Acalculia in 2 autopsy-proven CBD cases

UPenn researchers recently got published a report of two cases of acalculia in autopsy-confirmed CBD. Acalculia is an impairment in the ability to calculate or performing simple mathematical tasks, such as adding or subtracting.

I don’t consider this particularly new information but the authors say that “While the original case descriptions mentioned acalculia, few studies have investigated this, and reports of acalculia in autopsy-proven CBD are very rare. We detail 2 autopsy-defined CBD cases with acalculia to emphasize that CBD compromises cognitive functioning due to disease that includes parietal cortex.”

This paragraph from the Discussion section is interesting: “In 15 patients with autopsy-proven CBD that included the 2 cases detailed here, acalculia was noted in 28.6%, although this was thought to be an underestimation since calculations were not often examined. … Patients with CBS have significant impairments estimating and comparing quantities, performing calculations with small numerosities, and using quantity knowledge to support word meaning. … MRI in CBS regularly shows parietal atrophy, including areas associated with number knowledge.”

I’ve copied the citation below.

Robin

Neurology. 2011 Feb 15;76(7 Suppl 2):S61-3.

Acalculia in autopsy-proven corticobasal degeneration.

Pantelyat A, Dreyfuss M, Moore P, Gross R, Schuck T, Irwin D, Trojanowski J, Grossman M.
Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.

How disordered proteins spread

This news article, written for laypeople, is about how disordered proteins spread from neuron to neuron in Huntington’s Disease, and probably in other diseases as well (such as PD, AD, PSP, and CBD). What seems to be new here is a confirmation that the misfolded protein spends part of its time outside neurons as this “opens up the possibility for therapeutics.”

http://news.stanford.edu/news/2011/febr … 21811.html

Stanford Report
February 18, 2011
Stanford researchers study how disordered proteins spread from cell to cell, potentially spreading neurodegenerative disease

Misfolded proteins can get into cells and form large aggregates by recruiting normal proteins. These aggregates are associated with neurodegenerative diseases. Stanford biology Professor Ron Kopito has found that the protein linked to Huntington’s can spread from one cell to another. His research may explain how these diseases spread through our brains, an understanding that might lead to the development of drugs to target the misfolded proteins.

By Sandeep Ravindran

One bad apple is all it takes to spoil the barrel. And one misfolded protein may be all that’s necessary to corrupt other proteins, forming large aggregations linked to several incurable neurodegenerative diseases such as Huntington’s, Parkinson’s and Alzheimer’s.

Stanford biology Professor Ron Kopito has shown that the mutant, misfolded protein responsible for Huntington’s disease can move from cell to cell, recruiting normal proteins and forming aggregations in each cell it visits.

Knowing that this protein spends part of its time outside cells “opens up the possibility for therapeutics,” he said. Kopito studies how such misfolded proteins get across a cell’s membrane and into its cytoplasm, where they can interact with normal proteins. He is also investigating how these proteins move between neuronal cells.

The ability of these proteins to move from one cell to another could explain the way Huntington’s disease spreads through the brain after starting in a specific region. Similar mechanisms may be involved in the progress of Parkinson’s and Alzheimer’s through the brain.

Kopito discussed his research Friday at the annual meeting of the American Association for the Advancement of Science in Washington, D.C.

Not all bad

Not all misfolded proteins are bad. The dogma used to be that all our proteins formed neat, well-folded structures, packed together in complexes with a large number of other proteins, Kopito said. But over the past 20 years, researchers have found that as much as 30 percent of our proteins never fold into stable structures. And even ordered proteins appear to have some disordered parts.

Disordered proteins are important for normal cellular functions. Unlike regular proteins, they interact with only one partner at a time. But they are much more dynamic, capable of several quick interactions with many different proteins. This makes them ideal for a lot of the standard communication that happens within a cell for its normal functioning, Kopito said.

But if some of our proteins are always disordered, how do our cells tell which proteins need to be properly folded, and which don’t? “It’s a big mystery,” said Kopito, and one that he’s studying. This question has implications for how people develop neurodegenerative diseases, all of which appear to be age-related.

Huntington’s disease is caused by a specific mutated protein. But the body makes this mutant protein all a person’s life, so why does that person get the disease in later adulthood? Kopito said it’s because the body’s protective mechanisms stop doing their job as we get older. He said his lab hopes to determine what these mechanisms are.

A bad influence

But it’s clear what happens when these mechanisms stop working – misfolded proteins start recruiting normal versions of the same protein and form large aggregations. The presence of these aggregations in neurons has been closely linked with several neurodegenerative diseases.

