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Adra N, Goodheart AE, Rapalino O, Caruso P, Mukerji SS, González RG, Venna N, Schmahmann JD. MRI Shrimp Sign in Cerebellar Progressive Multifocal Leukoencephalopathy: Description and Validation of a Novel Observation. AJNR Am J Neuroradiol 2021; 42:1073-1079. [PMID: 33985948 DOI: 10.3174/ajnr.a7145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/07/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE There are no validated imaging criteria for the diagnosis of progressive multifocal leukoencephalopathy in the cerebellum. Here we introduce the MR imaging shrimp sign, a cerebellar white matter lesion identifiable in patients with cerebellar progressive multifocal leukoencephalopathy, and we evaluate its sensitivity and specificity. MATERIALS AND METHODS We first identified patients with progressive multifocal leukoencephalopathy seen at Massachusetts General Hospital between 1998 and 2019 whose radiology reports included the term "cerebellum." Drawing on a priori knowledge, 2 investigators developed preliminary diagnostic criteria for the shrimp sign. These criteria were revised and validated in 2 successive stages by 4 additional blinded investigators. After defining the MR imaging shrimp sign, we assessed its sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS We identified 20 patients with cerebellar progressive multifocal leukoencephalopathy: 16 with definite progressive multifocal leukoencephalopathy (mean, 46.4 [SD, 9.2] years of age; 5 women), and 4 with possible progressive multifocal leukoencephalopathy (mean, 45.8 [SD, 8.5] years of age; 1 woman). We studied 40 disease controls (mean, 43.6 [SD, 21.0] years of age; 16 women) with conditions known to affect the cerebellar white matter. We defined the MR imaging shrimp sign as a T2- and FLAIR-hyperintense, T1-hypointense, discrete cerebellar white matter lesion abutting-but-sparing the dentate nucleus. MR imaging shrimp sign sensitivity was 0.85; specificity, 1; positive predictive value, 1; and negative predictive value, 0.93. The shrimp sign was also seen in fragile X-associated tremor ataxia syndrome, but radiographic and clinical features distinguished it from progressive multifocal leukoencephalopathy. CONCLUSIONS In the right clinical context, the MR imaging shrimp sign has excellent sensitivity and specificity for cerebellar progressive multifocal leukoencephalopathy, providing a new radiologic marker of the disease.
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Affiliation(s)
- N Adra
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology (N.A., A.E.G., J.D.S.).,Wellesley College (N.A.), Wellesley, Massachusetts
| | - A E Goodheart
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology (N.A., A.E.G., J.D.S.)
| | - O Rapalino
- Neuroradiology Division (O.R., P.C., R.G.G.)
| | - P Caruso
- Neuroradiology Division (O.R., P.C., R.G.G.)
| | - S S Mukerji
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Department of Neurology, (S.S.M., N.V.), Neuroinfectious Diseases Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - N Venna
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Department of Neurology, (S.S.M., N.V.), Neuroinfectious Diseases Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - J D Schmahmann
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.) .,Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology (N.A., A.E.G., J.D.S.)
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Mazzai L, Facchinelli D, Borghero C, Vitale V, Ruggeri M, Iannucci G. Isolated cerebellar progressive multifocal leukoencephalopathy after allogeneic bone marrow transplantation: focus on imaging. TUMORI JOURNAL 2021; 107:NP45-NP48. [PMID: 33629654 DOI: 10.1177/0300891621997920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Progressive multifocal leukoencephalopathy (PML) is caused by JC virus opportunistic infection in the setting of immunodeficiency. Typical imaging features are multifocal and asymmetric lesions within supratentorial subcortical white matter in parieto-occipital regions. CASE DESCRIPTION A 47-year-old patient experienced a relapse of acute myeloid leukemia 21 months after hematopoietic stem cell transplantation. He also had visual impairment and magnetic resonance imaging showed an isolated cerebellar lesion without mass effect or enhancement. Common opportunistic infections and leukemic central nervous system involvement were excluded by cerebrospinal fluid (CSF) analysis. Given the worsening clinical and radiologic scenario, PML was suspected, and CSF protein chain reaction analysis was positive for JC virus. CONCLUSIONS Given its potential curability, PML should be thoroughly investigated in patients with hematologic neoplasms and atypical isolated cerebellar presentation.
