Amyloid deposits and amyloidosis. The beta-fibrilloses (first of two parts)

Relationship between morphological findings and function of the small intestine in familial amyloidosis with polyneuropathy

Twenty-seven patients with familial amyloidosis with polyneuropathy were studied with regard to the morphology of the small intestine, and this was correlated to symptoms and malabsorption features. The mucosa was normal in all cases investigated by the dissecting microscope, the light microscope, and the scanning electron microscope. Amyloid was demonstrated in 83% of the cases by the presence of green birefringent material in the biopsy specimens stained with alkaline Congo red and examined in polarized light. Nineteen patients had steatorrhea, and 12 had pathological D-xylose test results. The degree of amyloid infiltration did not correlate with these data, nor did the symptomatic state correlate with the amount of amyloid in the biopsy specimens. The surface ultrastructure was normal when investigated by means of the scanning electron microscope in all patients except five in whom the glycocalyx was altered. As a group, however, those five did not differ in any respect from the rest of the patients. Rod-shaped microorganisms were shown to adhere to the surface in one patient. The results suggest that mechanisms other than bowel-wall deposition of amyloid cause the dysfunction of the gastrointestinal tract in familial amyloid polyneuropathy.

Do serine proteases degrade amyloid A fibrils?

Human serum contains enzyme(s) able to degrade serum amyloid A protein (SAA) and amyloid A (AA) fibrils. On the basis of inhibition tests these enzymes are regarded as serine proteases, but further characterization of the enzymes has, however, so far not been done. Chymotrypsin, trypsin, elastase, collagenase and kallikrein, when added to SAA-containing serum, all degraded SAA to peptides within 2 h at 37 degrees C. With the exception of collagenase these enzymes also destroyed the Sirius-Red-binding ability of amyloidotic tissue and that of isolated AA fibrils. Hence, they altered the conformation of the beta-pleated structure and possibly also degraded the fibrils. These results suggest that any of these serine proteases could be responsible of the degradation of SAA in serum. The enzyme concentrations needed to degrade amyloid fibrils, however, were much higher than normally found in serum. Thus, it is unlikely that the amyloid-fibril-degrading activity in serum could be due to any of these enzymes.

The effect of treatment of the associated disease on the development of amyloidosis in the experimental animal

Thirty-five golden hamsters infected with Leishmania donovani were treated with Pentostam and followed up to determine the effect of treatment on the development of secondary amyloidosis. Seventy untreated golden hamsters infected with L. donovani were followed up as controls to determine the pattern of development of secondary amyloidosis. Amyloid developed in all animals treated and untreated. The treatment significantly prolonged the survival time, but did not inhibit the development of renal amyloid in animals shown by biopsy to be free from renal amyloid at the time of treatment. When amyloid was present in kidney at the time of treatment it progressed invariably to renal failure.

Amyloid fibril in hereditary cerebral hemorrhage with amyloidosis (HCHWA) is related to the gastroentero-pancreatic neuroendocrine protein, gamma trace

Amyloid fibrils were isolated from the leptomeningeal blood vessels obtained at autopsy from three Icelandic patients dying of Hereditary Cerebral Hemorrhage with Amyloidosis (HCHWA) and verified by Congo red staining and electron microscopy. Gel filtration on Sephadex and Ultrogel columns yielded predominantly one component (molecular weight 11,500 daltons) and also another minor component (molecular weight 15,800 daltons). Automated amino terminal sequencing showed these proteins to be similar (36 residues) to a recently described human protein, gamma trace, beginning at its eleventh amino terminal residue. The amyloid deposits in all three patients stained with rabbit anti-gamma trace antiserum. Although the function of gamma trace is not known, it appears to have structural homology with several hormones and has been localized to the brain, pancreas and pituitary. The amyloid fibril subunits seem to have polymerized after cleavage of the amino terminal decapeptide from gamma trace-related proteins. Therefore, HCHWA appears to be the first genetically determined disease related to the gastroenteropancreatic neuroendocrine system.

