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Case ReportImages in Rheumatology

Amyloid Arthropathy: A Rare Mimic of Rheumatic Disease

DREW BOWIE, MOHAMMAD BARDI and IMAN HEMMATI
The Journal of Rheumatology November 2019, 46 (11) 1540-1541; DOI: https://doi.org/10.3899/jrheum.181197
DREW BOWIE
Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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  • For correspondence: bowie.drew@gmail.com
MOHAMMAD BARDI
Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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IMAN HEMMATI
Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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Amyloidosis is characterized by infiltrative deposition of amyloid into tissues1. Deposition into articular and periarticular spaces can result in amyloid arthropathy and can mimic rheumatic conditions such as gout or rheumatoid arthritis2.

A 79-year-old man with known type 2 diabetes, hypertension, chronic kidney disease (CKD) of unknown etiology, and monoclonal gammopathy of unknown significance, was admitted to hospital for worsening renal function with gross hematuria and creatinine 329 umol/l (estimated glomerular filtration rate 15 ml/min/1.73m2). While admitted, he fell and injured his left wrist. A computed tomography (CT) scan was negative for fracture but demonstrated unexpected extensive subchondral cysts (Figure 1) initially thought to be consistent with the punched-out lesions seen in crystal arthropathies. However, the patient had no history of gout flares, and uric acid and dual energy CT were normal. Investigations for other rheumatic conditions were negative (normal anticyclic citrullinated peptide antibodies, rheumatoid factor, C-reactive protein, and erythrocyte sedimentation rate), with otherwise normally presenting laboratory test results.

Figure 1.
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Figure 1.

Computed tomography scan with (A) left wrist sagittal and (B) axial views. Extensive subchondral cyst formation throughout the carpus, distal radius, and carpometacarpal joints, most pronounced at the first carpometacarpal joint.

CKD evaluation demonstrated elevated κ light chains, which led to both bone marrow and renal biopsies that demonstrated positive staining with Congo red, consistent with amyloid light-chain (AL) amyloidosis (Figure 2).

Figure 2.
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Figure 2.

Congo red stain under polarizing light microscopy of the bone marrow trephine biopsy. Strongly positive apple green birefringence of amyloid deposits in a bone marrow vessel wall.

Retrospective review of the wrist imaging in the context of AL amyloidosis revealed that the CT findings were most consistent with amyloid arthropathy. The typical radiographic features include juxtaarticular soft tissue swelling, periarticular osteoporosis, and subchondral cystic lesions with well-defined sclerotic and cortical margins, as seen in this case3. The arthropathy is progressive and commonly found in the shoulders, knees, and wrists4.

Footnotes

  • Providence Health Care does not require ethics board approval for case reports. A witnessed and written consent to publish this case has been obtained from the patient and is available on request.

REFERENCES

  1. 1.↵
    1. Rambaran RN,
    2. Serpell LC
    . Amyloid fibrils: abnormal protein assembly. Prion 2008;2:112–7.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Katoh N,
    2. Tazawa KI,
    3. Ishii W,
    4. Matsuda M,
    5. Ikeda SI
    . Systemic AL amyloidosis mimicking rheumatoid arthritis. Intern Med 2008;47:1133–8.
    OpenUrlPubMed
  3. 3.↵
    1. Sheldon PJ,
    2. Forrester DM
    . Imaging of amyloid arthropathy. Semin Musculoskelet Radiol 2003;7:195–203.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. M’bappé P,
    2. Grateau G
    . Osteo-articular manifestations of amyloidosis. Best Pract Res Clin Rheumatol 2012;26:459–75.
    OpenUrlPubMed
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1 Nov 2019
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Amyloid Arthropathy: A Rare Mimic of Rheumatic Disease
DREW BOWIE, MOHAMMAD BARDI, IMAN HEMMATI
The Journal of Rheumatology Nov 2019, 46 (11) 1540-1541; DOI: 10.3899/jrheum.181197

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Amyloid Arthropathy: A Rare Mimic of Rheumatic Disease
DREW BOWIE, MOHAMMAD BARDI, IMAN HEMMATI
The Journal of Rheumatology Nov 2019, 46 (11) 1540-1541; DOI: 10.3899/jrheum.181197
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