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Li EC, Lai QL, Cai MT, Fang GL, Fang W, Zheng Y, Du Y, Du BQ, Shen CH, Qiao S, Ding MP, Zhang YX. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): contemporary advances and current controversies. J Neurol 2024; 271:1747-1766. [PMID: 38286842 DOI: 10.1007/s00415-024-12189-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/31/2024]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory syndrome with characteristic clinical, radiological, and pathological features, and can be effectively treated with corticosteroid-based immunotherapies. The exact pathogenesis of CLIPPERS remains unclear, and specific diagnostic biomarkers are not available. According to the 2017 diagnostic criteria, probable CLIPPERS should be considered in middle-aged patients with subacute onset of pontocerebellar symptoms and typical punctuate and curvilinear gadolinium enhancement lesions ("salt-and-pepper" appearance) located in the hindbrain (especially pons) on magnetic resonance imaging. In addition, CLIPPERS-mimics, such as central nervous system (CNS) lymphoma, and several antibody-associated autoimmune CNS diseases (e.g., myelin oligodendrocyte glycoprotein antibody-associated disease, autoimmune glial fibrillary acidic protein astrocytopathy, and anti-N-methyl-D-aspartate receptor encephalitis), should be extensively excluded. The prerequisite for definite CLIPPERS is the perivascular T-cell-predominant inflammatory infiltration observed on pathological analysis. A biopsy is strongly suggested when clinical/radiological red flags are present. Most patients with CLIPPERS respond well to corticosteroids and have a good prognosis. Long-term low-dose corticosteroid maintenance therapy or corticosteroids coupled with immunosuppressants are recommended to prevent the recurrence of the syndrome. The potential progression of CLIPPERS to lymphoma has been suggested in some cases; therefore, at least 2-year clinical and radiological follow-up is essential. Here, we critically review the recent developments and provided an update on the clinical characteristics, diagnostic criteria, differential diagnoses, and therapeutic management of CLIPPERS. We also discuss the current controversies in this context that can be resolved in future research studies.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Taikang Ningbo Hospital, Ningbo, 315042, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Wei Fang
- Department of Neurology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Yang Zheng
- Department of Neurology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Ye Du
- Department of Neurology, Shaoxing People's Hospital, Shaoxing, 312000, China
| | - Bing-Qing Du
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Song Qiao
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
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Galazky I, Büntjen L, Voges J, Sandalcioglu IE, Mawrin C, Haghikia A. Brain biopsy in patients with CLIPPERS syndrome: why and when. Ther Adv Neurol Disord 2022; 15:17562864211062821. [PMID: 35126669 PMCID: PMC8808022 DOI: 10.1177/17562864211062821] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory disorder of the central nervous system (CNS), predominantly involving the brainstem with a characteristic magnetic resonance imaging (MRI) appearance and clinical and radiological responsiveness to glucocorticosteroids. Yet diagnostic biomarkers are missing and other immune-mediated, (para-) infectious and malignant causes mimic CLIPPERS-like MRI presentations. We report the case of a 51-year-old male patient with CLIPPERS who repeatedly responded well to high-dose corticosteroids. After 7 months, however, treatment failed, and he had a biopsy-confirmed diagnosis of a CNS B-cell lymphoma. Clinical and MRI signs of CLIPPERS include a wide spectrum of differential diagnoses which often arise only later during the course of disease. Similar to the case presented here, delayed diagnosis and specific therapy may contribute to an unfavorable outcome. Hence, we propose that in the absence of other diagnostic markers, brain biopsy should be performed as early as possible in CLIPPERS patients.
