Familial amyloidotic polyneuropathy type 1 in Kumamoto, Japan: A clinicopathologic, histochemical, immunohistochemical, and ultrastructural study

Familial Amyloidotic Polyneuropathy Type 1 in Kumamoto, Japan: A Clinicopathologic, Histochemical, Immunohistochemical, ancl Ultrastructural Study KIYOSHI TAKAHASHI, MD, SHIGEHIRO YI, MD, YOSHIHIRO KIMUW MD, AND SHUKURO ARAKI, MD Seventeen alutopsy and five biopsy cases of familial amyloidotic polyneuropathy were examined clinicopathologically, histochemically.. immunohistochemically, and ultrastructurally. In the autopsy cases, amyloid deposits were predominant in the peripheral n’erve tissues, autonomic nervous system, choroid plexus, cardiovascular system, and kidneys. Amyloid involvements in the anterior and posterior roots of the spinal cord, spinal ganglia, thyroid, and gastrointestinal tract were also frequent. In the cardiac conduction system, amyloid deposition was prominent in the sinoatrial node and in limbs of the intraventricular bundle. In the sural nerve biopsy, besides amyloid deposits, degenerative changes of nerve fibers and Schwann cells were detected ultrahstructurally, and the morphometric analysis showed a marked reduction in the number of myelinated fibers which correlated witlh the clinical stage. Amyloid deposits were resistant to pretreatment with potassium permanganate in Congo red staining, and transthyretin was confirmed immunohistochemically as a major component of amyloid deposits, along with the presence of serum amyloid P-component. Besides the amyloid deposits, transthyretin was proven in the liver cells, epithelial cells of the choroid plexus, and pancreatic islet A cells, suggesting that the transthyretin produced by these cells is secreted, transferred into tissues, amd deposited in situ as the major component of amyloid in this disorder. HUM PATHOL 22:519-527. Copyright P 1991 by W.B. Saunders Company

Fam.ilial amvloidotic polyneut-oph, (FM’) is ;I heredohmilial Gnyloidosis transmitted In ;tutosotn;il dotninant trait, occurring in middle age, and charw terized 1,~ scnsorv-dominant polvnettropthv, autonomic dvsf’unc.tiot~, cardiac arrhvthmia. c~~t-tl~nc conduction &st url~atices, and emaciation. Sine e its first description hv Andrade in 1952 in Portugal.’ this disorder has I&en reported in Sweden, the United and other countries.‘)-” XrStates, I~inlatici. Japan, cording to differences in clinical tnanif’est;ition, the previously wpot-fed cases are classif’ied into four clitiical typt’s: t\ pt’ 1 (Andrade type). ‘yIx 2 (Kukavina type), t,pe 3 (\;iti Allen type), and type -1 (hleretoja type).“-x ‘I‘\,lw I ha been reported itt Portitgal, Swe-

den, .JaIxut, :IIKI the Llnited Sta(e\. III ,J;tpan. largr tatnilv prdiqrecs of’ this disease were reported in Kutnanioto anal Sagan0 pretec~ture5.i Rtt Kutiiittnot~~ prefecture. there are ovet- 76 patiettts kttth F/41’ within SCLW fAtnilies in Atxo C:it\,.; Kcvxmt biochetnical studies havr elucidated that the ;intvloid precursor protein is ;i v;ttktnt trattsthyrrtiti (‘I “I‘K: prealhuniiti) \vith ;I single amitto acid suhstitutioti of saline hb niethionine at the 30th portion ot the ;ttnino acid sequence of tiornial ‘I“I‘K.!’ Besidrs thi5, ais other wriant .I“I‘Ks. each with a different singlr artiitto acid suhstitutioti. at-c ktuwtl to I)e ;I tnajor c~omponetlt of atn\loid fihi-il4 itt FAP and iti svttile cardiacan~~loidosis. I” ‘I‘hus. the classificatiott ~)f this di~ordet is lkssihle ;tt the genr level.‘” Pathologic- studies of :tiitops~~ LISTS of k Al’ were SM eden, Finl,itid, and the reported iti Pot.1 itgal. LTtiitetl States. and showetl gentxtli~c~ti amvloid deposition in v;trious organs antl tissues. pr~iculat-l\; in the peripheral nerve tissttcs. hr,tt-t. ‘itid kidneys.“-‘.’ ‘-lti Although ani\-loid in~olvetnents in the peripheral nerve tissues antI ;trttottoniic nervous svsletn have bw~ itivestigatetl in tn;iti\ autopsv c;ist’s (,f FA~p*17-‘” Ixttholo~gic studies of ;itrt~~loid deposition in the cxt-dix cottduction system arc few.“’ III J:ipatitw casei OF FA V, there is no detailetl \\ steltiic, strtd\ < ;lscs.t~*~2:-) cscepr f;,t- t\Yo I‘el’o”‘” c,t 2 fwi ;tltt(rpS!’ Furthrr. no tictailed iti~m~tt~ohisto~hentic~~il studies on the relatiottship Iwtweeti atnrloitl deposition anti production of \ atktnt huntan rix haIe ken reported in varioits tissues of atitopw cast5 1)1 the disease. Iti a prelitnitiat~~ stud\., wc wported the pathologic findings ot’ nine :tutops\ (xelr of F.-\I’ T’ In this paper. WC tlescrilw the ~lini~oI>;ttllolo~i~~, histochvmiattd rtltr;.t~tt~itctur~il fe;tcal, ittttiiit~tohisto~~~etiii~~il, riires of’ I7 ;tutopsv cases. In pat-tic~itlat-, be itiwstigated ann~loitl deposition in ;ttt(l pathologic. changes of the vat-diat conduction systent in II’ ot these axes to clarify thr pathogenesis of c-at-disc (ondwtion disturban&s. CVr also perfornwd siiral ttcbrve Ikpsies in tice other cases I0 esxnint~ the occurrtmce of atn~loid deposition in the nerve tissues. Based on the results of our stud\., we discuss the possible ntec:hanistn of’ atrtyloid deposition in mt-ious tissues of t\pe 1 FAP. MATERIALS AND METHODS

