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Patisiran and inotersen are two therapies approved for the treatment of hereditary transthyretin-mediated (hATTR) amyloidosis with polyneuropathy, a rapidly progressive disease with a substantial clinical burden. This analysis indirectly compares the efficacy of patisiran and inotersen on neuropathy and quality of life (QOL). Published results from the NEURO-TTR study of inotersen and individual patient data from the APOLLO study of patisiran were used. Indirect comparisons were conducted for 15-month changes in neuropathy and QOL endpoints: modified Neuropathy Impairment Score +7 (mNIS+7Ionis,), Norfolk Quality of Life-Diabetic Neuropathy (Norfolk QOL-DN) questionnaire, body mass index (BMI), and Polyneuropathy Disability (PND) score. Analyses were conducted under different assumptions about the impact of missing data and to adjust for baseline differences between studies. Patisiran showed significantly greater treatment effects than inotersen for mNIS+7Ionis (mean difference: −12.3 [95% confidence interval: −21.4, −3.3]), Norfolk QOL-DN (−11.3 [−19.8, −2.9]), and BMI (1.0 [0.4, 1.7]). The proportion of patients with improvement or no change from baseline on PND score was higher for patisiran-treated patients (odds ratio: 8.9 [4.6, 17.5]). Results were consistent and robust across analyses and methods. Patisiran demonstrated greater treatment effects on neuropathy and QOL than inotersen in patients with hATTR amyloidosis with polyneuropathy.

Background and purpose: Hereditary transthyretin (hATTR) amyloidosis causes progressive polyneuropathy resulting from transthyretin (TTR) amyloid deposition throughout the body, including the peripheral nerves. The efficacy and safety of inotersen, an antisense oligonucleotide inhibitor of TTR protein production, were demonstrated in the pivotal NEURO-TTR study in patients with hATTR polyneuropathy. Here, the long-term efficacy and safety of inotersen are assessed in an ongoing open-label extension (OLE) study. Methods: Patients who completed NEURO-TTR were eligible to enroll in the OLE (NCT02175004). Efficacy assessments included the modified Neuropathy Impairment Score plus seven neurophysiological tests composite score (mNIS + 7), the Norfolk Quality of Life - Diabetic Neuropathy (Norfolk QOL-DN) questionnaire total score and the Short-Form 36 Health Survey (SF-36) Physical Component Summary (PCS) score. Safety and tolerability were also assessed. Results: Overall, 97% (135/139) of patients who completed NEURO-TTR enrolled in the OLE. Patients who received inotersen for 39 cumulative months in NEURO-TTR and the OLE continued to show benefit; patients who switched from placebo to inotersen in the OLE demonstrated improvement or stabilization of neurological disease progression by mNIS + 7, Norfolk QOL-DN and SF-36 PCS. No new safety concerns were identified. There was no evidence of increased risk for grade 4 thrombocytopenia or severe renal events with increased duration of inotersen exposure. Conclusion: Inotersen slowed disease progression and reduced deterioration of quality of life in patients with hATTR polyneuropathy. Early treatment with inotersen resulted in greater long-term disease stabilization than delayed initiation. Routine platelet and renal safety monitoring were effective; no new safety signals were observed. info:eu-repo/semantics/publishedVersion

Introduction: Hereditary transthyretin-mediated (hATTR) amyloidosis is a rare, fatal, multisystem disease leading to deteriorating quality of life (QOL). The impact of patisiran on QOL in patients with hATTR amyloidosis with polyneuropathy from the phase 3 APOLLO study (NCT01960348) is evaluated. Methods: Patients received either patisiran 0.3 mg/kg (n = 148) or placebo (n = 77) intravenously once every three weeks for 18 months. Multiple measures were used to assess varying aspects of QOL. Results: At 18 months, compared with placebo, patisiran improved Norfolk Quality of Life-Diabetic Neuropathy (Norfolk QOL-DN) score; (least squares [LS] mean difference: −21.1; p = 1.10 × 10−10; improved across all domains), EuroQoL 5-dimensions 5-levels (LS mean difference: 0.2; p = 1.4 × 10−12), EuroQoL-visual analog scale (LS mean difference: 9.5; p=.0004), Rasch-built Overall Disability Scale (LS mean difference: 9.0; p = 4.07 × 10−16) and Composite Autonomic Symptom Score-31(COMPASS-31; LS mean difference: −7.5; p=.0008). Placebo-treated patients experienced rapid QOL deterioration; treatment effects for patisiran were observed as early as 9 months. At 18 months, patisiran improved Norfolk QOL-DN total score and three individual domains as well as COMPASS-31 total scores relative to baseline. Consistent benefits were also observed in the cardiac subpopulation. Conclusion: The benefits of patisiran across all QOL measures and the rapid deterioration observed with placebo, highlight the urgency in early treatment for patients with hATTR amyloidosis with polyneuropathy.

Introduction Polyneuropathy signs (Neuropathy Impairment Score, NIS), neurophysiologic tests (m+7Ionis ), disability, and health scores were assessed in baseline evaluations of 100 patients entered into an oligonucleotide familial amyloidotic polyneuropathy (FAP) trial. Methods We assessed: (1) Proficiency of grading neurologic signs and correlation with neurophysiologic tests, and (2) clinometric performance of modified NIS+7 neurophysiologic tests (mNIS+7Ionis ) and its subscores and correlation with disability and health scores. Results The mNIS+7Ionis sensitively detected, characterized, and broadly scaled diverse polyneuropathy impairments. Polyneuropathy signs (NIS and subscores) correlated with neurophysiology tests, disability, and health scores. Smart Somatotopic Quantitative Sensation Testing of heat as pain 5 provided a needed measure of small fiber involvement not adequately assessed by other tests. Conclusions Specially trained neurologists accurately assessed neuropathy signs as compared to referenced neurophysiologic tests. The score, mNIS+7Ionis , broadly detected, characterized, and scaled polyneuropathy abnormality in FAP, which correlated with disability and health scores. Muscle Nerve 56: 901-911, 2017.

