Another human Prion desease

[Murgen]

[flounder]

for those of you that are interested in Genetic Prion disease, i thought some might be interested in this study. i think some of your questions might be answered here, however, maybe not all of them.....kind regards, terry

About 47% of all gTSE cases were reported to have no

TSE or other neurological disorder in family members.

Almost 90% of V210I gCJD patients had a negative

family history implying that a correct classification of

these cases would not have been possible without PRNP

genetic analysis. Interestingly, a positive family history

for TSE was reported in only about two-thirds of GSS

patients (Table 3).

ORIGINAL INVESTIGATION

Ga´ bor G. Kova´ cs Æ Maria Puopolo Æ Anna Ladogana

Maurizio Pocchiari Æ Herbert Budka

Cornelia van Duijn Æ Steven J. Collins Æ Alison Boyd

Antonio Giulivi Æ Mike Coulthart

Nicole Delasnerie-Laupretre Æ Jean Philippe Brandel

Inga Zerr Æ Hans A. Kretzschmar

Jesus de Pedro-Cuesta Æ Miguel Calero-Lara

Markus Glatzel Æ Adriano Aguzzi Æ Matthew Bishop

Richard Knight Æ Girma Belay Æ Robert Will

Eva Mitrova

Genetic prion disease: the EUROCJD experience

Received: 18 March 2005 / Accepted: 15 June 2005 / Published online: 27 September 2005


Springer-Verlag 2005

Abstract A total of 10-15% of human transmissible

spongiform encephalopathies (TSEs) or prion diseases

are characterised by disease-specific mutations in the

prion protein gene (PRNP). We examined the phenotype,

distribution, and frequency of genetic TSEs

(gTSEs) in different countries/geographical regions. We

collected standardised data on gTSEs between 1993 and

2002 in the framework of the EUROCJD collaborative

I. Zerr

Department of Neurology, Georg-August-Universita¨ t Go¨ ttingen,

Robert-Koch Strasse 40, 37075 Gottingen, Germany

H. A. Kretzschmar

Institute of Neuropathology, University of Munich,

Marchioninistr. 17, 81377 Munich, Germany

J. de Pedro-Cuesta

Departamento de Epidemiologia Aplicada, Instituto de Salud

Carlos III, Centro Nacional de Epidemiologia, Calle Sinesio

Delgado 6, 28029 Madrid, Spain

M. Calero-Lara

Centro National de Microbiologia Unidad de Encefalopatias

Espongiformes, Ctra Majadakonda-Pozuelo km2,

28220 Majadakonda, Madrid, Spain

M. Glatzel Æ A. Aguzzi

Swiss National Reference Centre for Prion Diseases, University

Hospital of Zurich, Schmelzbergstrasse 12,

CH-8091 Zurich, Switzerland

M. Bishop Æ R. Knight

National CJD Surveillance Unit, Western General Hospital,

Edinburgh, EH4 2XU UK

G. Belay Æ R. Will Æ E. Mitrova (&)

Institute of Preventive and Clinical Medicine, Research Base of

Slovak Medical University, National Reference Centre of prion

Diseases, Limbova 14, 833 01 Bratislava, Slovakia

E-mail: eva.mitrova@szu.sk

Tel.: +421-2-59-36-9564

Fax: +421-2-59-36-9585

Ga´ bor G. Kova´ cs and Maria Propolo Contributed equally

G. G. Kova´ cs Æ H. Budka

Austrian Reference Centre for Human Prion Diseases (OERPE)

and Institute of Neurology, Medical University AKH 4J,

Waehringer Guertel 18-20, 1097 Vienna, Austria

M. Puopolo Æ A. Ladogana Æ M. Pocchiari

Department of Cell Biology and Neurosciences,

Istituto Superiore di Sanita` , Viale Regina Elena 299, 00161

Rome, Italy

C. van Duijn

Department of Epidemiology and Biostatistics, Erasmus MC,

PO Box 1738, 3000 DR, Rotterdam, The Netherlands

S. J. Collins Æ A. Boyd

Department of Pathology, The University of Melbourne, Parkville,

Victoria, 3052 Australia

A. Giulivi

Blood Safety Surveillance and Health Care Acquired Infections

Division, The Centre for Infectious Disease Prevention

and Control, LCDC Building, PL 0601E2,

Tunney's Pasture, Ottawa, ON,

K1A 0L2 Canada

M. Coulthart

National Laboratory for Host Genetic and Prion Diseases,

NML, PHAC, Health, Winnipeg, MB, Canada

N. Delasnerie-Laupretre Æ J. P. Brandel

U.360 INSERM, Hopital de la Salpetriere, 75651 Paris,

Cedex 13, France

Hum Genet (2005) 118: 166-174

DOI 10.1007/s00439-005-0020-1

surveillance project. Our results show that clinicopathological

phenotypes include genetic Creutzfeldt-Jakob

disease (gCJD), fatal familial insomnia (FFI), and

Gerstmann-Stra¨ ussler-Scheinker disease (GSS). Genetic

TSE patients with insert mutation in the PRNP represent

a separate group. Point and insertional mutations in

the PRNP gene varies significantly in frequency between

countries. The commonest mutation is E200K. Absence

of a positive family history is noted in a significant

proportion of cases in all mutation types (12-88%). FFI

and GSS patients develop disease earlier than gCJD.

Base pair insertions associated with the Creutzfeldt-Jakob

disease (CJD) phenotype, GSS, and FFI cases have

a longer duration of illness compared to cases with point

mutations and gCJD. Cerebrospinal fluid 14-3-3

immunoassay, EEG, and MRI brain scan are useful in

the diagnosis of CJD with point mutations, but are less

sensitive in the other forms. Given the low prevalence of

family history, the term ''gTSE'' is preferable to

''familial TSE''. Application of genetic screening in

clinical practice has the advantage of early diagnosis and

may lead to the identification of a risk of a TSE.

Keywords Prion protein gene Æ Creutzfeldt-Jakob

disease Æ Fatal familial insomnia Æ Gerstmann-

Stra¨ ussler-Scheinker disease Æ Point

mutation Æ Insertional mutation

Introduction

Human transmissible spongiform encephalopathies

(TSEs) or prion diseases are characterised by neurological

and psychiatric symptoms and a progressive fatal

course. Accumulation in the central nervous system

(CNS) of the pathological prion protein (PrPSc) is a

common disease marker (Prusiner 2001). The most frequent

human TSE is Creutzfeldt-Jakob disease (CJD).

The majority of cases (85%) present as a sporadic disorder

(sCJD) without defined aetiology (Masters et al.

1979; WHO 2003). Acquired forms, including iatrogenic

CJD due to transmission of infection in the course of

medical or surgical treatment, and variant CJD (vCJD),

which has been linked to infection with bovine spongiform

encephalopathy, are less frequent (Masters et al.

1979; Prusiner 2001; WHO 2003). The familial occurrence

of cases has been reported with a broad range of

frequency: 6% of TSE cases in France (Brown et al.

1979), 25.5% in Israel (Kahana et al. 1974), 26% in Chile

(Galvez et al. 1980), 53.6% in Slovakia (Mitrova and

Belay 2002), and world-wide 15% (Masters et al. 1979).

Current clinical and neuropathological diagnostic

criteria distinguish familial or genetic TSEs (gTSEs),

including familial/genetic CJD (gCJD), fatal familial

insomnia (FFI), and Gerstmann-Stra¨ ussler-Scheinker

disease (GSS) (Budka et al. 1995; Prusiner 2001; WHO

2003). Experimental transmissibility of all the major

subtypes has been established, albeit not with all mutations

(Masters et al. 1981; Tateishi et al. 1979, 1995). In

gTSEs, disease-specific point or insertional mutations in

the prion protein gene (PRNP) have been demonstrated

(Goldfarb et al. 1990a, b, 1992; Goldgaber et al. 1989;

Haltia et al. 1991; Owen et al. 1989), with individual

PRNP mutations showing variable geographical distribution

and frequency. While certain mutations are rare

(Kovacs et al. 2002), the E200K mutation has been reported

not only in Europe but also in Chile, Israel, Japan,

and USA (Goldfarb et al. 1990a, b; Goldgaber et al.

1989; Miyakawa et al. 1998). Geographic or ethnic clusters

of cases of gTSEs have been found in Israel, Slovakia,

Chile, and Italy (Chapman et al. 1994; D'Alessandro

et al. 1998; Kahana et al. 1974; Mayer et al. 1977;

Mitrova and Belay 2002; Mitrova and Bronis 1991).

In parallel with the increasing numbers of PRNP

mutations, it has been recognised that, unexpectedly, not

all patients with PRNP mutations appear to have affected

family members (Chapman et al. 1994; D'Alessandro

et al. 1998; EuroCJD group 2001; Goldman et al. 2004;

Mitrova and Belay 2002). Therefore the terms ''familial'',

''hereditary'', or ''inherited'' TSE may not be appropriate

in cases without a family history and the inclusive term

''genetic TSE'' may be preferable for cases associated

with a mutation, whether or not there is a family history.

The negative family history in some gTSE cases and

the identification of ''healthy'' carriers has drawn

attention to the issue of penetrance, i.e., the proportion

of carriers who will eventually develop the disease

(Chapman et al. 1994; D'Alessandro et al. 1998; Goldfarb

et al. 1990a, b; Mitrova and Belay 2002). Penetrance

of the E200K mutation shows considerable

variability. While in Israeli carriers, penetrance appears

to be almost complete (89%), in Slovakian and Italian

E200K carriers, penetrance is partial (54-59%) (Chapman

et al. 1994; D'Alessandro et al. 1998; Goldfarb

et al. 1990a, b; Mitrova and Belay 2002).

The EUROCJD project, funded by the European

Commission, started in 1993 and compares data from

national registries in Australia, Austria, Canada,

France, Germany, Italy, The Netherlands, Slovakia,

Spain, Switzerland, and the UK. The present study

analyses the EUROCJD data on gTSE cases. Recently

clinicopathological data of more than 500 published

genetic cases of the literature has been reviewed (Kovacs

et al. 2002) and some of the data on genetic epidemiology

of CJD in Europe has been published (EuroCJD

group 2001). The present paper includes standardised

data from a large number of cases not previously reported

in the context of a study carried out over a period

of years in a defined population. Our aims are: (1) to

describe the distribution and frequency of gTSEs, (2) to

define and describe specific features of subgroups of

gTSEs, (3) to contribute to a better understanding on

how mutations and polymorphisms of PRNP influence

clinical phenotypes, and (4) to assess the terms genetic

and familial according to epidemiological and molecular

biological data.

167

Patients and methods

The EUROCJD database contains data on sporadic,

variant, iatrogenic, and gTSE cases collected between

1993 and 2002 (for detailed methodology see Ladogana

et al. 2005a). In this paper we have analysed data of 455

gTSE cases from the following groups: gCJD cases

(including patients with PRNP analysis and those with

no available PRNP analysis but positive family history

for TSE), FFI, GSS, and gTSE patients carrying base

pair insertions (insert gTSE): referred to in previous

publications as BPI (Kovacs et al. 2002) because these

mutations are associated with repeat base pair insertions

in the octarepeat region. No deletions in this region were

identified in this study. We evaluated E200K gCJD and

V210I gCJD separately as there were sufficient numbers

of cases to allow statistical analyses. Cases of gCJD

without either an E200K or V210I mutation are classi-

fied as ''other CJD''. Cases were classified either as

definite or probable according to recent surveillance criteria

(WHO 2003), which for the diagnosis of ''familial''

CJD require definite or probable CJD in the index case

and a first-degree relative or a neuropsychiatric disorder

in association with a PRNP mutation.

