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Hogg R, Centola J, McDermott EA, Mastaglio F, Grundy A, Awe T, Carey M, Miller M, Chin CA, Quibell R, Bajorek T, Pal S, Bradley V. Prion diseases motor and neuropsychiatric symptom cluster pharmacotherapy: structured scoping review. BMJ Support Palliat Care 2024:spcare-2024-005027. [PMID: 39060092 DOI: 10.1136/spcare-2024-005027] [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: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Prion diseases are a group of rare, neurodegenerative conditions that are invariably fatal and cause a variety of symptoms, which can prove challenging to control. Through this paper, we aim to review the current evidence regarding pharmacological management of neuropsychiatric and motor symptoms of prion disease as well as draw on experts' and relatives' experience, to evaluate the current evidence and provide recommendations moving forwards. METHODS A scoping review of the literature for pharmacological management of symptoms was conducted using the systematic review tool, COVIDENCE, with searches conducted through four databases. 120 papers were selected for inclusion, and data extraction was carried out by two independent reviewers. Given the lack of high-quality data and small numbers, no further attempt at statistical analysis was made, and results are presented in a thematic synthesis. RESULTS Although a broad range of approaches and pharmacotherapies are trialled to manage these challenging symptoms, there are patterns emerging of some efficacy seen with the use of benzodiazepines, antipsychotic and anticonvulsant medications in both motor and neuropsychiatric symptoms in prion disease. These approaches and associated challenges were reflected in international expert opinion that was gathered via online survey. CONCLUSION There continues to be a paucity of good-quality evidence and we suggest a need for longitudinal, population-based and standardised research to allow a robust evidence base, which in turn will guide excellent symptom control and end of life care for this group of complex patients.
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Affiliation(s)
- Roseanagh Hogg
- Oxford University Hospitals NHS Foundation Trust Palliative Care, Oxford, Oxfordshire, UK
| | | | - Eugene Ace McDermott
- University of Edinburgh, National CJD Research and Surveillance Unit, Edinburgh, UK
| | | | - Anna Grundy
- Palliative Medicine, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Terri Awe
- University of Edinburgh, National CJD Research and Surveillance Unit, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Matthew Carey
- Palliative Care, Sir Michael Sobell House Hospice, Oxford, Oxfordshire, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Miller
- Palliative Care, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Chloe Antoinette Chin
- Palliative Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Rachel Quibell
- RVI Palliative Care, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Tomasz Bajorek
- Psychological Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Suvankar Pal
- University of Edinburgh, National CJD Research and Surveillance Unit, Edinburgh, UK
| | - Victoria Bradley
- Sobell House, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
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Burke O, Jacobs JW, Tormey CA, Rinder HM, Figueroa Villalba CA, Lee ES, Silva Campos JJ, Abels E, Yurtsever N. Heidenhain variant of Creutzfeldt-Jakob disease masquerading as neuromyelitis optica spectrum disorder: recognizing when apheresis is not the answer. Lab Med 2024; 55:520-523. [PMID: 38142129 DOI: 10.1093/labmed/lmad107] [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: 12/25/2023] Open
Abstract
The Heidenhain variant of Creutzfeld-Jakob disease (CJD) is a rare form that initially presents with visual disturbances. In early stages, the presentation can mimic neuromyelitis optica spectrum disorders (NMOSD) and lead to unnecessary treatment modalities. Herein, we describe a case of a 66-year-old man who presented with bilateral vision loss and retro-orbital discomfort. In addition to immunosuppressive therapy, he received 4 rounds of therapeutic plasma exchange after his preliminary diagnosis of NMOSD. We were surprised to note that his condition did not show improvement but deteriorated, with severe neurocognitive symptoms. Eventually, CJD was suspected, and real-time quaking-induced conversion (RT-QuIC) was performed. By the time the diagnosis of Heidenhain variant of CJD was confirmed, the patient was discharged to hospice care and died shortly after.
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Affiliation(s)
- Olivia Burke
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
- Department of Pathology, and Yale School of Medicine, New Haven, CT, US
| | - Jeremy W Jacobs
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, US
| | | | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
- Internal Medicine (Hematology), Yale School of Medicine, New Haven, CT, US
| | | | - Edward S Lee
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
| | - Juan J Silva Campos
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
- Department of Pathology, and Yale School of Medicine, New Haven, CT, US
| | - Elizabeth Abels
- Department of Pathology, Baylor College of Medicine, Houston, TX, US
| | - Nalan Yurtsever
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
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McDermott EA, Watson N, Tam J, Centola J, Kurucu King H, Mackenzie J, Summers D, Green A, Barria MA, Smith C, Pal S. Sporadic Creutzfeldt-Jakob disease in adults over 80 years: a 10-year review of United Kingdom surveillance. Age Ageing 2024; 53:afae086. [PMID: 38706391 PMCID: PMC11070723 DOI: 10.1093/ageing/afae086] [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: 09/09/2023] [Revised: 02/25/2024] [Indexed: 05/07/2024] Open
Abstract
INTRODUCTION Sporadic Creutzfeldt-Jakob disease (sCJD) is a rapidly progressive neurodegenerative disease with public health implications. Mean age of onset is 68 years. Age-specific incidence declines after 80 years. This may arise from under-ascertainment or other biological features of the disease. Accurate characterisation of late-onset sCJD is important for early diagnosis, avoiding unnecessary investigations and improving ascertainment for public health purposes. OBJECTIVE To phenotype the clinical features and investigation profile of sCJD in adults >80 years. METHODS We analysed all probable and definite sCJD cases identified by the UK National CJD Research & Surveillance Unit over a 10-year period (2011-2021). Individuals were grouped by age of onset. Clinical features and investigation profiles were compared. RESULTS 10.3% (123/1196) had an age of onset over 80. Median survival was shorter (3.2 vs 4.3 months; P < 0.001). Pyramidal signs (48.3% vs 34.2%; P = 0.008) and akinetic mutism (55.1% vs 33.2%; P < 0.001) were more frequent. Psychiatric symptoms (26.3% vs 39.6%; P = 0.01) and cerebellar signs (65.4% vs 78.6%, P = 0.007) were less frequent. Cognitive impairment and myoclonus were highly prevalent regardless of age. Between age groups, the diagnostic sensitivity of cerebrospinal fluid real-time quaking-induced conversion (CSF RT-QuIC) (92.9% vs 91.9%, P = 0.74) was comparable, electroencephalography was superior (41.5% vs 25.4%; P = 0.006) and MRI was inferior (67.8% vs 91.4%; P < 0.001). CONCLUSIONS Late-onset sCJD has distinct clinical features, shorter survival and a different profile of investigation sensitivity. CSF RT-QuIC, MRI brain and specialist CJD review is recommended in older adults with a rapidly progressive neurological disorder. Autopsy is valuable when the cause remains elusive.
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Affiliation(s)
- Eugene Ace McDermott
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Neil Watson
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Johnny Tam
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - John Centola
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hatice Kurucu King
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jan Mackenzie
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - David Summers
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alison Green
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Marcelo A Barria
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Colin Smith
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Suvankar Pal
- The National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Sahyouni M, Casey B, Carpenter Z, Estrella F, Okafor C. Euphoric Presentation in Creutzfeldt-Jakob Disease and Its Diagnostic Implications: A Case Report. Cureus 2024; 16:e57419. [PMID: 38694643 PMCID: PMC11062774 DOI: 10.7759/cureus.57419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/04/2024] Open
Abstract
Creutzfeldt-Jakob disease (CJD) constitutes an aggressively advancing, terminal neurodegenerative condition classified within the spectrum of transmissible spongiform encephalopathies. The difficulty in establishing a diagnosis before death arises from the condition's rarity and the resulting limited level of suspicion attributed to it. The polymorphic nature of CJD symptoms contributes to the challenge of early diagnostic recognition. Emotional and behavioral changes have been well documented, but the initial presentation of euphoria has not been documented. Here, we present the case of a female patient who was experiencing an unusual state of euphoria followed by intermittently altered mental status. She was ultimately diagnosed with sporadic CJD, discharged home on hospice, and died within six months of discharge.
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Affiliation(s)
- Mark Sahyouni
- Internal Medicine, Campbell University School of Osteopathic Medicine, Buies Creek, USA
- Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
| | - Bradley Casey
- Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
| | - Zachary Carpenter
- Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
| | - Frank Estrella
- Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
| | - Chika Okafor
- Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
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Zerr I, Ladogana A, Mead S, Hermann P, Forloni G, Appleby BS. Creutzfeldt-Jakob disease and other prion diseases. Nat Rev Dis Primers 2024; 10:14. [PMID: 38424082 DOI: 10.1038/s41572-024-00497-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
Prion diseases share common clinical and pathological characteristics such as spongiform neuronal degeneration and deposition of an abnormal form of a host-derived protein, termed prion protein. The characteristic features of prion diseases are long incubation times, short clinical courses, extreme resistance of the transmissible agent to degradation and lack of nucleic acid involvement. Sporadic and genetic forms of prion diseases occur worldwide, of which genetic forms are associated with mutations in PRNP. Human to human transmission of these diseases has occurred due to iatrogenic exposure, and zoonotic forms of prion diseases are linked to bovine disease. Significant progress has been made in the diagnosis of these disorders. Clinical tools for diagnosis comprise brain imaging and cerebrospinal fluid tests. Aggregation assays for detection of the abnormally folded prion protein have a clear potential to diagnose the disease in peripherally accessible biofluids. After decades of therapeutic nihilism, new treatment strategies and clinical trials are on the horizon. Although prion diseases are relatively rare disorders, understanding their pathogenesis and mechanisms of prion protein misfolding has significantly enhanced the field in research of neurodegenerative diseases.
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Affiliation(s)
- Inga Zerr
- National Reference Center for CJD Surveillance, Department of Neurology, University Medical Center, Georg August University, Göttingen, Germany.
| | - Anna Ladogana
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Simon Mead
- MRC Prion Unit at UCL, Institute of Prion Diseases, London, UK
| | - Peter Hermann
- National Reference Center for CJD Surveillance, Department of Neurology, University Medical Center, Georg August University, Göttingen, Germany
| | - Gianluigi Forloni
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Brian S Appleby
- Departments of Neurology, Psychiatry and Pathology, Case Western Reserve University, Cleveland, OH, USA
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Calva-González M, Tello-Gerez TJ, Serrano-Arias F, Cano-Nigenda V, Ramírez-Bermúdez J. The Neuropsychiatric Side of Cerebral Venous Thrombosis: A Case of Delirium and Catatonia. J Psychiatr Pract 2023; 29:493-498. [PMID: 37948175 DOI: 10.1097/pra.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
We report a patient with cerebral venous thrombosis who initially presented with psychosis and who then progressed to delirium and catatonia within a few days. Upon treatment and resolution of the thrombosis, she presented complete remission of the psychiatric disturbances. This case highlights a specific neuropsychiatric presentation of cerebral venous thrombosis involving psychosis, catatonia, and delirium, which, to our best knowledge, has not been reported in the neurological or psychiatric literature. However, it reminds us of mental status and behavioral abnormalities which are not infrequent features of cerebral venous thrombosis. This leads to a discussion regarding the psychopathology, etiology, and pathophysiology of the case.
