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a senile variant or wild-type ATTR &#40;wt-ATTR&#41; and another resulting from pathogenic variants of the TTR gene &#40;m-ATTR&#41; of which approximately 100 pathogenic variants have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;3&#44;6&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">M-ATTR is a progressive and fatal disease&#44; with considerable variability in the clinical manifestations&#44; which are predominantly neurological &#40;in the form of sensory-motor neuropathy&#41; and cardiac &#40;in the form of cardiomyopathy&#41;&#46; This variability depends on the genetic variant&#44; transmitted in an autosomal dominant manner with variable phenotypic penetrance&#44; and on factors such as the geographical area&#44; leading to significant difficulty in its diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;5&#44;7&#44;9&#44;10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We selected 63 patients with suspected TTR amyloidosis in the University Clinic Hospital of Zaragoza&#44; 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scintigraphy &#40;uptake of 99mTc-DPD in the heart&#41;&#44; echocardiogram &#40;thickening of the left ventricular free wall &#91;&#62;12<span class="elsevierStyleHsp" style=""></span>mm&#93; or of the septum &#91;&#62;13<span class="elsevierStyleHsp" style=""></span>mm&#93; and&#47;or granular pattern&#41;&#44; cardiac magnetic resonance imaging &#40;MRI&#41; &#40;late gadolinium enhancement&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Electroneurography&#47;electromyography compatible with familial amyloid polyneuropathy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">History of amyloidosis of unknown origin&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Exclusion criteria&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Underage patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patient refusal&#46;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">We included patients who met 2 or more criteria to obtain a sample with a high probability of ATTR&#46; Once the patients were selected&#44; they were informed about the study and asked for their appropriate consent&#46; They then underwent a genetic study using Sanger sequencing&#46; First-degree relatives of those patients with positive results were offered the option of a study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We studied 63 patients&#44; half of whom were male&#44; with a mean age of 73&#46;08 &#40;&#177;17&#46;8&#41; years&#44; and 95&#37; were Spanish&#46; The symptoms presented at diagnosis were predominantly cardiac &#40;dyspnea&#44; chest pain and edema&#41; and neurological &#40;paresthesia and muscle weakness&#41;&#46; There were 7 cases positive for m-ATTR distributed among 3 families and 3 polymorphisms not associated with disease&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The 3 cases with genetic variants of TTR are described below&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Family A</span>&#46; Genetic variant Glu74Gln &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A 43-year-old woman from Romania&#44; with no family history but with a history of bilateral CTS who was admitted for decompensated heart failure &#40;HF&#41;&#46; During her hospitalization&#44; the patient underwent numerous additional tests&#44; which revealed restrictive cardiomyopathy in the echocardiogram and suspected amyloidosis in the cardiac MRI&#46; The genetic study found the genetic variant Glu74Gln&#46; While on the waiting list for a heart and liver transplant&#44; the patient died after experiencing a massive ischemic stroke&#46; Genetic counseling was provided to her 2 children&#44; a healthy male and a daughter who carried the same genetic variant in heterozygosity&#46; The daughter is currently asymptomatic and in follow-up in internal medicine consultations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Family B&#46;</span> Genetic variant Val142Ile&#44; in heterozygosity &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; An 86-year-old Spanish woman&#44; with no family history but with a history of arterial hypertension &#40;AHT&#41;&#44; atrial fibrillation and HF&#44; was admitted for symptoms of decompensated HF&#46; Tests revealed symmetrical ventricular hypertrophy suggestive of senile amyloidosis&#46; The results of a monoclonal gammopathy study were negative&#44; NT-proBNP levels were high&#44; and fine-needle aspiration cytology of abdominal fat was negative&#46; Scintigraphy was not performed&#46; A genetic study was requested&#44; which showed the genetic variant Val142Ile&#46; The patient&#39;s 90-year-old sister was also examined&#46; The sister had a history of AHT&#44; HF and macular degeneration and was admitted for syncope secondary to a complete atrioventricular block&#46; The echocardiogram revealed moderate valvular heart disease and preserved ejection fraction&#46; Neither scintigraphy nor biopsy was performed on the sister&#46; The genetic study detected the same variant as in her sister&#44; Val142Ile&#46; The genetic study was performed on the rest of the family&#44; detecting the same genetic variant in a 42-year-old nephew&#44; who was asymptomatic&#46; The results of additional tests on the nephew showed normal values&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Family C&#46;</span> Genetic variant Val142Ile&#44; in homozygosity &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A 59-year-old Ghanaian woman&#44; with a medical history of AHT&#44; type 2 DM&#44; dyslipidemia&#44; lacunar stroke without sequela&#44; chronic pulmonary thromboembolism and pulmonary fibrosis and user of home oxygen therapy&#46; The echocardiogram revealed infiltrative cardiomyopathy with severe concentric hypertrophy&#44; preserved systolic function&#44; restrictive filling pattern