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Ream S, Ma J, Rodriguez T, Sarabia-Gonzalez A, Alvarado LA, Dwivedi AK, Mukherjee D. Ethnic/racial differences in risk factors and clinical outcomes among patients with amyloidosis. Am J Med Sci 2023; 365:232-241. [PMID: 36543303 DOI: 10.1016/j.amjms.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/21/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiac amyloidosis is caused by abnormal extracellular deposition of insoluble fibrils in cardiac tissue. It can be fatal when untreated and is often underdiagnosed. Understanding the ethnic/racial differences in risk factors is critical for early diagnosis and treatment to improve clinical outcomes. METHODS We performed a retrospective cross-sectional study utilizing the National Inpatient Sample database from 2015 to 2018 using ICD-10-CM codes. The primary variables of interest were race/ethnicity and amyloidosis subtypes, while the primary outcomes were in-hospital mortality, gastrointestinal bleeding, renal failure, and hospital length-of-stay. RESULTS Amyloidosis was reported in 0.17% of all hospitalizations (N = 19,678,415). Of these, 0.09% were non-Hispanic whites, 0.04% were non-Hispanic blacks, and 0.02% were Hispanic. Hospitalizations with ATTR amyloidosis subtype were frequently observed in older individuals and males with coronary artery disease, whereas AL amyloidosis subtype was associated with non-Hispanic whites, congestive heart failure, and longer hospital length of stay. Renal failure was associated with non-Hispanic blacks (adjusted relative risk [RR] = 1.31, p < 0.001), Hispanics (RR = 1.08, p = 0.028) and had an increased risk of mortality. Similarly, the hospital length of stay was longer with non-Hispanic blacks (RR = 1.19, p < 0.001) and Hispanics (RR = 1.05, p = 0.03) compared to non-Hispanic whites. Hispanics had a reduced risk of mortality (RR = 0.77, p = 0.028) compared to non-Hispanic whites and non-Hispanic blacks, and no significant difference in mortality was seen between non-Hispanic whites and non-Hispanic blacks (RR = 1.00, p = 0.963). CONCLUSIONS Our findings highlight significant ethnic/racial differences in risk factors and outcomes among amyloidosis-related US hospitalizations that can possibly be used for early detection, treatment, and better clinical outcomes.
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Affiliation(s)
- Sarah Ream
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Jennifer Ma
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Tayana Rodriguez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Alejandro Sarabia-Gonzalez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Luis A Alvarado
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Alok Kumar Dwivedi
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States; Department of Molecular and Translational Medicine, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, TX, United States.
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Abstract
Amyloidosis constitutes a large spectrum of diseases characterized by an extracellular deposition of a fibrillar aggregate, generating insoluble and toxic amasses that may be deposited in tissues in bundles with an abnormal cross-β-sheet conformation, known as amyloid. Amyloid may lead to a cell damage and an impairment of organ function. Several different proteins are recognized as able to produce amyloid fibrils with a different tissue tropism related to the molecular structure. The deposition of amyloid may occur as a consequence of the presence of an abnormal protein, caused by high plasma levels of a normal protein, or as a result of the aging process along with some environmental factors. Although amyloidosis is rare, amyloid deposits play a role in several conditions as degenerative diseases. Thus, the development of antiamyloid curative treatments may be a rational approach to treat neurodegenerative conditions like Alzheimer's disease in the future. Nowadays, novel treatment options are currently refined through controlled trials, as new drug targets and different therapeutic approaches have been identified and validated through modern advances in basic research. Fibril formation stabilizers, proteasome inhibitors, and immunotherapy revealed promising results in improving the outcomes of patients with systemic amyloidosis, and these novel algorithms will be effectively combined with current treatments based on chemotherapeutic regimens. The aim of this review is to provide an update on diagnosis and treatment for systemic amyloidosis.
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Yahya F, Kesenheimer E, Decard BF, Sinnreich M, Wand D, Goldblum D. Gelsolin-Amyloidosis - An Exceptional Cause of Blepharochalasis. Klin Monbl Augenheilkd 2021; 238:349-352. [PMID: 33930908 DOI: 10.1055/a-1386-3051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Faady Yahya
- Eye Clinic, University Hospital Basel Eye Clinic, Basel, Switzerland
| | - Eva Kesenheimer
- Departments of Medicine, Neurologic Clinic and Policlinic, University of Basel, Basel, Switzerland
| | - Bernhard F Decard
- Departments of Medicine, Neurologic Clinic and Policlinic, University of Basel, Basel, Switzerland
| | - Michael Sinnreich
- Departments of Medicine, Neurologic Clinic and Policlinic, University of Basel, Basel, Switzerland
| | - Dorothea Wand
- Department of Medical Genetics and Pathology, University of Basel, Basel, Switzerland
| | - David Goldblum
- Eye Clinic, University Hospital Basel Eye Clinic, Basel, Switzerland
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Chkheidze R, Pytel P. What Every Neuropathologist Needs to Know: Peripheral Nerve Biopsy. J Neuropathol Exp Neurol 2020; 79:355-364. [PMID: 32167544 DOI: 10.1093/jnen/nlaa012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Peripheral neuropathy is a common disorder with many possible etiologies including metabolic diseases, inflammatory conditions, infections, malignancy, inherited diseases, drugs, and toxins. In most instances, diagnosis and treatment plan can be established based on clinical presentation, family history, laboratory results, genetic testing, and electrophysiological studies. But in some situations, a peripheral nerve biopsy remains a valuable tool. This is especially true in patients with rapidly progressive disease, with atypical presentation or for whom other approaches fail to yield a definitive diagnosis. The pathologic examination starts with basic decisions about specimen triage. A few basic questions help to provide an initial framework for the assessment of a nerve biopsy-is the specimen adequate; are there inflammatory changes; are there vascular changes; is there amyloid; are there changes to axonal density and the Schwann cell-myelin-axon unit. In the appropriate context and with such an approach peripheral nerve biopsies can still represent a clinically helpful test.
