AMYLOID PLEURAL EFFUSION CAUSING CARDIAC ARREST

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Systemic amyloidosis and multiple myeloma have a known association. We encountered a cardiac arrest with subsequent diagnosis of pulmonary amyloidosis. CASE PRESENTATION: 59-year-old female presented to an outside hospital with 3 weeks of progressive dyspnea and orthopnea. Recent history was significant for a diagnosis of multiple myeloma actively being treated with bortezomib and dexamethasone. She also had a diagnosis of amyloidosis via inguinal lymph node biopsy, atrial fibrillation, diastolic congestive heart failure, hypertension, and hyperlipidemia. In the ED, she was tachycardic with a rate of 117 per minute and hypotensive with a pressure of 84/64 millimeter mercury. Labs showed a white count of 18,000, creatinine of 1.61 mg/dL, and lactate of 5.0 mmol/L. Although dyspneic, she was still able to carry conversation. Shortly after a fluid bolus was started, the patient became unresponsive and was found to be in ventricular tachycardia. After 10 minutes of CPR, ROSC was achieved and she was transferred to the intensive care unit. The patient was successfully intubated and post cardiac arrest hypothermia was initiated. The patient had extensive bilateral pulmonary effusions and was transferred to our institution. Patient had a preserved neurological function. She had an initial thoracentesis for evacuation of the effusion and followed by bilateral Pleurex catheters for continuous drainage due to rapid reaccumulation. Pleural fluid showed milky appearance with protein of 3.4 g/dL, cholesterol 63 mg/dL, glucose 120 mg/dL, triglycerides of 445 mg/dL, and LDH of 150 U/L consistent with chylothorax. We proceeded to VATS pleural biopsy which showed positive Congo red staining confirming pleural amyloid. She drains 100 ml pleural fluid on alternate side daily. DISCUSSION: Pulmonary amyloidosis can lead to persistent pleural effusions, trachea-bronchial infiltrations, parenchymal nodules and pulmonary hypertension. Pleural amyloidosis has been found in about 1-2% of patients with systemic amyloidosis. Pleural amyloidosis can be secondary to systemic amyloidosis, which can occur due to systemic conditions such as multiple myeloma, connective tissue disease and monoclonal gammopathy of uncertain significance. In our case, we were able to obtain a pleural biopsy confirming the diagnosis of pleural amyloidosis. We postulate that enlarging pleural effusions led to acute hypoxic respiratory failure and subsequent cardiac arrest. Chylothorax effusions are found in patients that have extensive amyloid burden on the mediastinal lymphatic system. CONCLUSIONS: Our patient’s pleural amyloidosis caused substantial pleural effusions. The rarity of diagnosing pleural amyloidosis after initial presentation of cardiac arrest makes this case a unique case. Pleural amyloidosis should be considered in patients with dyspnea and persistent pleural effusions with underlying disease which predispose to amyloidosis. Reference #1: Agarwal A, Singla S, Bansal M, Nair B. Bilateral Pleural Effusions due to Pulmonary Amyloidosis as the Presenting Manifestation of Multiple Myeloma. Mediterr J Hematol Infect Dis. 2012;4(1):e2012010. Reference #2: Coolbear F, Bilawich AM, Tongson J, Adamo J, Churg A. Pleural amyloidosis imitating pleural malignancy. Respir Med Case Rep. 2017;20:195-197. Published 2017 Mar 6. https://doi.org/10.1016/j.rmcr.2017.03.004 Reference #3: George S, Ravindran M, Anandan PT, Kiran VN. Primary systemic amyloidosis: A rare cause for pleural effusion. Respir Med Case Rep. 2014;13:39-42. Published 2014 Sep 16. https://doi.org/10.1016/j.rmcr.2014.09.001 DISCLOSURES: No relevant relationships by Cristian Dumitrescu, source=Web Response No relevant relationships by Kunal Mehta, source=Web Response No relevant relationships by Vipul Singh, source=Web Response