Download glycogen, calcification

General Pathology
Cellular and Organ Pathology
Disorders of Glycogen Degradation.
Pathology of Calcification.
Jaroslava Dušková
Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague
Disorders of Glycogen Degradation.
Pathology of Calcification. Table of contents
 Glycogen
– morphology, function, regulation
– pathology states
 inborn - glycogenoses
 acquired
–
–
–
–
hyperglycemia – DM I, DM II, MODY
hypoglycemia – insulinoma
hyperglycemia – glucagonoma
glycogen storage in the neoplasms (clear cell kidney ca,
seminoma, Ewing sarcoma…
 Calcification
– dystrophic
– metastatic
clinical manifestations
complications
Glycogen
 linear
and branched polymer
 cca 60 000 - D-glucose molecules
– monoparticles (beta) - muscle
– complex particles (alpha) - hepatocyte
Main Hormones in Glycogen Metabolism
insulin
glucagon
Insulin
The Actions of Insulin on Cells
glycogen synthesis –in liver (and
muscle) cells. Reducing high blood glucose levels
in diabetes.
 Forces adipose tissue to make fats; lack of insulin
causes the reverse.
 Decreased proteolysis
 Decreased lipolysis
 Decreased gluconeogenesis
 Increased amino acid uptake
 Increased potassium uptake
 Arterial muscle tone – forces arterial wall muscle
to relax, increasing blood flow, especially in micro
arteries; lack of insulin reduces flow by allowing
these muscles to contract
 Increased
Glucagon -physiologic effects
 increase
in blood concentration of glucose.
Neurons can not utilize alternative energy
sources like fatty acids
 Glucagon stimulates breakdown of glycogen
stored in the liver.
 Glucagon activates hepatic gluconeogenesis.
Non-hexose substrates such as amino acids are
converted to glucose.
 Glucagon also appears to have a minor effect of
enhancing lipolysis of triglyceride in adipose
tissue.
Control of Glucagon Secretion

Secreted in response to hypoglycemia

Two other conditions :
– Elevated blood levels of amino acids, after consumption of a
protein-rich meal . Since high blood levels of amino acids also
stimulate insulin release both insulin and glucagon are active.
– Exercise: not clear whether the actual stimulus is exercise per
se, or the accompanying exercise-induced depletion of glucose.

Negative control - glucagon secretion is inhibited by
– high levels of blood glucose
– insulin
– somatostatin
Glucagon – 29AA
α-cells in islets
opposite effect of
insulin
insulin
glucagon
Clear Intracellular Vacuoles
& adjunct techniques



accumulations of water neg.
lipides SUDAN, OIL RED
polysaccharides PAS, A-PAS
Glycogen Metabolism Diseases

diabetes mellitus type I
(& LADA – late autoimmune diabetes of
adults) - polygenic HLA-DR 3, 4

diabetes mellitus type II - polygenic

MODY - more than 10 types described – monogenic

insulinoma

glucagonoma

insulin resistance in :
– metabolic syndrome (=obesity, glucose intolerance, hypertension,
hyperlipemia… )
– insulin receptor mutations
– polycystic ovary syndrome
– hypercortisolism…….
Enzymes
Involved in Glycogen Metabolism
 glucokinase,
hexokinase
isomerases
 g.-synthase - brancher
 phophorylase kinase - debrancher
 g-6-phosphatase
 -glucosidase…

