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The Paradox of Prion Disease

Rosalind M. Ridley and Harry F. Baker

1. introduction
The study of that group of diseases now collectively known as the prion
diseaseshas always been a source of excitement and argument between scien-
tists. These obscure diseases usually have been of extremely rare occurrence
and have had little impact on the general public. When an epidemic occurs,
however, as in the case of bovme sponglform encephalopathy (BSE) m the
United Kmgdom, the bizarreness of the prion diseasesand the profound differ-
ence between them and any other “mfectlous” condition can (and did) lead to
public consternation. Three features of prlon diseases give them an apparently
diabolical quality.
7.1. Their Occurrence Is Largely Unpredictable
1. In acquired casesthere 1sa silent mcubatlon period that can vary from a few
weeksto up to 40 yr, dependmgon the species the circumstances
2 During the incubation period there are no symptoms and no detectable signs,
e.g., there IS no measurable Immune response that will predict subsequent illness.
3. No mode of transmission could be established for the majority of human cases
that appear to occur “out of the blue.”

1.2. They Exhibit Certain Impossible Properties
In relation to established principles of microbiology, the prion diseases
exhibit certain “impossible” properties.
1 “Infectious” disease seems to arise spontaneously.
2. Inherited cases give rise to a disease that is transmissible but acquired cases do
not produce a heritable disease

From Methods m Molecular Medicrne Prron Dmeases
Edlted by H Baker and R M Rdley Humana Press Inc. Totowa, NJ

2 Rciley and Baker
3. Procedures and chemical treatments that specifically destroy nucleic acids (which
all replicatmg organisms possess) do not destroy the mfecttous agent
4 The mfecttous agent can persist m the envtronment almost indetimtely
1.3. They Are Invariably Fatal
1 No treatments have been found that ˜111 alter the progression of the disease
2 In animal transmtssion studies, the duratton of symptoms from onset to death can
be as short as a few hours followmg an mcubation period of many months, during
which the animal appears to be completely healthy

These three features have combined to stroke fear into the general publtc,
who regard priori dtseases(perhaps with some justification) as uncontrollable,
mcomprehensible, mdestructable, and incurable. This fear 1s probably only
matched by an excessive dread of radioactivity, which IS similarly imbued with
great “strangeness.” In sharp contrast, the public steadfastly refuses to worry
about “ordmary” factors, such as diet, exercise, and safety, which are known to
have an enormous effect on morbidity.
2. Scientific Investigation
In recent years the screntific investigation of prron diseases has expanded
greatly, leading to strongly held convictions and arguments that have some-
times degenerated into acrimony. Scientists are particularly exercised by the
fact that some accounts of the pathogenesis of prion disease seem to contradict
basic tenets of molecular biology:
1 That proteins are made using information encoded in nucleic acid,
2. That different proteins are encoded by different nucleic acid sequences;
3 That protein synthesis cannot occur without nucleic acid; and
4. That any “agent” that increases m titer must involve rephcatton of nucleic acid.
The central argument has been about “viruses vs genes (or proteins).” As
in other great scientific debates, e.g., “particles vs waves” or “nature vs nur-
ture,” the resolutton of the problem 1sunhkely to be that one vtew is correct
and the other incorrect but that a new way of understanding the phenomenon
allows the dichotomy to dissolve. For many years the body of data on priori
diseases was like a Rubik cube; when one face was intact the others were not.
Thus, rt was easy enough on the basis of experimental transmtssion studies to
make the case for disease being caused by a virus-except that it was not
possible to explain how the majority of cases were “caught.” The transmis-
sible agent appeared to behave like a replicating, infectious agent--except
that treatments that destroy nucleic acid did not reduce infectivtty. Further-
more, some human cases clearly were inherited, whereas other cases clearly
were not.
The Paradox of Prion Disease
2.1. Misinterpretations
These difficulties m producing a coherent story for prton diseases were com-
pounded by certain mismterpretations of the available evidence.
1 The demonstration of experimental transmissibihty led to the presumption that
all cases were acquired by mfectron.
2 The difficulty in demonstrating contact between cases of human prion disease
led to exaggerated concern about the mfecttousness of the disease. For example,
the apparently higher incidence in cities (probably owmg to sampling and demo-
graphic effects) could be interpreted as meaning that casual contact between
strangers was all that was necessary to transmit disease
3 The not infrequent occurrence of priori disease m another family member of the
proband led to the fear that the disease was transmissible vertically through con-
tamination zn utero or through the incorporation of the agent (perhaps a
retrovnus) m the genome of an acquired case. Where the disease occurred m a
proband and a parent who had been separated for many years the suspicion grew
that transmisston of “agent” had occurred m childhood. Where disease occurred
m a proband and a distant relative who had met for only the briefest of meetings
it was supposed that genetically susceptible people were quite exquisitely vul-
nerable to mfection
4 The transmtssibility of the disease and the apparent rnformatron-carrying prop-
erty of the agent, as demonstrated by the phenomenon of strain of agent m
experimental scrapie, lead to the insistence that failure to find the virus was only
a temporary technical failure rather than evidence that there might not be such an
independent orgamsm m these diseases

