Congo Red Staining Research Articles

Exploring cellulolytic microorganisms from coffee industry by-products and their enzyme properties

Cellulolytic microorganism has immense potential due to their cellulase production, enzyme complexity and widespread habitat of life. This study was conducted to obtain microbial cellulase with vast industrial applicability from the coffee industry by-product in East Java, Indonesia. Fifty-four isolates with significant clear zone formation were obtained by Congo red staining in CMC agar plates. Eighteen bacteria, two yeasts and two moulds with high cellulolytic index were subjected to protein content determination as well as reducing sugar analysis in various conditions such as pH, temperature, addition of metal ions, surfactant and inhibitor agent. The specific activity measurements of all the crude enzymes result in the highest value of cellulase activity produced by isolate C12 which was 0.401 ± 0.018 U/mg. This enzyme activity was known to be optimum at 50°C and pH 9. It was also stimulated by K+, Na+, Mg2+, Fe3+, and SDS. However, the enzyme activity was inhibited by EDTA at 10 mM concentration. The use of coffee industry by-products as the source of cellulolytic microorganisms offers a promising approach for its various types of indigenous microorganisms and their unique property of cellulase produced that is useful for industrial application.

Flexor tenosynovectomy in carpal tunnel syndrome as a screening tool for early diagnosis of amyloidosis.

Amyloidosis is a heterogeneous group of diseases that most often presents with advanced cardiac pathology. Another presentation of the disease can include symptoms consistent with carpal tunnel syndrome; however, the true incidence of amyloidosis in patients with carpal tunnel syndrome remains unclear. We performed a retrospective chart review on all patients who underwent an open carpal tunnel release, with tenosynovium biopsy by a single surgeon between 01/2000 and 12/2018. Samples were stored in formalin following hematoxylin-eosin or congo red staining. A total of 199 patients were excluded for incomplete records, and carpal tunnel release performed for traumatic or infectious etiologies. Histologic findings of the attending pathologist were examined and categorized as follows: amyloidosis, fibrous tissue, tenosynovitis/inflammation edematous, benign tenosynovium, and gout. Exactly 898 open carpal tunnel releases were performed, and 699 patients were included for final analysis. In all patients, biopsies for histology with hematoxylin-eosin (HE) staining were taken; in those HE stains where amylogenic proteins were suspected (73 or 10.4%), a subsequent congo red staining was additionally performed which confirmed the diagnosis of amyloidosis in 10 patients (1.4% of the carpal tunnel procedures). Overall, 10 patients were identified and constituted 1.4% of all HE stains (n = 10/699) and 13.7% of all congo red stains (n = 10/73). Our results suggest that the incidence of amyloidosis in the general CTS patient population may be as high as 1.4% with routine screening by synovial biopsy and the diagnosis should be considered as a potential cause.Level of Evidence: III, retrospective study.

Rare presentation of kappa light chain proximal tubulopathy with fibrillar aggregates

Abstract Introduction/Objective Patients with dysproteinemias may show a spectrum of renal alterations due to organized deposits of excess immunoglobulins, including primary amyloidosis, myeloma cast nephropathy, monoclonal immunoglobulin deposition disease, and light chain proximal tubulopathy (LCPT). Among the least common is LCPT, which shows ultrastructural cytoplasmic light chain inclusions with crystalline morphology or rarely fibrillar aggregates. We present the case of a patient with LCPT with fibrillar aggregates that is the only such case registered in our large academic surgical pathology electronic database. Our aim is to increase understanding and recognition of this rare variant. Methods/Case Report A 73-year-old man presented with 540 mg/day proteinuria, serum creatinine 5.73 mg/dL, platelets 178,000/cc, and 20% plasma cells in his bone marrow biopsy specimen. Kidney needle biopsy cores examined by light, fluorescent and transmission electron microscopy (EM) showed kappa light chain cast nephropathy and kappa LCPT with fibrillary aggregates, the latter requiring unmasking of kappa epitopes using pronase-treated paraffin sections. Congo red stain was negative. By EM, proximal tubules contained intracellular bundles of tightly aggregated fibrils with mean fibril diameter of 7.7 +/- 1.6 nm. Individual bundles were variably shaped as round, oval, spicular or irregular blobs. Fibrils were not seen in glomeruli. Results (if a Case Study enter NA) NA Conclusion This rare presentation of LCPT with fibrillar aggregates reinforces the utility of renal biopsy diagnosis that includes careful ultrastructural examination of renal tubules. In the absence of EM, the unique fibrillar organization of these cytoplasmic light chain aggregates would otherwise go unrecognized.

Characterization And Screening Of Protease, Amylase, And Cellulase From Phylloplane Fungi Isolates Of Avicennia marina (Forssk.) Vierh.