HUMANPATHOLOGY

Volume 22, No. 6 [June 1991) Con, the Ilear-ts were C‘LI~ and their cardiac- conduction bvsWm was examir~ed ac-corcling to the methods of’ Lev et aj” md Ht~fson.~” Briefly, approximately IO tissue blocks, it)&cling rhe sinoatri;ll nocle, were cut f’rom the upper part of’ the crista terminalis otthe right atrium; those including the atrioventrirular node ancl H’is’ hundle were obtained f’rom the ~~trioventricula~. septum. These blocks were embedded in paraffin, and paraffin blocks were serially sectioned 5-k thick and stained with hematox~lin-ec,sin. (:ongo I-ed, OI Azan stain. For ~elnic~Lr;intitati~,e investigation of. the sural nerve tissues in biops!. cases. sum1 nerve tissues processed toi elec-tron microscopy were examined. Semithin sections were prepared f’rom the E:pon-elnt)edded biopsy materials, stained with 0.05’J toluidine hItIe. and obszrved light microscopic:tll~. After t;tking Inicrop~lotogI.~~f~t~s at a magnification of. about W-fiJld. the numhet- of‘ mvelinated fibers per 1 mml) was cauntetl and ;I histogram oi‘ fiber distribution was made. ItI Iwo biopsy cases, ;I nerve fiber teasing study W;I\ performed. For comparison. sural nelves were ohtamed f’rotn thI’e? autopsv cases (Jfsudden death without metabolic or svstemic. diseases.

where the heart alone was examined. In IL’ cases. the cardiac contfuc~ion system wits investigated systenia&Aly. Peripheral nerve tissues were examined in all bum one of‘ the autopsy cases. and sural nerve biopsies were performed in five cases. Tissue specimens harvesled f1-om the organs and tissues were fixed in 10% neutral formalin and embedded in paraffin. Besides routine histologic examination, paraffin sections were stained with Congo red after or without potassium permanganate treatment according to Wright’s method. After (:ongo red staining, the sections were observed with a polarization microscope to confirm an enie~.aid green birefringenc-e in the amyloid deposits. In some sections. Azan, Bodian, Klue\~er-Barrera* or Masson trichrome stainings were pertiJrmed. For demonstr_aGon of’;m~yloicl fibril IJroteins, formalinfixed tissue specimens were embedded in p;traf’fin. and paraffin sections were stained with the peroxidase-antiperoxidase 1nethod using anti-human ‘1‘7.K antibody (Behringwerke, Marburg. Germany), anti-human serum amyloid .4 (SAA) antibody (Dako, Santa Barbara. CA). or anti-human immunoglobuhn amyloid (AL) antibody. ‘1’0 detect serum amyloid P-component (SAP), we used anti-human SAP antibody (Dako). For electron microscopy, tissues were cut into small blocks which were then fixed in chilled 2.5% glutaraldehyde for 2 hours. After washing with a c:acocl~:late buffer solution. small blocks were post fixed in 1% osmium tetroxide for 2 hours, dehydrated through a graded series of ethanols and propylene oxide, and embeclded in Upon X 12. Ultrathin sections were cut by an ultrot(Jme Nova (LKB, Uppsala, Sweden) and observed in a_lEM 2,OOOEX electron microscope UEOL, Tokyo, japan) afier staining with ura nvl acetate and leacl citrate. For histologic and histochemical examin;Aon of’ the cardiac conduction system, afier thorough fin-malin fixaTABLE 1.

RESULTS Clinicopathologic Subjects ‘l‘ahle 1 shows age at death. sex. age at onset of. disease. stage of disease at death or at biopsy. and pertinent ciinical manifestations. were 10 nwn antI seven wornen;

1

Death or- Biups)

YX

(:lirlical

Sex

onset

stage

I’NI)

AN 1)

$1

33

II

++

+++

+

III I\’ I\, I\ IV IV IL’ IL’

+++ +++ +++ +++ +++ +++ +++ +++

+++ +++ +++ +++ +++ +++ +++ +++

t +

11’ I\: IV I\’ I\’ I\: IV I\’

+++ +++ +++ +++ +++ +++ +++ +++ ++ ++ t+ ++ ++

+++ +++ +++ +++ +++ +++ +++ +++ ++ ++ ++ ++ ++

hi 6 F F

8 0

10 II 12 13 14 I .i

4x 3X 53

47 44 36

cases

Subject\

Age at

M 21

L’

autopsy

Clinical Subjects of 17 Autopsy and Five Biopsy Cases of Type 1 Familial Amyloidotic Polyneuropathy

Age at C&e No.

‘I‘he

age at death varied I’ronn 35 to 56 years (rnem, 43.9 years). Accclrtling to the classification of‘clinical stage proposed by Araki,?” most of the ;lutopsy cases were in the terminal stage

II II II 111

OI1

NOTE: Cases “CJ. 1-l i were aLltop GISTS: cases 110. 1% 22 were biol+ caseh. Symbols: ~, absent; +, slight; + +, moderate; + + +, marked. Abbreviations: PND, peripheral nervous disturbances: AND, autonomic ~ler\ou.\ atrioventricular block: (W). M’enckrbach: (M), IMobitr; SSS. sick sinus svndromc.

520

E:le~t~orat.dio#ranr

_ + +

+ +

disturbances;

OH,

orthostatic

hcputrnsion:

.-\VB.