Polymorphism of human plasma thyroxine binding prealbumin

Amyloid fibrils from an individual with heredofamilial amyloidosis were found to be composed of plasma prealbumin. To study this protein a three step procedure to isolate prealbumin from plasma was developed. It entailed ion exchange chromatography on DEAE Sephadex, affinity chromatography on Affi-gel Blue and gel filtration on AcA-34. Trypsin Digests of prealbumin were separated by reverse phase HPLC and the pattern compared to that from the normal protein. Only one unexpected peptide was found and it represented the substitution of a methionine for a valine at position 30 in the molecule. This substitution accounts for about 1/3 of the isolated molecules and it represents the first point mutation identified in human plasma prealbumin.

Localized amyloid of the ureter--case report and review of the literature

An unusual case of localized amyloidosis of the ureter is described and a review of the 12 previously reported cases is presented. No case had been diagnosed prior to surgery. Loin pain, with or without haematuria, associated with a sterile pyuria and an abnormal pyelogram were the commonest clinical signs. In the case reported an incidental small renal cell carcinoma was also present and the association of amyloidosis and neoplasia is discussed.

Localized amyloidosis of urethra

A case of primary amyloidosis of the urethra is described. Although rare, this entity is important since its antecedent causes, clinical symptoms, and panendoscopic and radiographic appearance are similar to and must be differentiated from carcinoma of the urethra. The prognosis of this disorder is excellent, and aggressive therapy is not indicated.

Renal cell carcinoma and systemic amyloidosis: demonstration of AA protein and review of the literature

A case of renal cell carcinoma associated with systemic amyloidosis in a patient with nephrotic syndrome is presented. Amyloid deposits were present in the resected tumor, ipsilateral kidney, and spleen. Potassium permanganate treatment of histologic sections as well as immunoperoxidase staining identified AA protein within the amyloid. Surgical removal of the tumor caused marked remission of the patient's proteinuria. Thirty-nine previously reported cases of renal cell carcinoma with amyloidosis are reviewed. Most tumors have clear cell histologic features, and the amyloid distribution follows the "secondary" pattern. A possible mechanism of amyloid production in renal cell carcinoma is presented in which the tumor directly or indirectly participates in the modification of SAA protein into a precipitable form.

Thickening of glomerular capillary walls: a guide to differential diagnosis by electron microscopy

Thickening of capillary walls is a feature of many glomerular diseases. Widening of the wall may be produced by deposits and other changes affecting either subepithelial and subendothelial regions or the glomerular basement membrane itself. Careful light microscopic examination using special stains can distinguish some patterns of capillary wall thickening, but electron microscopy is needed to demonstrate most lesions clearly. In this brief review, a guide to the major causes for capillary wall thickening is discussed, using a simple classification, and some of the patterns are illustrated. Precise delineation of the capillary wall changes in glomerular diseases is important to insure accurate classification and a clear understanding of pathogenetic mechanisms.

Characterization of amyloid deposits and P component from a patient with factor X deficiency reveals proteins derived from a lambda VI light chain

Amyloid fibrils were isolated from a spleen obtained at surgery from a 58-year-old white man with primary amyloidosis presenting with factor X deficiency and responding dramatically to splenectomy. Gel filtration on Ultragel ACA 54 in 5 M guanidine 1 M acetic acid yielded components with molecular weights between 17,000 and 13,000. Two of them (17K and 15K) were studied in detail. Antigenic and amino acid sequence analysis showed that these proteins were related to lambda VI immunoglobulin light chain. The predominant protein subunits of the amyloid fibril of the deposits (17K) was processed at the carboxy terminus in the same section of the constant region as the only other lambda VI amyloid protein previously reported. Amino terminal sequence of the 15K protein revealed not only degradation at the C terminal, but also minor degradation at the amino terminal (three residues difference from the 17K species). P component was also isolated from the spleen and characterized. This represents the first antigenic and sequence analysis of tissue amyloid proteins and P component from a patient presenting with factor X deficiency and another example of amyloid proteins derived from the newly discovered amyloidogenic lambda VI light chain subgroup.

