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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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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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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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Abstract
Multiple sclerosis (MS) is the most common immune-mediated disease of the central nervous system, characterized by demyelinating lesions of the brain and the spinal cord. Although it is extremely important to diagnose this condition in a timely manner, to initiate and monitor treatment to prevent permanent neurologic damage and disability, it is also necessary that other demyelinating conditions collectively referred to as MS mimics be identified and excluded. This article describes the in-depth neuroimaging characteristics and morphology of the pathologic lesions on the various neuroimaging modalities.
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Ramadan SM, Al-Ghamdi A, Saleh AI, Muddassir R, Rahman SS, Attahan A, Algahtani M, Ghaith MM, Theyab A. Case report with review of literature for the dilemma of diagnosis of CLIPPERS. FUTURE NEUROLOGY 2019. [DOI: 10.2217/fnl-2018-0038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
CLIPPER is a chronic inflammatory disorder in the CNS, which is characterized by MRI appearance of punctate and curvilinear gadolinium enhancement that involve the pons and the cerebellum and exquisite response to steroid. We report a patient presented with clinical and radiological features suggestive of CLIPPERS. However, despite the initial response to steroid, there were dramatic changes in the course of his disease that were conducive to considering another diagnosis. We searched PubMed using word (CLIPPERS) till December 2018. The pathogenesis, clinical manifestations, imaging features, treatment and prognosis of this disorder are summarized. A review of the literature for cases of CLIPPERS demonstrated a subset of patients who later discovered to have an alternative pathology. Indeed, clinicians should be scrupulous to diagnose this disease based solely on the clinical and radiological findings and they should have a lower threshold of having a brain biopsy.
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Affiliation(s)
- Shadi M Ramadan
- Department of Internal Medicine, MRCP (UK), Security Forces Hospital, Makkah, Saudi Arabia
| | - Abdulaziz Al-Ghamdi
- Department of Internal Medicine, Security Forces Hospital, Makkah, Saudi Arabia
| | - A Idris Saleh
- Department of Internal Medicine, Security Forces Hospital, Makkah, Saudi Arabia
| | - Rabia Muddassir
- Department of Internal Medicine, Security Forces Hospital, Makkah, Saudi Arabia
| | - Sayed S Rahman
- Department of Internal Medicine, Security Forces Hospital, Makkah, Saudi Arabia
| | - Ayman Attahan
- Department of Radiology, Security Forces Hospital, Makkah, Saudi Arabia
| | - Mohammad Algahtani
- Department of Laboratory Medicine, The Comprehensive Specialised Clinics of the Security Forces, Jeddah, Saudi Arabia
| | - Mazen M Ghaith
- Department of Laboratory Medicine, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
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Zhang L, Liu XH, Jin F, Liu MX, Zhang M, Zhang Y, Zhou DB, Zhang W. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) associated with or without lymphoma: Comparison of clinical features and risk factors suggestive of underlying lymphomas. J Clin Neurosci 2019; 66:156-164. [PMID: 31088767 DOI: 10.1016/j.jocn.2019.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We studied patients with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) associated with or without lymphoma and measured risk factors suggestive of an underlying lymphoma and follow-up outcomes. METHODS CLIPPERS patients associated with or without lymphoma were included into this study. Clinical presentations were documented, risk factors suggestive of an underlying lymphoma were tested, and prognostic differences in terms of death were compared. RESULTS Ten patients had a diagnosis of CLIPPERS associated with lymphoma, with 6 B-cell non-Hodgkin lymphoma, 2 T-cell non-Hodgkin lymphoma and 2 Hodgkin lymphoma. Using multivariate logistic analysis, the following 3 independent risk factors were found to be related to a final diagnosis of lymphoma: hyperreflexia (HR 16.56; 95% CI 1.03-265.29; p = 0.032), elevated protein in CSF (HR 11.59; 95% CI 1.24-108.39; p = 0.047), and recurrences between 2 months and 1 year after treatment (HR 29.27; 95% CI 2.09-409.58; p = 0.012). The model calibration was satisfactory (p = 0.392 with the Hosmer-Lemeshow test), and the discrimination power was good (area under the receiver operating characteristic curve 0.921; p < 0.001, 95% CI 0.826-1.000). Patients with CLIPPERS associated with lymphoma had higher mortality rate and lymphoma was a significant predictor of total mortality (HR 0.040; 95% CI 0.006-0.262; p = 0.001). CONCLUSIONS Hyperreflexia, elevated protein in CSF and recurrences between 2 months and 1 year after treatment are risk factors suggesting an underlying lymphoma. Relapses during high-dose steroids maintenance therapy can be indicative of lymphoma, too. Patients having CLIPPERS associated with lymphoma have a worse prognosis than those without lymphoma.
