Israel Medical Association Journal

Eosinophilic myocarditis (EM) is a rare form of myocardial inflammation defined by eosinophilic infiltration with associated myocyte injury. Its clinical expression is heterogeneous, ranging from subtle symptoms of heart failure to fulminant cardiogenic shock. Because these features often overlap with other types of myocarditis and systemic conditions, establishing the diagnosis can be difficult. In such cases, endomyocardial biopsy (EMB) remains the reference standard.

Amyloid transthyretin (ATTR) cardiac amyloidosis is an infiltrative cardiomyopathy marked by amyloid fibril deposition in the heart's extracellular space. It usually presents with signs of heart failure, and echocardiography often shows concentric left ventricular hypertrophy (LVH), restrictive physiology, and a distinctive pattern of apical strain sparing. In recent years, the development of non-invasive diagnostic methods, as well as the availability of disease-modifying treatments, has significantly improved diagnosis and management.

To the best of our knowledge, the coexistence of ATTR cardiac amyloidosis and EM has not been previously reported. Such overlap presents distinct diagnostic and therapeutic challenges. These conditions may have synergistic effects on the structure and function of the myocardium. We describe a case of concurrent ATTR cardiac amyloidosis and EM, highlighting the role of multimodality imaging and multidisciplinary management of these overlapping pathologies.

Background: Cardiac amyloidosis (CA) is characterized by the extracellular deposition of misfolded protein in the heart. Precise identification of the amyloid type is often challenging, but critical, since the treatment and prognosis depend on the disease form and the type of deposited amyloid. Coexistence of clinical conditions such as old age, monoclonal gammopathy, chronic inflammation, or peripheral neuropathy in a patient with cardiomyopathy creates a differential diagnosis between the major types of CA: amyloidosis light chains (AL), amyloidosis transthyretin (ATTR) and amyloidosis A (AA).

Objectives: To demonstrate the utility of the Western blotting (WB)-based amyloid typing method in patients diagnosed with cardiac amyloidosis where the type of amyloid was not obvious based on the clinical context.

Methods: Congo red positive endomyocardial biopsy specimens were studied in patients where the type of amyloid was uncertain. Amyloid proteins were extracted and identified by WB. Mass spectrometry (MS) of the electrophoretically resolved protein-in-gel bands was used for confirmation of WB data.

Results: WB analysis allowed differentiation between AL, AA, and ATTR in cardiac biopsies based on specific immunoreactivity of the electrophoretically separated proteins and their characteristic molecular weight. The obtained results were confirmed by MS.

Conclusions: WB-based amyloid typing method is cheaper and more readily available than the complex and expensive gold standard techniques such as MS analysis or immunoelectron microscopy. Notably, it is more sensitive and specific than the commonly used immunohistochemical techniques and may provide an accessible diagnostic service to patients with amyloidosis in Israel.

Background: Transthyretin (TTR)-associated familial amyloid polyneuropathy (FAP) is an autosomal dominant multisystem disease with neurological and extra-neurological manifestations. It is caused by various mutations in the TTR gene leading to the formation of insoluble amyloid.

Objectives: To describe the clinical and genetic findings in patients with TTR-associated FAP in Israel.

Methods: We evaluated eight patients clinically and genetically during the years 2006 to 2011.

Results: At onset, all the patients exhibited sensory loss of the lower and upper limbs, five patients experienced muscle pain, and one patient had lower limb weakness. Five patients had autonomic nervous system manifestations, and four demonstrated evidence of amyloid cardiomyopathy. Nerve conduction studies showed sensorimotor axonal neuropathy in all patients. Sural nerve biopsies were obtained in five patients; only three biopsies revealed amyloid deposit. In four patients of Yemenite descent, genetic analysis of the TTR gene demonstrated ser77tyr mutation. One patient of Tunisian descent and one Ashkenazi patient harbored the val30met mutation. One patient of Iranian descent showed val32ala mutation, and another Ashkenazi patient showed phe33leu mutation.

Conclusions: TTR-associated FAP is a progressive and fatal disease that exists in the Israeli population and is unproportionally common among Yemenite Jews. This disease may be under-diagnosed and should be considered in the differential diagnosis of any patient with rapidly progressive neuropathy, especially with autonomic involvement or extra-neural features. The absence of amyloid in nerve biopsy should not rule out the diagnosis.