Mangrove (Avicennia marina) is an important mangrove species, because it has many benefits for human life, including in the ecological scope as a source of food and medicine. These plants can also be used as a source of symbiont mold isolates which can be developed as an alternative to produce bioactive compounds, one of which is enzymes. Enzymes are protein compounds that can catalyze all chemical reactions in biological systems. This study aims to determine whether mangrove symbiont fungi (A. marina) can produce amylase, protease and cellulase enzymes. This research was conducted using a method based on enzyme activity, namely amylase activity with lugol iodine staining, protease activity and cellulase activity with congo red staining. on agar media enriched with 1% skim milk, 1% starch and 1% CMC. The results showed that 4 isolates were able to show potential enzymatic activity to be developed as agents for enzyme production.

Structural properties and antioxidant activity of polysaccharides extracted from Laminaria japonica using various methods

Polysaccharides in brown algae, including the kelp Laminaria japonica, are economically important to both food and pharmaceutical industries. The method used to extract polysaccharides significantly influences their characteristics and functions. In this study, L. japonica polysaccharides (LJP) were extracted using four techniques: hot-water extraction (HWE), ultrasound-assisted extraction (UAE), enzyme-assisted extraction (EAE), and acid-assisted extraction (AAE). The highest yield (9.73 ± 0.29 %) and sulfate content (12.47 ± 0.79 %) were obtained via UAE, whereas EAE yielded the highest total carbohydrate content (53.50 ± 1.38 %), with an extraction yield of 9.12 ± 0.13 %. The minimum molecular weight (Mw) was found after AAE, whereas a higher Mw was obtained after EAE and HWE, and a homogeneous Mw was obtained after UAE. All four LJP extracts contained a helix-coil conformation based on Congo red staining, with five monosaccharides, fucose, galactose, mannose, xylose, and glucuronic acid, in varying proportions. Polysaccharides extracted via EAE and UAE exhibited higher antioxidant activity with morphological and conformation changes. A significant correlation was noted between sulfate content and antioxidant activity, and antioxidant capacity was positively correlated to mannose content rather than uronic acid. The results indicate UAE to be the best of the four extraction methods for polysaccharides with homogeneous Mw and high antioxidant activity. This study sheds light on the effects of extraction processes on the physiochemical characteristics of polysaccharides and the relationship between chemical composition and antioxidant activities.

Concomitant wild type transthyretin amyloidosis & severe aortic stenosis in elderly Indian population: pilot study

Abstract Background Prevalence of both severe aortic stenosis (AS) and wild-type transthyretin cardiac amyloidosis (wtTTRCA) increases with age. Dual disease (AS+wtTTRCA) occurs in a significant proportion of patients undergoing aortic valve replacement. Prognostic significance of this dual disease is not established. Purpose TTRCA distribution has ethnic variability. This has not been studied in an Indian/Asian population before. India alone has >4.6 million estimated elderly individuals with severe AS. This pilot study was designed as part of a larger study to determine the prevalence of coexistence of severe AS and wtTTRCA in elderly Indian population and identify non-invasive predictors of its diagnosis. Methods Symptomatic severe AS patients aged ≥65 years undergoing surgical aortic valve replacement (SAVR) were enrolled. Detailed 2-D transthoracic echocardiogram including speckle tracking and longitudinal strain assessment was done preoperatively. TTRCA diagnosis was based on preoperative 99m-Technitium pyrophosphate scan (PYP), and intra-operatively obtained basal inter-ventricular septum (IVS) biopsy and excised native aortic valve subjected to histopathological examination (HPE). Congo red staining and immunohistochemistry using TTR monospecific antibodies were performed to identify and sub-type amyloid respectively. Serum/urine protein electrophoresis with serum immunofixation to rule out primary amyloidosis and genetic analysis to rule out mutant TTRCA were also done. Results SAVR was done in 46 severe AS patients (mean age 70±5 years, 70% men), 32 (70%) of whom also underwent PYP scan. Significant PYP uptake (Perrugini grade II or III) was seen in 3 (9%) patients (Figure 1E, F). On HPE, 33 (72%) native aortic valves had amyloid deposits, of which 19 (58%) had TTR deposition (Figure 1A, B, C, D). However, none of the IVS biopsies showed amyloid deposits. None of the patients had evidence of monoclonal protein elevation and mutation in the TTR gene. Non-invasive markers of this dual coexistence included elevated troponin-I (≥26.2 pg/mL, 35% vs 67%), combined elevated troponin-I & NT-ProBNP (≥26.2 pg/mL & ≥400 pg/mL, 24% vs 33%), and significantly low myocardial contraction fraction (≤30%, 72% vs 100%), deceleration time (207±80 msec vs 85±23 msec) and global longitudinal strain (−19.3±4.3% vs −13.6±3.7%). At median follow-up of 12.5 months, 1 patient each had died in TTR negative and TTR positive groups (3% vs 33%). The results are summarised in the central illustration (Figure 2). Conclusion In the Indian context, concomitant existence of severe AS and wtTTRCA is common. This pilot study suggests an absolute burden of >450,000 patients with dual disease of AS and wtTTRCA, in those otherwise believed to have lone severe AS. Further larger studies are thus indicated to establish the prevalence of this dual disease and to assess its prognostic implication. Funding Acknowledgement Type of funding sources: None. Figure 1. Histopathology and PYP scan resultsFigure 2. Central illustration

IKK2/NF-κB Activation in Astrocytes Reduces amyloid β Deposition: A Process Associated with Specific Microglia Polarization.

