Amyloidosis of the Lung

Current status and prospect of anti-amyloid fibril therapy in AL amyloidosis

Amyloid light-chain (AL) amyloidosis is a rare hematological disease that produces abnormal monoclonal immunoglobulin light chains to form amyloid fibrils that are deposited in tissues, resulting in organ damage and dysfunction. Advanced AL amyloidosis has a very poor prognosis with a high risk of early mortality. The combination of anti-plasma cell therapy and amyloid fibrils clearance is the optimal treatment strategy, which takes into account both symptoms and root causes. However, research on anti-amyloid fibrils lags far behind research on anti-plasma cells, and there is currently no approved treatment that could clear amyloid fibrils. Nevertheless, anti-amyloid fibril therapies are being actively investigated recently and have shown potential in clinical trials. In this review, we aim to outline the preclinical work and clinical efficacy of fibril-directed therapies for AL amyloidosis.

Nodular pulmonary amyloidosis diagnosed by ultrasound-guided percutaneous needle biopsy

Pulmonary amyloidosis is characterized by extracellular deposition of fibrous protein called amyloid in the lungs and has three subtypes: nodular, diffuse, and tracheobronchial amyloidosis. Pulmonary nodular amyloidosis can mimic other lung diseases including infectious diseases, metastatic lung tumors, sarcoidosis, and pulmonary hyalinizing granuloma. A biopsy of the lesion is essential for a definitive diagnosis. Herein, we report the case of a 66-year-old man who presented for shortness of breath on exertion and was diagnosed with nodular pulmonary amyloidosis on ultrasound-guided percutaneous needle biopsy. A chest X-ray and computed tomography (CT) revealed bilateral slowly growing multiple calcified pulmonary nodules and cavities. Malignancy was suspected based on 18F-fluoro-deoxyglucose (18F-FDG) positron emission tomography/CT (PET/CT) images. An ultrasound-guided percutaneous needle biopsy was performed, and histopathologic examination of the lesion confirmed nodular pulmonary amyloidosis. This case highlights the importance of considering nodular pulmonary amyloidosis in the differential diagnosis of pulmonary nodules with increased uptake of 18F-FDG on PET/CT and the utility of ultrasound-guided needle biopsy in the definitive diagnosis.

Kinetic analysis of cardiac dynamic 18F-Florbetapir PET in healthy volunteers and amyloidosis patients: A pilot study

Objectives

This study aimed to explore the potential of full dynamic PET kinetic analysis in assessing amyloid binding and perfusion in the cardiac region using 18F-Florbetapir PET, establishing a quantitative approach in the clinical assessment of cardiac amyloidosis disease.

Materials & methods

The distribution volume ratios (DVRs) and the relative transport rate constant (R1), were estimated by a pseudo-simplified reference tissue model (pSRTM2) and pseudo-Logan plot (pLogan plot) with kidney reference for the region of interest-based and voxel-wise-based analyses. The parametric images generated using the pSRTM2 and linear regression with spatially constrained (LRSC) algorithm were then evaluated. Semi-quantitative analyses include standardized uptake value ratios at the early phase (SUVREP, 0.5-5 min) and late phase (SUVRLP, 50-60 min) were also calculated.

Results

Ten participants [7 healthy controls (HC) and 3 cardiac amyloidosis (CA) subjects] underwent a 60-min dynamic 18F-Florbetapir PET scan. The DVRs estimated from pSRTM2 and Logan plot were significantly increased (HC vs CA; DVRpSRTM2: 0.95 ± 0.11 vs 2.77 ± 0.42, t'(2.13) = 7.39, P = 0.015; DVRLogan: 0.80 ± 0.12 vs 2.90 ± 0.55, t'(2.08) = 6.56, P = 0.020), and R1 were remarkably decreased in CA groups, as compared to HCs (HC vs CA; 1.08 ± 0.37 vs 0.56 ± 0.10, t'(7.63) = 3.38, P = 0.010). The SUVREP and SUVRLP were highly correlated to R1 (r = 0.97, P < 0.001) and DVR(r = 0.99, P < 0.001), respectively. The DVRs in the total myocardium region increased slightly as the size of FWHM increased and became stable at a Gaussian filter ≥6 mm. The secular equilibrium of SUVR was reached at around 50-min p.i. time.

Conclusion

The DVR and R1 estimated from cardiac dynamic 18F-Florbetapir PET using pSRTM with kidney pseudo-reference tissue are suggested to quantify cardiac amyloid deposition and relative perfusion, respectively, in amyloidosis patients and healthy controls. We recommend a dual-phase scan: 0.5-5 min and 50-60 min p.i. as the appropriate time window for clinically assessing cardiac amyloidosis and perfusion measurements using 18F-Florbetapir PET.

Pulmonary manifestations of amyloidosis

Amyloidosis is caused by abnormal protein deposition in various tissues, including the lungs. Pulmonary manifestations of amyloidosis may be categorized by areas of involvement, such as parenchymal, large airway and pleural involvement. We describe four distinct manifestations of amyloidosis involving the lung and review their clinical, radiological and pathological features and summarize the evidence for treatment in each of these presentations. We describe alveolar-septal amyloidosis, cystic amyloid lung disease, endobronchial amyloidosis and pleural amyloidosis.