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Affiliation(s)
- Lu Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Xiao-Hang Liu
- Dept. of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Fan Jin
- Dept. of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Mei-Xi Liu
- Dept. of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Meng Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Yan Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Dao-Bin Zhou
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Wei Zhang
- Dept. of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
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Nemani T, Udwadia-Hegde A, Keni Karnavat P, Kashikar R, Epari S. CLIPPERS Spectrum Disorder: A Rare Pediatric Neuroinflammatory Condition. Child Neurol Open 2019; 6:2329048X19831096. [PMID: 30873425 PMCID: PMC6407169 DOI: 10.1177/2329048x19831096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/13/2018] [Accepted: 01/13/2019] [Indexed: 12/03/2022] Open
Abstract
CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is a recently described, rare neuroinflammatory disorder diagnosed by clinical symptoms involving the brain stem with a distinct pattern on neuroimaging and a perivascular T-lymphocyte infiltrate on brain biopsy. It is a condition usually described in adults in the fourth to fifth decade. We report a case of 13-year-old Indian boy who presented with recurrent episodes of ataxia and diplopia with onset at 7 years of age. He was investigated extensively to rule out infective, neoplastic, autoimmune, and demyelinating conditions over a span of 6 years. The diagnosis of CLIPPERS was entertained on the basis of clinico-radio-pathological correlation. Treatment with steroids and steroid-sparing agents, particularly methotrexate, seems to provide a promising outcome. With very few cases in literature so far, reporting of a larger case series with pediatric onset may expand it to CLIPPERS spectrum disorder.
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Affiliation(s)
- Tarishi Nemani
- Department of Pediatric Neurology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Anaita Udwadia-Hegde
- Department of Pediatric Neurology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Purva Keni Karnavat
- Department of Pediatric Neurology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Ritu Kashikar
- Department of Radiology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Shridhar Epari
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Sivertseva SA, Sivertsev MY, Bazhukhin DV, Vorobev DP, Boyko AN. [Syndrome CLIPPERS (literature review and a case report)]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:24-34. [PMID: 29359730 DOI: 10.17116/jnevro201711710224-34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This paper presents a brief literature review on chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome. Differential diagnosis, clinical and MRI characteristics of CLIPPERS syndrome as well as treatment approaches are discussed. The authors present a case of a 56-year old patient with CLIPPERS syndrome in West Siberia.
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Affiliation(s)
- S A Sivertseva
- Tyumen State Medical University, Tyumen, Russia; Tyumen Regional Center of Multiple Sclerosis 'Neftyanik', Tyumen, Russia
| | - M Yu Sivertsev
- Noginsk Consultation and Diagnostic Polyclinic, Tyumen, Russia
| | - D V Bazhukhin
- Tyumen Regional Center of Multiple Sclerosis 'Neftyanik', Tyumen, Russia
| | - D P Vorobev
- Tyumen State Medical University, Tyumen, Russia
| | - A N Boyko
- Pirogov Russian National Research Medical University, Moscow, Russia
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Abstract
OPINION STATEMENT CLIPPERS for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, is a steroid-sensitive and steroid-dependent brainstem inflammatory disease of unknown origin. Since its first description in 2010, about 60 cases have been reported throughout the world. The mean age at onset is 50 years and men seem to be more frequently affected. In patients without chronic corticosteroid therapy or immunosuppressive agents, the disease had a relapsing remitting course, and the mean annualized relapse rate was 0.5. During attacks, although clinical and radiological improvement after high doses of corticosteroids was systematically observed, patients could display subsequent disability and hindbrain atrophy. Since no progressive course was observed, clinical and radiological sequelae were correlated with previous severe attacks. Therefore, maintaining the disease in remission may prevent the accumulation of disability. In the literature, no relapse occurred when chronic corticosteroid therapy was maintained above 20 mg per day. However, steroids side effects led to propose corticosteroid-sparing therapies. Unfortunately, no controlled therapy studies for CLIPPERS have been performed yet, and no therapeutic recommendations exist. Using the PubMed database, all articles having the following keywords "chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids" and "CLIPPERS" have been analysed. Considering that the mean annual relapse rate was 0.5, and that no relapse occurred when corticosteroid therapy was maintained above 20 mg per day, the therapeutic efficiency of corticosteroid-sparing agents was considered as "probable" when patients had a relapse-free period ≥24 months, in the absence of concomitant corticosteroid therapy. Corticosteroid-sparing agents whose efficiency is "probable" are methotrexate in two cases, cyclophosphamide in one case and hydroxychloroquine in one case. Considering the risk benefit ratio of corticosteroid-sparing agents, methotrexate seems to be the most suitable. Nevertheless, randomized controlled trials testing the different corticosteroid-sparing agents in CLIPPERS are necessary.
