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Domit OCC, Corrêa DG. I saw the "shrimp sign": Cerebellar progressive multifocal leukoencephalopathy. Clin Imaging 2024; 111:110171. [PMID: 38759601 DOI: 10.1016/j.clinimag.2024.110171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
The shrimp sign is characterized by a well-defined lesion in the deep cerebellar white matter, with hyperintense signal on T2- and hypointense signal on T1-weighted imaging, abutting and outlining the dentate nucleus, unilaterally or bilaterally. This sign has high sensitivity and specificity for cerebellar progressive multifocal leukoencephalopathy (PML) within the correct clinical scenario. In this article, we present a case of cerebellar PML in a woman living with human immunodeficiency virus, who was not using antiretroviral therapy, and presented the shrimp sign on brain MRI.
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Affiliation(s)
- Oliver Casagrande Calomeno Domit
- Department of Radiology, Hospital Univesitário Pedro Ernesto, Rio de Janeiro State University, Boulevard 28 de Setembro 77, Vila Isabel, Rio de Janeiro, RJ 20551-030, Brazil.
| | - Diogo Goulart Corrêa
- Department of Radiology, Hospital Univesitário Pedro Ernesto, Rio de Janeiro State University, Boulevard 28 de Setembro 77, Vila Isabel, Rio de Janeiro, RJ 20551-030, Brazil; Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil
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2
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Waraya Y, Habuka M, Sakurazawa C, Sakamaki Y, Ogawa A, Shimbo J, Nakamichi K, Yamamoto S, Narita I. A case of a cerebellar form of progressive multifocal leukoencephalopathy in a patient undergoing peritoneal dialysis. CEN Case Rep 2024:10.1007/s13730-024-00896-w. [PMID: 38824484 DOI: 10.1007/s13730-024-00896-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/25/2024] [Indexed: 06/03/2024] Open
Abstract
Progressive multifocal leukoencephalopathy (PML), a severe demyelinating disease of the central nervous system, is caused by the reactivation of the polyomavirus JC virus (JCV). It favors the cerebrum and typically occurs in patients with immunodeficiencies, with a progressive course and fatal outcome in the majority of cases. However, the cerebellar form of PML, characterized by isolated posterior fossa lesions, such as those in the cerebellum or brainstem at disease onset, is rare, and reports of its occurrence in peritoneal dialysis (PD) patients are lacking. In this paper, we describe a rare case of a cerebellar form of PML in a PD patient. A 64-year-old man undergoing PD was referred to our hospital for anorexia, nausea, and vomiting in the past month. He had finger-to-nose test abnormalities, gaze-directed nystagmus, and scanning speech. He was diagnosed with the cerebellar form of PML based on his progressive cerebellar symptoms, the typical magnetic resonance imaging findings, and the presence of JCV-DNA in the cerebrospinal fluid polymerase chain reaction test. He developed nocturnal delirium, aggravated disquiet, and died of pneumonia on the 69th day. Clinicians should consider the cerebellar form of PML as a differential diagnosis if PD patients develop progressive cerebellar symptoms.
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Affiliation(s)
- Yu Waraya
- Division of Nephrology, Niigata Prefectural Shibata Hospital, 1-2-8 Honcho, Shibata City, Niigata, 957-8588, Japan
| | - Masato Habuka
- Division of Nephrology, Niigata Prefectural Shibata Hospital, 1-2-8 Honcho, Shibata City, Niigata, 957-8588, Japan.
| | - Chihiro Sakurazawa
- Division of Nephrology, Niigata Prefectural Shibata Hospital, 1-2-8 Honcho, Shibata City, Niigata, 957-8588, Japan
| | - Yuichi Sakamaki
- Division of Nephrology, Niigata Prefectural Shibata Hospital, 1-2-8 Honcho, Shibata City, Niigata, 957-8588, Japan
| | - Asa Ogawa
- Division of Nephrology, Niigata Prefectural Shibata Hospital, 1-2-8 Honcho, Shibata City, Niigata, 957-8588, Japan
| | - Junsuke Shimbo
- Division of Neurology, Niigata Prefectural Shibata Hospital, Niigata, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo, Japan
| | - Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Cimmino AT, Carlomagno V, Sciarrone MA, Di Lazzaro G, Silvestri G. Isolated pontocerebellar leukoencephalopathy in HIV-related PML: focus on the "shrimp sign". Neurol Sci 2024; 45:1295-1298. [PMID: 37870644 DOI: 10.1007/s10072-023-07133-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Affiliation(s)
| | - Vincenzo Carlomagno
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Giulia Di Lazzaro
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gabriella Silvestri
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Braga VL, Sarmento FP, Fraiman P, Bichuetti DB, Ferraz HB, Oliveira EMLD. Progressive multifocal leukoencephalopathy with hypointense halo on MRI. Pract Neurol 2024; 24:78-79. [PMID: 37604682 DOI: 10.1136/pn-2023-003836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Vinícius Lopes Braga
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Filipe Pereira Sarmento
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
- Neurology Department, University of Florida Norman Fixel Institute for Neurological Diseases, Gainesville, Florida, USA
| | - Pedro Fraiman
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Denis Bernardi Bichuetti
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Henrique Ballalai Ferraz
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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Ramawad HA, Toloui A, Chen V, Sun Y. Cerebellar Leukoencephalopathy following Fentanyl Intoxication. A case report and review of the literature. Qatar Med J 2024; 2023:36. [PMID: 38187991 PMCID: PMC10770733 DOI: 10.5339/qmj.2023.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/09/2023] [Indexed: 01/09/2024] Open