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Kitazaki Y, Ikawa M, Hamano T, Sasaki H, Yamaguchi T, Enomoto S, Shirafuji N, Hayashi K, Yamamura O, Tsujikawa T, Okazawa H, Kimura H, Nakamoto Y. Magnetic resonance imaging arterial spin labeling hypoperfusion with diffusion-weighted image hyperintensity is useful for diagnostic imaging of Creutzfeldt-Jakob disease. Front Neurol 2023; 14:1242615. [PMID: 37885479 PMCID: PMC10598551 DOI: 10.3389/fneur.2023.1242615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/14/2023] [Indexed: 10/28/2023] Open
Abstract
Background and objectives Magnetic resonance imaging with arterial spin labeling (ASL) perfusion imaging is a noninvasive method for quantifying cerebral blood flow (CBF). We aimed to evaluate the clinical utility of ASL perfusion imaging to aid in the diagnosis of Creutzfeldt-Jakob disease (CJD). Methods This retrospective study enrolled 10 clinically diagnosed with probable sporadic CJD (sCJD) based on the National CJD Research & Surveillance Unit and EuroCJD criteria and 18 healthy controls (HCs). Diffusion-weighted images (DWIs), CBF images obtained from ASL, N-isopropyl-(123I)-p-iodoamphetamine (123IMP)-single-photon emission computed tomography (SPECT) images, and 18F-fluorodeoxyglucose (18FDG)-positron emission tomography (PET) images were analyzed. First, the cortical values obtained using volume-of-interest (VOI) analysis were normalized using the global mean in each modality. The cortical regions were classified into DWI-High (≥ +1 SD) and DWI-Normal (< +1 SD) regions according to the DWI-intensity values. The normalized cortical values were compared between the two regions for each modality. Second, each modality value was defined as ASL hypoperfusion (< -1 SD), SPECT hypoperfusion (< -1 SD), and PET low accumulation (< -1 SD). The overall agreement rate of DWIs with ASL-CBF, SPECT, and PET was calculated. Third, regression analyses between the normalized ASL-CBF values and normalized SPECT or PET values derived from the VOIs were performed using a scatter plot. Results The mean values of ASL-CBF (N = 10), 123IMP-SPECT (N = 8), and 18FDG-PET (N = 3) in DWI-High regions were significantly lower than those in the DWI-Normal regions (p < 0.001 for all); however, HCs (N = 18) showed no significant differences in ASL-CBF between the two regions. The overall agreement rate of DWI (high or normal) with ASL-CBF (hypoperfusion or normal) (81.8%) was similar to that of SPECT (85.2%) and PET (78.5%) in CJD. The regression analysis showed that the normalized ASL-CBF values significantly correlated with the normalized SPECT (r = 0.44, p < 0.001) and PET values (r = 0.46, p < 0.001) in CJD. Discussion Patients with CJD showed ASL hypoperfusion in lesions with DWI hyperintensity, suggesting that ASL-CBF could be beneficial for the diagnostic aid of CJD.
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Affiliation(s)
- Yuki Kitazaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
- Department of Aging and Dementia (DAD), University of Fukui, Fukui, Japan
- Life Science Innovation Center, University of Fukui, Fukui, Japan
| | - Hirohito Sasaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tomohisa Yamaguchi
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Soichi Enomoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Norimichi Shirafuji
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kouji Hayashi
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
- Department of Rehabilitation, Faculty of Health Science, Fukui Health Science University, Fukui, Japan
| | - Osamu Yamamura
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tetsuya Tsujikawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Hirohiko Kimura
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Jabarkhil AA, Rasib AR, Asady A, Farzam F. Misdiagnosis of rarest subtype of sporadic Creutzfeldt Jakob Disease: a case report. BMC Neurol 2023; 23:274. [PMID: 37464286 DOI: 10.1186/s12883-023-03318-z] [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: 11/24/2022] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Creutzfeldt-Jakob disease (CJD), is a deadly degenerative condition of the central nervous system marked by rapidly progressive dementia. Magnetic resonance imaging (MRI) abnormalities in the cerebral cortex, basal ganglia, thalamus, and cerebellum could indicate severe acute diseases caused by a variety of factors. Although their MRI patterns may resemble those of CJD, clinical history, additional MRI findings, and laboratory testing are all necessary to provide a reliable difference. Here, we report a misdiagnosed case of probable VV1 subtype of sporadic CJD (sCJD) in which follow-up MRI supported the diagnosis. CASE PRESENTATION A 41-year-old male patient attended the Neuropsychiatry Department with rapidly progressive dementia, akinetic mutism, and difficulty walking and speaking. His problem began with forgetfulness, disorganized behavior, and disorganized speech 7 months earlier which progressed rapidly and was accompanied by aphasia, apraxia, agnosia, and akinetic mutism in the last 2 months. On neurologic examination, hypertonia, hyperreflexia, frontal ataxia, bradykinesia, gait apraxia, and aphasia were noted. Based on clinical features and rapid symptoms progression the likely diagnosis of CJD was suspected. MRI and electroencephalography (EEG) were advised. MRI revealed features of diffuse cortical injury of both cerebral hemispheres also involving bilateral corpus striatum with evidence of cerebral volume loss. EEG showed lateralized periodic theta slow waves on the right side. According to the CDC's diagnostic criteria for CJD, the diagnosis of probable sCJD was established. Supportive care and symptomatic treatment are provided for the patient. After a 1-month follow up the patient's condition deteriorated significantly. The time-lapse from the first reported symptom to death was about 13 months. CONCLUSION The need of addressing CJD in patients presenting with rapidly progressive dementia is highlighted in this case report. In the early stages of the disease, interpretation of MRI results might cause diagnostic difficulties; therefore, follow-up MRI is critical in obtaining the correct diagnosis.
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Affiliation(s)
- Aemal Aziz Jabarkhil
- Department of Neuropsychiatry, Kabul University of Medical Sciences, Kabul, 1001, Afghanistan
| | - Aziz Rahman Rasib
- Department of Neuropsychiatry, Kabul University of Medical Sciences, Kabul, 1001, Afghanistan.
| | - Abdullah Asady
- Department of Microbiology, Kabul University of Medical Sciences, Kabul, 1001, Afghanistan
| | - Farhad Farzam
- Department of Medical Imaging and Radiation Sciences, Kabul University of Medical Sciences, Kabul, 1001, Afghanistan
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Kishida H, Ueda N, Tanaka F. The advances in the early and accurate diagnosis of Creutzfeldt-Jakob disease and other prion diseases: where are we today? Expert Rev Neurother 2023; 23:803-817. [PMID: 37581576 DOI: 10.1080/14737175.2023.2246653] [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] [Received: 05/16/2023] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Before the introduction of MRI diffusion-weighted images (DWI), the diagnosis of Creutzfeldt-Jakob disease (CJD) relied upon nonspecific findings including clinical symptoms, EEG abnormalities, and elevated levels of cerebrospinal fluid 14-3-3 protein. Subsequently, the use of DWI has improved diagnostic accuracy, but it sometimes remains difficult to differentiate CJD from encephalitis, epilepsy, and other dementing disorders. The revised diagnostic criteria include real-time quaking-induced conversion (RT-QuIC), detecting small amounts of CJD-specific prion protein, and clinically sensitive DWI. Combining these techniques has further improved diagnostic accuracy, enabling earlier diagnosis. AREAS COVERED Herein, the authors review the recent advances in diagnostic methods and revised diagnostic criteria for sporadic CJD. They also discuss other prion diseases, such as variant CJD and chronic wasting disease, where the emergence of new types is a concern. EXPERT OPINION Despite improvements in diagnostic methods and criteria, some subtypes of prion disease are still difficult to diagnose, and even the diagnosis using the most innovative RT-QuIC test remains a challenge in terms of accuracy and standardization. However, these revised criteria can be adapted to the emergence of new types of prion diseases. It is essential to continue careful surveillance and update information on the latest prion disease phenotypes.
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Affiliation(s)
- Hitaru Kishida
- Department of Neurology, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Naohisa Ueda
- Department of Neurology, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Alloush TK, Alloush AT, Abdelazeem Y, Shokri HM, Abdulghani KO, Elzoghby A. Creutzfeldt-Jakob disease in a post-COVID-19 patient: did SARS-CoV-2 accelerate the neurodegeneration? THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023; 59:69. [PMID: 37251549 PMCID: PMC10201512 DOI: 10.1186/s41983-023-00666-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Background Creutzfeldt-Jakob disease (CJD) is a rare, fatal neurodegenerative disorder, with few months as a usual duration from onset to death. Case presentation In this case report, a patient of Sporadic CJD (sCJD) who presented one month after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The diagnosis of this case was established after confirming findings from clinical, neurophysiology, radiological, and laboratory features of this disease. Conclusion Putting in mind all the updated data on the pathogenesis of CJD and the immune responses to SARS-CoV-2, we can suggest that COVID-19 can lead to accelerated pathogenesis and exaggerated manifestations of this fatal neurodegenerative disease.
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Affiliation(s)
- Taha K. Alloush
- Department of Neurology and Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Adel T. Alloush
- Department of Geriatrics and Gerontology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Yaser Abdelazeem
- Departement of Diagnostic Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hossam M. Shokri
- Department of Neurology and Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Khaled O. Abdulghani
- Department of Neurology and Psychiatry, Helwan University School of Medicine, Cairo, Egypt
| | - Ahmed Elzoghby
- Departement of Diagnostic Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Tam J, Centola J, Kurudzhu H, Watson N, MacKenzie J, Leitch M, Hughes T, Green A, Summers D, Barria M, Smith C, Pal S. Sporadic Creutzfeldt-Jakob Disease in the young (50 and below): 10-year review of United Kingdom surveillance. J Neurol 2023; 270:1036-1046. [PMID: 36334135 PMCID: PMC9886636 DOI: 10.1007/s00415-022-11467-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Sporadic Creutzfeldt-Jakob Disease (sCJD) is the commonest human prion disease, with a median age of onset of 68 years. We characterise the clinical, investigation, and neuropathological features in young individuals with sCJD using data from UK national CJD surveillance. METHODS Referrals between 2011 and 2021 were examined, with definite (post-mortem confirmed) or probable sCJD cases included. Clinical features, MRI, EEG, CSF RT-QuIC, 14-3-3, PRNP sequencing and neuropathological findings were examined. We compared younger (≤ 50 years age of onset) with older individuals. Records of Non-sCJD referrals were also reviewed. RESULTS 46 (4%) young individuals were identified (age at onset 25-50) from 1178 cases. 15 (33%) were autopsy confirmed. Psychiatric disturbance (37% vs 22%, p = 0.02) and headache (11% vs 3%, p = 0.01) at presentation, and longer disease duration (by 1.45 months, 95% CI 0.43-2.79, logrank p = 0.007) were commoner. CSF RT-QuIC showed lower sensitivity (82% vs 93%, p = 0.02). There was no difference in sensitivity of MR brain or CSF 14-3-3. There were no significant co-pathologies in autopsy-confirmed cases. For non-sCJD referrals, 41 cases were of other CJD subtypes, and 7 non-prion diagnoses. CONCLUSIONS Young-onset sCJD is more likely to present with neuropsychiatric symptoms and headache, longer disease duration, and lower sensitivity of RT-QuIC. These findings may be driven by the underlying molecular subtypes. Our results guide the evaluation of younger individuals presenting with rapidly progressive cognitive, neuropsychiatric, and motor decline, and emphasise the need for additional vigilance for atypical features by clinicians and CJD surveillance programmes worldwide.
