Detection of 14-3-3 protein in the CSF of a patient with Hashimoto's encephalopathy

Clinical Correlates of Cerebrospinal Fluid 14-3-3 Protein in Non-Prion Rapid Progressive Dementia

BACKGROUND

The 14-3-3 protein in cerebrospinal fluid (CSF) is a suitable biomarker for the diagnosis of Creutzfeldt-Jakob disease (CJD). However, it has also been detected in various non-prion-related rapidly progressive dementia (RPD), which affected its diagnostic performance and clinical utilization.

OBJECTIVE

To investigate the general disease distribution with positive 14-3-3 result and to evaluate the association between CSF 14-3-3 protein and the clinical features in patients with non-prion RPD.

METHODS

A total of 150 patients with non-prion RPD were enrolled. The clinical data were collected and CSF 14-3-3 test was performed for all patients. The distribution of various diseases with a positive 14-3-3 result was analyzed and the association of CSF 14-3-3 with clinical features was tested.

RESULTS

The CSF 14-3-3 protein was detected in 23.3% of non-prion RPD patients, and the most frequent diagnoses were autoimmune encephalitis (22.9%) and neurodegenerative disease (22.9%). CSF 14-3-3 protein was more common in older patients (p = 0.028) and those presenting myoclonus (p = 0.008). In subgroup analysis, the positive 14-3-3 test was more common in neurodegenerative disease with a long time from the symptom onset to CSF 14-3-3 test (p = 0.014).

CONCLUSION

CSF 14-3-3 protein could be detected in a broad spectrum of non-prion RPD. In particular, patients with autoimmune encephalitis and rapidly progressive neurodegenerative diseases and those with myoclonus have a greater likelihood of a positive 14-3-3 result. These results could help clinicians interpret the results of CSF 14-3-3 protein more reasonably.

Anti-Thyroid Peroxidase/Anti-Thyroglobulin Antibody-Related Neurologic Disorder Responsive to Steroids Presenting with Pure Acute Onset Chorea

Background:

Pure acute onset chorea without encephalopathy has rarely been reported in anti-thyroid peroxidase (anti-TPO)/anti-thyroglobulin (anti-TG) antibody-related neurologic disorders responsive to steroids (ATANDS).

Case report:

We report a 16-year-old female who presented with acute chorea without encephalopathy. Anti-TPO antibodies were found to be strongly positive (>1200 IU/ml) along with anti-thyroglobulin and anti-thyroid stimulating hormone receptor antibodies. After pulse intravenous methylprednisolone therapy (1 g/day for five consecutive days), all the movements seized, and she was discharged with oral prednisolone 30 mg/day with gradual tapering over next three months. After one year of follow-up, she is stable, drug-free, and never had any other problems.

Discussion:

Anti-thyroid antibodies testing should be included in routine/conventional panel that is done for elucidating causes of chorea as ATANDS can be easily missed and is treatable with widely available, relatively low-cost drugs like steroids with a promising outcome.

Relapsing encephalopathy with dancing eyes and jerky limbs

We report a case of relapsing-remitting opsoclonus-myoclonus-ataxia syndrome (OMAS) in a patient with Hashimoto's encephalopathy, diagnosed after comprehensive evaluation. OMAS as a manifestation of Hashimoto's encephalopathy has been reported once previously. It is hoped that recognition of this entity and early initiation of immunotherapy will improve clinical outcomes for patients.

An easily missed cause for low GCS in a Scottish Intensive Care Unit

A case report of a 36-year-old patient who presented with seizures, a large thyroid and decreased consciousness level requiring admission to the intensive care unit, where the final diagnosis had a prevalence of 2.1/100,000 and a female to male ratio of 4:1. The final diagnosis was suggested early by a focussed internet search. This is unusual because as clinicians we often tell the general public to ignore an internet search. The early suggestion demonstrated that in the right hands the use of internet searches can help us make more informed decisions and aid patient management when combined with traditional investigative medical practice. However, the lesson with this case is that there are many unusual and rare causes of presentations to critical care units and as clinicians we should keep an open mind and wide differential diagnosis so as not to miss the rarer reasons for these presentations.

