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Kojita Y, Okada N, Hirakawa M, Fujii K, Satou T, Ishii K. Extensive brainstem lesions in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD): A case report. Radiol Case Rep 2024; 19:5589-5594. [PMID: 39296754 PMCID: PMC11406359 DOI: 10.1016/j.radcr.2024.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/05/2024] [Accepted: 08/07/2024] [Indexed: 09/21/2024] Open
Abstract
Myelin oligodendrocyte glycoprotein antibody-associated disease is a group of central nervous system demyelinating disorders caused by autoantibodies. While myelin oligodendrocyte glycoprotein antibody-associated disease typically presents as optic neuritis and myelitis in adults, this case report details a patient with brainstem lesions. A 45-year-old male presented with episodes of vertigo, nystagmus, and diplopia in left lateral gaze, which had persisted for 2 months, accompanied by headache. Computed tomography showed hyperdensity extending from the left side of the pons to the middle cerebellar peduncle. Magnetic resonance imaging revealed lesions exhibiting heterogeneous diffusion restriction, with enhancement that included granular and linear patterns. 18F-fluorodeoxyglucose positron emission tomography demonstrated increased uptake in these lesions. Following further evaluation, myelin oligodendrocyte glycoprotein antibody-associated disease was diagnosed. Treatment with high-dose corticosteroids initially alleviated symptoms, but symptoms flared upon reduction of the steroids. This case underscores the importance of considering myelin oligodendrocyte glycoprotein antibody-associated disease in the differential diagnosis of brainstem lesions and discusses distinguishing imaging features from similar conditions.
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Affiliation(s)
- Yasuyuki Kojita
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Nonoka Okada
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Mayumi Hirakawa
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Kanako Fujii
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takao Satou
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Kazunari Ishii
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
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2
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Alkabie S, Diamond EL. Erdheim-Chester Disease Masquerading as CLIPPERS. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200294. [PMID: 39047207 PMCID: PMC11270893 DOI: 10.1212/nxi.0000000000200294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES To present 4 patients with Erdheim-Chester disease (ECD) based on clinical, radiologic, histopathologic, and molecular genetic findings who had enhancing brainstem lesions and were initially believed to have chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). METHODS Case series. RESULTS Although patients with ECD can demonstrate clinical and imaging features similar to CLIPPERS, refractoriness to corticosteroids, lack of fulfillment of specific MRI criteria (i.e., enhancing lesions >3 mm, T2 abnormalities that exceed areas of T1 postgadolinium enhancement), and systemic findings such as "hairy kidney" appearance and metadiaphyseal osteosclerosis on 18F-fluorodeoxyglucose PET-CT help discriminate it from CLIPPERS. DISCUSSION ECD is a histiocytic neoplasm characterized by multiorgan infiltration of clonal histiocytes carrying activating variants of the MAPK-ERK pathway. Neurologic involvement occurs in up to 40% of ECD with frequent brainstem lesions that can mimic acquired neuroinflammatory disorders, such as CLIPPERS. ECD is an important CLIPPERS mimic with distinct pathophysiology and targeted treatments. We highlight the need to consider histiocytic disorders among other alternate diagnoses when findings are not classic for CLIPPERS.
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Affiliation(s)
- Samir Alkabie
- From the Department of Neurology (S.A.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital; and Department of Neurology (E.L.D.), Memorial Sloan Kettering Cancer Center, New York
| | - Eli L Diamond
- From the Department of Neurology (S.A.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital; and Department of Neurology (E.L.D.), Memorial Sloan Kettering Cancer Center, New York
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3
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Cruciani A, Motolese F, Tortorella C, Haggiag S, Santoro F, Pozzilli V, Rossi M, Pilato F, Gasperini C, Di Lazzaro V, Capone F. Unusual CLIPPERS presentation with a predominant spinal cord involvement: case report and review of the literature. Neurol Sci 2024; 45:3737-3742. [PMID: 38499887 DOI: 10.1007/s10072-024-07469-w] [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: 01/28/2024] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a discrete nosological entity characterized by punctate and curvilinear gadolinium enhancement "peppering" the pons and a strong response to steroids. MRI images typically show pontine and cerebellar punctate-enhancing lesions, which occasionally spread up to the juxtacortical areas and down to the spinal cord. Interestingly, the more distant the lesion is from the pons, the less intense they become. Herein, we describe an extremely rare case of CLIPPERS presenting with predominant spinal cord involvement; then, we searched in the literature the available cases with a similar presentation. Our case focuses attention on a rare MRI CLIPPERS presentation. Since CLIPPERS has a dramatic response to corticosteroid treatment, it is fundamental to promptly recognize its MRI pattern to start treatment as soon as possible.
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Affiliation(s)
- Alessandro Cruciani
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy.
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| | - Francesco Motolese
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carla Tortorella
- Dipartimento di Neuroscienze, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Shalom Haggiag
- Dipartimento di Neuroscienze, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Francesca Santoro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Valeria Pozzilli
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Mariagrazia Rossi
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabio Pilato
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Claudio Gasperini
- Dipartimento di Neuroscienze, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fioravante Capone
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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4
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Mashriqi F, Saks R, Alkabie S, Franceschi AM. 18 F-FDG Brain PET/MRI in Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids. Clin Nucl Med 2024; 49:669-671. [PMID: 38498679 DOI: 10.1097/rlu.0000000000005166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
ABSTRACT An 89-year-old man presented with progressive gait disturbance, diplopia, and ataxia. Initial brain MRI demonstrated T2/FLAIR hyperintense signal abnormality in the pons extending along the middle cerebellar peduncles into the cerebellum, with associated punctate, patchy, and linear enhancement on postcontrast imaging. Initially, this was attributed to brainstem encephalitis; however, sarcoidosis, histiocytosis, and paraneoplastic/autoimmune encephalitis remained on the differential. One month after initial MRI, 18 F-FDG brain PET/MRI was performed and showed marked pontine hypermetabolism corresponding to the signal abnormality and enhancement on structural imaging. Collectively, these findings are characteristic of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids.
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Affiliation(s)
| | - Rachel Saks
- From the Neuroradiology Division, Department of Radiology
| | - Samir Alkabie
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
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Abdelkader O, Abuzenah H, Shuhaiber H. Headache As the Sole Symptom in Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS): A Case Report and Literature Review. Cureus 2024; 16:e64310. [PMID: 39130962 PMCID: PMC11316347 DOI: 10.7759/cureus.64310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) is a rare central nervous system inflammatory condition usually presenting with a range of symptoms, including ataxia, diplopia, dysarthria, seizures, and headaches. We present a unique case of a 22-year-old woman exhibiting headache as the sole symptom. Imaging and biopsy confirmed the diagnosis, and initial steroid treatment provided relief, though it relapsed on tapering. Long-term management with low-dose steroids and mycophenolate mofetil achieved remission. This case highlights the importance of recognizing atypical presentations of CLIPPERS, emphasizing the need for prompt diagnosis and appropriate treatment plans to improve patient outcomes. Further research is necessary to enhance our understanding and management of CLIPPERS.
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Affiliation(s)
| | | | - Hans Shuhaiber
- Department of Neurology, University of Florida College of Medicine, Gainesville, USA
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6
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Lemarchant B, de Saint Basile G, Zephir H, Roelens M, Dubois R, Boucher J, Taieb G. Familial hemophagocytic lymphohistiocytosis: from macrophage activation syndrome to CLIPPERS. J Neurol 2024; 271:2893-2897. [PMID: 38383762 DOI: 10.1007/s00415-024-12241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Bruno Lemarchant
- Department of Neurology, Unité de Neurologie Inflammatoire, CRC-SEP, CHU Lille, Hôpital Roger Salengro, Lille, France.
| | - Geneviève de Saint Basile
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children-Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Hélène Zephir
- Department of Neurology, Unité de Neurologie Inflammatoire, CRC-SEP, CHU Lille, Hôpital Roger Salengro, Lille, France
| | - Marie Roelens
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children-Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Julie Boucher
- Department of Neurology, CH Boulogne Sur Mer, Hôpital Duchenne, Boulogne-sur-Mer, France
| | - Guillaume Taieb
- Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, Montpellier, France.
