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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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Uchino A, Saito Y, Oonuma S, Murayama S, Yagishita S, Kitamoto T, Hasegawa K. An autopsy case of variably protease-sensitive prionopathy with Met/Met homogeneity at codon 129. Neuropathology 2023; 43:486-495. [PMID: 37253452 DOI: 10.1111/neup.12911] [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: 12/19/2022] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 06/01/2023]
Abstract
The typical clinical manifestations of sporadic Creutzfeldt-Jakob disease (sCJD) are rapid-progressive dementia and myoclonus. However, the diagnosis of atypical sCJD can be challenging due to its wide phenotypic variations. We report an autopsy case of variably protease-sensitive prionopathy (VPSPr) with Met/Met homogeneity at codon 129. An 81-year-old woman presented with memory loss without motor symptoms. Seventeen months after the onset, her spontaneous language production almost disappeared. Diffusion-weighted images (DWI) showed hyperintensity in the cerebral cortex while electroencephalogram (EEG) showed nonspecific change. 14-3-3 protein and real-time qualing-induced conversion (RT-QuIC) of cerebrospinal fluid were negative. She died at age 85, 3.5 years after the onset. Pathological investigation revealed spongiform change, severe neuronal loss, and gliosis in the cerebral cortex. Mild to moderate neuronal loss and gliosis were observed in the basal ganglia. PrP immunostaining revealed plaque-like, dotlike, and synaptic structures in the cerebral cortex and small plaque-like structures in the molecular layer of the cerebellum. Analysis of PRNP showed no pathogenic mutations, and Western blot examination revealed the lack of a diglycosylated band consistent with VPSPr. The present case, which is the first report on a VPSPr case in Japan, supports previously published evidence that VPSPr cases can present variable and nonspecific clinical presentations. Because a small number of VPSPr cases can show typical magnetic resonance imaging (MRI) change in sCJD. We should investigate the possibility of VPSPr in a differential diagnosis with atypical dementia that presented DWIs of high intensity in the cortex, even though 14-3-3 proteins and RT-QuIC are both negative. In addition, VPSPr cases can take a longer clinical course compared to that of sCJD, and long-term follow-up is important.
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Affiliation(s)
- Akiko Uchino
- Department of Preventive Medical Center, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Neuropathology (Brain Bank for Aging Research), Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Yuko Saito
- Department of Pathology and Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Saori Oonuma
- Department of Neurology, NHO Sagamihara National Hospital, Sagamihara-shi, Japan
| | - Shigeo Murayama
- Brain Bank for Neurodevelopmental, Neurological and Psychiatric Disorders, United Graduate School of Child Development & Department of Neurology, Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Neurology and Neuropathology (Brain Bank for Aging Research), Tokyo Metropolitan Geriatric Hospital & Institute of Gerontology, Tokyo, Japan
| | - Saburo Yagishita
- Department of Neurology, NHO Sagamihara National Hospital, Sagamihara-shi, Japan
| | - Tetsuyuki Kitamoto
- Department of Neurological Science, Tohoku University School of Medicine, Sendai, Japan
| | - Kazuko Hasegawa
- Department of Neurology, NHO Sagamihara National Hospital, Sagamihara-shi, Japan
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Chang BK, Day GS, Graff-Radford J, McKeon A, Flanagan EP, Algeciras-Schimnich A, Mielke MM, Nguyen A, Jones DT, Toledano M, Kremers WK, Knopman DS, Petersen RC, Li W. Alzheimer's disease cerebrospinal fluid biomarkers differentiate patients with Creutzfeldt-Jakob disease and autoimmune encephalitis. Eur J Neurol 2022; 29:2905-2912. [PMID: 35735602 PMCID: PMC9463096 DOI: 10.1111/ene.15469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Autoimmune encephalitis (AE) is a potentially treatable cause of rapidly progressive dementia that may mimic Creutzfeldt-Jakob disease (CJD). Alzheimer disease (AD) cerebrospinal fluid (CSF) biomarkers may discriminate CJD from AD, but utility in discriminating CJD and AE is unclear. This study compared AD CSF biomarkers in CJD and AE. METHODS Patients with probable or definite CJD and probable or definite AE who underwent Roche Elecsys AD CSF biomarker testing at Mayo Clinic from March 2020 through April 2021 were included. Total-tau, phosphorylated181 tau and amyloid-β42 levels were compared. RESULTS Of 11 CJD cases, four were autopsy proven; the rest had positive real-time quaking-induced conversion testing. Disease-associated autoantibodies were detected in 8/15 cases of AE: leucine-rich glioma-inactivated 1 and neuronal intermediate filaments (two cases each), and N-methyl-d-aspartate receptor, contactin-associated protein-like 2, dipeptidyl-peptidase-like protein 6 and immunoglobulin-like cell adhesion molecule IgLON family member 5. Total-tau provided excellent discrimination between CJD and AE in a univariate model (odds ratio 1.46 per 100 pg/ml, 95% confidence interval 1.17-2.11, p < 0.05, c = 0.93). Total-tau was elevated in 91% of CJD cases (median > 1300, range 236->1300 pg/ml), of which 55% were above the limit of assay measurement (>1300 pg/ml). Total-tau was elevated in 20% of AE cases (median 158, range 80->1300 pg/ml). CONCLUSION Total-tau was greater in CJD than AE. Given that amyloid-β42 and phosphorylated181 tau were comparable, the ratio differences were probably driven by elevated total-tau in CJD. This study supports the role for AD biomarker testing in patients with rapidly progressive dementia.
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Affiliation(s)
| | | | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Eoin P. Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Michelle M. Mielke
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Aivi Nguyen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Walter K. Kremers
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Ronald C. Petersen
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Wentao Li
- Department of Neurology, Mayo Clinic, Rochester, MN
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