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AA protein in a case of “primary” or “idiopathic” amyloidosis
AA Protein in a Case of “Primary” or “Idiopathic” Amyloidosis
MORDECHAI PRAS, M.D.” JOAN ZARETZKY, B.A. BLAS FRANGIONE. M.D.. Ph.D. EDWARD C. FRANKLIN. M.D. New York, New York
From the Irvington House Institute, New York University Medical Center, New York, New York. This paper was supported by US. Public Health Service Research grants AM 00458, AM 01431 and AM 02594: and grants from The Irvington House Institute and The Michael and Helen Schaffer Fund. Requests for reprints should be addressed to Dr. Edward C. Franklin, New York University Medical Center, 550 First Avenue, New York, New York 10016. Manuscript accepted July 16,1979. * Present address: Heller Institute of Medical Research, Department of Medicine, TelHashomer Hospital, Tel-Aviv, Israel.
Amyloidosis constitutes a group of diseases in which extracellular fibrils with a characteristic appearance are deposited in a variety of tissues. Several different proteins have been identified as the major subunits of the fibrils. In the primary and myeloma-associated type, the amyloid fibrils consist of immunoglobulin light chain fragments, whereas in the secondary type and the amyloid associated with familial Mediterranean fever the major component is the AA protein. In this report a 21 year old man of Yemenite extraction with no underlying disease and no family history of amyloidosis was found to have amyloid deposits composed of AA protein. Although clinically this might be classified as primary amyloidosis, the absence of light chain fragments makes that diagnosis unlikely. Therefore, it is suggested that whenever possible the clinical classification be supplemented by a description of the biochemical nature of the fibrils. Amyloidosis is a group of diseases resulting from the systemic or localized extracellular accumulation of typical fibrillar deposits in the ground substance of various organs [l]. Exploitation of the solubility properties of the amyloid fibrils has made possible the isolation of the major protein constituents [z]. This in turn has led to rapid advances in the knowledge of their chemistry [3,4]. In view of the existence of a number of different clinical types of amyloidosis, it did not come as a complete surprise when chemical analyses revealed marked differences in the nature of amyloid deposits in the different clinical forms of the disease. Immunoglobulin light chain related components were found to be the major constituent of amyloid fibrils derived from patients with primary amyloidosis and amyloidosis associated with plasma cell dyscrasias [5,6], whereas the AA protein has been identified in secondary amyloidosis associated with chronic infections, inflammatory diseases and Hodgkin’s disease [7,8], as well as in the genetic amyloidosis of familial Mediterranean fever. A similar AA protein has been found in all experimentally and naturally occurring amyloid deposits in different species of animals [g-12]. In addition, rarer forms of amyloid appear to be derived from peptide hormones and perhaps other /3pleated sheet proteins characteristic of different tissues [XI]. In the present report, we present evidence that AA protein was the major constituent of amyloid fibrils of a patient who died from amyloidosis with no underlying infectious, neoplastic or inflammatory disorder and no family history of amyloidosis, thus emphasizing the
February
1980
The American
Journal of Medicine
Volume 68
291
AA PROTEIN IN AMYLOIDOSIS-PRAS
ET AL.
Protein
BSA Ovalbumin
Myoglobin
17.0 -
Lysozyme Ribonuclease
13.9 12.5 -
Insulin
6.0 -
Figum 1. Fifteen per cent sodium dodecyl sulfate polyacrylamide gel. 1 = markers; 2 = amyloid fibril-spleen; 3 = purified AA protein-spleen; 4 = purified AA protein-familial Mediterranean fever; 5 = purified AA protein-osteomyelitis.