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7
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John DS, Kankara SR, Palasamudram Kumaran S, Hussain AS. Clinicoradiological features of probable chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome. BMJ Case Rep 2024; 17:e258067. [PMID: 38627057 PMCID: PMC11029188 DOI: 10.1136/bcr-2023-258067] [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] [Indexed: 04/19/2024] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently described chronic inflammatory central nervous system disease. This case report describes a young female patient presenting with weakness in bilateral upper and lower limbs and tinnitus for 2 months. A neurological examination revealed signs of brainstem and cerebellar involvement. MRI brain showed characteristic features of CLIPPERS, with punctate and nodular enhancement in the pons and cerebellum. Differential diagnoses were systematically considered and excluded. The patient showed significant clinical and radiological improvement with steroid therapy. No clinical or radiological red flags occurred during the follow-up. This case underscores the critical role of integrating clinical and radiological findings to effectively diagnose and manage CLIPPERS. It emphasises the importance of ruling out alternative diagnoses through a thorough evaluation.
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Affiliation(s)
- Deepa Susan John
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
| | - Shreyas Reddy Kankara
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
| | | | - Adnan Sarfaraz Hussain
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
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8
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Thomas M, Kontzialis M. CLIPPERS With Supratentorial Brain and Cord Enhancement. Neurohospitalist 2024; 14:224-225. [PMID: 38666281 PMCID: PMC11040632 DOI: 10.1177/19418744231225796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Affiliation(s)
- Michael Thomas
- Department of Radiology, McGaw Medical Center, Northwestern University, Chicago, IL, USA
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9
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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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García de Andoin Sojo C, Gómez Muga JJ, Aza Martínez I, Antón Méndez L, Fornell Pérez R. Inflammatory lesions of the brainstem: Keys for the diagnosis by MRI. RADIOLOGIA 2024; 66:32-46. [PMID: 38365353 DOI: 10.1016/j.rxeng.2023.01.010] [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: 09/20/2022] [Accepted: 01/15/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE To describe the magnetic resonance imaging (MRI) findings for the most common inflammatory and immune-mediated diseases that involve the brainstem. CONCLUSION Inflammatory lesions involving the brainstem are associated with a wide range of autoimmune, infectious, and paraneoplastic syndromes, making the differential diagnosis complex. Being familiar with these entities, their clinical characteristics, and their manifestations on MRI, especially the number of lesions, their shape and extension, and their appearance in different sequences, is useful for orienting the radiological diagnosis.
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Affiliation(s)
| | - J J Gómez Muga
- Servicio de Radiodiagnóstico, Hospital Universitario Basurto, Bilbao, Spain
| | - I Aza Martínez
- Servicio de Radiodiagnóstico, Hospital Universitario Basurto, Bilbao, Spain
| | - L Antón Méndez
- Servicio de Radiodiagnóstico, Hospital Universitario Basurto, Bilbao, Spain
| | - R Fornell Pérez
- Servicio de Radiodiagnóstico, Hospital Universitario Basurto, Bilbao, Spain
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11
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Shervedani AK, Tabibian F, Khotbesara MG, Adibi I. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids triggered by Hodgkin's lymphoma: A case report and brief literature review. Clin Case Rep 2024; 12:e8377. [PMID: 38161651 PMCID: PMC10753635 DOI: 10.1002/ccr3.8377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/27/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Key Clinical Message We presented a patient, diagnosed with lymphoma-associated CLIPPERS, 11 years after lymphoma treatment. Therefore, CLIPPERS may be paraneoplastic neurological syndrome of lymphoma, which needs to be considered in the follow-up of lymphoma cases. Abstract Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare central nervous system disorder with a recent increase in incidence. There are few reports of lymphoma-associated CLIPPERS, although the relationship between these two diseases and the pathophysiology of CLIPPERS in general need further investigation. Here, we present a patient with a history of Hodgkin's lymphoma (HL) more than 10 years before the onset of CLIPPERS, in contrast to the majority of previously reported lymphoma-associated cases, and discuss the possibility that CLIPPERS is the paraneoplastic neurological syndrome of HL. This highlights the need to consider CLIPPERS as a differential diagnosis during follow-up of patients with a history of lymphoma.
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Affiliation(s)
| | - Farinaz Tabibian
- Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | | | - Iman Adibi
- Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
- Department of NeurologyIsfahan University of Medical SciencesIsfahanIran
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Kovacova S, Hnilicova P, Grossmann J, Hajas G, Kantorova E, Kurca E. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome: Treatment approach depends on disease course. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:303-308. [PMID: 35332344 DOI: 10.5507/bp.2022.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/14/2022] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare inflammatory central nervous system (CNS) disorder, chiefly involving the brainstem, especially the pons. The diagnosis is challenging, requires careful exclusion of alternative diagnoses and a targeted therapeutic approach. CLIPPERS is known to respond well to corticosteroids, but the treatment needs to be long-term and can cause significant side-effects. Moreover, subsequent corticosteroid withdrawal often leads to a relapse. It has been suggested that anti-CD20 molecules could benefit several antibody-mediated CNS inflammatory diseases, including CLIPPERS. CASE REPORT This paper describes two cases of CLIPPERS. The first demonstrates the benefit of early introduction of corticosteroids with side effects in cases of long-term use. The second demonstrates the efficacy of ocrelizumab (anti-CD20 molecule) in a severe course of CLIPPERS. CONCLUSION These two cases bring attention to this rare, often misdiagnosed but treatable disease.
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Affiliation(s)
- Slavomira Kovacova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
| | - Petra Hnilicova
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Jan Grossmann
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
| | - Gabriel Hajas
- Clinic of Neurology, Faculty Hospital of Constantine the Philosopher University, Nitra, Slovak Republic
| | - Ema Kantorova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
| | - Egon Kurca
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
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Freua F, Mahler JV, Lima PLGDSB, Neville IS, Portella LB, Marussi VHR, Lancellotti CLP, Nobrega PR, Silva GD. Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS)-Does it Really Exist? Brain Sci 2023; 13:1191. [PMID: 37626547 PMCID: PMC10452368 DOI: 10.3390/brainsci13081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS) is a rare variant of the CLIPPERS spectrum with less than ten reports published so far. There is ongoing discussion regarding whether SLIPPERS is a disease entity on its own or just an acronym encompassing many underlying diagnoses, such as sarcoidosis, vasculitis and anti-glial fibrillary acidic protein (GFAP)-associated disease. A 40-year-old woman presented with episodes of language and attention impairment. Magnetic resonance imaging (MRI) revealed T2/FLAIR hyperintense lesions in the subcortical white matter associated with a micronodular, curvilinear perivascular contrast-enhancement. Alternative diagnoses were excluded. There was a remarkable response to steroids. A relapse occurred after six years, and the biopsy showed perivascular T-cell lymphocytic infiltrate, without granulomas, vasculitis, or neoplasia. There was complete resolution of the relapse after steroids. This case represents the longest reported follow-up of a patient diagnosed with SLIPPERS, and brain biopsy after 6 years did not suggest alternative diagnoses. This report contributes to the discussion regarding the possibility that exclusive supratentorial CLIPPERS-like pathology might be an isolated disease entity, but more biopsy-proven cases with a longer follow-up are needed to support this hypothesis. Recently, GFAP astrocytopathy has been characterized and might correspond to a significant number of cases previously diagnosed as CLIPPERS or SLIPPERS.
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Affiliation(s)
- Fernando Freua
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | - João Vitor Mahler
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | | | - Iuri Santana Neville
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | | | - Victor Hugo Rocha Marussi
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
| | | | - Paulo Ribeiro Nobrega
- Division of Neurology, Walter Cantidio University Hospital, Federal University of Ceara, Prof. Costa Mendes St., 1608, 4th Floor, Rodolfo Teófilo, Fortaleza 60430-140, Brazil
- Faculty of Medicine, Centro Universitário Christus, Fortaleza 60160-230, Brazil
| | - Guilherme Diogo Silva
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
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Coggins JM, Harazeen A, Alfattal R, Corona K, Bhargava P, Felicella M, Li X. A Case of Radiologically Compatible Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) With Demyelinating Lesions. Cureus 2023; 15:e43000. [PMID: 37546693 PMCID: PMC10404135 DOI: 10.7759/cureus.43000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 08/08/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently identified diagnosis that can cause a variety of severe symptoms, including ataxia, dysarthria, diplopia, paraparesis, and vertigo. These symptoms rarely present in isolation but often accompany one another in various combinations. Magnetic Resonance Imaging (MRI) of the brain is critical for making the diagnosis and typically reveals scattered enhancement within the pons and adjacent structures. The syndrome responds well to high-dose steroids, and maintenance therapy is required to prevent a recurrence. In this report, we present a case of a 62-year-old man who developed CLIPPERS syndrome. The patient presented with hemiparesis and dysarthria, which developed over four months and then acutely worsened within 24 hours. After diagnosing CLIPPERS, the patient was placed on high-dose steroids and experienced rapid clinical improvement, as well as improvement on repeat MRI. The patient's treatment was complicated by an incidental diagnosis of tuberculosis, which required simultaneous management with isoniazid.
