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Kuru

  • Author: Zartash Zafar Khan, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Feb 17, 2016
 

Background

Kuru is among the fatal neurodegenerative prion protein (PrP) diseases in humans. Others include Creutzfeldt–Jakob disease (CJD), Gerstmann–Straüssler–Scheinker (GSS) disease, fatal familial insomnia (FFI), and variant CJD (vCJD).[1, 2] PrP diseases in nonhuman animals include bovine spongiform encephalopathy (BSE) also known as, mad cow disease, chronic wasting disease (CWD), scrapie, transmissible mink encephalopathy, feline spongiform encephalopathy, and ungulate spongiform encephalopathy. Although cross-species transmission of prion diseases seems to be limited by an apparent species barrier, the epidemic of BSE in the United Kingdom, which began in 1986, and its transmission to humans indicated that animal prion diseases could pose a significant public health risk.[3, 4]

Human prion diseases can be divided etiologically into inherited, sporadic, and acquired forms.[2, 5, 6, 7] Kuru is the focus of discussion in this article. The pathological and clinical characteristics of kuru that distinguish it from other PrP diseases in humans are also discussed.

The solution of the kuru riddle, which was initially considered a slow conventional viral disease,[8] opened a novel field of biomedical sciences and initiated more than a quarter century of research. This research has resulted in two Nobel prizes (D. Carleton Gajdusek in 1976 and Stanley B. Prusiner in 1997) and is linked to a third prize (Kurt Wüthrich, who determined the structure of the PrP).[9] Kuru research has affected the concepts of nucleation-polymerization protein cancers and conformational disorders.[9, 10]

Kuru affected the Fore (pronounced for-ay) linguistic group of the Eastern Highlands of Papua New Guinea and, to a lesser extent, neighboring groups with whom the Fore intermarried.[11] The word kuru is derived from a term in the Fore language that means “to shake from fear” and stems from trembling as a conspicuous symptom of the disease.[12] Local verbal history, recorded when the disease was first studied by Western medicine in the 1950s, dated the onset of the first case of kuru to the 1920s. During the epidemic, this disease predominantly affected women and children of both sexes, but only rarely affected men.[13]

Kuru was spread by the endocannibalistic funeral practices of the Fore. Family members were ritualistically cooked and eaten following their death, with the female relatives usually consuming the brain, which was the most infectious organ.[14] The brain of the deceased was usually removed by one of the older women from the community whose hand would be wrapped in ferns.[14] The prohibition of endocannibalism in the 1950s led to the decline in the epidemic; however, the disease has persisted into the present century because of an incubation period that may exceed 50 years. Only two kuru-related deaths were reported from 2003-2008, indicating that the epidemic is approaching its end.[15]

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Pathophysiology

The prion is a naturally occurring protein found in the CNS and elsewhere. Prion diseases are associated with an accumulation of a disease-related isoform of host-encoded PrP through a posttranslational process involving conformational change and aggregation. According to the protein-only hypothesis, an abnormal PrP isoform is the principal, and possibly sole, constituent of the transmissible agent or prion.[16] A common coding polymorphism at codon 129 of the PrP gene (PRNP), where either methionine (M) or valine (V) may be encoded, is a strong susceptibility factor for human prion diseases. Codon 129 heterozygosity protects against the development of iatrogenic and sporadic CJD and kuru.[17, 18, 2]

Protease-resistant glycoprotein, designated PrP, was isolated as a result of work done by Prusiner and coworkers in 1982 by progressive enrichment of brain homogenates for infectivity. The central feature of this protein was a posttranslational conversion of the host-encoded cellular prion protein (PrPC) to an abnormal isoform, termed PrPSc, that consists of ‘‘small proteinaceous infectious particles that resist inactivation by procedures which modify nucleic acids,” ie, radiation, heat, or enzymatic degradation.[19, 20]

A possible mechanism for prion propagation involves the largely alpha-helical isoform (PrPC) refolding into a beta-sheet isoform (beta-PrP). Beta-PrP is prone to aggregation in physiological salt concentrations. The process of recruitment of beta-PrP monomers is essentially thermodynamically irreversible and driven by intermolecular interactions.[19, 21] Any immunologic or inflammatory response to this infection is absent,[10] as prions are naturally occurring proteins.

Based on etiological classification, human prion diseases can be divided into inherited, sporadic, and acquired forms.

