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Pou C, Ferreiro L, Suárez-Antelo J, Golpe A, Álvarez-Dobaño JM, Toubes ME, Lama A, Rodríguez-Núñez N, Ricoy J, Rábade C, Lourido T, Valdés L. Characteristics of pleural effusion due to amyloidosis. Ann Thorac Med 2023; 18:53-60. [PMID: 37323369 PMCID: PMC10263077 DOI: 10.4103/atm.atm_433_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 06/17/2023] Open
Abstract
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.
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Affiliation(s)
- Cristina Pou
- Department of Pulmonology, Álvaro Cunqueiro University Teaching Hospital, Vigo, Spain
| | - Lucía Ferreiro
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Juan Suárez-Antelo
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Golpe
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - José M. Álvarez-Dobaño
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - María Elena Toubes
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Adriana Lama
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nuria Rodríguez-Núñez
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jorge Ricoy
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Carlos Rábade
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Tamara Lourido
- Department of Pulmonology, Álvaro Cunqueiro University Teaching Hospital, Vigo, Spain
| | - Luis Valdés
- Department of Pulmonology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
- Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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Muñoz-Moreno J, Añorga-Ocmin J, Espinola-García S, Aguilar-Carranza C, Alarco-León W. [Cardiac Amyloidosis: Experience in a National Reference Cardiovascular Institute]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2020; 1:75-84. [PMID: 38572335 PMCID: PMC10986346 DOI: 10.47487/apcyccv.v1i2.40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/15/2020] [Indexed: 04/05/2024]
Abstract
Objectives To determine the clinical, imaging and laboratory characteristics and one year after diagnosis survival of patients with cardiac amyloidosis in a national reference hospital. Materials and methods Case series study. We evaluated the clinical characteristics, complementary examinations and survival of patients with cardiac amyloidosis diagnosed, treated and followed up in the Clinical Cardiology service of the National Cardiovascular Institute - INCOR EsSalud in Lima, Peru. Results We found eight patients with diagnosis of cardiac amyloidosis. The median age was 64.5 years and 75% were male. The etiology of cases was unspecified cardiac amyloidosis (25%), transthyretin cardiac amyloidosis (37.5%), and light chain cardiac amyloidosis (37.5%). Symptomatic heart failure (NYHA II-III) was the most common initial presentation symptom (87.5%). The most frequent extracardiac manifestations were: sensory-motor neuropathy (62.5%), musculoskeletal (37.5%), nephropathy (25%), bilateral carpal tunnel syndrome (25%), monoclonal gammopathies (25%) and refractory pleural effusion (25 %). Survival at one year was 75% and the cause of the 2 deaths was sudden death. Conclusions In this study of cardiac amyloidosis at a specialized center, the most frequent clinical manifestations were heart failure and sensory-motor neuropathy. Mortality was 25% per year, and in all cases as sudden death.
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Affiliation(s)
- Juan Muñoz-Moreno
- Médico residente de Cardiología. Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Instituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - José Añorga-Ocmin
- Médico residente de Cardiología. Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Instituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - Sandra Espinola-García
- Médico residente de Cardiología. Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Instituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - Cristian Aguilar-Carranza
- Médico asistente del Laboratorio de Patología. Instituto Nacional Cardiovascular INCOR EsSalud. Lima, Perú.Instituto Nacional Cardiovascular INCOR EsSaludLimaPerú
| | - Walter Alarco-León
- Unidad de Insuficiencia Cardíaca, Trasplante Cardíaco e Hipertensión Pulmonar. Lima, Perú.Unidad de Insuficiencia Cardíaca, Trasplante Cardíaco e Hipertensión PulmonarLimaPerú
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Xiong J, Ren Y, Li H, Fu B, Wu R. First case of pleural amyloidosis in systemic erythematosus: report and literature review. Z Rheumatol 2018; 77:841-843. [PMID: 30191392 DOI: 10.1007/s00393-018-0532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- J Xiong
- Department of Rheumatology, the First Affiliated Hospital of Nanchang University, 330006, Nanchang, China
| | - Y Ren
- Department of Rheumatology, the First Affiliated Hospital of Nanchang University, 330006, Nanchang, China
| | - H Li
- Department of Rheumatology, the First Affiliated Hospital of Nanchang University, 330006, Nanchang, China
| | - B Fu
- Department of Rheumatology, the First Affiliated Hospital of Nanchang University, 330006, Nanchang, China
| | - R Wu
- Department of Rheumatology, the First Affiliated Hospital of Nanchang University, 330006, Nanchang, China.
