sign in sign up
<<
Home , Microorchidism, Testicle

ORIGINAL ARTICLE

Endocrine Care—Brief Report

Spermatogenic and Steroidogenic Impairment of the Characterizes the Hereditary Leucine-75- Proline Apolipoprotein A-I Amyloidosis

Tiziano Scalvini, Paola Rossana Martini, Alessandro Gambera, Regina Tardanico, Luciano Biasi, Francesco Scolari, Gina Gregorini, and Enrico Agabiti Rosei

Departments of and (T.S., P.R.M.), Gynecological Endocrinology (A.G.), and (R.T.), and Divisions of Downloaded from https://academic.oup.com/jcem/article/93/5/1850/2598903 by guest on 25 September 2021 Infectious Diseases (L.B.) and (F.S., G.G.), Spedali Civili, and Department of (E.A.R.), University of Brescia, 25123 Brescia, Italy

Context: The leucine-75-proline variant of apolipoprotein A-I leads to a new hereditary systemic amyloidosis involving mostly the liver and kidney.

Objective: The objective of the study was to examine the effects of this amyloidosis on testicular structure and function.

Design: This was an observational study in which patients with testicular amyloidosis were characterized.

Setting: The study was carried out at the Endocrinology Department of Brescia University.

Patients or Other Participants: Over a 13-yr period, 25 patients were found to be affected by leucine-75-proline apolipoprotein A-I testicular amyloidosis. Thirteen had the testicle as the first or only involved (group 1); in 12 testicular damage followed that of other organs (group 2).

Interventions: There were no interventions.

Main Outcome Measure: and lipidic profiles, analysis, echographic volume of , testicular histology, and genetic analysis were carried out.

Results: Group 1 patients were younger than those of group 2. In group 1, eight had hypergona- dotropic and five were normogonadic with high ; in group 2 all subjects were hypogonadic. All men had low high-density lipoprotein values. Group 1 patients were macroorchid, whereas the testicular volume was at the highest limit in group 2 (group 1 vs. group 2, P Ͻ 0.05). All men in the first group and six in the second group were azoospermic; the remaining had oligoposia. Biopsies showed the germinal replaced by amyloid. Leydig cells were essentially preserved in normogonadic but not hypogonadic patients.

Conclusions: This amyloidosis may determine , macroorchidism, and hypogonadism. En- docrine impairment follows spermatogenic impairment. (J Clin Endocrinol Metab 93: 1850–1853, 2008)

polipoprotein (Apo) A-I is the main protein of high-density Twelve Apo A-I variants are known to be responsible for A lipoprotein (HDL), which plays a key role in the delivery systemic amyloidosis, mainly involving the kidneys, heart, of cholesterol to steroidogenic tissues and in the reverse transport , liver, and larynx (2). of cholesterol itself (1). Recently the new amyloidogenic variant Leucine-75-Proline

0021-972X/08/$15.00/0 Abbreviations: Apo, Apolipoprotein; HDL, high-density lipoprotein; Leu75Pro, leucine-75- Printed in U.S.A. proline; T, . Copyright © 2008 by The Endocrine Society doi: 10.1210/jc.2007-1656 Received July 25, 2007. Accepted February 12, 2008. First Published Online February 19, 2008

1850 jcem.endojournals.org J Clin Endocrinol Metab. May 2008, 93(5):1850–1853 J Clin Endocrinol Metab, May 2008, 93(5):1850–1853 jcem.endojournals.org 1851