necessity to modify the clinical diagnosis with a description of the nature of the amyloid protein whenever possible. CASE REPORT A 21 year old man of Yemenite extraction was admitted first to the medical ward at the Sheba Medical Center, after an acute illness of vomiting. The referring physicians were impressed by an enlarged liver and spleen and sent him for invcstigation. At the age of 15 he had been hospitalized in the Pediatric Department of another hospital for lymphadenopathy and mild hepatosplenomegaly. Laboratory tests that included lymph gland and rectal biopsies were unremarkable, and he was released without any treatment. Over the next six years. he studied and worked as a mechanic and joined the Army in 1972. Until admission the only physical findings were enlargement of the liver 4 cm below the costal margin and the spleen, and 3 cm below the costal margin. Laboratory tests showed an erythrocyte sedimentation rate of 112 mm/hour, albumin 3.4 g/100 ml, globulin 3.7 g/100 ml, alkaline phosphatase 130 and 180 IU [normal 50 IU), Bromsulfalein retention 11 per cent and prothrombin time 30 seconds. It did not improve after vitamin K. Urinalysis was normal. Rectal and liver biopsy specimens showed no amyloid deposits when examined by polarization microscopy after Congo Red staining. The patient left the hospital with a tentative diagnosis of cirrhosis of the liver and was discharged from the Army. Three years later, at age 24, he was admitted to the medical ward of the first hospital because of a nephrotic syndrome. A liver biopsy revealed extensive deposition of amyloid. Roentgenograms of the gastrointestinal tract and small bowel revealed no abnormalities. There was no clinical evidence for rheumatoid ar-
292
February 198s The American Journal of Medicine
thritis and roentgenograms of the spine and sacroiliac joints gave no indication of ankylosing spondylitis. The creatinine clearance was normal, nonprotein nitrogen 20 mg/lOO ml, serum albumin 2 g/100 ml. No abnormal proteins were found on electrophoresis and immunoelectrophoresis of the serum and urine. Bone marrow examination disclosed no abnormalities. The patient was released from the hospital on a regimen of colchicine, 1 mg/day and diuretics, but his renal function deteriorated rapidly, and seven months later he was admitted for long-term hemodialysis treatment. Five months later, a cadaver renal transplantation was performed at the Sheba Medical Center, but the allograft was rejected and removed three weeks after the first operation. After the second operation, Pseudomonas aeruginosa septicemia developed and, despite massive antibiotic treatment, he died six weeks after the first operation. At autopsy, extensive amyloidosis of the kidneys, liver, spleen and blood vessels was found. There was no evidence of chronic infection, chronic inflammation, ulcerative colitis or regional enteritis, At the site of transplantation in the right iliac fossa, there was an acute abscess secondary to the surgical procedures performed during the last hospital admission.
SPECIAL
STUDIES
Extraction of Amyloid. Amyloid fibrils were extracted from liver and spleen by the water solubilization method of Pras et al. [2]. Purified fibrils were acid extracted as previously described [14], and the subunit was purified by G-75 column chromatography in 5M guanidine hydrochloride in 1M acetic acid [5]. Molecular weights and purity of protein fractions were determined
Volume 66
AA PROTEIN
by sodium dodecyl sulfate polyacrylamide disc and slab electrophoresis [15]. Amino acid analysis was performed on a Durrum D-500 automatic amino acid analyzer. Proteins were hydrolyzed under vacuum at 1lO’C for 20 hours in 6M hydrochloric acid containing 0.1 percent phenol to prevent destruction of tyrosine [16]. Amino acid sequence determinations were performed by the method of Edman and Begg [17] with a Beckman Model 890C sequencer as previously described by using the accelerated DMAA (dimethylallylamine-trifluoroacetic acid buffer) program. Each recovered amino acid was identified by gas and thin layer chromatography and by back hydrolysis with hydrochloric acid [18,19]. Both liver and spleen yielded large quantities of water-soluble amyloid fibrils; about 1 g (800 mg to 1,100 mg) of dry material for each 30 g of wet liver or spleen. Sodium dodecyl sulfate acrylamide gel electrophoresis of native fibrillar material showed the major protein constituent to have the same mobility as an AA protein [14][Figure 1). From 60 to 65 per cent of the amyloid fibril was recovered as a homogeneous component having a mobility similar to that of the AA protein [7,8]. There was no clinical or immunologic evidence of light chain related proteins. The amino acid sequence of Amino Acid Sequence. the liver AA protein was obtained for 57 steps, that of the spleen for 23. The amino acid sequences were:
IN AMYLOIDOSIS--PRAS
ET AL.
