Investigation of variant Creutzfeldt-Jakob disease and other human prion diseases with tonsil biopsy samples

Creutzfeldt-Jakob disease

It is valuable to summarize the milestone study of prion diseases done in Japan for review in the journal Neuropathology in 2000. Many studies done in Japan promote world prion research activity, and also influence further research projects in other groups abroad. In this review the author focuses on the transmission experiment, the discovery of abnormal prion protein localization in the synaptic structures or follicular dendritic cells, and the genetic analysis of prion protein gene for the establishment of familial prion diseases.

Follicular dendritic cells in TSE pathogenesis

The pathogenesis of transmissible spongiform encephalopathies (TSEs) often includes a replication phase in lymphoid tissues before infection spreads to the central nervous system. Recent studies show that the follicular dendritic cells of the germinal centres are critical for this replication. These cells are therefore potential targets for therapy or prophylaxis in natural TSEs, such as variant Creutzfeldt-Jakob disease.

Leucocyte depletion of blood components

Universal leucocyte depletion has been implemented in the UK and several other European countries as a precautionary measure against the potential risk of transmission of variant Creutzfeldt-Jakob disease by blood transfusion. Leucocyte depletion had previously only been recommended for a relatively small proportion of transfusion recipients based on clinical and experimental evidence showing clinical benefit. However there is now increasing evidence to support its value in preventing transfusion transmission of infectious agents and in reducing some of the adverse immunomodulatory effects of allogeneic transfusion. The financial costs of providing universal leucocyte depletion are substantial, but, if it transpires that leucocyte depletion has a beneficial effect in reducing, for example, postoperative infection rates, then the health economic gains in this patient group alone may largely or wholly offset these financial costs. The experience in the UK and other European countries in terms of these collateral clinical benefits will help other countries, where the risk of variant Creutzfeldt-Jakob disease may not be so great, to decide whether to similarly adopt universal leucocyte depletion.

Gene expression profiling: monitoring transcription and translation products using DNA microarrays and proteomics

Novel and powerful technologies such as DNA microarrays and proteomics have made possible the analysis of the expression levels of multiple genes simultaneously both in health and disease. In combination, these technologies promise to revolutionize biology, in particular in the area of molecular medicine as they are expected to reveal gene regulation events involved in disease progression as well as to pinpoint potential targets for drug discovery and diagnostics. Here, we review the current status of these technologies and highlight some studies in which they have been applied in concert to the analysis of biopsy specimens.

Prion diseases and the immune system

Transmissible spongiform encephalopathies are caused by unusual infectious agents that are purported to contain a single type of macromolecule, a modified host glycoprotein. The term prion has been applied to this group of agents. Surprisingly, the immune system appears to behave as a Trojan's horse rather than a protective fortification during prion infections. Because prions seem to be essentially composed of a protein, PrP(Sc), identical in sequence to a host encoded protein, PrP(C), the specific immune system displays a natural tolerance. However, lymphoid organs are strongly implicated in the preclinical stages of the disease. Certain immunodeficient animals are resistant to prions after peripheral inoculation. In normal subjects, cells of the immune system support the replication of prions and/or allow neuroinvasion. A better understanding of these aspects of prion diseases could lead to immunomanipulation strategies aimed at preventing the spread of infectious agents to the central nervous system.

Variant Creutzfeldt-Jakob disease: immunocytochemical studies and image analysis

Variant Creutzfeldt-Jakob disease (vCJD) is a recently identified human prion disease that appears to arise from exposure to the bovine spongiform encephalopathy agent. The clinical features and neuropathology of vCJD are distinctive, particularly the patterns of PrP(sc) accumulation in the brain. PrP immunocytochemistry has also demonstrated the accumulation of PrP(sc) in tissues outside the central nervous system, including sensory ganglia and lymphoid tissues. These observations have allowed the use of tonsillar biopsy as an investigation to aid the diagnosis of vCJD, since accumulation of PrP(sc) in lymphoid tissues does not occur in other forms of human prion disease. The patterns of PrP(sc) accumulation in vCJD can be studied by image analysis techniques, using both quantitative and qualitative approaches. Preliminary results of textural analysis are presented, which indicate that this approach can be used to discriminate and study the unique features of PrP(sc) accumulation in the brain in vCJD. This technique has major potential as a research tool in human prion diseases, particularly for the characterisation of disease phenotype in large series of cases.

