J Clin Pathol 1987;40:798-802

Accumulation of ceroid in smooth muscle indicatessevere malabsorption and vitamin E deficiencyG W H STAMP, D J EVANS

From the Department ofHistopathology, Royal Postgraduate Medical School, Hammersmith Hospital, London

SUMMARY Four patients had accumulation of ceroid in smooth muscle (lipofuscinosis), whichindicated severe or uncontrolled malabsorption, with confirmed vitamin E deficiency in three cases.The distribution of the pigment was systematic, and there seemed to be an association betweenmalabsorption syndrome and vitamin E deficiency. Vitamin E supplementation seems to beindicated in such patients, and it is suggested that studies of smooth muscle function should be madein cases of heavy accumulation of ceroid.

Accumulation of ceroid pigment in intestinal smoothmuscle (lipofuscinosis or brown bowel syndrome) isan association of malabsorption syndromes, but sys-temic ceroid deposition in vascular or other smoothmuscle has only occasionally been documented inman. 1-4 We report four cases in which a mal-absorption syndrome or vitamin E deficiency wasinferred from surgical biopsy material, an inferencethat has therapeutic implications.

Case reports

CASE IA 30 year old man came to surgery with a history of"Noonan's syndrome." Histological examinationshowed atrophic testes with Sertoli cell nodules, andno evidence of malignancy. Ceroid was noted insmooth muscle cells of vasa deferentia and small arte-ries and veins of the spermatic cord (fig 1). Althoughhaematoxylin and eosin stained sections had shownthat the material was lipofuscin, this was confirmed.The pigment stained strongly with periodic acidSchiff and was resistant to diastase digestion. It alsostained with methylene blue, methenamine silver, andMasson-Fontana, and was distinguished from mel-anin by its positive staining with Sudan black and thelong Ziehl-Neelsen technique using a picric acid coun-terstain (as the usual methylene blue counterstainmasks the fuchsinophilia).3 Orange autofluorescenceis another property of lipofuscin,5 and this was

Accepted for publication 9 March 1987

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Fig I Ceroid in smooth niiusCle of' las defi'rens (arrowed).(HaematoxilIin an?d eosini.)

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observed on unstained sections. Finally, Perls's stainfor iron pigment yielded negative results. This panel rof stains were performed in all the cases reported 'here. *

Further enquiries showed that he had had a four 'wyear history of diarrhoea and steatorrhoea. Multiplenutritional deficiencies had been documented withfaecal fat ranging from 5-30g/24 hours (normal lessthan 7) and a protein losing enteropathy (Cr5' 47% *aloss in four days; normal less than 008%). Pro-inounced sacral oedema and lower limb oedema waspresent, and a pedal lymphangiogram showed lymph-angiectasia, which was also present in the jejunalbiopsy specimen (fig 2). Intestinal lymphangiectasia is;associated with malabsorption and relatively severevitamin E deficiency.' Intestinal lymphangiectasiahas been documented in Noonan's syndrome (alsocalled "male Turner's syndrome") and is presumablya consequence of the generalised disturbance in lym-phatic drainage that often occurs.7

Following the histological findings in the testis,vitamin E concentrations were measured and foundX

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Fig 3 Staining accentuates ceroid pigmentation in smoothI X v 'tu >wb*memuscle ofoesophageal wall. (Periodic acid Schiff.)

xt'^- ) fbx ^' ** rto e low at 4-Opmol/l (n = 11 5-35). Prophylacticvitamin E supplements were added to the patient's

a j . dietary regimen.

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' * ^¢k, - gW 8 Q - ~~An oesophagogastrectomy specimen from a 53 year->\; **[< Ss.= 401 * ~~old man was submitted for surgical pathology. He*;JT' /had had a clinical history of dysphagia of three

months duration. Macroscopically there was a largeannular tumour, 0 5cm above the oesophagogastnic

* X t, g junction, extending to within I-5cm of the proximalmargin. Microscopically, the tumour was a poorlyoiffer entiated carcinoma extending through the walldfof the oesophagus. Heavy ceroid pigmentation was

ILft W i7 .* noted in the muscularis propria (fig3). The patient-v ~. whad had bouts of steatorrhoea for eight years. A

jejunal biopsy specimen showed severe partial villous

; *..4/:w ~;;i ':atrophy. Initially, he responded to a gluten free diet,but he subsequently deteriorated, with complaints of

Fig 2 Pronounced widening of villous lymphatics in well weight loss and chest pain, and clinical hepatomegaly.orientatedjejunal biopsy specimen. Spaces are clearly lined He died four months postoperatively.by endothelium. (Haematoxylin and eosin.) Necropsy showed local recurrence of the

Accumulation of ceroid in smooth muscle 799

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Stamp, Evans800

oesophageal carcinoma and secondary deposits inlymph nodes, liver, and vertebrae. Extensive lipo-fuscinosis was noted both macroscopically andmicroscopically in oesophagus, small bowel, colonand heart. Ceroid pigment was shown in many arte-ries and veins. The jejunum and ileum showed exten-sive villous atrophy. This may well be an example ofcoeliac disease complicated by oesophageal car-cinoma, but formal histological proof of a response togluten withdrawal could not be obtained.

