Primary Vesical Amyloidosis Masquerading as Vesical Calculus in a Retroviral Positive Patient

Abstract

The common causes of irritative voiding symptoms in women include cystitis, vesical calculi, carcinoma bladder and neurologic disorders. Isolated primary vesical amyloidosis (VA) is a rare cause of irritative voiding symptoms. A 50-year-old female, a known case of retroviral disease but not on anti-retroviral therapy, presented with right flank and suprapubic pain for six months, worsening over the past 15 days with dysuria. She also presented with increased frequency of micturition with nocturia and urgency for the same duration. She had no hematuria, other lower urinary tract symptoms or fever. Clinical examination revealed suprapubic tenderness. Ultrasonogram (USG) revealed 1.7 cm vesical calculus. Cystoscopy revealed three spiky vesical calculi. There was a fluffy lesion with mucosal edema over the right lateral wall in the region of the right ureteric orifice, which was biopsied. Biopsy showed fragments of urothelial mucosa with focal areas of ulceration. The underlying stroma was edematous with amorphous pale eosinophilic acellular deposits. Congo red stain showed apple-green birefringence under polarized microscopy suggestive of amyloid. Sections were negative for dysplasia, granulomas or malignancies. VA presents with intermittent gross hematuria in up to 77% patients and irritative voiding symptoms in 23% patients. VA is an uncommon differential diagnosis of cancer urinary bladder, with less than 200 cases reported in the literature. Hence we report this case to highlight that primary VA should also be considered in the evaluation of irritative voiding symptoms.