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Affiliation(s)
- Rati Chkheidze
- From the Department of Pathology, UT Southwestern Medical Center, Dallas, Texas
| | - Peter Pytel
- Department of Pathology, University of Chicago, Chicago, Illinois
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Cuddy SA, Falk RH. Amyloidosis as a Systemic Disease in Context. Can J Cardiol 2020; 36:396-407. [DOI: 10.1016/j.cjca.2019.12.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
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Fernandes A, Coelho T, Rodrigues A, Felgueiras H, Oliveira P, Guimarães A, Melo-Pires M, Taipa R. Clinicopathological correlations of sural nerve biopsies in TTR Val30Met familial amyloid polyneuropathy. Brain Commun 2019; 1:fcz032. [PMID: 32954271 PMCID: PMC7425381 DOI: 10.1093/braincomms/fcz032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/18/2019] [Accepted: 10/07/2019] [Indexed: 01/02/2023] Open
Abstract
Familial amyloid polyneuropathy with the substitution of methionine for valine at position 30 in the TTR gene is the most common type of hereditary transthyretin amyloidosis. Although several authors have previously reported a size-dependent fibre loss, predominantly involving unmyelinated and small-diameter myelinated fibres, the mechanisms of nerve fibre loss have not been fully understood. In this study, we establish the morphometric pattern of peripheral neuropathy in patients with familial amyloid polyneuropathy and asymptomatic mutation carriers in the biopsies from our archive and correlated the pathological findings with clinical features. A total of 98 patients with familial amyloid polyneuropathy and 37 asymptomatic mutation carriers (TTR Val30Met mutation), aged between 17 and 84 years, who underwent sural nerve biopsy between 1981 and 2017 at Centro Hospitalar Universitário do Porto were studied. Thirty-one controls were included for comparison. The median age at nerve biopsy was 26.0 [interquartile range = 23.5–39.5] years for asymptomatic mutation carriers, 45.0 [35.0–60.0] years for patients with familial amyloid polyneuropathy and 44.0 [30.0–63.0] years for controls. The median duration between nerve biopsy and symptoms’ onset was 7.0 [3.3–11.8] years (range: 1–27 years) in the asymptomatic carriers. Most patients were in an earlier disease stage (93% with a polyneuropathy disability scale ≤2). Patients had loss of small and myelinated fibres compared with both asymptomatic carriers and controls (P < 0.001), whereas asymptomatic carriers showed loss of small myelinated fibres when compared with controls (P < 0.05). The loss of myelinated fibres increased with disease progression (P < 0.001), and patients in more advanced clinical stage showed more frequent amyloid deposition in the nerve (P = 0.001). There was a positive correlation between large myelinated fibre density and time to symptoms’ onset in the asymptomatic carriers that developed early-onset form of the disease (r = 0.52, P < 0.01). In addition, asymptomatic carriers with amyloid deposition already present in sural nerve biopsies developed symptoms earlier than those with no amyloid (P < 0.01). In conclusion, this study confirms that the loss of small fibre size is an initial event in familial amyloid polyneuropathy, already present in asymptomatic gene carriers, starting several years before the onset of symptoms. We show for the first time that large myelinated fibres’ loss and amyloid deposition are pathological features that correlate independently with short period to the onset of symptoms for asymptomatic carriers that developed early-onset form of the disease. These findings are therapeutically relevant, as it would allow for a better interpretation of the role of disease-modifying agents in transthyretin familial amyloid polyneuropathy.