Laboratory diagnosis of variant Creutzfeldt-Jakob disease

The neuropathological and biochemical features of 33 cases of variant Creutzfeldt-Jakob disease (vCJD) diagnosed up to the end of 1998 are analysed in relation to the 646 cases of suspected CJD referred to the CJD Surveillance Unit laboratory from 1990 to 1998. Morphological studies of the central nervous system, lymphoid tissues and other organs were accompanied by immunocytochemistry; Western blot analysis of PrPRES was performed on frozen brain tissue. The findings were analysed in relation to clinical and genetic data. The pathology of vCJD showed morphological and immunocytochemical characteristics distinct from other cases of CJD. PrP accumulation was widespread in lymphoid tissues in vCJD, but was not identified in other non-neural tissues. PrPRES accumulation in vCJD brain tissue showed a uniform glycotype pattern distinct from sporadic CJD. All analysed cases of vCJD were methionine homozygotes at codon 129 of the PrP gene. No evidence currently exists to suggest that cases of CJD diagnosed in individuals who are MV or VV at codon 129 of the PrP gene represent 'human bovine spongiform encaphalopathy (BSE)'. Continued surveillance is required to further investigate this possibility, with the need to investigate autopsy tissues from suspected cases by histological and biochemical techniques.

Detection of PrP in extraneural tissues

Transmissible spongiform encephalopathies (TSEs) or "prion diseases" are a group of unconventional fatal diseases. TSEs are characterised by the accumulation of a modified form of the normal host glycoprotein, PrP (PrP(c)). In the course of infection PrP(c) is converted to an abnormally protease resistant form, PrP(Sc). The exact nature of the infectious agent responsible for these diseases remains controversial. While there is compelling evidence that TSE agents contain an informational molecule, possibly a nucleic acid, some believe that the infectious agent or "prion" is solely composed of PrP(Sc). Nevertheless, PrP is required for TSE pathogenesis, as mice devoid of the PrP gene (PrP(-/-)) remain healthy when challenged with TSE isolates and are unable to replicate infectivity within the central nervous system (CNS) or in other tissues. In recent years immunocytochemistry has been used to pinpoint which cells are associated with abnormal accumulations of PrP, providing important information on the cellular targeting of TSE infection. In uninfected and scrapie-infected mice, PrP protein is found in the CNS and in extraneural tissues such as spleen and lymph nodes. In the peripheral lymphoid system, PrP is associated with follicular dendritic cells that are known to be important for replication of infectivity for at least one TSE strain. This review will focus on current methods for the immunocytochemical detection of PrP in murine extraneural tissues, mainly lymphoid tissues, and will discuss recent findings on the role of the peripheral lymphoid system in TSE pathogenesis.

Protease-resistant prion protein in brain and lymphoid organs of sheep within a naturally scrapie-infected flock