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Affiliation(s)
- Imke Galazky
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Lars Büntjen
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jürgen Voges
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- German Center for Neurodegenerative Disease (DZNE), Bonn, Germany
| | - I. Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Mawrin
- Institute of Neuropathology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Aiden Haghikia
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
- German Center for Neurodegenerative Disease (DZNE), Bonn, Germany
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Taieb G, Mulero P, Psimaras D, van Oosten BW, Seebach JD, Marignier R, Pico F, Rigau V, Ueno Y, Duflos C, Fominykh V, Guiraud V, Lebrun-Frénay C, Camdessanché JP, Kerschen P, Ahle G, Téllez N, Rovira A, Hoang-Xuan K, Pelletier J, Labauge P. CLIPPERS and its mimics: evaluation of new criteria for the diagnosis of CLIPPERS. J Neurol Neurosurg Psychiatry 2019; 90:1027-1038. [PMID: 31072955 DOI: 10.1136/jnnp-2018-318957] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/20/2019] [Accepted: 04/10/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the accuracy of the recently proposed diagnostic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). METHODS We enrolled 42 patients with hindbrain punctate and/or linear enhancements (<3 mm in diameter) and tested the CLIPPERS criteria. RESULTS After a median follow-up of 50 months (IQR 25-82), 13 out of 42 patients were CLIPPERS-mimics: systemic and central nervous system lymphomas (n=7), primary central nervous system angiitis (n=4) and autoimmune gliopathies (n=2). The sensitivity and specificity of the CLIPPERS criteria were 93% and 69%, respectively. Nodular enhancement ( ≥ 3 mm in diameter), considered as a red flag in CLIPPERS criteria, was present in 4 out of 13 CLIPPERS-mimics but also in 2 out of 29 patients with CLIPPERS, explaining the lack of sensitivity. Four out of 13 CLIPPERS-mimics who initially met the CLIPPERS criteria displayed red flags at the second attack with a median time of 5.5 months (min 3, max 18), explaining the lack of specificity. One of these four patients had antimyelin oligodendrocyte glycoprotein antibodies, and the three remaining patients relapsed despite a daily dose of prednisone/prednisolone ≥ 30 mg and a biopsy targeting atypical enhancing lesions revealed a lymphoma. CONCLUSIONS Our study highlights that (1) nodular enhancement should be considered more as an unusual finding than a red flag excluding the diagnosis of CLIPPERS; (2) red flags may occur up to 18 months after disease onset; (3) as opposed to CLIPPERS-mimics, no relapse occurs when the daily dose of prednisone/prednisolone is ≥ 30 mg; and (4) brain biopsy should target an atypical enhancing lesion when non-invasive investigations remain inconclusive.
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Affiliation(s)
- Guillaume Taieb
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Patricia Mulero
- Centre d'Esclerosi Mútiple de Catalunya, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Dimitri Psimaras
- Department of Neurology, AP-HP Pitié-Salpêtrière, Service de Neurologie Mazarin, Paris, France
| | - Bob W van Oosten
- Department of Neurology, VU University Medical Center, Amsterdam, Netherlands
| | - Jörg D Seebach
- Department of Immunology and Allergology, University Hospital of Genève, Geneva, Switzerland
| | - Romain Marignier
- Centre de Recherche en Neurosciences de Lyon, INSERM U1028 and CNRS UMR5292, Equipe FLUID, Lyon, France
| | - Fernando Pico
- Department of Neurology, Centre Hospitalier de Versailles, Versailles, France.,University of Versailles Saint Quentin en Yvelines et Paris Saclay, Versailles, France
| | - Valérie Rigau
- Department of Neuropathology, University Hospital of Montpellier, Montpellier, France
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, DIM, University Hospital of Montpellier, Montpellier, France
| | - Vera Fominykh
- Department of Neurology, University Hospital of Moscow, Moscow, Russia
| | - Vincent Guiraud
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | | | - Jean-Philippe Camdessanché
- Centre de Recherche en Neurosciences de Lyon, INSERM U1028 and CNRS UMR5292, Equipe FLUID, Lyon, France.,Department of Neurology, University Hospital of Sainte Anne, Paris, France
| | - Philippe Kerschen
- Department of Neurology, University Hospital of Luxembourg, Luxembourg, Luxembourg
| | - Guido Ahle
- Department of Neurology, Hospital of Colmar, Colmar, France
| | - Nieves Téllez
- Department of Neurology, Hospital Clinico de Valladolid, Valladolid, Spain
| | - Alex Rovira
- Centre d'Esclerosi Mútiple de Catalunya, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Khe Hoang-Xuan
- Department of Neurology, AP-HP Pitié-Salpêtrière, Service de Neurologie Mazarin, Paris, France
| | - Jean Pelletier
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - Pierre Labauge
