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Cracco L, Cali I, Cohen ML, Aslam R, Notari S, Kong Q, Newell KL, Ghetti B, Appleby BS, Gambetti P. Efficient transmission of human prion diseases to a glycan-free prion protein-expressing host. Brain 2024; 147:1539-1552. [PMID: 38000783 PMCID: PMC10994570 DOI: 10.1093/brain/awad399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/12/2023] [Indexed: 11/26/2023] Open
Abstract
It is increasingly evident that the association of glycans with the prion protein (PrP), a major post-translational modification, significantly impacts the pathogenesis of prion diseases. A recent bioassay study has provided evidence that the presence of PrP glycans decreases spongiform degeneration and disease-related PrP (PrPD) deposition in a murine model. We challenged (PRNPN181Q/197Q) transgenic (Tg) mice expressing glycan-free human PrP (TgGlyc-), with isolates from sporadic Creutzfeldt-Jakob disease subtype MM2 (sCJDMM2), sporadic fatal insomnia and familial fatal insomnia, three human prion diseases that are distinct but share histotypic and PrPD features. TgGlyc- mice accurately replicated the basic histotypic features associated with the three diseases but the transmission was characterized by high attack rates, shortened incubation periods and a greatly increased severity of the histopathology, including the presence of up to 40 times higher quantities of PrPD that formed prominent deposits. Although the engineered protease-resistant PrPD shared at least some features of the secondary structure and the presence of the anchorless PrPD variant with the wild-type PrPD, it exhibited different density gradient profiles of the PrPD aggregates and a higher stability index. The severity of the histopathological features including PrP deposition appeared to be related to the incubation period duration. These findings are clearly consistent with the protective role of the PrP glycans but also emphasize the complexity of the conformational changes that impact PrPD following glycan knockout. Future studies will determine whether these features apply broadly to other human prion diseases or are PrPD-type dependent.
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Affiliation(s)
- Laura Cracco
- Department of Pathology and Laboratory Medicine, Indiana University, School of Medicine, Indianapolis, IN 46202, USA
| | - Ignazio Cali
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
- National Prion Disease Pathology Surveillance Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
| | - Mark L Cohen
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
| | - Rabail Aslam
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
| | - Silvio Notari
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
| | - Qingzhong Kong
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
- National Prion Disease Pathology Surveillance Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
- Department of Neurology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
| | - Kathy L Newell
- Department of Pathology and Laboratory Medicine, Indiana University, School of Medicine, Indianapolis, IN 46202, USA
| | - Bernardino Ghetti
- Department of Pathology and Laboratory Medicine, Indiana University, School of Medicine, Indianapolis, IN 46202, USA
| | - Brian S Appleby
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
- National Prion Disease Pathology Surveillance Center, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
- Department of Neurology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Pierluigi Gambetti
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
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Clemmensen FK, Areskeviciute A, Lund EL, Roos P. Variably protease-sensitive prionopathy with methionine homozygosity at codon 129 in the prion protein gene. BMJ Case Rep 2024; 17:e258199. [PMID: 38388201 PMCID: PMC10884235 DOI: 10.1136/bcr-2023-258199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Variably protease-sensitive prionopathy (VPSPr) is a recently characterised rare subtype of sporadic prion disease, mainly affecting individuals with valine homozygosity at codon 129 in the prion protein gene, with only seven methionine homozygote cases reported to date. This case presents clinical, neuropathological and biochemical features of the eighth VPSPr case worldwide with methionine homozygosity at codon 129 and compares the features with the formerly presented cases.The patient, a woman in her 70s, presented with cognitive decline, impaired balance and frequent falls. Medical history and clinical presentation were suggestive of a rapidly progressive dementia disorder. MRI showed bilateral thalamic hyperintensity. Cerebrospinal fluid real-time quaking-induced conversion was negative, and the electroencephalogram was unremarkable. The diagnosis was established through post-mortem pathological examinations. VPSPr should be suspected in rapidly progressive dementia lacking typical features or paraclinical results of protein misfolding diseases.
