Amyloid Substance Research Articles

#6325 A LONG TERM EXPERIENCE OF MANAGEMENT OF BIOPSY-PROVEN RENAL AL AMYLOIDOSIS WITH DARATUMUMAB MONOTHERAPY

Abstract Background and Aims Daratumumab is an anti-CD38 monoclonal antibody recently approved as a first-line therapy on top of standard therapy for the treatment of multiple myeloma and AL amyloidosis. The mechanism of action of Daratumumab is based on its ability to bind CD38, a transmembrane receptor expressed in particular by pathogenic plasma cells, inducing their death through multiple intra and extracellular signaling mechanisms and thus interrupting the production of monoclonal light chains and consequently the deposition of new amyloid substance. The following data describe the good results reported by our group and the long-term experience achieved in recent years on the efficacy of daratumumab used in monotherapy. Methods This paper describes 17 patients affected by AL amyloidosis who were treated with Daratumumab alone, 24 iv administration at a dose of 16 mg/kg. All of them had an histological confirmation and staging of renal involvement before treatment was started and were ineligible for ASCT A bone marrow biopsy excluded overt multiple myeloma and the patient could either be naïve or refractory. Haematological and organ response was evaluated every 4 infusions by checking NTproBNP, dFLC and FLC ratio, serum creatinine, Upt (24h), serum and urine IF; responses were defined by using the International Society of Amyloidosis extended criteria. When feasable, the patient who underwent the whole cycle of therapy underwent a second kidney biopsy at the end of the treatment. Results | mean age at diagnosis was 73 years. 16 out of 17 patients had proteinuria (in the nephrotic range in 11) that was associated with renal function impairment in 11. Two patients were on dialysis at the time of therapy initiation. 9 patient completed the treatment; 13 over 17 underwent at least 12 infusions. At this time, At the 12 th administrations 11 out of 13 pts (84,6%) had an overall hematological response. 6 pts (46,5%) achieved a complete hematological response, 5 pts had a very good partial response (38%), and 2 were non responders (15,5%). As regard to renal response 5/13 had already achieved an organ response; 6 didn't meet renal response criteria yet; the 2 patients who were in dialysis at the time of therapy initiation, remained on dialysis. 1 of them had a complete hematological and cardiac responses, the remaining pt didn't have any response. 7/9 achieved a renal response; the 2 remaining patients who were in dialysis at the time of therapy initiation, remained on dialysis. A significant decrease in 24-hour proteinuria from 6,02 g/24 hours (range 0,8 – 16,8) to 1,28 g/die (range 0,9 – 3,6 gr/die, p < 0.005) with stabilization or improvement of sCr (from 1,66 mg/dl to 1,1 mg/dl, p = 0.17) were observed. 8/9 patients with cardiac involvement obtained at least amelioration. At the end of follow-up (mean 30 months, range 19-46) 5 patients have persistent hematological and renal response. One patient with initial partial response had a relapse and initiated a treatment with Bortezomib plus cyclophosphamide and dexamethasone. Two patients died to COVID infection and cardiovascular disease respectively. The last patient is still alive and is currently being treated with a second line of therapy, because no hematologic or organ response was achieved with Daratumumab. 7 patients underwent a second kidney biopsy at the end of the treatment. Histological findings showed stable deposits in 6 over 7 cases, while the last one showed a reduction in the extention and amount of amyliod deposits. Conclusion The optimal management of patients with AL amyloidosis remains to be defined. In particular patients who are ineligible for transplant continue to have a poor outcome. In recent years daratumumab has emerged as an appealing therapeutic alternative as shown by several reports. However, in clinical trials daratumumab was always added to bortezomib, cyclophosphamide and dexamethasone. Our data, based on the real life experience of our center, suggest that daratumumab monotherapy may represent an effective therapeutic option, capable not only of inducing a substantial improvement in the renal status in pretreated or naïve patients, but also of limiting progression of amyloid deposition.