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Affiliation(s)
- John M Coggins
- Neurology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Ahmed Harazeen
- Neurology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Rasha Alfattal
- Pathology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Kassandra Corona
- Neurology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Peeyush Bhargava
- Radiology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Michelle Felicella
- Pathology, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Xiangping Li
- Neurology, University of Texas Medical Branch at Galveston, Galveston, USA
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15
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Shrestha NM, Acharya N, Desar R. Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS Syndrome): A Case Report and Literature Review. Case Rep Neurol Med 2023; 2023:5811243. [PMID: 37520771 PMCID: PMC10382238 DOI: 10.1155/2023/5811243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 08/06/2022] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
CLIPPERS is a rare, chronic inflammatory neurological syndrome affecting multiple regions of the brain including the brainstem, cerebellum, and spinal cord. More than 100 cases have been documented globally since its initial description in 2010. This article reports the first case of the CLIPPERS syndrome in Nepal. Clinical and radiological evidences of the patient lead to the diagnosis of this disease. Brain MRI reveals punctate and curvilinear gadolinium enhancement in the pons and cerebellum, which is diagnostic for the disease. Steroid therapy has been reported to be effective in treating CLIPPERS syndrome. Although its pathophysiology indicates an immune-mediated process, the etiology is yet unknown. The treatment and prognosis of this illness depend on an early and accurate diagnosis.
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16
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Khan A, Khan MM, Al-Bozom IA, Baregzai Y, Ibrahim W, Hammadi F. The Elusive SLIPPERS Syndrome (Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids): A Case Report and Literature Review. Int Med Case Rep J 2023; 16:357-361. [PMID: 37324164 PMCID: PMC10266482 DOI: 10.2147/imcrj.s411204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023] Open
Abstract
Background In 2015, the term "SLIPPERS" was created to refer to a rare type of encephalomyelitis called CLIPPERS syndrome that affects the pons and sometimes other nearby structures, but in this case, it primarily affects the supratentorial region. This variation of the condition is responsive to treatment with steroids. Case Description We report the case of a patient who presented with seizures and visual field deficit and had typical radiological and histopathological characteristics of SLIPPERS syndrome. Conclusion Although the literature is inundated with CLIPPERS syndrome, its supratentorial variant is extremely rare. To our knowledge, this is fourth case of SLIPPERS syndrome to be reported in literature and serves to enhance clinicopathological understanding of this elusive entity.
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Affiliation(s)
- Adnan Khan
- Department of Neurosurgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Mohsin Khan
- Department of Neurosurgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Issam A Al-Bozom
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
| | - Younis Baregzai
- Department of Neurosurgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Wanis Ibrahim
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Firas Hammadi
- Department of Neurosurgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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17
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Cao L, Liu M, Guo L, Li M, Xu M, Wang R. The pathogenesis hypothesis and research progress of CLIPPERS: A literature review. Medicine (Baltimore) 2023; 102:e33211. [PMID: 36930124 PMCID: PMC10019105 DOI: 10.1097/md.0000000000033211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is still a rare autoimmune disease in the world. In recent years, there are more and more reports about the clinical manifestations of CLIPPERS, but the specific etiology and pathogenesis are not clear. In this paper, by collating the literature reported in recent years, in the reported effective treatment cases, we found the current hypothesis about the pathogenesis of CLIPPERS. Three pathogenesis hypotheses: organ-specific autoimmunity; virus infection affects autoimmunity; and helper T lymphocyte 17 mediates autoimmunity. Although it is hypothetical, it is expected to further clarify the pathogenesis, evolution characteristics, and treatment of CLIPPERS, so as to provide a reference for further understanding of the disease. In the future, more observations and studies are needed to further verify the feasibility of the hypothesis. This article expands on atypical clinical manifestations and summarizes treatment options. Hope to provide a reference for clinical diagnosis and treatment of CLIPPERS.
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Affiliation(s)
- Long Cao
- College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Meiping Liu
- First College of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Li Guo
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Mingyan Li
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Min Xu
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Rui Wang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
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Meller A, Pawlukowska W, Machowska-Sempruch K, Marta M. Spectrum of Autoimmune Diseases—Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS)—Clinical Case. Medicina (B Aires) 2023; 59:medicina59030549. [PMID: 36984550 PMCID: PMC10058906 DOI: 10.3390/medicina59030549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome is a rare inflammatory disease of an undetermined aetiology. The condition is characterised by a range of clinical manifestations generally associated with damage to brainstem structures, the cerebellum, with characteristic magnetic resonance imaging (MRI) findings. The main feature is a good clinical and radiological response to glucocorticosteroid (GCS)-based immunosuppressive treatment. The diagnosis of CLIPPERS is difficult and requires extensive differential diagnosis. A specific biomarker in serum or cerebrospinal fluid (CSF) for this disorder is currently unknown. The pathogenesis of CLIPPERS remains poorly understood and its nosological position has not yet been established. Whether CLIPPERS represents an independent, genuine new disorder or a syndrome in the course of diseases with heterogeneous aetiology and/or their precursor stages remains debatable and incompletely clarified. We present a case report of a patient who was diagnosed with CLIPPERS syndrome on the basis of her clinical and radiological features and by performing an extensive differential diagnosis. The patient has been under neurological follow-up for five years.
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Saénz-Silva J, Ordinola Navarro A. CLIPPERS Syndrome After Vaccination. An Unusual ASIA Presentation. REUMATOLOGIA CLINICA 2023; 19:168-170. [PMID: 36906391 DOI: 10.1016/j.reumae.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/19/2021] [Indexed: 03/11/2023]
Abstract
The chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) and autoimmune/inflammatory syndrome induced by adjuvants (ASIA) were described a decade ago. There are a limited number of reports and these diseases are still underdiagnosed. We presented a 35 years-old patient with clinical manifestations of cerebellum affection and enhancement in the MRI, with the influenza vaccine as the only triggering factor. Infectious diseases, malignancy, and additional systemic involvement were ruled out; therefore, on suspicion of CLIPPERS syndrome, the patient received corticosteroid therapy with an adequate response. The knowledge of CLIPPERS syndrome as an unusual ASIA presentation and high response to the corticosteroids may lead to a timely diagnosis, appropriate treatment, and follow up with better outcomes for patients.
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Affiliation(s)
- Juan Saénz-Silva
- Department of Neurology, Hospital de Especialidades «Dr. Antonio Fraga Mouret»,Centro Médico Nacional La Raza del Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Alberto Ordinola Navarro
- Department of Internal medicine, Hospital de Especialidades «Dr. Antonio Fraga Mouret», Centro Médico Nacional La Raza del Instituto Mexicano del Seguro Social, Mexico City, Mexico.
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Olmsted AM, Choi H, Rovner B. Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids Presenting as Anhedonia: A Case Report. J Acad Consult Liaison Psychiatry 2023; 64:313-315. [DOI: 10.1016/j.jaclp.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 03/12/2023]
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21
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García de Andoin Sojo C, Gómez Muga J, Aza Martínez I, Antón Méndez L, Fornell Pérez R. Lesiones inflamatorias del troncoencéfalo: claves diagnósticas en RM. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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22
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Ang BSP, Umapathi T, Lim T. The Changing Epidemiology of Central Nervous System Infection. Neuroimaging Clin N Am 2023; 33:1-10. [DOI: 10.1016/j.nic.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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23
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Duong MT, Rudie JD, Mohan S. Neuroimaging Patterns of Intracranial Infections: Meningitis, Cerebritis, and Their Complications. Neuroimaging Clin N Am 2023; 33:11-41. [PMID: 36404039 PMCID: PMC10904173 DOI: 10.1016/j.nic.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neuroimaging provides rapid, noninvasive visualization of central nervous system infections for optimal diagnosis and management. Generalizable and characteristic imaging patterns help radiologists distinguish different types of intracranial infections including meningitis and cerebritis from a variety of bacterial, viral, fungal, and/or parasitic causes. Here, we describe key radiologic patterns of meningeal enhancement and diffusion restriction through profiles of meningitis, cerebritis, abscess, and ventriculitis. We discuss various imaging modalities and recent diagnostic advances such as deep learning through a survey of intracranial pathogens and their radiographic findings. Moreover, we explore critical complications and differential diagnoses of intracranial infections.
