Multimodality imaging in amyloidosis

Cardiac Amyloid - A Hidden Contributor to Cardiac Dysfunction Following Cardiac Surgery: Case Report and Literature Review

We present two patients who underwent cardiac surgery followed by post-operative low cardiac output, diastolic dysfunction and resistance to inotropic support. Despite aggressive medical management, both patients died. At autopsy, the hearts were enlarged and showed previously undiagnosed myocardial and vascular amyloidosis. Occult cardiac amyloidosis is an uncommon, often occult, contributor to post-operative complications post cardiac surgery. Pre-operative or intra-operative myocardial biopsy may be useful in patients with unexplained diastolic dysfunction.

Amyloidosis in the head and neck: CT findings with clinicopathological correlation

PURPOSE

To characterize the CT imaging features of head and neck amyloidosis and correlate with extent of disease and clinical outcomes.

MATERIALS AND METHODS

This retrospective study included 80 patients with head and neck amyloidosis who underwent soft tissue neck CT imaging between November 2003 and April 2018. The CT imaging features including lesion distribution, morphology (focal, diffuse/circumferential, or combined), presence and pattern of calcification, (punctate or diffuse), and thickness of airway lesion were evaluated and compared with the extent of amyloidosis (localized or systemic), and clinical course (stable, no recurrence, or progression requiring repeated surgical treatment).

RESULTS

Localized disease (83.8%, 67/80) was most common with AL type (97.6%, 41/42) representing nearly all cases of head and neck amyloidosis. The larynx was the most frequently affected organ (60.0%, 48/80), specifically the glottis (43.8%, 35/80). Calcification was seen in 65.0% of cases (52/80). Non-airway or tongue lesions were significantly associated with systemic (92.3%, 12/13) as opposed to localized amyloidosis (4.5%, 3/67; P < 0.001). Repeated surgical treatment was significantly associated with laryngeal amyloidosis (35.3%, 12/34; P = 0.002) and multi-centric disease (33.3%, 10/30; P = 0.048). Airway wall thickness in patients who required repeated surgical treatment was significantly greater than in patients with stable or no recurrent disease (P = 0.016).

CONCLUSION

Knowledge of the imaging features of head and neck amyloidosis can aid the diagnosis, disease monitoring, and prediction of patients requiring repeated surgical intervention.

MR enterography: what is next after Crohn's disease?

Within the gastrointestinal system, the small bowel represents the most difficult site to approach with imaging modalities. During the last decades, magnetic resonance enterography has reached an increasing interest, up to be considered an essential part in the diagnostic framework of Crohn's disease patients. Nevertheless, the distention of the intestinal loops provided by the administration of oral contrast medium, the possibility of a dynamic evaluation, and the lack of radiation exposure are huge advantages that can be exploited for the assessment of other clinical conditions affecting the small bowel. Physicians and radiologists should be aware of the possibilities offered by this technique, looking at it as a trustful alternative to the well-worn radiological examinations. In this respect, the purpose of this work is to show some uncommon clinical conditions that can be assessed with magnetic resonance enterography and that fall within the various differential diagnosis of the intestinal disorders.

A rare case of omental cake

Systemic amyloidosis is normally detected on histology by deposition of amyloid into soft tissue organs. Omental and peritoneal involvement are rare manifestations of the disease. The differential diagnosis for omental and peritoneal disease does not, therefore, normally include amyloid.

Primary systemic amyloidosis: imaging interpretation of this complex multisystemic disease

This report highlights the diagnostic complexities involved in the case of a 63-year-old female who presented with a non-productive cough and shortness of breath on exertion. Initial chest radiograph demonstrated generalized abnormal interstitial lung markings with thickened peripheral septal lines. Further characterization was sought by CT scan of the chest, and given the possibility of lymphangitic carcinomatosis, a CT scan of the abdomen and pelvis was also performed. The CT scan findings revealed septal line thickening, abnormal omental soft tissue with calcified deposits and wall thickening of the stomach and proximal duodenum. A preliminary differential diagnosis of peritoneal carcinomatosis was made, but cancer markers were equivocal. A CT-guided biopsy of the “omental cake” was non-diagnostic, hence formal biopsy via laparoscopy was undertaken. While awaiting the results, the patient was readmitted with acute haematemesis. Gastric and duodenal biopsies from the endoscopic assessment were positive for Congo red stain and birefringent under polarizsed light, which was consistent with amyloidosis. Histology from the omental biopsies and additional haematological tests concurred. The patient was diagnosed with advanced systemic amyloid light-chain amyloidosis comprising diffuse pulmonary amyloidosis, calcified omental soft tissue deposits, and extensive soft tissue amyloid with cardiac and gastrointestinal involvement. We discuss the spectrum of differential diagnoses posed by the imaging findings and the difficulties faced in interpreting this complex case of systemic amyloidosis.

Respiratory Tract Amyloidosis. State-of-the-Art Review with a Focus on Pulmonary Involvement

Amyloidosis is a constellation of disease entities characterized by abnormal extracellular deposition and accumulation of protein and protein derivatives, which show apple-green birefringence when stained with Congo red and viewed under polarized light. Amyloid can infiltrate virtually all organ systems and can display multiple and diverse imaging findings. Pathologically, respiratory involvement occurs in 50 % of patients with amyloidosis, and its clinical signs and symptoms vary depending on whether the disease is systemic or localized. The four main patterns of respiratory tract involvement are tracheobronchial, nodular parenchymal, diffuse alveolar septal, and lymphatic. Imaging findings of amyloidosis are nonspecific and vary in each pattern; knowledge about the disease impairment type is thus very important, and amyloidosis should be considered in the differential diagnosis of other very common diseases, such as infectious diseases, neoplasms, and vasculitis. This literature review describes the main clinical and imaging manifestations of amyloidosis, focusing on respiratory tract involvement and differential diagnosis.

Computational modeling of the relationship between amyloid and disease

Amyloid is a title conferred upon a special type of linear protein aggregate that exhibits a common set of structural features and dye binding capabilities. The formation of amyloid is associated with over twenty-seven distinct human diseases which are collectively referred to as the amyloidoses. Although there is great diversity amongst the amyloidoses with regard to the polypeptide monomeric precursor, targeted tissues and the nature and time course of disease development, the common underlying link of a structurally similar amyloid aggregate has prompted the search for a unified theory of disease progression in which amyloid production is the central element. Computational modeling has allowed the formulation and testing of scientific hypotheses for exploring this relationship. However, the majority of computational studies on amyloid aggregation are pitched at the atomistic level of description, in simple ideal solution environments, with simulation time scales of the order of microseconds and system sizes limited to a hundred monomers (or less). The experimental reality is that disease related amyloid aggregation processes occur in extremely complex reaction environments (i.e. the human body), over time-scales of months to years with monitoring of the reaction achieved using extremely coarse or indirect experimental markers that yield little or no atomistic insight. Clearly a substantial gap exists between computational and experimental communities with a deficit of 'useful' computational methodology that can be directly related to available markers of disease progression. This Review will place its focus on the development of these latter types of computational models and discuss them in relation to disease onset and progression.