The hallmark of transmissible spongiform encephalopathies (TSE), such as scrapie in sheep, is the accumulation in tissues of an insoluble and protease resistant form (PrPres) of the cellular prion protein. In this study, we evaluated whether the diversity in both the clinical pattern and the PrP genotypes of scrapied sheep from the same flock was connected with different levels and/or glycoform patterns of the PrPres in the brain and lymphoid organs of the animals. Whereas the PrPres levels in spleen, lymph nodes and tonsils from sheep of different PrP genotypes and clinical status appeared comparable, they were highly variable in brain, particularly in the brain stem and the cerebellum. PrPres was only detected in sheep bearing at least one VRQ allele, including three asymptomatic sheep and the highest PrPres load was found in the cerebellum of VRQ/VRQ animals. All together, levels of PrPres in brain did not necessarily correlate with the severity of the clinical disease but might depend on the PrP genotype of the animals. Different brain regions from a given sheep displayed a similar glycopattern of PrPres, whereas the apparent molecular sizes of the unglycosylated and diglycosylated forms of the protein differed between brain and lymphoid tissues. We did not find any notifiable differences in the glycopattern of PrPres in brain from sheep of different PrP genotypes or different clinical status and this PrPres glycotype was also similar to that found in brain from four cattle BSE.

Creutzfeldt-Jakob disease and the eye. I. Background and patient management

This article attempts to summarise our current understanding of TSEs as they affect man. Specific aspects relevant to ophthalmological practice, in particular the management of patients in day-to-day clinical practice and with respect to corneal transplantation, have been discussed. In the companion article we discuss the specific ophthalmic and neuro-ophthalmic features of these diseases.

Retrospective study of prion-protein accumulation in tonsil and appendix tissues

To identify individuals who could be at high risk of developing vCJD, a sensitive immunohistochemical technique was used to detect prion protein in a retrospective series of over 3000 tonsil and appendix specimens. No positives were detected but further studies are required to help reduce uncertainties about possible future numbers of vCJD cases in the UK.

Recent advances in the pre-mortem diagnosis of Creutzfeldt-Jakob disease

Included in the spectrum of human transmissible spongiform encephalopathies are Creutzfeldt-Jakob disease (CJD) and the new variant form (vCJD), Gerstmann-Sträussler-Scheinker syndrome, fatal familial insomnia, kuru and various less distinct neuropsychiatric disorders. Progress in our understanding of this group of disorders continues at a prodigious rate, although important vexing practical issues persist. The definitive confirmation of symptomatic prion disease still requires pathological examination, most reliably performed post-mortem. However, paralleling the recent advances in the molecular biological understanding of normal prion protein (PrP(c)) function and the pathophysiology of prion diseases, there have been worthwhile developments in the pre-mortem diagnosis of CJD. Efforts to develop less invasive but very reliable ante-mortem diagnostic tests have received an additional impetus because of the potential epidemic of vCJD. Historically, the ancillary investigation of most merit has been the EEG, whereas the recent advances have encompassed a broader range of technologies, including both magnetic resonance and radioisotopic neuroimaging, and immunoassays for a range of non-specific marker proteins in both CSF, and less commonly, blood. However, given the recent refinement of sophisticated immunoassays, it is envisaged that the pathognomonic, protease-resistant, disease-associated isoforms of the prion protein (PrPres) may soon be directly detectable in the blood and tissues of patients manifesting or incubating a spongiform encephalopathy.

The human transmissible spongiform encephalopathies (TSEs): implications for dental practitioners

Transmissible spongiform encephalopathies (TSEs) are rare, fatal degenerative brain diseases which affect humans and certain animals, and are caused by inheritance or acquisition of prions (PrPs). Inherited TSEs include Fatal Familial Insomnia (FFI), Gerstmann-Straussler-Scheinker syndrome (GSS) and other less well clinically characterised disorders, while the human infective TSEs include sporadic, iatrogenic and variant Creutzfeldt-Jakob disease (vCJD). The causative prions are found especially in neural tissues and spinal fluid, and in the case of vCJD, in lymphoreticular tissue. Available epidemiological evidence suggests that normal social or routine clinical contact with affected patients does not present a risk to health care workers, relatives or the community. Isolation of patients is not considered necessary. Nevertheless as the prions are resistant to conventional chemical, irradiation and heat sterilisation methods, highly specific cross-infection control measures are required for the dental management of patients with, or at notable risk, of TSE. The present article reviews current knowledge of the clinical consequences of prion disease and provides information regarding necessary changes to the cross-infection routine when managing patients infected, or at risk of, prion disease.

