Brief Scientific Reports
Alpha-1-antitrypsin Globules in Hepatocytes of
Elderly Persons with Liver Disease
VICTOR L ROGGLI, M.D., RICHARD J. HAUSNER, M.D., AND J. B. ASKEW, JR., M.D.
Roggli, Victor L., Hausner, Richard J., and Askew, J. B., Jr.:
Alpha-1-antitrypsin globules in hepatocytes of elderly persons
with liver disease. Am J Clin Pathol 75: 538-542, 1981.
Percutaneous needle biopsy specimens of the liver from three
elderly persons (aged 77, 71, and 66) demonstrated eosinophilic intracytoplasmic globules within hepatocytes, particularly in the periportal and periseptal areas. These globules
were periodic acid-Schiff positive and diastase resistant, and
were identified as alpha-1-antitrypsin by immunofluorescence
technics. Two of the patients had cirrhosis, and identification
of protease inhibitor (P,) type by acid starch electrophoresis
and crossed Immunoelectrophoresis demonstrated SZ and MZ
genotypes. The patient with SZ genotype also had a long
history of chronic obstructive pulmonary disease. Pi-typing
was not performed for the third patient, who did not have
cirrhosis. The morphologic identification of alpha-1-antitrypsin disease in liver biopsies of persons of any age is
important because of (1) possible multisystem involvement
(hepatic and pulmonary), (2) increased frequency of hepatocellular carcinoma, and (3) implications for genetic counseling
for other family members. (Key words: Alpha-1-antitrypsin;
Liver disease; Cirrhosis; Elderly persons.)
Department of Pathology, Baylor College of Medicine
and The Methodist Hospital, Houston, Texas
the importance of the characteristic globules in percutaneous needle biopsy specimens of the liver from
three elderly persons not previously suspected of
having alpha-1-antitrypsin deficiency.
Reports of Three Cases
Case 1
In January 1979, a 66-year-old white woman was
evaluated for a chief complaint of increasing abdominal
girth. A percutaneous needle biopsy of the liver was
performed. Laboratory data included serum alkaline
phosphatase, 138 U/l (upper limit of normal [ULN],
100 U/l); serum glutamic oxaloacetic transaminase
(SGOT), 27 U/l (ULN, 30 U/l); albumin, 2.6 g/dl;
total bilirubin, 1.6 mg/dl; prothrombin time (PT), 15
sec; partial thromboplastin time (PTT), 43 sec. Serum
protein electrophoresis demonstrated diffuse hypergammaglobulinemia with beta-gamma bridging. After
interpretation of the biopsy, serum alpha-1-antitrypsin
(A[AT) level by radial immunodiffusion was 214 mg/dl
(normal range, 205-575 mg/dl; coefficient of variation
of measurement, ±13%). P r typing by acid starch
electrophoresis and crossed Immunoelectrophoresis 11
demonstrated an MZ genotype.
SINCE the initial association of alpha-1-antitrypsin
deficiency with liver disease in 1969,18 many cases have
been described to have occurred in children who were
either homozygous or, less often, heterozygous for the
protease inhibitor (P,) Z allele.17,20 Its occurrence in
older persons is less frequent. 23,912,14,1619 The morphologic hallmark for the Pj Z allele is the presence of
spherical eosinophilic globules that are periodic acidSchiff (PAS) positive, diastase resistant in the hepatocytes of affected persons. 7 These globules may be
confirmed as alpha-1-antitrypsin by immunofluorescence technics, and are present in patients who are
either heterozygous or homozygous for the Z allele.17 In
this report, we describe the identification and discuss
Case 2
Received June 23, 1980; received revised manuscript and accepted
for publication August 27, 1980.
Dr. Roggli is a Fellow of the American Cancer Society, 1979-1980.
Address reprint requests to Dr. Hausner: Department of Pathology, Baylor College of Medicine, Texas Medical Center,
Houston, Texas 77030.
