Amyloidosis and Pleural Disease: Discussion (Part 3)
During examination of patients with pleural effusions, if history suggests the presence of multiorgan disease and there is suspicion for systemic amyloidosis, then a closed pleural biopsy with special stains for amyloid should be performed. Routinely prepared microscopic sections stained with hematoxylin-eosin may not suggest amyloidosis. Special stains, such as crystal violet or Congo red (with polarization), are required for the diagnosis of amyloidosis. A single staining procedure, typically with Congo red, is adequate to establish the diagnosis. buy asthma inhaler
Closed pleural biopsy is a simple bedside or outpatient procedure that is widely performed. Potential complications, including pneumothorax and vasovagal reaction, can be minimized by appropriate technique. There were no complications associated with the five percutaneous pleural biopsies that were performed in this series.
Although the actual incidence is not known, our experience suggests that amyloid deposition in the pleura in systemic amyloidosis is likely very common. Five of five patients with systemic amyloidosis and pleural effusions, including three patients with transudative effusions, had marked deposition of amyloid in small specimens of pleura obtained by closed Cope needle biopsy and the specimens were appropriately stained.
In summary, we have described five patients with systemic amyloidosis in whom pleural amyloidosis was established by percutaneous needle biopsy specimens taken during evaluation of pleural effusions of indeterminate cause. Review of the literature suggests that there are only five case reports that describe pleural involvement with amyloid. It is likely that the incidence of pleural involvement is underestimated in the literature. Pleural effusions do occur with systemic amyloidosis, with congestive heart failure being the most common mechanism. In an appropriate clinical setting, in patients with multiorgan disease and undiagnosed pleural effusions, the diagnosis of systemic amyloidosis could be established simply by percutaneous pleural biopsy and appropriate stains. Although pleural biopsy is not typically recommended in the evaluation of transudative effusions, in patients with suspected systemic amyloidosis, this may be the diagnostic procedure of choice.