Alzheimer’s disease (AD) is a common neurodegenerative disease that is accompanied by pronounced neuroinflammatory responses mainly characterized by marked microgliosis and astrogliosis. However, it remains open as to how different aspects of astrocytic and microglial activation affect disease progression. Previously, we found that microglia expansion in the spinal cord, initiated by IKK2/NF-κB activation in astrocytes, exhibits stage-dependent beneficial effects on the progression of amyotrophic lateral sclerosis. Here, we investigated the impact of NF-κB-initiated neuroinflammation on AD pathogenesis using the APP23 mouse model of AD in combination with conditional activation of IKK2/NF-κB signaling in astrocytes. We show that NF-κB activation in astrocytes triggers a distinct neuroinflammatory response characterized by striking astrogliosis as well as prominent microglial reactivity. Immunohistochemistry and Congo red staining revealed an overall reduction in the size and number of amyloid plaques in the cerebral cortex and hippocampus. Interestingly, isolated primary astrocytes and microglia cells exhibit specific marker gene profiles which, in the case of microglia, point to an enhanced plaque clearance capacity. In contrast, direct IKK2/NF-κB activation in microglia results in a pro-inflammatory polarization program. Our findings suggest that IKK2/NF-κB signaling in astrocytes may activate paracrine mechanisms acting on microglia function but also on APP processing in neurons.

Cardiac Amyloidosis Screening at Trigger Finger Release Surgery

Cardiac amyloidosis is often preceded by orthopedic manifestations such as carpal tunnel syndrome, and 10% of patients who underwent idiopathic carpal tunnel release surgery will have biopsy-confirmed amyloid deposits in the tenosynovial sheath. Trigger finger is also commonly reported in patients with amyloidosis and involves the same tendon sheath as carpal tunnel syndrome, but the prevalence of amyloid deposition is unclear. This prospective cross-sectional study enrolled 100 patients aged ≥50 years at the time of surgery for idiopathic trigger finger. Patients underwent release surgery, and a sample of the tenosynovium of the affected finger was excised, stained with Congo red, and subtyped with mass spectrometry if amyloid was demonstrated. Further cardiac evaluation was performed in patients with amyloid deposition. Of the 100 patients (mean age 65.5 ± 8.1years) enrolled, only 2 demonstrated amyloid deposits on Congo red staining. One patient with previous proteinuric kidney disease had fibrinogen A α-chain amyloidosis, and the other patient had untyped amyloidosis. Neither patient had cardiac involvement. A total of 13 of the 100 patients underwent concomitant carpal tunnel release surgery, and 2 of these patients had amyloid deposits in the carpal tunnel with "false-negative" samples from the trigger finger tenosynovium. In conclusion, biopsy during trigger finger release surgery demonstrated a 2% yield for amyloidosis, which is significantly lower than the previously published yield of 10% during carpal tunnel release surgery. This observation has important implications for the development of diagnostic algorithms to screen patients for amyloidosis during orthopedic operations.

S1823 A Case of Early Isolated Rectal Amyloidosis on Routine Screening Colonoscopy

Introduction: AL Amyloidosis is a rare condition most often implicating the cardiovascular and renal systems. We report a case of early amyloidosis with isolated rectal involvement discovered incidentally during a routine colonoscopy. Highlighted is the significance of a thorough workup and management of early gastrointestinal amyloidosis. Case Description/Methods: A 54-year-old male with a history of hypercholesterolemia presented for a screening colonoscopy. He denied any gastrointestinal symptoms or other concerns. During the procedure, two diminutive polyps and Grade II internal hemorrhoids were found. A solitary rectal ulcer with irregular borders measuring 10 X 20 mm was visualized. The ulcer base appeared shiny with yellow, fatty patches and no bleeding. The ulcer biopsy samples showed rectal mucosa with acellular pink deposits in the lamina propria resembling amyloid which was confirmed via Congo Red stain. Diagnostic EGD and enteroscopy found no UGI lesions and random biopsies throughout were negative. Hematologic work-up revealed AL amyloidosis and an underlying lambda clonal plasma cell dyscrasia. Systemic assessment showed no renal, cardiac, or neurological involvement and abdominal fat pad aspirates were negative. Repeat colonoscopy, EGD, and enteroscopy performed 2 years after the initial screening found no new lesions or bleeding, but did find enlargement of the ulcer to 20 x 40 mm. Otherwise, there was no involvement of the visualized UGI tract and the patient remains asymptomatic. He has declined bone marrow transplant in favor of serologic and urine markers along with organ-specific surveillance. Discussion: Most often implicated in primary AL amyloidosis are the cardiac and renal systems, while GI involvement is only seen in about 5% of cases.1 When gastrointestinal AL amyloid occurs, it is more often associated with gastric rather than rectal involvement. 2 Treatment recommendations for AL amyloidosis at an early stage are sparse, with the leading one being bone marrow transplantation. A reasonable alternative is active surveillance for disease progression and systemic involvement. Our case brings to light an unusually early involvement of the GI tract with AL amyloidosis and it’s management dilemma.Figure 1.: A: Solitary rectal mucosal ulceration discovered during routine colonoscopy (10mm x 20mm). B: Repeat imaging of the same solitary rectal ulcer 2 years later (20mm x 40mm). C: Rectal mucosal biopsy with H&E staining demonstrating pink, acellular deposits in the lamina propria consistent with amyloid deposition. (200X) D: Rectal mucosa biopsy with Congo Red staining under polarized light demonstrating "apple-green" birefringence, confirming the presence of amyloid. (200X).

