by post graduates from Maratha Mandal's NathajiRao Halgekar Institute of Dental Sciences, Belgavi. A step wise presentation of Amylodosis covering, INTRODUCTION DEFINITION HISTORY PHYSICAL NATURE CHEMICAL NATURE CLASSIFICATION PATHOGENESIS STAINING CHARACTERISTICS DIAGNOSTIC TESTS MORPHOLOGY CLINICAL FEATURES TREATMENT PROGNOSIS

2. Amyloidosis/am-uh-loi-DO-sis//

3. CONTENTS
• INTRODUCTION
• DEFINITION
• HISTORY
• PHYSICAL NATURE
• CHEMICAL NATURE
• CLASSIFICATION
• PATHOGENESIS
• STAINING CHARACTERISTICS
• DIAGNOSTIC TESTS
• MORPHOLOGY
• CLINICAL FEATURES
• TREATMENT
• PROGNOSIS

4. INTRODUCTION
• The fibrils are formed by the aggregation of misfolded, normally
soluble proteins .
• Deposition of amyloid fibrils is usualy extracellular.
• Amyloidosis or “protein aggregation diseases” should not be considered as
single disease entity its rather a group of inherited & inflammatory disorders
which are resposible for tissue damage and functional compromise.

5. Definition :
Amyloidosis is the term used for a group of diseases
characterised by extracellular deposition of fibrillar insoluble
proteinacious substance called amyloid having common
morphological appearance, staining properties and physical
structure but with variable protein (or biochemical) composition.

6. HISTORY
• First described by Rokitansky in 1842.
• Term first used by Rudolf Virchow in 1854 based on the
color after staining it with crude iodine- staining techniques.
• Later recognized as Protein by Friedreich and Kekule 5
years later.

7. PHYSICAL NATURE

8. On Electron microscopy
These fibrils are
• continuous,
• non- branching,
• insoluble,
• linear,
• rigid and
• measures 7.5 - 10 mm in diameter
• Double-helix
• Twin filament with clear space in between. .

9. Thus called
“beta fibrillosis”
On X-Ray Crystallography & Infrared spectroscopy
• Characteristic Beta pleated sheet
confirmation.
• 1000Amstrong periodicity.
Amyloid protein chains Congo red molecules
Fibril composed of paired filament
Beta plated sheets

10. Chemical Nature of Amyloid
Fibrillar protein
(95%)
Non-Fibrillar Protein
(5%)

11. The most common forms of amyloid fibril proteins are:
1. Amyloid light chain(AL)- made up of complete immunoglobulin light
chain, derived from the lambda light chain.
2. Amyloid associated(AA)- derived from a unique non-Ig protein made by
the liver, derived from larger precursor protein SAA(serum amyloid
associated protein)

12. Others :-
1.Aβ2 Microglobulin(AβM)-seen in patients on long term hemodialysis
2.Transthyretin(TTR) - serum protein synthesized in liver
& transports thyroxine and retinol.
4. Amyloid β-peptide(Aβ)- seen in Alzheimers disease.
5. Prion proteins(APrP)
6. Precursor of AA=SAA(Serum Amyloid Associated Protein)

13. NON FIBRILLAR AMYLOID PROTEINS ARE
• 1.Amyloid P(AP) – predominant
• (stacks of doughnut-shaped proteins)
• 2.Apolipoprotein-E (apoE)
• 3.Sulfated glycosaminoglycans(GAGs)
(responsible for the positive reaction with iodine.
• 4.Alpha-1 anti-chymotrypsin
• 5.Protein X
• 6. proteases & membrane constituents .

14. PATHOGENESIS OF AMYLOID DEPOSITION
 BASIC MECHANISM
 SPECIFIC ENTITIES

17. CLASSIFICATION

19. PRIMARY AMYLODOSIS(AL TYPE)
(ASSOCIATED WITH IMMUNOCYTE DYSCRASIAS)
Most common form
Associated with plasma cell dyscrasias
Monoclonal plasma cells synthesis either Lamba & kappa chains that
gives M (myeloma) protein spikes on serum electrophoresis
Due to small molecular size- Bence Jone’s protein is found in urine.

