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Asselta R, Paraboschi EM, Duga S. Hereditary Hypofibrinogenemia with Hepatic Storage. Int J Mol Sci 2020; 21:ijms21217830. [PMID: 33105716 PMCID: PMC7659954 DOI: 10.3390/ijms21217830] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Fibrinogen is a 340-kDa plasma glycoprotein constituted by two sets of symmetrical trimers, each formed by the Aα, Bβ, and γ chains (respectively coded by the FGA, FGB, and FGG genes). Quantitative fibrinogen deficiencies (hypofibrinogenemia, afibrinogenemia) are rare congenital disorders characterized by low or unmeasurable plasma fibrinogen antigen levels. Their genetic basis is represented by mutations within the fibrinogen genes. To date, only eight mutations, all affecting a small region of the fibrinogen γ chain, have been reported to cause hereditary hypofibrinogenemia with hepatic storage (HHHS), a disorder characterized by protein aggregation in the endoplasmic reticulum, hypofibrinogenemia, and liver disease of variable severity. Here, we will briefly review the clinic characteristics of HHHS patients and the histological feature of their hepatic inclusions, and we will focus on the molecular genetic basis of this peculiar type of coagulopathy.
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Affiliation(s)
- Rosanna Asselta
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (E.M.P.); (S.D.)
- Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-02-8224-5215
| | - Elvezia Maria Paraboschi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (E.M.P.); (S.D.)
- Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Stefano Duga
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (E.M.P.); (S.D.)
- Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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Fraga M, Moradpour D, Artru F, Romailler E, Tschopp J, Schneider A, Chtioui H, Neerman-Arbez M, Casini A, Alberio L, Sempoux C. Hepatocellular type II fibrinogen inclusions in a patient with severe COVID-19 and hepatitis. J Hepatol 2020; 73:967-970. [PMID: 32585161 PMCID: PMC7308036 DOI: 10.1016/j.jhep.2020.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Montserrat Fraga
- Division of Gastroenterology and Hepatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Florent Artru
- Division of Gastroenterology and Hepatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Elodie Romailler
- Division of Gastroenterology and Hepatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jonathan Tschopp
- Division of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Adult Intensive Care Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haithem Chtioui
- Division of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Lorenzo Alberio
- Division and Central Laboratory of Hematology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Zen Y, Nishigami T. Rethinking fibrinogen storage disease of the liver: ground glass and globular inclusions do not represent a congenital metabolic disorder but acquired collective retention of proteins. Hum Pathol 2020; 100:1-9. [PMID: 32330484 DOI: 10.1016/j.humpath.2020.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 11/18/2022]
Abstract
Three types of intracytoplasmic inclusions immunoreactive to fibrinogen are collectively diagnosed as hepatic fibrinogen storage disease. This study aimed to better characterize ground glass (type II) and globular (type III) fibrinogen inclusions by the pathological examination of 3 cases and a literature review. Three adults (age: 32-64 years; male/female = 2:1) were unexpectedly found to have fibrinogen-positive ground glass changes (type II inclusions) by liver needle biopsy, against a background of acute hepatitis E, resolving acute cholangitis, or severe lobular hepatitis of unknown etiology. One patient also had fibrinogen-positive intracytoplasmic globules (type III inclusions) in the first biopsy, but they were not present in a second biopsy. None had coagulation abnormalities or hypofibrinogenemia. On immunostaining, both inclusions were strongly positive for not only fibrinogen but also C-reactive protein and C4d. Ultrastructurally, ground glass changes corresponded to membrane-bound cytoplasmic inclusions containing amorphous, granular material. The pathological features of type II fibrinogen inclusions were identical to those of pale bodies in hepatocellular carcinoma. The literature review suggested that type I fibrinogen inclusions characterized by a polygonal appearance are strongly associated with mutations in fibrinogen genes, coagulopathy, and family history, whereas type II/III inclusions are immunoreactive to multiple proteins and typically develop in cases of other unrelated liver diseases. In conclusion, type II and III fibrinogen inclusions do not represent a true hereditary storage disease but instead the collective retention of multiple proteins. Given the lack of clinical significance, a less specific name (e.g., pale body) may be more appropriate for those inclusions.
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Affiliation(s)
- Yoh Zen
- Institute of Liver Studies, King's College Hospital & King's College London, London SE5 9RS, UK; Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan.
| | - Takashi Nishigami
- Department of Diagnostic Pathology, Steel Memorial Hirohata Hospital, Himeji 671-1122, Japan.
