CASE REPORT May-June, Vol. 14 No. 3, 2015: 416-419 Cutaneous amyloidosis associated with autoimmune hepatitis-primary biliary cirrhosis overlap syndrome Emmanuel I. González-Moreno,* Carlos R. Cámara-Lemarroy,** David O. Borjas-Almaguer,** Sylvia A. Martínez-Cabriales,*** Jonathan Paz-Delgadillo,* Rodrigo Gutiérrez-Udave,* Ana S. Ayala-Cortés,*** Jorge Ocampo-Candiani,*** Carlos A. Cortéz-Hernández,* Héctor J. Maldonado-Garza* * Servicio de Gastroenterología, ** Departamento de Medicina Interna, *** Servicio de Dermatología. Hospital Universitario Dr. José E. González. Universidad Autónoma de Nuevo León. Monterrey, N.L. México. ABSTRACT Cutaneous amyloidosis is a rare disease characterized by the deposition of amyloid in the dermis. It can be primary or secondary, depending on associated diseases. It has been linked to various autoimmune diseas- es, including primary biliary cirrhosis. We present the case of a patient with an autoimmune hepatitis-pri- mary biliary cirrhosis overlap syndrome with concomitant cutaneous amyloidosis, a very unusual association, and discuss similar cases and possible pathophysiological implications. Key words. Amyloid. Autoimmunity. Cholestasis. Pruritus. INTRODUCTION CASE REPORT Amyloidosis can be classified as either systemic or A 36-years-old male patient presents with pruritic cutaneous, with both primary and secondary forms. papules with brownish pigmentation of his arms for Histopathologic evidence of extracellular deposition 5 months. The patient also referred 3 months with of amyloid protein (apple-green birefringence in Con- icteric jaundice, acholia and choluria. During this go red stained slides under polarized light) within period, the patient reported no fever, use of medica- the dermis is the prominent characteristic of cutane- tions or blood transfusions. On physical examination ous amyloidoses.1,2 Autoimmune hepatitis (AIH), there were several hyperpigmented papules super primary biliary cirrhosis (PBC) and primary sclero- imposed upon macular areas over extensor surfaces sing cholangitis (PSC) are the three main variants of arms and legs, also hyperpigmented macules with of autoimmune liver disease, and when patients a rippled appearance on upper chest and upper back present with clinical, biochemical or histopathologi- (Figures 1A and 1B). A painless liver with a thick cal features of more that one of these entities, they edge 1 cm below the right costal margin was noted. are called overlap syndromes.3,4 We present a case of No evidence of chronic liver disease. a patient showing AIH-PBC overlap syndrome and Laboratory exams revealed: simultaneous primary localized cutaneous amyloido- sis (PLCA), an extremely rare association. • Total bilirubin = 6.2 mg/dL (normal value: 1.0 mg/dL). • Direct bilirubin = 3.4 mg/dL (0.4 mg/dl). • Gamma-glutamyltransferase = 849 U/l (30 U/l), and • Alkaline phosphatase = 767 U/l (250 U/l). • Alanine aminotransferase = 254 U/I (48 U/I) and Correspondence and reprint request: Emmanuel I. González-Moreno, M.D. • Aspartate aminotransferase = 231 U/I (49U/I). Servicio de Gastroenterología. Hospital Universitario Dr. José E. González. Universidad Autónoma de Nuevo León. Monterrey, N.L. México. Madero y Gonzalitos S/N, Monterrey, Nuevo León. 64460 México. Serology for hepatitis A, B and C was negative, Tel./Fax: (+52) 818333-7798 and the iron store profile was normal. Ultrasound of E-mail: [email protected] the liver only showed a homogeneous liver in the ab- Manuscript received: August 18, 2014. sence of biliary lithiasis or dilatation of the bile Manuscript accepted: October 01, 2014. ducts. 417 Cutaneous amyloidosis associated with AIH-PBC overlap syndrome. , 2015; 14 (3): 416-419 Skin biopsy with Congo red staining revealed an may co-exist in the same patient and is known as apple-green birefringence under polarized light (Fig- biphasic amyloidosis. Systemic amyloidosis, famil- ure 1C). These lesions were diagnosed as the macu- ial and hemodialysis-associated amyloidosis are lar form of PLCA. may also present with skin involvement.5,6 Nodular Determination of serum anti-mitochondrial anti- amyloidosis typically presents as crusted nodules body (AMA) and anti-smooth muscle antibody on the face, acral sites or the extremities. Macular (ASMA) was positive (1:320). amyloidosis is characterized by brownish macules The patient was submitted to a percutaneous liv- in a rippled pattern, distributed predominantly over er biopsy to rule out hepatic involvement with depo- the trunk and extremities. Papular amyloidosis sition of amyloid material. The liver biopsy showed present as pruriginous brownish papular eruptions non-suppurative destructive cholangitis with ducto- in the trunk and extremities and characterized by penia with interface hepatitis and the absence of an amyloid deposits in the papillary derma.1,2 amyloid deposit after staining with Congo red (Fig- AIH, PBC and PSC are the three main variants ures 2A and 2B). of autoimmune liver disease, and can all present as The patient was treated with a combination of ur- overlap syndromes.3,4 The AIH-PBC overlap syn- sodeoxycholic and prednisone. Unfortunately, there drome is the most common form, affecting almost the patient did no show to the follow-up visits. 