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Affiliation(s)
- Michael Tran Duong
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jeffrey D Rudie
- Department of Radiology, Scripps Clinic and University of California San Diego, 10666 Torrey Pines Road, La Jolla, CA 92037, USA
| | - Suyash Mohan
- Division of Neuroradiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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24
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Branson HM, Longoni G. Clinical Neuroimaging in Pediatric Dysimmune Disorders of the Central Nervous System. Semin Roentgenol 2023; 58:67-87. [PMID: 36732013 DOI: 10.1053/j.ro.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/23/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Helen M Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Department of Medical Imaging, Toronto, Ontario, Canada.
| | - Giulia Longoni
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada; Garry Hurvitz Centre for Brain & Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Department of Paediatrics, Toronto, Ontario, Canada
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25
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Thebault S, Bergman H, Atkins HL, Freedman MS, Brooks J. CLIPPERS Responsive to Cladribine as a Durable Steroid-Sparing Agent. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2023; 10:10/1/e200060. [DOI: 10.1212/nxi.0000000000200060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/21/2022] [Indexed: 11/18/2022]
Abstract
ObjectiveWe report a case of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) who achieved durable and steroid-free remission after IV cladribine.MethodsA 25 year-old man presented with progressively worsening headaches, polydipsia, dysarthria, diplopia and vertigo, and obtundation requiring respiratory support. CSF revealed lymphocytosis, and MRI revealed a perivascular pattern of punctate enhancement involving the pons. An extensive workup for inflammatory, autoimmune, infective, and malignant explanations was unrevealing. He responded dramatically to steroids, compatible with CLIPPERS as a diagnosis of exclusion. Attempts to wean prednisone over the ensuing year resulted in 2 clinical relapses and persistent punctate enhancement. Given significant steroid side effects, steroid-sparing agents were considered.ResultsIV cladribine IV (0.0875 mg/kg adjusted body weight daily × 4 days at 0, 4, 8, and 16 months) was selected, given its favorable side effect profile including lower risks of malignancy and infertility and the potential for long-lasting effects. The only side effect was short-term fatigue at the time of infusion. At 20 months after cladribine initiation, he was able to wean-off prednisone altogether. Now at 33 months, he remains in clinical and MRI remission.DiscussionCladribine is a rational candidate steroid-sparing treatment for presumed neurologic autoimmune conditions such as CLIPPERS.Classification of EvidenceThis study provides Class IV evidence that cladribine is a steroid-sparing treatment consideration in CLIPPERS.
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26
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The role of MRI in the early diagnosis of chronic lymphocytic inflammation (CLIPPERS syndrome). КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract114814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
ABSTRACT
Background. Chronic lymphocytic inflammation with perivascular contrast enhancement in the pons responsive to steroids (CLIPPERS) is a rare and relatively "new" pathology and MRI is highly important in its diagnosis.
Clinical Case Description. Chronic lymphocytic inflammation with perivascular contrast enhancement in the pons responsive to steroids (CLIPPERS) is a rare and relatively "new" pathology and MRI is highly important in its diagnosis.
Conclusion. MRI not only enables high-quality neuroimaging of CLIPPERS, it also allows avoiding invasive, traumatic diagnostic methods.
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27
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Al-Chalabi M, DelCimmuto NR, Beran A, Devarasetty PP, Mhanna A, Mahfooz N, Sheikh A. Clinical characteristics, management, and outcomes of CLIPPERS: A comprehensive systematic review of 140 patients from 100 studies. Mult Scler Relat Disord 2022; 68:104112. [PMID: 36029706 DOI: 10.1016/j.msard.2022.104112] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare inflammatory disorder of the central nervous system, characterized by symptoms referable to the brainstem and cerebellum such as, diplopia, gait ataxia and cerebellar dysarthria. The features and outcomes of CLIPPERS remains uncertain. we conducted this comprehensive systematic review to summarize all the existing studies that described CLIPPERS in the literature and to provide a quantitative assessment on the clinical characteristics, management, and outcomes of this rare syndrome. METHODS A comprehensive search of PubMed and Web of Science databases was conducted from inception until January 15, 2022, was conducted. We only included the cases that clearly reported probable or definite diagnosis of CLIPPERS based on Taieb et al.'s criteria. The quality of the included studies was assessed using the JBI Critical Appraisal Tool. Descriptive statistics were performed to analyze the studies. Data were expressed as mean and standard deviation (SD) for continuous variables and proportions for categorical variables. RESULTS We identified 100 case reports and series including a total of 140 patients with CLIPPERS (mean age: 46±18 years and males were 60%). The average follow-up duration was 32.27±57.8 months. Ataxia was the most common presenting symptom. Sixteen percent of the cases were associated with malignancy, mostly hematologic malignancies. The overall relapse rate was 59.2%, and the duration of steroid therapy was considerably shorter in the relapsed cases than in the non-relapsed (mean 6.19±7.9 vs. 10.14±12.1 days, respectively, P = 0.04). The overall mortality rate was 10%, but mortality in patients with malignancy was 30% and it was 12% in patients with relapses. In the case of steroid dosing (less than 20 mg/d versus greater than 20 mg/d) there was no significant modification in the risk of relapse. CONCLUSION CLIPPERS is a rare clinical syndrome that affects mainly middle-aged males. Diagnosis of CLIPPERS is often challenging, and delays in diagnosis and treatment can lead to unfavorable outcomes. Therefore, neurologists should maintain a high index of suspicion for CLIPPERS in any patient presenting with symptoms and signs referrable to the brainstem. These patients should be screened for associated malignancies, especially hematological malignancies. The cases associated with malignancy tend to have worse outcomes. The relapse rate is relatively high. The relapse rate may be associated with worse mortality. Based on our findings, we recommend that CLIPPERS be treated with high-dose steroid therapy for at least ten days during the acute phase with a very slow taper. Prospective studies with a larger sample size are needed to validate our findings and guide the clinical care of these patients.
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Affiliation(s)
- Mustafa Al-Chalabi
- Department of Neurology, University of Toledo, 2130W Central Ave., Toledo, OH 43606, United States.
| | - Nicholas R DelCimmuto
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, OH, United States
| | | | - Asmaa Mhanna
- The University of Toledo, Promedica Toledo Hospital, Toledo, OH, United States
| | - Naeem Mahfooz
- Department of Neurology, University of Toledo, 2130W Central Ave., Toledo, OH 43606, United States; College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Ajaz Sheikh
- Department of Neurology, University of Toledo, 2130W Central Ave., Toledo, OH 43606, United States; College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
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Korostyshevskaya AM, Stankevich JA, Vasilkiv LM, Bogomyakova OB, Korobko DS, Gornostaeva AM, Tulupov AА. CLIPPERS: Multiparametric and quantitative MRI features. Radiol Case Rep 2022; 18:368-376. [PMID: 36411846 PMCID: PMC9674504 DOI: 10.1016/j.radcr.2022.10.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/10/2022] [Accepted: 10/13/2022] [Indexed: 11/18/2022] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare chronic central-nervous-system inflammatory disorder that became known only recently, and the pathogenesis of CLIPPERS remains poorly understood. This report presents clinical and radiological features of a rare case: a young female patient who rapidly died of suspected CLIPPERS. Helpful multiparametric MRI diagnostic criteria are proposed that can help discriminate CLIPPERS from non-CLIPPERS pathologies. We reviewed clinical history, symptoms, quantitative data from brain multiparametric MRI before and after treatment, and histopathological data. Perfusion-weighted imaging revealed a decrease in regional cerebral blood flow by 31% and in cerebral blood volume by 64%, with a moderate increase in transit time and in time to peak by up to 23% in affected pontine and cerebral white matter. As estimated by diffusion tensor imaging, there was elevated density of tracts (n/mm2) and a decrease of fraction anisotropy (×10-3 mm/s2) in the patient's pons as compared to a healthy control: density of tracts = 13.5 vs 12.4 and fraction anisotropy = 0.32 vs 0.45, respectively. Macromolecular proton fraction values proved to be reduced (15.8% and 14.5% in the control, respectively) in the patient's cerebral peduncles by 3% and in the pons by 4.1% and in a periventricular white matter lesion by 6.4% (11.3% in the normal-looking contralateral hemisphere). Based on our findings, we argue that quantitative MRI techniques may be a valuable source of biomarkers and reliable diagnostic criteria and can shed light on the pathogenesis and exact nosological position of this disorder.
