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Abstract
Heritable cardiac amyloidosis (CA) is an underrecognized cause of morbidity and mortality in the USA. It results from the accumulation of the misfolded protein transthyretin within the myocardium, resulting in amyloid transthyretin-associated cardiomyopathy (ATTR-CM). Over 150 different pathologic point mutations within the transthyretin gene have been identified, each carrying variable clinical phenotypes and penetrance. In the USA, the most common cause of hereditary ATTR is the Val122Ile point mutation, with a prevalence of 3.4-4.0% in North Americans of African and Caribbean descent. Among Caucasians with hereditary ATTR-CM, the V30M mutation is the most commonly identified variant. Overall, the incidence of ATTR disease in the USA has been increasing, likely due to an increase in practitioner awareness, utilization of new non-invasive imaging technologies for ATTR diagnosis, and the growth of multidisciplinary amyloid programs across the country. Yet significant numbers of patients with evidence of left ventricular thickening on cardiac imaging, senile aortic stenosis, and/or symptoms of heart failure with preserved ejection fraction likely have undiagnosed CA, especially within the African American population. With the emergence of new disease-modifying therapies for ATTR, recognition and the prompt diagnosis of CA is important for patients and their potentially affected progeny. Herein, we review the genetics of heritable CA as well as the importance of genetic counseling and testing for patients and their families.
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Affiliation(s)
- Scott Arno
- Henry Ford Hospitals, 2799 W. Grand Blvd, K14 Cardiology, Detroit, MI, 48202, USA
| | - Jennifer Cowger
- Henry Ford Hospitals, 2799 W. Grand Blvd, K14 Cardiology, Detroit, MI, 48202, USA.
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Zanazzi G, Arshad M, Maurer MS, Brannagan TH, Tanji K. Demyelinating Neuropathy in a Patient Treated With Revusiran for Transthyretin (Thr60Ala) Amyloidosis. J Clin Neuromuscul Dis 2019; 20:120-128. [PMID: 30801482 PMCID: PMC6392216 DOI: 10.1097/cnd.0000000000000242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Transthyretin amyloidosis patients develop length-dependent peripheral neuropathy, autonomic dysfunction, and restrictive cardiomyopathy associated with deposition of amyloid fibrils in these tissues. Despite advances in management over the past decade, this disorder causes profound debilitation and ultimately proves fatal. In this report, we describe a man with late-onset cardiac amyloidosis due to a transthyretin Thr60Ala mutation who was treated with an investigational RNAi therapeutic, revusiran, which targets hepatic transthyretin production. Sixteen months into treatment, he developed bilateral lower-extremity weakness and numbness, worsening balance, difficulty manipulating objects with his hands, and finger numbness. Nerve conduction studies were consistent with multifocal demyelinating neuropathy. Intravenous immunoglobulin therapy improved sensation in his hands and feet, and improved hand dexterity. A sural nerve biopsy demonstrated demyelination with substantial axonal loss in the absence of histologically detectable endoneurial amyloid deposition. This case expands the clinicopathologic spectrum of transthyretin amyloidosis and may represent complex disease and treatment effects.