P351 FATAL RECURRING SYSTEMIC THROMBOEMBOLYSM IN A PATIENT WITH CARDIAC AL AMYLOIDOSIS WITHOUT EVIDENCE OF ATRIAL FIBRILLATION

Abstract Backgound: Cardiac amyloidosis is associated with an increased thromboembolic risk. While the need to anticoagulate patients in atrial fibrillation regardless of the CHA2DS2–VASc score is evident, it is not clear whether and which patients in sinus rhythm should be treated with anticoagulant drugs Case Presentation A 51–year–old man presented with repeated episodes of chest pain and exertional dyspnea. The ECG showed synus rhythm, left–axis deviation, 1st degree AV–block, left anterior hemiblock and no significant anomalies of ventricular repolarisation. Transthoracic echocardiography revealed markedly thickened left ventricular (IN) walls (maximum interventricular septum dimension 18 mm) with a granular–sparkling appearance of the myocardium, bi–atrial enlargement, preserved LV ejection fraction (EF 52%), restrictive mitral flow pattern with a very small A–wave, thickened interatrial septum and atrio– ventricular valves; circumferential pericardial effusion ( maximum 11mm). Laboratory tests showed an increase in troponin and NTproBNP levels and serum and urine immunoelectrophoresis showed a monoclonal component in zone kappa. A periumbilical fat biopsy was negative for amyloidosis so the patient underwent an endomyocardial biopsy which showed positive Congo red, and immunohistochemistry positive for kappa light chains and negative for transthyretin. A diagnosis of cardiac amyloidosis AL was then made and the patient was referred to the hematologist to perform specific therapy. One week after discharge he was hospitalized for acute pain in the lower limbs due to acute thrombosis of the left common femoral artery treated with Fogarty embolectomy. Discharged in therapy with low molecular weight heparin after a few days he was again symptomatic for pain in the lower limbs and went to the emergency room where he died of electromechanical dissociation. Conclusions Our case demonstrates that cardiac AL amyloidosis is associated with an increased thromboembolic risk, irrespective of the presence of atrial fibrillation, for the hematological disease itself and for the infiltration of the atrium by the amyloid substance. This suggests that in selected cases, with reduced A–wave amplitude and evidence of impaired atrial mechanics, empirical anticoagulation should be considered even in sinus rhythm.

P479 PATIENT WITH REGRESSION MULTIPLE MYELOMA AND INFILTRATIVE HYPERTROPHIC CARDIOMYOPATHY OF NDD UNDERGO CARDIAC TRANSPLANT

Abstract Introduction We report the case of a 52–year–old patient with a history of multiple myeloma undergoing chemotherapy treatment according to the DaraRD scheme and currently in remission. Associated with haematological pathology, infiltrative hypertrophic cardiomyopathy of ndd is highlighted. Following haematological and instrumental screening tests, the patient underwent a heart transplant for frequent exacerbations of heart failure. Case Report A 52–year–old patient, suffering from multiple myeloma for about 1 year, for which he began chemotherapy treatment with DaraRD scheme and good response to therapy. The patient also presented dyspnoic symptoms and declining edema with echocardiographic finding of infiltrative hypertrophic heart disease for which he undergoes diagnostic investigations. He performs: • Serial echocardiograms which showed marked uniform hypertrophy with ground glass appearance of the left ventricle and severely reduced systolic function; • PET–CT with no hyperaccumulation of the radiopharmaceutical; • Cardiac MRI with evidence of severely hypocontractile left ventricle and wall changes which could be associated with amyloid infiltration; • myocardial scintigraphy that does not give evidence for the deposit of the amyloid substance of the ATTR type in the heart; • biopsy of umbilical fat and cardiac biopsy, both negative for deposition of substance AL with Congo Red staining; • Right cardiac catheterization with evidence of post–capillary pulmonary hypertension. The patient was subjected to several exacerbations of heart failure which required continuous infusion therapy with inotropes and, ultimately, heart transplantation. At the time of surgery, the heart appeared enlarged, extremely hypocontractile and with rigid walls, with poor compliance of the ventricular muscle wall. The patient responded well to the surgical procedure, in the absence of signs and symptoms of rejection, with improvement of general clinical condition. Conclusions At the end of the surgical procedure and the rehabilitation period, the patient was discharged home, without showing signs and symptoms of graft rejection or multiple myeloma exacerbations, in stable and satisfactory general clinical conditions.

