We document a case of 61-year-old woman with a 24 year history of
rheumatoid arthritis (RA), who developed severe
polyarthralgia, dry
cough,
paresthesia in the legs, frequent micturition, and severe macrohematuria. We diagnosed as severe RA with extraarticular manifestations based on
interstitial pneumonia,
mononeuritis multiplex, subcutaneous nodules, and high titer of
rheumatoid factor. Ultrasonography demonstrated an intravesical mass lesion. A histological examination of the urinary bladder by endoscopic biopsy revealed marked deposition of AA
amyloid. The diagnosis of secondary
amyloidosis and bacterial
cystitis were made based on histological findings and urine culture. At first, we administered
antibiotics by
intravenous infusion, which resulted in cure of
cystitis and partial improvement of macrohematuria. Then combination
therapy of
corticosteroids and
cyclophosphamide successfully reduced the disease activity of RA. There have only been a few reports published so far on the vesical
amyloidosis in patients with RA. However, 5 of 10 patients (50%) in vesical
amyloidosis died because of continuous massive
hematuria, which induced
disseminated intravascular coagulation and
multiple organ failure. In conclusion, secondary
amyloidosis of the urinary bladder should be considered as a possible cause of
hematuria in patients with long-term RA and as an important prognosis factor of RA.