Introduction: Gastric amyloidosis is seen in up to 8% of patients. Immunoglobulin light chain amyloidosis (AL) is rarely associated with chronic lymphocytic leukemia (CLL). We report a rare case of symptomatic gastric AL amyloidosis in a patient in CLL presenting as a subepithelial lesion.
Case Description/Methods: 68-year-old male with a medical history of chronic kidney disease, and chronic lymphocytic leukemia presents with 1 month of melanic stools. He had endogastroduodenoscopy (EGD) revealing a duodenal dieulafoy lesion requiring endoclip placement at an outside hospital. Two weeks later he presented with a recurrence of melena. The patient was afebrile with vitals notable for bradycardia to 34 beats per minute. Physical examination revealed subconjunctival pallor without abdominal tenderness. Labs revealed a hemoglobin of 7.4 g/dL, platelets 84 K/uL, Bun 68 mg/dL, and Cr 5.02 mg/dL. Flex sigmoidoscopy showed normal colonic mucosa. EGD revealed the previous endoclip on the anterior wall of the gastric body and a single 5 mm red nodular mass in the gastric fundus. No source of active bleed was identified. The nodule was biopsied. Random biopsies taken from the stomach and colon revealed normal mucosa. Biopsy from gastric nodule revealed apple-green birefringence and AL amyloid. Diagnosis of AL with kappa light chain was verified with bone marrow biopsy and liquid chromatography with tandem mass spectrometry.
Discussion: Only 1% of gastric amyloidosis becomes symptomatic. This patient presented with melena, and his diagnosis was clinically challenging due to the atypical presentation of AL amyloidosis as a submucosal lesion. Endoscopically gastric amyloidosis commonly presents with erosions, erythema, and up to 44% of patients have an endoscopy-negative disease. The submucosal tumor is one of the least common presentations of gastric amyloidosis. His case highlights the importance of a complete evaluation of the cause of upper GI bleeds and how crucial careful endoscopic inspection is to make a diagnosis of gastric amyloidosis.