FAMILIAL AMYLOIDOTIC POLYNEUROPATW TYPE 1 vakahashi et al]

(\ta#r I\‘) ,it ilc~ith. hut the clinical stage of the hiops\ (zxs v;irictl lro111stages I to III. All thy GISCSshout4 lwriphrr;tl 11t’i.vt’tlistllrtxiric.es 01’ both eslreniities ,ttiil :iutiitIoI1lii t1erw ilisturlx1i1crs. Orthost~ttk hviiiitl ;i~)nol.niiilitieh ~~otrnsion \z’;I~ t’o11Iiil iii l,l c;1ses. on ~lei~troc;r~~tlio~:r;~~~~ wzw ~lti.io\.criti.icul~iI. I)lo~E; iI1 I -I ~xst’s: low voI~+gc sinus

hr;i(l\(

in ti)11r

;iritI;i.

or

i ;ISYS: 21iil i,iindlr

GISCS;

sick

hrmc

sinus

sinus

;1rrh\.thIIIi:1,

ayI~droIi~r.

.iIi

fi\,r

h bloc-k

iI1 ;M.Oc‘;Isc’s. AI1 thr I)resrIit ~x~5 ;II‘C tr01Ii wvfw t’;imilics living iti ,413o (:itv. li~~n~iin~oto.,];itx1ii. E’igurr 1 shows ;I 1;1Iniiy pailiq-vr ot. t he most rq~rescnt:itive C‘;ws of. F.L\l’. iric4Lrd;iIi ;111tosonial ing ais ;tlitc)J)x\ c:ist3. and indicates iloniiIi~1tit

Amyloid Deposition and Associated Change:; in the Autopsy Cases ‘1’;ihlt~L’shokx the cte,qrw i~i \,;iric,Lb or~:;iris ;IIIct tissuw. A.4 ~,ill bc tion

expmdetl

tieposit

I)\

srctioIIs

.II~ rnwi-;tlct

tions

with

Ioiil itqx~sition

heloru.

dir

light.

(:ongo

In the

1\‘15 proniinwt

t)rtfwritc

115 ;i posilivr rect

I)irrt’riIiqnCc

,gpw~

in ~)ol;1ri7c:ct

ctq~ositioI1

upon

Pathologic

ot’ ;iIii\

&ttwnirIed

\%.‘itS

iII p.1ixtfiii

in

aiitopsv

in

the

ot wx-

staitii1ig. the

4;1tIie

C;~xs.

md

t tic ;ttlVt:ntiti;i,

niore

\yr\

w-

~\;Is n~;trkrd III

hc;irc

#) :tritl

\veighPtt sliowect

IL’ c;~st’s 4iiiI

iIi

t’roni slight

q to

the

~valls

h\twrtroph\ 2triuIii

right

(xsc.4.

1,111 IIO \;11\:111;1r ;1tIIioI-Inalitits

or

I-o&.

.Amvloicl

d

ctepositetl

h;15ceil

proIi~inentlv

c.ir~tI*lIfreIlti~illV

iii

i 0roii;irv in ttic or

1-I

si-leinvoi‘;1I~-

~);1rti;Ill)

;Iil\,:Iititi.1

loss.

iInp;Irtin~

ot. sin;111

the

picture

of‘;iIn(~loid

or

pwtlv

in

hut

‘in two

ilt Ihc

tht’

;ilso

showed

Iiiort

slight

III<, 1~i~II~o;~in;lI c;1st5

pancrwtic.

ile-

01

itt’position

intrr\IiIi1lm.

tIx3

I;1\-Cl. ;1ntl

ik:posiIioIi

i1rC,llll~l

Iti the stii;ill iiitestilies.

~ini~loid

the

ni~~~x~s;~c.

I;iIiliri:1

wlls

\‘;15i irl,ir

. ;iiiI~~loiit clt.l)osits wi-e stagr i2sek I ri t Iie tw)phapls

:1liIIItwI;tr\.

intisi-ularis

;1t’ltsc7rtl

I,v ;ini\:loicl

Ijosits \\‘r‘i-e swii thr iI1lrrstiti111ii,

l~looct

histologic

ainyloict

islrts,

s1lhIlllllolIs

v,we

iIi

\,essvls. ~x~rliwl;ci-I\ ill :irtt’i-ks. (:oin~xiiwt with thy iteef~ ;irea of the In\oc,arttiunl. ;iitl\,loid tttq)osits werr nlore niarkrtt kwath the s~ll,ndoc~~rtli~tl layer (Fig L’),where the ill\ocartlial c.ells showed degeneration. atroph\,. ;1nd &II rhy

w;14

:trItl

thy

0(~.11rwd

ll1lIsl~L1l;ir

itrposItt4

in

L1~t3-s.

ttitt‘riselv

iti

III tlit’ splr~ii. ;iIIi~~loid ilcfwsits \vt’re olxrwct sf)oi-;iitic-:tll\ :~routicl the tr:~hec~ks. sli$rl>, iii thy wxlls 01’ thy cwitixl ;irleries. :~iiil h;irtll! ;It AI iii the red l)iilp. kiowt~vr, there w;is little an)> Ioicl clq~osition iti the Iyiiif~h iiotlt5 :kn(t hone iii;irrob. 111the kictntys. ;tniyloi
(i(H) g (nle~ln.

of

the

,litIni

ilil~1tatioIi

“50

to mottktr

I;1\t~r

ni~ic~osal

Iii;1rkrtl in t ht. trrriiiri~d and sl~~ii;~~ h. \;ISC 11l;ir aIii\loitt

;iriivloicl ileposIts w3.e t0wd tn;~rl\t~llv iii thr st~l-I-0dillg ~01mw ti\,r tissws at~cl in thv sni:~ll wssvl wk ;iiiit the iI)tini;i wx in\, ~l\,erl a~~oI-;idii~~ill~~. ‘1%~

slighIl\

l.;Ii;~:t’I~h;iiiS

ot ~irtcrks th:iii ot krins. In the aorL1.

+07.:3

hroric-hi.

