S3280 A Rare Case of Isolated ALECT-2 Hepatic Amyloidosis

Abstract

Introduction: Amyloidosis is a rare disease that is defined by deposition of extracellular fibrils from immunoglobulin light chains which results in organ dysfunction. Many patients with primary systemic amyloid have hepatic involvement. Hepatic amyloid deposition is characterized by mild hepatomegaly and occasional elevated liver enzymes. Ultrasound may reveal a heterogenous echogenicity of the liver and Computed Tomography (CT) may reveal decreased parenchymal attenuation. Biopsy is the gold standard for diagnosis, seen as extracellular amorphous material, and Congo red staining will reveal apple-green birefringence under polarized light. Whereas amyloidosis is most often systemic, there are rare cases of isolated hepatic amyloid deposition. Leukocyte cell-derived chemotaxin 2 (ALECT-2) is a novel amyloid subtype, previously thought to be found in renal amyloid with a predominance in Hispanic patients but has recently been reported in the liver. We present a rare case of isolated hepatic amyloidosis without systemic involvement. Case Description/Methods: A 53-year-old Hispanic female with history of diabetes mellitus, hyperlipidemia, and nonalcoholic fatty liver disease presented to hepatology clinic for liver enzyme elevation. Lab studies were significant for AST 36 U/L, ALT 67 U/L, Alkaline Phosphatase, total bilirubin 2.7 mg/dL, positive anti-smooth muscle antibody (22 U), immunoglobulin G 1049 mg/dL, normal anti-nuclear antibody screen and normal anti-mitochondrial antibody. CT showed post cholecystectomy changes, a calcified granuloma in the right hepatic lobe, but otherwise normal liver. Liver biopsy showed focal amyloid deposition, mild steatosis, mild lobular activity, and rare ballooning hepatocytes without fibrosis. Positron emission tomography-CT, bone marrow biopsy, urine and serum protein electrophoresis were unremarkable. Further amyloid testing showed leukocyte chemotactic factor-2 (ALECT-2) amyloidosis. A referral for second opinion and experimental treatment options was recommended, however the patient declined. The patient has had stable lab values over the last two years with observation. Discussion: This is a rare case of isolated hepatic amyloidosis, highlighting the need for maintaining a broad differential diagnosis in a patient presenting with elevated liver enzymes. Given the rare nature of this condition, it is important to demonstrate this patient's presentation and two-year outcomes with observation, given lack of available treatment regimens.