Less protease-resistant PrP in a patient with sporadic CJD treated with intraventricular pentosan polysulphate.

Treatment with intraventricular pentosan polysulphate (PPS) might be beneficial in patients with Creutzfeldt-Jakob disease. We report a 68-year-old woman with sporadic Creutzfeldt-Jakob disease who received continuous intraventricular PPS infusion (1-120 microg/kg/day) for 17 months starting 10 months after the onset of clinical symptoms. Treatment with PPS was well tolerated but was associated with a minor, transient intraventricular hemorrhage and a non-progressive collection of subdural fluid. The patient's overall survival time was well above the mean time expected for the illness but still within the normal range. Post-mortem examination revealed that the level of abnormal protease-resistant prion protein in the brain was markedly decreased compared with levels in brains without PPS treatment. These findings suggest that intraventricular PPS infusion might modify the accumulation of abnormal prion proteins in the brains of patients with sporadic Creutzfeldt-Jakob disease.

Cerebroventricular infusion of pentosan polysulphate in human variant Creutzfeldt-Jakob disease.

Variant Creutzfeldt-Jakob disease (CJD) is a transmissible spongiform encephalopathy believed to be caused by the bovine spongiform encephalopathy agent, an abnormal isoform of the prion protein (PrP(sc)). At present there is no specific or effective treatment available for any form of CJD. Pentosan polysulphate (PPS), a large polyglycoside molecule with weak heparin-like activity, has been shown to prolong the incubation period of the intracerebral infection when administered to the cerebral ventricles in a rodent scrapie model. PPS also prevents the production of further PrP(sc) in cell culture models. These properties of PPS prompted its cerebroventricular administration in a young man with vCJD. Long-term continuous infusion of PPS at a dose of 11 microg/kg/day for 18 months did not cause drug-related side effects. Follow-up CT scans demonstrated progressive brain atrophy during PPS administration. Further basic and clinical research is needed in order to address the issue of efficacy of PPS in vCJD and in other prion diseases.

Enhanced CD9 expression in the mouse and human brains infected with transmissible spongiform encephalopathies.

A tetraspan protein CD9, normally expressed in the myelin sheath of the central and peripheral nervous system, was identified to be up-regulated in mouse brains infected with transmissible spongiform encephalopathy (TSE), by mRNA differential display screening. To elucidate its role in the neurodegeneration process observed in TSE, CD9 expression was examined in the murine disease model and in the human disease materials. Up-regulation of CD9 gene expression in the TSE-infected mouse brains was detected as early as a preclinical stage, when abnormal prion protein deposition and vacuolation were obviously manifested in the internal capsule and thalamus. In contrast, other myelin protein genes showed a reverse pattern of CD9 gene expression. Enhanced CD9 expression was immunohistochemically detected in the astrocytes of such pathological regions. In human specimens of TSE, enhanced CD9 immunoreactivity was observed in the astrocytes and some oligodendrocytes in the brains, but no relevant alteration in CD9 immunoreactivity was observed in the other organs or tissues. Positive CD9 immunoreactivity in astrocytes was also manifest in other neurological disorders in a less prominent manner. The findings indicate that up-regulated CD9 plays a role in glial cells in pathological conditions, especially in such a devastating condition as TSE.

Restraint stress enhances the gene expression of prolactin receptor long form at the choroid plexus.

