脂质沉积性肌病的临床和病理分析(附8例报告)

脂质沉积性肌病 (ｌｉｐｉｄｓｔｏｒａｇｅｍｙｏｐａｔｈｙ ,ＬＳＭ )是肌肉中长链脂肪酸代谢障碍 ,致脂质沉积在肌纤维中而引起的一组肌病 ,属于常染色体隐性遗传病。其病因较多 ,但以肉毒碱缺乏所致常见。 70年代初才被认识[1] 。该病较少见 ,国内报道尚少。本文对其临床表现、肌肉病理特点及治疗进行报道与分析。临床资料一、一般资料　 8例中 ,男 4例 ,女 4例 ,年龄 12～ 36岁 ,病程 1～ 10年 ,平均 3.9年。 8例均进行肌活检组织化学病理与电镜观察而确诊。二、临床表现　起病缓慢 ,8例均明显累及四肢近端与颈项肌 ,四肢远端肌受累较…     

组织化学和免疫组织化学技术对脂质沉积性肌病和糖原沉积性肌病的鉴别

目的脂质沉积性肌病和糖原沉积性肌病是罕见的肌肉疾病,其常规病理形态十分相似。本文探讨这两种疾病组织化学和免疫组化反应,寻找其鉴别诊断的形态差异。方法采用三磷酸腺苷(ATP)酶、还原性尼克酰胺腺嘌呤二核苷酸(NADH-Tr)、苏丹Ⅲ、PAS组织化学染色和抗肌萎缩蛋白(Dystrophin)免疫组化染色,分析2例脂质沉积性肌病和2例糖原沉积性肌病的组织形态特征和差别。结果脂质沉积性肌病和糖原沉积性肌病在常规HE染色均表现为肌纤维内出现大量的空泡,但前者空泡大小较一致,且边界清楚,后者空泡大小差异大,边界不清。ATP酶组化染色显示脂质沉积性肌病出现空泡变性的肌纤维均为Ⅰ型肌纤维,而糖原沉积性肌病出现空泡变性的肌纤维两型均有,以Ⅰ型严重。脂肪染色和糖原染色可作为这两种肌病的确诊依据。Dystrophin免疫组化染色显示脂质沉积性肌病的肌纤维强阳性,而在糖原沉积性肌病的反应为不连续弱阳性。结论组化和免疫组化检测可用于脂质沉积性肌病和糖原沉积性肌病的鉴别诊断。     

脂质沉积性肌病10例临床病理分析

目的 检测抗线粒体抗体(anti-mitochondrial antibody,AMA)、BCL-2、Bax在脂质沉积性肌病(lipid storage myopathy,LSM)患者骨骼肌中的表达,探讨AMA在LSM中的诊断价值及细胞凋亡在LSM发病机制中的作用.方法 对18例患者肌肉组织活检标本进行AMA、BCL-2、Bax免疫组化染色,其中经临床、肌肉活检病理确诊的LSM患者10例,正常肌肉组织3例及非线粒体肌病组织5例作为对照组.结果 光镜下,LSM患者骨骼肌AMA免疫组化染色可见Ⅰ型肌纤维中有大量棕黄色细颗粒沉积;BCL-2在18例患者的肌纤维和小血管中有不同程度的表达,Bax在5例非线粒体肌病组织中的肌纤维和小血管中有表达.结论 LSM患者的骨骼肌纤维中存在有异常线粒体增多现象,AMA可作为诊断LSM的一个病理学指标.LSM和非线粒体肌病的发病机制中均存在凋亡因素的异常调节.     

中央轴空病2例及文献复习

目的：探讨中央轴空病的病理特点,方法：通过HE、特殊染色及透射电镜的方法,观察2例中央轴空病患者的肌肉活检标本,并复习文献。结果：HE染色肌纤维中央有圆型深红色区,NADH－TR染色见肌纤维中央有圆型无着色的轴空区（尤其在Ⅰ型纤维）。该区PAS染色不着色,MGT染色呈紫色,电镜观察显示,轴空区肌节结构消失,肌丝排列紊乱,Z线物质呈水纹状,肌原纤维间未见线粒体,肌管,糖原和脂滴结构。结论：中央轴空病的确诊主要依靠肌活检病理诊断,组织化学,酶组织化学染色及电镜观察对该病确诊有重要意义。     