The spectrum of pulmonary amyloidosis

Amyloidosis is a disease caused by misfolded proteins that deposit in the extracellular matrix as fibrils, resulting in the dysfunction of the involved organ. The lung is a common target of Amyloidosis, but pulmonary amyloidosis is uncommonly diagnosed since it is rarely symptomatic. Diagnosis of pulmonary amyloidosis is usually made in the setting of systemic amyloidosis, however in cases of localized pulmonary disease, surgical or transbronchial tissue biopsy might be indicated. Pulmonary amyloidosis can be present in a variety of discrete entities. Diffuse Alveolar septal amyloidosis is the most common type and is usually associated with systemic AL amyloidosis. Depending on the degree of the interstitial involvement, it may affect alveolar gas exchange and cause respiratory symptoms. Localized pulmonary Amyloidosis can present as Nodular, Cystic or Tracheobronchial Amyloidosis which may cause symptoms of airway obstruction and large airway stenosis. Pleural effusions, mediastinal lymphadenopathy and pulmonary hypertension has also been reported. Treatment of all types of pulmonary amyloidosis depends on the type of precursor protein, organ involvement and distribution of the disease. Most of the cases are asymptomatic and require only close monitoring. Diffuse alveolar septal amyloidosis treatment follows the treatment of underlying systemic amyloidosis. Tracheobronchial amyloidosis is usually treated with bronchoscopic interventions including debulking and stenting or with external beam radiation. Long-term prognosis of pulmonary amyloidosis usually depends on the type of lung involvement and other organ function.

Risk Stratification in Transthyretin Cardiac Amyloidosis: The Added Value of Lung Spirometry

Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized disease that often results in heart failure and death. Traditionally, biological staging systems are used to stratify disease severity. Reduced aerobic capacity has recently been described as useful in identifying higher risk of cardiovascular events and death. Assessment of lung volume via simple spirometry might also hold prognostic relevance. We aimed to assess the combined prognostic value of spirometry, cardiopulmonary exercise testing (CPET) and biomarker staging in ATTR-CA patients in a multi-parametric approach. We retrospectively reviewed patient records with pulmonary function and CPET testing. Patients were followed until study endpoint (MACE: composite of heart-failure-related hospitalization and all-cause death) or censure (1 April 2022). In total, 82 patients were enrolled. Median follow-up was 9 months with 31 (38%) MACE. Impaired peak VO₂ and forced vital capacity (FVC) were independent predictors of MACE-free survival, with peak VO₂ < 50% and FVC < 70% defining the highest risk group (HR 26, 95% CI: 5-142, mean survival: 15 months) compared to patients with the lowest risk (peak VO₂ ≥ 50% and FVC ≥ 70%). Combined peak VO₂, FVC and ATTR biomarker staging significantly improved MACE prediction by 35% compared to ATTR staging alone, with 67% patients reassigned a higher risk category (p < 0.01). In conclusion, combining functional and biological markers might synergistically improve risk stratification in ATTR-CA. Integrating simple, non-invasive and easily applicable CPET and spirometry in the routine management of ATTR-CA patients might prove useful for improved risk prediction, optimized monitoring and timely introduction of newer-generation therapies.

Hemoptysis After Heart Transplantation Caused by Pulmonary Amyloidosis

Pulmonary involvement is a common sequela of systemic amyloidosis, occurring in up to 50% of cases. The patterns of involvement include focal nodular, diffuse interstitial, and tracheobronchial. This can lead to a variety of symptoms, including cough and shortness of breath. Although hemoptysis is not uncommon, massive hemoptysis is rare. (Level of Difficulty: Advanced.).

Amyloidoma and Plasmacytoma Presented as a Solitary Lung Nodule in a Patient of Multiple Myeloma With AL-Amyloidosis: A Case Report and Review of Literature

Nodular amyloidoma in the lungs is a rare entity, also the occurrence of extramedullary plasmacytoma (EMP) in the lungs is rare. To have concomitant EMP and amyloidoma presented as a single lung mass is even rarer. There was only one similar case reported in the abstract form previously. Our case did not respond to many novel chemotherapy agents, suggesting that this combination of amyloidoma and plasmacytoma belonged to a poor prognosis entity, requiring different treatment modalities, such as early bone marrow transplantation or CART (chimeric antigen receptors T) therapy.

In Silico Study of the Interactions of Anle138b Isomer, an Inhibitor of Amyloid Aggregation, with Partner Proteins

Herein, we aimed to highlight current "gaps" in the understanding of the potential interactions between the Anle138b isomer ligand, a promising agent for clinical research, and the intrinsically disordered alpha-synuclein protein. The presence of extensive unstructured areas in alpha-synuclein determines its existence in the cell of partner proteins, including the cyclophilin A chaperone, which prevents the aggregation of alpha-synuclein molecules that are destructive to cell life. Using flexible and cascaded molecular docking techniques, we aimed to expand our understanding of the molecular architecture of the protein complex between alpha-synuclein, cyclophilin A and the Anle138b isomer ligand. We demonstrated the possibility of intricate complex formation under cellular conditions and revealed that the main interactions that stabilize the complex are hydrophobic and involve hydrogen.

Airway Amyloidosis: A Retrospective Analysis of 43 Patients

BACKGROUND

Amyloidosis can involve any compartment in the thorax. We aimed to explore the clinical and radiologic presentation, treatment, and clinical course of airway amyloidosis.

METHODS

A computer-assisted search was performed to identify patients who had biopsy-proven airway amyloidosis and were evaluated at Mayo Clinic in Rochester, MN, from January 1, 1997 through December 31, 2019. Demographic, clinical, and radiologic features along with clinical outcomes were analyzed.

RESULTS

We identified 43 patients who had airway amyloidosis. Median age was 60 years (range: 33 to 91 y), and 58% were female. Shortness of breath (63% of patients) and cough (44%) were the most common presenting symptoms. Most patients (82%) had localized amyloidosis with light chain being the most common amyloid type; 63% had tracheobronchial amyloidosis, and 23% had tracheal and upper airway involvement. On computed tomography of the chest, the most common findings were airway wall thickening with nodularity (60% of patients), airway calcification (53%), and airway occlusion without collapse (47%). On bronchoscopy (33 patients), the extent of amyloid involvement was most commonly submucosal (n=15) or nodular (n=8). External beam radiotherapy was the most common treatment modality. Among the 30 patients who had follow-up at our institution, the prognosis appeared to depend on the extent of the disease and whether patients had localized or systemic amyloidosis.

