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Clinical presentation, laboratory manifestations, and diagnosis of immunoglobulin light chain (AL) amyloidosis (primary amyloidosis)

S Vincent Rajkumar, MD
Angela Dispenzieri, MD
Section Editors
Richard J Glassock, MD, MACP
Robert A Kyle, MD
Deputy Editor
Rebecca F Connor, MD


Amyloidosis is a generic term that refers to the extracellular tissue deposition of fibrils composed of low molecular weight subunits of a variety of normal serum proteins. These fibrils have a predominantly antiparallel ß-pleated sheet configuration (noted on x-ray diffraction), and can be identified on biopsy specimens both by their characteristic appearance on electron microscopy and by their ability to bind Congo red (leading to green birefringence under polarized light) and thioflavine T (producing an intense yellow-green fluorescence).

More than 30 distinct low molecular weight proteins are recognized to form amyloid fibrils. The four most common causes of systemic amyloid deposition are:

Immunoglobulin light chain (AL) amyloidosis (previously referred to as primary amyloidosis) in which the fibrils are composed of fragments of monoclonal light chains. Affected patients may have amyloidosis alone or in association with other plasma cell dyscrasias (multiple myeloma, Waldenström macroglobulinemia). All forms of systemic amyloidosis in which the fibrils are derived from monoclonal light chains, regardless of the nature of the underlying plasma cell disorder (eg, monoclonal gammopathy of undetermined significance, multiple myeloma, or Waldenström macroglobulinemia) are considered AL amyloidosis.

Age-related (senile) amyloidosis typically involves the heart and causes a restrictive cardiomyopathy. It is caused by deposition of normal unmutated transthyretin (TTR), which appears to be an inherently amyloidogenic protein. (See "Overview of amyloidosis", section on 'Age-related (senile) systemic amyloidosis'.)

Hereditary (familial) amyloidosis are the result of mutations in genes coding for several different proteins that are normally present in the body. The most common "amyloidogenic proteins" implicated in hereditary amyloidosis are mutated forms of TTR, the alpha chain of fibrinogen A, apolipoprotein AI and AII, lysozyme, and gelsolin. (See "Genetic factors in the amyloid diseases".)

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Literature review current through: Nov 2017. | This topic last updated: Nov 22, 2017.
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