Acquired prion disease

Kuru is the most well-known example of acquired prion disease[2] that results from exposure to human prions during endocannibalism. Susceptibility to the disease is associated with homozygosity for methionine at PRNP codon 129. As stated above, heterozygosity on this codon is protective. A novel PRNP variant—G127V polymorphism—is recognized as an acquired prion disease resistance factor selected during the kuru epidemic.[17] There is no evidence for vertical transmission of kuru.[13]

Other examples of acquired prion disease include iatrogenic CJD and vCJD. Iatrogenic CJD has been caused by implantation of dura mater grafts, treatments using growth hormone derived from pituitary glands of human cadavers, corneal transplantation, contaminated electroencephalographic (EEG) electrodes, and surgical operations using contaminated instruments.[2] vCJD was recognized in the United Kingdom in 1995 and is caused by the same prion strain that causes BSE in cattle.[4, 2, 3] Concerns persist about the potential for transmission of prions via blood transfusion, nonnervous tissue organ donation, and other iatrogenic routes not involving consumption of central nervous system tissue from infected cattle.[22, 4]

Sporadic prion disease

Approximately 85% of cases of human prion disease occur sporadically as sporadic CJD at a rate of 1-2 cases per million population per year worldwide. It does not have a sexual predilection. The cause of sporadic CJD is unknown, although hypotheses include somatic PRNP mutation or spontaneous conversion of PrPC into PrPSc as a rare stochastic event.[23]

Inherited prion disease

Approximately 15% of human prion diseases are associated with autosomal dominant pathogenic mutations in PRNP.[23] The three main diseases that fall in this category include GSS, familial CJD, and FFI.[2, 19] Over 30 autosomal dominant pathogenic PRNP mutations have been described, and PRNP analysis can be used for presymptomatic genetic testing in affected families.[2]

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Epidemiology

Frequency

United States

Kuru does not occur in the United States.

Four cases of BSE, which is a prion disease in cattle, have been reported in the United States. The most recent was reported on April 24, 2012.[24]

Three cases of variant CJD in humans have been reported from the United States. By convention, variant CJD cases are ascribed to the country of initial symptom onset, regardless of where the exposure occurred. There is strong evidence that suggests 2 of the 3 cases were exposed to the BSE agent in the United Kingdom and that the third was exposed while living in Saudi Arabia.[25]

International

Kuru is restricted to the Fore, a people found in the New Guinea highlands, although there is a single report of a case of transmissible subacute spongiform encephalopathy occurring in a visitor to the eastern highlands of New Guinea.[10] Kuru was acquired during endocannibalistic funeral rituals.

When first investigated in 1957, kuru was found to be present in epidemic proportions, with approximately 1000 associated deaths in the first 5 years of observation, 1957-1961.[15] The total number of kuru cases from 1957-2004 exceeded 2700, with more than 200 dying of the disease every year in the late 1950s. This number fell to about 6 per year in the early 1990s and between one and two cases per year in late 1990s, with only 11 cases identified from July 1996 through June 2004.[13] More recently, kuru-related deaths declined to only two from 2003-2008.[15]

The prohibition of the practice of endocannibalism in the 1950s has clearly led to the decline in the epidemic, with a few cases still occurring because of kuru’s long potential incubation period, which can exceed 50 years.[15, 2] Only 9 cases of kuru have been reported among Fore people who were born after 1956, and no cases have been reported among those born after 1959.[13] The last fatality due to kuru was reported in 2005, and no known kuru cases have occurred since then.

However, zoonotic, not human, prion disease, that is BSE continues to be sporadically seen. The BSE epizootic in the United Kingdom peaked in January 1993. There exists strong epidemiologic and laboratory evidence for a causal association between a new human prion disease called variant CJD that was first reported from the United Kingdom in 1996 and the BSE outbreak in cattle.[26]

Mortality/Morbidity

There is no effective treatment for kuru. It is uniformly fatal within 4-24 months of symptom onset.[27] The incubation period may be as short as 5 years or as long as 50 years.[13]

Race

Kuru has affected only the people of the Fore linguistic group of the Eastern Highlands of Papua New Guinea and their neighbors with whom they intermarried.[13, 11]

The practice of endocannibalism was important to the Fore people as a way of respecting their dead relatives. It was rigorously forbidden, however, by the Australian government following the establishment of the Okapa patrol post in 1954 as one of the first administrative controls following contact with the people. Public consumption of dead relatives ceased almost immediately, and compliance was ensured by local police responsible for the subdistrict. By 1956, endocannibalism was effectively eliminated. Surreptitious eating of dead relatives was reported in remote communities for some years afterward, but, by the end of the 1950s, the practice had effectively ended. Epidemiological surveillance for kuru began in 1957 and has continued since.[13]

Sex

During the New Guinea epidemic, kuru was found to predominantly affect women and children of both sexes. Only 2% of overall cases were found in men from 1957-1958.[13]

