Creutzfeldt–Jakob disease (CJD) is an incurable, terminal, neurodegenerative disease belonging to the transmissible spongiform encephalopathy (TSE) group, also known as prion diseases. Early symptoms include memory problems, behavioral changes, poor coordination, visual disturbances and auditory disturbances. Later symptoms include dementia, involuntary movements, blindness, deafness, weakness, and coma. About 70% of patients die within a year of diagnosis.
The condition was first described in 1920. The name "Creutzfeldt–Jakob disease" was introduced by Walther Spielmeyer in 1922, after the German neurologists Hans Gerhard Creutzfeldt and Alfons Maria Jakob.Creutzfeldt–Jakob disease @ Who Named It
CJD is caused by a prion, an infectious, abnormally folded variant of a protein called the prion protein. About 85% of cases of CJD occur for unknown reasons ('sporadic CJD'), while about 10–15% of cases are inherited in an autosomal dominant manner. In rare instances, exposure to brain or spinal tissue from an infected person has resulted in transmission of disease, and a variant form of CJD was caused by exposure to meat from cows with bovine spongiform encephalopathy ("mad cow disease"). There is no evidence that sporadic CJD can spread among people via normal contact or blood transfusions, although this is possible in variant Creutzfeldt–Jakob disease.
Diagnosis of CJD involves ruling out other potential causes. An electroencephalogram, spinal tap, or magnetic resonance imaging (MRI) may support the diagnosis. Another diagnostic technique is the real-time quaking-induced conversion assay, which can detect the disease in early stages.
There is currently no specific treatment for CJD. Opioids may be used to help with pain, while clonazepam or sodium valproate may help with involuntary movements. CJD affects about one person per million people per year. Onset of sporadic CJD is typically around 60 years of age.
Signs and symptoms The first symptom of CJD is usually rapidly progressive dementia, leading to memory loss, personality changes, and hallucinations. Myoclonus (jerky movements) typically occurs in 90% of cases, but may be absent at initial onset. Other frequently occurring features include anxiety, depression, paranoia, obsessive-compulsive symptoms, and psychosis.Murray ED, Buttner N, Price BH. (2012) Depression and Psychosis in Neurological Practice. In: Neurology in Clinical Practice, 6th Edition. Bradley WG, Daroff RB, Fenichel GM, Jankovic J (eds.) Butterworth Heinemann. April 12, 2012.
This is accompanied by physical problems such as speech impairment, balance and coordination dysfunction (ataxia), changes in gait, and rigid posture. In most people with CJD, these symptoms are accompanied by involuntary movements. Rarely, unusual symptoms like the alien limb phenomenon have been observed. The duration of the disease varies greatly, but sporadic (non-inherited) CJD can be fatal within months or even weeks.
Most affected people die six months after initial symptoms appear, often of pneumonia due to impaired coughing reflexes. About 15% of people with CJD survive for two or more years.
The symptoms of CJD are caused by the progressive death of the brain's nerve cells, which are associated with the build-up of abnormal prion proteins forming in the brain. When brain tissue from a person with CJD is examined under a microscope, many tiny holes can be seen where the nerve cells have died. Parts of the brain may resemble a sponge where the prions were infecting the areas of the brain.
Cause CJD is a type of transmissible spongiform encephalopathy (TSE), which is caused by prions. Prions are misfolded proteins that occur in the neurons of the central nervous system (CNS). The CJD prion is dangerous because it promotes refolding of cellular prion proteins into the diseased state.
The number of misfolded protein molecules will increase exponentially, and the process leads to a large quantity of insoluble proteins in affected cells. This mass of misfolded proteins disrupts neuronal cell function and causes cell death. Mutations in the gene for the prion protein can cause a misfolding of the dominantly alpha helical regions into beta pleated sheets. This change in conformation disables the protein's ability to undergo digestion. Once the prion is transmitted, the defective proteins invade the brain and induce other prion protein molecules to misfold in a self-sustaining feedback loop. These neurodegenerative diseases are commonly called prion diseases.
PrPC, the normal fibril cellular proteins responsible for a wide range of CNS functions, are misfolded by what current research suggests are small, highly neurotoxic oligomeric aggregates, known as PrPSc, which interact with cell surfaces to disrupt neuronal function. The binding of prion oligomers to normal prion protein on neurons may trigger toxic signals similar to how oligomeric β-amyloid causes synaptic damage in Alzheimer's disease.
Different conformations of PrPSc (often termed prion "strains") are thought to cause the distinct subtypes of prion disease, explaining variations in clinical features and progression. They are thought to affect signaling processes, damaging neurons and resulting in degeneration that causes the spongiform appearance in the affected brain. Other forms of TSEs that are found in humans are Gerstmann–Sträussler–Scheinker syndrome, fatal familial insomnia, kuru, and variably protease-sensitive prionopathy. Susceptibility and disease phenotype are influenced by a common polymorphism at codon 129 of the PRNP gene (methionine/valine). Notably, individuals homozygous at codon 129 are over-represented in sporadic CJD cases and tend to have shorter incubation periods.
