Primary localized amyloidosis of urinary bladder: a case report and review of literature

New case of secondary bladder amyloidosis with massive hematuria-role of intravesical instillations with dimethyl sulfoxide

Secondary bladder amyloidosis is a rare condition with less than 60 cases published in the world. It is usually secondary to chronic inflammatory processes such as rheumatologic diseases. Hematuria is its predominant and most important symptom, and usually occurs after a bladder catheterization. The diagnostic confirmation is made through a pathological and immunohistochemical study. The treatment must be staggered from less to more invasive. Our objectives are to present a new case of secondary bladder amyloidosis in a woman with a history of chronic bronchiectasis after tuberculosis and frequent super infections, whose main manifestation was a massive hematuria, and review this rare pathology. We have obtained very good initial results using intravesical instillations with dimethyl sulfoxide (DMSO) with complete resolution of the hematuria, the patient remaining asymptomatic for 6 months. After that, there was a recurrence of the hematuria that was treated with embolization of the hypogastric arteries, with good results. We can conclude that, despite being a rare condition, we must consider secondary bladder amyloidosis in patients who have already been diagnosed with systemic amyloidosis and/or chronic pathologies who develop hematuria after bladder catheterization. Based on our experience, instillations with dimethyl sulfoxide are a safe option and provide a quick and temporary resolution of hematuria symptoms.

Primary Vesical Amyloidosis Masquerading as Vesical Calculus in a Retroviral Positive Patient

The common causes of irritative voiding symptoms in women include cystitis, vesical calculi, carcinoma bladder and neurologic disorders. Isolated primary vesical amyloidosis (VA) is a rare cause of irritative voiding symptoms. A 50-year-old female, a known case of retroviral disease but not on anti-retroviral therapy, presented with right flank and suprapubic pain for six months, worsening over the past 15 days with dysuria. She also presented with increased frequency of micturition with nocturia and urgency for the same duration. She had no hematuria, other lower urinary tract symptoms or fever. Clinical examination revealed suprapubic tenderness. Ultrasonogram (USG) revealed 1.7 cm vesical calculus. Cystoscopy revealed three spiky vesical calculi. There was a fluffy lesion with mucosal edema over the right lateral wall in the region of the right ureteric orifice, which was biopsied. Biopsy showed fragments of urothelial mucosa with focal areas of ulceration. The underlying stroma was edematous with amorphous pale eosinophilic acellular deposits. Congo red stain showed apple-green birefringence under polarized microscopy suggestive of amyloid. Sections were negative for dysplasia, granulomas or malignancies. VA presents with intermittent gross hematuria in up to 77% patients and irritative voiding symptoms in 23% patients. VA is an uncommon differential diagnosis of cancer urinary bladder, with less than 200 cases reported in the literature. Hence we report this case to highlight that primary VA should also be considered in the evaluation of irritative voiding symptoms.

Secondary bladder amyloidosis with familial Mediterranean fever in a living donor kidney transplant recipient: a case report

Background

Secondary bladder amyloidosis is an extremely rare disease, resulting from a chronic systematic inflammatory disorder associated with amyloid deposits. Although uncommon in Japan, familial Mediterranean fever (FMF) is a hereditary autoinflammatory disease characterized by recurrent episodes of fever of short duration and serositis and is frequently associated with systemic amyloidosis. Here, we present a case of a Japanese patient complaining of fever and macroscopic hematuria after a living donor renal transplantation. Consequently, he was diagnosed with secondary bladder amyloidosis with FMF.

Case presentation

A 64-year-old Japanese male received a living ABO-incompatible kidney transplant from his wife. The postoperative clinical course was normal, and the patient was discharged 21 days after the transplantation with a serum creatinine level of 0.78 mg/dl. The patient frequently complained of general fatigue and fever of unknown origin. Six months later, the patient presented with continuous general fatigue, macroscopic hematuria, and fever. Cystoscopic examination of the bladder showed an edematous region with bleeding, and a transurethral biopsy revealed amyloid deposits. His wife stated that the patient had a recurrent high fever since the age of 40 years and that his younger brother was suspected to have a familial autoinflammatory syndrome; thus, the patient was also suspected to have a familial autoinflammatory syndrome. Based on his brother’s medical history and the genetic tests, which showed a homozygous mutation (M694V/M694V) for the Mediterranean fever protein, he was diagnosed with FMF. Although colchicine treatment for FMF was planned, the patient had an untimely death due to heart failure. We re-evaluated the pathological findings of the various tissue biopsies obtained during the treatment after the renal transplantation. Immunohistochemistry revealed amyloid deposits in the bladder region, renal allograft, and myocardium and the condition was diagnosed as AA amyloidosis associated with FMF.

Conclusion

We presented a case of systemic amyloidosis with FMF, involving the bladder region, myocardium, and renal allograft, diagnosed after renal transplantation. Bladder amyloidosis should be considered in patients with macroscopic hematuria, particularly in the kidney transplant recipients with idiopathic chronic renal disease. Diagnosis of secondary bladder amyloidosis may result in the early detection of underlying diseases, which may contribute to patient prognosis.