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Table of Contents    
LETTERS TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 529-531

Atypical sporadic Creutzfeldt–Jakob disease presenting as progressing schizophrenia


1 Department of Neurology, Chung-Ang University Hospital, Chung-Ang, Seoul, Republic of Korea
2 Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
3 Department of Neurology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
4 Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Suk-Won Ahn
Department of Neurology, Chung-Ang University Hospital, Chung-Ang University, College of Medicine, Seoul
Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.227321

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How to cite this article:
Ahn SW, Park MS, Han SH, Yoon BN, Shin JY. Atypical sporadic Creutzfeldt–Jakob disease presenting as progressing schizophrenia. Neurol India 2018;66:529-31

How to cite this URL:
Ahn SW, Park MS, Han SH, Yoon BN, Shin JY. Atypical sporadic Creutzfeldt–Jakob disease presenting as progressing schizophrenia. Neurol India [serial online] 2018 [cited 2019 Dec 7];66:529-31. Available from: http://www.neurologyindia.com/text.asp?2018/66/2/529/227321




Sir,

Creutzfeldt–Jakob disease (CJD) is a progressive, fatal, and potentially transmissible disease.[1] A clinical diagnosis of CJD is based on the occurrence of rapidly progressive dementia and myoclonus as well as multifocal neurological dysfunction, and can be verified by the characteristic generalized periodic sharp wave complexes of an electroencephalogram (EEG) and a positive 14-3-3 protein test of cerebrospinal fluid (CSF).[2.3] In addition, brain magnetic resonance images (MRI) reveal high signal intensities involving the basal ganglia, thalamus, and cerebral cortex in T2-weighted, fluid-attenuated inversion recovery (FLAIR), and diffusion weighted images (DWI).[4],[5] However, given the rarity of the condition and the characteristic clinical findings of CJD, critical psychiatric manifestations are often under-appreciated. Recently, we encountered a patient with sporadic CJD who had presented with only psychiatric manifestations followed by development of a vegetative state without myoclonus, dementia, and seizure. Therefore, we describe this unusual case of sporadic CJD and the consecutive MRI findings.

A 46-year old man presented to our hospital with lethargy, delusion of persecution, and auditory hallucinations. He had been suffering from depression and compulsive behavior for 3 months. Initially, he did not complain of gait disturbance, limb weakness, sensory change, tremor, myoclonus, and convulsive movement, and therefore, he was clinically diagnosed as schizophrenic, followed by treatment with psychiatric medications.[6] However, his psychiatric symptoms aggravated and he lost the ability to take care for himself and could not even have a meal by himself.

On admission, his neurological manifestations rapidly progressed. Neurological examination revealed an impaired speech in the form of progressive mutism, difficulty in walking, involuntary jerky movement, and lead pipe rigidity in all four extremities. Deep tendon reflexes were brisk and plantar responses were flexor bilaterally. Further, he had disorganized thinking and judgment, aggressiveness, agitation, and sleeping tendency. Brain MRI showed cortical high signal intensities indicating a typical cortical “ribbon” on fluid attenuated inversion recovery (FLAIR) [Figure 1]a and diffusion weighted images (DWI) [Figure 1]b. EEG revealed periodic triphasic waveforms with background slowing suggesting the presence of sporadic CJD [Figure 2].[7] In addition, in our patient, pathogenic 14-3-3 prion protein (PrP Sc) in human CSF using RT-QuIC assay showed elevation from the normal value.[8] Routine blood tests of liver, kidney, electrolytes, blood cells, hemoglobin, and nutrition were normal, and special tests for autoimmune encephalitis, vasculitis, and malignancy were negative.
Figure 1: The patient presented with the first episode of rapidly progressing psychosis and showed typical cortical hyperintensities (white arrows) suggestive of Creutzfeldt–Jakob disease (CJD) on brain magnetic resonance images (MRI) with fluid-attenuated inversion recovery (FLAIR, a) and diffusion weighted images (DWI, b)