(Leu75Pro), due to a thymine to cytosine transition in the Apo (Diagnostic Product Corp. Medical Systems, Genoa, Italy) for SHBG A-I gene, has been demonstrated to cause asymptomatic chole- (reagents by Diagnostic Products Corp., Los Angeles, CA). static hepatopathy and nephropathy (3, 4). Our laboratory participates in the External Quality Assessment Schemes (UK-NEQAS, Birmingham, UK) and Immunocheck (IFC-CNR- Testicular amyloidosis is rare. Recently isolated testicular EQAS, Pisa, Italy). amyloid deposits were found in two hypogonadic and infertile patients (5, 6) but also in a heterozygous for a nondeter- mined type of familial amyloidosis, associated with an abnormal Results production of Apo A-I (7). Few cases of testicular involvement in patients affected by Table 1 shows the clinical characteristics of the two groups of primary systemic amyloidosis have been described, but in liter- patients at diagnosis. Men affected by testicular amyloidosis as ature the cases of early testicular involvement, preceding cardiac early or single manifestation of the disease were included in or multiple organ disease are purely anecdotal (8–11). group 1. Group 2 consisted of those with testicular disease after Downloaded from https://academic.oup.com/jcem/article/93/5/1850/2598903 by guest on 25 September 2021 Secondary involvement of the testicles during chronic inflam- other organ involvement: six renal; one hepatic; four renal and matory diseases or neoplasias is much more frequent (6, 9, hepatic; and one renal, hepatic, and adrenal. 12–13). The mean age of group 2 was significantly higher than The aim of this study is to examine the effects of systemic group 1. amyloidosis due to the Leu75Pro variant of ApoA-I on testicular On physical examination, 11 men in the first group (84.6%) structure and function. but only four in the second (33.3%) were macroorchid with testicles appearing smooth and tough. Group 1 came to observation due to infertility, reduced li- Subjects and Methods bido, , and , isolated or vari- ously associated, and only three by screening when a family Over a 13-yr period at the Endocrinology Department of Brescia Uni- member was affected. versity (Italy), 25 men were found to be affected by testicular amyloidosis All group 2 subjects were diagnosed by screening as being caused by the Leu75Pro variant of Apo A-I, and they were all included in the study. Thirteen had the testicle as the first or only organ involved patients with other organ damage. They complained of reduced (group 1), whereas in 12, testicular damage followed renal, hepatic, or , erectile dysfunction, but only 8.3% of infertility (Table 1). adrenal damage (group 2). Only five men in group 1 (38.5%) had managed to father, Medical history was collected and all patients had a physical exam- from 3 to 27 yr before the diagnosis of testicular amyloidosis, ination. Particular attention was paid to libido, erectile function, past whereas 11 (91.7%) men in group 2 had fathered, from 10 to 48 testicular , difficulty in fathering, and age of conception. All patients underwent an endocrine and lipidic profile, semen anal- yr before the onset of testicular disease. ysis, echographic evaluation of the testicles, testicular biopsies for his- Table 2 shows the clinical, endocrine, echographic, and - tological diagnosis, and DNA analysis. idic parameters of men with early and late testicular amyloidosis. Total testosterone (T), SHBG, LH, and FSH, cholesterol, triglycer- The first group of patients was divided into two subgroups: ides, and HDL cholesterol were measured at 0900 h in a fasting condi- normogonadic (n ϭ 5) and hypogonadic (n ϭ 8). The former tion. Free testosterone was calculated using the Vermeulen formula (14). Ultrasonographic evaluation was carried out by the same and were significantly younger than the latter. testicular volume was calculated using the Lambert formula (15). A vol- Normogonadic patients had normal testosterone levels with ume of 15–25 ml is considered normal (16). was read high gonadotropins, whereas the hypogonadic subjects had sig- using the World Health Organization criteria. nificantly lower levels and higher gonadotropins (P Ͻ The same pathologist examined the biopsies after hematoxylin-eosin 0.05). and Congo-red staining under polarized light. An antibody panel against ␬- and ␭-chains, serum amyloid-A, fibrinogen, and apoA-I (Dako, Milan, Italy) was used on the paraffin-embedded sections to immunohisto- TABLE 1. Clinical characteristics of patients at diagnosis chemically characterize the amyloid deposits. DNA analyses were carried out using standard procedures and direct (group 1 with early or single testicular amyloidosis, group 2 sequencing was used to search for any Apo A-I mutation in the whole with testicular disease following other organ involvement) gene (3). A written informed consent was given by all patients and the insti- Clinical characteristics Group 1, % (n) Group 2, % (n) tutional review board approved the study. No. of patients 13 12 Mean age (yr) 39.5 Ϯ 9.6a 62.3 Ϯ 9.3 Statistical analysis Familiarity for amyloidosis 38.5% (5) 66.7% (8) Past testicular pathologies 30.8% (4) None All values were expressed as mean Ϯ SD. Student’s unpaired t test was used to compare the hormone levels, lipid parameters, and echographic Clinical macroorchidism 84.6%(11) 33.3% (4) measures of the different groups of patients. P Ͻ 0.05 was considered Infertility 61.5% (8) 8.3% (1) statistically significant. Reduced libido 61.5% (8) 83.4% (10) Erectile dysfunction 61.5% (8) 83.4% (10) Gynecomastia 46.1% (6) None Hormone assays Patients who fathered 38.5% (5) 91.7% (11) were determined by an automated analyzer using chemi- Age range at conception (yr) 22–36 25–49 luminescent immunoassay: the Architect System (Abboth Diagnostic Di- vision, Milan, Italy) for LH, FSH, and T (reagents by Ortho-Clinical Unpaired Student t test. Diagnostics, Amersham, UK); and Immulite Automated Analyzer 2000 a P Ͻ 0.01 group 1 vs. group 2. 1852 Scalvini et al. Testicular Amyloidosis due to Apo A-I Leu75Pro J Clin Endocrinol Metab, May 2008, 93(5):1850–1853