Statistical analysis

Differences among distinct forms of gTSE cases with

respect to age at onset or clinical duration were assessed

by Mann-Whitney test; variation in clinical signs by the

chi-square test or the Fisher's exact probability test. The

Bonferroni correction for multiple testing was adopted

within the six subgroups of gTSE (E200K, V210I, and

other forms of gCJD, GSS, FFI, and insert mutations)

at an experimental probability type 1 error of 0.05.

Age at onset was given as mean, standard deviation

(SD), and range; clinical duration as median and half

interquartile range (IQR) because of highly skewed

distribution of data. Box-plots were used for the graphic

representations of continuous variables. Statistical

analyses were performed using BMDP and STATA.

Crude and sex-specific mortality rates were calculated

using as denominator populations data for 1998 provided

from National or Federal Statistics Bureau of

participating countries. For Canada, population data

(2001) were taken from the Canadian Statistics website.

The annual mortality rates were calculated using data

collected from 1999-2002 when the surveillance system

was well established in all countries.

Results

Distribution of cases and mutations

The distribution and frequency of PRNP mutations

among countries participating in the study are summarised

in Table. 1 and 2. The proportion of all gTSE

cases with respect to the total number of TSE cases

(including sporadic, iatrogenic, and variant CJD) was

10.2%, but, this varied significantly among participating

countries ranging from 69.5% in Slovakia to 1.2% in

Switzerland. The overall annual mortality rate of gTSE

cases was 0.17 patients per million people for the period

1999-2002. It is of note that Slovakia had an overall

mortality rate for gTSE diseases 3.5 times that of the

second highest country (Italy). However, while the

E200K mutation was the only mutation present in the

Slovak population, several mutations were present in the

Italian population, including the E200K and V210I

gCJD, FFI, and GSS. Switzerland reported a single

Table 1 EUROCJD 1993-2002: number of reported cases in each EUROCJD country

All genetic TSE diseases gCJD GSS FFI Insert

n gTSE (%) gTSE (%)

with respect

to all TSE

in each

country

Mortality rates

(million people)a

Australia 22/215 4.8 10.2 0.14 14 3 4 1

Austria 13/90 2.9 14.4 0.28 9 0 3 1

Canada 16/189 3.5 8.5 0.12 7 9 0 0

France 84/938 18.5 9.0 0.18 68 5 6 5

Germany 68/900 14.9 7.6 0.13 31 8 17 12

Italy 115/662 25.3 17.4 0.30 94 8 10 3

Netherlands 3/142 0.7 2.1 0.02 1 0 0 2

Slovakia 41/59 9.0 69.5 1.07 41 0 0 0

Spain 44/429 9.7 10.3 0.23 18 0 25 1

Switzerland 1/85 0.2 1.2 0.04 1 0 0 0

UK 48/732 10.5 6.6 0.07 11 19 1 17

Total 455/4,441 - - 0.17 295 52 66 42

% Total - 100 10.2 - 64.9 11.4 14.5 9.2

Abbreviations: gTSE, genetic transmissible spongiform encephalopathy; gCJD, genetic Creutzfeldt-Jakob disease; FFI, fatal familial

insomnia; GSS, Gerstmann-Stra¨ ussler-Scheinker disease; Insert, gTSE patients with insert mutations.

a For the period 1999-2002.

168

gTSE patient for the period 1996-2002 while the Netherlands

had the lowest mortality rate for gTSE diseases.

More than 90% of FFI and 75% of GSS patients

underwent post-mortem examination and were classified

as definite gTSE cases, while 52% of V210I gCJD patients

did not undergo autopsy (see Table 3) and were

classified as probable gTSE based on clinical and laboratory

features. There was an excess of females in gCJD

(more pronounced for E200K than V210I or ''other''

gCJD patients) and, to a lesser extent, in GSS or insert

gTSE cases, and an excess of males in FFI cases (Table

3). Data on the polymorphic codon 129 of the PRNP

gene were available in 87% of all cases (95% in E200K,

97% in V210I, 75% in ''other'' gCJD, 95% in FFI, 56%

in GSS, and 79% in insert gTSE). The distribution of the

polymorphic codon 129 in all forms of gTSE is shown in

Table 3. Differences between codon 129 distribution in

controls (39% methionine homozygous (MM), 50%

heterozygous (MV), 11% valine homozygous (VV), Alperovitch

et al. 1999) and in individual gTSE groups

have been evaluated by chi-sqared test with the following

results: E200K gCJD, V210I gCJD and FFI,

P<0.0001, ''other'' gTSE, P=0.0010, Insert gTSE,

P=0.0577 and GSS, P=0.3825. The majority of PRNP

mutations co-segregate with methionine at the polymorphic

codon 129 (see Table 2). Thus, the majority of

gTSE patients overall were either MM (67.9%) or MV

(25.8%) with only a few valine homozygotes (6.3%).

Family history

About 47% of all gTSE cases were reported to have no

TSE or other neurological disorder in family members.

Almost 90% of V210I gCJD patients had a negative

family history implying that a correct classification of

these cases would not have been possible without PRNP

genetic analysis. Interestingly, a positive family history

for TSE was reported in only about two-thirds of GSS

patients (Table 3).

Age at onset

There were significant differences in the age at onset in

gTSE forms (Fig. 1a). Patients with FFI (mean

51.2 years, SD 12.3, range 19-83) and GSS (51.6, 12.8,

26-87) developed disease significantly earlier than

E200K gCJD (60.4, 10.2, 33-84, p<0.0001), V210I

gCJD (59.3, 9.8, 39-82, p=0.0001 and 0.0009, respectively),

and ''other'' gCJD cases (60.4, 14.7, 31-87,

p=0.0004, 0.0036). There was no significant difference

in the age at onset between FFI and GSS patients and

among distinct forms of gCJD. Age at onset in patients

with insert mutations (57.2, 14.8, 32-85) did not significantly

differ from that of gCJD, GSS, or from FFI

(p=0.0193) after Bonferroni's correction. The youngest

age at onset was 19 years (FFI, MM at codon 129),

while the two oldest were 87 years (gCJD with missing

information on PRNP mutation, and A117V GSS, VV

at codon 129). The age at onset was earlier in valine

homozygotes in comparison to methionine homozygotes

(P=0.0001) and, to a lesser extent, in MV vs MM

(P=0.0059, not significant after Bonferroni's correction)

in ''other'' gCJD patients. The codon 129 polymorphism

did not significantly influence the age at onset in all the

other forms of gTSEs (Table 4). Gender did not have

any significant effect on the age at onset (data not

shown).

Duration of illness

The duration of disease varied between different forms

of gTSE (Fig. 1b). Clinical durations of E200K (median

5.0 months, IQR 2.5) and V210I (4.0, 1.5) gCJD

patients were shorter than ''other'' gCJD (7.0, 7.0,

p=0.0031 and 0.0012, respectively), FFI (12.4, 4.2,

P<0.0001 and 0.0001), GSS (40.0, 25.0, P<0.0001 and

0.0001) and insert gTSE (13.0, 35.5, P=0.0001 and

0.0001). GSS patients had a longer survival than FFI

(P<0.0001) and ''other'' gCJD (P<0.0001) patients.

Table 2 EUROCJD 1993-2002: number of reported cases and distribution of PRNP mutations in each EUROCJD country

Country gCJD

P105T-129? N171S-129V D178N-129V V180I-129M T188A-129M E196K-129M/V E200K-129M/V V203I-129M R208H-129M V210I-129M E211Q-129M NS

Australia 1 - - - 1 - 8 - - 2 - 2

Austria - - 1 - - 1 5 - - 1 - 1

Canada - - 2 - - - 4 1 - - - -

France - 1 8 1 - 1 46 3 - 6 2 -

Germany - - - - 2 3 15 - 1 9 1 -

Italy - - - - - - 35 1 1 50 1 6

Netherlands - - 1 - - - - - - - - -

Slovakia - - - - - - 40 - - - - 1

Spain - - 4 - - - 14 - - - - -

Switzerland - - - - - - 1 - - - - -

UK - - - - - - 7 - - 1 - 3

Total 1 1 16 1 3 5 175 5 2 69 4 13

% Total 0.2 0.2 3.5 0.2 0.7 1.1 38.5 1.1 0.4 15.2 0.9 2.9

Abbreviations: NS, not specified; others as in Table 1.

169

The longest duration of illness was 216 months in an

insert gTSE case, the group with the highest variability

in clinical duration. However, in all other groups there

were a few cases with an exceptional long clinical

duration for their group (outliers in Fig. 1b). This included

11 cases in E200K gCJD (five MM at codon 129:

16, 19, 20 and two 24 months; 6 MV: 17, two 18, 19,

and two 36 months), four cases in V210I gCJD (MM:

11, 15, 31, and 34 months), four in ''other'' gCJD

(43 months, D178N-129VV, 46 months, V180I-129MV,

52 months, V203I-129MV, 59 months, missing mutation

and codon 129), and one in FFI (MV: 97 months),

and two in insert gTSE (216 months 120 bp insert-

129MV, and 192 months 168 bp insert-129 MV).

Investigations

Data on CSF 14-3-3 immunoassay were available in

57% of cases (60% in E200K, 72% in V210I, 59% in

''other'' gCJD, 58% in FFI, 31% in GSS, and 50% in

insert gTSE), EEG in 82% of cases (90% in E200K,

96% in V210I, 86% in ''other'' gCJD, 77% in FFI, 50%

in GSS, and 67% in insert gTSE), and MRI brain scan

in 43% of cases (38% in E200K, 67% in V210I, 31% in

''other'' gCJD, 52% in FFI, 33% in GSS, and 36% in

insert gTSE). In the various forms of gTSEs, there were

significant differences in the frequency in positivity of

the 14-3-3 test in the CSF (P<0.0001, Fisher's exact

test), the EEG (P<0.0001, chi-squared test) and the

MRI brain scan (P=0.0038, Fisher's exact test) (WHO

2003). A positive 14-3-3 test was present in the majority

of gCJD patients and insert gTSE patients (Fig. 2). A

typical EEG (WHO 2003) was more frequent in gCJD

than in other forms of gTSE diseases. About 50% of

GSS cases had a positive 14-3-3 test in the CSF, while

the EEG showed typical pseudoperiodic activity in only

2 of 26 patients with available information (Fig. 2). In

GSS and FFI, neither the EEG nor the 14-3-3 tests were

of help in the clinical diagnosis of disease. MRI brain

scan was performed in a small proportion of cases and

was positive (WHO 2003) in about 50% of E200K and

''other'' gCJD and in about 30% of GSS and insert

gTSE cases. In FFI and V210I gCJD patients, the MRI

brain scan was positive in only 18 and 15%, respectively.

Classification of protease-resistant PrP

Results were available in only 43 cases. Twenty-two

E200K, 6 V210I gCJD, 9 ''other'' gCJD, 1 FFI, 2 GSS,

and 3 insert gTSE cases (Table 5). Thirty-four patients

had type 1 protease-resistant prion protein (according to

the system described by Parchi et al.) (Parchi et al. 1999)

in brain samples, six had type 2A, and three patients had

both type 1 and type 2A.

