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Liu XH, Jin F, Zhang M, Liu MX, Wang T, Pan BJ, Zhang L. Peripheral T cell lymphoma after chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): a case report. BMC Neurol 2019; 19:266. [PMID: 31684908 PMCID: PMC6827254 DOI: 10.1186/s12883-019-1507-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory disorder in the central nervous system (CNS) with distinct clinical, radiological, and pathological characteristics. The pathophysiology of CLIPPERS still remains unclear. Because a few cases about lymphoma mimicking the manifestations of CLIPPERS were reported and the prognosis of lymphoma is much worse, early identification of lymphoma is very important. CASE PRESENTATION A 31-year-old woman was admitted with 3 months' history of diplopia, dizziness, gait ataxia, and right facial numbness. The diagnosis of CLIPPERS was established based on the finding of punctate enhancing lesions in the cerebellum, thalamus, pons, medulla, and midbrain region in magnetic resonance imaging (MRI), together with the favorable clinical and radiological responses to corticosteroids. However, she was diagnosed as peripheral T cell lymphoma, not otherwise specified (PTCL-NOS) by the pulmonary nodular and the skin biopsy almost 10 years later, and she got complete remission within 1 year after chemotherapy. CONCLUSION We report the first case of CLIPPERS developing PTCL-NOS. This case proposes that when brain biopsy was difficult to achieve, biopsies in extra-cerebral lesions under the assisting examination of positron emission tomography-computed tomography (PET-CT) can be helpful in further identification.
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Affiliation(s)
- 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
| | - Meng Zhang
- Dept. of Hematology, 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
| | - Tao Wang
- Dept. of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Bo-Ju Pan
- Dept. of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Lu 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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Crowell EL, Adesina OO. Reply to Tobin and Keegan’s “Reply to Idiopathic Central Nervous System Inflammatory Disease in the Setting of HLA-B27 Uveitis”. Ocul Immunol Inflamm 2019; 27:1194. [DOI: 10.1080/09273948.2018.1498694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Eric L. Crowell
- Ruiz Department of Ophthalmology and Visual Science, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
- Robert Cizik Eye Clinic, Houston, Texas, USA
| | - Ore-ofe Adesina
- Ruiz Department of Ophthalmology and Visual Science, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA
- Robert Cizik Eye Clinic, Houston, Texas, USA
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas, USA
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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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Diffuse white matter alteration in CLIPPERS: Advanced MRI findings from two cases. J Neurol Sci 2019; 402:40-47. [DOI: 10.1016/j.jns.2019.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/26/2019] [Accepted: 04/30/2019] [Indexed: 11/18/2022]
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Unusual CLIPPERS presentation and role of MRI examination in the proper diagnostic assessment: A case report. Eur J Radiol Open 2019; 6:212-214. [PMID: 31198819 PMCID: PMC6556810 DOI: 10.1016/j.ejro.2019.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/14/2019] [Indexed: 11/26/2022] Open
Abstract
CLIPPERS is a recently described, underestimated CNS inflammatory disorder involving midbrain and cerebellum. Unusual clinical presentation can make the diagnosis particularly challenging to the clinician. MRI plays a pivotal role in the correct diagnostic assessment, helping discriminate CLIPPERS from potential mimickers.
Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids syndrome (CLIPPERS) is a newly described, underestimated CNS inflammatory disorder involving predominantly the midbrain and the cerebellum. CLIPPERS pathogenesis is largely unknown, and its clinical manifestations are polymorphic and sometimes confounding. Recently clinical, radiological and pathological diagnostic criteria have been proposed to discriminate CLIPPERS from potential mimickers, but the diagnosis still remains challenging. Here we present the case of a patient with radiological findings consistent with CLIPPERS but with atypical clinical presentation, highlighting the importance of a proper diagnostic assessment.
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Nguyen PB, Prentice D, Brazel R, Leong WK. Hemidysgeusia, phantosmia and respiratory arrest: a case of CLIPPERS. BMJ Case Rep 2019; 12:12/5/e230094. [PMID: 31151979 DOI: 10.1136/bcr-2019-230094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 56-year-old man presented with a relapse of likely chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) after a reduction of steroid dose. MRI demonstrated new perivascular FLuid-Attenuated Inversion Recovery (FLAIR) signal hyperintensity involving the dorsal pontomedullary junction and progressing inferiorly into the dorsal medulla oblongata. His admission to hospital was complicated by a respiratory arrest.