basis of these negative findings, this patient might be considered to have primary amyloidosis on purely clinical grounds. However, it is notable that he did not have marrow plasmacytosis and no involvement of heart, muscle, tongue or other organs frequently involved in primary amyloidosis. Until the present report, all amyloid fibrils derived from patients who suffered from primary amyloidosis yielded protein subunits related to immunoglobulin light chains and were designated as AL (amyloid light chain) proteins. Amyloid fibrils derived from patients who suffered from plasma cell dyscrasias also yielded AL proteins, except in one case of Waldenstrom’s macroglobulinemia reported by Husby et al. [z] in which a protein was found that demonstrated an amino acid content characteristic to an AA protein. Amino acid sequence studies were not performed in that case. The secondary form of the disease, associated with AA protein deposits, usually is found in association with an obvious and clinically apparent underlying disease, most often of an infectious, inflammatory or neoplastic nature and usually of long duration. The present finding of an AA protein as the major component of what might appear as primary amyloidosis suggests that it would be advisable whenever possible to supplement the clinical classification by a description of the chemical nature of the deposits. Thus,
1 10 Ser-Phe-Phe-Ser-Phe-Leu-Gly-Glu-Ala-Phe-Asp-Gly-Ala-Arg-
Liver Spleen
Arg/Ser-Phe-Phe-Ser-Phe-Leu-Gly-Glu-Ala-Phe-Asp-Gly-Ala-Arg-
Spleen
20 Asp-Met-Trp-Arg-Ala-Tyr-Ser-Asp-Met-Arg-Glu-Ala-Asn-TyrAsp-Met-Trp-Arg-Ala-Tyr-Ser-Asp-Met
Liver
30 Ile-Gly-Ser-Asp-Lys-Tyr-Phe-(
Liver
40
]-Ala-(
)-Gly-Asn-Tyr-Asp-
50
Liver ( ) = unidentified
Ala-Ala-Lys-(
)-Gly-Pro-Gly-Gly-Val-Trp-Ala-Ala-Glu-Ala-Ile
position
These sequences were identical to each other and to those of AA proteins previously published [7,8]. COMMENTS An AA protein appears to be the major subunit constituent of the amyloid fibrils of a young patient with amyloidosis in the absence of any predisposing disease clinically or at postmortem examination. Since physical examination and urinalysis of all his close relatives, including his mother and all his seven brothers and one sister, did not reveal any pathologic findings except a palpable spleen in two brothers, a frequent finding among Israelis of Yemenite extraction, a familial form of the disease appears unlikely. The father died at the age of 67 from carcinoma of the prostate. Thus, on the
amyloidosis should be designated as hereditary when there is evidence for genetic transmission with a statement of the type of deposit when known, acquired or secondary when a predisposing disease is found, myeloma associated and by tradition primary in the presence of a plasmacellular or lymphoid neoplasm and/or monoclonal proteins, and idiopathic when none of the aforegoing is established. The chemical nature of the amyloid subunit, i.e., AA protein, AL protein, or prealbumin and perhaps others, should then be added to complete the description especially in instances of the idiopathic type [21]. In patients without an obvious underlying disease, the term “primary amyloidosis” might be limited, because of tradition to patients with overt or latent plasma cell
February 1980
The American Journal of Medicine
Volume 68
293
AA PROTEIN IN AMYLOIDOSIS-PRAS
ET AL
dyscrasias associated with the production of AL proteins. A patient, such as the one described herein, should preferably be referred to as idiopathic AA amyloid to avoid confusion with the classic “primary” type. An unusual feature, which may perhaps provide a hint as to the chemical type of the amyloid protein, is related to the clinical features of the disease. Most patients with amyloidosis related to AA protein present with the nephrotic syndrome, often associated with hepatosplenomegaly, whereas amyloidosis related to AL protein, results, in addition, or exclusively in cardiopathy, ma-
croglossia or progressive enlargement of the liver [4]. The extremely rapid progression of the renal failure seen in this patient is not a characteristic feature of nephropathic amyloidosis in secondary amyloidosis and in familial Mediterranean fever in which the course of progression from a nephrotic syndrome to renal failure is often a matter of several years rather than five months. Perhaps this. type of amyloidosis may be recognized more frequently in the future as more careful analyses of the deposits are carried out either biochemically or by immunofluorescence.