Discussion

EUROCJD has data on 23 specified PRNP mutations.

Currently more than 30 mutations have been reported in

the world literature, but many of these mutations are

very rare or are restricted to specific populations (Kovacs

et al. 2002). Comparison of genetic and sporadic

TSEs shows striking differences in their frequency and

geographic distribution. While sCJD has a similar incidence

in all participating countries (Ladogana et al.

2005a), PRNP mutations show significant variability.

Some mutations (P105L, N171S, V180I, T188A, E196K,

R208H, V203I, 168 BPI) are extremely rare, while

E200K is recognised in 9 out of 10 reporting countries.

The high absolute and proportionate incidence of the

V210I mutation in Italy is striking; most affected families

lived in three adjacent areas (Ladogana et al. 2005b).

It is a pertinent point that a single report on the N171S

mutation suggested a psychiatric phenotype, whereas in

our series this mutation was associated with CJD

(Samaia et al. 1997). A high proportion of all cases in

each category underwent genetic analysis. The three

lowest percentages of PRNP tests were 42.3% (Canada),

32% (Australia) and 31.7% (Netherlands). The variability

in the frequency of mutations countrywise is

unexpected and is not related to variation countrywise in

GSS FFI Insert

P102L-129M A117V-129V G131V-129M NS D178N-129M NS 24-129M 48-129M 72-129? 96-129M/V 120-129M/V 144-129M 168-129M 192-129M/V NS

1 - 1 1 3 1 - - - - - - 1 - -

- - - - 3 - - - - - - 1 - - -

1 - - 8 - - - - - - - - - - -

3 2 - - 6 - 2 - - 1 - 1 - 1 -

3 5 - - 17 - 1 - 1 2 8 - - - -

8 - - - 10 - 2 - - 1 - - - - -

- - - - - - 1 - - - - - - 1 -

- - - - - - - - - - - - - - -

- - - - 24 1 - 1 - - - - - - -

- - - - - - - - - - - - - - -

8 5 - 6 1 - - - - 1 4 9 1 - 2

24 12 1 15 64 2 6 1 1 5 12 11 2 2 2

5.3 2.6 0.2 3.3 14.1 0.4 1.3 0.2 0.2 1.1 2.6 2.4 0.4 0.4 0.4

170

the availability of genetic data. Focal accumulations of

genetic patients (Mayer et al. 1977) may be due to genetic

isolation but the explanation for the overall intercountry

variability in this study is uncertain.

The ratio of female to male mortality rates in Table 3

indicates that there is an excess of females in all mutations

except FFI. Taking account of varying distribution by

age, the weighted female to male ratio (1.59 for E200K,

1.62 for V210I, 1.90 for other gCJD, 1.43 for GSS, 1.62

for insert gTSE, and 0.62 for FFI) strongly confirms the

excess of female cases in all forms of gCJD except FFI.

Although consistent with similar findings in sporadic

CJD (Ladogana et al. 2005a), the explanation for this

gender bias in mortality is uncertain. Possible explanation

include sex-linked genetic factors influencing disease

expression, bias in case ascertainment linked to gender or

differential susceptibility/exposure to a co-factor.

Clinical and laboratory parameters show considerable

similarity between the most frequent gCJD (e.g.,

E200K mutation) and sCJD cases. Although gCJD cases

with point mutations have an earlier mean age at death,

there is no difference between gCJD cases with point

mutations and sCJD in the mean duration of the disease

(Alperovitch et al. 1999; Pocchiari et al. 2004). As in

sCJD (Zerr et al. 2000), analysis of CSF 14-3-3 protein,

EEG, and MRI is helpful in the diagnosis of gTSEs and

Table 3 Characteristics of genetic transmissible spongiform encephalopathies

Forms of gTSE n Percentage of

definite cases

(n)

Gender Codon 129 polymorphism Percentage of

positive family

history for TSE

(available data)

F M F/M ratios

of mortality

ratesa

MM % (n) MV%(n) VV%(n)

E200K gCJD 175 68.0 (119) 107 68 1.69 78.3 (130) 19.9 (33) 1.8 (3) 49.1 (114)

V210I gCJD 69 47.8 (33) 39 30 1.42 73.1 (49) 26.9 (1 - 12.3 (57)

Other gCJD 51 58.8 (30) 28 23 1.38 36.8 (14) 34.2 (13) 29.0 (11) 75.9 (29)

FFI 66 92.4 (61) 29 37 0.62 71.4 (45) 28.6 (1 - 88.0 (50)

GSS 52 76.9 (40) 29 23 1.17 51.7 (15) 34.5 (10) 13.8 (4) 69.7 (33)

Insert gTSE 42 69.0 (29) 21 21 1.23 48.5 (16) 30.3 (10) 21.2 (7) 48.0 (25)

Abbreviations: gTSE, genetic transmissible spongiform encephalopathy; gCJD, genetic Creutzfeldt-Jakob disease; FFI, fatal familial

insomnia; GSS, Gerstmann-Stra¨ ussler-Scheinker disease; Insert, gTSE patients with insert mutations.

a For the period 1999-2002.

Fig. 1 Box- and whisker-plots of age at onset (a) and clinical

duration (b) in different forms of genetic TSE diseases. The line in

the middle of the box represents median. The box extends from the

25th percentile (x[25]) to the 75th percentile (x[75]), the so-called

interquartile range (2IQR). The lines emerging from the box are

called the whiskers and they extend to the upper and lower adjacent

values. The upper adjacent value is defined as the largest data point

less than or equal to x[75]+1.52IQR. The lower adjacent value is

defined as the smallest data point greater than or equal to x[25]


1.52IQR. Filled circles represent values more extreme than the

adjacent values (referred to as outliers)

Table 4 Influence of codon 129 polymorphism of the PRNP gene

in determining the age at onset

Forms of gTSE Codon 129

Met/ Met

mean (SD)

Met/Val

mean (SD)

Val/Val

mean (SD)

E200K gCJD 60.4 (10. 60.7 (8.6) 55.7 (9.0)

V210I gCJD 59.3 (9.7) 57.9 (9. -

Other gCJD 70.9 (7.5) 56.2 (14.2) 48.1 (12.6)

FFI 50.8 (13.4) 52.5 (10.0) -

GSS 54.0 (11.1)a 49.0 (12.1) 66.2 (17.9)

Insert gTSE 60.9 (14.0)a 56.2 (15.2) 62.7 (11.3)

Abbreviations: gTSE, genetic transmissible spongiform encephalopathy;

gCJD, genetic Creutzfeldt-Jakob disease; FFI, fatal

familial insomnia; GSS, Gerstmann-Stra¨ ussler-Scheinker disease;

Insert, gTSE patients with insert mutations.

a Two patients had missing data on age at onset.

171

in particular in gCJD cases with point mutations, while

in other gTSE cases these laboratory examinations are

less sensitive. Our data confirm previous studies that

insertional mutations often present atypically with a

relatively protracted duration of illness (although less

protracted than a previous study which included larger

numbers of cases and with a unique type of PrP

immunoreactivity in the cerebellum (Kovacs et al. 2002;

Vital et al. 1999).

We also demonstrate that, except for some specific

mutations like D178N-129M, protease-resistant PrP

may be variable within the same brain in some gTSEs as

in sCJD (Puoti et al. 1999).

It is of great importance that a positive family

history of a human TSE is absent in a high proportion

of cases overall and with all the mutations. Although

this has been reported previously by this group and

others (EuroCJD group 2001; Goldman et al. 2004;

Mitrova and Belay 2002), this is the first study to

provide a detailed analysis of the frequency of a positive

family history in a range of PRNP mutations.

Possible explanations include lack of knowledge of the

family history in the relatives of index cases, premature

death in antecedents prior to the development of a

TSE, and non-paternity. However, there must be some

doubt that the very high frequency of a negative family

history in this study can be explained by these mechanisms

and there remains the possibility that a

minority of mutations arise de novo (Dagvadorj et al.

2003) or that the mutations are not fully penetrant

(Mitrova and Belay 2002).

As cases considered as sCJD often lack full-length

PRNP analysis, accurate diagnosis of gTSEs may depend

on more widespread genetic screening, particularly

as some mutations, e.g., E200K and V210I, are associated

with a phenotype indistinguishable from sCJD. The

negative family history in a high proportion of cases

indicates that mutations may be identified unexpectedly

in cases thought to have sCJD or indeed some other

neurological disorder and this may have important

implications for other family members.

At present gTSEs are the only sub-group of human

TSEs in which the diagnosis can be supported by

genetic screening in life. There is the potential for

early diagnosis and the risk of developing a TSE can

be identified before the onset of disease in asymptomatic

carriers. This may be an important advantage

in the application of potential therapies as treatment

could be instituted before severe and irreversible

damage to the CNS occurs, or perhaps, as a means to

prevent iatrogenic transmission of CJD from at-risk

patients.

Fig. 2 Percentage of cases

showing positive 14-3-3 protein

in the CSF, typical EEG

pattern, and positive MRI brain

scan in different forms of

genetic TSE disease. The

number of patients with

available data is shown on top

of each column

Table 5 Type of the pathological PrP in the brain of genetic TSE cases

PrP type gCJDa FFIa GSSa Inserta

N171S D178N E196K E200K V203I R208H V210I E211Q D178N P102L

Type 1 - 2 VV 1 MM 17 MM 1 MM 1 MM 5 MM 1 NA - 2 MV 1 MV

1 MV 1 MV 1 MV

Type 2A 1 VV - - 1 MV 1 MV - - - - - 1 VV

1 VV

Type 1-2A - - - 2 MM - - - - - - 1 MV

Type 2B - - - - - - - - 1 MV - -

Abbreviations: gTSE, genetic transmissible spongiform encephalopathy;

gCJD, genetic Creutzfeldt-Jakob disease; FFI, fatal

familial insomnia; GSS, Gerstmann-Stra¨ ussler-Scheinker disease;

Insert, gTSE patients with insert mutations; MM, methionine

homozygous; VV, valine homozygous; MV, heterozygous patients;

NA, not available.

a Number of cases of codon 129 polymorphism.

172

The occurrence of asymptomatic carriers of PRNP

mutations (Mitrova and Belay 2002) underlines the

importance of genetic testing in all suspect cases of human

TSEs and, in positive cases, relatives may be offered

genetic testing, provided appropriate ethical protocols

are followed. Although there may be incomplete penetrance

and an absence of presymptomatic neuropathological

changes or accumulation of disease-associated

PrP (Sasaki et al. 2003), healthy carriers of PRNP

mutations are at greater risk of developing a TSE and

may be subject to restrictions, such as donating blood

and tissues (e.g., cornea, dura mater), because of the risk

of iatrogenic transmission.

It is not known why there is partial penetrance in

some mutations, or why there is marked variability in

clinical phenotype, including age at onset, both between

and within pedigrees. There is a need to analyse events

preceding the onset of clinical manifestation in carriers

of PRNP mutations as possible triggering factors. In

E200K, psychological stress (divorce, death of a close

relative, retirement, loss of a job), complicated surgery

with prolonged anaesthesia, serious accidents, or current

infectious disease have been frequently noted (Brandel

and Delasnerie-Laupretre 1997; Mitrova and Belay

2002).