S1779 Gastrointestinal Amyloidosis: An Unexpected Cause of Diarrhea in an HIV Patient

Introduction: Systemic amyloidosis is a rare multisystem disease caused by the deposition of misfolded protein in various organs, including the gastrointestinal (GI) tract. Amyloidosis occurs in the setting of chronic inflammatory states. The association of acquired immune deficiency syndrome (AIDS) and amyloidosis has been rarely described. We present a case of amyloidosis involving the colon in a patient with uncontrolled human immunodeficiency virus (HIV). Case Description/Methods: A 50-year-old male presented with non-bloody diarrhea of 2 weeks duration. He had a past medical history of Hepatitis C, active IV heroin use, and AIDS. Most recent CD4 count was less than 10 cells/mm3 with an HIV viral load of 36,000 copies/mL. Laboratory workup on admission was significant for severe normocytic anemia, leukopenia, and acute renal failure with proteinuria. An extensive infectious evaluation of the patient’s persistent diarrhea was unremarkable. Computed tomography (CT) scan of the abdomen demonstrated diffuse wall thickening of the sigmoid and descending colon suggestive of colitis. Flexible sigmoidoscopy was performed to further characterize the etiology of colitis. Pale, friable mucosa with scattered telangiectasia was noted on gross examination. Colonic tissue biopsy revealed the presence of extensive perivascular and lamina propria amyloid deposition, which was confirmed by Congo red staining. Apple green birefringence was observed on polarizing microscopy exam. Negative HSV, CMV, AFB, and HHV stains were noted on pathological exam. Subsequent tissue typing was consistent with AA Amyloid secondary to chronic inflammatory state. Discussion: The two most common type of amyloidosis are Amyloid Light chain (AL) amyloidosis and serum Amyloid A (AA) amyloidosis. AL amyloid occurs in the presence of a plasma cell dyscrasia and AA amyloidosis due to ongoing or recurring inflammation from chronic disease. GI involvement has been described in all major systemic amyloid subtypes. The most common GI presentations include GI bleeding, weight loss, diarrhea, and dysmotility. Patients with uncontrolled HIV are at risk for recurrent infections and therefore chronic inflammation. This case highlights the possibility of gastrointestinal AA amyloidosis as an underlying etiology of persistent diarrhea in a patient with AIDS. While amyloidosis secondary to AIDS is rare, it should be considered as part of the broad differential diagnosis of diarrhea in this patient population.Figure 2.: Tissue biopsy showing extensive perivascular and lamina propria amyloid deposition confirmed by Congo red staining.

S3169 An Unusual Cause for Persistent Anemia: Gastric Amyloidosis

Introduction: This case highlights an unusual presentation of amyloidosis and multiple myeloma which was discovered during endoscopic and histological evaluation of the gastrointestinal tract for persistent anemia. Thus, it is important to consider these underlying malignancies during work up of anemia with proper biopsies and staining. Case Description/Methods: 67 year old woman with Zenker’s diverticulum and chronic gastrointestinal symptoms attributed to IBS presented for persistent iron deficiency anemia of Hgb 10 and rectal bleeding. A 2 cm sigmoid colon Hamartomatous polyp and a 4 mm cecal tubular adenoma were resected during colonoscopy with normal terminal ileum. While rectal bleeding resolved, surveillance colonoscopy in 6 months showed no residual polyp. Due to persistent anemia despite iron replacement, she underwent an EGD which showed a grossly normal stomach and mild duodenitis. Random biopsies of antrum and duodenum showed acellular pink/amorphic matrix in lamina propria and muscularis mucosa with green birefringence on congo red staining, consistent with amyloid. The patient was referred to hematology/oncology for further work up of amyloidosis. SPEP and immunofixation showed IgA monoclonal gammopathy and free light chain assay revealed 2401.9 mg/L kappa light chains, with a kappa/lamda ratio of 343.13. UPEP showed M spike with positive Bence Jones protein, kappa type. Bone marrow biopsy revealed 13% plasma cells. Patient was diagnosed with amyloid light chain amyloidosis and multiple myeloma and began treatment with systemic chemotherapy. Later in the course, patient had recurrence of rectal bleeding. Repeat colonoscopy was normal, but EGD showed multiple small gastric ulcers which was felt to be the sequelae of gastric amyloidosis. Discussion: Gastric amyloidosis as the presenting pathology of multiple myeloma is rare. Symptoms include abdominal pain, bleeding, motility issues, and malabsorption. Endoscopic findings most commonly show ulcerations, mucosal erosions, and submucosal hematomas. Because these findings are nonspecific, it can be difficult to diagnose unless the clinician has high suspicion for the disease. In our patient’s case, the initial investigation was prompted due to persistent anemia. Unlike the typical mucosal abnormalities seen in gastric amyloidosis, our patient had grossly normal mucosa. Only after biopsies of the stomach and duodenum to rule out H. pylori and celiac disease were performed did we discover the patient had amyloidosis and ultimately multiple myeloma.