;11-011~~tl the

;IIiit

;inivloiit

in the

clqx~sitiori

s11heIicto~ardi~1l

gl;i11&. Ioitl ctqosit\ o( t llr-rcit in the III the li\rr , a1111 \v& cbt sni;ill xi-trrics in C;lisson’s 5he;lt h:, biit I1oI ill rlic wills ot thtx l)ort;~l, htyttic, or 1cntl .11vcilis; in the siiiusoict; xrorliiil the Me it1IiTs: ;rtiil .II~~IIII~~ the est txhep;1ticbili;ir\ trx~t. Iii thr ~;illhl;~tlil~r. :innvloiil clt.f)osits 1vc’i.et’oliIid only in thv falls of SIIMII ;1rtt’rit’s. ilepositett It1 t ht. /,;iiic.rc:itic. Ixiren~h! in;1. a~n~loiil

~;1I~ttio~~1ac~11l~1r h\s-

iiI;1rkrctl\

, ;iInyloitl

~iicloi~;1I-tliuI~I in the

;ciitl

tixhci

kidnc\5. thvi-oict. :iIitl c~horoiil pksua. Iii the ixctio\xcxrlar \\‘stvnl , ;inlvloi(l deposits \vt’r~ ol~ser\~eit l”-r(loIiiiilanrl\ in the walls ot’ sIii;ill :irterirs, p;irtic-11ii1

IIi:irkect

t’rqurnt iii the IiiitIxl aiiit tric rbt)iil v:tlvea. In th( Iwtk1rctiunl. ;itnvloicl clqx)sits 5vvrc ftwrxt t’requrntl\ in thv ;idiyw tissues of‘ thr riglir ,ilriirIn. ii) rhe AUlonoti~ii nei vv I)llndles xnd g:iligli;i, ;ili(t iii rhv w:ills ot. sixill hlooit \ rssels. Ii~volvt7nt~iit iii tht, cxrtli;tc, ix)n(lwtio~i svstenl is tlesixilwt Iwlow. -l.llr ilr~rev ot wrtliai, ;tin\ l;,itt dq)ositiori (-orwl:itetl Iv41 kvith the cliiiical st;lyy. 111the 11111~:s. ;iniyloitl tltyb5its wart infrtxjwnt ii1 thv ~;1si~1tl~ii ~\xlls and iii t hr ;tl~rola~ hAIs. In Ihe

itwi,

larl~

L’). I ii t Ire

niore

positiII3

iIih~rit~1Iiie.

.11llrloict

( Fig

ilepositicttl.

ttit’f’usely

;1rouI1it

p:1rtic11l;trly

itI

;1rtil 2nivloitl thch t1Il)ul& Ihr.

!-tw:tl

(It>-

ii)

and

mtxl11lla.

I Iowevei~, amyloid i~ivoIvt~tIieI~l ili thr I twk1l @vis wx Ji+t, In Itlr ilriIi;try Matlilei-, \~;ksc-kw ,ind interstitial ;t~nvloiil tlt’fx~sitioii LYIS toi~nil. Also in the IllerLis antl ov;irirs, \ ;iscxll:tr ;un\,loid tlq~ositioib w;is ohservett.

rings

p;irtic Ioid

ularl\~ 111 thr

thr

nixkect

ileposition thykl

in 1\vo

w;is

very

ctidoi~ririe glwct

c‘xt’s.

slight

ors:ins, w;is

marktxt

hut

t estic 11l:ir :1IIly-

in Inoat ~xscs. ~iiii~loid iIivolveIne11t

in

iI; AI t)i11 0IIe

it

cxw:

occiti-reti I)i-“to”iinantl~~ in thr. iIrrc~i.t‘ollicul~ll-re+ons. blit ilot within the follicles. :\rollnd the xlren:kl $lncls. ;tmvloid tkpositecl it1 tht ;idifx)se tissues 01 small vaswl:tr wall. but Iiot iii the .itlrenal pnrenc.hvm;i. ‘l‘hv t>ituitary $antts !vt~c’ It35 involved. I II the

f

*r’yg

‘I*&&‘_;!T, 11

16

;

protninent

llerVl)lls in the

systetn. peripheral

;11iivloitl nek~~

ctepositioII tissues

such

wi1s x

the

si.ixtic. ;lntt sulal I~cI-L’~~, irx the 5l)inxl ~;~n#ia. 2nd iii the aIjter_ior and twsterior roots of the sl)in:il cold. ‘l‘he degrre of kimyloicl detx)sitii,ri it,i the fx3ipheral nent tisstres correlate
FIGURE 1. A family pedigree of the representative cases of FAP including SIXautopsy cases. Symbols are as follows: circles, females; squares, males, n, 0 affected with FAP; ti, F suspected of FAP. A slashed symbol indicates that the individual died; an asterisk Indicates autopsy cases. The number below the autopsy cases Indicates the autopsy (case no. used in the present study

deposition

521

in thr

posterior

r01\t \+a

r~tu;d

lo ()I-

IIlol‘e

HUMANPATHOLOGY 2.

TABLE

Heart Aorta Lungs Alveoli Interstitium Trachea Liver Lobule P&portal Gallbladder Spleen Trabecle Pancreas Kidneys Cortex Medulla Urinarv bladder Adrenals Thvroid Esdphagus Stomach Intestines Lymph nodes Bone marrow Uterus Ovaries Prostate Testis Grebrum Cerebellum Arachnoid membrane Choroid pkXUS

Spinal cord Anterior root Posterior root Spinal ganglion Sciatic nerve Sural nerve Automonic nerve

Degree of Amyloid Deposition in Various Organs and Tissues of 17 Autopsy Cases of Type 1 Familial Amyloidotic Polyneuropathy

:!t

2t It

“t ?t

3t I+

2+

Cl+

2-t

3t It

1+

ND ND KD

I+ 0t SD

1t Of If

It ot ND

0t ND

If It

Volume 22, No. 6 (June 1991)

