paper macrophages
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Paper Macrophages. Gastroenterology Dr. JLeR Malherbe Prof. J Van Zyl. Case Presentation. Mr. V is a 21 year old gentleman of Angolan descent, living in Kimberley and studying computer science Long standing history of hepatosplenomegaly - PowerPoint PPT PresentationTRANSCRIPT
GASTROENTEROLOGYDR. JLER MALHERBE
PROF. J VAN ZYL
Paper Macrophages
Case Presentation
Mr. V is a 21 year old gentleman of Angolan descent, living in Kimberley and studying computer science
Long standing history of hepatosplenomegalyPreviously diagnosed as having cryptogenic
liver cirrhosis with portal hypertension
Systemic Enquiry
Only complaint is that of a painless enlarged liver
No abdominal pain, nausea or vomitingNormal bowel habitNo melena or haematemesisNo cardiovascular or respiratory complaintsNo nervous system complaintsNo joint or bone pain. No other
musculoskeletal complaints
Examination
Healthy looking young man. Normal growth and development. No dysmorphic features
Normal vital signsj- a- c- c- o- l- No nail abnormalitiesCVS → normal apex, normal jvp, normal heart
sounds, no added sounds or murmers, no signs of pulmonary hypertension
RESP→ normal chest expansion and air entry. No added sounds
Examination
ABD Hepatomegaly with span of 17cm. Spleen not palpable. No tenderness Normal bowel sounds No distended veins No spider naevi
Special Investigations
U/ENa 144K 3.7Cl 103Ur 2.3Cr 78
Liver FunctionsTotal Bili 7Conj Bili 2Total Prot 82Alb 41AST 25ALT 20ALP 55GGT 49LDH 127
CMPMg 0.89Ca 2.44PO4
1.02
FBCWCC 3.52Neutro 1.90Lympho 1.28HB 14.2MCV 80.1PLT 190CoagulationPT 13PTT 37 (2 seconds
up)INR 1.1Inflammation
CRP 11ESR 42
Special Investigations
Hepatitis A,B and C → NegativeHIV → NegativeIron Studies → NormalANA and Anti-SMA → NegativeCaeruloplasmin → 0.4 (Normal)Protein Electrophoresis → Polyclonal increase
in gammaglobulins. No Beta-gamma bridging
Special Investigations
Abdominal Sonar → Normal liver architecture, portal vein flow and size normal
Liver Spleen Scintography → Diffusely enlarged liver. Spleen moderately enlarged. Normal uptake
Liver Biopsy
H&E, 25 mag. Low power overview of liver biopsy shows expansion of the portal tracts and periportal regions with enlarged macrophages and Kupffer cells
H&E 100 mag. Periseptal and intra-lobular aggregates of enlarged Kupffer cells
H&E 400 mag. Closer view of enlarged periportal macrophages with striated wrinkled cytoplasm
PAS stain, 400mag. The cytoplasmic striations within the Kupffer cells are enhanced with a PAS stain.
GAUCHER’S DISEASE
Wrinkled Tissue PaperMacrophages
Lysosomal Storage Disease
Inborn error of metabolismLysosomes derived from fusion of trans-Golgi
network vesicles Synthesis of new membranes and membrane
constitutive proteins Complex hydrolyase enzyme system for processing
and degradation of proteins, nucleic acids, carbohydrates and lipids
Lysosomal Storage Disease
Mutation → Deficiency of specific enzyme → accumulation of substrate More than 30 diseases Mucopolysaccharidoses → Hurler GM2 Gangliosidoses → Tay-Sachs Neutral Lipids → Pompe Glycosphingolipidoses → Gaucher, Niemann-Pick,
Fabry
Gauchers Disease
Most common of lysosomal storage diseasesDeficiency → Glucocerebrosidase Substrate → Glucocerebroside → Component
of cell membranesAccumulation in macrophage lysosomes
(wrinkled tissue paper) → spleen, liver and bone marrow
Genetics
1 in 1000 Ashkenazi Jews<1 in 100 000 other populations> 250 mutations → 4 common in 85%
N370S, L44P, 84GG, IVS-2 Phenotypic/Genotypic linkage
Clinical
Type 1 Most common type → 90% N370S/N370S Visceral involvement, No neurology Variable severity
Type 2 Severe early neurological disease, die by 2 years
Type 3 Variable neurological and visceral disease
Visceral Disease