The complement system bridges innate and adaptive immunity against microbial infections, with viral infection being a major trigger. Activation of the classical, alternative, and lectin pathways have been reported in chronic hepatitis C virus (HCV) infection and/or cryoglobulinemia. HCV infection leads to dysregulation of complement-mediated immune responses. Clinical and experimental evidence support involvement of complement in intra- and extrahepatic manifestations of HCV infection, such as liver fibrosis and type II cryoglobulinemia. In this review, we summarize studies that have investigated the interplay between HCV and the complement system to establish chronic infection and autoimmunity, as well as the association between HCV pathogenesis and abnormal complement profiles. Several unanswered questions are highlighted which suggest additional informative lines of investigation.

BACKGROUND: Hereditary transthyretin amyloidosis is caused by pathogenic single-nucleotide variants in the gene encoding transthyretin ( TTR) that induce transthyretin misfolding and systemic deposition of amyloid. Progressive amyloid accumulation leads to multiorgan dysfunction and death. Inotersen, a 2'- O-methoxyethyl-modified antisense oligonucleotide, inhibits hepatic production of transthyretin. METHODS: We conducted an international, randomized, double-blind, placebo-controlled, 15-month, phase 3 trial of inotersen in adults with stage 1 (patient is ambulatory) or stage 2 (patient is ambulatory with assistance) hereditary transthyretin amyloidosis with polyneuropathy. Patients were randomly assigned, in a 2:1 ratio, to receive weekly subcutaneous injections of inotersen (300 mg) or placebo. The primary end points were the change in the modified Neuropathy Impairment Score+7 (mNIS+7; range, -22.3 to 346.3, with higher scores indicating poorer function; minimal clinically meaningful change, 2 points) and the change in the score on the patient-reported Norfolk Quality of Life-Diabetic Neuropathy (QOL-DN) questionnaire (range, -4 to 136, with higher scores indicating poorer quality of life). A decrease in scores indicated improvement. RESULTS: A total of 172 patients (112 in the inotersen group and 60 in the placebo group) received at least one dose of a trial regimen, and 139 (81%) completed the intervention period. Both primary efficacy assessments favored inotersen: the difference in the least-squares mean change from baseline to week 66 between the two groups (inotersen minus placebo) was -19.7 points (95% confidence interval [CI], -26.4 to -13.0; P

Cryoglobulins are immunoglobulins (Igs) that precipitate out of solution below core body temperatures, either as a single isotype (simple cryoglobulins) or as immune complexes in which both antibody and antigen are Igs (mixed cryoglobulins). Mixed cryoglobulins are cold-precipitable rheumatoid factors (RFs), with the serum often being positive when standard assays for IgM antiglobulin activity are used. Although many clinical laboratories offer cryoglobulin determinations, rarely is testing rigorously carried out, and there is considerable interlaboratory variability. A search for cryofibrinogenemia may be dictated by unexplained thrombohemorrhagic coagulopathy or cold-dependent purpura; it may also be dictated by the finding of characteristic pathology, occurring in various affected organs, as for example an occlusive thrombotic diathesis due to eosinophilic deposits within vessel lumina, extending into the intima, which may be associated with a granulomatous vasculitic component. Cryofibrinogenemia can be screened by cryoprecipitating or freeze-thawing plasma collected in citrate that contains an inhibitor of thrombin generation and is most convincing in the absence of coexisting cryoglobulinemia. Recognition of the laboratory phenomenon of pyroglobulinemia has importance as a potentially confounding factor for heat-based assays used to inactivate complement or to measure fibrinogen levels. Proper identification of a pyroglobulin as being a monoclonal component may in turn lead to the diagnosis of macroglobulinemia or plasma cell dyscrasia.

Objective.The relationship between self-reported quality of life and disability and disease severity was evaluated in subjects with treatment-failure gout (n = 110) in a prospective, 52-week, observational study.Methods.Subjects had symptomatic crystal-proven gout of at least 2 years’ duration and intolerance or refractoriness to conventional urate-lowering therapy. Serum uric acid (sUA) concentration, swollen and tender joint counts, frequency and severity of gout flares, tophus assessments, comorbidities, and patient-reported outcomes data [Medical Outcomes Study Short Form-36 (SF-36), Health Assessment Questionnaire-Damage Index] were collected. Analyses included correlations of patient-reported outcomes with clinical variables and changes in clinical status.Results.Mean age of study subjects was 59 years. Mean scores on SF-36 physical functioning subscales were 34.2–46.8, analogous to persons aged ≥ 75 years in the general population. Subjects with more severe gout at baseline had worse health-related quality of life (HRQOL) in all areas (p < 0.02 for all measures), compared to patients with mild-moderate disease. Number of flares reported in past year, number of tender joints, swollen joints, and tophi correlated significantly with some or all HRQOL and disability measures. sUA was not significantly correlated with any HRQOL or disability measure. Subjects with comorbidities experienced worse physical, but not mental, functioning.Conclusion.Severe gout is associated with poor HRQOL and disability, especially for patients who experience more gout flares and have a greater number of involved joints. Subject perceptions of gout-related functioning and pain severity appear to be highly sensitive indicators of HRQOL and disability.