In conclusion, the term gTSE, which includes gCJD,

FFI, and GSS, is more appropriate than familial TSE

for all patients with TSE-specific genetic marker,

regardless of the number of affected family members,

while familial TSE designates only genetic cases with

other (one or more) TSE-affected relative. The distribution

of gCJD is geographically heterogeneous. The

codon 129 polymorphism influences phenotype. In

gTSEs, PRNP analysis may allow early or pre-symptomatic

diagnosis and this may be important if specific

therapies become available. Further studies are required

to identify whether PRNP mutations are sufficient in

themselves to cause disease.

Acknowledgements This study was funded through an EU Concerted

Action (BIOMED2 Contract No. BMH4-CT97-2216).

Australia: The Australian National CJD Registry is funded by the

Commonwealth Department of Health and Ageing. We are

grateful to the following people involved in the Australian National

CJD Registry: C.L. Masters, A. Boyd, G. Klug, and J. Lee. Austria:

The Austrian Reference Centre for Human Prion Diseases

(O¨ ERPE, Head: Prof. Herbert Budka) acknowledges the help of

Drs Christa Jarius, Ellen Gelpi, Christine Haberler, Thomas

Stro¨ bel, and Till Voigtla¨ nder; DI Dita Drobna; and Ms. Helga

Flicker, Brigitte Millan-Ruiz, and Monika Richter. Canada: The

Canadian Surveillance System is funded by Health Canada. Other

collaborators on the project are Dr C Bergeron, neuropathologist

(University of Toronto), Dr N Cashman, neurologist and one of

the principal investigators for CJD-SS, Dr D Westaway, consulting

scientist (University of Toronto). France: We would like to

acknowledge all reporting physicians and the members of the Reseau

National de surveillance de maladies de Creutzfeldt-Jakob et

maladies apparentees. Germany: The German surveillance system is

funded by the Federal Ministry of Health 9BMG, 325-4471-02/15.

We are grateful to all reporting physicians throughout Germany

who contributed to the German surveillance system and especially

to Maja Schneider-Dominico for her excellent support in the coordination

of surveillance. We also acknowledge the help of Drs

Otto Windl and Walter Sculz-Schaeffer. Italy: We would like to

acknowledge the Ministry of Health and the Istituto Superiore di

Sanita` for supporting the surveillance of CJD in Italy and S. Almonti,

V. Mellina, and L. Ingrosso for help in collecting data and

advice. The Netherlands: CJD surveillance in the Netherlands is

funded by the Dutch Ministry of Health, Welfare, and Sports. We

acknowledge the help of colleagues at the Department of Neurology

at the Academic Medical Centre, Amsterdam and the

Department of Pathology at the University Medical Centre, Utrecht.

Slovakia: The Slovak Surveillance System was supported by

the Slovak Ministry of Health and by grants from the European

Union. We would like to acknowledge the help of Dr. Dana Slivarichova

´ , Dr. Vladimi´ ra Verchovodkova´ , all reporting physicians

and collaborating pathologists. Spain: We are grateful to all

reporting physicians and to members of the Spanish TSE study

group at Consejo Interterritorial and co-workers at CNE and

ISCIII and laboratories, particularly to N. Cuadrado and J.Yague.

Switzerland: This work was supported by the Kanton of Zurich and

by grants from the European Union. The Swiss Reference Center

for Prion Diseases is being funded by the Swiss Federal Office of

Public Health. UK: The UK CJD Surveillance System is funded by

the Department of Health and the Scottish Executive Health

Department. We are grateful to all the members of staff at the

National CJD Surveillance Unit and in particular to James Ironside

for neuropathological expertise and to clinicians throughout

the UK for their co-operation with the study.

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174tss

[flounder]

CJD WATCH MESSAGE BOARD
TSS
GSS: A New Phenotype With 'Curly' PrP Deposits
Tue Jul 18, 2006 08:46
71.248.128.67

Gerstmann-Straussler-Scheinker: A New Phenotype With 'Curly' PrP Deposits.

Original Articles

Journal of Neuropathology & Experimental Neurology. 65(7):642-651, July 2006.
Colucci, Monica MD; Moleres, Francisco J. PhD; Xie, Zhi-Liang MD; Ray-Chaudhury, Abhik MD; Gutti, Sujata MD; Butefisch, Cathrin M. MD; Cervenakova, Larisa MD; Wang, Wen MD; Goldfarb, Lev G. MD; Kong, Qingzhong PhD; Ghetti, Bernardino MD; Chen, Shu G. PhD; Gambetti, Pierluigi MD
Abstract:
Gerstmann-Straussler-Scheinker (GSS) is a hereditary prion disease typically associated with prion protein (PrP)-containing plaques. The protease-resistant, scrapie PrP (PrPSc) is represented by internal fragments, whereas the C-terminal fragments associated with the other prion diseases are generally underrepresented. Different histopathologic and PrPSc features associated with at least 13 PrP gene (PRNP) mutations have been described in GSS. We report the histopathology and PrP characteristics in a father and son carrying a mutation at PRNP codon 187 that substitutes histidine (H) with arginine (R) and is coupled with valine (V) at position 129 (H187R-129V). The PrP plaques were present in both cases but with different structure and topography and minimal spongiform degeneration. A distinctive, "curly" PrP immunostaining was prominent in one case. The protease-resistant PrPSc differed in amount in the 2 cases, possibly depending on whether plaques or the curly immunostain was present. Two protease-resistant PrP fragments of 14 kDa and 7 kDa with, in at least one case, N-terminus between residues 90-99 and 82-90, respectively, codistributed with the plaques, whereas only very small amounts of the PK-resistant PrP were present in the curly staining regions. PK-resistant PrP recovered from the plaque and curly staining regions appeared to be full length.

(C) 2006 American Association of Neuropathologists, Inc

http://www.jneuropath.com/pt/re/jnen/abstract.00005072-200607000-00002.htm;jsessionid=G8jHsgLwLhhrLlLPDBcQmJlJGpLqyst5QvMmLgf2Rn2j1y5wfp7Z!-1725731959!-949856144!8091!-1



-------- Original Message --------
Subject: SCRAPIE, BRAIN CONSUMPTION AND CJD
Date: Wed, 31 Mar 2004 10:01:26 -0600
From: "Terry S. Singeltary Sr."
Reply-To: Bovine Spongiform Encephalopathy
To: BSE-L@uni-karlsruhe.de


######## Bovine Spongiform Encephalopathy #########

THE LIBYAN JEWISH FOCUS OF CREUTZFELDT-JAKOB DISEASE:

A SEARCH FOR THE MODE OF NATURAL TRANSMISSION1 Harvey Goldberg2, Milton
Alter3, and Esther Kahana4 ABSTRACT In 1974, we reported chat
Creutzfeldt-Jakob disease (CJD), a fatal slow virus disease of man,
occurred at least thirty tines more commonly In Libyan Jewish immigrants
to Israel than all other groups studied. The mode of natural
transmission of CJD Is unknown. This report describes genetic and
environ- mental factors Investigated In an effort to explain the focus
of CJD among Libyan Jews. A total-of 14 Libyan and 11 non-Libyan cases
of CJD were studied. Of these, three were diagnosed after completion of
our original report and two In the original report did not participate
in this study. Among the 14 Libyans with CJD diagnosed between 1963 and
1974 and available for this study, two definite and three possible
familial cases were identi- fied. Parents were first cousins in three of
14 (21%) cases among the Libyans, but 18% of a control sample of
Tunisians also report first cousin marriages between parents. Non-Libyan
patients had no familial cases but the holocaust and dispersion of
families made collection of reliable pedigrees difficult. Because CJD
can be transmitted experimentally by inoculation of susceptible animals
with brain tissue, dietary habits were investi- gated. Over 80% of
Libyan patients ate brain but they did not appear to differ in this
respect from controls. Libyan cases resembled controls also In source of
meat and frequency of meat consumption. However, Libyan Jews preferred
quick-grilled brain while Tunisians preferred fried and simmered brain.
In their occupations, Libyans 1This work was supported In part by grants
from the National Institutes of Health (NS13766-02) and from the Medical
Research Council of Israel. 2Department of Sociology and Social
Anthropology, Hebrew University of Jerusalem, Jerusalem, Israel.
3Department of Neurology, Temple University, School of Medicine, 3401 N.
Broad Street, Philadelphia. PA 19140. 4Uri Leibowicz Neuroepidemiology
Unit, Department of Neurology, Hadassah Hebrew University Hospital,
Jerusalem, Isr snip...

Harvey Golberg et al.

regularly by residents of rural towns; the rural population
ate goat as well. Chicken was eaten frequently by everyone,
turkey much less frequently. There was no systematic differ-
ence among the patients and the three control groups in the
type of meat eaten or in the frequency of meat consumption.

Table 3 contains more detailed information on the con-
sumption of brain. The percentages of those eating brain
sometimes ranged from 79 to 92 for the four groups. The
patient group was not consistently higher than any of the
control groups. A higher percentage of Libyans ate brain in
our small sample than in Bobowick's series (. The percent-
age eating spinal cord was consistently lower than that of
brain consumers, but many people said that some spinal cord
may have been found in bones purchased for soup, and the
actual consumption of spinal cord may have been higher than
that shown in Table 3.

Brain was commonly prepared in stew (m'chuma) and in a
patty (m'akod). The number of people who reported eating
these dishes at least once every two months was low (10-25%),
and was not different in patients compared to controls.

Brain was also prepared by grilling, typically while the
brain was wrapped in heavy paper, so that the full effect of
the heat did not reach the brain. Usually the grilling was
for a brief period of time, often less than five minutes. The
number of people who reported eating grilled brain which was
on the fire less than twenty minutes is shown in Table 3.
More than one-third of the patients were described as having
eaten brain prepared in this manner, but each of the control
groups reported a higher precentage.

The Libyans also reported eating eyeballs, although not
with great frequency. This question was introduced midway
through the research so that only some people were queried.
The small number of cases interviewed did not suggest any
difference between patients and controls.