慢性进行性眼外肌麻痹2例报道及文献复习

目的 探讨慢性进行性眼外肌麻痹(CPEO)的临床病理特征。方法 应用光镜、电镜和酶组织化学对2例CPEO肌肉活检标本进行形态学观察。结果 HE染色肌组织中见散在分布的，多少不等的嗜盐基性肌纤维。在改良GOMORI三色染色上，这些嗜盐基性肌纤维边缘由于呈现不规则红色，即称不整边红纤维或破碎红纤维。细胞色素氧化酶(CCO)和琥珀酸脱氢酶(SDH)双染色，阳性的蓝色纤维与不整边红纤维的分布一致，数量也较改良GOMORI三色染色增多。结论 改良GOMORI三色染色应作为诊断线粒体疾病的常规染色，CCO／SDH双染色可提高阳性肌纤维的检出率。     

妊娠相关性肾病9例临床病理分析

目的 探讨妊娠相关性肾病的病理形态特点。方法 观察9例妊娠性肾病肾穿活检组织的病理形态（光镜、特殊染色、免疫组化、电镜）及临床资料分析。结果 患者肾损害症状均出现在妊娠24周以后。肾小球毛细血管内皮细胞肿胀,血管袢缺血及管壁呈“双轨”样结构;各种免疫球蛋白、补体及纤维蛋白原在肾小球内有不同程度的沉积,其中C4c在血管袢沉积呈一致性阳性;电镜观察见肾小球毛细血管内皮细胞及足细胞肿胀,基膜肿胀、疏松,电子致密物少。结论肾小球毛细血管内皮细胞肿胀、管壁“双轨”样结构、C4c沿毛细血管壁沉积等是妊娠性肾病的病变特点,电镜检查有助于确诊。     

纤维样肾小球病1例报道及文献复习

目的 探讨纤维样肾小球病的病理形态特点.方法 观察1例纤维样肾小球病肾穿活检组织的病理形态(光镜、特殊染色、免疫组化、电镜)及临床资料分析,并结合文献讨论.结果 光镜下系膜增生、PAM-Masson染色系膜区见团块状状嗜复红蛋白沉积,GBM增厚、局灶节段细小钉突化;各种免疫球蛋白及补体在肾小球内不同程度的沉积;电镜见系膜区、GBM及肾小管基膜上沉积物中均见大量纤维样物质沉积,此类物质无分支,杂乱排列,较淀粉丝粗,较胶原纤维细.结论 纤维样肾小球病主要表现为膜性肾病型,其次为系膜增生型;超微结构观察是诊断纤维样肾小球病的主要依据,电镜下纤维样物质(直径15~25 nm)呈弥漫性或团块状分布于肾小球系膜区和(或)GBM是纤维样肾小球病的主要特点,患者多为中年女性,预后差.     

强直性肌营养不良的临床、肌肉病理与肌电图、神经传导速度对比研究

目的；研究强直性肌营养不良（MD）的临床、病理与肌电图（EMG）、神经传导速度（NCV）变化的关系。方法：总结3例MD的临床特点、对肌活检标本进行病理学观察并对相关肌肉进行EMG、NCV检查。结果：3例MD患者年龄25－40岁，临床特点为缓慢进行性四肢无力，肌强直发作。腱反射对称迟钝，前额秃发，EMG示肌源性损害 ，可见肌强直电位发放，NCV减慢；肌活检光镜下可见肌纤维萎缩，肌核内移呈核链形成，电镜下可见肌纤维变性，溶解，X带破坏，线粒体肿胀、变性。结论：MD患者的肌肉病理学与临床表现、EMG、NCV改变相关，临床表现愈重，肌肉损害愈明显。     

9例强直性肌营养不良症组织化学和超微结构的研究

总结９例强直性肌营养不良症（ＭｙＤ）骨胳肌的病理，组织化学和超微结构的改变。光镜下观察主要改变为肌纤维退行性变，肌核内移，核链形成，肌膜下肌浆块和环行纤维形成等。肌球蛋白ＡＴＰ酶和ＮＡＤＨ－ＴＲ组织化学染色７８％显示选择性Ⅰ型纤维萎缩。电镜下观察超微结构的突出表现为肌膜出现广泛微小缺损，Ｚ带破坏，肌丝溶解，线粒体肿胀，肌质网扩张和肌纤维再生。遗传缺陷导致广泛膜功能异常，可能是引起酶代谢紊乱，线粒体     