Objective To investigate whether treatment with abetimus delays renal flare in patients with lupus nephritis. Secondary objectives included evaluation of the effect of abetimus on C3 levels, anti–double-stranded DNA (anti-dsDNA) antibody levels, use of high-dose corticosteroids and/or cyclophosphamide, and major systemic lupus erythematosus (SLE) flare. Methods We conducted a randomized, placebo-controlled study of treatment with abetimus at 100 mg/week for up to 22 months in SLE patients. Three hundred seventeen patients with a history of renal flare and anti-dsDNA levels >15 IU/ml were randomized to a treatment group (158 abetimus, 159 placebo); 298 (94%) were enrolled in the intent-to-treat (ITT) population (145 abetimus, 153 placebo), based on the presence of high-affinity antibodies for the oligonucleotide epitope of abetimus at baseline screening. Results Abetimus did not significantly prolong time to renal flare, time to initiation of high-dose corticosteroid and/or cyclophosphamide treatment, or time to major SLE flare. However, there were 25% fewer renal flares in the abetimus group compared with the placebo group (17 of 145 abetimus-treated patients [12%] versus 24 of 153 placebo-treated patients [16%]). Abetimus treatment decreased anti-dsDNA antibody levels (P < 0.0001), and reductions in anti-dsDNA levels were associated with increases in C3 levels (P < 0.0001). More patients in the abetimus group experienced ≥50% reductions in proteinuria at 1 year, compared with the placebo group (nominal P = 0.047). Trends toward reduced rates of renal flare and major SLE flare were noted in patients treated with abetimus who had impaired renal function at baseline. Treatment with abetimus for up to 22 months was well tolerated. Conclusion Abetimus at 100 mg/week significantly reduced anti-dsDNA antibody levels but did not significantly prolong time to renal flare when compared with placebo. Multiple positive trends in renal end points were observed in the abetimus treatment group.

Objective. Amyloid A protein quantification in fat tissue is a new immunochemical method for detecting AA amyloidosis, a rare but serious disease. The objective was to assess diagnostic performance in clinical AA amyloidosis.Methods. Abdominal subcutaneous fat tissue of patients with AA amyloidosis was studied at the start of an international clinical trial with eprodisate (NC-503; 1,3-propanedisulfonate; Kiacta (TM)), an antiamyloid compound. All patients had renal findings, i.e. proteinuria (>= 1 g/day) or reduced creatinine clearance (20-60 ml/min). Controls were patients with other types of amyloidosis and arthritic patients without amyloidosis. Amyloid A protein was quantified by ELISA using monoclonal antihuman serum amyloid A antibodies. Congo red stained slides were scored by light microscopy in a semiquantitative way (0 to 4+).Results. Ample fat tissue (>50 mg) was available for analysis in 154 of 183 patients with AA amyloidosis and in 354 controls. The sensitivity of amyloid A protein quantification for detection of AA amyloidosis (>11.6 ng/mg fat tissue) was 84% (95% CI: 77-89%) and specificity 99% (95% CI: 98-100%). Amyloid A protein quantification and semiquantitative Congo red scoring were concordant. Men had lower amyloid A protein values than women (p Conclusions. Amyloid A protein quantification in fat tissue is a sensitive and specific method for detection of clinical AA amyloidosis. Advantages are independence from staining quality and observer experience, direct confirmation of amyloid AA type, and potential for quantitative monitoring of tissue amyloid over time.

Cryoglobulins are immunoglobulins that precipitate as serum is cooled below core body temperatures. A cryoglobulin screen is the observation of a serum specimen collected and separated while warm for cryoprecipitation over a period of up to 7 days. Values of the screening may be reported as a cryocrit, which is the volume percent of the precipitate compared with the total volume of serum. Further proof that the precipitate is indeed a cryoglobulin can be obtained by demonstrating resolubilization with warming and immunochemical analysis by immunofixation. Detailed characterization of cryoglobulins may also require rigorous washing of the precipitate, quantitation of total protein and immunoglobulins, and evaluation of serum for monoclonal gammopathy, rheumatoid factor activity, evidence of complement activation, and presence of hepatitis C virus seroreactivity or hepatitis C virus RNA. The single most important variable confounding standardization of cryoglobulin testing is the frequently improper separation of warm serum from other blood elements prior to screening and characterization.

Systemic amyloid A (AA) amyloidosis is a serious complication of chronic inflammation. Serum AA protein (SAA), an acute phase plasma protein, is deposited extracellularly as insoluble amyloid fibrils that damage tissue structure and function. Clinical AA amyloidosis is typically preceded by many years of active inflammation before presenting, most commonly with renal involvement. Using dose-dependent, doxycycline-inducible transgenic expression of SAA in mice, we show that AA amyloid deposition can occur independently of inflammation and that the time before amyloid deposition is determined by the circulating SAA concentration. High level SAA expression induced amyloidosis in all mice after a short, slightly variable delay. SAA was rapidly incorporated into amyloid, acutely reducing circulating SAA concentrations by up to 90%. Prolonged modest SAA overexpression occasionally produced amyloidosis after long delays and primed most mice for explosive amyloidosis when SAA production subsequently increased. Endogenous priming and bulk amyloid deposition are thus separable events, each sensitive to plasma SAA concentration. Amyloid deposits slowly regressed with restoration of normal SAA production after doxycycline withdrawal. Reinduction of SAA overproduction revealed that, following amyloid regression, all mice were primed, especially for rapid glomerular amyloid deposition leading to renal failure, closely resembling the rapid onset of renal failure in clinical AA amyloidosis following acute exacerbation of inflammation. Clinical AA amyloidosis rarely involves the heart, but amyloidotic SAA transgenic mice consistently had minor cardiac amyloid deposits, enabling us to extend to the heart the demonstrable efficacy of our unique antibody therapy for elimination of visceral amyloid.

