IJCS | Volume 31, Nº4, July / August 2018

459 Figure 2 - (A) Skin biopsy showing deposits of amorphous and eosinophilic material on the papillary dermis (hematoxylin-eosin - original 40x magnification). (B) Congo red staining showing amyloid material in the dermal papillae (original magnification 100x and 400x). (C) Amyloid deposit around the sebaceous gland (Congo red - original magnification 400x). (D) Amyloid deposit around adipocytes (Congo red - original magnification 400x). Jorge et al Cardiac amyloidosis Int J Cardiovasc Sci. 2018;31(4)457-460 Case Report systemic amyloidosis. The AL form of amyloidosis is caused by the deposition of immunoglobulin light chains segregated from monoclonal proliferation of plasma cells. Currently, the AL amyloidosis is considered less frequent than TTR. The cardiac diagnosis in patients with AL amyloidosis is often earlier, at a mean age of 65 years and more commonly associated with the female gender, with lower left ventricular mass and lower voltage at the ECG than those with TTR. 2 The AL form of amyloidosis (immunoglobulin light chain deposition disease) may coexist in patients with myeloma in 10 to 15% of cases, such as the patient in this case report. That does not mean the presence of multiple myeloma with secondary amyloidosis, but the coexistence of two separate and concomitant plasma cell diseases. 7 HF in amyloidosis is classically described as either HFpEF or HFrEF (heart failure with reduced ejection fraction) in their more advanced forms. 8 HF guidelines have recognized that there is a gray area between HFrEF and HFpEF, which shows mild systolic dysfunction and has some characteristics of diastolic dysfunction, defined as HF with mid-range ejection fraction (HFmrEF). 3 The patient in this case had LVEF between 40 and 49% both in the second echocardiogram and the cardiac MRI and, therefore, was characterized as having HFmrEF. The disease can be suspected noninvasively through a characteristic low-voltage ECG. Recently, cardiac imaging techniques have allowed the diagnosis to be attained through the echo-doppler-cardiogram with an apical sparing of the longitudinal strain, MRI with transmural global subendocardial late enhancement, and technetium-99m-pyrophosphate myocardial scintigraphy. 1 The definitive diagnosis of amyloid