1. Amyloidosis is a disorder of protein metabolism characterized by abnormal extracellular deposition of proteinaceous material called amyloid. 2. Amyloidosis can be systemic, affecting multiple organs, or localized to a single organ. Systemic types include AL amyloidosis associated with monoclonal immunoglobulin light chains and AA amyloidosis associated with chronic inflammatory conditions. 3. Diagnosis involves biopsy of affected tissues stained with Congo red dye to identify the pathognomonic apple-green birefringence of amyloid under polarized light. Understanding the underlying causes is important for preventing or treating amyloidosis.

1. General Pathology
Amyloidosis
Fibrinoid, Hyalin
Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague
http://www1.lf1.cuni.cz/~jdusk/
Jaroslava Dušková

2. Amyloidosis
DEF.:
disorder of protein
metabolism accompanied
with abnormal extracellular
deposition of proteinaceous
material - amyloid

3. Amyloid = starch like
Karl Freiherr von Rokitansky (1804-1878)
Rudolf Ludwig Karl Virchow (1821-1902).
Amyloid - history

4. Karl Freiherr von Rokitansky (1804-1878)
Austrian pathologist, born February 19, 1804,
Königgrätz, Böhmen, Austrian Empire (now
Hradec Králové, East Bohemia, Czech
Republic); died July 23, 1878, Wien.
Handbuch der pathologischen Anatomie
IInd Band, Wien 1842
Amyloid - history 2.

5. Amyloidosis – morphology
Macroscopy:
 small amounts – invisible
 larger deposits – enlarged,
firm, waxy organs

6. Ultrastructure &
Biochemistry of Amyloid
90-95% non branched
fibrils diam. 10-12nm
5-10% p-component - glycoprotein +
fibronectin, laminin, collagen 4

7. Amyloidosis
conformational disease
(Carrell and Lomas, Lancet, 1997)
„…arises when a constituent protein
undergoes a change in size or
fluctuation in shape with resultant
self - association and tissue
deposition“
pleated β – sheet structure

8. Conformational diseases
(Carrell and Lomas, Lancet, 1997)
 Amyloidosis
 Prionoses - transmissible
spongiform encephalopathies (incl. m.
CJD)
 m. Alzheimeri
pleated β – sheet structure

9. Amyloidosis
Classification:
 according to the source protein
(more than 20 different identified)
 according to the distribution
 systemic (generalised)
 localised

10. Systemic Amyloidosis - I.
AL - imunocyte dyscrasia associated
light chains Ig (mostly )
„primary“
Distribution: tongue, heart, GIT, liver,
spleen, kidney
Associated diseases: Plasma cell myeloma,
B cell lymphoma,

11. Systemic Amyloidosis - II.
AA - reactive systemic amyloidosis
SAA = Serum Amyloid Associated
protein „secondary“
Distribution: liver, kidney, spleen, GIT, lymph nodes,
bowel, adipose tissue
Associated diseases: rheumatoid arthritis, chronic
infections (tb, leprosy, bronchiectasiae,
osteomyelitis, IBD, neoplasms MLH , RCC

12. Systemic Amyloidosis - III.
senile systemic SSA
25% people over the age of 80 years (!)
-normal transthyretin TTR (prealbumin)
-mostly heart & vessels invilvement

13. Systemic Amyloidosis - IV.
A2 - hemodialysis associated
2 microglobulin
Hereditary
AA - Familial Mediterranean Fever
ATTR - Famil. polyneuropatia
transthyretin (mutated form)

14. Systemic Amyloidosis - complications
diminished functions of some organs, esp.
KIDNEY FAILURE
IIIrd stage Amyloid nephrosis

15. Localised Amyloidosis - I.
Senile cardial
ATTR - transthyretin -
(structurally normal)
Senile cerebral
A -  -amyloid
protein

16. Cardiac Amyloidosis – clinical manifestations
 Dilated Cardiomyopathy (predominant systolic
dysfunction)
 Restrictive cardiomyopathy (predominant diastolic
dysfunction)
 Congestive heart failure
 Rhytm abnormalities
 Coronary insufficiency
 Valvular dysfunction
 Pericardial tamponade
 Enhance sensitivity to digitalis glycosides
 Atrial thrombosis - embolisation