Hormonal control of brain functions is considered to be important in the tolerance of stress, and it is now established that stress elevates serum PRL levels in male or cycling female rats. To investigate whether or how serum PRL acts on the brain during exposure to stress, we analyzed serum PRL levels and the gene expression of brain PRL receptors in rats subjected to restraint stress in the water (RSW). The serum PRL concentration was remarkably increased within 30 min in the rats by exposure to RSW and decreased to the initial level after 4 h of RSW, remaining at this level for up to 7 h of RSW. After the rats were released from the stress, the serum PRL level was significantly lowered in 6 h. Ribonuclease protection assay and in situ hybridization analysis revealed that messenger RNA (mRNA) expression for the long form PRL receptor [PRL-R(L)] was remarkably induced in the rat choroid plexus in 2 h of RSW. The high expression level of PRL-R(L) mRNA in the region was reduced after the rats were released from the stress. PRL-R(L) mRNA expression in the hypothalamus was at lower levels than those in the choroid plexus before and during the RSW treatment. The short form PRL receptor mRNA expression in the rat brain was considerably lower than expression of the long form receptor mRNA before or during RSW. The results indicated that the restraint stress caused a rapid increase in serum PRL and induced the gene expression for PRL-R(L) in the choroid plexus, suggesting stress-induced and choroid plexus PRL-R(L)-mediated transport of serum PRL into the cerebrospinal fluid.

Genomic organization of the human amyloid beta-protein precursor gene.

Amyloid beta-protein (BP) deposited in Alzheimer brains is a cleavage product of a larger precursor (BPP). The BPP gene encodes three types of mRNA generated by alternative splicing, two of which contain the sequence encoding Kunitz-type serine-protease inhibitor (serpin). To investigate the regulatory mechanisms of BPP synthesis at the gene level, we isolated 36 genomic DNA clones covering all the exons of the human BPP gene. This gene consists of 18 exons and spans more than 170 kb. BP is encoded by the 16th and the 17th exons and the serpin domain by the 7th exon. Sequence analysis showed that the 7th and 8th introns lack a typical branchpoint for splicing. This might relate to the alternative splicing. The promoter of the BPP gene has some characteristics of those of housekeeping genes and contains a number of possible methylation sites. The methylation status of the promoter was analyzed by Southern blotting but no alteration was observed among tissues and between control and Alzheimer brains. We also tested the roles of two possible activator protein-1-binding sites and a possible heat-shock element found within the promoter. Northern blotting showed that the transcription of the BPP gene was apparently induced by 12-O-tetradecanoylphorbol-13-acetate (phorbol derivative) in HeLa cells.

A prion protein missense variant is integrated in kuru plaque cores in patients with Gerstmann-Sträussler syndrome.

Kuru plaques are the pathologic hallmark in Gerstmann-Sträussler syndrome (GSS). To demonstrate that prion protein (PrP) is a component of kuru plaque cores, we fractionated and sequenced kuru plaque core derived peptides, following digestion with Achromobacter lyticus protease I. We identified 3 PrP-derived peptides by reverse-phase high-performance liquid chromatography and found a fragment of digests derived from a missense variant of PrP. The variant PrP was also present in the prion rod fraction in patients with GSS. This substitution may play a major role in cerebral amyloidogenesis.

Japanese family with parkinsonism, depression, weight loss, and central hypoventilation.

BACKGROUND: The authors describe the clinical and pathologic characteristics of the Fukuoka 1 family, the first Japanese family recognized to have hereditary parkinsonism associated with depression, weight loss, and central alveolar hypoventilation. METHODS: The pedigree contains 14 family members spanning four generations, with five affected individuals. All available medical records were collected for affected members, including autopsy results. RESULTS: The inheritance pattern was autosomal dominant. The average age at onset of symptoms was 41 years. All patients had parkinsonism characterized by rigidity, bradykinesia, and resting and postural tremor. Bradykinesia and depression developed in the proband at age 43 years. He responded to levodopa in the initial stage only. A year later, he had weight loss and central hypoventilation leading to respiratory failure. Symptoms developed in his cousin at age 38 years. The proband's father developed a resting tremor and depression at age 43 years. The tremor was initially responsive to levodopa therapy, but the disease was relentlessly progressive, leading to severe bradykinesia, rigidity, weight loss, and respiratory distress. He died of respiratory failure at age 49 years. Autopsy showed marked neuronal loss and gliosis in the substantia nigra and locus ceruleus. Lewy bodies, neurofibrillary tangles, senile plaques, and other abnormal structures were not seen in the cortical and subcortical regions. CONCLUSIONS: The Fukuoka 1 family shares many clinical and pathologic features with five previously reported kindreds from North America and Europe, suggesting that this syndrome has a worldwide distribution and can occur in different ethnic populations.