REFERENCES 1. RokitanskyC: Handbuch der pathologisthen Anatomie, vol 2. 3. 4. 5. 6. 7.
8. 9.
10.
11.
294
3, Braumuller and Seidel, Vienna, 1842, p 311. Pras M, Schubert M, Zucker-Franklin D, et al.: The characterization of soluble amyloid prepared in water. ] Clin Invest 47: 925,1968. Cohen AS, Franklin EC, Glenner GG, et al.: Nomenclature, Amyloidosis, (Wegelius 0, Pasternak A, eds), New York, Academic Press, 1976, p 9. Pras M, Gafni J: The nature of amyloid. Immunochemistry. 1978. (Glynn EG, Steward M, eds), London, John Wiley & Sons Publishing Co., p 509. Glenner GG, Terry W, Harada M, et al.: Amyloid fibril proteins: proof of homology with immunoglobulin light chains by sequence analyses. Science 172: 1150,197l. Kimura S, Guyer R, Terry WD, et al.: Chemical evidence for X-type amyloid fibril proteins. J ImmunollO9: 891,1972. Benditt EP, Eriksen N, Hermodson MA, et al.: The major proteins of human and monkey substance: Common properties including unusual N-terminal amino acid sequences. Febs Lett 19: 169,197l. Levin M, Franklin EC, Frangione B, et al.: The amino acid sequence of a major non-immunoglobulin component of some amyloid fibrils. J Clin Invest 51: 2773.1972. Skinner M, et al.: Isolation and identification by sequence analysis of experimentally induced guinea pig amyloid fibrils. J Exp Med 140: 871, 1974. Husby G, Natvig JB, Sletten K. et al.: An experimental model in mink for studying the relation between amyloid and fibril protein AA and the related protein SAA. Stand J Immunol4: 811,1975. Gorevic PD. Greenwald M, Frangione B, et al.: The amino
February 1980 The American Journal of Medicine
‘12. 13. 14. 15. 16. 17. 18. ‘19.
20. 21.
acid sequence of duck amyloid A (AA] protein. J Immunol 118: 1113,1977. Skinner M, Shirahama T, Benson MD, et al.: Murine amyloid protein AA in casein-induced experimental amyloidosis. Lab Invest 36: 420,1977. Franklin EC, Calkins E: Amyloidosis. Immunological Diseases, vol II, 3rd ed, (Samter M, ed), Boston, Little. Brown & Co, 1978, p 1158. Pras M. Reshef T: The acid soluble fraction of amyloid. A fibrilformin protein. Biochim Biophys Acta 271: 193, 1972. Weber K, Osborn M: The reliability of molecular weight determination of dodecyl-sulfate polyacrylamide gel electronhoresis. I Biol Chem 244: 4406.1969. Sanger F: Thompson EOP: Halogenation of tyrosine during acid hvdrolvsis. Biochim Bionhvs Acta 71: 468. 1936. Edman P, Be&G: A protein sequenator. Eur J B&hem 1: 80, 1967. Pisano JJ. Bronzert TJ: Analysis of amino acid phenylthiohydantoins by gas chromatography. J Biol Chem 244: 5597, 1969. Summers MR. Smvthers GW, Orozzlan S: Thin-laver chromatography of sub-nanomole amounts of phenylthiohydantoin (PTHI amino acids on oolvamide sheets. Anal Biol . I Chem 53: 624; 1973. Husby G, Sletten K. Michaelsen TE, et al.: Amino acid analysis of AA in macroglobulinemia. Stand J Immunol 2: 395. 1973. Costa PP. Figueira AS, Bravo FR: Amyloid fibril protein related to prealbumin and familial amyloidotic polyneuropathy. Proc Nat1 Acad Sci 75: 4499, 1978.