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Affiliation(s)
- Peter Baoviet Nguyen
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - David Prentice
- Perron Institute, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Robert Brazel
- Neurological Intervention and Imaging Service of Western Australia, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia
| | - Wai Kuen Leong
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
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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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Nagano M, Ayaki T, Koita N, Kitano T, Nishikori M, Goda N, Minamiguchi S, Ikeda A, Takaori-Kondo A, Takahashi R. Recurrent Epstein-Barr Virus-positive (EBV+) Primary Central Nervous System Lymphoma (PCNSL) in a Patient with Clinical Features of Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS). Intern Med 2019; 58:849-854. [PMID: 30880301 PMCID: PMC6465023 DOI: 10.2169/internalmedicine.1246-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/16/2018] [Indexed: 12/19/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) and chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) can share clinical features and may be indistinguishable, even after brain biopsy. We encountered a case of Epstein-Barr virus-positive (EBV+) PCNSL recurrence in a patient with clinical features of CLIPPERS, and repeat brain biopsy was required to reach the correct diagnosis. Four years after the initial diagnosis and treatment of PCNSL, "peppering" punctate enhanced lesions with transient steroid responsiveness were detected during brain magnetic resonance imaging (MRI). A second brain biopsy supported a diagnosis of CLIPPERS, while a third biopsy confirmed the diagnosis of recurrent PCNSL.
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Affiliation(s)
- Masahiro Nagano
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Takashi Ayaki
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Natsuko Koita
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Toshiyuki Kitano
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Japan
| | - Naoki Goda
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Japan
| | - Akio Ikeda
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
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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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Rempe T, Becktepe JS, Metz I, Brück W, Stürner KH, Deuschl G, Berg D, Baron R, Zeuner R, Leypoldt F. A case of CLIPPERS syndrome responsive to tocilizumab. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e545. [PMID: 30882019 PMCID: PMC6410928 DOI: 10.1212/nxi.0000000000000545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/08/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Torge Rempe
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Jos Steffen Becktepe
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Imke Metz
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Wolfgang Brück
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Klarissa Hanja Stürner
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Günther Deuschl
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Daniela Berg
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Ralf Baron
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Rainald Zeuner
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
| | - Frank Leypoldt
- Department of Neurology (T.R., J.S.B., K.H.S., G.D., D.B., R.B., F.L.), Department of Rheumatology (R.Z.), and Neuroimmunology, Institute of Clinical Chemistry (F.L.), Division of Neurological Pain Research and Therapy (R.B.), University Hospital of Schleswig-Holstein, Kiel, Germany; Department of Neurology (T.R.), University of Florida, Gainesville, FL; and Institute of Neuropathology (I.M., W.B.), University Hospital Göttingen, Germany
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Joshi K, Golden T, Ghazala S. CLIPPERS: An Increasingly Recognized Chronic Inflammatory Central Nervous System Disorder. Am J Med 2019; 132:e35-e36. [PMID: 30367853 DOI: 10.1016/j.amjmed.2018.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 11/16/2022]
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Bathla G, Watal P, Policeni B. Neurosarcoidosis. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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63
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Sánchez Aliaga E. Vasculitis and Other Inflammatory Disorders. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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64
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Vasculitis and Other Inflammatory Disorders. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_45-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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65
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Comparison of costs and outcomes of patients presenting with a rare brainstem syndrome. eNeurologicalSci 2018; 13:21-23. [PMID: 30450430 PMCID: PMC6226594 DOI: 10.1016/j.ensci.2018.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 11/01/2018] [Indexed: 11/22/2022] Open
Abstract
In this case report we compare two patients presenting with similar symptoms of a brainstem syndrome including ataxia, dysarthria, and diplopia. Their MRIs showed hyperintense FLAIR signal changes with patchy areas of contrast enhancement within the brainstem particularly the pons and cerebellum. The broad differential diagnosis of this brainstem pathology included rhomboencephalitis, neurosarcoidosis, lymphoma, vasculitis, infection, and paraneoplastic or autoimmune process. Patient 1 had an extensive work up including CSF cytology, MRI brain spectroscopy, full body CT, cerebral angiogram, and ultimately brainstem biopsy. None of these studies were diagnostic of a specific etiology and total cost was $176,069. After months of declining medical condition without a clear diagnosis, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was considered and the patient began steroid therapy resulting in clinical and radiographic improvement. Patient 2 had serum and CSF studies that were negative for infectious, paraneoplastic, and other inflammatory processes. The team diagnosed CLIPPERS and initiated steroid therapy within days resulting in dramatic clinical and radiographic resolution. The workup cost $12,905. Comparison of these cases shows how early awareness of CLIPPERS and a directed diagnostic work up can limit invasive diagnostic testing, expedite initiation of effective therapy, improve patient outcomes, and reduce cost.