TABLE 2. Clinical, endocrine, echographic, and lipid profiles of the two groups of patients (group 1 with early testicular amyloidosis vs. group 2 with late testicular disease)

Group 1 Normogonadic Hypogonadic Group 1 Group 2 (12 ؍ n) (13 ؍ n) (8 ؍ n) (5 ؍ n) Age at diagnosis (yr) 31.4 Ϯ 2.9 44.6 Ϯ 8.8† 39.5 Ϯ 9.6b 62.3 Ϯ 9.3# LH (IU/liter) 13.7 Ϯ 3.9 27.6 Ϯ 11.2* 22.2 Ϯ 11.3b 40.5 Ϯ 18.5 FSH (IU/liter) 25.6 Ϯ 6.5 53.0 Ϯ 22.0* 42.4 Ϯ 22.1 53.7 Ϯ 18.7 T (nmol/liter) 14.2 Ϯ 0.69 5.9 Ϯ 3.8§ 9.0 Ϯ 5.2b 3.8 Ϯ 3.4 Free T (pmol/liter) 292 Ϯ 50 92 Ϯ 63§ 146 Ϯ 107a 68 Ϯ 64 SHBG (nmol/liter) 34.6 Ϯ 9.7 43.1 Ϯ 21.2 39.8 Ϯ 17.7 54.8 Ϯ 19.4

Cholesterol (mmol/liter) 4.03 Ϯ 0.44 4.54 Ϯ 0.99 4.34 Ϯ 0.84 4.85 Ϯ 1.27 Downloaded from https://academic.oup.com/jcem/article/93/5/1850/2598903 by guest on 25 September 2021 Triglycerides (mmol/liter) 1.08 Ϯ 0.62 1.19 Ϯ 0.27 1.15 Ϯ 0.42 1.42 Ϯ 0.70 HDL (mmol/liter) 0.87 Ϯ 0.18 0.96 Ϯ 0.10 0.93 Ϯ 0.14 0.89 Ϯ 0.25 Right testicular volume (ml) 34.6 Ϯ 2.2 27.2 Ϯ 7.3 30.5 Ϯ 7.0a 24.3 Ϯ 6.6 Left testicular volume (ml) 33.4 Ϯ 10.3 28.0 Ϯ 8.0 30.1 Ϯ 9.0b 20.8 Ϯ 6.9‡

Unpaired Student t test. † P Ͻ 0.01; * P Ͻ 0.05; § P Ͻ 0.001, group 1: hypogonadic vs. normogonadic. a P Ͻ 0.05; b P Ͻ 0.01, group 1 vs. group 2. # P Ͻ 0.001; ‡ P Ͻ 0.05, group 2 vs. hypogonadic group 1.