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Affiliation(s)
- Frederikke Kragh Clemmensen
- Danish Dementia Research Centre, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ausrine Areskeviciute
- Danish Reference Centre for Prion Disease, Department of Pathology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Eva Løbner Lund
- Danish Reference Centre for Prion Disease, Department of Pathology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter Roos
- Danish Dementia Research Centre, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Myskiw J, Lamoureux L, Peterson A, Knox D, Jansen GH, Coulthart MB, Booth SA. Development of an Automated Capillary Immunoassay to Detect Prion Glycotypes in Creutzfeldt-Jakob Disease. J Transl Med 2023; 103:100029. [PMID: 36925197 DOI: 10.1016/j.labinv.2022.100029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 09/23/2022] [Accepted: 11/07/2022] [Indexed: 01/11/2023] Open
Abstract
Creutzfeldt-Jakob disease (CJD) comprises a group of transmissible neurodegenerative diseases with vast phenotypic diversity. Sporadic CJD heterogeneity is predominantly influenced by the genotype at codon 129 of the prion-encoding gene and the molecular weight of PrPSc fragments after protease digestion, resulting in a classification of 6 subtypes of CJD (MM1, MM2, MV1, MV2, VV1, and VV2). The majority of cases with CJD can be distinguished using this classification system. However, a number of reported CJD cases are phenotypically unique from others within their same subtype, such as variably protease-sensitive prionopathies, or exist as a mixture of subtypes within the same patient. Western blotting of brain tissue, along with the genotyping of codon 129 of the prion-encoding gene, is considered the "gold standard" for the biochemical characterization of CJD. Western blotting requires a significant amount of prion protein for detection, is labor-intensive, and is also associated with high interassay variability. In addition to these limitations, a growing body of research suggests that unique subtypes of CJD are often undetected or misdiagnosed using standard diagnostic western blotting protocols. Consequently, we successfully optimized and developed a capillary-based western assay using the JESS Simple Western (ProteinSimple) to detect and characterize prion proteins from patients with CJD. We found that this novel assay consistently differentiated CJD type 1 and type 2 cases with a limit of detection 10 to 100× higher than traditional western blotting. Cases with CJD in which type 1 and type 2 coexist within the same brain region can be detected using type 1-specific and type 2-specific antibodies, and we found that there was remarkable specificity for the detection of cases with variably protease-sensitive prionopathy. The assay presented displays outstanding sensitivity, allowing for the preservation of valuable samples and enhancing current detection methods.
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Affiliation(s)
- Jennifer Myskiw
- One Health Division, Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg, Manitoba, Canada; Department of Medical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lise Lamoureux
- One Health Division, Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Anne Peterson
- One Health Division, Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - David Knox
- One Health Division, Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg, Manitoba, Canada
| | - Gerard H Jansen
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael B Coulthart
- Canadian Creutzfeldt-Jakob Disease Surveillance System, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Stephanie A Booth
- One Health Division, Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg, Manitoba, Canada; Department of Medical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
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Silva CJ, Erickson-Beltran ML. General Method of Quantifying the Extent of Methionine Oxidation in the Prion Protein. JOURNAL OF THE AMERICAN SOCIETY FOR MASS SPECTROMETRY 2023; 34:255-263. [PMID: 36608322 DOI: 10.1021/jasms.2c00280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The normal cellular prion protein (PrPC) and its infectious conformer, PrPSc, possess a disproportionately greater amount of methionines than would be expected for a typical mammalian protein. The thioether of methionine can be readily oxidized to the corresponding sulfoxide, which means that oxidation of methionine can be used to map the surface of the conformation of PrPC or PrPSc, as covalent changes are retained after denaturation. We identified a set of peptides (TNMK, MLGSAMSR, LLGSAMSR, PMIHFGNDWEDR, ENMNR, ENMYR, IMER, MMER, MIER, VVEQMCVTQYQK, and VVEQMCITQYQR) that contains every methionine in sheep, cervid, mouse, and bank vole PrP. Each is the product of a tryptic digestion and is suitable for a multiple reaction monitoring (MRM) based analysis. The peptides chromatograph well. The oxidized and unoxidized peptides containing one methionine readily separate. The unoxidized, two singly oxidized, and doubly oxidized forms of the MLGSAMSR and MMER peptides are also readily distinguishable. This approach can be used to determine the surface exposure of each methionine by measuring its oxidation after reaction with added hydrogen peroxide.
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Affiliation(s)
- Christopher J Silva
- Produce Safety and Microbiology Research Unit, Western Regional Research Center, United States Department of Agriculture, Agricultural Research Service, 800 Buchanan Street, Albany, California 94710, United States
| | - Melissa L Erickson-Beltran
- Produce Safety and Microbiology Research Unit, Western Regional Research Center, United States Department of Agriculture, Agricultural Research Service, 800 Buchanan Street, Albany, California 94710, United States
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Mastrianni JA, Seibert K. Challenging Cases of Neurocognitive Disorders. Semin Neurol 2022; 42:742-751. [PMID: 36623535 DOI: 10.1055/s-0042-1760378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Dementia is broadly defined by DSM-V as cognitive decline from a previous level that impacts the patient's functioning at work or play. This broad definition does not provide information about the underlying disease process, an aspect of clinical care that is of increasing importance, as therapeutic development inches closer to effective disease-modifying treatments. The most common neurodegenerative dementias include Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, and Parkinson's disease dementia. Although rare, the prion diseases constitute an important group of dementias that should be routinely considered in the evaluation. Over the last two decades, advances in neuroimaging, biomarker development, and neurogenetics have not only led to a better understanding of the biology of these diseases, but they have improved our awareness of less common clinical subtypes of dementia. As such, to best define the disease process, the evaluation of a patient with cognitive decline requires attention to a myriad of disease aspects, such as the primary symptom at onset (memory, language, visual perception, praxis, etc.), the age at onset (younger or older than 65 years), the rate of disease progression (weeks to months or years), the cognitive and behavioral profile (neuropsychological assessment), and involvement of physical findings. We present here three cases that highlight the decision-making process in the evaluation of patients with atypical presentations of dementia.
