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Localized dystrophic amyloidosis of heart valves
Localized Dystrophic Amyloidosis of Heart Valves JOHN H. COOPER, MBChB, FRCP[C], FRCPath A survey of 152 surgically resected heart valves (90 aortic, 60 mitral, two pulmonic) from a. consecutive series of 142 adult patients revealed congophilic, green birefringent, amyloid deposits in 81 valves (59 aortic, 22 mitral) from 77 patients from 41 to 79 years of age. Amyloid was found in 50 (82 per cent) of 61 valves showing degenerative calcific sclerosis and in 31 (53 per cent) of 58 valves showing post-rheumatic sclerosis but in none of 33 valves showing more acute disease processes (myxoid transformation, "stretch lesions," healed bacterial endocarditis). All the amyloidotic valves showed some calcification, and amyloid deposits frequently occurred around the calcified loci. Histochemically, the valvular amyloid was distinguishable from other major forms of amyloid by its largely negative alcian blue and periodic acid-Schiff staining and by its pepsin-resistant iodine staining. The localized, dystrophic nature and unusual histochemical properties of this valvular amyloidosis clearlydistlnguish it from other forms of cardiac amyloidosis. HUM PATHOL 14:649--653, 1983.
its association with calcification warrants fltrther emphasis, and 3) its amyloid deposits have a characteristic histochemical profile, which distinguishes it fl'om other forms of cardiac amyloid. MATERIALS AND METHODS
Two main types of cardiac amyloidosis have been recognized in the medical literature: the primarymyelomatous type, in which the heart is involved more or less severely as part of a disseminated pattern of deposition, and the senile type(s), in which the heart is involved usually to a lesser extent and in a more localized fashion. ~-3 Recently, however, a third type of cardiac amyloidosis, which appears to be restricted entirely to the heart valves, has been described, first by Goffin, 4 and then by Falk et al. 5 The present paper provides additional information about this disease, both confirming and amplifying the previously reported findings. In particular it demonstrates that 1) the incidence of this dystrophic valvular amyloidosis is significantly higher than was originally found, 2)
Received from the Department of Pathology, Victoria General Hospital and Dalbousie University, Halifax, Nova Scotia. Address correspondence and reprint requests to Dr. Cooper: Department of PatlmlogT, Victoria General Hospital, Halifax, Nova Scotia B3H 2Y9, Canada.
This was a light- and electron-microscopic study of 152 surgically resected heart valves (90 aortic, 60 mitral, two puhnonic) from a consecutive series of 142 adult patients. T h e age distribution is indicated in table 1. All the valve specimens were fixed in neutral buffered formalin, decalcified when necessary in 10 per cent aqueous formic acid, and processed to paraffin. Three or more blocks of each valve were obtained, including at least one sample of any evidently calcified focus. All sections were stained routinely with alum hematoxylin-eosin stain and by the alkaline Congo red method of Puchtleret al.6; tissue deposits that stained red and showed green birefringence by the Congo-red method wer e identified as amyloid. Sections from six representative cases of valvular amyloidosis, from six ca~s of primary-myelomatous cardiac anayloidosis, mid from six cases o f senile cardiac amyloidosis were" also stained, both directly and following digestidn in pepsin (0.1 per cent in 0.1y hydrogen chloride at 37~ for 18 horn-s), by the following methods: alcian blue in 0.2M magnesium chloride at pH 5.8, 7 0.1 per cent crystal violet in 0.05N hydrogen chloride for 30 minutes, acidic iodine solution, 8 periodic acid-Sclfiff (PAS), permang a n a t e - C o n g o red, 9 and rosindole. '~ Furthermore, selected portions of blocks from three positive cases were excised, deparaffinized, and reprocessed for electron microscopic examination. The valve specimens were classified, on the basis of their pathologic features, into five different diagnostic categories: degenerative sclerosis (calcific scle-
TABLE 1. Incidence of Amyloidosis in t52 Valve Specimens from 442 Patients Between 40 and 80 Years of Age* Age Range (Years)
Bacterial endocarditis Stretch lesions Myxoid transformation Rheumatic sclerosis Degenerative sclerosis TOTAL
10-20
20-30
30-40
40-50
50-60
60-70
70-80
Total
0/1 0/1 0/0 0/1 0/0
0/0 0/I 0/0 012 0/0
0/1 0/1 0/0 0/2 010
0/1 0/4 0/2 9/15 2/2
0/1 0/3 0/5 9/19 9/11
0/0 0/3 0/9 12/17 26/29
0/0 0/0 0/0 112 13119
0/-1 0/13 0/16 31158 50/61
0/3
013
0/4
1 1/24
18/39
3 8158
14/21
81 /152"
* Values are expressed as the number of amyloidotic valves per the total number of valves from patients in each age group.