P2 A RARE CASE OF MUTANT TRANSTHYRETIN CARDIAC AMYLOIDOSIS

Abstract A 65–year–old man with a history of multiple hospitalizations in the past 12 months for heart failure with preserved left ventricular ejection fraction (HFpEF) attended the emergency department for exertional dyspnea, peripheral edema, abdominal bloating, and weight gain. An ECG showed sinus bradycardia with first degree AV block, RBBB, and inferior pseudo–q. Blood tests showed NT–proBNP 8985 pg/ml, troponin hs–cTnI 106 ng/L. An echocardiogram demonstrated severe left ventricular hypertrophy, EF 50%, GLS –11% with apical sparing, and restrictive transmitral pattern, raising suspicion of infiltrative disease (Figure 1). A cardiac MRI corroborated the suspicion, showing altered gadolinium kinetics, diffuse subendocardial LGE, and increased native T1 and extracellular volume (Figure 2). A search for monoclonal components on serum and urine was negative. A bone tracer scintigraphy showed cardiac uptake (Perugini grade 2). A genetic test showed the presence of p.Ile88Leu (Ile68Leu) mutation in heterozygosity, so a non–biopsy diagnosis of mutant transthyretin cardiac amyloidosis (ATTRv) was posed. A thorough neurological evaluation did not document signs of amyloid neuropathy. The patient was then started on tafamidis therapy. Transthyretin cardiac amyloidosis (ATTR) is still an underdiagnosed but increasingly recognized condition, causing up to 13% of HFpEF cases. ATTR is caused by extracellular accumulation of amyloid substance resulting from transthyretin misfolding. In Italy ATTRv is rare and Ile68Leu is among the most frequent mutations, especially in the Tuscan–Emilian Apennines. Ile68Leu is usually associated with an almost exclusively cardiac phenotype, clinically indistinguishable from ATTR wild type, except for an earlier age of onset. Because effective treatments are available for ATTRv with cardiac and/or neurological involvement, it is important to suspect the diagnosis of ATTR in patients with HFpEF and to proceed with genetic testing to identify individuals with ATTRv.

P354 REMOVAL OF CARDIAC AL–AMYLOID LEADS TO CARDIOMYOCYTE POSITIVE REMODELING AND RESTRICTIVE PATTERN REVERSAL

Abstract Background Properly treated AL cardiac amyloidosis can have a long survival. However, the mechanism involved in arresting or reversing cardiomyopathy, such as toxic suppression of the light chain or removal of the amyloid substance, is still unclear. We describe the case of a patient with AL amyloidosis treated with chemotherapy in whom serial endomyocardial biopsies were performed at diagnosis and after 17 years. Clinical case A 71–year–old lady onset with a hypertrophic phenotype cardiomyopathy (maximum thickness LV 18.2 mm, diastolic dysfunction with E/A ratio 2.45. preserved contractility (EF 55%) and NYHA class 3) received a diagnosis in 2004 of AL amyloidosis and underwent several cycles of chemotherapy. At clinical onset, cardiac amyloidosis was documented by endomyocardial biopsy. After 17 years, in 2021, the patient was hospitalized for palpitations and chest pain and documented intermittent phases of atrial fibrillation. The patient was reevaluated with immunoelectrophoresis, echocardiogram, cardiac magnetic resonance, coronary angiography, and left ventricular endomyocardial biopsy. Serum monoclonal chain AL–K was reduced from initial 233 mg/L to 18.2 mg/L, vn<19.4 mg/L. The echocardiogram showed reduction of the heart walls with reduction of the thickness to 14 mm, with regression of the restrictive pattern (E/A ratio from 2.45 to 0.5). Serum NT–proBNP decreased from 3188 pg/mL to 480 pg/mL (n.v.<334 pg/mL). Cardiac MRI revealed normal myocardial wall thickness, with preserved systolic function, in the absence of the typical late gadolinium enhancement pattern. Histology and electron microscopy showed no more hypo/atrophic cardiomyocytes and the interstitium was almost completely devoid of amyloid fibrils, which were distant from the cardiac cell allowing an improvement in oxygenation and trophism. Conclusions Remission of monoclonal gammopathy is associated with a removal of cardiac amyloid deposits and with a regression of cardiac hypertrophy and restrictive pattern. Histologically, the degradation of amyloid fibrils determines a better trophism of cardiomyocytes.

