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Case Report

Case Report: Creutzfeldt-Jakob disease and diagnosis challenges: case report and evidence synthesis

[version 1; peer review: 2 approved with reservations]
PUBLISHED 11 Apr 2025
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Abstract

Introduction

Prion diseases are mortal neurodegenerative disorders, which include Creutzfeldt-Jakob disease (CJD). Due to its heterogenous clinical presentation diagnosis uncertainties are common. In this paper we explore CJD diagnostic challenges focusing on differential diagnosis and diagnostic delays.

Methods

We report a case of a patient who was misclassified and evaluated by several medical specialties before the CJD suspicion. A systematic review of the literature of the CJD case reports focused on the timely and differential diagnosis was carried out in Medline and Embase until May 2023.

Results

Patient with diagnosis was made due to the form of presentation and clinical evolution, neuroimaging and the presence of protein 14-3-3. In systematic review, fifteen articles were selected, who reported 31 cases of CJD with problems in the timely diagnosis and incorrect initial diagnosis, the main initial differential diagnoses were psychiatry exacerbation, myelopathy, epilepsy, stroke, parkinsonism, cerebellar ataxia and autoimmune encephalitis. The most common clinical onset was psychobehavioral disturbances (apathy, confusion and sleep disturbance), extrapyramidal signs and cognitive impairment. The diagnosis delay was from one to eighteen months.

Conclusion

A discussion of the case report and the diagnostic challenges reported in the literature was made. Patients can present a wide range of symptoms. It is recommended to consider CJD for the differential diagnosis in patients with behavioral symptoms, and cognitive impairment.

Keywords

Creutzfeldt-Jakob syndrome; Prion diseases; differential diagnosis; behavioral symptoms; 14-3-3 Proteins; Peru

Introduction

Creutzfeldt-Jakob disease (CJD) is one of the main prion diseases, a neurodegenerative disorder with high mortality.1 The common pathological process is characterized by the conversion of the normal cellular prion protein (PrPc) to an insoluble anomalous form (PrPSc) that accumulates progressively in the brain, forming extracellular amyloid plaques.2

CJD is classified, according to the etiology, into sporadic (idiopathic or classic) (85%), acquired (or exogenous) (5%), genetic (or hereditary) (10%), and other variants such as Gerstmann-Sträussler-Scheinker disease (GSSD), fatal familial insomnia (FFI) and kuru.1,3,4

The probable diagnosis is based on progressive dementia and other clinical criteria (myoclonus, visual disorders, cerebellar signs, pyramidal or extrapyramidal signs, and akinetic mutism), as well as a compatible electroencephalogram (EEG) (periodic epileptiform discharges) and/or detection of neuronal protein related to neuronal destructions that accumulates in cerebrospinal fluid (CSF), called protein 14-3-3.1,3,5 The definitive diagnosis requires a post-mortem study.6

Due to these clinical complexities and the variable initial onset, it presents a common delayed detection with issues during the differential diagnosis. In this paper, we include a representative case from our institution and discuss the common challenges during the course of the disease.

We present a case report from the “Hospital Regional Lambayeque”, in Lambayeque, Peru. This report followed the CARE guidelines.7

Consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient.

Case report

We present the case of a 47-year-old male from the Amazon region of Peru, unemployed, with no pathological or surgical history. His symptoms start with oppressive non-located headache 80-weeks before, which were treated with analgesic medication without response. It was associated with a hands rest tremor, perceptual alteration of time, difficulty in recognizing relatives, aggressiveness, agitation, and mild memory impairment.

24-weeks before, symptomatology persists and progress until presenting alterations of sphincter control and difficulty for walking, and upper limb rest and intention tremor generating partial dependence for their daily activities. He had a hospital admission for presenting focal to bilateral tonic-clonic seizures for which he received antiepileptic drugs with an incomplete response. Subsequently, due to the persistence of symptomatology and the development of epileptic status, he was hospitalized again. The blood studies showed anemia (10.2 g/dl), with any other abnormalities. The CSF analysis found a clear fluid without alterations.

Brain magnetic resonance imaging (MRI) showed moderate to severe cortico-subcortical atrophic changes and subcortical hyperintensities ( Figure 1). Additionally, an EEG was performed, without any alteration. The progressive neurological compromise with the development of early and progressive dementia in the next months, and the MRI suggestive of prion disease, CJD diagnostic was suspected. We performed a 14-3-3 protein western blot test in CSF, finding elevated titles, indicative results of CJD. The patient was classified as spongiform encephalopathy, probable CDJ. Symptomatic treatment and palliative care were indicated to the patient.

e91746c7-8283-41b1-bde2-fd12c01ee13c_figure1.gif

Figure 1. Axial brain-MRI of the patient with probable sporadic CJD.

