Disease of the liver associated with a. -antitrypsin deficiency D. CUTHBERT, MD; H. CHAUN, BM, MRCP, FRCP[C]; J. F4RQLICH, MD, FRCP[C]; W.B. CHUNG, MD, FRCS[C], FACS
Alpha-1-antitrypsin accounts for about Case report 90% of the trypsin inhibitory capacity 38-year-old mentally retarded man of human serum.1 However, it has a wasA admitted to hospital with recurrent greater range of activity than its name hematemeses in September 1974. Radioimplies; it inhibits various proteases, in- logic study of the upper gastrointestinal cluding elastin, collagenase, chymotryp- tract revealed esophageal varices; endosin and thrombin.2 Its physiologic func- scopy confirmed this finding. A Sengstion is not known, but ai-antitrypsin is taken-Blakemore tube was inserted and an acute-phase reactant protein; in- the patient was transferred to Vancouvcr creased concentrations of it are found General Hospital. He had no past history alcoholism or hepatitis and no family in inflammatory and infective condi- of history of liver or lung disease. There was tions and as a result of hormonal stimu- no evidence of portosystemic encephalolation such as in pregnancy or with the pathy. use of contraceptive drugs. The clinical importance of ai-antitrypsin deficiency was first recognized in 1963 when Laurell and Eriksson4 observed its association with chronic obstructive lung disease. In 1969 Sharp and associates5 reported similar observations in some patients with "juvenile cirrhosis". The finding of serum aiantitrypsin deficiency in certain individuals with chronic obstructive lung disease, neonatal hepatitis and liver cirrhosis has now been well documented. More recently an unusually high prevalence of this deficiency has been reported in patients with hepatocellular carcinoma.2'6 Berg and Eriksson7 reported two cases of hepatocellular carcinoma and one of cholangiocarcinoma in association with the homozygous state of ai-antitrypsin deficiency, and Rawlings and colleagues8 described two cases of hepatocellular carcinoma associated with the heterozygous state. An unusually high prevalence of the heterozygous state has also been observed in patients with rheumatoid arthritis.9 From the departments of medicine, pathology and surgery, University of British Columbia and Vancouver General Hospital Presented in part at the Canadian Association of Pathologists meeting, Calgary, June 25 to 29, 1975 Reprint requests to: Dr. H. Chaun, 805 West Broadway, Ste. 601, Vancouver, BC V5Z iKi
F'
FIG. 1-Liver biopsy: positive results of testing with linmunoperoxidase stains specific for a,-antitrypsin (x400).
264 CMA JOURNAL/AUGUST 6, 1977/VOL. 117
The liver was not enlarged but the spleen tip was palpable below the left costal margin. The serum bilirubin concentration was less than 1 mg/dL; serum albumin concentration, 3.3 g/dL; prothrombin activity, 95%; and sodium sulfobromophthalein retention, 6.7% at 45 minutes. A mesenteric angiographic study showed no evidence of an extrahepatic cause of portal hypertension. A percutaneous liver biopsy revealed irregular fibrosis, moderate fatty degeneration and foci of inflammatory cells in the parenchyma, largely associated with clusters of cytoplasmic eosinophilic bodies of various sizes, positive to periodic acid-Schiff (PAS) staining. The findings were interpreted as compatible with cirrhosis associated with a1-antitrypsin deficiency. Testing with immunoperoxidase stains specific for cs1-antitrypsin gave positive results (Fig. 1). The serum c&1-antitrypsin value was 60 mg/dL (normal, 200 to 400 mg/dL). An elective therapeutic portocaval shunt was performed. The liver was found to be finely nodular and cirrhotic; there were large, tortuous venous collaterals, and the spleen was four times the normal size. The postoperative course was uneventful and the patient was discharged from hospital on the 9th postoperative day. Chest radiography and respiratory function studies had revealed no indication of pulmonary disease. The family members were screened. The patient's sister also had a low serum xiantitrypsin value (60 mg/dL), but results of her liver function tests were normal. Phenotype studies (acid-starch-gel electrophoresis followed by immunoelectrophoresis10) of the family showed the patient and his sister to be homozygous; both parents were heterozygous.
