An uncommon cause of bilateral pulmonary nodules in a long-term smoker

Nodular Pulmonary Amyloidosis Mimicking Metastatic Pulmonary Nodules: A case report and review of the literature

Amyloidosis is a disorder characterised by the extracellular deposition of amyloid, a fibrillary protein, in various organs such as the lungs. Pulmonary nodular amyloidosis can mimic other lung conditions that present with pulmonary nodules, such as metastasis, sarcoidosis and hyalinising granuloma. We report a 60-year-old man who presented to the Royal Hospital, Muscat, Oman, in 2017 with a history of shortness of breath upon exertion, orthopnoea and bilateral lower limb swelling. A chest X-ray showed bilateral nodular opacities. Enhanced chest computed tomography revealed bilateral pulmonary nodules with a predominantly perilymphatic and subpleural distribution, giving the impression of a neoplastic nodule. A histopathological examination of biopsied lung tissue confirmed a diagnosis of nodular pulmonary amyloidosis.

A 70-Year-Old Man With Large Cervical and Mediastinal Lymphadenopathies

We present a case of a 70-year-old man with enlarged mediastinal and cervical lymph nodes that provided interesting radiologic and pathologic observations. The 70-year-old black man was found to have enlarged mediastinal lymph nodes. He had symptoms of atypical chest pain and generalized weakness for 2 weeks prior to the diagnosis. He denied shortness of breath, fever, chills, or night sweats. He was treated for hypertension and onychomycosis. Basic laboratory findings were within normal limits. Pulmonary function tests at the time of presentation showed FEV1, FVC, and FEV1/FVC ratio of 123% predicted, 133% predicted, and 0.7, respectively. Meanwhile, total lung capacity and carbon monoxide diffusing capacity were 103% and 107% predicted, respectively. Two weeks before he presented to our institution, the patient underwent bronchoscopy with transbronchial biopsies of the right lower lobe and endobronchial ultrasound-guided transbronchial needle aspiration of the right hilar lymph nodes.

Clinical characteristics of amyloidosis with isolated respiratory system involvement: A review of 13 cases

BACKGROUND:

Isolated pulmonary amyloidosis is a very rare disease.

METHODS:

We retrospectively reviewed the records of patients with pathologically proven isolated pulmonary amyloidosis treated at our hospital from 1990 to 2011.

RESULTS:

There were 9 males and 4 females with a mean age of 54.7 years (range, 45–72 years) and the mean course of disease was 46.5 months (range, 5 months–15 years). The most common symptoms were cough (10/13), expectoration (8/13), hemoptysis (4/13), chest tightness (12/13), dyspnea (10/13), chest pain (3/13), fever (5/13), and body weight loss (2/13). Radiological findings included tracheal stenosis (2/13), bronchial stenosis with atelectasis (5/13), pulmonary nodules (3/13), lung consolidation (1/13), and lymph node enlargement with pleural effusion (2/13). Treatments included endotracheal stenting, endoscopic resection of tracheal and bronchial lesions, lung resection, and drug therapy with glucocorticoids, antineoplastic agents, or antibiotics. Four patients died of the disease within 1 year of diagnosis, 2 died of pneumonia at 3–4 years after original treatment, and the remaining patients are alive with follow-up ranging from 3 to 15 years.

CONCLUSIONS:

Isolated pulmonary amyloidosis is a rare disease with a relatively high mortality and its various manifestations make diagnosis challenging. Surgical resection of lesions and chemotherapy tend to be effective treatments.

How to manage primary amyloidosis

Immunoglobulin light chain amyloidosis is a protein deposition disorder where the precursor protein represents a monoclonal immunoglobulin light or heavy chain. Deposition in viscera results in restrictive cardiomyopathy, nephrotic range proteinuria, demyelinating peripheral neuropathy, hepatomegaly and malabsorption syndrome. Diagnosis requires biopsy with Congo red staining. Invasive biopsies are not required generally. It is essential that after a histologic diagnosis is obtained, the tissue is validated to have an immunoglobulin light chain composition so patients are spared unnecessary chemotherapy. The disease prognosis and patient monitoring are linked to serialized measurement of cardiac biomarkers and immunoglobulin-free light chains. Most patients require cytotoxic chemotherapy. For some patients, this therapy involves stem cell collection and myeloablative chemotherapy; for others, chemotherapy includes an alkylator and a corticosteroid; and for some, it involves addition of a novel agent in the form of an immunomodulatory drug or a proteasome inhibitor. Delays in diagnosis continue to be an obstacle to initiating effective therapy. Early mortality rates remain high. Effective chemotherapy can result in reversal of organ dysfunction and recovery. Reductions in light chain production translate to improved survival.

ALkappa(I) (UNK) - primary structure of an AL-amyloid protein presenting an organ-limited subcutaneous nodular amyloid syndrome of long duration. Case report and review

Slowly progressing subcutaneous nodules all over the body were detected in 1994 in an otherwise healthy, now 66-year-old woman (UNK). A first biopsy was taken 10 years ago and revealed amyloid. Immunohistochemistry was suggestive for ALkappa. From a nodular excisate, performed in the same year for cosmetic reasons, amyloid fibrils were extracted. Protein separation according to their size revealed multiple protein fragments below the MW of an intact kappa-light chain. They were identified as kappa-fragments by Western blotting. The kappa-fragments were cleaved into overlapping peptides using tryptic, N-Asp and chymotryptic digests. Peptides were sequenced by Edman-degradation and mass spectrometry. The complete amino acid sequence of the variable region and most of the constant region of ALkappa (UNK) was identified in various fragments comprising positions 1 to 207 of a monoclonal kappa(I)-light chain. Four novel and several rare amino acid exchanges have been identified as compared to 17 amyloidogenic and >100 non-amyloidogenic kappa(I)-sequences published, leading to increased hydrophobicity of ALkappa (UNK). Sequence analysis of C-region peptides allowed one to determine the kappa-allotype as being invb(+). A rabbit antibody was produced against ALkappa(I) (UNK). It strongly reacted with amyloid on formalin-fixed paraffin embedded tissue sections of the same patient and detected ALkappa-amyloid of many other patients. In contrast, antibodies produced against kappaBJP of subclasses kappa(I)-kappa(IV) failed to label ALkappa (UNK) amyloid deposits. The patient continues to be free of systemic disease, already for 14 years until today.

Pulmonary amyloidosis with calcified nodules and masses - a six-year computed tomography follow-up: a case report

Introduction

Pulmonary amyloidosis is an uncommon disease, characterized by extracellular deposition of fibrillary protein in the lungs. It appears in three forms: tracheobronchial, nodular pulmonary, and alveolar septal. There are few reports of long-term observation of primary pulmonary amyloidosis.

Case presentation

We present the case of a 47-year-old man who presented with fever, dyspnea, cough and hemoptysis. Chest radiograph and computed tomography revealed multiple pulmonary nodules and masses. The patient underwent open lung biopsy, which diagnosed pulmonary amyloidosis.

Conclusion

Pulmonary nodular amyloidosis should be considered in the differential diagnosis of pulmonary nodules or masses.