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Affiliation(s)
- Armindo Fernandes
- Institute of Biomedical Sciences Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
| | - Teresa Coelho
- Unidade Corino de Andrade, Department of Neurosciences, Centro Hospitalar do Porto, 4099-001 Porto, Portugalu
| | - Aurora Rodrigues
- Neuropathology Unit, Department of Neurosciences, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal
| | - Helena Felgueiras
- Department of Neurology, Centro Hospitalar Vila Nova de Gaia-Espinho, 4434-502 Vila Nova de Gaia, Portugal
| | - Pedro Oliveira
- Institute of Biomedical Sciences Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal.,Epidemiological Research Unit (EPIUnit), Institute of Public Health, Universidade do Porto, 4050-091 Porto, Portugal
| | - António Guimarães
- Neuropathology Unit, Department of Neurosciences, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal
| | - Manuel Melo-Pires
- Institute of Biomedical Sciences Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal.,Unidade Corino de Andrade, Department of Neurosciences, Centro Hospitalar do Porto, 4099-001 Porto, Portugalu.,Neuropathology Unit, Department of Neurosciences, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal
| | - Ricardo Taipa
- Institute of Biomedical Sciences Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal.,Unidade Corino de Andrade, Department of Neurosciences, Centro Hospitalar do Porto, 4099-001 Porto, Portugalu.,Neuropathology Unit, Department of Neurosciences, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal
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Bhattacharjee P, De D, Bhattacharyya D. Degradation of fibrin-β amyloid co-aggregate: A novel function attributed to ubiquitin. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2018; 1865:1465-1478. [PMID: 30031899 DOI: 10.1016/j.bbamcr.2018.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/17/2018] [Accepted: 07/17/2018] [Indexed: 12/28/2022]
Abstract
Human placental extract contains numerous bioactive components that are effective wound healing, antimicrobial and anti-inflammatory agents. During our investigation on the therapeutic potency of human placental extract, we have purified ubiquitin-like molecules that showed strong fibrino(geno)lytic activity. Further investigation confirmed similar potency of ubiquitin purified from adult human erythrocyte. Additionally, ubiquitin efficiently degraded disordered amyloid β 42 peptide (Aβ42) aggregate and fibrin-Aβ42 co-aggregate in vitro and reduced co-aggregate induced cytotoxicity in SH-SY5Y human neuroblastoma cells as compared to plasmin. Ubiquitin also degraded abnormal co-aggregates of fibrin with other plasma proteins such as fibronectin, albumin, lysozyme, tranthyretin and α-synuclein. To elucidate the mechanism of degradation, synthetic peptides (ADG, GKT, DQQ, QRL, LIF, AGK, HLVL) derived from ubiquitin template as well as synthetic ubiquitin (8565.32 Da) were employed. Synthetic ubiquitin completely degraded preformed Aβ 42 aggregate and fibrin-Aβ42 co-aggregate, whereas, the smaller synthetic peptides showed varying degrees of degradation. These observations attribute a novel function of ubiquitin that may be used for degrading abnormal fibrin clots in human body. Thorough investigation might unfold a novel molecular mechanism of ubiquitin in protein homeostasis.
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Affiliation(s)
- Payel Bhattacharjee
- Division of Structural Biology and Bioinformatics, CSIR - Indian Institute of Chemical Biology, 4, Raja S. C. Mallick Road, Jadavpur, Kolkata 700032, India
| | - Debashree De
- Division of Structural Biology and Bioinformatics, CSIR - Indian Institute of Chemical Biology, 4, Raja S. C. Mallick Road, Jadavpur, Kolkata 700032, India
| | - Debasish Bhattacharyya
- Division of Structural Biology and Bioinformatics, CSIR - Indian Institute of Chemical Biology, 4, Raja S. C. Mallick Road, Jadavpur, Kolkata 700032, India; Department of Zoology, Tripura University, Suryamaninagar, West Tripura 799022, India.
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9
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Abstract
Tissue deposition of protein fibrils causes a group of rare diseases called systemic amyloidoses. This Seminar focuses on changes in their epidemiology, the current approach to diagnosis, and advances in treatment. Systemic light chain (AL) amyloidosis is the most common of these conditions, but wild-type transthyretin cardiac amyloidosis (ATTRwt) is increasingly being diagnosed. Typing of amyloid fibrils, a critical determinant of therapy, has improved with the wide availability of laser capture and mass spectrometry from fixed histological tissue sections. Specific and accurate evaluation of cardiac amyloidosis is now possible using cardiac magnetic resonance imaging and cardiac repurposing of bone scintigraphy tracers. Survival in AL amyloidosis has improved markedly as novel chemotherapy agents have become available, but challenges remain in advanced disease. Early diagnosis, a key to better outcomes, still remains elusive. Broadening the amyloid-specific therapeutic landscape to include RNA inhibitors, fibril formation stabilisers and inhibitors, and immunotherapeutic targeting of amyloid deposits holds promise to transform outcomes in systemic amyloidoses.
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Affiliation(s)
- Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
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10
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Arnold R, Pussell BA, Howells J, Grinius V, Kiernan MC, Lin CSY, Krishnan AV. Evidence for a causal relationship between hyperkalaemia and axonal dysfunction in end-stage kidney disease. Clin Neurophysiol 2013; 125:179-85. [PMID: 23867066 DOI: 10.1016/j.clinph.2013.06.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 05/22/2013] [Accepted: 06/17/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Potassium (K(+)) has been implicated as a factor in the development of uraemic neuropathy. This study was undertaken to investigate whether hyperkalaemia plays a causal role in axonal dysfunction in end-stage kidney disease (ESKD). METHODS Median motor nerve excitability studies were undertaken in four haemodialysis patients during a modified dialysis session. The serum K(+) level was "clamped" (fixed) for the first 3h of dialysis, whilst allowing all other solutes to be removed, this was followed by dialysis against low dialysate K(+) for a further 4 h. Blood chemistry and nerve excitability studies were undertaken prior to, during and following dialysis. Results were compared to results from the same patients during routine dialysis sessions. RESULTS All patients demonstrated significant nerve excitability abnormalities reflective of nerve membrane depolarization in pre-dialysis recordings (p<0.01). After the 3 h clamp period, serum K(+) remained elevated (5.0 mmol/L) and nerve excitability remained highly abnormal, despite the significant clearance of other uraemic toxins. In contrast, studies undertaken during routine dialysis sessions demonstrated significant improvement in both serum K(+) and nerve function after 3 h. CONCLUSIONS The current study has established a causal relationship between serum K(+) and axonal membrane depolarization in haemodialysis patients. SIGNIFICANCE From a clinical perspective, strict K(+) control may help improve nerve function in ESKD.