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Affiliation(s)
- Johnny Tam
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - John Centola
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Hatice Kurudzhu
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Neil Watson
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Janet MacKenzie
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Margaret Leitch
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Terri Hughes
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Alison Green
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - David Summers
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Marcelo Barria
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Colin Smith
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK
| | - Suvankar Pal
- National CJD Research & Surveillance Unit (NCJDRSU), Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, Scotland, UK.
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12
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Gurram S, Holla VV, Sharma P, Kamble N, Saini J, Netravathi M, Yadav R, Pal PK. Spectrum and Pattern of Movement Disorders in Patients with Sporadic Creutzfeldt-Jakob Disease. Tremor Other Hyperkinet Mov (N Y) 2023; 13:14. [PMID: 37152622 PMCID: PMC10162196 DOI: 10.5334/tohm.753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/20/2023] [Indexed: 05/09/2023] Open
Abstract
Background Creutzfeldt-Jakob disease (CJD) is a rare neuro degenerative disease that is mainly characterized by rapidly progressive dementia along with a varying combination of myoclonus, visual, cerebellar, pyramidal/extrapyramidal and akinetic mutism. Several movement disorders phenomenologies can occurs either at onset, as presenting symptom or during the course of illness. Present study aims to characterize the clinical, radiological features and the outcome of patients with CJD with movement disorders as the forthcoming manifestation. Methods Chart review of patients with CJD with movement disorders. Demographic, clinical and radiological details of the patients were reviewed. Results 25 patients (13 males) of sCJD with median age at presentation of 58 years and median duration of illness of 5 months were included in the study. According to revised CDC diagnostic criteria 1 patient was classified as definite sCJD, 20 as probable and 2 as possible CJD. Myoclonus, ataxia and parkinsonism were the most common movement disorder and chorea was the least common. Magnetic resonance imaging of brain was performed in all and basal ganglia abnormality and cortical ribboning was seen in more than two-third of cases. Electroencephalographic abnormality was noted in 21 patients with triphasic waves and periodic sharp waves seen in 7 and 6 patients respectively. Cerebrospinal fluid 14-3-3 assay was abnormal in 2 out of 4 patients. Atypical presentations were noted in the form of ataxic presentation, CBS like presentation and choreiform presentation. Conclusion Myoclonus, ataxia and parkinsonism are the most frequent movement disorders phenomenology observed in patients with sCJD.
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Affiliation(s)
- Sandeep Gurram
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Vikram V. Holla
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Praveen Sharma
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Nitish Kamble
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Manjunath Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health & Neurosciences, Hosur Road, Bengaluru-560029, Karnataka, India
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13
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Zhang J. Investigating neurological symptoms of infectious diseases like COVID-19 leading to a deeper understanding of neurodegenerative disorders such as Parkinson's disease. Front Neurol 2022; 13:968193. [PMID: 36570463 PMCID: PMC9768197 DOI: 10.3389/fneur.2022.968193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/08/2022] [Indexed: 12/12/2022] Open
Abstract
Apart from common respiratory symptoms, neurological symptoms are prevalent among patients with COVID-19. Research has shown that infection with SARS-CoV-2 accelerated alpha-synuclein aggregation, induced Lewy-body-like pathology, caused dopaminergic neuron senescence, and worsened symptoms in patients with Parkinson's disease (PD). In addition, SARS-CoV-2 infection can induce neuroinflammation and facilitate subsequent neurodegeneration in long COVID, and increase individual vulnerability to PD or parkinsonism. These findings suggest that a post-COVID-19 parkinsonism might follow the COVID-19 pandemic. In order to prevent a possible post-COVID-19 parkinsonism, this paper reviewed neurological symptoms and related findings of COVID-19 and related infectious diseases (influenza and prion disease) and neurodegenerative disorders (Alzheimer's disease, PD and amyotrophic lateral sclerosis), and discussed potential mechanisms underlying the neurological symptoms and the relationship between the infectious diseases and the neurodegenerative disorders, as well as the therapeutic and preventive implications in the neurodegenerative disorders. Infections with a relay of microbes (SARS-CoV-2, influenza A viruses, gut bacteria, etc.) and prion-like alpha-synuclein proteins over time may synergize to induce PD. Therefore, a systematic approach that targets these pathogens and the pathogen-induced neuroinflammation and neurodegeneration may provide cures for neurodegenerative disorders. Further, antiviral/antimicrobial drugs, vaccines, immunotherapies and new therapies (e.g., stem cell therapy) need to work together to treat, manage or prevent these disorders. As medical science and technology advances, it is anticipated that better vaccines for SARS-CoV-2 variants, new antiviral/antimicrobial drugs, effective immunotherapies (alpha-synuclein antibodies, vaccines for PD or parkinsonism, etc.), as well as new therapies will be developed and made available in the near future, which will help prevent a possible post-COVID-19 parkinsonism in the 21st century.
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Affiliation(s)
- Jing Zhang
- Department of Neurology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
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14
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Barnwal S, Jha G, Sola SC, Anand P, Shariff SY. Creutzfeldt-Jakob Disease: A Case Report and Literature Review for Understanding the Big Picture. Cureus 2022; 14:e31303. [PMID: 36398040 PMCID: PMC9647838 DOI: 10.7759/cureus.31303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
Abstract
Creutzfeldt-Jakob disease (CJD) is a rare, rapidly progressive neurodegenerative disorder that has an invariably fatal outcome. Aside from rapidly progressive dementia, this condition manifests as myoclonus, cerebellar, pyramidal, extrapyramidal, visual, and psychiatric symptoms. On the other hand, nonspecific symptoms might be difficult to diagnose, leading to a late or incorrect diagnosis. Given its high fatality, most patients die within 12 months of the disease's onset. This case report describes a healthy man who presented with cerebellar and pyramidal signs along with memory loss worsening over six weeks. He also had indications of corticobasal degeneration, such as myoclonus and alien limb syndrome, but with reasonably maintained cognition. These signs are all non-specific, and premortem diagnosis is typically difficult and challenging owing to a lack of knowledge and clinical suspicion. However, after a thorough and extensive investigation, CJD was diagnosed. Despite the fact that CJD is a rare disease, it should always be included in the differential diagnosis whenever neuropsychological manifestations are present. Nevertheless, CJD can be successfully and promptly ruled out with a detailed clinical examination and appropriate investigation.
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15
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Sequeira D, Nihat A, Mok T, Coysh T, Rudge P, Collinge J, Mead S. Prevalence and Treatments of Movement Disorders in Prion Diseases: A Longitudinal Cohort Study. Mov Disord 2022; 37:1893-1903. [PMID: 35841311 PMCID: PMC9543300 DOI: 10.1002/mds.29152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prion diseases cause a range of movement disorders involving the cortical, extrapyramidal, and cerebellar systems, and yet there are no large systematic studies of their prevalence, features, associations, and responses to commonly used treatments. OBJECTIVES We sought to describe the natural history and pharmacological management of movement disorders in prion diseases. METHODS We studied the serial examination findings, investigation results, and symptomatic treatment recorded for 700 patients with prion diseases and 51 mimics who had been enrolled onto the prospective longitudinal National Prion Monitoring Cohort study between 2008 and 2020. We performed an analysis to identify whether there were patterns of movement disorders associated with disease aetiology, PRNP codon 129 polymorphism, disease severity rating scales, magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) findings. RESULTS Gait disturbances, myoclonus, and increased tone are the most frequently observed movement disorders in patients with prion diseases. The typical pattern of early motor dysfunction involves gait disturbance, limb ataxia, impaired smooth pursuit, myoclonus, tremor, and increased limb tone. Disturbances of gait, increased tone, and myoclonus become more prevalent and severe as the disease progresses. Chorea, alien limb phenomenon, and nystagmus were the least frequently observed movement disorders, with these symptoms showing spontaneous resolution in approximately half of symptomatic patients. Disease severity and PRNP codon 129 polymorphism were associated with different movement disorder phenotypes. Antiepileptics and benzodiazepines were found to be effective in treating myoclonus. CONCLUSIONS We describe the prevalence, severity, evolution, treatment, and associated features of movement disorders in prion diseases based on a prospective cohort study. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Danielle Sequeira
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
| | - Akin Nihat
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
| | - Tzehow Mok
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
| | - Thomas Coysh
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
| | - Peter Rudge
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
| | - John Collinge
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
| | - Simon Mead
- National Prion ClinicUniversity College London Hospitals NHS Foundation TrustLondonUK,MRC Prion Unit at UCLInstitute of Prion DiseasesLondonUK
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16
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Kanguru L, Logan G, Waddel B, Smith C, Molesworth A, Knight R. A clinicopathological study of selected cognitive impairment cases in Lothian, Scotland: enhanced CJD surveillance in the 65 + population group. BMC Geriatr 2022; 22:603. [PMID: 35858858 PMCID: PMC9298168 DOI: 10.1186/s12877-022-03280-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Background Variant Creutzfeldt-Jakob Disease (vCJD) is primarily associated with dietary exposure to bovine-spongiform-encephalopathy. Cases may be missed in the elderly population where dementia is common with less frequent referral to specialist neurological services. This study’s twin aims were to determine the feasibility of a method to detect possible missed cases in the elderly population and to identify any such cases. Methods A multi-site study was set-up in Lothian in 2016, to determine the feasibility of enhanced CJD-surveillance in the 65 + population-group, and undertake a clinicopathological investigation of patients with features of ‘atypical’ dementia. Results Thirty patients are included; 63% male, 37% female. They were referred because of at least one neurological feature regarded as ‘atypical’ (for the common dementing illnesses): cerebellar ataxia, rapid progression, or somato-sensory features. Mean-age at symptom-onset (66 years, range 53–82 years), the time between onset-of-symptoms and referral to the study (7 years, range 1–13 years), and duration-of-illness from onset-of-symptoms until death or the censor-date (9.5 years, range 1.1–17.4 years) were determined. By the censor-date, 9 cases were alive and 21 had died. Neuropathological investigations were performed on 10 cases, confirming: Alzheimer’s disease only (2 cases), mixed Alzheimer’s disease with Lewy bodies (2 cases), mixed Alzheimer’s disease with amyloid angiopathy (1 case), moderate non-amyloid small vessel angiopathy (1 case), a non-specific neurodegenerative disorder (1 case), Parkinson's disease with Lewy body dementia (1 case), and Lewy body dementia (2 cases). No prion disease cases of any type were detected. Conclusion The surveillance approach used was well received by the local clinicians and patients, though there were challenges in recruiting sufficient cases; far fewer than expected were identified, referred, and recruited. Further research is required to determine how such difficulties might be overcome. No missed cases of vCJD were found. However, there remains uncertainty whether this is because missed cases are very uncommon or because the study had insufficient power to detect them.
