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Nan H, Liu L, Chen Z, Chu M, Li J, Jing D, Wang Y, Wu L. Octapeptide repeat alteration mutations of the prion protein gene in clinically diagnosed Alzheimer's disease and frontotemporal dementia. Clin Genet 2023. [PMID: 37148197 DOI: 10.1111/cge.14354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
Studies focusing on octapeptide repeat alteration mutations in PRNP in Alzheimer's disease (AD) and frontotemporal dementia (FTD) cohorts have been rare. We aim to screen sporadic AD and FTD patients with unknown etiology for the octapeptide repeat insertions and deletions in PRNP. Two hundred and six individuals were screened for alterations to the repeat region in the PRNP gene, including 146 sporadic AD and 60 sporadic FTD patients. Our study showed a 1.5% (3/206) occurrence of the octapeptide repeat alteration mutations in PRNP in a Chinese cohort of sporadic dementia. One late-onset FTD patient and one early-onset AD patient each had a two-octapeptide repeat deletion in PRNP, while one early-onset AD patient had a five-octapeptide repeat insertion mutation. PRNP octapeptide repeat alteration mutations are present in sporadic AD and FTD patients. The genetic investigation for PRNP octapeptide repeat alteration mutations in sporadic dementia patients should be carried out in future clinical studies.
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Affiliation(s)
- Haitian Nan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhongyun Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Chu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jieying Li
- Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, Chengdu, China
| | - Donglai Jing
- Department of Neurology, Rongcheng People's Hospital, Hebei, China
| | - Yihao Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liyong Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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2
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Stephen CD, Schaefer PW, Appleby BS, Oakley DH. Case 5-2022: A 65-Year-Old Woman with Rapidly Progressive Weakness in the Right Arm and Recurrent Falls. N Engl J Med 2022; 386:674-687. [PMID: 35172059 DOI: 10.1056/nejmcpc2115852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Christopher D Stephen
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Pamela W Schaefer
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Brian S Appleby
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Derek H Oakley
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
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3
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Brennecke N, Cali I, Mok TH, Speedy H, Hosszu LLP, Stehmann C, Cracco L, Puoti G, Prior TW, Cohen ML, Collins SJ, Mead S, Appleby BS. Characterization of Prion Disease Associated with a Two-Octapeptide Repeat Insertion. Viruses 2021; 13:1794. [PMID: 34578375 PMCID: PMC8473248 DOI: 10.3390/v13091794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/31/2021] [Accepted: 09/04/2021] [Indexed: 12/03/2022] Open
Abstract
Genetic prion disease accounts for 10-15% of prion disease. While insertion of four or more octapeptide repeats are clearly pathogenic, smaller repeat insertions have an unclear pathogenicity. The goal of this case series was to provide an insight into the characteristics of the 2-octapeptide repeat genetic variant and to provide insight into the risk for Creutzfeldt-Jakob disease in asymptomatic carriers. 2-octapeptide repeat insertion prion disease cases were collected from the National Prion Disease Pathology Surveillance Center (US), the National Prion Clinic (UK), and the National Creutzfeldt-Jakob Disease Registry (Australia). Three largescale population genetic databases were queried for the 2-octapeptide repeat insertion allele. Eight cases of 2-octapeptide repeat insertion were identified. The cases were indistinguishable from the sporadic Creutzfeldt-Jakob cases of the same molecular subtype. Western blot characterization of the prion protein in the absence of enzymatic digestion with proteinase K revealed that 2-octapeptide repeat insertion and sporadic Creutzfeldt-Jakob disease have distinct prion protein profiles. Interrogation of large-scale population datasets suggested the variant is of very low penetrance. The 2-octapeptide repeat insertion is at most a low-risk genetic variant. Predictive genetic testing for asymptomatic blood relatives is not likely to be justified given the low risk.
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Affiliation(s)
- Nicholas Brennecke
- Department of Neurology, Case Western Reserve University & University Hospitals Cleveland Medical, Cleveland, OH 44106, USA; (N.B.); (M.L.C.)
| | - Ignazio Cali
- Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA;
- National Prion Disease Pathology Surveillance Center (NPDPSC), Cleveland, OH 44106, USA
| | - Tze How Mok
- MRC Prion Unit at University College London, Institute of Prion Diseases, London W1W 7FF, UK; (T.H.M.); (H.S.); (L.L.P.H.); (S.M.)
| | - Helen Speedy
- MRC Prion Unit at University College London, Institute of Prion Diseases, London W1W 7FF, UK; (T.H.M.); (H.S.); (L.L.P.H.); (S.M.)
| | | | - Laszlo L. P. Hosszu
- MRC Prion Unit at University College London, Institute of Prion Diseases, London W1W 7FF, UK; (T.H.M.); (H.S.); (L.L.P.H.); (S.M.)
| | - Christiane Stehmann
- Australian National Creutzfeldt-Jakob Disease Registry, The Florey Institute, The University of Melbourne, Melbourne, VIC 3010, Australia; (C.S.); (S.J.C.)
| | - Laura Cracco
- Department of Pathology and Laboratory Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, USA;
| | - Gianfranco Puoti
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy;
- Prion Disease Diagnosis and Surveillance Center (PDDSC), University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy
| | - Thomas W. Prior
- Center for Human Genetics Laboratory, Case Western Reserve University & University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA;
| | - Mark L. Cohen
- Department of Neurology, Case Western Reserve University & University Hospitals Cleveland Medical, Cleveland, OH 44106, USA; (N.B.); (M.L.C.)
- Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA;
- National Prion Disease Pathology Surveillance Center (NPDPSC), Cleveland, OH 44106, USA
| | - Steven J. Collins
- Australian National Creutzfeldt-Jakob Disease Registry, The Florey Institute, The University of Melbourne, Melbourne, VIC 3010, Australia; (C.S.); (S.J.C.)
| | - Simon Mead
- MRC Prion Unit at University College London, Institute of Prion Diseases, London W1W 7FF, UK; (T.H.M.); (H.S.); (L.L.P.H.); (S.M.)
| | - Brian S. Appleby
- Department of Neurology, Case Western Reserve University & University Hospitals Cleveland Medical, Cleveland, OH 44106, USA; (N.B.); (M.L.C.)
- Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA;
- National Prion Disease Pathology Surveillance Center (NPDPSC), Cleveland, OH 44106, USA
- Department of Psychiatry, Case Western Reserve University & University Hospitals, Cleveland, OH 44106, USA
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Douzono M, Nobuhara Y, Maruta K, Okamoto Y, Sonoda Y, Takashima H. [Inherited Creutzfeldt-Jakob disease with four-octapeptide repeat insertional mutation in the prion gene]. Rinsho Shinkeigaku 2021; 61:314-318. [PMID: 33867415 DOI: 10.5692/clinicalneurol.cn-001558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of a 60-year-old man who presented with symptoms of memory loss, gait disorder, and sluggish movement. We considered both Parkinson's disease and multiple system atrophy as possible diagnoses and consequently hospitalized the patient owing to the worsening symptoms and the development of consciousness disorder. During the course of the disease, dementia, loss of consciousness, and movement disorders worsened rapidly within one year after admission, and the patient eventually developed mutism. The significant clinical characteristics of our case included no myoclonus and involuntary tremors in the extremities. There was no periodic synchronous discharge on electro-encephalography and cranial MRI with diffusion-weighted images showed no high-intensity findings in cortex. Prion protein genetic analysis identified four repeated insertional mutations in the octapeptide repeat (OPR) region, and the patient was diagnosed with inherited Creutzfeldt-Jakob disease. Cases of OPR insertional mutations are a few in Japan and occur in about 10% of population in Europe. Creutzfeldt-Jakob disease with OPR insertional mutation shows various clinical manifestations and atypical findings on electroencephalography and cranial MRI. Diagnosing for Creutzfeldt-Jakob disease with OPR insertional mutation is important in Prion protein genetic analysis.
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Affiliation(s)
- Mika Douzono
- Department of Neurology, National Hospital Organization Minamikyushu Hospital
| | - Yasuyuki Nobuhara
- Department of Neurology, National Hospital Organization Minamikyushu Hospital
| | - Kyouko Maruta
- Department of Neurology, National Hospital Organization Minamikyushu Hospital
| | - Yuji Okamoto
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences.,Department of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University
| | - Yoshito Sonoda
- Department of Neurology, National Hospital Organization Minamikyushu Hospital
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences
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Soluble dimeric prion protein ligand activates Adgrg6 receptor but does not rescue early signs of demyelination in PrP-deficient mice. PLoS One 2020; 15:e0242137. [PMID: 33180885 PMCID: PMC7660510 DOI: 10.1371/journal.pone.0242137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/28/2020] [Indexed: 02/07/2023] Open
Abstract
The adhesion G-protein coupled receptor Adgrg6 (formerly Gpr126) is instrumental in the development, maintenance and repair of peripheral nervous system myelin. The prion protein (PrP) is a potent activator of Adgrg6 and could be used as a potential therapeutic agent in treating peripheral demyelinating and dysmyelinating diseases. We designed a dimeric Fc-fusion protein comprising the myelinotrophic domain of PrP (FT2Fc), which activated Adgrg6 in vitro and exhibited favorable pharmacokinetic properties for in vivo treatment of peripheral neuropathies. While chronic FT2Fc treatment elicited specific transcriptomic changes in the sciatic nerves of PrP knockout mice, no amelioration of the early molecular signs demyelination was detected. Instead, RNA sequencing of sciatic nerves revealed downregulation of cytoskeletal and sarcomere genes, akin to the gene expression changes seen in myopathic skeletal muscle of PrP overexpressing mice. These results call for caution when devising myelinotrophic therapies based on PrP-derived Adgrg6 ligands. While our treatment approach was not successful, Adgrg6 remains an attractive therapeutic target to be addressed in other disease models or by using different biologically active Adgrg6 ligands.