ANMCO Position paper: Amyloidosis for the clinical cardiologist. A "clinical primer" from the ANMCO Rare Disease Working Group

Cardiac amyloidosis, in the three forms of immunoglobulin light chain (AL), transthyretin (ATTR) wild type (ATTRwt) and mutated (ATTRv) amyloidosis, is an increasingly known and recognized disease in the cardiovascular setting. The first stage of the patient's journey is the clinical suspicion of the disease, which is placed, in presence of a hypertrophic phenotype, by the identification of red flags, both extracardiac and cardiac clues whose presence increase the probability of being faced with a patient with this disease. The second stage is represented by diagnosis, which occurs with certainty through the identification of amyloid substance in cardiac tissue. This stage is spotted in wo parts, i.e. disease confirmation and disease etiology definition (AL vs ATTRwt vs ATTRv). However, it is possible in some selected cases to make a diagnosis of ATTR without the need for tissue assessment, in presence of a positive grade 2-3 bisphosphonate scintigraphy and absence of monoclonal component. Once the diagnosis has been made, the third stage is the assessment of prognosis, the fourth is the patient therapy pathway and fifth is the follow-up plan. Prognosis evaluation is based on different staging systems at the onset of the disease, whose applicability in the era of new effective therapies is still to be defined. To date, the transthyretin tetramer stabilizer tafamidis is the only approved treatment for both wild-type and mutant ATTR cardiomyopathy without polyneuropathy, while ATTRv with associated neuropathy can benefit from treatment with patisiran, an inhibitor of hepatic protein synthesis. Therapies for complications and comorbidities, must be addressed individually, due to the lack of specific clinical trials on this category of patients. In fact, it is important to take into consideration the risks linked to the use of some drugs due to the infiltration of the conduction tissue by the amyloid substance, which increases the risk of bradycardia and heart blocks, the tendency towards hypotension and the increased thromboembolic risk. It is also essential to follow the course of the disease and the efficacy of the treatment in affected patients with a standardized follow-up, and to identify early the signs/symptoms of the disease in asymptomatic TTR mutation carriers.This ANMCO position paper on amyloidosis aims to provide the clinical cardiologist with a practical summary of the disease, to accompany the patient with amyloidosis in the various stages of his journey.

Improving mechanical stability of anammox granules with organic stress by limited filamentous bulking

Under organic stress, the limited filamentous bulking (FB) was demonstrated to improve anammox capability by inhibiting granule disintegration and washout. The accumulation of internal stress played a more important role than the adverse physicochemical properties (low viscoelasticity and hydrophobicity) of granules in limiting granular strength by consuming the granular elastic energy. Different from the floc-forming heterotrophic bacteria (HB) that stored its growth stress as internal stress by pushing the surrounded anammox micro-colonies outwards under the spatial constraint of elastic anammox “shell”, the filamentous HB grew into a uniform network structure within granules, endowed granules low internal stress and acted as the granular skeleton due to its rich amyloid substance, which was benefited from the elimination of inhomogeneous growth and the consequent expansion competition for living space. Combined with the mechanical instability and sticking-spring models, controlling FB at limited level was effective for improving granular strength without affecting sludge-water separation.

A Case of Glottic Amyloidosis Presenting as Leukoplakia

Amyloidosis is defined as a deposit of amyloid substance. While it rarely occurs in the head and neck region, it is most commonly found in the larynx. Laryngeal amyloidosis can occur in the false vocal cord, ventricle, and glottis etc. The typical feature of laryngeal amyloidosis is a round yellowish submucosal mass. A 72-year-old male presented with voice change that began a couple of years ago. The rigid laryngoscopy showed a whitish patch in the medial and superior surfaces of the left true vocal fold. He was pathologically diagnosed with amyloidosis by laryngeal microsurgery. With a relevant review of literature, we report this case as it demonstrates rare, atypical features of laryngeal amyloidosis.