CASE 3A specimen ofjejunum from refashioning of choledo-chojejunostomy from a 37 year old man was submit-ted for surgical pathology. Histological examinationshowed a very heavy accumulation of ceroid in themuscularis mucosae, muscularis propria, and sub-mucosal blood vessels (fig 4). The mucosal villousarchitecture was normal.The patient had undergone total pancreatectomy

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Fig4 Accumulation ofceroid in muscularis propria.Pigment is present in both layers but is much easier toidentify in longitudinally sectionedfibres. (HaematoxvYlin andeosin.)

Fig 5 Ceroid within wall ofsubmucosal blood vessel.(Periodic acid Schiff.)

15 years previously for chronic pancreatitis, afterwhich he had been given pancreatic enzyme supple-ments and replacement insulin. His only symptomswere attacks of ascending cholangitis beginning threeyears prior to admission to hospital in this instance.The extent of malabsorption was not fully

investigated as the patient was referred from anotherhospital, but the serum albumin was 38 g/l, calcium2 20.pmol/l, and haemoglobin concentration13 1 g/dl. Malabsorption was presumably due to pan-creatic enzyme deficiency, possibly exacerbated bybiliary insufficiency as a consequence of the recurrentcholangitis. He made an uneventful postoperativerecovery and remained asymptomatic. Vitamin Econcentrations were measured on request twelvemonths postoperatively and found to be low at3.3 umol/l.

CASE 4A jejunal biopsy specimen from a 71 year old manwas assessed for coeliac disease. The biopsy specimenshowed severe partial villous atrophy, with pro-

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Accumulation of ceroid in smooth muscle 801

nounced accumulation of ceroid in the muscularismucosae and lamina propria, and in a small sub-mucosal blood vessel (fig 5).

Coeliac disease had been diagnosed 10 years pre-viously. Intermittent bouts of steatorrhoea hadoccurred since then, which the patient admitted wererelated to poor dietary compliance. This wasexacerbated after the death of his wife six months ear-lier. He was found to be cachectic with generalisedmuscular weakness. Investigation showed that thehaemoglobin concentration was 10-2g/dl (mean cor-puscular volume, 107 fl), albumin 27 g/dl, magnesium0.74 mmol/l. Vitamin E concentrations wereundetectable, a highly unusual finding.During the course of his admission he developed

signs of subacute intestinal obstruction, attributed tofaecal impaction in the sigmoid colon. His generalcondition did not improve, and although furtherinvestigations were planned, the patient dischargedhimself against advice. Two weeks later he died athome of extensive burns, having been unable to turnoff the hot tap while in his bath.

Discussion

Accumulation of ceroid (lipofuscinosis) occurs insmooth muscle of the bowel in malabsorption syn-dromes,1 8 and may be so severe that it is visible mac-roscopically (so called "brown bowel syndrome").9Vascular disease is much less conspicuous and hasonly occasionally been described in man,1 3 4although generalised ceroidosis is well documented inexperimental animals,10 in whom there is a clear cutassociation between vitamin E deficiency and accu-mulation of ceroid.`0 `l It is thought that vitamin Ehas an important protective role in mitochondria,complementing the effect of selenium (a constituent ofglutathione reductase) in preventing the unsaturatedlipids of the mitochondrial membrane being damagedby free radicals formed during oxidative phos-phoxylation.2 In vitamin E deficiency the accumu-lation of ceroid can be shown to be intra-mitochondrial by electron microscopy.212 In rats,which are made deficient of vitamin E or selenium,subsequent adminstration can prevent the accumu-lation of lipid peroxidation products.13The major role of vitamin E in man concerns the

maintenance of normal neurological function. Themost severe deficiencies occur in abetalipoprotein-aemia and are associated with ataxic neuropathy andpigmentary retinopathy.14 The benefits of vitamin Esupplementation have been convincingly shown.'415Other malabsorptive states have been associated withspinocerebellar degeneration, attributed to vitamin Edeficiency. 16 17

Neuropathological studies in vitamin E deficient

subjects, monkeys, and rats have shown axonaldegeneration in the posterior columns, with selectiveloss of large calibre myelinated sensory axons in thespinal cord and peripheral nerves.'8 Cardiomyopathyand skeletal myopathy have been repeatedly shown inexperimental animals, but only on rare occasions hasa similar association been noted in man.419 Smoothmuscle function has not been adequately investigatedeither in experimental animals or in man, althoughvarious authors have suggested that it might be per-manently impaired.' 320The identification of accumulation of ceroid may

have two distinct implications: (i) the patient has orhas had a malabsorption syndrome; (ii) vitamin Edeficiency is, or was, present and should be an indi-cation for evaluating the nutritional status and serumvitamin E concentrations. It may indicate poor com-pliance (as in cases 1 and 4), or malabsorption whichmay not be clinically manifest (case 3). In cases inwhich vitamin E deficiency is shown, it seems perverseto withhold a treatment, which, in suitable doses, isharmless2` and may prevent occasional serious com-plications.

