How to tackle a possible Creutzfeldt-Jakob disease necropsy

Non-traumatic forensic neuropathology

The practicing Forensic Pathologist is likely to encounter case material in which either the cause of death or a major contribution to the cause of death is underlying damage to or disease of the central nervous system. While it is good practice in many instances to have a working relationship with a Department of Neuropathology, from which advice and practical help can be sought, there may be instances when the Forensic Pathologist needs to proceed on a basis of a working knowledge of Forensic Neuropathology up to and including how to examine the specimen and take tissue blocks for processing and subsequent histological examination. Some of the more common conditions of the central nervous system such as damage consequent to hypoxia-ischaemia, hypoglycemia and epilepsy, the encephalopathies associated with altered sodium concentration, deficiency due to Vitamin B(1) and various neurodegenerative diseases that manifest as dementia and include Alzheimer's disease, cortical Lewy body disease and the prion disorders, are outlined in this article.

ACP Best Practice No 164: Necropsy techniques in ophthalmic pathology

Much important information can be obtained at necropsy by the pathological examination of the eye and its adnexal structures in adults and children. This information may be related to the cause of death (for example, violent shaking trauma in physical child abuse), or may pertain to disease processes affecting the eye, the orbit, and surrounding structures outside the orbit. This article reviews the technical methods used to remove the following: the vitreous (for example, for biochemistry); the eye itself (anterior approach); the eye and orbital contents (posterior approach); the eye, orbit and orbital walls; and the eye, orbital walls, and surrounding structures. The removal of the eye and adnexal ocular structures must be recognised as a "culturally sensitive" issue, which must be approached cautiously. It should only be undertaken for sound scientific reasons, with the fully informed consent of the relatives and/or the coroner (or equivalent authority), and with properly agreed procedures for the eventual retention or disposal of the ocular tissues. For this reason, this article reviews not only the scientific indications and methods for the removal of such tissues, but also the legal and ethical issues that must underpin this pathology "best practice".

The 'high-risk' neuropathological autopsy in AIDS and Creutzfeldt-Jakob disease: principles and practice

There is much current clinical, pathological and scientific interest in infective disorders of the central nervous system, particularly those associated with the human immunodeficiency virus (AIDS) and the transmissible human spongiform encephalopathies (Creutzfeldt-Jakob disease, Gerstmann-Sträussler-Scheinker syndrome and fatal familial insomnia). To investigate these disorders it is necessary to develop and follow procedures for performing autopsies on known or suspected cases which allow both diagnostic and research investigations to be carried out, while at the same time presenting minimal risk to pathologists, mortuary and laboratory technical staff. This article reviews the objectives for performing 'high-risk' autopsies, and summarizes current guidelines for autopsy procedures and laboratory tissue handling in light of extensive experience in the Neuropathology Laboratory, University of Edinburgh. Neuropathology has a leading role to play in diagnosis and research in this important field; the need for 'high-risk' autopsies is likely to increase into the next century.

Human prion diseases

The classical prion diseases in man comprise Creutzfeldt-Jakob disease (CJD), Kuru and Gerstmann-Sträussler-Scheinker syndrome (GSS). Recent advances in the biochemistry and the molecular biology of the transmissible agents responsible for these human spongiform encephalopathies have prompted renewed interest in their clinical and pathological features. A broadening spectrum of human prion diseases has now been identified including novel entities such as Fatal Familial Insomnia and variants of CJD and GSS characterised by specific abnormalities in the human prion protein (PrP) gene on chromosome 20. Accumulation of PrP in the central nervous system is a characteristic feature of all these disorders, although the relationship between PrP localisation, classical neuropathology, clinical features and genotype still requires clarification. A national surveillance project for CJD was established in 1990 in the United Kingdom in order to assess the possible implications of bovine spongiform encephalopathy for human health. The identification of an apparently new variant of CJD in young patients in UK raises the possibility of such a link; further studies are required to assess the significance of this observation.

Tissue handling in suspected Creutzfeldt-Jakob disease (CJD) and other human spongiform encephalopathies (prion diseases)

Despite many sensational and intimidating reports in the mass media, transmissible spongiform encephalopathies (prion disease) are not contagious in the usual sense. Successful transmission requires both specific material (an affected individual's tissue, from or adjacent to CNS) and specific modes (mainly penetrating contact with the recipient). Nevertheless, specific safety precautions are mandatory to avoid accidental transmission and to decontaminate any infectivity. Autopsy is essential for definite diagnosis of these disorders. Recommendations are given here for performance of the autopsy, for neuropathology service and appropriate decontamination; they are based on the current literature and on precautions taken in most laboratories with experience in handling tissue from transmissible spongiform encephalopathies. In particular, special care must be taken to avoid penetrating wounds, possible contamination should be kept to a minimum, and potential infectious material must be adequately decontaminated by specific means.

Prion protein accumulation in the spinal cords of patients with sporadic and growth hormone associated Creutzfeldt-Jakob disease

An immunohistological study of the spinal cord in 20 cases of sporadic and 4 iatrogenic (growth hormone) cases of Creutzfeldt-Jakob (CJD) disease patients was performed to detect the presence of disease specific prion protein using a number of different antisera. Prion protein was present in all the growth hormone recipients and in 11 of the 20 sporadic CJD cases. Plaque-like deposits of prion protein were found in all the growth hormone cases and three of the sporadic cases. This is the first demonstration of the topographic immunolocalisation of prion protein in the spinal cord of CJD patients, a feature which could help elucidate some important aspects of the pathogenesis of CJD.

What's new in managing health hazards in pathology departments

Health hazards related to activities performed in pathology departments have represented, in recent years, an increasing concern among pathologists and pathology technicians. The major occupational health problems encountered in pathology departments are reviewed. They include biological hazards (tuberculosis, hepatitis, HIV, other infectious diseases), chemical hazards (formaldehyde, xylene(s), aromatic amines, methacrylates, glutaraldehyde, latex) and physical hazards (cut injuries, accidental fires, radiation). Current data suggest that infections (particularly, tuberculosis and hepatitis) still represent the more relevant risk. Exposure to HIV and Creutzfeldt-Jakob agent may be highly harmful but containment measures have been proven to be effective. The actual adverse effects due to chemicals seem to be less alarming than was previously believed. Attaining a safe work environment is an inherent element of good quality assurance management. This task is largely a matter of information, education, organization and common sense. Well-designed premises, efficient equipment and well-trained personnel are the keys to preventing and minimizing hazardous exposures. In order to provide current information that may be used by pathology staff to implement the functional quality of the workplace, organizational and preventive measures are described.