and severe pulmonary hypertension&#46; The cardiac MRI suggested cardiac amyloidosis as the first option&#46; The patient presented dyspnea &#40;New York Heart Association functional class II-III&#41;&#46; Myocardial scintigraphy revealed intense uptake in both ventricles&#46; The results of the fine-needle aspiration cytology of subcutaneous fat were negative&#44; and a genetic study was positive for ATTR due to the genetic variant Val142Ile in homozygosity&#46; The patient&#39;s daughter underwent the genetic study&#44; which revealed that the daughter carried the same pathogenic variant&#46; Two of the patient&#39;s nieces underwent the test with negative results&#46; We assume that the parents of the index case were carriers of the genetic variant due to the involvement in homozygosity of the index case&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">We present the pathogenic variants of 3 families with compatible symptoms and positive genetic study results for amyloidogenic variants&#46; The Zaragoza area &#40;Aragon&#41; is a nonendemic area for m-ATTR&#46; This sample is obviously highly selected&#44; and the results of this study cannot therefore be extrapolated to the general population&#46; The study should also not be viewed as a prevalence study&#46; However&#44; the presence of 3 cases of a rare disease in a sample of only 63 patients has a certain value and suggests we are faced with an underdiagnosed disease&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The first family presented the pathogenic variant Glu74Gln&#44; whose initial involvement is usually CTS&#44; with subsequently cardiac manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> This genetic variant has been described in 2 Romanian individuals&#44; as well as in our index case&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> These data suggest that there are clusters in regions considered nonendemic&#44; from which we have no data&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The other 2 families presented the pathogenic variant Val142Ile&#44; one in heterozygosity and the other in homozygosity&#46; As described in the literature&#44; this genetic variant is the most common in the US &#40;23&#37;&#41;&#44; especially in individuals of African-American descent&#44; and is rare in other ethnic groups&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> The frequency of this variant in the white and Hispanic population in the US is 0&#46;44&#37; and 0&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> In our population&#44; the first family described is Spanish&#44; and the second was Ghanaian&#44; which shows that cases can occur in nonendemic areas&#44; native and imported&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The Val142Ile allele generally presents in heterozygosity and with cardiac symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#44;6</span></a> Our 2 families started with cardiac impairment and&#44; in the homozygous patient&#44; with pulmonary involvement categorized as &#8220;fibrosis&#8221;&#44; which we have not been able to confirm due to the negative results of the lung biopsy&#46; Pulmonary involvement in m-ATTR consists mainly of diffuse alveolar septal amyloidosis&#44; which can be confused with pulmonary fibrosis if amyloid deposits are not specifically searched for&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In our series&#44; 2 families presented with the variant Val142Ile&#44; one of the patients in homozygosity and the others in heterozygosity&#46; Although not the rule&#44; homozygous cases typically develop symptoms approximately 10 years before heterozygous cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Certain gene variants are characterized by their strong genotype&#47;phenotype correlation and are associated with predominantly neurological &#40;Val50Met&#41;&#44; cardiac &#40;Val142Ile&#41; or mixed &#40;Thr80Ala&#41; disease&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Nevertheless&#44; this disease has a considerable phenotypic variability&#44; which impedes its diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">This difficulty is greater in nonendemic areas and in atypical cases&#44; such as the ones we presented&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The first case is significant due to its rare and imported variant&#46; The second case stands out for being a variant with homozygous involvement and with possible pulmonary involvement&#46; The third case is important for being diagnosed in a native family from a nonendemic area affected by a pathogenic variant almost exclusively of the African-American population&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">This study highlights the need to include ATTR in our differential diagnosis of diseases as common as peripheral neuropathy and heart failure with preserved ejection fraction&#44; especially in young patients with no clear etiology&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study&#39;s limitations include the small sample size&#44; due to the fact that we decided to require 2 inclusion criteria from the patients&#44; which increased the possibility of recruiting positive patients&#59; however&#44; just one of the previously mentioned criteria would have been sufficient to include them in the differential diagnosis of ATTR&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">ATTR is a rare disease that manifests mainly in endemic areas but can appear in any population&#44; both in native and immigrant patients&#46; Maintaining a high index of suspicion is essential for initiating the appropriate diagnostic methods for an early diagnosis of the disease&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">The present study was partially funded by <span class="elsevierStyleGrantSponsor" id="gs1">Pfizer</span>&#46;</p></span></span>"