S1818 Colonic Amyloidosis: A Rare Cause of Gastrointestinal Bleeding

Introduction: AL-amyloidosis is a rare systemic disorder with an annual U.S. incidence of ∼2000 cases. It results from abnormally folded protein deposition. Gastrointestinal (GI) amyloidosis presents with non-specific symptoms of weight loss, abdominal pain, diarrhea, and bleeding. Endoscopic findings vary from bulky mucosal lesions to friable, ulcerated mucosa. Endoscopy and histology are crucial in making the diagnosis. Our case highlights this rare, but important, etiology of GI bleeding, and showcases the interesting endoscopic findings seen. Case Description/Methods: 79-year-old male with a history of type-2 diabetes mellitus, chronic heart failure, hypothyroidism, and coronary artery disease presented with hematochezia. Other non-specific symptoms included lower abdominal pain, constipation, early satiety, dysphagia, 40-lbs weight loss, and weakness. History was negative for heavy alcohol use. Colonoscopy 13 years prior was normal. Physical exam showed an ill-appearing male with abdominal distension and generalized abdominal pain without rebound or guarding. Labs were notable for a WBC 16, chronic iron deficiency anemia (baseline hemoglobin 9), AST 54, ALT 24, ALP 369, and creatinine 1.7. CT scan demonstrated hepatosplenomegaly with ascites and diffuse colitis. Serum ascites albumin gradient was >1.1. Colonoscopy showed bulky clot-like masses protruding from the mucosa with patchy colitis throughout. Biopsies were positive for Congo Red stain, making the diagnosis of AL-kappa type amyloidosis. He was started on the appropriate therapy, but his clinical course deteriorated with eventual death from multi-organ failure. Discussion: Colonic involvement from amyloidosis is extremely uncommon. Within the GI tract, amyloid deposits in the muscularis mucosae leading to frailty of blood vessels, impaired peristalsis, and decreased gut wall compliance. Patients present with bleeding, malabsorption, dysmotility, and protein losing enteropathy resulting in ascites, edema, and pericardial effusion. Endoscopic findings are variable with more bulky mucosal deposition seen in AL-type compared to ulceration and friability seen in AA-type. Diagnosis is made by histology. Amyloidosis also may involve non-luminal organs of the GI tract, including the liver. Deposition within hepatic stellate cells promotes a fibrogenic state resulting in cirrhosis as seen in our patient. Early recognition of intestinal amyloidosis is important as it carries a poor prognosis. Multi-specialty approach is crucial for diagnosis and management.Figure 1.: A,B: Large intestine amyloid deposition noted on colonoscopy. You can see extension from mucosa in part A. C,D: Biopsy evaluation of mass on colonoscopy. D highlights positive Congo Red Staining leading to diagnosis of AL-Amyloidosis.