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FIGURE t (top left)9 Degenerative sclerosis of aortic valve. The amyloid deposit in the center is enclosed in a hematoxyphil zone of calcification; and at the bottom there are small amyloid deposits scattered in a larger calcific focus. (Alkaline Congo red-hematoxylin stain9• FIGURE 2 [top center]. Rheumatic sclerosis of mitral valve. Floccules of amyloid are scattered among stromal cells, which show varying degrees of cytoplasmic enlargement and granularHy. [Alkaline Congo red-hematoxylin stain, x 640.] FIGURE 3 [top right]. Degenerative sclerosis of aortic valve. The amyloid deposits in and around the center show marked eosinophilia. (Hematoxylin-eosinstain, x 400.] FIGURE 4 [bottom row]. Rheumatic sclerosis of mitral valve, Left, the amyloid deposits are uniformly stained with Congo red. (Alkaline Congo red-hematoxylin stain, x 400). Right, the same amyIo[d deposits show peripheral staining with periodic acid-Schiff stain. ( x 400.]
rosis of congenitally deformed valve or of senile valve); rheumatic sclerosis, myxoid transformation (floppy valve); "stretch" lesions (fibromyxoid rolled thickening of free edges of cusps or leaflets secondary to valve-ring stretching or papillary muscle dysfunction); and bacterial endocarditis (post-inflammatory deformity) (table 1). RESULTS In the entire series of 152 valves from 142 patients, congophilic, green birefringent, amyloid deposits were found in 81 valves (59 aortic, 22 mitral) from 77 patients from age 41 to 79 )'ears. The incidence of amyloidosis did not show any consistent correlation with patient age (table 1) but (lid appear to be strongly correlated with the type of valvular disease. Thus, amyloid was found in 50 (82 per cent) of 61 valves showing degenerative sclerosis and in 31 (53 per cent) of 58 valves showing rheumatic sclerosis, but in none of 33 valves showing the more acute
myxoid, "stretch," or bacterial-endocarditis disease processes. Another significant correlation appeared with calcification, since all the amyloidotic valves showed some degree of calcification, and, conversely, 81 per cent of the calcified valves showed amyloidosis. T h e microscopic amyloid deposits were often fonnd within or at the edge of calcified foci of degenerate collagen (fig. 1). However, they also appeared as plaques in non-calcified dense collagen (fig. 1) and as small floccules adjacent to stromal cells, which in some cases showed cytoplasmic enlargement and granularity (fig. 2). In many of the affected valves the amyloid deposits were sparsely and irregularly distributed, so they frequently were found in only one region of one leaflet or cusp. Despite the statistical and topographic association with calcification, unequivocally amyloidotic deposits did not always appear in the most heavily calcified regions. However, such regions tended to show weak, non-birefringent or marginal staining with Congo red, possibly indicative of altered or degraded amyloid. 650
LOCALIZEDAMYLOIDOSISOF HEARTVALVES(Cooper)
Histochemically (table 2), the valvular amyloid consistently gave positive permanganate-Congo red, rosindole, and iodine reactions and showed weakly positive crystal-violet metachromatic staining similar to that of the other two major types of cardiac amyl o i d - - p r i m a r y - m y e I o m a t o u s inlmunoamyloid and senile cardiac amyloid. -~ However, the valvular amyloid differed from these other amyloids in four respects: 1) the resistance of its staining reactions (notably the iodine reaction) to pepsin pretreatment, 2) its marked eosinophilia (fig. 3) with associated strong green birefringence, 3) its irregular PAS staining, whereby the deposits tended to lmve intensely stained perimeters and virtua(ly unstained centers (fig. 4), and 4) its almost complete lack of staining with alcian blue (except after 18 hours of pepsin pretreatment). Electron microscopic exanfination disclosed some relatively large, discrete aggregates of reasonably typical amyloid fibrils as well as smaller, less well defined clusters of very short fibrils mixed with deformed collagen fibrils (fig. 5).
TABLE 2.
Staining Patterns of Cardiac Amyloids
Congo red (CR) Permanganate-CR Crystal violet Rosindole Iodine (IO Pepsin-Iz Hematoxylin-eosin Periodic a c i d - S c h i f f Alcian blue
Valvular Amyloid
P r i m a r y - Myelomatous and Senile Amyloids
+ + + + + + ++ -/+ -/+
+ + + + + + + +
KEY: + = positive; + + = strongly positive; - / + = mainly negative (see text); - = negative.
DISCUSSION
T h e age distribution and disease association-of amyloidosis in this series of surgically excised cardiac valves supports Goffin's contention ~ that localized valvular amyloidosis occurs as a dystrophic phenomenon more or less independent of a patient's age. F u r t h e r m o r e , as Goffin notes, 4 it seems that only chronically sclerosing processes (whether degenerative o r inflammatory in origin) p r o d u c e the dys-
trophic amyloidosis, since no examples have been found in vah'es affected only by acute and subacute processes, such as myxoid transformation, "stretch lesions" due to valve-ring or papillar)' muscle dysfunction, or the inflammatory-reparative changes of recent bacterial endocarditis. The higher incidence (53 per cent) o f valvular amyloidosis in this study, compared with that of Goffin (who found only 15.5 per cent in a similar series)/is probably clue mainly to more generous sanapling, since the same histologic criteria for amyloid recognition were used in the two studies and since, ,'is already noted, microscopic amyloid deposits fretiuently occur in only one part of severa( blocks of affected valves. Furthermore, in the subsequen~t:~study by Falk et al., 5 amyloid deposits were found in all of 39 severely calcified aortic valves, an even higher incidence than that in
FIGURE 5. Electron micrograph of sclerotic mitrat valve. A tract of irregularly clustered, short amyloid fibrils (center] separates longitudinally sectioned collagen fibrils (above] from a calcified spheruIe and transversely sectioned collagen fibrils (below]. (x 25,000.]