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Affiliation(s)
- Ria Arnold
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Bruce A Pussell
- Department of Nephrology, Prince of Wales Hospital Randwick, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - James Howells
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital and The University of Sydney, Sydney, Australia
| | - Virginija Grinius
- Department of Nephrology, Prince of Wales Hospital Randwick, Sydney, Australia
| | - Matthew C Kiernan
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Cindy S-Y Lin
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Arun V Krishnan
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales, Sydney, Australia.
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Cerebral Amyloidal Angiopathy--a disease with implications for neurology and psychiatry. Brain Res 2013; 1519:19-30. [PMID: 23651976 DOI: 10.1016/j.brainres.2013.04.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/19/2013] [Accepted: 04/29/2013] [Indexed: 12/30/2022]
Abstract
Cerebral Amyloidal Angiopathy (CAA), which occurs sporadically in most cases but can also occur hereditarily, belongs to the group amyloidoses and is characterized by the deposition and accumulation of beta-amyloid (Aβ) in smaller arterial vessels of the brain. The deposition of Aβ leads to degenerative changes in the cerebral vessel system (thickening of the vessel wall, microaneurysm, constriction of vascular lumen, dissection), which favour the development of the clinical symptomatology most often associated with CAA. Besides haemorrhages, cerebral ischaemia, transient neurological symptoms, leukoencephalopathy as well as cognitive decline and even dementia may appear in connection with CAA. A definite diagnosis of CAA can only be made on the basis of a pathological assessment, even though diagnostic findings of cerebral neuroimaging and clinical symptoms allow the diagnosis of a probable CAA. At present, no causal therapy options are available. Although CAA is placed within the range of neurological illnesses, psychiatric symptoms such as cognitive impairment, personality change or behavioural problems as well as depression are plausible clinical manifestations of CAA and may even dominate the clinical picture. Apart from epidemiological, pathogenetical, clinical and diagnostical aspects, possible psychiatric implications of CAA are discussed in the review article.
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Faridian-Aragh N, Chalian M, Soldatos T, Thawait GK, Deune EG, Belzberg AJ, Carrino JA, Chhabra A. High-resolution 3T MR neurography of radial neuropathy. J Neuroradiol 2011; 38:265-74. [DOI: 10.1016/j.neurad.2011.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/24/2011] [Accepted: 05/27/2011] [Indexed: 12/01/2022]
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Thawait SK, Chaudhry V, Thawait GK, Wang KC, Belzberg A, Carrino JA, Chhabra A. High-resolution MR neurography of diffuse peripheral nerve lesions. AJNR Am J Neuroradiol 2010; 32:1365-72. [PMID: 20966057 DOI: 10.3174/ajnr.a2257] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
High-resolution MR imaging of peripheral nerves is becoming more common and practical with the increasing availability of 3T magnets. There are multiple reports of MR imaging of peripheral nerves in compression and entrapment neuropathies. However, there is a relative paucity of literature on MRN appearance of diffuse peripheral nerve lesions. We attempted to highlight the salient imaging features of myriad diffuse peripheral nerve disorders and imaging techniques for MRN. Using clinical and pathologically proved relevant examples, we present the MRN appearance of various types of diffuse peripheral nerve lesions, such as traumatic, inflammatory, infectious, hereditary, radiation-induced, neoplastic, and tumor variants.
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Affiliation(s)
- S K Thawait
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Weller RO, Preston SD, Subash M, Carare RO. Cerebral amyloid angiopathy in the aetiology and immunotherapy of Alzheimer disease. ALZHEIMERS RESEARCH & THERAPY 2009; 1:6. [PMID: 19822028 PMCID: PMC2874258 DOI: 10.1186/alzrt6] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Amyloid is deposited in the walls of arteries and capillaries as cerebral amyloid angiopathy (CAA) in the brains of older individuals and of those with Alzheimer disease (AD). CAA in AD reflects an age-related failure of elimination of amyloid-beta (Abeta) from the brain along perivascular lymphatic drainage pathways. In the absence of conventional lymphatic vessel in the brain, interstitial fluid and solutes drain from the brain to cervical lymph nodes along narrow basement membranes in the walls of capillaries and arteries, a pathway that is largely separate from the cerebrospinal fluid. In this review we focus on the pathology and pathogenesis of CAA, its role in the aetiology of AD and its impact on immunotherapy for AD. The motive force for lymphatic drainage of the brain appears to be generated by arterial pulsations. Failure of elimination of Abeta along perivascular pathways coincides with a reduction in enzymic degradation of Abeta, reduced absorption of Abeta into the blood and age-related stiffening of artery walls that appears to reduce the motive force for lymphatic drainage. Reduced clearances of Abeta and CAA are associated with the accumulation of insoluble and soluble Abetas in the brain in AD and the probable loss of homeostasis of the neuronal environment due to retention of soluble metabolites within the brain. Tau metabolism may also be affected. Immunotherapy has been successful in removing insoluble plaques of Abeta from the brain in AD but with little effect on cognitive decline. One major problem is the increase in CAA in immunised patients that probably prevents the complete removal of Abeta from the brain. Increased knowledge of the physiology and structural and genetic aspects of the lymphatic drainage of Abeta from the brain will stimulate the development of therapeutic strategies for the prevention and treatment of AD.