Reviewing the dietary data presented in Tables 2 and 3,
it appears that meat consumption was relatively high among
Libyan Jews, that brain was eaten by most people at some time,
and that brain was eaten by many people several times a year.
Patients, however, did not appear different from controls in
most of the variables studied. Thus, there is an overall
consistency in the answers among the four groups of Libyan
respondents. While this was encouraging so far as the quality
of the data is concerned, it did not support the hypothesis
that (diseased) brain consumption set patients apart from
other Libyans. It is still conceivable that high consumption
of brain places the Libyan population at high risk with
regard to CJD, but that another mechanism, perhaps genetic,
makes some individuals more vulnerable than others...

snip...END


1: J Infect Dis 1980 Aug;142(2):205-8


> Analysis of unusual accumulation of Creutzfeldt-Jakob disease cases
> in Orava and Liptov regions (northern Slovak focus) 1983-2000.
>
> Mad'ar R, Maslenova D, Ranostajova K, Straka S, Baska T.
>
> Institute of Epidemiology, Jessenius Faculty of Medicine, Comenius
> University, Sklabinska 26, Martin, 037 53 Slovakia. MADAR@jfmed.uniba.sk
>
> While familial cases of Creutzfeldt-Jakob disease are extremely rare
> all over the world, 3 familial clusters were observed between
> 1983-2000 in a relatively small area situated in the North of
> Slovakia. Prevalence of CJD in this area exceeded the overall
> prevalence in Slovakia more than 8 times. The majority of CJD
> patients admitted consuming sheep brain. Most patients lived in
> small secluded villages with rather common familial intermarriage.
> CJD affected both sexes equally. All patients were prior to the
> disease mentally normal individuals. Shortly after the onset of CJD
> their mental status deteriorated remarkably with an average survival
> rate of 3.6 months.
>
> PMID: 12690798
>
>
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
> ds=12690798&dopt=Abstract
>
> ------------------------------------------------------------------------
>
> 1: Eur J Epidemiol 1991 Sep;7(5):520-3
> > =pubmed_pubmed&from_uid=1761109>
>
>
> "Clusters" of CJD in Slovakia: the first laboratory evidence of scrapie.
>
> Mitrova E, Huncaga S, Hocman G, Nyitrayova O, Tatara M.
>
> Institute of Preventive and Clinical Medicine, Bratislava.
>
> Epidemic-like occurrence of Creutzfeldt-Jakob disease was observed in
> 1987 in Slovakia (Orava). Search for the cause of CJD focus indicated a
> coincidence of genetic and environmental risks in clustering patients.
> Since Spongiform Encephalopathies might be transmitted orally, (Bovine
> Spongiform Encephalopathy), the possibility of zoonotic source of CJD
> cases in Orava was also considered. A deficient knowledge about the
> occurrence of scrapie in Slovakia stimulated an examination of sheep
> with signs of CNS disorders in two flocks of Valasky breed in Orava. In
> one flock, neurohistopathological examination revealed in sheep brains
> lesions characteristic for scrapie. Frozen brain tissue of these animals
> were used for the detection of scrapie associated fibrils. They were
> found in 2 animals from the same flock. This is the first laboratory
> confirmation of scrapie in Czecho-Slovakia. The possible epidemiological
> and economical implications are emphasized.
>
>
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
> ds=1761109&dopt=Abstract
>
>
> STATEMENT OF DR HELEN GRANT MD FRCP
> ISSUED 13/05/1999
>
> BSE INQUIRY
>
> http://www.bseinquiry.gov.uk/files/ws/s410.pdf
> http://www.bseinquiry.gov.uk/files/ws/s410x.pdf
>
> http://www.bseinquiry.gov.uk/evidence/ws/ws8.htm
>
> CWD to CJD in humans (why not?), as easy as BSE/Scrapie;
>
> The EMBO Journal, Vol. 19, No. 17 pp. 4425-4430, 2000
> © European Molecular Biology Organization
>
> Evidence of a molecular barrier limiting
> susceptibility of humans, cattle and sheep to
> chronic wasting disease
>
> G.J. Raymond1, A. Bossers2, L.D. Raymond1, K.I. O?Rourke3,
> L.E. McHolland4, P.K. Bryant III4, M.W. Miller5, E.S. Williams6, M.
> Smits2
> and B. Caughey1,7
>
> 1NIAID/NIH Rocky Mountain Laboratories, Hamilton, MT 59840,
> 3USDA/ARS/ADRU, Pullman, WA 99164-7030, 4USDA/ARS/ABADRL,
> Laramie, WY 82071, 5Colorado Division of Wildlife, Wildlife Research
> Center, Fort Collins, CO 80526-2097, 6Department of Veterinary Sciences,
> University of Wyoming, Laramie, WY 82070, USA and 2ID-Lelystad,
> Institute for Animal Science and Health, Lelystad, The Netherlands
> 7Corresponding author e-mail: bcaughey@nih.gov Received June 7, 2000;
> revised July 3, 2000; accepted July 5, 2000.
>
> Abstract
>
> Chronic wasting disease (CWD) is a transmissible
> spongiform encephalopathy (TSE) of deer and elk,
> and little is known about its transmissibility to other
> species. An important factor controlling
> interspecies TSE susceptibility is prion protein (PrP)
> homology between the source and recipient
> species/genotypes. Furthermore, the efficiency with which
> the protease-resistant PrP (PrP-res) of one
> species induces the in vitro conversion of the normal PrP
> (PrP-sen) of another species to the
> protease-resistant state correlates with the cross-species
> transmissibility of TSE agents. Here we
> show that the CWD-associated PrP-res (PrPCWD) of cervids
> readily induces the conversion of recombinant cervid PrP-sen
> molecules to the protease-resistant state in accordance
> with the known transmissibility of CWD between cervids. In contrast,
> PrPCWD-induced conversions of human and bovine PrP-sen were
> much less efficient, and conversion of ovine PrP-sen was
> intermediate. These results demonstrate a barrier at the
> molecular level that should limit the susceptibility of these non-cervid
> species to CWD.
>
> snip...
>
> Clearly, it is premature to draw firm conclusions about CWD
> passing naturally into humans, cattle and sheep, but the present
> results suggest that CWD transmissions to humans would be as
> limited by PrP incompatibility as transmissions of BSE or sheep
> scrapie to humans. Although there is no evidence that sheep
> scrapie has affected humans, it is likely that BSE has caused variant
> CJD in 74 people (definite and probable variant CJD cases to
> date according to the UK CJD Surveillance Unit). Given the
> presumably large number of people exposed to BSE infectivity,
> the susceptibility of humans may still be very low compared with
> cattle, which would be consistent with the relatively inefficient
> conversion of human PrP-sen by PrPBSE. Nonetheless, since
> humans have apparently been infected by BSE, it would seem prudent
> to take reasonable measures to limit exposure of humans
> (as well as sheep and cattle) to CWD infectivity as has been
> recommended for other animal TSEs.
>
> snip...
>
> http://www.emboj.org/current.shtml
>
> Scrapie to Humans USA?
>
>
> 1: Neuroepidemiology. 1985;4(4):240-9.
>
> Sheep consumption: a possible source of spongiform encephalopathy in
humans.
>
> Davanipour Z, Alter M, Sobel E, Callahan M.
>
> A fatal spongiform encephalopathy of sheep and goats (scrapie) shares many
> characteristics with Creutzfeldt-Jakob disease (CJD), a similar dementing
> illness of humans. To investigate the possibility that CJD is acquired by
> ingestion of contaminated sheep products, we collected information on
> production, slaughtering practices, and marketing of sheep in
Pennsylvania.
> The study revealed that sheep were usually marketed before central nervous
> system signs of scrapie are expected to appear; breeds known to be
> susceptible to the disease were the most common breeds raised in the area;
> sheep were imported from other states including those with a high
frequency
> of scrapie; use of veterinary services on the sheep farms investigated
and,
> hence, opportunities to detect the disease were limited; sheep producers
in
> the area knew little about scrapie despite the fact that the disease has
> been reported in the area, and animal organs including sheep organs were
> sometimes included in processed food. Therefore, it was concluded that in
> Pennsylvania there are some 'weak links' through which scrapie-infected
> animals could contaminate human food, and that consumption of these foods
> could perhaps account for spongiform encephalopathy in humans. The weak
> links observed are probably not unique to Pennsylvania.
>
>
>
>
http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list
> _uids=3915057&dopt=Abstract
>
>
> Oral transmission of kuru, Creutzfeldt-Jakob disease, and scrapie to
> nonhuman primates.
>
> Gibbs CJ Jr, Amyx HL, Bacote A, Masters CL, Gajdusek DC.
>
> Kuru and Creutzfeldt-Jakob disease of humans and scrapie disease of
> sheep and goats were transmitted to squirrel monkeys (Saimiri sciureus)
that
> were exposed to the infectious agents only by their nonforced consumption
of
> known infectious tissues. The asymptomatic incubation period in the one
> monkey exposed to the virus of kuru was 36 months; that in the two monkeys
> exposed to the virus of Creutzfeldt-Jakob disease was 23 and 27 months,
> respectively; and that in the two monkeys exposed to the virus of scrapie
> was 25 and 32 months, respectively. Careful physical examination of the
> buccal cavities of all of the monkeys failed to reveal signs or oral
> lesions. One additional monkey similarly exposed to kuru has remained
> asymptomatic during the 39 months that it has been under observation.
>
> PMID: 6997404
>
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui
> ds=6997404&dopt=Abstract
>
>
>
>
> Approved-By: tom
> Message-ID:
> Date: Mon, 19 Jul 1999 11:21:25 -0800
> Reply-To: Bovine Spongiform Encephalopathy
> Sender: Bovine Spongiform Encephalopathy
> From: tom
> Subject: iatrogenic scrapie from sheep dura mater?
> Someone kindly sent me the full text of a very curious 1993 Lancet
article.
> This is available from the Ovid service -- Lancet itself ironically does
not
> offer an electronic version this far back.
>
> An orthopaedic surgeon employed by the lyodura company [Braun Melsungen]
> extracted dura mater from sheep and human cadavers and came down with fast
> CJD 22 years later. The ratio of sheep to human dura mater he collected
> was150 sheep to 12 humans. Apparently the surgeon and the sheep were
German.
> Scrapie has long been present in Germany but reported levels are very low,
> about a flock a year has to be destroyed. I am not aware of any high
> sensitivity tests or random screening every being used in Germany to
assess
> the levels of preclinical animals.
>
> This raises the question, what did the lyodura company do with so much
dura
> mater from sheep? The market for specialty surgical products was
> overwelmingly in humans in 1968. The Lancet article only says it was for
> research -- but in what species? Perhaps dura mater gives an immune
> response across species after processing, ruling out its use in humans.
> But as far as I know, blood type or other genetic differences do not
matter
> within humans, ie, there is no tissue matching with dura mater.
>
> I always wondered how CJD could show up from a handful of human dura mater
> donations with sporadic CJD supposedly so rare -- on the other hand, there
> would be no surprise at all if a case of subclinical scrapie showed up in
> 150 sheep.
>
> This raises the question, have dura mater recipients or the surgeon
> subsequently been strain-typed? This might give a very different outcome
> than other forms of iatrogenic CJD or simply co-classify with pituitary
> growth hormone if route of infection (injected, oral, hereditary, etc.) is
> more important than strain source.
>
> Otherwise, iatrogenic scrapie (like cwdCJD) is somwhat unpredictable in
its
> gel pattern (though strains of scrapie in other primate species might be
> re-examined). The original scrapie strain is not be identifiable directly
> because material was not likely retained. Strain-typing was not available
> at the time of the article -- but Collinge was one of the authors.
>
> There is little doubt that scrapie could be transfered to humans by
> intracerebral injection (based on lack of species barrier in primates) and
> that processed pooled (human?) dura mater can carry sufficient infectivity
> to cause CJD. I am not aware of animal experiments that specifically used
> sheep dura mater as experimental dose source.
>
>
> tom
>
> -=-=-=-=-=-=-
>
>
> Transmission of Creutzfeldt-Jakob disease by handling of dura mater.
