Medical Student Texas Tech University Health Sciences Center, School of Medicine Amarillo, Texas
Agent Orange (AO) was the most utilized tactical herbicide by the US military during the Vietnam war. Much research has focused on the association between AO metabolites and several disorders, including systemic AL amyloidosis. This paper presents a rare case of heart failure secondary to cardiac AL amyloidosis (AL-CA) as a consequence of Agent Orange exposure, and discussion of this case may assist clinicians in the recognition and treatment of similar cases. A 71-year-old man with known heart failure, peptic ulcer disease, and coronary artery disease was transferred from Veterans Affairs with elevated troponin and a possible gastrointestinal bleed. He reported dyspnea, swelling of extremities, and melena for a day as well as worsening fatigue for several months. He had frank blood on digital rectal examination with elevated brain natriuretic peptide and creatinine. Electrocardiogram showed sinus rhythm with low voltage in the limb leads. He was admitted to ICU as he was requiring oxygen, vasopressors, pantoprazole drip, and transfusion of red blood cells. Echocardiogram revealed concentric left ventricular “hypertrophy”, dilated atria, thickened mitral and tricuspid valves, and impaired left ventricular diastolic function with preserved ejection fraction in a restrictive filling pattern. Serum and urine measurements of lambda and kappa free light chains were elevated with a ratio of 14.37. Abdominal fat pad biopsy confirmed AL amyloidosis; multiple myeloma was ruled out with bone marrow biopsy. The patient confirmed deployment in the Vietnam War from 1969-1971 with significant AO exposure. Subsequent care was taken over by Veterans Affairs. Identifying the presence of cardiac amyloidosis is important as the treatment goal is to prevent further amyloid deposition and deterioration of cardiac function; therapy includes loop diuretics, aldosterone antagonists, and salt restriction while the regimen for preventing further amyloid deposition is cyclophosphamide, bortezomib, and dexamethasone.