Immunohistochemical identification of the AA protein in lattice dystrophy

We examined the amyloid deposits of lattice dystrophy type I for common components of primary and secondary amyloid using the sensitive unlabelled antibody peroxidase-antiperoxidase technique. Tissue sections of formalin-fixed, paraffin-embedded specimens from three patients with lattice dystrophy were reacted with antisera specific for free immunoglobulin light chains, prealbumin, amyloid A (AA) protein, and amyloid P (AP) protein. The lattice amyloid was positive for the AA protein associated with secondary amyloid. The deposits were also stained with the protein AP antiserum in each case. We were unable to detect the presence of immunoglobulin light chains associated with primary amyloid or prealbumin associated with another heredofamilial form of amyloid. Sera from two patients with lattice dystrophy were tested for the presence of the serum amyloid A related protein, the apparent precursor of AA amyloid, by immunoelectrophoresis and immunodiffusion. The sera showed no reaction with the AA antiserum with these techniques. Lattice amyloid differed from secondary systemic amyloid in the reaction with potassium permanganate. Congo red staining of lattice deposits was not abolished by treatment with potassium permanganate. Our findings suggest that the amyloid proteins in lattice dystrophy are antigenically similar to those of secondary amyloid and the hereditary form associated with familial Mediterranean fever.

Massive amyloidosis of mediastinal lymph nodes in a patient with multiple myeloma

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Demonstration of amyloid A (AA) protein and amyloid P component (AP) in deposits of systemic amyloidosis associated with renal adenocarcinoma

The fibril protein in three cases of systemic amyloidosis associated with renal adenocarcinoma was identified as amyloid A protein (AA) using immunohistochemical staining techniques. Amyloid P component was also present in all deposits. In one case unfixed snap frozen tissues were studied directly whilst in the other two, which were investigated retrospectively, fixed paraffin sections were stained by immunofluorescence and immunoperoxidase methods after treatment with trypsin. Enzymatic digestion was necessary to restore reactivity with anti-AP but anti-AA reacted well without any such treatment. These findings establish that renal carcinoma, the carcinoma most frequently associated with systemic amyloidosis, causes the same type of secondary or reactive systemic amyloid as chronic infections and inflammatory disorders.

The isolation and amino acid composition of senile plaque core protein

A new method has been developed for the isolation of intact senile (neuritic) plaque cores from post-mortem brains of patients with Alzheimer's disease. The plaque cores were found to be insoluble in various protein denaturants. The amino acid composition of the plaque core protein does not resemble that of any known form of amyloid.

Acute phase proteins with special reference to C-reactive protein and related proteins (pentaxins) and serum amyloid A protein

The acute phase response among plasma proteins is a normal response to tissue injury and is therefore a fundamental aspect of many diverse disease processes. It probably usually has a beneficial net function in limiting damage and promoting repair but in some circumstances it may have pathological consequences. Sustained high levels of acute phase proteins and especially SAA are associated with the development of amyloidosis in some individuals. Increased concentrations of CRP may, by activating the complement system, contribute to inflammation and enhance tissue damage. Failure of the normal or appropriate CRP response may also possibly have deleterious effects. SAA is a polymorphic protein which is normally present only in trace amounts but which, during the acute phase response, becomes one of the major apolipoproteins associated with high-density lipoprotein particles. The function of apoSAA is not known but it must have considerable physiological significance apart from its role as the putative precursor of amyloid A protein fibrils. CRP and SAP have been very stably conserved throughout vertebrate evolution and homologous proteins are apparently present even in vertebrates. This strongly suggests that they have important functions although these have not yet been precisely delineated. The main role of CRP may be to provide for enhanced clearance of inappropriate materials from the plasma whether these are of extrinsic origin, such as microorganisms and their products, or the autologous products of cell damage and death. The interaction between aggregated CRP and plasma low-density lipoprotein may play a significant part in the normal function of CRP and may also have a role in lipoprotein metabolism, clearance, and deposition. SAP is a normal tissue protein as well as being a plasma protein. Aggregated SAP selectively binds fibronectin and this may represent an aspect of the normal function of SAP. The deposition of SAP in amyloid is evidently not a normal function but it is not known whether this deposition is involved in the pathogenesis of amyloid or whether it is merely an epiphenomenon. In any case immunohistochemical staining for SAP is useful in the diagnosis of amyloid, in investigation of glomerulonephritis, and in studying disorders of elastic tissue. Regardless of its physiological or pathophysiological functions, the assay of serum CRP is a valuable aid to clinical management in a number of different situations and in different diseases provided results are interpreted in the light of full clinical information.(ABSTRACT TRUNCATED AT 400 WORDS)