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Affiliation(s)
- James A Mastrianni
- Department of Neurology, Center for Comprehensive Care and Research on Memory Disorders, University of Chicago, Chicago, Illinois
| | - Kaitlin Seibert
- Department of Neurology, Center for Comprehensive Care and Research on Memory Disorders, University of Chicago, Chicago, Illinois
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Igel A, Fornara B, Rezaei H, Béringue V. Prion assemblies: structural heterogeneity, mechanisms of formation, and role in species barrier. Cell Tissue Res 2022; 392:149-166. [PMID: 36399162 PMCID: PMC10113350 DOI: 10.1007/s00441-022-03700-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022]
Abstract
AbstractPrions are proteinaceous pathogens responsible for a wide range of neurodegenerative diseases in animal and human. Prions are formed from misfolded, ß-sheet rich, and aggregated conformers (PrPSc) of the host-encoded prion protein (PrPC). Prion replication stems from the capacity of PrPSc to self-replicate by templating PrPC conversion and polymerization. The question then arises about the molecular mechanisms of prion replication, host invasion, and capacity to contaminate other species. Studying these mechanisms has gained in recent years further complexity with evidence that PrPSc is a pleiomorphic protein. There is indeed compelling evidence for PrPSc structural heterogeneity at different scales: (i) within prion susceptible host populations with the existence of different strains with specific biological features due to different PrPSc conformers, (ii) within a single infected host with the co-propagation of different strains, and (iii) within a single strain with evidence for co-propagation of PrPSc assemblies differing in their secondary to quaternary structure. This review summarizes current knowledge of prion assembly heterogeneity, potential mechanisms of formation during the replication process, and importance when crossing the species barrier.
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Appleby BS, Shetty S, Elkasaby M. Genetic aspects of human prion diseases. Front Neurol 2022; 13:1003056. [PMID: 36277922 PMCID: PMC9579322 DOI: 10.3389/fneur.2022.1003056] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Human prion diseases are rapidly progressive and fatal neurodegenerative conditions caused by a disease-causing isoform of the native prion protein. The prion protein gene (PRNP) encodes for the cellular prion protein, which is the biological substrate for prion disease transmission and neurotoxicity. Human prion diseases have three etiologies: sporadic, genetic, and acquired. PRNP polymorphisms and pathogenic variants play a large role in the frequency, age at onset, and clinicopathologic phenotype of prion diseases. Genetic prion diseases will be covered in detail and information necessary for clinical care, predictive genetic testing, and genetic counseling will be reviewed. Because the prion protein is necessary for transmission and neurotoxicity, many experimental treatments targeting its production are being investigated and hold potential promise as a disease modifying treatment for all forms of prion disease, including asymptomatic mutation carriers. This article will review genetic aspects of human prion disease and their influence on epidemiology, clinicopathologic phenotype, diagnostics, clinical management, and potential treatment approaches.
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Affiliation(s)
- Brian S. Appleby
- Department of Pathology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University, Cleveland, OH, United States
- Department of Neurology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, United States
- *Correspondence: Brian S. Appleby
| | - Shashirekha Shetty
- Department of Pathology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University, Cleveland, OH, United States
- Department of Pathology, Center for Human Genetics Laboratory, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, United States
| | - Mohamed Elkasaby
- Department of Neurology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, United States
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Silva CJ. Chronic Wasting Disease (CWD) in Cervids and the Consequences of a Mutable Protein Conformation. ACS OMEGA 2022; 7:12474-12492. [PMID: 35465121 PMCID: PMC9022204 DOI: 10.1021/acsomega.2c00155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/18/2022] [Indexed: 05/15/2023]
Abstract
Chronic wasting disease (CWD) is a prion disease of cervids (deer, elk, moose, etc.). It spreads readily from CWD-contaminated environments and among wild cervids. As of 2022, North American CWD has been found in 29 states, four Canadian provinces and South Korea. The Scandinavian form of CWD originated independently. Prions propagate their pathology by inducing a natively expressed prion protein (PrPC) to adopt the prion conformation (PrPSc). PrPC and PrPSc differ solely in their conformation. Like other prion diseases, transmissible CWD prions can arise spontaneously. The CWD prions can respond to selection pressures resulting in the emergence of new strain phenotypes. Annually, 11.5 million Americans hunt and harvest nearly 6 million deer, indicating that CWD is a potential threat to an important American food source. No tested CWD strain has been shown to be zoonotic. However, this may not be true for emerging strains. Should a zoonotic CWD strain emerge, it could adversely impact the hunting economy and game meat consumers.