Screening Congo Red and its analogues for their ability to prevent the formation of PrP-res in scrapie-infected cells

Transmissible spongiform encephalopathies (TSEs) are incurable, fatal diseases. The dye Congo Red (CR) can cure cells infected with agents of the sheep TSE, scrapie, but is not used as a therapeutic or prophylactic agent in vivo, as its effects are small, possibly due to low blood-brain barrier permeability, and complicated by its intrinsic carcinogenicity. In this paper, the development is described of a structure-activity profile for CR by testing a series of analogues of this dye for their ability to inhibit the formation of the protease-resistant prion protein, PrP-res, a molecular marker for the infectious agent, in the scrapie-infected, SMB cell line. It was found that the central benzidine unit in CR, which gives the molecule potential carcinogenicity, can be replaced by other, less toxic moieties and that the sulphonate groups on the core molecule can be replaced by carboxylic acids, which should improve the brain permeability of these compounds. However, detailed dose-response curves were generated for several derivatives and they revealed that, while some compounds showed inhibition of PrP-res accumulation at high concentrations, at low concentrations they actually stimulated levels of PrP-res above control values.

[Transfusion safety: emergent or hypothetical risks]

Three categories of emerging risks are studied: 1) A new variant of Creutzfeld-Jakob disease, different from its sporadic form; limited to the British isles (48 of 51 cases), it affects younger patients, and has a higher duration with a predominance of psychiatric symptoms. Environmental risk factors include a previous stay in the British isles and oral transmission via contaminated food. No link has been made evident between blood component (BC) transfusion and occurrence of the disease. A potential risk exists if its agent is found in blood and peripheral lymphoid tissues and if buffy coat from infected animals has been inoculated intracerebrally. Since 1993, prevention measures have been taken: exclusion of donors with a potential risk as well as transfused donors, systematic leukocyte reduction and implementation of disease surveillance. Excluding donors after a several month-stay in the British Isles is being discussed. 2) Novel hepatitis viruses. Hepatitis G virus (HGV) has been detected in 2-4% of blood donors. Ten percent of patients with chronic non-A-E hepatitis are HGV RNA positive. The incidence of HGV infection is higher than expected from PCR studies. HGV has a high prevalence in the world. Novel DNA non-enveloped virus (TTV) has a normal distribution. Its prevalence varies from 2 to 80%, depending on the country. Although it has not been shown to be aggressive for the liver, prolonged follow-up is required. 3) Human herpes virus 8 (HHV8) is associated with Kaposi's sarcoma in 80% of cases. Its prevalence (0-20%) varies depending on the country. Kaposi's sarcoma has never been reported after BC transfusion. PCR-based viral DNA searches have yielded negative results in 19 poly-transfused subjects. Continuous monitoring is required for recipients at risk (e.g., immunosuppressed). In response to a possible health risk, emerging risks govern the "Precaution Principle", so difficult to implement.

Variant Creutzfeldt-Jakob disease: an update

There cannot have been many medical publications this decade that have had an impact to equal that of the paper by Robert Will and colleagues on a ‘new variant’ of Creutzfeldt–Jakob disease (CJD), published in the Lancet in April 1996 (Will et al, 1996). This did not simply affect the scientific community, but also farming, economics, politics and diplomacy.

Mammalian prion proteins

The past two years have seen the extension of our knowledge on the cellular prion protein structure with new NMR data on both the hamster and human proteins. In addition, the folding dynamics of two cellular prion proteins have been elucidated. There are now several examples of recombinant prion proteins that are able to adopt different conformations in solution and recent work on the molecular basis of prion strains has done much to consolidate the protein-only hypothesis. Important advances in relating disease to structure have also been made through the identification of the minimal prion protein fragment that is capable of conferring susceptibility to and propagation of the scrapie agent.

