Amyloid localized to tenosynovium at carpal tunnel release. Natural history of 124 cases

A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release

PURPOSE

Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR.

METHODS

We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases.

RESULTS

A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%).

CONCLUSIONS

Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Evaluation of peripheral nerve involvements in patients with familial Mediterranean fever

Objectives

The aim of this study was to evaluate possible peripheral and autonomic nerve involvement in familial Mediterranean fever (FMF) patients with nerve conduction studies, sympathetic skin response (SSR) and RR interval variability (RRIV).

Patients and methods

The comparative case series was conducted with 76 participants between November 2017 and December 2018. Forty-six FMF patients, [12 with amyloidosis (5 males, 7 females; mean age: 44.7±13.9 years) and 34 without amyloidosis (14 males, 20 females; mean age: 35.9±8.7 years)], and 30 healthy volunteers (11 males, 19 females; mean age: 38.4±10 years) were included in this study. Nerve conduction parameters, SSR latency and amplitude from palmar and plantar responses, and RRIV at rest and deep breathing were studied in all the subjects. Neuropathic symptoms of the patient group were evaluated using the survey of autonomic symptoms scale and the neuropathy disability score.

Results

Nerve conduction studies of the patient group revealed polyneuropathy in seven (15.21%) patients and carpal tunnel syndrome in six (13.04%) patients. The mean amplitudes of SSR measured from the soles were significantly lower than the control group (p=0.041). The mean values of RRIV during rest and hyperventilation were lower in the patient group compared to the control group, but no statistically significant difference was found (p=0.484, p=0.341).

Conclusion

We detected that the prevalence of carpal tunnel syndrome in our patient population (13.04%) was higher than in the general population. Most of the changes in the range of parameters of SSR and RRIV determined in the patient group did not reach statistical significance, suggesting subclinical dysautonomia in FMF patients.

Results of Implementation of Amyloidosis Screening for Patients Undergoing Carpal Tunnel Release

PURPOSE

Many patients with amyloidosis undergo carpal tunnel release (CTR) before amyloidosis diagnosis and before developing cardiac or other serious disease manifestations. The purposes of this study were to examine if our patient population had a similar prevalence of positive amyloidosis diagnoses to that in prior studies and to describe the results of implementing a screening program for amyloidosis.

METHODS

We retrospectively reviewed the biopsy results and subsequent interventions for all patients who underwent screening tenosynovial biopsy during CTR from March 2020 through December 2021. Amyloid screening was offered to patients who met the criteria for increased risk of disease using an appropriateness screening algorithm.

RESULTS

Seventy-five (48%) of 156 patients who underwent CTR met the eligibility criteria for amyloidosis testing. Of the 62 patients who agreed to undergo tenosynovial biopsy, 14 had amyloid-positive biopsy specimens (10 men and 4 women). All patients with positive tenosynovial biopsies had bilateral carpal tunnel syndrome and wild-type transthyretin amyloid subtype. One patient was diagnosed and started treatment for otherwise asymptomatic cardiac amyloidosis.

CONCLUSIONS

The incidence of amyloid-positive tenosynovial biopsy results from CTR was 22.5% in patients using the criteria from an appropriateness screening algorithm, which was higher than previously reported. Implementation of a screening program for patients undergoing CTR requires a multidisciplinary approach and may result in early diagnosis and lifesaving interventions for patients with amyloidosis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Differential diagnosis/symptom prevalence study, II.

Association between spinal stenosis and wild-type ATTR amyloidosis

Age-related cardiac amyloidosis results from deposits of wild-type tranthyretin amyloid (ATTRwt) in cardiac tissue. ATTR may play a role in carpal tunnel syndrome (CTS) and in spinal stenosis (SS), indicating or presaging systemic amyloidosis. We investigated consecutive patients undergoing surgery for SS for ATTR deposition in the resected ligamentum flavum (LF) and concomitant risk of cardiac amyloidosis. Each surgical specimen (LF) was stained with Congo red, and if positive, the amyloid deposits were typed by mass spectrometry. Patients with positive specimens underwent standard of care evaluation with fat pad aspirates, serum and urine protein electrophoresis with immunofixation, free light-chain assay, TTR gene sequencing and technetium 99 m-pyrophosphate-scintigraphy. In 2018-2019, 324 patients underwent surgery for SS and 43 patients (13%) had ATTR in the LF with wild-type TTR gene sequences. Two cases of ATTRwt cardiac amyloidosis were diagnosed and received treatment. In this large series, ATTRwt was identified in 13% of the patients undergoing laminectomy for SS. Patients with amyloid in the ligamentum flavum were older and had a higher prevalence of CTS, suggesting a systemic form of ATTR amyloidosis involving connective tissue. Further prospective study of patients with SS at risk for systemic amyloidosis is warranted.

Musculoskeletal pathology as an early warning sign of systemic amyloidosis: a systematic review of amyloid deposition and orthopedic surgery

BACKGROUND

Transthyretin and immunoglobulin light-chain amyloidoses cause amyloid deposition throughout various organ systems. Recent evidence suggests that soft tissue amyloid deposits may lead to orthopedic conditions before cardiac manifestations occur. Pharmacologic treatments reduce further amyloid deposits in these patients. Thus, early diagnosis improves long term survival.

QUESTIONS/PURPOSES

The primary purpose of this systematic review was to characterize the association between amyloid deposition and musculoskeletal pathology in patients with common orthopedic conditions. A secondary purpose was to determine the relationship between amyloid positive biopsy in musculoskeletal tissue and the eventual diagnosis of systemic amyloidosis.

