National Library of Medicine / Hot Medical News
This silent film clip shows several victims of a disease called kuru. They are - or rather were - members of the South Fore, a tribe of approximately 8,000 people who inhabit the Okapa subdistrict of the Eastern Highlands Province of Papua New Guinea. In the 1950s and '60s, a kuru epidemic swept through the South Fore, claiming the lives of more than 1,000 members of the tribe. Later it was established that the disease was transmitted by the tribe's practice of ritualistic mortuary cannibalism.
The word kuru means "shaking death" in the Fore language, and describes the characteristic symptoms of the disease. Because it affects mainly the cerebellum, a part of the brain involved in the co-ordination of movement, the first symptoms to manifest themselves in those infected with the disease would typically be an unsteady gait and tremors. As the disease progresses, victims become unable to stand or eat, and eventually die between 6-12 months after the symptoms first appear.
Kuru belongs to a class of progressive neurodegenerative diseases called the transmissible spongiform encephalopathies (TSEs), which also includes variant Creutzfeldt-Jakob Disease (vCJD) and bovine spongiform encephalopathy (BSE, more popularly known as "Mad Cow Disease"). TSEs are fatal and infectious; in humans, they are relatively rare, and can arise sporadically, by infection, or because of genetic mutations. They are unusual in that the infectious agent which transmits the diseases is believed to a misfolded protein. (Hence, the TSEs are also referred to as the prion diseases, "prion" being a shortened form of the term "proteinaceous infectious particle").
BSE first appeared in the U.K. in 1986. A decade later, a young man from Wiltshire who had eaten contaminated beef became the first victim of vCJD. Health officials realized that the disease was spreading among livestock because of the practice of feeding them offal. They warned that tens of thousands of people could be at risk and subsequently more than 200,000 cattle were culled in order to prevent this, at a huge expense to the British economy.
To date, though, only 156 people in the U.K., and a much smaller number in other countries, have died from vCJD. However, a longitudinal study of the Fore people, published 2 years ago, suggests that kuru and related diseases may have an incubation period of up to 50 years, leading some researchers to argue that we may yet face an epidemic of vCJD. And last month, neurologists reported a previously unidentified prion disease which has killed 10 people in the U.S. and infected 6 others.
The prion hypothesis was proposed by Stanley Prusiner in 1982. It states that TSEs are transmitted by an abnormally folded form of the prion protein. The normal form of this protein is present in all cells, but its function remains unknown. The abnormal prion protein is insoluble and prone to accumulate in clumps which give the brain tissue a characteristic sponge-like appearance (spongiform encephalopathy means "sponge-like brain disease"). The clumps cause the shaking and abnormal gait, because they make cerebellar cells unable to properly conduct nervous impulses.
It is now known that the clumps of abnormally folded prion protein can break down into smaller fragments. Thus, if infected tissue is consumed, these fragments act as "seeds", which cause the normal protein in the host cells to adopt the abnormal configuration and begin to accumulate, in a process called a nucleation-polymerization reaction. The proposed structures of both forms of prion proteins are shown in this figure. The abnormal, pathogenic form of the prion protein (on the right) has a higher proportion of structures called beta-pleated sheets, and a lower proportion of alpha-helices, than the normal cellular form (left). The normal form of the protein is thought to be converted to the abnormal one by a series of point mutations. Recent evidence suggests that the abnormal prion protein is not itself toxic neurons, but rather that its propagation generates a toxic by-product.
Experiments in yeast have implicated heat shock proteins in the propagation of the prion seed. Heat shock proteins are a large family of molecules present in all cells and in all organisms. Their concentrations are increased in response to elevated temperatures, but they also act as "chaperones" which assist newly-synthesized proteins in assuming their correct three-dimensional structure, and prevent them from clumping together. Thus heat shock proteins are also involved in disassembling the clumps of abnormally folded prion proteins. In yeast cells with a mutated form a specific heat shock protein, the clumps of prion protein are not fragmented, and so are not passed on during cell division.
Following the outbreak of kuru among the Fore in the 1950s, cultural anthropologists quickly established that the disease was transmitted by the practice of mortuary cannibalism. When an individual died, the female relatives were responsible for dismembering the body. They would remove the brain, arms and feet, strip the muscle from the limbs and open the chest and abdomen to remove the internal organs. Those that died of kuru were highly regarded as sources of food, because they had layers of fat which resembled pork. It was primarily the Fore women who took part in this ritual. Often they would feed morsels of brain to young children and elderly relatives. Among the tribe, it was, therefore, women, children and the elderly who most often became infected.
Although the Fore's cannibalism was outlawed by Australian authorities in the late 1950s, cases of kuru contined to appear among members of the tribe. This led John Collinge, head of UCL's Department of Neurodegenerative Disease, to travel to Papua New Guinea to investigate. Between 1996 and 2004, Collinge and his team collected information about the life histories of Fore tribesmen and women, and during that time, they identified 11 new cases of kuru. Writing in The Lancet, Collinge concluded that "the minimum estimated incubation periods ranged from 34 to 41 years... [but] incubation periods of infection with human prions can exceed 50 years," and last week he reiterated the possibility of a vCJD epidemic:
We must not forget that almost every person in the UK was exposed to the agent that causes variant CJD. It went through the entire food chain, not just in burgers but in cakes containing gelatins made from meat products. Even cosmetics contained beef-derived chemicals then.