CONCLUSION

Computed tomography of the chest, bronchoscopy, and biopsy are needed to establish the diagnosis of airway amyloidosis, and systemic amyloidosis should be ruled out. Treatment of amyloidosis requires a multidisciplinary approach.

Pulmonary AL amyloidosis: A review and update on treatment options

Amyloidosis is a rare disease that involves the extracellular deposition of abnormally folded proteins, precipitating organ dysfunction. Pulmonary amyloidosis is frequently characterized by the AL amyloid subtype and can be localized or associated with systemic involvement, presenting in a nodular, diffuse alveolar-septal, or tracheobronchial pattern. Presentation of disease can vary from clinically silent to severe. Pulmonary amyloidosis is typically first suspected on CT scan of the chest. Diagnostic workup requires tissue biopsy and identification by immunohistochemical staining. Systemic treatment has evolved over recent years to include the combination of daratumumab, bortezomib, cyclophosphamide, and dexamethasone (dara-VCD) as first-line therapy, with the goal of quickly attaining complete hematologic response. Through clinical vignettes, we review pulmonary AL amyloidosis and discuss current treatment options.

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Amyloidosis.

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Localized.

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Tracheobronchial.

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Diffuse pulmonary.

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Treatment.

A stepwise data interpretation process for renal amyloidosis typing by LMD-MS

Backgrounds

Systemic amyloidosis is classified according to the deposited amyloid fibril protein (AFP), which determines its best therapeutic scheme. The most common type of AFP found are immunoglobulin light chains. The laser microdissection combined with mass spectrometry (LMD-MS) technique is a promising approach for precise typing of amyloidosis, however, the major difficulty in interpreting the MS data is how to accurately identify the precipitated AFP from background.

Objectives

The objective of the present study is to establish a complete data interpretation procedure for LMD-MS based amyloidosis typing.

Methods

Formalin-fixed paraffin-embedded specimens from patients with renal amyloidosis and non-amyloid nephropathies (including diabetic nephropathy, fibrillary glomerulonephritis, IgA nephropathy, lupus nephritis, membranous nephropathy, and normal tissue adjacent to tumors) were analyzed by LMD-MS. Forty-two specimens were used to train the data interpretation procedure, which was validated by another 50 validation specimens. Area under receiver operating curve (AUROC) analysis of amyloid accompanying proteins (AAPs, including apolipoprotein A-IV, apolipoprotein E and serum amyloid P-component) for discriminating amyloidosis from non-amyloid nephropathies was performed.

Results

A stepwise data interpretation procedure that includes or excludes the types of amyloidosis group by group was established. The involvement of AFPs other than immunoglobulin was determined by P-score, as well as immunoglobulin light chain by variable of λ-κ, and immunoglobulin heavy chain by H-score. This achieved a total of 88% accuracy in 50 validation specimens. The AAPs showed significantly different expression levels between amyloidosis specimens and non-amyloid nephropathies. Each of the single AAP had a AUROC value more than 0.9 for diagnosis of amyloidosis from non-amyloid control, and the averaged level of the three AAPs showed the highest AUROC (0.966), which might be an alternative indicator for amyloidosis diagnosis.

Conclusions

The proteomic data interpretation procedure for LMD-MS based amyloidosis typing was established successfully that has a high practicability in clinical application.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02785-9.

Pulmonary 99mTc-HMDP uptake correlates with restrictive ventilatory defects and abnormal lung reactance in transthyretin cardiac amyloidosis patients

BACKGROUND

Pulmonary involvement in individuals with transthyretin cardiac amyloidosis is unclear. The aim of this study was to quantify 99mTc-hydroxy methylene diphosphonate (HMDP) lung retention in hereditary transthyretin (ATTRv) cardiac amyloidosis patients and to relate tracer uptake intensity to pulmonary function and aerobic capacity.

METHODS

We prospectively enrolled 20 patients with biopsy-proven ATTRv cardiac amyloidosis and 20 control subjects. Cardiac involvement was confirmed by echocardiography and nuclear imaging using 99mTc-HMDP. Semi-quantitative analysis of the heart, rib and lung retention was assessed using a simple region of interest technique. Pulmonary function was evaluation by the means of whole-body plethysmography, diffusing capacity of the lung for carbon monoxide, forced oscillation technique and cardiopulmonary exercise testing.

RESULTS

Pulmonary tracer uptake estimated by lung to rib retention ratio was higher in ATTRv amyloidosis patients compared with control subjects: median 0.62 (0.55-0.69) vs 0.51 (0.46-0.60); p = 0.014. Analysis of relation between lung 99mTc-HMDP retention and pulmonary function parameters shown statistically significant correlations with total lung volume (% predicted), lung reactance (Xrs 5 Hz) and peak VO2, suggesting total lung capacity restriction impaired elastic properties of the lung and poor aerobic capacity.

CONCLUSION

Our study suggests that some grade of pulmonary retention of 99mTc-HMDP may occur in patients with cardiac ATTRv amyloidosis, which can elicit deleterious effects on patient's lung function and aerobic capacity.

Nodular Pulmonary Amyloidosis Associated with Sjögren's Syndrome

Amyloidosis is a rare disease characterized by the deposition of abnormal proteins in extracellular tissues. We herein report a case with instructive radiologic features of nodular pulmonary amyloidosis associated with Sjögren's syndrome. A 67-year-old woman was referred to our department because of an abnormal chest radiograph. Chest computed tomography revealed multiple round cysts accompanied by calcified nodules. The patient was clinically diagnosed with primary Sjögren's syndrome and pathologically diagnosed with nodular pulmonary amyloidosis (light chain, kappa). Although multiple lung cysts have many etiologies, the presence of calcified nodules associated with multiple lung cysts is useful for narrowing down the differential diagnosis.

