DNA viruses- Verma Flashcards
1
Q
What are the three types of enveloped DNA viruses?
A
pox, herpes, hepadna
2
Q
What are the four types of nake capsid DNA viruses?
A
polyoma
papilloma
adeno
Parvo (SS)
3
Q
What kind of virus is the human herpes virus?
A
enveloped DNA virus
4
Q
What are the three types of alpha herpes virus?
A
VZV
HSV-1
HSV-2
5
Q
What are the three types of beta-herpesvirus?
A
CMV
HHV-6
HHV-7
6
Q
What are the 2 types of gamma-herpesvirus?
A
KSHV
EBV
7
Q
What happens after the primary infection of herpesvirus?
A
you get latent or persisten infection
8
Q
When will you get reactivation of herpesvirus?
A
during immunosuppresion
9
Q
Both primary herpesvirus infection and reactivations are likely to be more serious in (blank) patients.
A
immunocompromised
10
Q
Herpesvirus encode their own (blank) which are targets of anti-viral drugs.
A
DNA polymerase
11
Q
How does herpesvirus enter the cell?
A
receptor-mediated endocytosis
12
Q
How does herpesvirus replicate?
A
receptor mediated endocytosis viral DNA translocates to nucleus transcription via cellular RNA polymerase IE-> regulatory E- enzymes for DNA rep L-> structural
13
Q
What is the Herpes simplex virus?
A
HSV-1 and HSV-2
14
Q
HSV-1 and HSV-2 show latency in (blank)
A
neurons (latency associated with transcripts)
15
Q
How do you know someone has herpes simplex virus 1 versus herpes simplex virus 2?
A
antigenicity and location of lesions
16
Q
In HSV-1 where will you see lesions?
A
mouth, eye, skin (above the waist) CNS (encephalitis), disseminate to viscera in immunocompromised people
17
Q
IN HSV-2 where will you see lesions?
A
vesicular lesions below the waist (especially genitals), CNS (meningitis), neonates and doesnt disseminate to viscera in immunocompromised people
18
Q
What diseases are associated with HSV-1?
A
gingivostomatosis
herpes labialis (cold sores)
encephalitis
19
Q
Who primarily gets gingivostomatitis?
A
children
20
Q
What are the symptoms of gingivostomatitis?
A
fever, irritabiity, and vesciular lesions in the mouth. THe primary disease is more severe than the recurrences
21
Q
What is characteristic of herpes labialis (cold sores)?
A
reucrrent form-characterized by the crops of vesices at the mucocutaneous junctions of the lips or nose
22
Q
What is characteristic of encephalitis?
A
necrotic lesion in the temporal lobe. Fever, headache and seizures
23
Q
What are the 2 types of HSV-2 diseases?
A
genital herpes
neonatal herpes
24
Q
What is characteristic of genital herpes?
A
painful vesicular lesions on the genitals.
lesions are more severe in primary disease than in recurrences
primary infection present with fever
asymptomatic infections (some people have antibody to HSV-2 but have no history of disease)
25
What is charachteristic of neonatal herpes?
contact with vesicular lesions within the birth cana
| varies from severe disease (encephalitis) to milder local lesions (skin, eye, mouth) to asymptomatic infection
26
How is HSV-1 transmitted?
| Where do symptoms show?
through saliva
| face
27
How is HSV-2 transmitted?
| Where do symptoms show?
sexual contact
| genital area
28
How can you get HSV-2 in the oral region and HSV-1 on the genitals?
oral-genital sexual practices
29
(blank) percent of people in the US are infected with HSV-1 and (bank) percent have recurrent herpes labialis
50-60%
| 40%
30
Most primary infections by HSV-1 occur when?
childhood (evidenced by early antibodies)
31
When does HSV-2 appear?
at age of sexual activity
32
How can you diagnose HSV through the lab?
virus isolation and growth in culture (most definitive)
PCR-rapid diagnosis of encephalitis :detects DNA in spinal fluid
Serology-> for primary infection
Tzanck smear
33
What is this:
| base of vesicles are stained with Giesma stain. Multinucleated giant cells
Tzanck smear
34
How do you treat encephalitis caused by HSV-1 and HSV-2?