> The Lancet Volume 341(8837) January 9, 1993 pp
> 123-124
> Weber, Thomas; Tumani, Hayrettin; Holdorff, Bernd; Collinge, John; Palmer,
> Mark; Kretzschmar, Hans A.; Felgenhauer, Klaus
>
>
> Sir,- Creutzfeldt-Jakob disease (CJD) can be transmitted iatrogenically by
> human pituitary growth hormone, corneal transplants, and dura mater grafts
> (1). Possible accidental transmission has been reported in only four
> people-a neurosurgeon (2), a pathologist (3), and two laboratory
technicians
> (4,5) . We have encountered an unusually rapid case of CJD probably
acquired
> through handling of sheep and human dura mater.
> In May, 1992, a 55-year-old orthopaedic surgeon developed paraesthesia of
> the left arm. A few days later he had spatial disorientation, apraxia, and
> gait ataxia. In June he was admitted and a neurologist suspected CJD on
the
> basis of the clinical signs, typical electroencephalogram (EEG) pattern,
and
> history. An EEG in June revealed a typical pattern of periodic biphasic
and
> triphasic sharp wave complexes. We saw the patient in July, 1992. He was
> awake and oriented, with dyscalculia, dysgraphia, disturbed vision,
apraxia
> mainly of the left side, rigidity of wrists, spasticity of all muscles,
> myoclonus of the left arm, increased tendon reflexes, ataxia of limbs and
> trunk, and incoordination of left arm. Within 3 weeks he had impaired
> consciousness and attention, mildly impaired memory, and threatening
visual
> hallucinations with restless turning. He had periodic states with
movements
> of his head and eye-bulbs resembling tonic adversive seizures. During
sleep
> these motor disturbances stopped. 2 1/2 months later the patient died.
>
> This patient had worked with sheep and human dura mater from 1968 to 1972.
> He handled about 150 specimens of ovine origin and at least a dozen human
> preparations for research. Handling involved opening skulls with a band
saw,
> removing dura, and testing them either fresh (usually), preserved, or
> lyophilised for mechanical qualities. These specimens were sent to a
company
> that has sold dura mater preparations by which CJD was transmitted in six
> instances. No information was available from the company about a possible
> connection with this patient's disease and the earlier cases of
transmitted
> CJD. Brain biopsy was consistent with diagnosis of CJD. Cerebrospinal
fluid
> obtained in July showed neuron-specific enolase (NSE) at 82.0 ng/mL,
> compared with 16.7 ng/mL in serum of other cases (6). Proton magnetic
> resonance spectroscopy of parieto-occipital and temporal grey matter,
> parietal white matter, and thalamus revealed a 20-30% reduction of
> N-acetylaspartate, as described (7). DNA was genotyped with
allele-specific
> oligonucleotides ( and was homozygous for methionine at the polymorphic
> codon 129. Subsequent direct DNA sequencing for the PrP gene open-reading
> frame demonstrated normal sequence on both alleles, excluding known or
novel
> pathogenic PrP mutations.
>
> It is tempting to speculate that prions were transmitted to this patient
> from sheep or human dura mater through small lacerations of his skin, but
> the patient and his wife did not remember any significant injury during
his
> four years of working with these samples. It cannot be excluded that this
> was a case of sporadic CJD although this assumption is unlikely in view of
> the clinical course which was similar to iatrogenic CJD transmitted by
> peripheral inoculation, such as with human pituitary growth hormone or
> gonadotropin or to kuru (1). Iatrogenic cases resulting from intracerebral
> inoculation with the transmissible agent, for instance following dura
mater
> grafts (2-5), present with a dementing picture, as is usual in sporadic
CJD,
> rather than with ataxia as in this case.
>
>
> 1. Brown P, Preece MA, Will RG. "Friendly fire" in medicine: hormones,
> homografts, and Creutzfeldt-Jakob disease. Lancet 1992; 340: 24-27.
[Medline
> Link] [Context Link]
>
> 2. Schoene WC, Masters CL, Gibbs CJ Jr, et al. Transmissible spongiform
> encephalopathy (Creutzfeldt-Jakob Disease): atypical clinical and
> pathological findings. Arch Neurol 1981; 38: 473-77. [Medline Link]
[Context
> Link]
>
> 3. Gorman DG, Benson DF, Vogel DG, Vinters HV. Creutzfeldt-Jakob disease
in
> a pathologist. Neurology 1992; 42: 463. [Medline Link] [Context Link]
>
> 4. Miller DC. Creutzfeldt-Jakob disease in histopathology technicians. N
> Engl J Med 1988; 318: 853-54. [Medline Link] [Context Link]
>
> 5. Sitwell L, Lach B, Atack E, Atack D, Izukawa D. Creutzfeldt-Jakob
disease
> in histopathology technicians. N Engl J Med 1988; 318: 854. [Medline Link]
> [Context Link]
>
> 6. Wakayama Y, Shibuya S, Kawase J, Sagawa F, Hashizume Y. High
> neuron-specific enolase level of cerebrospinal fluid in the early stage of
> Creutzfeldt-Jakob disease. Klin Wochenschr 1987; 65: 798-801. [Medline
Link]
> [Context Link]
>
> 7. Bruhn H, Weber T, Thorwirth V, Frahm J. In-vivo monitoring of neuronal
> loss in Creutzfeldt-Jakob disease by proton magnetic resonance
spectroscopy.
> Lancet 1991; 337: 1610-11. [Medline Link] [Context Link]
>
> 8. Collinge J, Palmer MS, Dryden AJ. Genetic predisposition to iatrogenic
> Creutzfeldt-Jakob disease. Lancet 1991; 337: 1444-42. [Medlin
>
> Issues raised by a subsequent comment letter seem dubious at best in the
> case of this surgeon:
>
>
> Ridley: Lancet, Volume 341(8845).Mar 6, 1993.pp 641-642.
> The Lancet Volume 341(8845) Mar 6, 1993 pp 641-642
>
> Occupational risk of Creutzfeldt-Jakob disease.
> [Letters to the Editor]
> Ridley, R.M.; Baker,H.F.
> Division of Psychiatry, Clinical Research Centre, Harrrow, Middlesex HA1
> 3UJ, UK.
>
>
> Sir,- Readers should be cautious about Dr Weber and colleagues' (Jan 9, p
> 123) suggestion that occupational transmission of Creutzfeldt-Jakob
disease
> (CJD) may have taken place in a neurosurgeon, a pathologist, 2 histology
> technicians, and an orthopaedic surgeon. Large epidemiological surveys
> (1,2) have failed to find a link between occupation and CJD. This disease
> has been reported in several people working in occupations in which
exposure
> to neural tissue could have happened (eg, butchers, farmers, and various
> health professionals (3) ) but the number of these cases is not in excess
> of that which would be expected by random association. In the absence of a
> clear excess of cases, as has occurred in the iatrogenic transmission of
> spongiform encephalopathy by exposure to human derived growth hormone (4),
> the occurrence of CJD in people from the medical and paramedical
professions
> is no more remarkable than its occurence in people of any other
profession.
> Brown et al (1) rep!
> orted six cases among clerics, but this does not necessarily implicate
their
> occupation in their ultimate demise.
>
> The notion that CJD is always acquired (as opposed to idiopathic) and that
> the existence of any hypothetical risk factor must therefore be the cause
of
> the disease led to the much cited claim that the high incidence of CJD
among
> Libyan Jews was due to their consumption of sheep's eyeballs (5), despite
a
> lack of evidence that their dietary habits differed from their ethnic
> neighbours in whom no increased incidence of this disease was recorded.
The
> high frequency of CJD in the Libyan Jews is now known to be due to a codon
> 200 mutation in the PrP gene in affected families in that ethnic group
(6).
>
> CJD is a peculiar disease that does not fit into any single pattern of
> distribution. The great majority of cases cannot be attributed to
> environmental exposure. Very particular precautions are required to
prevent
> transmission from cases of human and animal spongiform encephalopathy
since,
> when this does occur, a major outbreak of disease can arise. Under these
> circumstances it is especially important that the occurrence of CJD is
> viewed from an epidemiological rather than an anecdotal perspective.
>
> REFERENCES
>
> 1. Brown P, Cathala F, Raubertas RF, et al. The epidemiology of
> Creutzfeldt-Jakob: conclusion of a 15-year investigation in France and a
> review of the world literature. Neurology 1987; 37: 895-904. [Medline
> Link] [Context Link]
>
> 2. Harries-Jones R, Knight R, Will RG, et al. Creutzfeldt-Jakob disease in
> England and Wales, 1980-1984; a case control study of potential risk
> factors. J Neurol Neurosurg Psychiatry 1988; 51: 1113-19. [Medline Link]
> [Context Link]
>
> 3. Masters CL, Harris JO, Gajdusek C, et al. Creutzfeldt-Jakob disease:
> patterns of worldwide occurrence and the significance of familial and
> sporadic clustering. Ann Neurol 1978; 5: 177-88. [Medline Link] [Context
> Link]
>
> 4. Brown P, Gajdusek C, Gibbs CJ, Asher DM. Potential epidemic of
> Creutzfeldt-Jakob disease from human growth hormone therapy. N Engl J Med
> 1985; 313: 728-31. [Medline Link] [Context Link]
>
> 5. Kahana E, Alter M, Braham J, Sofer D. Creutzfeldt-Jakob disease: focus
> among Libyan Jews in Israel. Science 1974; 183: 90-91. [Medline Link]
> [Context Link]
>
> 6. Hsiao K, Meiner Z, Kahana E, et al. Mutation of the prion protein in
> Libyan Jews with Creutzfeldt-Jakob disease. N Engl J Med 1991; 324:
1091-97.
>
>
> --------------------------------------------------------------------------
--
> ----
>
>
>
>
> Approved-By: "Roland Heynkes @ T-Online"
> Message-ID: <006a01bed26b$d48e9400$31be9ec1@pentium>
> Date: Mon, 19 Jul 1999 23:28:00 +0200
> Reply-To: Bovine Spongiform Encephalopathy
> Sender: Bovine Spongiform Encephalopathy
> From: "Roland Heynkes @ T-Online"
> Subject: Re: iatrogenic scrapie from sheep dura mater?
> Dear Tom,
>
> >An orthopaedic surgeon employed by the lyodura company [Braun Melsungen]
> >extracted dura mater from sheep and human cadavers and came down with
> >fast CJD 22 years later.
> >
> the article does not say that he was an employee of Braun Melsungen, but
> sent et least some of the lyodoras to the company. Do you have additional
> information from one of the authors and do you know if the company got
> the ovine dura maters too?
>
> >Scrapie has long been present in Germany but reported levels are very
> >low, about a flock a year has to be destroyed. I am not aware of any
> >high sensitivity tests or random screening every being used in Germany
> >to assess the levels of preclinical animals.
> >
> I don't know if the Groschup group in Tuebingen does use a sensitive
> scrapie test like the dutch test in order to perform a random screening
> program. When I asked last time a few years ago, they "only" tested
animals
> with unclear neurological symptoms.
> Scrapie still occurs in Germany, but we have less than one recorded case
> per year.
>
> >This raises the question, what did the lyodura company do with so much
> >dura mater from sheep? The market for specialty surgical products was
> >overwelmingly in humans in 1968. The Lancet article only says it was for
> >research -- but in what species?
> >
> Are you sure that this research with the ovine dura mater has been done
> at Braun Melsungen?
>
> best regards
>
> Roland Heynkes
>
> Erkwiesenstr. 19
> D-52072 Aachen (Germany)
> Tel.: +49 (0)241/932070
> Fax: +49 (0)241/932071
> email: roland.heynkes@t-online.de
> http://home.t-online.de/home/Roland.Heynkes
>
>
> --------------------------------------------------------------------------
--
> ----
>
>
>
>
> Approved-By: tom
> Message-ID:
> Date: Tue, 20 Jul 1999 11:48:17 -0800
> Reply-To: Bovine Spongiform Encephalopathy
> Sender: Bovine Spongiform Encephalopathy
> From: tom
> Subject: Re: iatrogenic scrapie from sheep dura mater?
> In-Reply-To: <006a01bed26b$d48e9400$31be9ec1@pentium>
>
> >
> >>An orthopaedic surgeon employed by the lyodura company [Braun Melsungen]
> >>extracted dura mater from sheep and human cadavers and came down with
> >>fast CJD 22 years later.
> >>
> >the article does not say that he was an employee of Braun Melsungen, but
> >sent et least some of the lyodoras to the company. Do you have additional
> >information from one of the authors and do you know if the company got
> >the ovine dura maters too?
>
> I really do not know any more at this time than what was in the article.
> The way I read it, he was not an internal employee but an independent
> orthopaedic surgeon who had a contract to supply dura mater to the
company.
> The victim's wife may be able to supply details, however the family name
is
> not given.
>
> >