Abstract
The opioid crisis has become a significant public health concern in recent years. Although respiratory depression and overdose are the most reported side effects of fentanyl, there have been rare cases of cerebellar leukoencephalopathy (CLE) following fentanyl intoxication. A 29-year-old man with a history of opioid use disorder and intravenous drug use presented to the emergency room with significant ataxia and dysarthria following fentanyl intoxication. According to the patient, the symptoms began four days prior after "chasing the dragon" with "pure fentanyl", and he reported experiencing nausea and dizziness, particularly during ambulation. Neurological examination revealed a positive Romberg test, ataxia, and delayed speech. Brain magnetic resonance imaging (MRI) indicated there was toxic degeneration of the cerebellar white matter that extended into the posterior limbs of the internal capsule. Urine drug screening was positive for opioids, making fentanyl-induced cerebellar leukoencephalopathy the most likely diagnosis in this case. This case of opioid-induced CLE underscores the critical significance of early recognition, which is vital for enhancing a patient's recovery and averting the development of severe neurological complications.
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Affiliation(s)
- Hamzah Adel Ramawad
- NYC Health & Hospital, South Brooklyn Health, Brooklyn, New York, USA ORCID iD: 0000-0002-9687-3599
| | | | - Victor Chen
- New York Institute of Technology College of Osteopathic Medicine, New York, USA ORCID iD: 0000-0002-9687-3599
| | - Yan Sun
- NYC Health & Hospital, South Brooklyn Health, Brooklyn, New York, USA ORCID iD: 0000-0002-9687-3599
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Suri V, Sinha AK, Priyaranjan M, Patel V. Cerebellar progressive multifocal leucoencephalopathy identified by the shrimp sign. BMJ Case Rep 2024; 17:e258289. [PMID: 38182166 PMCID: PMC10773296 DOI: 10.1136/bcr-2023-258289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
Progressive multifocal leucoencephalopathy (PML) is a demyelinating disease caused by the John Cunningham (JC) virus, which may get reactivated under certain immunosuppressive states such as AIDS, immunomodulatory therapy and haematological malignancies. PML has been reported rarely even in immunocompetent individuals where no immunodeficiency was present. PML characteristically involves periventricular and juxtacortical white matter. Isolated cerebellar or brainstem PML may be seen rarely. We present a case of a man in his 70s who presented with rapidly progressive cerebellar ataxia, ptosis and bipyramidal signs. Investigations excluded a direct viral cerebellar infection, acute disseminated encephalomyelitis, paraneoplastic cerebellar degeneration or any structural cerebellar lesion. MRI PET study revealed the classical shrimp sign which raised the possibility of cerebellar PML, and the same was confirmed by a positive JC virus PCR in the cerebrospinal fluid. Our patient had no known immune-compromising state, but further workup revealed a low CD4 count suggestive of idiopathic CD4 lymphopenia. The case illustrates the importance of the shrimp sign on MRI, the possibility of cerebellar involvement of PML as well as the need to consider a differential diagnosis of PML even in individuals with no obvious immunocompromised state.
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Affiliation(s)
- Vinit Suri
- Neurology, Indraprastha Apollo Hospitals New Delhi, New Delhi, New Delhi, India
| | - Ajay Kumar Sinha
- Neurology, Indraprastha Apollo Hospitals New Delhi, New Delhi, New Delhi, India
| | - Mayank Priyaranjan
- Neurology, Indraprastha Apollo Hospitals New Delhi, New Delhi, New Delhi, India
| | - Vipin Patel
- Neurology, Indraprastha apollo hospital, New Delhi, Delhi, India
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Agarwal A, Garg D, Garg A, Srivastava AK. "Shrimp Sign" in Progressive Multifocal Leukoencephalopathy. Ann Indian Acad Neurol 2024; 27:82-83. [PMID: 38495251 PMCID: PMC10941904 DOI: 10.4103/aian.aian_932_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 03/19/2024] Open
Affiliation(s)
- Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Divyani Garg
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Achal K. Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Dekeyzer S, Vanden Bossche S, De Cocker L. Anything but Little: a Pictorial Review on Anatomy and Pathology of the Cerebellum. Clin Neuroradiol 2023; 33:907-929. [PMID: 37410171 DOI: 10.1007/s00062-023-01326-7] [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: 04/24/2023] [Accepted: 06/09/2023] [Indexed: 07/07/2023]
Abstract
Despite its small size the cerebellum is an anatomically complex and functionally important part of the brain. Traditionally the cerebellum is viewed as a motor control structure entirely devoted to motor control and learning, but recent functional magnetic resonance imaging (fMRI) studies demonstrated significant involvement of the cerebellum in higher order cognitive functions. The anatomical complexity of the cerebellum is reflected by the several nomenclature systems that exist for the description of cerebellar anatomy. The cerebellum can be affected by a variety of pathological processes, including congenital, infectious and inflammatory, neoplastic, vascular, degenerative and toxic metabolic diseases. The purpose of this pictorial review is to (1) provide a general overview of cerebellar anatomy and function, (2) demonstrate normal cerebellar anatomy on imaging studies, and (3) illustrate both common as well as rare pathological conditions affecting the cerebellum.