过碘酸-Schiff染色法与苏丹黑B双重染色在肌病诊断中的应用

在肌病病理诊断过程中,对骨骼肌活检标本冰冻切片进行H-E染色后,观察时发现有空泡现象的组织切片,除排除冰晶以外,一般考虑是否有糖原累积或脂质沉积,需要分别进行糖原染色与脂肪染色,以做进一步的鉴别诊断.过碘酸-Schiff染色法(periodic acid schiff,PAS),是一种常用的糖原染色方法;苏丹黑B是常用脂肪染色方法之一.笔者尝试将这2种染色方法在同一张切片上先后进行染色,实验结果表明,方法可行、结果满意;并且给观察提供方便.     

Carnitine deficiency

We present the case of a female patient, aged 12 years, with fatigability and exertional myalgias, progressively developed within the last two years. Negative family history, as well as negative personal medical history, were found. At physical examination, short stature, proximal muscle weakness and mild hepatomegaly were noted. Urine ketones level was slightly decreased, serum transaminases, creatine kinase and lactate dehydrogenase levels were increased. Electromyographical examination showed a myopathic non-specific pattern. Deltoid muscle biopsy revealed: small, clear vesicles are present on Hematoxylin-Eosin and modified G?m?ri trichrome stains; modified G?m?ri trichrome stain also revealed muscle fibers (especially type I of muscle fibers) having mild to moderate mitochondrial proliferation (red rim and speckled sarcoplasm). The lipid storage has been well demonstrated by Sudan Black stain, which revealed small lipid droplets in type I muscle fibers. Abnormal internal architecture with a punctate pattern was showed by adenine dinucleotide tetrazolium reductase and succinate dehydrogenase stains. Electron microscopy showed small inter-myofibrillar accumulations of round, amorphous, homogeneous acellular substances that are not membrane bounded. These features indicate that these are neutral fat (lipid) droplets. Subsarcolemmal accumulations of mitochondria were also revealed. The differential diagnosis of this case is discussed, and the up to date general data concerning carnitine deficiency are presented. The aim of our case-report is to emphasize the role of muscle biopsy in carnitine deficiency, as well as to remind the necessity of keeping in mind such metabolic disorders when doing the differential diagnostic of a muscular weakness.     

Fatal lipid storage myopathy with deficiency of cytochrome-c-oxidase and carnitine

Summary Two newborn female siblings fell ill with apathy, failure of suckling and a generalized progressive muscular hypotonia. Death occured at the age of 7 weeks, obviously caused by impairment of respiratory musculature. Biochemical studies in one child revealed carnitine deficiency especially in skeletal muscle; hepatic encephalopathy was absent. Both children had a generalized hyperaminoaciduria, an unusual finding in primary carnitine deficiency.Besides fatty metamorphosis of the liver, bilateral hydroureters and tubular calcifications of both kidneys, morphological studies showed a generalized lipid storage myopathy which predominated in Type-I-fibres and was accentuated in the muscles of the neck. Enzymehistochemical electron microscopy in longterm frozen muscle demonstrated that cytochrome-c-oxidase activity was absent not only in myopathic but also in most of the morphological unchanged muscle fibres. Only some fibres and endothelial cells displayed normal activity of mitochondria. Biochemically no cytochrome aa₃ (cytochrome-c-oxidase) could be found in skeletal muscle; cytochrome b was almost undetectable. - In newborns with fatal lipid storage myopathy and carnitine deficiency it seems necessary to look for additional defects in the respiratory chain. Enzyme histochemical electron microscopy is a sensitive method in identifying cytochrome-c-oxidase even after a 12 months period of storage.     

Adult onset lipid storage in gastric mucosa and skeletal muscle fibers associated with gastric pain, progressive muscle weakness and partial deficiency of cytochrome C oxidase.