METHODS

We performed a systematic review using PRISMA guidelines. Inclusion criteria were level I-IV evidence articles that analyzed light-chain or transthyretin amyloid deposits in common orthopedic surgeries. Study methodological quality, risk of bias, and recommendation strength were assessed using MINORS, ROBINS-I, and SORT.

RESULTS

This systematic review included 24 studies for final analysis (3606 subjects). Amyloid deposition was reported in five musculoskeletal pathologies, including carpal tunnel syndrome (transverse carpal ligament and flexor tenosynovium), hip and knee osteoarthritis (synovium and articular cartilage), lumbar spinal stenosis (ligamentum flavum), and rotator cuff tears (tendon). A majority of studies reported a mean age greater than 70 for patients with TTR or AL positive amyloid.

CONCLUSIONS

This systematic review has shown the presence of amyloid deposition detected at the time of common orthopedic surgeries, especially in patients ≥70 years old. Subtyping of the amyloid has been shown to enable diagnosis of systemic light-chain or transthyretin amyloidosis prior to cardiac manifestations.

LEVEL OF EVIDENCE

Level IV.

Light chain and transthyretin cardiac amyloidosis: Clinical characteristics, natural history and prognostic factors

INTRODUCTION AND OBJECTIVES

Light-chain amyloidosis (AL-CA) and transthyretin amyloidosis (ATTR-CA) are the most common types of cardiac amyloidosis (CA). We sought to study the clinical characteristics and prognosis of both diseases.

METHODS

We conducted a single-centre, retrospective review of all patients diagnosed with CA between 1998 and 2018. Clinical characteristics, complementary tests, survival and other adverse clinical events were studied.

RESULTS

We identified 105 patients with CA, 65 ATTR-CA and 40 AL-CA. Mean age was 74.4 years; 24.8% were women. In both groups, heart failure was the most frequent clinical presentation (55.2%). The most prevalent electrocardiographic findings were the pseudoinfarct pattern (68.5%) and a Sokolow-Lyon index < 1.5 mV (67.7%), with no differences between the two subtypes of CA. One-year, 3-year, and 5-year survival was 43.3%, 40.4% and 35.4%, respectively, in AC-AL patients, and 85.1%, 57.3% and 31.4% in AC-ATTR patients (p = 0.004). AL-CA subtype (HR 3.41; 95% CI 1.45-8.06; p = 0.005), previous admission for heart failure (HR 4.25; 95% CI 1.63-11.09; p = 0.003) and a NYHA class III-IV (HR 2.76; 95% CI; 1.09-7.03; p = 0.033) were independent predictors of mortality, while beta-blocker therapy was associated with longer survival (HR 0.23; 95% CI 0.09-0.59; p = 0.002).

CONCLUSIONS

Differences exist between the clinical presentation of AL-CA and ATTR-CA patients. Both diseases, particularly AL-CA, are associated with poor life prognosis.

Acute Carpal Tunnel Syndrome Secondary to Amyloidosis

Introduction

ACTS secondary to amyloidosis is a very rare situation in the literature, and here, we present a unique case of ACTS secondary to amyloidosis.

Case Report

A 61-year-old male patient was admitted to our hospital with complaints of numbness in the lateral half of his 1, 2, 3, and 4 fingers of his right hand. These complaints started acutely, and the patient did not have a history of trauma. His clinical examination was suitable for acute carpal tunnel syndrome.

Discussion

Carpal tunnel syndrome, as well as acute carpal tunnel syndrome, may occur based on different causes. ACTS is very rare, especially when it is not caused by a trauma. Here, we presented a unique case of ACTS based on amyloidosis.

Conclusion

It should be kept in mind when ACTS may occur in patients with the diagnosis of amyloidosis.

Carpal Tunnel Syndrome: A Potential Early, Red-Flag Sign of Amyloidosis

Carpal tunnel syndrome (CTS) can be caused by the deposition and accumulation of misfolded proteins called amyloid and is often an early manifestation of systemic amyloidosis. In patients undergoing surgery for idiopathic CTS, a recent study identified amyloidosis by tenosynovial biopsy in 10.2% of men older than 50 years and women older than 60 years; all positive patients had bilateral symptoms. These findings have led to a renewed interest in amyloidosis as an etiology of CTS. The 2 most common systemic amyloidoses, immunoglobulin light chain and transthyretin amyloidosis, affect the heart, nerves, and other organ systems throughout the body including the soft tissues. Patients with cardiac involvement of amyloidosis have an especially poor prognosis if the disease remains unrecognized and untreated. Early diagnosis is paramount, and patients classically present with cardiac disease several years after being operated on by a hand surgeon for carpal tunnel release. Herein, we present a review of amyloidosis as it pertains to CTS and an algorithm for the detection of amyloidosis in patients undergoing carpal tunnel release. Implementation of this straightforward algorithm will allow for early diagnosis of amyloidosis, a group of progressive and lethal diseases.

Tenosynovial and Cardiac Amyloidosis in Patients Undergoing Carpal Tunnel Release

BACKGROUND

Patients with cardiac amyloidosis often have carpal tunnel syndrome that precedes cardiac manifestations by several years. However, the prevalence of cardiac involvement at the time of carpal tunnel surgery has not been established.

OBJECTIVES

The authors sought to identify the prevalence and type of amyloid deposits in patients undergoing carpal tunnel surgery and evaluate for cardiac involvement. The authors also sought to determine if patients with soft tissue transthyretin (TTR) amyloid had abnormal TTR tetramer kinetic stability.

METHODS

This was a prospective, cross-sectional, multidisciplinary study of consecutive men age ≥50 years and women ≥60 years undergoing carpal tunnel release surgery. Biopsy specimens of tenosynovial tissue were obtained and stained with Congo red; those with confirmed amyloid deposits were typed with mass spectrometry and further evaluated for cardiac involvement with biomarkers, electrocardiography, echocardiography with longitudinal strain, and technetium pyrophosphate scintigraphy. Additionally, serum TTR concentration and tetramer kinetic stability were examined.