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Manur R, Lamzabi I. Amyloidosis diagnosed in cytology specimen of pleural effusion: A case report. Diagn Cytopathol 2017; 46:522-524. [PMID: 29280335 DOI: 10.1002/dc.23877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/21/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022]
Abstract
Amyloidosis is a rare condition resulting from extracellular deposition of amyloid, a fibrillary material derived from various precursor proteins. Involvement of the pleura by amyloidosis is a rare but serious complication. Pleural amyloidosis is primarily diagnosed by identifying amyloid deposition by histology on pleural biopsy specimens. Hereby, we report a case of systemic amyloidosis where we were able to identify amyloid in a pleural effusion specimen sent for cytopathology evaluation. A 59-year-old male with newly diagnosed multiple myeloma and systemic amyloidosis underwent therapeutic thoracentesis. The H&E stained cell block sections revealed a single, less than one millimeter focus of waxy material surrounded by a rim of reactive mesothelial cells suspicious for amyloid deposit in a background of fibrin, lymphocytes, and reactive mesothelial cells. The focus stained salmon pink with Congo-red special stain and showed apple-green birefringence under polarized light. Our finding suggests that pleural involvement in patients with systemic amyloidosis can be identified on effusion specimens and avert the need for more invasive procedures like pleural or pulmonary parenchymal biopsies.
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Affiliation(s)
- Rashmi Manur
- Department of Pathology and Laboratory Medicine, Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ihab Lamzabi
- Department of Pathology and Laboratory Medicine, Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Nakano T, Endo S, Tetsuka K, Fukushima N. Asymptomatic localized pleural amyloidosis mimicking malignant pleural mesothelioma: report of a case. J Thorac Dis 2016; 8:E157-60. [PMID: 26904248 DOI: 10.3978/j.issn.2072-1439.2016.01.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
We herein report an asymptomatic 65-year-old male with localized pleural amyloidosis mimicking malignant pleural mesothelioma. He had a history of exposure to asbestos and was admitted for investigation of an abnormal pleural thickness detected by chest radiography. Positron emission tomography showed elevation of standardized uptake value corresponding to the pleural thickness. Partial pleurectomy including the tumor was performed for the purpose of diagnosis and local disease control. The pathological examination showed that the tumor was pleural amyloidosis. The tumor was diagnosed as localized primary amyloidosis, because serum monoclonal protein concentration did not increase. Pleural amyloidosis should be considered as a differential diagnosis from pleural mesothelioma.
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Affiliation(s)
- Tomoyuki Nakano
- 1 Departments of General Thoracic Surgery, 2 Departments of Pathology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Shunsuke Endo
- 1 Departments of General Thoracic Surgery, 2 Departments of Pathology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Kenji Tetsuka
- 1 Departments of General Thoracic Surgery, 2 Departments of Pathology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Noriyoshi Fukushima
- 1 Departments of General Thoracic Surgery, 2 Departments of Pathology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
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Localized pleural amyloidosis: report of a case. Surg Today 2012; 42:597-600. [DOI: 10.1007/s00595-012-0122-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/05/2011] [Indexed: 11/26/2022]
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Rafii R, Leslie K, Heo J, Chan A. A 71-year-old woman with an unusual cause for pleural effusions. Chest 2011; 139:1237-1241. [PMID: 21540222 DOI: 10.1378/chest.10-1375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Rokhsara Rafii
- Division of Pulmonary, Critical Care, and Sleep Medicine, Sacramento, CA; VA Northern California Health System, Mather, CA.
