Amyloidosis

Dr Kingsly Robert
14/4/2011
OBJECTIVES
Definition
Mechanism of formation
Characteristics common to all amyloid
subtypes
Classification
Clinical Importance/Symptoms
Diagnosis and Treatment
Take home message
 In 1854 Rudolph Virchow named it
amyloid based on color after staining
these proteins with iodine and
sulfuric acid. Meaning cellulose or
starch
AMYLOIDOSIS
Amyloid (starch-like from the Greek
amylon )

Amyloidosis is a condition associated with a

number of inherited and inflammatory
disorders in which extracellular deposits of
fibrillar proteins are responsible for tissue
damage and functional compromise.

Amyloid is a pathologic proteinaceous

substance, deposited in the extracellular
space in various tissues and organs of the
body in a wide variety of clinical settings.
Amyloid
It is an amorphous, eosinophilic, hyaline,
extracellular substance seen on H&E stain .

It can be easily demonstrated tissue in bright red

colour in ordinary light by Congo Red Stain. But
when see under polarizing microscopy it give
green bi regringense

With progressive accumulation, amyloid encroaches

on and produces pressure atrophy of adjacent
cells.
Mechanism of formation
Amyloid fibrils arise from misfolded proteins.
Alpha helix to beta pleated sheet
Proteins are deposited extracellularly
Proteins aggregate and form fibrils called
amyloid fibrils.
Misfolded proteins may result from point
mutations.
Deposited as localized vs systemic
-localized; close to cells producing it.
-Systemic; distant sites from these cells producing
these abnormal proteins.
Structure of Amyloidal
material
Three main types but there are several minor types
and all are deposited by different mechanism
By electron microscopy Amyloid is seen to be
made up largely of continuous, nonbranching
fibrils with a diameter of approximately 7.5
to 10 nm. This electron-microscopic structure
is identical in all types of amyloidosis.
Approximately 95% of the amyloid material
consists of fibril proteins, the remaining 5%
being the P component and other
glycoproteins.
 Overview of Amyloidosis

Disorder of protein folding

Structurally diverse
precursors adopt an
abnormal common fibrillar
conformation

Involves refolding of
precursor protein
self-assembly into fibrils
Pathogenesis of
Amyloidosis
Amyloidosis is fundamentally a
disorder of protein misfolding.
Several factors may contribute to
the aggregation of certain proteins
and the formation of fibrils that
deposit in extracellular tissues
Pathogenesis of Amyloidosis
Amyloid types
Of the more than 20 biochemically distinct forms
of amyloid proteins that have been identified,
Three are most common are :

(1) AL (amyloid light chain) is derived from Ig

light chains produced in plasma cells;

The amyloid fibril protein of the AL type is
produced from free Ig light chains secreted by a
monoclonal population of plasma cells, and its
deposition is associated with certain forms of
plasma cell tumors
Amyloid types
(2) AA (amyloid-associated) is derived from a unique
non-Ig protein synthesized by the liver.
It has a molecular weight of 8500

Consists of 76 amino acid residues.

AA fibrils are derived by proteolysis from (serum

amyloidassociated) protein
SAA is a larger (12,000 Daltons) precursor in the serum.

Synthesized in the liver and circulates with high density

lipoproteins.
SAA protein is increased in inflammatory states as part

of the acute phase response.

Therefore, this form of amyloidosis is associated with
chronic inflammation, and is often called secondary
amyloidosis.
Characteristics common to all
amyloid subtypes
Hematoxylin and Eosin (HE)
staining results in amorphous
eosinophilic appearance when
viewed on light microscopy.
 Organ changes

