Mystery in the mediastinum: Rare case of indolent primary thoracic amyloids

A 53-year-old African American male smoker presented with epigastric pain, tarry stools, and laboratory results indicative of acute pancreatitis. Chest X-ray showed a right perihilar mass with pleural effusion. Computed tomography scan showed multiple large right paratracheal and hilar nodes with internal calcification. The patient underwent a fiberoptic bronchoscopy with biopsies which were negative for malignancy. Mediastinoscopy was performed and revealed amyloidosis. Evaluation for multiple myeloma showed elevated kappa and lambda light chains and diffuse polyclonal gammopathy, but there was no monoclonal spike on serum protein electrophoresis. Bone marrow and abdominal fat pad were negative for amyloid, and the patient continues to lack chronic underlying systemic disease with no symptoms on cardiac or pulmonary examination.