Discussion Sharp3 in 1971 first observed eosinophilic inclusion bodies in the parenchymal liver cells in patients with a1-antitrypsin deficiency. The same year Gherardi11 reported the first instance of cirrhosis associated with this deficiency in an adult. The inclusion bodies may
be seen in sections stained with hematoxylin and eosin but are more clearly evident after staining with PAS (preceded by diastase digestion to eliminate PAS staining of glycogen). Immunoperoxidase staining techniques are advantageous in that they can be performed on paraffin-imbedded tissue, thus allowing retrospective tissue anal12 ysis. Inclusions in the parenchymal cells may be the only abnormality seen in the liver. This finding may be associated with portal fibrosis and later with micronodular cirrhosis in more advanced disease. There may be a variable amount of inflammatory cells in the collagen septa. The differential diagnosis of liver disease with periportal fibrosis and deposits within the hepatocytes in an adult includes alcoholic liver disease, but alcoholic hyalin is negative to PAS staining. The globules differ morphologically from "acidophil bodies" or Councilman-like bodies, which are likewise PAS-negative. Electron microscopic studies have demonstrated the amorphous material to be in the dilated endoplasmic reticulum.3 Analysis of the isolated inclusion bodies has indicated that the material is similar to as-antitrypsin with much of the carbohydrate and all of the sialic acid missing.13 Several tests are currently available for the diagnosis of as-antitrypsin deficiency. Serum protein electrophoresis is often used as a screening procedure but it does not provide an accurate quantitative determination of the aiantitrypsin. Radial immunodiffusion provides a quantitative assessment, and the phenotypes can be determined by acid-starch-gel electrophoresis with crossed antigen-antibody electrophoresis.10 The value of screening procedures depends on the clinical significance of the heterozygous ai-antitrypsin deficiency state, which remains uncertain. Since 5 to 14% of a general population is heterozygous for this defect the question is of considerable public health concern, particularly with regard to genetic counselling, in view of the lack of effective treatment.14 The characteristic histopathologic findings in a liver biopsy can indicate ai-antitrypsin deficiency or the heterozygous state when it has not previously been suspected. Ishak and associates15 considered the histologic features to be pathognomonic of the condition. The pathophysiology of the liver and lung diseases associated with as-antitrypsin deficiency is not fully elucidated. Studies have suggested that asantitrypsin is synthesized and stored in the liver. After experimental hepatectomy in animals the serum concentration of a.-antitrypsin decreases, and
following liver transplantation in one patient with this deficiency state the serum values increased rapidly in the postoperative period.3 There is no known association of mental retardation with ai-antitrypsin deficiency, but retardation of growth and development has been noted in some patients.16'17 Rarely conditions such as celiac disease, peptic ulcer and glomerular lesions have been observed in patients with low serum values of ai-antitrypsin.18 We thank Dr. Philip E. Palmer, pathology department, New England Medical Center Hospitals, Boston, for performing the staining tests in the liver biopsy tissue by the specific immunoperoxidase method, and Dr. Diane Wilson Cox, department of pediatrics and genetics, Hospital for Sick Children, Toronto, for the phenotyping.
5. SHARP HL, BRIDGES RA, KRIvIT W, Ct al: Cirrhosis associated with a.-antitrypsin deficiency: a previously unrecognized inherited disorder. J Lab Cli,, Med 73: 934, 1969 6. LAWSON EE, GRAND RJ: Juvenile ni-antitrypsin deficiency: inevitable cirrhosis follows neonatal hepatitis (abstr). Pediatr Res 9: 306, 1975 7. BERG NO, EasKssoN 5: Liver disease in adults with alphai-antitrypsin deficiency. N Engi J Med 287: 1264, 1972 8. RAwLINOS W JR, Moss 3, COOPER HS, Ct al: Hepatocellular carcinoma and partial deficiency of alpha-i antitrypsin (MZ). Ann Intern Med 81: 771, 1974 9. Cox DW, HUBER 0: Rheumatoid arthritis and alpha-1-antitrypsin. Lancet 1: 1216, 1976 10. LIEBERMAN J, GAiouLss L, GAROUTTE B, et al: Identification and characteristics of the common aiphai-antitrypsin phenotypes. Chest 62: 557, 1972 Ii. GHERARDI GJ: Alpha-i-antitrypsin deficiency and its effect on the liver. Hum Pathol 2: 173, 1971 12. PALMER PE, DELELLIS RA, Wou'a HJ: Immunohistochemistry of liver in aiphai-antitrypsin deficiency. A comparative study. Am
J Gun PathoL 62: 350, 1974 13. ERIKSsON 5, LARSSON C: Purification and partial characterization of PAS-positive inclusion bodies from the liver in alphai-antitrypsin deficiency. N Engi J Med 292: 176, 1975 14. LIEBERMAN J: Alphai-antitrypsin deficiency.
