COLLECTIVE REVIEWS
Prions: Reassessment of
the Germ Theory of Disease
Donald E Fry, MD, FACS
The recognition that prion infection from animal-to-
human and iatrogenic human-to-human transmission
without the presence of a microbial pathogen means that
the germ theory of disease must be reassessed. A review of
the literature on human prion-associated diseases was con-
ducted to identify the etiology, pathophysiology, and clin-
ical associations of these uncommon but transmissible neu-
rodegenerative diseases. Particular interest was placed on
recognition of iatrogenic transmission of disease in the
health care setting and in the potential for transmission
with transfusion of blood products. Acquired (or second-
ary) Creutzfeldt-Jakob (CJ) disease has occurred in more
than 200 patients from the ingestion of beef products con-
taminated with prion proteins from cattle infected with
bovine spongiform encephalopathy. More than 400 cases
of iatrogenic transmission of CJ disease have occurred in
the health care setting from contaminated bioextracts, bi-
ologic implants, and surgical instruments. Four cases of
transmission have been associated with blood transfusions.
BACKGROUND
The germ theory of disease evolved in the 1860s and 1870s
and has been the fundamental principle in our understand-
ing and management of infectious diseases. Pasteur con-
ceived of the germ theory from his studies of fermentation
and observations of infection in the silk worm.1 Robert
Koch scientifically documented the fundamental postu-
lates of the germ theory. From Koch’s postulates we have
traditionally believed that living microorganisms cause in-
fection and contagious disease. The microorganism must
be cultured from the infected individual, the pathogen
should be grown in vitro, and the pathogen can then be
reinoculated and re-recovered from the susceptible host
that has been challenged and developed the disease. For
surgeons the germ theory was an important consideration
in Lister’s clinical studies on the prevention of surgical site
Disclosure Information: Nothing to disclose.
Received May 17, 2010; Revised June 28, 2010; Accepted June 29, 2010.
From the Department of Surgery, Northwestern University Feinberg School
of Medicine, Chicago, IL, and the Department of Surgery, University of New
Mexico School of Medicine, Albuquerque, NM.
Correspondence address: Donald E Fry, MD, Michael Pine and Associates,
5020 S Lake Shore Dr, 304N, Chicago, IL 60615. Email: dfry@consultmpa.
com.
© 2010 by the American College of Surgeons
Published by Elsevier Inc.
infection. Among all theories in human disease, the germ
theory is one of the most sacred.
In 1982, Prusiner2 identified a protein that was associ-
ated with transmission of a degenerative neurologic illness
of sheep and goats that is known as scrapie, a condition in
which the affected animal would try to “scrape” its wool
coat off on a fence post or fixed object. This infectious
agent was a protein only and did not have any nucleic acid
associated with it. Administration of the protein resulted in
transmission of the disease to the naïve host, and infection
could even be transmitted across species. A fascinating fea-
ture of the protein was that it did not generate any antibody
response within the newly “infected” host. Prusiner labeled
this protein a prion, a term derived from PRotein Infection
ONly, for which he received the Nobel Prize. Although
some dispute remains about many specific aspects of prion
disease, pathogenic prion protein has been generally ac-
cepted as the etiologic agent in a host of transmissible dis-
eases of animals and of man.3 Furthermore, cross-species
transmission with prions has now been documented to
occur to man from cattle4 (eg, mad cow disease) and has
created yet even more interest and fear about whether these
agents may have a far greater role in human illness than has
been appreciated.
PRION PROTEIN
Prion protein is a normal product of a specific human gene.