We report on the first case, a 21-year-old man, with partial deficiency of cytochrome c oxidase, lipid storage myopathy and concomitant lipid storage in the gastric mucosa affecting chief, parietal, and argentaffine cells as well as interstitial macrophages. The clinical symptoms consisted of increasing muscle weakness, cramps of the legs, and severe gastric pain that was resistant to treatment. Muscle biopsy specimens showed severe lipid storage in muscle fibers. Enzyme histochemistry revealed partial deficiency of cytochrome c oxidase (COX) with scattered non-reactive fibers among a majority of COX-positive fibers whereas biochemical analysis of muscle homogenates resulted in no corresponding defect of mitochondrial enzymes. Gastric biopsy specimens showed similarly to muscle fibers an extensive accumulation of lipid droplets in the chief cells, HCl producing parietal cells, macrophages, neutrophilic and eosinophilic leucocytes, and to a lesser degree also in argentaffine cells and unmyelinated axons of the gastric mucosa. The lipid droplets were associated with an insignificant increase in the number and size of mitochondria although paracristalline mitochondrial inclusions were neither noted in muscle fibers nor in cells of the gastric mucosa. These findings resemble those in multisystem triglyceride storage disease although the clinical signs were not reminiscent of this disease, and indicate that among the clinically heterogeneous group of cytochrome c oxidase deficiencies lipid storage may not be confined to muscle, but can affect the gastric mucosa as well.     

High frequency of ETFDH c.250G>A mutation in Taiwanese patients with late‐onset lipid storage myopathy

Lan M‐Y, Fu M‐H, Liu Y‐F, Huang C‐C, Chang Y‐Y, Liu J‐S, Peng C‐H, Chen S‐S. High frequency of ETFDH c.250G>A mutation in Taiwanese patients with late‐onset lipid storage myopathy. Lipid storage myopathies (LSMs) are characterized pathologically by the accumulation of lipid droplets in muscle fibers due to impaired cellular lipid metabolism. The purpose of this study was to determine etiologies and genetic mutations associated with LSMs in ethnic Han Taiwanese. The usefulness of the blood acylcarnitine (AC) profile for diagnosing LSMs in adult patients was also investigated. Nine patients were diagnosed with late‐onset LSMs following a review of muscle biopsies and medical records and were recruited retrospectively. Genetic studies were performed to detect mutations in the SLC22A5 for primary carnitine deficiency, PNPLA2 for neutral lipid storage disease with myopathy, ABHD5 for neutral lipid storage disease with ichthyosis, ETFDH for multiple acyl‐CoA dehydrogenation deficiency (MADD), and CPT2 for carnitine palmitoyltransferase II deficiency. Blood AC levels were measured by tandem mass spectrometry. The mutation c.250G>A in ETFDH was detected in seven (78%) patients, six of whom were homozygous for the variant. Patients with ETFDH mutations had elevated blood levels of ACs ranging from C8 to C16 species, a pattern consistent with MADD. ETFDH c.250G>A mutation is common in Taiwanese patients with late‐onset LSMs. The blood AC profile is a sensitive biochemical marker for diagnosing MADD arising from ETFDH mutations in adults.     

A new lipid storage myopathy observed in individuals with the Ruvalcaba-Myhre-Smith syndrome

Four patients with the Ruvalcaba-Myhre-Smith syndrome (primary macrocephaly with associated anomalies including pigmented macules on the penis in affected males, hamartomatous intestinal polyps, and lipomas) had evidence of delayed psychomotor development and/or hypotonia in childhood. Electromyography in 3 patients showed evidence of a myopathic process. Muscle biopsy in all four demonstrated a lipid storage myopathy with increased numbers of neutral lipid droplets--predominatly in type 1 fibers. The type 2 fibers were consistently smaller than expected. Electron microscopy was unremarkable except for evidence of lipid accumulation. Muscle carnitine and carnitine palmityl transferase levels were normal in one patient. This appears to be a previously unreported type of lipid storage myopathy characteristic of the Ruvalcaba-Myhre-Smith syndrome, a probable autosomal dominant trait.     

Metabolic triglyceride storage disorders. A report of 2 cases of systemic carnitine deficiency