20. Secondary Amylodosis
(Reactive systemic amylodosis)
• Secondary to infective conditions like TB, bronchiectasis, chronic
osteomyelitis
• Inflammatory conditions like Rheumatoid arthritis, Ankylosing
spondylitis,
• Inflammatory bowel disease, Crohn’s and ulcerative colitis
• “ skin popping” in heroin abusers
• non immunocyte derived tumors like renal cell carcinomas and
Hodgkin’ssecondary

21. Familial Hereditary Amyloidosis
• it is an autosomal recessive disease
• Seen in Mediterranean region (Jews, Armenian, Arabs and Turks)
• Characterised by periodic attacks of fever and polyserositis i.e.
inflammary involvement of the pleura, peritoneum and synovium
causing pain in the chest, abdomen and joints respectively.
• It is AA type, suggesting relationship to secondary amyloidosis due to
chronic inflammation.

22. LOCALISED AMYLOIDOSIS
• Limited to a single tissue or organ.
• Can be only microscopic foci or maybe evident grosslsy as nodular
masses.
• The common sites : lungs, Larynx, Skin, Bladder, Tongue, etc.
• Microscopic findings: Lymphocytes and plasma cells can be seen in
the periphery of the amyloid deposits.
• Some cases the amyloid consists of AL protein.

23. STAINING CHARACTERISTICS

24. •1.Stain on Gross- oldest method
used by Virchow on cut section of
gross specimen is Lugols Iodine
which imparts mahogany brown
colour to the amyloid deposit which on
addition of sulfuric acid turns blue.

25. •2.In routine histological sections
(hematoxylin and eosin stains)
amyloid appears amorphous,
eosinophilic, hyaline, extracellular
substance.
• However all proteins are stained
pink by eosin and thus this stain is
not specific

26. •3.All amyloids stain pink-red with the Congo Red
stain

27. •But when these sections
are viewed with polarized
light they exhibit a apple
green birefrigence. This
feature of amyloid can be
used to identify it in tissue
sections.

28. • Loss of Congo Red staining caused
by pretreatment of the tissue with
potassium permanganate is a useful
tool for the diagnosis of amyloidosis
AA.

29. •4.Metachromatic
stains(rosaniline dyes) i.e dye
reacts with amyloid and
undergoes color change-methyl
voilet/crystal voilet imparts rose
pink color.

30. • 5.Flourescent stains-
Thioflavin- T/Thioflavin S- on
ultravoilet light imparts
yellow flourescence.

31. • 6.Immunohistochemistry stains-positive with
anti-AA stain

32. DIAGNOSIS

33. • Presence of amyloid:
- Evaluation of organ involvement (In-vivo tests & Imaging )
- Tissue Biopsy and its histology
- Congo red staining
• Type of amyloid:
Immunohistochemistry. – “anti-AP stain”
anti-AA
anti-lamba & anti-kappa antibody stains.
• Mutation type: amino acid sequence analysis.

34. Imaging techniques
• Technetium scan: .
• Technetium labeled aprotinin more sensitive.
• Quantitative scintigraphy
-Done with iodine-123- labeled serum amyloid P component (sensitive for
AL, ATTR and AA )
• Cardiovascular magnetic resonance imaging (CMR)
• Research:
-Magnetic Resonance Microimaging
-Near infrared imaging using an oxazine- derivative probe
• Scintigraphy with radiolabeled serum amyloid(SAP-SERUM AMYLOID
P component) -component is rapid & specific test since SAP binds to
amyloid, it gives measure of extent of amyloidosis.