Med Gun North Am 57: 691, 1973
15. ISHAK KG, JENIS EH, MARSHALL ML, et al:
References 1. ERIKSSON S: Studies in ai-antitrypsin deficiency. Acta Med Scand 177 (suppi 432): 1, 1965 2. KUEPPERS F, BLACK LF: ai-antitrypsin and Its
deficiency. Am Rev Respir Dis 110: 176, 1974 3. SHARP HL: Alpha-1-antitrypsin deficiency. Hosp Pract 6: 83, 1971 4. LAURELL CB, EiuKssoN 5: The electrophoretic ai-globulin pattern of serum in et-antitrypsin
deficiency. Scand I Clin Lab Invest 15: 132, 1963
Cirrhosis of the liver associated with ci-antitrypsin deficiency. Arch Pathol 94: 445, 1972 16. GLASGOW JET, LYNCH MJ, Haacz A, et al: Alpha1 antitrypsin deficiency in association with both cirrhosis and chronic obstructive lung disease in two sibs. Am J Med 54: 181, 1973 17. AAGENAES 0, MATLARY A, ELOJO K, et al: Neonatal cholestasis in a.-antitrypsin deficient chjldren. Clinical, genetic, histological and immunohistochemical findings. Acta Paediatr Scand 61: 632, 1972 18. SHARP HL: The current status of ci-antitrypsin, a protease inhibitor, in gastrointestinal disease. Gastroenterology 70: 611, 1976
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Alpha-1-antitrypsin accounts for about Case report 90% of the trypsin inhibitory capacity 38-year-old mentally retarded man of human serum.1 However, it has a wasA admitted to hospital with recurrent greater range of activity than its name hematemeses in September 1974. Radioimplies; it inhibits various proteases, in- logic study of the upper gastrointestinal cluding elastin, collagenase, chymotryp- tract revealed esophageal varices; endosin and thrombin.2 Its physiologic func- scopy confirmed this finding. A Sengstion is not known, but ai-antitrypsin is taken-Blakemore tube was inserted and an acute-phase reactant protein; in- the patient was transferred to Vancouvcr creased concentrations of it are found General Hospital. He had no past history alcoholism or hepatitis and no family in inflammatory and infective condi- of history of liver or lung disease. There was tions and as a result of hormonal stimu- no evidence of portosystemic encephalolation such as in pregnancy or with the pathy. use of contraceptive drugs. The clinical importance of ai-antitrypsin deficiency was first recognized in 1963 when Laurell and Eriksson4 observed its association with chronic obstructive lung disease. In 1969 Sharp and associates5 reported similar observations in some patients with "juvenile cirrhosis". The finding of serum aiantitrypsin deficiency in certain individuals with chronic obstructive lung disease, neonatal hepatitis and liver cirrhosis has now been well documented. More recently an unusually high prevalence of this deficiency has been reported in patients with hepatocellular carcinoma.2'6 Berg and Eriksson7 reported two cases of hepatocellular carcinoma and one of cholangiocarcinoma in association with the homozygous state of ai-antitrypsin deficiency, and Rawlings and colleagues8 described two cases of hepatocellular carcinoma associated with the heterozygous state. An unusually high prevalence of the heterozygous state has also been observed in patients with rheumatoid arthritis.9 From the departments of medicine, pathology and surgery, University of British Columbia and Vancouver General Hospital Presented in part at the Canadian Association of Pathologists meeting, Calgary, June 25 to 29, 1975 Reprint requests to: Dr. H. Chaun, 805 West Broadway, Ste. 601, Vancouver, BC V5Z iKi
F'
FIG. 1-Liver biopsy: positive results of testing with linmunoperoxidase stains specific for a,-antitrypsin (x400).