Hashimoto encephalopathy: literature review

Hashimoto encephalopathy (HE) presents as an encephalopathy without central nervous system infection or tumor. HE is associated with autoimmune thyroiditis and is thus considered to be an autoimmune disorder. The prevalence of HE is low, but death and status epilepticus have been reported. HE manifests with a wide range of symptoms that include behavioral changes and confusion. Elevated thyroid antibodies are present in the majority of cases and are required for the diagnosis of HE. Normal brain MRI findings are found in the majority of patients diagnosed with HE. The most consistent CSF abnormality noted in HE patients is the presence of elevated protein. Most HE patients respond well to steroid therapy. Clinical improvements are also observed with IV immunoglobulin and plasmapheresis. In conclusion, it is now generally accepted that the diagnosis of HE must include encephalopathy characterized by cognitive impairment associated with psychiatric features, such as hallucinations, delusions, and paranoia. Autoimmune encephalitis and prion disease should be considered in the differential diagnosis due to the similarity of the clinical features of these conditions to those of HE.

Hashimoto's encephalopathy: A rare proteiform disorder

Hashimoto's encephalopathy (HE) is a rare not well understood, progressive and relapsing multiform disease, characterized by seizures, movement disorders, subacute cognitive dysfunction, psychiatric symptoms and responsiveness to steroid therapy. The disorder is generally associated with thyroid diseases and the most common feature is the presence of anti-thyroperoxidase antibodies (TPOAb). Patients are usually euthyroid or mildly hypothyroid at presentation. All age groups can be affected. The pathophysiology is still unclear, especially the link between elevated serum TPOAb and the encephalopathy. Most reported cases occurred in women and girls. Unspecific symptoms, non-pathognomonic laboratory neurophysiology and neuroimaging features make its diagnosis a real challenge for clinicians. The case of a 16 year old boy, with a clinical picture of HE associated with hypothyroidism, demonstrating an excellent response to high dose steroids is presented together with a systematic review of the literature.

Imaging of prion diseases

Prion diseases are caused by self-replicating proteins that induce lethal neurodegenerative disorders. In the last decade, the understanding of the different clinical, pathological, and neuroimaging phenotypes of this group of disorders has evolved paralleling the advances in prion molecular biology. From an imaging standpoint, the implementation of diffusion-weighted imaging in routine practice has markedly facilitated the detection of prion diseases, especially Creutzfeldt-Jakob. Less frequent prion-related disorders, including genetic diseases, may also benefit from progresses in the field of quantitative diffusion-weighted imaging, MR spectroscopy or molecular imaging. Herein, we present a review of the neuroimaging features of the prion disorders known to affect humans emphasizing the important contribution of MRI in the diagnosis of this group of disorders.

Cerebrospinal fluid biomarkers in human prion diseases

Cerebrospinal fluid (CSF) is the main component of the brain extracellular space and participates in the exchange of many biochemical products in the CNS. Consequently, CSF contains a dynamic and complex mixture of proteins that reflect the physiological or pathological state of the CNS. Changes in the CSF proteome have been described in various neurodegenerative disorders. These alterations are also thought to reflect pathological changes in the brain, and thus understanding them will contribute to a better awareness of the pathophysiology that underlies these disorders. Proteomics offers a new methodology for the analysis of pathological changes and mechanisms occurring in neurodegenerative processes and provides the possibility of novel biomarker discovery in order to supplement faster, earlier and more precise diagnosis. In general, the following criteria have to be applied in order to qualify a protein or a gene as a potential biomarker: the selected parameters have to be sensitive (able to detect the abnormalities at early stage of disease), specific (to allow differential diagnosis), reproducible with a high positive predictive value, and should allow for disease monitoring as well as a potential therapeutic response. In Creutzfeldt–Jakob disease, two major approaches have been followed that aim to detect the pathological form of the prion protein (PrPSc) in various peripheral tissues, while other approaches look for surrogate parameters that are a consequence of the neurodegenerative process. While the amount of abnormal disease-related PrPSc in CSF and blood in human transmissible spongiform encephalopathies appears to be extremely low, the development of a PrPSc-based biomarker was hampered by technical problems and detection limits. However, a variety of other proteins have been investigated in the CSF, and recently a variety of potential biomarkers have been reported that contribute to clinical diagnosis. Already established markers are 14-3-3, β-amyloid, tau-protein and phosphorylated isoforms, S100b, as well as neuron-specific enolase. Since some of these markers display certain limitations, the search continues. This review summarizes current knowledge of biomarker development in prion diseases and discusses perspectives for new approaches.

