Rapidly evolving Creutzfeldt–Jakob disease in COVID-19: from early status epilepticus to fatal outcome

SWAlexander

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Abstract
We report the case of a 70-year-old man coming to our attention for new onset refractory status epilepticus (NORSE) in a rapidly evolving CJD during SARS-CoV-2 co-infection. Our case report describes a fulminant CJD evolution associated with SARS-CoV-2 infection, which led to patient death after 15 days from admission. First EEG presented continuous diffuse spikes, sharp waves and sharp-and-slow wave complexes, pattern consistent with a non-convulsive status epilepticus (NORSE). Our case supports how CJD with SARS-CoV-2 co-infection could be characterized by an accelerated evolution, as already hypothesize for others microorganism infections, and how the diagnosis might be more challenging due to its uncommon presentations, such as NORSE.


Introduction
Creutzfeldt–Jakob Disease (CJD) may be challenging to diagnose, in particular in COVID-19 era [1]. Usually, the initial course of the disease is characterized by a subtle onset of psychiatric and neurological symptoms, with most of patients experiencing depression, anxiety, nervousness, autonomic disturbances, disruption of sleep–wakefulness rhythm, gait alterations, ataxia and myoclonus [2, 3]. Seizures are not a common manifestation in the first phase of the disease, and status epilepticus is rare, while still remaining possible [4]. Non-convulsive status epilepticus (NCSE) in patients with confusion may be difficult to differentiate from non-epileptic encephalopathies, potentially leading to a wrong diagnosis [5]. We report the case of a 70-year-old right-handed patient coming to our attention for new onset refractory status epilepticus (NORSE) in a rapidly evolving CJD during SARS-CoV-2 co-infection.

Case report
In the 40 days before the admission, the patient experienced non-specific ailment. The first complains were related to motor symptoms, including inability to sign, compromised coordination and paresis to the right leg. Owing to these initial symptoms, the patient was evaluated by a private practicing neurologist who prescribed a MRI scan, which reported no abnormalities. In the meantime, neurological symptoms rapidly worsened, including speech impairments, dystonia and myoclonus. Hence, the patient was admitted to the emergency department (ED). Neurological evaluation showed a mild right hemiparesis, non-fluent speech and bilateral myoclonus augmented by startle. A brain CT scan was performed, showing no acute alterations. Since the screening nasopharyngeal swab for SARS-CoV-2 previous to admission resulted positive, the patient was diverted to the COVID-19 ward. Comprehensive metabolic panel did not show abnormalities, while chest radiography showed mild bilateral interstitial pneumonia requiring low oxygen inspired fraction support. An EEG was performed, showing continuous diffuse spikes, sharp waves and sharp-and-slow wave complexes, pattern consistent with a non-convulsive status epilepticus (NORSE) (Fig. 1A). The patient was treated with 10 mg Diazepam e.v. with a complete resolution of the abnormal electric activity but without a clinical improvement (Fig. 1B). An antiepileptic therapy with Levetiracetam 3000 mg daily was started. The following day, EEG tracings showed the abnormal pattern previously recorded consistent with status epilepticus. Diagnosis of NORSE was made and an additional antiepileptic treatment with valproic acid 2400 mg daily was started, without clinical response. Based on the clinical history of a rapidly progressive dementia with epileptic seizures, a prion disorder or an autoimmune encephalitis were suspected and a lumbar puncture was performed. Standard CSF analysis showed only a mild glycorrhachia and further tested for autoimmune encephalitis, neurodegeneration markers and for RT-QuIC (Table 1). A trained neuroradiologist re-evaluated the first MRI scan and highlighted the presence of a diffuse cortical ribboning in DWI (Fig. 1C). An empirical therapy with high dose Methylprednisolone 1 g daily was started. In the following days, periodic triphasic complexes were observed at EEG consistent with the diagnosis of CJD (Fig. 1D). The clinical condition of the patient rapidly evolved into akinetic mutism and coma, leading to his death in two weeks. The RT-QuIC results confirmed the probable diagnosis of CJD.
https://link.springer.com/article/10.1007/s13760-022-02023-x
 

Violeta

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"In theory, CJD can be transmitted from an affected person to others, but only through an injection or consuming infected brain or nervous tissue. There's no evidence that sporadic CJD is spread through ordinary day-to-day contact with those affected or by airborne droplets, blood or sexual contact."

How would COVID cause this?

This is a medical journal from Belgium.
 
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"In theory, CJD can be transmitted from an affected person to others, but only through an injection or consuming infected brain or nervous tissue. There's no evidence that sporadic CJD is spread through ordinary day-to-day contact with those affected or by airborne droplets, blood or sexual contact."

How would COVID cause this?

This is a medical journal from Belgium.
I don't think the article sais Covid causes CJD, but accelerates its evolution. Most CJD cases don't have a known cause, but the protein folds itsself spontaneously into the prion-form.
With the constantly high numbers of Covid cases, I guess it was only a matter of time until the two fell together, statistically speaking.
 

Violeta

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I don't think the article sais Covid causes CJD, but accelerates its evolution. Most CJD cases don't have a known cause, but the protein folds itsself spontaneously into the prion-form.
With the constantly high numbers of Covid cases, I guess it was only a matter of time until the two fell together, statistically speaking.
Yes, you're right, it doesn't say COVID was the cause.
 

SNT Gatchaman

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Recent studies showed the role of SARS-CoV-2 in favoring the initiation of protein aggregation (including Aβ, α-synuclein, tau, prion, and TDP-43 RRM) leading to neurodegeneration and a link between neurodegeneration and cerebral inflammation.
There is evidence of (1) amyloid form fibrinogen, (2) amyloidogenesis via spike protein, (3) perivascular fibrinogen in the brains of COVID patients, (4) neuroinflammation induced by or relating to fibrinogen
  1. Amyloid fibrin(-ogen)
  2. Amyloidogenesis of SARS-CoV-2 Spike Protein
  3. Neurovascular injury with complement activation and inflammation in COVID-19
  4. Fibrinogen in neurological diseases: mechanisms, imaging and therapeutics
From #4 —

At the same time, fibrinogen binding to proteins such as latent transforming growth factor-β (TGFβ) or Aβ contributes to brain trauma and AD, respectively. Thus, fibrinogen is at the nexus of crosstalk between neurons and glia, the vasculature and immune cells and is a key molecular integrator of neurological, cerebrovascular and immune mechanisms of CNS injury and disease