Fine structural lesions in the myocardium of a beer drinker with reversible heart failure

xperimental and laboratory

reports

Fine structural lesions in the myocardium of a beer drinker with reversible heart

failure

Robert T. Bulloch, M.D. Marvin L. Murphy, M.D. Malcolm B. Pearce, M.D. Little Rock. Ark.

P

Irevious reports1p2 regarding electronmicroscopic examination of the myocardium in patients with alcoholic cardiomyopathy have described generalized change of mitochondria, myofibrils, and the sarcoplasmic reticulum. These studies suggest that damage of myocardial subcellular organelles in this disorder is diffuse and perhaps nonspecific. T!ie purpose of this communication is to report unusual pathologic change detected by examination of a myocardial biopsy taken from a young beer drinker who developed myocardial failure and subsequently recovered. The pathologic data sugg;ests that this patient’s disease is different from that of patients with alcoholic cardiomyopathy who have been studied in a similar manner. Case report The patient was a 36-year-old Caucasian male career Air Force sergeant. He dated his present illne:,s to April, 1966, when he had the “flu” with fever and a cough lasting three days. Following this illne:;s there was persistent fatigue and anorexia. In June, 1966, he developed dyspnea on exertion

followed by paroxysmal nocturnal dyspnea, orthopnea, and edema of the lower extremities. He was admitted to the Little Rock Air Force Base Hospital on June 20, 1966. Past history revealed that the patient had been a beer drinker for twenty years with an average consumption of 96 oz. daily. Since 1959, he drank only one brand of beer. He denied the intake of different brands-American or Canadian-and did not consume alcohol in any other form. On examination, blood pressure was 104/70 and pulse was 110 per minute. The neck veins were distended in the sitting position. His heart was markedly enlarged and a summation gallop was heard. There was a Grade 2/6 soft apical pansystolic murmur. The liver was percussed 4 cm. below the right costal margin. Two plus pitting edema of the lower extremities was present. Initial laboratory tests revealed that the hemoglobin averaged 18 grams and the hematocrit 5.5 per cent. Electrocardiograms showed right-axis deviation with generalized nonspecific T-wave changes. Chest roentgenograms revealed marked enlargement of the cardiac silhouette with pleural eff usions. Pericardial effusion was suggested. Hospital course. Treatment consisted of bed rest, a low salt diet, digitaiis, and diuretics. Following clinical improvement he was transferred to the Little Rock Veterans Administration Hospital on July 6, 1966, for further evaluation. At that time venous pressure was 90 mm. Ha0 and circulation time

From

the Departments of Medicine. University Of Arkansas School of Medicine and the Veterans Administr&m Hospital, Little Rock, Ark. This study was supported in part by United States Public Health Service Grant No. HE 11947 and by the Arkansas Heart Association. Received for publication Jan. 5, 1970. Reprint requests to: Dr. Bulloch, University of Arkansas, Medical Center, Little Rock, Ark. 72201.

Vol. 80, No. 5, pp. 629437

November, 1970

American

Heart Journal

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(Decholin, arm to tongue) was 23 seconds. Hematological study revealed an erythrocytosis, probably secondary. Serum glutamic oxaloacetic tra.nsaminase was 37 units and lactic dehydrogenase was 610 units. Follow-up roentgenograms showed marked decrease in heart size. A right heart catheterization and intracardiac biopsy of the ventricular septum were done without difficulty. Right ventricular pressure was 35/4 mm. Hg. and mean right atria1 pressure was 4 mm. Hg. Pulmonary function studies and blood gases were normal. Subsequerd course. Following six months of restricted activity the patient returned to full-time active duty. Follow-up cardiovascular examination

is completely grams and drink four brands.

