A 57-year-old male patient with a history of active smoking.
She had a history of multiple hospitalizations in different centers during 2010 for the study of self-limiting hemoptysis and of little amount in relation to physical effort.
When asked directly, she reported a 2-year history of asthenia, adynamia, mild dyspnea on exertion that, over the years, worsened with the appearance of orthopnea and dyspnoea in mildly stressed hands 10 minutes.
The patient presented chest X-ray, abdominal ultrasound, upper digestive endoscopy, echocardiogram, biochemical profile, plasma creatinine, liver and coagulation tests normal.
He had a blood count with mild anemia (35% hematem).
In subsequent controls, mild normocytic-normochromic anemia persisted, but ESR returned to normal.
The patient presented a chest computed tomography (CAT) 3 days after hemoptysis, which showed multiple diffuse "emerged glass" images suggestive of alveolar hemorrhage and pulmonary emphysema, but only a CT scan showed mild emphysema.
Fiberoptic bronchoscopy revealed normal bronchial alveolar lavage findings.
She had negative immunoreactivity tests (ANA, AntiDNAds, ANCA by IFI, direct and indirect Coombs, RF).
Handwriting showed mild degenerative changes in distal radiophalangeal joints.
On physical examination, nail dystrophy, increased volume of soft parts of the hands without edema, pigmentation of the hands with eyelids and slight periocular macrogray petechiae were investigated.
Due to these findings it was suggested to rule out deposition disease, postulating as a diagnostic hypothesis systemic amyloidosis.
An incisional biopsy of the eyelid, cheek and hand was performed, which showed an interstitial amorphous infiltrate of eosinophilic hyaline material of amyloid type, as well as foci of microgyria.
Cressillet staining and Congo red staining were positive for chamomile green dichroism under polarized light and potassium permanganate resistance.
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An echocardiogram showed left ventricular hypertrophy, compatible with amyloid deposits.
With thyroid study and normal protein electrophoresis, the diagnosis of AA amyloidosis was proposed.
