Renal Amyloidosis Associated With 5 Novel Variants in the Fibrinogen A Alpha Chain Protein.

INTRODUCTION: Fibrinogen A alpha chain amyloidosis is an autosomal dominant disease associated with mutations in the fibrinogen A alpha chain (FGA) gene, and it is the most common cause of hereditary renal amyloidosis in the UK. Patients typically present with kidney impairment and progress to end-stage renal disease over a median time of 4.6 years. METHODS: Six patients presented with proteinuria, hypertension, and/or lower limb edema and underwent detailed clinical and laboratory investigations. RESULTS: A novel FGA gene mutation was identified in each case: 2 frameshift mutations F521Sfs*27 and G519Efs*30 and 4 single base substitutions G555F, E526K, E524K, R554H. In 5 subjects, extensive amyloid deposits were found solely within the glomeruli, which stained specifically with antibodies to fibrinogen A alpha chain, and in one of these cases, we found coexistent fibrinogen A alpha chain amyloidosis and anti-glomerular basement membrane antibody disease. One patient was diagnosed with light-chain amyloidosis after a bone marrow examination revealed a small clonal plasma cell population, and laser microdissection of the amyloid deposits followed by liquid chromatography and tandem mass spectrometry identified kappa light chain as the fibril protein. DISCUSSION: We report 6 novel mutations in the FGA gene: 5 were associated with renal fibrinogen A alpha chain amyloidosis and 1 was found to be incidental to light-chain amyloid deposits discovered in a patient with a plasma cell dyscrasia. Clinical awareness and suspicion of hereditary amyloidosis corroborated by genetic analysis and adequate typing using combined immunohistochemistry and laser microdissection and mass spectrometry is valuable to avoid misdiagnosis, especially when a family history of amyloidosis is absent.

Myocardial uptake of bone scintigraphic agents associated with increased pulmonary uptake.

OBJECTIVE: Due to delivery problems with the most commonly used bone scintigraphic agent medronate-(99m)Tc-methylene diphosphonate (MDP) (medronate), several regional institutions changed, at various time points, to (99m)Tc-dicarboxypropane diphosphonate (DPD) (Teceos) from 2010. Extraosseous uptake, in particular, myocardial uptake, was observed in a number of patient examined with DPD, with reduced quality of the bone scans. Additionally, an increase in pulmonary uptake was apparent in many of these patients. The aim of this quality control was to assess pulmonary soft tissue uptake in the patients with high myocardial uptake. METHODS: A retrospective analysis of the 2435 bone scintigraphies performed during a 3-year period revealed relatively intense myocardial uptake in 10 of the 1195 patients examined with DPD (Teceos). A comparison of pulmonary uptake in a control group of age- and gender-matched subjects and a control group of patients examined with the same preparation of DPD were assessed. RESULTS: In patients with cardiac uptake of DPD, it could also be shown a relatively intense background uptake in the lungs with significantly higher uptake ratio over intercostals regions versus the abdomen, compared to the control groups. Furthermore, we found, as already well documented, a significantly lower bone to soft tissue uptake in these patients, as quantified by a femur to surrounding soft tissue ratio. CONCLUSION: Cardiac uptake of bone scintigraphic agents is associated with high pulmonary uptake. This may be a sign of pulmonary involvement which may give extraosseous bone tracer uptake its own importance and DPD a new role.

Nasal and ocular amyloidosis in a 15-year-old horse.

Localized nasal, conjunctival and corneal amyloidosis was diagnosed in a 15-year-old pony with nasal and conjunctival masses and severe dyspnoea. Multiple swellings had been evident in the nostrils for at least two years and had gradually increased in size before presentation due to dyspnoea and exercise intolerance. Surgical debulking of the masses was performed and histological examination revealed large amounts of extracellular, hyaline, eosinophilic, Congo red positive material in the lamina propria of the nasal mucosa. A tentative diagnosis of localized nasal amyloidosis was made. The treatment relieved the clinical signs, however, the nasal masses recurred and bilateral conjunctival, papillary masses developed. The horse was euthanized. Nodular nasal and papillary conjunctival masses consisting of rubbery, grey to yellow tissue were found at necropsy. At the limbus this tissue infiltrated and expanded the cornea. The masses consisted of amyloid and moderate infiltrates of T lymphocytes and B lymphocytes were present in the tissue. No predominance of either cell type was observed and no distinct neoplastic mass could be identified. Ultrastructural examination of the nasal mucosa and cornea confirmed the presence of abundant extracellular deposits of non-branching fibrils ranging from 9-11 nm in diameter consistent with amyloid. Immunohistochemistry of amyloid revealed no labelling for AA amyloid, and no peptides representing serum amyloid A (SAA) were detected by microscopic laser dissection and subsequent mass spectrometry. Peptides from immunoglobulin kappa-like light chains were detected and are suggestive of AL amyloidosis, however the results were inconclusive and a final identification of the amyloid protein could not be made.Nasal amyloidosis is a clinical entity of localized amyloid deposits in the horse. Localized amyloidosis involving the conjunctiva of the horse is previously described in only seven cases and the present case is the first case of combined, localized nasal and corneal amyloidosis in the horse. In several reported cases surgical excision has provided clinical improvement and return to normal levels of exercise, while medical treatment has had no effect. The present case however, shows that rapid recurrence and progression of nasal amyloidosis to involve ocular tissues can occur and lead to recurrent respiratory obstruction.

Serum amyloid P component in mink, a non-glycosylated protein with affinity for phosphorylethanolamine and phosphorylcholine.

Experimental AA amyloidosis in the mink is used as a model for the amyloid disease process. In that context it is important to characterize the different proteins involved in the amyloid formation. In the present work, we have characterized the serum amyloid P component (SAP) in mink. SAP was purified from serum by affinity chromatography using phosphorylethanolamine-coupled ECH-sepharose 4B. SDS-PAGE showed one major protein band (approximately 26 kDa) together with one minor band (10% of the major band) with a higher molecular mass (approximately 30 kDa) corresponding to a non-glycosylated and a glycosylated variant. All SAP molecules elucidated so far have at least one major subunit that is heavily glycosylated. It is therefore the first time that a non-glycosylated SAP protein is found in a mammalian species. The amino acid sequence was established using Edman degradation and mass spectrometry. As expected, the protein showed high homology with the other mammalian SAP molecules, ranging from 73% (human) to 63% (mouse). The SAP protein showed affinity for phosphorylcholine and thus expressed CRP-like properties.

Splenic ellipsoids: an early target for deposition of AA amyloid induced in mink.

The spleen is the primary target for spontaneous as well as experimental AA amyloidosis in animals such as mice and mink, and is therefore a valuable organ for study of the initial phases of amyloid fibrillogenesis and deposition. We have investigated splenic amyloid AA deposits induced in the mink, and we demonstrate a novel target for AA, namely the splenic ellipsoids. We show presence of amyloid P component (AP), glycosaminoglycans (GAGs) and apolipoprotein E (apoE), all well-known common elements of amyloid, co-localizing with AA. In addition, apolipoprotein AI (apoAI) was seen co-localized to the AA deposits in the ellipsoids. We hypothesize that the ellipsoids may be important splenic structures for initial AA formation. The apoAI in the ellipsoids could displace SAA from acute phase HDL at this site, thereby making SAA available for amyloid formation and deposition.