CEREBRAL AMYLOID ANGIOPATHY IN PREGNANCY: A CASE REPORT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cerebral Amyloid Angiopathy (CAA) is amyloid deposition within cerebral vessel walls which increases risk for spontaneous intracerebral hemorrhage (ICH) and occurs almost exclusively in patients over age 65. We report a young woman patient who presented for ICH with both imaging and tissue pathology consistent with CAA. CASE PRESENTATION: A 36-year-old G1P0 woman at 34 weeks gestation presented to the hospital after one day of severe headache. She denied recent trauma. Upon arrival the fetus was in distress prompting emergent delivered via cesarean section. The patient subsequently underwent CT head revealing an acute 6.3cm x 5.4cm x 3.1cm right parieto-occipital parenchymal hemorrhage and significant vasgoenic edema. Also noted, a concomitant subdural component to the hemorrhage, extending extra-axially up to 1 cm in diameter in the same right parieto-occipital region. There was resulting right-to-left midline shift, with the body of the right lateral ventricle nearly completely effaced. She was intubated due to developing encephalopathy and neurosurgery completed an urgent craniotomy. She initially improved and extubated three days later; however, four days after the procedure she developed recurrent right subdural hemorrhage with CT pertinent for further right-to-left midline shift with right lateral ventricular narrowing and new uncal deviation. She underwent middle meningeal artery embolization via interventional radiology to remove the source of the bleed. She recovered in the following days without complications and transferred out of the ICU. During the initial craniotomy, a tissue sample sent for pathology evaluation noted congophilic tissue consistent with CAA. DISCUSSION: While CAA can be presumed with CT or MRI imaging, it is optimally confirmed via tissue sample with Congo Red stain under polarized light microscopy. Epidemiologically, CAA strongly correlates with age thus rarely considered in women of childbearing age. There are few reports of CAA diagnosis in the pregnant population, likely due to misdiagnosis given other common pathologies such as gestational hypertension and preeclampsia which predispose patients to ICH. Additionally, invasive nature of confirming this pathology may play a role in misdiagnosis due to the risk of procedures in pregnancy. Mortality of CAA with ICH is 10-30% depending on location and size of the bleeding. Risk of recurrent bleeding is much higher than other causes of ICH. There is no currently agreed upon management of CAA. However, there is some evidence for the use of steroids and immunosuppressants to decrease CAA related vasogenic edema. It is also reasonable to suggest prevention of further hemorrhagic events with the avoidance of blood thinners. CONCLUSIONS: CAA should be considered in patients who present with ICH regardless of age or pregnancy. Confirmation with tissue biopsy is preferred for proper diagnosis and treatment. REFERENCE #1: Vinters, H. Cerebral amyloid angiopathy. A critical review. Stroke. 1987; 8(2):311-324. REFERENCE #2: Rosand, J. Muzikansky, A. Kumar, A. Wisco, JJ. Smith, EE. Betensky, RA. Greenberg, SM. Spatial clustering of hemorrhages in probable cerebral amyloid angiopathy. Ann Neurol. 2005;58(3):459. REFERENCE #3: Greenberg, S. Vonsattel J. Diagnosis of cerebral amyloid angiopathy. Sensitivity and specificity of cortical biopsy. Stroke. 1997;28(7):1418. DISCLOSURES: No relevant relationships by PARNEET DHALIWAL, source=Web Response No relevant relationships by Jessica Kent, source=Web Response No relevant relationships by Adan (Adam) Mora, source=Web Response No relevant relationships by Ciara Wisecup, source=Web Response

S3118 Through Thick and Thick: An Unusual Presentation of Gastric Amyloidosis

Introduction: GI amyloidosis (GIA) is relatively rare constitutes 3% to 8% of patients with systemic amyloidosis. A mere 1% of primary gastric amyloidosis were found to be symptomatic. We elaborate on an unusual presentation of GIA where nausea and vomiting were the only symptoms. Case Description/Methods: A 55-year-old male presents with nausea and vomiting for the past 3 weeks, found to have acute normocytic anemia (hemoglobin 6.1), leukocytosis (16K/mm3), and acute renal failure. Upper endoscopy revealed diffuse gastric wall thickening and subsequent endoscopic ultrasound revealed diffuse gastric wall thickening up to deep mucosa, up to 1.1cm in the cardia, fundus, body, and antrum. Biopsies revealed pale eosinophilic material, orangeophilic on congo red stain, and apple green birefringent on polarization microscopy consistent with AL (kappa)-type amyloidosis. Bone marrow biopsy showed hypercellular bone marrow (60%) with 6% plasma cells, chemotherapy with cyclophosphamide plus daratumumab was initiated. Free light chain levels improved to 50% within 1 month and he continues therapy for hematologic remission. Discussion: GIA is defined as the presence of GI symptoms with direct tissue biopsy with positive staining of amyloid by Congo red. Those with AL amyloidosis have median survival times of 15.84 months for those without GIA, and 7.95 months for those with GIA. Our patient with nonspecific symptoms, had lab and endoscopic evaluation; biopsy is necessary to clinch such a diagnosis.Figure 1.: Image 1: CT image demonstrating gastric mass (red arrow). Image 2: Endoscopy image demonstrating gastric mass (yellow arrow). Image 3: H&E stain of gastric mass demonstrating smooth muscle cells. Image 4: Positive smooth muscle actin stain.

S2830 The Presentation of Hepatic Amyloidosis

Introduction: Amyloidosis is a disorder characterized by the abnormal deposition of proteins into bodily tissue. This causes changes to both organ structure and function. Amyloidosis has a wide variety of presentations which makes it a difficult diagnostic encounter. Case Description/Methods: An 81 year old male with history of choledocholithiasis, partial gastrectomy and gastroparesis presents with several months of intermittent nausea with new abnormal liver chemistries. On his initially presentation he reported fatigue, shortness of air, nausea with dry heaving and an unintentional 13lb weight loss. At this time MRCP showed dilatation of the common hepatic duct at 12mm, with hepatic changes concerning for parenchymal disease. He returned one month later with worsening elevations in alkaline phosphatase, bilirubin and creatinine. EGD showed mild chronic gastritis otherwise pathology was unrevealing. He then underwent EUS with ERCP which re-demonstrated dilated CBD, the biliary tree was swept and otherwise unremarkable. Random colon biopsies were without pathologic abnormalities. Due to continuation of symptoms with a fairly unrevealing workup he underwent liver biopsy. His liver biopsy showed diffuse replacement of the hepatic parenchyma with sheets of amorphous, eosinophilic material. Trichrome stain highlighted a predominantly sinusoidal pattern. A Congo red stain demonstrates apple-green birefringence, consistent with amyloid. Discussion: Amyloidosis consist of variable etiologies and manifestations. This case is important as it shows that hepatic amyloidosis typically presents with very non-specific symptoms and when an extensive workup has been unremarkable, amyloid should be considered. When a patient is diagnosed with amyloidosis, clinicians should be suspicious of possible predisposed factors. Amyloid is most commonly a result of an underlying process such as hematologic malignancy, chronic infection or autoimmune disease. Tissue is required for diagnosis. After diagnosis, further workup should include investigating possible underlying conditions and ruling out other organ involvement, particularly cardiac or renal involvement. Prognosis depends on subtype as well as any predisposing processes. Those with GI involvement typically have demonstrated worse outcomes. Treatment ideally includes identifying underlying processes and treating appropriately. However, others may be considered for chemotherapy or stem-cell transplant.