Clinical case report: Nephrotic syndrome as presentation of AL amyloidosis, a rare association in our setting

BACKGROUND: Amyloidosis is a heterogeneous group of diseases with multi-organ involvement and different clinical manifestations; one of them is nephrotic syndrome. Amyloidosis results from the extracellular deposit of fibrillar proteins that form the amyloid substance; amyloidogenic proteins resistant to proteolysis infiltrate tissues extracellularly and are capable of severely altering their structure and function. Amyloid deposits in the renal parenchyma can be observed in the mesangium, capillary wall, interstitium, and arterial vessels. Its diagnosis requires a biopsy of the comprised organs. CASE REPORT: 53-year-old male patient, presented with the incidental finding of microalbuminuria. The only clinical manifestations were mild lower limbs edema and foamy urine. Laboratory tests showed: hypoalbuminemia, hypercholesterolemia, hypertriglyceridemia and nephrotic- range proteinuria. With pure nephrotic syndrome diagnosis a renal biopsy was performed, leading to the histopathological diagnosis of amyloidosis. EVOLUTION: Nephroprotective measures were instituted and the extent of systemic involvement was studied, we diagnosed congestive heart failure and amyloid deposition in the digestive system. The patient initially received treatment based on Cyclophosphamide, Bortezomib and dexamethasone, with no renal or haematological response after four cycles of treatment, so treatment was changed to Bortezomib and Bendamustine. CONCLUSION: It is vitally important to have a high index of suspicion and to make an early diagnosis of the disease through a biopsy with Congo red staining. The treatment depends on the type of amyloidosis, its opportune start allows to increase survival rate, as well as, to avoid the deposit of amyloid in other organs.

Genetic Testing in Amyloidosis: For Whom?

Over the past years, the recognition of cardiac involvement due to deposition of amyloid substances has received greater emphasis. Cardiac amyloidosis (CA), as it is known, has been shown to be a more prevalent cause of heart failure with preserved ejection fraction than in previous decades, although diagnosis remains a constant challenge. With advances in pathophysiological knowledge of this disease, as well as relevant advances in diagnostic methods, particularly in the field of cardiovascular imaging, there has been a significant [...]

Bactrospora totonacae (Arthoniales, Ascomycota), una nueva especie de Veracruz, México

Antecedentes y Objetivos: Bactrospora es un género de líquenes costrosos que se caracteriza por el color negro, aspecto verrucoso a denticulado y pequeño de sus apotecios, posee esporas mayoritariamente aciculares y en ocasiones muriformes, pero siempre más largas que anchas. El género está representado por 38 especies aceptadas. El objetivo de este trabajo es describir Bactrospora totonacae, una especie nueva del bosque tropical seco de Veracruz, México.Métodos: Los especímenes fueron recolectados en el “Cerro de los Metates”, municipio Actopan, Veracruz, México. Se realizaron pruebas macroquímicas, reacción UV y cromatografía en capa fina; asimismo, con la solución de Lugol se verificó la presencia de sustancias amiloides distribuidas en el talo y el ascoma. Las muestras estudiadas se depositaron en el herbario XALU de la Facultad de Biología de la Universidad Veracruzana.Resultados clave: La nueva especie Bactrospora totonacae se caracteriza por presentar pruina K + magenta rojizo en el disco. Conclusiones: La especie que se describe en Bactrospora es única porque la combinación de pruina K + magenta rojizo y un excípulo carbonizado y grueso no había sido reportada en alguna otra especie de este género.

Prognostication of cardiac amyloidosis by pittsburgh b compound positron emission tomography

Abstract Introduction Regardless of the underlying pathogenesis of amyloid production, cardiac involvement is the leading cause of morbidity and mortality in systemic amyloidosis. In the cardiac variant, there is an extracellular deposition of amyloid substance throughout the heart. The infiltrative process results in ventricular wall thickening with concentric hypertrophy and low cardiac output. The PiB compound has been promising for the detection of amyloid deposits in the brain but it remains unknown whether this noninvasive evaluation can predict the prognosis of patients with cardiac amyloidosis. Purpose This study sought to investigate the efficacy of 11C-Pittsburgh B (PiB) positron emission tomography for prognostication of cardiac amyloidosis by noninvasively imaging the myocardial amyloid deposition. Methods A total of 33 consecutive patients were enrolled in this prospective pilot study with suspected cardiac amyloidosis. The amyloid deposit was assessed with amyloid P immunohistochemistry in endomyocardial biopsy specimens and was compared with the degree of myocardial 11C-PiB uptake on PET. Results It was found that the degree of myocardial 11C-PiB PET uptake was significantly greater in the patients of cardiac amyloidosis compared with control group subjects and was parallel with the degree of amyloid deposit on histology (p<0.001). When the cardiac amyloidosis patients were divided into tertiles by the degree of myocardial 11C-PiB PET uptake, patients with the highest PiB uptake experienced the worst clinical event-free survival (log-rank p=0.013). The clinical outcome was significantly predicted by the degree of myocardial PiB PET uptake on multivariate Cox regression analysis (adjusted hazard ratio: 1.191; 95% confidence interval: 1.062 to 1.340; p=0.005). Conclusion Our study concludes that the noninvasive evaluation of myocardial amyloid load by 11C-PiB PET reflects the degree of amyloid deposit and is an independent predictor of clinical outcome in cardiac amyloidosis patients. 11-C Pittsburgh B PET imaging Funding Acknowledgement Type of funding source: Other. Main funding source(s): Self funding