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Hou X, Wang X, Xie B, Lin W, Liu J, Ma D, Zhang HL. Horizontal eyeball akinesia as an initial manifestation of CLIPPERS: Case report and review of literature. Medicine (Baltimore) 2016; 95:e4640. [PMID: 27559963 PMCID: PMC5400330 DOI: 10.1097/md.0000000000004640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare chronic inflammatory disorder in the central nervous system (CNS), which is characterized by magnetic resonance imaging (MRI) appearance with punctate and curvilinear gadolinium enhancement "peppering" the pons. Lesions of CLIPPERS mainly involve the pons and the cerebellum. Adjacent structures such as the medulla and the midbrain may also be involved. It is proposed that CLIPPERS is an immune-mediated inflammatory condition characteristic of T-cell-predominant infiltrates and good responsiveness to corticosteroids. METHODS AND RESULTS We report a 46-year-old woman who presented with horizontal eyeball akinesia and gait ataxia with characteristic MRI features of CLIPPERS. The possible pathogenesis, clinical manifestations, imaging features, treatment, and prognosis of this peculiar disorder are summarized. CONCLUSION This report contributes to the clinical understanding of CLIPPERS which may present with horizontal eyeball akinesia as an initial manifestation. The characteristic presentation of a subacute cerebellar and brainstem syndrome and pepper-like gadolinium enhancement was confirmed in this report. Long-term immunosuppressive treatment seems to be mandatory to sustain improvement. Azathioprine alone may be capable of maintaining remission.
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Affiliation(s)
- Xiaohe Hou
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University
| | - Xiaoke Wang
- Department of Neurosurgery, the Second Hospital of Jilin University, Jilin University, Changchun, China
| | - Bo Xie
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University
| | - Weihong Lin
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University
| | - Jun Liu
- Department of Neurosurgery, the Second Hospital of Jilin University, Jilin University, Changchun, China
- Correspondence: Jun Liu, Dihui Ma, and Hong-Liang Zhang, Jilin University, 130000, Changchun, China (e-mail: [JL]; [DM]; [HLZ)
| | - Dihui Ma
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University
- Correspondence: Jun Liu, Dihui Ma, and Hong-Liang Zhang, Jilin University, 130000, Changchun, China (e-mail: [JL]; [DM]; [HLZ)
| | - Hong-Liang Zhang
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University
- Correspondence: Jun Liu, Dihui Ma, and Hong-Liang Zhang, Jilin University, 130000, Changchun, China (e-mail: [JL]; [DM]; [HLZ)
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Blaabjerg M, Ruprecht K, Sinnecker T, Kondziella D, Niendorf T, Kerrn-Jespersen BM, Lindelof M, Lassmann H, Kristensen BW, Paul F, Illes Z. Widespread inflammation in CLIPPERS syndrome indicated by autopsy and ultra-high-field 7T MRI. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e226. [PMID: 27144217 PMCID: PMC4841643 DOI: 10.1212/nxi.0000000000000226] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 02/12/2016] [Indexed: 11/29/2022]
Abstract
Objective: To examine if there is widespread inflammation in the brain of patients with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome by using histology and ultra-high-field MRI at 7.0T. Methods: We performed a detailed neuropathologic examination in 4 cases, including 1 autopsy case, and studied 2 additional patients by MRI at 7.0T to examine (1) extension of inflammation to areas appearing normal on 3.0T MRI, (2) potential advantages of 7.0T MRI compared to 3.0T MRI in reflecting widespread inflammation, perivascular pathology, and axonal damage, and (3) the possibility of lymphoma. Results: In the autopsy case, perivascular inflammation dominated by CD4+ T cells was not only detected in the brainstem and cerebellum but also in brain areas with normal appearance on 3.0T MRI, including supratentorial regions and cranial nerve roots. There was no evidence of lymphoma in any of the 4 patients. The 7.0T MRI in clinical remission also revealed supratentorial lesions and perivascular pathology in vivo with contrast-enhancing lesions centered around a small venous vessel. Ultra-high-field MRI at 7.0T disclosed prominent T1 hypointensities in the brainstem, which were not seen on 3.0T MRI. This corresponded to neuropathologic detection of axonal injury in the autopsy case. Conclusion: Our findings suggest more widespread perivascular inflammation and postinflammatory axonal injury in patients with CLIPPERS.