Acyclovir (acycloguanosine, zovirax)
35
How should you treat HSV-1 that is resistant to acyclovir?
with foscarnet
36
What is used to treat genita herpes?
valcyclovir and famciclovir
37
What can you do to prevent the spread of HSV-1 or HSV-2?
avoid vesicular lesions and if pregnant have a C-section if active lesions are present
38
A 20y old women present to the university health clinic with painful vesicular lesions on the vulva and perineum. She has not felt well the past week and complains of pain on urination. During the history, you find out that she has had unprotected sex with three different partners the past month. On physical examination, she has a low-grade fever and lymphadenopathy. You swab a vesicular lesion and submit the specimen to the laboratory to confirm your diagnosis. What is this?
HSV-2
39
What is varicella-zoster virus (HHV-3)?
```
Chicken pox (primary infection)
shingles (reactivation)
```
40
What does the primary infection of varicella result in?
chickenpox
41
What is the incubation period of varicella?
14-21 days
42
What is the clinical presentation of varicella?
fever, lymphadenopathy, and widespread vesicular rash
43
Complications with varicella are rare but occures more frequently in (blank) and (Blank) patients, it includes what three disease?
adults and immunocompromised
| viral pneumonia, encephalitis and hemorrhagic chickenpox
44
What is herpes zoster?
shingles
45
Who usually gets shingles?
people over the age of 50
46
How does herpes zoster (shingles) work?
the latent virus reactivates in sensory ganglion and tracks down the sensory nerve to the appropriate segment
47
What areas of the body will herpes zoster create major problems?
in the eye and face
48
Which people should not get shingles cuz it will unbelievable awful for them?
immunocompromised patients
| reactivation may occur mutiple times with severe complications
49
How do you treat varicella and herpes zoster?
with prevention; vaccines (varivax for varicella) and zostavax for zoster
50
Who should get varivax?
| Who should get zostavax?
recommended in 1-12 years children
| people over 60
51
What medications can reduce the duration of varicella/shingles in aduls?
acyclovir, famciclovir, valcyclovir
52
How can you diagnose varicella/shingles?
Cytology-Direct IFA, PCR (most sensitive)
Virus Isolation (difficult to isolate, virus very labile)
Serology: antibody titers are normally low
53
A 55y old women undergoing chemotherapy for metastatic breast cancer is seen by her oncologist because of ithcy, burning blisters on her rib cage that began 3 days earlier as a tingly or numb sensation. Physical examination reveals an otherwise healthy patient with vesicular eruptions along a thoracic dermatome.
What is this?
shingles!
54
What is epstein barr virus (HHV4)?
causes infectious mononucleosis, B-cell lymphoma and nasopharyngeal carcinoma (NPC)
55
What are the antigens found on epstein barr virus?
```
Viral capsid antigen (VCA)
Early antigens (EA)
Nuclear antigens (EBNA)
```
56
How can epstein barr virus present?
Infectious mononucleosis
Nasopharyngeal carcinoma
African Burkitt's lymphoma
Post-transplant lymphoproliferative disease (PTLD)
Oral Hairy Leukoplakia-(whitish non-malignant hairy surface on the lateral side of the tongue)
57
What does infectious mononucleosis present like?
infection in children is subclinical
| fatigue, fever, sore throat
58
How is EBV transmitted?
by saliva (greater than 90% of infected people shed virus for life)
59
At least (blank) percent of population is infected by age 30
70%
60
(blank) and (blank) people are at high risk for lymphoproliferative disorders.
AIDS and immunodeficient
61
How does the esptein barr virus spread throughout the body?
the infection occurs in oropharynx and spreads to blood to infect B lymphocytes
62
What is the immune response to EBV infection?
IgM antibody to VCA
IgG antibody to VCA persists for life.
IgM for acute infection and IgG for prior infection
63
What will a productive infection cause antibodies to make?
antibodies to VCA-MA-EA and when cell lysis occurs then to EBNA
64
If you are looking at blood, how do you know you are looking at EBV?
30% are atypical lymphocytes (enlarged nucleus and vaculoated cytoplasm)
65
How can you diagnose EBV?
hematologically
immunologically (heterophile antibody, EBV antibody)
PCR
66
What is heterophile antibody for?
for early diagnosis of Infectious mononucleosis
67
What is oral hairy leukoplakia?
whitish non-malignant hairy surface on the lateral side of the tongue caused by EBV
68
Can you use acyclovir on EBV?
| Is there a vaccine for EBV?
