Immunocytochemical study of hepatocyte synthesis of amyloid AA. Demonstration of usual site of synthesis and intracellular pathways but unusual retention on the surface membrane

For determination of the intracellular site of synthesis and the pathways followed by amyloid protein AA, immunocytochemical localization of the anti-AA reactive substance was investigated in the livers of CBA/J mice in an acute-phase response evoked by a single subcutaneous injection of 0.5 ml of 10% casein. In the cytoplasm of the hepatocytes, the positive reaction was localized on and/or in the rough endoplasmic reticulum and the single membrane-bound vesicles, vacuoles and lamellae including the Golgi apparatus, confirming that amyloid protein AA follows the common routes of synthesis and secretion established for other proteins. The anti-AA-reactive substance was also localized on the free surface of the hepatocyte membrane, including the microvilli. The latter reaction appeared as early as but lasted at least several hours longer than its cytoplasmic counterpart, suggesting that a certain retention period exists before the release of the AA-reactive substance from the cellular surface to the free blood plasma.

Primary (AL) amyloidosis as a cause of breast masses

Amyloidosis is rarely considered in the differential diagnosis of breast masses. During the past six years, 27 women with primary (24) and multiple myeloma-associated (three) amyloidosis (AL amyloid) were evaluated at our center. In five of these patients, amyloid was demonstrated on microscopic examination of breast tissue. The clinical presentations were similar to fibrocystic breast disease in two cases and malignancy in two others. Amyloidosis of the breast may be more common than previously recognized, especially considering the predilection of amyloid for depositing around fat cells. Therefore, pathologic examination of nonmalignant breast tissue should include Congo red staining and viewing under polarized light.

Cloning of human prealbumin complementary DNA. Localization of the gene to chromosome 18 and detection of a variant prealbumin allele in a family with familial amyloid polyneuropathy

Prealbumin, a 55,000 Mr protein, is a normal constituent of human serum. In patients with familial amyloid polyneuropathy (FAP), an autosomal dominant disease, variant prealbumin molecules are found in association with systemic amyloid deposits. One variant prealbumin has a methionine for valine substitution at amino acid 30 and has been implicated in the pathogenesis of type 1 FAP. A prealbumin-specific complementary DNA clone has been isolated from an adult human liver library and used in Southern blot hybridization experiments to identify a unique NsiI restriction endonuclease site in the variant allele carried by type 1 FAP patients with the methionine for valine substitution. The complementary DNA clone has been used to analyse a panel of human-mouse and human--hamster somatic cell hybrid DNAs and localize the prealbumin gene to chromosome 18.

Nephelometric measurement of human serum prealbumin and correlation with acute-phase proteins CRP and SAA: results in familial amyloid polyneuropathy

Prealbumin, a negative acute-phase reactant, has a role as a clinical index of patient status after inflammation, trauma, or surgery that is gaining recognition. We developed a rate nephelometric assay that allows quantitation of prealbumin levels in a large number of samples to be performed quickly, efficiently, and reproducibly. The generation of data by this method is more rapid and precise than the alternative measurement techniques of radioimmunoassay, radial immunodiffusion, and electroimmunoassay. Nephelometric analysis of serum prealbumin in 33 patients with familial amyloidosis showed significantly depressed concentrations compared with levels in normal individuals and in patients with primary and secondary amyloidosis. Prealbumin levels were compared with corresponding amounts of the acute-phase proteins C-reactive protein and serum amyloid A in the three amyloid groups. Lowered prealbumin concentrations corresponded to elevated levels of C-reactive protein and serum amyloid A in the sera from patients with primary and secondary amyloidosis. In the group with familial amyloidosis, however, the lower than normal levels of prealbumin did not correspond to elevations in C-reactive protein and serum amyloid A. Our data suggest that depressed plasma prealbumin concentrations noted in individuals with familial amyloidosis are not simply reflections of a negative acute-phase response.

Colchicine in acute inflammation: stimulation of production of interleukin-1 and modulation of the acute phase serum amyloid A protein response

The effects of colchicine on the acute phase serum amyloid A (SAA) response were studied in CBA/J mice to determine whether these effects are mediated via inhibition of interleukin-1 (IL-1) production. Prolonged pretreatment (72 h) with colchicine blunted the SAA response to stimulation with silver nitrate (AgNO3), while brief pretreatment (12 h) unexpected augmented SAA production. In a macrophage model, colchicine stimulated baseline production of IL-1 (SAA inducer and lymphocyte activating factor activities) and augmented lipopolysaccharide (LPS) induced IL-1 production. This indicates that colchicine does not inhibit amyloidosis via direct effects on early inducers of the acute phase SAA response.