Assessment of the prevalence of vCJD through testing tonsils and appendices for abnormal prion protein

The objective of this study was to determine the age group or groups which will provide the most information on the potential size of the vCJD epidemic in Great Britain via the sampling of tonsil and appendix material to detect the presence of abnormal prion protein (PrP(Sc)). A subsidiary aim was to determine the degree to which such an anonymous age-stratified testing programme will reduce current uncertainties in the size of the epidemic in future years. A cohort- and time-stratified model was used to generate epidemic scenarios consistent with the observed vCJD case incidence. These scenarios, together with data on the age distribution of tonsillectomies and appendectomies, were used to evaluate the optimal age group and calendar time for undertaking testing and to calculate the range of epidemic sizes consistent with different outcomes. The analyses suggested that the optimal five-year age group to test is 25-29 years, although a random sample of appendix tissue from all age groups is nearly as informative. A random sample of tonsil tissue from all age groups is less informative, but the information content is improved if sampling is restricted to tissues removed from those over ten years of age. Based on the assumption that the test is able to detect infection in the last 75% of the incubation period, zero detected infections in an initial random sample of 1000 tissues would suggest that the epidemic will be less than 870,000 cases. If infections are detected, then the model prediction suggests that both relatively small epidemics (800+ cases if one is detected or 8300+ if two are detected) and larger epidemics (21,000+ cases if three or more are detected) are possible. It was concluded that testing will be most informative if undertaken using appendix tissues or tonsil tissues removed from those over ten years of age. Large epidemics can only be excluded if a small number of infections are detected and the test is able to detect infection early in the incubation period.

Distribution of cell-associated prion protein in normal adult blood determined by flow cytometry

Leucocyte subpopulations from normally healthy individuals were identified by recognized combinations of fluorochrome-conjugated antibodies to CD markers and stained by different monoclonal antibodies (MAb) to normal cellular prion protein (PrPC), including the 3F4 MAb. Cell preparations were examined by three-colour flow cytometry. All mononuclear leucocyte subpopulations and platelets expressed PrPC, but polymorphonuclear leucocytes and red blood cells expressed little or no PrPC. The amounts of PrPC expressed by the different cells were calculated by comparison to bead standards. Mononuclear leucocytes expressed 3000-4000 molecules of antibody-reactive PrPC per cell. Resting platelets expressed around 1400 molecules of PrPC per cell, whereas activated platelets expressed around 4800 molecules of PrPC per cell. Extrapolation of these values to the amounts of the various cells in whole blood showed that platelet PrPC accounted for at least 96% of cell-expressed PrPC in blood. The PrPC on mononuclear cells and platelets was sensitive to enzymatic treatment of cells by proteinase k and phosphatidylinositol-specific phospholipase C. Certain anti-PrPC MAbs which showed equivalent intensity of staining to MAb 3F4 on fresh cells showed relative reductions of staining compared to MAb 3F4 on stored cells, indicating possible structural alterations of PrPC under these conditions.

Prions and the ENT surgeon

Recent developments in our understanding of prion diseases have raised concerns for the public health. There is now compelling evidence that the transmissible agent for variant Creutzfeldt-Jakob disease (vCJD) in affected individuals is accumulated in lymphoreticular tissues such as the appendix and tonsils. This agent demonstrates a remarkable resistance to standard methods of sterilisation used in hospital sterile services departments. The possible implications this has on the safety of surgical instruments in ENT and other surgical practice is discussed. This review also outlines the history of our understanding of prion diseases and describes the development of a diagnostic test for vCJD in the living patient by pharyngeal tonsil biopsy.

