This is a case of a young middle-aged woman with a history of drug use found dead at home with drug paraphenalia nearby. At autopsy, she had high levels of both methamphetamine and fentanyl. However, on anatomic evaluation, she had an enlarged and dilated heart (620 g). That isn’t all that uncommon in my jurisdiction, since many intravenous drug users have endocarditis/valvular disease with resulting functional impairment. However, in this case, the valves were a little thickened, but there were no vegetations. Instead, the heart was rock hard to the touch. It felt as if it had already been fixed in formalin. On histologic examination, there was a lot of interstitial fibrosis, some of which had that amorphous hyaline look you see in amyloid. So, I got a Congo red, and sure enough, it had the characteristic “green apple” birefringence.
Here’s an H&E section of the interventricular septum at the septal base, with a portion of the atrioventricular node (click on the image to see the 7Kx4K version):
As an aside, I recognize the nonuniformity of the background here, but it’s hard to correct for in this instance. For those of you who pay attention to this stuff, I cannot just take a brightfield image and divide it out. This is actually a composite (panorama) stitched together from 42 low power shots. The software I use is great (Hugin is the name), but it does interpolation of brightness as part of the stitching process. Thus, the background is not only nonuniform, but very nonlinear. I tried the simple approach of making a gradient from the brightest background to the lightest and dividing that out, but it looked even worse. The ImageJ/Fij background subtraction didn’t work all that well, either. I’m working on some code to do it in an adaptive manner, making local estimations, but I haven’t finished it yet. If it works, I’ll post it. If you download it, you can dry different background subtraction methods.
In any case, you can see there’s a little fibrosis there. Here’s the polarized Congo Red (once again, click on the image to see the 7Kx4K version):
As another aside, one of my colleagues here noted that everything seems brighter than what he sees in the microscope. He’s right. It’s a bit of a long exposure. Looking directly through the microscope, for instance, the background is black.
Here’s a more random section of myocardium, just to show it’s not just a cardiac skeleton thing:
Secondary amyloidosis, particularly of the kidney and skin, is associated with intravenous drug use. I’m not aware of literature that describes cardiac amyloidosis as a consequence of it, however.
As always, free for use in lecture, or teaching, with or without attribution (though attribution is appreciated). If you put these in a publication, please contact me. Higher resolution images with lossless compression are available on request until I lose them, if you need them for a lecture or such. Email me if you want me to send them to you.