Materials

normal. Hemoglobin presenely is 17.5 hematocrit 51. The patient continues to beers daily (48 oz.) and has changed

and methods

Intracardiac needle biopsy of the ventricular septum was performed using a method3 previously described. Electron microscopy. The myocardial biopsy specimen was immediately fixed with 3 per cent glutaraldehyde in 0.1 molar (M)

Fig. 1. This electron micrograph of a myocardial cell shows intramitochondriai particles. The particles appear to progressively increase from a few in normal-sized mitochondria to large deposits in mitochondria that are markedly enlarged. One mitochondrion appears disrupted(d). Loss of contractile elements can be seen along the right border of the cell. The sarcolemma is intact. (X 17,600.)

Volume 80

Number

5

phosphate buffer for two hours and postfixed in phosphate-buffered osmium tetroxide for one hour. After dehydration the tissue was embedded in araldite M and sectioned with an LKB microtome. Thin sections were stained with uranyl acetate alone and in combination with lead citrate. After glutaraldehyde fixation, some of the tissue blocks were digested with saliva and

Myocardium

of a beer drinker

631

then embedded as described. Micrographs were taken with an RCA Emu 3F electron microscope. Resdfs M&ochondria. The majority of mitochondria, except for a slightly shrunken appearance, appeared structurally normal. However, in some areas up to 35 per cent

Fig. il. This is a higher magnification of the enlarged myocardial mitochondria shown in Fig. 1. There are large deposits of intramitochondrial particles which are surrounded only by the mitochondrial limiting membrane along with a thin layer of subjacent cristae. Because of their variable size, shape, and affinity for lead stain, the particles are morphologically consistent with the alpha or rosette form of glycogen. A myelin figure (MP) is present within one mitochondrion. Extramitochondrial glycogen in the usual monoparticuiate or beta form is present.

632

BuSloch, Mur$hy,

and Pearce

of these organelles were found to contam varying amounts of particulate inclusions. The inclusions appeared to have progressively increased until the mitochondria were markedly enlarged (Fig. 1). Occasionally the mitochondrial limiting membrane was disrupted. The particles varied from approximately 50 to 200 millimicrons in diameter, were irregular in shape, and stained densely with lead citrate (Fig. 2). On staining with uranyl acetate alone, the

intramitochondriaI particles could still be seen but were much less electron-dense. Examination of tissue blocks which had been digested with saliva revealed the presence of similar enlarged mitochondria, but the particulate inclusions were uniformly absent with large vacuoles remaining (Fig. 3). Some of the vacuoles contained amorphous debris. These observations suggest that the intramitochondrial particles were aggregates of glycogen resembling the

Fig. 3.4 portion of the myocardial tissue from the same biopsy was digested with saliva. This micrograph shows enlarged mitochondria similar to those in undigested mpocardium but the intramitochondrial particks are suggests that the intramitochondrial completely absent with only amorphous debris (d) remainin,. o- This strongly material was glycogen in the alpha or rosette configuration. The monoparticulate glycogen particles usually seen dispersed throughout the cytoplasm are also absent. (X35,200.)

hfyocardiurm. oj a beer drinker

alpha or rosette form commonly found in the cytoplasm of liver cells.4r5 A few mitochondria showed loss of cristae with formation of myelin figures. Occasionally very large mitochondria were observed which appeared to contain disorganized cristae and vacuoles but no partkles (Fig. 4). However on single sections it was impossible to be certain that inclusions were not present. The number and distribution of mitochondria appeared norm al. Contra&e elements. The most consistent finding observed was loss of contractile elements (Fig. 5). The degree of damage was variable; in an occasional cell almost

633

all the myofibrils were disrupted or absent and replaced by subcellular debris (Fig. 6). All divisions of the sarcomere were involved and it was not possible to determine whether pathologic change began at any specific site. It is of interest that the mitochondria present in these damaged areas frequently appeared normal. Glycogen. The usual monoparticulate or beta glycogen particles were abundantly dispersed throughout the cytoplasm of the myocardial cells. There was definite focal increase in damaged myocardial cells and possibly an over-all increase. This glycogen differed morphologically from the intramitochondrial glycogen with no

