Popeye Sign in Transthyretin Amyloidosis ( 2 фото )

A 75-year-old man presented to the cardiology clinic with a 3-week history of fatigue and palpitations. On physical examination, the heart rhythm was irregular. Distention of the jugular vein and leg edema were noted, as was bulging of the biceps muscles during elbow flexion (Panels A and B). This finding — known as the Popeye sign, which indicates distal biceps tendon rupture — had been present for 4 years. An electrocardiogram showed atrial fibrillation and low-voltage QRS complexes in the limb leads. A transthoracic echocardiogram showed concentric left ventricular hypertrophy with a wall thickness of 14 mm and an ejection fraction of 44%. Technetium-99m–labeled pyrophosphate scintigraphy was notable for high myocardial uptake (Panel C), which was also seen on single-photon-emission computed tomography. Serum and urine tests for a monoclonal protein were negative. Histopathological analysis of an endomyocardial-biopsy sample revealed amyloid deposits. Genetic sequencing identified a wild-type transthyretin gene. A diagnosis of wild-type transthyretin amyloidosis with spontaneous biceps tendon ruptures and cardiomyopathy was made. Spontaneous biceps tendon rupture is a musculoskeletal manifestation of systemic amyloidosis that results from amyloid deposition within tendons that weakens their structure. Treatment with a loop diuretic, edoxaban, and tafamidis was initiated. No intervention was performed for the biceps tendon rupture owing to the patient’s mild symptoms. At the 6-month follow-up, the patient’s condition was stable.
Satoshi Kurisu, M.D., and Hitoshi Fujiwara, M.D.Author Info & Affiliations
Published August 30, 2025
N Engl J Med 2025;393:906
DOI: 10.1056/NEJMicm2503880
VOL. 393 NO. 9


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