Gene rearrangement studies in the diagnosis of primary systemic and nodular primary localized cutaneous amyloidosis

Difficulties may arise in the diagnosis of patients with clinical features suggestive of plasma cell dyscrasia-related amyloidosis (amyloidosis L), but without evidence of a paraprotein. We have employed gene rearrangement methodology to demonstrate the clonality of bone marrow cells not only in a patient with myeloma-associated systemic amyloidosis, but also in a patient with "primary" systemic amyloidosis without overt myeloma or a detectable paraprotein. Furthermore, we have shown the clonality of the amyloid-producing plasma cells within a skin nodule of a patient with primary localized cutaneous amyloidosis; by contrast, clonal rearrangement was not detected in bone marrow cells from this patient. This finding provides definitive proof that organ-limited nodular primary localized cutaneous amyloid deposits arise in relation to cutaneous plasmacytomas. Gene rearrangement studies may enable early diagnosis and initiation of treatment in patients with systemic amyloidosis L, as well as their differentiation from patients with organ-limited nodular cutaneous amyloidosis, who do not require aggressive therapy.     

Histopathological and immunohistochemical study of amyloidosis cutis nodularis atrophicans—Comparison with systemic amyloidosis

Three cases of amyloidosis cutis nodularis atrophicans (ACNA) were investigated histologically and immunohistochemically to determine the nature and origin of the deposited amyloid. A pulmonary lesion from a case of nodular pulmonary amyloidosis, and cutaneous lesions from three cases of primary systemic amyloidosis, two cases of secondary systemic amyloidosis and three cases of secondary cutaneous amyloidosis following basal cell epithelioma were also examined for comparison. Histology showed infiltration of numerous plasma cells adjacent to amyloid deposits in ACNA and nodular pulmonary amyloidosis, but not in systemic amyloidosis. Immunohistochemically, the cytoplasm of the plasma cells was stained with anti-immunoglobulin light chain or anti-Bence-Jones protein antisera or both, and amyloid material stained with anti-AL antiserum in ACNA and nodular pulmonary amyloidosis. These results suggest that, in ACNA, the plasma cells may produce and secrete immunoglobulin light chains or Bence-Jones protein or both, which undergo proteolysis to protein AL or amyloid fibril proteins which have the same immunoglobulin determinants as protein AL. The product is then deposited locally to form nodules in the dermis.     

Immunohistochemical staining properties of amyloids with anti-keratin antibodies using formalin-fixed, paraffin-embedded sections

Immunohistochemical staining properties of amyloids with anti-keratin antibodies were investigated using an avidin-biotin-peroxidase complex (ABC) system on formalin-fixed, paraffin-embedded sections. Anti-keratin antibody EAB-903 which recognize 66K and 57K daltons keratin peptides reacted with amyloid deposits in both lichen amyloidosus (LA) and macular amyloidosis (MA), but did not react with either primary systemic amyloidosis (AL), secondary systemic amyloidosis (AA) or heredofamilial amyloid polyneuropathy (AF). However, anti-keratin antibodies EAB-904 and MAK-6 did not react with any types of amyloids. These results suggested that immunohistochemical staining with anti-keratin antibody EAB-903 using formalin-fixed, paraffin-embedded sections appeared to be a useful method in making differential diagnosis of primary localized cutaneous amyloidosis (AD).     

A monoclonal anti-keratin antibody reactive with amyloid deposit of primary cutaneous amyloidosis

Specimens from cutaneous amyloidoses (lichen amyloidosis and macular amyloidosis) were stained immunohistochemically with monoclonal anti-keratin antibodies. One monoclonal antibody raised against hair keratin (HKN-6) reacted with the amyloids of both primary amyloidoses. Another monoclonal antibody, HKN-2, did not decorate the amyloid deposit. HKN-6 did not stain the interfollicular epidermis, but HKN-2 did. The possible explanations of these findings are 1) amyloid deposits contain keratin protein modulated to react with HKN-6; 2) amyloid deposits contain a protein unrelated to keratin protein, but reactive to HKN-6.     

