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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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Tso HL, Pradhan S, Davila-Siliezar PA, Mortensen PW, Lee AG. Kelch-Like Protein 11 Paraneoplastic Autoimmune Encephalitis in Primary Retroperitoneal Müllerian Adenocarcinoma. J Neuroophthalmol 2024:00041327-990000000-00572. [PMID: 38358818 DOI: 10.1097/wno.0000000000002106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Affiliation(s)
- Hanna L Tso
- Baylor College of Medicine (HLT, AGL), Cullen Eye Institute, Houston, Texas; Houston Methodist Hospital (PAD-S, PWM, AGL), Blanton Eye Institute, Houston, Texas; Departments of Ophthalmology (AGL), Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Li EC, Lai QL, Cai MT, Fang GL, Shen CH, Ding MP, Zhang YX. Anti-adenylate kinase 5 encephalitis: Clinical characteristics, diagnosis, and management of this rare entity. J Transl Autoimmun 2023; 7:100218. [PMID: 37859804 PMCID: PMC10582738 DOI: 10.1016/j.jtauto.2023.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/08/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
The spectrum and understanding of antibody-positive autoimmune encephalitis (AE) have expanded over the past few decades. In 2007, a rare subtype of AE known as anti-adenylate kinase 5 (AK5) encephalitis, was first reported. This disease is more common in elderly males, with limbic encephalitis as the core phenotype (characterized by subacute anterograde amnesia, sometimes with psychiatric symptoms, and rarely with seizures). Brain magnetic resonance imaging typically demonstrated initial temporal lobe T2/fluid-attenuated inversion recovery hyperintensities, and subsequent atrophy. No concomitant tumors have been found yet. AK5 antibody, targeting the intracellular antigen, is a biomarker for a non-paraneoplastic T-cell autoimmunity response, and can be detected in serum and cerebrospinal fluid using tissue-based and cell-based assays. Cytotoxic T-cell-mediating neuronal injury and loss play a pivotal role in the immunopathogenesis of anti-AK5 encephalitis. Patients mostly show poor response to immunotherapy and thus a poor prognosis in the long run. Herein, we review the literature and provide updated knowledge of this less-known entity, focusing on clinical characteristics, paraclinical findings, diagnosis process, and therapeutic approaches.
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Affiliation(s)
- Er-Chuang Li
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
- 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, Hangzhou, 310009, China
| | - Gao-Li Fang
- Department of Neurology, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, 310003, China
| | - Chun-Hong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Mei-Ping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Yin-Xi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, China
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Yang W, Yang J, Zhang J, Wei N, Xuan T, Wang Z, Li H. KLHL11 antibody-associated autoimmune encephalomyelitis in a middle-aged female patient: a case report and literature review. Int J Neurosci 2023:1-6. [PMID: 37881832 DOI: 10.1080/00207454.2023.2269306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
HEADINGS Kelch-like protein 11antibody is a recently identified biomarker for paraneoplastic neurological syndromes associated with germ-cell tumors that was first described as an onconeural antibody causing autoimmune encephalitis associated with seminoma in 2019. Ataxia is the most prevalent presenting symptom, with other neurological symptoms including vertigo, double vision, hearing loss, tinnitus and dysarthria. Magnetic resonance imaging scans reveal that the lesions are mostly located in the cerebellum and brainstem, particularly in the pontine region, and may also exhibit cerebellar atrophy. AIM OF THE STUDY In this study, we report the clinical features of Kelch-like protein 11 antibody-associated paraneoplastic neurological syndrome. MATERIALS AND METHODS We present a middle-aged female patient who presented with vertigo, cognitive decline, ataxia and limb weakness. A cell-based assay (CBA) showed positive IgG Kelch-like protein 11 in both her serum and CSF, as well as positive oligoclonal bands in her CSF. She was diagnosed with KLHL11 antibody-associated autoimmune encephalomyelitis and received high-dose intravenous methylprednisolone pulse therapy. RESULT AND CONCLUSIONS Clinical outcomes suggest that patients with Kelch-like protein 11 antibody mostly have poor prognoses, excepting our case. We propose that early and appropriate treatments are critical for timely diagnosis and rapid improvement.
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Affiliation(s)
- Wanqiu Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Juan Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
| | - Junmei Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Na Wei
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Tingting Xuan
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
- Clinical College of Ningxia Medical University, Ningxia, Yinchuan, China
| | - Zhenhai Wang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
| | - Haining Li
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia, Yinchuan, China
- Diagnosis and Treatment Engineering Technology Research Center of Nervous System Diseases of Ningxia Hui Autonomous Region, Ningxia, Yinchuan, China
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Williams CM, Allison DB, Coleman AB, Bardhan R, Miller JD, Myint ZW. Primary mediastinal seminoma presenting with paraneoplastic anti-Hu encephalitis: a case report and literature review. Front Oncol 2023; 13:1156566. [PMID: 37781193 PMCID: PMC10540842 DOI: 10.3389/fonc.2023.1156566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Primary mediastinal seminomas are exceedingly rare tumors, often localized to the anterior mediastinum. They may present with numerous complications, including superior vena cava syndrome, chylothorax, and pericardial effusions. Less commonly, they may present with paraneoplastic encephalitis. In this report we describe a case of a 19-year-old male with no significant past medical history who presented with bilateral hearing loss, progressive neuropathy, and ataxia. Subsequently the patient was found to have mediastinal mass with a high-titer anti-Hu antibody. To our knowledge, only one other case of mediastinal seminoma presenting with anti-Hu antibodies has been described in the literature. In this report, we describe a rare case of mediastinal seminoma, describe treatment options, and discuss additional known cases presenting with paraneoplastic encephalitis.