AMYLOIDOSIS IN DROMEDARY CAMEL (ONE-HUMPED) IN ASWAN SLAUGHTER HOUSES, EGYPT

The amyloidosis are a group of disorders in which soluble proteins aggregate and deposit extracellular in tissue as insoluble fibrils, causing progressive organ dysfunction. A definitive diagnosis of amyloidosis is based on the histological presence of amyloid substance in tissue specimens. Under light microscope, amyloid substance appears as homogenous pink extracellular deposits in hematoxylin and eosin. On stained sections with Congo red, the extracellular deposits appear orange red in color. In this study, amyloidosis was diagnosed by histopathological examination under light microscope in the liver and kidney tissues from 30 adult dromedary camels (one-humped) collected from a total 50 adult dromedary camels (one-humped) that were presented for slaughter at Draw abattoir in Aswan Governorate between 2018 and 2019. Amyloid deposits in the kidney were located around Bowmans capsule, mesangial areas and peritubular interstitial tissues. Amyloid was also seen in liver were located around blood vessels and along the sinusoids. Concurrent lesions of amyloid in liver include fatty changes, hydropic degeneration and necrosis. Also Concurrent lesions with amyloid in kidneys include proliferative glomerulonephritis and necrosis in tubules.

PF639 IMMUNE ELECTRON MICROSCOPY AND MASS SPECTROMETRY FOR CLASSIFICATION OF AMYLOID DEPOSITS

Background:Amyloidosis is a shared name for a number of rare, complex and serious disease entities with an annual incidence in Denmark of about 2 per 100,000. Amyloidosis is caused by extra‐cellular deposits of amyloid substance created by accumulation of different misfolded proteins. Accurate characterization of the amyloid protein is essential. Amyloid light chain (AL) amyloidosis is a plasma cell dyscrasia that can be treated with chemotherapy, whereas transthyretin (ATTR) and secondary Amyloid A (AA) amyloidosis are other entities that are not treated within haematology. It is generally recognized that conventional immunohistochemistry has limitations, particular due to unspecific staining. Immune electron microscopy (IEM) and laser dissection microscopy followed by tandem mass spectrometry (LDM‐MS) are the new gold standards. It has not been established if one of the methods is superior; each method have some strengths and weaknesses. At Odense Amyloidosis Center, IEM and LDM‐MS have been established for standard diagnostics in 2017.Aims:To compare the sensitivity and specificity of IEM and MS for sybtyping amyloid deposits in different organsMethods:We performed a retrospective study of 106 Congo red positive biopsies from a number of different involved organs; heart, kidney, lung, gut mucosa, subcutaneous fat, bone marrow. IEM was performed with gold‐labeled antibodies against kappa, lambda, transthyretin and amyloid A.Results:IEM identified specific staining of amyloid fibrils in 91.6% of the biopsies; in 6 biopsies amyloid fibrils were not identified, and in 2 biopsies the subtype of the amyloid fibrils could not be established. MS identified an amyloigenic protein signature in 104/106 biopsies but in 9 of the biopsies the amyloid subtype could not be clearly identified. Protein subtype was established in 95 biopsies (89.6%). The concordance of the results ranged from 89.6–100% for the different subtypes. Importantly, the combined use of both methods increased the diagnostic sensitivity to 100%. Some variety in performances of the methods was observed on organ level.Summary/Conclusion:In conclusion, we demonstrate that both IEM and LDM‐MS are sensitive and specific methods for the identification of amyloidogenic proteins in amyloid deposits in biopsies from various organs.