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Affiliation(s)
- Lovney Kanguru
- National CJD Research & Surveillance Unit (NCJDRSU), University of Edinburgh, Western General Hospital, Edinburgh, Scotland.
| | - Gemma Logan
- NHS Lothian and Queen Margaret University, Edinburgh, Scotland
| | - Briony Waddel
- Department of Neurology, Ninewells Hospital, Dundee, Scotland
| | - Colin Smith
- National CJD Research & Surveillance Unit (NCJDRSU), University of Edinburgh, Western General Hospital, Edinburgh, Scotland.,Edinburgh Brain Bank (EBB), Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, Scotland
| | | | - Richard Knight
- National CJD Research & Surveillance Unit (NCJDRSU), University of Edinburgh, Western General Hospital, Edinburgh, Scotland
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17
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Establishing a committee for antemortem reviews of suspect Creutzfeldt-Jakob disease cases in Ireland. Ir J Med Sci 2022:10.1007/s11845-022-03070-2. [PMID: 35840825 PMCID: PMC9286704 DOI: 10.1007/s11845-022-03070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/11/2022] [Indexed: 11/09/2022]
Abstract
Background
Creutzfeldt-Jakob disease (CJD) is a rapidly progressive, neurodegenerative disease. In Ireland, clinical diagnostics and laboratory testing remain the responsibility of the managing clinician and the Neuropathology Department at the Beaumont Hospital, respectively. Centralized review of individual cases is not undertaken. Aims To determine how diagnostic processes for CJD could be improved in Ireland and to outline the structure and referral process for a new CJD review panel at the Beaumont Hospital. Methods We surveyed Irish neurologists’ experiences on the management of CJD in Ireland. We measured turnaround times (TAT) for CSF samples referred for diagnostic CJD testing. Finally, we retrospectively reviewed imaging of autopsy-proven CJD cases to compare with initial reports. Results Ninety-three percent of neurologists supported a national central review of suspect CJD cases. A second clinical opinion was considered to be of likely benefit by 79%. Additionally, 93% reported that a centralized review of neuroradiology would be useful. All respondents felt that expediting turnaround of CSF analysis would be of benefit. The average TAT for CSF testing was 35.4 days. In retrospective review of imaging, all patients demonstrated MRI findings consistent with CJD. However, in only one of these cases were the initial pre-autopsy radiological findings reported as being consistent with CJD. Conclusions These findings support the need for improvements to the Irish National CJD Surveillance Unit to maximize antemortem diagnostic accuracy. On foot of this, a clinical CJD Multidisciplinary Team (CJD MDT) has been established to provide a second opinion on (i) the patient’s clinical history, (ii) neuroradiology and (iii) and neurophysiology reports (where available).
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18
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Bhatia P, Sonbol M, Jain D, Rincon-Flores N, Frontera A. Status Epilepticus in Creutzfeldt-Jakob Disease: A Case Report of an Unusual Presentation. Cureus 2022; 14:e26470. [PMID: 35919371 PMCID: PMC9338842 DOI: 10.7759/cureus.26470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/05/2022] Open
Abstract
Although non-prion neurodegenerative illnesses are the main causes of rapidly progressive dementia (RPD), a case of RPD should be evaluated for Creutzfeldt-Jakob disease (CJD), a kind of prion disease. We describe a 71-year-old man who first displayed a lack of coordination before developing focal seizures accompanied by myoclonic jerks as well as left hemibody weakness and incoordination. As part of the additional diagnostic workup, cerebrospinal fluid (CSF) analyses, 72 hours of prolonged electroencephalogram (EEG) monitoring, and additional brain imaging were obtained. Cortical ribboning was seen in the magnetic resonance imaging (MRI) of the brain, protein 14-3-3 test in the CSF was normal, lateralized and generalized periodic discharges were seen on the EEG. After the patient was examined for additional causes, such as autoimmune encephalitis and seizures, the diagnosis of likely CJD was made. Ultimately, an autopsy was performed and confirmed the diagnosis of definitive CJD.
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19
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Abstract
PURPOSE OF REVIEW This article presents a practical approach to the evaluation of patients with rapidly progressive dementia. RECENT FINDINGS The approach presented in this article builds upon the standard dementia evaluation, leveraging widely available tests and emergent specific markers of disease to narrow the differential diagnosis and determine the cause(s) of rapid progressive decline. The discovery of treatment-responsive causes of rapidly progressive dementia underscores the need to determine the cause early in the symptomatic course when treatments are most likely to halt or reverse cognitive decline. SUMMARY A pragmatic and organized approach to patients with rapidly progressive dementia is essential to mitigate diagnostic and therapeutic challenges and optimize patient outcomes.
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20
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Hermann P, Zerr I. Rapidly progressive dementias - aetiologies, diagnosis and management. Nat Rev Neurol 2022; 18:363-376. [PMID: 35508635 PMCID: PMC9067549 DOI: 10.1038/s41582-022-00659-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/15/2022]
Abstract
Rapidly progressive dementias (RPDs) are a group of heterogeneous disorders that include immune-mediated, infectious and metabolic encephalopathies, as well as prion diseases and atypically rapid presentations of more common neurodegenerative diseases. Some of these conditions are treatable, and some must be diagnosed promptly because of their potential infectivity. Prion disease is considered to be the prototypical RPD, but over the past two decades, epidemiological reports and the identification of various encephalitis-mediating antibodies have led to a growing recognition of other encephalopathies as potential causes of rapid cognitive decline. Knowledge of RPD aetiologies, syndromes and diagnostic work-up protocols will help clinicians to establish an early, accurate diagnosis, thereby reducing morbidity and mortality, especially in immune-mediated and other potentially reversible dementias. In this Review, we define the syndrome of RPD and shed light on its different aetiologies and on secondary factors that might contribute to rapid cognitive decline. We describe an extended diagnostic procedure in the context of important differential diagnoses, discuss the utility of biomarkers and summarize potential treatment options. In addition, we discuss treatment options such as high-dose steroid therapy in the context of therapy and diagnosis in clinically ambiguous cases. The term ‘rapidly progressive dementia’ (RPD) describes a cognitive disorder with fast progression, leading to dementia within a relatively short time. This Review discusses the wide range of RPD aetiologies, as well as the diagnostic approach and treatment options. Definitions of rapidly progressive dementia (RPD) vary according to the aetiological background and relate to the speed of cognitive decline, time from first symptom to dementia syndrome and/or overall survival. RPD can occur in rapidly progressive neurodegenerative diseases, such as prion diseases, or in primarily slowly progressive diseases as a consequence of intrinsic factors or concomitant pathologies. Besides neurodegenerative diseases, inflammatory (immune-mediated and infectious), vascular, metabolic and neoplastic CNS diseases are important and frequent causes of RPD. To identify treatable causes of RPD, the technical diagnostic work-up must include MRI and analyses of blood and cerebrospinal fluid, and further diagnostics might be indicated in unclear cases. Therapeutic options for many non-neurodegenerative causes of RPD are already available; disease-modifying therapies for neurodegenerative RPDs are an important focus of current research and could become a treatment option in the near future.
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Affiliation(s)
- Peter Hermann
- Department of Neurology, Clinical Dementia Center and National Reference Center for CJD Surveillance, University Medical Center, Göttingen, Germany
| | - Inga Zerr
- Department of Neurology, Clinical Dementia Center and National Reference Center for CJD Surveillance, University Medical Center, Göttingen, Germany. .,German Center for Neurodegenerative Diseases (DZNE), Göttingen, Germany.
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21
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Corriveau-Lecavalier N, Li W, Ramanan VK, Drubach DA, Day GS, Jones DT. Three cases of Creutzfeldt-Jakob disease presenting with a predominant dysexecutive syndrome. J Neurol 2022; 269:4222-4228. [PMID: 35233692 PMCID: PMC9516260 DOI: 10.1007/s00415-022-11045-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022]
Abstract
Creutzfeldt-Jakob disease (CJD) is a rare, uniformly fatal prion disease. Although CJD commonly presents with rapidly progressive dementia, ataxia, and myoclonus, substantial clinicopathological heterogeneity is observed in clinical practice. Unusual and predominantly cognitive clinical manifestations of CJD mimicking common dementia syndromes are known to pose as an obstacle to early diagnosis and prognosis. We report a series of three patients with probable or definite CJD (one male and two females, ages 52, 58 and 68) who presented to our tertiary behavioral neurology clinic at Mayo Clinic Rochester that met criteria for a newly defined progressive dysexecutive syndrome. Glucose hypometabolism patterns assessed by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) strongly resembled those of dysexecutive variant of Alzheimer's disease (dAD). However, magnetic resonance imaging (MRI) demonstrated restricted diffusion in neocortical areas and deep nuclei, while cerebrospinal fluid biomarkers indicated abnormal levels of 14-3-3, total-tau, and prion seeding activity (RT-QuIC), establishing the diagnosis of CJD. Electroencephalogram (EEG) additionally revealed features previously documented in atypical cases of CJD. This series of clinical cases demonstrates that CJD can present with a predominantly dysexecutive syndrome and FDG-PET hypometabolism typically seen in dAD. This prompts for the need to integrate information on clinical course with multimodal imaging and fluid biomarkers to provide a precise etiology for dementia syndromes. This has important clinical implications for the diagnosis and prognosis of CJD in the context of emerging clinical characterization of progressive dysexecutive syndromes in neurodegenerative diseases like dAD.
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Affiliation(s)
| | - Wentao Li
- Department of Neurology, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Vijay K Ramanan
- Department of Neurology, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Daniel A Drubach
- Department of Neurology, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - David T Jones
- Department of Neurology, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA. .,Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA.
