Familial amyloid polyneuropathy with marked hypertrophy of the peripheral nerves

Autopsy findings in a 40-year-old male with heredofamilial amyloidosis and polyneuropathy are reported. He had been suffering from progressive autonomic as well as sensorimotor dysfunctions. Prominent amyloid deposit was found in the kidney, heart, thyroid, and testis, and less in the interstitium and small vessels of almost all organs. The peripheral nerves, some showing prominent hypertrophy, were most severely involved by amyloid deposit in a form of stellate mass, which ultrastructurally consisted of radially arranged amyloid filaments. In the hypertrophied nerves and ganglia, in addition to amyloid, massive accumulation of acid mucopolysaccharide (AMPS) was seen filling up the interstitial space, which was the cause of hypertrophy. Ultrastructurally, AMPS was seen as finely granular substance. An extracted amyloid from the kidney showed 8 nm filament on negative staining and was estimated of having a molecular weight of 14,000.     

Pancreatic ganglioneuronal amyloid. Occurrence in diabetic cats with islet amyloidosis.

Amyloid in pancreatic ganglia and nerves (ganglioneuronal amyloid) was demonstrated in 4 of 8 diabetic cats with islet amyloid deposits. Eighteen nondiabetic cats (including 4 with islet amyloid) did not have detectable amyloid in pancreatic nerves or ganglia. Ganglioneuronal amyloid had staining characteristics identical to those previously reported for islet amyloid, including 1) congophilia, 2) resistance to oxidation by KMnO4, 3) immunoreactivity (PAP technique) with antiserum to a B-chain-rich insulin fraction, and 4) no reactivity with antisera to insulin, glucagon, or somatostatin. Nonneuronal cells with insulin, glucagon, and somatostatin immunoreactivity were seen in many pancreatic ganglia and nerves; and in a few instances, B cells were found near ganglioneuronal amyloid deposits. The premise that these ganglioneuronal amyloid deposits (like islet amyloid) are insulin-related is supported by their immunoreactivity with antiserum to B-chain-rich insulin and the demonstration of B cells in pancreatic ganglia and nerves.     

Amyloid A protein amyloidosis induced in apolipoprotein-E-deficient mice.

Apolipoprotein E (apoE) is a constituent of lipoproteins other than low-density lipoprotein, and it principally acts in the transport and metabolism of plasma cholesterol and triglyceride. ApoE is a minor constituent of various kinds of amyloidoses and may play a role as a pathological chaperone for fibrillogenesis of amyloid fibril protein with the amyloid P component and proteoglycans. In this study, we examined the role of apoE in amyloidogenesis in vivo in apoE-deficient mutant mice with amyloid A protein (AA) amyloidosis induced by inflammatory stimulation. Amyloid deposition was seen in six of nine C57BL/6J control mice and in six of eight apoE-deficient mutant mice after the intraperitoneal and subcutaneous injections of the mixture of complete Freund's adjuvant and Mycobacterium butyricum. Moreover, amyloid deposition in apoE-deficient mice as well as C57BL/6J control mice started 48 or 72 hours after injection of amyloid-enhancing factor and silver nitrate, although the amount of amyloid deposit in C57BL/6J control mice was slightly larger than that in apoE-deficient mice. These amyloid deposits reacted with anti-mouse AA antibody were seen in the perifollicular area of the spleen. Immunoreactivity of apoE was seen irregularly in the amyloid deposits of C57BL/6J control mice but not in the amyloid deposit of apoE-deficient mice. From these results, we concluded that apoE is not always necessary for amyloid deposition and that the existence of apoE might slightly accelerate AA amyloid deposition in the earliest phase of AA amyloid deposition.     

Immunohistochemical characterization of amyloid proteins in sural nerves and clinical associations in amyloid neuropathy.