Background: AA amyloidosis is a systemic disease characterized by the extracellular deposition of amyloid fibrils derived from the acute-phase reactant serum amyloid A protein. It is typically a consequence of chronic inflammatory conditions like rheumatoid arthritis or Crohn's disease, although more patients are being identified who have more unusual causes or no known inflammatory stimulus. Methods: We performed a retrospective chart review of all patients with AA amyloidosis seen at Mount Sinai during the period of 1997–2012. Particular attention was paid to the patients' underlying diseases, extent of organ involvement, levels of inflammatory markers and proinflammatory cytokines, presence of pyrin gene mutations, and outcomes. Results: Forty-three patients were seen at Mount Sinai with AA amyloidosis during this period. The most common underlying diseases were rheumatoid arthritis (21%) and Crohn's disease (16%), though 21% of patients were considered to have idiopathic AA amyloid after an extensive search found no underlying inflammatory disease. Almost all patients (95%) had renal involvement based on biopsy or clinical criteria, with 19 patients (44%) eventually requiring dialysis and 5 (12%) undergoing renal transplantation. Inflammatory markers were elevated in most patients; however, interleukin-6 was the only consistently elevated cytokine. Three patients (of 9 tested) were found to be positive for the E148Q pyrin gene mutation. Conclusions: Our study confirms the increasing number of patients being seen with idiopathic AA amyloidosis. More research is needed to determine if these patients have an underlying genetic susceptibility encoded in pyrin or other genes. Our study also confirms the dominance of renal disease in this population. The elevated levels of interleukin-6, in comparison with other cytokines, could represent a therapeutic target. Mt Sinai J Med 79:749–756, 2012. © 2012 Mount Sinai School of Medicine

Familial amyloidotic polyneuropathy (FAP) is a protein folding disorder that induces neuropathy and cardiomyopathy, leading to death within 7-15 years after onset of clinical disease. In vitro, small ligands binding the thyroid hormone docking site stabilize tetrameric transthyretin, inhibiting amyloid fibril formation. We undertook a randomized, placebo-controlled clinical trial to determine whether diflunisal, a well-known non-steroidal anti-inflammatory drug (NSAID) alters neurologic disease progression in FAP. We enrolled 130 subjects with wide age and FAP mutation representation. To date, few recognized complications of NSAIDs have occurred in the study cohort. Data collection will be completed by November 2012.

The two most common autosomal dominant dystrophies of the corneal stroma are lattice corneal dystrophy type I and granular dystrophy. A third autosomal dominant stromal dystrophy (Avellino) has also been recognized. Chromosome linkage analysis of four families with Avellino dystrophy mapped the disease-causing gene to chromosome 5q. Subsequent linkage analysis of two families with typical lattice dystrophy and two with typical granular dystrophy also revealed significant linkage with the same markers. Thus, each of three clinically and histopathologically distinct phenotypes is independently linked to 5q. The maximum combined lod score using all 114 affected patients was 28.6 with marker D5S393. None of the 14 known human amyloid-associated genes map to chromosome 5.

A review of mixed cryoglobulinemia (MC) cross-reactive idiotypes (CRI) published 20 years ago (Sem Hematol 28, 79–94, 1991) is updated to include information regarding the structural correlates of these CRIs, prevalence and expression on specific B-cell subsets in hepatitis C virus (HCV) infection, and the occurrence of lymphoproliferative diseases complicating MC, HCV, and primary Sjogren’s syndrome (SS). MC occurring in association with HCV or primary SS shares selective usage of specific V-region H-chain (V1-69; V3-7; V4-59) and/or κ L-chain (V3-20; V3-15) genes, expression of which has been correlated with polyclonal (Wa) or monoclonal (Ccl-1; Lcl-1; G6; G8; 17.109) antibodies to MC CRIs expressed on CD27+ memory B cells in the peripheral blood of patients productively infected by HCV. In HCV, the expression of MC CRIs recognized by monoclonal and polyclonal antibodies to these idiotypes may be expanded on specific B-cell subsets or may provide a marker for coexistent lymphoproliferative disease, both of which may regress with clearance of the virus. In other instances, MC CRI and cryoglobulinemia may persist even after successful antiviral therapy. The full utility of antibodies to MC CRIs for diagnosis and treatment remains to be defined.

Familial amyloidotic polyneuropathy (FAP) is a lethal genetic disorder that affects the peripheral and autonomic nervous systems, heart, gastro-intestinal (GI) tract, and soft tissues. Di ...

Gerstmann-Sträussler-Scheinker disease (GSS) is a prion-related encephalopathy pathologically characterized by massive deposition of prion protein (PrP) amyloid in the central nervous system. The major component of amyloid fibrils isolated from patients of the Indiana kindred of GSS (GSS-Ik) is an 11-kDa fragment of PrP spanning residues 58 to approximately 150. These patients carry a missense mutation of the PRNP gene, causing a Phe-->Ser substitution at codon 198. We investigated fibrillogenesis in vitro by using synthetic peptides homologous to consecutive segments of GSS-Ik amyloid protein (residues 57-64, 89-106, 106-126, and 127-147) as well as peptides from the PrP region with the GSS-Ik mutation (residues 191-205 and 181-205, both wild type and mutant). Peptide PrP-(106-126) formed straight fibrils similar to those extracted from GSS brains, whereas peptide PrP-(127-147) formed twisted fibrils resembling scrapie-associated fibrils isolated from subjects with transmissible spongiform encephalopathies. Congo red staining and x-ray fibril diffraction showed that both straight and twisted fibrils had tinctorial and conformational properties of native amyloid. Conversely, the other peptides did not form amyloid-like fibrils under similar conditions. These findings suggest that the sequence spanning residues 106-147 of PrP is central to amyloid fibril formation in GSS and related encephalopathies.

