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Abdelkader O, Abuzenah H, Shuhaiber H. Headache As the Sole Symptom in Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS): A Case Report and Literature Review. Cureus 2024; 16:e64310. [PMID: 39130962 PMCID: PMC11316347 DOI: 10.7759/cureus.64310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) is a rare central nervous system inflammatory condition usually presenting with a range of symptoms, including ataxia, diplopia, dysarthria, seizures, and headaches. We present a unique case of a 22-year-old woman exhibiting headache as the sole symptom. Imaging and biopsy confirmed the diagnosis, and initial steroid treatment provided relief, though it relapsed on tapering. Long-term management with low-dose steroids and mycophenolate mofetil achieved remission. This case highlights the importance of recognizing atypical presentations of CLIPPERS, emphasizing the need for prompt diagnosis and appropriate treatment plans to improve patient outcomes. Further research is necessary to enhance our understanding and management of CLIPPERS.
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Affiliation(s)
| | | | - Hans Shuhaiber
- Department of Neurology, University of Florida College of Medicine, Gainesville, USA
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John DS, Kankara SR, Palasamudram Kumaran S, Hussain AS. Clinicoradiological features of probable chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome. BMJ Case Rep 2024; 17:e258067. [PMID: 38627057 PMCID: PMC11029188 DOI: 10.1136/bcr-2023-258067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently described chronic inflammatory central nervous system disease. This case report describes a young female patient presenting with weakness in bilateral upper and lower limbs and tinnitus for 2 months. A neurological examination revealed signs of brainstem and cerebellar involvement. MRI brain showed characteristic features of CLIPPERS, with punctate and nodular enhancement in the pons and cerebellum. Differential diagnoses were systematically considered and excluded. The patient showed significant clinical and radiological improvement with steroid therapy. No clinical or radiological red flags occurred during the follow-up. This case underscores the critical role of integrating clinical and radiological findings to effectively diagnose and manage CLIPPERS. It emphasises the importance of ruling out alternative diagnoses through a thorough evaluation.
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Affiliation(s)
- Deepa Susan John
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
| | - Shreyas Reddy Kankara
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
| | | | - Adnan Sarfaraz Hussain
- Department of Radiology, St John's Medical College Hospital, Bangalore, Karnataka, India
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Li EC, Lai QL, Cai MT, Fang GL, Fang W, Zheng Y, Du Y, Du BQ, Shen CH, Qiao S, Ding MP, Zhang YX. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): contemporary advances and current controversies. J Neurol 2024; 271:1747-1766. [PMID: 38286842 DOI: 10.1007/s00415-024-12189-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/31/2024]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory syndrome with characteristic clinical, radiological, and pathological features, and can be effectively treated with corticosteroid-based immunotherapies. The exact pathogenesis of CLIPPERS remains unclear, and specific diagnostic biomarkers are not available. According to the 2017 diagnostic criteria, probable CLIPPERS should be considered in middle-aged patients with subacute onset of pontocerebellar symptoms and typical punctuate and curvilinear gadolinium enhancement lesions ("salt-and-pepper" appearance) located in the hindbrain (especially pons) on magnetic resonance imaging. In addition, CLIPPERS-mimics, such as central nervous system (CNS) lymphoma, and several antibody-associated autoimmune CNS diseases (e.g., myelin oligodendrocyte glycoprotein antibody-associated disease, autoimmune glial fibrillary acidic protein astrocytopathy, and anti-N-methyl-D-aspartate receptor encephalitis), should be extensively excluded. The prerequisite for definite CLIPPERS is the perivascular T-cell-predominant inflammatory infiltration observed on pathological analysis. A biopsy is strongly suggested when clinical/radiological red flags are present. Most patients with CLIPPERS respond well to corticosteroids and have a good prognosis. Long-term low-dose corticosteroid maintenance therapy or corticosteroids coupled with immunosuppressants are recommended to prevent the recurrence of the syndrome. The potential progression of CLIPPERS to lymphoma has been suggested in some cases; therefore, at least 2-year clinical and radiological follow-up is essential. Here, we critically review the recent developments and provided an update on the clinical characteristics, diagnostic criteria, differential diagnoses, and therapeutic management of CLIPPERS. We also discuss the current controversies in this context that can be resolved in future research studies.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Taikang Ningbo Hospital, Ningbo, 315042, China
| | - Qi-Lun Lai
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Meng-Ting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Wei Fang
- Department of Neurology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Yang Zheng
- Department of Neurology, First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Ye Du
- Department of Neurology, Shaoxing People's Hospital, Shaoxing, 312000, China
| | - Bing-Qing Du
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Song Qiao
- Department of Neurology, Zhejiang Hospital, Hangzhou, 310013, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
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Kovacova S, Hnilicova P, Grossmann J, Hajas G, Kantorova E, Kurca E. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome: Treatment approach depends on disease course. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:303-308. [PMID: 35332344 DOI: 10.5507/bp.2022.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/14/2022] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare inflammatory central nervous system (CNS) disorder, chiefly involving the brainstem, especially the pons. The diagnosis is challenging, requires careful exclusion of alternative diagnoses and a targeted therapeutic approach. CLIPPERS is known to respond well to corticosteroids, but the treatment needs to be long-term and can cause significant side-effects. Moreover, subsequent corticosteroid withdrawal often leads to a relapse. It has been suggested that anti-CD20 molecules could benefit several antibody-mediated CNS inflammatory diseases, including CLIPPERS. CASE REPORT This paper describes two cases of CLIPPERS. The first demonstrates the benefit of early introduction of corticosteroids with side effects in cases of long-term use. The second demonstrates the efficacy of ocrelizumab (anti-CD20 molecule) in a severe course of CLIPPERS. CONCLUSION These two cases bring attention to this rare, often misdiagnosed but treatable disease.