Autoimmune Encephalopathies

BACKGROUND

Evaluation of patients with recent onset of progressive cognitive and behavioral problems can be challenging. Psychiatric disorders, metabolic derangements, toxins and infections are generally considered in the differential diagnosis along with prion disorders (Creutzfeldt-Jakob disease) and rapidly progressive degenerative dementias. Some subacute encephalopathies are caused by autoimmune or inflammatory mechanisms, recognized by the association with autoantibody markers and/or clear response to immunomodulatory treatment. This review describes the clinical features of these potentially reversible autoimmune encephalopathies.

REVIEW SUMMARY

Morvan syndrome, paraneoplastic limbic encephalitis (PLE), and nonparaneoplastic autoimmune limbic encephalitis have characteristic clinical and serological features. Limbic encephalitis is characterized by short-term memory impairment, complex partial temporal lobe seizures and psychiatric symptoms. Signal abnormalities in the mesial temporal lobes without contrast enhancement are the typical MRI findings. Morvan syndrome presents with behavioral changes, hallucinations, severe insomnia, autonomic hyperactivity and neuromyotonia (spontaneous muscle activity). Corticosteroid-responsive encephalopathy associated with evidence of thyroid autoimmunity (sometimes called Hashimoto encephalopathy) has a broad range of clinical presentation. Cognitive impairment with tremor, seizures, stroke-like events (including transient aphasia) and normal thyroid hormone levels is a common scenario. In the absence of diagnostic serological findings, clinical improvement with corticosteroids may be the only evidence of autoimmune encephalopathy.

CONCLUSIONS

Autoimmune encephalopathies are an important cause of rapidly progressive cognitive and behavioral decline that probably remain under recognized. Electroencephalography, brain MRI, cerebrospinal fluid examination and serological tests are useful diagnostic tools. With increased clinical suspicion, these diseases may be diagnosed and treated successfully.

Fulminant Lewy body disease

The clinical distinction between Parkinson's disease (PD) with dementia (PDD) and dementia with Lewy bodies (DLB) is challenged by most neuropathological studies showing nearly identical changes in both conditions. We report an unusual case of PD evolving into a rapidly progressive dementia leading to death within 3 months that showed nearly all clinical features of DLB. At autopsy, numerous Lewy bodies and Lewy neurites were found in several areas of the brainstem, the limbic system, and the neocortex, consistent with pure DLB. This case demonstrates that Lewy body disease may exhibit a dramatic course without any coexisting pathology and exemplifies that PD, PDD, and DLB may sometimes represent sequential, yet overlapping, phenotypes of a same clinicopathological entity.

Anti-GAD antibody cerebellar ataxia mimicking Creutzfeldt–Jakob disease

In a patient with a rapidly progressive neurological condition with ataxia and cognitive complaints, Creutzfeldt-Jakob disease (CJD) is often high in the differential, particularly when there is an elevated CSF 14-3-3 protein level. We present a case of anti-glutamic acid decarboxylase antibody (anti-GAD65) positive cerebellar ataxia associated with cognitive complaints and elevated CSF 14-3-3 protein.

The neurological disorder associated with thyroid autoimmunity

The neurological disorder associated with thyroid autoimmunity is an elusive disease that neurologists have learned to recognize in the last few years. The diagnosis is made, after excluding more common diseases, when neuropsychiatric symptoms develop in a patient with high serum concentrations of anti-thyroid antibodies. The clinical presentations of the disease and the many controversial issues surrounding the diagnosis, the pathogenesis, the role of thyroid autoantibodies, and the choice of therapy are reviewed and discussed in the light of the medical literature in English.