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Affiliation(s)
- Roy O Weller
- Clinical Neurosciences, University of Southampton School of Medicine, LD74, South Laboratory & Pathology Block, Southampton General Hospital, Southampton, SO16 6YD, UK.
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Lymphatic drainage of the brain and the pathophysiology of neurological disease. Acta Neuropathol 2009; 117:1-14. [PMID: 19002474 DOI: 10.1007/s00401-008-0457-0] [Citation(s) in RCA: 347] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2008] [Revised: 10/28/2008] [Accepted: 10/29/2008] [Indexed: 12/25/2022]
Abstract
There are no conventional lymphatics in the brain but physiological studies have revealed a substantial and immunologically significant lymphatic drainage from brain to cervical lymph nodes. Cerebrospinal fluid drains via the cribriform plate and nasal mucosa to cervical lymph nodes in rats and sheep and to a lesser extent in humans. More significant for a range of human neurological disorders is the lymphatic drainage of interstitial fluid (ISF) and solutes from brain parenchyma along capillary and artery walls. Tracers injected into grey matter, drain out of the brain along basement membranes in the walls of capillaries and cerebral arteries. Lymphatic drainage of antigens from the brain by this route may play a significant role in the immune response in virus infections, experimental autoimmune encephalomyelitis and multiple sclerosis. Neither antigen-presenting cells nor lymphocytes drain to lymph nodes by the perivascular route and this may be a factor in immunological privilege of the brain. Vessel pulsations appear to be the driving force for the lymphatic drainage along artery walls, and as vessels stiffen with age, amyloid peptides deposit in the drainage pathways as cerebral amyloid angiopathy (CAA). Blockage of lymphatic drainage of ISF and solutes from the brain by CAA may result in loss of homeostasis of the neuronal environment that may contribute to neuronal malfunction and dementia. Facilitating perivascular lymphatic drainage of amyloid-beta (Abeta) in the elderly may prevent the accumulation of Abeta in the brain, maintain homeostasis and provide a therapeutic strategy to help avert cognitive decline in Alzheimer's disease.
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Maag R, Binder A, Maier C, Scherens A, Toelle T, Treede RD, Baron R. Detection of a Characteristic Painful Neuropathy in Fabry Disease: A Pilot Study. PAIN MEDICINE 2008; 9:1217-23. [DOI: 10.1111/j.1526-4637.2008.00470.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weller RO, Subash M, Preston SD, Mazanti I, Carare RO. SYMPOSIUM: Clearance of Aβ from the Brain in Alzheimer's Disease: Perivascular Drainage of Amyloid-β Peptides from the Brain and Its Failure in Cerebral Amyloid Angiopathy and Alzheimer's Disease. Brain Pathol 2007; 18:253-66. [PMID: 18363936 DOI: 10.1111/j.1750-3639.2008.00133.x] [Citation(s) in RCA: 472] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Roy O Weller
- Clinical Neurosciences, School of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK.
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Bahat G, Erten N, Saka B, Uzun S, Onur I, Kalayoglu-Besisik S, Buyukbabani N. Immunoglobulin D lambda multiple myeloma and amyloidosis with predominant soft tissue involvement. Amyloid 2007; 14:305-8. [PMID: 17968692 DOI: 10.1080/13506120701614206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Multiple myeloma (MM) is associated with amyloidosis in approximately 15% of the patients. The most frequent presenting signs of such an association are nephrotic syndrome, cardiomyopathy and peripheral neuropathy. Amyloid arthropathy is not a frequent feature. We report a patient with immunoglobulin D (IgD) lambda type MM with presenting symptoms related to mucocutaneous amyloidosis and also amyloid arthropathy. He had no clinical and laboratory involvement due to nephrotic syndrome or cardiomyopathy. IgD myeloma is a rare form of MM and therefore much of the information about the disease is derived from case reports describing patients with associated symptoms. Our case also shows an unusual organ distribution of amyloid.
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Affiliation(s)
- Gulistan Bahat
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Rocha N, Velho G, Horta M, Martins A, Massa A. Cutaneous manifestations of familial amyloidotic polyneuropathy. J Eur Acad Dermatol Venereol 2005; 19:605-7. [PMID: 16164719 DOI: 10.1111/j.1468-3083.2005.01222.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Familial amyloidotic polyneuropathy is an autosomal dominant amyloidosis, characterized by the systemic deposition of amyloid with a particular involvement of the peripheral nerves. The disease generally manifests as a severe sensory, motor and autonomic neuropathy. Cardiomyopathy, nephropathy, vitreous opacities and carpal tunnel syndrome may occur in a variable association with the neuropathy. Trophic dermatological lesions are frequent in the more advanced stages of the disease. We examined the skin of 142 patients. The cutaneous manifestations more frequently observed were: xerosis (81.6%), seborrheic dermatitis (21.8%), traumatic and burn lesions (19.7%), acne (18.3%), neurotrophic ulcers (14%) and onychomycosis (10.5%). Among the hepatic transplanted patients (31%), seborrheic dermatitis and acne were the most frequent diagnoses.