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Key Words
- ADC, apparent diffusion coefficient
- CBF, cerebral blood flow
- CLIPPERS
- CNS, central nervous system
- CSF, cerebrospinal fluid
- DOT, density of tracts
- DTI, diffusion tensor imaging
- DWI, diffusion-weighted imaging
- Diffusion tensor imaging
- FLAIR, fluid attenuated inversion recovery
- ITC, International Tomography Center
- MPF, macromolecular proton fraction
- MS, multiple sclerosis
- Macromolecular proton fraction mapping
- PWI, perfusion-weighted imaging
- Perfusion-weighted imaging
- Quantitative MRI
- SWI, susceptibility-weighted imaging
- WI, weighted image
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Affiliation(s)
- Alexandra M. Korostyshevskaya
- The Institute International Tomography Center of the Russian Academy of Sciences, Institutskaya str., Bldg. 3а, Novosibirsk, 630090, Russian Federation
- Federal State Budgetary Scientific Institution «The Federal Research Center of Fundamental and Translational Medicine», 2 Timakova str., Novosibirsk, 630060, Russian Federation
| | - Julia A. Stankevich
- The Institute International Tomography Center of the Russian Academy of Sciences, Institutskaya str., Bldg. 3а, Novosibirsk, 630090, Russian Federation
- Novosibirsk State University, 1, Pirogova str., Novosibirsk, 630090, Russian Federation
| | - Liubov M. Vasilkiv
- The Institute International Tomography Center of the Russian Academy of Sciences, Institutskaya str., Bldg. 3а, Novosibirsk, 630090, Russian Federation
- Novosibirsk State University, 1, Pirogova str., Novosibirsk, 630090, Russian Federation
| | - Olga B. Bogomyakova
- The Institute International Tomography Center of the Russian Academy of Sciences, Institutskaya str., Bldg. 3а, Novosibirsk, 630090, Russian Federation
- Novosibirsk State University, 1, Pirogova str., Novosibirsk, 630090, Russian Federation
- Lavrentyev Institute of Hydrodynamics, 15, Akademika Lavrent'yeva pr., Novosibirsk, 630090, Russian Federation
| | - Denis S. Korobko
- Regional Center for Multiple Sclerosis and other autoimmune diseases of the nervous system, State Budgetary Healthcare Institution of the Novosibirsk Region "State Novosibirsk Regional Clinical Hospital" (GBUZ NSO GNOKB); 126, Nemirovich – Danchenko str., Novosibirsk, 630087, Russian Federation
- Novosibirsk State Medical University; 52, Krasny prospect av., Novosibirsk, 630091, Russian Federation
| | - Alyona M. Gornostaeva
- The Institute International Tomography Center of the Russian Academy of Sciences, Institutskaya str., Bldg. 3а, Novosibirsk, 630090, Russian Federation
- Corresponding author.
| | - Andrey А. Tulupov
- The Institute International Tomography Center of the Russian Academy of Sciences, Institutskaya str., Bldg. 3а, Novosibirsk, 630090, Russian Federation
- Novosibirsk State University, 1, Pirogova str., Novosibirsk, 630090, Russian Federation
- Lavrentyev Institute of Hydrodynamics, 15, Akademika Lavrent'yeva pr., Novosibirsk, 630090, Russian Federation
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Lv C, Zhu F, Chen C, Wang Y, Guo D, Zhang Z. A rare case report of primary Sjögren’s syndrome with clinical characteristics similar to those of CLIPPERS. BMC Neurol 2022; 22:414. [DOI: 10.1186/s12883-022-02945-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Primary Sjögren’s syndrome (pSS) is an autoimmune inflammatory disease characterized by dryness of the eyes, mouth and other mucous membranes. Patients with pSS can also present with extraglandular manifestations, such as pulmonary, kidney and nervous system involvement. Central nervous system (CNS) manifestations have rarely been described in pSS.
Case presentation
A 33-year-old man was admitted with a one-month history of dizziness, speech disturbance, and walking instability. His brain enhanced magnetic resonance imaging (MRI) showed symmetrical, enhanced “salt-and-pepper-like” speckled lesions in the brainstem, basal ganglia, and subcortical regions, and his diagnosis was considered possible chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). Further examination revealed that anti-SSA antibody was positive, and the Schirmer test and labial salivary gland histopathology were abnormal, which supported the diagnosis of pSS.
Conclusion
pSS is a chronic systemic autoimmune disease that involves neurological complications. This case suggests that CNS lesions of pSS can present with clinical and MRI findings similar to those of CLIPPERS.
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Rare Etiologies in Immune-Mediated Cerebellar Ataxias: Diagnostic Challenges. Brain Sci 2022; 12:brainsci12091165. [PMID: 36138901 PMCID: PMC9496914 DOI: 10.3390/brainsci12091165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/06/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
The cerebellum is particularly enriched in antigens and represents a vulnerable target to immune attacks. Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies, such as gluten ataxia (GA), post-infectious cerebellitis (PIC), Miller Fisher syndrome (MFS), paraneoplastic cerebellar degeneration (PCD), opsoclonus myoclonus syndrome (OMS), and anti-GAD ataxia. Apart from these well-established entities, cerebellar ataxia (CA) occurs also in association with autoimmunity against ion channels and related proteins, synaptic adhesion/organizing proteins, transmitter receptors, glial cells, as well as the brainstem antigens. Most of these conditions manifest diverse neurological clinical features, with CAs being one of the main clinical phenotypes. The term primary autoimmune cerebellar ataxia (PACA) refers to ataxic conditions suspected to be autoimmune even in the absence of specific well-characterized pathogenic antibody markers. We review advances in the field of IMCAs and propose a clinical approach for the understanding and diagnosis of IMCAs, focusing on rare etiologies which are likely underdiagnosed. The frontiers of PACA are discussed. The identification of rare immune ataxias is of importance since they are potentially treatable and may lead to a severe clinical syndrome in absence of early therapy.
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Ayrignac X, Carra-Dallière C, Marelli C, Taïeb G, Labauge P. Adult-Onset Genetic Central Nervous System Disorders Masquerading as Acquired Neuroinflammatory Disorders: A Review. JAMA Neurol 2022; 79:1069-1078. [PMID: 35969413 DOI: 10.1001/jamaneurol.2022.2141] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Adult-onset genetic disorders may present with clinical and magnetic resonance imaging (MRI) features suggestive of acquired inflammatory diseases. An ever-growing number of potentially treatable adult-onset genetic neuroinflammatory disorders have been described in the past few years that need to be rapidly identified. Observations Adult-onset acquired neuroinflammatory disorders encompass a large group of central nervous system (CNS) diseases with varying presentation, MRI characteristics, and course, among which the most common is multiple sclerosis. Despite recent progress, including the discovery of specific autoantibodies, a significant number of adult-onset neuroinflammatory disorders with progressive or relapsing course still remain without a definite diagnosis. In addition, some patients with genetic disorders such as leukodystrophies, hemophagocytic lymphohistiocytosis, or genetic vasculopathies can mimic acquired neuroinflammatory disorders. These genetic disorders, initially described in pediatric populations, are increasingly detected in adulthood thanks to recent progress in molecular genetics and the larger availability of high-throughput sequencing technologies. Conclusions and Relevance Genetic adult-onset neuroinflammatory diseases are at the border between primary CNS inflammatory diseases and systemic disorders with multiorgan involvement and predominantly neurologic manifestations. Neurologists must be aware of the main clues and red flags so they can confirm a diagnosis early, when some of these genetic disorders can be successfully treated.