The spectrum of arthropathy in non-HIV immune deficiency states includes arthritis due to prevalent infectious pathogens and autoimmunity that may in some instances be triggered by microorganisms. Joint symptoms may be clinical manifestations of disease, or they may develop later during therapy for immunodeficiency. Pathogenesis can be related to occult infection, loss of mucosal barrier function, defective clearance of immune complexes, or aberrant immune responses. Proper treatment includes an appreciation of likely pathogens, an understanding of the nature of immunologic deficits, and rigorous exclusion of immune dysfunction that may be secondary to treatment.

Immunohistologic studies of tissue sections obtained from patients with type 1 or type 2 lattice corneal dystrophy, polymorphic amyloid degeneration, or gelatinous amyloid degeneration were performed by using a monoclonal antibody raised to a chymotryptic fragment inclusive of the carboxy-terminal half of plasma gelsolin, and also with a series of polyclonal antibodies specific for synthetic peptides corresponding to immunogenic epitopes of gelsolin. These epitopes are parts of sequences at the amino- and carboxy-terminal ends of gelsolin, as well as adjacent to and inclusive of the codon 187 mutant 7-11 kD fragment that has been shown to be the subunit protein of amyloid fibrils occurring systemically in patients affected by Finnish type familial amyloidosis. These antibodies were also tested on tissue sections obtained from patients with granular and macular corneal dystrophy, corneal wounds, and normal control corneas. Specificity of staining was established by absorption with gelsolin purified from plasma, or the appropriate synthetic peptide. Gelsolin immunoreactivity was detected in the conjunctival and skin amyloid in familial amyloidosis by using familial amyloid (Finnish type) antibody. In other types of corneal amyloid, including lattice dystrophy type 1, immunoreactivity with gelsolin and synthetic peptides was observed adjacent to the deposits, but rarely within them. In macular dystrophy, variable staining of the deposits could result from the association of subunit proteins with glycosaminoglycans.

AMYLOID is a homogeneous, largely extracellular, proteinaceous material with a fibrillar ultrastructure and the property of green birefringence when stained with Congo red and viewed by polarizatio...

Human T cell lymphotropic virus type I (HTLV-I) gag and env protein-specific antibodies were identified in 6 of 13 patients with essential cryoglobulinemia (EC), by Western blot and radioimmunoprecipitation analysis. Supernatants of cells from 2 of the 5 EC patients tested showed reverse transcriptase activity. DNA sequences homologous to HTLV-I could not be detected by polymerase chain reaction, thus excluding the presence of prototype HTLV-I in each patient with EC. The data suggest that retroviral proteins distinct from but related to HTLV-I may be involved in the pathogenesis of EC in some patients.

Background: Amyloid A (AA) amyloidosis is a complication of chronic inflammatory conditions that develops when proteolytic fragments of serum amyloid A protein (SAA) are deposited in tissues as amyloid fibrils. Amyloid deposition in the kidney causes progressive deterioration in renal function. Eprodisate is a member of a new class of compounds designed to interfere with interactions between amyloidogenic proteins and glycosaminoglycans and thereby inhibit polymerization of amyloid fibrils and deposition of the fibrils in tissues. Methods: We performed a multicenter, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of eprodisate in patients with AA amyloidosis and kidney involvement. We randomly assigned 183 patients from 27 centers to receive eprodisate or placebo for 24 months. The primary composite end point was an assessment of renal function or death. Disease was classified as worsened if any one of the following occurred: doubling of the serum creatinine level, reduction in creatinine clearance by 50% or more, progression to end-stage renal disease, or death. Results: At 24 months, disease was worsened in 24 of 89 patients who received eprodisate (27%) and 38 of 94 patients given placebo (40%, P=0.06); the hazard ratio for worsening disease with eprodisate treatment was 0.58 (95% confidence interval, 0.37 to 0.93; P=0.02). The mean rates of decline in creatinine clearance were 10.9 and 15.6 ml per minute per 1.73 m2 of body-surface area per year in the eprodisate and the placebo groups, respectively (P=0.02). The drug had no significant effect on progression to end-stage renal disease (hazard ratio, 0.54; P=0.20) or risk of death (hazard ratio, 0.95; P=0.94). The incidence of adverse events was similar in the two groups. Conclusions: Eprodisate slows the decline of renal function in AA amyloidosis.

Angioendotheliomatosis is an uncommon condition that manifests with both cutaneous and systemic clinical signs and symptoms. It is characterized histologically by the proliferation of endothelial cells within vascular lumina resulting in the obliteration of the involved vessels secondary to intravascular thrombi. Cases have been classically divided into the benign or reactive variants and a malignant variant. The reactive variant is considerably more rare and has mainly been described in patients with systemic infections including subacute bacterial endocarditis. In this report we present a case of reactive angioendotheliomatosis in a patient with sarcoidosis.

