A 74-year-old otherwise healthy woman presented with diffuse alopecia of the scalp. Two biopsies were taken for investigation of suspected telogen effluvium or diffuse alopecia areata. No clinical features of amyloidosis, such as macroglossia, purpura, infiltrative skin lesions or nail changes, were observed.\nThe skin biopsies showed no inflammation or evidence of a scarring alopecia. A large proportion of follicles were shifted into catagen and telogen phase in both biopsies. The residual fibrous stelae within the deep dermis and subcutis showed a remarkable appearance, with an empty center and a peripheral zone containing eosinophilic periodic acid Schiff (PAS)-positive and diastase-resistant ( and ), Congo-red-positive (), apple-green-birefringent material characteristic of amyloid. Similar amyloid deposits were also evident to a lesser extent surrounding follicular epithelium within the mid-dermis. There was no discernible amyloid deposition within dermal blood vessels, surrounding sweat apparati or adipocytes, or within the dermal interstitium.\nFurther special staining was carried out on one of the biopsies, with PAS with diastase (PASD) staining showing no fungal organisms or dermoepidermal basement-membrane-zone thickening. Alcian blue staining showed no dermal mucin accumulation and was negative within the amyloid deposits. Verhoeff staining showed no scarring that might suggest a scarring alopecia.\nWithin one biopsy, 14 of 37 (38%) hairs were vellus or vellus-like. Of the non-miniaturized hairs, 16 of 23 (70%) were in catagen or telogen phase. The other biopsy was more irregularly shaped and subsequently obliquely sectioned, allowing visualization of only 14 hairs, 5 of which (36%) were vellus or vellus-like; of the 9 remaining hairs, 2 were in catagen or telogen phase (22%).\nAs such, the biopsies were assessed to show a shift toward catagen and telogen hair follicles, consistent with the early phase of telogen effluvium. There was also moderate hair miniaturization consistent with pre-existing senile alopecia or androgenetic hair loss.\nPerifollicular deposition of amyloid prompted further workup of the patient for systemic forms of amyloidosis. Plasma protein electrophoresis and immunofixation showed a 1.4 g/L monoclonal band in the mid-to-late gamma region. Additional minor bands were noted in the beta-gamma region of both the alpha heavy chain and lambda light-chain classes and migrated with slightly different mobility, suggesting that they were not the same paraprotein. Urine protein electrophoresis showed moderate proteinuria in a glomerular pattern, without excretion of the monoclonal protein in the urine.\nBased on these findings, the patient was diagnosed with lambda AL amyloidosis. A bone-marrow biopsy performed 6 months after presentation showed a plasma-cell dyscrasia with lambda light-chain restriction and 8% plasma cells in the bone marrow. She subsequently received treatment with melphalan, and her disease is stable. At time of publication, she has no known involvement of the lymph nodes, oropharynx, liver, spleen, and cardiovascular system, and only mild renal impairment and proteinuria.
The present case is of a 60 year old woman who initially presented with back pain. There was no history of trauma or history suggestive of any comorbid conditions.\nExamination revealed tenderness on right side of lumbosacral spine and right sacroilliac joint. Hip movements were normal.\nMRI scan showed wedge compression fracture of D6, D7, D9 & D10 vertebrae with areas of altered signal intensity involving right sided pedicle of D9 & D10 vertebrae compressing the thecal sac and dorsal spinal cord.\nEdema in dorsal spinal cord at D10 level was also noted.\nLab investigations revealed\nHemoglobin of 13g/dl,\nTotal Leukocyte Count of 10,890 and\nPlatelet count of 1.5 lac/cumm.\nESR =27mm/hr\nViral markers revealed HCV positive (incidental finding).\nHypercalcemia with a serum calcium level of 12.5g/dl.\nPBF shows normal blood picture with mild neutrophilia (75%) and no rouleaux formation.\nBone marrow aspiration and biopsy revealed plasmacytosis (>45%)\nSerum protein electrophoresis showed absence of M band with hypogammaglobulinemia.\nThe above patient meets the criteria laid down by the international myeloma working group and chronic leukemia myeloma task force.\nIt was also a diagnostic dilemma as other disorders such as secondary deposits, osteoporosis and hyperparathyroidism can present with a similar picture.\nOur patient did not undergo serum immunoglobulinfree light chain assay (FLC).\nNow patient is currently being managed on the lines of treatment of multiple myeloma.