General Pathology Amyloidosis Fibrinoid Hyalin Jaroslava Dukov Inst

General Pathology Amyloidosis Fibrinoid, Hyalin Jaroslava Dušková Inst. Pathol. , 1 st Med. Faculty, Charles Univ. Prague http: //www 1. lf 1. cuni. cz/~jdusk/

Amyloidosis DEF. : disorder of protein metabolism accompanied with abnormal extracellular deposition of proteinaceous material - amyloid

Amyloid - history Amyloid = starch like Karl Freiherr von Rokitansky (1804 -1878) Rudolf Ludwig Karl Virchow (1821 -1902).

Amyloid - history 2. Karl Freiherr von Rokitansky (1804 -1878) Austrian pathologist, born February 19, 1804, Königgrätz, Böhmen, Austrian Empire (now Hradec Králové, East Bohemia, Czech Republic); died July 23, 1878, Wien. Handbuch der pathologischen Anatomie IInd Band, Wien 1842

Amyloidosis – morphology Macroscopy: small amounts – invisible u larger deposits – enlarged, firm, waxy organs u

Ultrastructure & Biochemistry of Amyloid 90 -95% non branched fibrils diam. 10 -12 nm 5 -10% p-component - glycoprotein + fibronectin, laminin, collagen 4

Amyloidosis conformational disease (Carrell and Lomas, Lancet, 1997) „…arises when a constituent protein undergoes a change in size or fluctuation in shape with resultant self - association and tissue deposition“ pleated β – sheet structure

Conformational diseases (Carrell and Lomas, Lancet, 1997) u u Amyloidosis Prionoses - transmissible spongiform encephalopathies (incl. m. CJD) u m. Alzheimeri pleated β – sheet structure

Amyloidosis Classification: u according to the source protein (more than 20 different identified) u according to the distribution v systemic (generalised) v localised

Systemic Amyloidosis - I. AL - imunocyte dyscrasia associated light chains Ig (mostly ) „primary“ Distribution: tongue, heart, GIT, liver, spleen, kidney Associated diseases: Plasma cell myeloma, B cell lymphoma,

Systemic Amyloidosis - II. AA - reactive systemic amyloidosis SAA = Serum Amyloid Associated protein „secondary“ Distribution: liver, kidney, spleen, GIT, lymph nodes, bowel, adipose tissue Associated diseases: rheumatoid arthritis, chronic infections (tb, leprosy, bronchiectasiae, osteomyelitis, IBD, neoplasms MLH , RCC

Systemic Amyloidosis - III. senile systemic SSA 25% people over the age of 80 years (!) -normal transthyretin TTR (prealbumin) -mostly heart & vessels invilvement

Systemic Amyloidosis - IV. A 2 - hemodialysis associated 2 microglobulin Hereditary AA - Familial Mediterranean Fever ATTR - Famil. polyneuropatia form) transthyretin (mutated

Systemic Amyloidosis - complications diminished functions of some organs, esp. KIDNEY FAILURE IIIrd stage Amyloid nephrosis

Localised Amyloidosis - I. Senile cardial ATTR - transthyretin (structurally normal) Senile cerebral A - -amyloid protein

Cardiac Amyloidosis – clinical manifestations u Dilated Cardiomyopathy u Restrictive cardiomyopathy u Congestive heart failure Rhytm abnormalities Coronary insufficiency Valvular dysfunction Pericardial tamponade Enhance sensitivity to digitalis glycosides Atrial thrombosis - embolisation u u u (predominant systolic dysfunction) (predominant diastolic dysfunction)

Localised Amyloidosis - II. Endocrine ACal - ca medullare gl. thyreoideae AIAPP - islets of Langerhans associated AANF - isolated atrial amyloidosis atrial natriuretic polypeptide Nodular tumoriform amyloid deposits (tongue, lung, larynx, skin, urinary bladder, orbita)

Clinical Diagnosis of Amyloid Scintigraphy (in vivo) using human serum amyloid component marked with 123 J Echocardiography (atrial amyloid)

Clinical Diagnosis of Amyloid Biochemistry sequening DNA -hered. forms extraction of fibrils (from a biopsy specimen) spectrometry sequening of the amyloid protein

Amyloidosis – morphology Macroscopy: small amounts – invisible u larger deposits – enlarged, firm, waxy organs u

Morphological Diagnosis of Amyloid Macroscopy – reaction Virchow II (sol. Lugolli) (H 2 SO 4)

Morphological Diagnosis of Amyloid Microscopy: – KONGO red (+POLARISATION!) + KMn. O 4 – thioflavine S, T – crystal. violet (metachromasia) – IMMUNOHISTOCHEMISTRY (electron microscopy)

Morphological Diagnosis of Amyloid Materials: – GIT (stomach, duodenum rectum, gingiva) biopsy – kidney – sural nerve & muscle – fat aspiration biopsy – needle with an internal diam. 0, 7 -1, 2 mm Röcken Ch. Sletten K. : Amyloid in Surgical Pathology Virchows Arch. , 2003, 1 -26

CONGO Red synthesized by young chemist at Bayer comp. 1883 as the first of economically lucrative direct (nod needing a mordant) textile dyes u patented by AGFA 1885 (Aktiengeselschaft für Anilinfarbenfabrikation) 3 weeks after the conclusion of the West Africa Conference u to Europeans in 1885, the word Congo evoked exotic images of far-off central Africa known as The Dark Continent u the Congo red stain was named „Congo“ for marketing purposes by a German textile dyestuff company in 1885 u Steensma DP: „Congo“ Red. Out of Africa? Arch. Pathol. Lab. Med. , 2001, 125, 250 -2

Reversibility of Amyloid u The deposits are NOT irreversible. e. g. Hrncic R. et al: Antibody mediated resolution of light chain – associated amyloid deposits. Am. J. Pathol. , 2000, 157, 12369 -46 u Progression of generalised amyloidosis can be delayed or stopped by treatment of the underlying disease. Röcken Ch. Shakespeare Ann: Pathology, diagnosis and pathogenesis of AA amyloidosis. Virchws Arch. , 2002, 440, 11 -122

Prevention & Therapy of Amyloid Prevention & treatment of the underlying diseases u Vaccination against β am. protein in mice diminished senile plaque formation and improved memory. u Nature Medicine, 2001, 7, 18 th Jan. u. A β –based experimental therapies based on degrading enzymes. Zlokovic et al. : Neurovascular Pathways and Alzheimer Amyloid β-peptide. Brain Pathol. , 2005, 15, 78 -83

Fibrinoid & Hyalin disorders of protein metabolism

Fibrinoid Change of Collagen vessels and connective tissue damage u plasmorrhagia (leakage of plasma) u deposits of Ag-AB complexes u staining characteristics fibrin - like u

Hyaline change Definition (historical, descriptive): intra- or extracellular change of homogenous rose „ glassy“ appearance in the H&E stained histological sections

Hyaline change Extracellular: corpus albicans, scars, hyalinoses of serous membranes Intracellular: Crooke cells, Mallory´ hyaline, Russell bodies

Ultrastructure Fibrinoid - collagen fibres surrounded by plasma proteins may be reversible u Hyalin – collagen fibres increased in thickness, changed architecture rather u stable

Hyaline change Extracellular: corpus albicans, scars, hyalinoses of serous membranes Intracellular: Crooke cells, Mallory´ hyaline, Russell bodies

Significance of Fibrinoid Change diminished quality of the collagen u ( firmness, permeability) tendency to thrombosis in the vessels, aneurysms formation u

Significance of Hyalin Change diminished quality of the collagen ( elasticity) u ischemia in organs with thickened arterial walls u intracellular function, death u