Lymph node enlargement due to amyloid

A case of a patient presenting with supraclavicular and cervical lymph node enlargement with demonstration of amyloid is presented. Histologic features are described. Amyloid deposition was not found in any other organ. Immunohistochemical typing with antisera raised against protein AA, A lambda, and A kappa showed a reaction only against A lambda. Thus, this case belongs to the immunoglobulin lambda light chain-derived types that occur in many other parts of the body, particularly the respiratory tract.

Neuroaxonal dystrophy with neuromelanin deposition, neurofibrillary tangles, and neuronal loss. Light- and electron-microscopic changes in a 45-year-old woman with progressive psychomotor deterioration

Neuroaxonal spheroids became evident microscopically after the autopsy of a 45-year-old woman with pigmentation of the globus pallidus suggesting Hallervorden-Spatz disease. In our opinion the fine floccular pigment seen electron-microscopically in many of the axonal spheroids is melanin, an end product of catecholamine metabolism. Neurofibrillary degeneration, senile plaques, and granulovacuolar degeneration in the hippocampus produced a picture of Alzheimer's disease. Pontocerebellar degeneration and motor neuron disease were also observed.

Plasma protein induction by isolated hepatocytes

Hepatocytes can be maintained in culture for periods of a few hours to many days. This review summarizes the metabolic characteristics of these cultures and describes their use in studying the regulation of plasma protein synthesis. Hormones selectively stimulate the synthesis of certain proteins. Cortisol stimulates the synthesis of fibrinogen and other acute-phase proteins; whereas, insulin stimulates albumin synthesis. In the latter case insulin increases the rate of a nuclear process. Mediators elaborated by leukocytes stimulate acute-phase protein synthesis in hepatocytes. Plasmin-generated fibrin peptides stimulate fibrinogen synthesis via a leukocytic mediator. Lipoprotein synthesis is stimulated by fatty acids and is inhibited by albumin and other macromolecules. These and other processes are susceptible to detailed analysis using sub-cellular fractions (mRNA, nuclei, transcription factors, etc.) isolated from hepatocytes. Studies on fetal or embryonic hepatocytes and hepatomas are yielding information on the regulation of secretory protein synthesis during development and following neoplastic transformation.

Manifestation and ultrastructural typing of amyloid deposits in the heart

Using light and electron microscopy, 65 cases of amyloid deposits in the heart were examined. Five different groups were distinguished: I. isolated atrial amyloidosis, II. senile cardiac amyloidosis, III. cardiac amyloid accompanying chronic infections and tumors, IV. cardiac amyloid accompanying plasma cell dyscrasia, V. idiopathic cardiac amyloidosis. Seen structurally, no principal differences in the precise localization of the amyloid deposits were found in any of the groups investigated. Amyloid is always deposited in the vicinity of cells with myocytic cell differentiation (i.e. the heart muscle cells, non-striated muscle cells of the vessels), whereby the relevant basement membranes serve as conductors. A systematic relationship between amyloid and the collagenous fibers of the interstitium or the tunica adventitia of the vessels could not be demonstrated, which shows the concept "pericollagen" to be inadequate for the morphological characterization of amyloid deposits in the heart. Whereas for group I a localized mechanism for the production of amyloid must be considered, in the case of groups II-V a vascular principle expression of a generalized amyloidosis seems to be the major factor. The question of the differing concentration of amyloid deposits in the heart suggests that localized factors (e.g. changes in the myocytic basement membranes) and quantitative changes of the amyloid-building proteins may also be important.