RESULTS

Of 98 patients enrolled (median age 68 years, 51% male), 10 (10.2%) had a positive biopsy for amyloid (7 ATTR, 2 light chain [AL], 1 untyped). Two patients were diagnosed with hereditary ATTR (Leu58His and Ala81Thr), 2 were found to have cardiac involvement (1 AL, 1 ATTR wild-type), and 3 were initiated on therapy. In those patients who had biopsy-diagnosed ATTR, there was no difference in plasma TTR concentration or tetramer kinetic stability.

CONCLUSIONS

In a cohort of patients undergoing carpal tunnel release surgery, Congo red staining of tenosynovial tissue detected amyloid deposits in 10.2% of patients. Concomitant cardiac evaluation identified patients with involvement of the myocardium, allowing for implementation of disease-modifying therapy. (Carpal Tunnel Syndrome and Amyloid Cardiomyopathy; NCT02792790).

Carpal tunnel syndrome and associated symptoms as first manifestation of hATTR amyloidosis

Background

Hereditary transthyretin amyloidosis (hATTR) is associated with significant morbidity and mortality. Early diagnosis and treatment are essential to improve patient's outcome. Carpal tunnel syndrome (CTS) is a common complication of hATTR amyloidosis. However, because CTS is also common in the general population, we wanted to assess whether CTS, when associated with systemic manifestations, could help direct physicians to screen for TTR gene mutation and early diagnosis.

Methods

We reviewed the charts and interviewed the patients with hATTR seen between 2017 and 2018. We noted the details of CTS diagnosis, treatment, and other systemic features of the disease.

Results

Seventeen of the 23 patients studied had CTS. CTS was the first manifestation of the disease in 10 of 17 patients. On average, CTS symptoms occurred 10.4 years before their diagnosis of hATTR amyloidosis. In 6 of 10 patients with CTS, the following systemic symptoms were present as the first manifestation: erectile dysfunction, dysautonomia, polyneuropathy, exercise intolerance, and gastrointestinal and ocular symptoms.

Conclusion

CTS occurs in most patients with hATTR amyloidosis and frequently precedes the hATTR diagnosis. Most patients with CTS preceding hATTR diagnosis have systemic features. Recognizing systemic features at the time of CTS presentation may help in early diagnosis of hATTR amyloidosis.

The Austrian Flag - Severe Carpal Tunnel Syndrome: A Case Report

In severe carpal tunnel syndrome a continuum of neural changes takes place depending on the degree and duration of the compression, beginning with breakdown of the blood-nerve barrier, followed by endoneurial oedema and, subsequently, perineurial thickening and ischemia. Persisting chronic compression will eventually result in axonal degeneration. We report a case of longstanding carpal tunnel syndrome with amyloid deposits and the unusual intraoperative 'Austrian flag' sign.

Localised foot and ankle amyloid deposition

BACKGROUND

Localised (transthyretin-associated) amyloid is commonly seen in articular/periarticular tissues of elderly individuals. Whether age-associated, amyloid deposition occurs in foot and ankle (F&A) tissues has not previously been investigated. In this study we assessed the nature and frequency of F&A amyloid deposition and determined whether it is associated with age and/or specific articular/periarticular F&A lesions.

METHODS

Histological sections of twenty five normal F&A articular/periarticular tissues (16-71 years) and a range of F&A lesions were stained by Congo Red. The amyloid protein was identified by immunohistochemistry and type of matrix glycosaminoglycans determined by Alcian Blue (critical electrolyte concentration) histochemistry.

RESULTS

Amyloid deposits were found in the joint cartilage and capsule of 3/25 normal specimens (57, 62 and 78 years). Amyloid deposits were small, contained transthyretin, and found in areas of matrix degeneration associated with the presence of highly sulphated glycosaminoglycans. In patients older than 47 years, small amyloid deposits were noted in some F&A lesions, including osteoarthritis, Charcot arthropathy, bursa, ganglion, chondrocalcinosis, gout, calcific tendonitis and Achilles tendonitis.

CONCLUSION

Small localised amyloid deposits in F&A tissues contain transthyretin and occur in areas of matrix degeneration associated with the presence of highly sulphated glycosaminoglycans; these deposits are age-associated and, although seen more commonly in some F&A lesions, are small and unlikely to be of pathogenic significance.

Carpal Tunnel Syndrome and Trigger Wrist Caused by Localized Amyloidosis: A Case Report

We report a case of carpal tunnel syndrome and trigger wrist caused by localized amyloidosis. A 37-year-old man, who worked as a manufacturer, presented with a 5-month history of tingling sensation in the three radial fingers of the left hand and a painful click at the volar aspect of the wrist during digital motion. We divided the transverse carpal ligament and detected diffuse tenosynovitis that was especially severe around the flexor digitorum profundus tendons. Histological findings led to a diagnosis of amyloidosis. Localized amyloidosis could thus be a cause of trigger wrist. Systemic amyloidosis may develop in patients with localized amyloidosis; therefore, patients with trigger wrist caused by flexor tenosynovitis should be investigated for the existence of localized amyloidosis, with biopsy of the flexor tenosynovium.

Early diagnosis of systemic amyloidosis by means of a transverse carpal ligament biopsy carried out during carpal tunnel syndrome surgery

INTRODUCTION AND OBJECTIVE

The systematic analysis of a carpal transverse ligament (CTL) sample obtained during routine carpal tunnel syndrome (CTS) surgery may constitute a method of early diagnosis for systemic amyloidosis.