Pulmonary amyloidosis and multiple myeloma mimicking lymphoma in a patient with Sjogren’s syndrome: A case report

BACKGROUND

Sjogren’s syndrome (SS), which affect salivary gland function, is an autoimmune disease. SS may involve extraglandular organs. Approximately 10 to 20 percent of SS patients have clinically significant lung disease, but presentation of pulmonary amylodosis is extremly rare. The incidence of benign monoclonal gammopathy in SS patients is high, but multiple myeloma is rare. No case involving the simultaneous occurrence of two rare diseases, pulmonary amyloidosis and multiple myeloma, in the same patient with SS has been reported so far.

CASE SUMMARY

A 41-year-old male patient was referred to our hematology department due to incidentally detected gastric plasmacytoma. He had been diagnosed with SS four years earlier. Multiple miliary nodules, ground glass opacity in both lung fields, and enlargement of both inguinal lymph nodes was observed on chest and abdomen computer tomography. Based on the pathological findings of lung and lymph node biopsied specimens, the patient was diagnosed with pulmonary amyloidosis and multiple myeloma. Pulmonary amyloidosis and multiple myeloma associated with SS has rarely been reported.

CONCLUSION

This is an extremely rare case of simultaneous pulmonary amyloidosis and multiple myeloma in the same patient with SS.

Pulmonary amyloidosis diagnosed via transbronchial lung cryobiopsy without surgical lung biopsy: A case series

Pulmonary amyloidosis is a rare disease characterized by abnormal extracellular deposition of amyloid fibril in the lung tissue, and the identification of amyloid deposits is essential for its diagnosis. Surgical lung biopsy (SLB) is a standard diagnostic method for pulmonary amyloidosis. However, it has a relatively high post-procedural mortality rate. Recently, transbronchial lung cryobiopsy (TBLC) has been gradually used for diagnosing interstitial lung disease. However, its diagnostic efficacy for pulmonary amyloidosis has not yet been validated. Here, we describe two cases of pulmonary amyloidosis with deposition of amyloid light chain detected via TBLC. Since SLB is a high-risk procedure for the patients due to age and complications, TBLC was performed. Both patients presented with Congo red-positive amyloid deposits. One patient with localized pulmonary amyloidosis had a good clinical course without therapeutic intervention and was followed up. The other with systemic amyloidosis received chemotherapy and presented with a stable clinical course. TBLC can collect a larger pulmonary specimen for pulmonary amyloidosis than forceps biopsy and has fewer complications and a lower mortality rate than SLB. Thus, it can be a diagnostic method for pulmonary amyloidosis.

Wild-type Transthyretin Amyloidosis with Diffuse Alveolar-septal Amyloidosis Diagnosed by a Transbronchial Lung Biopsy

A 69-year-old man visited our pulmonary medicine department for dyspnea. Chest computed tomography (CT) revealed ground-glass opacity bilaterally in the lungs. Upon performing a transbronchial lung biopsy (TBLB), organizing pneumonia was diagnosed. His electrocardiogram revealed low voltage, and the cardiac ultrasound revealed hypertrophy of the interventricular septum. The patient had bilateral carpal tunnel syndrome, and amyloidosis was suspected. Congo red stain was added to the lung biopsy specimen. Amyloid deposition of transthyretin (ATTR) was positive, mutations with amino acid changes were not observed in the TTR gene. Wild-type ATTR Amyloidosis (ATTRwt amyloidosis) was diagnosed using a TBLB. Chest CT after treatment with steroids revealed diffuse alveolar-septal amyloidosis.

Case Report: Management of Primary Tracheobronchial Light Chain Amyloidosis in a Patient With Biclonal Gammopathy Using a Systemic Bortezomib-Based Regimen

Primary tracheobronchial light chain (AL) amyloidosis is a rare and heterogeneous disease characterized by the buildup of amyloid deposits in the airway mucosa. Although its treatment remains challenging, the current view is that the localized form can be treated conservatively due to its slow progression. While radiotherapy has proven effective in treating localized form of the disease, some patients do not respond to local treatment and continue to experience poor quality of life, highlighting the need to explore additional treatment strategies. In this report, we discuss a case of primary tracheobronchial AL amyloidosis with biclonal gammopathy (IgA κ and IgG κ) in a 46-year-old man who was transferred to our hospital due to dyspnea progression over the preceding 3 years. Chest computed tomography revealed irregular tracheobronchial stenosis with wall thickening, and histological examination of the bronchial biopsies confirmed the diagnosis of endobronchial AL amyloidosis. Owing to the poor effect of radiation therapy and treatments for improving airway patency, he was treated with a systemic chemotherapy regimen [cyclophosphamide-bortezomib-dexamethasone (CyBorD)]. We observed substantial improvements in his dyspnea, highlighting the potential of systemic therapy to improve quality of life of patients with tracheobronchial AL amyloidosis. However, the long-term pathological changes associated with local bronchial lesions require further investigation.

Autopsy case with concurrent transthyretin and immunoglobulin amyloidosis

An 85-year-old man with a history of aortic dissection suddenly fainted, underwent cardiac heart arrest, and died. An autopsy was performed, but the cause of death was not grossly identified. Congo red staining detected amyloid deposits in systemic organs, including the heart, lungs, liver, and kidneys. Immunohistochemical (IHC) analysis revealed immunoglobulin (Ig) λ light chain (-λ) in systemic blood vessels and transthyretin (TTR) in the heart and lungs. Ig-λ was predominantly positive in the blood vessels of the lungs, while TTR was detected in the alveolar septum. In the heart, Ig-λ was positive in the endocardium and blood vessels, and TTR was positive in nodular deposits between cardiomyocytes. The concurrent deposition of Ig-λ and TTR in the heart was further substantiated by laser microdissection (LMD)-liquid chromatography-tandem mass spectrometry (LC-MS/MS) at each deposition site. Despite systemic deposition of Ig-λ, bone marrow biopsy findings were not diagnostic for multiple myeloma. In summary, we present an autopsy case of concurrent Ig-λ and TTR deposition as revealed by IHC and LC-MS/MS. When Congo red staining and IHC results are indeterminate due to the deposition of multiple amyloid proteins, LMD-LC-MS/MS is useful for determining the precursor protein.