To test whether immunohistochemical characterization of proteins in amyloid deposits in biopsied sural nerves gives reliable and useful diagnostic information using commercially available reagents, biopsy specimens of sural nerves from 38 patients with amyloid neuropathy were studied. Transthyretin (TTR) was detected in the amyloid deposits of 11 nerves, lambda light chains (LC) in 8 nerves, kappa LC in 7 nerves, and both lambda and kappa LC in 3 nerves. In 9 nerves, the amyloid deposits were too small to allow adequate immunohistochemical characterization of amyloid proteins in serial sections. Evidence that immunohistochemical characterization was correct came from: 1) evaluation of kin, 2) search for monoclonal proteins in the plasma, and 3) sequencing of the gene abnormalities in TTR+ cases. In 9 of 11 TTR+ cases, in which DNA could be obtained, sequencing of the gene showed that each of the 9 cases was heterozygous for a gene mutation; 7 had previously described mutations and 2 undescribed mutations. Therefore, in the nine sporadic cases without plasma monoclonal light chains, the immunohistochemical characterization correctly identified the protein in amyloid as transthyretin. Likewise, there was a high concordance between immunoglobulin light chains in plasma and light chains in amyloid in primary amyloidosis. Evaluation of the type, distribution, and severity of the neurologic symptoms and deficits showed: 1) the sensorimotor and autonomic neuropathy of amyloidosis characteristically affects proximal as well as distal limbs, and 2) the type of amyloidosis probably cannot be determined from the characteristics or severity of the neuropathy alone or from the location or size of amyloid deposits in nerve.     

Orthotopic liver transplantation for familial amyloidotic polyneuropathy: a pathological study

Familial amyloidotic polyneuropathy (FAP), a hereditary form of systemic amyloidosis with clinically significant neuropathy and cardiomyopathy, is caused by a genetic defect of the transthyretin gene, which is mostly synthesized in the liver. Orthotopic liver transplantation (OLT) is thought to eliminate the amyloidogenic protein and currently is the only definitive treatment for this disorder. The aim of this study was to define the distribution and extent of amyloid deposition in tissues from these patients and evaluate the suitability of the resected FAP livers for transplantation into non-FAP patients. Surgical specimens from 14 patients removed at the time of OLT and autopsy tissues from 3 of the 14 were examined histologically using hematoxylin and eosin and Congo red-stained sections. The extent of amyloid deposits was evaluated, semiquantitatively graded from negative to marked, and correlated with clinical course and patient outcome. Amyloid deposits were consistently seen in hilar and vagus nerves. Liver lobular involvement was minimal in 1 and absent in the other 13 cases, with portal arterial amyloid deposits seen in 7 cases. At autopsy, extensive amyloid deposition in the heart was seen in all 3 cases with involvement of the conduction system. The extent of amyloid deposition at OLT did not correlate with the duration of symptoms before OLT or patient outcome after OLT. In conclusion, liver parenchymal involvement in FAP is minimal, and these explants are suitable for grafting in non-FAP patients. The recipients of such grafts must be carefully observed for the development of any amyloid-related disease, particularly cardiomyopathy. Of the tissues removed at OLT, the histopathologic confirmation of FAP is most consistently made by the examination of hilar and vagus nerves.     

An immunohistochemical study of amyloid P component, apolipoprotein E and ubiquitin in human and murine amyloidoses

Amyloid P component (AP) and apolipoprotein E (Apo E), which are known to be minor constituents of amyloid deposits, commonly are associated with almost all types of amyloid deposits. In this study, the distribution of AP-, Apo E- and ubiquitin (Ub)-lmmunoreactlvlty (IR) In amyloid deposits In the liver and spleen of human systemic amyloldosls (34 autopsy cases: 17 Immunoglobulln light chain derived, 17 amyloid A protein derived) and experimental murine amyloldosls is examined using an immunohistochemical technique. In human cases, all of the amyloid deposits examined showed colocallzation of AP- and Apo E-IR with Individual amyloid proteins. In experimental amyloldosls, AP-IR of amyloid deposits in the liver and spleen and Apo E-IR in the liver were seen uniformly throughout this experiment. In contrast, Apo E-IR In the spleen was not uniform at the phase of amyloid deposition. At 4 weeks and at 16 weeks after casein injection, Apo E-IR was unevenly distributed in amyloid deposits in the perifollicular area; however, from 6 to 12 weeks it was seen to be uniform. Ublqultin-IR of amyloid deposits in human cases was seen In 22 of 34 livers and in 22 of 33 spleens. In experimental amyloldosls, Ub-IR of amyloid deposits was demonstrated In the space of Disse In all mice examined, and there appeared to be a gradual Increase in intensity with the amount of amyloid deposition. However, in the spleen, amyloid deposits did not react with anti-Ub antibody In any phase of amyloid Induction. These results suggest that Apo E and Ub are not always associated with the process of amyloid deposition and may appear in a deposit after the deposition.     