MATERIAL AND METHODS

Prospective study carried out on 147 consecutive CTL samples collected from patients intervened for CTS at the University Hospital of León from April 2006 to May 2007. In those cases in which amyloid deposition was observed in the CTL sample, the study was completed with a fine needle aspiration biopsy (FNAB) of the subcutaneous fascia, using the Red Congo stain in both cases. Positive cases were referred to the Internal Medicine and/or Hematology departments, and their evolution was monitored for up to 8 years.

RESULTS

CTL amyloid deposition was observed in 29 patients (19.7%), with a FNAB only being performed in 19 of them (65.5%). The test was positive in 11 cases (57.9%), and 4 patients in this subgroup (3% of the total) developed events attributable to amyloidosis over the following 3 years.

CONCLUSIONS

A CTL routine biopsy carried out during CTS surgery may anticipate the systemic amyloidosis diagnosis.

Effect of synovial transthyretin amyloid deposition on preoperative symptoms and postoperative recovery of median nerve function among patients with idiopathic carpal tunnel syndrome

BACKGROUND

The clinical characteristics of wild-type transthyretin amyloid deposition among patients with carpal tunnel syndrome (CTS) have not been well investigated.

METHODS

One-hundred and seven patients with idiopathic CTS who underwent carpal tunnel release were enrolled. They underwent physical examination of the hand, nerve-conduction study, and magnetic resonance imaging (MRI) study of the wrist, and completed a patient-oriented questionnaire. The tests, except for MRI, were repeated 1, 3, and 6 months postoperatively. Synovial tissue was obtained during surgery and analyzed by Congo red and immunohistochemical staining. Ordinal logistic regression analysis was used to evaluate the significance of different clinical and subjective findings between patients with and without amyloid deposition. Postoperative improvements were also compared.

RESULTS

Wild-type transthyretin amyloid deposition was observed for 38 patients. Greater symptom severity and 2-point discrimination scores, and larger cross-sectional areas of the carpal tunnel, were significantly correlated with a larger amount of preoperative amyloid deposition. However, the presence and amount of preoperative amyloid deposition did not affect postoperative improvements in physical findings and nerve-conduction studies.

CONCLUSIONS

Although transthyretin amyloid deposition can worsen CTS symptoms, postoperative improvements were similar for patients with and without this deposition.

Transthyretin-derived amyloidosis: probably a common cause of lumbar spinal stenosis

BACKGROUND

Senile systemic amyloidosis (SSA) derived from wild-type transthyretin is a fairly common condition of old individuals, particularly men. The main presentation is by cardiac involvement, which can lead to severe restrictive cardiomyopathy. SSA is, however, a systemic disease, and amyloid deposits may appear in many other tissues but are thought to be without clinical symptoms outside the heart. Amyloid is a very common finding in cartilage and ligaments of elderly subjects, and transthyretin has been demonstrated in some deposits. Lumbar spinal stenosis is also a condition of usually elderly individuals in whom narrowing of the lumbar spinal canal leads to compression of nerves to the lower limbs.

RESULTS

We questioned whether lumbar spinal stenosis sometimes could be a manifestation of undiagnosed SSA. In this first report we have studied the presence of amyloid in material obtained at surgery for spinal stenosis in 26 patients. Amyloid was found in 25 subjects. Transthyretin was demonstrated immunohistochemically in 5 out of 15 studied resected tissues. Four of the positive materials were analyzed with Western blot revealing both full-length transthyretin (TTR) and C-terminal TTR fragments, typically seen in SSA.

CONCLUSION

We conclude that lumbar spinal stenosis quite frequently may be a consequence of SSA and that further studies are warranted.

Synovial deposition of wild-type transthyretin-derived amyloid in knee joint osteoarthritis patients

OBJECTIVE

To investigate histological features of deposited amyloid in the synovial tissue and its clinical significance in knee joint osteoarthritis (OA) patients.

METHODS

We prospectively enrolled 232 consecutive patients who underwent arthroplasty or total replacement of the knee joint for treatment of OA. Congo red staining and immunohistochemistry were performed in the synovial tissue obtained at surgery. When transthyretin (TTR)-derived amyloid was positive, we analyzed all 4 exons of the TTR gene using the direct DNA sequencing method in order to detect mutations.

RESULTS

We analyzed 322 specimens in this study. Twenty-six specimens (8.1%) obtained from 21 patients (5 men and 16 women; mean, 79.0 ± 4.6 years) showed deposition of amyloid, which was positively stained with the anti-TTR antibody. Eighteen patients showed inhomogeneous accumulations of amyloid in the loose connective tissue under the synovial epithelia sometimes with nodule formation, while in the remaining three, small vessels in the adipose tissue were involved. Medical records of these patients revealed nothing remarkable in the clinical course, laboratory data or macroscopic intraarticular findings at surgery. No mutations were detectable in the TTR gene analysis.

CONCLUSION

Wild-type TTR-derived amyloid may affect the synovial tissue as a result of long-term mechanical stress or as a part of senile systemic amyloidosis in approximately 8% of knee joint OA patients. No obvious clinical significance was found in synovial deposition of amyloid.

Diagnosis of familial amyloid polyneuropathy: wide-ranged clinicopathological features

IMPORTANCE OF THE FIELD

Owing to the recent development of biochemical and molecular analyses, familial amyloid polyneuropathy (FAP) is not considered to be as rare as was previously thought. Transthyretin (TTR) Val30Met-associated FAP (FAP ATTR Val30Met) is the most common form of FAP. Although patients with FAP ATTR Val30Met had been considered to be concentrated in geographically restricted areas of Japan, Portugal and Sweden, a late-onset form of this type of FAP was discovered in non-endemic areas and revealed to be widely distributed throughout the world. Therefore, there is an increasing necessity to characterize the variability in the clinical, electrophysiological and histopathological features of this disease.

