Primary amyloidosis with multiple pulmonary nodular lesions and IgA nephropathy-like renal involvement

A 66-year-old woman demonstrated multiple nodular lesions in the lungs without symptoms, and laboratory tests and transbronchial lung biopsy (TBLB) had been negative for malignancy, tuberculosis and sarcoidosis 15 years ago. She developed proteinuria and hematuria 10 years later. Renal biopsy revealed focal segmental mesangial proliferation with predominant IgA deposition in the paramesangium, suggesting IgA nephropathy. However, electron-microscopic observation revealed 8-12 nm fibril deposits in the interstitium and few in the mesangium that were positively stained with amyloid P protein and negative for amyloid A protein. Re-evaluation of previous TBLB samples showed apple-green birefringence with Congo-red staining that was resistant to potassium permanganate reaction. Electron-microscopic observation with high magnification and immunostaining for amyloid components led to a diagnosis of AL amyloidosis in this patient with predominant mesangial IgA deposition and slowly progressive nodular lesions in the lungs.