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
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Zhang L, Liu XH, Jin F, Liu MX, Zhang M, Zhang Y, Zhou DB, Zhang W. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) associated with or without lymphoma: Comparison of clinical features and risk factors suggestive of underlying lymphomas. J Clin Neurosci 2019; 66:156-164. [PMID: 31088767 DOI: 10.1016/j.jocn.2019.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We studied patients with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) associated with or without lymphoma and measured risk factors suggestive of an underlying lymphoma and follow-up outcomes. METHODS CLIPPERS patients associated with or without lymphoma were included into this study. Clinical presentations were documented, risk factors suggestive of an underlying lymphoma were tested, and prognostic differences in terms of death were compared. RESULTS Ten patients had a diagnosis of CLIPPERS associated with lymphoma, with 6 B-cell non-Hodgkin lymphoma, 2 T-cell non-Hodgkin lymphoma and 2 Hodgkin lymphoma. Using multivariate logistic analysis, the following 3 independent risk factors were found to be related to a final diagnosis of lymphoma: hyperreflexia (HR 16.56; 95% CI 1.03-265.29; p = 0.032), elevated protein in CSF (HR 11.59; 95% CI 1.24-108.39; p = 0.047), and recurrences between 2 months and 1 year after treatment (HR 29.27; 95% CI 2.09-409.58; p = 0.012). The model calibration was satisfactory (p = 0.392 with the Hosmer-Lemeshow test), and the discrimination power was good (area under the receiver operating characteristic curve 0.921; p < 0.001, 95% CI 0.826-1.000). Patients with CLIPPERS associated with lymphoma had higher mortality rate and lymphoma was a significant predictor of total mortality (HR 0.040; 95% CI 0.006-0.262; p = 0.001). CONCLUSIONS Hyperreflexia, elevated protein in CSF and recurrences between 2 months and 1 year after treatment are risk factors suggesting an underlying lymphoma. Relapses during high-dose steroids maintenance therapy can be indicative of lymphoma, too. Patients having CLIPPERS associated with lymphoma have a worse prognosis than those without lymphoma.
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Affiliation(s)
- Lu Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Xiao-Hang Liu
- Dept. of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Fan Jin
- Dept. of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Mei-Xi Liu
- Dept. of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Meng Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Yan Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Dao-Bin Zhou
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Wei Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
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Anand S, Das A, Choudhury SS. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) in limited cutaneous sclerosis: a rare disease combination. BMJ Case Rep 2019; 12:12/1/e226259. [PMID: 30617191 DOI: 10.1136/bcr-2018-226259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 26-year-old patient of limited cutaneous sclerosis presented to us with insidious-onset posterior fossa symptoms of headache, vomiting, vertigo and gait imbalance, progressing over a period of 3 weeks. A diagnosis of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids was made by combining the clinical features with radiological evidence showing punctate infiltration of the pons, brainstem and cerebellum. Relevant differentials in the form of neurosarcoid, infections, central nervous system (CNS) lymphoma and Neuro-Behcet's disease were ruled out by history and investigations. The patient responded dramatically to steroid therapy, and had no neurological deficits after 18 months of follow-up. This case highlights the rare association of a not-so-common immunological disease with a rare neurological disease.
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Affiliation(s)
- Sucharita Anand
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Animesh Das
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Tian D, Zhu X, Xue R, Zhao P, Yao Y. Case 259: Primary Central Nervous System Lymphomatoid Granulomatosis Mimicking Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS). Radiology 2018; 289:572-577. [PMID: 30332362 DOI: 10.1148/radiol.2018161475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Decai Tian
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Xiaodong Zhu
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Rong Xue
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Peng Zhao
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Yuanrong Yao
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
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Taieb G, Labauge P. CLIPPERS, a possible symptomatic lymphohistiocytic immune reaction. Brain 2017; 141:e5. [DOI: 10.1093/brain/awx298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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