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          "titulo" => "Resumen"
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    "fechaRecibido" => "2018-07-20"
    "fechaAceptado" => "2018-09-17"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1095905"
          "palabras" => array:5 [
            0 => "Hereditary amyloidosis"
            1 => "Transthyretin"
            2 => "Cardiomyopathy"
            3 => "Polyneuropathy"
            4 => "Heterogeneous disease"
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        ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Amiloidosis hereditaria"
            1 => "Transtiretina"
            2 => "Miocardiopat&#237;a"
            3 => "Polineuropat&#237;a"
            4 => "Enfermedad heterog&#233;nea"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are 2 types of amyloidosis caused by transthyretin deposits&#58; the wild type &#40;wt-ATTR&#41; and the mutant type &#40;m-ATTR&#41;&#44; transmitted by autosomal dominant inheritance with variable penetrance&#44; manifesting with neurological and&#47;or cardiac symptoms&#46; We report on 3 families affected by m-ATTR diagnosed in a nonendemic area&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We studied 63 patients with a high suspicion of ATTR&#46; The diagnosis was subsequently performed by magnification through polymerase chain reaction of DNA&#46; For the positive cases&#44; we studied the first-degree relatives&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We detected 7 positive cases of m-ATTR&#44; distributed among 3 families &#40;Glu74Gln&#44; Val142Ile in heterozygosity and Val142Ile in homozygosity&#41;&#44; and 3 cases of nonpathogenic variants&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hereditary ATTR is a rare disease but is present in nonendemic areas and should therefore be considered in the differential diagnosis of patients with polyneuropathy and&#47;or heart failure with preserved ejection fraction&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedente y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existen 2 tipos de amiloidosis producidas por dep&#243;sitos de transtiretina&#44; el tipo salvaje &#40;wt-ATTR&#41; y el tipo mutante &#40;m-ATTR&#41;&#44; transmitido por herencia autos&#243;mica dominante con penetrancia variable&#44; manifest&#225;ndose con cl&#237;nica neurol&#243;gica y&#47;o card&#237;aca&#46; Describimos 3 familias afectadas por m-ATTR diagnosticadas en un &#225;rea no end&#233;mica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 63 pacientes con alta sospecha de amiloidosis TTR&#46; Posteriormente&#44; el diagn&#243;stico se realiz&#243; por amplificaci&#243;n mediante PCR de ADN y en los casos positivos se estudiaron a los familiares de primer grado&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se detectaron 7 casos positivos para m-ATTR&#44; distribuidos en 3 familias &#40;Glu74Gln&#44; Val142Ile en heterocigosis y Val142Ile en homocigosis&#41; y 3 casos de variantes no patog&#233;nicas&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La amiloidosis hereditaria por TTR es una enfermedad rara&#44; pero presente en &#225;reas no end&#233;micas&#44; por lo que debe tenerse en cuenta en el diagn&#243;stico diferencial de los pacientes con polineuropat&#237;a y&#47;o insuficiencia cardiaca con fracci&#243;n de eyecci&#243;n preservada&#46;</p></span>"
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            "titulo" => "Material y m&#233;todos"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gracia Guti&#233;rrez A&#44; Bueno Juana E&#44; Lahuerta Pueyo C&#44; Menao Guill&#233;n S&#44; Escota Villanueva J&#44; Aibar Arregui M&#193;&#46; Presentaci&#243;n at&#237;pica de amiloidosis por transtiretina en un &#225;rea no end&#233;mica&#46; Rev Clin Esp&#46; 2019&#59;219&#58;141&#8211;144&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Family A&#46; Mother and daughter carriers of the genetic variant Glu74Gln&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Family B&#46; Sisters and nephew carriers of the genetic variant Val142Ile&#46; Family C&#46; Mother with the genetic variant Val142Ile in homozygous form&#46; Daughter carrier of the same genetic variant&#46;</p>"
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                      "autores" => array:1 [
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                            1 => "J&#46; Gilmore"
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                        ]
                      ]
                    ]
                  ]
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            1 => array:3 [
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                            5 => "M&#46; Saraiva"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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            2 => array:3 [
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                          "etal" => false
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                            1 => "L&#46;J&#46; Anderson"
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                  ]
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Brief Original
Atypical presentation of transthyretin amyloidosis in a non-endemic area
Presentación atípica de amiloidosis por transtiretina en un área no endémica
A. Gracia Gutiérreza,
Corresponding author
agraciagut@gmail.com

Corresponding author.
, E. Bueno Juanaa, C. Lahuerta Pueyob, S. Menao Guillénb, J. Escota Villanuevac, M.Á. Aibar Arreguia
a Departamento de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Departamento de Bioquímica Clínica y Patología Molecular, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
c Departamento de Cardiología, Hospital Clínico Universitario Lozano Blesa, ISS-Aragón, Zaragoza, Spain

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