LIGHT CHAIN DEPOSITION DISEASE: WHAT?

TOPIC: Diffuse Lung Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary light chain deposition disease (PLDD) is an exceptionally rare diagnosis characterized by the deposition of nonamyloid light chains leading to progressive dyspnea and airflow obstruction. Cystic PLDD demonstrates extensive, bilateral thin-walled cysts. Pathologically, deposition of amorphous eosinophilic material surrounded by giant cell reaction that does not react Congo-Red staining is noted. Lung transplantation can be curative. CASE PRESENTATION: A 38-year-old female with past medical history of mixed connective tissue disease with lupus-like features, and long-term tobacco use was seen in the pulmonology office for worsening dyspnea on exertion and dry cough. CT-Chest showed bilateral and multiple thin-walled cysts. Pulmonary function tests were unremarkable. VEGF-D, Alpha-1-antitrypsin genotype, and HIV were unremarkable. A left upper lobe video assisted thorascopic lung biopsy was performed. Pathology was consistent with pulmonary light chain deposition disease associated with giant cell reaction and patchy lymphocytic infiltrates, without evidence of lymphoproliferative disease. There were amyloid-like nodules that did not react with Congo-Red, and staining for Pulmonary Langerhans Histiocytosis was negative.Further work-up revealed normal cell counts, kidney function, and a normal SPEP and UPEP. Free light chains and Kappa/Lambda ratio were slightly elevated. Bone marrow biopsy, FISH analysis, and karyotype were performed to rule-out a clonal process. These studies were unremarkable. She was referred to a transplant center. DISCUSSION: Light chain deposition disease is a result of monoclonal immunoglobulin deposits, and typically involves the renal, hepatic, and cardiac systems. Isolated pulmonary involvement (PLDD) is exceptionally rare, and is only a recently noted phenomenon. Cystic-predominant PLDD is characterized by extensive, bilaterally thin-walled and progressively expanding cysts that are similar in appearance to lymphangioleiomyomatosis (LAM). Clinically, PLDD is characterized by progressive dyspnea that correlates with worsening obstructive disease on PFT's. Free light chains and the Kappa/Lambda ratio are often elevated without other lab abnormalities. Surgical biopsy should be obtained, particularly if the patient has a tobacco history, as differentiating PLDD from Pulmonary Langerhans is crucial. Pathologically, PLDD is similar to amyloidosis, with amorphous eosinophilic material in cystic walls that stains positive on hematoxylin and eosin. The amorphous material is usually surrounded by giant cell reactions, and material can also be noted in airways and blood vessels. However, there is no reaction in Conge-Red staining. Treatment for PLDD is limited to lung transplantation. CONCLUSIONS: Cystic lung disease often requires surgical biopsy, particularly if rheumatologic or hematologic comorbidities are present. REFERENCE #1: Colombat M, Caudroy S, Lagonotte E, et al. Pathomechanisms of cyst formation in pulmonary light chain deposition disease. Eur Respir J 2008;32:1399-403. 10.1183/09031936.00132007 REFERENCE #2: Khawaja et al. Shedding Light on Cystic Lung Disease. The Expert Clinician. 2019. DISCLOSURES: No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Dylan Soller, source=Web Response No relevant relationships by Richard Strobel, source=Web Response

Monoclonal Gammapathy of Renal Significance: Morphological Variants of Lesion

The article discusses the concept of monoclonal renal gammopathy, which combines various renal diseases caused by the deposition of monoclonal immunoglobulin and / or their components in the glomeruli and tubulointerstitium. This nosological group was identified within the group of monoclonal gammopathies of undetermined significance (in 2012). The data on the study of morphological kidney damage associated with monoclonal renal gammopathy are presented. The spectrum of renal diseases in monoclonal renal gammopathy is diverse, and its classification is based on the localization of renal lesions in the glomeruli, tubules, vascular interstitium and stroma, as well as the peculiarity of the deposition of immunoglobulins (organized and unorganized). Kidney biopsy is required in most cases to locate the lesion, assess its severity, and predict patient survival. Diagnostics requires the integration of morphological changes using light microscopy, immunofluorescence, electron microscopy, and in some cases, staining of monoclonal protein for Ig isotypes is used (staining with hematoxylin / eosin, Schiff stain (PAS reaction), Jones stain, Congo Red stain, Masson’s trichromal stain). Early diagnosis and timely prescription of clone-oriented therapy by a hematologist and / or a hematooncologist can stop the progression of the malignant process and kidney malfunction. A nephrologist should monitor the patient, interacting with the hematologist.