The protein product of this gene (PrPc) appears physiolog-
ically as a glycoprotein that has a molecular weight of ap-
proximately 35 kDa.5 It is a ubiquitous protein that is
anchored on all cell membranes, but appears under normal
circumstance to be principally located within neural tis-
sues. The functional role of PrPc remains poorly under-
stood but is associated with central nervous system devel-
opment, synaptic transmission, regulation of circadian
rhythms, and memory and cognitive functions.6
The pathologic prion protein (PrPsc) represents an un-
changed amino acid sequence, but has a misfolded second-
ary and tertiary protein structure.7 Degenerative neuro-
logic disease is the consequence of the abnormally folded or
configured protein. PrPsc has other important features in-
cluding resistance to proteinases, radiation, and detergents
that have particular significance for transmission and ex-
pression of disease.8
Several animal diseases are associated with prion infec-
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Vol. 211, No. 4, October 2010
tion. In addition to scrapie (sheep and goats), transmissible
mink encephalopathy,9 feline spongiform encephalopa-
thy,10 and chronic wasting disease of muledeer and elk11 are
all rare prion-mediated diseases. Mad cow disease, or bo-
vine spongiform encephalopathy, is of greatest interest be-
cause it is more common than the other animal diseases,
but especially because of experimental and clinical evidence
of transmission to man from beef products.12,13 The term
spongiform has been used to describe many of the prion-
associated diseases because of the vacuolation and cavita-
tion that give the “sponge-like” histologic appearance of the
brain tissue from infected animals and humans.14
Human diseases associated with prions have been few in
number and have been rarely seen. They assumed limited
clinical interest until recent years. Creutzfeldt-Jakob (CJ)
disease was first described in the 1920s and has had an
overall incidence of about 1 case per million people.15
Gerstmann-Straussler-Scheinker syndrome is a rare degen-
erative neurologic illness that has a much longer time
course than CJ disease and is quite rare.16 It is exclusively a
familial disease and has been reported in only 50 families
around the world. Fatal familial insomnia is a genetic illness
of central and southern Europe.17 Kuru is from Papua New
Guinea and was associated with past cannibalistic rites of
eating human brain tissue.18 Observations of Kuru led ini-
tially to speculation that a viral pathogen might account for
this oral transmission, until the prion link was defined.
CJ disease has been the most thoroughly studied of the
prion-associated diseases. It has been traditionally identi-
fied in 2 different forms. About 15% of all CJ disease is a
familial illness.19 It is an autosomal dominant disease asso-
ciated with genetic mutation that results in a phenotype of
all prion proteins being PrPsc. Until recently, about 85% of
CJ disease was noted to be sporadic disease. The sporadic
form of the disease is not associated with a mutant germ-
line gene locus and protein transcripts are PrPc, but are
transformed to the pathologic PrPsc after synthesis. This
transformation may potentially be from a somatic muta-
tion or spontaneous reconfiguration of the protein. With
recognition of transmission of bovine spongiform enceph-
alopathy, speculation has focused on an environmentally
acquired cause of sporadic disease. Regardless of cause, the
prion proteins of the sporadic cases assume the pathologic
configuration that characterizes all forms of CJ disease.20
Both familial and sporadic diseases cause clinical disease to
develop in the 50- to 70-year age group and have similar
symptoms of progressive dementia, myoclonus, and
ataxia.21 Death follows the onset of symptoms, usually
within 6 months.
New variant-CJ (vCJ) Disease has emerged in the wake
of the bovine spongiform encephalopathy epidemic in the
Fry Prions and the Germ Theory of Disease 547
Table 1. Source of Iatrogenic Creutzfeldt-Jakob Disease Re-
ported from All Countries
Source of iatrogenic Creutzfeldt-Jakob Disease n
Dura mater grafts 196
Growth hormone 194
Surgical instruments 4
Gonadotropin 4
Transfusion 4
EEG needles 2
Corneal transplants 2
Total 406*
*The total is updated by one additional case of blood transfusion-associated
disease not in the original report by Brown and coauthors.38 The incubation
time of iatrogenic infection is quite long with most exposure events occurring
in the 1980s. It is anticipated that some additional cases will be identified and
reported.
United Kingdom,22 with the majority of the cases being in
that country (Table 1). Ingestion of beef products13 con-
taminated with infected neural tissue resulted in the emer-
gence of unanticipated numbers of cases of CJ disease that
were subsequently identified as vCJ disease,23 an illness that
has different characteristics than traditional CJ disease. Pa-
tients with vCJ disease have a median age in the late 20s
(with a wide age range) and tend to have psychiatric symp-
toms of depression, anxiety, cognitive decline, and then
progressive neurologic deficits.24 The vCJ disease patients
live longer than 1 year after clinical onset of the disease. The
disease is the consequence of the transformation of the
host’s normal PrPc protein to the pathologic PrPsc
configuration.
