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Karam S, Kaushal A, Abu Amer N, Royal V, KItchlu A. Non-Immunoglobulin Amyloidosis-Mediated Kidney Disease: Emerging Understanding of Underdiagnosed Entities. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:334-345. [PMID: 39084759 DOI: 10.1053/j.akdh.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/24/2024] [Accepted: 02/06/2024] [Indexed: 08/02/2024]
Abstract
Amyloidosis is a complex group of rare disorders characterized by the deposition of misfolded proteins in the extracellular space of various tissues and organs, leading to progressive organ dysfunction. The kidneys constitute a very common site affected, most notably by immunoglobulin-mediated (light chain, heavy chain, and light and heavy chain amyloidosis), but other types that include serum amyloid A (AA) amyloidosis and leukocyte chemotactic factor 2 amyloidosis, along with mutant proteins in several hereditary forms of amyloidosis such as transthyretin, fibrinogen α-chain, gelsolin, lysozyme, and apolipoproteins AI/AII/AIV/CII/CIII amyloidosis have been incriminated as well. The clinical presentation is variable and can range from minimal proteinuria for leukocyte chemotactic factor 2 amyloidosis to a full-blown nephrotic syndrome for AA amyloidosis. Clinical correlation, genetic analysis, and adequate tissue typing through a kidney biopsy are essential to make the correct diagnosis, especially when a family history of amyloidosis is absent. Except for AA and transthyretin amyloidosis, the treatment is usually purely supportive. Kidney transplantation is an acceptable form of treatment for end-stage kidney disease in all types of non-Ig-mediated renal amyloidosis.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis.
| | - Amit Kaushal
- Division of Nephrology, West Virginia University, Morgantown, WV
| | - Nabil Abu Amer
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Abhijat KItchlu
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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Sarkar S, Hill DD, Rosenberg AF, Eaton EF, Kutsch O, Kobie JJ. Injection Drug Use Alters Plasma Regulation of the B Cell Response. Cells 2024; 13:1011. [PMID: 38920641 PMCID: PMC11202061 DOI: 10.3390/cells13121011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/27/2024] Open
Abstract
The opioid epidemic continues to be a major public health issue that includes millions of people who inject drugs (PWID). PWID have increased incidence of serious infections, including HIV as well as metabolic and inflammatory sequelae. We sought to discern the extent of systemic alterations in humoral immunity associated with injection drug use, including alterations in the plasma proteome and its regulation of B cell responsiveness. Comprehensive plasma proteomics analysis of HIV negative/hepatitis C negative individuals with a history of recent injection heroin use was performed using mass spectrometry and ELISA. The effects of plasma from PWID and healthy controls on the in vitro proliferation and transcriptional profile of B cell responses to stimulation were determined by flow cytometry and RNA-Seq. The plasma proteome of PWID was distinct from healthy control individuals, with numerous immune-related analytes significantly altered in PWID, including complement (C3, C5, C9), immunoglobulin (IgD, IgM, kappa light chain), and other inflammatory mediators (CXCL4, LPS binding protein, C-reactive protein). The plasma of PWID suppressed the in vitro proliferation of B cells. Transcriptome analysis indicated that PWID plasma treatment increased B cell receptor and CD40 signaling and shifted B cell differentiation from plasma cell-like toward germinal center B cell-like transcriptional profiles. These results indicate that the systemic inflammatory milieu is substantially altered in PWID and may impact their B cell responses.