AREAS COVERED IN THIS REVIEW

Recent progress in the diagnostic techniques for FAP is described, focusing especially on those for FAP ATTR Val30Met. Clinical, electrophysiological and histopathological features in early-onset FAP ATTR Val30Met cases from endemic foci and those in late-onset cases from non-endemic areas in Japan are comparatively described.

WHAT THE READER WILL GAIN

Patients with FAP ATTR Val30Met from endemic foci and those from non-endemic areas show different clinical, electrophysiological and histopathological features. As compared with the classic FAP phenotype, the clinicopathological features of patients from the non-endemic areas tend to be nonspecific.

TAKE HOME MESSAGE

Awareness of the possibility of sporadic late-onset FAP ATTR Val30Met is needed at the time of the initial clinical and electrophysiological evaluation of neuropathy with an undetermined etiology to avoid a missed diagnosis.

High prevalence of wild-type transthyretin deposition in patients with idiopathic carpal tunnel syndrome: a common cause of carpal tunnel syndrome in the elderly

Carpal tunnel syndrome is the most common type of entrapment neuropathy. However, the cause of carpal tunnel syndrome remains unclear in most cases. Senile systemic amyloidosis, induced by wild-type transthyretin deposition, is a prevalent aging-related disorder and often accompanied by carpal tunnel syndrome. In this study, we measured the frequency of unrecognized wild-type transthyretin deposition in patients with idiopathic carpal tunnel syndrome. One hundred twenty-three patients with carpal tunnel syndrome, including 100 idiopathic patients, treated by carpal tunnel release surgery were analyzed. Tenosynovial tissues obtained at surgery were analyzed by Congo red and immunohistochemical staining. If staining for transthyretin was positive, the entire transthyretin gene was analyzed by direct DNA sequencing. We also analyzed tenosynovial tissues from 32 autopsy cases as controls. Thirty-four patients (34.0%) with idiopathic carpal tunnel syndrome showed amyloid deposition in the tenosynovial tissue, and all amyloid showed specific immunolabeling with antitransthyretin antibody. Direct DNA sequencing of the entire transthyretin gene did not reveal any mutations, indicating that all amyloid deposits were derived form wild-type transthyretin. Statistical analysis using logistic regression showed that the prevalence of transthyretin deposition in the idiopathic carpal tunnel syndrome group was significantly higher than that in controls (odds ratio, 15.8; 95% confidence interval, 3.3-5.7), and age and male sex were independent risk factors for transthyretin amyloid deposition. Our results demonstrate that wild-type transthyretin deposition is a common cause of carpal tunnel syndrome in elderly men. It is likely that many patients develop carpal tunnel syndrome as an initial symptom of senile systemic amyloidosis.

[Diagnostic pitfalls in carpal tunnel syndrome]

BACKGROUND

This review focuses on the main aspects of positive and differential diagnosis of carpal tunnel syndrome (CTS) in different clinical situations encountered in daily practice.

STATE OF THE ART

Authentic CTS can be discovered in situations, which alter the usual presentation or therapeutic management. This is the case for instance in pregnant women or in the elderly subject or with acute motor forms where CTS discloses a focal intratunnel disorder (neuroma, lipoma, arterial condition, bone disorder) or a general disease (hereditary neuropathy, amylosis). In certain situations, the clinical manifestations suggest a more proximal compression of the medial nerve (round pronator, Struthers arcade, or superficial flexor) or an inflammatory condition (mononeuritis, inflammatory demyelinising neuropathy). Locoregional disease may also be involved, for instance a plexus (thoracobrachial outlet syndrome, post-radiation plexitis) or radicular condition. The clinical presentation of diffuse polyneuropathy with initial manifestations involving the upper limb (ganglioneuropathies, polyradiculoneuritis, small-fiber neuropathies) may also be misleading. Finally central conditions can sometimes be confused with CTS.

CONCLUSION

A rigorous physical examination and an electroneuromyogram are determining to avoid diagnostic pitfalls.

Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation

The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.

The significance of carpal tunnel syndrome in transthyretin Val30Met familial amyloid polyneuropathy

Carpal tunnel syndrome (CTS) is frequently reported in association with amyloidosis. We determined the significance of CTS in transthyretin Val30Met-associated familial amyloid polyneuropathy (FAP ATTR Val30Met) by comparing the electrophysiological indices of the median and ulnar nerves in 58 patients. As a whole, sensory nerve conduction velocity (SCV) was slowed and distal motor latency (DML) was prolonged to a similar extent in the median and ulnar nerves in these patients. The extent of abnormalities in the median nerve was almost similar to that in the ulnar nerve in both early-onset cases from endemic foci and late-onset cases from non-endemic areas. In age-matched idiopathic patients with CTS (20 patients, 27 hands), the slowing of SCV and the prolongation of DML in the median nerve were significant, while the slowing of motor conduction velocity was much less compared to FAP ATTR Val30Met patients. Although concomitant lesions in the ulnar nerve entrapment site at the wrist cannot be excluded, these findings indicate that CTS is not the sole distinctive feature in the majority of FAP ATTR Val30Met patients. The electrophysiological abnormality at the distal portion of the median nerve may be a consequence of polyneuropathy rather than an entrapment injury.

Soft tissue, joint, and bone manifestations of AL amyloidosis: clinical presentation, molecular features, and survival

OBJECTIVE

To characterize symptoms and signs of AL amyloidosis that may bring patients to the attention of rheumatologists, evaluate Ig V(L) gene usage in this subgroup of patients, and assess the impact of soft tissue and bone involvement and V(L) gene usage on survival.