264 CMA JOURNAL/AUGUST 6, 1977/VOL. 117
The liver was not enlarged but the spleen tip was palpable below the left costal margin. The serum bilirubin concentration was less than 1 mg/dL; serum albumin concentration, 3.3 g/dL; prothrombin activity, 95%; and sodium sulfobromophthalein retention, 6.7% at 45 minutes. A mesenteric angiographic study showed no evidence of an extrahepatic cause of portal hypertension. A percutaneous liver biopsy revealed irregular fibrosis, moderate fatty degeneration and foci of inflammatory cells in the parenchyma, largely associated with clusters of cytoplasmic eosinophilic bodies of various sizes, positive to periodic acid-Schiff (PAS) staining. The findings were interpreted as compatible with cirrhosis associated with a1-antitrypsin deficiency. Testing with immunoperoxidase stains specific for cs1-antitrypsin gave positive results (Fig. 1). The serum c&1-antitrypsin value was 60 mg/dL (normal, 200 to 400 mg/dL). An elective therapeutic portocaval shunt was performed. The liver was found to be finely nodular and cirrhotic; there were large, tortuous venous collaterals, and the spleen was four times the normal size. The postoperative course was uneventful and the patient was discharged from hospital on the 9th postoperative day. Chest radiography and respiratory function studies had revealed no indication of pulmonary disease. The family members were screened. The patient's sister also had a low serum xiantitrypsin value (60 mg/dL), but results of her liver function tests were normal. Phenotype studies (acid-starch-gel electrophoresis followed by immunoelectrophoresis10) of the family showed the patient and his sister to be homozygous; both parents were heterozygous.
Discussion Sharp3 in 1971 first observed eosinophilic inclusion bodies in the parenchymal liver cells in patients with a1-antitrypsin deficiency. The same year Gherardi11 reported the first instance of cirrhosis associated with this deficiency in an adult. The inclusion bodies may
be seen in sections stained with hematoxylin and eosin but are more clearly evident after staining with PAS (preceded by diastase digestion to eliminate PAS staining of glycogen). Immunoperoxidase staining techniques are advantageous in that they can be performed on paraffin-imbedded tissue, thus allowing retrospective tissue anal12 ysis. Inclusions in the parenchymal cells may be the only abnormality seen in the liver. This finding may be associated with portal fibrosis and later with micronodular cirrhosis in more advanced disease. There may be a variable amount of inflammatory cells in the collagen septa. The differential diagnosis of liver disease with periportal fibrosis and deposits within the hepatocytes in an adult includes alcoholic liver disease, but alcoholic hyalin is negative to PAS staining. The globules differ morphologically from "acidophil bodies" or Councilman-like bodies, which are likewise PAS-negative. Electron microscopic studies have demonstrated the amorphous material to be in the dilated endoplasmic reticulum.3 Analysis of the isolated inclusion bodies has indicated that the material is similar to as-antitrypsin with much of the carbohydrate and all of the sialic acid missing.13 Several tests are currently available for the diagnosis of as-antitrypsin deficiency. Serum protein electrophoresis is often used as a screening procedure but it does not provide an accurate quantitative determination of the aiantitrypsin. Radial immunodiffusion provides a quantitative assessment, and the phenotypes can be determined by acid-starch-gel electrophoresis with crossed antigen-antibody electrophoresis.10 The value of screening procedures depends on the clinical significance of the heterozygous ai-antitrypsin deficiency state, which remains uncertain. Since 5 to 14% of a general population is heterozygous for this defect the question is of considerable public health concern, particularly with regard to genetic counselling, in view of the lack of effective treatment.14 The characteristic histopathologic findings in a liver biopsy can indicate ai-antitrypsin deficiency or the heterozygous state when it has not previously been suspected. Ishak and associates15 considered the histologic features to be pathognomonic of the condition. The pathophysiology of the liver and lung diseases associated with as-antitrypsin deficiency is not fully elucidated. Studies have suggested that asantitrypsin is synthesized and stored in the liver. After experimental hepatectomy in animals the serum concentration of a.-antitrypsin decreases, and
following liver transplantation in one patient with this deficiency state the serum values increased rapidly in the postoperative period.3 There is no known association of mental retardation with ai-antitrypsin deficiency, but retardation of growth and development has been noted in some patients.16'17 Rarely conditions such as celiac disease, peptic ulcer and glomerular lesions have been observed in patients with low serum values of ai-antitrypsin.18 We thank Dr. Philip E. Palmer, pathology department, New England Medical Center Hospitals, Boston, for performing the staining tests in the liver biopsy tissue by the specific immunoperoxidase method, and Dr. Diane Wilson Cox, department of pediatrics and genetics, Hospital for Sick Children, Toronto, for the phenotyping.