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Affiliation(s)
- N Rocha
- Dermatology, Hospital Geral st. Antonio, sa, Porto--Portugal.
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Gertz MA, Comenzo R, Falk RH, Fermand JP, Hazenberg BP, Hawkins PN, Merlini G, Moreau P, Ronco P, Sanchorawala V, Sezer O, Solomon A, Grateau G. Definition of organ involvement and treatment response in immunoglobulin light chain amyloidosis (AL): a consensus opinion from the 10th International Symposium on Amyloid and Amyloidosis, Tours, France, 18-22 April 2004. Am J Hematol 2005; 79:319-28. [PMID: 16044444 DOI: 10.1002/ajh.20381] [Citation(s) in RCA: 1018] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We undertook this study to develop uniformly accepted criteria for the definition of organ involvement and response for patients on treatment protocols for immunoglobulin light-chain amyloidosis (AL). A consensus panel was convened comprising 13 specialists actively involved in the treatment of patients with amyloidosis. Institutional criteria were submitted from each, and a consensus was developed defining each organ involved and the criteria for response. Specific criteria have been developed with agreed on definitions of organ and hematologic response as a result of discussions at the 10th International Symposium on Amyloid and Amyloidosis held in Tours, France, April 2004. These criteria now form the working definition of involvement and response for the purposes of future data collection and reporting. We report criteria that centers can now use to define organ involvement and uniform response criteria for reporting outcomes in patients with light-chain AL.
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Affiliation(s)
- Morie A Gertz
- Dysproteinemia Clinic, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Vital C, Vital A, Bouillot-Eimer S, Brechenmacher C, Ferrer X, Lagueny A. Amyloid neuropathy: a retrospective study of 35 peripheral nerve biopsies. J Peripher Nerv Syst 2005; 9:232-41. [PMID: 15574136 DOI: 10.1111/j.1085-9489.2004.09405.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We performed a retrospective study of 35 peripheral nerve biopsies (PNBs) with amyloid deposits in the endoneurium. In every case, nerve lesions were studied on paraffin-embedded fragments (PEFs) and by ultrastructural examination (USE). In addition, muscle fragments were taken and embedded in paraffin. Immunohistochemistry was performed with anti-transthyretin (TTR) serum on 19 nerve and 15 muscle PEFs. Direct immunofluorescence with anti-light-chain sera was performed on frozen nerve fragments in 19 cases. Endoneurial amyloid deposits were easily identified on routine PEF in 26 cases, after Congo red or thioflavine staining in three, and by USE in six. A dramatic myelinated fiber loss was evidenced in 34 cases (77-2970 per mm2), and features of axonal degeneration were present in every case. Segmental demyelination was observed in 10 cases. A mutation in the TTR gene was present in 14 cases, with Met30 mutation in 10 and Ala49 in four members of the same family. Amyloid deposits were strongly marked by the anti-TTR serum in 11 other cases, twice in the endoneurium, five around muscle fibers, and four in both locations. In eight patients, light-chain positivity was evidenced in endoneurial deposits, lambda in six and kappa in two. Two other patients with monoclonal gammopathy did not present any light-chain fixation. In 17 cases, amyloidosis was disclosed by PNB and 13 had a TTR pathology; eight of them, over 65 years old, correspond to a late-onset form of familial amyloid polyneuropathy which is an underdiagnosed condition.
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Affiliation(s)
- Claude Vital
- Neuropathology Laboratory, Victor Segalen University, Bordeaux, France.
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Abstract
Histopathologic evaluation of nerve biopsy specimens provides important diagnostic information in some patients with peripheral neuropathy. The role of nerve biopsy is more restricted than that of muscle biopsy. Nerve biopsy is utilized mainly for diagnosis of vasculitis and infiltrative neuropathies. It is also utilized in diagnosis of atypical inflammatory demyelinating neuropathies in which the clinical, electrodiagnostic, and laboratory features are inconclusive. In addition, the study of nerve histopathology can also enhance our understanding of disease pathogenesis.
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Affiliation(s)
- David Lacomis
- University of Pittsburgh Medical Center, UPMC Presbyterian, 200 Lothrop Street, F878, Pittsburgh, PA 15213, USA.
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Abstract
Small-fiber neuropathy is a common disorder. It is often "idiopathic" and typically presents with painful feet in patients over the age of 60. Autoimmune mechanisms are often suspected, but rarely identified. Known causes of small-fiber neuropathy include diabetes mellitus, amyloidosis, toxins, and inherited sensory and autonomic neuropathies. Occasionally, small-fiber neuropathy is diffuse or multifocal. Depending on the type of small-fiber neuropathy, autonomic dysfunction can be significant or subclinical. Diagnosis is made on the basis of the clinical features, normal nerve conduction studies, and abnormal specialized tests of small-fiber function. These specialized studies include assessment of epidermal nerve fiber density as well as sudomotor, quantitative sensory, and cardiovagal testing. The sensitivities of these tests range from 59-88%. Each has certain advantages and disadvantages, and the tests may be complementary. Unless an underlying disease is identified, treatment is usually directed toward alleviation of neuropathic pain.
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Affiliation(s)
- David Lacomis
- Department of Neurology, University of Pittsburgh School of Medicine, UPMC Presbyterian, 200 Lothrop Street, F878, Pittsburgh, Pennsylvania 15213, USA.