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HUMAN PATHOLOGY
Volume "14,No. 7 [July "1983]
the present study, in which 59 (81 per cent) of 73 calcified aortic valves were found to be amyloidotic. Although recognition of localized valvular amyloidosis as a common dystrophic phenomenon may be credited to these recent publications, one should acknowledge as well the previous observations of Ravid et alJ I who noted, in 1967, the occurrence of localized amyloidosis at the sites of various pathologic lesions, including two examples of chronic rheumatic valve disease, and the extensive studies of Schwartz, ~2 who recorded the occurrence of anwloid deposits in cicatricial and calcified heart valves and also in calcified mitral valve rings in 1970. A particularly interesting dystrophic feature is this observed relationship of the valvular amyloid with calcification, since other types of amyloid deposits have been found to contain calcium 13 and since one form o f amyloidosis, the localized bronchopulmonary variety, is known to progress to calcification and even to osseous transformation. ~4 Although the subset relationship of amyloidotic valves to calcified valves, which is noted in the present study, might suggest that calcification precedes amyloidogenesis, the morphologic observations o f incomplete Congo red staining of some calcific deposits, and of gradation in size of amyloid deposits from pericellular through collagenous to calcific locations, both suggest that amyloid deposition may precede and then eventually be replaced by calcification. Falk et al. 5 have come to similar conclusions and have suggested that the amyloid develops from the cytofilamentous residues of degenerate fibrocytes and then later becomes calcified. T h e tmusual histochemical properties of this valvular amyloid provide fllrther evidence Of its distinctive nature. Its notable eosinophilia is resistant to pepsin pretreatment and therefore probably resides in the skeletal fibril protein itself rather than in any ancillary protein component of the fibril complex. The strong green birefringence, which is an associated feature of this eosinophilia, bespeaks a regular linear array of bound eosin molecnles and therefore suggests close-range dye-binding facilitated by some particular conformational feature of the protein fibril rather titan ionic dye-binding by an abundance of cationic (e.g., arginyl) residues in the fibril protein. The pepsin resistance of the iodine reaction provides significant new implications concerning the general basis of iodine binding by anayloids8.15as well as fllrther evidence of the distinctive chemical nature of the valvular amyloid. T h e peculiar peripheral staining of the amyloid deposits produced by PAS matches the pattern reportedly produced by staining with labeled antibody to P component, t6 and therefore appears to reflect a peripheral distribution of this glycoprotein in valvtdar amyloid. Since P component has a known affinity for calciumJ 7 it may be relevant to observe that any calcification in the deposits tends to ha~,'e a similar peripheral distribution. (fig. I) T h e largely negative alcian blue staining reaction is of unclear significance.
Whether this peculiar histochemical profile reflects derivation o f the amyloid from fibroblastic cytofilaments (intermediate filaments, vimentin), as suggested by Falk et al., 5 is not certain, since these submicroscopic filaments have not yet been characterized histochemically, although they have been shown to bind and to show green birefringenc ewith Congo red stain, la Localized valvular amyloidosis thus appears to be a distinctive form o f amyloidosis, with characteristic disease associations, tissue distribution, and h'istochemical properties. It seems unlikely, however, that this dystrophic form of amyloidosis would occur only in the heart valves; in fact, other localized amyloidoses, which may represent the same or analogous forms of the disease, have been reported. Localized amyloidosis has been found in the joint capsule or articular cartilage of hip or knee joints in a high proportion of cases of osteoarthritis'9 and pyrophosphate arthritis 2~ and in the majority of older persons in a random autopsy series?-~ Another group of investigators has f o u n d amyloid deposits in the hip joint capsule and the sternoclavicular disc of, respectively, 22 and 48 per cent of subjects i n a random autopsy series. 22 The age incidence, disease association, and interstitial distribution o f these skeletal amyloid deposits suggest analogies with localized dystrophic valvular amyloidosis. F u r t h e r studies are needed to clarify the relationship beq~e~'en"the valvular and these other forms o f localized am.yloidosis and to explore possible connections between dystrophic amyloidosis and dystrophic calcification.