Antikeratin autoantibodies in the amyloid deposits of lichen amyloidosus and macular amyloidosis

Summary In order to characterize immunoglobulins found on amyloid deposits of lichen amyloidosus and macular amyloidosis, an elution from cryostat sections was performed with citrate buffer, glycine buffer, NaCl, and PBS. Resulting eluates (mainly IgG) were examined with dot immunoblotting and SDS-PAGE immunoblotting and were found to react with the human epidermal keratin of 50 and 67 kD. Antikeratin autoantibody activities in normal murine and human sera were examined using a dot immunoblotting assay. In murine sera, titers of IgG and IgM autoantibodies were higher in older mice. The human cord blood showed significantly lower IgM autoantibody titers, whereas IgG antibody titers showed no significant differences from adults' sera, probably due to the permeability of IgG through the placental barrier. A stronger antibody activity in older individuals was thought to be due to the repeated exposures to keratin proteins derived from apoptotic keratinocytes. Sera from lichen amyloidosus and macular amyloidosis patients did not show any difference from normal controls in their antikeratin titers. It was concluded that the patients with lichenoid or macular amyloidosis are capable of producing a normal level of antikeratin autoantibodies. However, the removal of opsonized keratin-type amyloid from the skin is slow or deficient due to as yet unknown factors.Part of this study was reported on May 5, 1987 at the 48th Annual Meeting of the Society for Investigative Dermatology at San Diego, CA, USA     

Immunohistochemical studies on fibrillin in amyloidosis, lichen ruber planus and porphyria.

The pathogenesis of macular amyloidosis and lichen amyloidosis remains unsolved and the primary amyloid fibril protein(s) has not yet been identified. Ultrastructural association of skin amyloid with elastin associated microfibrils has been noted earlier. The presence of fibrillin in conjunction with such microfibrils was recently demonstrated immunohistochemically. The presence of fibrillin immunoreactivity in the amyloid deposits in skin biopsies from 3 patients with macular amyloidosis and 3 patients with lichen amyloidosis was studied, using monoclonal anti-fibrillin antibodies. For comparison, skin specimens were studied from five patients with lichen ruber planus, four patients with erythropoietic protoporphyria and from a patient with myeloma-associated cutaneous amyloidosis. Renal specimens from two cases of the amyloid A type of renal amyloidosis also were investigated. There was no immunostaining either of the keratin bodies in specimens of lichen ruber planus, the cutaneous PAS-positive vascular deposits in patients with erythropoietic protoporphyria, or the amyloid deposits in specimens of systemic amyloidosis and it was faint or absent in amyloid deposits in the specimens from patients with lichen amyloidosis. In contrast, distinct fibrillin immunoreactivity could be demonstrated in amyloid deposits in specimens from patients with macular amyloidosis. It was sometimes absent in deposits located in the upper part of the papillary dermis, close to the dermal epidermal junction zone, while consistently strong in deposits located lower down in the dermis. The results suggest that fibrillin or part of the fibrillin molecule may be present in some of the amyloid deposits in specimens of macular amyloidosis.     

Advanced glycation end product-modified beta2-microglobulin is a component of amyloid fibrils of primary localized cutaneous nodular amyloidosis

Primary localized cutaneous nodular amyloidosis is a rare form of cutaneous amyloidosis. Amyloid fibrils in primary localized cutaneous nodular amyloidosis have been reported to be originated from immunoglobulin light chains. Immunohistochemical studies on the lesional skins of four patients with primary localized cutaneous nodular amyloidosis demonstrated that amyloid deposits of all cases showed a positive reaction with the antibodies for beta2-microglobulin and advanced glycation end products as well as immunoglobulin light chain (kappa or lambda). No beta2-microglobulin and advanced glycation end product immunoreactivity was found in the amyloid deposits of other primary localized cutaneous amyloidosis (lichen amyloidosis and macular amyloidosis). Double immunofluorescence study of the lesional skin of primary localized cutaneous nodular amyloidosis showed that anti-kappa light chain, anti-beta2-microglobulin and anti-advanced glycation end product antibodies mostly reacted with the same area of amyloid deposit. Amyloid proteins were sequentially extracted with distilled water from one case of primary localized cutaneous nodular amyloidosis and recovered in the five water-soluble fractions (fractions I-V). Immunoblot assay of amyloid fibril proteins demonstrated that immunoreactive polypeptides with anti-kappa light chain antibody (29 kDa) and with anti-beta2-microglobulin antibody (12 kDa) were detected in fractions I-V, whereas immunoreactive polypeptide with anti-advanced glycation end product antibody (12 kDa) was detected exclusively in fractions III-V but not in fractions I and II. Two-dimensional polyacrylamide gel electrophoresis revealed that 12 kDa polypeptide in fractions I and II was electrophoretically identical with authentic beta2-microglobulin and that beta2-microglobulin in fractions III-V was advanced glycation end product-modified beta2-microglobulin with more acidic pI value. These results indicate that beta2-microglobulin is another major component of amyloid fibrils in primary localized cutaneous nodular amyloidosis and that beta2-microglobulin in primary localized cutaneous nodular amyloidosis is partly subjected to the modification of advanced glycation end product.     

