical approach to patient evaluation will promote better understanding of the prevalence and severity of extra-cardiac disease in amyloidosis patients referred for heart transplantation and of any disparities in decision outcomes in this population.

A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications

Post-acute sequelae of COVID (PASC), usually referred to as 'Long COVID' (a phenotype of COVID-19), is a relatively frequent consequence of SARS-CoV-2 infection, in which symptoms such as breathlessness, fatigue, 'brain fog', tissue damage, inflammation, and coagulopathies (dysfunctions of the blood coagulation system) persist long after the initial infection. It bears similarities to other post-viral syndromes, and to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Many regulatory health bodies still do not recognize this syndrome as a separate disease entity, and refer to it under the broad terminology of 'COVID', although its demographics are quite different from those of acute COVID-19. A few years ago, we discovered that fibrinogen in blood can clot into an anomalous 'amyloid' form of fibrin that (like other β-rich amyloids and prions) is relatively resistant to proteolysis (fibrinolysis). The result, as is strongly manifested in platelet-poor plasma (PPP) of individuals with Long COVID, is extensive fibrin amyloid microclots that can persist, can entrap other proteins, and that may lead to the production of various autoantibodies. These microclots are more-or-less easily measured in PPP with the stain thioflavin T and a simple fluorescence microscope. Although the symptoms of Long COVID are multifarious, we here argue that the ability of these fibrin amyloid microclots (fibrinaloids) to block up capillaries, and thus to limit the passage of red blood cells and hence O2 exchange, can actually underpin the majority of these symptoms. Consistent with this, in a preliminary report, it has been shown that suitable and closely monitored 'triple' anticoagulant therapy that leads to the removal of the microclots also removes the other symptoms. Fibrin amyloid microclots represent a novel and potentially important target for both the understanding and treatment of Long COVID and related disorders.

Pulmonary AL amyloidosis and multiple myeloma presenting as cough with diffuse pulmonary opacities

Amyloidosis is an uncommon multisystem disease that can affect many organs. However, interstitial lung involvement is very rare. A 68-year-old man presented with long-standing dyspnoea and productive cough. After extensive investigation, including two non-diagnostic bronchoscopies, a surgical lung biopsy demonstrated pulmonary amyloidosis. A bone marrow biopsy confirmed multiple myeloma. The patient was treated with chemotherapy and an autologous stem cell transplant.

Chronic Diarrhea as the Presenting Feature of Amyloidosis with Multiple Myeloma: A Case Report Diagnosed by a Myocardial Biopsy

A 73-year-old woman with a history of diarrhea for one year and other various symptoms was admitted to our hospital. Gastrointestinal endoscopy that included enteroscopy with multiple biopsies was performed. However, no significant findings were observed. Electrocardiography showed low voltage in all limb leads, and an echocardiogram showed thickened cardiac walls with granular sparkling pattern. A myocardial biopsy revealed amyloidosis, and a bone marrow biopsy showed multiple myeloma. This case suggests that we should suspect the possibility of amyloidosis in a patient with diarrhea and various symptoms involving multiple organ systems. Additionally, electrocardiograms and echocardiograms should be performed even when gastrointestinal biopsies reveal negative results.

Perilymphatic micronodular pattern as a manifestation of pulmonary amyloidosis on high-resolution computed tomography

The term amyloidosis describes a group of diseases caused by the fibrillar deposit of poorly folded proteins in tissues with a secondary alteration of their function. Diffuse parenchymal lung disease associated with amyloidosis is rare and is most often diagnosed in autopsy. A 45-year-old male patient presented an acute episode of cough with mucoid expectoration. He had also dyspnea, dry cough, chest pain, and constitutional symptoms of 6 months of evolution. Initially the case was treated as acute pneumonia. After taking radiological images of the thorax, a diagnostic suspicion of lymphangitic spread of neoplasia was assumed. Histopathological findings of an open pulmonary biopsy demonstrated interstitial thickening with perivascular eosinophilic invasion. Congo Red staining and immunohistochemistry studies were done and turned out to be positive for amyloid. The perilymphatic micronodular pattern as a radiological manifestation of parenchymal pulmonary amyloidosis has been very rarely described in the literature, therefore it must be considered as a differential diagnosis in patients with this pattern in CT scan and should be an incentive for its histopathological study once a neoplasm is ruled out.