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Tian D, Zhu X, Xue R, Zhao P, Yao Y. Case 259: Primary Central Nervous System Lymphomatoid Granulomatosis Mimicking Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS). Radiology 2018; 289:572-577. [PMID: 30332362 DOI: 10.1148/radiol.2018161475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Decai Tian
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Xiaodong Zhu
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Rong Xue
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Peng Zhao
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
| | - Yuanrong Yao
- From the Bejing-TJ Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (D.T.); Department of Neurology, Neurologic Institute, Tianjin Medical University General Hospital, Tianjin, China (X.Z., R.X., P.Z.); and Department of Neurology, Guizhou Provincial People’s Hospital, Medical School of Guizhou University, Zhongshan East Road 83, Guiyang 550002, China (Y.Y.)
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Dutra BG, da Rocha AJ, Nunes RH, Maia ACM. Neuromyelitis Optica Spectrum Disorders: Spectrum of MR Imaging Findings and Their Differential Diagnosis. Radiographics 2018; 38:169-193. [PMID: 29320331 DOI: 10.1148/rg.2018170141] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neuromyelitis optica (NMO) is an autoimmune demyelinating disorder for which the aquaporin-4 (AQP4) water channels are the major target antigens. Advances in the understanding of NMO have clarified several points of its pathogenesis, clinical manifestations, and imaging patterns. A major advance was the discovery of the AQP4 antibody, which is highly specific for this disorder. Descriptions of new clinical and radiologic features in seropositive patients have expanded the spectrum of NMO, and the term NMO spectrum disorder (NMOSD) has been adopted. NMOSD is now included in a widening list of differential diagnoses. Acknowledgment of NMOSD imaging patterns and their mimicry of disorders has been crucial in supporting early NMOSD diagnosis, especially for unusual clinical manifestations of this demyelinating disease. This pictorial review summarizes the wide imaging spectrum of NMOSD and its differential diagnosis, as well as its historical evolution, pathophysiology, and clinical manifestations. ©RSNA, 2018.
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Affiliation(s)
- Bruna Garbugio Dutra
- From the Division of Neuroradiology, Serviço de Diagnóstico por Imagem, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Motta Jr. 112, Vila Buarque, São Paulo-SP 01221-020, Brazil; Division of Neuroradiology, Grupo DASA, São Paulo, Brazil (B.G.D., A.J.d.R., R.H.N.); and Division of Neuroradiology, Fleury Medicina e Saúde, São Paulo, Brazil (B.G.D, A.C.M.M.J.)
| | - Antônio José da Rocha
- From the Division of Neuroradiology, Serviço de Diagnóstico por Imagem, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Motta Jr. 112, Vila Buarque, São Paulo-SP 01221-020, Brazil; Division of Neuroradiology, Grupo DASA, São Paulo, Brazil (B.G.D., A.J.d.R., R.H.N.); and Division of Neuroradiology, Fleury Medicina e Saúde, São Paulo, Brazil (B.G.D, A.C.M.M.J.)
| | - Renato Hoffmann Nunes
- From the Division of Neuroradiology, Serviço de Diagnóstico por Imagem, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Motta Jr. 112, Vila Buarque, São Paulo-SP 01221-020, Brazil; Division of Neuroradiology, Grupo DASA, São Paulo, Brazil (B.G.D., A.J.d.R., R.H.N.); and Division of Neuroradiology, Fleury Medicina e Saúde, São Paulo, Brazil (B.G.D, A.C.M.M.J.)
| | - Antônio Carlos Martins Maia
- From the Division of Neuroradiology, Serviço de Diagnóstico por Imagem, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Motta Jr. 112, Vila Buarque, São Paulo-SP 01221-020, Brazil; Division of Neuroradiology, Grupo DASA, São Paulo, Brazil (B.G.D., A.J.d.R., R.H.N.); and Division of Neuroradiology, Fleury Medicina e Saúde, São Paulo, Brazil (B.G.D, A.C.M.M.J.)