It is, however, possible that some members of the Fore tribe continued to practice cannibalism after it was outlawed. This could explain the cases that emerged during Collinge's study, but does not necessarily preclude a long incubation period for kuru. It would, however, be very difficult to determine how effectively the law against cannibalism was enforced by the Australians. It is prudent to continue research into the prion diseases, because it is possible that we may face an epidemic of vCJD. (A study published last year, also led by Collinge, showed that prion disease symptoms and pathology are reversible.)
During their time with the Fore tribe, Collinge and his colleagues collected DNA samples from 10 of the 11 new cases of kuru that had emerged. Analysis of the samples showed that the 10 individuals were all homozygous for (i.e. had two identical copies of) one particular allele, or version, of the prion gene, which may have made them susceptible to infection. Similarly, the 156 British victims of vCJD could, Collinge says, "represent a distinct genetic subpopulation with unusually short incubation periods for BSE."
The newly identified prion disease, which has been named protease-sensitive prionopathy (PSPr), was reported by American physicians in last month's Annals of Neurology. In the 11 cases, the average age of onset of the disease was 62, and its duration, from the appearance of symptoms to time of death, ranged from 10 months and 5 years. Unlike most human prion diseases, the loss of motor function had been accompanied by cognitive decline, and the post-mortems showed a distinctive neuropathology.
Lead author Pierluigi Gambetti, head of the National Prion Disease Pathology Surveillance Center in Ohio, believes that the disease has probably "been around for many years, unnoticed." PSPr differs from other prion diseases in several ways. The disease gets its name because the prion protein isolated from the victims, unlike that from other prion diseases, was susceptible to degradation by enzymes called proteases. The abnormal prion protein was also detected at concentrations 16 times lower than in other prion diseases.
Gambetti insists that the disease is likely to caused by genetic and not environmental factors, and that there is no need for alarm. Significantly, none of the 10 victims had mutations in the prion gene, but several of them had close relatives who had been diagnosed with dementia. Thus, it seems that a mutation or mutations outside of the prion gene can generate prion-like pathology. This is the case in Alzheimer's Disease, in which there are mutations outside of the gene encoding the amyloid precursor protein. The new study should lead to a better understanding of the genetics of prion diseases, and Gambetti is now carrying out experiments in mice to determine how the new disease is transmitted.
Collinge, J. et al (2006). Kuru in the 21st century: an acquired human prion disease with very long incubation periods. Lancet 367: 2068-2074. DOI: 10.1016/S0140-6736(06)68930-7
Gambetti, P. et al (2008). A novel human disease with abnormal prion protein sensitive to protease. Ann. Neurol. 63: 697-708. DOI: 10.1002/ana.21420
Prions are scary. I find one of the most worrying things about them is that they don't know how to test for them in blood. For all we know they've been circulating around the blood domation clinics for the last ten/twenty years.
I never knew the incubation period was 50 years. I thought it was twenty. It's twenty in cattle, but I guess people are different. I'll go take a look at the review now :)
Thanks for a very interesting take on a difficult subject.
To satiate my own curiosity, is there any significant link between the proteins above and those that contribute to other neurological diseases like Alzheimer's disease?
opie: Very good question. The accumulation of abnormal proteins is a feature that is common to most, if not all, neurodegenerative diseases, not least of all Alzheimer's and the prion diseases.
In Alzheimer's, 2 different proteins accumulate: amyloid-beta protein builds up outside cells to form senile plaques, and tau protein builds up within cells to form neurofibrillary tangles.
Recent research suggests that amyloid-beta forms clumps in the same as prion diseases, by nucleation-polymerization. But whether the senile plaques are neurotoxic is still open to debate.
This is, for me, a very interesting post. Long before the British 'Mad Cow' scare, a seventy year old relative of mine went into a sudden decline (leading to death within several months of noticeable symptoms) which was eventually diagnosed as CJD. At the time, none of the family, self included, had even heard of the disease. At the same time, a much younger man with no connection to the family whatsoever, other than living about sixty km. away, also died of the disease. We were left with many unanswered questions.
You mentioned that kuru victims were considered extra tasty because of their fat distribution. Does kuru (or any of the other prion diseases) cause notable changes outside of neural tissue, or would people dying of kuru have lifestyle influences that affected their fat content?
Nice post, Mo.
Re: it would be good to know how effective the outlaw of cannibalisms was. I very briefly looked in to this after reading D.T. Max's book on the subject. In it, he said that cannibalism in the Fore was only adopted a few years before the Australians moved in. Allegedly, they had picked it up from a "more advanced" neighbouring tribe that they admired, and, admiring the Australians more, promptly dropped it when told to.