All patients in the second group had clear hypergonadotropic dig cells or few cells without a well-structured organization. On hypogonadism, with androgen values significantly lower and LH the contrary, few normal aggregates of Leydig cells were present significantly higher if compared with those of group 1. No sta- in normogonadic men. Immunohystochemical analysis showed tistical differences in androgen and gonadotropins levels were considerable immunoreactive amyloid deposits with the anti- found between group 2 and the hypogonadic patients of Apo A-I antibody but not with the other antibodies. group 1. Direct DNA sequencing showed that all 25 patients were het- In all groups, the mean SHBG, triglycerides, and cholesterol erozygous due to the same thymine to cytosine mutation at po- appeared normal. HDL values were low in both groups, without sition 1772 of the Apo A-I gene, corresponding to a leucine to statistical differences. proline replacement at position 75 of the mature polypeptidic Ultrasonographic investigation confirmed the increased vol- chain. No patient had other Apo A-I variants. ume of the testicles in the first group (19–44 ml), without sta- tistical differences between the two subgroups. In the second group, ultrasonography revealed a normal vol- ume for the left testicle with the right testicle at the top of the Discussion normal values. Group 2 testicles were smaller than those of group 1(P Ͻ 0.05). Mean left volume of group 2 was also significantly This study shows that testicular involvement frequently occurs in lower than that of the hypogonadic men in group 1. Apo A-I Leu75Pro amyloidosis, after other organ damage, or Semen analysis in group 1 showed complete in being the first or single manifestation. A dramatic impairment of 100% of men. Moreover, a 29-yr-old man had previous semen may occur even from the third decade of life and nor- analyses showing an evolution from normozoospermia to mospermia can evolve to azoospermia in less than 2 yr. In fact, azoospermia in only 23 months. Six men in group 2 had 61.5% of men in group 1 failed to father. azoospermia, and in six the examination resulted not feasible due The progressive spermatogenic impairment, shown by the to oligoposia. two biopsies with mixed tissue morphology, proceeds to the Biopsies showed abundant deposits of amorphous eosino- gradual endocrine damage. In fact, in group 1 five azoospermic philic material positive to Congo Red staining. Amyloid was patients showed Leydig cells only focally involved and the high deposited in the epithelium of seminiferous , causing their levels being able to maintain a normal T secretion narrowing or obstruction with the disappearance of Sertoli cells (subclinical hypogonadism). On the contrary, complete damage in most cases. Only in two subjects of the normogonadic sub- to the Leydig cells was seen in hypogonadic patients. group was the histological picture characterized by areas of com- Spermatogenetic damage may be caused by the obliteration of plete replacement of the epithelium or with only Sertoli cells intratesticular canaliculi, the direct effect of amyloid on the sem- mixed with areas of partial damage of the germinal epithelium, iniferous tubules (12), or hypoxia due to vessel lumen obstruc- with the evidence of all stages of to . tion (9). All biopsies showed amyloid deposits also in the interstitium, Usually pathologies causing impairment of spermatogenesis in the walls of the , , and capillaries, leading to an lead to (congenital and chromosomal abnor- increase in the vessel walls. malities, Klinefelter, , myotonic dystrophy), Biopsies belonging to hypogonadic patients showed no Ley- whereas the testicular volume in this kind of amyloidosis is nor- J Clin Endocrinol Metab, May 2008, 93(5):1850–1853 jcem.endojournals.org 1853