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Didier PGJ, Adrián MGL, Paola SGA, Mauricio FS, Omar CS, Liset RVY, Luis RSJ. CLIPPERS syndrome responsive to Leflunomide: A case report. Mult Scler Relat Disord 2018; 25:265-267. [PMID: 30149302 DOI: 10.1016/j.msard.2018.07.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/03/2018] [Accepted: 07/19/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) was recently described in 2010, therefore the long-term prognosis is uncertain and there is no consensus on which steroid-sparing treatment is the most indicated. We present a case of CLIPPERS successfully treated with leflunomide. CASE REPORT A 43-year-old man with progressive symptoms of pontocerebellar dysfunction and radiological findings consistent with CLIPPERS was admitted to our clinic and treated with steroids in the acute phase, then he continue leflunomide for one year, showing sustained clinical and radiological remission. The treatment was changed to azathioprine and continued two more years in remission. CONCLUSION As far as we have documented, this is the first case of CLIPPERS kept under control with leflunomide in the medium-term with a good relative prognosis.
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Affiliation(s)
- Parada-Garza Juan Didier
- Servicio de Neurología, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Hospital 278, Guadalajara, Jalisco 44280, México
| | - Miranda-García Luis Adrián
- Servicio de Neurología, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Hospital 278, Guadalajara, Jalisco 44280, México
| | - Salvatella-Gutierrez Ana Paola
- Servicio de Neurología, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Hospital 278, Guadalajara, Jalisco 44280, México
| | | | - Cárdenas-Saenz Omar
- Department of Internal Medicine, Hospital Civil de Guadalajara "Fray Antonio Alcalde", México
| | | | - Ruiz-Sandoval Jose Luis
- Servicio de Neurología, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Hospital 278, Guadalajara, Jalisco 44280, México; Department of Neurosciences, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de Guadalajara, México.
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69
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Bobba S, Narasimhan M, Zagami AS. Isolated painful trigeminal neuropathy as an unusual presentation of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids: A case report. Cephalalgia 2018; 39:316-322. [PMID: 29863408 DOI: 10.1177/0333102418781789] [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: 11/15/2022]
Abstract
BACKGROUND Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory central nervous system disorder, typically presenting with subacute symptoms referable to brainstem and cerebellar pathology. This is the first report of CLIPPERS presenting with a painful trigeminal neuropathy. CASE REPORT We report an unusual case of CLIPPERS presenting with facial pain and sensory symptoms, in the absence of other brainstem or cerebellar signs. Perivascular enhancement of peri-pontine structures on neuroimaging, lymphocytic infiltrate on histopathology and rapid clinical and radiological responsiveness to glucocorticosteroids were key to diagnosis. Extensive investigations excluded various differential aetiologies. CONCLUSION The pathogenesis of CLIPPERS is poorly understood, and the diagnostic criteria are yet to be validated. In this case, facial pain was not associated with other brainstem or cerebellar signs, broadening current understanding of how CLIPPERS may present. This has clinical implications in guiding future investigations for patients presenting with painful trigeminal neuropathy.
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Affiliation(s)
- Samantha Bobba
- 1 Department of Ophthalmology, Westmead Hospital, Sydney, Australia.,2 Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | | | - Alessandro S Zagami
- 2 Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,4 Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
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Crowell EL, Pfeiffer ML, Kamdar AA, Koenig MK, Wittenberg SE, Supsupin EP, Adesina OOO. Idiopathic Central Nervous System Inflammatory Disease in the Setting of HLA-B27 Uveitis. Ocul Immunol Inflamm 2018; 27:912-917. [PMID: 29652210 DOI: 10.1080/09273948.2018.1449865] [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: 10/17/2022]
Abstract
Purpose: The purpose of the article is to describe a novel case of idiopathic central nervous system inflammatory disease with bilateral human leukocyte antigen (HLA)-B27-positive anterior uveitis. Methods/Results: A 15-year-old African American boy with bilateral HLA-B27-positive anterior uveitis controlled with topical and oral steroids for 8 months acutely developed headaches, left eyelid ptosis, and binocular diplopia. Imaging showed lesions in the right midbrain, superior colliculus, cerebellar peduncles, and cerebellar vermis and leptomeningeal enhancement along the vermian foliae. Cerebral spinal fluid tests showed mild lymphohistiocytic pleocytosis with negative cytology; inflammatory and infectious workup were negative. He received intravenous methylprednisolone without initial symptomatic improvement; repeat magnetic resonance imaging (MRI) showed reduced lesion burden. Oral steroids were continued; his symptoms resolved in 1 month. Repeat MRI 2 months after presentation showed almost complete lesion resolution. Conclusions: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) was diagnosed. HLA-B27 positivity may represent a novel association with CLIPPERS.