Volume 68
MORDECHAI PRAS, M.D.” JOAN ZARETZKY, B.A. BLAS FRANGIONE. M.D.. Ph.D. EDWARD C. FRANKLIN. M.D. New York, New York
From the Irvington House Institute, New York University Medical Center, New York, New York. This paper was supported by US. Public Health Service Research grants AM 00458, AM 01431 and AM 02594: and grants from The Irvington House Institute and The Michael and Helen Schaffer Fund. Requests for reprints should be addressed to Dr. Edward C. Franklin, New York University Medical Center, 550 First Avenue, New York, New York 10016. Manuscript accepted July 16,1979. * Present address: Heller Institute of Medical Research, Department of Medicine, TelHashomer Hospital, Tel-Aviv, Israel.
Amyloidosis constitutes a group of diseases in which extracellular fibrils with a characteristic appearance are deposited in a variety of tissues. Several different proteins have been identified as the major subunits of the fibrils. In the primary and myeloma-associated type, the amyloid fibrils consist of immunoglobulin light chain fragments, whereas in the secondary type and the amyloid associated with familial Mediterranean fever the major component is the AA protein. In this report a 21 year old man of Yemenite extraction with no underlying disease and no family history of amyloidosis was found to have amyloid deposits composed of AA protein. Although clinically this might be classified as primary amyloidosis, the absence of light chain fragments makes that diagnosis unlikely. Therefore, it is suggested that whenever possible the clinical classification be supplemented by a description of the biochemical nature of the fibrils. Amyloidosis is a group of diseases resulting from the systemic or localized extracellular accumulation of typical fibrillar deposits in the ground substance of various organs [l]. Exploitation of the solubility properties of the amyloid fibrils has made possible the isolation of the major protein constituents [z]. This in turn has led to rapid advances in the knowledge of their chemistry [3,4]. In view of the existence of a number of different clinical types of amyloidosis, it did not come as a complete surprise when chemical analyses revealed marked differences in the nature of amyloid deposits in the different clinical forms of the disease. Immunoglobulin light chain related components were found to be the major constituent of amyloid fibrils derived from patients with primary amyloidosis and amyloidosis associated with plasma cell dyscrasias [5,6], whereas the AA protein has been identified in secondary amyloidosis associated with chronic infections, inflammatory diseases and Hodgkin’s disease [7,8], as well as in the genetic amyloidosis of familial Mediterranean fever. A similar AA protein has been found in all experimentally and naturally occurring amyloid deposits in different species of animals [g-12]. In addition, rarer forms of amyloid appear to be derived from peptide hormones and perhaps other /3pleated sheet proteins characteristic of different tissues [XI]. In the present report, we present evidence that AA protein was the major constituent of amyloid fibrils of a patient who died from amyloidosis with no underlying infectious, neoplastic or inflammatory disorder and no family history of amyloidosis, thus emphasizing the
February
1980
The American
Journal of Medicine
Volume 68
291
AA PROTEIN IN AMYLOIDOSIS-PRAS
ET AL.
Protein
BSA Ovalbumin
Myoglobin
17.0 -
Lysozyme Ribonuclease
13.9 12.5 -
Insulin
6.0 -
Figum 1. Fifteen per cent sodium dodecyl sulfate polyacrylamide gel. 1 = markers; 2 = amyloid fibril-spleen; 3 = purified AA protein-spleen; 4 = purified AA protein-familial Mediterranean fever; 5 = purified AA protein-osteomyelitis.