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Schilling KM, Tao L, Wu B, Kiblen JTM, Ubilla-Rodriguez NC, Pushie MJ, Britt RD, Roseman GP, Harris DA, Millhauser GL. Both N-Terminal and C-Terminal Histidine Residues of the Prion Protein Are Essential for Copper Coordination and Neuroprotective Self-Regulation. J Mol Biol 2020; 432:4408-4425. [PMID: 32473880 PMCID: PMC7387163 DOI: 10.1016/j.jmb.2020.05.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 01/19/2023]
Abstract
The cellular prion protein (PrPC) comprises two domains: a globular C-terminal domain and an unstructured N-terminal domain. Recently, copper has been observed to drive tertiary contact in PrPC, inducing a neuroprotective cis interaction that structurally links the protein's two domains. The location of this interaction on the C terminus overlaps with the sites of human pathogenic mutations and toxic antibody docking. Combined with recent evidence that the N terminus is a toxic effector regulated by the C terminus, there is an emerging consensus that this cis interaction serves a protective role, and that the disruption of this interaction by misfolded PrP oligomers may be a cause of toxicity in prion disease. We demonstrate here that two highly conserved histidines in the C-terminal domain of PrPC are essential for the protein's cis interaction, which helps to protect against neurotoxicity carried out by its N terminus. We show that simultaneous mutation of these histidines drastically weakens the cis interaction and enhances spontaneous cationic currents in cultured cells, the first C-terminal mutant to do so. Whereas previous studies suggested that Cu2+ coordination was localized solely to the protein's N-terminal domain, we find that both domains contribute equatorially coordinated histidine residue side-chains, resulting in a novel bridging interaction. We also find that extra N-terminal histidines in pathological familial mutations involving octarepeat expansions inhibit this interaction by sequestering copper from the C terminus. Our findings further establish a structural basis for PrPC's C-terminal regulation of its otherwise toxic N terminus.
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Affiliation(s)
- Kevin M Schilling
- Department of Chemistry and Biochemistry, University of California, 1156 High Street, Santa Cruz, CA 95064, USA
| | - Lizhi Tao
- Department of Chemistry, University of California, 1 Shields Ave., Davis, CA 95616, USA
| | - Bei Wu
- Department of Biochemistry, Boston University School of Medicine, 72 E. Concord St Silvio Conte., Boston, MA 02118, USA
| | - Joseph T M Kiblen
- Department of Chemistry and Biochemistry, University of California, 1156 High Street, Santa Cruz, CA 95064, USA
| | - Natalia C Ubilla-Rodriguez
- Department of Chemistry and Biochemistry, University of California, 1156 High Street, Santa Cruz, CA 95064, USA
| | - M Jake Pushie
- Department of Surgery, College of Medicine, University of Saskatchewan, 107 Wiggins Rd B419, Saskatoon, SK S7N 5E5, Canada
| | - R David Britt
- Department of Chemistry, University of California, 1 Shields Ave., Davis, CA 95616, USA
| | - Graham P Roseman
- Department of Chemistry and Biochemistry, University of California, 1156 High Street, Santa Cruz, CA 95064, USA
| | - David A Harris
- Department of Biochemistry, Boston University School of Medicine, 72 E. Concord St Silvio Conte., Boston, MA 02118, USA.
| | - Glenn L Millhauser
- Department of Chemistry and Biochemistry, University of California, 1156 High Street, Santa Cruz, CA 95064, USA.