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Affiliation(s)
- Slavomira Kovacova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
| | - Petra Hnilicova
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Jan Grossmann
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
| | - Gabriel Hajas
- Clinic of Neurology, Faculty Hospital of Constantine the Philosopher University, Nitra, Slovak Republic
| | - Ema Kantorova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
| | - Egon Kurca
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, Slovak Republic
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Freua F, Mahler JV, Lima PLGDSB, Neville IS, Portella LB, Marussi VHR, Lancellotti CLP, Nobrega PR, Silva GD. Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS)-Does it Really Exist? Brain Sci 2023; 13:1191. [PMID: 37626547 PMCID: PMC10452368 DOI: 10.3390/brainsci13081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS) is a rare variant of the CLIPPERS spectrum with less than ten reports published so far. There is ongoing discussion regarding whether SLIPPERS is a disease entity on its own or just an acronym encompassing many underlying diagnoses, such as sarcoidosis, vasculitis and anti-glial fibrillary acidic protein (GFAP)-associated disease. A 40-year-old woman presented with episodes of language and attention impairment. Magnetic resonance imaging (MRI) revealed T2/FLAIR hyperintense lesions in the subcortical white matter associated with a micronodular, curvilinear perivascular contrast-enhancement. Alternative diagnoses were excluded. There was a remarkable response to steroids. A relapse occurred after six years, and the biopsy showed perivascular T-cell lymphocytic infiltrate, without granulomas, vasculitis, or neoplasia. There was complete resolution of the relapse after steroids. This case represents the longest reported follow-up of a patient diagnosed with SLIPPERS, and brain biopsy after 6 years did not suggest alternative diagnoses. This report contributes to the discussion regarding the possibility that exclusive supratentorial CLIPPERS-like pathology might be an isolated disease entity, but more biopsy-proven cases with a longer follow-up are needed to support this hypothesis. Recently, GFAP astrocytopathy has been characterized and might correspond to a significant number of cases previously diagnosed as CLIPPERS or SLIPPERS.
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Affiliation(s)
- Fernando Freua
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | - João Vitor Mahler
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | | | - Iuri Santana Neville
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | | | - Victor Hugo Rocha Marussi
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
| | | | - Paulo Ribeiro Nobrega
- Division of Neurology, Walter Cantidio University Hospital, Federal University of Ceara, Prof. Costa Mendes St., 1608, 4th Floor, Rodolfo Teófilo, Fortaleza 60430-140, Brazil
- Faculty of Medicine, Centro Universitário Christus, Fortaleza 60160-230, Brazil
| | - Guilherme Diogo Silva
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
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Shrestha NM, Acharya N, Desar R. Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS Syndrome): A Case Report and Literature Review. Case Rep Neurol Med 2023; 2023:5811243. [PMID: 37520771 PMCID: PMC10382238 DOI: 10.1155/2023/5811243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 08/06/2022] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
CLIPPERS is a rare, chronic inflammatory neurological syndrome affecting multiple regions of the brain including the brainstem, cerebellum, and spinal cord. More than 100 cases have been documented globally since its initial description in 2010. This article reports the first case of the CLIPPERS syndrome in Nepal. Clinical and radiological evidences of the patient lead to the diagnosis of this disease. Brain MRI reveals punctate and curvilinear gadolinium enhancement in the pons and cerebellum, which is diagnostic for the disease. Steroid therapy has been reported to be effective in treating CLIPPERS syndrome. Although its pathophysiology indicates an immune-mediated process, the etiology is yet unknown. The treatment and prognosis of this illness depend on an early and accurate diagnosis.
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Cao L, Liu M, Guo L, Li M, Xu M, Wang R. The pathogenesis hypothesis and research progress of CLIPPERS: A literature review. Medicine (Baltimore) 2023; 102:e33211. [PMID: 36930124 PMCID: PMC10019105 DOI: 10.1097/md.0000000000033211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is still a rare autoimmune disease in the world. In recent years, there are more and more reports about the clinical manifestations of CLIPPERS, but the specific etiology and pathogenesis are not clear. In this paper, by collating the literature reported in recent years, in the reported effective treatment cases, we found the current hypothesis about the pathogenesis of CLIPPERS. Three pathogenesis hypotheses: organ-specific autoimmunity; virus infection affects autoimmunity; and helper T lymphocyte 17 mediates autoimmunity. Although it is hypothetical, it is expected to further clarify the pathogenesis, evolution characteristics, and treatment of CLIPPERS, so as to provide a reference for further understanding of the disease. In the future, more observations and studies are needed to further verify the feasibility of the hypothesis. This article expands on atypical clinical manifestations and summarizes treatment options. Hope to provide a reference for clinical diagnosis and treatment of CLIPPERS.
