Rapid clinical improvement of amyloid A amyloidosis following treatment with tocilizumab despite persisting amyloid deposition: a case report

Abstract

BackgroundAmyloid A amyloidosis is one of the most common forms of amyloidosis. It is secondary to rheumatoid arthritis, which is difficult to manage and has a poor prognosis. We present a patient with rheumatoid arthritis and amyloid A amyloidosis who was treated with tocilizumab, a humanized monoclonal antibody against interleukin 6 receptor, resulting in improvement in both proteinuria and gastrointestinal symptoms; however, amyloid deposition remained.Case presentationA 67-year-old woman who had previously been treated for rheumatoid arthritis presented with abdominal pain and diarrhea. Right renal cell carcinoma was found, and amyloid A amyloidosis was diagnosed concomitantly based on colon biopsy. The renal cell carcinoma was resected, and the non-cancerous part of the renal tissue also showed amyloid A deposition. Following surgery, protein levels in the urine increased to the nephrotic range, and administration of tocilizumab was initiated, which resulted in resolution of the proteinuria. The patient’s gastrointestinal symptoms were also alleviated. However, repeat colon biopsy showed amyloid deposition.ConclusionsThis case of amyloid A amyloidosis suggests that amyloid deposition indicates only structural change of the affected tissue, and that it is not amyloid deposition per se that causes the clinical symptoms of amyloidosis.

Elevated interleukin-6 levels are associated with impaired outcome in cardiac transthyretin amyloidosis

“…, rheumatoid arthritis)[ 27 ]. In these patients, application of the human monoclonal antibody tocilizumab directed against the IL-6 receptor induced rapid clinical improvement without influencing the amyloid deposits[ 28 , 29 ]. Therefore, for AA-amyloidosis the IL-6 axis is known to be causally involved in the pathogenesis of the inflammatory disease.…”

Biologic therapy for amyloid A amyloidosis secondary to rheumatoid arthritis treated with interleukin 6 therapy

“…Successful outcomes for tocilizumab have been reported in several cases of GI AA amyloidosis secondary to RA. Most of these patients were female, and AA amyloid deposition was confirmed in biopsy specimens obtained by endoscopy [17,18,22–24] . One patient started tocilizumab therapy after two different TNF inhibitors failed to control the manifestations of AA amyloidosis, and another patient suffered a small intestine perforation with extensive amyloid deposition after one administration of tocilizumab.…”

Serum Amyloid A Protein–Associated Kidney Disease: Presentation, Diagnosis, and Management

“… 43 Subsequent treatment with tocilizumab lead to rapid improvement in proteinuria over a 9-week follow-up period; however, the patient experienced GFR decline because of gastrointestinal illness, ultimately leading to the need for hemodialysis. Since then, there have been several case reports regarding the efficacy of tocilizumab in chronic diseases, including Behcet disease, polyarteritis nodosa, psoriatic arthritis, and rheumatoid arthritis ( Table 1 44 , 45 , 46 , 47 , 48 , 49 , 50 ).…”

“…Since then, there have been several case reports regarding the efficacy of tocilizumab in chronic diseases, including Behcet disease, polyarteritis nodosa, psoriatic arthritis, and rheumatoid arthritis ( Table 1 44 , 45 , 46 , 47 , 48 , 49 , 50 ).…”