Age

The latest year of birth recorded for any patient with kuru was 1959; only 9 individuals with kuru are recorded as having been born since 1956.[13] During the peak of the epidemic, it was estimated that most of the affected individuals were young women, but a small number of children and postmenopausal women were found to be infected, as well as postpubertal males in rare cases.[27]

These findings can be explained by women cooking and handling a dead relative's organs and women most commonly consuming the cooked brains. After age 6–8 years, boys were taken from their mothers and raised in the houses of men. From this point on, their exposure risk was the same as that for men, who typically had little participation in these feasts and did not eat cooked brains, by far the most infectious organ responsible for kuru. These cultural practices most likely explain why so few men developed kuru.[13]

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Contributor Information and Disclosures
Author

Zartash Zafar Khan, MD, FACP Infectious Disease Consultant

Zartash Zafar Khan, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, International Society for Infectious Diseases

Disclosure: Nothing to disclose.

Coauthor(s)

Mary Buechler, MD Staff Physician, Emergency Center, Lawrence General Hospital

Mary Buechler, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Occupational and Environmental Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Paul A Janson, MD Instructor, Tufts University School of Medicine; Consulting Staff, Department of Emergency Medicine, Lawrence General Hospital

Paul A Janson, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Mark Martin Huycke, MD Professor of Medicine, Infectious Diseases Section, University of Oklahoma Health Sciences Center; Chief, Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City

Mark Martin Huycke, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Rachel H Chung, MD Consulting Staff, Department of Family Practice, North Clinic, North Memorial Hospital

Disclosure: Nothing to disclose.

References
  1. Collinge J. Prion diseases of humans and animals: their causes and molecular basis. Annu Rev Neurosci. 2001. 24:519-50. [Medline].

  2. Wadsworth JD, Collinge J. Update on human prion disease. Biochim Biophys Acta. 2007 Jun. 1772(6):598-609. [Medline].

  3. Almond JW. Bovine spongiform encephalopathy and new variant Creutzfeldt-Jakob disease. Br Med Bull. 1998. 54(3):749-59. [Medline].

  4. Belay ED, Schonberger LB. The public health impact of prion diseases. Annu Rev Public Health. 2005. 26:191-212. [Medline].

  5. Haïk S, Brandel JP. Infectious prion diseases in humans: Cannibalism, iatrogenicity and zoonoses. Infect Genet Evol. 2014 Aug. 26C:303-312. [Medline].

  6. Takada LT, Geschwind MD. Prion diseases. Semin Neurol. 2013 Sep. 33(4):348-56. [Medline].

  7. Araújo AQ. Prionic diseases. Arq Neuropsiquiatr. 2013 Sep. 71(9B):731-7. [Medline].

  8. Gajdusek DC. Unconventional viruses and the origin and disappearance of kuru. Science. 1977 Sep 2. 197(4307):943-60. [Medline].

  9. Liberski PP, Brown P. Kuru: a half-opened window onto the landscape of neurodegenerative diseases. Folia Neuropathol. 2004. 42 Suppl A:3-14. [Medline].

  10. Grabow JD, Campbell RJ, Okazaki H, et al. A transmissible subacute spongiform encephalopathy in a visitor to the eastern highlands of New Guinea. Brain. 1976 Dec. 99(4):637-58. [Medline].

  11. Gajdusek DC, Zigas V, Baker J. Studies on kuru. III. Patterns of kuru incidence: demographic and geographic epidemiological analysis. Am J Trop Med Hyg. 1961 Jul. 10:599-627. [Medline].

  12. Hornabrook RW. Kuru. Contemp Neurol Ser. 1975. 12:71-90;294. [Medline].

  13. Collinge J, Whitfield J, McKintosh E, Beck J, Mead S, Thomas DJ, et al. Kuru in the 21st century--an acquired human prion disease with very long incubation periods. Lancet. 2006 Jun 24. 367(9528):2068-74. [Medline].

  14. Whitfield JT, Pako WH, Collinge J, Alpers MP. Mortuary rites of the South Fore and kuru. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3721-4. [Medline].

  15. Alpers MP. Review. The epidemiology of kuru: monitoring the epidemic from its peak to its end. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3707-13. [Medline].

  16. Prusiner SB. Novel proteinaceous infectious particles cause scrapie. Science. 1982 Apr 9. 216(4542):136-44. [Medline].

  17. Mead S, Whitfield J, Poulter M, Shah P, Uphill J, Campbell T, et al. A novel protective prion protein variant that colocalizes with kuru exposure. N Engl J Med. 2009 Nov 19. 361(21):2056-65. [Medline].