17. Localised Amyloidosis - II.
Endocrine
ACal - ca medullare gl. thyreoideae
AIAPP - islets of Langerhans associated
AANF - isolated atrial amyloidosis
atrial natriuretic polypeptide
Nodular tumoriform amyloid deposits
(tongue, lung,larynx, skin, urinary bladder, orbita)

18. Clinical Diagnosis of Amyloid
Scintigraphy (in vivo)
using human serum amyloid component
marked with 123J
Echocardiography
(atrial amyloid)

19. Clinical Diagnosis of Amyloid
Biochemistry
sequening DNA -hered. forms
extraction of fibrils (from a biopsy
specimen)
spectrometry
sequening of the amyloid protein

20. Amyloidosis – morphology
Macroscopy:
 small amounts – invisible
 larger deposits – enlarged,
firm, waxy organs

21. Morphological
Diagnosis of Amyloid
Macroscopy
–reaction Virchow I (sol. Lugolli)
Virchow II (H2SO4)

22. Morphological
Diagnosis of Amyloid
Microscopy:
– KONGO red
(+POLARISATION!) + KMnO4
– thioflavine S,T
– crystal. violet (metachromasia)
– IMMUNOHISTOCHEMISTRY
(electron microscopy)

23. Morphological Diagnosis of Amyloid
Materials:
–GIT (stomach, duodenum rectum, gingiva)
biopsy
– kidney
– sural nerve & muscle
– fat aspiration biopsy – needle with an internal
diam. 0,7-1,2mm
Röcken Ch. Sletten K.: Amyloid in Surgical Pathology
Virchows Arch., 2003, 1-26

24. CONGO Red
 synthesized by young chemist at Bayer comp. 1883 as
the first of economically lucrative direct (nod needing a
mordant) textile dyes
 patented by AGFA 1885
(Aktiengeselschaft für Anilinfarbenfabrikation)
3 weeks after the conclusion of the
West Africa Conference
 to Europeans in 1885, the word Congo evoked exotic
images of far-off central Africa known as The Dark
Continent
 the Congo red stain was named „Congo“ for marketing
purposes by a German textile dyestuff company in 1885
Steensma DP: „Congo“ Red. Out of Africa? Arch. Pathol.Lab.Med.,2001, 125, 250-2

25. Reversibility of Amyloid
The deposits are NOT irreversible.
e.g. Hrncic R. et al: Antibody mediated
resolution of light chain – associated amyloid
deposits. Am.J. Pathol., 2000, 157,12369-46
Progression of generalised amyloidosis
can be delayed or stopped by treatment
of the underlying disease.
Röcken Ch. Shakespeare Ann: Pathology,
diagnosis and pathogenesis of AA amyloidosis.
Virchws Arch. , 2002, 440, 11-122

26. Prevention & Therapy of Amyloid
 Prevention & treatment of the
underlying diseases
 Vaccination against β am. protein in
mice diminished senile plaque formation
and improved memory.
Nature Medicine, 2001, 7, 18th Jan.
A β –based experimental therapies
based on degrading enzymes.
Zlokovic et al.: Neurovascular
Pathways and Alzheimer Amyloid β-peptide. Brain
Pathol. , 2005, 15, 78-83

27. Fibrinoid & Hyalin
disorders of protein metabolism

28. Fibrinoid Change of
Collagen
 vessels and connective tissue damage
plasmorrhagia (leakage of plasma)
deposits of Ag-AB complexes
staining characteristics fibrin - like

29. Hyaline change
Definition (historical, descriptive):
intra- or extracellular change
of homogenous rose „ glassy“
appearance
in the H&E stained histological
sections

30. Hyaline change
Extracellular:
corpus albicans, scars, hyalinoses of
serous membranes
Intracellular:
Crooke cells, Mallory´ hyaline,
Russell bodies

31. Ultrastructure
 Fibrinoid - collagen fibres
surrounded by plasma
proteins may be reversible
 Hyalin – collagen fibres
increased in thickness,
changed architecture rather
stable

32. Hyaline change
Extracellular:
corpus albicans, scars, hyalinoses of
serous membranes
Intracellular:
Crooke cells, Mallory´ hyaline,
Russell bodies

33. Significance of Fibrinoid
Change
 diminished quality of the collagen
( firmness, permeability)
 tendency to thrombosis in the
vessels, aneurysms formation

34. Significance of Hyalin
Change
 diminished quality of the
collagen ( elasticity)
 ischemia in organs with
thickened arterial walls
 intracellular - function, death