Heterogeneous participation of the hepatocyte population in amyloid protein AA synthesis

Amyloid protein AA is believed to be synthesized in the liver in a form of its precursor, the acute phase reactant, SAA. To identify precisely the cell involved in SAA biosynthesis, immunohistochemical reaction to anti-mouse AA was analysed on the liver sections from CBA/J mice which had received a single casein injection and were sacrificed at predetermined times up to 48 hours. Two different primary localizations of the reaction were revealed. One was in the cytoplasm of certain hepatocytes. This reaction peaked at 6-8 hours after the casein injection in the intensity of the reaction and in the number of the cells involved. The hepatocytes with positive cytoplasmic reaction were scattered over the lobule and even at the peak did not exceed 20% of the total hepatocyte population. The other localization of the reaction covered linearly the surface of the hepatocyte cords, and peaked at 12-16 hours after the casein injection.

Serum amyloid A protein concentration in progressive systemic sclerosis (scleroderma)

Serum amyloid A protein (SAA) concentrations were determined in 62 patients with progressive systemic sclerosis (PSS). Forty-seven patients had normal or slightly elevated SAA levels (less than 1000 ng/ml = micrograms/l), while 15 patients had moderately to markedly elevated SAA levels, similar to those observed in active rheumatoid arthritis (RA) (greater than or equal to 1000 ng/ml = micrograms/l). Five patients with PSS had SAA levels corresponding to those observed in amyloidosis secondary to RA. High SAA was associated with more severe skin thickening and diminished cumulative survival at five years. The rarity of amyloidosis secondary to PSS is unlikely to be related to an intrinsic defect in SAA production.

Familial amyloid polyneuropathy: a new kinship of German ancestry

Familial amyloid polyneuropathy (FAP) is an autosomal dominant inherited disorder that primarily affects the peripheral and autonomic nervous systems and usually becomes symptomatic in the third or fourth decade. Because of the confusion with other genetically transmitted neurologic conditions, the diagnosis is often delayed until advanced stages. We describe a new German kinship with FAP in which the disorder was detected in two asymptomatic family members who were seeking genetic counseling.

Localized amyloidosis of the head and neck and upper aerodigestive and lower respiratory tracts

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist/head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Hepatic amyloidosis. A histopathologic analysis of primary (AL) and secondary (AA) forms

The liver is a major site of amyloid deposition. The spectrum of histopathologic changes in the liver was studied in 38 patients with systemic amyloidosis (25 with primary or myeloma-associated amyloidosis [AL] and 13 with secondary, reactive [AA] amyloidosis). Overall architectural distortion, alterations of portal triads, as well as predilection for topographic deposition in the parenchyma and/or blood vessel walls were noted. Significant histopathologic differences in AL or AA amyloid liver involvement included 1) portal fibrosis, seen in 7 of 25 (28%) AL patients and 8 of 13 (62%) AA patients (P = 0.05), 2) parenchymal amyloid deposition in 25 of 25 (100%) AL amyloid and 10 of 13 (77%) AA amyloid patients (P = 0.04), and 3) vascular amyloid deposition found in 17 of 25 (68%) with AL amyloid and 13 of 13 (100%) patients with AA amyloid (P = 0.02). These data vary from the widely held concept that deposition of amyloid is predominantly vascular in the AL form and parenchymal in amyloid AA. Clearly, however, in individual cases significant overlap occurred, and characterization of amyloid types based on morphologic distribution of amyloid deposits may be possible in only a minority of cases. In most cases, differentiation of amyloid AL and amyloid AA forms requires clinical, histochemical, immunochemical, and sometimes more elaborate laboratory amino acid sequence studies for accurate identification.

Measurement of murine serum amyloid P component by rate nephelometry

Murine serum amyloid P component (SAP) is an acute-phase protein that is increased 2-10-fold in concentration following appropriate inflammatory or infectious stimuli. Previous studies of the acute-phase SAP response have employed quantitative immunoelectrophoresis or radioimmunoassay to measure SAP concentration. A rate nephelometric procedure has been developed which measures SAP concentration rapidly and with equivalent or greater precision than the previously applied techniques. This simple method will facilitate experimental and clinical studies of the acute-phase response.