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Kuscuoglu D, Janciauskiene S, Hamesch K, Haybaeck J, Trautwein C, Strnad P. Liver - master and servant of serum proteome. J Hepatol 2018; 69:512-524. [PMID: 29709680 DOI: 10.1016/j.jhep.2018.04.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 12/20/2022]
Abstract
Hepatocytes synthesise the majority of serum proteins. This production occurs in the endoplasmic reticulum (ER) and is adjusted by complex local and systemic regulatory mechanisms. Accordingly, serum levels of hepatocyte-made proteins constitute important biomarkers that reflect both systemic processes and the status of the liver. For example, C-reactive protein is an established marker of inflammatory reaction, whereas transferrin emerges as a liver stress marker and an attractive mortality predictor. The high protein flow through the ER poses a continuous challenge that is handled by a complex proteostatic network consisting of ER folding machinery, ER stress response, ER-associated degradation and autophagy. Various disorders disrupt this delicate balance and result in protein accumulation in the ER. These include chronic hepatitis B infection with overproduction of hepatitis B surface antigen or inherited alpha1-antitrypsin deficiency that give rise to ground glass hepatocytes and alpha1-antitrypsin aggregates, respectively. We review these ER storage disorders and their downstream consequences. The interaction between proteotoxic stress and other ER challenges such as lipotoxicity is also discussed. Collectively, this article aims to sharpen our view of liver hepatocytes as the central hubs of protein metabolism.
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Affiliation(s)
- Deniz Kuscuoglu
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany; The Interdisciplinary Center for Clinical Research (IZKF), University Hospital Aachen, Aachen, Germany
| | - Sabina Janciauskiene
- Department of Respiratory Medicine, Hannover Medical School, BREATH, German Center for Lung Research (DZL), Hannover, Germany
| | - Karim Hamesch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes Haybaeck
- Institute of Pathology, Medical University Graz, Graz, Austria; Department of Pathology, Medical Faculty, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany
| | - Christian Trautwein
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany; The Interdisciplinary Center for Clinical Research (IZKF), University Hospital Aachen, Aachen, Germany.
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Asselta R, Robusto M, Braidotti P, Peyvandi F, Nastasio S, D'Antiga L, Perisic VN, Maggiore G, Caccia S, Duga S. Hepatic fibrinogen storage disease: identification of two novel mutations (p.Asp316Asn, fibrinogen Pisa and p.Gly366Ser, fibrinogen Beograd) impacting on the fibrinogen γ-module. J Thromb Haemost 2015; 13:1459-67. [PMID: 26039544 DOI: 10.1111/jth.13021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/13/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND Quantitative fibrinogen deficiencies (hypofibrinogenemia and afibrinogenemia) are rare congenital disorders characterized by low/unmeasurable plasma fibrinogen antigen levels. Their genetic basis is invariably represented by mutations within the fibrinogen genes (FGA, FGB and FGG coding for the Aα, Bβ and γ chains). Currently, only four mutations (p.Gly284Arg, p.Arg375Trp, delGVYYQ 346-350, p.Thr314Pro), all affecting the fibrinogen γ chain, have been reported to cause fibrinogen storage disease (FSD), a disorder characterized by protein aggregation, endoplasmic reticulum retention and hypofibrinogenemia. OBJECTIVES To investigate the genetic basis of FSD in two hypofibrinogenemic patients. METHODS The mutational screening of the fibrinogen genes was performed by direct DNA sequencing. The impact of identified mutations on fibrinogen structure was investigated by in-silico molecular modeling. Liver histology was evaluated by light microscopy, electron microscopy and immunocytochemistry. RESULTS Here, we describe two hypofibrinogenemic children with persistent abnormal liver function parameters. Direct sequencing of the coding portion of fibrinogen genes disclosed two novel FGG missense variants (p.Asp316Asn, fibrinogen Pisa; p.Gly366Ser, fibrinogen Beograd), both present in the heterozygous state and affecting residues located in the fibrinogen C-terminal γ-module. Liver sections derived from biopsies of the two patients were examined by immunocytochemical analyses, revealing hepatocyte cytoplasmic inclusions immunoreactive to anti-fibrinogen antibodies. CONCLUSIONS Our work strongly confirms the clustering of mutations causing FSD in the fibrinogen γ chain between residues 284 and 375. Based on an in-depth structural analysis of all FSD-causing mutations and on their resemblance to mutations leading to serpinopathies, we also comment on a possible mechanism explaining fibrinogen polymerization within hepatocytes.