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Affiliation(s)
- Eric L Crowell
- Ruiz Department of Ophthalmology and Visual Science, McGovern Medical School at The University of Texas Health Science Center in Houston (UTHealth) , Houston , Texas , USA.,Robert Cizik Eye Clinic , Houston , Texas , USA
| | - Margaret L Pfeiffer
- Ruiz Department of Ophthalmology and Visual Science, McGovern Medical School at The University of Texas Health Science Center in Houston (UTHealth) , Houston , Texas , USA.,Robert Cizik Eye Clinic , Houston , Texas , USA
| | - Ankur A Kamdar
- Department of Pediatrics, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Mary K Koenig
- Division of Child and Adolescent Neurology, Department of Pediatrics, McGovern Medical School at UTHealth , Houston , Texas , USA
| | | | - Emilio P Supsupin
- Department of Diagnostic and Interventional Imaging, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Ore-Ofe O Adesina
- Ruiz Department of Ophthalmology and Visual Science, McGovern Medical School at The University of Texas Health Science Center in Houston (UTHealth) , Houston , Texas , USA.,Robert Cizik Eye Clinic , Houston , Texas , USA.,Department of Neurology, McGovern Medical School at UTHealth , Houston , Texas , USA
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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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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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Cordano C, López GY, Bollen AW, Nourbakhsh B. Occipital Headache in Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS). Headache 2017; 58:458-459. [PMID: 29193048 DOI: 10.1111/head.13232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/12/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Christian Cordano
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Giselle Y López
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Andrew W Bollen
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Bardia Nourbakhsh
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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75
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Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): A pediatric case report with six year follow-up. Mult Scler Relat Disord 2017; 17:95-98. [DOI: 10.1016/j.msard.2017.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 11/18/2022]
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76
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Ohta Y, Nomura E, Tsunoda K, Yamashita T, Takahashi Y, Sato K, Takemoto M, Hishikawa N, Abe K. Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) with Limbic Encephalitis. Intern Med 2017; 56:2513-2518. [PMID: 28824066 PMCID: PMC5643184 DOI: 10.2169/internalmedicine.8533-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory central nervous system disorder that mainly involves in the brainstem, basal ganglia and cerebellum. We herein report the case of a patient with CLIPPERS, which was diagnosed based on the clinical and radiological features. After initially responded to steroid treatment, the patient developed limbic encephalitis. The patient presented with memory disturbance, a delirious state and emotional incontinence. A cerebrospinal fluid study revealed interleukin-6 elevation and enhanced bilateral hippocampal lesions were observed on MRI. The patient was successfully treated with methylprednisolone pulse therapy. This is the first case of CLIPPERS with limbic encephalitis involving the bilateral hippocampus.
