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Nigam N, Rastogi A, Bhatt P, Bihari C. Topographic Distribution Pattern in Hepatic Amyloidosis Presenting with Portal Hypertension. J Clin Exp Hepatol 2023; 13:259-264. [PMID: 36950500 PMCID: PMC10025754 DOI: 10.1016/j.jceh.2022.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022] Open
Abstract
Background/aims The liver is often involved in both primary and secondary forms of amyloidosis. Significant clinical evidence of portal hypertension is relatively uncommon and seems to be related to the reduced sinusoidal lumen and increased resistance to blood flow due to massive perisinusoidal amyloid deposits. The relationships between the pattern and extent of amyloid deposition in patients presenting with portal hypertension have not yet been clearly demonstrated. This study is focusing on the topographic distribution of amyloidosis in patients presenting with portal hypertension. Methods The study included biopsy-proven cases of hepatic amyloidosis. The clinical, biochemical, and serological data, involvement of the extrahepatic organs, and HVPG values were recorded. Tissue sections were re-evaluated for the distribution patterns of amyloid deposits. Results We had 41 patients with hepatic amyloidosis, of which, 32 were male. A mixed pattern (sinusoidal and vascular) was the most common (32/41; 78%). Hepatic venous pressure gradient was available in 21 cases. Portal hypertension was found in 14 patients (14/21; 67%). Cases of portal hypertension were found to have a sinusoidal pattern (3/14; 21.4%), vascular pattern (1/14; 7.1%), or a mixed sinusoidal and vascular pattern (10/14; 71.4%). Those not having portal hypertension showed hepatic artery (HA) involvement in 6/7 (85.7%) cases. A comparative analysis between portal hypertension (PTH) and non-PTH groups showed that HA amyloid deposition was dominant in the non-PTH group (6/7; 85.7%) and sinusoidal deposition in the PTH group (13/14; 92.8%). The difference was found to be significant (P < 0.05). Conclusion We found that portal hypertension was noted in cases with diffuse sinusoidal deposition or mixed sinusoidal with portal vein deposition. In the non-PHT group, the deposition was mainly in HA alone.
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Affiliation(s)
- Neha Nigam
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Pavni Bhatt
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
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Hosseini DK, Delcalzo K, Patel A, Rodriguez R, Shukla NB. A Rare Cause of Liver Cirrhosis and Gastritis: Primary Gastrointestinal Amyloidosis in a Patient With Multiple Myeloma. Cureus 2022; 14:e24858. [PMID: 35547944 PMCID: PMC9084857 DOI: 10.7759/cureus.24858] [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] [Accepted: 05/09/2022] [Indexed: 11/05/2022] Open
Abstract
A 65-year-old male with a 25-year history of chronic alcoholism presented to the emergency department for a two-week history of non-radiating right upper quadrant abdominal pain associated with pruritus, nausea, coffee-ground emesis, and clay-colored stools. The exam was notable for icteric sclera, right upper quadrant abdominal tenderness, ascites, and hepatomegaly. Initial workup revealed new-onset unexplained elevated liver enzyme. The CT scan revealed diffuse liver cirrhosis, periportal lymphadenopathy, and stigmata of portal hypertension including hepatosplenomegaly, ascites, and varices. Esophagogastroduodenoscopy (EGD) with endoscopic ultrasound was performed, which showed gastritis and enlarged porta hepatis, which was ultimately biopsied and revealed extracellular amyloid deposition in peri-sinusoidal spaces consistent with amyloidosis. Transesophageal echocardiogram raised suspicion for cardiac involvement with amyloid deposit. The patient was started on steroids and chemotherapy with daratumumab, however his condition was complicated by septic shock, which led to an admission in the ICU followed by endotracheal intubation and multi-organ failure and eventual palliative care. Our case highlights the importance of clinical suspicion of GI amyloidosis in patients with constitutional symptoms including fatigue, weight loss, and unexplained liver disease. Once amyloidosis is considered, the diagnosis can be obtained by tissue biopsy from either the GI tract or subcutaneous adipose tissue.