Amyloid deposition in renal angiomyolipoma

An irregular tumor shadow, seen on the left kidney in a 48-year-old woman by computed tomography, was pathologically diagnosed as 'angiomyolipoma'. HMB-45 immunoreactivity distinguished angiomyolipoma from renal cell carcinoma of sarcomatoid type. The amyloid deposition was limited to the tumor. M-protein and Bence-Jones protein were negative. For amyloid protein characterization, immunohistochemical studies were performed with antiamyloid A, anti-kappa, anti-lambda, anti-prealbumin and anti-beta-2 microglobulin, but none reacted with the amyloid. This is the first documented case of amyloid deposition in angiomyolipoma and may represent a novel precursor protein of amyloid.     

Amyloidosis of pancreatic islets in primary amyloidosis (AL type)

Seven cases of primary amyloidosis (AL-type) were studied immunocytochemically for the possible involvement of pancreatic islets. The two cases with extensive organ involvement by AL-amyloidosis revealed amyloid deposits in pancreatic islets by routine HE and Congo red staining, which were positive for amyloid p and amyloid a, but were only focally positive for light chains kappa and lambda. Positive staining for amyloid p and amyloid a was also noted in the scattered pancreatic acinar tissues, and this positive staining was not specifically located in pancreatic islets as seen in type 2 diabetes mellitus. It is concluded that amyloid deposits in pancreatic islets occur in systemic AL-amyloidosis by a different mechanism from type 2 diabetes. Islet amyloidosis in AL-amyloidosis appears to deposit via circulation, depositing in both pancreatic islets and acinar tissue through blood vessels. In type 2 diabetes, beta islet cells die by cytotoxic effects of smaller amylin (islet amyloid polypeptide, IAPP) aggregates, and the interstitial space created by the necrotic beta cells is replaced by larger IAPP aggregates, to form complex, polymerized islet amyloid. In AL-amyloidosis, the amount of amyloid and light chain deposits in pancreatic islets is much less than that of the other organs and appears to have no connection to type 2 diabetes because the patients did not present diabetes or hyperglycemia. However, considerable islet amyloidosis can be seen in severe AL-type amyloidosis.     

Reticular cell hyperplasia and amyloidosis in a line of mice with low leukocyte counts.

Two pathologic conditions, reticular cell hyperplasia and amyloidosis, were studied in a strain of mice selectively bred for low leukocyte counts (LLC). At the age of 3 to 6 months, 70% of the mice developed reticular cell hyperplasia in the inguinea lymph nodes, and at 11 to 18 months, about 100% of them developed amyloidosis in the spleen and in the kidney, liver, and adrenal glands. Immunofluorescence was revealed in the glomeruli, interstitium of the tubules, and the amyloid skeleton of the papilla when the kidney sections were incubated with fluorescein-labeled antimouse immunoglobulins. Both intracellular and extracellular amyloid fibrils were found in the liver, spleen, and kidney sections by electron microscopy. Distended rough endoplasmic reticulum (RER) cisternae and hypertrophy of RER with or without the simultaneous presence of amyloid fibrils in the reticular cells of the spleen and Kupffer cells of the liver were observed. In this light, we believe that the pathologic conditions are manifestations of immunologic events that are characteristic of the LLC mice with immune deficiency or abnormality in the immune system. We conclude that the origin of amyloid protein is at the RER. We discuss processes of amyloid fibril formation and some genetic aspects of amyloid development.     

A beta and perlecan in rat brain: glial activation, gradual clearance and limited neurotoxicity