Electron-microscopic examination of primary diffuse tracheobronchial amyloidosis. Role of fibroblasts in amyloid formation

The author reports on the electron-microscopic examination of the diffuse tracheobronchial amyloidosis of a 51-year-old patient. The amyloid deposits were located in the lamina propria of the tracheal and bronchial mucosa. At the edge of the nodular deposits, condensation and radial arrangement of amyloid fibrils could be seen. Closely connected with the amyloid, active fibroblasts were present and their cytoplasm contained amyloid fibrils. The cell membrane of the fibroblasts was missing in part. Intracellular amyloid fibrils mingled with extracellular deposits. It can be assumed that active fibroblasts play an important role in local amyloid formation.

Senile amyloidosis: principles of localization in a heterogeneous form of amyloidosis

In order to identify amyloid deposits in patients over 60 years of age (so-called senile amyloid), the following five tissues were investigated under the light and electron microscope: 1. pituitary gland, 2. pancreatic islets of Langerhans, 3. heart, 4. aorta, and 5. brain. In all an increasing incidence of amyloid deposits was found with increasing age, and in the brain a significant quantitative increase in amyloid deposits with increasing age was observed. Despite the biochemical heterogeneity of amyloid found in old age, all the deposits seen in tissues examined were morphologically similar. Typical amyloid fibrils were always found (diameter 60-100 A), and these were invariably deposited extracellularly and primarily on basement membranes. The amyloid-binding basement membranes were in most cases those of myocytic, but were also those of endothelial or epithelial cells. The almost invariable involvement of blood vessels, indicates the importance of these structures in the genesis of the various forms of senile amyloid.

Immuno-electron microscopic identification and classification of amyloid in tissue sections by the postembedding protein-A gold method

Amyloid deposits from 3 patients with amyloid of the AA, A lambda, or A kappa type were investigated on ultrathin sections using the protein-A gold method and affinity purified amyloid-type-specific immunoglobulins. Anti-AA, -A lambda, and -A kappa reacted specifically with the corresponding amyloid fibril visualized by the agglomeration of the gold colloid particles. Therefore, this method can identify and classify amyloid fibrils and can distinguish them from other fibrillar proteins at the electron microscopic level.

Renal lesions in multiple myeloma: their relationship to associated protein abnormalities

Renal biopsy and autopsy specimens were studied in 43 patients with renal complications of multiple myeloma and correlated with immunoelectrophoresis (IEP) and other clinical data at the time of biopsy. Lesions specifically related to multiple myeloma fell into two categories, with different patterns of protein excretion. (1) Myeloma Cast Formation: When other lesions which might contribute to renal insufficiency (RI) were excluded, there was a good correlation between the extent of myeloma cast formation and severity of RI. Sixteen of 19 patients excreted free light chains (LCs) in the urine, in seven as the predominant or sole urinary protein. (2) Tissue Deposition of Paraproteins: Nine cases had generalized glomerular, tubular basement membrane and vascular deposits of presumed kappa-chains (one with associated alpha-heavy chains). Four patients, all with myelomas secreting lambda LCs, had diffuse amyloid deposits in similar distribution. All patients (save two who were anuric) had diffuse, nonselective proteinuria by IEP, most within the nephrotic range. Four patients had free LCs in the urine, but in none was this the predominant component. Cast nephropathy and LC tissue deposition tended to occur in mutually exclusive fashion. Cases with diffuse tissue deposits of LCs showed few or no myeloma casts. Cases with cast nephropathy had only occasional mild mesangial lesions and focal interstitial and vascular deposits of amyloid. Evidence indicates that these lesions represent incidental LC deposition in cases whose basic lesion is longstanding and/or severe cast nephropathy, and that their contribution to RI is minor in comparison to that of the myeloma casts.