Sulfhydryl and disulfide stainings in amyloids of skin-limited and systemic amyloidoses

Disulfide (S-S) bonds and sulfhydryl (-SH) groups in skin-limited and systemic amyloidoses in frozen and paraffin-embedded sections were examined with a thiol reagent, N-(7-dimethylamino-4-methyl-3-coumarinyl)-maleimide (DACM). In frozen sections, dermal amyloids of skin-limited amyloidoses contained a large number of S-S bonds but no -SH groups [macular amyloidosis (9 cases), lichen amyloidosis (4), and skin tumor-associated (seborrheic keratosis) amyloidosis (1)]. In contrast, amyloids of systemic amyloidoses contained no S-S bonds or -SH groups [primary and myeloma-associated amyloidoses (1 each)]. The identical results were obtained from paraffin-embedded sections in skin-limited amyloidoses [macular (31), biphasic (4), lichenoid (9) and skin tumor-associated Bowen's disease (3), seborrheic keratosis (2), solar keratosis (2), porokeratosis Mibelli (1), and basal cell epithelioma (1) amyloidoses], systemic amyloidoses [primary (3), myeloma-associated (2), and secondary (2) amyloidoses] and tumefactive amyloidoses of the tongue (2). Furthermore, amyloid-like deposits confirmed by various histochemical stainings were found in the epidermis in 27/67 cases of skin-limited amyloidoses in both frozen and paraffin sections. These intraepidermal amyloid-like deposits contained S-S bonds in all cases (27/27) and -SH groups in 10 of 27 cases. In contrast, an intraepidermal amyloid-like deposit was not observed in any systemic amyloidoses (0/9) or tumefactive amyloidoses of the tongue (2). These results showed that skin-limited amyloidoses could be differentiated from systemic amyloidoses by DACM methods (this appears to depend upon the differences of amino acid composition between skin-limited and systemic amyloidoses) and that paraffin-embedded sections were usable for DACM methods. Present study further suggests that amyloids ion skin-limited amyloidoses are, at least in part, derived from epidermal keratinocytes.     

Amiloidosis cutánea primaria localizada nodular con patrón diseminado

Amyloid is a proteinaceous material that is deposited in the tissues in a large variety of clinical contexts; in the skin it can be found with or without concomitant systemic disease. Primary localized cutaneous amyloidosis encompasses those amyloidoses restricted to the skin without involvement of other systems. The most common forms within this group are macular and lichen amyloidosis. Nodular amyloidosis is extremely rare, and there are notable differences in clinical presentation, prognosis, histology, and pathogenesis between this entity and the macular and lichenoid variants.We report a new case of nodular primary localized cutaneous amyloidosis with disseminated plaques and nodules in which no systemic disease developed in the 3 years following the appearance of the lesions.     

Amyloid in localized cutaneous amyloidosis: immunofluorescence studies with anti-keratin antiserum especially concerning the difference between systemic and localized cutaneous amyloidosis

Amyloid of localized cutaneous amyloidosis and systemic amyloidosis were subjected to study with an indirect immunofluorescence technique using anti-keratin antiserum. Anti-keratin antiserum was prepared ad modum Sun & Green. Amyloid of localized cutaneous amyloidosis was positively stained for the antiserum, whereas amyloid of systemic amyloidosis (primary and multiple myeloma-associated) was negative. There was no difference between primary localized cutaneous amyloidosis (lichen amyloidosus and macular amyloidosis) and secondary localized cutaneous amyloidosis (amyloidosis associated with skin tumor). These results indicate that amyloid of localized cutaneous amyloidosis contains components derived from epidermal fibrous protein, probably tonofilaments of keratinocytes.     