| | - Kevin Leslie
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Joline Heo
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Andrew Chan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Sacramento, CA; VA Northern California Health System, Mather, CA
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Araoka T, Takeoka H, Nishioka K, Ikeda M, Kondo M, Hoshina A, Kishi S, Araki M, Mimura R, Murakami T, Mima A, Nagai K, Abe H, Doi T. Successful management of refractory pleural effusion due to systemic immunoglobulin light chain amyloidosis by vincristine adriamycin dexamethasone chemotherapy: a case report. J Med Case Rep 2010; 4:322. [PMID: 20955545 PMCID: PMC2967566 DOI: 10.1186/1752-1947-4-322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 10/18/2010] [Indexed: 11/17/2022] Open
Abstract
Introduction Refractory pleural effusion in systemic immunoglobulin light chain amyloidosis without cardiac decompensation is rarely reported and has a poor prognosis in general (a median survival of 1.6 months). Moreover, the optimum treatment for this condition is still undecided. This is the first report on the successful use of vincristine, adriamycin and dexamethasone chemotherapy for refractory pleural effusion due to systemic immunoglobulin light chain amyloidosis without cardiac decompensation. Case presentation We report the case of a 68-year old Japanese male with systemic immunoglobulin light chain amyloidosis presenting with bilateral pleural effusion (more severe on the right side) in the absence of cardiac decompensation that was refractory to diuretic therapy. The patient was admitted for fatigue, exertional dyspnea, and bilateral lower extremity edema. He had been receiving intermittent melphalan and prednisone chemotherapy for seven years. One month before admission, his dyspnea had got worse, and his chest radiograph showed bilateral pleural effusion; the pleural effusion was ascertained to be a transudate. The conventionally used therapeutic measures, including diuretics and thoracocentesis, failed to control pleural effusion. Administration of vincristine, adriamycin, and dexamethasone chemotherapy led to successful resolution of the effusion. Conclusion Treatment with vincristine, adriamycin, and dexamethasone chemotherapy was effective for the refractory pleural effusion in systemic immunoglobulin light chain amyloidosis without cardiac decompensation and appears to be associated with improvement in our patient's prognosis.
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Affiliation(s)
- Toshikazu Araoka
- Division of Nephrology, Hyogo Prefectural Amagasaki Hospital, Hyogo, Japan.
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Abstract
Persistent pleural effusions are not common in patients with primary systemic amyloidosis (AL). A recent review of this complication of the disease hypothesized that the pathophysiology of these effusions is pleural amyloid deposition, disrupting lymphatic drainage. We report the case of a 73-year-old woman with primary systemic AL and persistent bilateral pleural effusions, refractory to diuresis and repeated thoracenteses. The patient's cardiac and renal dysfunction was not severe enough to explain these persistent effusions. Thus, despite a lack of biopsy-proven amyloid deposition, we suggest that these effusions may be secondary to pleural amyloid deposition.
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Affiliation(s)
- Dan Schwarz
- Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
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10
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Abstract
PURPOSE OF REVIEW Large, recurrent pleural effusions in systemic amyloidoses are rare but clinically challenging events predominantly affecting patients with primary systemic amyloidosis. Examining the mechanisms by which these effusions form and persist offers perspective on the pathophysiology and basis for therapeutic interventions. RECENT FINDINGS Between 1977 and 2003, the literature consisted of approximately 21-25 case reports on pleural effusions in systemic amyloidosis. In 2003, Boston University published a retrospective single-center analysis of 35 primary systemic amyloidosis patients with large, refractory pleural effusions. To define the role of cardiomyopathy in large, refractory pleural effusions, the Boston University Amyloid Program compared demographics, pleural fluid chemistries, echocardiographic indices, and renal function measures of the pleural effusion group with data from 120 primary systemic amyloidosis cardiomyopathy patients with no pleural effusions. Neither cardiomyopathy nor nephrotic syndrome explained pleural effusions in primary systemic amyloidosis patients. The large number of exudative effusions supported primary disruption of the pleural surface and its function by amyloid. Disease mechanisms, natural history, and management options are discussed here. SUMMARY Large pleural effusions in systemic amyloidosis occur most often in primary systemic amyloidosis, predominantly resulting from direct infiltration of the parietal pleural surface. Left atrial hypertension from primary systemic amyloidosis cardiomyopathy contributes to but is not sufficient to form and sustain these effusions. Untreated patients have a median survival of 1.6 months. Secondary, familial, and senile systemic amyloidosis do not infiltrate the pleural surfaces or induce pleural effusions in a clinically significant fashion.
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Affiliation(s)
- John L Berk
- The Pulmonary and Amyloid Treatment and Research Program, Department of Medicine, Boston University School of Medicine, Massachusetts 02118-2526, USA.