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Affiliation(s)
- Yasuyuki Ohta
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Emi Nomura
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Keiichiro Tsunoda
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Toru Yamashita
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Yoshiaki Takahashi
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Kota Sato
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Mami Takemoto
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Nozomi Hishikawa
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
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Berkman J, Ford C, Johnson E, Malow BA, Aulino JM. Misdiagnosis: CNS Erdheim-Chester disease mimicking CLIPPERS. Neuroradiol J 2017; 31:399-402. [PMID: 28685649 DOI: 10.1177/1971400917710251] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory central nervous system (CNS) disorder with particular involvement of the pons. Diagnostic criteria include a range of clinical symptoms related to the underlying brainstem pathology, visible with magnetic resonance imaging (MRI). MRI findings include the appearance of punctuate and curvilinear gadolinium enhancement 'peppering' the pons. We discuss a patient presenting with clinical and radiographic characteristics of CLIPPERS who was diagnosed with Erdheim-Chester disease (ECD). Case report A 52-year-old male presented with 2 years of progressive spasticity, dysarthria, and gait instability. Initially, he was diagnosed with Parkinson's disease at an outside hospital, based on tremor, rigidity, and gait instability; however, he failed to improve with a trial of levodopa. Brain MRI showed small enhancing parenchymal nodules coalescing in the central pons, but also affecting the cerebellum and cerebellar peduncles, with more punctate enhancing lesions in the cerebral lobar subcortical white matter. When the patient's response to steroids was inadequate, further imaging was done, revealing perinephric processes. Subsequent biopsy revealed ECD. Conclusions A review of the literature for cases of CLIPPERS demonstrated a subset of patients later found to have various malignancies involving the CNS. This case report uses the patient's unique radiographic and clinical presentation to demonstrate the importance of the exclusion criteria within the CLIPPERS diagnostic requirements and stresses red flags suggestive of alternative diagnoses. This distinction is of high importance when differentiating a relatively benign process such as CLIPPERS from more malignant diseases.
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Affiliation(s)
- Jillian Berkman
- 1 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Caleb Ford
- 1 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Emily Johnson
- 2 Vanderbilt University Medical Center, Department of Neurology, Nashville, TN, USA
| | - Beth A Malow
- 2 Vanderbilt University Medical Center, Department of Neurology, Nashville, TN, USA
| | - Joseph M Aulino
- 3 Vanderbilt University Medical Center, Department of Radiology and Radiological Sciences, Nashville, TN, USA
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Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids, with Cranial and Caudal Extension. Case Rep Neurol Med 2017; 2017:2593096. [PMID: 28589049 PMCID: PMC5446869 DOI: 10.1155/2017/2593096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/23/2017] [Indexed: 11/21/2022] Open
Abstract
A 23-year-old lady presented with vertigo and imbalance in walking, blurring of vision, diplopia, and headache, in addition to numbness in the lower limbs over a period of six days. On examination patient had nystagmus, ataxia, positive Romberg test, and hyperreflexia. MRI examination of the brain and spinal cord showed evidence of faint bright signal intensity foci in T2/FLAIR involving bilateral cerebral hemispheres, subcortical deep white matter, bilateral thalami, posterior pons and left brachium pontis, and basal ganglia, with small nodular enhancement that aligned along curvilinear structures; those lesions also were apparent along the spinal cord at multiple levels. The clinical and radiological features suggested CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) syndrome. Symptoms improved dramatically with high dose oral corticosteroids. Our report addresses the radiological and clinical pattern of a case of CLIPPERS rhombencephalitis, with added superior and inferior extension to involve the brain and spinal cord, which is to emphasize the importance of raising the awareness of this disease and the combined role of radiologist and physicians for the diagnosis of this potentially treatable entity, responsive to glucocorticosteroid immunosuppression.
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Wang X, Huang D, Huang X, Zhang J, Ran Y, Lou X, Gui Q, Yu S. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): A lymphocytic reactive response of the central nervous system? A case report. J Neuroimmunol 2017; 305:68-71. [PMID: 28284348 DOI: 10.1016/j.jneuroim.2017.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/01/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroid (CLIPPERS) was first described in 2010. The characteristic clinical picture, radiological distribution and steroid response have been well-described in previous reports. However, the underlying pathogenesis and nosological position of CLIPPERS in the CNS require further investigation for the primary CNS lymphoma have been identified by autopsy subsequently. Here, we report a 51-year-old woman who was diagnosed with CLIPPERS but progressed to primary CNS lymphomatoid granulomatosis, which supports that CLIPPERS is not just an inflammatory CNS disorder.
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Affiliation(s)
- Xiaolin Wang
- The PLA General Hospital, Department of Neurology, PR China
| | - Dehui Huang
- The PLA General Hospital, Department of Neurology, PR China
| | - Xusheng Huang
- The PLA General Hospital, Department of Neurology, PR China
| | - Jiatang Zhang
- The PLA General Hospital, Department of Neurology, PR China
| | - Ye Ran
- The PLA General Hospital, Department of Neurology, PR China
| | - Xin Lou
- The PLA General Hospital, Department of Radiology, PR China
| | - Qiuping Gui
- The PLA General Hospital, Department of Pathology, PR China
| | - Shengyuan Yu
- The PLA General Hospital, Department of Neurology, PR China.