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Affiliation(s)
- Long Cao
- College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Meiping Liu
- First College of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Li Guo
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Mingyan Li
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Min Xu
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Rui Wang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
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Salt-and-pepper appearance pontine and cerebellar enhancing lesions in CLIPPERS. Neurol Sci 2023; 44:775-776. [PMID: 36322210 DOI: 10.1007/s10072-022-06476-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/22/2022] [Indexed: 11/07/2022]
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The role of MRI in the early diagnosis of chronic lymphocytic inflammation (CLIPPERS syndrome). КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract114814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
ABSTRACT
Background. Chronic lymphocytic inflammation with perivascular contrast enhancement in the pons responsive to steroids (CLIPPERS) is a rare and relatively "new" pathology and MRI is highly important in its diagnosis.
Clinical Case Description. Chronic lymphocytic inflammation with perivascular contrast enhancement in the pons responsive to steroids (CLIPPERS) is a rare and relatively "new" pathology and MRI is highly important in its diagnosis.
Conclusion. MRI not only enables high-quality neuroimaging of CLIPPERS, it also allows avoiding invasive, traumatic diagnostic methods.
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Al-Chalabi M, DelCimmuto NR, Beran A, Devarasetty PP, Mhanna A, Mahfooz N, Sheikh A. Clinical characteristics, management, and outcomes of CLIPPERS: A comprehensive systematic review of 140 patients from 100 studies. Mult Scler Relat Disord 2022; 68:104112. [PMID: 36029706 DOI: 10.1016/j.msard.2022.104112] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare inflammatory disorder of the central nervous system, characterized by symptoms referable to the brainstem and cerebellum such as, diplopia, gait ataxia and cerebellar dysarthria. The features and outcomes of CLIPPERS remains uncertain. we conducted this comprehensive systematic review to summarize all the existing studies that described CLIPPERS in the literature and to provide a quantitative assessment on the clinical characteristics, management, and outcomes of this rare syndrome. METHODS A comprehensive search of PubMed and Web of Science databases was conducted from inception until January 15, 2022, was conducted. We only included the cases that clearly reported probable or definite diagnosis of CLIPPERS based on Taieb et al.'s criteria. The quality of the included studies was assessed using the JBI Critical Appraisal Tool. Descriptive statistics were performed to analyze the studies. Data were expressed as mean and standard deviation (SD) for continuous variables and proportions for categorical variables. RESULTS We identified 100 case reports and series including a total of 140 patients with CLIPPERS (mean age: 46±18 years and males were 60%). The average follow-up duration was 32.27±57.8 months. Ataxia was the most common presenting symptom. Sixteen percent of the cases were associated with malignancy, mostly hematologic malignancies. The overall relapse rate was 59.2%, and the duration of steroid therapy was considerably shorter in the relapsed cases than in the non-relapsed (mean 6.19±7.9 vs. 10.14±12.1 days, respectively, P = 0.04). The overall mortality rate was 10%, but mortality in patients with malignancy was 30% and it was 12% in patients with relapses. In the case of steroid dosing (less than 20 mg/d versus greater than 20 mg/d) there was no significant modification in the risk of relapse. CONCLUSION CLIPPERS is a rare clinical syndrome that affects mainly middle-aged males. Diagnosis of CLIPPERS is often challenging, and delays in diagnosis and treatment can lead to unfavorable outcomes. Therefore, neurologists should maintain a high index of suspicion for CLIPPERS in any patient presenting with symptoms and signs referrable to the brainstem. These patients should be screened for associated malignancies, especially hematological malignancies. The cases associated with malignancy tend to have worse outcomes. The relapse rate is relatively high. The relapse rate may be associated with worse mortality. Based on our findings, we recommend that CLIPPERS be treated with high-dose steroid therapy for at least ten days during the acute phase with a very slow taper. Prospective studies with a larger sample size are needed to validate our findings and guide the clinical care of these patients.
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Affiliation(s)
- Mustafa Al-Chalabi
- Department of Neurology, University of Toledo, 2130W Central Ave., Toledo, OH 43606, United States.
| | - Nicholas R DelCimmuto
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, OH, United States
| | | | - Asmaa Mhanna
- The University of Toledo, Promedica Toledo Hospital, Toledo, OH, United States
| | - Naeem Mahfooz
- Department of Neurology, University of Toledo, 2130W Central Ave., Toledo, OH 43606, United States; College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Ajaz Sheikh
- Department of Neurology, University of Toledo, 2130W Central Ave., Toledo, OH 43606, United States; College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
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MOG autoimmunity mimicking CLIPPERS syndrome: Case report and literature review. J Neuroimmunol 2022; 367:577875. [DOI: 10.1016/j.jneuroim.2022.577875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/30/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022]
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Corral MAP, Gavito-Higuera J, O'Neill T, Chennan SRE. CLIPPERS associated with hypersensitivity pneumonitis: a case report. Radiol Case Rep 2021; 16:2411-2415. [PMID: 34257770 PMCID: PMC8259229 DOI: 10.1016/j.radcr.2021.05.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/29/2021] [Accepted: 05/29/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare and poorly understood pathology. In this case report we present a 51-year-old male that presented with neurological deficits with recent hypersensitivity pneumonitis. Imaging studies showed multiple punctate enhancing lesions involving the brainstem. After initiation of corticosteroids his symptoms improved, with a decrease in size of his lesions 6-months after his initial presentation. Due to its misdiagnosis, we propose the use of diagnostic criteria, described on this case report, for prompt treatment to avoid neurological sequelae.