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Affiliation(s)
- Xavier Ayrignac
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France.,Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
| | - Clarisse Carra-Dallière
- Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
| | - Cecilia Marelli
- Department of Neurology, Montpellier University Hospital, Montpellier, France.,Molecular Mechanisms in Neurodegenerative Dementias, University of Montpellier, École Pratique des Hautes Études, INSERM, Montpellier, France.,Expert Centre for Neurogenetic Diseases and Adult Mitochondrial and Metabolic Diseases, Montpellier University Hospital, Montpellier, France
| | - Guillaume Taïeb
- Department of Neurology, Montpellier University Hospital, Montpellier, France
| | - Pierre Labauge
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France.,Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
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Longbrake E. Myelin Oligodendrocyte Glycoprotein-Associated Disorders. Continuum (Minneap Minn) 2022; 28:1171-1193. [PMID: 35938661 PMCID: PMC9523511 DOI: 10.1212/con.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Anti-myelin oligodendrocyte glycoprotein (MOG) autoantibodies have become a recognized cause of a pathophysiologically distinct group of central nervous system (CNS) autoimmune diseases. MOG-associated disorders can easily be confused with other CNS diseases such as multiple sclerosis or neuromyelitis optica, but they have a distinct clinical phenotype and prognosis. RECENT FINDINGS Most patients with MOG-associated disorders exhibit optic neuritis, myelitis, or acute disseminated encephalomyelitis (ADEM) alone, sequentially, or in combination; the disease may be either monophasic or relapsing. Recent case reports have continued to expand the clinical spectrum of disease, and increasingly larger cohort studies have helped clarify its pathophysiology and natural history. SUMMARY Anti-MOG-associated disorders comprise a substantial subset of patients previously thought to have other seronegative CNS diseases. Accurate diagnosis is important because the relapse patterns and prognosis for MOG-associated disorders are unique. Immunotherapy appears to successfully mitigate the disease, although not all agents are equally effective. The emerging large-scale data describing the clinical spectrum and natural history of MOG-associated disorders will be foundational for future therapeutic trials.
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Vattoth S, Aker L, Abdelhady M, El Beltagi AH. Case 302: Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids. Radiology 2022; 303:726-730. [PMID: 35604843 DOI: 10.1148/radiol.204423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
HISTORY Part one of this case appeared 4 months previously and may contain larger images. A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and perfusion study were performed and included different sequences (Figs 1-3).
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Affiliation(s)
- Surjith Vattoth
- From the Department of Radiology, Neuroradiology Section, University of Arkansas for Medical Sciences, Little Rock, Ark (S.V.); Department of Clinical Imaging, Hamad General Hospital (L.A.), and Department of Neuroradiology, Neuroscience Institute (M.A., A.H.E.B.), Hamad Medical, PO Box 3050, Alsadd, Doha, Qatar; and Department of Clinical Radiology, Weill Cornell Medicine, Doha, Qatar (A.H.E.B.)
| | - Loai Aker
- From the Department of Radiology, Neuroradiology Section, University of Arkansas for Medical Sciences, Little Rock, Ark (S.V.); Department of Clinical Imaging, Hamad General Hospital (L.A.), and Department of Neuroradiology, Neuroscience Institute (M.A., A.H.E.B.), Hamad Medical, PO Box 3050, Alsadd, Doha, Qatar; and Department of Clinical Radiology, Weill Cornell Medicine, Doha, Qatar (A.H.E.B.)
| | - Mohamed Abdelhady
- From the Department of Radiology, Neuroradiology Section, University of Arkansas for Medical Sciences, Little Rock, Ark (S.V.); Department of Clinical Imaging, Hamad General Hospital (L.A.), and Department of Neuroradiology, Neuroscience Institute (M.A., A.H.E.B.), Hamad Medical, PO Box 3050, Alsadd, Doha, Qatar; and Department of Clinical Radiology, Weill Cornell Medicine, Doha, Qatar (A.H.E.B.)
| | - Ahmed H El Beltagi
- From the Department of Radiology, Neuroradiology Section, University of Arkansas for Medical Sciences, Little Rock, Ark (S.V.); Department of Clinical Imaging, Hamad General Hospital (L.A.), and Department of Neuroradiology, Neuroscience Institute (M.A., A.H.E.B.), Hamad Medical, PO Box 3050, Alsadd, Doha, Qatar; and Department of Clinical Radiology, Weill Cornell Medicine, Doha, Qatar (A.H.E.B.)
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Guo J, Bu Y, Liu W. Case Report: A Case With MOGAD and Anti-NMDAR Encephalitis Overlapping Syndrome Mimicing Radiological Characteristics of CLIPPERS. Front Immunol 2022; 13:832084. [PMID: 35493443 PMCID: PMC9047684 DOI: 10.3389/fimmu.2022.832084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Herein, we reported a case of a young man diagnosed with MNOS (anti-myelin oligodendrocyte glycoprotein associated disease (MOGAD) and anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis overlapping syndrome, i.e., MNOS), whose imaging findings in magnetic resonance imaging (MRI) mimicked chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). We reported a case of refractory anti-NMDAR encephalitis that recurred after standard first-line and second-line treatment. The patient presented with CLIPPERS on imaging at recent hospital admission, and his MOG antibodies were seropositive. After intravenous methylprednisolone (IVMP) treatment, the patient’s symptoms were significantly alleviated. In this case, we demonstrated that MNOS could mimic the radiological characteristics of CLIPPERS. Future studies should focus on the diagnosis and treatment of antibody overlap syndrome.
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Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2022; 35:152-169. [PMID: 34490814 PMCID: PMC9130615 DOI: 10.1177/19714009211042879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
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Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology
(Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology
(Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
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36
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Magnetic Resonance Imaging of Autoimmune Demyelinating Diseases as a Diagnostic Challenge for Radiologists: Report of Two Cases and Literature Review. Life (Basel) 2022; 12:life12040488. [PMID: 35454978 PMCID: PMC9027326 DOI: 10.3390/life12040488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/12/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
The magnetic resonance characteristics of autoimmune demyelinating diseases are complex and represent a challenge for the radiologist. In this study we presented two different cases of detected autoimmune demyelinating diseases: one case of acute disseminated encephalomyelitis and one case of neuromyelitis optica, respectively. Expected and unexpected findings of magnetic resonance imaging examination for autoimmune demyelinating diseases were reported in order to provide a valuable approach for diagnosis. In particular, we highlight, review and discuss the presence of several uncommon imaging findings which could lead to a misinterpretation. The integration of magnetic resonance imaging findings with clinical and laboratory data is necessary to provide a valuable diagnosis.
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37
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Yokoyama K, Oyama J, Tsuchiya J, Karakama J, Tamura K, Inaji M, Tanaka Y, Kobayashi D, Maehara T, Tateishi U. Branch-like enhancement on contrast enhanced MRI is a specific finding of cerebellar lymphoma compared with other pathologies. Sci Rep 2022; 12:3591. [PMID: 35246572 PMCID: PMC8897486 DOI: 10.1038/s41598-022-07581-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/18/2022] [Indexed: 11/09/2022] Open
Abstract
Branch-like enhancement (BLE) on contrast-enhanced (CE) magnetic resonance imaging (MRI) was found to be effective in differentiating primary central nervous system lymphoma (PCNSL) from high-grade glioma (HGG) in the cerebellum. However, whether it can be applied to assessments of secondary central nervous system lymphoma (SCNSL), or other cerebellar lesions is unknown. Hence, we retrospectively reviewed cerebellar masses to investigate the use of BLE in differentiating cerebellar lymphoma (CL), both primary and secondary, from other lesions. Two reviewers qualitatively evaluated the presence and degree of BLE on CE-T1 weighted imaging (T1WI). If multiple views were available, we determined the view in which BLE was the most visible. Seventy-five patients with the following pathologies were identified:17 patients with CL, 30 patients with metastasis, 12 patients with hemangioblastoma, 9 patients with HGG, and 7 patients with others. Twelve patients presented with PCNSL and five with SCNSL. Of 17 patients with CL, 15 (88%) had BLE, whereas three (5%) out of 58 patients in the non-CL group showed BLE. In patients who underwent three-dimensional-CE-T1WI, BLE was the most visible on the sagittal image. In conclusion, BLE is a highly specific finding for CL and the sagittal image is important in evaluating this finding.