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Figure 2: Electroencephalogram (EEG) revealed periodic triphasic waveforms with background slowing suggesting the presence of sporadic Creutzfeldt–Jakob disease (CJD)

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Therefore, based on the diagnostic criteria, our patient was diagnosed as probable sporadic CJD by the two clinical signs of extrapyramidal features and mutism combined with the laboratory findings of typical EEG feature of periodic sharp wave complexes, positive 14-3-3 protein in CSF, and asymmetric hyperintensities on MRI.[2],[3],[4],[5],[7]

Two years later, he still shows a sustained vegetative state and lead pipe rigidity with a tracheostomy and percutaneous endoscopic gastrostomy insertion. A follow-up brain MRI revealed significant brain atrophy and white matter changes involving both the cerebrum and cerebellum [Figure 3].
Figure 3: Two years later, the patient showed a sustained vegetative state, and a follow-up brain MRI revealed significant brain atrophy and white matter changes involving both the cerebrum and cerebellum on fluid-attenuated inversion recovery (FLAIR, a) and diffusion weighted images (DWI, b)

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Interestingly, he did not present with the characteristic myoclonus, seizure, or dementia in the beginning of disease, but was mainly showing psychiatric symptoms including delusion of persecution, auditory hallucinations, disorganized thinking, aggressiveness, and agitation before the vegetative state following decreased mental status developed.

When a patient's first episode of neuropsychiatric symptoms is rapidly progressive, brain MRI including DWI, EEG test and CSF study are warranted to investigate the possibility of CJD. There has been a rare report of CJD presenting with only psychiatric manifestations, followed by a sustained vegetative state; this rare condition is likely to be misdiagnosed initially as psychosis. This unusual case serves to remind clinicians that patients who present with the first episode of progressive psychosis of an uncertain origin should undergo brain MRI, EEG, and CSF study, and the possibility of CJD should be considered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education (NRF-2016R1D1A1B03936287).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramasamy I, Law M, Collins S, Brooke F. Organ distribution of prion proteins in variant. Creutzfeldt-Jakob disease. Lancet Infect Dis 2003;3:214-22.  Back to cited text no. 1
    
2.
Tschampa HJ, Kallenberg K, Urbach H, Meissner B, Nicolay C, Kretzschmar HA, et al. MRI in the diagnosis of sporadic Creutzfeldt-Jakob disease: A study on inter-observer agreement. Brain 2005;128:2026-33.  Back to cited text no. 2
    
3.
Kamtchum Tatuene J, Vargas MI, Burkhardt K, Chofflon M. Illustrating the relevance of updated diagnostic criteria for sporadic Creutzfeldt-Jakob disease: A teaching neurocase. BMJ Case Rep 2013;2013.  Back to cited text no. 3
    
4.
Caverzasi E, Mandelli ML, DeArmond SJ, Hess CP, Vitali P, Papinutto N, et al. White matter involvement in sporadic Creutzfeldt-Jakob disease. Brain 2014;137:3339-54.  Back to cited text no. 4
    
5.
Donald AC, David MS, Robin JS, Ironside JW, Cooper S, Zeidler M, et al. Diagnosing variant Creutzfeldt-Jakob disease with the pulvinar sign: MR imaging findings in 86 neuropathologically confirmed cases. AJNR Am J Neuroradiol 2003;24:1560-9.  Back to cited text no. 5
    
6.
Freedman R. Schizophrenia. N Engl J Med 2003;349:1738-49.  Back to cited text no. 6
    
7.
Meissner B, Kallenberg K, Sanchez-Juan P, Collie D, Summers DM, Almonti S, et al. MRI lesion profiles in sporadic Creutzfeldt-Jakob disease. Neurology 2009;72:1994-2001.  Back to cited text no. 7
    
8.
Giraud P, Biacabe AG, Chazot G, Later R, Joyeux O, Moene Y, et al. Increased detection of 14-3-3 protein in cerebrospinal fluid in sporadic Creutzfeldt-Jakob disease during the disease course. Eur Neurol 2002;48:218-21.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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