Nodular Pulmonary Amyloidosis: A Case over Fourteen Years

Abstract

A 75-year-old man presented with pleuritic chest pain, haemoptysis and dyspnoea. Imaging found multiple pulmonary nodules, concerning for malignancy. CT-guided biopsy was consistent with amyloid. The patient has a history of pulmonary amyloidosis, with a single nodule resected 14 years prior. This case allows comparison between imaging fourteen years apart, providing insight into the progressive nature of these benign nodules. Nodular pulmonary amyloidosis is a rare condition with few case reports published. Of those published, few are of nodular amyloidosis in the absence of underlying neoplastic aetiology. This case presents a 14-year interval of a patient with nodular amyloidosis, allowing insight into disease progression which has not previously been well described. A 75-year-old man presented to a regional hospital in Australia with right sided pleuritic chest pain, and a 2-week history of productive cough, haemoptysis, dyspnoea and reduced exercise tolerance. Further questioning revealed a 3-month history of worsening dyspnoea, haemoptysis and cough, with no orthopnoea, paroxysmal nocturnal dyspnoea or weight loss. The patients’ past medical history included resection of an amyloid tumour from the left lower lobe of the lung in 2004, ex-smoker with a 30-pack year history, significant occupational asbestos exposure through work as a diesel mechanic, and hypercholesterolaemia. The patient lives at home with his partner and is independent with the activities of daily living. On examination, the patient appeared well, in no respiratory distress. Observations were within normal limits, with oxygen saturations of 94% on room air, respiration rate of 18. On auscultation, there were late inspiratory crackles, as well as decreased hepatic dullness to percussion. There was a central trachea and no palpable cervical lymphadenopathy. Cardiovascular examination was unremarkable, and the patient was euvolaemic. Abdominal examination was unremarkable with no palpable organomegaly, and he did not have a rash or skin abnormalities seen. The initial investigations were conducted to investigate a potential lung malignancy underlying malignancy, based on the appearance on CT scan. The patient advised us that he had a previous diagnosis of primary pulmonary amyloidosis, first diagnosed 14 years ago. The diagnosis was made after a chest x-ray and CT showed a nodule, suspicious for cancer. Pulmonary function tests were performed and he was referred to a Cardiothoracic surgeon for consideration of a left lower lobectomy. He was treated with a wedge resection. Histopathology from this specimen showed primary pulmonary amyloidosis. There was a delay in the understanding of how the patient came to have this rare diagnosis, as it took five days for the medical records to be sourced from the archive.