CT findings of non-neoplastic central airways diseases

Non-neoplastic lesions of central airways are uncommon entities with different etiologies, with either focal or diffuse involvement of the tracheobronchial tree. Clinical symptoms of non-neoplastic tracheobronchial diseases are non-specific, and diagnosis is difficult, especially in the early stages. Three-dimensional computed tomography (3D-CT) is an evaluable tool as it allows to assess and characterize tracheobronchial wall lesions and meanwhile it enables the evaluation of airways surrounding structures. Multiplanar reconstructions (MPR), minimum intensity projections (MinIP), and 3D Volume Rendering (VR) (in particular, virtual bronchoscopy) also provide information on the site and of the length of airway alterations. This review will be discussed about (1) primary airway disorders, such as relapsing polychondritis, tracheobronchophathia osteochondroplastica, and tracheobronchomegaly, (2) airway diseases, related to granulomatosis with polyangiitis, Chron's disease, Behcet's disease, sarcoidosis, amyloidosis, infections, intubation and transplantation, (3) tracheobronchial malacia, and (4) acute tracheobronchial injury. 3D-CT findings, especially with MPR and 3D VR reconstructions, allows us to evaluate tracheobronchial disease morphologically in detail.

Lung cancer combined with diffuse peritoneal and mesenteric amyloidosis detected on 18F-FDG PET/CT: A case report

RATIONALE

Amyloidosis is a heterogeneous group of diseases characterized by extracellular deposition of amyloid fibrils. Lung carcinoma is rarely reported to be associated with AA amyloidosis. With regard to the manifestation of amyloidosis infiltrating organs, most of the cases focus on the heart, liver, kidneys, and peripheral nervous system. Amyloidosis with diffuse abdominal involvement in combination with pulmonary squamous cell carcinoma carcinoma is an exceptionally rare occurrence.

PATIENT CONCERNS

A 70-year-old man was admitted to hospital for a 2-month history of repeated cough, low grade fever, hemoptysis and left back shoulder pain, which was not relieved by nonsteroid anti-inflammatory drugs. Meanwhile, he complained of intermittent diffuse abdominal discomfort and chronic persistent constipation.

DIAGNOSES

The patient was diagnosed with poorly differentiated lung squamous cell carcinoma and diffuse peritoneal and mesenteric amyloidosis based on the pathological biopsy.

INTERVENTIONS

The patient received surgery and chemotherapy for lung tumor. He did not receive any treatment against amyloidosis.

OUTCOMES

The patient died of a severe respiratory infection.

LESSONS

This case indicates that lung carcinoma is suspected to play a causative role in the development of amyloidosis. In addition, amyloidosis should be considered in the differential diagnosis in cases in which diffuse greater omentum, peritoneal, and mesenteric calcifications on 18F-2-fluoro-2-deoxy-D-glucose(18F-FDG) photon emission computed tomography (PET/CT).

Systemic AL amyloidosis presenting with diffuse alveolar septal involvement and respiratory failure: a case report and review of the literature

Background

Amyloidosis is the extracellular deposition of amyloid fibril protein in any tissue or organ. The clinical manifestations of pulmonary amyloidosis are variable and without specific symptoms. We report a rare case of diffuse alveolar septal amyloidosis which is an extremely rare pattern of involvement, with a very poor prognosis, to improve our understanding of the disease.

Case presentation

A 27-year-old man complained of shortness of breath and cyanosis. High-resolution computed tomography revealed diffuse ground-glass opacifications with interlobular septal thickening in both lungs. The immune-histochemistry showed monoclonal lambda light chains. This case also showed nephrotic syndrome and cardiac arrhythmia, suggesting an involvement of the kidney and the heart. Diagnosis: The diagnosis was finally established by tru-cut transthoracic sonar guided lung biopsy (TSLB), and histological examination revealed Congo red-positive amorphous eosinophilic deposits in the alveolar sept. Interventions: The patient was admitted to a respiratory intensive care unit and put on non-invasive ventilation, then discharged on domiciliary oxygen therapy, and started treatment with chemotherapy melphalan 2 mg daily plus prednisone 60 mg daily immediately after the result of histopathology. Outcomes: Three months after treatment, dyspnea and hypoxemia improved, and he continued treatment. The patient was in a good clinical condition after 10 months of follow-up, but he died suddenly.

Conclusion

As it is difficult to distinguish diffuse alveolar septal amyloidosis from other interstitial and granulomatous lung diseases because of their similar symptoms and imaging findings, thus, transthoracic sonar guided lung biopsy and histological examination is very important in the diagnosis of diffuse alveolar septal amyloidosis.

Pulmonary amyloidosis complicated with pulmonary hemosiderosis, diagnosed with bronchoscopy

We describe a case of an 82-year-old Japanese woman with pulmonary amyloidosis and hemosiderosis associated with multiple myeloma. She had a background of end-stage renal failure of unknown etiology and had been on maintenance dialysis for 2 years. She complained of exertional dyspnea for four months. High-resolution CT of the chest revealed diffuse ground-glass opacities with mosaic attenuation, consolidation in the left lingular lobe, and wedge-shaped, subpleural nodules in the bilateral lower lobes. A transbronchial lung biopsy of the left lingular lobe showed deposition of amorphous, eosinophilic amyloid at the smooth muscle layer of bronchial tissue, with a positive Congo red staining signal in polarized light. Bronchoalveolar lavage fluid was brownish-yellow, and numerous hemosiderin-laden macrophages were detected with Berlin blue staining. From these findings, a diagnosis of pulmonary amyloidosis complicated with pulmonary hemosiderosis was made. Further work-up led to a diagnosis of multiple myeloma. Pulmonary amyloidosis complicated with pulmonary hemosiderosis is a rare disorder and may be underdiagnosed. Physical examination, such as the appearance of the tongue, can assist the diagnosis of systemic amyloidosis. Use of bronchoscopy allows physicians make an early diagnosis of pulmonary amyloidosis that is minimally invasive.