Transmission
The defective protein can be transmitted by contaminated harvested human brain products, corneal grafts, dural grafts, or electrode implants and pituitary human growth hormone, which has been replaced by recombinant human growth hormone that poses no such risk.
It can be familial (fCJD) or it may appear without clear risk factors (sporadic form: sCJD). In the familial form, a mutation has occurred in the gene for PrP, PRNP, in that family. All types of CJD are transmissible irrespective of how they occur in the person.
It is thought that humans can contract the variant form of the disease by eating food from animals infected with bovine spongiform encephalopathy (BSE), the bovine form of TSE, also known as mad cow disease. However, it can also cause sCJD in some cases.
Cannibalism has also been implicated as a transmission mechanism for abnormal prions, causing the disease known as kuru, once found primarily among women and children of the Fore people in Papua New Guinea, who previously engaged in funerary cannibalism. While the men of the tribe ate the muscle tissue of the deceased, women and children consumed other parts, such as the brain, and were more likely than men to contract kuru from infected tissue.
Prions, the infectious agent of CJD, may not be inactivated using routine surgical instrument sterilization procedures. The World Health Organization and the US Centers for Disease Control and Prevention recommend that instrumentation used in such cases be immediately destroyed after use; short of destruction, it is recommended that heat and chemical decontamination be used in combination to process instruments that come in contact with high-infectivity tissues. Thermal depolymerization also destroys prions in infected organic and inorganic matter, since the process chemically attacks protein at the molecular level, although more effective and practical methods involve destruction by combinations of detergents and enzymes similar to biological washing powders.
Genetics People can also develop CJD because they carry a mutation of the gene that codes for the prion protein (PRNP), located on chromosome 202p12-pter. This occurs in only 10–15% of all CJD cases. In sporadic cases, the misfolding of the prion protein is a process that is hypothesized to occur as a result of the effects of aging on cellular machinery, explaining why the disease often appears later in life. An EU study determined that "87% of cases were sporadic, 8% genetic, 5% iatrogenic and less than 1% variant."
Diagnosis
Testing for CJD has historically been problematic, due to the nonspecific nature of early symptoms and difficulty in safely obtaining brain tissue for confirmation. The diagnosis may initially be suspected in a person with rapidly progressing dementia, particularly when it is also found with the characteristic medical signs and symptoms such as involuntary muscle jerking, difficulty with coordination/balance and walking, and visual disturbances. Further testing can support the diagnosis and may include: Electroencephalography – may have a characteristic generalized periodic sharp wave pattern. Periodic sharp wave complexes develop in half of the people with sporadic CJD, particularly in the later stages. Cerebrospinal fluid (CSF) analysis for elevated levels of 14-3-3 protein and tau protein could be supportive in the diagnosis of sCJD. The two proteins are released into the CSF by damaged nerve cells. Increased levels of tau or 14-3-3 proteins are seen in 90% of prion diseases. The markers have a specificity of 95% in clinical symptoms suggestive of CJD, but specificity is 70% in other, less characteristic cases. 14-3-3 and tau proteins may also be elevated in the CSF after ischemic strokes, inflammatory brain diseases, or seizures. The protein markers are also less specific in early CJD, genetic CJD or the bovine variant. However, a positive result should not be regarded as sufficient for the diagnosis. The real-time quaking-induced conversion (RT-QuIC) assay, which amplifies misfolded PrPSc, now plays a central role in CJD diagnosis. Second-generation RT-QuIC on cerebrospinal fluid has sensitivity in the 90–97% range and ~100% specificity in sporadic CJD, far superior to earlier CSF tests. A positive RT-QuIC (on CSF or other tissues) is now included as a criterion for probable CJD in many national surveillance centers. Studies have shown RT-QuIC can also be done on olfactory mucosa swabs obtained via nasal brushing and on skin biopsies, with high diagnostic accuracy (reported sensitivities ~90–100%). MRI with diffusion weighted inversion (DWI) and fluid-attenuated inversion recovery (FLAIR) shows a high signal intensity in certain parts of the cortex (a cortical ribboning appearance), the basal ganglia, and the thalami. The most common presenting patterns are simultaneous involvement of the cortex and striatum (60% of cases), cortical involvement without the striatum (30%), thalamus (21%), cerebellum (8%) and striatum without cortical involvement (7%). In populations with a rapidly progressive dementia (early in the disease process), MRI has a sensitivity of 91% and specificity of 97% for diagnosing CJD. The MRI changes characteristic of CJD may also be seen in the immediate aftermath (hours after the event) of autoimmune encephalitis or focal seizures.
In recent years, studies have shown that the tumour marker neuron-specific enolase (NSE) is often elevated in CJD cases; however, its diagnostic utility is seen primarily when combined with a test for the 14-3-3 protein. , screening tests to identify infected asymptomatic individuals, such as blood donors, are not yet available, though methods have been proposed and evaluated.
Imaging Imaging of the brain may be performed during medical evaluation, both to rule out other causes and to obtain supportive evidence for diagnosis. Imaging findings are variable in their appearance and also variable in sensitivity and specificity. While imaging plays a lesser role in diagnosis of CJD, characteristic findings on brain MRI in some cases may precede onset of clinical manifestations.