However, while reading Max, I regularly found myself wondering whether he was simply making it up as he went along -- large passages struck me as being more appropriate for the fiction shelves. According to Wikipedia, cannibalism did continue, but then, they cite Jared Diamond (doi:10.1038/35024175) who doesn't actually mention the Fore.
Re: comments #2 and #3 -- amyloid plaques aren't just found in neurodegenerative diseases -- http://en.wikipedia.org/wiki/Amyloid
Re: comment #4 -- sporadic CJD is 1:1 million. We'd expect 60 cases per year in the UK. However, BSE must have been around for an unknown period of time before it was actually identified...
Re: incubation times for vCJD -- here are a couple of open access papers with pretty pictures:
As for prions in the blood supply, in Canada, people who lived in the U.K. during certain years are not allowed to donate blood in case we may have contracted CJD. This is a reasonable limit, but not foolproof. A blood-screening test will be very helpful world-wide.
phisrow: I'm not sure how to answer your question, so I'll need to investigate further. That information comes from Shirley Lindenbaum, who was among the first cultural anthropologists to study the Fore.
Ann: Actually, a blood test for prions was developed over 2 years ago.
Joe: your comment went into the spam folder, as it contains a few links. I'll add that there are several genetic prion diseases in humans: Gertsmann-Straussler-Scheinker Syndrome (GSS) and Fatal Familial Insomnia (FFI), both of which are extremely rare.
From our website is:
In particular, I would flag up this:- http://www.scribd.com/doc/4022442/CJD-Presentation
Funny, I just read an excellent, if rather creepy SciFi story about the Fore, Kuru and Prions called "Damascus" by Daryl Gregory, in The Year's Best Science Fiction, volume 24. Funny how these things occur, hmm? :)
Astonishing. One of those things that jolt you. Reality is far more interesting than anything we can imagine.
Adam Zeeman in 'A Portrait of the Brain' gives an account of this. Although, he says the reason why women and children were affected more than men was because they were given the brain to eat (as it was not tasty), while men ate the fleshy bits which did not have the deadly prions.
I am still trying to digest the fact that Geometry can cause disease.
I wonder what is the smallest possible molecular devil that can cause disease by infection? We now know about prions' proteins. The minutest of lifeform, capable of replicating either directly or indirectly, seems headed to be redefined (or discovered).
Great ... eat a burger when you're 10 and die a horrible death when your 40, 50, or 60.
May I put my neck on the line, and I'm far from the only one to do so.
If one subscribes to Prof Prusiner's "Prion only" theory, nothing makes sense in reality. How he ever got a Nobel for this remains an utter $$$ mystery.
Unrelated, I cite the most recent TSE related Manuscript that actually has objective major significance. The fact that the authors chose to make this OA is a sign of the times.
This is a deeply disturbing paper. The extremely rapid time-course of the disease in the one primate innoculated with BASE presents an interesting clinical scenario if repeated in humans ï¿½ the diagnosis of vCJD, sCJD or ï¿½otherï¿½ takes longer than the time course of the disease. Therefore, human victims with the same profile would not be diagnosed as having ever had a prion disease. It would just appear on the death certificate as one of many, non-selective symptoms.
I will also recommend Richard Rhodes's "Deadly Feasts" that focuses on kuru, BSE and Gajdusek
Is it possible that the act of cannibalism itself can cause spongiform encephalopathy to spontaneously emerge within an individual? a species? or, does TSE/BSE require a patient zero with a natural genetic mutation of the abnormally folded prion protein to be consumed to get the whole prion disease/epidemic started?
@Mark: Some cases are associated with mutations in the prion gene (and likely other genes too), but many are sporadic.
Fascinating blog. I just happened to come across it after doing a search related to (and am surprised to have not seen this yet) the movie we just watched, The Book of Eli. The movie is a post-apocolyptic tale which, among other things, features an elderly couple and the female had a pronounced hand tremor. It is shortly after realized that these people have resorted to cannibalism as a means of survival. Throughout the movie, other humans encountered seem to be suspicious of strangers, always wanting to see their hands (presumably, for tremors). Long(er) story short, all of this led me to research and found, this article. It had been stated elsewhere that the couple had Prion disease.
Which, in and of itself, I find fascinating. However....all of the reading so far leads me to another question. You see, I am 35 and was diagnosed at age 26 with relapsing-remitting multiple sclerosis. I remember when I was diagnosed, and being told nobody knew the cause of MS, that I WAS told it was theorized to have a fifteen or twenty year "incubation period." (Seemingly odd to me, since they didn't know WHAT it was in the first place that causes it) So, while I realize that you cannot come out and say, "why yes, prion disease causes MS!," I would however like to hear your thoughts on the scientific POSSIBILITY of it at least being a factor. Specifically, why or why not (again, using scientific possibilities). Thank you for your time!
@Amy R: I don't know anything about a link between prions and MS. That both have long incubation periods is not reason enough to argue that one causes the other. There is some new research linking MS to gut bacteria, though.