Primary systemic amyloidosis initially presenting with digestive symptoms: a case report and review of the literature

A near-complete genome assembly of the allotetrapolyploid Cenchrus fungigraminus (JUJUNCAO) provides insights into its evolution and C4 photosynthesis

JUJUNCAO (Cenchrus fungigraminus; 2n = 4x = 28) is a Cenchrus grass with the highest biomass production among cultivated plants, and it can be used for mushroom cultivation, animal feed, and biofuel production. Here, we report a nearly complete genome assembly of JUJUNCAO and reveal that JUJUNCAO is an allopolyploid that originated ∼2.7 million years ago (mya). Its genome consists of two subgenomes, and subgenome A shares high collinear synteny with pearl millet. We also investigated the genome evolution of JUJUNCAO and suggest that the ancestral karyotype of Cenchrus split into the A and B ancestral karyotypes of JUJUNCAO. Comparative transcriptome and DNA methylome analyses revealed functional divergence of homeologous gene pairs between the two subgenomes, which was a further indication of asymmetric DNA methylation. The three types of centromeric repeat in the JUJUNCAO genome (CEN137, CEN148, and CEN156) may have evolved independently within each subgenome, with some introgressions of CEN156 from the B to the A subgenome. We investigated the photosynthetic characteristics of JUJUNCAO, revealing its typical C4 Kranz anatomy and high photosynthetic efficiency. NADP-ME and PEPCK appear to cooperate in the major C4 decarboxylation reaction of JUJUNCAO, which is different from other C4 photosynthetic subtypes and may contribute to its high photosynthetic efficiency and biomass yield. Taken together, our results provide insights into the highly efficient photosynthetic mechanism of JUJUNCAO and provide a valuable reference genome for future genetic and evolutionary studies, as well as genetic improvement of Cenchrus grasses.

Primary Localized Small Bowel Amyloidosis: A Rare Cause of Diarrhea Detected by Balloon-Assisted Enteroscopy

Gastrointestinal involvement occurs in approximately 4% of cases of systemic amyloidosis and may be associated with heterogeneous and nonspecific clinical manifestations and endoscopic findings, which poses important diagnostic challenges. A 76-year-old female with previous medical history of breast cancer, hypertension, dyslipidemia, asthma, and depression presented to emergency department with a 1-month history of diarrhea, abdominal pain, anorexia, asthenia, and weight loss. Physical examination revealed dehydration and abdominal tenderness. Stool microbiologic studies, Clostridium difficile toxin, fecal leukocyte count, stool fat, and celiac serology were all negative. Remarkably, an axillary lymphadenopathy was also noted and its investigation revealed multiple myeloma, which raised suspicion for gastrointestinal amyloidosis. However, upper digestive endoscopy and colonoscopy did not reveal abnormalities and both gastric and colon biopsies were negative for amyloid, as was abdominal fat biopsy. As the patient also presented hypoproteinemia and hypoalbuminemia suggestive of protein-losing enteropathy, videocapsule endoscopy was performed where petechiae, villous atrophy, and fissures were seen along jejunal mucosa. These findings were confirmed with double-balloon enteroscopy and jejunal biopsies revealed extensive deposition of an amorphous hyaline material in lamina propria and muscularis mucosae that exhibited apple-green birefringence under polarized light after Congo red staining, consistent with localized small bowel amyloidosis secondary to multiple myeloma. Chemotherapy was started, but she would die after 3 weeks. This case illustrates the role of balloon-assisted enteroscopy in diagnosis of localized small bowel amyloidosis with jejunal involvement.

Upper Gastrointestinal Manifestation of Bezoars and the Etiological Factors: A Literature Review

A gastric bezoar is a compact mass of indigestible foreign materials that accumulate and consolidate in the stomach; however, it can be found in other sites of the gastrointestinal tract. The causative manner of this condition is complex and multifactorial. The main purpose of the review was to raise awareness among clinicians, particularly gastroenterologists, that patients with certain risk factors or comorbid conditions are predisposed to gastric bezoar formation. Early diagnosis and prompt intervention are crucial to avoid bezoar-induced complications. Upper gastrointestinal endoscopy is the standard diagnostic and therapeutic method for gastric bezoars. However, for large size bezoars, surgical intervention is needed.

Dysphagia unveiling systemic immunoglobulin light-chain amyloidosis with multiple myeloma

Dysphagia is an uncommon presentation of systemic immunoglobulin light-chain (AL) amyloidosis with multiple myeloma (MM). Gastrointestinal (GI) involvement usually manifests with altered motility, malabsorption or bleeding. Furthermore, patients identified with GI amyloidosis, without previous diagnosis of a plasma cell disorder, are extremely rare. We report an elderly woman who presented with acute on chronic cardiac dysfunction, sick sinus syndrome and acute renal failure. While admitted, she developed intermittent dysphagia to both solids and liquids. Oesophagogastroduodenoscopy showed ulcerations of oesophagus and duodenum. Biopsies revealed focal amyloid deposition, stained with Congo red. Renal biopsy revealed amyloid deposition in renal arterioles. She underwent a bone marrow biopsy confirming MM, represented by more than 15% plasma cell population. She was started on treatment for heart failure, induction chemotherapy for MM and percutaneous gastrostomy tube for feeding. However, she continued to deteriorate, eventually opting for hospice, and ultimately died 2 days after discharge from hospital.

Case report: One case of primary AL amyloidosis repeatedly misdiagnosed as scleroderma

INTRODUCTION

Amyloid light chain (AL) results from the deposition of immunoglobulin light chain fragments, and can affect multiple organs/systems. Our patient was diagnosed as scleroderma repeatedly because of extensive skin thickening and hardening, but the treatment was not effective. We did extensive laboratory examinations including serum/urine protein electrophoresis and flow cytometry assay of bone marrow aspiration.

CONCLUSION

A diagnosis of primary AL amyloidosis was established.