Beta-CIT SPECT demonstrates reduced availability of serotonin transporters in patients with Fatal Familial Insomnia

Fatal Familial Insomnia Initially Developing Parkinsonism Mimicking Dementia with Lewy Bodies

We report a rare case of fatal familial insomnia in a 58-year-old man who initially developed parkinsonism, secondary dementia, and visual hallucinations that were suspected to be due to dementia with Lewy bodies. We evaluated the function of the striatum via dopamine transporter single-photon emission computed tomography (DAT SPECT) using ¹²³I-ioflupane and found marked presynaptic dopamine dysfunction in the bilateral striatum. This is the first reported case in which the initial symptom of fatal familial insomnia was parkinsonism and in which the dopamine transporter function was evaluated by DAT SPECT.

Fatal familial insomnia and sporadic fatal insomnia

Fatal familial insomnia (FFI) and sporadic fatal insomnia (sFI), or thalamic form of sporadic Creutzfeldt-Jakob disease MM2 (sCJDMM2T), are prion diseases originally named and characterized in 1992 and 1999, respectively. FFI is genetically determined and linked to a D178N mutation coupled with the M129 genotype in the prion protein gene (PRNP) at chromosome 20. sFI is a phenocopy of FFI and likely its sporadic form. Both diseases are primarily characterized by progressive sleep impairment, disturbances of autonomic nervous system, and motor signs associated with severe loss of nerve cells in medial thalamic nuclei. Both diseases harbor an abnormal disease-associated prion protein isoform, resistant to proteases with relative mass of 19 kDa identified as resPrP^TSE type 2. To date at least 70 kindreds affected by FFI with 198 members and 18 unrelated carriers along with 25 typical cases of sFI have been published. The D178N-129M mutation is thought to cause FFI by destabilizing the mutated prion protein and facilitating its conversion to PrP^TSE. The thalamus is the brain region first affected. A similar mechanism triggered spontaneously may underlie sFI.

A roadmap for investigating the role of the prion protein in depression associated with neurodegenerative disease

The physiological properties of the native, endogenous prion protein (PrP(C)) is a matter of concern, due to its pleiotropic functions and links to neurodegenerative disorders and cancer. In line with our hypothesis that the basic function of PrP(C) is to serve as a cell surface scaffold for the assembly of signaling modules, multiple interactions have been identified of PrP(C) with signaling molecules, including neurotransmitter receptors. We recently reported evidence that PrP(C) may modulate monoaminergic neurotransmission, as well as depressive-like behavior in mice. Here, we discuss how those results, together with a number of other studies, including our previous demonstration that both inflammatory and behavioral stress modulate PrP(C) content in neutrophils, suggest a distributed role of PrP(C) in clinical depression and inflammation associated with neurodegenerative diseases. An overarching understanding of the multiple interventions of PrP(C) upon physiological events may both shed light on the pathogenesis of, as well as help the identification of novel therapeutic targets for clinical depression, Prion and Alzheimer's Diseases.

Prions impair bioaminergic functions through serotonin- or catecholamine-derived neurotoxins in neuronal cells

The conversion of the cellular prion protein, PrP(C), to an abnormal isoform, PrP(Sc), is a central event leading to neurodegeneration in prion diseases. Deciphering the molecular and cellular changes imparted by PrP(Sc) accumulation remains an arduous task due to the small number of cell lines supporting prion replication. Here we introduce the 1C11 cell line as a new in vitro model to investigate prion pathogenesis. This cell line is a committed neuroectodermal progenitor able to differentiate into fully functional serotonergic or catecholaminergic neurons. 1C11 cells, which naturally express PrP(C) from the undifferentiated state, can be chronically infected with various prion strains. Prion infection does not promote any noticeable phenotypic change in the progenitor cells nor prevent the onset of the serotonergic and catecholaminergic differentiation programs. Pathogenic prions, however, deviate the overall neurotransmitter-metabolism in both pathways by decreasing bioamine synthesis, storage, and transport, and enhancing catabolism. Noteworthy, oxidized derivatives of both serotonin and catecholamines are selectively detected in the differentiated progenies of infected cells and contribute to irreversible impairment in bioamine synthesis. Finally, the level of PrP(Sc) accumulation, that of infectivity, and the extent of all prion-induced changes in infected cells appear to be correlated. The report of such specific effects of infection on neuronal functions provides a foundation for dissecting the events underlying loss of neuronal homeostasis in prion diseases.