Splenomegaly Most common presenting sign Mild to Massive (5 to 75x normal size) Early satiety, abdominal discomfort, Hypersplenism Splenic infarct → Acute abdomen
Hepatomegaly Universal Usually less severe than splenomegaly (2 to 3x normal) Hepatic fibrosis common → Hepatic failure, cirrhosis,
portal HPT uncommon
Skeletal Disease
Two pathologic processes in bone: Bone marrow encroachment by lipid-laden
macrophages Anemia Thrombocytopaenia Bleeding
Decreased mineral density → Osteopenia Uncertain mechanism Abnormal osteoclast regulation or overproduction of cytokines by activated
macrophages
Skeletal Disease
Osteopenia Pathologic fractures Vertebral compression
Osteolytic lesionsPainful crises → Osteonecrosis (AVN/Bone
infarction) Proximal and distal femur, proximal tibia and humerus
94% radiological evidence, 63% Bone pain, 33% bone crises, 8% joint pain
Other Manifestations
Growth retardation in children → Most catch up later
Interstitial Lung disease → Infiltration of alveolar spaces and interstitium
Pulmonary hypertension → Occlusion of pulmonary capillaries
Increased risk of haematologic malignancies especially myeloma
Nervous System (T 2 and 3)
Occulomotor dysfunctionHypertonia and rigidityOpisthotonusSwallowing impairmentSeizures and MyoclonusDementiaAtaxiaSupranuclear gaze palzy
Clinical Course
Spectrum of disease Asymptomatic disease found incidentally in elderly →
fulminant disease in childrenDie from sequelae of severe bone disease,
bleeding complications, infections, liver faliure or severe pulmonary disease
Diagnosis
Reduced glucocerebrosidase activity in peripheral leukocytes
Mutational analysisGaucher cells → Bone marrow (not necessary
for diagnosis)
ONCE DIAGNOSIS MADE INVESTIGATION FOCUS ON DETERMINING EXTENT AND SEVERITY OF DISEASE
Investigations
Radiography Fractures, Osteopenia, Lytic lesions Erlenmeyer Flask deformity
DEXAMRI femurs/axial skeleton → Bone marrow
involvementMRI/CT/Sonographic volumetric assesment of
spleen and liverFBC → ?Bone Marrow Aspiration/TrephineS-ACE, TRAP, ChitotriosidaseCXR, Lung functions, Heartsonar
Investigations Mr V
Skeletal survey reported as normalDEXA scan → AP spine Z score -2.7
Metabolic screen (Calcium, PTH, Vit D, Testosterone, Prolactin) negative for other causes
MRI femurs → Small areas of low signal intensity in metaphysis and diaphysis intramedullary → Early bone marrow involvement
CXR, Lung Functions, Heartsonar normalGlucocerebrosidase activity pending
Treatment
One of few IEM that’s treatable Recombinant human enzyme → Imiglucerase and
velaglucerase alfa → IV 15-60U/kg two weeklyAround R2.5 million/year → 70kg using 60U/kgIndication
Symptomatic Children Adults with severe disease → plt <60, liver >2.5x, spleen
>15x, radiologic bone diseaseSubstrate reduction therapy (Miglustat) Bisphosphonates for osteopeniaPt need careful regular follow-up to assess disease
activity and response
Mr V
Clinically Type 1 Gaucher’s disease with bone and visceral involvement
Confirmation with enzyme levels pendingAlendronate 10mg dly, Vit D 800iu dly,
CalciumWill be followed by Dr. Henderson of Human
Genetics Decision on possible low dose enzyme replacement
will be made after discussion with Gaucher’s disease committee
Take Home
Very rare diseaseMust be in differential of unexplained
organomegaly → especially massive splenomegaly
Variable presentation/severity/clinical courseTreatment is expensive and requires
specialized follow up
References
1. Harrison’s Principles of Internal Medicine 17th ed2. CM Eng. Genetics, clinical manifestations, and diagnosis of Gaucher
disease. UpToDate 18.33. CM Eng. Initial assessment and routine monitoring of Gaucher
disease. UpToDate 18.34. CM Eng. Treatment of Gaucher Disease. UpToDate 18.35. Guideline for Gaucher Disease South Africa. Dr. B Henderson