Amyloidosis

Dr.CSBR.Prasad, M.D.

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 Gist - AMYLOID
Its only a manifestation of different diseases
its an abnormal protein
Its deposited Extracellularly
Its bland and Non-reactive
Enzyme resistant
Affects all tissues
It causes organ failure by pressure atrophy

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 Gist - AMYLOID
Two processes are associated with
such deposition

Prolonged inflammation
Excessive immunoglobulin synthesis

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 Amyloid

Amyloid is a pathologic proteinaceous

substance, deposited between cells in
various tissues and organs of the body in
a wide variety of clinical settings.

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 Amyloid
With the light microscope and standard
tissue stains, amyloid appears as

An amorphous, eosinophilic, hyaline

like, extracellular substance

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 DD Hyaline & Amyloid
Feature Hyaline Amyloid
Location Both extra & intracellular Extracellular
Nature Protein / others Protein
Inflammation Inflammatory reaction No inflammation
Etiology Variety of agents Immunological
H&E Eosinophilic Eosinophilic
Congo red Negative Positive
CR+Polarizer No change Apple green
EM variety of morphology Nonbranching fibrils
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 Amyloid

Is not a single protein

Chemically different proteins with
identical staining properties

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 Amyloid Physical nature
By electron microscopy:
(Its common to all amyloid proteins)

Non-branching fibrils
Diameter of 7.5-10 nm
cross--pleated sheet conformation

This -pleated nature is responsible for its

special staining character
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Amyloid Physical nature

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 The Nature of Amyloid

Structure of an amyloid fibril

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Ultrastructure
Amyloid Chemical nature
Mainly composed of:

1. Fibrillary protein - 95%

2. P-component - 5%
3. Glycoprotein - a fraction

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 gist - The Nature of Amyloid
Physical Nature:
Electron microscopy: Amyloid material contains two
components. (1) Rigid nonbranching fibrils* (7.5 to 10 nm):
Constitute the major component (about 90%) (2) Pentagonal
rod shaped sub-unit (P components): Forms 10% of amyloid
tissue and is a glycoprotein (variable PAS positive staining).

X-ray diffraction analysis: Characteristic -pleated

configuration* in both major subtypes of amyloid.

Chemical nature:
Peptide mapping analysis of the sequence of amino
acids: Of the 15 biochemically distinct forms
identified, 3 are major chemical types of amyloid: (1) Amyloid
of light chain origin (AL) from plasma cells, (2) Unique
nonimmunoglobulin protein synthesized in the liver (AA), (3)
A amyloid in cerebral lesion of Alzheimer disease
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 Classification

Amyloid may be:

Systemic (generalized), involving several
organ systems, or
Localized, when deposits are limited to a
single organ, such as the Heart, Skin et.c.

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 Localized Amyloid Deposits
Endocrine associated:
Amyloid deposits in the stroma of medullary thyroid carcinoma, a C-
cell tumor; amyloid is derived from a polypeptide hormone calcitonin.
Amyloid deposits in the stroma of islet cell tumors, particularly those
producing insulin (amyloid is produced by proteolysis of insulin or its
prohormone).
Senile amyloidosis:
Deposits are common in the aged (seventies and eighties); found in
heart (atria affected more frequently than ventricles) and brain (as
senile plaques).
The plaques found in Alzheimers disease is derived from -amyloid
protein (A), derived from a glycoprotein called amyloid precursor
protein (APP).
Other localized deposits: Microscopic deposits to nodular
masses in sites such as lung, larynx, skin, bladder, and tongue.
Consist of AL protein in most cases.

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Clinicopathologic Category
Systemic (Generalized) Amyloidosis
Immunocyte dyscrasias with
amyloidosis (primary amyloidosis)
Major Fibril Chemically Related
Associated Diseases
Protein Precursor Protein
Multiple myeloma and other Immunoglobulin light
AL
monoclonal B-cell proliferations chains, chiefly type

Reactive systemic amyloidosis

Chronic inflammatory conditions AA SAA
(secondary amyloidosis)

Hemodialysis-associated A2m 2-microglobulin

Chronic renal failure
amyloidosis
Hereditary amyloidosis
Familial Mediterranean fever AA SAA
Familial amyloidotic neuropathies
ATTR Transthyretin
(several types)
Systemic senile amyloidosis ATTR Transthyretin

Localized Amyloidosis
Senile cerebral Alzheimer disease A APP
Endocrine
Medullary carcinoma of thyroid A Cal Calcitonin
Islet of Langerhans Type II diabetes AIAPP Islet amyloid peptide

