An 81-Year-Old Woman Reports Progressively Increasing Bilateral Shoulder Pain for 2

An 81-year-old woman reports progressively increasing bilateral shoulder pain for 2 months.  Over the past 2 weeks, she has developed burning pain in her right thumb, index, and middle fingers.  Medical history is significant for type 2 diabetes mellitus and end-stage renal disease due to diabetic nephropathy.  The patient has received hemodialysis for the past 10 years.  Vital signs are normal.  Examination reveals normal heart and lung sounds.  There is no organomegaly.  Both shoulders are hypertrophied.  There is thenar atrophy on the right hand and soft tissue fullness at the right wrist.  Which of the following is most likely responsible for this patient's current condition?

A) Clonal production of excess free immunoglobulin light chains
B) Cytokine-mediated increased production of amyloid A protein
C) Tissue deposition of beta2-microglobulin
D) Tissue deposition of mutated transthyretin
E) Tissue deposition of wild-type transthyretin

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