> >>Scrapie has long been present in Germany but reported levels are very
> >>low, about a flock a year has to be destroyed. I am not aware of any
> >>high sensitivity tests or random screening every being used in Germany
> >>to assess the levels of preclinical animals.
> >>
> >I don't know if the Groschup group in Tuebingen does use a sensitive
> >scrapie test like the dutch test in order to perform a random screening
> >program. When I asked last time a few years ago, they "only" tested
animals
> >with unclear neurological symptoms.
> >Scrapie still occurs in Germany, but we have less than one recorded case
> >per year.
>
> Sure. According to this, it was a bit of extraordinary bad luck that any
of
> 150 sheep + 12 humans could have carried the disease, but we know not to
> equate recorded cases with incidence. Portugal had very few recorded cases
> per year of BSE too.
>
> In your opinion, how exactly has it been possible for scrapie to persist
in
> Germany for all these decades at this vanishingly small level? Cases are
> probably not geographically or farm-exchange linked. Surely the
> authorities don't allow live imports from England.
>
> >
> >>This raises the question, what did the lyodura company do with so much
> >>dura mater from sheep? The market for specialty surgical products was
> >>overwelmingly in humans in 1968. The Lancet article only says it was for
> >>research -- but in what species?
> >>
> >Are you sure that this research with the ovine dura mater has been done
> >at Braun Melsungen?
>
> I would guess that they did not do the research there but sold it to the
> marketplace. Perhaps you could give the German authors a call (Weber,
> Thomas; Tumani, Hayrettin; Holdorff, Bernd all in Hamburg I think) I will
> shop around on Internet catalogues, see which companies today sell sheep
> dura mater for research (my guess is no one).
>
> It is annoying that so many details relevent to interpretation were left
out
> of the paper. Still, any forward tracing of the dura mater will soon hit a
> brick wall at the company, Braun Melsungen- B. Carl-Braun-Str. 1
> D-34212 Melsungen Germany Tel: ++49 5661 - 71-1739, Fax: ++49 5661 -
> 71-1632. If any humans received sheep dura mater, I doubt that this will
be
> disclosed or that specific recipients will be identified to their doctors.
> It is probably better to trace backwards from affected recipients -- see
if
> they strain-type out to be sheep.
>
> Japan has been particularly hard hit by dura mater CJD (curious in itself)
> and researchers there might be motivated to find out what happened. I am
> not aware of agricultural agencies that would impede research over there.
>
> tom
>
> P.S. The US would never think of pooling dura mater in the same container.
> However, even after the lyodura experience, apparently we thought it safe
to
> use the same rinse water on 26 consecutive dura mater donations:
>
> Creutzfeldt-Jakob Disease (CJD) in a Recipient of a U.S.-Processed Dura
> Mater Graft: Cause or Coincidence? Belay E.D.1, Dobbins, J.G.1, Malecki,
> J.2, Buck, B.E.3, Bell, M.1, Cobb, J.2, Schonberger, L.B.1, 1Centers for
> Disease Control and Prevention (CDC), Atlanta, GA; 2Palm Beach County
Health
> Department, West Palm Beach, FL; 3Department of Orthopedics and
> Rehabilitation, University of Miami School of Medicine, Miami, FL.
> http://www.life.umd.edu/jifsan/tse/belay.htm
>
> In 1997, CDC was notified about a 72-year-old man who developed CJD 54
> months after he received a dura mater graft during removal of a
meningioma.
> CDC confirmed that CJD diagnosis was based on standard clinical criteria,
> including typical electroencephalographic changes. Investigation of
patients
> who underwent craniotomy within 4 months before or after the
case-patient's
> surgery revealed no evidence for nosocomial transmission of CJD. The dura
> donor was a previously healthy 34-year-old man with no known risk factors
> fore CJD who had died in a motor vehicle collision. The dura was processed
> in the United States with no direct contact with other dura. However,
> possible indirect contact through water used to rinse dural grafts from
> about 25 other donors simultaneously could not be ruled out; tracing of
> recipients of these grafts is in progress. If this case-patient remains
the
> only recipient of a U.S.-processed dural graft with CJD, then this
graft-CJD
> association is more likely to be coincidental than causal. This report
> underscores the potential importance of recent recommendations to minimize
> the risk of CJD transmission by such grafts, including neuropathologic
> screening of all donors and removal of opportunities for
cross-contamination
> among grafts.
>
>
>
> IA#84-03 --- 6/27/87
> http://www.fda.gov/ora/fiars/ora_import_ia8403.html
>
> BACKGROUND
>
> A recent reported case of Creutzfeldt-Jakob Disease (CJD) in a 28 year-old
> patient who had received a human dura mater graft indicates that the graft
> may
> have been the source of this always fatal disease. The woman died 22
months
> after receiving the lyophilized, irradiated human cadaveric dura mater
> graft.
> The dura mater used in the graft was packaged in October 1982 under lot
> #2105
> by B. Braun Melsungen AG of West Germany, shipped to Tri Hawk
International,
> Inc., Montreal, Quebec, Canada and sold to Saint Francis Hospital,
Hartford,
> Connecticut, on April 4, 1985.
>
> This is the first known case of CJD transmission associated with a dura
> mater
> graft. Present methods of sterilizing the dura mater do not completely
> inactivate the CJD agent.
>
> The dura mater is manufactured by the West German firm under the trade
name
> Lyodura. Although the material is primarily used in neurosurgery, it is
> also
> used in orthopedic, otologic, dental, urologic, gynecologic, and cardiac
> surgical procedures.
>
> We have been unable to determine the total number of packages of Lyodura
> that
> were imported into the United States because the Canadian distributor
failed
> to maintain adequate records of distribution for all lots which may have
> been
> distributed by mail to hospitals in the United States and Canada.
>
> As stated in the FDA Safety Alert which issued April 28, 1987, we strongly
> recommend that users of dura mater choose only products from known sources
> which retrieve, process and handle the material according to guidelines
such
> as those of the American Association of Tissue Banks.
>
> To report cases or for further information, please contact:
>
> Gordon C. Johnson, M.D.
> Center for Devices and Radiological Health
> Food and Drug Administration
> 8757 Georgia Ave,
> Silver Spring, Maryland 20910
>
>
> GUIDANCE
>
> Alert your local Customs office to be aware of this import alert and to
> monitor mail shipments for this product.
>
> Detain all shipments of Lyodura (dura mater) received from Tri Hawk
> International, Inc., Montreal, Quebec, Canada or from B. Braun Melsungen
AG
> of
> West Germany. Charge: "The article is subject to refusal of admission
> pursuant to section 801(a)(1) in that it appears to be adulterated under
> section 501(h), because the methods and controls used for the storage and
> distribution of Lyodura (dura mater) are not in conformance with current
> good
> manufacturing practice requirements under section 520(f)(1)."
>
> -=-=-=-=-
>
> DR. MARTIN ZEIDLER:
> http://www.life.umd.edu/jifsan/tse/zeidler.htm
> 8 June 1998
>
> Thank you very much and I'd like to start this by thanking JIFSAN for
kindly
> inviting me here today.
>
> I became involved in the whole issue of Creutzfeldt-Jakob disease and dura
> mater grafts about a year ago when I had the good fortune to be working
with
> the World Health Organization. It was at this time that WHO had a
> consultation addressing the issue of safety of medicinal and other
products
> in relation to human and animal TSEs. This meeting recommended that dura
> mater grafts could no longer be used, which caused some controversy and I
> was involved in the debate which ensued with various dura mater
> manufacturers....
>
> So, what is dura mater? Well, it's the outer covering of the meninges,
this
> is the fibrous sheath which encircles the central nervous system. It
really
> has two functions, first, to keep the spinal fluid in, and, second, to
stop
> infection from getting into the central nervous system. Surgical
procedures
> or trauma that broach the dura mater may result in a hole, that because of
> the fibrous, inelastic nature of dura, may not be possible shut by primary
> closure. If the defect is to be filled, perhaps the obvious tissue to do
> this is a dural graft.
>
> Since the 1950s, dura mater grafts have been utilised ; some of the first
> grafts came from the U.S. Navy's Medical School here in the United States.
> The popularity of dural grafts came to the fore in the 1970s and 1980s
when
> they were commercially produced. It appeared that surgeons were actually
> very happy with these particular materials - they provided a good barrier
to
> infection and stopped the leakage of CSF.
>
> It was in 1987 that the first case was reported of a person with CJD who
> had previously been known to have received a dura mater graft. The patient
> was a 28-year-old woman who had an operation 18 months previously to
remove
> a cholesteatoma and she subsequently developed histologically confirmed
CJD.
> To date I've managed to find a total of 83 case reports of dura mater
> related CJD cases, and I am grateful Dr Paul Brown for providing me with
> data. There are 3 additions to the number which Paul mentioned during his
> talk earlier, although these three cases are slightly questionable. Two of
> these were reported from France, and both had undergone embolisation
> procedures with dura mater rather than receiving a conventional graft. The
> third case is from Thailand and has not yet been pathologically confirmed.
>
> The clinical phenotype of patients with dura mater-associated CJD is
similar
> to that seen in the classical sporadic form of CJD: rapidly progressive
> dementia, myoclonus, and in the majority of patients a characteristic EEG.
> However, there are some differences: dura-associated cases tend to have
more
> prominent early cerebellar symptoms and a somewhat more prolonged clinical
> course. In sporadic CJD the median illness duration is 4 1/2 months and
this
> is doubled on average in dura mater cases. The age at onset is about 10-15
> years younger on average than we see with sporadic CJD.
>
> I think the youngest dura mater case documented was 16 or 17. The average
> incubation period from the time the patient received their graft to onset
of
> their illness is approximately 6 years, but ranges from 16 months to 16
> years. Although most of these cases have arisen through the use of dura
> mater for cranial surgery, there are some cases which have been known to
> have resulted from ear, nose and throat surgery or from spinal surgery.
Two
> cases from France, as mentioned, followed embolism procedures, in one case
> the patient had a nasopharyngeal tumor and dura mater was cut up into lots
> of little pieces and injected into the external carotid artery to embolise
> this, and in the other case the dura mater was inoculated into an artery
in
> the chest to embolise an area of infection.
>
> I would like to just go back and show you the countries which are known to
> have had dura mater cases of CJD. Most of the reports come from Japan, and
> we were rather surprised at the WHO consultation last year in Geneva, to
> hear reports from Dr Tateishi of a recent study conducted in Japan which
had
> shown the presence of 43 cases of dura mater CJD.
>
> I think you will agree looking at the slide that the other cases have been
> reported really quite widely throughout the world. Virtually all of these
> patients received one particular form of dura mater graft that was
> commercially manufactured by a single German company. The product was
called
> Lyodura, and most of the patients had received grafts that had been
> manufactured during a 4 year period between 1983 and 1987. Lyodura was
> pooled during this time, so there was a potential for cross contamination
> and the sterilization procedures used involved 10% hydrogen peroxide for
24
> hours and ionizing radiation. Subsequent animal experiments have shown
that
> this is not an adequate form of sterilization.
>
> An important question is whether any of the dura mater cases were
recipients
