Creutzfeldt-Jakob Disease with Initial Typical Parkinsonism Precipitated by COVID-19? A Case Report

doi:10.21203/rs.3.rs-4138600/v1

Background

Creutzfeldt-Jakob disease (CJD) is a rare and fatal neurodegenerative disease caused by the accumulation of PrP_Sc. While COVID-19-induced sporadic CJD (sCJD) with parkinsonism as the initial symptom is extremely uncommon, this report aims to raise awareness of sCJD cases that present with parkinsonism that are not associated with genetic mutations or pathological α-synuclein (α-Syn) accumulation.

Case presentation

This report presents the case of a 72-year-old man with probable sporadic Creutzfeldt-Jakob disease (sCJD) who initially showed symptoms of parkinsonism, which worsened rapidly after contracting COVID-19. Despite a history of responsive tremor and bradykinesia, his condition deteriorated following the viral infection, leading to rapid consciousness decline and diffuse myoclonus. Diagnostic tests, including brain MRI, cerebrospinal fluid analysis, and EEG, pointed towards prion disease. PrPSc, a marker for CJD, was detected in both the cerebrospinal fluid and skin samples using RT-QuIC, further confirming the diagnosis. Notably, skin analysis revealed PrPSc but no pathological α-synuclein deposits, ruling out typical Parkinson's disease.

Conclussion

This case underscores the importance of considering sCJD in patients with parkinsonism, especially if they experience sudden neuropsychiatric symptoms, especially if they do not exhibit pathological α-Syn accumulation or have genetic mutations.

sCJD

Parkinsonism

COVID-19

α-Syn SAA

RT-QuIC

CJD is a rare, fatal neurodegenerative condition presenting rapidly progressive neurological deficits and is clinically characterized by rapidly progressive dementia, myoclonus, and ataxia[1]. COVID-19 is a primarily respiratory syndrome caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2]. The newly emerging SARS-CoV-2 virus that causes COVID-19 is associated with neurological complications[3–5], and raises the specter of a clinically meaningful interaction in which infection with SARS-CoV-2 precipitates or accelerates neurodegenerative diseases. Here we describe a case of sCJD following COVID-19.

RT-QuIC

The reaction buffer contained 100 mM phosphate buffer (pH 7.5–8.0), 40 µM ThT, 50 mM NaCl and 0.2 mg/ml human PrP or α-Syn monomer. Each well of a black 96-well plate with a clear bottom (Thermo Fisher Scientific) contained 95 µl of reaction buffer and one of 1 mm silica beads (Thermo Fisher Scientific). Reactions were seeded with 2µl of skin homogenate from the case to a final reaction volume of 100 µl. The plates were incubated in a SpectraMax iD5 plate reader (Molecular Device) at 42°C for 96 h with intermittent shaking cycles (high speed, double orbital, shake for 1 min followed by 14 min pause). ThT fluorescence (450 ± 10 nm excitation and 490 ± 10 nm emission; bottom read) was recorded at 15 min intervals in a SpectraMax iD5 plate reader (Molecular Device). The resulting curves were used for the analysis of lag time and apparent growth rate. At least six replicates were performed on each variant, and then the averaged lag times were calculated as well as the corresponding standard deviations. The threshold was calculated by background fluorescence plus 10 standard deviations (yielding a ~ 11.6% cut-off threshold).

Immunofluorescence staining

Skin samples were fixed using a 4% paraformaldehyde solution and sliced into 14 µm sections and immersed in a solution of TBS containing 0.01% Triton X-100, as well as 5% BSA and 3% FBS for one hour at RT. After incubation with primary antibody anti-p-syn (Abcam, No. 51253, 1:500) and Anti-Prion Protein Antibody (Sigma-Aldrich, No. MAB1562, 1:500) overnight at 4°C, sections were washed three times with TBST and incubated with 1:500 Cy-3-labeled and Alexa Fluor 488-labeled secondary antibodies (Thermo Fisher Scientific) for one hour at RT. Images were obtained with a fluorescence microscope (NIKON ECLIPSE 3000). Nuclei were identified with Dapi.

