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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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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 2024:10.1007/s10072-024-07469-w. [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] [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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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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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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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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Jin H, Gao Y, Lu Q, Liu R, Li Q, Hao H, Gao F. CLIPPERS syndrome: A case report in a Chinese patient with juxtacortical lesions. Mult Scler Relat Disord 2021; 50:102853. [PMID: 33640847 DOI: 10.1016/j.msard.2021.102853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome is an immune-mediated, treatable and inflammatory central nervous system (CNS) disease with unknown pathogenesis and polymorphic clinical and radiological manifestations. However, juxtacortical lesions have scarcely reported in patients with CLIPPERS. CASE PRESENTATION In this study, we report 32 year old man with complaint of intermittent dizziness, disordered fluency and walking difficulties for 2 weeks. The neuroimaging revealed multiple punctuate hyperintensities on T2-weighted images, with pepper-like gadolinium enhancement in the typical lesions of brainstem, cerebellum, periventricular as well as untypical lesions of juxtacortical area. After other similar diseases were carefully ruled out, the patient was diagnosed as CLIPPERS and exhibited a good response to immunosuppressive therapy on the acute phase and after 6 months of follow up. CONCLUSIONS The results reported here broaden the known radiologic features for this rare disorder. A long-term follow-up to rule out other potential differential diseases is essential.
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Affiliation(s)
- Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yuhan Gao
- Department of Transfusion, Peking University People's Hospital, Beijing, China
| | - Qianshuo Lu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Qunyan Li
- Department of Neurology, Beijing Haidian Hospital, Beijing, China
| | - Hongjun Hao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Feng Gao
- Department of Neurology, Peking University First Hospital, Beijing, China.
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Taieb G, Mulero P, Psimaras D, van Oosten BW, Seebach JD, Marignier R, Pico F, Rigau V, Ueno Y, Duflos C, Fominykh V, Guiraud V, Lebrun-Frénay C, Camdessanché JP, Kerschen P, Ahle G, Téllez N, Rovira A, Hoang-Xuan K, Pelletier J, Labauge P. CLIPPERS and its mimics: evaluation of new criteria for the diagnosis of CLIPPERS. J Neurol Neurosurg Psychiatry 2019; 90:1027-1038. [PMID: 31072955 DOI: 10.1136/jnnp-2018-318957] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/20/2019] [Accepted: 04/10/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the accuracy of the recently proposed diagnostic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). METHODS We enrolled 42 patients with hindbrain punctate and/or linear enhancements (<3 mm in diameter) and tested the CLIPPERS criteria. RESULTS After a median follow-up of 50 months (IQR 25-82), 13 out of 42 patients were CLIPPERS-mimics: systemic and central nervous system lymphomas (n=7), primary central nervous system angiitis (n=4) and autoimmune gliopathies (n=2). The sensitivity and specificity of the CLIPPERS criteria were 93% and 69%, respectively. Nodular enhancement ( ≥ 3 mm in diameter), considered as a red flag in CLIPPERS criteria, was present in 4 out of 13 CLIPPERS-mimics but also in 2 out of 29 patients with CLIPPERS, explaining the lack of sensitivity. Four out of 13 CLIPPERS-mimics who initially met the CLIPPERS criteria displayed red flags at the second attack with a median time of 5.5 months (min 3, max 18), explaining the lack of specificity. One of these four patients had antimyelin oligodendrocyte glycoprotein antibodies, and the three remaining patients relapsed despite a daily dose of prednisone/prednisolone ≥ 30 mg and a biopsy targeting atypical enhancing lesions revealed a lymphoma. CONCLUSIONS Our study highlights that (1) nodular enhancement should be considered more as an unusual finding than a red flag excluding the diagnosis of CLIPPERS; (2) red flags may occur up to 18 months after disease onset; (3) as opposed to CLIPPERS-mimics, no relapse occurs when the daily dose of prednisone/prednisolone is ≥ 30 mg; and (4) brain biopsy should target an atypical enhancing lesion when non-invasive investigations remain inconclusive.