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22
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Gandoglia I, Strada L, Poleggi A, Castaldi A, Del Sette M, Di Maria E. Penetrance of the V203I variant of the PRNP gene: report of a patient with stroke-like onset of Creutzfeld-Jacob Disease and review of published cases. Prion 2022; 16:19-22. [PMID: 35167423 PMCID: PMC8855849 DOI: 10.1080/19336896.2022.2035479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Creutzfeldt-Jakob disease (CJD) is usually sporadic, but 10–15% of cases are caused by autosomal-dominant pathogenic variants in the prion protein gene (PRNP). A few PRNP variants show low penetrance. We report the case of a 64-year-old man, admitted to the ward with acute onset of aphasia; death occurred 6 weeks later. Brain MRI, EEG pattern and brain pathology were consistent with CJD diagnosis. Genetic analysis revealed a heterozygous V203I variant. We summarized the key clinical findings in patients carrying the V203I variant who were described to date. We also discuss the hypothesis as to whether V203I is a risk factor for CJD rather than a Mendelian disease-associated variant, as well as the possible implications of such hypothesis in the clinical scenario.
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Affiliation(s)
| | - Laura Strada
- Unit of Neurology, Galliera Hospital, Genoa, Italy
| | - Anna Poleggi
- Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Antonio Castaldi
- Unit of Diagnostic and Interventional Neuroradiology, Galliera Hospital, Genoa, Italy
| | | | - Emilio Di Maria
- Department of Health Sciences, University of Genova, Genoa, Italy.,Unit of Medical Genetics, Galliera Hospital, Genoa, Italy
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23
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Hasebe K, Sato R, Kanagusuku L, Shu H. Non-convulsive Seizures Mimicking Creutzfeldt-Jakob Disease with Rapid Resolution and Recurrence of MRI Abnormalities. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2022; 81:31-33. [PMID: 35156053 PMCID: PMC8815002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
An 88-year-old man presented with acute altered mental status. Brain magnetic resonance imaging (MRI) demonstrated "cortical ribboning," which is classically associated with Creutzfeldt-Jakob disease. His rapid clinical improvement prompted a follow-up MRI three days after presentation, which showed resolution of the acute abnormal signals. The patient was eventually diagnosed with non-convulsive seizure. Five months later, he returned with a similar clinical presentation and MRI findings after self-discontinuation of anticonvulsant. It is important for clinicians to be aware that neurological changes associated with non-convulsive seizures can acutely mimic Creutzfeldt-Jakob disease, and to consider a short interval follow-up MRI for diagnostic challenges in acute settings.
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Affiliation(s)
- Kohei Hasebe
- Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (KH)
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH (RS)
| | - Leimomi Kanagusuku
- Department of Family Medicine and Community Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (LK)
| | - Huidy Shu
- Division of Neurology, Hawai‘i Pacific Health Medical Group, Honolulu, HI (HS)
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24
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Walker PE, Freeman P, Monforte Monteiro SR, Bexfield N, Harris G, Radke H, Alves L, Vanhaesebrouck AE. Description of neurological mimics presented to the neurology service of a small animal referral hospital. Vet Rec 2022; 190:e1268. [PMID: 34993971 DOI: 10.1002/vetr.1268] [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: 12/02/2020] [Revised: 06/28/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Clinicians observe that cats and dogs referred to neurology services often do not have an underlying neurological disorder. There has been no analysis of the frequency or categorisation of these neurological mimics. METHODS Retrospective study of 520 cases was carried out. Data on signalment, presenting clinical signs, neurological examination findings and final diagnosis were collected. Final diagnoses were classified as primary neurological, non-neurological in origin but with neurological clinical manifestation, completely non-neurological (neurological mimics) or undiagnosed. Presenting clinical signs and neurological examination results were compared between neurological mimics and primary neurological cases using Chi-square or Fischer exact test. Relative risk (RR) was calculated for significant associations. RESULTS A total of 74% were primary neurological conditions, 8% neurological mimics, 3% non-neurological with neurological manifestation and 15% undiagnosed. An animal referred for lameness was approximately five times more likely to be diagnosed as a neurological mimic than as a primary neurological disorder (RR = 5.42, p < 0.001). Cases with a normal neurological examination were approximately 15 times more likely to be a neurological mimic (RR = 14.97, p < 0.001). CONCLUSION Thorough examination with consideration of alternative diagnoses is important when a neurological condition is suspected in an animal that presents with lameness or normal neurological examination.
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Affiliation(s)
- Paige E Walker
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Paul Freeman
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | | | - Nicholas Bexfield
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Georgina Harris
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Heidi Radke
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Lisa Alves
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
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25
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Watson N, Hermann P, Ladogana A, Denouel A, Baiardi S, Colaizzo E, Giaccone G, Glatzel M, Green AJE, Haïk S, Imperiale D, MacKenzie J, Moda F, Smith C, Summers D, Tiple D, Vaianella L, Zanusso G, Pocchiari M, Zerr I, Parchi P, Brandel JP, Pal S. Validation of Revised International Creutzfeldt-Jakob Disease Surveillance Network Diagnostic Criteria for Sporadic Creutzfeldt-Jakob Disease. JAMA Netw Open 2022; 5:e2146319. [PMID: 35099544 PMCID: PMC8804913 DOI: 10.1001/jamanetworkopen.2021.46319] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Sporadic Creutzfeldt-Jakob disease (sCJD) is a rapidly lethal disease. Rapid, accurate diagnosis is imperative for epidemiological surveillance and public health activities to exclude treatable differentials and facilitate supportive care. In 2017, the International CJD Surveillance Network diagnostic criteria were revised to incorporate cortical ribboning on magnetic resonance imaging and the real-time quaking-induced conversion (RT-QuIC) assay, developments that require multicenter evaluation. OBJECTIVE To evaluate the accuracy of revised diagnostic criteria through the retrospective diagnosis of autopsy-confirmed cases (referred to as in-life diagnosis). DESIGN, SETTING, AND PARTICIPANTS This diagnostic study used a 3-year clinicopathological series using all cases of autopsy-confirmed sCJD and a noncase group with alternative neuropathological diagnoses from national surveillance centers in the United Kingdom, France, Germany, and Italy. Data were collected from January 2017 to December 2019 and analyzed from January 2020 to November 2021. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of revised diagnostic criteria and diagnostic investigations. Secondary analyses assessing sCJD subgroups by genotype, pathological classification, disease duration, and age. RESULTS A total of 501 sCJD cases and 146 noncases were included. Noncase diagnoses included neurodegenerative diseases, autoimmune encephalitis, and cerebral insults such as anoxia. Participants in the sCJD cases cohort were younger (mean [SD] age, 68.8 [9.8] years vs 72.8 [10.9] years; P < .001) and had longer median (IQR) disease duration (118 [74.8-222.3] days vs 85 [51.5-205.5] days; P = .002); sex ratios were equivalent (253 [50.5%] male cases vs 74 [50.7%] male noncases). Sensitivity of revised criteria in in-life diagnosis (450 of 488 [92.2%] diagnoses; 95% CI, 89.5%-94.4%) was increased compared with prior criteria (378 of 488 [77.5%] diagnoses; 95% CI, 73.5%-81.1%; P < .001), while specificity (101 of 125 [80.8%] diagnoses; 95% CI, 72.8%-87.3%) was unchanged (102 of 125 [81.6%] diagnoses; 95% CI, 73.7%-88.0%; P > .99). Among 223 cases and 52 noncases with the full panel of investigations performed, sensitivity of revised criteria (97.8%; 95% CI, 94.9%-99.3%) was increased compared with prior criteria (76.2%; 95% CI, 70.1%-81.7%; P < .001) while specificity was unchanged (67.3%; 95% CI, 52.9%-79.7% vs 69.2%; 95% CI, 54.9%-81.3%; P > .99). In 455 cases and 111 noncases, cortical ribboning was 67.9% sensitive (95% CI, 63.4%-72.2%) and 86.5% specific (95% CI, 78.7%-92.2%). In 274 cases and 77 noncases, RT-QuIC was 91.6% sensitive (95% CI, 87.7%-94.6%) and 100% specific (95% CI, 96.2%-100%). Investigation sensitivity varied with genetic and pathological features, disease duration, and age. CONCLUSIONS AND RELEVANCE This diagnostic study demonstrated significantly improved sensitivity of revised sCJD diagnostic criteria with unaltered specificity. The revision has enhanced diagnostic accuracy for clinical care and surveillance.
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Affiliation(s)
- Neil Watson
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Hermann
- National Reference Centre for TSE, Department of Neurology, University Medical Centre Göttingen, Göttingen, Germany
| | - Anna Ladogana
- Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Angeline Denouel
- Cellule Nationale de référence des MCJ, Groupe Hospitalier Pitié-Salpêtrière, Paris Cedex 13, France
| | - Simone Baiardi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neuropatologia delle Malattie Neurodegenerative, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Elisa Colaizzo
- Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Giorgio Giaccone
- Neurology 5/Neuropathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Alison J. E. Green
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Stéphane Haïk
- Cellule Nationale de référence des MCJ, Groupe Hospitalier Pitié-Salpêtrière, Paris Cedex 13, France
| | | | - Janet MacKenzie
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Fabio Moda
- Neurology 5/Neuropathology Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Colin Smith
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - David Summers
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Dorina Tiple
- Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Luana Vaianella
- Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Gianluigi Zanusso
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Maurizio Pocchiari
- Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Inga Zerr
- National Reference Centre for TSE, Department of Neurology, University Medical Centre Göttingen, Göttingen, Germany
| | - Piero Parchi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neuropatologia delle Malattie Neurodegenerative, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Jean-Philippe Brandel
- Cellule Nationale de référence des MCJ, Groupe Hospitalier Pitié-Salpêtrière, Paris Cedex 13, France
| | - Suvankar Pal
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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26
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Watson N, Kirby J, Kurudzhu H, Leitch M, MacKenzie J, Smith-Bathgate B, Smith C, Summers D, Green A, Pal S. The Impact of the COVID-19 Pandemic on Creutzfeldt-Jakob Disease Surveillance and Patient Care in the United Kingdom. Eur J Neurol 2021; 29:1222-1226. [PMID: 34941016 PMCID: PMC9305926 DOI: 10.1111/ene.15228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022]
Abstract
Background and purpose Creutzfeldt–Jakob disease (CJD) is lethal and transmissible. We assessed the impact of the COVID‐19 pandemic on UK CJD surveillance. We hypothesized that (i) disruptions prolonged diagnostic latency; (ii) autopsy rates declined; and (iii) COVID‐19 infection negatively affected diagnosis, care, and survival. Methods We retrospectively investigated the first year of the pandemic, using the preceding year as a comparator, quantifying numbers of individuals assessed by the UK National CJD Research & Surveillance Unit for suspected CJD, time to diagnosis, disease duration, and autopsy rates. We evaluated the impact of COVID‐19 status on diagnosis, care, and survival in CJD. Results A total of 148 individuals were diagnosed with CJD in the pandemic (from a total of 166 individuals assessed) compared to 141 in the comparator (from 145 assessed). No differences were identified in disease duration or time to diagnosis. Autopsy rates were unchanged. Twenty individuals had COVID‐19; 60% were symptomatic, and 10% had severe disease. Disruptions in diagnosis and care were frequently identified. Forty percent of COVID‐19‐positive individuals died; however, COVID‐19 status did not significantly alter survival duration in CJD. Conclusions The COVID‐19 pandemic has not impacted UK CJD case ascertainment or survival, but diagnostic evaluation and clinical care of individuals have been affected.