No :( this is very limited activity
| N0 :(
69
A 19y old college student presents to the student health clinic complaining of fever, fatigue and sore throat that developed about a month ago after spring break. Physical examination shows pharyngitis, cervical and axillary lymphadenopathy, and splenomegaly. Laboratory test show atypical lymphocytes and positive for heterophile antibody.
What is this?
EBV
70
What is the most common viral cause of congenital birth defects?
Cytomegalovirus (HHV5)
71
What kind of pathogen is cytomegalovirus and who does it sneak into?
opportunistic pathogen in immunocompromised patients
72
What can cytomegalovirus (HHV5) cause?
pneumonia, retinitis, and colitis in immunocompromised patients such as recipients of bone marrow.
73
Where is latency of cytomegalovirus found?
in stromal cells of the bone marrow
74
At what age can you get cytolomegalovirus?
any age, at birth you get congenital cytolomegalovirus that will effect .5-2.5% of all newborns in the US
75
How can you transmit CMV in children?
saliva
76
How can you transmit CMV in adults?
sexually
77
Risk for serious birth defects is extremely high for infants born to whom?
mothers with primary CMV infection during pregnancy
78
What wil you find in immune competent adults with CMV?
heterophile negative mononucleiosis fever and the presence of abnormal lymphocytes
79
What three inflammatory diseases occur in immune compromised individuals with CMV?
pneumonitis, retinitis, hepatitis
80
How do you treat CMV?
ganciclovir and foscarnet
81
How do you diagnose CMV?
histologicaly
w/ antibodies, probes, PCR
cell culture-easy
82
Is there a vaccine for CMV?
no
83
How do you prevent disseminated CMV infections in organ transplant patients?
a high titer immune globulin (cytogam)
84
What causes Roseola infantum?
HHV-6 and 7
85
What is the main target of HHV-6 and 7?
T lymphocyte, although B lymphocytes may be infected
86
HHV-6 and HHV-7 share limited nucelotide homology and antigenic (blank). SO how are they related to each other?
cross-reactivity
| similiar to how HSV1 and HSV2 are
87
Where do you find HHV-6 and HHV-7?
it is ubiquitous worldwide
88
How do you transmit HHV-6 and HHV-7?
through saliva and breast feeding
89
By the time of (blank), 90-99% of the population becomes infected by both viruses
adulthood
90
When is the earliest you can get HHV6 and HHV7 infection? Why?
acquired after the age of 4 months when the effect of maternal antibody wears off
91
Primary (blank) is associated with roseola infantum, a classic diease of childhood
HHV-6
92
What happens with HHV-6 after you get infected?
A spiking fever develops over a period of 2 days followed by a mild rash.
93
How do you diagnose HHV-6 and HHV-7?
IgM and IgG
94
A 9 month old infant is seen in a pediatric practice with a history of irritability and a fever of 103oF for 3 days followed by appearance of a generalized erythematous maculopapular rash on the neck and truck. The infant was treated symptomatically and recovered within a few days without complications
This is Roseola infantum caused by HHV-6
95
What is HHV8?
Kaposi sarcome herpesvirus
96
What is Kaposi's sarcoma herpesvirus associated with?
castleman's disease and primary effusion lymphomas
97
Most patients with KS have antibodies against (blank)
HHV-8
98
The seroprevalence of HHV8 is (blank) among the general population but (blank) in groups susceptible to KS, such as homosexuals
low
| high
99
A 28y old homosexual man is seen by a dermatologist with complaints of bluish-purple spots on his chest and thigh. History is significant for feeling tired and intermittent diarrhea for the past year and unprotected sex with multiple partners. Physical examination reveals generalized lymphadenopathy. A biopsy of a lesion is submitted to confirm the diagnosis.
What is this?
Kaposi's sarcoma herpesvirus: HHV8
100
In 18th centry, this virus accounted for 7-12% of deaths in england
pox virus
101
Has smallpox been eradicated?
yes
102
Pox virus is a category (blank) select agent
A
103
The virion paricle of the pox virus is....?
ds DNA genome and DNA dependent RNA polymerase
104
Where does the pox virus replicate?
in the cytoplasm
105
How many serotypes does the pox virus have?
one, this is why we can have a successful vaccine for it
106
How do you transmit pox virus?
respiratory aerosol or by direct contact with virus
107
What does the small pox virus infect?
upper respiratory tract-lymph node-blood vessels (primary viremia)
108
When pox virus is messing with the internal organs and the virus reenters blood and is exposed in the skin, what is this called?
secondary viremia
109
What is the rash in small pox due to?
replication of virus in the skin
110
What is the incubation period of the pox virus?