:It It

L't

3t

St

It

2+

0t

1t It If

IIt

It

0t It It

0+

It It

If It

It It

_ 0+ ot

I)f ND

IIt ot

ot If

2t

3t

0t

It

_ 0t

0t

3t It

L't It

“t

0t ot It

IIt ot If

Of I+ It

I)t It

Ibt It

_ ot It

I+

?t 1-t

3t 0t

Of ot

Iit It

It

It

0+ ND

0t I+

ot

ND rin ND

0t 0t

0t 0t

o+ 0+

Of ND

II+ ND

_ ot 0t

0+ 0+

ND ND

0t If

0+ ND

If 2+

1t ND

1t ‘Lt

It It

It If

"t It

L't I+

If It

It 3t

“t L't

(I+ I+

Of 0+

"t 2t

“t

XI) ND

“t

"t ?t

"t It

ot o+

3t

2t If

L't It

3t "t

3t "t

3t 3+

3t L'+

3t L'+

If "t

It L't

It "i

It 0t "+ 0t It It (It ND 0t 0t / / _

ND 0t "t 0t ot 0+ It ND / / (It 0t _

0t

"t 0t 3t If I+ It Of I)+ 2t 2t I / _

1t 0t L't ot I+ It 0+ o+ o+ I)t /

I+ ot L't Of It It ot IIt L't 2+ / / _ _

N 1) IIt 3t It I+ It SD ot

ND Of L't It "t It 0+ ot ND ND

ND It 3t I-t It If ND ot L't "t

"t It 3t If 1t If Of KD

L't 0t L't ot I+ It

It 0t :it ot It ot I)f

II+ 0+ XI) ND

If 1-t 3+ 0+ It If It 0t / ! 0t ot

I’+ o+ Xl) SD

; ot ot ND IiD

?f It 3t If It It IJt o+ / / Ilf 0t ND ND

ND

ND

0+

If

2t

If

If ut :‘+ ot 0+ 1+ 0+ _ / / 0+ lJ+ ND ND

SD ND ND ND ND h‘D ND T\‘D /

ND 0+ 3t 0+ 0t 0-t 0t ND i

ND ND IiD ND

O+ ot _

ND

ND

It

I+

I+

ND

It

1+

It

ND _

3t _ ?+ It

3+

"t

If

It L't

3t 3t

ND ND ND ND

"t

0+

ND ND ND ND

ND It

IiD I+ 2t

ND ND It

iiD "t 0t

3t ND ?+

ND ND tiD

ND ND ND

L’+

“t

2+

3+

5t

ND

NOTE: amvloid deposition: -. absent; marked). Abbreviation: ND, not examined.

0 t , vascular

0t It 0-t 0t I+ 0+ ot 0t (It i / ND KD

0-t IIt I

_

ND KD

/ ND ND

ND ND ND SD

ND

L'+

ND

ND

ND

ND

ED N 1) KD ND

"t

2+ 3t

It _ "t ??-

"t "t

ND KD ND ND

ND ND ND NL)

ND ND ND ND

ND ND ND SD

ND ND 1t

3t 3t 3t

3t 3t 3-t

nu ND "t

3t 3+ 3+

SD ND "t

ND ixD N I)

ND 3t 3t

ND 3t 3t

2t ND L't

?t

3t

3t

"t

3t

ND

ND

3t

L’t

L't

wallonly;It

to :i t

both vasc&~r

wall and cxtravasudar

region

(1 t , slight;

SD SD KD ND

L’t , moderate:

3+

FIGURE 2. Case no. 10. Amyloid deposition is marked in the subendocardiol layer of the heart Arrows indicate the histologic picture of amyloid rings, [a: Congo red stain; b: polarized light: magnification x 50.)

FAMILIAL AMYLOIDOTIC POLYNEUROPATHY TYPE 1 uakahashi et (II)

FIGURE 3. Case no. 11. Amvlold deDosited markedlv in the sural nerve emits a clear emerald-green blrefringence in polarized light [a: Congo red stair,, b polarize; Ilght; magnification L i3.)

protninetit thlr tliat iI1 the anterior root. In thr sural stkttic. Iwrvt~h, Iwsitlrs iasdar deposition, amymark4 in the entloneu1-ium and Ioitl deposits wei7 or epineuriuIn in the twencled to t tic perineuriutn ;~ct\;ancrd (;isc4 (Fis 3). ‘I‘hr \agal nerws sho~ved niasc-hanges. In si1.r amvloiti cteposit~ 2nd degenerative tile cen;r;Il IIC’ITOII~ \\~~trIn. there wrc no amvloid deposits ill tile I,rain ‘parvnch~ma aid spinal Cord: howe~rr. ;mi\ Ioid deposition was Inarketi in the walls of small hlootl vt3sels or in the loose connwtive tissue In the choroitl plexus. of thy arachrroid mtmlxanc. fwsitles wscular clepositiorl , ;tmyloiti tieposit~d partkIII~I-Iv iii the rdeniatous sti-omil connt’ctiw tissue. 111 t tw &ntricks of the cwd~runl , am\-loid tieposition wac \w~’ dight iri the ependynial 01‘ sulqenclvni;d Liver.

arId

Histochemical and Immunohistochemical

Findings

After trcatmcwt bvith potassium pernianganatt amyloiti deposit5 ,tccoIding to \1’right’s method. rn;tint;iiiled 2 Iwsitivt I~tZi1(~tiOIl in (k)tlp) red stain ;tlld rwiittecl ..ui emerald green I,iref’ringence in polariretl light. In all the autops> arid biopsy cases. the xiiyloiti deposits 4howetl immunoi-eacti~it~ with aiti-hiInian 1”l‘K (Fig -I) and anti-hunian SAP antibodks hut not with ant I-hIIInaIi SAA antihoclv. In three uses exanmed. hmvever, ;IIiivloid tlepkits were not ininlunostained I,vitli anti-Ii~Inian AL. antil~otlv. In all autops!- cases, as we II as iII the three control c;iws without amvloiti deposition. ‘I“I‘K was detected in the liar c,ells, epithelial c-ells of the choroid pIesus, and in the :\ c-ells of‘ the pancreatic idets.