Fatale familiäre Insomnie

Fatal familial insomnia (FFI) is a hereditary prion disease caused by a mutation in codon 178 of the prion protein gene PRNP on chromosome 20. It is characterized by disturbed night sleep, resulting in daily vigilance perturbations and a variety of other neurological symptoms. We present the case of a 46-year-old woman deteriorating despite immunosuppressive treatment which was initiated suspecting cerebral vasculitis as the cause of her progressive neurological symptoms. The correct diagnosis was established only post mortem. Based on the case presented here, we discuss typical clinical symptoms and imaging findings. In particular, we outline how modern diagnostic methods such as positron emission tomography with [(15)O]H(2)O and [(18)F]FDG and single photon emission computed tomography can add valuable information to results from conventionally performed imaging techniques and genetic testing.

Unaltered susceptibility to scrapie in serotonin transporter deficient mice

The serotonergic system has been hypothesized to play an important role in prion diseases. Specifically, hyperactivity of the serotonergic system in prion diseases is suggested by an increase in the turnover rate of the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT) in human and experimental prion diseases. The 5-HT transporter (5-HTT) determines the duration of serotonergic neurotransmission by way of reuptake of 5-HT from the extracellular space. 5-HTT availability is reduced in brains of patients with the human prion disease familial fatal insomnia. To further clarify a possible role of the 5-HTT in prion diseases we investigated whether mice lacking the 5-HTT display an altered susceptibility to experimental scrapie infection. Surprisingly, 5-HTT knockout mice developed mouse scrapie in a time course similar to wildtype control mice with accumulation of the pathological prion protein, PrP(Sc) and with typical pathological hallmarks of the disease. These findings argue against a major role of the 5-HTT in the pathogenesis of prion diseases in mice.

Fatal familial insomnia: a model disease in sleep physiopathology

Fatal Familial Insomnia (FFI) is characterized by loss of sleep, oneiric stupor with autonomic/motor hyperactivity and somato-motor abnormalities (pyramidal signs, myoclonus, dysarthria/dysphagia, ataxia). Positon emission tomography (PET) disclosed thalamic hypometabolism and milder involvement of the cortex; neuropathology severe neuronal loss in the thalamic nuclei variably affecting the caudate, gyrus cinguli and fronto-temporal cortices. Genetic analysis disclosed a mutation in the PRNP gene and FFI was transmitted to experimental animals, thus classifying FFI within the prion diseases. Rare Sporadic Fatal Insomnia (SFI) cases occur without PRNP mutation but with features similar to FFI. FFI represents a model disease for the study of sleep-wake regulation: (I) the profound thalamic hypometabolism/atrophy associated with lack of sleep spindles and delta sleep implicate the thalamus in the origin of slow wave sleep (SWS); (II) loss of SWS is associated with marked autonomic and motor hyperactivity; termed 'agrypnia excitata', this association has been proposed as a useful clinical concept representative of thalamo-limbic dysfunction; (III) lack of SWS occurs with substantial preservation of stage 1 NREM sleep, implying that the latter has mechanisms different from SWS and unaffected by thalamic atrophy; accordingly, conflating stage 1 NREM with SWS into NREM sleep is inappropriate.