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Affiliation(s)
- N Watson
- The University of Edinburgh, United Kingdom
| | - J Kirby
- The University of Edinburgh, United Kingdom
| | - H Kurudzhu
- The University of Edinburgh, United Kingdom
| | - M Leitch
- The University of Edinburgh, United Kingdom
| | | | | | - C Smith
- The University of Edinburgh, United Kingdom
| | - D Summers
- The University of Edinburgh, United Kingdom
| | - Aje Green
- The University of Edinburgh, United Kingdom
| | - S Pal
- The University of Edinburgh, United Kingdom
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27
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Beretta S, Stabile A, Balducci C, DiFrancesco JC, Patruno A, Rona R, Bombino M, Capraro C, Andreetta F, Cavalcante P, Moda F, Citerio G, Foti G, Bogliun G, Ferrarese C. COVID-19-associated immune-mediated encephalitis mimicking acute-onset Creutzfeldt-Jakob disease. Ann Clin Transl Neurol 2021; 8:2314-2318. [PMID: 34825771 PMCID: PMC8670319 DOI: 10.1002/acn3.51479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022] Open
Abstract
We report a subtype of immune‐mediated encephalitis associated with COVID‐19, which closely mimics acute‐onset sporadic Creutzfeldt–Jakob disease. A 64‐year‐old man presented with confusion, aphasia, myoclonus, and a silent interstitial pneumonia. He tested positive for SARS‐CoV‐2. Cognition and myoclonus rapidly deteriorated, EEG evolved to generalized periodic discharges and brain MRI showed multiple cortical DWI hyperintensities. CSF analysis was normal, except for a positive 14‐3‐3 protein. RT‐QuIC analysis was negative. High levels of pro‐inflammatory cytokines were present in the CSF and serum. Treatment with steroids and intravenous immunoglobulins produced EEG and clinical improvement, with a good neurological outcome at a 6‐month follow‐up.
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Affiliation(s)
- Simone Beretta
- Department of Neurology, San Gerardo Hospital ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.,NeuroMi (Milan Center for Neuroscience), Milano, Italy
| | - Andrea Stabile
- Department of Neurology, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Claudia Balducci
- Department of Neurology, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, San Gerardo Hospital ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.,NeuroMi (Milan Center for Neuroscience), Milano, Italy
| | - Adriana Patruno
- Department of Intensive Care, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Roberto Rona
- Department of Intensive Care, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Michela Bombino
- Department of Intensive Care, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Cristina Capraro
- Department of Neuroradiology, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Francesca Andreetta
- Department of Neurology 4 - Neuroimmunology and Neuromuscular Diseases, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paola Cavalcante
- Department of Neurology 4 - Neuroimmunology and Neuromuscular Diseases, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Fabio Moda
- Department of Neurology 5 - Neuropathology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.,Department of Intensive Care, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.,Department of Intensive Care, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Graziella Bogliun
- Department of Neurology, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Carlo Ferrarese
- Department of Neurology, San Gerardo Hospital ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy.,NeuroMi (Milan Center for Neuroscience), Milano, Italy
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28
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Cazzaniga FA, Bistaffa E, De Luca CMG, Bufano G, Indaco A, Giaccone G, Moda F. Sporadic Creutzfeldt-Jakob disease: Real-Time Quaking Induced Conversion (RT-QuIC) assay represents a major diagnostic advance. Eur J Histochem 2021; 65. [PMID: 34657408 PMCID: PMC8529530 DOI: 10.4081/ejh.2021.3298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/07/2021] [Indexed: 12/23/2022] Open
Abstract
Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare and fatal neurodegenerative disorder with an incidence of 1.5 to 2 cases per million population/year. The disease is caused by a proteinaceous infectious agent, named prion (or PrPSc), which arises from the conformational conversion of the cellular prion protein (PrPC). Once formed, PrPSc interacts with the normally folded PrPC coercing it to undergo similar structural rearrangement. The disease is highly heterogeneous from a clinical and neuropathological point of view. The origin of this variability lies in the aberrant structures acquired by PrPSc. At least six different sCJD phenotypes have been described and each of them is thought to be caused by a peculiar PrPSc strain. Definitive sCJD diagnosis requires brain analysis with the aim of identifying intracerebral accumulation of PrPSc which currently represents the only reliable biomarker of the disease. Clinical diagnosis of sCJD is very challenging and is based on the combination of several clinical, instrumental and laboratory tests representing surrogate disease biomarkers. Thanks to the advent of the ultrasensitive Real-Time Quaking-Induced Conversion (RT-QuIC) assay, PrPSc was found in several peripheral tissues of sCJD patients, sometimes even before the clinical onset of the disease. This discovery represents an important step forward for the clinical diagnosis of sCJD. In this manuscript, we present an overview of the current applications and future perspectives of RT-QuIC in the field of sCJD diagnosis.
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Affiliation(s)
| | - Edoardo Bistaffa
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Division of Neurology 5-Neuropathology, Milan.
| | | | - Giuseppe Bufano
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Division of Neurology 5-Neuropathology, Milan, Italy.
| | - Antonio Indaco
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Division of Neurology 5-Neuropathology, Milan.
| | - Giorgio Giaccone
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Division of Neurology 5-Neuropathology, Milan, Italy.
| | - Fabio Moda
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Division of Neurology 5-Neuropathology, Milan, Italy.
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29
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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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30
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Kimura M, Kimura H, Ishikawa H, Matsuo H, Takada M, Matsuo K. Hepatic Encephalopathy Mimicking Creutzfeldt-Jakob Disease on Laboratory, Physiological, and Imaging Evaluations. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932958. [PMID: 34420027 PMCID: PMC8392707 DOI: 10.12659/ajcr.932958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 84-year-old
Final Diagnosis: Hepatic encephalopathy
Symptoms: Cognitive impairment
Medication:—
Clinical Procedure: —
Specialty: Neurology
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Affiliation(s)
- Masamune Kimura
- Division of Neurology, Ohmihachiman Community Medical Center, Omihachiman, Shiga, Japan.,Division of Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hideki Kimura
- Division of Cardiology, Ohmihachiman Community Medical Center, Omihachiman, Shiga, Japan
| | - Hiroki Ishikawa
- Division of Gastroenterology, Ohmihachiman Community Medical Center, Omihachiman, Shiga, Japan
| | - Hisayasu Matsuo
- Division of Radiology, Ohmihachiman Community Medical Center, Omihachiman, Shiga, Japan
| | - Masahiko Takada
- Division of Radiology, Ohmihachiman Community Medical Center, Omihachiman, Shiga, Japan
| | - Koushun Matsuo
- Division of Neurology, Ohmihachiman Community Medical Center, Omihachiman, Shiga, Japan
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31
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Diagnosis of Creutzfeldt-Jakob disease after neurosyphilis: just bad luck or misdiagnosed? Acta Neurol Belg 2021; 121:1083-1085. [PMID: 34309786 DOI: 10.1007/s13760-021-01722-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
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32
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Hoppe SO, Uzunoğlu G, Nussbaum-Krammer C. α-Synuclein Strains: Does Amyloid Conformation Explain the Heterogeneity of Synucleinopathies? Biomolecules 2021; 11:931. [PMID: 34201558 PMCID: PMC8301881 DOI: 10.3390/biom11070931] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/17/2022] Open
Abstract
Synucleinopathies are a heterogeneous group of neurodegenerative diseases with amyloid deposits that contain the α-synuclein (SNCA/α-Syn) protein as a common hallmark. It is astonishing that aggregates of a single protein are able to give rise to a whole range of different disease manifestations. The prion strain hypothesis offers a possible explanation for this conundrum. According to this hypothesis, a single protein sequence is able to misfold into distinct amyloid structures that can cause different pathologies. In fact, a growing body of evidence suggests that conformationally distinct α-Syn assemblies might be the causative agents behind different synucleinopathies. In this review, we provide an overview of research on the strain hypothesis as it applies to synucleinopathies and discuss the potential implications for diagnostic and therapeutic purposes.
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Affiliation(s)
| | | | - Carmen Nussbaum-Krammer
- Center for Molecular Biology, Heidelberg University (ZMBH) and German Cancer Research Center (DKFZ), DKFZ-ZMBH Alliance, Im Neuenheimer Feld 282, D-69120 Heidelberg, Germany; (S.O.H.); (G.U.)
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33
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Diagnostic value of diffusion-weighted brain magnetic resonance imaging in patients with sporadic Creutzfeldt-Jakob disease: a systematic review and meta-analysis. Eur Radiol 2021; 31:9073-9085. [PMID: 33982159 DOI: 10.1007/s00330-021-08031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/14/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the diagnostic yield and performance of DWI in patients with sporadic CJD (sCJD). METHODS A systematic literature search of the MEDLINE and EMBASE databases was performed, since their inception up to July 28, 2020. Pooled diagnostic yield of diffusion-weighted imaging was calculated using DerSimonian-Laird random-effects model. Pooled diagnostic performance of DWI (sensitivity, specificity, and area under the curve) in diagnosing sCJD among patients with rapidly progressive dementia was calculated using a bivariate random-effects model. Subgroup analysis and meta-regression were performed. RESULTS Fifteen original articles with a total of 1144 patients with sCJD were included. The pooled diagnostic yield was 91% (95% confidence interval [CI], 86 to 94%); summary sensitivity, 91% (95% CI, 84 to 95%); and specificity, 97% (95% CI, 94 to 99%). The area under the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI, 0.97-0.99). Simultaneous involvement of the neocortex and striatum was the most common finding, and the neocortex was the most common site to be involved on DWI followed by striatum, thalamus, and cerebellum. Subgroup analysis and meta-regression demonstrated significant heterogeneity among the studies associated with the reference standards used for diagnosis of sCJD. CONCLUSIONS DWI showed excellent diagnostic value in diagnosis of sporadic Creutzfeldt-Jakob disease among patients with rapidly progressive dementia. Simultaneous involvement of the neocortex and striatum was the most common finding, and the neocortex was the most common site to be involved on diffusion-weighted imaging followed by striatum, thalamus, and cerebellum. KEY POINTS • The pooled diagnostic yield of diffusion-weighted imaging in sporadic Creutzfeldt-Jakob disease was 91%. • The diagnostic performance of diffusion-weighted imaging for predicting sporadic Creutzfeldt-Jakob disease among patients with rapidly progressive dementia was excellent, with pooled sensitivity, 91%, and specificity, 97%. • Simultaneous involvement in the neocortex and striatum was most commonly seen on diffusion-weighted imaging (60%), followed by the neocortex without striatum (30%), thalamus (21%), cerebellum (8%), and striatum without neocortex (7%).