in the linil)s of the hunclle ~\xs \ ari;itde iit the site of the ventric.les. 111 the se~~ei-cl\ insolwtl lesions, the nod;~l cells or l’nrkinjv fibers showetl atrophy,. degenand cell lc,ss, exhibitins ;t picttlre of ;III am\rration. fifwosis \vas nlarkecl in both loid rin$. In ;I ftw cases, limbs of the l~untlle, hut in most cwa it was alight. ;!roiIIi(t ttic siIio~Itri;Il and ;itriov~~tit~~i~ ula~ nodes. nIoder;ite to Inal-kcct ani) loitl deposition was ol)vr\,etl in the autonomic Iiervc l)iIIicllt~s or ganglia. \\ hich ;IlSO sllo\vtd OCGtSiOIliIl aSc111;1l loss. Amyloid Deposition in the Sural Nerve in the Biopsy Cases Iii sliglitl~~ in\ol\~ed sur;d iit’i VC‘S.atiiyloitl tleposits kverc ol~~w2d in the 5niall \ esscl wall ant1 its surrounding tissue (Fis 5). In inore ;idvatIc-ed cases. the tl~posits weI-e also fc~uncl iii the sIIlyrr_ineural md/or epineural I-cgions. Iii all these rc;gioIIs, cliIsters of ;IIti\~loid f’ihcrs consistinhr 01. anicloIcl f’ihrils 7.5 to 10 tini in clianirt~l- and piId\ extrntling to the intersti-

Histologic Changes of the Cardiac Conduction System III 211 12 c.:tses ~xaniineti, aniyloid deposition was found iii the cardiac conduction s\atenl, and it was in the sinoatr-ial node’ancl in both limbs more m1rkcci of’ the’ intl.~~\~entricular hurdle than in the atrioventricular 11ode and His’ hundIe. Amvloid iIrvolvenlent

FIGURE 4. Case no. 4. lmmunohlstochemlcal demonstration of TTR In amyloid deposits in the renal glomerull and in the wall of blood vessels in the renal interstitium. (Peroxidase-antiperoxidase method with anti-human TTR antibody; magnification 6 33.)

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Volume 22, No. 6 (June 1991)

FIGURE 5. Ultrastructure of the sural nerve biopsy specimen from case no. 18. showing amyloid deposition (A) in the vascular wall (VJ and perivascular region.

tium were detected ultrastructurally, but there was no amyloid deposition in the nerve tissues distant from the vessels. In almost all the biopsy cases, the number of myelinated nerve fibers decreased, even in stage I cases, and they disappeared with the progress of clinical stage, accompanied by an increased number of collagen fibers. The remaming myelinated nerve fibers revealed whorled changes. swelling, destruction, or disruption of the myelin sheath. Unmyelinated nerve fibers decreased markedly, showing degenerative changes together with the regressive changes of Schwann cells. These degenerative changes of the axon, myelin sheath, and Schwann cells, the decrease in myelinated nerve fibers, and the increase in colla-

gen fibers paralleled the severity of the patient’s peripheral nerve disturbances. In two biopsy cases, a nerve fiber teasing study revealed axonal degeneration and segmental demyelination in the sural nerve biopsies. Figure 6 shows the morphometric data on the number and caliber of myelinated fibers in the sural nerve biopsy of five cases. Compared with the three controls, the number of myelinated fibers decreased moderately in one case (stage I), showing a greater reduction of small-calibered fibers than largecalibered ones. In the more advanced cases (stages II and III), the number of myelinated fibers had decreased further.

FIGURE 6. Density and histogram of myelinoted fibers with different diameters in the sural nerves from five biopsy cases.

FAMILIAL AMYLOIDOTIC POLYNEUROPATHY TYPE 1 (Takahashi et al)

DISCUSSION

destruction of myelin sheaths in large-c,ilibered mvelinated nerve fibers, axonal degeneration. degeneiative changes of’ Schwann cells .~ncl Ilnmychnated nerve fibers, or decreases in the Iluml)er of’ largecalibered myelinatecl fibers were reported to occur prior to aniyloid deposition in asynptoniatic patients in FAP. Ix In one biopsy case. we also observed similar degenerative charTees ‘in the sural nerves regardless of am\,loid tleposltIon. In addition. our nerve fiber teasing study of two biops> cases demonstrated axonal degeneration and/or segrnelltal myelination in the sural nerve biopsies. ‘l‘hese changes seem to be important f’or investigating the p”Ihogenesis of’ peripheral nerve disturbances in this disorder. Consistent with the data fr-om previous biochemical and genetic studies.i.“-“’ WI- immuIlohistochemical approach demonstrated the prt’sem‘e of’ l’TR in almost all the amyloid deposits in our autopsy and biopsy cases. ‘I‘llis ‘I‘TR u’.ds 1:xoc 1lemically demonstrated to be a variarlt T.1.R with a single amino acid substitution of valine by niethionine at l)osition 30 of the amino ac.id sequence of normal I“1 R.‘,” In most type 1 FAI’ patients. TI‘R circulating in l)lood is known to form tetramers.’ ivhich are supposed to be composed of four variant ‘I“FR subunits alone or both variant and normal T~I‘R subunits. ‘I‘ransthyretin isolated fiwni aniyloid deposits in tissues was, however, proven to he ;I tetramcr consisting of’ t&r identical variant ‘I‘-1-R subunits alone.“‘l‘heI-efi)re, it seems that only the variant .I‘TR can participate in amyloid formatlon in tissues. In our study, SAP was proven imniunohistochernically in amylo’id deposits as reported in previous studies of other human .imvloidosis or experimental am~loidosis.““-:‘I In agreement with the results of’ previous studies by imnlunohistochernistr~~‘” or in situ hybridization technique,:“’ we f;,und localization of“I”l‘R in the liver cells, epithelial cells of’the choroid plexus. and in the pancreatic islet A cells in the autops) cases of type 1 FLU’ as well as in the control cases. Among these cells. the major sites of’ TTR production arc’ known to be the liver cells and the epithelial cells of the choroitl plexus.:‘-* However, amvloid deposition did not occur in the liver of the FAt; autopsv cases except f’or arteries in Glisson’s sheaths. ‘I‘his is because variant ‘I’TR produced by the LiveI- cells is directly secretecl into blood, transferred into other tissues, and deposited in situ as a major component of’ amyloid fibrils.“’ ‘l‘his also explains angiocentric amyloid deposition in various visceral organs and tissues, particularly in the cardiovascular system, renal glomeruli. and interf’ollicular region of’ thr thyroid. In the choroid plexus, amyloid deposits were observed in the walls of small blood vessels and in the loose stromal connective tissue. ‘l‘hesr deposits are interpreted to be related to production of variant ‘I“I’R by the choroid plexus epithelial cells. Further, amvloid deposits were confirmed in the arachnoid membrane, which seems due to an increment of variant .l’TR in ccrebrospinal fluid of. patients with F;ZP.‘“’ Sinc.e it is known that the l)eriIleurium of pe-

