Primary diffuse pulmonary amyloidosis with monoclonal gammopathy

[Tracheobronchial amyloidosis. A rare form of amyloidosis restricted to the lower respiratory tract]

We describe an 83-year-old man with diffuse tracheobronchial amyloidosis presenting with pneumonia, against a background of chronic obstructive pulmonary disease. The condition continued with intermittent episodes of obstruction for 2 years after diagnosis and the patient died after upper digestive tract hemorrhage. Monoclonally was never demonstrated.

Localized amyloidosis of the larynx: evidence for light chain composition

We report the biochemical characterization of amyloid fibrils from a patient with localized amyloidosis of the epiglottis and larynx. Biopsy specimens showed amorphous material consistent with amyloid deposits with a plasmacytic infiltrate. Both plasma cells and amyloid deposits stained positively by immunohistochemistry for kappa light chains. Amyloid fibrils were isolated. The major constituent resolved as a 13 kd band was sequenced and found to be consistent with a kappa 1 light chain. A tryptic digest was carried out and 3 tryptic peptides were sequenced defining the first 45 residues of the protein and residues 110 through 119. Four amino acid substitutions were found, 3 of which have not been described previously. This study defines the immunoglobulin origin of amyloid deposits in localized amyloidosis. The benign nature of localized amyloidosis suggests that a localized clone of plasma cells producing an amyloidogenic light chain may represent the pathogenetic mechanism of this disease, which appears to be a form of plasma cell dyscrasia.

Primary pulmonary lymphoma. Diagnosis by immunoglobulin gene rearrangement study using a novel polymerase chain reaction technique

A 63-yr-old-woman presented with pulmonary infiltrates and macroglobinemia. Open lung biopsy revealed an interstitial plasma cell infiltrate. Immunocytochemical staining to determine clonality of the infiltrate was negative for both kappa and lambda light chains and therefore was not helpful. Polymerase chain reaction (PCR) amplification of the CDR-III region of the immunoglobulin heavy chain gene revealed that the plasma cells were either monoclonal or biclonal, thus suggesting the diagnosis of a plasmacytoid pulmonary lymphoma. The advantages and limitations of the PCR technique over the traditional method of detecting gene rearrangements, i.e., restriction-digestion of DNA and Southern blotting, are discussed. To our knowledge this patient represents the first reported application of the PCR technique for detecting gene rearrangements to determine the clonality of a lymphoid infiltrate in the lung. This technique can also be applied to determine the clonality of lymphocytes obtained by bronchoalveolar lavage or needle biopsy, or from a pleural effusion.

Respiratory muscle weakness and ventilatory failure in AL amyloidosis with muscular pseudohypertrophy

Generalized muscle weakness culminating in ventilatory failure developed in a 59-year-old man with kappa light chain multiple myeloma. Physical examination demonstrated skeletal muscle enlargement, severe proximal muscle weakness, and macroglossia, consistent with amyloid-associated muscle pseudohypertrophy. Pulmonary function studies revealed a severe restrictive abnormality with a low maximal inspiratory pressure and maximal voluntary ventilation. Arterial blood gas values and chest radiographic results were normal. There was no clinical evidence of cardiac or central nervous system disease. At autopsy, skeletal muscles and diaphragm were diffusely infiltrated by amyloid. There was also multifocal deposition of amyloid in alveolar septae, esophagus, and subendocardium. This report suggests that ventilatory failure may occur as a complication of myeloma-associated (AL) amyloidosis involving the respiratory muscles.

Long-term survival with diffuse interstitial pulmonary amyloidosis

A 51 year old man presenting with amyloidosis involving the lungs, the testes, the skin and the stomach has been followed for eight years. Serial pulmonary function tests revealed slowly progressive physiologic deterioration. The various clinical features and the lengths of survival in the previously reported cases of diffuse interstitial pulmonary amyloidosis are reviewed. The unusually long survival of this patient and its implications are discussed.

The radiologic spectrum of cardiopulmonary amyloidosis

Amyloidosis, either primary or related to other pathologic states, may mimic a variety of disorders and produce a multitude of appearances demonstrable on radiographic examinations of the chest. All intrathoracic tissues and organs may be affected, but the major abnormalities most commonly involve the heart and lungs. The radiographic appearances in ten patients are described and correlated with the underlying gross and microscopic pathologic findings. No specific pattern of pulmonary involvement could be determined, aside from tracheobronchial amyloidosis. The final diagnosis is dependent upon the awareness of the clinical and radiologic spectrum and the final microscopic examination of involved tissue.