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Structure determination of extracellular fragments of amyloid proteins involved in Alzheimer's disease and Dutch-type hereditary cerebral haemorrhage with amyloidosis.

Amyloid deposition is a biochemical and histopathologic hallmark of various clinical forms of amyloidoses including Alzheimer's disease and the Dutch-type hereditary cerebral haemorrhage with amyloidosis. The self-aggregating peptides responsible for these irreversible deposits have been sequenced but the mechanisms involved in the aggregation processes are not well understood. In order to gain an understanding of the possible structures prior to self-association, the extracellular fragment of the Alzheimer amyloid protein (beta A4) responsible for the deposits (the 'native' fragment) and a mutant of this with a single residue substitution (which is responsible for deposits in the Dutch-type amyloidosis) were examined by 1H-NMR spectroscopy. Interproton distance constraints were derived from NMR experimental data and incorporated into tertiary structure calculations using a simulated annealing protocol. Solution conformations of the fragment peptides associated with the two forms of amyloidoses are presented and compared. Although in both peptides the existence of a mixture of conformations in equilibrium is likely, one such population of structures possesses a flexible N-terminus and a well defined C-terminal region. The latter region includes a helical segment and a terminal turn-like structure. These structural features may be important for the basis of amyloid formation. Comparison of the calculated structures of the two peptides revealed a conformationally different region arising from the conservative substitution of Gln22 for Glu22. This region may be responsible for altered binding in the mutant peptide, giving rise to the clinically different form of amyloidosis.

Alzheimer Disease↗

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.

Adolescent↗

Synchronous carcinomas of stomach and bladder together with AA amyloidosis.

Although the association and causality between chronic inflammatory states and systemic AA amyloidosis have been well established, the evidence linking solid malignancies to reactive AA amyloidosis is scarce. Here, a case of diagnosed AA amyloidosis associated with synchronous carcinomas of stomach and bladder complicated with nephrotic syndrome and renal failure is reported.

Adenocarcinoma↗

Effect of indomethacin and selective cyclooxygenase-2 inhibitors on proteinuria and renal function in patients with AA type renal amyloidosis.

AIMS: Because the cardiovascular system (CVS) side-effects of cyclooxygenase-2 (COX-2) selective inhibitors have recently been questioned, we aimed to compare the renal and haemodynamic effects of cyclooxygenase selective (celecoxib and rofecoxib) and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) (indomethacin) in patients with renal amyloidosis secondary to rheumatological diseases who required anti-inflammatory agents and are taking maximum tolerable dose of angiotensin-converting enzyme inhibitors. METHODS: The present study was performed on 11 patients with stable proteinuria who were diagnosed as AA amyloidosis secondary to rheumatological diseases confirmed by renal biopsies. The study had three consecutive stages (celecoxib 200 mg/day; indomethacin 100 mg/day; rofecoxib 25 mg/day.) Each was given for 4 weeks and a wash-out phase of 3 weeks was allowed between consecutive stages. RESULTS: Although the decrease of proteinuria in the celecoxib period was higher than in the rofecoxib and indomethacin periods, the difference was not statistically significant. No statistically significant differences were found between serum urea, creatinine, creatinine clearance and urinary sodium excretion. CONCLUSION: In this study, no differences were found between indomethacin and the two selective COX-2 inhibitors in respect to proteinuria and renal functions in 11 patients with renal amyloidosis secondary to rheumatological diseases with varying degrees of proteinuria. Routine doses of NSAIDs brought no additional benefit to the ACE inhibitor use in terms of proteinuria and renal functions. The use of selective COX-2 inhibitors should be limited to their anti-inflammatory and analgesic effects in this population.

Adult↗

Familial amyloidosis. A histopathological study.

Four autopsy cases of familial amyloidosis were reported. The ages of the patients ranged from 37 to 51 years consisting of 3 males and 1 female. They all complained of neurological symptoms. Histologically, amyloid deposition in familial amyloidosis was different in site and grade from that of other types of amyloidosis, showing heavy deposition in nervous and endocrine system but no differences were found referring to deposition in other tissues. Electronmicroscopically, the peripheral nervous tissue was examined and amyloid fibrils were found to be deposited massively in interstices of nerve fiber.

Adult↗

Multiple myeloma, IgA kappa type, accompanying crystal-storing histiocytosis and amyloidosis.