Isolated laryngeal amyloidosis: a case report

BackgroundAmyloidosis is extracellular deposition of an amorphous amyloid substance in various tissues. It can occur in any bodily organ. Clinically, it is divided into systemic and solitary amyloidosis. Isolated laryngeal amyloidosis is very rare in prevalence. We report a case of isolated laryngeal amyloidosis in a healthy 54-year-old lady who presented chronic dysphonia for 2 years with no history of smoking or alcohol intake. The histological, immunohistochemical study and further examinations confirmed the diagnosis of isolated laryngeal amyloidosis without systemic involvement. The larynx is a rare site for isolated laryngeal amyloidosis. Hoarseness or dysphonia is the main presentation of this disease, followed by difficulty in breathing, stridor, and chronic cough. Laryngoscopy may falsely suggest a neoplastic disease. Histopathology is the gold standard diagnostic tool to diagnose this disease. Amyloid can be identified histologically as subepithelial extracellular deposits of acellular, homogeneous, and amorphous eosinophilic material displaying apple–green birefringence with polarized light when stained with Congo red. Surgery is the mainstay of treatment of symptomatic laryngeal amyloidosis. The survival of patients with laryngeal amyloidosis often exceeds 10 years and the prognosis is better than systemic amyloidosis.

The effect of celastrol on learning and memory in diabetic rats after sevoflurane inhalation

IntroductionThe aim was to devise an animal model showing some of the neuropathological changes seen in senile dementia, and to investigate the effect of celastrol on cognition neuropathology in this model.Material and methodsForty male Sprague Dawley rats weighing 300–350 g were randomly divided into 5 groups (n = 8 each): control (Con); inhaled sevoflurane (Sev); diabetes mellitus (DM); diabetes mellitus + inhaled sevoflurane (DM/Sev); diabetes + inhaled sevoflurane + celastrol (Cel). Diabetes was induced by an intraperitoneal injection of streptozotocin (STZ). After 20 days, the Sev, DM/Sev and Cel group rats inhaled 3% sevoflurane for 2 h, while the control and DM groups inhaled air. Cel group rats were given intraperitoneal injections of celastrol (0.7 mg/kg) daily for 4 days, while the control group received intraperitoneal injections of an equal volume of dimethylsulfoxide. The Morris water maze test was performed to test cognition. Animals were killed after the last water maze test and Congo red staining was used to observe deposition of amyloid substance in the hippocampus. The expression of GFAP and IGF-1 in the hippocampus was observed by immunohistochemistry.ResultsDiabetes decreased cognition, increased amyloid substance and GFAP expression, and decreased IGF-1 expression in the hippocampus (all p-values < 0.05). Sevoflurane administration intensified and celastrol decreased these changes (all p-values < 0.05).ConclusionsSev/DM rats showed cognitive and neurochemical changes similar to those seen in senile dementia. Celastrol decreased these changes and should be evaluated further as a possible clinical agent in dementia.

Surgical treatment of a rare case of bilateral ptosis due to localized ocular amyloidosis

We describe a rare case of a 31-year old woman with bilateral ptosis due to localized amyloidosis. She referred a nine-year history of ptosis and surgical treatment with frontalis suspension three years previously. Following complete ophthalmological examination and evaluation of the ptosis we carried out tarsal and fornix biopsy, which revealed accumulation of a weakly eosinophilic amyloid positive substance. We performed surgical correction using the levator aponeurosis–Müller’s muscle complex re-adaptation technique and amyloid substance debulking in all the palpebral layers in the left eye. The material obtained was stained with hematoxylin–eosin, Congo Red, PAS and alpha-actin, which confirmed amyloid deposition. Successively, the right eye was operated in the same manner and entropion was managed by dissection and removal of amyloid from subconjunctival layers. Five years following surgery, the corrective procedure for ptosis was still effective. Surgical treatment of ptosis is very complex and requires precise indications. Appropriate management depends on the etiopathogenesis, accurate diagnosis, and clinical findings.

