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+A 62-year-old male presented with a 15-day history of dyspnea on exertion, associated with both lower extremity edema.
+Before this admission, he also had suffered from abdominal bloating and tasteless for a year with noticeable body weight loss at the same time (up to 20 kg).
+Over the past 6 months, he developed a multiple system disorder, which included painless paresthesias in the lower limbs, erectile dysfunction, and chronic diarrhea.
+He had an average stool frequency of up to ten times per day, with no obvious blood or mucus and no abdominal pain or tenesmus.
+Unfortunately, previous stomach and rectum biopsy did not examine for accumulations of amyloid fibril protein.
+His family history was unremarkable.
+On physical examination, his blood pressure was 82/56 mmHg and heart rate was 52 bpm.
+Significant jugular venous distention, moderate hepatomegaly, and lower extremity edema were noted.
+A neurological examination revealed weakness and muscular atrophy in the bilateral tibialis anterior and gastrocnemius.
+Hyporeflexia was noted on both knees and ankles.
+Sensory examination revealed diminished tactile and pain sensation in a stocking and glove pattern and vibratory sensation was distally reduced in the lower limbs.
+The motor and sensory functions of upper extremities were relatively spared.
+Initial laboratory data that included full blood count, transaminase, creatinine, electrolytes, cardiac troponin, and thyroid function were normal or negative.
+N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) was 3,996 pg/mL.
+Nerve conduction studies confirmed bilateral sensory-motor neuropathy (Table 1).
+An electromyography study demonstrated active denervation and chronic reinnervation changes in the tibialis anterior and gastrocnemius.
+Electrocardiogram (ECG) revealed sinus rhythm, low voltages in limb leads, QS waves in precordial and inferior leads, first-degree atrioventricular block, and prolonged QTc (Figure 1).
+Two-dimensional echocardiography revealed marked concentrically thickened and speckled appearance of ventricular walls, biatrial dilatation, and left ventricular ejection fraction of 70% (Figure 2).
+Doppler revealed a severe restrictive mitral filling pattern with E/A ratio 2.1.
+Coronary angiography findings were normal.
+The combined occurrence of low QRS voltage in the ECG, ventricular thickening, and signs of diastolic dysfunction is strongly suggestive of cardiac amyloidosis.
+The following serum λ light-chain concentration was 1,763 (normal range: 598–1,329 mg/dL, and κ light-chain concentration was normal.
+Rectum biopsy confirmed amyloid infiltrate (Figure 3).
+So, the diagnosis of AL amyloidosis was established.
+Despite chemotherapy administration of melphalan, dexamethasone, immunomodulator lenalidomide, and supportive therapy including montmorillonite to decrease diarrhea and low-dose furosemide to alleviate fluid retention, the patient continued to deteriorate and died at home after 3 months after the initial diagnosis.