When stained with Congo red and observed under

polarized light, the amyloid has a characteristic "apple
green" birefringence as seen here in a deposit around an
artery in the heart
When stained with Congo red and observed under
polarized light, the amyloid has a characteristic
"apple green" birefringence as seen here in a
deposit around an artery in the heart
Polarized light, shows a green birefringence, due to the
cross--pleated configuration of amyloid fibrils.
Classification: Historical vs
Modern
Historical (Clinical): Primary, Secondary,
multiple myeloma associated, Familial.
Modern (Biochemical): Since 1960s
based on ability to solubilize fibrils and
immunostain for protein subtypes.
23 different human subtypes named
based on A for amyloid followed the
precursor protein e.g AL, AH.
Amyloid types precursor
proteins
Monoclonal Ig light chains AL
Serum amyloid A protein AA

Transthyretin Senile systemic

amyloid
2 microglobulin Dialysis related
amyloid
Genetically variant proteins Hereditary
amyloid
- Fibrinogen A-chain - Gelsolin
- Transthyretin - Apo AI
Clinicopathologic Category Associated Major Chemically
diseases Fibril Related
Precursor Protein
Protei
n
Systemic (Generalized)
Amyloidosis
Reactive systemic amyloidosis Chronic inflam. AA SAA
(secondary amyloidosis) conditions
Hemodialysis-associated amyloidosis Chronic renal A2m 2 microglobulin
failure

Hereditary Amyloidosis
Familial Mediterranean fever
AA SAA
Familial amyloidotic neuropathies
ATTR Transthyretin
(several types)

Senile Amyloidosis ATTR Transthyretin

Localized Amyloidosis
Senile cerebral Alzheimer A APP
disease
Endocrine

Medullary carcinoma of thyroid
A Cal Calcitonin
Islets of Langerhans Type 2 diabetes AIAPP Islet amyloid
peptide
Isolated atrial amyloidosis
AANF Atrial natriuretic
factor
Types of Amyloidosis
 Primary Amyloidosis

Immunocyte Dyscrasias with Amyloidosis

Ex: Amyloidosis associated with multiple
myeloma, a malignant neoplasm of plasma
cells
Systemic in distribution

AL type

Present in the serum of multiple

myeloma( 70%) and in myeloma with

amyloidosis (100 %)
who also have Bence Jones proteins in the
serum or urine, or both.
Reactive Systemic Amyloidosis
(secondary amyloidosis)

Deposits is systemic in distribution and are composed of AA

protein
Occurs usually after infectious and noninfectious chronic
inflammatory conditions.
1-Infection : Ex: Tuberculosis, Bronchiectasis,
and Chronic osteomyelitis
2-Chronic inflammatory condition by
autoimmune states e.g., RA, ankylosing
spondylitis, and inflammatory bowel disease
3-Tumors not derived from immune cells, the
two most common being renal cell carcinoma
and Hodgkin lymphoma
 Familial (Hereditary) Amyloidosis
An autosomal recessive condition called
familial Mediterranean fever.
A febrile disorder c/zed by attacks of fever accompanied by inflammation of
serosal surfaces, including peritoneum, pleura, and synovial membrane.

Localized Amyloidosis
Amyloid deposits are limited to a single organ or
tissue.
Grossly detectable nodular masses or be evident
only on microscopic examination.
Nodular (tumor-forming) deposits of amyloid are
most often seen in..lung, larynx, skin, urinary
bladder, tongue, and the region about the eye.
 Endocrine Amyloid
Small deposits are seen in
o Medullary carcinoma of the thyroid gland,
o Islet tumors of the pancreas,
o Pheochromocytomas,
o Undifferentiated carcinomas of the stomach
o Islets of Langerhans (type 2 diabetes mellitus).
Amyloid of Aging
Senile systemic amyloidosis refers to the systemic
deposition of amyloid in elderly patients (70s and 80s).
Heart is mainly affected with restrictive cardiomyopathy
- and arrhythmias,(senile cardiac
amyloidosis).
The amyloid in this form is composed of the normal TTR
molecule.
A mutant form of TTR is another molecule affecting heart.
 Possible amyloid
phenotypes
Visible tissue infiltration Peripheral neuropathy
Bruising - periorbital, Carpal tunnel syndrome common
general Symmetrical sensorimotor
Macroglossia neuropathy