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Affiliation(s)
- R Asselta
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
- Humanitas Clinical and Research Center, Rozzano, Italy
| | - M Robusto
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
- Humanitas Clinical and Research Center, Rozzano, Italy
| | - P Braidotti
- Pathology Department, S. Paolo Hospital, Milan, Italy
| | - F Peyvandi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - S Nastasio
- Department of Clinical and Experimental Medicine, University of Pisa, Pediatric Gastroenterology, University Hospital Santa Chiara, Pisa, Italy
| | - L D'Antiga
- Paediatric Liver, GI and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - V N Perisic
- Department of Gastroenterology and Hepatology, University Children's Hospital, Belgrade, Serbia
| | - G Maggiore
- Department of Clinical and Experimental Medicine, University of Pisa, Pediatric Gastroenterology, University Hospital Santa Chiara, Pisa, Italy
| | - S Caccia
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, Segrate, Milan, Italy
| | - S Duga
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
- Humanitas Clinical and Research Center, Rozzano, Italy
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Strnad P, Nuraldeen R, Guldiken N, Hartmann D, Mahajan V, Denk H, Haybaeck J. Broad Spectrum of Hepatocyte Inclusions in Humans, Animals, and Experimental Models. Compr Physiol 2013; 3:1393-436. [DOI: 10.1002/cphy.c120032] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fibrinogen storage disease caused by Aguadilla mutation presenting with hypobeta-lipoproteinemia and considerable liver disease. J Pediatr Gastroenterol Nutr 2009; 49:133-6. [PMID: 19458552 DOI: 10.1097/mpg.0b013e31817ed7ea] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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8
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Celant A, Chichino G, Dal Bello B, Massarotti M, Minoli L, Marasini B. Visceral leishmaniasis, systemic lupus erythematosus and acute hepatitis. Rheumatol Int 2008; 29:111-2. [DOI: 10.1007/s00296-008-0624-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 05/13/2008] [Indexed: 10/22/2022]
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Bruzzi C, Bader A, Luban NLC, Przygodzki R, Ahmed AA. Pathology teach and tell: fibrinogen storage disease in a child with hypofibrinogenemia and decreased ceruloplasmin. Fetal Pediatr Pathol 2007; 26:101-5. [PMID: 17701692 DOI: 10.1080/15513810701448623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The authors present a clinical case of a patient with mild liver disease and coagulopathy. The diagnosis was reached through careful histologic examination of liver biopsy. Electron microscopy played an important role in confirming the diagnosis.
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Affiliation(s)
- Cynthia Bruzzi
- Department of Pathology, George Washington University School of Medicine, Washington, DC, USA
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Wisell J, Boitnott J, Haas M, Anders RA, Hart J, Lewis JT, Abraham SC, Torbenson M. Glycogen pseudoground glass change in hepatocytes. Am J Surg Pathol 2006; 30:1085-90. [PMID: 16931952 DOI: 10.1097/01.pas.0000208896.92988.fc] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ground glass cytoplasmic change in hepatocytes is typically associated with chronic hepatitis B infection. We report 12 cases of glycogen pseudoground glass change that closely mimics hepatitis B inclusions. Nine individuals were immunosuppressed secondary to liver or kidney transplant (N=3), bone marrow transplant (N=2), HIV infection (N=2), kidney dialysis (N=1), or chronic inflammatory bowel disease (N=1). Medication history was available in 10 individuals and all were on multiple medications (range 2 to 33). Histologically, the pseudoground glass change was identical to the ground glass change seen in chronic hepatitis B infection, with distinct, circumscribed, gray-glassy inclusions surrounded by a rim of cytoplasm. The background livers showed mild or no inflammation and mild or no fibrosis. All cases were negative for chronic hepatitis B infection. The pseudoground glass change was PAS positive and diastase sensitive. Electron microscopy of the inclusions showed glycogen in 3/3 cases. No evidence for viral particles or significant endoplasmic reticulum proliferation was seen. Three cases had follow-up biopsies (1, 1, and 36 mo), and the pseudoground glass was persistent in 2 cases and showed partial resolution in 1 case (1 mo biopsy interval). We conclude that glycogen pseudoground glass change is typically seen in immunosuppressed individuals on numerous medications. The changes are generally seen in the background of mild chronic hepatitis with mild or no fibrosis. Glycogen pseudoground glass change can resolve, but may also persist for years.