necessity to modify the clinical diagnosis with a description of the nature of the amyloid protein whenever possible. CASE REPORT A 21 year old man of Yemenite extraction was admitted first to the medical ward at the Sheba Medical Center, after an acute illness of vomiting. The referring physicians were impressed by an enlarged liver and spleen and sent him for invcstigation. At the age of 15 he had been hospitalized in the Pediatric Department of another hospital for lymphadenopathy and mild hepatosplenomegaly. Laboratory tests that included lymph gland and rectal biopsies were unremarkable, and he was released without any treatment. Over the next six years. he studied and worked as a mechanic and joined the Army in 1972. Until admission the only physical findings were enlargement of the liver 4 cm below the costal margin and the spleen, and 3 cm below the costal margin. Laboratory tests showed an erythrocyte sedimentation rate of 112 mm/hour, albumin 3.4 g/100 ml, globulin 3.7 g/100 ml, alkaline phosphatase 130 and 180 IU [normal 50 IU), Bromsulfalein retention 11 per cent and prothrombin time 30 seconds. It did not improve after vitamin K. Urinalysis was normal. Rectal and liver biopsy specimens showed no amyloid deposits when examined by polarization microscopy after Congo Red staining. The patient left the hospital with a tentative diagnosis of cirrhosis of the liver and was discharged from the Army. Three years later, at age 24, he was admitted to the medical ward of the first hospital because of a nephrotic syndrome. A liver biopsy revealed extensive deposition of amyloid. Roentgenograms of the gastrointestinal tract and small bowel revealed no abnormalities. There was no clinical evidence for rheumatoid ar-
292
February 198s The American Journal of Medicine
thritis and roentgenograms of the spine and sacroiliac joints gave no indication of ankylosing spondylitis. The creatinine clearance was normal, nonprotein nitrogen 20 mg/lOO ml, serum albumin 2 g/100 ml. No abnormal proteins were found on electrophoresis and immunoelectrophoresis of the serum and urine. Bone marrow examination disclosed no abnormalities. The patient was released from the hospital on a regimen of colchicine, 1 mg/day and diuretics, but his renal function deteriorated rapidly, and seven months later he was admitted for long-term hemodialysis treatment. Five months later, a cadaver renal transplantation was performed at the Sheba Medical Center, but the allograft was rejected and removed three weeks after the first operation. After the second operation, Pseudomonas aeruginosa septicemia developed and, despite massive antibiotic treatment, he died six weeks after the first operation. At autopsy, extensive amyloidosis of the kidneys, liver, spleen and blood vessels was found. There was no evidence of chronic infection, chronic inflammation, ulcerative colitis or regional enteritis, At the site of transplantation in the right iliac fossa, there was an acute abscess secondary to the surgical procedures performed during the last hospital admission.
SPECIAL
STUDIES
Extraction of Amyloid. Amyloid fibrils were extracted from liver and spleen by the water solubilization method of Pras et al. [2]. Purified fibrils were acid extracted as previously described [14], and the subunit was purified by G-75 column chromatography in 5M guanidine hydrochloride in 1M acetic acid [5]. Molecular weights and purity of protein fractions were determined
Volume 66
AA PROTEIN
by sodium dodecyl sulfate polyacrylamide disc and slab electrophoresis [15]. Amino acid analysis was performed on a Durrum D-500 automatic amino acid analyzer. Proteins were hydrolyzed under vacuum at 1lO’C for 20 hours in 6M hydrochloric acid containing 0.1 percent phenol to prevent destruction of tyrosine [16]. Amino acid sequence determinations were performed by the method of Edman and Begg [17] with a Beckman Model 890C sequencer as previously described by using the accelerated DMAA (dimethylallylamine-trifluoroacetic acid buffer) program. Each recovered amino acid was identified by gas and thin layer chromatography and by back hydrolysis with hydrochloric acid [18,19]. Both liver and spleen yielded large quantities of water-soluble amyloid fibrils; about 1 g (800 mg to 1,100 mg) of dry material for each 30 g of wet liver or spleen. Sodium dodecyl sulfate acrylamide gel electrophoresis of native fibrillar material showed the major protein constituent to have the same mobility as an AA protein [14][Figure 1). From 60 to 65 per cent of the amyloid fibril was recovered as a homogeneous component having a mobility similar to that of the AA protein [7,8]. There was no clinical or immunologic evidence of light chain related proteins. The amino acid sequence of Amino Acid Sequence. the liver AA protein was obtained for 57 steps, that of the spleen for 23. The amino acid sequences were:
IN AMYLOIDOSIS--PRAS
ET AL.