An autopsy case of multiple myeloma, IgA kappa type, accompanying systemic crystal-storing histiocytosis and generalized amyloidosis, is reported. Besides multiple destructive lesions in the skeletal bones, nodular myeloma cell infiltrates were scattered in the liver, spleen, and both kidneys. Not only in these lesions but also in the reticuloendothelial organs, crystal-storing macrophages appeared dispersively or in clusters. Electron microscopically, numerous crystalline inclusions contained in the cytoplasm of macrophages were membrane-bound and of variable configuration, comprising of a homogeneous electron-lucid material. Enzyme cytochemically, almost all of the inclusions showed acid phosphatase activity. On the basis of the results obtained from the immunohistochemical, immunofluorescent and immunoelectron microscopic studies, it was considered that the crystalline inclusions stored in the macrophages were derived from IgA kappa immunoglobulin secreted from the myeloma cells and were formed within secondary lysosomes by crystallization during lysosomal digestion and degradation of the ingested immunoglobulin by macrophages. Generalized amyloidosis developed in different sites from those of the crystal-storing histiocytosis and were proven immunohistochemically to belong to AL amyloidosis probably derived from a certain group of A kappa precursor protein.

Amyloidosis↗

Experimental amyloidosis induced by saponin.

White male rabbits, weighing about 3 kg, were injected intravenously with 5 ml of 0.1% saponin solution dissolved in physiological saline once a week for six months. The sequential histological changes in the kidneys were observed by repeated biopsies and, in addition, the animals were subjected to necropsy for light and electron microscopic examinations. Amyloid protein was purified from the animal tissues, estimated at approximately 6,300 daltons in molecular weight by SDS-PAGE and considered as an AA type protein based on its amino acid sequence study. The antibody against the purified amyloid protein was produced in guinea pigs and was used for immunohistochemical studies. The deposition of amyloid started initially in mesangial matrices and subendothelial regions of the glomeruli, but at the end the spleen, kidney and bowels were found to be frequent sites of deposition. The amyloid deposited in the tissues was specifically positive by the indirect immunohistochemistry using the prepared antibody. This antibody also reacted positively to human materials with secondary amyloidosis. These results indicate that amyloidosis induced by saponin is a good model of secondary amyloidosis.

Amino Acid Sequence↗

Spontaneous amyloidosis in senile NSY mice.

Senile Nagoya, Shibata, Yasuda (NSY) mice developed amyloidosis and died from renal failure as a result of amyloidosis. NSY mice were first reported as experimental congenital diabetic mice by Shibata et al. in 1980. This study questioned whether NSY mice died from diabetic nephropathy. The authors of the present study investigated the life span and cause of death in these mice. The life span of NSY mice was found to be 618.7 +/- 72.5 days. NSY mice that lived for more than 400 days showed rising blood urea nitrogen and large amounts of amyloid deposits in the glomerulus of the kidneys. NSY mice died of renal amyloidosis. Immunological methods revealed that AApoAII was evident in the amyloid deposits of NSY mice. Apart from the kidneys, amyloid deposition was also found in the tongue, esophagus, stomach, small intestine, large intestine, rectum, lung, heart and adrenal glands. Amyloid deposits were found to a slight degree in the liver and the spleen. The most dominant amyloid deposition in NSY mice was seen in the glomerulus of the kidneys. From the point of view of amyloid depositional distribution, NSY mice were unique compared with other spontaneous amyloid mice.

Amyloidosis↗

Severe autonomic neuropathy in amyloidosis secondary to rheumatoid arthritis.

Autonomic neuropathy, although reported to occur in 15% of patients with AL primary) amyloidosis, is extremely rare in AA (secondary) amyloidosis. We report a patient with amyloidosis secondary to rheumatoid arthritis in whom autonomic neuropathy resulted in severe and disabling orthostatic hypotension. Extensive amyloid deposits were found throughout the autonomic nervous system.

Amyloid↗

Etanercept treatment of renal amyloidosis complicating rheumatoid arthritis.

Rheumatoid arthritis and juvenile arthritis represent the commonest diseases complicated by AA amyloidosis in developed countries. Up to 5% of patients with rheumatoid arthritis will develop AA amyloidosis, with renal failure being the commonest cause of mortality. To date, treatment of this condition has focused on suppressing the underlying inflammatory condition with drugs such as cyclophosphamide and chlorambucil, but both these drugs are associated with myelotoxicity, leukaemia and sterility. Tumour necrosis factor-alpha (TNF-alpha) is thought to be involved in amyloid deposition. The efficacy of anti-TNF-alpha therapy (etanercept) in the treatment of renal amyloidosis complicating rheumatoid arthritis is demonstrated here and the current scientific data on this subject are presented.