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Pulmonary amyloidosis can present nodules, GGOs, and consolidations.

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Pulmonary amyloidosis can be complicated with pulmonary hemosiderosis.

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Pulmonary amyloidosis can be diagnosed using bronchoscopy.

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Physical examination of the tongue can assist diagnosis of systemic amyloidosis.

Extensive eye-oral-bronchial mucosal nodules with eosinopgillia: a rare case report and literature review

BACKGROUND

Mucosal nodules can be caused by infection, inflammation and neoplastic disease. Many noninfectious diseases, such as eosinophilia, amyloidosis, sarcoidosis, Wegener's granuloma, langerhans cell histiocytosis etc., are associated with the formation of multisytem mucosal nodules, especially significant bronchial lesions. Detailed medical history, comprehensive metabolic profile, biopsy specimen and imaging examinations are required for differentiating among these disorders. The process of diagnosis and treatment of our patient's mucosal nodules was challenging, which could be helpful to similar cases.

CASE PRESENTATION

We represent a case of a 29-year-old woman with plentiful nodules of unknown origin on extensive mucous membranes. Biopsy specimen reports inflammatory lesions with large numbers of neutrophils, lymphocytes, and varying degrees of eosinophils. Treatment of anti-infection, anti-tussive and anti-allergic was ineffective, but glucocorticoid showed great improvement to her symptoms.

CONCLUSION

We experienced a rare case with plentiful nodules of unknown origin on extensive mucous membranes. She may be a specific phenotype of eosinophilia or may be a novel multisystem disease with respiratory system as the primary symptom. The diagnosis of our patient remains unclear, but tentative glucocorticoid therapy was beneficial.

Amyloidosis of the respiratory system: 16 patients with amyloidosis initially diagnosed ante mortem by pulmonologists

Background

Ante mortem diagnosis of amyloidosis of the respiratory system is rare. Few data are available regarding clinical presentation, precursor proteins, diagnostic procedures, comorbidities, complications, and outcome. We assessed clinical features of a series of patients with amyloidosis of the respiratory system in two Japanese centres.

Methods

Medical records of 16 patients with amyloidosis of the respiratory system were retrospectively analysed. Amyloid was diagnosed by polarisation microscopy using Congo red-stained tissue specimens and classified immunohistochemically.

Results

Median patient age was 71 years, and median follow-up period was 5 years. Immunoglobulin light-chain (AL)-λ amyloidosis was found in eight and AL-κ in five patients. Two patients harboured wild-type transthyretin and one harboured serum amyloid A-derived amyloid. Five different forms of amyloidosis of the respiratory system were observed: nodular pulmonary amyloidosis (seven patients), diffuse alveolar-septal amyloidosis (five), mediastinal lymph node amyloidosis (three), tracheobronchial amyloidosis (one), and pleural amyloidosis (one). One patient had diffuse alveolar-septal amyloidosis and mediastinal lymph node amyloidosis. Three of five patients with diffuse alveolar-septal amyloidosis were diagnosed by transbronchial lung biopsy as having concurrent diffuse alveolar haemorrhage or pneumocystis pneumonia. Two of three patients with mediastinal lymph node amyloidosis were diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration.

Conclusions

Not only nodular pulmonary amyloidosis, diffuse alveolar-septal amyloidosis, and tracheobronchial amyloidosis but also mediastinal lymph node amyloidosis and pleural amyloidosis should be considered in the differential diagnosis of amyloidosis of the respiratory system. Useful diagnostic methods include transbronchial lung biopsy for diffuse alveolar-septal amyloidosis and endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal lymph node amyloidosis.

Not only nodular, diffuse alveolar-septal and tracheobronchial amyloidosis but also mediastinal lymph node and pleural amyloidosis should be considered in the differential diagnosis of amyloidosis of the respiratory systemhttps://bit.ly/2ZfZcxo

Quantitative [18F]florbetapir PET/CT may identify lung involvement in patients with systemic AL amyloidosis

PURPOSE

The clinical diagnosis of pulmonary involvement in individuals with systemic AL amyloidosis remains challenging. [18F]florbetapir imaging has previously identified AL amyloid deposits in the heart and extra-cardiac organs. The aim of this study is to determine quantitative [18F]florbetapir pulmonary kinetics to identify pulmonary involvement in individuals with systemic AL amyloidosis.

METHODS

We prospectively enrolled 58 subjects with biopsy-proven AL amyloidosis and 9 control subjects (5 without amyloidosis and 4 with ATTR cardiac amyloidosis). Pulmonary [18F]florbetapir uptake was evaluated visually and quantified as distribution volume of specific binding (Vs) derived from compartmental analysis and simpler semiquantitative metrics of maximum standardized uptake values (SUVmax), retention index (RI), and target-to-blood ratio (TBR).