basis of these negative findings, this patient might be considered to have primary amyloidosis on purely clinical grounds. However, it is notable that he did not have marrow plasmacytosis and no involvement of heart, muscle, tongue or other organs frequently involved in primary amyloidosis. Until the present report, all amyloid fibrils derived from patients who suffered from primary amyloidosis yielded protein subunits related to immunoglobulin light chains and were designated as AL (amyloid light chain) proteins. Amyloid fibrils derived from patients who suffered from plasma cell dyscrasias also yielded AL proteins, except in one case of Waldenstrom’s macroglobulinemia reported by Husby et al. [z] in which a protein was found that demonstrated an amino acid content characteristic to an AA protein. Amino acid sequence studies were not performed in that case. The secondary form of the disease, associated with AA protein deposits, usually is found in association with an obvious and clinically apparent underlying disease, most often of an infectious, inflammatory or neoplastic nature and usually of long duration. The present finding of an AA protein as the major component of what might appear as primary amyloidosis suggests that it would be advisable whenever possible to supplement the clinical classification by a description of the chemical nature of the deposits. Thus,
1 10 Ser-Phe-Phe-Ser-Phe-Leu-Gly-Glu-Ala-Phe-Asp-Gly-Ala-Arg-
Liver Spleen
Arg/Ser-Phe-Phe-Ser-Phe-Leu-Gly-Glu-Ala-Phe-Asp-Gly-Ala-Arg-
Spleen
20 Asp-Met-Trp-Arg-Ala-Tyr-Ser-Asp-Met-Arg-Glu-Ala-Asn-TyrAsp-Met-Trp-Arg-Ala-Tyr-Ser-Asp-Met
Liver
30 Ile-Gly-Ser-Asp-Lys-Tyr-Phe-(
Liver
40
]-Ala-(
)-Gly-Asn-Tyr-Asp-
50
Liver ( ) = unidentified
Ala-Ala-Lys-(
)-Gly-Pro-Gly-Gly-Val-Trp-Ala-Ala-Glu-Ala-Ile
position
These sequences were identical to each other and to those of AA proteins previously published [7,8]. COMMENTS An AA protein appears to be the major subunit constituent of the amyloid fibrils of a young patient with amyloidosis in the absence of any predisposing disease clinically or at postmortem examination. Since physical examination and urinalysis of all his close relatives, including his mother and all his seven brothers and one sister, did not reveal any pathologic findings except a palpable spleen in two brothers, a frequent finding among Israelis of Yemenite extraction, a familial form of the disease appears unlikely. The father died at the age of 67 from carcinoma of the prostate. Thus, on the
amyloidosis should be designated as hereditary when there is evidence for genetic transmission with a statement of the type of deposit when known, acquired or secondary when a predisposing disease is found, myeloma associated and by tradition primary in the presence of a plasmacellular or lymphoid neoplasm and/or monoclonal proteins, and idiopathic when none of the aforegoing is established. The chemical nature of the amyloid subunit, i.e., AA protein, AL protein, or prealbumin and perhaps others, should then be added to complete the description especially in instances of the idiopathic type [21]. In patients without an obvious underlying disease, the term “primary amyloidosis” might be limited, because of tradition to patients with overt or latent plasma cell
February 1980
The American Journal of Medicine
Volume 68
293
AA PROTEIN IN AMYLOIDOSIS-PRAS
ET AL
dyscrasias associated with the production of AL proteins. A patient, such as the one described herein, should preferably be referred to as idiopathic AA amyloid to avoid confusion with the classic “primary” type. An unusual feature, which may perhaps provide a hint as to the chemical type of the amyloid protein, is related to the clinical features of the disease. Most patients with amyloidosis related to AA protein present with the nephrotic syndrome, often associated with hepatosplenomegaly, whereas amyloidosis related to AL protein, results, in addition, or exclusively in cardiopathy, ma-
croglossia or progressive enlargement of the liver [4]. The extremely rapid progression of the renal failure seen in this patient is not a characteristic feature of nephropathic amyloidosis in secondary amyloidosis and in familial Mediterranean fever in which the course of progression from a nephrotic syndrome to renal failure is often a matter of several years rather than five months. Perhaps this. type of amyloidosis may be recognized more frequently in the future as more careful analyses of the deposits are carried out either biochemically or by immunofluorescence.
