1. Amyloidosis Fibrinoid, Hyalin General Pathology Jaroslava Dušková
Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague

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

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

4. Handbuch der pathologischen Anatomie IInd Band, Wien 1842
Amyloid - history 2.
Karl Freiherr von Rokitansky ( )
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

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

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

7. conformational disease (Carrell and Lomas, Lancet, 1997)
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

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

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

10. 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,

11. 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

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

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

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

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

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

17. 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)

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

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

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

21. Morphological Diagnosis of Amyloid
Macroscopy
reaction Virchow I (sol. Lugolli)
Virchow II (H2SO4)

22. Morphological Diagnosis of Amyloid
Microscopy:
KONGO red (+POLARISATION!) + KMnO4
thioflavine S,T
crystal. violet (metachromasia)
IMMUNOHISTOCHEMISTRY (electron microscopy)

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

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

25. Reversibility of Amyloid
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,
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,

26. Prevention & Therapy of Amyloid
Prevention & treatment of the underlying diseases
Vaccination against β am. protein in mice diminished senile plaque formation and improved memory Nature Medicine, 2001, 7, 18th Jan.
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

27. Fibrinoid & Hyalin
disorders of protein metabolism

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

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

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

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

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

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

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