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Affiliation(s)
- Kota Yokoyama
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Jun Oyama
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Junichi Tsuchiya
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Jun Karakama
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kaoru Tamura
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Daisuke Kobayashi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ukihide Tateishi
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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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: 3.0] [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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Ambia AR, AlZahrani N, Almakadma AH, Elgazzar TA, Almustanyir S. Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids: An Acute Presentation. Cureus 2022; 14:e21382. [PMID: 35198294 PMCID: PMC8853718 DOI: 10.7759/cureus.21382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/11/2022] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare disease with an unknown etiology which most commonly results in subacute diplopia and ataxia. Diagnosis is achieved through a triad of the following findings: lymphocytic pleocytosis with increased CD4+ T cells on cerebrospinal fluid (CSF) analysis; perivascular punctate and curvilinear hemorrhages in the pons, medulla, or cerebellum on magnetic resonance imaging (MRI) with contrast; and the cessation of symptoms after the initiation of corticosteroids. Here, we report the case of a 23-year-old male who presented with non-specific signs and symptoms, including diffuse weakness in all limbs, ataxia, and slurred speech. The diagnosis was achieved through a contrast MRI of the brain, suggestive of brainstem encephalitis, and a CSF analysis, which revealed elevated glucose and protein levels. Intravenous methylprednisolone was administered for five days and resulted in acute improvement of the patient’s clinical status. Repeat CSF analysis and MRI of the brain with contrast two weeks later showed resolution of previous findings. CLIPPERS syndrome is a newly identified disease thought to cause a predominantly inflammatory reaction in the pons, medulla, cerebellum, and supratentorial region. MRI with contrast tends to reveal a “salt and pepper appearance” in a punctate and curvilinear fashion. The hallmark of treatment is corticosteroid therapy, and discontinuation of therapy should be done with caution as relapse of the syndrome with corticosteroid withdrawal has been documented.
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40
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Ahmad Khan A, Bridson JD, Davenport RJ. A patient with headache and fever. Pract Neurol 2021; 22:334-337. [PMID: 34965983 DOI: 10.1136/practneurol-2021-003215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Aimal Ahmad Khan
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - James D Bridson
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
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Kimura A, Kato S, Takekoshi A, Yoshikura N, Yanagida N, Kitaguchi H, Akiyama D, Shimizu H, Kakita A, Shimohata T. Autoimmune glial fibrillary acidic protein astrocytopathy resembling isolated central nervous system lymphomatoid granulomatosis. J Neuroimmunol 2021; 361:577748. [PMID: 34653948 DOI: 10.1016/j.jneuroim.2021.577748] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 11/28/2022]
Abstract
We report two patients with meningoencephalomyelitis without evidence of extra central nervous system (CNS) involvement. Brain MRI showed linear perivascular radial gadolinium enhancement patterns and spinal cord MRI showed longitudinal extensive T2-hyperintensity lesions. Pathological findings from brain biopsies were angiocentric T-cell predominant lymphoid infiltrates that lacked Epstein-Barr virus-positive atypical B cells. The patients were initially suspected to have isolated CNS-lymphomatoid granulomatosis (LYG). Thereafter, glial fibrillary acidic protein (GFAP)-immunoglobulin G were detected in their cerebrospinal fluid. This finding suggested autoimmune GFAP astrocytopathy. We speculate there is a link between isolated CNS-LYG and autoimmune GFAP astrocytopathy.
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Affiliation(s)
- Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, Japan.
| | - Shinei Kato
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, Japan.
| | - Akira Takekoshi
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, Japan.
| | - Nobuaki Yoshikura
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, Japan.
| | - Narufumi Yanagida
- Department of Neurology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan.
| | - Hiroshi Kitaguchi
- Department of Neurology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan.
| | - Daisuke Akiyama
- Department of Hematology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan.
| | - Hiroshi Shimizu
- Department of Pathology, Brain Research Institute, Niigata University, 1-757 Asahimachidori, Chuo-ku Niigata, Niigata, Japan.
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, 1-757 Asahimachidori, Chuo-ku Niigata, Niigata, Japan.
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, Gifu, Japan.
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42
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Doubrovinskaia S, Sahm F, Thier MC, Bendszus M, Wick W, Seliger C, Kaulen LD. Primary CNS lymphoma after CLIPPERS: a case series. J Neurol Neurosurg Psychiatry 2021; 92:1348-1349. [PMID: 33789924 DOI: 10.1136/jnnp-2020-325759] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/25/2021] [Accepted: 02/16/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Sofia Doubrovinskaia
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Baden-Württemberg, Germany
| | - Marc Christian Thier
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany.,Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Baden-Württemberg, Germany
| | - Corinna Seliger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Leon D Kaulen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
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Abstract
Meningitis and encephalitis are inflammatory syndromes of the meninges and brain parenchyma, respectively, and may be identified either by finding definitive evidence of inflammation on tissue pathology or by cerebrocpinal fluid (CSF) analysis showing pleocytosis or intrathecal antibody synthesis. Clinicians evaluating undifferentiated meningitis or encephalitis should simultaneously consider autoimmune, infectious, and neoplastic causes, using patient risk factors, clinical syndrome, and diagnostic results including CSF and MRI findings to narrow the differential diagnosis. If an autoimmune cause is favored, an important early diagnostic question is whether a specific neural autoantibody is likely to be identified.
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Affiliation(s)
- Megan B Richie
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
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Malik P, Antonini L, Mannam P, Aboobacker FN, Merve A, Gilmour K, Rao K, Kumar S, Mani SE, Eleftheriou D, Rao A, Hemingway C, Sudhakar SV, Bartram J, Mankad K. MRI Patterns in Pediatric CNS Hemophagocytic Lymphohistiocytosis. AJNR Am J Neuroradiol 2021; 42:2077-2085. [PMID: 34620587 DOI: 10.3174/ajnr.a7292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/19/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Neuroimaging has an important role in detecting CNS involvement in children with systemic or CNS isolated hemophagocytic lymphohistiocytosis. We characterized a cohort of pediatric patients with CNS hemophagocytic lymphohistiocytosis focusing on neuroradiologic features and assessed whether distinct MR imaging patterns and genotype correlations can be recognized. MATERIALS AND METHODS We retrospectively enrolled consecutive pediatric patients diagnosed with hemophagocytic lymphohistiocytosis with CNS involvement treated at 2 pediatric neurology centers between 2010 and 2018. Clinical and MR imaging data were analyzed. RESULTS Fifty-seven children (40 primary, 70%) with a median age of 36 months (interquartile range, 5.5-80.8 months) were included. One hundred twenty-three MR imaging studies were assessed, and 2 broad imaging patterns were identified. Pattern 1 (significant parenchymal disease, 32/57, 56%) was seen in older children (P = .004) with worse clinical profiles. It had 3 onset subpatterns: multifocal white matter lesions (21/32, 66%), brainstem predominant disease (5, 15%), and cerebellitis (6, 19%). All patients with the brainstem pattern failed to meet the radiologic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. An attenuated imaging phenotype (pattern 2) was seen in 25 patients (44%, 30 studies) and was associated with younger age. CONCLUSIONS Distinct MR imaging patterns correlating with clinical phenotypes and possible genetic underpinnings were recognized in this cohort of pediatric CNS hemophagocytic lymphohistiocytosis. Disruptive mutations and missense mutations with absent protein expression correlate with a younger onset age. Children with brainstem and cerebellitis patterns and a negative etiologic work-up require directed assessment for CNS hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- P Malik
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | - L Antonini
- Department of Paediatric Hemato-Oncology (L.A.), G. Salesi Hospital, Ancona, Italy
| | - P Mannam
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | | | - A Merve
- Department of Histopathology (A.M.)
| | | | - K Rao
- Bone Marrow Transplant Unit (K.R.)
| | - S Kumar
- Child Heath (S.K.), Christian Medical College, Vellore, India
| | - S E Mani
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | - D Eleftheriou
- Paediatric Rheumatology (D.E.), Great Ormond Street Hospital for Children and University College, London, UK
| | - A Rao
- Department of Pediatric Hematology (A.R., J.B.)
| | | | | | - J Bartram
- Department of Pediatric Hematology (A.R., J.B.)
| | - K Mankad
- Pediatric Neuroradiology Unit (S.V.S., K.M.)
