The development of technologies for the in vitro amplification of the abnormal conformers of prion protein (PrP Sc ) has generated the potential for a novel diagnostic assay for prion disease. Previously, we developed a new PrP Sc amplification assay designated quaking-induced conversion (QUIC), which involves intermittent, automated shaking of the substrate, soluble recombinant PrP. We further improved the rapidity and practicality of this method by combining it with thioflavin T fluorescence to monitor the amyloid fibril formation. This assay, termed "real-time QUIC (RT-QUIC)", allows within 48 h, the detection of ≥1 fg of PrP Sc in diluted Creutzfeldt-Jakob disease (CJD) brain homogenate. Moreover, we assessed the technique first in a series of Japanese subjects, and then in a blind study of 30 cerebrospinal fluid specimens from Australia, which achieved greater than 80% sensitivity and 100% specificity. These findings indicate the promising enhanced diagnostic capacity of RT-QUIC in the ante-mortem evaluation of suspected CJD. Definitive ante-mortem confirmation of CJD requires the detection of PrP Sc in patient biopsy specimens, the practice of which is discouraged because it is both invasive and poses risks to health care personnel. Recently, however, in vitro PrP Sc amplification techniques, including protein misfolding cyclic amplification (PMCA) 5-7 , the amyloid seeding assay 8 , as well as QUIC have been reported to enable the direct and highly sensitive detection of PrP Sc in various tissues, including cerebrospinal fluid (CSF). QUIC assays involve the use of soluble recombinant PrP (rPrP-sen) as a substrate, which is seeded with PrP Sc , and then subjected to intermittent automated shaking. This technique can be performed more easily than the PMCA, which requires repeated sonication. Previous studies have demonstrated that QUIC assays correctly discriminated between normal and scrapie-infected CSF samples in both hamster and sheep prion disease models 9,10 . However, ultrasensitive PrP Sc detection in CSF from CJD subjects has not yet been accomplished. Accordingly, we further refined the QUIC 5 assay to improve its sensitivity and practicability, and then applied the technique in a blind pilot study to detect PrP Sc in CJD-CSF specimens.Given that a correlation between protease-resistant rPrP aggregate (rPrP-res) levels and thioflavin T (ThT) fluorescence had been shown previously 7 , we sought to determine the relative kinetics of rPrP-res formation by monitoring levels of ThT fluorescence in the QUIC assay. This was intended to minimize the time needed to detect rPrP-res. We first tested whether PrP Sc -dependent rPrP-res (rPrP-res (Sc) ) formation could be induced using a microplate reader with intermittent shaking. Human rPrP-sen (rHuPrP-sen) and a 10 -7 dilution of CJD (molecular subtype MM1) brain homogenate (BH) were used as the substrate and "seed", respectively. We conducted QUIC reactions at various concentrations (0, 0.25, 0.5 and 1.0 M) of guanidine-HCl (GdnHCl), because it h...