AMYLOIDOSIS

Surg Cdr Gurpreet Kaur

Assoc Prof Pathology
 Amyloidosis protein folding
disorder

finPicken USCAP 2015

HISTORY
• 1639-Lardaceous liver, white
stone-containing spleen
• 1854 Virchow defines amyloid
• 1927- Birefringence
enhanced by Congo red: amyloid
is structured
• 2009-β2 m fibril structure
 AMYLOIDOSIS
• Pathological proteinaceous substance,
deposited in the extracellular space.

• The term amyloid, meaning starch or

cellulose, was introduced by Virchow in the
mid-19th century
 Physical nature
• In electron microscope : continuous,
nonbranching fibrils with diameter of 7.5 to
10 nm.
 Physical nature
• X- ray crystallography : cross β- pleated
sheet conformation.
 Ultrastructure amyloid

A B
Fig. 1 Structure of amyloid. A schematic
diagram of an amyloid fiber showing four Figure 2. (A) Amyloid fibrils are composed of long
fibrils) wound around one another with filaments that are visible in negatively stained transmission
regularly spaced binding of the Congo red electron micrographs.
dye. (B) The schematic diagram of the cross-β sheets in a fibril,
with the backbone hydrogen bonds represented by dashed
lines
1) Biology of amyloid: structure, function, and regulation. – Structure. 2010 Oct
13;18(10):1244-60.
 Chemical nature
• It consist of 95% fibril protein
5% P component & other glycoprotein.

TYPE PRECURSOR SYNDROME/ TISSUE INVOLVED

1. AL Immunoglobulin light chain Immunocyte dyscrasias

2.AA Serum AA Chronic inflammation

3.Aβ AβPP Alzheimer’s disease.

4.Aβ2 M β2 microglobulin hemodialysis

5.ATTR Transthyretin Familial,

Senile systemic.
Pathogenesis
 Classification
1. Systemic
▪ Primary
▪ Secondary
▪ Hereditary/ Familial
2. Localised
 •
Amyloidosis

Systemic
involving several Localized
organs

Secondary
Primary occurs as a
associated with complication of an involving single organ
immunocyte dyscrasia underlying
chronic inflammation
 Clinical Features In Amyloidosis
• Clinical manifestations depends on the number and extent of
organ involvement but are usually not specific
• Most common symptoms in Systemic amyloidosis are weight
loss, fatigue, edema and dyspnoea on exertion
Organ Frequency of
Involvement
Heart 71%

AL amyloidosis Kidneys 58%

(most
common in
AA)
GI tract 22%

Nervous 23%
system
Liver 16%
Xiang-Hua Huang Zhi-Hong Liu The Clinical Presentation and Management of Systemic Light-Chain Amyloidosis in China Kidney
 Primary Amyloidosis

Immunocyte dyscrasias
- systemic in distribution.
- AL type ( predominately λ subtype)
- plasma cell dyscrasias
- e.g., multiple myeloma
Secondary Amyloidosis

➢Systemic in distribution.
➢AA type.
➢Secondary to chronic inflammatory conditions
like
➢Tuberculosis, bronchiectasis, chronic
osteomyelitis, rheumatoid arthritis,
inflammatory bowel disease, etc.,
AA amyloidosis
 Secondary Amyloidosis
• Reactive Systemic Amyloidosis
• AA protein
• Protracted breakdown of cells from chronic inflammatory
conditions
• Rheumatoid arthritis - 3% of patients & clinically significant in
half of those affected
• Ankylosing spondylitis, Inflammatory bowel disease,
tuberculosis, bronchiectasis, chronic osteomyelitis
• Non-immunocyte derived tumors – renal cell carcinoma &
Hodgkin disease
• Mainly affects spleen, kidneys, liver, and adrenals; rarely
heart
Hemodialysis associated amyloidosis

➢Systemic in distribution.
➢β2 – microglobulin.
➢Long term dialysis
➢Amyloid often deposited in synovium, joints, or
tendon sheaths.
Heredofamilial(AF) amyloidosis
➢Familial amyloidotic cardiomyopathy.
• Mutation of transthyretin
• Presents with concentric cardiac hypertrophy
and with diastolic dysfunction & conduction
abnormality.
Heredofamilial(AF) amyloidosis
➢Familial amyloidotic polyneuropathy
• Mutation of transthyretin
• Often presents with peripheral & autonomic
neuropathy.

➢Familial mediterranean fever.

• Mutations in gene encoding pyrin.
• Presents with recurrent episodes of fever with
serosal, synovial or cutanenous inflammation.
Heredofamilial(AF) amyloidosis

➢Other AF syndromes

➢AFib - Renal amyloidosis

➢ALys – Hepato- splenic amyloidosis, organ rupture
is a complication.
➢ AApoAI – hepatic, cardiac & neuropathic
presentation.
➢AGel - cranial neuropathy and renal involvement.
 Localised amyloidosis
➢ localised to single organ/tissue
➢Most common sites are lung, larynx, skin, urinary
bladder, tongue, etc.,
➢E.g., senile cerebral amyloidosis
• Alzheimer’s disease.
• Aβ type.
 Endocrine amyloidosis

e.g., 1. Medullary carcinoma of thyroid

• ACal type.
2.Islets of langerhans
• Type 2 DM, insulinomas.
• AIAPP type
3. Prolatinomas
• APro type .
 Amyloid of aging