Clinical and diagnostic aspects of encephalopathy associated with autoimmune thyroid disease (or Hashimoto's encephalopathy)

Encephalopathy associated with autoimmune thyroid disease, currently known as Hashimoto's encephalopathy, but also defined as corticosteroid-responsive encephalopathy associated with autoimmune thyroiditis, is a relatively rare condition observed in a small percentage of patients presenting with autoimmune thyroid disease. It consists of a subacute, relapsing-remitting, steroid-responsive encephalopathy characterised by protean neurologic and neuropsychiatric symptoms, diffuse electroencephalographic abnormalities and increased titres of antithyroid antibodies in serum and/or in cerebrospinal fluid. Most of the cases presenting this neurologic complication are affected by Hashimoto's thyroiditis or, less frequently, by other autoimmune thyroid diseases, chiefly Graves' disease. The pathogenesis of this encephalopathy is still unknown and largely debated, because of extremely varied clinical presentation, possibly referable to different aetiologic and pathophysiologic mechanisms, as confirmed by the two clinical cases we report in this paper. Autoimmune aetiology is, however, very likely in view of the well established favourable response to corticosteroid administration. Both vasculitis and autoimmunity directed against common brain-thyroid antigens represent the most probable aetiologic pathways. Clinical manifestations include consciousness changes, neurologic diffuse or focal signs, headache, and altered cognitive function. Although unspecific, cerebral oedema has also been described. Cerebrospinal fluid examination often discloses an inflammatory process, with a mild increase in protein content and occasionally in lymphocyte count. In this review, clinical criteria for the diagnosis of defined, probable, or possible encephalopathy associated with autoimmune thyroid disease are suggested. Corticosteroid therapy currently allows us to obtain rapid remission of disease symptoms, but adverse outcomes as well as spontaneous remissions have also been reported.

Cerebrospinal fluid biomarkers in Creutzfeldt–Jakob disease

Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative disorder. Since the emergence of variant CJD (vCJD) vigilance concerning the disease's incidence has increased and the interest in accurate in vivo diagnosis has augmented. So far, a large number of biomarkers has been investigated as aid in the differential diagnosis of sporadic Creutzfeldt-Jakob disease (sCJD) and vCJD. These include, among others, neuron-specific enolase (NSE), microtubuli associated protein Tau, S-100beta, amyloid-beta (Abeta(1-42)) and the 14-3-3 protein. Multiple studies have confirmed that CSF detection of 14-3-3 protein by Western blot was the best single biomarker for sCJD with an average sensitivity and specificity of 92%. Also, in genetic and iatrogenic CJD (iCJD) patients with an average disease duration of less than 1 year, 14-3-3 is the best differential biomarker. Unfortunately, the 14-3-3 protein has a lower sensitivity if the disease duration exceeds beyond 1 year in both sporadic CJD and other CJD types (vCJD, and specific genetic or iatrogenic CJD types).

Hashimoto's encephalopathy: myth or reality? An endocrinologist's perspective

Since the first description of a case of episodic encephalopathy associated with Hashimoto's thyroiditis in 1966, many cases of corticosteroid-responsive encephalopathy associated with positive antithyroid antibodies, clinical Hashimoto's thyroiditis, or spontaneous autoimmune thyroid failure have been reported. These patients have neurologic manifestations of encephalopathy unrelated to other known causes. The condition has thus been termed 'Hashimoto's encephalopathy'. The literature shows no proven association between thyroid disease and the neurologic process. Although the association of a common endocrinologic condition and a rare neurologic disease may occur by chance, this type of encephalopathy probably has an autoimmune nature and thus is more likely to occur in the background of another autoimmune condition such as autoimmune thyroid disease. Until the pathogenesis of these coincident conditions is better defined, the term 'corticosteroid-responsive encephalopathy associated with autoimmune thyroiditis' is more accurate and descriptive than Hashimoto's encephalopathy. Advances in the field may clarify this seemingly inconsistent terminology.

14-3-3 proteins in Lewy body-like hyaline inclusions in patients with sporadic amyotrophic lateral sclerosis

14-3-3 proteins are highly conserved eukaryotic proteins that regulate various types of signal transduction pathways through phosphorylation-dependent protein-protein interactions. 14-3-3 mRNAs have been shown to be up-regulated in the injured rat motor neurons and in the spinal cords of patients with amyotrophic lateral sclerosis (ALS). To investigate the role of 14-3-3 proteins in ALS, we performed immunohistochemical studies on 14-3-3 using autopsied spinal cords from patients with sporadic ALS (sALS) and non-ALS subjects without spinal cord involvement. In the anterior horn of both groups, strong 14-3-3 immunoreactivity was observed in the somata and proximal processes of motor neurons. Many spheroids from all of the sALS cases were also immunopositive for 14-3-3. In addition, Lewy body-like hyaline inclusions (LBHIs), which were present in some sALS cases, were intensely immunostained. Our findings suggest that even in the severely affected anterior horn of patients with sALS, remaining motor neurons may contain abundant 14-3-3 proteins, and that 14-3-3 proteins may be partly associated with the pathogenesis of sALS, in particular with the formation of LBHIs.