Amyloid goiter: preoperative scintigraphic diagnosis using Tc-99m pyrophosphate

Amyloid goiter is a rare clinical entity. The diagnosis is rarely made preoperatively because clinical and laboratory findings are nonspecific. We report two cases of amyloid goiter in whom the diagnosis was made preoperatively using Tc-99m pyrophosphate scintigraphy.

Behavior modification and the treatment of myopia

Myopia is a highly prevalent disorder of vision that has traditionally been managed by means of corrective lenses. In recent years, however, there has been an upsurge of interest in the use of vision training programs as an alternative form of treatment, and particularly in the application of behavior modification techniques for the improvement of visual acuity. The most impressive experimental work to date has been in the area of operant conditioning methods (principally feedback and fading) on the modification of acuity, and this research is reviewed in depth. Also considered here are a number of relevant studies on the use of hypnosis and biofeedback training of accommodation. Research in this area is particularly timely in view of the increasing interest in the role of learning factors in both the development and maintenance of myopia. Despite a number of methodological problems identified in this review, there appears to be considerable promise in the application of behavior modification to disorders of vision.

Acute-phase proteins or tumour markers: the role of SAA, SAP, CRP and CEA as indicators of metastasis in a broad spectrum of neoplastic diseases

Two hundred and seventy-seven patients with a broad spectrum of neoplastic diseases, including 10 classes of solid tumours and three classes of haematologic malignancies, were retrospectively surveyed, and from the same sample of plasma or serum their concentrations of serum amyloid A (SAA), serum amyloid P component (SAP), C-reactive protein (CRP), and carcinoembryonic antigen (CEA) were measured. SAA levels varied from 105 ng/ml to 105,000 ng/ml, and mean SAA levels were higher in patients with metastatic tumours than in those with limited disease (P less than 0.001). Similarly, CRP levels varied from less than 8 micrograms/ml to 328 micrograms/ml and were significantly higher in the metastatic disease category. In contrast, SAP levels varied from 32 micrograms/ml to 120 micrograms/ml and showed no difference in patients with limited or metastatic disease, although an overall slight elevation was present. CEA levels were available in 150 patients and were significantly higher in patients with advanced lung or breast cancer than in patients with limited disease. The correlation between mean SAA and CRP levels was significant (r = 0.74, P less than 0.001), suggesting that SAA originates as an acute-phase protein rather than as a tumour cell product. However, the consistent elevation of SAA in all tumour types and the more marked elevation in metastatic disease may make its measurement useful in malignancy.

Iatrogenic morbidity accompanying suppression of temporal arteritis by adrenal corticosteroids

The records of 19 patients receiving corticosteroid therapy for temporal arteritis were reviewed. Of 11 patients (58%) who suffered major corticosteroid related complications (group A), four died. Eight patients (group B) remained free of serious corticosteroid related complications. The average daily maintenance prednisone dose was 26.3 mg in group A and 13 mg in group B. Although all disease recrudescenses in both groups were treated by increasing the corticosteroid dose, a slower tapering of the dose to the pre-flare level was observed in group A. These findings emphasize the necessity of keeping the maintenance corticosteroid dose in patients with temporal arteritis at the lowest level consistent with suppression of disease activity.

Immunocytochemical demonstration of prealbumin in the vitreous in heredofamilial amyloidosis

Vitreous material obtained at pars plana vitrectomy from a patient with heredofamilial amyloidosis with vitreous involvement and control vitreous from a patient without amyloidosis were subjected to immunocytochemical studies. P component (AP), a minor constituent of all amyloid deposits, was found in trace amounts in the familial amyloid vitreous, but other amyloid proteins, which occur in secondary amyloidosis or in primary amyloidosis, were not found. The major amyloid protein in the vitreous in heredofamilial amyloidosis (but not control vitreous) was found to be prealbumin.