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Abstract
Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) is a rare chronic inflammatory disorder of the central nervous system. Herein, we describe the case of a 62-year-old female who presented with right sided facial tingling, gait ataxia and diplopia. Neuroimaging revealed pontine curvilinear enhancing lesions with extension into cerebellar peduncles, characteristic of CLIPPERS. This report discusses the differential diagnosis and the importance of prolonged immunomodulatory treatment for this rare neuro-inflammatory disorder. Long-term immunosuppression appears to be mandatory in order to achieve sustained remission and prevent disability related to atrophy of the structures involved in repeated attacks.
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81
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Tyrakowska Z, Jakubowicz-Lachowska D, Kułakowska A, Galińska-Skok B, Drozdowski W, Tarasów E. Relapsing-Remitting Severe Bickerstaff's Brainstem Encephalitis - Case Report and Literature Review. Pol J Radiol 2016; 81:622-628. [PMID: 28096906 PMCID: PMC5214676 DOI: 10.12659/pjr.898647] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/05/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Bickerstaff's brainstem encephalitis (BBE) is a very rare disease of the central nervous system. Aetiology of the disease is auto-immunological. However, it is not entirely understood. Clinically BBE manifests in progressive ophthalmoplegia, ataxia and consciousness disturbances. Clinical symptoms are usually preceded by an unidentified infection of the upper respiratory tract. Usually, the disease has one phase, but individual relapses have also been described. Despite quite severe clinical symptoms, the prognosis is usually good. CASE REPORT The article presents a case of a patient with relapsing-remitting severe BBE. The case is presented due to the relapsing-remitting clinical course of the disease that resulted in patient's death, rarely described in the literature. We also present the results of subsequent MR scans in the course of the disease, so far described only in individual reports. It is also the first report in the world's literature presenting the results of series of MR spectroscopy (MRS) examinations in the course of BBE. CONCLUSIONS MR examination is an important component in BBE diagnostics, allowing to differentiate atypical cases and place them under special supervision due to the possibility of the severe clinical course. MR also facilitates differentiation between Miller-Fisher Syndrome (MFS) and BBE in cases of diagnostic doubts. Adding MRS and MRI to the protocol allows us to define the nature of morphological changes more accurately in patients with suspected or diagnosed BBE.
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Affiliation(s)
- Zuzanna Tyrakowska
- Department of Radiology, Medical University of Białystok, Białystok, Poland
| | | | - Alina Kułakowska
- Department of Neurology, Medical University of Białystok, Białystok, Poland
| | - Beata Galińska-Skok
- Department of Psychiatry, Medical University of Białystok, Białystok, Poland
| | - Wiesław Drozdowski
- Department of Neurology, Medical University of Białystok, Białystok, Poland
| | - Eugeniusz Tarasów
- Department of Radiology, Medical University of Białystok, Białystok, Poland
- TMS Diagnostyka, Białystok, Poland
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Chen J, Carletti F, Young V, Mckean D, Quaghebeur G. MRI differential diagnosis of suspected multiple sclerosis. Clin Radiol 2016; 71:815-27. [DOI: 10.1016/j.crad.2016.05.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 04/08/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
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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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Abstract
In this paper we report the case of a 52-year-old woman with multiple contrast enhancing lesions associated with a chronic lymphocytic inflammation of the infratentorial structures. We discuss the symptoms, imaging and treatment of this rare disorder, in which magnetic resonance imaging (MRI) has a crucial role in the diagnosis. Early recognition on MRI and radiological follow-up are also important to optimize the treatment.