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Affiliation(s)
- Linda Mazzai
- Neuroradiology Unit, Department of Diagnostics, San Bortolo Hospital, Vicenza, Italy
| | - Davide Facchinelli
- Hematology Unit, Department of Clinical Oncology, San Bortolo Hospital, Vicenza, Italy
| | - Carlo Borghero
- Hematology Unit, Department of Clinical Oncology, San Bortolo Hospital, Vicenza, Italy
| | - Valerio Vitale
- Neuroradiology Unit, Department of Diagnostics, San Bortolo Hospital, Vicenza, Italy
| | - Marco Ruggeri
- Hematology Unit, Department of Clinical Oncology, San Bortolo Hospital, Vicenza, Italy
| | - Giuseppe Iannucci
- Neuroradiology Unit, Department of Diagnostics, San Bortolo Hospital, Vicenza, Italy
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HIV-associated opportunistic CNS infections: pathophysiology, diagnosis and treatment. Nat Rev Neurol 2018; 12:662-674. [PMID: 27786246 DOI: 10.1038/nrneurol.2016.149] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nearly 30 years after the advent of antiretroviral therapy (ART), CNS opportunistic infections remain a major cause of morbidity and mortality in HIV-positive individuals. Unknown HIV-positive disease status, antiretroviral drug resistance, poor drug compliance, and recreational drug abuse are factors that continue to influence the morbidity and mortality of infections. The clinical and radiographic pattern of CNS opportunistic infections is unique in the setting of HIV infection: opportunistic infections in HIV-positive patients often have characteristic clinical and radiological presentations that can differ from the presentation of opportunistic infections in immunocompetent patients and are often sufficient to establish the diagnosis. ART in the setting of these opportunistic infections can lead to a paradoxical worsening caused by an immune reconstitution inflammatory syndrome (IRIS). In this Review, we discuss several of the most common CNS opportunistic infections: cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), tuberculous meningitis, cryptococcal meningitis and cytomegalovirus infection, with an emphasis on clinical pearls, pathological findings, MRI findings and treatment. Moreover, we discuss the risk factors, pathophysiology and management of IRIS. We also summarize the challenges that remain in management of CNS opportunistic infections, which includes the lack of phase II and III clinical trials, absence of antimicrobials for infections such as PML, and controversy regarding the use of corticosteroids for treatment of IRIS.
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Saylor D, Venkatesan A. Progressive Multifocal Leukoencephalopathy in HIV-Uninfected Individuals. Curr Infect Dis Rep 2016; 18:33. [PMID: 27686675 DOI: 10.1007/s11908-016-0543-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS) caused by the human neurotropic polyomavirus JC (JCV). The disease occurs virtually exclusively in immunocompromised individuals, and, prior to the introduction of antiretroviral therapy, was seen most commonly in the setting of HIV/AIDS. More recently, however, the incidence of PML in HIV-uninfected persons has increased with broader use of immunosuppressive and immunomodulatory medications utilized in a variety of systemic and neurologic autoimmune disorders. In this review, we discuss the epidemiology and clinical characteristics of PML in HIV-uninfected individuals, as well as diagnostic modalities and the limited treatment options. Moreover, we describe recent findings regarding the neuropathogenesis of PML, with specific focus on the unique association between PML and natalizumab, a monoclonal antibody that prevents trafficking of activated leukocytes into the CNS that is used for the treatment of multiple sclerosis.
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Affiliation(s)
- Deanna Saylor
- Division of Neuroimmunology and Neuro-Infectious Diseases, Department of Neurology, The Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Arun Venkatesan
- Division of Neuroimmunology and Neuro-Infectious Diseases, Department of Neurology, The Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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