mal or high. In particular, the testicular volume of group 1 is Disclosure Statement: The authors have nothing to disclose. increased, whereas that of group 2 is normal or high. The testicular volume of elderly men (group 2) was signifi- cantly lower than that of the hypogonadic men in the first group, who had similar degree of hypogonadism. References In literature age-related reduction in testicular volume is dem- 1. Fielding CJ, Fielding PE 1995 Molecular physiology of reverse cholesterol onstrated only from the eighth decade of life (17), a clearly higher transport. J Lipid Res 36:211–228 age than that of group 2 patients (range 50–79 yr). 2. Murphy CL, Wang S, Weaver K, Gertz MA, Weiss DT, Solomon A 2004 Renal We can suppose that the mechanism of testicular damage may be apolipoprotein A-I amyloidosis associated with a novel mutant Leu64Pro. Am J Kidney Dis 44:1103–1109 different between the younger patients (group 1) and the older ones 3. Obici L, Palladini G, Giorgetti S, Bellotti V, Gregorini G, Arbustini E, Verga (group 2). Studies on transthyretin amyloidosis show that the oli- L, Marciano S, Donadei S, Perfetti V, Calabresi L, Bergonzi C, Scolari F, gomeric intermediates of the fibril assembly are directly cytotoxic, Merlini G 2004 Liver biopsy discloses a new apolipoprotein A-I hereditary Downloaded from https://academic.oup.com/jcem/article/93/5/1850/2598903 by guest on 25 September 2021 causing oxidative stress and activation of apoptosis (18). Testicular amyloidosis in several unrelated Italian families. 126:1416– 1422 damage in group 1 may be mainly due to a rapid replacement of 4. Gregorini G, Izzi C, Obici L, Tardanico R, Ro¨ cken C, Viola BF, Capistrano M, parenchyma by amyloid, leading to macroorchidism, whereas in Donadei S, Biasi L, Scalvini T, Merlini G, Scolari F 2005 Renal apolipoprotein the second group, the cytotoxic mechanism may be predominant, A-I amyloidosis: a rare and usually ignored cause of hereditary tubulointer- stitial nephritis. J Am Soc Nephrol 16:3680–3686 causing failure without significant increase in volume. 5. Handelsman DJ, Yue DK, Turtle JR 1983 Hypogonadism and massive testic- The gene penetrance, the proportion of testicular damage in ular infiltration due to amyloidosis. J Urol 129:610–612 carriers or in patients already affected by other organ disease, is 6. Casella R, Nudell D, Cozzolino D, Wang H, Lipshultz LI 2002 Primary tes- still unknown. ticular amyloidosis mimicking tumor in a cryptorchid testis. 59:445, xxiii-xxiv The high number of patients described in this study is likely 7. Schrepferman CG, Lester DR, Sandlow JI 2000 Testicular amyloid deposition to be due to a founder effect, i.e. to a dominant mutation in as a cause of secondary azoospermia. Urology 55:145, i-ii previous generations. 8. Van Allen MW, Frohlich JA, Davis JR 1969 Inherited predisposition to gen- eralized amyloidosis. 19:10–25 Azoospermic men, normogonadic or not, with or without mac- 9. O¨ zdemir BH, O¨ zdemir OG, O¨ zdemir FN, O¨ zdemir AI 2002 Value of testis roorchidism and low HDL levels are to be considered highly sus- biopsy in the diagnosis of systemic amyloidosis. Urology 59:201–205 picious, even if there is no family history. Because this disease, also 10. Bonacina R, Virgili G, Rosi P, Vespasiani G, Capodicasa E, Micali F 1992 shown in a different ethnic background (19), may involve only the Testicular and cardiac amyloidosis. Scand J Urol Nephrol 26:297–299 11. Kanada DJ, Sharma OP 1979 Long-term survival with diffuse interstitial pul- testicle, a small part of idiopathic infertilities may be so explained. monary amyloidosis. Am J Med 67:879–882 Why the testicle is a target organ is still unknown. Apo A-I in 12. Haimov-Kochman R, Prus D, Ben-Chetrit E 2001 Azoospermia due to testic- the testicle removes cholesterol from Sertoli cells and carries it to ular amyloidosis in a patient with familial Mediterranean fever. Hum Reprod 16:1218–1220 Leydig cells (20). Conformational changes of the mutated pro- 13. Corvino C, Balloni F, Meliani E, Giannini A, Serni S, Carini M 2002 Testicular tein during cholesterol trafficking may start proteolitic remod- amyloidosis. Urol Int 69:162–163 eling, producing fibrillogenic oligomers. 14. Vermeulen A, Verdonck L, Kaufman JM 1999 A critical evaluation of simple methods for the estimation of Free Testosterone in serum. J Clin Endocrinol In conclusion, infertility, subclinical or overt hypogonadism, Metab 84:3666–3672 and macroorchidism are clinical features of Leu75Pro Apo A-I 15. Schiff JD, Li PS, Goldstein M 2004 Correlation of ultrasonographic and or- amyloidosis. Testicular involvement may be the first or only chidometer measurements of testis volume in adults. BJU Int 93:1015–1017 manifestation of disease, with deterioration of spermatogenesis 16. Griffin JE, Wilson JD 2003 Disorders of the testes and the male reproduc- tive tract. In: Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, eds. and steroidogenesis from the third decade of life. Semen analysis Williams textbook of endocrinology. 10th ed. Philadelphia: Saunders; is recommended annually in young asymptomatic carriers of the 709–770 mutation, and retrieval is suggested. Repeated evaluation 17. Mahmoud AM, Goemaere S, El-Garem Y, Van Pottelbergh I, Comhaire FH, Kaufman JM 2003 Testicular volume in relation to hormonal indices of go- of endocrine parameters is advisable annually to start androgen nadal function in community-dwelling elderly men. J Clin Endocrinol Metab replacement , when necessary. 88:179–184 18. Merlini G, Bellotti V 2003 Molecular mechanisms of amyloidosis. N Engl J Med 349:583–596 19. Coriu D, Dispenzieri A, Stevens JF, Murphy CL, Wang S, Weiss DT, Solomon Acknowledgments A 2003 Hepatic amyloidosis resulting from deposition of the apolipoprotein A-I variant Leu75Pro. Amyloid 10:215–223 Address all correspondence and requests for reprints to: Dr. Alessandro 20. Marcel YL, Kiss RS 2003 Structure-function relationships of apolipoprotein Gambera, Via XXV Aprile, 10, 24058 Romano di L. (BG), Italy. E-mail: A-I: a flexible protein with dynamic lipid associations. Curr Opin Lipidol [email protected]. 14:151–157