Glucokinase Role
in
Maintenance of Glucose Homeostasis
 coded on 7th chromosome

inactivating and activating mutations -
GLUCOKINASE DISEASES
 inactivating mutation – MODY 2
– autosomal dominant - heterozygots – mild
hyperglycemia
– homozygots - severe newborn diabetes

activating mutation - heterozygots – severe
hypoglycemia
Glucokinase role in maintenance of glucose homeostasis
M
glucose – G6P
GLUT2
ATP/ADP
pancreas – B cell
K+
GKB
Ca2+
insulin
glucose
GLUT2
GKA
GKh
glucose
IR
G6P
glycogen
hepatocyte
Storage Diseases
Def.:
inborn errors of metabolism
(mostly single gene abnormality) leading to
an enzyme defect with subsequent
accumulation of the substrate (& lack of
the product) in tissues or organs
„thesaurismoses“
Gr. thesaurus = treasure, storage
Causes of Glycogenoses I-VIII & Fructose Intolerance
lysosomal breakdown
Glycogenoses - complications
glycogen
glucose
liver
other
organs
liver types
blood glucose
hepatomegaly
glucose
glycogen
other types
hypoglycemia
muscle types
in muscle effort
cardiomegaly,
cramps, weeknes
resp. muscles palsy
myoglobinuria
cardiorespiratory
insufficiency
kidney failure
E defect - gl-6 - phosphatase
Organ damage - liver, kidney
Glycogenosis I – von Gierke
E-defect-alpha1, 4 - glucosidase
Organ damage - heart
Glycogenosis II – Pompe
Glycogen Storage Diseases -1.
Disease
E- def
Severity of Tissues
Disease
Involved
von
Gierke
Glucose-6
Severe
phosphatase
Liver,kidney,
gut
Pompe
 1,4
Lethal
glucosidase
Heart
(+systemic)
Cori
Amylo-1,6
Lethal
Glucosidase
(debrancher)
Liver
(+systemic)
Glycogen Storage Diseases -2.
Disease
E- def
Andersen Amylo-1,4-1,6
Mc Ardle
Hers
transglucosidase
(brancher)
Muscle
phosphorylase
Liver
phosphorylase
Severity
of
Disease
Lethal
Tissues
Involved
Mild
Skeletal
muscle
Mild
Liver
Liver
(+systemic)
Andersen dis. /glycogenosis type IV - liver
PAS
Armani´cells
Best´carmine
Complications of Diabetes
Glucotoxicity due to:
 formation of Advanced Glycation E products
release of pro-inflammatory cytokines
and growth factors
 generation of ROS (free radicals) in endothelia

accelerated
developmeent
of
atherosclerosis
Complications of Diabetes


macroangiopathy
microangiopathy
– retinopathy
– nephropathy


neuropathy
infections…..
diabetic gangrene
Nesidioma capitis pancreatis
GAF
HE
Glycogen
water soluble
easily lost
in long lasting
water based fixative solutions
Clear cell kidney ca
Clear cell
kidney ca
Metastases in
cervical lymph
nodes
TGB
Calcification
Def.:
depositions of Ca (mostly phosphate
salts) in tissues or organs
Ca Salts in the Calcified Foci
Ca phophate
Ca3(PO4)2
Ca diphosphate Ca2P2O7
Hydroxyapatite
Ca5 (PO4)3.OH
Ca salts in the body
bones, teeth
 dissolved in body fluids (bound

to proteins)

blood Ca levels 2,1-2,6 mmol/l
Calcification - physiology
 Osteoblasts - collagen I synthesis - matrix vesicles
(phragments of osteoblast cytoplasm- storage of hydroxyapatite)


Alkalic phosphatase – bone formation
Osteoblasts - receptors for PTH on the membrane
osteoclasts activation




Vitamin D - bone formation
PTH - bone resorption
Calcitonine – inhibition of osteoclasts
Insulin, GH, thyroid hormones, steroids ….
Pathology Conditions
with Calcium Deposits
Calcification
 dystrophic
 metastatic
Calcinosis
 localized
 generalized
Chondrocalcinosis - pseudogout
Calcification - Microscopy

common
microtoms
tissues – chelates, HCl,

non-decalcified
–
decalcified
acetic acid
tissues
embedding, special microtoms
–
resin
Calcification - Microscopy

