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Tonsillar material from patients with new variant CreutzfeldtJakob disease ( mad cow disease ) stains with antibodies against abnormal prion protein, but this technique does not appear to be applicable to the early diagnosis of the sporadic disease (Hill) Whether the above mentioned nding of infectious prion material in the nasal mucosa will prove to have practical value in diagnosis is yet to be determined The National Prion Disease Pathology Surveillance Center which has been established at Case Western Reserve University is available to assist clinicians by performing, free of charge, a variety of diagnostic tests (http://wwwcjdsurveillancecom) Pathology The disease affects principally the cerebral and cerebellar cortices, generally in a diffuse fashion, although in some cases the occipitoparietal regions are almost exclusively involved, as in those described by Heidenhain In others, such as the cases of Brownell and Oppenheimer, the cerebellum has been most extensively affected, with early and prominent ataxia The degeneration and disappearance of nerve cells is associated with extensive astroglial proliferation; ultrastructural studies have shown that the microscopic vacuoles, which give the tissue its typically spongy appearance, are located within the cytoplasmic processes of glial cells and dendrites of nerve cells The loss in particular of certain inhibitory neurons in the thalamic reticular nuclei corresponds to the presence of myoclonus and positive sharp waves in the EEG, according to Tschampa and colleagues Despite the fact that the disease is due to a transmissible agent, the lesions show no evidence of an in ammatory reaction and no viral particles are seen Differential Diagnosis The diagnosis of most cases of SSE presents no dif culty Not infrequently, however, we have been surprised by a typical case that proves to be some other disease Lithium intoxication, Hashimoto encephalopathy (as emphasized by Seipelt who found a number of cases in an epidemiologic survey of SSE (page 978), Whipple disease (page 603), intravascular lymphoma, carcinomatous meningitis all of them characterized by myoclonus and dementia may mimic SSE in the early weeks of illness Contrariwise, the early mental changes of SSE may be.

Figure 33-5 A MRI showing T2 signal changes in the lenticular nuclei in a patient with Creutzfeldt-Jakob disease of 1 month s duration B Diffusion-weighted imaging sequence of cortical signal change in an early case

04-06-2005

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fects (more so in children than in adults) with the anticholinergic agents trihexyphenidyl (Artane) and ethopropazine (Parsidol) given in massive doses which are achieved by increasing the dosage very gradually The drug-induced tardive dyskinesias require specialized treatment, as described in Chaps 6 and 42 Reinstitution of the offending drug or anticholinergic agents is often tried Tetrabenazine, a centrally active monoamine-depleting agent, is effective but not easily available The acute dystonic drug reactions are treated as noted above In the focal dystonias, the most effective treatment has proved to be the periodic injection of botulinum toxin into the affected muscles Stereotactic surgery on the pallidum and ventrolateral thalamus has given rather unpredictable results, but in recent years there has been a renewed interest in this form of treatment (see page 91) Paroxysmal Choreoathetosis and Dystonia Under the names paroxysmal kinesigenic dyskinesia, familial paroxysmal choreoathetosis, and periodic dystonia, among others, there has been described an uncommon sporadic or familial disorder characterized by paroxysmal attacks of choreoathetotic movements or dystonic spasms of the limbs and trunk Both children and young adults are affected There are three main forms of familial paroxysmal choreoathetosis One, which has an autosomal dominant (less often recessive) pattern of inheritance and a tendency to affect males, has an onset in adolescence or earlier It is characterized by numerous brief (less than minutes) attacks of choreoathetosis provoked by startle, sudden movement, or hyperventilation hence the title paroxysmal kinesigenic choreoathetosis There may be many dozens of attacks per day or occasional ones This disorder responds well to anticonvulsant medication, particularly to phenytoin and carbamazepine In other families, such as those originally described by Mount and Reback and subsequently by Lance and by Plant et al, the attacks take the form of persistent (5 min to 4 h) dystonic spasms and have reportedly been precipitated by the ingestion of alcohol or coffee or by fatigue but not by movement per se (nonkinesigenic type) The attacks may be predominantly one-sided or bilateral This form of the disease is inherited as an autosomal dominant trait; a few families have displayed diplopia and spasticity and others have shown a familial tendency to infantile convulsions (each of these types has a different gene locus) Attacks may occur every several days or be separated by years A favorable response to benzodiazepines (clonazepam) has been reported, even when the drug is given on alternate days (Kurlan and Shoulson) A third type, formerly thought to be a variant of the MountReback type mentioned above, is precipitated by prolonged exercise and has a separate gene locus In addition to a response to benzodiazepines, it has the unique characteristic of improving with acetazolamide Because of their paroxysmal nature and the response (of the kinesigenic type) to anticonvulsant drugs, these familial disorders had been thought to represent seizures originating in the basal ganglia Whether the conventional notions of synchronous neuronal activity generating a seizure are even applicable to the basal ganglia seems doubtful to us Consciousness is not lost and the electroencephalogram is normal, even when recorded during an attack of choreoathetosis, arguing against an epileptic discharge in any case More common than these familial dyskinesias are sporadic cases and those secondary to focal brain lesions, such as the ones reported by Demirkirian and Jankovic They classify the paroxys-.

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