A 61-year-old man presented with progressive bilateral hearing loss, and gait disturbance for 2 months. On examination, he presented anacusis, cerebellar syndrome, myoclonus, and frontal signs. Brain magnetic resonance imaging (MRI) showed bilateral striatum fluid-attenuated inversion recovery hyperintensity and restricted diffusion on diffusion-weighted imaging and corresponding apparent diffusion coefficient hypointense areas in the cerebral cortex (Figure 1). The electroencephalogram (Figure 2) showed three-phase periodic activity (0.8-1.3 Hz). Cerebrospinal fluid was in range, tau protein was 440 ng/L (slightly elevated), and 14-3-3 protein was negative. Auditory evoked potential revealed severe bilateral dysfunction of the vestibulocochlear nerves. In addition, laboratory tests, anti-thyroid peroxidase (TPO) test, autoimmune tests, and paraneoplastic screening were performed with negative results. The patient developed progressive cognitive worsening, akinetic mutism, and cortical blindness. After 5 weeks in hospital, the patient developed aspiration pneumonia progressing to sepsis and death. The pathology with immunohistochemistry was positive for PrPSc protein.


Figure 2. Electroencephalogram with periodic activity, biphasic or triphasic morphology, of 0.8-1.3 seconds, with diffuse distribution, lateralized to the right cerebral hemisphere, and predominantly posterior.


In the literature, few cases of bilateral hearing loss have been reported as an initial symptom of Creutzfeldt-Jakob disease (CJD). In our review, these cases were evaluated with audiometry and/or auditory evoked potentials. In only one of the cases, the auditory evoked potentials showed a central pattern of hearing loss. Two cases, including ours, had vestibulocochlear pattern involvement, another case was normal, and in the remaining cases, it was not possible to carry out the test or if the result was inconclusive.^1-6

Other causes of hearing loss associated with progressive encephalopathy should be taken under consideration, such as Whipple's disease, Lyme disease, human immunodeficiency virus, Susac disease, sarcoidosis, central nervous system vasculitis, lymphoma, and paraneoplastic disease.⁴

Prion disease should be considered in cases of rapidly progressive dementia with myoclonus; however, in one-third of the cases, it may initially manifest with atypical symptoms such as aphasia, pure ataxia, and visual or hearing loss. In atypical cases, the recognition of typical patterns for CJD on the brain is MRI and is of great importance to guide for further investigation. [5,6] Despite of bilateral hearing loss being a rare form of initial presentation of CJD, it should be part of the differential diagnosis of progressive encephalopathies with auditory symptoms.

Authors' contributions. JMAMBM: manuscript writing, study concept, and design. ESM, FLM, CSC, and PRBM: study concept and design.


REFERENCES

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4. Prodi E, Rossi S, Bertaina I, Pravatà E, Sacco L. Report of a case of Creutzfeldt-Jakob disease with an unusual clinical presentation. Front Behav Neurosci. 2020;14:55. https://doi.org/10.3389/fnbeh.2020.00055

5. Salazar R, Cerghet M, Ramachandran V. Bilateral hearing loss heralding sporadic Creutzfeldt-Jakob disease: a case report and literature review. Otol Neurotol. 2014;35(8):1327-9. https://doi.org/10.1097/MAO.0000000000000485

6. Geschwind MD, Murray K. Differential diagnosis with other rapid progressive dementias in human prion diseases. Handb Clin Neurol. 2018;153:371-397. https://doi.org/10.1016/B978-0-444-63945-5.00020-9










This study was conducted by the Hospital Universitário Oswaldo Cruz de Universidade de Pernambuco, Recife, PE, Brazil.

1. Department of Neurology, Hospital Universitário Oswaldo Cruz, Universidade de Pernambuco - Recife, PE, Brazil
2. Department of Neuropsychiatry, Unit of Neurology and Neurosurgery, Universidade Federal de Pernambuco - Recife, PE, Brazil
3. Medical Sciences College, University of Pernambuco, Recife, PE, Brazil

Janaina Mariana de Araujo Miranda Brito-Marques
Department of Neurology, Hospital Universitário Oswaldo Cruz, Universidade de Pernambuco
Rua Arnóbio Marques, 310 - Santo Amaro
50100-130 Recife PE - Brazil
E-mail: marianaaraujo6@gmail.com

Received on June 26, 2021
Accepted in final form on September 20, 2021

Disclosure: The authors report no conflicts of interest

Funding: none