PATHOGENESIS
Although not fully elucidated, considerable progress has
been made in understanding the pathogenicity of this in-
fectious protein.25 The abnormal configuration of the
prion protein structure appears to be the key. With vCJ
disease the orally ingested prion protein resists digestion
and appears to enter the gut-associated lymph tissue.26,27
The ingested prion is transported to neural tissues via the
blood borne route, either as free protein or with B-cell
lymphocyte carriers. The presence of the pathologically
configured protein then serves as a biologic template for
the reconfiguration of normal host PrPc to the patho-
logic PrPsc. As the host continues to synthesize new
PrPc, the presence of the pathologic PrPsc reconfigures
the normal protein to the abnormal and pathologic
structure. Natural proteolysis is ineffective in eradicat-
ing the pathologic proteins. Progressive accumulation of
PrPsc and associated protein fragments lead to the toxic
neurologic phenotype. The progressive accumulation of
the PrPsc results in dysfunctional synaptic activity, amy-
548 Fry Prions and the Germ Theory of Disease
loid deposition in tissue, and progressive neurodegen-
erative changes that are thought to be mediated at least
in part by apoptotic mechanisms. Partial proteolysis of
PrPsc results in a very protease-resistant residue that po-
lymerizes and results in amyloid deposition.28
Because not all people ingesting contaminated beef de-
veloped the disease, the inoculum of ingested PrPsc may be
critical. The local environment within the host, other foods
that were concurrently eaten with the protein contami-
nant, and the integrity of the host defense mechanisms may
also be significant variables. Finally, a genetic predisposi-
tion may be a major risk factor in all types of prion disease
including vCJ disease. Infected patients consistently are
found to be methionine/methionine homozygotes for the
polymorphic codon 129 of the normal prion amino acid
sequence, which is the genotype for 40% of the Caucasian
population.
Methionine/valine heterozygotes (50%) or valine/valine
homozygotes (10%) appear to not be susceptible or rela-
tively resistant to infection.29 Some evidence in the few
cases identified among the heterozygotes demonstrates a
longer period of time from exposure to clinical disease.30,31
So although new cases of vCJ disease have declined with
improved cattle feeding practices and more rigorous sur-
veillance to identify evidence of diseased animals, concern
persists that late evolving cases from the initial wave of
illness may still occur.
DIAGNOSIS
The diagnosis of CJ disease is based on development of
progressive neurodegenerative symptoms and is highly
variable in clinical presentation.32-34 Dementia is present in
100% of the patients. Myoclonus is identified in more than
80%. Pyramidal and extrapyramidal signs are seen in the
majority of cases. Visual disturbances and extraocular mus-
cle signs are present in 20% to 30%. Lower motor neuron
signs, sensory deficits, and seizures are seen in advanced
disease, but are identified in less than 20% of patients at the
time of diagnosis. Because prions do not stimulate an in-
flammatory response, fever and leukocytosis are not char-
acteristics of this transmissible disease.
The EEG can be useful, with periodic sharp-wave com-
plexes being identified in vCJ disease; sporadic disease pa-
tients have normal EEGs until the illness is very advanced.
Magnetic resonance imaging may demonstrate hyperlu-
cency of the putamen, and other evidence to support this
diagnosis.35 Lumbar punctures followed by a Western blot
assay have identified the 14-3-3 kinase-inhibitor family of
proteins.36
Pathologic assessment of brain tissue from either brain
biopsy or at necropsy confirms the diagnosis. Spongiform
J Am Coll Surg
changes are typically found with astrocytosis and neuronal
loss. There are no neutrophil or lymphocyte infiltrates
around the spongiform changes. Amyloid plaques are seen,
which are extracellular accumulations of prion protein. Im-
munohistochemical stains can demonstrate PrPsc in fixed
or unfixed brain tissue. Immunohistologic staining of ton-
sillar biopsies have been of value in making the diagnosis in
vCJ disease. Because the protein composition of the PrPsc
has a normal amino acid sequence, the malconfigured en-
tity does not generate an antibody response and serologic
studies are not of value. New therapies are being explored,
but the treatment for all types of CJ disease remains sup-
portive care only.37
IATROGENIC DISEASE
More than 400 cases of iatrogenic CJ disease have now been
identified.38 Iatrogenic illness has followed the clinical pat-
tern of vCJ disease except that the age of the patients is
highly variable. Iatrogenic disease is disproportionately as-
sociated with the methionine/methionine homozygotes for
codon 129, which again reflects the susceptibility of this
genotype for transmission.
Iatrogenic transmission has occurred with the use of hu-
man brain extracts,39 dura mater implants,40 corneal trans-
plants,41 use of contaminated surgical instruments that
have previously been used on CJ patients,42 and most re-
cently from blood transfusions.43,44 Table 1 shows the num-
ber of patients that have been identified with CJ disease by
each route. Iatrogenic transmissions have occurred in Eu-
rope, Asia, and the United States, and reflect the interna-
tional distribution of prion disease (Table 2). Transmission
through the administration of growth hormone is no
longer an issue with recombinant technology. Dura mater
grafts are being limited in use and donors are intensively
screened. Corneal transplant donors are screened very
carefully.
