Hepatocytic PAS-positive diastase-resistance inclusions in the absence of alpha-1-antitrypsin deficiency--high prevalence in alcoholic cirrhosis

The presence of PAS-positive, diastase-resistant inclusions in the cytoplasm of the hepatocytes is characteristic of alpha-1-antitrypsin deficiency. The purpose of this investigation was to determine whether the presence of these inclusions is a specific feature, permitting the recognition of alpha-1-antitrypsin deficiency in patients with liver disease. We examined the liver specimens from 20 patients suffering from alcoholic cirrhosis with the Pi M phenotype, i.e., in whom alpha-1-antitrypsin deficiency was excluded. In seven of these patients, PAS-positive, diastase-resistant inclusions were seen in the hepatocytes; in two patients, these inclusions contained a material antigenically similar to alpha-1-antitrypsin. These inclusions might represent deposits of glycoproteins poorly excreted by the diseased hepatocytes. It is concluded that, in patients with liver disease, the presence of PAS-positive, diastase-resistant inclusions--even containing alpha-1-antitrypsin--in the cytoplasm of the hepatocytes does not permit the hepatic lesions to be ascribed to alpha-1-antitrypsin deficiency.     

Fine structural observations of the liver in alpha-1-antitrypsin deficiency.

Morphologic studies of liver tissue in individuals deficient in alpha-1-antitrypsin (alpha-1-AT) have established the presence of membrane-delimited deposits which are diastase resistant, perodic acid-Schiff positive, sialic acid deficient, and immunologically related to serum alpha-1-AT. The molecular basis for the accumulation alpha-1-AT-like substance in hepatocytes and the serum deficiency in alpha-1-AT patients is unknown.In an effort to gain insight into the membrane sites involved in the storage of the alpha-1-AT-like material, we examined liver biopsies by light and electron microscopy from 3 children with homozygous PiZZ deficiency and varying degrees of liver pathology. Contrary to the more widely held belief that accumulation occurs primarily in the rough endoplasmic reticulum, we find the earliest and greatest accumulation of alpha-1-AT-like material in smooth endoplasmic reticulum of hepatocytes. We have combined our ultrastructural observations with the current knowledge which is available concerning the structural properties of M-type and Z-type alpha-1-AT and have proposed a model which may explain the basis for the hepatic accumulation of alpha-1-AT-like material and the serum deficiency state in the PiZZ genotypes.     

Alpha-1-antitrypsin globules in liver biopsies

In order to examine the frequency of alpha-1-antitrypsin (AAT) deficiency of phenotype Pi-Z in a consecutive liver biopsy material, PAS/diastase resistent globules with positive immunohistochemical reaction for AAT (AAT globules) were used as a marker of the Pi-Z gene. 34 (4%) of 850 liver biopsies contained AAT globules. More than half of the biopsies with globules had chief histological diagnoses within the groups fibrosis, suspicion of cirrhosis and cirrhosis. Micronodular cirrhosis was significantly more frequent in biopsies with AAT globules. The results support the assumption that AAT deficiency of phenotype Pi-Z as well in homozygous as heterozygous form is associated with development of liver cirrhosis.     

ALPHA-1-ANTITRYPSIN DEFICIENCY IN ADULTS

A clinicopathological examination was carried out on eight adult patients with alpha-1-antitrypsin (ATT) deficiency. Phenotyping comfirmed five patients with PiMZ, two patients with PiZ-, and one patient with PiZZ. Cirrhosis was found in six of the patients, four of whom had a history of excessive ethanol comsumption. Hepatitis B surface antigen was positive in two patients with cirrhosis. Dysplastic change was present in four patients, although no neoplasia in the liver was found in all patients. All patients had periodic acid-Schiff positive and diastase resistant inclusions of hepatocytes, which were identified as ATT by indirect immunoperoxidase stain. The possibility of. the combined effects of ATT inclusions and such harmful stimuli such as alcohol or viral hepatitis infection may render the hepatocytes more susceptible to damage, and may contribute to development of cirrhosis.     