‘l‘he present study has revealed marked an~yloid deposition in the carclwvascular system. kidtieys, peripheral and autoIiomic nerve tissues. choroid plexus, and thvroid of 17 autopsv cases of’ type 1 F.4P. The degree of‘ ani\ loid tleposiiion paralleled the progress of’ clinical sta+ in the crises. Comparing four clinical types of. FAP. our autopsy cases showed a pattern of amyloid deposition similar to the autopsv cases of ttpe 1 FAP occurring in Nagano, ‘!‘.‘l(land ;o those of. tvpe 1 FAP reported in Portugal and Sweden. with ;I few exceptions.Y-* ].I“ Most 1)atients with type 1 FAl’ manifest cardiat conduction disturbances. which are clinicall\, characteri/ed by sinoatrial or supraventricular arrhythmia or h\, iiitr~~veiltricul~ir conduction disturbances,“.’ I:I!!.I~.I.L’IlI n our study, we concluded that these cardiac conduction disturbances resulted tram amyloid involvements in the sinoatrial node and in ho& lirnlx of the intraventricular bundle, ocmtrring as part of the generalir.ed amvloidosis. However. arnyloid deposition was mild in the ~~triovrlltricular node and His’ bundle. Besides the anlyloicl deposition, nodal cells or Purkinje fibers slww atrophy, degeneration. and cell loss. which cause disturbances in the cardiac conduction system. As shown in ‘l‘able 1. the t’acts to tw noted in ;>ur cases are the autonomic nerve disturhatlces and orthostatic hypotension. Furthermore, ou I- study clernonstrated amyloid deposition and its associated degenerative changes in the svrnpathctic ganglia. vagal nerves, \entral and dorsal roots of rhe spinal nerve, and in the subpericardial branches of the autonomic nerves distributing into the heart. ‘I‘hrse findings suggest that there is a condition of denervation in the heart of’ FAP patients, and that their cx-disc conduction disturbances are due essentially to aniyloid deposition and degenerative changes in both the cardiac conduction and autonomic. nervous svstenis. In contrCist to’the tact that the incidence of’ peripheral l.“‘l)neuropath~ is below 10’2 in various tvpes of’ nonfamilial. nonhereditary amsloidoses and ii1 tnveloIlla-associated amyloidosis,“’ alkos~ all F.41’ patients ;tlso show marked peripheral polyneuropathy ancl autonomic nerve disturbances. The results of the preserlt studv indicate that anlvloid deposition in the endoneurium begins arigioce;trically, and that the degrfre of amyloid deposItIon in the endoneurium and degenerative changes of’ nerve fibers parallel the clinical stage, accompanied by a decrease in myelinated nerve fibers. These findings agree with those of 17m ‘Thus, amyloid deposiprevious in\wtigations. tion seems to act as an accelerating fitctor for peripheral nerve disturbances. -4s for the pathogenesis of the peripheral nerve disturbances in FAP. i,arious theories, such as a local compression bv amyloid deposition, ischemia. or a neurotoxic effect of’some circulating substances, have 7.11’.‘7but its mechanism remains unheen presented, clear. Irl this regard. thickening. degeneration, and 525

HUMAN PATHOLOGY

Volume 22, No. 6 (June 1991)

,J. Rijswijk MI1 (eds): Xmyloidosis. Dordrccht. ? he Netherlands, Nijhoff. I ‘3X6.pp lY.?-2 I X X. <;lennet-
ripheral nerves is open-ended with respect to the subarachnoid space,“’ amyloid deposition in the subperineural region of the peripheral nerve tissues is suggested to result from variant TTR produced by the choroid plexus epithelial cells, secreted into cerebrospinal fluid, and transported by it to the peripheral nerves. Interestingly enough, in transgenic mice produced by microinjection into fertilized mouse eggs of human mutant TTR (MT-hMet30) gene (the 7.8kilobase pairs Stu I-EcoRI fragment was constructed by ligating the promoter region of the mouse methallothionein-I gene to the entire structural gene of the human mutant TTR gene:‘-‘). we have recently demonstrated that amyloid deposition occurs in various visceral organs and tissues, induced by deposition of human variant TTR produced in the mice.“4.“5 We failed, however, to induce amyloid deposition in the mouse peripheral nerve tissues, subependymal layer of the brain ventricles, and choroid plexus stroma, or to detect immunohistochemitally the presence of human TTR in the choroid plexus epirhelial cells. Taking all these data into consideration, a possible relationship between amyloid deposition in the choroid plexus, arachnoid membrane, and peripheral nerve tissues, and the production of variant TTR by the choroid plexus epithelial cells is suggested. Further. as for the pathogenesis of amyloid deposition in the peripheral nerve tissues, we would direct attention to the occurrence of degenerative changes in the nerve fibers prior to or regardless of amyloid deposition in the early stage of FAP. suggesting another intrinsic factor(s). However, subsequent studies are required to elucidate whether these degenerative changes are induced by an effect of variant TTR itself or by some other genetic cause. Ackruml~dgmm~. We thank Fumiya Uchino, Department of Pathology. Yamaguchi University Medicine, Ube. Japan. f‘or providing anti-human