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Roux CH, Breuil V, Brocq O, Euller-Ziegler L. Pleural amyloidosis as the first sign of IgD multiple myeloma. Clin Rheumatol 2004; 24:294-5. [PMID: 15940563 DOI: 10.1007/s10067-004-1030-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2004] [Accepted: 08/23/2004] [Indexed: 10/26/2022]
Abstract
We describe a case of IgD myeloma with amyloid and plasmocytic pleural localisations. At the onset of the disease it mimicked rheumatoid arthritis, which can be the first presentation of both AL amyloidosis and multiple myeloma. Pleural effusion can happen first in IgD myeloma, but our observation is of interest in that it confirms the very rare possibility of pleural amyloid and plasmocytic localisations devoid of pleural effusion.
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Affiliation(s)
- Christian Hubert Roux
- Service de Rhumatologie du Professeur L. Euller-Ziegler, CHU Archet I de Nice, Hopital l'Archet 1, BP 3079 06202, Nice cedex 3, France.
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Abstract
Nearly all hematologic malignancies can occasionally present with or develop pleural effusions during the clinical course of disease. Among the most common disorders are Hodgkin and non-Hodgkin lymphomas, with a frequency of 20 to 30%, especially if mediastinal involvement is present. Acute and chronic leukemias, myelodysplastic syndromes, are rarely accompanied by pleural involvement. Furthermore, 10 to 30% of patients receiving bone marrow transplantation develop pleural effusions. In cases of hematologic pleural effusions, drug toxicity, underlying infectious, secondary malignant or rarely autoimmune causes should be carefully sought. In most cases, the pleural fluid responds to treatment of the primary disease, whereas resistant or relapsing cases may necessitate pleurodesis.
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Affiliation(s)
- Michael G Alexandrakis
- Department of Hematology, University Hospital of Heraklion, and Medical School, University of Crete, Greece
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Berk JL, Keane J, Seldin DC, Sanchorawala V, Koyama J, Dember LM, Falk RH. Persistent pleural effusions in primary systemic amyloidosis: etiology and prognosis. Chest 2003; 124:969-77. [PMID: 12970025 DOI: 10.1378/chest.124.3.969] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Restrictive cardiomyopathy frequently complicates primary systemic amyloidosis (AL), yet only a small number of these patients develop large pleural effusions refractory to diuretic therapy and thoracentesis. We hypothesized that disruption of pleural function by amyloid deposits underlies persistent pleural effusions (PPEs) in patients with AL disease. METHODS We performed a retrospective study of AL patients with and without PPEs who had been referred to Boston University between 1994 and 2001. The presence of PPEs was defined by a failure to resolve the condition with thoracentesis and aggressive diuresis. AL cardiomyopathy patients without pleural effusions constituted the control (cardiac) group. Indexes of plasma cell dyscrasia, nephrotic syndrome, thyroid function, and echocardiographic measures of left and right ventricle performance were compared between groups. When available, closed needle biopsies and autopsy specimens of parietal pleura were examined for amyloid deposits. RESULTS Among 636 patients with AL, 35 PPE patients underwent a median of three thoracenteses each. No statistical differences were found between the PPE and cardiac groups in echocardiographic measures of septal thickness, left ventricular systolic function, or diastolic compliance. Right ventricular (RV) hypokinesis occurred more often in PPE patients; however, nearly half of this group had normal RV systolic function. Renal function, plasma protein levels, and thyroid function were the same between groups. Nephrotic range proteinuria (ie, > 3 g/d) was more prevalent in the cardiac group than in the PPE group (44% vs 26%, respectively; p = 0.057). All pleural biopsies in the PPE group (six biopsies) revealed amyloid deposits. Autopsy samples of parietal pleura were negative for disease in two cardiac patients. Eighteen patients had chest tubes placed, and 11 underwent pleurodesis. PPE signaled limited survival among patients who were ineligible for treatment. Untreated PPE patients lived a median 1.8 months vs 6 months for untreated cardiac patients (p = 0.031). Survival after intensive chemotherapy and autologous stem cell transplantation was comparable in the PPE and cardiac groups (21.8 vs 15.6 months, respectively; p = 0.405). CONCLUSION In AL patients with cardiac amyloid, neither echocardiographic measures of ventricular function nor the degree of nephrosis distinguished those patients with PPEs. We conclude that pleural amyloid infiltration plays a central role in the creation and persistence of pleural effusions among patients with AL.
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Affiliation(s)
- John L Berk
- Amyloid Treatment and Research Program, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
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