Kopito found that the mutant protein associated with Huntington’s disease can leave one cell and enter another one, stirring up trouble in each new cell as it progresses down the line. The spread of the misfolded protein may explain how Huntington’s progresses through the brain.

This disease, like Parkinson’s and Alzheimer’s, starts in one area of the brain and spreads to the rest of it. This is also similar to the spread of prions, the self-replicating proteins implicated in mad cow disease and, in humans, Creutzfeldt-Jakob disease. As the misfolded protein reaches more parts of the brain, it could be responsible for the progressive worsening of these diseases.

Now that we know that these misfolded proteins spend part of their time outside of cells, traveling from one cell to another, new drugs could target them there, Kopito said. This could help prevent or at least block the progression of these diseases.

Kopito is currently working to figure out how misfolded proteins get past cell membranes into cells in the first place. It is only once in the cell’s cytoplasm that these proteins can recruit others. So these studies could help find ways to keep these mischief-makers away from the normal proteins.

He is also collaborating with biology Professor Liqun Luo to track these proteins between cells in the well-mapped fruit fly nervous system. In the future, Kopito said he hopes to link his cell biology work to disease pathology in order to understand the role misfolded proteins play in human disease.

Sandeep Ravindran is a science-writing intern at the Stanford News Service.

AD Presenting as CBS (2006)

CBS folks –

Probably half of the people I’ve helped with brain donation who had a clinical diagnosis of CBS (or CBD) ended up with a confirmed diagnosis of Alzheimer’s disease (AD) upon brain autopsy. The case of someone recently was the same. One clue in that case was that the person experienced myoclonus which, surprisingly, is more associated with AD than CBD. The Mayo Clinic neuropathology report in this recent case gave the citation to a 2006 article as a reference item. This post is about that 2006 article.

That 2006 article is a case report of a 60-year-old man presenting with “slowly progressive left hemi-Parkinsonism, left hand apraxia, myoclonus, dystonia, visuospatial disturbances, and alien limb phenomenon, resembling corticobasal syndrome.” The man died 8 years after symptom onset. Neuropathological analysis showed that the man had Alzheimer’s Disease. The authors say that the “CBS-like presentation in AD is rare.” Four years later, I don’t think researchers would make the same statement. Indeed, in late 2009, researchers from Mayo, led by Dr. Hu, published research in which 11 of 16 clinical CBS cases ended up having Alzheimer’s Disease upon brain autopsy. One thing I learned from that late 2009 article was that alien limb is not a significant syndrome when differentiating between CBD and AD.

I’ve copied the abstract below.

Robin

Movement Disorders. 2006 Nov;21(11):2018-22.

Alzheimer’s disease presenting as corticobasal syndrome.

Chand P, Grafman J, Dickson D, Ishizawa K, Litvan I.
Department of Neurology, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA.

Abstract
A 60-year-old man presented with slowly progressive left hemi-Parkinsonism, left hand apraxia, myoclonus, dystonia, visuospatial disturbances, and alien limb phenomenon, resembling corticobasal syndrome. Eight years later, neuropathology revealed features of Alzheimer’s disease, with asymmetrical (right more than left) cortical tau burden with image analysis. The videotaped clinical features, neuropsychological aspects, and neuropathological correlates are presented and discussed.

PubMed ID#: 16977625 (see pubmed.gov for the abstract only)

Clinical diagnosis of CBD; autopsy showed CJD

In case you needed more evidence that CBD mimics other disorders… This is a case of a 73-year-old Japanese woman who “showed slowly progressive aphasia, apraxia and dementia. She had no family history of prion disease or dementia. One year later she showed parkinsonism and corticobasal degeneration was initially suspected. … The patient developed myoclonus and an akinetic mutism state 15 months and 22 months after onset, respectively.”

She died at age 81. A brain autopsy was performed. It revealed she had a genetic form of Creutzfeldt-Jakob disease.

Robin

Neuropathology. 2011 Jan 27. [Epub ahead of print]

An autopsied case of V180I Creutzfeldt-Jakob disease presenting with panencephalopathic-type pathology and a characteristic prion protein type.

Iwasaki Y, Mori K, Ito M, Nagaoka M, Ieda T, Kitamoto T, Yoshida M, Hashizume Y.
Departments of Neurology Pathology, Oyamada Memorial Spa Hospital Department of Neurology, Yokkaichi Municipal Hospital, Yokkaichi Division of CJD Science and Technology, Department of Neurological Science, Tohoku University Graduate School of Medicine, Sendai Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan.