The baste phenomenon that the various hypotheses of the etiology of prion
diseases have sought to address 1s experimental transmrsstblltty, and advocates
for each side draw on a number of facts to support then view.
2.2. Evidence in Favor of the Viral Hypothesis
1. The increase m mfectivity titer in brain during disease progression is taken as
evidence of a replicatmg agent
2. No bacteria or other organism can be found so that, by default, the disease is
attributed to a vnus.
3. In experimental transmisston the long incubation period followed by the rapid
course of disease resembles the occurrence of diseases caused by lentivn-uses.
4 Different isolates of priori disease “agent” appear to behave differently in terms
of species specificity, incubation time, and lesion profile on experimental trans-
mtssion to other animals leading to the concept of “strain variation ”
5. The existence of different “strains of agent” is regarded as evidence of an infor-
mattonal, rephcating molecule that is presumed to be composed of nuclerc acrd
6 The familial occurrence of priori disease m humans is explained as a genetic
susceptibility to an infectious agent in the environment.
Ridley and Baker

2.3. Evidence in Favor of a Gene (Protein) Hypothesis
No vnus particles are associated with infectivity
No immune response to mfectron 1s found m an affected host
No nucleic acid IS associated specifically with infectivity
Infectivity titer is associated with levels of the abnormal isoform of priori protein
known as PrPSC
PrPSC and the normal form of prton protein (PrPc) do not differ m primary struc-
ture, thus negating the need for PrPsc-specific nucleic acid
PrPSChas the primary structure dictated by the PrP gene of the host, thus negating
the need for agent-specific nucleic acid in the production of PrPSC
When priori disease is experimentally transmitted from one species to another the
PrPSC m the recipient has the primary structure of the recipient species, not of the
donor species or agent Agent replication does not, therefore, need to occur for
levels of PrPSC to increase
Most (but not all) of the variation m species specificity, mcubation time, and
lesion profile can be accounted for by variations m the PrP protein of the host and
the homology between that and the PrP protein of the agent (1 e , donor), thus
reducing the variation attributable to “stram of agent ”
9 Familial prion disease occurs m pedigrees with a mutation m the PrP gene
10 Transgemc mice carrying mutations m the PrP gene produce a transmissible
spongiform encephalopathy despite being kept m controlled conditions where
accidental contamination with an exogenous agent can be avoided (I)
11 PrPSC can be reversibly denatured with guamdme-chloride and renatured by
dilutmg out the guamdine chloride If radiolabeled PrPC IS added during the rena-
turation stage, protemase K digestion results m the formation of radiolabeled
proteinase K-resistant fragments of similar size to protemase K-digested PrPSC
from scrapie-affected ammals (2) (and see Caughey et al , this volume) This
suggests that PrPC can be converted directly mto PrPSC by mteraction with other
PrPSC molecules

2.4. Resolution of the Dichotomy
A number of arguments are leading to a resolutton of the dichotomy.
2.4.1. Acquired, Familial, and Sporadic Cases
It is now recognized that cases of prton disease arise m three different
ways-acquired, familial, and sporadic, and that data from one type of case do
not have to be applied to other cases. This resolves the argument between
“mherited” and “acquired” factors in the etiology of different cases

Acquired cases of prion disease arise because a person or an animal has
ingested or absorbed a quantity of the infectious agent. In humans, the majority
The Paradox of Prion Disease

