Grand-round meeting for Dementia - A patient with rapidly progressing dementia. Dr. Ho Ka Shing Tuen Mun Hospital

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1 Grand-round meeting for Dementia - A patient with rapidly progressing dementia Dr. Ho Ka Shing Tuen Mun Hospital

2 Mr. Wong, 60 years old Security guard Ex-smoker for over 20 years, non-drinker Premorbid walked unaided and independent in all his daily living activities Good past health No regular medication

3 History of illness Mr. Wong frequently forgot his shift duty since 5/2014 Poor short and long term memory, reduced spontaneous speech Admission in 6/2014 Routine blood tests and blood tests for dementia screening were all unremarkable Plain CT brain and contrast MRI brain were reported normal EEG reviewed excessive slow wave MMSE 20/30 with marks lost in orientation and attention (primary education level) Modified Barthel index 98/100 Opinion from psychiatrist : pre-senile dementia

4 History of illness 2 months after onset of memory problem, abnormal behaviour was noted Self-muttering, irrelevant speech Agitation, violent behaviour? Visual hallucination His self-caring abilities rapidly declined and required help in dressing, toileting and bathing There was no fever all along Mr. Wong was being admitted again in 7/2014 for further investigations

5 Physical examination on admission Cheerful with social smile Answered simple questions with poverty of speech Cranial nerves were grossly intact. Limbs power were full with mild hypertonicity and hyperreflexeia. Bilaterally up-going plantar. Not follow instruction for cerebellar signs Occasional myoclonic jerks and startle myoclonus were detected Fontal release signs were absence

6 Interview with Mr. Wong

7 Gait assessment

8 Global decline Required frame for walking with fair stability and tendency to lean backward MMSE 20/30 (6/2014) 4/30 (7/2014) Modified Barthel index 98/100 (6/2014) 31/100 (7/2014)

9 CXR

10 CT brain plain

11 Routine blood test unremarkable again (ESR 26 only, ANA negative) Urine toxicology : unremarkable Lumbar puncture : clear cerebrospinal fluid with normal opening pressure White cell count < 1 Protein 0.81g/dL (RBC < 1) Glucose 4.2mmol/L (serum glucose 5.2mmol/L) Gram stain, bacterial culture, acid fast bacillus smear and culture, viral titre were all negative, Venereal Disease Research Laboratory for syphilis was nonreactive. Cryptococcal antigen negative No malignant cells were detected

12 Short summary of symptoms Subacute onset, rapidly deteriorating cognitive and executive function Atypical features for Alzheimer disease Relatively short deterioration time Presence of myoclonus Early involvement of language ability Early involvement of walking ability Early development of psychotic symptoms

13 Differential diagnosis Creutzfeldt Jakob disease Antibody mediated encephalitis Paraneoplastic limbic encephalitis, anti-nmda receptor encephalitis Voltage gated potassium channel associated limbic encephalitis Lung cancer with brain metastasis HIV associated dementia Subacute sclerosing panencephalitis Hashimoto s encephalitis

14 Differential diagnosis Pros Against Creutzfeldt Jakob disease Paraneoplastic limbic encephalitis Voltage gated potassium channel associated limbic encephalitis Subacute sclerosing panencephalitis Rapid cognitive decline Myoclonus Suspicious lung shadow No mass in MRI brain Initial memory problem Rapid cognitive decline Initial memory problem Rapid cognitive decline Myoclonus No history of stay in Europe No history of brain surgery No pleocytosis in CSF Raised protein in CSF No seizure Not typical age HIV associated dementia Neuropsychiatric symtpoms Early cortical signs Normal cell count Lung cancer with brain metastasis Hashimoto s encephalitis Ex-smoker Suspicious lung shadow Neuropsychiatric symptoms Myoclonus No mass / vasogenic edema in MRI brain No pleocytosis in CSF Not typical age No fluctuation No seizure Diagnosis by exclusion

15 Differential diagnosis Creutzfeldt Jakob disease Born in Guangdong province, no history of stay in Europe, no history of surgery, blood product transfusion, hormonal replacement, no family history of CJD Paraneoplastic limbic encephalitis Tumor markers and paraneoplastic antibodies levels were within suggested limits, but up to 40% of paraneoplastic limbic encephalitis cases have no detectable antibodies with current testing 1 Contrast CT thorax / abdomen / pelvis : no suspicious mass, but discovery of the underlying malignancy frequently postdates the neurology, sometimes by several years Voltage gated potassium channel associated limbic encephalitis Anti-VGKC titre (? Not a/v in HK) Lung cancer with brain metastasis Contrast CT thorax : a large calcified granuloma near left hilar region. Contrast MRI brain with diffuse weighted imaging : no focal lesion. HIV associated dementia Anti-HIV negative Subacute sclerosing panencephalitis cerebrospinal fluid anti-measles IgG titre was low Harshimoto encephalitis anti-thyroid antibodies were negative 1. Schott J. Limbic encephalitis: a clinician s guide. Pract Neurol 2006;6:143 53

