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of 51 years&#44; was a consumer of 37 packs of cigarettes&#47;year and occasional user of cocaine and cannabinoids&#44; and until 16 years prior&#44; was an intravenous heroin addict&#44; with HIV infection recognised 25 years prior&#59; received multiple doses of retroviral treatment due to failure and viral resistance issues&#44; and is currently under treatment with maraviroc&#44; raltegravir&#44; darunavir&#44; and norvir&#44; with adequate viral loads and CD4 levels since 1 year prior&#46; An HCV infection was diagnosed in 2006&#44; but treatment was ruled out at that time due to difficulties with compliance&#46; The patient sought treatment for dyspnoea&#44; purulent cough&#44; fever of 40&#186;C&#44; abdominal distension&#44; and general poor physical state with 10 days evolution&#46; Upon hospitalisation the patient was in a poor general state of health&#44; normotensive&#44; afebrile&#44; with severe bradycardia at 45bpm&#46; The physical examination revealed cutaneous-mucosal pallor&#44; soft tissue oedema&#44; bimalleolar cold&#44; prolonged expiratory interval with diminished respiratory sounds in the apical thirds of both hemithoraxes&#44; crepitation and bilateral rhonchi&#44; distended abdomen with diffuse pain upon deep palpation&#44; timpani to sound&#44; and absence of bowel sounds&#46;</p><p class="elsevierStylePara">Complementary examinations revealed normocytic&#47;normochromic anaemia at 10&#46;9g&#47;dl&#44; leukocytosis at 11&#160;700x10<span class="elsevierStyleSup">3</span>&#47;&#181;l&#44; with neutrophilia and lymphopoenia &#40;85&#37; and 8&#37;&#44; respectively&#41;&#46; We also observed elevated urea and creatinine values &#40;293mg&#47;dl and 9&#46;53mg&#47;dl&#44; respectively&#41;&#44; hyperkalemia at 7mEq&#47;l&#44; and hyponatraemia at 125mEq&#47;l&#44; with metabolic acidosis&#46; The urine sediment analysis revealed a red blood cell count of 563 cells&#47;&#181;l&#44; leukocytes at 103 cells&#47;&#181;l&#44; proteins at 351mg&#47;dl&#44; and Fe Na&#43; was 2&#46;6&#37;&#46; Antigenuria for pneumococcus was positive&#46; We observed heterogeneous opacities with apex air bronchograms in both lung fields in the chest x-ray&#46; The abdominal x-ray showed diffuse colon dilation&#44; with no view of flatulence&#46; An abdominal ultrasound taken as an emergency procedure showed the kidneys at 15cm &#40;nephromegaly&#41; with cortical hyperechogenicity&#44; symmetrical resistive index&#44; and free ascites&#46; The ECG indicated nodal rhythm&#46; We performed a computed tomography of the abdomen&#44; observing oedema of the subcutaneous cellular tissue&#44; bilateral pleural effusion&#44; ascites&#44; and mural thickening of the small intestinal loops&#44; with no evidence of occlusion&#44; subocclusion&#44; or findings indicative of ischaemia&#46; We also observed globular kidneys with significant phase delay and attenuation&#46;</p><p class="elsevierStylePara">The patient had satisfactory evolution in terms of the respiratory infection &#40;following antimicrobial treatment&#41; and abdominal distension&#46; However&#44; the deteriorated renal function persisted&#44; with glomerular filtration rates close to 18ml&#47;min&#46; The 24-hour urine analysis revealed proteinuria at 22g and persistent microscopic haematuria&#46; The tentative diagnosis of complex nephrotic syndrome led to a renal biopsy&#44; in which we observed a total of 11 glomeruli&#44; with diffuse&#44; global mesangial expansion and a positive Congo red stain for acellular nodes&#44; thickening of the basal capillary membranes&#44; dilated tubules with dense intratubular casts and some inflammatory cells&#44; and interstitial oedema &#40;Figure 1&#41;&#46; The permanganate test also resulted positive&#46; The immunohistochemical analysis was positive only for amyloid AA&#46;</p><p class="elsevierStylePara">We did not identify any neoplastic&#44; infectious&#44; autoimmune&#44; or anti-inflammatory pathologies that could explain the presence of the secondary amyloidosis&#46;</p><p class="elsevierStylePara">The relationship between the subcutaneous and&#47;or intravenous consumption of drugs&#44; above all heroin&#44; and the development of secondary amyloidosis has been well-known for over 30 years&#44;<span class="elsevierStyleSup">1-3</span> mainly in patients that develop repeated cutaneous infections&#46; Until now&#44; only two cases have been recorded in the literature<span class="elsevierStyleSup">4&#44;5</span> of patients infected with this virus and with amyloidosis that have no history of drug consumption&#46; Despite the unclear nature of the relationship between amyloidosis and HIV&#44; it has been observed that serum amyloid A protein &#40;SAA&#41; levels are high in these patients&#44;<span class="elsevierStyleSup">6</span> which would&#44; in theory&#44; predispose the patient to the development of amyloidosis&#46; The mechanism that could explain the increased secretion of amyloid A is the reduction of IL-2 levels<span class="elsevierStyleSup">7</span> due to HIV infection&#44; which would cause a decreased expression of the IL-1 receptor antagonist &#40;IL-1Ra&#41;&#44; which in turn would stimulate tumour necrosis factor alpha &#40;TNF&#945;&#41; and interleukin 6 &#40;IL-6&#41; and the activation of NF&#954;&#8722;&#946;&#8218; which stimulates the production of SAA&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">In the case of our patient&#44; given the long evolution of the HIV infection and long history of parenteral drug consumption&#44; it would be impossible to discern the cause of the amyloidosis&#44; which could be due to drug consumption and recurrent infections&#44; the HIV infection&#44; or perhaps the sum of all of these factors&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11026&#95;108&#95;25093&#95;en&#95;11026&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11026_108_25093_en_11026_f1.jpg" alt="Positive Congo red staining for mesangial deposits "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Positive Congo red staining for mesangial deposits </p>"
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