  18. Lee HS, Brown P, Cervenakova L, et al. Increased susceptibility to Kuru of carriers of the PRNP 129 methionine/methionine genotype. J Infect Dis. 2001 Jan 15. 183(2):192-196. [Medline].

  19. Collinge J. Molecular neurology of prion disease. J Neurol Neurosurg Psychiatry. 2005 Jul. 76(7):906-19. [Medline].

  20. Brandner S, Whitfield J, Boone K, Puwa A, O'Malley C, Linehan JM, et al. Central and peripheral pathology of kuru: pathological analysis of a recent case and comparison with other forms of human prion disease. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3755-63. [Medline].

  21. Chakraborty C, Nandi S, Jana S. Prion disease: a deadly disease for protein misfolding. Curr Pharm Biotechnol. 2005 Apr. 6(2):167-77. [Medline].

  22. Collinge J. Variant Creutzfeldt-Jakob disease. Lancet. 1999 Jul 24. 354(9175):317-23. [Medline].

  23. Collinge J. Human prion diseases and bovine spongiform encephalopathy (BSE). Hum Mol Genet. 1997. 6(10):1699-705. [Medline].

  24. Statement by USDA Chief Veterinary Officer John Clifford Regarding a Detection of Bovine Spongiform Encephalopathy (BSE) in the United States. United States Department of Agriculture. Available at http://usda.gov/wps/portal/usda/usdahome?contentid=2012/04/0132.xml. Accessed: April 29, 2012.

  25. vCJD (Variant Creutzfeldt-Jakob Disease) Date: August 23, 2010. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/ncidod/dvrd/vcjd/factsheet_nvcjd.htm. Accessed: April 29, 2012.

  26. BSE (Bovine Spongiform Encephalopathy, or Mad Cow Disease). Centers for Disease Control and Prevention. Available at http://www.cdc.gov/ncidod/dvrd/bse/. Accessed: April 29, 2012.

  27. Hornabrook RW. Kuru--a subacute cerebellar degeneration. The natural history and clinical features. Brain. 1968 Mar. 91(1):53-74. [Medline].

  28. Mandell G, Bennett J, Dolin R. Prions and prion diseases of the central nervous system. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier; 2005. Vol 2: 2221.

  29. Fiorino AS. Sleep, genes and death: fatal familial insomnia. Brain Res Brain Res Rev. 1996 Oct. 22(3):258-64. [Medline].

  30. Ridley RM, Baker HF. The myth of maternal transmission of spongiform encephalopathy. BMJ. 1995 Oct 21. 311(7012):1071-5; discussion 1075-6. [Medline].

  31. Collinge J. New diagnostic tests for prion diseases. N Engl J Med. 1996 Sep 26. 335(13):963-5. [Medline].

  32. Kobayashi A, Parchi P, Yamada M, Mohri S, Kitamoto T. Neuropathological and biochemical criteria to identify acquired Creutzfeldt-Jakob disease among presumed sporadic cases. Neuropathology. 2015 Dec 15. [Medline].

  33. Lampert PW, Gajdusek DC, Gibbs CJ. Subacute spongiform virus encephalopathies. Scrapie, Kuru and Creutzfeldt-Jakob disease: a review. Am J Pathol. 1972 Sep. 68(3):626-52. [Medline].

  34. Fichet G, Comoy E, Duval C, Antloga K, Dehen C, Charbonnier A, et al. Novel methods for disinfection of prion-contaminated medical devices. Lancet. 2004 Aug 7-13. 364(9433):521-6. [Medline].

  35. Rogez-Kreuz C, Yousfi R, Soufflet C, Quadrio I, Yan ZX, Huyot V, et al. Inactivation of animal and human prions by hydrogen peroxide gas plasma sterilization. Infect Control Hosp Epidemiol. 2009 Aug. 30(8):769-77. [Medline].

  36. Greenlee JJ, Nicholson EM, Hamir AN, Noyes GP, Holtzapple MT, Kehrli ME Jr. Ablation of prion protein immunoreactivity by heating in saturated calcium hydroxide. BMC Res Notes. 2008 Oct 28. 1:99. [Medline]. [Full Text].

  37. Gajdusek DC, Gibbs CJ Jr, Alpers M. Transmission and passage of experimental "kuru" to chimpanzees. Science. 1967 Jan 13. 155(759):212-4. [Medline].

  38. Brown P, Will RG, Bradley R, et al. Bovine spongiform encephalopathy and variant Creutzfeldt-Jakob disease: background, evolution, and current concerns. Emerg Infect Dis. 2001 Jan-Feb. 7(1):6-16. [Medline].