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Zoghaib R, Sreij A, Maalouf N, Freiha J, Kikano R, Riachi N, Chalah MA, Ayache SS, Ahdab R. Autoimmune Brainstem Encephalitis: An Illustrative Case and a Review of the Literature. J Clin Med 2021; 10:jcm10132970. [PMID: 34279454 PMCID: PMC8269049 DOI: 10.3390/jcm10132970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Autoimmune brainstem encephalitis (BSE) is a rare neurological condition with a wide range of underlying etiologies. It can be subdivided into two broad groups: a primary inflammatory disease of the central nervous system (CNS) or a brainstem disorder secondary to systemic diseases where the CNS is only one of many affected organs. Symptoms range from mild to life-threatening manifestations. Most cases respond well to immunotherapy. Therefore, broad and in-depth knowledge of the various inflammatory disorders that target the brainstem is essential for guiding the diagnostic approach and assisting in early initiation of appropriate therapy. We herein report on a case of BSE and provide an overview of the various causes of autoimmune BSE with an emphasis on the clinical manifestations and diagnostic approach.
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Affiliation(s)
- Romy Zoghaib
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Neurology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
| | - Ali Sreij
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Neurology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
| | - Nancy Maalouf
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Neurology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
| | - Joumana Freiha
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Neurology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
| | - Raghid Kikano
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Radiology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
| | - Naji Riachi
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Neurology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
| | - Moussa A. Chalah
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, 51 Avenue de Lattre de Tassigny, 94010 Créteil, France; (M.A.C.); (S.S.A.)
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est Créteil, 94010 Créteil, France
| | - Samar S. Ayache
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, 51 Avenue de Lattre de Tassigny, 94010 Créteil, France; (M.A.C.); (S.S.A.)
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est Créteil, 94010 Créteil, France
| | - Rechdi Ahdab
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (R.Z.); (A.S.); (N.M.); (J.F.); (R.K.); (N.R.)
- Neurology Department, Lebanese American University Medical Center, Rizk Hospital, Beirut 113288, Lebanon
- Hamidy Medical Center, Tripoli 1300, Lebanon
- Correspondence: ; Tel.: +961-1-200800
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Zhuang E, Shane L, Ramezan N, Ismail AF, Vora NL. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, a mimicker of malignancy: a case report and review of the literature. J Med Case Rep 2021; 15:246. [PMID: 34001259 PMCID: PMC8130263 DOI: 10.1186/s13256-021-02814-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022] Open
Abstract
Background Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids is a clinically and radiographically distinct inflammatory syndrome affecting multiple structures of the brain, including the cerebellum, brainstem, and spinal cord. The clinical presentation can be variable, including ataxia, nystagmus, dysarthria, dysphagia, and other subacute brainstem, cranial nerve, or cerebellar symptoms. These symptoms can be subacute to chronic, episodic, and progressive, making the diagnosis challenging. The hallmark radiographic magnetic resonance imaging findings are gadolinium-enhancing punctate lesions predominantly “peppering” the pons in a perivascular pattern. Case presentation Here, we describe a case and literature review of a 74-year-old Caucasian male who presented with subacute symptoms of ataxia, diplopia, and generalized fatigue. Physical examination was notable for horizontal nystagmus and wide-based gait. Magnetic resonance imaging revealed angiocentric enhancement predominantly in the brainstem and cerebellum, with involvement of the basal ganglia, thalami, and supratentorial white matter. Meanwhile, a screening computed tomography scan demonstrated a right upper lobe mass with biopsy proving primary lung cancer. Biopsy of one of the brain lesions showed perivascular infiltrate primarily composed of CD3+ T cells, scattered CD20+ B cells, and no signs of malignancy. The patient was started on high-dose glucocorticoids followed by a maintenance regimen with rapid improvement clinically and radiographically. Given extensive work-up was negative, these clinical and radiographic findings were consistent with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. Conclusions This case illustrates the difficulty of diagnosing chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, given its variable presentation, lack of specific laboratory findings, and poorly understood pathogenesis. We demonstrate a case that responded well to oral corticosteroid burst followed by a taper to the lowest corticosteroid dose clinically possible. Failure to recognize this syndrome could result in permanent central nervous system morbidity. Therefore, earlier recognition is crucial for this treatable condition.
