A 48-year-old woman with conjunctival amyloidosis and a history of oral ulcers (Fig. 1), previously treated with amoxicillin for presumed acute pharyngitis, presented with a cough lasting one month. She endorsed fatigue and weight loss, denying fevers, chills, or shortness of breath. Outpatient chest X-ray showed calcified densities and lymph nodes, and CT imaging (Fig. 2), in the emergency department, further revealed extensive bilateral tree-in-bud opacifications, lymphadenopathy, and cystic changes concerning for Tuberculosis. However, subsequent TB testing was negative. Bronchoscopy revealed scattered yellow mucosal lesions in the trachea, bronchi, and vocal cords; biopsies confirmed systemic amyloidosis. Both tracheobronchial and conjunctival amyloidosis have been considered as distinct, localized conditions, infrequently part of systemic amyloidosis. On the other hand, septal-alveolar and oral amyloid deposits are more commonly found in patients with systemic disease. This makes concurrent involvement of the eye, oral mucosa, upper airway, and tracheobronchial tree highly unusual.1,2 Clues pointing toward amyloidosis before biopsy included her long-standing oral ulcers and prior conjunctival involvement, which are both sites of potential localized amyloid deposition. This case highlights the importance of amyloid typing and that a work-up for systemic involvement should be pursued based on the clinical presentation and context of amyloid deposition.