Specimens

The biopsy skin samples were collected by Dept. of Neurology of First Affiliated Hospital of Guangzhou Medical University with informed consent from patients and approval by the Ethics Committee of First Affiliated Hospital of Guangzhou Medical University (No. EC-2016-005(XJS)). Briefly, skin samples containing approximately 3 mm epidermis, dermis, and fat layer were obtained by punch biopsy from the posterior cervical site with a ring drill extractor (USHIO). The biopsy specimens were divided into two halves perpendicularly, and both halves were blindly coded and stored at -80°C. Written consent was obtained from patients or their legal representatives.

Data Availability

Anonymized data not published within this article will be made available by request from any qualified investigator.

Clinical Summary

The patient, a 72-year-old Chinese man, had no history of exposure to environmental toxins or a family history of neurodegenerative diseases, such as Parkinson's disease (PD) and CJD. At the age of 62, he developed a gradual right-sided upper extremity resting tremor and bradykinesia without rigidity. Initial treatment with a single oral dose of levodopa can ameliorate dramatically motor signs. His symptoms progressively worsened, including emotional, cognitive, and motor impairments in March 2023 after being diagnosed with COVID-19, and experienced a severe decline in cognitive function, followed by muscular hypertonia and myoclonus. By April 2023, the patient developed decorticate rigidity and akinetic mutism. Magnetic resonance imaging (MRI) using diffusion-weighted imaging (DWI) revealed extensive hypersignals in the left cortical ribbon (Fig. 1A-B). EEG showed frequent diffuse theta-delta slowing with periodic triphasic sharp-wave complexes (PSWCs), which were strongly consistent with CJD (Fig. 1C). Cerebrospinal fluid (CSF) examination revealed elevation of 14-3-3 protein (> 8000 AU/mL) and total tau (> 1028.63 pg/mL). Considering the extrapyramidal symptoms, the patient underwent D6-[18F] AV133 PET/CT assessment. The results showed a slight and uneven reduction in metabolism in the bilateral caudate, more pronounced on the left side. Metabolism in the anterior part of the bilateral putamen was significantly reduced, with metabolic defects observed in the posterior part of the bilateral putamen, particularly on the left side (Fig. 1D). Serum and CSF levels of interleukin (IL)-1β, IL-6, IL-8, and neurofilament light chain (NfL) were increased, along with elevated C-reactive protein levels in serum. Autoimmune and infectious panels yielded negative results. Multiple nasal swabs were positive for SARS-CoV-2.

Genetic findings

Genomic DNA extracted from the patient's blood was analyzed for genes associated with adult neurodegenerative diseases, including the PRNP gene responsible for encoding PrP. No genetic mutations were found in these genes.

RT-QuIC, α-Syn SAA, and immunofluorescence studies

RT-QuIC tests for PrPsc in CSF and skin samples yielded positive results (Fig. 2A-B). However, both CSF and skin sample showed no α-Syn seeding activity using α-Syn SAA (Fig. 2C). Immunostaining of skin PrP (3F4, Signet, Dedham, MA, USA) without proteinase K pre-treatment revealed robust staining characterized by fine punctate and irregular granular deposits, which was exempted from all of the control(n = 10) (Fig. 2D). After proteinase K (PK) treatment, the majority of the staining disappeared, leaving only a few granular PrP PK-resistant deposits (Fig. 2D). Similarly, anti-p-α-Syn (Ser129) staining showed phosphorylated α-Syn was exempted from immunofluorescence staining in the biopsy skin sample (Fig. 2D).