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Affiliation(s)
- Eric Zhuang
- Department of Medicine, University of California Irvine, 101 The City Drive South, Orange, CA, 92688, USA.
| | - Lisa Shane
- Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - Nima Ramezan
- Long Beach Memorial Medical Center, Long Beach, CA, USA
| | | | - Nilesh L Vora
- Long Beach Memorial Medical Center, Long Beach, CA, USA.,Todd Cancer Institute, Long Beach, CA, USA
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Taieb G, Kaphan E, Duflos C, Lebrun-Frénay C, Rigau V, Thouvenot E, Duhin-Gand E, Lefaucheur R, Hoang-Xuan K, Coulette S, Ouallet JC, Menjot de Champfleur N, Tranchant C, Picard C, Fusaro M, Sepulveda FE, Labauge P, de Saint Basile G. Hemophagocytic Lymphohistiocytosis Gene Mutations in Adult Patients Presenting With CLIPPERS-Like Syndrome. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/3/e970. [PMID: 33658321 PMCID: PMC7963436 DOI: 10.1212/nxi.0000000000000970] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022]
Abstract
Objective To determine whether adult cases of Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) may be related to familial hemophagocytic lymphohistiocytosis (HLH) causes, we have screened patients with adult-onset CLIPPERS for mutations in primary HLH-associated genes. Methods In our cohort of 36 patients fulfilling the criteria for probable or definite CLIPPERS according to the CLIPPERS-2017 criteria, we conducted a first study on 12 patients who consented to genetic testing. In these 12 patients, systemic HLH criteria were searched, and genetic analysis of 8 genes involved in primary HLH was performed. Results Four definite and 8 probable CLIPPERS were enrolled (n = 12). Mutations involved in HLH were identified in 2 definite and 2 probable CLIPPERS (4/12). Three of them had biallelic PRF1 mutations with reduced perforin expression in natural killer cells. The remaining patient had biallelic UNC13D mutations with cytotoxic lymphocyte impaired degranulation. None of the mutated patients reached the criteria for systemic HLH. During follow-up, 3 of them displayed atypical findings for CLIPPERS, including emergence of systemic non-Hodgkin lymphoma (1/3) and confluent gadolinium-enhancing lesions on brain MRI (3/3). Conclusions In our patients presenting with adult-onset CLIPPERS, one-third have HLH gene mutations. This genetic treatable condition should be searched in patients with CLIPPERS, especially in those presenting with atypical findings.
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Affiliation(s)
- Guillaume Taieb
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France.
| | - Elsa Kaphan
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Claire Duflos
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Christine Lebrun-Frénay
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Valérie Rigau
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Eric Thouvenot
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Emeline Duhin-Gand
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Romain Lefaucheur
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Khe Hoang-Xuan
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Sarah Coulette
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Jean Christophe Ouallet
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Nicolas Menjot de Champfleur
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Christine Tranchant
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Capucine Picard
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Mathieu Fusaro
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Fernando E Sepulveda
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Pierre Labauge
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
| | - Geneviève de Saint Basile
- From the Department of Neurology (G.T., P.L.), CHU Montpellier, Hospital Gui de Chauliac; Pôle de Neurosciences Cliniques (E.K.), CHU Timone, Assistance Publique Hôpitaux de Marseille; Clinical Research and Epidemiology Unit (C.D.), CHU Montpellier, University Montpellier; Unité de recherche clinique côte d'azur UR2CA (URRIS) (C.L.-F.), CRCSEP Nice; Department of Pathology (V.R.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (E.T.), CHU Carémeau, Nîmes; Department of Neurology (E.D.-G.), CH Valenciennes; Department of Neurology (R.L.), Rouen University Hospital; APHP (K.H.-X.), Sorbonne Université, IHU, ICM, Department of Neurology Mazarin, Groupe Hospitalier Pitié-Salpêtrière, Paris; Department of Neurology (S.C.), CH Gonesse; Department of Neurology (J.C.O.), CHU de Bordeaux; Department of Neuroradiology (N.M.C.), CHU Montpellier, Hospital Gui de Chauliac; Department of Neurology (C.T.), CHU Strasbourg; Université de Paris (C.P., M.F., F.E.S., G.S.B.), Imagine Institute, INSERM U 1163; Centre d'Etude des Déficits Immunitaires (C.P., M.F., G.S.B.), AP-HP, Hôpital Necker-Enfants Malades, Paris; and Centre national de la recherche scientifique (CNRS) (F.E.S.), Paris, France
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16
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Jin H, Gao Y, Lu Q, Liu R, Li Q, Hao H, Gao F. CLIPPERS syndrome: A case report in a Chinese patient with juxtacortical lesions. Mult Scler Relat Disord 2021; 50:102853. [PMID: 33640847 DOI: 10.1016/j.msard.2021.102853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome is an immune-mediated, treatable and inflammatory central nervous system (CNS) disease with unknown pathogenesis and polymorphic clinical and radiological manifestations. However, juxtacortical lesions have scarcely reported in patients with CLIPPERS. CASE PRESENTATION In this study, we report 32 year old man with complaint of intermittent dizziness, disordered fluency and walking difficulties for 2 weeks. The neuroimaging revealed multiple punctuate hyperintensities on T2-weighted images, with pepper-like gadolinium enhancement in the typical lesions of brainstem, cerebellum, periventricular as well as untypical lesions of juxtacortical area. After other similar diseases were carefully ruled out, the patient was diagnosed as CLIPPERS and exhibited a good response to immunosuppressive therapy on the acute phase and after 6 months of follow up. CONCLUSIONS The results reported here broaden the known radiologic features for this rare disorder. A long-term follow-up to rule out other potential differential diseases is essential.
