PMC3805163_01
A) Low-voltage of QRS complexes and the absence of P wave in all leads on electrocardiography (ECG) performed on hospital admission. B) The results of 24-h Holter ECG reveal a long pause (arrow) and short-run of premature contractions (asterisks). C) Results from a continuous bed-side monitoring device during 1 week around bortezomib subcutaneous injections. The day when the cardiac arrest occurred is referred to as day 0. DEXA, dexamethasone. D) Histopathological analyses of the region of atrioventricular nodes. Deposits of amorphous materials (arrows) can be seen in a hematoxylin and eosin stained section (x100). E) The amorphous deposits (arrows) are stained positively by Congo-red (x100). The asterisks indicate perivascular amorphous materials that are positively stained with Congo-red.
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Electrocardiography (ECG) revealed left-axis deviation, low-voltage QRS complexes, and first degree atrioventricular block (Figure 1A). A 24-h Holter ECG demonstrated 129 beats of ventricular premature contractions (VPCs) and 1268 beats of atrial premature contractions (APCs), including 5 VPC short runs (maximum, 5 runs) and APC short runs (maximum, 8 runs; Figure 1B). AL amyloidosis associated with Bence Jones protein type multiple myeloma (MM). After written informed consent was obtained from the patient, administration of dexamethasone and bortezomib (oral dexamethasone, 20 mg/day, days 1-4; bortezomib, 1.3 mg/m2/day, subcutaneous injection on day 4) was initiated under 24-h ECG monitoring (Figure 1C). Histopathological examination revealed cardiac amyloid deposition, even in the atrioventricular node, and no ischemic lesion was complicated (Figure 1D, E).