A 71-year-old white man had a uvulectomy, tonsillectomy, and right radical neck dissection in 1973 for
squamous cell carcinoma of the oropharynx. In 1979,
radiation therapy was administered to the left chest for
an enlarging left lung mass noted on chest roentgenogram. The patient had a history of severe chronic
obstructive pulmonary disease for several years, and
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538
BRIEF SCIENTIFIC REPORTS
Vol. 75 • No. 4
had smoked five to six cigars a day for many years.
Liver-spleen scan showed hepatomegaly with an area
of decreased uptake in the left lobe. A percutaneous
needle biopsy of the liver was performed. Laboratory
data included serum alkaline phosphatase, 112 U/l;
SGOT, 84 U/l; serum glutamic pyruvic transaminase
(SGPT), 62 U/l (ULN, 35 U/l). Total protein, albumin,
PT, PTT, and total bilirubin were within normal
limits. After interpretation of the biopsy, serum
A,AT level was 145 mg/dl, and P r typing showed an
SZ genotype.
Case 3
A 77-year-old white woman had a right radical
mastectomy for breast carcinoma in 1969, and was
treated and observed for a subsequent metastatic carcinoma. A percutaneous needle biopsy of the liver was
performed in December 1978 for hepatomegaly and
elevated alkaline phosphatase level (238 U/l). Other
tests of hepatic function, including total protein,
albumin, SGOT, SGPT, total bilirubin, PT, and PTT,
were within normal limits. Serum A[AT was 777 mg/
dl; P r typing was not performed. The patient died
several months later, and an autopsy was not done.
Pathologic Features
In all three cases, spherical intracytoplasmic globules
were identified within hepatocytes, especially those
in the vicinity of portal triads or fibrous septa, on
hematoxylin and eosin-stained sections (Figs. 1 and 2).
These globules were PAS positive, diastase resistant
(Fig. 1, inset), and stained positively for alpha-1-antitrypsin by immunofluorescence technics (Fig. 3).
Cirrhosis was present in Cases 1 and 2, and was
micronodular in the former and of undetermined type
with moderate activity in the latter. An additional
feature of Case 2 was the finding of hepatocytes with
"ground glass" cytoplasm staining positively with
aldehyde fuchsin, indicating the presence of hepatitis
B surface antigen." Cirrhosis was not present in Case 3,
in which the liver showed mild fatty metamorphosis,
periportal fibrosis, and chronic nonspecific portal inflammation. Alcoholic hyalin or other morphologic
features of alcoholic liver disease were not identified
in any case.
Comments
Characteristic PAS-positive, diastase-resistant intracytoplasmic globules were identified in liver biopsy
specimens from three elderly persons not suspected of
having an alpha-1-antitrypsin abnormality. The globules were initially identified on hematoxylin and eosin-
539
stained sections while evaluating periportal and periseptal areas for evidence of activity (e.g., "piecemeal"
necrosis); these areas typically contain the greatest
number of A, AT globules in affected persons. 9 Two of
the patients had cirrhosis, and one had chronic obstructive pulmonary disease, both well-recognized complications of A[AT deficiency. 8 Positive identification
of the globules as A! AT by immunologic technics was
necessary, since rare examples of globules with identical histologic and histochemical characteristics, but
failing to stain for AjAT by immunohistochemical
technics, have been described. 19
Pi-typing is necessary for complete evaluation of the
patient suspected of having A,AT deficiency, because
simply measuring the serum A,AT value may be misleading. Heterozygous persons may (perhaps at times
of stress) have a serum A,AT value that is within the
normal range. 17 A few cases with immunohistochemically proven A,AT globules in hepatocytes but with
Pi M phenotypes have been reported. 1,5 Two of our
cases illustrate these considerations. Patient 1 had an
MZ genotype and a low normal serum A,AT level.
Patient 3 had a serum A, AT value of 777 mg/dl, which is
over 200 mg/dl above the upper limit of normal. P r
typing is not available for this patient. Thus, despite the
presence of A! AT globules in the liver parenchyma, we
are not able to infer that this patient is genotypically
deficient.
