P712 When Popeye had shortness of breath

Abstract

Abstract A 61-year-old man presented to our clinic with progressive shortness-of-breath in the last 3 months. He had a history of hospitalization and endotracheal intubation due to acute pulmonary edema and type – I respiratory failure a week ago and discharged after diagnostic coronary angiography which demonstrating normal coronary arteries. Physical examination revealed bunching of the left biceps when he flexed his left arm which is consistent with rupture of distal biceps tendon (Panel A, Popeye Sign). A 12-lead electrocardiography (ECG) showed low QRS voltage in the limb leads and ST segment depression and asymmetrical T wave inversion in the anterolateral leads (Panel B). Transthoracic echocardiography (TTE) showed concentric left ventricular hypertrophy with left ventricular ejection fraction of 60% (Panel C). Pulsed wave-Doppler obtained from the mitral valve demonstrated restrictive filling pattern with high early diastolic velocity (E-wave) and low late diastolic filling (A-wave) peaks with E/A ratio > 2.0 and reduced lateral mitral annular diastolic velocities with E/e’ ratio > 15 which are compatible with impaired left ventricular diastolic function with elevated left ventricular filling pressures (Panel D-E). Biceps tendon rupture, low QRS voltage and left ventricular hypertrophy with restrictive filling pattern were considered suggestive of cardiac amyloidosis and patient was referred to hematology clinic for diagnostic work-up. Protein electrophoresis demonstrated monoclonal gammopathy in the serum and immunoelectrophoresis showed free lambda light chains. The patient diagnosed as AL amyloidosis with cardiac and musculoskeletal involvement. Biceps tendon rupture is a rare finding of amyloidosis due to musculoskeletal involvement. In the setting of acute pulmonary edema and/or heart failure with preserved ejection fraction with massive left ventricular hypertrophy, restrictive filling pattern, low QRS voltage and spontaneous tendon rupture should raise clinical suspicion of amyloidosis with cardiac and musculoskeletal involvement. Abstract P712 Figure.