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case_images: PA/lateral radiograph of the chest. Demonstrates an eccentrically based circumscribed mass in the periphery of the right mid- to upper-thorax demonstrating obtuse margins with tapering superiorly and inferiorly; note the absence of air bronchograms, indicating pleural origin. There is associated destruction of the angle/body of the right fourth rib.. Abbreviation: PA, posterior anterior.
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case_images: Chest X-ray detected a large pleural-based mass with associated rib destruction in the right thorax as shown in Figure 1.
case_images: Initial CT scan of the chest without contrast. (A) Axial plane soft tissue window: There is a corresponding eccentrically based, circumscribed, heterogeneous, pleura-based mass in the right upper lobe with the peripheral area of low intensity, without associated calcifications, measuring 11 x 11 x 9 cm. Associated small to moderate simple pleural effusion. No suspicious mediastinal, hilar, or axillary lymphadenopathy. (B) Coronal plane bone window: There is associated expansion of the third through the fifth ribs with destruction/involved of the body and angle of the fourth rib and extension beyond the rib cage into the right hemithorax soft tissues.. Abbreviation: CT, computerized tomography.
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case_images: Computerized tomography (CT) chest with contrast showed a large heterogeneous soft tissue mass in the right upper lobe measuring 13.5 x 12.4 x 9.2 cm associated with adjacent rib destruction and extension into the soft tissues of the right chest wall as shown in Figures 2 and 3.
case_images: CT of the chest with IV contrast. (A) Axial and (B) coronal plane soft tissue window demonstrates pleura-based mass measuring 12 x 10 x 8 cm with peripheral curvilinear calcifications and minimal to no enhancement. Small simple right pleural effusion. No pulmonary embolism. Increased compressive atelectasis of the right upper lobe.. Abbreviations: CT, computerized tomography; IV, intravenous.
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case_images: Computerized tomography (CT) chest with contrast showed a large heterogeneous soft tissue mass in the right upper lobe measuring 13.5 x 12.4 x 9.2 cm associated with adjacent rib destruction and extension into the soft tissues of the right chest wall as shown in Figures 2 and 3.
case_images: Lung core biopsy, H&E stain: 50x. Abundant homogeneous and eosinophilic pink material consistent with amyloid with scattered atypical plasma cells.. Abbreviation: H&E, hematoxylin and eosin.
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case_images: A percutaneous transthoracic image-guided biopsy of the lung mass was done and pathology was reported as amyloid sheets deposition on light microscopy with myeloma cells as shown in Figures 4 and 5.
case_images: Lung core biopsy. Amyloid A on immunohistochemical stain. 50x. Positive for deposits of amyloid.
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case_images: A percutaneous transthoracic image-guided biopsy of the lung mass was done and pathology was reported as amyloid sheets deposition on light microscopy with myeloma cells as shown in Figures 4 and 5.
case_images: Kidney biopsy H&E stain. The mycangium shows moderate mesangial expansion with amorphous eosinophilic material.. Abbreviation: H&E, hematoxylin and eosin.
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case_images: Renal biopsy (Figures 6-8) was positive for AL-amyloidosis.
case_images: Congo red stain. It shows salmon-colored areas in the glomeruli.
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case_images: Renal biopsy (Figures 6-8) was positive for AL-amyloidosis.
case_images: Immunofluorescence stain of kidney biopsy. There is homogeneous mesangial, capillary loops, and interstitial staining for kappa.
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case_images: Renal biopsy (Figures 6-8) was positive for AL-amyloidosis.
case_images: Bone marrow biopsy, H&E stain, 50x. Plasma cell neoplasm. Monoclonal IgG kappa plasma cells by flow cytometry. Bone marrow biopsy showed predominantly atypical plasma cells, in the range of 20% to 30% with an average of 25%, suggestive of plasma cell neoplasm with patchy interstitial deposition of eosinophilic amorphous material, confirmed by Congo red stain as positive for amyloidosis which on immunohistochemistry showed positive staining for amyloid A amyloidosis. Liquid chromatography-tandem mass spectrometry (LCMS/MS) on bone marrow tested positive for AL-amyloid.. Abbreviations: H&E, hematoxylin and eosin; IgG, immunoglobulin G; AL, amyloid light.
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case_images: Figure 9.
case_images: Clinical graph depicting the levels of NT-proBNP (N-terminal pro-brain natriuretic peptide), troponin-I levels, 24-hour urine total protein. The patient was diagnosed in December with MM and AL-amyloidosis. CyBorD regimen was started in January. NT-proBNP, troponin-I, and 24-hour total protein progressions are depicted in this clinical graph over 6 months. Normal range of NT-proBNP = 0 to 125 pg/ml, troponin-I = 0 to 0.034 ng/ml, 24-hour total protein = 42 to 225 mg/24 h. The data were plotted as troponin-I levels as values x 101 ng/ml, 24-hour total protein as values x 103 mg, and NT-proBNP as values x 102 pg/ml.. Abbreviations: AL, amyloid light; MM, multiple myeloma; CyBorD, cyclophosphamide, bortezomib, and dexamethasone.
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case_images: Although the patient's myeloma parameters improved, due to his worsening amyloidosis evident by increasing proteinuria, declining renal functions, rising proBNP and troponin-I levels as in Figure 10, and worsening of generalized edema, we referred him to a tertiary care center for more aggressive and advanced management and autologous bone marrow transplantation.