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Affiliation(s)
- Sanghita Sarkar
- Infectious Diseases Division, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Dave D. Hill
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Alexander F. Rosenberg
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Ellen F. Eaton
- Infectious Diseases Division, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - Olaf Kutsch
- Infectious Diseases Division, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, USA
| | - James J. Kobie
- Infectious Diseases Division, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, USA
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Andeen NK, DiFranza L, Kung VL, Henriksen K, Gupta R, Dinesh K, Akilesh S, Kudose S, Smith KD, Troxell ML. AA amyloidosis With Ig-Dominant Staining and Diagnostically Unusual Features. Kidney Int Rep 2024; 9:162-170. [PMID: 38312779 PMCID: PMC10831352 DOI: 10.1016/j.ekir.2023.10.005] [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: 06/30/2023] [Revised: 09/20/2023] [Accepted: 10/09/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Although serum amyloid A (AA) amyloid may occasionally show nonspecific staining by immunofluorescence (IF), the correct diagnosis can usually be determined by integrating pathologic features and clinical scenario, and using AA amyloid immunohistochemistry (IHC) and/or mass spectrometry. A recent mass spectrometry-based study described false-positive Ig IF staining in a subset of AA amyloid cases. Methods We sought to delineate clinicopathologic features of AA amyloid with Ig-dominant staining by using a retrospective review. Results AA amyloid with Ig-dominant staining was identified in 10 patients from 5 institutions, representing 1.2% to 4% of AA amyloid kidney biopsies. Evidence of a monoclonal protein was documented in 0% to 2.7% of patients with AA amyloid screened for inclusion, but 30% of those with Ig-dominant staining. The patient population had equal sex distribution and presented at median age of 68.5 years with nephrotic proteinuria and kidney impairment. Etiologies of AA amyloid included injection drug use (30%), autoimmune disease (20%), and chronic infection (10%); 40% had no identified clinical association. On biopsy, heavy chain (co)dominant staining by IF (in 80%), discordant distribution in Ig staining (in 20%), tubulointerstitial nephritis (in 30%), and/or crescents (in 10%) were present. Two of 3 patients with paraproteinemia had concordant heavy and/or light chain dominant staining within the AA amyloid. Two cases were initially misdiagnosed as Ig-associated amyloidosis. Conclusion We describe the morphologic spectrum of AA amyloidosis with Ig-dominant staining which may have clinical, laboratory, and pathologic overlap with amyloid light chain (AL), amyloid heavy chain, and heavy and light chain (AHL) amyloidosis.
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Affiliation(s)
- Nicole K. Andeen
- Department of Pathology and Laboratory Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Lanny DiFranza
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vanderlene L. Kung
- Department of Pathology and Laboratory Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kammi Henriksen
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Renu Gupta
- Renal Care Consultants, Medford, Oregon, USA
| | | | - Shreeram Akilesh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Kelly D. Smith
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Megan L. Troxell
- Department of Pathology, Stanford University, Stanford, California, USA
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Steel TL, Bhatraju EP, Hills-Dunlap K. Critical care for patients with substance use disorders. Curr Opin Crit Care 2023; 29:484-492. [PMID: 37641506 DOI: 10.1097/mcc.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW To examine the impact of substance use disorders (SUDs) on critical illness and the role of critical care providers in treating SUDs. We discuss emerging evidence supporting hospital-based addiction treatment and highlight the clinical and research innovations needed to elevate the standards of care for patients with SUDs in the intensive care unit (ICU) amidst staggering individual and public health consequences. RECENT FINDINGS Despite the rapid increase of SUDs in recent years, with growing implications for critical care, dedicated studies focused on ICU patients with SUDs remain scant. Available data demonstrate SUDs are major risk factors for the development and severity of critical illness and are associated with poor outcomes. ICU patients with SUDs experience mutually reinforcing effects of substance withdrawal and pain, which amplify risks and consequences of delirium, and complicate management of comorbid conditions. Hospital-based addiction treatment can dramatically improve the health outcomes of hospitalized patients with SUDs and should begin in the ICU. SUMMARY SUDs have a significant impact on critical illness and post-ICU outcomes. High-quality cohort and treatment studies designed specifically for ICU patients with SUDs are needed to define best practices and improve health outcomes in this vulnerable population.