Isolated atrial amyloidosis AANF Atrial natriuretic factor

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Various prion diseases of the Misfolded prion Normal prion protein
Prion diseases
CNS protein (PrPSC) PrP
Classification of Systemic Amyloidosis
on clinical grounds
Primary amyloidosis, when associated with
some immunocyte dyscrasia, or
Secondary amyloidosis, when it occurs as a
complication of an underlying chronic
inflammatory or tissue destructive process.
Hereditary or familial amyloidosis constitutes a
separate, albeit heterogeneous group, with
several distinctive patterns of organ
involvement.
Hemodialysis associated Amyloidosis
Localized amyloidosis - (A). Endocrine
associated, (B). Senile, and (C). Others
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 Immunocyte Dyscrasias with
Amyloidosis (Primary Amyloidosis)

Most common form of amyloidosis

many of these patients have some form of
plasma cell dyscrasia / B-cell dyscrasia
Amyloid has AL composition

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 Reactive Systemic Amyloidosis
Secondary to an inflammatory condition
Protracted breakdown of cells
Composed of AA protein

Chronic osteomyelitis Rheumatoid arthritis

Bronchiectasis Connective tissue disease
Tuberculosis RCC
Leprosy Hodgkins disease

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 Hemodialysis-Associated
Amyloidosis

Patients on long-term hemodialysis for renal failure

High 2-microglobulin in the serum
Amyloid deposits in the synovium, joints, and
tendon sheaths

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 Heredofamilial Amyloidosis

Many familial forms of amyloidosis

Confined to limited geographic areas
The most common is familial Mediterranean fever
Others - familial amyloidotic polyneuropathies

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 Endocrine Amyloid
Microscopic localized deposits of amyloid in
endocrine tumors,
Eg: Medullary carcinoma of the thyroid gland,
Islet tumors of the pancreas
Pheochromocytomas and
Undifferentiated carcinomas of the stomach
Amyloid derived from hormones or unique proteins

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 Amyloid of Aging

Several well-documented forms of amyloid

deposition occur with aging
Senile systemic amyloidosis - systemic
deposition of amyloid in elderly patients
called senile cardiac amyloidosis

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 Amyloid Chemical nature
Fibrillary component: 15 bio-chemically distinct
forms have been identified

Three are most common:

(1) AL (amyloid light chain) immunoglobulin light
chains
(2) AA (amyloid-associated) nonimmunoglobulin
protein synthesized by the liver and
(3) A amyloid is found in Alzheimer disease
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Proposed Scheme of Pathogenesis of Two
Major Forms of Amyloid Fibrils

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 Pathogenesis of Amyloidosis
Amyloid fibrils (AL protein or AA protein) formed in
vivo from a variety of polypeptide fragments, derived
either from immunoglobulin of plasma cell origin or
from other protein (SAA) of hepatocytic origin.
Amyloidogenic proteins (Immunoglobulin light
chains or SAA) present in the blood is deposited in
various sites following limited proteolysis by the
action of monocyte-derived enzymes.
Thus, mononuclear phagocyte system may play a
role by taking up immunoglobulins, Ag-Ab
complexes, or other proteins and produce necessary
polypeptides for formation of amyloid fibrils.

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The Beta-Sheet, rigid folding pattern

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Morphology

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 Specific Organ Involvement in Amyloid
Disease
Kidney
Liver
Spleen
Heart
Lymph nodes
Adrenal
Thyroid
Pituitary
Gastrointestinal tract
Respiratory tract
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Cutaneous Amyloidosis

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Skin

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Bilateral periorbital
Another example of "raccoon
ecchymosis (raccoon eyes)
eyes" which is a clinical sign of a
and mild proptosis.
base of skull fracture.

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 Kidney in Amyloidosis
Gross: The organ is usually
enlarged and pale but a small
scarred kidney results in long
standing cases due to
secondary ischemic changes.

Micro: Amyloid is deposited

primarily in the glomeruli.
Mesengial deposition and the
deposits along basement
membrane cause capillary
narrowing and distortion of
glomerular tuft. The arterioles,
and interstitial tissue between
the tubules are also affected.
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 Kidney in Amyloidosis

Clinical impact:
Renal involvement in
amyloidosis is most
common and result is
nephrotic syndrome,
often as the
presenting feature. It
is the most serious
manifestation and
major cause of death.