There is considerable controversy in the literature
whether heterozygous A ^ T deficiency can in itself
result in cirrhosis. The reported cases of heterozygous
A,AT deficiency associated with cirrhosis are summarized in Table 1. The median age is 45 years (range,
three days to 78 years), with a male to female ratio of
2.5:1. The genotypes for the 13 persons for whom P,typing was done were 6 MZ, 6 SZ, and 1 FZ. The expected serum A,AT level of the eight persons for whom
data is available ranged from 42 to 214 mg/dl. Three
additional cases of cryptogenic cirrhosis with a heterozygous genotype (MS in two instances, MZ in one)
were reported by Fisher and associates 5 ; all three patients were women, but age and serum A,AT levels
were not given.
Some investigators believe that the association of
cirrhosis with heterozygous A,AT deficiency is fortuitous. 5 1 0 1 3 1 7 Morin and colleagues 13 found no difference in the frequency of the Z allele in a population
of blood donors when compared with 37 patients who
had cryptogenic cirrhosis. Fisher and associates 5 found
similar results in a comparison of 65 patients who had
cryptogenic cirrhosis and 98 healthy control subjects.
Other investigators support the concept of a direct
relationship between heterozygous A,AT deficiency
and cirrhosis, suggesting that the rarity of the associ-
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FIG. 1 (upper). Case 2. Eosinophilic spherical intracytoplasmic inclusions (arrowheads) are seen in periseptal hepatocytes. Hematoxylin
and eosin. x293. Inset: PAS-stained section treated with diastase shows characteristic PAS-positive diastase-resistant histochemical features
of spherical inclusions. Periodic acid-Schiff (PAS) with diastase. x427.
FIG. 2 (lower). Case 3. Intracytoplasmic globules (arrowheads) show same characteristics as those in Figure 1. Hematoxylin and eosin. x733.
BRIEF SCIENTIFIC REPORTS
Vol. 75 • No. 4
541
5
screened for P r type, will be necessary to resolve
this issue.
A striking association between A,AT deficiency and
the development of hepatocellular carcinoma has been
noted,17 and a few cases occurring in heterozygous
persons have been described.12,16 Experimental studies
have suggested that antitrypsin may be involved in the
regulation of cancer cell growth and progression,12 and
theoretically, neoplasia could occur more frequently in
A^T-deficient persons. Although the association between A,AT and hepatocellular carcinoma has been
emphasized, it is of interest that two of our patients
had carcinoma, one squamous carcinoma of the oropharynx metastatic to the lung and possibly the liver
(Case 2), and one with metastatic breast cancer, of
which she died (Case 3). Further studies of the possible
association between AiAT deficiency and neoplasia
primary in sites other than the liver are needed.
FIG. 3. Case 1. Immunofluorescence studies positively identify
intracytoplasmic globules as alpha-1-antitrypsin. Positive staining
was not seen in appropriate controls. Rabbit anti-alpha- 1-antitrypsin followed by fluorescein-conjugated goat antirabbit globulin.
ation and the difficulty of the correct diagnosis could
significantly affect statistical results in small clinical
studies.14 The association between heterozygous A, AT
deficiency and cirrhosis is not proven, but the cases
summarized in Table 1 indicate that close scrutiny of
available data, as well as prospective studies of persons
In conclusion, three cases with characteristic globules within hepatocytes (proven immunohistochemically to contain AjAT) have recently been identified
in elderly persons over a ten-month period at our institution. Two of these were shown to be heterozygous
for the Z allele by P,-typing. The apparent association
of A,AT deficiency with cirrhosis and emphysema,
the possible correlation with the development of
malignancy (particularly hepatocellular carcinoma),
the hereditary nature of the condition, and the lack of
signs and symptoms specific for the disorder are important reasons for the pathologist to consider the
diagnosis for patients of all ages who have biopsies
of the liver.
Acknowledgment. The immunofluorescence studies for alpha-1antitrypsin in all three cases were performed by Dr. Kama! G.