  39. Brown P, Bradley R. 1755 and all that: a historical primer of transmissible spongiform encephalopathy. BMJ. 1998 Dec 19-26. 317(7174):1688-92. [Medline].

  40. Carp RI, Kascsak RJ, Wisniewski HM, et al. The nature of the unconventional slow infection agents remains a puzzle. Alzheimer Dis Assoc Disord. 1989 Spring-Summer. 3(1-2):79-99. [Medline].

  41. Collinge J, Whitfield J, McKintosh E, Frosh A, Mead S, Hill AF, et al. A clinical study of kuru patients with long incubation periods at the end of the epidemic in Papua New Guinea. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3725-39. [Medline].

  42. Gajdusek DC. Kuru: an appraisal of five years of investigation. Eugen Q. 1962 Mar. 9:69-74. [Medline].

  43. Gajdusek DC, Zigas V. Degenerative disease of the central nervous system in New Guinea; the endemic occurrence of kuru in the native population. N Engl J Med. 1957 Nov 14. 257(20):974-8. [Medline].

  44. Gardash'ian AM. [Kuru]. Zh Nevropatol Psikhiatr Im S S Korsakova. 1969. 69(5):767-72. [Medline].

  45. Hadlow WJ. Scrapie and Kuru. Lancet. 1959. 2:289-290.

  46. Keohane C. The human prion diseases. A review with special emphasis on new variant CJD and comments on surveillance. Clin Exp Pathol. 1999. 47(3-4):125-32. [Medline].

  47. Lessons from kuru. Lancet. 2006 Jun 24. 367(9528):2034. [Medline].

  48. Liberski PP, Brown P. Kuru: its ramifications after fifty years. Exp Gerontol. 2009 Jan-Feb. 44(1-2):63-9. [Medline].

  49. Lindenbaum S. Review. Understanding kuru: the contribution of anthropology and medicine. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3715-20. [Medline].

  50. Mead S, Whitfield J, Poulter M, Shah P, Uphill J, Beck J, et al. Genetic susceptibility, evolution and the kuru epidemic. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3741-6. [Medline].

  51. Miller MW, Williams ES. Chronic wasting disease of cervids. Curr Top Microbiol Immunol. 2004. 284:193-214. [Medline].

  52. Mocsny N. The spongiform encephalopathies: prion diseases. J Neurosci Nurs. 1998 Oct. 30(5):302-6. [Medline].

  53. Nutr Rev. Nutrition and infection: cannibalism. Nutr Rev. 1971 Oct. 29(10):226-7. [Medline].

  54. Polo JM. [The history and classification of human prion diseases]. Rev Neurol. 2000 Jul 16-31. 31(2):137-41. [Medline].

  55. Serpell LC, Sunde M, Blake CC. The molecular basis of amyloidosis. Cell Mol Life Sci. 1997 Dec. 53(11-12):871-87. [Medline].

  56. Simpson NE. The map of chromosome 20. J Med Genet. 1988 Dec. 25(12):794-804. [Medline].

  57. Sy MS, Gambetti P, Wong BS. Human prion diseases. Med Clin North Am. 2002 May. 86(3):551-71, vi-vii. [Medline].

  58. Toledano-Gasca A. Hypotheses concerning the aetiology of Alzheimer's disease. Pharmacopsychiatry. 1988 Aug. 21 Suppl 1:17-25. [Medline].

  59. Tyler KL. Prions and prion diseases of the central nervous system. Curr Clin Top Infect Dis. 1999. 19:226-51. [Medline].

  60. Verdrager J. Kuru and "new variant" CJD. Southeast Asian J Trop Med Public Health. 1997 Sep. 28(3):535-40. [Medline].

  61. Wadsworth JD, Joiner S, Linehan JM, Asante EA, Brandner S, Collinge J. Review. The origin of the prion agent of kuru: molecular and biological strain typing. Philos Trans R Soc Lond B Biol Sci. 2008 Nov 27. 363(1510):3747-53. [Medline].

  62. Will RG, Ironside JW, Zeidler M, et al. A new variant of Creutzfeldt-Jakob disease in the UK. Lancet. 1996 Apr 6. 347(9006):921-5. [Medline].

  63. Wojtowicz S. Multiple sclerosis and prions. Med Hypotheses. 1993 Jan. 40(1):48-54. [Medline].

  64. Zigas V, Gajdusek DC. Kuru: clinical study of a new syndrome resembling paralysis agitans in natives of the Eastern Highlands of Australian New Guinea. Med J Aust. 1957 Nov 23. 44(21):745-54. [Medline].

 
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