Hashimoto Encephalopathy (Autoimmune Encephalitis)

Patients with Hashimoto thyroiditis may have neurologic manifestations that have been described in the literature for some decades now; these include psychiatric disorders, abnormal movements, and simulation of cerebrovascular events. Nuclear magnetic resonance (MRI) studies have revealed diffuse leukoencephalopathy in most cases. We describe a case having clinical manifestations simulating cerebrovascular events, together with cognitive alterations (a presentation already described in other patients). Among the 2 main forms of neurologic manifestations, the cognitive type, which is probably associated with endocrinologic alteration, may improve with hormone supplement. Those alterations simulating cerebrovascular events are most probably related to autoimmune vasculitis. The latter may improve with the administration of corticosteroids, which are proposed as treatment of this disorder.

Hashimoto's encephalopathy: an unusual cause of seizures in the intensive care unit

OBJECTIVE

To present a case study of Hashimoto's encephalopathy.

DESIGN

Case report.

SETTING

Paediatric Intensive Care Unit, Nottingham University Hospital, UK.

PATIENTS

Two adolescent females presented with encephalopathy and raised venous lactate. Both had subtle signs of neurocognitive deterioration before initial presentation. Extensive investigation revealed elevated antithyroid antibody titer, suggesting Hashimoto's encephalopathy.

INTERVENTIONS

Steroid administration.

MEASUREMENTS AND MAIN RESULTS

Symptoms rapidly resolved in both cases after steroid treatment.

CONCLUSION

Hashimoto's encephalopathy should be considered in cases of unexplained encephalopathy presenting to the intensive care unit. Teenage girls with an antecedent history suggestive of thyroid disease or progressive cognitive decline warrant special attention. Antithyroid antibody titers should be measured even if standard thyroid function tests are normal. Although the etiology is unknown, prompt steroid responsiveness suggests an inflammatory or autoimmune disorder, and patients should be treated accordingly.

Enhanced expression of 14-3-3 proteins in reactive astrocytes in Creutzfeldt-Jakob disease brains

14-3-3 proteins have been reported to be detected specifically in the cerebrospinal fluid (CSF) from patients with Creutzfeldt-Jakob disease (CJD). To elucidate the role of 14-3-3 proteins in patients with CJD, we performed immunohistochemical studies on 14-3-3 proteins in autopsied brains from five patients with sporadic CJD (sCJD), three patients with Alzheimer's disease (AD), and seven normal control subjects. Formalin-fixed, paraffin-embedded sections from all cases were immunostained with several types of specific anti-14-3-3 antibodies. In the normal control brains, 14-3-3 immunoreactivity was localized mainly in the neuronal somata and processes; in contrast, glial cells showed no or faint immunoreactivity. In the brains from the patients with AD, 14-3-3 immunoreactivity was observed in the surviving neurons as well as some neurofibrillary tangles. In the brains from the patients with sCJD, 14-3-3 immunoreactivity was well preserved in the remaining neurons. Furthermore, the glial cells, especially the reactive astrocytes, were intensely immunostained in the brains affected by sCJD. Our findings suggest that 14-3-3 proteins may be up-regulated in the glial cells, particularly in reactive astrocytes, and that the enhanced expression of 14-3-3 proteins in these glial elements may be associated with the pathogenesis of sCJD.

Progressive dementia caused by Hashimoto's encephalopathy - report of two cases

Dementia induced by Hashimoto's encephalopathy (HE) seems to be a rare condition. We report on two patients, who revealed a syndrome consisting of a rapid progressive dementia with myocloni. In both patients, the detection of antithyroid antibodies enabled the diagnosis of HE. The symptoms receded completely during a high-dose glucocorticoid therapy. In patients with rapidly progressive dementia or with dementia of unknown origin, HE should be considered.