Familial amyloid polyneuropathy. Demonstration of prealbumin in a kinship of German/English ancestry with onset in the seventh decade

A family with autosomal dominant transmitted familial amyloid polyneuropathy residing in Texas is described. Clinically, the prominent sensory and severe autonomic nervous system involvement resembles the Andrade (Portuguese) type I familial amyloid polyneuropathy but is unique in that the age of onset is in the seventh decade in all family members affected to date. Using an immunoperoxidase technique, prealbumin was demonstrated in the amyloid deposits. This finding suggests that this family shares biochemical as well as clinical characteristics consistent with similar kinships with type I familial amyloid polyneuropathy of diverse geographic origin.

Cardiac arrhythmias in systemic amyloidosis: correlation with echocardiographic abnormalities

To determine the prevalence of cardiac arrhythmias in patients with systemic amyloidosis 24 hour electrocardiographic monitoring was performed in 27 patients with primary amyloidosis and in 6 patients with familial amyloid polyneuropathy. All patients underwent echocardiographic studies. Despite a high prevalence of conduction disturbances on standard electrocardiogram, clinically significant bradyarrhythmias were rare (one patient). Complex ventricular arrhythmias (multiform, paired or repetitive beats) occurred in 14 patients (47%) with primary amyloid and 3 patients (50%) with familial amyloid polyneuropathy. The presence of cardiac arrhythmia correlated with heart failure and, more strongly, with an abnormal echocardiogram. There were four sudden deaths, all in patients with abnormal echocardiograms and complex ventricular arrhythmias. These findings suggest that complex ventricular arrhythmia on Holter monitoring is common in cardiac amyloidosis and may be a harbinger of subsequent sudden cardiac death.

Esophageal manometry in systemic amyloidosis. A study of 30 patients

The motility of the esophagus was studied by esophageal manometry in 24 patients with primary amyloidosis and six with secondary amyloidosis. Resting lower esophageal sphincter pressure was decreased in 12 patients with primary amyloidosis and two with secondary amyloidosis; 12 of these 14 patients complained of heartburn. Abnormalities in the motility of the body of the esophagus were found in nine patients with primary amyloidosis and one with secondary amyloidosis. No abnormality of the upper esophageal sphincter was demonstrated in any of the 30 patients. Six of the nine patients with primary amyloidosis exhibiting the most marked esophageal motor dysfunction had striking evidence of peripheral and/or autonomic nervous system involvement. No consistent pattern of motility disorder was observed in either group. The manometric abnormalities observed are consistent with a random deposition of amyloid in the esophagus involving a myopathic and/or neuropathic component.

Nephelometric measurement of human serum amyloid P component (SAP)

Serum amyloid P component (SAP) is a normal constituent of human serum. A rate nephelometric technique has been developed that can measure this protein more rapidly and reproducibly than previously described methods. Materials required are simple and commercially available. Studies on 30 patients with amyloidosis show no difference in SAP levels from control patients. Rate nephelometry is a simple technique that could expand the ability to measure SAP beyond the research setting.

Use of abdominal fat tissue aspirate in the diagnosis of systemic amyloidosis

The needle aspirate of abdominal fat was investigated for its sensitivity in giving a tissue diagnosis in 32 consecutive patients with systemic amyloidosis. The fat tissue aspirate was stained with Congo red and examined with a polarizing microscope. Positive results were obtained in 95% (18/19) of patients with primary (AL) amyloidosis, 66% (4/6) of patients with secondary (AA) amyloidosis, and 86% (6/7) of patients with the heredofamilial (AF) form. The overall positive yield was 88% (28/32). Abdominal fat tissue aspiration is proposed as a simple, rapid, and effective technique for the diagnosis of amyloidosis. The prevalence of positive results in known amyloid disease are comparable with the rectal biopsy specimen and are more frequent than gingival or skin biopsy specimens.

Amyloidosis of heart and liver: comparison of Tc-99m pyrophosphate and Tc-99m methylene diphosphonate for detection

A prospective, comparative study was made of the efficacy of technetium-99m pyrophosphate (Tc PYP) and technetium-99m methylene diphosphonate (Tc MDP) in detecting soft-tissue amyloidosis. Tc PYP and Tc MDP scans were obtained within ten-day intervals in seven patients with histologically proven amyloidosis. Tc PYP was a better scanning agent for soft-tissue amyloidosis in all patients. Cardiac and hepatic involvement were proved by autopsy in one patient. Involvement of the heart was confirmed by echocardiography in five patients. The potential use of Tc PYP scanning as a screening test for soft-tissue amyloidosis is discussed.