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Advanced tests for early and accurate diagnosis of Creutzfeldt–Jakob disease

An Erratum to this article was published on 17 June 2016

This article has been updated

Key Points

  • Early and accurate diagnosis of Creutzfeldt–Jakob disease (CJD) is essential to avoid iatrogenic transmission and to distinguish CJD from potentially treatable dementias

  • Diagnosis of CJD in living patients is challenging, mainly because the disease phenotypes are highly heterogeneous, and detection of the misfolded protein in the brain tissue is often not feasible

  • Supportive investigations such as EEG, MRI and cerebrospinal fluid biomarkers have a relatively low diagnostic sensitivity and specificity in CJD

  • Diagnosis of CJD has been markedly improved by novel ultrasensitive seeding assays, such as real-time quaking-induced conversion (RT-QuIC) and protein misfolding cyclic amplification (PMCA), which are based on amplified prion detection

  • RT-QuIC is specific and highly sensitive for sporadic CJD, whereas PMCA is extremely sensitive for detecting variant CJD prions in biological fluids and in extraneural or lymphatic tissues

  • In the future, novel assays analogous to RT-QuIC or PMCA might provide a protein-seeding-based diagnosis in other neurodegenerative diseases in which prion-like neurodegenerative processes are implicated


Early and accurate diagnosis of Creutzfeldt–Jakob disease (CJD) is a necessary to distinguish this untreatable disease from treatable rapidly progressive dementias, and to prevent iatrogenic transmission. Currently, definitive diagnosis of CJD requires detection of the abnormally folded, CJD-specific form of protease-resistant prion protein (PrPCJD) in brain tissue obtained postmortem or via biopsy; therefore, diagnosis of sporadic CJD in clinical practice is often challenging. Supporting investigations, including MRI, EEG and conventional analyses of cerebrospinal fluid (CSF) biomarkers, are helpful in the diagnostic work-up, but do not allow definitive diagnosis. Recently, novel ultrasensitive seeding assays, based on the amplified detection of PrPCJD, have improved the diagnostic process; for example, real-time quaking-induced conversion (RT-QuIC) is a sensitive method to detect prion-seeding activity in brain homogenate from humans with any subtype of sporadic CJD. RT-QuIC can also be used for in vivo diagnosis of CJD: its diagnostic sensitivity in detecting PrPCJD in CSF samples is 96%, and its specificity is 100%. Recently, we provided evidence that RT-QuIC of olfactory mucosa brushings is a 97% sensitive and 100% specific for sporadic CJD. These assays provide a basis for definitive antemortem diagnosis of prion diseases and, in doing so, improve prospects for reducing the risk of prion transmission. Moreover, they can be used to evaluate outcome measures in therapeutic trials for these as yet untreatable infections.

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Figure 1: Tissue and body fluid samples for prion protein detection in patients with CJD.
Figure 2: Diagnostic testing for Creutzfeldt–Jakob disease: PMCA versus RT-QuIC.

Change history

  • 14 June 2016

    In the version of this article initially published online and in print, the Figure 2 erroneously depicted recombinant prion protein with attached glycans, and Table 2 listed an erroneous glycotype for sporadic Creutzfeldt–Jakob disease. The errors have been corrected for the PDF and HTML versions of the article.


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We thank the E-learning facility of the University of Verona for producing the olfactory brushing video. This work was funded in part by Joint Programming Neurodegenerative Disease BIOMARKPD (G.Z.), Fondazione Cariverona “Biomarcatori predittivi e diagnostici in patologie neoplastiche, infiammatorie e neurodegenerative” (G.Z., S.M.) and the Intramural Research Program of the NIAID (B.C.).

Author information




G.Z. and B.C. researched literature for the article and provided substantial contributions to discussion of content. All authors participated in writing of the article and in reviewing/editing the manuscript before submission.

Corresponding author

Correspondence to Gianluigi Zanusso.

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Competing interests

B.C. is an inventor on patents and patent applications related to RT-QuIC assays. The other authors declare no competing interests.

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Supplementary information

Supplementary information S1 (video)

This video shows the procedure for obtaining olfactory mucosa samples with nasal brushing. (AVI 883721 kb)



The infectious, often partially protease-resistant form of prion protein that is associated with Creutzfeldt–Jakob disease.

Prion paradigm

According to the prion paradigm, a misfolded, usually pathological, form of a host protein acts as an infectious agent by servingas a folding template, inducing the conversion of its normal counterpart into more of the misfolded form; the misfolded proteins then propagate within and/or between hosts to cause phenotypic changes, such as neurodegenerative disease.

14-3-3 protein

A protein biomarker of neuronal damage that is not disease-specific for Creutzfeldt–Jakob disease. However, elevated cerebrospinal fluid levels of 14-3-3 can serve as a useful diagnostic aid for for distinguishing Creutzfeldt–Jakob disease from other dementias.

PRNP methionine/valine (MV) polymorphism

The normal polymorphism at codon 129 of the human prion protein (PRNP) gene that codes for the prion protein.

Protein misfolding cyclic amplification (PMCA)

A highly sensitive and specific in vitro prion amplification reaction in which a test sample is mixed with suitable sources of PrPC (usually brain homogenates) and subjected to cycles of sonication and rest; amplified protease-resistant, infectious prions are typically detected by western blot after proteinase K treatment.


Real-time quaking-induced conversion (RT-QuIC) is a highly sensitive and specific in vitro test for prion-associated seeding activity in which a test sample is mixed with recombinant PrPC in multiwell plates that are subjected to cycles of shaking and rest. As the reaction progresses, prion-seeded, but apparently non-infectious recombinant PrP amyloid fibrils are detected by enhanced fluorescence of an amyloid-sensitive dye.

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Zanusso, G., Monaco, S., Pocchiari, M. et al. Advanced tests for early and accurate diagnosis of Creutzfeldt–Jakob disease. Nat Rev Neurol 12, 325–333 (2016).

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