REFERENCES
652
1. Smith RL, Hutchins GM: Ischemicheart disease secondaryto amyloidosisof intramyocardialarteries. AmJ Cardio144:413, 1979 2. KyleRA, Bayrd ED: Amyloidosis:reviewof 236 cases. Medicine 54:271, 1975 3. Glenner GG: Amyloiddeposits and amyloidosis:tile [3-fibrilloses. N EnglJ Med 302:1283 and 1333, 1980 4. Goffin Y: Microscopicamyloiddeposits in the heart valves: a common complication of chronic damage and scarring. J Clin Pathol 33:262, 1980 5. Falk E, Ladefoged C, Christensen HE: Amyloiddeposits in calcifiedaortic valves.Acta Pathol MicrobiolScand [A] 89:23, 1981 6. PuchtlerH, Sweat F, LevineM: On the binding of Congo Red by amyloid.J HistochemCytochem10:355, 1962 7. Scott JE, Dorlingj: Differential staining of acid glycosaminoglycans (mucopolysacclmrides)by alcian blue in salt solutions. Histochemie5:221, 1965 8. CooperJH: Selectiveamyloidstainingas a functionof amyloid composition and structure. Lab Invest 31:232, 1974 9. WrightJR. Calkins E, Humphrey RL: Potassium permanganate reaction in amyloidosis.Lab Invest 36:274, 1977 10. Glenner GG: The histochemicaldemonstrationof.indole derivativesby the rosindole reactionof E. Fischer.J Histochem Cytochem 5:297, 1957 11. RavidM, GafniJ, Sohar E, et al: Incidenceand origin of nonsystemicmicrodepositsof amyloid.J Clin Patho120:15, 1967 12. SchwartzP: Amyloidosis:cause and manifestationsof senile
LOCALIZEDAMYLOIDOSISOF HEARTVALVES[Cooper]
13. 14. 15. 16.
17.
deterioration. Springfield, I11., Charles C Thotnas, Publishers, 1970, p 107 Kula RW, Engel WK, Line BR: Scanning for soft-tissue amyloid. Lancet 1:92, 1977 Symmers W St C: Primary amyloidosis: a review.J Clin Pathol 9:187, 1956 Cooper JH: A histochemical construct of the amyloid fibril (abstract). European Amyloidosis Research Symposium program, 1981, p 48. Coffin Y, Cornwell GG, Murdoch W: Microdeposition ofamyloid in sternoclavicular discs and sclerocalcified heart valves: a combined immunofhtorescence and Ifistochemical sntdy (abstract). European Amyloidosis Research Symposittm, 1981, p 19 Pepys MD, Dash AC, Munn EA, et ah Isolation of anayloid P
18. 19. 20. 21. 22.
component (protein AP) from normal serum as a calciumdependent binding protein. Lancet 1: 1029, 1977 Linder E, Lehto VP, Virtanen I: Atnyloid-like green birefringence in cytoskeletal 10-nm filaments after staining with Congo red. Acta Pathol Microbiol Scand [A] 87:299, 1979 Christensen HE, Sorensen KH: Local atnyloid formation of capsula fibrosa in arthrosis coxae. Acta Pathol Microbiol Scand [A] 233(snppl):128, 1972 Teglbjaerg PS, Ladefoged C, Sorensen KH, et al: Local articular amyloid deposition in pyrophosphate arthritis. Acta Pathol Microbiol Scand [A] 87:307, 1979 Ladefoged C, Christensen HE: Congophilic substance with, green dichroism in Ifipjoints in autopsy material. Acta Pathol Microbiol Scand [A] 88:55, 1980 Goffin YA, Thoua Y, Potvliege PR: Microdeposition of amyloid in the joints. Ann Rheum Dis 40:27, 1981
CORRESPONDENCE Lymphadenopathy in Leprosy
To the Editor:--In r e f e r e n c e to tile article by R.-E. Cytowic et al. entitled "Chronic Relapsing Polyneuropathy Associated with h n m u n o b l a s t i c L y m p h a d e n o p a t h y , ''t I wonder whether tile diagnosis of leprosy was taken into consideration. Lymphadenopathy in leprosy is known, although not with immunoblastic features. However, the painful neuritis, the sensoritnotor neuropathies, and especially tile features a p p a r e n t in figure 2 of their report suggest nerve involvement by Mycobacterium leprae. 2 JonAs D E WiT, MD Black Lion Hospital of the Medical Faculty of Addis Ababa University, Addis Ababa, Ethiopia 1. CytowicRE, Challa VR, Buss DH, et al: Chronicrelapsingpolyneuropathy associated with immunoblasticlymphadenopathy.Hum Pathol 13:167, 1982 2. Binford CH, Connor DH: Pathology of Tropical and Extraordinary Diseases Vol 1. Washington,DC, Armed Forces Institute of Pathology, 1976, pp 205-225 Perianal Spindle Cell Lipoma
To theEditor:--Spindle ceil Iipoma is a benign fatty neoplasm whose histologic characteristics have been well docu m e n t e d in the literature.' Several articles and monographs have stressed the clinicopathologic correlation of its occurrence in the region of the posterior neck and shoulders of older men. i n a recent case report, Robb and Joues~"described an otherwise classic spindle cell lipoma in the perianal location. We have had the opportunity to observe another such case. REPORT OF A CASE. A 51-year-old man presented with a chief complaint of a lump at the "end of his spine," which had been present for )'ears. He had had no problems with altered bowel habits or b l e e d i n g but had had a h e m o r rhoidectomy 30 years previously. T h e r e was a 6.0 x 5.0crn pedunculated lesion in the coccygeal region at the apex of the cleft arising from the skin and subcutaneous tissue. Figure 1 illustrates the typical microscopic appearance
FIGURE 1. Perianal spindle cell lipoma. The histologic appearance is identical to that of spindle cell lipamas of the neck and back. the more typical locations.
