Pulmonary low-grade MALT-lymphoma associated with localized pulmonary amyloidosis. A case report

A unique case of AH-dominant type nodular pulmonary amyloidosis presenting as a spontaneous pneumothorax: a case report and review of the literature

Amyloidosis is a rare metabolic disorder primarily brought on by misfolding of an autologous protein, which causes its local or systemic deposition in an aberrant fibrillar form. It is quite rare for pulmonary tissue to be impacted by amyloidosis; of the three forms it can take when involving pulmonary tissue, nodular pulmonary amyloidosis is the most uncommon. Nodular pulmonary amyloidosis rarely induces clinical symptoms, and most often, it is discovered accidentally during an autopsy or via imaging techniques. Only one case of nodular pulmonary amyloidosis, which manifested as a spontaneous pneumothorax, was found in the literature. In terms of more precise subtyping, nodular amyloidosis is typically AL or mixed AL/AH type. No publications on AH-dominant type of nodular amyloidosis were found in the literature. We present a case of an 81 years-old male with nodular pulmonary AH-dominant type amyloidosis who presented with spontaneous pneumothorax. For a deeper understanding of the subject, this study also provides a review of the literature on cases with nodular pulmonary amyloidosis in relation to precise amyloid fibril subtyping. Since it is often a difficult process, accurate amyloid type identification is rarely accomplished. However, this information is very helpful for identifying the underlying disease process (if any) and outlining the subsequent diagnostic and treatment steps. Even so, it is crucial to be aware of this unit and make sure it is taken into consideration when making a differential diagnosis of pulmonary lesions.

Uncommon Presentation of Undiagnosed B-Cell Lymphoproliferative Disorder as Nodular Pulmonary Amyloidosis

B-cell lymphoproliferative disorders are characterized by the accumulation of mature B lymphocytes in the bone marrow, lymphoid tissues, and/or peripheral blood. They can cause amyloid deposits in the lungs. In rare cases, lung nodules can be the first sign of this disorder. We present the case of an 89-year-old woman with stable shortness of breath and lung nodules on imaging. A positron emission tomography-computed tomography (PET-CT) scan showed the most intense hypermetabolic nodule in the patient's lung, which was 1.5 × 1.4 cm. A biopsy of this nodule showed amyloid material with trapped plasma cell infiltrate on microscopy. Congo red stain under polarizing microscopy showed apple-green birefringence, which is diagnostic for amyloidosis. Immunohistochemistry showed a mixture of kappa-positive and lambda-positive cells. B-cell gene rearrangement-clonal gene rearrangements were detected in the immunoglobulin heavy chain (IgH) gene and the kappa light chain (IGK). These findings suggest a B-cell lymphoproliferative disorder, such as a plasmacytoma or a marginal cell lymphoma with plasma cell differentiation. The patient was diagnosed with a B-cell lymphoproliferative disorder and pulmonary amyloidosis. Isolated amyloidosis in the lungs usually has a good prognosis, but it can be a sign of autoimmune diseases or B-cell lymphoproliferative disorders, as in this case. Early diagnosis of B-cell lymphoproliferative disorder can lead to successful treatment and prevents complications.

Sjögren syndrome-related plasma cell disorder and multifocal nodular AL amyloidosis: clinical picture and pathological findings

Background: Localized nodular deposits of AL amyloid are seen in different tissues/organs; however, the pathogenesis of this form of amyloidosis remains unclear. Recently, Sjögren syndrome combined with localized nodular AL amyloidosis has been noted. Here, we report Sjögren syndrome cases showing multifocal nodular AL amyloidosis and the followed benign course. Materials and methods: We investigated the clinical pictures and histopathological findings of three cases with both presence of Sjögren syndrome and localized nodular AL amyloidosis, paying a special attention to the distribution of amyloidoma. Results: All three cases were middle-aged females. In two of three cases localized deposits of AL amyloid preceded Sjögren syndrome. Amyloidoma was detected in scalp, eyelid, cheek, larynx, trachea, lung and breast, and around these amyloid-deposited lesions infiltration of plasma cells was seen. Pulmonary amyloidosis was consistently accompanied with parenchymal cystic lesions, but this amyloidosis did not produce any significant respiratory symptoms. Some of large pulmonary amyloidomas showed cavity formation and subsequent shrinkage. In two cases amyloid deposition was found on gastric mucosa. Two cases received small doses of oral prednisone, with no further appearance of amyloidoma. Conclusion: Sjögren syndrome-related plasma cell disorder may be responsible for the formation of this unique multifocal nodular AL amyloidosis.