REFERENCES 1. RokitanskyC: Handbuch der pathologisthen Anatomie, vol 2. 3. 4. 5. 6. 7.
8. 9.
10.
11.
294
3, Braumuller and Seidel, Vienna, 1842, p 311. Pras M, Schubert M, Zucker-Franklin D, et al.: The characterization of soluble amyloid prepared in water. ] Clin Invest 47: 925,1968. Cohen AS, Franklin EC, Glenner GG, et al.: Nomenclature, Amyloidosis, (Wegelius 0, Pasternak A, eds), New York, Academic Press, 1976, p 9. Pras M, Gafni J: The nature of amyloid. Immunochemistry. 1978. (Glynn EG, Steward M, eds), London, John Wiley & Sons Publishing Co., p 509. Glenner GG, Terry W, Harada M, et al.: Amyloid fibril proteins: proof of homology with immunoglobulin light chains by sequence analyses. Science 172: 1150,197l. Kimura S, Guyer R, Terry WD, et al.: Chemical evidence for X-type amyloid fibril proteins. J ImmunollO9: 891,1972. Benditt EP, Eriksen N, Hermodson MA, et al.: The major proteins of human and monkey substance: Common properties including unusual N-terminal amino acid sequences. Febs Lett 19: 169,197l. Levin M, Franklin EC, Frangione B, et al.: The amino acid sequence of a major non-immunoglobulin component of some amyloid fibrils. J Clin Invest 51: 2773.1972. Skinner M, et al.: Isolation and identification by sequence analysis of experimentally induced guinea pig amyloid fibrils. J Exp Med 140: 871, 1974. Husby G, Natvig JB, Sletten K. et al.: An experimental model in mink for studying the relation between amyloid and fibril protein AA and the related protein SAA. Stand J Immunol4: 811,1975. Gorevic PD. Greenwald M, Frangione B, et al.: The amino
February 1980 The American Journal of Medicine
‘12. 13. 14. 15. 16. 17. 18. ‘19.
20. 21.
acid sequence of duck amyloid A (AA] protein. J Immunol 118: 1113,1977. Skinner M, Shirahama T, Benson MD, et al.: Murine amyloid protein AA in casein-induced experimental amyloidosis. Lab Invest 36: 420,1977. Franklin EC, Calkins E: Amyloidosis. Immunological Diseases, vol II, 3rd ed, (Samter M, ed), Boston, Little. Brown & Co, 1978, p 1158. Pras M. Reshef T: The acid soluble fraction of amyloid. A fibrilformin protein. Biochim Biophys Acta 271: 193, 1972. Weber K, Osborn M: The reliability of molecular weight determination of dodecyl-sulfate polyacrylamide gel electronhoresis. I Biol Chem 244: 4406.1969. Sanger F: Thompson EOP: Halogenation of tyrosine during acid hvdrolvsis. Biochim Bionhvs Acta 71: 468. 1936. Edman P, Be&G: A protein sequenator. Eur J B&hem 1: 80, 1967. Pisano JJ. Bronzert TJ: Analysis of amino acid phenylthiohydantoins by gas chromatography. J Biol Chem 244: 5597, 1969. Summers MR. Smvthers GW, Orozzlan S: Thin-laver chromatography of sub-nanomole amounts of phenylthiohydantoin (PTHI amino acids on oolvamide sheets. Anal Biol . I Chem 53: 624; 1973. Husby G, Sletten K. Michaelsen TE, et al.: Amino acid analysis of AA in macroglobulinemia. Stand J Immunol 2: 395. 1973. Costa PP. Figueira AS, Bravo FR: Amyloid fibril protein related to prealbumin and familial amyloidotic polyneuropathy. Proc Nat1 Acad Sci 75: 4499, 1978.
Volume 68