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Affiliation(s)
- Christopher J. Silva
- Produce Safety & Microbiology
Research Unit, Western Regional Research Center, Agricultural Research
Service, United States Department of Agriculture, Albany, California 94710, United States of America
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Phenotypic Heterogeneity of Variably Protease-Sensitive Prionopathy: A Report of Three Cases Carrying Different Genotypes at PRNP Codon 129. Viruses 2022; 14:v14020367. [PMID: 35215959 PMCID: PMC8879235 DOI: 10.3390/v14020367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Variably protease-sensitive prionopathy is an exceedingly rare, likely underestimated, sporadic prion disease that is characterized by heterogeneous and often non-specific clinical and pathological features posing diagnostic challenges. We report the results of a comprehensive analysis of three emblematic cases carrying different genotypes at the methionine (M)/valine (V) polymorphic codon 129 in the prion protein gene (PRNP). Clinical, biochemical, and neuropathological findings highlighted the prominent role of the host genetic background as a phenotypic modulator. In particular, the PRNP codon 129 showed a remarkable influence on the physicochemical properties of the pathological prion protein (PrPSc), especially on the sensitivity to proteinase K (PK) digestion (VV > MV > MM), which variably affected the three main fragments (i.e., of 19, 17, and 7 kDa, respectively) comprising the PrPSc profile after PK digestion and immunoblotting. This, in turn, correlated with significant differences in the ratio between the 19 kDa and the 7 kDa fragments which was highest in the MM case and lowest in the VV one. The relative amount of cerebral and cerebellar PrP mini-plaques immunohistochemistry showed a similar association with the codon 129 genotype (i.e., VV > MV > MM). Clinical manifestations and results of diagnostic investigations were non-specific, except for the detection of prion seeding activity by the real-time quaking-induced conversion assay in the only cerebrospinal fluid sample that we tested (from patient 129VV).
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Jankovska N, Rusina R, Bruzova M, Parobkova E, Olejar T, Matej R. Human Prion Disorders: Review of the Current Literature and a Twenty-Year Experience of the National Surveillance Center in the Czech Republic. Diagnostics (Basel) 2021; 11:1821. [PMID: 34679519 PMCID: PMC8534461 DOI: 10.3390/diagnostics11101821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023] Open
Abstract
Human prion disorders (transmissible spongiform encephalopathies, TSEs) are unique, progressive, and fatal neurodegenerative diseases caused by aggregation of misfolded prion protein in neuronal tissue. Due to the potential transmission, human TSEs are under active surveillance in a majority of countries; in the Czech Republic data are centralized at the National surveillance center (NRL) which has a clinical and a neuropathological subdivision. The aim of our article is to review current knowledge about human TSEs and summarize the experience of active surveillance of human prion diseases in the Czech Republic during the last 20 years. Possible or probable TSEs undergo a mandatory autopsy using a standardized protocol. From 2001 to 2020, 305 cases of sporadic and genetic TSEs including 8 rare cases of Gerstmann-Sträussler-Scheinker syndrome (GSS) were confirmed. Additionally, in the Czech Republic, brain samples from all corneal donors have been tested by the NRL immunology laboratory to increase the safety of corneal transplants since January 2007. All tested 6590 corneal donor brain tissue samples were negative for prion protein deposits. Moreover, the routine use of diagnostic criteria including biomarkers are robust enough, and not even the COVID-19 pandemic has negatively impacted TSEs surveillance in the Czech Republic.
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Affiliation(s)
- Nikol Jankovska
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University and Thomayer University Hospital, 14059 Prague, Czech Republic; (M.B.); (E.P.); (T.O.); (R.M.)
| | - Robert Rusina
- Department of Neurology, Third Faculty of Medicine, Charles University and Thomayer University Hospital, 14059 Prague, Czech Republic;
| | - Magdalena Bruzova
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University and Thomayer University Hospital, 14059 Prague, Czech Republic; (M.B.); (E.P.); (T.O.); (R.M.)
| | - Eva Parobkova
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University and Thomayer University Hospital, 14059 Prague, Czech Republic; (M.B.); (E.P.); (T.O.); (R.M.)
| | - Tomas Olejar
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University and Thomayer University Hospital, 14059 Prague, Czech Republic; (M.B.); (E.P.); (T.O.); (R.M.)
| | - Radoslav Matej
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University and Thomayer University Hospital, 14059 Prague, Czech Republic; (M.B.); (E.P.); (T.O.); (R.M.)