Iatrogenic infections have permitted estimates of the la-
tency of the infection after exposure to the pathologic pro-
tein. Clinical disease has been relatively short, at 1 to 2
years after exposure with contaminated neurosurgical in-
struments, but has been greater than 20 years after admin-
istration of growth hormone, corneal transplants, and
human gonadotropin administration.45 Incubation is es-
timated at anywhere from 5 to 15 years for vCJ disease and
may be even longer for selected cases and for specific geno-
types.46 Attributing transmissible CJ disease either to iatro-
genic causes or ingestion of contaminated foods makes
identification of outbreaks a most difficult proposition.
Surgical instruments that have been used on patients
with documented CJ disease must be treated with a vigor-
Vol. 211, No. 4, October 2010 Fry Prions and the Germ Theory of Disease 549

Table 2. Countries of Origin for All Secondary Cases of SURGICAL SIGNIFICANCE OF PRIONS
Creutzfeldt-Jakob Disease that are Variant Creutzfeldt-Jakob
Although CJ disease has principally been the clinical pur-
Disease from Consumed Prions
vCJ Iatrogenic CJ
view of the neurologist, prion diseases need to be under-
Country of origin disease* disease† stood and appreciated by surgeons. These diseases remain
United Kingdom 169 65‡ rare at the present time, but the latency of vCJ disease
France 25 121 speaks to the issue that unknown numbers of clinically
Spain 5 10 occult new cases may be in the offing.
Ireland 4 1 Transmission from blood transfusion from CJ patients
United States 3 30 has been documented. PrPsc has been identified in blood of
Netherlands 3 3 humans and animals with clinical disease, and experimen-
Italy 2 4 tal transfusion from sheep with either scrapie or bovine
Portugal 2 0 spongiform encephalopathy has been documented to
Japan 1 123 transmit infection to naïve recipients.51 There is no practi-
Canada 1 4 cal method for screening units of blood for an illness that is
Saudia Arabia 1 0 this uncommon. In the UK and Europe, leukocyte reduc-
Australia 0 10 tion of donated units is a practice that is used to reduce the
Germany 0 9 risk of vCJ disease transmission.52 Even though patients
New Zealand 0 8 with clinical CJ disease would not be donating blood, the 4
Switzerland 0 3 cases of transfusion-associated transmission occurred from
Austria 0 2 donors who only demonstrated clinical illness years after
Argentina, Brazil, Croatia, Qatar, giving blood. Blood transfusion can be a risk for transmis-
South Africa, Thailand: 1 each 0 6 sion of vCJ disease to the recipient patient.
Total 216 406§ Could vCJ disease be an occupational risk for surgeons?
*Data from The National Creutzfeldt-Jakob Disease Surveillance Unit There are no documented reports of occupational trans-
(NCJDSU). http://www.cjd.ed.ac.uk.
†
mission. It is apparent that PrPsc is present in large quanti-
From contaminated medical instruments, tissues, blood products, or biolog-
ical extracts.39
ties in lymphoid tissues. The tonsil is biopsied for diagnosis
‡
Includes the 4 transfusion-associated cases from the UK. of vCJ disease, and the appendix is a common surgical
§
The country of origin is not identified in 7 cases. structure that is dense in lymphoid tissues.53 Multiple other
CJ, Creutzfeld-Jakob; vCJ, new variant Creutzfeld-Jakob. tissues from a patient with vCJ disease have recently been
identified with prion protein.54 Exposure of the surgeon
ous and intense decontamination process.47 It must be em- with a percutaneous injury could transmit infection when
phasized that 4 cases of iatrogenic transmission have oc- tissues are laden with the pathologic prion. In the experi-
curred in patients undergoing intracranial neurosurgical mental laboratory there have been documented transmis-
procedures with surgical instruments used in previous sions from dermal injury,55 and from oral56 and lingual57
brain operations of CJ-diseased patients.48,49 These trans- sites. The transmission of vCJ disease to neurosurgical pa-
missions occurred despite conventional sterilization of the tients from instruments used in previous cases makes expo-
instrumentation used on the source patients, which led to sure in the operating room a theoretical threat to the sur-
geon. An argument could be made that transmission might
the subsequent iatrogenic transmissions! Conventional
occur by exposure from blood that contains PrPsc. Two
sterilization processes of surgical instruments do not neu-
such publications by surgeons have raised this source of
tralize the prion of CJ disease. Incineration and discarding
concern.58,59 Any occurrence of CJ disease in surgeons or
of instrument sets is the only certain method to avoid iat-
any healthcare worker requires reporting and an in-depth
rogenic transmission after contact with CJ brain tissue be- evaluation of possible occupational transmission.