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Affiliation(s)
- Haiqiang Jin
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yuhan Gao
- Department of Transfusion, Peking University People's Hospital, Beijing, China
| | - Qianshuo Lu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Ran Liu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Qunyan Li
- Department of Neurology, Beijing Haidian Hospital, Beijing, China
| | - Hongjun Hao
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Feng Gao
- Department of Neurology, Peking University First Hospital, Beijing, China.
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17
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Yang B, Liu F, Li J, Wen Y. Increased Number of Perivascular CD20-Positive B Lymphocytes in the Neuropathology of CLIPPERS: Findings of 6 Patients from Mainland China. Eur Neurol 2021; 84:22-30. [PMID: 33498046 DOI: 10.1159/000512406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome is a recently described chronic inflammatory disease of the central nervous system. There are few reports of CLIPPERS in the Chinese population to date. We summarized the clinical characteristics of 6 CLIPPERS patients to deepen the understanding of this disease. METHODS The clinical manifestations and treatment of 6 CLIPPERS patients confirmed by pathology or clinical diagnosis in our hospital were retrospectively analyzed. RESULTS The common clinical manifestations included ataxia, dysarthria, diplopia, dysphagia, dizziness, cognitive impairment, facial paresthesia, and paralysis. Most of the lesions showed typical symmetric "pepper powder"-like dot and nodular enhancement centered in the pontine and cerebellum except 1 patient with unilateral nodular enhancement. The brain histopathological examination of the 5 biopsied patients indicated that, with the exception of patient 4 with no lymphocyte infiltration, a large amount of perivascular lymphocytic infiltration was found in the other 4 patients, among whom only 1 patient was dominated by CD3+ T cell infiltration and the other 3 patients were dominated by CD20+ B cell infiltration. After treatment with intravenous methylprednisolone, all patients had significant clinical recovery associated with complete or significant MRI recovery, but they were prone to relapse after withdrawal or reduction of the corticosteroid. CONCLUSION Our reports highlight the importance of neuropathological examinations when encountering atypical imaging manifestations, such as unilateral and large nodular Gd+ lesions, in order to establish a final diagnosis of CLIPPERS. In addition, the lymphocytic infiltration in the lesions of CLIPPERS may be dominated by CD20+ B cells instead of CD3+ T cells.
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Affiliation(s)
- Baifeng Yang
- Department of Rehabilitation, Changsha Mingzhou Rehabilitation Hospital, Changsha, China
| | - Fan Liu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yanbin Wen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China, .,Hunan Clinical Research Center for Cerebrovascular Disease, Changsha, China,
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18
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CLIPPERS syndrome: A case report. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2019.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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[CLIPPERS syndrome: A case report]. Neurologia 2020; 35:690-692. [PMID: 31982217 DOI: 10.1016/j.nrl.2019.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 11/23/2022] Open
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20
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Kalashnikova LA, Dobrynina LA, Novikov PI, Dreval MV, Gubanova MV, Shabalina AA, Kostyreva MV. [Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:79-87. [PMID: 32621472 DOI: 10.17116/jnevro202012005179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory disease of the central nervous system, mainly affecting the brain stem, cerebellum and spinal cord. The clinical picture includes gradually developing ataxia, double vision, dysarthria, pyramidal and cognitive impairment. Morphological examination reveals T-cell perivascular lymphocytic infiltration with CD4 lymphocytes predominance over CD8 lymphocytes. The cause of the disease is unknown. The article describes two patients (a 18-year-old woman and a 40-year-old man) with typical clinical and MRI manifestations of CLIPPERS, which was confirmed by brain biopsy in the female patient. The duration of follow-up was 3 and 7 years, respectively. Both patients survived an infection 2-3 weeks before the onset of disease that allows one to discuss its role in CLIPPERS pathogenesis. Both patients had a clear clinical and MRI responsiveness to steroids. In the female patient, steroids were replaced by intramuscular administration of the TNF-α blocker adalimumab. During 1,5 years of its use, there were no clinical relapses and pathological brain changes on MRI.