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Affiliation(s)
- Tessa L Steel
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine
| | - Elenore P Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Kelsey Hills-Dunlap
- University of Colorado Anschutz Medical Campus, Division of Pulmonary Sciences & Critical Care, Department of Medicine, University of Colorado, Aurora, Colorado, USA
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Shih S, Francoisse CA, Xu KY, Tadisina KK. Skin Popping for the Hand Surgeon: A Case Report and Review. Ann Plast Surg 2023; 91:64-77. [PMID: 37450863 DOI: 10.1097/sap.0000000000003602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Subcutaneous injection of illicit drugs, colloquially known as skin popping, is associated with skin and soft tissue infections of the upper extremity. Sequelae of these infections often present to hand surgeons in the late stages of disease, are associated with challenging clinical scenarios, and are a significant burden to both patients and providers. The authors present an illustrative case and review the literature regarding this growing phenomenon in upper extremity surgery. METHODS A case report detailing the surgical reconstruction of a large forearm wound in the setting of intravenous heroin use and skin popping is presented. Search terms related to upper extremity subcutaneous drug injection were used to find relevant articles in PubMed and EMBASE. A total of 488 articles were found, with 22 studies meeting the inclusion criteria. RESULTS In this case report, the patient had a long history of skin popping to the forearm and presented with a chronic wound with exposed bone. The patient was treated with serial debridement, bony fixation, intravenous antibiotics, and soft tissue coverage using an arteriovenous loop and a muscle-only latissimus flap. Literature review yielded 22 studies comprising 38 patients with 55% (11/20) women and age range of 23 to 58 years. Heroin was the most commonly used drug (50.0%). The most common presentation was soft tissue infection (6/20 patients), manifestations of noninfected wounds (5/20), and wound botulism (4/20 of patients). Seventy percent of patients presented with multiple injection sites. Surgical management was described in 18% of cases, with all but one case describing drainage and debridement techniques. Only one case of formal reconstruction using a dermal template was described. CONCLUSIONS Skin popping infections have unique pathogenesis, presentation, and management patterns that hand surgeons must be aware of when treating these patients. A literature review revealed a relative paucity of reports regarding risk factors and surgical management of "skin popping" sequelae. If patients are reconstructive candidates, complex reconstruction requiring free tissue transfer may be warranted.
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Affiliation(s)
- Sabrina Shih
- From the Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Caitlin A Francoisse
- Division of Plastic and Reconstructive Surgery, Saint Louis University School of Medicine, St Louis, MO
| | - Kyle Y Xu
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL
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Andeen NK, Kung VL, Robertson J, Gurley SB, Avasare RS, Sitaraman S. Fibrillary Glomerulonephritis, DNAJB9, and the Unfolded Protein Response. GLOMERULAR DISEASES 2022; 2:164-175. [PMID: 36817290 PMCID: PMC9936766 DOI: 10.1159/000525542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/30/2022] [Indexed: 11/19/2022]
Abstract
Background Fibrillary glomerulonephritis (FGN) is found in approximately 1% of native kidney biopsies and was traditionally defined by glomerular deposition of fibrils larger than amyloid (12-24 nm diameter) composed of polyclonal IgG. Recent identification of DNAJB9 as a sensitive and specific marker of FGN has revolutionized FGN diagnosis and opened new avenues to studying FGN pathogenesis. In this review, we synthesize recent literature to provide an updated appraisal of the clinical and pathologic features of FGN, discuss diagnostic challenges and pitfalls, and propose molecular models of disease in light of DNAJB9. Summary DNAJB9 tissue assays, paraffin immunofluorescence studies, and IgG subclass testing demonstrate that FGN is distinct from other glomerular diseases with organized deposits and highlight FGN morphologic variants. Additionally, these newer techniques show that FGN is only rarely monoclonal, and patients with monoclonal FGN usually do not have a monoclonal gammopathy. DNAJB9 mutation does not appear to affect the genetic architecture of FGN; however, the accumulation of DNAJB9 in FGN deposits suggests that disease is driven, at least in part, by proteins involved in the unfolded protein response. Treatments for FGN remain empiric, with some encouraging data suggesting that rituximab-based therapy is effective and that transplantation is a good option for patients progressing to ESKD. Key Messages DNAJB9 aids in distinguishing FGN from other glomerular diseases with organized deposits. Further investigations into the role of DNAJB9 in FGN pathogenesis are necessary to better understand disease initiation and progression and to ultimately develop targeted therapies.
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Affiliation(s)
- Nicole K. Andeen
- Department of Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, Oregon, USA,*Nicole K. Andeen,
| | - Vanderlene L. Kung
- Department of Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Josh Robertson
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Susan B. Gurley
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Rupali S. Avasare
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Systemic AA Amyloidosis Associated With Intravenous Injection of Oral Prescription Opioids-An Autopsy Case Report. Am J Forensic Med Pathol 2021; 43:191-194. [PMID: 34510052 PMCID: PMC9076248 DOI: 10.1097/paf.0000000000000718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There are reports of AA amyloidosis associated with intravenous and/or subcutaneous injection of street drugs, such as heroin and cocaine. Most reports describe patients with substance use disorder, renal amyloidosis and concurrent viral infections, such as hepatitis and/or human immunodeficiency virus. Herein, we present a case of systemic AA amyloidosis and sepsis in a 34-year-old woman with a history of intravenous injection of oral prescription medications (as evidenced by excipient lung disease) who had no known history of human immunodeficiency virus nor of hepatitis B or C. Our case shows the broader spectrum of pathology that can occur with the misuse of prescription medications.