Pulmonary amyloidosis complicated with pulmonary hemosiderosis, diagnosed with bronchoscopy

We describe a case of an 82-year-old Japanese woman with pulmonary amyloidosis and hemosiderosis associated with multiple myeloma. She had a background of end-stage renal failure of unknown etiology and had been on maintenance dialysis for 2 years. She complained of exertional dyspnea for four months. High-resolution CT of the chest revealed diffuse ground-glass opacities with mosaic attenuation, consolidation in the left lingular lobe, and wedge-shaped, subpleural nodules in the bilateral lower lobes. A transbronchial lung biopsy of the left lingular lobe showed deposition of amorphous, eosinophilic amyloid at the smooth muscle layer of bronchial tissue, with a positive Congo red staining signal in polarized light. Bronchoalveolar lavage fluid was brownish-yellow, and numerous hemosiderin-laden macrophages were detected with Berlin blue staining. From these findings, a diagnosis of pulmonary amyloidosis complicated with pulmonary hemosiderosis was made. Further work-up led to a diagnosis of multiple myeloma. Pulmonary amyloidosis complicated with pulmonary hemosiderosis is a rare disorder and may be underdiagnosed. Physical examination, such as the appearance of the tongue, can assist the diagnosis of systemic amyloidosis. Use of bronchoscopy allows physicians make an early diagnosis of pulmonary amyloidosis that is minimally invasive.

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Pulmonary amyloidosis can present nodules, GGOs, and consolidations.

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Pulmonary amyloidosis can be complicated with pulmonary hemosiderosis.

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Pulmonary amyloidosis can be diagnosed using bronchoscopy.

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Physical examination of the tongue can assist diagnosis of systemic amyloidosis.

Pulmonary nodules associated with pulmonary embolism: A rare and misleading presentation of amyloidosis

Amyloidosis is a rare disease especially the localized form involving pulmonary parenchyma. We report the case of a 74 years old woman who presented with chest pain and dyspnoea. CT scan showed pulmonary embolism and bilateral nodules. Laboratory examinations highlighted circulating Kappa IgM. 18F-FDG PET/CT showed intense activity of the nodules. Histological investigation supported the diagnosis of nodular pulmonary amyloidosis. There were no sign of systemic amyloidosis or autoimmune disease. No treatment was initiated: the patient remains asymptomatic after one year. Localized pulmonary amyloidosis related to MGUS was the most likely diagnosis. Malignancy, a differential diagnosis of pulmonary amyloidosis, must be excluded: histological examinations are overriding. Difference between systemic and localized amyloidosis conditions treatment and prognosis. This observation emphasizes the difficulty to establish the diagnosis of pulmonary nodular amyloidosis and the complex relationship between amyloidosis and thromboembolism.

A case report of pulmonary amyloidosis recognized by detection of AA amyloid exclusively in alveolar macrophages

Amyloidosis is a rare condition in which tissue deposits of inert fibrillar protein result in organ damage and dysfunction. There are several types of amyloid fibrils. Some of the most common forms are AL (amyloid light chain) protein and AA (amyloid-associated) type of amyloid fibril protein. Pulmonary amyloidosis is relatively common but is usually asymptomatic. Thus, the diagnosis may be easily overlooked. A 78-year-old male with a history of multiple myeloma followed by systemic amyloidosis presented with abnormal chest CT showing diffuse interlobular thickening in the whole lung field with bilateral pleural effusion. Bronchoalveolar lavage and transbronchial biopsy were performed. Due to the patient's poor condition and hemorrhage, only one fragment was available from forceps biopsy. Histologically, there was no amyloid deposition in the lung parenchyma; however, some histiocytes showed eosinophilic granular contents which prompted us to perform additional staining. The cytoplasmic material turned to be positive with direct fast scarlet (DFS) staining and AA amyloid immunostaining. Similar macrophages with AA amyloid were also found in the bronchoalveolar fluid. We experienced a case with AA amyloidosis affecting the lung diagnosed by the presence of intracytoplasmic amyloid in alveolar macrophages. The microscopic changes were so subtle that they may be overlooked. Recognition of amyloid deposition in alveolar macrophages may be an important clue to diagnose pulmonary amyloidosis. Such finding is of particular significance in the small-sized specimens, such as biopsies and cytologic smears.

Diffuse Infiltration of Multiple Myeloma With Initial Manifestation of Cavernous Sinus Syndrome Unveiled by 18F-FDG PET/CT

Intracranial infiltration is a rare complication of multiple myeloma (MM), which is usually seen in advanced stage. Here, we report a 47-year-old woman with only cavernous sinus syndrome as first manifestation. Brain MR revealed cavernous sinus masses, leptomeningeal nodules, and osseous erosion, which were considered metastases. F-FDG PET/CT, which was further performed to identify potential primary lesions, showed increased uptake not only in cavernous sinus and leptomeninges but also in diffuse bone lesions, hepatic nodules, lymph nodes, subcutaneous nodules, and bilateral ovarian masses. Multiple myeloma with intracranial involvement was confirmed by biopsy and cerebrospinal fluid examination.