Aguiar Rosa, S

Brás, P

Cardoso, I

Viegas, JM

English

Repositório do Centro Hospitalar de Lisboa Central, EPE

TAGGEDENDCLINICAL COMMUNICATION TO THE EDITORTaggedFigure TaggedEndTaggedH1Popeye Deformity: A Red Flag forWild-Type TransthyretinAmyloidosis TaggedEndTo the Editor:TAGGEDH1CASE REPORT TAGGEDENDTaggedPA 72-year-old man with past medical history of hyperten-sion was referred to a cardiology consultation due to recentheart failure hospitalization and newly diagnosed atrialfibrillation. Physical examination revealed a large bulge onhis anterior mid-upper left arm, more pronounced duringelbow flexion (Figure). This deformity had developed sev-eral months before, after lifting a heavy object. He remem-bers hearing a “pop” sound, followed by a sudden sharppain and weakness in his left arm. He did not seek medicalTaggedFigureFigure Patient’s left arm in flexion positioceived in the anterior mid-upper arm. TaggedEndTaggedEndTaggedEndFunding: None declared.TaggedEndConflicts of Interest: None declared.TaggedEndAuthorship: JMV was the major contributor in writing the manuscript.The remaining authors revised the manuscript. All authors read andapproved the final manuscript.TaggedEndRequests for reprints should be addressed to Jose Miguel Viegas, MD,Department of Cardiology, Hospital de Santa Marta, Centro HospitalarUniversitario de Lisboa Central Rua de Santa Marta 50, 1169-024, Lisbon,Portugal.E-mail address: miguel09@gmail.com0002-9343/$ -see front matter © 2023 Elsevier Inc. All rights reserved.Downloaded for Ana Quininha (ana.quininha@chlc.min-saude.pt) at UnivElsevier on November 29, 2023. For personal use only. No other uses withcare and started self-treatment with cryotherapy and nonste-roidal anti-inflammatory drugs. The pain totally relievedwithin a few days and no longer affected his daily life. TaggedEndTaggedPResting electrocardiogram revealed atrial fibrillationwith a normal ventricular rate. Transthoracic echocardio-gram showed asymmetric septal hypertrophy with granularsparkling appearance, normal left ventricular ejection frac-tion yet reduced global longitudinal strain (9.7%) with“apical sparing” pattern, impaired diastolic function, andsevere biatrial dilatation. TaggedEndTaggedP ransthyretin amyloidosis was diagnosed after diphos-phonate scintigraphy displaying strong myocardial uptake of99mTc-DPD (Perugini scoring system: grade 3) and labora-tory testing that excluded immunoglobulin light-chain amy-loidosis. Genetic testing was negative for hereditarytransthyretin amyloidosis, indicating wild-type transthyretinamyloidosis. Treatment with tafamidis was initiated.TaggedEndn. A deformity (Popeye sign) is per-TAGGEDH1 ISCUSSION TAGGEDENDTaggedP his typical finding on physical examination is known asPopeye sign or Popeye deformity, named after the ball-shaped biceps of the fictional cartoon character of the1930s. It is caused by bulging of the biceps musclebelly after rupture of the long head of the bicepstendon.1 Rupture of this tendon is not uncommon;2 how-ever, a patient presenting with the Popeye sign is rare.ersity Hospital Center of Central Lisbon from ClinicalKey.com by out permission. Copyright ©2023. Elsevier Inc. All rights reserved.TaggedEndViegas et al Wild-Type Transthyretin Amyloidosis e91The risk factors include older age, smoking habits,corticosteroid use, fluoroquinolone antibiotics, andbiceps muscle overuse. As forearm flexion and supina-tion are maintained by the short head of the biceps, con-servative management is sufficient for most cases.Nonetheless, patients whose occupations demand fullarm strength may require surgical repair.1 TaggedEndTaggedPCardiac involvement in systemic amyloidosis, due toeither immunoglobulin light-chain or transthyretin amyloid-osis, is a major determinant of unfavorable outcome.3 It isstill mis/underdiagnosed, although effective treatments inimproving patient survival are now available, particularlyfor transthyretin amyloidosis. Recognition of early clinicalfindings, some of them preceding cardiac manifestations,are key to achieving a timely diagnosis. Clues to extracar-diac amyloid deposition in wild-type transthyretin amyloid-osis include bilateral carpal tunnel syndrome, lumbar spinalstenosis, or biceps tendon rupture, which may produce thePopeye sign.3 TaggedEndTAGGEDH1 CKNOWLEDGMENTS TAGGEDENDTaggedP he authors would like to recognize the physicians, nurses,and other allied health care workers who were responsiblefor the care of this patient. TaggedEndDownloaded for Ana Quininha (ana.quininha@chlc.min-saude.pt) at UnivElsevier on November 29, 2023. For personal use only. No other uses withTAGGEDH1CONSENT TAGGEDENDTaggedP he authors confirm that written consent for submission ofthe case report including images and associated text hasbeen obtained from the patient in line with COPE guidance. TaggedEndJose Miguel Viegas, MDPedro Garcia Bras, MDIsabel Cardoso, MDSılvia Aguiar Rosa, MD, PhDersity Hospital Center of Central Lisboout permission. Copyright ©2023. ElsDepartment of Cardiology, Hospitalde Santa Marta, Centro HospitalarUniversitario de Lisboa Central,Lisbon, Portugalhttps://doi.org/10.1016/j.amjmed.2023.01.021TaggedH1ReferencesTaggedEndTaggedP1. Yoshida N, Tsuchida Y. “Popeye” sign. N Engl J Med 2017;377(20):1976.TaggedEndTaggedP2. Lim CH, Lee KA, Liew JW. Popeye’s sign: biceps tendon rupture. BMJCase Rep 2020;13(2):e234205. TaggedEndTaggedP3. Vergaro G, Aimo A, Barison A, et al. Keys to early diagnosis of cardiacamyloidosis: red flags from clinical, laboratory and imaging findings.Eur J Prev Cardiol 2020;27(17):1806–15.TaggedEndn from ClinicalKey.com by evier Inc. All rights reserved.

Popeye Deformity: a Red Flag for Wild-Type Transthyretin Amyloidosis

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Popeye Deformity: a Red Flag for Wild-Type Transthyretin Amyloidosis

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Repositório do Centro Hospitalar de Lisboa Central, EPE