A 71-year-old woman was investigated for a one-year history of deteriorating dyspnoea on a background of well-controlled asthma. Other co-morbidities included cutaneous systemic lupus erythematosus, rheumatoid arthritis and Sjogren’s syndrome. High-resolution computerised tomography (HRCT) showed multiple cysts, solid nodules and aggregate masses – the largest (2 × 1.5 cm) in the peripheral left lower lobe with fine-needle aspiration suggestive of amyloid. Serum biochemistry showed a polyclonal elevation of IgG, no detectable monoclonal band and normal serum-free light chains. Immunohistochemistry showed no specific staining for kappa or lambda antibodies. Mass spectrometry was not performed. Echocardiography excluded cardiac involvement and no visceral uptake by 123I SAP scintigraphy. Pulmonary function tests demonstrated a restrictive pattern, and a further HRCT raised suspicion of lymphocytic interstitial pneumonitis. FDG-PET/CT demonstrated similar low-grade uptake in all lung nodules (). A mini-thoracotomy was performed to obtain tissue from the largest nodule showing evidence of amyloid but too few infiltrating cells were present to confirm clonality.\nA low-grade lymphoplasmocytic lymphoma (LPL) was presumed to be driving the pulmonary amyloid, based on the assumption of low-grade B-cell clonal disorders that can occur with Sjogren’s syndrome. A trial of R-CVP (Rituximab – Cyclophoshamide, Vincristine, Prednisolone) chemotherapy was commenced for four months resulting in no progression of symptoms and stable lesions.
A 67-year-old male ex-smoker (>20 years) with a 30 pack-year history was investigated for morning cough and clear sputum with no constitutional symptoms and an active lifestyle. Past medical history included chronic obstructive pulmonary disease and ischaemic heart disease. External physical examination was unremarkable. Chest computed tomography (CT) showed a right middle lobe nodule which increased from 11 mm to 16 mm over six months. A positron emission tomography (PET) scan showed low radiolabeled [18F]-2-fluoro-2-deoxy-D-glucose (FDG) uptake with a standardised uptake value (SUV) max of 2.0 and no evidence of metastatic disease (). CT-guided biopsy identified eosinophilic amorphic material, which was Congo red negative, with no definitive diagnosis reached. Due to the volume increase of the suspicious lesion, a right middle lobe lobectomy was performed.