Isoform pattern of 14-3-3 proteins in the cerebrospinal fluid of patients with Creutzfeldt-Jakob disease

Two-dimensional polyacrylamide gel electrophoresis of CSF has been used in the diagnosis of Creutzfeldt-Jakob disease (CJD). One of the two diagnostic protein spots was identified as isoform(s) of the 14-3-3 family of abundant brain proteins. This has led to the development of one-dimensional 14-3-3 sodium dodecyl sulfate polyacrylamide gel electrophoresis immunoblot, which is currently used to support the diagnosis of CJD. In the present study employing western blot analysis, we have identified the panel of 14-3-3 isoforms that appear in the CSF of 10 patients with CJD compared with 10 patients with other dementias. The results clearly show that the 14-3-3 isoforms beta, gamma, epsilon, and eta are present in the CSF of patients with CJD and can be used to differentiate other dementias. 14-3-3eta also gave a baseline signal in all patients with other dementias, including six patients with Alzheimer's disease. The presence of 14-3-3eta in the CSF of a patient with herpes simplex encephalitis was particularly noteworthy. This study has determined that isoform-specific 14-3-3 antibodies against beta, gamma, and epsilon should be considered for the neurochemical differentiation of CJD from other neurodegenerative diseases.

Transmission of the 263K scrapie strain by the dental route

Apart from a few cases of iatrogenic and familial human transmissible spongiform encephalopathies (TSEs) or prion diseases, the cause of Creutzfeldt-Jakob disease (CJD) remains unknown. In this paper we investigated the possibility that dental procedures may represent a potential route of infection. This was assessed by using the experimental model of scrapie in hamster. In the first part of this study we found that after intraperitoneal inoculation, oral tissues commonly involved in dental procedures (gingival and pulp tissues) bore a substantial level of infectivity. We also found high scrapie infectivity in the trigeminal ganglia, suggesting that the scrapie agent had reached the oral tissues through the sensitive terminal endings of the trigeminal nerves. In the second part of the study we inoculated a group of hamsters in the tooth pulp and showed that all of them developed scrapie disease. In these animals, we detected both infectivity and the pathological prion protein (PrPsc) in the trigeminal ganglion homolateral to the site of injection but not in the controlateral one. This finding suggests that the scrapie agent, and likely other TSE agents as well, spreads from the buccal tissues to the central nervous system through trigeminal nerves. Although these findings may not apply to humans affected by TSEs, they do raise concerns about the possible risk of transmitting these disorders through dental procedures. Particular consideration should be taken in regard to new variant CJD patients because they may harbour more infectivity in peripheral tissues than sporadic CJD patients.

Scrapie replication in lymphoid tissues depends on prion protein-expressing follicular dendritic cells

The immune system is central in the pathogenesis of scrapie and other transmissible spongiform encephalopathies (TSEs) or 'prion' diseases. After infecting by peripheral (intraperitoneal or oral) routes, most TSE agents replicate in spleen and lymph nodes before neuroinvasion. Characterization of the cells supporting replication in these tissues is essential to understanding early pathogenesis and may indicate potential targets for therapy, for example, in 'new variant' Creutzfeldt-Jakob disease. The host 'prion' protein (PrP) is required for TSE agent replication and accumulates in modified forms in infected tissues. Abnormal PrP is detected readily on follicular dendritic cells (FDCs) in lymphoid tissues of patients with 'new variant' Creutzfeldt-Jakob disease, sheep with natural scrapie and mice experimentally infected with scrapie. The normal protein is present on FDCs in uninfected mice and, at lower levels, on lymphocytes. Studies using severe combined immunodeficiency (SCID) mice, with and without bone marrow (BM) grafts, have indicated involvement of FDCs and/or lymphocytes in scrapie pathogenesis. To clarify the separate roles of FDCs and lymphocytes, we produced chimeric mice with a mismatch in PrP status between FDCs and other cells of the immune system, by grafting bone marrow from PrP-deficient knockout mice into PrP-expressing mice and vice versa. Using these chimeric models, we obtained strong evidence that FDCs themselves produce PrP and that replication of a mouse-passaged scrapie strain in spleen depends on PrP-expressing FDCs rather than on lymphocytes or other bone marrow-derived cells.

