title: Agraphia of Kanji (Chinese characters): an early symptom of sporadic Creutzfeldt-Jakob disease in a Japanese patient: a case report.
abstract: BACKGROUND
  Slowly progressive cognitive decline is the most frequent initial manifestation in MM2-cortical-type sporadic Creutzfeldt-Jakob disease. Agraphia has never been noted in patients with this type of sporadic Creutzfeldt-Jakob disease, however, we report the case of a Japanese patient with sporadic Creutzfeldt-Jakob disease in whom agraphia of Kanji was an initial cardinal symptom.
  
  
  METHODS
  A 59-year-old right-handed Japanese woman complained of agraphia of Kanji (Chinese characters) as an initial symptom. A neurological examination revealed mild word-finding difficulty, constructive disturbance, hyperreflexia in her jaw and lower limbs, and bilateral extensor plantar reflexes. An examination of her cerebrospinal fluid revealed increased levels of 14-3-3 and total tau proteins, and abnormal conformation of the proteinase K-resistant prion protein. Diffusion-weighted magnetic resonance imaging showed diffuse hyperintensity in bilateral cerebral cortices. Single-photon emission computed tomography scans revealed hypoperfusion in the left temporal lobe, bilateral parietal and occipital lobes. An analysis of the prion protein gene demonstrated no mutation with homozygous for methionine at the codon 129. We diagnosed our patient with sporadic Creutzfeldt-Jakob disease. Although a histological examination was not performed, it was assumed that our patient could be the MM2-cortical type according to the clinical findings and the elevated levels of 14-3-3 protein in her cerebrospinal fluid. The left posterior inferior temporal area, which was affected in our patient as a hypoperfusion area, is associated with selecting and recalling Kanji characters.
  
  
  CONCLUSIONS
  Focal signs as an early symptom and hypoperfusion areas in sporadic Creutzfeldt-Jakob disease are critical to recognize initial brain lesions damaged by the proteinase K-resistant prion protein accumulation.
authors.affiliation: Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa 9208640, Japan. k-nkmr@med.kanazawa-u.ac.jp.
authors.forename: Keiko
authors.initials: K
authors.lastname: Nakamura
authors.forename: Kenji
authors.initials: K
authors.lastname: Sakai
authors.forename: Miharu
authors.initials: M
authors.lastname: Samuraki
authors.forename: Ichiro
authors.initials: I
authors.lastname: Nozaki
authors.forename: Masako
authors.initials: M
authors.lastname: Notoya
authors.forename: Masahito
authors.initials: M
authors.lastname: Yamada
mesh_terms: D000381:Agraphia / Q000175:diagnosis* / Q000209:etiology; D002540:Cerebral Cortex / Q000000981:diagnostic imaging / Q000473:pathology*; D007562:Creutzfeldt-Jakob Syndrome / Q000150:complications / Q000175:diagnosis*; D038524:Diffusion Magnetic Resonance Imaging; D016643:Encephalopathy, Bovine Spongiform / Q000150:complications / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008875:Middle Aged; D015899:Tomography, Emission-Computed, Single-Photon
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