cause of the great difficulties that have been documented
with conventional sterilization procedures of instruments
that would ordinarily denature any protein. The resilience FUTURE CONSIDERATIONS
of this protein to high temperatures, chemical agents, and Recognition of transmissible disease mediated by a protein
enzymatic digestion is one of the very interesting and dif- that is not associated with a microbe or nucleic acid is
ficult issues with PrPsc. The current recommended steril- revolutionary and means that our traditional view of the
ization process for surgical instruments (in addition to in- germ theory of disease needs to be modified. It immedi-
cineration) and the surgical environment from the World ately begs the question of how many other neurodegenera-
Health Organization is detailed in Table 3.50 tive illnesses may be mediated by prions or other protein
550 Fry Prions and the Germ Theory of Disease J Am Coll Surg

Table 3. Options for Decontamination and Sterilization of Surgical Supplies after Exposure to a Patient with Creutzfeldt-Jakob
Disease
Incineration
● Preferred method for all instruments exposed to high infectivity tissues (brain, spinal cord, eye).
● Use for all disposable instruments, materials, and wastes.
Autoclave/chemical methods for heat-resistant instruments
● Immerse in 1N sodium hydroxide (NaOH) and heat in a gravity displacement autoclave at 121°C for 30 min; clean; rinse in water and
subject to routine sterilization, or
● Immerse in 1N NaOH or sodium hypochlorite (20,000 ppm) for 1 h; transfer instruments to water; heat in a gravity displacement
autoclave at 121°C for 1 h; clean and subject to routine sterilization, or
● Immerse in 1N NaOH or sodium hypochlorite (20,000 ppm) for 1 h.; remove and rinse in water, then transfer to open pan and heat
in a gravity displacement (121°C) or porous load (134°C) autoclave for 1 h; clean and subject to routine sterilization, or
● Immerse in 1N NaOH and boil for 10 min at atmospheric pressure; clean, rinse in water and subject to routine sterilization, or
● Immerse in sodium hypochlorite (20,000 ppm) (preferred) or 1N NaOH (alternative) at ambient temperature for 1 h; clean; rinse in
water and subject to routine sterilization, or
● Autoclave at 134°C for 18 minutes (infectivity may not be completely removed).
Chemical methods for surfaces and heat sensitive instruments
● Flood with 2N NaOH or undiluted sodium hypochlorite; let stand for 1 h.; mop up and rinse with water.
● Where surfaces cannot tolerate NaOH or hypochlorite, thorough cleaning will remove most infectivity by dilution and some
additional benefit may be derived from the use of one or another chemical disinfectants.
Wherever possible, instruments and other materials subject to re-use should be kept moist between the time of exposure to infectious materials and subsequent
decontamination and cleaning. If it can be done safely, removal of adherent particles through mechanical cleaning will enhance the decontamination process.50
(Adapted from: World Health Organization. WHO manual for surveillance of human transmissible spongiform encephalopathies including variant Creutzfeldt-
Jakob disease. 2003. Annex 4.1, page 85, with permission.)

products.60 Slow viruses or autoimmune disease have been
hypothesized for many years to explain chronic neurologic
illnesses. Abnormal protein configurations that result in
relentless dementia could lead to speculation for such an
etiology in Alzheimer’s disease. Prions and other configu-
rational abnormalities of neuroproteins could be far more
important in human disease than have been appreciated.
For surgeons, it should be appreciated that microbes are
not a requirement for transmissible diseases. It does raise
the specter of prions and other proteins as infectious agents
in the operating room. Transmission may occur from pa-
tient to patient from contaminated surgical instru-
ments.61,62 Occupational risks of blood exposure from pa-
tients with unappreciated protein-mediated diseases
cannot be discounted. Although threats from hepatitis B
and human immunodeficiency virus infections appear to
have waned in the last decade, the vigilance in the use of
personal protective equipment and safe practices that avoid
blood exposure in the operating room must be continued.
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