Immunoglobulins in urine of hamsters with scrapie

In the prion diseases, a prolonged, asymptomatic incubation period precedes the onset of neurologic dysfunction. At present, a noninvasive test is not available for the presymptomatic diagnosis of prion disease, and thus the report of a test for prions using urine has been of great interest (Shaked, G. M., Shaked, Y., Kariv-Inbal, Z., Halimi, M., Avraham, I., and Gabizon, R. (2001) J. Biol. Chem. 276, 31479-31482). Using Western immunoblots with the anti-prion protein (PrP) 3F4 monoclonal antibody and an anti-mouse IgG secondary antibody, a protease-resistant PrP was reported in the urine of Syrian hamsters and humans with prion disease. Here we have demonstrated that this purportedly "protease-resistant PrP" band in the urine of diseased hamsters is detectable using the anti-mouse IgG secondary antibody in the absence of the 3F4 monoclonal antibody. Mass spectrometric analysis identified an immunoglobulin light chain in the band but found no PrP peptides. No similar band was found in the urine of uninfected hamsters or in brain homogenates from normal or prion-infected hamsters. Moreover, the band in the urine of infected hamsters was not detected using two chimeric human-mouse recombinant anti-PrP antibody fragments followed by an anti-human IgG secondary antibody. Our results indicate that the band detected under previously published conditions is due to the cross-reactivity of the anti-mouse IgG antibody with IgG light chains and possibly heavy chain fragments in urine, but not with PrP.

Detection of the 14-3-3 protein in the cerebrospinal fluid of Japanese multiple sclerosis patients presenting with severe myelitis

Recent studies showed that the 14-3-3 protein is detectable in the cerebrospinal fluid (CSF) of prion-unrelated neurological diseases, such as meningoencephalitis and myelitis. To investigate the possible association between the amounts of the 14-3-3 protein in the CSF and the clinical severity of multiple sclerosis (MS), its levels were determined by Western blot in the CSF of the patients with relapsing-remitting MS (RRMS) (n=10), secondary progressive MS (SPMS) (n=7), primary progressive MS (PPMS) (n=2), and non-MS inflammatory diseases of the CNS (n=5). The 14-3-3 protein was identified in seven CSF samples, including four patients with SPMS in acute relapse, one with SPMS in remission accompanied by fresh cerebral infarction, one with RRMS in acute relapse, and one with human T-lymphotropic virus type I (HTLV-I)-associated myelopathy. The patients positive for the CSF 14-3-3 protein immunoreactivity showed more severe disability and higher levels of pleocytosis, protein, IgG, beta2-microglobulin, and neuron-specific enolase in the CSF, compared with those negative for its immunoreactivity. Four of these patients exhibited extensive lesions distributed along multiple vertebral segments in the spinal cord on MRI. In contrast, none of the MS patients without an extensive involvement of the spinal cord showed the CSF 14-3-3 protein immunoreactivity. These results suggest that detection of the 14-3-3 protein in the CSF provides a marker for severe inflammation-induced extensive damage of the central nervous system tissues responsible for poor therapeutic responses and irreversible neurological deficits in MS.

Hashimoto's encephalopathy in the elderly: relationship to cognitive impairment

Hashimoto's encephalopathy (HE) is a steroid-responsive encephalopathy associated with high titers of antithyroid antibodies. To date, 57 pediatric-, adult-, and elderly-onset cases have been described in the literature. The clinical picture is pleomorphic, and cognitive impairment is a frequently reported symptom. We report the case of a patient with slowly progressive cognitive impairment possibly caused by HE. The issue of the differential diagnosis with primary dementia is discussed. A review of cases of HE showing cognitive deterioration is also presented, and factors possibly related to characteristics of cognitive impairment and outcome after therapy are considered.

EEG findings in steroid-responsive encephalopathy associated with autoimmune thyroiditis

OBJECTIVE

To analyze the electroencephalogram (EEG) findings of patients with steroid-responsive encephalopathy associated with autoimmune (Hashimoto) thyroiditis.

METHODS

We reviewed 51 EEGs and the clinical records of 17 patients (5 men and 12 women, 27-84 years old).