A beta1-40 and perlecan (A beta + perlecan) were infused into rat hippocampus for 1 week via osmotic pumps. At the end of the infusion a deposit of A beta immunoreactive material was found surrounding the infusion site. No neurons could be identified within this A beta deposit. The neuron-free area resulting from A beta + perlecan was significantly larger than that found after infusions of A beta40-1 and perlecan (reverse A beta + perlecan), perlecan alone or phosphate-buffered saline vehicle. Following infusion of A beta + perlecan, the glial cells segregated in a manner similar to that associated with compacted amyloid plaques in Alzheimer's disease (AD). Activated microglia/macrophages were prevalent within the A beta deposit while the perimeter of the deposit was delimited by reactive astrocytes. Thioflavin S and Congo red staining indicated a beta-pleated sheet conformation of the A beta deposits, implying formation of fibrils. Intact, apparently healthy neurons were found immediately adjacent to the A beta + perlecan deposit. In contrast, reverse A beta peptide did not form congophilic deposits despite the presence of perlecan. Apoptotic profiles visualized with bisbenzamide or TUNEL staining of fragmented DNA were not seen at any of the infusion sites, yet were readily seen in hippocampal sections from animals treated with kainic acid. At 8 weeks, A beta immunoreactivity, Thioflavin S and Congo red staining was reduced, indicating that A beta was being cleared. There also was no evidence of neuron loss by Nissl or TUNEL staining. The zone of apparent necrosis did not expand between 1 and 8 weeks, and in some instances appeared to contract. The consistency of the A beta + perlecan infusion method in producing reliable A beta amyloid deposits permits estimates of the rate at which fibrillar A beta amyloid can be removed from the brain, and may provide a useful model to study this process in vivo. However, the absence of clearly identifiable degenerating/dying neurons at the 1 or 8 week survival times suggests that either fibrillar A beta + perlecan slowly displaced the brain parenchyma during infusion, or neurons were killed very gradually during the process of clearing the A beta.     

Simultaneous AL-type amyloid and light chain deposit disease in a liver biopsy: a case report

A 57-year-old male caucasian presented with a peripheral neuropathy which had an autonomic component. Clinical examination revealed hepatomegaly and laboratory tests showed derangement of liver function tests and IgG lambda myeloma. Biopsy of the liver was performed. Histological examination revealed AL-type amyloid in the hepatic arteries and a perisinusoidal deposit of diastase resistant, periodic acid-Schiff positive material which did not react in the same way as the arterial deposit, giving no apple green birefringence when stained with Congo red. Immunohistochemistry showed the material to consist of lambda light chains. Electron microscopy confirmed that the material did not have the ultrastructural characteristics of amyloid. A diagnosis of light chain deposit disease concurrent with vascular AL-type amyloid was made.     

Substance P-immunoreactive nerves in the rat kidney

Previously published data have indicated that in the rat, unlike other species examined, the kidney is not supplied by sensory nerves containing substance P (SP). As part of a study of reflex control of renal function in the rat, we have now reassessed this situation. Many fine, varicose, SP-immunoreactive nerve fibers were found in the wall of the proximal ureter and the renal pelvis, and around the larger renal blood vessels. Sparser populations of similar nerves were also seen running close to proximal and distal tubules in the renal cortex. Occasional fibers were seen at the margins of the glomeruli. Our findings suggest that sensory nerves containing SP may carry sensory information of several types from the rat kidney.     

Two cases of limited cutaneous nodular amyloidosis with primary Sj?gren's syndrome]

We described two female patients with primary Sj?gren's syndrome associated with localized cutaneous nodular amyloidosis (LCNA), in which amyloid protein was derived from immunoglobulin light chain. Case 1; a 70-year-old female had complained with polyarthralgia, low-grade fever and parotid gland swelling. She was diagnosed as primary Sj?gren's syndrome. Three years later she noticed brown color small tumor on the thigh and yellow to brown nodules on the bilateral calves of legs. Skin biopsy from the left thigh revealed amyloid L protein deposition, which was positive for anti-lambda light chain staining, in almost entire dermis. Infiltration of lymphocytes and plasma cells around the amyloid deposit were prominent. Case 2; a 51-year-old female had noticed increasing eruption on the hip. Skin biopsy revealed amyloid L protein deposition in the dermis, which was negative for anti-lambda nor kappa light chain staining. When she was refereed to our hospital, she complained of xerostomia and xerophthalmia. She was diagnosed as primary Sj?gren's syndrome. In both cases, histological examination of a minor salivary gland biopsy revealed infiltration of lymphocytes and plasma cells but not amyloid deposit. Serum M protein and urine Bence-Jones protein were not detected. These cases represent localized amyloidosis without systemic involvement. It is widely recognized that Sj?gren's syndrome is frequently accompanied by B cell lymphoproliferative disorders. In LCNA, infiltration of plasma cells around the amyloid deposits was frequently prominent. The relation between these two disorders is discussed.     