Japanese family with Creutzfeldt-Jakob disease with codon 200 point mutation of the prion protein gene.

We report the first Japanese case of familial Creutzfeldt-Jakob disease (CJD) with the heterozygous point mutation at codon 200 of the prion protein gene. This suggests that the mutation is not race-specific. The clinical and pathologic features of this case are not different from those of sporadic CJD without point mutations. Some healthy members of the family also carry the same mutation in the autosomal dominant inheritance expression.

Immunochemical, molecular genetic, and transmission studies on a case of Gerstmann-Sträussler-Scheinker syndrome.

Using immunostaining with anti-prion protein (PrP) antiserum, we detected numerous kuru plaques in the brain of a 24-year-old man with Gerstmann-Sträussler-Scheinker syndrome. Immunoreactivity on Western blotting of the protease-resistant PrP fraction from the frozen brain was weak. PrP gene analysis showed substitution of alanine to valine in codon 117 but no substitution in codon 102. As the experimental transmission of the disease to mice was negative, a pathogen of a relatively low infectivity may cause the disease in predisposed family members.

A comparative study of abnormal prion protein isoforms between Gerstmann-Sträussler-Scheinker syndrome and Creutzfeldt-Jakob disease.

Proteinase K (PK)-resistant prion protein (PrPres) isoforms were examined in three patients with Gerstmann-Sträussler-Scheinker syndrome (GSS) carrying proline-to-leucine mutation at codon 102 in prion protein gene (PRNP), and in nine patients with sporadic Creutzfeldt-Jakob disease (CJD). PrPres isoform termed 'type A', which showed a more prominent band of highly glycosylated form than both a lower glycosylated band and an unglycosylated band in immunoblotting, was exclusively found in the GSS patients examined. In eight of nine CJD patients, electrophoretic mobilities of three PrPres glycoforms were similar to type A, but the ratio of these glycoforms termed 'type B' was distinct from that of type A. On the other hand, one sporadic CJD case with wild-type PRNP had a different PrPres isoform termed type C, which showed higher molecular shift of each of the PrPres glycoforms. There was no significant relationships among genotypes, clinical features and PrPres isoforms in sporadic CJD cases. Our finding suggests that type A PrPres isoform is specifically found in the patients with GSS carrying codon 102 mutation, and there are at least two different PrPres isoforms in the patients with sporadic CJD.

Immunohistochemical analysis in a case of idiopathic Lennox-Gastaut syndrome.

We herein report a neuropathological and immunohistochemical analysis of a brain from a 25-year-old male with idiopathic type of Lennox-Gastaut syndrome (LGS). The clinical pictures, such as seizure type and progressive mental deterioration with an initial normal psychomotor and mental development in a man were typical of LGS. A routine neuropathological examination showed no pronounced changes, such as neuronal loss, morphologically abnormal neurons, inflammation, vascular changes, Lafora bodies and tumor cells, except that mild gliosis was seen only in CA4 of the hippocampus. Numerous corpora amylacea were observed throughout the cerebral cortices subjacent to the pia mater. An immunohistochemical analysis showed no marked findings for such proteins as glutamate transporters, glutamate decarboxylase, glutamine synthetase, neuronal cytoskeleton proteins and heat-shock proteins. However, intense ubiquitin-immunostained neurons were only found in CA4 of the hippocampus, whereas numerous astrocytes showed a strong immunoreaction for glial fibrillary acidic protein, but showed an exclusively reduced immunoreactivity for metallothionein-I/II, zinc-chelating protein. Our findings thus suggest that the pathology in the hippocampus is either causally or consequentially associated with the seizures occurring in LGS.

