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 The finding of fibrils on electron microscopy of a renal biopsy specimen may be an extremely important clue in establishing the diagnosis. In fact, for many of the conditions listed below, the diagnosis may be based PURELY on a detailed ultrastructural characterization of the fibril, as in fibrillary or immunotactoid glomerulopathy. The first step in the differential diagnosis of fibrillary glomerulopathies is to divide the condition into an IMMUNOGLOBULIN-MEDIATED versus a NON-IMMUNOGLOBULIN MEDIATED process, which is typically done by immunofluorescent staining against different heavy and light chain classes. IMMUNOGLOBULIN-MEDIATED fibrillary glomerulopathies include: -AL amyloidosis. -MIDD (monoclonal immunoglobulin deposition disease). -type 2 cryoglobulinemia. -immunotactoid glomerulopathy (see picture) -fibrillary glomerulopathy. NON-IMMUNOGLOBULIN-MEDIATED fibrillary glomerulopathies include: -AA amyloidosis. -fibronectin glomerulopathy. -diabetic fibrillary glomerulopathy. (note: the latter two on this list are pretty rare). Another crucial distinction here is whether the biopsy specimen stains negative or positive for CONGO RED (indicating the beta-pleating sheet structure of precipitated amyloid protein).
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