Iatrogenic, insulin-dependent, local amyloidosis

Human and experimental amyloidosis can occur either as a generalized widespread deposit of various proteins or a localized deposit. We looked for local amyloidosis caused iatrogenically under clinical and experimental conditions. Subcutaneous tissue from one diabetic patient and six Wistar rats, which had received a continuous local infusion of 1.2 iu of insulin daily for 6 weeks, was examined histologically. In all cases the development of granulation tissue around the tip of the catheter was observed. In addition, inhomogenous extracellular deposits showing green birefringence under polarized light when stained Congo red were seen. Immunohistologically, they displayed binding of anti-insulin antibody. Electron microscopy demonstrated a typical spear-like fibrillar structure with a fibril diameter of 60 to 80 A. These findings confirmed that the deposited substance was amyloid. Iatrogenically administered protein produced in vivo amyloidosis at the site of its entry. Insulin can lead to the formation of amyloid fibrils not only in vitro but also in vivo.     

Lymphatic amyloidosis, a previously unrecognized form of amyloid deposition in generalized amyloidosis

Although amyloid deposition in relation to blood vessels is a well-recognized feature of generalized amyloidosis, lymphatic vessel amyloidosis is not mentioned in the literature. Systematic investigation of tissue removed at autopsy from patients with generalized amyloidosis and biopsy specimens from cases of localized amyloidosis and familial Mediterranean fever showed that amyloid deposition around lymphatics is by no means uncommon. The material investigated was mainly large and small bowel, lung, heart and kidney. Amyloid was identified by green birefringence with the Congo red stain on cross-polarization and lymphatics by their lack of immunostaining for CD34. Involvement of lymphatics was noted in 20 of the 42 organs from which specimens were examined, and was always accompanied by involvement of blood vessels and/or the interstitium. In the intestine, lymphatic amyloidosis was found mainly in the submucosa and subserosa, and was also demonstrated by electronmicroscopy in one case. Although lymphatic amyloidosis was equally common in the heart, lung and kidney, it was usually less prominent here than in the intestine. No lymphatic involvement was seen in localized amyloidosis. As the lymphatics play a central role in the resorption of interstitial proteins, they are probably also involved in the resorption of amyloid proteins. Amyloid deposition in the vicinity of lymphatics is probably the result of decompensation of this process.     

EXPERMIMENTAL AMYLOIDOSIS INDUCED BY 20-METHYLCHOLANTHRENE IN RABBITS†

In the course of repeated intrabronchial application of 20-methylcholanthrene to the rabbits, many of them were found to die from uremia with nephrotic syndrome. Approximately 60 % of animals, 3 months or longer under the experiment, showed swollen kidneys with the glomerular tufts deposited with amyloid and tubules dilated with hyaline casts. These lesions in the kidneys as well as in the liver, spleen and adrenals seen in 24 rabbits were consistent with systemic amyloidosis. Autofluorescence similar to that of 20-methylcholanthrene was observed in the unstained frozen sections of the kidney at the site of amyloid deposition. Amyloidosis developed only in one rabbit of each group which received either intrabronchial application of 4-nitroquinoline N-oxide or intravenous administration of 20-methylcholanthrene. Experimental procedures for inducing amyloidosis and pathogenesis of experimental amyloidosis were discussed.     

In-vivo study on the harmful effect of the extremely low frequency unipolar pulsating magnetic field in mice.

We studied the biological effect of a magnetic field on murine brain and kidney. Magnetic field we used was generated by Magno-DR apparatus (Hanil Co., Korea) which produced a high density unipolar square pulsating magnetic field, about 0.3 approximately 0.5 Tesla at 7 Hertz. Animals were placed in the chamber of the machine for various times from 4 hours to 24 hours. Histological sections of brain and kidney were made after perfusion fixation with paraformaldehyde. The light microscopic examination showed eosinophilic change of cytoplasm and positive immunohistochemical reaction to amyloid precursor protein in the neurons of the cerebral cortex. However, the thalamus and brain stem were less affected. The changes in the brain was seen in the mouse exposed more than 12 hours. The renal tubular epithelium showed degenerated tubules scattered in cortical area but little change was noted in glomeruli in the cortex and collecting tubules in the medulla. Immunohistochemistry of the kidney showed weakly positive reaction for the amyloid precursor protein in the distal tubular epithelium after 4 hours of exposure. These data suggest that strong pulsating magnetic fields could induce deleterious effect on the murine brain tissue and renal cortical tubules.     