> of grafts that were treated with more thorough and adequate sterilisation.
> By this, I mean treatment with 1N sodium hydroxide, which is in the
standard
> step which was introduced in the treatment of Lyodura after 1987. There
are
> four cases out of this series of 83 which perhaps I'll talk about in a
> little bit more detail. Two cases were clearly not Lyodura. These were
> locally procured grafts, one from Italy and the other from the United
> Kingdom - these were used between 1969 and 1981.
>
> Furthermore, there was the a recently reported case from America which we
> heard about yesterday. Perhaps the case of most interest is one from the
> Japanese series. This was a lady in her mid-60s who received a graft in
1991
> and later developed clinically probable CJD, but this was not
histologically
> confirmed. The hospital records did not note whether or not her graft was
> Lyodura or the other form of dura used in that hospital at that time. It
was
> concluded in the report of the Japanese cases that it was unlikely that
this
> patient had received Lyodura produced before 1987.
>
> So the possibility exists that this patient had received a form of dura
> which was considered to be adequately sterilised. It is important to note
> two points, first, as this case did not undergo histological examination
the
> diagnosis of CJD is not 100% certain, and second, we can not be absolutely
> sure that in this or some of the of other 82 cases that the history of
> receiving a dural mater graft is coincidental. In none of these cases is
> there data which tells if the graft donor had CJD.
>
> Following the announcement of the first case here in the United States,
> doctors in the United Kingdom, Australia and New Zealand decided that they
> were going to use alternatives to cadaveric dura homografts, and here in
the
> States I believe there was an importation ban on Lyodura.
>
> So what alternatives are there to cadaveric-derived dura? There are
> several - I'll just run through these. One of the most popular is fascia
> lata, this is the fibrous covering of the lateral thigh muscle. The
removal
> of this can add about 30 minutes to the length of the operation and of
> course leaves a wound which, as with all wounds, can potentially become
> infected or have other complications.
>
> Other alternatives include pericranium (the covering of the skull bone),
> temporalis fascia (the membrane which surrounds the temporalis muscle at
the
> side of the head) and synthetic materials - a number of such materials
have
> been tried over the years including gold foils, cellophane, and dacron
> grafts. However, there has been some concern about the safety of synthetic
> materials and neurosurgeons have felt that these were rather inferior,
> although I think with the newer materials that's not so clearly the case.
I
> should note that there is no controlled trial that has ever been conducted
> to answer the question as to whether or not these substitutes are better
or
> worse than cadaveric-derived dura.
>
> I think there are two key questions that need to be addressed, first, are
> there situations where cadaveric dura is better than available
alternatives?
> If the answer is no then we need to question why we are using cadaveric
> dural grafts at all. If the answer is yes, then the next question is how
can
> dura be made as safe as possible? I'd like to show you some of the report
> from the WHO meeting over a year ago. I'll read it to you.
>
> "Because over 50 cases of CJD have resulted from cadaveric dura mater
> grafts, the group strongly recommended that dura mater no longer be used,
> especially in the case of neurosurgery, unless no alternative is
available.
> If dura mater is to be used, only material which is from non-pooled
sources
> originating from carefully screened donors subjected to validated
> inactivated treatment should be considered."
>
> Following this recommendation the Japanese authorities decided that they
> were no longer going to issue a license for the use of dura mater and the
> TSE Advisory Committee here in the States met again to discuss the issue
of
> dura mater. I just want to run through their recommendations, there were
> some differences from WHO's: although they also discouraged use of dura
> mater, the final decision on its usage was left up to the individual
> physicians, but certain additional safeguards were put into place.
>
> For instance, it was felt mandatory that for every donor a full brain
> autopsy should be performed and examined histologically and with
> immunocytochemistry, which is probably the most sensitive method that we
> have, other than transmission studies. It was further recommended that a
> sample of the dura and the brain should be kept for further testing as
> needed.
>
> Additionally, standard protocols for determining donors eligibility and
> tissue procurement were recommended, and dura should be collected before
the
> brain at autopsy - which obviously makes sense to avoid contamination of
the
> graft. Furthermore, decontamination with 1N sodium hydroxide for one hour
> should be used. This had previously been confirmed by Paul Brown and
> colleagues to be an effective decontamination procedure. There should be
no
> pooling of grafts, to prevent cross-contamination and there should be
> documentation to allow tracking from the donor to the recipient and from
the
> recipients to the donor. I think there can be little doubt that if these
> recommendations are adopted, then the safety of dura mater grafts will be
> dramatically improved.
>
> However, I would like to just play the devil's advocate here and to
mention
> a few cautions. We know from animal experiments that infectivity can
predate
> any pathological changes and this includes immunocytological changes as
> well. We also know that standard decontamination procedures using sodium
> hydroxide, as David Taylor mentioned yesterday, may not completely be
> effective. I think we have to remember that dura is a potentially
high-risk
> material, and that studies also performed by David Taylor have shown that
> dura mater can have 106 ID50 per gram. Perhaps through the use of current
> decontamination procedures we will produce grafts which are much safer
than
> those previously used, with but with low-level residual infectivity which
> may lead to disease with a potentially long incubation period. (For TSE
> agents it is known that dose administered is inversely proportional to
> incubation period)...
>
>
> http://www.life.umd.edu/jifsan/tse/brown.htm
>
> 3 corneal
> 2 sterotactic
> 4 neurosurgery
> 80 dura mater
> 106 growth hormone
> ...25 US (includes 5 New Zealand + 1 Brazilian case using US-prepared
> hormone)
> ...28 UK
> ...53 France
> 4 gonadotrophin Approved-By: "Roland Heynkes @ T-Online"
>
> Message-ID: <001601bed3c7$60a91940$0f2d9c3e@pentium>
> Date: Wed, 21 Jul 1999 11:33:00 +0200
> Reply-To: Bovine Spongiform Encephalopathy
> Sender: Bovine Spongiform Encephalopathy
> From: "Roland Heynkes @ T-Online"
> Subject: Re: iatrogenic scrapie from sheep dura mater?
> Dear Tom,
>
> >>>An orthopaedic surgeon employed by the lyodura company [Braun
Melsungen]
> >>>extracted dura mater from sheep and human cadavers and came down with
> >>>fast CJD 22 years later.
> >
> >>the article does not say that he was an employee of Braun Melsungen, but
> >>sent et least some of the lyodoras to the company. Do you have
additional
> >>information from one of the authors and do you know if the company got
> >>the ovine dura maters too?
> >
> >I really do not know any more at this time than what was in the article.
> >The way I read it, he was not an internal employee but an independent
> >orthopaedic surgeon who had a contract to supply dura mater to the
company.
> >The victim's wife may be able to supply details, however the family name
> >is not given.
> >
> Perhaps the journal's editors were happy to demonstrate with this
ambiguous
> letter the advantages of peer reviewing.
>
> >>>Scrapie has long been present in Germany but reported levels are very
> >>>low, about a flock a year has to be destroyed. I am not aware of any
> >>>high sensitivity tests or random screening every being used in Germany
> >>>to assess the levels of preclinical animals.
> >
> >>I don't know if the Groschup group in Tuebingen does use a sensitive
> >>scrapie test like the dutch test in order to perform a random screening
> >>program. When I asked last time a few years ago, they "only" tested
> animals
> >>with unclear neurological symptoms.
> >>Scrapie still occurs in Germany, but we have less than one recorded case
> >>per year.
> >
> >Sure. According to this, it was a bit of extraordinary bad luck that any
> >of 150 sheep + 12 humans could have carried the disease, but we know not
> >to equate recorded cases with incidence. Portugal had very few recorded
> >cases per year of BSE too.
> >
> Of course the incidence must be higher than the number of recorded cases
> and the Lelystad-scrapie-test should be used in order to approach the real
> incidence of scrapie in Germany. But in Germany sheep unlike cows are not
> high productivity farm animals that become killed very young and
especially
> when their productivity decreases. Therefore in my opinion scrapie
infected
> sheep have a good chance to develop symptomes and if a vet observes such
> neurological symptomes, governmental vets including the central German lab
> for scrapie diagnosis in Tuebingen will check it histopathologically.
>
> >In your opinion, how exactly has it been possible for scrapie to persist
> >in Germany for all these decades at this vanishingly small level?
> >
> A good question that I can not answer. One reason may be the use of
> occationally contaminated animal meal. But of course a much higher
> incidence of sublethal infected sheep is also possible.
>
> >Cases are probably not geographically or farm-exchange linked.
> >Surely the authorities don't allow live imports from England.
> >
> Unfortunately importing british sheep has never been forbidden in
> Germany. In my opinion this is extreemly stupid and may be a further
> reason for scrapie in Germany.
>
>
> >>>This raises the question, what did the lyodura company do with so much
> >>>dura mater from sheep? The market for specialty surgical products was
> >>>overwelmingly in humans in 1968. The Lancet article only says it was
for
> >>>research -- but in what species?
> >
> >>Are you sure that this research with the ovine dura mater has been done
> >>at Braun Melsungen?
> >
> >I would guess that they did not do the research there but sold it to
> >the marketplace. Perhaps you could give the German authors a call
> >(Weber, Thomas; Tumani, Hayrettin; Holdorff, Bernd all in Hamburg I
> >think)
> >
> Thomas Weber at least was at the Institut for Neurology, University of
> Goettingen, but we have hundreds of Thomas Weber in Germany and at least
> seven around Goettingen. But perhaps I can find an email-address on the
> Institute site.
>
> >It is annoying that so many details relevent to interpretation were
> >left out of the paper. Still, any forward tracing of the dura mater
> >will soon hit a brick wall at the company, Braun Melsungen- B.
> >Carl-Braun-Str. 1 D-34212 Melsungen Germany Tel: ++49 5661 - 71-1739,
> >Fax: ++49 5661 - 71-1632. If any humans received sheep dura mater,
> >I doubt that this will be disclosed or that specific recipients will
> >be identified to their doctors. It is probably better to trace
> >backwards from affected recipients -- see if they strain-type out
> >to be sheep.
> >
> This letter to the editor is indeed of such a low quality that it hardly
> could be worse if it were published on internet instead of a well known
> journal.
>
> >P.S. The US would never think of pooling dura mater in the same
container.
> >However, even after the lyodura experience, apparently we thought it safe
> >to use the same rinse water on 26 consecutive dura mater donations:
> >
> unbelievable clever!
>
> best regards
>
> Roland Heynkes
>
> Erkwiesenstr. 19
> D-52072 Aachen (Germany)
> Tel.: +49 (0)241/932070
> Fax: +49 (0)241/932071
> email: roland.heynkes@t-online.de
> http://home.t-online.de/home/Roland.Heynkes
> --------------------------------------------------------------------------TSS

[PORKER]

http://www.cihr-irsc.gc.ca/e/25519.html This link is from the meeting, The Challenge of Prion Diseases: Conference Proceedings and Invitational Research Planning Workshop Report .