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Cali I, Cracco L, Saracino D, Occhipinti R, Coppola C, Appleby BS, Puoti G. Case Report: Histopathology and Prion Protein Molecular Properties in Inherited Prion Disease With a De Novo Seven-Octapeptide Repeat Insertion. Front Cell Neurosci 2020; 14:150. [PMID: 32733203 PMCID: PMC7362343 DOI: 10.3389/fncel.2020.00150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/05/2020] [Indexed: 12/27/2022] Open
Abstract
The insertion of additional 168 base pair containing seven octapeptide repeats in the prion protein (PrP) gene region spanning residues 51–91 is associated with inherited prion disease. In 2008, we reported the clinical features of a novel de novo seven-octapeptide repeat insertion (7-OPRI) mutation coupled with codon 129 methionine (M) homozygosity in the PrP gene of a 19-year-old man presenting with psychosis and atypical dementia, and 16-year survival. Here, we describe the histopathological and PrP molecular properties in the autopsied brain of this patient. Histopathological examination revealed widespread brain atrophy, focal spongiform degeneration (SD), cortical PrP plaques, and elongated PrP formations in the cerebellum. Overall, these histopathological features resemble those described in a Belgian pedigree with 7-OPRI mutation except for the presence of PrP plaques in our case, which are morphologically different from the multicore plaques described in some OPRI mutations and in Gerstmann–Sträussler–Scheinker (GSS) syndrome. The comparative characterization of the detergent-soluble and detergent-insoluble PrP in our patient and in sporadic Creutzfeldt–Jakob disease (CJD) revealed distinct molecular signatures. Proteinase K digestion of the pathogenic, disease-associated PrP (PrPD) revealed PrPD type 1 in the cerebral cortex and mixed PrPD types 1 and 2 in the cerebellum. Altogether, the present study outlines the importance of assessing the phenotypical and PrP biochemical properties of these rare conditions, thereby widening the spectrum of the phenotypic heterogeneity of the 7-OPRI insertion mutations. Further studies are needed to determine whether distinct conformers of PrPD are associated with two major clinico-histopathological phenotypes in prion disease with 7-OPRI.
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Affiliation(s)
- Ignazio Cali
- Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, OH, United States.,National Prion Disease Pathology Surveillance Center (NPDPSC), School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Laura Cracco
- Department of Pathology and Laboratory Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Dario Saracino
- Division of Neurology, University of Campania "Luigi Vanvitelli", Caserta, Italy.,Prion Disease Diagnosis and Surveillance Center (PDDSC), University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Rossana Occhipinti
- Department of Physiology and Biophysics, School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Cinzia Coppola
- Division of Neurology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Brian Stephen Appleby
- Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, OH, United States.,National Prion Disease Pathology Surveillance Center (NPDPSC), School of Medicine, Case Western Reserve University, Cleveland, OH, United States.,Department of Neurology, School of Medicine, Case Western Reserve University, Cleveland, OH, United States.,Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Gianfranco Puoti
- Division of Neurology, University of Campania "Luigi Vanvitelli", Caserta, Italy.,Prion Disease Diagnosis and Surveillance Center (PDDSC), University of Campania "Luigi Vanvitelli", Caserta, Italy
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Piazza M, Prior TW, Khalsa PS, Appleby B. A case report of genetic prion disease with two different PRNP variants. Mol Genet Genomic Med 2020; 8:e1134. [PMID: 31953922 PMCID: PMC7057106 DOI: 10.1002/mgg3.1134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/08/2019] [Accepted: 01/06/2020] [Indexed: 12/22/2022] Open
Abstract
Background Prion diseases are a group of lethal neurodegenerative conditions that occur when the normal, cellular form of the prion protein (PrPC) is converted into an abnormal, scrapie, form of the protein (PrPSc). Disease may be caused by genetic, infectious, or sporadic etiologies. The genetic form of prion disease comprises~10%–15% of all cases. Prion disease is typically inherited in an autosomal dominant manner. The low incidence of disease makes it highly unlikely that a patient would have two different pathogenic variants. However, we recently identified a case in which the patient did have two pathogenic PRNP variants and presented with an atypical phenotype. Methods The patient was evaluated at the Washington Hospital Healthcare System in Fremont, CA. The clinical information for this case report was obtained retrospectively. Variants in the PRNP were identified by polymerase chain reaction (PCR) amplification of exon two of the gene followed by bi‐directional sequence analysis. To determine the phase of the identified variants, a restriction enzyme digestion was utilized, followed by sequence analysis of the products. Cerebral spinal fluid (CSF) was analyzed for surrogate markers of prion disease, 14–3–3 and Tau proteins. CSF real‐time quaking‐induced conversion (RT‐QuIC) assays were also performed. Results The patient was a compound heterozygote for the well‐characterized c.628G>A (p.Val210Ile) variant and the rare octapeptide deletion of two repeats [c.202_249del48 (p.P68_Q83del)]. Clinically, the patient presented with an early onset demyelinating peripheral neuropathy, followed by later onset cognitive symptoms. Conclusion This presentation is reminiscent of prion protein knockout mice whose predominate symptom, due to complete loss of PrP, was late‐onset peripheral neuropathy. To our knowledge this is the first case reported of a patient with prion disease who had two different pathogenic variants in PRNP.
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Affiliation(s)
- Megan Piazza
- Center for Human Genetics Laboratory, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thomas W Prior
- Center for Human Genetics Laboratory, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Prabhjot S Khalsa
- Fremont Neurology Medical Associates, Fremont, CA, USA.,Washington Hospital Healthcare System, Fremont, CA, USA.,University of California Davis, Davis, CA, USA
| | - Brian Appleby
- National Prion Disease Pathology Surveillance Center, Case Western Reserve University, Cleveland, OH, USA
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