Alpha-1-antitrypsin deficiency in adults

A clinicopathological examination was carried out on eight adult patients with alpha-1-antitrypsin (ATT) deficiency. Phenotyping confirmed five patients with PiMZ, two patients with PiZ-, and one patient with PiZZ. Cirrhosis was found in six of the patients, four of whom had a history of excessive ethanol consumption. Hepatitis B surface antigen was positive in two patients with cirrhosis. Dysplastic change was present in four patients, although no neoplasia in the liver was found in all patients. All patients had periodic acid-Schiff positive and diastase resistant inclusions of hepatocytes, which were identified as ATT by indirect immunoperoxidase stain. The possibility of the combined effects of ATT inclusions and such harmful stimuli such as alcohol or viral hepatitis infection may render the hepatocytes more susceptible to damage, and may contribute to development of cirrhosis.     

Inherited defect of alpha-1-antitrypsin associated with chronic liver and respiratory tract diseases in children

The frequency of occurrence of alpha-1-antitrypsin (A1AT) deficiency among total of 3228 Polish children with chronic liver diseases and chronic disease of respiratory tract was determined. It was observed that among children with chronic liver diseases which disclosed more frequent defect (concentration of A1AT below 150 mg/dl was found in 10.3% of children), the highest occurrence of deficiency was in children with neonatal hepatitis (23.1%). The deficiency was connected with the presence of ZZ and MZ phenotypes of A1AT.     

Risk of cirrhosis and primary liver cancer in alpha 1-antitrypsin deficiency

Previous reports have suggested an association between homozygous alpha 1-antitrypsin deficiency, cirrhosis, and primary liver cancer. To assess the risk of these complications we conducted a retrospective study based on 17 autopsied cases of alpha 1-antitrypsin deficiency identified during the period 1963 to 1982 in the city of Malm?, Sweden. During the study period, autopsies were performed in 38,250, or 68.2 percent, of all patients in the city who died. From the homozygote frequency in the population, 21 of these were expected to have alpha 1-antitrypsin deficiency. The disease had been diagnosed in 20, and autopsies had been performed in 17 (1 child and 16 adults). Each autopsied case was matched with four controls selected from the same autopsy register, and the Mantel-Haenszel odds ratio (ORmh) was calculated. The results indicated a strong relation between alpha 1-antitrypsin deficiency and cirrhosis (ORmh = 7.8; 95 percent confidence limits, 2.4 to 24.7) and primary liver cancer (ORmh = 20; 95 percent confidence limits, 3.5 to 114.3). When data were stratified according to sex, these associations were statistically significant only for male patients. We conclude that men with alpha 1-antitrypsin deficiency may be at higher risk for cirrhosis and primary liver cancer. The apparent male predominance suggests the additive effects of exogenous factors.     

Alpha-1-antitrypsin hepatic cell globules in autotransplanted liver of rats.

The autotransplantation of liver into the subcutaneous tissues in rats and hamsters resulted in the development of periodic acid Schiffs staining positive granules, which were resistant to diastase digestion. These granules were confirmed as alpha-1-antitrypsin by immunohistochemical staining. The appearance of the alpha-1-antitrypsin containing hepatic granules is comparable to those seen in the liver of humans with genetically determined alpha-1-antitrypsin deficiency.     

A case of liver cirrhosis with alpha-1-antitrypsin globules and hepatitis B surface antigen seropositivity

PAS staining, immunohistochemical examination and electron microscopy revealed presence of alpha-1-antitrypsin (AAT) globules in the hepatocytes of a HBsAg and anti-HBc seropositive female patient diseased of liver cirrhosis. The possible causes of cirrhosis are briefly analysed and the diagnostic importance of PAS-positive, amylase-resistant hepatocellular inclusions is discussed. Apart from the case reported, only two of 509 cirrhotic livers of adults, examined either by biopsy or post mortem, demonstrated similar characteristic PAS-positive globules. This indicates that in the population group (135,000 persons) referred for health care to the hospital where the examinations were done, AAT deficiency has played a negligible role in the development of liver cirrhosis in adults.     

Alpha-1-antitrypsin hepatic cell globules in autotransplanted liver of rats

The autotransplantation of liver into the subcutaneous tissues in rats and hamsters resulted in the development of periodic acid Schiffs staining positive granules, which were resistant to diastase digestion. These granules were confirmed as alpha-1-antitrypsin by immunohistochemical staining. The appearance of the alpha-1-antitrypsin containing hepatic granules is comparable to those seen in the liver of humans with genetically determined alpha-1-antitrypsin deficiency.     