Lamina densa malformation involved in histogenesis of primary localized cutaneous amyloidosis.

Skin lesions of lichenoid amyloidosis and macular amyloidosis were immunohistochemically investigated using five monoclonal antibodies against basement membrane zone (BMZ) components. A hemidesmosomal component did not contribute to amyloid deposits, but components of the lamina densa and anchoring fibrils were associated with amyloid deposits in the uppermost dermis. Immunoelectron microscopy revealed that these BMZ components were not only aggregated in the BMZ and dermis, but were also involved in the individual amyloid islets. The lamina densa was disrupted in the interface areas just above the amyloid deposits, where cytoplasm of the basal cells directly faced the aggregate of amyloid filaments. Aggregates of some BMZ components were continuous to the amyloid islets from the lamina densa area. These findings suggest that a lamina densa malformation is involved in amyloid production in the interface of the BMZ, and support the secretion theory rather than the fibrillar body theory of amyloidogenesis in these types of primary localized cutaneous amyloidosis.     

Cytokeratins in primary cutaneous amyloidosis

The expression of keratins was investigated immunohistochemically on formalin-fixed and snap-frozen primary cutaneous amyloidosis tissue with a panel of monospecific and polyspecific antikeratin antibodies which recognized keratins K1, K5, K6, K7, K8, K10, K14, K16, K17, K18, and K19. Amyloid deposits in frozen section of seven cases of macular amyloidosis and lichen amyloidosus always reacted with antibodies LP34 (labeling K5, K6 and K18) MNF (labeling K5, K6, K8, K10, K17 and K18) and RCK 102 (labeling K5 and K8); frozen section in one case each of the seven cases also reacted with antibodies LL001 (labeling K14), Lp1K (labeling K7 and K17), and LP2K (labeling K19), LP1K (labelling K7 and K17), and LP2K (labelling K19), In formalin fixed section of 13 cases of macular amyloidosis and lichen amyloidosus amyloid deposits were labeled with LP34 in three section LL020 ()labelling keratins K5 and K6) in one section and LP2K in two section. In nodular primary cutaneous amyloidosis amyloid deposits were not labeled with any antikeratin antibodies. These data confirm that amyloid in macular amyloidosis and lichen amyloidosus contains keratin epitopes, and suggests derivation of the fibrillar component from keratin intermediate filaments Several different keratins appear to undergo conversion to amyloid, LP34, MNF 116 and RCK 102 antibodies, which have in common the labelling of keratin K5, may be useful in the diagnosis of macular and popular amyloidosis with frozen tissue section.     

原发性皮肤淀粉样变淀粉样蛋白组织来源的研究

对30份原发性皮肤淀粉样变标本石腊切片进行抗角蛋白抗体免疫组化及复染荧光刚果红的对比观察,发现淀粉样蛋白的沉积非常广泛,而角蛋白的沉积仅发生在病变中期及后期少数标本的个别乳头内。在大多数有淀粉样蛋白沉积处并不存在角蛋白成分,电镜下也未见表皮角朊细胞破坏变性,而真皮乳头内有角蛋白沉积的部位均有淀粉样蛋白的沉积及基底细胞破坏。说明乳头内角蛋白的沉积是在淀粉样蛋白沉积之后发生的,是后果而不是原因。     

Localized amyloidosis of the glans penis: a case report and literature review

BACKGROUND: Primary localized cutaneous amyloidosis is an uncommon lesion with a varied pathogenesis. METHODS: We report the case of a 67-year-old-male discovered to have a localized amyloid lesion of the glans penis. RESULTS: Biopsy of the lesion revealed dermal deposits of amorphous eosinophilic material which stained positive with Congo red and amyloid P protein. Additional stains, including kappa and lambda light chains, amyloid A, and transthyretin, were negative. The lesion has remained asymptomatic, with no evidence of systemic disease identified, and no further treatment has been necessary. CONCLUSIONS: This is the sixth reported case of localized amyloidosis of the glans penis. Based on the clinical behavior and pathologic characteristics, this type of lesion is best classified as primary localized cutaneous amyloidosis, in the same family as the macular/lichenoid type lesions.     

Epidermal origin of the amyloid in localized cutaneous amyloidosis

A case of localized cutaneous amyloidosis which developed after a lichen planus-like skin reaction is reported. The amyloid consisted of amyloid fibrils enveloped by heparan sulphate granules. These amyloid fibrils reacted to anti-human keratin antibody, indicating an epidermal origin for the fibrils.     