- Department of Pathology, First Faculty of Medicine, Charles University, and General University Hospital, 12800 Prague, Czech Republic
- Department of Pathology, Third Faculty of Medicine, Charles University, and University Hospital Kralovske Vinohrady, 10034 Prague, Czech Republic
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Huang J, Cohen M, Safar J, Auchus AP. Variably Protease-sensitive Prionopathy in a Middle-aged Man With Rapidly Progressive Dementia. Cogn Behav Neurol 2021; 34:220-225. [PMID: 34473674 PMCID: PMC8803003 DOI: 10.1097/wnn.0000000000000276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/27/2020] [Indexed: 11/26/2022]
Abstract
Variably protease-sensitive prionopathy (VPSPr) is a recently described sporadic prion disease with distinctive clinical and histopathological features. We report the clinical, imaging, and neuropathological features of VPSPr in a 46-year-old right-handed man who presented with progressive cognitive decline, behavior disturbances, and a 50-pound weight loss over 6 months. The initial evaluation revealed severe cognitive impairment with no focal neurologic deficits. His cognitive, psychiatric, and behavior symptoms progressed rapidly, and he died 12 months after the initial visit. Throughout his disease course, workup for rapid progressive dementia was unremarkable except that brain MRI diffusion-weighted imaging showed persistent diffuse cortical and thalamic signal abnormalities. Sporadic Creutzfeldt-Jakob disease was highly suspected; however, two EEGs (8 months apart) demonstrated only nonspecific cerebral dysfunction. The patient's CSF 14-3-3 protein was negative at the initial visit and again 8 months later. His CSF real-time quaking-induced conversion and total tau level were normal. An autopsy of his brain was performed, and the neuropathological findings confirmed VPSPr. Our case underlines the importance of considering VPSPr in the spectrum of prion disease phenotypes when evaluating individuals with rapidly progressive dementia.
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Affiliation(s)
- Juebin Huang
- Department of Neurology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mark Cohen
- Department of Pathology and Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University, Cleveland, Ohio
| | - Jiri Safar
- Department of Pathology and Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University, Cleveland, Ohio
| | - Alexander P. Auchus
- Department of Neurology, University of Mississippi Medical Center, Jackson, Mississippi
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Candelise N, Scaricamazza S, Salvatori I, Ferri A, Valle C, Manganelli V, Garofalo T, Sorice M, Misasi R. Protein Aggregation Landscape in Neurodegenerative Diseases: Clinical Relevance and Future Applications. Int J Mol Sci 2021; 22:ijms22116016. [PMID: 34199513 PMCID: PMC8199687 DOI: 10.3390/ijms22116016] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 12/13/2022] Open
Abstract
Intrinsic disorder is a natural feature of polypeptide chains, resulting in the lack of a defined three-dimensional structure. Conformational changes in intrinsically disordered regions of a protein lead to unstable β-sheet enriched intermediates, which are stabilized by intermolecular interactions with other β-sheet enriched molecules, producing stable proteinaceous aggregates. Upon misfolding, several pathways may be undertaken depending on the composition of the amino acidic string and the surrounding environment, leading to different structures. Accumulating evidence is suggesting that the conformational state of a protein may initiate signalling pathways involved both in pathology and physiology. In this review, we will summarize the heterogeneity of structures that are produced from intrinsically disordered protein domains and highlight the routes that lead to the formation of physiological liquid droplets as well as pathogenic aggregates. The most common proteins found in aggregates in neurodegenerative diseases and their structural variability will be addressed. We will further evaluate the clinical relevance and future applications of the study of the structural heterogeneity of protein aggregates, which may aid the understanding of the phenotypic diversity observed in neurodegenerative disorders.
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Affiliation(s)
- Niccolò Candelise
- Fondazione Santa Lucia IRCCS, c/o CERC, 00143 Rome, Italy; (S.S.); (I.S.); (A.F.); (C.V.)
- Institute of Translational Pharmacology, National Research Council, 00133 Rome, Italy
- Correspondence: ; Tel.: +39-338-891-2668
| | - Silvia Scaricamazza
- Fondazione Santa Lucia IRCCS, c/o CERC, 00143 Rome, Italy; (S.S.); (I.S.); (A.F.); (C.V.)
| | - Illari Salvatori
- Fondazione Santa Lucia IRCCS, c/o CERC, 00143 Rome, Italy; (S.S.); (I.S.); (A.F.); (C.V.)
- Department of Experimental Medicine, University of Rome “La Sapienza”, 00161 Rome, Italy; (V.M.); (T.G.); (M.S.); (R.M.)
| | - Alberto Ferri
- Fondazione Santa Lucia IRCCS, c/o CERC, 00143 Rome, Italy; (S.S.); (I.S.); (A.F.); (C.V.)