RESULTS

On visual analysis, pulmonary tracer uptake was absent in most AL subjects (40/58, 69%); 12% (7/58) of AL subjects demonstrated intense bilateral homogeneous tracer uptake. In this group, compared to the control group, Vs (median Vs 30-fold higher, 9.79 vs. 0.26, p < 0.001), TBR (median TBR 12.0 vs. 1.71, p < 0.001), and RI (median RI 0.310 vs. 0.033, p < 0.001) were substantially higher. Notably, the AL group without visually apparent pulmonary [18F]florbetapir uptake also demonstrated a > 3-fold higher Vs compared to the control group (median 0.99 vs. 0.26, p < 0.001). Vs was independently related to left ventricular SUVmax, a marker of cardiac AL deposition, but not to ejection fraction, a marker of cardiac dysfunction. Also, intense [18F]florbetapir lung uptake was not related to [11C]acetate lung uptake, suggesting that intense [18F]florbetapir lung uptake represents AL amyloidosis rather than heart failure.

CONCLUSIONS

[18F]florbetapir PET/CT offers the potential to noninvasively identify pulmonary AL amyloidosis, and its clinical relevance warrants further study.

Atypical primary pulmonary amyloidosis: A rare case report

RATIONALE

Pulmonary amyloidosis is a rare respiratory disease characterized by amyloid deposition in the lungs. The clinical manifestations of pulmonary amyloidosis are variable and without specific symptoms.

PATIENT CONCERNS

We report a rare case of tracheobronchial amyloidosis to improve our understanding of the disease.

DIAGNOSES

The diagnosis of tracheobronchial amyloidosis was finally established by transbronchoscopic lung biopsy and histological examination.

INTERVENTIONS

The patient significantly improved with methylprednisolone sodium succinate for injection (40 mg/day) for 5 days and low-dose oral prednisone for 10 days.

OUTCOMES

After treatment, discomfort, such as cough, stridor, dyspnea, and chest tightness, disappeared, and he was discharged. The patient was in good clinical condition after 8 months of follow-up.

CONCLUSION

This case clearly shows that it is difficult to distinguish tracheobronchial amyloidosis from other diseases with manifestations of cough, dyspnea and chest tightness because of their similar symptoms and imaging findings. Thus, the role of transbronchoscopic lung biopsy and histological examination in the diagnosis of tracheobronchial amyloidosis is very important.

Extensive multifocal and pleomorphic pulmonary lesions in Waldenström macroglobulinemia: A case report

BACKGROUND

Waldenström macroglobulinemia (WM) is a type of small lymphocytic lymphoma that mainly affects the bone marrow, spleen, and lymph nodes. A subset of patients with WM demonstrates extramedullary involvement (4.4%), and the most frequent extramedullary disease site involved is the lungs (30%).

CASE SUMMARY

A 60-year-old male patient who experienced intermittent breath-holding for 6 mo was admitted on August 14, 2017. Chest computed tomography indicated multiple pulmonary cavities in the upper lobes of both lungs, with pulmonary consolidation, ground-glass opacities, patchy infiltrates, fibrous bands, large bullae, and enlarged lymph nodes in the mediastinum. The patient was a heavy smoker (20 cigarettes/d for 40 years). Diagnostic fiberoptic bronchoscopy revealed normal findings. Serological examination revealed a remarkable increase in serum immunoglobulin M levels (30.24 g/L; normal: 0.4-2.30 g/L). A computed tomography-guided percutaneous pulmonary biopsy was performed in the left lower lobe of the lung with pulmonary consolidation and indicated that the alveolar structure disappeared and that a large amount of amyloid-like deposition was present along with the infiltration of very few lymphocytes and plasma cells. The patient was treated with the combined treatment of dexamethasone + rituximab + lenalidomide over four courses. Serum immunoglobulin M did not normalize, and he received ibrutinib + dexamethasone.

CONCLUSION

This patient with WM and lung amyloidosis had a wide range of pulmonary lesions and a variety of morphological features, which was a rare case. Yet, some changes might be ascribed to heavy smoking.

A case report of pulmonary amyloidosis recognized by detection of AA amyloid exclusively in alveolar macrophages

Amyloidosis is a rare condition in which tissue deposits of inert fibrillar protein result in organ damage and dysfunction. There are several types of amyloid fibrils. Some of the most common forms are AL (amyloid light chain) protein and AA (amyloid-associated) type of amyloid fibril protein. Pulmonary amyloidosis is relatively common but is usually asymptomatic. Thus, the diagnosis may be easily overlooked. A 78-year-old male with a history of multiple myeloma followed by systemic amyloidosis presented with abnormal chest CT showing diffuse interlobular thickening in the whole lung field with bilateral pleural effusion. Bronchoalveolar lavage and transbronchial biopsy were performed. Due to the patient's poor condition and hemorrhage, only one fragment was available from forceps biopsy. Histologically, there was no amyloid deposition in the lung parenchyma; however, some histiocytes showed eosinophilic granular contents which prompted us to perform additional staining. The cytoplasmic material turned to be positive with direct fast scarlet (DFS) staining and AA amyloid immunostaining. Similar macrophages with AA amyloid were also found in the bronchoalveolar fluid. We experienced a case with AA amyloidosis affecting the lung diagnosed by the presence of intracytoplasmic amyloid in alveolar macrophages. The microscopic changes were so subtle that they may be overlooked. Recognition of amyloid deposition in alveolar macrophages may be an important clue to diagnose pulmonary amyloidosis. Such finding is of particular significance in the small-sized specimens, such as biopsies and cytologic smears.

An autopsy case of amyloid tubulopathy exhibiting characteristic spheroid-type deposition

An 84-year-old woman with a history of haemodialysis for renal failure from approximately 1 year before death. Autopsy revealed numerous spheroid-type amyloid deposits in the kidney that were observed mainly in the interstitium but not the glomeruli and vessels. In addition, intracytoplasmic small globular amyloid deposits in the proximal tubules in addition to amyloid casts were identified. Immunohistochemistry and proteomic analyses indicated these deposits were composed of λ light chains. Amyloid deposition was also found in the lung and heart. λ-type monoclonal protein was detected in her serum and increased numbers of CD138-positive cells with λ-restriction was observed in the bone marrow. The case was diagnosed as amyloid tubulopathy (AT) associated with systemic ALλ amyloidosis related to plasma cell neoplasm. This case indicates that AT is associated with ALλ amyloidosis, which developed systemically with characteristic amyloid deposition forms. These pathological features may be associated with her rapid progressive renal failure.