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Affiliation(s)
- Davood K Hosseini
- Department of Internal Medicine, Hackensack University Medical Center, Hackensack, USA
| | | | - Antik Patel
- School of Medicine, St. George's University, True Blue, GRD
| | - Raul Rodriguez
- Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Nilesh B Shukla
- Department of Gastroenterology and Hepatology, Hackensack University Medical Center, Hackensack, USA
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3
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Ledesma FL, Castelli JB. Autopsy findings in a patient with primary systemic AL (kappa light chain) amyloidosis. AUTOPSY AND CASE REPORTS 2021; 11:e2021273. [PMID: 34307229 PMCID: PMC8214892 DOI: 10.4322/acr.2021.273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/28/2021] [Indexed: 02/03/2023] Open
Abstract
First described by Rokitansky in 1842, and further characterized by Virchow in 1854, amyloidosis is a disorder caused by amyloid deposition, a fibrillary insoluble protein. The clinical spectrum of amyloidosis is broad, as the amyloid deposition may virtually occur in all tissues. Herein, we report the case of a 66-year-old man with a long-lasting emaciating disease, diagnosed, at autopsy, with primary systemic amyloidosis. Amyloid protein deposition was found in many tissues and organs. The involvement of the vessels’ wall rendered ischemic injury most prominent in the intestinal loops causing mesenteric ischemia. Despite the thorough organic involvement, the immediate cause of death was aspiration bronchopneumonia. Massive amyloid deposition was found in virtually all major organs, such as the heart, liver, kidneys, spleen, pancreas, adrenals, prostate, skin, and thyroid: the latter, a complication of the amyloidosis known as amyloid goiter. Post-mortem review of the deceased’s laboratory workup showed a slightly abnormal kappa:lambda ratio in the blood; however, no clonal lymphoplasmacytic disorder was confirmed in the bone marrow and other lymphoreticular system organs either by the microscopic examination and immunohistochemical staining. Laser-capture microdissection and tandem mass spectrometry of the splenic tissue detected a peptide profile consistent with an immunoglobulin Kappa light chain. The presence of amyloid purpura favors the diagnosis of primary systemic amyloidosis.
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Affiliation(s)
- Felipe Lourenço Ledesma
- Universidade de São Paulo (USP), Faculdade de Medicina, Departamento de Patologia, São Paulo, SP, Brasil
| | - Jussara Bianchi Castelli
- Universidade de São Paulo (USP), Hospital das Clínicas, Divisão de Anatomia Patológica, São Paulo, SP, Brasil.,Grupo Fleury Medicina e Saúde, São Paulo, SP, Brasil
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Oye M, Sanders K, Ghali M, Alkhasawneh A. Multiple myeloma with hepatic amyloid light-chain amyloidosis manifesting as progressive liver failure. BMJ Case Rep 2020; 13:13/6/e234637. [PMID: 32601138 DOI: 10.1136/bcr-2020-234637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of a 45-year-old man admitted to the hospital with new-onset ascites and bilateral subconjunctival haemorrhages. He was found to have elevated liver enzymes in a hepatocellular pattern and direct hyperbilirubinemia. A diagnostic paracentesis was consistent with portal hypertension (PH). Extensive workup for acute and chronic liver disease was unremarkable. In the absence of clinical evidence of cirrhosis to explain PH, a liver biopsy with hepatic venous pressure gradient was pursued, which revealed proteinaceous material and apple-green birefringence under polarised light consistent with amyloid deposits. Bone marrow biopsy revealed plasma cell neoplasm with proteinaceous deposits consistent with concomitant multiple myeloma with AL amyloidosis. He developed rapidly progressive liver failure and passed shortly after presentation despite treatment with chemotherapy. This case illustrates how primary hepatic amyloidosis can present with a physiology that mimics cirrhosis and can easily be missed.
