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The not so innocent bystander: an unusual cause of progressive breathlessness
  1. Max Lyon1,
  2. Alastair Whiteway2,
  3. Michael Darby3,
  4. Nidhi Bhatt4,
  5. Shaney L Barratt5
  1. 1 Department of Respiratory Medicine, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  2. 2 Department of Haematology, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
  3. 3 Department of Radiology, North Bristol NHS Trust, Bristol, UK
  4. 4 Cellular Pathology, North Bristol NHS Trust, Bristol, UK
  5. 5 Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
  1. Correspondence to Dr Shaney L Barratt, Bristol Interstitial Lung Disease service, North Bristol NHS Trust, Bristol BS10 5NB, UK; mdzslb{at}


This case report discusses a 76-year-old man who presented with symptomatic diffuse alveolar-septal and tracheobronchial amyloidosis with a low-grade monoclonal gammopathy. This patient had a combination of both symptomatic diffuse alveolar-septal interstitial disease and tracheobronchial amyloidosis, features that contradict the widely accepted presentations seen in this disease. First, tracheobronchial amyloidosis has been documented as localised disease without systemic involvement. Second, diffuse alveolar-septal interstitial disease is rarely identified with clinical symptoms unless there is significant cardiac involvement. This case highlights a number learning points in the diagnosis and management of systemic amyloid light chain amyloidosis;(1) There is a need for a high index of suspicion for diagnosis due to the potential subtlety of a plasma cell clone underlying AL amyloidosis, requiring serum-free light chain assays to increase sensitivity; (2) Haematological response and recovery of organ dysfunction are not a linear relationship due to the slower reversal of amyloid deposition; therefore, ongoing monitoring is required to identify those in need of repeated therapy. However, haematological response is a marker of overall survival and (3) Multisystem assessment and multidisciplinary collaboration are critical in optimising the care of patients with systemic AL amyloidosis.

  • systemic disease and lungs
  • interstitial Fibrosis
  • rare lung diseases

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  • Contributors SLB and ML wrote the first draft of the manuscript. NB kindly provided the histological images. MD provided the radiological images. ML, SLB, AW, MD and NB all contributed towards the final draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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