653
its association with calcification warrants fltrther emphasis, and 3) its amyloid deposits have a characteristic histochemical profile, which distinguishes it fl'om other forms of cardiac amyloid. MATERIALS AND METHODS
Two main types of cardiac amyloidosis have been recognized in the medical literature: the primarymyelomatous type, in which the heart is involved more or less severely as part of a disseminated pattern of deposition, and the senile type(s), in which the heart is involved usually to a lesser extent and in a more localized fashion. ~-3 Recently, however, a third type of cardiac amyloidosis, which appears to be restricted entirely to the heart valves, has been described, first by Goffin, 4 and then by Falk et al. 5 The present paper provides additional information about this disease, both confirming and amplifying the previously reported findings. In particular it demonstrates that 1) the incidence of this dystrophic valvular amyloidosis is significantly higher than was originally found, 2)
Received from the Department of Pathology, Victoria General Hospital and Dalbousie University, Halifax, Nova Scotia. Address correspondence and reprint requests to Dr. Cooper: Department of PatlmlogT, Victoria General Hospital, Halifax, Nova Scotia B3H 2Y9, Canada.
This was a light- and electron-microscopic study of 152 surgically resected heart valves (90 aortic, 60 mitral, two puhnonic) from a consecutive series of 142 adult patients. T h e age distribution is indicated in table 1. All the valve specimens were fixed in neutral buffered formalin, decalcified when necessary in 10 per cent aqueous formic acid, and processed to paraffin. Three or more blocks of each valve were obtained, including at least one sample of any evidently calcified focus. All sections were stained routinely with alum hematoxylin-eosin stain and by the alkaline Congo red method of Puchtleret al.6; tissue deposits that stained red and showed green birefringence by the Congo-red method wer e identified as amyloid. Sections from six representative cases of valvular amyloidosis, from six ca~s of primary-myelomatous cardiac anayloidosis, mid from six cases o f senile cardiac amyloidosis were" also stained, both directly and following digestidn in pepsin (0.1 per cent in 0.1y hydrogen chloride at 37~ for 18 horn-s), by the following methods: alcian blue in 0.2M magnesium chloride at pH 5.8, 7 0.1 per cent crystal violet in 0.05N hydrogen chloride for 30 minutes, acidic iodine solution, 8 periodic acid-Sclfiff (PAS), permang a n a t e - C o n g o red, 9 and rosindole. '~ Furthermore, selected portions of blocks from three positive cases were excised, deparaffinized, and reprocessed for electron microscopic examination. The valve specimens were classified, on the basis of their pathologic features, into five different diagnostic categories: degenerative sclerosis (calcific scle-
TABLE 1. Incidence of Amyloidosis in t52 Valve Specimens from 442 Patients Between 40 and 80 Years of Age* Age Range (Years)
Bacterial endocarditis Stretch lesions Myxoid transformation Rheumatic sclerosis Degenerative sclerosis TOTAL
10-20
20-30
30-40
40-50
50-60
60-70
70-80
Total
0/1 0/1 0/0 0/1 0/0
0/0 0/I 0/0 012 0/0
0/1 0/1 0/0 0/2 010
0/1 0/4 0/2 9/15 2/2
0/1 0/3 0/5 9/19 9/11
0/0 0/3 0/9 12/17 26/29
0/0 0/0 0/0 112 13119
0/-1 0/13 0/16 31158 50/61
0/3
013
0/4
1 1/24
18/39
3 8158
14/21
81 /152"
* Values are expressed as the number of amyloidotic valves per the total number of valves from patients in each age group.
649
HUMAN PATHOLOGY
Volume '14,No. 7 (July 1983]
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FIGURE t (top left)9 Degenerative sclerosis of aortic valve. The amyloid deposit in the center is enclosed in a hematoxyphil zone of calcification; and at the bottom there are small amyloid deposits scattered in a larger calcific focus. (Alkaline Congo red-hematoxylin stain9• FIGURE 2 [top center]. Rheumatic sclerosis of mitral valve. Floccules of amyloid are scattered among stromal cells, which show varying degrees of cytoplasmic enlargement and granularHy. [Alkaline Congo red-hematoxylin stain, x 640.] FIGURE 3 [top right]. Degenerative sclerosis of aortic valve. The amyloid deposits in and around the center show marked eosinophilia. (Hematoxylin-eosinstain, x 400.] FIGURE 4 [bottom row]. Rheumatic sclerosis of mitral valve, Left, the amyloid deposits are uniformly stained with Congo red. (Alkaline Congo red-hematoxylin stain, x 400). Right, the same amyIo[d deposits show peripheral staining with periodic acid-Schiff stain. ( x 400.]