16 Serial EEG 6/2014 Right Left Triphasic waveform 1 2 3

17 Serial EEG 7/2014 Right Left Triphasic waveform 1 2 3

18 Serial EEG 9/6/ /7/ /8/2014

19 EEG

20 Progression in MRI brain in 2 months 6/2014 7/2014

21 Mr Wong was diagnosed to have probable Creutzfeldt Jakob disease (progressive dementia, myoclonus, akinetic mutism, visual hallucination, typical EEG pattern) Cerebrospinal fluid for protein was not checked as its results did not further alter diagnosis or management.

22 Creutzfeldt-Jakob disease (CJD) - transmissible spongiform encephalopathy Dr. Hans Gerhard Creutzfeldt Dr. Alfons Maria Jakob Freely adapted from and

23 85-90% 5-10% >5% ~170 cases from Freely adapted from 2. World Health Organization. Fact sheets: Variant Creutzfeldt-Jakob disease. 2002

24 ~70% present CSF protein ~90% present Not elevated Prion protein in lymphoid tissue Modified from World Health Organization. WHO manual for surveillance of human transmissible spongiform encephalopathies including variant Creutzfeldt-Jakob disease, World Health Organization. The Revision of the Surveillance Case Definition for Variant Creutzfeldt-Jakob disease (vcjd), 2001

25 CJD in Hong Kong The mean annual incidence from was estimated to be 0.6 per million population (US: 1 per million, Canada: 1.11 per million, UK: 1.11 per million) CJD surveillance has been established by the Department of Health since 4/1996 and became a statutory notifiable disease since 7/2008 The survival duration ranged from 23 days to 1418 days (median 226 days), while 93% died within 2 years from symptom onset Tsoi G., Review of Creutzfeldt-Jakob disease in Hong Kong, Centre for Health Protection, Communicable Diseases Watch, 2012, 9: 26

26 Diagnosis of Sporadic CJD World Health Organization. WHO manual for surveillance of human transmissible spongiform encephalopathies including variant Creutzfeldt-Jakob disease, 2003.

27 Diagnostic value of EEG Triphasic waveform Periodic, triphasic sharp wave complexes at a frequency of 1 Hz, usually generalised throughout the trace Sensitivity about 65% and specificity about 80% 1 Lacks sensitivity in the early stages of scjd False positive EEGs are recognised in Alzheimer s disease, Lewy body dementia, vascular dementia and lithium toxicity Steinhoff BJ et al. Accuracy and reliability of periodic sharp wave complexes in Creutzfeldt Jakob disease. Arch Neurol 1996;53:162 6

28 Diagnostic value of MRI Typical features for scjd hyperintensity of the putamen and caudate head Cortical hyperintensity Both sensitivity and specificity based on either changes in at least two areas is up to 80%? WHO diagnostic criteria 1. Zerr I et al. Updated clinical diagnostic criteria for sporadic Creutzfeldt Jakob disease. Brain 2009; 132:

29 Diagnostic value of CSF protein Sensitivity of 90 97% and specificity of % in patients with suspected scjd referred to a CJD surveillance unit 1 Confirmed scjd cases with a normal are often clinically and pathologically atypical, with a younger age of onset and prolonged disease duration False positive results occur with acute neuronal damage 1. Collins S et al. Creutzfeldt Jakob disease: diagnostic utility of protein immunodetection in cerebrospinal fluid. J Clin Neurosci 2000;7:203 8.

30 Caring plan for Mr. Wong Disease nature of rapid deterioration and supportive treatment plan explained to wife and children through repeated family meeting Advanced care planning was discussed : for Ryle tube feeding when patient was not fit for oral feeding for comfort care and not for cardiopulmonary resuscitation or intubation if patient develops arrest. Relatives preferred placement rather than home care Department of Health and infective control nurse were notified Universal precaution

31 Progess of Mr. Wong Mr. Wong s general condition was rapidly deteriorating Became mute, bedridden more frequent aggressive behavior more prominent myoclonus refused oral intake and Ryle tube feeding was started in 8/2014 He developed pneumonia in late 8/2014 and succumbed at 3 months after symptoms onset Category II body Post-mortem examination was not done

32 Thank you Welcome for your questions

33 Variant CJD definition