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Affiliation(s)
- George Zanazzi
- Division of Neuropathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Muhammad Arshad
- Department of Neurology, Columbia Neuropathy Research Center, The Neurological Institute of New York, Columbia University Medical Center, New York, NY; and
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Thomas H. Brannagan
- Department of Neurology, Columbia Neuropathy Research Center, The Neurological Institute of New York, Columbia University Medical Center, New York, NY; and
| | - Kurenai Tanji
- Division of Neuropathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
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Crutcher KA, Anderton BH, Barger SW, Ohm TG, Snow AD. Cellular and molecular pathology in alzheimer's disease. Hippocampus 2013. [DOI: 10.1002/hipo.1993.4500030730] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Keith A. Crutcher
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | | | - Steven W. Barger
- Department of Anatomy and Neurobiology, University of Kentucky Medical Center, Lexington, Kentucky, U.S.A
| | - Thomas G. Ohm
- Zentrum der Morphologie, J. W. Goethe‐Universität, Frankfurt, Germany
| | - Alan D. Snow
- Department of Neuropathology, University of Washington, Seattle, Washington, U.S.A
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Ihse E, Stangou AJ, Heaton ND, O’Grady J, Ybo A, Hellman U, Edvinsson Å, Westermark P. Proportion between wild-type and mutant protein in truncated compared to full-length ATTR: An analysis on transplanted transthyretin T60A amyloidosis patients. Biochem Biophys Res Commun 2009; 379:846-50. [PMID: 19118530 DOI: 10.1016/j.bbrc.2008.12.095] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 12/16/2008] [Indexed: 10/21/2022]
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Brett M, Persey MR, Reilly MM, Revesz T, Booth DR, Booth SE, Hawkins PN, Pepys MB, Morgan-Hughes JA. Transthyretin Leu12Pro is associated with systemic, neuropathic and leptomeningeal amyloidosis. Brain 1999; 122 ( Pt 2):183-90. [PMID: 10071047 DOI: 10.1093/brain/122.2.183] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We report a middle-aged woman with a novel transthyretin (TTR) variant, Leu12Pro. She had extensive amyloid deposition in the leptomeninges and liver as well as the involvement of the heart and peripheral nervous system which characterizes familial amyloid polyneuropathy caused by variant TTR. Clinical features attributed to her leptomeningeal amyloid included radiculopathy, central hypoventilation, recurrent subarachnoid haemorrhage, depression, seizures and periods of decreased consciousness. MRI showed a marked enhancement throughout her meninges and ependyma, and TTR amyloid deposition was confirmed by meningeal biopsy. The simultaneous presence of extensive visceral amyloid and clinically significant deposits affecting both the peripheral and central nervous system extends the spectrum of amyloid-related disease associated with TTR mutations. The unusual association of severe peripheral neuropathy with symptoms of leptomeningeal amyloid indicates that leptomeningeal amyloidosis should be considered part of the syndrome of TTR-related familial amyloid polyneuropathy.
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Affiliation(s)
- M Brett
- Neurology Department, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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Petersen RB, Goren H, Cohen M, Richardson SL, Tresser N, Lynn A, Gali M, Estes M, Gambetti P. Transthyretin amyloidosis: a new mutation associated with dementia. Ann Neurol 1997; 41:307-13. [PMID: 9066351 DOI: 10.1002/ana.410410305] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Familial transthyretin (TTR) amyloidosis commonly presents with peripheral neuropathy and involvement of visceral organs. In contrast, signs of central nervous system (CNS) involvement are exceptional. We report that members of a kindred affected by a slowly progressive dementia, seizures, ataxia, hemiparesis, and decreased vision without neuropathy have TTR amyloid deposits in the leptomeninges, the brain parenchyma, and the eye. This condition, previously labeled oculoleptomeningeal amyloidosis, is linked to a mutation at codon 30 of TTR gene, resulting in the substitution of valine with glycine in this family, TTR amyloid deposits were present in the leptomeninges, especially the leptomeningeal vessels, and in the subependymal regions of the ventricular system where they disrupted the ependymal lining and resulted in amyloid-glial formations protruding into and narrowing the ventricular system. Hydrocephalus and atrophy and infarction of cerebral and cerebellar cortexes were also present. Review of the literature shows that amyloid deposition in the leptomeninges is not uncommon in TTR amyloidoses clinically characterized by peripheral neuropathy and lack of CNS signs. The present kindred, which presented exclusively with signs of CNS involvement, expands the phenotype of TTR amyloidosis and raises questions concerning the mechanisms determining phenotypic expression in TTR familial amyloidosis.