[Mutation of codon 117 of the prion gene in Gerstmann-Sträussler-Scheinker disease]. / Mutation du codon 117 du gène du prion dans une maladie de Gerstmann-Sträussler-Scheinker.

We report the clinical progression of the Gerstmann-Sträussler-Scheinker disease (GSS) in a family of Alsatian origin. The age of onset and duration of evolution were variable. The clinical picture became more complex over the generations: isolated dementia in the first generations, then, more recently, a triad of pyramidal, pseudobulbar syndrome and dementia associated with symptoms indicating spread of damage to the spinal cord and cerebellum. Study of the prion gene showed that in all patients analyzed and in 10 healthy family members, there is a double mutation of codon 117 leading to loss of the restriction site PvuII and to the replacement of an alanine by a valine. We did not find the mutation of codon 102 reported in 5 GSS families. The role of these mutations in the pathogenesis of the disease is unclear: marker for a particular susceptibility to the encephalopathies due to the prion, or direct role in the disease? Further study of the family, particularly the healthy carriers, could suggest the answer. GSS seems to be an especially useful model for the study of the role of a foreign abnormal protein in the synthesis and regulation of host proteins.

[Prion diseases and a new variant of Creutzfeldt-Jakob disease].

The causal link of a new variant of CJD (v-CJD) with bovine spongiform encephalopathy (BSE) has led to world-wide panic. BSE emerged in 1986 through dietary products contaminated with scrapie pathogen, BSE case reports increased in number up to 37,000/year in 1993, then declined in 1994 when the first case of v-CJD emerged. There is a 3-year gap between the emergence of BSE and the introduction of a ban on the use of specified bovine offal in human food. People might have consumed dietary products contaminated with BSE pathogen for the period. Species barrier which has protected human from being transmitted with sheep scrapie pathogen might not work so well in cow-to-human transmission as in sheep-to-human. There are familial forms and sporadic forms of human prion diseases. The familial prion diseases are always related to prion protein (PrP) gene mutations. Sporadic forms of prion diseases are composed of sporadic CJD, iatrogenic CJD and kuru. Sporadic CJD occurs in elder people and shows cortical signs and periodic synchronous discharges (PSD) in short clinical course and pathologically spongiform degeneration and abnormal PrP deposition in synapse structures, but no amyloid plaque deposition in the brain is observed. Since the v-CJD patients had no mutations in PrP gene, v-CJD belongs to sporadic forms of prion diseases. v-CJD shows quite different clinicopathological features from those of sporadic CJD, rather shows similar features to iatrogenic CJD of pituitary hormone and kuru. These three diseases share several features, which are younger patient age, main clinical manifestation of cerebellar signs, negative or rare record of PSD, and PrP amyloid plaque deposition in the brain. The patients of v-CJD, however, had no history of exposure to iatrogenic factors and of cannibalism. Also they did not have a valine polymorphism at PrP codon 129 which is frequently observed in the patients with iatrogenic CJD and kuru. Thus, v-CJD is a quite novel entity in human prion diseases.

[Recurrent unilateral painful oculomotor nerve palsy with an ipsilateral posterior ethmoidal mucocele].

We presented a case of 6 episodes of the right painful oculomotor nerve palsy for 10 years, accompanied by a posterior ethmoidal mucocele on the same side. No destructive bone lesions were shown on every recurrence with the brain CT. For the pathogenesis of neurological involvement in cases of mucocele, either the direct compression by an expanding mucocele or the inflammatory infiltration from a mucocele has been considered. In this case the latter mechanism is considered to be responsible for the etiology of the painful oculomotor nerve palsy. Cases of the painful oculomotor nerve palsy with paranasal lesion or history of parasinusitis are characterized by (1) predominant in male, (2) neurological manifestations unilaterally on the same side of paranasal lesion, and (3) frequent recurrence of neurological symptoms.