Problem!
Muscle pseudohypertrophy
Renal
Autonomic neuropathy
Orthostatic hypotension/arrhythmias
Proteinuria Gut motility/bladder emptying
Uncommon, non-specific
Renal failure
Gastrointestinal
Weight loss/anorexia/bloating
Cardiac
presentation, and therefore
Restrictive cardiomyopathy
Blood loss
Constipation/diarrhoea
often not considered
ECG - low voltage,
pseudoinfarct
Adrenal axis
Hypoadrenalism
Liver
Lymphoreticular system
Hepatomegaly, high ALP
Hyposplenism/splenomegaly
Liver failure rarely Lymphadenopathy
Morphology
Kidneys, liver, spleen, lymph nodes,
adrenals, and thyroid are involved in
amyloidosis secondary to chronic
inflammatory disorders.

Heart, gastrointestinal tract,

respiratory tract, peripheral nerves,
skin, and tongue are usually involved in
immunocyte-associated amyloidosis
Morphology
Grossly : Organ is enlarged and appears gray with a waxy, firm
consistency on cut surface.

Microscopically : The amyloid deposition is always extracellular and

begins between cells, closely near to basement membranes.

Later on it encroaches on the cells in time and than destroying the

cells.

Peri-vascular and vascular localizations are commonly seen in MM .

The most commonly used staining technique is Congo red, Gives a

pink or red color to amyloid deposits.

Under polarized light the Congo red-stained amyloid shows so-called

apple-green birefringence
Heart
It May be as isolated organ involvement in old age (senile
amyloidosis)
1. or as a systemic distribution.( immunocyte dyscrasias, MM)

The deposits may not be evident on gross examination, or

They may cause minimal to moderate cardiac enlargement.
Gross findings:
Gray-pink, dew drop-like subendocardial elevations,
particularly evident in the atrial chambers.
Microscopically :
Deposits are typically found throughout the myocardium,
beginning between myocardial fibers and eventually
causing their pressure atrophy
Gross section of heart tissue.
The tissue was firm and had a waxy
texture. See pale yellow areas within this
tissue which represent the amyloid
deposits.
 CARDIAC AMYLOID

Adapted from K. Shah et al, Archives of internal medicine 2006.

Kidney (renal amyloidosis)
Most common and most serious, Major cause of death.
Gross - large pale kidney or shrunken and contracted in
advanced cases.
Histologically - the amyloid is deposited in the glomeruli,
interstitial peritubular tissue, arteries, and arterioles
This is a gross photograph of kidney. Note the pale yellow
material within the cortex (arrows). This is indicative of amyloid
within the cortex and the glomeruli. Also note that there are
multiple red spots in the cortex. These represent congested
glomeruli due to the vascular compromise produced by the
amyloid.
Amyloidosis in
Glomerulus
Amyloidosis Kidney
Spleen
Moderate or even marked enlargement (200-800
gm). Firm in consistency,
Cut surfaces reveal pale gray, waxy deposits;

One of two patterns of deposits may develop.

1. The deposits limited to the splenic follicles, ("sago

spleen"),

2. Or Splenic sinuses and eventually extend to the

splenic pulp, forming large, sheet like deposits
("lardaceous spleen").
 Cardiac amyloidosis

Thick-walled LV on echocardiography
Diastolic, not systolic dysfunction
Low voltages on ECG (not always)
High Serum NT Pro BNP and troponins
Late gadolinium enhancement on MRI
Usually AL or TTR (senile systemic or hereditary)
 Localised AL amyloidosis

Bladder, brochopulmonary tract, prostate,

conjunctiva, other.
Good prognosis generally, local treatment
Liver
Liver may be markedly enlarged.
liver is extremely pale, grayish, and waxy