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Abstract
BACKGROUND Most peripheral neuropathies involve large as well as small-fiber dysfunction. A small subset of neuropathies present with restricted or predominant small-fiber involvement. REVIEW SUMMARY In this review, we discuss the differential diagnosis, clinical presentation, evaluation, and treatment of small-fiber neuropathies. Although these neuropathies are rare, their differential diagnosis is broad, and includes many disorders, including metabolic, toxic, inflammatory, infectious, and genetic etiologies. As small fibers subserve pain and autonomic functions, these neuropathies usually present with pain and temperature loss, painful dysesthesias, autonomic dysfunction, or a combination. These neuropathies are especially challenging as nerve conductions and EMG, which help guide the evaluation of most peripheral neuropathies, may have normal findings in patients with small-fiber neuropathies. Other specialized studies, including tests of autonomic function, intraepidermal nerve fiber analysis, and quantitative sensory testing, are often required to confirm the presence of a small-fiber neuropathy. In some cases, the underlying etiology can be directly treated. In most, management is limited to symptomatic treatment of sensory and autonomic dysfunction. CONCLUSION Small-fiber neuropathies are a heterogeneous group of disorders. They vary in etiologies and require special attention, as many disorders are rare and the differential diagnosis is broad. Evaluation is often extensive and may need pathologic specimen. Many patients respond to symptomatic therapy, but some are difficult to treat.
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Affiliation(s)
- Amer Al-Shekhlee
- Department of Neurology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio 44016-5098, USA
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Kiuru-Enari S, Somer H, Seppäläinen AM, Notkola IL, Haltia M. Neuromuscular pathology in hereditary gelsolin amyloidosis. J Neuropathol Exp Neurol 2002; 61:565-71. [PMID: 12071640 DOI: 10.1093/jnen/61.6.565] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Hereditary gelsolin amyloidosis (AGel amyloidosis) is a systemic disorder reported worldwide in kindreds with a G654A or G654T gelsolin gene mutation. The clinically characteristic peripheral nerve involvement has been poorly characterized morphologically, and its pathogenesis remains unknown. We studied peripheral nerve and skeletal muscle biopsy or autopsy specimens of 35 patients with a G654A gelsolin gene mutation. Histological, immunohistochemical, and electron microscopic studies showed consistent deposition of gelsolin amyloid (AGel), particularly in the vascular walls and perineurial sheaths. Nerve roots were more severely affected than distal nerves. The amyloid deposits also displayed variable immunoreactivity for apolipoprotein E, amyloid P component, cystatin C, and alpha-smooth muscle actin. Sural nerve morphometry showed preferential age-related large myelinated nerve fiber loss and reduction of myelin sheath cross-sectional area. There was evidence of denervation atrophy and fiber type grouping in skeletal muscle. Our study shows that marked proximal nerve involvement with AGel angiopathy is an essential feature of AGel amyloidosis. The preferential large fiber loss, not generally seen in amyloid neuropathy, may be caused by ischemia due to AGel angiopathy. Deficient actin modulation by variant gelsolin in neurons and Schwann cells, however, may alter axonal transport and myelination and contribute to AGel polyneuropathy.
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Affiliation(s)
- Sari Kiuru-Enari
- Department of Neurology, Helsinki University Central Hospital, Finland
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Rajani B, Rajani V, Prayson RA. Peripheral nerve amyloidosis in sural nerve biopsies: a clinicopathologic analysis of 13 cases. Arch Pathol Lab Med 2000; 124:114-8. [PMID: 10629141 DOI: 10.5858/2000-124-0114-pnaisn] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Amyloidosis is a well-recognized but uncommon cause of peripheral neuropathy. Our objectives were to determine the overall prevalence of peripheral nerve amyloidosis in sural nerve biopsies and to evaluate the clinical and pathologic features of these lesions. METHODS All available histologic and ultrastructural materials on biopsy tissue from 13 cases of peripheral nerve amyloidosis were examined. Muscle biopsies performed at the same time as the nerve biopsy were reviewed when available. Clinical data were collected on all patients. RESULTS The prevalence of amyloidosis in sural nerve biopsies at our institution was 13 (1.2%) of 1098 cases over a 15.8-year period. These patients ranged in age from 41 to 82 years (median, 61 years) at initial presentation and included 10 men and 3 women. Presenting neuropathy symptoms were sensory in 6 of the 13 patients, motor in 2 cases, and mixed in 5 cases. Cardiac, renal, or gastrointestinal involvement was present in 7 of 13 cases. Two patients had myeloma and 7 had systemic autonomic symptoms. Two patients had probable familial amyloid polyneuropathy, and 1 patient demonstrated an alanine 60 point mutation. Amyloid, identified as amorphous eosinophilic extracellular deposits demonstrating apple green birefringence on Congo red stain or recognized by its characteristic fibrillar ultrastructure by electron microscopy, was identified in the endoneurium in 12 nerves, perineurium in 2 nerves, and epineurium in 9 nerves. Chronic inflammation was identified in 5 nerves. Axonal loss was recorded as mild (<25%) in 1 nerve, moderate (25% to 75%) in 8 nerves, and severe (>75%) in 4 nerves. Axonal degeneration predominated over demyelination in 8 of 10 cases that could be evaluated. Concomitant muscle biopsies contained amyloid deposits in 8 of 9 cases. CONCLUSIONS Amyloidosis is a rare (1.2% in our series) cause of peripheral neuropathy with a distinct microscopic and ultrastructural appearance. Just over half the patients in our study had visceral organ involvement and systemic autonomic symptoms. The peripheral neuropathy was associated with axonal degeneration and a moderate to severe axonal loss in the majority of cases. Amyloid deposition was present in 8 out of 9 muscle biopsies performed at the same time.