Objective: To review autoimmune disease complicating therapy with type I interferons (IFNs), specifically in the setting of hepatitis C virus (HCV) infection. Methods: This study describes 13 reported cases of drug-induced systemic lupus erythematosus (SLE) associated with IFN therapy for the period reported during 1990-2002 by searching MEDLINE. In addition, 2 additional patients are presented, 1 with SLE and 1 with an antineutrophil cytoplasmic antibody (ANCA)-positive nephritis, with long-term follow-up. Results: Of 13 cases of SLE-like syndromes caused by IFN, 2 occurred in patients being treated for HCV infection. Two occurred in patients with rheumatoid arthritis (RA); 1 had Sjogren's syndrome (SS), and 1 laryngeal papillomatosis. The rest were receiving IFN for hematologic malignancies. Symptoms developed between 2 weeks and 7 years after initiation of therapy. Most developed fever and arthralgias/arthritis. Other findings included serositis manifested by tachycardia, dyspnea and pleural effusions, headaches, and hair loss. All had a positive antinuclear antibody (ANA), and the majority had double stranded (ds) DNA antibodies. Two additional patients with chronic HCV infection developed autoimmune disease after combination treatment with IFN-α and ribavirin. In each patient, autoimmune disease manifested as severe joint pains, myalgias, fever, rash, and proteinuria. Skin and renal biopsy specimens showed vasculitis and crescentic glomerulonephritis (GN) in the first case, and typical histologic findings of lupus nephritis in the second; clinical and laboratory features were consistent with Wegener's granulomatosis and SLE, respectively. Although both patients had mixed polyclonal cryoglobulins, they were HCV RNA and HCVAb negative. Both received corticosteroids, with gradual clinical and biochemical improvement and without recurrence of viremia. Conclusions: Autoimmune disorders occur in 4% to 19% of patients receiving IFN-α, though SLE-like syndromes are only seen in 0.15% to 0.7%. Clinical and laboratory features of SLE in this setting resemble idiopathic disease, with a generally good outcome after discontinuance of the drug. Relevance: Type I IFNs may cause autoimmune disease such as SLE. As the armamentarium of drugs expands to include other biologics, such as the tumor necrosis factor (TNF)-α–inhibiting drugs, the development of autoimmune diseases induced by these drugs is an important consideration for diagnosis and appropriate treatment. Semin Arthritis Rheum 32:163-173. Copyright 2002, Elsevier Science (USA). All right reserved.

Amyloid beta (A beta) is a normal proteolytic fragment of a large precursor protein (beta PP) which undergoes altered conformation, leading to fibril formation. Two main beta PP processing pathways have been described, and we are now reporting the characterization of a third beta PP pathway. A membrane-associated 16 kDa component identified in human platelets isolated from normal donors. Based on size, immunoreactivity and amino acid sequence analysis, the fragment is a C-terminal beta PP component which starts at position 642 (APP770 numbering) and contains the intact A beta sequence. The presence of this novel pathway of beta PP processing in resting platelets suggest that it occurs as a normal event.

The case of a 68-year-old woman who presented with dyspnea and upper lobe pulmonary infiltrates and shortly thereafter developed seropositive, erosive polyarticular rheumatoid arthritis (RA) is presented. An open-lung biopsy to evaluate progression of infiltrates showed bronchiolitis obliterans-organizing pneumonia (BOOP). Both lung and articular disease responded rapidly to corticosteroid therapy. Interrelationships between BOOP, bronchiolitis obliterans, and interstitial fibrosis with connective tissue disease are discussed.

The p41 flagellin of Borrelia burgdorferi is the most common antigen recognized by serum of patients with Lyme borreliosis. This antigen shares amino acid homology, particularly in the amino and carboxy termini, with periflagellar antigens found in other microorganisms including Treponema pallidum . We cloned and expressed the p41 open reading frame in Escherichia coli and expressed it both as TrpE fusion and full-length unfused proteins. Also, we generated deletion constructs of various portions of the gene. Sera from patients with late Lyme borreliosis and secondary syphilis were used to identify the recombinant proteins by immunoblot analysis. Sera from 26 patients with Lyme borreliosis, 20 with secondary syphilis and 10 controls were used to identify cross-reactive domains of the B. burgdorferi flagellin. The variable region (amino acids 131–234) of the protein was recognized by 59% (15/26) of patients with late Lyme borreliosis compared to 30% (6/20) of patients with secondary syphilis and no (0/10) control patients. It appears that cross-reactive epitopes between B. burgodorferi and T. pallidum extend to the variable region of the flagellin.

Amyloid deposition in the iris is rare, scanty and associated with systemic disease. We present a case of isolated localized heavy amyloid infiltration of the iris and describe a new hillock-pattern feature visualized using scanning electron microscopy.

Amyloid may involve the cornea in sporadic and familial forms of LCD, as Polymorphic Amyloid Degeneration (PAD), primary gelatinous drop-like dystrophy or, in rare cases, as part of systemic light chain deposition. LCD is prominent in Familial Amyloidosis, Finnish type (FAF), clinical features of which have also been described in rare kindreds from the Netherlands, Denmark and the United States. Previous studies from our laboratories have found AP, but not AA, AL or prealbumin (transthyretin)-reactivity in cases of FAF, hereditary and sporadic LCD from the United States, and PAD examined immunohistologically and by Western Blot analysis of solubilized corneal proteins. Because we have now shown the FAF amyloid to be composed of a 12 kD internal fragment of plasma or cytoplasmic gelsolin, we sought to extend our previous observations using a rabbit antibody developed to the FAF subunit protein, and a commercially-available murine monoclonal antibody to plasma gelsolin. Anti-FAF reacted strongly in tissue section with amyloid deposits from Finnish patients in kidney and cornea, as well as with cornea, conjunctival and skin amyloid deposits from one previously described (Ophthalmology 9:1512, 1983) American case of Meretoja-type familial LCD. No reaction was obtained with cases of sporadic LCD (3), PAD (2) or drop dystrophy (1). The murine antibody, which is specific for a peptide that includes the carboxy terminal actin-binding site of gelsolin, also reacted with amyloid deposits in various tissues of FAF patients (Amer. J. Pathol. 136:1223-1228, 1990). Anti-gelsolin did not react with cases of AL, AA or prealbumin (TTr)-related amyloid in tissue section. It thus appears that sporadic LCD, PAD and drop dystrophy are antigenically distinct from FAF and at least one form of familial LCD; additional studies will be necessary to determine if the former are due to fibril formation involving other gelsolin epitopes, or are due to other amyloidogenic proteins.