Immunofluorescence and histochemical studies of localized cutaneous amyloidosis

Lichen amyloidosus (LA) and macular amyloidosis (MA) are two forms of localized cutaneous amyloidosis in which the amyloid occurs as larger and smaller deposits respectively in the papillary dermis. The histogenesis of the amyloid of these conditions is unknown. By using an indirect immunofluarescence technique we showed that LA and MA do not react with antibodies against different previously characterized amyloid fibril proteins. These results indicate that the amyloid of LA and MA is different from other known types of amyloid. Protein AP, which was demonstrated in amyloid of MA and LA, is known to be present in all forms of amyloid and is of unknown significance. Antiserum against keratin did not react with the larger homogeneous amyloid bodies, but showed a weak reaction with some small deposits. Histochemical staining failed to show keratin in any of the tissues containing LA or MA.     

PRIMARY LOCALISED CUTANEOUS AMYLOIDOSIS IN MALAYSIANS

A review of consecutive biopsies from 85 Malaysian patients with primary localised cutaneous amyloidosis (PLCA) revealed 63 with papular amyloidosis (PA) and 22 with macular amyloidosis (MA). PLCA appeared to affect the Chinese more frequently than the other major ethnic groups but MA was more common than expected among the Indians. Of patients with PA, one had systemic lupus erythematosus, one scleroderma and in another, connective tissue disease was suspected. MA was not found to be associated with any other disease. Histologically, PA differed from MA by the larger size of amyloid deposits in the papillary dermis. There was no difference in their tinctorial and immunohistochemical characteristics. Deposits were permanganate-resistant and negative for AA protein, immunoglobulin light chains and keratin. A few cases exhibited positively for cytokeratin. Strong immunoreactivity for AP protein was observed. PA and MA appear chemically similar and are likely to be of epidermal origin.     

Nodular primary cutaneous amyloidosis. Isolation and characterization of amyloid fibrils

A case of nodular cutaneous amyloidosis and Sj?gren's syndrome occurred in a 63-year-old woman. Nodules had been seen for the past ten years and Sj?gren's syndrome had accompanied amyloidosis for the last three years. The concomitant occurrence of nodular cutaneous amyloidosis and Sj?gren's syndrome may not be by chance, since four of 12 cases of nodular cutaneous amyloidosis that have been reported to date in Japan were in patients with both amyloidosis and Sj?gren's syndrome. The amyloid deposits in the tissue were stained with anti-lambda light-chain amyloid antibody. Amyloid fibrils were purified from the skin lesions in this patient and were characterized biochemically, immunologically, and ultrastructurally. The results indicated that the amyloid fibrils consisted of 29,000-, 20,000-, and 17,000- dalton peptides, the 29,000-dalton peptide of which was shown to react with the lambda light chain of immunoglobulin by immunoblot study.     

Primary cutaneous amyloidosis of the external ear: a clinicopathological and immunohistochemical study of 17 cases

Primary cutaneous amyloidosis includes several forms of localized amyloidosis characterized by superficial amyloid deposits occurring at or near the dermal–epidermal junction in the absence of systemic involvement. Primary cutaneous amyloidosis of the auricular concha and external ear represents a rarely described variant. There have been 27 cases reported in the English language literature, and herein we report 17 additional cases. This article demonstrates that the amyloid observed in this context is generally positive for Congo red, crystal violet and thioflavin T. It also expresses cytokeratin 34ßE12 via immunohistochemistry. Our immunohistochemical results and review of the literature suggest that the amyloid in amyloidosis of the external ear is the result of basal keratinocyte degeneration and does not signify deposition from a systemic or generalized process. Wenson SF, Jessup CJ, Johnson MM, Cohen LM, Mahmoodi M. Primary cutaneous amyloidosis of the external ear: a clinicopathological and immunohistochemical study of 17 cases.     

Unusual primary cutaneous localized amyloidosis

The case of a 41-year-old female patient with an unusual type of primary localized cutaneous amyloidosis is reported. Clinical examination revealed lesions typical for macular cutaneous amyloidosis, while histology and histochemistry, in contrast, revealed the presence of nodular amyloidosis of the skin with deposition of lambda light chain amyloid.