- Institute of Translational Pharmacology, National Research Council, 00133 Rome, Italy
| | - Cristiana Valle
- Fondazione Santa Lucia IRCCS, c/o CERC, 00143 Rome, Italy; (S.S.); (I.S.); (A.F.); (C.V.)
- Institute of Translational Pharmacology, National Research Council, 00133 Rome, Italy
| | - Valeria Manganelli
- Department of Experimental Medicine, University of Rome “La Sapienza”, 00161 Rome, Italy; (V.M.); (T.G.); (M.S.); (R.M.)
| | - Tina Garofalo
- Department of Experimental Medicine, University of Rome “La Sapienza”, 00161 Rome, Italy; (V.M.); (T.G.); (M.S.); (R.M.)
| | - Maurizio Sorice
- Department of Experimental Medicine, University of Rome “La Sapienza”, 00161 Rome, Italy; (V.M.); (T.G.); (M.S.); (R.M.)
| | - Roberta Misasi
- Department of Experimental Medicine, University of Rome “La Sapienza”, 00161 Rome, Italy; (V.M.); (T.G.); (M.S.); (R.M.)
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Figgie MP, Appleby BS. Clinical Use of Improved Diagnostic Testing for Detection of Prion Disease. Viruses 2021; 13:v13050789. [PMID: 33925126 PMCID: PMC8146465 DOI: 10.3390/v13050789] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
Prion diseases are difficult to recognize as many symptoms are shared among other neurologic pathologies and the full spectra of symptoms usually do not appear until late in the disease course. Additionally, many commonly used laboratory markers are non-specific to prion disease. The recent introduction of second-generation real time quaking induced conversion (RT-QuIC) has revolutionized pre-mortem diagnosis of prion disease due to its extremely high sensitivity and specificity. However, RT-QuIC does not provide prognostic data and has decreased diagnostic accuracy in some rarer, atypical prion diseases. The objective of this review is to provide an overview of the current clinical utility of fluid-based biomarkers, neurodiagnostic testing, and brain imaging in the diagnosis of prion disease and to suggest guidelines for their clinical use, with a focus on rarer prion diseases with atypical features. Recent advancements in laboratory-based testing and imaging criteria have shown improved diagnostic accuracy and prognostic potential in prion disease, but because these diagnostic tests are not sensitive in some prion disease subtypes and diagnostic test sensitivities are unknown in the event that CWD transmits to humans, it is important to continue investigations into the clinical utility of various testing modalities.
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Affiliation(s)
- Mark P. Figgie
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Brian S. Appleby
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA;
- National Prion Disease Pathology Surveillance Center, Case Western Reserve University, Cleveland, OH 44106, USA
- Correspondence:
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14
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Huntington's disease: lessons from prion disorders. J Neurol 2021; 268:3493-3504. [PMID: 33625583 DOI: 10.1007/s00415-021-10418-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/06/2023]
Abstract
Decades of research on the prion protein and its associated diseases have caused a paradigm shift in our understanding of infectious agents. More recent years have been marked by a surge of studies supporting the application of these findings to a broad array of neurodegenerative disorders such as Alzheimer's and Parkinson's diseases. Here, we present evidence to suggest that Huntington's disease, a monogenic disorder of the central nervous system, shares features with prion disorders and that, it too, may be governed by similar mechanisms. We further posit that these similarities could suggest that, like other common neurodegenerative disorders, sporadic forms of Huntington's disease may exist.
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15
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Yakubu UM, Catumbela CSG, Morales R, Morano KA. Understanding and exploiting interactions between cellular proteostasis pathways and infectious prion proteins for therapeutic benefit. Open Biol 2020; 10:200282. [PMID: 33234071 PMCID: PMC7729027 DOI: 10.1098/rsob.200282] [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] [Indexed: 12/13/2022] Open
Abstract
Several neurodegenerative diseases of humans and animals are caused by the misfolded prion protein (PrPSc), a self-propagating protein infectious agent that aggregates into oligomeric, fibrillar structures and leads to cell death by incompletely understood mechanisms. Work in multiple biological model systems, from simple baker's yeast to transgenic mouse lines, as well as in vitro studies, has illuminated molecular and cellular modifiers of prion disease. In this review, we focus on intersections between PrP and the proteostasis network, including unfolded protein stress response pathways and roles played by the powerful regulators of protein folding known as protein chaperones. We close with analysis of promising therapeutic avenues for treatment enabled by these studies.