METHODS

Clinical features of soft tissue and bone involvement were assessed in 191 patients with AL amyloidosis. V(L) gene sequencing was carried out to determine light-chain family, rate of somatic mutation, and evidence of antigen selection. The association of soft tissue and bone involvement with V(L) gene usage was assessed by logistic regression analysis, and survival time was analyzed using log rank tests and Cox regression models.

RESULTS

Soft tissue and bone involvement occurred in 42.9% of the patients, and 9.4% had dominant soft tissue and bone involvement. The most common manifestations were submandibular gland enlargement, macroglossia, and carpal tunnel syndrome. Dominant soft tissue and bone involvement was significantly associated with V(L)kappaI gene usage. Mutation rate and evidence of antigen selection in the V(L) genes were not found to be confounding factors, providing evidence against a contribution of autoimmunity in this type of AL amyloidosis. Survival time was initially longer in patients with dominant soft tissue and bone involvement than in patients with other dominant organ involvement; however, this difference diminished over time.

CONCLUSION

Amyloid infiltration into soft tissue, joints, periarticular structures, and bones can bring patients with AL amyloidosis to the attention of rheumatologists. Recognition of the presenting symptoms is essential for accurate diagnosis and appropriate treatment, since the long-term outlook for untreated patients with dominant soft tissue and bone involvement is not better than that for patients with other dominant features of AL amyloidosis.

Bilateral carpal tunnel syndrome associated to familial Mediterranean fever

A unique case of bilateral severe carpal tunnel syndrome due to familial Mediterranean fever is reported. The syndrome was diagnosed by clinical examination and electrophysiological studies. Bilateral transverse carpal ligaments were released and the biopsy specimens revealed systemic type A amyloidosis. Up to our knowledge, the co-existence of bilateral carpal tunnel syndrome and familial Mediterranean fever has not been reported previously in the literature.

Myélome à chaînes légères révélé par une arthropathie amyloïde. À propos de deux observations

INTRODUCTION

Amyloid arthropathy occurs in 5-15% of patients with multiple myeloma. It is rarely inaugural. Some cases are reported in which the articular manifestations are present many months before the diagnosis of myeloma. We report two unusual cases where the amyloid arthropathy reveals the multiple myeloma.

EXEGESIS

Case 1: A 54-year-old man take medical advice for a polyarthritis evolving for 6 months. He has no evidence of multiple myeloma except a hypercalcemia and a hypoalbuminemia. The diagnosis of multiple myeloma is based on an immunobinding of plasmatic proteins. It is a light chain multiple myeloma, lambda type. Amylosis is revealed by biopsy specimens from the synovial tissue of the knee. The patient died rapidly because of an intestinal hemorrhage. Case 2: A 78-year-old woman complains from a polyarthritis evolving for 4 months. She has besides an elevated erythrocyte sedimentation rate, an anemia and a renal insufficiency, a profound hypogammaglobulinemia. There is no radiological abnormalities. The diagnosis of multiple myeloma is based on serum and urine immunoelectrophoresis. It is a light chain multiple myeloma, lambda type. The patient is at her sixth monthly course of cyclophosphamid and prednisone. As far as amyloid arthropathy is concerned, it is relatively improved by corticoid intra-articular injections.

CONCLUSION

These are two case reports of a light chain multiple myeloma of lambda type, associated to an amyloid arthropathy in its polyarticular presentation, mimicking a rheumatoïd arthritis. The revelatory nature of the amyloid arthropathy is interesting to report.

Atypical presentations of primary amyloid neuropathy

Primary amyloidosis (AL) may be complicated by peripheral neuropathy in 15-35% of cases. We report on four patients with atypical neurological presentations of AL neuropathy, whose diagnoses were delayed due to varied clinical presentations. The clinical presentation included painful sensory neuropathy (two patients), mononeuropathy multiplex (one patient), and primary demyelinating polyneuropathy (one patient). The latter two types of presentation have not been reported previously. The diagnosis was established by fat pad biopsy in two patients, lymph node biopsy in one, and sural nerve biopsy in one. Two patients were treated with high-dose melphalan followed by stem cell rescue, and one was treated with oral melphalan and prednisone. All three cases experienced stabilization of neuropathic symptoms. We report these cases in order to raise awareness of the varied clinical presentation of AL neuropathy.

Congo red-positive cardiac kappa-AL amyloidosis in plasmacytoma -- case report and review of the literature

We report on a 51-year-old female patient who was diagnosed in 2001 as suffering from plasmacytoma. The patient had had complaints of bilateral carpal tunnel syndrome in 1999, treated by a simple dissection without performing histological examination. Congestive heart failure had gradually developed since that time. In 2001 echocardiography revealed a pronounced thickening of the left ventricular wall with systolic and diastolic dysfunction. A kappa-light chain M component and kappa-light chain-restricted bone marrow plasmacytosis were detected. Amyloid deposits staining positive in the kappa-light chain-restriction analysis were observed in a gastric biopsy. Taking into consideration all these findings, a plasmacytoma-associated systemic AL amyloidosis was diagnosed. Cyclophosphamide/prednisolone chemotherapy regimen led to complete haematological remission. Cardiac transplantation, combined with autologous peripheral blood stem cell graft, was considered as the next therapeutic step, but the patient died while on the waiting list for transplantation. Autopsy detected a highly hypertrophic myocardium with narrowed heart cavities. Microscopic examination revealed dense, pink, acellular, Congo red-staining and kappa-immunoperoxidase-positive AL amyloid masses splitting the cardiomyocytes. The present case is remarkable as it demonstrates that carpal tunnel syndrome and congestive heart failure could be symptoms of plasma cell dyscrasia-associated amyloidoses.