7-14 days
111
What is the clinical presentation of the pox virus?
fever, malaise
| rash worst on the face and extremities
112
How do you diagnose pox virus?
culturing virus, viral antigens
113
Disease is eradicated by the global use of (blank)
live attenuated vaccine
114
Why was the vaccine successful for small pox?
single serotype, and no animal reservoir
115
How do you give the small pox vaccine?
intra-dermally, forms vesicles
116
Exposed individuals can be immunized up to (blank) days POST infection and be protected from small pox!!! AMAZING
4 days
117
How can you treat small pox?
vaccine immune globulins-high titer antibodies- treat complications
118
What does molluscum contagiosum virus cause?
small papule of the skin or mucus membrane. This are painless, non-itchy and non-inflamed lesions
119
Where do the lesions of molluscum contagiosum virus most commonly occu?
on trunk, genitalia, proximal extremities
120
Do the lesions of molluscum contagiosum virus occur in lines or clusters?
clusters
121
What is the incubation period of lesions of molluscum contagiosum virus?
2-8 weeks
122
How do you diagnose molluscum contagiosum virus?
clinically cuz the virus is not culturalable
123
A 9y old boy is seen in a pediatric practice with a chief complaint of multiple lumps on his face that have persisted for 2 weeks. Physical examination reveals multiple painless, flesh-colored, nodule on the face and trunk without signs of inflammation. What is this?
molluscum contagiosum virus
124
What is the structure of HBV (hepatitis B virus)?
small enveloped DNA virus-DsDNA
125
Viral particles of HBV are resistant to what?
low pH, freezing, moderate heating (this hinders disinection)
126
What does the envelope of HBV contain?
surace antigens (HBsAg) which are used for diagnosis
127
What are 2 other important antigens of HBV other than HBsAg?
HBcAG
| HBeAG
128
What are the only natural hosts of HBV?
humans
129
What are the three main modes of transmission for HBV?
blood, sexual and perinatal (mother to newborn)
130
HBV is prevalent in (blank) users
IV drug
131
HBV is worldwide but prevalent in (blank)-high incidence of hepatocellular carcinoma
asia
132
(blank) vaccine is the first to prevent human cancer
HBV
133
Many HBV infections are (blank) and can be detecte dby HBsAG?
asymptomatic
134
HBV can cause acute hepatitis, what are the symptoms of this?
fever, fatigue, nausea, pain associated with hepatomegaly
135
(blank) occurs in 5-10% of the people infected with HBV
Chronic hepatitis
136
One third of chronic hepatitis patients caused by HBV will develop what?
cirrhosis and liver failure
137
80% of cases of (blank) are due to chronic HBV infection.
primary hepatocellular carcinoma (HCC)
138
How do you diagnose HBV?
biochemical (liver enzymes)
| and serological tests
139
What is IgM antibody to HBcAg and indicator of
acute infection of HBV
140
HbsAg antibody is associated with (blank) infection
chronic
141
Is there a treatment for acute hepatitis B?
no
142
How do you treat chronic hepatitis B?
interferon alpha, lamivudine, adefovir, or entecavir
143
How can you get immunized against HBV?
with recombinant HBsAg vaccine
144
Neonates born to HBsAg (+) mothers are given (blank)
HBV IgG
145
A 29y old man with a history of injection drug use is seen by an internist with complaints of fever, fatigue, nausea loss of appetite, joint pain and abdominal soreness for the past few weeks, he reports that his urine is dark and his skin looks yellowish. On examination, he is jaundiced, with an enlarged and tender liver, subsequent laboratory tests were positive for elevated liver enzymes and serum bilirubin. Serologic tests was positive for HBsAg and IgM anti-HBc.
HBV
146
Approx. (bank) people worldwide are infected by Hep D virus
15 million
147
What is the structure of Hep D?
small circular enveloped RNA genome
148
When will HDV propagate?