We report the case of a patient with probable sCJD that fulfills the clinical criteria[6] (Table). In this particular case, the patient exhibited symptoms of sCJD shortly after contracting COVID-19, with parkinsonism manifesting as the initial symptom. The initial question was whether it was a combination of PD with CJD or if it was CJD with parkinsonism as the initial symptom. To explore this matter, SAA and pS129 staining were employed in the skin biopsy sample from the case to detect pathological α-Syn. Interestingly, the skin sample did not display α-Syn seeding activity using SAA or manifested phosphorylated α-Syn by immunofluorescence, but it exhibited the deposition of PrPsc manifested by RT-QuIC and PK-resistant PrP shown by immunofluorescence. The latency period is now known to be at least 30 years [7], so it is fair enough to hypothesize that parkinsonism may act as a clinical manifestation of sporadic CJD. Mechanistically, cytotoxic aggregation of PrP might be linked to the damage in the nigrostriatal pathway in this case of CJD. Previous research has proposed the hypothesis of nigrostriatal pathway dysfunction in CJD[3], our findings align with this hypothesis, as we observed a presynaptic dopaminergic deficit in the bilateral posterior putamen through the D6-[18F] AV133 PET/CT scan. To the best of our knowledge, there are scarce reports of D6-[18F] AV133 PET/CT cases in CJD. This discovery is in line with previous studies utilizing 18F-fluorodeoxyglucose-PET/CT [8, 9].

The factors that contribute to the misfolding of PrPc in sCJD are not fully understood, but they may include stress, genetic mutations, aging, and excessive production of the protein itself[10]. Recent research has shown that certain strains of influenza A can directly trigger the misfolding of PrPc into PrPSc, leading to the formation of infectious prions[11]. Based on this evidence, we propose that a COVID-19-related neuroinflammatory condition, acting on a presymptomatic background, could have played a role in accelerating the misfolding and aggregation of PrPsc. In this case, the cytokine profile in both the serum and cerebrospinal fluid revealed the presence of a post-COVID-19 neuroinflammatory condition, which has been reported to accelerate the progression of neurodegenerative diseases [12, 13]. This case underscores the connection between neuroinflammation and protein misfolding, highlighting how distinct intracellular environments can accelerate the conversion of PrPc into PrPSc, thereby facilitating the spread of infectious prions. Further research is required to confirm the role of SARS-CoV-2 as a trigger for neurodegeneration.

The combination of clinical, neurophysiological, neuroradiological, biochemical, and genetic characteristics strongly indicates the diagnosis of probable sCJD[14]. Without a neuropathological analysis (the Chinese Epidemic Prevention and Control policy mandates that COVID-19 infected cases must be promptly cremated), we still cannot completely rule out a case in which Parkinson's pathology overlaps with prion pathology; however, biochemical and genetic characteristics are highly atypical for PD.

In addition, we would like to propose the concept of parkinsonism-CJD, assuming a state that CJD presented with PD-like symptoms in the early stages of infection. CJD must be seriously considered when it presents with early-stage parkinsonism in the absence of pathological α-Syn accumulation and Parkinson-related gene mutation. The combination of PK-resistant PrP staining alongside α-Syn SAA in skin serves as a practical way to uncover unique abnormalities beyond the brain, serving as valuable instruments for exploring the underlying mechanisms and enabling early diagnosis of CJD in cases displaying extrapyramidal symptoms and signs.

Ethics declarations

The study was conducted according to the revised Declaration of Helsinki and Good Clinical Practice guidelines. The collection of skin samples followed protocols sanctioned by the Ethical Committee of the First Affiliated Hospital of Guangzhou Medical University (Medical Research Ethics, MRE. No.155; No. EC-2016-005(XJS)). Written consent was obtained from patients or their legal representatives.

Consent for publication

Not applicable.

Conflict of interests

The authors report no competing interests.

Funding statement

Financial Disclosure: National Natural Science Foundation of China (grants 81870856, 81870992, 82071416), the Central government guiding local science and technology development projects (grant ZYYD2022C17), the Key Research and Development Program of Guangzhou (grant 2023B03J0631), and the Guang Dong Basic and Applied Basic Research Foundation (grants 2021B1515140026, 2022B1515230004). City- school joint funding project (grants 202201020472). Guangdong Provincial Basic and Applied Basic Research Fund Regional Joint Project (2021B1515140026).

Author Contribution

P.X., X.Y. and X.H. conceived the idea, designed the study, and supervised the overall experiments. Y.K. and H.M. designed and carried out experiments and analyzed data. X.Y. and H.L. performed statistical analysis. S.H. and W.D. performed PET CT analysis. T.T.G and W.X.L contributed to the clinical diagnosis and skin sample collection. P.X. and Y.K performed manuscript writing, reviewing, and editing. All authors read and approved the final manuscript.