Numerous age-related alterations in immune function and regulation were defined and recently summarized by Makinodan and Hirokawa (1985), Hausman and Weksler (1985), and Siskind (1987). Among the most common are those abnormalities of immune function that are mediated by B lymphocytes. In their simplest form, this may be reflected as a gradual increase in the percentage of sera obtained from presumably healthy individuals from the fifth through and past the ninth decade, which contain monoclonal immunoglobulins. Analysis of sera from 27,000 consecutive blood donors showed that while monoclonal immunoglobulins occur with a frequency of 0.17% in the general population, their incidence increases progressively with age, rising from 0.025% to 0.5% between the ages of 18–29 and 50–60 years, respectively (Fine et al., 1979). Kyle (1984) and others (Radl et al., 1975) extended these observations and demonstrated the presence of serum paraproteins in 19% of individuals 90 years and older. These paraproteins (1) do not involve a particular subset of immunoglobulin; (2) are not confined to a particular immunoglobulin class, their distribution being similar to that noted for a random population of patients with multiple myeloma and for the frequency of occurrence of immunoglobulins of various classes and subclasses in a pool of healthy individuals; (3) do not generally have any demonstrable antigenic specificity; and (4) may be at serum concentrations similar to those found in multiple myeloma (Melistedy et al., 1984). It is presumed that these paraproteins are synthesized at an accelerated rate by an amplified clone of B cells, which may reflect an abnormal immune response.

Lyme borreliosis is a multisystem inflammatory disorder caused by the tick-borne spirocheteBorrelia burgdorferi. Clinical manifestations are protean, involving the skin, joints, peripheral and central nervous systems, and the heart. However, the presentation of Lyme disease often overlaps with that of other conditions. We describe four patients from a region endemic for Lyme disease who had elevated levels of antibodies reactive toB burgdorferiand whose signs and symptoms were initially attributed to Lyme borreliosis but whose subsequent blood cultures established a diagnosis of nonspirochetal subacute bacterial endocarditis. Although immunoblots on serum samples from three of the four patients were consistent with prior infection fromB burgdorferi, a positive immunoblot does not establish active infection. Similarly, seropositivity toB burgdorferionly indicates possible exposure to this organism. The occurrence of positive serologies toB burgdorferiin the presence of other diseases can lead to diagnostic confusion. (JAMA. 1990;264:2916-2918)

Two cases of idiopathic amyloidosis are described. AA protein was found to be the major constituent of tissue amyloid in both, based on sensitivity of Congo red birefringence to pretreatment of slides with potassium permanganate and immunoperoxidase staining with a monospecific antiserum. However, an underlying inflammatory, infectious or neoplastic disorder was not identified. The occurrence of AA amyloidosis without clearcut underlying disease is rare, having been described in only thirteen previous instances. Recent clinical series suggest that such cases may have a different course and response to therapy from “primary” amyloidosis due to systemic light chain deposition. Such cases may also underscore the importance of genetic factors in the pathogenesis of AA amyloid and the importance of characterizing the amyloidoses biochemically, as well as clinically. (The J Histotechnol 12:137, 1989.)

A prospective clinical study evaluated the effects of combined chemotherapy, steroids and plasmapheresis on 5 patients with mixed cryoglobulinemia with renal or neurologic and vasculitic manifestations. Treatment included prednisone (1mg/kg/day), chlorambucil (white blood cell count at greater than 3,000/mm3), and plasmapheresis (1 to 3 liters/week). There was healing of cutaneous ulcers (3/3), improvement in renal function (4/4), and diminution of purpura (2/2), but little improvement in peripheral neuropathy. Complications included leukopenia, perineal ulcers, and osteomyelitis.

In view of a high frequency of liver involvement in patients with essential mixed cryoglobulinemia, we looked for evidence for hepatitis B virus infection in 25 serum specimens and 19 cryoprecipitates obtained from 30 patients. Three of the 25 serum specimens contained HBs Ag, and 12 had antibody. The frequency of positive results was increased to six and 11 of 19 respectively when cryoprecipitates were examined, and 14 of 19 (74 per cent) of the cryoprecipitates were positive for either HBs Ag or its antibody. Electron microscopy of four cryoprecipitates showed structures resembling the 20-nm and 27-nm spheres, tubules, as well as the Dane particles characteristic of hepatitis B virus infection. Since such infection appears to be involved in the pathogenesis of the syndrome, the term "essential mixed cryoglobulinemia" should be replaced by "mixed cryoglobulinemia secondary to hepatitis B virus" or perhaps to other viral infections. (N Engl J Med 296:1501–1504, 1977)

Vitreous amyloid may be the presenting clinical manifestation of types 1 and 2 familial amyloidotic polyneuropathy or complicate the course of these syndromes. Recent studies have shown that the major subunit protein composing amyloid fibrils in these conditions is a variant or abnormal prealbumin molecule and that affected individuals have low levels of this protein in their blood. The authors studied material obtained at vitrectomy from two cases of vitreous amyloid. One of these was nonfamilial and the other familial. Two-dimensional gels of solubilized protein from pelleted and washed vitreous amyloid in both cases were found to consist of material with the molecular weight and isofocusing coordinates of prealbumin monomer. Reactivity of fibrils with a monospecific antiserum to prealbumin was confirmed by colloidal gold immunoelectron microscopy. Non-familial as well as familial vitreous amyloid may in fact be systemic forms of amyloidosis due to deposition of prealbumin which can be characterized by biochemical or immunohistologic studies of material obtained at vitrectomy.