[An autopsy case of rhino-orbito-cerebral mucormycosis associated with multiple cranial nerve palsy and subsequent subarachnoid hemorrhage].

We report an autopsy case of 53-year-old male with poor controlled diabetes mellitus and hepatocellular carcinoma who developed rhino-orbito-cerebral mucormycosis. Initial complaints were epistaxis and headache followed by a sudden blindness, the 2nd through 7th cranial nerve palsy and diabetes inspidus. Laboratory data revealed that he had liver cirrhosis due to hepatitis C virus infection and diabetes mellitus. Head CT and MRI showed no significant findings. Eleven days after the onset, he died of subarachnoid hemorrhage. The postmortem examination revealed severe infiltration of numerous mucors in the sphenoid sinus, cavernous sinus and bilateral internal carotid arteries. Severe granulomatous vasculitis was seen in the cavernous portion of the bilateral internal carotid arteries. Thus, we considered that this case had been caused by the infiltration of mucors to the cavernous sinus, resulting in the obstruction of ophthalmic arteries. Rupture of the right internal carotid artery was seen at the branching portion of the ophthalmic artery, demonstrating the cause of his death. We would like to emphasize that rhino-orbito-cerebral mucormycosis should be ruled out if we examine a nondiagnostic case of diabetes mellitus or immunosuppressed disease associated with rapid multiple cranial nerve palsy following the orbital symptoms.

[A case of Gerstmann-Sträussler-Scheinker syndrome (GSS) with late onset--a haplotype analysis of Glu219Lys polymorphism in PrP gene].

We report a 74-year-old man with late onset Gerstmann-Sträussler-Scheinker syndrome (GSS). In this family, 3 out of 6 siblings and his father developed cerebellar ataxia and mental deterioration in their fifth decades. He complained of unsteady walking and tingling pain in the legs at the age of 70. Neurological examination revealed moderate truncal ataxia, mild limb ataxia, ataxic speech, sensory impairment, paresthesia and areflexia in the lower extremities. CSF examination showed elevated CSF and 14-3-3 proteins with a normal cell count. EEG and brain MRI demonstrated no abnormality. Somatosensory evoked potential (SEP) study showed delayed N13-N20 interpeak latencies in the upper extremities and delayed N20 at 12th thoracic spinous process, indicating dysfunction of the posterior roots or columns of the spinal cord including the dorsal horns and proximal peripheral nerve. Analysis of the prion protein gene demonstrated a Pro102Leu amino acid substitution, which is compatible with classical GSS. Haplotype analysis of the PrP gene identified a Glu219Lys polymorphism on another allele. Recently, it was confirmed that protein X, which accelerates the conversion of the normal type of PrP (PrPC) into a pathological type of PrP (PrPSc), binds to the 219th amino acid residue of PrP. Therefore, the 219Lys polymorphism theoretically inhibited formation of PrPSc and may thus have delayed the onset of the disease in this patient.

Experimental treatments for human transmissible spongiform encephalopathies: is there a role for pentosan polysulfate?

Human transmissible spongiform encephalopathies (TSEs), also known as prion diseases, are caused by the accumulation of an abnormal isoform of the prion protein in the CNS. Creutzfeldt-Jakob disease in its sporadic form is the most frequent type of human TSE. At present, there is no proven specific or effective treatment available for any form of TSE. Pentosan polysulfate (PPS) has been shown to prolong the incubation period when administered to the cerebral ventricles in a rodent TSE model. Cerebroventricular administration of PPS has been carried out in 26 patients with TSEs and has been shown to be well tolerated in doses < or = 220 microg/kg/day. Proof of efficacy has been difficult because the specific and objective criteria for measurement of response have not been established yet. Preliminary clinical experience confirms extended survival in patients with variant Creutzfeldt-Jakob disease receiving intraventricular PPS; however, it is still not clear if this is due to PPS itself. Further prospective investigations of long-term intraventricular PPS administration are essential for the assessment of its effects.