Pathogenesis of the oral route of infection of mice with scrapie and bovine spongiform encephalopathy agents

Transmissible spongiform encephalopathies can be transmitted via the oral route. The understanding of this mode of contamination has become a major issue since it is responsible for the appearance of bovine spongiform encephalopathy (BSE) and is probably implicated in new variant Creutzfeldt-Jakob disease. In this study, we addressed the questions of the propagation pathway and the strain specificity of the pathogenesis of oral contamination of mice with the C506M3 scrapie strain and the 6PB1 BSE strain. PrPres was used as a marker of infectivity and was searched for sequentially in 22 organs during the whole incubation period and clinical stage. PrPres was first detectable in the Peyer's patches and mesenteric lymph nodes at 45 days post-inoculation. It became detectable 1 to 3 months later in the other tissues of the lymphoreticular system (LRS) such as the spleen and the lymph nodes not related to the digestive tract. These data indicate that after an oral route of entry, the infectious agent is propagated from the Peyer's patches to the mesenteric lymph nodes by the lymphatic route, then enters the bloodstream and is distributed to the secondary replication site, the LRS. The major difference between the two agents is that PrPres could be detected in the digestive tract (from the stomach to the colon) with the scrapie agent only. This observation may have implications for the horizontal transmission of scrapie in endemically affected sheep flocks.

Inherited prion disease with an alanine to valine mutation at codon 117 in the prion protein gene

A large English family with autosomal dominant segregation of presenile dementia, ataxia and other neuropsychiatric features is described. Diagnoses of demyelinating disease, Alzheimer's disease, Creutzfeldt-Jakob disease (CJD) and Gerstmann-Sträussler-Scheinker syndrome have been attributed to particular individuals at different times. An Irish family, likely to be part of the same kindred, is also described, in which diagnoses of multiple sclerosis, dementia, corticobasal degeneration and new variant CJD have been considered in affected individuals. Molecular genetic studies have enabled the classification of this disease at the molecular level as one of the group of inherited prion diseases, with the substitution of valine for alanine at codon 117 of the prion protein gene (PRNP). Only three other kindreds have been described world-wide with this mutation and only limited phenotypic information has been reported. Here we describe the phenotypic spectrum of inherited prion disease (PrPA117V). The diversity of phenotypic expression seen in this kindred emphasizes the logic of molecular classification of the inherited prion diseases rather than classification by specific clinicopathological syndrome. Indeed, inherited prion disease should be excluded by PRNP analysis in any individual presenting with atypical presenile dementia or neuropsychiatric features and ataxia, including suspected cases of new variant CJD.

Variant Creutzfeldt-Jakob disease

It is clear that the prion strain causing bovine spongiform encephalopathy (BSE) in cattle has infected human beings, manifesting itself as a novel human prion disease, variant Creutzfeldt-Jakob disease (CjD). Studies of the incubation periods seen in previous epidemics of human prion disease and of the effect of transmission barriers limiting spread of these diseases between species, suggest that the early variant CJD cases may have been exposed during the preclinical phase of the BSE epidemic. It must therefore be considered that many cases may follow from later exposure in an epidemic that would be expected to evolve over decades. Since the number of people currently incubating this disease is unknown, there are concerns that prions might be transmitted iatrogenically via blood transfusion, tissue donation, and, since prions resist routine sterilisation, contamination of surgical instruments. Such risks remain unquantified. Although variant CJD can be diagnosed during life by tonsil biopsy, a prion-specific blood test is needed to assess and manage this potential threat to public health. The theoretical possibility that BSE prions might have transferred to other species and continue to present a risk to human health cannot be excluded at present.