Basophilic

Von
Kossa
-
Ag
impregnation
(ass. phosphates)
 Alizarine
red +

+ Tetracyclin
fluorescence

Polarized light birefringence
Calcification
Def.:
depositions of Ca (mostly phosphate
salts) in tissues or organs
Classification:
dystrophic
metastatic
Calcification
Dystrophic
Metastatic
Serum Ca level: normal
Serum Ca level:
Tissues/Organs status
Tissues/Organs status
dystrophic changes
normal, local alcalisation
(necrosis, scar…, low
metab. turnover)
(acid secretion - urine,
stomach juice, sweat…)
Dystrophic Calcification
Frequent





necrotic tissue
connective tissue
vessels
calcospherites
intracellular calcification of lysosomes
Less frequent
tendon, cartilage, elastics, bas. membranes
Huether S., Mc Cance K.L. eds.:
Understanding
Huether SE, Mc Cance KL:Pathophysiology.
Understanding Pathophysiology
3rd ed., Mosby, 2004, 1235 pages, p.70
clinic
reversible
ireversible
Ca in mitochondria
and GER
in cytoplasm
bound to proteins
Released
after cell damage
Activaton
of protein kinases
Activaton
of phospholipid
degradation
and loss
Phosphorylation
of protein
and
chromatin
phragmentation
Membrane
damage
Calcium
disturbances
leading to cell
death
Activaton
of proteases
Cytoskeletal
disassembly
Dystrophic Calcification
Necrosis or
degeneration
of tissue
Release
of enzymes
Breakdown
of organic
Alteration of pH
phophates
Increased
deposition
of calcium
Schaumann´s inclusions
Mediocalcinosis
Mediocalcinosis
Phlebolith
H
y
a
li
n
o
s
i
s
Calcificatio anuli fibrosi valvae mitralis
Calcificatio valvae aortalis
Atherosclerosis aortae gr. I, II, III
Aneurysma aortae abdominalis
Atherosclerosis calcificata aa. coronariae stenosans
Cor petrosum
P Ribeiro, R
Sapsford, T Evans,
G Parcharidis and C
Oakley
Constrictive
pericarditis as a
complication of
coronary artery
bypass surgery.
Heart 1984;51;205-210
Cholelithiasis. Empyema vesicae felleae chronicum.
Metastatic calcification - causes
PTH secretion
adenoma, carcinoma
 destruction of bone – leukemia, myeloma,
metastases, Paget (polyostotic)
 vitamin D intoxication

 renal
failure – phophate retention -
secondary hyperparathyreosis - PTH
Vitamin D3 (1,25(OH)2D3) is a Hormone
 Vitamin
D3 is responsible for regulating the calcium
and phosphorus levels in the blood by their
absorption from food and re-absorption of calcium in
the kidney.
 It promotes bone formation
 It also inhibits parathyroid hormone secretion from
the parathyroid gland.
 Vitamin D affects the immune system by promoting
immunosuppression and anti-tumor activity.
Vitamin D3 (1,25(OH)2D3) is a Hormone