Pathological review of cardiac amyloidosis using autopsy cases in a single Japanese institution

AimAmyloidosis is a systemic or localized disease of protein deposition characterized by amorphous eosinophilic morphology and positivity of Congo Red staining. The typing of amyloidosis is becoming increasingly important because therapeutic agents for each amyloidosis type have been developed. Herein, the authors review the autopsy cases at an institution to reveal the putative Japanese characteristics of each amyloidosis type and evaluate the clinicopathological significance of each type. Materials and methods: A total of 131 autopsy cases of systemic and localized amyloidosis were retrieved for classification by immunohistochemistry. Immunohistochemistry for transthyretin, amyloid A (AA), immunoglobulin light-chain kappa and lambda, and β2-microglobulin was performed for all cases. ResultsThe 131 amyloidosis cases were classified as follows: 71 cases (54.2%) of transthyretin amyloidosis, 32 cases (24.4%) of AA amyloidosis, 8 cases (6.1%) of light-chain amyloidosis, and 5 cases (3.8%) of β2-microglobulin amyloidosis, along with 15 equivocal cases (11.5%). All cases showed myocardial involvement of amyloidosis. Histopathologically, the transthyretin type was significantly associated with the interstitial and nodular patterns, and with the absence of the perivascular and endocardial patterns. The AA type was significantly associated with the perivascular and endocardial patterns, and with the absence of the nodular pattern. ConclusionThe authors revealed the putative characteristics of cardiac amyloidosis in Japan by using autopsy cases. About 90% of amyloidosis cases were successfully classified using only commercially available antibodies.

C4d as a Practical Marker for Cutaneous Amyloidosis.

Cutaneous amyloidosis (CA) is defined by the accumulation of amyloid in the dermis; it might be primary or secondary. The diagnosis is based on histopathological findings with the demonstration of amyloid deposits, confirmed by Congo red stain under the polarized light. Studies on other diagnostic markers are ongoing in the literature. The aim of this study was to demonstrate the utility of C4d staining in the recognition of amyloid in CA and using it as an alternative or substitute marker for the diagnosis. In this retrospective study, 199 skin biopsies with a clinical provisional diagnosis of CA were analyzed, the Congo red stain was performed, and, in a subgroup (n = 97) with histopathological findings probably for CA, C4d immunohistochemistry was assessed. Forty-eight cases of CA were detected. Congo red birefringence was positive in all cases, whereas in 14 cases, it was faded. In these 14 cases, the diagnosis of CA was made by means of Congo red fluorescence and Thioflavin T because the histopathological findings were highly suggestive for CA. All CA cases were positive with C4d, and in 12 of the 49 inflammatory dermatoses, C4d was positive. The interpretation of C4d immunohistochemistry can be performed more easily and rapidly than Congo red evaluation. The sensitivity and specificity of C4d were 100% and 75.5%, respectively. In our experience, C4d staining was a useful method for detecting amyloid deposits in CA. Although Congo red staining is the gold standard for amyloid detection, we propose C4d immunohistochemistry as a routine screening method or hybrid transition while further investigations are completed.

Identification of a Region in the Common Amino-terminal Domain of Hendra Virus P, V, and W Proteins Responsible for Phase Transition and Amyloid Formation.

Henipaviruses are BSL-4 zoonotic pathogens responsible in humans for severe encephalitis. Their V protein is a key player in the evasion of the host innate immune response. We previously showed that the Henipavirus V proteins consist of a long intrinsically disordered N-terminal domain (NTD) and a β-enriched C-terminal domain (CTD). These terminals are critical for V binding to DDB1, which is a cellular protein that is a component of the ubiquitin ligase E3 complex, as well as binding to MDA5 and LGP2, which are two host sensors of viral RNA. Here, we serendipitously discovered that the Hendra virus V protein undergoes a liquid-to-hydrogel phase transition and identified the V region responsible for this phenomenon. This region, referred to as PNT3 and encompassing residues 200–310, was further investigated using a combination of biophysical and structural approaches. Congo red binding assays, together with negative-staining transmisison electron microscopy (TEM) studies, show that PNT3 forms amyloid-like fibrils. Fibrillation abilities are dramatically reduced in a rationally designed PNT3 variant in which a stretch of three contiguous tyrosines, falling within an amyloidogenic motif, were replaced by three alanines. Worthy to note, Congo red staining experiments provided hints that these amyloid-like fibrils form not only in vitro but also in cellula after transfection or infection. The present results set the stage for further investigations aimed at assessing the functional role of phase separation and fibrillation by the Henipavirus V proteins.