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Affiliation(s)
- Joshua Wisell
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD 21231, USA
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Bejarano PA, Garcia MT, Rodriguez MM, Ruiz P, Tzakis AG. Liver glycogen bodies: ground-glass hepatocytes in transplanted patients. Virchows Arch 2006; 449:539-45. [PMID: 17024424 DOI: 10.1007/s00428-006-0286-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Accepted: 07/31/2006] [Indexed: 01/20/2023]
Abstract
Ground-glass hepatocytes have been described in Lafora's disease, fibrinogen deposition, hepatitis B, type IV glycogenosis, and alcohol aversion (cyanamide) therapy. We encountered ground-glass hepatocytes with intracytoplasmic inclusions in four liver biopsies from three transplanted patients who had none of the above-mentioned underlying diseases. One patient was a 4-year-old boy who had a kidney transplant for severe ureterovesical reflux. Patient 2 was a 52-year-old man who had two liver transplants because of hepatitis C. The third patient was a 7-month-old girl who underwent a multivisceral transplant because of necrotizing enterocolitis and liver failure induced by total parenteral nutrition. The patients developed liver abnormalities from 45 days to 4 years after their transplants. The livers showed conspicuous ground-glass hepatocytes in 90% of the children's samples and 30% of the adult liver cells. The cytoplasmic bodies stained strongly for Gomori methenamine-silver; they were positive for periodic acid-Schiff without diastase, but negative after diastase digestion. They were negative for colloidal iron and hepatitis B core and surface antigens. Electron microscopy revealed non-membrane bound aggregates of glycogen. Idiopathic ground-glass hepatocytes occur in transplanted patients and represent accumulation of altered glycogen. However, their clinical significance and cause are not entirely elucidated.
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Affiliation(s)
- Pablo A Bejarano
- Department of Pathology, University of Miami School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave Holtz Bldg, Room 2042, Miami, FL 33136, USA.
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Lefkowitch JH, Lobritto SJ, Brown RS, Emond JC, Schilsky ML, Rosenthal LA, George DM, Cairo MS. Ground-glass, polyglucosan-like hepatocellular inclusions: A "new" diagnostic entity. Gastroenterology 2006; 131:713-8. [PMID: 16952540 DOI: 10.1053/j.gastro.2006.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 06/08/2006] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Ground-glass (GG) inclusions within hepatocytes are an important histopathologic marker of chronic hepatitis B virus (HBV) infection but may also be seen in Lafora's disease (myoclonus epilepsy), cyanamide alcohol aversion therapy, and type IV glycogenosis. We have noted a recent increased incidence of liver biopsy and postmortem specimens with GG inclusions associated with none of these etiologic factors. This study was undertaken to further delineate the clinical and liver pathologic features in such cases and their possible pathogenesis. METHODS Ten cases with GG inclusions (8 biopsy, 2 postmortem) were examined by light and electron microscopy, and the patients' clinical records were reviewed. RESULTS Light microscopy demonstrated pale pink, oval to crescentic intracytoplasmic inclusions with a predilection for periportal hepatocytes but sometimes present throughout the lobules. The inclusions were intensely positive on periodic acid-Schiff stain and digested with diastase. Transmission electron microscopy of two cases showed non-membrane-bound cytoplasmic collections of granules with mild-to-moderate electron density, consistent with abnormal glycogen granules. The patients included 7 transplant recipients (liver, hematopoietic stem cell), 3 with type 2 diabetes and a child on chronic parenteral nutrition for short bowel syndrome. Medications included immunosuppressive agents, antibiotics, and insulin. CONCLUSIONS GG hepatocellular inclusions may be seen in individuals without HBV infection or other recognized etiologies, appear to be composed of abnormal glycogen and closely resemble polyglucosan bodies described in humans, animals, and experimental models. The possible pathogenetic roles of disturbed glycogen metabolism and polypharmacotherapy are stressed.
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Affiliation(s)
- Jay H Lefkowitch
- Department of Pathology, Columbia University Medical Center, New York, New York, USA.
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Rubbia-Brandt L, Neerman-Arbez M, Rougemont AL, Malé PJ, Spahr L. Fibrinogen Gamma375 Arg→Trp Mutation (Fibrinogen Aguadilla) Causes Hereditary Hypofibrinogenemia, Hepatic Endoplasmic Reticulum Storage Disease and Cirrhosis. Am J Surg Pathol 2006; 30:906-11. [PMID: 16819336 DOI: 10.1097/01.pas.0000209848.59670.2c] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypofibrinogenemia is a rare inherited disorder characterized by low levels of circulating fibrinogen, caused by mutations within 1 of the 3 fibrinogen genes. We report here the case of a 61-year-old man with chronic liver function test alterations. Liver biopsy examination revealed chronic hepatitis complicated by cirrhosis and weakly eosinophilic globular cytoplasmic inclusions within the hepatocytes, faintly stained with PAS-diastase. On immunohistochemistry, the inclusions reacted strongly with human antifibrinogen antibodies. Coagulation investigations of the propositus and his 2 sons showed low functional and antigenic fibrinogen concentrations that were indicative of hypofibrinogenemia. A liver biopsy performed on the 28-year-old son demonstrated the same globular cytoplasmic inclusions, albeit without associated chronic liver disease. PCR amplification followed by sequencing showed that all 3 were heterozygous for a CGG>TGG mutation at codon 375 of the fibrinogen gamma-chain gene (FGG), corresponding to an Arg>Trp substitution. This is the first in an adult male and the second published case with a discernible hepatic fibrinogen endoplasmic reticulum storage disease due to an FGG Arg375Trp (fibrinogen Aguadilla) mutation. Our results suggest that familial hypofibrinogenemia should be considered in the differential diagnosis of a progressive liver disease associated to hepatocellular intracytoplasmic globular inclusions.