Axial section in a fluid attenuated inversion recovery (FLAIR) sequence showing hippocampal volume decreased in both temporal lobes with increase of temporal horns predominantly on right side; mild hyperintensity in right caudate nucleus and moderate in periventricular regions with confluent zones in the right parietal region; and moderate to severe atrophic cortical-subcortical with frontotemporal predominance.

All these tests were performed during the hospitalization of the patient. The Western blot test of the protein 14-3-3 was performed two weeks after his hospitalization. The patient was evaluated one month after discharge, but he did not return for his next consultation, and it was not possible to follow up on his case.

Discussion

The case reported a progressive neurological condition (headache that progress to dementia) with early onset of cognitive impairment and behavioral symptoms at the age of 47 years, a Brain-MRI showing moderate to severe cortico-subcortical trophic changes, and basal nuclei hyperintensity, added to a positive Western-Blot quantification of CSF 14-3-3 protein (sensitivity of 94% and specificity of 84%),5,8 hence the condition was classified as spongiform encephalopathy, probable CJD. It was not possible to make the definitive diagnosis with brain biopsy confirmation, where neuronal loss, gliosis, and intracytoplasmic vacuolization are observed in the brain parenchyma.6,9

CJD is a rare and fatal neurodegenerative disease, due to the high mortality, an early and timely diagnosis must be made.10,11 However, currently the diagnostic criteria are controversial and there are several variances of the onset symptoms, thus, the diagnosis is usually made in the terminal phases of the disease.

We search the available literature to compare with our experience and found ten articles reporting diagnostic challenges in CJD ( Table 1).1221 The age range of the patients reported was 30 to 86 years [median 64 years]. The main initial clinical manifestation was psycho-behavioral symptoms (50% of the cases), predominantly: apathy, confusion, aggressiveness, irritability, and sleep disturbance. The initial differential diagnoses were psychiatry exacerbation (depression and schizophrenia), myelopathy, epilepsy, stroke and parkinsonism. Our patient is 47-years old, male, with an initial presentation of headache, extrapyramidal signs, and behavioral symptoms. In another case series,22 they found that the presentation was nonspecific, from headache to ataxias. The extrapyramidal and cerebellar signs onset is presented as a frequent initial manifestation.23 These data coincide with our systematic review results, indicating a common non-specific initial symptomatology in these cases.

Table 1. Description of previously reported cases with diagnostic challenges.