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Affiliation(s)
- Sven Dekeyzer
- Department of Radiology and Medical Imaging, Ghent University Hospital (UZG), Corneel Heymanslaan 10, 9000, Gent, Belgium.
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium.
| | - Stephanie Vanden Bossche
- Department of Radiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650, Edegem, Belgium
- Department of Radiology, AZ Sint Jan Bruges, Ruddershove 10, 8000, Bruges, Belgium
| | - Laurens De Cocker
- Department of Radiology, AZ Maria Middelares Gent, Buitenring-Sint-Denijs 30, 9000, Gent, Belgium
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Varela FJ, Chaves H, Rossi M. Teaching NeuroImage: Shrimp Sign in Ataxic Cerebellar Progressive Multifocal Leukoencephalopathy. Neurology 2023; 101:918-919. [PMID: 37652696 PMCID: PMC10662992 DOI: 10.1212/wnl.0000000000207868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023] Open
Affiliation(s)
- Francisco J Varela
- From the Departamento de Neurología (F.J.V.), Departamento de Diagnóstico por Imágenes (H.C.), and Servicio de Movimientos Anormales (M.R.), Departamento de Neurología, Fleni, Ciudad Autónoma de Buenos Aires, Argentina
| | - Hernan Chaves
- From the Departamento de Neurología (F.J.V.), Departamento de Diagnóstico por Imágenes (H.C.), and Servicio de Movimientos Anormales (M.R.), Departamento de Neurología, Fleni, Ciudad Autónoma de Buenos Aires, Argentina
| | - Malco Rossi
- From the Departamento de Neurología (F.J.V.), Departamento de Diagnóstico por Imágenes (H.C.), and Servicio de Movimientos Anormales (M.R.), Departamento de Neurología, Fleni, Ciudad Autónoma de Buenos Aires, Argentina.
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Soni N, Ora M, Mangla R, Singh R, Ellika S, Agarwal A, Meyers SP, Bathla G. Radiological abnormalities in progressive multifocal leukoencephalopathy: Identifying typical and atypical imaging patterns for early diagnosis and differential considerations. Mult Scler Relat Disord 2023; 77:104830. [PMID: 37418930 DOI: 10.1016/j.msard.2023.104830] [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: 03/29/2023] [Revised: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 07/09/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare viral central nervous system (CNS) demyelinating disease primarily associated with a compromised immune system. PML is seen mainly in individuals with human immunodeficiency virus, lymphoproliferative disease, and multiple sclerosis. Patients on immunomodulators, chemotherapy, and solid organ or bone marrow transplants are predisposed to PML. Recognition of various PML-associated typical and atypical imaging abnormalities is critical for early diagnosis and differentiating it from other conditions, especially in high-risk populations. Early PML recognition should expedite efforts at immune-system restoration, allowing for a favorable outcome. This review aims to provide a practical overview of radiological abnormalities in PML patients and address differential considerations.
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Affiliation(s)
- Neetu Soni
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA.
| | - Manish Ora
- Department of Nuclear Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Rohit Singh
- Division of Hematology-Oncology at the University of Vermont Medical Center, Burlington, VT, USA
| | - Shehanaz Ellika
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
| | - Amit Agarwal
- Radiology, Mayo Clinic in Florida, San Pablo Dr, Jacksonville, FL 32224-1865, USA
| | - Steven P Meyers
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
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Ciochon UM, Scheie D, Shekhrajka N. Radiological “milky way sign” as an important pattern in progressive multifocal leukoencephalopathy in patients with or without apparent immunocompromise. J Neuroradiol 2022; 49:288-292. [DOI: 10.1016/j.neurad.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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Anand P, Vincent Lau K, Martinez-Ramirez S. MRI Shrimp Sign in Sarcoidosis-Associated Cerebellar Progressive Multifocal Leukoencephalopathy. AJNR Am J Neuroradiol 2022; 43:E1-E2. [PMID: 35058301 PMCID: PMC8985664 DOI: 10.3174/ajnr.a7407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- P. Anand
- Department of NeurologyBoston Medical CenterBoston University School of MedicineBoston, Massachusetts
| | - K.H. Vincent Lau
- Department of NeurologyBoston Medical CenterBoston University School of MedicineBoston, Massachusetts
| | - S. Martinez-Ramirez
- Department of NeurologyBoston Medical CenterBoston University School of MedicineBoston, Massachusetts
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