Ony in the presence of HBV
149
HBV and HDV are transmitted through the (blank) so the person is co-infected
same route
150
What does HDV do?
codes for delta agent which surrounds the genome.
151
Where is delta agent present?
blood, semen, vaginal secretions
152
Replication of the delta agent leads to (blank) damage
liver
153
How can you tell if HDV is present?
detecting RNA genome, delta antigen or anti-HDV antibodies
154
A 45y old male is seen in the medical clinic with complaints of fatigue, anorexia, nausea, vomiting and low grade fever for the past 5 days. In the morning, he noticed his urine was dark and stools were clay-colored. On examination, his liver was enlarged and tender. He recently returned from a week-long trip to Nepal.
What is this?
HEV (hepatitis E virus)
155
What are symptoms of HEV?
```
dark colored urine
clay colored stools
hepatitis
trip to nepal
fecal-oral route pathogen
```
156
IS adenovirus enveleoped or naked?
Naked
157
Where do you find adenovirus?
upper and lower respiratory tract disease (pharyngitis, conjuctivitis, common cold and pneumonia)
158
How many different serotypes are there of adenovirus?
50
159
What are the clinical manifestations of adenovirus?
pharyngo-conjuctival fever (adenovirus type 3 and 7)-fever, pharyngitis, conjuctivitis and cervical adenopathy
160
What is responsible for this:
Pneumonias and common cold- all ages
conjunctivitis (pink eye)-all ages
Acute respiratory disease (types 4 and 7)-all ages
Kerato-conjunctivitis (types 8, 19 and 37)-adults
Acute gastroenteritis (types 40 and 41)-infants and young children
adenovirus
161
What types of adenovirus cause acute respiratory disease?
4 and 7
162
What types of adenovirus cause kerato-conjunctivitis?
8,19,37
163
What types of adenovirus cause acute gastroenteritis?
40 and 41
164
How does the adenovirus work?
infects epithelial cell lining of oropharynx, respiratory and intestinal tract and causes cytotoxic damage
165
How is the adenovirus spread?
aersol, close contact or fecal oral route
166
What is important for resolving an infection caused by adenovirus?
antibody
167
How can you identify the idenovirus?
cultures, or direct antigen detection (serology) and PCR
168
Is there a specific antiviral therapy for adenovirus?
no
| just wash your hands
169
A 9-year-old girl is seen in a pediatric practice with conjunctivitis and sore throat that has continued for 3 days. On examination, the child has a fever; pharyngitis, conjunctival redness, watering, pain and cervical adenopathy. A rapid strep test is negative. You collect a conjunctival and pharyngeal swab for viral culture and antigen detection.
What is this?
adenovirus
170
HPV causes (blank)
papillomas (benign tumors of squamos cells)
171
Which HPV types cause carcinoma of cervix, penis and anus?
16 and 18
172
WHich virally encoded genes are implicated in carcinogenesis of HPV? How come?
E6 and E7
| cuz they inhibit tumor suppressor genes
173
How can you get warts (skin and planter warts) from HPV?
HPV 1-4
174
How can you get Anogenital warts from HPV?
HPV6 and HPV11
175
HPV can give you laryngeal papilloma in young children, what are these?
benign head and neck tumors
176
Carcinoma of the uterine cervix, penis and anus are caused by what HPV strandS
16 and 18
177
HPV is very (resistant/responden) to inactivation
resistant
178
How can you get infected with HPV?
breaks in skin/sexual intercourse, infant passing through infected birth canal
179
Planter/flat warts are common in who?
young children/middle aged adults
180
What is the most prevalently sexually transmitted infection in the world?
HPV (20 million infected in US, 6 million new genital cases per year)
181
(Blank) occur in young children/middle aged adults
laryngeal papillomas
182
HPV is present in (blank) percent of all cervcal cancers
99.7%
183
What are all the high risk HPV strains?
| What are the low risk?
16,18,31,45
| 6 and 11
184
What will happen if HPV infects and replicats within the squamos epithelium?
general warts
185
What will happen if HPV infects and replicates within the mucous membranes ?
genital, oral & conjuctival papilomas
186
HPV 16 and 18 create cervical carcinomas contain (Blank)
integrated DNA
187
E6/E7 are oncogenes- they inactivate cellular growth supressors which are (blank and blan)
p53 and RB
188
How do you diagnose HPV?
microscopic examination. DNA molecular probes/PCR
189
How do you treat HPV?