Effects on the serotoninergic system in sub-acute transmissible spongiform encephalopathies: current data, hypotheses, suggestions for experimentation

Sub-acute transmissible spongiform encephalopathies (TSEs), or prion diseases, are affections in which little is known of their etiology. The predominant theory stipulates that an abnormal protease-resistant prion protein (PrPres) would be infectious by directly inducing its defective conformation to the normal native protein (PrPC). The function of PrPC remains unknown. The preferred localization of PrPC at the level of the synapses supposes a function in neuronal transmission. Several neurotransmitter systems (acetylcholine, GABA, dopamine, etc.) are damaged in TSEs, mainly the serotonin (5-HT) system. At a hypothetical level, PrPC would play a trophic and functional role by regulating the capture of amino acid precursors of neurotransmitters and the functions of neuroreceptors, in particular regarding tryptophan and 5-HT receptors. By comparison with the modes of action of Ras proteins and of the envelope glycoprotein of jaagsiekte sheep retrovirus, the adaptation of an oncogenic model is suggested for the mode of action of PrPres. The sequence of events could be the following: capture of PrPres and forming of an abnormal receptor, chronic disturbance of transduction pathways, more particularly of the phosphatidylinositol-3 kinase (PI-3K)/protein kinase B (Akt)/glycogen synthetase kinase 3 (GSK 3)/Wnt-beta catenin pathway, deregulation of the PrP gene and infrequent and transitory forming of abnormal RNA messengers and, finally, the forming of abnormal proteins and the deterioration of the serotoninergic system. The involvement of endogenous nucleic acids is supposed. The infectious agent of TSEs could be an ancestral form of retrovirus, such as a retrotransposon using the prion protein as an envelope glycoprotein. Pharmacological tests, by comparison with a rare disease of unknown etiology in cattle, bovine spastic paresis, are suggested with the amino acid precursors of neuromediators (tryptophan, tyrosine, glutamic acid, etc.) and with lithium, neuroprotector and regulator of the serotonergic system.

Familial and sporadic fatal insomnia

Familial fatal insomnia (FFI)--a hereditary prion disease caused by a mutation at codon 178 of the prion-protein (PrP) gene (PRNP) that leads to a D178N substitution in the protein--and its sporadic form, sporadic fatal insomnia (SFI), have similar disease phenotypes. Both disorders have clinical features of disrupted sleep (loss of sleep spindles and slow-wave sleep and enacted dreams during rapid-eye-movement sleep), autonomic hyperactivation, and motor abnormalities (myoclonus, ataxia, dysarthria, dysphagia, and pyramidal signs). PET shows pronounced thalamic and limbic hypometabolism that becomes more widespread in later stages. Neuropathological assessment reveals severe neuronal loss and astrogliosis of the anterior medial thalamus and inferior olives, with later cerebral cortical and cerebellar involvement. Accumulation of an isoform of protease-resistant PrP fragment in FFI distinct from that found in a familial form of Creutzfeldt-Jakob disease with the same D178N mutation, shows the effect of the polymorphism at codon 129 of PRNP on phenotypic expression and the possibility of distinct prion "strains" with diverse pathological potential. Intriguing clinicopathological correlations in FFI and SFI suggest a role for the thalamolimbic system in the regulation of sleep and other circadian functions.

Sporadic and familial CJD: classification and characterisation

Prion diseases are unique transmissible neurodegenerative diseases that have diverse phenotypes and can be familial, sporadic, or acquired by infection. Recent findings indicate that the PrP genotype and the PrP(Sc) type have a major influence on the disease phenotype in both sporadic and familial human prion diseases. This review attempts to classify and characterise sporadic and familial Creutzfeldt-Jakob disease (CJD) as a function of these two disease determinants. Based on the genotype at codon 129 on both PRNP alleles, the size of protease resistant PrP(Sc) fragments and disease phenotype, we divide sporadic CJD into six subtypes: sCJDMM1/sCJDMV1, sCJDVV2, sCJDMV2, sCJDMM2, sCJDVV1, and sporadic fatal insomnia (sFI). Familial CJD is classified into many haplotypes based on the PRNP mutation and codon 129 (and other polymorphic codons) on the mutant allele. The clinical and pathological features are summarised for each sporadic CJD subtype and familial CJD haplotype.