Prolonged dimethylsulphoxide treatment in 13 patients with systemic amyloidosis

Continuous oral dimethylsulphoxide (DMSO) treatment (7-15 g/day) was given to 3 patients with amyloidosis of familial Mediterranean fever (FMF), 3 patients with idiopathic amyloidosis, and 7 patients with secondary amyloidosis. The nephrotic syndrome and various degrees of renal insufficiency were the major clinical manifestation in all case. Renal function was used as the main parameter for evaluation of therapy. DMSO treatment for 7-16 months produced no effect in the FMF patients and in the patient with idiopathic amyloidosis; they all ran the predictable clinical course of their disease and either died of cardiac failure or have been maintained on chronic haemodialysis. In the 7 patients with secondary amyloidosis an unequivocal improvement of renal function was observed following 3-6 months of DMSO treatment. It was shown by a 30-100% rise of creatinine clearance and a decline in proteinuria. This new equilibrium has been maintained as long as DMSO was administered. No serious side effects of DMSO wee encountered. Mild nausea and an unpleasant breath odour were the patients' main concern. We conclude that a therapeutic trial with oral DMSO is warranted in all patients with secondary amyloidosis. This treatment is unpleasant but bears no exceptional risks. It may significantly prolong life, though its effect on amyloid deposits themselves is doubtful.

Monoclonal gammopathy with neurological signs and symptoms. A clinical, neurophysiological and muscle biopsy study

Clinical, neurophysiological and muscle biopsy findings in ten patients with monoclonal gammopathy are reported. Three patients had polyneuropathy, one had hemiparkinsonism, one migraine and radicular symptoms and one paresthesiae and radicular symptoms. Amyloidosis was not found in muscle biopsy specimens. All but one patient with neurological findings also had positive immunofluorescence staining for tissue-bound immunoglobulins in muscle biopsy specimens. The tissue-bound immunoglobulins usually belonged to the same class as the M-component. None of the biopsies of patients without neurological findings were positive.

Primary structure of the variable part of an amyloidogenic Bence-Jones Protein (Mev.). An unusual insertion in the third hypervariable region of a human kappa-immunoglobulin light chain

The complete amino acid sequence of the variable region of Bence-Jones protein Mev. from a patient suffering from multiple myeloma and generalized amyloidosis is presented. The amino acid sequence of the Bence-Jones protein Mev. is related to other human kappa-immunoglobulin L-chains of subgroup I. With valine established in Position 191 of the constant region, it is of the Inv (3) allotype. Two types of the Bence-Jones protein Mev. were found, one beginning with the typical N-terminal aspartic acid, and another lacking the N-terminal tripeptide and commencing with methionine in Position 4. A unique insertion of glutamic acid after Position 95 was found in the Bence-Jones protein. This is the position where the V- and J-gene segments join. The J-region of Bence-Jones protein Mev. exhibits some marked differences to the five J-regions recently established by nucleic acid sequencing. This suggests, that there must be considerable polymorphism in human kappa-J-genes. The amyloid fibril protein from the same patient (A Mev.) has also been sequenced up to Position 27. It was found to be identical to the sequence of Bence-Jones protein Mev. commencing with aspartic acid. The molecular mass of the amyloid fibril protein was found to be between 11 000 and 12 000 Da as estimated by gelfiltration and dodecyl sulfate-polyacrylamide electrophoresis.

beta-Fibrillary bodies in low-grade adenocarcinoma of parotid gland: a histochemical and ultrastructural study