Podophylin/interferon/cidofovir
| Liquid nitrogen for skin warts (surgical removal or treated with salicylic acid)
190
What are the vaccines you can get against HPV and what do they protect against?
gardasil: 6,11,16,18
Cervarix: 16 and 18
191
A 25y old women presents to her gynecologist with complaints of itching, burning and tenderness in the genital area. The patient is sexually active but with no history of sexually transmitted disease. Physical examination is significant for for flesh-colored papules on the labia and vulva. A pap smear is performed to check for cervical abnormalities. WHat is this?
genital warts
| HPV 6 and 11
192
Tell me about the parvovirus?
Parvirus B19 is very small non-enveloped ssDNA virus. Only one serotype. Virus replicates in the nucleus
193
What can parvovirus cause??
1 erythema infectiosum (slapped cheek syndrome, fifth disease)
194
What does 1 erythema infectiousum look like?
bright red rash prominent on cheeks accompannied by low grade fever, runny nose and sore throat
195
Several Children in a kindergarten class were seen at a pediatric practice with a bright red rash on the cheeks. All children were in a good physical condition, other than mild fever and some abdominal rash. The rashes resolved over 1 to 2 weeks without specific treatment. What is this?
1 erythema infectiosum
196
What are the three types of polyomaviridae viruses and whom do they affect?
JC virus and BK virus infects humans
| SV40, a monkey virus can also infect humans
197
Is polyomavirus bigger or somaller than papilloma?
smaller (genome 5kb)
198
What can JC virus cause?
Progressive multifocal leukoencephalopathy (PML)
199
What is progressive multifocal leukoencephalopathy?
fatal demyelinating disease of white matter (involves multiple areas of the brain)
Affects visual field and results in blindness, weakness, dementia, and patients die wtihin 6 months. Mostly occurs in AIDS patients
200
What can BK virus cause?
nephropathy and graft loss in immune suppressed renal transplant patients
201
Antibodies to JC virus are found in (blank) of normal human sera.
75%
202
BK virus infection is (blank)
widespread
203
In immune compromised individuals, latent virus is (blank) to cause disease
reactivated
204
Polyomavirus persists in the (blank) cells, and is excreted in the urine
kidney cells
205
How do you diagnose polyomavirus?
PCR from CSF
206
How do you treat polyomavirus?
no treatment but cidofovir may be beneficial
207
A 69y old man with complaints of speech and vision abnormalities and decreasing mental function is referred to a neurologist. The patient has a 3y history of chronic lymphocytic leukemia that is being treated with chemotherapy. MRI reveals multiple focal areas of demyelination.
What is this?
Progressive multifocal leukoencephalopathy caused by JC
208
A 34y old male presented to the ER with gait disorder of about 2 months. A series of laboratory tests were ordered that came out to be either negative of within normal limits. His condition got progressively worse over the next few weeks. MRI revealed patchy lesions in the white matter of the brain. Past medical history was significant for HIV+ immunoassay, CD+ count of 10 and viral load of 500,000.
What is this?
Progressive multifocal leukoencephalopathy
209
What are prions?
a unconventional slow virus that lacks nucleic acid and creates degenerative disorders of the brain
210
What do prions cause?
transmissible spongiform encephalopathies which cause spongiform degeneration.
211
What is caused by ingesting or handing brain tissue; occured in new guinea tribes people
KURU
212
How long is the incubation period of Kuru?
can exceed 50 years
213
What is caused by iatrogenic transmission by corneal transplant, brain electrodes, or growth hormone, OR mutation in germ cells, or can be caused sporadicly?
Creutzfeldt Jakob Disease
214
(blank) are the cause of transmissible spongiform encephalopathies such as creutzfeldt-jakob disease.
Prions
215
What all can create prions?
```
familial
sporadic
iatrogenic
vCJD
Kuru
Human
Feline encephalopaty
chronic wasting disease of deer and elk
bovine spongiform encephalopathy (BSE)
mink encephalopathy
scrapie
```
216
A 67y old previously healthy women was referred to a neurologist because of a 2-month history of increased dementia manifested as confusion, memory loss, and bizarre behavior. On physical examination , she exhibited ataxia and slurred speech. Hematologic studies were normal.
What is this?
creutzfeldt jakob disease