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34
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Sokhi D, Yakub F, Sharma K, Waa S, Mativo P. Heidenhain Variant of Sporadic Creutzfeldt-Jakob Disease: First Reported Case from East Africa. Int Med Case Rep J 2021; 14:39-44. [PMID: 33564270 PMCID: PMC7866935 DOI: 10.2147/imcrj.s287358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/19/2020] [Indexed: 11/23/2022] Open
Abstract
Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare prion disease that causes rapidly progressive fatal neurodegeneration. The rarer Heidenhain variant of sCJD presents with visual symptoms and is rarely reported in the literature from sub-Saharan Africa. We report the case of a 57-year-old male with a three-week history of losing direction when driving home and visual hallucinations described as seeing rainbows. Magnetic resonance imaging (MRI) of the brain revealed unilateral parieto-occipital sulcal hyperintensities with restriction on diffusion-weighted imaging (DWI), and electroencephalography (EEG) showed right para-central slowing leading to an initial diagnosis of non-convulsive status epilepticus. He was treated with anti-epileptic medication but was re-admitted less than a month later with worsening spatial memory, aggression, ataxia, dysarthria, myoclonic jerks and a positive startle response, later developing generalised tonic-clonic seizures. Repeat MRI brain scan showed widespread posterior-predominant sulcal DWI restriction in a cortical ribboning pattern pathognomonic for sCJD. EEG showed diffuse slowing, and cerebrospinal fluid was analyzed for abnormal prion protein using real-time quaking-induced conversion but was inconclusive due to suboptimal sample collection. The patient fulfilled the diagnostic criteria for probable sCJD, Heidenhain variant; the family declined brain biopsy for definitive diagnosis. He was subsequently palliated at a local hospice where he died approximately three months after the onset of symptoms. Our case highlights the presence of a rare form of sCJD, and the diagnostic challenges faced in our resource-limited setting.
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Affiliation(s)
- Dilraj Sokhi
- Department of Medicine, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Fazal Yakub
- Department of Medicine, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Karishma Sharma
- Department of Medicine, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Sheila Waa
- Department of Radiology, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, Kenya
| | - Peter Mativo
- Department of Medicine, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, Kenya
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Mbizvo GK, Ziso B, Larner AJ. Epilepsy and prion diseases: A narrative review. Epilepsy Behav 2021; 115:107630. [PMID: 33309427 DOI: 10.1016/j.yebeh.2020.107630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 12/26/2022]
Abstract
Epileptic seizures have been described as one feature of prion diseases, but are an unusual clinical presentation. The aim of this narrative Review was to summarize current knowledge of epileptic seizures in the various forms of prion diseases, from a clinical perspective. Examination of the published literature identified no systematic studies; the evidence base is largely anecdotal, consisting mainly of case studies and small case series. Hence, uncertainty prevails as to seizure frequency, semiology, treatment, and pathogenesis in prion diseases. Seizures probably occur in around 10% of sporadic cases but less frequently in iatrogenic and familial forms, with the possible exception of the E200K mutation. The literature suggests a predominance of focal motor and nonconvulsive status epilepticus. Electroencephalographic accompaniments include periodic lateralized or generalized periodic epileptiform discharges (PLEDs, GPEDs), sometimes predating the more typical periodic sharp wave complexes. There are no convincing accounts of successful antiepileptic drug therapy. The underlying mechanisms of epileptogenesis in prion diseases may include loss of cellular prion protein function (PrPc) and aggregation of abnormally folded prion protein (PrPSc). The need for systematic studies and clinical trials to expand the evidence base surrounding epilepsy and prion diseases is evident.
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Affiliation(s)
- Gashirai K Mbizvo
- Cognitive Function Clinic, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.
| | - Besa Ziso
- Cognitive Function Clinic, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Andrew J Larner
- Cognitive Function Clinic, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Watson N, Kurudzhu H, Green A, Summers D, Smith C, Pal S. Application of telehealth for comprehensive Creutzfeldt-Jakob disease surveillance in the United Kingdom. J Neurol Sci 2021; 420:117221. [PMID: 33223148 DOI: 10.1016/j.jns.2020.117221] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/23/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
Creutzfeldt-Jakob disease (CJD) is a fatal human prion disease. Surveillance systems operate globally with the goals of accurate in-life case ascertainment, appropriate public health interventions to minimise secondary transmission, and monitoring trends in disease epidemiology. The UK experienced the highest incidence of variant CJD (vCJD) in the world following widespread population exposure to bovine spongiform encephalopathy (BSE). 178 cases of vCJD have been identified in the UK by the National CJD Research & Surveillance Unit (NCJDRSU), including three cases of secondary transmission via blood transfusion. The NCJDRSU performs high-fidelity surveillance, assessing all cases of suspected CJD referred to the unit. COVID-19 has caused widespread disruption to healthcare and poses a threat to services. The NCJDRSU converted to telehealth-based surveillance in March 2020. We report the results of the application of telehealth for comprehensive CJD surveillance during the first four months of the pandemic. 59 cases were assessed for suspected CJD. In 52 cases the relatives were interviewed for an informant history, by video conference or telephone call. 34 patients underwent video examination; 1 case was examined in-person. MRI images were assessed in all cases and 46 underwent CSF testing. Feedback was obtained from interviewees and the NCJDRSU team on their experiences. 50 cases were diagnosed with sporadic CJD; 5 received an alternative diagnosis, and the remaining 4 remained unresolved, with further investigations underway. Telehealth significantly reduced time taken to assessment compared to in-person assessments in 2019. Telehealth is an effective way to provide comprehensive CJD surveillance at a national level.
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Affiliation(s)
- Neil Watson
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Hatice Kurudzhu
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Alison Green
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - David Summers
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Colin Smith
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Suvankar Pal
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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McMurran CE, Chaggar GH, Ugoya SO. A patient with sporadic Creutzfeldt-Jakob disease: challenges of rare diseases in the COVID-19 era. Oxf Med Case Reports 2021; 2020:omaa113. [PMID: 33391769 PMCID: PMC7768533 DOI: 10.1093/omcr/omaa113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/02/2020] [Accepted: 10/17/2020] [Indexed: 11/24/2022] Open
Abstract
We describe a patient who presented to hospital during the coronavirus disease 2019 (COVID-19) pandemic with sporadic Creutzfeldt–Jakob disease (sCJD). The case demonstrates the typical clinical, radiological and laboratory features of this condition. It also highlights some of the challenges associated with diagnosis and care of patients with rare diseases such as sCJD, and how these have been intensified by COVID-19.
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Affiliation(s)
- Christopher E McMurran
- Stroke Unit, West Suffolk NHS Foundation Trust, Bury St Edmunds, UK.,Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | | | - Solomon O Ugoya
- Stroke Unit, West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
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38
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Adan G, Mitchell JW, Ziso B, Larner AJ. Diagnosis and Management of Seizures in Neurodegenerative Diseases. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-020-00656-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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39
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Watson N, Brandel JP, Green A, Hermann P, Ladogana A, Lindsay T, Mackenzie J, Pocchiari M, Smith C, Zerr I, Pal S. The importance of ongoing international surveillance for Creutzfeldt-Jakob disease. Nat Rev Neurol 2021; 17:362-379. [PMID: 33972773 PMCID: PMC8109225 DOI: 10.1038/s41582-021-00488-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 02/04/2023]
Abstract
Creutzfeldt-Jakob disease (CJD) is a rapidly progressive, fatal and transmissible neurodegenerative disease associated with the accumulation of misfolded prion protein in the CNS. International CJD surveillance programmes have been active since the emergence, in the mid-1990s, of variant CJD (vCJD), a disease linked to bovine spongiform encephalopathy. Control measures have now successfully contained bovine spongiform encephalopathy and the incidence of vCJD has declined, leading to questions about the requirement for ongoing surveillance. However, several lines of evidence have raised concerns that further cases of vCJD could emerge as a result of prolonged incubation and/or secondary transmission. Emerging evidence from peripheral tissue distribution studies employing high-sensitivity assays suggests that all forms of human prion disease carry a theoretical risk of iatrogenic transmission. Finally, emerging diseases, such as chronic wasting disease and camel prion disease, pose further risks to public health. In this Review, we provide an up-to-date overview of the transmission of prion diseases in human populations and argue that CJD surveillance remains vital both from a public health perspective and to support essential research into disease pathophysiology, enhanced diagnostic tests and much-needed treatments.
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Affiliation(s)
- Neil Watson
- grid.4305.20000 0004 1936 7988National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jean-Philippe Brandel
- grid.411439.a0000 0001 2150 9058Cellule Nationale de référence des MCJ, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Alison Green
- grid.4305.20000 0004 1936 7988National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Hermann
- grid.411984.10000 0001 0482 5331National Reference Centre for TSE, Department of Neurology, University Medical Centre Göttingen, Göttingen, Germany
| | - Anna Ladogana
- grid.416651.10000 0000 9120 6856Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Terri Lindsay
- grid.4305.20000 0004 1936 7988National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Janet Mackenzie
- grid.4305.20000 0004 1936 7988National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Maurizio Pocchiari
- grid.416651.10000 0000 9120 6856Registry of Creutzfeldt-Jakob Disease, Department of Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | - Colin Smith
- grid.4305.20000 0004 1936 7988National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Inga Zerr
- grid.411984.10000 0001 0482 5331National Reference Centre for TSE, Department of Neurology, University Medical Centre Göttingen, Göttingen, Germany
| | - Suvankar Pal
- grid.4305.20000 0004 1936 7988National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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40
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Xu Z, Zhao Y. A Creutzfeldt-Jakob disease case misdiagnosed with acute cerebral infarction and review of the literature. Clin Case Rep 2020; 8:3311-3315. [PMID: 33363924 PMCID: PMC7752480 DOI: 10.1002/ccr3.3388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
It was critical for the clinician to be aware of the neuroimaging and early-onset symptoms of this fatal neurodegenerative disease, and avoid initiating inappropriate therapy. Neuroimaging plays a key role in differentiating it from other mimics.
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Affiliation(s)
- Zhouwei Xu
- Department of NeurologyShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Yuwu Zhao
- Department of NeurologyShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
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41
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Bartlett K, Kane KE, Kane BG, Weaver KR, Barr GC. Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report. Clin Pract Cases Emerg Med 2020; 4:656-659. [PMID: 33217301 PMCID: PMC7676806 DOI: 10.5811/cpcem.2020.7.47384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/21/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Determination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important. CASE REPORT A 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease. CONCLUSION This case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.