35. Instrumental methods
• Ultrasonography: kidney’s size (non- specific)
• CT scanning: with technetium which binds to soft-tissue
amyloid deposits (to monitor progression)
• Radiolabeled P-component gamma scanning:

36. OTHER TESTS
AL-Diagnosis
• -protein electrophoresis immunoelectrophoresis of serum and urine.
• bone marrow aspiration.
• Serum immunoglobulins (to exclude AL)
In AA amyloidosis :
• polyclonal hypergammaglobulinemia
• IL-1,6 levels
• SAA as an exquisitely sensitive acute phase protein (more sensitive than CRP)
Immunohistochemistry- to know the type of amyloid.
Eg :- “anti-AA stain."

37. Morphlogical features
of amyloidosis of organs

38. Amyloidosis of different organs show variation in morphologic patterns.
general features are:
Grossly- affected organ is large, grey, waxy and rubbery(firm
consistency).
Microscopically: deposits are always extracellular,begins between the
cells close to the basement membrane and are
amorphous,eosinophilic.

39. Amyloidosis of KIDNEY
• Most common and serious form.
• Grossly,kidneys may be normal-sized, enlarged or shrunken
in advance cases because of ischemia.
• C/S is pale, waxy,translucent.
• Microscopically, amyloid deposit primarily in glomeruli, but
arteries, arterioles and peritubular tissues are also affected.

40. MACROSCOPIC KIDNEY
MICROSCOPIC KIDNEY

41. Amyloidosis of spleen
• Amyloidosis of the spleen has two
different anatomical patterns.
• Most commonly, the amyloid deposition is limited to the splenic
follicles, resulting in the gross appearance of a moderately enlarged
spleen dotted with gray nodules (so called "sago" spleen). .

42. Microscopicaly
-deposits involve the
red pulp in the wall
of splenic sinuses,
small arteries and
connective tissue.

43. Alternatively, the amyloid deposits may spare the follicles
and mainly infiltrate the red pulp sinuses, producing a
large, firm spleen mottled with waxy discolorations
showing map like areas ("lardaceous" spleen)

44. Amyloidosis of liver
Grossly, liver is enlarged, pale, waxy & firm.
Microscopically-
Amyloid initially appears in space
of disse(space b/w the
hepatocytes & sinusoidal
endothelial cells).
Later,disappearence of hepatocytes occur
due to pressure atrophy.
Vascular involvement & deposits
in kupffer cells are frequent.

45. Amyloidosis of heart
• It may occur in any form of systemic amyloidosis.
• Grossly,heart is enlarged and firm.
• Epi/endocardium and valves show tiny nodular deposits.
• Microscopically-focal subendocardial accumulations,in primary
form,deposits are seen around myocardial fibres in ring forms
also known as ring fibres,
• In localized,deposits seen in left atrium.

46. Brain
(Alzheimers disease.)
• AD and many other neurodegenerative
disorders belong to the family of protein
misfolding diseases, characterized by
protein self-aggregation and deposition.
• In vivo detection of amyloid plaques &
neurofibrilary tangles in the brain enables
early identification of AD.
• Molecular PET imaging using beta-sheet
binding agents has the potential to be
extended to these wide spectrums of
protein misfolding diseases.

47. Other organs
• Alimentary tract
-may occur at any level from oral cavity to anus,
deposits initially in vessel wall and then adjacent layers of
bowel wall.In tongue can cause macroglossia.
• Respiratory tract
- involved focally or diffuse from larynx to
bronchioles.

48. CLINICAL FEATURES

49. Presentation is broad and depends on the site and type of amyloid accumulation.
Clinical suspicion:
unexplained nephropathy, cardiomyopathy, neuropathy,
enteropathy, arthropathy or macroglossia.
• The kidneys and the heart are the most commonly involved organs
In some tissues amyloid accumulation causes organ
enlargement.
However, in certain other tissues amyloid deposits
cause progressive decline in
organ function and ultimately organ failure.