Localized AL amyloidosis of the colon: an unrecognized entity

Virtually all patients who present with rectal bleeding and amyloid of the colon have evidence of systemic amyloidosis and require therapy. The small subset of patients with amyloidosis localized to the colon must be recognized and treatment avoided. We queried our file for patients who had amyloidosis of the colon but no evidence of systemic amyloidosis during long-term follow-up. We identified 3 patients who presented with rectal bleeding and who, on investigation, had primary amyloidosis of the colon but no evidence of systemic amyloidosis during a follow-up of 4.5 to 20 years. These patients had no evidence of a plasma cell dyscrasia and received no chemotherapy to prevent deposition of amyloid. It is important to recognize this rare subset and avoid treatment with alkylating agents or high-dose therapy followed by autologous stem cell transplantation. Alkylating agent therapy may be associated with myelodysplasia or acute leukemia. In addition, the cost, inconvenience, and morbidity of therapy are avoided by observation. Patients who present with rectal bleeding and a subsequent diagnosis of amyloidosis of the colon likely will be subjected to chemotherapy or transplantation. Such patients must be recognized and treatment avoided if there is no evidence of systemic amyloidosis because they remain stable for many years.

Localized amyloid deposition in trigger finger

Trigger finger is due to degeneration and thickening of the proximal portion (A1 pulley) of the flexor tendon sheath, which causes constriction of the flexor tendon. This study reports the presence of localized amyloid deposition in the tendon sheath of 11 of 47 cases (23%) of idiopathic primary trigger finger. Amyloid deposits were only found in patients aged over 46 years old and were present around cells and at sites of mucinous and fibrinoid degeneration which contained highly sulphated glycosaminoglycans. The pathogenic significance of these deposits is uncertain but their small size and presence only in middle-aged and elderly adults suggests that they represent a form of age-associated amyloid deposition.

[Clinical or biological symptoms leading to the search for amyloidosis]

INTRODUCTION

The extracellular, multifocal, disseminated or diffuse localization of amyloidosis accounts for the diversity of clinical presentations and late diagnosis.

CURRENT KNOWLEDGE AND KEY POINTS

However, early diagnosis is important, as new drugs have been recently introduced. Both clinical picture and biology help guide diagnosis, including either kidney, heart, skin or neurologic involvement associated with monoclonal gammapathy (primary idiopathic amyloidosis AL); underlying inflammatory or infectious disease, familial Mediterranean fever with proteinuria (secondary amyloidosis AA); cardiac, neurologic or ocular involvement (heredofamilial amyloidosis); carpal tunnel syndrome, joint pain (amyloidosis of hemodialysis). Furthermore, amyloid fibrils are identified on salivary gland biopsy.

FUTURE PROSPECTS AND PROJECTS

Due to the introduction of new specific drugs aimed at curing various amyloidoses, early diagnosis is important. Chemotherapy and hematopoietic stem cell transplantation are promising regarding AL amyloidosis, while liver transplantation has proven remarkably successful in heredofamilial amyloidosis. Progress in molecular biology should allow identification of various forms of familial amyloidosis.

Fine-needle aspiration cytology of amyloid associated with nonneoplastic and malignant lesions

To assess the value of fine-needle aspiration (FNA) cytology for the diagnosis of amyloid, we retrospectively studied all FNA cases diagnosed as having amyloid during a 6-yr period (1990-1996). FNA was performed on both superficial and deep locations. A total of 6 cases containing amyloid was studied, including primary medullary thyroid carcinoma, metastatic medullary thyroid carcinoma to a vertebrae, multiple myeloma, squamous-cell carcinoma of the lung metastatic to a hilar lymph node, primary pulmonary amyloid, and amyloid tumor in a vertebral body in a patient with primary systemic amyloidosis. Despite the location or disease association, the cytologic appearance of amyloid in all cases was similar. On Diff-Quik stain, amyloid appeared as amorphous, irregular, waxy basophilic to metachromatic clumps of material. Papanicolaou stain revealed cyanophilic to organophilic clumps of material with occasional prominent fissures. In all 6 cases, amyloid was confirmed by Congo red stain and in 3 cases by a thioflavin T stain. In 4 of the 6 cases (67%), amyloid was associated with an underlying malignancy. In 3 cases malignant cells were admixed with the amyloid, and in another case malignancy was present at a distant site. We conclude that FNA biopsy is a helpful initial procedure for the evaluation of patients with amyloid deposits. The clinical implications of amyloid found in any particular body site include both benign and malignant conditions. The presence of an associated neoplasm must be especially considered in the differential diagnosis of amyloid deposits.

Focal tenosynovial amyloid deposition as a rare cause of median nerve compression at the wrist

Although certain local and systemic aetiologies for the carpal-tunnel syndrome are known, a large number of cases of this syndrome do not have a conclusive aetiology. We present a case of histologically proven focal tenosynovial deposition of amyloid presenting as a rare cause of median nerve compression at the wrist.