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Affiliation(s)
- Kathryn Bartlett
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania
| | - Kathleen E Kane
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
| | - Bryan G Kane
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
| | - Kevin R Weaver
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
| | - Gavin C Barr
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
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42
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Qamar MS, Yousaf A, Nida A. Creutzfeldt-Jakob Disease With Atypical Magnetic Resonance Imaging Features. Cureus 2020; 12:e11294. [PMID: 33282571 PMCID: PMC7710345 DOI: 10.7759/cureus.11294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Creutzfeld-Jakob disease (CJD) is a rare neurodegenerative condition characterized by rapid progression and fatal outcomes. Patients with progressive dementia and associated atypical features should be investigated, especially with the MRI brain for CJD. Cortical ribboning on diffusion-weighted MRI images is a very crucial diagnostic sign for CJD. Here we present a case of a 52-year-old woman admitted to the hospital after a seizure episode and two-month history of altered mental status. She presented with a 40-minute episode of status epilepticus, necessitating admission to the intensive care unit. Head CT showed no acute intracranial abnormalities, and MRI showed generalized brain atrophy. Electroencephalography (EEG) demonstrated an intermittent slowing of the left hemisphere. Two weeks after admission, she got discharged. Four days later, she presented to the hospital after being found disoriented in a park. MRI showed ventricular dilation and a questionable focus of restricted diffusion in the left thalamus posteriorly. CJD protein panel was collected. Three days after discharge, she was brought to the hospital, and CJD protein testing revealed the presence of 14-3-3 protein, elevated T-tau, and negative real-time quaking-induced conversion (RT-QuIC). The National Prion Disease Surveillance Center reviewed her case, and the CJD diagnosis was confirmed.
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Osman D, Weidner A, Madhra M. Progressive ataxia and cognitive decline in a 67-year-old male: a diagnostic challenge. J R Coll Physicians Edinb 2020; 50:281-283. [PMID: 32936103 DOI: 10.4997/jrcpe.2020.313] [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: 11/19/2022] Open
Abstract
We report the case of a 67-year-old male who presented with a six-week history of progressive unsteadiness, cognitive impairment and weight loss, in the context of a recent bereavement. Magnetic resonance imaging (MRI) performed several weeks earlier excluded acute stroke. Examination revealed gross bilateral ataxia, bradyphrenia and physical manifestations of depression. Collateral history suggested rapidly progressing symptoms over three months. Repeat MRI head showed features suggestive of Creutzfeldt-Jakob disease (CJD) including T2 hyperintensities in the basal ganglia. Cerebrospinal ˜fluid (CSF) samples were positive for 14-3-3 protein, S100b and real-time quaking-induced conversion (RT-QuIC) proteins confirming the diagnosis of sporadic CJD (sCJD).
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Affiliation(s)
- Dina Osman
- General Internal Medicine, Cumberland Infirmary of Carlisle, Newtown Road, Carlisle, CA2 7HY, UK,
| | - Alice Weidner
- Cumberland Infirmary of Carlisle, Newtown Road, Carlisle, CA2 7HY, UK
| | - Mayuri Madhra
- Cumberland Infirmary of Carlisle, Newtown Road, Carlisle, CA2 7HY, UK
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Dressing Apraxia as Initial Manifestation of Creutzfeldt-Jakob Disease. Tremor Other Hyperkinet Mov (N Y) 2020; 10:14. [PMID: 32775028 PMCID: PMC7394209 DOI: 10.5334/tohm.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Creutzfeldt-Jakob disease (CJD) is a rare prion disease characterized by rapidly progressive dementia. Case Report A 76-year-old woman exhibited pronounced signs and symptoms of dressing apraxia for about seven weeks before the disease progressed and probable CJD was diagnosed supported by imaging and CSF findings. Discussion Dressing apraxia as the initial manifestation of CJD has been sparsely reported. This remarkably focal syndrome should be considered with view on movement and neuropsychological disorders in early CJD.
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Katsikaki G, Dagklis IE, Angelopoulos P, Ntantos D, Prevezianou A, Bostantjopoulou S. Atypical and early symptoms of sporadic Creutzfeldt – Jakob disease: case series and review of the literature. Int J Neurosci 2020; 131:927-938. [DOI: 10.1080/00207454.2020.1759594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Grammatiki Katsikaki
- 3rd Department of Neurology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Ioannis E. Dagklis
- 3rd Department of Neurology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Petros Angelopoulos
- 3rd Department of Neurology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Dimitrios Ntantos
- 3rd Department of Neurology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Angeliki Prevezianou
- 3rd Department of Neurology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Sevasti Bostantjopoulou
- 3rd Department of Neurology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
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46
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Filatov A, Khanni JL, Alusma-Hibbert K, Espinosa PS. Sporadic Creutzfeldt-Jakob Disease: Case Report and Literature Review. Cureus 2020; 12:e7767. [PMID: 32461843 PMCID: PMC7243655 DOI: 10.7759/cureus.7767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/21/2020] [Indexed: 11/07/2022] Open
Abstract
The proverbial "zebras" in neurology are often times missed due to their low prevalence and incidence in the community. The number of misdiagnoses and improper therapeutic interventions that occur are further increased when patients with these rare diseases present with signs and symptoms of more common disorders. One such disease is sporadic Creutzfeldt-Jakob disease (sCJD), a prion disease that causes neuronal derangement and classically presents as a rapidly progressing dementia with extrapyramidal signs, ataxia, behavioural problems, and myoclonus in the advanced stage. It falls into the category of neurodegenerative disease, which also includes Alzheimer's disease, Huntington's disease, Parkinson's disease, and other Parkinson-related diseases. Though these diseases have overlapping symptomologies - such as cognitive impairment and neuromuscular dysfunction - they can be differentiated from one another based on the time course of the illness and the specific constellation of signs and symptoms. Our case report describes a patient who was found to have sCJD after months of treatment for Parkinson's disease and trigeminal neuralgia. Thus, we are highlighting the importance of recognizing rare diseases so that proper management can be initiated in a timely manner. Furthermore, we review the current literature on the diagnosis and management of sCJD.
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Affiliation(s)
- Asia Filatov
- Neurology, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Javed L Khanni
- Neurology, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | | | - Patricio S Espinosa
- Neurology, Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, USA
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47
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Guadarrama-Ortiz P, Choreno-Parra J, Carnalla-Cortes M, Rodriguez-Munoz P, Angeles-Castellanos M. A Complete and State of the Art Pre-mortem Diagnostic Approach to Creutzfeldt-Jakob Disease: A Case Report. Neurol India 2020; 68:927-929. [DOI: 10.4103/0028-3886.293483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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48
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Nakagawa Y, Yamada S. Metal homeostasis disturbances in neurodegenerative disorders, with special emphasis on Creutzfeldt-Jakob disease - Potential pathogenetic mechanism and therapeutic implications. Pharmacol Ther 2019; 207:107455. [PMID: 31863817 DOI: 10.1016/j.pharmthera.2019.107455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/09/2019] [Indexed: 12/14/2022]
Abstract
Creutzfeldt-Jakob disease (CJD) is characterized by a rapidly progressive dementia often accompanied by myoclonus and other signs of brain dysfunction, relying on the conversion of the normal cellular form of the prion protein (PrPC) to a misfolded form (PrPSc). The neuropathological changes include spongiform degeneration, neuronal loss, astrogliosis, and deposition of PrPSc. It is still unclear how these pathological changes correlate with the development of CJD symptoms because few patients survive beyond 2 years after diagnosis. Inasmuch as the symptoms of CJD overlap some of those observed in Alzheimer's, Parkinson's, and Huntington's diseases, there may be some underlying pathologic mechanisms associated with CJD that may contribute to the symptoms of non-prion neurodegenerative diseases as well. Data suggest that imbalance of metals, including copper, zinc, iron, and manganese, induces abnormalities in processing and degradation of prion proteins that are accompanied by self-propagation of PrPSc. These events appear to be responsible for glutamatergic synaptic dysfunctions, neuronal death, and PrPSc aggregation. Given that the prodromal symptoms of CJD such as sleep disturbances and mood disorders are associated with brain stem and limbic system dysfunction, the pathological changes may initially occur in these brain regions, then spread throughout the entire brain. Alterations in cerebrospinal fluid homeostasis, which may be linked to imbalance of these metals, seem to be more important than neuroinflammation in causing the cell death. It is proposed that metal dyshomeostasis could be responsible for the initiation and progression of the pathological changes associated with symptoms of CJD and other neurodegenerative disorders.
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Affiliation(s)
- Yutaka Nakagawa
- Center for Pharma-Food Research (CPFR), Division of Pharmaceutical Sciences, Graduate School of Integrative Pharmaceutical and Nutritional Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka 422-8526, Japan.
| | - Shizuo Yamada
- Center for Pharma-Food Research (CPFR), Division of Pharmaceutical Sciences, Graduate School of Integrative Pharmaceutical and Nutritional Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka 422-8526, Japan
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49
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Hsiao PS, Lee YM, Chu FS, Lee CL, Liu FC, Tsai PH. Probable sporadic Creutzfeldt-Jakob disease mimicking focal epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2019; 11:77-80. [PMID: 30788213 PMCID: PMC6369248 DOI: 10.1016/j.ebcr.2019.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 11/20/2022]
Abstract
Creutzfeldt-Jakob disease (CJD) presents with seizures as an early symptom in only approximately 3% of cases. These seizures often present as nonconvulsive status epilepticus (NCSE) or epilepsia partialis continua (EPC). Here, we describe a case of probable sporadic CJD (sCJD) in an 83-year-old man whose manifest an unusual presentation of left-hand tonic seizures without evolution to EPC, as well as brain MRI findings interpreted as peri-ictal changes, which led to an initial misdiagnosis of focal epilepsy.
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Affiliation(s)
- Pei-Shan Hsiao
- Department of Laboratory Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
- Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
| | - Yuan-Ming Lee
- Department of Laboratory Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
| | - Fu-Sin Chu
- Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
- Center for Dementia Care and Evolution, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
| | - Chao-Lin Lee
- Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
- Center for Dementia Care and Evolution, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
| | - Fang-Chun Liu
- Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
- Center for Dementia Care and Evolution, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
| | - Ping-Huang Tsai
- Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
- Center for Dementia Care and Evolution, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan
- Department of Neurology, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei 112, Taiwan
- Corresponding author at: Division of Neurology, Department of Internal Medicine, National Yang-Ming University Hospital, No.169, Siaoshe Rd., Yilan City, Yilan County 26058, Taiwan.
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Chandra S, Chakravarthula N, Santosh V, Mailankody P, Mondal M, Bhat D, Vidhya Annapoorni CS, Narendiran S, Sharma P, Dhar D, Sudha Gorthi NS. Look for the “Treatables” among dementias: It is lifesaving: An experience from a tertiary care center in India in the past 5 years. JOURNAL OF GERIATRIC MENTAL HEALTH 2019. [DOI: 10.4103/jgmh.jgmh_28_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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