Vitamin D3 is not politically correct.
– It discriminates depending where you live, the further you
live from the equator the less sun exposure consequently
the lower your Vitamin D3 level.
– It discriminates against the elderly, as you age your skin
loses up to 75% of its ability to make Vitamin D3.
– It discriminates against the obese. They have lower levels
of Vitamin D3, due to the fact it is oil soluble, that it builds
up in the fat tissue.
– It discriminates against skin color a dark complected
person needs more sun exposure to produce their Vitamin
D3 than a fair skinned person.
– It also discriminates against a person who does as they
are told. It has been reported the incident of breast
cancers have increased 40% in Australia due to Vitamin
D3 deficiency caused by sunscreen use.
alcalic substances
inactivity
neoplastic cells
renal
retention
vit.D3 intake
excess
hypercalcemia
Disorders
of
Calcium
metabolism
fall out
tight
junctions
impermeable
lack of
vit.D3
hypocalcemia
(hypercalcemia,
hypocalcemia)
decreased bowel
resorption
insufficient
mobilisation
Ca2+
renal loss of
and
retention of PO42-
formation of
complexes
Recklingausen´s
disease
adenoma
gl. para
thyreoideae
Osteodystrophia fibrosa (Recklinghauseni)
Calcificatio
metastatica
ventriculi et
pulmonum
„Pumice“
lung
osteoid
Morphometry of the non-ossified bone tissue
PACIENT Starec Bohumil
BIOPSIE
57
KOST
RODNÉ ČÍSLO
KLINIKA III.int.
NumberObjects
AreaFraction
Perimeter MeanChordClass
3
0,25389 7,79E+03
249,713
2 0,294111
7108,63
316,82
RO KT ( % )
481029/073
1
1
RO O S ( % )
27%
MORFOMETRIE
OSTEOID NumberObjects
AreaFraction
Perimeter MeanChord
2 0,003747 1,34E+03
21,4015
0
0 1,62E-01
0
FO O S ( % )
100
%
Průměr
2,50
LEGENDA ROKT
ROOS
FOOS
RPOS
STKT
STOS
RPO S ( % )
1%
0%
73%
Dun
5%
99%
27,40%
7447,10
283,27
1,00
27,40%
72,60%
Relativní objem kostního trámce (vztaženo k měřenému poli)
Relativní objem osteoidu (vztaženo k měřenému poli)
Frakční objem osteoidu (vztaženo k objemu kostního trámce)
Relativní povrch trámce krytý osteoidem
Střední tloušťka kostního trámce
Střední tloušťka osteoidu
95%
1,00
27,40%
0,19%
0,68%
4,50%
293,97
10,70
0,19%
670,50
99,81% 0,0450173
0,68%
0,95
99,32%
Střední šířky kostních komponent
1
0,00
50,00
100,00
150,00
200,00
mikrome try
250,00
300,00
350,00
TRÁMEC
OSTEOID
10,70
Pathology Conditions with Calcium Deposits
Calcification
 dystrophic
 metastatic
Calcinosis
 localized
 generalized
Chondrocalcinosis – pseudogout
Calciphylaxix – extensive microvascular
calcification and occlusion / thrombosis
Calcinosis – the result of either
dystrophic or
metastatic calcification described first in the skin by Virchow
1855
Forms - localised
generalised
Localisation – connective tissue, cartilage,
skin, muscles
Chondrocalcinosis
crystal deposit disease (pseudogout)
Ca-pyrophosphate and
Ca- hydroxyapatite deposits
localisation – synovial membrane,
cartilage, bone
Calcium pyrophosphate deposition disease
(Chondrocalcinosis, pseudogout)
Clinic: may simulate
different diseases
Arthroscopy - chalky
white deposits
Tophaceus deposits with
crystalline aggregates
Crystals stain with von
Kossa technique
Foreign body type
multinucleated giant cell
reaction
Deposits are in
synovium, cartilage,
bone
Almafragi A, Vandorpe J, Dujardin K.
Calciphylaxis in a cardiac patient without renal
disease.
Acta Cardiol. 2009 Feb;64(1):91-3.




Calciphylaxis is a rare complication that occurs in 1% of patients with
end-stage renal disease (ESRD) each year.
Extensive microvascular calcification and occlusion/thrombosis lead to
violaceous skin lesions, which progress to nonhealing ulcers with
secondary infection, often leading to sepsis and death.
The lower extremities are predominantly involved (roughly 90% of
patients).
A case of histologically proven calciphylaxis in a 54-year-old woman
with normal renal function and normal calcium-parathyroid
homeostasis. She had a history of alcoholic cardiomyopathy, and was
treated with warfarin anticoagulation. She has been successfully
treated with antibiotics, i.v. biophosphonates and intensive local wound
care. We recorded a complete wound healing in contrast to what is
reported in other series.
Calciphylaxis was reported in:
 hypoalbuminemia
 malignant








neoplasm
systemic corticosteroid use
anticoagulation with warfarin
chemotherapy
systemic inflammation
hepatic cirrhosis
obesity
rapid weight loss, and
infection….