Fig. 4. An occasional enlarged mitochondrion without inclusions and there is vacuole formation. The mitochondrion immediately ing membrane appears disrupted. (X37,400.)

was seen adjacent

(~1). (~2)

The cristae appear disorganized contains particles and the limit-

634

Bulbch,

Fig. 5. Myofibrils localized to any

Murphy,

in this particular

myocyte division

and Pearce

are disrupted and of the sarcomeres.

apparent tendency to form aggregates. These particles were also completely removed by digestion with saliva. Additional findings. Cellular nuclei and sarcolemma were structurally intact. Lipid deposits did not appear increased. Minimal interstitial fibrosis was present. No abnormality of capillaries was observed.

Discussion

In previous electron microscopic studies of alcoholic cardiomyopathy, generalized changes of subcellular organelles have been reported.ls2 Mitochondrial lesions consisted mainly of swelling and loss of cristae mito-

partially destroyed (X 13,200.)

(arrows).

This

damage

could

not

be

inchondriales. No intramitochondriai clusions resembling those in our patient were described. We have examined myocardial biopsies of five additional patients with alcoholic cardiomyopathy6 in a manner similar to that described above. These patients were whiskey or wine drinkers and did not consume beer. Mitochondria appeared normal in four of these patients. Mitochondrial changes in the remaining patient (minimal loss of cristae and swelling) were inconsistent and in ao way resembled those present in the beer drinker described in this report. During the Quebec study of beer-cobalt

Fig. 6. This portion somewhat dense but

of a myocyte are otherwise

shows intact.

almost complete The sarcolemma

cardiomyopathy, Auger and Chenard’ examined a myocardial biopsy taken from one patient. They observed consistent loss of contractile elements and a few mitochondria containing particulate inclusions. Communication with Dr. Auger8 revealed that these lesions appeared similar to those seen in our patient. However their other findings, edema and generalized swelling of the sarcoplasmic reticulum, were not observed by us. The Canadian patient

loss of contractile elements. is also intact. (X 17,600.)

Mitochondria

appear

had consumed beer known to contain cobalt and recovered after cobalt was no longer added even while continuing to drink the same brand. Information obtained from the brewery and a private testing firm indicated that the beer consumed by our patient did not contain cobalt or other unusual additives. He also recovered while continuing to drink beer but did change brands and reportedly drinks a lesser amount.

536

Bulloch, Murf&y,

and Pearce

There are two other reports that cou!d have some bearing on this discussion. Hug and Schubert9 reported a case of cardiomyopathy in an infant and noted that an occasional mitochondrion contained particles resembling glycogen. This was not verified histochemically nor were they certain that all the inclusions were morphologically consistent with glycogen. They were unable to find evidence of cobalt or other potentially toxic agents in their patient’s environment.lO AlexandeP examined myocardial biopsies of six men with beer drinkers’ cardiomyopathy and noted the presence of electron-dense deposits within enlarged mitochondria in one patient. The beer that these patients drank was found to contain 1 to 1.2 parts per million of cobalt. However, the nature of the intramitochondrial deposits was uncertain. Cobalt alone given to rabbits is reported to cause extensive myocardial damage-l2 The mitochondrial lesions described did not resemble those seen in our patient or in the Canadian beer drinker. There have been reports of glycogen particles located within mitochondria of certain tissues in both invertebrates and vertebrates.ls-I5 Some evidence has been presented which suggests that glycolytic enzymes can be located inside mitochondria,l” There are, as yet, no reports indicating that myocardial mitochondria are normally associated with glycogen storage or metabolism. Of further interest is that the intramitochondrial glycogen in our case was largely in the alpha or aggregated form while the extramitochondrial glycogen was in the usual monoparticulate or beta form. The factors controlling the intramitochondrial location and morphology of glycogen are unknown. The etiology of the myocardial damage observed is also unknown. Excessive alcoholic intake, a brief flu-like illness, and anorexia may be factors. With the possible exception of the Canadian beer drinker, the myocardial lesions appear to be different from those reported in other patients having myocardial disease associated with excessive intake of alcohol. Further experience is required to determine whether our patient’s myocardial lesions are due to an

unusual manifestation of alcoholic cardio-. myopathy or a different and previously undescribed type of myocardial disease. Summary