RESULTS

All patients had mild to severe generalized slowing on the EEG which corresponded to the clinical severity of the underlying encephalopathy. Other findings included triphasic waves, epileptiform abnormalities, photomyogenic response, and photoparoxysmal response. Follow-up EEGs of 13 patients showed slowing in 7 and a return to normal in 6. Myoclonic jerks were recorded during the EEG study of 8 patients but did not have an EEG correlate. The EEG and clinical condition improved after treatment with corticosteroids. When encephalopathy recurred, the EEG showed corresponding abnormalities.

CONCLUSIONS

EEG findings in steroid-responsive encephalopathy associated with autoimmune thyroiditis consist mainly of slow wave abnormalities that reflect the degree of severity of the underlying encephalopathy. The EEG findings often paralleled the course of the disease, showing improvement with improvement in the clinical condition and worsening with recurrence of symptoms.

SIGNIFICANCE

The EEG is helpful in evaluating and following patients with steroid-responsive encephalopathy associated with autoimmune thyroiditis in reflecting the degree of central nervous system (CNS) involvement, in determining whether their condition is better or worse, and in ruling out other causes of encephalopathy.

Subacute cerebellar syndrome and Hashimoto's thyroiditis. Association or simple coincidence?

Numerous neurological symptoms have been observed in thyroid autoimmune disorders. The case of a 47-year-old euthyroid woman who develops a cerebellar syndrome associated with thyroiditis is discussed. Reference is made to the favorable outcome of combined per os thyroxine, corticosteroid and intravenous human normal immunoglobulin (Sandoglobulin) treatment.

[Creutzfeldt-Jakob disease: case report with spinal cord involvement]

Creutzfeldt-Jakob disease (CJD) is the most common subacute transmissible spongiform encephalopathy. Approximately 85% of the cases are sporadic. The remaining 15% consist of genetic and iatrogenic forms. We report a sporadic form of CJD with spinal cord involvement and a clinical manifestation characterized by dementia and cerebellar syndrome, myofasciculation with absent reflexes and seizures. The two last manifestations are rare. The clinical hypothesis was probable CJD which was confirmed with autopsy and immunohistochemistry. We conclude that CJD should always be suspected when rapidly progressive dementia occurs and the absence of pyramidal or extrapyramidal signs suggest a spinal cord and/or peripheral nerve involvement.

Use of 14-3-3 and other brain-specific proteins in CSF in the diagnosis of variant Creutzfeldt-Jakob disease

OBJECTIVES

The detection of the protein 14-3-3 in the CSF has been shown to be a reliable and sensitive marker for sporadic Creutzfeldt-Jakob disease (CJD). Other brain-specific proteins such as neuron specific enolase (NSE), S-100b, and tau protein have also been reported to be increased in the CSF of patients with sporadic CJD. In 1996 a variant of CJD (vCJD) was described which is likely to be causally linked to the bovine spongiform encephalopathy agent. This study reports and compares the findings of CSF brain specific protein analysis in 45 patients with vCJD and in 34 control patients.

METHODS

The CSF from 45 patients with vCJD and 34 controls were investigated for the presence of 14-3-3 by SDS-polyacrylamide gel electrophoresis (SDS-PAGE) and western blotting with chemiluminescent detection. Tau protein, S-100b, and NSE concentrations in CSF were measured using enzyme immunoassays.

RESULTS

Protein 14-3-3 was detected in the CSF of 22/45 patients with vCJD and in 3/34 controls. The mean concentrations of NSE, S-100b, and tau protein in CSF were significantly raised in patients with vCJD compared with controls. The positive predictive value of CSF 14-3-3 was 86% and the negative predictive value was 63%. These values are lower than those reported for sporadic CJD. An increased CSF tau had a positive predictive value of 93% and a negative predictive value of 81%. The combination of CSF 14-3-3 and/or increased CSF tau had a positive predictive value of 91% and a negative predictive value of 84%.

CONCLUSIONS

CSF protein 14-3-3 is not as useful a marker for vCJD as it is for sporadic CJD. Increased concentration of CSF tau was found to be a sensitive marker of vCJD but as concentrations may be increased in many forms of non-CJD dementia, this may limit its usefulness as a diagnostic test.