Abstract
A 73-year-old Japanese woman showed slowly progressive aphasia, apraxia and dementia. She had no family history of prion disease or dementia.

One year later she showed parkinsonism and corticobasal degeneration was initially suspected. On MRI, the left temporal neocortex seemed swollen on T2-weighted images in the initial stage, and a later high-signal intensity region was observed in the cerebral cortex in diffusion-weighted images.

The patient developed myoclonus and an akinetic mutism state 15 months and 22 months after onset, respectively. Consecutive electroencephalography revealed no periodic sharp-wave complexes.

Prion protein (PrP) gene analysis revealed a valine to isoleucine point mutation at codon 180, and methionine homozygosity at codon 129.

This patient’s clinical symptoms and disease course were atypical for Creutzfeldt-Jakob disease (CJD), and a stable state with nasal tube-feeding lasted several years.

She died of respiratory failure at the age of 81, 102 months after the onset.

Autopsy revealed widespread spongiform degeneration with weak synaptic-type PrP deposition, confirming the diagnosis of genetic CJD. Neurons in the cerebral cortex were relatively preserved in number and hypertrophic astrocytosis was generally moderate for such long-term disease, but cerebral white matter showed diffuse severe myelin pallor with tissue rarefaction suggestive of panencephalopatic-type pathology. The cerebellar cortex was relatively well preserved with observation of mild spongiform change in the molecular layer, moderate neuron loss in the Purkinje neuron layer, and scattered small plaque-like PrP deposition. Western blot analysis of protease-resistant PrP showed a characteristic pattern without a diglycoform band.

V180I CJD is an interesting form of genetic CJD with regards to the clinicopathologic, molecular and genetic findings.

© 2011 Japanese Society of Neuropathology.

PubMed ID#: 21269331 (see pubmed.gov for this abstract only)

“Applause sign” may be due to frontal lobe impairment

PSP and CBD folks –

This is further evidence that the “applause sign” is not a very useful tool when diagnosing PSP or, by inference, CBD. This research shows that the applause sign can occur in FTD (only the behavioral variant of FTD was included) and AD. (Previously others have argued that it is unique to PSP. More recently, researchers have argued that it is specific to parkinsonian disorders.)

Here’s a description of the applause sign from the article: “The applause sign was detected using the three clap test which was administered and scored according to the literature: subjects were asked ‘to clap three times as quickly as possible after demonstration of the examiner’. The subject’s performance was considered normal when he/she clapped three times (score=3), abnormal when the subject clapped more than three times (2=four times, 1=five to ten times; 0= more than 10 times).”

“An abnormal applause sign was present in all patient groups (80% in PSP, 70% in FTD and 31% in AD) while it was absent in normal controls. …[P]oor specificity and low positive predictive value of the applause sign should raise questions about its diagnostic usefulness.”

Robin

Journal of Neurology, Neurosurgery and Psychiatry. 2011 Jan 18. [Epub ahead of print]

Applause sign: is it really specific for Parkinsonian disorders? Evidence from cortical dementias.

Luzzi S, Fabi K, Pesallaccia M, Silvestrini M, Provinciali L.
Department of Neuroscience, Polytechnic University of Marche, Ancona, Italy.

Abstract

Objective
The applause sign, originally reported as a specific sign of progressive supranuclear palsy (PSP), has recently been found in several parkinsonian disorders. Its nature is still uncertain. It has been interpreted as a motor perseveration or a form of apraxia.

The present study aims to: (a) verify the specificity of the applause sign for parkinsonian disorders, examining the presence of the applause sign in cortical dementias which should be error free and (b) clarify the nature of the applause sign (resulting or not from apraxia).

Methods
77 subjects were included: 10 PSP, 15 frontotemporal dementia (FTD), 29 Alzheimer’s disease (AD) and 23 normal
controls. The presence of apraxia was an exclusion criterion. All patients underwent a detailed neuropsychological examination, and cognitive performance was correlated to the applause sign.

Results
All patient groups showed the applause sign and differed significantly from normal subjects who were error free.

No difference was found when comparing PSP with FTD and FTD with AD.

AD differed significantly from PSP but they were not error free (31% of patients with AD showed the applause sign).

The only correlation with background neuropsychology was found for measures of executive functions.

Conclusions
The presence of the applause sign in cortical dementia does not confirm the specificity of the applause sign for parkinsonian disorders. The applause sign should be interpreted as a sign of frontal lobe dysfunction rather than a form of apraxia, and can likely be detected in any kind of disease which involves frontal lobe structures to some extent.

Pub Med ID#: 21245475 (see pubmed.gov for this abstract only)