Secondary amyloidosis associated with heroin use and recurrent infections - A case report

A 49-year-old lady with history of polysubstance use disorder, recurrent cutaneous abscesses, spinal diskitis and septic thrombophlebitis presented to the emergency room with complaints of intermittent fevers, worsening right hip pain and bilateral lower extremity edema. A month before the presentation, she had left another hospital against medical advice after being diagnosed with Methicillin-resistant Staphylococcus aureus bacteremia and right hip septic arthritis. Post discharge, she was off antibiotics, but continued heroin and methamphetamine use. On admission, she had right hip chronic osteomyelitis and was also in acute renal failure with evidence of nephrotic range proteinuria. Her renal biopsy subsequently revealed acute tubular necrosis and secondary (AA) amyloidosis with the classic apple green birefringence and positive immunohistochemical stain for serum amyloid A protein. Secondary amyloidosis, where there is deposition of fibrils composed of fragments of the acute phase reactant - serum amyloid A protein, often complicates chronic diseases with ongoing or recurring inflammation like spondyloarthropathies, inflammatory bowel disease and heredofamilial periodic fever syndromes. Epidemiological studies now indicate that chronic inflammation as noted in illicit drug users, especially heroin users is on the rise as the etiology for AA amyloidosis in some parts of the developed world. The most common organ system involved in AA amyloidosis is the kidney. Given the opioid epidemic, clinicians are more likely to encounter similar cases of secondary amyloidosis.