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Affiliation(s)
- Monique Oye
- Internal Medicine, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
| | - Kimberly Sanders
- Internal Medicine, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
| | - Maged Ghali
- Gastroenterology, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
| | - Ahmad Alkhasawneh
- Pathology, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
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Li TT, Wu YF, Liu FQ, He FL. Hepatic amyloidosis leading to hepatic venular occlusive disease and Budd-Chiari syndrome: A case report. World J Clin Cases 2019; 7:3282-3288. [PMID: 31667180 PMCID: PMC6819297 DOI: 10.12998/wjcc.v7.i20.3282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/30/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Systemic amyloidosis in which multiple systems can be involved has become a common clinical disease. When the liver is affected, symptoms such as abdominal distension, fatigue, edema, liver, and jaundice could appear. To date, hepatic amyloidosis combined with hepatic venular occlusive disease and Budd-Chiari syndrome has not been reported.
CASE SUMMARY A 54-year-old female patient was admitted to the Beijing Shijitan Hospital with hepatic amyloidosis leading to hepatic venular occlusion and Budd-Chiari syndrome in 2018. The patient underwent surgery 1 mo previously for liver rupture and hemorrhage after Budd-Chiari syndrome was diagnosed. She was diagnosed with hepatic venular occlusion, liver amyloidosis, and Budd-Chiari syndrome (i.e. extensive hepatic vein occlusion). Transjugular intrahepatic portosystem shunt was performed. After the treatment, the clinical symptoms improved markedly with increase in urine volume.
CONCLUSION Hepatic amyloidosis with hepatic venous occlusion and Budd-Chiari syndrome is relatively rare clinically, and transjugular intrahepatic portosystem shunt is an effective treatment for this disease.
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Affiliation(s)
- Ting-Ting Li
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing 100038, China
| | - Yi-Fan Wu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing 100038, China
| | - Fu-Quan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing 100038, China
| | - Fu-Liang He
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing 100038, China
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Hasan SM, Ahmed NN, Ahmed Z, Seibert A. Response of Bortezomib Chemotherapy in Hepatic Amyloidosis. J Investig Med High Impact Case Rep 2018; 6:2324709618760079. [PMID: 29552568 PMCID: PMC5846928 DOI: 10.1177/2324709618760079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 01/15/2018] [Accepted: 01/22/2018] [Indexed: 11/15/2022] Open
Abstract
Amyloidosis is a rare disorder with a wide spectrum of presentations and anomalies. It is subdivided into 2 broad categories based on protein deposition; primary and secondary amyloidosis. It can present as a single-organ involvement or as a diffuse infiltrative multi-organ process. Isolated hepatic amyloidosis presentation is a rare phenomenon that develops due to insoluble amyloid deposition in liver. Its clinical presentation is usually vague and ranges from mild hepatomegaly with elevated liver enzymes to acute liver failure and hepatic rupture. Currently, there are scarce data available regarding treatment options for biopsy-proven hepatic amyloidosis. In this review article, we present an interesting case of hepatic amyloidosis and its poor outcome to new molecular targeted chemotherapy. Furthermore, we aim to review current and future diagnostic tools for early detection and advancements in targeted chemotherapeutics options available for hepatic amyloidosis.
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Affiliation(s)
- Syed M Hasan
- University of Alabama at Birmingham, Montgomery, AL, USA
| | - Nida N Ahmed
- University of Alabama at Birmingham, Montgomery, AL, USA
| | - Zunirah Ahmed
- University of Alabama at Birmingham, Montgomery, AL, USA
| | - Allan Seibert
- University of Alabama at Birmingham, Montgomery, AL, USA
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Primary Hepatic Amyloidosis Presenting as Acute-on-Chronic Liver Failure. ACG Case Rep J 2017; 4:e22. [PMID: 28286788 PMCID: PMC5340654 DOI: 10.14309/crj.2017.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/30/2016] [Indexed: 12/30/2022] Open
Abstract
Systemic amyloidosis of amyloid light chain associated protein (AL), also called primary amyloidosis, frequently involves the liver, but rarely causes clinically apparent liver disease. The more common presentation is with acute renal failure. Hepatomegaly and mild elevation of alkaline phosphatase are the most common clinical and biochemical findings, respectively. We report a case of systemic amyloidosis of AL that clinically presented as acute-on-chronic liver failure and resulted in a fatal clinical course in a 56-year-old man.
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