Author (year)Patient informationClinical manifestationsInitial diagnosisNeuroimagingEEGDifferential diagnosis Time until final diagnosisFinal diagnosis
Ziso, B. et al (2017)57-years-old woman, no previous diseases history.1-month history of sensorial disturbances in left arm and walk difficulties. Hypertonia and hyperreflexia. 5 weeks after worsening of mobility, quadriparesis, and sphincter dysfunction.MyelopathyRestricted diffusion in the right frontal cortical region.Theta range with slower delta rhythms.Cervical radiculopathy6 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Roest et al. (2016)51-years-old woman, depression history.Suicide ideation, memory impairment and sleep disturbances. 14 weeks after worsening cognitive impairment and confusion.Depression exacerbationNormalInitial: w/o alterations.
After 14 weeks: generalized, synchronous triphasic complexes.
Depression and posttraumatic stress disorder.14 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Ghadiri-Sani et al. (2015)56-years old woman, with history of stroke 10 years ago.Left homonymous hemianopia, dysarthria, mild left-sided weakness, hyperreflexia with bilateral Babinski. After 4 weeks: progressive episodes of confusion and apparent blindness, cognitive deterioration.Multiple territory strokesInitial: w/o alterations. After 4 weeks: mild global brain atrophy was noted.Triphasic wavesVertebral artery dissection with showers of emboli or cerebral vasculitis.5 weeksSporadic CJD (Biopsy)
Chauvin et al. (2014)78-years-old man, no previous diseases history.Tonic-clonic seizures. 3-months after: muscular weakness. 4-months after: progressive cognitive impairment (apraxia and akinetic mutism).EpilepsyInitial: w/o alteration.
After 3 months: Fronto-temporal hypersignal.
NormalMyelopathy15 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Damato et al. (2014)78 years-old man, hypertension history.Right hemiparesis, Babinski sign present and dysarthria. After 4 weeks: intermittent myoclonic jerks in both arms and legs and a rapidly progressive cognitive decline and abnormal behavior, confusion and agitation.StrokeShowed hyperintensity of left frontal gyri on T2-weighted FLAIR.Diffuse theta -delta activity.Stroke mimics5 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Jacquin et al. (2014)64-years-old man, no previous diseases history.Language disorders, apathy and behavioral disorders.Progressive primary aphasiaNot reportedNot reportedCJDNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
68-years-old man, no previous diseases history.Aphasia, apraxia and ataxia of right upper limb with parkinsonian syndrome.Corticobasal degenerationNot reportedNot reportedParkinsonismNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
2 Case reports, females, 58 and 61 years-old, no previous diseases history.Anxiety and depression syndrome, falls, visual hallucinations, extra-pyramidal syndrome and fluctuating cognitive decline.Lewy body dementiaNot reportedNot reportedCJDNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Chuang et al. (2012)61 years-old man, history of schizophrenia.Initial: visual hallucinations, hyperreflexia and parkinsonism. After 4 days: multifocal myoclonus.
After 1 month: cognitive decline and behavior change.
Exacerbation of schizophreniaAfter 8 days: Hyperintensities on diffusion weighted imaging in the occipital lobes bilaterally.After 6 days: left periodic lateralizing epileptiform discharges (PLEDs), generalized disorganization, and slowing.Parkinsonism4 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Mahmoudi et al. (2010)74-year-old man, no previous diseases history.Psychobehavioral disturbances including verbal aggressiveness, anxiety, and irritability.
After 18 months: cognitive and psychobehavioral symptoms increased, and gait disorders appeared.
Alzheimer diseaseCortico-subcortical atrophyNot reportedAtypical AD72 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Chadenat et al. (2009)79-years-old woman, no previous diseases history.Subacute dementia associated with gait disorder. Serum calcium elevated.CJDNot reportedNot reportedMetabolic-originated cognitive impairmentNot reportedCreutzfeldt-Jakob like syndrome due to parathyroid Adenoma
duPlessis et al. (2008)74-year-old man, no previous diseases history.Cognitive impairment and visual hallucination and parkinsonism. After 18 months: rapid cognitive decline and orthostatic hypotensionDementia with Lewy bodiesNot reportedNot reportedCJD72 weeksSporadic CJD (Biopsy)
Hamaguchi et al. (2005)Case 1: 65-year-old womanDementia, pyramidal signs, insomnia.CJDNot reportedNot reportedDementiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 2: 75-year-old womanPsychiatric symptoms, dementia, myoclonusCJDNot reportedNot reportedMajor depressionNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 3: 65-year-old manDementia, myoclonus, cerebellar ataxia, akinetic mutismCJDNot reportedNot reportedCerebellar ataxiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 4: 49-year-old womanInsomnia, dementia, psychiatric symptoms, pyramidal signs, extrapyramidal signs, autonomic symptoms, myoclonus, akinetic mutismProgressive supranuclear palsyNot reportedNot reportedDementiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 5: 64-year-old manVisual symptoms, extrapyramidal signs, dementia, autonomic symptoms, psychiatric symptoms, myoclonus, akinetic mutismProgressive supranuclear palsyNot reportedNot reportedDementiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 6: 30-year-old womanVisual symptoms, psychiatric symptoms, cerebellar ataxia, dementia, pyramidal signs, extrapyramidal signs, myoclonus, akinetic mutismSpinocerebellar degenerationNot reportedNot reportedDementiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 7: 71-year-old manCerebellar ataxia, autonomic symptoms, dementiaSpinocerebellar degenerationNot reportedNot reportedCerebellar ataxiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Case 8: 58-year-old manDementia, cerebellar ataxia, myoclonus, pyramidal signs, psychiatric symptomsAlzheimer diseaseNot reportedNot reportedDementiaNot reportedSporadic CJD (clinical + 14-3-3 protein in CSF)
Pereira et al. (2002)63-year-old man, no previous diseases history.Progressive memory loss and word finding difficultyAlzheimer diseaseLarge areas of increased signal in the frontal, temporoparietal and occipital lobes in DWI.NormalCJD32 weeksSporadic CJD (Biopsy)
Walsh et al. (2001)76-year-old woman, history of multiple stroke.Memory impairment and behavioral changesVascular dementiaBrain Atrophy, older stroke lesions.Not reportedCJD4 weeksSporadic CJD (clinical + 14-3-3 protein in CSF)
Seipelt et al. (1999)7 Case reports, females, 44-86 years-old, history of Hashimoto’s thyroiditisProgressive cognitive impairment, myoclonus, ataxia, and personality change or psychotic phenomenaCJDNot reportedNot reportedautoimmune encephalitisNot reportedAutoimmune encephalitis (Hashimoto’s encephalitis)
Wilhelm-gling et al. (1998)58-year-old woman, history of Hashimoto’s thyroiditisUnconsciousness, progressive severe dementia and generalized myoclonus. Increased thyroid antibodies titles.CJDNot reportedSlowing activity and episodes of triphasic waves.Infectious encephalitis, autoimmune encephalitisNot reportedAutoimmune encephalitis (Hashimoto’s encephalitis)

The initial neuroimaging evaluations were reported in nine of the cases,1214,1621 mainly, they found hyperintensity in frontotemporal lobes and cortico-subcortical atrophy. EEG evaluations reporting theta range with slower delta rhythms.