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Affiliation(s)
| | | | - P I Novikov
- Research Center of Neurology, Moscow, Russia
| | - M V Dreval
- Research Center of Neurology, Moscow, Russia
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21
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Mello DFRE, Queiroz RM, Miyake C, Fábio SRC, Abud LG. CLIPPERS: a recognizable image of a treatable disease. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 77:903-904. [PMID: 31939590 DOI: 10.1590/0004-282x20190170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/27/2019] [Indexed: 11/22/2022]
Affiliation(s)
| | - Rodolfo Mendes Queiroz
- MED Medicina Diagnóstica, Hospital São Lucas, Departamento de Radiologia e Diagnóstico por Imagem, Ribeirão Preto SP, Brasil
| | - Cecilia Miyake
- MED Medicina Diagnóstica, Hospital São Lucas, Departamento de Radiologia e Diagnóstico por Imagem, Ribeirão Preto SP, Brasil
| | | | - Lucas Giansante Abud
- MED Medicina Diagnóstica, Hospital São Lucas, Departamento de Radiologia e Diagnóstico por Imagem, Ribeirão Preto SP, Brasil
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22
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Hosaka T, Nakamagoe K, Tozaka N, Aizawa S, Tamaoka A. Steroid pulse therapy of radiological disease activity without clinical relapse in CLIPPERS. Neurol Sci 2020; 41:709-711. [PMID: 31482246 DOI: 10.1007/s10072-019-04064-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Takashi Hosaka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kiyotaka Nakamagoe
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Naoki Tozaka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Satoshi Aizawa
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akira Tamaoka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
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23
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Atteinte insidieuse du tronc cérébral : penser au syndrome CLIPPERS. Rev Med Interne 2019. [DOI: 10.1016/j.revmed.2019.10.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Taieb G, Mulero P, Psimaras D, van Oosten BW, Seebach JD, Marignier R, Pico F, Rigau V, Ueno Y, Duflos C, Fominykh V, Guiraud V, Lebrun-Frénay C, Camdessanché JP, Kerschen P, Ahle G, Téllez N, Rovira A, Hoang-Xuan K, Pelletier J, Labauge P. CLIPPERS and its mimics: evaluation of new criteria for the diagnosis of CLIPPERS. J Neurol Neurosurg Psychiatry 2019; 90:1027-1038. [PMID: 31072955 DOI: 10.1136/jnnp-2018-318957] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/20/2019] [Accepted: 04/10/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the accuracy of the recently proposed diagnostic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). METHODS We enrolled 42 patients with hindbrain punctate and/or linear enhancements (<3 mm in diameter) and tested the CLIPPERS criteria. RESULTS After a median follow-up of 50 months (IQR 25-82), 13 out of 42 patients were CLIPPERS-mimics: systemic and central nervous system lymphomas (n=7), primary central nervous system angiitis (n=4) and autoimmune gliopathies (n=2). The sensitivity and specificity of the CLIPPERS criteria were 93% and 69%, respectively. Nodular enhancement ( ≥ 3 mm in diameter), considered as a red flag in CLIPPERS criteria, was present in 4 out of 13 CLIPPERS-mimics but also in 2 out of 29 patients with CLIPPERS, explaining the lack of sensitivity. Four out of 13 CLIPPERS-mimics who initially met the CLIPPERS criteria displayed red flags at the second attack with a median time of 5.5 months (min 3, max 18), explaining the lack of specificity. One of these four patients had antimyelin oligodendrocyte glycoprotein antibodies, and the three remaining patients relapsed despite a daily dose of prednisone/prednisolone ≥ 30 mg and a biopsy targeting atypical enhancing lesions revealed a lymphoma. CONCLUSIONS Our study highlights that (1) nodular enhancement should be considered more as an unusual finding than a red flag excluding the diagnosis of CLIPPERS; (2) red flags may occur up to 18 months after disease onset; (3) as opposed to CLIPPERS-mimics, no relapse occurs when the daily dose of prednisone/prednisolone is ≥ 30 mg; and (4) brain biopsy should target an atypical enhancing lesion when non-invasive investigations remain inconclusive.
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Affiliation(s)
- Guillaume Taieb
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Patricia Mulero
- Centre d'Esclerosi Mútiple de Catalunya, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Dimitri Psimaras
- Department of Neurology, AP-HP Pitié-Salpêtrière, Service de Neurologie Mazarin, Paris, France
| | - Bob W van Oosten
- Department of Neurology, VU University Medical Center, Amsterdam, Netherlands
| | - Jörg D Seebach
- Department of Immunology and Allergology, University Hospital of Genève, Geneva, Switzerland
| | - Romain Marignier
- Centre de Recherche en Neurosciences de Lyon, INSERM U1028 and CNRS UMR5292, Equipe FLUID, Lyon, France
| | - Fernando Pico
- Department of Neurology, Centre Hospitalier de Versailles, Versailles, France.,University of Versailles Saint Quentin en Yvelines et Paris Saclay, Versailles, France
| | - Valérie Rigau
- Department of Neuropathology, University Hospital of Montpellier, Montpellier, France
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, DIM, University Hospital of Montpellier, Montpellier, France
| | - Vera Fominykh
- Department of Neurology, University Hospital of Moscow, Moscow, Russia
| | - Vincent Guiraud
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | | | - Jean-Philippe Camdessanché
- Centre de Recherche en Neurosciences de Lyon, INSERM U1028 and CNRS UMR5292, Equipe FLUID, Lyon, France.,Department of Neurology, University Hospital of Sainte Anne, Paris, France
| | - Philippe Kerschen
- Department of Neurology, University Hospital of Luxembourg, Luxembourg, Luxembourg
| | - Guido Ahle
- Department of Neurology, Hospital of Colmar, Colmar, France
| | - Nieves Téllez
- Department of Neurology, Hospital Clinico de Valladolid, Valladolid, Spain
| | - Alex Rovira
- Centre d'Esclerosi Mútiple de Catalunya, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Khe Hoang-Xuan
- Department of Neurology, AP-HP Pitié-Salpêtrière, Service de Neurologie Mazarin, Paris, France
| | - Jean Pelletier
- APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France