Nodular pulmonary amyloidosis with primary pulmonary MALT lymphoma masquerading as metastatic lung disease

Nodular pulmonary amyloidosis is a very rare form of localized amyloidosis involving the lung, with very little known about its nature. It is usually associated with indolent B cell lymphoproliferative disorder and also connective tissue disorders. No definite treatment guideline exists. Many patients respond to chemotherapy with low risk of progression and a 'wait and watch' strategy is also considered a valid treatment option. In this report the authors present a case of nodular pulmonary amyloidosis with pulmonary mucosa associated lymphoid tissue (MALT) lymphoma that presented with features of metastatic malignant disease and after definitive diagnosis decided not to undergo treatment.

Adnexal mass secondary to extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) with associated amyloid deposition

Systemic amyloid light chain amyloidosis (AL amyloidosis) is usually seen in association with a plasma cell disorder. Amyloid deposition associated with extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is a rare phenomenon that is not typically associated with systemic AL amyloidosis. We describe the unusual case of a patient with an adnexal mass secondary to MALT lymphoma with associated amyloid deposition.

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue with amyloid deposition: a clinicopathologic case series

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma is a mature B-cell neoplasm that typically follows an indolent clinical course. Amyloid deposition associated with MALT lymphoma is uncommon. We describe the clinical and pathologic features of 20 cases of MALT lymphoma and associated amyloid deposition across diverse primary sites. Frozen section immunofluorescence performed on 4 cases suggests that these deposits are a localized form of AL amyloid. Clinical follow-up was available for 15 patients. Amyloid deposits distant from the initial site occurred in 5 cases, always at sites also involved by the underlying lymphoma. No definitive evidence of systemic amyloidosis affecting the heart, kidneys, or liver was present in any patient. Given the generally indolent clinical behavior of MALT lymphomas with associated amyloid, we do not recommend extensive follow-up testing for systemic amyloidosis or more aggressive therapy than would be indicated for other MALT lymphomas of similar clinical stage.

AL amyloidosis associated with IgM paraproteinemia: clinical profile and treatment outcome

AL amyloidosis associated with immunoglobulin M (IgM) paraproteinemia is rare. We report 103 consecutive such patients evaluated at the National Amyloidosis Centre (London, United Kingdom) between 1988 and 2006. Renal, cardiac, and lymph node amyloid was present in 53%, 35%, and 21% of patients, respectively, at presentation and 2 or more organs were involved in 54%. Seventy-three percent had an abnormal bone marrow infiltrate (lymphoid in 87%). The median IgM paraprotein was 8 g/L and serum free light chain (FLC) ratio was abnormal in 77 (88%) of 87. The abnormal FLC component was more than 100 mg/L in only 31% cases. Thirty-two percent achieved a partial hematologic response to treatment with no complete responders, and there appeared to be a greater response to combination regimens than single-agent oral alkylators (59% vs 20%, respectively; P = .003). Four achieved amyloidotic organ responses; organ function remained stable in 68%. None with lymph node involvement showed nodal improvement. Median overall survival was 49 months. AL amyloidosis with IgM paraproteinemia represents a distinctive subset of patients with AL amyloidosis who have a wider variety of underlying clonal disorders (often lymphoid) than AL in general, have low-level FLC abnormality, and should be treated with appropriately tailored chemotherapeutic regimens for the underlying clonal disorder.

Pulmonary localized AA type amyloidosis with cyst-like structures and marginal zone B-cell lymphoma of the MALT type coexisting independently in the left upper lung

A 77-year-old man was found to have an abnormal shadow on chest X-ray. Chest CT indicated four lesions in both lungs. One was located in the left S1+2. The others were located in the left S3, right S8 and S9, and those had cyst-like structures. The tumor in S1+2 showed diffuse proliferation of atypical lymphocytes, which were positive for CD20. The diagnosis of pulmonary mucosa-associated lymphoid tissue lymphoma was made. The tumor in S3 was composed of eosinophilic amorphous deposits. The diagnosis of amyloidosis was confirmed by polarized light examination. After oxidation with permanganate solution, the Congo red staining disappeared.

Co-deposition of amyloidogenic immunoglobulin light and heavy chains in localized pulmonary amyloidosis

Localized pulmonary amyloidosis is a rare condition whose pathogenesis is insufficiently understood. In the present study, we report a case of localized pulmonary amyloidosis associated with lung-restricted lymphoplasmacytoid lymphoma, monoclonal for immunoglobulin (Ig) G lambda (lambda). Biochemical microtechniques have been applied for extraction, purification, and characterization of amyloid proteins. Surprisingly, chemical analysis of these proteins revealed a not-previously-described case of combined deposits containing Ig fragments of gamma heavy chain (variable domain) and lambda light chain (constant domain). In view of the absence of circulating monoclonal Ig, this case supports the hypothesis that localized amyloid is formed by local plasmacytoid cells.