rosis of congenitally deformed valve or of senile valve); rheumatic sclerosis, myxoid transformation (floppy valve); "stretch" lesions (fibromyxoid rolled thickening of free edges of cusps or leaflets secondary to valve-ring stretching or papillary muscle dysfunction); and bacterial endocarditis (post-inflammatory deformity) (table 1). RESULTS In the entire series of 152 valves from 142 patients, congophilic, green birefringent, amyloid deposits were found in 81 valves (59 aortic, 22 mitral) from 77 patients from age 41 to 79 )'ears. The incidence of amyloidosis did not show any consistent correlation with patient age (table 1) but (lid appear to be strongly correlated with the type of valvular disease. Thus, amyloid was found in 50 (82 per cent) of 61 valves showing degenerative sclerosis and in 31 (53 per cent) of 58 valves showing rheumatic sclerosis, but in none of 33 valves showing the more acute
myxoid, "stretch," or bacterial-endocarditis disease processes. Another significant correlation appeared with calcification, since all the amyloidotic valves showed some degree of calcification, and, conversely, 81 per cent of the calcified valves showed amyloidosis. T h e microscopic amyloid deposits were often fonnd within or at the edge of calcified foci of degenerate collagen (fig. 1). However, they also appeared as plaques in non-calcified dense collagen (fig. 1) and as small floccules adjacent to stromal cells, which in some cases showed cytoplasmic enlargement and granularity (fig. 2). In many of the affected valves the amyloid deposits were sparsely and irregularly distributed, so they frequently were found in only one region of one leaflet or cusp. Despite the statistical and topographic association with calcification, unequivocally amyloidotic deposits did not always appear in the most heavily calcified regions. However, such regions tended to show weak, non-birefringent or marginal staining with Congo red, possibly indicative of altered or degraded amyloid. 650
LOCALIZEDAMYLOIDOSISOF HEARTVALVES(Cooper)
Histochemically (table 2), the valvular amyloid consistently gave positive permanganate-Congo red, rosindole, and iodine reactions and showed weakly positive crystal-violet metachromatic staining similar to that of the other two major types of cardiac amyl o i d - - p r i m a r y - m y e I o m a t o u s inlmunoamyloid and senile cardiac amyloid. -~ However, the valvular amyloid differed from these other amyloids in four respects: 1) the resistance of its staining reactions (notably the iodine reaction) to pepsin pretreatment, 2) its marked eosinophilia (fig. 3) with associated strong green birefringence, 3) its irregular PAS staining, whereby the deposits tended to lmve intensely stained perimeters and virtua(ly unstained centers (fig. 4), and 4) its almost complete lack of staining with alcian blue (except after 18 hours of pepsin pretreatment). Electron microscopic exanfination disclosed some relatively large, discrete aggregates of reasonably typical amyloid fibrils as well as smaller, less well defined clusters of very short fibrils mixed with deformed collagen fibrils (fig. 5).
TABLE 2.
Staining Patterns of Cardiac Amyloids
Congo red (CR) Permanganate-CR Crystal violet Rosindole Iodine (IO Pepsin-Iz Hematoxylin-eosin Periodic a c i d - S c h i f f Alcian blue
Valvular Amyloid
P r i m a r y - Myelomatous and Senile Amyloids
+ + + + + + ++ -/+ -/+
+ + + + + + + +
KEY: + = positive; + + = strongly positive; - / + = mainly negative (see text); - = negative.
DISCUSSION
T h e age distribution and disease association-of amyloidosis in this series of surgically excised cardiac valves supports Goffin's contention ~ that localized valvular amyloidosis occurs as a dystrophic phenomenon more or less independent of a patient's age. F u r t h e r m o r e , as Goffin notes, 4 it seems that only chronically sclerosing processes (whether degenerative o r inflammatory in origin) p r o d u c e the dys-
trophic amyloidosis, since no examples have been found in vah'es affected only by acute and subacute processes, such as myxoid transformation, "stretch lesions" due to valve-ring or papillar)' muscle dysfunction, or the inflammatory-reparative changes of recent bacterial endocarditis. The higher incidence (53 per cent) o f valvular amyloidosis in this study, compared with that of Goffin (who found only 15.5 per cent in a similar series)/is probably clue mainly to more generous sanapling, since the same histologic criteria for amyloid recognition were used in the two studies and since, ,'is already noted, microscopic amyloid deposits fretiuently occur in only one part of severa( blocks of affected valves. Furthermore, in the subsequen~t:~study by Falk et al., 5 amyloid deposits were found in all of 39 severely calcified aortic valves, an even higher incidence than that in
FIGURE 5. Electron micrograph of sclerotic mitrat valve. A tract of irregularly clustered, short amyloid fibrils (center] separates longitudinally sectioned collagen fibrils (above] from a calcified spheruIe and transversely sectioned collagen fibrils (below]. (x 25,000.]