50. • Renal :-
- proteinuria ± ↑ Urea/↑SCr
-nephrotic syndromes
-20% death from amyloidosis.
- mostly in secondary amyloidosis.
Cardiovascular Heart:
- pressure atrophy on myocardial fibre=> ventricle impaired .
-may present with either diastolic or systolic heart failure.
Right Ventricular dysfunction more common than Left V dysfunction.
- may also cause conduction abnormalities as it deposites on the walls of the
vessel.
eg :- atrioventricular block, sinus node dysfunction, low voltage complexes on the ECG.

51. Cardiovascular Blood vessels: -
-↑ed susceptibility to bruising/bleeding around the eyes
(Raccoon eyes)
- caused by deposition of amyloid in vessels around the eyes + ↓ed activity of
Factor X and Thrombin

52.  -Macroglossia (˂ 15%) due to accumulation of amyloid in the tongue
 - dyspnoea
 - obstructive sleep apnoea
 dysphagia/dysphonia
 Sialorrhea
 Angular chelitis
 Crenated tongue
 Orthodontic abnormalities

53. Central Nervous System
- Dementia
(Alzheimer’s disease, Down’s
Syndrome)
- Haemorrhagic strokes
(2° to Cerebral amyloid
angiopathy)
Peripheral Nervous System
- Peripheral neuropathy
- Autonomic neuropathy
eg:- postural hypotension, GIT
symptoms
Nervous System:

54. Liver:
- liver enlargement .
- Functions normal even at an advanced stage.
- ↑alkaline phosphatases ± ↑ transaminases
Spleen:
- splenic enlargement (˂ 5% of cases)
- splenic dysfunction (˃ 25% of cases)Normal spleen

55. GIT (amyloid deposits seen in 80-90% of cases, only 1% are symptomatic):
- Malabsorption
- recurrent abdominal pain
- chronic diarrhea
Citation: . COLONIC AMYLOIDOMA: A RARELY ENCOUNTERED FINDING. Program No. P1878. World Congress of Gastroenterology at ACG2017 Meeting Abstracts. Orlando, FL: American
College of Gastroenterology.
Mucosal folds
Yellow discolorations
Deposits with
shelf like cover

56. Musculoskeletal:
- “Shoulder pad sign”: enlargement of the anterior shoulder
due amyloid deposition in periarticular soft tissue

57. Involvement of the synovial space may result in
chronic synovitis (Carpal tunnel syndrome in the wrist)
This involves distribution of
median nerve as shown. Patients
present with complaints of
numbness, pins and needles
sensation, or pain or both. It can
occur at night.

58. - lichenoid papules appearing bilaterally on the shins
( Lichenoid amyloidosis)
- nodules involving the acral area (nodular amyloidosis)
Lichenoid amyloidosis
• Skin:
- macular rash on the interscapular
region of the back (Macular amyloidosis)
Macular amyloidosis

59. Endocrine organs:
- Hypothyroidism 2° to infiltration of the thyroid gland
- Hypoadrenalism
- Type II Diabetes mellitus

60. TREATMENT
• Amyloidosis has no cure
• Initial management should include an assessment of the degree of organ involvement.
• Treatment goals are two-fold:
- supportive therapy
- measures targeted at limiting further production of amyloid protein (...where this is
possible)
Supportive therapy
- - Patient counselling
- - Pain medication
- - Diuretics
- - Low salt diet
- - Dietary modifications especially in those with GIT amyloid

61. Prognosisvaries with the type of amyloidosis.
• AL amyloidosis carries the worst prognosis if left untreated with median
survival of two years (↓es with ↑ing severity).
. • Outcomes in patients with AA amyloidosis depends on the underlying disease
and symptoms may improve if the underlying condition is treated.
• People with ATTR have the best prognosis and may survive over a decade.
Cause of death in most cases of amyloidosis is cardiac arrhythmias & renal failure.

62. Reference
• Harsh Mohan Text book of General Pathology.
• Robinsons Text book
• Citation: . COLONIC AMYLOIDOMA: A RARELY ENCOUNTERED FINDING. Program No. P1878. World Congress of Gastroenterology at ACG2017 Meeting Abstracts. Orlando, FL: American College of
Gastroenterology.
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