Clinical and therapeutic aspects of AA amyloidosis

Approach to the management of AA amyloidosis complicating RA. (A) In case of proteinuria or loss of renal function a rectal biopsy or a subcutaneous fat biopsy is a suitable screening method for the detection of amyloidosis. If in any doubt, try to ascertain the diagnosis by renal biopsy. Adequate staining with alkaline Congo red and preferably immunohistochemical staining with anti-AA antibodies should be performed. Beware of renal pathology other than amyloidosis even in the presence of a positive rectal biopsy. (B) A vigorous attempt to control disease activity of the RA should be made in order to eliminate the production of SAA, an acute phase protein. The response to treatment should be monitored by serial measurements of CRP and preferably SAA. (C) The function of some vital organs should be evaluated: (a) endogenous creatinine clearance and the extent of proteinuria; (b) electrocardiogram and optional echocardiography; (c) thyroid function and adrenocortical function; (d) intestinal absorption tests; (e) optional--SAP scintigraphy and turnover studies. (D) Attention should be given to adequate supportive treatment: (a) blood pressure control; (b) treatment of intercurrent infections; (c) corticosteroids during major surgical procedures; (d) pay attention to the possible effect of NSAID on proteinuria and renal function. (E) In case of total renal failure or uncontrollable proteinuria: (a) consider the possibility of primary renal transplantation; (b) otherwise regular haemodialysis is indicated.

Nerve Entrapment Syndromes in the Wrist

The patient with compression neuropathies of the median and ulnar nerves at the wrist commonly presents with pain, paresthesias, and weakness in the hand and digits. Diagnosis of these conditions is becoming more widespread with the increased attention given to "cumulative trauma disorders" during the past decade. Successful management requires a thorough understanding of the pathophysiology of compression neuropathy and how it relates to the various diagnostic tests available today. The authors review the epidemiology, etiology, and evaluation of compression neuropathy and discuss common clinical presentations, treatment recommendations, and controversies surrounding carpal and ulnar tunnel syndromes.

Conditions associated with carpal tunnel syndrome

With use of a comprehensive medical records-linkage system, we identified the comorbid conditions and risk factors in the residents of Rochester, Minnesota, who had a diagnosis of carpal tunnel syndrome during 1961 through 1980. In 43.2% of the 1,016 patients, no associated conditions were found on review of the medical records, whereas associated conditions were documented in 56.8%. The most frequent of these conditions were Colles' fracture, rheumatoid arthritis, hormonal agents or oophorectomy (or both), diabetes mellitus, and, among men, occupations that involved excessive use of the hands. Rheumatoid arthritis, diabetes mellitus, and pregnancy were significantly more frequent among the study patients with carpal tunnel syndrome than in the general population of Rochester, Minnesota. The standardized morbidity ratio was 3.6 for rheumatoid arthritis, 2.3 for diabetes mellitus, and 2.5 for pregnancy. The population attributable risk for pregnancy among women 15 to 44 years old was 7.0%. The standardized morbidity ratio for polymyalgia rheumatica was not significantly increased.

Carpal tunnel syndrome: role of occupation

A total of 21 consecutive patients who underwent surgery for carpal tunnel syndrome in a regional hospital were analysed for their trade and serum alpha 1-antitrypsin phenotypes. The majority of these cases were women and mostly manual trades and professions were involved. Furthermore, heterozygous antitrypsin phenotypes were more frequent among the surgical cases than among the general Swiss population. In a second stage, the incidence of carpal tunnel syndrome in Switzerland was studied for 1 year from June 1988 through May 1989 using the sentinel system developed by the Federal Office of Public Health Administration. In all, 188 cases were found, most of whom were women, which was compatible with the frequency in other countries. A complementary questionnaire that was filled out by 65 cases and their matched controls showed that housewives and shop clerks were overrepresented among the patients. Likewise, exposure to vibrating tools and frequent extensions and/or flexions of the wrist were mentioned more often by the cases than by the controls. The present study confirms previous findings that women are at greater risk of developing carpal tunnel syndrome especially in jobs requiring repetitive movements or operation of vibrating tools. A constitutional element in pathogenesis was suggested by observations that the mothers of the cases had often also been afflicted with carpal tunnel syndrome and that the frequency of distribution of antitrypsin phenotypes in patients differed from that in the general population.

beta 2-Microglobulin amyloidosis. A systemic amyloid disease affecting primarily synovium and bone in long-term dialysis patients

A number of rheumatic disorders occur in patients on long-term hemodialysis treatment. In recent years a clinical syndrome comprising carpal tunnel syndrome, destructive arthropathy, and cystic bone lesions has been recognized in these patients. Congo-red staining and microscopy in polarized light reveal a high frequency of amyloid in the affected tissues. Amino acid sequence data of the isolated major amyloid fibril protein show its identity with beta 2-microglobulin. beta 2-microglobulin amyloid has a predilection for synovial tissues and bone, but visceral deposits may also occur indicating the systemic nature of the disease. The clinicopathological features, pathogenesis, and diagnosis of beta 2-microglobulin amyloidosis are reviewed, and the therapeutic and prophylactic measures discussed. The identification of beta 2-microglobulin as an amyloidogenic protein has in an important way contributed to the understanding of the mechanisms of amyloidogenesis in general and emphasized the complexity of amyloid disease and the diversity of proteins capable of forming congophilic fibrillar deposits in human tissues.

Primary systemic amyloidosis--a diagnostic primer

Primary systemic amyloidosis (immunoglobulin light chain-derived) (AL) is an uncommon dysproteinemia with highly varied initial clinical manifestations. Among 153 patients with this disorder, the median survival was 20.4 months (5-year survival, 19.6%). The worst outcome was associated with overt congestive heart failure (median survival, 7.7 months; 5-year survival, 2.4%). The patients with the best outcome were those who had amyloid neuropathy without associated cardiac or renal involvement (median survival, 39.7 months; 5-year survival, 31.6%). Serum protein electrophoresis and immunoelectrophoresis are the most important tests because a monoclonal protein can be detected in almost two-thirds of the patients. When screening of both serum and urine is performed, a monoclonal protein is found in 86% of patients. Such screening is helpful if primary systemic amyloidosis is to be detected and treated early.