Rounded or polyhedral, acellular, dense lamellated structures were seen within the cystic and glandular spaces in a case of low-grade papillary adenocarcinoma of the parotid gland. These structures displayed the histochemical characteristics of amyloid, namely, pink color with apple-green birefringence and bright red fluorescence with alkaline congo red, orthochromasia and red birefringence with standardized toluidine blue, positive dimethylaminobenzaldehyde nitrite and diazotization coupling reactions, and spontaneous autofluorescence. At the ultrastructural level the tumor consisted of cuboid, flattened, or elongated epithelial cells with varying degrees of differentiation, but most mature tumor cells had numerous intracellular intermediate filaments. These filaments were randomly oriented and had no lateral fasciation; they were 10 nm wide and similar to those constituting the intraluminal corpora amylacea. These bodies displayed increased fibrillary density. Cellular organelles and pyknotic nuclei were frequently present at the periphery of the fibrillary masses. Amyloid masses, histochemically and ultrastructurally indistinguishable from those in the lumens, were present in the stroma as well. It is postulated that both stromal and intraluminal beta-fibrillary bodies result from apoptosis and desquamation of neoplastic cells, with progressive release and confluency of intracellular intermediate filaments within closed cystic spaces. This additional evidence of beta-fibrillosis associated with a slow-growing non-hormone-secreting salivary gland tumor suggests that these tumors may be associated with amyloidosis more frequently than was previously suspected.

Spinal cord compression by amyloid tissue

Spinal cord compression by a mass of amyloid tissue arising from the thoracic vertebrae is described in a 72-year-old female. Investigations failed to provide a primary cause for this amyloid tissue.

Solid-phase immunoradiometric assay for serum amyloid A protein using magnetisable cellulose particles

An immunoradiometric assay for human serum amyloid A protein (SAA) was developed using magnetisable cellulose particles as the solid phase. Rabbit antiserum to to SAA was raised by immunization with SAA isolated from acute-phase serum by gel filtration in formic acid. The antiserum was rendered monospecific for SAA by solid-phase immunoabsorption with normal human serum, which contains only traces of SAA, and some was coupled covalently to the cellulose particles. Immunopurified anti-SAA antibodies were isolated from the monospecific anti-SAA serum by binding to, and elution from insolubilized acute-phase serum and were radiolabelled with 125I. The assay was calibrated with an acute phase serum which contained 6000 times more SAA than normal sera with the lowest detectable level of SAA, and an arbitrary value of 6000 U/l was assigned to this standard. Sera were tested in the native, undenatured state and there was no increase in SAA immunoreactivity following alkali treatment or heating. The assay range was from 1-2000 U/l so that all SAA levels above 6 U/l could be measured on a single (1:6) dilution of serum. The intra- and interassay coefficients of variation were 11.7 and 15.0% respectively. Among 100 healthy normal subjects (50 male, 50 female) the median SAA level was 9 U/l, range less than 1-100, with 93% below 20 U/l and only 2% below the lower limit of sensitivity of the assay (1 U/l).

Differentiation of amyloid fibril proteins in tissue sections. Two simple and reliable histological methods applied to fifty-one cases of systemic amyloidosis

The potassium permanganate method and the unlabeled immunoperoxidase (PAP) method were applied for distinguishing different types of amyloid fibril proteins in conventionally fixed, paraffin-embedded tissue sections obtained from fifty-one autopsied cases of systemic amyloidosis and three control cases of well-analysed fibril proteins. All of the eighteen cases "sensitive" to permanganate treatment, whose amyloid deposits lost completely their affinity to Congo red and birefringence under polarized light, were shown to have AA antigenic determinants by the PAP method. Meanwhile, all of the remaining thirty-three "resistant" cases, where Congo red affinity and birefringence were retained at various degree even only in minimal areas, were negative for AA antigenicity. This indicated the feasibility of potassium permanganate method for the identification of AA protein based on this criterion of "sensitivity". Twenty-eight cases were classified as AA, A lambda, A kappa or AA+[A kappa] the remaining twenty-three cases were unclassified, and there were some discrepancies between the preliminary clinicopathological classification and the protein nature of the amyloid. It is important to differentiate the types of amyloid fibril protein of individual patients because the expedience of selective therapeutic approaches had been suggested. The two methods applied herein are handy and useful for this purpose.