Amyloid lesions of bone are rare and limited almost exclusively to patients with amyloidosis secondary to plasma cell dyscrasias. The present report describes the cases of two patients receiving long-term hemodialysis (nine and 12 years) who had multiple lytic lesions of bone proved by biopsy to contain an unusual type of amyloid. Results of serum protein electrophoreses and immunoelectrophoreses, as well as bone marrow examinations, were normal. In both cases the amyloid displayed characteristic Congo red affinity and birefringence on polarized light microscopy that was inhibited by potassium permanganate treatment of sections prior to staining. Although this staining reaction was described previously exclusively in AA amyloid (i.e., the material associated with classic secondary amyloidosis), immunoperoxidase staining for AA protein in these cases was negative. Transmission electron microscopy revealed the amyloid fibrils to have unusual curvilinear configurations. Immunoperoxidase staining for beta 2-microglobulin (beta 2m) was positive in the amyloid lesions of both patients at the light microscopic level. Ultrastructural immunohistochemical studies for beta 2m, performed in one case, were positive. Both patients had markedly elevated serum beta 2m levels. By Ouchterlony immunodiffusion, purified beta 2m demonstrated partial identity with purified amyloid protein fractions and a serum constituent. Bone lesions composed of amyloid related to beta 2M probably represent a new subgroup of amyloid disease that may be linked to renal failure and long-term hemodialysis.

Longitudinal studies of serum SAA (amyloid-related serum component) levels were done on a group of 17 patients hospitalized for acute bacterial infections, and the results were compared to another group of 24 patients undergoing elective surgical procedures. In the former, striking initial elevations were seen, resolving rapidly with therapy and clinical status; failure of response in two patients could be correlated with ongoing or recurrent infection. By contrast, the latter group manifested little variation in SAA level. Of all the acute-phase parameters tested, only the WBC (white blood cell count) could be related to variations in SAA. Levels obtained in patients and relatives of patients with the familial form of medullary carcinoma of the thyroid were generally normal. The possible significance of this finding is discussed in view of theories claiming the amyloid associated with this entity to be light-chain-related, “A” protein, or prohormone in nature. SAA was found to be present at low levels in CSF (cerebrospinal fluid), though no correlation to age could be made at the level of resolution of the radioimmunoassay. Simultaneous serum levels ranged up to 30 times the CSF levels. A small group of patients with elevated CSF levels were also noted to have acute infections, some without evidence of meningeal irritation.

Isolated amyloid fibrils from three cases of systemic senile amyloidosis (SSA) contained subunit proteins with molecular masses of 14 (10-20%), 10-12 (60-80%), and 5-6 kD (5-10%) when fractionated under reducing and dissociating conditions. This grouping was identical to that seen in SKO, a case of familial amyloidotic polyneuropathy (FAP) studied earlier. Amino acid sequencing confirmed that SSA subunit proteins were in fact prealbumin (transthyretin). Complete sequence analysis of one SSA preparation revealed the presence of a new variant Pa (TTr) molecule with a single amino acid substitution of isoleucine for valine at position 122. Further studies used an antiserum specific for SKO IV, a subunit protein of SKO previously shown to correspond to carboxy-terminal 78 residues (positions 49-127) of (TTr). Anti-SKO IV reacted with SSA in tissue at equivalent dilutions to anti-Pa (TTr) and with the 10-12-kD fraction of SSA on Western blots; reactivity was blocked by SKO IV, but not by Pa (TTr). SSA is a form of systemic amyloidosis caused by tissue deposition of Pa (TTr) and its fragments, with shared conformational or subunit antigenicity to at least one form of FAP. Identification of a new variant Pa (TTr) molecule in one case suggests further that SSA may be a genetically determined disease expressed late in life.

The molecular basis of fibril formation in Alzheimers disease was explored by electron micrographic and x-ray diffraction analysis of a series of synthetic peptides corresponding to portions of the amino acid sequence of beta protein and that of its putative precursor. A minimum 14 residue peptide was identified that formed typical amyloid fibrils under physiological conditions. Of these 14 residues, 10 were sufficient to give an identical 4.76 A and 10.6 A diffraction pattern as that recently described for isolated neurofibrillary tangles, amyloid plaque cores and leptomeningeal amyloid fibrils.

The diagnosis of gout and pseudogout has traditionally been established by the identification, in synovial fluid, of monosodium urate and calcium pyrophosphate dihydrate crystals with compensated polarizing light microscopy. In this paper the utility of electron microscopy in establishing these diagnosis in two cases, when the conventional means of synovial fluid analysis had failed to do so, is discussed. The application of ultrastructural analysis of synovial fluid increases diagnostic capability in the crystal deposition diseases, and it is recommended for those patients in whom the more usual studies have not established a diagnosis.

Fractions enriched in neurofibrillary tangles (NFT) and amyloid fibrils were isolated from the cerebral cortex of three cases of senile dementia of the Alzheimer type. Distilled water suspensions of these fractions were excluded from all pore size gels and resisted digestion with various proteolytic enzymes. Formic acid/chloroform treatment of each fraction resulted in the appearance of 4,000–6,000, 15,000–17,000 and 24,000 molecular weight proteins, with concomitant diminution in the amount of excluded material at the top of each gel. The 4,000–6,000 dalton band was best seen in fractions containing randomly arranged amyloid fibrils, and its amino acid composition resembled that of the recently reported “beta” protein. A polyclonal antiserum to purified NFT reacted with tangles in neurons and in dystrophic neurites around plaques by immunoperoxidase staining. No reaction was obtained with cerebrovascul ar or plaque core amyloid immunohistologically, or with the 4–6 kD prote in on immunoblots. Cross-reactivity with the neurofibrillary lesions occurring in Pick's disease, progressive supranuclear palsy, postencephalitic Parkinsonism and dementia pugilistica was also seen. Specific binding of this antiserum to the double filamentous structure was confirmed by immunoelectron microscopy. Although the presence of “beta” protein in both NFT and amyloid-containing fractions suggests that it may be an important constituent of both, cross-contamination cannot be excluded.