5. SHARP HL, BRIDGES RA, KRIvIT W, Ct al: Cirrhosis associated with a.-antitrypsin deficiency: a previously unrecognized inherited disorder. J Lab Cli,, Med 73: 934, 1969 6. LAWSON EE, GRAND RJ: Juvenile ni-antitrypsin deficiency: inevitable cirrhosis follows neonatal hepatitis (abstr). Pediatr Res 9: 306, 1975 7. BERG NO, EasKssoN 5: Liver disease in adults with alphai-antitrypsin deficiency. N Engi J Med 287: 1264, 1972 8. RAwLINOS W JR, Moss 3, COOPER HS, Ct al: Hepatocellular carcinoma and partial deficiency of alpha-i antitrypsin (MZ). Ann Intern Med 81: 771, 1974 9. Cox DW, HUBER 0: Rheumatoid arthritis and alpha-1-antitrypsin. Lancet 1: 1216, 1976 10. LIEBERMAN J, GAiouLss L, GAROUTTE B, et al: Identification and characteristics of the common aiphai-antitrypsin phenotypes. Chest 62: 557, 1972 Ii. GHERARDI GJ: Alpha-i-antitrypsin deficiency and its effect on the liver. Hum Pathol 2: 173, 1971 12. PALMER PE, DELELLIS RA, Wou'a HJ: Immunohistochemistry of liver in aiphai-antitrypsin deficiency. A comparative study. Am
J Gun PathoL 62: 350, 1974 13. ERIKSsON 5, LARSSON C: Purification and partial characterization of PAS-positive inclusion bodies from the liver in alphai-antitrypsin deficiency. N Engi J Med 292: 176, 1975 14. LIEBERMAN J: Alphai-antitrypsin deficiency.
Med Gun North Am 57: 691, 1973
15. ISHAK KG, JENIS EH, MARSHALL ML, et al:
References 1. ERIKSSON S: Studies in ai-antitrypsin deficiency. Acta Med Scand 177 (suppi 432): 1, 1965 2. KUEPPERS F, BLACK LF: ai-antitrypsin and Its
deficiency. Am Rev Respir Dis 110: 176, 1974 3. SHARP HL: Alpha-1-antitrypsin deficiency. Hosp Pract 6: 83, 1971 4. LAURELL CB, EiuKssoN 5: The electrophoretic ai-globulin pattern of serum in et-antitrypsin
deficiency. Scand I Clin Lab Invest 15: 132, 1963
Cirrhosis of the liver associated with ci-antitrypsin deficiency. Arch Pathol 94: 445, 1972 16. GLASGOW JET, LYNCH MJ, Haacz A, et al: Alpha1 antitrypsin deficiency in association with both cirrhosis and chronic obstructive lung disease in two sibs. Am J Med 54: 181, 1973 17. AAGENAES 0, MATLARY A, ELOJO K, et al: Neonatal cholestasis in a.-antitrypsin deficient chjldren. Clinical, genetic, histological and immunohistochemical findings. Acta Paediatr Scand 61: 632, 1972 18. SHARP HL: The current status of ci-antitrypsin, a protease inhibitor, in gastrointestinal disease. Gastroenterology 70: 611, 1976
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