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Affiliation(s)
- R B Petersen
- Division of Neuropathology, Institute of Pathology, Cleveland, OH, USA
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Koeppen AH, Wallace MR, Benson MD, Altland K. Familial amyloid polyneuropathy: alanine-for-threonine substitution in the transthyretin (prealbumin) molecule. Muscle Nerve 1990; 13:1065-75. [PMID: 2122246 DOI: 10.1002/mus.880131109] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A previously reported family with amyloid polyneuropathy (FAP) was reinvestigated to determine the type of mutation in the transthyretin (prealbumin) molecule. Transthyretin was isolated from amyloid-laden myocardium and serum, and tryptic peptides were resolved by high-performance liquid chromatography. Amino acid sequencing of an anomalous peptide revealed an alanine-for-threonine substitution corresponding to position No. 60 of the transthyretin monomer. Detection of the FAP gene in asymptomatic carriers was accomplished by hybrid isoelectric focusing of transthyretin in the presence of dithiothreitol and high concentrations of urea, and by Southern blotting of Pvull-digested leukocyte deoxyribonucleic acid. This type of FAP was found to be identical to the previously described Appalachian amyloid. Patients with FAP and their asymptomatic gene-carrying offspring had significantly reduced levels of serum transthyretin and retinol-binding protein.
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Affiliation(s)
- A H Koeppen
- Neurology Service, Veterans Administration Medical Center, Albany, New York 12208
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Sommer C, Schröder JM. Amyloid neuropathy: immunocytochemical localization of intra- and extracellular immunoglobulin light chains. Acta Neuropathol 1989; 79:190-9. [PMID: 2512758 DOI: 10.1007/bf00294378] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Sural nerve specimens from ten patients with amyloidosis (hereditary, associated with lymphoproliferative disorders, or of unknown origin) and peripheral neuropathy were investigated by immunohistochemistry at the light and electron microscopic level. Peroxidase-antiperoxidase and immunogold techniques were applied to glutaraldehyde-fixed, osmicated and epoxy-embedded tissue. In five cases, four of which associated with lymphoproliferative disorders, amyloid deposits strongly and exclusively reacted with antibodies to kappa or lambda light chains, respectively. By electron microscopy, bundles of immunogold-labelled amyloid fibrils could be identified in coated and uncoated single membrane-bound vesicles of endoneurial macrophages. Schwann cells did not contain intracellular amyloid but their processes were entangled in amyloid fibrils and their basement membranes were sometimes fused with the fibrillar masses. It is concluded that immunoglobulin light chains in AL (amyloid of immunoglobulin light chain origin) amyloidosis precipitate, forming amyloid fibrils, in the presence of, and presumably with the assistance of, endoneurial cells. Inefficiency of phagocytosis appears to be one of the major causes for the deleterious effects of amyloid.
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Affiliation(s)
- C Sommer
- Institut für Neuropathologie, Klinikum der Rheinisch Westfälischen Technischen Hochschule, Aachen, Federal Republic of Germany
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Wallace MR, Dwulet FE, Conneally PM, Benson MD. Biochemical and molecular genetic characterization of a new variant prealbumin associated with hereditary amyloidosis. J Clin Invest 1986; 78:6-12. [PMID: 3722385 PMCID: PMC329523 DOI: 10.1172/jci112573] [Citation(s) in RCA: 128] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Familial amyloidotic polyneuropathy (FAP) is an autosomal dominant late-onset disorder characterized by the extracellular deposition of amyloid fibrils. In all cases studied these fibrils have been found to be composed of plasma prealbumin (transthyretin) containing a single amino acid substitution. Biochemical studies were conducted on amyloid from one patient and plasma prealbumin from his affected brother, both part of a large kindred from the Appalachian region of the United States. Sequence analysis of the amyloid subunit protein showed it to be prealbumin with about two-thirds of the molecules containing a substitution of alanine for threonine at position 60. Studies of the plasma prealbumin showed that the same substitution was present in 40-45% of the protein. Based on this substitution and the prealbumin cDNA sequence, a Pvu II restriction fragment length DNA polymorphism (RFLP) was predicted and demonstrated in DNA of both patients as well as other family members. This RFLP confirms the predicted DNA mutation responsible for the protein variant, and represents an accurate method for detection of this gene.
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