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Affiliation(s)
- Unekwu M Yakubu
- Department of Microbiology and Molecular Genetics, McGovern Medical School at UTHealth, Houston, TX USA.,MD Anderson UTHealth Graduate School at UTHealth, Houston, TX USA
| | - Celso S G Catumbela
- MD Anderson UTHealth Graduate School at UTHealth, Houston, TX USA.,Mitchell Center for Alzheimer's Disease and Related Brain Disorders, Department of Neurology, McGovern Medical School at UTHealth, Houston, TX USA
| | - Rodrigo Morales
- Mitchell Center for Alzheimer's Disease and Related Brain Disorders, Department of Neurology, McGovern Medical School at UTHealth, Houston, TX USA.,Centro integrativo de biología y química aplicada (CIBQA), Universidad Bernardo O'Higgins, Santiago, Chile
| | - Kevin A Morano
- Department of Microbiology and Molecular Genetics, McGovern Medical School at UTHealth, Houston, TX USA
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16
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Abstract
PURPOSE OF REVIEW Prion diseases are rapidly progressive neurodegenerative conditions that can be difficult to diagnose and are transmissible under specific circumstances. The authors will provide background regarding prion disease and focus on diagnostic tools. RECENT FINDINGS Prion disease is caused by misfolded prion protein. The three possible causes of prion disease include sporadic (85%), genetic (10-15%), and acquired (<1%). Acquired prion diseases include kuru, iatrogenic, and variant Creutzfeldt-Jakob disease. Prion diseases differ in their clinical manifestation, neuropathology, and diagnostic test results. A variety of recent diagnostic tools have evolved that allow more reliable antemortem diagnosis of prion disease such as brain MRI and cerebrospinal fluid real-time quaking-induced conversion. Special infectivity guidelines must be followed when dealing with central nervous system tissue, but only standard precautions are needed for routine clinical care of patients with prion disease. SUMMARY The only way to definitely diagnose prion disease and determine its type is via neuropathologic examination. However, brain MRI and cerebrospinal fluid real-time quaking-induced conversion have drastically increased diagnostic accuracy and are important tests to use when evaluating patients with suspected prion disease.
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17
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Areškevičiūtė A, Broholm H, Melchior LC, Bartoletti-Stella A, Parchi P, Capellari S, Scheie D, Lund EL. Molecular Characterization of the Danish Prion Diseases Cohort With Special Emphasis on Rare and Unique Cases. J Neuropathol Exp Neurol 2020; 78:980-992. [PMID: 31553446 DOI: 10.1093/jnen/nlz089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/01/2019] [Indexed: 12/19/2022] Open
Abstract
The purpose of this study was to perform an updated reclassification of all definite prion disease cases with available fresh-frozen samples referred to the Danish Reference Center over the past 40 years, putting a special emphasis on the molecular characterization of novel disease subtypes. Investigation of the Danish prion diseases cohort revealed rare sporadic Creutzfeldt-Jakob disease cases with mixed subtypes and subtypes with previously uncharacterized white matter plaques, a new case of sporadic fatal insomnia, and 3 novel mutations, including 2 large octapeptide repeat insertions, and a point mutation in the prion protein gene. The evaluation of methionine and valine distribution at codon 129 among the prion disease patients in the cohort revealed the increased prevalence of methionine homozygotes compared to the general population. This observation was in line with the prevalence reported in other Caucasian prion disease cohort studies. Reclassification of the old prion diseases cohort revealed unique cases, the molecular characterization of which improves prion diseases classification, diagnostic accuracy, genetic counseling of affected families, and the understanding of disease biology.
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Affiliation(s)
- Aušrinė Areškevičiūtė
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Helle Broholm
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Linea C Melchior
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Anna Bartoletti-Stella
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Piero Parchi
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Sabina Capellari
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - David Scheie
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Eva L Lund
- Department of Pathology, Danish Reference Center for Prion Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; Department of Experimental Diagnostic and Specialty Medicine; and Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
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18
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Structural Consequences of Copper Binding to the Prion Protein. Cells 2019; 8:cells8080770. [PMID: 31349611 PMCID: PMC6721516 DOI: 10.3390/cells8080770] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022] Open
Abstract
Prion, or PrPSc, is the pathological isoform of the cellular prion protein (PrPC) and it is the etiological agent of transmissible spongiform encephalopathies (TSE) affecting humans and animal species. The most relevant function of PrPC is its ability to bind copper ions through its flexible N-terminal moiety. This review includes an overview of the structure and function of PrPC with a focus on its ability to bind copper ions. The state-of-the-art of the role of copper in both PrPC physiology and in prion pathogenesis is also discussed. Finally, we describe the structural consequences of copper binding to the PrPC structure.