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Affiliation(s)
- Morten Blaabjerg
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Klemens Ruprecht
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Tim Sinnecker
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Daniel Kondziella
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Thoralf Niendorf
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Bjørg Morell Kerrn-Jespersen
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Mette Lindelof
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Hans Lassmann
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Bjarne Winther Kristensen
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Friedemann Paul
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
| | - Zsolt Illes
- Departments of Neurology (M.B., Z.I.) and Pathology (B.W.K.), Odense University Hospital, Denmark; Clinical and Experimental Multiple Sclerosis Research Center (K.R., T.S., F.P.), Department of Neurology (K.R., F.P.), NeuroCure Clinical Research Center (T.S., F.P.), and Experimental and Clinical Research Center (T.N., F.P.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (T.S.), Universitatsspital Basel, Switzerland; Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, Denmark; Berlin Ultrahigh Field Facility (B.U.F.F.) (T.N.), Max Delbrueck Center for Molecular Medicine (F.P.), Berlin, Germany; Department of Neurology (B.M.K.-J., M.L.), Herlev Hospital, Denmark; Center for Brain Research (H.L.), Medical University of Vienna, Austria; and Institute of Clinical Research (M.B., B.W.K., Z.I.), University of Southern Denmark, Odense
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CLIPPERS Syndrome: An Entity to be Faced in Neurosurgery. World Neurosurg 2015; 84:2077.e1-3. [DOI: 10.1016/j.wneu.2015.07.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/23/2015] [Accepted: 07/24/2015] [Indexed: 11/19/2022]
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Trejo-Gabriel-Galán JM, Arenaza-Basterrechea N, Sedano-Tous MJ. Inflamación linfocítica crónica con captación perivascular de la protuberancia y respuesta a esteroides (síndrome de CLIPPERS). Med Clin (Barc) 2015; 144:187-8. [DOI: 10.1016/j.medcli.2014.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 11/30/2022]
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Bag AK, Davenport JJ, Hackney JR, Roy R, Fathallah-Shaykh HM. Case 212: chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. Radiology 2015; 273:940-7. [PMID: 25420171 DOI: 10.1148/radiol.14131355] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
History A previously healthy 23-year-old white man presented to the emergency department of our hospital with a 2-month history of dysarthria, progressively worsening vertigo, and difficulty walking. A diagnosis of retinitis pigementosa was made in this patient's childhood. He did not have any history of congenital syphilis. He did not have a history of nausea or vomiting, fever, weight loss, headache, photophobia, seizure, extremity weakness, or sensory disturbance. Physical examination revealed dysarthria, dysmetria, and ataxia. Kernig and Brudzinski signs were absent, and pathergy test results were negative. Laboratory evaluation revealed normal complete and differential blood counts and normal serum chemistry, including a normal serum angiotensin-converting enzyme level. Analysis of his serum was negative for antinuclear antibody (or ANA), cytoplasmic antineutrophil cvtoplasmic antibody (or cANCA), Sjögren syndrome antigens A and B (SS-A and SS-B, respectively), antitissue transglutaminase and antiendomysial antibodies, and paraneoplastic profile. Serum analysis was also negative for human immunodeficiency virus type 1 and type 2 RNA, Venereal Disease Research Laboratory (VDRL) test, rapid plasma regain (RPR), and fluorescent treponemal antibody absorption. Cerebrospinal fluid (CSF) analysis revealed clear fluid, a normal glucose level (64 mg/dL [3.6 mmol/L]; normal range, 40-70 mg/dL [2.2-3.9 mmol/L]), an elevated protein level (97 mg/dL; normal range, 12-60 mg/dL), and an elevated white blood cell count (7/mm(3) [0.007 ×10(9)/L] in tube 1 and 17/mm(3) [0.017 × 10(9)/L] in tube 2) with 84% lymphocytes. CSF immunoglobulin G level was elevated (30.1 mg/dL; normal, <5.9 mg/dL); however, there were no oligoclonal bands. Gram staining, acid-fast staining, and lactic acid, cryptococcal antigen, histoplasma antigen, herpes simplex virus polymerase chain reaction, VDRL, and RPR test results for CSF were negative. CSF did not grow any bacteria, fungus, or acid-fast bacillus at culture. CSF flow cytometry did not reveal a monoclonal lymphoid population. Initial imaging included brain magnetic resonance (MR) imaging. Computed tomography (CT) images of the chest, abdomen, and pelvis were normal (not shown). The patient's clinical symptoms and imaging findings responded to treatment with a high dose of oral steroids. However, the patient's symptoms exhibited clinical and radiologic progression after several attempts to taper the steroid dose.