Amyloidosis↗

Arresting dialysis-related amyloidosis: a prospective multicenter controlled trial of direct hemoperfusion with a beta2-microglobulin adsorption column.

We investigated the clinical efficacy of direct hemoperfusion with a beta2-microglobulin (beta2-m) adsorption column for the treatment of patients with dialysis-related amyloidosis. A 2-year prospective controlled study was performed to compare the effects of passaging blood through a (beta2-m) adsorption column (Lixelle) before it is passaged through the dialysis polysulfone membrane on the severity of amyloidosis in these individuals. Patients (n = 22) whose blood went through the Lixelle column prior to dialysis had a higher beta2-m removal rate compared to an equal number of controls, and they showed earlier improvement in their symptoms which included impaired daily activities, joint stiffness, and pain. The appearance of additional bone cysts was prevented in pre-adsorbed patients but not in the controls. Thus, the Lixelle column is useful in preventing the progression of dialysis-related amyloidosis and in ameliorating or arresting the progression of the symptoms of this disorder.

Activities of Daily Living↗

Cardiac stimulation threshold in familial amyloidosis with polyneuropathy.

It has been suggested that a higher cardiac stimulation threshold reduces the applicability of pacemaker therapy in cardiac amyloidosis. We therefore reviewed threshold data in patients with familial amyloidosis with polyneuropathy (FAP), which is an inherited type of systemic amyloidosis, invariably involving the heart. Fourteen FAP patients treated with a pacemaker were studied. The mean (+/- SD) voltage stimulation threshold during implantation was 1.0 +/- 0.5 V, and noninvasive follow-up 6 months later revealed a mean Vario threshold of 1.9 +/- 0.5 V. Beyond this time, the threshold tended to be stable, and high threshold exit block did not occur in any patient. Several FAP patients did show a moderately elevated threshold, and a multiprogrammable pulse generator with a high output capability is recommended when pacemaker therapy is considered in these patients.

Adult↗

Two-dimensional echocardiography in myocardial amyloidosis.

Two-dimensional echocardiography is the best means of identifying early cardiac amyloid infiltration and gauging its subsequent progression. The early asymptomatic phase is characterized on echocardiography by a mild-to-moderate increase in left ventricular and/or right ventricular wall thicknesses. The distinctive combination of low electrocardiography voltage and increase in left ventricular mass on the echocardiogram, both compatible with substantial amyloid infiltration, is valuable in diagnosis and appears to indicate the severity of the disease. Other ancillary but common findings are left atrial dilatation, a small pericardial effusion, thickening of cardiac valves, papillary muscles, and interatrial septum. Finally, there is a peculiar texture of myocardial walls, with highly refractile areas that are typical, although not specific, of myocardial amyloidosis and can also be quantitatively described by digital image analysis techniques. The echocardiographic appearance of amyloidosis can closely mimic several other diseases. Asymmetric hypertrophy of the septum due to amyloid deposition may occur, simulating hypertrophic cardiomyopathy. The granular sparkling of myocardial walls is also found in myocarditis with severe fibrosis, and it is quite common in hypertrophic cardiomyopathy, as well as in other infiltrative diseases of the myocardium. It is not uncommon that the echocardiographic examination represents a turning point in the work-up of the patient, briskly orienting the clinician towards the correct diagnostic pathway. However, the likelihood of the cardiologist-echocardiographer to successfully and prospectively identify myocardial amyloidosis is substantially higher if all the clinical and electrocardiographic information is reviewed at the time of the echocardiographic examination.

Amyloidosis↗

Acute small bowel pseudo-obstruction due to AL amyloidosis: a case report and literature review.

Amyloidosis may uncommonly present with intestinal pseudo-obstruction. Previous reports have described an acute presentation with AA amyloid and a more chronic syndrome with AL amyloid. We report the case of a 78-yr-old man who presented with clinical and radiographic features of an acute small bowel obstruction and who, at laparotomy, was found to have intestinal pseudo-obstruction due to AL amyloidosis. We believe this case represents the first report of acute pseudo-obstruction from AL amyloidosis; awareness of this presentation may facilitate earlier diagnosis.