Apparent monoclonal origin of lymphocytes and plasma cells infiltrating ocular adnexal amyloid deposits: report of 2 cases

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Bence Jones proteins and light chains of immunoglobulins. Preferential association of the V lambda VI subgroup of human light chains with amyloidosis AL (lambda)

An antiserum prepared against a lambda-Bence Jones protein from a patient (SUT) who had multiple myeloma and amyloidosis had specificity for lambda-light chains of the chemically defined variable (V) region lambda-chain subgroup lambda VI. Sequence analyses of protein SUT and of five other lambda-light chains recognized immunologically as of the V lambda VI subgroup revealed that all six proteins had the N-terminal sequence characteristic for prototype lambda VI proteins. The isotypic nature of the V lambda VI subgroup was demonstrated immunochemically: lambda VI molecules were detected among light chains isolated from the IgG proteins of each of 12 normal individuals and lambda VI antigenic determinants were also detectable on the intact IgG proteins. The frequency of lambda VI molecules among lambda-type light chains is estimated to be approximately 5% based on the finding that 5 of 91 lambda Bence Jones proteins were of the V lambda VI subgroup. Proteins of the V lambda VI subgroup, in contrast to those of the other five chemically-classified lambda chain subgroup, appear to be preferentially associated with the amyloid process as evidenced by the fact that all six lambda VI proteins were obtained from patients with amyloidosis AL and, in addition, 5 of 42 lambda-type monoclonal immunoglobulins from patients with primary or myeloma-associated amyloidosis were classified by immunodiffusion analyses as having lambda VI-type light chains.

Mechanism of reduced amyloid-A-degrading activity in serum of patients with secondary amyloidosis

Human serum contains amyloid-A-degrading (AADP) activity. This activity is reduced in amyloidosis associated with rheumatoid arthritis. Since AADP co-migrates with albumin on agarose-gel electrophoresis, the relationship between these serum factors was studied in patients with amyloidosis and patients with amyloidosis and patients with altered albumin synthesis and/or distribution. AADP activity correlated positively with albumin levels in patients with rheumatoid arthritis complicated by amyloidosis. A weaker association was noted between serum activity and prealbumin levels. The AADP activity in patients with rheumatoid arthritis without signs of amyloidosis and patients with liver cirrhosis was also positively associated with serum albumin level. During the acute-phase reaction after surgery serum AADP activity fell in parallel with serum albumin level. Purified albumin preparations displayed AADP activity. The results show that serum albumin level reflects AADP activity. It is suggested that the development of hypoalbuminaemia in patients with amyloidosis may give rise to a vicious circle which leads to an accelerated reduction in AADP activity and accelerated amyloidogenesis.

Serum amyloid-A protein concentration in inflammatory diseases and its relationship to the incidence of reactive systemic amyloidosis

Serum amyloid-A protein (SAA) is the putative precursor of amyloid-A (AA) protein which forms the fibrils in reactive systemic or secondary amyloidosis. By means of a novel immunoradiometric assay, the concentration of SAA was found to be greatly elevated in patients with rheumatoid arthritis and juvenile chronic arthritis and correlated with activity of their primary disease. However, in patients with systemic lupus erythematosus SAA levels were only modestly raised, even in those with severe active disease, unless significant intercurrent microbial infection was also present. In Crohn's disease SAA levels showed a pattern similar to that seen in rheumatoid arthritis, whereas in ulcerative colitis it resembled that of systemic lupus erythematosus. The level of SAA response in these different disorders corresponds with the incidence of reactive systemic amyloidosis in them. These observations support the view that major increases in SAA levels are a necessary condition for the deposition of this form of amyloid and suggest that prospective monitoring of the SAA concentration in predisposing diseases may help to identify those individuals who are most at risk for amyloidosis.