It is not clear to what extent the effects of vitamin Edeficiency are reversible. Disappearance of ceroidafter vitamin E supplementation has only rarely beendescribed,22 and the time scale is not established. Itseems clear, however, that ceroidosis is not itself anadequate reflection of current vitamin E concen-trations, but indicates an extended episode ofdeficiency that requires full clinical evaluation.

We thank Dr DPR Muller, at the Institute of ChildHealth, University of London, for arranging vitaminE estimation and for his valuable advice, and MrsP Weller for excellent secretarial help.

Referemo

1 Fox B. Lipofuscinosis of the gastrointestinal tract in man. J ClinPathol 1967;20:806-13.

2 Foster CS. The brown bowel syndrome: a possible smooth musclemitochrondrial myopathy? Histopathol 1979;3:1-17.

3 Gallagher RL. Intestinal ceroid deposition-"Brown bowelsyndrome". Virchows Arch (Pathol Anat) 1980;389:143-51.

4 Saito K, Saburo M, Yokoyama T, Okiniwa M, Shigehiko K.Pathology of chronic vitamin E deficiency in fatal familialintrahepatic cholestasis (Byler disease). Virchows Arch (PatholAnal) 1982;396:319-30.

5 Rost FWD, Pearce AGE. Fluorescence microscopy. In: Histo-chemistry-theoretical and applied. 4th ed. Vol 1. Edinburgh:Churchill Livingstone, 1980:346-78.

6 MacMahon MT, Neale G. The absorption of a-tocopherol incontrol subjects and in patients with intestinal malabsorption.Clin Sci 1970;38:197-210.

7 Herzog DB, Logan R, Kooistra JB. The Noonan syndrome withintestinal lymphangiectasia. J Pediatr 1976;S8(2):270-2.

8 Muller DPR, Harries JT, Lloyd JK. The relative importance ofthe factors involved in the absorption of vitamin E in children.Gut 1974;15:966-71.

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Intern Med 1963;58 (5):872-7.10 Cordes DO, Mosher AH. Brown pigmentation (lipofuscinosis) of

canine intestinal muscularis. J Pathol Bacteriol 1966;92:197-206.

11 Mason KE, Telford IR. Some manifestations of vitamin Edeficiency in the monkey. Arch Pathol 1947;43:363-73.

12 Lambert JR, Luk SC, Pritzker KPH. Brown bowel syndrome inCrohn's disease. Arch Pathol Lab Med 1980;104:201-5.

13 Dougherty JJ, Hoekstra WG. Effects of vitamin E and seleniumon copper-induced lipid peroxidation in vivo and on acutecopper toxicity. Proc Soc Exp Biol Med 1982;169:201-8.

14 Herbert PN, Gotto AM, Fredrickson DS. Familial lipoproteindeficiency. In: Stanbury JB, Wyngaarden JB, Frederickson DS,eds. The metabolic basis of inherited diseases. 4th ed. NewYork: McGraw-Hill, 1978.

15 Muller DPR. Vitamin E-its role in neurological function. Post-grad Med J 1986;62:107-12.

16 Harding AE, Muller DPR, Thomas PK, Willison HJ. Spino-cerebellar degeneration secondary to chronic intestinal mal-absorption: a vitamin E deficiency syndrome. Ann Neurol1982;12:419-24.

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resection with vitamin E deficiency and progressive spino-cerebellar syndrome. Neurology 1984;34:1046-52.

18 Nelson JS, Fitch CD, Fischer VW, Brown GD, Chou AC.Progressive neuropathologic lesions in vitamin E deficientrhesus monkeys. J Neuropathol Exp Neurol 1981;40:166-86.

19 Neville HE, Ringel SP, Guggenheim MA, Wheling CA,Starcevich JM. Ultrastructural and histochemical abnormal-ities of skeletal muscle in patients with chronic vitamin Edeficiency. Neurology 1983;33:483-8.

20 Hosler JP, Kimmel KK, Moeller DD. The "brown bowel syn-drome": a case report. Am J Gastroenterol 1982;77(ii):854-5.

21 Roberts HJ. Perspective on vitamin E as therapy. JAMA1981;246:129-31.

22 Lee SP, Nicholson GI. Ceroid enteropathy and vitamin Edeficiency. NZ Med J 1976;83:318-20.

Requests for reprints to: Dr GWH Stamp, Department ofHistopathology, Royal Postgraduate Medical School,Hammersmith Hospital, Du Cane Road, London W12 OHS,England.

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