10% of adults with AIH or PBC.3,4 Overlap syn- dromes show a very aggressive course, rapidly pro- DISCUSSION gressing to liver cirrhosis and liver failure without prompt diagnosis and treatment. Primary localized cutaneous amyloidosis (PLCA) Although rarely there can be cases of isolated consists of the deposition of amyloid in previously deposition of amyloid in the liver (primary hepatic healthy skin with no systemic involvement, and is amyloidosis), both immune and non-immune mediat- usually classified into three major forms, lichen ed liver diseases have also been associated with amyloidosis, the commonest type, macular, and a PLCA. While chronic hepatitis C virus infection has rare nodular form.1,2 Macular and papular forms been reported to co-occur in at least two cases, sug- gesting it could consist in another extrahepatic manifestation,7,8 hepatitis B infection has only been associated with systemic amyloidosis to date.9 A case of nodular cutaneous amyloidosis in a patient with chronic alcoholic liver cirrhosis has also been recently reported.10 However, an important associa- tion between amyloidosis and autoimmune liver dis- eases has been recognized recently. Systemic AA amyloidosis has been associated with PBC11,12 and PSC.13,14 There is only one case in the published lit- erature associating PBC and cutaneous amyloidosis in a 41 year old woman.15 AB Figure 1. Poorly delimited hyperpigmented macules pre- dominating on the trunk and limbs (A, B). Histopathological features of skin biopsy showing amorphous eosinophilic mate- Figure 2. Liver biopsy shows non-suppurative, destructive rial in the dermis and an apple-green birefringence under po- cholangitis wit ductopenia and interface hepatitis. There is an larized light with Congo red staining. absence of an amyloid deposit after staining with Congo red. 418 González-Moreno EI, et al. , 2015; 14 (3): 416-419 The precise pathogenesis of PLCA has not been and/or azathioprine, according to the course of dis- elucidated, but an increasing number of reports in ease.3,4 Liver transplantation is the treatment of the literature have associated it to autoimmune dis- choice in the setting of end-stage liver disease. Our orders, which suggests the possibility of a common patient was treated with a combination of ursodeox- underlying immune-mediated mechanism.16 Condi- ycholic and prednisone; however, a very important tions as diverse as Sjogren, Behcet, IgA nephropa- limitation in this case is that the patient did not thy, systemic lupus erythematosus and systemic show to follow-up consultations, thereby, we could sclerosis have been associated with PLCA.16-19 Nod- not evaluate the effect of treatment. ular cutaneous amyloidosis results from extra-cellu- lar deposition of fibril-forming monoclonal CONFLICT OF INTEREST immunoglobulin-derived light chains produced by a small plasma cell clone, and in systemic amyloidosis The authors declare no conflict of interest. the average plasma cell bone marrow infiltration is All authors read and approved the final manu- 7%. Abnormal folding of the light chains leads to script. amyloid deposition. In macular and papular amy- loidosis, an accepted theory is that amyloid could REFERENCES derive from apoptotic keratinocyte-released cytoker- 1,2 1. Borowicz J, Gillespie M, Miller R. Cutaneous amyloidosis. atin degradation. Skinmed 2011; 9: 96-100; quiz 1. It has been shown that cultivated keratinocytes 2. Schreml S, Szeimies RM, Vogt T, Landthaler M, Schroeder are damaged by bilirubin, and hyperbilirubinemia J, Babilas P. Cutaneous amyloidoses and systemic amy- can lead to widespread epidermal injury.20 In our loidoses with cutaneous involvement. Eur J Dermatol 2010; 20: 152-60. case, we surmise that bilirubin deposition in skin 3. Rust C, Beuers U. Overlap syndromes among autoimmune could have led to keratinocyte apoptosis and cytok- liver diseases. World J Gastroenterol 2008; 14: 3368- eratin release, leading to amyloid production. Inter- 73. estingly, overlap liver autoimmune diseases are also 4. Durazzo M, Premoli A, Paschetta E, Belci P, Spandre M, Bo S. Overlap syndromes of autoimmune hepatitis: an open associated to alterations in plasma cells and in im- question. Dig Dis Sci 2013; 58: 344-8. munoglobulin production. Besides a chronic hepati- 5. Desport