This report describes unusual pathologic changes detected by electron microscopic examination of a myocardial biopsy taken from a young beer drinker with reversible heart failure. The changes consisted of glycogen aggregates (alpha glycogen) in enlarged mitochondria and loss of contractile elements. It is not known whether these findings represent an unusual manifestation of alcoholic cardiomyopathy or a different and previously undescribed type of myocardial disease. We would like valuable assistance

1.

2.

3.

4.

5. 6.

7.

8. 9.

10. 11.

to thank Mr. in the electron

Sam

Oliver

for

his

microscopicwork.

REFERENCES Hibbs, R. G., Ferrans, V. J., Black, W. C. Weilbaecher, D. G., Walsh, J. J., and Burch, 6. E.: Alcoholic cardiomyopathy. An electron microscopic study, AMER. HEART J. 69~766, 1965. Alexander, C. S.: Idiopathic heart disease II. Electron microscopic examination of myocardial biopsy specimens in alcoholic heart disease, Amer. I. Med. 41:229. 1966. Bullock, R. ‘I., Murphy, M. L., and Pearce, M. B.: Intracardiac needle biopsy of the ventricular SeptUM, Amer. J. Cardiol. 16:227, 1965. Drochmans, P. : Morphologic du glycogene. Etude au microscooe eiectroniaue de colorations negatives du glycogene particulaire, J. Ultrastruct. Res. 6:141, 1962. Revel, J. P.: Electron microscopy of glycogen, J. Histochem. Cytochem. 12:104, 1964. Bulloch, R. T., Pearce, M. B., and Murphy, M. L.: Fine structural lesions in the myocardium of non-alcoholic and alcoholic patients with primary myocardial disease-A comparative study, Circulation 40 (Suppl. 3): 53, 1969. (Abst.) Auger, C., and Chenard, J.: Quebec beer-drinkers’ cardiomyopathy: Ultrastructural changes in one case, Canad. Med. Ass. J. 97:916, 1967. Auger, C.: Personal communication, 1968. Hug, G., and Schubert, W. K.: Mitochondria in cardiomyopathy: Alterations in size, number and internal structures, Proceedings, Electron Microscopic Society oi America, 1968, p. 126. (Abst.) Hug, G.: Personal communication, 1968. Alexander, C. S.: The syndrome of cobaltbeer cardiomyopathy including ultrastructural changes on biopsy, J. Lab. Clin. Med. 72:850, 1968. (Abst.)

Myocardium

12. Hall, J. L., and Smith, E. B.: Cobalt heart disease. An electron microscopic and histochemical study in the rabbi;, Arch. Path. (Chicago) 86:403. 1968. 13. Andre,-J:: Conthbution a la connaissance du chondriome, J. Ultrastruct. Res. Suppl. 3:1, 1!>62. 14. Ishikawa, T., and Pei, Y. F.: Intramitochondrial gl.ycogen particles in rat retinal receptor cells, J,, Cell Biol. 25:402, 1965.

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15. Lentz, T. L.: Intramitochondrial glycogen granules in digestive cells of hydra, J. Cell Biol. 29:162, 1966. 16. Anderson, W. A.: Cytochemistry of sea urchin gametes. I. Intramitochondrial localization of glycogen, glucose- 6-phosphatase, and adenosine triphosphatase activity in spermatozoa of Paracentrotus lividus, J. Ultrastruct. Res. 24: 398, 1968.