Acupuncture Led Attenuation of Inflammatory and Nociceptive Peripheral and Central Microenvironment in Sickle Mice

Background: Inflammation, neurogenic inflammation and pain remain challenging to treat in sickle cell disease (SCD). Alternative therapies including acupuncture have been used for centuries to reduce pain and ameliorate underlying pathobiology of many disorders. We examined the mechanisms underlying acupuncture therapy in sickle mice. To prevent the influence of anesthetics and constraint on the pathobiology we developed electroacupuncture (EA) treatment for awake/conscious freely moving mice to simulate treatment conditions in patients, and then examined the peripheral and central mechanisms of neuroinflammation and nociception.Methods: HbSS-BERK sickle and HbAA-BERK control mice were treated with four EA treatments (every 3rd day, frequency: 4 or 10 Hz, pulse width: 100 microsecond, duration: 30 min) at acupoint GB30. Untreated and sham-EA treated (acupuncture without electrical stimulation) were used as controls. Hyperalgesia was evaluated daily by determining mechanical threshold, deep tissue hyperalgesia and thermal hyperalgesia using von Frey filaments, grip force, and cold plate, respectively. Blood and tissues were collected for analysis after four sessions of treatment. Skin biopsies were incubated overnight and culture medium was analyzed for mast cell activation marker tryptase, and neuromodulatory marker substance P.Results: Varied analgesic response to EA treatment was observed in sickle mice. About 86% treated mice equally showed positive (>50% pain relief) or moderate (20-30% pain relief) response and 14% were non-responsive (<20% pain relief) to EA. In positive responders, EA significantly reduced white blood cells (p<.001 Vs moderate- and non-responders), serum amyloid protein (p<.01 Vs untreated), IL-1beta (p<.05 Vs untreated, p<.01 Vs non-responders), and substance P (p<.05 Vs untreated and p<.001 Vs non-responders and p<.05 Vs moderate-responders). Concurrently, spinal cord analysis of EA treated positive-responders showed reduced substance P (p<.05 Vs untreated and non-responders), IL-1 beta (p<.01 Vs untreated), TNF alpha (p<.05 and p<.01 Vs moderate- and non-responders, respectively). Consistent with this central and peripheral anti-inflammatory response, culture medium from skin biopsies of positive responders demonstrated reduced substance P (p<.01 Vs moderate- and non-responders) and tryptase (p<.01 Vs untreated, moderate- and non-responders), and significantly less toluidine blue stained degranulating mast cells in the skin (p<.05 Vs untreated and non-responders) suggestive of attenuation of mast cell and peripheral nervous system activation. Functionally, capsaicin and substance P-induced neurogenic inflammation were significantly attenuated in positive-responders vs non-responders (p<.05) or untreated (p<.05). Peripheral and central attenuation of inflammatory and neurogenic response to EA was accompanied by inhibition of nociceptive signaling in the spinal cord. Spinal phosphorylation of p38 MAPK decreased in EA treated mice (p<.05 Vs sham-EA and untreated control; and positive-responders Vs non-responders).Conclusions: EA treatment on conscious free-moving mice simulates clinical conditions in patients and excludes the potential influence due to restraint or anesthetics. EA leads to peripheral and central neuromodulation and anti-inflammatory response by attenuating mast cell activation, substance P, and cytokine release in the periphery and by abrogating spinal nociceptive signaling of p38MAPK and inflammation. Together, these molecular and cellular effects lead to EA-induced attenuation of neurogenic inflammation and hyperalgesia in sickle mice. Importantly, these data explain the cause of variable effectiveness of EA in SCD. DisclosuresNo relevant conflicts of interest to declare.

Novel TACSTD2 mutation in gelatinous drop-like corneal dystrophy.

We identified a novel mutation in the tumor-associated calcium signal transducer 2 (TACSTD2) gene in a consanguineous Thai family with gelatinous drop-like corneal dystrophy (GDLD). All affected family members presented with an intense amyloid substance deposited on the cornea, which required surgical management. Genetic analysis of these individuals revealed a homozygous mutation c.79delC, in the TACSTD2 gene. Both parents of these individuals were unaffected and showed heterozygous mutations in the TACSTD2 gene. The mutation produced a truncated protein sequence that might be the cause of GDLD.

Systemic amyloidosis and pneumatosis of bladder wall

A 72-year-old woman was admitted to our Department for syncopes, diarrhoea, and weight loss. We suspected the diagnosis of systemic amyloidosis after the detection of macroglossia and periorbital purpura, despite the biopsy of the previous year, that resulted negative for amyloid substance. We confirmed the diagnosis after the histological evidence of deposits of amyloid in bone marrow and the clinical evidence of pneumatosis of bladder wall. Chemotherapy improved only temporarily clinical condition.