Adult alpha1-antitrypsin deficiency.

Three adults with alpha 1-antitrypsin deficiency are described. In two of the cases the deficiency was genetically determined (cases 1 and 2), and each demonstrated unusual features of the disease. The liver in case 1 (homozygous) showed cholangiolar hyperplasia which has been recorded only once before. Case 2 (heterozygous) had emphysema and cirrhosis, a combination not previously documented in a heterozygote, in addition to malabsorption. Case 3 represents a case of spurious alpha 1-antitrypsin deficiency with cirrhosis included to emphasize the diagnostic improtance of phenotyping in such cases.     

Duodenal mucosal hemodynamics in patients with liver cirrhosis

Clinical studies show that patients with liver cirrhosis associated with portal hypertension have a high incidence of duodenal ulcer and duodenitis. However, little information is available concerning pathophysiological process of such duodenal diseases in liver cirrhosis. Hemodynamics of the duodenal mucosa was studied in cirrhotics with esophageal varices (68 cases) and in noncirrhotics with non-ulcer dyspepsia (37 cases) as well. In each group, hemoglobin concentration in the peripheral venous blood was measured, and mucosal hemodynamics was examined in 4 regions of the duodenum by endoscopic reflectance spectrophotometer. No significant intergroup difference was noted in the mean age or sex ratio. Hemoglobin concentration in the peripheral venous blood was significantly lower (p less than 0.01) in the cirrhotics. There were no significant intergroup differences in duodenal mucosal blood volume. However, the cirrhotics showed significantly lower oxygen saturation of hemoglobin in all regions of the duodenum (p less than 0.01). These results show that the cirrhotics with esophageal varices had relative increase in blood volume and decrease in oxygen saturation of hemoglobin in the duodenal mucosa. Such microcirculatory disturbances seem to predispose liver cirrhosis patients to duodenal injury.     

Alpha-1-antitrypsin and the liver: a routine immunohistological screen.

One hundred and eighty five consecutive liver biopsies were immunostained using anti-alpha-1-antitrypsin to assess the use of routine immunohistochemistry in the diagnosis of alpha-1-antitrypsin (AAT) deficiency. About half the livers showed staining of hepatocytes for alpha-1-antitrypsin, but most of these livers showed a panlobular pattern, possibly indicating increased synthesis of AAT. Only ten contained periportal granules, said to be typical of AAT deficiency. In cases in which serum was also available for quantitation and phenotyping there was no absolute relation between staining pattern, phenotype, and serum concentrations: the immunohistological screening technique, therefore, has limitations in the diagnosis of AAT deficiency in liver biopsy specimens.     

Cirrhosis and hepatocellular carcinoma in a patient with heterozygous (MZ) alpha-1-antitrypsin deficiency

A patient is described with micronodular cirrhosis, partial (heterozygous, MZ) deficiency of alpha-1-antitrypsin (AAT) and hepatocellular carcinoma. The patient did not drink alcohol and all serological markers of infection with hepatitis B virus were absent. Death was due to intra-peritoneal bleeding from a multifocal liver tumour. Histology revealed multiple intracytoplasmic AAT globules in hepatocytes at the periphery of the cirrhotic nodules. Copper granules, present in the same non-neoplastic liver cells may have resulted from minor cholestasis. Within the neoplastic hepatocytes AAT globules were sparse and copper deposits co-existed with the globular variant of Mallory bodies. The case is presented in support of the postulated association of partial deficiency of AAT, chronic liver disease and hepatic neoplasia.     

Comparative Study of Two Immunocytochemical Techniques in the Electron Microscopical Detection of Alpha-1-Antitrypsin in Routinely Processed Liver Biopsies

Two indirect immunocytochemical techniques using different markers, namely peroxidase and gold, were applied to ultrathin sections of liver biopsies to detect alpha-1-antitrypsin. The blocks used were taken from the routine electron microscopy files and had been processed optimally for maximum ultrastructural preservation. The immunogold technique provided the best method for localizing alpha-1 -antitrypsin and was associated with ultrastructural preservation equivalent to that seen in routinely processed liver biopsies. The procedure may be a useful adjunct to understanding the pathogenesis of alpha-1-antitrypsin deficiency and in recognizing further variants of this disorder.     