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Berns JS, Rapalino O, Fenves AZ, El Khoury JB, Klepeis VE, Anahtar MN. Case 11-2020: A 37-Year-Old Man with Facial Droop, Dysarthria, and Kidney Failure. N Engl J Med 2020; 382:1457-1466. [PMID: 32268031 DOI: 10.1056/nejmcpc1916252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jeffrey S Berns
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Otto Rapalino
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Andrew Z Fenves
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Joseph B El Khoury
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Veronica E Klepeis
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
| | - Melis N Anahtar
- From the Department of Medicine, Hospital of the University of Pennsylvania, and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.S.B.); and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Massachusetts General Hospital, and the Departments of Radiology (O.R.), Medicine (A.Z.F., J.B.E.K.), and Pathology (V.E.K., M.N.A.), Harvard Medical School - both in Boston
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Singh S. Dynamics of heroin molecule inside the lipid membrane: a molecular dynamics study. J Mol Model 2019; 25:121. [PMID: 31020452 DOI: 10.1007/s00894-019-4002-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
Heroin, or diamorphine (C21H23NO5), is an opium product used for various pharmaceutical and euphoric purposes. In this work, the molecular dynamics simulation study of the heroin inside the two lipid bilayers, dipalmitoylphosphatidylcholine (DMPC) and dipalmitoylphosphatidylcholine (DPPC) are presented. The whole study was conducted at three different temperatures. The location of the heroin drug, the nature of the diffusion, rotational correlation function and structural variation inside both lipid bilayers is studied. Moreover, the free energy of the solvation of the drug inside both lipid bilayers is calculated. It is found that during the whole molecular dynamics study, the drug locates at the center of both lipid membranes. The effect of the temperature is not seen at the drug location. The nature of the diffusion of the heroin drug is anomalous. The radius of gyration is calculated to study the structural variations of the heroin molecule inside both lipid bilayers. It is found that the heroin molecule does not change its structure at three temperatures. From the rotational correlation function, it is seen that the drug is more hindered for rotation inside the DPPC lipid bilayer as compared to the DMPC lipid bilayer. It is applicable for all three temperatures. The rotational correlation time of the drug is decreased while the temperature of the system is increased. In the case of DMPC, there is an abrupt change in rotational correlation time while the phase is changed.
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Affiliation(s)
- Satnam Singh
- Department of Physical Sciences, Indian Institute of Science Education & Research (IISER) Mohali, Sector 81 SAS Nagar, Manauli PO, 140306, Punjab, India.
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Mani D. Secondary amyloidosis associated with heroin use and recurrent infections - A case report. Ann Med Surg (Lond) 2018; 37:38-41. [PMID: 30581568 PMCID: PMC6297111 DOI: 10.1016/j.amsu.2018.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 11/01/2022] Open
Abstract
A 49-year-old lady with history of polysubstance use disorder, recurrent cutaneous abscesses, spinal diskitis and septic thrombophlebitis presented to the emergency room with complaints of intermittent fevers, worsening right hip pain and bilateral lower extremity edema. A month before the presentation, she had left another hospital against medical advice after being diagnosed with Methicillin-resistant Staphylococcus aureus bacteremia and right hip septic arthritis. Post discharge, she was off antibiotics, but continued heroin and methamphetamine use. On admission, she had right hip chronic osteomyelitis and was also in acute renal failure with evidence of nephrotic range proteinuria. Her renal biopsy subsequently revealed acute tubular necrosis and secondary (AA) amyloidosis with the classic apple green birefringence and positive immunohistochemical stain for serum amyloid A protein. Secondary amyloidosis, where there is deposition of fibrils composed of fragments of the acute phase reactant - serum amyloid A protein, often complicates chronic diseases with ongoing or recurring inflammation like spondyloarthropathies, inflammatory bowel disease and heredofamilial periodic fever syndromes. Epidemiological studies now indicate that chronic inflammation as noted in illicit drug users, especially heroin users is on the rise as the etiology for AA amyloidosis in some parts of the developed world. The most common organ system involved in AA amyloidosis is the kidney. Given the opioid epidemic, clinicians are more likely to encounter similar cases of secondary amyloidosis.
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Affiliation(s)
- Deepthi Mani
- Multi Care Good Samaritan Hospital, Puyallup, WA, USA.,University of Washington, Department of Family Medicine, Seattle, WA, USA
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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