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Affiliation(s)
- Chelsey M. Williams
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Derek B. Allison
- Markey Cancer Center, University of Kentucky, Lexington, KY, United States
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, KY, United States
| | - Adam B. Coleman
- Liberty University College of Osteopathic Medicine, Lynchburg, VA, United States
| | - Roshmita Bardhan
- University of Pikeville- Kentucky College of Osteopathic Medicine, Pikeville, KY, United States
| | - Jordan D. Miller
- Division of Thoracic Surgery, University of Kentucky, Lexington, KY, United States
| | - Zin W. Myint
- Markey Cancer Center, University of Kentucky, Lexington, KY, United States
- Department of Internal Medicine, Division of Medical Oncology, University of Kentucky, Lexington, KY, United States
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Gyongyosi B, Magyar-Stang R, Takacs T, Szekely E, Illes Z, Nilsson C, Gyorke T, Barsi P, Juhasz D, Banky B, Bereczki D, Honnorat J, Gunda B. Paraneoplastic Kelch-like protein 11 antibody-associated cerebellar and limbic encephalitis caused by metastatic “burned-out” seminoma – A scar(r)y phenomenon. J Neuroimmunol 2023; 378:578073. [PMID: 36989702 DOI: 10.1016/j.jneuroim.2023.578073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/09/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION The diagnosis of paraneoplastic neurologic syndromes is challenging when the primary tumor masquerades as scar tissue (i.e. "burned-out"). METHODS Case report. RESULTS A 45-year-old male patient presented with progressive cerebellar symptoms and hearing loss. Initial screening for malignancy and extensive testing of paraneoplastic and autoimmune neuronal antibodies gave negative results. Repeated whole-body FDG-PET CT revealed a single paraaortic lymphadenopathy, metastasis of a regressed testicular seminoma. Anti-Kelch-like protein-11 (KLHL11) encephalitis was finally diagnosed. CONCLUSION Our case highlights the importance of continued efforts to find an often burned-out testicular cancer in patients with a highly unique clinical presentation of KLHL11 encephalitis.
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Affiliation(s)
- Benedek Gyongyosi
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, Budapest, Hungary; János Szentágothai Doctoral School of Neurosciences, Semmelweis University, Budapest, Hungary.
| | - Timea Takacs
- Department of Neurology, Semmelweis University, Budapest, Hungary; János Szentágothai Doctoral School of Neurosciences, Semmelweis University, Budapest, Hungary
| | - Eszter Szekely
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Christine Nilsson
- Laboratory of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Tamas Gyorke
- Department of Nuclear Medicine, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Peter Barsi
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Daniel Juhasz
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Balazs Banky
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Diseases and Autoimmune Encephalitis, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Bence Gunda
- Department of Neurology, Semmelweis University, Budapest, Hungary
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León Betancourt A, Schwarzwald A, Millonig A, Oberholzer M, Sabater L, Hammer H, Kamber N, Diem L, Chan A, Hoepner R, Salmen A, Friedli C. Anti-kelchlike protein 11 antibody-associated encephalitis: Two case reports and review of the literature. Eur J Neurol 2023; 30:1801-1814. [PMID: 36815561 DOI: 10.1111/ene.15758] [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: 11/21/2022] [Revised: 01/19/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND PURPOSE Kelchlike protein 11 antibodies (KLHL11-IgGs) were first described in 2019 as a marker of paraneoplastic neurological syndromes (PNSs). They have mostly been associated with testicular germ cell tumors (tGCTs). METHODS Two patients with KLHL11-IgG encephalitis are reported, and the literature is comprehensively reviewed. RESULTS Patient 1 had been in remission from a tGCT 10 years prior. He developed episodic vertigo and diplopia progressing over a few days. Treatment with corticosteroids (CSs) was started a few days after symptom onset. Patient 2 had transient diplopia, which resolved spontaneously. Visual problems persisted for 7 months, when he additionally developed a progressive cerebellar syndrome. One year after onset, CS treatment was started. Initial magnetic resonance imaging was unremarkable in both patients, but analysis of cerebrospinal fluid (CSF) revealed chronic inflammation. KLHL11-IgG was positive in both patients (Patient 1 only in CSF, Patient 2 in serum). Neoplastic screening has so far not revealed any signs of active underlying malignancy. We found 15 publications of 112 patients in total with KLHL11-IgG encephalitis. Most patients (n = 82) had a cerebellar syndrome with or without signs of rhombencephalitis. The most common symptoms were ataxia (n = 82) and vertigo (n = 47), followed by oculomotor disturbances (n = 35) and hearing disorders (n = 31). Eighty of 84 patients had a GCT as an underlying tumor. CONCLUSIONS Our cases demonstrate classical symptoms of KLHL11-IgG encephalitis. Early diagnosis and therapy are imperative. As with other PNSs, clinical awareness is needed and further studies are required especially in regard to therapeutic management.
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Affiliation(s)
- Alejandro León Betancourt
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Anina Schwarzwald
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alban Millonig
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael Oberholzer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Lidia Sabater
- Neuroimmunology Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Fundació Clínic per a la Recerca Biomèdica, University Hospital Barcelona, Barcelona, Spain
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nicole Kamber
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christoph Friedli
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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