The broad clinical findings spectrum included a progressive neuropsychiatric syndrome –whose initial symptoms could be depression, insomnia, anxiety, apathy, and hallucinations. Besides, movement disorders– cerebellar ataxia, involuntary movements, myoclonus, chorea, and dystonia- and persistent pain or paresthesia, could be associated. Finally, dementia and akinetic mutism could be presented at the end of this disease.

In general, psychiatric symptoms precede neurological manifestations.9,22,24 We found that 65% of cases start clinical manifestation with psychobehavioral symptoms; it is according to our case report.

Timely diagnosis of CJD is often difficult, in part because of the frequency of unusual variants, with potential modifications due to early interventions. The available literature on this topic shows a wide diagnosis delay range from four to 80 weeks [median 14 (5-72 weeks)]. The best approach is to add CJD as our differential diagnosis options, not only in the classical rapid-progressive dementia diagnosis, but also in front of patients with suspicious of psychiatry exacerbation, myelopathy, epilepsy, stroke, and Parkinsonism.

The reports show that autoimmune encephalitis due to Hashimoto’s thyroiditis and a CJD-like syndrome due to parathyroid adenoma could simulate the CJD clinical manifestations even meeting partially the diagnostic criteria.25 Thus, it is important to evaluate carefully the autoimmune disease history in patients with CJD suspicious.

Current reviews indicate that the changes in brain-MRI are bilateral, symmetric, and predominant in basal ganglia and cortical regions,6,26 in addition, 85% show signs of atrophy in the MRI.6 Our case findings are according to this literature, however, in most of the cases with difficult timely diagnosis, the MRI results were inconclusive or normal until the end-stage of the disease, and the most common finding was cortical-subcortical atrophy and basal nuclei hyperintensity.

The patient presented unspecific characteristics of onset, in addition to a delay of 80-weeks before CJD diagnosis, with broad clinical manifestations, alterations in the MRI and the presence of protein 14-3-3 in CSF.

In conclusion, not all the CJD symptoms are at the beginning of the disease, and not all the classical symptoms and signs indicate CJD. In addition, as seen in the review, the delay to a proper diagnosis of this disease is large, so this is a significant diagnostic challenge for physicians and neurologists. CJD should be included as a differential diagnosis at the beginning of behavioral symptoms or rapid cognitive impairment, even if it is a remote possibility.

Authors’ contributions

Conceptualization: VEFR, YKYB, GAM, CAD, KPB; Data curation: VEFR, KPB; Investigation: VEFR, YKYB, GAM; Methodology: VEFR, ANF, CAD, KPB; Supervision: KPB; Writing – Original Draft Preparation: All authors; Writing – Review & Editing: All authors.

Ethics and consent

This study was conducted according to the ethical standards of the Declaration of Helsinki. Informed consent was obtained from the patient and this case study was approved by the ethical board of Hospital de Lambayeque. Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient.

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Failoc Rojas VE, Yazawa-Ballena Y, Alvarado-Moreno G et al. Case Report: Creutzfeldt-Jakob disease and diagnosis challenges: case report and evidence synthesis [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:425 (https://doi.org/10.12688/f1000research.150498.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Reviewer Report 16 Jun 2025
Shi-Lin Yang, Fudan University, Shanghai, China 
Approved with Reservations
VIEWS 4
This article made a detailed review and summary of the previous literature, which is helpful to improve understanding of the CJD. The clinical manifestations of CJD are heterogeneous. Multiple case analyses have been reported. This article focused on reviewing the ... Continue reading
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Yang SL. Reviewer Report For: Case Report: Creutzfeldt-Jakob disease and diagnosis challenges: case report and evidence synthesis [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:425 (https://doi.org/10.5256/f1000research.165074.r390131)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 14 Jun 2025
Anna Ladogana, Istituto Superiore di Sanità, Rome, Italy 
Approved with Reservations
VIEWS 5
The authors report a case of CJD with an atypical onset that initially made the diagnosis challenging. They also present a systematic review of the literature on published CJD case reports.

My suggestions are the following
... Continue reading
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Ladogana A. Reviewer Report For: Case Report: Creutzfeldt-Jakob disease and diagnosis challenges: case report and evidence synthesis [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:425 (https://doi.org/10.5256/f1000research.165074.r384616)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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