• Senile systemic amyloidosis ( senile

cardiac amyloidosis)
• Often presents with restrictive cardiomyopathy and
arrythmias.
• ATTR type.
 Morphology
GROSS : Organs are enlarged & firm
waxy appearance.
 Morphology
• c/s – on iodine application imparts yellow color & turns
blue color after application of sulfuric acid.
 Microscopic appearance
Renal amyloidosis:
Amyloid deposits in
- glomerulous,
- Interstitial
peritubular,
- Arteries & arterioles.
 Renal amyloidosis
• Congo red stain
 Renal amyloidosis
• Under polarizing microscope: apple- green
birefringence
 Renal amyloidosis
• Immuno fluorescence: a) Ab against λ b) antibody
against κ
 Cardiac amyloidosis
H&Estain Alcian blue - turquoise green
 Morphology

Liver
• Amyloid appears first in space of disse
 Spleen
Functional hyposplenism.
Two patterns of distribution
– Splenic follicles – sago spleen
– Sinusoids & connective tissue in red pulp –
lardaceous spleen.
 GIT
Macroglossia
Easy bruising due to amyloid deposit in capillaries
& deficiency of factor x.

Cutaneous ecchymoses appear particularly

around eyes (raccoon – eyes)
 Other findings
• Nail dystrophy, alopecia and amyloid
arthropathy with thickening of synovial
membrane are seen in systemic
amyloidosis.
 Diagnosis
• Detailed history and clinical features are first and essential step

• Inflammatory conditions, family history may indicate specific diagnosis.

• Predominant system involvement gives clue eg:- cardiac involvement more

common in AL, ATTR and rather uncommon in AA

• SIGNS of AMYLOIDOSIS

- Nephrotic syndrome -Monoclonal gammopathy with

- Unexplained cardiac dysfunction autonomic/sensory neuropathy

- Neuropathy Unexplained fatigue

- Easy brusiability (raccoon eyes) edema, unintentional weight loss

 Diagnosis
• Most common tissues biopsied
• Abdominal fat/
• Rectal mucosa/
• Gingival tissue

(negative)
Involved organs can be biopsied
e.g., kidney, endomyocardial, liver or an endoscopic
biopsy
 Diagnosis
In light microscope :
• H&E stain – amorphous, eosinophilic, hyaline,
extracellular substance.
• Congo red – salmon pink or red color.
• Alcian blue- polysaccharides.
• Metachromasia in crystal violet staining.

In polarizing microscopy:
• Congo red – apple green birefringence
 DIAGNOSIS
• Immunohistochemistry:
 Monoclonal antibodies directed against AA
amyloid.
 Polyclonal antibodies against
• Amyloid P-component,
• transthyretin,
• λ-light chain,
• κ-light chain, etc.,

• Immunofluorescence: Ab against κ chain, λchain &

fibrinogen.
• Heart-
Grossly- may be enlarged and firm
Histologically- deposits begin in focal subendocardial accumulations
and within the myocardium between muscle fibres.
• Adrenal Glands-
- begin adjacent to basement membranes of the cortical cells,
usually in zona glomerulosa
Immunohistochemistry
d) Ab against AA e) Ab against ALλ
 IHC

c) Ab directed against TTR .

d) Ab directed against λ-light chain
 Thioflavin T/S

SP- senile plaques,

NFT-Neurofibrillary
Tangles ,
LP- lipofuscin.
 Diagnosis

• Electron microscopy:
 Diagnosis
• Mass spectrometry
• In Immunocyte associated amyloidosis
• Serum & urine protein electrophoresis.
• Bone marrow aspirate - monoclonal plasmacytosis.
• Scintigraphy with radiolabelled serum amyloid P
(SAP) component.
 Typing of Amyloid
• Immunofluorescence
• Immunohistochemistry
• Immunoelectron microscopy
• Proteomic study
Diagnostic Criteria for AL amyloidosis – Mayo
clinic/ IMWG
• Presence of amyloid-related syndrome
• Positive congo red staining or presence of amyloid
fibrils on EM
• Evidence that amyloid is light chain related
established by direct examination on
spectroscopy-based proteomics or IEM
• Evidence of monoclonal plasma cell proliferative
disorder (serum M protein, abnormal FLC or clonal
All four criterias should be present
PC on BM)
Approach to diagnosis
 MCQS
1. Which parameter is most closely linked to
a poorer prognosis for primary amyloidosis?

A.Extent of cardiac involvement

B.Liver involvement
C.Macroglossia
D.Nephrotic range proteinuria
 MCQ
• Non-fibrillar amyloid components include
all except:

• A. Amyloid P component
• B. Apolipoprotein E
• C. Protein X
• D. Cystatin
 MCQs
• Which of the following is heredo-familial
form of amyloidosis?

• A. Polyneuropathic amyloidosis
• B. Cardiac amyloidosis
• C. Cerebral amyloidosis
• D. Endocrine amyloidosis
 MCQS
• Cardiac amyloidosis often produces:
• A. Dilated cardiomyopathy
• B. Constrictive cardiomyopathy
• C. Restrictive cardiomyopathy
• D. Ischaemic cardiomyopathy
 MCQS
• In Alzheimer’s disease, cerebral plaques
consist of:

• A. ATTR protein
• B. Ab2M protein
• C. Ab protein
• D. Prion protein
 MCQS
• In cases of renal failure on long-term
haemodialysis, there is development of
following type of amyloid:
• A. Amyloid light chain (AL)
• B. Amyloid-associated protein (AA)
• C. Amyloid b 2 microglobulin (Ab 2m)
• D.b amyloid protein (Ab)
 MCQS
• The most common form of amyloid in
developing countries is:
• A. Primary
• B. Secondary
• C. Hereditary
• D. Localised
THANKYOU