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Affiliation(s)
- Asim K Bag
- From the Departments of Radiology (A.K.B., J.J.D., R.R.), Pathology (J.R.H.), and Neurology (H.M.F.) University of Alabama at Birmingham, JT-N432, 619 19th St S, Birmingham, AL-35249-6830
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Tani H, Nakajima H, Yamane K, Ohnishi H, Kimura F, Hanafusa T. [Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) associated with swelling in the brainstem: a case report]. Rinsho Shinkeigaku 2014; 54:581-4. [PMID: 25087561 DOI: 10.5692/clinicalneurol.54.581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare central nervous system inflammatory disease characterized by the punctate gadolinium enhancement peppering the pons and the cerebellar peduncles as neuroimaging. We report the case of a 66-year-old woman who presented with CLIPPERS associated with swelling in the brainstem. She was hospitalized because of gait ataxia and consciousness disturbance. MRI of the brain showed FLAIR hyperintense lesions in the pons, cerebellar peduncles, cerebellum and the subcortical white matter lesion in the right occipital lobe with significant swelling in the brainstem. Diffusion-weighted MRI did not show an abnormal signal, indicating vasogenic edema. Post-contrast T1-weighted MRI showed enhanced area in the right occipital lobe and panctate gadolinium enhancement peppering brainstem. Treatment with steroids led to rapid improvement. However, she showed exacerbation of clinical and radiological findings during the tapering schedule of steroid. The biopsy from the occipital lobe revealed intense perivascular and parenchymal lymphocytic infiltrates composed of primarily T cells, B cells and macrophages. The patient was diagnosed with CLIPPERS, and treatment with increased dose of corticosteroid induced a clinical improvement. Previous reports well described a characteristic MRI finding of punctate enhancement peppering the pons. In addition, the pons and cerebellar peduncles swelling can occur in this disorder.
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Affiliation(s)
- Hiroki Tani
- Department of Internal Medicine I, Osaka Medical College
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Dudesek A, Rimmele F, Tesar S, Kolbaske S, Rommer PS, Benecke R, Zettl UK. CLIPPERS: chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. Review of an increasingly recognized entity within the spectrum of inflammatory central nervous system disorders. Clin Exp Immunol 2014; 175:385-96. [PMID: 24028073 DOI: 10.1111/cei.12204] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2013] [Indexed: 01/16/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently defined inflammatory central nervous system (CNS) disorder, prominently involving the brainstem and in particular the pons. The condition features a combination of clinical symptoms essentially referable to brainstem pathology and a characteristic magnetic resonance imaging (MRI) appearance with punctate and curvilinear gadolinium enhancement 'peppering' the pons. The radiological distribution is focused in the pons and adjacent rhombencephalic structures such as the cerebellar peduncles, cerebellum, medulla and the midbrain. While the lesion burden with a perivascular pattern is typically most dense in these pontine and peripontine regions, enhancing lesions may additionally extend into the spinal cord and supratentorial structures such as the thalamus, basal ganglia, capsula interna, corpus callosum and the cerebral white matter. Another core feature is clinical and radiological responsiveness to glucocorticosteroid (GCS)-based immunosuppression. As withdrawal of GCS treatment results commonly in disease exacerbation, long-term immunosuppressive therapy appears to be mandatory for sustained improvement. Diagnosis of CLIPPERS is challenging, and requires careful exclusion of alternative diagnoses. A specific serum or cerebrospinal fluid (CSF) biomarker for the disorder is currently not known. Pathogenesis of CLIPPERS remains poorly understood, and the nosological position of CLIPPERS has still to be established. Whether CLIPPERS represents an independent, actual new disorder or a syndrome that includes aetiologically heterogeneous diseases and/or their prestages remains a debated and not finally clarified issue. Clinicians and radiologists should be aware of this condition and its differential diagnoses, given that CLIPPERS constitutes a treatable condition and that patients may benefit from an early introduction of GCS ensued by long-term immunosuppression. Based on previous reports in literature - currently encompassing more than 50 reported cases of CLIPPERS - this review addresses clinical features, diagnostic criteria, differential diagnoses and therapeutic management of this peculiar disorder.