Acute Disease↗

Hepatic familial amyloidosis caused by a new mutation in the apolipoprotein AI gene: clinical and pathological features.

OBJECTIVE: Recently, we reported a nondescribed deletion/insertion mutation in the apolipoprotein AI gene as the cause of hereditary amyloidosis with hepatic presentation. We describe the clinical and pathological features of this type of amyloidosis in one affected family. METHODS: Demographic, clinical, and biochemical data were obtained from 33 members of the family in whom the apolipoprotein AI gene was studied. Diagnosis was based on the detection of the apolipoprotein AI gene mutation, scintigraphy using radioionated serum amyloid P component, and histological and immunohistochemical studies. RESULTS: Eight members with the mutation had hepatic involvement. Six patients were practically asymptomatic, presented with an elevation of alkaline phosphatase and gamma-glutamyl transpeptidase, and remained stable during follow-up (7.6 +/- 4.9 yr). One patient had jaundice, developed ascites and encephalopathy, and died of hepatorenal syndrome a few months after diagnosis. Jaundice and portal hypertension appeared in the remaining patient, who died 4 yr later. CONCLUSION: This form of familial amyloidosis is characterized by elevation in serum alkaline phosphatase and gamma-glutamyl transpeptidase secondary to amyloid deposits in the portal tracts. Patients remain stable and asymptomatic for many years, but portal hypertension and liver failure can develop later in life and lead to death. Thus, patients should be observed regularly and liver transplantation should be indicated when progression is detected.

Adult↗

The effect of desmopressin on platelet aggregation defect in systemic amyloidosis: a preliminary report.

Systemic amyloidosis may often be complicated with haemorrhagic tendency. The causes of this manifestation are factor deficiencies, hyperfibrinolysis and vasculopathy. In order to investigate the role of platelets, if any, we performed platelet aggregation tests with different aggregants in 10 patients with systemic amyloidosis due to familial Mediterranean fever and 10 healthy controls. Platelet aggregation was defective with different aggregants (ADP, epinephrine, collagen) in patients compared with controls. Platelet aggregation tests repeated after desmopressin (DDAVP) administration were normalized. These findings may suggest a role of a platelet aggregation defect in haemorrhagic diathesis complicating systemic amyloidosis. DDAVP may benefit patients with this disease in case of bleeding and before surgical interventions.

Adenosine Diphosphate↗

A highly sensitive method for diagnosis of secondary amyloidosis by labial salivary gland biopsy.

Both labial salivary gland and gingival biopsies were taken from 19 patients with clinical findings suggestive of secondary amyloidosis. Amyloid deposits were present in all salivary gland biopsies (19/19) while amyloid deposits in gingiva were observed only in three cases (16%). No amyloid was found in similar biopsies from 11 control patients. Periductal amyloid involvement was found along the basement membrane in all salivary gland samples; additionally, 16 cases had periacinar infiltration (84%), 13 had perivascular (68%) and 7 (37%) showed interstitial deposits. Amyloid in gingiva was seen along the epithelial basement membrane, as in salivary glands, although in isolated areas and scattered at the top of some dermal papillae and small blood vessels. In secondary amyloidosis it therefore appears that amyloid is deposited along the epithelial basement membrane before perivascular deposition occurs. This study presents a new highly sensitive and reliable method for the diagnosis of secondary amyloidosis, a method which is technically simple, free from complications and well-accepted by the patients.

Adolescent↗

Oral senile amyloidosis in senescence accelerated mouse (SAM).

Oral senile amyloidosis in senescence accelerated mouse (SAM) was examined for two SAM sublines (P/2/Iw and R/1/Iw) and for various ages by light microscopy, immunohistochemistry, and electron microscopy. The amyloid deposition, identified by green birefrigence following Congo red stain, was observed only in P/2/Iw. In P/2/Iw, no amyloid deposition was found at age 6 months; however, frequency and extent of such deposits increased with advancing age. Distribution of amyloid deposition was as follows: along papillary layers of mucous epithelium in the tongue, the gingiva, the palate, and the buccal mucosa; foci in connective tissues; along vessels, muscles, and minor salivary glands. Immunohistochemically, the amyloid deposition was positive with anti-ASSAM serum being raised against a unique amyloid protein ASSAM which probably induced "senile systemic amyloidosis". P/2/Iw is useful as an animal model of oral senile amyloidosis.

Aging↗