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Parida A, Abdel-Mannan O, Mankad K, Foster K, Ramdas S, Ram D, Eleftheriou D, Hemingway C, Hacohen Y, Wassmer E. Isolated central nervous system familial hemophagocytic lymphohistiocytosis (fHLH) presenting as a mimic of demyelination in children. Mult Scler 2021; 28:669-675. [PMID: 34704499 DOI: 10.1177/13524585211053565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Isolated central nervous system (CNS) presentations of haemophagocytic lymphohistiocytosis (HLH), traditionally a systemic inflammatory condition, have been reported in adults and children. We identified nine patients with a diagnosis of isolated CNS familial hemophagocytic lymphohistiocytosis (fHLH) with symptom onset <18 years of age, and one asymptomatic sibling. Children with atypical chronic/recurrent CNS inflammation should be considered for immunological and genetic panel testing for fHLH even in the absence of any systemic inflammatory features. Despite haematopoietic stem cell transplantation (HSCT) being a mainstay of treatment, treatment failure and high morbidity and mortality post-HSCT suggest that alternative immune therapies may be worth considering.
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Affiliation(s)
- Amitav Parida
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Omar Abdel-Mannan
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK/Queen Square MS Centre, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Kshitij Mankad
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Katharine Foster
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Dipak Ram
- Department of Neurology, Royal Manchester Children's Hospital, Manchester, UK
| | - Despina Eleftheriou
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK/Queen Square MS Centre, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK/Aston Neuroscience Institute, College of Health and Life Sciences, Aston University, Birmingham, UK
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Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids May Extend above and below Pons and Is Associated with Other Autoimmune Diseases. Life (Basel) 2021; 11:life11111120. [PMID: 34832996 PMCID: PMC8621219 DOI: 10.3390/life11111120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/16/2021] [Accepted: 10/19/2021] [Indexed: 11/22/2022] Open
Abstract
Many autoimmune diseases can affect the central nervous system, and their varying clinical presentations often confound a straightforward diagnosis. In this report, we describe a unique presentation of CLIPPERS syndrome. To our knowledge, this is the first case to demonstrate significant supratentorial involvement with symmetric and non-confluent lesions in the medial orbitofrontal cortex; additionally, this is the second case to describe an association between diagnoses of hypothyroidism and CLIPPERS.
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Axelerad AD, Stroe AZ, Mihai C, Frecus C, Jianu DC, Axelerad DD, Gogu AE. CLIPPERS, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids: A challenge in neurological practice, clinical landmarks (Review). Exp Ther Med 2021; 22:1191. [PMID: 34475981 PMCID: PMC8406757 DOI: 10.3892/etm.2021.10625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/14/2021] [Indexed: 11/06/2022] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a relatively newly discovered and characterized condition affecting the central nervous system (CNS) that involves the brainstem almost ubiquitously and that focuses primarily on the pons. Characteristically, CLIPPERS represents a combination of clinical symptoms related to the pathology of the brainstem in particular and has a characteristic appearance on magnetic resonance imaging (MRI), with punctate and curvilinear gadolinium enhancement 'peppering' the pons. The lesions can be viewed via neuroimaging with a predominance in the pons and adjacent rhombencephalic structures, such as the cerebellar peduncles, cerebellum, medulla, and middle brain. These lesions may also spread and appear in other areas of the brain such as the thalamus or white matter. As the name suggests, this clinical syndrome responds to immunosuppressive treatment based on glucocorticosteroids (GCSs), expressed as both clinical and radiological improvements. Support for this treatment is required for a long period, since exacerbations may occur without. Thus, the diagnosis of CLIPPERS has garnered increased attention from clinicians and the active exclusion of differential alternative diagnoses is needed. A specific biomarker of serum or cerebrospinal fluid (CSF) for this condition has not been discovered. The pathophysiology of this condition is not fully elucidated, and it is not yet clear whether CLIPPERS is a disease in its own right or is the culmination of several already known syndromes. Clinicians and radiologists should pay close attention to this condition as it is relatively easy to treat and patients can benefit from the early introduction of GCSs, which can produce significant results through long-term immunosuppression. Taking into account previous reports in the literature, which currently include over 50 cases reported as CLIPPERS, this analysis addressed the clinical features, and paraclinical and differential diagnoses of cases described in the literature.
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Affiliation(s)
- Any Docu Axelerad
- Department of Neurology, Faculty of General Medicine, ‘Ovidius’ University of Constanta, 900470 Constanta, Romania
- Neurology Department, County Emergency Clinical Hospital ‘Sf. Apostol Andrei’, 900591 Constanta, Romania
| | - Alina Zorina Stroe
- Department of Neurology, Faculty of General Medicine, ‘Ovidius’ University of Constanta, 900470 Constanta, Romania
- Neurology Department, County Emergency Clinical Hospital ‘Sf. Apostol Andrei’, 900591 Constanta, Romania
| | - Cristina Mihai
- Department of Pediatrics, Faculty of General Medicine, ‘Ovidius’ University of Constanta, 900470 Constanta, Romania
- Pediatrics Department, County Emergency Clinical Hospital ‘Sf. Apostol Andrei’, 900591 Constanta, Romania
| | - Corina Frecus
- Department of Pediatrics, Faculty of General Medicine, ‘Ovidius’ University of Constanta, 900470 Constanta, Romania
- Pediatrics Department, County Emergency Clinical Hospital ‘Sf. Apostol Andrei’, 900591 Constanta, Romania
| | - Dragos Catalin Jianu
- Department of Neurology, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | | | - Anca Elena Gogu
- Department of Neurology, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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48
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Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) after SARS-CoV-2 pneumonia. Neurol Sci 2021; 42:4373-4375. [PMID: 34273051 PMCID: PMC8285678 DOI: 10.1007/s10072-021-05472-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/07/2021] [Indexed: 11/09/2022]
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49
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Sudhakar V, Gersey Z, Polster SP, Mantica M, Zenonos G. Supratentorial lymphocytic inflammation with parenchymal perivascular enhancement responsive to steroids: A case report and literature review. Surg Neurol Int 2021; 12:327. [PMID: 34345468 PMCID: PMC8326066 DOI: 10.25259/sni_355_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids is a rare disorder that presents with subacute brainstem symptoms such as ataxia, facial paresthesias, and episodic diplopia, thought to be due to a T-cell medicated perivascular inflammatory process. A supratentorial variant, Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS), has been described in only three patients. Case Description: A 71-year-old male presented with word-finding difficulties, confusion, and left leg weakness. Radiographic workup demonstrated multiple supratentorial ring-enhancing lesions. PET/CT demonstrated hypermetabolism and susceptibility-weighted imaging demonstrated a hemorrhagic component. Frozen pathology revealed a predominately T-cell and monocyte inflammatory infiltrate. He demonstrated interval improvement to dexamethasone therapy, but then demonstrated worsening of his symptoms following discontinuation. Conclusion: Given his dramatic response to corticosteroids, he was diagnosed with SLIPPERS. SLIPPERS is an underrecognized diagnostic entity to consider in patients with ring-enhancing lesions and can present with hypermetabolic lesions on PET/CT.
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Affiliation(s)
- Vivek Sudhakar
- Department of Neurological Surgery University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Zachary Gersey
- Department of Neurological Surgery University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Sean P Polster
- Department of Neurological Surgery University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Megan Mantica
- Department of Neurology and Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - George Zenonos
- Department of Neurological Surgery University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Corral MAP, Gavito-Higuera J, O'Neill T, Chennan SRE. CLIPPERS associated with hypersensitivity pneumonitis: a case report. Radiol Case Rep 2021; 16:2411-2415. [PMID: 34257770 PMCID: PMC8259229 DOI: 10.1016/j.radcr.2021.05.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/29/2021] [Accepted: 05/29/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare and poorly understood pathology. In this case report we present a 51-year-old male that presented with neurological deficits with recent hypersensitivity pneumonitis. Imaging studies showed multiple punctate enhancing lesions involving the brainstem. After initiation of corticosteroids his symptoms improved, with a decrease in size of his lesions 6-months after his initial presentation. Due to its misdiagnosis, we propose the use of diagnostic criteria, described on this case report, for prompt treatment to avoid neurological sequelae.
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