Ishak of the Armed Forces Institute of Pathology, Washington,
D. C. Prtyping was performed in Cases 1 and 2 by Dr. Joseph C.
Table I. Reported Cases of Heterozygous Alpha-1-antitrypsin Deficiency Associated with Cirrhosis
Authors (Year)
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
Case 12
Case 13
Case 14
3
Campra el al. (1973)
Brand era/. (1974)2 2
Wilkinson el al. (1974) "
Wilkinson et al. (1974)620
Rawlings et al. (1974)'16
Rawlings et al. (1974) 2
Lieberman et al. (1975)'
Trigeref al. (1976)18
1415
Palmer er al. (1978)1415
Palmer et al. 4(1978)
Cutz and Cox4
Cutz and Cox
Present authors
Present authors
Patient's
Age/Sex
P,-type*
Serum ai-ATf
63, F
78, F
2 wk, F
3 day, M
66, M
64, M
16, M
54, F
73, M
54, M
22, M
5, M
71, M
66, M
SZ
FZ
ND§
SZ
MZ
MZ
MZ
MZ
SZ
SZ
MZ
SZ
SZ
MZ
135 mg/dl
128 mg/dlt
—
42 mg/dl
0.1 g/dlt
0.2 g/dlt
—
84 mg/dl
—
—
—
—
145 mg/dl
214 mg/dl
* Prlype: protease inhibitor phenotype by acid starch electrophoresis and crossed
immunoelectrophoresis.
t Serum alpha- 1-antitrypsin level by radial immunodiffusion method.
t Alpha-l-globulin concentration.
§ Not done. Genotypes of parents were MZ (father) and FS (mother).
ROGGLI, HAUSNER AND ASKEW
542
Taylor of the City of Hope National Medical Center, Duarte,
California.
References
1. Bradfield JWB, Blenkinsopp WK: Alpha- 1-antitrypsin globules
in the liver and P,M phenotype. J Clin Pathol 30:464-466,
1977
2. Brand B, Bezahler GH, Gould R: Cirrhosis and heterozygous
FZ a.-antitrypsin deficiency in an adult: case report and review of the literature. Gastroenterol 66:264-268, 1974
3. Campra JL, Craig JR, Peters RL, et al: Cirrhosis associated
with partial deficiency of alpha-1-antitrypsin in an adult. Ann
Intern Med 78:233-238, 1973
4. Cutz E, Cox DW: a,-antitrypsin deficiency: the spectrum of
pathology and pathophysiology, Perspectives in pediatric
pathology. Volume 5. Edited by HS Rosenberg, RP Bolande.
Chicago, Yearbook Medical Publishers, Inc., 1980, pp 1-38
5. Fisher RL, Taylor L, Sherlock S: a,-antitrypsin deficiency in
liver disease: the extent of the problem. Gastroenterol 71:
646-651, 1976
6. Gerber MA, Hadziyannis S, Vernace S, et al: Incidence and
nature of cytoplasmic hepatitis B antigen in hepatocytes.
Lab Invest 32:251-256, 1975
7. Gordon HW, Dixon J, Rogers JC, et al: Alpha,-antitrypsin
(A,AT) accumulation in livers of emphysematous patients
with A,AT deficiency. Hum Pathol 3:361-370, 1972
8. Greenberg SD, Jenkins DE, Stevens PM, et al: The lungs in
homozygous alpha,-antitrypsin deficiency. Am J Clin Pathol
60:581-592, 1973
9. Ishak KG, Jenis EH, Marshall ML, et al: Cirrhosis of the liver
associated with a,-antitrypsin deficiency. Arch Pathol 94:
445-455, 1973
A.J.C.P. • April 1981
10. Kueppers F, Dickson ER, Summerskill WHJ: Alpha,-antitrypsin phenotypes in chronic active liver disease and primary biliary cirrhosis. Mayo Clin Proc 51:286-288, 1976
Lieberman J, Gidulis L, Garoutte B, et al: Identification and
characteristics of the common alpha,-antitrypsin phenotypes.