Acknowledgements

Author Roles: YK and HM were responsible for experimental design, execution, and data analysis. HS, WD, TG and XW contributed to the data collection. PX and QL participated in manuscript writing, reviewing, and editing. All authors reviewed and approved the final manuscript. The authors declare no conflicts of interest related to this research.

Venneti S. Prion diseases. Clin Lab Med. 2010;30(1):293–309.
Roman GC, et al. The neurology of COVID-19 revisited: A proposal from the Environmental Neurology Specialty Group of the World Federation of Neurology to implement international neurological registries. J Neurol Sci. 2020;414:116884.
Douaud G, et al. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature. 2022;604(7907):697–707.
Bernardini A, et al. Creutzfeldt-Jakob disease after COVID-19: infection-induced prion protein misfolding? A case report. Prion. 2022;16(1):78–83.
Young MJ, et al. Creutzfeldt-Jakob disease in a man with COVID-19: SARS-CoV-2-accelerated neurodegeneration? Brain Behav Immun. 2020;89:601–3.
Hermann P, et al. Biomarkers and diagnostic guidelines for sporadic Creutzfeldt-Jakob disease. Lancet Neurol. 2021;20(3):235–46.
Ae R, et al. Update: Dura Mater Graft-Associated Creutzfeldt-Jakob Disease - Japan, 1975–2017. MMWR Morb Mortal Wkly Rep. 2018;67(9):274–8.
Kilic AK, et al. The Sole Initial Imaging Finding in Creutzfeldt-Jacob Disease: Focal FDG-PET Hypometabolism. Noro Psikiyatr Ars. 2019;56(3):226–8.
Xing XW, et al. Comparison of diffusion-weighted MRI with 18F-fluorodeoxyglucose-positron emission tomography/CT and electroencephalography in sporadic Creutzfeldt-Jakob disease. J Clin Neurosci. 2012;19(10):1354–7.
Scheckel C, Aguzzi A. Prions, prionoids and protein misfolding disorders. Nat Rev Genet. 2018;19(7):405–18.
Hara H, et al. Neurotropic influenza A virus infection causes prion protein misfolding into infectious prions in neuroblastoma cells. Sci Rep. 2021;11(1):10109.
Ashraf GM, et al. The Possibility of an Infectious Etiology of Alzheimer Disease. Mol Neurobiol. 2019;56(6):4479–91.
De Chiara G, et al. Infectious agents and neurodegeneration. Mol Neurobiol. 2012;46(3):614–38.
Parchi P, et al. Classification of sporadic Creutzfeldt-Jakob disease based on molecular and phenotypic analysis of 300 subjects. Ann Neurol. 1999;46(2):224–33.

Table: Diagnostic profile of the case according to the criteria for the clinical diagnosis of PD and sCJD

Clinical features	PD	CJD	Case reported
Cognitive decline	No	Acute or rapid progressive	acute
Memory impairment	No	early	early
Response to levodopa	Good	Poor	Good
Recurrent visual hallucination	No	Yes	No
Detection of 14-3-3	Rare	Yes	Yes
EEG (periodic sharp wave complexes)	No	Yes	Yes
DWI	Non-specific	Diffusion restriction (cortex, and basal ganglia)	Diffusion restriction (cortex, and basal ganglia)
Pathological α-Syn load (skin)	4/5 more severely involved	No	No
Pathological PrP load (skin)	No	Yes	Yes
Prognosis	Good	Bad	Bad

No competing interests reported.

Creutzfeldt-Jakob Disease with Initial Typical Parkinsonism Precipitated by COVID-19? A Case Report

Status:

Version 1

Abstract

Figures

Background

Case presentation

RT-QuIC

Immunofluorescence staining

Specimens

Data Availability

Clinical Summary

Genetic findings

RT-QuIC, α-Syn SAA, and immunofluorescence studies

Discussion and Conclusions

Declarations

Ethics declarations

Consent for publication

Funding statement

Author Contribution

Acknowledgements

References

Tables

Additional Declarations

Status:

Version 1