Amyloid fibril proteins

Amyloidosis refers to a group of protein folding diseases. Various innocuous and soluble proteins in physiological conditions polymerize to insoluble amyloid fibrils in several serious diseases, including Alzheimer's disease (AD) and prion diseases. In addition, senile amyloidosis is a form of amyloidosis in which the incidence and severity of amyloid deposition increases with age without any apparent predisposing conditions and it was thought that the amyloidosis was related to some physiological changes which accompany ageing. Although the etiology and pathogenesis of amyloid disease are not fully understood, drastic structural changes of the amyloid proteins from the normal forms to the unique beta-sheet fibrils is the most important event in amyloid diseases. The present article introduces the three amyloid diseases, AD, prion diseases and mouse senile amyloidosis in which Abeta, PrP(Sc) and AApoAII amyloid fibrils deposit respectively. We discuss the nucleation dependent polymerization model as a model that explains the kinetics of fibrillization of these amyloid proteins. Exogenous amyloid fibrils may act as templates (nuclei) and change the conformation of endogenous amyloid protein to polymerize into amyloid fibrils. This hypothesis makes the boundary between transmissible and non-transmissible amyloidosis ambiguous and proposes the common pathogenesis for them.     

The congo red stain revisited

The Congo red stain has undergone several modifications since it was first used by Bennhold in 1922 in order to increase the specificity for staining amyloid. Most of the laboratories in the United States use the method of Puchtler which uses alkaline Congo red solution. Some of the variables associated with the procedure were investigated by us. Our results showed the following: (1) amyloid showed green birefringence at all levels between 4 to 12 mu thick sections with better visualization of small deposits with increased thickness. Best results were obtained with 8 mu thick sections; (2) omission of the pretreatment with alkaline alcoholic solution of sodium chloride (NaCl) did not affect the sensitivity of the method; (3) the use of polar mounting media had no effect on amyloid and collagen birefringence; (4) 50 percent saturation of the Congo red staining solution with NaCl caused strong staining of collagen, elastic fibers and eosinophilic granules. In addition, collagen showed green birefringence and dichroism and its differentiation from amyloid became difficult; and (5) using the staining solution fully saturated with NaCl, no positive staining was seen with tissues other than amyloid. Collagen and elastic fibers showed red fluorescence which was of less intensity than amyloid. It is our conclusion that the method of Puchtler for detecting amyloid gives better results if the staining solution is fully saturated with NaCl. The pretreatment step may be deleted without compromising the quality of staining. Improved staining of amyloid enhances the specificity of green birefringence, dichroism, and red fluorescence.     

ALys amyloidosis caused by compound heterozygosity in exon 2 (Thr70Asn) and exon 4 (Trp112Arg) of the lysozyme gene

Hereditary amyloidoses are caused by germline mutations, which increase the propensity of a protein to form cross-beta aggregates and deposit as amyloid. Hereditary amyloidoses are particularly interesting as they help to understand how changes in the primary structure of an otherwise non-amyloidogenic protein contribute to amyloidogenesis. Here we report on a novel form of systemic ALys amyloidosis, caused by compound heterozygosity in exon 2 (p.T70N) and exon 4 (p.W112R) of the lysozyme gene (LYZ), with both mutations being present on the same allele. This type of hereditary ALys amyloidosis is characterized by extended amyloid deposits in the upper gastrointestinal tract, entire colon, and kidney, leading to gastrointestinal bleeding. Both mutations are probably effective in disease manifestation. The novel mutation at position 112 in the mature protein is located within the alpha-helical domain of the protein and therefore outside the cluster of residues that has so far been implicated in ALys amyloidosis. Taken together with the p.T70N mutation, this results in a lysozyme species where the correct folding of various protein domains is probably impaired and increases the propensity of amyloid fibril formation. Interestingly, this form of ALys amyloidosis is also characterized by the occurrence of proteolytic fragments of lysozyme in the amyloid deposits.