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85
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Rico M, Villafani J, Tuñón A, Mateos V, Oliva-Nacarino P. IFN beta 1a as Glucocorticoids-Sparing Therapy in a Patient with CLIPPERS. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:47-50. [PMID: 26813773 PMCID: PMC4734679 DOI: 10.12659/ajcr.896102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 31 Final Diagnosis: CLIPPERS Symptoms: Ataxia • diplopia Medication: IFNbeta 1a Clinical Procedure: — Specialty: Neurology
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Affiliation(s)
- María Rico
- Department of Neurology, Hospital de Cabueñes, Gijón, Spain
| | - Javier Villafani
- Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Alberto Tuñón
- Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Valentín Mateos
- Department of Neurology, Centrol Médico de Asturias, Oviedo, Spain
| | - Pedro Oliva-Nacarino
- Department of Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain
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86
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Zhang YX, Hu HT, Ding XY, Chen LH, Du Y, Shen CH, Guo Y, Ding MP. CLIPPERS with diffuse white matter and longitudinally extensive spinal cord involvement. Neurology 2015; 86:103-5. [DOI: 10.1212/wnl.0000000000002212] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 08/27/2015] [Indexed: 11/15/2022] Open
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Gupta HV, Samant R, Gokden M, Lee RW, Sahaya K, Virmani T. Clinical Reasoning: A 73-year-old man with diplopia and ataxia. Neurology 2015; 85:e96-100. [PMID: 26416806 DOI: 10.1212/wnl.0000000000001975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Harsh V Gupta
- From the Departments of Neurology (H.V.G., R.W.L., K.S., T.V.), Radiology (R.S.), and Pathology (M.G.), University of Arkansas for Medical Sciences, Little Rock.
| | - Rohan Samant
- From the Departments of Neurology (H.V.G., R.W.L., K.S., T.V.), Radiology (R.S.), and Pathology (M.G.), University of Arkansas for Medical Sciences, Little Rock
| | - Murat Gokden
- From the Departments of Neurology (H.V.G., R.W.L., K.S., T.V.), Radiology (R.S.), and Pathology (M.G.), University of Arkansas for Medical Sciences, Little Rock
| | - Ricky W Lee
- From the Departments of Neurology (H.V.G., R.W.L., K.S., T.V.), Radiology (R.S.), and Pathology (M.G.), University of Arkansas for Medical Sciences, Little Rock
| | - Kinshuk Sahaya
- From the Departments of Neurology (H.V.G., R.W.L., K.S., T.V.), Radiology (R.S.), and Pathology (M.G.), University of Arkansas for Medical Sciences, Little Rock
| | - Tuhin Virmani
- From the Departments of Neurology (H.V.G., R.W.L., K.S., T.V.), Radiology (R.S.), and Pathology (M.G.), University of Arkansas for Medical Sciences, Little Rock
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88
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Awada A, Rizk W, Rizk T. Un cas de « CLIPPERS » guéri par immunothérapie cinq ans avant la description du syndrome. Rev Neurol (Paris) 2015; 171:397-8. [DOI: 10.1016/j.neurol.2014.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 11/23/2014] [Accepted: 11/29/2014] [Indexed: 11/29/2022]
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89
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Symmonds M, Waters PJ, Küker W, Leite MI, Schulz UG. Anti-MOG antibodies with longitudinally extensive transverse myelitis preceded by CLIPPERS. Neurology 2015; 84:1177-9. [PMID: 25681455 DOI: 10.1212/wnl.0000000000001370] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Mkael Symmonds
- From John Radcliffe Hospital, Oxford University, Oxford, UK.
| | | | - Wilhelm Küker
- From John Radcliffe Hospital, Oxford University, Oxford, UK
| | - M Isabel Leite
- From John Radcliffe Hospital, Oxford University, Oxford, UK
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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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91
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Wang L, Holthaus EA, Jimenez XF, Tavee J, Li Y. MRI evolution of CLIPPERS syndrome following herpes zoster infection. J Neurol Sci 2015; 348:277-8. [DOI: 10.1016/j.jns.2014.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/22/2014] [Accepted: 11/17/2014] [Indexed: 12/11/2022]
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Stüve O, Zettl U. Neuroinflammation of the central and peripheral nervous system: an update. Clin Exp Immunol 2014; 175:333-5. [PMID: 24384012 DOI: 10.1111/cei.12260] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2013] [Indexed: 12/20/2022] Open
Abstract
Inflammatory disorders of the peripheral nervous system (PNS) and central nervous system (CNS) are common, and contribute substantially to physical and emotional disability of affected individuals. Often, the afflicted are young and in their active years. In the past, physicians and scientists often had very little to offer in terms of diagnostic precision and therapeutic effectiveness. During the past two decades, both of these relative shortcomings have clearly improved. Some of the recent developments in clinical neuroimmunology are illustrated in this special edition of Clinical and Experimental Immunology.
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Affiliation(s)
- O Stüve
- Neurology Section, VA North Texas Health Care System, Dallas VA Medical Center, Dallas, TX, USA; Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, 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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