Amyloidosis presenting as bilateral transudative pleural effusions with normal cardiac investigations: a case report

Characteristics of pleural effusion due to amyloidosis

The characteristics of patients with pleural amyloidosis (PA) are poorly known. A systematic review was performed of studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of PA. Case descriptions and retrospective studies were included. The review included 95 studies with a total sample of 196 patients. The mean age was 63 years, male/female ratio was 1.6:1, and 91.9% of patients were >50 years. The most common symptom was dyspnea (88 patients). PF was generally serious (63%), predominantly lymphocytic, and with the biochemical characteristics of transudates (43.4%) or exudates (42.6%). Pleural effusion was generally bilateral (55%) and <1/3 of the hemithorax (50%), although in 21% pleural effusion (PE) exceeded 2/3. Pleural biopsy was performed in 67 patients (yield: 83.6%; 56/67) and was positive in 54% of exudates and 62.5% of unilateral effusions. Of the 251 treatments prescribed, only 31 were effective (12.4%). The combination of chemotherapy and corticosteroids was effective in 29.6% of cases, whereas talc pleurodesis was effective in 21.4% and indwelling pleural catheter in 75% of patients (only four patients). PA is more frequent in adults from 50 years of age. PF is usually bilateral, serous, and indistinctly a transudate or exudate. A pleural biopsy can aid in diagnosis if effusion is unilateral or an exudate. Treatments are rarely effective and there may be definitive therapeutic options for PE in these patients.

Secondary renal amyloidosis associated with asbestos-related pleuropulmonary diseases

Here, we present a 67-year-old Japanese man who developed insidious-onset nephrotic syndrome. He had a history of occupational asbestos exposure for about 8 years during his 30s, and was found to have pleural effusion 3 years before his present illness. At that time, repeated cytology testing of his pleural effusion found no malignant cells, and pleural biopsy found fibrous pleuritis without evidence of malignant mesothelioma. Percutaneous kidney biopsy found massive deposits of AA-type amyloid in the glomeruli, small arteries, and medulla. Computed tomography showed a calcified mass in the right lower lung that was positive for ⁶⁷Ga uptake, but transbronchial lung biopsy and bronchoalveolar lavage found no evidence of malignancy. He was diagnosed with rounded atelectasis and diffuse pleural thickening. As these benign asbestos-related diseases have no standard treatment, we administered low-dose angiotensin II receptor blocker to preserve kidney function. Unfortunately, his nephrotic syndrome persists, with progressive chronic kidney failure. Kidney involvement in patients with asbestos-related disease is rare. To our knowledge, this is the first case to present with secondary amyloidosis. Kidney biopsy should be considered for patients with existing asbestos-related pleuropulmonary diseases who have urinary abnormalities or renal dysfunction, to clarify the incidence and pathophysiology of renal manifestations.

Pleural amyloidosis imitating pleural malignancy

CT chest performed to investigate dyspnea and malaise in an 83 year old man demonstrated bilateral circumferential pleural thickening highly suspicious for pleural mesothelioma or metastatic pleural malignancy. Histopathology of a subsequent pleural biopsy returned a diagnosis of pleural amyloid. This case identifies pleural amyloid as a rare differential consideration for diffuse pleural thickening; the difficulties in distinguishing pleural amyloid from pleural malignancy are highlighted.

Diagnosis of systemic amyloidosis and amyloidosis mediated cardiomyopathy by VATS pleural biopsy for chronic pleural effusion

Amyloidosis is a family of diseases characterized by the extracellular accumulation of amyloid protein, causing altered physiology based on its abnormal deposition in an organ. The etiology of persistent pleural effusions in patients with systemic amyloidosis is unknown. Endomyocardial biopsy is the gold standard of diagnosis for patients with cardiac involvement in systemic amyloidosis. We present the case of a patient with systemic amyloidosis whose diagnosis was made by pleural pathology collected via video-assisted thoracic surgery after a false negative endomyocardial biopsy.

Pleural findings in a patient with persistent pulmonary effusions from systemic amyloidosis

Persistent pleural effusions (PPE) occur in 1-2% of cases of systemic amyloidosis and have been postulated to result from direct disruption of the pleura by amyloid deposits. Patients are typically treated with percutaneous pleural drainage techniques. Pleural biopsies, done most commonly via percutaneous techniques, are infrequently obtained. The macroscopic and histologic pleural findings identified via video assisted thoracoscopic surgery (VATS) for these patients are lacking in the literature. In this case, we present the macroscopic and microscopic pleural findings in a patient who had VATS for the aetiologic diagnosis of PPE. The diagnosis of systemic amyloidosis was made from histologic analysis of the pleural biopsy.