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Renal biopsy in AL amyloidosis
Staining with anti-K light chain Abs

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Renal biopsy in secondary AA amyloidosis
Glomerulus is strongly positive for AA protein

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 Liver in Amyloidosis
Gross: Liver is enlarged,
heavy, pale, and firm.
Micro: Amyloid is deposited in
the space of Disse between the
endothelium and the liver cells,
and progressively encroaches
on adjacent hepatocytes and
sinusoids. The liver cells
undergo atrophy. Vascular
involvement and Kupffer cell
depositions are frequent.
Clinical impact: Liver
function is preserved in the
presence of marked
involvement.

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 Spleen in Amyloidosis

Gross: Spleen is enlarged and firm. Focal distribution is common.

The cut surface shows numerous translucent nodules distributed
throughout the red pulp (characteristic appearance, called sago
spleen). A diffuse type is also recognized.
Micro: In localized type amyloid is laid down in the walls of the
arterioles in the white pulp and subsequently replaces the malpighian
bodies. In diffuse type, amyloid is laid down in the walls of the
sinuses and tends to spare the follicles. Fusion of early deposits lead
to large map-like areas of amyloidosis (lardaceous spleen).
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Cycus Revoluta
(Sago palm)
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 Lardaceous spleen
fat from the abdomen of a pig, especially as
prepared for use in cooking

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 Lardaceous spleen

fat from the

abdomen of a
pig, especially
as prepared for
use in cooking

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 Heart in Amyloidosis
Cardiac involvement is the major
manifestation of primary
amyloidosis. It occurs in multiple
myeloma and usually in elderly
people.
Gross: Heart is enlarged, rigid, and
firm.
Micro: Begin with focal
subendocardial deposition. In due
course widespread deposition of
amyloid in the walls of blood
vessels and in the interstitial tissue
surrounding and replacing muscle
fibers.
Clinical impact: Cardiomegaly with intractable heart failure. Heart block
and arrhythmia due to involvement of conduction system are common.
Condition mimicking constrictive pericarditis due to rigidity of the muscle.

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 CNS

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Congo Red Staining of Liver in Amyloidosis

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Clinical feature

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 Immunocyte-derived Systemic
Amyloidosis
Found in with 5 to 15% multiple myeloma patients and in patients with
B-cell dyscrasias (monoclonal B-cell proliferations).
Amyloid is systemic indistribution (AL type) and derived from Ig light
chains (chiefly type).
An excess of corresponding light chain is usually present in the blood
and secreted in urine as Bence-Jones protein
Organ involvement and its effect:
Kidney involvement is a major feature and usual cause of death.
Myocardium : refractory heart failure.
Tongue: enlargement interferes with speech.
Esophagus: dysphagia.
Intestine: lesions lead to obstruction, bleeding, and perforation.
Skin: deposits cause purpura.
Nerve: peripheral neuropathy.
The liver, spleen, lungs, and endocrine organs are affected less
frequently.

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Diagnosis

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Diagnosis of Amyloid Disease in Life
Amyloid may be demonstrated in biopsy material obtained from liver,
spleen, kidney, intestine, and bone marrow. Most common site of
biopsy is kidney, when renal manfestations are present.
Tissue involved by amyloidosis has a tendency to bleed when
subjected to trauma. Biopsy of gingiva and rectal mucosa has
advantage over other sites in that, and should hemorrhage occur, it
can readily be controlled.
Fine needle aspiration biopsy of the abdominal fat is also an easily
followed and extemely useful procedure for detection of systemic
amyloidosis.
Appearance in routine stains: With light microscope and standard
tissue stains, amyloid appears as an amorphous, eosinophilic,
hyaline, extracellular substance.
Appearance by special stain (Congo red): Amyloid stains an orange
red color under ordinary light but when the stained slide is viewed in a
polarizing microscope, a characteristic green birefringence is
imparted.
Other investigations: In immunocyte-associated amyloidosis, serum
and urine protein electrophoresis, and immunoelectrophoresis. Bone
marrow aspiration for plasmacytosis.

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Amyloid - Apple green birefringence
under polarized light

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 Demonstration of Amyloid
Stain Result Technique
Lugols Iodine Mahagany brown Blue On Fresh tissue
Methyl violet Pink to Red Metachromasia
Thiflavine-T Bright red fluorescence Fluorescent technique
Thioflavine-S Bright red fluorescence Fluorescent technique
Alcian blue Green Chemical
Silver impregnantion Black Impregnation
Congo red Red Beta-pleated nature
CR + Polarization Apple green birefringens Polarization
Sirius red Green Polarization
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Amyloidosis, Lugol's Reaction

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END

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