Microscopically
Amyloid deposits first appear in the space of Disse
and then progressively enlarge to encroach on the
adjacent hepatic parenchyma and sinusoids
Compressed liver cells shows atrophy and are
eventually replaced by sheets of amyloid;
Remarkably, liver function is not affected even in
severe involvement.
This is a gross picture of the cut surface of the
liver from this case. The liver tissue is firm and
has a waxy appearance--although this is difficult
to appreciate in an image.
This is a high-power view of liver tissue
stained with Congo red. The orange
amyloid material (arrows) is seen clearly
between liver parenchymal cells.
 Hereditary amyloidosis
Family history often missing
Transthyretin
Iso122 variant: Isolated cardiac, Afro-
Caribbeans; like senile systemic but younger)
Met30, Ala60, others: Associated neuropathy

Fibrinogen A-chain
Predominant renal involvement

Lysozyme
Hepatic, gastrointestinal, lacrimal glands, other

apolipoprotein AI, apolipoprotein AII, Cystatin C, Gelsolin, and

Senile systemic
amyloidosis
Wild type transthyretin
Cardiac isolated disease
Slowly progressive
Does not respond to chemotherapy
Disease mainly of elderly, white men
Increasingly found incidentally on
echocardiography and cardiac MRI

Can be misdiagnosed as AL in the

presence of MGUS/MM
 AL Amyloidosis Clinical Features

Nephrotic syndrome
Med. survival 3-4 years
Renal impairment/failure
Cardiac failure
Peripheral or autonomic
neuropathy
Carpal tunnel syndrome
Factor X deficiency
Periorbital bruising
(raccoon eyes)
Bone marrow involved
Jaw claudication
Macroglossia
Lymphadenopathy
NOT CNS
AA Amyloidosis Clinical Features

Almost
never cardiac, or
central, peripheral
or autonomic NS
 AL amyloidosis
1 in 1500 deaths in UK

Typical subtle monoclonal gammopathies

Subtle monoclonal gammopathies in ~75-80%
Myeloma in ~20%
Clonal disease undetectable in ~2%

Extremely heterogeneous organ involvement

Median survival without treatment 6-15 months

A amyloid
A amyloid is produced from amyloid
precursor protein and is found in the
cerebral lesions of Alzheimer disease,
The amyloid deposited in walls of cerebral

blood vessels in individuals with this disease.

-amyloid protein (A): It is a 4000-dalton

peptide
The A protein is derived by proteolysis from a

much larger transmembrane glycoprotein,

called amyloid precursor protein.
 Diagnosis of amyloidosis
Can be very difficult
No blood test can diagnose or exclude
amyloidosis
Usually relies on clinical suspicion
Possibility supported by:
Underlying chronic inflammatory state AA
Underlying plasma cell dyscrasia AL
Family history - hereditary
Evidence of organ dysfunction
Treatment
Treatment of this medical disorder is limited and
research is still in progress.
Treatment differs depending on subtype.

AL and AH

-High dose mephalan plus

dexamethasone/prednisone
-In selected candidates autologous stem cell
transplant is an option.
- The goal with treatment is to get rid of clonal
plasma cells that lead to immunoglobulin protein
Treatment
AA: Treat the infection or chronic
inflammatory condition causing apo
serum A protein elevation.
Familial Mediterranean fever: Colchicine
Other conditions are treated
conservatively or require organ
transplant
Prognosis is poor with this medical
disorder.
 Conclusions
Amyloidosis is a complex, rare disease
SAP scintigraphy is a useful means of diagnosing
systemic amyloidosis but does not accurately
determine type

Accurate and early diagnosis of amyloid type by tissue

biopsy +/- DNA analysis is vital to determine appropriate,
rationale treatments

In AL amyloidosis, tolerance of treatment is varied but

survival is improving
Monitor response by serum free light chains and NT pro-BNP
Treatment of AA amyloidosis is suppression of the
underlying inflammatory drive
Solid organ transplantation seems to have an increasing
role in selected patients
Hope for the future of immunotherapy