A 45-Year-Old Woman With Multiple Pulmonary Nodules and Sjögren Syndrome

CASE PRESENTATION

A 45-year-old woman presented for evaluation for 3 months of coughing and dyspnea. A recent chest CT scan done for workup of her symptoms revealed a 2-cm right-sided pulmonary nodule. She had a medical history of Sjögren syndrome, hypertension, and obesity. She also noted a weight loss of 30 lb over the last 3 years. She denied smoking, alcohol consumption, illicit drug use, or occupational exposures. A chest radiograph done 3 years prior did not reveal any pulmonary nodules. She had no personal or family history of arteriovenous malformations, hamartomas, or any malignancies and had been up to date with her breast cancer screening. She was treated with courses of hydroxychloroquine and mycophenolate mofetil for her Sjögren syndrome and did not have a history of opportunistic pulmonary infections. She denied any recent travel or exposure to TB.

An Organ System-Based Approach to Differential Diagnosis of Amyloid Type in Surgical Pathology

CONTEXT.—

Amyloidosis is an uncommon but important entity. A protein-based classification of amyloidosis defines the underlying disease process, directing clinical management and providing prognostic information. However, in routine surgical pathology there often is no attempt to classify amyloid other than staining to determine light chain-associated amyloidosis. Systemic and localized amyloidosis vary with respect to frequency of organ involvement by different amyloid types, and most amyloid proteins have commercial antibodies available for identification.

OBJECTIVE.—

To provide a guide for the likelihood of amyloid type by organ system.

DATA SOURCES.—

Literature review based on PubMed searches containing the word amyloid, specifically addressing the prevalence and significance of amyloid proteins in each organ system other than the brain, and the authors' practice experience.

CONCLUSIONS.—

In patients with amyloidosis, determination of the responsible protein is critical for appropriate patient care. In large subspecialty practices and reference laboratories with experience in using and analyzing relevant immunohistochemistry, most amyloid proteins can be identified with an organ-specific algorithm. Referring to an organ-based algorithm may be helpful in providing clinicians with a more specific differential diagnosis regarding amyloid type to help guide clinical evaluation and treatment. When the protein cannot be characterized, mass spectrometry can be performed to definitively classify the amyloid type.

Diffuse Alveolar Septal Amyloidosis With Wild-Type Transthyretin With Spontaneous Lung Hematoma

We experienced a mass formation in the right lower lobe in a patient with cardiac amyloidosis and heart failure. Radiologic findings of the chest showed no abnormality except a mass. The patient had non-valvular atrial fibrillation and was taking edoxaban. Surgical resection of the mass revealed a hematoma. Further pathologic evaluation revealed diffuse alveolar septal amyloidosis with transthyretin (ATTR). The genetic testing found no mutation in the TTR gene. Therefore, systemic wild-type TTR amyloidosis (ATTRwt) was confirmed. Alveolar septal ATTRwt is rare and patient had alveolar septal ATTRwt with spontaneous lung hematoma.

Lower respiratory tract amyloidosis: Presentation, survival and prognostic factors. A multicenter consecutive case series

Lower-respiratory-tract (LRT) amyloidosis has rarely been investigated. Our study presents characteristics, outcomes and survival of LRT amyloidosis. This multicenter retrospective study, from 1995 to 2017, included 73 patients with amyloidosis and LRT involvement. Respiratory patterns were: tracheobronchial (n = 17), nodular (n = 10), interstitial (n = 14) or composite (several respiratory involvements, n = 32). Interstitial and composite patterns were associated with multi-organ amyloidosis (n = 37, 80%) while tracheobronchial and nodular patterns were associated with organ-limited amyloidosis (n = 21, 78%). Amyloid light chain (AL) amyloidosis was diagnosed in 43 patients (59%), mainly of lambda type (n = 33, 77%). Smokers' proportion was higher in tracheobronchial (71%) and nodular (90%) patterns than in interstitial (14%) and composite (34%) patterns. The B-cell neoplasms involved 15 patients (21%), solid neoplasms 8 (11%), connective tissue diseases 8 (11%) and multiple myeloma 6 (8%). The B-cell and solid neoplasms were most prevalent in nodular pattern. Median follow-up was 4.4 years (2.2-8.9). Twenty-four patients died, mostly from respiratory infection. Survival at 1, 5, 10 years was respectively 88%, 70% and 54% for multi-organ amyloidosis, 96%, 89% and 69% for organ-limited amyloidosis (P = .125). Tracheobronchial and nodular patterns survival was better than in other respiratory patterns (P = .039). Death risk factors (multivariate analysis) were: cardiac localization (hazard-ratio [HR] 4.3 [95% confidence interval 1.6-11.5]; P = .004), age (HR 2.1 [1.2-3.7]; P = .008) and dyspnea at diagnosis (HR 4.0 [1.3-12.3]; P = .014). Various LRT amyloidosis patterns depend on smoking habits, organ-limited or multi-organ extension and comorbidities. They are associated with a different survival, which is also predicted by age, cardiac localization and dyspnea at presentation.

Clinical observation of a combination of diffuse alveolar-septal pulmonary lesion and amyloid cardiomyopathy in systemic AL-amyloidosis in the elderly

A rare observation of systemic AL-amyloidosis with a debut in old age, accompanied by diffuse alveolar-septal lesion of the lungs and mediastinal lymphadenopathy in combination with amyloid cardiomyopathy in the absence of pathology of kidney and liver function.