1964 13. van Allen SfM’. Frohlich JA%.Davies JR: Inherited predisposition to generalized am) loid&. Clinical a11d pathological study of a family with neuropathy. nephropathv. and peptic ulce1-. Neurology 19: IO-?5. I969 14. hleretoia J, ‘I’eppo I.: ~listol’athulogital findings of familial amyloirlosis with cranial neuropathy as principal manifestations. Acta Pathol Microbial Immunol Stand [A] 79:132-140. 1971 15. Lambird PA. Ilartmann WH: Hereditary amyloidosis. rhe flexor I-rticulum. and the carpal tunnel syndrome. Am .J Clin Pathol 5?:711-719. 1969 16. jackson CE, Falls HF. Block LVD, et al: Inheritance of primary’svstemic amyloidosia. Am ,J Hum Genet 1?:434-439. 1960 17. (:oimhra A. Andrade (:: Familial amyloid polvneuropathy: An electron microscopic study of the peripheral nerve in five cases;. I. Interstitial changes. Brain 94: 199-206. 1971 IX. C:arvalho ,J, Coimbra A, Andradr (1: Peripheral nerve fiber changes in asymptomatic children of patients with familial am) loid neuropathv. Brain 99: I 10. 1976 19. Ike& S. Han’ru Iv, Hongo M. et al: Hereditary generalired arnvloidosis with oolvneuro1,ath~. Clinicooatholorrical study of 65 Jap&ese patients.‘Brain 11(;:315:337. l9d-i ” ’ 20. Hanvu N. Ikeda S. Nakadai A. et al: Pcrlpheral nerve pathological bindings in familial amyloid poly neuropathy: A co-relative study of proximal sciatic nerve and sural nerve lesions. Ann Neural 25:3-W350. 19X0 21. Eriktson A, Eriksson 0. Olof&on BO. et al: The ca1-disc arrioventricular conduction system in familial amvloidosis with pol\neuropathy. A clinico-pathologic study of six cases from No!-rhern Sweden. hcta Pathol Vicrobiol lmmunol Srand [A] 91 :343-:~49. 19x3 22. Shit-ahe T. Hashimoto $1. Araki S. et al: Pathology of poly nruritic amvloidosis in a Japanese family. A report of two cases, In Zimmermari HM (ed): Progress in Neuropathology. WI 2. Philadelphia, PA, Grune and Stratton, 1973, pp 409-420 23. Takahashi K. Kimura H. Yi S. et al: Pathology of familial amyloidotic polyneuropathy, in Isobe 7‘. Araki S. Vchino F. et al (eds): Amyloid and Amyloidosis. New York. NY, Plenum. 1988. pp 505-5 10 94. Lev M. Widran 1. Erickson EE: A method for the histopathologic study of th‘g atrioventricular node, bundle, and branches. Arch Pathol 52:73-83. 1951 25. Hudson REB: The human conducting-system and its examination. J Clin Pathol 16:492-49X. 1963 26. Araki S: Diagnostic criteria of amyloidosis. Naika 45: 1167I I7 1. 1980 (in Japanese) 27. Mathews WH: Primary systemic amyloidosis. Am J Med Sci 22X:3 17.333. 19.54

MD. First School of AL anti-

bodv.

REFERENCES I Andrade (;: A peculiar form of peripheral neuroparhy : Familial atypical generalized amyloidosis with special involvement of the peripheral ner\‘es. Brain 75:4OH-427, 1952 2. Hofer PA, Anderson R: Postmortem findings in primary familial amyloidosis with polyneuropathy. Acta Pathol Mirrobiol Stand [A] 83:309-322, 1952 3. Rukavina JG, Block WI). Jackson CE. et al: Primaq systemic amyloidosis: A review and an experimental. genetic, and clinical study of 29 cases with particular emphasis on the familial form. Medicine 35:239-X44, 1956 4. Meretoja J: Familial systemic paraamyloidosis with lattice dystrophy of ‘the cornea. progressive cranial neuropathy. skin changes and various internal symptoms. Ann Clin Res 1:31-G324. 1969 5. Araki S, Mawatari S. Ohta hf. et al: Polyneuritic amyloidosis in a Japanese family. Arch Neural 1X:593-602, 1968 6. Gafni 1. Fischel thy in a Jewis-h family. the lower limb familial 43, 1985 7. Araki

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28. Dvck PJ. Lamhert EH: Dissociated sensation in amyloidosis: C£ action potential, quantitative histologic and teased-fiber and electron microscopic studies of sural nerve biopsies. Arch Neural 20:490-507. 1969

B. Reif R, et al: Amyloidotic polyneuropaEvidence for the g&tic heterogeneity’of amyloidotic neuropathies. Q ,J Med 55:33amyloidotic

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29. Skinnrr M, Cohen AS. Shirahama ?, et al: P-component (pentagonal unit) of amyloid: Isolation, characterization, and sequence analysis. J Lab Clin Med X4:604-614. 1974 30. Pepys MB, Dyck RF, De Beer FC:. et al: Binding of seru1n

in Marrink

526

FAMILIAL AMYLOIDOTIC

POLYNEUROPATHY

527

TYPE 1 uakohashi

et al)