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Affiliation(s)
- B Rajani
- Departments of Anatomic Pathology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
Gelsolin-related amyloidosis (familial amyloidosis, Finnish type) is a rare disorder, reported worldwide in kindreds carrying a G654A or G654T gelsolin gene mutation. Facial palsy, mild peripheral neuropathy, and corneal lattice dystrophy are characteristic, but atrophic bulbar palsy, ataxia of gait, and minor cognitive impairment may occur. In histological and immunohistochemical studies of the central nervous system in 4 patients with a G654A gelsolin mutation, we found widespread spinal, cerebral, and meningeal amyloid angiopathy, with deposition of gelsolin-related amyloid (AGel). Marked extravascular deposits occurred in the dura, spinal nerve roots, and sensory ganglia. The amyloid deposits were also variably immunoreactive for apolipoprotein E (ApoE), alpha1-antichymotrypsin (alpha1-ACT), and cystatin C (Cys C). Cerebral perivascular fibrinogen immunoreactivity was occasionally noted. The patients showed posterior column degeneration and diffuse loss of myelin in the centrum semiovale with perivascular accentuation. Postmortem magnetic resonance imaging, performed on 1 patient, showed white matter lesions, colocalizing with the histological abnormalities. Our study shows that deposition of AGel in the spinal and cerebral blood vessel walls, meninges, as well as spinal nerve roots and sensory ganglia is an essential feature of this form of systemic amyloidosis and may contribute to the central nervous system symptoms.
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Affiliation(s)
- S Kiuru
- Department of Clinical Neurosciences, Helsinki University Central Hospital, Finland
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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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Laeng RH, Altermatt HJ, Scheithauer BW, Zimmermann DR. Amyloidomas of the nervous system: a monoclonal B-cell disorder with monotypic amyloid light chain lambda amyloid production. Cancer 1998; 82:362-74. [PMID: 9445195 DOI: 10.1002/(sici)1097-0142(19980115)82:2<375::aid-cncr18>3.0.co;2-w] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Amyloidomas or localized tumor-like amyloid deposits rarely affect the nervous system. To the authors' knowledge, no comprehensive studies on central and peripheral nervous system amyloidomas have been published. The amyloid subtype of amyloidomas of the nervous system only recently was characterized and almost invariably was found to be of amyloid light chain (AL) lambda type. The nature of the plasma cell population responsible for AL amyloid production has not been investigated further. METHODS The current analysis included the clinical findings, neuroimaging characteristics, and pathology of seven amyloidomas (four cerebral and three involving peripheral nerves). All were subjected to histochemical staining (Congo red, thioflavine S) and to immunohistochemical study using primary antibodies detecting serum amyloid component P, serum amyloid protein A (SAA), transthyretin, beta2 microglobulin (beta2m), and free immunoglobulin (Ig) light chain. For the detection of mRNA of light chain Ig, fluorescein-conjugated kappa and lambda mRNA oligonucleotide probes were used. For the assessment of B-cell clonality, polymerase chain reaction (PCR) was applied on extracted DNA from two cases using VH FRIII and JH primers. Two cases were assessed ultrastructurally. RESULTS All amyloidomas were organ restricted and unrelated to systemic amyloidosis. The clinical symptoms of the cerebral lesions were nonspecific, whereas neurologic deficits were noted in the distribution of the involved peripheral nerves. Cerebral deposits, either solitary or multiple, were associated spatially with the choroid plexus and secondarily extended into white matter. All peripheral nerve amyloidomas involved the gasserian ganglion of the trigeminal nerve. Imaging by computed tomography and magnetic resonance imaging scans revealed hyperdense and contrast-enhancing mass lesions unassociated with significant edema. Immunohistochemically, the amyloid was present in the interstitium and within the walls of the intralesional vessels, was invariably of AL lambda subtype, and was negative for free Ig kappa light chains, SAA, transthyretin, and beta2m. Plasma cells along the perivascular sheaths and occasionally squeezed between amyloid masses showed no cytologic atypia. In situ hybridization for Ig light chain mRNA reflected a massive preponderance of lambda-producing cells. PCR revealed monoclonal rearrangement of the heavy chain Ig gene. CONCLUSIONS The results of the current study provide strong support for the concept that amyloidomas of the nervous system are neoplasms of an AL lambda-producing B-cell clone capable of terminal differentiation. Nevertheless, all seven patients lacked clinical evidence of an aggressive or systemic lymphoplasmacytic neoplasm. Unlike plasmacytomas, the relatively indolent course of most nervous system amyloidomas is reminiscent of the similarly indolent biologic behavior of extranodal, low grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type.
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Affiliation(s)
- R H Laeng
- Department of Pathology, Kantonsspital, Aarau, Switzerland
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Affiliation(s)
- C N Martyn
- MRC Environmental Epidemiology Unit, Southampton University, Southampton General Hospital, UK
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