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HUMAN PATHOLOGY
Volume "14,No. 7 [July "1983]
the present study, in which 59 (81 per cent) of 73 calcified aortic valves were found to be amyloidotic. Although recognition of localized valvular amyloidosis as a common dystrophic phenomenon may be credited to these recent publications, one should acknowledge as well the previous observations of Ravid et alJ I who noted, in 1967, the occurrence of localized amyloidosis at the sites of various pathologic lesions, including two examples of chronic rheumatic valve disease, and the extensive studies of Schwartz, ~2 who recorded the occurrence of anwloid deposits in cicatricial and calcified heart valves and also in calcified mitral valve rings in 1970. A particularly interesting dystrophic feature is this observed relationship of the valvular amyloid with calcification, since other types of amyloid deposits have been found to contain calcium 13 and since one form o f amyloidosis, the localized bronchopulmonary variety, is known to progress to calcification and even to osseous transformation. ~4 Although the subset relationship of amyloidotic valves to calcified valves, which is noted in the present study, might suggest that calcification precedes amyloidogenesis, the morphologic observations o f incomplete Congo red staining of some calcific deposits, and of gradation in size of amyloid deposits from pericellular through collagenous to calcific locations, both suggest that amyloid deposition may precede and then eventually be replaced by calcification. Falk et al. 5 have come to similar conclusions and have suggested that the amyloid develops from the cytofilamentous residues of degenerate fibrocytes and then later becomes calcified. T h e tmusual histochemical properties of this valvular amyloid provide fllrther evidence Of its distinctive nature. Its notable eosinophilia is resistant to pepsin pretreatment and therefore probably resides in the skeletal fibril protein itself rather than in any ancillary protein component of the fibril complex. The strong green birefringence, which is an associated feature of this eosinophilia, bespeaks a regular linear array of bound eosin molecnles and therefore suggests close-range dye-binding facilitated by some particular conformational feature of the protein fibril rather titan ionic dye-binding by an abundance of cationic (e.g., arginyl) residues in the fibril protein. The pepsin resistance of the iodine reaction provides significant new implications concerning the general basis of iodine binding by anayloids8.15as well as fllrther evidence of the distinctive chemical nature of the valvular amyloid. T h e peculiar peripheral staining of the amyloid deposits produced by PAS matches the pattern reportedly produced by staining with labeled antibody to P component, t6 and therefore appears to reflect a peripheral distribution of this glycoprotein in valvtdar amyloid. Since P component has a known affinity for calciumJ 7 it may be relevant to observe that any calcification in the deposits tends to ha~,'e a similar peripheral distribution. (fig. I) T h e largely negative alcian blue staining reaction is of unclear significance.
Whether this peculiar histochemical profile reflects derivation o f the amyloid from fibroblastic cytofilaments (intermediate filaments, vimentin), as suggested by Falk et al., 5 is not certain, since these submicroscopic filaments have not yet been characterized histochemically, although they have been shown to bind and to show green birefringenc ewith Congo red stain, la Localized valvular amyloidosis thus appears to be a distinctive form o f amyloidosis, with characteristic disease associations, tissue distribution, and h'istochemical properties. It seems unlikely, however, that this dystrophic form of amyloidosis would occur only in the heart valves; in fact, other localized amyloidoses, which may represent the same or analogous forms of the disease, have been reported. Localized amyloidosis has been found in the joint capsule or articular cartilage of hip or knee joints in a high proportion of cases of osteoarthritis'9 and pyrophosphate arthritis 2~ and in the majority of older persons in a random autopsy series?-~ Another group of investigators has f o u n d amyloid deposits in the hip joint capsule and the sternoclavicular disc of, respectively, 22 and 48 per cent of subjects i n a random autopsy series. 22 The age incidence, disease association, and interstitial distribution o f these skeletal amyloid deposits suggest analogies with localized dystrophic valvular amyloidosis. F u r t h e r studies are needed to clarify the relationship beq~e~'en"the valvular and these other forms o f localized am.yloidosis and to explore possible connections between dystrophic amyloidosis and dystrophic calcification.