Comparative study of two immunocytochemical techniques in the electron microscopical detection of alpha-1-antitrypsin in routinely processed liver biopsies

Two indirect immunocytochemical techniques using different markers, namely peroxidase and gold, were applied to ultrathin sections of liver biopsies to detect alpha-1-antitrypsin. The blocks used were taken from the routine electron microscopy files and had been processed optimally for maximum ultrastructural preservation. The immunogold technique provided the best method for localizing alpha-1-antitrypsin and was associated with ultrastructural preservation equivalent to that seen in routinely processed liver biopsies. The procedure may be a useful adjunct to understanding the pathogenesis of alpha-1-antitrypsin deficiency and in recognizing further variants of this disorder.     

Cirrhosis associated with partial deficiency of alpha-1-antitrypsin: A clinical and autopsy study

A 63 year old woman with cryptogenic cirrhosis, astiles, portal hypertension, and intermediate levels of alpha-l-antitrypsin of prolease inhibitor SZ phenotype who died of esophageal variceal hemorrhage is described. The partial deficiency of alpha-1-arrtihypsin and the diagnosis of cirrhosis were suspected one year prior to death because a needle biopsy liver showed PAS positive, diastase resistant cyloplasmic bodies within hepatocyles. This report illustrates three previously undescribed features: (1) Heterozygous protease inhibitor SZ phenotype may be associated with coarsely nodular cirrhosis in the older adult. (2) The large intracytoplasmic glycoprotein droplets that are distinctive by light microscopy are probably formalin induced aggregates of submicroscopic flocculent material. (3) 1n the older patients with aberrant alpha-1-anlilrypsin theflocculent material is present not only in the granular endoplasmic reticulmn but also in smooth endoplasmic reticulum vesicles and cytolysosomes.     

Molecular analysis of the Pi*Z allele in patients with liver disease.

Alpha1-antitrypsin (AAT) is the main protease inhibitor in human plasma. There are more than 75 variants of this protein that differ from each other by their isoelectric point. Most of these alleles cause a reduction in AAT levels; the most common allele is Pi*Z. The main complications related to the Pi*Z allele are obstructive pulmonary disease and liver disease. Some Pi*Z allele carriers present cholestatic jaundice and cirrhosis. The Z type is associated with a secretion defect, which leads to deficiency of AAT and to the formation of intrahepatocytic inclusions in affected subjects. The diagnosis of AAT deficiency can be made by different techniques, including molecular analysis, although the final diagnosis should be done in conjunction with demonstration of the periodic acid-Schiff-positive globules on liver biopsy. In this study, specimens of 29 patients with cryptogenic cirrhosis between age 1 month and 18 years, and of 100 controls were submitted to polymerase chain reaction followed by digestion with TaqI enzyme. Five of the 29 patients had undergone liver transplantation. Three patients were heterozygous for the Pi*Z allele, and two were homozygous (allele frequency = 12.07%; 7/58). Among the controls, who represented the population of Porto Alegre, 1 in 100 individuals was heterozygous for the Pi*Z allele, resulting in an allele frequency of 0.5% (1/200). The high frequency of Pi*Z alleles among the patients indicates the usefulness of AAT molecular testing in children with cholestatic jaundice and cirrhosis.     

''Durate variant with clinical signs'' has alpha1 -antitrypsin genotype ZZ.

A patient with neonatal jaundice and cirrhosis who was previously reported homozygous for the Durate variant of galactose-1-phosphate uridyl transferase has the ZZ genotype for alpha1-antitrypsin. A sister of the patient, also with ZZ genotype, is less severly affected with liver disease and is a heterozygote for the Durate variant. Since a number of patients with ZZ genotype of alpha1-antitrypsin have been previously reported to have liver disease, the latter genotype is the more probable explanation for the patients' clinical state. A question is raised, however, whether the Duarte variant may be specifically associated with the development of liver disease in ZZ individuals.     

Casuistic contribution to alpha1-antitrypsin deficiency with liver cirrhosis in adulthood (author's transl)]

A case of alpha1-antitrypsin deficiency with liver cirrhosis bioptically diagnosed is described. The 49 year old woman had a decreased serum-level of alpha1-antitrypsin and characteristic, PAS-positive, diastase-resistant conclusions in the cytoplasma of the liver cells. An emphysema of the lungs was not seen.