Amyloid fibril polymorphism in the heart and liver of an ATTR amyloidosis patient with polyneuropathy attributed to the ATTRv-V122Δ variant

ATTR amyloidosis is a phenotypically heterogeneous disease characterized by the pathological deposition of transthyretin in the form of amyloid fibrils into various organs. ATTR amyloidosis may result from mutations in variant (ATTRv) amyloidosis, or aging in wild-type (ATTRwt) amyloidosis. ATTRwt generally manifests as cardiomyopathy, whereas ATTRv may present as polyneuropathy, cardiomyopathy, or mixed, in combination with many other symptoms deriving from multisystem organ involvement. Over 220 different mutational variants of transthyretin have been identified, many of them being linked to specific disease symptoms. Yet, the role of these mutations in explaining differential disease manifestations remains unclear. Using cryo-electron microscopy, here we structurally characterized fibrils from the heart and the liver of an ATTRv patient carrying the V122Δ mutation, which is predominantly associated with polyneuropathy. Our results show that these fibrils are polymorphic, presenting as both single and double filaments. Our study alludes to a structural connection contributing to phenotypic variation in ATTR amyloidosis, as polymorphism in ATTR fibrils may manifest in patients with predominantly polyneuropathic phenotypes. Significance ATTR amyloidosis is a systemic, clinically diverse disease that results in organ failure due to the accumulation of transthyretin amyloid fibrils. ATTR patients present with varied symptoms, yet the root of this phenotypic heterogeneity remains unclear. Previous studies suggest an association between phenotype and fibril structure polymorphism. Here we describe the cryo-electron microscopy structure of variant transthyretin amyloid fibrils associated with a predominantly polyneuropathy phenotype. We have found polymorphism within these fibrils, a phenomenon we have thus far only observed in polyneuropathic associated transthyretin mutations. Our results signify an association between fibril structure and phenotype in ATTR amyloidosis.