Two cases of triglyceride storage in liver, kidney, heart, and skeletal muscle are described in infants who died at the age of 1 1/2 years and 4 d, respectively. In the first patient, a previously normal girl, the clinical symptoms began two months before death with encephalopathy (vomiting, unconsciousness), liver enlargement, hypoglycemia, increase in serum transaminases. These signs disappeared within the following days. Some weeks later she died during the second attack. The 4-d-old boy, the second child of healthy consanguineous parents, showed at the third day of life an impaired sucking, muscular hypotonia, respiratory arrest and bradycardia. An intensive therapy was inefficient. At autopsy gross examination showed only a moderately enlarged yellow liver and an edematous brain in the first case and pale organs in the second one but no cause of death. The microscopial examination of all tissues of both cases showed fat storage within the four organs mentioned above. The common histochemical methods for neutral lipids were positive, the Schultz-reaction for cholesterol and cholesterol esters was negative. The lipid loaden cells did not show birefringence in polarized light. A predominance and strong fat storage of the type I fibres was found in the skeletal muscle. The storage of triglyceride could be confirmed by histochromatography, a thin-layer chromatography of tissue sections. The triglyceride accumulation in liver, heart, kidney, and skeletal muscle is a characteristic feature of systemic carnitine deficiency. The clinical symptoms of the first patient are in agreement with reports of this disease also. A carnitine deficiency in a newborn was not yet described. Family studies revealed a low carnitine concentration in the mother's serum in both cases, while the serum of father and brother resp. sister showed normal carnitine levels.     

Symptomatic lipid storage in carriers for the PNPLA2 gene

Neutral lipid storage disease comprises a heterogeneous group of inherited disorders characterized by severe accumulation of cytoplasmic triglyceride droplets in several tissues and neutrophils. A novel type of autosomal recessive lipid myopathy due to PNPLA2 mutations was recently described with associated cardiac disease, myopathy and frequent infections, but without ichthyosis. Here we describe the clinical and biochemical characteristics of a long surviving patient and report on four carrier family members with diverse clinical involvement. Interestingly, heterozygous patients show neutral lipid storage in muscle and in the keratocytes of the skin, Jordans'' bodies, mild myopathy and frequent infections. Biochemical analysis of fibroblasts obtained from patients revealed increased triglyceride storage and reduced lipid droplet-associated triglyceride hydrolase activity. Together, our data implicate that the wild-type allele cannot fully compensate for the mutated dysfunctional allele of PNPLA2 leading to triglyceride accumulation in muscle and mild myopathy in PNPLA2 mutation carriers. The presence of neutral lipid droplets in the skin in PNPLA2 mutation carriers strengthens the link between NLSD and other neutral lipid storage diseases with ichthyosis.     

Utility of dystrophin and utrophin staining in childhood muscular dystrophy

To determine the utility of dystrophin and utrophin staining in the differential diagnosis of childhood muscular dystrophy. Fifty muscle biopsies of histologically confirmed cases of childhood muscular dystrophy, below 16 years of age, were stained immunohistochemically for dystrophin and utrophin. All the 30 muscle biopsies of patients with Duchenne muscular dystrophy (DMD) showed all or majority of muscle fibers deficient for dystrophin and positive for utrophin. In the 4 female DMD carriers there was mosaic pattern of staining for dystrophin and reciprocal positivity for utrophin. All the muscle biopsies of patients with other childhood onset muscular dystrophies were positive for dystrophin and negative for utrophin. This study shows that dystrophin staining differentiates DMD and DMD carriers from other childhood muscular dystrophies and utrophin staining is of no added value. Utrophin up-regulation may compensate for structural deficiency in dystrophic muscle.     

The myopathology of floppy and hypotonic infants in Singapore

AIMS: This study attempts to determine the type and relative frequency of muscle diseases contributing to floppy and hypotonic infants in Singapore. METHODS: Eighty consecutive muscle biopsies in the Department of Pathology, National University of Singapore, in the period 1978-2000, in which a clinical diagnosis of floppy or hypotonic infant was made, were reviewed. RESULTS: The commonest cause of severe hypotonia in infancy was spinal muscular atrophy, which accounted for 33% of cases followed by congenital muscular dystrophy (13%). Eight cases (10%) of infantile type II glycogenosis (Pompe's disease) were encountered. There were seven cases of congenital myopathy, of which four were centronuclear myopathy, and one each of central core myopathy, nemaline myopathy and congenital fibre type disproportion. One case of centronuclear myopathy was associated with type I fibre smallness. Type II atrophy, which is generally considered a non-specific change, was encountered in five cases. Of interest is the relatively large number of muscle biopsies (29%) in which no significant pathological features were encountered at the light microscopic, histochemical as well as ultra-structural level. CONCLUSIONS: The study has revealed a great variety of pathology affecting the muscle of children presenting as floppy infants or with hypotonia. The muscle diseases included spinal muscular atrophy, congenital muscular dystrophies, congenital myopathies and metabolic myopathies. However, 23 (29%) cases showed no significant pathology. For this group of floppy and hypotonic infants further studies are needed.