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Affiliation(s)
- Laura Rubbia-Brandt
- Gastrointestinal and Liver Pathology Unit, University Hospital, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland.
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Simsek Z, Ekinci O, Cindoruk M, Karakan T, Degertekin B, Akyol G, Unal S. Fibrinogen storage disease without hypofibrinogenemia associated with estrogen therapy. BMC Gastroenterol 2005; 5:36. [PMID: 16287505 PMCID: PMC1299324 DOI: 10.1186/1471-230x-5-36] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Accepted: 11/15/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cytoplasmic inclusion bodies within hepatocytes may have different etiologies, including the Endoplasmic Reticulum Storage Diseases (ERSDs). ERSD is a pathological condition characterized by abnormal accumulation of proteins destined for secretion in the endoplasmic reticulum of hepatocytes; it may be congenital (primary) or acquired (secondary). Fibrinogen storage disease is a form of ERSD. CASE PRESENTATION We present a case of fibrinogen storage disease secondary to estrogen replacement therapy. Its causal relationship to the drug is shown by histological, immunohistochemical and ultrastructural studies of paired liver biopsies obtained during and after the drug therapy. CONCLUSION The liver biopsies of patients with idiopathic liver enzyme abnormalities should be carefully evaluated for cytoplasmic inclusion bodies and, although rare, fibrinogen deposits.
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Affiliation(s)
- Z Simsek
- Gazi University Faculty of Medicine, Gastroenterology Department, Ankara, Turkey
| | - O Ekinci
- Gazi University Faculty of Medicine, Pathology Department, Ankara, Turkey
| | - M Cindoruk
- Gazi University Faculty of Medicine, Gastroenterology Department, Ankara, Turkey
| | - T Karakan
- Gazi University Faculty of Medicine, Gastroenterology Department, Ankara, Turkey
| | - B Degertekin
- Gazi University Faculty of Medicine, Gastroenterology Department, Ankara, Turkey
| | - G Akyol
- Gazi University Faculty of Medicine, Pathology Department, Ankara, Turkey
| | - S Unal
- Gazi University Faculty of Medicine, Gastroenterology Department, Ankara, Turkey
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Mitsui H, Miyauchi E, Miyahara J, Wada K, Yamakawa M, Kawata S. A case of primary biliary cirrhosis accompanied with fibrinogen storage disease. Pathol Res Pract 2005; 201:341-5. [PMID: 15991842 DOI: 10.1016/j.prp.2004.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report the first case of primary biliary cirrhosis (PBC) accompanied by fibrinogen storage disease (FSD). A 50-year-old Japanese woman had been treated for numbness of her right-side extremities for 5 years. Mildly elevated serum levels of alkaline phosphatase and gamma-glutamyl transferase were detected. The titers of both anti-mitochondrial (x 320) and anti-mitochondrial M2 (x 84) antibodies were elevated. The biopsied liver specimen showed mononuclear cell infiltrate densely encircling the bile ducts, poorly developed epithelioid cell granuloma, and loss of integrity of bile duct organization, which permitted a diagnosis of stage I PBC according to Scheuer's histologic classification. In addition, round to oval, eosinophilic, homogenous intracytoplasmic inclusions, several microm in average size, with a surrounding halo were found in the vast majority of hepatocytes. These inclusions were negative for the periodic acid-Schiff reaction. In immunohistochemistry, the inclusions were positive for fibrinogen and complement C3c, but not for HBs antigen and alpha1-antitrypsin. These findings were identical to FSD. To investigate the mechanism(s) of abnormal fibrinogen storage, immunostaining for heat shock protein 70 and ubiquitin was performed. The former was detected in all intracytoplasmic inclusions, whereas the latter was detected in only some inclusions, suggesting a partial loss of ubiquitin expression.
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Affiliation(s)
- Hiroko Mitsui
- Department of Pathology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan
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