A 57-year-old woman with no significant personal or familial medical history. She was seen for progressive dyspnea of 10-months duration and an increase in the MMII perimeter. On physical examination, there were signs of predominantly right-sided congestive cardiac insufficiency, and an ECG showed low voltage. An echocardiogram (Figures 1A and 1B) was performed that showed thickening of the ventricular walls, the mitral valve, and intra-atrial septum, and a dense spot in the VI myocardium, all suggesting cardiac amyloidosis. A right ventricular biopsy and tincture with congo red supported the echocardiography findings: a nodular interstitial and vascular wall protein deposit (Figure 2A), decreasing the lumen diameter was seen (Figure 2B). With polarized light (Figure 2C), green apple birefringence can be seen, characteristic of amyloidosis.
Fig. 1.
Fig. 2.