Persistent Fever and Destructive Arthritis Caused by Dialysis-Related Amyloidosis

Dialysis-related amyloidosis (DRA) can present rheumatic manifestations in patients on long-term hemodialysis. Typical articular symptoms with DRA involve carpal-tunnel syndrome, effusion in large joints, spondyloarthropathy, or cystic bone lesions, which are usually with non-inflammatory processes.

A 64-year-old man on hemodialysis for >30 years was admitted because of intermittent fever, polyarthritis, and elevated serum C-reactive protein (CRP) level, which was continuous for 2 years. Several antibiotics were ineffective for 3 months before his admission. On physical examination, joint swelling was observed at bilateral wrists, knees, ankles, and hip joints. Laboratory tests revealed elevation of serum inflammatory markers and b2-microglobulin (b2-MG). Synovial fluid showed predominant infiltration of polymorphonuclear leukocytes and the increase of b2-MG level.

Significant deposition of b2-MG with inflammatory cell infiltration was found in biopsied samples from synovium, skin, and ileum.

We decided to switch to the hemodialysis column with membrane that can effectively absorb b2-MG in circulation.

The relief of symptoms and a decrease of CRP level by changing the membrane lead to the final diagnosis of DRA.

Our case demonstrates that DRA arthropathy can be inflammatory and destructive, and also develop systemic inflammatory signs and symptoms. In such cases, aggressive absorption of b2-MG in circulation might help the amelioration of symptoms.