| | - Pierre Labauge
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
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25
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Sa M, Green L, Abdel-Mannan O, Chong WKK, Jacques T, Clarke A, Childs AM, Lim M, Hemingway C, Hacohen Y. Is chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) in children the same condition as in adults? Dev Med Child Neurol 2019; 61:490-496. [PMID: 30146710 DOI: 10.1111/dmcn.13997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 02/04/2023]
Abstract
This case series describes three children with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), an inflammatory condition characterized by a relapsing-remitting disease course responsive to steroids. The patients (two males, age 3y and 13y; one female, age 14y) presented with ataxia, dysarthria, and multiple cranial neuropathies. All patients demonstrated bilateral nodular lesions with contrast enhancement in the brainstem and cerebellum on magnetic resonance imaging, and perivascular lymphocytes and macrophages infiltrates on brain biopsies. Despite an initially good response to corticosteroids, all patients eventually became steroid-dependent or -resistant, with frequent relapses on maintenance immunosuppressive therapy. Natalizumab and intravenous immunoglobulin stopped neurological disease progression in Patient 1 but he died at 17 years from respiratory complications. Patient 2 went into remission on infliximab and intravenous methylprednisolone for several months but was then diagnosed with Epstein-Barr virus driven B-cell lymphoma 3 years after symptom onset. Patient 3 failed to respond to treatment and died 4 years after diagnosis. CLIPPERS disease in children is aggressive, with poor response to immunotherapy. Earlier use of newer immunotherapeutic agents such as natalizumab may be beneficial. Potential side effects need to be considered carefully. WHAT THIS PAPER ADDS: Paediatric chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) appears a more severe condition than previously reported in adults. Aggressive treatment before neuroaxonal loss may be required for a better outcome.
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Affiliation(s)
- Mario Sa
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Lydia Green
- Department of Paediatric Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Omar Abdel-Mannan
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - W K Kling Chong
- Neuroradiology Department, Great Ormond Street Hospital for Children, London, UK
| | - Thomas Jacques
- Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Antonia Clarke
- Department of Paediatric Neurology, St Georges Healthcare NHS Trust, London, UK
| | - Anne-Marie Childs
- Department of Paediatric Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Cheryl Hemingway
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Yael Hacohen
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
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26
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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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27
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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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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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Cipriani VP, Arndt N, Pytel P, Reder AT, Javed A. Effective treatment of CLIPPERS with long-term use of rituximab. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e448. [PMID: 29511706 PMCID: PMC5833333 DOI: 10.1212/nxi.0000000000000448] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/17/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Veronica P Cipriani
- Department of Neurology (V.P.C., N.A., A.T.R., A.J.), and Department of Pathology (P.P.), University of Chicago, IL
| | - Nancy Arndt
- Department of Neurology (V.P.C., N.A., A.T.R., A.J.), and Department of Pathology (P.P.), University of Chicago, IL
| | - Peter Pytel
- Department of Neurology (V.P.C., N.A., A.T.R., A.J.), and Department of Pathology (P.P.), University of Chicago, IL
| | - Anthony T Reder
- Department of Neurology (V.P.C., N.A., A.T.R., A.J.), and Department of Pathology (P.P.), University of Chicago, IL
| | - Adil Javed
- Department of Neurology (V.P.C., N.A., A.T.R., A.J.), and Department of Pathology (P.P.), University of Chicago, IL
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Rudie JD, Rauschecker AM, Nabavizadeh SA, Mohan S. Neuroimaging of Dilated Perivascular Spaces: From Benign and Pathologic Causes to Mimics. J Neuroimaging 2017; 28:139-149. [PMID: 29280227 DOI: 10.1111/jon.12493] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/18/2017] [Accepted: 11/20/2017] [Indexed: 12/22/2022] Open
Abstract
Perivascular spaces (PVSs), also known as Virchow-Robin spaces, are pial-lined, fluid-filled structures found in characteristic locations throughout the brain. They can become abnormally enlarged or dilated and in rare cases can cause hydrocephalus. Dilated PVSs can pose a diagnostic dilemma for radiologists because of their varied appearance, sometimes mimicking more serious entities such as cystic neoplasms, including dysembryoplastic neuroepithelial tumor and multinodular and vacuolating neuronal tumor, or cystic infections including toxoplasmosis and neurocysticercosis. In addition, various pathologic processes, including cryptococcosis and chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, can spread into the brain via PVSs, resulting in characteristic magnetic resonance imaging appearances. This review aims to describe the key imaging characteristics of normal and dilated PVSs, as well as cystic mimics and pathologic processes that directly involve PVSs.
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Affiliation(s)
- Jeffrey D Rudie
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andreas M Rauschecker
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Seyed A Nabavizadeh
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Suyash Mohan
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Taieb G, Labauge P. CLIPPERS, a possible symptomatic lymphohistiocytic immune reaction. Brain 2017; 141:e5. [DOI: 10.1093/brain/awx298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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