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19
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Nonno R, Notari S, Di Bari MA, Cali I, Pirisinu L, d'Agostino C, Cracco L, Kofskey D, Vanni I, Lavrich J, Parchi P, Agrimi U, Gambetti P. Variable Protease-Sensitive Prionopathy Transmission to Bank Voles. Emerg Infect Dis 2019; 25:73-81. [PMID: 30561322 PMCID: PMC6302590 DOI: 10.3201/eid2501.180807] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Variably protease-sensitive prionopathy (VPSPr), a recently described human sporadic prion disease, features a protease-resistant, disease-related prion protein (resPrPD) displaying 5 fragments reminiscent of Gerstmann-Sträussler-Scheinker disease. Experimental VPSPr transmission to human PrP-expressing transgenic mice, although replication of the VPSPr resPrPD profile succeeded, has been incomplete because of second passage failure. We bioassayed VPSPr in bank voles, which are susceptible to human prion strains. Transmission was complete; first-passage attack rates were 5%-35%, and second-passage rates reached 100% and survival times were 50% shorter. We observed 3 distinct phenotypes and resPrPD profiles; 2 imitated sporadic Creutzfeldt-Jakob disease resPrPD, and 1 resembled Gerstmann-Sträussler-Scheinker disease resPrPD. The first 2 phenotypes may be related to the presence of minor PrPD components in VPSPr. Full VPSPr transmission confirms permissiveness of bank voles to human prions and suggests that bank vole PrP may efficiently reveal an underrepresented native strain but does not replicate the complex VPSPr PrPD profile.
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Kim SH, Yu MM, Strutt AM. Variably protease-sensitive prionopathy: A differential diagnostic consideration for dementia. Neurol Clin Pract 2019; 9:145-151. [PMID: 31041129 DOI: 10.1212/cpj.0000000000000612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/27/2018] [Indexed: 11/15/2022]
Abstract
Purpose of review Prion diseases are rare neurodegenerative diseases that are caused by abnormal pathogenic agents and can affect both humans and animals. These diseases are categorized as sporadic, inherited, or acquired by infection. Clinical manifestations include psychiatric symptoms, cognitive impairment, and parkinsonism, which are similar to those of other prion diseases and frontotemporal dementia variants. Recent findings More recently, scientists discovered a new sporadic prion disease called variably protease-sensitive prionopathy. Summary The following case discusses a patient presenting with sudden onset and rapid decline in cognitive, neurobehavioral, and motor functioning and his clinical journey including treatment interventions and diagnostic confirmation.
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21
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Aizpurua M, Selvackadunco S, Yull H, Kipps CM, Ironside JW, Bodi I. Variably protease-sensitive prionopathy mimicking frontotemporal dementia. Neuropathology 2019; 39:135-140. [PMID: 30847986 PMCID: PMC6778052 DOI: 10.1111/neup.12538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 12/14/2022]
Abstract
Sporadic prion diseases are fatal neurodegenerative disorders characterized clinically by rapidly progressive dementia and myoclonus. Variably protease‐sensitive prionopathy (VPSPr) is a recently identified sporadic human prion disorder that may present with a lengthy atypical clinical history. Here, we describe a case of VPSPr in a patient with a long history of suspected frontotemporal dementia (FTD). A 61‐year‐old man presented with speech difficulties, including naming objects and constructing multipart sentences, while there was no difficulty in comprehension. Movement abnormalities included slightly jerky pursuit, minor dysmetria of saccades and brisk reflexes. There was no family history of dementia. Later he developed swallowing difficulties and the possibility of FTD with motor neuron disease was suspected. He died at the age of 71 and his brain was donated to the London Neurodegenerative Diseases Brain Bank. The brain (1004 g) showed mild to moderate atrophy, predominantly in the frontal lobe. Histology revealed moderate spongiform microvacuolation mostly affecting the frontal and parietal cortices, but also present focally in the basal ganglia and the cerebellum. Only mild Alzheimer pathology was found by extensive immunohistochemistry, in keeping with BrainNet Europe stage II. Trans‐activation response DNA‐binding protein 43 kDa and α‐synuclein immunostains were negative. Immunostaining for prion protein (PrP) showed granular/synaptic positivity in a patchy distribution, mainly within the deeper cortex, and also revealed microplaques in the cerebellum and basal ganglia. Western blotting confirmed a low molecular weight protease‐resistant PrP band with a faint ladder‐like pattern in the absence of types 1 and 2 isoforms. These features are diagnostic of VPSPr. VPSPr can mimic various neurodegenerative conditions; diagnosis requires both PrP immunohistochemistry and Western blotting. The presence of patchy spongiform change in the absence of other neurodegenerative pathology should raise suspicion of VPSPr, even in elderly patients with a lengthy clinical history.
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Affiliation(s)
- Miren Aizpurua
- Clinical Neuropathology, King's College Hospital, NHS Foundation Trust, London, UK
| | | | - Helen Yull
- National Creutzfeldt-Jakob Disease Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher M Kipps
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Clinical Neurosciences, University of Southampton, Southampton, UK
| | - James W Ironside
- National Creutzfeldt-Jakob Disease Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Istvan Bodi
- Clinical Neuropathology, King's College Hospital, NHS Foundation Trust, London, UK.,London Neurodegenerative Diseases Brain Bank, IOPPN, London, UK
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