Chest 62:557-564, 1972
12. Lieberman J, Silton RM, Agliozzo CM, et al: Hepatocellular
carcinoma and intermediate (^-antitrypsin deficiency (MZ
phenotype). Am J Clin Pathol 64:304-310, 1975
13. Morin T, Feldman G, Benhamou J-P, et al: Heterozygous
alpha,-antitrypsin deficiency and cirrhosis in adults, a
fortuitous association. Lancet 1:250-251, 1975
14. Palmer PE, Gherardi GJ, Baldwin JM, et al: Adult liver disease
in SZ phenotype alpha-1-antitrypsin deficiency. Ann Intern
Med 88:59-60, 1978
15. Palmer PE, Wolfe Hj, Dayal Y, et al: Immunocytochemical
diagnosis of alpha,-antitrypsin deficiency: Report of eight
cases. Am J Surg Pathol 2:275-281, 1978
16. Rawlings W, Moss J, Cooper HS, et al: Hepatocellular carcinoma and partial deficiency of alpha-1 antitrypsin (MZ). Ann
Intern Med 81:771-773, 1974
17. Sharp HL: The current status of a,-antitrypsin, a protease inhibitor, in gastrointestinal disease. Gastroenterol 70:611-621,
1976
18. Sharp HL, Bridges RA, Krivit W, et al: Cirrhosis associated
with alpha-1-antitrypsin deficiency: a previously unrecognized inherited disorder. J Lab Clin Med 73:934-939,
1969
19. Triger DR, Millward-Sadler GH, Czaykowski AA, et al: Alpha1-antitrypsin deficiency and liver disease in adults. Q J Med
45:351-372, 1976
20. Wilkinson EJ, Raab K, Browning CA, et al: Familial hepatic
cirrhosis in infants associated with alpha,-antitrypsin SZ
phenotype. J Pediatr 85:159-164, 1974
The Accuracy of Masson's Trichrome Stain in Predicting the
Presence or Absence of Glomerular Immune Complexes
NOEL WEIDNER, M.D., JAMES OATES, M.D., AND KENNETH S. K. TUNG, M.D.
Weidner, Noel, Oates, James, and Tung, Kenneth S. K.: The
accuracy of Masson's trichrome stain in predicting the presence
or absence of glomerular immune complexes. Am J Clin
Pathol 75:542-545, 1981. The accuracy of Masson's trichrome
stain to predict the presence of immune complexes was determined in 63 renal biopsies. When immunofluorescence was
defined as the reference method, the histologic method correctly predicted the presence or absence of deposits in 70%
of biopsy specimens, while electron microscopy was accurate
in 79% of specimens. This difference was not statistically
significant. The commonest error in our assessment of the
Received June 23, 1980; received revised manuscript and accepted
for publication September 2, 1980.
Results presented at the Sixty-ninth Annual Meeting of the International Academy of Pathology (United States-Canada Division),
New Orleans, Louisiana, February, 1980.
Address reprint requests to Dr. Weidner: Department of
Pathology, Penrose Hospital, Colorado Springs, Colorado.
Department of Pathology, Penrose Hospital,
Colorado Springs, Colorado; Department of Pathology,
Presbyterian Hospital and Department of Pathology,
University of New Mexico School of Medicine,
Albuquerque, New Mexico
Masson's trichrome-stained specimens was the erroneous interpretation of specimens showing minimal change nephropathy
or ischemic glomerulopathy by immunofluorescence and
electron microscopy. This resulted in a falsely positive diagnosis of one or another of the glomerulonephritides in 13%
of cases. Thus, the routine study of renal biopsies with Masson's trichrome stain is clearly useful and should be applied
with caution, but it does not replace electron-microscopic and
immunofluorescence studies. (Key words: Masson's trichrome
stain; Glomerular immune complexes; Glomerulonephritis;
Immunofluorescence; Electron microscopy.)
0002-9173/81/0400/0542 $00.70 © American Society of Clinical Pathologists