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Affiliation(s)
- Guillaume Taieb
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Patricia Mulero
- Centre d'Esclerosi Mútiple de Catalunya, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Dimitri Psimaras
- Department of Neurology, AP-HP Pitié-Salpêtrière, Service de Neurologie Mazarin, Paris, France
| | - Bob W van Oosten
- Department of Neurology, VU University Medical Center, Amsterdam, Netherlands
| | - Jörg D Seebach
- Department of Immunology and Allergology, University Hospital of Genève, Geneva, Switzerland
| | - Romain Marignier
- Centre de Recherche en Neurosciences de Lyon, INSERM U1028 and CNRS UMR5292, Equipe FLUID, Lyon, France
| | - Fernando Pico
- Department of Neurology, Centre Hospitalier de Versailles, Versailles, France.,University of Versailles Saint Quentin en Yvelines et Paris Saclay, Versailles, France
| | - Valérie Rigau
- Department of Neuropathology, University Hospital of Montpellier, Montpellier, France
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, DIM, University Hospital of Montpellier, Montpellier, France
| | - Vera Fominykh
- Department of Neurology, University Hospital of Moscow, Moscow, Russia
| | - Vincent Guiraud
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | | | - Jean-Philippe Camdessanché
- Centre de Recherche en Neurosciences de Lyon, INSERM U1028 and CNRS UMR5292, Equipe FLUID, Lyon, France.,Department of Neurology, University Hospital of Sainte Anne, Paris, France
| | - Philippe Kerschen
- Department of Neurology, University Hospital of Luxembourg, Luxembourg, Luxembourg
| | - Guido Ahle
- Department of Neurology, Hospital of Colmar, Colmar, France
| | - Nieves Téllez
- Department of Neurology, Hospital Clinico de Valladolid, Valladolid, Spain
| | - Alex Rovira
- Centre d'Esclerosi Mútiple de Catalunya, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Khe Hoang-Xuan
- Department of Neurology, AP-HP Pitié-Salpêtrière, Service de Neurologie Mazarin, Paris, France
| | - Jean Pelletier
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - Pierre Labauge
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
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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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Longitudinally extensive spinal cord lesions: not always neuromyelitis optica. Acta Neurol Belg 2018; 118:327-329. [PMID: 29633157 DOI: 10.1007/s13760-018-0916-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
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Abstract
PURPOSE OF REVIEW Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently described treatable, inflammatory, brainstem predominant encephalomyelitis. The diagnosis of CLIPPERS is challenging without a specific biomarker, and thus it is important to consider if both the clinical and radiographic features are consistent with the diagnosis, or rather a disease mimicker. RECENT FINDINGS Many patients with CLIPPERS-like lesions have been described in the literature with follow-up revealing a range of alternative diagnoses, such as malignancies, vasculitis, and other specific inflammatory diseases. As a result, some have proposed that CLIPPERS might represent a pre-malignancy state or simply an initial clinical syndrome of a variety of possible etiologies. We describe the typical clinical, radiographic, and pathological features of CLIPPERS and emphasize consideration for alternative diagnoses when findings are not classic. A recommended diagnostic evaluation and initial treatment plan is provided.
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Olmes DG, Metz I, Lee DH, Rosenwald A, Doerfler A, Brück W, Linker RA. CLIPPERS with longitudinally extensive transverse myelitis: Role of T versus B cells. J Neurol Sci 2018; 385:96-98. [PMID: 29406923 DOI: 10.1016/j.jns.2017.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/10/2017] [Accepted: 12/17/2017] [Indexed: 11/15/2022]
Affiliation(s)
- David G Olmes
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Germany.
| | - Imke Metz
- Department of Neuropathology, University Hospital Göttingen, Georg-August University Göttingen, Germany.
| | - De-Hyung Lee
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Germany.
| | - Andreas Rosenwald
- Institute of Pathology, University of Würzburg, Comprehensive Cancer Center Mainfranken, Würzburg, Germany.
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Germany.
| | - Wolfgang Brück
- Department of Neuropathology, University Hospital Göttingen, Georg-August University Göttingen, Germany.
| | - Ralf A Linker
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Germany.
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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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Taieb G, Labauge P, Ding MP, Zhang YX, Hu HT, Ding XY, Chen LH, Du Y, Shen CH, Guo Y. CLIPPERS with diffuse white matter and longitudinally extensive spinal cord involvement. Neurology 2016; 86:2216-7. [PMID: 27272037 DOI: 10.1212/01.wnl.0000484563.21777.9b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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