Preliminary assessment of whole-blood, red-cell and platelet- leucodepleting filters for possible induction of prion release by leucocyte fragmentation during room temperature processing

Universal leucodepletion is being introduced in the U.K. to reduce a theoretical risk of Creutzfeldt-Jakob disease (CJD) transmission. If CJD infectivity is associated with leucocytes, any cell fragmentation associated with filtration could reduce the potential benefit. Four types each of whole blood, red cell and platelet leucodepletion filters were assessed after holding of blood units for at least 4 h at 22 degrees C. In all cases the mean residual leucocyte content was <1 000 000 per unit, with only two individual filtered whole blood units having a leucocyte content exceeding this. Evidence of leucocyte fragmentation during filtration was sought but not found by assay of soluble elastase, beta-thromboglobulin and normal prion protein, as well as by isotopic labelling of leucocyte external membrane. These preliminary studies indicate that it was possible to prepare leucodepleted blood components by filtration at room temperature, and that this appeared not to be associated with overt cell fragmentation. Definitive demonstration that fragmentation does not occur requires the development of improved general (non-specific) assays for cell membrane fragments.

Molecular biology of prion propagation

The occurrence of new variant Creutzfeldt-Jakob disease and the experimental confirmation that it is caused by the same prion strain as BSE has dramatically highlighted the need for a precise understanding of the molecular basis of prion propagation. The molecular basis of prion-strain diversity, previously a major challenge to the protein-only model, is now becoming clearer. The conformational change thought to be central to prion propagation, from a predominantly alpha-helical fold to one predominantly comprising beta-structure, can now be reproduced in vitro, and the ability of beta-PrP to form fibrillar aggregates provides a plausible molecular mechanism for prion propagation. These and other advances in the fundamental biology of prion propagation are leading to prion diseases becoming arguably the best understood of the neurodegenerative conditions and strategies for the development of rational therapeutics are becoming clearer.

Strain-specific prion-protein conformation determined by metal ions

In animals infected with a transmissible spongiform encephalopathy, or prion disease, conformational isomers (known as PrPSc proteins) of the wild-type, host-encoded cellular prion protein (PrPc) accumulate. The infectious agents, prions, are composed mainly of these conformational isomers, with distinct prion isolates or strains being associated with different PrPSc conformations and patterns of glycosylation. Here we show that two different human PrPSc types, seen in clinically distinct subtypes of classical Creutzfeldt-Jakob disease, can be interconverted in vitro by altering their metal-ion occupancy. The dependence of PrPSc conformation on the binding of copper and zinc represents a new mechanism for post-translational modification of PrP and for the generation of multiple prion strains, with widespread implications for both the molecular classification and the pathogenesis of prion diseases in humans and animals.

Agents that cause transmissible subacute spongiform encephalopathies

Transmissible spongiform encephalopathies (TSE) are characterised by a long incubation period which precedes clinical symptoms related to the degeneration of the central nervous system (CNS). The nature of their etiologic agents (TSA/prions) remains unknown, although there exists strong experimental data supporting the prion hypothesis. This hypothesis suggests a key role for the host derived protein (the prion protein, PrP) as the transmissible agent. In infected individuals, PrP accumulates proportionally to infectivity titre and resists proteinase K treatment (PrP-res). Iatrogenic Creutzfeldt-Jakob disease (CJD) cases have been described in humans after neurosurgery, treatment with pituitary derived hormones, and cornea and dura mater grafting. TSA-associated infectivity is dependent upon the nature of the organ in a given infected individual, though the CNS has the highest infectivity rate. In vitro, TSA/prions do not replicate easily: only cells of neuronal origin are susceptible, and the replication rate is very low. TSA/prions have unconventional properties; in particular, they resist to almost all the chemical and physical processes which inactivate conventional viruses. Only autoclaving at 134/136 degrees C for 1 h or treatment with either 1N NaOH or sodium hypochlorite (2% Cl) during 1 h at room temperature are considered to give inactivation that is compatible with public health criteria. In vivo, the distribution of infectivity is dependent upon strain and host, for a given inoculum injected by a given route. Although supported by numerous experimental data, the prion only hypothesis has not yet been convincingly demonstrated.