of these acquired cases occurred in Papua New Guinea m the first half of this
century. The diseasewas known as kuru and spread slowly around various related
ethnic groups of the mdigenous population. Epidemiological analysis imph-
cated funerary practices and the people admitted to cannibalism, especially by
the women and the young children m then care (3). It is now supposed that the
epidemic began with a sporadic case of prion disease. The epidemic has now
almost run its course but the extremely long incubation periods that can occur,
especially following low oral exposure to the agent, means that a few cases
still occur each year.
In the West, prion diseasein humans has not been associatedwith any dietary
practice, but has occurred following the use of human tissue for medical pur-
poses. The largest number of cases (currently approx 100 worldwide) has
resulted from the prolonged use of human pituitary-derived growth hormone.
A few further casesare associated with the use of human dura mater tissue m
reconstructive surgery of the head and a small number of caseshave occurred
as a result of contammatron during cornea1 grafting or neurosurgery. In the
latter cases mstruments were used that had previously been used m patients
with priori disease and that probably were still contaminated despite sterihza-
non treatments that were standard at that time. The tissues that have been
implicated m these iatrogemc cases-pituitary gland, dura mater, and cornea-
all come from close to the brain, which is known to have the highest levels of
The largest epidemic of animal priori disease has affected cows m Britam
Bovme spongiform encephalopathy (BSE) was first recogmzed m 1986 and
the number of cases has followed a large distribution with the peak (approx
3500 cases/ma) occurrmg m 1993. The total number of cows affected so far is
approx 150,000 and the epidemic is expected to run beyond the year 2000. The
epidemic is believed to have resulted from changes m the method of rendering
carcasses(including ovine and bovine) for the production of animal food pel-
lets such that the mfectious agent associatedwith scrapie was not destroyed and
affected the calf population. Subsequently, carcassmaterial from BSE-affected
cattle inevitably would have been incorporated m the calf food pellets, adding
to the infectivity titer of this food preparation. The number of casesoccurring
in animals born after the feeding of rummant-derived protein to ruminants was
banned m 1988 has dropped dramatically, mdicatmg that, apart from a possible
very minor level of residual contamination in the system, the epidemic now is
under control. The long incubation period that can occur, however, implies
that there will be several years before the disease is eradicated. In addition to
BSE, the contamination of animal feed has led to a small number of cases of
prion disease m other ammals, notably cats and exotic ungulates, and other
food-related outbreaks have occurred in farmed mink and captive deer
Ridley and Baker
About 15% of casesof human prion disease occur m families where at least
one other family member has been affected and where rt can be established that
a large number of cases have occurred in one family, it can be seen that the
dtsease runs m an autosomal dommant pattern Linkage of disease to a muta-
tion m the PrP gene open reading frame was first estabhshed by Hsrao et al
(4). There are now known to be several point mutations and a number of
expansions m an octapepttde repeat sequence within the PrP gene open readmg
frame (5) that are associated with disease.
Sporadic cases of human prton disease occur, by definition, without any
known antecedent event through which the disease could have been acquired
and without any known family history or mutation m the PrP gene. Some
genetic influence ts now being recognized, however, because most sporadic
cases are homozygous for a common polymorphism in the PrP gene (6)
although, because the disease is exceedingly rare (affecting approx one m a
mullion people worldwtde), the vast majortty of people who share this genetic
feature are not affected.
Scrapre in sheep occupres a particularly important position among the prron
diseases because it is a relatively common, naturally occurrmg condition that
shares features of the acquired, inherited, and sporadic ettologtes. It is thought
to be the ortginal source of infection m the BSE epidemic, although this IS
difficult to prove. Persistent efforts to find an eptdemtological or case-con-
trolled association between scrapie and human priori disease, fortunately, have
been unsuccessful.
In the 1960s natural scrapie was reported to occur m a pattern consistent
with autosomal recessive inheritance m at least some breeds of sheep (7). More
recently rt has been shown that m some breeds naturally occurring disease is
linked to polymorphisms m the PrP gene that etther are of partial dommance or
recessive (8), largely vindicating the original observation despite the many
intervening years m whtch the experimental transmisstbility of mouse-adapted
scrapre blinded researchers to the possibrlity that the natural sheep disease
might wholly be genetic. These PrP polymorphisms also are linked to suscep-
tibility to experimental mfection m sheep but it remains unproven whether
linkage to naturally occurrmg disease is because of an influence of the poly-
morphisms on susceptibility to infection m the field or whether the malortty of
naturally occurring caseshave a genetic disease, in the absence of any contact
with agent m the environment. The more recent demonstration that the latter 1s
The Paradox of Prion Disease

the case m a proportion of human cases and that transgemc mace carrymg
mutations m the PrP gene (1) or additional copies of normal PrP alleles (9) can
develop prion disease without contact with an exogenous agent make a purely
genetic cause of natural scrapie, in at least some cases,more plausible than was
believed until recently. The possibtlny that natural scrapie may arise without
exogenous infection has, however, been recogmzed by some scientists for
many years (10). One of the arguments in favor of the infection hypothesis of
the eptdemiology of natural scrapie was the high coincidence of scrapte m dam
and progeny that was thought to be indicative of maternal transmission (1 l),
but such a pattern clearly is compatible also with a recessive model, especially
where the flock shares one ram, such that the variance is determined largely by
the status of the dam. Furthermore, although scrapie has been seen m sheep fed
with placentas from scrapie-affected sheep (22) this does not prove that oral
transmission necessarily determines the natural incidence of disease. Indeed, it

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