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Affiliation(s)
- A Dudesek
- Department of Neurology, University of Rostock, Rostock, Germany
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CLIPPERS With Chronic Small Vessel Damage: More Overlap With Small Vessel Vasculitis? J Neuropathol Exp Neurol 2014; 73:262-7. [DOI: 10.1097/nen.0000000000000050] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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López Fernández M, Pato Pato A, Santos Armentia E, Cimas Hernando I, Rodríguez Constenla I, Lorenzo González JR, Requena Caballero I. [Ataxia and nystagmus of unusual origin]. Rev Clin Esp 2014; 214:e29-31. [PMID: 24461783 DOI: 10.1016/j.rce.2013.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/18/2022]
Affiliation(s)
| | - A Pato Pato
- Servicio de Neurología, Hospital POVISA, Vigo, Pontevedra, España
| | - E Santos Armentia
- Servicio de Neurorradiología, Hospital POVISA, Vigo, Pontevedra, España
| | - I Cimas Hernando
- Servicio de Neurología, Hospital POVISA, Vigo, Pontevedra, España
| | | | | | - I Requena Caballero
- Servicio de Neurología, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
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Saigal G, Quencer R. Acute lacunar infarcts in CLIPPERS: is the chronic infiltrative lymphocytic perivascular disease process to blame? Neuroradiol J 2013; 26:629-35. [PMID: 24355180 DOI: 10.1177/197140091302600604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 09/27/2013] [Indexed: 11/17/2022] Open
Abstract
CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is a recently described chronic inflammatory disorder involving the brainstem with characteristic imaging findings. Since it was originally described in 2002, only a handful of cases have been reported in the literature. We describe two additional cases of CLIPPERS with characteristic clinical and radiological findings. Besides the previously described MR findings, one of the cases also demonstrated multiple basal ganglia lacunar infarcts, a finding which has not been previously reported. We hypothesize that the lacunar infarcts are caused by this chronic infiltrative perivascular disease process.
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Affiliation(s)
- Gaurav Saigal
- Department of Radiology, Jackson Memorial Hospital, University of Miami, Miller School of Medicine; Miami, USA -
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Need for prolonged immunosupressive therapy in CLIPPERS--a case report. BMC Neurol 2013; 13:49. [PMID: 23706003 PMCID: PMC3669048 DOI: 10.1186/1471-2377-13-49] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 04/20/2013] [Indexed: 11/10/2022] Open
Abstract
Background Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was first described in 2010 by Pittock and colleagues. All reported patients presented with diplopia and gait ataxia and had similar typical MRI findings with punctuate gadolinium enhancement of the pons. Alternative diagnoses were excluded by means of laboratory, radiological and histological tests. All patients were successfully treated with steroids. We present a case in which the steroid therapy was switched to long term immunosuppressive therapy, leading to several severe side-effects, but sustained clinical improvement. Case presentation A 63-year-old male presented with sub-acute diplopia and progressive gait ataxia. During admission his neurological condition worsened and he developed multiple cranial nerve deficits, paraparesis and urine retention. MRI-findings were remarkable with punctuate enhancement with gadolinium of the pons. Cerebrospinal fluid only showed elevated protein levels and all other additional investigations were normal. The probable diagnosis of CLIPPERS was made and intravenous corticosteroids were administered. This led to rapid clinical recovery and decreased enhancement on the MRI-scan. Long-term oral immunosuppressive therapy was started. One-and-a-half year later our patient has no recurrence of neurological symptoms, however due to the side effects of the immunosuppressive therapy he was readmitted several times. Conclusion CLIPPERS presents with distinctive clinical and MRI-findings and may be diagnosed after excluding other differential diagnoses. Patients are treated with corticosteroids with good clinical results. Since short term glucocorticoid treatment results into relapse of the disease, longer term immunosuppressive therapy appears to be mandatory for sustained improvement, although accompanied by severe side effects.
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Sczesni KC, Alekseyev A, Schlegel U, Skodda S. [Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids]. DER NERVENARZT 2012; 83:775-81. [PMID: 22215219 DOI: 10.1007/s00115-011-3430-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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