REFERENCES
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1. Smith RL, Hutchins GM: Ischemicheart disease secondaryto amyloidosisof intramyocardialarteries. AmJ Cardio144:413, 1979 2. KyleRA, Bayrd ED: Amyloidosis:reviewof 236 cases. Medicine 54:271, 1975 3. Glenner GG: Amyloiddeposits and amyloidosis:tile [3-fibrilloses. N EnglJ Med 302:1283 and 1333, 1980 4. Goffin Y: Microscopicamyloiddeposits in the heart valves: a common complication of chronic damage and scarring. J Clin Pathol 33:262, 1980 5. Falk E, Ladefoged C, Christensen HE: Amyloiddeposits in calcifiedaortic valves.Acta Pathol MicrobiolScand [A] 89:23, 1981 6. PuchtlerH, Sweat F, LevineM: On the binding of Congo Red by amyloid.J HistochemCytochem10:355, 1962 7. Scott JE, Dorlingj: Differential staining of acid glycosaminoglycans (mucopolysacclmrides)by alcian blue in salt solutions. Histochemie5:221, 1965 8. CooperJH: Selectiveamyloidstainingas a functionof amyloid composition and structure. Lab Invest 31:232, 1974 9. WrightJR. Calkins E, Humphrey RL: Potassium permanganate reaction in amyloidosis.Lab Invest 36:274, 1977 10. Glenner GG: The histochemicaldemonstrationof.indole derivativesby the rosindole reactionof E. Fischer.J Histochem Cytochem 5:297, 1957 11. RavidM, GafniJ, Sohar E, et al: Incidenceand origin of nonsystemicmicrodepositsof amyloid.J Clin Patho120:15, 1967 12. SchwartzP: Amyloidosis:cause and manifestationsof senile
LOCALIZEDAMYLOIDOSISOF HEARTVALVES[Cooper]
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deterioration. Springfield, I11., Charles C Thotnas, Publishers, 1970, p 107 Kula RW, Engel WK, Line BR: Scanning for soft-tissue amyloid. Lancet 1:92, 1977 Symmers W St C: Primary amyloidosis: a review.J Clin Pathol 9:187, 1956 Cooper JH: A histochemical construct of the amyloid fibril (abstract). European Amyloidosis Research Symposium program, 1981, p 48. Coffin Y, Cornwell GG, Murdoch W: Microdeposition ofamyloid in sternoclavicular discs and sclerocalcified heart valves: a combined immunofhtorescence and Ifistochemical sntdy (abstract). European Amyloidosis Research Symposittm, 1981, p 19 Pepys MD, Dash AC, Munn EA, et ah Isolation of anayloid P
18. 19. 20. 21. 22.
component (protein AP) from normal serum as a calciumdependent binding protein. Lancet 1: 1029, 1977 Linder E, Lehto VP, Virtanen I: Atnyloid-like green birefringence in cytoskeletal 10-nm filaments after staining with Congo red. Acta Pathol Microbiol Scand [A] 87:299, 1979 Christensen HE, Sorensen KH: Local atnyloid formation of capsula fibrosa in arthrosis coxae. Acta Pathol Microbiol Scand [A] 233(snppl):128, 1972 Teglbjaerg PS, Ladefoged C, Sorensen KH, et al: Local articular amyloid deposition in pyrophosphate arthritis. Acta Pathol Microbiol Scand [A] 87:307, 1979 Ladefoged C, Christensen HE: Congophilic substance with, green dichroism in Ifipjoints in autopsy material. Acta Pathol Microbiol Scand [A] 88:55, 1980 Goffin YA, Thoua Y, Potvliege PR: Microdeposition of amyloid in the joints. Ann Rheum Dis 40:27, 1981
CORRESPONDENCE Lymphadenopathy in Leprosy
To the Editor:--In r e f e r e n c e to tile article by R.-E. Cytowic et al. entitled "Chronic Relapsing Polyneuropathy Associated with h n m u n o b l a s t i c L y m p h a d e n o p a t h y , ''t I wonder whether tile diagnosis of leprosy was taken into consideration. Lymphadenopathy in leprosy is known, although not with immunoblastic features. However, the painful neuritis, the sensoritnotor neuropathies, and especially tile features a p p a r e n t in figure 2 of their report suggest nerve involvement by Mycobacterium leprae. 2 JonAs D E WiT, MD Black Lion Hospital of the Medical Faculty of Addis Ababa University, Addis Ababa, Ethiopia 1. CytowicRE, Challa VR, Buss DH, et al: Chronicrelapsingpolyneuropathy associated with immunoblasticlymphadenopathy.Hum Pathol 13:167, 1982 2. Binford CH, Connor DH: Pathology of Tropical and Extraordinary Diseases Vol 1. Washington,DC, Armed Forces Institute of Pathology, 1976, pp 205-225 Perianal Spindle Cell Lipoma
To theEditor:--Spindle ceil Iipoma is a benign fatty neoplasm whose histologic characteristics have been well docu m e n t e d in the literature.' Several articles and monographs have stressed the clinicopathologic correlation of its occurrence in the region of the posterior neck and shoulders of older men. i n a recent case report, Robb and Joues~"described an otherwise classic spindle cell lipoma in the perianal location. We have had the opportunity to observe another such case. REPORT OF A CASE. A 51-year-old man presented with a chief complaint of a lump at the "end of his spine," which had been present for )'ears. He had had no problems with altered bowel habits or b l e e d i n g but had had a h e m o r rhoidectomy 30 years previously. T h e r e was a 6.0 x 5.0crn pedunculated lesion in the coccygeal region at the apex of the cleft arising from the skin and subcutaneous tissue. Figure 1 illustrates the typical microscopic appearance
FIGURE 1. Perianal spindle cell lipoma. The histologic appearance is identical to that of spindle cell lipamas of the neck and back. the more typical locations.
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